Corrective Action Plans

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WIOA Cluster – Assistance Listing No. 17.258, 17.259, and 17.278 Compliance Requirement: Subrecipient Monitoring Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that management document review of subrecipient Single Audit reports when availabl...
WIOA Cluster – Assistance Listing No. 17.258, 17.259, and 17.278 Compliance Requirement: Subrecipient Monitoring Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that management document review of subrecipient Single Audit reports when available Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: DEDO has implemented procedures to ensure that reviews of subrecipient Single Audit reports are documented annually and maintained in greater detail than the Single Audit review currently incorporated into DEDO's existing risk assessment process. Name(s) of the contact person(s) responsible for corrective action: Travon Earl Planned completion date for corrective action plan: 6/23/26
Temporary Assistance for Needy Families (TANF) - Assistance Listing No. 93.558 Compliance Requirement: Subrecipient Monitoring Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that management update and formalize subrecipient monitoring procedu...
Temporary Assistance for Needy Families (TANF) - Assistance Listing No. 93.558 Compliance Requirement: Subrecipient Monitoring Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that management update and formalize subrecipient monitoring procedures to align with actual monitoring practices performed and ensure monitoring activities are consistently documented in accordance with Uniform Guidance requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: DHS Financial Services will formalize updates to the Subrecipient Monitoring policy and procedures (currently in draft status) to align with the requirement for monitoring all high-risk subrecipients annually. Name(s) of the contact person(s) responsible for corrective action: Robert Baker Planned completion date for corrective action plan: 9/30/2026
Finding Reference Number: 2025-002 Program: Assistance Listing 16.556 Finding: Late Submission of Federal Financial Report (FFR) and Programmatic Report Corrective Action Planned: Management agrees with the findings. To ensure timely submission of all required federal financial and programmatic repo...
Finding Reference Number: 2025-002 Program: Assistance Listing 16.556 Finding: Late Submission of Federal Financial Report (FFR) and Programmatic Report Corrective Action Planned: Management agrees with the findings. To ensure timely submission of all required federal financial and programmatic reports, the organization will implement the following corrective actions: • Both Andrianna Clark and Tanesha McDonald have been added to the reporting system to provide backup coverage and shared responsibility for report preparation and submission. • In addition, ongoing cross-training is being conducted to ensure that multiple staff members are knowledgeable about reporting requirements, deadlines, and submission procedures. This cross-training will reduce the risk of delays caused by staff absences, turnover, or other unforeseen circumstances. • Management will continue to monitor reporting deadlines and maintain internal procedures to ensure all future federal financial and programmatic reports are submitted accurately and on time, in compliance with grant requirements. Anticipated Completion Date: June 17, 2026 Responsible Official: Andrianna Clark and Tanesha McDonald
Finding Reference Number: 2025-001 Program: Assistance Listing 93.591 Finding: Late Submission of Federal Financial Report (FFR) and Programmatic Report Corrective Action Planned: Management agrees with the findings. To ensure timely submission of all required federal financial and programmatic repo...
Finding Reference Number: 2025-001 Program: Assistance Listing 93.591 Finding: Late Submission of Federal Financial Report (FFR) and Programmatic Report Corrective Action Planned: Management agrees with the findings. To ensure timely submission of all required federal financial and programmatic reports, the organization will implement the following corrective actions: • Both Andrianna Clark and Tanesha McDonald have been added to the reporting system to provide backup coverage and shared responsibility for report preparation and submission. • In addition, ongoing cross-training is being conducted to ensure that multiple staff members are knowledgeable about reporting requirements, deadlines, and submission procedures. This cross-training will reduce the risk of delays caused by staff absences, turnover, or other unforeseen circumstances. • Management will continue to monitor reporting deadlines and maintain internal procedures to ensure all future federal financial and programmatic reports are submitted accurately and on time, in compliance with grant requirements. Anticipated Completion Date: June 17, 2026 Responsible Official: Andrianna Clark and Tanesha McDonald
Corrective Action Plan (CAP): The College has reviewed the Federal Pell Grant calculation identified in this finding and confirmed that the student's award was calculated incorrectly, resulting in an under-award, due to staff error in applying the enrollment intensity calculation under the rules in ...
Corrective Action Plan (CAP): The College has reviewed the Federal Pell Grant calculation identified in this finding and confirmed that the student's award was calculated incorrectly, resulting in an under-award, due to staff error in applying the enrollment intensity calculation under the rules in effect for the 2024-25 award year. The College has recalculated the student's award using the correct enrollment intensity methodology, and the additional Pell Grant funds owed to the student (616.00) have been disbursed. Financial Aid staff are committed to maintaining current knowledge of federal regulatory changes affecting Title IV award calculations. To support this, staff will continue to participate in NASFAA training and U.S. Department of Education webinars addressing Pell Grant calculation methodology and other regulatory updates on an ongoing basis, including specific training addressing changes to enrollment intensity calculations.
