Corrective Action Plans

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FINDING 2024-004: US Department of Education and PA Department of Education - COVID-19 Education Stabilization Fund (ESF) - ALN #84.425 - Special Tests and Provisions - Wage Rate Requirements Criteria: In accordance with Uniform Guidance requirements found in Part 3 Section N, "Special Tests and Pro...
FINDING 2024-004: US Department of Education and PA Department of Education - COVID-19 Education Stabilization Fund (ESF) - ALN #84.425 - Special Tests and Provisions - Wage Rate Requirements Criteria: In accordance with Uniform Guidance requirements found in Part 3 Section N, "Special Tests and Provisions" of the Compliance Supplement, all laborers and mechanics employed by contractors or subcontractors to work on construction contracts in excess of $2,000 financed by federal assistance funds must be paid wages not less than the prevailing wages rates established by the Department of Labor (DOL). Nonfederal entities shall include in their construction contracts subject to the Wage Rate Requirements a provision that the contractor or subcontractor comply with those requirements and DOL regulations. This includes a requirement for the contractor or subcontractor to submit to the nonfederal entity weekly, for each week in which any contract work is performed, a copy of the payroll and a statement of compliance. Condition: The School District did not have adequate internal control procedures in place to ensure that all laborers and mechanics employed by contractors or subcontractors to work on construction contracts in excess of $2,000 financed by federal assistance funds were paid wages not less than those established for the locality of the project (prevailing wage rates) by the Department of Labor. As a result, the School District did not properly notify 1 of the 3 contractors tested of the requirements to comply with the wage rate requirements via the including of a prevailing wage rate clause in the contract between the contractor and the School District, and therefore, the use prevailing wage rates were not determined. Cause: The School District did not have formal procedures in place to ensure that prevailing wage rate requirements were met on all construction projects over $2,000. Effect: The School District was not in compliance with the Special Tests and Provisions - Wage Rate Requirements of the Uniform Guidance. Repeat Finding: No Questioned Costs: Unknown Recommendation: We recommend that the School District revise its purchasing policy to formally reflect the requirements of Special Tests and Provisions - Wage Rate Requirements. Additionally, we recommend that the School District establish procedures to ensure that prevailing wage rate requirements are met for federally funded construction projects over $2,000. Views of Responsible Officials and Planned Corrective Action: The School District agrees with the recommendation. The Business Office will require that projects over $2,000 involving federal must use prevailing wage rates.
View Audit 350127 Questioned Costs: $1
Corrective Action Plan: The Authority concurs with the finding. The following corrective actions are being implemented:  Reinstating and enhancing the inspection tracking log to monitor timely completion of all required inspections;  Utilizing property management software to schedule and track ins...
Corrective Action Plan: The Authority concurs with the finding. The following corrective actions are being implemented:  Reinstating and enhancing the inspection tracking log to monitor timely completion of all required inspections;  Utilizing property management software to schedule and track inspections;  Assigning oversight responsibility for inspections to the Property Manager and Safety Inspection Supervisor;  Conducting quarterly management reviews of inspection compliance;  Hired additional inspection sta􀀳, including Maintenance Operations Supervisor to complete any backlog and ensure ongoing compliance.  Requested funding from City, State, and County to assist in inspections compliance to address federal funding and revenue shortages due to rental income delinquency. Anticipated Completion Date: June 30, 2025 Responsible Party: Senior Manager of Housing Operations/Maintenance Manager
Corrective Action Plan: The Authority acknowledges the finding. Corrective actions to address the deficiencies are underway and include:  Updating internal policies and procedures related to tenant file documentation and income verification requirements;  Providing targeted sta􀀳 training on proper...
