Corrective Action Plans

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Finding 37458 (2022-001)
Significant Deficiency 2022
SIGNIFICANT DEFICIENCY. 2022-001 SEGREGATION OF DUTIES. NAME OF CONTACT PERSON: LEAH WICEVIC, EXECUTIVE DIRECTOR. CORRECTIVE ACTION: THE DUTIES WILL BE SEGREGATED AS MUCH AS POSSIBLE. WE UNDERSTAND THAT IN MOST CASES, THE ADDED COST OF PROVIDING ABSOLUTE SEGREGATION OF DUTIES WILL OUTWEIGH THE PROJE...
SIGNIFICANT DEFICIENCY. 2022-001 SEGREGATION OF DUTIES. NAME OF CONTACT PERSON: LEAH WICEVIC, EXECUTIVE DIRECTOR. CORRECTIVE ACTION: THE DUTIES WILL BE SEGREGATED AS MUCH AS POSSIBLE. WE UNDERSTAND THAT IN MOST CASES, THE ADDED COST OF PROVIDING ABSOLUTE SEGREGATION OF DUTIES WILL OUTWEIGH THE PROJECTED BENEFITS OF THE ADDED INTERNAL CONTROLS AND THEREFORE, MAY BE CONSIDERED UNJUSTIFIED. SISTERCARE, INC. WILL ENSURE THAT THE BOARD OF DIRECTORS WILL REMAIN INVOLOVED IN THE FINANCIAL AFFAIRS OF THE ORGANIZATION TO PROVIDE OVERSIGHT AND INDEPENDENT REVIEW FUNCTIONS. PROPOSED COMPLETION DATE: MANAGEMENT WILL IMPLEMENT THE ABOVE ACTION IMMEDIATELY.
FINDING THE SCHOOL DEPARTMENT DID NOT DOCUMENT COMPLIANCE WITH THE DA VIS-BACON ACT Response and Corrective Action Plan Prepared by: Jason D. Luallen, Director of Finance Person Responsible for Implementing the Corrective Action: Jason D. Luallen, Director of Finance Anticipated Completion D...
FINDING THE SCHOOL DEPARTMENT DID NOT DOCUMENT COMPLIANCE WITH THE DA VIS-BACON ACT Response and Corrective Action Plan Prepared by: Jason D. Luallen, Director of Finance Person Responsible for Implementing the Corrective Action: Jason D. Luallen, Director of Finance Anticipated Completion Date of Corrective Action: 7/1/22 Repeat Finding: No Reason Corrective Action was Not Taken in the Prior Year: N/A Planned Corrective Action: McMinn County has already taken steps to assure that Davis-Bacon Act compliance is included in bids for federally funded projects.
View Audit 28135 Questioned Costs: $1
Finding 37450 (2022-002)
Material Weakness 2022
Views of Responsible Officials and Planned Corrective Actions: During the pandemic, the TEFAP program was expanded using COVID-19 relief funds. Three Square had a misunderstanding in the classification of these supplemental commodities, and believed them to be part of COVID-19 relief and as such did...
Views of Responsible Officials and Planned Corrective Actions: During the pandemic, the TEFAP program was expanded using COVID-19 relief funds. Three Square had a misunderstanding in the classification of these supplemental commodities, and believed them to be part of COVID-19 relief and as such did not necessitate an executed TEFAP Agency Partner Services Agreement. The four entities mentioned in the finding who received TEFAP commodities only received these supplemental COVID-19 commodities. This finding was not pervasive throughout the organization, but rather isolated to a temporary program, which has now ended. To ensure effective internal controls, Three Square has designed a system to ensure an executed TEFAP Agency Partner Services Agreement is obtained prior to any TEFAP distribution to an Agency Partner. Moving forward, our agency services team will review all orders containing any federal commodity, regardless of the federal program. They will verify eligibility before approval is given to the warehouse to deliver the products.
Finding 37449 (2022-001)
Material Weakness 2022
Views of Responsible Officials and Planned Corrective Actions: During the pandemic, the TEFAP program was expanded using COVID-19 relief funds. Three Square had a misunderstanding in the classification of these supplemental commodities, and believed them to be part of COVlD-19 relief and as such did...
