Corrective Action Plans

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Project Legal Name: Catherine Booth Friendship House Residence, Inc., A Texas Corporation HUD Project No.: 113-EE021 Audit Firm: CohnReznick LLP Period covered by the audit: 10/1/2022-9/30/2023 Corrective Action Plan prepared by: Name: Sriparna Mitra Position: HUD Specialist, THQ (Legal) Telephone N...
Project Legal Name: Catherine Booth Friendship House Residence, Inc., A Texas Corporation HUD Project No.: 113-EE021 Audit Firm: CohnReznick LLP Period covered by the audit: 10/1/2022-9/30/2023 Corrective Action Plan prepared by: Name: Sriparna Mitra Position: HUD Specialist, THQ (Legal) Telephone Number: 404-728-6700 The following is a recommended format to be followed by the auditee for preparing a corrective action plan: A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2023-001 a. Comments on the Finding and Each Recommendation Management agrees with the finding and is taking steps to address the issue that caused it. b. Action(s) Taken or Planned on the Finding Management is reaching out to HUD for retroactive approval of the repayments and will implement procedures to ensure HUD approval is obtained in the future, if needed. B. Status of Corrective Actions on Findings Reported in the Schedule of the Status of Prior Audit Findings, Questioned Costs and Recommendations 1. Finding 2022-001 Resolved. See finding 2023-001
View Audit 310457 Questioned Costs: $1
Managements Planned Corrective Action: The Executive Director, Jamie Satterfield will review all statements received and match detailed invoices to the statements prior to a check being prepared for payment. That detail will be made available to the Board member designated to co-sign the checks pr...
Managements Planned Corrective Action: The Executive Director, Jamie Satterfield will review all statements received and match detailed invoices to the statements prior to a check being prepared for payment. That detail will be made available to the Board member designated to co-sign the checks prior to distribution. Payment should be withheld until adequate documentation is obtained from the employee initiating the purchase.
Reporting Requirements: Chief Dull Knife College will continue to review reporting requirements for all grants received. HEERF reports were posted to the College’s website, but the third quarter 2023 report was posted in the Financial Section rather than the IHE’s activities section. This procedur...
Reporting Requirements: Chief Dull Knife College will continue to review reporting requirements for all grants received. HEERF reports were posted to the College’s website, but the third quarter 2023 report was posted in the Financial Section rather than the IHE’s activities section. This procedure is being corrected and will be reviewed for all grants.
Even though prevailing wage was paid, contract was bid and awarded as such, in the future, the Treasurer will ensure that prevailing wage rate requirements of necessary clauses are included within all applicable contracts.
Even though prevailing wage was paid, contract was bid and awarded as such, in the future, the Treasurer will ensure that prevailing wage rate requirements of necessary clauses are included within all applicable contracts.
ASSISTANCE LISTING 93.569 – COMMUNITY SERVICES BLOCK GRANT FEDERAL GRANT AWARD NUMBERS: 2101TXCOSR AND 2201TXCOSR PASS-THROUGH ENTITY IDENTIFYING NUMBERS: 61220003647 AND 61230003800 FINDING NO. 2023-002: ALLEGED USE OF FEDERAL FUNDS IN FRAUDULENT MANNER Planned Corrective Action Plan: The Organizat...
ASSISTANCE LISTING 93.569 – COMMUNITY SERVICES BLOCK GRANT FEDERAL GRANT AWARD NUMBERS: 2101TXCOSR AND 2201TXCOSR PASS-THROUGH ENTITY IDENTIFYING NUMBERS: 61220003647 AND 61230003800 FINDING NO. 2023-002: ALLEGED USE OF FEDERAL FUNDS IN FRAUDULENT MANNER Planned Corrective Action Plan: The Organization is committed to combatting fraud by creating an organizational culture and structure conducive to focusing on control activities, fraud-awareness initiatives, reporting mechanisms and employee integrity activities including:Revise programmatic and departmental approval authority-related guidelines designed to counter the previously encountered fraud schemes. • Maximize the functionality of the existing client software systems (e.g., NewGen and Fastrack) to minimize the dependency on external documents. • Use multiple methods to reinforce key antifraud messages through education and training on an ongoing basis to increase managers’ and employees’ awareness of potential fraud schemes. • Provide a hotline and other options for potential reporters of fraud to communicate and ensure that the Organization’s stakeholders (e.g., employees, vendors, program beneficiaries, and the public) are aware of the Organization’s access points to report potential fraud. • Implement mandatory virtual conflict of interest trainings. • Develop a board-approved policy regarding the Organization’s employees receiving services. • Revise the Conflict-of-Interest Policy in the Employee Handbook to serve as a coaching guide that clearly conveys that anyone in the Organization may develop a conflict of interest, whether they are entry-level or a member of the leadership team. Anticipated Implementation Date: December 31, 2024 Contact Person Responsible for Corrective Action: Dr. Jonita Reynolds, Chief Executive Officer
View Audit 310350 Questioned Costs: $1
City of Madison Fire Department will coordinate with the City of Madison, Internal Audit and Grants function of the Finance Department, for an independent person to review the reports before submission to ensure the loss revenue calculation and amounts reported are accurate. This additional internal...
