Corrective Action Plans

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Finding 2023-003 Federal Agency Name: Department of Agriculture Federal Financial Assistance Listing #10.766 Program Name: Community Facilities Loans and Grants Cluster Compliance Requirement: Preparation of Schedule of Expenditures of Federal Awards Finding Summary: The Hospital does not have an i...
Finding 2023-003 Federal Agency Name: Department of Agriculture Federal Financial Assistance Listing #10.766 Program Name: Community Facilities Loans and Grants Cluster Compliance Requirement: Preparation of Schedule of Expenditures of Federal Awards Finding Summary: The Hospital does not have an internal control system designed to provide for the preparation of the schedule and notes to the schedule. We requested our auditors to assist with the preparation of the schedule and notes to the schedule. Responsible Individuals: Lisa Weisser, Director of Finance Corrective Action Plan: It is not cost effective to have an internal control system designed to provide for the preparation of the Schedule of Expenditures of Federal Awards. We requested that our auditors, Eide Bailly LLP, prepare the Schedule of Expenditures as part of their Single Audit. We have designated members of management to review the drafted Schedule and accompanying notes. Anticipated Completion Date: Ongoing
2023-004 - Material weakness and Material Noncompliance - Missing Timesheets FMC Comment: FMC was in the process of converting for a one payroll system to another system during the Audit year. The conversion process was time consuming and involved files being transferred from one system to another ...
2023-004 - Material weakness and Material Noncompliance - Missing Timesheets FMC Comment: FMC was in the process of converting for a one payroll system to another system during the Audit year. The conversion process was time consuming and involved files being transferred from one system to another system. This could have resulted in some timesheets being misplaced as opposed to staff being paid without a timesheet being approved. Corrective Action: FMC has a new timekeeping system - Paylocity- that should prevent the issue of missing timesheets since the system is all electronic. Staff cannot get paid unless within the Paylocity system there is an electronic timesheet. The process is described below: The employee's clock in and out electronically, through a web portal on their phone, desktop or laptop. The supervisor is notified through the Paylocity if there are errors or missed punches. The supervisor works with the employee to correct any errors. The supervisor electronically approves the electronic time card. All approved electronic timecards are locked by payroll, then electronically brought from the time and attendance system to the payroll system. Payroll and HR will review all timecards to ensure all hours are correct and the vacation, sick and personal time are within appropriate parameters. Any additional corrections are made electronically with the supervisor and employee's input. Once all the electronic records are approved, Payroll submits the payroll for processing by Paylocity. The electronic timesheet record is printed on one document and kept with the payroll register for each pay period.
2023-003 - Material Weakness and Material Noncompliance - Special Tests FMC Comment: Family Medical Center's Patient Accounts department has had significant turnover over the past three years as well as implementation of a new software. FMC hired several temporary staff to support that led to more ...
2023-003 - Material Weakness and Material Noncompliance - Special Tests FMC Comment: Family Medical Center's Patient Accounts department has had significant turnover over the past three years as well as implementation of a new software. FMC hired several temporary staff to support that led to more turnover and a lack of consistency in personnel. Many of the issues are due to improper documentation or manual error inputting the patients' slide scale into the system. Corrective Action: Family Medical Center will have management or assigned staff to review all current sliding fee patients and ensure that the Center has an updated sliding fee application for each. FMC will provide additional training to front desk staff at each site and require them to obtain the proper application and documentation. Patient Accounts will review the current application to ensure that the current patients are charged the proper sliding fee scale. Management will develop a training module with Human Resources to have each staff complete in addition to hiring additional staff. This corrective action is expected to be completed by March 31, 2024.
The Purchase ADD has been going through a transition period between personnel, accounting software and audit firms the last three years. As a result, this transition has caused the ADD to continually adapt policies & procedures for correctness. The report to EDA by the loan staff included loans th...
The Purchase ADD has been going through a transition period between personnel, accounting software and audit firms the last three years. As a result, this transition has caused the ADD to continually adapt policies & procedures for correctness. The report to EDA by the loan staff included loans that had been approved in FY 2023 but not yet closed. In the future, loan staff and finance staff need to coordinate more closely what is being reported to avoid discrepencies. Fortunately, all funding as accounted for and used for its intended purpose.
