Corrective Action Plans

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Finding 500421 (2024-001)
Significant Deficiency 2024
The Corporation will designate an individual in management to document financial statement preparation processes to ensure timely submission of the Single Audit Reporting Package. The 2023 Single Audit Reporting Package was filed in July 2024.
The Corporation will designate an individual in management to document financial statement preparation processes to ensure timely submission of the Single Audit Reporting Package. The 2023 Single Audit Reporting Package was filed in July 2024.
Finding 2024-003 Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants Federal Assistance Listing #10.766 Finding Summary: During our testing, there was no formal review separate from the preparer over the reserve fund reconciliation for the...
Finding 2024-003 Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants Federal Assistance Listing #10.766 Finding Summary: During our testing, there was no formal review separate from the preparer over the reserve fund reconciliation for the federal program and there was no formal review of the balance in comparison to the required minimum reserve balance. Responsible Individual: Mandy Robinson, Administrator Corrective Action Plan: We will implement additional control processes to ensure a formal review over the reserve fund reconciliation and a formal review of the balance in comparison to the required minimum reserve balance is completed by staff separate from the preparer. Anticipated Completion Date: 12/31/2024
2024-008 Cash Management Corrective action planned: Federal draws will be made with approval of the Director of Financial Operations or their designee for expenditures that have been incurred and recorded in the general ledger. Electronic documentation will be organized by draw to ensure proper d...
2024-008 Cash Management Corrective action planned: Federal draws will be made with approval of the Director of Financial Operations or their designee for expenditures that have been incurred and recorded in the general ledger. Electronic documentation will be organized by draw to ensure proper documentation is maintained. Anticipated completion date: 11-30-2024 Contact person responsible for corrective action: Cathy Liles, Director of Fiscal Operations
View Audit 322303 Questioned Costs: $1
2024-007 Reporting (repeat of finding 2023-003) Corrective action planned: The new accounting system which OMC implemented in April 2024, allows for better tracking of UDS related costs, primarily financial related data. Documentation for UDS reporting will be maintained and updated when needed. ...
2024-007 Reporting (repeat of finding 2023-003) Corrective action planned: The new accounting system which OMC implemented in April 2024, allows for better tracking of UDS related costs, primarily financial related data. Documentation for UDS reporting will be maintained and updated when needed. Internal auditing has already been implemented to ensure compliance with reporting requirements. Anticipated completion date: 11-30-2024 Contact person responsible for corrective action: Richard Bruce, Chief Operating Officer
Incorrect Return of Title IV Funds Calculation Planned Corrective Action: Extensive training on module (Summer, Summer 1, and Summer 2) refunds have been completed. Each summer refresher training will take place due to the complicated nature of summer module calculation. Students who complete FA...
Incorrect Return of Title IV Funds Calculation Planned Corrective Action: Extensive training on module (Summer, Summer 1, and Summer 2) refunds have been completed. Each summer refresher training will take place due to the complicated nature of summer module calculation. Students who complete FAFSA after a term will be reviewed to determine how much Title IV aid they are eligible to have disbursed. The R2T4 calculation will be processed to learn the percentage earned. Exception to the R2T4 will be if student completed the module/term successfully. Person Responsible for Corrective Action Plan: Karen LaQuey, Director of Student Financial Aid Anticipated Date of Completion: Immediately
View Audit 320424 Questioned Costs: $1
2024-001 – Tri-Partite Board Composition Condition: At times during the year, less than 1/3 of the members of the board of directors of Community Action for Improvement, Inc. were representative of the low-income individuals and families served by the Organization. This is a repeat of prior year a...
2024-001 – Tri-Partite Board Composition Condition: At times during the year, less than 1/3 of the members of the board of directors of Community Action for Improvement, Inc. were representative of the low-income individuals and families served by the Organization. This is a repeat of prior year audit findings 2021-001, 2022-002 and 2023-001. Recommendation: We recommend that Community Action for Improvement, Inc. establish procedures to ensure the composition of the members of its board of directors meets this requirement. Corrective Action Plan: The Board of Directors for CAFI has a Membership Committee. Their role is to guide the recruitment and retention of Board members. At the time of this plan (8/16/24) all Board seats are filled. The Committee embarked on a Board Development Plan, lowered their Board seats, and worked hard to ensure a full Board. Person(s) Responsible: Board of Directors / Jennifer Corcione Timing for Implementation: Implemented by 9/01/2024.
Management will work to ensure that the SFS discount applications are completed accurately and that the SFS discounts are recorded accurately in the system by auditing the SFS applications and verifying the SFS in the system matches the SFS application. In addition, Management will audit a sample of...
