Corrective Action Plans

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The Department of Health Care Policy and Financing has examined rate maintenance practices since FY2024 to determine the best course of action to strengthen internal controls to subsequently develop formal policies and procedures. The Waiver and Fee Schedule Rates section will develop a formal, reco...
The Department of Health Care Policy and Financing has examined rate maintenance practices since FY2024 to determine the best course of action to strengthen internal controls to subsequently develop formal policies and procedures. The Waiver and Fee Schedule Rates section will develop a formal, recorded training and corresponding training materials based on current, informal processes on completion of the rate update form to be submitted to the Department's fiscal agent, Gainwell Technologies. Since FY2024, the Waiver and Fee Schedule Rates section has implemented a multilevel secondary review process prior to any rate change submission to ensure accuracy in rate update submissions. The Rates section has also worked closely with other internal partners to formalize informal update processes for quality assurance and maintenance of a minimal error percentage. The Rates section has also implemented a post-implementation data analysis review of all rate update submissions to ensure the update was implemented as directed and expected to ensure accountability on behalf of the Department's fiscal agent Gainwell Technologies. The Rates section is currently in process of documenting and formalizing all rate update processes and policies for future training and process maintenance.
The Department agrees with the recommendation and will strengthen internal controls over Children’s Basic Health Plan eligibility determinations to ensure compliance with federal and state regulations. The Department will issue formal Management Decision Letters to the identified counties requiring ...
The Department agrees with the recommendation and will strengthen internal controls over Children’s Basic Health Plan eligibility determinations to ensure compliance with federal and state regulations. The Department will issue formal Management Decision Letters to the identified counties requiring Department-approved Corrective Action Plans. These plans will be required to address root causes related to income documentation, application of correct income thresholds, and compliance with CBHP eligibility requirements, including any necessary training or guidance for county and Medical Assistance site caseworkers. The Department will review, approve, and monitor corrective actions to ensure deficiencies are addressed.
The Department agrees with the recommendation and will strengthen internal controls over Medicaid eligibility determinations to ensure compliance with federal and state regulations. The Department will issue formal Management Decision Letters to the identified counties requiring the development and ...
The Department agrees with the recommendation and will strengthen internal controls over Medicaid eligibility determinations to ensure compliance with federal and state regulations. The Department will issue formal Management Decision Letters to the identified counties requiring the development and implementation of Department-approved Corrective Action Plans. These plans will be required to address root causes related to income and resource calculation, documentation of eligibility determinations, and household composition, including any necessary training or guidance for county and Medical Assistance site caseworkers. The Department will review, approve, and monitor corrective actions to ensure deficiencies are appropriately addressed.
Subject: Corrective Action Plan for Federal Direct Student Loans Program Compliance The University of the Pacific acknowledges the findings outlined in the audit related to the reporting of student enrollment status to the National Student Loan Data System (NSLDS) for the Federal Direct Student Loan...
