Corrective Action Plans

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Finding 390521 (2023-002)
Significant Deficiency 2023
Management's Response This is Mending Hearts first federal grant with a subrecipient. We were unaware of the FFATA reporting requirement for subrecipients. Upon notification of the error, the FFATA was filed in the FSRS. Views of Responsible Officials and Corrective Action See response for findin...
Management's Response This is Mending Hearts first federal grant with a subrecipient. We were unaware of the FFATA reporting requirement for subrecipients. Upon notification of the error, the FFATA was filed in the FSRS. Views of Responsible Officials and Corrective Action See response for finding 2023-002 Anticipated Completion Date Completed on March 22, 2024
Finding 390520 (2023-001)
Significant Deficiency 2023
Management's Response In error, an incorrect formula was used for applying 10 percent indirect cost on our grant draw spreadsheet; 1/12th of the indirect cost budget versus 10 percent of the monthly direct costs. Some months, the amount drawn for indirect cost was higher than 10 percent and other m...
Management's Response In error, an incorrect formula was used for applying 10 percent indirect cost on our grant draw spreadsheet; 1/12th of the indirect cost budget versus 10 percent of the monthly direct costs. Some months, the amount drawn for indirect cost was higher than 10 percent and other months lower than 10 percent of direct costs. When notified of error, immediate correction was made to indirect cost grant balance and grant draw spreadsheet. Views of Reponsible Officials and Corrective Action See response for finding 2023-001 Anticipated Completion Date Completed on March 22, 2024
View Audit 301275 Questioned Costs: $1
During October 2023, the $350 deposit was paid to the reserve for replacement account.
During October 2023, the $350 deposit was paid to the reserve for replacement account.
View Audit 301274 Questioned Costs: $1
HSEM concurs with the finding. Corrective actions are currently in place to address the accuracy of HSEM’s federal reporting, adding an additional review process prior to submittal. Corrected 425s have already been submitted to FEMA.
HSEM concurs with the finding. Corrective actions are currently in place to address the accuracy of HSEM’s federal reporting, adding an additional review process prior to submittal. Corrected 425s have already been submitted to FEMA.
HSEM concurs with the finding. As a result of the audit, the practice of using individual emails to submit correspondence to FEMA was immediately addressed with staff and future correspondence will only be sent using the general shared email inbox. Regularly during staff meetings employees are remin...
HSEM concurs with the finding. As a result of the audit, the practice of using individual emails to submit correspondence to FEMA was immediately addressed with staff and future correspondence will only be sent using the general shared email inbox. Regularly during staff meetings employees are reminded to copy communications to the general shared inbox. Additionally, HSEM is currently working with the State’s Department of Information and Technology to gain access to prior staff’s emails. To note, the final paragraph in the Conditions section makes an incorrect statement regarding the submittal timeline requirements for Project Completion and Certification reports. PCCs are due within 90 days of project completion, not project obligation.
(SSA 4513) The department concurs with this finding and plans to work on the following areas to make reviewing and understanding of the reports an easier process: NHDDS will make sure that line 7 on the 4513 report is checked appropriately on all future reporting. NH DDS will update all process d...
