Corrective Action Plans

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Finding 1217738 (2025-003)
Material Weakness 2025
Finding 2025-003 – Untimely Return of Security Deposits Name of contact person: Lisa Fischer, (Chief Operating Officer) Corrective action: Management agrees with the finding and has implemented procedures to monitor tenant move-outs, document amounts due to former tenants, and issue refund checks in...
Finding 2025-003 – Untimely Return of Security Deposits Name of contact person: Lisa Fischer, (Chief Operating Officer) Corrective action: Management agrees with the finding and has implemented procedures to monitor tenant move-outs, document amounts due to former tenants, and issue refund checks in a timely manner. Proposed completion date: Management has corrected the finding.
Finding 1217731 (2025-002)
Material Weakness 2025
FINDING 2025-002: Unauthorized receipt of COVID-19 Supplemental Payments (CSP) Corrective action - The applications for reimbursement for program periods 1 through 3 were made in error. Management has contacted HUD and is awaiting a response.
FINDING 2025-002: Unauthorized receipt of COVID-19 Supplemental Payments (CSP) Corrective action - The applications for reimbursement for program periods 1 through 3 were made in error. Management has contacted HUD and is awaiting a response.
Finding 1217726 (2025-001)
Material Weakness 2025
FINDING 2025-001: Unauthorized fees paid by the Corporation Corrective action - Management has reached out to HUD to determine a course of action and are waiting for a response.
FINDING 2025-001: Unauthorized fees paid by the Corporation Corrective action - Management has reached out to HUD to determine a course of action and are waiting for a response.
Internal Control Over Reporting Department of Human Services – Grants to States for Medicaid – Assistance Listing No. 93.778 Recommendation: We recommend that the County enact controls to assure employees included in grant are included in reporting submitted. Explanation of disagreement with audit f...
Internal Control Over Reporting Department of Human Services – Grants to States for Medicaid – Assistance Listing No. 93.778 Recommendation: We recommend that the County enact controls to assure employees included in grant are included in reporting submitted. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement procedures to ensure that all reports are reviewed prior to submission. Names of the contact person responsible for corrective action: Pat Paquin, Finance Manager Planned completion date for corrective action plan: December 31, 2026
Finding 1217684 (2025-003)
Material Weakness 2025
We will ensure that security deposits collected will be transferred to the security deposit bank account timely.
We will ensure that security deposits collected will be transferred to the security deposit bank account timely.
Finding 1217683 (2025-002)
Material Weakness 2025
We will develop a procedure to ensure the required monthly deposits to the replacement reserve are made timely.
We will develop a procedure to ensure the required monthly deposits to the replacement reserve are made timely.
Findings #2025-004 and #2025-006 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, 93.566, Refugee and Entrant Assistance State/Replacement Designee Administered Programs, Passed through Texas Office for Refugees: 10/01/24 –...
