Corrective Action Plans

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Contact Person – Krista Martin, Director of Finance and Administration, and Ryan Riesinger, Executive Director Corrective Action Plan – Review and update procedures to ensure accurate reporting. Completion Date –December 31, 2025
Contact Person – Krista Martin, Director of Finance and Administration, and Ryan Riesinger, Executive Director Corrective Action Plan – Review and update procedures to ensure accurate reporting. Completion Date –December 31, 2025
Ensure full compliance with HUD regulations and internal policies related to eligibility documentation, income verification, utility allowances, and rent reasonableness determinations in the Housing Choice Voucher (HCV) program. 1. Correct the Deficiencies in the Identified Files Issue Missing 214...
Ensure full compliance with HUD regulations and internal policies related to eligibility documentation, income verification, utility allowances, and rent reasonableness determinations in the Housing Choice Voucher (HCV) program. 1. Correct the Deficiencies in the Identified Files Issue Missing 214 Declaration Form Utility Allowance Calculation (2 files) Missing Third-Party Income Verification Missing Rent Reasonableness Determination Action Contact tenant to obtain and file the signed 214 declaration. Recalculate and document the utility allowance using the current approved utility schedule. Request and obtain third-party verification; if unavailable, follow up with tenant and document efforts per HUD guidelines. Conduct and document rent reasonableness review for the current unit. Responsible Party Housing Specialist Housing Specialist Housing Specialist HQS/Rent Reasonableness Officer Timeline Within 10 business days Within 10 business days Within 10 business days Within 10 business days 2. Expand Review to Broader File Population Action Details Responsible Party Timeline Risk-based Review of Additional Files Identify Systemic Issues Report Findings Identify a representative sample of 100-200 files from the broader tenant population to assess the prevalence of the noted deficiencies. Track and categorize findings to identify patterns of noncompliance. Present findings to leadership and recommend procedural changes if systemic issues are found. Quality Assurance (QA) Team QA Manager QA Manager Within 45 days Within 60 days Within 75 days 3. Strengthen Policies, Procedures, and Staff Training Update Procedures Revise Standard Operating Procedures (SOPs) for file documentation, utility allowances, and rent reasonableness. Include clear checklists. Program Manager Within 90 days Staff Training Conduct mandatory refresher training on eligibility documentation,income verification protocols, rent reasonableness, and utility allowance schedules. File Audit Checklist Implement a standardized checklist for file reviews before final approval. 4. Ongoing Monitoring and Compliance Quarterly File Audits Continue random quarterly audits of tenant files to ensure ongoing compliance. Compliance Reporting Include compliance metrics in monthly management reports. Corrective Action Tracking Maintain a tracking system for noted deficiencies and corrective actions taken.
Finding 558082 (2024-001)
Significant Deficiency 2024
U.S. Department of Treasury No. 21.027 – Coronavirus State and Local Fiscal Recovery Funds Grant Period Year Ended December 31, 2024 Corrective Action Plan: In order to ensure future submissions are containing segregation of duties, the organization will ensure there are two people a part of the rep...
U.S. Department of Treasury No. 21.027 – Coronavirus State and Local Fiscal Recovery Funds Grant Period Year Ended December 31, 2024 Corrective Action Plan: In order to ensure future submissions are containing segregation of duties, the organization will ensure there are two people a part of the reporting and submission process. One person will fill out the reporting information and another person will sign off and submit the information to ensure two people are part of the process. Responsible for this plan: Ariel Rodriguez, Executive Director Implementation Timeline: Immediately as of April 22nd, 2025
2024-001-Internal Control over Financial, United States Department of Health and Human Services Administration, Native Hawaiian Health Care 93.932 Significant adjusting journal entries Due to the high turnover of fiscal staff in previous years, the Organization fell behind in our audits. Therefor...
