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Corrective Action Plans

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Finding 530152 (2024-004)
Significant Deficiency 2024
State of Arkansas
AR
Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Questioned Costs § 200.303
Views of Responsible Officials and Planned Corrective Action: The Arkansas Department of Education (ADE), Division of Elementary and Secondary Education (DESE), Health and Nutrition Unit (HNU), concur with the finding. The HNU implemented a new application and payment system that began in 2024. Du...
Views of Responsible Officials and Planned Corrective Action: The Arkansas Department of Education (ADE), Division of Elementary and Secondary Education (DESE), Health and Nutrition Unit (HNU), concur with the finding. The HNU implemented a new application and payment system that began in 2024. During implementation and subsequent operations, several issues with data transfers between the old and new system were identified and now corrected. The HNU Application and Finance staff will receive training to ensure that all criteria are met prior to the retroactive payment of claims. Anticipated Completion Date: April 1, 2025 Contact Person: Sheila Chastain Associate Director Arkansas Department of Education, DESE, Nutrition Services #4 Capitol Mall, Box #12 Little Rock, AR 72201 (501) 324-9502 Sheila.Chastain@ade.arkansas.gov Pamela Burton Director Arkansas Department of Education, DESE, Nutrition Services #4 Capitol Mall, Box #19 Little Rock, AR 72201 (501) 320-8978 Pamela.Burton@ade.arkansas.gov
View Audit 348267 Questioned Costs: $1
Finding 530139 (2024-001)
Material Weakness 2024
Manchester School District
NH
Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring
Audit Finding Reference: 2024-001 Management’s Response and Planned Corrective Action: The District has historically managed our Title I grant as supplemental funding. Although we have a methodology for allocating local funds to schools without regard to whether they receive Title I funds, we do n...
Audit Finding Reference: 2024-001 Management’s Response and Planned Corrective Action: The District has historically managed our Title I grant as supplemental funding. Although we have a methodology for allocating local funds to schools without regard to whether they receive Title I funds, we do not have a formal written plan. The District will establish a written procedure to be in compliance with the Title I Supplement, Not Supplant requirement. Name of Contact Person and Completion Date: Karen DeFrancis, Executive Director of Finance Polly Golden, Title I Manager Anticipated Completion Date – March 31, 2025
View Audit 348254 Questioned Costs: $1
Finding 530127 (2024-002)
Significant Deficiency 2024
Collegiate Edu-Nation
TX
Questioned Costs Allowable Costs / Cost Principles Cash Management
Finding 2024-002: Allowable costs and activities – significant deficiency in internal controls over compliance. Management Response Finding: Failure to Provide an Itemized Receipt for a Restaurant Purchase Corrective Action Taken: Effective July 1, 2024, CEN implemented Ramp, an expense management p...
Finding 2024-002: Allowable costs and activities – significant deficiency in internal controls over compliance. Management Response Finding: Failure to Provide an Itemized Receipt for a Restaurant Purchase Corrective Action Taken: Effective July 1, 2024, CEN implemented Ramp, an expense management platform that ensures all purchases are documented with proper receipts before being charged to the grant. This solution directly addresses the issue of missing itemized receipts and ensures compliance with federal grant requirements. Steps Implemented: • Mandatory Receipt Submission: All purchases, including restaurant transactions, require an itemized receipt to be uploaded into Ramp before the expense can be approved. • Approval Before Grant Charging: An approver must review the itemized receipt to verify that no prohibited items were purchased before allowing the expense to be charged to the grant. • Grant Compliance Review: If an itemized receipt is not provided or contains unallowable expenses, the charge will not be allocated to the grant and must be covered by a non-grant funding source. • Training & Compliance: All employees who make purchases with grant funds have been trained on the requirement for itemized receipts and the consequences of non-compliance. Responsible Party: Kendall Guynes, CFO Completion Date: July 1, 2024 (Fully Implemented) Parties Responsible: Chief Executive Officer President Chief Financial Officer Business Manager The Corrective Action Plan is currently in place and was implemented on July 1, 2024.
