Corrective Action Plans

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Finding 291593 (2022-073)
Significant Deficiency 2022
CDLE will continue to develop, formally document, and implement policies for completing its federal reports for the Unemployment Insurance program. These policies will require the workbooks used to prepare the reports to be protected, for the data to be substantiated, and will require supervisory re...
CDLE will continue to develop, formally document, and implement policies for completing its federal reports for the Unemployment Insurance program. These policies will require the workbooks used to prepare the reports to be protected, for the data to be substantiated, and will require supervisory review on a monthly basis prior to submitting the reports to the federal government.
(A) The Department agrees with this finding. The Department is moving all adjudication and investigation of program integrity holds into the MyUI+ system, so there will be one system of record. The Department will ensure that all program integrity holds have all documentation through adjudication an...
(A) The Department agrees with this finding. The Department is moving all adjudication and investigation of program integrity holds into the MyUI+ system, so there will be one system of record. The Department will ensure that all program integrity holds have all documentation through adjudication and investigation, including log notes. The Department anticipates this to be fully implemented by July 2024. (B) The Department agrees with this finding. The department has modified processes to ensure all holds are only routed to the appropriate team to be adjudicated. In addition the Department is working to have all claims identified as fraud delivered in a workflow process in MyUI+ rather than the various processes in place now. Further the department is working with our MyUI+ system experts to implement new technology to strengthen and streamline the fraud indicator escalation process and systems within MyUI+. In working with our MyUI+ system experts, the Department anticipates this to be fully implemented by July 2024. (C) The Department agrees with this finding. The Department will continue strengthening security in this area and internal procedures to periodically monitor the potential for internal fraud activities. Additionally, the Department will periodically monitor and review My UI+ access levels for appropriateness. In consultation with our MyUI+ systems experts, the Department anticipates this finding to be fully implemented by July 2024. (D) The Department agrees with this finding. The Department will reinforce and strengthen the ethics policies in yearly communication to staff and tighten escalation policies to ensure pressures and inappropriate requests are handled in accordance with guidelines. The Department anticipates this will be completed by July 2023. (E) When a PI hold is identified as being highly suspicious for criminally fraudulent activity, it is routed to a specialized unit for review, thereby leaving the standard adjudication process. This is handled by passing the review to the UI Investigations and/or Criminal Enforcement (ICE) unit. The investigator performs their investigation and if no actual fraudulent activity is found they will release the hold. The UI Division also performs several quality control reviews of claims and claim decisions via Benefits Payment Control (BPC), Benefits Accuracy Measurements (BAM), Benefits Timeliness and Quality (BTQ), and internal Quality Assurance (QA) reviews. Claims are reviewed for such criteria as adequate support documentation, benefit payment accuracy, timely processing, and correct claim decision determination on all program integrity holds. The Green Book states in Section 10.14, ? If segregation of duties is not practical within an operational process because of limited personnel or other factors, management designs alternative control activities to address the risk of fraud, waste, or abuse in the operational process.? CDLE believes the reviews represent adequate and sufficient compensating controls for the need for segregation of duties on fraud holds. Changing the current process would hinder our ability to deliver UI benefit services timely to our customers and would put us in jeopardy of fulfilling our federal and state payment timeliness requirements.
Finding 291584 (2022-072)
Significant Deficiency 2022
(A) The Department will formalize IT security policies and procedures to comply with the Business Owner requirements contained within the Governor's Office of Information Technology's (OIT) March 2022, Colorado Information Security Policies. The Department will further formalize a procedure for prod...
