Corrective Action Plans

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Responsible Party: Jamie Clark, Coordinator, Campus and Financial Services Phone Number: 501-202-7436 Audit Period Ending: December 31, 2023 Audit Firm: Forvis Mazars, LLP Federal Program: Student Financial Assistance Program Assistance Listing Numbers: 84.007, 84.063, 84.268 Federal Agency: U...
Responsible Party: Jamie Clark, Coordinator, Campus and Financial Services Phone Number: 501-202-7436 Audit Period Ending: December 31, 2023 Audit Firm: Forvis Mazars, LLP Federal Program: Student Financial Assistance Program Assistance Listing Numbers: 84.007, 84.063, 84.268 Federal Agency: U.S. Department of Education Finding – Third Party Servicer The College entered into a contract with a servicer to deliver Title IV credit balances in 2018 but did not provide the contract URL to the Department of Education or include the contract on the College's website. The contract does not include a stated provision that the contract may be terminated based on student complaints nor does it discuss surcharge-free ATMs. The College did not perform a formal due diligence review of the contract fees as required every two years. The College did not post fee information within 60 days of the award year to its website and did not send cost information to the Department of Education. Comments on the Finding and Recommendation Management is in agreement with this finding and the related recommendation. Action(s) Taken or Planned on the Finding The third party servicer, Nelnet, contract will be uploaded to the Department of Education website as well as information added to the Baptist Health College Little Rock website. The contract will be reviewed to ensure required terms are present including the ability of contract to be terminated based on student complaints and the consideration of surcharge-free ATMs. Servicer fees information will be posted with the Department of Education and the College website and a formal due diligence assessment of fees will be completed. Estimated completion date for the above mentioned corrective action is October 31, 2024.
Finding 499256 (2023-002)
Significant Deficiency 2023
Management concurs with the recommendation as proposed and has developed written policies and procedures related to federal payments and allowability of costs. This has been implemented effective immediately.
Management concurs with the recommendation as proposed and has developed written policies and procedures related to federal payments and allowability of costs. This has been implemented effective immediately.
Finding 499255 (2023-001)
Material Weakness 2023
Management concurs with the recommendation as proposed and is implementing policies and procedures to provide for proper segregation of duties over grant activities. This has been implemented effective immediately.
Management concurs with the recommendation as proposed and is implementing policies and procedures to provide for proper segregation of duties over grant activities. This has been implemented effective immediately.
2023-002 Condition: Deficiencies Noted in Examination of New Construction Section 8 Tenant Files Steps to resolve: We will review the internal control procedures over tenant file re-certifications and documents and implement procedures which will eliminate such errors. Management has implement...
2023-002 Condition: Deficiencies Noted in Examination of New Construction Section 8 Tenant Files Steps to resolve: We will review the internal control procedures over tenant file re-certifications and documents and implement procedures which will eliminate such errors. Management has implemented procedures in order to clear this finding in FY 2024. Timeframe: By FYE December 31, 2024 Individual responsible for correction: Ms. Zena Zahran, Executive Director
Finding 499239 (2023-004)
Significant Deficiency 2023
Continuum of Care – Assistance Listing No. 14.267 Recommendation: We recommend Home Forward design controls to ensure formal documentation of approval of comparables is in the files. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in r...
Continuum of Care – Assistance Listing No. 14.267 Recommendation: We recommend Home Forward design controls to ensure formal documentation of approval of comparables is in the files. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Home Forward will add clarifying language in our Shelter Plus Care (Continuum of Care) Program operating manual indicating need for staff to document who completed rent reasonableness reviews including signatures from program supervisors or department staff responsible for approving comparables when necessary as part of the rent reasonableness review. Additional staff training will be conducted during Shelter Plus Care and department team meetings. Name(s) of the contact person(s) responsible for corrective action: Ian Slingerland, Director of Homeless Initiatives and Supportive Housing Planned completion date for corrective action plan: 10/1/2024
Item # 2023-003 Reconciliation of Bank Accounts (Significant Deficiency in Internal Control) Criteria: Under GAAP, bank accounts are required to be reconciled on a regular basis to ensure that they are properly stated under the accrual basis of accounting. Condition: During the year under audit, ...
