Corrective Action Plans

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Moving to Work Demonstration Program ALN: 14.881 Description: The Authority's fiscal year ended September 30, 2025. The unaudited Financial Data Schedule (FDS) was required to be submitted electronically to HUD's Real Estate Assessment Center (REAC) through the Financial Assessment Subsystem (FASS-P...
Moving to Work Demonstration Program ALN: 14.881 Description: The Authority's fiscal year ended September 30, 2025. The unaudited Financial Data Schedule (FDS) was required to be submitted electronically to HUD's Real Estate Assessment Center (REAC) through the Financial Assessment Subsystem (FASS-PH) no later than December 31, 2025 (60 days after fiscal year end). The Authority did not submit the unaudited FDS until May 29, 2026 -approximately five months after the required due date. Planned Corrective Action: The Authority concurs with the finding regarding late submission of the unaudited FDS. Establish a regulatory reporting calendar; assign responsibilities and supervisory review; and accelerate year-end closing procedures to support timely FDS submissions.
Title: Inadequate Tenant File Documentation in MTW Housing Choice Vouchers (ALN 14.881) (Repeat of Finding 2024-005) Program Name: Moving to Work Demonstration Program - Housing Choice Voucher ALN: 14.881 Description: During tenant file testing for the Housing Choice Voucher (HCV) component of the M...
Title: Inadequate Tenant File Documentation in MTW Housing Choice Vouchers (ALN 14.881) (Repeat of Finding 2024-005) Program Name: Moving to Work Demonstration Program - Housing Choice Voucher ALN: 14.881 Description: During tenant file testing for the Housing Choice Voucher (HCV) component of the MTW Demonstration Program, we identified the following deficiencies. This condition is a repeat of prior year finding 2024-005: 1. Melissa McCullum (port-out tenant): The tenant file did not contain the required HUD Form 50058 or the Enterprise Income Verification (EIV} documentation. As a result, the family's eligibility, income determination, and assistance could not be substantiated from the file. 2. Mark'elia Keyona Reaves: The Authority was unable to provide the HUD Form 50058; the form was not retained in the tenant file and only tenant balances from the Authority's housing software were available. The data is reportedly retrievable from HUD's IMS/PIC system but could not be reproduced from the Authority's records. 3. Deborah Waiters: The income determination was incorrect. Social Security income was not recalculated based on the prior-year recertification; although an updated Social Security benefit letter was received indicating a change in the monthly benefit, the income reported on the HUD Form 50058 was not updated accordingly, resulting in an inaccurate rent and housing assistance payment (HAP) calculation. Planned Corrective Action: The Authority concurs with the finding and questioned costs of $395,580.79 and acknowledges it is a repeat of finding 2024-005. Ensure Forms 50058 and supporting documentation are retained; recalculate household income when required; retrieve or reconstruct missing records; resolve questioned costs with HUD; conduct file reviews; and prcvide staff training. Timeline for completion: 6 months
The Authority's unaudited Financial Data Schedule (FDS) for the fiscal year ended September 30, 2025 was submitted on April 27, 2026, approximately four months after the HUD-required deadline of 60 days following fiscal year end (November 29, 2025). Planned Corrective Action: The Authority will esta...
The Authority's unaudited Financial Data Schedule (FDS) for the fiscal year ended September 30, 2025 was submitted on April 27, 2026, approximately four months after the HUD-required deadline of 60 days following fiscal year end (November 29, 2025). Planned Corrective Action: The Authority will establish a financial reporting calendar with assigned responsibility and interim deadlines to ensure the unaudited Financial Data Schedule (FDS) is prepared, reviewed, and submitted to HUD within 60 days of fiscal year end. The Authority will perform timely monthly general ledger reconciliations to support a timely year-end close.
During testing of the MTW Demonstration Program - Capital Fund Program (CFP), four eLOCCS drawdown vouchers were identified for which funds were drawn down but not disbursed within a reasonable timeframe (ranging from 7 to 36 days after deposit), contrary to the federal immediate-disbursement ("just...
During testing of the MTW Demonstration Program - Capital Fund Program (CFP), four eLOCCS drawdown vouchers were identified for which funds were drawn down but not disbursed within a reasonable timeframe (ranging from 7 to 36 days after deposit), contrary to the federal immediate-disbursement ("just-in-time") requirement. Planned Corrective Action: The Authority will implement a process to ensure that Capital Fund Program drawdowns are requested only when funds are needed for immediate disbursement, consistent with federal ca􀀉h management ("just-in-time") requirements. Drawdowns will be reconciled to disbursements, the elapsed time between each drawdown and the related disbursement will be monitored, and any excess cash held will be returned or interest remitted to HUD as required.