(A) The Department will formalize IT security policies and procedures to comply with the Business Owner requirements contained within the Governor's Office of Information Technology's (OIT) March 2022, Colorado Information Security Policies. The Department will further formalize a procedure for product owners to annually review the OIT Colorado Information Security Policies and ensure alignment with the formalized Department IT policies and update any affected formalized IT procedures. The Department will communicate the formalized policies and procedures to Department staff and IT Service Providers, and then any future changes, as deemed necessary. (B) The Department will formalize IT security policies and procedures to comply with the Business Owner requirements contained within the Governor's Office of Information Technology's (OIT) March 2022, Colorado Information Security Policies. The Department will further formalize a procedure for product owners to annually review the OIT Colorado Information Security Policies and ensure alignment with the formalized Department IT policies and update any affected formalized IT procedures. The Department will communicate the formalized policies and procedures to Department staff and IT Service Providers, and then any future changes, as deemed necessary. (C) CDLE agrees with the recommendation and as part of A and B recommendations of this document, the Department will include a requirement from vendors to affirm they have reviewed and will comply with OIT security policies for all new contracts. Furthermore, as the Department becomes aware of changes to OIT Security Policies through its annual review process, these will be communicated to the vendors, and they will be required to reaffirm their compliance with any applicable changes. We will work with our current vendors for MyUI+ and Connecting Colorado to address the compliance issues noted in the audit and ensure they are compliant with OIT Security Policies and IT policies developed in part A and B of this recommendation. If non-compliance is determined to be unavoidable, the Department will file for a security exception with OIT. (D) CDLE agrees with the recommendation and will implement recommendation Part D as noted in the confidential finding. (E) CDLE agrees with the recommendation and will implement recommendation Part E as noted in the confidential finding.
Finding 291430 (2022-061)
Significant Deficiency 2022
(A) Colorado School of Mines will ensure appropriate reviews of expenditures occur to ensure they are within the period of performance for the federal award, and ensure that staff have an appropriate understanding of the related period of performance requirements or obtain clarification from the fed...
(A) Colorado School of Mines will ensure appropriate reviews of expenditures occur to ensure they are within the period of performance for the federal award, and ensure that staff have an appropriate understanding of the related period of performance requirements or obtain clarification from the federal grantor, as appropriate. (B) Mines did not update published Procurement Policies specific to approval limits by position to accurately reflect the delegated approval authority. Mines will update the published policies to accurately reflect delegated approval limits and review the procurement approval process.
View Audit 282464 Questioned Costs: $1
Finding 286697 (2022-059)
Significant Deficiency 2022
Front Range: Moving forward the Director of Financial Aid will engage the Restricted Funds Accountants in a quality assurance review of both dollars spent, type of fund, and student counts before it is submitted for final review and publishing by the Director of Resource Development and Senior Grant...
Front Range: Moving forward the Director of Financial Aid will engage the Restricted Funds Accountants in a quality assurance review of both dollars spent, type of fund, and student counts before it is submitted for final review and publishing by the Director of Resource Development and Senior Grant Administrator. The most recently submitted information for the quarterly report of September 30, 2022 will be sent to the Restricted Funds Accountants to validate that FRCC has been and will continue to be in compliance for quarterly HEERF reporting. Lamar: The Financial Aid Director and the Controller will compile their reporting support on the shared drive they utilize for other routine purposes as well, to ensure clear documentation of the numbers reported. The original report containing errors was corrected, validated, and reposted. All past year?s reporting data was made available on the shared drive as of July 2022. Pueblo: Each quarter Financial aid will obtain and compare Cognos and Banner disbursement reports for accuracy. Once the unduplicated student count is determined it will be sent to the Vice President of Student Success to validate and approve going forward. Financial aid will ensure staff maintain supporting documentation for any institutional expenditures information that was obtained from the fiscal office. Disbursement and expenditure data will be compiled for the Department of Education?s Quarterly Report by the submission deadline and will be submitted as PDF to webmaster for posting on PCC?s website and a copy emailed to a contact at the Department of Education and will archive the submission for future reference.
Finding 286696 (2022-063)
Significant Deficiency 2022
In December 2022, the Office of Financial Aid strengthened its internal control over the reporting requirements for the Higher Education Emergency Relief Fund (HEERF), by adding the report due dates to the internal operational calendar. Additional level reviews were also added to the submission proc...
In December 2022, the Office of Financial Aid strengthened its internal control over the reporting requirements for the Higher Education Emergency Relief Fund (HEERF), by adding the report due dates to the internal operational calendar. Additional level reviews were also added to the submission process before the required reports will be sent to the Department of Education and posted on the financial aid website.
