Corrective Action Plans

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Finding Number: 2025-017 Planned Corrective Action: Beginning in the 2025-26 fiscal year, the Immunization Section implemented a policy requiring field staff to complete a compliance site visit to all providers in their assigned areas at least annually, rather than the two-year requirement establish...
Finding Number: 2025-017 Planned Corrective Action: Beginning in the 2025-26 fiscal year, the Immunization Section implemented a policy requiring field staff to complete a compliance site visit to all providers in their assigned areas at least annually, rather than the two-year requirement established by the Centers for Disease Control and Prevention (CDC) Vaccines for Children program. Spreadsheets were created to track assigned sites and due dates. Completion of compliance visits has also been added to field staff performance standards. The new policy also updated the process for conducting and documenting Orientation Site Visits (OSR). The program requires staff to conduct OSRs in person. Documentation is uploaded in CDC’s Provider Education, Assessment, and Reporting online system, and back-up documentation is uploaded to a FDOH shared drive and reviewed by the field staff’s supervisor. The supervisor maintains a spreadsheet with information on site visits and OSRs and follows up with staff on any missing documentation. Anticipated Completion Date: June 30, 2026 Responsible Contact Person: Tom Bendle
Finding Number: 2025-016 Planned Corrective Action: Immunization Section staff will implement a second level review on all expenditures to ensure they occurred in the authorized period of performance and make corrections when errors are identified. Anticipated Completion Date: June 30, 2026 Responsi...
Finding Number: 2025-016 Planned Corrective Action: Immunization Section staff will implement a second level review on all expenditures to ensure they occurred in the authorized period of performance and make corrections when errors are identified. Anticipated Completion Date: June 30, 2026 Responsible Contact Person: Tom Bendle
Finding Number: 2025-015 Planned Corrective Action: To prevent future late submissions, the Department will strengthen communication on grant closeout timelines, implement a formal tracking tool for Federal Financial Report (FFR) deadlines, cross train staff, establish written procedures, and increa...
Finding Number: 2025-015 Planned Corrective Action: To prevent future late submissions, the Department will strengthen communication on grant closeout timelines, implement a formal tracking tool for Federal Financial Report (FFR) deadlines, cross train staff, establish written procedures, and increase management oversight through routine compliance reviews. Anticipated Completion Date: June 30, 2026 Responsible Contact Person: Curtis Barker
Finding Number: 2025-014 Planned Corrective Action: Expenditures reviewed were for services or travel that occurred in June at the end of the grant budget period/state fiscal year but were paid by the Florida Department of Health (Department, FDOH) in July. During this time new Other Cost Accumulato...
Finding Number: 2025-014 Planned Corrective Action: Expenditures reviewed were for services or travel that occurred in June at the end of the grant budget period/state fiscal year but were paid by the Florida Department of Health (Department, FDOH) in July. During this time new Other Cost Accumulators (OCA) are created to match the new budget period/state fiscal year. Of the 16 expenditures provided to the Public Health Emergency Preparedness Program (PHEP) for review, 11 were for purchasing card (Pcard) charges for travel that occurred at the end of June but cleared in July. Previous year’s codes are not available when clearing Pcard charges from a previous fiscal year. The remaining expenditures were for payments that were redistributed by finance and accounting and could not be charged to current fiscal year OCAs once the new fiscal year began. Language has been added to the PHEP’s checkbook review process to specifically identify expenses that occur at the end of a budget period/fiscal year but are cleared or paid at the beginning of the next fiscal year. A correction will be submitted to move those expenses to the previous fiscal year as appropriate. Anticipated Completion Date: Completed Responsible Contact Person: Jennifer Coulter
Finding Number: 2025-006 Planned Corrective Action: Effective July 1, 2025, FCOM implemented new processes and procedures to enhance FFATA reporting controls and ensure the accuracy and timeliness of the subaward data reported in the SAM.GOV. Anticipated Completion Date: 7/1/2025 Responsible Contact...
Finding Number: 2025-006 Planned Corrective Action: Effective July 1, 2025, FCOM implemented new processes and procedures to enhance FFATA reporting controls and ensure the accuracy and timeliness of the subaward data reported in the SAM.GOV. Anticipated Completion Date: 7/1/2025 Responsible Contact Person: Tisha Womack
Finding Number: 2025-013 Planned Corrective Action: Effective July 1, 2025, FCOM implemented new processes and procedures to enhance FFATA reporting controls and ensure the accuracy and timeliness of the subaward data reported in the SAM.GOV. Anticipated Completion Date: 7/1/2025 Responsible Contact...
