Corrective Action Plans

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Management will have the employee responsible for the review of the LIHEAP Agency Invoice Reports sign each weekly report as approved.
Management will have the employee responsible for the review of the LIHEAP Agency Invoice Reports sign each weekly report as approved.
Finding 565190 (2024-003)
Significant Deficiency 2024
Finding NO. 2024-003 Cash Management View of the University of Guam and Corrective Action Plan: The Financial Aid Office (FAO) will conduct both internal and external monthly reconciliations to ensure the accuracy of financial aid disbursements and compliance with federal regulations. Internally, ...
Finding NO. 2024-003 Cash Management View of the University of Guam and Corrective Action Plan: The Financial Aid Office (FAO) will conduct both internal and external monthly reconciliations to ensure the accuracy of financial aid disbursements and compliance with federal regulations. Internally, the FAO and the Business Office will reconcile actual disbursements and adjustments against drawdowns, drawdown adjustments, refunds of cash, and returns weekly or bi-weekly, following each transmittal to the Business Office. Any discrepancies will be documented and resolved promptly. Externally, the FAO will reconcile with the COD system by the 10th of each month, comparing all disbursements, adjustments, and refunds to the balances reported in COD. A copy of the completed monthly reconciliation will be forwarded to Accounts Receivable as official documentation. Name of Contact Person: Mark Duarte, Director, Financial Aid and Triton One Stop Office Proposed Completion date: Ongoing
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
In Finding 2024-003, a condition was noted that during the year, the Organization failed to reconcile expenditures prior to drawing federal grant funds. Management recognizes the importance of the requirements to draw federal grant funds only after making qualifying expenditures. In response to Fi...
In Finding 2024-003, a condition was noted that during the year, the Organization failed to reconcile expenditures prior to drawing federal grant funds. Management recognizes the importance of the requirements to draw federal grant funds only after making qualifying expenditures. In response to Finding 2024-003, procedures will be established to reconcile all expenditures prior to making federal grant draws to ensure that advance draws of federal funds do not occur.
Federal Agency Name: Department of Health and Human Services Program Name: Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement Federal Financial Assistance Listing #93.912 Compliance Requirement: Cash Management Finding Summary: ...
Federal Agency Name: Department of Health and Human Services Program Name: Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement Federal Financial Assistance Listing #93.912 Compliance Requirement: Cash Management Finding Summary: The cash draw requests were done on a prospective basis despite the program requiring that cash draw requests must be for expenditures already incurred or that would be paid within three days. Responsible Individuals: Kayla Trent, Finance Director Corrective Action Plan: Management agrees with the finding and has reviewed the operating procedures of Robert C. Byrd Clinic. Furthermore, we have implemented procedures to understand program requirements related to cash draws. The Clinic began requesting funds only for expenditures already incurred or that would be paid within three days. Anticipated Completion Date: Ongoing
The cash draw findings were focused on tracking staff time and effort. The Museum implemented corrective action regarding the use of time sheets for federal award tracking immediately after the DOE grant performance period and exists for each time period in FY25. The Human Resources department has i...
The cash draw findings were focused on tracking staff time and effort. The Museum implemented corrective action regarding the use of time sheets for federal award tracking immediately after the DOE grant performance period and exists for each time period in FY25. The Human Resources department has incorporated the timesheets into employee training, onboarding, and the updated staff handbook. Already Completed. Kevin Cantfil, VP of Finance and Administration.
Drawdown requests that include reimbursement for time and attendance will include documented approval by one additional staff member. If programmatic staff prepare the drawdown, the VP of Finance and Administration will complete the final approval. If the VP of Finance and Administration prepares th...
Drawdown requests that include reimbursement for time and attendance will include documented approval by one additional staff member. If programmatic staff prepare the drawdown, the VP of Finance and Administration will complete the final approval. If the VP of Finance and Administration prepares the drawdown, a member of the Advancement department will complete the final approval. June 30, 2025. Kevin Cantfil, VP of Finance and Administration.
