Corrective Action Plans

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FINDING 2023-005 Finding Subject: Child Nutrition Cluster - Eligibility Summary of Finding: The School Corporation stated that 100% of Free/Reduced lunch applications were reviewed during the audit period. However, testing of controls indicated that 100% of Free/Reduced lunch applications were not b...
FINDING 2023-005 Finding Subject: Child Nutrition Cluster - Eligibility Summary of Finding: The School Corporation stated that 100% of Free/Reduced lunch applications were reviewed during the audit period. However, testing of controls indicated that 100% of Free/Reduced lunch applications were not being reviewed by an individual other than the individual making the initial determination. As a result, three of forty sampled students received the incorrect eligibility status in the system software when compared to supporting documentation (Direct Certifications and/or income-based applications). Contact Person Responsible for Corrective Action: Drew Cooper, Business Manager Contact Phone Number and Email Address: 765-425-7889 dcooper@shenandoah.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Currently all income based applications for free/reduced lunch status are processed by Pam Frost and then reviewed by the Business Manager. Beginning in the 2024-2025 school year Direct Certification students will also be reviewed by the Business Manager. Anticipated Completion Date: August 31, 2024
FINDING 2023-003 Finding Subject: Child Nutrition Cluster – Activities Allowed or Unallowed Summary of Finding: The School Corporation did not have internal controls in place over payroll disbursements charged to the food service program. Payroll disbursements were paid without evidence that the det...
FINDING 2023-003 Finding Subject: Child Nutrition Cluster – Activities Allowed or Unallowed Summary of Finding: The School Corporation did not have internal controls in place over payroll disbursements charged to the food service program. Payroll disbursements were paid without evidence that the detailed report of payroll disbursements was reviewed and approved by another person not involved in the original payroll process. Contact Person Responsible for Corrective Action: Drew Cooper, Business Manager Contact Phone Number and Email Address: 765-425-7889 dcooper@shenandoah.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Currently the Business Manager and Food Service Director hold a monthly financial meeting to review the status of finances for the Food Service. A review of the payroll distribution reports for the previous month will be added to the agenda of this meeting. Anticipated Completion Date: March 31, 2024
• Finding 2023-003 – Compliance and Significant Deficiency in Internal Control over compliance with Special Tests and Provisions o U.S. Department of Housing and Urban Development o Agency Response: Concurs with audit findings. o Corrective Action Plan: MHA uses the official HUD COC Rent Determinat...
• Finding 2023-003 – Compliance and Significant Deficiency in Internal Control over compliance with Special Tests and Provisions o U.S. Department of Housing and Urban Development o Agency Response: Concurs with audit findings. o Corrective Action Plan: MHA uses the official HUD COC Rent Determination worksheets, as well as an external vendor (Affordable Housing Network) to establish that reasonable rents are charged for comparable apartments. Worksheets are now updated annually and verified by the Director of Corporate Compliance. The Assistant Director of Housing and Care Coordination will notify all staff responsible for administering HUD programs of the changes and train those staff accordingly. The external contract was established in mid-2024, and is still being used. o Person Responsible: Director of Corporate Compliance. o Date of Completion: June 10, 2024.
Recommendation: We recommend that management implement processes to ensure timely completion and submission of the Single Audit report in future years. This could include setting internal deadlines, increasing oversight, and coordinating with the audit firm to identify and address potential delays e...
Recommendation: We recommend that management implement processes to ensure timely completion and submission of the Single Audit report in future years. This could include setting internal deadlines, increasing oversight, and coordinating with the audit firm to identify and address potential delays earlier in the audit process. Action Taken: Management agrees with the finding and will take steps to improve the timeliness of the audit process. Anticipated completion date: June 30, 2025 Name of contact person and title: Jeffrey Seymour, President / CEO
Management is actively working on retaining and recruiting knowledgeable personnel in the finance and account department to enhance the department's effectiveness and efficiency. OCAB has established agreements with account professionals to improve the training and efficiency of staff in the fiscal...
Management is actively working on retaining and recruiting knowledgeable personnel in the finance and account department to enhance the department's effectiveness and efficiency. OCAB has established agreements with account professionals to improve the training and efficiency of staff in the fiscal office, focusing on areas such as financial compliance, daily fiscal responsibilities month end closing and budget analysis. OCAB as slso hired 2 fiscal personnel in this department. We believe significant progress has been made since the last reorting period. A wage and benefits was completed and utilized in the process. OCAB believes that the measures taken will ensure compliance with all department of Health & Human Services regulations.
In alignment with this audit finding, Illuminate Colorado has implemented processes to improve working capital and address cash flow challenges, including:  improved invoicing procedures to ensure timely submission of invoices to minimize time elapsed between submission of invoices to funders and r...