Finding Number: 2025-013 Planned Corrective Action: Effective July 1, 2025, FCOM implemented new processes and procedures to enhance FFATA reporting controls and ensure the accuracy and timeliness of the subaward data reported in the SAM.GOV. Anticipated Completion Date: 7/1/2025 Responsible Contact Person: Tisha Womack
Finding Number: 2025-012 Planned Corrective Action: Security controls will be implemented at the Department’s secure remote access gateway. Additionally, security controls will be implemented at the application/system level. Anticipated Completion Date: The dates are June 30, 2027, and December 31, ...
Finding Number: 2025-012 Planned Corrective Action: Security controls will be implemented at the Department’s secure remote access gateway. Additionally, security controls will be implemented at the application/system level. Anticipated Completion Date: The dates are June 30, 2027, and December 31, 2028, respectively. Responsible Contact Person: The contacts are Michele Baxley-Branch, Service Maintenance Process Owner, and Kevin Wiggins, Information Security Manager, respectively.
Finding Number: 2025-011 Planned Corrective Action: FCOM submitted a Legislative Budget Request to obtain funding for resources to implement an Identity Access Management tool. The estimated cost is $990,550. The estimated resolution date is June 30, 2027, provided FCOM receives funding to resolve t...
Finding Number: 2025-011 Planned Corrective Action: FCOM submitted a Legislative Budget Request to obtain funding for resources to implement an Identity Access Management tool. The estimated cost is $990,550. The estimated resolution date is June 30, 2027, provided FCOM receives funding to resolve the issue. Anticipated Completion Date: June 30, 2027 Responsible Contact Person: Roosevelt Petithomme/Wendy Castle
Finding Number: 2025-010 Planned Corrective Action: FCOM worked with its Employ Florida vendor and deployed a fix for the connectivity issue between Reconnect and Employ Florida in January 2025. A follow up meeting in April of 2025 where the issue was discussed did not reveal that the issue persiste...
Finding Number: 2025-010 Planned Corrective Action: FCOM worked with its Employ Florida vendor and deployed a fix for the connectivity issue between Reconnect and Employ Florida in January 2025. A follow up meeting in April of 2025 where the issue was discussed did not reveal that the issue persisted. In February 2026, the Auditor General notified FCOM that the fiscal year 2024/2025 audit revealed that the connectivity issue raised previously may still persist. FCOM is currently conducting an evaluation of the Auditor General’s sample and its larger datasets to isolate the variables causing these inconsistencies to determine if the issue has been resolved or if there is potentially a new connectivity issue to be resolved. The updated resolution will be completed by December 31, 2026. Anticipated Completion Date: December 31, 2026 Responsible Contact Person: Roosevelt Petithomme/Wendy Castle
Finding Number: 2025-009 Planned Corrective Action: FCOM is working with the development team to remediate the listed security controls and will develop the necessary changes by June 30, 2026. Anticipated Completion Date: June 30, 2026 Responsible Contact Person: Roosevelt Petithomme/Paul Forrester
Finding Number: 2025-009 Planned Corrective Action: FCOM is working with the development team to remediate the listed security controls and will develop the necessary changes by June 30, 2026. Anticipated Completion Date: June 30, 2026 Responsible Contact Person: Roosevelt Petithomme/Paul Forrester
Finding Number: 2025-008 Planned Corrective Action: In the 2026 Legislative Session, FCOM submitted a Legislative Budget Request to obtain funding for resources to implement an Identity Access Management tool which would resolve this finding. The estimated cost is $990,550. The estimated resolution ...
Finding Number: 2025-008 Planned Corrective Action: In the 2026 Legislative Session, FCOM submitted a Legislative Budget Request to obtain funding for resources to implement an Identity Access Management tool which would resolve this finding. The estimated cost is $990,550. The estimated resolution date is June 30, 2027, provided FCOM receives funding to resolve the issue. Anticipated Completion Date: June 30, 2027 Responsible Contact Person: Roosevelt Petithomme
Finding Number: 2025-007 Planned Corrective Action: FCOM submitted a Legislative Budget Request to obtain funding for resources to ensure system code changes are corrected; however, FCOM is continuing development of the functional design documentation. The estimated resolution date is June 30, 2027....
