Corrective Action Plans

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The Authority has performed a review of all patients who have had indications of additional health insurance on an account with a HRSA payment, and made appropriate refunds.
The Authority has performed a review of all patients who have had indications of additional health insurance on an account with a HRSA payment, and made appropriate refunds.
View Audit 296311 Questioned Costs: $1
Corrective Action Plan Finding 2023-002 Internal Control Deficiency Activities Allowed or Unallowed/Allowable Costs Identification of the federal program: Federal Grantor: Department of Homeland Security; Federal Emergency Management Agency (FEMA); Assistance Listing No. 97.036, Disaster Grants – P...
Corrective Action Plan Finding 2023-002 Internal Control Deficiency Activities Allowed or Unallowed/Allowable Costs Identification of the federal program: Federal Grantor: Department of Homeland Security; Federal Emergency Management Agency (FEMA); Assistance Listing No. 97.036, Disaster Grants – Public Assistance (Presidentially Declared Disasters) Condition: Per discussion with management, OU Medicine, Inc. has processes and internal controls in place to ensure personnel expenses submitted to the FEMA program were allowable COVID-19-related expenses. These internal controls include ensuring completeness and accuracy of the expenses to ensure the expenses comply with the terms and conditions of the award. However, management did not consistently retain documentation evidencing the performance of these controls. Corrective Action: As part of the Uniform Guidance audit, OU Health provides documentation to explain how eligible costs are/will be identified and submitted. To ensure internal controls are documented to the level necessary under current audit standards, OU Health will develop a checklist to document the review and approval of supporting documentation of costs as reported as federal expenditures. The supporting documentation will be reviewed by management to ensure expenses charged to the federal program are allowable and have not been reimbursed under another federal program. The checklist and all correspondence will be retained with the report and within the Audit Folder. Responsible Official: Bernard Githinji, AVP – Corporate Controller Anticipated Completion Date: April 30, 2024
Corrective Action Plan Finding 2023-003 Internal Control Deficiency Activities Allowed or Unallowed/Allowable Costs Identification of the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA); Assistance Listing ...
Corrective Action Plan Finding 2023-003 Internal Control Deficiency Activities Allowed or Unallowed/Allowable Costs Identification of the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA); Assistance Listing No. 93.498, Provider Relief Fund and American Rescue Plan (ARP) Rural Distributions Condition: Per discussion with management, OU Medicine, Inc. has processes and internal controls in place to comply with the terms and conditions of the award and the reporting requirements. However, management did not retain documentation evidencing the performance of these controls. Corrective Action: At the beginning of the pandemic, OU Health created working groups to evaluate the requirements for COVID-19 funding received and ensure the funds were only used for allowable purposes. The working groups were assisted by outside consultants to stay updated on the reporting requirements as the continued to evolve. As part of the Uniform Guidance audit, OU Health provided documentation of the Provider Relief Fund review process that explained how eligible costs were identified and submitted. To ensure internal controls are documented to the level necessary under current audit standards, OU Health will develop a checklist to document the review and approval of supporting documentation of contract labor costs as reported federal expenditures. The supporting documentation will be reviewed by management to ensure expenses charged to the federal program are allowable and have not been reimbursed under another federal program. The checklist will be retained with the existing report. Responsible Official: Bernard Githinji, AVP Corporate Controller Anticipated Completion Date: April 30, 2024
Corrective Action Plan Finding 2023-001 Internal Control Deficiency Activities Allowed or Unallowed/Allowable Costs Identification of the federal program: Federal Grantor: Department of the Treasury; Assistance Listing No. 21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds (CSLRF) C...
Corrective Action Plan Finding 2023-001 Internal Control Deficiency Activities Allowed or Unallowed/Allowable Costs Identification of the federal program: Federal Grantor: Department of the Treasury; Assistance Listing No. 21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds (CSLRF) Condition: Per discussion with management, OU Medicine, Inc. has processes and internal controls in place to ensure expenses submitted to the CSLFRF program were allowable expenses per the grant agreement These internal controls include ensuring completeness and accuracy of the expenses to ensure the expenses comply with the terms and conditions of the award. However, management did not consistently retain documentation evidencing the performance of these controls. Corrective Action: As part of the Uniform Guidance audit, OU Health provides documentation to explain how eligible costs are/will be identified and submitted. To ensure internal controls are documented to the level necessary under current audit standards, OU Health will develop a checklist to document the review and approval of supporting documentation of costs as reported as federal expenditures. The supporting documentation will be reviewed by management to ensure expenses charged to the federal program are allowable and have not been reimbursed under another federal program. The checklist and all correspondence will be retained with the report and within the Audit Folder. Responsible Official: Bernard Githinji, AVP – Corporate Controller Anticipated Completion Date: April 30, 2024
Segregation of Duties Name of Contact Person: Shelley Wolf, County Auditor Corrective Action: The duties will be separated as much as possible and alternative controls will be considered to compensate for lack of separation. Proposed Completion Date: Ongoing.
