Corrective Action Plans

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Action Taken: We will implement internal controls to follow up with the Fee accountant at FYE to be certain they are preparing materials in accordance with Generally Accepted Accounting Principles (GAAP). Anticipated Date of Resolution: This finding will be corrected with the next financial data ...
Action Taken: We will implement internal controls to follow up with the Fee accountant at FYE to be certain they are preparing materials in accordance with Generally Accepted Accounting Principles (GAAP). Anticipated Date of Resolution: This finding will be corrected with the next financial data schedule submission. Individual Responsible: DawnEna Davidson, Executive Director.
Views of Responsible Officials and Planned Corrective Action: Quincy Asian Resources, Inc. agrees with the finding and will implement policies and procedures to draw down Federal funds only for its immediate Federal program cash needs.
Views of Responsible Officials and Planned Corrective Action: Quincy Asian Resources, Inc. agrees with the finding and will implement policies and procedures to draw down Federal funds only for its immediate Federal program cash needs.
Views of Responsible Officials and Planned Corrective Action: While Quincy Asian Resources, Inc. concurs with the ultimate outcome identified in the finding, we want to emphasize our review indicates all transactions were handled with appropriate intent. The identified adjustments were primarily due...
Views of Responsible Officials and Planned Corrective Action: While Quincy Asian Resources, Inc. concurs with the ultimate outcome identified in the finding, we want to emphasize our review indicates all transactions were handled with appropriate intent. The identified adjustments were primarily due to timing of personnel transitions on our accounting department. To further strengthen our financial reporting processes, we have subsequently hired a new controller with extensive nonprofit accounting experience. This addition to our team will help ensure continued accuracy in financial reporting while maintaining strong internal controls.
Finding 2024-004 - Procurement (Material Weakness) CFDA Title and Number: 20.526 Grants for Buses and Bus Facilities Formula Program Name of Federal Agency: Department of Transportation Internal Control over Compliance: Procurement CFDA Title and Number: 20.513 (5310) Enhanced Mobility of Seniors ...
Finding 2024-004 - Procurement (Material Weakness) CFDA Title and Number: 20.526 Grants for Buses and Bus Facilities Formula Program Name of Federal Agency: Department of Transportation Internal Control over Compliance: Procurement CFDA Title and Number: 20.513 (5310) Enhanced Mobility of Seniors & Individuals with Disabilities. Name of Federal Agency: Department of Transportation Internal Control over Compliance: Procurement CFDA Title and Number: 20.509 (5311) Operating Assistance. Formula Grants for Rural. Name of Federal Agency: Department of Transportation Internal Control over Compliance: Procurement Criteria: 2 CFR Part 200.318(a-k) Numerous procurement regulations exist requiring federal grant awardees to develop and implement internal control policies and procedures related to procurement activities. Condition: The District made expenditures and engaged in contracts without following relevant procurement requirements. Cause: Management lacked awareness of relevant procurement regulations. Consequently, no internal control policies or procedures related to procurement existed, or policies and procedures existed but were not implemented. Effect or Potential Effect: The lack of effective internal controls over procurement activities allowed for widespread deficiencies and noncompliant activities, which resulted in the District’s revocation of one award. Questioned Cost: No Context: Without proper procurement policies and procedures, the risk of compliance requirement violations is significant. The District failed to meet numerous procurement requirements throughout the year, and ultimately lost a significant award for bus acquisitions. Repeat of a Prior-Year Finding: No Recommendation: The District should design and implement internal controls related to procurement regulations that will reduce the risk that the District’s procurement activities are not in compliance with federal regulations. District's Response: The District acknowledges the weaknesses and its intention of correcting weaknesses. Corrective Action Plan: The District’s shall design and implement, or revise, policies and procedures for meeting procurement compliance requirements. The District will work with ODOT to ensure compliance. The new procurement policy must include not only policies for procurements, but also for documentation of solicitations, contracts activities. Planned Implementation Date: October 31, 2024 Responsible Persons: District Board, Umpqua Public Transit District
Finding 547981 (2024-003)
Significant Deficiency 2024
Management response: • Nuestra Escuela’s Program Director will adopt automated data collection software to ensure the timely availability of participants information, thereby preventing delays in report submission. • Nuestra Escuela will enhance its internal controls to ensure adherence to all req...
