Corrective Action Plans

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The District will implement a process to track the submission time for the data collection form and single audit package.
The District will implement a process to track the submission time for the data collection form and single audit package.
Finding 561175 (2024-001)
Significant Deficiency 2024
Finding no.: 2024-001 Contact person(s) responsible: Kymberly Horner, Executive Director for PCRI and Radha Mehrotra, Controller for Cascade Management Corrective action planned: The closing of books and preparation for audit procedures is being addressed via improvements in internal controls r...
Finding no.: 2024-001 Contact person(s) responsible: Kymberly Horner, Executive Director for PCRI and Radha Mehrotra, Controller for Cascade Management Corrective action planned: The closing of books and preparation for audit procedures is being addressed via improvements in internal controls related to property accounting, month and year end closing procedures which include a new property management accounting software package. It is also being addressed via the hiring of more experienced staff during fiscal year 2024-2025. The organization anticipates that these improvements will allow for the audit to be completed within the required timeframe in the upcoming cycle. Anticipated completion date: October 2025
The Agency has attempted to segregate accounting duties by having a person who does not initiate, prepare or post disbursements review the bank statements and co-sign all checks. The Agency will continue to monitor its policies and procedures in an effort to improve control efficiencies, however, a...
The Agency has attempted to segregate accounting duties by having a person who does not initiate, prepare or post disbursements review the bank statements and co-sign all checks. The Agency will continue to monitor its policies and procedures in an effort to improve control efficiencies, however, at this time, the Agency has determined that the cost of eliminating this material weakness in internal control would exceed its benefit.
The Authority has attempted to segregate accounting duties by having a person who does not initiate, prepare or post disbursements review the bank statements and co-sign all checks. The Authority will continue to monitor its policies and procedures in an effort to improve control efficiencies, howe...
The Authority has attempted to segregate accounting duties by having a person who does not initiate, prepare or post disbursements review the bank statements and co-sign all checks. The Authority will continue to monitor its policies and procedures in an effort to improve control efficiencies, however, at this time, the Authority has determined that the cost of eliminating the deficiency would exceed its benefit.
Finding Reference Number: 2024-003 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director and the Treasurer will review internal controls to ensure the proper segregation of duties. The Finance Director and the Executive Director will review job...
Finding Reference Number: 2024-003 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director and the Treasurer will review internal controls to ensure the proper segregation of duties. The Finance Director and the Executive Director will review job duties of the Finance Director and appropriate staff will be trained as back-up. We have a third party outside accountant that prepares quarterly and annual reporting. All reports are reviewed by the Executive Director, the Finance Director and the third-party accountant to ensure that the reports are accurate. After the initial review, the third-party accountant is present at the finance committee when the reports are presented. Name of Contact Person: Susan Dana, Finance Director Projected Completion Date: June 30, 2025
Finding Reference Number: 2024-002 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director reviewed the internal controls requiring all expenditures above $2,000 requiring dual signatures with the Office Administrator. If the Office Administrator ...
Finding Reference Number: 2024-002 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director reviewed the internal controls requiring all expenditures above $2,000 requiring dual signatures with the Office Administrator. If the Office Administrator is not in the office when checks are to be mailed, the staff mailing checks will refer to the procedures filed in the front office prior to processing checks. Name of Contact Person: Susan Dana, Finance Director Projected Completion Date: March 28, 2025
Finding Reference Number: 2024-001 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director will review personnel files for all raises to ensure that the required documentation supports the raise amount approved by the Executive Director. Name o...
Finding Reference Number: 2024-001 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director will review personnel files for all raises to ensure that the required documentation supports the raise amount approved by the Executive Director. Name of Contact Person: Susan Dana, Finance Director Projected Completion Date: May 31, 2025
Finding 561095 (2024-001)
Significant Deficiency 2024
Finding 2024-001 Condition: The federal awards expenditure data compiled by the County to prepare the SEFA was found to be incomplete and inaccurate. Plan: The County should consider the costs and benefits of establishing a financial management system that provides for the identification, in its...
