Corrective Action Plans

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2022-003: Student Financial Aid Cluster ? Assistance Listing No. 84.007, 84.033, 84.038 Recommendation: We recommend the University review its policies and procedures for the filing of the FISAP to ensure that there is sufficient time in the process to meet the due date in accordance with the stated...
2022-003: Student Financial Aid Cluster ? Assistance Listing No. 84.007, 84.033, 84.038 Recommendation: We recommend the University review its policies and procedures for the filing of the FISAP to ensure that there is sufficient time in the process to meet the due date in accordance with the stated criteria. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has scheduled data gathering and reconciling processes to ensure timely 2023 filing. Name(s) of the contact person(s) responsible for corrective action: Benjamin Soman Planned completion date for corrective action plan: 08/31/2023
2022-002: Student Financial Aid Cluster ? Assistance Listing No. 84.007, 84.033, 84.038, 84.063, 84.268, 84.379 Recommendation: We recommend that the University continue to work with the outside service provider to ensure compliance with the stated criteria. Explanation of disagreement with audit f...
2022-002: Student Financial Aid Cluster ? Assistance Listing No. 84.007, 84.033, 84.038, 84.063, 84.268, 84.379 Recommendation: We recommend that the University continue to work with the outside service provider to ensure compliance with the stated criteria. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University is working with an outside consultant that completed a cyber security review. The University will continue to work with the same consultant to ensure policy and procedures are in place Name(s) of the contact person(s) responsible for corrective action: Lynda Schultz Planned completion date for corrective action plan: 06/01/2023
Effective 2022-2023 fiscal year, the district purchased a point-of -sale system for nutrition services at all schools, except the Legacy High School (LHS), to ensure accurate reporting for reimbursable meals/snack. The Director of Nutrition Services has trained the LHS staff on the use of a bar code...
Effective 2022-2023 fiscal year, the district purchased a point-of -sale system for nutrition services at all schools, except the Legacy High School (LHS), to ensure accurate reporting for reimbursable meals/snack. The Director of Nutrition Services has trained the LHS staff on the use of a bar code meal count roster to scan students that receive a reimbursable meal/snack. The roster is turned in weekly to the Matilija Middle School Cafeteria Manager, who will process the meals counts for LHS. All meal count rosters are forwarded to the Director of Nutrition Services at the end of the month for review
Finding 2022-001 Significant Deficiency in Internal Control over Compliance Corrective Action Plan: The corrective plan is to examine all applicant and participant files for accuracy using a file checklist for forms such as Section 214 Declaration of Citizenship during the eligibility process and an...
Finding 2022-001 Significant Deficiency in Internal Control over Compliance Corrective Action Plan: The corrective plan is to examine all applicant and participant files for accuracy using a file checklist for forms such as Section 214 Declaration of Citizenship during the eligibility process and annual reexamination period. Management has decided not to purge tenant files for the current program participants. For the participants who are not in the program, the file will not be purged for a minimum of three years. In this specific instance, the participant entered the program in 2012 and ended program participation on March 31, 2022. The original file had been purged. Name of Responsible Person: Cherrie Escobar, Director of Section 8 Projected Completion Date: March 31, 2023
Finding 2022-002 ? Education Stabilization Fund ? Reporting Contact Person Responsible for Corrective Action: Kylie Enochs Contact Phone Number: (812) 659-1424 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Moving forward with the corporation?...
Finding 2022-002 ? Education Stabilization Fund ? Reporting Contact Person Responsible for Corrective Action: Kylie Enochs Contact Phone Number: (812) 659-1424 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Moving forward with the corporation?s ESF reporting, all data will be reviewed and have a formal sign-off, either by the superintendent or the other co-treasurer to ensure all data being reported is accurate. NOTE: The treasurer was in her first month in her position and was not a part of this filing. Moving forward, we are adjusting personnel to put the treasurer into the internal controls loop of the Title 1 program (which was responsible for filing the first ESF report. Anticipated Completion Date: Effective Immediately
FINDING 2022-005 Information on the federal program: Subject: Education Stabilization Fund - Annual Data Report Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listing Number: 84.425C, 84.425D, 84.425U Pass-Through Entity: Indiana Depa...
