Corrective Action Plans

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Finding 2023-001 Federal Program Information Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Period of Performance: ...
Finding 2023-001 Federal Program Information Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Period of Performance: July 1, 2020 to June 30, 2023 Corrective Action Planned: Management agrees that certain expenses to the COVID department were not reviewed and approved at the order entry level in specific cases. Although evidence of review was not retained for every charge to the COVID department, we believe the appropriateness of the charge was reasonable. Additionally, based on monthly review of departmental expenses and full-time equivalent (FTE) analysis at the facility level, we believe that these expenditures are subject to the appropriate level of review to identify unexpected variances. As it relates to the COVID Activity Code, this code was created as a means to track certain COVID hours worked, but was not configured to calculate the amounts associated with those hours, resulting in the need to make reasonable estimates. Even using the base pay rate at the time the hours were incurred would not have been accurate since it would omit adjustments for shift differentials, weekend hours, and overtime. We performed internal analyses and reviewed the results of samples selected by the auditors and concluded that the risk of a material overcharge to the program was minimal. Further, we have almost $40 million of unused lost revenues after our final PRF submission for Period 5, such that any questioned costs would easily be covered by other eligible uses of PRF funds. We have reviewed our processes related to the retention of expense documentation to improve audit evidence should this program ever be awarded in future periods. Responsible party: Lee Sonne, Vice President of Finance and Controller Implementation Date: Procedures were reviewed and analysis completed along with the Period 5 portal filing in September 2023.
View Audit 300159 Questioned Costs: $1
1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH Acute Communicable Disease Controls (ACDC) agrees with the finding and recommendation. ACDC staff will monitor subawards and submit the required FFATA reports in the FFATA system upon execution date of the ...
1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH Acute Communicable Disease Controls (ACDC) agrees with the finding and recommendation. ACDC staff will monitor subawards and submit the required FFATA reports in the FFATA system upon execution date of the amendment, but no later than the following month it was executed. This includes keeping monitoring logs of all contract amendments and modifications that are subject to FFATA reporting requirements. 3. Anticipated implementation date: March 1, 2024
1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH, Emergency Preparedness Response Program (EPRD) agrees with the finding and recommendation. EPRD staff will send the subrecipient/contractor the FFATA reporting notice, which includes a request for the fiv...
1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH, Emergency Preparedness Response Program (EPRD) agrees with the finding and recommendation. EPRD staff will send the subrecipient/contractor the FFATA reporting notice, which includes a request for the five most highly compensated officers at the same time the contract is sent to the subrecipient/contractor for signature. This will assist EPRD with tracking the reporting notice because once the subrecipient/contractor returns the signed contract, they will also return the FFATA reporting notice. Once staff receives the executed contract from DPH’s Contracts and Grants, the FFATA reporting system will be updated accordingly and a screenshot showing the date/time the report was submitted will be kept on file. 3. Anticipated implementation date: July 1, 2024
1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH, Division of HIV and STD Programs (DHSP) agrees with the finding and recommendation. DHSP will institute a new procedure that 1) notifies subaward recipients within 30 days of the effective date of the sub...
1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH, Division of HIV and STD Programs (DHSP) agrees with the finding and recommendation. DHSP will institute a new procedure that 1) notifies subaward recipients within 30 days of the effective date of the subaward execution or modification of relevant federal award information and 2) uploads federal subaward information to FFATA within 30 days of the effective date of the subaward execution or modification of relevant federal award information. These notifications will happen for all subawards that meet the threshold for FFATA reporting. DHSP understands that these notifications may precede the full execution of a new contract or subaward. 3. Anticipated implementation date: July 1, 2024
2023-007 Special Tests and Provisions – Material Weakness View of Responsible Officials Management agrees with the findings and recommendations. Corrective Action Plan The audit finding was due in large part to a vacancy in the Department ESSER grant support position that arose in the first qua...
