Corrective Action Plans

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Condition: During audit procedures, we noted expenditures were charged to the program via adjusting journal entry for which adequate supporting documentation could not be provided. Corrective Actions: Going forward, the Organization will implement procedures requiring supporting documentation for a...
Condition: During audit procedures, we noted expenditures were charged to the program via adjusting journal entry for which adequate supporting documentation could not be provided. Corrective Actions: Going forward, the Organization will implement procedures requiring supporting documentation for all journal entries made to the program to ensure that amount charged to the program are actual expenses/expenditure of the program. Employee Responsible for Corrective Action: Michelle Clarke Completion Date: March 31, 2025
View Audit 351890 Questioned Costs: $1
Condition: During audit procedures, it was noted total reimbursements received exceeded expenditures. The Organization has charged costs to the program and received reimbursement; however, the products cost charged to the program had not been received prior to June 30, 2024. Corrective Actions: Goi...
Condition: During audit procedures, it was noted total reimbursements received exceeded expenditures. The Organization has charged costs to the program and received reimbursement; however, the products cost charged to the program had not been received prior to June 30, 2024. Corrective Actions: Going forward, the Organization will review all vouchers being charged to the program to make sure costs have been incurred before being charged to the program. Employee Responsible for Corrective Action: Michelle Clarke Completion Date: March 31, 2025
View Audit 351890 Questioned Costs: $1
Reporting - Cash Management During the testing of the Department's cash management procedures, it was determined that eight out of sixty payments tested were not distributed within 21 days of the draw down of funds. For the items tested, the time elapsed between draw down and payment ranged from 22 ...
Reporting - Cash Management During the testing of the Department's cash management procedures, it was determined that eight out of sixty payments tested were not distributed within 21 days of the draw down of funds. For the items tested, the time elapsed between draw down and payment ranged from 22 to 44 days. Corrective Action Plan:WIC has developed a Quality Control Plan, procedures and a workflow to ensure invoices are timely released to ASO-Fiscal for processing. Implementation Date: April 1, 2025 Responding Official: Melanie Murakami, WIC Branch Chief
2024-003- Medical Assistance (Medicaid School Based Services) Criteria: For an agency to bill Wisconsin Medicaid for School Based Services (SBS), an IEP, and Consent to Bill Wisconsin Medicaid for Medically Related Special Education and Related Services (DPI Form M-5) must be current, signed, and d...
2024-003- Medical Assistance (Medicaid School Based Services) Criteria: For an agency to bill Wisconsin Medicaid for School Based Services (SBS), an IEP, and Consent to Bill Wisconsin Medicaid for Medically Related Special Education and Related Services (DPI Form M-5) must be current, signed, and dated by the parent or guardian of a student with an IEP before claims can be submitted. The School District must obtain parental consent before the District accesses Wisconsin Medicaid for the first time. Condition: There were two students tested that did not have signed consent to bill forms on file. The District received reimbursements for services provided to these two students from Medicaid SBS. Without the signed consent to bill forms, theses services are not eligible for reimbursement. Cause: The District had a transition in staffing and the process step to verify signed consent to bill forms was missed. Effect: A reimbursement request was made for services that were not eligible to be reimbursed and did not comply with Medicaid SBS requirements. Auditor's Recommendation: Establish controls to verify all student services billed to Medicaid SBS have a signed consent to bill on file. Grantee Response: The District will review Medicaid SBS consent to bill forms and verify signed copies are on file going forward. Contact Person: Jon Bosworth Anticipated Completion: On-going
View of Responsible Officials - The questioned costs were immaterial and relate to a pay period that was split across the fiscal year (6/26/23 to 7/9/23, with a pay date of 7/14/23). Reports to the funder for the year ending 6/30/23 were due on 7/10/23, before all payroll information and supporting ...
