Corrective Action Plans

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Finding 58426 (2022-003)
Significant Deficiency 2022
2022-003 Federal agency: U.S. Department of Housing and Urban Development Federal Program Title: Mortgage Insurance ? Nursing Homes, Intermediate Care Facilities, Board and Care Homes, and Assisted Living Facilities Assistance Listing #: 14.129 Criteria or specific requirement: Failure to Maintain A...
2022-003 Federal agency: U.S. Department of Housing and Urban Development Federal Program Title: Mortgage Insurance ? Nursing Homes, Intermediate Care Facilities, Board and Care Homes, and Assisted Living Facilities Assistance Listing #: 14.129 Criteria or specific requirement: Failure to Maintain Approved Management Agreements Condition: St. John Lutheran Care Center (St. John) was charged a management fee by Lutheran SeniorLife, its parent but did not have an approved management contract meeting the requirements of the regulatory agreement. Context: St. John did not have an approved management agreement. Recommendation: St. John should enter into an approved management agreement with Lutheran SeniorLife. Action taken in response to finding: St. John updated internal agreements to reflect the change from Lutheran Affiliated Services to Lutheran SeniorLife, but neglected to complete the process with HUD. St John will submit the paperwork to obtain a certified HUD approved management agreement. While the organization was operating without this agreement in place, management fees charged were only to reimburse costs incurred in performing these management functions. During Fiscal Year 2021, St John entered into a refinancing plan with a lender in order to facilitate a repositioning of the facility and to enable facility improvements that were identified. The closing on the refinancing of the existing HUD loan took place on July 8, 2021. Name of contact person responsible for corrective action: Jeffrey Carraway
Action taken in response to finding: After management was re-notified of the reporting errors in the HEERF reports on the college website, management has decided to completely reorganize the college webpage for HEERF reports. This will allow management and the reader to better understand the spendin...
Action taken in response to finding: After management was re-notified of the reporting errors in the HEERF reports on the college website, management has decided to completely reorganize the college webpage for HEERF reports. This will allow management and the reader to better understand the spending history of institutional and student portions of these grants. When the website is reorganized, quarterly reports will be reviewed and verified that student data is verified and reported correctly in the narrative of the reports. Name(s) of the contact person(s) responsible for corrective action: Ms. Karen Pelton, Mr. Timothy League and Mr. John Gay. Planned completion date for corrective action plan: Adjustments to the website and the review and correction of these reports, if needed, is currently in process and is expected to be completed no later than January 31, 2023.
Program: Coronavirus State Local Fiscal Recovery Funds (SLFR) CFDA No.: 21.027 Federal Grantor: U.S. Department of Treasury Passed-through: Fresno County Award No. and Date: Fresno County Agreement 22-126, April 5, 2022 Finding 2022-002: Reporting Type of Finding: Material weakness in internal contr...
Program: Coronavirus State Local Fiscal Recovery Funds (SLFR) CFDA No.: 21.027 Federal Grantor: U.S. Department of Treasury Passed-through: Fresno County Award No. and Date: Fresno County Agreement 22-126, April 5, 2022 Finding 2022-002: Reporting Type of Finding: Material weakness in internal controls over Reporting and Noncompliance View of Responsible Officials: Concur with the finding. Corrective Action Plan: ? The District will develop and implement a more robust system for the preparation and submission of reporting. ? The District will include monitoring of all award contracts for reporting and other compliance conditions. Projected Implementation Date: May 1, 2023
Program: Coronavirus State Local Fiscal Recovery Funds (SLFR) CFDA No.: 21.027 Federal Grantor: U.S. Department of Treasury Passed-through: Fresno County Award No. and Date: Fresno County Agreement 22-126, April 5, 2022 Finding 2022-001: Allowable Costs Type of Finding: Material weakness in internal...
Program: Coronavirus State Local Fiscal Recovery Funds (SLFR) CFDA No.: 21.027 Federal Grantor: U.S. Department of Treasury Passed-through: Fresno County Award No. and Date: Fresno County Agreement 22-126, April 5, 2022 Finding 2022-001: Allowable Costs Type of Finding: Material weakness in internal controls over compliance with Activities Allowable and Allowable Cost and Noncompliance View of Responsible Officials: Concur with the finding. Corrective Action Plan: ? Specifically related to future Coronavirus State Local Fiscal Recovery Funds (SLFR), The District will improve the method for tracking COVID-19 related emergency calls. ? The District will provide the appropriate training for all staff involved in the administration of federal awards to become knowledgeable of the District?s internal control processes related to federal awards. Projected Implementation Date: July 1, 2023
View Audit 55903 Questioned Costs: $1
2022-001 Sufficient documentation of eligibility not maintained for all items selected for testing. Contact Person Trisha Braswell Anticipated Completion Date 12/31/2023 Action Plan: Due to large turnover in staff at the front desk , we were not able to fully correct this finding this year. Th...
