Corrective Action Plans

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S3800-045 ACTIONS TAKEN OR TO BE TAKEN: Management will endeavor to check files at the site level to ensure that the approval of each certification is retained on file. Management will work with the site managers and the compliance reviewing company to ensure accuracy of certifications, verification...
S3800-045 ACTIONS TAKEN OR TO BE TAKEN: Management will endeavor to check files at the site level to ensure that the approval of each certification is retained on file. Management will work with the site managers and the compliance reviewing company to ensure accuracy of certifications, verifications and rent calculations. The deficiencies found in the files audited will be corrected by Compliance and the site manager and reviewed by the Affordable Housing Director for completion and accuracy.
MANAGEMENT AGREES WITH THE FINDING. THE FUNDS WERE DEPOSITED BACK INTO THE RESTRICTED ACCOUNT.
MANAGEMENT AGREES WITH THE FINDING. THE FUNDS WERE DEPOSITED BACK INTO THE RESTRICTED ACCOUNT.
Corrective Action Plan for Current Year Findings 2026-001 Deposit of Surplus Cash into a Residual Receipts Account Corrective Action Plan No later than 90 days past the end of the fiscal year, we will identify surplus cash in the project funds account and deposit into the residual receipts account. ...
Corrective Action Plan for Current Year Findings 2026-001 Deposit of Surplus Cash into a Residual Receipts Account Corrective Action Plan No later than 90 days past the end of the fiscal year, we will identify surplus cash in the project funds account and deposit into the residual receipts account. Person(s) Responsible: Aaron Franklin Timing for Implementation: Immediate
Finding 2026-002 CAPBM acknowledges the finding regarding inaccuracies identified in several tenant annual recertifications that required corrected HUD-50059-A forms to accurately reflect the Total Tenant Payment (TTP) and HUD subsidy amounts. The errors were the result of calculation and data entry...
Finding 2026-002 CAPBM acknowledges the finding regarding inaccuracies identified in several tenant annual recertifications that required corrected HUD-50059-A forms to accurately reflect the Total Tenant Payment (TTP) and HUD subsidy amounts. The errors were the result of calculation and data entry mistakes during the annual recertification process with past management. Current management is currently reviewing the affected tenant files and will complete any necessary corrections to ensure tenant rent and subsidy calculations are accurate and compliant with HUD requirements. To prevent similar errors in the future, CAPBM has implemented an additional review procedure for all annual recertifications. Once the Compliance Manager completes the annual recertification and prepares the HUD-50059, the Director of Affordable Housing will conduct a secondary review of the certification, including income calculations, asset determinations, applicable deductions, Total Tenant Payment (TTP), and subsidy calculations, prior to final approval and submission. Additionally, staff will continue to receive training on HUD occupancy requirements and annual recertification procedures to ensure compliance with HUD regulations. Management believes these corrective actions will strengthen internal controls and reduce the likelihood of future calculation errors. CAPBM is committed to maintaining accurate tenant certifications and ensuring ongoing compliance with HUD requirements. Completion Date: 12/1/2026 Contact: Jackie Oliveira-Director of Affordable Housing
Finding 2026-004 Plan: Please see below the new process regarding hiring additional staff and turnover at Community Action Partnership Belknap-Merrimack Counties Inc. Due to lack of management, it is understood the importance of having staff training on a regular basis to ensure management and compl...
Finding 2026-004 Plan: Please see below the new process regarding hiring additional staff and turnover at Community Action Partnership Belknap-Merrimack Counties Inc. Due to lack of management, it is understood the importance of having staff training on a regular basis to ensure management and compliance duties can be performed adequately. Community Action Program Belknap-Merrimack Counties Inc. plans to improve the standards of employee training and will be hosting quarterly trainings on employee responsibilities, performance, and areas for improvement. This includes HUD trainings and keeping up to date on any new HUD policies and procedures. We understand the importance of a well-trained staff. We are committed to our performance and adhering to HUD standards while implementing policies to follow for continuous improvement. Please see below the new process regarding filling vacancies and completing management duties in a timely manner: 1. Immediate Focus on Vacancies: We are prioritizing the filling of vacant units by having two staff members complete move ins at the same time. 2. 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. 3. 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, submitting budgets, and completing tenant recertifications, are handled in a timely and efficient manner. Completion Date: 11/1/2026 Contact: Jackie Oliveira-Director of Affordable Housing
Finding 2026-003 Action Plan: Management has submitted all corrections to HUD, but the MOR report has not been closed out or finalized as of yearend. See 2026-003. Completion Date: 9/1/2026 Contact: Jackie Oliveira-Director of Affordable Housing
Finding 2026-003 Action Plan: Management has submitted all corrections to HUD, but the MOR report has not been closed out or finalized as of yearend. See 2026-003. Completion Date: 9/1/2026 Contact: Jackie Oliveira-Director of Affordable Housing
Finding 2026-001 Plan: Please see below the new process ensuring replacement reserve requests are being made in a timely manner: 1) Quarterly Assessment: Quarterly review are now in place to assess reserve balances and ensure funds are used for necessary repairs. Monthly cash flow reports will align...