Management response: • Nuestra Escuela’s Program Director will adopt automated data collection software to ensure the timely availability of participants information, thereby preventing delays in report submission. • Nuestra Escuela will enhance its internal controls to ensure adherence to all required reporting deadlines, promoting timely and accurate submissions under the TANF program strengthen internal controls to ensure the compliance with the reporting. • Nuestra Escuela will conduct regular audits to verify data accuracy, maintaining open and consistent communication with all relevant parties to address potential reporting bottlenecks. • Nuestra Escuela Management staff will receive specialized training on participant qualification and proper requirements and efficient time management practices to improve reporting compliance. • The Executive President will develop and implement a contingency plan to address unforeseen circumstances that could otherwise hinder timely submission of reports. Corrective action plan: Action Date of Compliance Involved areas Adopt automated data collection software Jun 25 - 2025 Executive President Program Director Schedule of internal monitoring for compliance with Special Conditions Monthly Program Director Specialized training on participant qualification and proper requirements May 22 - 2025 External Consultant Program Director Directors in charge of Programs Develop a contingency plan to address unforeseen circumstances Apr 10 - 2025 Executive President External Consultant Actions to complete monthly: ● Internal monitoring by the Program Director with the automated data collection software. ● Meeting between the Program Director and the Directors of each of the Programs to validate the correct status of the reports. Actions to complete quarterly: ● Meeting between the Program Director and the Executive President for a physical review of the files. Contact Person: Ana Yris Guzmán – Executive President|
Finding 547968 (2024-002)
Significant Deficiency 2024
Management response: • Nuestra Escuela will design and implement internal controls specifically addressing the accounting of conditional advances. These controls will include developing a clear rubric to assess whether grants and contracts meet the criteria for conditional contributions under ASU 2...
Management response: • Nuestra Escuela will design and implement internal controls specifically addressing the accounting of conditional advances. These controls will include developing a clear rubric to assess whether grants and contracts meet the criteria for conditional contributions under ASU 2018-08. • The accounting staff will undergo specialized training on the proper recognition of conditional advances. Regular reviews will be conducted to ensure ongoing compliance with ASU 2018-08 and to maintain accurate financial reporting. • Recognizing the need to meet both agency (cash basis) and GAAP (accrual basis), Nuestra Escuela will prepare management reports on both bases. This approach will facilitate accurate grant reporting while ensuring compliance with generally accepted accounting principles. Corrective action plan: Action Date of Compliance Involved areas Developing a clear rubric to assess whether grants and contracts meet the criteria for conditional contributions under ASU 2018-08. Apr 21 - 2025 External Consultant Executive President Administrative Director Directors in charge of Programs Create a “Model reports” on both bases, to use monthly. Monthly Executive President Administrative Director Specialized training on the proper recognition of conditional advances. Jun 10 - 2025 External Consultant Executive President Administrative Director Directors in charge of Programs Actions to complete monthly: • To prepare management reports on both bases Actions to complete quarterly: • Use the rubric to assess whether grants and contracts meet the criteria for conditional contributions under ASU 2018-08. Contact Person: Ana Yris Guzmán – Executive President
Finding 547967 (2024-001)
Significant Deficiency 2024
Management response: • Nuestra Escuela will strengthen its processes to ensure that all grants and accrued expenses are recorded promptly and that services rendered are accounted for in the correct period accurately. • The Administrative Director will perform regular reconciliations of accounts to...
Management response: • Nuestra Escuela will strengthen its processes to ensure that all grants and accrued expenses are recorded promptly and that services rendered are accounted for in the correct period accurately. • The Administrative Director will perform regular reconciliations of accounts to detect, identify, and correct, any discrepancies that may indicate cut-off errors. • The administrative staff and accounting team will receive additional training on the best practices and proper cut-off procedures, emphasizing the importance of timely and accurate recognition of liabilities and receivables and the impact of errors on financial reporting. • Nuestra Escuela will reinforce its internal audit processes to periodically review compliance with cut-off procedures. This practice will involve analyzing the impact of contractual clauses on the period of receipt and use of funds. • Nuestra Escuela will Create documentation of its cut-off policies and procedures to ensure consistent application and understanding among all relevant staff and ensure that they are strictly enforced. • Nuestra Escuela is committed to preventing cut-off errors through a proactive approach from accountants. This involves a combination of robust procedures, leveraging technology, and fostering a culture of accuracy and compliance within the accounting department. By following these best practices, accountants can help ensure the integrity of the financial reporting process. Corrective action plan: Action Date of Compliance Involved areas Reconciliations of each account to identify any discrepancies that may indicate cut-off errors. Monthly Executive President Administrative Director Analyze the impact of contractual clauses on the period of receipt and use of funds. Apr 15 – 2025 Jul 15 -2025 Oct 15 – 2025 Ene 15 - 2026 Executive President Administrative Director Training on the best practices and proper cut-off procedures May 8 - 2025 External Consultant Executive President Administrative Director Directors in charge of Programs Complete file with cut-off policies and procedures Jun 20 - 2025 Administrative Director Directors in charge of Programs   Actions to complete monthly: • Reconciliations of each account to identify any discrepancies that may indicate cut-off errors. Actions to complete quarterly: • Analyze the impact of contractual clauses on the period of receipt and use of funds. • Training on the best practices and proper cut-off procedures • Complete file with cut-off policies and procedures Contact Person: Ana Yris Guzmán – Executive President
Reference Number: 2024-001 Name of Contact Person: Kelly Nakamura Phone: 530-642-7167 Email: Kelly.nakamura@edcgov.us Corrective Action: • Increasing Staffing Levels: o By April 1, 2025, the County will have 11 newly trained Eligibility Specialists who are fully trained to proces...
