Corrective Action Plans

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Audit Finding Reference: 2024-001 Management’s Response and Planned Corrective Action: The District will ensure that any further retention bonuses be formally reviewed and approved by the School Board and Superintendent. Stipends for work performed are now included in a formal Letter of Agreeme...
Audit Finding Reference: 2024-001 Management’s Response and Planned Corrective Action: The District will ensure that any further retention bonuses be formally reviewed and approved by the School Board and Superintendent. Stipends for work performed are now included in a formal Letter of Agreement and signed by the employee and administrator. Name of Contact Person and Completion Date: Name: Kathryn Ducharme Anticipated Completion Date – July 1, 2024
View Audit 352406 Questioned Costs: $1
LASH disagrees that this finding rises to the level of a "material weakness," but will proceed to address this finding through manual corrections and Legal Server improvements. From the prior fiscal year, significant progress was made to ensure the accuracy of the allocation of LSC work hours. This ...
LASH disagrees that this finding rises to the level of a "material weakness," but will proceed to address this finding through manual corrections and Legal Server improvements. From the prior fiscal year, significant progress was made to ensure the accuracy of the allocation of LSC work hours. This FY23 finding is related to an automatic allocation in Legal Server that occurs during a pay period when an exempt employee works more than the requisite hours and has charged a portion of time to LSC. The Legal Server system then automatically reallocates the time among the grants worked such that LSC may end up being charged a nominally less percentage of the total salary expense than it otherwise would have been These reallocations are deminimus, and result in less time, not more, being allocated to LSC. Therefore, LASH disagress that this finding is a "material weakness." LASH is committed to improving its performance in this area. In FY24, LASH employed a temporary Accountant who worked with staff to develop a process to indentify these misallcations and to correct them. While this manual process corrected the misallocation of LSC expenses, it did not correct the problem of employee numbers not matching up. There was one incident of employee numbers not matching in the sample of FY24. In FY25, LASH will continue to utilize the process it has proven will fix the misallocation of expenses for periods that have closed but will also attempt to move the process from after the distribution process to before and thus solve the problem up front. This move will not only identify any excess hours that triggers the problem and allow for fixing the allocations up front, but will identify mismatches in employee numbers and solve the problem identified in FY24.
COSA implemented a new timesheet process in June 2024 that aligns with payroll and provides a more accurate alignment with employee time, time and grant expense allocations.
COSA implemented a new timesheet process in June 2024 that aligns with payroll and provides a more accurate alignment with employee time, time and grant expense allocations.
View Audit 352372 Questioned Costs: $1
Management Response and Corrective Action Plan 1. Automatic payments for recurrent utility services are covered by blanket approval to ensure timely remittances. Individual utility invoices are not individually approved but are reviewed by agency location by the Operations department during their mo...
Management Response and Corrective Action Plan 1. Automatic payments for recurrent utility services are covered by blanket approval to ensure timely remittances. Individual utility invoices are not individually approved but are reviewed by agency location by the Operations department during their monthly finance meeting. Management has elected this method as most efficient for the volume and timeliness required. Documentation of the review during the meetings will be kept as evidence of review of these expenses. 2. Management allocates payroll for exempt salaried employees on an hourly basis to fund sources based on the 80-hour period for which they are compensated. Any hours worked in excess of 80 hours by these employees are not compensated nor charged to fund sources. Exempt salaried employees have been directed to report only compensated time on timesheets. 3. We concur with this finding. Changes in pay rates for staff who perform multiple roles will be redefined to include all possibly affected program fund sources that staff may impact. Contact person(s) responsible for the corrective action: Lisa Brabo, Chief Executive Officer, lbrabo@fsacares.org Denise Cicourel, Chief Operating Officer, denise@fsacares.org Jaime Kuczkowski, Chief Financial Officer, jaime@balancefm.com Anticipated Completion Date: Education and documentation on the above have already started and will be completed by June 30, 2025.