Finding 2024-001 Condition: The federal awards expenditure data compiled by the County to prepare the SEFA was found to be incomplete and inaccurate. Plan: The County should consider the costs and benefits of establishing a financial management system that provides for the identification, in its accounts, of all Federal awards received and expended and the Federal programs for which they are received for all County Departments receiving federal awards. Name of Contact Person: Nikki Lohman, Treasurer Management Response: In the 2025 Budget, the County has a new separate fund, Fund 385, established to deal solely with the grant money that comes into Montgomery County. The County has transferred coal money to begin the fund and all Haz Mat, DCEO, Elections, etc. will go through this fund to keep it separate from regular budgeted money. Expenses will be paid out and revenue will return to this fund. This is for General Fund accounts, the Health Department will still be on their own process. Anticipated Date of Completion: Completed in 2025 prior to the issuance of financial statements.
Finding 561094 (2024-003)
Significant Deficiency 2024
Finding 2024-003 Condition: The County incorrectly reported expenditures on their annual Project and Expenditure (P&E) report for the fiscal year ended November 30, 2024. There were excluded expenditures for one project and overstated expenditures for various projects related to prior year exclusi...
Finding 2024-003 Condition: The County incorrectly reported expenditures on their annual Project and Expenditure (P&E) report for the fiscal year ended November 30, 2024. There were excluded expenditures for one project and overstated expenditures for various projects related to prior year exclusions, which are now reported correctly in total. Plan: The County should ensure all expenditures incurred within the fiscal year are included on the annual report. Name of Contact Person: Nikki Lohman, Treasurer Management Response: The County will work closer with Bellwether to ensure the expenditures are matching and included in the report. Anticipated Date of Completion: November 2025, anticipated date of ARPA funds being fully expensed.
CORRECTIVE ACTION PLAN (UNAUDITED) Name of Auditee: Union Congregational Church Homes, Inc. HUD Project No.: 023-35372 Audit Firm: Kahn, Litwin, Renza & Co., Ltd. Period Covered by the Audit: Year ended December 31, 2024 Corrective Action Plan Prepared By: Name: Ronald Gates Position: Executive Dire...
CORRECTIVE ACTION PLAN (UNAUDITED) Name of Auditee: Union Congregational Church Homes, Inc. HUD Project No.: 023-35372 Audit Firm: Kahn, Litwin, Renza & Co., Ltd. Period Covered by the Audit: Year ended December 31, 2024 Corrective Action Plan Prepared By: Name: Ronald Gates Position: Executive Director Telephone No.: (781) 335-2667 A. Current Findings on the Schedule of Findings and Questioned Costs Finding 2024-001: Unauthorized Distribution of Project Funds a. Comments on Finding and Recommendations: Management concurs with the finding and agrees with the recommendation. b. Actions Taken or Planned: Management concurs with the finding. On March 11, 2025, the Organization transferred $118,186 from its entity cash account into the Project’s operating account. On March 27, 2025, the Organization transferred $14,681 from its entity cash account to the Project’s property insurance escrow deposits account. Supporting documentation for these transfers will be furnished to HUD upon request. Name of Responsible Person: Ronald Gates, Executive Director Projected Implementation Date: March 11, 2025 and March 27, 2025
View Audit 356732 Questioned Costs: $1
2024-001 Significant deficiency related to preparation of the schedule of federal awards Recommendation: The auditor recommends implementing a documented SEFA preparation process, assigning a reviewer to ensure accuracy, and providing staff training on Uniform Guidance standards. A checklist or simi...
2024-001 Significant deficiency related to preparation of the schedule of federal awards Recommendation: The auditor recommends implementing a documented SEFA preparation process, assigning a reviewer to ensure accuracy, and providing staff training on Uniform Guidance standards. A checklist or similar tool could enhance consistency and completeness. Planned Corrective Action: Management agrees with the recommendation and will take necessary steps to address the issue. These steps include developing a formal SEFA preparation process, reconciling federal expenditures to the general ledger, training staff on Uniform Guidance requirements, and instituting a review process to ensure accuracy. Management anticipates implementing these corrective actions prior to the next audit cycle.
