Corrective Action Plans

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Title X – Assistance Listing No. 93.217 Recommendation: We recommend management review its patient intake process to ensure income and household size is properly verified, the control is adequately documented and retained in accordance with organizational policies and program requirements. Explanati...
Title X – Assistance Listing No. 93.217 Recommendation: We recommend management review its patient intake process to ensure income and household size is properly verified, the control is adequately documented and retained in accordance with organizational policies and program requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: With our recent transition from NextGen to Epic, PPNCS is establishing a new process to ensure patient income and household size are accurately identified and documented in our medical records system. With the enhanced functionalities available in Epic, patients now have the ability to pre-register for appointments via e-Check In. This eliminates reliance on the formerly manual process of patients documenting their income and household size on the registration form (B209) which staff would then enter into the medical records system. In addition, PPNCS will continue to perform internal audits, ensuring that the information provided via e-Check In is accurately reflected in the medical records system. PPNCS’s Standard Operating Procedure will be updated to reflect these changes by July 1, 2026. Name of the contact person responsible for corrective action: Randy Drager, CFO Planned completion date for corrective action plan: July 1, 2026
Title X – Assistance Listing No. 93.217 Recommendation: We recommend management review the FFR instructions and develop procedures to ensure the required reporting submitted to the funder is complete and accurate. Additionally, systems should be put in place to both track and report its progress on ...
Title X – Assistance Listing No. 93.217 Recommendation: We recommend management review the FFR instructions and develop procedures to ensure the required reporting submitted to the funder is complete and accurate. Additionally, systems should be put in place to both track and report its progress on the non-federal share requirement and any program income. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PPNCS has initiated a review process to ensure the reporting is complete and accurate per the Federal Financial Report Instructions prior to submission. Name of the contact person responsible for corrective action: Randy Drager, CFO Planned completion date for corrective action plan: July 1, 2026
2025-001 – Eligibility Federal Agency: U.S. Department of Housing and Urban Development Federal Program: Section 8 Project-Based Cluster Responsible Official: Ernestine Carter, President Plan Detail: Management will strengthen procedures over tenant documents and income calculations. Corrective acti...
2025-001 – Eligibility Federal Agency: U.S. Department of Housing and Urban Development Federal Program: Section 8 Project-Based Cluster Responsible Official: Ernestine Carter, President Plan Detail: Management will strengthen procedures over tenant documents and income calculations. Corrective actions will include retraining property management staff on HUD income determination and verification requirements and implementing a supervisory review process to verify income calculations prior to tenant eligibility approval.
Finding Number: 2025-001 Condition: The City did not have established written cash management procedures for processing of federal payments. Planned Corrective Action: Develop and implement written Cash Managament Procedure for processing federal payments Contact person responsible for corrective ac...
Finding Number: 2025-001 Condition: The City did not have established written cash management procedures for processing of federal payments. Planned Corrective Action: Develop and implement written Cash Managament Procedure for processing federal payments Contact person responsible for corrective action: Benjamin Grier Anticipated Completion Date: 05/22/2026
Finding 2025-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 New Construction and Substantial Rehabilitation Federal Assistance Listing Numbers: 14.182 Noncompliance – E. Eligibility Non Compliance Material to the Financial Statements: No Signif...
Finding 2025-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 New Construction and Substantial Rehabilitation Federal Assistance Listing Numbers: 14.182 Noncompliance – E. Eligibility Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance for Eligibility Federal Award Findings and Questioned Costs (continued) Finding 2025-001 (continued) Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family members to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). These files are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority’s files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Context: There are approximately four hundred fifteen (415) Section 8 New Construction units. Of a sample size of sixteen (16) tenant files, declaration of citizenship forms were missing in six (6) files. Our sample size is statistically valid. Known Questioned Costs: Unknown Cause: There is a significant deficiency in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that reasonably assures the program is in compliance. Effect: The Section 8 New Construction and Substantial Rehabilitation Program is in non-compliance with the eligibility type of compliance related to the maintenance of tenant files. Recommendation: We recommend the Authority strengthen internal controls over eligibility compliance by implementing formal procedures to ensure all required tenant eligibility documentation is obtained, reviewed, retained, and readily available for examination. Management should also perform periodic internal reviews of tenant files to confirm completeness and compliance with HUD requirements. These procedures will reasonably assure compliance with the Uniform Guidance and the compliance supplement. Authority Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will improve the maintenance and monitoring of tenant eligibility documentation in the Section 8 New Construction and Substantial Rehabilitation Program to ensure that established internal control policies are being followed on a timely basis. Management’s corrective action plan will include enhanced file review procedures and staff training. Donald Grondahl, Executive Director, is responsible for implementing this corrective action by December 31, 2026.
