Corrective Action Plans

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Corrective action plan: To strengthen SEFA preparation and review, DSHS has designated the recently hired DSHS Financial Reporting Unit Manager and Accounting Section Director to oversee the following corrective action plan actions:  Formal updates to procedures to better implement policy;  Co...
Corrective action plan: To strengthen SEFA preparation and review, DSHS has designated the recently hired DSHS Financial Reporting Unit Manager and Accounting Section Director to oversee the following corrective action plan actions:  Formal updates to procedures to better implement policy;  Completion of hiring key financial reporting positions;  A refresher training for staff and contractors involved in SEFA preparation and review; and  Development of an internal quality review process for implementation during the next SEFA. Implementation dates: November 30, 2025 Responsible persons: Paige Lovejoy, DSHS Financial Reporting Unit Manager
Corrective Action Plan: The unaudited statements were corrected for FY2024 and are reflected in the audited statements. FY2023’s were corrected through the retained earnings that show on the FY2024’s audited statements as well in the prior year’s number on the statements. The FY2024 Single Audit ref...
Corrective Action Plan: The unaudited statements were corrected for FY2024 and are reflected in the audited statements. FY2023’s were corrected through the retained earnings that show on the FY2024’s audited statements as well in the prior year’s number on the statements. The FY2024 Single Audit reflects these changes as well. Management invoices at the times allowed upon the different grant funders based upon percentage of completion of the project/s. We will review all on-going projects at the end of each fiscal year during the audit with the auditors to determine what reporting has to be done in order to comply with the requirements of the requirements of Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, (Uniform Guidance), Subpart F, Audit Requirements.
Name of Contact Person: Sara Graul Corrective Action: Case File Oversight: • The Program Director has always reviewed case files but previously failed to sign the checklists. This has now been corrected and checklists are being signed upon review. • This process will continue to ensure proper docu...
Name of Contact Person: Sara Graul Corrective Action: Case File Oversight: • The Program Director has always reviewed case files but previously failed to sign the checklists. This has now been corrected and checklists are being signed upon review. • This process will continue to ensure proper documentation and compliance. • The Department structure is currently being reviewed with additional staff likely to add capacity and oversight. Financial Review & Approval Process: • The Finance team will continue preparing projection worksheets reconciled to the general ledger. • The Program Director will formally review and approve these financial documents before reimbursement requests are submitted. • We resolved this deficiency in April 2024 and have put the following additional controls in place to prevent this deficiency from recurring. Training & Standardization: • All program staff, including case managers and finance personnel, will receive training on compliance and proper documentation. • A standardized process and accountability measures will be in place to maintain adherence to these corrective actions. Monitoring & Reporting: • Quarterly internal audits will be conducted to verify compliance with the updated review and approval process. • An internal compliance officer or manager will oversee adherence to the new protocols. Completion Date: Full compliance with these measures is expected by the end of the next reporting quarter.
U.S. Department of Housing and Urban Development Cicero Commons Senior Housing Development Fund Company, Inc. (Lucille Manor Apartments), HUD Project No. 014-EE070-NY06-S941-009 respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of independ...
U.S. Department of Housing and Urban Development Cicero Commons Senior Housing Development Fund Company, Inc. (Lucille Manor Apartments), HUD Project No. 014-EE070-NY06-S941-009 respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of independent public accounting firm: Bonadio & Co., LLP 432 North Franklin Street #60 Syracuse, New York 13204 Audit period: July 1, 2023 – June 30, 2024 The findings from the 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS – FINANCIAL STATEMENT AUDIT None FINDINGS – FEDERAL AWARD PROGRAM AUDIT Finding 2024-001: Supportive Housing for the Elderly (Section 202), Federal Assistance Listing Number 14.157 Condition: The required deposit of $7,387 for the year ended June 30, 2023 was made after the 60 day deadline. Recommendation: Lucille Manor Apartments should ensure residual receipts are made within 60 days of year-end in accordance with the HUD Regulatory Agreement. Action Taken: The required deposit was made in March 2024. Completion Date: March 2024 Name of Contact Person Responsible for Corrective Action: Kyle Lyskawa, CFO, (315) 424-1821.
