Corrective Action Plans

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• 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 appli...
• 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. o The recertification application and documentation will be forwarded to the PM for review and approval. o The PM will review the form, sign, and date it after confirming that all information is accurate and complete. o If there are inaccuracies and/or missing information, the form will be returned to the ES who will follow up with the host site to obtain the missing information or correct the inaccuracy. o Steps 1 and 2 will be repeated. o The QI department will conduct quarterly file reviews to determine if processes are being followed. Re-certification was modified during the pandemic out of an abundance of caution for the participants in the program. Those who had access to the internet were asked to email their documentation, and those who didn’t were asked to mail theirs. A drive through recertification process was implemented when COVID restrictions eased, and participants were asked to remain in their vehicles while SCSEP employment specialists obtained their recertification documentation. Many participants do not have transportation and were not able to participate in the drive through. The most recent, pre-pandemic certification information for participants was used for those who were not able to attend the drive through or virtual recertification processes. CWI did not end COVID protocols until Q4 of PY2022 (April 1, 2023). Alternative recertification methods were used to comply with the protocols. With the end of the COVID protocols and restrictions, we have reinstituted the in-person/face-to-face recertification process required by the funder. • Anticipated Completion Date: Implemented in September 2023, but the process will be ongoing while the program is funded.
• 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. • Anticipated Completion Date: Implemented in September 2023, but the process will be ongoing whi...
• 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. • Anticipated Completion Date: Implemented in September 2023, but the process will be ongoing while the program is funded. o A SCSEP Employment Specialist will meet with participants to complete the recertification application and gather the necessary documentation. o The recertification application and documentation will be forwarded to the PM for review and approval. o The PM will review the form, sign, and date it after confirming that all information is accurate and complete. o If there are inaccuracies and/or missing information, the form will be returned to the ES who will follow up with the host site to obtain the missing information or correct the inaccuracy. o Steps 1 and 2 will be repeated. o The QI department verify eligibility and recertification documents are within the file during their quarterly reviews to determine if processes are being followed.
• Corrective Action Plan: Caritas Family Solutions acknowledge the finding and are committed to establishing and enforcing internal control procedures for earmarking compliance requirements. We will work to improve our oversight and compliance in this regard. o A compliance team from the QI Departm...
• Corrective Action Plan: Caritas Family Solutions acknowledge the finding and are committed to establishing and enforcing internal control procedures for earmarking compliance requirements. We will work to improve our oversight and compliance in this regard. o A compliance team from the QI Department will be appointed to ensure that the program adheres to all compliance requirements. o The compliance team will work closely with the PM to coordinate and delegate tasks to determine how and what data will be collected. o The compliance team will work closely with the PM to determine who has responsibility for data entry, compilation, and processing. o The compliance team will assist the program in creating a process for maintaining, storing, and securing data for the required period. o The compliance team will review compliance throughout the life of the grant and adjust, as necessary. • Anticipated Completion Date: The process will be implemented on January 3, 2024, and will be continually updated to align with best practices.
• 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 After the PM has verified that timesheets are accurate and complete, they will be scanned and s...
• 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 After the PM has verified that timesheets are accurate and complete, they will be scanned and sent to Payroll for processing. o Payroll will maintain a copy of the email providing the documents and will comply with federal guidelines of storing records for a period after the close of the grant. o The PM will file a hard copy of the timesheets in the SCSEP office. o The files will be kept in the office until completion of quarterly reviews for the fiscal year by the QI department, and then they will be transferred to the agency’s long-term storage facility for files. • Anticipated Completion Date: Implemented in September 2023, but the process will be ongoing while the program is funded
Finding 2023-001: Lack of Internal Control Review for Allowable Costs • Responsible Party: Gary Huelsmann, Chief Executive Officer • Corrective Action Plan: This deficiency was also discovered during our internal investigation, and Caritas Family Solutions has implemented a new process to ensure t...