Subject: Corrective Action Plan for Federal Direct Student Loans Program Compliance The University of the Pacific acknowledges the findings outlined in the audit related to the reporting of student enrollment status to the National Student Loan Data System (NSLDS) for the Federal Direct Student Loans Program (Federal Assistance Listing Number: 84.268) for the award year July 1, 2024 – June 30, 2025. The audit identified a system-level transmittal configuration issue in which campus-level enrollment updates inadvertently overrode certain program-level enrollment status fields within NSLDS reporting. We take our responsibility to comply with the federal regulations under 34 CFR Section 685.309 very seriously and are committed to strengthening our internal controls and system governance processes to ensure accurate, complete, and timely reporting of enrollment changes at both the campus and program levels. Corrective Action Plan: To address the identified deficiency, Finding# 2025-001, related to program-level enrollment status reporting and to strengthen preventive controls over NSLDS submissions, the University has implemented the following measures, effective immediately (February 19, 2026): 1. Root Cause Isolation and System Logic Review: The University identified that a specific NSLDS transmittal file configuration resulted in campuslevel enrollment updates overriding program-level enrollment status fields. In collaboration with Information Technology, the Registrar’s Office has isolated the reporting logic and corrected the configuration to prevent program-level status fields from being overwritten by subsequent campus-level submissions. Documentation of the revised logic has been retained for audit purposes. 2. Full Population Review and Remediation: The University will conduct a comprehensive review of NSLDS records for the affected student population to confirm accuracy of program-level enrollment status. Where discrepancies are identified, corrected submissions will be transmitted promptly to NSLDS. Documentation of the review and any corrections will be maintained to ensure a complete audit trail. 3. Segregation of Campus-Level and Program-Level Reporting Logic: Enrollment reporting procedures have been updated to formally distinguish campus-level and program-level reporting workflows. Any future modifications to enrollment reporting logic will require documented change management review, regression testing, and joint approval from the Registrar’s Office and Information Technology prior to implementation. 4. Targeted Program-Level Monitoring Dashboard: In addition to existing monthly NSC and NSLDS reconciliations, the Registrar’s Office will implement a targeted monthly exception report specifically monitoring program-level enrollment status changes. This report will identify discrepancies between SIS records and transmitted data, including concurrent program records and recent status changes, to ensure ongoing data integrity. 5. Quarterly Compliance Sampling and Oversight: On a quarterly basis, an independent staff member not involved in file preparation will conduct a sampling review of transmitted NSLDS records to verify program-level status accuracy. Results will be documented and reviewed by the Registrar to ensure sustained compliance. 6. SOP Enhancement and Staff Training: The University has updated its Enrollment Reporting Standard Operating Procedures to incorporate explicit review steps for program-level data validation and transmission oversight. Targeted training has been provided to staff responsible for enrollment reporting to reinforce compliance expectations and system configuration awareness. The University remains committed to ensuring accurate and timely reporting of student enrollment data in full compliance with federal regulations. These enhanced preventive and governance controls build upon prior corrective actions and further strengthen the integrity of our Title IV reporting framework. Anticipated Completion Date: 6/30/26 Person Responsible: Michael Snyder, Associate University Registrar
The Council is award of the requirements concerning advances from the Payment Management System and plan to establish internal controls concerning such advances in the future.
The Council is award of the requirements concerning advances from the Payment Management System and plan to establish internal controls concerning such advances in the future.
Management has put procedures in place in the current year to ensure timely submission.
Management has put procedures in place in the current year to ensure timely submission.
The Medical Center will create calendar appointments prior to required deadline for submission of the audited financial statements and annual budget for the responsible personnel including the chief financial officer.
The Medical Center will create calendar appointments prior to required deadline for submission of the audited financial statements and annual budget for the responsible personnel including the chief financial officer.
Re: Finding 2025 001 – Significant Deficiency in Internal Control Over Financial Reporting – Preparation of the Schedule of Expenditures of Federal Awards (SEFA) The Corporation agrees with the recommendation. Management acknowledges that certain federal expenditures were not initially reported on t...
Re: Finding 2025 001 – Significant Deficiency in Internal Control Over Financial Reporting – Preparation of the Schedule of Expenditures of Federal Awards (SEFA) The Corporation agrees with the recommendation. Management acknowledges that certain federal expenditures were not initially reported on the Schedule of Expenditures of Federal Awards (SEFA) in the appropriate fiscal periods due to a misunderstanding of applicable Uniform Guidance requirements and reliance on prior audit treatment. Specifically, expenditures related to Federal Emergency Management Agency (FEMA) programs were not included on the SEFA until reimbursement was received, and certain per patient payments associated with federally funded research were not initially identified as SEFA reportable. To address this matter and strengthen internal controls over the preparation and review of the SEFA, management will implement the following corrective actions: • Future FEMA expenditures will be reported on the SEFA in the fiscal year in which the projects are obligated and eligible expenditures are incurred, regardless of the timing of reimbursement. • Per patient payments received in connection with federally funded research programs will be evaluated for SEFA reporting and included as required. • A formal Standard Operating Procedures related to the preparation of the SEFA will be developed and implemented to clarify reporting requirements for obligated expenditures, per patient grant activity, and other federal awards. • Review procedures will be enhanced to include confirmation by entity and corporate leadership that all federal awards and related expenditures have been identified, evaluated, and appropriately reported on the SEFA. • Management will evaluate opportunities to complete SEFA preparation and preliminary review earlier in the audit cycle to allow for timely identification and resolution of potential reporting issues. Management believes these actions will improve the accuracy and completeness of the SEFA and reduce the risk of similar issues in future reporting periods.
