Corrective Action Plans

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SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION – TITLE i GRANTS TO LOCAL EDUCATION AGENCIES FUNDS (FEDERAL ALN 84.010) 2024-005 Internal Control Over Compliance With Federal Reimbursement Submission Deadline Requirements Finding Summa...
SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION – TITLE i GRANTS TO LOCAL EDUCATION AGENCIES FUNDS (FEDERAL ALN 84.010) 2024-005 Internal Control Over Compliance With Federal Reimbursement Submission Deadline Requirements Finding Summary 2 CFR § 200.328 requires the Academy to establish and maintain effective internal control over compliance with requirements applicable to federal program reporting, including reimbursement submission requirements applicable to Title I grants. During our audit, we noted the Academy did not have sufficient controls within its Title I federal program to ensure compliance with federal reporting requirements. Corrective Action Plan Actions Planned – The Academy is in the process of reviewing and updating its policies and procedures relating to reimbursement submission for its federal programs to ensure compliance with the Uniform Guidance in the future. The review of procedures will also include steps to ensure that academy personnel are following the requirements of the Uniform Guidance related to reimbursement submission requirements. Official Responsible – The Academy's Executive Director, Farhiya Einte. Planned Completion Date – June 30, 2025. Disagreement With or Explanation of Finding – The Academy agrees with this finding. Plan to Monitor – The School’s Executive Director, Farhiya Einte, will assure appropriate internal controls and procedures are updated and in place to ensure compliance with reimbursement submission requirements.
SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION – CHILD NUTRITION CLUSTER (FEDERAL ALN 10.553 AND 10.555) 2024-004 Internal Control Over Compliance With Federal Reimbursement Submission Deadline Requirements Finding Summary 7 CFR § 21...
SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION – CHILD NUTRITION CLUSTER (FEDERAL ALN 10.553 AND 10.555) 2024-004 Internal Control Over Compliance With Federal Reimbursement Submission Deadline Requirements Finding Summary 7 CFR § 210.8 requires the Academy to establish and maintain effective internal control over compliance with requirements applicable to federal programs, including reimbursement submission requirements applicable to the child nutrition federal program. During our audit, we noted the Academy did not have sufficient controls in place within its child nutrition cluster federal program to ensure compliance with federal submission requirements related to claims for reimbursement. Corrective Action Plan Actions Planned – The Academy is in the process of reviewing and updating its policies and procedures relating to reimbursement submission for its federal programs to ensure compliance with the Uniform Guidance in the future. The review of procedures will also include steps to ensure that Academy personnel are following the requirements of the Uniform Guidance related to reimbursement submission requirements. Official Responsible – The Academy's Executive Director, Farhiya Einte. Planned Completion Date – June 30, 2025. Disagreement With or Explanation of Finding – The Academy agrees with this finding. Plan to Monitor – The Academy’s Executive Director, Farhiya Einte, will assure appropriate internal controls and procedures are updated and in place to ensure compliance with reimbursement submission requirements.
Reportable Condition: See Condition 2024-003 Recommendation: We recommend the Municipality to maintain adequate accounting records related to the federal funds in order to property prepare the financial statements accurately and in a timely manner Action Taken: The Finance Department staff is aw...
Reportable Condition: See Condition 2024-003 Recommendation: We recommend the Municipality to maintain adequate accounting records related to the federal funds in order to property prepare the financial statements accurately and in a timely manner Action Taken: The Finance Department staff is aware of the compliance requirement, and instructions were given to the accounting staff to maintain a due date control sheet to ascertain that the required reports were submitted within the due date.
Reportable Condition: See Condition 2024-002 Recommendation: We recommend the Municipality to maintain adequate records related to the non-fedeal and federal funds in order to properly prepare the financial statements accurate and in a timely manner. In addition, the Municipality needs to implemen...
