Corrective Action Plans

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Expected Completion Date: November 7, 2025. As of the date of the audit report, semi-annualcertifications have already been obtained for applicable personnel.
Expected Completion Date: November 7, 2025. As of the date of the audit report, semi-annualcertifications have already been obtained for applicable personnel.
2025-001 Audit Submissions the Federal Audit Clearinghouse - Significant Deficiency The audit was submitted on time this year, demonstrating that Opportunities, Inc. has addressed the system gaps that affected last year's submission. The corrective action established clear communication points durin...
2025-001 Audit Submissions the Federal Audit Clearinghouse - Significant Deficiency The audit was submitted on time this year, demonstrating that Opportunities, Inc. has addressed the system gaps that affected last year's submission. The corrective action established clear communication points during the audit process and ensured all timelines were followed. Opportunities, Inc. remains dedicated to upholding the highest standards of fiscal responsibility and regulatory compliance.
In Finding 2025-001, it was reported that the Organization did not properly apply sliding fee discounts for certain patients with visits to the Organization during the year ended June 30, 2025. Management recognizes the importance of complying with sliding fee guidelines. In response to Finding 2025...
In Finding 2025-001, it was reported that the Organization did not properly apply sliding fee discounts for certain patients with visits to the Organization during the year ended June 30, 2025. Management recognizes the importance of complying with sliding fee guidelines. In response to Finding 2025-001, proper training will be given to employees and sliding fee discounts will be reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale.
Reference Number: 2025-001 Description: Finding 2025-001 - Federal ALN 93.778 Medicaid Cluster Corrective Action Plan: The District will update the setup for Medicaid reporting in Skyward Qmlativ to back out expenditures coded to federal grants, specifically project numbers 341 and 347. Anticipated ...
Reference Number: 2025-001 Description: Finding 2025-001 - Federal ALN 93.778 Medicaid Cluster Corrective Action Plan: The District will update the setup for Medicaid reporting in Skyward Qmlativ to back out expenditures coded to federal grants, specifically project numbers 341 and 347. Anticipated Corrective Action Plan Completion Date: Corrective action was implemented on July 23, 2025. The district has reviewed reports generated after this date and verified the accuracy of reporting. Contact Information: For additional information regarding this finding please contact Beth Sheridan, Assistant Superintendent of Finance and Operations, at 262-560-2119. Beth Sheridan Assistant Superintendent of Finance and Operations
View Audit 374355 Questioned Costs: $1
The District agrees with this finding and will implement the following:  Data Integrity Verification: o Implement a data review process to ensure data completeness and accuracy prior to sampling.  Staff Training: o Conduct training sessions for staff involved to ensure the accuracy of the populati...
The District agrees with this finding and will implement the following:  Data Integrity Verification: o Implement a data review process to ensure data completeness and accuracy prior to sampling.  Staff Training: o Conduct training sessions for staff involved to ensure the accuracy of the population used to calculate and select samples.  Internal Review Process o Establish manual review process to confirm all required documentation and applications are retained and accurately represent the population.
We acknowledge the audit finding and agree that, for the two vendors identified, documentation of suspension and debarment verification was not completed or retained in accordance with proper internal controls for our federal programs. This was an oversight in our procurement documentation process a...
We acknowledge the audit finding and agree that, for the two vendors identified, documentation of suspension and debarment verification was not completed or retained in accordance with proper internal controls for our federal programs. This was an oversight in our procurement documentation process and not an intentional omission. Neither vendor had any exclusions based on the SAM.gov database record. Since becoming aware of this issue, the organization is in the midst of implementing the following corrective actions to strengthen compliance with suspension and debarment requirements: (1) Revised Procurement Procedures- We will update our written procurement policies and procedures to explicitly require and document suspension and debarment checks prior to the execution of any contract using federal funds. This includes checking the federal SAM.gov database or obtaining a signed certification from the vendor, as permitted. (2) Standardized Documentation- We will create a standardized checklist that must be completed and filed in the procurement record for each vendor before payment of federal funds. This form documents the date, verification method, and staff member responsible. (3) Staff Training- All staff involved in procurement and accounts payable will complete training on federal procurement requirements, including suspension and debarment verification. This training will be repeated annually and upon onboarding of new staff. (4) Internal Control Review- A secondary review step has been added. Before any payment of federal funds is processed, our finance team will verify that the suspension and debarment check is on file. This dual review adds an additional layer of assurance.