2024-001-Internal Control over Financial, United States Department of Health and Human Services Administration, Native Hawaiian Health Care 93.932 Significant adjusting journal entries Due to the high turnover of fiscal staff in previous years, the Organization fell behind in our audits. Therefore, many adjusting entries were required to reconcile accounts, while upkeeping the current financial state of the Organization during fiscal year’s 2024 and 2025, accordingly. In addition to the high turnover, during fiscal year 2024, Maui experienced devastation with the Lahaina wildfires, which led to an increase of funding from donors to support the communities’ needs to recover. Again, our staff were challenged to meet the demands of the requirements of the funding and continue to monitor the previous fiscal year and the current fiscal years financial state. Internal control over disbursements We have made significant improvements from prior years in internal control processes, with regards to disbursements. With the turnover of staff, there was no communication of fiscal internal controls. Since the turnover, we have hired new staff and implemented processes and reviewed the internal controls policies with the new staff to address these issues. We expect these issues to be resolved in fiscal year ending 2025, as these findings have been carryover issues from previous years. Review of cancelled check images During fiscal year 2022, the bank statements no longer included copies of cancelled checks. Due to this change, the cancelled check images are available online. As of January 2025, the Executive Director reviews cancelled check images online monthly. She also reviews the bank statements for awareness of the transactions and balances of accounts monthly.
FINDING NUMBER: 2024-002 Condition: The CMHSP included all contract costs, including amounts over $25,000, in the modified total direct costs. Recommendation: We recommend that the CMHSP review/update policies and procedures to ensure that amounts used to calculate indirect costs charged to the gr...
FINDING NUMBER: 2024-002 Condition: The CMHSP included all contract costs, including amounts over $25,000, in the modified total direct costs. Recommendation: We recommend that the CMHSP review/update policies and procedures to ensure that amounts used to calculate indirect costs charged to the grant properly exclude contract amounts over the allowed limit. Planned Corrective Action: Going forward the Authority will calculate the indirect costs based on up to $25,000 per contract employee. Contact Person: Anthony Shaver, Chief Financial Officer Anticipated Completion Date: 9/30/2025
View Audit 354928 Questioned Costs: $1
Finding 558068 (2024-002)
Significant Deficiency 2024
View of Responsible Officials: Management agrees with recommendation of refund operating cash for the distributions in excess of allowable surplus cash calculations and will refund operating cash. Responsible Party: Sherri Friedrich Estimated Completion: Cash will be refunded by May 31, 2025
View of Responsible Officials: Management agrees with recommendation of refund operating cash for the distributions in excess of allowable surplus cash calculations and will refund operating cash. Responsible Party: Sherri Friedrich Estimated Completion: Cash will be refunded by May 31, 2025
View of Responsible Officials: The Project agrees and will replenish the replacement reserve account. Responsible Party: Sherri Friedrich Estimated Completion: Funds will be replenished by April 30, 2025
View of Responsible Officials: The Project agrees and will replenish the replacement reserve account. Responsible Party: Sherri Friedrich Estimated Completion: Funds will be replenished by April 30, 2025
The Smithsonian agrees with the finding. The Smithsonian would like to add that the reports were delivered to the sponsor and that the sponsor was satisfied with them. Furthermore, the sponsor has provided written acknowledgment that they were “verbally kept up to date” by the National Postal Museum...
The Smithsonian agrees with the finding. The Smithsonian would like to add that the reports were delivered to the sponsor and that the sponsor was satisfied with them. Furthermore, the sponsor has provided written acknowledgment that they were “verbally kept up to date” by the National Postal Museum (NPM) regarding this potential delay. Moving forward, NPM will strengthen senior management oversight of report delivery, review due dates more rigorously, and enhance internal controls to ensure timely submission. Any potential delays will be confirmed in writing to the sponsor ahead of the due date, and compliance updates will be provided by NPM senior management to the sponsor on a regular basis. Additionally, NPM will establish procedures to cross train staff to perform required responsibilities applicable to the NPM Project.