The Health System met with grant managers and reviewed the expectations and responsibilities to ensure appropriate reviews and sign offs prior to submitting reports to the granting agency. The Health System will implement a centralized process with dedicated resources that will establish consistent ...
The Health System met with grant managers and reviewed the expectations and responsibilities to ensure appropriate reviews and sign offs prior to submitting reports to the granting agency. The Health System will implement a centralized process with dedicated resources that will establish consistent policies for grant management, including a layered review process with executive sign off on reports prior to submission.
Auditor Description of Condition and Effect: During our audit, we noted a variance between amounts reported in the Form 5100-127 and amounts recorded in the general ledger and audit report for the related fiscal year. The report was amended during the audit to reflect the correct amounts. Auditor R...
Auditor Description of Condition and Effect: During our audit, we noted a variance between amounts reported in the Form 5100-127 and amounts recorded in the general ledger and audit report for the related fiscal year. The report was amended during the audit to reflect the correct amounts. Auditor Recommendation: We recommend that the Airport reconciles Form 5100-127 with amounts in the general ledger to ensure that all items on the report are correct. Corrective Action: Form 5100-127 was corrected during the audit and resubmitted with accurate information. Going forward, Management will reconcile between the amounts on the general ledger and amounts reported on Form 5100-127 to ensure accuracy. Management will also complete an independent review of the Form before submission. Responsible Person: James Canders, Airport Director Anticipated Completion Date: 12/31/2025
Finding 2024-001 – Special Tests and Provisions, SEMAP reporting – ALN 14.871 – Significant Deficiency & Other Matter Corrective Action Plan: Since the audit, I have completed a SEMAP training course provided by The Nelrod Company. I will draft a binder for each indicator. I will complete the anal...
Finding 2024-001 – Special Tests and Provisions, SEMAP reporting – ALN 14.871 – Significant Deficiency & Other Matter Corrective Action Plan: Since the audit, I have completed a SEMAP training course provided by The Nelrod Company. I will draft a binder for each indicator. I will complete the analysis for each indicator and provide verification of all findings. Person Responsible: Annette Carper, Executive Director Anticipated Completion Date: I have completed the SEMAP training. The FYE 2025 SEMAP is due to be submitted by July 31, 2025. I will prepare a binder that will show collected data from August 1, 2024-July 31, 2025.
We are reviewing all accounting procedures to determine changes to be implemented.
We are reviewing all accounting procedures to determine changes to be implemented.
2024-003: Reporting Compliance Requirement The City will review the current procedures for maintaining documentation for when quarterly project and expenditures reports are completed, reviewed and submitted. Contact Person: Rosie Cavazos, CFO Proposed implementation date: September 30, 2025
2024-003: Reporting Compliance Requirement The City will review the current procedures for maintaining documentation for when quarterly project and expenditures reports are completed, reviewed and submitted. Contact Person: Rosie Cavazos, CFO Proposed implementation date: September 30, 2025
Finding Number: 2024‐001 Program Names/Assistance Listing Titles: Assistance Listing Numbers: Title I Grants 84.010 Child Nutrition Cluster 10.553, 10.555, 10.559 Impact Aid 84.041 Education Stabilization Fund 84.425 Contact Person: Arlene Laughter, Business Coordinator Anticipated Completion Date: ...
Finding Number: 2024‐001 Program Names/Assistance Listing Titles: Assistance Listing Numbers: Title I Grants 84.010 Child Nutrition Cluster 10.553, 10.555, 10.559 Impact Aid 84.041 Education Stabilization Fund 84.425 Contact Person: Arlene Laughter, Business Coordinator Anticipated Completion Date: December 30, 2025 Planned Corrective Action: The District will implement better controls over financial reporting and records retention to ensure all documents are prepared and available for the timely completion of the financial reports.
