Corrective Action Plans

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GDOL Response: GDOL acknowledges this is a repeated finding from previous years and is partially resolved, therefore the Department concurs with this finding and offers the following response. GDOL’s limited technology resources and funding will hinder our ability to update our current system to s...
GDOL Response: GDOL acknowledges this is a repeated finding from previous years and is partially resolved, therefore the Department concurs with this finding and offers the following response. GDOL’s limited technology resources and funding will hinder our ability to update our current system to satisfy the state audit’s recommendation. Therefore, we acknowledge that this finding will persist until a system-wide resolution is implemented in the new modernized UI system. GDOL will include a self-certification and dual certification process for employer-filed claims in the new solution. GDOL will also secure data analytic tools to aid GDOL staff with the identification of potential improper or fraudulent Payments, which will include payments linked to employer filed claims.
VIEWS OF RESPONSIBLE OFFICIALS AND PLANNED CORRECTIVE ACTION Management is responsible for designing and maintaining internal controls over financial reporting that is sufficient to provide reasonable assurance that management can prepare the financial statement and the Uniform Guidance Audit Report...
VIEWS OF RESPONSIBLE OFFICIALS AND PLANNED CORRECTIVE ACTION Management is responsible for designing and maintaining internal controls over financial reporting that is sufficient to provide reasonable assurance that management can prepare the financial statement and the Uniform Guidance Audit Report in conformity with US GAAP and federal regulations. Management will improve accounting and financial reporting policies and procedures to include the timely issuance of the financial statement and the uniform guidance report. IMPLEMENTATION DATE March 31, 2026 RESPONSIBLE PERSON Paola Rosario CPA, CFO
Recommendation: We recommend the Agency more carefully monitor expenditures incurred near grant end dates to ensure compliance with period of performance compliance requirements. Action taken: Management agrees with this finding and will more carefully monitor grant end dates to comply with period...
Recommendation: We recommend the Agency more carefully monitor expenditures incurred near grant end dates to ensure compliance with period of performance compliance requirements. Action taken: Management agrees with this finding and will more carefully monitor grant end dates to comply with period of performance compliance requirements.
Recommendation: We recommend the Agency revise federal award cash draw procedures to ensure compliance with cash management requirements. Such draws should be made solely for immediate cash needs. Action taken: Management agrees with this finding and has implemented corrective actions. Current and ...
Recommendation: We recommend the Agency revise federal award cash draw procedures to ensure compliance with cash management requirements. Such draws should be made solely for immediate cash needs. Action taken: Management agrees with this finding and has implemented corrective actions. Current and future draws are made for immediate cash needs for expenses already incurred.
Finding 555839 (2024-001)
Significant Deficiency 2024
Develop and implement a standardized file checklist for all tenant files Conduct staff training on housing documentation requirements and retention Perform a comprehensive audit of all current tenant files Correct all deficiencies found in tenant files and document corrections Establish a monthl...
Develop and implement a standardized file checklist for all tenant files Conduct staff training on housing documentation requirements and retention Perform a comprehensive audit of all current tenant files Correct all deficiencies found in tenant files and document corrections Establish a monthly internal file review schedule Implement a digital tracking system for file compliance status Housing Program Mgr DONE In Progress Housing Program Mgr 5/9/2025 In Progress Assigned Housing Team Ongoing In Progress Assigned Program Staff Quarterly In Progress Assigned Program Staff 5/1/2025 In Progress Housing Program Mgr 5/1/2025 Not Started Proposed Completion Date: 06/30/2025 Contact Person: Antonechia Smith – Housing Program Manager Kasi Jones – Property Manager
View Audit 354536 Questioned Costs: $1
Finding 555741 (2024-002)
Significant Deficiency 2024
a. Comments on the Finding and Each Recommendation Management agrees that an expense in the amount of $3,941 was paid on behalf of an affiliate from project cash without HUD approval. We attribute this finding to a clerical error made during invoice processing. b. Action(s) Taken or Planned on the F...
a. Comments on the Finding and Each Recommendation Management agrees that an expense in the amount of $3,941 was paid on behalf of an affiliate from project cash without HUD approval. We attribute this finding to a clerical error made during invoice processing. b. Action(s) Taken or Planned on the Finding The Management Agent will ensure that invoices will be recorded accurately and according to HUD guidelines. A list of service accounts by property is cross-referenced prior to invoice approval and utility accounts will be transferred to a third party for processing and payment.
