Corrective Action Plans

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U.S. Department of Health and Human Services Bullhook Community Health Center, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 through June 30, 2023 The findings from the schedule of findings and questioned costs are discuss...
U.S. Department of Health and Human Services Bullhook Community Health Center, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 through June 30, 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 SIGNIFICANT DEFICIENCY 2023-001 Health Center Program Cluster Recommendation: Management should review their policies and procedures with the personnel responsible for providing the sliding fee discount and for ensuring that documentation is maintained to support the eligibility of sliding fee discount. We also recommend that management implement, monthly or quarterly, a self-audit process of newly approved sliding fee discount recipients and their associated patient record. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Staff were retrained on sliding fee policy and procedure. Going forward frequent audits from the sliding fee applications received and entered will be conducted to ensure that proper documentation is maintained. Name(s) of the contact person(s) responsible for corrective action: Kyndra Hall, CEO Planned completion date for corrective action plan: June 30, 2024 If the U.S. Department of Health and Human Services has questions regarding this plan, please call Kyndra Hall, Chief Executive Officer at (406) 395-6904.
Recommendation: Although the small size of the Coalition’s accounting staff limits the extent of segregation of duties, we believe the Board of Directors needs to remain involved in financial affairs of the Coalition.
Recommendation: Although the small size of the Coalition’s accounting staff limits the extent of segregation of duties, we believe the Board of Directors needs to remain involved in financial affairs of the Coalition.
Views of Responsible Officials and Planned Correction: The Coalition concurs with the recommendations that Missouri Coalition of Community Mental Health Centers d/b/a Missouri Behavioral Health Council and Related Entity would be best served by segregating fiscal duties as outlined above. Upon recei...
Views of Responsible Officials and Planned Correction: The Coalition concurs with the recommendations that Missouri Coalition of Community Mental Health Centers d/b/a Missouri Behavioral Health Council and Related Entity would be best served by segregating fiscal duties as outlined above. Upon receiving this recommendation, the Coalition has worked to implement this recommendation. In addition, the Association’s Board of Directors will remain involved in the financial affairs of the Association to provide oversight and independent review functions.
This segregation of duties weakness is impratical to totally correct due to the limited resources and staff available to the district. The District will continue to use other controls, where practical, to compensate for this limitation.
This segregation of duties weakness is impratical to totally correct due to the limited resources and staff available to the district. The District will continue to use other controls, where practical, to compensate for this limitation.
Finding 386797 (2023-003)
Significant Deficiency 2023
Management’s response/corrective action plan: Grant fund administrators have been notified of their responsibility to check SAM.GOV for any new vendors who may do work under a Federal Grant. The business office is also reviewing existing vendors to ensure compliance along with checking any new vendo...
Management’s response/corrective action plan: Grant fund administrators have been notified of their responsibility to check SAM.GOV for any new vendors who may do work under a Federal Grant. The business office is also reviewing existing vendors to ensure compliance along with checking any new vendors added to the system by the school department. A shared tracking document has been created and a note added to the vendor's profiles in the financial software.
Finding 386795 (2023-001)
Significant Deficiency 2023
Management response/corrective action plan: An incorrect formula was applied to the GDI invoices for the FY23 year. The grant had sufficient overall funds and was not over spent. The current (FY24) invoices for services under the Pre-K grant are being split based on the latest grant revision.
Management response/corrective action plan: An incorrect formula was applied to the GDI invoices for the FY23 year. The grant had sufficient overall funds and was not over spent. The current (FY24) invoices for services under the Pre-K grant are being split based on the latest grant revision.
Management Response/Corrective Action Plan: The Business Manager is working with the new Buildings, Grounds, and Transportation Director, as well as the vendors directly to ensure that we include this in any projects moving forward. The Business Manager has requested to be involved in any projects o...
Management Response/Corrective Action Plan: The Business Manager is working with the new Buildings, Grounds, and Transportation Director, as well as the vendors directly to ensure that we include this in any projects moving forward. The Business Manager has requested to be involved in any projects over $2,000 to ensure we are compliant. In the past projects were started without the knowledge of the Business Manager and often vendors did not want to comply after the fact.
Management Response/Corrective Action Plan: Before the Nutrition Director submits the claim, the Business Manager will review the claim with the Nutrition Director.
Management Response/Corrective Action Plan: Before the Nutrition Director submits the claim, the Business Manager will review the claim with the Nutrition Director.
