Corrective Action Plans

Finding 537236 (2024-001)

Material Weakness 2024

Learningworks

ME

HUD Housing Programs Material Weakness Internal Control / Segregation of Duties

LearningWorks is utilizing a temporary plan that engages existing staff in aspects of segregation. The recently revised Finance Manual includes a full matrix that explicitly includes additional finance staff to ensure segregation of duties through the transaction cycle. LearningWorks is committed to...

LearningWorks is utilizing a temporary plan that engages existing staff in aspects of segregation. The recently revised Finance Manual includes a full matrix that explicitly includes additional finance staff to ensure segregation of duties through the transaction cycle. LearningWorks is committed to and engaged in hiring a Finance Associate. The agency will incorporate these criteria and the matrix in our routine operations. Additionally, we are willing to institute further recommended practices that will remediate this finding.

View Audit 348423

Finding 530389 (2024-020)

Significant Deficiency 2024

State of Texas C/o Comptroller of Public Accounts

TX

Internal Control / Segregation of Duties Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

Corrective action plan: TxDOT AVN will implement procedures to ensure FFATA reports are reviewed and approved by a separate individual and submitted in a timely manner. Implementation dates: The procedure has been partially implemented, including the addition of the screen shots. A full implementa...

Corrective action plan: TxDOT AVN will implement procedures to ensure FFATA reports are reviewed and approved by a separate individual and submitted in a timely manner. Implementation dates: The procedure has been partially implemented, including the addition of the screen shots. A full implementation will be completed by March 1, 2025. Responsible persons: Michelle Burcham, AVN Grant & Admin Section Director, Allison Martin, Grant Manager Lead, Cassandra Moore, Grant Manager

View Audit 348386

Finding 530379 (2024-017)

Significant Deficiency 2024

State of Texas C/o Comptroller of Public Accounts

TX

Internal Control / Segregation of Duties Special Tests & Provisions Subrecipient Monitoring § 200.303

Corrective action plan: CMS is in the process of training the Manager of Physical Inspection to review and assign properties for timely inspections to ensure multiple staff members have oversight of the process. In addition, CMS is utilizing a new process using Excel to ensure all HOME-rental prop...

Corrective action plan: CMS is in the process of training the Manager of Physical Inspection to review and assign properties for timely inspections to ensure multiple staff members have oversight of the process. In addition, CMS is utilizing a new process using Excel to ensure all HOME-rental properties are inspected within required federal timeframes and this process is completed by two staff members independently. Implementation dates: On February 6, 2025, the new process of reconciling travel using Excel tools by independent staff was implemented to ensure no HOME-rental properties are inspected late. Responsible persons: Wendy Quackenbush, Director of Multifamily Compliance, Manual Pena, Manager of Physical Inspections and Carolyn Metzger, Team Leader.

View Audit 348386

Finding 530372 (2024-015)

Significant Deficiency 2024

State of Texas C/o Comptroller of Public Accounts

TX

Special Tests & Provisions Allowable Costs / Cost Principles Reporting § 200.303

Corrective action plan: Based on the recommendation above, HHSC Medicaid & CHIP Services (MCS) Financial Reporting and Audit Coordination (FRAC) has incorporated the suggested enhanced controls around the review of MLR report submissions to ensure they are complete and accurate. In order to enhan...

Corrective action plan: Based on the recommendation above, HHSC Medicaid & CHIP Services (MCS) Financial Reporting and Audit Coordination (FRAC) has incorporated the suggested enhanced controls around the review of MLR report submissions to ensure they are complete and accurate. In order to enhance existing controls, MCS FRAC has included a section for MLR reviewers to ensure Methodology(ies) for allocation of expenditures tab questions are complete. Likewise, specific instructions have been added to the review document to ensure the recommendations are met. These enhanced controls will be included in Fiscal Year (FY) 2025 and ongoing review of MLR report submissions. Implementation dates: November 2025 Responsible persons: Jason Mendl, Deputy Associate Commissioner, FRAC

View Audit 348386

Finding 530367 (2024-014)

Significant Deficiency 2024

State of Texas C/o Comptroller of Public Accounts

TX

Special Tests & Provisions Subrecipient Monitoring Eligibility § 200.303

Corrective action plan: HHSC's OIG has taken action to ensure timely reviews of the Centers for Medicare/Medicaid Services (CMS) Data Exchange Portal (DEX) reports. HHSC's OIG has multiple employees that have access to the systems necessary to retrieve the reports and has trained those employees o...