View of Responsible Officials - The questioned costs were immaterial and relate to a pay period that was split across the fiscal year (6/26/23 to 7/9/23, with a pay date of 7/14/23). Reports to the funder for the year ending 6/30/23 were due on 7/10/23, before all payroll information and supporting documentation for this pay period was available. Therefore, the full pay period was included in the July reimbursement report. This practice was approved by the funder and the funder will not seek to recoup out of period costs. Moving forward, the Organization will be more cognizant of accrual dates for payroll reporting and submit a true-up as needed to ensure that payroll costs are correctly allocated at the end of the fiscal year
CCS discovered this and self-reported it to the appropriate agencies. The former employee mentioned and his immediate supervisor were terminated by CCS immediately upon its discovery of the conflict of interest and not following CCS’s procurement procedures. CCS refined its Conflict-of-Interest an...
CCS discovered this and self-reported it to the appropriate agencies. The former employee mentioned and his immediate supervisor were terminated by CCS immediately upon its discovery of the conflict of interest and not following CCS’s procurement procedures. CCS refined its Conflict-of-Interest and Procurement procedures. Conflict-of-Interest and procurement policy training sessions were conducted with all levels of staff and will continue to be conducted on a recurring basis. CCS is implementing additional layers of oversight and compliance monitoring. This is the responsibility of the CCS Chief Financial Officer. CCS is committed to continuous improvement, conducting regular internal audits and reviews to verify adherence to federal procurement standards. This is the responsibility of the CCS Revenue Cycle Manager. We are working to ensure that every vendor has a contract on file and all procurement policies are strictly followed. This is the responsibility of the CCS Controller and is expected to be completed by June 30, 2025.
FY24 interest in the amount of$331.01 was returned to USDHHS PS Program Suppmi Center on 1/30/2025. We are keeping a smaller balance in the Federal Funds bank account to lessen the amount of interest earned on the account. Any amount over $500 at the end of the fiscal year will be returned through t...
FY24 interest in the amount of$331.01 was returned to USDHHS PS Program Suppmi Center on 1/30/2025. We are keeping a smaller balance in the Federal Funds bank account to lessen the amount of interest earned on the account. Any amount over $500 at the end of the fiscal year will be returned through the same process as prior years. Responsible Person for Correction Action Plan: Deana Rogers, Vice President of Administration & Finance Implementation Date/or Corrective Action Plan: 01/30/25
View Audit 351835 Questioned Costs: $1
Identification and Review • Identify all students who received incorrect loan amounts (Completed) • Make appropriate adjustments to loan disbursements (Completed) • Notify affected students and provide guidance on next steps (Completed) Policy and Procedure Enhancements • Develop clear, written proc...
Identification and Review • Identify all students who received incorrect loan amounts (Completed) • Make appropriate adjustments to loan disbursements (Completed) • Notify affected students and provide guidance on next steps (Completed) Policy and Procedure Enhancements • Develop clear, written procedures for verifying loan amounts prior to disbursement • Implement a two-step verification process for loan packaging System Controls • Collaborate with IT to implement automated system checks to flag discrepancies • Enhance reporting tools for regular audits and monitoring Staff Training • Conduct comprehensive training sessions for financial aid staff on federal regulations regarding Direct Loans • Provide ongoing refresher courses and updates as federal policies change Monitoring Continuous Improvement • Establish a quarterly audit process to ensure compliance • Monitor loan discrepancies detected and correct as needed • Conduct regular audits to confirm compliance with federal loan regulations. • Collect feedback from staff on the effectiveness of training Responsible Person for Correction Action Plan: Alexis Brown, Director of Financial Aid Implementation Date for Corrective Action Plan: 03/03/25
NCHE implemented a new policy in January 2025 regarding missing receipts. In January 2024, a new policy was instituted requiring receipt of vendor invoice before payment approval by the Accountant and Executive Director. All copies of approvals, receipts, and invoices, are now attached to each expen...
NCHE implemented a new policy in January 2025 regarding missing receipts. In January 2024, a new policy was instituted requiring receipt of vendor invoice before payment approval by the Accountant and Executive Director. All copies of approvals, receipts, and invoices, are now attached to each expense transaction in QuickBooks Online. In January 2025, NCHE required email documentation for any missing receipts, sent to the accountant for inclusion in QBO.
