Corrective Action Plans

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Finding 2024-001 By April 1, 2025, HCEB will implement a process whereby monthly gross rent potential is calculated monthly based on contract rents, including manager rent free unit and vacancies, if any. This calculation will be automated and subject to system checks in HCEB’s Yardi Breeze software...
Finding 2024-001 By April 1, 2025, HCEB will implement a process whereby monthly gross rent potential is calculated monthly based on contract rents, including manager rent free unit and vacancies, if any. This calculation will be automated and subject to system checks in HCEB’s Yardi Breeze software, utilizing the following workflow: • Portfolio Assistant calculates the monthly gross rent potential within Yardi Breeze based on contract rents. • Portfolio Assistant will alert the General Ledger A/R accountant when the task is completed, and the General Ledger A/R accountant will download the information and will record in the general ledger. • Once the monthly gross rent potential general ledger entry is complete, it will be reviewed by the Controller or their designee.
When this matter was brought to the District's attention it was too late to adjust for FY 2023-2024 but the District took steps to ensure all ESSER Funds impacted were fully expended and the indirect charges were ultimately balanced out.
When this matter was brought to the District's attention it was too late to adjust for FY 2023-2024 but the District took steps to ensure all ESSER Funds impacted were fully expended and the indirect charges were ultimately balanced out.
The Fiscal team lacked sufficient knowledge and understanding to properly execute accurate financial statements. During FY24 there was significant turnover in the Fiscal department, necessitating contractual services from outside fiscal parties. A total of four additional fiscal content contractors ...
The Fiscal team lacked sufficient knowledge and understanding to properly execute accurate financial statements. During FY24 there was significant turnover in the Fiscal department, necessitating contractual services from outside fiscal parties. A total of four additional fiscal content contractors were secured to assist the Finance Director. The Finance Director has been replaced by a qualified CPA. There is currently an ongoing rebuilding of the Fiscal Department with the intent of filling positions with qualified permanent staff. Internal controls are to be reviewed, revised as necessary, and followed, by the new team to ensure accurate and timely financial reporting.
The Finance Director was unable to balance competing priorities, resulting in delayed submission of SF-425 reports. The Finance Director has been replaced by a CPA. Support from an external content specialist was secured to train the current CFO on the proper preparation of the SF-425 reports. Repo...
The Finance Director was unable to balance competing priorities, resulting in delayed submission of SF-425 reports. The Finance Director has been replaced by a CPA. Support from an external content specialist was secured to train the current CFO on the proper preparation of the SF-425 reports. Reporting has been brought current. Alert emails from HSES are being reviewed by leadership and the HSES website is being monitored for submission deadlines. Priority is given to ensure timely deliverables.
Finding 555487 (2024-015)
Significant Deficiency 2024
Views of Responsible Officials and Planned Corrective Action This is completed and will be completed again in June 2025. Finding resolution timeline: No later than June 2025. Designation of employee position responsible for meeting this deadline: Andrea Montoya, Deputy County Manager
Views of Responsible Officials and Planned Corrective Action This is completed and will be completed again in June 2025. Finding resolution timeline: No later than June 2025. Designation of employee position responsible for meeting this deadline: Andrea Montoya, Deputy County Manager
Views of Responsible Officials and Planned Corrective Action The County submitted the Single Audit to the Federal Audit Clearinghouse as soon as it was is completed and released by the New Mexico Office of the State Auditor for the fiscal year ending June 30, 2023. Finding resolution timeline: As...
Views of Responsible Officials and Planned Corrective Action The County submitted the Single Audit to the Federal Audit Clearinghouse as soon as it was is completed and released by the New Mexico Office of the State Auditor for the fiscal year ending June 30, 2023. Finding resolution timeline: As soon as the fiscal year 2024 audit is released by the New Mexico Office of the State Auditor. Designation of employee position responsible for meeting this deadline: Andrea Montoya, Deputy County Manager
Finding 555420 (2024-002)
Material Weakness 2024
Views of Responsible Officials and Planned Corrective Action The County has established a document and an internal control structure designed for tracking in the future. Finding resolution timeline: This has been resolved for FY 25 as of 03/20/2025. Designation of employee position responsible fo...