Corrective Action Plan: The Authority acknowledges the finding. Corrective actions to address the deficiencies are underway and include:  Updating internal policies and procedures related to tenant file documentation and income verification requirements;  Providing targeted sta􀀳 training on proper file documentation and third-party income verification procedures;  Implementing a mandatory checklist to ensure all required documentation is obtained and verified before finalizing recertifications;  Establishing a quality control process where supervisory sta􀀳 conduct periodic file reviews to ensure compliance;  Maintaining an audit trail of verification documentation to ensure proper retention.  Hired third-party service provider, Quadel to assist with tenant file documentation compliance, annual and interim recertifications and rent calculations.  Hiring Senior Housing Manager to assist with monitoring verification documentation, income calculation, citizenship and/or legal residency documentation, and signed release documentation compliance. Anticipated Completion Date: June 30, 2025 Responsible Party: Senior Manager of Housing Operations and PH Property Managers
We have determined that the sliding fee set up in our EHR will miscalculate a patient’s sliding fee discount when a combination of particular conditions are met. A representative of the EHR company has confirmed that the system “does not behave as it should” when these circumstances occur. While it...
We have determined that the sliding fee set up in our EHR will miscalculate a patient’s sliding fee discount when a combination of particular conditions are met. A representative of the EHR company has confirmed that the system “does not behave as it should” when these circumstances occur. While it is rare that a slide patient would meet all of these conditions, it does happen from time to time. Because of this, we have begun verifying the discounts applied to every slide patient’s account to ensure accuracy. Additionally, we are restructuring the sliding fee discount program and will rebuild it within the EHR to remove the possibility of one of the conditions occurring, which should prevent the system from ever miscalculating the discount to be applied. Person(s) Responsible: Kim Wieloch, Finance Director Timing for Implementation: Verifying all SFS discounts: Currently in process and ongoing; Rebuilding SFS calculation structure in EHR: By 7/1/2025
2024-001 Special Tests and Provisions Name of Contact Person: Adam Miller, Chief Financial Officer Corrective Action: The JCC was unable to meet certain performance-based provisions of the contract, such as number of participants and break out of those participants by age category. The JCC acknowled...
2024-001 Special Tests and Provisions Name of Contact Person: Adam Miller, Chief Financial Officer Corrective Action: The JCC was unable to meet certain performance-based provisions of the contract, such as number of participants and break out of those participants by age category. The JCC acknowledges and agrees with the finding, and is in the process of developing procedures to ensure compliance with the grant/contract provisions and will start implementing this recommendation during the year ended June 30, 2025. The procedures: • The JCC will designate the responsibility of contract compliance to a specific individual at the JCC. • The JCC will ensure strict compliance with the IS49 Beacon program’s grant/contract provisions.
Contact Person Mary Vandal, Business Manager Planned Corrective Action This finding was noted by the auditors on the Impact Aid application submitted in January 2023. Both applications submitted in January of 2024 and 2025 had the proper support showing student enrollment information with review or ...
Contact Person Mary Vandal, Business Manager Planned Corrective Action This finding was noted by the auditors on the Impact Aid application submitted in January 2023. Both applications submitted in January of 2024 and 2025 had the proper support showing student enrollment information with review or approval by tribal authority prior to submitting the application. Applications made in the future will continue to have the required documentation to support the application. Planned Completion Date June 30, 2025
The Association’s management acknowledges the finding and has been working with DOL personnel on completing the required indirect cost rate proposals. Management will also engage a consultant to assist with the completion of the indirect cost rate proposals as soon as feasible.
The Association’s management acknowledges the finding and has been working with DOL personnel on completing the required indirect cost rate proposals. Management will also engage a consultant to assist with the completion of the indirect cost rate proposals as soon as feasible.
Finding 539551 (2024-005)
Significant Deficiency 2024
DCHS has reviewed its procedures and will ensure that awards are reported timely and accurately to FSRS and that documenation of compliance will be available for review.
DCHS has reviewed its procedures and will ensure that awards are reported timely and accurately to FSRS and that documenation of compliance will be available for review.
DCHS has reviewed its procedures and will ensure that suspension and debarement status is documented prior to contracting with a vendor.
