Corrective Action Plans

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2025-001 Recertifications 14.881 Moving to Work Demonstration Program – Award No. OCD26401344019MTW Responsible Official Sarah Scott Director of Leased Housing Plan Detail There has been a greater focus on ensuring new past dues (recertifications not completed on time) do not occur while we continue...
2025-001 Recertifications 14.881 Moving to Work Demonstration Program – Award No. OCD26401344019MTW Responsible Official Sarah Scott Director of Leased Housing Plan Detail There has been a greater focus on ensuring new past dues (recertifications not completed on time) do not occur while we continue to resolve older ones. Starting with April 1, 2024 regular recertifications, we implemented a more rigorous monitoring process. The day after data entry for each recertification is due, the Director of Leased Housing generates a comprehensive report that consolidates information from multiple sources, including our software and internal tracking systems. Once verified, the Director provides these reports—including past-due recertifications from prior months—to managers for follow-up. Managers are responsible for ensuring the timely resolution of all cases on the report. Managers are held accountable for ensuring past-due cases do not reappear in subsequent months. Since the implementation of this process, we have seen a significant reduction in the number of past-due recertifications for assigned caseloads as management is proactive in ensuring no name, especially those on vacant caseloads due to numerous staff medical leaves, reaches that list. Additionally, as of October 2025, the Leased Housing Department will be operating within our new Yardi software system, a significant upgrade designed to enhance efficiency, accuracy, and user experience across all aspects of program administration. Yardi enables considerably faster processing times compared to our current platform, reducing the time needed to complete certifications, adjustments, and case updates. One of the most beneficial features of Yardi is its Recertification Dashboard, which provides staff with real-time visibility into upcoming deadlines, pending tasks, and the overall status of each case. The dashboard includes automated prompts and workflow reminders throughout the recertification process, ensuring staff stay on track and that each step is completed in sequence. In addition to speed and organization, Yardi offers enhanced data accuracy and integration capabilities, minimizing duplication and manual entry errors. These improvements will help staff manage their caseloads more effectively, provide more timely service to participants and property owners, and ensure compliance with program requirements. Anticipated Completion Date June 30, 2026 – Past due percentages will be lowered to acceptable levels with those outstanding being a result of the hearings and appeals process.
The Property Manager will be responsible for completing all income verifications and calculations to ensure accuracy and compliance with HUD requirements. The income verification documentation and rent calculation worksheets will be reviewed and signed off by the Property Manager Supervisor, which i...
The Property Manager will be responsible for completing all income verifications and calculations to ensure accuracy and compliance with HUD requirements. The income verification documentation and rent calculation worksheets will be reviewed and signed off by the Property Manager Supervisor, which is the Chief Financial Officer (CFO) for Comprehend. This added level of oversight will strengthen interanl controls and help ensure that tenant and HUD rent portions are calculated correctly and supported by appropriate documentation.
Finding Number Federal Programs Audit: 2025-001; Responsible Person: Rachelle Roby; Management Views: Management agrees with the finding and is in the process of implementing the recommendation.; Corrective Action: The District will collaborate with the Director of Food Service to ensure that, when ...
Finding Number Federal Programs Audit: 2025-001; Responsible Person: Rachelle Roby; Management Views: Management agrees with the finding and is in the process of implementing the recommendation.; Corrective Action: The District will collaborate with the Director of Food Service to ensure that, when a physical count is conducted, the figures are verified by a second staff member for accuracy. Additionally, it will be required that all supporting documentation be submitted to the Chief Financial Officer (CFO) along with the claim figures. The CFO will review and compare the documentation against the data entered into the claiming system prior to the submission of the claim.; Anticipated Completion Date: 08/01/2025
Comments on the Finding and Each Recommendation: The Corporation did not make the total required reserve for replacement deposits during the year ended June 30, 2025, which resulted in the reserve for replacements account being underfunded by $1,205 as of June 30, 2025. The management agent should t...