According to 24 CFR 982.503(d) (3), "A PHA may establish exception payment standard amounts between 110 percent and 120 percent of the applicable FMR for such duration as HUD specifies by notice upon notification to HUD that the PHA meets at least one of the following criteria: (i) Fewer than 75 per...
According to 24 CFR 982.503(d) (3), "A PHA may establish exception payment standard amounts between 110 percent and 120 percent of the applicable FMR for such duration as HUD specifies by notice upon notification to HUD that the PHA meets at least one of the following criteria: (i) Fewer than 75 percent of the families to whom the PHA issued tenant‐based rental vouchers during the most recent 12‐month period for which there is success rate data available have become participants in the voucher program; (ii) More than 40 percent of families with tenant‐based rental assistance administered by the agency pay more than 30 percent of adjusted income as the family share; or (iii) Such other criteria as the Secretary establishes by notice." Additionally, The PHA must determine that the rent to the owner is reasonable at the time of initial leasing. Also, the PHA must determine reasonable rent during the term of the contract (a) before any increase in the rent to owner, and (b) at the HAP contract anniversary if there is a 10 percent decrease in the published Fair Market Rent in effect 60 days before the HAP contract anniversary. The PHA must maintain records to document the basis for the determination that rent to owner is a reasonable rent (initially and during the term of the HAP contract) (24 CFR sections 982.4, 982.54(d)(15), 982.158(f)(7), and 982.507). For 2023, the Authority was approved by HUD to use 120% FMRs. During the audit, we found that the Authority's approved payment standards for 2024 continued to use 120% of the HUD's FMR standard. They were using this without continued approval from HUD. During the audit, the auditor selected 40 tenants to test for eligibility and special tests. Out of the 40, 13 tenants on the 50058 used the 120% payment standard. Management continued to use the 120% threshold after the HUD approval had expired. The Authority did not get required approval to continue beyond 2023 to use the 120% FMR threshold. The Authority used incorrect FMR's to approve payments for HAP. This resulted in more HAP expense and revenue because tenants were housed in housing over the hUD approved 120% FMR rate. The Auditor recommends the Auhtority return to the 110% threshold approved by HUD.
Audit Finding 2025-002 in the area of Reporting An Authority official has been designated to develop and implement standardized processes and record-keeping procedures to ensure that all relevant divisions are informed of grant applications, award terms and conditions, financial responsibilities, an...
Audit Finding 2025-002 in the area of Reporting An Authority official has been designated to develop and implement standardized processes and record-keeping procedures to ensure that all relevant divisions are informed of grant applications, award terms and conditions, financial responsibilities, and reporting requirements. The Finance Division will continue to provide monthly expenditure reports to assigned grant personnel to support ongoing monitoring, reconciliation, and timely reporting. In addition, a supervisory review will be conducted by the Controller, Assistant Chief Financial Officer, or Chief Financial Officer to verify the completeness, accuracy, and compliance of all submitted financial and programmatic reports. Furthermore, relevant personnel will be notified of and encouraged to participate in grants management training to enhance their understanding of reporting requirements, internal controls, and compliance obligations.
Audit Finding 2025-001 in the area of Procurement and Suspension and Debarment The Authority will implement procedures to verify that all parties in covered transactions are not suspended, debarred, or otherwise excluded from federal programs. The verification results will be retained as part of bot...