A. Comments on Findings and Recommendations: We concur with the auditor’s suggestions for reporting program personnel cost. B. Actions Taken or Planned: Management will continue to evaluate their controls with respect to current federal awards and requirements to insure accurate information capt...
A. Comments on Findings and Recommendations: We concur with the auditor’s suggestions for reporting program personnel cost. B. Actions Taken or Planned: Management will continue to evaluate their controls with respect to current federal awards and requirements to insure accurate information captured and reported. Anticipated completion date: Already implemented, ongoing Contact information for this finding: Michelle Walsh, 636-528-6117
Corrective Action Plan: The College agrees with this finding. After disbursing aid for the first time in the Fall 2023 semester and sending Pell origination and disbursement records to COD, the College ran the Pell COD Reject Report (PCRR) in Colleague to identify records that COD had rejected. CO...
Corrective Action Plan: The College agrees with this finding. After disbursing aid for the first time in the Fall 2023 semester and sending Pell origination and disbursement records to COD, the College ran the Pell COD Reject Report (PCRR) in Colleague to identify records that COD had rejected. COD identified 8 students whose Pell disbursement was rejected due to citizenship status issues. These files were reviewed and it was identified that a required field in Colleague was not populated correctly to indicate to COD that the citizenship issue had been reviewed by collecting the required documentation from the student. The files were being reviewed and updates were made in Colleague but not within the 15-day window. Procedure notes have been updated and training has occurred to ensure all relevant personnel understand the process and know where to make the appropriate updates in Colleague when reviewing citizenship documents. Status of Correction Action: Completed
To address the issue of meal counts not being properly taken and recorded at the point of service, SCO Family of Services is reinforcing internal controls in accordance with 7 CFR 210.8 to ensure the accuracy of meal counts prior to submitting monthly claims for reimbursement. Staff involved in meal...
To address the issue of meal counts not being properly taken and recorded at the point of service, SCO Family of Services is reinforcing internal controls in accordance with 7 CFR 210.8 to ensure the accuracy of meal counts prior to submitting monthly claims for reimbursement. Staff involved in meal service have received refresher training on proper point-of-service meal counting procedures, and supervisors will continue to conduct routine monitoring to verify compliance. These steps will help ensure that all meal counts are accurately recorded in real-time, supporting the integrity of reimbursement claims. To ensure accountability, the agency is currently in the process of recruting a full-time Food Service Director who will have oversight over the Child Nutrition Porgram and will be responsible for continued compliance, staff training, on-site reviews, and all documentation required by both state and federal regulations. While we will recruit to fill this poistion, an interim Food Service Director will be appointed. Our PQI department will continue to support and monitor activities as well. Proposed Implementation Date: Immediately
Management Response We agree with the auditor's comments. The College is actively recruiting to fill critical vacancies. Procedures for documenting approvals and drawdowns in the G5 system are currently being reviewed. Documentation of procedures for drawdowns and monthly cash reconciliation will be...
Management Response We agree with the auditor's comments. The College is actively recruiting to fill critical vacancies. Procedures for documenting approvals and drawdowns in the G5 system are currently being reviewed. Documentation of procedures for drawdowns and monthly cash reconciliation will be implemented in FY 2026.
Finding 547421 (2024-003)
Significant Deficiency 2024
The agency is currently having discussions with both Department of Labor, as well as with Department of Administrative Services to see if UI benefits would be able to be added as an exemption to the Treasury Stat agreement for CMIA requirements.
The agency is currently having discussions with both Department of Labor, as well as with Department of Administrative Services to see if UI benefits would be able to be added as an exemption to the Treasury Stat agreement for CMIA requirements.
Finding 547414 (2024-004)
Significant Deficiency 2024
Federal Agency: U.S. Department of Veterans Affairs Federal Program Name: VA Supportive Services for Veteran Families (SSVF) Assistance Listing Number: 64.033 Federal Award Identification Number: 20-ZZ-026 Award Period: 10/01/2023 - 09/30/2024 Type of Finding: Significant Deficiency in Internal Cont...
