Corrective Action Plans

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Finding 539464 (2024-001)
Significant Deficiency 2024
Management's Response/Planned Corrective Action: The Organization has established and implemented a new procedure to ensure the correct allocation of substitute teachers. This change has already been made effective as of July 1, 2024 to meet the auditor's recommendations. The Organization will now b...
Management's Response/Planned Corrective Action: The Organization has established and implemented a new procedure to ensure the correct allocation of substitute teachers. This change has already been made effective as of July 1, 2024 to meet the auditor's recommendations. The Organization will now bill substitutes exclusively to the appropriate site and program, which will enhance financial tracking and accountability. Substitutes will no longer be included in any distribution tables. Currently, substitutes are assigned to a System of Support (SOS) as their direct supervisor. The SOS is responsible for scheduling substitutes, entering their schedules into Paycor, and assigning them to school sites. Additionally, the Payroll Coordinator, Joanna Qualls, is required to add a billing code to these substitutes. The Payroll Department follows a procedure every pay period to run a report on substitutes, ensuring they are coded correctly. This process has been established as a step for every payroll run. The Director of Finance, Juana Sierra-Perez, also does a final audit of payroll to ensure transactions are being coded properly.
View Audit 350003 Questioned Costs: $1
We will update our cost allocation plan to address the issues as outlined in our response above. We will also implement a formal quarterly review of cost allocations to contracts under the guidance of our outside accountant (Capalbo, Mather Dougherty). Finally, we will use improved grant accounting ...
We will update our cost allocation plan to address the issues as outlined in our response above. We will also implement a formal quarterly review of cost allocations to contracts under the guidance of our outside accountant (Capalbo, Mather Dougherty). Finally, we will use improved grant accounting worksheets as a final check that our contract billing and accounting records are fully consistent.
While the audit notes improvements in this area, we continued to face some challenges in properly allocating indirect costs and fringe benefits to individual contracts. We will close the remaining gap between the costs properly billed to individual contracts and the process of reflecting these costs...
While the audit notes improvements in this area, we continued to face some challenges in properly allocating indirect costs and fringe benefits to individual contracts. We will close the remaining gap between the costs properly billed to individual contracts and the process of reflecting these costs in our accounting system by refining our cost allocation plan. This revision will include consistent rules for allocating indirect and fringe plus a quarterly review by accounting staff and management. We will also use newly formatted grant worksheets shared with us by Whittlesey to help us identify and correct any allocation issues before closing out our accounting records for this fiscal year.
Finding 2024-002 – The Organization provided humanitarian assistance to migrants and asylum seekers turned over by Customs and Border Protection (CBP), including meals, transportation and shelter at hotels and the Organizations Respite Center. The Organization has intake procedures in place with res...
Finding 2024-002 – The Organization provided humanitarian assistance to migrants and asylum seekers turned over by Customs and Border Protection (CBP), including meals, transportation and shelter at hotels and the Organizations Respite Center. The Organization has intake procedures in place with respect to hotel shelter expenditures. However, the intake process was not consistently applied to all participants. The Organization was not able to provide supporting documentation for 5% of the requested sample of individuals who received shelter. Management's view: Management acknowledges this finding, and awareness has been brought to this area. The errors identified in this finding were made due to a lack of implementation of proper agency financial procedures by a former employee and occurred during a period of substantial influx in the number of non-citizen migrants being assisted. Authorization of credit card use was provided to one hotel vendor which led to unverified charges. This was identified and corrected by senior staff within three weeks. Proposed Corrective Action: The following measures were already taken to correct this finding: The organization has provided proper training to its program staff and accounting bookkeepers to improve the internal payment review process on all payment requests and has prohibited the use of credit cards to cover hotel stays for clients. All hotel payments are to be paid by check after reviewing the proper documentation submitted by the vendor, which includes an invoice with the non-citizen migrant's name as spelled in the Notice to Appear documentation provided by U.S. Customs and Border Protection. This documentation is then compared to the registration database maintained by the organization which includes name and A-number for all non-citizen migrants served. Any unauthorized payment will be immediately investigated and disputed on a timely basis. This policy has already been implemented successfully. An internal sample verification process was completed successfully with supporting evidence for all clients served after the previous unauthorized charges were identified within the period of three weeks. Anticipated Correction Date: These measures have been implemented.
