Corrective Action Plans

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Management agrees with the finding related to effort certifications. Dartmouth-Hitchcock published a new effort policy on February 11, 2025, for all research staff to emphasize the importance of Principal Investigators and Research Staff certifying their efforts on grants promptly. Management will b...
Management agrees with the finding related to effort certifications. Dartmouth-Hitchcock published a new effort policy on February 11, 2025, for all research staff to emphasize the importance of Principal Investigators and Research Staff certifying their efforts on grants promptly. Management will begin implementing and enforcing the policy starting with the quarter ending March 31, 2025. Leadership Responsible: John Muhlen, System Vice President of Corporate Finance Anticipated Completion Date: March 31, 2025
Management agrees with the finding related to cost transfer approval. The Dartmouth-Hitchcock Office of Research Operations experienced significant turnover in Fiscal Year 2024. Management will provide training materials for all new and existing staff in both the Research Post-Award and Research Fi...
Management agrees with the finding related to cost transfer approval. The Dartmouth-Hitchcock Office of Research Operations experienced significant turnover in Fiscal Year 2024. Management will provide training materials for all new and existing staff in both the Research Post-Award and Research Finance areas to reemphasize the Cost Transfer Policy. Additionally, management will review the current policy on cost transfers to determine whether any updates are needed to better align with current business practices and compliance requirements by June 30, 2025. Leadership Responsible: John Muhlen, System Vice President of Corporate Finance Anticipated Completion Date: June 30, 2025
Views of Responsible Officials and Planned Corrective Action: Quincy Asian Resources, Inc. agrees with the finding and will develop and implement policies and procedures to ensure that only actual hours spent working on the grant are charged to the grant as direct labor. The Organization is transit...
Views of Responsible Officials and Planned Corrective Action: Quincy Asian Resources, Inc. agrees with the finding and will develop and implement policies and procedures to ensure that only actual hours spent working on the grant are charged to the grant as direct labor. The Organization is transitioning to a new Time & Attendance system, which will address these issues.
View Audit 351904 Questioned Costs: $1
Views of Responsible Officials and Planned Corrective Action: While Quincy Asian Resources, Inc. concurs with the ultimate outcome identified in the finding, we want to emphasize our review indicates all transactions were handled with appropriate intent. The identified adjustments were primarily due...
Views of Responsible Officials and Planned Corrective Action: While Quincy Asian Resources, Inc. concurs with the ultimate outcome identified in the finding, we want to emphasize our review indicates all transactions were handled with appropriate intent. The identified adjustments were primarily due to timing of personnel transitions on our accounting department. To further strengthen our financial reporting processes, we have subsequently hired a new controller with extensive nonprofit accounting experience. This addition to our team Views of Responsible Officials and Planned Corrective Action: While Quincy Asian Resources, Inc. concurs with the ultimate outcome identified in the finding regarding timesheet the identified documentation issues stemmed from procedural gaps in our timekeeping processes rather than any misuse of funds. Our internal review confirms employees dedicated appropriate time to grant activities, but our timecard reporting system did not adequately capture this effort due to: 1. Staff’s incomplete understanding of federal documentation requirements 2. Need for enhanced timesheet review protocols 3. Limitations of our current time tracking system To strengthen our processes, we are: 1. Implementing a new time tracking system better aligned with federal requirements 2. Providing comprehensive training to all employees on proper time reporting 3. Training supervisors on thorough timesheet review procedures 4. Enhancing our internal controls around time documentation These improvements will ensure our documentation fully supports the valuable grant-funded services we provide to the community
View Audit 351904 Questioned Costs: $1
Views of Responsible Officials and Planned Corrective Action: Quincy Asian Resources, Inc. agrees with the finding and will develop and implement policies and procedures to ensure that only actual hours spent working on the grant are charged to the grant as direct labor. The Organization is transit...
Views of Responsible Officials and Planned Corrective Action: Quincy Asian Resources, Inc. agrees with the finding and will develop and implement policies and procedures to ensure that only actual hours spent working on the grant are charged to the grant as direct labor. The Organization is transitioning to a new Time & Attendance system, which will address these issues.