Corrective Action Plan (CAP): The College has reviewed the student identified in this finding and confirmed that the student had been placed on financial aid suspension during a previous term due to exceeding the 150% maximum timeframe for program completion, but the suspension status was not reflec...
Corrective Action Plan (CAP): The College has reviewed the student identified in this finding and confirmed that the student had been placed on financial aid suspension during a previous term due to exceeding the 150% maximum timeframe for program completion, but the suspension status was not reflected when the student's enrollment was subsequently evaluated, resulting in the student receiving Title IV aid for which they were not eligible during the period under audit. The College has identified that this occurred in connection with how the student's enrollment was recorded across programs within Anthology, the College's student information system, and is continuing to investigate the precise cause of the system behavior that allowed the student's Satisfacto1y Academic Progress (SAP)/150% status to not carry forward or recalculate appropriately. The aid improperly disbursed to this student has been identified, and repayment has been completed.
Corrective Action Plan (CAP): The College operates under a just- in-time (JIT) cash management model for Title IV funds, in which the disbursement date reported to COD and the date funds are credited to the student's ledger are intended to occur on the same day. Under this model, the CMN draws down ...
Corrective Action Plan (CAP): The College operates under a just- in-time (JIT) cash management model for Title IV funds, in which the disbursement date reported to COD and the date funds are credited to the student's ledger are intended to occur on the same day. Under this model, the CMN draws down Pell grant funds in conjunction with disbursing those funds to the student, rather than disbursing from institutional funds in advance of drawdown. This approach is designed to ensure the College does not hold excess cash on hand, consistent with cash management requirements under 34 CFR 668.164. The College has reviewed the six disbursements identified in this finding and confirmed that, in each instance, the COD submission was processed on schedule, but the corresponding batch process that credits funds to the student ledger ran four days later than intended, resulting in a misalignment between the reported disbursement date and the actual date the student was credited. The College has reviewed the timing and sequencing of COD submissions and ledger transactions with the Bursar's office and the Financial Aid office to ensure both are scheduled and performed on the same day. The existing weekly reconciliation process between Financial Aid and the Bursar's office will be expanded to include a verification that the disbursement date on the ledger matches the COD disbursement date. The College notes that this finding reflects a single disbursement- timing discrepancy across the sample, a reduction in both scope and recurrence compared to findings identified in prior audit periods, and reflects continued improvement in the College's cash management and COD reporting controls.
Corrective Action Plan (CAP): The College has identified that the dates of Return of Title IV Calculations and amounts (in one case) were out of compliance. The return calculations for both students identified through this audit have been completed and corrected to reflect the correct return amounts...
Corrective Action Plan (CAP): The College has identified that the dates of Return of Title IV Calculations and amounts (in one case) were out of compliance. The return calculations for both students identified through this audit have been completed and corrected to reflect the correct return amounts, if appropriate. Student 1: Student initiated an official withdrawal on October 5, 2024, and the withdrawal was processed on that date. A notification of student status was not received in the financial aid office in order to trigger an R2T4 calculation. This student's calculation was performed at the end of the fall 2024 term with the end of term processing, resulting in 89 days passing from notification to completion of R2T4. This instance resulted in an automatic trigger being built into the student information system, which sends an email to the financial aid office for each student when their status changes from active to withdrawal. Student 2: Student initiated an official withdrawal on February 13, 2025, and the withdrawal was processed on that date. The R2T4 calculation was not performed on this student until the end of spring 2025 term processing, resulting in 96 days passing from notification to completion of R2T4. Due to delayed calculations on these students, CMN will continue to work with financial aid staff and the registrar's office to streamline communication on withdrawals and students who complete the term with all F/NP grades, as indicated in CMN policy. CMN has already worked with Anthology (student information system) to provide electronic triggers to the financial aid office when a student status changes from active to drop/withdrawal. Additionally, Enrollment Management notifies all faculty by email at the beginning of the term and again prior to final grades being submitted that electronic notification must be sent by the faculty to financial aid in order to alert the financial aid office of the date of last academic engagement for students who earn an For NP grade. For the current audit period, the Director of Enrollment Management and the Financial Aid Coordinator work together to review a final grade report for all students and identify those who need R2T4 calculations based on that review. Both the director and coordinator sign the working documents to indicate that it has been reviewed by both parties. We will continue with this process and will refine as necessary, but we anticipate that this will resolve the issue of calculations not having been performed on students with all F/NP grades at the end of the term.