View Audit 349994 Questioned Costs: $1
AAA will create a worksheet to show unpaid balances and will create A/P transactions for those to be reported on monthly financials. Completion date March 31 st, 2025 by fiscal dept
AAA will create a worksheet to show unpaid balances and will create A/P transactions for those to be reported on monthly financials. Completion date March 31 st, 2025 by fiscal dept
Finding 539383 (2024-001)
Significant Deficiency 2024
Management agrees with the finding and recommendations, but also has determined that this finding will not be repeated in future years, as the arrearages program has come to a close.
Management agrees with the finding and recommendations, but also has determined that this finding will not be repeated in future years, as the arrearages program has come to a close.
Wisconsin Department of Health Services Planned Corrective Action: This FY 2022-23 finding continued through SFY 2023-24 because the public health emergency unwinding was completed after June 30, 2024, for this population. No new concerns were identified by LAB during their FY 2023-24 audit. Correct...
Wisconsin Department of Health Services Planned Corrective Action: This FY 2022-23 finding continued through SFY 2023-24 because the public health emergency unwinding was completed after June 30, 2024, for this population. No new concerns were identified by LAB during their FY 2023-24 audit. Corrective actions began during SFY 2023-24, and DHS completed a final analysis in November 2024. As part of this process, all outstanding cases were resolved. After the analysis was completed, DHS implemented an ongoing monthly monitoring plan with the IM agencies, which was outlined in the CARES Coordinator Notice (CCN) dated January 27, 2025. Anticipated Completion Date: January 27, 2025Persons responsible for corrective action: Autumn Arnold, Director Bureau of Eligibility and Enrollment Policy, Division of Medicaid Services autumn.arnold@dhs.wisconsin.gov Jonelle Brom, Director Bureau of Eligibility Operations and Training, Division of Medicaid Services Jonellem.Brom@dhs.wisconsin.gov Dave Varana, Director Bureau of Fiscal Accountability and Management, Division of Medicaid Services Dave2.Varana@dhs.wisconsin.gov
View Audit 349896 Questioned Costs: $1
Finding 539230 (2024-303)
Significant Deficiency 2024
Wisconsin Department of Health Services Planned Corrective Action: This finding is a continuation of a prior year finding. The current finding does not include any new recommendations. The prior year finding continued into SFY 2023-24 because we didn’t receive the finding until the final quarter of ...
Wisconsin Department of Health Services Planned Corrective Action: This finding is a continuation of a prior year finding. The current finding does not include any new recommendations. The prior year finding continued into SFY 2023-24 because we didn’t receive the finding until the final quarter of SFY 2023-24, and the federal website would not accommodate the solution we implemented immediately upon receipt of the finding. DHS adjusted its corrective action plan and successfully submitted all the SFY 2023-24 awards to the federal website in July 2024. This represents timely reporting for obligations occurring in June 2024, though technically after the audit period. No further corrective actions are needed for this finding. Anticipated Completion Date: July 2024 Person responsible for corrective action: Vanessa Salata, Section Chief Expenditure Accounting, Bureau of Fiscal Services, Division of Enterprise Services vanessaa.salata@dhs.wisconsin.govRebuttal from the Wisconsin Legislative Audit Bureau In its corrective action plan on page 349, the Department of Health Services noted that it had adjusted its prior year corrective action plan and successfully submitted all the FY 2023-24 Social Services Block Grant (SSBG) awards to the federal website in July 2024. To assist the reader in understanding the corrective action plan, we offer the following clarification: The July 2024 submission was not timely for amounts awarded under SSBG that were obligated through agreements signed in fall 2023.
Finding 539229 (2024-302)
Significant Deficiency 2024
Wisconsin Department of Health Services Planned Corrective Action: After the SFY 2022-23 audit finding was received, DHS immediately began corrective actions. No new concerns were identified by LAB during their SFY 2023-24 audit. DHS corrected the assistance listing number (ALN) of TANF funds transf...
