Corrective Action Plans

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Internal Control over Major Federal Program Compliance Program : Education Stabilization Fund CFDA 84.425 Condition: Lack of policies and procedures for verifying and monitoring Wage Rate Requirements. Material Weakness Corrective Action Plan: The District will adopt policies to ensure...
Internal Control over Major Federal Program Compliance Program : Education Stabilization Fund CFDA 84.425 Condition: Lack of policies and procedures for verifying and monitoring Wage Rate Requirements. Material Weakness Corrective Action Plan: The District will adopt policies to ensure prevailing wage payments for contractor employees on federally funded projects. The District will adopt policies requiring contractors on federally funded projects provide certified payroll reports to the District to ensure compliance with Wage Rate Requirements. The District will mimplement procedures to verify contractor compliance with Wage Rate Requirements. Planned Completion Date: March 31, 2024 Responsible Contact person: Aaron Dalton, Superintendent (417) 683-4717)
Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year - Period 4 TIN#421030129 Federal Financial Assistance Listing #93.498 Compliance Requirement: Repo...
Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year - Period 4 TIN#421030129 Federal Financial Assistance Listing #93.498 Compliance Requirement: Reporting Finding Summary: The Hospital selected option II to calculate lost revenue, which consists of a comparison of actual results during the period of availability to the approved budget. The Hospital did not have a budget for the entire reporting period that was approved prior to March 27, 2020. For the periods that the client did not have an approved budget, $0 was entered for net patient revenues even though there were patient revenues for this period. Responsible Individuals: Michael Coyle, CEO Corrective Action Plan: Management agrees with the finding and notes that there was no impact to the calculation or end results. Should this type of calculation be required in the future, controls will be put into place to ensure the reporting is complete. Anticipated Completion Date: November 30, 2023
Housing and Urban Development Independence Place Cooperative respectfully submits the following corrective action plan for the year ended December 31, 2023. Westberg Eischens, PLLP 2630 1st Street South P.O. Box 362 Willmar, MN 56201 Audit Period: December 31, 2023 The finding from the December 31, ...
Housing and Urban Development Independence Place Cooperative respectfully submits the following corrective action plan for the year ended December 31, 2023. Westberg Eischens, PLLP 2630 1st Street South P.O. Box 362 Willmar, MN 56201 Audit Period: December 31, 2023 The finding from the December 31, 2023 schedule of findings and questioned costs and the summary schedule of prior audit findings is discussed below. The finding is numbered consistently with the number assigned in the schedules. Summary of audit results does not include findings and is not addressed. Finding 2023-001 Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperative will continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles.
The district has already implemented the corrective action plan by submitting the PLE for the 2023-24 school year. The district will continue to submit the PLE on an annual basis.
The district has already implemented the corrective action plan by submitting the PLE for the 2023-24 school year. The district will continue to submit the PLE on an annual basis.
2023-02 – Gramm Leach Bliley Missing Elements. Auditor Description of Conditional and Effect. The most recent written security policy fails to address how the College will evaluate and adjust its information security program for any changes in the College's operations or the results of risk assessme...
2023-02 – Gramm Leach Bliley Missing Elements. Auditor Description of Conditional and Effect. The most recent written security policy fails to address how the College will evaluate and adjust its information security program for any changes in the College's operations or the results of risk assessments. Auditor Recommendation. We recommend that the College implement procedures to ensure that all Gramm Leach Bliley policies are met and confirmed by a second individual. Corrective Action. GOCC will require all procedures and policies are updated and reviewed on an annual basis to make sure we are incompliance with the requirements. Responsible Party. Chief Financial Officer/Controller and IT Director. Anticipated Completion Date. June 30, 2024.
2023-001 – Satisfactory Academic Progress. Auditor Description of Conditional and Effect. One student out of the 40 tested received federal aid, but did not meet the criteria for satisfactory academic progress, but did not receive a warning. The College's SAP policy published on its website is not b...
2023-001 – Satisfactory Academic Progress. Auditor Description of Conditional and Effect. One student out of the 40 tested received federal aid, but did not meet the criteria for satisfactory academic progress, but did not receive a warning. The College's SAP policy published on its website is not based on how the College determines whether students meet the College's SAP requirements. Auditor Recommendation. We recommend the College implement stronger procedures around awarding federal aid to ensure that students receive a warning letter from the College when they didn't meet SAP. We recommend that the College correct its SAP policy to match how they are currently evaluating whether students meet the requirements to continue receiving financial aid. Corrective Action. The school has edited the SAP policy on the College's website. The school will implement additional controls to address the failure to notify a student after they fail to meet the College's SAP policy. Responsible Party. Director of Financial Aid. Anticipated Completion Date. August 8, 2023
Adjusting Journal Entries, Required Disclosures, and Draft Financial Statements Auditor’s Recommendation: Although auditors may continue to provide such assistance both now and, in the future, under the new pronouncement, the District should continue to review and accept both proposed adjusting jour...
