Corrective Action Plans

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Finding 2023-002 Condition The Hospital did not complete the PRF reporting in accordance with the U.S. Department of Health and Human Services guidance. We noted that the Hospital erroneously entered information into the lost revenue calculation, resulting in lost revenues being understated $1,020,0...
Finding 2023-002 Condition The Hospital did not complete the PRF reporting in accordance with the U.S. Department of Health and Human Services guidance. We noted that the Hospital erroneously entered information into the lost revenue calculation, resulting in lost revenues being understated $1,020,030. The Hospital reported lost revenues amounting to $999,172 on distributions totaling $1,177,041. The Hospital had excess lost revenues from previous periods available to be used through June 30, 2023 amounting to $5,406,884. The Hospital also reported expenses of $907,051. Corrective Action Plan Corrective Action Planned: The Hospital will undertake a review of its internal control policies and procedures surrounding the reporting on federal grant activities and add additional layers of review where necessary to ensure future reporting is accurate. Name of Contact Person Responsible for Corrective Action: Kelli Kane, Chief Financial Officer Anticipated Completion Date: April 15, 2024
Finding 390135 (2023-101)
Material Weakness 2023
Assistance Listings number and program name: 21.027 COVID-19 Corona Virus State and Local Fiscal Recovery Fund Contact: Maryn Belling Anticipated completion date: June 30, 2024 Corrective Action Plan: The County will develop, implement, and maintain procedures requiring both the performance & doc...
Assistance Listings number and program name: 21.027 COVID-19 Corona Virus State and Local Fiscal Recovery Fund Contact: Maryn Belling Anticipated completion date: June 30, 2024 Corrective Action Plan: The County will develop, implement, and maintain procedures requiring both the performance & documentation of independent review and approval of all federal program reports prior to submitting them to the federal agency to ensure the reports are accurate, agree to County records, and contain only allowable expenditures. Program expenditures will be reconciled to the County’s accounting records. The County’s previous corrective action plan stated “Errors identified will be reported to the federal agency in adjusted or resubmitted reports” however the Federal Reporting interface lacks capacity for resubmitted reports. The adjusted reports resulted in the understatement and overstatement amounts noted in Federal Award Finding 2023-101. Departmental training will be provided for staff responsible for preparing and reviewing reports for both data management, compliance with Uniform Guidance, 2 Code of Federal Regulations (CFR) §200.510, and adherence to County’s policies and procedures.
See Corrective Action Plan
See Corrective Action Plan
2023-004 – Student Financial Aid Cluster – (a) Federal Pell Grant (b) Federal Supplemental Educational Opportunity Grant (c) Federal Work Study Grant (d) Federal Perkins Loan Program (e) Federal Direct Student Loans (f) Teacher education Assistance for College and Higher Education ALN. (a) 84.063 (b...
2023-004 – Student Financial Aid Cluster – (a) Federal Pell Grant (b) Federal Supplemental Educational Opportunity Grant (c) Federal Work Study Grant (d) Federal Perkins Loan Program (e) Federal Direct Student Loans (f) Teacher education Assistance for College and Higher Education ALN. (a) 84.063 (b) 84.007 (c) 84.033 (d) 84.038 (e) 84.268 (f) 84.379 – Year Ended June 30, 2023 Criteria: 34 CFR 668.22 (a)(1) states “When a recipient of title IV grant or loan assistance withdraws from an institution during a payment period or period of enrollment in which the recipient began attendance, the institution must determine the amount of title IV grant or loan assistance that the student earned as of the student's withdrawal date in accordance with paragraph (e) of this section.” 34 CFR 668.22 (e)(2) states, “The percentage of title IV grant or loan assistance that has been earned by the student is - (i) Equal to the percentage of the payment period or period of enrollment that the student completed (as determined in accordance with paragraph (f) of this section) as of the student's withdrawal date, if this date occurs on or before - (A) Completion of 60 percent of the payment period or period of enrollment for a program that is measured in credit hours; or…” 34 CFR 668.22(j) notes, “(1) An institution must return the amount of title IV funds for which it is responsible under paragraph (g) of this section as soon as possible but no later than 45 days after the date of the institution's determination that the student withdrew as defined in paragraph (l)(3) of this section. The timeframe for returning funds is further described in § 668.173(b).” An institution must notify the student of a post-withdrawal disbursement of Federal Direct Loans used to credit the student’s account for outstanding charges (34 CFR 668.22). Condition: The College did not accurately complete refund calculations in the Spring. In review of the Spring 2023 calculations the number of days in the break was not calculated correctly, resulting in the incorrect days in Spring 2023 return of Title IV funds calculations. As a result of the incorrect number of days, the amounts of Title IV amounts returned for all withdrawn students were incorrectly calculated for 1 out of the population of 4 (25%) total withdrawal calculations. We consider this finding to be an instance of noncompliance in relation to Special Tests and Provisions. Statistical sampling was not used in making sample selections. Views of Responsible Officials: After years of completing a manual calculation we had switched to a full automated process. Going forward we will be completing a manual calculation to compare to the automated response to ensure the correct number of days are used. Responsible Person: Andra Butler, Vice President of Financial Aid Implementation Date: October 2023
View Audit 301000 Questioned Costs: $1
2023-003 – Student Financial Aid Cluster – (a) Federal Pell Grant (b) Federal Supplemental Educational Opportunity Grant (c) Federal Work Study Grant (d) Federal Perkins Loan Program (e) Federal Direct Student Loans (f) Teacher education Assistance for College and Higher Education ALN. (a) 84.063 (b...
