Corrective Action Plans

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CORRECTIVE ACTION PLAN September 30, 2024 United States Department of Housing and Urban Development Mercer County Housing Authority respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of independent public accounting firm: Maher Duessel, CPA...
CORRECTIVE ACTION PLAN September 30, 2024 United States Department of Housing and Urban Development Mercer County Housing Authority respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of independent public accounting firm: Maher Duessel, CPA's 503 Martindale Street, Suite 600 Pittsburgh, PA 15212 Audit period: July 1, 2023 - June 30, 2024 The finding from the June 30, 2024 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS— FEDERAL AWARD PROGRAMS AUDITS Finding 2024-001 Section 8 Project-Based Cluster: Project Based Rental Assistance ALN # 14.195 Recommendation: The Company should follow the internal controls in place to ensure the accuracy of the application information entered into the tenant management system in order to ensure correct placement on the waiting list. Action taken: Management agrees with the finding, and as noted, has taken action to address the issue. Additional steps to prevent the issue from reoccurring are as follows: The Receptionist im-puts the applicant information in the system as well date and time stamps the application. When given to the Leasing Agent, she will revery the dates in the system match the application. Two-person verification before the application is filed away.
View Audit 324143 Questioned Costs: $1
Finding 2024-004 Planned corrective action: The checklist for CFP activity utilized by the Housing Agency was updated last year, but wording was updated this year to reflect the 3-day Treasury Rule. Nan McKay training varies from this rule. The Housing Agency made progress in this area this year, b...
Finding 2024-004 Planned corrective action: The checklist for CFP activity utilized by the Housing Agency was updated last year, but wording was updated this year to reflect the 3-day Treasury Rule. Nan McKay training varies from this rule. The Housing Agency made progress in this area this year, but will use the 3-day Treasury Rule as a guide and closely follow the checklist. Estimated completion date: The HA’s plan is to have this corrected at 2025’s audit. The CFP checklist was updated when the auditor was on-site and staff will closely utilize it.
Finding 2024-003 Planned corrective action: The Housing Agency has limited funds for additional staff hires. Internal controls will be implemented by building them into what the Board reviews monthly. This will provide additional oversight and aid in elimination of errors. Estimated completion dat...
Finding 2024-003 Planned corrective action: The Housing Agency has limited funds for additional staff hires. Internal controls will be implemented by building them into what the Board reviews monthly. This will provide additional oversight and aid in elimination of errors. Estimated completion date: The HA’s plan is to have this corrected at 2025’s audit. A new checklist of items for monthly Board review will be established within 30 days and followed.
Condition: The School District did not complete an on-site monitoring review for one building operating a school lunch program during the year ended June 30, 2024. Corrective Steps Taken: At this time, there have been some corrective steps taken to limit this from happening again which includes th...
Condition: The School District did not complete an on-site monitoring review for one building operating a school lunch program during the year ended June 30, 2024. Corrective Steps Taken: At this time, there have been some corrective steps taken to limit this from happening again which includes the Food Service Director better familiarizing herself with MDE’s requirements for on-site reviews. Corrective Steps to be Taken: The Food Service Director will coordinate the on-site monitoring reviews and its completion to Michigan Department of Education requirements. Monitoring: The plan for monitoring adherence is for the Superintendent to check in with he Food Service Director prior to the February 1st deadline to ensure all required on-site reviews were performed. Name of Responsible Person for Further Information: Tami Eisenga, Food Service Director and Scott Akom, Superintendent. Questioned Costs Related to this Finding: None.
Condition: The School District does not currently have a control in place whereby a review of the meal counts entered into the Michigan Nutrition Data (MiND) system takes place, which could result in an incorrect reporting of the number of free and reduced priced meals, which could result in the Sch...
