Corrective Action Plans

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Condition: Free or reduced meals applications could not be provided. The Food Service Department did not process free or reduced priced meals applications for the 2022-2023 school year. Corrective Action Planned: The School District has hired a qualified leader for the School Nutrition Program i...
Condition: Free or reduced meals applications could not be provided. The Food Service Department did not process free or reduced priced meals applications for the 2022-2023 school year. Corrective Action Planned: The School District has hired a qualified leader for the School Nutrition Program in order to comply with the requirements of this program. Additionally, the school district has enrolled all but the Brooks Elementary School as Community Eligibility Provision (CEP) sites and we are no longer required to collect these forms. At the Brooks School, these forms were sent to families from the Brooks School during the FY24 school year. Despite the efforts of the school and Food Services Director, no forms were returned to the school. Presently the forms are not required for the Brooks as the CEP eligibility requirements were reduced from 40% to 25% for determination. Anticipated Completion Date: 2/15/2025 Contact: Peter Cushing, Assistant Superintendent
Condition: Claims support could only be provided by the School for two months. For one month, support was in the form of spreadsheets with tray counts in lieu of a point-of-sale system. For the other month, the tray count spreadsheets were accompanied by reports from the point-of-sale system. Th...
Condition: Claims support could only be provided by the School for two months. For one month, support was in the form of spreadsheets with tray counts in lieu of a point-of-sale system. For the other month, the tray count spreadsheets were accompanied by reports from the point-of-sale system. The point-of-sale system reports provided did not agree to the amounts claimed for reimbursement. The tray counts did not indicate whether the meal provided was paid, free or reduced. The claims for reimbursement submitted by the School used allocation percentages derived from prior year claims when estimating amounts to be claimed as paid, free and reduced. The tray count spreadsheets for the other months could not be located by the School. Corrective Action Planned: In January 2023 DESE sent an auditor to review the Medford School Nutrition Program. Before this review, there was significantly limited oversight by the central office finance team. Almost no documents were prepared before the review as required by DESE. As a result of this audit a 58-item, 19-page Corrective Action Plan was issued to the district. A new district leader was assigned for departmental oversight. The district then had weekly meetings with DESE to address the corrective action plan, for this was the single largest CAP DESE has issued to any district of our size. Nearly $1.3 million in reimbursements were withheld from the district from approximately November 2022 through the end of the Fiscal Year. DESE issued the reimbursements with a nominal penalty during the summer of 2023. At the end of FY23, the district terminated the director of the program. We are now training several individuals in the MCPPO program for enhanced oversight. DESE forced an immediate return audit for FY24. This was an exceptional action as DESE has only rarely done this. The same reviewer attended and noted significant improvements as a result of district actions undertaken. As relates to this particular finding, the School Department has purchased and is consistently using a point of sale system for students to purchase their meals. The system is used to track all transactions. Anticipated Completion Date: 2/17/2025 Contact: Peter Cushing, Assistant Superintendent
View Audit 341024 Questioned Costs: $1
The Meadows Mental Health Policy Institute for Texas (the Institute) respectfully submits the following corrective action plan for the year ended December 31, 2023. Audit period: 01/01/2023 – 12/31/2023 The findings from the Schedule of Findings and Questioned Costs identified in the December 05, 20...
