Corrective Action Plans

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FINDING 2023-001 Finding Subject: Education Stabilization Fund - Internal Controls Over Annual Data Report Summary of Finding: Significant Deficiency; A failure to establish an effective internal control system creating a risk of noncompliance with the grant agreement and the reporting compliance r...
FINDING 2023-001 Finding Subject: Education Stabilization Fund - Internal Controls Over Annual Data Report Summary of Finding: Significant Deficiency; A failure to establish an effective internal control system creating a risk of noncompliance with the grant agreement and the reporting compliance requirement. Contact Person Responsible for Corrective Action: Mendy Shrout Contact Phone Number and Email Address: 765-795-4664 mshrout@cloverdale.k12.in.us Views of Responsible Officials: We concur with the finding. Explanation and Reasons for Disagreement: NA Description of Corrective Action Plan: Management has created a google doc to record the reviewed by and submitted by dates of the reporting. As well as including financial reports in respective report files. Anticipated Completion Date: Google doc was created February 5, 2024
Finding: Management's review of the enrollment reporting did not detect errors on certain student data elements. Certain student records within the NSLDS were identified with inaccurate data elements. The College is responsible for designing, implementing, and maintaining internal control over compl...
Finding: Management's review of the enrollment reporting did not detect errors on certain student data elements. Certain student records within the NSLDS were identified with inaccurate data elements. The College is responsible for designing, implementing, and maintaining internal control over compliance for special tests and provisions and for accurately reporting significant data elements under the Campus-Level and Program-Level records within the National Student Loan Data System (NSLDS) that the Department of Education (ED) considers high risk. The College's internal control over compliance for special tests are not operating effectively. The preparer did not update the student's status into NSLDS resulting in inaccuracies in significant Campus-Level and Program-Level enrollment date elements that ED considers high risk. Additionally, student with status changes were incorrectly reported as withdrawn but upon review of internal documentation, those same students graduated. We recommend management review and enhance its review policies and procedures surrounding enrollment reporting submissions to ensure the accuracy of data elements reported to ED. A review performed by an appropriate individual separate from the prepared prior to the submission of the enrollment reports to NSLDS may improve the accuracy of enrollment reporting. We also recommend management review all students reported to NSLDS to verify they are accurately reported. Corrective Action: Management agrees and has implemented necessary procedures/controls to ensure the College is in compliance with enrollment requirements.
Department of Health and Human Services Federal Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN #860554593 Reporting Material Weakness in Internal Control Over Compliance and Material N...
Department of Health and Human Services Federal Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN #860554593 Reporting Material Weakness in Internal Control Over Compliance and Material Noncompliance Finding Summary: The Organization selected option iii to calculate lost revenue using budgeted gross revenues to actual gross revenues. The Organization’s HHS Period 4 Report included lost revenues for three quarters that did not agree to the supporting calculation of lost revenues. Without proper implementation of internal controls over the Organization’s budget prior to submission errors could occur resulting in the Organization not calculating lost revenues correctly. Status: The Organization will be adopting a policy to enhance internal controls over the budget to ensure that the lost revenue calculation is not changed after submission and follows the option iii methodology utilized to calculate lost revenues. Responsibility of: Richard Leonard (Controller) and Andrew Horan (Director of F.P. and A.) Estimated Completion Date: 3/31/24
Material Weakness - Internal Controls over Reporting and Noncompliance The Office of Financial Management (OFM) Grant Program Administrator, Heather Larson will monitor and ensure that Federal Funding Accountability and Transparency Act of 2006 (FFATA) reports are filed as required in the FSRS syste...
Material Weakness - Internal Controls over Reporting and Noncompliance The Office of Financial Management (OFM) Grant Program Administrator, Heather Larson will monitor and ensure that Federal Funding Accountability and Transparency Act of 2006 (FFATA) reports are filed as required in the FSRS system. Since the recent transition of the CDBG Entitlement Cluster from an outside agency back to Sarasota County, the County has implemented a standardized form to capture needed information from current and future subrecipients to report appropriately the requirements of the Federal Funding Accountability and Transparency Act of 2006 (FFATA). The OFM Grant Analyst assigned to the funding award, upon review of any pending subaward/ subaward amendment, will create an Action Item utilizing the Grants Administration module of OnBase. The Action Item will require completion of any required FSRS reporting. Action item will be assigned and have a deadline date no late than the last day of the month following the month in which the subaward/ subaward amendment obligation was made. Implementation date for this process - On or before February 28, 2024.
Federal Agency Name: Department of Health and Human Services Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN #420868216 Federal Financial Assistance Listing #93.498 Compliance Requirement: Preparati...