Item: 2024-001 Assistance Listing Number: 93.243 Program: Substance Abuse and Mental Health Services, Expanded Access to Homeless Services Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: n/a Contract Number: 5H79TI082775-02 Award Year: 9/30/2023 – 9/29/2024 Compl...
Item: 2024-001 Assistance Listing Number: 93.243 Program: Substance Abuse and Mental Health Services, Expanded Access to Homeless Services Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: n/a Contract Number: 5H79TI082775-02 Award Year: 9/30/2023 – 9/29/2024 Compliance Requirement: Cash Management, Reporting Criteria: Per 2 CFR 200.305, under the reimbursement method, expenditures must be incurred prior to the date of the reimbursement request. The Organization is also responsible for submitting an annual Federal Financial Report (“FFR” or SF-425) to the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. Condition: The Organization erroneously included a duplicate request for reimbursement in a monthly reimbursement request report submitted to the granting agency and was overpaid by the amount of this duplicate request for reimbursement totaling $41,042. Additionally, the total expenditures reported in the FFR/SF-425 were misstated by $23,058. Name of Contact Person: Ramon Dominguez, CFO Phone Number: (480) 831-7566 x4909 Anticipated Completion Date: September 30, 2025 Views of Responsible Officials and Corrective Actions: The Organization will implement additional controls to ensure monthly requests for reimbursement and reviewed and approved prior to submission. Additionally, the annual FFR/SF-425 will be reviewed and reconciled to the monthly draws.
View Audit 358970 Questioned Costs: $1
CORRECTIVE ACTION PLAN Arizona Department of Education/U.S. Department of Education Sierra Vista Unified School District No. 68 respectfully submits the following corrective action plan for the year ended June 30, 2024. Audit period: July 1, 2023 – June 30, 2024 The findings from the schedule of fin...
CORRECTIVE ACTION PLAN Arizona Department of Education/U.S. Department of Education Sierra Vista Unified School District No. 68 respectfully submits the following corrective action plan for the year ended June 30, 2024. Audit period: July 1, 2023 – June 30, 2024 The findings from the 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 2024-003 REPORTING Program: Child Nutrition Cluster CFDA Number: 10.533, 10.555, 10.559 Federal Agency: U.S. Department of Agriculture Pass-Through Agency: Arizona Department of Education Grantor Number: ADE ED09-0001 Questioned Costs: $18.50 Type of Finding: Noncompliance, significant deficiency Compliance Requirement: L. Reporting Condition/Context: For two of 3 monthly submissions tested, meal counts did not agree between the District’s records and what was reported to ADE. There was a net of 3 meals over claimed by the District. Criteria: The District must follow Uniform Guidance and ensure that meal reimbursement claims are accurately reported and adequately supported. Action planned in response to finding: The District will establish a system of internal controls to ensure meal counts reported on ADE match with District records. Planned completion date for corrective action plan: For the period ending June 30, 2025. Name of the contact person responsible for corrective action: Janet Cline, Business Office Manager, Laurel McEwan, Business Manager.
View Audit 358925 Questioned Costs: $1
Management is aware of the duplicate expenditures that were reported under two federal grants and has put procedures in place to enhance internal controls, have a single review and validation group, and a log with invoice submission documentation for reference checks. The VP of Finance has also made...
Management is aware of the duplicate expenditures that were reported under two federal grants and has put procedures in place to enhance internal controls, have a single review and validation group, and a log with invoice submission documentation for reference checks. The VP of Finance has also made it clear to the senior leadership team that as part of this error was driven by two separate functions submitting data for this funding support, all communications internal and external reporting must run through the Finance department going forward. This will allow a central check function that will have historical data submissions with invoices and work order reference checks to ensure expenses are submitted one time only. Finance will be the control point going forward doing these validation checks.
Corrective Actions Taken Commons has taken the following actions to protect against such fraudulent incidents in the future: • Engaged a firm to assist with managing the incident; • Opened a new bank account; • Added account verification services with our banking partner, which will be utilized to v...