View Audit 348223
Finding 530126 (2024-001)
Material Weakness 2024
Collegiate Edu-Nation
TX
Questioned Costs Procurement, Suspension & Debarment Allowable Costs / Cost Principles
Finding 2024-001: Allowable costs and activities – material weakness in internal controls over compliance and compliance finding. Management Response Finding: Lack of Documented Approval for Purchases. Corrective Action Taken: Effective July 1, 2024, CEN implemented Ramp, an expense management platf...
Finding 2024-001: Allowable costs and activities – material weakness in internal controls over compliance and compliance finding. Management Response Finding: Lack of Documented Approval for Purchases. Corrective Action Taken: Effective July 1, 2024, CEN implemented Ramp, an expense management platform that ensures all purchases are documented and approved before processing. Ramp provides an automated and auditable approval workflow, ensuring compliance with federal grant requirements. Steps Implemented: • Centralized Purchasing System: All purchases are now made within Ramp using a Ramp credit card, ensuring complete oversight and control over spending. • Automated Approval Workflow: Each purchase requires approval within Ramp, and approvals are documented digitally, creating an auditable trail. • Receipt Verification: Every purchase must include a receipt, which the approver reviews before granting final approval. • Grant Compliance Review: Any charges that do not meet grant requirements are not charged to the grant and are instead assigned to an appropriate non-grant funding source. • Training & Compliance: All relevant staff members have been trained on Ramp’s approval and compliance procedures to ensure adherence to purchasing protocols. Responsible Party: Kendall Guynes, CFO Completion Date: July 1, 2024 (Fully Implemented)
View Audit 348223
Finding 530119 (2024-001)
Significant Deficiency 2024
Saving Grace
OR
Questioned Costs Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.324
Management acknowledges the auditor’s finding and agrees with the recommendation. The Organization has developed a Corrective Action Plan to ensure compliance with procurement regulations and strengthen internal controls. This plan outlines specific steps to prevent future occurrences and maintain a...
Management acknowledges the auditor’s finding and agrees with the recommendation. The Organization has developed a Corrective Action Plan to ensure compliance with procurement regulations and strengthen internal controls. This plan outlines specific steps to prevent future occurrences and maintain adherence to federal requirements. The Finance Committee has thoroughly reviewed this finding, and the Board of Directors has subsequently approved the audit, the Organization’s response, and the Corrective Action Plan. Regarding the finding, the Organization paid the amount agreed upon during contract negotiations. The issue identified pertains to the billing methodology rather than the appropriateness of the cost itself. The cost-plus method is a common practice in our geographical area, and the overall project cost was determined to be fair and consistent with industry standards. Moving forward, the Organization is implementing additional internal review procedures to ensure compliance with all federal procurement requirements.
View Audit 348173 Questioned Costs: $1
Finding 530114 (2024-001)
Material Weakness 2024
Burns Flat-Dill City School District #10
OK
Questioned Costs Subrecipient Monitoring Material Weakness
The District has developed and implemented internal control policies to ensure compliance with the Davis-Bacon Act any time the District is expending Federals awards. The District will post all required work site posters concerning prevailing wage rates and review and examine weekly payroll reports...
The District has developed and implemented internal control policies to ensure compliance with the Davis-Bacon Act any time the District is expending Federals awards. The District will post all required work site posters concerning prevailing wage rates and review and examine weekly payroll reports from contractors or subcontractors.
View Audit 348163
Finding 530113 (2024-002)
Significant Deficiency 2024
Home Healthcare, Hospice & Community Service, Inc. & Affiliate
NH
Allowable Costs / Cost Principles Questioned Costs Procurement, Suspension & Debarment
The Accounting Manager will educate the Senior Management Team so that all departments are aware of this finding and the steps to prevent its recurrence. The Accounting Manager will work in conjunction with the Director of Finance and Community Based Programs Billing Specialist to ensure all expendi...