Comments on the Finding and Each Recommendation: The Corporation did not make the total required reserve for replacement deposits during the year ended June 30, 2025, which resulted in the reserve for replacements account being underfunded by $1,205 as of June 30, 2025. The management agent should transfer funds of $1,205 from the operating account in order to bring the reserve for replacements account current. Action(s) taken or planned on the finding Management agrees with the recommendation. Management transferred $1,205 from the operating account to the reserve for replacements account on August 26, 2025. No further action is required.
Comments on the Finding and Each Recommendation: The Corporation's Flexible Subsidy Loan was due in full upon maturity of the Corporation's Section 202 mortgage loan, which occurred in March 2017. As of June 30, 2025, the Flexible Subsidy Loan has not been repaid and the Corporation is in technical ...
Comments on the Finding and Each Recommendation: The Corporation's Flexible Subsidy Loan was due in full upon maturity of the Corporation's Section 202 mortgage loan, which occurred in March 2017. As of June 30, 2025, the Flexible Subsidy Loan has not been repaid and the Corporation is in technical default on the Flexible Subsidy Loan. Management should continue communicating with HUD in order to obtain approval for the deferment request for the Section 201 Flexible Subsidy Loan. Action(s) taken or planned on the finding Management agrees with the recommendation. Management has submitted a request for deferment of the Flexible Subsidy Loan. Management is awaiting HUD approval of the deferment request.
Thank you for noting the omission of certain capital assets from the District’s depreciation schedule. Management acknowledges this oversight and appreciates the identification of the issue. To address this matter, the omitted capital assets have been reviewed and recorded on the depreciation schedu...
Thank you for noting the omission of certain capital assets from the District’s depreciation schedule. Management acknowledges this oversight and appreciates the identification of the issue. To address this matter, the omitted capital assets have been reviewed and recorded on the depreciation schedule to ensure accurate financial reporting. In addition, management will develop and implement a formalized procedure for identifying, recording, and reviewing capital asset activity as it occurs. This procedure will be put into place immediately and will include periodic reconciliation and supervisory review to ensure that all qualifying capital assets are properly captured and depreciated in accordance with applicable accounting standards. Management believes that these corrective actions will prevent similar omissions in the future and strengthen internal controls over capital asset accounting. Responsible Parties Marc Graff, Assistant Superintendent for Operations Nicole Guild, Assistant Business Official and District Treasurer Anticipated Completion Date This issue was reviewed with the Program Administrators on December 22, 2025 and will be an ongoing area of review.
Director of City Fare will implement conditional formatting within the reporting spreadsheet immediately upon finding to automatically identify and flag duplicated participant members. This will allow duplicates to be reviewed and resolved prior to finalizing and submitting the report, ensuring accu...
Director of City Fare will implement conditional formatting within the reporting spreadsheet immediately upon finding to automatically identify and flag duplicated participant members. This will allow duplicates to be reviewed and resolved prior to finalizing and submitting the report, ensuring accurate reporting of unduplicated participants served.
Auditor Description of Condition and Effect. The District indicated that they have no documentation of quotes being obtained for purchases over the micropurchase threshold but less than the small purchase threshold (greater than $5,000 but less than $30,512). This condition was caused by management ...
Auditor Description of Condition and Effect. The District indicated that they have no documentation of quotes being obtained for purchases over the micropurchase threshold but less than the small purchase threshold (greater than $5,000 but less than $30,512). This condition was caused by management oversight in knowing the federal compliance requirements of the grant, and maintaining appropriate supporting documentation to evidence compliance. As a result of this condition, the District was exposed to the risk that disbursements of federal awards were not subject to full and open competition. Auditor Recommendation. We recommend that for purchases over the micropurchase threshold but less than the small purchase threshold (greater than $5,000 but less than $30,512) the District obtain and retain price or rate quotations from an adequate number of qualified sources. For purchases over the small purchases threshold ($30,512), we recommend sealed bids are obtained and retained. Corrective Action. The district will obtain and retain price or rate qutoations for purchases over the micropurchase threshold but less than the small purchase threshold. Responsible Person. Kari Visnaw, Superintendent Anticipated Completion Date. June 30, 2026
Management has implemented a year-end reconciliation for all grant funds. Due to the timing of this grant - the District was able to capture the overpayment in the August 2025 expenditure report and therefore, no overpayment was owed. The District does not expect this finding to repeat again.