Federal Agency: U.S. Department of Veterans Affairs Federal Program Name: VA Supportive Services for Veteran Families (SSVF) Assistance Listing Number: 64.033 Federal Award Identification Number: 20-ZZ-026 Award Period: 10/01/2023 - 09/30/2024 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Compliance Requirement: Cash Management Actions Planned in Response to Finding: The organization will establish and implement a formal drawdown reconciliation process. This will include developing written procedures, training staff on reconciliation requirements, and maintaining clear documentation for each reconciliation. Executive personnel will conduct monthly reviews to verify compliance and address any discrepancies promptly prior to drawdown. Official Responsible for Ensuring CAP: The Interim ED will be responsible for overseeing the implementation of corrective actions. Planned Completion Date for CAP: The completion date is March 1, 2025. Plan to Monitor Completion of CAP: The Board of Directors meet with the Executive team at least quarterly to review financials.
Finding 547400 (2024-001)
Significant Deficiency 2024
During the fiscal year ended June 30, 2024, there was a high amount of turnover within the operational team responsible for this grant, including the Project Coordinator, the Program Manager and the Director of the department. The staff member who had been responsible for performing the rent reason...
During the fiscal year ended June 30, 2024, there was a high amount of turnover within the operational team responsible for this grant, including the Project Coordinator, the Program Manager and the Director of the department. The staff member who had been responsible for performing the rent reasonableness review terminated employment and the report documentation was either not completed, completed but not signed, or not filed in a secure location. Beginning in late 2024, all current staff members have been instructed to complete the rent reasonableness review for each incoming client, ensuring it is signed and saved in the client chart. In addition, the staff has been instructed to save an electronic copy of the rent reasonableness review in a secure folder to ensure it is accessible in the future. To ensure compliance with new process, the team will do periodic reviews of existing charts to ensure all documentation is in place and all requirements are met. Additionally, in some instances, damages were paid in excess of the allowable limits or were reimbursed for expenses made during the normal course of business instead of at the exit period. All team members associated with this grant have received and reviewed the Grant Agreement and are familiar with agreement terms and the damage payments not to exceed allowable limits. All future requests for damages will be reviewed and approved by the Departmental Director prior to the payment request being submitted for processing by the Accounts Payable Department. Additionally, the voucher submission process for damange requests will also include a Finance team member for review and authorization of the voucher detail to ensure compliance of all grant parameters before processing by the Accounts Payable Department.
View Audit 351637 Questioned Costs: $1
The PRDOH is working with the Finance Department to establish and strengthen our internal controls to ensure all payments comply with the guidelines established by the Federal Government. On the other hand, the PRDOH is working and verifying our own written procedures to ensure that payments are iss...
The PRDOH is working with the Finance Department to establish and strengthen our internal controls to ensure all payments comply with the guidelines established by the Federal Government. On the other hand, the PRDOH is working and verifying our own written procedures to ensure that payments are issued promptly after the drawdown is made.
The PRDOH is working with the Finance Department to establish and strengthen our internal controls to ensure all payments comply with the guidelines established by the Federal Government. On the other hand, the PRDOH is working and verifying our own written internal procedures to ensure that payment...
The PRDOH is working with the Finance Department to establish and strengthen our internal controls to ensure all payments comply with the guidelines established by the Federal Government. On the other hand, the PRDOH is working and verifying our own written internal procedures to ensure that payments are issued promptly after the drawdown is made.
The PRDOH is working with the Finance Department to establish and strengthen our internal controls to ensure all payments comply with the guidelines established by the Federal Government. On the other hand, the PRDOH is working and verifying our own written procedures to ensure that payments are iss...
The PRDOH is working with the Finance Department to establish and strengthen our internal controls to ensure all payments comply with the guidelines established by the Federal Government. On the other hand, the PRDOH is working and verifying our own written procedures to ensure that payments are issued promptly after the drawdown is made.
