Corrective Action Plans

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Recommendation: We realize that with a limited number of office employees, segregation of duties is difficult. However, the Center should review the operating procedures to obtain the maximum internal control possible under the circumstances. The Center should also consider the potential consequenc...
Recommendation: We realize that with a limited number of office employees, segregation of duties is difficult. However, the Center should review the operating procedures to obtain the maximum internal control possible under the circumstances. The Center should also consider the potential consequence of reliance on one person for financial, grant and payroll reporting.
Action Taken: This issue is reviewed annually through the audit review with the Board of Directors. The size of the Center prevents further segregation of duties.
Action Taken: This issue is reviewed annually through the audit review with the Board of Directors. The size of the Center prevents further segregation of duties.
Anticipated Date of Completion: June 30, 2024
Anticipated Date of Completion: June 30, 2024
The Organization has procedures in place to ensure timely submissions to the Federal Audit Clearinghouse are made. In the current year under audit, however, management faced challenges finding a replacement accounting firm timely with FQHC experience, which led to delays in completing the audit time...
The Organization has procedures in place to ensure timely submissions to the Federal Audit Clearinghouse are made. In the current year under audit, however, management faced challenges finding a replacement accounting firm timely with FQHC experience, which led to delays in completing the audit timely and submitting the necessary reports. Now that a replacement firm has been found, we will return to our historical timely filing with the Federal Audit Clearinghouse.
The district has implemented procedures for the future to ensure all transacttions are recorded in the period of benefit and account reconciliations are performed in a timely manner. Anticipated Completion Date: June 30, 2023 Responsible Party: Kathy VanSchaick
The district has implemented procedures for the future to ensure all transacttions are recorded in the period of benefit and account reconciliations are performed in a timely manner. Anticipated Completion Date: June 30, 2023 Responsible Party: Kathy VanSchaick
Finding 3759 (2023-003)
Significant Deficiency 2023
November XX, 2023 Office of the Secretary of State Audits Division 255 Capitol St. NE, Suite #500 Salem, OR 97310 Plan of Action for Wheeler County, Oregon Wheeler County, Oregon respectfully submits the following corrective action plan in response to deficiencies reported in our audit of fiscal yea...
November XX, 2023 Office of the Secretary of State Audits Division 255 Capitol St. NE, Suite #500 Salem, OR 97310 Plan of Action for Wheeler County, Oregon Wheeler County, Oregon respectfully submits the following corrective action plan in response to deficiencies reported in our audit of fiscal year ended June 30, 2023. The audit was completed by the independent auditing firm Solutions, CPAs PC, John Day, Oregon. The deficiencies are discussed below with the Action Plan listed for each. 1. Material Weakness – Financial Statement Preparation Criteria: The financial statements are the responsibility of the county’s management, including the prevention or detection of material misstatements in the presentation and disclosure of the financial statements. Non-attest services performed by the auditor in the preparation of the financial statements cannot be considered compensating controls. Condition: The county engages their auditors to provide non-attest services for the preparation of its financial statements. Although common for municipalities the size of the county, this condition represents a control deficiency over the financial reporting process that is required to be reported under professional standards as long as management makes all financial reporting decisions and accepts responsibility for the content of the financial statements. However, those activities performed by the auditor are not a substitute for, or extension of, internal controls over the preparation of the financial statements in accordance with generally accepted accounting principles (GAAP). Cause: The county’s accounting personnel do not possess the advanced training that would provide the expertise necessary to prepare the financial statements and related notes in accordance with GAAP, and therefore may not be able to prevent or detect a material misstatement in the preparation and disclosure of the financial statements. Misstatements in financial statements may include not only misstated financial amounts, but also the omission of disclosures required by GAAP. Effect: Material misstatement in the preparation and disclosure of the financial statements in accordance with GAAP may not be prevented or detected. Misstatements in financial statements include not only misstated dollar amounts, but also the omission of disclosures required under GAAP. Recommendations: We understand that it may not be practical to acquire or allocate the internal resources to perform all the controls necessary over financial reporting. However, management (including the County Court) should mitigate this deficiency by keeping informed about the county’s internal controls, performing supervisory reviews, studying the financial statements and related footnote disclosures, and understanding its responsibility for the financial statements as a whole. Action Plan: We understand the importance of risk management and the need to address risks in an informed, cost-beneficial way. As a result of our cost-benefit analysis we have determined the value of incurring the additional expense of hiring a staff person or another firm to prepare our financial statements does not justify the cost. We accept the auditor’s recommendations and will attempt to implement in a timely manner. 