FINDING 2022-005 Information on the federal program: Subject: Education Stabilization Fund - Annual Data Report Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listing Number: 84.425C, 84.425D, 84.425U Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Material Weakness FINDING 2022?005 (Continued) Condition: The School Corporation did not have a documented review control in place to ensure the annual data report was reviewed by someone other than the preparer. Context: There was no documented review by someone other than the preparer of the Annual Data Report to ensure the information submitted was complete and accurate. Additionally, the School Corporation was not able to provide support for the total expenditures reported on the Year 1 Annual Report. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and will take the following corrective action ... Responsible party and timeline for completion: Brian L Christner, will ensure that all data reports and reviewed and signed by a third party. Completion date is April 30, 2023.
Finding 2022-004 Contact Person: Peter Gray Contact Phone: 765-775-5150 Views of Responsible Official: 1. There were no material cost issues in the overall report. There was a categorization error. This was discussed in Finding 2022-003. 2. The Revenue Loss expenditures were all valid personnel cost...
Finding 2022-004 Contact Person: Peter Gray Contact Phone: 765-775-5150 Views of Responsible Official: 1. There were no material cost issues in the overall report. There was a categorization error. This was discussed in Finding 2022-003. 2. The Revenue Loss expenditures were all valid personnel costs. Over 80% of the costs are police & fire. Other various city departments comprise the balance of the expenditure. We concur with the finding. Corrective Action: A. An additional layer of review has been initiated. The Director of Development is familiar with the requirements of the SLFRF guidance and will review and sign off on future reports. Anticipated Completion Date: 30 June 2022
CORRECTIVE ACTION PLAN December 2, 2022 We have prepared the following corrective action plan as required by the standards applicable to financial audits contained in Government Auditing Standards and by the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administr...
CORRECTIVE ACTION PLAN December 2, 2022 We have prepared the following corrective action plan as required by the standards applicable to financial audits contained in Government Auditing Standards and by the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Specifically, for each finding we are providing you with the names of the contact people responsible for corrective action, the corrective action planned, and the anticipated completion date. 2022-101 Reporting (Noncompliance, Significant deficiency) Recommendation: We recommend that reports are reviewed and approved by management team member who is not involved in the preparation. Action Taken: CCHCI will have a member of the management team who is not involved in the preparation of federal reports review and approve prior to submission. Contract person: Gary McPherran Completion date: December 31, 2022
Finding 2022 ? 001 Fiscal year in which the finding occurred: 2022 Pass-Through Entity, if pass-through or Federal Grantor Agency, if direct: Chicago Bar Foundation Contact Person(s) Responsible for Corrective Action: Whitney Trumble and Cassandra Lively Contact Phone Number: 312-922-6464 Status ...
Finding 2022 ? 001 Fiscal year in which the finding occurred: 2022 Pass-Through Entity, if pass-through or Federal Grantor Agency, if direct: Chicago Bar Foundation Contact Person(s) Responsible for Corrective Action: Whitney Trumble and Cassandra Lively Contact Phone Number: 312-922-6464 Status of Audit Finding: At the time of the audit, CCR had not received funds for three months of work as a subgrantee on the large federal grant that is the subject of this plan. The grantor was awaiting the federal contract extension and funds, and so did not have the funds to release. CCR received communication from the grantor that the extension and funds would be available soon, so we prepared a check for a vendor. Then, there was an extensive additional delay in receiving the funds, and CCR did not send the check because the contract had not yet been signed and funds could not be dispersed. The expense had been approved by the grantor and the work was underway during the delay in mailing the check. Corrective Action: As of June 2022, stricter internal controls have been implemented to ensure that any reimbursements listed on a grant invoice have been sent out to the vendor before submitting the report. A more formal review process has been implemented: CCR?s Executive Director will review and approve monthly grant reports via email. She will also review and approve supporting documentation for reach grant report. Approval (sent via email) will be kept with in a digital file with the reporting documentation. An additional internal control has been implemented to ensure that expenditures submitted for reimbursement are within the period of performance for the grant agreement. The Executive Director will monitor the grant expenses against the grant agreement, paying specific attention to the invoices at the end of the grant period, in order to ensure that the invoice is dated prior to the end of the grant agreement or most current amendment.
Finding No. 2022-001 Corrective Action Plan 1. Name of the contact person responsible for corrective action Brooks Champion- Controller 2. Corrective action planned Regional One Health will implement controls and processes to ensure all costs are manually reviewed and approved to ensure allowab...