2023-003 – Student Financial Aid Cluster – (a) Federal Pell Grant (b) Federal Supplemental Educational Opportunity Grant (c) Federal Work Study Grant (d) Federal Perkins Loan Program (e) Federal Direct Student Loans (f) Teacher education Assistance for College and Higher Education ALN. (a) 84.063 (b) 84.007 (c) 84.033 (d) 84.038 (e) 84.268 (f) 84.379 – Year Ended June 30, 2023 Criteria: 34 CFR 685.203 states, "A student may not receive a Federal Direct Subsidized Loan amount that exceeds the student’s estimated cost of attendance for the period of enrollment less the borrower’s expected family contribution and estimated financial assistance for that period.” Condition: The College did not properly disburse direct loans for 1 out of 40 students (2.5%). Views of Responsible Officials: The financial aid office staff will complete the packaging aid and loans learning tracks on the Federal Student Aid Training Center. The staff will complete this training annually to ensure compliance of all regulations. Responsible Person: Andra Butler, Assistant Vice President of Financial Aid Implementation Date: October 2023
View Audit 301000 Questioned Costs: $1
ECLC is down to 2 employees consisting of the Executive Director and fiscal specialists. ECLC CFO resigned in April of 2022 and ECLC has not been able to fill that position since that time. UHY consultants have been obtained March 24, 2023 and they are helping with the fiscal process. The effect of ...
ECLC is down to 2 employees consisting of the Executive Director and fiscal specialists. ECLC CFO resigned in April of 2022 and ECLC has not been able to fill that position since that time. UHY consultants have been obtained March 24, 2023 and they are helping with the fiscal process. The effect of operating without a CFO has caused delays in preparing financials. ECLC has relinquished the Head Start Grant effective June 30, 2023, and is in the process of dissolution.
Finding 390080 (2023-003)
Significant Deficiency 2023
Condition: The College did not maintain required Tier One servicer information on their website and did not disclose the URL to the Department of Education. Recommendation: We recommend the College implement procedures to identify requirements about disclosures when using third-party servicers and t...
Condition: The College did not maintain required Tier One servicer information on their website and did not disclose the URL to the Department of Education. Recommendation: We recommend the College implement procedures to identify requirements about disclosures when using third-party servicers and to implement such requirements on a timely basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The College has updated the student refund webpage to include the contract maintained with the Tier One servicer and will disclose the URL to the Department of Education. The College will adjust internal review procedures to ensure disclosure requirements are identified and implemented. Name(s) of the contract person(s) responsible for corrective action: Kailey Block – Controller and Jennifer Gilsdorf – Assistant Controller Planned completion date for corrective action plan: May 1, 2024
Corrective Action Plan The Student Financial Services department has undergone process improvements over the previous fifteen months. The processes and procedures for the calculation and Return of Title IV funds have been reviewed and staff in charge of these functions have been trained. Effective f...