The Accounting Manager will educate the Senior Management Team so that all departments are aware of this finding and the steps to prevent its recurrence. The Accounting Manager will work in conjunction with the Director of Finance and Community Based Programs Billing Specialist to ensure all expenditures being charged to a grant are allowable based on Federal Cost Principles. A document was created and will be used when a client is a recipient of goods or services that fall under grant funding. The form will be completed, signed, and uploaded to Matrix and/or QuickBase for tracking purposes. Responsible Party: Judy Arellano Accounting Manager 603-352-2253 Anticipated Completion Date: 4/30/25
View Audit 348160 Questioned Costs: $1
Finding 530079 (2024-002)
Significant Deficiency 2024
Lacasa
MI
Internal Control / Segregation of Duties Questioned Costs Allowable Costs / Cost Principles
The Organization concurs with the finding and has already begun the process of developing a method of allocating shelter and hotline staff based on actual services provided and implementing regular training sessions for all staff involved in grant funded programs. Anticipated completion date is June...
The Organization concurs with the finding and has already begun the process of developing a method of allocating shelter and hotline staff based on actual services provided and implementing regular training sessions for all staff involved in grant funded programs. Anticipated completion date is June 30, 2025.
View Audit 348130
Robertsville Apartments, Inc.
TN
HUD Housing Programs Questioned Costs
Management will request a rent increase when the property is eligible and budget for monthly tax and escrow deposits to prevent future shortfalls in escrow cash.
Management will request a rent increase when the property is eligible and budget for monthly tax and escrow deposits to prevent future shortfalls in escrow cash.
View Audit 348120
Pedigo Apartments Ii, Inc.
TN
Questioned Costs
Corrective Action Plan: Management will request a rent increase when the property is eligible and budget for monthly tax and escrow deposits to prevent future shortfalls in escrow cash.
Corrective Action Plan: Management will request a rent increase when the property is eligible and budget for monthly tax and escrow deposits to prevent future shortfalls in escrow cash.
View Audit 348119
Pedigo Apartments I, Inc.
TN
HUD Housing Programs Questioned Costs
Management will request a rent increase when the property is eligible and budget for monthly tax and escrow deposits to prevent future shortfalls in escrow cash.
Management will request a rent increase when the property is eligible and budget for monthly tax and escrow deposits to prevent future shortfalls in escrow cash.
View Audit 348118
Clinch River Apartments, Inc.
TN
HUD Housing Programs Questioned Costs
Corrective Action Plan: Management will request a rent increase when the property is eligible and budget for monthly tax and escrow deposits to prevent future shortfalls in escrow cash.
Corrective Action Plan: Management will request a rent increase when the property is eligible and budget for monthly tax and escrow deposits to prevent future shortfalls in escrow cash.
View Audit 348115
Finding 530069 (2024-072)
Material Weakness 2024
State of Nebraska
NE
Questioned Costs Subrecipient Monitoring § 200.201
Program: AL 21.029 – COVID-19 Coronavirus Capital Projects Fund – Subrecipient Monitoring Corrective Action Plan: Prior to the second round of CPF awards, the department created a standardized “Budget Template” that has been incorporated into the grant application process. This tool allows for a...
Program: AL 21.029 – COVID-19 Coronavirus Capital Projects Fund – Subrecipient Monitoring Corrective Action Plan: Prior to the second round of CPF awards, the department created a standardized “Budget Template” that has been incorporated into the grant application process. This tool allows for a more robust documented review of reasonable and estimated costs. The updated budget process has already been applied to the 2024 Capital Projects Fund awards. The Commission has a standardized reimbursement template that further strengthens this process by allowing us to compare verified actual costs to the originally budgeted costs. The implementation of this enhanced process allows us to build a documented dataset of historical project data and associated costs, which will continue to expand as new awards are made and reimbursement requests reflecting actual costs are received. Contact: Carrie Gans Anticipated Completion Date: Completed
View Audit 348113 Questioned Costs: $1
Finding 530068 (2024-070)
Significant Deficiency 2024
State of Nebraska
NE
Matching / Level of Effort / Earmarking Questioned Costs Subrecipient Monitoring § 200.302 § 200.511
Program: AL 21.027 – COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Reporting Corrective Action Plan: As of the reporting period ended September 30, 2024, changes requested by agencies to obligations or expenditures have been updated. DAS will obtain the written justification for...
