Corrective Action Plans

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FINDING 2024-001 (Auditor Assigned Reference Number) Finding Subject: Child Nutrition Cluster - Eligibility Contact Person Responsible for Corrective Action: Brook Cleaver Contact Phone Number and Email Address: (765) 675-2147 Ext 3316; bcleaver@tcsc.k12.in.us Views of Responsible Officials: We conc...
FINDING 2024-001 (Auditor Assigned Reference Number) Finding Subject: Child Nutrition Cluster - Eligibility Contact Person Responsible for Corrective Action: Brook Cleaver Contact Phone Number and Email Address: (765) 675-2147 Ext 3316; bcleaver@tcsc.k12.in.us Views of Responsible Officials: We concur that there was not a documented control in place to ensure that timely eligibility determinations were made for direct certification eligibility determinations. Description of Corrective Action Plan: Etrition is our new system for the 2024-25 school year. Weekly, Susie Moore, kitchen manager, checks the state website for any direct certification file pulls. The file is saved by date and is used to import direct certs into the Etrition program on that same day. Each Friday, eligibility determination notices are issued via email to the parent or guardian email listed in the school’s information system, Powerschool. If such an email does not exist in the information system, a hard copy of the notice is mailed to the household. Duplicate copies will be retained in our files. Etrition syncs with PowerSchool at midnight each day successfully changing student lunch statuses. Benefit notifications will be reviewed by a second person and checked against the direct cert file pull to verify for accuracy. Income applications will work in a similar fashion, wherein we will retain evidence of the eligibility notices being sent to households. A binder of all notices will be kept on file. Anticipated Completion Date: Immediately - 3/4/2025
Finding #: 2024-001 – Special Tests and Provisions – Return of Title IV Funds Description of Finding: One record from the return to Title IV sampling of 12 students tested, had funds returned beyond the required timeline for an unofficial withdrawal. The record received a non-completed course grade ...
Finding #: 2024-001 – Special Tests and Provisions – Return of Title IV Funds Description of Finding: One record from the return to Title IV sampling of 12 students tested, had funds returned beyond the required timeline for an unofficial withdrawal. The record received a non-completed course grade for the fall 2023 term, but the return of funds based on the unofficial withdrawal was not performed until July 2024. The cause of the delayed return was the irregular non-completed course grade that was applied by faculty. The grade type was not incorporated into control measures for prompt identification. The University of La Verne concurs with this finding. Corrective Action: The reporting criteria used to identify non-completed courses are being modified to include all grade codes that meet the non-completed criteria, regardless of their appropriateness to the enrollment type. This revision is to ensure that any irregular grade reporting would still be captured. Secondly, all staff who perform return to Title IV calculations are expected to complete the Federal Student Aid training modules on return to Title IV funds to reinforce the staff knowledge base. Lastly, with the recent onboarding of a Financial Aid Compliance Manager, additional quality assurance steps are being added to include random sampling and secondary review of return to Title IV records for accuracy and timeliness. The responsible party is Laura Evans at levans2@laverne.edu. This will be completed by December 2024.
The Comprehensive Cancer Center (CCC) has implemented a Corrective Action Plan on November 2023 and has significantly improved the submission of the Single Audit Report FY 2023 and the data collection. The result of the implementation of the corrective action plan for FY 2023 allows the CCC to begin...
The Comprehensive Cancer Center (CCC) has implemented a Corrective Action Plan on November 2023 and has significantly improved the submission of the Single Audit Report FY 2023 and the data collection. The result of the implementation of the corrective action plan for FY 2023 allows the CCC to begin the financial statement and Single Audit of FY 2024 on time. We establish a procedure to ensure that the information required to be disclosed in the Single Audit is scheduled. Despite efforts to complete the Single Audit FY 2023 on March 31, 2024, CCCUPR Management and auditors agreed that they require two (2) additional months to complete the process. To ensure the timely completeness of the Financial Statement and Single audit of FY 2024 before March 31, 2025 we implement the following aggressive work plan:  Management closing and submission Final Trial Balance to Auditors August 26, 2024.  Completion and Delivery to Auditors PBC items November 30, 2024.  Distribution of Financial Statement and Single Audit Draft for review (management and Auditors) February 4, 2025  Final review of the Draft by the auditors – February 28, 2025.  Final Issuance of Financial Statement, Single Audit, and data collection March 14, 2025.