Views of Responsible Officials and Planned Corrective Action The County has established a document and an internal control structure designed for tracking in the future. Finding resolution timeline: This has been resolved for FY 25 as of 03/20/2025. Designation of employee position responsible for meeting this deadline: Andrea Montoya, Deputy County Manager
Tulsa Public Schools concurs with the finding regarding the late submission of the Single Audit package for the fiscal year ended June 30, 2024. The delay was due to the district's external auditors requesting additional time to complete extended testing and audit procedures prompted by the findings...
Tulsa Public Schools concurs with the finding regarding the late submission of the Single Audit package for the fiscal year ended June 30, 2024. The delay was due to the district's external auditors requesting additional time to complete extended testing and audit procedures prompted by the findings in the Oklahoma State Auditor and Inspector (OSAI) report. While this situation was outside the district’s direct control, the district recognizes the importance of timely federal reporting and is implementing a corrective strategy to mitigate future risks of noncompliance. Going forward, the district will revise its audit readiness timeline to account for possible additional audit procedures or investigative follow-up. The Director of Accounting will coordinate more proactively with external auditors to communicate any potential delays and ensure resource availability for timely completion. The district is committed to submitting its FY2025 Single Audit package on or before the required deadline and ensuring continued transparency in its federal compliance reporting. Tulsa Public Schools is committed to full compliance and confirms that the FY2024 Single Audit package will be submitted to the Federal Audit Clearinghouse no later than April 30, 2025. Owner: Vonnita Edwards, Financial Reporting Manager
Corrective Action Plan and Views of Responsible Officials Views of Responsible Officials The District acknowledges the audit finding regarding insufficient retention of financial records supporting the annual ESSER expenditure reports submitted to the California Department of Education. We understan...
Corrective Action Plan and Views of Responsible Officials Views of Responsible Officials The District acknowledges the audit finding regarding insufficient retention of financial records supporting the annual ESSER expenditure reports submitted to the California Department of Education. We understand that maintaining accurate and accessible documentation is essential to federal compliance under Title 2, Code of Federal Regulations (CFR) §200.334. The District takes full responsibility for this oversight and is taking immediate steps to strengthen its internal controls and documentation practices. Corrective Action Plan 1. Reason for the Finding: This issue arose due to high turnover in the position responsible for federal reporting. As a result, institutional knowledge and documentation practices were disrupted, making it difficult to locate supporting financial records for the annual ESSER expenditure report. While the quarterly reports submitted throughout the year were accurate and properly supported, the annual report was not fully aligned with available documentation due to incomplete record retention during the staffing transitions. 2. Actions to be Taken to Correct the Issue: Centralized Document Management System: The District will implement a centralized, secure electronic document management system (e.g., Google Drive, SharePoint, or a financial records database) specifically for tracking and retaining federal program documentation. All financial records supporting ESSER and similar federal grants will be stored here and categorized by funding source, fiscal year, and reporting period. Standard Operating Procedure (SOP): A formal SOP for federal grants management will be created and distributed to all relevant departments. This will include clear guidelines for documentation, record retention timelines, and roles/responsibilities for financial reconciliation and audit readiness. Staff Training: District staff responsible for federal program management and reporting will be trained on the new SOP, federal compliance regulations (including CFR §200.334), and the use of the document management system. Refresher trainings will be conducted annually or as needed. Pre-Submission Review: A dual review process will be instituted where both the Business Services and Federal Programs teams confirm the availability and accuracy of supporting documentation before any reports are submitted to oversight agencies. 3. Timeline for Implementation: All corrective actions will be in place within 90 days. The centralized document storage system and SOPs will be finalized and rolled out within 60 days. Staff training will be completed within the following 30 days. Immediate measures to retain ESSER documentation have already been initiated.