City of Madison Fire Department will coordinate with the City of Madison, Internal Audit and Grants function of the Finance Department, for an independent person to review the reports before submission to ensure the loss revenue calculation and amounts reported are accurate. This additional internal control procedure will ensure there are proper review and approval processes over completeness and accuracy of reports before submissions to federal agencies.
The Authority will attain weekly certified payrolls from contractors as applicable for all federally funded contracts subject to the Davis-Bacon Act. The Authority’s Executive Director, Erial Branch, has assumed the responsibility of executing this corrective action as of August 1, 2024.
The Authority will attain weekly certified payrolls from contractors as applicable for all federally funded contracts subject to the Davis-Bacon Act. The Authority’s Executive Director, Erial Branch, has assumed the responsibility of executing this corrective action as of August 1, 2024.
Response/Views: We agree with the finding and have already put actions in place to correct it. Corrective Action Planned: We have notified current Architects, Engineers, and General Contractors regarding the compliance with the Davis Bacon Act. In fact, some have already provided Addendums to our cu...
Response/Views: We agree with the finding and have already put actions in place to correct it. Corrective Action Planned: We have notified current Architects, Engineers, and General Contractors regarding the compliance with the Davis Bacon Act. In fact, some have already provided Addendums to our current contracts or have agreed to do so. Anticipated Completion Date: This has been initiated and anticipated to be completely complied with by September 30,2024 Contact Person(s): Mr. Chad Anderson, Executive Director of Operations Mr. Arthur Watts, Chief School Financial Officer
View Audit 310222 Questioned Costs: $1
Finding 2023-006: Crime Victim Assistance Documented Review and Approval Procedures U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20232575-00, E20233017-00, E20233431-00 Award Year End: Septemb...
Finding 2023-006: Crime Victim Assistance Documented Review and Approval Procedures U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20232575-00, E20233017-00, E20233431-00 Award Year End: September 30, 2023 Recommendation: The Organization should establish procedures to require the documented review and approval of all indirect cost calculations, cash management requests for funds, and reports by an individual with adequate skills, knowledge, and experience prior to submission. Action Taken: The Organization will establish the necessary policies and procedures to require the documented review and approval of all indirect calculations, cash management requests for funds and performance reports on a monthly basis prior to submission with documented approval. Responsible Person and Anticipated Completion Date: The Executive Director will oversee the implementation of this plan by September 30, 2024.
Finding 2023-005: MATERIAL WEAKNESS—Uniform Guidance Written Internal Control Procedures U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20232575-00, E20233017-00, E20233431-00 Award Year End: Sep...
Finding 2023-005: MATERIAL WEAKNESS—Uniform Guidance Written Internal Control Procedures U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20232575-00, E20233017-00, E20233431-00 Award Year End: September 30, 2023 Recommendation: The Organization should establish procedures to require the documented review and approval of all indirect cost calculations, cash management requests for funds, and reports by an individual with adequate skills, knowledge, and experience prior to submission. Action Taken: The Organization will establish the necessary policies and procedures for managing its federal awards in compliance with federal requirements. Responsible Person and Anticipated Completion Date: The Executive Director will oversee the implementation of this plan by September 30, 2024.
American Diabetes Association (ADA) is committed to ensuring the appropriate documentation is in place to adhere to federal regulations regarding activities allowed or unallowed and allowable costs. In response to the audit finding, ADA is taking the following corrective actions to address the audit...