View Audit 351904 Questioned Costs: $1
Views of Responsible Officials and Planned Corrective Action: While Quincy Asian Resources, Inc. concurs with the ultimate outcome identified in the finding regarding timesheet the identified documentation issues stemmed from procedural gaps in our timekeeping processes rather than any misuse of fun...
Views of Responsible Officials and Planned Corrective Action: While Quincy Asian Resources, Inc. concurs with the ultimate outcome identified in the finding regarding timesheet the identified documentation issues stemmed from procedural gaps in our timekeeping processes rather than any misuse of funds. Our internal review confirms employees dedicated appropriate time to grant activities, but our timecard reporting system did not adequately capture this effort due to: 1. Staff’s incomplete understanding of federal documentation requirements 2. Need for enhanced timesheet review protocols 3. Limitations of our current time tracking system To strengthen our processes, we are: 1. Implementing a new time tracking system better aligned with federal requirements 2. Providing comprehensive training to all employees on proper time reporting 3. Training supervisors on thorough timesheet review procedures 4. Enhancing our internal controls around time documentation These improvements will ensure our documentation fully supports the valuable grant-funded services we provide to the community
View Audit 351904 Questioned Costs: $1
Concur: The Maricopa County Human Services Department will update its procedures involving subaward actions as required by FFATA and Federal Uniform Guidance. These internal procedures will include reporting subaward actions equaling or exceeding more than $30,000 no later than month-end following t...
Concur: The Maricopa County Human Services Department will update its procedures involving subaward actions as required by FFATA and Federal Uniform Guidance. These internal procedures will include reporting subaward actions equaling or exceeding more than $30,000 no later than month-end following the subaward action. Additionally, the Department has updated all tracking listings and will ensure all grants contracted through other departments and amendments are included. On February 27, 2025, the Department completed and submitted the required FFATA form to USAspending.gov.
Condition: During audit procedures, we noted expenditures were charged to the program via adjusting journal entry for which adequate supporting documentation could not be provided. Corrective Actions: Going forward, the Organization will implement procedures requiring supporting documentation for a...
Condition: During audit procedures, we noted expenditures were charged to the program via adjusting journal entry for which adequate supporting documentation could not be provided. Corrective Actions: Going forward, the Organization will implement procedures requiring supporting documentation for all journal entries made to the program to ensure that amount charged to the program are actual expenses/expenditure of the program. Employee Responsible for Corrective Action: Michelle Clarke Completion Date: March 31, 2025
View Audit 351890 Questioned Costs: $1
Condition: During the audit several adjusting journal entries were proposed. These entries would have a material effect on the financial statements if not proposed and recorded. Corrective Actions: Going forward, the Organization will implement procedures to perform a more comprehensive monthly clo...
Condition: During the audit several adjusting journal entries were proposed. These entries would have a material effect on the financial statements if not proposed and recorded. Corrective Actions: Going forward, the Organization will implement procedures to perform a more comprehensive monthly closing, especially at year end, to ensure that all general ledger accounts are reviewed and reconciled to arrive at a complete and accurate set of books and records to be audited. Employee Responsible for Corrective Action: Michelle Clarke Completion Date: March 31, 2025
Condition: During audit procedures, it was noted total reimbursements received exceeded expenditures. The Organization has charged costs to the program and received reimbursement; however, the products cost charged to the program had not been received prior to June 30, 2024. Corrective Actions: Goi...
Condition: During audit procedures, it was noted total reimbursements received exceeded expenditures. The Organization has charged costs to the program and received reimbursement; however, the products cost charged to the program had not been received prior to June 30, 2024. Corrective Actions: Going forward, the Organization will review all vouchers being charged to the program to make sure costs have been incurred before being charged to the program. Employee Responsible for Corrective Action: Michelle Clarke Completion Date: March 31, 2025
View Audit 351890 Questioned Costs: $1
Reference Number: 2024-001 Name of Contact Person: Kelly Nakamura Phone: 530-642-7167 Email: Kelly.nakamura@edcgov.us Corrective Action: • Increasing Staffing Levels: o By April 1, 2025, the County will have 11 newly trained Eligibility Specialists who are fully trained to proces...