(SSA 4513) The department concurs with this finding and plans to work on the following areas to make reviewing and understanding of the reports an easier process: NHDDS will make sure that line 7 on the 4513 report is checked appropriately on all future reporting. NH DDS will update all process directions for all fiscal reporting. For these directions, NH DDS will update all spreadsheets used for reporting purposes, add labels to column headers and link to cells when able for better understanding of our business processes and where amounts are pulled from. NH DDS will keep all backup documentation needed for these directions, to review all current open grant years. NHDDS will create “Mock” documents of each reporting process to help in any further reviews. (SSA 4514) Administrator runs a leave report for a 1-month time frame. Put in alpha order and date order. In an excel spreadsheet, staff are in alpha order. Leave time is added to each individual staff member for a time frame of 3 months (quarterly report). The total for each individual staff member is then populated to a second spread sheet which is broken out by position categories and each position total is then populated to the 4514 report. • On Duty Hours (column A) are the number of days worked in a quarter, times 7.50 hours per day. • Holiday/Leave Hours (column B) are the number of Holidays (7.50 hours per day) during that quarter plus the amount of leave (hours and minutes) per individual staff member during that quarter. • Total Hours (column C) is the amount of column A, plus column B, equals column C. • Total Part-Time Personnel-Is the number of hours the physician worked during that quarter. A report is run in Virtual Time Clock for the quarterly time frame and hours are entered into Part-Time, Medical Consultants (h.) Prior to completing the quarterly report, the excel spread sheet, sheet 2, will be reviewed to ensure cell equations are correct to eliminate formula errors used to calculate quarterly hours. When emailing the Administrator, the quarterly report for signature, the following statement will be in the body of the email to certify cell equations were reviewed prior, to eliminate formula errors: “I certify that I reviewed the SSA-4514 prior to completion, to ensure that cell equations were correct to eliminate formula errors.” Sent to the Administrator for signature then sent off to Region. Sent emails will be saved in an outlook folder for future reference and proofs that reports were sent.
The Department underwent turnover and medical issues during the reporting period. The Department has hired additional program staff and arranged for annual training through a federal contractor to assist in reporting requirements. The Department is also in the process of procuring a new weatherizat...
The Department underwent turnover and medical issues during the reporting period. The Department has hired additional program staff and arranged for annual training through a federal contractor to assist in reporting requirements. The Department is also in the process of procuring a new weatherization and fuel assistance system which will assist in providing timely and accurate reporting data. The Department is also reviewing and updating policies and procedures, to include cross training and turnover contingencies.
The Department continues to work with its federal partners to ensure timely access to required reports.
The Department continues to work with its federal partners to ensure timely access to required reports.
This function (FFATA reporting) has now been designated to our Federal Reporting Group, which will allow for redundancy in personnel. A new policy and procedure, which will include internal controls, will be developed and implemented.
This function (FFATA reporting) has now been designated to our Federal Reporting Group, which will allow for redundancy in personnel. A new policy and procedure, which will include internal controls, will be developed and implemented.
The Office of ESEA Title programs and Covid-19 education programs have established an internal process to sample and test reports compiled to ensure operations are executed as intended. These internal controls include a monthly reporting sign off Excel sheet, certification on each FFATA submission a...
The Office of ESEA Title programs and Covid-19 education programs have established an internal process to sample and test reports compiled to ensure operations are executed as intended. These internal controls include a monthly reporting sign off Excel sheet, certification on each FFATA submission and a secondary certification for accuracy verification, and a division wide process for FFATA filing and verification. Division wide training occurred on October 26, 2023. Due to grant award notification (GAN) changes and development within our grants management system (GMS), the FFATA process has also been developing and shifting; therefore the FFATA process will be revisited annually and updated as needed. A revised procedure for FFATA reporting will be completed prior to additional training being offered. To ensure that processes are being followed, newly hired staff is trained appropriately, and updates to the GAN process are considered within the FFATA process we will hold another training this spring, March 14th, 2024, prior to new subawards being issued.
BEA will evaluate existing internal controls in place to ensure that the precision level of the control is such that it would detect an error in the expenditures reported in comparison to the expenditures incurred within the general ledger, account for precision level control when changing guidance ...
BEA will evaluate existing internal controls in place to ensure that the precision level of the control is such that it would detect an error in the expenditures reported in comparison to the expenditures incurred within the general ledger, account for precision level control when changing guidance exists, and that all documentation used to support the amounts reported on the federal report are properly maintained. Condition A has been completed. In January 2024, BEA evaluated internal controls related to the review and approval of expenditures. The following additional reconciliation step was added to the processes of preparation of expenditure draws and reporting preparation: • Broadband program Accountant II performs a data extract from NHFirst and reconciles the drawdown calculation totals as well as “dashboard” reporting totals to the NHFirst data extract to confirm accuracy of all data points. This second data validation step has been added to ensure all expenditures recorded in NHFirst are evaluated against program guidelines, submitted for reimbursement and included on required reports. Condition B & C to be completed no later than 12/31/2024.