Finding 2026-001 Plan: Please see below the new process ensuring replacement reserve requests are being made in a timely manner: 1) Quarterly Assessment: Quarterly review are now in place to assess reserve balances and ensure funds are used for necessary repairs. Monthly cash flow reports will align reserve balances with property needs. 2) Formal Utilization Procedure: A written procedure has been established for requesting and using replacement reserve funds. This includes clear guidelines, approval workflows, and thresholds for reserve levels based on property needs. 3) Monitoring & Reporting: Periodic audits will ensure funds are spent according to HUD guidelines. 4) Staff Training & Oversight: Staff will receive training on proper reserve management, and management will increase oversight to ensure funds are used appropriately. Completion Date: 11/1/2026 Contact: Jackie Oliveira-Director of Affordable Housing
DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2026-001: SECTION 811, ASSISTANCE LISTING NUMBER 14.181 Condition: One of the tenant files tested did not contain a copy of the tenant's disability verification. Recommendation: The Project should obtain a copy of the tenant's disability verificati...
DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2026-001: SECTION 811, ASSISTANCE LISTING NUMBER 14.181 Condition: One of the tenant files tested did not contain a copy of the tenant's disability verification. Recommendation: The Project should obtain a copy of the tenant's disability verification and place it in the tenant file. Action Taken: The Project agrees with the finding. They obtained a copy of the tenant's disability verification during June, 2026. If the Department of Housing and Urban Development has questions regarding this plan, please call Les Russo at 847-424-5601.
MANAGEMENT AGREENS WITH THE FINDING. THE SECURITY DEPOSIT DEFICIENCY WILL BE FUNDED IN THE AMOUNT OF $187. MANAGEMENT WILL ENSURE THAT THE SECURITY DEPOSITS ARE PROPERLY FUNDED IN THE FUTURE.
MANAGEMENT AGREENS WITH THE FINDING. THE SECURITY DEPOSIT DEFICIENCY WILL BE FUNDED IN THE AMOUNT OF $187. MANAGEMENT WILL ENSURE THAT THE SECURITY DEPOSITS ARE PROPERLY FUNDED IN THE FUTURE.
DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2026-001: SECTION 811, ASSISTANCE LISTING NUMBER 14.181 Condition: The Project's replacement reserve cash balance was underfunded at March 31, 2026. Recommendation: The Project should deposit $30 into the replacement reserve account. Action Taken: ...
DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2026-001: SECTION 811, ASSISTANCE LISTING NUMBER 14.181 Condition: The Project's replacement reserve cash balance was underfunded at March 31, 2026. Recommendation: The Project should deposit $30 into the replacement reserve account. Action Taken: The Project agrees with the finding. Management deposited $30 into the replacement reserve account in April 2026. If the Department of Housing and Urban Development has questions regarding this plan, please call Jeanne Overocker at 651-645-7271.
Remaining balance was deposited on April 16, 2026. In the future management will ensure deposits are made timely or obtain HUD appproval permitting delay if there were cash flows issues.
Remaining balance was deposited on April 16, 2026. In the future management will ensure deposits are made timely or obtain HUD appproval permitting delay if there were cash flows issues.
Statement of Condition 2026-001 (Assistance Listing 14.155): The Corporation did not make all of the HUD required reserve for replacement deposits for the year ended January 31, 2026. Recommendation: Management should notify the lender of the new reserve for replacement deposit amount and make an ad...
Statement of Condition 2026-001 (Assistance Listing 14.155): The Corporation did not make all of the HUD required reserve for replacement deposits for the year ended January 31, 2026. Recommendation: Management should notify the lender of the new reserve for replacement deposit amount and make an additional $565 deposit to the reserve for replacements fund on the next billing. Management Response: Agree. Management has notified the lender of the new required deposit and will make an additional $565 deposit to the reserve for replacements fund on the next billing.
