Corrective Action Plans

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Name of Contact Person: Karen Harrington, DSS Director Corrective Action/Management’s Response: Currently, DHB Administrative Letter 13-23 prohibits caseworkers from sending IV-D referrals for the remainder of the CCU period. Once this restriction is in removed, the Medicaid Program Manager will rev...
Name of Contact Person: Karen Harrington, DSS Director Corrective Action/Management’s Response: Currently, DHB Administrative Letter 13-23 prohibits caseworkers from sending IV-D referrals for the remainder of the CCU period. Once this restriction is in removed, the Medicaid Program Manager will review the requirement to send IV-D referrals with staff. The formal case file review process will continue to monitor this and other areas. Additional training will be offered if the case file reviews reveal deficiencies in this area. Proposed Completion Date: Immediately and ongoing.
Name of Contact Person: Karen Harrington, DSS Director Corrective Action/Management’s Response: The Medicaid Program Manager reviewed the verification process and the requirement to upload all information into NCFAST with the Medicaid staff. The formal case file review process will continue to monit...
Name of Contact Person: Karen Harrington, DSS Director Corrective Action/Management’s Response: The Medicaid Program Manager reviewed the verification process and the requirement to upload all information into NCFAST with the Medicaid staff. The formal case file review process will continue to monitor this and other areas. Additional training will be offered if the case file reviews reveal deficiencies in this area. Proposed Completion Date: Immediately and ongoing.
Management’s Corrective Action Plan Soka University acknowledges the finding and the recommendation regarding improving procedures. Finding 2023-001 - Special Tests and Provisions – Enrollment Reporting: Significant Deficiency in Internal Control over Compliance After addressing the identified defic...
Management’s Corrective Action Plan Soka University acknowledges the finding and the recommendation regarding improving procedures. Finding 2023-001 - Special Tests and Provisions – Enrollment Reporting: Significant Deficiency in Internal Control over Compliance After addressing the identified deficiency in our enrollment reporting process, a thorough evaluation was conducted to rectify the issue and prevent its recurrence. We recognized that alterations in students' academic plans, prompted by the COVID-19 pandemic, led to delays in fulfilling mandatory graduation requirements such as study abroad requirements, resulting in delays in posting study abroad grades to the Soka transcript. Consequently, during end-of-term degree audits by the Office of the Registrar, students with pending study abroad grades or incomplete grades in their final term were inadvertently not updated to a withdrawn status, thereby failing to trigger updates to the National Student Clearinghouse and subsequently National Student Loan Data System (NSLDS). In collaboration with the Office of the Registrar, robust internal controls have been implemented to mitigate this issue going forward. Following the conclusion of each term, the Registrar will generate a comprehensive report listing all students who have applied for degree completion. This report will be annotated to identify students who have fulfilled all degree requirements, enabling their degrees to be conferred promptly. Additionally, students with incomplete grades will be flagged, and their status will be promptly changed to withdrawn. In both scenarios, enrollment status updates will be transmitted to the clearinghouse and subsequently NSLDS. The Registrar will inform the Office of Financial Aid of graduates and students with updated statuses for NSLDS reporting, and Financial Aid will request an ad hoc enrollment request on NSLDS. To ensure accuracy, a manual spot-checking process will be conducted in NSLDS on 20% of the updated student records in NSLDS. Upon notification of completed incomplete grades, the Registrar will promptly update transcripts, review degree requirements, and confer degrees where applicable. Following this update, the Registrar will manually update the clearinghouse and ask the Office of Financial Aid to request an Ad hoc enrollment report on NSLDS, ensuring timely and accurate reporting. This manual request will be verified on NSLDS after the ad hoc report has been run. Students failing to meet degree requirements due to failed coursework and are enrolled to return in subsequent terms will not be updated to withdrawn status unless they fail to return as scheduled. These measures aim to enhance the integrity and accuracy of our enrollment reporting process, ensuring compliance with regulatory requirements and minimizing the risk of future deficiencies. Anticipated Completion Date: February 2024 Scott Brandos Director of Financial Aid Soka University of America 949-480-4048
Views of responsible officials and Corrective Action Plan: Controls will be implemented for future reporting and the School will correct the reporting errors in the following period.