Federal Agency Name: Department of Health and Human Services Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN #420868216 Federal Financial Assistance Listing #93.498 Compliance Requirement: Preparation of Schedule of Expenditures of Federal Awards ‐ Other Finding Summary: The Hospital does not have an internal control system designed to provide for a complete and accurate Schedule being audited. Eide Bailly, LLP, the auditors, were requested to draft the Schedule and notes to the Schedule. Responsible Individuals: Craig Carstens, CFO Corrective Action Plan: Management agrees with this finding. Management will develop and implement an internal control system tailored to ensure completeness and accuracy in auditing the Schedule. Management will clearly define the objectives of the internal control system to address gaps in auditing procedures. Management will set clear standards and protocols for auditing processes, ensuring adherence to regulatory requirements. Management will provide comprehensive training to staff involved in auditing processes to ensure they understand their roles and responsibilities. Management will conduct regular assessments and reviews of the internal control system's effectiveness and make adjustments as needed to improve accuracy and completeness. Anticipated Completion Date: 2/26/2024.
Federal Agency Name: Department of Health and Human Services Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN #420868216 Federal Financial Assistance Listing #93.498 Compliance Requirement: Reporting...
Federal Agency Name: Department of Health and Human Services Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN #420868216 Federal Financial Assistance Listing #93.498 Compliance Requirement: Reporting Finding Summary: There was no evidence retained that the Hospital’s special report submitted to the Department of Health and Human Services for Period 4 TIN #420868216 was reviewed or approved by an individual separate from the preparer prior to submission. Responsible Individuals: Craig Carstens, CFO Corrective Action Plan: Management agrees with this finding. Management will designate specific individuals to review HHS special report submissions before submission to HHS. Management will require documentation verifying independent review and approval prior to submission. Management will provide comprehensive training to staff on the importance of independent review processes. Management will set up automated workflow systems and checklists to enforce review procedures. Management will regularly audit the review process, gather feedback, and make necessary adjustments for enhancement. Anticipated Completion Date: 2/26/2024.
Responsible Contact Person(s): Kassandra Bullock, Director of Grants Management DeAndrea Williams, Grants Admin Supervisor Joseph Thompson, Grants Compliance Supervisor John Colligan, Director of Finance and Administration Corrective Action Planned: An internal compliance review has been implemented...
Responsible Contact Person(s): Kassandra Bullock, Director of Grants Management DeAndrea Williams, Grants Admin Supervisor Joseph Thompson, Grants Compliance Supervisor John Colligan, Director of Finance and Administration Corrective Action Planned: An internal compliance review has been implemented to ensure accuracy and timely reporting of FFATA data. Data is confirmed prior to upload by the Grants Compliance Team to address errors, missing information, and conflicting dates. Training has occurred via the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) by Grants Admin staff. Additionally all changes in statements of grant awards (SOGA) will be reviewed and reissued when needed and data re-entered to ensure FFATA correlates with SOGA. Estimated Completion Date: 1/26/2024
Responsible Contact Person(s): Ida Witherspoon, Chief Financial Officer Corrective Action Planned: Send periodic e-mail reminders to program staff responsible for submitting FFATA data to the Federal Reporting Unit for submission to the federal government. Additional time is needed to fully impleme...
Responsible Contact Person(s): Ida Witherspoon, Chief Financial Officer Corrective Action Planned: Send periodic e-mail reminders to program staff responsible for submitting FFATA data to the Federal Reporting Unit for submission to the federal government. Additional time is needed to fully implement an automated solution. Estimated Completion Date: 10/30/2024
Responsible Contact Person(s): Angela Morse, Director of Benefit Programs Frank Smith, Associate Director of Benefit Programs Corrective Action Planned: DSS will perform an analysis of identified reporting errors to determine causality and the appropriate actions to resolve reporting errors. Additio...
Responsible Contact Person(s): Angela Morse, Director of Benefit Programs Frank Smith, Associate Director of Benefit Programs Corrective Action Planned: DSS will perform an analysis of identified reporting errors to determine causality and the appropriate actions to resolve reporting errors. Additionally, DSS will create a systems modification request to correct errors that are identified as occurring as a result of inaccurate programming in the data modification phase of federal report creation. Estimated Completion Date: 12/31/2024
Responsible Contact Person(s): Angela Morse, Director of Benefit Programs Mark Golden, Economic Assistance and Employment Manager Division of Benefit Programs Corrective Action Planned: Perform an analysis of identified reporting errors to determine causality and the appropriate actions to resolve r...
