Corrective Action Plans

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Finding Number: 2025-002 Planned Corrective Action:Management acknowledges the importance of accurate reporting and proper documentation to meet grant compliance standards. To address this repeat finding, management is strengthening its corrective action plan as follows: •Mandatory Secondary Review ...
Finding Number: 2025-002 Planned Corrective Action:Management acknowledges the importance of accurate reporting and proper documentation to meet grant compliance standards. To address this repeat finding, management is strengthening its corrective action plan as follows: •Mandatory Secondary Review Process: Effective immediately, all federal reports submitted to granting agencies will undergo a formal secondary review prior to submission. The reviewer will be a designated individual with demonstrated expertise in federal reporting requirements. Evidence of review (e.g., sign-off or electronic approval) will be retained for audit purposes. Anticipated Completion Date: 12/31/2026 Responsible Contact Person: Angelita Thomas, Chief Financial Officer
Finding: Data collection form filing Corrective Actions Taken or Planned:  Taken: This finding was a result of staff turnover and Center on Halsted has put in place an established relationship with an external accounting firm (Sikich), that will help create stability and support in all financial pr...
Finding: Data collection form filing Corrective Actions Taken or Planned:  Taken: This finding was a result of staff turnover and Center on Halsted has put in place an established relationship with an external accounting firm (Sikich), that will help create stability and support in all financial processes including grant reconciliation. This updated contractual agreement & relationship occurred on March 1, 2024.  Taken: Center on Halsted leadership, with the assistance of our external accounting firm, will ensure proper documentation, internal controls, and processes that will support a timelier audit. This includes an organization-initiated internal audit for the Center on Halsted processes that will stress test our ability to produce accurate supporting documentation and allows us to build more effective and efficient processes prior to our annual audit. This will be led by Sikich with a targeted completion date of October 31st, 2025.  Taken: Center on Halsted leadership, with the assistance of our external accounting firm, will establish a timeline to complete the FY25 audit by May 2026. Though this plan results in a late filing, the timeline shows progression towards a faster audit process and enhancements to organization structures.  Planned: Center on Halsted leadership, with the assistance of our external accounting firm, will establish a timeline to complete a timely FY26 audit to ensure filing ahead of the imposed deadlines.
Management will formally document the CEO and CFO approval of all pay rate changes. Anticipated Completion Date: May 11, 2026
Management will formally document the CEO and CFO approval of all pay rate changes. Anticipated Completion Date: May 11, 2026
LSC-Basic Field Grant Significant Deficiency Internal Control over Compliance and Other Matters - Reporting Recommendation: We recommend that the Organization implement adequate controls to ensure the timely submission of the required grantor reports. If delays, with the submission of a report, occu...
LSC-Basic Field Grant Significant Deficiency Internal Control over Compliance and Other Matters - Reporting Recommendation: We recommend that the Organization implement adequate controls to ensure the timely submission of the required grantor reports. If delays, with the submission of a report, occur, we recommend that the Organization notifies its grantor and obtains an extension of the report due date. There is no disagreement with the audit finding. Action planned in response to finding: Essex-Newark Legal Services Project, Inc agrees that it will timely advise grantors when a delay in the timely submission of a report is anticipated. Name of the contact person responsible for corrective action: Felipe Chavana, Executive Director Planned completion date for corrective action plan: Effectively Immediately.
Finding Number: 2025-004 Condition: All disbursements need either an approved invoice or credit card receipt for the amount charged to the grant. Planned Corrective Action: Imagine! will send out a communication to all employees reviewing the current internal control process that requires receipts a...
Finding Number: 2025-004 Condition: All disbursements need either an approved invoice or credit card receipt for the amount charged to the grant. Planned Corrective Action: Imagine! will send out a communication to all employees reviewing the current internal control process that requires receipts and / or invoices from vendors to be attached to credit card disbursements. Employees who do not abide by the process are subject to losing credit card privileges. Contact person responsible for corrective action: Melody Kim Anticipated Completion Date: 7/31/2026
Finding Number: 2025-003 Condition: Per the HUD Handbook 4350.3, leases are to be signed by the tenant and owner and include the attachment of certain forms. When a tenant recertification is performed, amendments to the lease are prepared after the recertification and the amendments are signed by bo...