Title: Inadequate Tenant File Documentation in Public Housing Program Name: Moving to Work Demonstration Program - Public Housing ALN: 14.881 Description: During tenant file testing for the Public Housing component of the MTW Demonstration Program, food stamp (SNAP) income was not fully excluded fro...
Title: Inadequate Tenant File Documentation in Public Housing Program Name: Moving to Work Demonstration Program - Public Housing ALN: 14.881 Description: During tenant file testing for the Public Housing component of the MTW Demonstration Program, food stamp (SNAP) income was not fully excluded from the annual income calculations for three tenants. In addition, the Authority was unable to locate the entire tenant file, including all required compliance documentation, for one additional tenant. Planned Corrective Action: The Authority will review and correct the affected income determinations to ensure that food stamp (SNAP) benefits are properly excluded from tenant annual income, with corrections to be reflected at the December 2026 annual recertification. The Authority will reconstruct or obtain the missing tenant file and will implement supervisory review over annual recertifications. Staff will receive training on income calculation and exclusion requirements, and periodic file reviews will be performed to verify completeness and accuracy.
Title: Inadequate Tenant File Documentation in MTW Housing Choice Vouchers Program Name: Moving to Work Demonstration Program - Housing Choice Voucher Program ALN: 14.881 Description: During tenant file testing for the Housing Choice Voucher (HCV) component of the Moving to Work (MTW) Demonstration ...
Title: Inadequate Tenant File Documentation in MTW Housing Choice Vouchers Program Name: Moving to Work Demonstration Program - Housing Choice Voucher Program ALN: 14.881 Description: During tenant file testing for the Housing Choice Voucher (HCV) component of the Moving to Work (MTW) Demonstration Program, variances were identified between the amounts reported on HUD Form 50058 and the actual Housing Assistance Payment (HAP)/Utility Allowance Payment (UAP) disbursements for six tenants. The Authority did not maintain sufficient documentation to reconcile the differences. Planned Corrective Action: The Authority will implement a process to reconcile all Housing Assistance Payment (HAP) and Utility Allowance Payment (UAP) disbursements to the amounts reported on HUD Form 50058. Identified variances for the affected tenants will be researched and corrected, supporting documentation will be retained in each tenant file, and staff will be trained on documentation and reconciliation requirements under the MTW HCV program. Periodic quality-control reviews of tenant files will be performed to ensure ongoing compliance.
Finding Number: 2025-002 Planned Corrective Action: Management has implemented enhanced cash management and grant monitoring procedures, including strengthened review of draw requests, improved documentation requirements, and closer reconciliation of grant expenditures to amounts drawn. In addition,...
Finding Number: 2025-002 Planned Corrective Action: Management has implemented enhanced cash management and grant monitoring procedures, including strengthened review of draw requests, improved documentation requirements, and closer reconciliation of grant expenditures to amounts drawn. In addition, the Organization is undertaking process improvements to streamline grant accounting and reporting activities, improve the timeliness of expense recognition, and enhance overall oversight of federal awards. Management expects these actions will strengthen compliance with federal cash management requirements and reduce the risk of future occurrences. Anticipated Completion Date: 12/31/2026 Responsible Contact Person: Alison Roca, Chief Financial Officer
Subrecipient Monitoring – Other Matter Person responsible for corrective action – Andrea Olson, Executive Director Responsible official’s response – Management is in agreement with this finding. Corrective action planned – CAPND has a comprehensive monitoring plan to monitor all grantsupported activ...
Subrecipient Monitoring – Other Matter Person responsible for corrective action – Andrea Olson, Executive Director Responsible official’s response – Management is in agreement with this finding. Corrective action planned – CAPND has a comprehensive monitoring plan to monitor all grantsupported activities in accordance with program rules relative to LIHEAP program including rules established by the U.S. Department of Health & Human Services, those established by CAPND, and by 2 CFR Part 200. Planned implementation date of corrective action – July 1, 2026
Subrecipient Monitoring Controls - LIHEAP Person responsible for corrective action – Andrea Olson, Executive Director Responsible official’s response – Management is in agreement with this finding. Corrective action planned – CAPND has a comprehensive monitoring plan to monitor all grantsupported ac...
