Corrective Action Plans

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CORRECTIVE ACTION PLAN For the Year Ended September 30, 2022 Southwest Kansas Area Agency on Aging, Inc. respectfully submits the following corrective action plan for the fiscal year ended September 30, 2022. Name and address of independent public accounting firm: Kennedy McKee and Company LLP P...
CORRECTIVE ACTION PLAN For the Year Ended September 30, 2022 Southwest Kansas Area Agency on Aging, Inc. respectfully submits the following corrective action plan for the fiscal year ended September 30, 2022. Name and address of independent public accounting firm: Kennedy McKee and Company LLP P.O. Box 1477 Dodge City, Kansas 67801 Audit period: October 01, 2021 through September 30, 2022 The findings from the September 30, 2022 Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the Schedule. FINDINGS AND QUESTIONED COSTS - Major Federal Award Programs Audit U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT 2022-001 Title III Aging Cluster Title III B Supportive Services CFDA 93.044 Title III C Nutrition Services CFDA 93.045 Title III C Nutrition Services Incentive CFDA 93.053 Grant Period: Year ended September 30, 2022 Condition: The Organization did not have a written procurement policy to properly implement all the requirements of 2 CFR Section 200.318 through 200.326 of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Criteria: In accordance with 2 CFR Section 200.319(c), non-federal entities must have written procedures for procurement transactions. Such policy should incorporate all requirements within 2 CFR 200.318 through 200.326 of the Uniform Guidance. Cause: The Organization?s procurement policy does not incorporate all the requirements of 2 CFR Section 200.318 through 200.326 of the Uniform Guidance. Effect: An important component of internal controls is the existence of operating policies and procedures and that they are clearly understood and communicated. Without clear written policies and procedures, there is a higher risk of noncompliance with program compliance requirements. Southwest Kansas Area Agency on Aging, Inc. Corrective Action Plan February 9, 2023 Recommendation: Management should continue to develop comprehensive written policies and procedures to administer all federal programs. Current written policies should be evaluated for inclusion of and compliance with Uniform Guidance requirements. Grantee Response: Management agrees with the finding and will adopt written policies to comply with Uniform Guidance requirements. If the Oversight Agency has questions regarding this plan, please call Rick Schaffer at (620) 225-8230. Sincerely yours, Rick Schaffer Executive Director 236 San Jose Drive Dodge City, KS 67801
Finding 2022-004 ? Deadline for Federal Single Audit ? Noncompliance and Internal Control Over Compliance ? Significant Deficiency Corrective Action Plan The Borough will work with external auditors to have a financial statement draft prior to their fieldwork. Beginning balance reconciliations and y...
Finding 2022-004 ? Deadline for Federal Single Audit ? Noncompliance and Internal Control Over Compliance ? Significant Deficiency Corrective Action Plan The Borough will work with external auditors to have a financial statement draft prior to their fieldwork. Beginning balance reconciliations and year-end adjustments will be complete by September 5th, and a final trial balance and general ledger will be submitted to the external auditors. Expected Completion Date: Fiscal year 2023
2022-003 Housing Choice Vouchers -Assistance Listing No. 14.871 - Special Tests - HQS Inspections Recommendation: The Authority should imple...
2022-003 Housing Choice Vouchers -Assistance Listing No. 14.871 - Special Tests - HQS Inspections Recommendation: The Authority should implement processes to ensure all HQS biennial and re-inspections are completed timely and that there is proper documentation of approved extensions and abatements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: During this time GHA was short staffed and had a large number of initial inspections which are necessary to execute HAP contracts timely and to ensure adequate lease up. This coupled with the requirement for routine regular inspections created a large number of inspections at one time. During that time reports were run monthly to identify inspection requirement dates. Currently, GHA is caught up with inspections and inspections are three months ahead. Going forward, GHA will run the inspection reports twice a month to ensure inspection dates are not missed. Name(s) of the contact person(s) responsible for corrective action: Maria Godwin Planned completion date for corrective action plan: This is complete. GHA has hired and trained a new inspector and all inspections are current and three months ahead. GHA will run the inspection ad-hoc report twice a month to ensure inspection dates are tracked thoroughly. GHA will continue to conduct and submit all inspections timely.
