Corrective Action Plans

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U.S. DEPARTMENT OF EDUCATION AND INDIANA DEPARTMENT OF EDUCATION Charter Schools – AL #84.282 Education Stabilization Fund – AL #84.425C, 84.425D & 84.425U 2024-001 Risk Assessment Process Related to Compliance Requirements (Repeat Finding 2023-001) Material Weakness Recommendation: The Auditor reco...
U.S. DEPARTMENT OF EDUCATION AND INDIANA DEPARTMENT OF EDUCATION Charter Schools – AL #84.282 Education Stabilization Fund – AL #84.425C, 84.425D & 84.425U 2024-001 Risk Assessment Process Related to Compliance Requirements (Repeat Finding 2023-001) Material Weakness Recommendation: The Auditor recommended additional resources be allocated to federal award compliance to review federal award provisions and requirements, evaluate risks of noncompliance, and respond to such risks through internal controls. The process should include methods to identify and communicate changes to federal award requirements to all key individuals within the Organization and to verify internal controls are implemented correctly and are operating effectively. Planned Corrective Action: As the organization has grown and certain federal funding streams have ended, compliance of federal programs has become decentralized. Budget constraints have led to changes in leadership in key positions and limitations in staffing. We agree that additional resources need to be added to ensure compliance with all state and federal awards. Michelle Krauter, VP, Chief Financial Officer, is responsible for ensuring fiscal compliance and will coordinate program compliance activities with the Heads of School at each campus and the Directors of Academic Accountability. Through the monitoring activities conducted by the Indiana Department of Education during 2023, staff gained a better understanding the compliance requirements and are implementing processes to ensure ongoing adherence to the requirements. Evaluation of these processes will continue through 2025.
Finding 2024-005 Enrollment Reporting: (Significant Deficiency) Federal Agency: Department of Education Program: Federal Direct Student Loans, Pell Grants AL #: 84.268, 84.063 Award Year: 2023-2024 Condition: Nine out of eighteen Enrollment Reporting rosters received were returned back after 15 days...
Finding 2024-005 Enrollment Reporting: (Significant Deficiency) Federal Agency: Department of Education Program: Federal Direct Student Loans, Pell Grants AL #: 84.268, 84.063 Award Year: 2023-2024 Condition: Nine out of eighteen Enrollment Reporting rosters received were returned back after 15 days. Corrective Action Planned: The late Enrollment Reporting was a result of the significant turnover in the Registrar's office. The University formed an oversight committee outside of the Registrar's office that corrected inaccurate reporting and worked through the backlog to meet reporting requirements. The experienced oversight committee will train the Registrar's office in continuing this timely compliance process for Enrollment Reporting and can backstop if any future personnel turnover or other event could negatively impact timely reporting. Responsible Party: Mark Messingschlager, Director of Financial Aid Anticipated Completion Date: Immediately
Finding 2024-004 Notices and Authorizations: (Significant Deficiency) Federal Agency: Department of Education Program: Federal Direct Student Loans AL #: 84.268 Award Year: 2023-2024 Condition: The written notifications were not provided to students for the periods October 2, 2023 through October 26...
Finding 2024-004 Notices and Authorizations: (Significant Deficiency) Federal Agency: Department of Education Program: Federal Direct Student Loans AL #: 84.268 Award Year: 2023-2024 Condition: The written notifications were not provided to students for the periods October 2, 2023 through October 26, 2023 and December 19, 2023 through February 9, 2024. Corrective Action Planned: Corrective actions were taken to resolve the automated notification process. Additional failures were discovered, which led to these deficiencies, and subsequent corrections were made to the system. Based on the possibility of future failures in the automatic process, an additional safeguard procedure has been added to the Financial Aid Office at two levels to verify that the required notices are communicated timely. Responsible Party: Mark Messingschlager, Director of Financial Aid Anticipated Completion Date: Immediately
Condition: The School does not have a documented Direct Loan quality assurance program. Planned Corrective Action: The Iliff School of Theology has contracted with a professional, third-party processing company to administer its student aid programs. The school will coordinate with this third-party...
Condition: The School does not have a documented Direct Loan quality assurance program. Planned Corrective Action: The Iliff School of Theology has contracted with a professional, third-party processing company to administer its student aid programs. The school will coordinate with this third-party processor to ensure that there is a documented quality assurance program that is regularly exercised for compliance purposes. All documentation will be maintained. Contact person responsible for corrective action: Jason Warr, VP for Business, Controller Anticipated Completion Date: June 2024
Condition: Our audit procedures identified instances of untimely reporting of enrollment information to NSLDS. Planned Corrective Action: The Iliff School of Theology has contracted with a professional, third-party processing company to administer its student aid programs. The School has also ensur...