American Diabetes Association (ADA) is committed to ensuring the appropriate documentation is in place to adhere to federal regulations regarding activities allowed or unallowed and allowable costs. In response to the audit finding, ADA is taking the following corrective actions to address the audit recommendations: 1) Financial Services will communicate annual reminders of the existing policy relating toweekly completion and manager review of time records to all ADA team members. 2) Federal grant program management will perform weekly monitoring of all time recordsapplicable to federal awards to ensure that time is reviewed and approved by a manager with knowledge of staff activities so that ADA conforms to federal regulations regardingactivities allowed or unallowed and allowable costs. 3) Financial Services will execute a reimbursement request only once all time is reviewed and approved by a manager with knowledge of staff activities.
Corrective Action: Additional training for Registrar staff is in progress to include a full review of processes and controls related to monthly Student Information System – Clearinghouse – NLSDS reconciliation. This review includes a review of how program start dates (semester and session) vs. cours...
Corrective Action: Additional training for Registrar staff is in progress to include a full review of processes and controls related to monthly Student Information System – Clearinghouse – NLSDS reconciliation. This review includes a review of how program start dates (semester and session) vs. course starts affect reporting, as well as how multiple student status changes to registration affect reporting. The College’s third-party servicer, National Student Clearinghouse, is assisting in this training to include the update of policies, processes, and controls, as well as the maintenance of evidentiary documentation. Contact Person: Lori Arnder, Registrar & Enrollment Manager Anticipated Completion Date: July 31, 2024
Corrective Action: A monthly reconciliation process has been put into place to include control reporting of all status changes to ensure accuracy and timeliness of student status changes from the college’s student information system to National Student Clearinghouse to NSLDS. Contact Person: Lori Ar...
Corrective Action: A monthly reconciliation process has been put into place to include control reporting of all status changes to ensure accuracy and timeliness of student status changes from the college’s student information system to National Student Clearinghouse to NSLDS. Contact Person: Lori Arnder, Registrar & Enrollment Manager Anticipated Completion Date: July 1, 2024
Finding 403020 (2023-001)
Significant Deficiency 2023
Federal Program Information Federal Agency: United States Department of Education Federal Cluster: Student Financial Assistance Assistance Listing No.: 84.268, Federal Direct Student Loans (Direct Loans) Award Periods: July 1, 2022 through June 30, 2023; July 1, 2023 through June 30, 2024 Correctiv...
Federal Program Information Federal Agency: United States Department of Education Federal Cluster: Student Financial Assistance Assistance Listing No.: 84.268, Federal Direct Student Loans (Direct Loans) Award Periods: July 1, 2022 through June 30, 2023; July 1, 2023 through June 30, 2024 Corrective Action Planned Annually, tests of access to Business Objects and properly authorized changes made to the logic within Business Objects specific to the disbursement report used by management will be conducted. Testing will be performed initially by Mayo Clinic’s internal audit team and in subsequent years by the Financial Aid Director and Director of Data Analytics. Persons Responsible for Corrective Action Anne Dahlen, Director of Student Financial Aid Aaron Pendl, Director of Data Analytics Target Completion Date November 30, 2024
Finding 402904 (2023-002)
Material Weakness 2023
Federal Program Information Federal Agencies: U.S. Department of Health and Human Services and U.S. Department of Defense Pass-Through Entities: Georgia Institute of Technology, Massachusetts General Hospital, NYU Grossman School of Medicine, University of Chicago, University of Michigan, and Washin...
Federal Program Information Federal Agencies: U.S. Department of Health and Human Services and U.S. Department of Defense Pass-Through Entities: Georgia Institute of Technology, Massachusetts General Hospital, NYU Grossman School of Medicine, University of Chicago, University of Michigan, and Washington University Federal Cluster: Research and Development (R&D) Assistance Listing Nos.: 12.300, 12.420, 93.233, 93.273, 93.279, 93.310, 93.350, 93.393, 93.395, 93.396, 93.397, 93.837, 93.838, 93.846, 93.847, 93.853, 93.855, 93.865, and 93.866 Award Numbers: Various Award Periods: Various Corrective Action Planned Management implemented revisions to the monthly/quarterly review packet in January 2024 to ensure review of internal service charges and retention of review documentation. Management's expectations have been communicated to those responsible for the control process regarding timely reviews and retention of documentation. Persons Responsible for Corrective Action Susan Norby, Division Chair - Financial and Accounting Services, Research Finance Sarah Ward, Vice Chair - Financial and Accounting Services, Research Finance Target Completion Date January 31, 2024
Findings Related to the Financial Statements Reported in Accordance with Government Auditing Standards None Findings Related to Federal Awards 2023-001 Activities Allowed or Unallowed and Allowable Costs/Cost Principles Federal Agency: U.S. Department of Homeland Security: Passed through the Sta...