Findings #2025-004 and #2025-006 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, 93.566, Refugee and Entrant Assistance State/Replacement Designee Administered Programs, Passed through Texas Office for Refugees: 10/01/24 – 09/30/25, FFY2025-27946V-ASA RSS, 10/01/24 – 09/30/25, FFY2025-27946V-AUSAA-RSS, 10/01/24 – 09/30/25, FFY2025-27946V-CMA, 10/01/24 – 09/30/25, FFY2025-27946V-RSS, Passed through United States Conference of Catholic Bishops: 10/01/24 – 09/30/25, 25RSI13A, Passed through U. S. Committee for Refugees: 10/01/24 – 09/30/25, RHP-2025-YMCA-Houston TX-03, 93.567, Refugee and Entrant Assistance Voluntary Agency Programs, Passed through U. S. Committee for Refugees and Immigrants: 10/01/24 – 09/30/25, 2502VARVMG, 10/01/23 – 09/30/24, 2402VARVMG, 93.676, Unaccompanied Alien Children Program, Passed through U. S. Committee for Refugees and Immigrants: 01/01/25 – 12/31/25, 90ZU0630-02. Condition and context: During our testing of the accuracy of accounts payable cutoff and the testing of allowable costs charged to major programs, the following exceptions were identified for expenses recorded in the incorrect period: 3 of 19 subsequent disbursement transactions tested were recorded in the incorrect accounting period. Refugee and Entrant Assistance State/Replacement Designee Administered Programs (ALN 93.566) – 3 out of 40 transactions tested were recorded to the incorrect accounting period. Unaccompanied Alien Children Program (ALN 93.676) – 1 out 40 transactions tested was recorded in the incorrect accounting period. Refugee and Entrant Assistance Voluntary Agency Programs (ALN 93.567) – 1 out of 40 transactions tested was recorded in the incorrect accounting period. Recommendation: Policies and procedures should be enhanced for proper identification of the period that expenses relate to so that expenses will be recorded in the correct accounting period for financial statement reporting and for billing allowable costs to federal programs. Planned corrective action: Management acknowledges the deficiency identified related to the precision of procedures to ensure expenses are recorded in the appropriate accounting period. Processes were in place and operated to identify and record expenses in the correct period, and management’s review procedures are designed to capture all material items for financial reporting and program compliance purposes. The exceptions identified through audit testing represent a limited number of timing differences in a high-volume environment, primarily related to the timing of invoice receipt and processing, and were not material individually or in the aggregate. These items were recorded in the subsequent period in the normal course of operations and do not reflect a systemic breakdown in controls. In response, management has reinforced month-end cutoff procedures, including enhanced review of subsequent disbursements and clearer expectations around accrual identification and invoice timing. Management will continue to monitor cutoff procedures to ensure expenses are recorded in the appropriate period with an appropriate level of precision while maintaining timely vendor payment practices. Responsible officer: Lauren Rome, VP of Financial Operations/Interim CFO. Estimated completion date: June 15, 2026
Findings #2025-001 and #2025-005 – Material Weakness. Applicable federal programs: U. S. Department of Health and Human Services, 93.566, Refugee and Entrant Assistance State/Replacement Designee Administered Programs, Passed through Texas Office for Refugees: 10/01/24 – 09/30/25, FFY2025-27946V-ASA...
Findings #2025-001 and #2025-005 – Material Weakness. Applicable federal programs: U. S. Department of Health and Human Services, 93.566, Refugee and Entrant Assistance State/Replacement Designee Administered Programs, Passed through Texas Office for Refugees: 10/01/24 – 09/30/25, FFY2025-27946V-ASA RSS, 10/01/24 – 09/30/25, FFY2025-27946V-AUSAA-RSS, 10/01/24 – 09/30/25, FFY2025-27946V-CMA, 10/01/24 – 09/30/25, FFY2025-27946V-RSS, Passed through United States Conference of Catholic Bishops: 10/01/24 – 09/30/25, 25RSI13A, Passed through U. S. Committee for Refugees: 10/01/24 – 09/30/25, RHP-2025-YMCA-Houston TX-03, 93.567, Refugee and Entrant Assistance Voluntary Agency Programs, Passed through U. S. Committee for Refugees and Immigrants: 10/01/24 – 09/30/25, 2502VARVMG, 10/01/23 – 09/30/24, 2402VARVMG, 93.676, Unaccompanied Alien Children Program, Passed through U. S. Committee for Refugees and Immigrants: 01/01/25 – 12/31/25, 90ZU0630-02. Condition and context: During the planning phase of the audit, management disclosed that amounts reported as employee withholdings on Form 941 had been intentionally manipulated by the former payroll director resulting over reporting withholdings to the Internal Revenue Service. Management did not have a formal reconciliation process in place to compare Form 941 to the payroll register and general ledger, nor was there a periodic reconciliation of the payroll register to the general ledger. The absence of these independent reconciliation controls allowed the misstatement to occur and not be detected in a timely manner. In our testing of 110 