Adjusting Journal Entries, Required Disclosures, and Draft Financial Statements Auditor’s Recommendation: Although auditors may continue to provide such assistance both now and, in the future, under the new pronouncement, the District should continue to review and accept both proposed adjusting journal entries and footnote disclosures, along with the draft financial statements. School District’s Response: Jodi Flexman, Business Manager, has received, reviewed and accepted all journal entries, footnote disclosures and draft financial statements proposed for the current year audit and will continue to review similar information for the year ending June 30, 2024 and in future years. Further, the District believes it has a thorough understanding of these financial statements and the ability to make informed judgments based on these financial statements.
Finding 10059 (2023-001)
Significant Deficiency 2023
Management concurs with audit finding. The Center is developing procedures and policies surrounding review of sliding fee discounts are reviewed and revised in order to strengthen internal controls to help ensure calculations and applications are done correctly.
Management concurs with audit finding. The Center is developing procedures and policies surrounding review of sliding fee discounts are reviewed and revised in order to strengthen internal controls to help ensure calculations and applications are done correctly.
Criteria: The funds set aside for debt service reserve are to be used to make USDA loan payments, but must be approved by the USDA before they can be used. Condition: During our review of compliance requirements for the Community Facilities Loans & Grants Cluster, we identified funds were used durin...
Criteria: The funds set aside for debt service reserve are to be used to make USDA loan payments, but must be approved by the USDA before they can be used. Condition: During our review of compliance requirements for the Community Facilities Loans & Grants Cluster, we identified funds were used during the year for operational purposes and did not ask or receive permission from the USDA to use the funds. Cause: The requirement was not met due to an oversight of management. Potential Effect: As a result, the Agency reserves the right to withdraw Agency funding. Recommendation: The Organization should request permission before using reserve funds. Client Response: The Organization will request permission in the future.
Criteria: The funds set aside for debt service reserve are to be used to make USDA loan payments, but must be approved by the USDA before they can be used. Condition: During our review of compliance requirements for the Community Facilities Loans & Grants Cluster, we identified funds were used durin...
Criteria: The funds set aside for debt service reserve are to be used to make USDA loan payments, but must be approved by the USDA before they can be used. Condition: During our review of compliance requirements for the Community Facilities Loans & Grants Cluster, we identified funds were used during the year for operational purposes and did not ask or receive permission from the USDA to use the funds. Cause: The requirement was not met due to an oversight of management. Potential Effect: As a result, the Agency reserves the right to withdraw Agency funding. Recommendation: The Organization should request permission before using reserve funds. Client Response: The Organization will request permission in the future.
The Organization is aware of the lack of segregation of duties caused by the limited size of its staff, and will continue to use other controls, where practical to compensate for this limitation.
The Organization is aware of the lack of segregation of duties caused by the limited size of its staff, and will continue to use other controls, where practical to compensate for this limitation.
Name of Contact Person: Rob Wright, Superintendent. Recommendation: We recommend the District Check the Excluded Parties List System or collect certifications from the entity for any vendor in which the District expects to spend more than $25,000 of federal grant funds for the year. Corrective A...
Name of Contact Person: Rob Wright, Superintendent. Recommendation: We recommend the District Check the Excluded Parties List System or collect certifications from the entity for any vendor in which the District expects to spend more than $25,000 of federal grant funds for the year. Corrective Action: We were not aware of this requirement, but we will ensure that we comply going forward. Proposed Completion Date: Immediately.
Finding: 2023-001 Federal Agency Name: Department of Education Program Name: Student Financial Assistance Cluster ALN #: 84.007, 84.033, 84.063, and 84.268 Finding Summary: 34 CFR 690.83(b)(2) and 34 CFR 685.309 states that Institutions are responsible for timely and accurate reporting of a stu...