Views of responsible officials and Corrective Action Plan: Controls will be implemented for future reporting and the School will correct the reporting errors in the following period.
United States Department of Housing and Urban Development Gilbert Straub Plaza, Inc., respectfully submits the following corrective action plan for the year ended August 31, 2023. Name and address of independent public accounting firm: Maher Duessel, CPA's 503 Martindale Street, Suite 600 Pittsbur...
United States Department of Housing and Urban Development Gilbert Straub Plaza, Inc., respectfully submits the following corrective action plan for the year ended August 31, 2023. Name and address of independent public accounting firm: Maher Duessel, CPA's 503 Martindale Street, Suite 600 Pittsburgh, PA 15212 Audit period: September 1, 2022 - August 31, 2023 The finding from the August 31, 2023 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS—FINANCIAL STATEMENT AUDIT See Below FINDINGS— FEDERAL AWARD PROGRAMS AUDITS Finding 2023-001 Department of Housing and Urban Development Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects - Section 223(f)/207 ALN 14.155. Recommendation: The Property should have internal controls in place to review Form HUD-50059 to ensure all documentation used to calculate the tenant rent and assistance payment is supported and properly calculated. Action taken: The property management company has revisited the internal controls with the on-site manager. The manager certifies that they will do diligence in the future to ensure that they follow these controls in calculating tenant rent and assistance payments. If the Department of Housing and Urban Development has questions regarding this plan, please call Dan Barbusio at 412-646-5193.
Finding 2023-001 Planned Corrective Action Finding: During the fiscal 2023 financial statement audit, a material weakness in internal control was identified. A material weakness in internal control over compliance is a deficiency, or a combination of deficiencies, in internal control over complian...
Finding 2023-001 Planned Corrective Action Finding: During the fiscal 2023 financial statement audit, a material weakness in internal control was identified. A material weakness in internal control over compliance is a deficiency, or a combination of deficiencies, in internal control over compliance, such that there is a reasonable possibility that material noncompliance with a type of compliance requirement of a federal or state program will not be prevented, or detected and corrected, on a timely basis. During the audit as of and for the year ended August 31, 2023, costs were applied to CARES Act PRF funds which were found to be without sufficient backup documentation. The impact to the current year statutory basis financial statements was not material. Corrective Response: Management represents that there was not sufficient documentation and support surrounding Provider Relief Funding applied to expenses for the year ending August 31, 2023. Operational and reporting improvements will be pursued in an effort to better provide documentation and support on a go-forward basis. Since these transactions, management has added additional staff and more training for processing credit card receipts, check processing with clean approvals, and new leadership over its Accounts Payable function. The organization is also implementing a new ERP system with clear process flows and tight connections between transactions and the related backup. Anticipated Completion Date 8/31/2024 Responsible Contact Person Brian Savoie, CFO 414-345-7844 and Errol Meinholz, Controller 920-245-9275
View Audit 294179 Questioned Costs: $1
Auditor Description of Condition and Effect. A break of at least five consecutive days was not excluded from the reported enrollment period for the Fall 2022 semester, which resulted in the calculation being incorrect for all students who had returns in the Fall 2022 semester. As a result of this co...
Auditor Description of Condition and Effect. A break of at least five consecutive days was not excluded from the reported enrollment period for the Fall 2022 semester, which resulted in the calculation being incorrect for all students who had returns in the Fall 2022 semester. As a result of this condition, Return of Title IV calculations were incorrect for 60 students for the Fall 2022 semester, resulting in $10,459 less funds returned to the U.S. Department of Education. It is our understanding that on July 24, 2023, the College repaid the 60 students affected by this calculation error. Auditor Recommendation. We recommend that the College implement a review process to ensure the number of enrollment days used in the Return of Title IV calculations is accurate and that the R2T4 calculation is reviewed by a second individual. Corrective Action. Upon discovery of the Return of Title IV Calculation error, the College went through and made corrections to all student accounts affected. To prevent a similar problem arising in the future, the College has developed a review process that will require an additional sign‐off for the total days to be used in the calculation. Responsible Person. Ruth Carlson, Director of Financial Aid. Anticipated Completion Date. July 24, 2023.
