Corrective Action Plans

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Finding 539539 (2024-002)
Significant Deficiency 2024
The City acknowledges the finding regarding the untimely completion of Quality Assurance Program (QAP) checklists (Appendices K, E, and L) for federally funded projects. Although the required Quality Assurance Tests were performed, documentation of the checklists was not completed in real time. To c...
The City acknowledges the finding regarding the untimely completion of Quality Assurance Program (QAP) checklists (Appendices K, E, and L) for federally funded projects. Although the required Quality Assurance Tests were performed, documentation of the checklists was not completed in real time. To correct this, the City has reinforced internal procedures to ensure that these checklists are completed and signed at the appropriate project milestones. Staff have been retrained on QAP requirements, and a tracking system has been implemented to ensure timely completion of all necessary documentation. Responsible Person: Susan Michael, Capital Improvement Programs Manager Expected Implementation Date: March 2025
Finding Number: 2024-001 Condition: GBQ identified errors in how employee time was allocated to the program, and salaries and wages allocated to the program in excess of the Executive Level II Salary maximum. Specifically, one employee had salaries and wages allocated to the program in excess of ho...
Finding Number: 2024-001 Condition: GBQ identified errors in how employee time was allocated to the program, and salaries and wages allocated to the program in excess of the Executive Level II Salary maximum. Specifically, one employee had salaries and wages allocated to the program in excess of hours tracked to the program for a selected month. Another employee had an inappropriate wage rate applied to allocated time to the program. Last, two employees had compensation levels allocated to the program in excess of the Executive Level II Salary max amount in effect for the respective period. Planned Corrective Action: ECDI will put additional steps in place in Payroll Review process to ensure reconciliation of payroll charges to actual time records and rates. The organization will modify it's calculations to ensure that pay rates are reflective of the timeframe in question (not for periods before or after). ECDI will update its calculations to include thresholds for Executive pay so they are not entered in excess of approved rates. The company is also exploring technology enhancements so that information from ECDl's Payroll system flows directly into ECDl's Accounting system to limit the chance of errors during extraction from Payroll system and uploading into Accounting system. Contact Person Responsible for Corrective Action: Brian Barrett and Hudu Ahmed. Completion Date: In process
View Audit 350075 Questioned Costs: $1
Corrective Action Plan for Finding 2024-004 Community Care agrees with this finding. There are four bullets in this finding. We will be making a formal request to have the HMIS 72 hour data entry removed from our contract. The HMIS system does not have the capability to measure data entry timefram...
Corrective Action Plan for Finding 2024-004 Community Care agrees with this finding. There are four bullets in this finding. We will be making a formal request to have the HMIS 72 hour data entry removed from our contract. The HMIS system does not have the capability to measure data entry timeframes because of this we would need to design a data entry tracking process to track the timeframes. If our request is denied, we will create an entry tracking process. Bullets 2-4 are results of providing services in from the perspective of a low barrier service. Our priority is to have youth come to a safe place that is warm and where they are provided with a place to sleep, food, healthcare, and services to aid them. Staying in the program is not contingent on completing assessments or engaging in a service planning process. Each time a youth is in a program they are provided with the opportunity to participate in an assessment and are offered an organized service plan. Most participate but some do not. We will continue to offer the same level of support and opportunity for assessments and service planning to each youth. • There was no auditable evidence to test whether the participants were entered into HMIS within 72 hours. • Four participants did not have a service plan developed within 30 days. • The client was unable to provide the NavSEA for three participants. • The service plan for one participant did not have documented review. Responsible Official: David McCluskey, Executive Director Date of Corrective Action: Systems are in place and efforts will continue to encourage youth to participate in assessments and service planning practices. Regarding the HMIS data entry request will be made Friday the 21st March, 2025. If denied we will build a tracking process within 30 days.
2024-004 Eligibility U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement policies and procedures to ensure that the necessary controls are in place to properly verify the eligibility of all Youth Activities participants. Act...
