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Corrective Action Plans

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Good Shepherd Food Bank of Maine
ME
Reporting
Criteria: Management was responsible for submitting a timely report based on terms of grant agreement. Condition: During our compliance testing, it was identified that required a Project and Expenditure Report was not submitted timely. Context: The required Project and Expenditure Report was not s...
Criteria: Management was responsible for submitting a timely report based on terms of grant agreement. Condition: During our compliance testing, it was identified that required a Project and Expenditure Report was not submitted timely. Context: The required Project and Expenditure Report was not submitted timely based on terms of grant agreement. Effect: As a result of the condition, GSFB required reporting was not submitted timely based on terms of the grant agreement. Cause: Management has processes and controls over the reporting process, however, these were not updated to reflect the correct due date of the required report per the grant agreement. Recommendation: In the future, GSFB should ensure it implements appropriate processes and controls to ensure a required report is filed timely in accordance with terms of the grant agreement. Views of Responsible Officials: Management acknowledges the finding. During the year under review, Harvesting Good entered into a contract with a grant administrator who now manages all grant reporting. Management is confident that all reports will be submitted in a timely manner for the foreseeable future.
View Audit 5441
Finding 3468 (2023-101)
Significant Deficiency 2023
Good Shepherd Food Bank of Maine
ME
Questioned Costs Reporting School Nutrition Programs
USDA Foods Receipts: Criteria: Evidence of distribution in the form of signed invoices for USDA Foods is required to be maintained for CSFP and TEFAP. Evidence of receipt of USDA foods should be maintained to ensure compliance with the award. Condition: Signed invoices evidencing USDA food distri...
USDA Foods Receipts: Criteria: Evidence of distribution in the form of signed invoices for USDA Foods is required to be maintained for CSFP and TEFAP. Evidence of receipt of USDA foods should be maintained to ensure compliance with the award. Condition: Signed invoices evidencing USDA food distributed were not retained. Context: Our sample of 25 distributions of USDA Foods included two instances where invoices were not properly signed and one instance where the invoice was not retained. Known and likely questioned costs are unknown. Effect: GSFB runs the risk that improper distribution will not be prevented without appropriate document retention. Cause: In all three instances, administrative issues resulted in the untimely lack of retention of signed invoices. Recommendation: We recommend that GSFB reinforce the importance of retaining signed invoices in accordance with award requirements. GSFB should further assign an individual within their organization to assume a higher level of direct responsibility for the administration of federal awards by GSFB. Contact: Bryan O'Connor, VP, Finance & Administration Corrective Actions Taken or Planned: GSFB staff audit sales order paperwork in connection with product received from Maine Department of Agriculture, Conversation, and Forestry. The audit consists of running a list of any outbound order that had DACF allocated inventory on it, comparing that list to returned paperwork, and confirming that said paperwork was signed. For any agency paperwork that can not be located and/or is not signed, a follow-up email is sent to the specific partner requesting a signature. In June 2023, GSFB staff increased the frequency of auditing from monthly to weekly, allowing a more timely follow-up on any paperwork concerns. The Customer Service and Inventory Management teams share responsibility for auditing and follow-up.
View Audit 5441
Gustavus Adolphus College
MN
Student Financial Aid Reporting Questioned Costs
Condition: The College did not submit accurate and timely notification to the National Student Loan Data System (NSLDS) of student status changes and program-level enrollment data. Corrective Action: Because of the breach at the Clearinghouse, the College intentionally delayed its submission to the...
Condition: The College did not submit accurate and timely notification to the National Student Loan Data System (NSLDS) of student status changes and program-level enrollment data. Corrective Action: Because of the breach at the Clearinghouse, the College intentionally delayed its submission to the Clearinghouse to ensure its student data would not be compromised. The College’s policies and procedures are adequate to meet the 60 day requirement for reporting student status changes under normal circumstances. The College has reviewed the misreporting of one student’s campus and program-level record information and has determined that this is a unique circumstance. However, to strengthen its policies and procedures, a new form is being developed to properly document the timing of student enrollment changes to the Registrar. The document will be retained in the student’s file. Person Responsible For Corrective Action: Deann Schloesser, Registrar Anticipated Completion Date: October 2023
View Audit 5440
Finding 3465 (2023-002)
Significant Deficiency 2023
McPherson College
KS
Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties
We concur with the auditor’s finding. We have reviewed our processes related to the enrollment reporting of withdrawing students. The financial aid department has added a column in the tracking document to record the effective withdrawal date from NSLDS. On a weekly basis, the withdrawal dates from ...