In alignment with this audit finding, Illuminate Colorado has implemented processes to improve working capital and address cash flow challenges, including:  improved invoicing procedures to ensure timely submission of invoices to minimize time elapsed between submission of invoices to funders and reimbursement of those invoices, and  seeking increased working capital via a larger line of credit or other source (foundation, corporate, or individual donations) In addition, Illuminate Colorado is in process of developing a Standard Operating Procedure to ensure consistent identification of vendors utilized for direct Federal assistance programs in order to prioritize payment of those vendors with federal drawdown receipts. Standard Operating Procedure will include:  Process to identify vendors paid with federal funds  Process to monitor invoice timelines of vendors paid with federal funds  Process to prioritize payments of vendors paid with federal funds following federal drawdowns  Process for internal review of payment timelines
We concur that the Fire Department did not submit the Performance Progress Report by the due date. When the County Grants Manager realized the report was not filed, it was corrected immediately and filed June 22, 2023. A dedicated Grants Division was recently established within the finance departmen...
We concur that the Fire Department did not submit the Performance Progress Report by the due date. When the County Grants Manager realized the report was not filed, it was corrected immediately and filed June 22, 2023. A dedicated Grants Division was recently established within the finance department during the second quarter of 2023 and has started the proper management of federal grants and reporting. In 2024, the Grants Division commenced full oversight of the entire grant lifecycle which included closeout. The Grants Division will closely monitor grant spending, compliance, record-keeping, budgeting, and financial oversight.
Plan: To ensure accurate entry of all invoices, the CFO performs a thorough monthly review and reconciliation of the General Ledger accounts. Anticipated Date of Completion: 4/26/2025 Name of Contact Persons: Ieesha Jones Management Response: During the 2023 audit, the new CFO and management iden...
Plan: To ensure accurate entry of all invoices, the CFO performs a thorough monthly review and reconciliation of the General Ledger accounts. Anticipated Date of Completion: 4/26/2025 Name of Contact Persons: Ieesha Jones Management Response: During the 2023 audit, the new CFO and management identified system issues, noting that certain reports had calculation errors in the 2023 financials. However, the 2024 financials now reflect accurate reporting, thanks to the implementation of improved systems designed to address and prevent such issues.
The Municipality will take all necessary administrative measures to promptly address and correct the situation. I will instruct the Finance Department to submit all required financial information promptly to our financial consultant and external auditor to meet the deadline for submitting the Singl...
The Municipality will take all necessary administrative measures to promptly address and correct the situation. I will instruct the Finance Department to submit all required financial information promptly to our financial consultant and external auditor to meet the deadline for submitting the Single Audit Report for the year 2024. Expected completion date : April 30, 2026.
The College will develop and followed detailed controls over grants, federal requirements accomplished by 6‐1‐2025.
The College will develop and followed detailed controls over grants, federal requirements accomplished by 6‐1‐2025.
The College will continue to liquidate Perkins loans and verify all information received from the loan servicer is accurate. A reconcile of the information will be reviewed upon receiving this information from the loan servicer. This will be accomplished by 8/31/24.
The College will continue to liquidate Perkins loans and verify all information received from the loan servicer is accurate. A reconcile of the information will be reviewed upon receiving this information from the loan servicer. This will be accomplished by 8/31/24.
Recommendation: We recommend that the Agency reviews the controls in place to ensure that earmarking requirements are met. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To prevent a recurrence of the issue, we ...
Recommendation: We recommend that the Agency reviews the controls in place to ensure that earmarking requirements are met. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To prevent a recurrence of the issue, we began implementing a corrective action plan. A comprehensive review of current processes and internal controls related to earmarking requirements will be conducted by the Program Manager. Based on the findings of the review, policies and procedures will be updated to clearly define responsibilities and steps necessary to ensure compliance with earmarking requirements. Targeted training will be provided to relevant staff to ensure understanding of earmarking requirements and updated procedures. Regular monitoring and periodic internal compliance reviews will be implemented to ensure continued adherence to earmarking rules. Name(s) of the contact person(s) responsible for corrective action: Christine Weichert, Director of Development Planned completion date for corrective action plan: December 31, 2025
View Audit 354004 Questioned Costs: $1
Management recognizes its compliance requirements for maintaining and implementing sound controls over financial reporting and the potential non-compliance impacts of a lack of such control environment. Leadership is currently considering options for adequate oversight and review. Until such time th...