Management has implemented a year-end reconciliation for all grant funds. Due to the timing of this grant - the District was able to capture the overpayment in the August 2025 expenditure report and therefore, no overpayment was owed. The District does not expect this finding to repeat again.
Contact Person – Thomas A. Jerome, Superintendent Corrective Action Plan – The District will implement policies and procedures to ensure all students who receive a free or reduced meal have a current and accurate application on file. Completion Date – March 31, 2026
Contact Person – Thomas A. Jerome, Superintendent Corrective Action Plan – The District will implement policies and procedures to ensure all students who receive a free or reduced meal have a current and accurate application on file. Completion Date – March 31, 2026
Auditor Description of Condition and Effect. During our cost of attendance recalculation, we noted that for one student, an additional semester in which the student was not taking any classes was included in their calculation. As a result of this condition, the College overstated the student's finan...
Auditor Description of Condition and Effect. During our cost of attendance recalculation, we noted that for one student, an additional semester in which the student was not taking any classes was included in their calculation. As a result of this condition, the College overstated the student's financial need for the award year. However, no action was required by the College as the corrected cost of attendance still exceeded the student's awards. Auditor Recommendation. We recommend that the College implement a review process to ensure that all manual entries into the cost of attendance system are reviewed and approved by an independent second individual. Auditor Recommendation. We recommend that the College implement a review process to ensure that all manual entries into the cost of attendance system are reviewed and approved by an independent second individual. Corrective Action. Upon discovery of the cost of attendance calculation error, the College went through and determined that this was an isolated incident and had no impact on the amount of aid received by the student. To prevent a similar problem arising in the future, the College will implement a review process to have a second individual review and ensure the cost of attendance is being calculated accurately. Responsible Person. Michelle McNier, Director of Financial Aid. Anticipated Completion Date. June 30, 2026.
Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Actions Planned in Response to Finding: RAED will develop a set of procedures the will allow them to be in compliance for subrecipient monitoring. Official Responsible for Ensuring CAP: Savannah Walsh, E...
Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Actions Planned in Response to Finding: RAED will develop a set of procedures the will allow them to be in compliance for subrecipient monitoring. Official Responsible for Ensuring CAP: Savannah Walsh, Executive Director, is the official responsible for ensuring corrective action. Planned Completion Date for CAP: June 30, 2026 Plan to Monitor Completion of CAP: The Board of Education will be monitoring this corrective action plan. Savannah Walsh Executive Director
To ensure compliance with all reporting regulations and established procedures, the Executive Director of Operations, Alnita Miller, will implement segregation of duties so that all data is reviewed/certified. A system for verification and reconciliation of meal counts will be established prior to s...
To ensure compliance with all reporting regulations and established procedures, the Executive Director of Operations, Alnita Miller, will implement segregation of duties so that all data is reviewed/certified. A system for verification and reconciliation of meal counts will be established prior to submission. These controls will be implemented forthwith.
To ensure compliance with all procurement regulations and established procedures, the Executive Director of Operations, Alnita Miller, will ensure that procurement procedures are appropriately documented, reviewed and followed for all school food service department purchases; ensuring all inputs ent...
To ensure compliance with all procurement regulations and established procedures, the Executive Director of Operations, Alnita Miller, will ensure that procurement procedures are appropriately documented, reviewed and followed for all school food service department purchases; ensuring all inputs entered into the bid analysis summary are complete and accurate. These controls will be implemented forthwith.