Reference Number: 2024-001 Name of Contact Person: Kelly Nakamura Phone: 530-642-7167 Email: Kelly.nakamura@edcgov.us Corrective Action: • Increasing Staffing Levels: o By April 1, 2025, the County will have 11 newly trained Eligibility Specialists who are fully trained to process Medi-Cal applications. o Ongoing recruitment efforts will continue to fill vacant positions, including the hiring additional trainees to build capacity for timely eligibility determinations. • Improving Internal Processes: o The County is conducting a review of workflows to identify inefficiencies and implement streamlined processes that eliminate bottlenecks. o Digital tools and automation are being introduced to enhance efficiency and accuracy case processing. • Providing Additional Support: o Overtime opportunities are being offered to eligibility specialists to expedite the processing of pending cases. o Applications are being assigned to Eligibility Specialists on a weekly basis to ensure consistent progress in reducing the backlog. • Enhancing Monitoring and Reporting: o Administrative staff are generating weekly reports from CalSAWS to track the status Medi-Cal pending applications and monitor progress. o Weekly meetings are being held with supervisors to review performance, discuss challenges, and adjust strategies as needed. • Strengthening Internal Controls: o The County is improving its internal controls to prevent future delays, including increased use of system reports to identify applications nearing the 45-day processing requirement, regular audits of the eligibility determination process and enhanced compliance training for staff. • Ongoing Evaluation and Adaptation: o Progress will be assessed weekly to ensure the implemented measures are effective. Adjustments will be made as needed to maintain compliance with the 45-day requirement. Proposed Completion Date: The county has already implemented this process and expects it to be completed by July 31, 2026.
We gave instructions to the Finance Department Director to strengthen internal procedures and controls to ensure accurate preparation and submission of financial reports within the required timeframe. Implementation Date: April 1, 2025. Responsible Person: Mrs. Rosa J. La Torre Santiago, Executive...
We gave instructions to the Finance Department Director to strengthen internal procedures and controls to ensure accurate preparation and submission of financial reports within the required timeframe. Implementation Date: April 1, 2025. Responsible Person: Mrs. Rosa J. La Torre Santiago, Executive Director
CCS discovered this and self-reported it to the appropriate agencies. The former employee mentioned and his immediate supervisor were terminated by CCS immediately upon its discovery of the conflict of interest and not following CCS’s procurement procedures. CCS refined its Conflict-of-Interest an...
CCS discovered this and self-reported it to the appropriate agencies. The former employee mentioned and his immediate supervisor were terminated by CCS immediately upon its discovery of the conflict of interest and not following CCS’s procurement procedures. CCS refined its Conflict-of-Interest and Procurement procedures. Conflict-of-Interest and procurement policy training sessions were conducted with all levels of staff and will continue to be conducted on a recurring basis. CCS is implementing additional layers of oversight and compliance monitoring. This is the responsibility of the CCS Chief Financial Officer. CCS is committed to continuous improvement, conducting regular internal audits and reviews to verify adherence to federal procurement standards. This is the responsibility of the CCS Revenue Cycle Manager. We are working to ensure that every vendor has a contract on file and all procurement policies are strictly followed. This is the responsibility of the CCS Controller and is expected to be completed by June 30, 2025.
FINDING 2024-004 – Reporting; Material Weakness in Internal Control over Compliance and Instance of Material Noncompliance Views of responsible officials and planned corrective actions: Management agrees with the assessment and has implemented corrective action. The Organization has implemented a re...
FINDING 2024-004 – Reporting; Material Weakness in Internal Control over Compliance and Instance of Material Noncompliance Views of responsible officials and planned corrective actions: Management agrees with the assessment and has implemented corrective action. The Organization has implemented a review and documentation control surrounding the timely submission of all financial reports, special reports, and performance reports. Reports required by contract must be submitted timely and must have two levels of documented review. All financial reports required by contract must have a documented review by a member of the fiscal department. Additionally, report backup and proof of timely submission must be retained. Contact Persons: Ryan Berendsen, Chief Operating Officer Delana Kromer, Controller
FINDING 2024-003 – Reporting; Significant Deficiency in Internal Control over Compliance Views of responsible officials and planned corrective actions: Management agrees with the assessment and has implemented corrective action. The Organization has implemented a review and documentation control sur...