Responsible Contact Person(s): Angela Morse, Director of Benefit Programs Mark Golden, Economic Assistance and Employment Manager Division of Benefit Programs Corrective Action Planned: Perform an analysis of identified reporting errors to determine causality and the appropriate actions to resolve reporting errors. Create a systems modification request to correct errors that are identified as occurring as a result of inaccurate programming in the data modification phase of federal report creation. Estimated Completion Date: 6/30/2024
Responsible Contact Person(s): Angela Morse, Director of Benefit Programs Frank Smith, Associate Director of Benefit Programs Corrective Action Planned: DSS has requested the vendor's records. Once received, DSS will audit those records to provide reasonable assurance that the contractor administer...
Responsible Contact Person(s): Angela Morse, Director of Benefit Programs Frank Smith, Associate Director of Benefit Programs Corrective Action Planned: DSS has requested the vendor's records. Once received, DSS will audit those records to provide reasonable assurance that the contractor administered the LIHWAP federal grant program in accordance with federal statutes, regulations, and the terms and conditions of the federal award before it closes the grant award. Estimated Completion Date: 6/30/2024
Responsible Contact Person(s): Angela Morse, Director of Benefit Programs Frank Smith, Associate Director Senior Benefit Programs Denise Surber, EAP Manager - Division of Benefit Programs Corrective Action Planned: DSS will work to provide additional training to local agency eligibility workers on h...
Responsible Contact Person(s): Angela Morse, Director of Benefit Programs Frank Smith, Associate Director Senior Benefit Programs Denise Surber, EAP Manager - Division of Benefit Programs Corrective Action Planned: DSS will work to provide additional training to local agency eligibility workers on how to properly determine and document eligibility determinations in the case management system. Additionally, DSS will consider monitoring local agency eligibility worker’s use of manual overrides to confirm that they properly document eligibility determinations in the case management system. Estimated Completion Date: 12/31/2024
View Audit 295106 Questioned Costs: $1
Responsible Contact Person(s): Kevin Platea, Chief Information Officer Corrective Action Planned: DSS has 15 plus applications that are in active oversight; IT Business Administration is in receipt of the required SOC 2, Type 2 reports. However, additional requirements to capture the SOC 1, Type 2 ...
Responsible Contact Person(s): Kevin Platea, Chief Information Officer Corrective Action Planned: DSS has 15 plus applications that are in active oversight; IT Business Administration is in receipt of the required SOC 2, Type 2 reports. However, additional requirements to capture the SOC 1, Type 2 reports have not yet been accomplished. Several SOC reports were not captured by VITA and then provided to DSS for review. Additional requirements to capture SOC 1, Type 2 reports have been identified and VITA is requesting this information of the providers. Estimated Completion Date: 12/31/2024
Responsible Contact Person(s): Naveen Abraham, Chief Core Infrastructure Services Corrective Action Planned: Ensuring that infrastructure suppliers fulfill all contractual requirements with respect to Commonwealth security policies and standards necessitates a programmatic, continuous improvement ap...
Responsible Contact Person(s): Naveen Abraham, Chief Core Infrastructure Services Corrective Action Planned: Ensuring that infrastructure suppliers fulfill all contractual requirements with respect to Commonwealth security policies and standards necessitates a programmatic, continuous improvement approach. VITA has made improved cybersecurity a primary goal and major initiatives have completed and are underway. VITA has established a scoring mechanism, based on the Common Vulnerability Scoring System (CVSS), that delineates the necessary response based on the criticality of the vulnerability (critical, high, and medium). For vulnerabilities with a CVSS score of (critical and high), service level agreement (SLA) 1.1.3 is now in place to measure supplier performance and adjust supplier compensation accordingly through SLA credits and RCDs. For vulnerabilities below the critical and high score, in Q4 of 2023, suppliers started providing data in a quarterly report to the MSI and VITA. The new SLAs combined with the reports of vulnerabilities below the critical and high score are used to ensure suppliers’ contractual compliance. VITA’s data shows that patches for software on the enterprise software list are being applied on an ongoing basis. VITA will work with agencies and suppliers if there are any new technical difficulties or questions about patching. New tools are now available to agencies so that they can monitor and verify the remediation of the vulnerabilities for which infrastructure suppliers are responsible. Dashboards have also been provided to the suppliers so that they can review a shared and common vulnerability list. VITA and the suppliers monitor and review enterprise level logs and security events on behalf of customer agencies through the system dashboard and a 24x7 Security Operations Center. The dashboard is available for access by agencies as of Q4 2023. VITA will continue to monitor and improve the security of infrastructure services through ongoing governance, including the requirements of architecture documentation, system security plans, and audit reports. VITA’s infrastructure services group will work with the VITA security group to confirm that the current state achieves security standards compliance. Estimated Completion Date: 6/30/2024
Responsible Contact Person(s): Barry Davis, Chief Information Security Officer and Director of Information Security & Risk Management Melinda Raines, Director of Human Resources Karen Holt, Human Resources Business Process Consultant Corrective Action Planned: An agency-wide work group will be estab...