Audit Finding 2024-001: - There was a shortfall in the monthly deposits to the replacement reserve due to the December 2024 deposit not being made in a timely manner. - We have made up the shortfall in February 2025 and in the future, will ensure the monthly deposits are done in a timely manner. - N...
Audit Finding 2024-001: - There was a shortfall in the monthly deposits to the replacement reserve due to the December 2024 deposit not being made in a timely manner. - We have made up the shortfall in February 2025 and in the future, will ensure the monthly deposits are done in a timely manner. - Name and Title of contact person responsible for corrective action: - Steve Colella, -Making a Difference in Property Management, LLC - Management Agent - 6800 Park Ten Blvd, Ste 184-W - San Antonio, TX 78213
View Audit 348542 Questioned Costs: $1
Audit Finding 2024-001: Bookkeeping fees for the year ended December 31, 2024 were overpaid by $30. Additionally, there was still $30 due to the Project for overpaid management fees from the prior year. - Management will repay the $60 by deducting $30 from the management fee and $30 from the bookk...
Audit Finding 2024-001: Bookkeeping fees for the year ended December 31, 2024 were overpaid by $30. Additionally, there was still $30 due to the Project for overpaid management fees from the prior year. - Management will repay the $60 by deducting $30 from the management fee and $30 from the bookkeeping fee for March. - Name and Title of contact person responsible for corrective action: -Steve Colella, - Making a Difference in Property Management, LLC - Management Agent - 6800 Park Ten Blvd, Ste 184-W - San Antonio, TX 78213
View Audit 348541 Questioned Costs: $1
FINDING 2024-003 Finding Subject: Title I Grants to Local Educational Agencies-Eligibility Contact Person Responsible for Corrective Action: Dr. Eric Goggins, Superintendent Contact Phone Number and Email Address: 812-385-4851; egoggins@ngsc.k12..in.us Views of Responsible Officials: We concur with ...
FINDING 2024-003 Finding Subject: Title I Grants to Local Educational Agencies-Eligibility Contact Person Responsible for Corrective Action: Dr. Eric Goggins, Superintendent Contact Phone Number and Email Address: 812-385-4851; egoggins@ngsc.k12..in.us Views of Responsible Officials: We concur with the finding. Explanation and Reasons for Disagreement: Not applicable Description of Corrective Action Plan: The food service director will do monthly eligibility reporting through the food service software to determine any free, reduced, paid, or direct certification eligibility changes. Change reports will be generated and provided to each building secretary on a monthly basis. Copies of each school’s eligibility changes will be provided to Marissa Breidenbaugh (HR Coordinator/Administrative Secretary) in the district office. Marissa will provide a deadline for all schools to update eligibility. On the deadline date, she will review each students Harmony demographics to ensure that the changes in eligibility have been recorded. The assistant superintendent will continue to develop the Title I application collaboratively with non-public schools. This development will include continued review of eligibility and enrollment data to ensure that it agrees with all supporting documentation. Anticipated Completion Date: This corrective action plan was implemented on March 3, 2025 and will continue to be implemented with the next Title I grant application process beginning approximately May 2025. INDIANA STATE
The Emergency Rental Assistance Program was developed in response to the pandemic and was implemented swiftly to meet the needs of low-income tenants affected by Covid-19. The program design involves fourteen partner agencies and their varying accounting systems. In the current fiscal year, all part...
The Emergency Rental Assistance Program was developed in response to the pandemic and was implemented swiftly to meet the needs of low-income tenants affected by Covid-19. The program design involves fourteen partner agencies and their varying accounting systems. In the current fiscal year, all partnering agencies were required to submit program data through the online Neighborly software along with providing a general ledger report that supports and is reconciled to the data submitted prior to receiving reimbursement. In response to the compliance finding for our June 30,2024 Single Audit, United Way Monterey County will implement a year end ERAP closeout with all partners who received direct financial assistance. There will be monitoring visits done by the Vice President of Community Investments. Any record of noncompliance will be documented accordingly. The UWMC staff member overseeing these monitoring visits for us is: Josh Madfis VP, Community Investments Josh.madfis@unitedwaymcca.org (831) 372-8026
MANAGEMENT HAS STATED THAT THEY WILL CREATE A COMPLETE DETAILED LISTING OF ALL CAPITAL ASSETS AND DEPRECIATION SCHEDULE; HOWEVER, RECORDS OF THE TOWN AND UTILITY BOARDS ARE INSUFFICIENT TO ALLOW MANAGEMENT TO COMPARE IT TO EXISTING INFORMATION IN THE ACCOUNTING RECORDS.
