Corrective Action Plans

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The required semi-annual and annual reports have been prepared and submitted as of date of audit issuance. The reporting dates and processes will be documented to ensure timely submission in future. The responsibility for tracking and monitoring dates has transitioned to the new Assistant Executive ...
The required semi-annual and annual reports have been prepared and submitted as of date of audit issuance. The reporting dates and processes will be documented to ensure timely submission in future. The responsibility for tracking and monitoring dates has transitioned to the new Assistant Executive Director. Individual responsible Debbie Pinnock Completion Date Plan has been implemented as of date of audit submission.
Department of Housing and Urban Development Federal Financial Assistance Listing #93.224 and #93.527 Community Health Center Cluster Reporting – Material Weakness in Internal Control over Compliance Finding Summary Certain tables within the Universal Data System (UDS) Report did not reconcile to DAP...
Department of Housing and Urban Development Federal Financial Assistance Listing #93.224 and #93.527 Community Health Center Cluster Reporting – Material Weakness in Internal Control over Compliance Finding Summary Certain tables within the Universal Data System (UDS) Report did not reconcile to DAP Health, Inc. supporting information. The tables that did not reconcile to the supporting information include Table 4, Selected Patient Characteristics, and Table 5, Staffing and Utilization. Table 4 reports the total number of patients seen while Table 5 reports the number of clinic visits by the various types of providers. The primary causes of the differences were due to DAP Health, Inc. acquiring a large entity during the year which used a different Electronic Health Record System. The combination of bringing together information from two different systems caused the reporting to be more complicated. In addition, certain supporting documentation used to prepare the UDS report was not maintained. The review process for the UDS report was also not functioning properly. Responsible Individuals Rigo Garcia, Analytics Manager and Bill Lee, Director of Information Management Status Management of DAP Health, Inc. has already converted the 25 acquired clinics to the DAP Health, Inc. Electronic Health System, which streamlined the process for the preparation of the UDS Report for the calendar year ending December 31, 2024. In addition, management has implemented new procedures requiring supporting documentation to be maintained. Management has also implemented a formalized review procedure for the UDS Report prior to submission. Anticipated Completion Date March 31, 2025
Department of Housing and Urban Development Federal Financial Assistance Listing #14,421 Housing Opportunities for Person with AIDS (HOPWA) Reporting – Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary Internal controls were not in place to ensure that ...
Department of Housing and Urban Development Federal Financial Assistance Listing #14,421 Housing Opportunities for Person with AIDS (HOPWA) Reporting – Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary Internal controls were not in place to ensure that the monthly expenditure information that was summarized and used to prepare the Consolidate Annual Performance and Evaluation Report (Consolidated APR/CAPER) was reconciled to the general ledger which led to differences between the expenditures reported in the Consolidated APR/CAPER and the actual expenditures reflected in the general ledger. In addition, internal controls were not in place to ensure review of the supporting documentation and the Consolidated APR/CAPER prior to submission. Responsible Individuals Monica Atchison, Housing Manager, and JW Guay, Grants Accounting Manager Status Management of DAP Health, Inc. has already corrected the reports and submitted updated reports to the granting agency. We have also implemented additional procedures to review program required reporting between Program and Finance Leadership to ensure amounts reported reconcile to the general ledger prior to submission. Anticipated Completion Date March 31, 2025
Identifying Number: 2024-002 Finding: Special Tests: Enrollment Reporting – Improper Reporting of Withdrawal Date Applicable Regulation: Per the National Student Loan Data System (NSLDS) enrollment reporting guide (Section 4.4.3) when a student withdraws during a term, the effective date for the wi...
