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Corrective Action Plans

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Finding 1163615 (2025-003)
Material Weakness 2025
Cci Health & Wellness Services and Affiliate
MD
Special Tests & Provisions Eligibility Internal Control / Segregation of Duties
2025-03/2024-003 Health Center Program Cluster – ALN Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. H80CS10591 Program Years 17 and 18 Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts (42 USC 254(k)(3)(g); 42 CFR sections 51c.303(g...
2025-03/2024-003 Health Center Program Cluster – ALN Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. H80CS10591 Program Years 17 and 18 Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts (42 USC 254(k)(3)(g); 42 CFR sections 51c.303(g); and 42 CFR sections 56.303 (f)) Recommendation – We recommend management continue to ensure all personnel understand the sliding fee scale policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that eligible patients receive discounts in accordance with the sliding fee scale and the Health Center Program Compliance Manual. Views of Responsible Officials and Planned Corrective Actions – CCI is implementing a system update within eCW to ensure the sliding fee schedule is accurately configured and consistently applied across all service locations. As part of this corrective action, CCI is developing a formal training program to ensure that all applicable employees understand the sliding fee requirements and possess the necessary knowledge to follow the established procedures. CCI is also establishing an internal review process to monitor compliance with the sliding fee policy. This process will include periodic sampling and review of sliding fee scale assessments to verify that eligibility determinations and discounts are being applied correctly and in accordance with policy. Any identified discrepancies will be addressed through targeted staff retraining or process adjustments, as appropriate. These corrective actions are designed to strengthen internal controls, ensure consistent application of the sliding fee program, and maintain compliance with regulatory and organizational requirements. Reason for Recurrence – CCI experienced significant turnover within the Revenue Cycle Department during fiscal year 2025, which contributed to delays in updating system configurations and conducting required reviews. Anticipated Completion/Implementation Date: End of Fiscal Year 2026
View Audit 373376
Finding 1163612 (2025-002)
Material Weakness 2025
Cci Health & Wellness Services and Affiliate
MD
Reporting
2025-002/2024-002/2023-009 Health Center Program Cluster – ALN Nos. 93.224 and 93.527U.S. Department of Health and Human Services Award No. H80CS10591Program Year 16 and 17 Family Planning Services – ALN No. 93.217 U.S. Department of Health and Human Services Award No. FPHPA006584 Program Year 3 and...
2025-002/2024-002/2023-009 Health Center Program Cluster – ALN Nos. 93.224 and 93.527U.S. Department of Health and Human Services Award No. H80CS10591Program Year 16 and 17 Family Planning Services – ALN No. 93.217 U.S. Department of Health and Human Services Award No. FPHPA006584 Program Year 3 and 4 Criteria or Specific Requirement – Reporting – 45 CFR 75.342 Recommendation – The Organization should revise policies and procedures over federal reporting to ensure reports are prepared using accurate information and supporting documentation for federal grant reports should be maintained. Views of Responsible Officials and Planned Corrective Actions – CCI Health Services will strengthen its processes to ensure all UDS, FFR, and FCTR reports are prepared using accurate financial information supported by appropriate documentation. A standardized federal reporting checklist is being developed to identify required data sources, outline reconciliation steps, and document preparer and reviewer responsibilities. All reports will be reconciled to the system reports and reviewed by both the Controller and CFO before submission to ensure accuracy and completeness. Supporting documentation for all federal reports will be maintained in a centralized location to ensure consistency and future audit readiness. Reason for Recurrence – CCI experienced significant turnover in the Finance Department during fiscal year 2025, which contributed to delays and difficulties in locating supporting documentation for federal reports. Anticipated Completion/Implementation Date: End of Fiscal Year 2025
View Audit 373376
Finding 1163596 (2025-001)
Material Weakness 2025
Housing Authority of the City Or River Falls
WI
Internal Control / Segregation of Duties
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.
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.
View Audit 373356
Finding 1163593 (2025-001)
Material Weakness 2025
The Housing Authority of the City of Ozark, Alabama
AL
HUD Housing Programs
Corrective Action Plan (CAP) The Housing Authority of the City of Ozark, Alabama (Housing Authority) To the Department of Housing and Urban Development, During the audit of the Housing Authority’s fiscal year ended March 31, 2025 financial statements, it was determined that the Housing Authority did...