2022-001 Sufficient documentation of eligibility not maintained for all items selected for testing. Contact Person Trisha Braswell Anticipated Completion Date 12/31/2023 Action Plan: Due to large turnover in staff at the front desk , we were not able to fully correct this finding this year. The Clinic Manager will ensure all new staff are trained and that it is part of the of the orientation.
Name of Responsible Officials: Margherite Powell, Director of Financial Aid. The Policy and Procedures manual has been updated to reflect the following updated process: The Financial Aid Office has implemented measures to ensure students/parents tha...
Name of Responsible Officials: Margherite Powell, Director of Financial Aid. The Policy and Procedures manual has been updated to reflect the following updated process: The Financial Aid Office has implemented measures to ensure students/parents that have Title IV loans disbursed are sent loan disbursement notifications via Colleague once a loan disbursement has been made. The process is done via Colleague each day and captures all Title IV loan disbursements made for the previous day. The notifications are processed via the ST-PCB process in Colleague, which sends a system generated loan disbursement notification to the student/parent. Processes are being worked on with the Information Technology department to generate a copy of the notification and to put in place a paper notification if no parent email is provided.
Name of Responsible Officials: Carlos Chaves, Business Office Manager. The Business Office processes student refunds within 14 days after a Title IV credit balance appears on a student?s account. At least once per week, the Refunds Coordinator ...
Name of Responsible Officials: Carlos Chaves, Business Office Manager. The Business Office processes student refunds within 14 days after a Title IV credit balance appears on a student?s account. At least once per week, the Refunds Coordinator generates a refund report (ARTM) which lists students with credit balances. The University?s policy is that all refunds are processed via ACH (direct deposit), and all students are required to provide their bank account information. Communication is sent to students throughout the semester reminding them to sign up for direct deposit. To ensure that all students receive their refunds by the required 14 days, a paper check is issued to students missing banking information. Checks are sent to the mailing address on file. Communication will continue to be sent to all students encouraging them to sign up for ACH refunds. However, refunds are processed timely even if the banking information is not available. The Policy and Procedures manual has been updated to reflect this process.
Name of Responsible Officials: Carlos Chaves, Business Office Manager. The Business Office has implemented measures to ensure that Perkins Promissory Notes are identified, stored, and accessible during their repayment and collection period. In a...
Name of Responsible Officials: Carlos Chaves, Business Office Manager. The Business Office has implemented measures to ensure that Perkins Promissory Notes are identified, stored, and accessible during their repayment and collection period. In addition to the current filing system, the Business Office will utilize management software for ease of access and recording. To ensure that all remaining promissory notes are kept in accordance with Department of Education regulations, the Business Office will: ? Record all incoming promissory notes internally and externally. ? Promissory notes created prior to 2013 will be made digitally accessible through Perceptive Content, a secure content management system. Access to these promissory notes will only be accessible by parties with authorized access. ? Promissory notes created after 2013 will continue to be made available through Heartland ECSI?s third party filing system. ECSI records paid, completed, cancelled, and retired promissory notes that were created after 2013. ? In accordance with the Perkins Assignment and Liquidation Guide from the Department of Education (EA ID: General-21-53), all accounts with promissory notes unable to be located will be written off and/or purchased from the Department of Education prior to the end of FY 2023. The Policy and Procedures manual has been updated to reflect this process.
Finding 58405 (2022-002)
Significant Deficiency 2022
Coronavirus State and Local Fiscal Recovery Funds ? Assistance Listing No. 21.027 Recommendation: We recommend the Town establish and document procurement policies and procedures in conformity with the Federal requirements ?? 200.317 through 200.327. Explanation of disagreement with audit finding: T...
Coronavirus State and Local Fiscal Recovery Funds ? Assistance Listing No. 21.027 Recommendation: We recommend the Town establish and document procurement policies and procedures in conformity with the Federal requirements ?? 200.317 through 200.327. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Town of Easton will modify the current procurement procedures to add an additional section for those services, materials or products procured that have a Federal Grant Revenue source. Name(s) of the contact person(s) responsible for corrective action: Donald Richardson Planned completion date for corrective action plan: June 30, 2023
In Finding 2022-001, it was reported that the Organization did not properly apply the sliding fee discounts for certain patients with visits to the Organization during the year ended June 30, 2022. Management recognizes the importance of complying with sliding fee guidelines. In response to Findi...