Reference Number: 2024-001 Name of Contact Person: Kelly Nakamura Phone: 530-642-7167 Email: Kelly.nakamura@edcgov.us Corrective Action: • Increasing Staffing Levels: o By April 1, 2025, the County will have 11 newly trained Eligibility Specialists who are fully trained to process Medi-Cal applications. o Ongoing recruitment efforts will continue to fill vacant positions, including the hiring additional trainees to build capacity for timely eligibility determinations. • Improving Internal Processes: o The County is conducting a review of workflows to identify inefficiencies and implement streamlined processes that eliminate bottlenecks. o Digital tools and automation are being introduced to enhance efficiency and accuracy case processing. • Providing Additional Support: o Overtime opportunities are being offered to eligibility specialists to expedite the processing of pending cases. o Applications are being assigned to Eligibility Specialists on a weekly basis to ensure consistent progress in reducing the backlog. • Enhancing Monitoring and Reporting: o Administrative staff are generating weekly reports from CalSAWS to track the status Medi-Cal pending applications and monitor progress. o Weekly meetings are being held with supervisors to review performance, discuss challenges, and adjust strategies as needed. • Strengthening Internal Controls: o The County is improving its internal controls to prevent future delays, including increased use of system reports to identify applications nearing the 45-day processing requirement, regular audits of the eligibility determination process and enhanced compliance training for staff. • Ongoing Evaluation and Adaptation: o Progress will be assessed weekly to ensure the implemented measures are effective. Adjustments will be made as needed to maintain compliance with the 45-day requirement. Proposed Completion Date: The county has already implemented this process and expects it to be completed by July 31, 2026.
Reporting - FSRS Block Grants for Prevention & Treatment of Substance Abuse - FSRS were not timely submitted resulting in noncompliance with the reporting requirement. Corrective Action Plan: ADAD will meet with the program staff to complete the implementation of the policies and procedures relating...
Reporting - FSRS Block Grants for Prevention & Treatment of Substance Abuse - FSRS were not timely submitted resulting in noncompliance with the reporting requirement. Corrective Action Plan: ADAD will meet with the program staff to complete the implementation of the policies and procedures relating to the reporting of subawards to the new FSRS system to comply with the Federal reporting requirements. Implementation Date: July 1, 2025 Responding Official: John Valera and Melanie Muraoka, Administrative Officer/Alcohol and Drug Abuse Division
Earmarking Earmarking requirement was not met. Corrective Action Plan: State Procurement rules occasionally make it difficult to spend the earmark by the deadline. In the future, the committee that governs these earmarks will be more proactive about monitoring planned procurements to ensure they are...
Earmarking Earmarking requirement was not met. Corrective Action Plan: State Procurement rules occasionally make it difficult to spend the earmark by the deadline. In the future, the committee that governs these earmarks will be more proactive about monitoring planned procurements to ensure they are moving through the process so funds can be spent. In addition, vacancies contributed to falling short of the earmarking requirement, since those personnel funds were not spent. Vacancies will be monitored quarterly for re-allocation opportunities, and workforce development strategies will be developed and implemented to address shortages. Implementation Date: July 1, 2025 Responding Official: Keli, Acquaro, Administrator, Child & Adolescent Mental Health Division
Reporting - FSRS Substance Abuse and Mental Health Services - FSRS were not timely submitted resulting in noncompliance with the reporting requirement. Corrective Action Plan: Complete the implementation of the policies and procedures relating to the reporting of subawards to the new FSRS system to ...
Reporting - FSRS Substance Abuse and Mental Health Services - FSRS were not timely submitted resulting in noncompliance with the reporting requirement. Corrective Action Plan: Complete the implementation of the policies and procedures relating to the reporting of subawards to the new FSRS system to comply with the Federal reporting requirements. Implementation Date: April 1, 2025 Responding Official: John Valera and Melanie Muraoka, Administrative Officer/Alcohol and Drug Abuse Division
Finding 547943 (2024-003)
Significant Deficiency 2024
City staff will reconcile the employee’s time records to ensure accurate reporting.
City staff will reconcile the employee’s time records to ensure accurate reporting.