Corrective Action Plan The Student Financial Services department has undergone process improvements over the previous fifteen months. The processes and procedures for the calculation and Return of Title IV funds have been reviewed and staff in charge of these functions have been trained. Effective for the Fall semester of FY24, rather than just a sampling, every calculation has been, and continues to be, double checked by another staff member who does recalculations before the revised award letter is sent and funds returned. Management is also in the process of implementing a change in staff areas of responsibility and will be moving the individual whose errors have been most frequent to administer another, less complex process. Timeline for Implementation of Corrective Action Plan The corrective action plan was implemented as of October 1, 2023. Contact Person Karen Grant, Financial Aid Director
View Audit 300952 Questioned Costs: $1
Management has reviewed the recommendations and will review current and implement new procedures and controls to ensure that all post- award notices received from funding agencies are properly incorporated into the Schedule. Additionally, Management will review reconciliation procedures, and impleme...
Management has reviewed the recommendations and will review current and implement new procedures and controls to ensure that all post- award notices received from funding agencies are properly incorporated into the Schedule. Additionally, Management will review reconciliation procedures, and implement internal controls around the Schedule reconciliation process back to the consolidated financial statements. The corrective action will be implemented no later than June 30, 2024. The primary designated official is Chief Financial Officer.
View Audit 300946 Questioned Costs: $1
Finding #2023-001: Reconciliation of Allocated Costs CLIENT PLANNED ACTION: Hospital Sisters Health System agrees with the finding and will reevaluate the procedures in place to reconcile all costs allocated to grants. We will implement processes to ensure that all costs are substantiated with ap...
Finding #2023-001: Reconciliation of Allocated Costs CLIENT PLANNED ACTION: Hospital Sisters Health System agrees with the finding and will reevaluate the procedures in place to reconcile all costs allocated to grants. We will implement processes to ensure that all costs are substantiated with appropriate supporting detail and are reconciled and reviewed in a timely manner. CLIENT RESPONSIBLE PARTY: Steve Canny, System Director-Financial Reporting, Compliance & Internal Control COMPLETION DATE: We anticipate having these procedures in place by June 30, 2024.
View Audit 300930 Questioned Costs: $1
The School will work with its University Accounting Services (UAS) representative to obtain the UAS compliance examination report on a timely basis each year. If UAS is unable to provide the compliance examination report on a timely basis, the School will consider finding another vendor to assist wi...
The School will work with its University Accounting Services (UAS) representative to obtain the UAS compliance examination report on a timely basis each year. If UAS is unable to provide the compliance examination report on a timely basis, the School will consider finding another vendor to assist with the billings, collections and due diligence for the Federal Perkins Loan Program. Responsible Parties: Nathaniel Hibler – Vice President of Finance (802) 831-1204 Emily Parker – General Ledger Accountant (802) 831-1271 Estimated Completion Date: June 30, 2024
The Registrar’s office of Vermont Law and Graduate School (the School) will continue to run monthly enrollment reports and upload them into the Clearinghouse through their website. Any anomalies or glitches discovered by the Registrar’s Office will be discussed with the Information Technology depar...
The Registrar’s office of Vermont Law and Graduate School (the School) will continue to run monthly enrollment reports and upload them into the Clearinghouse through their website. Any anomalies or glitches discovered by the Registrar’s Office will be discussed with the Information Technology department who will contact the software manufacturer (Jenzabar). If a patch is deemed necessary, it will be installed through an update by the Software Manufacturer and Information Technology. Responsible Parties: Maureen Moriarty – Registrar (802) 831-1235 Melissa Erickson – Director, Financial Aid (802) 831-1235 Estimated Completion Date: June 30, 2024
Finding Number: 2023-003 Condition: The Corporation reported the incorrect amount of lost revenues for the period 4 portal submission for MedFlight. Planned Corrective Action: Management agrees and ...
Finding Number: 2023-003 Condition: The Corporation reported the incorrect amount of lost revenues for the period 4 portal submission for MedFlight. Planned Corrective Action: Management agrees and has revised existing internal control processes and policies to implement review and approval procedures to ensure data uploaded into the portal agrees to underlying supporting documentation. Contact person responsible for corrective action: Joe Abel, Chief Financial Officer Anticipated Completion Date: 4/30/2023
Finding Number: 2023‐001 Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425 Contact Person: Brianne Ford, Business Manager Anticipated Completion Date: March 25, 2024 Planned Corrective Action: The District will monitor and ensure amounts expended a...
Finding Number: 2023‐001 Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425 Contact Person: Brianne Ford, Business Manager Anticipated Completion Date: March 25, 2024 Planned Corrective Action: The District will monitor and ensure amounts expended and reported from the ESSER I, II, & III grants agree to the District's accounting records. The Business Manager and Federal Programs Director will work hand in hand to ensure expended funds are reported accurately.
The District agrees with the recommendation and has started the process of revising the claims filed.