Finding 2023-001: Lack of Internal Control Review for Allowable Costs • Responsible Party: Gary Huelsmann, Chief Executive Officer • 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 Program participants will only be paid for verified hours of service. An annual meeting (either one-on-one or in a group) will be held with site supervisors to discuss processes and procedures and program expectations. During this meeting, supervisors will be shown how to complete the timesheet and given details on how to submit them for processing. o Individual and group meetings will be held with program participants to explain the process to them and remind them that payments will not be made until timesheets are accurate and complete. Timesheets are due on Friday prior to pay dates. o The ES will review submitted timesheets for accuracy and completeness and will forward them to the PM for review and final approval before they are submitted to Payroll for processing. o The PM will review the form, sign, and date it after confirming that all information is accurate and complete. o If there are inaccuracies and/or missing information, the form will be returned to the ES who will follow up with the host site to obtain the missing information or correct the inaccuracy. o Steps 1 and 2 will be repeated. o The QI department will conduct quarterly file reviews to determine if processes are being followed. • Anticipated Completion Date: Implemented in September 2023, but the process will be ongoing while the program is funded.
Finding 10908 (2023-001)
Significant Deficiency 2023
Beginning with the January 10, 2024, reporting date the City is following the reporting requirement for OBDD and will continue to work with them on the other compliance issues listed above. The city has implemented procedures to guarantee filing of the require reports.
Beginning with the January 10, 2024, reporting date the City is following the reporting requirement for OBDD and will continue to work with them on the other compliance issues listed above. The city has implemented procedures to guarantee filing of the require reports.
Gavilan’s current process in submitting enrollment files to NSC involves a collaboration between two departments: Admissions and Records and Information Technology. During this period, primarily in Spring 2023, the two parties experienced a miscommunication between which file contained the current e...
Gavilan’s current process in submitting enrollment files to NSC involves a collaboration between two departments: Admissions and Records and Information Technology. During this period, primarily in Spring 2023, the two parties experienced a miscommunication between which file contained the current enrollment data versus which file was being submitted to NSC. Admissions and Records mistakenly submitted 4 incorrect files. Since, Admissions and Records has worked with IT to update procedures and strengthen communication when collecting the current enrollment data. To further correct the deficiency, discussions circled around Admissions and records working with a Banner Ellucian Consultant to review our Banner capabilities and strengthen the user control to oversee and submit the enrollment reports independent of IT’ s assistance. Admissions and Records will also develop a written manual to cover the step-by-step process in submitting the School Enrollment Transmission to National Student Clearinghouse in order for the correct NSLDS monitoring. The written manual will document: • Banner pages and strokes, including screen shots. • Current IT process, point of contact and file name • Link to future transmission page on the Na1onal Student Clearinghouse user page • Link to NSDLS Repor1ng page to validate and confirm correct submissions have been reported. The Director of Admissions and Records will coordinate business practices with Admissions and Records, Financial Aid and IT to ensure the school enrollment transmissions are submitted on time and are correct. The business process will be documented by Admissions and Records and shared with Financial Aid, IT, and the VP of Student Services
Finding: 2023-001 Federal Agency Name: U.S. Department of Education Program Name: Student Financial Assistance Cluster FAL #: 84.063, 84.007, 84.238, 84.033 Initial Fiscal Year Finding Occurred: 2023 Finding Summary: During the testing over student information security, it was determined the College...