The Meadows Mental Health Policy Institute for Texas (the Institute) respectfully submits the following corrective action plan for the year ended December 31, 2023. Audit period: 01/01/2023 – 12/31/2023 The findings from the Schedule of Findings and Questioned Costs identified in the December 05, 2024, audit report are discussed below. Findings are numbered consistently with the numbers assigned in the schedule. Findings – Federal Awards Audit Significant Deficiency Federal Awards Program Audit Findings and Recommendations Finding 2023-001: Reporting – significant deficiency in internal control over compliance and compliance finding. All federal grants. Criteria: Grantees who are subject to single audit requirements are required to submit their Data Collection form to the Federal Audit Clearinghouse within the earlier of 30 calendar days after receipt of the auditors’ report or 9 months after the audit period. Condition: The Institute’s Data Collection form was late for the years ended December 31, 2022, and 2023. Cause: Delays in completing the audits resulted in the Data Collection forms being submitted after 9 months from the end of the audit report. Effect: The Institute was not in compliance with single audit reporting requirements. Recommendation: Internal controls and processes should be implemented to ensure audits are completed in a timely manner to meet federal reporting deadlines. Institute Action Plan: • Hire new finance and accounting senior management [completed November 2024]. o Hired new CFO (October 2024; started January 02, 2025) o Hired new Controller (November 2024; starts February 17, 2025) Establish timeline for review and acceptance of 2024 audit [initiated December 2024]. o By May 01, 2025: Institute submits 2024 General Ledger and Trial Balance to auditor o May 01, 2025 – May 11, 2025: Auditor sends sample and other requests for information o May 12, 2025 – May 23, 2025: Audit fieldwork o Week of July 07, 2025: Auditor sends draft audit report to Institute management for review. o Week of July 21, 2025: Institute management reviews draft audit report and notes areas needing clarification and/or corrections. o By Week of August 11, 2025: Auditor provides a final revised audit report to Institute management. o Week of August 18, 2025: Institute management sends audit report to the Institute Board’s Audit and Finance Committee for review. o By week of September 1, 2025: The Audit and Finance Committee meets to review and accept final audit report on behalf of the Board. o By September 15, 2025: Data Collection Form is submitted to the Federal Audit Clearinghouse (i.e., well in advance of the September 30, 2025, submission due date for the Data Collection Form). o October 29, 2025: The Institute Board ratifies the Audit and Finance Committee’s acceptance of final audit report. • Q1-Q2 2025: Perform gap analysis evaluation of existing Accounting staff and address any gaps in coverage and provide access to and training on financial systems and historical data archives [initiated and ongoing]. Corrective Action Contact Person(s): Maryana Geller, Chief Financial and Administrative Officer Planned Completion Date for Corrective Action Plan: September 15, 2025
Internal control over payroll and disbursements In January 2023 changes to any pay rates were submitted on a Personnel Action Form (PAF) by the Operations Manager. The PAF included the old pay rate and the new pay rate and was submitted to the Executive Director for review and approval. After app...
Internal control over payroll and disbursements In January 2023 changes to any pay rates were submitted on a Personnel Action Form (PAF) by the Operations Manager. The PAF included the old pay rate and the new pay rate and was submitted to the Executive Director for review and approval. After approval, the form was filed in the employees paper file, as well as uploaded to their electronic record on the ProService platform. In May 2024, we hired a Human Resources Specialist who is responsible for updating and maintaining all personnel files and processing of payroll records. In October 2023, we hired an Accounting Specialist (AS) who is responsible for the processing of all vendor disbursements. Prior to ordering items or services, a Purchase Requisiton (PR) is submitted by the program manager to the Executive Director or Programs Director for review and approval. Upon approval the PR is submitted to the Controller for expense and grant coding. PR is then submitted to the AS to assign a PR number and enter the expenses on the PR tracking log. When the PR has been assigned a PR number it is sent to the Operations Manager for purchasing. When the invoice is received the PR is matched to the invoice indicating proper approvals. If the purchase is over $5,000, a Procurement form is completed to solicit 3 bids and reviewed and approved by the Executive Director. If the purchase is over $20,000, the Procurement form is submitted to the Board of Directors for approval. All Procurement forms are attached to invoices for payment processing. Internal control over account balances During the fiscal year, it was noted that there were credit card entries that were duplicated, and have been corrected as of the date of this report. Due to miscommunication with the previous fiscal staff, payments made by credit card were entered as an invoice and as an adjusting journal entry.
We concur with the finding. During the fiscal year 2024-2025, all participant files will be revised to include all missing documents referred to in the finding.
We concur with the finding. During the fiscal year 2024-2025, all participant files will be revised to include all missing documents referred to in the finding.
2023-001 – Special Test and Provision – Wage Rate Requirement – Material Weakness in Internal Controls over Compliance/Material Noncompliance Recommendation: The auditor recommends the Organization strengthen the controls in place to provide assurance that contract agreements entered into with subco...