District will work closely with external auditors with an initial calendar to meet the required deadline for next year’s (fiscal year 2025) audit.
District will work closely with external auditors with an initial calendar to meet the required deadline for next year’s (fiscal year 2025) audit.
MANAGEMENT’S VIEWS AND CORRECTIVE ACTION PLAN For the year ended December 31, 2024 Finding 2024-001 - Non-Compliance with Accurate Student Enrollment Change Submissions to the National Student Loan Data System (Significant Deficiency) Grantor: U.S. Department of Education Program: Student Fina...
MANAGEMENT’S VIEWS AND CORRECTIVE ACTION PLAN For the year ended December 31, 2024 Finding 2024-001 - Non-Compliance with Accurate Student Enrollment Change Submissions to the National Student Loan Data System (Significant Deficiency) Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing #: 84.268, 84.063 Award Titles: Federal Direct Student Loan Program, Federal Pell Grant Program Award Years: 7/2023 – 6/2025 Management agrees with the finding and proposes the following corrective action plan: Corrective Action Plan: Due to non-compliance with timely and accurate student enrollment change submissions to the National Student Loan Data System (NSLDS), Brigham Young University – Hawaii (BYUH) Management proposes the following corrective action plan to mitigate reporting errors. The Registrar’s Office, in coordination with BYUH’s Enterprise Information Systems team, will review and enhance the processes used to extract student data from PeopleSoft and transmit it to the National Student Clearinghouse (NSC) and NSLDS. This includes: -Reviewing all relevant PeopleSoft updates and ensuring that corresponding changes are reflected in the data transmitted to NSLDS. -Testing and validating the reporting processes within PeopleSoft to confirm data accuracy and completeness. -Verifying that the correct data is being transmitted to NSLDS. -Testing the student data within NSLDS to ensure its integrity. -Documenting the entire process for future reference and ongoing quality assurance. In addition, the Registrar’s office has already added additional resources to run all reporting processes. The Registrar’s office has also reached out to Ensign College to learn about their reporting process. The University is considering contacting the PeopleSoft reporting specialist that Ensign used, although that decision will be made at a later date, and if necessary. These actions will enable the Registrar’s Office to more effectively review credit load determinations and accurately establish program begin dates for students. Daryl Whitford, Registrar, will remain responsible for enrollment reporting at BYUH. She will oversee the implementation of the revised process, provide training to all relevant staff members, and lead the development and implementation of a control mechanism to ensurefuture compliance with NSLDS reporting requirements within PeopleSoft. Timing: Daryl Whitford, Registrar, will be responsible for overseeing that all items noted in the corrective action plan will be implemented by September 1, 2025. Signed and Acknowledged Daryl Whitford, BYUH Registrar
2024-004 – Material Weakness – Noncompliance in Reporting Federal Agency: U.S. Department of Agriculture, Rural Development, CFDA #10.766 Community Facilities Loans and Grants Cluster Corrective Action Plan: Management will put processes into place to ensure an auditor is engaged to complete a s...
2024-004 – Material Weakness – Noncompliance in Reporting Federal Agency: U.S. Department of Agriculture, Rural Development, CFDA #10.766 Community Facilities Loans and Grants Cluster Corrective Action Plan: Management will put processes into place to ensure an auditor is engaged to complete a single audit in accordance with the Uniform Guidance to complete timely submission to the Federal Audit Clearinghouse of the audit report and data collection form. Responsible Party: Mariah Voeltz, Acting Administrator Estimated completion date: June 30, 2025
Management Views and Corrective Action Plan Year Ending December 31, 2024 Finding 2024-001 – Enrollment Reporting Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing#: 84.268, 84.063 Award Titles: Federal Direct Student Loan Program, ...