In Finding 2022-001, it was reported that the Organization did not properly apply the sliding fee discounts for certain patients with visits to the Organization during the year ended June 30, 2022. Management recognizes the importance of complying with sliding fee guidelines. In response to Finding 2022-001, proper training will be given to employees and sliding fee discounts will be reviewed by a supervisor on a periodic basis the ensure compliance with the sliding fee scale.
2022-001 Policies and Procedures for Federal Awards Corrective action planned: We did not have a written policy and procedure in place for federal awards at year-end. Upon discovery, we have created required policies and procedures and have implemented them to our organization. Anticipated completi...
2022-001 Policies and Procedures for Federal Awards Corrective action planned: We did not have a written policy and procedure in place for federal awards at year-end. Upon discovery, we have created required policies and procedures and have implemented them to our organization. Anticipated completion date: December 16, 2022 Contact person responsible for corrective action: Pamela Stampfli, CFO
Finding 2022-001 - Lack of Segregation of Duties The District understands that this is a significant deficiency but feels it is not cost-effective at this time to hire additional employees to properly segregate duties. We feel that the oversight performed by the Superintendent and Board of Educat...
Finding 2022-001 - Lack of Segregation of Duties The District understands that this is a significant deficiency but feels it is not cost-effective at this time to hire additional employees to properly segregate duties. We feel that the oversight performed by the Superintendent and Board of Education over the financial statement activity and reports of the District is adequate to help mitigate the lack of segregation of duties. We believe it would be inefficient and cost prohibitive to hire the additional employees needed to properly segregate duties so at this time we do not plan on making any changes. However, we will continue to monitor this situation and periodically determine if it is cost-effective for us to properly segregate duties.
2022-001 - INTERNAL CONTROL OVER COMPLIANCE - SIGNIFICANT DEFICIENCY CONDITION: DLS submitted the 2021 data collection package to the Audit Clearinghouse after the required due date. CAUSE: The Judicial Council of California did not process the reimbursement requests timely. DLS was unable to dete...
2022-001 - INTERNAL CONTROL OVER COMPLIANCE - SIGNIFICANT DEFICIENCY CONDITION: DLS submitted the 2021 data collection package to the Audit Clearinghouse after the required due date. CAUSE: The Judicial Council of California did not process the reimbursement requests timely. DLS was unable to determine actual revenue and contract receivable until resolution. CRITERIA: Uniform Guidance 2 CFR 200.512(a) requires that the audit package and the data collection form shall be submitted 30 days after receipt of the auditor's report(s), or 9 months after the end of the fiscal year. EFFECT: DLS was not in compliance with Uniform Guidance 2 CFR 200.512(a). QUESTIONED COSTS: n/a RECOMMENDATION: DLS should ensure timely compliance as part of year end audit process. Management Response: DLS will schedule its annual audit to occur in August, at the latest. This will ensure that the annual audit is completed in time to meet the Sept. 30th filing deadline with the Audit Clearinghouse. In the event that the Judicial Council is unable to process reimbursements timely, DLS' management will estimate revenue and receivable balances based on reasonable and probable amounts so that the audit will still be completed on time. Date: 9.13.23 __________________________________ John P. Passalacqua, Executive Director
Finding 58377 (2022-001)
Significant Deficiency 2022
To Whom It May Concern: Midland University Single Audit Report: Corrective Action Plan - Year ended May 31, 2022 Finding 2022-001 ? Title IV Credit Balances Condition/Context: For 4 of 25 students tested, the credit balance was not resolved in compliance with the regulations, the student?s Title I...
To Whom It May Concern: Midland University Single Audit Report: Corrective Action Plan - Year ended May 31, 2022 Finding 2022-001 ? Title IV Credit Balances Condition/Context: For 4 of 25 students tested, the credit balance was not resolved in compliance with the regulations, the student?s Title IV credit balances on their accounts were held and applied to future charges without student or parent authorization. The first student?s Title IV credit balance was $759 of Direct Loan funds, the second student?s was $3,702 of Direct Loan funds, the third student?s was $390 of Direct Loan funds and the fourth student?s was $2,850 of Direct Loan funds and $943 of Teach Grant funds. The sample was not a statistically valid sample. Corrective Action Plan The University agrees with the finding. The occurrence of Title IV credit balances occurs primarily with graduate program students. A review is being conducted of current internal control processes and evaluating what additional reporting is capable within the student information system to assist in identifying these Title IV credit balances in a more timely manner. Title IV credit balances are being monitored during the Spring 2023 terms and new procedures will be put in place for the Fall 2024 term.