Corrective Action Plan (CAP) The Housing Authority of the City of Ozark, Alabama (Housing Authority) To the Department of Housing and Urban Development, During the audit of the Housing Authority’s fiscal year ended March 31, 2025 financial statements, it was determined that the Housing Authority did not perform annual HQS inspections for all units or conduct HQS re-inspections during the 30-day period required by HUD. Dannie Walker, Executive Director is responsible for implementing the corrective action plan. CAP developed to resolve audit findings: Finding 2025-001 - Section 8 HQS Inspection Deficiencies We concur with the recommendation and we will establish controls that ensure that annual inspection are performed, re-inspections are performed within the 30-day requirement and that HAP abatements are properly assessed. The Housing Authority is also planning on additional training for employees to make sure they are qualified to meet the HQS re-inspection requirements.
View Audit 373339
Finding 1163564 (2025-002)
Material Weakness 2025
Jasper County Rural Electric Membership Corporation
IN
Management of Jasper County REMC will implement procedures to ensure that required documents are obtained prior to services being performed. Management agrees with the findings.
Management of Jasper County REMC will implement procedures to ensure that required documents are obtained prior to services being performed. Management agrees with the findings.
View Audit 373288
Finding 1163563 (2025-001)
Material Weakness 2025
Jasper County Rural Electric Membership Corporation
IN
Management of Jasper County REMC was aware of lack of segregation of duties. It would not be cost effective to hire additional employees to properly segregate duties at this time. Management agrees with the findings.
Management of Jasper County REMC was aware of lack of segregation of duties. It would not be cost effective to hire additional employees to properly segregate duties at this time. Management agrees with the findings.
View Audit 373288
Finding 1163562 (2025-001)
Material Weakness 2025
Housing Authority of Elgin
IL
Internal Control / Segregation of Duties Subrecipient Monitoring
Corrective Action Management has responded to all of the Department of Labor’s Findings as of October 9, 2025, outlining specific corrective actions and considers the corrective actions satisfactorily implemented as of the date of this Report. The Authority’s Chief Executive Officer has assumed the ...
Corrective Action Management has responded to all of the Department of Labor’s Findings as of October 9, 2025, outlining specific corrective actions and considers the corrective actions satisfactorily implemented as of the date of this Report. The Authority’s Chief Executive Officer has assumed the responsibility of continued execution of the corrective actions.
View Audit 373283
Finding 1163561 (2025-001)
Material Weakness 2025
Old Town Voa Affordable Housing, Inc. (penobscot River House) Me36-H0173
ME
Questioned Costs HUD Housing Programs
FINDING 2025-001 Corrective Action Plan Management will implement a process of identifying any surplus cash to be deposited into its residual receipts reserve account and a timeline to provide reasonable assurance that the remittance of the required deposits are done within the specified timeframe s...
FINDING 2025-001 Corrective Action Plan Management will implement a process of identifying any surplus cash to be deposited into its residual receipts reserve account and a timeline to provide reasonable assurance that the remittance of the required deposits are done within the specified timeframe set by HUD. Responsible party: Kayla Thurlow, Controller; (207) 373-1140 Anticipated completion date: No later than September 30, 2025
View Audit 373280 Questioned Costs: $1
Finding 1163543 (2025-001)
Material Weakness 2025
San Francisco Medical Center Outpatient Improvement Programs, Inc.
CA
Special Tests & Provisions Eligibility
2025-001 Sliding Fee Discount Determination Name of Contact Person: Interim Chief Financial Officer: Shigeyuki Murota, Patient Accounts Manager: George Ward Corrective Action: San Francisco Medical Center Outpatient Improvement Programs, Inc. d/b/a Equity Health will: - Update the Sliding Fee Discou...
2025-001 Sliding Fee Discount Determination Name of Contact Person: Interim Chief Financial Officer: Shigeyuki Murota, Patient Accounts Manager: George Ward Corrective Action: San Francisco Medical Center Outpatient Improvement Programs, Inc. d/b/a Equity Health will: - Update the Sliding Fee Discount Program (SFDP) policies, procedures, and forms for better clarity and tracking. - Continue to perform monthly internal audits of sliding fee transactions and document audit findings, corrective actions, and report results to leadership. - Retrain current staff quarterly based on the monthly internal audit results. - Train all new staff at new hire orientations. - Validate staff understanding through annual knowledge checks and competency assessments. - Integrate SFDP compliance into staff performance evaluations. - Maintain centralized log of all SFDP applications and determinations. Proposed Completion Date: December 31, 2025
View Audit 373229
Finding 1163540 (2025-002)
Material Weakness 2025
Independent School District No. 31
MN
Internal Control / Segregation of Duties Eligibility School Nutrition Programs
1. Correcting Plan Food and Nutrition Service Coordinator will review applications and supporting documentation for completion and eligibility accuracy. 2. Explanation of Disagreement with the Audit Finding There is essentially no disagreement with the finding. 3. Official Responsible for Insuring C...