2025-001. Matching, Level of Effort, Earmarking United States Department of Education, Passed-through New York State Department of Education: Special Education Cluster Special Education Grants to StatesALN: 84.027 Special Education Preschool GrantsALN: 84.173 Condition: Upon review of the MOE, compl...
2025-001. Matching, Level of Effort, Earmarking United States Department of Education, Passed-through New York State Department of Education: Special Education Cluster Special Education Grants to StatesALN: 84.027 Special Education Preschool GrantsALN: 84.173 Condition: Upon review of the MOE, completed by the District to demonstrate the compliance requirement for the 2023-2024 grant program, it was noted that certain expenditures used in the MOE did not agree with the audited expenditure amounts. This resulted in an erroneous calculation indicating that the District had met the maintenance of effort requirement; however, the MOE completed using audited amounts would have indicated the District would not have met the MOE requirement without the District identifying allowable exceptions. Planned Corrective Action: The District concurs with the finding and has already provided additional training to the individuals responsible for preparing the MOE. Additionally, the District worked with its outside consultant to ensure the revised MOE was accurately completed. The revised MOE was subsequently transmitted to the New York State Education Department. Responsible Contact Person: Timothy Laube, Assistant Superintendent for Business & Operations. Eastport-South Manor Central School District 149 Dayton Avenue Manorville, New York 11949 laubet@esmonline.org 631-801-3001 Anticipated Completion Date: Corrective action completed.
Find new ways to spend down the district's food service surplus
Find new ways to spend down the district's food service surplus
Finding Reference Number: 2025-001 Federal Program: Supportive Housing for the Elderly-Section 202 (Assistance Listing No. 14.157) Federal Award Agency: U.S. Department of Housing and Urban Development Name of contact person: Shannon McCandlish, Controller Manor Management Services of Alaska Correct...
Finding Reference Number: 2025-001 Federal Program: Supportive Housing for the Elderly-Section 202 (Assistance Listing No. 14.157) Federal Award Agency: U.S. Department of Housing and Urban Development Name of contact person: Shannon McCandlish, Controller Manor Management Services of Alaska Corrective Action: A tenant file containing three income sources were not supported by third party verification, as required by HUD. The on site manager understands and will be diligent in using internal checklists that would have identified the missing income verification documentation. Date of Planned Corrective Action : January 06, 2026
Metropolitan Family Service respectfully submits the following corrective action plan for the year ending June 30, 2025. Audit: July 1, 2024 – June 30, 2025 The finding from the schedule of findings and questioned cost are discussed below. The finding is numbered with the number assigned in the sche...
Metropolitan Family Service respectfully submits the following corrective action plan for the year ending June 30, 2025. Audit: July 1, 2024 – June 30, 2025 The finding from the schedule of findings and questioned cost are discussed below. The finding is numbered with the number assigned in the schedule. 2025-001 FINDING – SUBRECIPIENT MONITORING Recommendation: We recommend that the Organization implement the necessary internal controls to ensure that subrecipient monitoring is performed and documented. Additionally, we recommend that the Organization revise their Subrecipient Monitoring Policy to address 2 CFR 332 and to give clear directives of how subrecipient monitoring will be performed and documented. Explanation of disagreement with audit findings: there is no disagreement with the audit findings. Action Plan: Steps were taken to update MFS’s Subrecipient Monitoring Policy and procedures to better address 2 CFR 332 giving clear directives of how subrecipient monitoring will be performed and documented going forward. Name(s) of the contact people responsible for correction action: Richard Seals, CFO; Nick Clark, Senior Financial Analyst; and the relevant Program Manager/Director Plan completion date for corrective action plan: December 31, 2025
FINDING 2025-003 Finding Subject: Child Nutrition Cluster - Eligibility Contact Person Responsible for Corrective Action: Katie Elliott Contact Phone Number and Email Address: 812-847-6020 ext. 1007 katieelliott@lssc.k12.in.us Views of Responsible Officials: We concur with the finding. Description o...