Audit Finding 2025-001 in the area of Procurement and Suspension and Debarment The Authority will implement procedures to verify that all parties in covered transactions are not suspended, debarred, or otherwise excluded from federal programs. The verification results will be retained as part of both the grant and procurement files.
Planned Corrective Action: The District is in the process of reviewing procedures for construction services and will ensure that the future use of Federal funds for these projects meet contracting and payment requirements. Anticipated Completion Date: July 1, 2026 Marleni Bruner, Sylvia Jackson, Bre...
Planned Corrective Action: The District is in the process of reviewing procedures for construction services and will ensure that the future use of Federal funds for these projects meet contracting and payment requirements. Anticipated Completion Date: July 1, 2026 Marleni Bruner, Sylvia Jackson, Brenton Hudson
Finding Number: 2025-001 Recommendation: Inform subrecipients of the required federal award info outlined in § 200.332 Requirements for pass-through entities. Action Taken: 1. Corrective Action was put into place in July of 2025 with the following changes. 2. In FY2025, AANA posted on its MAST websi...
Finding Number: 2025-001 Recommendation: Inform subrecipients of the required federal award info outlined in § 200.332 Requirements for pass-through entities. Action Taken: 1. Corrective Action was put into place in July of 2025 with the following changes. 2. In FY2025, AANA posted on its MAST website and application that: “The MAST program is funded by the United States Federal Government and is subject to all applicable federal statutes, regulations, and requirements. The receiving entity is not debarred, suspended, or otherwise excluded from using federal funds.” 3. AANA has included the following as a footnote on any MAST manuscripts and printed text: “Supported by a grant administered by The Arthroscopy Association of North America (AANA), with funding provided by the Military Advanced Surgical Treatment (MAST) Program.” 4. We are requesting the following information through the contracting process with any MAST Subrecipient: a. Subrecipient's name (must match the name associated with its unique entity identifier) b. Subrecipient's unique entity identifier c. Subaward Period of Performance Start and End Date d. Subaward Budget Period Start and End Date e. Amount of Federal Funds Obligated in the subaward f. Total Amount of Federal Funds Obligated to the subrecipient by the pass-through entity, including the current financial obligation g. Total Amount of the Federal Award committed to the subrecipient by the pass-through entity h. Federal award project description, as required by the Federal Funding Accountability and Transparency Act (FFATA) i. Identification of whether the Federal award is for research and development j. Indirect cost rate for the Federal award (including if the de minimis rate is used in accordance with § 200.414) i. An approved indirect cost rate negotiated between the subrecipient and the Federal Government. If no approved rate exists, a pass-through entity must determine the appropriate rate in collaboration with the subrecipient. The indirect cost rate may be either: 1. An indirect cost rate negotiated between the pass-through entity and the subrecipient. These rates may be based on a prior negotiated rate between a different pass-through entity and the subrecipient, in which case the passthrough entity is not required to collect information justifying the rate but may elect to do so; or 2. The de minimis indirect cost rate. k. A requirement that the subrecipient permit the pass-through entity and auditors to access the subrecipient's records and financial statements for the pass-through entity to fulfill its monitoring requirements l. Verify that a subrecipient is audited as required m. This corrective action went into effect in July 2025, as a result of the timing, the condition resulting in the corrective action continued to exist in part of the period under audit. Responsible Contact Person for Planned Corrective Action: Dennis Siena Actual Completion Date: July 1, 2025
FINDINGS—FEDERAL AWARD PROGRAMS AUDIT U.S. Department of Environmental Protection Agency 2025-003 Suspension and Debarment – Assistance Listing Number 66.468 Recommendation: We recommend the Village evaluate its existing policies and procedures to determine where additional enhancements should be ma...
