Corrective Action Plans

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Finding 530161 (2024-013)
Significant Deficiency 2024
Views of Responsible Officials and Planned Corrective Action: ARS Discussion The Agency acknowledges the lack of adequate internal controls necessary to ensure accurate maintenance of supporting documentation during our migration to our new case management system (CMS). ARS Action Taken The Agency h...
Views of Responsible Officials and Planned Corrective Action: ARS Discussion The Agency acknowledges the lack of adequate internal controls necessary to ensure accurate maintenance of supporting documentation during our migration to our new case management system (CMS). ARS Action Taken The Agency has taken the below steps to mitigate the lack of internal controls regarding supporting documentation, mainly attachments, located in our CMS in the future. • As the transfer of data to our new CMS platform concludes, that impediment has significantly diminished. The Agency has an appropriate method of control in place to detect any case file errors that may occur because of an incomplete retrieval or an insufficient data element input. In both instances, data analyst personnel from Program, Planning, Development and Evaluation (PPD&E) employ RSA’s edit check process that identifies specific errors prior to submission of the RSA 911 report. Those errors are then methodically corrected in our CMS ensuring the RSA 911 report is error free. • In instances where information is miscoded in the client case file, or is missing, the division’s Quality Assurance (QA) team identifies those errors and employes best practice training methods to ensure the case file complies with federal regulations. • Finally, our new CMS data hosted on an AR DIS platform is regularly backed up on a separate server to ensure that if anything were to happen to the primary CMS, we have a back up of all case data, including supporting documentation, and attachments. This data would be able to be accessed as a backup if data in the CMS was compromised in any way. Anticipated Completion Date: Complete Contact Person: Robert Trevino Associate Commissioner of PPD&E Arkansas Rehabilitation Services 1 Commerce Way Little Rock, AR 72202 (501) 296-1604 Robert.Trevino@Arkansas.gov
Finding 530160 (2024-012)
Significant Deficiency 2024
Views of Responsible Officials and Planned Corrective Action: ARS Discussion The Agency acknowledges the failure to adequately submit the RSA-17 report for the quarter ending June 30, 2024, for the federal fiscal year 2023 grant award. ARS Action Taken The Agency has taken the below steps to mitigat...
Views of Responsible Officials and Planned Corrective Action: ARS Discussion The Agency acknowledges the failure to adequately submit the RSA-17 report for the quarter ending June 30, 2024, for the federal fiscal year 2023 grant award. ARS Action Taken The Agency has taken the below steps to mitigate oversight of reporting deadlines and lack of internal controls. • ARS fiscal has hired three additional staff members whose purpose will be in-part to collect, interpret, and submit data with regards to RSA17 reports. • A RSA17 policy was submitted RSA in January 2025. This policy speaks to enhanced ARS internal controls for timeliness of collecting data, and oversight to ensure proper preparation and submission of these federal financial reports moving forward. These include multi personnel responsibility checks for collection at minimum one week prior to report submission with Manager and Deputy Commissioner to ensure data collection and submission are on-time. Anticipated Completion Date: Complete Contact Person: April Cooper Deputy Director of Finance Arkansas Department of Commerce 1 Commerce Way Little Rock, AR 72202 (501) 682-4771 April.Cooper@Arkansas.gov
Audit Finding Reference: 2024-001 Management’s Response and Planned Corrective Action: The District has historically managed our Title I grant as supplemental funding. Although we have a methodology for allocating local funds to schools without regard to whether they receive Title I funds, we do n...
Audit Finding Reference: 2024-001 Management’s Response and Planned Corrective Action: The District has historically managed our Title I grant as supplemental funding. Although we have a methodology for allocating local funds to schools without regard to whether they receive Title I funds, we do not have a formal written plan. The District will establish a written procedure to be in compliance with the Title I Supplement, Not Supplant requirement. Name of Contact Person and Completion Date: Karen DeFrancis, Executive Director of Finance Polly Golden, Title I Manager Anticipated Completion Date – March 31, 2025
View Audit 348254 Questioned Costs: $1
Views of Responsible Officials and Planned Corrective Action: Director of Child Nutrition will have a secondary person review claim before submitting to state department, to ensure accurate keying of data.