Finding: 2023-001 Federal Agency Name: Department of Education Program Name: Student Financial Assistance Cluster ALN #: 84.007, 84.033, 84.063, and 84.268 Finding Summary: 34 CFR 690.83(b)(2) and 34 CFR 685.309 states that Institutions are responsible for timely and accurate reporting of a student's enrollment status and changes in those enrollment statuses, whether they report directly or via a third-party servicer. When an Institution is made aware of a change in a student's enrollment status, the Institution has 60 days to update the change in enrollment status via NSLDS. During the testing of compliance for Enrollment Reporting, there were six instances out of 29 where CSI did not report a student's change in enrollment status accurately or within the required time frame of 60 days from the effective date of the student's change in enrollment status. Responsible Individuals: Bethany Parmer, Registrar and Larisa Alexander Information Technology Corrective Action Plan: The Office of the Registrar and Information Technology team is currently working with the Student Information System support to determine the cause of an issue with the National Student Clearinghouse reporting related to the graduated status. The Office of the Registrar will be ensuring these graduated statuses are entered manually to NSC/NSLDS within the 60 days of completion until the reporting issue is resolved. Anticipated Completion Date: January 12, 2024
Silverstone Living (SL) recognized several operational opportunities for the sustainability of the Foundation, which is the reason why the affiliation occurred. These opportunities were three-fold: increasing census to fill beds which have been unoccupied for some time, maximizing the reimbursemen...
Silverstone Living (SL) recognized several operational opportunities for the sustainability of the Foundation, which is the reason why the affiliation occurred. These opportunities were three-fold: increasing census to fill beds which have been unoccupied for some time, maximizing the reimbursement for services already being provided, and the control and reduction of expenses. In the short amount of time since the affiliation with SL, the average daily census has increased over the prior 3-year period by nearly 7% for Assisted Living services, and nearly 9% for skilled and nursing services. This equates to over $1,000,000 in additional annual revenues because of the census increase alone. SL believes that there is potential to further increase census as we continue to stabilize and onboard additional clinical staffing. SL recently brought on an individual skilled in coding maximization to ensure the Foundation receives the appropriate reimbursement for the services being provided which was previously lacking. On the expense side, SL renegotiated rates with staffing agencies for clinical positions as well as the contracted rehabilitation services to reduce the amounts being charged which has resulted in nearly $40,000 per month in savings from the earlier part of the calendar year. SL also brought the Foundation under its umbrella in the areas of employee benefits and facility insurance, negating any premium increases and a reduction of over $50,000 in Workers Compensation insurance premiums in the coming year. Through attrition, SL also worked to restructure and eliminate several non-clinical positions for operational efficiency and will continue to review staffing needs as turnover occurs. SL is continuing to transition administrative functions such as payroll and accounting onto its systems, further reducing outside contracted services and systems over the coming months. Through this multi-pronged approach, we are seeing dramatic improvements in the financial outlook of the Foundation. During the 3-month fiscal period beginning 2024 compared to the same period in 2023, there has been a $670,000 improvement in income from operations, which we believe will trend throughout the remainder of the new fiscal year, and into the future.
Action taken in response to finding: A clerical support position was recently hired at the end of November, 2023 who will be responsible for handling all receipts and processing of deposits via remote deposit, which was also recently implemented so deposits can be done daily. This will segregate th...
Action taken in response to finding: A clerical support position was recently hired at the end of November, 2023 who will be responsible for handling all receipts and processing of deposits via remote deposit, which was also recently implemented so deposits can be done daily. This will segregate the cash handling from the recording of receipts once he is fully trained on the system. Bank reconciliation reviews will be completed monthly.
Auditor’s recommendation: We recognize that the District has attempted to mitigate the lack of segregation of duties by having other individuals perform certain ancillary duties of record-keeping including: opening the mail; signing of checks; distribution of payroll and vendor checks; and bank reco...
Auditor’s recommendation: We recognize that the District has attempted to mitigate the lack of segregation of duties by having other individuals perform certain ancillary duties of record-keeping including: opening the mail; signing of checks; distribution of payroll and vendor checks; and bank reconciliations. These duties could be enhanced by having the individual responsible for the preparation of bank reconciliations compare the reconciled bank balances to the District’s general ledger software on a monthly basis, as currently reconciliations are compared against manual worksheets. In addition, we recommend that the individual responsible for opening mail also maintain a cash receipts log, with someone independent of the cash receipts function reconciling the log to the general ledger and bank statements at certain times during the year. For mitigating controls over the District’s payroll, the District should consider having the Superintendent review a monthly change report showing any changes in pay rates or employees. Finally, for controls over cash disbursements, the Board should account for the sequence of checks for each disbursement register to ensure that all checks are being reviewed. In addition a report should be generated that documents any new vendors added to the payable module. This report could be approved monthly by the Superintendent. District’s Response: Linda Benson, Business Manager, understands the importance of having strong segregation of duties and will attempt to separate certain responsibilities as outlined above for the year ending June 30, 2024.