Finding No. 2024-002 – Rental Costs of Real Property and Equipment Condition Found When renewing the rental contract for the administration of the Revolving Fund, the DOH, as the Revolving Fund administrator, complied with statutory laws and procedures governing contract renewal. However, under the ...
Finding No. 2024-002 – Rental Costs of Real Property and Equipment Condition Found When renewing the rental contract for the administration of the Revolving Fund, the DOH, as the Revolving Fund administrator, complied with statutory laws and procedures governing contract renewal. However, under the applicable regulations, if a contract renewal does not include a fee increase, there is no statutory requirement to evaluate comparable rental properties or conduct a periodic market study to assess potential changes in market conditions. As a result, the Revolving Fund lacks, within its existing processes and documentation, established policies and procedures for performing and documenting such assessments and did not conduct the evaluation required under 2 CFR § 200.465 in a timely manner. However, during discussions with the auditors, the required evaluation was performed, demonstrating that the rental costs remain reasonable in accordance with federal regulations. Views of Responsible Officials and Corrective Action Plan Having addressed and resolved the matter in reference, we also concur what was discussed with the auditors, that the required information was provided demonstrating that the costs for rent are reasonable and are in accordance with the provisions of the federal regulations, proceeded as follows: • In parallel to the current process of renewal of the lease contract, the Program performed the reasonableness study for rent cost, regardless of the non-requirement within the current procedure. The study confirmed that the rent costs are reasonable and cost effective. • For the purpose and as part of the corrective action plan, the Program incorporated as part of its processes a procedure to achieve the implementation of periodic evaluation of rental costs. This procedure incudes among others, the frequency in which such evaluations will be carried out. • The Program, as Administrator, will recommend the Department of Health’s management the need to incorporate the periodic requirement in compliance with the 2 CRF § 200.465 federal section. Name (s) of the Contact Person (s) Responsible for Corrective Action Ángel Pantoja Rodríguez, Secretary of the Treasury Department, Eduardo Rivera Cruz, Executive Director Puerto Rico Infrastructure Financing Authority and Victor Ramos, Secretary of the Puerto Rico Department of Health. Anticipated Completion Date Immediately
Finding No. 2024-001 -Allowable Activities-Loans repayments Condition Found Principal and interest have not been collected from the Revolving Fund on projects that were completed since before the execution of the loan agreement, which are included as part of the financial agreement dated September 2...
Finding No. 2024-001 -Allowable Activities-Loans repayments Condition Found Principal and interest have not been collected from the Revolving Fund on projects that were completed since before the execution of the loan agreement, which are included as part of the financial agreement dated September 2, 2022. Therefore, repayment of principal and payment of interest should have begun on their respective dates, as set forth in the loan agreement and notes payable executed thereto. Views of Responsible Officials and Corrective Action Plan Once the final inspection of a construction project is performed, DOH will submit notifications to PRASA requesting the Notice of Substantial Completion letter from PRASA concurring that the project is acceptable of the operation. Such letter will be an attachment to the formal notification that DOH will send to PRASA and PRIFA. DOH’s letter will specify the starting operating date and the useful life of the project. Therefore, PRIFA will be in position to collect principal and interest for the project according to federal regulations and as established in the loan agreement. Name (s) of the Contact Person (s) Responsible for Corrective Action Ángel Pantoja Rodríguez, Secretary of the Treasury Department, Eduardo Rivera Cruz, Executive Director Puerto Rico Infrastructure Financing Authority and Victor Ramos, Secretary of the Puerto Rico Department of Health. Anticipated Completion Date Immediately
Finding Number: 2024-003 Equipment Property Management Recommendation: The University needs to enhance the precision of the controls over equipment purchases to ensure that a property record is created within the system containing the required information for all federally funded equipment. Manage...