Identifying Number: 2024-002 Finding: Special Tests: Enrollment Reporting – Improper Reporting of Withdrawal Date Applicable Regulation: Per the National Student Loan Data System (NSLDS) enrollment reporting guide (Section 4.4.3) when a student withdraws during a term, the effective date for the withdrawn status is the withdrawal date used by the Institution in accordance with 34 CFR 668.22. Finding: 3 out of a total of 24 students tested for enrollment reporting in NSLDS had an incorrect date listed as the effective date of the student’s enrollment status. Summary: During our enrollment testing, we noted that the effective date of withdrawal in NSLDS for 3 students tested was incorrectly listed as the date of determination by UWS instead of the withdrawal date determined in accordance with 34 CFR 668.22. Internal controls in place did not identify the errors. Three students with incorrect enrollment reporting dates were due to the student’s out of school status treated by the relevant University department as an unofficial withdrawal instead of an official withdrawal for enrollment reporting purposes. The Dates of Determination were therefore used incorrectly. Corrective Action Planned or Taken: The University of Western States has updated its policy for all out of school and reporting for all out of school students. Additionally, an internal Decision Tree resource document has also been created for use when processing student withdrawals and reporting student statuses. All out of school students will have the appropriate out of school date selected and submitted for enrollment roster reporting based on the updated policy and the supplemental Decision Tree. UWS staff has also reviewed all students and confirms reporting statuses align with the updated policy. Contact Person: Michelle Miller, Senior Vice President of Enrollment Management mmiller10@tcsedsystem.edu Anticipated Completion Date: September 17, 2024
Finding 2023-004: Finding 2023-004: Reporting Compliance Federal Agency: U.S. Department of Transportation Passthrough Entity: Illinois Department of Transportation Assistance Listing Number and Federal Program: 20.106 – Airport Improvement Program Condition: During our compliance procedures, we not...
Finding 2023-004: Finding 2023-004: Reporting Compliance Federal Agency: U.S. Department of Transportation Passthrough Entity: Illinois Department of Transportation Assistance Listing Number and Federal Program: 20.106 – Airport Improvement Program Condition: During our compliance procedures, we noted that the City was not completing, reviewing, and submitting the necessary reports outlined in the Compliance Requirements shown in Uniform Guidance (2 CFR Part 200) for the Airport Improvement Program. Plan: The City Comptroller will meet with the Airport Director regularly to discuss the necessary reports required to be submitted to stay in compliance with the federal funding agency’s grant requirements. Prior to submission, the City Comptroller will review the reports with the Airport Director and then the necessary reports should be submitted on time and contain all the necessary information as outlined in the granting agency’s compliance requirements. Anticipated Date of Completion: Fiscal Year Ending April 30, 2025
Finding 2024-003: Grant Reporting, Reconciliation, and Monitoring Condition: During audit fieldwork, we noted that the City does not reconcile grants throughout the fiscal year, thus requiring many journal entries to properly adjust revenues and record grant accruals and deferrals at year-end. Plan:...
Finding 2024-003: Grant Reporting, Reconciliation, and Monitoring Condition: During audit fieldwork, we noted that the City does not reconcile grants throughout the fiscal year, thus requiring many journal entries to properly adjust revenues and record grant accruals and deferrals at year-end. Plan: The City Comptroller’s Office and the Treasurer’s Office will act together as a central location for grant activity. The appropriate offices will work together with each of the City’s departments to reconcile and appropriately manage and report grant activity throughout the year. Anticipated Date of Completion: Fiscal Year Ending April 30, 2025
Finding 2024-002: Material Journal Entries Condition: During audit fieldwork, our testing resulted in material journal entries to be posted to properly state the City’s financial statements. Plan: The City Comptroller, along with staff, will review year-end adjustments as part of the audit preparati...
Finding 2024-002: Material Journal Entries Condition: During audit fieldwork, our testing resulted in material journal entries to be posted to properly state the City’s financial statements. Plan: The City Comptroller, along with staff, will review year-end adjustments as part of the audit preparation process and work to reduce the number of entries proposed by the auditors and prepare fully adjusted financial statements prior to audit fieldwork Anticipated Date of Completion: Fiscal Year Ending April 30, 2025
Finding 2024-001: Material Restatement to Capital Assets and Accounts Payable Condition: During our current year-end audit fieldwork, our testing resulted in a material restatement of Capital Assets and Accounts Payable. Plan: The City will implement effective internal controls in order to provide a...