FINDING 2025-003 Finding Subject: Child Nutrition Cluster - Eligibility Contact Person Responsible for Corrective Action: Katie Elliott Contact Phone Number and Email Address: 812-847-6020 ext. 1007 katieelliott@lssc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Eligibility - Income guidelines will be entered by the Director of Food Services and reviewed by the Director of School Finance to ensure accuracy. Review by the Director of School Finance will be noted on the July monthly checklist completed by the Director of School Finance. Direct certification - The direct certification process will be completed on a weekly basis by the Director of Food Services and will be reviewed and signed off via email by the Director of School Finance. Review of Applications - The Food Service Management provider reviews and approves or denies online applications. The applications are printed monthly and maintained in the office of the Director of Food Service. The Director of Food Service will review a sample of applications each month to verify proper approvals and denials. The Director of Food Service will provide verified applications to the Director of School Finance for review. Anticipated Completion Date: This Corrective Action Plan will be put in effect February 2026.
FINDING 2025-002 Finding Subject: Child Nutrition Cluster - Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Katie Elliott Contact Phone Number and Email Address: katieelliott@lssc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of C...
FINDING 2025-002 Finding Subject: Child Nutrition Cluster - Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Katie Elliott Contact Phone Number and Email Address: katieelliott@lssc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: While the School Corporation completed the required Time and Effort logs, a time study was not completed and documented to justify the allocation of costs related to the compensation and fringe benefits of the food service director. The School Corporation Food Service Director is now documenting the hours spent each day completing food service activities. Anticipated Completion Date: This Corrective Action Plan will be put in effect January 2026.
The Owner has ended the additional principal payments being paid to the mortgage company, effective August 2025. The Owner is also in the process of requesting authorization from the US Department of HUD to disburse $260,000 from residual receipts (the sum of the additional principal payments made o...
The Owner has ended the additional principal payments being paid to the mortgage company, effective August 2025. The Owner is also in the process of requesting authorization from the US Department of HUD to disburse $260,000 from residual receipts (the sum of the additional principal payments made on the mortgage from August 2024 - August 2025, without previous HUD approval) to reimburse the operating account for these disbursements.
The Organization will develop a policy and procedures to ensure that it complies with the requirements of 2 CFR Part 180, Subpart C.
The Organization will develop a policy and procedures to ensure that it complies with the requirements of 2 CFR Part 180, Subpart C.
Reference Number: 2025-001 Finding: Other Instance of Noncompliance and Deficiency Status: In-Progress Corrective Action: An instance was found where the R2T4 calculation for one student had a typo of the incorrect date. This was subsequently corrected. We reviewed this student record and concluded ...
Reference Number: 2025-001 Finding: Other Instance of Noncompliance and Deficiency Status: In-Progress Corrective Action: An instance was found where the R2T4 calculation for one student had a typo of the incorrect date. This was subsequently corrected. We reviewed this student record and concluded that it was a human error made. There is no pattern of incorrect information being used. To avoid future errors, the Assistant Director will meet with the Dean monthly and we will review completed R2T4's during that period. We believe having another pair of eyes to review the work completed will be sufficient to correct any inconsistencies. Person(s) Responsible for Implementing: Lynda McKendree, Dean of Scholarships and Financial Aid and Thuylieu Aligo, Assistant Director of Scholarships and Financial Aid. Implementation Date: 1/27/2026
Contact Person Aaron Moss, Board President Corrective Action Plan The Center will review its process for keying amounts and percentages from employee time distributions into the allocation spreadsheet that is used to allocate expenses to the grant. Completion Date Ongoing
Contact Person Aaron Moss, Board President Corrective Action Plan The Center will review its process for keying amounts and percentages from employee time distributions into the allocation spreadsheet that is used to allocate expenses to the grant. Completion Date Ongoing
Contact Person Aaron Moss, Board President Corrective Action Plan The Center’s Office Manager will initial all invoices to signal that they have been reviewed and approved for payment. The Center’s employee supervisors will sign all of their subordinates’ time distributions to signal that they have ...
