Corrective Action Plans

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Finding 2023-001 Recommendations: The District should have an employee compare the Board Clerk’s supporting documentation and the Education Stabilization Fund spreadsheet report before its submission to the State of Kansas for its accuracy. After the approval by the secondary review employee, the r...
Finding 2023-001 Recommendations: The District should have an employee compare the Board Clerk’s supporting documentation and the Education Stabilization Fund spreadsheet report before its submission to the State of Kansas for its accuracy. After the approval by the secondary review employee, the report submitted should be printed, initialed by the secondary reviewer, stapled with the information used to compile the report and combined with all financial records for the fiscal year. Action Taken: We agree with the recommendation. Our targeted implementation date is March 2024.
Student Financial Aid Cluster – Federal Assistance Listing Numbers 84.007, 84.033, 84.063 and 84.268 Auditors’ Recommendation: We recommend the University review its policies and procedures related to outstanding student refund checks to ensure they are being returned to the Department of Education...
Student Financial Aid Cluster – Federal Assistance Listing Numbers 84.007, 84.033, 84.063 and 84.268 Auditors’ Recommendation: We recommend the University review its policies and procedures related to outstanding student refund checks to ensure they are being returned to the Department of Education after 240 days. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has developed a policy to identify uncashed Title IV refund checks prior to the 240-day expiration date. The policy includes steps to contact students whose checks did not clear and to return the funds to the Department within 240 days after the issue date of the check. The procedures will ensure that reviews are completed and returned timely according to applicable regulations. Name(s) of the contact person(s) responsible for corrective action: Cynthia McDaniel, Controller, (201) 761-7424 Planned completion date for corrective action plan: Completed
View Audit 15156 Questioned Costs: $1
Student Financial Aid Cluster – Federal Assistance Listing Numbers 84.007, 84.033, 84.063 and 84.268 Recommendation: We recommend the University review the R2T4 requirements and implement procedures to ensure scheduled breaks are properly factored into the R2T4 calculations as well as the correct d...
Student Financial Aid Cluster – Federal Assistance Listing Numbers 84.007, 84.033, 84.063 and 84.268 Recommendation: We recommend the University review the R2T4 requirements and implement procedures to ensure scheduled breaks are properly factored into the R2T4 calculations as well as the correct date of withdrawal. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The error identified has been recalculated with the correct date and funds have been returned. The office of Financial Aid will have two staff members review each withdrawal to ensure that withdrawal dates are checked and that scheduled breaks are appropriately accounted for prior to finalizing the calculations. Name(s) of the contact person(s) responsible for corrective action: Jennifer Ragsdale, Director of Student Financial Aid, (201) 761-6060 Planned completion date for corrective action plan: Completed
View Audit 15156 Questioned Costs: $1
Student Financial Aid Cluster – Federal Assistance Listing Numbers 84.063 and 84.268 Recommendation: We recommend the University evaluate its procedures and review policies in overseeing submissions to the NSLDS completed by the third-party servicer. Additionally, we recommend the University review...
Student Financial Aid Cluster – Federal Assistance Listing Numbers 84.063 and 84.268 Recommendation: We recommend the University evaluate its procedures and review policies in overseeing submissions to the NSLDS completed by the third-party servicer. Additionally, we recommend the University review its policies and procedures on reporting enrollment information to the NSLDS to ensure that all relevant information is being captured and reported timely in accordance with applicable regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: University has updated its policies and procedures for NSLDS submissions via their third-party servicer to ensure relevant information is being captured and reported timely in accordance with applicable regulations. Name(s) of the contact person(s) responsible for corrective action: Kamla Singh-Ramoutar, University Registrar, (201) 761-6051 Planned completion date for corrective action plan: Completed
Student Financial Aid Cluster – Federal Assistance Listing Number 84.063 Recommendation: We recommend that the University establish a process to review changes and updates to a student’s FASFA prior to disbursing funds to ensure the most up to date and accurate information is being used for Pell aw...