MANAGEMENT HAS STATED THAT THEY WILL CREATE A COMPLETE DETAILED LISTING OF ALL CAPITAL ASSETS AND DEPRECIATION SCHEDULE; HOWEVER, RECORDS OF THE TOWN AND UTILITY BOARDS ARE INSUFFICIENT TO ALLOW MANAGEMENT TO COMPARE IT TO EXISTING INFORMATION IN THE ACCOUNTING RECORDS.
Finding 537266 (2024-002)
Significant Deficiency 2024
Corrective Action Plan: Several steps have been taken to address the need for timely and accurate reporting. The steps taken and listed below will allow management to properly administer grants and file audit and data collection timely in the future. Turnover of finance staff occurred. Management ac...
Corrective Action Plan: Several steps have been taken to address the need for timely and accurate reporting. The steps taken and listed below will allow management to properly administer grants and file audit and data collection timely in the future. Turnover of finance staff occurred. Management acquired the services of an outside firm to address the deficiencies in the records and to correct and establish a system in order to prevent further occurrences of late reconciliations and untimely reporting. Management has restructuring the finance department with two positions, hiring a Director of Finance and Grants & Contracts Analyst. Additional steps implemented and processes improved in order to establish a system of recording and reporting all financial events: • Payroll entry is streamlined including contemporaneous entry. • Credit cards – Reporting and recording is established in a file so that purchases are logged at the initialization of each purchase. • Reconciliation of all balance sheet accounts are maintained on a current month basis. • A checklist is established for monthly steps. This checklist is maintained by Finance and forwarded to the CEO along with the monthly financial reports. • A thorough review of separation of duties for internal controls was conducted. Implementation is an ongoing process as is analyzing improvements. Persons Responsible: Jolyana Begay-Kroupa, CEO Katherine Gray, Finance Director Estimated Completion Date: June 30, 2025
Finding 537244 (2024-003)
Significant Deficiency 2024
Federal Direct Student Loans – Assistance Listing No. 84.268 Recommendation: We recommend the University evaluate its procedures around packaging and awarding students to ensure loan eligibility is reassessed prior to disbursement. Explanation of disagreement with audit finding: There is no disagr...
Federal Direct Student Loans – Assistance Listing No. 84.268 Recommendation: We recommend the University evaluate its procedures around packaging and awarding students to ensure loan eligibility is reassessed prior to disbursement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has strengthened its procedures to ensure student loan eligibility is reconciled after awarding. The Direct Loan project manager will conduct additional reviews to verify continued eligibility. Name(s) of the contact person(s) responsible for corrective action: Fatima Sulaman Planned completion date for corrective action plan: 3/17/25
View Audit 348448 Questioned Costs: $1
Finding 537243 (2024-002)
Significant Deficiency 2024
Federal Pell Grant Program – Assistance Listing No. 84.063 Recommendation: We recommend that a review is implemented to ensure calculations of Pell awards are using the correct EFC. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in respo...
Federal Pell Grant Program – Assistance Listing No. 84.063 Recommendation: We recommend that a review is implemented to ensure calculations of Pell awards are using the correct EFC. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has implemented a review process to ensure Pell Grant awards are calculated using the correct EFC/SAI. Financial Aid staff will conduct periodic quality control checks to verify that EFC/SAI values are accurately applied in award determinations. Name(s) of the contact person(s) responsible for corrective action: Fatima Sulaman Planned completion date for corrective action plan: 3/17/25
View Audit 348448 Questioned Costs: $1
Finding 537241 (2024-001)
Significant Deficiency 2024
Federal Pell Grant Program & Federal Supplemental Education Opportunity Grants – Assistance Listing No. 84.063 & 84.007 Recommendation: We recommend the University implement policies to review all student award packages at the start of the academic year to ensure no over awards exist. In addition, ...
