Corrective Action Plans

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Finding 2025-002 – Low Rent Public Housing Tenant Files – Eligibility – Rent Calculations Noncompliance & Significant Deficiency Low Rent Public Housing – ALN 14.850 Condition & Cause: Our review of thirty (30) Low Rent Public Housing tenant files identified noncompliance in twelve (12) files within...
Finding 2025-002 – Low Rent Public Housing Tenant Files – Eligibility – Rent Calculations Noncompliance & Significant Deficiency Low Rent Public Housing – ALN 14.850 Condition & Cause: Our review of thirty (30) Low Rent Public Housing tenant files identified noncompliance in twelve (12) files within one or more categories. Of these, eight (8) files, or roughly 26%, were for the determination of adjusted annual income. Specifically, we noted the following: • Three (3) files were missing proper income verification • Three (3) files included income miscalculations • Two (2) files lacked required documentation to support deductions • Five (5) units did not have evidence of an annual inspection on file Based on extrapolation of these errors to the population, we identified likely questioned costs totaling $134,699, representing approximately 3.25% of total dwelling rental income. We also observed that the Public Housing department operated with significant staffing shortages for much of the fiscal year, which likely contributed to these deficiencies. PHA Response: The SHA has reviewed these deficiencies with the responsible staff members. Public housing staff have received internal training on required and acceptable income and deduction verifications and subsequent calculations. A file integrity checklist has been created for housing managers to ensure all required forms, calculations and required support is included and accurate. Further, internal file review procedures will be established in the current fiscal year. File integrity reviews will be performed by the Division Director and SHA is also exploring the value of peer reviews between housing managers and support staff. Internal inspection processes have also been improved. SHA has created a new Director of Operations position that is responsible for oversight and scheduling of inspections. This will provide more direct oversight of unit inspections and ensure that all annual and other inspections are performed timely and resulting reports are provided to the housing manager for the resident file. Persons Responsible: Lisa Taylor, Director of Admissions, Occupancy and Compliance Anticipate Completion Date: March 31, 2026
Mount Saint Mary’s University Corrective Action Plan For the Year Ended June 30, 2025 Finding 2025-003 Condition: The University did not have updated procedures and processes in place specific to all the required GLBA elements. The GLBA policy review and updates are still in process. Corrective Acti...
Mount Saint Mary’s University Corrective Action Plan For the Year Ended June 30, 2025 Finding 2025-003 Condition: The University did not have updated procedures and processes in place specific to all the required GLBA elements. The GLBA policy review and updates are still in process. Corrective Action Plan: Due to the transition within the institution’s information security department, the University is still in the process of updating its information security policy and framework and will have these approved in fiscal year 2026. The University is continuing to work on implementing the remaining elements of the GLBA requirements and has been tracking and monitoring its progress. Name(s) of Contact Person(s) Responsible for Corrective Action: Jamal Nasser, Chief Information Officer Anticipated Completion Date: June 30, 2026 Joy E. Brathwaite, MBA MSA Vice President for Finance and Administration Dated: 12/4/2025
Mount Saint Mary’s University Corrective Action Plan For the Year Ended June 30, 2025 Finding 2025-002 Condition: For 5 of 25 students tested in the sample, the student’s status was reported late to the National Student Loan Data System (NSLDS). The sample was not a statistically valid sample. Corre...
Mount Saint Mary’s University Corrective Action Plan For the Year Ended June 30, 2025 Finding 2025-002 Condition: For 5 of 25 students tested in the sample, the student’s status was reported late to the National Student Loan Data System (NSLDS). The sample was not a statistically valid sample. Corrective Action Plan : The Registrar’s office generates enrollment reports every three (3) weeks and they are sent to NSLDS. These reports allow for frequent degree of enrollment reporting to correct this type of error. These changes are in place and have taken effect immediately. Name(s) of Contact Person(s) Responsible for Corrective Action: Rocio De Leon, Registrar Anticipated Completion Date: Immediately Joy E. Brathwaite, MBA MSA Vice President for Finance and Administration Dated: 12/4/2025
Mount Saint Mary’s University Corrective Action Plan For the Year Ended June 30, 2025 Finding 2025-001 Condition: The University did not have evidence or documentation available to support the control/review process for return of Title IV calculations. Corrective Action Plan : The University will co...