Finding Number: 2024-003 Equipment Property Management Recommendation: The University needs to enhance the precision of the controls over equipment purchases to ensure that a property record is created within the system containing the required information for all federally funded equipment. Management concurs with the auditor’s recommendation. The University has taken immediate steps to comply with 2 CFR 200.313 and is in process of implementing the following actions: Planned Corrective Action (1): The University is incorporating an additional worktag into the procurement approval workflow for asset management, enabling the identification of asset purchase orders and ensuring their proper routing to the Asset Management team for asset record creation. Anticipated Completion Date: May 2025 Responsible Contact Person: Eric Hughey, Fiscal Manager, Asset Accounting & Surplus/Nataliya Samodov, GCA Director Planned Corrective Action (2): The University will be implementing Multi-book functionality in the Workday ERP to improve asset management including creation of multiple asset books to meet different accounting standards as well as tracking of the assets from acquisition to disposal. This implementation will provide active monitoring of assets to ensure compliance. Anticipated Completion Date: Fall 2025 Responsible Contact Person: Eric Hughey, Fiscal Manager, Asset Accounting & Surplus/Nataliya Samodov, GCA Director
View Audit 351508 Questioned Costs: $1
Planned Corrective Action: Management agrees with this finding. Copies of the Verizon invoices for Hot Spots are given to the IT Department designee to collect and submit to the E-Rate Consultant. Prior to sending the invoices, the IT designee and CFO will meet to confirm the budgets units used and ...
Planned Corrective Action: Management agrees with this finding. Copies of the Verizon invoices for Hot Spots are given to the IT Department designee to collect and submit to the E-Rate Consultant. Prior to sending the invoices, the IT designee and CFO will meet to confirm the budgets units used and the submission. Scott Young is going to make contact with our E-Rate consultant, Sharon Dowdy, who will confirm the repayment of $80,750 of duplicate support by April 7, 2025. Persons responsible for corrective action: Scott Young, IT Project Manager; Jimmy Hogg, IT Director; Jackie Rowlett, District Treasurer. Anticipated corrective action implementation date: April 7, 2025.
View Audit 351448 Questioned Costs: $1
Action taken in response to finding: The September 2023 claiming error was caused in part by the Food Service Management Company manually entering the claims in the DESE Portal incorrectly. Newton took responsibility for entering the claims for the balance of FY24. For FY25, Newton now uploads the...
Action taken in response to finding: The September 2023 claiming error was caused in part by the Food Service Management Company manually entering the claims in the DESE Portal incorrectly. Newton took responsibility for entering the claims for the balance of FY24. For FY25, Newton now uploads the meal count data from Mosaic, the point-of-sale software, directly into the DESE portal. That upload is done by the Business Operations Analyst and then approved by the Director of Business Operations, which removes substantial exposure for human error during data entry and creates two levels of review prior to approval and submission. The other five discrepancies between the source counts and what was submitted for the DESE claim was to address identified human error in advance to ensure that the monthly claim was accurate. For the September 2023 error, Newton has submitted a Claim Adjustment Form to DESE to provide guidance for the necessary action steps. Name(s) of the contact person(s) responsible for corrective action: Amy Mistrot, NPS Director of Business Operations. Planned completion date for corrective action plan: The internal controls to reduce data entry errors have been implemented and are consistently being used. DESE will provide guidance for the Claim Adjustment Request to address the September 2023 error, which Newton will then implement.
View Audit 351352 Questioned Costs: $1
Finding Number: 2024-002 Condition: The Organization failed to correctly account for unconditional contribution revenue during the year ended June 30, 2024 Planned Corrective Action: Management will continue to evaluate current processes and practices to determine that contributions, whether uncon...
Finding Number: 2024-002 Condition: The Organization failed to correctly account for unconditional contribution revenue during the year ended June 30, 2024 Planned Corrective Action: Management will continue to evaluate current processes and practices to determine that contributions, whether unconditional or conditional, are being recognized in the appropriate period. This will include building out and utilizing certain flowcharts/checklists to identify the appropriate timing of revenue recognition as well as adding indicators into their assessment which will result in additional clarity regarding donor restrictions, what conditions are present in each grant agreement and what conditions preclude revenue recognition until the condition is met. Contact Person Responsible for Corrective Action: Justin Fisher, Director of Accounting Anticipated Completion Date: June 30, 2025
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