View Audit 351875 Questioned Costs: $1
Management will work with Athena to correct the workflow to ensure slide fees are adjusted at the correct updated Federal Poverty Level at the beginning of the new year. Organization contact persons responsible for corrective action: Michele Sarrett Anticipated completion date: 12/31/2025
Management will work with Athena to correct the workflow to ensure slide fees are adjusted at the correct updated Federal Poverty Level at the beginning of the new year. Organization contact persons responsible for corrective action: Michele Sarrett Anticipated completion date: 12/31/2025
Management agrees with the auditors' recommendations. The UDS formulas were updated and the issues corrected for the 2024 UDS report. In the upcoming year it is expected that new accounting leadership and Grant Management will work together to ensure the accuracy of the UDS Report. Organization con...
Management agrees with the auditors' recommendations. The UDS formulas were updated and the issues corrected for the 2024 UDS report. In the upcoming year it is expected that new accounting leadership and Grant Management will work together to ensure the accuracy of the UDS Report. Organization contact persons responsible for corrective action: Michele Sarrett Anticipated completion date: 12/31/2025
We gave instructions to the Finance Department Director to strengthen internal procedures and controls to ensure accurate preparation and submission of financial reports within the required timeframe. Implementation Date: April 1, 2025. Responsible Person: Mrs. Rosa J. La Torre Santiago, Executive...
We gave instructions to the Finance Department Director to strengthen internal procedures and controls to ensure accurate preparation and submission of financial reports within the required timeframe. Implementation Date: April 1, 2025. Responsible Person: Mrs. Rosa J. La Torre Santiago, Executive Director
FY24 interest in the amount of$331.01 was returned to USDHHS PS Program Suppmi Center on 1/30/2025. We are keeping a smaller balance in the Federal Funds bank account to lessen the amount of interest earned on the account. Any amount over $500 at the end of the fiscal year will be returned through t...
FY24 interest in the amount of$331.01 was returned to USDHHS PS Program Suppmi Center on 1/30/2025. We are keeping a smaller balance in the Federal Funds bank account to lessen the amount of interest earned on the account. Any amount over $500 at the end of the fiscal year will be returned through the same process as prior years. Responsible Person for Correction Action Plan: Deana Rogers, Vice President of Administration & Finance Implementation Date/or Corrective Action Plan: 01/30/25
View Audit 351835 Questioned Costs: $1
Identification and Review • Students clocked in during scheduled class times. Blackburn did not initially educate nor send reminders to students and faculty about students not being able to clock in during class times. • During the 2023-2024 fiscal year, there was a transition in the Dean of Work ro...
Identification and Review • Students clocked in during scheduled class times. Blackburn did not initially educate nor send reminders to students and faculty about students not being able to clock in during class times. • During the 2023-2024 fiscal year, there was a transition in the Dean of Work role. There was not as much oversight of student payroll reports Corrective Actions • The Work Office and Provost Office has increased communication and education about students not being able to work during scheduled class times. Reminders have also been sent out. • The Work Office now has a Dean of Work who is educated about how to run student payroll. Process and Policy Improvements • Starting in the Fall 2024 semester, the Work Office and Provost Office increased awareness and communication regarding students not being allowed to work during scheduled class times. • Student Communication- Student managers communicated with student employees at monthly department meetings and through electronic communication that students are not allowed to clock in during scheduled class times. The exception is when their class is cancelled, and students must send the class cancellation notice (email from Professor or screenshot of Learning Management System announcement) to the Work Office before clocking in during the cancelled class time. Once the cancelled claim information is received, it is added to a spreadsheet maintained jointly by the Provost and Work Office. Professor Communication- The Provost sent an electronic communication to all professors notifying them they must communicate with the Provost and Work Office when they cancel a class. Once the cancelled class information is received, it is added to a spreadsheet maintained jointly by the Provost and Work Office. • Additionally, the Work Office reached out to our time tracking and payroll software vendor to identify a solution to limit students' ability to clock in during scheduled class times. Monitoring and Compliance • The Work Office and Provost Office will dedicate time to educate and remind students and faculty that students are not allowed to work during scheduled class time, and how to report a cancelled class. • The Work Office will dedicate time to double check the student payroll reports before sending them to Human Resources. • The Dean of Work will ensure students are educated in department meetings and through electronic communication that they are not allowed to clock in to work during scheduled class times, and how to report a cancelled class. • The Dean of Work will coordinate with the Provost Office to ensure faculty are educated about students not being able to clock in during scheduled class times, and how to report a class cancellation. • The Dean of Work will randomly select 10 students each payroll to ensure they are not clocking in during their scheduled class times. • The Dean of Work will