1. Correcting Plan Food and Nutrition Service Coordinator will review applications and supporting documentation for completion and eligibility accuracy. 2. Explanation of Disagreement with the Audit Finding There is essentially no disagreement with the finding. 3. Official Responsible for Insuring CAP The Food and Nutrition Service Coordinator. 4. Planned Completion Date for CAP The CAP was implemented immediately during audit fieldwork performed in October 2025. 5. Plan to Monitor Completion of CAP The Food and Nutrition Service Coordinator will continually review applications and supporting documentation for completion and eligibility accuracy. Any issues noted will be communicated to appropriate staff and fixed immediately.
View Audit 373219
Finding 1163529 (2025-001)
Material Weakness 2025
Faith Baptist Bible College and Theological Seminary
IA
Questioned Costs Eligibility Significant Deficiency
Our Financial Aid Director will implement an independent review process for those students for whom professional judgment is applied when calculating student financial aid benefits.
Our Financial Aid Director will implement an independent review process for those students for whom professional judgment is applied when calculating student financial aid benefits.
View Audit 373203 Questioned Costs: $1
Finding 1163520 (2025-002)
Material Weakness 2025
Hoosic Valley Central School District
NY
Procurement, Suspension & Debarment School Nutrition Programs § 200.214 § 200.314 § 200.318
Implementation plan of action: The Business Manager will review these requirements with the Sr. Account Clerk. The Sr. Account Clerk will verify that all vendors are eligible to participate in the federal assistance program on an annual basis. Specifically, a note will be entered on the vendor recor...
Implementation plan of action: The Business Manager will review these requirements with the Sr. Account Clerk. The Sr. Account Clerk will verify that all vendors are eligible to participate in the federal assistance program on an annual basis. Specifically, a note will be entered on the vendor record in the accounting system each time a purchase order is issued, which will detail that the proper verification was performed. Person Responsible for Implementation: Jodi Birch, Business Manager and Amanda Lestage, Sr. Account Clerk Anticipated Completion Date: August 30, 2025
View Audit 373178
Finding 1163511 (2025-002)
Material Weakness 2025
Seton Village, Inc.
ME
Questioned Costs Reporting
We have posted the adjustments recommended by the auditors and management will implement the following control: Management agent will refund $48,720 in fees to the project and conduct staff training on monthly and annual procedures over financial close and reporting by October 31, 2025.
We have posted the adjustments recommended by the auditors and management will implement the following control: Management agent will refund $48,720 in fees to the project and conduct staff training on monthly and annual procedures over financial close and reporting by October 31, 2025.
View Audit 373145 Questioned Costs: $1
Finding 1163504 (2025-001)
Material Weakness 2025
Fox Valley Technical College District
WI
Student Financial Aid Reporting Special Tests & Provisions
Records & Registration will now submit modified enrollment files as Graduates Only records to ensure accurate and timely graduation status updates. This solution has been confirmed by NSC. Additional staff have been trained on the updated procedures, and new processes are in place to ensure discrepa...
Records & Registration will now submit modified enrollment files as Graduates Only records to ensure accurate and timely graduation status updates. This solution has been confirmed by NSC. Additional staff have been trained on the updated procedures, and new processes are in place to ensure discrepancies and error flags are resolved promptly. Records & Registration and the Financial Aid Office continue to collaborate to identify and address discrepancies that may affect Title IV eligibility. Person(s) Responsible: Assistant Registrar, Director of Financial Aid Timing for Implementation: Immediate
View Audit 373105
Finding 1163472 (2025-002)
Material Weakness 2025
Oak Springs Villas, Inc.
TX
Questioned Costs
MANAGEMENT AGREES WITH THE FINDING. THE RELATED PROJECT WILL REIMBURSE THE PROJECT FOR THE RENTS IN THE AMOUNT OF $14,054.
MANAGEMENT AGREES WITH THE FINDING. THE RELATED PROJECT WILL REIMBURSE THE PROJECT FOR THE RENTS IN THE AMOUNT OF $14,054.
