Corrective Action Plans

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2024-004 Eligibility U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement policies and procedures to ensure that the necessary controls are in place to properly verify the eligibility of all Youth Activities participants. Act...
2024-004 Eligibility U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement policies and procedures to ensure that the necessary controls are in place to properly verify the eligibility of all Youth Activities participants. Action Taken: The Board has established policies and procedures to strengthen eligibility verification for the Youth program participants. These policies outline clear documentation requirements, verification steps, and staff responsibilities. Staff involved in eligibility determination have been trained on the new procedures to ensure consistency and compliance with federal and state guidelines and will receive ongoing training and technical assistance. The Board has implemented internal controls, including multi-level verification and supervisory review to ensure the accuracy and completeness of participant eligibility determinations.
View Audit 350052 Questioned Costs: $1
2024-003 Subrecipient Monitoring U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement its recently adopted policies and procedures and commit the appropriate personnel to subrecipient monitoring to ensure that the Board is in ...
2024-003 Subrecipient Monitoring U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement its recently adopted policies and procedures and commit the appropriate personnel to subrecipient monitoring to ensure that the Board is in compliance with all federal requirements. Action Taken: The Board has formally integrated the new adopted policies and procedures into our operational framework to ensure consistency and adherence to federal guidelines. Specific staff members have been designated to subrecipient monitoring responsibilities, ensuring adequate oversight and compliance. Executive staff will conduct period internal reviews to assess the effectiveness of our monitoring processes and make improvements as needed.
View Audit 350052 Questioned Costs: $1
2024-002 Reporting U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board design and implement controls to ensure that all required reporting is submitted accurately and in a timely fashion. Action Taken: Region III will establish cle...
2024-002 Reporting U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board design and implement controls to ensure that all required reporting is submitted accurately and in a timely fashion. Action Taken: Region III will establish clear documentation checklist with requirements for each report to ensure completeness and accuracy. Assign specific roles and responsibilities for report preparation, review and approval before submission to ensure that multiple levels of review are in place.
View Audit 350052 Questioned Costs: $1
2024-001 Activities Allowed or Unallowed U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board design and implement controls to ensure that all charges to federal programs are adequately reviewed and approved prior to payment. Action T...
2024-001 Activities Allowed or Unallowed U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board design and implement controls to ensure that all charges to federal programs are adequately reviewed and approved prior to payment. Action Taken: Region III will create a detailed workflow of the approval process that includes the following: Initial request, review by finance department, and approval by designated individuals. Ensure that no single individual has control over all aspects of the charge approval process. We will schedule quarterly internal audits to review samples of transactions for compliance.
View Audit 350052 Questioned Costs: $1
Finding 2024-003 – Capital Fund Grant Reconciliations – Special Tests – Significant Deficiency Capital Fund Program – ALN #14.872 Corrective Action Plan: The Housing Authority has brough forward all schedules related to Capital Fund Grant as of March 2025. Person Responsible: Sheila Crisp, Executi...
Finding 2024-003 – Capital Fund Grant Reconciliations – Special Tests – Significant Deficiency Capital Fund Program – ALN #14.872 Corrective Action Plan: The Housing Authority has brough forward all schedules related to Capital Fund Grant as of March 2025. Person Responsible: Sheila Crisp, Executive Director Anticipated Completion Date: June 2025
Finding 539480 (2024-010)
Significant Deficiency 2024
Cash Management – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit...
Cash Management – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Director will ensure that when processes are completed, they are verifiable through documentation. Credit Balance refunds as well as drawdowns will be tracked for proper compliance requirements. Name(s) of the contact person(s) responsible for corrective action: Levi Powell, Student Financial Aid Director Planned completion date for corrective action plan: 6/30/2025
Finding 539478 (2024-009)
Significant Deficiency 2024
Special Tests and Provisions Direct Loan Reconciliation – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding:...
Special Tests and Provisions Direct Loan Reconciliation – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid director will institute a documented review of the Direct Loan reconciliations prepared by Campus Ivy or future third-party processors. Name(s) of the contact person(s) responsible for corrective action: Levi Powell, Student Financial Aid Director Planned completion date for corrective action plan: 6/30/2025
Finding 539476 (2024-008)
Significant Deficiency 2024
Special Tests and Provisions 240 Day Checks – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no...