Views of Responsible Officials and Planned Corrective Action: Director of Child Nutrition will have a secondary person review claim before submitting to state department, to ensure accurate keying of data.
Finding 530127 (2024-002)
Significant Deficiency 2024
Finding 2024-002: Allowable costs and activities – significant deficiency in internal controls over compliance. Management Response Finding: Failure to Provide an Itemized Receipt for a Restaurant Purchase Corrective Action Taken: Effective July 1, 2024, CEN implemented Ramp, an expense management p...
Finding 2024-002: Allowable costs and activities – significant deficiency in internal controls over compliance. Management Response Finding: Failure to Provide an Itemized Receipt for a Restaurant Purchase Corrective Action Taken: Effective July 1, 2024, CEN implemented Ramp, an expense management platform that ensures all purchases are documented with proper receipts before being charged to the grant. This solution directly addresses the issue of missing itemized receipts and ensures compliance with federal grant requirements. Steps Implemented: • Mandatory Receipt Submission: All purchases, including restaurant transactions, require an itemized receipt to be uploaded into Ramp before the expense can be approved. • Approval Before Grant Charging: An approver must review the itemized receipt to verify that no prohibited items were purchased before allowing the expense to be charged to the grant. • Grant Compliance Review: If an itemized receipt is not provided or contains unallowable expenses, the charge will not be allocated to the grant and must be covered by a non-grant funding source. • Training & Compliance: All employees who make purchases with grant funds have been trained on the requirement for itemized receipts and the consequences of non-compliance. Responsible Party: Kendall Guynes, CFO Completion Date: July 1, 2024 (Fully Implemented) Parties Responsible: Chief Executive Officer President Chief Financial Officer Business Manager The Corrective Action Plan is currently in place and was implemented on July 1, 2024.
Finding 2024-001: Allowable costs and activities – material weakness in internal controls over compliance and compliance finding. Management Response Finding: Lack of Documented Approval for Purchases. Corrective Action Taken: Effective July 1, 2024, CEN implemented Ramp, an expense management platf...
Finding 2024-001: Allowable costs and activities – material weakness in internal controls over compliance and compliance finding. Management Response Finding: Lack of Documented Approval for Purchases. Corrective Action Taken: Effective July 1, 2024, CEN implemented Ramp, an expense management platform that ensures all purchases are documented and approved before processing. Ramp provides an automated and auditable approval workflow, ensuring compliance with federal grant requirements. Steps Implemented: • Centralized Purchasing System: All purchases are now made within Ramp using a Ramp credit card, ensuring complete oversight and control over spending. • Automated Approval Workflow: Each purchase requires approval within Ramp, and approvals are documented digitally, creating an auditable trail. • Receipt Verification: Every purchase must include a receipt, which the approver reviews before granting final approval. • Grant Compliance Review: Any charges that do not meet grant requirements are not charged to the grant and are instead assigned to an appropriate non-grant funding source. • Training & Compliance: All relevant staff members have been trained on Ramp’s approval and compliance procedures to ensure adherence to purchasing protocols. Responsible Party: Kendall Guynes, CFO Completion Date: July 1, 2024 (Fully Implemented)
Management is cognizant of this limitation and will implement additional procedures where possible.
Management is cognizant of this limitation and will implement additional procedures where possible.
Finding 530119 (2024-001)
Significant Deficiency 2024
Management acknowledges the auditor’s finding and agrees with the recommendation. The Organization has developed a Corrective Action Plan to ensure compliance with procurement regulations and strengthen internal controls. This plan outlines specific steps to prevent future occurrences and maintain a...
Management acknowledges the auditor’s finding and agrees with the recommendation. The Organization has developed a Corrective Action Plan to ensure compliance with procurement regulations and strengthen internal controls. This plan outlines specific steps to prevent future occurrences and maintain adherence to federal requirements. The Finance Committee has thoroughly reviewed this finding, and the Board of Directors has subsequently approved the audit, the Organization’s response, and the Corrective Action Plan. Regarding the finding, the Organization paid the amount agreed upon during contract negotiations. The issue identified pertains to the billing methodology rather than the appropriateness of the cost itself. The cost-plus method is a common practice in our geographical area, and the overall project cost was determined to be fair and consistent with industry standards. Moving forward, the Organization is implementing additional internal review procedures to ensure compliance with all federal procurement requirements.