Finding No. 2022-001 Corrective Action Plan 1. Name of the contact person responsible for corrective action Brooks Champion- Controller 2. Corrective action planned Regional One Health will implement controls and processes to ensure all costs are manually reviewed and approved to ensure allowability under the grant and that evidence of review is maintained. 3. Completion date November 1, 2022 4. If the client does not agree with the audit findings or believes corrective action is not required, include an explanation and specific reasons We agree with Finding No. 2022-001 5. The reference numbers the auditors assigned to the audit findings in the schedule of findings and questioned costs Finding No. 2022-001
Finding No. 2022-003 Corrective Action Plan 1. Name of the contact person responsible for corrective action Brooks Champion- Controller 2. Corrective action planned ROH will implement controls and processes to ensure program income is reviewed by those familiar with both the program and specifi...
Finding No. 2022-003 Corrective Action Plan 1. Name of the contact person responsible for corrective action Brooks Champion- Controller 2. Corrective action planned ROH will implement controls and processes to ensure program income is reviewed by those familiar with both the program and specifically the program income allocation methodology prior to submission and that evidence of review is maintained. 3. Completion date April 15, 2023 4. If the client does not agree with the audit findings or believes corrective action is not required, include an explanation and specific reasons We agree with Finding No. 2022-003 5. The reference numbers the auditors assigned to the audit findings in the schedule of findings and questioned costs Finding No. 2022-003
Finding No. 2022-002 Corrective Action Plan 1. Name of the contact person responsible for corrective action Brooks Champion- Controller 2. Corrective action planned ROH will implement controls and processes to ensure grant reports are reviewed prior to submission and that evidence of review is ...
Finding No. 2022-002 Corrective Action Plan 1. Name of the contact person responsible for corrective action Brooks Champion- Controller 2. Corrective action planned ROH will implement controls and processes to ensure grant reports are reviewed prior to submission and that evidence of review is maintained. 3. Completion date November 1, 2022 4. If the client does not agree with the audit findings or believes corrective action is not required, include an explanation and specific reasons We agree with Finding No. 2022-002 5. The reference numbers the auditors assigned to the audit findings in the schedule of findings and questioned costs Finding No. 2022-002
Finding 24845 (2022-002)
Significant Deficiency 2022
2022-002 Higher Education Emergency Relief Fund (HEERF) Reporting Recommendation: We recommend that the College review their reporting policies and procedures to ensure accurate and timely reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Act...
2022-002 Higher Education Emergency Relief Fund (HEERF) Reporting Recommendation: We recommend that the College review their reporting policies and procedures to ensure accurate and timely reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Although the student data for the September 30, 2021 report was gathered timely and accurately, the report was posted on-line three days late and had an error in the quarterly amount awarded. The College will provide a more careful review of all reporting both before and after posting to ensure timeliness and accuracy. Name(s) of the contact person(s) responsible for corrective action: Rich Killion, V.P. of Institutional Advancement; Stephanie Knight, Director of Enrollment Services; Sandi Rysell, Chief Financial Officer Planned completion date for corrective action plan: Completed. If the U.S. Department of Education has questions regarding this plan, please call Dale Herold, Vice President for Admissions and Enrollment Management, Beacon College, 855-220-5376, dherold@beaconcollege.edu.
Finding 24843 (2022-001)
Significant Deficiency 2022
2022-001 Awarding of Direct Loans and Pell Grants Recommendation: We recommend the College evaluate its policies and procedures for identifying transfer credits and other changes made after the initial packaging to ensure that federal awards are revised as needed. Explanation of disagreement with au...
2022-001 Awarding of Direct Loans and Pell Grants Recommendation: We recommend the College evaluate its policies and procedures for identifying transfer credits and other changes made after the initial packaging to ensure that federal awards are revised as needed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Beacon is implementing a new comprehensive software system (Jenzabar One) which ? paired with NetPartner and PowerFAIDS ?will better identify changes in student status. The system will also include InfoMaker software which the financial aid office will use to pull information needed to double check for late changes in student eligibility. Full implementation of the new software is now estimated to occur in December 2022. In the interim, enhanced procedures have been put in place by the Financial Aid Office to prevent further issues: a. Requesting an updated anticipated graduation list from the Registrar at the beginning of each term to confirm students are awarded appropriately b. Requesting a final graduation list from the Registrar at the end of each term to identify any students whose graduation plan has been delayed and making immediate adjustments to their aid eligibility, if needed. c. Performing a finalized review of all graduating students prior to the end of the academic year to ensure proper adjustments have been made. d. Requesting updated reports from the Registrar of any student receiving credit for transfer coursework prior to the start of each semester and making adjustments immediately to their aid eligibility; e. Prior to disbursement, a second review of all students is being performed to identify students whose grade-level conflicts with determination level for pending loans f. A final review prior to the end of each term is conducted so late adjustments can be made if needed. Name(s) of the contact person(s) responsible for corrective action: Daphne Parks, Vice President of Processing at FAS; Stephanie Knight, Director of Enrollment Services & Financial Aid, Beacon College; Carrie Santaw, Registrar, Beacon College Planned completion date for corrective action plan: Interim measures ? already implemented. Software implementation is scheduled to go live in December 2022.