Finding 374462 (2023-002)
Significant Deficiency 2023
2023-002 Finding – Federal Award – Significant Deficiency in Internal Control over Compliance - Allowable Costs Context: Expenditures should be charged to the proper programs and allocated in accordance with the cost allocation plan and documentation of approval of any subsequent change to the alloc...
2023-002 Finding – Federal Award – Significant Deficiency in Internal Control over Compliance - Allowable Costs Context: Expenditures should be charged to the proper programs and allocated in accordance with the cost allocation plan and documentation of approval of any subsequent change to the allocation plan should be maintained. Recommendation: We recommend management implement procedures to ensure that costs charged to the grant follow the approved cost allocation and documentation of approved changes to allocations be maintained. Action Taken: Management concurs with the auditor’s finding and will enhance documentation protocols, standardize the approval process, and have regular reviewing and monitoring.
The district will develop a process to ensure that capital assets are recorded to the appropriate general ledger accounts that properly represents the transaction being recorded.
The district will develop a process to ensure that capital assets are recorded to the appropriate general ledger accounts that properly represents the transaction being recorded.
Finding 2023‐003 Special Tests – Wage Rate Requirement Significant Deficiency Finding Summary: The District did not sure proper and timely inclusion of prevailing wage clauses in one construction contract issued in the prior year and still in effect this year. Responsible Individuals: Shawn Kreman, ...
Finding 2023‐003 Special Tests – Wage Rate Requirement Significant Deficiency Finding Summary: The District did not sure proper and timely inclusion of prevailing wage clauses in one construction contract issued in the prior year and still in effect this year. Responsible Individuals: Shawn Kreman, Superintendent Corrective Action Plan: The District will include prevailing requirements in contracts utilizing federal dollars. Anticipated Completion Date: Ongoing
Finding #2023-003: Internal Controls Over Grant Expenditures Response and Corrective Action Plan Prepared by: Justin Norton Person Responsible for Implementing the Corrective Action: Justin Norton Anticipated Date of Corrected Action: June 30, 2024. Repeat Finding: No Planned Corrective Action: We w...
Finding #2023-003: Internal Controls Over Grant Expenditures Response and Corrective Action Plan Prepared by: Justin Norton Person Responsible for Implementing the Corrective Action: Justin Norton Anticipated Date of Corrected Action: June 30, 2024. Repeat Finding: No Planned Corrective Action: We will establish and implement internal control policies to maintain federal grant expenditures and reimbursements.
FINDING2023-004 Finding Subject: COVID-19 Emergency Connectivity Fund Program - Equipment, Special Tests and Provisions - Restricted Purpose Summary of Findings: An effective internal control system was not in place at the School Corporation to ensure compliance with requirements related to the gra...
FINDING2023-004 Finding Subject: COVID-19 Emergency Connectivity Fund Program - Equipment, Special Tests and Provisions - Restricted Purpose Summary of Findings: An effective internal control system was not in place at the School Corporation to ensure compliance with requirements related to the grant agreement and the Equipment and Real Property Management and Special Tests and Provisions - Restricted Purpose compliance requirements. Equipment Management A listing of equipment purchased with program funds was maintained, however, there was no documented oversight or review process to ensure the listing was accurate and complete. Special Tests and Provisions - Restricted Purpose There was no documented control process in place to ensure that each student or staff member received only one device, as required by the per-user limitations in the grant award. Officials stated that the Asset Management system would not have allowed the same student to register multiple devices, however, there was no documented oversight or review to ensure that the user limitations in the system were in place during the audit period, and operating effectively. Contact Person Responsible for Corrective Action: Julie Dudley Contact Phone Number and Email Address: 812.537.7205 jdudley@lburg.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Beginning with the 2024-2025 school year, the technology department will provide each building principal with a list that includes all students and asset tag numbers. The principals will then have each student sign next to their information acknowledging that information is accurate. Anticipated Completion Date: August 2024
FINDING 2023-002 Finding Subject: Child Nutrition Cluster - Eligibility Summary of Findings: An effective internal control system, which would include segregation of duties, was not in place at the School Corporation to ensure compliance with requirements related to the grant agreement and the Elig...