FINDINGS—FEDERAL AWARD PROGRAMS AUDIT U.S. Department of Environmental Protection Agency 2025-003 Suspension and Debarment – Assistance Listing Number 66.468 Recommendation: We recommend the Village evaluate its existing policies and procedures to determine where additional enhancements should be made or new policies created. Explanation of disagreement with audit finding: There is no disagreement with the finding. Action planned in response to finding: The Village is reviewing its policy related to suspension and debarment and is reviewing procedures to ensure that requirements are consistently followed in future years. Name(s) of the contact person(s) responsible for corrective action: Ryan VanDeWalle, Village Administrator and Melanie Wiskow, Finance Director/Treasurer Planned completion date for corrective action plan: The Village is evaluating procedures and will implement as soon as possible. If the granting agencies have questions regarding this schedule, please call Ryan VanDeWalle, Village Administrator at (715) 359-3660.
Management's View and Corrective Action Plan Audit Finding for the Year Ended December 31, 2025 2025-001 – Schedule of Expenditures of Federal Awards Reporting Significant Deficiency - Community Development Block Grant Cluster Entitlement/Special Purpose Grants Response Management agrees that the Co...
Management's View and Corrective Action Plan Audit Finding for the Year Ended December 31, 2025 2025-001 – Schedule of Expenditures of Federal Awards Reporting Significant Deficiency - Community Development Block Grant Cluster Entitlement/Special Purpose Grants Response Management agrees that the Community Development Block Grant Cluster Entitlement/Special Grant was not identified in the system as federally funded at the time of grant set up in 2024. During the preparation of the prior year Schedule of Expenditures of Federal Awards (“Federal Schedule”), this award was omitted from the Federal Schedule since it was not identified as a federal grant within the grant listings. Management has implemented the following improvements: • Management will confirm federal grants with all government agencies the Association has received grants from each calendar year end • Retrain staff on identification of federal grants • Institute appropriate review procedures of the Federal Schedule Completion date: March 31, 2026 Responsible person contact name: Heather Livernois, Vice President, Finance/Chief Accounting Officer
The Charter School will require the Food Service
The Charter School will require the Food Service
Management Company (FSMC) to provide a current SOC 1 Type II Report in accordance with the bid and contract requirements. Written notification will be sent to the FSMC requesting the report within a specified timeframe.
Management Company (FSMC) to provide a current SOC 1 Type II Report in accordance with the bid and contract requirements. Written notification will be sent to the FSMC requesting the report within a specified timeframe.
Dear Katelyn, Please see below the Corrective Action Plan, number referenced above: New Tenant: 1. Gather intake information 2. Identify apartment close to the Fair Market Value that tenant seeks to sign a lease with. 3. . Gather information about that apartment, enter into the Affordable Housing .c...
Dear Katelyn, Please see below the Corrective Action Plan, number referenced above: New Tenant: 1. Gather intake information 2. Identify apartment close to the Fair Market Value that tenant seeks to sign a lease with. 3. . Gather information about that apartment, enter into the Affordable Housing .com form. 4. Submit the form to Affordable Housing.com. 5. Affordable Housing returns the results to us, showing comparable properties in the area. This form indicates whether the rent is or is not reasonable based on the prevailing market conditions. 6. If the rent is both Reasonable and within the Fair Market Value guidelines, approve the lease. Existing Tenant: 1. Rent reasonableness forms have been added to every chart. 2. Any time there is a change in the rent due, we gather the information again and re-submit it to Affordable Housing for a new comparable analysis. 3. Quarterly review will be done to verify all rents are correct and Rent Reasonableness has been done if warranted. Responsible Staff 1. Patricia Skinner, Assistant Director of Housing and Care Coordination 2. John Lent, Director of Corporate Compliance Expected Date of Correction: already in place
Finding 2025-002 Corrective Action Plan: GWA has updated the federally funded fixed asset register to include the omitted assets and has implemented additional procedures to strengthen compliance with 2 CFR § 200.3 13(d). Corrective actions include the following: 1. Finance personnel will review cap...