Finding 553761 (2024-002)
Significant Deficiency 2024
Replacement Reserve Deposits Recommendation: We recommend that management develop procedures to ensurereplacement reserve deposits are updated timely to ensure compliance with the HUDregulatory agreement. Explanation of disagreement with audit finding: There is no disagreement with the auditfinding....
Replacement Reserve Deposits Recommendation: We recommend that management develop procedures to ensurereplacement reserve deposits are updated timely to ensure compliance with the HUDregulatory agreement. Explanation of disagreement with audit finding: There is no disagreement with the auditfinding. Action taken in response to finding: Management has made an additional deposit in 2025 and developed processes to verify replacement reserve deposits are updated based on the regulatory agreement annually. Name(s) of contact person(s) responsible for corrective action: Theresa Bertram Planned completion date for corrective action plan: March 2025 If
View Audit 352352 Questioned Costs: $1
Corrective Action Plan We are in the process of updating the Organization’s written policies and procedures to include the requirements of the Uniform Guidance. Completion Date Fiscal year end 2025
Corrective Action Plan We are in the process of updating the Organization’s written policies and procedures to include the requirements of the Uniform Guidance. Completion Date Fiscal year end 2025
Finding 553699 (2024-002)
Significant Deficiency 2024
Invest in Kids updated its policies and procedures in October 2024. The updated language states “Disbursements to subrecipients of federal funds: The Director(s) and Finance & Administrative Manager will review all relevant documentation to confirm that funds were used for the approved amount and in...
Invest in Kids updated its policies and procedures in October 2024. The updated language states “Disbursements to subrecipients of federal funds: The Director(s) and Finance & Administrative Manager will review all relevant documentation to confirm that funds were used for the approved amount and intended activity, goods, or services, and that only allowable expenses are charged. Invoice payments will be delayed until the necessary supporting documentation is received and verified.” Additionally, all staff participated in the organization's annual financial management and internal controls training in October 2024 with a focus on the accounts payable and invoicing process.
View Audit 352269 Questioned Costs: $1
Finding 553698 (2024-001)
Significant Deficiency 2024
Invest in Kids updated its human resources system to ensure timesheets accurately reflect time allocated across various funding sources and cost objectives. Additionally, all staff attended the organization’s annual financial management and internal controls training in October 2024, that included u...
Invest in Kids updated its human resources system to ensure timesheets accurately reflect time allocated across various funding sources and cost objectives. Additionally, all staff attended the organization’s annual financial management and internal controls training in October 2024, that included updated policies and a focus on accurate submissions of time and effort. Policy reviews have also been completed by management.
View Audit 352269 Questioned Costs: $1
Finding 2024-001 Condition: Costs were recorded for service periods prior to grant approval date. Corrective Action Planned: The district will implement controls to prevent the recording of costs for service periods prior to grant approval date by written guidance to all staff involved in federal ...
Finding 2024-001 Condition: Costs were recorded for service periods prior to grant approval date. Corrective Action Planned: The district will implement controls to prevent the recording of costs for service periods prior to grant approval date by written guidance to all staff involved in federal grant funds. Please note, that the practice at question is not in violation of school committee policy as we have not made any expenditures outside that entity’s approval date. Anticipated Completion Date: By July 1, 2025 Contact: Ross Mulkerin, Director of Finance and Operations
View Audit 352205 Questioned Costs: $1
Finding: 2024-004 Written Financial Policies- Activitities Allowable, Allowable Cost Name of responsible official: Melissa Spear -Treasurer Corrective action: Adopt suggested policies as outlined by auditor. Anticipated completion date: June 30, 2025
Finding: 2024-004 Written Financial Policies- Activitities Allowable, Allowable Cost Name of responsible official: Melissa Spear -Treasurer Corrective action: Adopt suggested policies as outlined by auditor. Anticipated completion date: June 30, 2025
Finding 2024-02: Indirect Costs (IDC) Views of Responsible Officials Management agrees with the finding and recommendations. Through the merger with Old Dominion University, additional controls have adopted around the processes and controls around the accuracy of the review over indirect costs calcu...