Finding: 2023-001 Federal Agency Name: U.S. Department of Education Program Name: Student Financial Assistance Cluster FAL #: 84.063, 84.007, 84.238, 84.033 Initial Fiscal Year Finding Occurred: 2023 Finding Summary: During the testing over student information security, it was determined the College did not have all nine elements of the new GLBA requirements in place with written policies and documented follow through protocols. Responsible Individuals: Jeremy Taylor, Chief Information Officer and Josh Ogle, former Chief Information Officer. Corrective Action Plan: : Subsequent to the June 30, 2023 finding the College has already implemented or updated process to ensure student information security safeguards are in place. This includes a Security Information and Event Management (SIEM) solution fully equipped to log all user access within our network and capture detailed information about user activities on the network and their individual PCs. Additionally, it comprehensively monitors and collects data on all network switch and firewall activity. This data is stored and analyzed on-premises and reported to Sophos for enhanced monitoring through their Managed Detection and Response (MDR) service. Rogue Community College has extended its security measures by integrating our Microsoft 365 tenant and Okta with Sophos, enabling 24/7 user activity monitoring across these platforms. These integrations and vigilant monitoring practices demonstrate our unwavering commitment to robust security and adherence to regulatory compliance standards, ensuring meticulous surveillance of authorized user actions and safeguarding against unauthorized access. We have contracted with Eide Bailly’s Technology Consulting group. The Statement of Work focuses on creating an Incident Response Plan which is leading to updated policies and procedure documentation. We are working on a GLBA specific policy as well. Anticipated Completion Date: As of December 2023, we believe we have the minimum safeguards in place. By early 2024, a written GLBA specific policy including how we document follow through on monitoring efforts will be in place.
Since the inception of HEERF, the US Department of Education has continuously issued changes to program guidance and reporting requirements. Due to the unusual and unprecedented circumstances surrounding COVID-19 and the inconsistency in HEERF requirements from month-to-month, management of the awar...
Since the inception of HEERF, the US Department of Education has continuously issued changes to program guidance and reporting requirements. Due to the unusual and unprecedented circumstances surrounding COVID-19 and the inconsistency in HEERF requirements from month-to-month, management of the award has posed significant challenges for institutions of higher education during a time where we are also experiencing high staff turnover. At the same time, the college was impacted by a cyber-security event which impacted the institution’s ability to post required reports in a timely fashion. To ensure compliance, the Finance Department and the grant management team has incorporated HEERF reporting due dates into its operational calendar. These requirements will be reviewed regularly, and the team will direct timely compliance with all future reporting requirements. Person(s) Responsible: Mary Schulte, Christina Russell, Carrie Patton Timing for Implementation: Immediate
Finding 10821 (2023-009)
Material Weakness 2023
Date: 12/27/2023 Division: Office of the County Manager Corrective Action Plan Audit Report Number: Year ended June 30, 2023 Finding Number: 2023-009 Finding: The Office of the County Manager did not have internal controls established over the determination of eligibility of the participants in the ...
Date: 12/27/2023 Division: Office of the County Manager Corrective Action Plan Audit Report Number: Year ended June 30, 2023 Finding Number: 2023-009 Finding: The Office of the County Manager did not have internal controls established over the determination of eligibility of the participants in the Emergency Rental Assistance Program. Corrective Action Taken or To Be Taken: Internal controls will include determining the eligibility of the participants in the Emergency Rental Assistance Program. If already taken, date of completion: If to be taken, estimated date of completion: January 2024 Agency Response Does the Agency Agree with finding?: Yes 􀜈 No 􀜆 Partially 􀜆 If No or Partial, Please explain reason(s) why: Additional Comments: Division Responsible for Corrective Action Plan Name, Title: Cathy Hill, Comptroller Address or Mailstop: 1001 E. Ninth St. City, State, Zip Code: Reno, NV 89512 Phone Number: (775) 328-2552 Email: chill@washoecounty.gov Reviewed and Approved Cathy HillDigitally signed by Cathy Hill Date: 2023.12.27
Finding 10820 (2023-008)
Material Weakness 2023
Date: 12/27/2023 Division: Office of the County Manager Corrective Action Plan Audit Report Number: Year ended June 30, 2023 Finding Number: 2023-008 Finding: The Office of the County Manager did not have internal controls established over the direct payments made to participants of the Emergency Re...