View Audit 20958 Questioned Costs: $1
Finding 24837 (2022-004)
Significant Deficiency 2022
Finding No.: 2022-_ 004__ Condition: The District prepared analysis of the profitability of the food service program was not clerically accurate by a material amount. Plan: The profitability analysis will be reviewed by someone independent of the preparer to ensure that ...
Finding No.: 2022-_ 004__ Condition: The District prepared analysis of the profitability of the food service program was not clerically accurate by a material amount. Plan: The profitability analysis will be reviewed by someone independent of the preparer to ensure that all food service receipts and disbursements are included in the profitability analysis. Anticipated Date of Completion: 06/30/2023 Name of Contact Person: Adam Clapp Management Response: Management will implement the corrective action plan for the year ended June 30, 2023.
Finding 24826 (2022-002)
Significant Deficiency 2022
Finding No. 2022-002 Corrective Action Plan University Response: The University concurs with the finding concerning quarterly reporting of HEERF funds. Corrective Action: Rockhurst will conduct an additional review of the released guidance and reporting requirements to ensure compliance of any pub...
Finding No. 2022-002 Corrective Action Plan University Response: The University concurs with the finding concerning quarterly reporting of HEERF funds. Corrective Action: Rockhurst will conduct an additional review of the released guidance and reporting requirements to ensure compliance of any published, missing or future reports. In accordance with HEERF guidance, any reports with expenses that were incorrectly reported will be revised and publicly published, if applicable. Responsible Official: Kris Pace, Controller Anticipated Completion Date: June 30, 2023
Finding 24824 (2022-001)
Significant Deficiency 2022
Finding #2022-001- Segregation of Duties Criteria: Segregation of duties is an aspect of internal control intended to prevent or decrease opportunities of intentional and unintentional errors and fraud. Duties and responsibilities are properly segregated if no single individual either has control ov...
Finding #2022-001- Segregation of Duties Criteria: Segregation of duties is an aspect of internal control intended to prevent or decrease opportunities of intentional and unintentional errors and fraud. Duties and responsibilities are properly segregated if no single individual either has control over all phases of a transaction or can both make and conceal an error, whether such error is intentional or unintentional. Condition: A properly designed system of internal control includes adequate staffing, policies, and procedures to properly segregate duties. All internal control duties can be classified into four broad categories: authorization, custody, recordkeeping, and reconciliation. No one person should have control of two or more of these four categories for any one cycle. There are key controls related to significant transaction cycles that are important in reducing the risk of errors or irregularities. Currently, there are the following overlapping duties: - Both Accounting Specialists have the authority to enter invoices into the system, print checks, and have access to the electronic signatures. Preferably, the check cutting process would separate the entering of payment information into the system and the ability to print signed checks. - One Accounting Specialist creates deposits and makes deposits with the bank. Although not the standard procedure, the Accounting Specialist has the authority to collect cash receipts. Ideally, separate individuals would collect cash and make deposits. - The Housing Authority Executive Director opens the mail, creates deposits and takes deposits to the bank. The Executive Director also enters invoices into the system and prints checks. The Board of Commissioners approves disbursements and all checks require dual signatures. Effect: Errors or intentional fraud could occur and not be detected timely by other employees in the normal course of their responsibilities because of the lack of segregation of duties. Cause: Limited number of personnel. Recommendation: We recommend that the City consider the benefits of implementing additional policies and procedures to address key controls related to its significant transaction cycles as noted. Response: We agree with this finding but do not believe it is cost effective to increase personnel to bring about a more effective segregation of duties.
Finding 24783 (2022-059)
Significant Deficiency 2022
Finding 2022-059 Social Services Block Grant, ALN 93.667 - Post-Expenditure Report Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS revised its methodology to include Independent Living Services recipients in the Social Services Block Grant (SSBG) Post-Expenditure ...