Finding Number: 2025-007 Planned Corrective Action: FCOM submitted a Legislative Budget Request to obtain funding for resources to ensure system code changes are corrected; however, FCOM is continuing development of the functional design documentation. The estimated resolution date is June 30, 2027. Anticipated Completion Date: June 30, 2027 Responsible Contact Person: Roosevelt Petithomme/Paul Forrester
Finding Number: 2025-005 Planned Corrective Action: Effective July 1, 2025, FCOM implemented new processes and procedures to enhance FFATA reporting controls and ensure the accuracy and timeliness of the subaward data reported in the SAM.GOV. Anticipated Completion Date: 7/1/2025 Responsible Contact...
Finding Number: 2025-005 Planned Corrective Action: Effective July 1, 2025, FCOM implemented new processes and procedures to enhance FFATA reporting controls and ensure the accuracy and timeliness of the subaward data reported in the SAM.GOV. Anticipated Completion Date: 7/1/2025 Responsible Contact Person: Tisha Womack
Finding Number: 2025-004 Planned Corrective Action: During training on the new Federal Funding Accountability and Transparency Act (FFATA) reporting system, the department understood federal guidance to require the creation of a new report each month, consistent with the process used in the previous...
Finding Number: 2025-004 Planned Corrective Action: During training on the new Federal Funding Accountability and Transparency Act (FFATA) reporting system, the department understood federal guidance to require the creation of a new report each month, consistent with the process used in the previous system. However, the department later discovered that the new system aggregates amounts cumulatively across reports. As a result, generating new reports each month inadvertently created the appearance of overstated expenditures. The correct procedure is to update the existing report rather than create a new one. This issue was identified and resolved within three months (three reporting periods). Since implementing the corrected process, the department’s reporting has been accurate and compliant. The Department will continue to follow the current procedure, which has proven effective and ensures the integrity of its reporting. Anticipated Completion Date: The department’s new process was implemented June 2025. Responsible Contact Person: Jim Lewandowski, Division of Administration, Chief of Finance and Accounting; Trisha Williams, Assistant Chief of Finance and Accounting
Finding Number: 2025-003 Planned Corrective Action: To address this finding, FNW immediately implemented a temporary solution. On or about September 8, 2025, FNW created a ticket to commence work on a permanent solution to address the audit finding. The solution deployed on March 18, 2026. Anticipat...
Finding Number: 2025-003 Planned Corrective Action: To address this finding, FNW immediately implemented a temporary solution. On or about September 8, 2025, FNW created a ticket to commence work on a permanent solution to address the audit finding. The solution deployed on March 18, 2026. Anticipated Completion Date: March 18, 2026 Responsible Contact Person: Terricka Washington, Division of Food, Nutrition and Wellness Information Office/LaSharonté Williams-Potts, Assistant Division Director
Corrective Action Plan 2025-003: Student Financial Aid and Accounts Receivable will work in coordination to sync the process of importing files and posting to accounts on the same day. Our new ERP has streamlined reporting to COD and catches and corrects any date discrepancies between the two system...
Corrective Action Plan 2025-003: Student Financial Aid and Accounts Receivable will work in coordination to sync the process of importing files and posting to accounts on the same day. Our new ERP has streamlined reporting to COD and catches and corrects any date discrepancies between the two systems. This finding was directly related to the migration from our old system and the disruption of data flow. Additionally, a review for matching COD disbursement dates will now be included during the monthly reconciliation process moving forward as a second layer of quality control. Anticipated Completion Date: June 30, 2026 Contact Person: Mary Reed, Director of Financial Aid & Advising
Corrective Action Plan 2025-004: The University will update its procurement procedures to require documented verification of vendor eligibility prior to award and when using the simplified acquisition procedure and to obtain price or rate quotations from an adequate number of qualified sources. Anti...
Corrective Action Plan 2025-004: The University will update its procurement procedures to require documented verification of vendor eligibility prior to award and when using the simplified acquisition procedure and to obtain price or rate quotations from an adequate number of qualified sources. Anticipated Completion Date: June 30, 2026 Contact Person: Tom Corley, Controller
Corrective Action Plan 2025-002: This finding is related to the transition to a new Jenzabar One (J1) ERP system. The Jenzabar Financial Aid (JFA) module, while now integrated into the broader J1 suite, remains a stand-alone solution rather than a fully native component. As a result, Ottawa Universi...