Wisconsin Department of Health Services Planned Corrective Action: After the SFY 2022-23 audit finding was received, DHS immediately began corrective actions. No new concerns were identified by LAB during their SFY 2023-24 audit. DHS corrected the assistance listing number (ALN) of TANF funds transferred to the SSBG on the DHS website (https://www.dhs.wisconsin.gov/gears/index.htm) for the calendar year 2023 and 2024 Basic County Allocation on March 20, 2024. DHS changed the ALN for TANF funds transferred to the SSBG on the calendar year 2025 Basic County Allocation contracts that started January 1, 2025. Anticipated Completion Date: January 1, 2025 Person responsible for corrective action: Rebecca Mogensen, Section Chief Managerial Accounting, Bureau of Fiscal Services, Division of Enterprise Services rebeccaj.mogensen@dhs.wisconsin.gov
Finding 539225 (2024-901)
Significant Deficiency 2024
Planned Corrective Action: The Office of the Commissioner of Insurance accepts the Legislative Audit Bureau’s recommendation to ensure claims meet eligibility requirements and include appropriate documentation. The following corrective actions are planned: • A spreadsheet is used to collect claims s...
Planned Corrective Action: The Office of the Commissioner of Insurance accepts the Legislative Audit Bureau’s recommendation to ensure claims meet eligibility requirements and include appropriate documentation. The following corrective actions are planned: • A spreadsheet is used to collect claims service and payment dates. A formula will be applied to either restrict or flag dates outside the allowable period. • Insurance carriers will be notified of the formula change and reminded to only include claims that were paid within the allowable period. Anticipated Completion Date: The PY 2025 spreadsheet will be updated by February 2025 and insurance carriers notified when provided the updated spreadsheet for PY 2025 reporting. Reporting for 1st quarter 2025 is due in May 2025. Person responsible for corrective action: Rebecca Easland, Deputy Commissioner of Insurance Rebecca.easland@wisconsin
Planned Corrective Action: The Wisconsin State Public Defenders Office (SPD) resolved the Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) costs questioned by the auditors by adjusting accounting records to use GPR funding for the leave and termination payment for unused leave for the empl...
Planned Corrective Action: The Wisconsin State Public Defenders Office (SPD) resolved the Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) costs questioned by the auditors by adjusting accounting records to use GPR funding for the leave and termination payment for unused leave for the employee identified in the audit. SPD will continue to ensure only allowable costs are charged to federal grant programs. Furthermore, SPD Human Resources will review and update HR Policy 101 and the New Supervisor Onboarding resources to ensure procedures for approving employee timesheets are clear and accurate. Furthermore, SPD will update their procedures with HR payroll and the fiscal staff to ensure costs for leave and termination payments are charged to the proper funding source. Anticipated Completion Date: June 30, 2025 Person responsible for corrective action: Andrea Eilers, Budget Director eilersa@opd.wi.gov Garth Maletic, Human Resources Director maleticg@opd.wi.gov
View Audit 349896 Questioned Costs: $1
Wisconsin Department of Health Services Explanation Why Corrective Action Plan is Not Needed: DHS disagrees with the unallowable costs identified in this finding. The $862,677 identified by LAB was spent on vaccination distribution provided by a third-party provider, which is an allowable cost accor...