Student Financial Aid Cluster – Federal Assistance Listing Number 84.063 Recommendation: We recommend that the University establish a process to review changes and updates to a student’s FASFA prior to disbursing funds to ensure the most up to date and accurate information is being used for Pell awards. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The error was identified prior to the end of the award year and the student’s award was corrected. The ISIR Alert Report (IART) is generated during the ISIR import process and identifies all ISIR transaction updates. All updates are reviewed and the student accounts are updated appropriately where necessary prior to the completion of the rest of the import process. The office of Financial Aid will add a 2nd reviewer of the IART report. Name(s) of the contact person(s) responsible for corrective action: Jennifer Ragsdale, Director of Student Financial Aid, (201) 761-6060 Planned completion date for corrective action plan: Completed
View Audit 15156 Questioned Costs: $1
2023-001 - Eligibility Federal Agency: U.S. Department of Health and Human Services Federal Program: 93.596 and 93.575 Child Care Development Fund (CCDF) Cluster Responsible Official Sharon Fuller, CFO Plan Detail The Organization will implement a quarterly audit process whereby a person in a superv...
2023-001 - Eligibility Federal Agency: U.S. Department of Health and Human Services Federal Program: 93.596 and 93.575 Child Care Development Fund (CCDF) Cluster Responsible Official Sharon Fuller, CFO Plan Detail The Organization will implement a quarterly audit process whereby a person in a supervisory capacity will verify completion and signatures of the Child Care Subsidy Application and Fee Agreements. Anticipated Completion Date June 30, 2024
Action taken in response to finding:  The Financial Aid Office (FAO) has implemented, another line of communication with the Registrar’s office to ensure that all complete withdrawals are sent to the financial aid office by forwarding them to a designated email box. The Financial Aid Office is also...
Action taken in response to finding:  The Financial Aid Office (FAO) has implemented, another line of communication with the Registrar’s office to ensure that all complete withdrawals are sent to the financial aid office by forwarding them to a designated email box. The Financial Aid Office is also working with IT services to develop a report that can be pulled to capture and compare all withdrawal students, with the Registrar’s office to make sure none are overlooked.  The Financial Aid Office is working with our 3rd Party Servicer, Ellucian, to identity the issues with our rules that do not capture the correct data elements, so that loans are not disbursed after a student has completely withdrawn.
View Audit 15077 Questioned Costs: $1
2023-002: Special Tests and Provisions – Wage Rate Requirements Condition: The District did not have sufficient controls in place to ensure that all construction contracts in excess of $2,000 financed by federal assistance funds included verbiage to ensure that all laborers and mechanics employed by...
2023-002: Special Tests and Provisions – Wage Rate Requirements Condition: The District did not have sufficient controls in place to ensure that all construction contracts in excess of $2,000 financed by federal assistance funds included verbiage to ensure that all laborers and mechanics employed by the contractors or subcontractors were paid wages not less than those established for the locality of the project (prevailing wage rates) by the Department of Labor (40 USC 3141-3144, 3146, and 3147) Recommendation: Management implement internal control procedures to review all construction contracts and ensure prevailing wage requirements are met Action Taken: We concur with the recommendation and a procedure has been defined and implemented to ensure all construction contracts include prevailing wage requirements prior to signature. If the Pennsylvania Department of Education has questions regarding this corrective action plan, please call Gary Levin at 717-244-4021 x 4245.
Finding 11248 (2023-004)
Significant Deficiency 2023
Identifying Number: 2023-004 Finding: While the College does have a program that addresses information security, the College did not have a readily accessible program document to address the required safeguards for the nine required elements under the implementing regulations of the Gramm-Leach Bl...
Identifying Number: 2023-004 Finding: While the College does have a program that addresses information security, the College did not have a readily accessible program document to address the required safeguards for the nine required elements under the implementing regulations of the Gramm-Leach Bliley Act (GLBA) known as the “Safeguards Rule” by June 9, 2023. Corrective Action Taken or Planned: The College will create a readily accessible written information security program document outlining all standards to meet and maintain compliance with the GLBA. While the College has not yet formally adopted an information security program, they have demonstrated substantial compliance with the required elements under the Gramm-Leach Bliley Act, including: • Development and implementation of risk assessment frameworks that include penetration testing (16 C.F.R. 314.4(b)); • Adoption of a cybersecurity roadmap and various College policies based on internationally recognized NIST standards (16 C.F.R. 314.4(c)); • Regular testing and monitoring of the effectiveness of the safeguards currently implemented (16 C.F.R. 314.4(d)); • Implementation of policies and procedures to ensure personnel can enact safeguards that should be formally included in the information security program (16 C.F.R. 314.4(e)); • Adoption of procedures and policies for the evaluating and adjusting the safeguards that have been implemented, including monthly vulnerability scans accompanied by a remediation plan for any vulnerabilities identified (16 C.F.R. 314.4(g)); • Creation of a Cybersecurity Incident Response Plan (16 C.F.R. 314.4(h)); and • Annual training and reporting for the College’s Board of Trustees on cybersecurity safeguards (16 C.F.R. 314.4(i)). The Director of Cybersecurity and the Chief Information Officer are designated as the responsible parties for oversight and implementation of the program. Anticipated Completion Date: June 30, 2024 Responsible Person: Allison Porterfield-Woods, Chief Information Officer
View Audit 15031 Questioned Costs: $1
Finding 11245 (2023-003)
Significant Deficiency 2023
Identifying Number: 2023-003 Finding: For 2 out of 17 (11.7%) expenditures tested, portions of the expenditures had service periods that extended beyond the grant’s period of performance and were charged to the grant for reimbursement. Corrective Action Taken or Planned: To prevent a recurrence...