payroll transactions, we identified the following exceptions: Refugee and Entrant Assistance State/Replacement Designee Administered Programs (ALN 93.566) – 1 out of 40 payroll transactions tested utilized the incorrect pay rate. Unaccompanied Alien Children Program (ALN 93.676) – 1 out of 40 payroll transactions tested utilized the incorrect pay rate. Refugee and Entrant Assistance State/Replacement Designee Administered Programs (ALN 93.566) – 1 out of 40 payroll transactions tested was incorrectly charged to the program. Additionally, in testing the reconciliation of payroll expense recorded in the payroll register to the amount recorded in the general ledger system, an error of $349,000 was identified. The error was related to credit card charges erroneously being recorded to payroll expense. Recommendation: Policies and procedures should be designed and implemented to prepare a formal reconciliation of Form 941 to the payroll register and the general ledger and a reconciliation between the payroll register and the general ledger. Additionally, procedures should be strengthened over the review of pay rates utilized in the payroll system and the allocation of payroll to cost centers and government programs. Planned corrective action: Management acknowledges the deficiency identified in the execution and precision of payroll reconciliation processes. During the audit planning phase, management disclosed that a former payroll director intentionally manipulated employee withholding amounts reported on Form 941 in prior periods. While reconciliation procedures between the payroll register, general ledger, and Form 941 filings were in place, they were not performed with sufficient precision and consistency to detect the misstatement in a timely manner. Additionally, audit testing identified isolated instances of incorrect payrates and program allocations, as well as a misclassification of approximately $349,000 related to credit card return charges recorded to accrued payroll; management has confirmed this item represents a classification error and not an issue impacting payroll processing or employee compensation. In response, management has refined reconciliation procedures to require more detailed comparison across systems, established clearer expectations for investigation and resolution of variances, and enhanced documentation standards to evidence the level of review performed. Management has also strengthened oversight of payroll activity, including review of payrates and allocation of payroll costs to programs, and will continue to monitor these controls to ensure they are operating with an appropriate level of precision and consistency. In May 2026, an interim leadership structure was established in response to the departure of the Chief Financial Officer. During this interim period management is assessing departmental functions and organizational structure to better align responsibilities and further strengthen internal controls in the areas noted above. Responsible officer: Lauren Rome, VP of Financial Operations/Interim CFO. Estimated completion date: June 15, 2026.
Finding #2025-008 – Eligibility – Material Weakness and Material Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, 93.566, Refugee and Entrant Assistance State/Replacement Designee Administered Programs, Passed through Texas Office for Refugees: 10/01/24 – 09...
Finding #2025-008 – Eligibility – Material Weakness and Material Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, 93.566, Refugee and Entrant Assistance State/Replacement Designee Administered Programs, Passed through Texas Office for Refugees: 10/01/24 – 09/30/25, FFY2025-27946V-ASA RSS, 10/01/24 – 09/30/25, FFY2025-27946V-AUSAA-RSS, 10/01/24 – 09/30/25, FFY2025-27946V-CMA, 10/01/24 – 09/30/25, FFY2025-27946V-RSS, Passed through United States Conference of Catholic Bishops: 10/01/24 – 09/30/25, 25RSI13A, Passed through U. S. Committee for Refugees: 10/01/24 – 09/30/25, RHP-2025-YMCA-Houston TX-03, 93.567, Refugee and Entrant Assistance Voluntary Agency Programs, Passed through U. S. Committee for Refugees and Immigrants: 10/01/24 – 09/30/25, 2502VARVMG, 10/01/23 – 09/30/24, 2402VARVMG. Condition and context: The following exceptions were noted in the testing of eligibility and maintenance of documentation: Refugee and Entrant Assistance State/Replacement Designee Administered Programs – 25 out of 40 files tested for eligibility and maintenance of documentation were incomplete and lacked information to support the eligibility of the participants, and 5 out of 40 files could not be located. Refugee and Entrant Assistance Voluntary Agency Programs – 11 out of 40 files tested for eligibility and maintenance of documentation were incomplete and lacked information to support the eligibility of the participants. Planned corrective action: Management acknowledges the deficiencies identified related to documentation and retention of eligibility determinations and notes that the programs associated with this finding are no longer active within the organization. The organization maintained procedures for determining client eligibility prior to the provision of services; however, in