Corrective Action Plans

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RE: Audit Finding-Missing EIV Reports Montpelier Housing Authority Audit Finding Response: The auditor reviewed the finding with me and the following action plan was put in place to ensure that key EIV reports are run on a scheduled basis and appropriate actions are taken: • Policies and procedures ...
RE: Audit Finding-Missing EIV Reports Montpelier Housing Authority Audit Finding Response: The auditor reviewed the finding with me and the following action plan was put in place to ensure that key EIV reports are run on a scheduled basis and appropriate actions are taken: • Policies and procedures surrounding EIV were reviewed. •We implemented the use of a chart to prompt EIV reports within 90 days for new moveins. (see attached chart) •We already monitor EIV monthly and quarterly to ensure that EIV reports are run for all move-ins and re-certifications. This action plan is effective immediately, as of the date of this letter, February 17,2025.
Finding 2024-001: Late Audit Submission Synopsis of Finding The fiscal year audit and reporting package is being submitted after the required due date. Management’s Response Sonoma CAN has contracted with One Abacus to support design and implementation of procedures to maintain real time reconciliat...
Finding 2024-001: Late Audit Submission Synopsis of Finding The fiscal year audit and reporting package is being submitted after the required due date. Management’s Response Sonoma CAN has contracted with One Abacus to support design and implementation of procedures to maintain real time reconciliation and improve accuracy of data as it is entered into the general ledger. Additionally, we have replaced several internal roles with more qualified individuals for the coming year. Contact Person Responsible for Corrective Action: Johnny Nolen, COO + CFO Anticipated Completion Date: 7/1/2025
Recommendation We recommend DNA formally respond, in detail, to all deficiencies reported in the OIG Report, including Accounting Policies and other Policies such as the Vehicle Use Policy. As the Board needs to formally adopt all revised policies as noted in the OIG Report, we recommend: DNA prov...
Recommendation We recommend DNA formally respond, in detail, to all deficiencies reported in the OIG Report, including Accounting Policies and other Policies such as the Vehicle Use Policy. As the Board needs to formally adopt all revised policies as noted in the OIG Report, we recommend: DNA provide the Board a redline copy of the changes for each revised policy. Correlate each revised policy to each finding in the OIG report and, Provide the Board each related policy section guidance in the LSC Financial Guide. Management Response Corrective Action: As of April 30, 2025, our accounting department is fully staffed and we are supporting accounting staff training needs. As of April 30, 2025, management has drafted updates to many of the policies and procedures referenced in the OIG report. Updated policies, including a revised Accounting Manual and an updated Personnel Manual will be presented to the Board, the Board Budget & Audit Committee, or the Board Executive Committee prior to the June 2, 2025 OIG response deadline. Management acknowledges that during the 2024 audit period the Legal Services Corporation Office of Inspector General (OIG) issued a final report on December 2, 2024 noting inadequate accounting policies, practices, and oversight for the period of January 1, 2022 through April 30, 2023. Also, while many of the policies noted in the OIG report have been updated, the policies mentioned in the OIG report have not been reviewed or adopted by the Board. Three primary causes contributed to the deficiencies noted during the period under review by the OIG (January 1, 2022 through April 30, 2023), and before the issuance of the final LSC OIG report in December 2024: Staffing shortages. For most of the January 1, 2022 to April 30, 2023 review period DNA had three vacancies in our five-person accounting operation. Additionally, our Chief Financial Officer was hired during the middle of the period under review, and even though he has extensive legal services accounting experience, he just started learning about DNA's organizational structure and accounting practices, and refamiliarizing himself with LSC accounting policies and financial guidelines. A change in LSC accounting standards applicable to nonprofit LSC funded organizations was implemented during the period under review which made some of our policies and procedures outdated. Management made a strategic decision to wait for the issuance of the final OIG report to ensure that updates to policies and practices would fully align with the OIG's expectations, rather than implementing piecemeal or interim measures that might have required further revision. Due Date of Completion: June 2, 2025 Responsible Person(s): Executive Director and Chief Financial Officer
Finding Number 2024-003– Enrollment Reporting Contact Person(s): Shanell Tilo, Financial Aid Officer Dr. Emilia Le’i, Dean of Student Services Dr. Letupu Moananu, Vice President of Academics, Community, and Student Affairs Explanation and specific reasons for disagreement with the audit finding or t...
