Corrective Action Plans

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Lack of Documentation of Exit Counseling Planned Corrective Action: Current SIS is set to trigger the Exit Counseling to all students that are coded anything other than E (Enrolled). The Registrar updates all student files with any enrollment changes triggering the email to go to the student. The FA...
Lack of Documentation of Exit Counseling Planned Corrective Action: Current SIS is set to trigger the Exit Counseling to all students that are coded anything other than E (Enrolled). The Registrar updates all student files with any enrollment changes triggering the email to go to the student. The FA Director will run a report in the middle of each term to pick up any students that may have been missed by the Registrar. Person Responsible for Corrective Action Plan: Stephanie Castillo, Director of Financial Aid Anticipated Date of Completion: Fall 2024
Return of Title IV (R2T4) Calculations Planned Corrective Action: Calander was set using prior year information it was not until notification in April 2024 from the DOE Audit Resolution Group that the error was made known to Financial Aid Director. Prior year R2T4 was handled by 3rd party vendor. T...
Return of Title IV (R2T4) Calculations Planned Corrective Action: Calander was set using prior year information it was not until notification in April 2024 from the DOE Audit Resolution Group that the error was made known to Financial Aid Director. Prior year R2T4 was handled by 3rd party vendor. The calendar for 2023-2024 was updated immediately and all calculations were processed and adjustments made. The ABU director has now taken NASFAA R2T4 Specialist training and is in charge of updating and maintaining the calendar. Person Responsible for Corrective Action Plan: Stephanie Castillo, Director of Financial Aid Anticipated Date of Completion: Fall 2024
View Audit 332741 Questioned Costs: $1
Internal Control over Compliance and Other Matters Recommendation: The organization should design and implement controls to ensure an adequate review process is in place to review compliance with LSC Regulation 45 C.R.F. Part 1611 Eligibility as it relates to obtaining and maintaining signed retain...
Internal Control over Compliance and Other Matters Recommendation: The organization should design and implement controls to ensure an adequate review process is in place to review compliance with LSC Regulation 45 C.R.F. Part 1611 Eligibility as it relates to obtaining and maintaining signed retainer agreements and eligibility forms for cases requiring such documentation. There is no disagreement with the audit finding. Action taken in response to finding: NNJLS created a Case File Checklist Form and implemented a procedure in which all supervising attorneys must complete the form weekly by reviewing cases to ensure that required signed retainer agreements and eligibility documentation are obtained by the client and uploaded to the case management system. The supervising attorney must report their findings of the review weekly to the Executive Director, obtain any necessary signatures and/or documents, and upload the Case File Checklist Form and documents to the case management system. The supervising attorneys receive a weekly-generated report of cases from the case management system. Name of the contact person responsible for corrective action: Leah Ashe, Executive Director Planned completion date for corrective action plan: As of September 30, 2024, this procedure became effective for all supervising attorneys and will remain in effect with no anticipated expiration.
Recommendation: We recommend that the District retain supporting documentation on file as required by federal guidelines for all transactions related to federal grants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to f...
Recommendation: We recommend that the District retain supporting documentation on file as required by federal guidelines for all transactions related to federal grants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will implement policies to ensure all documentation is kept. Name of the contact person responsible for corrective action: Phan Tu, Business Manager Planned completion date for corrective action plan: June 30, 2025
Planned Corrective Action: DHNP will create a checklist for all staff, to ensure all documents are maintained in the file. DHNP has an effective Quality Control review process that was implemented February 2024. The audit findings were based on files completed in FY 23/24. All files go through the Q...
Planned Corrective Action: DHNP will create a checklist for all staff, to ensure all documents are maintained in the file. DHNP has an effective Quality Control review process that was implemented February 2024. The audit findings were based on files completed in FY 23/24. All files go through the QC process and if errors are found, they must be corrected before payments are approved to be released. Anticipated Completion Date: March 31, 2025 Responsible Contact Person: Ruth Hill, Director
Student Financial Assistance Cluster– Assistance Listing Number: 84.007, 84.033, 84.063, and 84.268 Recommendation: We recommend the College work to update the written security program to ensure compliance with all the standards. Explanation of disagreement with audit finding: There is no disagreeme...