Subrecipient Monitoring Controls - LIHEAP Person responsible for corrective action – Andrea Olson, Executive Director Responsible official’s response – Management is in agreement with this finding. Corrective action planned – CAPND has a comprehensive monitoring plan to monitor all grantsupported activities in accordance with program rules relative to LIHEAP program including rules established by the program, those established by CAPND, and by 2 CFR Part 200. The plan was not fully adhered to during the year 2025. Planned implementation date of corrective action – July 1, 2026
The Organization acknowledges its responsibility to complete required audits and will do so in a timely manner.
The Organization acknowledges its responsibility to complete required audits and will do so in a timely manner.
The Organization acknowledges its responsibility to complete required audits and will do so in a timely manner.
The Organization acknowledges its responsibility to complete required audits and will do so in a timely manner.
Name of Contact Person: Meagan O’Neal Management Response: As covered in 2025-001, several years of late audits have inevitably created a lag. With the challenges of a new finance director, Hurricane Helene, 600+ acres of wildfire due to blowdown from Helene, County staff across all departments have...
Name of Contact Person: Meagan O’Neal Management Response: As covered in 2025-001, several years of late audits have inevitably created a lag. With the challenges of a new finance director, Hurricane Helene, 600+ acres of wildfire due to blowdown from Helene, County staff across all departments have been maxed out, including Finance staff trying to balance regular duties, audit fieldwork and disaster related responsibilities. 180 Corrective Action Plan (continued) We completed the FY24 audit at the end of September 2025 and immediately began the FY25 process. With systems implemented over the last two years, we were able to complete all year-end reconciliations and FY25 audit fieldwork in approximately seven months. This has been the most efficient completion of an audit for Transylvania since FY19, reflecting the effectiveness of these changes. Procedures to reconcile subsidiary ledgers monthly have been implemented as an ongoing responsibility of the Finance Director and Accountant to minimize year-end adjustments. The Finance Director has also completed over 50 hours of CPE through the School of Government to support continued process improvement. Communication between the auditor and the County has remained open throughout this period of transition and disaster management. Proposed Completion Date: Immediately.
Name of Contact Person: Nathanael Carver Management Response: In FY24, the County’s Information Technology Department implemented enhanced procedures under the Computer and Internet Use Policy to strengthen the security of County and State data. These updates include restricting unused network ports...
Name of Contact Person: Nathanael Carver Management Response: In FY24, the County’s Information Technology Department implemented enhanced procedures under the Computer and Internet Use Policy to strengthen the security of County and State data. These updates include restricting unused network ports, limiting network access by non-County devices, enforcing stronger password requirements, and requiring all IT-related support requests to be submitted through a centralized ticketing system. Automatic time-out procedures were implemented across all County workstations. In addition, staff were reminded of their responsibility to secure workstations when unattended. Compliance is reinforced through random verification checks conducted by DSS supervisors and IT staff to confirm users have properly logged out of their workstations. Further review identified that the specific instance in question involved a workstation assigned to a contracted worker. In response, targeted training was provided to both the contractor and the contracting organization to ensure a clear understanding of County security expectations and procedures. These actions demonstrate the County’s commitment to strengthening controls, addressing identified gaps, and maintaining ongoing compliance with data security requirements. Proposed Completion Date: Immediately
Management’s Response/Corrective Action Plan (Unaudited) – Management acknowledges the finding. The City has reviewed and updated its written procedures to require that evidence of suspension and debarment checks (e.g., SAM.gov search results, vendor certifications, or contract clauses) be saved in ...
Management’s Response/Corrective Action Plan (Unaudited) – Management acknowledges the finding. The City has reviewed and updated its written procedures to require that evidence of suspension and debarment checks (e.g., SAM.gov search results, vendor certifications, or contract clauses) be saved in the SUSPENSION-DEBARMENT CHECKS file at the time of verification. The new ERP system has project accounting, grant accounting, and contract accounting modules that allow tracking of the certification numbers/SAM.gov number, etc. Staff have been trained on these requirements and procedures to ensure documentation is consistently maintained for all covered transactions in accordance with federal guidelines. Planned Completion Date – These modifications are being implemented immediately. Contact Person Responsible for Correction Action – Finance Director
Finding 1224495 (2025-002)
Material Weakness 2025
Medical Assistance - Eligibility Recommendation: We recommend the County strengthen its supervisory review control over Medicaid eligibility casefile reviews by implementing procedures to ensure that identified errors or required corrections are documented, followed up on, and verified as completed ...