2. Material Weakness – Preparation of the Schedule of Expenditures of Federal Awards Criteria: The schedule of expenditures of federal awards (SEFA) is the responsibility of the county’s management, including the prevention or detection of material misstatements in the presentation and disclosures of SEFA. Services performed in reconciling the SEFA to the trial balance during the annual compliance audit cannot be considered compensating controls of the county. Condition: During our reconciliation of the SEFA to the financial statements, and testing of controls, we noted material omissions from program expenditures reported. Additionally, identification of funds passed-thru to subrecipients were omitted from the county drafted SEFA. Cause: The county’s system of controls over the SEFA is lacking effective controls over completeness. Effect: Material misstatement in the preparation and disclosure of the financial statements in accordance with GAAP may not be prevented or detected. Misstatements in financial statements include not only misstated dollar amounts, but also the omission of required disclosures. Recommendations: We recommend the county develop further control procedures over drafting the SEFA to address completeness. We recommend the county develop a system of tracking federal awards and related compliance requirements to assist in accumulating information to prepare the SEFA. This deficiency is related specifically to the preparation of the SEFA and does not reflect on controls over compliance or transactional controls. Action Plan: We understand the importance of risk management and the need to address risks in an informed, cost-beneficial way. We have addressed this finding with plans to develop controls over preparing the SEFA. Specifically, we intend to track compliance requirements for all grants in a database to address internal control issues over completeness. We also intend to implement review and approval controls over the county drafted SEFA. 3. Significant Deficiency – Internal Control over Compliance with Federal Program Requirements Criteria or specific requirement (including statutory, regulatory, or other citation): The Secure Rural Schools and Community Self-Determination Act of 2000 requires a county receiving funds under the Forest Service Schools and Roads Cluster to perform an allocation of funds between Title I, II, and II under based on county court certified allocations. In the current year, that allocation included a federal sequestration of funds that was also required to be allocated to Title I and Title III, which resulted in noncompliance with the requirements related to earmarking and with special tests and provisions. Annual certification of funds spent under Title III is also required. In the current year, that certification included funds that were included in previous certifications, which resulted in noncompliance with the requirements related to reporting. Condition and context: During our review of the allocation of 2023 funds received, we noted an error in the allocation performed by the county. Title I had an overallocation of funds by $2,203, and Title III was under allocated by the same $2,203. The reconciliation of the amounts included in the 2022 annual certification for Title III funding identified an over certification of $11,303 that had already been included in the 2021 annual certification. Questioned Costs: Actual questioned costs totaled $2,203 and consisted of amounts passed through to local schools and expended in the road department on otherwise compliant uses. Cause: There is a lack of internal control over earmarking, reporting, and special tests and provisions over allocation of Forest Service Schools and Roads funding and the annual certification. The county lacks review and approval controls over the allocation of funds and the annual certification. Effect: The effect is noncompliance with earmarking, reporting, and special tests and provisions requirements. Recommendations: It is recommended that the county implement review procedures over the annual receipt to verify amounts allocated are complete and accurate prior to posting to the general ledger. A recalculation of both the certification and a detailed review of amounts used in the annual reporting is recommended. Action Plan: The county understands and concurs with this finding. It is the intention of the county to implement a review process to be completed prior to making formal allocation and reporting of Forest Service Schools and Roads Cluster.
Views of responsible officials and planned corrective actions: • Asher CHC agrees to the Auditors recommendations above in addition the CPA firm that oversees our accounting department will review monthly draws. • Prior to submitting a draw request for federal funds, a Profit and Loss by Class shoul...