2024-004 Eligibility U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement policies and procedures to ensure that the necessary controls are in place to properly verify the eligibility of all Youth Activities participants. Action Taken: The Board has established policies and procedures to strengthen eligibility verification for the Youth program participants. These policies outline clear documentation requirements, verification steps, and staff responsibilities. Staff involved in eligibility determination have been trained on the new procedures to ensure consistency and compliance with federal and state guidelines and will receive ongoing training and technical assistance. The Board has implemented internal controls, including multi-level verification and supervisory review to ensure the accuracy and completeness of participant eligibility determinations.
View Audit 350052 Questioned Costs: $1
2024-002 Reporting U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board design and implement controls to ensure that all required reporting is submitted accurately and in a timely fashion. Action Taken: Region III will establish cle...
2024-002 Reporting U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board design and implement controls to ensure that all required reporting is submitted accurately and in a timely fashion. Action Taken: Region III will establish clear documentation checklist with requirements for each report to ensure completeness and accuracy. Assign specific roles and responsibilities for report preparation, review and approval before submission to ensure that multiple levels of review are in place.
View Audit 350052 Questioned Costs: $1
FINDING 2024-004: Impact Aid Application Controls (Repeated 2023-004) Response: The District has implemented that the documentation for the Impact Aid application will be kept in the Business Manager office rather than the Superintendent office to ensure that this documentation is maintained for fut...
FINDING 2024-004: Impact Aid Application Controls (Repeated 2023-004) Response: The District has implemented that the documentation for the Impact Aid application will be kept in the Business Manager office rather than the Superintendent office to ensure that this documentation is maintained for future years.
Finding 2024-001 Subrecipient Monitoring, Non-Compliance (Significant Deficiency) Finding Summary: The subawards did not include the required federal provisions or list the assistance listing numbers. Corrective Action Plan for Subrecipient Contracts: Revise all subrecipient contracts to include...
Finding 2024-001 Subrecipient Monitoring, Non-Compliance (Significant Deficiency) Finding Summary: The subawards did not include the required federal provisions or list the assistance listing numbers. Corrective Action Plan for Subrecipient Contracts: Revise all subrecipient contracts to include the federal provisions and list the assistance listing numbers. All LIFT 2.0 contracts will end on December 31, 2024. For those renewed contracts the aforementioned information will be included. All other existing contracts are currently being updated to include this information. The procurement policy will be updated to include this control as well as all other requirements per 2 CFR Section 200.303(a). A reviewer’s checklist will be created using this section to ensure that all future contracts are in compliance. Responsible Individual: Santanna Johnson, Director of Accounting and Contracts Anticipated Completion Date: December 2024
Finding 2024-003 – Capital Fund Grant Reconciliations – Special Tests – Significant Deficiency Capital Fund Program – ALN #14.872 Corrective Action Plan: The Housing Authority has brough forward all schedules related to Capital Fund Grant as of March 2025. Person Responsible: Sheila Crisp, Executi...
Finding 2024-003 – Capital Fund Grant Reconciliations – Special Tests – Significant Deficiency Capital Fund Program – ALN #14.872 Corrective Action Plan: The Housing Authority has brough forward all schedules related to Capital Fund Grant as of March 2025. Person Responsible: Sheila Crisp, Executive Director Anticipated Completion Date: June 2025
Finding 2024-001 – Accounting Controls – Internal Controls over Financial Statement Preparation ALN 14.850 – Noncompliance and Material Weakness Corrective Action Plan: The Housing Authority is working with new personnel to ensure processes are documented and proper training is taking place. The...
Finding 2024-001 – Accounting Controls – Internal Controls over Financial Statement Preparation ALN 14.850 – Noncompliance and Material Weakness Corrective Action Plan: The Housing Authority is working with new personnel to ensure processes are documented and proper training is taking place. The Housing Authority has contracted with BDO to assist with year-end processes and training. Person Responsible: Sheila Crisp, Executive Director Anticipated Completion Date: June 2025
Finding 539476 (2024-008)
Significant Deficiency 2024
Special Tests and Provisions 240 Day Checks – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no...