Corrective Actions Taken Commons has taken the following actions to protect against such fraudulent incidents in the future: • Engaged a firm to assist with managing the incident; • Opened a new bank account; • Added account verification services with our banking partner, which will be utilized to verify account updates; • Limited the amount of per vendor/subrecipient daily payments to our insurance limits, with verifications prior to releasing additional funds when the total payment exceeds the insurance limits; • Subrecipient payment receipt is verified by both the subrecipient and the Commons grants team; • Updated our policy and procedures to direct our subrecipients to request banking changes through our procurement system and not through email; and • Expanded implementation of our Kissflow procurement system across the organization, which includes new vendor process as well as a change of vendor information module. Vendor changes would be approved first by the program/department that works with the vendor prior to Finance approval. Completion Date With the exception of implementing the change of vendor information module in Kissflow, the above actions have all been completed by the date of this report. The projected completion date for Kissflow change of vendor information module is April 30, 2025. Responsible Party Dana Thomas, Chief Financial Officer Angela Allen, Vice President of Finance
2024-001 GRANT REPORTING U.S. Department of Treasury ALN 21.027 – Coronavirus State and Local Fiscal Recovery Funds Contract No. 23.saa.900.46 (2023) Passed through the Florida Department of State 2024 Funding Repeat Finding Criteria: 2 CFR 200.303 requires non-federal entities to establish and main...
2024-001 GRANT REPORTING U.S. Department of Treasury ALN 21.027 – Coronavirus State and Local Fiscal Recovery Funds Contract No. 23.saa.900.46 (2023) Passed through the Florida Department of State 2024 Funding Repeat Finding Criteria: 2 CFR 200.303 requires non-federal entities to establish and maintain effective internal controls. Reports and reimbursement requests should be subject to independent review for the full fiscal year to verify completeness, validity and timeliness of submission. The grant agreement requires quarterly progress reports to be filed with the pass through entity, Florida Department of State. Condition: Review of quarterly reports was not always documented by City officials before submittal by their third party consultant. Cause of condition: The department at the City that is responsible for managing the grant did not originally have a process in place to document their review of progress reports submitted to the Florida Department of State by their third party consultant. Potential effect of condition: Reports submitted to the Florida Department of State may be incomplete, include errors, or be submitted late. Perspective: After this condition was reported as a finding for the fiscal year ending September 30, 2023, the City’s department that is responsible for managing the grant implemented a review process, but it was not in place for the full fiscal year 2024. Questioned costs: None. Recommendation: The City’s department responsible for the grant should continue to perform the review process that was put in place late in fiscal year 2024. Management’s Response: The City updated its control process to ensure that reports prepared by thirdparty consultant are reviewed by City staff prior to being submitted to the grantor. Responsible Parties: Natalia Eckroth, CFO and Christine Aiken, Assistant Finance Director. Anticipated Completion: December 31, 2024.
Finding 564783 (2024-001)
Significant Deficiency 2024
Subject: Management Response to FY 2024 Single Audit finding 2024-001 Based on changes in The Parenting Center personnel assigned to the Federal Grant programs in early 2024, a decision was made for staff to be cross trained on similar grant programs. In this situation, TPC lost a few key personnel,...