Finding 6373 (2023-002)
Material Weakness 2023
Views of Responsible Officials and Planned Corrective Actions: The College agrees with the finding. The College had internally identified the failure to send the required notifications in January 2023 and took corrective action to create new processes and made system adjustments effective for the fa...
Views of Responsible Officials and Planned Corrective Actions: The College agrees with the finding. The College had internally identified the failure to send the required notifications in January 2023 and took corrective action to create new processes and made system adjustments effective for the fall 2023 semester. All required notifications were made for fall 2023 disbursements. The College is evaluating alternate notification processes to improve efficiencies and ensure completeness. Names of Contact Persons Responsible for Corrective Action: Barbara Schmitt, Director of Financial Aid Anticipated Completion Date: Changes were effective for the fall 2023 semester
Finding 2023-002 Reporting – Late REAC Submission 14.155 Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects 14.195 Section 8 Housing Assistance Payments Program Material Weakness in Internal Control – Material Noncompliance Condition: The Organization’s ...
Finding 2023-002 Reporting – Late REAC Submission 14.155 Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects 14.195 Section 8 Housing Assistance Payments Program Material Weakness in Internal Control – Material Noncompliance Condition: The Organization’s annual financial statement data was not submitted within the timeframes specified by HUD. The financial statement data was due by September 30, 2023, but was not filed until December 21, 2023. Auditor’s Recommendation: We recommend that the Organization make every effort to submit its annual financial statement data within the timeframe specified by HUD. Action Taken: The Organization has maintained contact with HUD and prioritized submitting the annual financial statement data after they were informed it was late. Effective Date: December 21, 2023 Contact Information: Kristy Hust, Director of Operations Northside Mental Health Center, Inc. Management Agent 12512 Bruce B Downs Blvd Tampa, FL 33612 (813) 977-8700
2023-005 Special Tests and Provisions Recommendation: We recommend that management retains all documentation related to new tenants being admitted to program Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding...
2023-005 Special Tests and Provisions Recommendation: We recommend that management retains all documentation related to new tenants being admitted to program Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: We are using Housing Data Systems (HDS) as a tenant management solution. This software will produce all documentation related to new tenants being admitted to the program. The Program Coordinator will use checklists and the HDS to ensure that we collect the appropriate documents which we will retain in Laserfiche. The Housing Director will review a minimum random sampling of 25% of the documentation for completeness throughout the year. If the Housing Director discovers significant issues with the documentation, they will review all the paperwork and retrain the Program Coordinator, so the documentation meets performance standards. Name of the contact person responsible for corrective action: Amanda Mackie Planned completion date for corrective action plan: The HDS system is currently being utilized. The documentation review will begin on 10.31.2023 and continue indefinitely.
2023-004 Special Tests and Provisions Recommendation: We recommend that management implements a process to perform inspections and re-inspections within the timeframes required by the Administrative Plan. Explanation of disagreement with audit finding: There is no disagreement with the audit findi...
2023-004 Special Tests and Provisions Recommendation: We recommend that management implements a process to perform inspections and re-inspections within the timeframes required by the Administrative Plan. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: We are using Housing Data Systems (HDS) as a tenant management solution. This software will track the timelines for inspections and reinspection. The Program Coordinator will use the HDS and their calendars to ensure that any inspections or re-inspections are carried out in accordance with the Administrative Plan. The Program Coordinator will use checklists and the HDS to ensure that we collect the appropriate documents which we will store in Laserfiche. The Housing Director will review a minimum random sampling of 25% of the documentation for completeness throughout the year. If the Housing Director discovers significant issues with the documentation, they will review all the paperwork and retrain the Program Coordinator, so the documentation meets performance standards. Name of the contact person responsible for corrective action: Amanda Mackie Planned completion date for corrective action plan: The HDS system is currently being utilized. The documentation review will begin on 10.31.2023 and continue indefinitely.
2023-003 Special Tests and Provisions Recommendation: We recommend that management implements a process to perform rent reasonableness calculation and retain documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in res...