FINDING 2023-002 Finding Subject: Child Nutrition Cluster - Eligibility Summary of Findings: An effective internal control system, which would include segregation of duties, was not in place at the School Corporation to ensure compliance with requirements related to the grant agreement and the Eligibility compliance requirement. The free and reduced-price applications were completed online by the applicants, and the information was automatically uploaded into the School Corporation's nutrition program software system. The software system then calculated the student's eligibility for free and reduced-price meals based on the parameters in the system. There was no documented oversight, review, or approval process to ensure the parameters in the system were correct and that the eligibility determination made complied with the requirements of the programs. The lack of internal controls was a systematic issue throughout the audit period. Contact Person Responsible for Corrective Action: Julie Dudley Contact Phone Number and Email Address: 812.537.7205 jdudley@lburg.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Food Service Director and Business Manager have added the verification of every 30th Free/Reduce application that is submitted during the school year to their monthly checklists. Beginning with the 2024-25 school year, the Food Service Director will enter the eligibility parameters into the school nutrition software. Once entered the Food Service Director will provide a copy of the prices entered into the system to be reviewed and approved by the Business Manager or Superintendent. Anticipated Completion Date: January 2024/July 2024
Criteria and Condition: 2 CFR 200.303 requires the non-federal entity to establlish and maintain effective internal controls over compliance with Federal statues, regulations, and the terms and conditions of the Federal award including proper tracking of grant expenditures or compliance. Certain int...
Criteria and Condition: 2 CFR 200.303 requires the non-federal entity to establlish and maintain effective internal controls over compliance with Federal statues, regulations, and the terms and conditions of the Federal award including proper tracking of grant expenditures or compliance. Certain internal controls were not in place to prevent costs from outside the period of performance from being charged to the grant. Action taken: In regard to 2023-003, Management will provide a 2nd review of project worksheets before submission. The designated FEMA Coordinator will be responsible for this corrective action and anticipates completion of corrective action before October 1, 2023.
View Audit 294076 Questioned Costs: $1
FINDING 2023-001 Finding Subject: COVID-19 – Education Stabilization Fund – Equipment and Real Property Management Summary of Finding: An effective internal control system, which would include segregation of duties, was not in place at the School Corporation in order to ensure compliance with requir...
FINDING 2023-001 Finding Subject: COVID-19 – Education Stabilization Fund – Equipment and Real Property Management Summary of Finding: An effective internal control system, which would include segregation of duties, was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the following compliance requirements: Equipment and Real Property Management. The School Corporation presented the equipment and real property records for the ESF grant equipment: however, the records failed to include a description (including serial number or other identification number), source of funding for the property (including the federal award identification number), who holds title, the acquisition date, cost of the property, percentage of federal participation in the project costs for the federal award under which the property was acquired, location, use, and condition of the property, and any ultimate disposition data including the date of disposal and sales price of the property (2 CFR 200.313(d)(1)). Contact Person Responsible for Corrective Action: Jacob Heuchan Contact Phone Number and Email Address: (317)-878-2100; jheuchan@nhj.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Business Manager will work with the Technology Director and the respective departments to ensure the appropriate information is being entered into the Corporation’s equipment and real property records for items purchased through ESF/federal funds. A physical inventory of the property will be taken and the results reconciled with the property records at least once every two years. Anticipated Completion Date: Immediate.
Finding 2023-005 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing #93.498 Compliance Requirement: Reporting Finding Summary: The Hospital’s expenditures identified as eligible and c...