Finding 2025-002 Corrective Action Plan: GWA has updated the federally funded fixed asset register to include the omitted assets and has implemented additional procedures to strengthen compliance with 2 CFR § 200.3 13(d). Corrective actions include the following: 1. Finance personnel will review capital asset additions to identify federally funded assets and ensure the appropriate federally funded asset code is assigned when recorded in the Authority’s main fixed asset register. 2. Federally funded assets will be recorded in the federally funded fixed asset register and periodically reconciled to related procurement and capital expenditures records to ensure completeness and accuracy. 3. A supervisory review process has been enhanced to verify that federally funded asset codes are properly assigned prior to posting and that federally funded assets are accurately reflected in the federally funded fixed asset register. Additionally, at the general ledger level, fund source identifiers will be incorporated into the asset close-out journal entry process to furtlier strengthen visibility and review of federally funded asset activity. 4. Finance personnel responsible for asset recording will be briefed on federal property management requirements and revised internal procedures related to federally funded asset coding, tracking and reporting. GWA believes these corrective measures adequately address the control gap identified in the finding and will ensure compliance with 2 CFR § 200.3 13(d) on a prospective basis. Expected completion date: September 30, 2026 Point of contact for Follow-Up: Bryan Iriarte, Accountant III Josephine Sanalila, Accountant III Sandra Santos, Controller
Finding 2025-001 Corrective Action Plan: Management will complete the retrospective review of appliable federally funded procurements to ensure required suspension and debarment verifications are documented and retained in the procurement files. In addition, Procurement supervisory personnel will im...
Finding 2025-001 Corrective Action Plan: Management will complete the retrospective review of appliable federally funded procurements to ensure required suspension and debarment verifications are documented and retained in the procurement files. In addition, Procurement supervisory personnel will implement periodic compliance reviews to verify that required SAM.gov verifications are completed, documented and maintained prior to contract execution. Additionally, the Internal Audit team will conduct random reviews of federally funded procurement files to ensure compliance with the SOPs and to verify that proper documentation is maintained. Expected completion date: September 30, 2026 Point of contact for Follow-Up: Diana Hayashi, Buyer Supervisor II Rita Aquiningoc, Program Coordinator III Janet Taitano-Arroyo, Internal Auditor
Corrective Action: The City acknowledges that HUD Cash on Hand reports were not submitted within the required deadline and that FFATA reports were not submitted. The Finance Department had various vacancies during Fiscal Year 2025 which caused resource constraints and caused required reporting to be...
Corrective Action: The City acknowledges that HUD Cash on Hand reports were not submitted within the required deadline and that FFATA reports were not submitted. The Finance Department had various vacancies during Fiscal Year 2025 which caused resource constraints and caused required reporting to be submitted late. Finance also experienced a loss of key staff that would have completed FFATA reporting requirements, current staff were not aware of this reporting requirement. The Finance Department will work on correcting reporting issues related to grant reporting that were mentioned in the finding. Finance department was notified of the required FFATA reporting during audit process. The Finance staff will review the required FFATA reporting and will create a tracking mechanism to ensure proper subrecipient awards are reported in a timely manner when awarded. Finance will also create a tracking mechanism for quarterly HUD Cash on Hand reports to ensure the reporting is completed by the required HUD deadline. Proposed Completion Date: Partially during Fiscal Year ending June 30, 2026, and full correction for Fiscal Year ending June 30, 2027. For any questions regarding Corrective Action Plan, please contact Scott Williams, Director of Finance or Janet Franco, Deputy Director of Finance.
Management agrees controls over dual counts of program income should be complied with and will follow up with centers that do not comply with controls.
Management agrees controls over dual counts of program income should be complied with and will follow up with centers that do not comply with controls.
Management agrees controls over cash disbursements should be complied with and will be more meticulous in maintaining documentation that approval be granted before payment is made.
Management agrees controls over cash disbursements should be complied with and will be more meticulous in maintaining documentation that approval be granted before payment is made.
Management will implement a formal reporting calendar or tracking mechanism to monitor and ensure timely submission of all interim and annual fiscal year-end financial reports required under applicable grant agreements. Procedures will include designated responsibility for report submission and rete...