Management recognizes its compliance requirements for maintaining and implementing sound controls over financial reporting and the potential non-compliance impacts of a lack of such control environment. Leadership is currently considering options for adequate oversight and review. Until such time that adequate staffing for review is in place, a member of management or their designee will develop and maintain a tickler list of all reporting requirements and due dates to ensure all reports are submitted timely.
Finding 555180 (2023-002)
Significant Deficiency 2023
We will utilize new software to automate the preparation and compilation of audit reports and compliance reports, streamlining the entire process and reducing the likelihood of delays. We will establish a centralized document management system with robust retention protocols. This system will ensure...
We will utilize new software to automate the preparation and compilation of audit reports and compliance reports, streamlining the entire process and reducing the likelihood of delays. We will establish a centralized document management system with robust retention protocols. This system will ensure that all relevant documents and information required for the reports are readily accessible and properly maintained, minimizing delays caused by searching for necessary materials. We will institute a schedule for regular reviews and monitoring of the reporting process. This will involve conducting periodic assessments to identify any bottlenecks or potential issues that could lead to delays, allowing for proactive intervention and resolution. By implementing these measures, we aim to mitigate the risk of late filing of the audit report, thereby enhancing compliance with regulatory requirements and ensuring timely and accurate reporting.
Finding 555151 (2023-008)
Significant Deficiency 2023
Views of Responsible Officials: Based on this audit finding, SAMU agreed addressing the following: 1. Implement a formal review and approval process for program reports, including documentation of reviewer's name and date. 2. Establish a system to retain internal documentation of report submission d...
Views of Responsible Officials: Based on this audit finding, SAMU agreed addressing the following: 1. Implement a formal review and approval process for program reports, including documentation of reviewer's name and date. 2. Establish a system to retain internal documentation of report submission dates. 3. Develop a reporting calendar with internal deadlines for report preparation and review. 4. Designate specific individuals responsible for report preparation, review, and submission.
Finding 555148 (2023-005)
Significant Deficiency 2023
Views of Responsible Officials: SAMU management has ordered that all SAMU staff that corresponds with grantor personnel has to document such correspondence via emails or other means the afreed procedures including those of delayed submission of drawdowns.
Views of Responsible Officials: SAMU management has ordered that all SAMU staff that corresponds with grantor personnel has to document such correspondence via emails or other means the afreed procedures including those of delayed submission of drawdowns.
Finding 555146 (2023-003)
Significant Deficiency 2023
Views of Responsible Officials: SAMU has finalized comprehensive Logistics and procurement policy that covers the credit cards policy and the respective treatment and control for approvals. A comprehensive corrective action plan has been greed it addresses: 1. Establishment of a documented review pr...
Views of Responsible Officials: SAMU has finalized comprehensive Logistics and procurement policy that covers the credit cards policy and the respective treatment and control for approvals. A comprehensive corrective action plan has been greed it addresses: 1. Establishment of a documented review process with clear timelines 2. Training program for staff on federal cost principles and internal procedures 3. Regular monitoring and internal audit procedures By implementing these measures, SAMU emphasizes the importance of strengthened internal controls, ensure compliance with federal regulations, and mitigate the risk of charging unallowable costs to federal awards.
The Department has ramped up recruiting efforts by advertising positions on external websites such as indeed. The accounting department has recently increased the wages of existing staff and the starting wages of all positions in an effort to attract and retain qualified staff.
The Department has ramped up recruiting efforts by advertising positions on external websites such as indeed. The accounting department has recently increased the wages of existing staff and the starting wages of all positions in an effort to attract and retain qualified staff.
Material Weakness in Compliance and Internal Control over Compliance Recommendation: CLA recommends that additional emphasis of documentary evidence of approvals be made, and such evidence is retained by ICEDC as proof of oversight of expenditure of federal funds. Additionally, we recommend adding ...
Material Weakness in Compliance and Internal Control over Compliance Recommendation: CLA recommends that additional emphasis of documentary evidence of approvals be made, and such evidence is retained by ICEDC as proof of oversight of expenditure of federal funds. Additionally, we recommend adding a review and approval process for the ED’s timesheets. There is no disagreement with the audit finding. Action taken in response to finding: ICEDC appreciates CLA’s recommendation to enhance processes concerning the retention of documentary evidence of approvals and importance of maintaining strong oversight of expenditures, especially when handling federal funds. ICEDC will place greater emphasis on obtaining and retaining documentation of approvals related to the expenditure of funds. This documentation will serve as proof of oversight, ensuring compliance with federal regulations and enhancing transparency in fund management. A formal review and approval process will be established for the Executive Director's (ED’s) timesheets. This process will involve periodic reviews by a designated authority and documentation will be retained to maintain a clear audit trail. Name(s) of the contact person(s) responsible for corrective action: Kristina Hines Planned completion date for corrective action plan: 8/31/2025
View Audit 353072 Questioned Costs: $1
Finding 554151 (2023-019)
Significant Deficiency 2023
The CDSS’ Disability Determination Services Division (DDSD) has implemented corrective measures to address inaccuracies in the Modernized Integrated Disability Adjudicative System (MIDAS) and Disability Case Processing System (DCPS) invoice review processes. This includes an internal quality control...