certain instances, supporting documentation was either incomplete or not available for review at the time of audit testing. Management conducted an extensive search for the requested files and determined that the missing or incomplete documentation was primarily attributable to operational disruption during a period of organizational transition, including staffing changes and the transfer or wind-down of the specific programs noted. While documentation was not consistently retained or retrievable in these instances, management does not believe this indicates that eligibility determinations were not performed. In response, management has reinforced documentation and retention procedures across current programs, including clearer expectations for file completeness and centralized retention practices to ensure documentation remains accessible regardless of staffing or program transitions. Management will continue to monitor compliance with these procedures to strengthen consistency in documentation and retention of eligibility determinations. Responsible officer: Lauren Rome, VP of Financial Operations/Interim CFO. Estimated completion date: May 15, 2026
Finding #2025-007 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Health and Human Services, 93.567, Refugee and Entrant Assistance Voluntary Agency Programs, Passed through U. S. Committee for Refugees and Immigrants: 10/01/24 – 09/30/25, 2502VARVMG...
Finding #2025-007 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Health and Human Services, 93.567, Refugee and Entrant Assistance Voluntary Agency Programs, Passed through U. S. Committee for Refugees and Immigrants: 10/01/24 – 09/30/25, 2502VARVMG, 10/01/23 – 09/30/24, 2402VARVMG. Condition and context: During our testing of 40 transactions reported as matching grant costs, we identified one exception totaling $2,679 with lack of documentation of fair value of in-kind donations. Recommendation: Provide additional training and emphasize adherence to established policies and procedures to ensure maintenance of documentation for valuation documentation. Planned corrective action: Management acknowledges the exception identified related to documentation supporting the fair value of an in-kind contribution. The organization maintains policies and procedures requiring that matching contributions be verifiable, appropriately valued, and supported by documentation; however, in this instance, documentation for one volunteer timesheet totaling $2,679 was not available for review. Management conducted an extensive search for the supporting documentation and determined the absence was due to records associated with a former employee that were not retained following a staffing transition. In response, management has reinforced documentation retention expectations and procedures related to in-kind contributions, including centralized retention practices to reduce reliance on individual personnel. Management will continue to monitor compliance with these procedures to ensure documentation supporting matching contributions is consistently maintained. Responsible officer: Lauren Rome, VP of Financial Operations/Interim CFO. Estimated completion date: May 15, 2026
Management agrees with the finding and acknowledges that the Schedule of Expenditures of Federal Awards (SEFA) was not prepared accurately and completely in accordance with Uniform Guidance requirements. In response, the City will strengthen its procedures over SEFA preparation and review to ensure ...
Management agrees with the finding and acknowledges that the Schedule of Expenditures of Federal Awards (SEFA) was not prepared accurately and completely in accordance with Uniform Guidance requirements. In response, the City will strengthen its procedures over SEFA preparation and review to ensure the schedule is complete, accurate, and supported by underlying accounting records. Corrective action will include the following: 1. Establish a centralized federal awards listing - Management will maintain a current listing of all federal awards received and expended during the fiscal year. This listing will include the federal agency, pass-through entity (if applicable), Assistance Listing number, contract or grant number, and whether the award was received directly or indirectly. 2. Implement a formal SEFA preparation process - At year-end, management will prepare the SEFA using expenditure information derived from the general ledger, grant reimbursement requests, grant agreements, and other supporting documentation. Federal expenditures will be accumulated by program and reconciled to the accounting records. 3. Perform a documented reconciliation - Prior to issuance of the SEFA, management will perform and retain a formal reconciliation of SEFA amounts to the general ledger and other supporting records to verify completeness and accuracy of reported expenditures. 4. Provide training to responsible personnel - Personnel involved in grant accounting and SEFA preparation will receive training on Uniform Guidance SEFA requirements, including requirements related to completeness, pass-through awards, Assistance Listing numbers, and presentation of federal expenditures.