Finding 2024-02: Indirect Costs (IDC) Views of Responsible Officials Management agrees with the finding and recommendations. Through the merger with Old Dominion University, additional controls have adopted around the processes and controls around the accuracy of the review over indirect costs calculation requirements. Corrective Action Plan Effective July 1, 2024, EVMS merged with ODU and the ODU Research Foundation became the fiscal and administrative agent for EVMS’s transferring sponsored programs on behalf of ODU. As per ODU’s Memorandum of Understanding (MOU) with the ODU Research Foundation, the ODU Research Foundation has policies and processes in place to manage how the indirect costs are calculated. The ODU Research Foundation uses its own system of internal controls for IDC calculation with no reliance on ODU systems for those processes and are audited separately. As a corrective action moving forward, ODU management will notify the ODU Research Foundation management of the audit findings, so they are aware of the internal control deficiencies. ODU will request the Research Foundation to provide a copy of their single audit report to monitor continued compliance with Uniform Guidance. The corrective action plan will be completed by March 31, 2025 and the contact person for this finding is Victoria Dean.
View Audit 352191 Questioned Costs: $1
Finding 553590 (2024-002)
Significant Deficiency 2024
Finding 2024-002 Significant Deficiency and Noncompliance - Lack of Required Uniform Guidance Policies and Procedures Condition: The City did not update their federal policies and procedures to be in full compliance with Uniform Guidance. Anticipated Completion Date: September 30, 2025 Corrective Ac...
Finding 2024-002 Significant Deficiency and Noncompliance - Lack of Required Uniform Guidance Policies and Procedures Condition: The City did not update their federal policies and procedures to be in full compliance with Uniform Guidance. Anticipated Completion Date: September 30, 2025 Corrective Action: The City will implement a new policy document specifically for Uniform Grant Compliance to have one document to ensure compliance.
Management’s Response/Corrective Action Plan: This program received significantly more distributions in 2024 than the City had received in the past. The funds initially were not considered to be federal since the source was private companies, but staff has since taken required grant agency training...
Management’s Response/Corrective Action Plan: This program received significantly more distributions in 2024 than the City had received in the past. The funds initially were not considered to be federal since the source was private companies, but staff has since taken required grant agency training. The City is implementing workflow for purchasing and credit card transactions which will provide electronic approvals and the ability to attach receipts.
Management’s Response/Corrective Action Plan: Management will have staff prepare monthly personnel activity reports for time worked on grants and will review and adjust budgeted payroll allocations accordingly. Monthly budget report have already been set up on the Google Drive for management and sta...
Management’s Response/Corrective Action Plan: Management will have staff prepare monthly personnel activity reports for time worked on grants and will review and adjust budgeted payroll allocations accordingly. Monthly budget report have already been set up on the Google Drive for management and staff to access and review.
Management’s Response/Corrective Action Plan: Management will reconcile reimbursement requests to general ledger detail and review available grant amounts before submitting the drawdown.
Management’s Response/Corrective Action Plan: Management will reconcile reimbursement requests to general ledger detail and review available grant amounts before submitting the drawdown.
View Audit 352169 Questioned Costs: $1
Management’s Response/Corrective Action Plan: The Director and Operations Manager abruptly left in spring of 2024, leaving the Finance Department to take over all financial functions. The City contracted with Greater Portland Metro to run the service until we could determine next steps. The City Co...
Management’s Response/Corrective Action Plan: The Director and Operations Manager abruptly left in spring of 2024, leaving the Finance Department to take over all financial functions. The City contracted with Greater Portland Metro to run the service until we could determine next steps. The City Council approved joining Greater Portland Metro in September 2024, effective January 2025. The City no longer has a bus service.
Management’s Views and Corrective Action Plan Management response to finding 2024-004: Review over cost transfers of subrecipient expenditures Cluster Name: Research and Development Federal Awarding Agency: Various Award Name: Various Award Number: Various Award Years: Various Assistance Listing T...