Special Tests and Provisions 240 Day Checks – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid office along with Student Accounts and the Business Office at Urshan University will collaborate on an SOP which will establish a process of reviewing any outstanding Title IV checks. Checks will be reissued as necessary to ensure the university stays compliant with all Title IV regulations. Name(s) of the contact person(s) responsible for corrective action: Levi Powell, Student Financial Aid Director Planned completion date for corrective action plan: 6/30/2025
Finding 539474 (2024-007)
Significant Deficiency 2024
Eligibility – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit fin...
Eligibility – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid office will be implementing an SOP which will document a review process of work done by the third-party processor, to include COD reporting, and Verification procedures. We will also be implementing a process to review students who need to complete their exit counseling. Name(s) of the contact person(s) responsible for corrective action: Levi Powell, Student Financial Aid Director Planned completion date for corrective action plan: 6/30/2025
View Audit 350009 Questioned Costs: $1
Finding 539472 (2024-006)
Significant Deficiency 2024
Special Tests and Provisions Gramm-Leach-Bliley Act– Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: Ther...
Special Tests and Provisions Gramm-Leach-Bliley Act– Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The IT department continues to improve its processes; an annual review of the WISP has been started and will continue. The Financial Aid Office will work with IT to make sure that the WISP is improved to include and provide secure disposal of customer information and make sure the review is documented. Name(s) of the contact person(s) responsible for corrective action: Levi Powell, Student Financial Aid Director Planned completion date for corrective action plan: 6/30/2025
View Audit 350009 Questioned Costs: $1
Special Tests and Provisions R2T4 – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreeme...
Special Tests and Provisions R2T4 – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid office will be crafting a new SOP to address R2T4 audit findings. The team will work more closely with the Registrar and Academic Deans when determining the withdrawal status of a student and make sure that the R2T4 documentation is accurately completed, a review of completed R2T4s will also be conducted. Name(s) of the contact person(s) responsible for corrective action: Levi Powell, Student Financial Aid Director Planned completion date for corrective action plan: 6/30/2025
View Audit 350009 Questioned Costs: $1
Finding 539468 (2024-004)
Significant Deficiency 2024
Special Tests and Provisions Enrollment Reporting – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College provide additional resources to ensure all compliance requirements are met. Explanation of disagreement with audit finding: There is no disagreement with the audit find...
Special Tests and Provisions Enrollment Reporting – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College provide additional resources to ensure all compliance requirements are met. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A new Standard Operating Procedure (SOP) is being created, which will address enrollment reporting concerns. The Financial Aid office will work with the Registrar to increase communication between offices and eliminate enrollment reporting errors. The Financial Aid office will also improve reporting to the third-party processor, so that timely and accurate information is uploaded to NSLDS. Furthermore, a recurring review of the third-party’s reporting to NSLDS will be instituted. Name(s) of the contact person(s) responsible for corrective action: Levi Powell, Director of Financial Aid Planned completion date for corrective action plan: 6/30/2025
Finding 539464 (2024-001)
Significant Deficiency 2024
Management's Response/Planned Corrective Action: The Organization has established and implemented a new procedure to ensure the correct allocation of substitute teachers. This change has already been made effective as of July 1, 2024 to meet the auditor's recommendations. The Organization will now b...
Management's Response/Planned Corrective Action: The Organization has established and implemented a new procedure to ensure the correct allocation of substitute teachers. This change has already been made effective as of July 1, 2024 to meet the auditor's recommendations. The Organization will now bill substitutes exclusively to the appropriate site and program, which will enhance financial tracking and accountability. Substitutes will no longer be included in any distribution tables. Currently, substitutes are assigned to a System of Support (SOS) as their direct supervisor. The SOS is responsible for scheduling substitutes, entering their schedules into Paycor, and assigning them to school sites. Additionally, the Payroll Coordinator, Joanna Qualls, is required to add a billing code to these substitutes. The Payroll Department follows a procedure every pay period to run a report on substitutes, ensuring they are coded correctly. This process has been established as a step for every payroll run. The Director of Finance, Juana Sierra-Perez, also does a final audit of payroll to ensure transactions are being coded properly.
View Audit 350003 Questioned Costs: $1
We will update our cost allocation plan to address the issues as outlined in our response above. We will also implement a formal quarterly review of cost allocations to contracts under the guidance of our outside accountant (Capalbo, Mather Dougherty). Finally, we will use improved grant accounting ...
We will update our cost allocation plan to address the issues as outlined in our response above. We will also implement a formal quarterly review of cost allocations to contracts under the guidance of our outside accountant (Capalbo, Mather Dougherty). Finally, we will use improved grant accounting worksheets as a final check that our contract billing and accounting records are fully consistent.
