Corrective Action Plans

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Views of responsible officials: There is no disagreement with the audit finding. Reason for finding’s reoccurrence: • The Department did not provide costs identified as matching requirements of program expenses, in the quarterly submission of fiscal reporting. Name(s) of the contact person(s) respon...
Views of responsible officials: There is no disagreement with the audit finding. Reason for finding’s reoccurrence: • The Department did not provide costs identified as matching requirements of program expenses, in the quarterly submission of fiscal reporting. Name(s) of the contact person(s) responsible for corrective action: • Anthony Walker, Associate Director • Anissa Curtis, Budget Analyst Planned completion date for corrective action: • The Department will ensure that all expenses related to the delivery of services are properly reported in expenditure reports. The Management Services Division (MSD) Associate Director will revise monthly compensation reports to include all required reporting information. The relevant reporting information will be updated and included in the next cycle of quarterly reporting (quarter ending March 2026) by the MSD Budget Analyst. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: • The Department of Family Services has conducted follow-up meetings with the grantor (Maryland Department of Aging) and developed a Corrective Action Plan to address items required for monthly reporting. The Plan addressed Fiscal reporting, Salary Allocation and Compliance with contract rates. It was submitted to the grantor in January 2026. Name(s) of the contact person(s) responsible for corrective action: • Elana Belon-Butler, Director • Anthony Walker, Associate Director Planned completion date for corrective action plan: • The DFS Corrective Action Plan was submitted on January 16, 2026 and is currently being followed. DFS CORRECTIVE ACTION PLAN I. Finance and Budget Management 1. The AAA Director will work closely with each program manager in developing program budgets that are realistic, responsible and align with the Area plan budget. These budgets will be based on actual expenditures, historical spending patterns and planned program activities. This will ensure accurate spending, which aligns with the area plan and ensure that programmatic activity and spending are aligned with program performance goals. Responsible Party: AAA Director, Program managers Timeline: Ongoing/Quarterly Monitoring 1a. Monthly Administrative Review meetings will be held to review spending, budgets, contracts and other procurement related activities. The monthly review meetings will engage all parties and allow for in depth spending discussions that provide the necessary data needed to make responsible decisions that address the need for any budget modifications. All budget modifications would be the result of careful review and analysis by the appropriate program staff and fiscal staff. All budget modifications will be reviewed and approved by the AAA Director before submission to the MDOA. Responsible Party: AAA Director, Program managers, Division planner, Fiscal Manager, Budget analyst, Contracts manager and Agency Director. Timeline: Monthly 2. The Management Services team (Fiscal Manager and Budget analyst) will prepare and review monthly internal fiscal reports to appropriately track expenditures and spending. Fiscal data will be reviewed by the Fiscal Manager and Budget Analyst and compiled as a monthly expenditure report. The reports will be provided to the AAA Director, who will be responsible for disseminating them to the appropriate Program managers for their review and action. Monthly Administrative Review meetings will be held to review spending, budgets, contracts and other procurement related activities. The monthly review meetings will allow for in depth spending discussions that provide the necessary data needed to make responsible decisions that address the need for any budget modifications. All budget modifications would be the result of careful review and analysis by the appropriate program staff and fiscal staff. All budget modifications will be reviewed and approved by the AAA Director before submission to the MDOA. Responsible Party: AAA Director, Program managers, Division planner, Fiscal Manager, Budget analyst, Contracts manager and Agency Director. Timeline: Monthly 9187
Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: a. Utilizing the verification method of checking SAM.gov Exclusions provided in 2 CFR 180.300 (a), the County determined that no contracts were awarded to any individ...
Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: a. Utilizing the verification method of checking SAM.gov Exclusions provided in 2 CFR 180.300 (a), the County determined that no contracts were awarded to any individual, firm or organization debarred from Government contracts pursuant to 2 CFR 200.332 (a). Note this finding did not determine any contracts were awarded improperly by the County or the Clean Water Partnership. b. The County is in the process of its procedures and internal controls with the Clean Water Partnership to ensure that all vendors’ suspension and debarment status will be verified utilizing the methods provided in 2 CFR 180.300 prior to all contract awards, as well as in conformance with state and local laws. The Clean Water Partnership is in the process of developing the documentation required for the certifications and clauses and conditions requirements for each covered transaction. Name(s) of the contact person(s) responsible for corrective action: James Lyons Planned completion date for corrective action plan: May 31, 2026
The District will review their processes and procedures for quarterly financial submissions reported in the SAS Medicaid System for fiscal year 2025-2026. All contracted services will have proper documentation supporting the costs in the quarter that it relates to.