The University concurs with the recommendation. The University will review and enhance its procedures and internal controls to ensure the SEFA is complete and accurate
The University concurs with the recommendation. The University will review and enhance its procedures and internal controls to ensure the SEFA is complete and accurate
The University concurs with the recommendation. The University will further review and refine the policies and procedures to strengthen internal controls and to ensure the timely and accurate reporting to NSLDS.
The University concurs with the recommendation. The University will further review and refine the policies and procedures to strengthen internal controls and to ensure the timely and accurate reporting to NSLDS.
Finding 2024-004 – Schedule of Expenditures of Federal Awards (SEFA) – Significant Deficiency The errors in the SEFA, including incorrect pass-through grants and outdated grant numbers, have been corrected, and a review process is now in place before the audit, with a second check for accuracy. The ...
Finding 2024-004 – Schedule of Expenditures of Federal Awards (SEFA) – Significant Deficiency The errors in the SEFA, including incorrect pass-through grants and outdated grant numbers, have been corrected, and a review process is now in place before the audit, with a second check for accuracy. The Senior Accountant will prepare the SEFA, and the Finance Manager will review it to ensure accuracy. We will communicate with granting agencies to confirm whether grants are federal and use a checklist to ensure proper classifications. Moving forward, federal and state grants will be correctly recorded, grants will be properly classified when recorded in the general ledger, and annual training on SEFA preparation and Uniform Guidance compliance will be provided.
Procedures for maintaining accurate accounts receivable records will be reinforced, including periodic review. Beginning June 1, 2025, we will implement steps and procedures to eliminate the tardiness of Data Collection in Federal Audit Clearinghouse.
Procedures for maintaining accurate accounts receivable records will be reinforced, including periodic review. Beginning June 1, 2025, we will implement steps and procedures to eliminate the tardiness of Data Collection in Federal Audit Clearinghouse.
Auditee Response: Management concurs with the finding. A new financial reporting calendar has been implemented and distributed to all staff. A formal review and approval process for financial reports has been implemented. The report for the quarter ended June 2024 will be submitted by end of March 2...
Auditee Response: Management concurs with the finding. A new financial reporting calendar has been implemented and distributed to all staff. A formal review and approval process for financial reports has been implemented. The report for the quarter ended June 2024 will be submitted by end of March 2025.
Recommendation: We recommend that the Organization electronically file their reporting package, including the audited financial statements, to the Federal Audit Clearinghouse by the due date or request an extension for more time is needed. Response: Management agreed with the recommendation and pla...
Recommendation: We recommend that the Organization electronically file their reporting package, including the audited financial statements, to the Federal Audit Clearinghouse by the due date or request an extension for more time is needed. Response: Management agreed with the recommendation and plans on adhering to the deadline for future submissions.
Finding 555296 (2024-001)
Significant Deficiency 2024
The Organization has implemented improved internal controls and reporting mechanisms to ensure timely submission of reporting packages in accordance with 2 CFR Part 200, Subpart F, Section 200.512. Steps include a compliance calendar, internal reminders, and accountability measures to prevent future...
The Organization has implemented improved internal controls and reporting mechanisms to ensure timely submission of reporting packages in accordance with 2 CFR Part 200, Subpart F, Section 200.512. Steps include a compliance calendar, internal reminders, and accountability measures to prevent future delays.
Management concurs with the finding and has initiated immediate steps to strengthen record retention and succession planning for federal award management. A key element of our response is the engagement of RDM Associates, our outsourced accounting provider, to ensure compliance with federal regulati...
Management concurs with the finding and has initiated immediate steps to strengthen record retention and succession planning for federal award management. A key element of our response is the engagement of RDM Associates, our outsourced accounting provider, to ensure compliance with federal regulations and establish robust processes. To address this finding, the following actions are underway: By June 30, 2025, management, with the expertise of RDM Associates, will implement a comprehensive record retention policy tailored to federal award management. This policy will outline retention periods, storage protocols, and access requirements, ensuring all documentation is systematically organized and readily available. For fiscal year 2025, RDM Associates is assisting in the creation and retention of adequate reconciling schedules to support all grant draw requests, aligning our processes with federal compliance standards. RDM Associates is also supporting the development of detailed procedure manuals for federal award processes and the implementation of a document management system to centralize and secure critical records. These efforts will mitigate the risks associated with staff turnover and ensure continuity of operations. By June 30, 2025, management will formalize a succession planning process for key positions involved in federal award management, incorporating cross-training of staff under the guidance of RDM Associates to facilitate knowledge transfer and operational resilience. The transition to RDM Associates as our outsourced accounting provider addresses the root causes of this finding by bringing specialized expertise and structured processes to our federal award management. We are confident that these actions will result in sustainable improvements and full compliance with federal requirements. Anticipated completion date for these initiatives is June 30, 2025.