Condition: Our audit procedures identified instances of untimely reporting of enrollment information to NSLDS. Planned Corrective Action: The Iliff School of Theology has contracted with a professional, third-party processing company to administer its student aid programs. The School has also ensured that this third-party processor is properly coordinated with the registrar’s office to meet federal requirements for NSLDS enrollment reporting. Contact person responsible for corrective action: Jason Warr, VP for Business, Controller Anticipated Completion Date: June 2024
Contact Person – Cassandra Heide, City Administrator Corrective Action Plan – Will establish a procedure to review certified payrolls. Completion Date – Immediately
Contact Person – Cassandra Heide, City Administrator Corrective Action Plan – Will establish a procedure to review certified payrolls. Completion Date – Immediately
The District had the three buses enrolled in the EPA Program crushed in entirety at Cunningham Metals in Russellville, AR. The motor was only to be drilled if the District was keeping the chassis on site. The receipt from the salvage was uploaded to the EPA portal in the close out process. Pictur...
The District had the three buses enrolled in the EPA Program crushed in entirety at Cunningham Metals in Russellville, AR. The motor was only to be drilled if the District was keeping the chassis on site. The receipt from the salvage was uploaded to the EPA portal in the close out process. Pictures taken at the salvage yard and a letter was provided by the salvage yard. As of April 2, 2025, we are waiting on instructions from the EPA for our next actions. Contact person responsible for corrective action: Kim Foster. Anticipated completion date of corrective action: The EPA was contacted on February 3, 2025.
The District has contacted the EPA regarding buses replaced and the new buses purchased in the 2022 Clean School Bus Rebate. As of April 2, 2025, we are still waiting on their instructions for our next actions. The District uploaded all required documentation to the EPA portal in the close out pro...
The District has contacted the EPA regarding buses replaced and the new buses purchased in the 2022 Clean School Bus Rebate. As of April 2, 2025, we are still waiting on their instructions for our next actions. The District uploaded all required documentation to the EPA portal in the close out process. Contact person responsible for corrective action: Kim Foster. Anticipated completion date of corrective action: The EPA was contacted on February 3, 2025.
View Audit 353537 Questioned Costs: $1
Finding 554905 (2024-001)
Significant Deficiency 2024
U.S. Department of Education Year ended June 30, 2024 Student Financial Assistance Cluster: Federal Pell Grant Program (Assistance Listing #84.063) Federal Direct Student Loans (Assistance Listing #84.268) Compliance Requirement: Special Tests and Provisions Criteria: The Gramm-Leach-Bliley Act (Pub...
U.S. Department of Education Year ended June 30, 2024 Student Financial Assistance Cluster: Federal Pell Grant Program (Assistance Listing #84.063) Federal Direct Student Loans (Assistance Listing #84.268) Compliance Requirement: Special Tests and Provisions Criteria: The Gramm-Leach-Bliley Act (Public Law 106-102) (GLBA) requires the BOCES, on an annual basis, to identify reasonably foreseeable internal and external risks to the security, confidentiality, and integrity of customer (student) information that could result in the unauthorized disclosure, misuse, alteration, destruction, or other compromise of such information, and assess the sufficiency of any safeguards in place to control these risks. At a minimum, the GLBA risk assessment should include consideration of risk in each relevant area of operations, including: 􀀄 Employee training and management. 􀀄 Information systems, including network and software design, as well as information processing, storage, transmission, and disposal. 􀀄 Detecting, preventing, and responding to attacks, intrusions, or other system failures. Condition: During our testing, we noted the following: 􀀄 A periodic inventory of data, noting where it is collected, stored, and transmitted was not performed. 􀀄 Vulnerability scanning and penetration testing is not completed annually. 􀀄 A written information security program is not fully in place. Policies surrounding risk management have not been implemented. 􀀄 Unsupported operating systems in use. Cause: The expected documentation supporting the required controls to adequately confirm compliance with GLBA safeguards was not complete. Effect: Without demonstrable, documented controls supporting compliance with the GLBA standards for safeguarding the protected data, compliance with the law and the requirements in the federal PPA may not be assured. Context: Inquiry and observation of the information received from the BOCES related to compliance with GLBA. Auditor’s Recommendation: The BOCES should review the GLBA safeguarding rules and as soon as practical implement and document the controls necessary for compliance with the rule, focusing on the completion of a documented, thorough, and standardized risk assessment and management reporting framework. The BOCES should perform comprehensive risk assessments on a regular basis, which is suggested to be at least annually, and at any significant change in infrastructure or business process. Contact Period Responsible for Corrective Action Plan: Warren Taylor, Chief Financial Officer Corrective Action Plan and Timing of Planned Corrective Action Plan: The BOCES is actively engaged in a formal Request for Proposals (RFP) process to procure a qualified vendor for the design and implementation of a comprehensive Information Security Program aligned with GLBA requirements. The selected vendor will conduct a full assessment of existing controls, help develop required policies and procedures, and assist in ensuring full compliance with GLBA mandates, including employee training, information systems safeguards, and incident response protocols. This process will be completed by December 2025. As part of the upcoming vendor engagement, a complete data inventory and structured risk assessment will be conducted. This will identify where sensitive data is collected, stored, transmitted, and processed, and will form the basis for implementing technical and administrative safeguards. This process will be completed by March 2026. In the past several years the BOCES has reviewed several student systems and was unable to identify a system that met all of their needs due to the differences between requirements applicable to school districts and those appropriate to the unique needs of a BOCES. The organization is on track to discontinue the use of all unsupported operating systems by June 30, 2026.