Finding Number: 2025-003 Condition: Per the HUD Handbook 4350.3, leases are to be signed by the tenant and owner and include the attachment of certain forms. When a tenant recertification is performed, amendments to the lease are prepared after the recertification and the amendments are signed by both the tenant and owner. The name of the HUD Project is to be listed in the lease. Planned Corrective Action: Imagine! brought in a HUD consultant to assist with HUD training, compliance and processes. Imagine! has put in place proper workflows to ensure leases are signed by the tenants going forward. Contact person responsible for corrective action: Robin Grey Anticipated Completion Date: 7/31/2026
Finding Number: 2025-002 Condition: HUD Form 50059 is filed electronically with HUD and per the HUD Handbook 4350.3, Form 50059 is to be printed, signed by the tenant and owner, and kept on file by the owner for each month the owner receives assistance payments. When the tenant’s income increases or...
Finding Number: 2025-002 Condition: HUD Form 50059 is filed electronically with HUD and per the HUD Handbook 4350.3, Form 50059 is to be printed, signed by the tenant and owner, and kept on file by the owner for each month the owner receives assistance payments. When the tenant’s income increases or decreases by $200 or more per month, an interim recalculation is to be performed. Planned Corrective Action: Imagine! brought in a HUD consultant to assist with HUD training, compliance and processes. Imagine! has put in place proper workflows to ensure Form 50059s are signed by the tenant and owner going forward. Contact person responsible for corrective action: Robin Grey Anticipated Completion Date: 7/31/2026
The Wytheville Redevelopment & Housing Authority had experienced turnover during FY2025. The hiring of a new Executive Director (3/1/2025) and a new Housing Director (10/31/2025). All of the FY 2025 new admissions, annual, & interim recertifications would have been completed by our previous Housing ...
The Wytheville Redevelopment & Housing Authority had experienced turnover during FY2025. The hiring of a new Executive Director (3/1/2025) and a new Housing Director (10/31/2025). All of the FY 2025 new admissions, annual, & interim recertifications would have been completed by our previous Housing Director. Both new hires have obtained specialized training in the Housing Choice Voucher program and have gained competencies in administering the program. 2025-001- Participant Signatures A portion of our HCV tenants & landlords did not fulfill their obligation to sign and return certification documents. Moving forward, the following has system has been implemented:  All HCV participants are to be given a strict return documents deadline. If a tenant or landlord fails to bring in their signed documents, Housing Assistance Payments will be suspended. If the participant fails to bring in the aforementioned documents before the end of the month. Their participation with the WRHA HCV program will be terminated.  No HCV applicant will be placed onto the program until their new admission documents have been signed  All HCV participants (tenants and landlords) will be receiving a letter informing them of the WRHA’s obligation to receive signed documents  At the end of every month, I will review documents with housing staff here to ensure corrective action is enforced. Our housing operations staff will be cross training with other agencies as well to strengthen their competencies with the HCV program. Since the completion of our FY2025 audit, I have taken the time to review our internal procedures and find that this corrective action plan will assist our agency in its ongoing dedication to compliance.
Going forward, Edison Local Schools Eligibility process to determine Free/Reduced/Denied Status of applications submitted for the National School Lunch Program are: All applications collected at Edison Local School will be reviewed prior to the data entered into pay schools to ensure the application...
Going forward, Edison Local Schools Eligibility process to determine Free/Reduced/Denied Status of applications submitted for the National School Lunch Program are: All applications collected at Edison Local School will be reviewed prior to the data entered into pay schools to ensure the applications have all the information and data to make the correct determination. The income eligibility criteria is established by the Ohio Department of Education. The eligibility for paper applications will be made by the food service director and the superintendent is the determining official and each application is reviewed prior to entering this into the POS system, and a free/reduced and benefits issuance reports is compared to ensure all information is correct after it is entered to ensure the determination is correct, additionally annual verification is also done on free/reduced applications.
The Organization filed the required reports in 2026.
The Organization filed the required reports in 2026.
Consolidated Health Centers Grant – Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categori...
Consolidated Health Centers Grant – Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We have found that our electronic medical record (eCW) is automatically classifying the federal poverty level (FPL) for all patients no matter if we have their insurance or household income inputted into the system. This has led to some inaccuracies in the rating of their FPL in eCW. We are actively manually overriding this setting, so we will have full control when to run the FPL after patient information is collected.
The two residential properties purchased by PMHDC were the 42nd and 43rd properties purchased using funds from this award, which has been in place since 2012. The properties were included in the funding source approved Budget Narrative and Scope of Work. The requests for reimbursement were submitted...