Program: AL 21.027 – COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Reporting Corrective Action Plan: As of the reporting period ended September 30, 2024, changes requested by agencies to obligations or expenditures have been updated. DAS will obtain the written justification for capital expenditures for the projects identified. Contact: Philip Olsen Anticipated Completion Date: January 31, 2025
View Audit 348113
Finding 530067 (2024-069)
Material Weakness 2024
State of Nebraska
NE
Allowable Costs / Cost Principles Questioned Costs § 200.303 § 200.403 § 200.511
Program: AL 21.027 – COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Allowability   Corrective Action Plan: DHHS has implemented a process to obtain signed legal affidavits from all recipients attesting to using the employee retention and recruitment funds in accordance with state a...
Program: AL 21.027 – COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Allowability   Corrective Action Plan: DHHS has implemented a process to obtain signed legal affidavits from all recipients attesting to using the employee retention and recruitment funds in accordance with state and federal law. Additionally, the department subsequently requested and received supporting documentation of expenditures from all samples selected by the APA, supporting allowable use of the funds distributed. The Department will request documentation of expenditures for SFY25 payments made under this program for a sample of recipients for final payments received as part of LB1014 in SFY25. The State Fair Board contract with NDEE is ongoing and the change in the calculated tourism loss amount will result in tourism loss section and Clean Water (all other) section contractual revisions (offsetting adjustments). No additional impact or follow up action noted. Contact: Philip Olsen Anticipated Completion Date: January 31, 2025
View Audit 348113 Questioned Costs: $1
Finding 530065 (2024-067)
Material Weakness 2024
State of Nebraska
NE
Eligibility Questioned Costs Allowable Costs / Cost Principles § 200.303
Program: AL 21.023 – COVID-19 Emergency Rental Assistance – Allowability & Eligibility Corrective Action Plan: • Additional guidance will be provided to Nelnet reviewers, specifically regarding households with no income that need to be verified every 90 days and households with more than one ad...
Program: AL 21.023 – COVID-19 Emergency Rental Assistance – Allowability & Eligibility Corrective Action Plan: • Additional guidance will be provided to Nelnet reviewers, specifically regarding households with no income that need to be verified every 90 days and households with more than one adult in the home. • Additional guidance will be provided to Nelnet reviewers regarding applicant communication such as move outs, relocations, payment concerns, etc. • NEMA will work with NIFA and will continue to pursue any payments that should be returned due to tenant vacating rental unit. • NEMA will advise NIFA and will implement any recommended changes to late fee policy. Contact: Erv Portis, Impala Carey, NEMA Anticipated Completion Date: 28 March, 2025
View Audit 348113 Questioned Costs: $1
State of Nebraska
NE
Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.332 § 200.403 § 200.405 § 200.430 § 200.442
Program: AL 20.509 – Formula Grants for Rural Areas – Allowability & Subrecipient Monitoring Corrective Action Plan: • NDOT will continue to enhance its financial review procedures to ensure that all subrecipients provide adequate supporting documentation for expenditures, including personnel ...