Subject: Management Response to FY 2024 Single Audit finding 2024-001 Based on changes in The Parenting Center personnel assigned to the Federal Grant programs in early 2024, a decision was made for staff to be cross trained on similar grant programs. In this situation, TPC lost a few key personnel, and restructuring was done by cross-training so that there should always be a trained employee that could step from one Youth program to the other and also grant directors that were familiar with each of the Federal Grant programs. In doing this, personnel costs for some individuals have to be spread across multiple grants in a given pay period. That spread is tracked and calculated based on time sheets prepared by the employee and approved by their supervisor. At the beginning of the 2024 fiscal period, if a grant employee used PTO, their PTO continued to be charged to the grant they had been hired under and not spread according to time sheets, since the budgets had been prepared in October 2023 with that job basis. However, at the beginning of the new grant year in October 2024, it appeared more equitable to spread PTO for a grant employee based on the FTE they were budgeted in each grant. The PTO is not earned in one pay period, so I do not believe using the time sheet that could fluctuate between grants each pay period matches how they earn the PTO as well as using the FTE percentage does. The alloca􀆟on of time was not smooth throughout the year, but the change was made as practice made it clear that the second method was a more accurate depiction of what was happening. We are commitied to the spread as it was being done at the end of FY 2024. Starting FY 2025, our internal control procedures specify allocations of hours worked being based on the employee time sheets and allocations of PTO being based on the FTE assignments of the employee.
MATERIAL WEAKNESS 2024-004 – Education Stabilization Fund - Reporting Condition The quarterly reports had incorrect expenditures reported for the ESSER III award. Recommendation Reporting methods required by the awarding agency should be well understood, and an individual other than the preparer ...
MATERIAL WEAKNESS 2024-004 – Education Stabilization Fund - Reporting Condition The quarterly reports had incorrect expenditures reported for the ESSER III award. Recommendation Reporting methods required by the awarding agency should be well understood, and an individual other than the preparer should review all reports prior to their submission. Comments on the Finding The District is aware of the oversight and has implemented procedures to prevent this in the future. Actions Taken As of the date of this notice, an individual other than the one preparing the ESSER reporting will be asked to review it, prior to submission.
FINDING 2024-005 Finding Subject: Special Education Cluster (IDEA) - Internal Controls Contact Person Responsible for Corrective Action: Whitney Dixon, Treasurer Contact Phone Number: 574-533-8631 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Cash ...
FINDING 2024-005 Finding Subject: Special Education Cluster (IDEA) - Internal Controls Contact Person Responsible for Corrective Action: Whitney Dixon, Treasurer Contact Phone Number: 574-533-8631 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Cash Management Requests for reimbursement will not be submitted until the Treasurer has attached the supporting documentation from the financial software system (member schools will provide documentation). The documentation will be reviewed and approved by the Executive Director of ECSEC prior to submission to the Treasurer. The reimbursement request will require an approval signature from the Chief Financial Officer/Treasurer prior to submittal. Anticipated Completion Date: June 2025
The Council has hired a grant financial manager to handle all grant and financial related reporting. The Council will develop, improve, and implement policies and procedures for grant reimbursement requests. This will reduce or eliminate delays when potential errors are avoided or detected and corre...
The Council has hired a grant financial manager to handle all grant and financial related reporting. The Council will develop, improve, and implement policies and procedures for grant reimbursement requests. This will reduce or eliminate delays when potential errors are avoided or detected and corrected timelier.
Finding 564425 (2024-102)
Significant Deficiency 2024
REFERENCE: 2024-102 CFDA NUMBER: 10.558 – CHILD AND ADULT CARE FOOD PROGRAM U.S. DEPARTMENT OF AGRICULTURE - FOOD AND NUTRITION - 2024 PASSED THROUGH ARIZONA STATE DEPARTMENT OF EDUCATION GRANT NUMBER 6AZ300003 CLIENT RESPONSE AND CORRECTIVE ACTION PLAN We concur with the condition. 1. Name of the...