The two residential properties purchased by PMHDC were the 42nd and 43rd properties purchased using funds from this award, which has been in place since 2012. The properties were included in the funding source approved Budget Narrative and Scope of Work. The requests for reimbursement were submitted for payment to the Department of Labor and subsequently processed and paid to the organization, without having submitted pre-acquisition documentation. The Federal Project Officer assigned to this award had previously visited the sites of the prior properties purchased on several occasions. Closeout reports required at the end of each funding cycle were submitted and subsequently approved by the funding source. At no time was a prior-approval package required to be submitted on any of the properties previously purchased.
The properties purchased have always been listed as an item under the Contractual category in the federally approved budget and budget narrative; thus, while these costs appeared as a program expenditure for federal reporting purposes, the costs were properly categorized in PMHDC’s books as property...
The properties purchased have always been listed as an item under the Contractual category in the federally approved budget and budget narrative; thus, while these costs appeared as a program expenditure for federal reporting purposes, the costs were properly categorized in PMHDC’s books as property and equipment.
PMHDC contends that it has substantially complied with the purpose of the award and has successfully developed permanent and temporary farm labor rental housing to meet the dire needs of migrant and seasonal farmworkers. The Organization is of the belief that the lack of prior written approval was a...
PMHDC contends that it has substantially complied with the purpose of the award and has successfully developed permanent and temporary farm labor rental housing to meet the dire needs of migrant and seasonal farmworkers. The Organization is of the belief that the lack of prior written approval was an administrative oversight, not previously enforced by the Department of Labor, and PMHDC, therefore, vigorously defends its position that no costs should be disallowed.
See the response at Finding 2025-004 for the history of homes purchased under the Department of Labor’s National Farmworkers Jobs Program and administration of the program. The Organization received the results of the July 2025 program monitoring report by the Department of Labor on March 30, 2026. ...
See the response at Finding 2025-004 for the history of homes purchased under the Department of Labor’s National Farmworkers Jobs Program and administration of the program. The Organization received the results of the July 2025 program monitoring report by the Department of Labor on March 30, 2026. The Organization is currently working to resolve the compliance findings and to provide additional documentation, as requested. Additionally, the Organization is reviewing the monitoring report to determine whether changes to the current grant controls are deemed necessary. In the event that the Department of Labor deems that pre-approval is necessary, adequate pre-obligation workflow procedures will be developed and implemented immediately.
Condition: An employee was identified as being paid more per paycheck than their contract approved of. This was related to an error from the payroll specialist previously employed by the District. Plan: The District will verify pay rates input into the system so that employees cannot be paid more th...
Condition: An employee was identified as being paid more per paycheck than their contract approved of. This was related to an error from the payroll specialist previously employed by the District. Plan: The District will verify pay rates input into the system so that employees cannot be paid more than their contracted rates. Anticipated Date of Completion: The District will correct this for the 2025-2026 school year. Name of Contact Person: Nicki Ells, Business Manager Management Response: The Adams-Friendship School District accepts the plan for the Corrective Action listed above and does not dispute anything.
Condition: Purchases did not have an approval within the system before the purchase was made. Plan: The District will update its procedures for approval of purchases before purchases are made. Anticipated Date of Completion: The District will correct this for the 2025-2026 school year. Name of Conta...
Condition: Purchases did not have an approval within the system before the purchase was made. Plan: The District will update its procedures for approval of purchases before purchases are made. Anticipated Date of Completion: The District will correct this for the 2025-2026 school year. Name of Contact Person: Nicki Ells, Business Manager Management Response: The Adams-Friendship School District accepts the plan for the Corrective Action listed above and does not dispute anything.
Condition: During our review of the Wisconsin Medicaid School-Based Services Program, the School District was unable to provide adequate supporting documentation for quarterly payroll costs reported to Medicaid. Additionally, the District could not provide a complete and reliable population of payro...
Condition: During our review of the Wisconsin Medicaid School-Based Services Program, the School District was unable to provide adequate supporting documentation for quarterly payroll costs reported to Medicaid. Additionally, the District could not provide a complete and reliable population of payroll transactions attributable to the Medicaid program to support payroll sampling procedures. Plan: The District will strengthen its internal controls over payroll reporting for the Medicaid School- Based Services Program by: establishing and maintaining detailed supporting documentation for all payroll costs claimed; developing procedures to ensure a complete and auditable payroll population can be generated for each reporting period; and providing training to staff responsible for Medicaid payroll reporting and documentation. Management should implement corrective actions to ensure future Medicaid payroll claims are fully supported and compliant with program requirements. Anticipated Date of Completion: The District will correct this for the 2025-2026 school year. Name of Contact Person: Nicki Ells, Business Manager Management Response: The Adams-Friendship School District accepts the plan for the Corrective Action listed above and does not dispute anything.