Management’s Views and Corrective Action Plan Management response to finding 2024-004: Review over cost transfers of subrecipient expenditures Cluster Name: Research and Development Federal Awarding Agency: Various Award Name: Various Award Number: Various Award Years: Various Assistance Listing Title: Various Assistance Listing Number: Various Pass-through entities: Various As described in Finding 2024-004, and as a result of improper training related to the implementation of the university’s new financial system in FY22, the university lacked adequate controls to identify the proper application of indirect costs as it relates to subrecipient expenses when using the cost transfer process to make corrections. Additionally, the university failed to properly apply its policy for the classification of subawards versus direct expenditures. As such, while cost transfers are a small percentage of overall transfer activity, an update to training materials will be made by June 2025 to educate cost transfer initiators on the proper method to use for this subset of subrecipient expenditures. Since February 2025, the Sponsor Projects Accounting (SPA) representative responsible for central office review of cost transfers now reviews to ensure that all intended grant related attributes are in effect before approving any subrecipient cost transfers. Additionally, as of February 2025, the university reinforced its policy regarding the classification of subawards versus direct expenditures with both the Procurement department and the SPA staff to ensure the proper expenditure classification is set up during the onboarding process of a contractor. The SPA team has completed its analysis and review of all previous subrecipient cost transfers to verify and correct the improper application of indirect cost limits and expenditure classifications. As of March 2025, all subrecipient cost transfer errors have been identified and corrected, resulting in questioned costs of approximately $587,000. Separately, this resulted in an under-recovery of $306,000 of indirect costs that were not charged to the original award. As all awards impacted are still open and active, the correcting expenditure adjustments were applied to the awards impacted that will affect future draw downs. Contact Person: Cindy Lee, Director, Sponsored Projects Accounting, cmlee@usc.edu
Management’s Views and Corrective Action Plan Management response to finding 2024-003: Unallowable costs – Cost transfers based on budgeted amounts Cluster Name: Research and Development Federal Awarding Agency: Department of Health and Human Services Award Name: Leveraging natural phenotypic vari...
Management’s Views and Corrective Action Plan Management response to finding 2024-003: Unallowable costs – Cost transfers based on budgeted amounts Cluster Name: Research and Development Federal Awarding Agency: Department of Health and Human Services Award Name: Leveraging natural phenotypic variations of heterogenous ALS populations-in-a-dish to enable scalable drug discovery Award Number: 5R01NS131409-03 Award Years: 2022-2025 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders Assistance Listing Number: 93.853 Pass-through entities: Not applicable As described in finding 2024-003, the university inadvertently processed a cost transfer moving expenses from one grant to another based on budgeted figures instead of actual expenses incurred. This resulted in an amount transferred that was greater than the actual costs incurred. The administrator in question has been identified and further review of this administrator’s work has been performed to determine if additional instances occurred. Upon review of the administrator’s work, it was determined that no additional corrections were required as no other instances of this nature were identified outside of the total questioned costs. As part of the department’s efforts to minimize further cost transfer errors, training was provided to all their grant administrators beginning November 1, 2024. This training will now be held annually to ensure the department responsible for administering the award is current on the University’s existing compliance policies. Furthermore, to support accuracy and transparency, the department will allocate separate time commitments during weekly administration meetings to review any required cost transfers. This time will be dedicated to ensuring proper documentation is in place, confirming the appropriateness of the transfer, and ensuring full compliance of the transaction(s). This updated review process involves representatives from Grant Administration, Keck School of Medicine Finance Office, and Purchasing, to ensure a full comprehensive review of each transfer. As such, beginning November 2024, a cost transfer will not move forward until it has been reviewed by the group. Contact Person: Andres Chan, Director, FBS Financial Analysis, andres.chan@usc.edu
View Audit 352166 Questioned Costs: $1
Management’s Views and Corrective Action Plan Management response to finding 2024-002: Unallowable costs over the NIH salary cap Cluster Name: Research and Development Federal Awarding Agency: Department of Health and Human Services Award Name: Alzheimer's Clinical Trial Consortium Award Number: ...