Student Financial Assistance Cluster– Assistance Listing Number: 84.007, 84.033, 84.063, and 84.268 Recommendation: We recommend the College work to update the written security program to ensure compliance with all the standards. Explanation of disagreement with audit finding: There is no disagreement with the finding. Action taken in response to finding: While the College's "written" information security program did not include the minimum requirements, all required activities were being performed. The College is in the process of updating its written information security program to achieve compliance with the Gramm-Leach-Bliley Act. Name of the contact person responsible for corrective action: Carl Lewis, Assistant Vice President and Chief Information Officer Planned completion date for corrective action plan: June 30, 2025
Student Financial Assistance Cluster – 84.063 and 84.268 Recommendation: We recommend the College reevaluate its procedures and review policies surrounding reporting status changes to NSLDS to put a process in place to ensure the student status changes are being reported timely. Explanation of disag...
Student Financial Assistance Cluster – 84.063 and 84.268 Recommendation: We recommend the College reevaluate its procedures and review policies surrounding reporting status changes to NSLDS to put a process in place to ensure the student status changes are being reported timely. Explanation of disagreement with audit finding: There is no disagreement with the finding. Action taken in response to finding: The College utilizes a third-party, National Student Clearinghouse (NSC) to report to NSLDS. The College will report to NSC earlier to provide additional time to review and verify that accurate data was transferred from NSC to NSLDS. Name of the contact person responsible for corrective action: Jonathan Jett, Director of Financial Aid Planned completion date for corrective action plan: June 30, 2025
Student Financial Assistance Cluster– Assistance Listing Number: 84.007, 84.033, 84.063, and 84.268 Recommendation: We recommend the College implement policies and procedures surrounding reviews of return of title IV calculations and direct loan reconciliations. Explanation of disagreement with audi...
Student Financial Assistance Cluster– Assistance Listing Number: 84.007, 84.033, 84.063, and 84.268 Recommendation: We recommend the College implement policies and procedures surrounding reviews of return of title IV calculations and direct loan reconciliations. Explanation of disagreement with audit finding: There is no disagreement with the finding. Action taken in response to finding: The return of title IV calculations and the direct loan reconciliations are generated by Colleague and verified by a Financial Aid Staff member utilizing a different method for the calculation. Effective immediately the Financial Director will review the calculation and initial approval. Name of the contact person responsible for corrective action: Jonathan Jett, Director of Financial Aid Planned completion date for corrective action plan: Completed
Child Nutrition Cluster - Assistance Listing Nos. 10.553, 10.555, 10.559 Recommendation: We recommend the District review their controls and procedures surrounding procurement to ensure their purchasing policy is followed. Explanation of disagreement with audit finding: There is no disagreement with...
Child Nutrition Cluster - Assistance Listing Nos. 10.553, 10.555, 10.559 Recommendation: We recommend the District review their controls and procedures surrounding procurement to ensure their purchasing policy is followed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will review the Sole Soure form on an annual basis to make sure the form has not expired. Name(s) of the contact person(s) responsible for corrective action: Debrah Jones, Director of Strategic Sourcing and Contract Management (SSCM) Planned completion date for corrective action plan: 12/31/2024
Finding 514319 (2024-002)
Significant Deficiency 2024
2024-002 – 93.432 ACL Centers for Independent Living Significant Deficiency and Noncompliance: One expense charged to this major federal award program lacked readily available support and 2 expenses did not have documented approval. Questioned Costs: Expenses charged to major federal award program...
2024-002 – 93.432 ACL Centers for Independent Living Significant Deficiency and Noncompliance: One expense charged to this major federal award program lacked readily available support and 2 expenses did not have documented approval. Questioned Costs: Expenses charged to major federal award program for which there was not readily available support or approval of expenditures was not documented totaled $558. Recommendation: Procedures should be implemented requiring documentation be maintained to support every expense charged to federal programs including documentation of approval of expenditures. Responsible Person for Corrective Action: Thomas Newman, Executive Director Corrective Action to be Taken: Management agrees with the audit findings and has already taken immediate corrective action by re-training accounting staff on the importance of maintaining all supporting documentation and obtaining the necessary approvals before processing any cash disbursements. To further strengthen internal controls, management is exploring the implementation of a system upgrade that would automate the documentation and approval process for expenditures charged to federal award programs. The anticipated completion date for this corrective action is 11/30/2024.