View Audit 348173 Questioned Costs: $1
Finding Reference Number: 2024-001 Description of Finding: Inaccurate effective dates for unofficial withdrawals according to NSLDS enrollment reporting requirements Statement of Concurrence or Nonconcurrence: We agree with the finding. Corrective Action: Miles Community College will take corr...
Finding Reference Number: 2024-001 Description of Finding: Inaccurate effective dates for unofficial withdrawals according to NSLDS enrollment reporting requirements Statement of Concurrence or Nonconcurrence: We agree with the finding. Corrective Action: Miles Community College will take corrective action, by adding to our end of term SAP processing the step of updating National Student Clearinghouse with last date of attendance according to the grade roster from the instructor. This will be done prior to the processing of the R2T4’s. Name of Contact Person: Danielle Dinges, Director of Financial Aid & Admissions, 406-874-6182, dingesd@milescc.edu Projected Completion Date: As this is an action that needs to be completed at the end of each term, it will be completed in December, May and July/August.
The District has developed and implemented internal control policies to ensure compliance with the Davis-Bacon Act any time the District is expending Federals awards. The District will post all required work site posters concerning prevailing wage rates and review and examine weekly payroll reports...
The District has developed and implemented internal control policies to ensure compliance with the Davis-Bacon Act any time the District is expending Federals awards. The District will post all required work site posters concerning prevailing wage rates and review and examine weekly payroll reports from contractors or subcontractors.
Finding 530079 (2024-002)
Significant Deficiency 2024
Lacasa
MI
The Organization concurs with the finding and has already begun the process of developing a method of allocating shelter and hotline staff based on actual services provided and implementing regular training sessions for all staff involved in grant funded programs. Anticipated completion date is June...
The Organization concurs with the finding and has already begun the process of developing a method of allocating shelter and hotline staff based on actual services provided and implementing regular training sessions for all staff involved in grant funded programs. Anticipated completion date is June 30, 2025.
Program: AL 21.023 – COVID-19 Emergency Rental Assistance – Reporting Corrective Action Plan: On February 3, 2025, the vendor system report was corrected. A review of summary AMI data will be reconciled to detailed data to ensure subsequent reports are correct. Contact: Philip Olsen – DAS Acc...
Program: AL 21.023 – COVID-19 Emergency Rental Assistance – Reporting Corrective Action Plan: On February 3, 2025, the vendor system report was corrected. A review of summary AMI data will be reconciled to detailed data to ensure subsequent reports are correct. Contact: Philip Olsen – DAS Accounting Administrator Anticipated Completion Date: February 2, 2025
Finding 530061 (2024-064)
Significant Deficiency 2024
Program: AL 17.225 – Unemployment Insurance (UI) – State – Special Tests Corrective Action Plan: Work with vendor to implement system changes needed. Continuous process improvement of adjudication is ongoing. Contact: Andi Bridgmon Anticipated Completion Date: December 2025
Program: AL 17.225 – Unemployment Insurance (UI) – State – Special Tests Corrective Action Plan: Work with vendor to implement system changes needed. Continuous process improvement of adjudication is ongoing. Contact: Andi Bridgmon Anticipated Completion Date: December 2025
Program: AL 17.225 – Unemployment Insurance (UI) – State – Reporting Corrective Action Plan: NDOL has reviewed the federal directions associated with the report in question and has an increased understanding of the report requirements. NDOL has developed a better understanding of reports related...