The District agrees with the recommendation and has started the process of revising the claims filed.
View Audit 300912 Questioned Costs: $1
We recommend that the City develop and maintain policies and procedures regarding loan monitoring and ensure that all documentation of loan monitoring be maintained on an annual basis. Management's Response: The City concurs with the finding. Responsible Individual: Marti Brown, City Manager. Co...
We recommend that the City develop and maintain policies and procedures regarding loan monitoring and ensure that all documentation of loan monitoring be maintained on an annual basis. Management's Response: The City concurs with the finding. Responsible Individual: Marti Brown, City Manager. Corrective Action Plan: Given the strain on resource available among City staff, the City is working to hire an outside consulting firm to assure a consisten loan monitoring program is in place. Anticipated Completion Date: June 2024
We recommend that the City develop procedures to ensure that the CDBG Annual Performance Report is filed by the required due date. Management's Response: The City concurs with the finding. Responsible Individual: Marti Brown, City Manager. Corrective Action Plan: The City has recently brought on ...
We recommend that the City develop procedures to ensure that the CDBG Annual Performance Report is filed by the required due date. Management's Response: The City concurs with the finding. Responsible Individual: Marti Brown, City Manager. Corrective Action Plan: The City has recently brought on staff to complete the periodic reports required by HCD. It is the intent of the City to have this finding resolved by the end of FY 2023-24. Anticipated Completion Date: June 2024.
Recommendation: We recommend that the University implement processes and/or internal controls that ensure that a student has completed entrance counseling prior to disbursing Direct Loans proceeds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Acti...
Recommendation: We recommend that the University implement processes and/or internal controls that ensure that a student has completed entrance counseling prior to disbursing Direct Loans proceeds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action in Response to Finding: The error was caused by an abrupt resignation of loan processing staff and a lack of redundancy in critical processing areas. A staff member who was new to loan administration originated a loan then disbursed it to the student the moment it returned from COD. This rapid processing was in response to the student’s dire need for housing funding; however, the expedited process inadvertently circumvented the Banner system’s safeguards. This previously unknown issue has been resolved with the following systems updates: 1. Improved training and documentation 2. The previous system relied on RRAAREQ to prevent disbursement; however, the new system has a secondary and tertiary check that prevents disbursement. Both the entrance counseling tick box on RLADLOR and a positive indicator on the table that captures raw entrance counseling data (RPILECS) must align for a loan disbursement. Name of the contact person responsible for corrective action: Elijah Herr, Director of Financial Aid Planned completion date for corrective action plan: March 2024
View Audit 300906 Questioned Costs: $1
Recommendation: We recommend that the University strengthen its internal controls over monitoring the academic engagement for students that are enrolled in distance education courses at the University. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. A...
Recommendation: We recommend that the University strengthen its internal controls over monitoring the academic engagement for students that are enrolled in distance education courses at the University. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action in Response to Finding: The University had already identified this weakness prior to the Single Audit. To address this weakness, Portland State University has implemented a robust Initiation of Attendance protocol that is required of every instructor. Faculty were informed of: 1) Federal regulations related to initiation of attendance. 2) The standards used for documenting academic engagement in an online environment. 3) The method by which the instructor positively indicates that an online student has academically engaged in the course. The University has provided written policies on its website and engaged in a vigorous communication plan with both faculty and students. Compliance with the new policy is monitored through weekly reporting, and instructors who have not documented the initiation of attendance are referred to their dean, chair or department head. Prior to any reduction in Title IV aid, students are notified of any missing documentation and encouraged to speak with their instructors immediately. Last, reconciliation reports are monitored by the financial aid office for discrepancies and any conflicting information is resolved by contacting the instructor. Name of the contact person responsible for corrective action: Elijah Herr, Director of Student Financial Aid, Cindy Baccar, Associate Vice Provost & University Registrar and Karenna Wait, Director of Enterprise Applications. Planned completion date for corrective action plan: September 2023
NOTE: While discrepancies in payroll entries were observed during the period of emergency declaration, which provided full flexibility in fund usage, it's important to note that this doesn't justify inconsistencies between timesheets and the general ledger. The CFO will immediately evaluate the proc...