Identifying Number: 2023-003 Finding: For 2 out of 17 (11.7%) expenditures tested, portions of the expenditures had service periods that extended beyond the grant’s period of performance and were charged to the grant for reimbursement. Corrective Action Taken or Planned: To prevent a recurrence, grants transactions will be reviewed by the Principal Investigator/Program Director, the Strategic Advancement unit, and the Finance Office for allowability and alignment with the grant’s performance period. Anticipated Completion Date: This process has already been implemented by the College. Responsible Persons: Nick Branson, Assistant Vice President for Strategic Advancement Jean Stephan, Controller
View Audit 15031 Questioned Costs: $1
Recommendation – We encourage the Board of Directors and management to strengthen internal controls or implement mitigating controls where possible. Management’s Response – In 2023, the Organization implemented a new accounting information system at Adoray, as well as reviewing job responsibilities ...
Recommendation – We encourage the Board of Directors and management to strengthen internal controls or implement mitigating controls where possible. Management’s Response – In 2023, the Organization implemented a new accounting information system at Adoray, as well as reviewing job responsibilities and duties, to create opportunities for segregation of duties and separation of incompatible functions in the future. Management plans to continue this process and review and provide additional updates in 2024.
Finding 2023-002 Federal Agency Name: Department of the Treasury Program Name: COVID-19 Coronavirus State and Local Fiscal Recovery Fund CFDA #21.027 Finding Summary: The original project and expenditure reports provided to the auditors did not include all expenditures made during the reporting peri...
Finding 2023-002 Federal Agency Name: Department of the Treasury Program Name: COVID-19 Coronavirus State and Local Fiscal Recovery Fund CFDA #21.027 Finding Summary: The original project and expenditure reports provided to the auditors did not include all expenditures made during the reporting periods they selected for testing. Responsible Individuals: Aaron Price Corrective Action Plan: This is the result of an end of year timing issue wherein the reporting deadline to the Federal Government occurred prior to year-end close, resulting in a reconciling item being accurately reported within the City’s fiscal year despite being reported to the Federal Government in a subsequent quarter, but still accurately within the Federal Government’s fiscal year. Moving forward, greater efforts will be used to reconcile year end grant transactions prior to federal reporting, however, this is considered to be a non-recurring issue given the nature of the grant. Anticipated Completion Date: December 2023
The College experienced a transition in a key management position, Controller, at the end of fiscal year 2023. The new appointed Controller will revise the month-end, and year-end, closing activities to include detailed procedures, the roles of those responsible on the Financial Services team, and d...
The College experienced a transition in a key management position, Controller, at the end of fiscal year 2023. The new appointed Controller will revise the month-end, and year-end, closing activities to include detailed procedures, the roles of those responsible on the Financial Services team, and deadlines that support timely financial reporting. The Financial Services team will maintain regularly scheduled progress meetings to ensure the audit remains on track for timely submission and uphold the responsibility for ensuring that the audit commences on a timely basis. A quarterly progress review will be conducted with the Vice President of Financial Services and Operations. Additionally, the Controller will submit a request to fill vacant Financial Services positions to the Senior Team for approval and will submit a recommendation to the Senior Team to fire additional resources with appropriate accounting experience and knowledge.
Recommendation – We recommend that all accounts be reconciled and adjustments be posted to the accounting records on a quarterly basis, at a minimum. Management’s Response – The Hospital will work to establish policies and procedures to reduce the number of adjusting journal entries proposed by the ...
Recommendation – We recommend that all accounts be reconciled and adjustments be posted to the accounting records on a quarterly basis, at a minimum. Management’s Response – The Hospital will work to establish policies and procedures to reduce the number of adjusting journal entries proposed by the auditors.