Type of Finding: Other Finding Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to Finding: The health center will submit the May 31, 2025, Statements timely. A calendar of scheduled financial reports is active and has b...
Type of Finding: Other Finding Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to Finding: The health center will submit the May 31, 2025, Statements timely. A calendar of scheduled financial reports is active and has been implemented effectively with the submission of this Audit. Official Responsible for Ensuring CAP: Responsible Parties: Board of Directors (Althea Riddick, Chair), Chief Executive Officer (Rose Turner), Interim Chief Financial Officer (Dan Miles), Finance Director (Kelly Glover). Planned Completion Date for CAP: This is an ongoing requirement.
Finding 2024-003 – U.S. Department of Agriculture – Community Facilities Loan and Grant, Assistance Listing # 10.766 Following the hiring of a permanent president, the new CFO has developed a quarterly reporting template to ensure compliance with the U.S. Department of Agriculture (USDA) reporting r...
Finding 2024-003 – U.S. Department of Agriculture – Community Facilities Loan and Grant, Assistance Listing # 10.766 Following the hiring of a permanent president, the new CFO has developed a quarterly reporting template to ensure compliance with the U.S. Department of Agriculture (USDA) reporting requirements. The CFO submits the completed reports to the USDA on a quarterly basis and maintains regular communication with USDA representatives to address any concerns or clarifications regarding compliance.
Finding 2024-002 – Student Financial Aid Cluster, Assistance Listing # 84.063 and 84.268 Limestone University utilizes Jenzabar software to extract and report enrollment data to the National Student Clearinghouse (NSC). However, in some instances, the data reported was incorrect. Since the occurrenc...
Finding 2024-002 – Student Financial Aid Cluster, Assistance Listing # 84.063 and 84.268 Limestone University utilizes Jenzabar software to extract and report enrollment data to the National Student Clearinghouse (NSC). However, in some instances, the data reported was incorrect. Since the occurrence of this issue, the University hired a new Registrar in August 2024. After reviewing the findings, the Registrar implemented the use of the NSC Edit Student Data Records window, in addition to the NSC Edit Registration Transactions window. This change allows a special status on the NSC Edit Student Data Records window to override the status on the Registration Transactions window, providing more precise monitoring of withdrawal dates and ensuring the accuracy and timeliness of the data reported to NSC. To ensure ongoing accuracy, the Registrar now reports enrollment status changes to NSC on a monthly basis. Additionally, the University reviewed the students identified in the findings, along with other students who had the same status (withdrawn) and made adjustments as necessary to ensure that all student data was accurately reported.
Finding 554740 (2024-032)
Significant Deficiency 2024
2024-032 Department of Justice Ensure program expenditures are supported Management Response: The Oregon Department of Justice agrees with the finding and provides the following information regarding the cause of this error and corrective action planned for implementation by June 30, 2025, which wil...
2024-032 Department of Justice Ensure program expenditures are supported Management Response: The Oregon Department of Justice agrees with the finding and provides the following information regarding the cause of this error and corrective action planned for implementation by June 30, 2025, which will be implemented by the Interim Financial Services Manager Richard Rylander. This error was caused through a lack of secondary validation of expenditures which resulted in incorrect expenditures being entered into the system. The correction action plan will update the Secondary Review of Expenditures and Batch Entry Process to ensure that the secondary review identifies and prevents errors which caused the finding above. Anticipated Completion Date: June 30, 2025 Contact person: Richard Rylander, Interim Financial Services Manager
View Audit 353343 Questioned Costs: $1
2024-001 Planned Corrective Action Management Comments and Corrective Action: The project manual included in the solicitation issued for construction of the North Brushy Creek Fork Trail Project did contain FHWA Required Contract Provisions that include the wage rate requirements and submission of...