Condition: The School District does not currently have a control in place whereby a review of the meal counts entered into the Michigan Nutrition Data (MiND) system takes place, which could result in an incorrect reporting of the number of free and reduced priced meals, which could result in the School District being reimbursed an incorrect amount by the Michigan Department of Education. Planned Corrective Action: The Business Office has implemented a formalized internal control procedure for the Food Service Department to adhere, alongside performing a thorough review of the monthly claims reimbursement submission. The formalized internal control procedure will accompany the supporting documentation submitted to the Business Office monthly (Attachment A). The procedure involves a review of inputted meal counts, prior to the claim submission. The Food Service Department Administrator responsible for meal claim input will provide corroboration of input accuracy, as documented by signoff from a secondary reviewer. In addition, the Business Office has prepared a Meal Claim Check Tool spreadsheet to utilize, on a monthly basis, as another layer of validation. The Meal Claim Check Tool spreadsheet allows the Business Office to input meal count figures from the Food Service POS system report and compare against the figures from the claims submission report. Any discrepancy identified would be immediately addressed with the Food Service Department and would require an amended claim submission. Contact person responsible for corrective action: Danielle Jacobs, Director of Business Services Anticipated Completion Date: 08/01/2024
View Audit 323903 Questioned Costs: $1
Finding 501793 (2024-002)
Significant Deficiency 2024
Student Financial Assistance Cluster— Assistance Listing Nos. 84.007, 84.033, 84.063,84.268 Recommendation: We recommend that the University review the updated GLBA requirements and ensure their WISP includes all required elements and is formally implemented. Explanation of disagreement with audit f...
Student Financial Assistance Cluster— Assistance Listing Nos. 84.007, 84.033, 84.063,84.268 Recommendation: We recommend that the University review the updated GLBA requirements and ensure their WISP includes all required elements and is formally implemented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Augsburg University will update its Written Information Security Program to: • Include a risk management section describing how Augsburg is identifying, assessing, and communicating risks. • Identify the use of multi-factor authentication for individuals accessing sensitive information across systems. • Define the procedures to in place to securely dispose of sensitive information. • Document procedures to monitor and log activity of authorized users and detect unauthorized activity. • Document the process for performing annual penetration tests and annual vulnerability assessments. Names of the contact persons responsible for corrective action: Scott Krajewski Planned completion date for corrective action plan: May 31, 2025
Finding 501787 (2024-001)
Significant Deficiency 2024
Student Financial Assistance Cluster— Assistance Listing Nos. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the University review its reporting procedures to ensure that students’ statuses are accurately and timely reported to NSLDS as required by regulations. Explanation of disagreeme...
Student Financial Assistance Cluster— Assistance Listing Nos. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the University review its reporting procedures to ensure that students’ statuses are accurately and timely 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: Student Financial Services is working with the Registrar and IT to review the current reporting system. Adjustments will be made to reporting process to ensure accurate and timely reporting of students’ enrollment status to NSLDS. Names of the contact persons responsible for corrective action: Amanda Burgess Planned completion date for corrective action plan: May 31, 2025
Finding 2024-002 Internal Control Structure Material Weakness – Eligibility, Reporting and Special Tests and provisions Repeat Finding 2023-002 I agree with finding The Authority is small with limited administrative staff. Further, the Board of Commissioners is a volunteer oversight board and not a...
Finding 2024-002 Internal Control Structure Material Weakness – Eligibility, Reporting and Special Tests and provisions Repeat Finding 2023-002 I agree with finding The Authority is small with limited administrative staff. Further, the Board of Commissioners is a volunteer oversight board and not a managing board and does not have the time or expertise to provide the necessary services to correct the internal control deficiencies noted. The Board has reviewed the issue and determined that there are no additional procedures which can be done to eliminate the deficiencies and accepts them at this time.
Finding #2024-002 – Material Weakness and Other Noncompliance. Applicable federal program: U. S. Department of Health and Human Services, Family Planning Services, Assistance Listing #93.217, Contract Number: FPHPA006521-02-00, Contract Year: 04/01/23 – 03/31/24. Condition and context: The find...
Finding #2024-002 – Material Weakness and Other Noncompliance. Applicable federal program: U. S. Department of Health and Human Services, Family Planning Services, Assistance Listing #93.217, Contract Number: FPHPA006521-02-00, Contract Year: 04/01/23 – 03/31/24. Condition and context: The finding reported as finding #2024-001 includes adjustments for the year ended March 31, 2024 to increase federal expenditures by $220,388. Recommendation: See finding #2024-001. Planned corrective action: WHFPT will strengthen its policies and procedures by documenting the subrecipient reconciliation process in greater detail and will add a requirement for additional reviews. Responsible officer: Kathie Nixon, CEO. Estimated completion date: October 31, 2024
Finding 501689 (2024-001)
Significant Deficiency 2024
Student Financial Assistance – Assistance Listing No. 84.063, 84.268 Recommendation: CLA recommends that the College update their procedures to identify changes in breaks for purposes of R2T4 calculations. Explanation of disagreement with audit finding: There is no disagreement with the audit findi...