Recommendation – We recommend management and those charged with governance continue to evaluate whether to accept the degree of risk associated with this condition because of cost or other considerations. Management’s Response – The Hospital does not have the resources available to increase staff si...
Recommendation – We recommend management and those charged with governance continue to evaluate whether to accept the degree of risk associated with this condition because of cost or other considerations. Management’s Response – The Hospital does not have the resources available to increase staff size and address this internal control deficiency. The Board of Directors and management are aware of the incompatible duties and will continue to provide oversight and monitor the Hospital’s operations
Recommendation – We recommend management and those charged with governance continue to evaluate whether to accept the degree of risk associated with this condition because of cost or other considerations. Management’s Response – The Hospital does not have the resources and staff to prepare the finan...
Recommendation – We recommend management and those charged with governance continue to evaluate whether to accept the degree of risk associated with this condition because of cost or other considerations. Management’s Response – The Hospital does not have the resources and staff to prepare the financial statements and notes but will continue to oversee the auditor’s services and review and approve the financial statements and notes.
Response and corrective action plan: The District will review current processes for identifying, coding, and reporting federal expenditures and implement processes to ensure amounts reported are supported by the District's general ledger.
Response and corrective action plan: The District will review current processes for identifying, coding, and reporting federal expenditures and implement processes to ensure amounts reported are supported by the District's general ledger.
CORRECTIVE ACTION PLAN (CAP): 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding Administration will ensure sufficient backup documentation is available. 3. Official Responsible for Ensuring CAP ...
CORRECTIVE ACTION PLAN (CAP): 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding Administration will ensure sufficient backup documentation is available. 3. Official Responsible for Ensuring CAP The Superintendent is responsible for ensuring corrective action of the deficiency. 4. Planned Completion Date for CAP The planned completion date for the CAP is immediate. 5. Official Responsible for Ensuring CAP The Board of Education will be monitoring this CAP
A. Comments on Finding and Recommendations Recommendation – Auditor recommends that the Entity fund the reserve immediately to make it current and create a better system of controls to ensure no future occurrences. Auditor notes deposit was made prior to issuance of the financial statements. No furt...
A. Comments on Finding and Recommendations Recommendation – Auditor recommends that the Entity fund the reserve immediately to make it current and create a better system of controls to ensure no future occurrences. Auditor notes deposit was made prior to issuance of the financial statements. No further action is required. B. Actions Taken or Planned Auditee agrees with the finding and has made an additional deposit of $6,000 to the security deposit bank account on July 24, 2023, in order to fully fund the account. The Entity has established a monthly review to prevent shortfalls in the future. The error occurred because a miscalculation by a new oversight employee.
The district has established a checkout form, effective July 1, 2023, the student registrar at the school site will be responsible for reaching out to the parent/ guardian to get the check-out form completed upon the exit of a student. The site administrator (principal, assistant principal, or couns...
The district has established a checkout form, effective July 1, 2023, the student registrar at the school site will be responsible for reaching out to the parent/ guardian to get the check-out form completed upon the exit of a student. The site administrator (principal, assistant principal, or counselor) at the school site will be reviewing this form for accuracy and competition. The check-out form will be saved and stored at the school site as a permanent record.
Finding 2023-002 Federal Agency Name: U.S. Department of Education Federal Financial Assistance Listing: 84.063, 84.007, 84.268, 84.033, 84.038, 84.379 Program Name: Student Financial Assistance Cluster Compliance Requirement: Special Tests & Provisions – Gramm-Leach-Bliley Act (GLBA) – Student ...
