Corrective Action Plans

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2. 2025-02 i. Comments on Finding: During the year ended December 31, 2025, HUD replacement reserve loans were not repaid in a timely manner, and monthly replacement reserve deposits were not funded consistently. ii. Actions Taken or Planned: In January 2026, the client received the retroactive subs...
2. 2025-02 i. Comments on Finding: During the year ended December 31, 2025, HUD replacement reserve loans were not repaid in a timely manner, and monthly replacement reserve deposits were not funded consistently. ii. Actions Taken or Planned: In January 2026, the client received the retroactive subsidy from HUD in the amount of $114,299, which was deposited into the operating account, and subsequently made the October 2025 deposit on January 21, 2026. Responsible Person: Denise Crowder Anticipated Completion Date: 12/31/2026 Steps to Implement: Management will review and strengthen policies and procedures related to the repayment of HUD loans and the timely funding of replacement reserve deposits.
Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Control over Compliance (Procurement, Suspension and Debarment). Program. Coronavirus State and Local Fiscal Recovery Funds (SLFRF); U.S. Department of Treasury; Assistance Listing Number 21.027. Auditor Description of Conditi...
Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Control over Compliance (Procurement, Suspension and Debarment). Program. Coronavirus State and Local Fiscal Recovery Funds (SLFRF); U.S. Department of Treasury; Assistance Listing Number 21.027. Auditor Description of Condition and Effect: The Authority was unable to provide documentation supporting its consideration of suspension and debarment requirements for one of the nine vendors selected for testing. In addition, we noted a formal request for proposals (RFP) was not issued despite the procurement exceeding the Authority’s established threshold. As a result, no bid tabulation or supporting documentation of the procurement process was available. Auditor Recommendation: We recommend that the Authority strengthen internal controls over procurement and suspension and debarment compliance by (1) Implementing procedures to document verification of vendor eligibility (e.g., SAM.gov search results or signed certifications) at the time of contract award and retaining this documentation within the procurement file; (2) Ensuring that all procurements exceeding established thresholds are subject to formal bidding procedures in accordance with both Uniform Guidance and the Authority’s procurement policy; (3) Enhancing monitoring controls to ensure that procurement documentation is complete, consistently prepared, and properly retained in accordance with federal requirements. conducted for all applicable projects in accordance with federal procurement requirements. Corrective Action: The Authority will insure that Sam.gov Debarment is reviewed for all contractors prior to the awarding of a contract. It will be included on our project documentation check list and proof of the review will be included in both the vendor’s and property’s permanent files.The RFP audited project was a unique case and we believed we had followed all required procedures but realize some steps were missed. The Authority will follow all procedures and thresholds in accordance with the Authority’s procurement policies. Documentation will be consistently processed and included in all permanent files and folders.
Management concurs with the recommendation and will review the policies and procedures surrounding sliding fee write-offs. In addition, management plans to implement changes to the system where write-offs are automatically calculated and applied. Management plans on providing additional training to ...
Management concurs with the recommendation and will review the policies and procedures surrounding sliding fee write-offs. In addition, management plans to implement changes to the system where write-offs are automatically calculated and applied. Management plans on providing additional training to staff and performing periodic reviews of sliding fee write-offs to ensure compliance with the policies and procedures.
2025-001 Finding – Internal controls over compliance Comments on findings and recommendations Management agrees with the finding and recommendation. Actions taken or planned The organization plans to enhance its procedures for income verification by requiring that all excluded income amounts, includ...
2025-001 Finding – Internal controls over compliance Comments on findings and recommendations Management agrees with the finding and recommendation. Actions taken or planned The organization plans to enhance its procedures for income verification by requiring that all excluded income amounts, including loans, be supported by appropriate third-party documentation and retained in the tenant file. Anticipated completion date September 30, 2026
Corrective Action Plan: The organization has implemented targeted training, revised patient intake forms to include standardized income calculations, and established monthly audits for 2026 to ensure compliance with Sliding Fee Discount Program requirements. Clinics identified with a 10% or greater ...
Corrective Action Plan: The organization has implemented targeted training, revised patient intake forms to include standardized income calculations, and established monthly audits for 2026 to ensure compliance with Sliding Fee Discount Program requirements. Clinics identified with a 10% or greater error rate are receiving focused retraining and ongoing monitoring, with audit results shared with leadership to promote accountability. Two mandatory training sessions for CARs, AR staff, and administrators are being conducted to reinforce consistent and compliant program implementation. Persons Responsible: Steven Hansen, President & CEO; Pearl Lujan, Central Billing Office Director Estimated Completion Date: December 31, 2026
Management concurs and subsequent to year-end the Organization notified HUD of the additional indebtedness and repaid the outstanding balance.