We concur with the auditor’s finding. We have reviewed our processes related to the enrollment reporting of withdrawing students. The financial aid department has added a column in the tracking document to record the effective withdrawal date from NSLDS. On a weekly basis, the withdrawal dates from NSLDS will be compared to the withdrawal dates per the financial aid records to ensure the two dates are the same. Contact Person Responsible for Corrective Action: Andy Olsen, Director of Financial Aid; Rhianna Reed, Assistant Registrar Anticipated Completion Date: Corrective action was completed in October.
View Audit 5437
Finding 3407 (2023-001)
Significant Deficiency 2023
Northwestern College
IA
Student Financial Aid Reporting Significant Deficiency
2023-001 Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the College review its reporting procedures to ensure that students’ statuses are accurately and timely reported to National Student Loan Data System (NSLDS) as required by regulations. Explan...
2023-001 Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the College review its reporting procedures to ensure that students’ statuses are accurately and timely reported to National Student Loan Data System (NSLDS) as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: After being alerted to the finding, the Registrar changed the submission dates to the National Student Clearinghouse (NSC) to allow more time for the NSC to timely report to the NSLDS. The Registrar’s Office will notify the Business Office when files have been submitted to the NSC. The Business Office will periodically monitor the NSLDS system and alert the Registrar of their observations. Name(s) of the contact person(s) responsible for corrective action: Austin Nyhof, Registrar Planned completion date for corrective action plan: June 30, 2024
View Audit 5338
Finding 3405 (2023-003)
Material Weakness 2023
Brodstone Memorial Hospital D/b/a Brodstone Healthcare and Affiliate
NE
Allowable Costs / Cost Principles Questioned Costs Cash Management § 200.303
Material Weakness: Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the feder...
Material Weakness: Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. The Hospital claimed reimbursement for health-related lost revenue during the COVID-19 pandemic. Condition: The Hospital claimed reimbursement for health-related lost revenue based on a comparison of actual monthly revenue for the months of March, April, and May 2020 to the same corresponding months of 2019. Within the calculation, the Hospital excluded certain other operating revenue from the 2020 monthly totals which were included in the 2019 monthly totals. As a result, the compilation of revenue used between the periods was not consistently applied resulting in a higher lost revenue calculation than prescribed by the applicable guidance. Views of Responsible Officials: Management agrees with the finding. Planned Completion Date: April 30, 2024. Person Responsible: Cyrstal Wyatt, CFO.
View Audit 5310 Questioned Costs: $1
Finding 3404 (2023-001)
Significant Deficiency 2023
Alabama Hospital Association
AL
Cash Management Reporting Significant Deficiency § 200.302 § 200.303
Corrective Action Plan: AlaHA will accomplish the following: 1) Send guidance to hospital systems with multiple facilities reported on their 941s that they should retain general ledger detail reconciliations to support the funds received. 2) Request the hospital involved in the exception cited fo...
Corrective Action Plan: AlaHA will accomplish the following: 1) Send guidance to hospital systems with multiple facilities reported on their 941s that they should retain general ledger detail reconciliations to support the funds received. 2) Request the hospital involved in the exception cited for not having submitted general ledger evidence submit additional support for the reconciliation they submitted. 3) Should a similar tranche of funds become available in the future, AlaHA will ensure disbursements are not made before receipt of general ledger evidence to support the amount reported by the hospital. Target Date: For items 1 & 2 in the corrective action plan, November 6, 2023.
View Audit 5303
Finding 3399 (2023-001)
Significant Deficiency 2023
South Plains College
TX
Reporting Student Financial Aid
South Plains College will modify system generated reports to include all reportable status changes and resubmit enrollment reports in which errors were identified. The College will implement a process to monitor the accuracy of enrollment reporting for future submissions. The anticipated completion ...
South Plains College will modify system generated reports to include all reportable status changes and resubmit enrollment reports in which errors were identified. The College will implement a process to monitor the accuracy of enrollment reporting for future submissions. The anticipated completion date for the corrective action plan is no later than May 31, 2024.
View Audit 5297
Parker University
TX
Student Financial Aid Reporting Matching / Level of Effort / Earmarking
November 20, 2023 To Whom It May concern: Corrective Action Plan – finding number 2023-001 Overall responsible individual for implementation of plan – Amy Hoss, Senior Director of Financial Aid While most of the reporting discrepancies occurred during the Christmas and New Year holidays ensuring...