Finding 286695 (2022-062)
Significant Deficiency 2022
In January 2023, the Executive Director of Financial Aid and Scholarships implemented a code of conduct that addresses and prohibits University personnel from awarding financial aid to their family members or other persons considered conflicts of interest. The Office of Financial Aid and Scholarship...
In January 2023, the Executive Director of Financial Aid and Scholarships implemented a code of conduct that addresses and prohibits University personnel from awarding financial aid to their family members or other persons considered conflicts of interest. The Office of Financial Aid and Scholarships will draft policy by June 30, 2023, to address the segregation of duties that prohibits awarding and disbursing federal, state, or institutional funding to students by one employee.
View Audit 282464 Questioned Costs: $1
Finding 286694 (2022-064)
Significant Deficiency 2022
Management agrees. After the notification of the missing HEERF report in December 2021, the UCCS Controller proposed a ?cross-check? process to ensure all future reporting is in compliance and reported in a timely manner. This process is used for both the quarterly and annual reporting process. In ...
Management agrees. After the notification of the missing HEERF report in December 2021, the UCCS Controller proposed a ?cross-check? process to ensure all future reporting is in compliance and reported in a timely manner. This process is used for both the quarterly and annual reporting process. In the quarterly reporting process, the UCCS Controller completes the institutional report and emails the report to the UCCS Financial Aid office Senior Executive Director for verification of the amounts and the data submitted. The Senior Executive Director then enters the student aid portion?s information and provides this to the UCCS Controller for verification of the data. Once verified, the report is uploaded to the UCCS website and a confirmation email is sent to the UCCS Controller as well as the heerfreporting@ed.gov for verification of completion of the website posting.
(A) Going forward, the Director of Purchasing will perform all Sam.Gov searches. The secondary reviews to ensure compliance for the System's procurement and suspension and debarment procedures will be conducted by the Vice President of Administration and Finance. (B) The corresponding documents sup...
(A) Going forward, the Director of Purchasing will perform all Sam.Gov searches. The secondary reviews to ensure compliance for the System's procurement and suspension and debarment procedures will be conducted by the Vice President of Administration and Finance. (B) The corresponding documents supporting procurement transactions and suspension and debarment checks will be scanned and filed along with the Purchase order. (C) Training will be provided to fiscal and grant staff for identifying when suspension and debarment must be checked for vendors of federal programs, processes and websites to access, and methodology for documenting with the purchase documentation.
View Audit 282464 Questioned Costs: $1
(A) Otero College has adopted the system offices Sole Source justification form that will be posted to the State procurement site, requires supervisory approval, and has put that into place as of August 2022. (B) Otero College will ensure they maintain supporting documentation for procurements. (C...
(A) Otero College has adopted the system offices Sole Source justification form that will be posted to the State procurement site, requires supervisory approval, and has put that into place as of August 2022. (B) Otero College will ensure they maintain supporting documentation for procurements. (C) Otero College has a new procurement official that has attended various trainings regarding procurement rules.
View Audit 282464 Questioned Costs: $1
(A) Beginning in October 2022, the duty was moved from the Principal Investigator or instructional staff previously responsible for this step to the Director of Purchasing to ensure compliance for all grant transactions. (B) Training will be provided for identifying when suspension and debarment mu...
(A) Beginning in October 2022, the duty was moved from the Principal Investigator or instructional staff previously responsible for this step to the Director of Purchasing to ensure compliance for all grant transactions. (B) Training will be provided for identifying when suspension and debarment must be checked for vendors of federal programs, processes and websites to access, and methodology for documenting with the purchase, to fiscal and grant staff.
View Audit 282464 Questioned Costs: $1
The Food Bank has updated the weight and has implemented procedures to ensure products are updated annually.
The Food Bank has updated the weight and has implemented procedures to ensure products are updated annually.
CAP Services, Inc. submits the following corrective action plan for the identified finding for the audit period January 1, 2022 through December 31, 2022: Finding 2022-001 Tri-Partite Board Composition As stated in CAP's bylaws, the composition of CAP's Board of Directors requires tri-partite repr...