Medical Assistance - Eligibility Recommendation: We recommend the County strengthen its supervisory review control over Medicaid eligibility casefile reviews by implementing procedures to ensure that identified errors or required corrections are documented, followed up on, and verified as completed in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will ensure that supervisors will properly follow up with staff during casefile review and will retain documentation supporting that evaluation. Name of the contact person responsible for corrective action: Steven Jones Planned completion date for corrective action plan: December 31, 2026
2025-002 – Reporting Requirements Recommendation: The Organization should develop internal controls over reporting to ensure that it is meeting its reporting requirements. Action Taken: We have reviewed our project set up process and modified it to capture all federal projects upon initiation to ena...
2025-002 – Reporting Requirements Recommendation: The Organization should develop internal controls over reporting to ensure that it is meeting its reporting requirements. Action Taken: We have reviewed our project set up process and modified it to capture all federal projects upon initiation to enable accurate monitoring and tracking of accumulated expenditures on a fiscal year basis so we can timely determine if the Organization meets the threshold for a Single Audit.
2025-001 – Insufficient Documentation Recommendation: The Organization should develop internal controls over reporting to ensure that it is meeting its reporting requirements. The Organization should ensure it maintains documentation of its controls over allowable costs and reporting. Throughout the...
2025-001 – Insufficient Documentation Recommendation: The Organization should develop internal controls over reporting to ensure that it is meeting its reporting requirements. The Organization should ensure it maintains documentation of its controls over allowable costs and reporting. Throughout the year, the Organization should retain records of these operating effectively. Action Taken: We have reviewed our required documentation submission process and updated it to require capture of proof of documentation submission.
Name of Contact Person: Brent Boren, Superintendent. Recommendation: We recommend that the District only charge costs that are allowable under the grant agreement. We also recommend that the District contact ISBE to discuss if the District will need to return the funds reimbursed by the Illinois Sch...
Name of Contact Person: Brent Boren, Superintendent. Recommendation: We recommend that the District only charge costs that are allowable under the grant agreement. We also recommend that the District contact ISBE to discuss if the District will need to return the funds reimbursed by the Illinois School Board of Education for these unallowed expenditures. Corrective Action: The District will ensure that all costs charged to the Title I grant are allowable per the grant agreement going forward.
Name of Contact Person: Brent Boren, Superintendent. Recommendation: We recommend that the Superintendent approves all timesheets and the approval is documented and maintained. Corrective Action: The Superintendent will begin to document his approval for all timesheets. Proposed Completion Date: Imm...
Name of Contact Person: Brent Boren, Superintendent. Recommendation: We recommend that the Superintendent approves all timesheets and the approval is documented and maintained. Corrective Action: The Superintendent will begin to document his approval for all timesheets. Proposed Completion Date: Immediately.
Name of Contact Person: Brent Boren, Superintendent. Recommendation: We recommend that the District complete the required semi-annual certifications or time and effort logs for each employee who has time allocated to a grant. Corrective Action: The District will begin completing the necessary semi-a...
Name of Contact Person: Brent Boren, Superintendent. Recommendation: We recommend that the District complete the required semi-annual certifications or time and effort logs for each employee who has time allocated to a grant. Corrective Action: The District will begin completing the necessary semi-annual certifications of time and effort distribution records. Proposed Completion Date: Fiscal year 2026.
2025-001: Internal Controls Over Disbursement Approvals Action Taken/Planned: The University acknowledges the control deficiencies identified related to disbursement approval documentation for federal awards. While policies requiring multi-level approvals are formally established, management recogni...
2025-001: Internal Controls Over Disbursement Approvals Action Taken/Planned: The University acknowledges the control deficiencies identified related to disbursement approval documentation for federal awards. While policies requiring multi-level approvals are formally established, management recognizes that consistent execution and documentation of these controls were not fully adhered to in all instances. Management will formally re-communicate federal disbursement approval requirements to all relevant personnel, i ncluding principal investigators, department heads, and finance staff. This will include mandatory training sessions on federal compliance and approval protocols and distribution of updated written procedures outlining required approval l evels and documentation standards. To reduce reliance on manual processes, the University will configure the financial system/workilow to require multiple l evels of electronic approval prior to payment processing and restrict disbursement processing until all required a pprovals are completed and documented within the system. Management will implement ongoing monitoring procedures to ensure compliance, including monthly reviews of a sample of federal disbursements by the Controller's Office or Grants Accounting, quarterly compliance reporting to the CFO and senior leadership, and documentation of review results and corrective follow-up actions. Anticipated Completion Date/Date Completed: This will be implemented immediately with an anticipated completion date of June 30, 2026
2025-002: Missing Supporting Documentation Action Taken/Planned: Management acknowledges the instance identified in which supporting documentation for a federal award disbursement could not be located at the time of audit. While this appears to be an isolated occurrence, the University recognizes th...