Views of Responsible Officials and Planned Corrective Actions: During the pandemic, the TEFAP program was expanded using COVID-19 relief funds. Three Square had a misunderstanding in the classification of these supplemental commodities, and believed them to be part of COVlD-19 relief and as such did not necessitate an executed TEFAP Agency Partner Services Agreement. The four entities mentioned in the finding who received TEFAP commodities only received these supplemental COVlD-19 commodities. This finding was not pervasive throughout the organization, but rather isolated to a temporary program, which has now ended. To ensure effective internal controls, Three Square has designed a system to ensure an executed TEFAP Agency Partner Services Agreement is obtained prior to any TEFAP distribution to an Agency Partner. Moving forward, our agency services team will review all orders containing any federal commodity, regardless of the federal program. They will verify eligibility before approval is given to the warehouse to deliver the products.
Finding Type: Material Weakness for CFDA 84.425D, 84.425U, and 84.425W. Name of Contact Person: Ryan Fritch, Superintendent. Recommendation: We recommend that the District provide proper documentation of the Superintendent's approval for payment of invoices. Corrective Action: The Superintend...
Finding Type: Material Weakness for CFDA 84.425D, 84.425U, and 84.425W. Name of Contact Person: Ryan Fritch, Superintendent. Recommendation: We recommend that the District provide proper documentation of the Superintendent's approval for payment of invoices. Corrective Action: The Superintendent will begin noting his approval by signing all invoices that are not accompanied by an approved purchase order.
Finding Type: Significant Deficiency of CFDA 10.553 and 10.555. Name of Contact Person: Ryan Fritch, Superintendent. Recommendation: We recommend the Food Service Director input the amounts into the Illinois State Board of Education monthly meal count report, print the report before submission,...
Finding Type: Significant Deficiency of CFDA 10.553 and 10.555. Name of Contact Person: Ryan Fritch, Superintendent. Recommendation: We recommend the Food Service Director input the amounts into the Illinois State Board of Education monthly meal count report, print the report before submission, and give to the Bookkeeper or Superintendent the report along with the daily meal count sheets to review in order to ensure the amounts are accurate. The review should be documented on the report. Corrective Action: The Bookkeeper or Superintendent will begin reviewing the monthly meal count reports prepared by the Food Service Director to ensure accuracy before they are submitted. We will ensure the review is documented. Proposed Completion Date: Immediately.
Finding --- Internal controls over financial statement reporting lack segregation of duties. Corrective action --- During the year, internal controls have been enhanced for layers of review. However, the Organization understands that it is imperative that the assigned preparer and reviewer have th...
Finding --- Internal controls over financial statement reporting lack segregation of duties. Corrective action --- During the year, internal controls have been enhanced for layers of review. However, the Organization understands that it is imperative that the assigned preparer and reviewer have the suitable skill, knowledge and experience to perform preparation and oversight responsibilities, respectively. Management and the board are seeking both at the governance level and internally, additional personnel to assist with financial duties through active recruitment. Status --- Corrective action in progress. Completion date --- Before 9/30/2023 Contact --- Doug Goudsward, CFO Contact phone --- 732-918-9901, Ext 107 Contact address --- 3301 C Route 66, Neptune, New Jersey, 07754
Finding 37412 (2022-003)
Significant Deficiency 2022
Finding: 2022-003 Name of contact person: Brittany Majors (Program Manager), Donna Rimmer (AM Supervisor), Joanna Thompson and Meredith Farmer (Leadworkers) Corrective Action: Some of the verifications missing were lost in the County 2020 Cyber Incident. The County cons...
Finding: 2022-003 Name of contact person: Brittany Majors (Program Manager), Donna Rimmer (AM Supervisor), Joanna Thompson and Meredith Farmer (Leadworkers) Corrective Action: Some of the verifications missing were lost in the County 2020 Cyber Incident. The County consulted with State Medicaid Reps who advised the County would be in error to request information previously used to make those determination of eligibility which were lost due to not being able to 100% recover from the Cyber Incident. Therefore, the County implemented a new procedural requirement regarding document management and retention of verification used to determine eligibility. Effective January 2022, all economic benefit programs at Person County DSS were required to upload all verifications used in determining eligiblity into NCFAST. In regards to incorrect data being entered as evidence the Management team conducted individual and unit meeting/trainings to inform parties of the errors discovered and how to reduce/eliminate in future processing. The County would like for it to be notated that eligibility would not have been affected due to the data entry level. Proposed Completion Date: 9/30/2022
Corrective action plan: HHSC ? Medicaid and CHIP Services - FRAC identified the missing requirements and updated the MLR report template and instructions in August 2022. Unfortunately, work was not completed in time for the Managed Care Organizations (MCO) to use the new template for reports subm...
