Corrective Action Plans

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Audit Firm: RSM US LLP 30 South Wacker Drive, Suite 3300 Chicago, IL 60606 Audit Period: 07/01/2022 – 06/30/2023 Contract Number: FSCWJ00302 Award Year: 2022 – 2023 Comments on Findings and Recommendations: Finding 2023-001—Certification over payroll cost allocation (Control Finding)— Envision Un...
Audit Firm: RSM US LLP 30 South Wacker Drive, Suite 3300 Chicago, IL 60606 Audit Period: 07/01/2022 – 06/30/2023 Contract Number: FSCWJ00302 Award Year: 2022 – 2023 Comments on Findings and Recommendations: Finding 2023-001—Certification over payroll cost allocation (Control Finding)— Envision Unlimited allocated staff salaries and related fringe benefits to the federal program based on budgeted estimates, which were determined before the services were provided. There was no employee certification or documented review of actual time and effort incurred for the payroll costs charged to the grant at the time audit procedures were performed. 2 CFR 200.430(i) Standards for Documentation of Personnel Expenses (1) Charges to federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. Budget estimates (i.e., estimates determined before the services are performed) alone do not qualify as support for charges to federal awards, but may be used for interim accounting purposes, provided that the non-federal entity's system of internal controls includes processes to review after-the-fact interim charges made to a federal award based on budget estimates. All necessary adjustments must be made such that the final amount charged to the federal award is accurate, allowable, and properly allocated. Action Taken- Employee certifications were obtained and reviewed by supervisors for all grant payroll costs charged during the award year and were provided to the auditors. A new process is in place for quarterly certifications to follow 2CFR 200.430(i). The required corrective action for Finding 2023-001 for the period 07/01/2022 – 06/30/2023 was completed in December 2023. The person now responsible for completion of the corrective action plan is Dennis James, Chief Financial Officer.
Finding No. 2023-003 Management Response: Management agrees with findings. This was discussed by our Fiscal Manager with the Agency during a meeting on November 15, 2022. The period between our month end close procedures and the report deadlines is to short considering an AUP needs to be performed b...
Finding No. 2023-003 Management Response: Management agrees with findings. This was discussed by our Fiscal Manager with the Agency during a meeting on November 15, 2022. The period between our month end close procedures and the report deadlines is to short considering an AUP needs to be performed before each submission. However, we have taken some actions to advance some of the program information to comply. The report scheduled for January 2024 was submitted on time. Corrective Action Plan:  Management has been reviewing the procedures and identifying steps that can be performed before month end closing.  A formal extension request will be submitted at the renewal of the award. Contact Person: Roxana Rivera Manuel Joglar Team: Fiscal Manager, Fiscal Agent, Program leaders. Anticipated Completion Date: Next report deadline May 17, 2024
The Authority will perform an internal review of the toll credits usage Excel spreadsheet and will reconcile all credits used by the projects with a starting date in FY 2023 and later with the last version of the Federal-Aid Project Agreement approved by FHWA. Also, the credits summary will be deliv...
The Authority will perform an internal review of the toll credits usage Excel spreadsheet and will reconcile all credits used by the projects with a starting date in FY 2023 and later with the last version of the Federal-Aid Project Agreement approved by FHWA. Also, the credits summary will be delivered on a quarterly basis to the Executive Staff for the approval process. For the fiscal year 2024, the manual process of reconciling toll credits balance of the new projects with a starting date of January 2024 and later will be changed to an automated process with the PMIS Program, as agreed in Section II of the Memorandum of Understanding (MOU) signed in February 2016 between FHWA and the Authority. In addition, current toll credits tracking, reconciliation, and approval processes are reviewed by FHWA PR Division for compliance. Responsible: Mr. Enrique J. Rosa Torres, Budget Office Auxiliary Director Status: In process. Expected to be completed on or before June 30, 2025.
Corrective Action Plan: The Authority assigned an Analyst and a Supervisor the responsibility to monitor compliance with all related Federal requirements for the reporting process of these funds. Also, an adequate training was provided to the personnel involved in the administration of this program....
Corrective Action Plan: The Authority assigned an Analyst and a Supervisor the responsibility to monitor compliance with all related Federal requirements for the reporting process of these funds. Also, an adequate training was provided to the personnel involved in the administration of this program. Responsible: Mr. Ramon L. Rivera Rivera, Analyst Mr. Enrique J. Rosa Torres, Budget Office Auxiliary Director Status: Completed on June 30, 2023.
Corrective Action Plan: The Authority will develop a new procedure to ensure compliance with these reporting requirements. All personnel involved in the administration of these programs for which federal funds are expended should receive adequate training about federal compliance and reporting requi...