Program: AL 17.225 – Unemployment Insurance (UI) – State – Reporting Corrective Action Plan: NDOL has reviewed the federal directions associated with the report in question and has an increased understanding of the report requirements. NDOL has developed a better understanding of reports related to benefits paid, reissued, cancelled, and recouped. NDOL can reconcile the timing of benefits drawn, benefits paid, benefits failed, benefits reissued to that activity in bank statements. NDOL is developing a reconciliation process for the timing of recouped benefits, and that activity on bank statements. NDOL will be able to accurately report benefits paid by relevant source, netted for any cancelled or recouped amounts in accordance with reporting guidelines, and directly traceable to supporting documentation. Contact: Rea Easton Anticipated Completion Date: September 2025
Program: AL 97.036 – Disaster Grants – Public Assistance (Presidentially Declared Disasters) – Subrecipient Monitoring Corrective Action Plan: NEMA has implemented a process, effective immediately, to review the information submitted by subrecipient organizations regarding their 2 CFR Single Audi...
Program: AL 97.036 – Disaster Grants – Public Assistance (Presidentially Declared Disasters) – Subrecipient Monitoring Corrective Action Plan: NEMA has implemented a process, effective immediately, to review the information submitted by subrecipient organizations regarding their 2 CFR Single Audit Certification. Responses will be cross-referenced with our own records of Federal funds passed through NEMA to the subrecipient. Any subrecipient responding that it was not required to conduct a single audit will prompt NEMA to validate against payment data. Any subrecipient’s noncompliance will be followed up by NEMA staff. Contact: Erv Portis Anticipated Completion Date: February 11, 2025
Program: AL 93.778 – Medical Assistance Program – Special Tests and Provisions Corrective Action Plan: Program Integrity staff will continue to attempt to update cases at least every 30 days when case totals are at or below 25 and every 45 days when higher than 25. Trainings and regular conversa...
Program: AL 93.778 – Medical Assistance Program – Special Tests and Provisions Corrective Action Plan: Program Integrity staff will continue to attempt to update cases at least every 30 days when case totals are at or below 25 and every 45 days when higher than 25. Trainings and regular conversations emphasize the need for descriptive narrative entries. As a result, the narrative entries will be more descriptive of the status of the case. For the exception reporting, the team continues to work on developing alternatives to using the reports in the Fraud Abuse Detection System. Concerning the misreported check, Program Integrity staff will give the Financial Team accurate information about collected refunds. The Department will ensure reports are accurate and make any necessary adjustments. Contact: Anne Harvey, Heather Arnold Anticipated Completion Date: 6/30/2025
View Audit 348113 Questioned Costs: $1
Finding 530048 (2024-054)
Significant Deficiency 2024
Program: AL 93.778 – Medical Assistance Program – Special Tests and Provisions Corrective Action Plan: The Department updated procedures in July 2024 to obtain General Ledger data from nursing facilities with their FY2024 Cost Report. Additionally, the Department is expanding testing for large c...
Program: AL 93.778 – Medical Assistance Program – Special Tests and Provisions Corrective Action Plan: The Department updated procedures in July 2024 to obtain General Ledger data from nursing facilities with their FY2024 Cost Report. Additionally, the Department is expanding testing for large cost variances and will request additional substantiating documentation from the impacted nursing facilities. Contact: Jerry Vanderbeek Anticipated Completion Date: 3/31/2025
View Audit 348113 Questioned Costs: $1
Finding 530047 (2024-053)
Significant Deficiency 2024
Program: AL 93.778 – Medical Assistance Program; AL 93.778 – COVID-19 Medical Assistance Program – Allowability Corrective Action Plan: The Department has been actively working with program, technology, and the EVV vendor to implement system controls to address the deficiencies identified in this...
Program: AL 93.778 – Medical Assistance Program; AL 93.778 – COVID-19 Medical Assistance Program – Allowability Corrective Action Plan: The Department has been actively working with program, technology, and the EVV vendor to implement system controls to address the deficiencies identified in this and prior year’s findings. The Department has two system change releases scheduled, the first in February 2025 and the second in late June 2025 to implement additional system improvements. Contact: Jeremy Brunssen Anticipated Completion Date: 7/1/2025
View Audit 348113 Questioned Costs: $1
Program: AL 93.778 – Medical Assistance Program; AL 93.767 – Children’s Health Insurance Program (CHIP) – Special Tests and Provisions Corrective Action Plan: The corrective action has already been completed. MCO contracts were amended, effective with the contract period beginning January 1, 2024...