View Audit 54189 Questioned Costs: $1
Summary description - The School District failed to maintain proper time and activity reports for employees charged to the Title I grant. Corrective Action Plan - That the School District time and activity reports must be completed within federal guidelines for salaries charged to Title 1 program. ...
Summary description - The School District failed to maintain proper time and activity reports for employees charged to the Title I grant. Corrective Action Plan - That the School District time and activity reports must be completed within federal guidelines for salaries charged to Title 1 program. Method of Implementation - Enhanced internal controls and additional staff training. Person Responsible for Implementation - Chief Academic Officer Planned Completion Date of Implementation - September 1, 2023
Finding Type: Compliance and Material Weakness. Name of Contact Person: Eric Witges, Superintendent. Recommendation: We recommend that a supervisor review the quarterly expenditure reports and supporting documentation to ensure all costs are reported timely and accurately. Corrective Action: ...
Finding Type: Compliance and Material Weakness. Name of Contact Person: Eric Witges, Superintendent. Recommendation: We recommend that a supervisor review the quarterly expenditure reports and supporting documentation to ensure all costs are reported timely and accurately. Corrective Action: We will ensure that more time is dedicated to this procedure and more accuracy is implemented with an additional administrator review. Proposed Completion Date: Immediately.
Finding Type: Material Weakness. Name of Contact Person: Eric Witges, Superintendent. Recommendation: We recommend that the District check the Excluded Parties List System or collect certifications from any vendor that the District expects to spend more than $25,000 for the year. Corrective Ac...
Finding Type: Material Weakness. Name of Contact Person: Eric Witges, Superintendent. Recommendation: We recommend that the District check the Excluded Parties List System or collect certifications from any vendor that the District expects to spend more than $25,000 for the year. Corrective Action: The District will begin making all significant vendors sign a certification. Proposed Completion Date: Immediately.
2022-001 HEERF Reporting Recommendation: We recommend that the University review their reporting policies and procedures to ensure accurate reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Immediate act...
2022-001 HEERF Reporting Recommendation: We recommend that the University review their reporting policies and procedures to ensure accurate reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Immediate action was taken to update the quarterly report and post the updated report to our university?s website. Error was made due to data file showing category under other uses in previous quarterly reports. When new quarterly report was prepared the amount was reported on proper lost revenue line but was not deducted from the other uses total. This resulted in an overstatement of expenditures. An additional step was implemented to confirm total balance with data spreadsheet balance of expenditures. Name(s) of the contact person(s) responsible for corrective action: Jennifer Martell, Controller Planned completion date for corrective action plan: This was immediately corrected when brought to our attention on 5/26/22 for the quarterly report ending 3/31/22 which was originally posted to our website on 4/10/22.
FINDINGS-FINANCIAL STATEMENT AUDIT MATERIAL WEAKNESS 2022-001 Segregation of duties- Procedures should be established and implemented where the Organization segregates duties in the receipts and expenditures cycles and implements additional controls over the accounting and recording functions. ...
FINDINGS-FINANCIAL STATEMENT AUDIT MATERIAL WEAKNESS 2022-001 Segregation of duties- Procedures should be established and implemented where the Organization segregates duties in the receipts and expenditures cycles and implements additional controls over the accounting and recording functions. Involvement by the Board of Directors can help mitigate the risk of error or fraud. The Board of Directors should remain involved in the financial affairs of the Organization with oversight and independent review of internal control functions. Action Taken: We agree the size of the Organization prohibits hiring additional personnel. Duties have been segregated where possible. The Board of Directors is involved where possible.
Finding 58233 (2022-003)
Significant Deficiency 2022
Finding 2022-003 Condition One of the two reports selected for testing were not independently reviewed before submission. The sample is not statistically valid. Corrective Action Plan Corrective Action Planned: The City does not currently have sufficient staffing to provide segregation of duties...
Finding 2022-003 Condition One of the two reports selected for testing were not independently reviewed before submission. The sample is not statistically valid. Corrective Action Plan Corrective Action Planned: The City does not currently have sufficient staffing to provide segregation of duties in all areas. Upon start of employment of a new City Administrator/Treasurer on October 9, 2023, that position employee will be reviewing such reports and financial documents on a regular basis as part of his job duties. Name of Contact Person Responsible for Corrective Action: Barbara J. Van Clake, City Clerk/Deputy Treasurer. Anticipated Completion Date: October 2023.