Corrective action plan: HHSC's OIG has taken action to ensure timely reviews of the Centers for Medicare/Medicaid Services (CMS) Data Exchange Portal (DEX) reports. HHSC's OIG has multiple employees that have access to the systems necessary to retrieve the reports and has trained those employees on the review process. Implementation dates: July 10, 2024 (Implemented) Responsible persons: Robin Bernard, Director, Financial Analysis and Case Management

View Audit 348386

Finding 530357 (2024-012)

Significant Deficiency 2024

State of Texas C/o Comptroller of Public Accounts

TX

Internal Control / Segregation of Duties Special Tests & Provisions Subrecipient Monitoring § 200.303

Corrective action plan: For awareness, effective February 1, 2025, Anil Koindala was hired as the Health and Human Services (HHS) Chief Information Security Officer (CISO). At HHSC, the Deputy Executive Commissioner for each HHS organizational area is responsible for assigning an information owne...

Corrective action plan: For awareness, effective February 1, 2025, Anil Koindala was hired as the Health and Human Services (HHS) Chief Information Security Officer (CISO). At HHSC, the Deputy Executive Commissioner for each HHS organizational area is responsible for assigning an information owner (IO) for each of their area’s HHS information systems which also includes performing Risk Assessments for the systems they are responsible for. To ensure Risk Assessment compliance is met, the CISO will send out quarterly reminders to the IO for the completion of risk assessments. The reminders have started to be sent on July 31, 2024. While the risk assessment will be completed by the IO, the CISO will assist any non-compliant area with training that will be provided by their Information Security Portfolio Manager (ISPM). Additionally, the CISO office ensures that a risk assessment and System Security Plan (SSP) are in place before granting an Authority to Operate (ATO). The CISO is currently developing policies and procedures to establish and publish a process for the successful completion of Risk Assessments, including roles and responsibilities, processes, and procedures to ensure timely completion and ongoing compliance. Implementation date: August 31, 2025 Responsible persons: Anil Koindala, Chief Information Security Officer, Information Technology Jeremy Sadler, Director, Information Security Risk Cristina Denz, Manager, Policy and Compliance

View Audit 348386

Finding 530352 (2024-011)

Significant Deficiency 2024

State of Texas C/o Comptroller of Public Accounts

TX

Eligibility Significant Deficiency Internal Control / Segregation of Duties § 200.303

Corrective action plan: Since fiscal year 2022, Access and Eligibility Services (AES) has focused on hiring initiatives, strategic workload strategies, system improvements, and training to improve workload capacity to enable AES to reallocate workforce resources to applications waiting the longest...

Corrective action plan: Since fiscal year 2022, Access and Eligibility Services (AES) has focused on hiring initiatives, strategic workload strategies, system improvements, and training to improve workload capacity to enable AES to reallocate workforce resources to applications waiting the longest to be processed. In addition, AES has reviewed regular monitoring and reporting mechanisms to track application processing times and identify any delays. HHSC conducted a comprehensive review of application processing workflows to identify strategies to increase capacity and/or reduce workload. The review identified more than 40 strategies to improve end-user function, eliminating unnecessary actions and interactions, improving client experience, and promoting timely workflow. As of January 31, 2025, procedural improvements implemented have resulted in most Medicaid applications being processed within three days of receipt, allowing for a greater amount of the full processing timeframe (45 days) being available to establish proper eligibility. AES began implementing identified strategies in September 2024 and ongoing efforts will continue to focus on workforce and workload balance to meet the needs of timeliness of applicable programs. AES will continue to evaluate effectiveness of procedures through feedback loops, ensuring changes made result in sustained improvements and compliance with all relevant regulations. Implementation dates: December 31, 2028 Responsible persons: Molly Regan, Deputy Executive Commissioner, AES Rachel Patton, Associate Commissioner, AES Operations

View Audit 348386

Finding 530320 (2024-005)

Material Weakness 2024

State of Texas C/o Comptroller of Public Accounts

TX

Procurement, Suspension & Debarment Subrecipient Monitoring Material Weakness § 200.303

Corrective action plan: HHSC cannot commit to the specific designation of CAPPS-Financials as the improvement solution for FFATA reporting. However, HHSC is currently engaged in long-term planning related to improving FFATA reporting. HHSC continues to implement a quality review of selected progr...

Corrective action plan: HHSC cannot commit to the specific designation of CAPPS-Financials as the improvement solution for FFATA reporting. However, HHSC is currently engaged in long-term planning related to improving FFATA reporting. HHSC continues to implement a quality review of selected programs to assess FFATA compliance on an annual basis. Implementation dates: September 1, 2025 Responsible persons: Racheal Kane, Director, Federal Funds

View Audit 348386

Finding 530286 (2024-004)

Significant Deficiency 2024

Philippian Gardens, Inc.