View Audit 332596 Questioned Costs: $1
Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System will ensure that the FEMA reimbursement requests have clear evidence of the individuals preparing and reviewing of the submission. Documentation will be maintained to evidence preparat...
Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System will ensure that the FEMA reimbursement requests have clear evidence of the individuals preparing and reviewing of the submission. Documentation will be maintained to evidence preparation and review process.
Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System will review, modify, and implement policies and procedures over the program to ensure that expenditures being charged to the program are specifically identified in the grant contract.
Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System will review, modify, and implement policies and procedures over the program to ensure that expenditures being charged to the program are specifically identified in the grant contract.
Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System has finalized the standard work procedure titled, Request for Funds/Reimbursement Claims (2-201’s), to ensure costs are appropriately charged based on the contract’s performance period...
Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System has finalized the standard work procedure titled, Request for Funds/Reimbursement Claims (2-201’s), to ensure costs are appropriately charged based on the contract’s performance periods. Review of cost activity will occur in fiscal year 2025 to ensure policy is followed.
Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System finalized the standard work procedures titled, Internal Controls for Proper Verification, which include procedures to ensure reported timesheet hours agree to hours on the time study a...
Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System finalized the standard work procedures titled, Internal Controls for Proper Verification, which include procedures to ensure reported timesheet hours agree to hours on the time study and costs incurred are appropriately charged based on the contracts’ performance periods. Staff is implementing policy in fiscal year 2025.
Corrective Action Plan: (unaudited): We agree with the recommendation and have updated the accounting manual. It should also be noted that the Organization has never filed late and has only had this happen once in the history of the Organization which is concurrent with the change in the FAC website...
Corrective Action Plan: (unaudited): We agree with the recommendation and have updated the accounting manual. It should also be noted that the Organization has never filed late and has only had this happen once in the history of the Organization which is concurrent with the change in the FAC website update.
Finding Number: 2024-002 – Approval of Payroll Expense Transactions Corrective Action Plan: A process was put in place in January 2024 to ensure that all principal approvals are documented in writing or electronic approval in the system which can be date stamped by the system. Payroll will not be ...
Finding Number: 2024-002 – Approval of Payroll Expense Transactions Corrective Action Plan: A process was put in place in January 2024 to ensure that all principal approvals are documented in writing or electronic approval in the system which can be date stamped by the system. Payroll will not be run, nor grants submitted until proper approval is received. Personnel Responsible for Corrective Action: Nachum Golodner, Academica Director of Accounting Anticipated Completion Date: June 30, 2025
Finding Number: 2024-003 – Approval of Payroll Expense Transactions Corrective Action Plan: A process was put in place in January 2024 to ensure that all principal approvals are documented in writing or electronic approval in the system which can be date stamped by the system. Payroll will not be ...
Finding Number: 2024-003 – Approval of Payroll Expense Transactions Corrective Action Plan: A process was put in place in January 2024 to ensure that all principal approvals are documented in writing or electronic approval in the system which can be date stamped by the system. Payroll will not be run, nor grants submitted, until proper approval is received. Personnel Responsible for Corrective Action: Nachum Golodner, Academica Director of Accounting Anticipated Completion Date: June 30, 2025
AAPS has corrected for this finding at the beginning of FY25 by having offer letters issued by our HR Manager to all employees. Offer letters are securely stored in individual employees’ personnel folders.
AAPS has corrected for this finding at the beginning of FY25 by having offer letters issued by our HR Manager to all employees. Offer letters are securely stored in individual employees’ personnel folders.
Recommendation: We recommend that the organization review the changes in income limits published by HUD during the tenant certification and recertification process to update form HUD-50059 income limits accordingly. Explanation of disagreement with audit finding: There is no disagreement with the au...
Recommendation: We recommend that the organization review the changes in income limits published by HUD during the tenant certification and recertification process to update form HUD-50059 income limits accordingly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management to update income limits in Onesite to reflect HUD income limits applicable as of the tenant’s application date. Name(s) of the contact person(s) responsible for corrective action: Brad Hughes Planned completion date for corrective action plan: 09/30/24
Finding 514129 (2024-002)
Significant Deficiency 2024
Recommendation: We recommend that the housing specialist complete the rent computation and review all support provided to the entity by the tenant to ensure all assets and income has been addressed on the rent computation form. We also recommend that a secondary person review the rent computation fo...