Corrective action plan: HHSC ? Medicaid and CHIP Services - FRAC identified the missing requirements and updated the MLR report template and instructions in August 2022. Unfortunately, work was not completed in time for the Managed Care Organizations (MCO) to use the new template for reports submitted in August 2022. MCOs will use the new template with reports submitted in August 2023. Implementation date(s): Fully implemented August 2022. Responsible persons: Director, Medicaid and CHIP Services ? FRAC
Corrective action plan: TDA maintains an internal policy that requires SOC reports to be reviewed annually and document complementary user entity controls included in each SOC report. TDA?s contract with Colyar LLC requires the vendor to produce a SOC report annually. The vendor was late in provid...
Corrective action plan: TDA maintains an internal policy that requires SOC reports to be reviewed annually and document complementary user entity controls included in each SOC report. TDA?s contract with Colyar LLC requires the vendor to produce a SOC report annually. The vendor was late in providing the SOC report as a 2022 contract deliverable. TDA took actions to ensure vendor accountability for submitting the late contract deliverable and the vendor was required to complete a corrective action plan. TDA will review and assess the SOC report as soon as it is delivered by the vendor to ensure CLA?s recommendations can be followed and will consider additional procedures to ensure internal controls are assessed in the absence of a SOC report. Implementation date(s): June 2023 Responsible persons: Chief Information Officer and the Director for Food and Nutrition Program Support
Corrective action plan: The Federal Funds Instruction Guide will be revised to require that PCAs associated with closed grants are inactivated by the end of the approved close-out period. Budget and Planning management will discuss the revised guidance with staff to ensure proper implementation. TCE...
Corrective action plan: The Federal Funds Instruction Guide will be revised to require that PCAs associated with closed grants are inactivated by the end of the approved close-out period. Budget and Planning management will discuss the revised guidance with staff to ensure proper implementation. TCEQ will implement the Centralized Accounting and Payroll/Personnel System (CAPPS) in September of 2023; grant numbers will include beginning and ending dates at the time the grant is created and will not require inactivation. TCEQ will ensure thorough documentation of its internal controls and the associated staff roles and responsibilities and will conduct periodic reviews of its controls. Implementation date(s): April 11. 2023 for update of the Federal Funds Instruction Guide and training staff. CAPPS: September 1, 2023. Responsible Persons: TBD, Federal Funds Section Manager; Stephanie Robinson, Assistant Deputy Director of Budget and Planning Division; Jene Bearse, Deputy Director of Budget and Planning Division
Corrective action plan: The Texas Workforce Commission will initiate a formal and documented review procedure to ensure that FFATA reports are submitted timely. Implementation date(s): March 1, 2023 Responsible persons: Teri Goodwin, Financial Reporting Manager
Corrective action plan: The Texas Workforce Commission will initiate a formal and documented review procedure to ensure that FFATA reports are submitted timely. Implementation date(s): March 1, 2023 Responsible persons: Teri Goodwin, Financial Reporting Manager
Corrective action plan: ? For FFATA, Community Affairs Division (CAD) is currently updating Standard Operating Procedure (SOP) to include two review and approval processes that will take place prior to the submission in the FSFR system. The two additional review and approval process will be perfor...
Corrective action plan: ? For FFATA, Community Affairs Division (CAD) is currently updating Standard Operating Procedure (SOP) to include two review and approval processes that will take place prior to the submission in the FSFR system. The two additional review and approval process will be performed by the Team Lead, Laura White in CAD and Elizabeth Yevich, Director of Housing Resource Center (HRC). The two additional reviews will strengthen the process to ensure accurate and timely submission of monthly FFATA reporting. ? For Annual Financial Report, CAD is currently working with the Information System Division (IS) to correct issues identified in the data pulls to the summary sheets used for the submission of the Annual Report. CAD has identified that these issues emerged when federal funding sources began requesting data by individual grants. In order to address the identified issues, CAD and IS will continue to correct and test the data queries and formulas to ensure accurate reporting is achieved. Implementation date(s): ? For FFATA, March 2023 ? For Annual Financial Report, August 2023 Responsible persons: ? For FFATA, Director of Housing Resource Center and Team Leader of Community Affairs. ? For Annual Financial Report, Manager of Fiscal & Reporting and Team Leader of Community Affairs.
Corrective action plan: TWC has already reviewed all ACF-196R and ACF-204 Report queries and made the appropriate criteria modifications to appropriately reflect and report Agency activities. The query review and modifications were completed in October 2022, and subsequent Federal Financial Reports,...