2022-002 Housing Choice Vouchers - Assistance Listing No. 14.871 - Eligibility Recommendation: The Authority should implement processes to ensure...
2022-002 Housing Choice Vouchers - Assistance Listing No. 14.871 - Eligibility Recommendation: The Authority should implement processes to ensure that all documentation is received and that the correct inputs are being accurately reported on the HUD-50058. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: During this time GHA's HCV program was extremely short staffed and GHA was using temporary employees to assist in program delivery. Specifically, the department suffered two staff- members deaths, one family emergency that removed dedicated staff from this task, and two resignations. GHA has hired and trained new staff to ensure that recertifications are being performed annually for all tenants as applicable. The annual recertifications will be three months ahead by the end of 2023. Name(s) of the contact person(s) responsible for corrective action: Maria Godwin Planned completion date for corrective action plan: GHA has hired and trained new staff and will conduct additional refresher training courses for existing staff focusing on accuracy. This will be complete by August 2023. GHA annual recertification's are currently being completed timely and will be three months ahead by the end of 2023.
View Audit 37744 Questioned Costs: $1
2022-001 Housing Choice Vouchers - Assistance Listing No. 14.871 - Reporting Recommendation: The Authority should implement processes to ensure...
2022-001 Housing Choice Vouchers - Assistance Listing No. 14.871 - Reporting Recommendation: The Authority should implement processes to ensure the HUD-50058's are submitted into the PIC system timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: During this time GHA's HCV program was extremely short staffed and GHA was using temporary employees to assist in program delivery. Specifically, the department suffered two staff- members deaths, one family emergency that removed dedicated staff from this task, and two resignations. GHA has hired and trained new staff and increased the form 50058 submissions times to daily. GHA also provided training to existing staff on the importance of timely completion of form 50058. There is now dedicated back-up staff to assist with this important task. Name(s) of the contact person(s) responsible for corrective action: Maria Godwin Planned completion date for corrective action plan: This is complete. GHA has hired and trained both new and existing staff in form 50058 submission. Form 50058's are submitted daily.
This finding was due to a clerical error when entering the expense information into the PRF portal. Only the carryover expense from prior filings and current period expenses should have been entered, but all prior expenses were entered into the prior period columns. This error was identified during ...
This finding was due to a clerical error when entering the expense information into the PRF portal. Only the carryover expense from prior filings and current period expenses should have been entered, but all prior expenses were entered into the prior period columns. This error was identified during our audit and the incorrect information was replaced with eligible expenses from the current period. Our standard process for all surveys and filings is to include a second review step prior to completing the filing. This step was not taken due to filing so close to the cut-off time on the last day. Going forward, our standard process of performing a second review prior to filing will be followed. This will be effective with the September 30, 2023 filing. We apologize for the error. This will not happen again.
Finding 41412 (2022-014)
Significant Deficiency 2022
Name of Responsible Individual: Brenda Willis - Senior Director of Financial Grants and Contracts and Rawle Howard - Assistant Vice President and Chief Procurement Officer Corrective Action: The Controller?s Office and Grants and Contracts will work with Accounts Payable to ensure that payments to v...
Name of Responsible Individual: Brenda Willis - Senior Director of Financial Grants and Contracts and Rawle Howard - Assistant Vice President and Chief Procurement Officer Corrective Action: The Controller?s Office and Grants and Contracts will work with Accounts Payable to ensure that payments to vendors are applied timely in Workday. Accounts payable will be required to review all wire requests to ensure the invoices have not been previously paid by check prior to initiating wires. Anticipated Completion Date: June 30, 2023
View Audit 37632 Questioned Costs: $1
Finding 41410 (2022-001)
Significant Deficiency 2022
Name of Responsible Individual: Brenda Willis - Senior Director of Financial Grants and Contracts Corrective Action: The Office of Grants and Contracts will update the policies and procedures to include a detailed, timely and accurate submission of federal expenditures in accordance with the Uniform...