Student Financial Assistance – Assistance Listing No. 84.063, 84.268 Recommendation: CLA recommends that the College update their procedures to identify changes in breaks for purposes of R2T4 calculations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Corrective action was taken immediately. R2T4 calculations for 2024-25 include a five-day break for fall semester (Thanksgiving Break November 27 – December 1). Name(s) of the contact person(s) responsible for corrective action: Jenae Schmidt Planned completion date for corrective action plan: September 1, 2024 If the Department of Education has questions regarding this plan, please call Jenae Schmidt at 651-696-6214.
View Audit 323740 Questioned Costs: $1
Segregation of Duties Supportive Housing for the Elderly – Assistance Listing No. 14.157 Recommendation: The Project should continue to evaluate its staffing in order to segregate incompatible duties whenever possible. Explanation of disagreement with audit finding: There is no disagreement with the...
Segregation of Duties Supportive Housing for the Elderly – Assistance Listing No. 14.157 Recommendation: The Project should continue to evaluate its staffing in order to segregate incompatible duties whenever possible. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The board of directors will continue to closely monitor the financial operations of the Project. Name(s) of the contact person(s) responsible for corrective action: Mary Gilberts, Management Agent Planned completion date for corrective action plan: June 2025
Plan: A second staff member will review certifications and annual certifications to ensure accuracy based on the required back up documentation. Contact: Christina Morin, Program Director. Anticipated completion date: September 1, 2025.
Plan: A second staff member will review certifications and annual certifications to ensure accuracy based on the required back up documentation. Contact: Christina Morin, Program Director. Anticipated completion date: September 1, 2025.
Student financial aid programs cluster Significant Deficiency in Internal Control Condition: During our testing of the regulations, one student who was identified as a withdrawn student did not have the proper calculation performed to determine if funds should be returned in accordance with the ...
Student financial aid programs cluster Significant Deficiency in Internal Control Condition: During our testing of the regulations, one student who was identified as a withdrawn student did not have the proper calculation performed to determine if funds should be returned in accordance with the regulations. Auditor Recommendations: The University should continue to update processes and procedures to ensure compliance in the future. These updated processes should include adequate segregation of duties and review steps to ensure that all students who are subject to potential recapture and return of funds are analyzed in the time frame dictated by the CFR. Action Taken: A new weekly quality assurance report has been created that identifies all withdrawn students. It identifies any student that requires a return calculation in the financial aid management system, and that all required Title IV aid has been returned. The report is generated and reviewed by both the Associate Director and Assistant Director of Financial Aid to ensure adequate segregation of duties and review. This report was run for the entirely of fiscal year 2024 and no other returns were found to be outstanding.
During the past few months management has been in discussions with two banks and reviewing their options for either opening accounts with corresponding banks or purchasing revolving Treasury notes. A final decision will be made in the current fiscal year.
During the past few months management has been in discussions with two banks and reviewing their options for either opening accounts with corresponding banks or purchasing revolving Treasury notes. A final decision will be made in the current fiscal year.
We have corrected/updated the clients records where necessary. Subsequent to your field work the client files were updated for the rent and deposit calculations. William Mann, Housing Coordinator, will be the responsible party.
We have corrected/updated the clients records where necessary. Subsequent to your field work the client files were updated for the rent and deposit calculations. William Mann, Housing Coordinator, will be the responsible party.
FINDING 2024‐002 – Special Tests and Provisions – Return of Title IV (R2T4) Funds Significant Deficiency in Internal Control over Compliance Recommendation: The University should design and implement a robust review process of all R2T4 calculations for official and unofficial withdrawals. This will ...