For clarity the Department will create a redundant manual ledger that duplicates the functions of the current ledger and Detailed Transaction Register (DTR). DMAVS has existing policies and procedures in place to track all federal funds, state funds and mixed funds, and uses spreadsheets for all tr...
For clarity the Department will create a redundant manual ledger that duplicates the functions of the current ledger and Detailed Transaction Register (DTR). DMAVS has existing policies and procedures in place to track all federal funds, state funds and mixed funds, and uses spreadsheets for all transactions that reconciles every month to NH First Detail Transaction Register (DTR), Federal Fund tracking sheet, and Federal reimbursement tracking sheet with backup documents. The tracking sheet for the federal register is not intended to account for the state share of billing. The state share is accurately accounted for in the DTR, the cumulative accounting in the SF-270 and associated back up documentation. Supporting documentation to substantiate the accuracy of lines a, c, e, and f is in the DTR, the cumulative accounting of each SF-270, the supporting documentation sent with the billing to the Federal Government, and Year-end Agency Report for Federal Awards. This includes reconciliation and analysis of SADB expenditures and revenues to the Statement of Appropriations by each Program Accounting Unit. The SF-270 form is continuous cumulative data that starts Oct 1st and runs through the end of that Federal Fiscal Year. The SF-270 is the required federal form DMAVS submits to the Federal National Guard Appendix Program Manager for reimbursement. Back up documentation is submitted with the SF-270. The National Guard Appendix Program Manager, National Guard Grants Officer Representative, and National Guard United States Property Fiscal Officer (USPFO)/controller located in Concord, NH review, sign and submit the form to the Department of Defense to affect the cash draw. DMAVS does not unilaterally make cash draws to the federal government. The USPFO, who is substantially involved provides an independent review and reconciles any discrepancies prior to approving any requests for reimbursement. One possible explanation for the finding is that the selected test works were not continuous.
Department of Health and Human Services: Federal Financial Assistance Listing #93.498 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year - Period 4 TIN #426037759 Activities Allowed or Unallowed and Allowable Costs/Cost Principles ...
Department of Health and Human Services: Federal Financial Assistance Listing #93.498 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year - Period 4 TIN #426037759 Activities Allowed or Unallowed and Allowable Costs/Cost Principles and Reporting Material Weakness in Internal Control Over Compliance Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition: Guthrie County Hospital (the Hospital) reported expenses in the Department of Health and Human Services (HHS) special report for Period 4 that were not reduced by reimbursement from other sources or that other sources were obligated to reimburse. Additionally, the Hospital did not report its excess expenses as unreimbursed expenses attributable to Coronavirus in the HHS special report, did not report total interest earned on the ARP Rural Payments and Period 4 General Distribution Payments, and reported gross revenues/net charges from patient care by quarter for 2021 when net revenues should have been reported. In addition, there was no evidence retained that the HHS special report was reviewed by an individual separate from the preparer prior to submission. Planned Corrective Action: Management will implement an internal control policy for federal awards compliance to more diligently review the reporting of expenses and revenues to ensure all reporting requirements are met. However, had the errors in reporting of expenses and lost revenues been identified and corrected prior to reporting, the Hospital would have demonstrated that they had incurred eligible expenses and lost revenue in excess of the Period 4 funds received, including interest on such funds. Contact Person, Title and Phone Number: Christopher Stipe, Chief Executive Officer, (641)332-2201 Anticipated Date of Completion: June 30, 2024
2023‐004 Material Weakness in Internal Control over Compliance – Other for Preparation of Schedule of Expenditures of Federal Awards Condition: The Organization does not have an internal control system designed to provide for the preparation of the schedule. There was no documentation of review of t...