Federal Fund Source liquidation is monitored monthly via the Fund Source Reconciliation Report and the Provider Utilization Report. Requests to close purchase orders associated with expiring federal fund sources are submitted to OPC accordingly. The Federal Financial Reporting Group will now have th...
Federal Fund Source liquidation is monitored monthly via the Fund Source Reconciliation Report and the Provider Utilization Report. Requests to close purchase orders associated with expiring federal fund sources are submitted to OPC accordingly. The Federal Financial Reporting Group will now have the right to close purchase orders with federal fund sources to expedite this process. Also, the Provider Utilization Report has been updated with Key Performance Indicators (KPIs), Contract End Date Exceeds Period of Performance and Payments Exceed Period of Performance, that specifically address the period of performance as of December 2024.
View Audit 354902 Questioned Costs: $1
DCH will review MO 598348 within the Gateway system to ensure the established interface process is functioning properly. DCH will draft additional guidance through a policy memo to revise DHS policy 2750 as it relates to the processing of Ex-Parte members. The DCH policy memo will clarify that upon ...
DCH will review MO 598348 within the Gateway system to ensure the established interface process is functioning properly. DCH will draft additional guidance through a policy memo to revise DHS policy 2750 as it relates to the processing of Ex-Parte members. The DCH policy memo will clarify that upon the completion of the determination by DHS, Gateway will notify GAMMIS of A/R's approval or denial thorough daily interface files sent from Gateway to GAMMIS. The non-confirmation report will be reviewed to determine SOP and validate that the file has been received. Additionally, the DCH policy memo will require Gateway to complete the DMA-962 and submit to Gainwell for manual processing if the file has not been received. DCH is also reviewing current policy to determine if the infinity date established for Ex-Parte members can be revised to a time-limited date.
View Audit 354902 Questioned Costs: $1
DCH will develop a reconciliation process between members denied within Georgia Gateway and members removed within GAMMIS. DHS will provide training as outlined within the current contract to address changes and updates to Medicaid policy and the Georgia Gateway system.
DCH will develop a reconciliation process between members denied within Georgia Gateway and members removed within GAMMIS. DHS will provide training as outlined within the current contract to address changes and updates to Medicaid policy and the Georgia Gateway system.
View Audit 354902 Questioned Costs: $1
DCH is implementing a comprehensive risk analysis framework utilizing the ServiceNow GRC module. This framework will systematically assess risks across all relevant systems and evaluate the effectiveness of existing controls in mitigating identified risks. While DCH has historically obtained and le...
DCH is implementing a comprehensive risk analysis framework utilizing the ServiceNow GRC module. This framework will systematically assess risks across all relevant systems and evaluate the effectiveness of existing controls in mitigating identified risks. While DCH has historically obtained and leveraged independent security assessments—including SOC Type II reports, Security Assessment Reports, and HITRUST validations—to inform its security posture, we recognize the need for enhanced documentation and a formalized assessment process. To address this finding, DCH has taken the following corrective actions: • Standardized Documentation Procedures: Implemented a formalized process to document the receipt, review, and analysis of SOC Type II reports, Complementary User Entity Controls (CUECs), and other relevant security assessments. • Automated Assessment Framework: Leveraging the ServiceNow GRC module to establish a structured, repeatable process for evaluating the effectiveness of implemented controls and their role in mitigating identified risks. • Training & Process Integration: Conducted staff training on the importance of documentation and the new assessment framework to ensure consistent execution and compliance. We remain committed to strengthening our security posture and refining our processes to enhance compliance and risk management. While the SSP approval occurred outside the audit period, DCH has since ensured that approved SSPs for critical Medicaid systems—including Georgia Medicaid Management Information System (GAMMIS), Gateway, and the Enterprise Analytics Solution for Everyone (EASE) are in place. DCH has already begun implementing these corrective actions and anticipates full implementation by April 30, 2025
At the end of the Low Income Home Energy Assistance Program (LIHEAP) season, the State Program Office and other applicable areas such as Grant Administration, Office of Information Technology, etc. (Team) will attend the annual training completed by the Office of Community Services (OCS). The OCS Ho...