The Town will put in place a process for more accurate year-end closing and financial statement preparation. Management will work with the auditor to identify and correct the problematic areas.
The Town will put in place a process for more accurate year-end closing and financial statement preparation. Management will work with the auditor to identify and correct the problematic areas.
The District recognizes the importance of supervisory review in ensuring the accuracy of meal count documentation and reimbursement claims. To address this, the District will implement a standardized review process across all schools requiring supervisory personnel to sign or initial daily meal cou...
The District recognizes the importance of supervisory review in ensuring the accuracy of meal count documentation and reimbursement claims. To address this, the District will implement a standardized review process across all schools requiring supervisory personnel to sign or initial daily meal count sheets. In addition, we will institute a reconciliation step to verify that reported counts align with reimbursement claims. Training will be provided to ensure compliance with these procedures. Anticipated Date of Completion: A review and determination will be completed in fiscal year 2025. Contact Person: Joe Barker, CSBO.
Spartanburg County First Steps (SCFS) management acknowledges its responsibility for complying with all applicable state and federal reporting requirements. SCFS maintains a comprehensive fiscal policies and procedures manual that outlines the responsibilities and processes necessary to ensure compl...
Spartanburg County First Steps (SCFS) management acknowledges its responsibility for complying with all applicable state and federal reporting requirements. SCFS maintains a comprehensive fiscal policies and procedures manual that outlines the responsibilities and processes necessary to ensure compliance with all reporting obligations. The late submission of certain federal reports for the 2023-2024 program year was primarily due to challenges associated with the agency's financial management system, Blackbaud. Specifically, the system generated extended wait times for necessary reports, significantly impacting the agency's ability to meet required deadlines. Over the past six months, SCFS has conducted an extensive evaluation of the Blackbaud system and determined that it does not adequately meet the operational needs of SC First Steps offices across the state. As a result, an emergency procurement process has been initiated to procure a new financial management system that will better support timely and accurate reporting. Spartanburg County First Steps is committed to ensuring all future state and federal reporting requirements are completed and submitted accurately and within required deadlines.
Finding 555195 (2024-001)
Significant Deficiency 2024
Condition During our audit, CBIZ noted that the Organization did not have adequate internal controls surrounding reception of food boxes, or backpacks provided as some selections did not contain recipient and driver signatures. Views of Responsible Officials: Management agrees with the finding and...
Condition During our audit, CBIZ noted that the Organization did not have adequate internal controls surrounding reception of food boxes, or backpacks provided as some selections did not contain recipient and driver signatures. Views of Responsible Officials: Management agrees with the finding and observation. Contact Person: Fendy Wogu, Finance Controller Proposed Completion Date: February 7, 2025
Item: 2024-001 Assitance Listing Number: 93.959 Programs: Block Grants for Substance Abuse Prevention, Treatment and Recovery Services Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: Care 1st Compliance Reqauirements: Reporting Criteria of Specific Requireme...
Item: 2024-001 Assitance Listing Number: 93.959 Programs: Block Grants for Substance Abuse Prevention, Treatment and Recovery Services Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: Care 1st Compliance Reqauirements: Reporting Criteria of Specific Requirement: In accordance with the grant agreement, the Organization is required to submit quarterly reports during the grant period which include qualifying costs incurred under the grant award. Condition: A required quarterly report submitted to the granting agency included inaccurate reporting of the qualifying expenditures. Additionally, for all four quarterly reports there was no evidence of management review or approval of the reports prior to submission to the funder. Name of Contact Person: Michael Kuzmin, Chief Financial Officer Phone Number: (928) 714-6478 Anticipated Completion Date: March 31, 2025 Views of Responsible Officials and Corrective Action: Management agrees with the finding and will implement additional controls to ensure expense information included in the quarterly reports in reviewed and approved prior to submission. Management will ensure this additional process includes clearly documenting the review and approval.