2023‐004 Material Weakness in Internal Control over Compliance – Other for Preparation of Schedule of Expenditures of Federal Awards Condition: The Organization does not have an internal control system designed to provide for the preparation of the schedule. There was no documentation of review of the Schedule retained and the Schedule required adjustments. Cause: The Organization had turnover and limited staffing available. Management’s Response and Corrective Action Plan: The weekly tracking of expenses as indicated in #3 will keep the issue top of mind throughout the year. The CEO will review all Schedules and reports prior to their submission for audit review. Responsible Individuals: - Accountability for understanding and management of the entire process – Marcia Meyer, CEO - Preparation of regular schedules during year – Jennie Myers - Preparation of quarterly schedule updates – Jennie Myers - Approval of quarterly schedules and presentation to Finance Committee – Marcia Meyer (approval) and Jennie Myers -Preparation of annual schedule in advance of the audit – Jennie Myers - Approval of annual schedule before submiting for audit – Marcia Meyer Anticipated Completion Date: This will be implemented immediately and will be up to date by June 2024
Condition - The schedule of expenditures of federal awards (SEFA) as originally issued did not include loans with continuing compliance requirements. Context - Prior to the June 30, 2022 fiscal year end, the USDA did not classify loans outstanding under ALN 10.766 as having continuing compliance req...
Condition - The schedule of expenditures of federal awards (SEFA) as originally issued did not include loans with continuing compliance requirements. Context - Prior to the June 30, 2022 fiscal year end, the USDA did not classify loans outstanding under ALN 10.766 as having continuing compliance requirements. The USDA changed its position and began treating these loans as having continuing compliance and issued a notice to loan recipients that they must report the loan balances on their schedule of expenditures of federal awards beginning with fiscal years ending June 30, 2022. The College did not identify this change in policy and incorrectly excluded the loan entered into during the year ($38,970,352) from the originally issued schedule of expenditures of federal awards. Planned Corrective Action - In December 2023 management identified that with its participation as borrower on a Community Facilities Loan, guaranteed by the USDA, that it had a compliance obligation to include the loan program in the SEFA. The College has designed and implemented controls that require the VP of Business Affairs (or designee) to identify new and modified compliance and reporting obligations under the currently enrolled programs or for any new programs in which the College may participate.
Condition: The College did not report certain students’ status to the National Student Loan Data System (NSLDS) in an accurate and timely manner during the fiscal year. Context - There were two errors identified that attributed to this finding: 1) Of the 40 students tested, there were 10 students w...
Condition: The College did not report certain students’ status to the National Student Loan Data System (NSLDS) in an accurate and timely manner during the fiscal year. Context - There were two errors identified that attributed to this finding: 1) Of the 40 students tested, there were 10 students who withdrew or graduated whose status changes were not reported accurately to the NSLDS. The students were reported timely but with an incorrect effective date. 2) Of the 40 students tested, there were 33 students who withdrew or graduated whose status changes were not reported to the NSLDS within 60 days. Planned Corrective Action: The College corrective action plan implemented as of the time of this communication has included integrated feedback from multiple campus constituencies received through a series of meetings led by our Academic Dean in order to define a process focused on managing this particular compliance obligation. The participating departments included; Academic Affairs, Enrollment, Financial Aid, Business Office, IT, Registrar, Student Life, Academic Services and the President’s Office. The result was development of an internal policy with clearly defined protocols, procedures and timelines (referred to as the “Adrian College Data Integrity Notification Guidelines” policy document). Assessment will be periodically evaluated via the College’s internal audit process. Note: • Re status change for withdrawn or graduating students: The College submitted its report to the National Student Clearinghouse (NSC) twenty-eight (28) days prior to the sixty (60) day requirement to be received by the NSLDS. The College was subsequently notified by NSC that it had been the victim of a third-party security breach. We believe this event contributed to delay for the NSC to review, certify and post to the NSLDS; contributing to this finding. Re student reporting with incorrect effective dates posted: It appears that the effective dates submitted by the College to NSC were subsequently modified within the NSC database. We believe a third-party security breach identified to the College by NSC may have contributed to the posting of incorrect effective dates to NSLDS; contributing to this finding. There were no questioned costs associated with the finding. Contact person responsible for corrective action: Andrea Milner VP Academic Affairs/Dean Anticipated Completion Date: Academic Year 2023-2024
Finding 390438 (2023-001)
Significant Deficiency 2023
Student Financial Assistance Cluster – Assistance Listing No. 84.268, 84.063, 84.007 Recommendation: CLA recommends that the University enhance its policies and procedures regarding enrollment reporting including additional monitoring over the third-party service provider to ensure that reporting i...