Corrective Action Plan (CAP): The College has identified that the dates of enrollment submissions and status changes for the two students identified in the audit were out of compliance (92 days and 66 days). The statuses of both students are correct with NSLDS. Student 1: Student earned all F grades...
Corrective Action Plan (CAP): The College has identified that the dates of enrollment submissions and status changes for the two students identified in the audit were out of compliance (92 days and 66 days). The statuses of both students are correct with NSLDS. Student 1: Student earned all F grades during the fall 2024 trimester. The student's status was changed to withdrawal in the internal student information system on January 17, 2025. This change was not communicated to NSLDS until the March 2025 enrollment report, due to issues with the February 2025 enrollment report. Student 2: Student was a non-returner in the spring 2025 trimester. The student's status was changed to withdrawal in the internal student information system on January 21, 2025. This change was not communicated to NSLDS until the March 2025 enrollment report, due to issues with the February 2025 enrollment report. The College acknowledges this repeat finding and recognizes that, although the gap was narrowed days beyond tolerance, the prior corrective action plan did not fully resolve the underlying cause of late NSLDS reporting. The previous plan relied primarily on manual identification and status-change processes within the student information system, which remained vulnerable to human error and processing delays. To address this gap, the college will implement a secondary review checkpoint that flags students with status changes in the student information system to ensure timely transmission to NSLDS. To prevent additional recurrences, the College has implemented a monthly reconciliation procedure between the Registrar's Office and the Financial Aid Office, replacing the prior plan's reliance on manual status-chang communication alone. Each month, the Registrar's Office provides a student status change report to the Financial Aid Office. The Financial Aid Office then reconciles each status change against the institution's NSLDS submission history to confirm timely and accurate reporting. This added verification step, paired with documented recordkeeping of each reconciliation cycle, directly addresses the root cause of the repeat finding by introducing a cross-office check that does not depend solely on a single manual status update being correctly carried through to NSLDS reporting.
Management agrees with the finding and will implement additional review
Management agrees with the finding and will implement additional review
procedures to ensure tenant files are complete and rent calculations are
procedures to ensure tenant files are complete and rent calculations are
accurate. The Authority has new staff and will provide training to the staff
accurate. The Authority has new staff and will provide training to the staff
performing these duties.
performing these duties.
Special Test and Provisions-Monthly Board Financial Reporting and Budgetary Comparisons. Auditor’s Recommendation: We recommend that management establish formal procedures requiring the preparation and review of monthly budget-to-actual financial reports and ensure that accurate financial statements...
Special Test and Provisions-Monthly Board Financial Reporting and Budgetary Comparisons. Auditor’s Recommendation: We recommend that management establish formal procedures requiring the preparation and review of monthly budget-to-actual financial reports and ensure that accurate financial statements are presented to the Board of Directors on a regular basis. Documentation of financial reports presented, discussions held, and actions taken should be maintained in meeting records to demonstrate compliance with Head Start governance and financial oversight requirements. Organization’s Response: Management acknowledges the finding related to governance reporting requirements not being consistently presented to the Board during fiscal year 2025 in report form. The Board had more robust discussions regarding financial statements, concentrated around the time of drawdowns and the use of funds. Effective 2026, management will implement a structured monthly reporting process to ensure the Board and Finance Committee receive timely financial statements, budget-to-actual reports, grant expenditure reports, and other required compliance updates. Board meeting agendas will include financial oversight as a standing item, and meeting minutes document the Board’s review and acceptance. The Finance Director and CEO are responsible for monitoring compliance with this process to ensure the condition does not recur.
Special Test and Provisions-Monthly Board Financial Reporting and Budgetary Comparisons. Auditor’s Recommendation: We recommend that management establish formal procedures requiring the preparation and review of monthly budget-to-actual financial reports and ensure that accurate financial statements...
Special Test and Provisions-Monthly Board Financial Reporting and Budgetary Comparisons. Auditor’s Recommendation: We recommend that management establish formal procedures requiring the preparation and review of monthly budget-to-actual financial reports and ensure that accurate financial statements are presented to the Board of Directors on a regular basis. Documentation of financial reports presented, discussions held, and actions taken should be maintained in meeting records to demonstrate compliance with Head Start governance and financial oversight requirements. Organization’s Response: Management acknowledges the finding related to governance reporting requirements not being consistently presented to the Board during fiscal year 2025 in report form. The Board had more robust discussions regarding financial statements, concentrated around the time of drawdowns and the use of funds. Effective 2026, management will implement a structured monthly reporting process to ensure the Board and Finance Committee receive timely financial statements, budget-to-actual reports, grant expenditure reports, and other required compliance updates. Board meeting agendas will include financial oversight as a standing item, and meeting minutes document the Board’s review and acceptance. The Finance Director and CEO are responsible for monitoring compliance with this process to ensure the condition does not recur.