Wisconsin Department of Health Services Explanation Why Corrective Action Plan is Not Needed: DHS disagrees with the unallowable costs identified in this finding. The $862,677 identified by LAB was spent on vaccination distribution provided by a third-party provider, which is an allowable cost according to the memorandum of understanding (MOU) with DOA and the 2022 Treasury final rule. DHS acknowledges that it incorrectly categorized these expenses in its federal reporting. However, given the nature of these expenses, they would not have been unallowable, except for their misclassification on the federal report. Our position is supported by the fact that no accounting entries were needed to correct the eligible use category for purposes of federal reporting, which has been completed. No further action is required.Contact Information: Barry Kasten, Director Bureau of Fiscal Services, Division of Enterprise Services barry.kasten@dhs.wisconsin.govRebuttal from the Wisconsin Legislative Audit Bureau In its corrective action plan on page 351, the Department of Health Services (DHS) indicated that it disagrees with the unallowable costs identified in this finding and noted that the costs are allowable in accordance with its memorandum of understanding with the Department of Administration and the 2022 Treasury final rule. As stated in the finding, DHS used $862,677 in expenditures under its COVID-19 vaccination distribution program as match for the Public Assistance grant. The 2022 Treasury final rule and the U.S. Department of the Treasury (U.S. Treasury) frequently asked questions related to the Coronavirus State Local and Fiscal Recovery Funds (CSLFRF) grant indicate that only funding under the revenue loss eligible use category may be used to meet non-federal match for another federal program. Therefore, using the expenditures for the COVID-19 vaccination distribution program as the non-federal match for the Public Assistance grant is not allowable. DHS indicated that “given the nature of these expenditures, they would not have been unallowable, except for their misclassification on the federal report.” We note that the COVID-19 vaccination distribution program has been reported under the public health eligible use category since its inception. Therefore, no misclassification occurred on the federal report. DHS noted that its position is supported by the fact that no accounting entries were needed to resolve the eligible use category for the purpose of federal reporting. As we have stated, this issue relates to the unallowable use of CSLFRF funding as non-federal match for another federal program. This is not a federal reporting issue. We note that subsequent to our questions regarding the use of these funds for non-federal match, the State created a new U.S. Treasury project called COVID-19 Vaccination Non-Federal Match with a budget of $862,677 and reported the project under the revenue loss eligible use category in its report filed for the quarter ended December 31, 2024. Although the State chose to address the finding in this manner, it does not change the fact that DHS was non-compliant with the matching requirements of the CSLFRF grant when it used the funding from the COVID-19 vaccination distribution program as non-federal match for another federal program.
View Audit 349896 Questioned Costs: $1
Finding 539170 (2024-701)
Significant Deficiency 2024
Planned Corrective Action To assist research and program managers in managing subrecipient monitoring requirements for sponsored awards, RSP will review current procedures to ensure they are up-to-date and provide training to staff as required. Additionally, RSP will generate a report of subrecipien...
Planned Corrective Action To assist research and program managers in managing subrecipient monitoring requirements for sponsored awards, RSP will review current procedures to ensure they are up-to-date and provide training to staff as required. Additionally, RSP will generate a report of subrecipients that have met the threshold of federal expenditures in which a single audit is required. These reports will assist RSP staff in verifying compliance with single audit requirements by flagging subrecipients without a single audit on file, supporting the current procedure that prevents the issuance of new subaward agreements and modifications to active subawards. RSP has communicated to the subrecipient in question that their fiscal year 2024 single audit is required and that RSP will pause any issuance of subaward agreements and/or modifications until receipt and approval of their audit report. Anticipated Completion Date: Anticipated Completion Date is August 30, 2025 Person responsible for corrective action: Angie Johnson, Assistant Director of Research and Financial Services Research and Sponsored Programs (RSP) angie.johnson@rsp.wisc.edu
In response to this finding, Vermont Land Trust is taking the following corrective actions intended to add capacity, strengthen skills and create processes to provide financial statement accuracy and completeness: Hired a Director with nonprofit and GAAP financial statement experience and added a th...
In response to this finding, Vermont Land Trust is taking the following corrective actions intended to add capacity, strengthen skills and create processes to provide financial statement accuracy and completeness: Hired a Director with nonprofit and GAAP financial statement experience and added a third member to the accounting team to increase capacity and provide for timely and complete account reconciliations and review.
View Audit 349893 Questioned Costs: $1
The organization will strengthen and document a formal process for documenting attendance. This process will include provide training to employees responsible for tracking attendance, implementing a signature sheet to be submitted and reviewed by program managers after each class, and incorporate re...
The organization will strengthen and document a formal process for documenting attendance. This process will include provide training to employees responsible for tracking attendance, implementing a signature sheet to be submitted and reviewed by program managers after each class, and incorporate review of attendance sheets into the payment processes for participant stipend payments ensuring only participants who correctly documented attendance are able to receive the stipend funds.