Responsible Contact Person(s): Barry Davis, Chief Information Security Officer and Director of Information Security & Risk Management Melinda Raines, Director of Human Resources Karen Holt, Human Resources Business Process Consultant Corrective Action Planned: An agency-wide work group will be established to determine the exact processes need to implement the controls necessary to address this finding. HR and ISRM have identified the need for new reporting and interfaces to regain compliance. DSS had deployed DOA human capital management system and an internal system that will need to have interfaces developed. Estimated Completion Date: 6/30/2024
FINDING 2023-004 Finding Subject: COVID-19 - Education Stabilization Fund – Reporting Summary of Finding: Reports were not reviewed by someone other than the preparer Contact Person Responsible for Corrective Action: Todd Nobbe Contact Phone Number: 812-934-2194 Views of Responsible Official: We con...
FINDING 2023-004 Finding Subject: COVID-19 - Education Stabilization Fund – Reporting Summary of Finding: Reports were not reviewed by someone other than the preparer Contact Person Responsible for Corrective Action: Todd Nobbe Contact Phone Number: 812-934-2194 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The school corporation will establish a proper system for internal controls and develop procedure to ensure report are review by someone other than the preparer. Completion Date: Immediately 2/26/2024
FINDING 2023-002 Finding Subject: Title I Grants to Local Educational Agencies - Reporting Summary of Finding: The School Corporation had established a system of internal controls over the Final Expenditure report for Title I. However, the internal control process was not documented. It is recommend...
FINDING 2023-002 Finding Subject: Title I Grants to Local Educational Agencies - Reporting Summary of Finding: The School Corporation had established a system of internal controls over the Final Expenditure report for Title I. However, the internal control process was not documented. It is recommended that the School Corporation's management establish a system of internal controls. Contact Person Responsible for Corrective Action: James H. Hardman Contact Phone Number and Email Address: 219-663-3371 jhardman@cps.k12.in.us Views of Responsible Officials: The management of the Crown Point Community School Corporation concurs with the finding. Description of Corrective Action Plan: The management of the Crown Point Community School Corporation will establish a system of internal controls consisting of policies and procedures. Anticipated Completion Date: April 5, 2024
Finding number: 2023-002 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Clusters AL #’s: 84.268 Award year: 2023 Corrective Action Plan: The College will be looking at making some business process changes to review files submitted to ...
Finding number: 2023-002 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Clusters AL #’s: 84.268 Award year: 2023 Corrective Action Plan: The College will be looking at making some business process changes to review files submitted to NSC(National Student Clearing House) and NSLDS (National Student Loan Data Service) on a monthly basis and perform monthly reconciliation between responsible offices to ensure students are accurately reported to ED/NSLDS. This new implementation will allow the College/Office to better verify each student’s enrollment status visibility of reporting issues in the future. Timeline for Implementation of Corrective Action Plan: This new procedure was implemented starting with the Fall 2023 semester and beyond. Contact Person Alex Jean-Jacques Director of Financial Aid of Operations
Finding 2023-001- Enrollment Reporting Recommendation: It is recommended that the University review policies and procedures in place to resolve reporting issues in a timely manner to facilitate compliance with Title IV regulations. Action Taken: Each error was corrected within the system. Going forw...
Finding 2023-001- Enrollment Reporting Recommendation: It is recommended that the University review policies and procedures in place to resolve reporting issues in a timely manner to facilitate compliance with Title IV regulations. Action Taken: Each error was corrected within the system. Going forward, the reports submitted to NSLDS will be closely reviewed to ensure effective dates for student changes are appropriately reported. In addition, the registrar has updated their process notes which are used each time they pull the report. Responsible Individual for Corrective Action: Registrar - Joanna Raudenbush Anticipated Completion Date: December 31, 2023
Corrective Actions Taken or Planned: Management will make necessary revisions to previous reporting. Management will complete and file all past due quarterly and annual reports accurately and in compliance with all HEERF reporting requirements. The fiscal year 2024 annual report will be filed in a t...