Pursuant to federal regulations, Uniform Administrative Requirements Section 200.511, the following is the finding as noted in the Northern Michigan University Single Audit Act Compliance report for the year ended June 30, 2025, and corrective action to be completed. 2025-001 – Lack of Drawdown Revi...
Pursuant to federal regulations, Uniform Administrative Requirements Section 200.511, the following is the finding as noted in the Northern Michigan University Single Audit Act Compliance report for the year ended June 30, 2025, and corrective action to be completed. 2025-001 – Lack of Drawdown Review Procedures Auditor Description of Condition and Effect. The University did not have documented review procedures in place for federal grant drawdowns under the Research and Development cluster. Drawdowns were processed without a formal review or approval process to verify that amounts requested were based on allowable expenditures. This deficiency increases the risk of drawing federal funds in excess of actual expenditures or for unallowable costs, potentially resulting in noncompliance with federal regulations. Auditor Recommendation. The University should implement formal review procedures for all federal grant drawdowns, including enhancing policies around reviewing drawdowns, designated reviewers, and system controls to ensure drawdowns are accurate, allowable, and properly supported. Corrective Action. The University is developing formal grant drawdown review procedures that outlines required documentation and review steps around federal grant drawdowns. Responsible Person. Jamie Beauchamp, Controller Anticipated Completion Date. January 31, 2026.
Views of Responsible Officials and Planned Corrective Actions: The District will implement a secondary review process for verifying, entering, and confirming the status of the free and reduced applications. Documentation will be maintained to indicate the individuals performing completion and second...
Views of Responsible Officials and Planned Corrective Actions: The District will implement a secondary review process for verifying, entering, and confirming the status of the free and reduced applications. Documentation will be maintained to indicate the individuals performing completion and secondary review of required steps to verify timeliness and accuracy of eligibility determination and reporting.
Finding: 2025-001 Bond Covenant Compliance Finding: 2025-002 Edgecombe County, NC For the Year Ended June 30, 2025 Corrective Action Plan Section III - Federal Award Findings and Question Costs Name of contact person: Angel Joyner, Brandy Dawes, Tina Radford, and Virginia Ewuell - Medicaid Superviso...
Finding: 2025-001 Bond Covenant Compliance Finding: 2025-002 Edgecombe County, NC For the Year Ended June 30, 2025 Corrective Action Plan Section III - Federal Award Findings and Question Costs Name of contact person: Angel Joyner, Brandy Dawes, Tina Radford, and Virginia Ewuell - Medicaid Supervisors; Denise McKnight - Social Services Program Administrator Corrective Action: All Medicaid Supervisors will meet to review the findings from this audit. A PowerPoint training will be developed and delivered to staff based on these findings. During this training, supervisors will be retrained on the use of application checklist for their programs and will review the checklist to identify and add any information workers may be missing when completing their casework. The application checklist will be updated to include the dates when actions are taken to prevent workers from simply checking items off. This will require case workers to complete a second verification of each action so the date can be accurately entered. Supervisors will also receive training on pulling reports to ensure SSI terminations are reviewed and ex-parte reviews are completed timely. After the refresher training for Medicaid Supervisors, a mandatory group training will be provided for Medicaid workers on Income calculations, including pulling and viewing electronic verification sources, household composition, requests for Informaiton, SSI terminations, and Documentation. Workers will also be trained on the proper use and importance of the application checklist. Supervisors will be responsible for completing weekly random audits focusing on accuracy and timeliness. A 30-day performance improvement plan will be implemented for workers who identify through these audits as having repeated errors. Proposed Completion Date: June 30, 2026. Section II. Financial Statement Findings Name of contact person: Linda Barfield, Chief Financial Officer Corrective Action: The County acknowledges that Water District No. 4 did not meet the 100% debt service coverage requirement for general obligation and installment financing for the fiscal year ended June 30, 2025. While the District exceeded the required revenue bond coverage, the district-level net revenues were not sufficient to meet the combined debt service requirement. The County operates its water and sewer system as a single integrated utility system and does not maintain district-level rate structures. Revenues are generated and managed on a system-wide basis for financial stability and operational efficiency; however, USDA bond covenants require compliance to be measured by individual district. Although full compliance has not yet been achieved, the coverage ratio for District No. 4 continues to improve, increasing from 49% in