2023-001 – Special Test and Provision – Wage Rate Requirement – Material Weakness in Internal Controls over Compliance/Material Noncompliance Recommendation: The auditor recommends the Organization strengthen the controls in place to provide assurance that contract agreements entered into with subcontractors contain the required clauses set by Davis-Bacon Act and projects that fall under the requirement maintain the weekly certified payrolls. Action Taken: The Director of Operations and management is aware of the noncompliance with the Davis-Bacon Act wage rate requirement. We understand the importance of implementing sound internal controls to ensure the company meets all federal and state compliance requirements. To prevent future noncompliance findings, The Learning Tree, Inc. will implement staff training to fully adhere to all applicable federal and state compliance requirements. In addition, the company will increase oversight over federal grant programs. Responsible Person: Ben Rogers, Director of Operations Anticipated Completion Date: December 31, 2024.
View Audit 340570 Questioned Costs: $1
The District continues to have segregation of duties as a priority. We accept the auditor’s guidance and continue to keep the task of segregation of duties as a priority.
The District continues to have segregation of duties as a priority. We accept the auditor’s guidance and continue to keep the task of segregation of duties as a priority.
2023-004 Ineffective Internal Controls over Sliding Fee Revenues Health Center Program – CFDA #93.527 & 93.224 Condition: During the compliance testing of the Uniform Guidance “Special Tests and Provisions – Sliding Fee Applications” requirements, we noted the following exceptions: • Three (3) out...
2023-004 Ineffective Internal Controls over Sliding Fee Revenues Health Center Program – CFDA #93.527 & 93.224 Condition: During the compliance testing of the Uniform Guidance “Special Tests and Provisions – Sliding Fee Applications” requirements, we noted the following exceptions: • Three (3) out of eighteen (18) sampled did not have the slide fee applied to the lab portion. • Two (2) out of eighteen (18) sampled were calculated incorrectly based on the sliding fee schedule (wrong sliding fee applied based on application). • Two (2) out of eighteen (18) sampled were missing applications. • One (1) out of eighteen (18) sampled were incorrectly in the system with a medical slide A on a dental charge. This patient was also one of the sampled items missing an application so it could not be determined if slide A would have been correct. Action Taken: • CHESI has implemented a new workflow process to ensure compliance with the program requirements of the sliding fee program. CHESI has developed a new sliding fee procedure and trained all staff to ensure the applications are complete and signed by the patient, income is verified, the proper discount is calculated based on the sliding fee schedule, the proper amount of discount is applied to the patient’s account, and the application is approved and signed by the CFO. All sliding fee applications will also be scanned into the patient’s chart once completed and approved. Anticipated Date of Completion and Name of Contact Person: December 31, 2023 – J.P. Champion, Chief Financial Officer
Management will continue to rely on CliftonLarsonAllen to draft the financial statements and the related notes to the financial statements, and will review, approve, and accept responsibility for the annual financial statements prior to their issuance.
Management will continue to rely on CliftonLarsonAllen to draft the financial statements and the related notes to the financial statements, and will review, approve, and accept responsibility for the annual financial statements prior to their issuance.
The Authority’s Board of Commissioners and management will continue to rely on the use of their outside auditors to prepare draft financial statements that were presented in accordance with generally accepted accounting principles. Management will assign a person within the Authority with the skills...
The Authority’s Board of Commissioners and management will continue to rely on the use of their outside auditors to prepare draft financial statements that were presented in accordance with generally accepted accounting principles. Management will assign a person within the Authority with the skills, knowledge and expertise to review and approve the draft financial statements.
Finding 520554 (2023-004)
Significant Deficiency 2023
Coronavirus State and Local Fiscal Recovery Funds -Assistance Listing No. 21.027 Recommendation: We recommend that approval of all expenditures, whether initiated by an invoice or a journal entry be documented. In the case where the expenditure is likely to be charged to a Federal program, it is rec...