FINDING 2024-003 – Reporting; Significant Deficiency in Internal Control over Compliance Views of responsible officials and planned corrective actions: Management agrees with the assessment and has implemented corrective action. The Organization has implemented a review and documentation control surrounding the timely submission of all financial reports, special reports, and performance reports. Reports required by contract must be submited timely and must have two levels of documented review. All financial reports required by contract must have a documented review by a member of the fiscal department. Additionally, report backup and proof of timely submission must be retained. Contact Persons: Ryan Berendsen, Chief Operating Officer Delana Kromer, Controller
We appreciate the audit team’s diligence and acknowledge the reporting finding. This appears to reflect a difference in interpretation around when “final adjustments” to Weatherization Assistance Program contracts may occur. Based on our longstanding experience with the program and past guidance, we...
We appreciate the audit team’s diligence and acknowledge the reporting finding. This appears to reflect a difference in interpretation around when “final adjustments” to Weatherization Assistance Program contracts may occur. Based on our longstanding experience with the program and past guidance, we understood that adjustments could be made within the active contract period and up to 60 days after contract closeout. In this case, NWBCCC made an adjustment in 2024 to an active multi-year contract with a September 2025 end date, which we believed to be within allowable guidelines. However, based on the auditor’s definition of “final adjustment”, which is that every monthly voucher is a final adjustment, our action resulted in a finding. Going forward as a corrective measure, NWBCCC will treat each monthly voucher as a final submission for that period and enhance internal review processes to avoid retroactive changes. Where adjustments are necessary, we will coordinate with HCR to ensure proper documentation and compliance.
2024-010 Program: Disaster Grants – Public Assistance (Presidentially Declared Disasters) Federal Financial Assistance Listing Number: 97.036 Federal Grantor: U.S. Department of Homeland Security Pass Through: California Office of Emergency Services Award No. and Year: 059-00000 and 2019 Compliance ...
2024-010 Program: Disaster Grants – Public Assistance (Presidentially Declared Disasters) Federal Financial Assistance Listing Number: 97.036 Federal Grantor: U.S. Department of Homeland Security Pass Through: California Office of Emergency Services Award No. and Year: 059-00000 and 2019 Compliance Requirements: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance Criteria: 2 CFR Section 200.303(a), Internal Controls, states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Condition: For two (2) out of three (3) project application summary reports tested, the OCPW did not retain evidence to document the individual who reviewed and approved the required reports. Cause: The department’s procedures did not include documenting the review and approval of the reports prior to submission. Effect: Ineffective controls over this area of compliance could result in reports that are inaccurate or incomplete being submitted or disclosed to the granting agency. Questioned Costs: No questioned costs were identified as a result of our audit procedures. Context/Sampling: A non-statistical sample of three (3) of nine (9) Grant Project Application Summary Reports were selecting for testing. The condition above was identified during our procedures over reporting testing. Repeat Finding: No. Recommendation: We recommend the OCPW department revise its procedures to include evidence to document the individual who reviewed and approved required reports prior to submission. Management Response and Corrective Action: 1. Person Responsible: • FEMA Public Assistance Grants Coordinator – Responsible for completing reports, uploading documents to the FEMA Grants Portal, and ensuring accurate records. • OCPW Emergency Manager Responsible for reviewing, approving, and submitting project applications. 2. Corrective Action Plan: • Revised Procedures for Review and Approval: i. The FEMA Public Assistance Grants Coordinator will be responsible for completing the Project Application Summary Reports. ii. Upon completion, the Grants Coordinator will upload all supporting documents into the FEMA Grants Portal. The system automatically timestamps each document and records the name of the individual who uploaded it, ensuring clear documentation of the review process. iii. After all required documents are uploaded, the OCPW Emergency Manager will be notified that the project application is ready for review. iv. The OCPW Emergency Manager will then: 1. Review the submitted documents in the FEMA Grants Portal. 2. Confirm that the reported costs align with the information provided by the reporting County agency. 3. Approve and submit the project application to Cal OES and FEMA for project approval. • Retention of Documentation: i. The FEMA Grants Portal serves as the official system of record, ensuring all uploaded documents are timestamped and traceable. ii. All project application approvals, cost documentation, and required forms will be retained electronically within the system for audit and compliance purposes. • Training and Implementation: i. Staff responsible for grant reporting will receive training on the revised process, including proper document upload procedures and compliance expectations. ii. The updated process will be implemented immediately. • Monitoring and Compliance: i. The OCPW Emergency Manager will conduct semiannual internal reviews of project applications to ensure compliance with the updated procedures. ii. Any issues identified during internal reviews will be addressed through additional staff training and process improvements. 3. Anticipated Implementation date: Immediate, March 18, 2025 • Staff Training: Within 30 days • Semiannual Compliance Review: Beginning next quarter i. First review will take place May 1, 2025. Followed by another review in October 2025.