PA

Internal Control / Segregation of Duties

Management agrees with the above and we review the tenant security deposit listing and the tenant security liability monthly for accuracy.

View Audit 348378

Finding 530285 (2024-003)

Significant Deficiency 2024

Philippian Gardens, Inc.

PA

Internal Control / Segregation of Duties

Management agrees with the above and we follow the organization’s capitalization policy.

View Audit 348378

Finding 530284 (2024-002)

Material Weakness 2024

Philippian Gardens, Inc.

PA

Internal Control / Segregation of Duties

Management agrees with the above and we review the transaction posted to the general ledger monthly.

View Audit 348378

Finding 530283 (2024-001)

Material Weakness 2024

Philippian Gardens, Inc.

PA

Internal Control / Segregation of Duties

Management agrees with the above and we reconcile all cash and reserve accounts on a monthly basis.

View Audit 348378

Finding 530278 (2024-002)

Material Weakness 2024

Richmond Community Schools

IN

Equipment & Real Property Management Internal Control / Segregation of Duties § 200.313

RCS will update the current practice of formal updates to the Fixed Asset List from every other year, to every year effective the 2025 year

View Audit 348364

Finding 530275 (2024-001)

Material Weakness 2024

Richmond Community Schools

IN

Internal Control / Segregation of Duties Material Weakness Reporting § 200.302 § 200.303 § 200.328

Future reporting of ESSR information will be noted wherever possible either in written notation or email format to document who worked on and reviewed reporting information and submissions. We will attempt to take screenshots of any forms that are not available for printing

View Audit 348364

Finding 530270 (2024-004)

Material Weakness 2024

Wayne Community School District

IA

Internal Control / Segregation of Duties

WE WILL EVALUATE THIS AND ATTEMPT TO SEGREGATE DUTIES AS MUCH AS POSSIBLE.

View Audit 348347

Finding 530266 (2024-006)

Significant Deficiency 2024

Salem Community College

NJ

Special Tests & Provisions Student Financial Aid Matching / Level of Effort / Earmarking

Views of Responsible Officials: SCC has taken measures to strengthen internal controls. We have begun running a withdrawn/change report weekly. SCC has improved communication by implementing an email between Registrar and Financial Aid as well as Student Accounts. We have enhanced the process of mon...

Views of Responsible Officials: SCC has taken measures to strengthen internal controls. We have begun running a withdrawn/change report weekly. SCC has improved communication by implementing an email between Registrar and Financial Aid as well as Student Accounts. We have enhanced the process of monitoring the withdrawn students and ensuring the R2T4 calculations and the notification process have all been completed and compliant.

View Audit 348343

Finding 530262 (2024-005)

Significant Deficiency 2024

Salem Community College

NJ

Special Tests & Provisions Student Financial Aid Reporting

Views of Responsible Officials: The College will conduct an audit of status change protocols; reporting procedures to the National Clearinghouse; and pursue National Clearinghouse procedures for uploading to National Student Loans Data System (NSLDS).

View Audit 348343

Finding 530244 (2024-004)

Significant Deficiency 2024

Wyandanch Union Free School District

NY

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Reporting § 200.430

U.S. Department of Education -Passed-through the NYS Education Department Title I Grants to Local Educational Agencies (LEAs); Assistance Listing Number (ALN) 84.010; Project # 's 0021-23-2955, 0011-23-6011, 0011-23-7200, 0011-24-2160, 0021-24-2955, Grant Period Fiscal Year Ended June 30, 2024 U....