Program: AL 20.509 – Formula Grants for Rural Areas – Allowability & Subrecipient Monitoring Corrective Action Plan: • NDOT will continue to enhance its financial review procedures to ensure that all subrecipients provide adequate supporting documentation for expenditures, including personnel charges and cost allocations. • Training sessions will continue to be conducted for subrecipients to reinforce compliance requirements related to allowable costs, proper documentation, and cost allocation methods. • Revised internal procedures will clarify expectations for travel costs, fuel charges, personnel reimbursements, and revenue reporting to prevent improper charges to the grant. • Assigning audit staff to conduct periodic sampling throughout the year enhances our ability to ensure costs are properly supported, adapt to necessary changes, and effectively communicate updates to our subrecipients. Contact: Jodi Gibson Anticipated Completion Date: NDOT appreciates the audit’s recommendations and remains committed to ensuring compliance with Federal requirements through strengthened internal controls and enhanced subrecipient oversight. This will be an ongoing and continual effort to address anticipated compliance requirements and evolving state and federal regulations.
View Audit 348113 Questioned Costs: $1
State of Nebraska
NE
Questioned Costs Allowable Costs / Cost Principles § 200.405
Program: AL 17.225 – Unemployment Insurance (UI) – Admin – Allowability Corrective Action Plan: NDOL has reviewed the current cost allocation plan with the Federal authority and received conditional approval for changes beginning in state fiscal year 2025. Contact: Rea Easton Anticipated Compl...
Program: AL 17.225 – Unemployment Insurance (UI) – Admin – Allowability Corrective Action Plan: NDOL has reviewed the current cost allocation plan with the Federal authority and received conditional approval for changes beginning in state fiscal year 2025. Contact: Rea Easton Anticipated Completion Date: Completed
View Audit 348113 Questioned Costs: $1
Finding 530059 (2024-061)
Material Weakness 2024
State of Nebraska
NE
Eligibility Questioned Costs
Program: AL 17.225 – Unemployment Insurance (UI) – State – Allowability & Eligibility Corrective Action Plan: For wage crossmatches, we are providing additional training to more staff so they can effectively handle these tasks. We are also optimizing the crossmatch system to better detect potent...
Program: AL 17.225 – Unemployment Insurance (UI) – State – Allowability & Eligibility Corrective Action Plan: For wage crossmatches, we are providing additional training to more staff so they can effectively handle these tasks. We are also optimizing the crossmatch system to better detect potential fraud. NDOL has emphasized the importance of thoroughly reviewing separation information requests during the adjudication process. If we identify any issues, they are addressed on an individual basis. Additionally, we review separation information as part of our internal quality control process to ensure consistent and thorough evaluation. Additional BIU staff were trained on quarterly wage crossmatches by 12/31/2024. Contact: Andi Bridgmon Anticipated Completion Date: September 2025
View Audit 348113 Questioned Costs: $1
State of Nebraska
NE
Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.332 § 200.403 § 200.430 § 200.431 § 200.447
Program: AL 15.611 – Wildlife Restoration and Basic Hunter Education and Safety – Allowability & Subrecipient Monitoring Corrective Action Plan: NGPC will continue to work closely with our subrecipients. We will review subrecipient monitoring procedures and determine documentation that can be pr...
Program: AL 15.611 – Wildlife Restoration and Basic Hunter Education and Safety – Allowability & Subrecipient Monitoring Corrective Action Plan: NGPC will continue to work closely with our subrecipients. We will review subrecipient monitoring procedures and determine documentation that can be provided to meet the intent of federal regulations. Contact: Eli Kass Anticipated Completion Date: July 1, 2025
View Audit 348113 Questioned Costs: $1
State of Nebraska
NE
Subrecipient Monitoring Allowable Costs / Cost Principles Questioned Costs § 200.332 § 200.501 § 200.514
Program: AL 97.036 – Disaster Grants – Public Assistance (Presidentially Declared Disasters) – Subrecipient Monitoring Corrective Action Plan: NEMA has implemented a process, effective immediately, to review the information submitted by subrecipient organizations regarding their 2 CFR Single Audi...