Management will work to ensure that the SFS discount applications are completed accurately and that the SFS discounts are recorded accurately in the system by auditing the SFS applications and verifying the SFS in the system matches the SFS application. In addition, Management will audit a sample of the SFS discounts on a monthly basis to assure the SFS is applied correctly. Management will also provide additional training to staff as needed and provide further guidance on the internal SFS policies and procedures.
We concur with the observations and recommendations as placed forth by our auditors – KCM. As a result of employee turnover in fiscal year 2024, the company experienced difficulties completing certain forms. Since then, however, controls have been implemented to reduce the risk of noncompliance. Th...
We concur with the observations and recommendations as placed forth by our auditors – KCM. As a result of employee turnover in fiscal year 2024, the company experienced difficulties completing certain forms. Since then, however, controls have been implemented to reduce the risk of noncompliance. These include the hiring of a new compliance manager and the cross-collaboration of three property accountants, with a master trial balance shared to support teammates when they are on vacation or turnover occurs. We will work to re/file these forms immediately and begin tracking their status to prevent inaccurate/untimely filing.
2024-002 Student Financial Aid – 84.268 – Federal Direct Loan Program, 84.063 – Federal Pell Grant Program, 84.007 – Federal Supplemental Educational Opportunity Grant Program, 84.033 – Federal Work-Study Program Recommendation: We recommend the review process for awarding be documented and retain...
2024-002 Student Financial Aid – 84.268 – Federal Direct Loan Program, 84.063 – Federal Pell Grant Program, 84.007 – Federal Supplemental Educational Opportunity Grant Program, 84.033 – Federal Work-Study Program Recommendation: We recommend the review process for awarding be documented and retained as support for the review and approval process. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Director of Financial Aid will document each change to an award by printing a new award offer and saving to document tracking. As this is the final year in which Lincoln Christian University will have academic operations, we believe this corrective action to be sufficient for the remainder of the year. Name of the contact person responsible for corrective action: Margie Martin, Director of Accounting Planned completion date for corrective action plan: May 31, 2024.
Section 232 Mortgage Insurance for Nursing Homes – Assistance Listing No. 14.157 Recommendation: The auditor recommends that management increase their coverage amount to come into compliance with HUD requirements, as well as develop policies and procedures to monitor required coverage minimums to e...
Section 232 Mortgage Insurance for Nursing Homes – Assistance Listing No. 14.157 Recommendation: The auditor recommends that management increase their coverage amount to come into compliance with HUD requirements, as well as develop policies and procedures to monitor required coverage minimums to ensure that actual coverage amount is kept at least at that level. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Fidelity Bond insurance coverage was immediately increased from $1,135,927 to $1,182,615 to be above the minimum required threshold of $1,164,177 when identified. The new process implemented will assess potential organizational revenue growth ahead of insurance renewal to maintain at least the minimum required coverage threshold. Name(s) of the contact person(s) responsible for corrective action: Edward Forfa Planned completion date for corrective action plan: 8/12/2024
Finding 485172 (2024-002)
Significant Deficiency 2024
Finding 2024-002 Personnel Responsible for Corrective Action: Cathy Gorrell, Registrar Anticipated Completion Date: September 30, 2024 Corrective Action Plan: The Office of the Registrar recognizes the systematic programming of a pseudo academic program after a pseudo course has been added with a ...
Finding 2024-002 Personnel Responsible for Corrective Action: Cathy Gorrell, Registrar Anticipated Completion Date: September 30, 2024 Corrective Action Plan: The Office of the Registrar recognizes the systematic programming of a pseudo academic program after a pseudo course has been added with a future date after the student’s current program has been inactivated or graduated. This process has been at the request of the Office of Student Accounts for the graduation fee. The Office of the Registrar will work with the Office of Student Accounts to move to the system Graduation Application process rather than the customized and manual process of pseudo courses. Further, the Office of the Registrar has increased its data quality checks on the pseudo programs and courses. In conjunction, this should eliminate the reporting of active programs when the student has graduated.
August 20, 2024 Department of Housing and Urban Development Washington DC East Central Kansas Economic Opportunity Corporation respectfully submits the following corrective action plan for the year ended March 31, 2024. SSC CPAs, PA 3320 Clinton Parkway Court, Suite 120 Lawrence, KS 66047 Audit ...