Views of responsible officials and planned corrective actions: • Asher CHC agrees to the Auditors recommendations above in addition the CPA firm that oversees our accounting department will review monthly draws. • Prior to submitting a draw request for federal funds, a Profit and Loss by Class should be exported from the QuickBooks file. The total federal draw should match the total expenditures on the report for the applicable time frame. This report should be kept with the payroll reports and invoices for the draw. • Prior to submitting the Federal Financial Report, the same Profit and Loss by Class should be exported for the grant period referenced in the report. The report from QuickBooks should be reconciled to the FFR prior to submission. • As part of the monthly financial review, the CEO should review the Profit and Loss by Class from QuickBooks to verify the federal grant classes do not show a profit or a loss, unless there are timing variances. The grants are reimbursement grants, so the net income should be zero, assuming the allocation of transactions across the classes is accurate
Finding 3732 (2023-001)
Significant Deficiency 2023
Corrective Action Plan (Prepared by the Charter Holder) Finding 2023 – 001 Management has recognized the need for additional personnel to assist in ensuring compliance and accuracy with various reporting and compliance requirements. In September 2023, the Charter Holder posted a grant manager positi...
Corrective Action Plan (Prepared by the Charter Holder) Finding 2023 – 001 Management has recognized the need for additional personnel to assist in ensuring compliance and accuracy with various reporting and compliance requirements. In September 2023, the Charter Holder posted a grant manager position to support the Chief Financial Officer with state and federal reporting, budgeting, and grant compliance. While the position is vacant, the Charter Holder’s business manager is reviewing financial and compliance reports for accuracy. Management has reached out to Texas Education Agency about the reporting error and is waiting for further instructions on how to correct the reporting error. Responsible Party: Marian Hamlett, CFO Implementation Date: Immediately
2023-002 Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend that the University consider any NSLDS access and documentation requirements necessary to ensure compliance with the stated criteria. Explanation of disagreement with audit fin...
2023-002 Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend that the University consider any NSLDS access and documentation requirements necessary to ensure compliance with the stated criteria. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: As part of the University winding down operations, and no longer providing educational services, University management will consider any modifications to the NSLDS access and documentation requirements necessary to ensure compliance with the stated criteria. Name(s) of the contact person(s) responsible for corrective action: Rachel Nielsen, Vice President of Finance and Administration Planned completion date for corrective action plan: July 31, 2024
CFPP will implement the following processes to improve the accuracy in the reporting process. Management: * submitted a revised SF-425 Federal Financial Report through Fed Connect on July 13, 2023, updating Line 10f Federal share of unliquidated obligations to include the approximately $7.9 million ...
CFPP will implement the following processes to improve the accuracy in the reporting process. Management: * submitted a revised SF-425 Federal Financial Report through Fed Connect on July 13, 2023, updating Line 10f Federal share of unliquidated obligations to include the approximately $7.9 million adjustment. Scott Fox, CFO, reviewed the revised SF-425 which reconciled to the general ledger and included the year-end accrual. A copy of the revised SF-425 is available upon request. * will develop a written policy and procedure to address the preparation, reconciliation, review and approval process of the SF-425 Federal Financial Report. * will provide training to all personnel responsible for the preparation of federal financial reports to ensure that the expenditures reported in the Federal Financial Report include all accruals for expenditures and that the amount of the expenditures reported are reconciled to the expenditures included in the general ledger. * will implement a new control in which the reconciliation of the expenditures reported in the Federal Financial Report to the general ledger is reviewed by the chief financial officer.
CFPP will implement the following processes to improve the accuracy in the reporting process. Management will: * develop a written policy and procedure to address the preparation, reconciliation, review and approval process of the SF-425 Federal Financial Report. * provide training to all personnel...
CFPP will implement the following processes to improve the accuracy in the reporting process. Management will: * develop a written policy and procedure to address the preparation, reconciliation, review and approval process of the SF-425 Federal Financial Report. * provide training to all personnel responsible for the preparation of federal financial reports to ensure that the expenditures reported in the Federal Financial Report include all accruals for expenditures and that the amount of the expenditures reported are reconciled to the expenditures included in the general ledger. * implement a new control in which the reconciliation of the expenditures reported in the Federal Financial Report to the general ledger is reviewed by the chief financial officer.