At the end of the Low Income Home Energy Assistance Program (LIHEAP) season, the State Program Office and other applicable areas such as Grant Administration, Office of Information Technology, etc. (Team) will attend the annual training completed by the Office of Community Services (OCS). The OCS Household Report training is typically scheduled in November of each year. After the training session, the team will discuss any changes to the new Household Report. The State Program Office will contact the Georgia Environmental Finance Authority (GEFA) to request information about their annual household report. The Household Report will be printed from the Online Data Collection (OLDC) system for review, discussion, and completion by the team, usually around the middle of December to finalize the draft report. Upon completion of the review and approval by the necessary areas, the State Program Office will submit the Household Report to OLDC for approval and acceptance.
The Office of Procurement Services (OPS) has dedicated staff that have attended Federal Funding Accountability and Transparency Act (FFATA) training and webinars. In addition, the same dedicated staff will verify that all federal grants with sub-recipients are properly reported. Beginning in FY 202...
The Office of Procurement Services (OPS) has dedicated staff that have attended Federal Funding Accountability and Transparency Act (FFATA) training and webinars. In addition, the same dedicated staff will verify that all federal grants with sub-recipients are properly reported. Beginning in FY 2025 (September 2024), the OPS has required programs that receive federal funding to email a PDF copy of the monthly FFATA report submitted in the FFATA Subaward Reporting System (FSRS) to the designated staff no later than the fifth of each month. Currently, the FY25 FFATA Reporting is up to date and the Office of Procurement Services will continue to review and adjust the process through FY 2025 (June 30, 2025).
On July 29, 2024, Georgia State University (GSU) was made aware of a National Student Loan Data System (NSLDS) reporting defect in our student information system related to program level reporting. A system correction was installed on November 25, 2024. GSU will enhance monitoring procedures to ensu...
On July 29, 2024, Georgia State University (GSU) was made aware of a National Student Loan Data System (NSLDS) reporting defect in our student information system related to program level reporting. A system correction was installed on November 25, 2024. GSU will enhance monitoring procedures to ensure discrepancies in reporting to the NSLDS are identified and corrected in a timely manner.
The Financial Aid Office has worked with the Registrar's Office to streamline the collection, review and processing of student who are unofficial withdrawals. Streamlining the unofficial withdrawal process will allow for timely and accurate reporting, return to title IV, and reconciliation of funds ...
The Financial Aid Office has worked with the Registrar's Office to streamline the collection, review and processing of student who are unofficial withdrawals. Streamlining the unofficial withdrawal process will allow for timely and accurate reporting, return to title IV, and reconciliation of funds between Lanier Technical College and Common Origination and Disbursement (COD).
View Audit 354902 Questioned Costs: $1
The University of Georgia acknowledges the need for increased monitoring over the return to Title IV aid for students withdrawn from the University. UGA has taken immediate corrective action and has filled key staffing vacancies and implemented additional internal controls to monitor and ensure comp...
The University of Georgia acknowledges the need for increased monitoring over the return to Title IV aid for students withdrawn from the University. UGA has taken immediate corrective action and has filled key staffing vacancies and implemented additional internal controls to monitor and ensure compliance. A self-audit of Fall 2024 revealed no non-compliance issues.
To prevent future errors, staff will undergo training to ensure accurate processing of withdrawals that occur after the term has ended. Both official and unofficial withdrawals will be evaluated based on the student's last date of attendance when the withdrawal date is after the end of term. While...