Reportable Condition: See Condition 2024-002 Recommendation: We recommend the Municipality to maintain adequate records related to the non-fedeal and federal funds in order to properly prepare the financial statements accurate and in a timely manner. In addition, the Municipality needs to implement adequate internal controls procedures in order to ensure that the supporting documentation is available in a timely manner. Action Taken: Management gave instructions to the Department staff to submit, in a timely manner, all required information to our external consultants and to our external auditors, to comply with the due date for the submission of the Single Audit Report.
In response to this finding, the Culinary Services department under the guidance of the Operations team in SPS has made the following adjustments and changes to business practices: 1. The PLE tool has been formally integrated into the annual budgeting process to ensure routine compliance with this ...
In response to this finding, the Culinary Services department under the guidance of the Operations team in SPS has made the following adjustments and changes to business practices: 1. The PLE tool has been formally integrated into the annual budgeting process to ensure routine compliance with this guidance and accurate financial planning. 2. If a price increase is deemed necessary, it will undergo a thorough review and approval through the SPS board governance process. This will include a landscape review of meal prices in other districts in the Puget Sound region as well as similarly scaled districts nationally. This structured approach guarantees alignment with strategic objectives while maintaining transparency and accountability. 3. As of May 2025, the Culinary Services department under the direction of the Operations department will be taking action on a price increase for school lunches beginning for the 2025-26 school year with annual reviews scheduled for subsequent years.
Item: 2024-001 Assistance Listing Number: 17.289 Program: Community Project Funding/ Congressionally Directed Spending Federal Agency: U.S. Department of Labor Pass-Through Agencies: N/A Contract Number: 24A60CP000265-01-00 Award Year: April 1, 2024 – December 31, 2024 Compliance Requ...
Item: 2024-001 Assistance Listing Number: 17.289 Program: Community Project Funding/ Congressionally Directed Spending Federal Agency: U.S. Department of Labor Pass-Through Agencies: N/A Contract Number: 24A60CP000265-01-00 Award Year: April 1, 2024 – December 31, 2024 Compliance Requirement: Reporting Criteria: Per the grant agreement, award recipients are required to submit quarterly and final narrative reports on grant activities funded under this award. All reports are due by the 15th day of the second month after each calendar-year quarter. Condition: A required report was not submitted to the granting agency timely. Name of Contact Person: Connie Nelson, Chief Administration Officer Phone Number: 480-695-8799 Anticipated Completion Date: May 31, 2025 Views of Responsible Officials and Corrective Actions: The current YMCA Grant tracking form will be updated to include reporting requirement dates. The Associate Vice President of Finance (AVP) will maintain a calendar of all grant reporting requirements. The calendar will be populated as grants are awarded and reporting deadlines will be clarified with the governmental agencies if questions arise. The tracking form is reviewed twice monthly and is accessible to all members of the Finance team tasked with grant reporting and will be monitored by the AVP and Sr. Vice President of Finance.
Finding 561400 (2024-001)
Significant Deficiency 2024
Recommendation: The county staff and management should review roles and responsibilities related to the annual reporting requirements and develop controls to ensure that regardless of position turnover, the required reporting is able to be submitted in a timely manner. This may include ensuring mult...
Recommendation: The county staff and management should review roles and responsibilities related to the annual reporting requirements and develop controls to ensure that regardless of position turnover, the required reporting is able to be submitted in a timely manner. This may include ensuring multiple county personnel are aware of deadlines and required reporting. Views of Responsible Officials and Planned Corrective Actions: The county understands and concurs with this finding. The county will employ a system to ensure timely reporting that includes additional oversite of the program by the County administration. The position responsible for reporting has also undergone turnover and the new employee responsible for such reporting will be informed of the required deadlines.
Finding 561396 (2024-001)
Significant Deficiency 2024
U.S Department of Treasury 2024-001 Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommended that the organization implement a review and approval process for all quarterly progress report submissions. This should include: •Training staff on...