REFERENCE: 2024-102 CFDA NUMBER: 10.558 – CHILD AND ADULT CARE FOOD PROGRAM U.S. DEPARTMENT OF AGRICULTURE - FOOD AND NUTRITION - 2024 PASSED THROUGH ARIZONA STATE DEPARTMENT OF EDUCATION GRANT NUMBER 6AZ300003 CLIENT RESPONSE AND CORRECTIVE ACTION PLAN We concur with the condition. 1. Name of the contact person responsible for corrective action: Katie O’Neill, MPH, RD 2. Corrective action planned: B J Enterprises has hired a Payroll Service that double checks the timesheets each month. Both the Director and Assistant Director will double check the Administrative costs prior to submitting that month’s claim in order to ensure that the administrative costs are accurately reported. 3. Anticipated completion date: June 2025
Finding 564424 (2024-101)
Significant Deficiency 2024
REFERENCE: 2024-101 REPEAT FINDING REFERENCE: 2023-001 CFDA NUMBER: 10.558 – CHILD AND ADULT CARE FOOD PROGRAM U.S. DEPARTMENT OF AGRICULTURE - FOOD AND NUTRITION - 2024 PASSED THROUGH ARIZONA STATE DEPARTMENT OF EDUCATION GRANT NUMBER 6AZ300003 CLIENT RESPONSE AND CORRECTIVE ACTION PLAN We concur ...
REFERENCE: 2024-101 REPEAT FINDING REFERENCE: 2023-001 CFDA NUMBER: 10.558 – CHILD AND ADULT CARE FOOD PROGRAM U.S. DEPARTMENT OF AGRICULTURE - FOOD AND NUTRITION - 2024 PASSED THROUGH ARIZONA STATE DEPARTMENT OF EDUCATION GRANT NUMBER 6AZ300003 CLIENT RESPONSE AND CORRECTIVE ACTION PLAN We concur with the condition. 1. Name of the contact person responsible for corrective action: Katie O’Neill, MPH, RD 2. Corrective action planned: The menu reader (Area Coordinator) will double check the meal counts to the menus to ensure all meal counts: * are clerically accurate; * are claimed for providers own, only when day care children are present; * are claimed only when children are present to eat those meals and; * are claimed only when 2 snacks and 1 meal or 2 meals and 1 snack are claimed for each child. The menu reader will double check the list of Income Eligible providers each month to make sure providers’ own are claimed only when we have the Income Affidavits. The Director will re-train the menu readers in these specific areas at the next staff meeting and through virtual training. 3. Anticipated completion date: June 2025 through October 2025
2024-002 – Internal Controls Over Reporting Corrective Action Plan: The City will develop and implement procedures that require all reports be reviewed by a responsible City official, other than the preparer, prior to being submitted to a federal reporting agency. Responsible Party(ies): o Chief ...
2024-002 – Internal Controls Over Reporting Corrective Action Plan: The City will develop and implement procedures that require all reports be reviewed by a responsible City official, other than the preparer, prior to being submitted to a federal reporting agency. Responsible Party(ies): o Chief Financial Officer o City Manager Anticipated Completion Date: September 30, 2025
reports be reviewed by a responsible City official prior to being submitted to a federal reporting agency. Responsible Party(ies): o Chief Financial Officer o City Manager Anticipated Completion Date: September 30, 2025
reports be reviewed by a responsible City official prior to being submitted to a federal reporting agency. Responsible Party(ies): o Chief Financial Officer o City Manager Anticipated Completion Date: September 30, 2025
Federal Agency Name: Legal Services Corporation Program Name: Legal Services Corporation – Basic Field Grant FFAL#: 09-542026 Finding Summary: Testing identified one case in which the U.S. Citizen Attestation was not obtained and one case in which documentation was not obtained and retained within ...
Federal Agency Name: Legal Services Corporation Program Name: Legal Services Corporation – Basic Field Grant FFAL#: 09-542026 Finding Summary: Testing identified one case in which the U.S. Citizen Attestation was not obtained and one case in which documentation was not obtained and retained within the case file detailing immigration documents being received and reviewed. Responsible Individuals: Lea Wroblewski, Executive Director. Corrective Action Plan: The Organization will communicate to staff the importance of ensuring all required case file documentation is obtained and retained as required by the federal program. The compliance officer will review case file documentation for compliance after the case is closed and will provide staff training as needed to improve compliance. Completion Date: May 2025
Condition: The District audit resulted in a material restatement to fund balance/net position that was detected by auditing procedures. Plan: The District acknowledges the finding and will continue to review new standards as part of the fiscal audit process. Anticipated Date of Completion: The Distr...