Corrective Actions Taken or Planned: Management will make necessary revisions to previous reporting. Management will complete and file all past due quarterly and annual reports accurately and in compliance with all HEERF reporting requirements. The fiscal year 2024 annual report will be filed in a timely manner. Anticipated Completion Date: March 31, 2024 Responsible Contact Person: Jacalyn Kovach, AVP Finance/Controller
FISAP Reporting Planned Corrective Action: Corban will work collaboratively with the Department of Education to investigate FISAP reporting and resolve any inconsistencies appropriately. Additionally, independent of the individual who prepares the FISAP, Corban will appoint a knowledgeable individua...
FISAP Reporting Planned Corrective Action: Corban will work collaboratively with the Department of Education to investigate FISAP reporting and resolve any inconsistencies appropriately. Additionally, independent of the individual who prepares the FISAP, Corban will appoint a knowledgeable individual to review the completed FISAP for quality assurance (QA). These actions will ensure a diversity of accountability and prevent reoccurrence. Person Responsible for Corrective Action Plan: Jordan Lindsey, Associate Vice President for Enrollment Management and Marketing Anticipated Date of Completion: April 30, 2024
Finding 2023-003: Allowable Cost/Cost Principles and Reporting Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provide Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year Period 4 TIN#237224698 Federal Financial A...
Finding 2023-003: Allowable Cost/Cost Principles and Reporting Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provide Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year Period 4 TIN#237224698 Federal Financial Assistance Listing Number: 93.498 Finding Summary: Imagine the Possibilities, Inc. final eligible expenditure listing identified as eligible and claimed under the Provider Relief Fund program was not reviewed and approved by a separate individual outside of the preparer. In addition, the Organization’s special report submitted to the Department of Health and Human Services for Period 4 TIN #237224698 was not reviewed and approved by a separate individual outside of the preparer. Responsible Individuals: Megan Simmons, CFO Corrective Action Plan: Management agrees with the finding. The Organization will review the internal controls and implement improvements related to allowability of all federal cost claimed, including those regarding the identification of duplicate items and approved costs. Anticipated Completion Date: March 31, 2024
Finding 2023-002: Preparation of Schedule of Expenditures of Federal Awards Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provide Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year Period 4 TIN#237224698 Medica...
Finding 2023-002: Preparation of Schedule of Expenditures of Federal Awards Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provide Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year Period 4 TIN#237224698 Medicaid Cluster Federal Financial Assistance Listing Number: 93.498 & 93.778 Finding Summary: The Organization does not have an internal control system designed to provide for a complete and accurate schedule being audited. Eide Bailly LLP was requested to draft the schedule and notes to the schedule. Responsible Individuals: Megan Simmons, CFO Corrective Action Plan: Management agrees with the finding. However, management feels that committing the resources necessary to remain current on SEFA reporting requirements and corresponding footnote disclosures would lack benefit in relation to the cost but will continue to evaluate on a regular basis. Anticipated Completion Date: March 31, 2024
The Downey Adult School concurs with the finding and to prevent future occurrences, the school purchased a new student database management software system (Campus Café) that was implemented on August 1, 2023. The school also partnered with National Student Clearinghouse (NSCH). NSCH articulates with...
The Downey Adult School concurs with the finding and to prevent future occurrences, the school purchased a new student database management software system (Campus Café) that was implemented on August 1, 2023. The school also partnered with National Student Clearinghouse (NSCH). NSCH articulates with the new student database management software system (Campus Café). The new student database management software system together with National Student Clearinghouse will help to prevent human errors and omissions from occurring when reporting National Student Loan Data System (NSLDS) data. While the district purchased the new system in November of 2022, the school did not begin using the new system(s) until August of 2023 because the switch had to be implemented at the beginning of the fiscal year. Implementation is a several month process and all DAS employees have been receiving extensive training (ongoing) to be proficient and comfortable with the new system(s). We have ongoing weekly training for all DAS staff as we continue to fully implement the new student database management software system.
Finding: Late Issuance of the 2023 Single Audit Reporting Package The City’s fiscal year 2023 Single Audit package was not submitted to the Federal Audit Clearinghouse within the required time period. The Single Audit package for the City’s fiscal year ended April 30, 2023 should have been submitt...
Finding: Late Issuance of the 2023 Single Audit Reporting Package The City’s fiscal year 2023 Single Audit package was not submitted to the Federal Audit Clearinghouse within the required time period. The Single Audit package for the City’s fiscal year ended April 30, 2023 should have been submitted to the Federal Audit Clearinghouse by January 31, 2024. Corrective Action Taken or Planned: City will schedule and complete future external audits in a manner that will allow timely reporting of the Single Audit. Anticipated Completion Date: June 2024 Responsible Person(s): Cynthia Smith, Assistant Finance Director
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