Mount Saint Mary’s University Corrective Action Plan For the Year Ended June 30, 2025 Finding 2025-001 Condition: The University did not have evidence or documentation available to support the control/review process for return of Title IV calculations. Corrective Action Plan : The University will continue to review and adhere to our procedures for refunding awards, and the Financial Aid office will formally document the weekly review of the Return of Title IV funds. Name(s) of Contact Person(s) Responsible for Corrective Action: La Royce Housley, Director of Financial Aid Anticipated Completion Date: Immediately Joy E. Brathwaite, MBA MSA Vice President for Finance and Administration Dated: 12/4/2025
The District will develop and implement a formal procurement checklist. This checklist will be completed by the Business Manager for all purchases expected to exceed the micro-puchase threshold. The procedure will require the checklist to be completed and attached to the purchase order before the pu...
The District will develop and implement a formal procurement checklist. This checklist will be completed by the Business Manager for all purchases expected to exceed the micro-puchase threshold. The procedure will require the checklist to be completed and attached to the purchase order before the purchase is finalized, ensuring and documenting that the required price of rate quotations have been obtained in accordance with 2 CFR section 200.320.
The duties will be segregated as much as possible and the Board of Directors will remain involved in the financial affairs of the Network to provide oversight and independent review functions.
The duties will be segregated as much as possible and the Board of Directors will remain involved in the financial affairs of the Network to provide oversight and independent review functions.
Management agrees with the finding, and will evaluate available personnel to coordinate monitoring procedures to ensure accurate tenant calculations.
Management agrees with the finding, and will evaluate available personnel to coordinate monitoring procedures to ensure accurate tenant calculations.
SECTION III - FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2025-001 – SPECIAL TESTS AND PROVISIONS: PAYMENT STANDARDS Other Matter/Significant Deficiency U.S. Department of Housing and Urban Development CFDA #: 14.871 / 14.879 – Housing Voucher Cluster Issue Identified: It was brought to the attentio...
SECTION III - FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2025-001 – SPECIAL TESTS AND PROVISIONS: PAYMENT STANDARDS Other Matter/Significant Deficiency U.S. Department of Housing and Urban Development CFDA #: 14.871 / 14.879 – Housing Voucher Cluster Issue Identified: It was brought to the attention of the North Providence Housing Authority (NPHA) in May 2025 that a procedural error occurred regarding the implementation of decreased payment standards for existing subsidized participants. The error involved applying the decreased payment standards immediately (at most recent annual reexamination), rather than adhering to the required 12-month written notice period for existing participants. The correct procedure, as per HUD policy, requires applying the decreased payment standards only at the participant's second annual review of income following the effective date of the decrease. Corrective Action: The NPHA took the following immediate and diligent steps to rectify this oversight: 1. Identification of Affected Participants: A comprehensive review was conducted to accurately identify all families whose subsidies were incorrectly calculated due to the premature application of the decreased payment standards. 2. Recalculation and Adjustment: For all affected participants, the housing assistance payment (HAP) was retroactively recalculated using the higher, correct payment standard that should have remained in effect during the notice period. 3. Issuance of Refunds: The difference between the higher, correct HAP, and the lower, incorrect HAP was calculated. This amount was then refunded to compensate participants for any increased tenant rent they may have paid as a result of the error. Status of Correction: The NPHA confirms that the corrective action is complete. • As of Friday, September 26, 2025, all identified affected participants have been fully compensated and made whole. • The distribution of all calculated refunds related to the incorrect application of the 2024/2025 payment standards is finalized. Preventative Measures: To prevent recurrence, the NPHA has implemented updated policies and procedures to ensure strict compliance with HUD regulations regarding changes to payment standards: • The NPHA staff is now fully aware of the specific HUD policy requiring a 12-month written notice for existing participants before a decreased payment standard is applied. • New internal controls and verification steps have been established to ensure that future decreased payment standards are applied only at the second annual income review for existing participants, following the issuance of the 12-month notice. Planned Implementation Date of Corrective Action: July 1, 2025. Person Responsible for Corrective Action: Marilee Arsenault, Stephnie Dos Reis, and Eileen Reyes
Planned Corrective Action: The District remains committed to maintaining the highest standards of accurate reporting and will implement the following action steps: 1. Withdrawal Documentation Requirement: All student withdrawals in grades nine through twelve that will be removed from the cohort must...