Finding 2024-001: Material Restatement to Capital Assets and Accounts Payable Condition: During our current year-end audit fieldwork, our testing resulted in a material restatement of Capital Assets and Accounts Payable. Plan: The City will implement effective internal controls in order to provide an accurate assessment of reporting requirements for year-end balances. This implementation of improved controls would result in the appropriate recognition of financial reporting requirements Anticipated Date of Completion: Fiscal Year Ending April 30, 2025
AUDIT FINDING Finding 2024-001 NSLDS Status Reporting Error MANAGEMENT'S COMMENTS ON FINDINGS AND RECOMMENDATIONS We concur with the auditor's finding and identification of a deficiency in our internal controls. ACTIONS TAKEN OR PLANNED We will increase internal controls to ensure all NSLDS status ...
AUDIT FINDING Finding 2024-001 NSLDS Status Reporting Error MANAGEMENT'S COMMENTS ON FINDINGS AND RECOMMENDATIONS We concur with the auditor's finding and identification of a deficiency in our internal controls. ACTIONS TAKEN OR PLANNED We will increase internal controls to ensure all NSLDS status reporting is done correctly. EMPLOYEE/ DIVISION RESPONSIBLE Financial Aid Director TIMELINE AND ESTIMATED COMPLETION DATE Immediately
The Project received the necessary approval from HUD for a withdrawal from the reserve for replacement, however the withdrawal was duplicated and taken out of the reserve for replacement twice. The amount of questioned costs Totaled $4,906 during the year ended December 31, 2024. LSS identified the...
The Project received the necessary approval from HUD for a withdrawal from the reserve for replacement, however the withdrawal was duplicated and taken out of the reserve for replacement twice. The amount of questioned costs Totaled $4,906 during the year ended December 31, 2024. LSS identified the duplication of the HUD approved reserve for replacement withdrawal and properly corrected the reserve for replacement bank account balance in March 2025. The LSS finance team is taking ownership for the request for replacement reserve process from operations during 2025 and also updated the online banking dual control process during March 2025. Once we receive HUD approval for future reserve requests, we will review the general ledger for the previous reserve for replacement activity prior to releasing cash within the banking system. Anticipated Completion Date: March 2025 Responsible Contact Person: Randy Oleszak CFO 414-246-2353
View Audit 352493 Questioned Costs: $1
The organization will update policies and procedures to obtain and review evidence for all cost reimbursement requests from subrecipient organizations.
The organization will update policies and procedures to obtain and review evidence for all cost reimbursement requests from subrecipient organizations.
Finding 553798 (2024-001)
Significant Deficiency 2024
Corrective Action Plan: The City of Healdsburg will no longer miss federal grant reporting deadlines due to the comprehensive grant tracker developed. This tool tracks both quarterly and annual submission dates for all grants, ensuring a clear overview of upcoming deadlines. Additionally, these crit...
Corrective Action Plan: The City of Healdsburg will no longer miss federal grant reporting deadlines due to the comprehensive grant tracker developed. This tool tracks both quarterly and annual submission dates for all grants, ensuring a clear overview of upcoming deadlines. Additionally, these critical dates have been added to the internal calendar, providing extra visibility and reminders to stay on top of all reporting requirements. This streamlined process will help ensure that all deadlines are met promptly and efficiently. Contact: Katie Edgar, Finance Director Estimated Implemented: FY24/25
FINDING No. 2024-004: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: Management should ensure that initial and ongoing tenant eligibility documentation is obtained timely and appropriately maintained, tenant eligibility is verified, and all tenants eligible to receive PR...
FINDING No. 2024-004: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: Management should ensure that initial and ongoing tenant eligibility documentation is obtained timely and appropriately maintained, tenant eligibility is verified, and all tenants eligible to receive PRAC are included on the monthly HAP requests. Action Taken: Monthly reminders are being sent to all managers to run their tenant reports to maintain eligibility. In addition, random files are being reviewed by compliance to ensure all required documentation is completed. If the Oversight Agency for Audit has questions regarding this plan, please call Irene Phillips at 954-835-9200. Sincerely yours, Irene Phillips, CFO Irene Phillips CFO
FINDING No. 2024-003: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: Management should implement procedures to ensure the required monthly funding amount is deposited into the replacement reserve account monthly. Action Taken: The Project agrees with the finding and the ...
FINDING No. 2024-003: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: Management should implement procedures to ensure the required monthly funding amount is deposited into the replacement reserve account monthly. Action Taken: The Project agrees with the finding and the auditor’s recommendations have been adopted. Deposits are made on a monthly basis with balances being monitored by property leadership and accounting.