U.S Department of Treasury 2024-001 Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommended that the organization implement a review and approval process for all quarterly progress report submissions. This should include: •Training staff on the importance of the review and approval process. •Ensuring adequate staffing levels to handle the review process. •Developing clear guidelines and procedures for the review and approvalprocess. •Regularly monitoring and auditing the review process to ensure compliance. Explanation of disagreement with audit finding: Management concurs with the finding. Action taken in response to finding: Additional fiscal staff has been hired to assist with various fiscal tasks including grant compliance and reporting. The guidelines are being updated, the checklist expanded, and documentation of secondary approval of reports is being retained. Grant guidelines, procedures, and checklists will be utilized to ensure compliance is maintained. Name(s) of the contact person(s) responsible for corrective action: Pete Winton Planned completion date for corrective action plan: The above action plan will be implemented in fiscal year 2025.
Finding 2024-002 Description of Finding Significant Deficiency in Internal Control over Compliance, and Other Matter Statement of Concurrence or Nonconcurrence The Town concurs. Corrective Action The Town agrees with this finding and will ensure the Board of Education department heads and Director...
Finding 2024-002 Description of Finding Significant Deficiency in Internal Control over Compliance, and Other Matter Statement of Concurrence or Nonconcurrence The Town concurs. Corrective Action The Town agrees with this finding and will ensure the Board of Education department heads and Director of Operations sign all invoices. Name of Contact Person Robert Buden, Director of Finance Completion Date May 20, 2025
Audit Finding Reference: 2024 - 001 Planned Corrective Action: BRHP continues weekly reporting of Request for Tenancy Approval processing and HAP Contract executions to identify any files where the 60-day deadline is approaching. PIC uploads continue to occur weekly. Hiring and retention of staff wh...
Audit Finding Reference: 2024 - 001 Planned Corrective Action: BRHP continues weekly reporting of Request for Tenancy Approval processing and HAP Contract executions to identify any files where the 60-day deadline is approaching. PIC uploads continue to occur weekly. Hiring and retention of staff while also managing through transitions remains a focus to preserve continuity for Housing Choice Voucher functions. Name of Contact Person: FaShaunDa Walton, Housing Mobility Director, fwalton@brhp.org Anticipated completion date: December 31, 2025
FFATA reporting for all existing and future subawards will be implemented immediately. All SAWC staff involved in the writing and granting of subawards will be briefed on FFATA reporting requirements, and FFATA reporting will be included as a required step in any materials guiding the subaward grant...
FFATA reporting for all existing and future subawards will be implemented immediately. All SAWC staff involved in the writing and granting of subawards will be briefed on FFATA reporting requirements, and FFATA reporting will be included as a required step in any materials guiding the subaward granting process going forward.
Finding 561177 (2024-003)
Significant Deficiency 2024
Finding no.: 2024-003 Contact person(s) responsible: Kymberly Horner, Executive Director for PCRI and Radha Mehrotra, Controller for Cascade Management Corrective action planned: The monthly deposits to the replacement reserve account have been reinstated after the lapse which was due to a peri...
Finding no.: 2024-003 Contact person(s) responsible: Kymberly Horner, Executive Director for PCRI and Radha Mehrotra, Controller for Cascade Management Corrective action planned: The monthly deposits to the replacement reserve account have been reinstated after the lapse which was due to a period of transition of management in the property management department. The funding processes have been reestablished and procedures are in place to ensure there are no unplanned lapses in funding the reserve going forward. Anticipated completion date: February 2025
Finding 561176 (2024-002)
Significant Deficiency 2024
Finding no.: 2024-002 Contact person(s) responsible: Kymberly Horner, Executive Director for PCRI and Radha Mehrotra, Controller for Cascade Management Corrective action planned: The improvements in processes mentioned in the plan to address Fining no. 2024-001 will serve to accelerate closing ...
Finding no.: 2024-002 Contact person(s) responsible: Kymberly Horner, Executive Director for PCRI and Radha Mehrotra, Controller for Cascade Management Corrective action planned: The improvements in processes mentioned in the plan to address Fining no. 2024-001 will serve to accelerate closing procedures and help the audit to be completed on schedule allowing for the required calculation and deposit of the residual receipt reserve funds within the required time frame. Anticipated completion date: October 2025
Finding 561175 (2024-001)
Significant Deficiency 2024
Finding no.: 2024-001 Contact person(s) responsible: Kymberly Horner, Executive Director for PCRI and Radha Mehrotra, Controller for Cascade Management Corrective action planned: The closing of books and preparation for audit procedures is being addressed via improvements in internal controls r...