Planned Corrective Action: The District remains committed to maintaining the highest standards of accurate reporting and will implement the following action steps: 1. Withdrawal Documentation Requirement: All student withdrawals in grades nine through twelve that will be removed from the cohort must be accompanied by a completed withdrawal form sent to parents via email or provided in person. This form will be uploaded directly into the student's record to ensure required documentation is readily available and securely archived. 2. Enhance Fields in Student Records: When a withdrawal code is applied that removes a student from a graduation cohort, additional fields will be added to the student's record: a. "Move To" Field: This field will now be required and will capture the anticipated new school or location of enrollment. b. Withdrawal Form Upload Field: This field will require the upload of the completed withdrawal form and supporting documentation. 3. Development of a Monitoring Tool: The District will design and deploy an enhanced monitoring tool for use by schools and designated district staff. This tool will provide a comprehensive report, tracking withdrawal codes removing students from graduation cohorts within the student information system. 4. Staff Training and Ongoing Monitoring: The District will provide additional training for relevant staff on enhanced procedures. Monitoring measures to ensure compliance will be completed by designated District staff and include direct follow-up with schools that have incomplete documentation. Anticipated Completion Date: March 17, 2026 Responsible Contact Person: Holly Rockhill, Technology & Information Services, Sr. Manager
Management agrees with the finding. The financial statements were submitted to HUD on June 25, 2025.
Management agrees with the finding. The financial statements were submitted to HUD on June 25, 2025.
2025-005 – Medicaid – Allowable Activities and Costs - The District is aware of the student’s receiving benefits need to have their billed services included in their IEPs. Responsible Official – Austin Moore, Business Manager Anticipated Completion Date – The District will correct this in the subseq...
2025-005 – Medicaid – Allowable Activities and Costs - The District is aware of the student’s receiving benefits need to have their billed services included in their IEPs. Responsible Official – Austin Moore, Business Manager Anticipated Completion Date – The District will correct this in the subsequent fiscal year.
2025-004 – Child Nutrition Cluster - Eligibility - The District is aware of the student’s receiving benefits that are not eligible for benefits and will implements new procedures and a plan to update eligibility. Responsible Official – Austin Moore, Business Manager Anticipated Completion Date – The...
2025-004 – Child Nutrition Cluster - Eligibility - The District is aware of the student’s receiving benefits that are not eligible for benefits and will implements new procedures and a plan to update eligibility. Responsible Official – Austin Moore, Business Manager Anticipated Completion Date – The District will correct this in the subsequent fiscal year.
We are compiling award letters in our shared drive as they come in so we have all of the pieces needed to complete the schedule of expenditures. We are also enhancing our grant monitoring throughout the year to have a better handle on the grants and accurately report the activity.
We are compiling award letters in our shared drive as they come in so we have all of the pieces needed to complete the schedule of expenditures. We are also enhancing our grant monitoring throughout the year to have a better handle on the grants and accurately report the activity.
Management's Views and Corrective Action Plan 2025-001- Compliance with Federal Funding Accountability and Transparency Act (FFATA) Reporting Sponsoring Agency: National Endowment for the Humanities Award Name: American Experience, A Man Called White Award Number: TR-297125-24 Assistance Listing Tit...
Management's Views and Corrective Action Plan 2025-001- Compliance with Federal Funding Accountability and Transparency Act (FFATA) Reporting Sponsoring Agency: National Endowment for the Humanities Award Name: American Experience, A Man Called White Award Number: TR-297125-24 Assistance Listing Title: Promotion of the Humanities Public Programs Assistance Listing Number: 45.164 Award Year: 2024-2025 Management's Views and Corrective Action Plan WGBH Educational Foundation (“the Foundation”) concurs with this finding. During fiscal year 2025, the Foundation identified a control failure with their established FFATA reporting control. After thorough review of active subaward agreements, the Foundation identified one contract that was not reported timely. Due to the grant's termination date of April 2, 2025, the Foundation was not able to file the report through SAM.gov. However, the Foundation promptly reached out to the National Endowment for Humanities (NEH) for assistance with filing. At this time, the Foundation has not received a response from NEH on next steps. The Foundation has since enhanced its control to include a three-way reconciliation using system generated reports to validate completeness of the Foundation’s monthly list of executed subaward agreements prior to reporting deadline. In addition to the reconciliation, the Foundation has implemented a FFATA process checklist which captures the process steps, applicable contract execution date(s), report submission date(s) and sign off/approval of the monthly process. A secondary review and approval of the process have been included in the updated control. The enhanced control was implemented for the September 2025 FFATA reporting. Contact person: Katie Dillon Managing Director, Production Finance and Grants Compliance 617-300-3829
Management agrees with the finding. The residual receipts account deficiency was funded on November 27, 2024 in the amount of $58,162. Management will ensure that the residual receipts account is properly funded in the future.