FINDING 2024-004 – Child Nutrition Cluster - Reporting Context: We noted that for all sponsor claim reimbursements in a sample of four claims, the sponsor claim reimbursement was prepared without a secondary, documented review before the submission of the claim to ensure the accuracy of the sponsor...
FINDING 2024-004 – Child Nutrition Cluster - Reporting Context: We noted that for all sponsor claim reimbursements in a sample of four claims, the sponsor claim reimbursement was prepared without a secondary, documented review before the submission of the claim to ensure the accuracy of the sponsor claim reimbursement summary. Contact Person Responsible for Corrective Action: Michelle L. Keene Contact Phone Number: (812) 384-4386 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The treasurer will formally review and document the review of all reimbursement claims Anticipated Completion Date: March 2025
Finding 530180 (2024-031)
Significant Deficiency 2024
Views of Responsible Officials and Planned Corrective Action: DMS concurs with this finding. For Sample Item 15, DMS has implemented an automated process to notify providers of pending revalidations and to terminate them when revalidation is not completed within five years. For Sample Item 21, DMS ...
Views of Responsible Officials and Planned Corrective Action: DMS concurs with this finding. For Sample Item 15, DMS has implemented an automated process to notify providers of pending revalidations and to terminate them when revalidation is not completed within five years. For Sample Item 21, DMS has implemented automated processes utilizing data transfers from licensing boards that will now terminate providers when their license lapses. In addition, DMS is developing a mechanism to obtain information provided on W-9’s by utilizing an electronic process through the provider portal during enrollment. This provider was terminated on 10/2/23. For Sample Item 40, DMS has coordinated with Division of Provider Services and Quality Assurance (DPSQA) to interface with their certification tracking system and to provide additional notifications to providers when their certification period is nearing expiration. Notifications are being sent 30 days prior to the lapse of certification. DMS confirmed with DPSQA that there were no adverse events that lead to the termination of the provider’s certification. Anticipated Completion Date: June 30, 2025 Contact Person: Elizabeth Pitman Director, Division of Medical Services Department of Human Services 700 Main Street Little Rock, AR 72201 (501) 244-3944 Elizabeth.Pitman@dhs.arkansas.gov
View Audit 348267 Questioned Costs: $1
Views of Responsible Officials and Planned Corrective Action: DHS concurs with the finding. For Sample Item 32, the agency’s revalidation date was set for March 27, 2024, and the provider submitted their application for revalidation prior to that date. System updates and monitoring controls have bee...
Views of Responsible Officials and Planned Corrective Action: DHS concurs with the finding. For Sample Item 32, the agency’s revalidation date was set for March 27, 2024, and the provider submitted their application for revalidation prior to that date. System updates and monitoring controls have been implemented to ensure correct revalidation dates are entered in MMIS. For Sample Item 15, the provider submitted a revalidation application prior to their scheduled termination date. Since there was an active application in the system, the provider was not terminated. The revalidation was successfully completed. For Sample Item 21, the provider submitted their revalidation application on October 16, 2023, which was prior to the November 11, 2023 deadlines. Multiple follow-ups and requests for additional information from the provider resulted in completion of the revalidation after the deadline date. Anticipated Completion Date: Complete Contact Person: Elizabeth Pitman Director, Division of Medical Services Department of Human Services 700 Main Street Little Rock, AR 72201 (501) 244-3944 Elizabeth.Pitman@dhs.arkansas.gov
View Audit 348267 Questioned Costs: $1
Views of Responsible Officials and Planned Corrective Action: Moving forward the Department will require recipients to provide a list of invoices with the invoice date, period of performance, invoice amount and amount requested/disbursed from ARPA and/or other funding sources to be included with eac...