Recommendation: We recommend that the housing specialist complete the rent computation and review all support provided to the entity by the tenant to ensure all assets and income has been addressed on the rent computation form. We also recommend that a secondary person review the rent computation form for accuracy. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management to make the correction in the rent computation and return the amount overpaid by the grantor to HUD in FY2024-2025. Name(s) of the contact person(s) responsible for corrective action: Brad Hughes Planned completion date for corrective action plan: 10/04/2024
Finding 514127 (2024-001)
Significant Deficiency 2024
Recommendation: We recommend that the organization review the changes in income limits published by HUD during the tenant certification and recertification process to update form HUD-50059 income limits accordingly. Explanation of disagreement with audit finding: There is no disagreement with the au...
Recommendation: We recommend that the organization review the changes in income limits published by HUD during the tenant certification and recertification process to update form HUD-50059 income limits accordingly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management to update income limits in Onesite to reflect HUD income limits applicable as of the tenant’s application date. Name(s) of the contact person(s) responsible for corrective action: Brad Hughes Planned completion date for corrective action plan: 09/30/24 2024
Recommendation: We recommend that the organization review the changes in income limits published by HUD during the tenant certification and recertification process to update form HUD-50059 income limits accordingly. Explanation of disagreement with audit finding: There is no disagreement with the au...
Recommendation: We recommend that the organization review the changes in income limits published by HUD during the tenant certification and recertification process to update form HUD-50059 income limits accordingly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management to update income limits in Onesite to reflect HUD income limits applicable as of the tenant’s application date. Name(s) of the contact person(s) responsible for corrective action: Brad Hughes Planned completion date for corrective action plan: 09/30/24
The District is reviewing its policy and procedures to explore various options for enhancements to our current enrollment management business practices. The District is currently working on building targeted, automated email messages that would go out before and after the grade deadline to reduce th...
The District is reviewing its policy and procedures to explore various options for enhancements to our current enrollment management business practices. The District is currently working on building targeted, automated email messages that would go out before and after the grade deadline to reduce the number of RD grades. The District has contracted with consulting services to further evaluate our financial aid policies and procedures, enhance our system reports and provide best practices to ensure compliancy in accurate withdrawal calculations.
2024-001 Eligibility – Tenant Files Section 8 Housing Choice Vouchers Program – CFDA Number 14.871 Mainstream – Vouchers CFDA Number 14.879 Material Weakness in Internal Control and Material Noncompliance This is a repeat finding (the prior year finding was a significant deficiency) of 2023-002 from...
2024-001 Eligibility – Tenant Files Section 8 Housing Choice Vouchers Program – CFDA Number 14.871 Mainstream – Vouchers CFDA Number 14.879 Material Weakness in Internal Control and Material Noncompliance This is a repeat finding (the prior year finding was a significant deficiency) of 2023-002 from March 31, 2023 (initially occurred as Finding 2021-003, Significant Deficiency) Condition: Out of a total tenant population of approximately 1,775 tenants, 25 files were selected for testing. Exceptions were noted as follows: • 1 tenant file had the following errors: o Miscalculation of social security income reported on the form 50058 (used a prior year SSI instead of the current year). Correcting this error would decrease the HAP rent from $1,610 to $1,567. o One missing 214-affidavit form for a member of the household. However, based on the birth certificate, the member of the household is a U.S. citizen. • 1 tenant file had the following errors: o Two members of the household did not check the checkbox on the 214-affidavit form indicating their immigration status. However, based on the birth certificates, the two household members are U.S. citizens. o The 9886 form was not dated. Thus, we do not know if the 9886 form was signed within 15 month required timeframe. • 1 tenant file had the following errors: o Missing 214-affidavit form for a member of the household. However, based on the birth certificate, the member of the household is a U.S. citizen. o The tenant did not sign and date the Form 9886. • 1 tenant file had the following errors and correcting the errors would increase the HAP rent from $1,130 to $1,159: o Miscalculation of social security income reported on the 50058. o Miscalculation of medical expense reported on the 50058. • 1 tenant file error where a member of the household over the age of 18 did not sign the Form 9886. • 1 tenant file error where