also ensure that the student payroll is double checked before sending to Human Resources. Reporting and Documentation • Fall 2024 o Student managers educated students during their first department meeting And students also received electronic communication that they could not work during a scheduled class time, and informed them how to report a cancelled class. o The Provost Office sent electronic communication to faculty on the importance of reporting a class cancellation. • Spring 2025 o Student managers educated students during their first department meeting and students also received electronic communication that they could not work during a scheduled class time, and informed them how to report a cancelled class. o The Provost Office sent electronic communication to faculty on the importance of reporting a class cancellation. o The Work Office is facilitating monthly Supervisor trainings. In the February training, supervisors were informed verbally and in writing about students not being able to work during scheduled class times, and what documentation is needed when a class is cancelled. • Fall 2025 o The Work Office will facilitate a Supervisor training before the academic year begins. In the training, we will review policies and procedures with one of them being students not being able to clock in during scheduled class times. Responsible Person for Correction Action Plan: Leslie Johnson, Dean of Work Implementation Date for Corrective Action Plan: 09/03/24
View Audit 351835 Questioned Costs: $1
Identification and Review • Conduct an internal audit to identify all students who failed all courses and determine the last date of attendance for each. • Review institutional records (For example, faculty attendance records, Learning Management or participation records) to establish when students ...
Identification and Review • Conduct an internal audit to identify all students who failed all courses and determine the last date of attendance for each. • Review institutional records (For example, faculty attendance records, Learning Management or participation records) to establish when students stopped engaging academically • Verify whether R2T4 calculations should have been performed Corrective Actions • Process R2T4 calculations for affected students based on their last date of attendance • Return any unearned Title IV funds • Update students file to reflect accurate withdrawal dates and notify them of any financial obligations resulting from the adjustment • If students are still enrolled in future terms, ensure they understand satisfactory academic progress (SAP) implications Process and Policy Improvements • Implement an early alert system to identify students who cease attendance before the end of the term. • Strengthen collaboration between academic departments, the registrar, and the financial aid office to improve withdrawal tracking • Run monthly withdrawal reports to see when students earn all failing grades. Monitoring and Compliance • Conduct regular audits to ensure compliance with R2T4 regulations and timely student withdrawals • Provide staff training on withdrawal procedures and the importance of accurately tracking last dates of attendance. • Establish a set time to review withdrawal policies and ensure adherence to federal regulations. Reporting and Documentation • Maintain detailed records of all identified cases, R2T4 calculations, and funds returned. • Document all policy and procedural updates made to prevent recurrence. • If required, submit a report to the U.S. Department of Education outlining corrective actions taken. Responsible Person for Correction Action Plan: Alexis Brown, Director of Financial Aid Implementation Date for Corrective Action Plan: 2/25/25
View Audit 351835 Questioned Costs: $1
Identification and Review • Conduct an internal audit of all financial aid awards for the affected students to determine the extent of the overaward • Identify the sources of aid contributing to the excess amount and whether any adjustments can be made within the same academic year. • Review packagi...
Identification and Review • Conduct an internal audit of all financial aid awards for the affected students to determine the extent of the overaward • Identify the sources of aid contributing to the excess amount and whether any adjustments can be made within the same academic year. • Review packaging procedures to pinpoint the cause of the discrepancy (e.g., late outside scholarships, system errors, or manual adjustments Student Award Adjustments • Reduce or cancel institutional or federal aid (such as loans, Federal Work-Study, or certain grants) in accordance with federal regulations and institutional policies. • Notify students of any changes to their financial aid package and provide guidance on alternative funding options if needed. Process and Policy Improvements • Implement a cross-check system for all financial aid components and strengthen internal controls to ensure total aid does not exceed COA before disbursement • Implement additional system checks and alerts in the financial aid management system to flag overawards automatically. • Require timely reporting of external scholarships and third-party payments to prevent adjustments after disbursement Monitoring and Compliance • Conduct periodic reconciliation of student aid packages throughout the academic year to prevent overawards • Train financial aid staff on COA regulations and best practices for awarding aid Responsible Person for Correction Action Plan: Alexis Brown, Director of Financial Aid Implementation Date for Corrective Action Plan: 2/25/25
View Audit 351835 Questioned Costs: $1
Identification and Review • Identify all students who received incorrect loan amounts (Completed) • Make appropriate adjustments to loan disbursements (Completed) • Notify affected students and provide guidance on next steps (Completed) Policy and Procedure Enhancements • Develop clear, written proc...