Conditon: The District's accounting records did not support reported program expenditures totaling $32,734 due to the following: 1. Expenditures of $15,589 incurred and claimed for reimbursement in the prior year were claimed again in the current year. 2. Current year expenditures of $12,854 were cl...
Conditon: The District's accounting records did not support reported program expenditures totaling $32,734 due to the following: 1. Expenditures of $15,589 incurred and claimed for reimbursement in the prior year were claimed again in the current year. 2. Current year expenditures of $12,854 were claimed twice. 3. Payroll expenditures were claimed based on budget rather than actual amounts, resulting in claimed expenditures of $4,291 which were not supported. Corrective Action Plan: Management will review its policies and procedures and implement changes to strengthen internal control over federal reporting. Responsible Person: Joe Zotto, Superintendent Anticipated Completion Date: June 30, 2026
View Audit 374308 Questioned Costs: $1
Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the University enhance system controls to ensure disbursements match awards. View of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: The Fin...
Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the University enhance system controls to ensure disbursements match awards. View of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Office normally attempts to disburse aid within the term for which it is designated. However, unusual workloads brought about by FAFSA disruptions, staffing reductions, and duty changes led to delays in the disbursement of some aid for the 2024-2025 school year. A significant amount of Fall 2024 and Spring 2025 aid was not disbursed until August and September 2025. While this does not fall outside of rules set by the Department of Education, later disbursements caused extra challenges for the Accounting Team and meant a delay in receiving federal funds into the organization. As of September 30, 2025, All Pell Grant and Federal Supplemental Education Opportunity Grant Funds for 2024-2025 were been dispersed — and the matching amounts have been certified by the Department of Education. All federal loans for 2024-2025 have been dispersed, with the exception of 11 students. Nine of the students still have not accepted or declined their loans. They have been given until October 15, or the loans will be rescinded. Two more students had errors that stopped disbursement. This issue is being resolved by the team within the next week. Actions taken to resolve the issue: The Financial Aid team is taking the following actions to ensure that financial aid is disbursed in the term it is awarded. (Note: there are always a few exceptions due to highly unusual circumstances.) • Restructuring the awarding process to disperse funds soon after Census Date, before manually checking each record for anomalies. In 2024-2025, the manual checking process was completed first, which dramatically delayed disbursement. • Restructuring duties to spread out the awarding processing among more than one team member to allow for it to be completed more quickly. • Reviewing and enhancing financial aid policies governing the awarding and disbursing process to ensure that the amounts match at the end of the fiscal year (May 31) for spring and fall terms, and at the end of the award year (August 1) for the summer term. Name(s) of the contact person(s) responsible for corrective action: Tricia Harris, Financial Aid Director Planned completion date for corrective action plan: The Financial Aid Office has already begun implementation of this action plan and will complete implementation before the end of the current school term.
View Audit 374299 Questioned Costs: $1
Recommendation: We recommend the University implements procedures moving forward to ensure that all necessary MPN's are retained in accordance with the Perkins recordkeeping regulations. View of responsible officials: There is no disagreement with the audit finding. Action taken in response to findi...
Recommendation: We recommend the University implements procedures moving forward to ensure that all necessary MPN's are retained in accordance with the Perkins recordkeeping regulations. View of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: The process Union Adventist University follows to ensure promissory notes are signed is coordinated through Financial Aid. Financial Aid determines eligibility of awards and adds them to the student financial package. Once a loan has been accepted, Financial Aid has the student sign the promissory note. The loan is disbursed once the paperwork has been completed and reviewed. Perkins loans followed this procedure in the time they were available. The Perkins program is no longer active so there are no new promissory notes going forward. Student accounts is currently reviewing student files to ensure promissory notes, or documentation deemed appropriate by the Department of Education, are available for the Perkins loans that will be assigned to the Department of Education. Unfortunately, previous employees did not keep accurate records; this was brought to light when a new employee took over student accounts in August 2021. While the new employee has worked hard to track down all MPNs, we know that there are some that will never be found. As a result, this will likely be a repeat finding until all Perkins Loans are assigned or liquidated. It is our hope that this process will be completed by May 31, 2027. Promissory notes or documentation will be retained until the loans are either assigned or liquidated. Name(s) of the contact person(s) responsible for corrective action: Brandie Kolff van Oosterwyk, Controller Planned completion date for corrective action plan: We hope to assign or liquidate all Perkins loans by May 31, 2027. Until then, it is likely that this will be a recurring item on our corrective action report.
Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the University reevaluate its procedures and review policies surrounding reporting status changes to NSLDS to put a process in place to ensure the enrollment effective date reported to NSLDS on the cam...
Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the University reevaluate its procedures and review policies surrounding reporting status changes to NSLDS to put a process in place to ensure the enrollment effective date reported to NSLDS on the campus and program level is aligning with the University. View of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: The Records Office at Union Adventist University submits an enrollment report to the National Student Clearinghouse every 30 days to ensure that the National Student Loan Data System (NSLDS) receives the most accurate and up-to-date information. If any errors are identified, the Clearinghouse returns them to the university for correction. The Records Office reviews all error reports and resolves any issues. To ensure that accurate enrollment data is reported to NSLDS within the required effective dates, Union Adventist University will review and resolve the errors within 3-5 business days. Name(s) of the contact person(s) responsible for corrective action: Nicole Houdek, Director of Records/Registrar Planned completion date for corrective action plan: May 2026
Stoneboro Development Corporation Stoneboro, Pennsylvania CORRECTIVE ACTION PLAN December 2, 2025 U.S. Department of Housing and Urban Development City Crescent Building 10 South Howard Street Baltimore, Maryland 21201-2505 Stoneboro Development Corporation respectfully submits the following Correct...
Stoneboro Development Corporation Stoneboro, Pennsylvania CORRECTIVE ACTION PLAN December 2, 2025 U.S. Department of Housing and Urban Development City Crescent Building 10 South Howard Street Baltimore, Maryland 21201-2505 Stoneboro Development Corporation respectfully submits the following Corrective Action Plan for the year ended June 30, 2025. Bernard Robinson & Company, L.L.P. 1501 Highwoods Blvd., Suite 300 Post Office Box 19608 Greensboro, North Carolina 27419-9608 The findings from the year ended June 30, 2025 Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Finding 2025-001: U.S. Department of Housing and Urban Development, Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects, Market Interest Rate, Assistance Listing #14.155 Recommendation: We recommend that management and the board of directors continue to work to improve occupancy and submit special claims requests to HUD for vacant units to improve cash flow to ensure timely payment of the mortgage payments and escrow deposits. Action Taken: We agree with Finding 2025-001 described in the accompanying schedule of findings and questioned costs. Effective June 1, 2023, the board of directors contracted with a new management company. The new management company is increasing advertising to fill vacancies and submitting special claims requests to improve the cash flow. Additionally, in July 2025, the Corporation executed a reinstatement agreement with the lender to make additional monthly mortgage payments of $1,000 through May 2026 to bring the mortgage to current. If HUD has questions regarding this corrective action plan, please call (412) 246-9213. Sincerely yours, Trisha Jester Director of Multifamily Housing Arbors Management, Inc. Managing Agent
View Audit 374286 Questioned Costs: $1
The Academy has already resolved this process, since we did get the current Food Service contract for the 25-26 school year approved by the Board in August 2025 and will continue to do so every year going forward.
The Academy has already resolved this process, since we did get the current Food Service contract for the 25-26 school year approved by the Board in August 2025 and will continue to do so every year going forward.
The Academy has now put a control in place with the Accounts Payable Team, to review vendors, expected to be paid more than $25,000 on Sam.gov for active suspensions or disbarments.
The Academy has now put a control in place with the Accounts Payable Team, to review vendors, expected to be paid more than $25,000 on Sam.gov for active suspensions or disbarments.
The Academy has now put a control in place in which the Business Manager at each district reviews the monthly reimbursement request to ensure it agrees to the daily counts' spreadsheet.
The Academy has now put a control in place in which the Business Manager at each district reviews the monthly reimbursement request to ensure it agrees to the daily counts' spreadsheet.