Name of Responsible Individual: Brenda Willis - Senior Director of Financial Grants and Contracts Corrective Action: The Office of Grants and Contracts will update the policies and procedures to include a detailed, timely and accurate submission of federal expenditures in accordance with the Uniform Guidance, ?200.510(b) to reflect on the annual SEFA. Quarterly meetings and annual reviews will be established with appropriate Howard University Hospitals? personnel to ensure required expenditures are included on the SEFA per federal requirements. Sr. Director of Grants and Contracts and the Controller will prepare the SEFA going forward and will receive formal approval by the Controller. Anticipated Completion Date: June 30, 2023
Finding 41409 (2022-013)
Significant Deficiency 2022
Name of Responsible Individual: Brenda Willis - Senior Director of Financial Grants and Contracts Corrective Action: Grants and Contracts will implement a two-tier review process to ensure expenditures charged to the HEERF grant are allowable and in accordance with the Department of Education polici...
Name of Responsible Individual: Brenda Willis - Senior Director of Financial Grants and Contracts Corrective Action: Grants and Contracts will implement a two-tier review process to ensure expenditures charged to the HEERF grant are allowable and in accordance with the Department of Education policies and procedures. Additionally, any expenditures requested and/or transferred to the HEERF grant will require the two-tier review/approval process. Anticipated Completion Date: June 30, 2023
View Audit 37632 Questioned Costs: $1
Finding 41406 (2022-009)
Significant Deficiency 2022
Name of Responsible Individual: Sammara Evans, Director of Institutional Research Corrective Action: On March 21, 2023, Howard assigned Ms. Sammara Evans, the Director of Institutional Research, as the lead for quarterly and annual HEERF reporting. The areas with access to the information required t...
Name of Responsible Individual: Sammara Evans, Director of Institutional Research Corrective Action: On March 21, 2023, Howard assigned Ms. Sammara Evans, the Director of Institutional Research, as the lead for quarterly and annual HEERF reporting. The areas with access to the information required to complete the quarterly and annual HEERF reporting have now been added to the Education Stabilization Fund (ESF) site as editors. This list of editors on the ESF site includes representatives from the Financial Aid Office, the Bursar?s Office, Enrollment Analytics and Grants & Contracts. These offices can now receive notifications regarding submission deadlines and have access to update the information for each report. Prior to the quarterly or annual report due date, the Director of Institutional Research will request the necessary information from each department and is aware of her responsibilities to do so. HEERF reporting responsibilities have been defined. Anticipated Completion Date: March 31, 2023
Finding 40172 (2022-012)
Significant Deficiency 2022
Name of Responsible Individual: Brenda Willis - Senior Director of Financial Grants and Contracts Corrective Action: Workday implementation challenges and the September cyberattack caused delays in allocating personnel earnings to grants during the first half of the fiscal year. As a result, certifi...
Name of Responsible Individual: Brenda Willis - Senior Director of Financial Grants and Contracts Corrective Action: Workday implementation challenges and the September cyberattack caused delays in allocating personnel earnings to grants during the first half of the fiscal year. As a result, certificates were not generated for employees with unallocated earnings for the first six-month reporting period. Certificates were issued on an ad-hoc basis as earnings were allocated. This issue was resolved for the second half of the fiscal year. To further address this finding, Grants and Contracts will adjust the effort certification process to expand the pool of secondary approvers, improve the user interface, and allow for easier reassignments of certificates. In addition, a training module will be developed to assist employees during their review. Anticipated Completion Date: June 30, 2023
Finding 40171 (2022-008)
Significant Deficiency 2022
Name of Responsible Individual: Bruce Jones, Vice President for Research Administration Corrective Action: The Vice President for Research will establish procedures to adhere to federal regulations requiring appropriate acknowledgements and disclaimers for federally funded publications including pre...