Identification and Review • Identify all students who received incorrect loan amounts (Completed) • Make appropriate adjustments to loan disbursements (Completed) • Notify affected students and provide guidance on next steps (Completed) Policy and Procedure Enhancements • Develop clear, written procedures for verifying loan amounts prior to disbursement • Implement a two-step verification process for loan packaging System Controls • Collaborate with IT to implement automated system checks to flag discrepancies • Enhance reporting tools for regular audits and monitoring Staff Training • Conduct comprehensive training sessions for financial aid staff on federal regulations regarding Direct Loans • Provide ongoing refresher courses and updates as federal policies change Monitoring Continuous Improvement • Establish a quarterly audit process to ensure compliance • Monitor loan discrepancies detected and correct as needed • Conduct regular audits to confirm compliance with federal loan regulations. • Collect feedback from staff on the effectiveness of training Responsible Person for Correction Action Plan: Alexis Brown, Director of Financial Aid Implementation Date for Corrective Action Plan: 03/03/25
Identification and Review • Immediately review and recalculate the subsidized need for the affected students. (Completed) • Identify the sources of aid contributing to the excess amount and whether any adjustments can be made within the same academic year • Adjust the loan amounts as necessary and r...
Identification and Review • Immediately review and recalculate the subsidized need for the affected students. (Completed) • Identify the sources of aid contributing to the excess amount and whether any adjustments can be made within the same academic year • Adjust the loan amounts as necessary and return any excess funds to the Department of Education. (Completed) • Review packaging procedures to pinpoint the cause of the discrepancy (e.g., late outside scholarships, system errors, or manual adjustments Student Award Adjustments • Reduce or cancel institutional or federal aid (such as loans, Federal Work-Study, or certain grants) in accordance with federal regulations and institutional policies • If the excess aid cannot be adjusted within the same academic year, follow federal guidelines to return any over awarded federal funds through the Common Origination and Disbursement (COD) system • Notify students of any changes to their financial aid package and provide guidance on alternative funding options if needed System Enhancements • Implement system-level edits and warnings in the financial aid software to flag over-awards before disbursement. • Schedule regular audits of loan disbursements to ensure ongoing compliance Policy and Procedure Update • Update the financial aid packaging policy to include stricter controls for verifying subsidized need calculations. • Implement a cross-check system for all financial aid components before loan disbursement • Require timely reporting of external scholarships and third-party payments to prevent adjustments after disbursement Monitoring and Compliance • Conduct training sessions for financial aid staff on loan eligibility calculations. • Conduct periodic reconciliation of student aid packages throughout the academic year to prevent over awards • Provide guidance on using the financial aid management system's tools to avoid over-awards Responsible Person for Correction Action Plan: Alexis Brown, Director of Financial Aid Implementation Date for Corrective Action Plan: 02/25/25
View Audit 351835 Questioned Costs: $1
FINDING 2024-005 – Allowable Costs; Significant Deficiency in Internal Control over Compliance Views of responsible officials and planned corrective actions: Management agrees with the assessment and understands the importance of strong controls surrounding payroll allocation. The Organization has w...
FINDING 2024-005 – Allowable Costs; Significant Deficiency in Internal Control over Compliance Views of responsible officials and planned corrective actions: Management agrees with the assessment and understands the importance of strong controls surrounding payroll allocation. The Organization has worked hard to bring the new payroll so􀅌ware in line with the complex requirements of grant accounting and at the time of this audit issuance the error has been resolved. The Organization will complete employee level reviews each payroll to ensure that salaries and benefits continue to be allocated accurately according to hours charged to programs. The Organization is in the process of revising the accounting policy manual with the full revision expected to be completed by December 2025. Individual policies will be submited to the board for approval as they are revised. Contact Persons: Ryan Berendsen, Chief Operating Officer Delana Kromer, Controller
View Audit 351833 Questioned Costs: $1
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