View Audit 354366 Questioned Costs: $1
a. Comments on the Finding and Each Recommendation Management agrees that certain costs were paid on behalf of an affiliate project. We attribute this finding to an error by prior management. b. Action(s) Taken or Planned on the Finding As there has been a change in the Management Agent, the new age...
a. Comments on the Finding and Each Recommendation Management agrees that certain costs were paid on behalf of an affiliate project. We attribute this finding to an error by prior management. b. Action(s) Taken or Planned on the Finding As there has been a change in the Management Agent, the new agent will ensure invoices are recorded to the correct property. The site has been reimbursed for the $2,969 as of March 2025.
View Audit 354356 Questioned Costs: $1
Finding #2024-002 Comments on the Finding and Each Recommendation: During the year ended September 30, 2024, the Corporation made three withdrawals from the reserve for replacements account totaling $31,043 without obtaining RD approval. Management should request retroactive approval for the reserve...
Finding #2024-002 Comments on the Finding and Each Recommendation: During the year ended September 30, 2024, the Corporation made three withdrawals from the reserve for replacements account totaling $31,043 without obtaining RD approval. Management should request retroactive approval for the reserve for replacements withdrawals totaling $31,043 and obtain RD approval prior to making withdrawals from the reserve for replacements account in the future. Action(s) taken or planned on the finding: Management concurs with the finding. Management requested and received retroactive approval for the reserve for replacements withdrawals totaling $31,043 and will obtain RD approval prior to making withdrawals from the reserve for replacements account in the future.
View Audit 354311 Questioned Costs: $1
Finding #2024-001 Comments on the Finding and Each Recommendation: During the year ended September 30, 2024, two of the nine resident files selected for testing under the HUD Consolidated Audit Guide lacked properly executed and documented resident eligibility forms. The Agent should ensure that all...
Finding #2024-001 Comments on the Finding and Each Recommendation: During the year ended September 30, 2024, two of the nine resident files selected for testing under the HUD Consolidated Audit Guide lacked properly executed and documented resident eligibility forms. The Agent should ensure that all resident files are maintained at the site for each resident of the Property, and the Agent should ensure that the resident files include all properly executed and documented resident eligibility forms. Action(s) taken or planned on the finding: The Agent concurs with the finding and recommendation. The resident files noted in the statement of condition were for residents who moved out of the Property during the year ended September 30, 2024. No further action is required related to these residents' files. The Agent intends to review and update, as necessary, the other resident files during the year ended September 30, 2024 to ensure the Property is in compliance with HUD requirements.
Name of the Contact Person Responsible for the Corrective Action Plan: Stacey Merritt, Interim Finance Director Corrective Action Plan: Management concurs with the finding. We will work to ensure that future reports are submitted timely and that evidence of submissions is retained for each report ...
Name of the Contact Person Responsible for the Corrective Action Plan: Stacey Merritt, Interim Finance Director Corrective Action Plan: Management concurs with the finding. We will work to ensure that future reports are submitted timely and that evidence of submissions is retained for each report filing. Anticipated Completion Date: June 30, 2025
Name of the Contact Person Responsible for the Corrective Action Plan: Stacey Merritt, Interim Finance Director Corrective Action Plan: Management concurs with the finding. We will work to ensure that future reports are submitted timely and that evidence of submissions is retained for each report ...
Name of the Contact Person Responsible for the Corrective Action Plan: Stacey Merritt, Interim Finance Director Corrective Action Plan: Management concurs with the finding. We will work to ensure that future reports are submitted timely and that evidence of submissions is retained for each report filing. Anticipated Completion Date: June 30, 2025
Management is currently conducting a comprehensive review of the process to ensure alignment with compliance requirements and identify areas for improvement. Completion Date: Immediately
Management is currently conducting a comprehensive review of the process to ensure alignment with compliance requirements and identify areas for improvement. Completion Date: Immediately
1. Implement pre-approval controls; require date validation for all expenses against the award' s period of performance. Program Director or Executive Director or Accounting Director to review and approve. 2. Conduct training; educating staff on 2 CFR requirements and period-of-performance limitatio...
1. Implement pre-approval controls; require date validation for all expenses against the award' s period of performance. Program Director or Executive Director or Accounting Director to review and approve. 2. Conduct training; educating staff on 2 CFR requirements and period-of-performance limitations. 3. Perform periodic reviews; monitor compliance quarterly to detect outliers.