While the audit notes improvements in this area, we continued to face some challenges in properly allocating indirect costs and fringe benefits to individual contracts. We will close the remaining gap between the costs properly billed to individual contracts and the process of reflecting these costs...
While the audit notes improvements in this area, we continued to face some challenges in properly allocating indirect costs and fringe benefits to individual contracts. We will close the remaining gap between the costs properly billed to individual contracts and the process of reflecting these costs in our accounting system by refining our cost allocation plan. This revision will include consistent rules for allocating indirect and fringe plus a quarterly review by accounting staff and management. We will also use newly formatted grant worksheets shared with us by Whittlesey to help us identify and correct any allocation issues before closing out our accounting records for this fiscal year.
Finding 2024-002 – The Organization provided humanitarian assistance to migrants and asylum seekers turned over by Customs and Border Protection (CBP), including meals, transportation and shelter at hotels and the Organizations Respite Center. The Organization has intake procedures in place with res...
Finding 2024-002 – The Organization provided humanitarian assistance to migrants and asylum seekers turned over by Customs and Border Protection (CBP), including meals, transportation and shelter at hotels and the Organizations Respite Center. The Organization has intake procedures in place with respect to hotel shelter expenditures. However, the intake process was not consistently applied to all participants. The Organization was not able to provide supporting documentation for 5% of the requested sample of individuals who received shelter. Management's view: Management acknowledges this finding, and awareness has been brought to this area. The errors identified in this finding were made due to a lack of implementation of proper agency financial procedures by a former employee and occurred during a period of substantial influx in the number of non-citizen migrants being assisted. Authorization of credit card use was provided to one hotel vendor which led to unverified charges. This was identified and corrected by senior staff within three weeks. Proposed Corrective Action: The following measures were already taken to correct this finding: The organization has provided proper training to its program staff and accounting bookkeepers to improve the internal payment review process on all payment requests and has prohibited the use of credit cards to cover hotel stays for clients. All hotel payments are to be paid by check after reviewing the proper documentation submitted by the vendor, which includes an invoice with the non-citizen migrant's name as spelled in the Notice to Appear documentation provided by U.S. Customs and Border Protection. This documentation is then compared to the registration database maintained by the organization which includes name and A-number for all non-citizen migrants served. Any unauthorized payment will be immediately investigated and disputed on a timely basis. This policy has already been implemented successfully. An internal sample verification process was completed successfully with supporting evidence for all clients served after the previous unauthorized charges were identified within the period of three weeks. Anticipated Correction Date: These measures have been implemented.
View Audit 349994 Questioned Costs: $1
The sliding fee schedule has been updated several times in the last 24 months with subsequent staff training. Beginning in December 2024 our organization will begin charging a nominal fee then accurately utilizing sliding discounts based on income levels/family size. The organization has also increa...
The sliding fee schedule has been updated several times in the last 24 months with subsequent staff training. Beginning in December 2024 our organization will begin charging a nominal fee then accurately utilizing sliding discounts based on income levels/family size. The organization has also increased training in processing and entering the collected patient income forms and sliding fee schedule packet of forms needed to accurately account for providing the patient with the sliding fee schedule adjustment.
Analysis is provided on a monthly basis by the Chief Financial Officer and the Accounting department. Balance Sheet, Profit & Loss, Cash Flow and A/P Agings are reviewed and provided to the CEO, the BOD Finance Committee and then to all BOD Members. Also provided is an organization dashboard present...
Analysis is provided on a monthly basis by the Chief Financial Officer and the Accounting department. Balance Sheet, Profit & Loss, Cash Flow and A/P Agings are reviewed and provided to the CEO, the BOD Finance Committee and then to all BOD Members. Also provided is an organization dashboard presentation with 12-14 Key Performance Indicators monthly.
Condition: There was a lack of internal controls in place related to the return of Title IV funds. Planned Corrective Action: Director will update academic calendar on COD R2TIV calculator yearly and verify dates and length of breaks are correct. The University will continue to have the Senior Fina...
Condition: There was a lack of internal controls in place related to the return of Title IV funds. Planned Corrective Action: Director will update academic calendar on COD R2TIV calculator yearly and verify dates and length of breaks are correct. The University will continue to have the Senior Financial Aid Advisor complete R2TIV and the Director will sign off on calculations. Contact person responsible for corrective action: Callie Zake, Senior Director Student Financial Services Anticipated Completion Date: June 30, 2025
View Audit 349964 Questioned Costs: $1
Finding 539409 (2024-004)
Significant Deficiency 2024
Finding 2024‐004: Significant Deficiency and Non‐Material Noncompliance – Housing Voucher Cluster REAC Report Name of Contact Person: Joan Duckett, Director of Housing & Community Development Corrective Action: The Office of Housing and Community Development (OHCD) has taken corrective measures to e...