Management will implement a formal reporting calendar or tracking mechanism to monitor and ensure timely submission of all interim and annual fiscal year-end financial reports required under applicable grant agreements. Procedures will include designated responsibility for report submission and retention of supporting documentation evidencing the date of submission for all future reporting periods.
Management will implement reconciliation procedures to ensure that payroll allocations recorded to federal award programs are supported by and agree to actual time records prior to recording journal entries to the general ledger. A supervisory review process will be established to periodically compa...
Management will implement reconciliation procedures to ensure that payroll allocations recorded to federal award programs are supported by and agree to actual time records prior to recording journal entries to the general ledger. A supervisory review process will be established to periodically compare time card data against payroll journal entries to identify and resolve discrepancies on a timely basis.
Management will continue to strengthen year-end and subsequent review procedures over invoices and employee reimbursements to ensure expenditures are recorded in the appropriate reporting period and within the applicable grant period. Additional controls will be implemented to monitor submission dea...
Management will continue to strengthen year-end and subsequent review procedures over invoices and employee reimbursements to ensure expenditures are recorded in the appropriate reporting period and within the applicable grant period. Additional controls will be implemented to monitor submission deadlines for employee reimbursement requests to prevent recording expenditures in periods other than those in which the related costs were incurred.
a. Administrator: V.P. Finance/ CFO ................... Victor Parker 601-857-3961 b. Administrator: V.P. Student Services ....... Jennifer Scott-Gilmore 601-857-3250 Student Financial Assistance Cluster: The District did not properly calculate the total amount disbursed or to be disbursed which lea...
a. Administrator: V.P. Finance/ CFO ................... Victor Parker 601-857-3961 b. Administrator: V.P. Student Services ....... Jennifer Scott-Gilmore 601-857-3250 Student Financial Assistance Cluster: The District did not properly calculate the total amount disbursed or to be disbursed which lead to incorrect calculation of funds to be returned to Title IV. Additionally, the District did not provide evidence of date of determination used in calculation. Corrective Action Plan: The District is an attendance taking institutional and has reviewed its internal controls on how total days in the semester are calculated correctly and timely disbursements are made. The District understands that it should be using the Last Day of Attendance in the calculation of earned aid and made that modification Spring 2025 in collaboration with the U.S. Department of Education and outlined the calculation variables to align with that calculation change. Management has revised its Policy and Procedures accordingly and was submitted to the Hinds Board of Trustees for final approval December of 2025. The correction implementation date was June 2025 and finalized December 2025. With the corrected action initially taking place June 2025, this will be a continuation into this FY2025 audit. The correction implementation date was June 2025 and finalized December 2025. With the corrected action initially taking place June 2025, this will be a continuation into this FY2025 audit.
a. Administrator: V.P. Finance/ CFO ................... Victor Parker 601-857-3961 b. Administrator: V.P. Student Services ....... Jennifer Scott-Gilmore 601-857-3250 Student Financial Assistance Cluster: The District did not report timely and accurate student status information to the National Stud...
a. Administrator: V.P. Finance/ CFO ................... Victor Parker 601-857-3961 b. Administrator: V.P. Student Services ....... Jennifer Scott-Gilmore 601-857-3250 Student Financial Assistance Cluster: The District did not report timely and accurate student status information to the National Student Loan Data System (NSLDS). The District did not ensure internal controls were in place to ensure timely and accurate reporting. Corrective Action Planned: The Management has implemented additional organizational and internal controls to ensure students' enrollment statuses are reported timely and accurately. In reviewing the causation of the finding, it was determined that it was a personnel error and as of June 2024, there is a new Registrar for Hinds Community College charged with compliance of this requirement. During the AY2024-25, the Registrar worked within the new student information system (SIS) to generate the required student data on a monthly cycle to be submitted to the National Clearinghouse which is then transmitted to NSLDS. This update in internal controls should satisfy future reviews. The correction date was July 2024. With the corrected action taking place July 2024, this will be a continuation into this FY2025 audit.
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