2024-008 Program: Medicaid Cluster Federal Financial Assistance Listing Number: 93.778 Federal Grantor: U.S. Department of Health and Human Services Pass-Through: California Department of Health Care Services Award No. and Year: Various Compliance Requirements: Eligibility Type of Finding: Significa...
2024-008 Program: Medicaid Cluster Federal Financial Assistance Listing Number: 93.778 Federal Grantor: U.S. Department of Health and Human Services Pass-Through: California Department of Health Care Services Award No. and Year: Various Compliance Requirements: Eligibility Type of Finding: Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance Criteria: Title 42 Chapter IV Subchapter C Part 435 Subpart J Section 435.916, Regularly Scheduled Renewals of Medicaid Eligibility, states that the agency must renew MAGI-based determination of eligibility once every 12 months and no more frequently than once every 12 months. For non- MAGI beneficiaries, entities must renew eligibility at least once every 12 months. Condition: During our testing of the Social Service Agency’s (SSA) provisions for eligibility requirements, we noted that for one (1) of sixty (60) samples tested the department did not suspend, or pause, program eligibility despite being over the income limit for MAGI. Cause: The SSA department did not ensure the department’s policies and procedures relating to eligibility determination were followed. We noted that when a participant is determined to be over the income limit for MAGI, the participant is placed on a “soft pause” until a determination of eligibility under non-MAGI or Covered California is made. The department had erroneously marked the application as complete rather than placing the account on “soft pause” which caused the case to auto-renew. Effect: The County’s control was not consistently followed which caused an inaccurate determination of eligibility. Questioned Costs: None noted. Context/Sampling: A non-statistical sample of sixty (60) out of all active program participants were selected for testing. The condition noted above was identified during our procedures related to eligibility. Repeat Finding: No. Recommendation: We recommend the SSA department adhere to their policies and procedures to ensure that participant eligibility determinations and redeterminations are performed accurately. Management Response and Corrective Action: 1. Person Responsible: Michael Ueda, Human Services Manager and Yesenia Zapien, Human Service Manager 2. Corrective Action Plan: SSA will add administrative controls to track cases in soft pause to ensure eligibility determinations and redeterminations are performed accurately. Additionally, staff will be reminded of the policy and procedures surrounding soft pause. 3. Anticipated Implementation date: May 2025
The District acknowledges the material correction of an error to the District’s financial statements. This situation occurred due to internal controls checks and balances having not been corrected or delegated appropriately. Current management has improved procedures related to the these checks and ...
The District acknowledges the material correction of an error to the District’s financial statements. This situation occurred due to internal controls checks and balances having not been corrected or delegated appropriately. Current management has improved procedures related to the these checks and balances by changing the signatures on accounts that exclude staff who write checks. Administrative action occurred at the November board meeting. The process is already complete and working for the internal controls of the district.
A. Comments on Findings and Recommendations: We concur with the auditor’s suggestions for reporting program personnel cost. B. Actions Taken or Planned: Management will continue to evaluate their controls with respect to current federal awards and requirements to insure accurate information capt...
A. Comments on Findings and Recommendations: We concur with the auditor’s suggestions for reporting program personnel cost. B. Actions Taken or Planned: Management will continue to evaluate their controls with respect to current federal awards and requirements to insure accurate information captured and reported. Anticipated completion date: Already implemented, ongoing Contact information for this finding: Michelle Walsh, 636-528-6117
Department of Health and Human Services TASC of Northwest Ohio respectfully submits the following corrective action plan for the year ended June 30, 2024. Audit period: July 1, 2023 to June 30, 2024 The findings from the schedule of findings and questioned costs are discussed below. The findings ...
Department of Health and Human Services TASC of Northwest Ohio respectfully submits the following corrective action plan for the year ended June 30, 2024. Audit period: July 1, 2023 to June 30, 2024 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FINANCIAL STATEMENT AUDIT None FINDINGS—FEDERAL AWARD PROGRAMS AUDITS SIGNIFICANT DEFICIENCY 2024-001 Improper controls over allocation of salaried employees time and effort. Recommendation: Implement strategy of using time and effort documentation in determining payroll costs charged to grants Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: TASC of Northwest Ohio will implement a policy that includes a lookback and reconciliation to time and effort recorded by salaried employees to ensure that time is accurately charged to grants. Name(s) of the contact person(s) responsible for corrective action: Jason Pollick, Executive Director Planned completion date for corrective action plan: January 31, 2025 If the Department of Health and Human Services has questions regarding this plan, please call Sonya Sparks at 419-242-9955.
Finding 547610 (2024-002)
Significant Deficiency 2024
2. Identifying Number: 2024-002: Enrollment Reporting Finding: During the course of our special tests and provisions, we identified 3 students from a sample of 25 where the number of days between the enrollment change and reporting to National Student Loan Data System (NSLDS) was not within the req...