Finding Number 2024-003– Enrollment Reporting Contact Person(s): Shanell Tilo, Financial Aid Officer Dr. Emilia Le’i, Dean of Student Services Dr. Letupu Moananu, Vice President of Academics, Community, and Student Affairs Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreement. Corrective actions taken/planned: The Financial Aid Office has strengthened the review process by reinforcing the dual- review control system. In this system:  Control #1 (Financial Aid Coordinator) is responsible for conducting the initial review of the NSLDS Enrollment Report roster, performing data entry, and updating the status.  Control #2 (Financial Aid Manager) performs a secondary review and signs off on all NSLDS roster files before submission. Additionally, a log of all NSLDS submissions will be maintained, with both reviewers' signatures, to ensure proper documentation and accountability. Action Plan: The anticipated completion date for Finding Number 2024-0003 is March 2025
Finding 2024-002 – Special Tests and Provisions – Return of Title IV Funds Contact Person(s): Shanell Tilo, Financial Aid Officer Dr. Emilia Le’i, Dean of Student Services Dr. Letupu Moananu, Vice President of Academics, Community, and Student Affairs Explanation and specific reasons for disagreemen...
Finding 2024-002 – Special Tests and Provisions – Return of Title IV Funds Contact Person(s): Shanell Tilo, Financial Aid Officer Dr. Emilia Le’i, Dean of Student Services Dr. Letupu Moananu, Vice President of Academics, Community, and Student Affairs Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreement. Corrective actions taken/planned: The Financial Aid Office has updated the Financial Aid Handbook, Standard Operating Procedures (SOP), and the R2T4 total days calculation chart to exclude scheduled breaks of five or more consecutive days. To ensure compliance with these updates, the Financial Aid Office conducted a policy review session with the financial aid staff. Additionally, mandatory training sessions were held to reinforce R2T4 calculation procedures, with a specific focus on the proper exclusion of scheduled breaks. The Financial Aid Manager is responsible for calculating the total days for R2T4 purposes each award year. The Financial Aid Officer performs a secondary review to verify the accuracy of these calculations. Action Plan: The anticipated completion date for Finding Number 2024-0002 is March 2025.
The College is working to increase enrollment and adjusting the budget accordingly with available resources to reflect a positive net income from unrestricted operations.
The College is working to increase enrollment and adjusting the budget accordingly with available resources to reflect a positive net income from unrestricted operations.
The College will make the necessary correction to the student's award. Review procedures will be conducted for student awards and disbursements to ensure accuracy for the next fiscal year.
The College will make the necessary correction to the student's award. Review procedures will be conducted for student awards and disbursements to ensure accuracy for the next fiscal year.
CAASTLC acknowledges the timing discrepancy in the documentation of staff review and signature during the drive-through food pantry operations in early 2024. Although eligibility was appropriately determined prior to the distribution of food, we recognize the importance of ensuring that all related ...
CAASTLC acknowledges the timing discrepancy in the documentation of staff review and signature during the drive-through food pantry operations in early 2024. Although eligibility was appropriately determined prior to the distribution of food, we recognize the importance of ensuring that all related documentation is contemporaneously completed and appropriately approved to maintain a strong internal control environment. The current intake and eligibility verification procedures was revised to include explicit language requiring staff signatures and approval of eligibility documentation on the date of service. These updated procedures will reflect both in-office and drive-through (if resumed) operations. All relevant staff members will receive updated training on intake documentation requirements, including the importance of contemporaneous staff review and approval. Training materials will be revised to emphasize compliance with federal requirements related to eligibility documentation. While data entry into MIS may still occur post-service, staff will be required to document and date eligibility approvals on the intake fonns at the time of service. Intake forms will now include a section for immediate staff verification with date stamps to reflect real-time approval. Name of Responsible Person: Linda Huntspon, Chief Executive Officer Anticipated Completion Date: Implemented in January 31, 2025
The Town has reviewed the reporting procedures and how to maintain accurate expenditures, in accordance with U.S. Treasury guidelines. This corrective action has been sustained for the March 2025 filing, and will be adhered to for any subsequent reporting by the Director of Finance and the First S...
The Town has reviewed the reporting procedures and how to maintain accurate expenditures, in accordance with U.S. Treasury guidelines. This corrective action has been sustained for the March 2025 filing, and will be adhered to for any subsequent reporting by the Director of Finance and the First Selectman.
We will continue to review our control procedures to obtain the maximum internal controls possible under the circumstances.
We will continue to review our control procedures to obtain the maximum internal controls possible under the circumstances.