Date: 12/27/2023 Division: Office of the County Manager Corrective Action Plan Audit Report Number: Year ended June 30, 2023 Finding Number: 2023-008 Finding: The Office of the County Manager did not have internal controls established over the direct payments made to participants of the Emergency Rental Assistance Program. Corrective Action Taken or To Be Taken: Internal controls will be monitored/created for future awards. If already taken, date of completion: If to be taken, estimated date of completion: January 2024 Agency Response Does the Agency Agree with finding?: Yes 􀜈 No 􀜆 Partially 􀜆 If No or Partial, Please explain reason(s) why: Additional Comments: Division Responsible for Corrective Action Plan Name, Title: Cathy Hill, Comptroller Address or Mailstop: 1001 E. Ninth St. City, State, Zip Code: Reno, NV 89512 Phone Number: (775) 328-2552 Email: chill@washoecounty.gov Reviewed and Approved Cathy HillDigitally signed by Cathy Hill Date: 2023.12.27
SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF EDUCATION, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, SPECIAL EDUCATION CLUSTER (INCLUDING COVID-19 FUNDING) – FEDERAL ALN 84.027 AND 84.173 2023-001 Internal Control Over Compliance with Federal Suspension and...
SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF EDUCATION, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, SPECIAL EDUCATION CLUSTER (INCLUDING COVID-19 FUNDING) – FEDERAL ALN 84.027 AND 84.173 2023-001 Internal Control Over Compliance with Federal Suspension and Debarment Requirements Finding Summary 2 CFR § 180 and CFR § 200 requires the Cooperative to establish and maintain effective internal control over compliance with requirements applicable to federal program expenditures, including suspension and debarment requirements. The Cooperative did not have sufficient controls in place within its special education cluster federal programs to assure that it was not contracting for goods or services with parties that are suspended or debarred, or whose principals are suspended or debarred from participating in contracts involving the expenditures of federal program funds. Corrective Action Plan Actions Planned – The Cooperative will review policies and procedures relating to suspension and debarment for its federal programs and will ensure that all parties with which it contracts for goods or services are eligible to participate in contracts involving the expenditures of federal program funding. Official Responsible – Tracy Wells, Business Manager. Planned Completion Date – June 30, 2024. Disagreement With or Explanation of Finding – The District agrees with this finding. Plan to Monitor – Tracy Wells, Business Manager, will assure appropriate controls are in place, and will review internal control procedures relating to suspension and debarment to ensure they are in line with the Uniform Guidance requirements.
Finding 10807 (2023-001)
Significant Deficiency 2023
Gramm-Leach-Bliley Act (GLBA) Recommendation: We recommend that the College review the updated GLBA requirements and ensure their written information security program (WISP) includes all required elements. Explanation of disagreement with audit finding: There is no disagreement with the audit find...
Gramm-Leach-Bliley Act (GLBA) Recommendation: We recommend that the College review the updated GLBA requirements and ensure their written information security program (WISP) includes all required elements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Reason for finding: Non-compliance with GLBA Action taken in response to finding: Management has already taken action and developed a written information security plan and will implement the written policy that includes all the required elements. Name(s) of the contact person(s) responsible for corrective action: Brant Wright Planned completion date for corrective action plan: December 31, 2023
Finding 2023-001 - Lack of Segregation of Duties The District understands that this is a significant deficiency but feels it is not cost-effective at this time to hire additional employees to properly segregate duties. We feel that the oversight performed by the Superintendent and Board of Educati...
Finding 2023-001 - Lack of Segregation of Duties The District understands that this is a significant deficiency but feels it is not cost-effective at this time to hire additional employees to properly segregate duties. We feel that the oversight performed by the Superintendent and Board of Education over the financial statement activity and reports of the District is adequate to help mitigate the lack of segregation of duties. We believe it would be inefficient and cost prohibitive to hire the additional employees needed to properly segregate duties so at this time we do not plan on making any changes. However, we will continue to monitor this situation and periodically determine if it is cost-effective for us to properly segregate duties.