CAP Services, Inc. submits the following corrective action plan for the identified finding for the audit period January 1, 2022 through December 31, 2022: Finding 2022-001 Tri-Partite Board Composition As stated in CAP's bylaws, the composition of CAP's Board of Directors requires tri-partite representation from three sectors: low-income community, community at large, and public elected officials. CAP is the locally designated community action agency for five counties. The Board composition includes four members from each county and one member elected by CAP's Head Start Policy Council for a total of twenty-one members. One-third (7 of 21) represent each of the three sectors. In 2022, CAP experienced two unexpected resignations of low-income representatives during the course of the year and retained the remaining nineteen members. As a result of the vacancies, the one-third representation was not met as the remaining members were actively engaged in their respective seats (average 90% participation). Recruitment was ongoing and several low-income community members expressed interest in the seats, however, the continued uncertainty of the ongoing pandemic was a challenge and a barrier. Corrective Action Plan for Future: ? CAP's Governance Committee will take a more active role in recruitment and retention of Board members. ? CAP's executive team will maintain a list of interested candidates and send regular communication to keep candidates engaged and ready if a seat becomes available. ? CAP's bylaws will be reviewed for consideration of shifting designated seats to offer more flexibility that will better ensure at least one-third low-income representation when unexpected vacancies occur. ? CAP will consult with other community action agencies and the National Community Action Partnership to explore best practices related to recruitment of low-income representatives. As of the date of this letter, CAP's 21-member Board of Directors is fully seated and meets the tri-partite board requirement.
Finding 279107 (2022-002)
Significant Deficiency 2022
2022-002: Special Tests and Provisions Recommendation: We recommend that management implement a procedure to maintain documentation of employees written acceptance of the policies. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in respon...
2022-002: Special Tests and Provisions Recommendation: We recommend that management implement a procedure to maintain documentation of employees written acceptance of the policies. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: The Organization will implement a process whereby new staff sign an acknowledgment that they have received and reviewed the Organization?s policies. This will happen during the HR onboarding process. For existing staff members, the Organization will separately secure written acknowledgement and retain in our organizational files. Name of the contact person responsible for corrective action: McKenzie Marks, Director of Human Resources Planned completion date for corrective action plan: September 30, 2023
Finding 279106 (2022-001)
Significant Deficiency 2022
2022-001: Eligibility Recommendation: We recommend that management implement a control to ensure documentation is maintained to support that all cases have been reviewed when closed. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in respon...
2022-001: Eligibility Recommendation: We recommend that management implement a control to ensure documentation is maintained to support that all cases have been reviewed when closed. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: We will draft a supervisor case closing checklist. We will distribute the checklist to supervisors once it is finalized. We will then pull a random sample of recently closed cases in October to see if supervisors are completing the review as instructed. Name of the contact person responsible for corrective action: Daniel Lindsey, Chief Litigation Officer Planned completion date for corrective action plan: September 30, 2023
Finding: 2022-002 Internal Control over Compliance with Reporting Agency: Greater Cleveland Food Bank Name of responsible contact person and title: Jessica Morgan, CPO & Valissa Turner Howard, VP of Talent and Legal Affairs Anticipated completion date: 7/31/2023 Agency's response: Concur Planned Cor...
Finding: 2022-002 Internal Control over Compliance with Reporting Agency: Greater Cleveland Food Bank Name of responsible contact person and title: Jessica Morgan, CPO & Valissa Turner Howard, VP of Talent and Legal Affairs Anticipated completion date: 7/31/2023 Agency's response: Concur Planned Corrective Action(s): ? The Agency Services Analyst will complete the quarterly report within 35 days of the end of the quarter to ensure proper review, approval, and corrections if necessary, in order to be submitted within the 45-day requirement. Prior to the report being submitted, the Director of Agency Services will continue to review and will provide oversight for timely submission. ? Include in our Internal Auditing Program of the OAF/TANF contract, review of all supporting documents to validate timely reporting. ? The VP of Talent and Legal Affairs with the support of the Compliance Manager will review the timelines for all required reporting to the Ohio Association of Food banks on an annual basis with supervisors and those employees responsible for reporting.