2023-003 Special Tests and Provisions Recommendation: We recommend that management implements a process to perform rent reasonableness calculation and retain documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: We are using Housing Data Systems (HDS) as a tenant management solution. This software will track the reasonableness of rent and produce the appropriate documentation. The Program Coordinator will use checklists and the HDS to ensure that we collect the appropriate documents which we will store in Laserfiche. The Housing Director will review a minimum random sampling of 25% of the documentation for completeness throughout the year. If the Housing Director discovers significant issues with the documentation, they will review all the paperwork and retrain the Program Coordinator, so the documentation meets performance standards. Name of the contact person responsible for corrective action: Amanda Mackie Planned completion date for corrective action plan: The HDS system is currently being utilized. The documentation review will begin on 10.31.2023 and continue indefinitely.
2023-002 Special Tests and Provisions Recommendation: We recommend that management implements a tenant management software system which will track the contract rents annually, admissions from the waiting list, and re-inspections performed. Explanation of disagreement with audit finding: There is no...
2023-002 Special Tests and Provisions Recommendation: We recommend that management implements a tenant management software system which will track the contract rents annually, admissions from the waiting list, and re-inspections performed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: We are using Housing Data Systems (HDS) as a tenant management solution. This software will track the contract rents annually, the admissions from the waiting list and it tracks re-inspections that are performed. The Program Coordinator will use checklists and the HDS to ensure that we collect the appropriate documents which we will store in Laserfiche. The Housing Director will review a minimum random sampling of 25% of the documentation for completeness throughout the year. If the Housing Director discovers significant issues with the documentation, they will review all the paperwork and retrain the Program Coordinator, so the documentation meets performance standards. Name of the contact person responsible for corrective action: Amanda Mackie Planned completion date for corrective action plan: The HDS system is currently being utilized. The documentation review will begin on 10.31.2023 and continue indefinitely.
Finding 2023-004: Quarterly Reporting of Emergency Financial Aid Grants to Students and Annual Reporting for COVID-19 Education Stabilization Fund Contact person responsible for correction action – Mitzi Suhler, Vice President of Enrollment Services Anticipated completion date – June 30, 2023 Co...
Finding 2023-004: Quarterly Reporting of Emergency Financial Aid Grants to Students and Annual Reporting for COVID-19 Education Stabilization Fund Contact person responsible for correction action – Mitzi Suhler, Vice President of Enrollment Services Anticipated completion date – June 30, 2023 Corrective action Sterling College agrees with the finding of not meeting the posting deadline for the quarterly reports for March 31, 2023, and June 30, 2023. The reports were posted within the required month but did not meet the ten-day limit for posting. Sterling College recognizes the importance of meeting reporting requirements for all federal programs and if any additional programs were to arise that are similar in nature, we will review the compliance requirements, and prior findings, to ensure proper processes are in place to ensure compliance in reporting are met.
Finding 2023-003: Cash Management for the Institutional Portion of the COVID-19 Education Stabilization Fund Contact person responsible for correction action – Michelle Hall, CFO Anticipated completion date – Corrective action completed in January 2023 Corrective action Sterling College agrees w...
Finding 2023-003: Cash Management for the Institutional Portion of the COVID-19 Education Stabilization Fund Contact person responsible for correction action – Michelle Hall, CFO Anticipated completion date – Corrective action completed in January 2023 Corrective action Sterling College agrees with the finding of not meeting the posting deadline for drawing down the funds and spending the funds within the three calendar days of the drawdown. Sterling College recognizes this compliance requirement and will in the future for any other COVID-19 funds review the drawdown requests prior to execution and be cognizant of the timing and fund accordingly.
Contact person responsible for correction action – Mitzi Suhler, Financial Aid Director Anticipated completion date – June 30, 2023 Corrective action Sterling College agrees with the finding of the under award and over award of federal aid for two students. During the 2022-2023 year we hired new ...