Management Response/Corrective Action Plan: Management should ensure all documentation is filed and maintained after it is received.
Management Response/Corrective Action Plan: Management should ensure all documentation is filed and maintained after it is received.
Finding 386725 (2023-001)
Significant Deficiency 2023
Finding: The College’s internal controls over compliance of special tests regarding the Gramm-Leach Bliley Act (GLBA) were not operating effectively in 2023 as the College did not have a comprehensive information security program in compliance with the Safeguards Rule prepared by June 9, 2023. The...
Finding: The College’s internal controls over compliance of special tests regarding the Gramm-Leach Bliley Act (GLBA) were not operating effectively in 2023 as the College did not have a comprehensive information security program in compliance with the Safeguards Rule prepared by June 9, 2023. The College is required to have a completed and approved information security program available on or before June 9, 2023. The College did not complete and review the information security program until fall 2023. The controls over GLBA compliance were not operating effectively to be in compliance as of June 9, 2023. Subsequent to year end, management finalized and approved the security program. We recommend the College ensure that individuals responsible for completion and review of the information security program are aware of the program requirements and complete the assessment annually with documented review prior to fiscal year-end. Corrective Action: Management agrees and has implemented necessary procedures and management oversight to meet the requirements.
Education Stabilization Fund – Assistance Listing Number 84.425F Granite State College (recently merged as part of a new college within the University of New Hampshire) will work to resolve the reporting finding for fiscal year 2023 reporting. The College will provide training to staff on reporting...
Education Stabilization Fund – Assistance Listing Number 84.425F Granite State College (recently merged as part of a new college within the University of New Hampshire) will work to resolve the reporting finding for fiscal year 2023 reporting. The College will provide training to staff on reporting policies and procedures to ensure that information is reported in a timely manner. Name(s) of the contact person(s) responsible for corrective action: Susan Zipkin, Director, Accounting and Financial Compliance, University of New Hampshire Planned completion date for corrective action plan: February 29, 2024
CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Treasury The City of Peabody, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Powers & Sullivan, LLC 100 Qu...
CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Treasury The City of Peabody, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Powers & Sullivan, LLC 100 Quannapowitt Parkway, Suite 101 Wakefield, MA 01880 Audit period: July 1, 2022 through June 30, 2023 The finding from the June 30, 2023, 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 U.S. DEPARTMENT OF EDUCATION Passed through Massachusetts Department of Elementary and Secondary Education Education Stabilization Fund Education Stabilization Fund Federal Assistance Listing No. 84.425D, 84.425U and 84.425W 2023-008: Reporting to the State Compliance Requirement: Reporting Type of Finding: Compliance and Material Weakness in Internal Control Over Compliance Criteria or Specific Requirement: Grantees must comply with reporting requirements established by the Massachusetts Department of Elementary and Secondary Education, the City’s Pass-Through Grantor (State). In order for the State to comply with federal reporting requirements, the City is required to submit complete and accurate “Recipient Data Collection Forms” to the State. Condition: The City was unable to provide copies of the Recipient Data Collection Forms submitted to the State. Context: The City did not maintain sufficient documentation to demonstrate compliance with grant reporting requirements. Effect: The City has not complied with the grant requirements. Cause: Management has not established guidelines and procedures to ensure and demonstrate that required reporting is completed, retained, and available upon request. Questioned Costs: None reported. Recommendation: The City should implement internal control procedures to ensure compliance with all grant requirements including the completion and retention of all required reports. The documentation should be filed in an organized manner and readily available upon request. Views of Responsible Officials and Planned Corrective Actions: The School District will implement internal control procedures to ensure that the required reporting is completed, retained and maintained in an organized manner. Management plans to implement these procedures in 2024. If the Oversight Agency has questions regarding this plan, please call Samuel Rippin, School Business Manager, at 978-536-6520. Sincerely yours, Samuel Rippin School Business Manager City of Peabody
CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Treasury The City of Peabody, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Powers & Sullivan, LLC 100 Qu...
CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Treasury The City of Peabody, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Powers & Sullivan, LLC 100 Quannapowitt Parkway, Suite 101 Wakefield, MA 01880 Audit period: July 1, 2022 through June 30, 2023 The finding from the June 30, 2023, 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 U.S. DEPARTMENT OF EDUCATION Passed through Massachusetts Department of Elementary and Secondary Education Title I Grants to Local Educational Agencies Title I Grants to Local Educational Agencies Federal Assistance Listing No. 84.010 2023-005: Affirmation of Consultation Forms to Private Schools Compliance Requirement: Special Tests and Provisions Type of Finding: Compliance and Material Weakness in Internal Control Over Compliance Criteria or Specific Requirement: Grantees must provide equitable services to eligible private school children, their teachers, and their families. Grantees must conduct timely and meaningful consultation with private school officials to determine the kind of educational services to provide to eligible private school children. Grantees must also ensure that planned services are provided and that the required amount was used for private school children. Condition: The City was required to ensure that a portion of this grant was available for the equitable participation of students, families, and educators in non-profit, non-public (private) schools. Public school officials were required to initiate contact and make good faith efforts to have timely and meaningful consultation with private school officials regarding participation in programs and services. The City was also required to document these consultations via signed Affirmation of Consultation forms. The supporting documentation was not available upon request and was not provided in a timely manner. The information required to perform this testing was requested in May 2023, and was not provided until January 2024, after several repeated requests were made throughout that time. Context: The City did not provide sufficient documentation to demonstrate compliance with its requirement to conduct timely and meaningful consultations with officials from eligible private schools in a timely manner. Effect: The City has not complied with the grant requirements. Cause: Management has not established guidelines and procedures to ensure that the required consultations with private schools take place and that the consultations performed are adequately documented, retained and filed in an organized manner that is made readily available upon request. Questioned Costs: None reported. Recommendation: The City should implement internal control procedures to ensure compliance with all grant requirements including the completion and retention of all required forms. The documentation should be filed in an organized manner and readily available upon request. Views of Responsible Officials and Planned Corrective Actions: The School District will implement internal control procedures to ensure that timely consultations with private schools occur, and that the required documentation is completed, retained and maintained in an organized manner. Management plans to implement these procedures in 2024. If the Oversight Agency has questions regarding this plan, please call Samuel Rippin, School Business Manager, at 978-536-6520. Sincerely yours, Samuel Rippin School Business Manager City of Peabody
CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Treasury The City of Peabody, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Powers & Sullivan, LLC 100 Qu...
CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Treasury The City of Peabody, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Powers & Sullivan, LLC 100 Quannapowitt Parkway, Suite 101 Wakefield, MA 01880 Audit period: July 1, 2022 through June 30, 2023 The finding from the June 30, 2023, 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 U.S. DEPARTMENT OF EDUCATION Passed through Massachusetts Department of Elementary and Secondary Education Title I Grants to Local Educational Agencies Title I Grants to Local Educational Agencies Federal Assistance Listing No. 84.010 2023-004: Eligibility of Schools and Allocations to Schools Compliance Requirement: Eligibility Type of Finding: Compliance and Material Weakness in Internal Control Over Compliance Criteria or Specific Requirement: Grantees must determine which schools or school attendance areas are eligible to participate in the program. When determining eligibility, grantees must select a poverty measure from among one of the allowable data sources. Grantees must serve eligible schools or attendance areas in rank order according to their percentage of poverty. Grantees must also provide equitable services to eligible private school students and homeless students prior to allocating funds to the eligible public schools using similar allowable data sources. Condition: The City was required to determine which schools or school attendance areas, including private school students and homeless students, were eligible to participate in the grant program. The City was also required to ensure that eligible schools or school attendance areas were served in rank order in accordance with their percentage of poverty. The supporting documentation was not available upon request and was not provided in a timely manner. The information required to perform this testing was requested in May 2023, and was not provided until January 2024, after several repeated requests were made throughout that time. Context: The City did not provide sufficient documentation to demonstrate the compliance of its eligibility determinations or allocations to schools in a timely manner. Effect: The City has not complied with the grant requirements. Cause: Management has not established guidelines and procedures to ensure that documentation regarding eligibility determinations and allocations is retained and filed in an organized manner that is made readily available upon request. Questioned Costs: None reported. Recommendation: The City should implement internal control procedures to ensure compliance with all grant requirements including the completion and retention of all documentation regarding eligibility determinations and allocations to schools. The documentation should be filed in an organized manner and should be readily available upon request. Views of Responsible Officials and Planned Corrective Actions: The School District will implement internal control procedures to ensure that the required documentation is completed, retained and maintained in an organized manner. Management plans to implement these procedures in 2024. If the Oversight Agency has questions regarding this plan, please call Samuel Rippin, School Business Manager, at 978-536-6520. Sincerely yours, Samuel Rippin School Business Manager City of Peabody
Finding 386673 (2023-004)
Significant Deficiency 2023
Views of Responsible Officials and Planned Corrective Actions: The Organization has established a list of authorized signers for checks drawn on its bank accounts. Checks shall be reviewed prior to mailing to ensure dual signatures are present on checks over $10,000.