Special Tests and Provisions 240 Day Checks – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid office along with Student Accounts and the Business Office at Urshan University will collaborate on an SOP which will establish a process of reviewing any outstanding Title IV checks. Checks will be reissued as necessary to ensure the university stays compliant with all Title IV regulations. Name(s) of the contact person(s) responsible for corrective action: Levi Powell, Student Financial Aid Director Planned completion date for corrective action plan: 6/30/2025
Finding 539472 (2024-006)
Significant Deficiency 2024
Special Tests and Provisions Gramm-Leach-Bliley Act– Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: Ther...
Special Tests and Provisions Gramm-Leach-Bliley Act– Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The IT department continues to improve its processes; an annual review of the WISP has been started and will continue. The Financial Aid Office will work with IT to make sure that the WISP is improved to include and provide secure disposal of customer information and make sure the review is documented. Name(s) of the contact person(s) responsible for corrective action: Levi Powell, Student Financial Aid Director Planned completion date for corrective action plan: 6/30/2025
View Audit 350009 Questioned Costs: $1
Special Tests and Provisions R2T4 – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreeme...
Special Tests and Provisions R2T4 – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid office will be crafting a new SOP to address R2T4 audit findings. The team will work more closely with the Registrar and Academic Deans when determining the withdrawal status of a student and make sure that the R2T4 documentation is accurately completed, a review of completed R2T4s will also be conducted. Name(s) of the contact person(s) responsible for corrective action: Levi Powell, Student Financial Aid Director Planned completion date for corrective action plan: 6/30/2025
View Audit 350009 Questioned Costs: $1
While the audit notes improvements in this area, we continued to face some challenges in properly allocating indirect costs and fringe benefits to individual contracts. We will close the remaining gap between the costs properly billed to individual contracts and the process of reflecting these costs...
While the audit notes improvements in this area, we continued to face some challenges in properly allocating indirect costs and fringe benefits to individual contracts. We will close the remaining gap between the costs properly billed to individual contracts and the process of reflecting these costs in our accounting system by refining our cost allocation plan. This revision will include consistent rules for allocating indirect and fringe plus a quarterly review by accounting staff and management. We will also use newly formatted grant worksheets shared with us by Whittlesey to help us identify and correct any allocation issues before closing out our accounting records for this fiscal year.
Finding 2024-002 – The Organization provided humanitarian assistance to migrants and asylum seekers turned over by Customs and Border Protection (CBP), including meals, transportation and shelter at hotels and the Organizations Respite Center. The Organization has intake procedures in place with res...
Finding 2024-002 – The Organization provided humanitarian assistance to migrants and asylum seekers turned over by Customs and Border Protection (CBP), including meals, transportation and shelter at hotels and the Organizations Respite Center. The Organization has intake procedures in place with respect to hotel shelter expenditures. However, the intake process was not consistently applied to all participants. The Organization was not able to provide supporting documentation for 5% of the requested sample of individuals who received shelter. Management's view: Management acknowledges this finding, and awareness has been brought to this area. The errors identified in this finding were made due to a lack of implementation of proper agency financial procedures by a former employee and occurred during a period of substantial influx in the number of non-citizen migrants being assisted. Authorization of credit card use was provided to one hotel vendor which led to unverified charges. This was identified and corrected by senior staff within three weeks. Proposed Corrective Action: The following measures were already taken to correct this finding: The organization has provided proper training to its program staff and accounting bookkeepers to improve the internal payment review process on all payment requests and has prohibited the use of credit cards to cover hotel stays for clients. All hotel payments are to be paid by check after reviewing the proper documentation submitted by the vendor, which includes an invoice with the non-citizen migrant's name as spelled in the Notice to Appear documentation provided by U.S. Customs and Border Protection. This documentation is then compared to the registration database maintained by the organization which includes name and A-number for all non-citizen migrants served. Any unauthorized payment will be immediately investigated and disputed on a timely basis. This policy has already been implemented successfully. An internal sample verification process was completed successfully with supporting evidence for all clients served after the previous unauthorized charges were identified within the period of three weeks. Anticipated Correction Date: These measures have been implemented.