The CDSS’ Disability Determination Services Division (DDSD) has implemented corrective measures to address inaccuracies in the Modernized Integrated Disability Adjudicative System (MIDAS) and Disability Case Processing System (DCPS) invoice review processes. This includes an internal quality control process to monitor and review additional invoice samples from Branches after they have been processed and reviewed by Branch Program Technicians and Branch Auditors. Additionally, the DDSD Central Support Services Branch implemented a secondary audit process and created a new Auditor role to routinely sample additional Medical Evidence of Record (MER) and Consultative Examination (CE) contracts. Findings are provided to branches to reinforce accuracy and assure compliance. The DDSD, also transitioned from MIDAS to DCPS, which provides more sophisticated fiscal controls. To remediate any inaccuracies, DDSD’s centralized auditor will assess findings and develop an action plan to prevent erroneous invoices. The CDSS ensures that all necessary controls are in place to verify the accuracy and proper documentation of invoices. The CDSS concludes that the sample size of 15 MER cases does not provide sufficient audit evidence that controls are not operating effectively resulting in a calculated $54,398 in potential costs. However, CDSS agrees with the finding and is committed to the control and mitigation of risk related to the audit recommendation. Estimated Implementation Date: Implemented Contact: Bernice Stanfield, Fiscal and Procurement Section Chief Central Support Services Branch Disability Determination Service Division California Department of Social Services
View Audit 352774 Questioned Costs: $1
CDPH is addressing the findings of the audit through a combination of outreach and training for internal stakeholders, updated internal policies, and data verification to ensure proper review and approval of the Form CMS-1539. Estimated Implementation Date: April 2025 Contact: Nate Gilmore, Branch ...
CDPH is addressing the findings of the audit through a combination of outreach and training for internal stakeholders, updated internal policies, and data verification to ensure proper review and approval of the Form CMS-1539. Estimated Implementation Date: April 2025 Contact: Nate Gilmore, Branch Chief Center for Health Care Quality California Department of Public Health
The CDSS agrees with the finding. The Child Care and Development Division's Program Quality Improvement Branch (PQIB) recognized the need for tracking monitoring procedures starting from risk assessment identification to closing out of Continuous Improvement Plans (CIP) to ensure that contractors wi...
The CDSS agrees with the finding. The Child Care and Development Division's Program Quality Improvement Branch (PQIB) recognized the need for tracking monitoring procedures starting from risk assessment identification to closing out of Continuous Improvement Plans (CIP) to ensure that contractors with the highest risk factors are prioritized and agencies requiring follow up received a CIP. • Tracking Use of the Risk Assessment: Annually, the PQIB identifies risk criteria for the upcoming Fiscal Year (FY) monitoring through the Contract Monitoring Protocols Agreement document. Using the Consultant Caseload Cohorts spreadsheet staff identify the agencies they will monitor using the FY Monitoring Priorities criteria (risk assessment criteria). The PQIB Travel Team and Administrators review the monitoring schedules for each consultant to ensure the risk assessment criteria has been followed. The risk assessment criteria are reviewed and updated annually based on trends and support needs of the field. In FY 2023-2024 PQIB implemented a cohort review cycle to apply the risk assessment criteria to all contracted programs subject to monitoring reviews. • Maintaining Monitoring Reports: Each Contract Monitoring Report includes a “Monitoring Summary Page” containing all items reviewed during a Contract Monitoring Review (CMR). Any item from the Program Integrity Monitoring Tool identified during a review as unmet and/or identified for a CIP is automatically tracked by the analysts for follow-up and resolution. A spreadsheet with all the reviews scheduled for any contract monitoring visit are maintained by FY and the findings are recorded for each item on the tool. The PQIB analysts track the review dates, reports, findings, and CIPs. The analysts meet with the administrators monthly to track missing reports. All reports are filed by individual agency. • Continuous Improvement Plan (CIP): The PQIB analysts use the Contract Monitoring Report to determine if a CIP is required. A standard CIP template was developed, and all staff are required to use the same document. Every CIP has a 45-day corrective action period; however, programs may be granted extensions if requested in writing. Programs can request up to an additional 180 days to complete corrective actions. To receive an extension, a plan must be submitted in writing detailing how the program will address the actions by the end of the extension period. The PQIB analyst conducts follow-up with the consultant until the CIP is received. The CIP is not closed until all items identified for corrective action are resolved. A completed CIP and Resolution Letter are sent to the contractor and filed in the Common Folder in the agency’s folder. All spreadsheets, agreements, forms, and records of completed monitoring reports referenced above are maintained in the Common Folder and on the PQIB SharePoint page. Furthermore, CDSS is actively working to fully adopt audit report monitoring responsibilities of Local Education Agencies (LEA) and certain non-LEAs receiving Child Care and Development Fund (CCDF) Cluster program funds by July 1, 2025. Estimated Implementation Date: July 1, 2025 Contact: Jeff Fowler, Staff Services Manager III Child Care and Development Program California Department of Social Services
View Audit 352774 Questioned Costs: $1
The CDSS has sufficient internal controls for the Federal Fiscal Year (FFY) 2022 grants onward. The CDSS was not the lead agency for the FFY 2020 and 2021 grants. During those years, the California Department of Education (CDE) held the responsibilities as the lead agency and had custody of the gran...