Management agrees with the finding. The residual receipts account deficiency was funded on November 27, 2024 in the amount of $58,162. Management will ensure that the residual receipts account is properly funded in the future.
Management agrees with the finding. The excess funds were accrued to offset future Section 8 HAP requests.
Management agrees with the finding. The excess funds were accrued to offset future Section 8 HAP requests.
Management agrees with the finding. The residual receipts account deficiency was funded on November 15, 2024 in the amount of $4,556. Management will ensure that the residual receipts account is properly funded in the future.
Management agrees with the finding. The residual receipts account deficiency was funded on November 15, 2024 in the amount of $4,556. Management will ensure that the residual receipts account is properly funded in the future.
Management agrees with the finding. The excess funds were accrued to offset future Section 8 HAP requests.
Management agrees with the finding. The excess funds were accrued to offset future Section 8 HAP requests.
See table on page 34.
See table on page 34.
Finding 2025-001 (Material Weakness) AL# 11.307: COVID-19 Economic Adjustment Assistance, Economic Development Cluster, U.S. Department of Commerce, Federal Award # 05-79-06082 - 2021 Condition: The required performance reports ED-916 and ED-917 were not completed or submitted during the fiscal year...
Finding 2025-001 (Material Weakness) AL# 11.307: COVID-19 Economic Adjustment Assistance, Economic Development Cluster, U.S. Department of Commerce, Federal Award # 05-79-06082 - 2021 Condition: The required performance reports ED-916 and ED-917 were not completed or submitted during the fiscal year. Criteria: 2 CFR 200.303(a) states that the Center is required to establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Questioned Costs: None noted. Context: The Center transitioned to the revolving stage of the program and there was a misunderstanding that the ED-916 and ED-917 had to be filed during the revolving stage. The sample size was determined based upon the guidelines provided by the AICPA which is not a statistically valid sample. Cause: The Center misunderstood that the performance reports were applicable during the revolving stage. Effect: Not reporting performance reports may impact the federal agency’s ability to assess the effectiveness of the federal program. Corrective Action Plan: All EDA reporting will be completed and submitted to ensure the Center is up to date on required filings. In addition, the Center will work with the EDA to understand when reporting requirements will change during the revolving process.
Corrective Action Plan: The University will continue to improve upon Enrollment Reporting as well as continue with all of the changes previously identified and corrected. The University will ensure that the Received Date by NSLDS is within the 60 day compliance reporting requirement. With respect to...
Corrective Action Plan: The University will continue to improve upon Enrollment Reporting as well as continue with all of the changes previously identified and corrected. The University will ensure that the Received Date by NSLDS is within the 60 day compliance reporting requirement. With respect to the reporting of Program Lengths in error, the University took steps to update the processes associated with that activity subsequent to the issuance of the report containing the prior year Single Audit finding 2024-001. Upon consultation with the Office of the Provost and the appropriate Deans of the affected Colleges, the program length for the Master’s programs at the University was updated to two (2), for those programs between 30 and 36 credit hours in length; and three (3) academic years, for those whose minimum credit hours exceeds 36 credit hours, which will meet a reasonable progression to such degree. The Office of Registrar updated all such programs to reflect the decision for the University in November 2024. The students noted in the 2025-001 finding ceased to be active prior to the updated process’ implementation and were excluded from the reporting population. All activity contained in the sample selection for changes after the implementation date were handled in accordance with the regulations. One of those students reenrolled and the Program Length was updated to correctly reflect the student’s new program. The University will continue to monitor this area for any future discrepancies. Responsible Parties: The University has identified the Registrar – Paula Brown along with the Director of the Office of Financial Aid – James Hubener as the responsible parties to ensure continued monitoring of the activity on these types of items to ensure timely and accurate reporting to NSLDS. Estimated Completion Date: November 30, 2024
SIGNIFICANT DEFICIENCY 2025-001 Federal Program Student Financial Assistance Cluster Compliance requirements Special Tests and Provisions – Return to Title IV Condition Of the 37 students tested for Return to Title IV procedures, 2 were determined to have had errors in their calculation. Recommendat...