Finding no.: 2024-001 Contact person(s) responsible: Kymberly Horner, Executive Director for PCRI and Radha Mehrotra, Controller for Cascade Management Corrective action planned: The closing of books and preparation for audit procedures is being addressed via improvements in internal controls related to property accounting, month and year end closing procedures which include a new property management accounting software package. It is also being addressed via the hiring of more experienced staff during fiscal year 2024-2025. The organization anticipates that these improvements will allow for the audit to be completed within the required timeframe in the upcoming cycle. Anticipated completion date: October 2025
The Authority has attempted to segregate accounting duties by having a person who does not initiate, prepare or post disbursements review the bank statements and co-sign all checks. The Authority will continue to monitor its policies and procedures in an effort to improve control efficiencies, howe...
The Authority has attempted to segregate accounting duties by having a person who does not initiate, prepare or post disbursements review the bank statements and co-sign all checks. The Authority will continue to monitor its policies and procedures in an effort to improve control efficiencies, however, at this time, the Authority has determined that the cost of eliminating the deficiency would exceed its benefit.
2024-001 Significant deficiency related to preparation of the schedule of federal awards Recommendation: The auditor recommends implementing a documented SEFA preparation process, assigning a reviewer to ensure accuracy, and providing staff training on Uniform Guidance standards. A checklist or simi...
2024-001 Significant deficiency related to preparation of the schedule of federal awards Recommendation: The auditor recommends implementing a documented SEFA preparation process, assigning a reviewer to ensure accuracy, and providing staff training on Uniform Guidance standards. A checklist or similar tool could enhance consistency and completeness. Planned Corrective Action: Management agrees with the recommendation and will take necessary steps to address the issue. These steps include developing a formal SEFA preparation process, reconciling federal expenditures to the general ledger, training staff on Uniform Guidance requirements, and instituting a review process to ensure accuracy. Management anticipates implementing these corrective actions prior to the next audit cycle.
The Health System met with grant managers and reviewed the expectations and responsibilities to ensure appropriate reviews and sign offs prior to submitting reports to the granting agency. The Health System will implement a centralized process with dedicated resources that will establish consistent ...
The Health System met with grant managers and reviewed the expectations and responsibilities to ensure appropriate reviews and sign offs prior to submitting reports to the granting agency. The Health System will implement a centralized process with dedicated resources that will establish consistent policies for grant management, including a layered review process with executive sign off on reports prior to submission.
Management response: Warren Easton is reviewing and updating the procurement section of the policy manual to explicitly include procedures for verifying the suspension and debarment status of all vendors and contractors receiving federal funds. Documentation of each vendor's verification will be mai...
Management response: Warren Easton is reviewing and updating the procurement section of the policy manual to explicitly include procedures for verifying the suspension and debarment status of all vendors and contractors receiving federal funds. Documentation of each vendor's verification will be maintained in procurement files. A printed or PDF record from SAM.gov showing the vendor's status will be retained as audit evidence.
Finding 2024-001 – Special Tests and Provisions, SEMAP reporting – ALN 14.871 – Significant Deficiency & Other Matter Corrective Action Plan: Since the audit, I have completed a SEMAP training course provided by The Nelrod Company. I will draft a binder for each indicator. I will complete the anal...
Finding 2024-001 – Special Tests and Provisions, SEMAP reporting – ALN 14.871 – Significant Deficiency & Other Matter Corrective Action Plan: Since the audit, I have completed a SEMAP training course provided by The Nelrod Company. I will draft a binder for each indicator. I will complete the analysis for each indicator and provide verification of all findings. Person Responsible: Annette Carper, Executive Director Anticipated Completion Date: I have completed the SEMAP training. The FYE 2025 SEMAP is due to be submitted by July 31, 2025. I will prepare a binder that will show collected data from August 1, 2024-July 31, 2025.