Federal Pell Grant Program & Federal Supplemental Education Opportunity Grants – Assistance Listing No. 84.063 & 84.007 Recommendation: We recommend the University implement policies to review all student award packages at the start of the academic year to ensure no over awards exist. In addition, we recommend the University implement procedures for adjusting aid when an outside scholarship is received by the student. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has implemented enhanced procedures to review all student award packages at the start of the academic year to ensure compliacne with federal overaward regulations. Additionally, the new staff member that is responsible for adding outside scholarships to student accounts has received training to ensure they review for potential over awards. Name(s) of the contact person(s) responsible for correcitve action: Marivic Delacruz and Renato Aguilar Planned completion date for corrective action plan: 3/17/25
View Audit 348448 Questioned Costs: $1
Finding 537236 (2024-001)
Material Weakness 2024
LearningWorks is utilizing a temporary plan that engages existing staff in aspects of segregation. The recently revised Finance Manual includes a full matrix that explicitly includes additional finance staff to ensure segregation of duties through the transaction cycle. LearningWorks is committed to...
LearningWorks is utilizing a temporary plan that engages existing staff in aspects of segregation. The recently revised Finance Manual includes a full matrix that explicitly includes additional finance staff to ensure segregation of duties through the transaction cycle. LearningWorks is committed to and engaged in hiring a Finance Associate. The agency will incorporate these criteria and the matrix in our routine operations. Additionally, we are willing to institute further recommended practices that will remediate this finding.
Corrective action plan: TxDOT AVN will implement procedures to ensure FFATA reports are reviewed and approved by a separate individual and submitted in a timely manner. Implementation dates: The procedure has been partially implemented, including the addition of the screen shots. A full implementa...
Corrective action plan: TxDOT AVN will implement procedures to ensure FFATA reports are reviewed and approved by a separate individual and submitted in a timely manner. Implementation dates: The procedure has been partially implemented, including the addition of the screen shots. A full implementation will be completed by March 1, 2025. Responsible persons: Michelle Burcham, AVN Grant & Admin Section Director, Allison Martin, Grant Manager Lead, Cassandra Moore, Grant Manager
Corrective action plan: CMS is in the process of training the Manager of Physical Inspection to review and assign properties for timely inspections to ensure multiple staff members have oversight of the process. In addition, CMS is utilizing a new process using Excel to ensure all HOME-rental prop...
Corrective action plan: CMS is in the process of training the Manager of Physical Inspection to review and assign properties for timely inspections to ensure multiple staff members have oversight of the process. In addition, CMS is utilizing a new process using Excel to ensure all HOME-rental properties are inspected within required federal timeframes and this process is completed by two staff members independently. Implementation dates: On February 6, 2025, the new process of reconciling travel using Excel tools by independent staff was implemented to ensure no HOME-rental properties are inspected late. Responsible persons: Wendy Quackenbush, Director of Multifamily Compliance, Manual Pena, Manager of Physical Inspections and Carolyn Metzger, Team Leader.
Corrective action plan: Based on the recommendation above, HHSC Medicaid & CHIP Services (MCS) Financial Reporting and Audit Coordination (FRAC) has incorporated the suggested enhanced controls around the review of MLR report submissions to ensure they are complete and accurate. In order to enhan...
Corrective action plan: Based on the recommendation above, HHSC Medicaid & CHIP Services (MCS) Financial Reporting and Audit Coordination (FRAC) has incorporated the suggested enhanced controls around the review of MLR report submissions to ensure they are complete and accurate. In order to enhance existing controls, MCS FRAC has included a section for MLR reviewers to ensure Methodology(ies) for allocation of expenditures tab questions are complete. Likewise, specific instructions have been added to the review document to ensure the recommendations are met. These enhanced controls will be included in Fiscal Year (FY) 2025 and ongoing review of MLR report submissions. Implementation dates: November 2025 Responsible persons: Jason Mendl, Deputy Associate Commissioner, FRAC
Corrective action plan: HHSC's OIG has taken action to ensure timely reviews of the Centers for Medicare/Medicaid Services (CMS) Data Exchange Portal (DEX) reports. HHSC's OIG has multiple employees that have access to the systems necessary to retrieve the reports and has trained those employees o...
Corrective action plan: HHSC's OIG has taken action to ensure timely reviews of the Centers for Medicare/Medicaid Services (CMS) Data Exchange Portal (DEX) reports. HHSC's OIG has multiple employees that have access to the systems necessary to retrieve the reports and has trained those employees on the review process. Implementation dates: July 10, 2024 (Implemented) Responsible persons: Robin Bernard, Director, Financial Analysis and Case Management
Corrective action plan: For awareness, effective February 1, 2025, Anil Koindala was hired as the Health and Human Services (HHS) Chief Information Security Officer (CISO). At HHSC, the Deputy Executive Commissioner for each HHS organizational area is responsible for assigning an information owne...