Corrective Action Plan: The Authority will develop a new procedure to ensure compliance with these reporting requirements. All personnel involved in the administration of these programs for which federal funds are expended should receive adequate training about federal compliance and reporting requirements related to such programs. In addition, an individual should be assigned with the responsibility to monitor compliance with all related federal requirements. These procedures will also include a quarterly reconciliation of amounts reported between the Schedule of Federal Awards with the trial balance. Responsible: Mr. Angel M. Felix Cruz, Finance Office Auxiliary Director Ms. Maria Del R. Ramos Ocasio, Accounting and Finance Manager Status: In process. Expected to be completed on or before December 31, 2024.
Management’s response - New management in place starting in February 2023 will ensure that the Town reviews and correctly separates these items going forward.
Management’s response - New management in place starting in February 2023 will ensure that the Town reviews and correctly separates these items going forward.
Management’s response - New management in place starting in February 2023 will ensure that the Town reviews and correctly reports federal expenditures on the Schedule of Expenditures of Federal Awards moving forward.
Management’s response - New management in place starting in February 2023 will ensure that the Town reviews and correctly reports federal expenditures on the Schedule of Expenditures of Federal Awards moving forward.
Material Weakness in Internal Control over Compliance Condition: The Town did not submit the required SLFRF Project and Expenditure Report Due April 30, 2023 on time. Recommendation: The Town review grant award documents thoroughly and set up processes and procedures in place to ensure reporting r...
Material Weakness in Internal Control over Compliance Condition: The Town did not submit the required SLFRF Project and Expenditure Report Due April 30, 2023 on time. Recommendation: The Town review grant award documents thoroughly and set up processes and procedures in place to ensure reporting requirements to the awarding agency are completely accurately and timely based on grant requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Town has begun a full review of all grants, especially those received in prior administrations and pre-hire of the current CFO, to assure the compliance of reporting requirements are complete accurate and will be timely reported as stated in the grant requirements. Contact person: Dawn Norton Responsible for corrective action: Dawn Norton, CFO Planned completion date for corrective action plan: March 2024
Finding 391171 (2023-004)
Significant Deficiency 2023
Finding 2023-004 Reporting Identification of the federal program: Federal Grantor: United States Department of Homeland Security Pass-Through Grantor: State of Missouri, State Emergency Management Agency Assistance Listing No.: 97.036, COVID-19 Disaster Grants – Public Assistance (Presidentially D...
Finding 2023-004 Reporting Identification of the federal program: Federal Grantor: United States Department of Homeland Security Pass-Through Grantor: State of Missouri, State Emergency Management Agency Assistance Listing No.: 97.036, COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) (“FEMA”) Pass-Through Award Numbers: Project# 699963 P/W# 624; Project# 185883 P/W# 529; and Project# 150136 P/W# 171 Condition: Timeliness and submission of the quarterly reports required by the State of Missouri could not be verified. Views of Responsible Officials and Planned Corrective Actions: The state of Missouri requires all quarterly reports be mailed. While we did send in our quarterly reports to the state of Missouri as required, we do not have proof of submissions as we did not send by certified mail. All future quarterly reporting will be documented with an email to our State SEMA representative when we send out quarterly reports so there is documentation for our records. Responsible Party: Emily Bruening, Director – Finance Date of Completion: This will be implemented for our next round of quarterly reporting, due in April 2024.
Finding 391169 (2023-002)
Significant Deficiency 2023
Finding 2023-002 Reporting Information on the federal program: Federal Grantor: United States Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498, COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distrib...
Finding 2023-002 Reporting Information on the federal program: Federal Grantor: United States Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498, COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (“PRF”) Payment Received Period: 01/01/2020–12/31/2022 (Period 4) and 01/01/2020–06/30/2023 (Period 5) Condition: For one of the sampled PRF reports (Mercy Hospital South Period 5 PRF Report), the amount reported for net patient service revenue (NPSR) for calendar year 2023 quarter 2 (CY2023 Q2) was incorrect for one reporting tax identification number (TIN). Views of Responsible Officials and Planned Corrective Actions: One cost report adjustment for the current year was inaccurately labeled as a prior year adjustment. This was an isolated oversight by our revenue analysis team. We will perform additional review of cost report adjustments used for PRF funding to ensure the amounts reported are accurate and in compliance with the terms of the agreement. Responsible Party: Kathryn Stecich, Executive Director, Revenue Cycle Date of Completion: By 6/30/24
FINDING 2023-8- Untimely Enrollment Status Reporting The Institute had not processed May 1 roster by the 5/15/23 deadline. A.Comments on Findings and Recommendations: The Institute agrees with the finding and Auditor's recommendation. B.Actions Taken or Planned OIAH has now moved to a new SIS system...