Program: AL 93.778 – Medical Assistance Program; AL 93.767 – Children’s Health Insurance Program (CHIP) – Special Tests and Provisions Corrective Action Plan: The corrective action has already been completed. MCO contracts were amended, effective with the contract period beginning January 1, 2024, to include provision(s) which require audited financial reports with GAAP. Contact: Jeremy Brunssen Anticipated Completion Date: 12/6/2024
View Audit 348113 Questioned Costs: $1
Finding 530034 (2024-051)
Significant Deficiency 2024
Program: AL 93.659 – Adoption Assistance – Allowability & Eligibility Corrective Action Plan: Resource Developers (RD) will increase initial and annual billing trainings with child care subsidy providers and assist them with any billing needs they have. Contact: Bryan Gilliland Anticipated Com...
Program: AL 93.659 – Adoption Assistance – Allowability & Eligibility Corrective Action Plan: Resource Developers (RD) will increase initial and annual billing trainings with child care subsidy providers and assist them with any billing needs they have. Contact: Bryan Gilliland Anticipated Completion Date: 06/30/2025
View Audit 348113 Questioned Costs: $1
Finding 530030 (2024-050)
Significant Deficiency 2024
Program: AL 93.658 – Foster Care Title IV-E; AL 93.658 – COVID-19 Foster Care Tile IV-E – Allowability & Eligibility Corrective Action Plan: Resource Developers (RD) will increase initial and annual billing trainings with child care subsidy providers and assist them with any billing needs they ha...
Program: AL 93.658 – Foster Care Title IV-E; AL 93.658 – COVID-19 Foster Care Tile IV-E – Allowability & Eligibility Corrective Action Plan: Resource Developers (RD) will increase initial and annual billing trainings with child care subsidy providers and assist them with any billing needs they have. Contact: Bryan Gilliland Anticipated Completion Date: 06/30/2025
View Audit 348113 Questioned Costs: $1
Finding 530029 (2024-049)
Significant Deficiency 2024
Program: AL 93.658 – Foster Care Title IV-E – Allowability Corrective Action Plan: The agency will update the grant reconciliation process to include steps to review journal entries on the general ledger prior to moving costs to grant to ensure journal entries are proper. The cost in question wi...
Program: AL 93.658 – Foster Care Title IV-E – Allowability Corrective Action Plan: The agency will update the grant reconciliation process to include steps to review journal entries on the general ledger prior to moving costs to grant to ensure journal entries are proper. The cost in question will also be removed from the grant. Contact: Ann Murphy Anticipated Completion Date: 02/28/2025
View Audit 348113 Questioned Costs: $1
Program: AL 93.575 – COVID-19 Child Care and Development Block Grant – Period of Performance Corrective Action Plan: The Agency will work with Federal Partners to determine allowability of these claims. Contact: Heather Arnold Anticipated Completion Date: 6/30/2025
Program: AL 93.575 – COVID-19 Child Care and Development Block Grant – Period of Performance Corrective Action Plan: The Agency will work with Federal Partners to determine allowability of these claims. Contact: Heather Arnold Anticipated Completion Date: 6/30/2025
View Audit 348113 Questioned Costs: $1
Finding 530020 (2024-046)
Significant Deficiency 2024
Program: AL 93.575 and 93.596 – CCDF Cluster – Special Tests and Provisions Corrective Action Plan: An inspection of the Family Child Care Home I license was completed for 2024 on December 13, 2024. The following procedure will be followed in cases in which Children’s Services Licensing inspecto...