2. Identifying Number: 2024-002: Enrollment Reporting Finding: During the course of our special tests and provisions, we identified 3 students from a sample of 25 where the number of days between the enrollment change and reporting to National Student Loan Data System (NSLDS) was not within the required 60 days. We also identified 3 students from our sample of 25 whose withdrawal date was reported as the day after the withdrawal began and 1 student whose withdrawal date was reported as the end of the semester in which the student was attending. We also identified 2 students from our sample of 25 who were reported as withdrawn instead of graduated. Corrective Action Taken or Planned: Actions Taken The University has already taken corrective action on this finding. The issues raised were addressed in the following ways: number of days between the enrollment change and reporting was not within the required 60 days Graduate File Corrections: We discovered (Fall 2023) an error in the reporting of graduates, despite timely reporting via Degree Verify. Upon this discovery, we met with the National Student Clearinghouse (NSC) to determine the cause of the issue and how to correct it. We learned that students with enrollment in more than one program, or where the program reported did not match the program on record with NSC, were not being properly processed with a G status via the Degree Verify submissions. We were informed that this is common for institutions where students may be enrolled in more than one program at a time. We were advised by NSC to submit a “Graduates only” file, in addition to the Degree Verify file submission. Upon discovering this, we submitted Graduates only files for branches 02, 03, 04, 05, 80, 82, 84, and 97, for all terms for 2020, 2021, 2022, and 2023 beginning in December 2023 and ending in April 2024. We worked through these submissions with NSC, and incorrect withdrawn statuses were corrected to graduated statuses. Antioch’s enrollment reporting process has been updated to include a monthly submission of a graduates only file in addition to degree verify file monthly submission. The University has experienced changes in staffing for personnel involved in enrollment reporting. The person previously in charge of Enrollment Reporting retired on 02/29/24. He was responsible for the enrollment reporting for the majority of this audit period, as well as the prior year. Antioch University hired a new Director of Records Administration with a primary responsibility for NSLDS reporting on 03/28/24. The University has implemented a comprehensive training plan, including improved documentation of procedures, increased clarity regarding the process for the necessity of error resolution, and a review of system processing to help reduce errors in reporting and increase efficiency. The review of current practice and improved procedures was in conjunction with consultants from AACRAO, NSC, Ellucian (the student information system company). Actions Planned The University plans for corrective action on this finding. This includes policy updates for withdrawal processing and implementation of internal audits. Withdraw date was reported as the day after the withdraw began. It has been the practice to process withdrawal requests in this way: When a student withdrawal is submitted, the notification date is considered the last date of active enrollment. The withdraw (W) status begins effective on the following date. This has not been raised as a finding in prior audits. This process will be updated (effective April 1, 2025) to follow 34 CFR 668.22(c). For withdrawal processing effective immediately, this process will be updated to start the withdrawal on the date the student provides official notification, rather than starting on the day following. This means the last date attended and the start of the withdrawal will be the same date. Per the CFR 668.22(c). the student's withdrawal date is—(ii) The date, as determined by the institution, that the student otherwise provided official notification to the institution, in writing or orally, of his or her intent to withdraw; For withdrawal processing effective at the end of the term, the effective date for the ‘W’ status is the final day of the term in which the student was last enrolled. Per the Withdrawal versus Graduation and Effective Dates section of the NSLDS Manual Nov 2022, p.23 - In the case of the student who completes a term and does not return for the next term, leaving the course of study uncompleted, the effective date for the ‘W’ status is the final day of the term in which the student was last enrolled. The policy and process will be updated and training will occur to begin this processing change effective April 1, 2025. Withdraw date was reported as the end of the semester in which the student was attending It has been the practice to process withdrawal requests in this way: When a student requests withdrawal but has completed courses, the grades are updated prior to processing the withdrawal request. The withdrawal is effective on the start date of the next term. This process will be updated (effective April 1, 2025) to follow 34 CFR 668.22(c) and the NSLDS Manual as outlined in the prior bullet point. For students withdrawing immediately from a term in which they’ve already completed one or more courses, the effective date for the ‘W’ status is the date AU is notified. However, they will only be dropped from courses still in progress. Completed courses cannot be withdrawn. The policy and process will be updated and training will occur to begin this processing change effective April 1, 2025. Reported as withdrawn instead of graduated The Grads Only submission did not return student records for 24SPTRI. We will need to review this with Ellucian to determine the issue. Once this is determined, we will re-run the submission for this term to update records. An internal audit process will be implemented to spot check 3-5 records on each submission for enrollment, grads only, or degree verify reporting. In addition, an audit report will be created to review 9 sample records on a quarterly basis from the current list of active students and the last two years of graduated and withdrawn students. The review will select 3 records from each status. An audit log will document these reviews. Person Responsible for Corrective Action: The Registrar and Executive Director of Financial Aid & Scholarships are responsible for executing the corrective action plan. The Executive Director of Financial Aid and Scholarships and the University Registrar will meet on a recurring basis to jointly review enrollment reporting procedures and National Student Loan Data System (NSLDS) reporting timelines. This collaboration ensures that all enrollment data submitted for Title IV purposes is accurate, timely, and aligned with institutional policies and federal regulations. Any discrepancies or issues identified are addressed collaboratively and corrective steps are documented. Anticipated Completion Date: Fiscal year 2025
Finding 547609 (2024-001)
Significant Deficiency 2024
1. Identifying Number: 2024-001: Title IV Refund and Return of Funds Compliance Issue: A sample review found instances where Title IV refunds were miscalculated and not returned within the required timeframe. Cause: Administrative oversight led to inaccurate and untimely calculation. Effect: The U...