Item # 2023-003 Reconciliation of Bank Accounts (Significant Deficiency in Internal Control) Criteria: Under GAAP, bank accounts are required to be reconciled on a regular basis to ensure that they are properly stated under the accrual basis of accounting. Condition: During the year under audit, the Organization did not reconcile the ending balances of all accounts held with financial institutions during the fiscal year. Cause: The Organization did not compare the balances per statements received for bank accounts from financial institutions with its own internal account balances and failed to make the necessary accrual based accounting adjustments for reconciling items. Effect: Failure to update internal controls to comply with the requirements of the GAAP could result in ineffective monitoring of costs allocated to the federal program. Recommendation: The Organization should strengthen its internal control practices by updating its policies and procedures to comply with GAAP. Views of Responsible Officials and Planned Corrective Actions: Management has been making updates to its policies and procedures throughout 2024 to be in full compliance with GAAP. This exercise is anticipated to be complete by the end of the fiscal year.
Item # 2023-002 Net Assets with Donor Restrictions (Material Weakness in Internal Control) Criteria: Under GAAP, net assets with donor restrictions should be released from restrictions when the award terms of the related grants or contributions are met. Condition: Management did not release all r...
Item # 2023-002 Net Assets with Donor Restrictions (Material Weakness in Internal Control) Criteria: Under GAAP, net assets with donor restrictions should be released from restrictions when the award terms of the related grants or contributions are met. Condition: Management did not release all restricted net assets within the proper period. Cause: Management did not examine grant and contribution agreements carefully enough to determine the nature of the applicable terms for restrictions and did not take necessary measures to ensure that net assets with donor restrictions were properly released throughout the fiscal year. Effect: Net assets with donor restrictions were overstated by $3,571,287 and net assets without donor restrictions was understated by $3,571,287. Recommendation: We recommend that management ensures that it examines grant agreements carefully to determine the nature of the applicable terms for restrictions, and to take necessary measures to ensure that net assets with donor restrictions were properly released throughout the fiscal year. Views of Responsible Officials and Planned Corrective Actions: Management has been making updates to its policies and procedures throughout 2024 to be in full compliance with GAAP. This exercise is anticipated to be complete by the end of the fiscal year.
Item # 2023-001 Conditional Grant Revenue Recognition (Material Weakness in Internal Control) Criteria: Under Generally Accepted Accounting Principles (GAAP), advances received for conditional grants for expenses not yet incurred are considered a refundable advance liability and should be recognize...
Item # 2023-001 Conditional Grant Revenue Recognition (Material Weakness in Internal Control) Criteria: Under Generally Accepted Accounting Principles (GAAP), advances received for conditional grants for expenses not yet incurred are considered a refundable advance liability and should be recognized as revenue only once the barriers are overcome, which includes incurrence of allowable costs under Office of Management and Budget Circular A-122. Condition: Management did not recognize conditional grant revenue for the full amount of the award after allowable costs were incurred. Cause: Management was unaware that conditional grant revenue was required to be deferred until allowable costs under the federal grant agreement were incurred and did not record the related revenue in the proper period. Effect: Conditional grant revenue was understated by $593,838. This is considered a material weakness in the Organization’s internal control over financial reporting. Recommendation: We recommend that management ensure that conditional grant revenue is recognized upon incurrence of allowable costs under the federal grant. We also recommend that management enroll in a professional education program that covers Uniform Guidance compliance. Views of Responsible Officials and Planned Corrective Actions: Management has been making updates to its policies and procedures throughout 2024 to be in full compliance with GAAP and the Uniform Guidance. This exercise is anticipated to be complete by the end of the fiscal year.
Management’s Response: Management agrees with the finding. Management plans to complete a review of resources assigned to accounting and finance departments as well as identify and implement sufficient internal controls over expenditures cutoff to ensure compliance with the period of performance com...
Management’s Response: Management agrees with the finding. Management plans to complete a review of resources assigned to accounting and finance departments as well as identify and implement sufficient internal controls over expenditures cutoff to ensure compliance with the period of performance compliance requirement.
