Corrective Action Plans

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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
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
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