Environmental Protection Agency, passed through State of North Dakota Department of Environmental Quality Federal Financial Assistance Listing 66.468 Capitalization Grants for Drinking Water Procurement, Suspension, Debarment Material Weakness Finding Summary: The District did not have a written p...
Environmental Protection Agency, passed through State of North Dakota Department of Environmental Quality Federal Financial Assistance Listing 66.468 Capitalization Grants for Drinking Water Procurement, Suspension, Debarment Material Weakness Finding Summary: The District did not have a written policy on procurement that satisfied the requirements of 2 CFR sections 200.318 through 200.326. Responsible Individuals: Jordyne Lee, General Manager Corrective Action Plan: The District will review the applicable 2 CFR 200 sections and implement procedures necessary to ensure compliance with all of these requirements. Anticipated Completion Date: December 31, 2025.
Management concurs with the finding and has agreed to implement the recommended procedures. Management has also: 1) hired a Director of Finance to oversee financial reporting; 2) implemented a monthly grant reconciliation process; 3) implemented segregation of duties so that no single individual wil...
Management concurs with the finding and has agreed to implement the recommended procedures. Management has also: 1) hired a Director of Finance to oversee financial reporting; 2) implemented a monthly grant reconciliation process; 3) implemented segregation of duties so that no single individual will be responsible for preparing reimbursement requests and subsequently submitting them; 4) provided extensive training to staff involved in the grant reimbursement procedures; 5) implemented a centralized grant tracking sheet to monitor billed amounts by category and date that is verified by two staff members; 6) implemented a quarterly internal audit review by a Board of Directors member with any findings reported to the Board of Directors for oversight.
View Audit 355230 Questioned Costs: $1
Recommendations: We recommend the Organization implement additional procedures during year-end close out procedures to ensure residual receipt deposits due at year-end are deposited in a timely manner. Management agrees with the recommendations and to adhere to current internal control processes tha...
Recommendations: We recommend the Organization implement additional procedures during year-end close out procedures to ensure residual receipt deposits due at year-end are deposited in a timely manner. Management agrees with the recommendations and to adhere to current internal control processes that are in place to ensure the Organization is in compliance with all requirements as it relates to their federal awards.
Recommendations: We recommend the Organization implement and follow a checklist of procedures for moveout occurrences to ensure security deposits due upon move-out are returned in a timely manner. Management agrees with the recommendations and to adhere to current internal control processes that are...
Recommendations: We recommend the Organization implement and follow a checklist of procedures for moveout occurrences to ensure security deposits due upon move-out are returned in a timely manner. Management agrees with the recommendations and to adhere to current internal control processes that are in place to ensure the Organization is in compliance with all requirements as it relates to their federal awards.
Corrective Action: 1. Sliding fee applications have been streamlined to provide registration colleagues with a more efficient process. 2. Registration and billing colleagues have received and will continue to receive ongoing training on the sliding fee discount application and process. 3. The inform...
Corrective Action: 1. Sliding fee applications have been streamlined to provide registration colleagues with a more efficient process. 2. Registration and billing colleagues have received and will continue to receive ongoing training on the sliding fee discount application and process. 3. The information provided for the training will be translated to a process document and provided to all registration staff and billers. Colleagues will be expected to use this document as reference guide to improve program adherence. 4. Registration colleagues will participate in a peer review process where each colleague reviews 5 accounts monthly. They will audit demographics and insurance, as well as slide fee program adherence. Feedback will be provided to the colleagues responsible for errors to make corrections. 5. A leadership team member supervising patient registration colleagues will continue to audit 50 patient accounts each month. The accounts selected will have at least one billable medical, behavioral health, SUD, or dental encounter in the audit month. The audit criteria will include identifying the colleague responsible for inputting income information and application of discounts. Errors identified through the audit process will be sent to the colleage responsible for correction. Supervision and coaching will be provided to colleagues while fixing their errors to improve future performance. Responsible Party(s): Melissa Darko, Revenue Cycle Director and Lisa DeMallie, Associate Vice President of Patient Experience Estimated Completion Date: Applications were streamlined in March 2025; training was provided in April 2025 and will be ongoing; a process document will be provided to staff in May 2025; peer reviews were started in February 2025; and auditing has been ongoing and will continue.
All Students who were not reported were entered into the NSLDS website and their records were updated. A process has been established to capture all official and unofficial withdrawal. The Financial Aid and Registrars offices have developed a system to capture all withdrawals in our new FAMS system ...