Finding 2023-002 Federal Agency Name: U.S. Department of Education Federal Financial Assistance Listing: 84.063, 84.007, 84.268, 84.033, 84.038, 84.379 Program Name: Student Financial Assistance Cluster Compliance Requirement: Special Tests & Provisions – Gramm-Leach-Bliley Act (GLBA) – Student Information Security Type of Finding: Material Weakness in Internal Controls Finding Summary: During testing over GLBA compliance, it was noted that the University had not updated the information security program and was missing aspects of the required nine elements. Responsible Individuals: Kella Helyer, Director of Financial Aid (DFA) and Michael Ellis, Assistant Director of University Computing Solutions (AD UCS) Corrective Action Plan: Management agrees with this finding. See the GLBA Draft Corrective Action Plan table below. Anticipated Completion Date: See the attached GLBA Draft Corrective Action Plan table below: GLBA documentation 314.4 Reference What WOU will do Complete by Date Who will do it Completion Date Document full status of 314.4 4/1/24 AD UCS a Complete b Update our CIS18 controls - aka InfoSec Program 7/1/24 AD UCS b.2 Risk assessment for on-prem servers with FinAid* data 4/1/24 AD UCS, Lead Windows Admin, Warehouse Programmer c.1 Document current processes and access controls 4/1/24 AD UCS, DFA c.2 Document current information, including Business Office 12/20/23 Financial Aid Accountant 12/13/23 c.3 Encrypte NetApp volumes, and ensure encryption on DB links 8/1/24 AD UCS, Lead Windows Admin, Warehouse Programmer c.4 Assess warehouse & BannerRPT 7/1/24 AD UCS, Warehouse Programmer, Operating Systems/Security Analyst c.5 Complete c.6 Review PowerFAIDS electronic files for purging Review paper files for purging Have Business Office review files for purging 8/1/24 DFA c.7 Audit FinAid data access upon addition to Warehouse 8/1/24 Warehouse Programmer and/or Operating Systems/Security Analyst c.8 Add access logs to WOU central logging system 8/1/24 AD UCS, Web & Banner Programmer d.2.i Annual pentest by Campus Guard 2/29/24 AD UCS e Complete f Document all 3rd party providers who interact with FinAid data. Audit yearly 8/1/24 DFA, AD UCS g Complete h Complete i Verbal report given in 2023. Anticipated written report to Board on 7/1/24 7/1/24 AD UCS
• Corrective Action Plan: Caritas Family Solutions acknowledges the finding and is committed to establishing and enforcing internal control procedures for compliance with performance reporting requirements. We will work to improve our oversight and compliance in this regard. o A compliance team wil...
• Corrective Action Plan: Caritas Family Solutions acknowledges the finding and is committed to establishing and enforcing internal control procedures for compliance with performance reporting requirements. We will work to improve our oversight and compliance in this regard. o A compliance team will be appointed to ensure that the agency adheres to all compliance requirements. o The compliance team will work closely with the PM to coordinate and delegate tasks to collect the data needed to complete the report. o The compliance team will assist in creating a process for maintaining documentation to support what is reported. o The compliance team will document the level of compliance in which internal controls are followed and report results to program and agency leadership along with recommendations for improvement. Internal audits will be conducted in preparation for external audits. • Anticipated Completion Date: The process will be implemented on January 3, 2024, and will continuously be reviewed and updated to align with best practices.
• Corrective Action Plan: Caritas Family Solutions acknowledges the finding and agree to implement procedures for reviewing financial reports and ensuring that the CFAO signs off on the review before submission to the granting agency. We are committed to improving the accuracy and compliance of fina...
• Corrective Action Plan: Caritas Family Solutions acknowledges the finding and agree to implement procedures for reviewing financial reports and ensuring that the CFAO signs off on the review before submission to the granting agency. We are committed to improving the accuracy and compliance of financial reports. • Anticipated Completion Date: In July 2023, management implemented formal review, performed by the CFAO, of all SA1 and SA2 reports.
• Corrective Action Plan: The monthly reports are submitted through the CWI portal and since the former Project Manager left the agency, no one else has been granted access to the portal. Several requests have been made to CWI and promises from CWI to grant access to the current Project Manager, but...
• Corrective Action Plan: The monthly reports are submitted through the CWI portal and since the former Project Manager left the agency, no one else has been granted access to the portal. Several requests have been made to CWI and promises from CWI to grant access to the current Project Manager, but access remains elusive. Without access to the portal, - Caritas Family Solutions does not have the template for the report and do not know what data are reported. Moving forward, a hardcopy of the report will be kept on file in the SCSEP office for future reference and audit purposes. The reports are submitted via the funder’s portal and with the departure of the previous program manager, no one at Caritas has access to the poral. Several requests were made to the funder to grant the new program manager access, but those requests have not been honored. • Anticipated Completion Date: The process will be ongoing once management receives access to the portal.
• Corrective Action Plan: This deficiency was also discovered during our internal investigation, and Caritas Family Solutions has implemented a new process to ensure that internal controls are in place. o A SCSEP Employment Specialist will meet with participants to complete the recertification appl...
• Corrective Action Plan: This deficiency was also discovered during our internal investigation, and Caritas Family Solutions has implemented a new process to ensure that internal controls are in place. o A SCSEP Employment Specialist will meet with participants to complete the recertification application and gather the necessary documentation.
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