ELIGIBILITY VERIFICATIONS – GRANTS TO STATES FOR MEDICAID PROGRAM Recommendation: It is recommended that the County increase review over casefiles and ensure verifications are sent out when necessary. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Ac...
ELIGIBILITY VERIFICATIONS – GRANTS TO STATES FOR MEDICAID PROGRAM Recommendation: It is recommended that the County increase review over casefiles and ensure verifications are sent out when necessary. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will remind staff to perform reviews and to ensure that verifications are sent out when necessary. Name of the contact person responsible for corrective action plan: Kayla Matter, HHS Deputy Director Planned completion date for corrective action plan: December 31, 2026
Staff will closely monitor all expenditures for a grant paid in future fiscal years and will record them properly on the Statement of Expenditures of Federal Awards
Staff will closely monitor all expenditures for a grant paid in future fiscal years and will record them properly on the Statement of Expenditures of Federal Awards
Staff that oversaw keeping the documentation for the grants was on vacation. In the future documentation will be kept by the departments awarded the grants.
Staff that oversaw keeping the documentation for the grants was on vacation. In the future documentation will be kept by the departments awarded the grants.
Finding 1221287 (2025-004)
Material Weakness 2025
Eligibility Determination Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Grants to States for Medicaid (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award Identification Numbers and Year: 2505MN5MAP and 2505MN5ADM, 2025 Pass-Through Agency: Minnesot...
Eligibility Determination Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Grants to States for Medicaid (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award Identification Numbers and Year: 2505MN5MAP and 2505MN5ADM, 2025 Pass-Through Agency: Minnesota Department of Human Services Pass-Through Numbers: 2505MN5MAP and 2505MN5ADM Compliance Requirement Affected: Eligibility Award Period: Year-Ended December 31, 2025 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Recommendation: It is recommended the County implement procedures to ensure the citizenship, asset, and income verification documentation in the casefiles be retained and that it matches the METS eligibility system. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will review procedures and show staff proper documentation and entry into METS and staff will be reminded to perform reviews. Name of the contact person responsible for corrective action plan: Loni Swenson, Finance Director Planned completion date for corrective action plan: December 31, 2026
We have implemented a plan for proper training to make sure everyone is aware of HUD rules regarding family eligibility. We will complete a quarterly audit of randomly selected files to ensure we are adhering to HUD rules. We will ensure staff monitors eligibility for each resident within the requir...
We have implemented a plan for proper training to make sure everyone is aware of HUD rules regarding family eligibility. We will complete a quarterly audit of randomly selected files to ensure we are adhering to HUD rules. We will ensure staff monitors eligibility for each resident within the required time frame.
In order to keep cash as accurate as possible, we will work to clear interfund as often as possible. With upcoming development revenue that we will see come in over the next 1-2 years on the non profit side, we will work to prioritize returning funds to the Public Housing Operating Funds. To prevent...
In order to keep cash as accurate as possible, we will work to clear interfund as often as possible. With upcoming development revenue that we will see come in over the next 1-2 years on the non profit side, we will work to prioritize returning funds to the Public Housing Operating Funds. To prevent co-mingling of cash, we will begin a plan to break apart the funds for each program - Spencer, COCC, 3rd and 11th. Each quarter, we access payroll allocations to better reflect employees’ use of time and actual costs incurred by program and by LITC property. Public Housing and COCC training is planned that all finance staff will attend to make sure proper HUD procedures, rules, and guidelines are followed. The plan is to reduce the receivable down to $-0- as soon as possible and within 5 years.
MCR has established a procedure to require a completed application with signature and supporting documentation in order to qualify for a sliding fee scale. Any incomplete applications or those with incomes greater than 200% of the poverty level will only result in consideration for courtesy discount...
MCR has established a procedure to require a completed application with signature and supporting documentation in order to qualify for a sliding fee scale. Any incomplete applications or those with incomes greater than 200% of the poverty level will only result in consideration for courtesy discount. Financial counselors have 7 business days from the return of a patient application to determine completeness and eligibity for sliding fee scale. The Chief Financial Officer, Kara Onorato, will be responsible for ensuring that this process is followed. The new policy was approved by the board of Directors in December 2025. The new process is being implemented in 2026. Internal audit began monthly audits and corrective training in February 2026 with target goal by Q3 2026.