Corrective Action: The District will establish internal controls that will be designed to ensure the compliance with the Wage Rate Requirements (Davis-Bacon Act) provision applicable to contracts that are governed by federally financed and assisted construction projects. The Chief Financial Officer ...
Corrective Action: The District will establish internal controls that will be designed to ensure the compliance with the Wage Rate Requirements (Davis-Bacon Act) provision applicable to contracts that are governed by federally financed and assisted construction projects. The Chief Financial Officer will implement a new Vendor Contract Packet. The Vendor Contract Packet will consist of an EDGAR Certification Form that will address the assurances under the Uniform Administrative Requirements, Cost Principles and Audit Requirements for Federal Awards, 2 CFR 200 (EDGAR). Within the vendor packet, will be the vendor’s agreement and ability to comply with EDGAR regulations. Further, it will require the vendor to agree to the wage rate determinations and a copy of the certified payrolls and a statement of compliance with requirement. Contact person: Sylvia S. Garza, CFO Completion: January 31, 2024
Condition: We noted during testing that the City had omitted a subrecipient from its search to ensure that the subrecipient was not suspended, debarred, or otherwise excluded pursuant to 2 CFR section 180.300. Planned Corrective Action: Procedures have already been put into place to ensure that each...
Condition: We noted during testing that the City had omitted a subrecipient from its search to ensure that the subrecipient was not suspended, debarred, or otherwise excluded pursuant to 2 CFR section 180.300. Planned Corrective Action: Procedures have already been put into place to ensure that each new contractor is not on the Federal list of suspended and/or debarred contractors. Furthermore, all vendors previously paid have been searched for in the Federal list and none were suspended and/or debarred. Contact person responsible for corrective action: Lee Ward, Director of Finance. Anticipated Completion Date: 12/15/2023
Finding: 2023-002 – Special Tests and Provisions – Wage Rate Requirements U.S. Department of Education – COVID-19 - Education Stabilization Fund (ALN 84.425D and 84.425U); Passed through the Michigan Department of Education; All project numbers. Auditor Description of Condition and Effect: Three o...
Finding: 2023-002 – Special Tests and Provisions – Wage Rate Requirements U.S. Department of Education – COVID-19 - Education Stabilization Fund (ALN 84.425D and 84.425U); Passed through the Michigan Department of Education; All project numbers. Auditor Description of Condition and Effect: Three of the contracts selected for testing that were subject to the Wage Rate Requirements did not include the required provision, and the District did not obtain the required certified payrolls. The District did not follow federal requirements to include the prevailing wage rate provision in its contract. Auditor Recommendation: We recommend that the District reviews its policies to ensure that applicable prevailing wage requirements are included in construction contracts whenever federal funds are used and certified payrolls are obtained. Corrective Action: District officials will ensure that construction contracts contain these requirements during the bidding and/or proposal process. Responsible Person: Rebecca Jones, Superintendent and Tara Newman, Business Manager Anticipated Completion Date: June 30, 2024
View Audit 14327 Questioned Costs: $1
Finding 10633 (2023-001)
Significant Deficiency 2023
Finding 2023-001: Special Tests and Provisions: Enrollment Reporting Context/Condition: Of the 40 students selected for enrollment reporting testing, 3 students within the sample were reported to NSLDS outside the maximum 60-day window. Recommendation: The auditor recommended that the College rev...