Segregation of Duties Name of Contact Person: Shelley Wolf, County Auditor Corrective Action: The duties will be separated as much as possible and alternative controls will be considered to compensate for lack of separation. Proposed Completion Date: Ongoing.
Finding 2023-007 – Education Stabilization Fund - Special Tests and Provisions - Wage Rate Requirement Contact Person Responsible for Corrective Action: Brad DeRome Contact Phone Number: X Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We wil...
Finding 2023-007 – Education Stabilization Fund - Special Tests and Provisions - Wage Rate Requirement Contact Person Responsible for Corrective Action: Brad DeRome Contact Phone Number: X Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will ensure all construction projects using federal funding will meet the wage rate requirements. Anticipated Completion Date: March 2024
Finding 2023-006 – Education Stabilization Fund - Reporting Contact Person Responsible for Corrective Action: Brad DeRome Contact Phone Number: X Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will ensure all ESSER reports include accurate...
Finding 2023-006 – Education Stabilization Fund - Reporting Contact Person Responsible for Corrective Action: Brad DeRome Contact Phone Number: X Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will ensure all ESSER reports include accurate information that agree to the underlying disbursement records. Anticipated Completion Date: Next ESSER reports due in FY24
Finding 2023-005 – Title I Grants to Local Educational Agencies - Maintenance of Effort Contact Person Responsible for Corrective Action: Brad DeRome Contact Phone Number: X Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will ensure all ex...
Finding 2023-005 – Title I Grants to Local Educational Agencies - Maintenance of Effort Contact Person Responsible for Corrective Action: Brad DeRome Contact Phone Number: X Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will ensure all expenses are recorded correctly and any capital items over the threshold are properly recorded to capital object codes. Anticipated Completion Date: March 2024
Finding 2023-004 – Title I Grants to Local Educational Agencies - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Brad DeRome Contact Phone Number: X Views of Responsible Official: We concur with the finding. Description of Co...
Finding 2023-004 – Title I Grants to Local Educational Agencies - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Brad DeRome Contact Phone Number: X Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will ensure all payroll amounts recorded to Title I are reviewed to ensure they represent Title I payroll activity only. Anticipated Completion Date: March 2024
View Audit 296252 Questioned Costs: $1
FINDING 2023-001 Finding Subject: Child Nutrition Cluster – Eligibility Summary of Finding: The Food Service Director was responsible for running the direct certification match report monthly from the Indiana Department of Education and uploading it to the school lunch point-of-sale system. The Scho...
FINDING 2023-001 Finding Subject: Child Nutrition Cluster – Eligibility Summary of Finding: The Food Service Director was responsible for running the direct certification match report monthly from the Indiana Department of Education and uploading it to the school lunch point-of-sale system. The School Corporation did not have a proper system of oversight or review to ensure that all students on the direct certification match report were entered accurately into the point-of-sale system. We recommended that the School Corporation's management establish a system of internal control to ensure compliance and comply with the Eligibility compliance requirement Contact Person Responsible for Corrective Action: Nick Alessandri Contact Phone Number and Email Address: 219-962-7551 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: River Forest Community School Corporation is now part of the Community Eligibility Provision (CEP) and therefore the direct certification process will no longer take place. In the event that we are no longer CEP and begin the direct certification process, we will implement a process of internal controls that ensure proper oversight and review to ensure all students are entered accurately into our point-of-sale system. Anticipated Completion Date: July 1, 2023
The Admissions & Records Department discovered that there was an error in our reporting. The issue is that the wrong field was being picked up by NSLDS because our report was not pulling the correct data field. This has been corrected by the District IT department. We also discovered that although w...
The Admissions & Records Department discovered that there was an error in our reporting. The issue is that the wrong field was being picked up by NSLDS because our report was not pulling the correct data field. This has been corrected by the District IT department. We also discovered that although we reported the correct data to the National Clearinghouse, it never transferred over to NSLDS. We will reach out to the Clearinghouse to ensure that this will not occur again. We also discovered that with one student enrollment issue, the college did not follow the correct process so that the report did not pick up the student enrollment. This has been resolved by providing staff with appropriate training. The director has and will continue to provide ongoing training.