FY 2023 to 61% in FY 2024 and to 65% in FY 2025. Management will continue to address this issue through ongoing financial monitoring and long-term system planning to achieve full covenant compliance. Edgecombe County County Administration Building 201 St. Andrew St., PO Box 10 Tarboro, NC 27886 252-641-7834 · Fax 252-641-0456 www.edgecombecountync.gov 176For the Year Ended June 30, 2025 Corrective Action Plan Edgecombe County County Administration Building 201 St. Andrew St., PO Box 10 Tarboro, NC 27886 252-641-7834 · Fax 252-641-0456 www.edgecombecountync.gov Section IV - State Award Findings and Question Costs Edgecombe County, NC Proposed Completion Date: Training and implementation of additional reviews and procedures will be implemented by January 15, 2025. Corrective actions for finding 2025-002 also apply to the State Award findings. Section III - Federal Award Findings and Question Costs (continued) 177
Condition: The Corporation failed to refund a security deposit to a tenant within 30 days of their move out date. Planned Corrective Action: The security deposit has been refunded and management is currently reviewing internal controls over security deposit refunds to ensure all deposits are returne...
Condition: The Corporation failed to refund a security deposit to a tenant within 30 days of their move out date. Planned Corrective Action: The security deposit has been refunded and management is currently reviewing internal controls over security deposit refunds to ensure all deposits are returned timely. Contact person responsible for corrective action: Sean Alexander, Vice President – Housing Accounting Completion Date: October 8, 2025
Condition: The Corporation failed to refund a security deposit to a tenant within 30 days of their move out date. Planned Corrective Action: The security deposit has been refunded and management is currently reviewing internal controls over security deposit refunds to ensure all deposits are returne...
Condition: The Corporation failed to refund a security deposit to a tenant within 30 days of their move out date. Planned Corrective Action: The security deposit has been refunded and management is currently reviewing internal controls over security deposit refunds to ensure all deposits are returned timely. Contact person responsible for corrective action: Sean Alexander, Vice President – Housing Accounting Completion Date: November 8, 2024
Condition: The District failed to identify that two contracts, previously procured using competitive methods, had expired and should have been competitively procured prior to purchasing food supplies from the vendors during the fiscal year ended June 30, 2025. Corrective Action Plan: The District’s ...
Condition: The District failed to identify that two contracts, previously procured using competitive methods, had expired and should have been competitively procured prior to purchasing food supplies from the vendors during the fiscal year ended June 30, 2025. Corrective Action Plan: The District’s Nutrition Services Program has documented procurement procedures for the Child Nutrition Programs. These procedures were last reviewed and updated in August 2024 when the District Board of Directors amended the District’s public contracting rules to increase the small and intermediate procurement thresholds. The Nutrition Services Program’s procurement procedures were updated to increase the micro-purchasing threshold to $25,000 (self-certified annually) and the simplified acquisition threshold to $250,000. Unfortunately, for the two procurements noted in the finding, the Nutrition Services Program staff did not annually monitor the dollar value of the procurements and implement the appropriate competitive procurement process as required by the procurement procedures. To remedy this, the District will:  Require annual ODE Child Nutrition Program-sponsored procurement training, specifically one focused on the USDA’s formal procurement process, for all Nutrition Services Program employees involved in purchasing, specifically the Director of Nutrition Services and the Operations Lead.  By April 1, 2026, the Nutrition Services Program will either conduct a competitive procurement and have an agreement in place or identify an existing pricing agreement which meets the USDA procurement standards for purchases of dairy products and produce.  The Fiscal Services Department, specifically the Accounts Payable Specialist, under the supervision of the Accounting Manager, will review the aggregate total spent with each vendor of goods or services for the Nutrition Services Program with the Director of Nutrition Services to identify which procurements require evidence of competitive procurement methods. The Accounts Payable Specialist will require the appropriate evidence and documentation of the competitive procurement process or a pricing agreement for all procurements that exceed the micro-purchasing threshold of $25,000 prior to approving a purchase requisition. Name of Contact Person Responsible for Corrective Action: Lance McMurphy, Director of Nutrition Services Anticipated Completion Date: April 1, 2025 143
Condition: Two vendors provided goods or services in excess of the simplified acquisition threshold without having been procured through a competitive process. Corrective Action Plan: The District’s Nutrition Services Program has documented procurement procedures for the Child Nutrition Programs. Th...