View Audit 349994 Questioned Costs: $1
The sliding fee schedule has been updated several times in the last 24 months with subsequent staff training. Beginning in December 2024 our organization will begin charging a nominal fee then accurately utilizing sliding discounts based on income levels/family size. The organization has also increa...
The sliding fee schedule has been updated several times in the last 24 months with subsequent staff training. Beginning in December 2024 our organization will begin charging a nominal fee then accurately utilizing sliding discounts based on income levels/family size. The organization has also increased training in processing and entering the collected patient income forms and sliding fee schedule packet of forms needed to accurately account for providing the patient with the sliding fee schedule adjustment.
Analysis is provided on a monthly basis by the Chief Financial Officer and the Accounting department. Balance Sheet, Profit & Loss, Cash Flow and A/P Agings are reviewed and provided to the CEO, the BOD Finance Committee and then to all BOD Members. Also provided is an organization dashboard present...
Analysis is provided on a monthly basis by the Chief Financial Officer and the Accounting department. Balance Sheet, Profit & Loss, Cash Flow and A/P Agings are reviewed and provided to the CEO, the BOD Finance Committee and then to all BOD Members. Also provided is an organization dashboard presentation with 12-14 Key Performance Indicators monthly.
Condition: There was a lack of internal controls in place related to the return of Title IV funds. Planned Corrective Action: Director will update academic calendar on COD R2TIV calculator yearly and verify dates and length of breaks are correct. The University will continue to have the Senior Fina...
Condition: There was a lack of internal controls in place related to the return of Title IV funds. Planned Corrective Action: Director will update academic calendar on COD R2TIV calculator yearly and verify dates and length of breaks are correct. The University will continue to have the Senior Financial Aid Advisor complete R2TIV and the Director will sign off on calculations. Contact person responsible for corrective action: Callie Zake, Senior Director Student Financial Services Anticipated Completion Date: June 30, 2025
View Audit 349964 Questioned Costs: $1
Finding 539409 (2024-004)
Significant Deficiency 2024
Finding 2024‐004: Significant Deficiency and Non‐Material Noncompliance – Housing Voucher Cluster REAC Report Name of Contact Person: Joan Duckett, Director of Housing & Community Development Corrective Action: The Office of Housing and Community Development (OHCD) has taken corrective measures to e...
Finding 2024‐004: Significant Deficiency and Non‐Material Noncompliance – Housing Voucher Cluster REAC Report Name of Contact Person: Joan Duckett, Director of Housing & Community Development Corrective Action: The Office of Housing and Community Development (OHCD) has taken corrective measures to ensure that the REAC reports are supported with accurate data and submitted in a timely manner. There are monthly reconciliation procedures in place which include management oversight and review of all reports. OHCD has and will continue to enter into a contractual agreement with a knowledgeable and reputable accounting firm that the County is under contract for services applicable to the need. REAC reports will be extensively reviewed by management prior to submission to HUD. Proposed Completion Date: Immediately
Recommendation: CLA recommends the University review its reporting procedures to ensure the students' statuses are accurately reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to fin...
Recommendation: CLA recommends the University review its reporting procedures to ensure the students' statuses are accurately reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: By reviewing the ordering of internal processes and procedures St. Thomas determined two internal processes ran out of order causing incorrect reporting. Procedural documentation has been updated and training provided to ensure this error is not repeated. Name(s) of the contact person(s) responsible for corrective action: Yuko Kachinsky: yuko.kachinsky@stthomas.edu Planned completion date for corrective action plan: A process error was identified and corrected in August 2024.
Finding 539386 (2024-005)
Significant Deficiency 2024
The Department of Public Works, will incorporate the Federal Statement of Compliance form (C-56) within the Technical Specifications section of all federally-funded VDOT project contracts.
The Department of Public Works, will incorporate the Federal Statement of Compliance form (C-56) within the Technical Specifications section of all federally-funded VDOT project contracts.