Finding No. 2023-003: Compliance Controls Responsible Individuals: Stephanie Mayfield, Executive Director Corrective Action Plan: The Organization is continuing to evaluate its internal control systems to ensure proper segregation of duties surrounding various compliance with grant programs. After t...
Finding No. 2023-003: Compliance Controls Responsible Individuals: Stephanie Mayfield, Executive Director Corrective Action Plan: The Organization is continuing to evaluate its internal control systems to ensure proper segregation of duties surrounding various compliance with grant programs. After the Department of Labor review in fiscal year 2024, the Organization implemented new processes and internal controls to improve segregation of duties and address eligibility documentation issues. Anticipated Completion Date: Ongoing
Finding No. 2023-001: Financial Statement and Schedule of Expenditures of Federal Awards (SEFA) Preparation Responsible Individuals: Stephanie Mayfield, Executive Director Corrective Action Plan: It is more cost effective for the Organization to hire Ketel Thorstenson, LLP, a public accounting firm,...
Finding No. 2023-001: Financial Statement and Schedule of Expenditures of Federal Awards (SEFA) Preparation Responsible Individuals: Stephanie Mayfield, Executive Director Corrective Action Plan: It is more cost effective for the Organization to hire Ketel Thorstenson, LLP, a public accounting firm, to prepare the full disclosure financial statements as a part of the annual audit process. The Organization has designated a member of management to review the draft financial statements and accompanying notes to the financial statements. The Organization has accepted the risk associated with the finding regarding the preparation of the financial statements, and will continue to have the independent auditor prepare the annual financial statements. Anticipated Completion Date: Ongoing
The Tipton School District will immediately implement the following controls to assure that the district has adequate internal controls in place should any future expenditures of federal funds for Capital Projects be made. The district will review the Federal Procurement and contractor requirements...
The Tipton School District will immediately implement the following controls to assure that the district has adequate internal controls in place should any future expenditures of federal funds for Capital Projects be made. The district will review the Federal Procurement and contractor requirements prior to submitting documents to use Federal Funds for Capital Projects. The district will provide training to staff to ensure compliance with all Federal Program Procurement including compliance with the Davis-Bacon Act (prevailing wage rate) requirements, and reviewing weekly certified payroll reports from the contractor or subcontractor. The district will ensure that all items are posted at the work site to confirm compliance. This corrective action plan will go into effect by March 11, 2024.
Finding 382621 (2023-002)
Significant Deficiency 2023
Student Financial Aid Cluster – Special Tests and Provisions – GLBA Recommendation: We recommend the College finalize its written information security program to ensure its compliance with the GLBA Safeguards Rule along with appropriately managing its information technology and cybersecurity risks....
Student Financial Aid Cluster – Special Tests and Provisions – GLBA Recommendation: We recommend the College finalize its written information security program to ensure its compliance with the GLBA Safeguards Rule along with appropriately managing its information technology and cybersecurity risks. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College’s Information Technology department will amend the written program and policy to include all necessary aspects of GLBA compliance and IT management and cybersecurity risk. Names of the contact person responsible for corrective action: Gwen Pechan Planned completion date for corrective action plan: March 31, 2024
Finding 382620 (2023-001)
Significant Deficiency 2023
Student Financial Aid Cluster – Special Tests and Provisions – NSLDS Recommendation: We recommend that the College continue to enhance its policies and procedures regarding enrollment reporting including additional monitoring over the third-party service provider to ensure that reporting is complet...
Student Financial Aid Cluster – Special Tests and Provisions – NSLDS Recommendation: We recommend that the College continue to enhance its policies and procedures regarding enrollment reporting including additional monitoring over the third-party service provider to ensure that reporting is completed accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Office of the Registrar reports enrollment to NSLDS using the National Student Clearinghouse (NSC). The Registrar’s Office will collaborate with our Information Technology Department to identify and correct all students with erroneous program start dates. As recommended by CLA, the Registrar’s Office is reviewing its process for Clearinghouse submissions in collaboration with the Information Technology Department and Advising Office to ensure that the program-level enrollment effective dates are accurately reflected when a student submits a change of major. Names of the contact persons responsible for corrective action: Sheia Pleasant-Doine and Adam Doine Planned completion date for corrective action plan: May 3, 2024
Audit Period: June 30, 2023 The finding from the June 30, 2023 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number in the schedule. FINDING – FEDERAL AWARDS PROGRAM AUDIT U.S. Department of Health and Human Services, Health Center Clust...