MANAGEMENT’S VIEWS AND CORRECTIVE ACTION PLAN For the year ended December 31, 2024 Finding 2024-001 - Non-Compliance with Accurate Student Enrollment Change Submissions to the National Student Loan Data System (Significant Deficiency) Grantor: U.S. Department of Education Program: Student Fina...
MANAGEMENT’S VIEWS AND CORRECTIVE ACTION PLAN For the year ended December 31, 2024 Finding 2024-001 - Non-Compliance with Accurate Student Enrollment Change Submissions to the National Student Loan Data System (Significant Deficiency) Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing #: 84.268, 84.063 Award Titles: Federal Direct Student Loan Program, Federal Pell Grant Program Award Years: 7/2023 – 6/2025 Management agrees with the finding and proposes the following corrective action plan: Corrective Action Plan: Due to non-compliance with timely and accurate student enrollment change submissions to the National Student Loan Data System (NSLDS), Brigham Young University – Hawaii (BYUH) Management proposes the following corrective action plan to mitigate reporting errors. The Registrar’s Office, in coordination with BYUH’s Enterprise Information Systems team, will review and enhance the processes used to extract student data from PeopleSoft and transmit it to the National Student Clearinghouse (NSC) and NSLDS. This includes: -Reviewing all relevant PeopleSoft updates and ensuring that corresponding changes are reflected in the data transmitted to NSLDS. -Testing and validating the reporting processes within PeopleSoft to confirm data accuracy and completeness. -Verifying that the correct data is being transmitted to NSLDS. -Testing the student data within NSLDS to ensure its integrity. -Documenting the entire process for future reference and ongoing quality assurance. In addition, the Registrar’s office has already added additional resources to run all reporting processes. The Registrar’s office has also reached out to Ensign College to learn about their reporting process. The University is considering contacting the PeopleSoft reporting specialist that Ensign used, although that decision will be made at a later date, and if necessary. These actions will enable the Registrar’s Office to more effectively review credit load determinations and accurately establish program begin dates for students. Daryl Whitford, Registrar, will remain responsible for enrollment reporting at BYUH. She will oversee the implementation of the revised process, provide training to all relevant staff members, and lead the development and implementation of a control mechanism to ensurefuture compliance with NSLDS reporting requirements within PeopleSoft. Timing: Daryl Whitford, Registrar, will be responsible for overseeing that all items noted in the corrective action plan will be implemented by September 1, 2025. Signed and Acknowledged Daryl Whitford, BYUH Registrar
Finding 560845 (2024-001)
Significant Deficiency 2024
Finding 2024-001 Condition: The Town has not documented in writing its policies regarding federal awards. Corrective Action Planned: In conjunction with the Town Administrator and Accountant, the Select Board will establish a written policy based on Uniform Guidance regarding cash management,...
Finding 2024-001 Condition: The Town has not documented in writing its policies regarding federal awards. Corrective Action Planned: In conjunction with the Town Administrator and Accountant, the Select Board will establish a written policy based on Uniform Guidance regarding cash management, determination of allowable costs, employee travel, procurement and subrecipient monitoring pertaining to federal awards. Anticipated Completion Date: December 31, 2025 Contact: Holly Young, Interim Town Administrator
2024-002 Student Financial Aid Cluster – Assistance Listing 84.063 and 84.268 Recommendation: The College should evaluate their procedures and review policies surrounding reporting enrollment effective dates and program enrollment effective dates NSLDS. Explanation of disagreement with audit finding...