2024-002 – Enrollment Reporting (Significant Deficiency) Department of Education, SFA Cluster; Compliance Requirement Affected – Special Tests and Provisions Condition: The University did not report student enrollment data to the National Student Clearinghouse accurately and within minimum required ...
2024-002 – Enrollment Reporting (Significant Deficiency) Department of Education, SFA Cluster; Compliance Requirement Affected – Special Tests and Provisions Condition: The University did not report student enrollment data to the National Student Clearinghouse accurately and within minimum required timeframe. Criteria: Based on requirements set forth by 34 CFR 685.309(b)(2), the University is responsible for notifying the National Student Loan Data System (NSLDS) to changes to student’s enrollment data within minimum required timeframes. Cause: The University does not have adequate procedures in place to ensure changes in students’ enrollment statuses are identified and reported in a timely manner. Effect: Enrollment data was not reported timely or accurately to the Department of Education thus, the Department could not properly service the student’s loans. The accuracy of Title IV student loan records depends heavily on the accuracy of the enrollment information reported by institutions. Context: A sample of nine official and unofficial student withdrawals was selected for audit from a population of 63. The test found three student withdrawals that were not in compliance with timely enrollment reporting in NSLDS, the enrollment status for one student was not updated after the student was no longer enrolled on at least a half-time basis, and one student’s enrollment status date reported to NSLDS did not agree to date of withdraw reported on the R2T4 form. Repeat Finding: No. Recommendation: We recommend that the University put procedures in place to ensure that student enrollment statuses are updated in a timely manner. Management Response: The University has modified its withdrawal procedures and instructions related to the requirements set forth by 34 CFR 685.309(b)(2). Related to the findings above, due to staffing turnover, the appropriate test of controls needed to identify changes in a student’s enrollment status was not run in a timely manner. Going forward, the University has informed related staff that the aforementioned test of controls needs to be run at the end of each semester, and upon completion, staff must notify the NSLDS within the required timeframe. If the Federal Audit Clearinghouse has questions regarding this plan, please call Brad Sheriff, PhD, MBA, CMA, Interim Chief Financial Officer at (540) 887-7285. Brad Sheriff, PhD, MBA, CMA, Interim Chief Financial Officer, Mary Baldwin University, 540-887-7285
2024-001 – Return of Title IV Funds (Significant Deficiency)Department of Education, SFA Cluster; Compliance Requirement Affected – Special Tests and Provisions Condition: Return of Title IV funds occurred untimely for three students, exceeding 45 days as required, when considering the University’s ...