Views of Responsible Officials and Planned Corrective Actions: The Organization has established a list of authorized signers for checks drawn on its bank accounts. Checks shall be reviewed prior to mailing to ensure dual signatures are present on checks over $10,000.
Finding 386670 (2023-003)
Material Weakness 2023
Views of Responsible Officials and Planned Corrective Actions: The Organization has established procedures to require formal approval of any payroll payments outside of the standard hourly or salary commitments. Documentation to support such payments shall be retained with the bi-weekly payroll fi...
Views of Responsible Officials and Planned Corrective Actions: The Organization has established procedures to require formal approval of any payroll payments outside of the standard hourly or salary commitments. Documentation to support such payments shall be retained with the bi-weekly payroll files. All hours worked by non-exempt employees shall be entered into the time card entry system and approved by the employee’s supervisor.
Finding 386667 (2023-002)
Material Weakness 2023
Views of Responsible Officials and Planned Corrective Actions: The Organization has reviewed its invoice approval process, and has notified staff of the requirement to approve and code invoices for payment. The Accounts Payable Specialist is monitoring compliance, and forwarding invoices for appro...
Views of Responsible Officials and Planned Corrective Actions: The Organization has reviewed its invoice approval process, and has notified staff of the requirement to approve and code invoices for payment. The Accounts Payable Specialist is monitoring compliance, and forwarding invoices for approval where necessary. Invoices pertaining to recurring expenses are approved either via the credit card expense report or invoice approval processes.
Finding 386659 (2023-007)
Significant Deficiency 2023
Student Financial Assistance Cluster – Assistance Listing No. 84.063, 84.268 Recommendation: The University should review its policies and procedures on reporting of enrollment status changes to NSLDS to ensure that all status changes are being reported accurately to be in compliance with regulatio...
Student Financial Assistance Cluster – Assistance Listing No. 84.063, 84.268 Recommendation: The University should review its policies and procedures on reporting of enrollment status changes to NSLDS to ensure that all status changes are being reported accurately to be in compliance with regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Typically this sort of error does not occur with the NSC and its handling of transmitted data. However, the Registrar’s Office will check enrollment transmissions approximately two weeks following submissions, to affirm proper handling of transmitted data. Name(s) of the contact person(s) responsible for corrective action: Marita Hurst, Registrar Planned completion date for corrective action plan: April 1, 2024
Finding 386653 (2023-006)
Significant Deficiency 2023
Student Financial Assistance Cluster – Assistance Listing No. 84.063, 84.007, 84.268, 84.379, 84.033, & 84.038 Recommendation: We recommend the University review all R2T4 calculations to ensure the correct net disbursed amounts are entered for all Title IV aid. Explanation of disagreement with au...
Student Financial Assistance Cluster – Assistance Listing No. 84.063, 84.007, 84.268, 84.379, 84.033, & 84.038 Recommendation: We recommend the University review all R2T4 calculations to ensure the correct net disbursed amounts are entered for all Title IV aid. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Director will utilize the R2T4 Calculator on COD to determine the correct amount of earned aid when a student withdraws completely. Additional attention will make sure the adjustments are made in Banner & COD in an accurate manner. Name(s) of the contact person(s) responsible for corrective action: Sean Hudson, Interim Director of Financial Aid Planned completion date for corrective action plan: Corrective action plan has already been implemented.
View Audit 298971 Questioned Costs: $1
Finding 386651 (2023-005)
Significant Deficiency 2023
Student Financial Assistance Cluster – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the University evaluate its procedures and policies around reporting to the COD to ensure that student information is reported accurately and timely. Explanation of disagreement with audit fin...
Student Financial Assistance Cluster – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the University evaluate its procedures and policies around reporting to the COD to ensure that student information is reported accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Currently, some files are being transferred automatically between COD & Cabrini by IT and some are being transferred manually by staff. Going forward all files will be transferred manually by the Financial Aid Director on a daily basis to ensure completion. Name(s) of the contact person(s) responsible for corrective action: Sean Hudson, Interim Director of Financial Aid Planned completion date for corrective action plan: April 1, 2024
Finding 386650 (2023-004)
Significant Deficiency 2023
Student Financial Assistance Cluster – Assistance Listing No. 84.268 Recommendation: We recommend the University evaluate its procedures and a policy around packaging Title IV based on need. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action ta...