Management’s Response: Management agrees with the finding. Management plans to complete a review of resources assigned to accounting and finance departments as well as identify and implement sufficient internal controls over financial reporting.
Management’s Response: Management agrees with the finding. Management plans to complete a review of resources assigned to accounting and finance departments as well as identify and implement sufficient internal controls over financial reporting.
Name of Auditee’s Contact Person Responsible for Corrective Action: Molly Gravholt Corrective Action Planned: Management is in the process of implementing Bill.com, which will require review and approval by a direct supervisor or higher, to ensure proper segregation of duties for approval of expendi...
Name of Auditee’s Contact Person Responsible for Corrective Action: Molly Gravholt Corrective Action Planned: Management is in the process of implementing Bill.com, which will require review and approval by a direct supervisor or higher, to ensure proper segregation of duties for approval of expenditures. Management will also reinforce the importance of employees providing the appropriate invoices or supporting documentation for all expenditures submitted for payment. Expenditures will not be paid without the appropriate supporting documentation. All approvals will be tracked through an online system. In addition, management will reinforce the importance of reviewing the timing of when expenditures are incurred, to ensure they are recorded in the appropriate fiscal year. Anticipated completion date: Implemented November 2023
Name of Auditee’s Contact Person Responsible for Corrective Action: Molly Gravholt Corrective Action Planned: Management is in the process of implementing Bill.com, which will require review and approval by a direct supervisor or higher, to ensure proper segregation of duties for approval of expendi...
Name of Auditee’s Contact Person Responsible for Corrective Action: Molly Gravholt Corrective Action Planned: Management is in the process of implementing Bill.com, which will require review and approval by a direct supervisor or higher, to ensure proper segregation of duties for approval of expenditures. Management will also reinforce the importance of employees providing the appropriate invoices or supporting documentation for all expenditures submitted for payment. Expenditures will not be paid without the appropriate supporting documentation. All approvals will be tracked through an online system. In addition, management will reinforce the importance of reviewing the timing of when expenditures are incurred, to ensure they are recorded in the appropriate fiscal year. Anticipated completion date: Implemented November 2023
STARTING IN QUARTER 4, 2023, ALL METHODOLOGY FOR TRACKING AND ALLOCATING WAGES HAS BEEN MOVED TO TRACKING VIA OUR HRIS SYSTEM. INSURANCE BENEFITS ARE CODED DIRECTLY FROM THE SOURCE DOCUMENT. ONLY FICA/MEDICARE IS BEING TRACKED VIA A SPREADSHEET, WHICH IS BEING REVIEWED EACH MONTH.
STARTING IN QUARTER 4, 2023, ALL METHODOLOGY FOR TRACKING AND ALLOCATING WAGES HAS BEEN MOVED TO TRACKING VIA OUR HRIS SYSTEM. INSURANCE BENEFITS ARE CODED DIRECTLY FROM THE SOURCE DOCUMENT. ONLY FICA/MEDICARE IS BEING TRACKED VIA A SPREADSHEET, WHICH IS BEING REVIEWED EACH MONTH.
Views of Responsible Officials and Planned Corrective Actions Finding Reference: 2023-001 Responsible Individual: Melissa Mason Operator Foundation received a pass-through, subgrant extension from a partner organization under 19.22 Regional Democracy Program during the calendar year 2023. The subgr...