2025-003 Inadequate Contract Review Name of Contact Person: Samantha Hurd, DSS Director Corrective Action: The Deaprtment of Social Services will implement new review procedures to verify that all certifications and provisions are included in contracts for the purchase of services. Proposed Completi...
2025-003 Inadequate Contract Review Name of Contact Person: Samantha Hurd, DSS Director Corrective Action: The Deaprtment of Social Services will implement new review procedures to verify that all certifications and provisions are included in contracts for the purchase of services. Proposed Completion Date: May 31, 2026.
Name of Contact Person: Jeffrey Hartung, Finance Director. Corrective Action: Management concurs with the recommendation and is working toward more timely completion and closing of the accounting records for audit. Proposed Completion Date: Immediately.
Name of Contact Person: Jeffrey Hartung, Finance Director. Corrective Action: Management concurs with the recommendation and is working toward more timely completion and closing of the accounting records for audit. Proposed Completion Date: Immediately.
Finding Number: 2025-005 Planned Corrective Action: Management is implementing additional review and validation procedures for UDS reporting. Corrective actions include formal UDS preparation and review protocols, standardized validation checklists, retention of supporting documentation, and annual ...
Finding Number: 2025-005 Planned Corrective Action: Management is implementing additional review and validation procedures for UDS reporting. Corrective actions include formal UDS preparation and review protocols, standardized validation checklists, retention of supporting documentation, and annual training for personnel responsible for preparing and reviewing HRSA reports. Anticipated Completion Date: 12/31/2026 Responsible Contact Person: Charles Tong, Chief Financial Officer
Finding Number: 2025-004 Planned Corrective Action: Management has already begun to implement corrective actions to strengthen compliance with HRSA Sliding Fee Discount Program requirements. Corrective measures include updating sliding fee procedures, annual staff training, monthly quality assurance...
Finding Number: 2025-004 Planned Corrective Action: Management has already begun to implement corrective actions to strengthen compliance with HRSA Sliding Fee Discount Program requirements. Corrective measures include updating sliding fee procedures, annual staff training, monthly quality assurance reviews, and ongoing management oversight of sliding fee adjustments and supporting documentation. Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Charles Tong, Chief Financial Officer
Implement cross training of staff member, maintain updated procedures for tasks, and establish backup coverage for critical reporting functions to mitigate the impact of future staffing changes in the reporting compliance process. Anticipated completion date: December 31, 2026. Responsible contact: ...
Implement cross training of staff member, maintain updated procedures for tasks, and establish backup coverage for critical reporting functions to mitigate the impact of future staffing changes in the reporting compliance process. Anticipated completion date: December 31, 2026. Responsible contact: Mike Gagliardi, Administrator.
Training for all Medicaid staff on correct determination of income, resources, ownership, household composition, proper verification requests (clarity and completeness), and timely processing of recertifications. Ongoing Quality Assurance Second-party reviews will continue to ensure compliance with ...
Training for all Medicaid staff on correct determination of income, resources, ownership, household composition, proper verification requests (clarity and completeness), and timely processing of recertifications. Ongoing Quality Assurance Second-party reviews will continue to ensure compliance with Medicaid policy and to catch errors in real time. Starting in 2026, the agency will conduct mandatory quarterly training sessions focused on accuracy, policy updates, and lessons learned from reviews and audits.
Corrective Action Planned: Due to the Authority's size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size. Completion Date: Ongo...
Corrective Action Planned: Due to the Authority's size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size. Completion Date: Ongoing
Statement of Condition: During our testing of participant eligibility for the WIOA Cluster, we identified an instance in which a male participant subject to Selective Service requirements was not registered with the Selective Service System, and no evidence of registration verification or documented...