Name of Responsible Individual: Bruce Jones, Vice President for Research Administration Corrective Action: The Vice President for Research will establish procedures to adhere to federal regulations requiring appropriate acknowledgements and disclaimers for federally funded publications including presentations, papers, posters, flyers, press releases, etc. The Vice President for Research will communicate the appropriate federal regulations to the Principal Investigators and staff regarding publications. Also, the Vice President for Research will maintain and monitor publications by updating the publication portal to be used by all Principal investigators. The link to the updated disclosure is https://research.howard.edu/research/research-tools/federal-sponsorrequirements- acknowledging-funding. The link was updated as of 08/2022. Anticipated Completion Date: June 30, 2023
Finding 40170 (2022-007)
Significant Deficiency 2022
Name of Responsible Individual: Brenda Willis - Senior Director of Financial Grants and Contracts Corrective Action: The University experienced challenges from the cyber-attack in September 2021 that impacted the transition to the Workday ERP. Equipment purchased with federal funds will be maintaine...
Name of Responsible Individual: Brenda Willis - Senior Director of Financial Grants and Contracts Corrective Action: The University experienced challenges from the cyber-attack in September 2021 that impacted the transition to the Workday ERP. Equipment purchased with federal funds will be maintained in the Workday property management system by Procurement and Grants and Contracts. Procurement will tag equipment when initially received at Howard University Central Receiving. An additional process will be implemented to ensure equipment delivered directly to departments will be timely tagged. Workday property records include fields for the equipment description, relevant identification numbers, source, title information, acquisition date and cost, percentage of Federal participation in the cost, location, condition, and ultimate disposition data. Anticipated Completion Date: August 31, 2023
Name of Responsible Individual: Roderick Johnson, Assistant Director for Compliance Corrective Action: The finance and financial aid divisions will collaborate to improve the internal controls that are in place to ensure there is a three-day turnaround for draws and refunds. The policies and procedu...
Name of Responsible Individual: Roderick Johnson, Assistant Director for Compliance Corrective Action: The finance and financial aid divisions will collaborate to improve the internal controls that are in place to ensure there is a three-day turnaround for draws and refunds. The policies and procedures for cash management were updated in July 2022. Anticipated Completion Date: June 30, 2023
Finding 40166 (2022-003)
Significant Deficiency 2022
Name of Responsible Individual: Benjamin Carmichael, Compliance Officer Corrective Action: Loan disbursement notifications are now the responsibility of the Office of Financial Aid (Financial Aid). Notifications are now being sent out through Ellucian Banner (Banner) when a student has been awarded....
Name of Responsible Individual: Benjamin Carmichael, Compliance Officer Corrective Action: Loan disbursement notifications are now the responsibility of the Office of Financial Aid (Financial Aid). Notifications are now being sent out through Ellucian Banner (Banner) when a student has been awarded. The disbursement notification documentation is now electronic and does not require manual actions from Howard University employees to be completed. The following areas identified in the audit have been addressed: ? Notifications are immediately sent out electronically when the student is awarded, allowing Howard to meet the required notification timeline for notification. ? Each notification is addressed to the specific person (i.e., parent, student) who is responsible for paying back the loan. ? The name of the student, exact amount of the disbursement and the date of disbursement is generated on the notification as well. Bi-semester reviews have been completed by the Associate Director for Compliance (Financial Aid) to ensure the loan disbursement notifications are being generated in the required timeline and includes all federally required information listed above in each notification. Spring 2022, Summer 2022, and Fall 2022 reviews have been completed thus far with no significant issues identified. The policies and procedures for loan disbursement notifications were updated in April 2022. These will be reviewed annually. Anticipated Completion Date: April 30, 2022
Finding 40164 (2022-002)
Significant Deficiency 2022
Name of Responsible Individual: Benjamin Carmichael, Compliance Officer and Roderick Johnson, Assistant Director for Compliance Corrective Action: The Enrollment Reporting process is supervised by the Office of the Registrar (Registrar), which is responsible for providing enrollment reports to Howar...