Management concurs and subsequent to year-end the Organization notified HUD of the additional indebtedness and repaid the outstanding balance.
Management concurs and subsequent to year-end the Organization notified HUD of the additional indebtedness and repaid the outstanding balance.
Management concurs and subsequent to year-end the Organization notified HUD of the additional indebtedness and repaid the outstanding balance.
Management agreed with the recommendation and the Organization will enhance its controls and procedures to ensure all journal entries are made accurately and timely.
Management agreed with the recommendation and the Organization will enhance its controls and procedures to ensure all journal entries are made accurately and timely.
April 1, 2026 U.S. Department of Justice Green River Regional Rape Vicitm’s Services, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2025. Name and address of independent public accounting firm: Alexander & Company CPAs PSC 2707 Breckenridge St., Suite 1 O...
April 1, 2026 U.S. Department of Justice Green River Regional Rape Vicitm’s Services, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2025. Name and address of independent public accounting firm: Alexander & Company CPAs PSC 2707 Breckenridge St., Suite 1 Owensboro, Kentucky Audit period: Fiscal year ending June 30, 2025 The findings from the June 30, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS FEDERAL AWARD PROGRAMS AUDIT DEPARTMENT OF JUSTICE 2025-001 16.575 Crime Victims Assistance Recommendation: Management should review all grant agreements for CFDA numbers and pass-through identification information. Management should reconcile the SEFA to the general ledger periodically throughout the year. Action Taken: Management has updated the SEFA process to incorporate safeguards. If the Department of Justice has questions regarding this plan, please call Karla Ward at 270-926-7273. Sincerely yours, Karla Ward Executive Director
Federal program: ALN 84.041 Impact Aid Federal agency: U.S. Department of Education Pass-through entity: NA Criteria: As a grantee under Impact Aid (ALN 84.041), the District is required to submit an annual application to the U.S. Department of Education that is accurate and supported by underlying ...
Federal program: ALN 84.041 Impact Aid Federal agency: U.S. Department of Education Pass-through entity: NA Criteria: As a grantee under Impact Aid (ALN 84.041), the District is required to submit an annual application to the U.S. Department of Education that is accurate and supported by underlying enrollment and financial records, in accordance with program regulations and 2 CFR 200. Condition: The District submitted the required annual Impact Aid application; however, key data elements, including total membership enrolled in state‑approved education programs for children with disabilities, did not agree to the underlying student membership and accounting records. Management Response and Planned Corrective Actions Criteria: Management agrees with this finding and is working on implementing an annual application reconciliation process as staffing allows. Responsibility for Corrective Action: Chris Smith, Superintendent and Brittany Clark, Business Manager Anticipated Completion Date: Summer 2026
Find new ways to spend down the district's food service surplus
Find new ways to spend down the district's food service surplus
Management of the Land Trust for Louisiana would like to present the following Corrective Action Plan for the results of the December 31, 2025, audit which was conducted by James Lambert Riggs & Associates, Inc. Finding: The auditee did not submit three out of four required quarterly Federal Financi...
Management of the Land Trust for Louisiana would like to present the following Corrective Action Plan for the results of the December 31, 2025, audit which was conducted by James Lambert Riggs & Associates, Inc. Finding: The auditee did not submit three out of four required quarterly Federal Financial Reports SF-425. Executive Director Cindy Brown and Operations Director Kristi Brocato are responsible for implementing the corrective action plan: incorporate in quarterly work flow deliverables for Operation Director. We implemented the corrective action plan by May 25, 2025. Management has reviewed the results of the audit for the period of January 1, 2025 through December 31, 2025 and concurs with the results from that report.
FINDING 2025-002 – SIGNIFICANT DEFICIENCY- REPORTING - INTERNAL CONTROL OVER COMPLIANCE Description of Finding: The Town is required to submit an annual Project and Expenditure report within 30-days of after the close of the reporting period. Statement of Concurrence or Nonconcurrence: The Town agre...