Findings Related to the Financial Statements Reported in Accordance with Government Auditing Standards None Findings Related to Federal Awards 2023-001 Activities Allowed or Unallowed and Allowable Costs/Cost Principles Federal Agency: U.S. Department of Homeland Security: Passed through the State of New Jersey, Department of Law and Public Safety Program Titles and Assistance Listing Numbers (ALN): Disaster Grants – Public Assistance (Presidentially Declared Disasters) – ALN 97.036 Federal Grant Numbers: State of New Jersey pass-through number: UH1WX, Project Worksheet #1822 – Award Year 2023 (Application 553330) Contact Person: Donna Wilser, Deputy Executive Director, 732-750-5300 Corrective Action: Management agrees with the finding. We are committed to strengthening our processes to ensure that all physical timesheets related to FEMA-declared disaster events are properly maintained and readily accessible. To achieve this, we will implement enhanced procedures and controls to ensure full compliance with the Uniform Guidance requirements. Anticipated Completion Date: December 1st, 2024
The Pickens County Board of Education will ensure that controls are in place to ensure the Davis-Bacon Act wage rate requirements are included in all construction contracts.
The Pickens County Board of Education will ensure that controls are in place to ensure the Davis-Bacon Act wage rate requirements are included in all construction contracts.
View Audit 310036 Questioned Costs: $1
The payroll department will be trained on the proper calculation of salary and compensation rates.
The payroll department will be trained on the proper calculation of salary and compensation rates.
The payroll department will be trained on the proper calculation of salary and compensation rates.
The payroll department will be trained on the proper calculation of salary and compensation rates.
The board will ensure the schools and central office departments are aware of and follow the federal procurement codes for federal funds.
The board will ensure the schools and central office departments are aware of and follow the federal procurement codes for federal funds.
View Audit 309995 Questioned Costs: $1
Finding 2023-014 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Expenditure Processing for Medical Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has been working since 2018 to ensure correct eligibil...
Finding 2023-014 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Expenditure Processing for Medical Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has been working since 2018 to ensure correct eligibility classifications in Bridges at the time of payment and a system change was implemented in April 2021 to correct the issue. All new cases are correctly routed. MDHHS originally expected to have all cases corrected at the end of the PHE unwind (July 2024), however, due to some of the mitigation strategies that CMS developed to ensure children did not lose eligibility, not all cases had their coding updated when they were renewed. MDHHS expects that all existing cases will be updated by May 2025, as MDHHS completes renewals for existing cases. MDHHS identified and updated its manual process of transferring expenditures from the Medicaid Cluster to the Children’s Health Insurance Program (CHIP) in June 2021; and will continue this manual process, on a quarterly basis, by completing a summary-level adjustment determined by analyzing the Community Health Automated Medicaid Processing System (CHAMPS) payment data and Bridges eligibility data until all existing cases have been updated. Anticipated Completion Date May 2025 Responsible Individual(s) Brant Cole, MDHHS Logan Dreasky, MDHHS Erin Emerson, MDHHS
Finding 402737 (2023-046)
Significant Deficiency 2023
Finding 2023-046 Temporary Assistance for Needy Families, ALN 93.558 - MARS User Access Management Views The Department of Labor and Economic Opportunity (LEO) agrees with the finding. The Management of Awards to Recipients System (MARS) is an older legacy system that does not automatically deactiv...