The CDSS has sufficient internal controls for the Federal Fiscal Year (FFY) 2022 grants onward. The CDSS was not the lead agency for the FFY 2020 and 2021 grants. During those years, the California Department of Education (CDE) held the responsibilities as the lead agency and had custody of the grants. As such, CDSS cannot be held accountable for the reports submitted by CDE. The CDSS is unable to validate or provide commentary on the data or information reported by CDE for those periods. The CDSS is the lead agency for FFY 2022 grants onward and has assumed full responsibilities for all related procedures, including the review, preparation, and submission of quarterly reports with complete and accurate information. The CDSS is diligently monitoring and managing the process to ensure that future reconciliations are conducted with the utmost accuracy and timeliness. The CDSS is also collaborating closely with all relevant stakeholders to ensure that the current data is thoroughly verified and aligned. The CDSS maintains comprehensive documentation supporting all expenditures, including the Schedule of Expenditures of Federal Awards (SEFA) report. Furthermore, CDSS has strengthened our internal checks and improved communication with all involved parties to mitigate the risk of issues arising in future reconciliations. Estimated Implementation Date: Implemented Contact: Daniel During, Federal Reporting Section Chief Accounting and Fiscal Systems Branch Finance and Accounting Division California Department of Social Services
Finding 554135 (2023-018)
Significant Deficiency 2023
DHCS recently implemented and instructed all staff on an improved leave management and timesheet submission process, effective November 20, 2024, beginning with the December 2024 pay period. The change addresses the recommendations from CSA by streamlining the submission, review, and storage of empl...
DHCS recently implemented and instructed all staff on an improved leave management and timesheet submission process, effective November 20, 2024, beginning with the December 2024 pay period. The change addresses the recommendations from CSA by streamlining the submission, review, and storage of employee timesheets, ensuring efficient and transparent management of time-related data across DHCS. Furthermore, the new process ensures a manager or supervisor reviews and approves all timesheets before submission. Estimated Implementation Date: November 20, 2024 Contact: California Department of Health Care Services • Primary – Erika Cristo Assistant Deputy Director, Behavioral Health • Secondary – Wendy Rasmussen, Chief, Office of Compliance - Internal Audits
Finding 554133 (2023-017)
Significant Deficiency 2023
Public Health’s Office of AIDS (OA) agrees with the finding and recommendation. OA introduced and fully implemented an internal Secondary Review (SR) process for all AIDS Drug Assistance Program (ADAP) applications in March 2018. This SR process enables ADAP staff to verify that contracted and certi...
Public Health’s Office of AIDS (OA) agrees with the finding and recommendation. OA introduced and fully implemented an internal Secondary Review (SR) process for all AIDS Drug Assistance Program (ADAP) applications in March 2018. This SR process enables ADAP staff to verify that contracted and certified enrollment workers across California are consistently adhering to eligibility and documentation requirements. However, due to staffing challenges caused by the redirection of staff during the state of emergency declared for the COVID-19 pandemic, ADAP faced significant workforce shortages from March 2020 through much of 2023. This caused a backlog in SR processing, which delayed tasks, including the review of this client’s application. The client’s eligibility lapsed after 130 days, before SR could be conducted. The Eligibility Operations Section (EOS) of ADAP which conducts SR, is now fully staffed and has successfully addressed the backlog. As of early 2024, SR processing has returned to normal operations and is current. Estimated Implementation Date: Already implemented as of April 2024 Contact: Joseph Lagrama, ADAP Branch Chief California Department of Public Health
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