Auditor’s Recommendation: Although auditors may continue to provide such assistance both now and in the future, under the new pronouncement, the District should continue to review and accept both proposed adjusting journal entries and footnote disclosures, along with the draft financial statements. ...
Auditor’s Recommendation: Although auditors may continue to provide such assistance both now and in the future, under the new pronouncement, the District should continue to review and accept both proposed adjusting journal entries and footnote disclosures, along with the draft financial statements. District’s Response: Linda Benson, Business Manager, has received, reviewed and accepted all journal entries, footnote disclosures and draft financial statements proposed for the current year audit and will continue to review similar information for the year ending June 30, 2024 and in future years. Further, the District believes it has a thorough understanding of these financial statements and the ability to make informed judgments based on these financial statements. Lastly, the District considers such assistance provided by the auditors to be the most cost effective in preparing such information.
Finding 9923 (2023-001)
Significant Deficiency 2023
Failure to comply with grant time-based requirements. Recommendation: We recommend that First Step corrects the formula in their bonus and hire date tracking spreadsheet to include 365 days of the year instead of a 360-day cycle. Additionally, we recommend payroll or HR reviews the bonus time frame...
Failure to comply with grant time-based requirements. Recommendation: We recommend that First Step corrects the formula in their bonus and hire date tracking spreadsheet to include 365 days of the year instead of a 360-day cycle. Additionally, we recommend payroll or HR reviews the bonus time frames provided by management before dispersing the payment. Action Taken: Chris Smith, CFO, has since updated spreadsheet used in calculation of bonuses. Going forward, any funding of this nature will have an initial review by HR before going to management and payment is disbursed. Name of person responsible for corrective action: Chris Smith, CFO Anticipated completion date for the corrective action: December 31, 2023
Enrollment Reporting Recommendation: We recommend that the College review and implement procedures to ensure the correct date and status is reported to the NSLDS in all cases. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response...
Enrollment Reporting Recommendation: We recommend that the College review and implement procedures to ensure the correct date and status is reported to the NSLDS in all cases. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: For the two students who were dual degree, manual entry errors were the cause and were corrected. The College will implement a process in September 2023 where a second reviewer from Institutional Research will review the manual entry for student status changes to ensure that the correct dates are reported to NSDLS. For the third student, the timing of the notification of withdrawal, which had to be processed retroactively, and when the certification file was sent to NSDLS caused the student to be left out of the certification file. The College has added additional College officials (in Institutional Research) to the daily and monthly withdrawal lists so students who are processed retroactively will not be missed. Name(s) of the contact person(s) responsible for corrective action: Lindsay Thibodaux Planned completion date for corrective action plan: September 2023
2023-001 Return to Title IV Recommendation: We recommend that the College review and implement procedures to ensure that withdrawals are properly communicated to all departments and processed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. ...
2023-001 Return to Title IV Recommendation: We recommend that the College review and implement procedures to ensure that withdrawals are properly communicated to all departments and processed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College will implement a plan to require faculty to update the last date of attendance at the end of the term in the portal for students attending distance learning classes. This date will be used by the Registrar’s Office and Financial Aid Office for reporting. Name(s) of the contact person(s) responsible for corrective action: Dr. Tracy Tedder Planned completion date for corrective action plan: August 2023
View Audit 13554 Questioned Costs: $1
Finding 9911 (2023-005)
Significant Deficiency 2023
Finding: 2023-005 Inaccurate Information Entry Finding: 2023-006 Inaccurate Resource Calculation Edgecombe County, NC Section III - Federal Award Findings and Question Costs Name of contact person: Veronica Lyons, Tina Radford, Virginia Ewuell, & Angel Joyner/Medicaid Supervisors Corrective Action: ...