Views of Responsible Officials and Planned Corrective Action: Moving forward the Department will require recipients to provide a list of invoices with the invoice date, period of performance, invoice amount and amount requested/disbursed from ARPA and/or other funding sources to be included with each disbursement request. Staff training will be modified to ensure staff understand allowable expenditures and period of performance restrictions. Anticipated Completion Date: June 30, 2025 Contact Person: Debby Dickson Water Development Division Manager Arkansas Department of Agriculture-Natural Resources Division 1 Natural Resources Drive Little Rock, AR 72205 (501) 225-1598 Debra.Dickson@agriculture.arkansas.gov
View Audit 348267 Questioned Costs: $1
Views of Responsible Officials and Planned Corrective Action: ASBO will work with our 3rd party program administrator to re-emphasize the importance of verifying the expenses for adequate supporting documentation and allowability. We will discuss the possibility of a repeat training with all federa...
Views of Responsible Officials and Planned Corrective Action: ASBO will work with our 3rd party program administrator to re-emphasize the importance of verifying the expenses for adequate supporting documentation and allowability. We will discuss the possibility of a repeat training with all federal grant subrecipients. Anticipated Completion Date: August 1, 2025 Contact Person: Glen Howie, Jr. Director, Ark State Broadband Office Department of Commerce 1 Commerce Way Little Rock, AR 72202 (501) 682-1123 Glen.Howie@Arkansas.gov
View Audit 348267 Questioned Costs: $1
Finding 530153 (2024-005)
Significant Deficiency 2024
Views of Responsible Officials and Planned Corrective Action: The Arkansas Department of Education (ADE), Division of Elementary and Secondary Education (DESE), Health and Nutrition Unit (HNU), concur with the finding. The HNU Finance staff implemented procedures for meal claim payment requests whic...
Views of Responsible Officials and Planned Corrective Action: The Arkansas Department of Education (ADE), Division of Elementary and Secondary Education (DESE), Health and Nutrition Unit (HNU), concur with the finding. The HNU Finance staff implemented procedures for meal claim payment requests which include an initial and final review of all requests to be conducted by two (2) staff. The review process includes, but is not limited to, ensuring expenditures are assigned correct codes related to the appropriate funding source within the appropriate grant year, mitigating the Child Nutrition Program (CNP), Child and Adult Care Food Program (CACFP) Sponsor Administrative expenditure errors going forward. When the request is determined to be compliant, the Associate Director of Finance and Training approves payments before being forwarded to the ADE Finance team for payment. Anticipated Completion Date: March 15, 2025 Contact Person: Sheila Chastain Associate Director Arkansas Department of Education, DESE, Nutrition Services #4 Capitol Mall, Box #12 Little Rock, AR 72201 (501) 324-9502 Sheila.Chastain@ade.arkansas.gov Pamela Burton Director Arkansas Department of Education, DESE, Nutrition Services #4 Capitol Mall, Box #19 Little Rock, AR 72201 (501) 320-8978 Pamela.Burton@ade.arkansas.gov
View Audit 348267 Questioned Costs: $1
Finding 530152 (2024-004)
Significant Deficiency 2024
Views of Responsible Officials and Planned Corrective Action: The Arkansas Department of Education (ADE), Division of Elementary and Secondary Education (DESE), Health and Nutrition Unit (HNU), concur with the finding. The HNU implemented a new application and payment system that began in 2024. Du...
Views of Responsible Officials and Planned Corrective Action: The Arkansas Department of Education (ADE), Division of Elementary and Secondary Education (DESE), Health and Nutrition Unit (HNU), concur with the finding. The HNU implemented a new application and payment system that began in 2024. During implementation and subsequent operations, several issues with data transfers between the old and new system were identified and now corrected. The HNU Application and Finance staff will receive training to ensure that all criteria are met prior to the retroactive payment of claims. Anticipated Completion Date: April 1, 2025 Contact Person: Sheila Chastain Associate Director Arkansas Department of Education, DESE, Nutrition Services #4 Capitol Mall, Box #12 Little Rock, AR 72201 (501) 324-9502 Sheila.Chastain@ade.arkansas.gov Pamela Burton Director Arkansas Department of Education, DESE, Nutrition Services #4 Capitol Mall, Box #19 Little Rock, AR 72201 (501) 320-8978 Pamela.Burton@ade.arkansas.gov
View Audit 348267 Questioned Costs: $1
March 24, 2025 In response to the finding, he Town hired a consultant to manage the High St Dam Project that was sourced with multiple grants. In FY2024, the Town was faced with a staffing shortage, and it did not properly oversee the reimbursement schedules. The Town anticipates this project to c...