Inaccurate and Untimely Return of Title IV Funds (R2T4) Planned Corrective Action: The oversight of R2T4 will be performed by the Financial Aid team. Going forward all Return of Title IV will be processed in PowerFAIDS enabling the calculation to be completed and the funds adjusted at the same tim...
Inaccurate and Untimely Return of Title IV Funds (R2T4) Planned Corrective Action: The oversight of R2T4 will be performed by the Financial Aid team. Going forward all Return of Title IV will be processed in PowerFAIDS enabling the calculation to be completed and the funds adjusted at the same time. This should eliminate the late return of funds. Person Responsible for Corrective Action Plan: Kary Tejeda, Executive Director of Financial Aid and Veteran Services, Julie Hodge-Assistant Director of Compliance Anticipated Date of Completion: January 15, 2024
View Audit 5875 Questioned Costs: $1
Finding 3696 (2023-002)
Significant Deficiency 2023
Views of Responsible Officials and Planned Corrective Actions – The Registrar's Office reports student enrollment status to the National Student Clearinghouse according to the predetermined reporting schedule based on our census dates. The University opened a case with the Clearinghouse's audit reso...
Views of Responsible Officials and Planned Corrective Actions – The Registrar's Office reports student enrollment status to the National Student Clearinghouse according to the predetermined reporting schedule based on our census dates. The University opened a case with the Clearinghouse's audit resource department to gather information on what may have led to reporting delays. The Clearinghouse has indicated there was an NSLDS outage between July 2022 and March 2023 which could have resulted in several delays, such as those noted in the audit. If future NSLDS outages are anticipated or known, the Registrar's Office will adjust our reporting practices accordingly. The Registrar's Office has created and made available a procedural guide to running and submitting reports to make sure program length and other data submitted is accurate.
Views of Responsible Officials and Planned Corrective Actions: The Association will undertake review of its procedures related to FFATA reporting and will implement additional controls to ensure timely submission of FFATA sub-award reports.
Views of Responsible Officials and Planned Corrective Actions: The Association will undertake review of its procedures related to FFATA reporting and will implement additional controls to ensure timely submission of FFATA sub-award reports.
This was a one-time grant from the Federal Emergency Management Agency in response to the college’s mitigation expenses related to the COVID-19 pandemic. Funding for this is now complete. The SEFA will be reviewed for accuracy of any new awards.
This was a one-time grant from the Federal Emergency Management Agency in response to the college’s mitigation expenses related to the COVID-19 pandemic. Funding for this is now complete. The SEFA will be reviewed for accuracy of any new awards.
The Health Center incorrectly reported patient revenue figures submitted via the HHS Provider Relief Fund (PRF) portal. Personnel Responsible for Corrective Action: Steve Davis, Chief Financial Officer Anticipated Completion Date: Change is in process and full adoption is anticipated by May 31, 202...
The Health Center incorrectly reported patient revenue figures submitted via the HHS Provider Relief Fund (PRF) portal. Personnel Responsible for Corrective Action: Steve Davis, Chief Financial Officer Anticipated Completion Date: Change is in process and full adoption is anticipated by May 31, 2023 Corrective Action Plan: While this did not lead to any additional lost revenues being made available to the Health Center, the Health Center is going to continue and improve its understanding of the guidance related to this type of reporting and work with their external advisors to ensure any future portal submissions are compliant with said guidance.
2023-001: Section 811, Assistance Listing No. 14.181 Three tenant files were selected for testing and the required documentation to determine eligibility, as required by the HUD regulations, could not be located as follows: • Two of the files were missing Form HUD-50059, Owner’s Certification of Com...
2023-001: Section 811, Assistance Listing No. 14.181 Three tenant files were selected for testing and the required documentation to determine eligibility, as required by the HUD regulations, could not be located as follows: • Two of the files were missing Form HUD-50059, Owner’s Certification of Compliance. Recommendation: We recommend the Corporation establish procedures to ensure that the annual recertifications are completed on a timely basis in accordance with HUD requirements. Action Taken: Management agrees with the recommendation and the Corporation’s Board of Directors has made the decision to change property managing agents effective January 1, 2024. It is anticipated that the change to a new property managing agent will allow the Corporation to establish procedures to ensure all recertifications are performed and maintained in accordance with the regulatory agreement. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Dr. Seanelle Hawkins at (585) 325-6530.