Corrective Action Plan 2025-002: This finding is related to the transition to a new Jenzabar One (J1) ERP system. The Jenzabar Financial Aid (JFA) module, while now integrated into the broader J1 suite, remains a stand-alone solution rather than a fully native component. As a result, Ottawa University needed to modify its financial aid refund disbursement processes to ensure accurate and efficient data flow between systems. These adjustments created challenges in achieving the timely distribution of student refunds. The primary issue involved the timely processing of PLUS Loan refunds. Parent IDs for these refunds were extracted from financial aid data in JFA and established as individual vendors in J1. These IDs then needed to be properly linked to the corresponding student before any parent refunds could be issued. To address this, Financial Aid has designated staff to oversee the creation and linking of parent IDs in J1 to ensure timely processing. Additionally, reports have been developed to identify accounts eligible for refunds, helping to ensure compliance with the 14-day requirement. The Accounting Department also encountered challenges related to vendor setup and the ability to process student refunds in batches. To address these issues, we collaborated with the J1 support team and IT to customize the system, ensuring that student refund checks could be processed and formatted in accordance with bank specifications. While we were not initially prepared for these challenges and had to adapt throughout the process, a solution has since been implemented. As a result, check printing has become an efficient and streamlined operation. The Student Accounts Receivable Office, Controller’s Office, Financial Aid, and IT departments are actively collaborating to establish a more structured and efficient process for managing Federal Student Aid. The first step has been to implement a weekly workflow with clearly defined responsibilities and completion timelines as follows: Financial Aid posts all activity at the beginning of the week, followed by Student Accounts generating credit balance refund reports and initiating student refunds. Accounting then completes the process by issuing refunds to students via check or direct deposit. In addition, Student Accounts and IT are working to develop a datespecific report to identify students with current financial aid disbursements who have outstanding credit balances. This detective control report will be reviewed weekly, and refunds will be processed in accordance with the established workflow. The departments are also developing a detailed Accounts Receivable Aging Report to help the Receivables team more effectively identify any students who have a credit balance. This effort is intended to ensure full compliance with the 14-day requirement outlined in the Federal Student Aid Handbook. Anticipated Completion Date: June 30, 2026 Contact Person: Heather Long, Director of Student Accounts
Corrective Action Plan 2025‐001: The Registrar and the IT department are working together to ensure timely and accurate data is being transmitted on a regular schedule to the Clearinghouse as needed. When date determination exceptions occur (e.g., degrees being conferred after initial reporting or w...
Corrective Action Plan 2025‐001: The Registrar and the IT department are working together to ensure timely and accurate data is being transmitted on a regular schedule to the Clearinghouse as needed. When date determination exceptions occur (e.g., degrees being conferred after initial reporting or withdrawal dates being retroactively determined for administrative purposes), the Registrar’s Office, IT, and Financial Aid will work together to determine the appropriate date adjustments needed to manually update the Clearinghouse with the correct information if needed as quickly as possible. Anticipated Completion Date: June 30, 2026 Contact Person: Julie McAdoo, University Registrar
Corrective Action Plan: The Financial Aid Office will revise procedures to ensure reconciliation of Pell funding against enrollment on a monthly basis. Additionally, the Registrar’s office will revise and implement procedures to ensure timely reporting of administrative add/drops to SFS. Timeline fo...
Corrective Action Plan: The Financial Aid Office will revise procedures to ensure reconciliation of Pell funding against enrollment on a monthly basis. Additionally, the Registrar’s office will revise and implement procedures to ensure timely reporting of administrative add/drops to SFS. Timeline for Implementation: Spring 2027 Contact Person: Joe DaSilva (or Director of Student Financial Services upon hire) Vice President of Administration and Finance Peter Long Registrar & Director of Student Records
Corrective Action Plan: The Financial Aid Office will develop and implement procedures to reconcile disbursement dates on a monthly basis. Timeline for Implementation: Spring 2027 Contact Person: Joe DaSilva (or Director of Student Financial Services upon hire) Vice President of Administration and F...
Corrective Action Plan: The Financial Aid Office will develop and implement procedures to reconcile disbursement dates on a monthly basis. Timeline for Implementation: Spring 2027 Contact Person: Joe DaSilva (or Director of Student Financial Services upon hire) Vice President of Administration and Finance
Corrective Action Plan: Student Records will ensure that all National Student Clearinghouse data is transmitted to NSLDS for reconciliation in a timely manner and coordinate with student accounts to ensure timely transmission of NSLDS data. Timeline for Implementation: Spring 2027 Contact Person: Pe...