Contact person responsible for correction action – Mitzi Suhler, Financial Aid Director Anticipated completion date – June 30, 2023 Corrective action Sterling College agrees with the finding of the under award and over award of federal aid for two students. During the 2022-2023 year we hired new financial aid staff that required significant training in the regulations of financial aid. Although checks and balances were in place these two instances were overlooked. Continued training, along with improved checks and balances through our updated software system, will enable the financial aid office to avoid issues with under and over-awarding federal student aid. The office will perform periodic reviews of awarding through reports from the system that will flag students who have potentially been under or over awarded federal aid.
View Audit 7826 Questioned Costs: $1
Finding 2023-001: Enrollment Reporting Contact person responsible for correction action – Mitzi Suhler, Financial Aid Director Anticipated completion date – June 30, 2023 Corrective action Sterling College agrees with the finding. A review of enrollment reporting is being done at the end of each...
Finding 2023-001: Enrollment Reporting Contact person responsible for correction action – Mitzi Suhler, Financial Aid Director Anticipated completion date – June 30, 2023 Corrective action Sterling College agrees with the finding. A review of enrollment reporting is being done at the end of each semester with particular attention being paid to students who have withdrawn during the semester or graduated at the end of the term. Along with reviewing those students, a random list of students that are not a part of the withdrawal or graduation list are being chosen for review, and if no student enrollment is found to be reported inaccurate, no further review is required per our policy. We feel that there are some changes soon that will help us with our enrollment reporting. One of them is that Sterling College is implementing a new version of our software system, Jenzabar, in 2024. This system will have better checks and balances for enrollment reporting, cleaner data, and will enable the College to have more accurate reporting. There will still be a need to do a review of each semester’s enrollment reporting. The financial aid office will review all student enrollment records that are enrolled for the semester to ensure the reporting dates are correct from this point forward. Once we have confidence that the system is doing what is expected, we will adjust the review to a random list of students.
Management’s Response and Planned Corrective Actions: 1. The name of the contact person(s) responsible for the corrective action a. Kathleen Broadhurst, Sr Director of Finance/ShelterCare b. Amanda Smith, Property Development Manager/ShelterCare 2. The corrective action planned: a. Pinehurst Managem...
Management’s Response and Planned Corrective Actions: 1. The name of the contact person(s) responsible for the corrective action a. Kathleen Broadhurst, Sr Director of Finance/ShelterCare b. Amanda Smith, Property Development Manager/ShelterCare 2. The corrective action planned: a. Pinehurst Management was overseeing property through 4/30/2023. ShelterCare was assigned as new managing agent 5/1/2023. b. ShelterCare is working to ensure that the onsite manager will be trained in HUD compliance. Training started in October 2023. c. We are currently prioritizing recertifications by oldest first so we are able to catch them up and get the property certifications back on track. d. Monthly review of Tenant Rental Assistance Certification System (TRACS) reports to ensure recertifications are being completed in a timely manner. 3. The anticipated completion date: e. New onsite HUD compliance training was started in October 2023 and to be completed by 12/31/2023. Monthly review of TRACS reports was implemented 10/1/2023.
While the total revenue amounts reported by the Organization were accurate, there were two quarters (the third and fourth quarters of calendar year 2021) where the amounts identified for individual payors were not correct by offsetting amounts. The Organization's controls in place for reporting subm...
While the total revenue amounts reported by the Organization were accurate, there were two quarters (the third and fourth quarters of calendar year 2021) where the amounts identified for individual payors were not correct by offsetting amounts. The Organization's controls in place for reporting submissions ensured that the grand totals for each quarter were correct, but did not identify that individual payor amounts were correct. Planned Corrective Action: The Organization agrees with this finding. The Organization will implement and document a secondary level of review prior to all submissions to ensure submitted amounts agree back to supporting documentation. Contact person responsible for corrective action: Nate Guzman, Controller Anticipated Completion Date: 12/6/2023
2023-001 Cash Disbursement Review and Approval. BPC established its policies and procedures that included processes for proper approval of all transactions in September of 2023 during the audit for the previous year. The transactions without approval were all prior to the new policy and procedure. T...