Audit Period: June 30, 2023 The finding from the June 30, 2023 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number in the schedule. FINDING – FEDERAL AWARDS PROGRAM AUDIT U.S. Department of Health and Human Services, Health Center Cluster Programs (Assistance Listing Number 93.224/93.527/COVID-19 93.224) SIGNIFICANT DEFICIENCY Item 2023-001 –Special Tests and Provisions Recommendation: We recommend that proper training be given to employees and that sliding fee discounts be reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. Action Taken Management will be training all registration personnel in teams meetings or one on one training sessions. The staff will be trained on how to appropriately monitor and use the sliding fee discounts. Staff will be shown how to maintain the applicable documentation to support the maintenance of the sliding fee discounts. In addition, a team of management and billing staff will be assigned to periodically review the process to ensure the Center always complies with the sliding fee regulations. Completion Date: July 1, 2024 If the Health Resources and Services Administration has questions regarding this plan, please call Tamisha McPherson, Executive Director of URAM at 212-803-2850.
Coos County Airport District (District) respectfully presents the following corrective action plan in response to deficiencies reported in the District’s June 30, 2023 audit conducted by the independent auditing firm Pauly, Rogers and Co., P.C., Tigard, Oregon. The audit identified both a material w...
Coos County Airport District (District) respectfully presents the following corrective action plan in response to deficiencies reported in the District’s June 30, 2023 audit conducted by the independent auditing firm Pauly, Rogers and Co., P.C., Tigard, Oregon. The audit identified both a material weakness and a significant deficiency: • Material Weakness: During testing of the SEFA, it was observed that the amount originally reported for AIP 44 was materially overstated. We recommend that the SEFA only reflect the current year expenditures. Corrective action plan: The District will only record the amount on the SEFA reflected in the current year expenditures.
2023-001: Incorrect Pell Disbursement - Student Financial Aid Cluster Assistance Listing Number 84.007, 84.033, 84.063, 84.268, Grant Period - Year Ended August 31, 2023 Condition Found During our student file testing we noted one student out of forty was not disbursed the correct Pell Grant. The ...
2023-001: Incorrect Pell Disbursement - Student Financial Aid Cluster Assistance Listing Number 84.007, 84.033, 84.063, 84.268, Grant Period - Year Ended August 31, 2023 Condition Found During our student file testing we noted one student out of forty was not disbursed the correct Pell Grant. The student was enrolled as three-quarters time but was awarded as being a full-time student resulting in an over award of $574. We consider this error to be an instance of noncompliance relating to the Eligibility Compliance Requirement. This finding was repeated from last year, see Prior Year finding 2022-002. Corrective Action Plan Financial Aid Office will make sure to disburse the accurate Pell Grant amoutn according to the students' enrollment status. EWU will return the over awarded Pell to reflect the correct amount for the student. We have never had a finding for awarding full time Pell to a three-quarters attending student. This was an isolated incident. Responsible Person for Corrective Action Plan Director of Financial Aid Cesar Campos Implementation Date of Corrective Action Plan February 15, 2024
View Audit 296164 Questioned Costs: $1
2023-002 Incorrect Direct Loans Disbursement Amount - Student Financial Aid Cluster Assistance Listing Number 84.007, 84.033, 84.063, 84.268, Grant Period - Year Ended August 31, 2023 Condition Found During our student file testing we noted two students out of forty were disbursed the incorrect ...
2023-002 Incorrect Direct Loans Disbursement Amount - Student Financial Aid Cluster Assistance Listing Number 84.007, 84.033, 84.063, 84.268, Grant Period - Year Ended August 31, 2023 Condition Found During our student file testing we noted two students out of forty were disbursed the incorrect Direct Loan amount. Based on the student’s enrollment status and need the students were over awarded $4,500 in Subsidized Loans and under awarded $4,500 in Unsubsidized Loans. We consider this error in awarding to be an instance of noncompliance of the Eligibility Compliance Requirement. Corrective Action Plan Financial Aid office will make sure the correct amount is awarded based on the student enrollment status and need of the student. EWU will make the proper adjustments to the Direct Subsidized Loan and Direct Unsubsidized Loan to reflect the correct amount foer the two students. Responsible Person for Corrective Action Plan Director of Financial Aid Cesar Campos Implementation Date of Corrective Action Plan February 15, 2024
Major Program: 93.568 - Low Income Home Energy Assistance (Grantor - Department of Health and Social Services) Condition: The 2023 program year heating funds reconciliation report was not completed and submitted to the State of Delaware in a timely manner. Corrective Action Plan: Charities DEAP prog...