Views of Responsible Officials and Planned Corrective Actions Finding Reference: 2023-001 Responsible Individual: Melissa Mason Operator Foundation received a pass-through, subgrant extension from a partner organization under 19.22 Regional Democracy Program during the calendar year 2023. The subgrant paperwork Operator received from the partner did not include an Audit Certification form. The form was later provided and requested by the pass through entity on March 18, 2024, and Operator provided the form on the same day that the email request was received. However, passthrough recipients are required to submit a completed Audit Certification Form within 30 days of the end of each subrecipient fiscal year. Operator’s controls did not realize that the form was missing from the provided award package. Corrective Action Plan (CAP) Operator Foundation will strengthen the internal controls as it relates to submitting required reports to its granting agencies by establishing policies and procedures to ensure that reporting information is submitted timely. Operator will review each grant at inception and list out requirements related to reporting and deadlines. Operator Foundation will ensure that all reporting requirements are put on the organizational tracking system including calendars and that reminders are set to ensure timely submission. Operator will communicate any missing requirements in award packages to the funder for the purpose of strengthening compliance of all responsible parties receiving federal funds. Anticipated Completion date: 10/31/2024
Finding 499182 (2023-004)
Significant Deficiency 2023
Corrective Action Plan: Management is developing a process to include a periodic review of all compliance aspects related to the grants including financial and performance reporting. This will be completed by December 31, 2024. Individual responsible for corrective action plan: Steven Ramirez
Corrective Action Plan: Management is developing a process to include a periodic review of all compliance aspects related to the grants including financial and performance reporting. This will be completed by December 31, 2024. Individual responsible for corrective action plan: Steven Ramirez
2023-001 Reporting - Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number 21.027 Grant Period - Year Ended December 31, 2023 Condition Found The City failed to submit all quarterly reports, in a timely manner. We consider this to be an instance of non-compliance relating to ...
2023-001 Reporting - Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number 21.027 Grant Period - Year Ended December 31, 2023 Condition Found The City failed to submit all quarterly reports, in a timely manner. We consider this to be an instance of non-compliance relating to the Reporting Compliance Requirement. Corrective Action Plan The City attempted to file the required quarterly reports during the year ended December 31, 2023. However, the U.S. Treasury changed the reporting software during the first quarter of the year. Due to a technical issue with the file validation process, the City was unable to submit the reports. The information was tracked and compiled but the software prevented the City from completing the reporting process. The City contacted the technical support team numerous times for assistance in resolving this issue, however the issue was not resolved until the second quarter of 2024 when the City was finally able to file their report. This will not be an issue going forward. Responsible Person for Corrective Action Plan Linda Read, Comptroller/Deputy Treasurer Implementation Date of Corrective Action Plan The City received communication from the U.S. Treasury on June 18, 2024 that the technical issue has been fixed and the city was able to file the report for the second quarter in 2024.
New staff were put into place, the finding has been corrected through training and procedure review. Allyson Kreder is responsible for accounting record keeping. The finding was corrected by the issuance date, September 20, 2024
New staff were put into place, the finding has been corrected through training and procedure review. Allyson Kreder is responsible for accounting record keeping. The finding was corrected by the issuance date, September 20, 2024
Management Response Management acknowledges the recommendation of placing internal controls in place to ensure that costs are charged and allocated to the proper grant period. REMEDIATION PLAN Management has hired Jess Vaughn-Jansen as Director of Financial Strategy (Director) to ensure transaction...
Management Response Management acknowledges the recommendation of placing internal controls in place to ensure that costs are charged and allocated to the proper grant period. REMEDIATION PLAN Management has hired Jess Vaughn-Jansen as Director of Financial Strategy (Director) to ensure transactions are charged and allocated to the individual grants in the proper grant period. The Director has reviewed the process documents that are in place to assist in recording transactions. Excel Tracking Sheets have been created and are maintained by the Director for each grant. Per the grant agreements, the Grant Period (i.e., Effective Date and Expiration Date) has been documented on all the Tracking Sheets. This will allow the Director to properly include and exclude items that may occur before the Effective Date or after the Expiration Date. These Tracking Sheets have been used by the Director since February 2023. The 1 selection not in compliance was posted prior to the Director’s hire date. No findings have been identified after the Director’s hire date. The Director has and will continue to be cognizant of including and excluding items that may occur before the Effective Date or after the Expiration Date.
The System will be terminating the contract with the outside third party and bringing administration of the program internal to increase communications and verifications of the start and ending dates of our programs.  Monthly meetings will continue to occur with financial aid, finance and the bursar...
The System will be terminating the contract with the outside third party and bringing administration of the program internal to increase communications and verifications of the start and ending dates of our programs.  Monthly meetings will continue to occur with financial aid, finance and the bursar to ensure that timing is within regulations.  This will be effective January 1, 2025.
Finding: Management did not have an internal control in place to review the allowability of the expenses to be allocated to the Congressional Directives grant. Corrective Action Plan: Akron Children's will implement a more detailed review and documentation process for allowable expenses prior to de...