U.S. Department of Education -Passed-through the NYS Education Department Title I Grants to Local Educational Agencies (LEAs); Assistance Listing Number (ALN) 84.010; Project # 's 0021-23-2955, 0011-23-6011, 0011-23-7200, 0011-24-2160, 0021-24-2955, Grant Period Fiscal Year Ended June 30, 2024 U.S. Department of Education -Passed-through the NYS Education Department - Education Stabilization Fund COVID-19 - Elementary and Secondary School Emergency Relief (ESSER) Fund; ALN 84.425D; Project #5891-21-2955; Grant Period - Fiscal Year Ended June 30, 2024 COVID-19 - American Rescue Plan - Elementary and Secondary School Emergency Relief (ARP ESSER) Fund; ALN 84.425U; Project 5880-21-2955, 5884-21-2955, 5883-21-2955, 5882-21- 2955; Grant Period -Fiscal Year Ended June 30, 2024 COVID-19 -American Rescue Plan -Elementary and Secondary School Emergency Relief - Homeless Children and Youth; ALN 84.425W; Project#5218-21-2955; Grant Period - Fiscal Year Ended June 30, 2024 Significant Deficiency Compliance Req uirement: Allowable Activities and Cost Principles Criteria: Per Uniform Guidance (2 CFR §200.430), payroll costs charged to federal grants must be supported by appropriate documentation reflecting actual time and effort spent on grant-related activities. Per District policy employees are required to submit Personnel Activity Reports (PARs) to certify time worked on a federal grant. PARs are then required to be reviewed and approved by a direct supervisor. Condition: We identified seventeen (17) instances of missing or incomplete PAR forms for Title I. Six (6) out of (17) employees did not complete a PAR form. Eleven (11) out of (17) did not document supervisor review and approval. For the education stabilization fund the District was unable to provide support for time and effort worked on the grant for eleven (11) employees. Cause: Due to significant changes in personnel and work environments of key employees, the District was unable to maintain adequate oversight over the payroll function. Effect: The District is not in compliance with federal grant requirements and District policy. Questioned Costs: None Recommendation: We recommend the District enhance internal control measures to verify the accuracy and completeness of PARs in a timely manner. We also recommend the District conduct independent reviews of the payroll process and time and effort reporting to verify established controls are functioning as intended. District's Response: The District agrees with this finding. The procedures that are typically followed were not in place during the 2024 school year due to staff changes but the District is back on track and following the correct protocol for the current year and going forward

View Audit 348332

Finding 530238 (2024-008)

Significant Deficiency 2024

Bloomfield School District

IN

Internal Control / Segregation of Duties Special Tests & Provisions Reporting § 200.303

FINDING 2024-008 - Education Stabilization Fund (ESSER) – Special Tests and Provisions - Wage Rate Requirements Context: For the one project subject to Davis-Bacon requirements, the School Corporation did not obtain the weekly payroll reports certifications from the company that performed renovati...

FINDING 2024-008 - Education Stabilization Fund (ESSER) – Special Tests and Provisions - Wage Rate Requirements Context: For the one project subject to Davis-Bacon requirements, the School Corporation did not obtain the weekly payroll reports certifications from the company that performed renovations on the School Corporation. Therefore, no review was performed to ensure that pay rates complied with the federal wage rate requirements. Additionally, the School Corporation did not have a contract with the company that included the clauses for the federal wage rate requirements. The amount disbursed and reported on the SEFA during the audit period is $64,720. Contact Person Responsible for Corrective Action: Michelle L. Keene Contact Phone Number: (812) 384-4386 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will ensure any future federal construction projects comply with the Davis-Bacon requirements. Anticipated Completion Date: Next federally funded construction project.

View Audit 348324

Finding 530237 (2024-007)

Material Weakness 2024

Bloomfield School District

IN

Equipment & Real Property Management Internal Control / Segregation of Duties § 200.313

FINDING 2024-007 - Education Stabilization Fund (ESSER) – Equipment Context: The School Corporation expended $341,336 on building renovations which was charged to the ESSER III (84.425U) grant award. It was noted these capital asset acquisitions were not reported on the capital asset listing for ...

FINDING 2024-007 - Education Stabilization Fund (ESSER) – Equipment Context: The School Corporation expended $341,336 on building renovations which was charged to the ESSER III (84.425U) grant award. It was noted these capital asset acquisitions were not reported on the capital asset listing for the School Corporation as of June 30, 2024. Additionally, we noted the School Corporation’s capital asset listing did not contain all the required information, including the source of funding for the property, outlined in the criteria above. Contact Person Responsible for Corrective Action: Michelle L. Keene Contact Phone Number: (812) 384-4386 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will ensure the capital asset ledger is updated to include all capital asset activity. Anticipated Completion Date: June 30, 2025

View Audit 348324

Finding 530235 (2024-006)

Material Weakness 2024

Bloomfield School District

IN

Internal Control / Segregation of Duties Material Weakness Reporting § 200.302 § 200.303 § 200.328

FINDING 2024-006 - Education Stabilization Fund (ESSER) – Reporting Context: The School Corporation was required to submit two Annual Data Reports to the Indiana Department of Education (IDOE) during the audit period to meet federal reporting requirements for ESSER grant awards. We noted that the ...