Finding 2023-046 Temporary Assistance for Needy Families, ALN 93.558 - MARS User Access Management Views The Department of Labor and Economic Opportunity (LEO) agrees with the finding. The Management of Awards to Recipients System (MARS) is an older legacy system that does not automatically deactivate user accounts after 60 days of inactivity. The LEO Finance unit continues to experience challenges related to staffing shortages and competing priorities. Accordingly, the LEO Internal Controls unit will assist the LEO Finance unit in the interim with implementing corrective action until this legacy application is replaced, and new procedures are implemented. Planned Corrective Action LEO has received a Technical Review Board exception from SOM Technical Standard 1340.00.020.01 (Access Control Standard). The exception allows MARS inactive accounts to remain open for up to 90 days - an interval at which Michigan Works! Agency administrators make quarterly approvals (sometimes their only activity on the system). The exception was granted on April 12, 2024, and is valid through October 9, 2024, but may be extended. LEO staff has begun manually pulling an inactive users report monthly and manually deactivating accounts that were not accessed during the previous 90-day period. LEO is currently working on a request for proposal to replace MARS and anticipates that the new system will be able to automatically deactivate user accounts in accordance with the SOM Technical Standard. The LEO Finance unit has updated its procedures to reflect its interim process and will further revise them once the MARS replacement system goes live. Anticipated Completion Date September 30, 2026 Responsible Individual(s) Lora MacKay, LEO Allen Williams, LEO
Finding 402645 (2023-041)
Significant Deficiency 2023
Finding 2023-041 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - ADP Security Program Management Views MDHHS agrees with part a. of the finding. MDHHS and DTMB disagree with part b. of the finding. For part b., although MDHHS agrees that system security plans were not updated timely for the sys...
Finding 2023-041 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - ADP Security Program Management Views MDHHS agrees with part a. of the finding. MDHHS and DTMB disagree with part b. of the finding. For part b., although MDHHS agrees that system security plans were not updated timely for the systems cited and the authority to operate expired for both systems, MDHHS disagrees that effective controls were not implemented to ensure confidentiality, integrity, and availability of its automated data processing (ADP) information systems. MDHHS also disagrees that the security of critical systems was at risk by failing to mitigate potential vulnerabilities as described above. MDHHS has compensating controls in place to ensure confidentiality, integrity, and availability of its ADP information systems in addition to mitigating potential vulnerabilities. MDHHS monitors remediation of Plans of Actions and Milestones for all information systems even after expiration of the authority to operate. The ADP systems cited for not having an updated risk assessment are reviewed biennially through the Internal Control Evaluation process where control evidence is updated to demonstrate effectiveness of controls. For one system cited, MDHHS is required to audit the system as part of the responsibilities related to the Affordable Care Act and the Medicaid Expansion marketplace. Those audits are conducted to show compliance with federal information security and privacy requirements related to data stored in those systems. The other system cited did not have any significant changes and implemented controls are still working as expected. Planned Corrective Action For part a., MDHHS will perform annual reviewing and testing of the business continuity plan (BCP). MDHHS has completed annual review and testing of the BCP as of April 22, 2024. For part b., MDHHS and DTMB will complete the necessary updates to the system security plans, including updating the risk assessments, and anticipate completion for both systems by December 31, 2024. MDHHS and DTMB anticipate that authority to operate renewals will be attained for both systems by December 31, 2024. Anticipated Completion Date December 31, 2024 Responsible Individual(s) Jim Bowen, MDHHS Nathan Buckwalter, DTMB Heather Frick, DTMB Karen Scott, MDHHS Keelie Honsowitz, MDHHS
Finding 402644 (2023-040)
Significant Deficiency 2023
Finding 2023-040 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Practitioner Reimbursement Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has determined the primary remaining source for overlaps between fee-for-service and capitation payments is due to retroact...
Finding 2023-040 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Practitioner Reimbursement Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has determined the primary remaining source for overlaps between fee-for-service and capitation payments is due to retroactive removal of Medicaid eligibility within Bridges. An upgraded interface fix is being implemented that will address several issues. This upgraded interface will remove the existing limitations to mitigate the occurrence of retroactive disenrollment. The interface fix is scheduled for March 2025 implementation. Anticipated Completion Date March 31, 2025 Responsible Individual(s) Latina McCausey, MDHHS Alexis Bond, MDHHS
View Audit 309982 Questioned Costs: $1
Finding 402643 (2023-039)
Significant Deficiency 2023
Finding 2023-039 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Ineligible HHP Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS presented the audit findings and planned corrective action to local office workers, managers, and staff at an Adult Services ...
Finding 2023-039 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Ineligible HHP Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS presented the audit findings and planned corrective action to local office workers, managers, and staff at an Adult Services statewide meeting during March 2024. During the meeting, MDHHS reviewed recoupment policies and procedures and the importance of reviewing work for accuracy. MDHHS issued an Adult Services Notification to managers and directors during April 2024 informing them of the recent recoupment audit findings and reminding local office management of the expectation to review hospitalization reports to ensure timely and accurate action is taken. Anticipated Completion Date Completed Responsible Individual(s) Elaina Brown-Mingo, MDHHS Michelle Martin, MDHHS
View Audit 309982 Questioned Costs: $1
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