2023-001 Cash Disbursement Review and Approval. BPC established its policies and procedures that included processes for proper approval of all transactions in September of 2023 during the audit for the previous year. The transactions without approval were all prior to the new policy and procedure. The organization continues to follow written policies and procedures for proper approval of all transactions posted in the general ledger.
Reportable Condition: 2023-003 Check Issued for a Materially Misstated Amount Recommendation: Follow internal controls already in place, double check work prior to finalizing, and provide education to the personnel on the proper procedures and internal controls. Action: We are currently follow...
Reportable Condition: 2023-003 Check Issued for a Materially Misstated Amount Recommendation: Follow internal controls already in place, double check work prior to finalizing, and provide education to the personnel on the proper procedures and internal controls. Action: We are currently following the recommendation. Also, we feel that this was an isolated instance and personnel changes have been made.
View Audit 7557 Questioned Costs: $1
In Finding 2023-004, it was reported that the Provider Relief Fund report submitted to DHHS for Phase 4 funding contained incorrect data. The expenditures of the funding were reported in periods prior to the year ended May 31, 2022 when the funds were expended during the year ended May 31, 2022. Ma...
In Finding 2023-004, it was reported that the Provider Relief Fund report submitted to DHHS for Phase 4 funding contained incorrect data. The expenditures of the funding were reported in periods prior to the year ended May 31, 2022 when the funds were expended during the year ended May 31, 2022. Management recognizes the importance of complying with federal reporting guidelines. In response to Finding 2023-004, efforts will be made to ensure that reporting submitted to the DHHS is accurately completed. This will be implemented by the Chief Financial Officer and completed by December 31, 2023.
2023-A Budgetary Compliance Criteria: The Budgetary Compliance guidelines require the School to limit total expenditures, by fund, to the amounts appropriated in the final adopted budget. Condition: The School had total expenditures in the general fund that exceeded the final adopted budgeted amount...
2023-A Budgetary Compliance Criteria: The Budgetary Compliance guidelines require the School to limit total expenditures, by fund, to the amounts appropriated in the final adopted budget. Condition: The School had total expenditures in the general fund that exceeded the final adopted budgeted amounts. Cause: Total expenditures for the year ended June 30, 2023, exceeded the budgeted amount. This is due to the School exceeding budget primarily with instructional expenditures for salaries and benefits. Effect: Expenditures in excess of the final adopted budgeted amounts. Recommendation: We recommend that management ensures their final adopted budget amounts are sufficient to cover the total expenditures by fund. Management Response: Management agrees with this finding and plans to implement additional control procedures and training of personnel to ensure that expenditures by fund don’t exceed the final adopted budgeted amounts. 53
Finding 2023-004 Eligibility Administration for Children and Families FFAL 93.566 Refugee and Entrant Assistance – State Administered Programs Finding Summary: a. Four participant case files were not reviewed through the Organization’s peer review process and two participant case files were not revi...
Finding 2023-004 Eligibility Administration for Children and Families FFAL 93.566 Refugee and Entrant Assistance – State Administered Programs Finding Summary: a. Four participant case files were not reviewed through the Organization’s peer review process and two participant case files were not reviewed in a timely manner through the Organization’s peer review process. b. Four instances in which the family’s first month’s prorated cash assistance payment was not properly calculated based upon the date the Cooperative Agreement and Rights and Responsibilities Form was signed by the client. c. One instance in which a family was underpaid based upon their family size and eligibility for the month. d. One instance in which a family was moved from the Refugee Cash Assistance program to another program and the expenses remained to be charged under the Refugee Cash Assistance program. Responsible Individuals: Nathan Beyer, Sheri Ekdom, Tim Jurgens Corrective Action Plan: a. The procedures for case file review will be reviewed to ensure the process can be followed, even when there is turnover in staff. b. The procedures will be reviewed with staff, and an additional review put in place where necessary, to ensure staff are fully trained on how to calculate the arrival date for proration of the first month of payments. c. The procedures will be reviewed with staff, and an additional review put in place where necessary, to ensure staff are fully trained on how to calculate family size and eligibility. d. The procedures will be reviewed with staff for removing a client from the program, and notifying staff to void checks. The checks in question were voided and credited back to the grant for $481.48 and $878.00 in September 2023 which is within the grant’s budget period. LSS is also implementing a new software program to help the review process be more efficient, and less reliant on manual processes. Checks and balances will be integrated into the software, allowing for electronic review of files. The software will also help automate some of the ongoing documentation requirements. Anticipated Completion Date: December 31, 2023
View Audit 7260 Questioned Costs: $1
Action Taken: The cost of implementing a complete set of controls far outweighs the benefits derived by such. It is not financially feasible to have a complete set of controls.