Corrective Action Plan: Student Records will ensure that all National Student Clearinghouse data is transmitted to NSLDS for reconciliation in a timely manner and coordinate with student accounts to ensure timely transmission of NSLDS data. Timeline for Implementation: Spring 2027 Contact Person: Peter Long Registrar & Director of Student Records
Corrective Action Plan: The Financial Aid Office will revise and implement procedures to reconcile SEOG funding at the end of each semester. Timeline for Implementation: Spring 2027 Contact Person: Joe DaSilva (or Director of Student Financial Services upon hire) Vice President of Administration and...
Corrective Action Plan: The Financial Aid Office will revise and implement procedures to reconcile SEOG funding at the end of each semester. Timeline for Implementation: Spring 2027 Contact Person: Joe DaSilva (or Director of Student Financial Services upon hire) Vice President of Administration and Finance
Item: 2025-002 Assistance Listing Number: 93.224 Programs: Health Center Program Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: N/A Contract Number: 24H80CS28365; H8JCS54690; 21H8HCS44987 Award Year: June 1, 2024 to May 31, 2025; December 1, 2024 to November 30, 20...
Item: 2025-002 Assistance Listing Number: 93.224 Programs: Health Center Program Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: N/A Contract Number: 24H80CS28365; H8JCS54690; 21H8HCS44987 Award Year: June 1, 2024 to May 31, 2025; December 1, 2024 to November 30, 2025; September 1, 2023 to August 31, 2025 Compliance Requirement: Special Tests and Provisions Criteria: Health Centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. Condition: For five claims tested, the discount for eligible patients was inaccurately calculated and billed. Name of Contact Person: Michele Grebisz, CFO Phone Number: (602)776-0776 Anticipated Completion Date: March 31, 2026 Views of Responsible Officials and Corrective Actions: Management agrees with the finding and will implement additional controls to ensure sliding fee discounts applied are reviewed and approved before patients are billed. Management will ensure this additional process includes clearly documenting the review and approval.
Finding Numbers: 2025-001 and 2025-002 Program: USDA Rural Rental Housing Loans – ALN 10.415 Title: Noncompliance with Loan Agreement Corrective Action Plan: The Jackson County Development Corporation (JCDC) defaulted on the USDA Rural Development loan in 2017 due to insufficient operating cash flow...
Finding Numbers: 2025-001 and 2025-002 Program: USDA Rural Rental Housing Loans – ALN 10.415 Title: Noncompliance with Loan Agreement Corrective Action Plan: The Jackson County Development Corporation (JCDC) defaulted on the USDA Rural Development loan in 2017 due to insufficient operating cash flow generated by the Walker Hill Apartments. Since that time, the Housing Authority of Jackson County (JCHA) and JCDC have actively engaged in ongoing communication with USDA Rural Development to resolve the matter. During fiscal year 2025 and continuing into 2026, JCHA has taken the following actions to resolve the default: • In January 2025, JCHA requested an appraisal from USDA Rural Development; however, Rural Development indicated that an appraisal would not be conducted until an offer was received on the property. • JCHA coordinated with a licensed broker and posted the Walker Hill development for sale on April 15, 2025, for the balance owed on the USDA note. • Due to lack of offers, the listing price was reduced to $355,000. • Two residents relocated to public housing units, and the property currently has one remaining resident. • USDA Rural Development also indicated that they would post an additional listing on their portal to assist with marketing the property. • On August 8, 2025, JCHA received a cash offer for the property and forwarded the information to USDA Rural Development for review. • USDA Rural Development ordered an appraisal on August 11, 2025; the appraisal inspection was completed October 3, 2025. • The appraisal resulted in a value of approximately $250,000. USDA Rural Development indicated that a $75,000 offer could not be accepted based on the appraised value. • The property was subsequently listed at $285,000 to solicit additional interest. • As of March 25, 2026, a potential buyer has provided proof of funds and is pursuing financing. Upon receipt of a pre-approval letter, the offer will be formally submitted to USDA Rural Development for approval. It remains the intent of JCHA and JCDC to fully resolve this matter through completion of the USDA foreclosure and disposition process. JCHA will continue to cooperate with USDA Rural Development and provide documentation, property access, and administrative support necessary to facilitate resolution. Upon final disposition of the property, JCHA anticipates dissolving the JCDC entity, thereby eliminating any remaining obligations associated with the loan. Anticipated Completion Date: Resolution is dependent upon USDA Rural Development approval of a sale or completion of foreclosure proceedings. Management anticipates resolution during fiscal year ending June 30, 2026, subject to USDA Rural Development timelines. Responsible Party: Executive Director, Housing Authority of Jackson County JCDC Board of Commissioners Respectfully Submitted,
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