1. Implement pre-submission controls; require Date validation for all expenses against the award's period of performance. Program Director or Executive Director or Accounting Director to review and approve. 2. Conduct training; educating staff on 2 CFR requirements and period-of-performance limitati...
1. Implement pre-submission controls; require Date validation for all expenses against the award's period of performance. Program Director or Executive Director or Accounting Director to review and approve. 2. Conduct training; educating staff on 2 CFR requirements and period-of-performance limitations. 3. Perform periodic reviews; monitor compliance quarterly to detect outliers.
Finding 2024-001: The Property paid expenses totaling $6,702 on behalf of another property without HUD approval. Comments on the Finding and Each Recommendation: Management should seek reimbursement for these transactions from the other property. Action(s) taken or planned on the finding: Manageme...
Finding 2024-001: The Property paid expenses totaling $6,702 on behalf of another property without HUD approval. Comments on the Finding and Each Recommendation: Management should seek reimbursement for these transactions from the other property. Action(s) taken or planned on the finding: Management concurs with the finding and agrees with the auditor's recommendation. On February 11, 2025, a reimbursement from the other property totaling $6,702 was deposited into the Property's operating account.
View Audit 354222 Questioned Costs: $1
Name of auditee: Friendship Manor Housing Development Fund Company, Inc. Project No.: 01411252 TIN: 20-8665840 Name of audit firm: EFPR Group, CPA, PLLC Period covered by audit: March 31, 2024 CAP prepared by: Andrea D. Mays President of the Managing Agent ADM Management Group, Inc. (716) 892-1799 ...
Name of auditee: Friendship Manor Housing Development Fund Company, Inc. Project No.: 01411252 TIN: 20-8665840 Name of audit firm: EFPR Group, CPA, PLLC Period covered by audit: March 31, 2024 CAP prepared by: Andrea D. Mays President of the Managing Agent ADM Management Group, Inc. (716) 892-1799 (1) Finding 2024-001 Management will use the $42,926 of funds withdrawn from the reserves for replacements to payoff the loan acquired for the vehicle as originally intended.
Finding 2024-001 By April 1, 2025, HCEB will implement a process whereby monthly gross rent potential is calculated monthly based on contract rents, including manager rent free unit and vacancies, if any. This calculation will be automated and subject to system checks in HCEB’s Yardi Breeze software...
Finding 2024-001 By April 1, 2025, HCEB will implement a process whereby monthly gross rent potential is calculated monthly based on contract rents, including manager rent free unit and vacancies, if any. This calculation will be automated and subject to system checks in HCEB’s Yardi Breeze software, utilizing the following workflow: • Portfolio Assistant calculates the monthly gross rent potential within Yardi Breeze based on contract rents. • Portfolio Assistant will alert the General Ledger A/R accountant when the task is completed, and the General Ledger A/R accountant will download the information and will record in the general ledger. • Once the monthly gross rent potential general ledger entry is complete, it will be reviewed by the Controller or their designee.
The City is in agreement with the finding and noted and will consider formally documenting policies and procedures. Heather Shippey, City Clerk will be responsible for the corrective action and anticipated completion of corrective action is undetermined.
The City is in agreement with the finding and noted and will consider formally documenting policies and procedures. Heather Shippey, City Clerk will be responsible for the corrective action and anticipated completion of corrective action is undetermined.
The University concurs with the recommendation. The University will further review and refine the policies and procedures to strengthen internal controls and to ensure the timely and accurate reporting to NSLDS.
The University concurs with the recommendation. The University will further review and refine the policies and procedures to strengthen internal controls and to ensure the timely and accurate reporting to NSLDS.
Going forward, Edison Local Schools Eligibility process to determine Free/Reduced/Denied Status of applications submitted for the National School Lunch Program are: All applications collected at Edison Local School will be reviewed prior to the data entered into pay schools to ensure the application...
Going forward, Edison Local Schools Eligibility process to determine Free/Reduced/Denied Status of applications submitted for the National School Lunch Program are: All applications collected at Edison Local School will be reviewed prior to the data entered into pay schools to ensure the applications have all the information and data to make the correct determination. The income eligibility criteria is established by the Ohio Department of Education. The eligibility for paper applications will be made by the food service director and the superintendent is the determining official and each application is reviewed prior to entering this into the POS system, and a free/reduced and benefits issuance reports is compared to ensure all information is correct after it is entered to ensure the determination is correct, additionally annual verification is also done on free/reduced applications.