Statement of Condition: During our testing of participant eligibility for the WIOA Cluster, we identified an instance in which a male participant subject to Selective Service requirements was not registered with the Selective Service System, and no evidence of registration verification or documented exemption was maintained in the participant file. Management Response and Corrective Action Plan: Management agrees with the recommendation and has developed a guideline in which a participant is not to be co-enrolled in WIOA Youth while being enrolled in another youth program. Responsibility of: Chief Finance and Admin Officer, Sherri Emitte Planned Implementation Date of Corrective Action Plan: 2026 Audit
Statement of Condition: During our testing of compliance with requirements applicable to major federal programs, we noted that the entity did not have formal, consistently applied review and approval controls over key compliance areas. Specifically, evidence of supervisory review and approval was no...
Statement of Condition: During our testing of compliance with requirements applicable to major federal programs, we noted that the entity did not have formal, consistently applied review and approval controls over key compliance areas. Specifically, evidence of supervisory review and approval was not consistently documented for compliance-related transactions. As a result, review procedures appear to be informal, inconsistent, or reliant on individual practices rather than standardized, documented controls. Management Response and Corrective Action Plan: Management agrees with the recommendation and has developed a much more stringent review and approval process. Responsibility of: Chief Finance and Admin Officer, Sherri Emitte Planned Implementation Date of Corrective Action Plan: 2026 Audit
Adeline Montessori School will establish a policy for recording, safeguarding, and maintaining property and equipment purchased with federal funding.
Adeline Montessori School will establish a policy for recording, safeguarding, and maintaining property and equipment purchased with federal funding.
Adeline Montessori School will establish a policy for not entering into a contract with a party that is suspended or debarred and follow this policy for future purchases.
Adeline Montessori School will establish a policy for not entering into a contract with a party that is suspended or debarred and follow this policy for future purchases.
Adeline Montessori School will comply with its procurement policy related to noncompetitive procurement transactions for future purchases.
Adeline Montessori School will comply with its procurement policy related to noncompetitive procurement transactions for future purchases.
Condition: During audit fieldwork, we noted the District’s management has not received a bank reconciliation from the Calumet Township Treasurer for pooled cash and investments. This represents a material weakness in the internal control over financial reporting. Plan: The Superintendent, along with...
Condition: During audit fieldwork, we noted the District’s management has not received a bank reconciliation from the Calumet Township Treasurer for pooled cash and investments. This represents a material weakness in the internal control over financial reporting. Plan: The Superintendent, along with staff, will work with the Calumet Township Treasurer to ensure that monthly bank reconciliations and support documents are performed and received prior to or during audit fieldwork. Anticipated Date of Completion: June 30, 2026 Name of Contact Person: Sheryl Colemen – Chief School Board Official Management Response: The CSBO and Superintendent will work with the Calumet Township Treasurer to establish a process to receive monthly bank reconciliation for the pooled cash and investments.
Management agrees with the finding that sliding fee discounts must be applied consistently and in accordance with our approved policy. We are committed to ensuring access to care while maintaining compliance with HRSA program requirements. To strengthen compliance with our sliding fee discount polic...
Management agrees with the finding that sliding fee discounts must be applied consistently and in accordance with our approved policy. We are committed to ensuring access to care while maintaining compliance with HRSA program requirements. To strengthen compliance with our sliding fee discount policy, East Valley Community Health Center has implemented several corrective measures. Re-training for intake and billing staff began in April 2025 and is ongoing as part of our quarterly training cycle. In addition, we are currently reviewing our sliding fee discount policy and procedures to ensure they are clear, consistently applied, and aligned with HRSA guidance and the Health Center Program Compliance Manual. Monthly audits of patient encounters involving sliding fee adjustments began in October 2024 by the billing department and are now a permanent component of our internal compliance process. Audit results are reviewed by our Revenue Cycle Manager and shared with Health Center Administrators and Patient Access Manager, Front Office Leads, and Senior Leadership to ensure accountability and timely corrective action when needed. The CFO is responsible for overseeing these processes and ensuring that all compliance measures are implemented effectively.
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