Action taken in response to finding: The organization has implemented a procedure to review and approve required reports prior to submission.
Action taken in response to finding: The organization has implemented a procedure to review and approve required reports prior to submission.
Action taken in response to finding: The organization has worked with appropriate staff to provide further clarification on sliding fee intake and approval process.
Action taken in response to finding: The organization has worked with appropriate staff to provide further clarification on sliding fee intake and approval process.
Action Taken/Planned: Management acknowledges the deficiencies identified in subrecipient monitoring controls during FY25. These deficiencies occurred during a period of substantial growth in the College's sponsored programs portfolio, organizational restructuring, staffing constraints, and continue...
Action Taken/Planned: Management acknowledges the deficiencies identified in subrecipient monitoring controls during FY25. These deficiencies occurred during a period of substantial growth in the College's sponsored programs portfolio, organizational restructuring, staffing constraints, and continued refinement of grants administration processes. In response, the College implemented a comprehensive transformation of its grants management framework during FY26. Corrective actions include establishment of the Unified Grants Hub, creation of a dedicated Subaward Manager position, addition of specialized post-award personnel, establishment of a Grants Management Task Force, implementation of formalized subrecipient monitoring procedures and documentation requirements, expansion of grants management training, enhanced coordination among Finance, Research Administration, Compliance, Budget, and Treasury functions, and deployment of Power BI reporting tools to strengthen oversight and compliance monitoring. Anticipated Completion Date/Date Completed: The majority of corrective actions were implemented during FY2026. The Unified Grants Hub, staffing enhancements, Grants Management Task Force, and enhanced monitoring procedures were operational as of June 30, 2026. Ongoing monitoring and compliance reviews will continue thereafter.
Criteria: The objective of the Assistance Listing 93.912 is to improve services for substance use disorder (SUD) and opioid use disorder (OUD) through prevention, treatment, and recovery services. Management is responsible for establishing and maintaining internal controls, including formal policies...
Criteria: The objective of the Assistance Listing 93.912 is to improve services for substance use disorder (SUD) and opioid use disorder (OUD) through prevention, treatment, and recovery services. Management is responsible for establishing and maintaining internal controls, including formal policies and procedures for the review and approval of journal entries, adjustments to expenditures, and account reconciliations, to ensure expenditures reported to granting agencies are complete, accurate, allowable, and properly supported. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Containment -Once we were made aware of this finding through the audit, we began thinking of the most efficient way to document the Board’s knowledge and approvals of journal entries, including adjustments to expenditures and account reconciliations. Root Cause -HOPE is currently revising all policies and procedures. This was HOPE’s first federal single audit, so once we heard of the finding we prioritized revisions of fiscal policies and procedures to address the finding. Action Taken- The first board meeting after learning of this finding will be held on July 27th, 2026. Beginning with that meeting, the Board’s approval of the statement of activity detail, consisting of all charges and journal entries entered into HOPE’s accounting system since the date of the last Board meeting, will be approved via motion and seconded and noted as such in the Board meeting minutes. Most journal entries made during the month are currently entered into the system by HOPE’s CPA. The remaining journal entries are entered by HOPE’s Executive Director. To ensure that the Board is aware of the adjustments made in the system, all journal entries made since the last Board meeting will be approved via a motion and a second as a separate agenda item to ensure that the Board is reviewing these items particularly. All approvals will be noted in the Board meeting minutes. The list of journal entries viewed during the meeting will be initialed by a Board member and kept on file as documentation of internal controls.
Criteria: The objective of Assistance Listing 93.912, Rural Healthcare Services Programs, is to improve access to and delivery of rural health care services, including prevention, treatment, and recovery services. The Organization’s fiscal policies require expenditures to be approved in advance to e...