FINDING 2025-002 – SIGNIFICANT DEFICIENCY- REPORTING - INTERNAL CONTROL OVER COMPLIANCE Description of Finding: The Town is required to submit an annual Project and Expenditure report within 30-days of after the close of the reporting period. Statement of Concurrence or Nonconcurrence: The Town agrees with the audit finding. Corrective Action: The Town will establish policies and procedures to ensure the reports are filed on time and accurately. Name of Contact Person: Shelley Cates, Finance Director, (860) 779-3411 x133. Projected Completion Date: June 30, 2026.
FEDERAL FINDING 2025-001 – SIGNIFICANT DEFICIENCY- PROCUREMENT AND SUSPENSION AND DEBARMENT- INTERNAL CONTROL OVER VERIFICATION AGAINST THE SYSTEM FOR AWARD MANAGEMENT (“SAM”) Description of Finding: 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Fede...
FEDERAL FINDING 2025-001 – SIGNIFICANT DEFICIENCY- PROCUREMENT AND SUSPENSION AND DEBARMENT- INTERNAL CONTROL OVER VERIFICATION AGAINST THE SYSTEM FOR AWARD MANAGEMENT (“SAM”) Description of Finding: 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, (Uniform Guidance) requires compliance with provisions of procurement, suspension, and debarment. Non-federal entities are required to ensure that they do not award contracts or make subawards to any parties that are suspended or debarred from receiving federal funds. This verification may be accomplished by checking the System for Award Management (SAM). The Town does not have a process in place to check that vendors are not suspended or debarred by checking the System for Award Management (SAM). Statement of Concurrence or Nonconcurrence: The Town agrees with the audit finding. Corrective Action: The Town will establish policies and procedures to ensure vendors are not suspended or debarred by checking the System for Award Management (SAM) and maintain documentation showing that verification. Name of Contact Person: Shelley Cates, Finance Director, (860) 779-3411 x133. Projected Completion Date: June 30, 2026.
The Center will perform a thorough review of its subaward management process in response to this finding to ensure that this remains an isolated instance caused by the extenuating circumstances of the federal funding shutdown.
The Center will perform a thorough review of its subaward management process in response to this finding to ensure that this remains an isolated instance caused by the extenuating circumstances of the federal funding shutdown.
Finding Number: 2025-001 Significant Deficiency -Internal Control over Compliance Planned Corrective Action Plan: Health Projects Center will address the finding by talcing the steps outlined below: 1. As of November 2025, Health Projects Center has hired a new Finance Director to strengthen oversig...
Finding Number: 2025-001 Significant Deficiency -Internal Control over Compliance Planned Corrective Action Plan: Health Projects Center will address the finding by talcing the steps outlined below: 1. As of November 2025, Health Projects Center has hired a new Finance Director to strengthen oversight of financial reporting and internal controls. This role will be responsible for ensuring timely and accurate financial close processes and supporting audit readiness. 2. Health Projects Center will implement a more structured and timely year-end close process, with the goal of completing the fiscal year close within the first quarter following year-end. With the improved close timeline, Health Projects Center aims to complete the annual audit by the end of the second quarter. Person Responsible for Corrective Action Plan: John Beleutz, Executive Director Anticipated Date of Completion: June 30, 2026 fiscal year-end
Finding 2025-002 Late Reporting and Noncompliance with Reporting Requirements Name of Contact: Charlanne Thomas, Finance Director Corrective Action Plan: The delay in completing the FY 2025 audit was an isolated occurrence resulting from a combination of staffing challenges and an audit timeline tha...
Finding 2025-002 Late Reporting and Noncompliance with Reporting Requirements Name of Contact: Charlanne Thomas, Finance Director Corrective Action Plan: The delay in completing the FY 2025 audit was an isolated occurrence resulting from a combination of staffing challenges and an audit timeline that did not align with the Borough's established accounting close cycle. The Borough has engaged Maureen Crosby, Contract Controller, to provide audit preparation services to ensure that the books are closed and all necessary documentation is available to auditors in a timely manner. The FY 2026 audit has been scheduled in accordance with the Borough's normal close cycle, with fieldwork beginning in the August and on-site work the last week of October, to ensure completion well in advance of the nine-month Uniform Guidance reporting deadline. Proposed Completion Date: May 31, 2026
We acknowledge the finding and have already implementing corrective actions to ensure it does not occur again. To address this issue the Financial Aid Office will transition Pell Grant processing to a fully automated system that supports direct origination and disbursement. Under this new process, P...