The District will review their processes and procedures for quarterly financial submissions reported in the SAS Medicaid System for fiscal year 2025-2026. All contracted services will have proper documentation supporting the costs in the quarter that it relates to.
The District will review their processes and procedures for reimbursement claims. In addition, there will be a manager level review of claims for reasonableness.
The District will review their processes and procedures for reimbursement claims. In addition, there will be a manager level review of claims for reasonableness.
The District will implement internal controls to properly record accounts payable on a timely basis prior to audit fieldwork. This will include an in-depth review and account reconciliation with substantiating support for all payables on our financials as of year-end.
The District will implement internal controls to properly record accounts payable on a timely basis prior to audit fieldwork. This will include an in-depth review and account reconciliation with substantiating support for all payables on our financials as of year-end.
Narragansett Bay Commission Corrective Action Plan For the Fiscal Year Ended June 30, 2025 NBC acknowledges and concurs with the finding 2025-001 in the Fiscal Year 2025 Single Audit of the Narragansett Bay Commission conducted by Bacon & Company LLC. The Bucklin Point Wastewater Treatment Facility ...
Narragansett Bay Commission Corrective Action Plan For the Fiscal Year Ended June 30, 2025 NBC acknowledges and concurs with the finding 2025-001 in the Fiscal Year 2025 Single Audit of the Narragansett Bay Commission conducted by Bacon & Company LLC. The Bucklin Point Wastewater Treatment Facility Digester Complex Improvements “the Project”) has been funded by state revolving fund loan proceeds from the Rhode Island Infrastructure Bank (RIIB) and a Department of Energy grant. NBC’s contracting for civil projects has procedures in place to ensure the inclusion of all applicable Federal requirements as it relates to the use of RIIB funds. Although the Project followed Federal requirements as it relates to RIIB funds, NBC did not have appropriate controls in place to verify that applicable construction contracts for the Project included additional Federal requirements related to compliance with the Build America, Buy America Act as ostensibly required by the Department of Energy grant agreement. NBC has subsequently verified and received certification from the Project’s prime contractor that the Project satisfies Build America, Buy America Act requirements. Corrective Action Plan: In order to ensure that all applicable grant agreement terms are satisfied, NBC has hired a grant administrator to centralize all grant related activities within the Finance Division. NBC intends to develop additional procedures in conjunction with the acceptance and execution of a grant agreement to accomplish the following: 1) Coordinate with applicable Cost Center (as grant recipient) to verify that NBC has the ability to comply with the terms of the grant agreement, and 2) Create a comprehensive checklist of key obligations, including reporting deadlines, allowable costs, matching requirements, and special conditions and verify continued compliance on a regular interval, and 3) Limit award of contracts, expenditure of funds for grant funded projects, and reimbursement requests for grant funds until grant administrator verifies compliance with applicable terms and conditions. Anticipated Completion Date- May 31, 2026 Contact Person – Kevin McDonald, Chief Financial Officer
Name of Responsible Individual: Vice President of Enrollment Management (Dr. Stacey Sowell), University Registrar (Charee Ellison) Corrective Action: The University concurs with this finding. Shaw University acknowledges the finding regarding variances between institutional records and the status re...
Name of Responsible Individual: Vice President of Enrollment Management (Dr. Stacey Sowell), University Registrar (Charee Ellison) Corrective Action: The University concurs with this finding. Shaw University acknowledges the finding regarding variances between institutional records and the status reported in NSLDS. For students 1-3 listed for campus enrollment details, the students withdrew then subsequently re-enrolled. The University, to date has had static to confer degrees which do not coincide with the required timeframe of NSLDS reporting. The University will change degree conferral dates to better coincide with timely NSLDS reporting. Management will continue to monitor this process to ensure ongoing compliance. Anticipated Completion Date: May 15, 2026
Name of Responsible Individual: Vice President of Enrollment Management (Dr. Stacey Sowell), Director of Financial Aid (Dr. Ojebe Ifegwu) Corrective Action: The University concurs with the finding and acknowledges the difference between the auditor’s calculations and what was determined as the varia...