To prevent future errors, staff will undergo training to ensure accurate processing of withdrawals that occur after the term has ended. Both official and unofficial withdrawals will be evaluated based on the student's last date of attendance when the withdrawal date is after the end of term. While the Financial Aid Office (FAO) staff have adhered to the current withdrawal procedures, we recognize the need for an update to address instances when the date a student initiates the official withdrawal process is earlier than when the withdrawal is completed. To address this, we will adopt the date the student begins the withdrawal process as the official withdrawal date, if this date precedes the completion of the withdrawal form. Additionally, we will implement automated and electronic system controls to ensure withdrawals are processed accurately and within the required timelines by monitoring the full withdrawal cycle. The withdrawal policy and administrative procedures documentation will be updated to reflect these changes. Staff will have annual refresher training at the beginning of each academic year. Confirmation of employees, date of training, and training process will be documented.
View Audit 354902 Questioned Costs: $1
Georgia State University (GSU) will ensure all team members are appropriately trained related to the return to title IV process. Procedures have been enhanced to ensure that unearned funds required to be returned to the program due to return to title IV calculations are immediately reconciled and re...
Georgia State University (GSU) will ensure all team members are appropriately trained related to the return to title IV process. Procedures have been enhanced to ensure that unearned funds required to be returned to the program due to return to title IV calculations are immediately reconciled and returned during the required window. GSU has established an Assistant Director over Electronic Processing to carry out these procedures.
Georgia State University (GSU) will ensure all team members are appropriately trained related to the process for locking student financial aid records and completing verifications after the term ends. Additionally, GSU has enhanced monitoring procedures to identify changes to institutional student i...
Georgia State University (GSU) will ensure all team members are appropriately trained related to the process for locking student financial aid records and completing verifications after the term ends. Additionally, GSU has enhanced monitoring procedures to identify changes to institutional student information records after term ends with a verification indicator to ensure these accounts are resolved in a timely manner.
View Audit 354902 Questioned Costs: $1
Effective November 16, 2024, GDOL restructured the Benefit Accuracy Measurement (BAM) unit to strengthen internal controls by incorporating a secondary review process prior to the final review by the supervisor. This process allows the reconciliation of discrepancies and validates the accuracy of th...
Effective November 16, 2024, GDOL restructured the Benefit Accuracy Measurement (BAM) unit to strengthen internal controls by incorporating a secondary review process prior to the final review by the supervisor. This process allows the reconciliation of discrepancies and validates the accuracy of the case findings prior to the supervisory review. If the reviewer identifies questionable items during the review, the case is returned to the auditor for corrections and updates. Once completed, it is returned back to the reviewer for an additional review, sign-off, and then submission to the supervisor for review and closure. Beginning April 2025, an initiative will be implemented to train staff to perform quality checks. Staff will review a sample of cases completed by other auditors in the previous quarter and provide feedback. This plan is being established to posture staff to supplement gaps in resources if the need arises and address challenges, such as, attrition. This allows staff to effectively fulfill the responsibility of reviewing cases and preparing them for official signoff in a timely manner. Summary: GDOL greatly appreciates the feedback and recommendations and has and will continue to take appropriate measures to ensure the established BAM procedures are followed.
GDOL Response: GDOL acknowledges this is a repeated finding from previous years, therefore the Department concurs with this finding and offers the following response. GDOL now freezes the overpayment data at the end of every month so we can conduct periodic reconciliation of the overpayment recor...