Finding: Management did not have an internal control in place to review the allowability of the expenses to be allocated to the Congressional Directives grant. Corrective Action Plan: Akron Children's will implement a more detailed review and documentation process for allowable expenses prior to determining expenses that are eligible for federal grant reimbursement. Responsible Party: Vice President Finance Completion Date: November 30, 2024
Finding: Management did not retain sufficient evidence supporting the review and approval of the financial reports prior to submission. Corrective Action Plan: Akron Children’s implemented a review checklist and sign-off process to document controls for the review of the monthly financial reports s...
Finding: Management did not retain sufficient evidence supporting the review and approval of the financial reports prior to submission. Corrective Action Plan: Akron Children’s implemented a review checklist and sign-off process to document controls for the review of the monthly financial reports submitted to the granting agency. Completion Date: October 31, 2023 Corrective Action Plan: Akron Children’s will implement a review checklist and sign-off process to document controls for the review of the quarterly performance reporting. Completion Date: November 30, 2024 Responsible Party: Vice President Finance
Finding 499130 (2023-009)
Significant Deficiency 2023
Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2305MN5ADM, 2305MN5MAP; 2023 Pass-Through Agency: Minnesota department of Human Services Type of Finding: Significant Deficiency ...
Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2305MN5ADM, 2305MN5MAP; 2023 Pass-Through Agency: Minnesota department of Human Services Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Award Period: Year Ended December 31, 2023 Recommendation: We recommend that the County implement review procedures to ensure that the reports are submitted timely and accurately, and record of review is kept on file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County has implemented procedures and policies to have a secondary person review the reports and in a timely manner. Name of the contact person responsible for corrective action: Stacie Golomiecki, Community Services Director – Stephani Diekmann, Fiscal Supervisor Planned completion date for corrective action plan: December 31, 2024
Finding 499129 (2023-008)
Significant Deficiency 2023
Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2305MN5ADM, 2305MN5MAP; 2023 Pass-Through Agency: Minnesota department of Human Services Type of Finding: Significant Deficiency ...
Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2305MN5ADM, 2305MN5MAP; 2023 Pass-Through Agency: Minnesota department of Human Services Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Award Period: Year Ended December 31, 2023 Recommendation: We recommend that the County review the contract with MN DHS, and implement proper review and approval procedures for all LCTS reports. We recommend that paper copies are kept on file for the required timeframe. We recommend that the County implement procedures to remit the quarterly funding to the collaborative in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County has implemented procedures and policies to ensure all requirements of LCTS special provisions are followed. Name of the contact person responsible for corrective action: Stacie Golomiecki, Community Services Director – Stephani Diekmann, Fiscal Supervisor Planned completion date for corrective action plan: December 31, 2024
Finding 499128 (2023-007)
Significant Deficiency 2023
Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2305MN5ADM, 2305MN5MAP; 2023 Pass-Through Agency: Minnesota department of Human Services Type of Finding: Significant Deficiency ...
Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2305MN5ADM, 2305MN5MAP; 2023 Pass-Through Agency: Minnesota department of Human Services Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Award Period: Year Ended December 31, 2023 Recommendation: We recommend that the County continue to be diligent in their review of what is allowable when coding to certain account codes that flow into the DHS reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will adhere to established procedures and policies. Name of the contact person responsible for corrective action: Stacie Golomiecki, Community Services Director – Stephani Diekmann, Fiscal Supervisor Planned completion date for corrective action plan: December 31, 2024
Finding 499127 (2023-006)
Significant Deficiency 2023
Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2305MN5ADM, 2305MN5MAP; 2023 Pass-Through Agency: Minnesota department of Human Services Type of Finding: Significant Deficiency ...
Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2305MN5ADM, 2305MN5MAP; 2023 Pass-Through Agency: Minnesota department of Human Services Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Award Period: Year Ended December 31, 2023 Recommendation: We recommend procedures and controls be implemented to ensure each quarterly listing is properly reviewed and accurate employees are on the listings. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will adhere to established procedures and policies. Name of the contact person responsible for corrective action: Stacie Golomiecki, Community Services Director – Stephani Diekmann, Fiscal Supervisor Planned completion date for corrective action plan: December 31, 2024
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