Management Views and Corrective Action Plan Year Ending December 31, 2024 Finding 2024-001 – Enrollment Reporting Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing#: 84.268, 84.063 Award Titles: Federal Direct Student Loan Program, Federal Pell Grant Program Award Years: 7/2023 – 6/2026 Management agrees with the finding and proposes the following corrective action plan: Corrective Action Plan Campus Status Matt Smith, College Registrar, will work with Tom Cote, NSC Enrollment Reporting Consultant, to adjust the enrollment report produced by PeopleSoft. With this change, PeopleSoft will report a student's campus-level enrollment as withdrawn when they withdraw in the middle of a semester instead of leaving them as less than half-time. Program Status Matt Smith, College Registrar, and Riley Niemand, Director of Financial Aid, will use the NSLDS Enrollment Error Report to reconcile what is being reported from NSC to NSLDS to ensure it is accurate. Timing Campus Status Matt Smith is currently working with Tom Cote to make these changes and work will be completed by the end of May 2025. Program Status Matt Smith and Riley Niemand will have this reconciliation implemented by the end of June 2025. Sincerely, S. Christopher Reitz Director of Financial Services and Controller creitz@ensign.edu 801-524-8109
Finding #2: Untimely Return of Title IV Funds (R2T4) Criteria: Under 34 CFR 668.22(j), institutions must return unearned Title IV funds no later than 45 days from the date the institution determines that a student has withdrawn. Condition: Six R2T4s were submitted late. While four were linked to thi...
Finding #2: Untimely Return of Title IV Funds (R2T4) Criteria: Under 34 CFR 668.22(j), institutions must return unearned Title IV funds no later than 45 days from the date the institution determines that a student has withdrawn. Condition: Six R2T4s were submitted late. While four were linked to third-party service platform transitions, two delays were related to students experiencing hardship (homelessness and mental health emergencies) and internal documentation gaps. Effect: Noncompliance with R2T4 deadlines may result in program findings, increased liabilities, and recurring audit scrutiny if unresolved. Corrective Actions for R2T4: 6. R2T4 Tracker Implementation o Action: Launch a live R2T4 tracker in Campus Café, flagged by withdrawal status and showing days remaining until the 45-day deadline. o Due Date: May 15, 2025 o Lead: Registrar, Business Office, Financial Aid Lead 7. Case Ownership Assignment Protocol o Action: Assign R2T4 responsibility to ECM and Business Office, written timelines and escalation criteria. o Due Date: May 15, 2025 o Lead: Executive Director 8. R2T4 Checklist & Escalation Framework o Action: Finalize a standardized checklist for all R2T4 cases including withdrawal date, calculation verification, fund return confirmation, and dual review. o Due Date: May 15, 2025 o Lead: Operations Manager 9. Quarterly R2T4 Audit o Action: Conduct quarterly compliance audits on all R2T4 files and include findings in compliance reports. o Due Date: First audit by June 30, 2025 o Lead: Compliance Officer 10. Emergency Circumstance Protocol o Action: Document a formal protocol for handling R2T4 cases with student hardship that allows internal escalation, verification, and documentation of exception handling. o Due Date: July 1, 2025 o Lead: Executive Director Monitoring Plan: Compliance will provide a quarterly report on R2T4 timeliness to the Executive Director. Any case that nears 35 days will be auto escalated for executive intervention.
Finding #1: Delayed or Incomplete Enrollment Reporting Criteria: Per 34 CFR 685.309(b), institutions must report student enrollment status changes (withdrawals, graduations, leaves of absence) within 30 days of determination or every 60 days using a consistent reporting schedule. Condition: Enrollme...