Finding: 2023-005 Inaccurate Information Entry Finding: 2023-006 Inaccurate Resource Calculation Edgecombe County, NC Section III - Federal Award Findings and Question Costs Name of contact person: Veronica Lyons, Tina Radford, Virginia Ewuell, & Angel Joyner/Medicaid Supervisors Corrective Action: The errors that were found were under the policy of having to comply with Child Support. As of August 18, 2023, this policy is no longer in effect while we are under the CCU (Continuous Coverage Unwinding). Medicaid Supervisors will continue to abide by the policy changes as they come into effect to reconvene the compliance with Child Support. Proposed Completion Date: Not applicable. Name of contact person: Virginia Ewuell & Angel Joyner - Medicaid Supervisors Name of contact person: Veronica Lyons, Tina Radford, Virginia Ewuell, & Angel Joyner - Medicaid Supervisors Proposed Completion Date: Training and implementation of additional reviews and procedures will be implemented by February 15, 2024. Corrective Action: MA-2230 Financials Resources training will be conducted with all workers. Documentation template will be updated to cover all of the possible resources for workers to check for when completing applications and reviews. Caseworkers will be instructed to end date evidence and start a new evidence for the new review period to show the updated information. Medicaid Supervisors and the Quality Control workers will review files internally to ensure verifications received from AB matches information in NCFAST and changes are applied. Proposed Completion Date: Training and implementation of additional reviews and procedures will be implemented by February 15, 2024. Corrective Action: MA-3300 Income training will be conducted with all workers. Documentation template updated to include running TWN, OVS, AVS and double checking to ensure that all household members are included. Them template will also ensure that evidence is updated and changes are applied. Workers will also use the automated budget to ensure that information matches the determination in NCFAST. Medicaid Supervisors and Quality Control workers will review files internally to ensure verifications match the evidence put in NCFAST and changes are applied to the cases and case evidence includes all household members.
Adjusting Journal Entries, Required Disclosures and Draft Financial Statements Year ended June 30, 2023 Auditors’ Recommendation: Although auditors may continue to provide such assistance both now and in the future, under this pronouncement, the District should continue to review and accept both pro...
Adjusting Journal Entries, Required Disclosures and Draft Financial Statements Year ended June 30, 2023 Auditors’ Recommendation: Although auditors may continue to provide such assistance both now and in the future, under this pronouncement, the District should continue to review and accept both proposed adjusting journal entries and footnote disclosures, along with the draft financial statements. District’s Response: Adam Moate, Business Manager, has received, reviewed and accepted all journal entries, footnote disclosures and draft financial statements proposed for the current year audit and will continue to review similar information for the year ending June 30, 2024 and in future years. Further, the District believes it has a thorough understanding of these financial statements and the ability to make informed judgments based on these financial statements. Lastly, the District considers such assistance provided by the auditors to be the most cost effective in preparing such information.
The District relies on the auditor to propose adjustments necessary to prepare the schedule of expenditures of federal awards including the related note disclosures. The District reviews the schedule of expenditures of federal awards and approves all adjustments.
The District relies on the auditor to propose adjustments necessary to prepare the schedule of expenditures of federal awards including the related note disclosures. The District reviews the schedule of expenditures of federal awards and approves all adjustments.
Finding: 2023-003 – Special Tests and Provisions – Wage Rate Requirements Auditor Description of Condition and Effect: The amounts tested 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 Dist...
Finding: 2023-003 – Special Tests and Provisions – Wage Rate Requirements Auditor Description of Condition and Effect: The amounts tested 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 bid process. Responsible Person: Mike Beltnick, CFO Anticipated Completion Date: June 30, 2024
View Audit 13486 Questioned Costs: $1
2023-002 – Federal Work Study (FWS) Over Award – Federal Assistance Listing No. 84.033 Recommendation: We recommend the College review its policies and procedures when packaging students for FWS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Actio...
2023-002 – Federal Work Study (FWS) Over Award – Federal Assistance Listing No. 84.033 Recommendation: We recommend the College review its policies and procedures when packaging students for FWS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the finding: The Financial Aid Office acknowledges that three students on the preliminary list of Title IV recipients provided to the auditors reflected an over-award based on the inclusion of FWS funds in their packages. All students are initially packaged through automated packaging, with the College’s software preventing over-awards. However, many awards are adjusted during the course of an academic year, and when this happens, the software’s checks no longer operate. To ensure compliance, the Financial Aid Office conducts ongoing audits throughout the year and a final audit at the end of each year, which also incorporates a final reconciliation of the FWS program. This year, the FWS/final audit was not completed before the preliminary list was submitted to the auditors. Had the audit been completed on time, the three students would not have shown as over-awards, nor would they be counted as FWS recipients. Corrective Action Plan The Financial Aid Office already audits financial aid packages to prevent over-awards. The office will ensure that such audits are completed in a timelier fashion, resulting in a proper final list of Title IV recipients to be submitted for audit review. Name(s) of the contact person(s) responsible for corrective action: Michael Colahan, Student Financial Aid Director Planned completion date for corrective action plan: Effective November 2023
View Audit 13479 Questioned Costs: $1
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