Corrective Action Plan: Management concurs with the findings. Sheltering Arms has strengthened controls to ensure that all Head Start/ Early Head Start charges are adequately documented, properly approved, and reviewed for compliance with allowable cost requirements. The Organization has implemented...
Corrective Action Plan: Management concurs with the findings. Sheltering Arms has strengthened controls to ensure that all Head Start/ Early Head Start charges are adequately documented, properly approved, and reviewed for compliance with allowable cost requirements. The Organization has implemented processes requiring documented approval for Head Start/Early Head Start charges. Required support includes invoices or payroll documentation, allocation support when applicable, evidence of allowability, and documented supervisory approval. Finance will verify that required support is complete before costs are charged to the program. Periodic internal monitoring procedures are currently being performed to review Head Start/ Early Head Start expenditures for documentation sufficiency, evidence of approval, and compliance with allowable cost principles. Any deficiencies identified will be corrected timely, and recurring issues will be addressed through staff training or process improvements. Management will review the questioned costs identified in the audit and determine the appropriate corrective action, including obtaining additional supporting documentation or reclassifying costs, as needed. Responsible Party: Chief Financial Officer, with support from the Finance Team and Head Start Program Leadership. Anticipated Completion Date: Updated processes have been implemented and are currently in operation to mitigate the risk of future findings. Monitoring Plan: Management will perform quarterly reviews of Head Start/ Early Head Start expenditures. Results will be reviewed with the CFO and Program Leadership, and any corrective actions will be documented and tracked through resolution.
Corrective Action Plan: Management concurs with the findings. Sheltering Arms has strengthened its grant accounting, financial close and reporting controls to ensure that grant revenue, receivables, expenses, refundable advances and SEFA amounts are recorded accurately and in the appropriate reporti...
Corrective Action Plan: Management concurs with the findings. Sheltering Arms has strengthened its grant accounting, financial close and reporting controls to ensure that grant revenue, receivables, expenses, refundable advances and SEFA amounts are recorded accurately and in the appropriate reporting period. During fiscal year 2025, the Finance department experienced significant personnel changes. New management performed a transaction review to determine whether transactions were properly allocated and recorded. During this review, several transactions totaling $741,113 were identified as having been allocated to the incorrect fiscal period. In addition, the $357,774 liability resulted from an adjustment made by a contractor in March 2025 that incorrectly allocated CACFP revenues and related expenses to fiscal year 2024. Responsible Party: Chief Financial Officer, with support from the Finance Team. Anticipated Completion Date: Updated processes have been implemented and are currently in operation to mitigate the risk of future findings. Monitoring Plan: Management will perform monthly reviews of grant reconciliations, cost transfers, and significant grant-related journal entries to ensure transactions are recorded accurately, supported by appropriate documentation, and recognized in the proper reporting period.
Corrective Action Plan – Single Audit Finding Entity Name: Brocton Housing Development Company, Inc. Audit Period: For the year Ended September 30, 2025 Finding Reference Number: 14.157 Federal Program: Supportive Housing for the Elderly (Section 202) 1. Audit Finding Summary Describe the audit find...
Corrective Action Plan – Single Audit Finding Entity Name: Brocton Housing Development Company, Inc. Audit Period: For the year Ended September 30, 2025 Finding Reference Number: 14.157 Federal Program: Supportive Housing for the Elderly (Section 202) 1. Audit Finding Summary Describe the audit finding and the specific noncompliance identified by the auditor. In accordance with 24 CFR 891.400(e), a separate interest-bearing project fund account shall be maintained in a depository or depositories which are members of the Federal Deposit Insurance Corporation or National Credit Union Share Insurance Fund and all tenant payments, charges, income and revenues arising from project operation or ownership shall be deposited to this account. 2. Root Cause Explain the underlying reasons for the finding, such as process gaps, training issues, or lack of controls. Subsequent to the initial rental assistance contract, changes to HUD regulations resulted in the requirement that the project fund account be an interest-bearing account. This change was an oversight by the Company's management. 3. Corrective Actions Action Item: Use an interest-bearing account for project funds Responsible Person: Chief Financial Officer Completion Date: TBD Status: In process 4. Monitoring Plan Describe how the implementation of corrective actions will be monitored and evaluated. Management inquired with the bank and deemed the cost outweighs the benefit due to the fees charged for an interest bearing account exceeding the interest that would be earned. 5. Contact Information Name: Aaron Hejmowski Title: Chief Financial Officer Phone: 716-884-7791 Email: ahejmowski@belmonthousingwny.org
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