FINDING 2024‐002 – Special Tests and Provisions – Return of Title IV (R2T4) Funds Significant Deficiency in Internal Control over Compliance Recommendation: The University should design and implement a robust review process of all R2T4 calculations for official and unofficial withdrawals. This will help ensure the accuracy of the calculation before the return of funding. Response: There is no disagreement with this audit finding. Action taken in response to finding: To ensure the accuracy of R2T4 calculations, the Student Financial Services Office will take the following actions: • Implementation of R2T4 Module: Starting with the 2024-2025 academic year, the Financial Aid Office will utilize the Banner-delivered R2T4 module to perform calculations, ensuring more accurate and consistent data management. • Multi-Step Review Process: A multi-step review process has been implemented by Student Financial Services staff to ensure thorough verification of all R2T4 calculations and timely returns of funds. • Enhanced Training: Staff are pursuing additional training on R2T4 regulations and procedures to further strengthen their expertise and reduce the risk of future discrepancies. These actions are in process currently, and expected to be fully implemented and corrected by October 2024 to ensure that R2T4 calculations are prepared and reviewed for accuracy for the 2024-2025 award year. Enhanced training will continue on a go forward basis. Contact Person(s): Louisa Diana, Director of Compliance; Sarah Everitt, Dean of Student Financial Services;
FINDING 2024‐001 – Special Tests and Provisions – Enrollment Reporting Significant Deficiency in Internal Control over Compliance Recommendation: The University should implement a policy to ensure graduates for all semesters/terms are reported timely. Response: There is no disagreement with this aud...
FINDING 2024‐001 – Special Tests and Provisions – Enrollment Reporting Significant Deficiency in Internal Control over Compliance Recommendation: The University should implement a policy to ensure graduates for all semesters/terms are reported timely. Response: There is no disagreement with this audit finding. Action taken in response to finding: Upon identifying this deficiency, Gonzaga University immediately updated its enrollment reporting schedules to ensure timely reporting of mid-summer conferrals. Going forward, all mid-summer degree conferrals will be reported within the required federal timeframe to maintain compliance with Title IV regulations. This adjustment guarantees accurate and timely data submission to the National Student Loan Data System (NSLDS), preventing future delays or discrepancies in reporting. Our new schedule has 9 reporting dates for degree transmission and 14 reporting dates for enrollment transmission in a calendar year. The increased frequency ensures compliance with the 60-day threshold and guarantee that no student will be reported outside the 60-day threshold. We consider this to be remediated. Contact Person(s): Sarah Everitt, Dean of Student Financial Services; Maxwell Kwenda, University Registrar & Director of Institutional Research
1. The CFO will generate an exception report directly from eCW, the health records system where billing records are recorded, to identify mismatches between the claim slide group write-off and the slide group assignment on the patient info screen. 2. The initial exception report will be run during t...
1. The CFO will generate an exception report directly from eCW, the health records system where billing records are recorded, to identify mismatches between the claim slide group write-off and the slide group assignment on the patient info screen. 2. The initial exception report will be run during the week of September 16th with a 12-month look-back period. Any slide adjustments posted in eCW with effective dates within those 12 months and later will be evaluated for matches to Patient Slide Group assignments determined during the slide eligibility process. 3. The billing team and CFO will meet on September 18th to review the report and findings. 4. All exceptions from the exception report will be reviewed by the billing team. Any necessary adjustments will be made in eCW. 5. All exceptions listed in the exception report will be marked, and comments will be added to the exception report regarding the actions taken on those exceptions. All changes will also be documented in eCW notes. 6. The exception report will be signed off by each billing team member who worked on it and sent for final review and approval to the CFO. 7. The CFO will train the billing team on how to run this report directly from eCW. 8. The report will be run monthly on the 10th business day of each month for the trailing prior 12 months as part of the month-end closing process. After initial report on September 18th, 2024, the next monthly report will start on October 14th, 2024.9. All exceptions from the report will be reviewed by the billing team. Any necessary adjustments will be made in eCW. 10. Any exceptions will be addressed, corrected within two business days, and posted in the month being closed for the month end. 11. All exceptions listed in the exception report will be marked, and comments will be added to the report regarding the actions taken on those exceptions. All changes will also be documented in eCW notes. 12. The exception report will be signed off by each billing team member who worked on it and sent for final review and approval by the CFO monthly.
Completed corrective action: Manager completed correction and new HUD 50059A recertification's corrected for June 30, 2024. Ongoing Corrective Action: Additional file review after recertifications and move-ins. Additional trainings for Income VS Assets for all managers. Complete review of all previ...