Finding 2022-059 Social Services Block Grant, ALN 93.667 - Post-Expenditure Report Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS revised its methodology to include Independent Living Services recipients in the Social Services Block Grant (SSBG) Post-Expenditure Report. In addition, MDHHS revised and re-submitted the fiscal year 2022 SSBG Post-Expenditure Report with the correct recipient counts. Anticipated Completion Date Completed Responsible Individual(s) Emiliza Noel, MDHHS Tiffany Clarke, MDHHS Rebecca Jones, MDHHS
Finding 24737 (2022-058)
Significant Deficiency 2022
Finding 2022-058 Low Income Home Energy Assistance, ALN 93.568 - Annual Report on Households Assisted by LIHEAP Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS and DTMB plan to improve communication with Treasury to help ensure that accurate data is received prior t...
Finding 2022-058 Low Income Home Energy Assistance, ALN 93.568 - Annual Report on Households Assisted by LIHEAP Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS and DTMB plan to improve communication with Treasury to help ensure that accurate data is received prior to the report submission. MDHHS will also evaluate the Interagency Agreement and determine if changes are needed. In addition, DTMB is currently evaluating the cause of query inaccuracies and plans to make necessary changes to the query. Anticipated Completion Date MDHHS and DTMB will coordinate with Treasury to clarify when the data is needed for the report by July 31, 2023. MDHHS will evaluate and make changes to the fiscal year 2024 Interagency Agreement by September 30, 2023. DTMB will make necessary changes to the query by December 1, 2023. Responsible Individual(s) Denise Hawkins, DTMB Julie McLaughlin, MDHHS
Finding 24719 (2022-055)
Significant Deficiency 2022
Finding 2022-055 Temporary Assistance for Needy Families, ALN 93.558 - Accuracy of Financial Reports Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS will revise the financial reports for the quarters ending September 30, 2022, and December 31, 2022, and submit to t...
Finding 2022-055 Temporary Assistance for Needy Families, ALN 93.558 - Accuracy of Financial Reports Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS will revise the financial reports for the quarters ending September 30, 2022, and December 31, 2022, and submit to the U.S. Department of Health and Human Services Administration for Children and Families by May 15, 2023. MDHHS will also evaluate the internal control approval process and determine if any changes are needed. Anticipated Completion Date MDHHS will complete its evaluation of the internal control approval process by September 30, 2023, and will then develop a timeline for implementing changes identified during the evaluation, if applicable. Responsible Individual(s) Rebecca Jones, MDHHS Tiffany Clarke, MDHHS Emiliza Noel, MDHHS
Finding 24714 (2022-002)
Material Weakness 2022
Finding Number: 2022-002 Finding Title: Eligibility Program: 93.778 Medicaid Cluster Name of Contact Person Responsible for Corrective Action: Penny Messer, Health and Human Services Division Leader, and Karrie Kolb, Financial Assistance Supervisor Corrective Action Planned: The errors from this rev...
Finding Number: 2022-002 Finding Title: Eligibility Program: 93.778 Medicaid Cluster Name of Contact Person Responsible for Corrective Action: Penny Messer, Health and Human Services Division Leader, and Karrie Kolb, Financial Assistance Supervisor Corrective Action Planned: The errors from this review will be thoroughly discussed at the next all unit meeting. The Income Maintenance Supervisor plans to meet with each worker independently to review the errors and ensure understanding of policy and requirements, and a coaching plan will be implemented with each employee that had two or more case errors. Additionally, the Income Maintenance unit will conduct an average of 15 case reviews on a quarterly basis. Anticipated Completion Date: These actions were implemented on June 6, 2023, and the case reviews will begin in the third quarter of 2023, and be completed on an ongoing basis thereafter.
Finding 24685 (2022-001)
Material Weakness 2022
Guild
MN
Finding 2022-001 Federal Agency Name: Department of Housing and Urban Development, Passed through Hearth Connections Program Name: Continuum of Care CFDA # 14.267 Finding Summary: Identified five instances where the participant?s file did not have documentation that the rent reasonableness test was ...
Finding 2022-001 Federal Agency Name: Department of Housing and Urban Development, Passed through Hearth Connections Program Name: Continuum of Care CFDA # 14.267 Finding Summary: Identified five instances where the participant?s file did not have documentation that the rent reasonableness test was performed in a timely manner. In addition, we identified 19 instances where the participant?s file did not have documentation that the rent reasonableness test was reviewed. Creating Inadequate internal controls over compliance could result in noncompliance with the federal program. Responsible Individuals: Paul Bloomer, VP of Finance Corrective Action Plan: A complete review and policy and procedures along with proper training for new staff. The findings occurred during position vacancy and onboarding training. Additional steps are taken to ensure training is completed and random spot checks of client files. Anticipated Completion Date: Ongoing in nature.