FINDING 2023-8- Untimely Enrollment Status Reporting The Institute had not processed May 1 roster by the 5/15/23 deadline. A.Comments on Findings and Recommendations: The Institute agrees with the finding and Auditor's recommendation. B.Actions Taken or Planned OIAH has now moved to a new SIS system that is able to batch upload under the NSLDS ERR report. This system has been in effect since 9/2023. crediting $3,569 to the students' accounts that were affected. Signed Betsy Bremke, Administrative Campus Director Date: _3/29/2024__
FINDING 2023-4- Untimely Paid and Unpaid Credit Balances The Institute had Untimely Paid and Unpaid Credit Balances while Participating under the Zone Alternative and the Heightened Cash Monitoring 1 Payment Method A.Comments on Findings and Recommendations: The Institute agrees with the finding and...
FINDING 2023-4- Untimely Paid and Unpaid Credit Balances The Institute had Untimely Paid and Unpaid Credit Balances while Participating under the Zone Alternative and the Heightened Cash Monitoring 1 Payment Method A.Comments on Findings and Recommendations: The Institute agrees with the finding and Auditor's recommendation. B.Actions Taken or Planned We have revised the process of student stipends ofdisbursements. Each student whose account receives a disbursement whom results in a credit balance, will be given stipend prior to any draw down. We shall also make process and procedures with new third-party servicer to ensure stipend is sent prior to drawdown. Signed Betsy Bremke, Administrative Campus Director Date: _3/29/2024__
View Audit 301753 Questioned Costs: $1
Finding 391130 (2023-002)
Significant Deficiency 2023
Finding Reference Number: SA2023-002 - Federal Funding Accountability and Transparency Act (FFATA) Reporting Assistance Listing Number: 14.218 Assistance Listing Title: Community Development Block Grant – Entitlement Grant COVID-19 - Community Development Block Grants/ Entitlement Grants-CV ...
Finding Reference Number: SA2023-002 - Federal Funding Accountability and Transparency Act (FFATA) Reporting Assistance Listing Number: 14.218 Assistance Listing Title: Community Development Block Grant – Entitlement Grant COVID-19 - Community Development Block Grants/ Entitlement Grants-CV Name of Federal Agency: Department of Housing and Urban Development Federal Award Identification Number: B-22-MC-06-0009 COVID-19 – B-20-MW-06-0009 • Fiscal Year of Initial Finding: 2022 • Name(s) of the contact person: Leng Powers • Corrective Action Plan: In April 2023, City staff received training on the FFATA website and reporting requirements. After review of the website, the website's requirements, and the FFATA reporting requirements, City staff assigned reporting roles to individuals in Housing and Finance to report within 30 days of executing agreements of $30,000 with sub-recipients. During Fiscal Year 2022/23, the City entered into contract with (3) sub-recipients for awards over $30,000. These contracts were officially executed in December2022/January 2023. The City has been working to obtain the UEI and other miscellaneous reporting information from the sub-recipients in order to complete the required FFATA report for FY2022-23. Going forward, the City will require the FFATA information to be included in the sub-awardee prior to executing the grant award. • Anticipated Completion Date: June 30, 2024
Identifying Number: 2023-002: U.S. Department of Education: Education Stabilization Fund: Student Aid Portion – 84.425E; Institutional Portion – 84.425F Finding: Three of the four required quarterly reports were not posted to the District’s website in a timely manner. In addition, there was no revie...
Identifying Number: 2023-002: U.S. Department of Education: Education Stabilization Fund: Student Aid Portion – 84.425E; Institutional Portion – 84.425F Finding: Three of the four required quarterly reports were not posted to the District’s website in a timely manner. In addition, there was no review of quarterly or annual HEERF reports prior to their submission. Corrective Action Taken or Planned: STC will implement a master calendar that will establish and publish deadlines for reporting requirements prior to their respective submission dates. Additionally, STC will explore training staff and delegating responsibility for report preparation to other Finance and Operation positions to allow the Vice President – Finance and Operations to provide oversight and guidance in report preparation and to review reports prior to submission. Contact person: Rich Kluin, Vice President – Finance and Operations, Southeast Technical College Status of finding – The above corrective actions will be implemented beginning July 1, 2024.
Identifying Number: 2023-005: U.S. Department of Education: Student Financial Aid Cluster – 84.268, Federal Direct Student Loans Finding: The following instances were identified during testing of enrollment reporting: 7 instances in which a student’s status change was certified outside the 60-day re...