DCHS has reviewed its procedures and will ensure that suspension and debarement status is documented prior to contracting with a vendor.
Finding 2024 - 003 - Housing Choice Vouchers Tenant Files Housing Choice Vouchers - CFDA No. 14.871; Grant period - year ended June 30, 2024 Corrective Action: The Authority will work on strengthening its internal controls to correct this situation and ensure that they will be in compliance with the...
Finding 2024 - 003 - Housing Choice Vouchers Tenant Files Housing Choice Vouchers - CFDA No. 14.871; Grant period - year ended June 30, 2024 Corrective Action: The Authority will work on strengthening its internal controls to correct this situation and ensure that they will be in compliance with the federal guidelines and the Authority’s policies. Responsible Party: Matthew McClammey, Executive Director, (334)745-4171. Anticipated Completion Date: June 30, 2025.
Finding 2024 - 002 - Section 8 HQS Inspection Deficiencies Housing Choice Vouchers - CFDA No. 14.871; Grant period - year ended June 30, 2024 Corrective Action: The Authority is continuing to work on the procedures for failed inspections to ensure that the reinspections are performed within the 30-d...
Finding 2024 - 002 - Section 8 HQS Inspection Deficiencies Housing Choice Vouchers - CFDA No. 14.871; Grant period - year ended June 30, 2024 Corrective Action: The Authority is continuing to work on the procedures for failed inspections to ensure that the reinspections are performed within the 30-day requirement. The Authority is also planning on additional training for employees to make sure they are qualified to meet the HQS re-inspection requirements. Responsible Party: Matthew McClammey, Executive Director, (334)745-4171. Anticipated Completion Date: June 30, 2025.
RESET is a cost reimbursement grant. The agency maintains an Excel workbook that tracks costs over the course of the 12-month award year. The workbook is updated prior to each month's request for reimbursement. The grant accountant accrued a reimbursable expense for clothing for September, then inex...
RESET is a cost reimbursement grant. The agency maintains an Excel workbook that tracks costs over the course of the 12-month award year. The workbook is updated prior to each month's request for reimbursement. The grant accountant accrued a reimbursable expense for clothing for September, then inexplicably entered a slightly different amount into the workbook. This l ne item was selected for audit, and the agency is unable to provide support for the difference. In addition, in October the grant accountant improperly recorded a payroll cost in the General Ledger and the grant workbook. While the documentation clearly shows how the amount was calculated, it was nor a legitimate period cost. The agency charges expenses to a unique department number in the General Ledger. Costs are assigned in the workbook to one of three categories: reimbursable, ineligible, and pending. The control process calls for the grant accountant to assign each GL expense to a category, then to ensure the workbook ties to the GL for the month and award year-to-date. An initial review indicates the control worked because the cost column for the month consistently matches the GL. A closer review shows that for September, the accountant matched the GL by entering a rounding error. Rounding errors should be limited to a penny or so. The control failed. The lack of accuracy and attention to detail is regrettable. The grant accountant is no longer with the agency. The grant accountant is responsible for the integrity of the workbook. The CFO is responsible for the overall integrity of the financial statements. The CFO and grant accountant meet monthly to review the workbook. The CFO reviews the workbook for reasonableness and completeness. This review includes observing the grant accountant's assertion that the workbook matches the GL. To reduce the risk of future errors, the CFO has 1. Reviewed the monthly process with the new grant accountant, emphasizing the need to match the GL. Status: Complete. 2. Created an agenda template for monthly workbook reviews. This agenda includes confirmation that the workbook matches the GL and identification of any amount of rounding for the month and award year-to-date. Status: Complete. 3. Added a step to the workbook. In addition to the current process of entering GL information to the workbook, the grant accountant will enter date of confirmation and save a copy of the GL that matches the workbook. Status: complete, effective as of January 2025 activity. 4. Added a step to the department's close checklist. The grant accountant explicitly confirms that Step 3 is done. Status: complete, effective as of January 2025 activity.
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.
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