View Audit 352378 Questioned Costs: $1
FINDING No. 2024-002: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: Management should keep track of the balance in the residual receipts account in excess of $250 per unit at the PRAC expiration date and ensure a timely request for remittance of the excess amount due to ...
FINDING No. 2024-002: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: Management should keep track of the balance in the residual receipts account in excess of $250 per unit at the PRAC expiration date and ensure a timely request for remittance of the excess amount due to HUD. Furthermore, the Project should establish a payable for the amount due until payment is remitted. Action Taken: The Project agrees with the finding and the auditor’s recommendations have been adopted. Excess funds are monitored on a monthly basis going forward.
Oversight Agency for Audit, Edward M. Marx Apartments, Inc., respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067 ...
Oversight Agency for Audit, Edward M. Marx Apartments, Inc., respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067 Audit period: July 1, 2023, through June 30, 2024 The findings from the June 30, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. SECTION III – FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING No. 2024-001: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: Management should implement procedures to ensure the Project submits PRAC renewal requests in accordance with HUD requirements. Action Taken: The Project agrees with the finding and the auditor’s recommendations have been adopted. The PRAC contract has since been renewed and approved for a 3-year term. Calendar reminders and deadlines have been set up to ensure timing filing in the future.
Management Response and Corrective Action Plan We agree with this finding. While reports were approved by funding agencies, we have educated the staff responsible for submitting the reports on the required due dates. Contact person(s) responsible for the corrective action: Lisa Brabo, Chief Executi...
Management Response and Corrective Action Plan We agree with this finding. While reports were approved by funding agencies, we have educated the staff responsible for submitting the reports on the required due dates. Contact person(s) responsible for the corrective action: Lisa Brabo, Chief Executive Officer, lbrabo@fsacares.org Jaime Kuczkowski, Chief Financial Officer, jaime@balancefm.com Anticipated Completion Date: Education and documentation on the above have already started and will be completed by April 1, 2025.
The University has established policies and procedures to report a change in a student’s enrollment status in its next updated Enrollment Reporting roster. The University will take the necessary steps to ensure compliance with established policies and procedures with regard to reporting a change in ...
The University has established policies and procedures to report a change in a student’s enrollment status in its next updated Enrollment Reporting roster. The University will take the necessary steps to ensure compliance with established policies and procedures with regard to reporting a change in a student’s enrollment status.
Corrective Action Plan The 2024 single audit reporting package has been submitted by March 31, 2025. Completion Date Fiscal year end 2025
Corrective Action Plan The 2024 single audit reporting package has been submitted by March 31, 2025. Completion Date Fiscal year end 2025
Finding 553686 (2024-002)
Significant Deficiency 2024
Management will implement internal tracking and deadline reminders. This process will include assigning a responsibility to monitor submission deadlines and establish automated internal reminders to prevent future late submissions.
Management will implement internal tracking and deadline reminders. This process will include assigning a responsibility to monitor submission deadlines and establish automated internal reminders to prevent future late submissions.
The Director of Finance created a new tracking spreadsheet to complete each month during the month-end process. This spreadsheet shows the monthly expenses for each grant and the total for the year. This allows us to monitor the grant funds closely. The information is shared with the board of dir...
The Director of Finance created a new tracking spreadsheet to complete each month during the month-end process. This spreadsheet shows the monthly expenses for each grant and the total for the year. This allows us to monitor the grant funds closely. The information is shared with the board of directors in their financial statement reports
Our Organization has developed a Monitoring Policy to have better oversight of our sub-recipients. Our Chief Executive Office will implement this Monitoring Policy. The Grant Coordinator, will oversee the direct communications related to sub-recipients monitoring. The implementation of enhanced m...
Our Organization has developed a Monitoring Policy to have better oversight of our sub-recipients. Our Chief Executive Office will implement this Monitoring Policy. The Grant Coordinator, will oversee the direct communications related to sub-recipients monitoring. The implementation of enhanced monitoring tools and documentation standards will be completed by June 30, 2025
Finding 553682 (2024-002)
Significant Deficiency 2024
Lane College acknowledges the audit finding regarding delayed reporting of withdrawal and graduation dates to the National Student Loan Data System (NSLDS). The College recognizes the importance of timely and accurate reporting as a critical compliance requirement under 2 CFR Part 200 and the compli...