Name of Responsible Individual: Benjamin Carmichael, Compliance Officer and Roderick Johnson, Assistant Director for Compliance Corrective Action: The Enrollment Reporting process is supervised by the Office of the Registrar (Registrar), which is responsible for providing enrollment reports to Howard University?s third-party servicer, National Student Clearinghouse (NSC), who then submits the report to the National Student Loan Data System (NSLDS). The departure of a key registrar personnel resulted in miscommunication and neglect of the enrollment reporting duties. The issue has since been remedied, but due to the time lag, will take an additional fiscal year for improvements to be observed. Anticipated Completion Date: March 31, 2023
Finding 40163 (2022-011)
Significant Deficiency 2022
Name of Responsible Individual: Brenda Willis - Senior Director of Financial Grants and Contracts Corrective Action: The original lost revenue calculation was completed by the Deputy Chief Financial Officer in August 2021. The calculation was reviewed by the Controller and Assistant Treasurer prior ...
Name of Responsible Individual: Brenda Willis - Senior Director of Financial Grants and Contracts Corrective Action: The original lost revenue calculation was completed by the Deputy Chief Financial Officer in August 2021. The calculation was reviewed by the Controller and Assistant Treasurer prior to drawing funds. The lost revenue calculation was compiled by management before the draw was completed on 09/09/2021. Deloitte was contracted for an additional review of the lost revenue increasing the lost revenue from $23M to $29M. Howard University will continue to comply with cash management policies and procedures in accordance with ALN: 84.915A. Anticipated Completion Date: June 30, 2023
B-K Health Center Inc. d/b/a NEPA Community Health Care (the Organization) respectfully submits the following corrective action plan for the year ending September 30, 2022. Audit Finding Reference: 2022-001 ? Significant Deficiency in Internal Control ? Reporting Condition/Context: The Organizat...
B-K Health Center Inc. d/b/a NEPA Community Health Care (the Organization) respectfully submits the following corrective action plan for the year ending September 30, 2022. Audit Finding Reference: 2022-001 ? Significant Deficiency in Internal Control ? Reporting Condition/Context: The Organization was required to submit the Annual Federal Financial Report by July 30, 2022 and the report was submitted on September 1, 2022. This is not a statistically valid sample. Recommendation: The Organization should implement procedures to identify and ensure compliance with all reporting requirements for the program. Planned Corrective Action: Both the CEO and CFO will add the reporting deadlines to their calendars to ensure timely filing. The CFO will prepare the document for reporting and the CEO will certify documents. A monthly update will be given to the finance committee as to reports filed for the prior month. Name of Contact Person: Kristen Follert, CEO Anticipated Completion Date: 1/19/2023
See corrective action plan for chart/table.
See corrective action plan for chart/table.
View Audit 53516 Questioned Costs: $1
In Finding 2022-001, it was reported that the Organization did not properly substantiate that proper documentation was obtained and that proper sliding fee discounts were applied for certain patients for the year ended December 31, 2022. During the pandemic, the Organization has experienced signif...
In Finding 2022-001, it was reported that the Organization did not properly substantiate that proper documentation was obtained and that proper sliding fee discounts were applied for certain patients for the year ended December 31, 2022. During the pandemic, the Organization has experienced significant turnover of staff, especially in those personnel who are responsible for obtaining documentation for sliding fee discounts and calculating the discounts. Employees will be given proper training to document and apply the sliding fee discounts, and the Organization will ensure that the sliding fee discounts are reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. This review and training will be completed by July 31, 2023.
2022-002 Federal agency: U.S. Department of Housing and Urban Development Federal program title: Supportive Housing for the Elderly Section 202 CFDA Number: 14.157 Criteria or specific requirement: Unapproved replacement reserve withdrawal. Condition: The Corporation mistakenly withdrew an unapprove...