2023-007 Special Tests and Provisions – Material Weakness View of Responsible Officials Management agrees with the findings and recommendations. Corrective Action Plan The audit finding was due in large part to a vacancy in the Department ESSER grant support position that arose in the first quarter of the fiscal year, which contributed to the breakdown in construction project tracking. The Department hired a replacement for this grant support position in the second quarter of the fiscal year, and during the third quarter hired a second grant support position to ensure enhanced support capacity and continuity. These two individuals continue to comprise the ESSER Grant Management Office (team) and in the fourth quarter of the fiscal year initiated a process to document school and complex area use of ESSER funds for construction purposes. The team held a department-wide informational webinar in partnership with the Department’s Office of Facilities and Operations on May 22, 2023. The webinar agenda included the newly implemented pre-approval construction application process and federal requirements pursuant to Title 2, Section 200, Appendix II, of the Code of Federal Regulations (CFR). The team will continue to work with the Department’s Complex Area Staff to reiterate the award requirements and examine construction-related contracts over $2,000 to verify compliance with the award requirements. Contact Person: Brian Hallett Assistant Superintendent and CFO Office of Fiscal Services Anticipated Completion Date: June 30, 2024
2023-002 Reporting – Material Weakness View of Responsible Officials Administration agrees with the findings and recommendations. Corrective Action Plan The Office of Monitoring and Compliance (MAC) will provide training to recipients when funds are allocated within the Department. The Policy, ...
2023-002 Reporting – Material Weakness View of Responsible Officials Administration agrees with the findings and recommendations. Corrective Action Plan The Office of Monitoring and Compliance (MAC) will provide training to recipients when funds are allocated within the Department. The Policy, Innovation, Planning and Evaluation Branch (PIPE) will communicate with the Office of Fiscal Services and MAC on a semi-annual basis to start the reporting process on December 1 and June 1 of each year to meet the January 31 and July 31 respective deadlines. Additionally, PIPE has identified a dedicated staff member who will spearhead the administration of this grant to ensure that any changes in the reporting requirements as defined in the OIA Cooperative Agreement will be quickly identified and followed. Contact Persons: Ken Kakesako, Director Policy, Innovation, Planning and Evaluation Branch Office of Strategy Innovation and Performance Jacy Yamamoto, Interim Director Office of Monitoring and Compliance Office of the Deputy Superintendent Anticipated Completion Date: June 1, 2024
Description of Corrective Action Plan: Prior to the completion of this audit, EmployIndy already made a number of changes to its financial operations. It parted ways with its Chief Financial Officer and procured the services of an outside Certified Public Accounting firm to begin the process of rev...
Description of Corrective Action Plan: Prior to the completion of this audit, EmployIndy already made a number of changes to its financial operations. It parted ways with its Chief Financial Officer and procured the services of an outside Certified Public Accounting firm to begin the process of reviewing and updating its financial operations. In addition, it hired an Executive Vice President of Finance and Operations to lead the final development and implementation of updated financial processes. The Executive Vice President of Finance and Operations has worked with EmployIndy’s Board of Directors and Finance Committee to document a plan for improving EmployIndy’s financial operations across the board by the 2nd quarter of Calendar Year 2024. As part of the ongoing plan to improve its financial operations, EmployIndy Financial Operations, Grants & Contracts, and Program Management staff will work with WIOA subrecipients to update processes and provide any necessary training for documenting personnel costs that are charged to WIOA funding/cluster. WIOA subrecipients requesting reimbursements for personnel costs will be required to include staff timecards with documentation that shows the specific number of hours of work time charged to each program in the WIOA cluster. EmployIndy staff reviewing monthly invoices or accrued expenditure reports will be retrained on how to properly review subrecipient expenditures and supporting documentation prior to approval. Further, EmployIndy Financial and Program monitors will specifically review subrecipient time charging and invoicing activity to ensure that personnel costs are not allocated proportionately but based upon actual time worked within each program/cluster. Finally, Financial Operations, Grants & Contracts, and Program Leadership teams will receive further training on Uniform Administrative Requirements for Federal Awards to ensure there is greater understanding of documentation requirements necessary to support federal expenditures. Responsible Party and Timeline for Completion: Corrective Activity Responsible Party Timeline for Completion Develop training for subrecipient and contractor staff time charging and documentation requirements. Associate Director of Grants & Contracts, Controller 1st Quarter of Calendar Year 2024 Develop and provide updated training to EmployIndy Leadership on documentation requirements needed to approve subrecipient or contractor accrued expenditure reports or invoices that contain personnel costs Controller 1st Quarter of Calendar Year 2024 Deliver training to subrecipient and contractor staff time charging, submission, and documentation requirements Vice President of WorkOne, Vice President of Career Connected Learning, Vice President of Community Career Services 2nd Quarter of Calendar Year 2024 Update subrecipient monitoring process to review staff time charging and documentation requirements Associate Director of Grants & Contracts, Associate Director of Performance and Technical Assistance Completed in January 2024 Hold staff and subrecipients accountable for following processes Executive Vice President of Finance and Operations, EmployIndy Leadership Ongoing Complete training on Uniform Administrative Requirements for Federal Awards Financial Operations, Grants & Contracts, and Program Leadership Teams 1st Quarter of Calendar Year 2024
Finding Number: 2023-001 Planned Corrective Action: In 2022- 2023, Aramark hired a new Food Service Supervisor. The Supervisor failed to report the numbers correctly. She was told to pull the POS report and use the Aramark calendar, which differs from a monthly calendar. Once she had the numbers, ...