Major Program: 93.568 - Low Income Home Energy Assistance (Grantor - Department of Health and Social Services) Condition: The 2023 program year heating funds reconciliation report was not completed and submitted to the State of Delaware in a timely manner. Corrective Action Plan: Charities DEAP program has revised and implemented reconciliation procedures to ensure the program year 2023 heating reconciliation benefit report is completed on April 6, 2024. The final reconciliation report for the 2023 heating benefit refund will be remitted to the State of Delaware Office of Community Services (OCS) in accordance with the established guidelines by April 14, 2024. Process of completion is performed manually: 1. The collection of delivered and non-delivered fuel vendors’ unexpended benefits reports has been obtained from the non-delivered vendors. Completed November 2023. 2. Inter-Agency households’ report of benefits returned to the State of Delaware OCS for the heating season 2023 by the county and by invoice number is in process of being manually completed. 3. The documents noted in procedures 1 and 2 must reconcile with the DEAP billing supervisor report of heating benefits issued - funded and refunded by the vendors. The agency finance unit reporting of paid benefits vs refunded benefits must be compared to the noted reports to verify all report totals equal. 4. The unused benefit report noting the total amount to be returned to the State OCS, is completed once the agency finance unit verification of totals reported in procedures 2 and 3 are accurate for the 2022-2023 heating reconciliation. The program year 2023 reconciliation report will be completed according to OCS’s format and submitted along with the check from the agency for the total amount of the refund. Contact Person Responsible for Corrective Action: Samantha Wallace, Interim Executive Director Anticipated Completion Date of Corrective Action: April 6, 2024
Major Program: 10.558 - Child and Adult Care Food Program (Grantor - Department of Agriculture) Condition: We tested 18 provider files and identified two billing errors within the May 2022 claim submissions. For each instance of error, the number of meals served was incorrectly determined and submit...
Major Program: 10.558 - Child and Adult Care Food Program (Grantor - Department of Agriculture) Condition: We tested 18 provider files and identified two billing errors within the May 2022 claim submissions. For each instance of error, the number of meals served was incorrectly determined and submitted for reimbursement. Corrective Action Plan: Catholic Charities Program Manager, Joanne Varnes, conducted a training on December 19, 2023 with all staff involved in the CACFP that included income eligibility/enrollment categorization and meal count accuracy. Catholic Charities staff will review each income form/enrollment and double check that children’s reimbursement rate is properly categorized based on their family’s income. Staff members will review each claim before it is entered for reimbursement to ensure the claim is accurate. Program Manager, Joanne Varnes, will oversee this process and conduct case record reviews quarterly for all providers under Catholic Charities Sponsorship. Contact Person Responsible for Corrective Action: Samantha Wallace, Interim Executive Director Anticipated Completion Date of Corrective Action: Immediately
Finding 2023-006 – Education Stabilization Fund – Equipment and Real Property Management Contact Person Responsible for Corrective Action: Nicholas Gron Contact Phone Number: 219-764-6011 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Portage To...
Finding 2023-006 – Education Stabilization Fund – Equipment and Real Property Management Contact Person Responsible for Corrective Action: Nicholas Gron Contact Phone Number: 219-764-6011 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Portage Township Schools is currently tracking Capital Assets on the Form No. 369. The PTS Finance Department will work with other PTS departments to establish a process of completing the capital assets inventory every two years. Anticipated Completion Date: July 2024
Finding 2023-005 – Education Stabilization Fund – Reporting Contact Person Responsible for Corrective Action: Linda Williams Contact Phone Number: 219-764-6209 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The PTS Office of Grants and Assessmen...
Finding 2023-005 – Education Stabilization Fund – Reporting Contact Person Responsible for Corrective Action: Linda Williams Contact Phone Number: 219-764-6209 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The PTS Office of Grants and Assessments will collaborate with the PTS Finance Office to establish a system of internal controls and separation of duties to ensure a thorough review prior to the submission of the Annual ESSER Data Report. Anticipated Completion Date: April 2024
Finding 2023-004 – Special Education Cluster – Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Quinnlyn Van Rys Contact Phone Number: 219-850-1914 - qvanrypces.k12.in.us Views of Responsible Official: We concur with the finding. Description of Correct...
Finding 2023-004 – Special Education Cluster – Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Quinnlyn Van Rys Contact Phone Number: 219-850-1914 - qvanrypces.k12.in.us Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Provider/Employee will utilize the Sam.gov website and will view the exclusions prior to entering into any covered transaction. This list will be saved and dated in a separate folder to provide evidence of this requirement. A list of vendors verified will be kept in the same folder as the exclusions list. This will be prepared by the CFO and be reviewed and verified by the bookkeeper. Semi-annual documented review of this process will be by the PTS Director of Finance Anticipated Completion Date: March 2024
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