Criteria: The objective of Assistance Listing 93.912, Rural Healthcare Services Programs, is to improve access to and delivery of rural health care services, including prevention, treatment, and recovery services. The Organization’s fiscal policies require expenditures to be approved in advance to ensure adequate financial resources are available. The policies also require all checks to include two signatures, one of which must be an authorized Board member; purchases of non-expendable personal property and other purchases or contracts exceeding $5,000 to be supported by three competitive quotes; and all nonrecurring expenditures to be approved at least monthly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Containment - Once we were made aware of this finding through the audit, we determined that we need to find a more effective way to document the Board’s knowledge and approvals of expenditures. Root Cause -HOPE is currently revising all policies and procedures. This was HOPE’s first federal single audit, so once we heard of the finding we prioritized revisions of fiscal policies and procedures to address the finding. Action Taken- The first board meeting after learning of this finding will be held on July 27th, 2026. Beginning with that meeting, the Board’s approval of the Statement of Activity Detail, consisting of all charges and journal entries entered into HOPE’s accounting system since the date of the last Board meeting, will be approved via motion and seconded and noted as such in the Board meeting minutes.
Federal Agency Name: Department of Homeland Security Pass-Through Entity: State of South Dakota Office of Emergency Management Assistance Listing Number: 97.039 Program Name: Hazard Mitigation Grant Program Finding Summary: The Association does not have an internal control system designed to provide...
Federal Agency Name: Department of Homeland Security Pass-Through Entity: State of South Dakota Office of Emergency Management Assistance Listing Number: 97.039 Program Name: Hazard Mitigation Grant Program Finding Summary: The Association does not have an internal control system designed to provide for a complete and accurate schedule of federal expenditures of federal awards being audited. As auditors, we were requested to assist with the preparation of the schedule and accompanying notes to the schedule. Corrective Action Plan: It is not cost effective to have an internal control system designed to provide for the preparation of the schedule of federal expenditures of federal awards and the accompanying notes to the schedule. We requested that our auditors, Eide Bailly, LLP, prepare the schedule and accompanying notes. We have designated a member of management to review the drafted schedule and accompanying notes to the schedule. Responsible Individuals: Char Hager, CEO Anticipated Completion Date: Ongoing
Finding: 2025-003 Condition Found: During testing of a statistically valid sample of 19 patient accounts that received sliding fee discounts, 2 patient files did not contain eligibility documentation to support that the patients qualified for the sliding fee discount at the time the discount was app...
Finding: 2025-003 Condition Found: During testing of a statistically valid sample of 19 patient accounts that received sliding fee discounts, 2 patient files did not contain eligibility documentation to support that the patients qualified for the sliding fee discount at the time the discount was applied Individual(s) Responsible for Corrective Action: Chief Executive Officer, Fractional CFO, Billing Team Planned Corrective Action: The Organization revised its sliding fee discount policies, implemented centralized documentation tracking, and enhanced staff training related to eligibility determination and documentation requirements. Monitoring procedures, including periodic supervisory review, were established to ensure compliance. Anticipated Completion Date: Implemented and in progress. Due to the timing of the prior year’s audit completion, the Organization did not have time to complete a full monitoring cycle prior to audit testing.
Finding: 2025-002 Condition Found: The FAC filing for the fiscal year ended March 31, 2025, was submitted late. Individual(s) Responsible for Corrective Action: Chief Executive Officer, Fractional CFO, Board of Directors Planned Corrective Action: Management agrees with the finding. Due to the timin...
Finding: 2025-002 Condition Found: The FAC filing for the fiscal year ended March 31, 2025, was submitted late. Individual(s) Responsible for Corrective Action: Chief Executive Officer, Fractional CFO, Board of Directors Planned Corrective Action: Management agrees with the finding. Due to the timing of prior year audit completion and associated late filing, the Organization did not have sufficient time within the current audit period to fully implement and demonstrate the effectiveness of corrective actions related to audit timeliness. As a result, this finding has reoccurred. The Organization has strengthened oversight by formalizing a compliance calendar, assigning clear ownership of Single Audit and Federal Audit Clearinghouse deadlines, and incorporating milestone tracking into finance operations and executive oversight processes. In addition, continued fractional CFO support provides enhanced accountability and monitoring of financial reporting timelines. These actions build upon prior year corrective efforts and are designed to ensure timely and compliant filings going forward. Anticipated Completion Date: FY2026 filing cycle.
DJFS will begin to use project numbers to allow for an additional check of all amounts reported. DJFS is also going to provide federal grant information to the Auditor’s office as soon as they complete their final report in order to give the Auditor’s office adequate time to review the information w...
DJFS will begin to use project numbers to allow for an additional check of all amounts reported. DJFS is also going to provide federal grant information to the Auditor’s office as soon as they complete their final report in order to give the Auditor’s office adequate time to review the information with MUNIS and will afford the Auditor’s office more time to compile the SEFA and have a secondary review to avoid any computational or clerical errors.