Finding Number: 2023-001 Planned Corrective Action: In 2022- 2023, Aramark hired a new Food Service Supervisor. The Supervisor failed to report the numbers correctly. She was told to pull the POS report and use the Aramark calendar, which differs from a monthly calendar. Once she had the numbers, they would be manually input into the Aramark program. She was using these numbers to report to the ODE. When doing this, she made several errors, which resulted in us reporting more meals than we actually served. Correction : 1) Report numbers to the ODE using the CN6 and CN7 reports. 2) Correct our reported number to ODE using the CN6 and CN7 reports for August - November 2023. Anticipated Completion Date: 1) We started in December 2023 using the correct report s, the CN6 and CN 7, to report our numbers to the ODE for reimbursement. 2) In February, we put in the correct numbers for August- November 2023 with the ODE, so our numbers will balance for the 2023-2024 school year. Responsible Contact Person : Michael Pissini, Treasurer Leslie McKimmie, Food Service Director
Department: Defense, Veterans and Emergency Management Title: Internal control over DG – PA program special reporting needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will develop written procedures for the monthly identification of sub...
Department: Defense, Veterans and Emergency Management Title: Internal control over DG – PA program special reporting needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will develop written procedures for the monthly identification of subawards, the collection of UEIs, input to FSRS, and a reconciliation to MEMA records. The Department will identify FSRS entries recorded for current awards and compare them to the actual subawards (identified by the review of contracts, analysis of Advantage payments, and interview of program staff). The Department will input the remaining subawards into FSRS. The Department will compare the complete subaward list in FSRS to MEMA records. The Department will switch over to a monthly input of new subawards. Completion Date: April 1, 2024, May 3, 2024 and June 20, 2024 respectively Agency Contact: James Belanger, Business Office Director MEMA, 207-707-2912
Department: Health and Human Services Title: Internal control over Medicaid Nursing Facility audits needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will check with HR weekly for new applicants, interview qualified candidates as soon a...
Department: Health and Human Services Title: Internal control over Medicaid Nursing Facility audits needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will check with HR weekly for new applicants, interview qualified candidates as soon as possible, and hire and train qualified individuals. The Department will complete the COVID audits. The Department will reassign COVID auditors to the LTC program audits. Completion Date: Ongoing (first item), June 30, 2024 (second item) and July 1, 2024 (third item) Agency Contact: Herb Downs, Director, Division of Audit, DHHS, 207-287-2778
Department: Redacted Title: ________ over ________ and ________ needs improvement Questioned Costs: Redacted Status: Corrective action in progress Corrective Action: The Department agrees with the finding. The Department’s corrective action plan has been excluded to protect confidential information....
Department: Redacted Title: ________ over ________ and ________ needs improvement Questioned Costs: Redacted Status: Corrective action in progress Corrective Action: The Department agrees with the finding. The Department’s corrective action plan has been excluded to protect confidential information. The complete corrective action plan has been provided to the Office of the State Auditor under separate cover. Completion Date: April 1, 2024 (first three items) and May 1, 2024 (fourth item) Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Department: Redacted Title: ________ over ________ and ________ needs improvement Questioned Costs: Redacted Status: Corrective action complete Corrective Action: The Department agrees with the finding. The Department’s corrective action plan has been excluded to protect confidential information. Th...