Corrective action plan: For awareness, effective February 1, 2025, Anil Koindala was hired as the Health and Human Services (HHS) Chief Information Security Officer (CISO). At HHSC, the Deputy Executive Commissioner for each HHS organizational area is responsible for assigning an information owner (IO) for each of their area’s HHS information systems which also includes performing Risk Assessments for the systems they are responsible for. To ensure Risk Assessment compliance is met, the CISO will send out quarterly reminders to the IO for the completion of risk assessments. The reminders have started to be sent on July 31, 2024. While the risk assessment will be completed by the IO, the CISO will assist any non-compliant area with training that will be provided by their Information Security Portfolio Manager (ISPM). Additionally, the CISO office ensures that a risk assessment and System Security Plan (SSP) are in place before granting an Authority to Operate (ATO). The CISO is currently developing policies and procedures to establish and publish a process for the successful completion of Risk Assessments, including roles and responsibilities, processes, and procedures to ensure timely completion and ongoing compliance. Implementation date: August 31, 2025 Responsible persons: Anil Koindala, Chief Information Security Officer, Information Technology Jeremy Sadler, Director, Information Security Risk Cristina Denz, Manager, Policy and Compliance
Corrective action plan: Since fiscal year 2022, Access and Eligibility Services (AES) has focused on hiring initiatives, strategic workload strategies, system improvements, and training to improve workload capacity to enable AES to reallocate workforce resources to applications waiting the longest...
Corrective action plan: Since fiscal year 2022, Access and Eligibility Services (AES) has focused on hiring initiatives, strategic workload strategies, system improvements, and training to improve workload capacity to enable AES to reallocate workforce resources to applications waiting the longest to be processed. In addition, AES has reviewed regular monitoring and reporting mechanisms to track application processing times and identify any delays. HHSC conducted a comprehensive review of application processing workflows to identify strategies to increase capacity and/or reduce workload. The review identified more than 40 strategies to improve end-user function, eliminating unnecessary actions and interactions, improving client experience, and promoting timely workflow. As of January 31, 2025, procedural improvements implemented have resulted in most Medicaid applications being processed within three days of receipt, allowing for a greater amount of the full processing timeframe (45 days) being available to establish proper eligibility. AES began implementing identified strategies in September 2024 and ongoing efforts will continue to focus on workforce and workload balance to meet the needs of timeliness of applicable programs. AES will continue to evaluate effectiveness of procedures through feedback loops, ensuring changes made result in sustained improvements and compliance with all relevant regulations. Implementation dates: December 31, 2028 Responsible persons: Molly Regan, Deputy Executive Commissioner, AES Rachel Patton, Associate Commissioner, AES Operations
Corrective action plan: HHSC cannot commit to the specific designation of CAPPS-Financials as the improvement solution for FFATA reporting. However, HHSC is currently engaged in long-term planning related to improving FFATA reporting. HHSC continues to implement a quality review of selected progr...
Corrective action plan: HHSC cannot commit to the specific designation of CAPPS-Financials as the improvement solution for FFATA reporting. However, HHSC is currently engaged in long-term planning related to improving FFATA reporting. HHSC continues to implement a quality review of selected programs to assess FFATA compliance on an annual basis. Implementation dates: September 1, 2025 Responsible persons: Racheal Kane, Director, Federal Funds
Management agrees with the above and we review the tenant security deposit listing and the tenant security liability monthly for accuracy.
Management agrees with the above and we review the tenant security deposit listing and the tenant security liability monthly for accuracy.
Management agrees with the above and we follow the organization’s capitalization policy.
Management agrees with the above and we follow the organization’s capitalization policy.
Management agrees with the above and we review the transaction posted to the general ledger monthly.
Management agrees with the above and we review the transaction posted to the general ledger monthly.
Management agrees with the above and we reconcile all cash and reserve accounts on a monthly basis.
Management agrees with the above and we reconcile all cash and reserve accounts on a monthly basis.
RCS will update the current practice of formal updates to the Fixed Asset List from every other year, to every year effective the 2025 year
RCS will update the current practice of formal updates to the Fixed Asset List from every other year, to every year effective the 2025 year
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