Name of Responsible Individual: Vice President of Enrollment Management (Dr. Stacey Sowell), Director of Financial Aid (Dr. Ojebe Ifegwu) Corrective Action: The University concurs with the finding and acknowledges the difference between the auditor’s calculations and what was determined as the variance of R2T4. To ensure full compliance with federal Return to Title IV (R2T4) requirements and to strengthen institutional oversight, Shaw University will implement enhanced processes designed to improve accuracy, documentation, and accountability. Each R2T4 calculation will undergo a dual review process in which one Financial Aid team member completes the calculation and a second independently verifies it before any returns are processed. The University will also maintain comprehensive documentation and audit trail for all R2T4 files, including withdrawal documentation, calculation worksheets, COD records, disbursement summaries, and proof of timely returns, stored systematically to support audit readiness and internal review. To reinforce oversight, management will reconcile internal Financial Aid records with the Business Office and COD on a scheduled basis, conduct monthly or biweekly reconciliations for Pell Grants, Direct Loans, and campus-based funds, and review open balances and disbursement records before posting or adjusting aid. Financial Aid staff will continue to receive annual and periodic training on R2T4 regulations, updated federal guidance, and internal process revisions to ensure consistent application of rules. Additionally, management will conduct periodic internal audits of R2T4 files to identify potential issues proactively and respond with timely corrective measures. These strengthened procedures will ensure that future R2T4 calculations are accurate, fully documented, and completed within federally required timeframes, thereby maintaining strong compliance, reinforcing internal controls, and meeting all expectations for federal oversight. Anticipated Completion Date: April 30, 2026
Name of Responsible Individual: Vice President of Enrollment Management (Dr. Stacey Sowell), Director of Financial Aid (Dr. Ojebe Ifegwu) Corrective Action: The University concurs with the findings. Shaw University acknowledges the findings regarding variances between institutional records and the a...
Name of Responsible Individual: Vice President of Enrollment Management (Dr. Stacey Sowell), Director of Financial Aid (Dr. Ojebe Ifegwu) Corrective Action: The University concurs with the findings. Shaw University acknowledges the findings regarding variances between institutional records and the amounts reported on the FISAP, as well as the delay in submitting corrections by the required deadline. The variances were due to insufficient reconciliation between the University’s records and the FISAP prior to submission. In addition, controls were not adequate to ensure that identified discrepancies were corrected within the required timeframe. The University has since completed a full reconciliation of the FISAP, and further corrections will be made. To prevent recurrence, the University has implemented procedures requiring a formal reconciliation of supporting records to the FISAP prior to submission, along with enhanced review and approval controls to ensure accuracy and timely reporting. Management will continue to monitor this process to ensure ongoing compliance. Anticipated Completion Date: April 30, 2026
Name of Responsible Individual: Vice President of Enrollment Management (Dr. Stacey Sowell), Director of Financial Aid (Dr. Ojebe Ifegwu) Corrective Action: The University concurs with the finding and will provide professional justification for the students identified in the audit testing; however, ...
Name of Responsible Individual: Vice President of Enrollment Management (Dr. Stacey Sowell), Director of Financial Aid (Dr. Ojebe Ifegwu) Corrective Action: The University concurs with the finding and will provide professional justification for the students identified in the audit testing; however, to strengthen internal controls and prevent potential over awards, the Financial Aid Office will enhance cross departmental communication through routine reconciliation meetings and real time reporting of enrollment, housing, scholarship, and waiver changes, implement a double review process in which an assigned counselor and secondary counselor verify aid packages against COA and financial need before disbursement, and provide annual staff training on need analysis, COA construction, Title IV over award regulations (34 CFR 673.5), and proper use of SIS tools to identify conflicts, ensuring stronger compliance and proactive prevention of award discrepancies. Anticipated Completion Date: April 30, 2026
Name of Responsible Individual: Vice President of Financial Operations/CFO (Michelle Lane) Corrective Action: The University concurs with the findings. Shaw University acknowledges that this finding is a repeat condition related to excess cash balances for Pell Grant, Direct Loan, and FSEOG funds no...