2025-002: Missing Supporting Documentation Action Taken/Planned: Management acknowledges the instance identified in which supporting documentation for a federal award disbursement could not be located at the time of audit. While this appears to be an isolated occurrence, the University recognizes the importance of maintaining complete and readily accessible documentation to support all federal expenditures in accordance with institutional policy and federal compliance requirements. The University will reinforce documentation and record retention requirements with all relevant personnel, including finance staff, grant administrators, and principal investigators. Additionally, management will implement enhanced controls to ensure that all required supporting documentation is properly maintained and centrally accessible. This will include transitioning toward a more standardized and, where feasible, electronic document management process to reduce the risk of missing records. Furthermore, periodic monitoring procedures will be established, including routine reviews of disbursement files to confirm the presence of required supporting documentation. Any identified deficiencies will be promptly addressed, and corrective actions will be taken to prevent recurrence. Anticipated Completion Date/Date Completed: This will be implemented immediately with an anticipated completion date of June 30, 2026
2025-003: Period of Performance Compliance Action Taken/Planned: Management acknowledges the instances identified in which disbursements were processed after the award's period of performance. While no questioned costs were noted, the University recognizes that timely processing of expenditures and ...
2025-003: Period of Performance Compliance Action Taken/Planned: Management acknowledges the instances identified in which disbursements were processed after the award's period of performance. While no questioned costs were noted, the University recognizes that timely processing of expenditures and drawdowns is critical to ensuring compliance with federal requirements governing grant periods. To Strengthening Grant Closeout Procedures management will establish a formal grant closeout timeline to begin 90 days prior to the award end date, require principal investigators (PIs) and grant administrators to review all outstanding obligations and ensure timely submission of final expenses and implement a standardized closeout checklist to confirm all costs are recorded within the allowable period To Enhanced Monitoring of Grant Periods management will develop and maintain a centralized tracking system for all federal awards, including start and end dates, generate monthly reports identifying grants nearing expiration (within 90, 60, and 30 days) and distribute reports to Pis, Grants Accounting, and Finance leadership for proactive management. For timely processing and drawdown controls management will require all invoices and expenditures to be submitted within a defined timeframe (e.g., within 30 days of service or project completion), establish internal deadlines for processing disbursements and drawdowns prior to the grant end date and implement a review step within Grants Accounting to verify that expenses fall within the period of performance before payment is released. The grants department will conduct mandatory training for PIs, grant managers, and finance staff on period of performance requirements and federal compliance expectations and reinforce accountability for timely submission and processing of expenditures Management will also put in place for any costs identified outside the period of performance will require, documented justification, review and approval by the Director of Grants Accounting and CFO, and verification of allowability under award terms or sponsor approval, if applicable. Anticipated Completion Date/Date Completed: This will be implemented immediately with an anticipated completion date of June 30, 2026
Finding Number: 2025-001 Condition: While the System had controls over accumulating the data for inputs into the portal, it did not have an adequate control in place to ensure transactions subject to FFATA reporting were reviewed for completeness and accuracy upon submission. Planned Corrective Acti...
Finding Number: 2025-001 Condition: While the System had controls over accumulating the data for inputs into the portal, it did not have an adequate control in place to ensure transactions subject to FFATA reporting were reviewed for completeness and accuracy upon submission. Planned Corrective Action: Management concurs with this recommendation. MetroHealth will establish and maintain a log documenting FFATA report submission, with internal reviews of disclosures prior to submission Contact person responsible for corrective action: Michele Benos, Manager, Grants Accounting and Brynna Baird, Manager, Sponsored Programs Anticipated Completion Date: 05/31/2026
Finding 1224391 (2025-002)
Material Weakness 2025
Fraser
MN
Cash Management Significant Deficiency in Internal Control over Compliance Finding Summary: During testing there was an instance identified were an unallowed payroll item in the amount of $761.08 was submitted for reimbursement. In addition, there was no documented review of the reimbursement reques...
Cash Management Significant Deficiency in Internal Control over Compliance Finding Summary: During testing there was an instance identified were an unallowed payroll item in the amount of $761.08 was submitted for reimbursement. In addition, there was no documented review of the reimbursement request prior to submission. Responsible Individuals: Jim Strickland, Jim Olson Corrective Action Plan: We have designated a member of management to review more extensively reimbursement requests at a more detailed level prior to submission. Anticipated Completion Date: Already in place
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