Corrective Action Item 2022-002: Reporting on Federal Awards Individual Responsible: Paul Huberty, Executive Director Anticipated Completion Date: September 2023 Corrective Action: WRDF will develop a new system for monitoring and tracking grant reporting requirements and deadlines. In additi...
Corrective Action Item 2022-002: Reporting on Federal Awards Individual Responsible: Paul Huberty, Executive Director Anticipated Completion Date: September 2023 Corrective Action: WRDF will develop a new system for monitoring and tracking grant reporting requirements and deadlines. In addition, WRDF will utilize QuickBooks to track each grant, develop workflows to ensure that all deadlines are met, monitor its performance, and provide regular updates to its Board of Directors.
The District agrees and intends to continue supervision and monitoring of accounting information and operations, including obtaining explanations for variances from unexpected results. The Superintendent will continue to sign off on all payroll check registers and journal entries.
The District agrees and intends to continue supervision and monitoring of accounting information and operations, including obtaining explanations for variances from unexpected results. The Superintendent will continue to sign off on all payroll check registers and journal entries.
Finding #2022-001 ? Special Tests and Provisions: Selection from the Waiting List The Authority acknowledges that waiting list documentation could not be located for two (2) new admissions during the audit period. The Authority experienced significant staff turnover in recent years that resulted in ...
Finding #2022-001 ? Special Tests and Provisions: Selection from the Waiting List The Authority acknowledges that waiting list documentation could not be located for two (2) new admissions during the audit period. The Authority experienced significant staff turnover in recent years that resulted in lacking internal controls. The Authority has effectively corrected this deficiency by contracting with the Chelsea Housing Authority for administration of the Authority?s Section 8 Housing Choice Voucher Program. The Chelsea Housing Authority has staff capacity, experience, and certifications to effectively administer all aspects of this program including selections from the waiting list. Implementation Date of Corrective Action: February 7, 2022 Person Responsible for Correction Action: Adam Garvey, Executive Director
Finding 2022-001 Condition ? Material audit adjustments were required in order for the accounting records, and thus the Organization?s financial statements, to not be materially misstated. Similar conditions existed for the during the year ended September 30, 2017 (finding 2017-001) Planned Correct...
Finding 2022-001 Condition ? Material audit adjustments were required in order for the accounting records, and thus the Organization?s financial statements, to not be materially misstated. Similar conditions existed for the during the year ended September 30, 2017 (finding 2017-001) Planned Corrective Action ? Nicole Speedy, the Operation Director, on behalf of the organization will implement procedures to ensure journal entries related to investment fees, asset addition/disposal, and grant receivables are prepared and recorded prior to the start of the annual audit. Nicole Speedy, the Operations Director, will be responsible for all corrective actions and it is anticipated this will be completed with the audit of fiscal year ending September 30, 2023.
Program: Medicaid Cluster CFDA No.: 93.778 Federal Agency: U.S. Department of Health and Human Services Passed-through: California Department of Health Care Services Award Year: 2021-2022 Compliance Requirement: Eligibility Grant Award Number: In-Home Supportive Services (IHSS) Type of Finding: Mat...
Program: Medicaid Cluster CFDA No.: 93.778 Federal Agency: U.S. Department of Health and Human Services Passed-through: California Department of Health Care Services Award Year: 2021-2022 Compliance Requirement: Eligibility Grant Award Number: In-Home Supportive Services (IHSS) Type of Finding: Material Noncompliance and Material Weakness in Internal Control over Compliance Repeat Finding from Prior Year: Yes, prior year finding 2021-06. Management?s or Department?s Response: With the 2021-2022 budget, the County allocated an additional seven Social Worker positions to assist in maintaining compliance with the redetermination backlog of cases. With the 2022-2023 budget, the County requested one additional unit of seven Social Worker positions to comply with this requirement. The County also continues to use overtime and part-time Social Workers to ensure compliance with the 12-month requirement. Views of Responsible Officials and Corrective Action: The County will continue to process the backlog of redetermination cases to comply with the 12-month requirement. Name of Responsible Person: Renee Smith, IHSS Program Manager Name of Department Contact: Renee Smith, IHSS Program Manager Projected Implementation Date: The County hired additional staff to assist with the processing of the redetermination of eligible cases.
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