Finding 2023-001: Special Tests and Provisions: Enrollment Reporting Context/Condition: Of the 40 students selected for enrollment reporting testing, 3 students within the sample were reported to NSLDS outside the maximum 60-day window. Recommendation: The auditor recommended that the College review and update internal controls to ensure student enrollment status in the National Student Loan Data System (NSLDS) is updated in a timely manner to ensure compliance with Federal requirements. Persons Responsible for Corrective Action: Dr. Deokhyo Kim, Registrar Planned Corrective Action: We communicated with our software vendor, Aptron, to determine what caused the enrollment reporting issues. We identified two issues and worked with Aptron to put measures in place so that these issues do not happen in the future. 1. Missing withdrawn students who were not pulled up by system when they withdrew before or on the 1st enrollment report date. APTRON fixed the programming and the system now pulls those who are withdrawn before or on the 1st enrollment report date for each semester. 2. Missing graduates with their 2nd degree. APTRON fixed the programming, so that our Degree Verify file will now report a student who has earned a second degree with us. A Degree Verify File of graduates was submitted to the NSCH for any student who had earned a second degree not previously reported. Anticipated Completion Date: Fixes with our software vendor have been completed.
Comments on the Finding and Each Recommendation: Management agrees with both the finding and the recommendations. Action(s) Taken or Planned on the Finding Under the direction of the Assistant Executive Director, the Housing Administrator has already established an inspection oversight process with ...
Comments on the Finding and Each Recommendation: Management agrees with both the finding and the recommendations. Action(s) Taken or Planned on the Finding Under the direction of the Assistant Executive Director, the Housing Administrator has already established an inspection oversight process with HQS staff addressing the deficiencies noted in the finding, including the timeliness of reinspection. The process also includes implementing an updated voucher abatement and loss procedure before 12/31/2023. The operations memorandum detailing the oversight process will be distributed to staff before 01/01/2024.
The district will adjust its operations to include a financial review and reconciliation of the reimbursement requests prepared on its behalf by the private consultant administering the program.
The district will adjust its operations to include a financial review and reconciliation of the reimbursement requests prepared on its behalf by the private consultant administering the program.
The Board of Directors is and will remain involved in the financial affairs of the Cooperative. The Cooperative hired a new management agent with proper segregation of duties.
The Board of Directors is and will remain involved in the financial affairs of the Cooperative. The Cooperative hired a new management agent with proper segregation of duties.
The Board of Directors is and will remain involved in the financial affairs of the Cooperative. The Cooperative hired a new management agent with proper segregation of duties.
The Board of Directors is and will remain involved in the financial affairs of the Cooperative. The Cooperative hired a new management agent with proper segregation of duties.
The Board of Directors is and will remain involved in the financial affairs of the Cooperative. The Cooperative hired a new management agent with proper segregation of duties.
The Board of Directors is and will remain involved in the financial affairs of the Cooperative. The Cooperative hired a new management agent with proper segregation of duties.
Finding 2023.004 - Reporting Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Action Taken Health contracted with an interim Chief Financial Officer in January 2023. The interim CFO de...
Finding 2023.004 - Reporting Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Action Taken Health contracted with an interim Chief Financial Officer in January 2023. The interim CFO departed in February 2023 and was unable to provide the organization with work source documents for the 2022 UDS submission. Effective January 2024, the current Chief Financial Officer and the electronic medical records specialist (IT) will ensure all source documentation for the UDS submission is saved on the organization’s shared file drive to support the annual UDS submission.
Finding 2023.003 - Activities Allowed or Unallowed Recommendation The Organization should establish a system of internal controls to ensure that all employees are being paid the correct amounts. Action Taken United Methodist Western Kansas Mexican-American Ministries Inc. d/b/a Genesis Family Heal...
Finding 2023.003 - Activities Allowed or Unallowed Recommendation The Organization should establish a system of internal controls to ensure that all employees are being paid the correct amounts. Action Taken United Methodist Western Kansas Mexican-American Ministries Inc. d/b/a Genesis Family Health implemented PayCom in January 2023. With this system update, the organization has implemented an automated process to ensure changes to employee pay rates are approved and adjusted timely. This process requires all changes to employee’s compensation being entered into the PayCom (payroll system) by the departmental managers/supervisors. Changes in pay are automatically flagged for review and approval by the human resources department. These changes improved internal controls to ensure all employee rate changes are implemented timely and employees are being paid the correct amount.
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