Finding 24684 (2022-002)
Significant Deficiency 2022
Guild
MN
Finding 2022-002 Federal Agency Name: Department of Housing and Urban Development, Passed through Hearth Connections Program Name: Continuum of Care CFDA # 14.267 Finding Summary: Identified three months in which the reimbursement amount received from the pass-through entity was more than the Org...
Finding 2022-002 Federal Agency Name: Department of Housing and Urban Development, Passed through Hearth Connections Program Name: Continuum of Care CFDA # 14.267 Finding Summary: Identified three months in which the reimbursement amount received from the pass-through entity was more than the Organization?s documentation. In addition, there was no indication that a review was performed of the information submitted for one of the four months tested, which resulted in the reimbursement amount from the pass-through entity being more than the support maintained by the Organization for three of the 12 months and no documentation of the review for one of the months. Responsible Individuals: Paul Bloomer, VP of Finance Corrective Action Plan: Schedule meetings with 3rd party vendor to identify the significant rounding errors occurring. Develop an agreement on rounding procedures to be used by both parties ensuring reconciliation. Anticipated Completion Date: 12/31/23 ? Note- this system of reimbursement terminated on 3/31/23
Finding 24681 (2022-008)
Significant Deficiency 2022
Finding 2022-008 MiSACWIS Security Management and Access Controls Management Views MDHHS agrees with parts a., b., d., and e. of the finding. DTMB disagrees with part c. of the finding. For part c., although MDHHS and DTMB had not fully documented all database specific configuration standards unti...
Finding 2022-008 MiSACWIS Security Management and Access Controls Management Views MDHHS agrees with parts a., b., d., and e. of the finding. DTMB disagrees with part c. of the finding. For part c., although MDHHS and DTMB had not fully documented all database specific configuration standards until after the audit period, DTMB disagrees that during the audit period the system contained potentially vulnerable database configurations and disagrees that DTMB cannot ensure the security of the data. DTMB has been and continues to implement the manufacturer?s recommendations regarding security configurations. In addition, the databases reside in restricted trusted internal security zones, protected by firewalls, which are specific to each application and database, in conjunction with intrusion protection, antivirus software, and SOM standard security safeguards. Planned Corrective Action For parts a. and e., MDHHS will continue to provide training for LOSCs via quarterly webinars to emphasize the proper procedures for granting access and how to review and compare access to DSA approved requests. For part b., MDHHS will add an Incompatible Role form into the DSA Michigan Statewide Automated Child Welfare Information System (MiSACWIS) request with automated routing for appropriate approval. This would ensure that documentation was maintained, and appropriate approvals secured in all situations. For part c., DTMB developed an organization-wide framework for database security configuration management. For part d., MDHHS has implemented a quarterly report in MiSACWIS that will identify any financial authorization that was approved by the same person that created the authorization. Anticipated Completion Date a. and e. Corrective action is ongoing. b. MDHHS has not yet determined an anticipated completion date because implementation is dependent on funding, approval, and prioritization of proposed system changes. c. DTMB anticipates having compliance documentation by September 30, 2023. d. MDHHS will receive the first quarterly report on September 30, 2023, and will perform a review of the transactions identified on that report during October 2023. Responsible Individual(s) a., b., and e. Alana Lowe and Deon Nelson, MDHHS c. Heather Frick and Nathan Buckwalter, DTMB d. Alana Lowe, MDHHS
Finding 24674 (2022-026)
Significant Deficiency 2022
Finding 2022-026 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC), ALN 93.323 and Disaster Grants - Public Assistance (Presidentially Declared Disasters), ALN 97.036 - Long-Term Care (LTC) Facility COVID-19 Testing Reimbursements Management Views MDHHS agrees with the finding. ...
Finding 2022-026 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC), ALN 93.323 and Disaster Grants - Public Assistance (Presidentially Declared Disasters), ALN 97.036 - Long-Term Care (LTC) Facility COVID-19 Testing Reimbursements Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS will enhance written procedures to reflect the process in place to ensure that LTC facility COVID-19 testing reimbursement requests are reasonable and appropriate. MDHHS will also improve documentation of the procedures performed as part of the current process. Anticipated Completion Date MDHHS expects completion of the written procedures and improved documentation going forward by June 15, 2023. MDHHS expects to process all remaining payments for costs incurred during the PHE by September 30, 2023. Responsible Individual(s) Shannah Havens, MDHHS
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