2024-001 Planned Corrective Action Management Comments and Corrective Action: The project manual included in the solicitation issued for construction of the North Brushy Creek Fork Trail Project did contain FHWA Required Contract Provisions that include the wage rate requirements and submission of weekly certified payrolls to the City. City sta􀀁 was requesting the certified payrolls from the construction contractor upon request from TXDOT, the federal funding representative. Therefore, not all weekly payrolls were initially obtained. Upon request of the auditor, all weekly payrolls were obtained from the contractor and no issues were identified. City sta􀀁 has begun implementing a checklist for City sta􀀁 surrounding construction contracts on which Federal funding is involved. In addition, sta􀀁 and third-party representatives will be trained in federal reporting requirements. Proposed Implementation Date of Corrective Action: In process and to be completed by September 30, 2025. Person Responsible for Corrective Action: Chris Brickey, P.E., Capital Projects Manager – Engineering and Capital Projects
Finding 2024-003: Lower Income Housing Assistance Program - Section 8 New Construction and Substantial Rehabilitation Assistance Listing Number: 14.182 U.S. Department of Housing and Urban Development Compliance Require...
Finding 2024-003: Lower Income Housing Assistance Program - Section 8 New Construction and Substantial Rehabilitation Assistance Listing Number: 14.182 U.S. Department of Housing and Urban Development Compliance Requirements: Special Tests and Provisions Type of finding: Internal Control (material weakness) and Compliance (material noncompliance) Recommendation: The Organization should strengthen its internal controls with adopted policies and procedures to establish a monitoring process to ensure compliance with Mortgage Restructuring Loan terms and conditions. Action Taken: Director should review monthly statements and provide to bookkeeper for documentation. Annually, the bookkeeper and director should review the terms and determine the amount due for electronic payment of the Mortgage Restructuring Loan to be made by the bookkeeper. If there are any questions regarding this plan, please call the responsible party at (719) 852-5778. Sincerely yours, Monica Wolfe Executive Director Tri-County Senior Citizens and Housing, Inc.
Finding 2024-002: Lower Income Housing Assistance Program - Section 8 New Construction and Substantial Rehabilitation Assistance Listing Number: 14.182 U.S. Department of Housing and Urban Development ...
Finding 2024-002: Lower Income Housing Assistance Program - Section 8 New Construction and Substantial Rehabilitation Assistance Listing Number: 14.182 U.S. Department of Housing and Urban Development (Repeat of Finding 2023-002 and 2022-002) Compliance Requirements: Cash Management, Eligibility, Reporting, Special Tests and Provisions Type of finding: Internal Control Over Compliance (significant deficiency) Recommendation: The Organization should strengthen its internal controls with adopted policies and procedures to ensure a review process is established through adequate segregation of duties. The Organization should consider assessing and realigning the duties and responsibilities of administrative staff allowing the administrator to act in a more supervisory position. Action Taken: At this time, we do not have an administrative assistant/Activities Coordinator. Administrator works closely with the bookkeeper. Administrator and Executive Director will schedule every third recertification for review. Executive Director does review of the financial statements on a monthly basis when they are emailed over just before Policy Board meetings. During audit last year, we understood that reporting and eligibility did not have to happen at each interval but a review by another party in office every few re-certifications, as well as reviewing cash management. If there are any questions regarding this plan, please call the responsible party at (719) 852-5778. Sincerely yours, Monica Wolfe Executive Director Tri-County Senior Citizens and Housing, Inc.
Recommendation: Management should implement a formalized process for reviewing all required reports prior to submission. Management’s Response: Management agrees that all financial data would potentially be more accurate if reviewed by an additional qualified person prior to use. However, limited ...
Recommendation: Management should implement a formalized process for reviewing all required reports prior to submission. Management’s Response: Management agrees that all financial data would potentially be more accurate if reviewed by an additional qualified person prior to use. However, limited staff has prevented this from always being practical. In the future, management will seek ways to add more controls to all of our processes, including reviews, to ensure more accurate and reliable data is submitted. Responsible Parties: Jeff Sabo, Airport Manager Anticipated Completion Date: April 1, 2025
Finding 554594 (2024-032)
Significant Deficiency 2024
2024-032 Department of Justice Ensure program expenditures are supported Management Response: The Oregon Department of Justice agrees with the finding and provides the following information regarding the cause of this error and corrective action planned for implementation by June 30, 2025, which wil...