Corrective action plan: TWC has already reviewed all ACF-196R and ACF-204 Report queries and made the appropriate criteria modifications to appropriately reflect and report Agency activities. The query review and modifications were completed in October 2022, and subsequent Federal Financial Reports, for active TWC grants, were modified to reflect accurate cumulative activities. Implementation date(s): October 31, 2022 Responsible persons: Teri Goodwin, Financial Reporting Manager
Corrective action plan: In December 2022, the Federal Funds Office (FFO) identified all prime awards with a potential subaward action date of 10/1/2021 or later. FFO is in the process of determining which of these have issued subawards for which no Federal Funding Accountability and Transparency A...
Corrective action plan: In December 2022, the Federal Funds Office (FFO) identified all prime awards with a potential subaward action date of 10/1/2021 or later. FFO is in the process of determining which of these have issued subawards for which no Federal Funding Accountability and Transparency Act (FFATA) reporting has been received from the program areas. In addition, FFO has revised the subaward reporting templates for programs. The goal of the revised templates is to 1) clearly state instructions for the information requested and 2) delineate between a) earlier subawards that are being reported late and b) subawards that fall into the current reporting period. These changes will assist FFO in maintaining current reporting and bringing all past due reporting up to date. The goal is to have all past due subawards from 10/1/2021 forward submitted to FFATA Subaward Reporting System (FSRS) by 12/31/2023. Implementation date(s): December 1, 2022 Responsible persons: Director, Federal Funds
Corrective action plan: HHSC Accounting has implemented the reporting of Early Childhood Intervention (ECI) expenditures on Line 16 of the Administration for Children and Families (ACF) 196R. The HHSC Accounting policies and procedures related to the ACF 196R were revised and corrected for all ope...
Corrective action plan: HHSC Accounting has implemented the reporting of Early Childhood Intervention (ECI) expenditures on Line 16 of the Administration for Children and Families (ACF) 196R. The HHSC Accounting policies and procedures related to the ACF 196R were revised and corrected for all open years. Implementation date(s): August 31, 2022 Responsible persons: Manager, State and Federal Reporting
Corrective action plan: DFPS will revise its policies and procedures related to the ACF-196R report review process to ensure all expenditure amounts are being properly classified. Implementation date(s): May 31, 2023 Responsible persons: Maura Flores
Corrective action plan: DFPS will revise its policies and procedures related to the ACF-196R report review process to ensure all expenditure amounts are being properly classified. Implementation date(s): May 31, 2023 Responsible persons: Maura Flores
EA Application/Determination Corrective action plan: DFPS will ensure that INV/AR staff receive ongoing communication/training regarding EA and how to correctly document and record income within the IMPACT. DFPS will update the current EA policy and publishing a new resource guide for staff. DFPS ...
EA Application/Determination Corrective action plan: DFPS will ensure that INV/AR staff receive ongoing communication/training regarding EA and how to correctly document and record income within the IMPACT. DFPS will update the current EA policy and publishing a new resource guide for staff. DFPS staff will be provided training, tip sheets and ongoing support regarding the new policy and resource guide. The policy will be published by April 1, 2023. DFPS will continue to strengthen our internal quality assurance review of cases eligible for EA to ensure that INV/AR staff are complying with federal guidelines and internal policies. DFPS has submitted an IT ticket request to resolve the condition for the participant that had the incorrect income range of $0-$10,000 selected to the correct income range of $20,550 to $40,549 to align with the investigation report. The participant remains eligible for assistance regardless as the family unit makes less than $63,000. CPI will initiate a request for an IT project to conduct analysis of any limitations with verifying Emergency Assistance eligibility in the IMPACT system regarding why two of the three EA statements now show not answered. DFPS staff will be researching the issue to determine next steps by 2nd quarter FY 2024. Implementation date(s): Ongoing communication ? will vary, first communication by April 1, 2023; IMPACT research January 31, 2024. Responsible persons: Jerome Green PEAF Corrective action plan: DFPS uses an established recoupment process to address overpayments. A Kinship Development Worker writes a letter to the kinship caregiver regarding the overpayment and details the steps needed to return funds. This letter is also sent to accounting for follow up. DFPS maintains a proactive approach to strengthening/enhancing IMPACT limitations to ensure accurate data is maintained for accurate payments/disbursements through continuous program improvement. Implementation date(s): On January 13, 2023 ? staff initiated the above described recoupment process to recoup the second payment for the subject children. Responsible persons: Debbie Bouldin
View Audit 28519 Questioned Costs: $1
Corrective action plan: Management will strengthen agency?s existing internal control over the review of project IDs to ensure all approvals are obtained on the project allocation percentage forms. Implementation date(s): May 31, 2023 Responsible persons: Maura Flores
Corrective action plan: Management will strengthen agency?s existing internal control over the review of project IDs to ensure all approvals are obtained on the project allocation percentage forms. Implementation date(s): May 31, 2023 Responsible persons: Maura Flores
Corrective action plan: DSHS will continue to utilize the updated procedure and FFATA checklist that was implemented on March 1, 2022 to ensure the verification of FFATA reports are formally documented prior to submission. DSHS will continue to maintain all relevant documentation to support that t...