Contact Person Aaron Moss, Board President Corrective Action Plan The Center’s Office Manager will initial all invoices to signal that they have been reviewed and approved for payment. The Center’s employee supervisors will sign all of their subordinates’ time distributions to signal that they have been reviewed and approved for grant allocation. Completion Date The Center implemented an internal control in January 2025 to ensure all invoices are reviewed and approved by management. The Center will also ask employee supervisors to sign their subordinates’ time distributions through a desktop computer and avoid mobile approvals to reduce the number of glitches in saving.
Contact Person Aaron Moss, Board President Corrective Action Plan The Center will review its process for keying amounts and percentages from employee time distributions into the allocation spreadsheet that is used to allocate expenses to the grant. The Center will also review its process for keying ...
Contact Person Aaron Moss, Board President Corrective Action Plan The Center will review its process for keying amounts and percentages from employee time distributions into the allocation spreadsheet that is used to allocate expenses to the grant. The Center will also review its process for keying amounts into the Mutual of America contribution portal. Completion Date Ongoing
Contact Person Aaron Moss, Board President Corrective Action Plan The Center’s Office Manager will initial all invoices to signal that they have been reviewed and approved for payment. The Center’s employee supervisors will sign all of their subordinates’ time distributions to signal that they have ...
Contact Person Aaron Moss, Board President Corrective Action Plan The Center’s Office Manager will initial all invoices to signal that they have been reviewed and approved for payment. The Center’s employee supervisors will sign all of their subordinates’ time distributions to signal that they have been reviewed and approved for grant allocation. Completion Date The Center implemented an internal control in January 2025 to ensure all invoices are reviewed and approved by management. The Center will also ask employee supervisors to sign their subordinates’ time distributions through a desktop computer and avoid mobile approvals to reduce the number of glitches in saving.
Recommendation – The County Officials should review the operating procedures of all offices to obtain the maximum internal control possible under the circumstances utilizing currently available staff, including elected officials.
Recommendation – The County Officials should review the operating procedures of all offices to obtain the maximum internal control possible under the circumstances utilizing currently available staff, including elected officials.
Corrective Actions Taken or Planned: Management concurs with the auditor’s assessment that this was a control oversight and a breakdown in the internal control system for payroll documentation, rather than intentional noncompliance. As part of our federal grant closeout efforts, we have taken the fo...
Corrective Actions Taken or Planned: Management concurs with the auditor’s assessment that this was a control oversight and a breakdown in the internal control system for payroll documentation, rather than intentional noncompliance. As part of our federal grant closeout efforts, we have taken the following steps to address the deficiency: •After-the-Fact Certifications: As of this response, WETA has obtained ten after-the-factemployee certifications confirming that the payroll allocations for FY 2025 accurately reflectthe effort performed. These certifications are on file and available for review. •Managerial Oversight Confirmation: The Director of Production Operations has provided writtenconfirmation that monthly allocation decisions were discussed with project managers andreflected in payroll actions, though these reviews were not formally documented at the time. •Policy Review and Update: Management is currently reviewing and updating internal policiesto ensure that documentation procedures align with operational practices. These updates willrequire contemporaneous certification and documentation of payroll allocations for any futurefederal or restricted awards. •Training and Controls: We are developing additional training to reinforce documentationexpectations and strengthen internal controls among finance and operational staff. Completion Date: January 31, 2026 Contact Person: Dorian Davis Title: Corporate Controller Phone Number: (703) 998-2216
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