2024-002 Student Financial Aid Cluster – Assistance Listing 84.063 and 84.268 Recommendation: The College should evaluate their procedures and review policies surrounding reporting enrollment effective dates and program enrollment effective dates NSLDS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Through the review of program reporting and campus reporting, the college will identify the cause for the data error. The college will explore the impact of branch campuses and the potential to shift to a single college reporting model. The following specific steps will be completed. 1. Identify and Analyze the Issues 2. Root Cause Analysis 3. Corrective Measures 4. Automation: Implement automated checks and balances to ensure data integrity before files are processed and sent. Name(s) of the contact person(s) responsible for corrective action: Patricia Munsch, Ph.D. Vice President for Student Affairs Nancy Brewer, College Director for Financial Aid Cheryl Eldredge, College Associate Dean for Registrar and Master Schedule Planned completion date for corrective action plan: December 31, 2026
2024-001 Student Financial Aid Cluster – Assistance Listing 84.063 and 84.268 Recommendation: The College should review their reporting internal controls and procedures to ensure that they require students' statuses to be reported timely to NSLDS as required by federal regulations. The College shoul...
2024-001 Student Financial Aid Cluster – Assistance Listing 84.063 and 84.268 Recommendation: The College should review their reporting internal controls and procedures to ensure that they require students' statuses to be reported timely to NSLDS as required by federal regulations. The College should evaluate their procedures and review policies surrounding reporting status changes to NSLDS to ensure the enrollment effective date reported to NSLDS aligns with the College’s last date of attendance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Through the work of a college-wide task force the following actions will be taken in response to the finding. The task force will include representatives from Information Technology, Institutional Research, Financial Aid, Registrar, along with Ellucian consultants. To summarize the steps and details of implementation to the specific areas are as follows: 1. Review Reporting Controls and Procedures 2. Address Error Code 22 3. Review Procedures Surrounding Reporting Status Changes 4. Assure Accuracy in Reporting Enrollment Effective Date Name(s) of the contact person(s) responsible for corrective action: Patricia Munsch, Ph.D. Vice President for Student Affairs Nancy Brewer, College Director for Financial Aid Planned completion date for corrective action plan: December 31, 2026
2024-003 Student Financial Aid Cluster – Assistance Listing 84.063, 84.268, 84.007, and 84.033 Recommendation: We recommend reviewing and implementing GLBA guidelines in order to explain the College’s information-sharing practices to their customers and to safeguard sensitive data, including student...
2024-003 Student Financial Aid Cluster – Assistance Listing 84.063, 84.268, 84.007, and 84.033 Recommendation: We recommend reviewing and implementing GLBA guidelines in order to explain the College’s information-sharing practices to their customers and to safeguard sensitive data, including student financial information. We also recommend designating a qualified individual responsible for implementing and monitoring the institution’s information security program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College is working toward documenting its policy and procedures with the proper oversight and its continual monitoring of all GLBA guidelines and the sensitive student data therein. While the College has been in the practice of safeguarding all its sensitive student data and adhering to all the GLBA guidelines. It has not been properly documented. The qualified designated individual responsible for the implementation and continued monitoring is Jason Fried, College Director of Service Delivery and IT Compliance. Name(s) of the contact person(s) responsible for corrective action: Sara E. Gorton, CPA, Vice President for Business and Financial Affairs Holmer A. Avellan, CPA, CFE, Controller Jaime Hahn, Senior Auditor Stephen Clark, College Administrative Director of Infrastructure Services Jason Fried, College Director of Service Delivery and IT Compliance Planned completion date for corrective action plan: August 31, 2025 If the Department of Education has questions regarding this plan, please call: Sara Gorton, CPA, VP of Finance and Business Affairs 631-451-4223
Views of Responsible Officials: The Grants manager and Grants Compliance manager positions had turnover in 2024. The search for their replacements continues. With various temporary staff filling the roles in 2024, delays occurred in meeting reporting deadlines. Management has reviewed all agreements...
Views of Responsible Officials: The Grants manager and Grants Compliance manager positions had turnover in 2024. The search for their replacements continues. With various temporary staff filling the roles in 2024, delays occurred in meeting reporting deadlines. Management has reviewed all agreements to ensure its tracking tools reflect all relevant due dates for financial and narrative reports, as required by the agreements. These tracking tools will be monitored monthly to ensure timely submissions of reports by the established due dates.
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