Condition: During audit fieldwork, our testing resulted in a restatement of fund balance in order to correctly record capital asset activity. Plan: The District will implement internal controls to properly record capital assets on a timely basis prior to audit fieldwork. Anticipated Date of Completi...
Condition: During audit fieldwork, our testing resulted in a restatement of fund balance in order to correctly record capital asset activity. Plan: The District will implement internal controls to properly record capital assets on a timely basis prior to audit fieldwork. Anticipated Date of Completion: The District will correct this for the 2025-2026 school year. Name of Contact Person: Nicki Ells, Business Manager Management Response: The Adams-Friendship School District accepts the plan for the Corrective Action listed above and does not dispute anything.
The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants.
The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants.
The Board of County Commissioners will work with all County Officials to inform them of all grants and federal monies that Pottawatomie County receives to ensure that proper internal controls are implemented.
The Board of County Commissioners will work with all County Officials to inform them of all grants and federal monies that Pottawatomie County receives to ensure that proper internal controls are implemented.
The Board of County Commissioners will work to assess and identify risks to design a written county-wide controls policy over federal grant programs to ensure compliance with grant requirements.
The Board of County Commissioners will work to assess and identify risks to design a written county-wide controls policy over federal grant programs to ensure compliance with grant requirements.
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2025-002: • Heart City Health Center, Inc. continues to focus on the controls related to both the filing and review process of these required reports before final submission
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2025-002: • Heart City Health Center, Inc. continues to focus on the controls related to both the filing and review process of these required reports before final submission
Student Financial Assistance Program Cluster – Department of Education Federal Financial Assistance Listing/CFDA #84.268 Federal Direct Student Loans - 2024/2025 P268K211430 Federal Financial Assistance Listing/CFDA #84.063 Federal Pell Grant Program - 2024/2025 P063P201430 Special Tests & Provision...
Student Financial Assistance Program Cluster – Department of Education Federal Financial Assistance Listing/CFDA #84.268 Federal Direct Student Loans - 2024/2025 P268K211430 Federal Financial Assistance Listing/CFDA #84.063 Federal Pell Grant Program - 2024/2025 P063P201430 Special Tests & Provisions: Enrollment Reporting Material Weakness in Internal Control over Compliance and Noncompliance not Considered Material Finding Summary: Fourteen instances were identified where the enrollment status reported to the National Student Clearing House did not match the student’s actual enrollment status. Responsible Individuals: Robert Hoover, Director of Financial Aid and Kristi Bagstad, Registrar Corrective Action Plan: The University will strengthen controls over enrollment reporting by implementing a reconciliation process that includes sampling of enrollment statuses prior to submission. In addition, procedures will be updated to ensure reports are submitted within required timeframes. A secondary review of enrollment files will be conducted prior to submission, and staff will receive training on reporting requirements. Periodic reviews will be performed to monitor ongoing compliance and accuracy. Anticipated Completion Date: August 1, 2026/ongoing
Student Financial Assistance Program Cluster – Department of Education Federal Financial Assistance Listing/CFDA #84.268 Federal Direct Student Loans - 2024/2025 P268K211430 Federal Financial Assistance Listing/CFDA #84.063 Federal Pell Grant Program - 2024/2025 P063P201430 Special Tests & Provision...
Student Financial Assistance Program Cluster – Department of Education Federal Financial Assistance Listing/CFDA #84.268 Federal Direct Student Loans - 2024/2025 P268K211430 Federal Financial Assistance Listing/CFDA #84.063 Federal Pell Grant Program - 2024/2025 P063P201430 Special Tests & Provisions: Return of Title IV Funds Material Weakness in Internal Control over Compliance and Noncompliance not Considered Material Finding Summary: Two instances were identified where the amount of Title IV funds to be returned was not remitted correctly, and two instances were identified where the funds were returned in the correct amount but not in a timely manner. Responsible Individuals: Robert Hoover, Director of Financial Aid and Ashley Hantelmann, Associate Director of Financial Aid Corrective Action Plan: The Financial Aid Office will continue strengthening its Return of Title IV (R2T4) procedures to ensure accurate and timely processing. The secondary review process has been expanded and formalized, now including the Associate Director of Financial Aid to provide additional oversight. The R2T4 checklist has been updated to better align with compliance standards and ensure consistent documentation. Staff will receive ongoing training, and periodic internal reviews will be conducted to monitor compliance. Anticipated Completion Date: August 1, 2026
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