Finding #1: Delayed or Incomplete Enrollment Reporting Criteria: Per 34 CFR 685.309(b), institutions must report student enrollment status changes (withdrawals, graduations, leaves of absence) within 30 days of determination or every 60 days using a consistent reporting schedule. Condition: Enrollment changes for several students were not reported to NSLDS within the required timelines. Delays resulted from third-party servicer (ECM) processing issues, gaps in cross-verification, and lack of internal triggers for mid-enrollment aid recipients. Effect: Untimely reporting may result in incorrect loan repayment statuses for borrowers and may trigger additional oversight by the Department of Education. Corrective Actions for Enrollment Reporting: 1. Shared Operational Calendar with Alerts o Action: Expand the institutional calendar to include enrollment reporting cycles with automated alerts 15 and 5 days before reporting deadlines. o Due Date: May 15, 2025 o Lead: Registrar 2. Internal Monthly Cross-Verification Audit o Action: Reconcile Campus Café enrollment records with ECM NSLDS batch confirmations monthly to catch and correct discrepancies. o Due Date: Begins May 2025, ongoing o Lead: Compliance Officer 3. Enhanced Title IV Status Tracking o Action: Update batch tracker template to log when students begin receiving Title IV aid after initial enrollment, with clear notation requirements. o Due Date: May 15, 2025, Ongoing o Lead: Registrar 4. Targeted Staff Training o Action: Deliver internal training on accurate Title IV status coding and enrollment reporting procedures to Registrar and Business Office teams. o Due Date: May 15, 2025 o Lead: Executive Director & Registrar 5. Bi-Monthly Enrollment Reporting Review o Action: Conduct a compliance review every 8 weeks to assess reporting timeliness and documentation quality. o Due Date: Begins May 2025 o Lead: Compliance Officer Monitoring Plan: Compliance team will issue bi-monthly reports to the Executive Director summarizing reporting performance and identifying risk patterns.
2024-002 Student Financial Aid Cluster – Assistance Listing 84.063 and 84.268 Recommendation: The College should evaluate their procedures and review policies surrounding reporting enrollment effective dates and program enrollment effective dates NSLDS. Explanation of disagreement with audit finding...
2024-002 Student Financial Aid Cluster – Assistance Listing 84.063 and 84.268 Recommendation: The College should evaluate their procedures and review policies surrounding reporting enrollment effective dates and program enrollment effective dates NSLDS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Through the review of program reporting and campus reporting, the college will identify the cause for the data error. The college will explore the impact of branch campuses and the potential to shift to a single college reporting model. The following specific steps will be completed. 1. Identify and Analyze the Issues 2. Root Cause Analysis 3. Corrective Measures 4. Automation: Implement automated checks and balances to ensure data integrity before files are processed and sent. Name(s) of the contact person(s) responsible for corrective action: Patricia Munsch, Ph.D. Vice President for Student Affairs Nancy Brewer, College Director for Financial Aid Cheryl Eldredge, College Associate Dean for Registrar and Master Schedule Planned completion date for corrective action plan: December 31, 2026
2024-001 Student Financial Aid Cluster – Assistance Listing 84.063 and 84.268 Recommendation: The College should review their reporting internal controls and procedures to ensure that they require students' statuses to be reported timely to NSLDS as required by federal regulations. The College shoul...
2024-001 Student Financial Aid Cluster – Assistance Listing 84.063 and 84.268 Recommendation: The College should review their reporting internal controls and procedures to ensure that they require students' statuses to be reported timely to NSLDS as required by federal regulations. The College should evaluate their procedures and review policies surrounding reporting status changes to NSLDS to ensure the enrollment effective date reported to NSLDS aligns with the College’s last date of attendance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Through the work of a college-wide task force the following actions will be taken in response to the finding. The task force will include representatives from Information Technology, Institutional Research, Financial Aid, Registrar, along with Ellucian consultants. To summarize the steps and details of implementation to the specific areas are as follows: 1. Review Reporting Controls and Procedures 2. Address Error Code 22 3. Review Procedures Surrounding Reporting Status Changes 4. Assure Accuracy in Reporting Enrollment Effective Date Name(s) of the contact person(s) responsible for corrective action: Patricia Munsch, Ph.D. Vice President for Student Affairs Nancy Brewer, College Director for Financial Aid Planned completion date for corrective action plan: December 31, 2026
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