FINDING 2024-006 - Education Stabilization Fund (ESSER) – Reporting Context: The School Corporation was required to submit two Annual Data Reports to the Indiana Department of Education (IDOE) during the audit period to meet federal reporting requirements for ESSER grant awards. We noted that the ESSER II, and ESSER III amounts reported for the reports covering the FY22 time period ($99,969 and $251,848, respectively) did not agree to the underlying expenditure records ($105,319 and $369,743, respectively, for the period of July 1, 2021 through June 30, 2022). Additionally, we noted that the ESSER II, and ESSER III amounts reported for the reports covering the FY23 time period ($168,087 and $266,122, respectively) did not agree to the underlying expenditure records ($169,046 and $241,329, respectively, for the period of July 1, 2022 through June 30, 2023). We also noted there was no documented, secondary review of the information in the annual data reports by someone other than the preparer. Contact Person Responsible for Corrective Action: Michelle L. Keene Contact Phone Number: (812) 384-4386 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will ensure all ESSER reports include accurate information that agree to the underlying disbursement records. Anticipated Completion Date: Next report due to IDOE.

View Audit 348324

Finding 530232 (2024-005)

Material Weakness 2024

Bloomfield School District

IN

School Nutrition Programs Internal Control / Segregation of Duties Eligibility § 200.303

FINDING 2024-005 – Child Nutrition Cluster - Eligibility Context: During sample testing of 60 students for eligibility, we noted 5 instances where there was no documented review by someone other than the individual making the eligibility determination. Additionally, we noted 4 instances where the ...

FINDING 2024-005 – Child Nutrition Cluster - Eligibility Context: During sample testing of 60 students for eligibility, we noted 5 instances where there was no documented review by someone other than the individual making the eligibility determination. Additionally, we noted 4 instances where the School Corporation was unable to provide the application. The issues were isolated to paper applications Contact Person Responsible for Corrective Action: Michelle L. Keene Contact Phone Number: (812) 384-4386 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The treasurer will formally review a sample of applications and the School Corporation will ensure all supporting applications and reviews are maintained. Anticipated Completion Date: March 2025

View Audit 348324

Finding 530229 (2024-004)

Material Weakness 2024

Bloomfield School District

IN

School Nutrition Programs Internal Control / Segregation of Duties Cash Management § 200.303

FINDING 2024-004 – Child Nutrition Cluster - Reporting Context: We noted that for all sponsor claim reimbursements in a sample of four claims, the sponsor claim reimbursement was prepared without a secondary, documented review before the submission of the claim to ensure the accuracy of the sponsor...

FINDING 2024-004 – Child Nutrition Cluster - Reporting Context: We noted that for all sponsor claim reimbursements in a sample of four claims, the sponsor claim reimbursement was prepared without a secondary, documented review before the submission of the claim to ensure the accuracy of the sponsor claim reimbursement summary. Contact Person Responsible for Corrective Action: Michelle L. Keene Contact Phone Number: (812) 384-4386 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The treasurer will formally review and document the review of all reimbursement claims Anticipated Completion Date: March 2025

View Audit 348324

Finding 530223 (2024-003)

Material Weakness 2024

City of Framingham

MA

Eligibility Material Weakness Internal Control / Segregation of Duties

2024-003 Adult Education - Assistance Listing Number 84.002 Recommendation: We recommend procedures to maintain records related to eligibility determinations be implemented/strengthened. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken ...

2024-003 Adult Education - Assistance Listing Number 84.002 Recommendation: We recommend procedures to maintain records related to eligibility determinations be implemented/strengthened. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Adult Education department will now scan in the physical intake form that Adult ESL students self-report their eligibility status for MA DESE ACLS as well as have the student sign that form. This form will be stored electronically in addition to the information from the form being entered into the Adult ESL Access database and LACES . Name(s) of the contact person(s) responsible for corrective action: Dr. Kevin O’Connor, Claudia Castro Alves and Kate Fiore Planned completion date for corrective action plan: Effective as of 08/01/2024

View Audit 348312

Finding 530221 (2024-006)

Significant Deficiency 2024

City of Framingham

MA

Reporting Significant Deficiency Internal Control / Segregation of Duties

2024-006 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing Number 21.027 Recommendation: We recommend procedures to file all required reports be strengthened. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in resp...

2024-006 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing Number 21.027 Recommendation: We recommend procedures to file all required reports be strengthened. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The City of Framingham acknowledges the finding and is committed to strengthening procedures for filing all required reports under the Coronavirus State and Local Fiscal Recovery Funds program. The City will implement additional internal controls, including enhanced tracking mechanisms and periodic internal audits, to ensure the timely and accurate submission of reports. Staff responsible for grant reporting will also undergo additional training on federal reporting requirements to improve compliance and reduce the risk of future findings. Name(s) of the contact person(s) responsible for corrective action: Jennifer Pratt Planned completion date for corrective action plan: 3/31/2025

View Audit 348312

Corrective Action Plans

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