Finding 555235 (2024-002)
Significant Deficiency 2024
Finding: 2024-001 Finding Summary: (1) During the auditor’s testing for unrecorded liabilities, it was noted the County Finding: 2024-002 Federal Agency Name: U.S. Department of Treasury Assistance Listing Number(s): 21.027 Program Name: Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Fin...
Finding: 2024-001 Finding Summary: (1) During the auditor’s testing for unrecorded liabilities, it was noted the County Finding: 2024-002 Federal Agency Name: U.S. Department of Treasury Assistance Listing Number(s): 21.027 Program Name: Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Finding Summary: Recipients of CSLFRF can calculate lost revenue for the years 2020, 2021, 2022, and 2023 based on the formula provided in the 2022 Final Rule to determine the amount of CSLFRF funds that can be used for the “provision of government services”. In calculating revenue loss, recipients can choose whether to use calendar or fiscal year dates but must be consistent throughout the period of performance. If calculating revenue loss, recipients must provide auditors with evidence supporting their revenue loss calculation. Non-Federal entities may be required to submit performance reports at least annually but not more frequently than quarterly, except in unusual circumstances, using a form or format authorized by OMB (2 CFR section 200.329). During the testing over Earmarking, it was noted the County was not able to completely support the amounts used in the calculation. Further, there was no evidence of review of the calculation. As a result, the revenue loss number calculated by the County was incorrect. This incorrect number was reported to the Treasury as part of the County’s quarterly reporting requirement. Responsible Individuals: Kyle Wilmot Canyon County Controller Corrective Action Plan: The Auditor’s Office was short staffed when calculation was due for the earmarking requirements. Now with the office having a full team, the County has updated the process for the earmarking calculation requirements. After the amounts are calculated for the requirement, another member of the audit office will review the calculation and support documentation. Once reviewed, the calculation and supporting documents will be added to a file on the shared drive for the reporting requirements for the CSLFRF. Anticipated Completion Date: Canyon County will complete the corrective actions for the September 30, 2025, reporting period.
Finding 555196 (2024-002)
Significant Deficiency 2024
Finding 2024-002 Corrective Action Plan The College reassigned the duties within its business office to ensure remittances to students or parent borrowers of credit balances are executed in accordance with the timeline mandated by the U.S. Department of Education. Gratz College notes that this was ...
Finding 2024-002 Corrective Action Plan The College reassigned the duties within its business office to ensure remittances to students or parent borrowers of credit balances are executed in accordance with the timeline mandated by the U.S. Department of Education. Gratz College notes that this was the only instance of noncompliance and resulted from turnover in Gratz College’s business office staff. Anticipated Completion Date The corrective action plan was completed June 1, 2024 Names of Contact People Responsible for Corrective Action Thomas R. Cipriano, Jr. – Manager of Business Operations and Facilities Ross Holgado – Manager of Financial Reporting Karen West – Senior Accounting Associate and Coordinator of Student Billing
2024-002 – Enrollment Reporting (Significant Deficiency) Department of Education, SFA Cluster; Compliance Requirement Affected – Special Tests and Provisions Condition: The University did not report student enrollment data to the National Student Clearinghouse accurately and within minimum required ...
2024-002 – Enrollment Reporting (Significant Deficiency) Department of Education, SFA Cluster; Compliance Requirement Affected – Special Tests and Provisions Condition: The University did not report student enrollment data to the National Student Clearinghouse accurately and within minimum required timeframe. Criteria: Based on requirements set forth by 34 CFR 685.309(b)(2), the University is responsible for notifying the National Student Loan Data System (NSLDS) to changes to student’s enrollment data within minimum required timeframes. Cause: The University does not have adequate procedures in place to ensure changes in students’ enrollment statuses are identified and reported in a timely manner. Effect: Enrollment data was not reported timely or accurately to the Department of Education thus, the Department could not properly service the student’s loans. The accuracy of Title IV student loan records depends heavily on the accuracy of the enrollment information reported by institutions. Context: A sample of nine official and unofficial student withdrawals was selected for audit from a population of 63. The test found three student withdrawals that were not in compliance with timely enrollment reporting in NSLDS, the enrollment status for one student was not updated after the student was no longer enrolled on at least a half-time basis, and one student’s enrollment status date reported to NSLDS did not agree to date of withdraw reported on the R2T4 form. Repeat Finding: No. Recommendation: We recommend that the University put procedures in place to ensure that student enrollment statuses are updated in a timely manner. Management Response: The University has modified its withdrawal procedures and instructions related to the requirements set forth by 34 CFR 685.309(b)(2). Related to the findings above, due to staffing turnover, the appropriate test of controls needed to identify changes in a student’s enrollment status was not run in a timely manner. Going forward, the University has informed related staff that the aforementioned test of controls needs to be run at the end of each semester, and upon completion, staff must notify the NSLDS within the required timeframe. If the Federal Audit Clearinghouse has questions regarding this plan, please call Brad Sheriff, PhD, MBA, CMA, Interim Chief Financial Officer at (540) 887-7285. Brad Sheriff, PhD, MBA, CMA, Interim Chief Financial Officer, Mary Baldwin University, 540-887-7285
Identifying Number: 2024-004 Finding: Material Weakness: Period of Performance Context: Expenditures were included on the 2024 Schedule of Expenditures of Federal Awards, however, the expenditures were incurred prior to the budget period start date. Corrective Actions Taken or Planned: The Director ...