Name of Responsible Individual: Vice President of Financial Operations/CFO (Michelle Lane) Corrective Action: The University concurs with the findings. Shaw University acknowledges that this finding is a repeat condition related to excess cash balances for Pell Grant, Direct Loan, and FSEOG funds not being eliminated within the required seven business days. Management has determined that prior corrective actions were not sufficiently formalized or consistently executed, particularly with respect to reconciliation and monitoring controls. Since that time, the University has strengthened its internal controls over Title IV cash management. A formal monthly reconciliation between G5 drawdowns and the general ledger has been implemented to ensure excess cash balances are identified and resolved timely. In addition, procedures have been revised to limit drawdowns to actual or immediate disbursement needs, and monitoring controls have been established to ensure compliance with the seven-business-day requirement. Management will continue to monitor these processes to ensure ongoing compliance with federal cash management regulations. Anticipated Completion Date: June 30, 2026
2025-001 – Internal Control over Compliance and Compliance with Reporting Contact Name: Bryant Davis Position: Controller Telephone Number: (202) 796 2500 Corrective Action Plan – Management will continue to work with Federal agencies to resolve any grants that a FAIN was not issued. Estimated Compl...
2025-001 – Internal Control over Compliance and Compliance with Reporting Contact Name: Bryant Davis Position: Controller Telephone Number: (202) 796 2500 Corrective Action Plan – Management will continue to work with Federal agencies to resolve any grants that a FAIN was not issued. Estimated Completion – September 30, 2026
Finding Number: 2025-103 The deficiencies resulted from the absence of a comprehensive, system-based control structure capable of: ● Enforcing secure system access protocols, including multi-factor authentication The institution will implement multi-factor authentication (MFA) across all financial a...
Finding Number: 2025-103 The deficiencies resulted from the absence of a comprehensive, system-based control structure capable of: ● Enforcing secure system access protocols, including multi-factor authentication The institution will implement multi-factor authentication (MFA) across all financial aid and student information systems to: ● Protect Title IV data from unauthorized access ● Align with federal information security expectations ● Ensure compliance with institutional cybersecurity policies Anticipated Completion Date: 8/31/2026 Responsible Contact Person: Angela Reese
Finding Number: 2025-102 The deficiencies resulted from the absence of a comprehensive, system-based control structure capable of: ● Generating automated alerts to ensure compliance with federal return-of-funds deadlines To ensure compliance with 34 CFR § 668.22(j): ● The institution will utilize sy...
Finding Number: 2025-102 The deficiencies resulted from the absence of a comprehensive, system-based control structure capable of: ● Generating automated alerts to ensure compliance with federal return-of-funds deadlines To ensure compliance with 34 CFR § 668.22(j): ● The institution will utilize system-generated alerts to track all R2T4 deadlines ● Staff will follow standardized procedures aligned with federal timelines ● Supervisory review will be required prior to final processing of all returns Anticipated Completion Date: 8/31/2026 Responsible Contact Person: Angela Reese
Finding Number: 2025-101 The deficiencies resulted from the absence of a comprehensive, system-based control structure capable of: ● Tracking and documenting R2T4 calculations, including secondary review and approval Tom P. Haney Technical College will implement systemic and procedural corrective ac...
Finding Number: 2025-101 The deficiencies resulted from the absence of a comprehensive, system-based control structure capable of: ● Tracking and documenting R2T4 calculations, including secondary review and approval Tom P. Haney Technical College will implement systemic and procedural corrective actions designed to ensure full compliance with Title IV requirements. The institution will procure and implement the Point-of-Sale (POS) module within the FOCUS School Software system to establish automated internal controls. The system will: ● Require documented review and approval workflows for all R2T4 calculations ● Maintain electronic audit trails for all transactions and approvals ● Provide automated notifications and deadline tracking to ensure timely return of funds ● Generate compliance reports for ongoing monitoring The Financial Aid Office will revise and formalize written policies to include: ● R2T4 calculation, review, and approval procedures ● Timelines for return of funds ● System access and authentication requirements All policies will be maintained in accordance with federal recordkeeping requirements under 34 CFR § 668.24. All financial aid and relevant administrative staff will receive training on: ● R2T4 regulatory requirements ● Use of the FOCUS POS system ● Updated institutional policies and procedures Training will be documented and retained for audit purposes. Anticipated Completion Date: 8/31/2026 Responsible Contact Person: Angela Reese
The District acknowledges the audit finding related to documentation of suspension and debarment verification for vendors participating in federally funded programs. While no vendors reviewed were suspended or debarred and no questioned costs were identified, the District agrees that formal document...