NOTE: While discrepancies in payroll entries were observed during the period of emergency declaration, which provided full flexibility in fund usage, it's important to note that this doesn't justify inconsistencies between timesheets and the general ledger. The CFO will immediately evaluate the procedures involved in recording employee time on timesheets and transferring this data to the financial management system. The CFO will immediately evaluate the need for additional controls to ensure accurate recording of time charged to programs as reflected on the employee's timesheet. The CFO will immediately implement new processes that establish checks and balances to verify that the programs charged in the general ledger align with the time recorded by the employees and is verified by their supervisor. The CFO and HR director will provide training sessions to all staff and new hires on the importance of accurately capturing and recording payroll costs by April 30, 2024. The CEO will immediately provide training to the CFO and staff accountant on the significance of aligning time charged with the programs designated in the general ledger for proper grant award billing. The CFO will conduct periodic reviews of payroll transactions to identify any discrepancies or irregularities promptly and take action immediately upon identification of such. These reviews will continue through FY 2025.
Individual Responsible for Corrective Action: Everett Jeter, Director of Compliance Corrective Action: The error falls into the category of human oversight rather than fundamental misunderstanding of the regulation or timing of processes. A loan disbursement notification was sent to the student for...
Individual Responsible for Corrective Action: Everett Jeter, Director of Compliance Corrective Action: The error falls into the category of human oversight rather than fundamental misunderstanding of the regulation or timing of processes. A loan disbursement notification was sent to the student for both the fall 2022 and spring 2023 semesters. We can document the spring 2023 loan disbursement notification was sent but are unable to document the date. Our internal processes dictate that the notification would normally be sent on the date of disbursement. We will develop and implement additional controls to effectively capture a student’s disbursement notification to ensure that both a record of the notification and the date are maintained. Anticipated Completion Date: August 15, 2024
NFP concurs with this finding and notes the $52,982 of questioned costs were written off to the wrong adjustment code due to the automated write-off with the patient software. NFP identified the issue in December of 2022 and the Vice President of Compliance and Chief Financial Officer performed a r...
NFP concurs with this finding and notes the $52,982 of questioned costs were written off to the wrong adjustment code due to the automated write-off with the patient software. NFP identified the issue in December of 2022 and the Vice President of Compliance and Chief Financial Officer performed a root cause analysis as to the starting point. Management corrected the write-off with the patient software that was causing the automated adjustments when initially identified. Management will continue to audit and review the automated write-off with the patient software on a quarterly/monthly basis (as determined) going forward as well as implementing procedures to ensure the sliding scale eligible visits are properly documented and adjusted in the billing system.
View Audit 300892 Questioned Costs: $1
I will ensure the Financial Aid Office works closely with the Accounts Payables department to monitor that all Title IV refund checks have been cashed after 30 days of issuance of the refund. If a check has not been cashed a new check will be reissued immediately. If, after 30 days of the reissuance...
I will ensure the Financial Aid Office works closely with the Accounts Payables department to monitor that all Title IV refund checks have been cashed after 30 days of issuance of the refund. If a check has not been cashed a new check will be reissued immediately. If, after 30 days of the reissuance, the check has not been cashed then the funds will be returned to the Department of Education within the mandated 45-day period.
View Audit 300889 Questioned Costs: $1
We recently completed the transition and onboarding of departmental staff which would allow the University to fully enact its plan to ensure both the financial aid and the Registrar's office will perform prompt review of processing University withdrawals. The Registrar's office will develop process ...
We recently completed the transition and onboarding of departmental staff which would allow the University to fully enact its plan to ensure both the financial aid and the Registrar's office will perform prompt review of processing University withdrawals. The Registrar's office will develop process and procedures documentation as an internal control measuring tool to ensure that Administrative Withdrawals (AW) and Withdrawals for lack of attendance (WA) that affect student emollment are identified immediately. Staff in the Financial Aid and the Registrar's office will actively take part in training workshops and webinars provided by the Depatiment of Education and NASF AA for continuing education to stay abreast of new developments and best practices in the industry.
View Audit 300889 Questioned Costs: $1
Beginning immediately the District will develop internal controls to meet the requirements of the Davis-Bacon Act that ensure any time federal awards are used on construction that compliance with contracts, including inserting the prevailing wage clauses and ensuring that federal wage rates and frin...
Beginning immediately the District will develop internal controls to meet the requirements of the Davis-Bacon Act that ensure any time federal awards are used on construction that compliance with contracts, including inserting the prevailing wage clauses and ensuring that federal wage rates and fringes are met by an effective monitoring process which includes collecting and reviewing weekly certified payroll reports from the contractor or subcontractor. The District will also ensure that all items are posted at the work site to ensure compliance.
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