2024-001 – Return of Title IV Funds (Significant Deficiency)Department of Education, SFA Cluster; Compliance Requirement Affected – Special Tests and Provisions Condition: Return of Title IV funds occurred untimely for three students, exceeding 45 days as required, when considering the University’s date of determination as reported on R2T4 forms. Criteria: Returns of Title IV funds are required to be deposited or transferred into the SFA account or electronic funds transfers initiated to the Department of Education as soon as possible, but no later than 45 days after the date the institution determines that the student withdrew in accordance with 34 CFR 668.173(b). Cause: The University does not have adequate procedures in place to ensure students’ Title IV funds are returned timely. R2T4 forms improperly reported the date of determination the same as the student withdraw date. Effect: The University failed to return Title IV funds to the Department of Education within 45 days of the students’ date of determination as reported on the R2T4 forms. Context: A sample of nine official and unofficial student withdrawals was selected for audit from a population of 63. The test found three student withdrawals that were not in compliance with timely return of funds. Repeat Finding: No. Recommendation: We recommend that the University implement procedures to ensure that R2T4 forms are filed timely and properly reflect the University’s date of determination for all student withdrawals. Management Response: The University concedes that the R2T4 forms improperly reported the date of determination as the same date reported for the student’s date of withdrawal and the University has modified its withdrawal procedures and processes to reflect separate dates when necessary for date of determination and date of withdrawal. Instructions related to R2T4 requirements and timeliness of return of funds will be triggered from the appropriate date of determination. Related to the findings above, the University failed to accurately report the date of determination on R2T4 documentation, causing the return of funds to be out of the window for timely return. Although the funds were returned in a timely manner, the recordkeeping of the determination date was not documented properly. The University has since clarified for staff the importance of this documentation and change in process. Additionally, the university has identified the appropriate test of controls needed to accurately identify the student withdrawal date. This test of controls will be run at the end of each semester, and upon completion, the date the report is run will be used as the correct date of determination. If the Federal Audit Clearinghouse has questions regarding this plan, please call Brad Sheriff, PhD, MBA, CMA, Interim Chief Financial Officer at (540) 887-7285. Brad Sheriff, PhD, MBA, CMA, Interim Chief Financial Officer, Mary Baldwin University, 540-887-7285
Identifying Number: 2024-004 Finding: Material Weakness: Period of Performance Context: Expenditures were included on the 2024 Schedule of Expenditures of Federal Awards, however, the expenditures were incurred prior to the budget period start date. Corrective Actions Taken or Planned: The Director ...
Identifying Number: 2024-004 Finding: Material Weakness: Period of Performance Context: Expenditures were included on the 2024 Schedule of Expenditures of Federal Awards, however, the expenditures were incurred prior to the budget period start date. Corrective Actions Taken or Planned: The Director of the Office of Sponsored Programs and the Manager of Sponsored Programs will develop a standardized document checklist for all high-value expenditures. This checklist will require all Sponsored Programs analysts to submit complete documentation with expense reports and proof of payment and have their respective immediate supervisor/manager review for compliance before final approval by the Director. a. Implementing organizational changes such as updated policies and/or procedures b. Educating the team(s) and/or Department(s) on internal controls, processes and accuracy best practices during the Grant management process c. Oversight of drawdown requests by the Director of Sponsored Programs to ensure accuracy of request Planning Process: Compliance with Regulations: The Director and Manager from Sponsored Programs will ensure the corrective actions align with applicable federal grant regulations and guidelines. We will create: - Implement internal controls, with the Director and Manager from Sponsored Programs developing checks and balances at the end of each month to ensure compliance in all the grant's portfolio. - Oversight of all drawdown requests, ensuring complete and accurate supporting documentation. Communication: The Director and Manager from Sponsored Programs will communicate the corrective action plan to all relevant staff and stakeholders. Follow-up: The Director and Manager from Sponsored Programs will regularly monitor progress and adjust to resolve any inefficiencies. Training: The Director and Manager from Sponsored Programs will work on the development and delivery of mandatory training sessions for all Sponsored Programs relevant staff. This will include (not limted to): - Retrain on updated policies and procedures (OSP team, Departments and stakeholders, if applicable) - Retrain on workflows and system (OSP team, Departments and stakeholders, if applicable) - Retrain on process improvement (OSP team, Departments and stakeholders, if applicable) Policy Updates: Revision of existing policies or creation of new ones to clarify procedures. System Enhacements: Implementing new software/program that improves data accuracy and compliance in all Federal/State and Local Grants throughout Nicklaus Children's Hospital. Monitoring and Oversight: The Director and Manager from the Sponsored Programs will monitor transactions and reporting processed more frequently. Deadline for Implementation: Immediate Action: The Director of Sponsored Programs transitioned the staff member responsible for the findings to an area where their expertise is most valuable. This CAPA will take effect immediately and be fully implemented within six weeks by April 07, 2025, allowing time to create/revise SOPs, Working Practice Guidelines (WPGs), Checklists and training/retraining sessions for stakeholders and OSP team members.
View Audit 353775 Questioned Costs: $1
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