View Audit 349874 Questioned Costs: $1
Description of Corrective Action Plan: Shoals Community School Corporation’s Director of School Nutrition, Tamara Florio, will ensure that all time cards are signed by the employee and by herself before submitting to the Payroll Administrator, Darla Holt. Responsible Party and Time and Timeline for ...
Description of Corrective Action Plan: Shoals Community School Corporation’s Director of School Nutrition, Tamara Florio, will ensure that all time cards are signed by the employee and by herself before submitting to the Payroll Administrator, Darla Holt. Responsible Party and Time and Timeline for Completion: Tamara Florio, Director of School Nutrition-this will be implemented immediately, this 2024-2025 school year.
Finding 539103 (2024-003)
Significant Deficiency 2024
Condition: Of the testing population of 40 payroll transactions tested, for 10 transactions the Center was unable to provide a timesheet or other documentation to substantiate the application of the individual's time for that period. Corrective Action Plan: The Center will implement updated personal...
Condition: Of the testing population of 40 payroll transactions tested, for 10 transactions the Center was unable to provide a timesheet or other documentation to substantiate the application of the individual's time for that period. Corrective Action Plan: The Center will implement updated personal activity reports to substantiate each employee's time allocated to the grant for each pay period. Anticipated Completion Date: June 30, 2025 Responsible Individual: Andy Navarro, Senior Accountant
View Audit 349811 Questioned Costs: $1
COVID-19 Coronavirus State and Local Fiscal Recovery Fund– Assistance Listing No. 21.027 Recommendation: The City should enhance or modify its internal controls over suspension and debarment, as necessary, to ensure compliance with suspension and debarment provisions. Explanation of disagreement wi...
COVID-19 Coronavirus State and Local Fiscal Recovery Fund– Assistance Listing No. 21.027 Recommendation: The City should enhance or modify its internal controls over suspension and debarment, as necessary, to ensure compliance with suspension and debarment provisions. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We provided training to procurement staff about the suspension and debarment requirements of 2 CFR 200.214. Further, we expanded language in the City’s formal soliciation template regarding suspension and debarment and added a specifc step on our solitication timeline checklist to perform SAM checks. Name(s) of the contact person(s) responsible for corrective action Levi Gibson, Budget and Finance Director Planned completion date for corrective action plan: December 2024
Boston Public Schools will take a multi-step approach to ensure accuracy of spending to the grant award period. Anticipated Completion Date: January 31, 2025 Responsible Contact Person: Colin Musto, Assistant City Auditor, Grants Monitoring Unit colin.musto@boston.gov
Boston Public Schools will take a multi-step approach to ensure accuracy of spending to the grant award period. Anticipated Completion Date: January 31, 2025 Responsible Contact Person: Colin Musto, Assistant City Auditor, Grants Monitoring Unit colin.musto@boston.gov
View Audit 349776 Questioned Costs: $1
Finding 539070 (2024-010)
Significant Deficiency 2024
Boston Public Schools has updated its’ training and guidance for timekeepers. Timekeepers participate in enhanced trainings annually in August in preparation of the new school year. Anticipated Completion Date: August 31, 2025 Responsible Contact Person: Colin Musto, Assistant City Auditor, Grants...
Boston Public Schools has updated its’ training and guidance for timekeepers. Timekeepers participate in enhanced trainings annually in August in preparation of the new school year. Anticipated Completion Date: August 31, 2025 Responsible Contact Person: Colin Musto, Assistant City Auditor, Grants Monitoring Unit colin.musto@boston.gov
View Audit 349776 Questioned Costs: $1
Finding 539067 (2024-009)
Significant Deficiency 2024
Boston Public Schools has revised its’ eligibility record keeping process to ensure that records are accurate and complete. This adjustment to record keeping practice has been instituted beginning with the FY25 grant application cycle. Anticipated Completion Date: June 30, 2025 Responsible Contact...