November 20, 2023 To Whom It May concern: Corrective Action Plan – finding number 2023-001 Overall responsible individual for implementation of plan – Amy Hoss, Senior Director of Financial Aid While most of the reporting discrepancies occurred during the Christmas and New Year holidays ensuring that students would receive their funding in a timely manner, Parker has put in place additional controls to ensure compliance is dependent on initial and monthly reviews. Amanda Etheridge, Academic Business Analyst, and Amy Hoss, Senior Director of Financial Aid, will review PowerFAIDS and ensure that disbursement dates are appropriate and accurate, 10 days prior to the start of a term, regardless of the calendar day. Parker University will ensure that Title IV funds disbursed via PowerFAIDS are applied to student accounts via Jenzabar and reported to COD the same day. Parker University will further enhance the monthly reconciliation process. Once SAS reports are received, imported into PowerFAIDS, and the reconciliation report is generated for the respective Title IV programs, the file will be reviewed for any discrepancies in dates between the reported To_COD_Disb_Date, From_SAS_Disb_Date, and To_Bus_Disb_Date. Rodica Calin, Senior Accounting Analyst, will identify students with discrepant dates and provide to Angela McFadden, Compliance Officer, for further review. If the Compliance Officer confirms a discrepancy, the Academic Business Analyst or Senior Director of Financial Aid will complete a second review and update the appropriate system (PowerFAIDS, Jenzabar, or COD). Parker University will complete this data review for September disbursements by December 15, 2023 and October disbursements by December 31, 2023. It will be a part of our updated reconciliation process for subsequent months.
View Audit 5220
Marysville Quilceda Meadows
WA
HUD Housing Programs Cash Management Reporting
Management agrees with the recommendation of the auditor, and will ensure that future residual receipts deposits are made timely.
Management agrees with the recommendation of the auditor, and will ensure that future residual receipts deposits are made timely.
View Audit 5201
Marysville Quilceda Meadows
WA
Questioned Costs Subrecipient Monitoring HUD Housing Programs
fter discussion with the auditor, senior management understands the importance of having a properly functioning monitoring system in place to ensure that housing quality unit inspections are performed on an annual basis.
fter discussion with the auditor, senior management understands the importance of having a properly functioning monitoring system in place to ensure that housing quality unit inspections are performed on an annual basis.
View Audit 5201
Finding 3176 (2023-003)
Material Weakness 2023
Marysville Quilceda Meadows
WA
Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring
After discussion with the auditor, senior management understands the importance of having a properly functioning monitoring system in place to ensure that controls that are properly designed are in fact placed in operation and functioning as intended. The compliance manager responsible for implement...
After discussion with the auditor, senior management understands the importance of having a properly functioning monitoring system in place to ensure that controls that are properly designed are in fact placed in operation and functioning as intended. The compliance manager responsible for implementing the controls over compliance has been terminated, and senior management will institute monitoring procedures to ensure that controls over compliance are both properly designed and functioning as intended.
View Audit 5201
Finding 3173 (2023-002)
Material Weakness 2023
Reading Partners
CA
Allowable Costs / Cost Principles Reporting
Management agrees with the findings presented by the auditors. Management has taken the following actions already to ensure that there is proper review and approval. The Organization went through a payroll system transition in FY23. During the implementation phase of the new payroll system, the orga...
Management agrees with the findings presented by the auditors. Management has taken the following actions already to ensure that there is proper review and approval. The Organization went through a payroll system transition in FY23. During the implementation phase of the new payroll system, the organization encountered a significant learning curve. As we progress into FY24, we will utilize our payroll system to document the approval process for staff working on federal grants. We offer two options for this documentation: either via timesheets or written confirmation of hours worked on federal grants for recordkeeping.Management will continue to conduct staff training and education regarding the importance of time tracking when allocating time to federal grants. To ensure strong internal controls, management is committed to conducting periodic internal reviews as part of our compliance checks.
View Audit 5193
Finding 3171 (2023-004)
Material Weakness 2023
City of Scott
LA
Internal Control / Segregation of Duties Reporting
The City of Scott will review financial policies and procedures and make any necessary changes to ensure an effective control environment.
The City of Scott will review financial policies and procedures and make any necessary changes to ensure an effective control environment.