Student Financial Assistance Cluster – Assistance Listing No. 84.268 Recommendation: We recommend the University evaluate its procedures and a policy around packaging Title IV based on need. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Staff will be retrained on packaging requirements and the importance of monitoring for over-award situations. The Financial Aid Director will also work with IT to make sure reporting mechanisms are set up to identify potential overawards for timely investigation and review. Name(s) of the contact person(s) responsible for corrective action: Sean Hudson, Interim Director of Financial Aid Planned completion date for corrective action plan: April 30, 2024
View Audit 298971 Questioned Costs: $1
Finding 386644 (2023-003)
Significant Deficiency 2023
Student Financial Assistance Cluster – Assistance Listing No. 84.063, 84.007, 84.268, 84.379 & 84.033 Recommendation: The University should review the procedures surrounding the verification process to ensure all necessary support and documentation is obtained and retained in the student files. Ex...
Student Financial Assistance Cluster – Assistance Listing No. 84.063, 84.007, 84.268, 84.379 & 84.033 Recommendation: The University should review the procedures surrounding the verification process to ensure all necessary support and documentation is obtained and retained in the student files. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University will enhance the verification process to include guidance regarding which documentation is required to be reviewed and retained for each verification number. The supporting documentation will be maintained in the Financial Aid office records and stored alphabetically by student’s last name for ease of future reference. Name(s) of the contact person(s) responsible for corrective action: Sean Hudson, Interim Director of Financial Aid Planned completion date for corrective action plan: April 1, 2024
Finding 386643 (2023-002)
Significant Deficiency 2023
Student Financial Assistance Cluster – Assistance Listing No. 84.268 Recommendation: The University should ensure all necessary employees receive proper training, support, and time to follow the University’s policies and federal requirements related to monthly reconciliations. There should be a pro...
Student Financial Assistance Cluster – Assistance Listing No. 84.268 Recommendation: The University should ensure all necessary employees receive proper training, support, and time to follow the University’s policies and federal requirements related to monthly reconciliations. There should be a process to maintain all reconciliations to support these were performed as required monthly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A monthly schedule will be established and staff assigned to the task of monthly reconciliation will be trained in the federal requirements. This training will include a review of where such files are to be retained. Name(s) of the contact person(s) responsible for corrective action: Sean Hudson, Interim Director of Financial Aid Planned completion date for corrective action plan: May 15, 2024
Finding 386637 (2023-001)
Significant Deficiency 2023
Department of Education Student Financial Assistance Cluster – Assistance Listing No. 84.063, 84.007, 84.268, 84.379 & 84.033 Recommendation: We recommend that the University ensure proper support and approval is maintained for all Title IV drawdowns. Explanation of disagreement with audit finding...
Department of Education Student Financial Assistance Cluster – Assistance Listing No. 84.063, 84.007, 84.268, 84.379 & 84.033 Recommendation: We recommend that the University ensure proper support and approval is maintained for all Title IV drawdowns. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Approval is documented via email and retained in department files prior to completion of a Title IV drawdown. Name(s) of the contact person(s) responsible for corrective action: Lynda Buzzard, Vice President, Finance & Administration Planned completion date for corrective action plan: Corrective action plan has already been implemented.
Condition: The College utilizes a third-party service provider for Perkins Loan servicing. Federal regulations require the institution to perform due diligence on the third-party servicer to ensure they are following federal regulations. The College did not perform their due diligence for fiscal yea...
Condition: The College utilizes a third-party service provider for Perkins Loan servicing. Federal regulations require the institution to perform due diligence on the third-party servicer to ensure they are following federal regulations. The College did not perform their due diligence for fiscal year 2023. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action in Response to Finding: The College typically receives its third-party servicer’s compliance report to meet our due diligence obligations. For Fiscal Year 2023, the third-party servicer’s compliance report was delayed and was not received in time for the College’s audit deadlines. In future years, we will request the compliance report by December 31. We will then develop a cost-effective alternative plan for performing due diligence over the third-party servicer if the compliance report is not received by that date. Name of the contact person responsible for corrective action: Amy Ingalsbe, Student Accounts Manager Planned completion date for corrective action plan: December 31, 2024
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