All Students who were not reported were entered into the NSLDS website and their records were updated. A process has been established to capture all official and unofficial withdrawal. The Financial Aid and Registrars offices have developed a system to capture all withdrawals in our new FAMS system (Banner from Ellucian). All students who have withdrawn are being updated through National Student Clearinghouse and from there to NSLDS.
Monitor compliance through regular internal reviews and sample audits of personnel records.
Monitor compliance through regular internal reviews and sample audits of personnel records.
Add a new staff member to the Federal Funds Office to strengthen segregation of duties. Update and document internal procedures to ensure proper role separation in the drawdown process. Leverage the upcoming implementation of a new ERP system to support workflow automation and enforce segregation. C...
Add a new staff member to the Federal Funds Office to strengthen segregation of duties. Update and document internal procedures to ensure proper role separation in the drawdown process. Leverage the upcoming implementation of a new ERP system to support workflow automation and enforce segregation. Conduct training to clarify and reinforce individual roles and responsibilities. Introduce periodic internal reviews to verify compliance with segregation protocols.
Transfers and Disbursement process will be reviewed to minimize the time between drawdown and disbursement and comply with Federal regulations. Funds are regularly monitored to ensure that only needed funds for immediate use are drawdown. Drawdowns are initiated when accounting department send the G...
Transfers and Disbursement process will be reviewed to minimize the time between drawdown and disbursement and comply with Federal regulations. Funds are regularly monitored to ensure that only needed funds for immediate use are drawdown. Drawdowns are initiated when accounting department send the Grant monthly reconciliation to Federal and State Funds Administration Office, Compliance officer reviews the reconciliation and Director of Federal Funds Administration determine needed funds to be requested. A new Enterprise Resource Planning (ERP) software it’s under implementation and will address this issue as part of the implementation process.
Finding 558941 (2024-002)
Significant Deficiency 2024
Management concurs with the finding. The new ERP system implementation and first year of operations resulted in delays in timely preparation for the audit. In addition, the unexpected loss of the audit liaison contributed to further delay. The University has begun strengthening its year-end financ...
Management concurs with the finding. The new ERP system implementation and first year of operations resulted in delays in timely preparation for the audit. In addition, the unexpected loss of the audit liaison contributed to further delay. The University has begun strengthening its year-end financial reporting and audit preparation processes. Items that can be compiled prior to year-end will be identified and the compilation of those items will begin. Areas that presented challenges during the FY 24 audit will be given special attention in advance. Lastly, audit assignments will be delegated to improve response efficiency. A detailed closing schedule has been developed. Staff duties and responsibilities have been reassigned and repurposed to improve processing timelines and audit preparation. The audit timeline will be monitored more closely to ensure timely responses to audit requests that support the timely completion and issuance of the audit to meet Uniform Guidance timeline requirements.
Finding: The Community Colleges of Spokane did not have adequate controls over and did not comply with program governance requirements for its Head Start program. Questioned Costs: Assistance Listing # 93.600 Status: Corrective action in progress Corrective Action: The College District will...
Finding: The Community Colleges of Spokane did not have adequate controls over and did not comply with program governance requirements for its Head Start program. Questioned Costs: Assistance Listing # 93.600 Status: Corrective action in progress Corrective Action: The College District will enhance our monthly financial reporting to include a unique identifier for monthly expenditures. Additionally, a report of expenditures procured by credit card will be attached to the regular financial report. The College District acknowledges the importance of clear documentation and tracking of the required training and meeting attendance by all Board of Trustees members and Policy Council members. Beginning in March 2025, the College District started providing additional methods and opportunities for new members to receive fiscal and governance training. To strengthen controls over program governance requirements and to demonstrate the commitment to continuous improvement of existing processes, the College District will further document training completion and the distribution of monthly financial information to all members. Completion Date: Estimated June 2025 Agency Contact: Linda McDermott Chief Financial Officer 501 N Riverpoint Blvd, PO Box 6000 Spokane, WA 99217-6000 (509) 434-5275 Linda.McDermott@ccs.spokane.edu
Finding: Skagit Valley College did not have adequate internal controls over and did not comply with program governance requirements for its Head Start program. Questioned Costs: Assistance Listing # 93.600 Amount $0 Status: Corrective action complete Corrective Action: The College has rev...