Lane College acknowledges the audit finding regarding delayed reporting of withdrawal and graduation dates to the National Student Loan Data System (NSLDS). The College recognizes the importance of timely and accurate reporting as a critical compliance requirement under 2 CFR Part 200 and the compliance supplement. In response to this audit finding, Lane College commits to implementing immediate and sustained corrective actions as follows: 1. Enhanced Tracking System: Lane College will implement a robust tracking system specifically designed to monitor student enrollment status changes, including withdrawals and graduations, to ensure these changes are promptly identified and reported. The tracking system will be integrated within the existing enrollment management software, enabling automatic notifications to designated staff when an enrollment status change occurs. 2. Internal Control Improvements: The College will strengthen internal controls by clearly delineating responsibilities for enrollment reporting among relevant departments. The Registrar's Office will have primary accountability for overseeing timely reporting, supported by coordinated 3. checks and balances from the Financial Aid Office to cross-verify reporting accuracy and timeliness. 4. Staff Training: Regular training sessions will be conducted for all staff involved in reporting enrollment status changes. These trainings will focus on compliance requirements, reporting timelines, and use of the updated tracking and reporting system. Attendance will be mandatory, and training effectiveness will be evaluated through periodic assessments. 5. Periodic Audits: To sustain compliance, the College will institute internal audits conducted quarterly by the Office of Enrollment Management. These audits will sample enrollment status changes and assess the timeliness of reports submitted to NSLDS. Audit results will be documented, reviewed by senior management, and any deviations will be promptly addressed. 6. Reporting Accountability: Staff responsible for reporting enrollment status changes will be required to submit monthly summaries of reporting activities to their supervisors. Supervisors will review these summaries to ensure adherence to the 60-day reporting deadline and address any delays proactively. Lane College is committed to rectifying this compliance issue swiftly and effectively. The College understands that maintaining accurate and timely reporting to NSLDS is essential to prevent inaccuracies in student loan records, avoid potential financial consequences, and uphold regulatory compliance. These measures demonstrate our dedication to robust compliance practices and continuous institutional improvement.
Federal Program: Student Financial Assistance (SFA) Cluster - Various ALN Compliance Requirement - Enrollment Reporting Management’s Response The UPR concurs with this finding. On February 26, 2025, we met with all deans for Academic Affairs and explained to them the importance of complying with ...
Federal Program: Student Financial Assistance (SFA) Cluster - Various ALN Compliance Requirement - Enrollment Reporting Management’s Response The UPR concurs with this finding. On February 26, 2025, we met with all deans for Academic Affairs and explained to them the importance of complying with federal requirements. Twenty-two exceptions were found in the FY2023 single audit report, and an exception was found in FY2024 single audit report. We recognize that we have improved, however, we are not satisfied with the results. We understand that we have not achieved 100% compliance, and our correction action plan remains in force. We will take additional actions such as: • Continue to guide professors on the importance of taking and reporting attendance timely. • One of the special assistants of the Vice Presidency for Academic Affairs will send a reminder to the registrars every month indicating how much time they have left to inform the NSLDS of the change in status on or before 60 days after the change occurred. • The next meeting of the University Board will be used to inform members (chancellors, faculty, and student representatives) so that they can take the message to their institutional units. The goal is to have 100% compliance. Responsible Person or Office: Executive Vice President for Academic Affairs and Research. Timeline: 2025-2026
Recommendation: This control deficiency is not unusual in a small company. However, it is the responsibility of management and the board of directors to decide whether to accept the degree of risk associated with this condition based on the cost of correction and other considerations. Management’s R...
Recommendation: This control deficiency is not unusual in a small company. However, it is the responsibility of management and the board of directors to decide whether to accept the degree of risk associated with this condition based on the cost of correction and other considerations. Management’s Response and Actions Planned: The Company’s management is aware of this significant deficiency. Management reviews and approves the draft annual audited financial statements and distributes them to the users. For entities of this size, it generally is not practical to obtain the internal expertise needed to handle all aspects of the external financial reporting. Management recognizes this and feels it is effectively handling its reporting responsibilities with the procedures described above.
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