Corrective action plan: DSHS will continue to utilize the updated procedure and FFATA checklist that was implemented on March 1, 2022 to ensure the verification of FFATA reports are formally documented prior to submission. DSHS will continue to maintain all relevant documentation to support that the key data elements were reported within the required timeframes. Implementation date(s): March 1, 2022 Responsible persons: FFATA Coordinator
Corrective action plan: Program management adopted policies and procedures to ensure supporting documentation for federal submissions are maintained, including any reconciling calculations or adjustments to support information. Implementation date(s): Implemented as of February 8, 2023 Responsib...
Corrective action plan: Program management adopted policies and procedures to ensure supporting documentation for federal submissions are maintained, including any reconciling calculations or adjustments to support information. Implementation date(s): Implemented as of February 8, 2023 Responsible persons: Mariana Salazar, Texas Rent Relief Director
Corrective action plan: To prevent similar errors from occurring until program closure, TRR management shared these findings with the external application review vendor on January 26, 2023, reiterating the processes for reviewing and approving rental assistance according to all program policies an...
Corrective action plan: To prevent similar errors from occurring until program closure, TRR management shared these findings with the external application review vendor on January 26, 2023, reiterating the processes for reviewing and approving rental assistance according to all program policies and procedures and ensuring that appropriate documentation related to review of applications is maintained in the files. Eligibility errors are expected in all programs, and TRR has developed different processes to address errors when identified. For these particular cases, TRR management requested the vendor take corrective action for each case as applicable (e.g., by requesting a return of funds for overpayment or by requesting additional information from applicants). Implementation date(s): January 26, 2023 Responsible persons: Danny Shea, TRR Senior Program Manager
View Audit 28519 Questioned Costs: $1
Management's Corrective Action Plan - Finding 2022-001: Special Tests: Return of Title IV Funds - In our 2021-22 audit it was identified that a Return of Title IV funding (R2T4) occurred outside of the required 45 day window. During the 2021-22 year the Financial Aid Office was continually working o...
Management's Corrective Action Plan - Finding 2022-001: Special Tests: Return of Title IV Funds - In our 2021-22 audit it was identified that a Return of Title IV funding (R2T4) occurred outside of the required 45 day window. During the 2021-22 year the Financial Aid Office was continually working on finding the most accurate ways to ensure that all withdrawals were identified and reviewed for R2T4 processing within the necessary time frames. We were using multiple reports that were created and delivered from various departments to screen all enrollment status changes, however, these reports were not capturing all necessary information which caused us to not identify the student in question until we were outside of the 45 day window to return funds. We have since worked to create a new report that captures all enrollment changes for the semester within one report. The new report is now delivered on a weekly basis for review to ensure that all required R2T4 deadlines are met. - Contact Person: Chris, Preszler, Director of Financial Aid - Anticipated Completion Date: November 30, 2022.
Finding 2022 - 003 - Housing Choice Vouchers Tenant Files, Significant Deficiency The Authority will work on strengthening its internal controls to correct this situation and ensure that they will be in compliance with the federal guidelines and the Authority?s policies. Patricia Logan, Executive Di...
Finding 2022 - 003 - Housing Choice Vouchers Tenant Files, Significant Deficiency The Authority will work on strengthening its internal controls to correct this situation and ensure that they will be in compliance with the federal guidelines and the Authority?s policies. Patricia Logan, Executive Director has assumed the responsibility to ensure that controls are put in place to properly maintain the tenant files. She expects the deficiencies which led to this finding to be resolved by December 31, 2023.
Finding 2022 - 002 - Section 8 HQS Inspection Deficiencies The Authority is continuing to work on the procedures for failed inspections to ensure that the reinspections are performed within the 30-day requirement. The Authority is also planning on additional training for employees to make sure they ...
Finding 2022 - 002 - Section 8 HQS Inspection Deficiencies The Authority is continuing to work on the procedures for failed inspections to ensure that the reinspections are performed within the 30-day requirement. The Authority is also planning on additional training for employees to make sure they are qualified to meet the HQS re-inspection requirements. Patricia Logan, Executive Director, has assumed the responsibility of ensuring that the inspections will be performed within the timeframe to meet the HUD compliance requirements and expects the deficiencies which led to this finding to be resolved by December 31, 2023.
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