Boston Public Schools has revised its’ eligibility record keeping process to ensure that records are accurate and complete. This adjustment to record keeping practice has been instituted beginning with the FY25 grant application cycle. Anticipated Completion Date: June 30, 2025 Responsible Contact Person: Colin Musto, Assistant City Auditor, Grants Monitoring Unit colin.musto@boston.gov
Finding 539064 (2024-006)
Significant Deficiency 2024
Boston Public Schools has updated its’ training and guidance for timekeepers. Timekeepers participate in enhanced trainings annually in August in preparation of the new school year. Anticipated Completion Date: August 31, 2025 Responsible Contact Person: Colin Musto, Assistant City Auditor, Grants...
Boston Public Schools has updated its’ training and guidance for timekeepers. Timekeepers participate in enhanced trainings annually in August in preparation of the new school year. Anticipated Completion Date: August 31, 2025 Responsible Contact Person: Colin Musto, Assistant City Auditor, Grants Monitoring Unit colin.musto@boston.gov
View Audit 349776 Questioned Costs: $1
FINDING 2024-003 Information on the federal program: Subject: COVID-19 – Education Stabilization Fund – Activities Allowed or Unallowed/Allowable Costs Federal Agency: Department of Education Federal Program: COVID-19 – Education Stabilization Fund Assistance Listing Number: 84.425C, 84.425D, 84.425...
FINDING 2024-003 Information on the federal program: Subject: COVID-19 – Education Stabilization Fund – Activities Allowed or Unallowed/Allowable Costs Federal Agency: Department of Education Federal Program: COVID-19 – Education Stabilization Fund Assistance Listing Number: 84.425C, 84.425D, 84.425U Federal Award Numbers and Years (or Other Identifying Numbers): S425C200018, S425D210013, S425U210013 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Audit Finding: Material Weakness, Other Matters Condition: An effective internal control system was not in place at the School District to ensure compliance with requirements related to the Education Stabilization Fund and Activities Allowed or Unallowed. Context: During the testing of vendor and payroll disbursements charged to Education Stabilization Fund grant awards during the audit period, the following exceptions were noted:  Management was unable to provide an approved accounts payable voucher and supporting invoice for one vendor disbursement in a sample of 12 vendor disbursements.  For one salaried employee selected out of a sample of 40 payroll disbursements, the employee was charged to Education Stabilization Fund grants for 50% of their time worked in a pay period. The School Corporation did not maintain any time-and-effort logs to support the employee’s partial allocation to Education Stabilization Fund grants. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Management will implement control processes surrounding expenditures of federal funds to ensure documents are retained to support expenditures and their allocations to federal grants. Responsible Party and Timeline for Completion: Gretchen Berger, Corp Treasurer - 6-1-2025
View Audit 349745 Questioned Costs: $1
Substance Abuse and Mental Health Services Projects - Assistance Listing No. 93.243 Recommendation: Perform a review policies and procedures regarding proper monitoring of period of performance related to grant end dates. Explanation of disagreement with audit finding: There is no disagreement with ...
Substance Abuse and Mental Health Services Projects - Assistance Listing No. 93.243 Recommendation: Perform a review policies and procedures regarding proper monitoring of period of performance related to grant end dates. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: MURC will perform a review of policies and procedures to ensure recorded transactions are within the proper period of performance related to grant end dates. Name(s) of the contact person(s) responsible for corrective action: Jennifer Wood Planned completion date for corrective action plan: June 30, 2025
Research and Development Cluster- Assistance Listing Nos. 93.323, 93.847 Recommendation: Perform a review policies and procedures regarding proper monitoring of period of performance related to grant end dates. Explanation of disagreement with audit finding: There is no disagreement with the audit f...
Research and Development Cluster- Assistance Listing Nos. 93.323, 93.847 Recommendation: Perform a review policies and procedures regarding proper monitoring of period of performance related to grant end dates. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: MURC will perform a review of policies and procedures to ensure recorded transactions are within the proper period of performance related to grant end dates. Name{s) of the contact person(s) responsible for corrective action: Jennifer Wood Planned completion date for corrective action plan: June 30, 2025
View Audit 349740 Questioned Costs: $1
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