View Audit 5181
Finding 3170 (2023-003)
Material Weakness 2023
City of Scott
LA
Internal Control / Segregation of Duties Reporting
The City of Scott will review financial policies and procedures and make any necessary changes to ensure an effective control environment.
The City of Scott will review financial policies and procedures and make any necessary changes to ensure an effective control environment.
View Audit 5181
Finding 3160 (2023-002)
Material Weakness 2023
Loyal Heights Manor
WA
Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring
Management agrees with the recommendation of the auditor, and will ensure that evidence of certification review and approval is documented with a approval stamp or some other documentary evidence.
Management agrees with the recommendation of the auditor, and will ensure that evidence of certification review and approval is documented with a approval stamp or some other documentary evidence.
View Audit 5160
Finding 3153 (2023-003)
Significant Deficiency 2023
Yadkin County
NC
Questioned Costs Eligibility Reporting
Finding: 2023-003 Name of contact person: Corrective Action: Proposed Completion Date: Jessica Wall, Director YCHSA has revamped onboarding of new Medicaid staff to include individual staffing's with employee and their supervisor at least three times each week for a minimum of four months. These sta...
Finding: 2023-003 Name of contact person: Corrective Action: Proposed Completion Date: Jessica Wall, Director YCHSA has revamped onboarding of new Medicaid staff to include individual staffing's with employee and their supervisor at least three times each week for a minimum of four months. These staffing's would include direct education on what resources are used to accurately determine eligibility and how to document said resources. YCHSA is in the process of hiring an Eligibility Trainer to assist with onboarding of new staff, provide refresher trainings for established staff and conduct second party reviews. When issues are noted by the Trainer, they will notify the respective supervisor and provide follow-up training as needed (either in an individual or group setting). Knowledge checks will be administered following group training to determine if knowledge has increased. If not, supervisors will follow up with individual training on inaccurate resource entry. YCHSA will continue to utilize policy portal for needed clarification on policy interpretation. YCHSA will send training requests to the Operational Support Team at least quarterly. The onboarding process for YCHSA is an ongoing process. A training will be provided on the Single County Audit findings before 11/30/23. YCHSA will begin the hiring process for the Eligibility Trainer during the week of 10/30/23.
View Audit 5141
Pennsylvania College of Health Sciences
PA
Student Financial Aid Questioned Costs Special Tests & Provisions
Finding: 2023-001 Estimated Completion Date: Year Ended June 30, 2023 November 15, 2023 Pennsylvania College of Health Sciences is committed to meeting all regulatory policies and procedures related to student financial aid. Below are the changes that were implemented in March 2023 and communicat...
Finding: 2023-001 Estimated Completion Date: Year Ended June 30, 2023 November 15, 2023 Pennsylvania College of Health Sciences is committed to meeting all regulatory policies and procedures related to student financial aid. Below are the changes that were implemented in March 2023 and communicated to all staff members involved with student financial services: 1. Require the Student Account Specialist to run the Batch Assign Transmittal Communication process in the student information system immediately following each transmittal of financial aid. This will ensure communication will occur within the regulated timeframe. 2. Request that the Student Financial Services Coordinator note when loan disbursement notification e-mails are sent and alert the Student Account Specialist if notifications are not pulling in communications. These steps are monitored by the Director of Student Financial Services to ensure all updates and communication are occurring in a timely manner and in compliance with all regulations.
View Audit 5072
Finding 3132 (2023-003)
Significant Deficiency 2023
Delaware County Memorial Hospital D/b/a Regional Medical Center
IA
Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.303
Management agrees with the finding. The Medical Center’s secondary review control will ensure allowable expenses are being claimed.
Management agrees with the finding. The Medical Center’s secondary review control will ensure allowable expenses are being claimed.
View Audit 5069
Finding 3131 (2023-002)
Material Weakness 2023
Delaware County Memorial Hospital D/b/a Regional Medical Center
IA
Material Weakness Reporting Internal Control / Segregation of Duties § 200.303
Management agrees with the finding. Controls will be put into place to ensure the lost revenue calculation reported properly includes and excludes all relevant information.
Management agrees with the finding. Controls will be put into place to ensure the lost revenue calculation reported properly includes and excludes all relevant information.
View Audit 5069
Finding 3118 (2023-003)
Significant Deficiency 2023
Walthill Public Schools District #13
NE
Reporting
We had used the Impact Aid Coronavirus Relief Act when submitting FY2022 and FY2023 application so had not completed a survey for several years. We will add procedures and formulas in the source census files to ensure children count of each category agrees to the application.