Department: Redacted Title: ________ over ________ and ________ needs improvement Questioned Costs: Redacted Status: Corrective action complete Corrective Action: The Department agrees with the finding. The Department’s corrective action plan has been excluded to protect confidential information. The complete corrective action plan has been provided to the Office of the State Auditor under separate cover. Completion Date: January 31, 2024 Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Department: Redacted Title: ________ over the ________ needs improvement Questioned Costs: Redacted Status: Corrective action in progress Corrective Action: The Department agrees with the finding. The Department’s corrective action plan has been excluded to protect confidential information. The comp...
Department: Redacted Title: ________ over the ________ needs improvement Questioned Costs: Redacted Status: Corrective action in progress Corrective Action: The Department agrees with the finding. The Department’s corrective action plan has been excluded to protect confidential information. The complete corrective action plan has been provided to the Office of the State Auditor under separate cover. Completion Date: March 31, 2024 and June 30, 2024 respectively Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Department: Health and Human Services Title: Internal control over Income Eligibility and Verification System procedures needs improvement Questioned Costs: None Status: Management’s opinion is that corrective action is not required Corrective Action: The Department’s existing IEVS reports are part ...
Department: Health and Human Services Title: Internal control over Income Eligibility and Verification System procedures needs improvement Questioned Costs: None Status: Management’s opinion is that corrective action is not required Corrective Action: The Department’s existing IEVS reports are part of an Integrated Eligibility System whose format is in compliance with federal regulations. Completion Date: N/A Agency Contact: Ian Yaffe, Director, Office for Family Independence, DHHS, 207- 592-1481
Department: Redacted Title: ________ over ________ and ________ needs improvement Questioned Costs: Redacted Status: Corrective action in progress Corrective Action: The Department agrees with the finding. The Department’s corrective action plan has been excluded to protect confidential information....
Department: Redacted Title: ________ over ________ and ________ needs improvement Questioned Costs: Redacted Status: Corrective action in progress Corrective Action: The Department agrees with the finding. The Department’s corrective action plan has been excluded to protect confidential information. The complete corrective action plan has been provided to the Office of the State Auditor under separate cover. Completion Date: July 1, 2023, June 1, 2024 and June 15, 2024 respectively Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Department: Redacted Title: ________ over the ________ and ________ needs improvement Questioned Costs: Redacted Status: Corrective action in progress Corrective Action: The Department agrees with the finding. The Department’s corrective action plan has been excluded to protect confidential informat...
Department: Redacted Title: ________ over the ________ and ________ needs improvement Questioned Costs: Redacted Status: Corrective action in progress Corrective Action: The Department agrees with the finding. The Department’s corrective action plan has been excluded to protect confidential information. The complete corrective action plan has been provided to the Office of the State Auditor under separate cover. Completion Date: July 1, 2024 Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Department: Economic and Community Development Title: Internal control over ERA Program performance reporting needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will have quarterly onsite meetings with MaineHousing staff to review the dat...
Department: Economic and Community Development Title: Internal control over ERA Program performance reporting needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will have quarterly onsite meetings with MaineHousing staff to review the data and supporting documentation prior to the submission deadline. Completion Date: January 31, 2026 Agency Contact: Deborah Johnson, Director, Office of Community Development, DECD, 207-624-9817
Department: Redacted Title: ________ over ________ needs improvement Questioned Costs: Redacted Status: Corrective action in progress Corrective Action: The Department agrees with the finding. The Department’s corrective action plan has been excluded to protect confidential information. The complete...
Department: Redacted Title: ________ over ________ needs improvement Questioned Costs: Redacted Status: Corrective action in progress Corrective Action: The Department agrees with the finding. The Department’s corrective action plan has been excluded to protect confidential information. The complete corrective action plan has been provided to the Office of the State Auditor under separate cover. Completion Date: January 31, 2024 Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Department: Redacted Title: ________ over the ________ needs improvement Questioned Costs: Redacted Status: Corrective action in progress Corrective Action: The Department agrees with the finding. The Department’s corrective action plan has been excluded to protect confidential information. The comp...
Department: Redacted Title: ________ over the ________ needs improvement Questioned Costs: Redacted Status: Corrective action in progress Corrective Action: The Department agrees with the finding. The Department’s corrective action plan has been excluded to protect confidential information. The complete corrective action plan has been provided to the Office of the State Auditor under separate cover. Completion Date: June 1, 2024 Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Department: Health and Human Services Title: Internal control over WIC subrecipient monitoring needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will continue training and finalizing processes with DHHS Internal Audit for ongoing complet...