Condition: The District audit resulted in a material restatement to fund balance/net position that was detected by auditing procedures. Plan: The District acknowledges the finding and will continue to review new standards as part of the fiscal audit process. Anticipated Date of Completion: The District will immediately implement yearly review of new standards as part of the fiscal audit process.
Procedures have been put in place to request reimbursements timely on a monthly basis.
Procedures have been put in place to request reimbursements timely on a monthly basis.
Finding 2024-001 – Review of Expense Details for Compliance Condition: From the selections made for internal controls testing, the auditor noted no review/approval for compliance with the terms of the grant agreement was conducted prior to submission of the costs to the grantor. Recommendation: W...
Finding 2024-001 – Review of Expense Details for Compliance Condition: From the selections made for internal controls testing, the auditor noted no review/approval for compliance with the terms of the grant agreement was conducted prior to submission of the costs to the grantor. Recommendation: We recommend management implement processes and controls to perform a review of expenses being submitted for reimbursement to document approval of costs in compliance with the terms of the grant. View of responsible officials and planned corrective actions: Management agrees with the finding and will conduct an internal review of federal expenditures for compliance with the requirements applicable to each federal grant received prior to submission for reimbursement. Anticipated Completion Date: May 31, 2025
Finding 2024-001: Late Submission of Reports Audit Finding: School District 12 Education Foundation (dba Five Star Education Foundation) is required to submit Monthly Financial Reports by the 10th of each month for the periods January through February and by the 15th of each month for the remain...
Finding 2024-001: Late Submission of Reports Audit Finding: School District 12 Education Foundation (dba Five Star Education Foundation) is required to submit Monthly Financial Reports by the 10th of each month for the periods January through February and by the 15th of each month for the remaining months through December. In addition, School District 12 Education Foundation (dba Five Star Education Foundation) is required to submit Quarterly Reports by the 15th of each month. In our audit, we found that 2 out of 8 Reports tested were submitted after the 15th of the following month. After reviewing all the reports with School District 12 Education Foundation (dba Five Star Education Foundation), we noted 3 monthly reports, out of a total of 50 required reports, and 7 quarterly reports, out of a total of 25 required reports, were submitted untimely Audit Recommendation: We recommend School District 12 Education Foundation (dba Five Star Education Foundation) review and follow policies and procedures to ensure timely submission of reports. Management’s Response and Corrective Action Plan: School District 12 Education Foundation (dba Five Star Education Foundation) agrees with the finding and recommendation. Late submissions occurred due to delays in responses from the grantor and verbal approval of changes in due dates from the grantor. Management will be more proactive in documenting communication regarding reports to ensure that, if they are submitted late, there is clear evidence of approved date modifications, why and what date they were initially submitted. Management is now aware that the grantor’s system only reflects the final submission date once approved, not the initial submission date for reports that required modification at the request of the grantor. To address this, School District 12 Education Foundation (dba Five Star Education Foundation) will implement a process to document the initial submission date along with any backup documentation of delays, including communications with Adams County or other relevant parties. Additionally, Adams County has a clear policy that while timely submission of reports is required by the original grant agreement, grantees who communicate a need for additional time by the 15th of the month are considered compliant. Adams County also noted that, based on School District 12 Education Foundation (dba Five Star Education Foundation’s) history and previous communications, they would not consider this a finding or an indicator of poor performance. Moving forward, School District 12 Education Foundation (dba Five Star Education Foundation) will ensure that any anticipated delays are formally communicated to Adams County in writing (not verbally) before the due date and that records of these communications are retained for audit purposes. Contact and Completion Date: Shannon Hancock, 720-972-4342, shannon.hancock@5starfoundation.org, is the primary contact, and the Executive Director at School District 12 Education Foundation (dba Five Star Education Foundation). The corrective action is already in place and active as of this audit.
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