Coronavirus State and Local Fiscal Recovery Funds -Assistance Listing No. 21.027 Recommendation: We recommend that approval of all expenditures, whether initiated by an invoice or a journal entry be documented. In the case where the expenditure is likely to be charged to a Federal program, it is recommended there be documentation of approval from someone knowledgeable of allowability of costs (it is permissible if this is the same individual as the initial approver). Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Ventures has moved to keeping copies of the check requests/payment requests and invoice in a restricted folder. The check request is initiated by someone knowledgeable of the program and approved by an overseeing director, also knowledgeable of the program. These two documents are required for accounting to pay and will be returned without proper approval and corresponding invoice. Name(s) of the contact person(s) responsible for corrective action: Theo Everheart and Monique Valenzuela Planned completion date for corrective action plan: 09/30/2024
View Audit 340111 Questioned Costs: $1
FA 2023-003 Improve Controls over Cash Management Compliance Requirement: Cash Management Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listi...
FA 2023-003 Improve Controls over Cash Management Compliance Requirement: Cash Management Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: 84.010 - Title I Grants to Local Educational Agencies Federal Award Number: SO10A210010-21A (Year: 2022) SO10A220010 (Year: 2023) Questioned Costs: None Identified Repeat of Prior Year Finding: FA 2022-003, FA 2021-001, FA 2020-001, FA 2019-001, FA 2018-001, FA 2017-002, FA 2016-001, FA 2015-002, FA 2014-003 Description: The School District made cash drawdowns in excess of immediate cash needs for the Title I Grants to Local Educational Agencies and Elementary and School Emergency Relief Fund programs. Corrective Action Plans: District office has put procedures in action to make sure that all drawdowns are in line with expenditures. All draw down packets will be viewed and singed off by federal programs director. This packet will include detail expenditure sheet for the month, year to date expenditure report and a cover sheet. Estimated Completion Date: December 31, 2024 Contact Person: Torrence H. Freeman, III CFO Telephone: 706-665-8577 Email: tfreeman@talbot.k12.ga.us
Invoices received by NYSSA pertaining to Federal Grants will be given to the Deputy Director, Lucas Ashby for review. (current procedure). Invoices to be paid will be entered into Quickbooks financial software by the Finance Manager, Jon Greenwalt (current procedure). Checks for payment to grant ven...
Invoices received by NYSSA pertaining to Federal Grants will be given to the Deputy Director, Lucas Ashby for review. (current procedure). Invoices to be paid will be entered into Quickbooks financial software by the Finance Manager, Jon Greenwalt (current procedure). Checks for payment to grant vendors follow the same procedures and processes as listed in 2022-001 above, numbers 1 and 2 [New procedure implemented]. Based on the timeline of the 2022 audit, many of the corrective actions were made in late Oct/November 2023.
FINDING 2023-007: LACK OF INTERNAL CONTROLS OVER COMPLIANCE Corrective Action Plan A compliance management framework will be developed by March 31, 2025, and training for relevant staff will begin shortly thereafter. Monitoring mechanisms and documentation practices will also be implemented to ensu...
FINDING 2023-007: LACK OF INTERNAL CONTROLS OVER COMPLIANCE Corrective Action Plan A compliance management framework will be developed by March 31, 2025, and training for relevant staff will begin shortly thereafter. Monitoring mechanisms and documentation practices will also be implemented to ensure ongoing compliance. Estimated Completion Date: 3/31/2025 Contact Person for Implementation of All Corrective Action Plans: Andre Thomas (Executive Director) (773) 756-6806
Finding 520151 (2023-004)
Significant Deficiency 2023
Auditor's Recommendation – CRI recommends that the contract immediately be amended to include the required prevailing wage rate clauses. Furthermore, a review process should be implemented to ensure all future contracts comply with prevailing wage requirements. Views of Responsible Officials and Pla...