Finding 2024‐004: Significant Deficiency and Non‐Material Noncompliance – Housing Voucher Cluster REAC Report Name of Contact Person: Joan Duckett, Director of Housing & Community Development Corrective Action: The Office of Housing and Community Development (OHCD) has taken corrective measures to ensure that the REAC reports are supported with accurate data and submitted in a timely manner. There are monthly reconciliation procedures in place which include management oversight and review of all reports. OHCD has and will continue to enter into a contractual agreement with a knowledgeable and reputable accounting firm that the County is under contract for services applicable to the need. REAC reports will be extensively reviewed by management prior to submission to HUD. Proposed Completion Date: Immediately
Finding 539408 (2024-003)
Significant Deficiency 2024
Finding 2024‐003: Significant Deficiency and Non‐Material Noncompliance – Housing Voucher Cluster Special Test 8 – Bank Accounts Name of Contact Person: Joan Duckett, Director of Housing & Community Development Corrective Action: The Office of Housing and Community Development began working with the...
Finding 2024‐003: Significant Deficiency and Non‐Material Noncompliance – Housing Voucher Cluster Special Test 8 – Bank Accounts Name of Contact Person: Joan Duckett, Director of Housing & Community Development Corrective Action: The Office of Housing and Community Development began working with the County’s Finance Department and the current Banking Financial Institution (Wells Fargo) and opened two separate accounts, one for the Housing Choice Voucher (HCV) program and one for the FSS Escrow Accounts in April 2024. The task included revised mapping of deposits and expenditures, including the establishment of related workflows within the County’s financial management system and therefore these changes were adequately tested. The migration to the two new bank accounts went live on July 1, 2024, and per HUD regulations a General Depository Agreement (HUD‐51999 GDA) was entered. Proposed Completion Date: Immediately
Recommendation: CLA recommends the University implements a process place to ensure the required reporting is completed in the timeline allowed by the granting agency and to complete any missed or late reporting as required. Explanation of disagreement with audit finding: There is no disagreement wit...
Recommendation: CLA recommends the University implements a process place to ensure the required reporting is completed in the timeline allowed by the granting agency and to complete any missed or late reporting as required. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: St. Thomas identified the applicable FFATA reporting requirements and assigned responsibility to the appropriate party. Name(s) of the contact person(s) responsible for corrective action: Sarah Ervin, sarah.ervin@stthomas.edu Planned completion date for corrective action plan: The additional reporting requirement has been added to the accounting department’s list of responsibilities beginning in January 2025.
Recommendation: CLA recommends the University review its reporting procedures to ensure the students' statuses are accurately reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to fin...
Recommendation: CLA recommends the University review its reporting procedures to ensure the students' statuses are accurately reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: By reviewing the ordering of internal processes and procedures St. Thomas determined two internal processes ran out of order causing incorrect reporting. Procedural documentation has been updated and training provided to ensure this error is not repeated. Name(s) of the contact person(s) responsible for corrective action: Yuko Kachinsky: yuko.kachinsky@stthomas.edu Planned completion date for corrective action plan: A process error was identified and corrected in August 2024.
Finding 539389 (2024-007)
Significant Deficiency 2024
The Department of Transportation will develop an electronic document storage policy and procedure for the on-site retention of project documentation, to include QAP testing, required by state and federal grant awards. The policy will include forms and reports completed by staff, contractors, and con...
The Department of Transportation will develop an electronic document storage policy and procedure for the on-site retention of project documentation, to include QAP testing, required by state and federal grant awards. The policy will include forms and reports completed by staff, contractors, and consultants, and will be reviewed for compliance prior to the distribution of vendor payments.
Finding 539387 (2024-006)
Significant Deficiency 2024
Internal controls will be established over reporting to the Virginia Department of Education to ensure accuracy of data, to include: · Student enrollment and membership data will be verified by the Department of Assessment, Research and Accountability. · Cost data and other financial information wil...
Internal controls will be established over reporting to the Virginia Department of Education to ensure accuracy of data, to include: · Student enrollment and membership data will be verified by the Department of Assessment, Research and Accountability. · Cost data and other financial information will be verified by the Accounting Department. · Information regarding children with disabilities will be verified by the Department of Learning Support.
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