2023-001: Section 202, Assistance Listing No. 14.157 One tenant file was selected for testing and the required documentation to determine eligibility, as required by HUD regulations, could not be located as follows: • The file was missing Form HUD-50059, Owner’s Certification of Compliance. Recommen...
2023-001: Section 202, Assistance Listing No. 14.157 One tenant file was selected for testing and the required documentation to determine eligibility, as required by HUD regulations, could not be located as follows: • The file was missing Form HUD-50059, Owner’s Certification of Compliance. Recommendation: We recommend the Corporation establish procedures to ensure that the annual recertifications are completed on a timely basis in accordance with HUD requirements. Action Taken: Management agrees with the condition and the Corporation’s Board of Directors has made the decision to change property managing agents effective January 1, 2024. It is anticipated that the change to a new property managing agent will allow the Corporation to establish procedures to ensure all recertifications are performed and maintained in accordance with the regulatory agreement. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Seanelle Hawkins at 585-325-6530.
2023-001: Section 811, Assistance Listing No. 14.181 One tenant file was selected for testing. However, this tenant file could not be located. As a result, the following documentation could not be located to determine eligibility, as required by HUD regulations: • Form HUD-50059, Owner’s Certificati...
2023-001: Section 811, Assistance Listing No. 14.181 One tenant file was selected for testing. However, this tenant file could not be located. As a result, the following documentation could not be located to determine eligibility, as required by HUD regulations: • Form HUD-50059, Owner’s Certification of Compliance • A completed and signed application • The signed lease agreement • The move-in and move-out inspection forms Recommendation: We recommend the Corporation establish procedures for maintaining tenant files to comply with HUD requirements for verification of tenant information, as required. Action Taken: Management agrees with the recommendation and the Corporation’s Board of Directors has made the decision to change property managing agents effective January 1, 2024. It is anticipated that the change to a new property managing agent will allow the Corporation to establish procedures to ensure all tenant files are properly maintained to comply with HUD regulations. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Seanelle Hawkins at 585-325-6530.
2023-001: Section 202, Assistance Listing No. 14.157 Two tenant files were selected for testing and the required documentation to determine eligibility, as required by the HUD Regulatory Agreement, could not be located as follows: • One file was missing Form HUD-50059, Owner’s Certification of Compl...
2023-001: Section 202, Assistance Listing No. 14.157 Two tenant files were selected for testing and the required documentation to determine eligibility, as required by the HUD Regulatory Agreement, could not be located as follows: • One file was missing Form HUD-50059, Owner’s Certification of Compliance Recommendation: We recommend the Corporation establish procedures to ensure that the annual recertifications are performed on a timely basis in accordance with HUD requirements. Action Taken: Management agrees with the recommendation and the Corporation’s Board of Directors has made the decision to change property managing agents effective January 1, 2024. It is anticipated that the change to a new property managing agent will allow the Corporation to establish procedures to ensure all recertifications are performed and maintained in accordance with the regulatory agreement. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Seanelle Hawkins at 585-325-6530.
2023-001: Section 202, Assistance Listing No. 14.157 Two tenant files were selected for testing and the required documentation to determine eligibility, as required by the HUD Regulatory Agreement, could not be located as follows: • One file was missing Form HUD-50059, Owner’s Certification of Compl...
2023-001: Section 202, Assistance Listing No. 14.157 Two tenant files were selected for testing and the required documentation to determine eligibility, as required by the HUD Regulatory Agreement, could not be located as follows: • One file was missing Form HUD-50059, Owner’s Certification of Compliance Recommendation: We recommend the Corporation establish procedures for maintaining tenant files to comply with HUD requirements for verification of tenant information, as required. Action Taken: Management agrees with the recommendation and the Corporation’s Board of Directors has made the decision to change property managing agents effective January 1, 2024. It is anticipated that the change to a new property managing agent will allow the Corporation to establish procedures to ensure all recertifications are performed and maintained in accordance with the regulatory agreement. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Seanelle Hawkins at 585-325-6530.