Program: AL 97.036 – Disaster Grants – Public Assistance (Presidentially Declared Disasters) – Subrecipient Monitoring Corrective Action Plan: NEMA has implemented a process, effective immediately, to review the information submitted by subrecipient organizations regarding their 2 CFR Single Audit Certification. Responses will be cross-referenced with our own records of Federal funds passed through NEMA to the subrecipient. Any subrecipient responding that it was not required to conduct a single audit will prompt NEMA to validate against payment data. Any subrecipient’s noncompliance will be followed up by NEMA staff. Contact: Erv Portis Anticipated Completion Date: February 11, 2025
View Audit 348113
State of Nebraska
NE
Questioned Costs Subrecipient Monitoring
Program: AL 93.959 – Block Grants for Prevention and Treatment of Substance Abuse – Allowability & Subrecipient Monitoring Corrective Action Plan: Agency will update the audit manual for subrecipient monitoring and will communicate time study requirements to the Regions. Contact: Erica Ziemann ...
Program: AL 93.959 – Block Grants for Prevention and Treatment of Substance Abuse – Allowability & Subrecipient Monitoring Corrective Action Plan: Agency will update the audit manual for subrecipient monitoring and will communicate time study requirements to the Regions. Contact: Erica Ziemann Anticipated Completion Date: 6/30/2025
View Audit 348113 Questioned Costs: $1
State of Nebraska
NE
Questioned Costs Special Tests & Provisions Allowable Costs / Cost Principles
Program: AL 93.778 – Medical Assistance Program – Special Tests and Provisions Corrective Action Plan: Program Integrity staff will continue to attempt to update cases at least every 30 days when case totals are at or below 25 and every 45 days when higher than 25. Trainings and regular conversa...
Program: AL 93.778 – Medical Assistance Program – Special Tests and Provisions Corrective Action Plan: Program Integrity staff will continue to attempt to update cases at least every 30 days when case totals are at or below 25 and every 45 days when higher than 25. Trainings and regular conversations emphasize the need for descriptive narrative entries. As a result, the narrative entries will be more descriptive of the status of the case. For the exception reporting, the team continues to work on developing alternatives to using the reports in the Fraud Abuse Detection System. Concerning the misreported check, Program Integrity staff will give the Financial Team accurate information about collected refunds. The Department will ensure reports are accurate and make any necessary adjustments. Contact: Anne Harvey, Heather Arnold Anticipated Completion Date: 6/30/2025
View Audit 348113 Questioned Costs: $1
Finding 530048 (2024-054)
Significant Deficiency 2024
State of Nebraska
NE
Questioned Costs Special Tests & Provisions Procurement, Suspension & Debarment
Program: AL 93.778 – Medical Assistance Program – Special Tests and Provisions Corrective Action Plan: The Department updated procedures in July 2024 to obtain General Ledger data from nursing facilities with their FY2024 Cost Report. Additionally, the Department is expanding testing for large c...
Program: AL 93.778 – Medical Assistance Program – Special Tests and Provisions Corrective Action Plan: The Department updated procedures in July 2024 to obtain General Ledger data from nursing facilities with their FY2024 Cost Report. Additionally, the Department is expanding testing for large cost variances and will request additional substantiating documentation from the impacted nursing facilities. Contact: Jerry Vanderbeek Anticipated Completion Date: 3/31/2025
View Audit 348113 Questioned Costs: $1
Finding 530047 (2024-053)
Significant Deficiency 2024
State of Nebraska
NE
Questioned Costs Allowable Costs / Cost Principles Eligibility
Program: AL 93.778 – Medical Assistance Program; AL 93.778 – COVID-19 Medical Assistance Program – Allowability Corrective Action Plan: The Department has been actively working with program, technology, and the EVV vendor to implement system controls to address the deficiencies identified in this...
Program: AL 93.778 – Medical Assistance Program; AL 93.778 – COVID-19 Medical Assistance Program – Allowability Corrective Action Plan: The Department has been actively working with program, technology, and the EVV vendor to implement system controls to address the deficiencies identified in this and prior year’s findings. The Department has two system change releases scheduled, the first in February 2025 and the second in late June 2025 to implement additional system improvements. Contact: Jeremy Brunssen Anticipated Completion Date: 7/1/2025
View Audit 348113 Questioned Costs: $1
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