Condition: Two vendors provided goods or services in excess of the simplified acquisition threshold without having been procured through a competitive process. Corrective Action Plan: The District’s Nutrition Services Program has documented procurement procedures for the Child Nutrition Programs. These procedures were last reviewed and updated in August 2024 when the District Board of Directors amended the District’s public contracting rules to increase the small and intermediate procurement thresholds. The Nutrition Services Program’s procurement procedures were updated to increase the micro-purchasing threshold to $25,000 (self-certified annually) and the simplified acquisition threshold to $250,000. Unfortunately, for the two procurements noted in the finding, the Nutrition Services Program staff did not annually monitor the dollar value of the procurements and implement the appropriate competitive procurement process as required by the procurement procedures. To remedy this, the District will: • Require annual ODE Child Nutrition Program-sponsored procurement training, specifically one focused on the USDA’s formal procurement process, for all Nutrition Services Program employees involved in purchasing, specifically the Director of Nutrition Services and the Operations Lead. • By April 1, 2026, the Nutrition Services Program will either conduct a competitive procurement and have an agreement in place or identify an existing pricing agreement which meets the USDA procurement standards for purchases of dairy products and produce. • The Fiscal Services Department, specifically the Accounts Payable Specialist, under the supervision of the Accounting Manager, will review the aggregate total spent with each vendor of goods or services for the Nutrition Services Program with the Director of Nutrition Services to identify which procurements require evidence of competitive procurement methods. The Accounts Payable Specialist will require the appropriate evidence and documentation of the competitive procurement process or a pricing agreement for all procurements that exceed the micro-purchasing threshold of $25,000 prior to approving a purchase requisition. Name of Contact Person Responsible for Corrective Action: Lance McMurphy, Director of Nutrition Services Anticipated Completion Date: April 1, 2025
Management's response: Management concurs with the finding. Corrective Action Plan: Management will request a rent increase when the property is eligible and budget for monthly tax and escrow deposits to prevent future shortfalls in escrow cash.
Management's response: Management concurs with the finding. Corrective Action Plan: Management will request a rent increase when the property is eligible and budget for monthly tax and escrow deposits to prevent future shortfalls in escrow cash.
Management's response: Management concurs with the finding. Corrective Action Plan: Management will re-evaluate controls around cost identified and authorization in efforts to minimize potential error going forward.
Management's response: Management concurs with the finding. Corrective Action Plan: Management will re-evaluate controls around cost identified and authorization in efforts to minimize potential error going forward.
Management’s response: Management concurs with the finding. Corrective Action Plan: Management will re-evaluate controls around cost identification and authorization in efforts to minimize potential error going forward.
Management’s response: Management concurs with the finding. Corrective Action Plan: Management will re-evaluate controls around cost identification and authorization in efforts to minimize potential error going forward.
Management’s response: Management concurs with the finding. Corrective Action Plan: Management will re-evaluate controls around cost identification and authorization in efforts to minimize potential error going forward.
Management’s response: Management concurs with the finding. Corrective Action Plan: Management will re-evaluate controls around cost identification and authorization in efforts to minimize potential error going forward.
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