Identifying Number: 2023-005: U.S. Department of Education: Student Financial Aid Cluster – 84.268, Federal Direct Student Loans Finding: The following instances were identified during testing of enrollment reporting: 7 instances in which a student’s status change was certified outside the 60-day reporting requirement, 7 instances in which a student’s status change was not reported within 60 days to the National Student Loan Data System (NSLDS) nor included in reporting to the National Student Clearinghouse (NSC), and 2 instances in which a student’s program start date reported in NSLDS did not agree with student records. Corrective Action Taken or Planned: The STC Financial Aid Office and Registrar will work to develop a process to review errors in the three systems that are involved in enrollment status reporting and identify any solutions. A common folder for submittal rosters will be shared between the offices so that they may also be reviewed for accuracy. National Student Clearinghouse issue notifications will also be kept on file for future reference. Contact person: Rich Kluin, Vice President – Finance and Operations, Southeast Technical College Status of finding – The above corrective actions will be implemented beginning July 1, 2024.
Finding 391119 (2023-008)
Significant Deficiency 2023
The Department established policies and procedures to ensure evidence of an independent review is documented by the reviewer and date of the review prior to submission, within the reporting deadline. The ETA 2208A report will be reviewed by the Chief Financial Officer or Comptroller and will be evid...
The Department established policies and procedures to ensure evidence of an independent review is documented by the reviewer and date of the review prior to submission, within the reporting deadline. The ETA 2208A report will be reviewed by the Chief Financial Officer or Comptroller and will be evidenced by email approval prior to any future ETA 2208A submissions to the ETA. The Department began this process September 2023.
Finding 391117 (2023-007)
Significant Deficiency 2023
and retrain as necessary to follow existing policies and procedures to ensure variances identified during the reconciliation process are corrected. The Department is also modifying policies and procedures related to the ETA 2112 report. In addition, management will review ETA 2112 reports for accu...
and retrain as necessary to follow existing policies and procedures to ensure variances identified during the reconciliation process are corrected. The Department is also modifying policies and procedures related to the ETA 2112 report. In addition, management will review ETA 2112 reports for accuracy and to identify if an amended report should be filed
Finding 391115 (2023-006)
Significant Deficiency 2023
Procedures have been established for transmitting the ETA 9050, 9052 and 9055 reports. Included in the procedures are where to retain the supporting data file and review of the report by the Division Administrator or Deputy Division Administrator prior to final transmission. The report must be retur...
Procedures have been established for transmitting the ETA 9050, 9052 and 9055 reports. Included in the procedures are where to retain the supporting data file and review of the report by the Division Administrator or Deputy Division Administrator prior to final transmission. The report must be returned with a signature and date prior to submitting the finalized reports to the Department of Labor within the reporting deadline
Finding 391113 (2023-005)
Significant Deficiency 2023
A policy and procedure has been established for reporting and filing the ETA 191. Included in the procedure is a requirement to submit the report to the Chief Financial Officer or Comptroller for review and approval. Evidence of review and transmittal is documented via email confirmation to the Acco...
A policy and procedure has been established for reporting and filing the ETA 191. Included in the procedure is a requirement to submit the report to the Chief Financial Officer or Comptroller for review and approval. Evidence of review and transmittal is documented via email confirmation to the Accountant 3 responsible for preparing the ETA 191. Review and approval of the ETA 191 is required to be completed prior to the reports due date. After transmittal to DOL of the ETA 191; a copy with supporting documentation is made available to the Unemployment Division Administrator
Finding 391107 (2023-002)
Significant Deficiency 2023
The Department will review allocable rates during the time frame to determine if corrective disbursement entries are needed to their respective program codes. The Department began the process in October 2023. The Department will also revise, and update policies and procedures related to allocable c...
The Department will review allocable rates during the time frame to determine if corrective disbursement entries are needed to their respective program codes. The Department began the process in October 2023. The Department will also revise, and update policies and procedures related to allocable costs based on time entries.
Finding 391105 (2023-001)
Significant Deficiency 2023
The Department has implemented a payroll policy and procedure, that requires staff to enter a work reporting code for time worked and addresses timelines in which correcting entries must be completed. The Department will review all pay periods during the time frame to determine if corrective disburs...
The Department has implemented a payroll policy and procedure, that requires staff to enter a work reporting code for time worked and addresses timelines in which correcting entries must be completed. The Department will review all pay periods during the time frame to determine if corrective disbursement entries need to be made to properly allocate actual time reported to their respective program codes. The Department began the process in October 2023.