Program: AL 93.575 and 93.596 – CCDF Cluster – Special Tests and Provisions Corrective Action Plan: An inspection of the Family Child Care Home I license was completed for 2024 on December 13, 2024. The following procedure will be followed in cases in which Children’s Services Licensing inspectors are unable to conduct an inspection of a licensed provider. Whenever a Child Care Inspection Specialist (CCIS) attempts to conduct a Provisional to Operating, annual, or semi-annual inspection to a Family Child Care Home I or II, Child Care Center, School Age Only Center, or Preschool and the child care/preschool facility is not open, the CCIS must follow this procedure. CCIS will: • Leave his/her business card in/on/under the door of the child care program • Before leaving the child care facility, call the licensee and leave a message asking the licensee to contact the CCIS within five (5) working days • If no contact from the licensee within five working days, send a letter or email giving the licensee fifteen calendar days from date of letter/email before further action is initiated. Copy Child Care Licensing Supervisor (CCLS) on letter. • Inform CCL Supervisor if no contact from licensee after fifteen calendar days from date of letter. • If licensee contacts CCIS within five working days of attempt to conduct inspection, or within fifteen calendar days from date of letter, CCIS identifies days/times in the following weeks the licensee will be available to conduct an unannounced inspection and conducts the inspection. • If the licensee does NOT contact CCIS within fifteen calendar days of the date of the letter, Children’s Services Licensing will pursue a Disciplinary Notice of Suspension of the license. The licensee will have fifteen business days to respond to the Notice of Suspension prior to the Suspension becoming effective. The Notice of Suspension will be withdrawn if the licensee: 1. Contacts the Department prior to the effective date of the Suspension; 2. Explains why s/he did not respond to the phone call and letter; 3. Agrees to an unannounced inspection; and 4. Is available when the CCIS conducts the inspection. When the licensee does not contact the Department in time for an inspection to be conducted prior to the effective date of the suspension, the licensee should be advised to appeal the Notice of Suspension. When the licensee does not contact the Department until after the effective date of the suspension and does not appeal, the license will be suspended. Through the SFM, DHHS will have further communication with the delegated authorities to clarify the expectations and timeframes for fire inspections in child care programs. Through the Nebraska Department of Environment and Energy (NDEE) Agency, DHHS will have further communication with the delegated authorities to clarify the expectations and timeframes for sanitation inspections in child care programs. DHHS will continue to implement policies and procedures for file reviews by CCSL and fire and sanitation inspection referrals. DHHS will continue to complete the statutory child care inspection requirements. DHHS continue to explore statutory, regulatory and/or contract options to place more accountability on the licensee and referred agencies for maintaining current fire and sanitation approvals. In 2025, DHHS will continue to communicate with SFM, NDEE, and delegated authorities regarding expectations and timeframes for fire and sanitation inspections. DHHS Child Care Inspection Specialists conduct inspections that occur annually at a minimum and which address regulatory requirements that address a healthy and safe child care environment. If serious fire and sanitation concerns are observed at any inspection that may endanger the health and safety of children in care, DHHS will work with the appropriate authority to request an immediate inspection. SFM, NDEE, or delegated authorities always respond timely to these requests. DHHS is establishing quarterly meetings with SFM, NDEE, and delegated authorities to review overdue routine inspections, address issues, and collaborate on best practices. Quarterly meetings have been established with NDEE as of January 2025. DHHS will have a Program Specialist create a report specifically for tracking overdue fire and sanitation inspections by the months they have been overdue, which will allow SFM, NDEE, and delegated authorities to prioritize those outstanding routine inspections. DHHS will explore entering into a contract with SFM, NDEE and delegated authorities to pay for timely fire and sanitation inspections and services contingent on available funding. Contact: Matthew Hayden; Lindsy Braddock Anticipated Completion Date: 7/1/2025
View Audit 348113 Questioned Costs: $1
Program: AL 84.425U – COVID-19 Education Stabilization Fund – American Rescue Plan – Elementary and Secondary School Emergency Relief Fund (ARP ESSER) – Reporting Corrective Action Plan: The Federal government is overhauling the FFATA reporting process completely so NDE is working to train on the...
Program: AL 84.425U – COVID-19 Education Stabilization Fund – American Rescue Plan – Elementary and Secondary School Emergency Relief Fund (ARP ESSER) – Reporting Corrective Action Plan: The Federal government is overhauling the FFATA reporting process completely so NDE is working to train on the new process to ensure that all required subawards are reported going forward. Contact: Lane Carr Anticipated Completion Date: June 2025
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