social security income was calculated incorrectly. Correcting the income would decrease the HAP rent from $1,155 to $1,153. • 1 tenant file error where a member of the household over the age of 18 did not sign the 9886. • 1 tenant file error where the tenant dated the year on the 9886 form 2013 when it should be 2023. • 1 tenant file error where a member of the household over 18 years old did not sign Form 9886. • 1 tenant file error where the tenant’s wage income was miscalculated. However, correcting the error would have no effect on the HAP rent amount. • 1 tenant file error where there was no EIV form for the recertification period. • 1 tenant file error where tenant wage income was calculated incorrectly. Correcting these income issues would decrease the HAP rent from $1,207 to $896. • 1 tenant file had the following errors and correcting the errors would decrease the HAP rent from $1,378 to $1,030: o An incorrect utility allowance was reported on the Form 50058. o Income support was not reported correctly on the Form 50058. • 1 tenant file had the following errors: o A member of the household did not check the checkbox on the 214-affidavit form indicating their immigration status. However, based on the birth certificate, the household member is a U.S. citizen. o Support for tenant’s pension income was over 12 months old. • 1 tenant file error where child support income was calculated incorrectly. However, correcting the error would have no effect on the HAP rent amount. Recommendation: The Authority should correct the deficiencies noted in the tested files and utilize an ongoing quality control review process on the entire tenant population to ensure proper compliance with the requirements related to tenant eligibility. Ongoing staff training and timely management reviews should be utilized to ensure staff is aware of acceptable procedures. In addition, the Authority should review staffing levels, skill sets and case load. Action Taken: We concur with the recommendation. Due to the COVID-19 pandemic and related staff absences and turnover, we were unable to provide an ongoing quality control review processes and provide ongoing staff training and timely management reviews. We are focused on implementing such procedures and will review staffing levels, skill sets, and case load for each employee.1 tenant file error where the Form 50058 reported an incorrect utility allowance, but correcting the allowance would not change the HAP rent amount.
Finding 514000 (2024-006)
Significant Deficiency 2024
U.S. Department of Health and Human Services Program Name: Maternal and Child Health Services Block Grant Federal Assistance Listing Number: 93.994 Significant Deficiency, Nonmaterial Noncompliance - Reporting Finding 2024-006 Criteria or Specific Requirement: Per Section 200.303 of the Uniform Gran...
U.S. Department of Health and Human Services Program Name: Maternal and Child Health Services Block Grant Federal Assistance Listing Number: 93.994 Significant Deficiency, Nonmaterial Noncompliance - Reporting Finding 2024-006 Criteria or Specific Requirement: Per Section 200.303 of the Uniform Grant Guidance, a nonfederal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Per 2 CFR 200.334 the recipient must retain all Federal award records for three years from the date of submission of their final financial report. Condition: During the audit we tested 13 reports and noted the following: a) There were four (4) instances out of 13 reports tested where the submitted reports were unable to be provided, including the date of submission for the reports. b) There were 10 instances out of 13 reports tested where the County was unable to provide evidence the report was reviewed prior to submission. Questioned Costs: None. Effect: By not having the required documentation and underlying support, the County is not able to demonstrate compliance with the applicable requirements. Cause: The County did not have a formal policy to ensure documentation was retained to evidence review and submission of all reports. Recommendation: The County should consider creating a formalized policy to require all submitted reports and underlying data are retained in accordance with the Uniform Grant Guidance requirements. Views of Responsible Officials: Management agrees with the finding and is implementing procedures to correct this which is further discussed in the Corrective Action Plan. Corrective Action Plan: See Corrective Action Plan prepared by the County. The Health Department will create and adopt a policy to ensure that federal award reports and data are retained in accordance with Uniform Guidance. The Health Department will also collaborate with NCDHHS to develop a procedure to address circumstances when the required report consists of answering a NCDHHS survey or form that does not have “save” or “download” capability, making it difficult to retain the required documentation. In addition, the Health Department will develop a standard operating procedure whereby program managers document that they have reviewed federal award reports prior to submission. While review of grant reports is common, the Health Department did not have adequate documentation to demonstrate completion of this step. Completion Date: April 30, 2025 Responsible Person(s): Jana Harrison, Business Operations Director
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