Identifying Number: 2024-004 Finding: Material Weakness: Period of Performance Context: Expenditures were included on the 2024 Schedule of Expenditures of Federal Awards, however, the expenditures were incurred prior to the budget period start date. Corrective Actions Taken or Planned: The Director of the Office of Sponsored Programs and the Manager of Sponsored Programs will develop a standardized document checklist for all high-value expenditures. This checklist will require all Sponsored Programs analysts to submit complete documentation with expense reports and proof of payment and have their respective immediate supervisor/manager review for compliance before final approval by the Director. a. Implementing organizational changes such as updated policies and/or procedures b. Educating the team(s) and/or Department(s) on internal controls, processes and accuracy best practices during the Grant management process c. Oversight of drawdown requests by the Director of Sponsored Programs to ensure accuracy of request Planning Process: Compliance with Regulations: The Director and Manager from Sponsored Programs will ensure the corrective actions align with applicable federal grant regulations and guidelines. We will create: - Implement internal controls, with the Director and Manager from Sponsored Programs developing checks and balances at the end of each month to ensure compliance in all the grant's portfolio. - Oversight of all drawdown requests, ensuring complete and accurate supporting documentation. Communication: The Director and Manager from Sponsored Programs will communicate the corrective action plan to all relevant staff and stakeholders. Follow-up: The Director and Manager from Sponsored Programs will regularly monitor progress and adjust to resolve any inefficiencies. Training: The Director and Manager from Sponsored Programs will work on the development and delivery of mandatory training sessions for all Sponsored Programs relevant staff. This will include (not limted to): - Retrain on updated policies and procedures (OSP team, Departments and stakeholders, if applicable) - Retrain on workflows and system (OSP team, Departments and stakeholders, if applicable) - Retrain on process improvement (OSP team, Departments and stakeholders, if applicable) Policy Updates: Revision of existing policies or creation of new ones to clarify procedures. System Enhacements: Implementing new software/program that improves data accuracy and compliance in all Federal/State and Local Grants throughout Nicklaus Children's Hospital. Monitoring and Oversight: The Director and Manager from the Sponsored Programs will monitor transactions and reporting processed more frequently. Deadline for Implementation: Immediate Action: The Director of Sponsored Programs transitioned the staff member responsible for the findings to an area where their expertise is most valuable. This CAPA will take effect immediately and be fully implemented within six weeks by April 07, 2025, allowing time to create/revise SOPs, Working Practice Guidelines (WPGs), Checklists and training/retraining sessions for stakeholders and OSP team members.
View Audit 353775 Questioned Costs: $1
Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing: #10.766 Compliance Requirement: Special Tests and Provisions Criteria: The Hospital must establish and maintain effective internal control over federal a...
Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing: #10.766 Compliance Requirement: Special Tests and Provisions Criteria: The Hospital must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Hospital is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. 2 CFR 200.327 and 2 CFR 200.328 require the auditee to collect financial information and monitor its activities under federal awards to assure compliance with applicable federal requirements and performance expectations are being achieved and report these items in accordance with program requirements. Terms and conditions of the federal award require the Hospital to maintain a debt service reserve fund as bookkeeping accounts or as separate bank accounts. Condition: Funds that represented the debt service reserve fund were commingled with an existing operating cash account. Planned Corrective Action: Management agrees with the funding and will deposit the required debt service reserve funds in either a separate bank account or general ledger account. Planned Completion Date: September 30, 2025 Person Responsible: Doug Brandt, Chief Financial Officer
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