March 24, 2025 In response to the finding, he Town hired a consultant to manage the High St Dam Project that was sourced with multiple grants. In FY2024, the Town was faced with a staffing shortage, and it did not properly oversee the reimbursement schedules. The Town anticipates this project to close out during the next fiscal year, and with new staff in place, it will properly manage and oversee all of the grant reporting and reimbursements. Sincerely yours, Laurie Guerrini, Finance Director
Views of Responsible Officials and Planned Corrective Action: Director of Child Nutrition will have a secondary person review claim before submitting to state department, to ensure accurate keying of data.
Views of Responsible Officials and Planned Corrective Action: Director of Child Nutrition will have a secondary person review claim before submitting to state department, to ensure accurate keying of data.
Finding 530127 (2024-002)
Significant Deficiency 2024
Finding 2024-002: Allowable costs and activities – significant deficiency in internal controls over compliance. Management Response Finding: Failure to Provide an Itemized Receipt for a Restaurant Purchase Corrective Action Taken: Effective July 1, 2024, CEN implemented Ramp, an expense management p...
Finding 2024-002: Allowable costs and activities – significant deficiency in internal controls over compliance. Management Response Finding: Failure to Provide an Itemized Receipt for a Restaurant Purchase Corrective Action Taken: Effective July 1, 2024, CEN implemented Ramp, an expense management platform that ensures all purchases are documented with proper receipts before being charged to the grant. This solution directly addresses the issue of missing itemized receipts and ensures compliance with federal grant requirements. Steps Implemented: • Mandatory Receipt Submission: All purchases, including restaurant transactions, require an itemized receipt to be uploaded into Ramp before the expense can be approved. • Approval Before Grant Charging: An approver must review the itemized receipt to verify that no prohibited items were purchased before allowing the expense to be charged to the grant. • Grant Compliance Review: If an itemized receipt is not provided or contains unallowable expenses, the charge will not be allocated to the grant and must be covered by a non-grant funding source. • Training & Compliance: All employees who make purchases with grant funds have been trained on the requirement for itemized receipts and the consequences of non-compliance. Responsible Party: Kendall Guynes, CFO Completion Date: July 1, 2024 (Fully Implemented) Parties Responsible: Chief Executive Officer President Chief Financial Officer Business Manager The Corrective Action Plan is currently in place and was implemented on July 1, 2024.
Finding 2024-001: Allowable costs and activities – material weakness in internal controls over compliance and compliance finding. Management Response Finding: Lack of Documented Approval for Purchases. Corrective Action Taken: Effective July 1, 2024, CEN implemented Ramp, an expense management platf...
Finding 2024-001: Allowable costs and activities – material weakness in internal controls over compliance and compliance finding. Management Response Finding: Lack of Documented Approval for Purchases. Corrective Action Taken: Effective July 1, 2024, CEN implemented Ramp, an expense management platform that ensures all purchases are documented and approved before processing. Ramp provides an automated and auditable approval workflow, ensuring compliance with federal grant requirements. Steps Implemented: • Centralized Purchasing System: All purchases are now made within Ramp using a Ramp credit card, ensuring complete oversight and control over spending. • Automated Approval Workflow: Each purchase requires approval within Ramp, and approvals are documented digitally, creating an auditable trail. • Receipt Verification: Every purchase must include a receipt, which the approver reviews before granting final approval. • Grant Compliance Review: Any charges that do not meet grant requirements are not charged to the grant and are instead assigned to an appropriate non-grant funding source. • Training & Compliance: All relevant staff members have been trained on Ramp’s approval and compliance procedures to ensure adherence to purchasing protocols. Responsible Party: Kendall Guynes, CFO Completion Date: July 1, 2024 (Fully Implemented)
Program: AL 93.778 – Medical Assistance Program – Special Tests and Provisions Corrective Action Plan: Program Integrity staff will continue to attempt to update cases at least every 30 days when case totals are at or below 25 and every 45 days when higher than 25. Trainings and regular conversa...