We had used the Impact Aid Coronavirus Relief Act when submitting FY2022 and FY2023 application so had not completed a survey for several years. We will add procedures and formulas in the source census files to ensure children count of each category agrees to the application.
View Audit 5037
Framingham State University
MA
Student Financial Aid Reporting Matching / Level of Effort / Earmarking
Corrective Action Plan: The University has a previously established detailed policy and procedure in place to process and to accurately report status changes timely via the National Student Clearinghouse (NSC) to NSLDS. The reporting of the Initial Submission along with the Subsequent Submissions oc...
Corrective Action Plan: The University has a previously established detailed policy and procedure in place to process and to accurately report status changes timely via the National Student Clearinghouse (NSC) to NSLDS. The reporting of the Initial Submission along with the Subsequent Submissions occurs approximately 5 business days prior to the month for which the report is due. This then ensures that NSC has the opportunity to transmit the data to NSLDS within 14 days of the 1st of the month. Submission of additional rosters would not change anything as NSC only submits once per month to NSLDS. The University will continue to submit on time to NSC and will continue to monitor when NSC transmit to NSLDS. Timeline for Implementation of Corrective Action Plan: The corrective action plan was implemented as of October 2023. Contact Person Mark Powers, Registrar Finding number: 2023-001 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster CFDA #: 84.063 and 84.268 Award year: 2023
View Audit 5025
Finding 3048 (2023-003)
Material Weakness 2023
Idaho Falls School District #91
ID
Reporting § 200.510
Response to Finding 2023-003 - Schedule of Expenditures of Federal Awards (SEFA) Preparation The district will strive for monthly requests for reimbursement for all applicable federal funds, thus creating awareness of the funds and potential issues before they arise. The District Director of Finance...
Response to Finding 2023-003 - Schedule of Expenditures of Federal Awards (SEFA) Preparation The district will strive for monthly requests for reimbursement for all applicable federal funds, thus creating awareness of the funds and potential issues before they arise. The District Director of Finance will be responsible for overseeing the implementation of these responses and anticipates corrective dates to be immediate. Person(s) responsible for action: Lanell Farmer/Director of Finance
View Audit 5012
New Hampshire Catholic Charities
NH
Reporting
Accuracy of Reporting: Criteria: Management was responsible for reporting COVID-related expenditures based on the terms of the grant agreement. Condition: During compliance testing, it was identified that certain expenditures included in the final report were not accurate based on the amounts re...
Accuracy of Reporting: Criteria: Management was responsible for reporting COVID-related expenditures based on the terms of the grant agreement. Condition: During compliance testing, it was identified that certain expenditures included in the final report were not accurate based on the amounts recorded within the Organization's general ledger. Context: The COVID-related expenditures reported for the period were not accurate. Cause: Certain COVID-related expenditures had inaccuracies in the expenditures reported for Period 3 and Period 4. Effect: As a result of the condition, the Organization's required reporting for this grant was misstated, however the Organization was able to recalculate the appropriate COVID-related expenditures and, in conclusion, report that there were enough expenditures to charge to this federal award to support the propriety of all funds received. Further, the expenditures reported on the Period filings were limited to the amount of funding received. Recommendation: In the future, the Organization should ensure it implements appropriate processes and controls to ensure a review is performed prior to submission to the awarding agency. Contact: David Hildenbrand, Chief Financial Officer. Corrective Actions Taken or Planned: Management acknowledges the finding and will ensure controls are implemented to prevent this error from reoccurring. Anticipated Completion Date: By December 31, 2023.
View Audit 4949
Volunteers of America Southwest California, Inc.
CA
Reporting
The Corporation recognizes the importance of timely reporting as specified by the Notice of Awards. The Corporation experienced turnover in key positions that resulted in resubmission of final reports past the deadline. The Corporation has designed and implemented policies and practices to support t...
The Corporation recognizes the importance of timely reporting as specified by the Notice of Awards. The Corporation experienced turnover in key positions that resulted in resubmission of final reports past the deadline. The Corporation has designed and implemented policies and practices to support timely reporting to funding agencies. The Corporation will employ the use of calendars to show reporting deadlines outlined in the Notice of Awards and will file in advance of the submission date where feasible.
View Audit 4810
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