Student Financial Assistance Cluster – Assistance Listing No. 84.268, 84.063, 84.007 Recommendation: CLA recommends that the University enhance its policies and procedures regarding enrollment reporting including additional monitoring over the third-party service provider to ensure that reporting is completed accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management respectfully agrees on all findings and recommendations. Management will engage in additional staff training and is committed to consistent application of current policies and procedures to ensure enrollment reporting and monitoring of third-party service providers results in accurate and timely reporting by the third-party service provider. While the third-party service provider has a national monopoly on enrollment reporting, with other institutions of higher education also facing similar reporting issues by the third-party service provider, Management believes that enhanced training and internal procedures over enrollment reporting will mitigate accuracy and timeliness errors made by the third party service provider, resulting in the University meeting U.S. Department of Education requirements. Name(s) of the contact person(s) responsible for corrective action: Ashlie Pence Planned completion date for corrective action plan: June 30, 2024
Contact person: Katherine Dannenfelser, Director of Finance Recommendation: Replacement reserve account should be reconciled monthly and reviewed to ensure all required deposit activity is made and there are no unapproved withdrawals from the account. Corrective Action: Upper Bay Counseling and S...
Contact person: Katherine Dannenfelser, Director of Finance Recommendation: Replacement reserve account should be reconciled monthly and reviewed to ensure all required deposit activity is made and there are no unapproved withdrawals from the account. Corrective Action: Upper Bay Counseling and Support Services, Inc. will implement monthly reporting of Replacement Reserve Account and other HUD information as part of an effort to improve internal financial reporting overall. Proposed Completion Date: Management is implementing the above recommendation. UPDATE-March 20, 2024 – This reporting requirement will be included in financial reporting package being developed. Information is being communicated in monthly meetings and emails as we have increased communication between Clinical and Financial staff. Anticipate supplemental schedules being added to basic financial package on or before June 30, 2023. Moving monthly amount for Reserves during March 2024 and will move on the first few business days of every month going forward.
To work with fee accountant in making the corrections necessary and recommended by the auditor.
To work with fee accountant in making the corrections necessary and recommended by the auditor.
2023-004 Student Financial Aid Cluster – Schedule of Expenditure of Federal Awards (SEFA) Recommendation: We recommend that the University reevaluate its policies and controls related to the preparation of the SEFA to ensure its complete and accurate. Explanation of disagreement with audit finding: ...
2023-004 Student Financial Aid Cluster – Schedule of Expenditure of Federal Awards (SEFA) Recommendation: We recommend that the University reevaluate its policies and controls related to the preparation of the SEFA to ensure its complete and accurate. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Director will reevaluate the controls and set in place policies and procedures for SEFA completion. Name(s) of the contact person(s) responsible for corrective action: Director of Restricted Funds Accounting, Symone Merritt Planned completion date for corrective action plan: October 2024
2023-007 COVID-19, Education Stabilization Fund: Higher Education Emergency Relief Fund - Student Aid Portion and Institutional Portion – Federal Assistance Listing Nos. 84.425E and 84.425F - Reporting Recommendation: We recommend the University enhances its procedures, controls, and review policie...