Finding 391081 (2023-002)
Material Weakness 2023
Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Funds and American Rescue Plan (ARP) Rural Distribution Preparation of the Consolidated Schedule of Expenditures of Federal Awards Material Weakness in Internal Control over Compliance - Ot...
Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Funds and American Rescue Plan (ARP) Rural Distribution Preparation of the Consolidated Schedule of Expenditures of Federal Awards Material Weakness in Internal Control over Compliance - Other Finding Summary: Management prepared the Schedule for the year ended June 30, 2023. During the audit process, changes were proposed to increase the amount reported related to the COVID-19 Provider Relief Funds and American Rescue Plan (ARP) Rural Distribution programs. Responsible Individuals: Jamie Schaefer, John Neth Corrective Action Plan: The Organization will review and strengthen the controls surrounding the preparation of the Consolidated Schedule of Expenditures of Federal Awards. There are no questioned costs related to this finding. The Organization is hiring additional financial staff in which the position duties are focused on reporting with an emphasis on the Consolidated Schedule of Expenditures of Federal Awards specifically. Additionally, the Organization is in the process of implementing a new enterprise resource planning software which will include a grant module. The Organization is working with the software staff to develop an automated Consolidated Schedule of Expenditures of Federal Awards that will be imbedded in the software module. Anticipated Completion Date: October 1, 2024
Department of Health and Human Services Federal Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Reporting Material Weakness in Internal Control Over Compliance and Material Noncompliance Finding Summary: The Hospital selection the Actual R...
Department of Health and Human Services Federal Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Reporting Material Weakness in Internal Control Over Compliance and Material Noncompliance Finding Summary: The Hospital selection the Actual Revenue Option (i.e., Option 1) in the HHS Special Report. Option 1 is based on actual quarterly net revenues by payor which are included in the HHS Special Report -Period 4 for years 2019 through 2022. However, management calculated the net revenues using various allocations due to reporting limitations within the accounting and billing system and did not use the actual quarterly financial statements to complete the HHS Special Report. The calculation used by management would be considered an Alternative Reasonable Methodology (i.e., Option 3). The selection of Option 1 was improperly reported within the HHS Special Report – Period 4 which caused the report to be inaccurate. In addition, for Quarter 3 and Quarter 4 of 2021, the amounts reported on the HHS Special Report do not agree to the related client support by $168,838 and $157,009, respectively. In both cases, the support indicated a higher amount of revenue. It should be noted that no lost revenue was reported for Quarter 3 and Quarter 4 in 2021, so there was no impact to the lost revenue calculation. In addition, lost revenue was not used to support the provider relief fund amounts claimed by the Hospital in the HHS Special Report – Period 4 as the Hospital had eligible expenditures to support the amount of provider relief funds claimed. Responsible Individuals: Lynn Broyles, CFO Corrective Action Plan: The Hospital will update the selection for lost revenue on the Report to option 3 and will include a lost revenue calculation narrative on the next Special Report that is required to be filed for Provider Relief Funds. Anticipated Completion Date: June 30, 2024
United States Department of Agriculture Federal Assistance Listing #10.766 Community Facilities Loans and Grants Cluster Department of Health and Human Services Federal Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Preparation of Schedul...
United States Department of Agriculture Federal Assistance Listing #10.766 Community Facilities Loans and Grants Cluster Department of Health and Human Services Federal Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Preparation of Schedule of Expenditures of Federal Awards Material Weakness in Internal Control Over Compliance – Other Finding Summary: The Hospital does not have an internal control system designed to provide for a complete and accurate schedule of expenditures of federal awards being audited. We were requested to draft the Schedule. Responsible Individuals: Lynn Broyles, CFO Corrective Action Plan: Having auditors assist with preparing the SEFA is not unusual. Due to the delays in obtained the guidance to conduct the compliance audit for the Provider Relief Funds, this finding would generally be included as part of the financial statement audit under Government Auditing Standards (Yellowbook). As the financial statement audit had been issued prior to the compliance audit being completed, this finding needed to be identified separately. Anticipated Completion Date: Ongoing
Condition: The District submitted all quarterly expenditure reports late per ISBE requirements. Plan: The District established policies and procedures regarding timely grant expenditure report submissions. These policies and procedures are trained on with staff and enforced to ensure compliance. Dat...
Condition: The District submitted all quarterly expenditure reports late per ISBE requirements. Plan: The District established policies and procedures regarding timely grant expenditure report submissions. These policies and procedures are trained on with staff and enforced to ensure compliance. Date of Completion: February 14, 2024. Name of Contact Person: Dennis Forst, Assistant Superintendent of Business & Operations. Management Response: Management concurs with the finding and has developed applicable procedures.
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