See table on page 26.
See table on page 26.
SF-425 Reporting Planned Corrective Action: American Bird Conservancy will prepare, review and maintain documented comparison of general ledger details to the SF-425 reports prepared. Person Responsible for Corrective Action Plan: Angela Modrick, Vice President of Finance Anticipated Date of Complet...
SF-425 Reporting Planned Corrective Action: American Bird Conservancy will prepare, review and maintain documented comparison of general ledger details to the SF-425 reports prepared. Person Responsible for Corrective Action Plan: Angela Modrick, Vice President of Finance Anticipated Date of Completion: Implemented
FINDING 2025-004 Internal Control over Compliance and Compliance with Special Tests and Provisions – NSLDS Reporting (Material Weakness and Material Noncompliance) Responsive to finding: We agree with the finding. Corrective Action Plan: Gallaudet University will continue to enhance its procedures f...
FINDING 2025-004 Internal Control over Compliance and Compliance with Special Tests and Provisions – NSLDS Reporting (Material Weakness and Material Noncompliance) Responsive to finding: We agree with the finding. Corrective Action Plan: Gallaudet University will continue to enhance its procedures for identifying, monitoring, reviewing, and reporting student enrollment status changes to the National Student Loan Data System (NSLDS) to help ensure that enrollment information is submitted accurately and within required timeframes. • Continue to refine NSLDS reporting procedures to ensure that enrollment status changes, including graduations, withdrawals, and changes in enrollment status, are appropriately identified and reported in accordance with federal requirements. • Enhance system-generated reporting and validation procedures associated with the University’s enterprise planning system to help ensure that all students with enrollment status changes are captured in NSLDS reporting files. • Continue to strengthen reconciliation procedures by comparing enrollment status changes recorded in student records to information included in NSLDS reporting submissions and investigating any discrepancies identified. • Enhance supervisory review procedures to verify the completeness, accuracy, and timeliness of NSLDS enrollment reporting prior to submission. • Conduct periodic monitoring of enrollment reporting processes and submission timeliness to verify compliance with federal reporting requirements and identify opportunities for continuous improvement. These corrective actions will further strengthen the University's internal controls over NSLDS reporting and help ensure compliance federal reporting requirements and identify opportunities for continuous improvement. Individual(s) Responsible for Corrective Action Plan: Amanda Jackson, Director of Financial Aid Elice Patterson, Registrar Estimated Completion Date: Immediate
FINDING 2025-003 Internal Control over Compliance and Compliance with Reporting (Significant Deficiency and Noncompliance) Responsive to finding: We agree with the finding. Corrective Action Plan: Gallaudet University will continue to enhance its procedures for the preparation, reconciliation, revie...
FINDING 2025-003 Internal Control over Compliance and Compliance with Reporting (Significant Deficiency and Noncompliance) Responsive to finding: We agree with the finding. Corrective Action Plan: Gallaudet University will continue to enhance its procedures for the preparation, reconciliation, review, and retention of supporting documentation related to the Fiscal operations Report and Application to Participate (FISAP) to ensure that all reported information is complete, accurate, adequately supported, and retained in accordance with federal requirements. The University will implement the following corrective actions: • Continue to refine FISAP preparation procedures by clearly identifying the source reports, calculations, reconciliations, review requirements, and supporting documentation necessary for key reporting line items to promote consistency, accuracy, and supportability of reported information. • Enhance documentation retention practices by maintaining a centralized electronic repository for FISAP-related source reports, supporting schedules, reconciliations, calculations, and review documentation to ensure supporting records are readily available for review and audit purposes. • Continue to strengthen reconciliation procedures by requiring documented reconciliation of key FISAP data elements, including Pell Grant expenditures, tuition and fee information, eligible applicant data, and campus-based program expenditures, to supporting financial aid records, federal reporting records, and the general ledger prior to submission. • Enhance supervisory review procedures to verify the completeness, accuracy, and supportability of information reported in the FISAP before certification and submission to the U.S. Department of Education. • Conduct periodic monitoring of FISAP preparation and documentation retention practices to verify compliance with established procedures and identify opportunities for continuous improvement. These corrective actions will further strengthen the University's internal controls over federal reporting and help ensure ongoing compliance with FISAP reporting requirements and documentation retention standards. Individual(s) Responsible for Corrective Action Plan: Amanda Jackson, Director of Financial Aid John Skjeveland, Controller Estimated Completion Date: September 30, 2026
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