2023-007 COVID-19, Education Stabilization Fund: Higher Education Emergency Relief Fund - Student Aid Portion and Institutional Portion – Federal Assistance Listing Nos. 84.425E and 84.425F - Reporting Recommendation: We recommend the University enhances its procedures, controls, and review policies around HEERF reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Office of Business & Finance will populate and upload the quarterly CARES HBCU and Institutional reports by the 10th day after the end of each calendar quarter. The Office of Student Accounts will create and upload the quarterly CARES Student Portion reports by the 10th day after the end of each calendar quarter. Name(s) of the contact person(s) responsible for corrective action: Assistant Controller, Clifton Smith, II & Executive Director of Student Accounts, Carold Boyer-Yancy. Planned completion date for corrective action plan: May 2024
2023-005 Student Financial Assistance Cluster – Federal Assistance Listing Nos. 84.063, and 84.268 – Enrollment Reporting Recommendation: We recommend the University evaluate its procedures and review policies in overseeing submissions to the NSLDS completed by the third-party servicer. Additionally...
2023-005 Student Financial Assistance Cluster – Federal Assistance Listing Nos. 84.063, and 84.268 – Enrollment Reporting Recommendation: We recommend the University evaluate its procedures and review policies in overseeing submissions to the NSLDS completed by the third-party servicer. Additionally, we recommend the University review its policies and procedures on reporting enrollment information to the NSLDS to ensure that all relevant information is being captured and reported timely in accordance with applicable regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Registrar’s Office will strengthen procedures and reporting practices to ensure timely submission to the National Student Clearinghouse (NSCL) & the National Student Load Data System (NSLDS). The Registrar’s Office will confirm and ensure the submissions to the National Student Clearinghouse (NSCL) corresponds with the timeframe the enrollment is rolled over to the National Student Loan Data System (NSLDS). Name(s) of the contact person(s) responsible for corrective action: Registrar, Dr. Genita Mangum Planned completion date for corrective action plan: July 2024
COVID-19 Education Stabilization Fund Recommendation: We recommend the College establish a system to ensure reports are submitted in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All HEERF funds ...
COVID-19 Education Stabilization Fund Recommendation: We recommend the College establish a system to ensure reports are submitted in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All HEERF funds have been spent and reports are posted on the website. No additional reports will need to be posted. Name(s) of the contact person(s) responsible for corrective action: Brenda Schumacher Planned completion date for corrective action plan: Prior to Summer 2023
Finding Number: 2023‐004 Program Name/Assistance Listing Title: COVID‐19 Education Stabilization Fund Assistance Listing Number: 84.425U Contact Person: Faron Logan, Business Manager Anticipated Completion Date: April 30, 2024 Planned  Corrective  Action:  The  Business  Manager  will  imme...
Finding Number: 2023‐004 Program Name/Assistance Listing Title: COVID‐19 Education Stabilization Fund Assistance Listing Number: 84.425U Contact Person: Faron Logan, Business Manager Anticipated Completion Date: April 30, 2024 Planned  Corrective  Action:  The  Business  Manager  will  immediately  ensure  that  all  payroll  withholdings/ deductions will be processed properly along with all stipends. This will correct the quarterly Form 941 that will be filed by the Business Manager. All time sheets will be reviewed by Business Manager to make sure all employees hours are correctly paid.
Finding Number: 2023‐003, 2022‐003, 2021‐003 Program Name/Assistance Listing Title: Indian School Equalization Assistance Listing Number: 15.042 Contact Person: Faron Logan, Business Manager Anticipated Completion Date: March 31, 2024 Planned Corrective Action: Since April 2023 the Busines...
Finding Number: 2023‐003, 2022‐003, 2021‐003 Program Name/Assistance Listing Title: Indian School Equalization Assistance Listing Number: 15.042 Contact Person: Faron Logan, Business Manager Anticipated Completion Date: March 31, 2024 Planned Corrective Action: Since April 2023 the Business Manager has corrected the dates for the SF‐425 reporting. SF‐425 reports are turned in on time and all current SF‐425 reports have correct dates.
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