Finding: Skagit Valley College did not have adequate internal controls over and did not comply with program governance requirements for its Head Start program. Questioned Costs: Assistance Listing # 93.600 Amount $0 Status: Corrective action complete Corrective Action: The College has reviewed and strengthened current internal controls to ensure the Board receives the required financial and credit card statements monthly and that all new Board members receive training within the required 180 days. Financial reporting procedures The Head Start Program Director prepares monthly reporting to be available for inclusion in the monthly board packet, or as requested. In January 2025, the Procedures of Policy Council and Board Reporting were updated to ensure that required monthly reporting is provided to each governing body, regardless of whether there is a scheduled meeting for that month. This procedure became effective for the February 2025 Board of Trustees meeting. All financial reporting that was not previously provided to the Board of Trustees for the period covering July 1, 2023, through December 31, 2024, was transmitted on February 24, 2025. Board member training In January 2025, the Head Start Director provided the Board of Trustees an updated document on the program’s selection criteria and enrollment process. Additionally, the Head Start Board of Trustees Handbook, which has incorporated other training materials, was provided to each board member. The Head Start Director will conduct an annual review of the handbook content and update as appropriate to ensure training materials remain current. Completion Date: March 2025 Agency Contact: Mike Cogan VP of Administrative Services and CFO 2405 East College Way Mount Vernon, WA 98273-5899 (360) 899-2945 mike.cogan@skagit.edu
Finding: Edmonds College did not have adequate internal controls over and did not comply with program governance requirements for its Head Start program. Questioned Costs: Assistance Listing # 93.600 Status: Corrective action in progress Corrective Action: In response to the audit finding, ...
Finding: Edmonds College did not have adequate internal controls over and did not comply with program governance requirements for its Head Start program. Questioned Costs: Assistance Listing # 93.600 Status: Corrective action in progress Corrective Action: In response to the audit finding, the College will explore options for a Governing Body that complies with governance requirements for the Head Start program. By May 2025, the College will consult with its Assistant Attorney General to discuss the composition of a new Governing Body and will take the necessary steps to fully comply with federal regulations. By July 2025, the College will: • Establish a Governing Body that is compliant with requirements outlined in the Head Start Act to perform the required monthly review of financial and credit card statements, major financial expenditures, and any funding applications. • Ensure the Policy Council receives and approves the required financial and credit card statements each month. • Provide training to the new Governing Body and active members of the Policy Council within the required 180 days. Completion Date: Estimated July 2025 Agency Contact: Ginger Williams Head Start Executive Director 20816 44th Ave. W. Lynnwood, WA 98036-7744 (425) 550-3840 ginger.williams@edmonds.edu
Finding: Edmonds College did not have adequate internal controls over and did not comply with protection of federal interest requirements for its Head Start program. Questioned Costs: Assistance Listing # 93.600 Amount $0 Status: Corrective action complete Corrective Action: In response ...
Finding: Edmonds College did not have adequate internal controls over and did not comply with protection of federal interest requirements for its Head Start program. Questioned Costs: Assistance Listing # 93.600 Amount $0 Status: Corrective action complete Corrective Action: In response to the audit finding, Edmonds College has completed the following: • Established a written protocol with the Department of Enterprise Services (DES) to ensure the Head Start Program Performance Standards 1303.46 is met in recording and posting federal interest. • Established internal controls to ensure college management monitor future work with DES to properly complete the Office of Head Start Lease Rider attachment in the lease agreements where federal funds are used to renovate leased property. Completion Date: February 2025 Agency Contact: Ginger Williams Head Start Executive Director 20816 44th Ave. W. Lynnwood, WA 98036-7744 (425) 550-3840 ginger.williams@edmonds.edu
Finding: Edmonds College did not have adequate controls over reporting for its Head Start Program. Questioned Costs: Assistance Listing # 93.600 Amount $0 Status: Corrective action complete Corrective Action: In response to the audit finding, the College established a documented procedu...
Finding: Edmonds College did not have adequate controls over reporting for its Head Start Program. Questioned Costs: Assistance Listing # 93.600 Amount $0 Status: Corrective action complete Corrective Action: In response to the audit finding, the College established a documented procedure for the compilation and submission of the SF-425 reports to ensure compliance with federal requirements. This procedure includes: • Defining roles and responsibilities of staff. • Performing a secondary review of all reports before submission. • Retaining source data used in creating the reports. Completion Date: April 2025 Agency Contact: Ginger Williams Head Start Executive Director 20816 44th Ave. W. Lynnwood, WA 98036-7744 (425) 550-3840 ginger.williams@edmonds.edu
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