The District acknowledges the audit finding related to documentation of suspension and debarment verification for vendors participating in federally funded programs. While no vendors reviewed were suspended or debarred and no questioned costs were identified, the District agrees that formal documentation of this verification should be maintained in the project file. To address this finding, the District has prepared a Standard Operating Procedure titled “Procedure for Debarment Verification for Federally Funded Contracts.” The procedure requires that at the time of contract review for federally funded contracts, prior to contract award, Finance and Business Services staff perform a search in SAM.gov to verify the contractor is not debarred or suspended from receiving federal funds. The result of the debarment search will be saved in the Finance and Business services project files. If the contractor is not registered with SAM.gov, a signed Non-Debarment Certification Form will be obtained from the selected vendor by the Project Manager prior to contract execution. The signed certification form will be saved in the Project Manager’s files along with the executed contract. The District is in the process of reviewing and documenting the debarment search for all vendors who received federal funding under this program. While the comprehensive review is in progress, all requests for federal funds will have the debarment search documentation verified before the request is submitted.
Finding #2025-003 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Treasury, COVID-19 Coronavirus State and Local Fiscal Recovery Funds, Assistance Listing #: 21.027, Contract #: 220163. Condition and context: In testing 40 nonpayroll transactions, we...
Finding #2025-003 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Treasury, COVID-19 Coronavirus State and Local Fiscal Recovery Funds, Assistance Listing #: 21.027, Contract #: 220163. Condition and context: In testing 40 nonpayroll transactions, we found one instance of an unallowable cost for a late fee charged to the grant and 2 instances of transactions recognized in the incorrect fiscal year. Additionally, 1 out of 9 payroll transactions were incorrectly allocated resulting in the understatement of payroll charged to the grant. Recommendation: Amend NBHP’s policies and procedures to include independent review of allowability of cost and payroll allocations. Planned corrective action: NBHP will modify its policies and procedures to include independent review of transaction for allowability and accuracy. Responsible officer: Lisa Albert, Executive Director. Estimated completion date: April 30, 2026.
Finding #2025-002 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Treasury, COVID-19 Coronavirus State and Local Fiscal Recovery Funds, Assistance Listing #: 21.027, Contract #: 220163. Condition and context: In testing 1 out of 6 vendors subject to ...
Finding #2025-002 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Treasury, COVID-19 Coronavirus State and Local Fiscal Recovery Funds, Assistance Listing #: 21.027, Contract #: 220163. Condition and context: In testing 1 out of 6 vendors subject to procurement, NBHP had not verified and documented that the Houston Health Department was not suspended or disbarred. Recommendation: Amend the procurement policy to require verification that person or organization is not suspended or disbarred. Planned corrective action: NBHP will modify its procurement policy to include verification that persons or organizations are not suspended or disbarred. Responsible officer: Lisa Albert, Executive Director. Estimated completion date: April 30, 2026.
Noncompliance with Reporting Requirements
Noncompliance with Reporting Requirements
Criteria: The Organization’s major department agreements carry with it certain periodic reporting requirements that are due at various points following the close of each month, quarter, or reporting period.
Criteria: The Organization’s major department agreements carry with it certain periodic reporting requirements that are due at various points following the close of each month, quarter, or reporting period.
Condition: We noted multiple instances in which required monthly performance measures and narrative reports were either submitted after the stated deadline or lacked support to indicate when or if a report was completed and submitted.
Condition: We noted multiple instances in which required monthly performance measures and narrative reports were either submitted after the stated deadline or lacked support to indicate when or if a report was completed and submitted.
Known Questioned Costs: None
Known Questioned Costs: None
Likely Questioned Costs: None
Likely Questioned Costs: None
Context: As part of our testing the monthly reporting requirements for ALN #93.959, we noted for the Shelter program two instances in which a required monthly performance measures and narrative report was submitted after the required deadline. For both the Detox and Extended Care programs, we noted ...
Context: As part of our testing the monthly reporting requirements for ALN #93.959, we noted for the Shelter program two instances in which a required monthly performance measures and narrative report was submitted after the required deadline. For both the Detox and Extended Care programs, we noted fourteen instances, and assumed an additional ten instances, in which a required monthly performance measures and narrative report lacked the support indicating when a report was filed, or whether the reports were completed on a monthly basis. Per discussions with the client, specific to reports with no indication as to whether the report was submitted, the cumulative fiscal year report was provided to support the annual completion of the report; however, given staff turnover, monthly submissions were unable to be located for both the Detox and Extended Care programs.
Cause: Management oversight.
Cause: Management oversight.
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