View Audit 373083 Questioned Costs: $1
Finding 1163471 (2025-001)
Material Weakness 2025
Oak Springs Villas, Inc.
TX
MANAGEMENT AGREES WITH THE FINDING. MANAGEMENT HAS SUBMITTED ALL CORRECTIONS AND HAS RECEIVED THE CLOSE OUT LETTER FROM HUD.
MANAGEMENT AGREES WITH THE FINDING. MANAGEMENT HAS SUBMITTED ALL CORRECTIONS AND HAS RECEIVED THE CLOSE OUT LETTER FROM HUD.
View Audit 373083
Finding 1163469 (2025-001)
Material Weakness 2025
Grand Valley Catholic Outreach INC
CO
The Organization is implementing a new timekeeping procedure requiring all employees who work on federal awards to complete and submit after-the-fact timesheets that accurately reflect the actual hours worked on each federal project. These timesheets are reviewed and approved by supervisors before p...
The Organization is implementing a new timekeeping procedure requiring all employees who work on federal awards to complete and submit after-the-fact timesheets that accurately reflect the actual hours worked on each federal project. These timesheets are reviewed and approved by supervisors before payroll charges are allocated to federal awards. Additionally, the organization provided training to staff on the new procedures to ensure understanding and compliance with Uniform Guidance requirements. This action ensures that all payroll charges to federal awards are supported by records of actual time worked, as required by federal regulations
View Audit 373070
Finding 1163468 (2025-003)
Material Weakness 2025
Cambridge Central School District
NY
Procurement, Suspension & Debarment School Nutrition Programs § 200.214
Views of Responsible Officials and Planned Corrective Action: The District acknowledges the finding and agrees with the recommendation. To address this issue, the following corrective actions will be implemented: The Business Office will verify all vendors used in federally funded programs at least ...
Views of Responsible Officials and Planned Corrective Action: The District acknowledges the finding and agrees with the recommendation. To address this issue, the following corrective actions will be implemented: The Business Office will verify all vendors used in federally funded programs at least once annually and prior to disbursing funds o Persons responsible: Michele Hogan and April Young o Anticipated Completion Date: This process will be completed by June 12th, 2026 ● Staff will review both 2 CFR Section 200.214 and 2 CFR Part 180 for understanding and compliance o Persons responsible: Michele Hogan and John Lybert o Anticipated Completion Date: This will be completed by September 30, 2025
View Audit 373057
Finding 1163460 (2025-002)
Material Weakness 2025
North Colonie Central School District
NY
Procurement, Suspension & Debarment School Nutrition Programs Subrecipient Monitoring § 200.214
Effective September 15, 2025 the District Treasurer will check the status of all vendors associated to the Child Nutrition program. In cooperation with the Food Service Director, the District Treasurer will review eligibility of any vendors that are requested to be used. Any vendor that is found not...
Effective September 15, 2025 the District Treasurer will check the status of all vendors associated to the Child Nutrition program. In cooperation with the Food Service Director, the District Treasurer will review eligibility of any vendors that are requested to be used. Any vendor that is found not to be eligibility list will be reported to the Food Service Director and Purchasing Agent. This list will be updated and checked annually.
View Audit 373046
Finding 1163452 (2025-003)
Material Weakness 2025
Nebraska Wesleyan University
NE
Questioned Costs Special Tests & Provisions Student Financial Aid
Return of Title IV Fund Calculations Condition/Context: For two of the six students selected in the sample, the amount of the Title IV refund was calculated incorrectly due to using the incorrect number break days for students that withdrew in the Spring term. This results in too much being returned...
Return of Title IV Fund Calculations Condition/Context: For two of the six students selected in the sample, the amount of the Title IV refund was calculated incorrectly due to using the incorrect number break days for students that withdrew in the Spring term. This results in too much being returned to the U.S Department of Education. Recommendation: The University should modify its procedures for refunding awards to ensure proper data computations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The scheduled break days for the spring semester accidentally failed to include the weekend before the week of Spring Break. The school calendar profile for the Return of Title IV Funds Calculation will now be reviewed by both the Director of Scholarships and Financial Aid and the Assistant Director of Financial Aid before being created in the COD Return of Title IV Funds Tool each term. Contact person: Tom Ochsner, Director of Scholarships and Financial Aid Planned completion date for corrective action plan: August 27, 2025 If the Department of Education has questions regarding this plan, please call Tom Ochsner at (402) 465- 2212.