Completed corrective action: Manager completed correction and new HUD 50059A recertification's corrected for June 30, 2024. Ongoing Corrective Action: Additional file review after recertifications and move-ins. Additional trainings for Income VS Assets for all managers. Complete review of all previous manager's files.
Completed corrective action: Manager completed correction and new HUD 50059A recertification's corrected for June 30, 2024. Ongoing Corrective Action: Additional file review after recertifications and move-ins to be compeleted by a different manager. Additional trainings for Income VS Assets for all...
Completed corrective action: Manager completed correction and new HUD 50059A recertification's corrected for June 30, 2024. Ongoing Corrective Action: Additional file review after recertifications and move-ins to be compeleted by a different manager. Additional trainings for Income VS Assets for all managers. Complete review of all previous manager's files.
2024-002 Housing Voucher Cluster – Assistance Listing No. No. 14.871 and 14.879 Recommendation: We recommend the housing authority designate an individual to assure HQS inspections are completed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding...
2024-002 Housing Voucher Cluster – Assistance Listing No. No. 14.871 and 14.879 Recommendation: We recommend the housing authority designate an individual to assure HQS inspections are completed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Although the agency understands the basis of the finding, the Agency feels the item in question for the inspection date is outside the scope of the audit dates which are July 1, 2023, to June 30, 2024. Additionally, when the agency discovered the error in March 2023 during a time of restructuring a very high turnover department, the newly appointed management and leadership took immediate action in correcting the inspection to be compliant. In addition to our current HCV internal processes, the agency has added an inspection section to review a 10% sample of all inspections monthly to ensure compliance. Name(s) of the contact person(s) responsible for corrective action: Morgan Gower Planned completion date for corrective action plan: In progress as of September 2024 and is ongoing.
2024-001 Housing Voucher Cluster – Assistance Listing No. No. 14.871 and 14.879 Recommendation: We recommend management should designate one person to review a sample of the files that have been recertified each month. The purpose of the review is to determine if the tenant files were prepared in a...
2024-001 Housing Voucher Cluster – Assistance Listing No. No. 14.871 and 14.879 Recommendation: We recommend management should designate one person to review a sample of the files that have been recertified each month. The purpose of the review is to determine if the tenant files were prepared in accordance with internal policies and verify the compliance deficiencies have been corrected. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Our internal audits take place monthly. The HCV department leadership pulls the list of recertifications, interims, and new admissions and samples 10% of each to ensure they have been done correctly, with all information documented. This internal audit includes checking the rent calculation, utilities, verification documents, and tenant/landlord notification. The agency has been completing this internal practice consistently since February 2024. Name(s) of the contact person(s) responsible for corrective action: Morgan Gower Planned completion date for corrective action plan: In progress as of February 2024 and is ongoing.
View Audit 323421 Questioned Costs: $1
Finding 2024-002 – Disbursement Support Condition: Kanesville’s disbursements omitted required support in accordance with the HUD handbook and PRAC contract This finding occurred when M3 was managing the property. Kanesville hired a new management agent that is familiar with HUD standards. Correctiv...
Finding 2024-002 – Disbursement Support Condition: Kanesville’s disbursements omitted required support in accordance with the HUD handbook and PRAC contract This finding occurred when M3 was managing the property. Kanesville hired a new management agent that is familiar with HUD standards. Corrective Action Plan: Management agent is currently retaining documentation concerning disbursements in compliance with the HUD handbook and PRAC contract. Status: Completed.
Finding 2024-001 – Tenant Files Condition: Kanesville’s tenant move out files omitted required elements in accordance with the HUD handbook and PRAC contract. This finding occurred when M3 was managing the property. Kanesville hired a new management agent that is familiar with HUD standards. Correct...
Finding 2024-001 – Tenant Files Condition: Kanesville’s tenant move out files omitted required elements in accordance with the HUD handbook and PRAC contract. This finding occurred when M3 was managing the property. Kanesville hired a new management agent that is familiar with HUD standards. Corrective Action Plan: Management agent is currently documenting tenant move out files in compliance with the HUD handbook and PRAC contract. Status: Completed.
After reviewing the analysis for this finding, the housing department will initiate the proper paperwork to process the refunds. William Mann, Housing Coordinator, will be the responsible party.
After reviewing the analysis for this finding, the housing department will initiate the proper paperwork to process the refunds. William Mann, Housing Coordinator, will be the responsible party.
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