We acknowledge the finding and have already implementing corrective actions to ensure it does not occur again. To address this issue the Financial Aid Office will transition Pell Grant processing to a fully automated system that supports direct origination and disbursement. Under this new process, Pell records will be transmitted directly to the U.S. Department of Education through the Common Origination and Disbursement (COD) system. This change will eliminate the need to create and manage files through ED Express and will significantly reduce manual processing, minimize the risk of erroneous originations, and improve overall compliance with federal reporting requirements. The IT and Financial Aid teams will work together on this project plan, with an anticipated completion timeline of 18 months. The Financial Aid Office will continue to monitor the new automated process to ensure accuracy, efficiency, and compliance with the U.S. Department of Education regulations.
Federal Program: 93.045/93.053, Department of Health and Human Services, Aging Cluster Condition per Auditor: The County did not maintain effective internal control over the reconciliation of expenditures reported on the Schedule of Expenditures of Federal Awards (SEFA) to amounts billed to the fund...
Federal Program: 93.045/93.053, Department of Health and Human Services, Aging Cluster Condition per Auditor: The County did not maintain effective internal control over the reconciliation of expenditures reported on the Schedule of Expenditures of Federal Awards (SEFA) to amounts billed to the funding agency. Planned Corrective Action: The County has established procedures for reconciling general ledger activity to supporting documentation and Federal Financial Reports (FFRs/FSRs) throughout the fiscal year, including additional reconciliation procedures performed at year end to capture late or adjusting entries. The condition was further impacted by timing differences between departmental reporting and subsequent adjusting entries, as well as the aggregation of adjustments across multiple programs without sufficient program level detail at the time of review. While follow up was initiated to obtain supporting breakdowns, the process did not require resolution of these items prior to final classification and inclusion in year end reporting.The County is strengthening internal controls over grant related financial activity and SEFA preparation by enhancing and enforcing requirements for accurate transaction recording, supporting documentation, and independent validation.Key improvements include:• Enhanced documentation and classification requirements for grant related entries • Strengthened review and validation controls to ensure proper support and classification • Improved reconciliation and adjustment protocols, including post reporting revalidation • Control enforcement and escalation for unsupported or unresolved items • Training and guidance on federal compliance requirements Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Shauntika Bullard
Federal Program: 93.045/93.053, Department of Health and Human Services, Aging Cluster Condition per Auditor:The County engaged a third party contractor to perform certain eligibility reassessments, including obtaining verification of medical necessity, when required. While the County had a process ...
Federal Program: 93.045/93.053, Department of Health and Human Services, Aging Cluster Condition per Auditor:The County engaged a third party contractor to perform certain eligibility reassessments, including obtaining verification of medical necessity, when required. While the County had a process in place to properly identify when reassessment was required and to follow up with the contractor about the status of reassessments, controls did not ensure the third party contractor followed through on reassessments on a timely basis. Planned Corrective Action: The Department of Senior Services would like to clarify that the third party contractor is contracted through The Senior Alliance, the Area Agency on Aging for region 1 C and not Wayne County.Wayne County Senior Services will continue to monitor the third party vendor for timely assessments and reassessments through the existing controls which include:• Providing the third party contractor monthly lists of clients in need of assessment/reassessment• Generating monthly lists of outstanding reassessments (clients not reassessed from the monthly list)• Reminding clients of the requirement for 6 month reassessments• Obtaining updated information (phone numbers, emergency contacts, etc.) twice per year • Providing updated information to third party contractor• Documentation of communicated information regarding third party contractor’s performance to The Senior Alliance Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Joan Siavrakas
Plan: Please see below the new process regarding filling vacancies and completing management duties in a timely manner: Immediate Focus on Vacancies: We are prioritizing the filling of vacant units by having two staff members complete move ins at the same time. Streamlined Recertification Process: W...
Plan: Please see below the new process regarding filling vacancies and completing management duties in a timely manner: Immediate Focus on Vacancies: We are prioritizing the filling of vacant units by having two staff members complete move ins at the same time. Streamlined Recertification Process: We have updated our process to ensure all tenants are recertified in a timely manner. There has been a new system in place to monitor deadlines and improve efficiency. Staffing and Training: We are actively recruiting and training additional staff to ensure these tasks are handled promptly, preventing future delays. These steps will address the backlog of management duties and ensure that all tasks, such as filling vacancies and completing tenant recertifications, are handled in a timely and efficient manner. Completion Date: 5/1/2026 Contact: Jackie Oliveira-Director of Affordable Housing
Plan: The Director of Affordable Housing will ensure that her staff submit allocation sheets each pay period. The Director will review the allocation sheets for accuracy, and the Director will approve the allocation sheets before submitting to Payroll for processing. The Chief Operating Officer will...