2024-032 Department of Justice Ensure program expenditures are supported Management Response: The Oregon Department of Justice agrees with the finding and provides the following information regarding the cause of this error and corrective action planned for implementation by June 30, 2025, which will be implemented by the Interim Financial Services Manager Richard Rylander. This error was caused through a lack of secondary validation of expenditures which resulted in incorrect expenditures being entered into the system. The correction action plan will update the Secondary Review of Expenditures and Batch Entry Process to ensure that the secondary review identifies and prevents errors which caused the finding above. Anticipated Completion Date: June 30, 2025 Contact person: Richard Rylander, Interim Financial Services Manager
View Audit 353285 Questioned Costs: $1
Amend the property records invenotry procedures to follow 2 CFR Section 200.313 (3 through (2); see the criteria of the finding for the detailed list of requirements.
Amend the property records invenotry procedures to follow 2 CFR Section 200.313 (3 through (2); see the criteria of the finding for the detailed list of requirements.
Corrective Action Plan (CAP): No Corrective Action Plan as the School is closed
Corrective Action Plan (CAP): No Corrective Action Plan as the School is closed
2024-002 – INTERNAL CONTROLS OVER COMPLIANCE – ALLOWABLE COSTS/COST PRINCIPLES Significant Deficiency Auditee’s Response and Planned Corrective Action FHA is retraining staff on procurement policy and reinforcing the requirement for pre-approval before payment. A checklist will be added to all invoi...
2024-002 – INTERNAL CONTROLS OVER COMPLIANCE – ALLOWABLE COSTS/COST PRINCIPLES Significant Deficiency Auditee’s Response and Planned Corrective Action FHA is retraining staff on procurement policy and reinforcing the requirement for pre-approval before payment. A checklist will be added to all invoices to confirm documentation is in place before submission for payment and a second signer will be responsible for signing invoices in the event of the absence of the Executive Director. Random monthly internal audits will be conducted to ensure continued compliance. Planned Implementation Date of Corrective Action: Immediate Person Responsible for Corrective Action: Benjamin Anako, Fiscal Officer
Recommendation: Our auditors recommended the Organization update their method of allocating expenditures to federal awards based on invoice date to ensure the incurred date is within the proper period of performance. Explanation of disagreement with audit finding: There is no disagreement with the ...
Recommendation: Our auditors recommended the Organization update their method of allocating expenditures to federal awards based on invoice date to ensure the incurred date is within the proper period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will review grant requirements and make sure that allowable costs are incurred and allocated to the grant within the grant period.
View Audit 353251 Questioned Costs: $1
ndation: Our auditors recommended the Organization create effective internal controls and procedures over the cash management process and drawdowns of federal funds that allows for compliance with all applicable Federal laws, regulations, and compliance requirements of various Federal grants. Expla...
ndation: Our auditors recommended the Organization create effective internal controls and procedures over the cash management process and drawdowns of federal funds that allows for compliance with all applicable Federal laws, regulations, and compliance requirements of various Federal grants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will review grant requirements and make sure that drawdown terms are followed and that a review will take place over any drawdowns prior to requesting the funds.
A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2024-001 a. Comments on the Finding and Each Recommendation Management concurs that the Project paid expenses in the amount of $14,215 on behalf of an affiliate from project cash without HUD approval. ...
A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2024-001 a. Comments on the Finding and Each Recommendation Management concurs that the Project paid expenses in the amount of $14,215 on behalf of an affiliate from project cash without HUD approval. b. Action(s) Taken or Planned on the Finding Management has retrained staff, reaffirmed the review and approval processes to ensure accuracy and existence of each transaction to ensure no cash disbursements are made on behalf of affiliates without HUD approval. Management will continue to reinforce its internal processes to prevent and detect unauthorized cash disbursements from project assets. It has requested reimbursement from the affiliated project, and the funds have been reimbursed.
View Audit 353197 Questioned Costs: $1
Head Start - AL #93.6000 Recommendation: The Organization should perform an inventory count with proper reconciliations to asset listing along with having a different individual review and document such review of count/reconciliation. Explanation of disagreement with audit finding: There is no disag...
Head Start - AL #93.6000 Recommendation: The Organization should perform an inventory count with proper reconciliations to asset listing along with having a different individual review and document such review of count/reconciliation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to findings: We are currently in the process of finalizing the physical inventory count reconciliations to the asset listing along with having a different individual review and document that review. Name(s) of the contact person(s) responsible for corrective action: Rita Zilka, Fiscal Director Planned completion date for corrective action plan: September 30, 2025
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