GDOL Response: GDOL acknowledges this is a repeated finding from previous years, therefore the Department concurs with this finding and offers the following response. GDOL now freezes the overpayment data at the end of every month so we can conduct periodic reconciliation of the overpayment records. This will allow discrepancies to be identified faster and resolved before the deadline to submit the report for the specified period. GDOL consults with USDOL’s national 227 reporting specialists on an ongoing basis to work towards a reconciliation of previously submitted reports. Federal regulations require an actual person to review and establish fraudulent overpayments. Due to the volume of claims and the number of cross matches to be performed on all state and federal pandemic programs, it requires multiple GDOL staffing levels to manually review all cross matches, requiring increased levels of state and federal funding. A cross match cannot be assumed to be an overpayment. GDOL must investigate cross matches and provide due process to all parties. GDOL developed an aggressive plan to complete all crossmatches. As of June 2024, GDOL was caught up and resume our regular crossmatch schedule. The current unemployment system is aged and distressed. GDOL’s limited technology resources will hinder our ability to update our current system to perform reconciliation between the multiple tools used to perform different functions. Therefore, we acknowledge that this finding may persist until a system-wide resolution is implemented in the new modernized UI system. The Department has a significant number of pending and potential overpayment investigations that may result in either a non-fraud or fraud determination. We are utilizing merit and time-limited staff to maximize productivity by conducting fact-finding interviews, assessing case details, creating overpayments in the system, and making overpayment determinations. The statutes provide that an overpayment be established up to four years after such occurrence, act, or omission. Additionally, GDOL has procured a vendor to build and implement a modernized UI system slated to be launched in 2026. We will continue to utilize available resources to investigate and establish overpayments in the legacy system as quickly as possible and will continue to do so within the program parameters in the new system. Throughout CY 2024, GDOL participated in quarterly meetings with United States Department of Labor (USDOL) and other regional states to discuss fraud, overpayment issues and best practices used. These meetings will continue in CY2025. Summary: GDOL greatly appreciates the feedback and recommendations and will ensure these and USDOL’s recommendations are incorporated into our new modernized system which is expected to be implemented in the Spring 2026.
After the September 2023 quarter, controls were put in place to ensure accurate Federal quarterly reports. These controls included preparing the report based on our accounting records, e.g. the general ledger. Another control is that the Chief Financial Officer or her designee reviews all reports an...
After the September 2023 quarter, controls were put in place to ensure accurate Federal quarterly reports. These controls included preparing the report based on our accounting records, e.g. the general ledger. Another control is that the Chief Financial Officer or her designee reviews all reports and compares them to the general ledger prior to signature, approval and our submission to the grantor. Furthermore, periodic reviews by program fiscal staff during the performance period take place to closely monitor activity. GDOL will continue to follow the updated procedures and internal controls. As we transition to GA@Work, the system itself will control overspending and provide alerts.
Georgia Tech management agrees that internal audit reports demonstrated departmental deficiencies in knowledge of policies and procedures that needed to be addressed. Upon disclosure of Internal Audit’s recommendations, the departments and central offices immediately responded with additional traini...
Georgia Tech management agrees that internal audit reports demonstrated departmental deficiencies in knowledge of policies and procedures that needed to be addressed. Upon disclosure of Internal Audit’s recommendations, the departments and central offices immediately responded with additional training, proactive compliance reviews, and re-enforcement of existing policies and procedures via Institute wide communications and enhanced reviews of support. New system controls regarding spend authorizations were put in place, with Georgia Tech’s Internal Audit department continuing to test these controls through the month of February. Central and departmental units within Georgia Tech will continue to work together to further enhance guidance and training to faculty and staff and to identify and test controls in our systems that will mitigate these issues.
Friday, April 11, 2025 Dear Sir(s): CORRECTIVE ACTION PLAN In prior years the accounting of Pyramid Learning Corp. was executed externally by a contracted accounting company. During the year ended June 30, 2024 we acquired a specialized accounting software. After the acquisition of the new software,...
Friday, April 11, 2025 Dear Sir(s): CORRECTIVE ACTION PLAN In prior years the accounting of Pyramid Learning Corp. was executed externally by a contracted accounting company. During the year ended June 30, 2024 we acquired a specialized accounting software. After the acquisition of the new software, we recorded the data from the beginning of the year to the present, which required significant staff effort and made it impossible to maintain accounting and financial reports on a month-to-month basis. At the present, the data is already being recorded, and the accounting is up to dates. This allows us to keep our accounting and interim financial reports such as Balance Sheet, Statement of Activities, Bank Reconciliations, and monthly analysis of accounts, up to date and on a current month-to-month basis to be more transparent, and any errors are corrected on a timely manner.
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