View Audit 374283 Questioned Costs: $1
2025-001: Late Return of Title IV Financial Aid - Student Financial Aid Cluster - Assistance Listing #s 84.007, 84.033, 84.063, 84.268 - Grant Period - Year Ended June 30, 2025 Condition Found During our Return of Title IV Fund testing, we noted that the College did not calculate or return Title IV ...
2025-001: Late Return of Title IV Financial Aid - Student Financial Aid Cluster - Assistance Listing #s 84.007, 84.033, 84.063, 84.268 - Grant Period - Year Ended June 30, 2025 Condition Found During our Return of Title IV Fund testing, we noted that the College did not calculate or return Title IV Student Financial Aid for one out of twenty-five students tested until after 45 days when the student ceased attendance. We consider the untimely calculation and Return of Title IV Student Financial Aid to be an instance of noncompliance relating to the Special Tests and Provisions Compliance Requirement. This is a repeat finding of prior year finding 2024-001. Corrective Action Plan We have done two things to help us process R2T4s within the required timeframe. First, we added a column to our initial withdrawal report that calculates when the 30-day limit will be for each student. This helps keep us on track for the 30-day deadline for when we must perfom the R2T4 calculation. This report was implemented in June 2025. Secondly, we created a new report called the ROF Transmittal Report. This weekly report shows us all students that have had an R2T4 done in Colleague for the current semester and it compares their awarded amount to their transmitted amount. This helps us identify students whose aid has not been disbursed within a week of the R2T4 calculation being performed. This report also promotes transparency and communication between the Financial Aid office and the Accounting Office in our respective parts of the R2T4 process. This report was implemented in February 2025. Responsible Person for Corrective Action Plan Kendra Souligne Implementation Date of Corrective Action Plan June 2025
OBI will update current purchasing and procurement policy to specifically address the acquisition of property or services using federal grant funds to ensure adherence to Federal procurement standards in 2 CFR Part 200 sections 200.317-200.327. Our policy will outline requirements regarding vendor s...
OBI will update current purchasing and procurement policy to specifically address the acquisition of property or services using federal grant funds to ensure adherence to Federal procurement standards in 2 CFR Part 200 sections 200.317-200.327. Our policy will outline requirements regarding vendor selection and vendor qualification. It will address the simplified acquisition threshold, micro purchases threshold, and the formal procurement methods that must be adhered to when the value exceeds those thresholds. The policy will include when sealed bids, proposals/requests for proposals are required and when sole source procurement is appropriate and allowable. Whenever sole source procurement is used, the rationale will be documented and approved. Our policy will include language requiring that all vendors and contractors paid using federal funds be checked for federal suspension & debarment using Sam.gov. Vendors found on the exclusion list will not be paid using federal funds. The policy outlines requirements for written approvals and documentation of all procurements. Additionally, OBI has implemented procedures to ensure that at the point of receiving the Notice of Award, any federal money or grant awarded to OBI will be immediately communicated to the CFO, Controller, and the Senior Accountant. Person(s) Responsible: Senior Accountant with review and approvals from Controller and CFO Estimated Completion Date: January 31, 2026
2025-001: Missing Exit Counseling Documentation - Student Financial Aid Cluster Assistance Listing Number 84.007, 84.033, 84.063, 84.268, Grant Period - Year Ended June 30, 2025 Condition Found During our student file testing, we noted four students out of forty did not have documentation in their f...
2025-001: Missing Exit Counseling Documentation - Student Financial Aid Cluster Assistance Listing Number 84.007, 84.033, 84.063, 84.268, Grant Period - Year Ended June 30, 2025 Condition Found During our student file testing, we noted four students out of forty did not have documentation in their file that exit counseling was sent thirty days after the student withdrew. We consider the missing exit counseling to be a instance of noncompliance with the Eligibility Compliance Requirement. This is a repeat finding, see Prior Year Audit Findings 2024-002. Corrective Action Plan LLCC has developed reports to identify students who require exit counseling. The Financial Aid Compliance Coordinator is responsible for overseeing and administering exit counseling process for students who are graduating, withdrawing, or dropping below half-time enrollment. Responsibilities include ensuring compliance with federal regulations, providing accurate loan repayment information, and maintaining proper documentation of completed counseling sessions. Responsible Person for Corrective Action Plan Alison Mills Implementation Date of Corrective Action Plan FY26
2025-002 Child Nutrition Cluster – 10.CNC Recommendation: CLA recommends the District ensure its policies are in effect by verifying vendors are not suspended or debarred and proper documentation is maintained of this verification. Explanation of disagreement with audit finding: There is no disagree...