Finding 2023-005 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing #93.498 Compliance Requirement: Reporting Finding Summary: The Hospital’s expenditures identified as eligible and claimed under the Provider Relief Fund program did not agree to the underlying detail listing. The current key financial personnel were unable to reconcile the differences between the support and the amounts reported. Responsible Individuals: John J Dempsey, Chief Executive Officer, Lona King, Chief Financial Officer Corrective Action Plan: Management will strengthen the control process for maintaining documentation of the final expenditure listing used to report under the federal program. Anticipated Completion Date: March 31, 2024
Finding 2023-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing #93.498 Compliance Requirement: Activities Allowed/Allowable Costs Finding Summary: The Hospital’s expenditures ide...
Finding 2023-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing #93.498 Compliance Requirement: Activities Allowed/Allowable Costs Finding Summary: The Hospital’s expenditures identified as eligible and claimed under the Provider Relief Fund program did not agree to the underlying detail listing. The current key financial personnel were unable to reconcile the differences between the support and the amounts reported. Responsible Individuals: John J Dempsey, Chief Executive Officer, Lona King, Chief Financial Officer Corrective Action Plan: Management will strengthen the control process for maintaining documentation of the final expenditure listing used to claim the allowable costs under the federal program. Anticipated Completion Date: March 31, 2024
Finding 2023-003 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing #93.498 Compliance Requirement: Reporting Finding Summary: The Hospital did not consider the impact of the year-end...
Finding 2023-003 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing #93.498 Compliance Requirement: Reporting Finding Summary: The Hospital did not consider the impact of the year-end audit adjustments on the quarters applicable to Period 4 when reporting lost revenue. Responsible Individuals: John J Dempsey, Chief Executive Officer, Lona King, Chief Financial Officer Corrective Action Plan: Management will strengthen the control process relating to calculating quarterly lost revenue under the federal program. Anticipated Completion Date: March 31, 2024
Finding 374364 (2023-001)
Material Weakness 2023
Management agrees with the auditor’s recommendation, and the following action will be taken to improve the situation. Grant billings will be prepared using reports obtained from the accounting system. Grants will be reconciled on a periodic basis, but no less than monthly.
Management agrees with the auditor’s recommendation, and the following action will be taken to improve the situation. Grant billings will be prepared using reports obtained from the accounting system. Grants will be reconciled on a periodic basis, but no less than monthly.
Specific corrective action plan for finding: The district will implement controls of review for all expenses related to the Impact Aid- Special Education Fund. Dom Atcitty, Grants Specialist, Carol Gonzales, Finance Director will ensure that proper budgets are authorized to Departments to ensure tha...
Specific corrective action plan for finding: The district will implement controls of review for all expenses related to the Impact Aid- Special Education Fund. Dom Atcitty, Grants Specialist, Carol Gonzales, Finance Director will ensure that proper budgets are authorized to Departments to ensure that the correct funding is available. These two instances were due to lack of budget within the Department that caused them to use the incorrect funding source at the time. The district will make sure to include Amanda Sutherland, Student Support Services Director within the review process and the district will provide additional training regarding uses of funds. Timeline for completion of corrective action plan: District has implemented this plan as of July 1, 2023 Employee position(s) responsible for meeting the timeline: Dom Atcitty, Grants Specialists, Carol Gonzales, Finance Director and Amanda Sutherland, Student Support Services Director
View Audit 293969 Questioned Costs: $1
Specific corrective action plan for finding: Rebecca Brandt, Coordinator Student Services Department, Sharon Hanagarne-Benally, Data Records Clerk will review and audit files to ensure student information is up to date in PowerSchool to ensure reliable, efficient, and timely data is being collected....