2022-002 Federal agency: U.S. Department of Housing and Urban Development Federal program title: Supportive Housing for the Elderly Section 202 CFDA Number: 14.157 Criteria or specific requirement: Unapproved replacement reserve withdrawal. Condition: The Corporation mistakenly withdrew an unapproved amount from the replacement reserve account in February 2022. Questioned costs: 7,796 Context: Upon receiving proper HUD withdrawal approval, the Corporation mistakenly duplicated the amount of the withdrawal. Upon discover of this mistake, these funds were deposited back into the replacement reserve account in February 2022. Recommendation: The Corporation should ensure all replacement reserve amounts are properly reviewed and approved prior to withdrawal occurs. Action taken in response to finding: Managements acknowledges this finding and is taking steps to correct. Management has counseled HUD building management on the need for appropriate process for handling of the replacement reserve account funds in the future. Name of contact person responsible for corrective action: Jeffrey Carraway
View Audit 53437 Questioned Costs: $1
2022-001 Federal agency: U.S. Department of Housing and Urban Development Federal program title: Supportive Housing for the Elderly Section 202 CFDA Number: 14.157 Criteria or specific requirement: Expired Project Rental Assistance Contract (PRAC). Condition: The Corporation did not renew the PRAC t...
2022-001 Federal agency: U.S. Department of Housing and Urban Development Federal program title: Supportive Housing for the Elderly Section 202 CFDA Number: 14.157 Criteria or specific requirement: Expired Project Rental Assistance Contract (PRAC). Condition: The Corporation did not renew the PRAC timely. Context: The PRAC expired September 30, 2021, and was not renewed until February 14, 2022. Recommendation: The Corporation should ensure the PRAC is renewed on a timely basis annually. Action taken in response to finding: Managements acknowledges this finding and is taking steps to correct. Management has counseled HUD building management on the need for timely submissions of proposed budgets and contract completion. A master schedule has been set up and all budget submissions will now be reviewed by the Finance Department prior to submission. Name of contact person responsible for corrective action: Jeffrey Carraway
Administration Funds Used for Unallowable Activities Department Name: Commerce Contact Name / Telephone Number of Person Responsible for CAP: Kevin Carlson - (984) 236-5933 The questioned nonautomation costs will be moved to an alternative funding source. In addition, new staff have been trained on ...
Administration Funds Used for Unallowable Activities Department Name: Commerce Contact Name / Telephone Number of Person Responsible for CAP: Kevin Carlson - (984) 236-5933 The questioned nonautomation costs will be moved to an alternative funding source. In addition, new staff have been trained on the internal controls that are in place to catch these types of errors. Additional monitoring on a quarterly basis will be instituted as well as identified during our federal fiscal year crossover process. Anticipated Completion Date: June 30, 2023.
View Audit 53638 Questioned Costs: $1
FINDING 2022-002 Contact Person Responsible for Corrective Action: Annette Brown, Treasurer Contact Phone Number: (812) 829-2233 Views of Responsible Official: We concur with the Audit Finding Description of Corrective Action Plan: The School Corporation will implement procedures and processes to en...
FINDING 2022-002 Contact Person Responsible for Corrective Action: Annette Brown, Treasurer Contact Phone Number: (812) 829-2233 Views of Responsible Official: We concur with the Audit Finding Description of Corrective Action Plan: The School Corporation will implement procedures and processes to ensure that the reporting compliance requirement is met for the Education Stabilization Fund. All reporting information will be gathered either by the Treasurer, Payroll Clerk or Accounts Payable depending on the information being requested. The information will then be reviewed for accuracy by the Grant Administrator or Superintendent before being submitted. All documentation will be signed and dated by the appropriate individuals and be filed with the appropriate ESF. Anticipated Completion Date: Will begin this process moving forward with future reporting after February 2023.
To ensure audits get submitted in a timely manner to the Federal Audit Clearinghouse, TLS? current financial officer will start compiling all necessary documentation and schedule an independent audit in late summer or early fall. This will allow TLS to meet the required deadlines.
To ensure audits get submitted in a timely manner to the Federal Audit Clearinghouse, TLS? current financial officer will start compiling all necessary documentation and schedule an independent audit in late summer or early fall. This will allow TLS to meet the required deadlines.
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