Department: Health and Human Services Title: Internal control over WIC subrecipient monitoring needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will continue training and finalizing processes with DHHS Internal Audit for ongoing completion of the financial component of MERs. Completion Date: June 1, 2024 Agency Contact: Ginger Roberts-Scott, Senior Health Program Manager, DHHS, 207-287-5342
Department: Redacted Title: ________ over ________, ________, and ________ needs improvement Questioned Costs: Redacted Status: Corrective action in progress Corrective Action: The Department agrees with the finding. The Department’s corrective action plan has been excluded to protect confidential i...
Department: Redacted Title: ________ over ________, ________, and ________ needs improvement Questioned Costs: Redacted Status: Corrective action in progress Corrective Action: The Department agrees with the finding. The Department’s corrective action plan has been excluded to protect confidential information. The complete corrective action plan has been provided to the Office of the State Auditor under separate cover. Completion Date: December 31, 2024 (first item) and March 18, 2024 (second and third items) Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Department: Redacted Title: ________ over ________ and ________ needs improvement Questioned Costs: Redacted Status: Corrective action in progress Corrective Action: The Department agrees with the finding. The Department’s corrective action plan has been excluded to protect confidential information....
Department: Redacted Title: ________ over ________ and ________ needs improvement Questioned Costs: Redacted Status: Corrective action in progress Corrective Action: The Department agrees with the finding. The Department’s corrective action plan has been excluded to protect confidential information. The complete corrective action plan has been provided to the Office of the State Auditor under separate cover. Completion Date: April 15, 2024 and June 30, 2024 respectively Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Department: Redacted Title: ________ over ________ and ________ needs improvement Questioned Costs: Redacted Status: Corrective action complete Corrective Action: The Department agrees with the finding. The Department’s corrective action plan has been excluded to protect confidential information. Th...
Department: Redacted Title: ________ over ________ and ________ needs improvement Questioned Costs: Redacted Status: Corrective action complete Corrective Action: The Department agrees with the finding. The Department’s corrective action plan has been excluded to protect confidential information. The complete corrective action plan has been provided to the Office of the State Auditor under separate cover. Completion Date: July 30, 2023 Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
2023-002 National Student Loan Data System (NSLDS) Enrollment Reporting Recommendation: We recommend that the University review their policies and procedures to ensure accurate reporting and responding to enrollment rosters to NSLDS. Explanation of disagreement with audit finding: There is no disagr...
2023-002 National Student Loan Data System (NSLDS) Enrollment Reporting Recommendation: We recommend that the University review their policies and procedures to ensure accurate reporting and responding to enrollment rosters to NSLDS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Reason for finding: Hodges University's enrollment and withdrawal policies did not align with the department of education requirements. In addition, internal controls in place were insufficient. Action taken in response to finding: Hodges University is updating its policies to follow the federal policies and best practices in order to remain compliant; that update will reflect as an addendum to the catalog. We have implemented additional internal controls to ensure the timeliness and accuracy of future reporting, and compliance. Name(s) of the contact person(s) responsible for corrective action: Nicole Hurley, Director of University Registrar, Olker Alva, Director of Students Financial Services, and Diana Schultz, SVP of Student Affairs and Financial Services and Provost. Planned completion date for corrective action plan: Effective immediately
Program: Nationally Significant Freight and Highway Projects Financial Assistance Listing Number: 20.934 Federal Agency: U.S. Department of Transportation Pass-through: California Department of Transportation Award Year: 2019 Grant Award Number: INFRALUL-5459(031) Compliance Requirements: Special Te...
Program: Nationally Significant Freight and Highway Projects Financial Assistance Listing Number: 20.934 Federal Agency: U.S. Department of Transportation Pass-through: California Department of Transportation Award Year: 2019 Grant Award Number: INFRALUL-5459(031) Compliance Requirements: Special Tests and Provisions - Wage Rate Requirements Views of Responsible Officials and Corrective Action: We concur with the finding. The City will implement controls to ensure there are procedures in place requiring the documented review of the certified payroll submitted by the construction contractors. Name of Responsible Person: Jennifer Hennessey, Director of Finance Projected Implementation Date: June 30, 2024
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