Specific corrective action plan for finding: Rebecca Brandt, Coordinator Student Services Department, Sharon Hanagarne-Benally, Data Records Clerk will review and audit files to ensure student information is up to date in PowerSchool to ensure reliable, efficient, and timely data is being collected. Timeline for completion of corrective action plan: Resolved Employee position(s) responsible for meeting the timeline: Rebecca Brandt, Coordinator Student Services Department, Sharon Hanagarne-Benally
View Audit 293969 Questioned Costs: $1
Update grant spreadsheet monthly
Update grant spreadsheet monthly
Adopt suggested policies as outlined by auditor
Adopt suggested policies as outlined by auditor
Re: 2023-01 Audit Finding/Plan of Action The Lexington Housing Authority (LHA) proposes this corrective plan of action to address the late recertifications (13) and annual recertification (1) from the audit conducted by Rector, Reeder & Lofton PC, onsite at LHA September 25-29, 2023. ADDRESSING S...
Re: 2023-01 Audit Finding/Plan of Action The Lexington Housing Authority (LHA) proposes this corrective plan of action to address the late recertifications (13) and annual recertification (1) from the audit conducted by Rector, Reeder & Lofton PC, onsite at LHA September 25-29, 2023. ADDRESSING STAFFING Securing qualified candidates to fill Housing Management Specialist (HMS) positions throughout 2020, 2021 and 2022 was challenging for LHA. In some instances, positions were vacant for up to 12 months before they were filled. LHA will do the following to address staffing: • Seek to fill HMS positions within forty-five (45) days of the position going vacant. • Advertise to hire two full-time HMS positions for the two management teams with the most units in their management portfolio. • Continue to advertise open positions online, on social media and in the local newspaper. • Offer incentive bonus up to $1,500 to newly hired HMS, paying $750 to new hires after six month of employment and an additional $750 after 12 months of employment. • Over-time will be allowed on an as-needed basis to complete and process certifications. CERTIFICATION PROCEDURES Further, LHA housing management staff will adhere to the following procedures to facilitate timely completion of annual certifications. - HMS staff will continue utilize in-person interviews and mail (via USPS and email) to complete needed documentation for annual certifications. - All housing management staff may utilize electronic signature to attain required signatures when necessary. - The first day of each month housing managers will run the certification audit report to be shared with the Chief Operating Officer to monitor the status of in-progress and upcoming certifications. - July 1, 2023, LHA implemented quality control (QC) of public housing files to be conducted by a newly created compliance position. LHA' s compliance coordinator will complete 229 (25%) QC reviews of public housing files during FY2024 (July 1, 2023 - June 30, 2024). - At least once monthly on a rotating basis housing management staff from all offices will convene at a selected housing management office to complete and process certifications. This schedule will continue until all offices are up to date on certifications. LHA staff will apply these procedures as outlined to mitigate this finding to ensure compliance and proper documentation of future certifications. Contact Person: Andrea Wilson, Chief Operating Officer Anticipated Completion Date: June 30, 2024
Auditors’ Recommendation: We recommend that as part of preparing monthly bank reconciliations, the reconciliation with the balance from the general ledger should be performed. Any differences should be immediately investigated and corrected. Once completed, the reconciliation should be reviewed by s...
Auditors’ Recommendation: We recommend that as part of preparing monthly bank reconciliations, the reconciliation with the balance from the general ledger should be performed. Any differences should be immediately investigated and corrected. Once completed, the reconciliation should be reviewed by someone independent of the preparer. Both, the individual preparing and reviewing the bank reconciliations should sign or initial and date the reconciliation when completed. We recommend that the District incorporate procedures to ensure that such general ledger accounts are reconciled on a monthly basis. It is important that a dual accounting system is utilized in each individual fund and transactions between funds should be booked through the interfund receivables and payables. School District’s Response: Penny Crowell, Business Manager will ensure that bank reconciliations are prepared on a timely basis throughout the year, which includes a reconciliation to the general ledger. The District will have the Superintendent review bank reconciliations. Once completed, the preparer and reviewer will sign and date each reconciliation to evidence their completion. Lastly, the District will reconcile due to/due from accounts on a monthly basis. These processes will take place during the year ending June 30, 2024.
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