Management’s Views and Corrective Action Plan Management response to finding 2024-002: Unallowable costs over the NIH salary cap Cluster Name: Research and Development Federal Awarding Agency: Department of Health and Human Services Award Name: Alzheimer's Clinical Trial Consortium Award Number: 5U24AG057437-07 Award Years: 2023-2025 Assistance Listing Title: Aging Research Assistance Listing Number: 93.866 Pass-through entities: Not applicable As described in finding 2024-002, the process for manually creating sub-grants within our financial systems required an attribute to be activated. In this instance the attribute in question was not activated, resulting in the NIH salary cap restriction not to be enforced within the payroll system. In November 2024, when this instance was identified, a correction was immediately made to stop any future amounts above the salary cap to be charged to the award and to avoid any further errors. To ensure any transactions that occurred while the incorrect system attribute was in place were properly addressed, corrective measures in the form of cost transfers were made during this period by the department to minimize inappropriate charges to the sponsor. As part of the university’s corrective action plan, the Sponsored Project Accounting (SPA) office has completed a full review of all awards and determined this to be an isolated event. As of March 2025, to further strengthen internal controls over compliance, the SPA office has implemented a revised approach for the creation of new manual sub-grants which will ensure the necessary NIH salary cap restrictions are applied. Additionally, training documents have been updated to reflect this revised approach, and all SPA staff have now received training on this new update. Contact Person: Cindy Lee, Director, Sponsored Projects Accounting, cmlee@usc.edu
View Audit 352166 Questioned Costs: $1
Name of Responsible Individual: Rawle Howard, Assistant Vice President, Procurement Corrective Action: Accounts Payable (AP) will create a Corrective Action plan to include the following. 1. The process to review Payment Request Forms (“PRFs”), used for payment to vendors that do not require the u...
Name of Responsible Individual: Rawle Howard, Assistant Vice President, Procurement Corrective Action: Accounts Payable (AP) will create a Corrective Action plan to include the following. 1. The process to review Payment Request Forms (“PRFs”), used for payment to vendors that do not require the use of a purchase order, will be improved by requiring the review of supporting documents to ensure expenses are allowable by the newly established Sponsored Program Office (SPO) post award team. This team will thoroughly review supporting documents to ensure expenses are allowable, allocable, and reasonable according to University policies and grant terms. PRFs will be reviewed by SPO and Grants and Contracts Accounting (GCA) and will serve as the key control point before transactions are forwarded to accounting to post to sponsored awards. 2. AP is working with Enterprise Technology Services (ETS) to modify the Workday Ad Hoc Business process to require additional review by PI, SPO, and GCA before payments can be issued. Each approval role will receive guidance regarding 3. AP will collaborate with SPO and GCA to issue communications and provide training to all PIs, SPO, GCA, and AP personnel. Anticipated Completion Date: December 31, 2025
View Audit 352153 Questioned Costs: $1
Finding 553086 (2024-013)
Significant Deficiency 2024
Name of Responsible Individual: Marchon Jackson, Associate Vice President of Research; Jaquion Gholston, Assistant Vice President for Post-Award and UARC Operations; Rawle Howard, Assistant Vice President, Procurement Corrective Action: The process to review subrecipient invoices will be improved b...
Name of Responsible Individual: Marchon Jackson, Associate Vice President of Research; Jaquion Gholston, Assistant Vice President for Post-Award and UARC Operations; Rawle Howard, Assistant Vice President, Procurement Corrective Action: The process to review subrecipient invoices will be improved by requiring the review of supporting documents to ensure expenses are allowable by the Sponsored Program Office (SPO) post award team. This team will thoroughly review supporting documents to ensure expenses are allowable, allocable, reasonable and recorded in the proper period according to university policies and grant terms. Invoices will be reviewed by SPO and will serve as the key control point before transactions are forwarded to accounting to post to sponsored awards. Subrecipient invoices will be paid by Accounts Payable only after approval by SPO and GCA. The Director of Compliance will conduct spot checks on all sponsored transactional activity, especially for high-risk grants to provide an additional layer of oversight. The new review process and training for these responsibilities will be implemented by spring 2025 as part of the broader campus-wide workflow training and staffing up of the new SPO Post-Award office. Anticipated Completion Date: June 30, 2025
Finding 552703 (2024-012)
Significant Deficiency 2024
Name of Responsible Individual: Marchon Jackson, Associate Vice President for Research, Brenda Willis, Senior Executive Director of Financial Grants & Contracts, Jaquion Gholston, Assistant Vice President for Post-Award and UARC Operations Corrective Action: A new office is being developed to addres...