View Audit 373043 Questioned Costs: $1
Finding 1163451 (2025-002)
Material Weakness 2025
Nebraska Wesleyan University
NE
Student Financial Aid Reporting Special Tests & Provisions
Enrollment Reporting Condition/Context: For one out of 25 students selected in the sample, the effective date that was reported to NSLDS did not match the date that the student changed status. For a second student, the student's enrollment status was not correctly reported within the 60 day requirem...
Enrollment Reporting Condition/Context: For one out of 25 students selected in the sample, the effective date that was reported to NSLDS did not match the date that the student changed status. For a second student, the student's enrollment status was not correctly reported within the 60 day requirement Recommendation: The University should review its procedures to ensure that all effective dates for enrollment status chan•;Jes are updated accurately in NSLDS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To prevent future occurrences: • We have implemented an additional verification step in our status update workflow. • We are reviewing how major changes interact with enrollment status updates in Colleague. • We will implement a validation step to ensure that effective dates reflect the original action date when multiple updates occur in close succession. Contact person: Tom Ochsner, Director of Scholarships and Financial Aid Planned completion date for corrective action plan: August 27, 2025 If the Department of Education has questions regarding this plan, please call Tom Ochsner at (402) 465- 2212.
View Audit 373043
Finding 1163431 (2025-001)
Material Weakness 2025
Community Housing Services - Wedgewood Ii, Inc.
UT
HUD Housing Programs
A last-minute change was made between our reconciliation of security deposits and the year end. We have set up a new control of locking our accounting system once the reconciliations & reviews are completed so no additional changes can be made without management being aware.
A last-minute change was made between our reconciliation of security deposits and the year end. We have set up a new control of locking our accounting system once the reconciliations & reviews are completed so no additional changes can be made without management being aware.
View Audit 373006
Finding 1163430 (2025-002)
Material Weakness 2025
Coxsackie-Athens Central School District
NY
Procurement, Suspension & Debarment School Nutrition Programs Subrecipient Monitoring § 200.214
The District will review the requirements of 2 CFR Section 200.214 and 2 CFR Part 180 and ensure that a review of the eligibility of potential vendors to participate in Federal assistance programs or activities is performed prior to disbursing funds to the vendor. This will be verified on an annual ...
The District will review the requirements of 2 CFR Section 200.214 and 2 CFR Part 180 and ensure that a review of the eligibility of potential vendors to participate in Federal assistance programs or activities is performed prior to disbursing funds to the vendor. This will be verified on an annual basis. Anticipated implementation date is October 1, 2025 by responsible person(s) District Business Official and District Treasurer Kelsey Reed.
View Audit 372996
Finding 1163425 (2025-001)
Material Weakness 2025
Aiken County Commission on Alcohol and Drug Abuse
SC
HUD Housing Programs
The duties will be segregated as much as possible, and the Board of Commissioners will remain involved in reviewing the financial statements of the Commission.
The duties will be segregated as much as possible, and the Board of Commissioners will remain involved in reviewing the financial statements of the Commission.
View Audit 372966
Finding 1163423 (2025-002)
Material Weakness 2025
Midland Univeristy
NE
Student Financial Aid Subrecipient Monitoring Reporting
Midland University Corrective Action Plan For the Year Ended May 31, 2025 Finding 2025-002: Significant Deficiency - NSLDS Enrollment Reporting Condition: Of the 25 students tested, two students had incorrect or late information reported. One student's withdrawn date reported in spring 2025 did not ...
Midland University Corrective Action Plan For the Year Ended May 31, 2025 Finding 2025-002: Significant Deficiency - NSLDS Enrollment Reporting Condition: Of the 25 students tested, two students had incorrect or late information reported. One student's withdrawn date reported in spring 2025 did not agree to the University's documentation to support the date of determination. A second student's status' certification date was reported 71 days after their date of determination. Corrective Action Plan: Beginning in Summer 2025, the new Financial Aid Director and Registrar have been meeting bi-weekly to discuss all aspects of enrollment reporting. This will ensure that both offices are aware of reporting requirements and timelines. Name(s) of Contact Person(s) Responsible for Corrective Action: Jon Dechant, Director of Financial Aid & Joseph Harnisch, CFO Anticipated Completion Date: Finding 2025-002: Completed in July 2025
View Audit 372942
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