Program: AL 93.778 – Medical Assistance Program – Special Tests and Provisions Corrective Action Plan: Program Integrity staff will continue to attempt to update cases at least every 30 days when case totals are at or below 25 and every 45 days when higher than 25. Trainings and regular conversations emphasize the need for descriptive narrative entries. As a result, the narrative entries will be more descriptive of the status of the case. For the exception reporting, the team continues to work on developing alternatives to using the reports in the Fraud Abuse Detection System. Concerning the misreported check, Program Integrity staff will give the Financial Team accurate information about collected refunds. The Department will ensure reports are accurate and make any necessary adjustments. Contact: Anne Harvey, Heather Arnold Anticipated Completion Date: 6/30/2025
View Audit 348113 Questioned Costs: $1
Program: AL 12.401 – National Guard Military Operations and Maintenance (O&M) Projects – Cash Management & Reporting Corrective Action Plan: The Agency is meeting with State Budget Office to discuss and review options for better separating future federal funding by fiscal year. This will allow f...
Program: AL 12.401 – National Guard Military Operations and Maintenance (O&M) Projects – Cash Management & Reporting Corrective Action Plan: The Agency is meeting with State Budget Office to discuss and review options for better separating future federal funding by fiscal year. This will allow for better tracking and transparency of drawdown times. Further, the Agency is aware of the finding for Award W91243-22-2-1001 (SAG 132) and currently reconciling all line items in the Award Program and year to determine and action on return of appropriate federal funding. Contact: Lauren Hargreaves Anticipated Completion Date: Ongoing
While all drawdown amounts were in alignment with incurred expenses, EF recognizes the importance of maintaining proper documentation to ensure compliance with federal cash management requirements. EF has established a formal practice requiring documented management approval for all drawdowns befor...
While all drawdown amounts were in alignment with incurred expenses, EF recognizes the importance of maintaining proper documentation to ensure compliance with federal cash management requirements. EF has established a formal practice requiring documented management approval for all drawdowns before they are initiated.
Recommendation – Auditors management to monitor and evaluate the performance of their accounting staff and to make improvements to prevent and/or detect noncompliance when necessary. Additionally, the Center should provide training to all personnel involved in accounting for federal awards. Action ...
Recommendation – Auditors management to monitor and evaluate the performance of their accounting staff and to make improvements to prevent and/or detect noncompliance when necessary. Additionally, the Center should provide training to all personnel involved in accounting for federal awards. Action Taken – The Center hired and filled a key financial position subsequent to the year end. Management believes a lack of permanent staff a significant factor in causing this finding. The Center has established proper accounting procedures and controls, and with the key postion being filled, federal draw downs will be perfomed according the Center's policy.
Department of Justice Housing - Assistance Listing No. 16.320 Recommendation: We recommend reimbursement requests be reviewed and traced back to supporting documentation prior to the filing of the reimbursement request. Explanation of disagreement with audit finding: There is no disagreement with ...
Department of Justice Housing - Assistance Listing No. 16.320 Recommendation: We recommend reimbursement requests be reviewed and traced back to supporting documentation prior to the filing of the reimbursement request. Explanation of disagreement with audit finding: There is no disagreement with audit finding. Action taken in response to finding: All reimbursement requests will follow a process of review with back-up documentation prior to submission for all reimbursable grants. Contact person(s) responsible for corrective action: Joseph Padilla Planned completion date for corrective action plan: 3/1/2025
Corrective Action: Child Nutrition will incorporate separation of duties when calculating the reimbursement for meals. At least one on—site review of the meal counting and claiming system for each school. Avery Johnson, Business Manager Robert Sanders, Superintendent Corrective Action Start Date: Fe...
Corrective Action: Child Nutrition will incorporate separation of duties when calculating the reimbursement for meals. At least one on—site review of the meal counting and claiming system for each school. Avery Johnson, Business Manager Robert Sanders, Superintendent Corrective Action Start Date: February 18, 2025
Condition: There was no evidence of a system of internal control over the cash management requirements, including a written policy related to reimbursement of funds on a per-refugee basis. In addition, it was noted that reimbursement was requested prior to incurring expenses on a per-refugee basis....