Finding 3670 (2023-001)
Significant Deficiency 2023
The District will implement controls in its meal claim process to ensure that student meals claimed for reimbursement equal student meals served. The Food Service Supervisor and/or Food Service Administrative Assistant will create a summary meal count sheet each month totaling the number of student ...
The District will implement controls in its meal claim process to ensure that student meals claimed for reimbursement equal student meals served. The Food Service Supervisor and/or Food Service Administrative Assistant will create a summary meal count sheet each month totaling the number of student meals seved based on the electronic and manual meal count sheets prior to submitting the meal claim in the Michigan Nutrition Data System (MiND). The monthly meal claim submitted will be filed with the supporting documentation an dsigned by the individual submitting the claim attesting that the meals claimed match the meals counted.
View Audit 5732 Questioned Costs: $1
Name of Responsible Individual: Jason Byrd, University Registrar Liberty acknowledges that there was one instance in which a student’s enrollment status was not reported within compliance timeframes. Additionally, Liberty recognizes that there were multiple months in the year in which there were re...
Name of Responsible Individual: Jason Byrd, University Registrar Liberty acknowledges that there was one instance in which a student’s enrollment status was not reported within compliance timeframes. Additionally, Liberty recognizes that there were multiple months in the year in which there were repeat errors found in the SSCR error file. Corrective Action: Liberty University continues to work to ensure the enrollment reporting process is handled compliantly and within allowable timeframes. There were multiple errors that were proactively addressed with National Student Clearinghouse (NSC) as Liberty was unable to resolve them internally. This was one of the contributing factors in having multiple months of repeat errors as NSC did not resolve. We will continue to work with NSC to resolve timing issue that result in errors outside of compliance timeframes. Additionally, the Registrar’s Office will work with ADS Academics to review the standard report used through Ellucian’s Banner to report student enrollment status to NSC. The goal of this review will be to better identify the source of errors and reduce error count for future submissions. Finally, over the last year, Liberty’s Financial Aid Office has hired an employee whose primary focus will be to provide an additional Quality Control (QC) process for enrollment reporting. This employee will work collaboratively with the Registrar’s Office to ensure roster errors and student enrollment level changes are resolved and reported within the permissible timeframes. While this position has been filled, we have been limited by the U.S. Department of Education’s National Student Loan Data System (NSLDS), as they transitioned to a new system and reporting used for this QC process was not released until July of 2023 and was not functional until September 2023 due to run-time errors that went unresolved. Liberty reached out to the U.S. Department of Education on multiple occasions (Case# 220920-00436 and Case# 230718-000084) in order to obtain a working report. Anticipated Completion Date: March 2024
FINDING SYNOPSIS: During audit testing of the expenditure reimbursement request reports, it was noted the accounting records established for accounting for ESSER grants funding did not match the reimbursement request reports. ACTION STEPS: Grant expenditure reports will be reconciled to accountin...
FINDING SYNOPSIS: During audit testing of the expenditure reimbursement request reports, it was noted the accounting records established for accounting for ESSER grants funding did not match the reimbursement request reports. ACTION STEPS: Grant expenditure reports will be reconciled to accounting records for the time period of the expenditure report and for the grant project in its entirety prior to the filing of each expenditure report. CONTACT PERSON(S): Kerry Herdes, Superintendent and Virginia Keen, Bookkeeper. ANTICIPATED COMPLETION DATE: September 1, 2023.
#2023-003 Significant Deficiency in internal controls and noncompliance related to reporting: The District did not have adequate internal controls over meal claiming process and as a result, errors were made and not detected. Recommendation: Personnel need to be assigned to provide a second rev...
#2023-003 Significant Deficiency in internal controls and noncompliance related to reporting: The District did not have adequate internal controls over meal claiming process and as a result, errors were made and not detected. Recommendation: Personnel need to be assigned to provide a second review of the meal counts. Ideally, software would be used to avoid human error in tallying. Action Taken: Since May of 2023, the Bandon School District has used Mealtime to avoid human error in tallying. The Food Services Director reviews these numbers monthly to ensure accuracy.
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