Finding: 2022-001 Internal Control over Compliance with Activities Allowed or Unallowable Agency: Greater Cleveland Food Bank Name of responsible contact person and title: Jessica Morgan, Chief Programs Officer and Dwayne Brake, VP of Operations Anticipated completion date: 7/31/2023 Agency's respon...
Finding: 2022-001 Internal Control over Compliance with Activities Allowed or Unallowable Agency: Greater Cleveland Food Bank Name of responsible contact person and title: Jessica Morgan, Chief Programs Officer and Dwayne Brake, VP of Operations Anticipated completion date: 7/31/2023 Agency's response: Concur Planned Corrective Action(s): ? Reimplementation of pre-COVID delivery and rece iving practices, signed receipts, regarding all food and commodities to sub-recipient agencies. ? Include a review of all supporting documents and signed receipts in our Internal Auditing Program of the TEFAP contract. ? Staff who are responsible for collecting invoice signatures, including the responsible parties, will be retrained on the procedure and will annually review the requirements for signed receipts for government commodities to ensure proper record keeping.
Finding: 2022-002 Agency: U.S. Department of Health and Human Services ? ALN 93.558 ? TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) Name of contact person and title: Shelia Triplett, Executive Director Anticipated completion date: September 2023 MYCAP?s respo...
Finding: 2022-002 Agency: U.S. Department of Health and Human Services ? ALN 93.558 ? TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) Name of contact person and title: Shelia Triplett, Executive Director Anticipated completion date: September 2023 MYCAP?s response: Concur MYCAP agrees with this finding and provided the following response for corrective action: U.S. Department of Health and Human Services ? Significant Deficiency ? Internal Controls over Compliance ? Eligibility Plan of Action: The Support Specialist will gather all required documents for the TANF program, ensuring the application documents and required income are on file. The Chief Operating Officer (COO) will conduct a second review of all TANF files for proper eligibility requirements including recalculations of income, ensuring all files are eligible, marking the file with initial and approval for processing.
Finding 2022-03 Expenditure of Funds Outside Contract Period Condition: In the course of testing direct disbursements for adherence to appropriate cutoffs concerning the contract's period of performance, it was discovered that the Organization incurred a substantial amount of expenditures on contr...
Finding 2022-03 Expenditure of Funds Outside Contract Period Condition: In the course of testing direct disbursements for adherence to appropriate cutoffs concerning the contract's period of performance, it was discovered that the Organization incurred a substantial amount of expenditures on contracts prior to the official contract start date. These disbursements took place without acquiring proper authorization for making disbursements prior to the contract's commencement. Despite the unique nature of Naloxone inventory being treated as a prepaid asset due to its delayed usage, the majority, if not all, of the Naloxone units were fully expended before the contract officially commenced. Corrective Actions Taken or Planned: The Organization?s Board and Executive Team consisting of the CEO and the COO acknowledge the finding of expending funds outside the contract period. This finding is connected to the purchase of the emergency medication naloxone. The Organization decided to purchase with no assurance of reimbursement in order to eliminate the lack of emergency medication in an overdose epidemic. The Organization had verbal approval but did not secure approval in writing. Numerous policies will be adopted in 2023 to ensure this does not occur again. Some of these policies include the transition to an experienced nonprofit bookkeeper, training for Finance and Grants Management and tracking mechanisms, monthly grants tracking meetings to ensure inventory and spending, and the adoption of a clear and documented approval process should spending, outside a contract period, be required.
View Audit 261078 Questioned Costs: $1
2022-007 Significant Deficiency in Controls over Compliance and Compliance Finding: Double Reporting of Student Counts. Effective January 2022, the Business Manager now reviews all count sheets and ties the counts to the summary report used to submit claims prior to submittal for reimbursement. She...