SIGNIFICANT DEFICIENCY 2025-001 Federal Program Student Financial Assistance Cluster Compliance requirements Special Tests and Provisions – Return to Title IV Condition Of the 37 students tested for Return to Title IV procedures, 2 were determined to have had errors in their calculation. Recommendation We recommend that the College review and update its policies to ensure that accurate Return to Title IV calculations are completed. Comments on the Finding For the issue with an institutional charge incorrectly considered in the R2T4 calculation, this was due to a Federal Direct Parent PLUS Loan that was processed and a refund to the parent. Only seven of these loans were processed in the aid year of 2024-25, and there were no other R2T4 situations that involved a Federal Direct Parent PLUS Loan. The refund to the parent was shown at the top of the Banner form while student refunds show at the bottom of the Banner form. Due to the rarity of these loans being included in the calculation and the variation of where this charge is shown in Banner, this was missed. Barton personnel are now aware of where to look for this in these very rare cases. For the situation where the incorrect starting date was identified, there was human error when that was entered. Barton does have a quality assurance process to double check all dates on the Banner withdrawal form, and the R2T4 calculation spreadsheet, however, this review will now extend to checking the enrollment dates in a second Banner form. Action Taken Since the 2024-25 aid year was still open, both instances were corrected. Barton’s Director of Financial Aid has made all personnel aware of the issues and has revised the quality assurance review to watch for these issues.
The Institution has reviewed the details of the finding and determined the error to be due to human error and the responsibility of the Institution. Subsequent to the audit, the Institution refunded $350 in 2023-2024 Federal Pell Grant program funds on behalf of student #20 (VR). In addition the Ins...
The Institution has reviewed the details of the finding and determined the error to be due to human error and the responsibility of the Institution. Subsequent to the audit, the Institution refunded $350 in 2023-2024 Federal Pell Grant program funds on behalf of student #20 (VR). In addition the Institution refunded $419 in 2024-2025 Federal Pell Grant program funds on behalf of student #2 (EL). These two students over-award was due to a schedule or grade change that took place after the start of student’s term or payment period. The Institution will implement reporting from our SIS to monitor schedule or grade changes that take place after the start of a student’s term or payment period.
Finding #2025-001 – Internal Control Over Compliance - Activities Allowed or Unallowed and Allowable Costs/Cost Principles Contact – Suzanne Tobin, Chief Financial Officer Telephone Number – (301)-832-3810 Completion Date – December 15, 2025 Corrective Action Plan: Effective immediately, the Organiz...
Finding #2025-001 – Internal Control Over Compliance - Activities Allowed or Unallowed and Allowable Costs/Cost Principles Contact – Suzanne Tobin, Chief Financial Officer Telephone Number – (301)-832-3810 Completion Date – December 15, 2025 Corrective Action Plan: Effective immediately, the Organization will strictly enforce its policy for supervisory review and approval of employees’ time sheets and invoices. To ensure compliance with this policy, the Organization will conduct random checks of time sheets and invoices every pay period to verify that supervisory approval is performed. Appropriate disciplinary action will be implemented for non-compliance.
Finding 1165234 (2025-004)
Material Weakness 2025
2025-004: Lack of Controls over Reporting Issue: Program reports were submitted without a documented supervisory review to ensure accuracy, completeness, and compliance with reporting requirements. Corrective Actions: 1. Establish a standardized finance report review procedure for all program report...
2025-004: Lack of Controls over Reporting Issue: Program reports were submitted without a documented supervisory review to ensure accuracy, completeness, and compliance with reporting requirements. Corrective Actions: 1. Establish a standardized finance report review procedure for all program reports, including a required supervisory review before submission. 2. Implement a review checklist that includes verification of data sources, accuracy of totals, reconciliation of reported information, and confirmation that all reporting elements required by the funding agency are included. 3. Require documented evidence of review, such as supervisor signatures or electronic approval recorded in the reporting system. 4. Train all reporting and supervisory staff on the new procedures, expectations, and documentation requirements. Responsible Personnel: Grant Accountants, CFO, Program Managers Timeline: Procedures will be finalized within 10 days. Staff training will occur within 30 days. The new review process will be fully implemented by the next reporting cycle for reports due for Q2. Monitoring: Compliance will conduct quarterly spot checks to confirm adherence to the new review procedures and report results to leadership.
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