1. Identifying Number: 2024-001: Title IV Refund and Return of Funds Compliance Issue: A sample review found instances where Title IV refunds were miscalculated and not returned within the required timeframe. Cause: Administrative oversight led to inaccurate and untimely calculation. Effect: The University did not fully comply with FSA Handbook and federal regulations for returning Title IV aid in a timely manner. Corrective Actions Underway 1. Enhanced Quality Assurance Measures Implementation of a new review protocol for Title IV refund calculations, including a secondary verification process before fund returns. Establishment of a biweekly internal audit of refund calculations to identify and resolve errors before submission. 2.Ongoing Compliance Monitoring and Prevention Efforts Establishment of a quarterly compliance review conducted by the Financial Aid leadership team to proactively address potential issues. Development of a standardized documentation process for all Title IV transactions and NSLDS updates to ensure clear audit trails. Creation of staff retraining initiative to reinforce compliance expectations and best practices. Next Steps: Conduct a full compliance assessment at 30, 60, and 90 days to confirm improvement and adjust protocols as needed. Establish a reporting dashboard for real-time tracking of Title IV refunds and enrollment status updates. Formalize a policy review cycle to ensure that all processes remain aligned with the latest federal regulations. These actions are intended to strengthen the University’s compliance posture, mitigate risks, and enhance the accuracy and timeliness of financial aid administration. Please let me know if additional measures or oversight mechanisms should be considered. Person Responsible for Corrective Action:The Executive Director of Financial Aid & Scholarships is responsible for executing the corrective action plan. Anticipated Completion Date: Fiscal year 2025
Audit Finding Number 2024-001: The audit of the financial statements identified adjustments to the current year financial statements that were considered to be material. Management’s Response to the Finding and Recommendation: Management understands and agrees the corrections are required to the 2...
Audit Finding Number 2024-001: The audit of the financial statements identified adjustments to the current year financial statements that were considered to be material. Management’s Response to the Finding and Recommendation: Management understands and agrees the corrections are required to the 2024 financial statements and is in agreement with the finding and the related recommendations. Action(s) to be Taken or Planned to be Taken on the Finding: The 2024 financial statements have been corrected to properly present the financial statement amounts. Management will review its process for the preparation of financial statements and evaluation of transactions in accordance with generally accepted accounting principles for proper recording of balances and amounts going forward. Anticipated Completion Date: Completed November 2024
Finding Number: 2024-001 Reporting – Noncompliance (Control Deficiency) Programs: U.S. Department of Health and Human Services ALN Number: 93.959 ALN Name: Block Grants for Prevention and Treatment of Substance Abuse Contract Period: 07/1/2023 – 06/30/2024 Planned Corrective Action: SCAN-Harbor, Inc...
Finding Number: 2024-001 Reporting – Noncompliance (Control Deficiency) Programs: U.S. Department of Health and Human Services ALN Number: 93.959 ALN Name: Block Grants for Prevention and Treatment of Substance Abuse Contract Period: 07/1/2023 – 06/30/2024 Planned Corrective Action: SCAN-Harbor, Inc. (SCAN-Harbor) acknowledges that the 2024 consolidated fiscal report (CFR) was not filed timely. The planned correction plan is to file the CFR upon issuing these financial statements and ensure that future CFRs are filed timely. Person Responsible: Lewis Zuchman, Executive Director Expected Completion Date: March 31, 2025
Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Program Federal Assistance Listing Numbers: 14.871, 14.879, and 14.EHV Noncompliance – N. Special Tests and Provisions - Reasonable Rent Non Compliance Material to the Financial...
Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Program Federal Assistance Listing Numbers: 14.871, 14.879, and 14.EHV Noncompliance – N. Special Tests and Provisions - Reasonable Rent Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance for Special Tests and Provisions Criteria: Reasonable Rent. The Authority must do the following: The Authority must determine that the rent to owner is reasonable at the time of initial leasing. Also, the Authority must determine reasonable rent during the term of the contract (a) before any increase in the rent to owner, and (b) at the HAP contract anniversary if there is a 5 percent decrease in the published Fair Market Rent in effect 60 days before the HAP contract anniversary. The Authority must maintain records to document the basis for the determination that rent to owner is a reasonable rent (initially and during the term of the HAP contract) (24 CFR sections 982.4, 982.54(d)(15), 982.158(f)(7), and 982.507). Condition: Based upon inspection of the Authority’s files and discussion with management, there were newly leased units for which the evaluation of rent reasonableness was not performed. Context: There were approximately 821 newly leased units. Of a sample size of forty-two (42) newly leased units, one (1) unit's documentation of reasonable rent was not available for examination. Our sample size is statistically valid. Known Questioned Costs: $16,685 Cause: There is a significant deficiency in internal controls over the compliance for the special tests and provisions type of compliance related to reasonable rent. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that reasonably assures the program is in compliance. Effect: The Housing Voucher Cluster is in non-compliance with the special tests and provisions type of compliance related to reasonable rent. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority has recognized the significant deficiency in the Housing Voucher Cluster and will implement internal control procedures that will ensure compliance with federal regulations. Gabriela Rivero, Executive Assistant, will be responsible to implement this corrective action by June 30, 2025.
View Audit 351761 Questioned Costs: $1
Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers and Mainstream Vouchers Federal Assistance Listing Numbers: 14.871, 14.879, and 14.EHV Noncompliance – N. Special Tests and Provisions – Selections from the Waiting List Non Com...
Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers and Mainstream Vouchers Federal Assistance Listing Numbers: 14.871, 14.879, and 14.EHV Noncompliance – N. Special Tests and Provisions – Selections from the Waiting List Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance for Special Tests and Provisions Criteria: Selections from the Waiting List. The PHA must have written policies in its HCVP administrative plan for selecting applicants from the waiting list and PHA documentation must show that the PHA follows these policies when selecting applicants from the waiting list. Except for as provided in 24 CFR section 982.203(Special admission (non-waiting list)), all families admitted to the program must be selected from the waiting list. “Selection” from the waiting list generally occurs when the PHA notifies a family whose name reaches the top of the waiting list to come in to verify eligibility for admission (24CFR sections 5.410, 982.54(d), and 982.201 through 982.207). Condition: Based upon inspection of the waiting list provided to us during the time of audit, the new move-in list and discussions with management, it could not be determined with any certainty that new move-ins were selected from the wait list in an order that is in accordance with the Authority’s policy. Context: Forty-two (42) names were selected from the new move-in list and those names were to be traced to the waiting list to verify new move-ins were chosen in an order that was in accordance with the Authority’s policy. It was determined that thirty-eight (38) out of forty-two (42) new move-ins selected could not be traced with any certainty back to the Authority's waiting list. Known Questioned Costs: $741,293. Cause: There is a material weakness in internal controls over the compliance for the special tests and provisions type of compliance related to selections from the waiting list. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that assures the program is in compliance. Effect: The Housing Voucher Cluster is in material non-compliance with the special tests and provisions type of compliance related to selections from the waiting list. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority has recognized the material weakness in the Housing Voucher Cluster will implement internal control procedures that will ensure compliance with federal regulations. Gabriela Rivero, Executive Assistant, will be responsible to implement this corrective action by June 30, 2025.
View Audit 351761 Questioned Costs: $1
Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Federal Catalog Numbers: 14.871, 14.879, and 14.EHV Noncompliance – L. Reporting - Special Reporting Non Compliance Material to the Financial Statements: No Significant Deficiency in Inte...
Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Federal Catalog Numbers: 14.871, 14.879, and 14.EHV Noncompliance – L. Reporting - Special Reporting Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance for Reporting Criteria: The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family members to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). These files are required to be maintained and available for examination at the time of audit. Cause: There is a significant deficiency in internal controls over the compliance for the reporting type of compliance related to special reporting. The Authority has not maintained and monitored a system of internal controls that reasonably assures the program is in compliance. Effect: The Housing Voucher Cluster is in non-compliance with the reporting type of compliance related to special reporting. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster to ensure that established internal control policies are being followed accurately and on a timely basis. Gabriela Rivero, Executive Assistant, will be responsible to implement this corrective action by June 30, 2025. Condition: Based upon inspection of the Authority’s files and on discussion with management, the Authority included income that was miscalculated during their annual reexamination. Context: Of a sample size of fifty-eight (58) tenant files, three (3) tenant's annual recertification (HUD-50058 form) included income that was miscalculated. Our sample size is statistically valid. Known Questioned Costs: $32,407
View Audit 351761 Questioned Costs: $1
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