View Audit 349937 Questioned Costs: $1
Finding 539383 (2024-001)
Significant Deficiency 2024
Management agrees with the finding and recommendations, but also has determined that this finding will not be repeated in future years, as the arrearages program has come to a close.
Management agrees with the finding and recommendations, but also has determined that this finding will not be repeated in future years, as the arrearages program has come to a close.
Description of Corrective Action Plan: Argos Community Schools will ensure that going forward any construction we have done, funded with federal dollars will be compliant with Davis-Bacon Act Reporting laws and ensure we receive required documentation, as required by Federal Law.
Description of Corrective Action Plan: Argos Community Schools will ensure that going forward any construction we have done, funded with federal dollars will be compliant with Davis-Bacon Act Reporting laws and ensure we receive required documentation, as required by Federal Law.
Recommendation: We recommend that the University strengthen its internal controls over reporting student enrollment changes to NSLDS to ensure that enrollment effective dates are reported to NSLDS within 60 days of an enrollment status change and that enrollment is being properly certified every 60 ...
Recommendation: We recommend that the University strengthen its internal controls over reporting student enrollment changes to NSLDS to ensure that enrollment effective dates are reported to NSLDS within 60 days of an enrollment status change and that enrollment is being properly certified every 60 days. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action in Response to Finding: Portland State University relies on a third party, National Student Clearinghouse, to report student enrollment status changes to the NSLDS. Fall 2023 and Winter 2024 enrollment certification files were provided to NSC for relay to NSLDS. Despite this, these enrollment files were never provided to NSLDS and as such the students status change, effective September 26, 2023, was not certified within the NSLDS until May 3, 2024. We are researching why these enrollment certification files were never provided to the NSLDS. Name of the Contact Person Responsible for Corrective Action: Nicolle DuPont, Associate Registrar Planned Completion Date for Corrective Action Plan: April 2025
Finding 539259 (2024-711)
Significant Deficiency 2024
Below please find our response and corrective action plan outline in reference to the above. Action: Provisioning and Deprovisioning Process The University is in the process of developing written procedures of provisioning and deprovisioning user access to our student information system, to include ...
Below please find our response and corrective action plan outline in reference to the above. Action: Provisioning and Deprovisioning Process The University is in the process of developing written procedures of provisioning and deprovisioning user access to our student information system, to include specifying those who are authorized to request user access and assigning responsibility to staff to assess access. This process will be an electronic workflow process which will house documentation of provisioning and deprovisioning activities. Anticipated Completion Date: August 2025 Action: Annual Attestation The University will conduct an audit and annual attestation process which will require managers to attest employee access to the system. Furthermore, every employee will be required to bi-annually confirm their understanding and adherence to specific policies, standards, and regulatory compliance. Action: Current Access to the Student Information System The University is assessing users who currently have access to the SIS. We will remove any student and/or employee who no longer requires access to the system. We will review this on an annual basis. Anticipated Completion Date: May 2025. Person responsible for corrective action: Name: Tammy McGuckin Title: Vice Chancellor for Student Affairs and Enrollment Services Email address; mcguckin@uwp.edu Person responsible for corrective action: Name: Sheronda Glass Title: Vice Chancellor for Operations Email address; glasss@uwp.edu
Finding 539227 (2024-200)
Significant Deficiency 2024
Planned Corrective Action: The DCF Bureau of Working Families (BWF) will review the Work Verification Plan, make updates as necessary, and submit it to the U.S. Department of Health and Human Services for approval. BWF will resume monitoring and documentation of the work participation information in...
Planned Corrective Action: The DCF Bureau of Working Families (BWF) will review the Work Verification Plan, make updates as necessary, and submit it to the U.S. Department of Health and Human Services for approval. BWF will resume monitoring and documentation of the work participation information in accordance with the approved Work Verification Plan. Anticipated Completion Date: The bureau will complete this work by June 30, 2025. Persons responsible for corrective action: Patara Horn, Director Bureau of Working Families Pataras.Horn@wisconsin.gov Rachelle Armstrong, Director Bureau of Finance Rachelle.Armstrong@wisconsin.gov
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