Auditor's Recommendation – CRI recommends that the contract immediately be amended to include the required prevailing wage rate clauses. Furthermore, a review process should be implemented to ensure all future contracts comply with prevailing wage requirements. Views of Responsible Officials and Planned Corrective Action – Prior to the transfer of the Housing Authority to the Eastern Regional Housing Authority (ERHA), the City of Alamogordo did not understand the limitations of the ERHA accounting and financial system. Since this time, the City has had multiple conversations with ERHA leadership about their financials systems. The City has no authority over ERHA and does not expect any changes in their accounting practices. Responsible Person – ERHA Accounting Staff Targeted Date of Completion – Fiscal Year 2025
Finding 2023-002-SpecialTests and Provisions-Citizen Participation Repeat Finding-See Finding 2022-003 Recommendation: We recommend the City implement internal control procedures to ensure compliance with citizen participation requirements and such documentation is maintained for annual HUD submissi...
Finding 2023-002-SpecialTests and Provisions-Citizen Participation Repeat Finding-See Finding 2022-003 Recommendation: We recommend the City implement internal control procedures to ensure compliance with citizen participation requirements and such documentation is maintained for annual HUD submission. Action Taken: The City has adopted HUD regulations to comply with all citizen participation requirements (24 CFR 91.105). These were implemented January 1, 2024.
Finding 520094 (2023-002)
Significant Deficiency 2023
Finding 2023 – 002: Audit Journal Entries Condition: During audit fieldwork, our testing resulted in audit adjustments in order to present materially accurate financial statements. Plan: The Finance Director, along with staff, will review year-end adjustments as part of the audit preparation process...
Finding 2023 – 002: Audit Journal Entries Condition: During audit fieldwork, our testing resulted in audit adjustments in order to present materially accurate financial statements. Plan: The Finance Director, along with staff, will review year-end adjustments as part of the audit preparation process and work to reduce the number of entries proposed by the auditors and prepare fully adjusted financial statements prior to audit fieldwork. Anticipated Date of Completion: December 31, 2024
Finding 2023 – 001: Restatement to Fund Balance Condition: During audit fieldwork, our testing resulted in a restatement of fund balance in order to correct insurance improperly recorded in prior years. Plan: The Village will implement internal controls to properly record insurance expenses, payable...
Finding 2023 – 001: Restatement to Fund Balance Condition: During audit fieldwork, our testing resulted in a restatement of fund balance in order to correct insurance improperly recorded in prior years. Plan: The Village will implement internal controls to properly record insurance expenses, payables, and prepaid expenses on a timely basis prior to audit fieldwork. Additionally, the Finance Director will provide monthly reviews of the financial statements. Anticipated Date of Completion: December 31, 2024
CAMcare has made significant revisions to the financial screening department's leadership and workflows. We have since revised our Sliding Fee Scale Policy, the scale itself, and the SOPs for both Financial Screening of Uninsured and Underinsured Patients and Financial Assistance. All patient regist...
CAMcare has made significant revisions to the financial screening department's leadership and workflows. We have since revised our Sliding Fee Scale Policy, the scale itself, and the SOPs for both Financial Screening of Uninsured and Underinsured Patients and Financial Assistance. All patient registration areas have the latest board-approved sliding fee scale, and the changes were announced during a weekly staff huddle. All PSRs and Financial Screeners were made aware of the change. The new Manager of the financial screening department has provided the team with subject matter expertise, additional training, and increased accountability in work product. CAMcare also has a new EMR system, Epic, (December of 2023) where applications are housed and tracked, creating a single record for financial screening with patient changes being more streamlined. The latest sliding fee scales have been uploaded to the EMR. Patients with applications in progress can be edited as needed more efficiently.
Finding 520084 (2023-003)
Material Weakness 2023
CORRECTIVE ACTION PLAN FINDING 2023-003 Contact Person Responsible for Corrective Action: Ragen Hatcher Contact Phone Number: 219‐881‐5085 View of Responsible Officials: We Concur Description of Corrective Action: The City will work with the department to develop a review process for the PR29 quarte...
CORRECTIVE ACTION PLAN FINDING 2023-003 Contact Person Responsible for Corrective Action: Ragen Hatcher Contact Phone Number: 219‐881‐5085 View of Responsible Officials: We Concur Description of Corrective Action: The City will work with the department to develop a review process for the PR29 quarterly reports, Section 2 Summary Reports, and FFATA report prior to submission to address internal control concerns. Anticipated Completion Date: November 2025
Department of Transportation Safer New Mexico Now, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. Audit period: January 1, 2023 to December 31, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings...