2022-007 Significant Deficiency in Controls over Compliance and Compliance Finding: Double Reporting of Student Counts. Effective January 2022, the Business Manager now reviews all count sheets and ties the counts to the summary report used to submit claims prior to submittal for reimbursement. She did not, however, review the actual claims before submittal and discovered after-the-fact that these duplicate counts had occurred. The review procedures were immediately changed to include reviewing the actual claim submittal before the Food Manager certifies their claims.
View Audit 261067 Questioned Costs: $1
2022-004 Material Weakness in Controls over Compliance: Activities Allowed or Unallowed We agree with the recommendations and have made improvements to our procedures. The schools were not prepared for the rapid expansion of the food program, not only at our two high schools, but our partner schoo...
2022-004 Material Weakness in Controls over Compliance: Activities Allowed or Unallowed We agree with the recommendations and have made improvements to our procedures. The schools were not prepared for the rapid expansion of the food program, not only at our two high schools, but our partner schools' which requested contracted breakfast/lunch food services for their students as well. This unprecedented growth coupled with supply chain issues from food wholesalers, and shortage of employees in the hiring pool, only exacerbated our issues. The audit sample showed a large error rate for one of the schools. We have gone through the entire year for the school(s) individual count sheets. In the event the Michigan Department of Education determines that the identified discrepancies warrant a repayment we have recorded an allowance in the financial statements for the year ended June 30, 2021. Staff were not properly trained in how to complete the count sheets; however, supervisors did not take the time once they saw there was a problem due to everyone trying to simply get the meals served to the children. In addition, there was a lack of oversight of the Food Service Manager by her direct supervisor. At the time of the 2021 audit, when the issue was brought to our attention, we developed new procedures. School staff performing counts have been trained in how to properly complete the count sheets. The Business Manager now reviews all count sheets and ties counts to the summary report used to submit claims prior to submittal for reimbursement. Given that training and implementation of procedures did not fully occur until January 2022, there are errors in counts prior to implementation of the procedures and repeat findings in fiscal year 2021-22. In addition, with the end of the pandemic, beginning with the 2022-23 school year, the schools were able to resume using electronic software to accurately capture the meal counts.
View Audit 261067 Questioned Costs: $1
Finding Number: 2022-015 ? Cash Management Corrective Action Plan: A process has been put in place for the school principal to review all RFRs prior to submission to the grantor. Approval is evidenced by email sent by principal to the Director of Grant Management, which is saved with the RFR as supp...
Finding Number: 2022-015 ? Cash Management Corrective Action Plan: A process has been put in place for the school principal to review all RFRs prior to submission to the grantor. Approval is evidenced by email sent by principal to the Director of Grant Management, which is saved with the RFR as support. Responsible Individuals: Nachum Golodner, Director of Accounting Anticipated Completion Date: June 30, 2023
Views of Responsible Officials and Planned Corrective Actions - Management recognizes the overall volume of transactions the Organization continues to grow each year and it being one of the reasons this is a repeat finding. The questioned costs were immaterial. While improvements were made during th...
Views of Responsible Officials and Planned Corrective Actions - Management recognizes the overall volume of transactions the Organization continues to grow each year and it being one of the reasons this is a repeat finding. The questioned costs were immaterial. While improvements were made during the year, the internal recordkeeping controls and protocols will continue to be reviewed with the new accounting service provider and improved measures implemented.
Proposed corrective action: The finance department has already implemented a process in which the Chief Financial Officer reviews the documentation for expenditures allowed and unallowed under the terms of the grant agreement, and the drawdown happens only when the amount of allowed expenditures has...
Proposed corrective action: The finance department has already implemented a process in which the Chief Financial Officer reviews the documentation for expenditures allowed and unallowed under the terms of the grant agreement, and the drawdown happens only when the amount of allowed expenditures has been determined. Anticipated correction date: This has already been implemented retroactively effective January 2023. Responsible official: Gabriela Cordero, Chief Financial Officer.
View Audit 235553 Questioned Costs: $1
Management agrees with the finding and has reviewed procedures with the appropriate personnel.
Management agrees with the finding and has reviewed procedures with the appropriate personnel.
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