Condition: There was no evidence of a system of internal control over the cash management requirements, including a written policy related to reimbursement of funds on a per-refugee basis. In addition, it was noted that reimbursement was requested prior to incurring expenses on a per-refugee basis. There were also refugee costs coded incorrectly within the general ledger. Planned Corrective Action: Financial policies will be updated to include cash management requirements to ensure expenditures are incurred, including any required per client expenditures, prior to reimbursement requests. Subsequent to year end a new process was put in place to compare the individual refugee ledgers to the reimbursement request to ensure no expenditures were requested in advance and that individual refugee costs were coded to the correct general ledger account. Contact person responsible for corrective action: Linda P. Foster, CEO Anticipated Completion Date: Refugee ledger reconciliation process completed 2/1/2025 Policy approval and implementation to be completed by 5/1/2025
Finding 2024-002 Cash Management – Timeliness of Subrecipient Payments Plan: UIC - The University of Illinois Chicago will provide additional training and guidance to research administrators on the requirement of timely payments to subrecipients. UIUC – Sponsored Program Administration continues the...
Finding 2024-002 Cash Management – Timeliness of Subrecipient Payments Plan: UIC - The University of Illinois Chicago will provide additional training and guidance to research administrators on the requirement of timely payments to subrecipients. UIUC – Sponsored Program Administration continues the development of a subaward invoice automation platform to create and capture efficiencies toward the 30-day payment requirement. In tandem, there is continual review of strategies to address the current manual, multi-layered approval and payment process. Expected Implementation Date: UIC - March 2025 UIUC - December 2025 Contact: Katrina Lopez, Assistant Director Office of Sponsored Programs (OSP) University of Illinois Chicago klopez3@uic.edu 312-996-3782 Karen Thomas, Director Post-award Sponsored Program Administration University of Illinois Urbana-Champaign Kthomas2@illinois.edu 217-265-4096
Finding: During a review of the awards population for fiscal year 2024, the University identified 6 accounts that had duplicate contact and bank information. After further investigation, these accounts were determined to be fraudulently created. In total, $54,112 in funds were paid out. The school ...
Finding: During a review of the awards population for fiscal year 2024, the University identified 6 accounts that had duplicate contact and bank information. After further investigation, these accounts were determined to be fraudulently created. In total, $54,112 in funds were paid out. The school worked with the U.S. Department of Education’s Cyber Incident Division to inform the Department of the fraudulent activity. Corrective Action Plan: Management agrees with the findings and has put the following in place. The Bursar will work with ITS to perform a scan of all students’ accounts for duplicate contact and banking information. If duplicates are found students will be notified and accounts frozen until students are identified. This will be critical before refund checks are dispersed to students every semester. The amount of $54,112 will be paid back with the next draw down before February 28, 2025. Responsible Officials and Implementation Date: The Bursar and Director of ITS will be responsible for this action plan and will implement by July 1, 2025, a scan done by the system. Bursar will spot check for duplicates until the report is built and put in place for the scan.
View Audit 347517 Questioned Costs: $1
Corrective Actions: 1. Segregation of Duties for Cash Management: o Align the RAIS policy to requiring that all reimbursement requests be reviewed and approved by a second staff member before submission as other programs. o Utilize electronic workflow approvals to track submission approvals. o Targe...
Corrective Actions: 1. Segregation of Duties for Cash Management: o Align the RAIS policy to requiring that all reimbursement requests be reviewed and approved by a second staff member before submission as other programs. o Utilize electronic workflow approvals to track submission approvals. o Target completion date: By the end of Fiscal Year 2025. 2. Formalized Written Procedures for Federal Drawdowns: o Develop and distribute a written standard operating procedure (SOP) outlining the review and approval process. o Provide staff training on the SOP to ensure compliance. o Target completion date: SOP finalized within six months. 3. Quarterly Internal Audit of Reimbursement Requests: o The finance department will conduct a quarterly review of drawdowns to ensure compliance with federal guidelines. o Maintain documentation of all approvals and reconciliations in an audit-ready format. o Target completion date: First review within the next quarter. Responsible Staff: Senior Director of Grants in conjunction with Chief Financial Officer
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