Action Taken: The cost of implementing a complete set of controls far outweighs the benefits derived by such. It is not financially feasible to have a complete set of controls.
Finding 2023-003 Reporting – Material Weakness in Internal Control Over Compliance Federal/State Agency Name: Department of Justice and State of South Dakota Department of Public Safety Program Name: Crime Victim Assistance FFAL # 16.575, 2022-COMBO-00022 Finding Summary: The Victims’ Service final ...
Finding 2023-003 Reporting – Material Weakness in Internal Control Over Compliance Federal/State Agency Name: Department of Justice and State of South Dakota Department of Public Safety Program Name: Crime Victim Assistance FFAL # 16.575, 2022-COMBO-00022 Finding Summary: The Victims’ Service final financial report was not completed until requested by the auditors. Responsible Persons: Shannon Clark, Chief Financial Officer Lynn Peterson, Controller Michelle Tarrell, Finance Administrator Corrective Action Plan: A Finance Administrator has been designated for each Federal Financial Assistance Program. The Controller and Finance Administrator(s) will monitor and ensure reporting requirements are timely completed. Anticipated Completion Date: June 30, 2024
Finding 4939 (2023-001)
Material Weakness 2023
Finding 2023-001 Finding Summary: Entheos Academy is required to submit an annual performance report to the State of Utah detailing GEER and ESSER expenditures by subgrant fund, expenditure category, object code, number of specific positions supported with GEER and ESSER funds, allocation of GEER an...
Finding 2023-001 Finding Summary: Entheos Academy is required to submit an annual performance report to the State of Utah detailing GEER and ESSER expenditures by subgrant fund, expenditure category, object code, number of specific positions supported with GEER and ESSER funds, allocation of GEER and ESSER funds and criteria used and number of full-time equivalent positions for all GEER & ESSER funds received from the USBE during the period of July 1, 2021 to June 30, 2022. Entheos Academy ESSER expenditures and number of specific positions supported with ESSER funds for funds received outside of the required reporting period. Responsible Individuals: Brian Cates, Business Manager and Ester Blackwell Executive Director Corrective Action Plan: Management will provide the USBE with the correct ESSER expenditures and number of specific positions supported with ESSER funds for the correct reporting period. Anticipated Completion Date: Ongoing Anticipated Completion Date: Management will ensure all necessary corrective action plan items are in place by the end of the next reporting period.
Segregation of Duties - ESSER Elementary and Secondary School Emergency Relief – Assistance Listing No. 84.425U Recommendation: CLA recommends the District review its processes related to entering approved wage rates and salary amounts into the payroll system and implement a control where someone ot...
Segregation of Duties - ESSER Elementary and Secondary School Emergency Relief – Assistance Listing No. 84.425U Recommendation: CLA recommends the District review its processes related to entering approved wage rates and salary amounts into the payroll system and implement a control where someone other than the payroll position review a report of all payroll rate changes and compare that to Board approved rates to help ensure the proper amount is used. CLA also recommends that the District implement a formal review process over the reporting requirement relating to ESSER annual reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will implement additional controls in response to this finding. When payroll rate changes occur payroll personnel will process a report of all pay records for the Superintendent to review and compare to the board approved rates to ensure accurate rates are being used. He will sign off on the report and it will be retained. In addition, the Superintendent will add a review process for all reporting requirements related to ESSER reports. The District Accountant will continue to prepare the ESSER annual report and the Superintendent will subsequently review and approve this report. Name(s) of the contact person(s) responsible for corrective action: Garrett Rogowski Planned completion date for corrective action plan: 2023-24 fiscal year
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