2025-002 Child Nutrition Cluster – 10.CNC Recommendation: CLA recommends the District ensure its policies are in effect by verifying vendors are not suspended or debarred and proper documentation is maintained of this verification. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The District will review its internal controls and implement a procedure to ensure vendors are not suspended or debarred. Name of the contact person responsible for corrective action: Kim Sinclair, District Business Manager. Planned completion date for corrective action plan: June 30, 2026
The Academy has put in place a review process within the Food Services Team to ensure future deadlines are met.
The Academy has put in place a review process within the Food Services Team to ensure future deadlines are met.
The Academy has already resolved this process, since we did get the current Food Service contract for the 25-26 school year approved by the Board in August 2025 and will continue to do so every year going forward.
The Academy has already resolved this process, since we did get the current Food Service contract for the 25-26 school year approved by the Board in August 2025 and will continue to do so every year going forward.
The Academy has now put a control in place with the Accounts Payable Team, to review vendors, expected to be paid more than $25,000 on Sam.gov for active suspensions or disbarments.
The Academy has now put a control in place with the Accounts Payable Team, to review vendors, expected to be paid more than $25,000 on Sam.gov for active suspensions or disbarments.
The Academy has now put a control in place in which the Business Manager at each district reviews the monthly reimbursement request to ensure it agrees to the daily counts' spreadsheet.
The Academy has now put a control in place in which the Business Manager at each district reviews the monthly reimbursement request to ensure it agrees to the daily counts' spreadsheet.
View Audit 374247 Questioned Costs: $1
CONTACT PERSON: Matt Pettit, Chief Financial Officer, matthew.pettit@cherokee1.org CORRECTIVE ACTION: The District will ensure that all employees charged to the Title I program have appropriate time and effort documentation. PROPOSED COMPLETION DATE: Prior to June 30, 2026
CONTACT PERSON: Matt Pettit, Chief Financial Officer, matthew.pettit@cherokee1.org CORRECTIVE ACTION: The District will ensure that all employees charged to the Title I program have appropriate time and effort documentation. PROPOSED COMPLETION DATE: Prior to June 30, 2026
CONTACT PERSON: Matt Pettit, Chief Financial Officer, matthew.pettit@cherokee1.org CORRECTIVE ACTION: The District will ensure that it does not use local exemptions for any federal programs. PROPOSED COMPLETION DATE: Prior to June 30, 2026
CONTACT PERSON: Matt Pettit, Chief Financial Officer, matthew.pettit@cherokee1.org CORRECTIVE ACTION: The District will ensure that it does not use local exemptions for any federal programs. PROPOSED COMPLETION DATE: Prior to June 30, 2026
View Audit 374232 Questioned Costs: $1
Finding Number Federal Programs Audit: 2025-001; Responsible Person: Kristen Curtis, Food Service Director. Holly Kleyn, Assitant Superintendent of Finance; Management Views: Management agrees with the finding and is in the proess of implementing the recommendation.; Corrective Action: The District ...
Finding Number Federal Programs Audit: 2025-001; Responsible Person: Kristen Curtis, Food Service Director. Holly Kleyn, Assitant Superintendent of Finance; Management Views: Management agrees with the finding and is in the proess of implementing the recommendation.; Corrective Action: The District has implemented internal controls to ensure the accuracy and integrity of reimbursement claims prior to submission to the State agency. As part of this process, a reimbursement claim report is generated and reviewed for potential anomalies, including but not limited to the number of students served and the number of operating days reported. These data points are then reconciled against site-level production records to confirm alignment and accuracy. In the event discrepancies are identified, the District requires the site lead to provide clarification and supporting documentation. Necessary corrections are made prior to laim submission. Furthermore, corrective action includes retraining of the site lead to mitigate recurrence of similar errors and to reinforce compliance with federal and state program requirements. These procedures were in place before fiscal year-end to maintain the accuracy of reimursement claims and to ensure compliance with all applicable program regulations.; Anticipated Completion Date: Procedures were in place before fiscal year-end.
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