Department of Transportation Safer New Mexico Now, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. Audit period: January 1, 2023 to December 31, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FINANCIAL STATEMENT AUDIT There were no findings or matters required to be reported in accordance with Governmental Auditing Standards. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS SIGNIFICANT DEFICIENCY Department of Transportation 2023-01 ALLOWABILITY – INTERNAL CONTROLS OVER PAYROLL DISBURSEMENTS, FINANCIAL CLOSE, AND REPORTING (REPEATED - PREVIOUSLY 2022-02) Federal Program Title(s): ALN 20.600 – State and Community Highway Safety ALN 20.608 – Minimum Penalties for Repeat Offenders for Driving While Intoxicated ALN 20.616 – National Priority Safety Program Recommendation: CLA recommends management continue to assess the current procedures for payroll allocations to ensure that expenditures are not claimed in error.. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action Planned/Taken in response to finding: The individual directly responsible for the errors is no longer with the Organization and the duties related to payroll have been assigned to someone more familiar with the responsibility that the role entails. The Organization has retained the services of a skilled accounting team to conduct a thorough review and assessment of all payroll related policies and procedures. As a result, processes have been updated and duties have been segregated related to this process. The Organization has implemented new procedures to verify and confirm payroll allocations, added in additional layers of review, and reinforced accountability to ensure accurate reporting and allocation moving forward. Name(s) of the contact person(s) responsible for corrective action: Lisa Kelloff, CEO Planned completion date for corrective action plan: Safer has currently implemented the above noted responses to the finding during 2024. If the Department of Transportation or other Cognizant or Oversight Agency for Audit has questions regarding this plan, please call Lisa Kelloff, CEO at 505-856-6143.
View Audit 339565 Questioned Costs: $1
NICAA will be strengthening their controls around year end close reporting. NICAA will be transitioning to MIP grant fund accounting system. This system will be implemented by year end of 2025
NICAA will be strengthening their controls around year end close reporting. NICAA will be transitioning to MIP grant fund accounting system. This system will be implemented by year end of 2025
The Director of Finance and Accounting Manager are working with the Billing Specialists to ensure all invoices are filed in a timely manner to funders. The importance of understanding the requirements of the agreements has been stressed to the finance team. The team has also been instructed to save ...
The Director of Finance and Accounting Manager are working with the Billing Specialists to ensure all invoices are filed in a timely manner to funders. The importance of understanding the requirements of the agreements has been stressed to the finance team. The team has also been instructed to save on SharePoint all communication with funders regarding changes of when invoices are to be filed when the instructions differ from the agreement. These conversations occurred with the team in July 2024.
The Director of Finance and Accounting Manager are working with the Billing Specialists and program managers and directors to ensure all reports are filed in a timely manner to funders. The internal procedures include required communication between Accounting Manager and finance or program staff to ...
The Director of Finance and Accounting Manager are working with the Billing Specialists and program managers and directors to ensure all reports are filed in a timely manner to funders. The internal procedures include required communication between Accounting Manager and finance or program staff to verify the reports were prepared and submitted following the contract requirements. These conversations occurred with the finance team in July 2024 and program managers and directors in December 2024.
The District reviews this audit finding internally on an annual basis, identifying control procedures and processes that would leverage movement toward the maximum internal control possible with available staffing. The District does recognize this is difficult with a limited number of employees. We ...
The District reviews this audit finding internally on an annual basis, identifying control procedures and processes that would leverage movement toward the maximum internal control possible with available staffing. The District does recognize this is difficult with a limited number of employees. We will continue to review our procedures to best meet the needs of the District as well as have internal control in place. We will work on dividing out duties and responsibilities so no one person is handling all cash, receipts, and financial transactions without checks & balance in place. A Business Office employee will collect cash and count, and another person will create the deposit slip, with a 3rd person (front office secretary) taking the actual deposit to the bank. Then the Business office employee will be the one responsible for entering the cash receipt into Software.
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