Name of Responsible Individual: Marchon Jackson, Associate Vice President for Research, Brenda Willis, Senior Executive Director of Financial Grants & Contracts, Jaquion Gholston, Assistant Vice President for Post-Award and UARC Operations Corrective Action: A new office is being developed to address the timeliness of the personnel payment request forms. In Phase I, CRAs will be assigned to high-volume research colleges to provide support for costing allocations. Phase 2 will encompass existing departmental administrators who will gradually transition into more centralized research workflows supported by CRAs. A shared services model for the remaining colleges is planned for FY26. Quarterly checklist and updates outlining cost allocation statuses will be completed with Deans and Associate Deans to determine the process needed to complete cost allocations timely. Anticipated Completion Date: July 1, 2025
View of Responsible Officials and Corrective Action Plan Air District Management concurs with the recommendation under Finding Reference Number F-2024-001. Upon review of the supporting travel expense documentation, management has found no discrepancies. Moving forward, the Air District will contin...
View of Responsible Officials and Corrective Action Plan Air District Management concurs with the recommendation under Finding Reference Number F-2024-001. Upon review of the supporting travel expense documentation, management has found no discrepancies. Moving forward, the Air District will continue to ensure that all supporting travel documentation agrees with the corresponding invoices to maintain compliance and accuracy. Regarding the overstatement of program expenditures, the Air District will initiate the recovery of the identified overcharges by deducting the amount from future reimbursement requests submitted to the Department of Homeland Security (DHS). Specifically, the Air District plans on recovering the $9,316 in overcharges from the contractor for fiscal year ending June 30, 2024. Additionally, the Air District is in the process of reviewing Fiscal Year 2025 invoices to identify any potential overcharges and will request reimbursement from the contractor, as necessary. To strengthen oversight and compliance, the Air District has begun implementing process changes as of February 2025. These changes ensure that consultant invoices align with the terms of the Air District’s contract prior to approval and payment processing. Name: Daniel Meer Title: Manager, Government Outreach & Special Projects Email: dmeer@baaqmd.gov
View Audit 352146 Questioned Costs: $1
Action in response to finding: The Organization will either add internal resources to address the matters noted in the finding or outsource its accounting function to a third party with these capabilities. Name of the contact person responsible for corrective action: Yvonne MacDonald Hames Planned c...
Action in response to finding: The Organization will either add internal resources to address the matters noted in the finding or outsource its accounting function to a third party with these capabilities. Name of the contact person responsible for corrective action: Yvonne MacDonald Hames Planned completion date for corrective action plan: June 30, 2025
Finding 551506 (2024-003)
Significant Deficiency 2024
Management accepts this finding. The error on the verification (1 student) was made by a former staff that did not verify the student wages. Clarkson’s procedure clearly states the income is required to be verified, however the former staff member made an error in processing this verification. Impr...
Management accepts this finding. The error on the verification (1 student) was made by a former staff that did not verify the student wages. Clarkson’s procedure clearly states the income is required to be verified, however the former staff member made an error in processing this verification. Improvements to the training process have been implemented including emphasis on the requirement that staff verify income as part of the review process. A multi-tier review system has been implemented whereby after the initial review process has been completed, verification documents are submitted to the Director who then performs a second review to ensure that the initial review process was correctly followed and that the data is reliable. Anticipated Completion Date December 2024 - completed Responsible Person Nicole Adner, Director of Financial Aid
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