Plan: The Director of Affordable Housing will ensure that her staff submit allocation sheets each pay period. The Director will review the allocation sheets for accuracy, and the Director will approve the allocation sheets before submitting to Payroll for processing. The Chief Operating Officer will ensure that the Director of Affordable Housing submits an allocation sheet each pay period. The COO will check the allocation sheet for accuracy before approving the allocation sheet and submitting to Payroll for processing. The allocation sheet submitted will include detailed information on the job duties performed during that pay period by the staff member submitting the allocation sheet. Additionally, the Director of Affordable Housing will document job duties for each position in the department. Anticipated Completion Date: 7/1/2026 Contact: Jill Lesmerises, CFO
Plan: Please see below the process for obtaining correct documentation including 50059’s. 1. Notification: Tenants are notified in advance to submit required documentation. 2. Tenant Submission: Tenants provide updated income and household info 3. Verification: Property management verifies the submi...
Plan: Please see below the process for obtaining correct documentation including 50059’s. 1. Notification: Tenants are notified in advance to submit required documentation. 2. Tenant Submission: Tenants provide updated income and household info 3. Verification: Property management verifies the submitted information (e.g., contacting employers, reviewing documents). 4. Rent Calculation: Rent is recalculated based on updated income and family composition, per HUD guidelines. 5. 50059 Form: Completing the 50059 form accurately is crucial. It documents eligibility, income, and rent calculations. Errors can lead to incorrect rent, delays, or compliance issues. 6. Finalizing Recertification: After verification and accurate completion of the 50059, tenants are informed of any rent changes. 7. Record-Keeping: All recertification documents, including the 50059 form, are filed for compliance and audit purposes. By ensuring that recertifications are done annually, all tenant information is updated, and 50059 forms are accurately completed, doing so maintains program compliance and ensure that tenants are paying the correct rent based on their current financial situation. This is critical not only for HUD compliance but also for ensuring that tenants receive the appropriate level of assistance. Completion Date: 7/1/2026 Contact: Jackie Oliveira-Director of Affordable Housing
Finding 2025-002 Plan: Please see below the process for obtaining correct documentation including 50059’s. 1. Notification: Tenants are notified in advance to submit required documentation. 2. Tenant Submission: Tenants provide updated income and household info 3. Verification: Property management v...
Finding 2025-002 Plan: Please see below the process for obtaining correct documentation including 50059’s. 1. Notification: Tenants are notified in advance to submit required documentation. 2. Tenant Submission: Tenants provide updated income and household info 3. Verification: Property management verifies the submitted information (e.g., contacting employers, reviewing documents). 4. Rent Calculation: Rent is recalculated based on updated income and family composition, per HUD guidelines. 5. 50059 Form: Completing the 50059 form accurately is crucial. It documents eligibility, income, and rent calculations. Errors can lead to incorrect rent, delays, or compliance issues. 6. Finalizing Recertification: After verification and accurate completion of the 50059, tenants are informed of any rent changes. 7. Record-Keeping: All recertification documents, including the 50059 form, are filed for compliance and audit purposes. By ensuring that recertifications are done annually, all tenant information is updated, and 50059 forms are accurately completed, doing so maintains program compliance and ensure that tenants are paying the correct rent based on their current financial situation. This is critical not only for HUD compliance but also for ensuring that tenants receive the appropriate level of assistance. Completion Date: 4/1/2026 Contact: Jackie Oliveira-Director of Affordable Housing
Plan: Management acknowledges the finding regarding non-property related expenses that were inadvertently paid by the property. Prior to the audit, management identified the error internally and corrective action was already completed. Upon discovery, the amounts were immediately reviewed, reclassif...
Plan: Management acknowledges the finding regarding non-property related expenses that were inadvertently paid by the property. Prior to the audit, management identified the error internally and corrective action was already completed. Upon discovery, the amounts were immediately reviewed, reclassified, and recorded from the related entity. Although the expense was not identified within the desired timeframe, management’s internal review process ultimately detected the issue before the audit process began, demonstrating that management understands that project funds must only be used for property-related expenses and that these types of transactions are not permissible. Management has since reinforced internal review procedures to ensure expenses are properly allocated to the correct entity in a more timely manner going forward. Management believes the corrective actions already taken adequately address this matter and will help prevent similar occurrences in the future. Completion Date: 1/1/2026 Contact: Jackie Oliveira-Director of Affordable Housing
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