August 20, 2024 Department of Housing and Urban Development Washington DC East Central Kansas Economic Opportunity Corporation respectfully submits the following corrective action plan for the year ended March 31, 2024. SSC CPAs, PA 3320 Clinton Parkway Court, Suite 120 Lawrence, KS 66047 Audit Period: Year ended March 31, 2024 The finding from March 31, 2024, schedule of findings and questioned costs are discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS 2024-001 Compliance and Controls over Eligibility of the Section 8 Housing Choice Vouchers Program (Significant Deficiency) Federal Agency: U.S. Department of Housing and Urban Development Program Name: Section 8 Housing Choice Vouchers Assistance Listing Number: 14.871 Award Period: March 31, 2024 Recommendation: The Board of Directors and management review the controls over the eligibility process to ensure the process is being followed and implemented correctly. Action Taken (Unaudited): ECKAN will create a policy in its Admin Plan, using any new HOTMA rules that may apply, to require zero-income forms in client files for households claiming zero-income. This Admin Plan edit will be presented to the ECKAN Board of Trustees for approval. Effective immediately (as of date of file inspection) ECKAN will use the Zero Income Verification Form for any new families claiming zero income. This had been a practice within the department but had not been formalized or provided oversight. ECKAN will also take steps to ensure current client files are searched for any families who claimed zero income prior and either locate the form or initiate contact with the family to obtain a completed form. A tracking spreadsheet will be created to ensure a complete list of zero-income households is maintained and monitored by the ECKAN housing staff. Anticipated completion date is March 31, 2025. If the Department of Housing and Urban Development has questions regarding this plan, please call Crystal Anderson at 785-242-7450. Sincerely yours, Crystal Anderson Crystal Anderson CEO East Central Kansas Economic Opportunity Corporation
Finding 479547 (2024-002)
Significant Deficiency 2024
Plan of Action: The area of compliance evaluated relates to the area of organizational workflow that includes patient intake. Due to the severity of this issue, management has implemented the following as a corrective action:  Contact granting organization for technical assistance with implementing...
Plan of Action: The area of compliance evaluated relates to the area of organizational workflow that includes patient intake. Due to the severity of this issue, management has implemented the following as a corrective action:  Contact granting organization for technical assistance with implementing and maintaining compliance during a period of increased staffing shortages and turnovers  Redesigned current workflow and office procedures to include the following changes: o Entry Level intake will only involve information gathering and collection of copays o 1st Level Supervision will review data and determine eligibility of sliding fee and application. The supervisor will also review the application to ensure that all signatures and demographic data has been included. o 2nd Level Supervision will perform random chart audits Monthly o 3rd Level Supervisor will perform random chart audits Quarterly  All patient intake staff will receive one-on-one training on Sliding Fee and the importance of documentation.
Plan: On June 4, 2024, the new Affordable Housing Director identified and corrected the incorrect authorized user information in the OneSite system with her own information. A protocol will be created for promptly updating authorized user information whenever there are personnel changes or role adju...
Plan: On June 4, 2024, the new Affordable Housing Director identified and corrected the incorrect authorized user information in the OneSite system with her own information. A protocol will be created for promptly updating authorized user information whenever there are personnel changes or role adjustments. Anticipated Completion Date: 06/04/2024 Responsible person: Jackie Oliveira, Director of Affordable Housing
Plan: On June 4, 2024, the new Affordable Housing Director identified and corrected the incorrect authorized user information in the OneSite system with her own information. A protocol will be created for promptly updating authorized user information whenever there are personnel changes or role adju...
Plan: On June 4, 2024, the new Affordable Housing Director identified and corrected the incorrect authorized user information in the OneSite system with her own information. A protocol will be created for promptly updating authorized user information whenever there are personnel changes or role adjustments. Anticipated Completion Date: 06/04/2024 Responsible person: Jackie Oliveira, Director of Affordable Housing
The Board of Directors will designate an individual to document financial statement preparation processes which ensure timely submission of the Single Audit Reporting Package.
The Board of Directors will designate an individual to document financial statement preparation processes which ensure timely submission of the Single Audit Reporting Package.
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to retaining the completed sliding fee applications in the patients record to support the sliding fee discount p...
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to retaining the completed sliding fee applications in the patients record to support the sliding fee discount provided to the patient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization is aware of the importance of properly applying the sliding fee scale to all eligible patients. We feel that we have strong policies and procedures to ensure this is performed accurately. However, the process is dependent on many individuals and is susceptible to human error. We will implement the following process to mitigate this risk. We will increase our internal audit procedures to audit sliding fee applications on a more frequent basis for any Enrollment Specialist who fails to maintain a 5% error rate. We will increase the number of Sliding Fee Discount applications to 5 every month. We will also conduct a retraining with the team to ensure all documents are uploaded into the document management system correctly for each patient. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Brian Johnston, CFO at 303-665-3036.
2023-002 Deficiency in controls related to services purchased with federal funds A. Name of contact person responsible for corrective action: Name: Dr. Andrea Pastchal Smith Title: Superintendent B. Corrective action planned: Aberdeen School District will follow the federal procurement standards req...
2023-002 Deficiency in controls related to services purchased with federal funds A. Name of contact person responsible for corrective action: Name: Dr. Andrea Pastchal Smith Title: Superintendent B. Corrective action planned: Aberdeen School District will follow the federal procurement standards requiring two quotes for services over $10,000.00. C. Anticipated completion date: June 30, 2025
IMPLEMENT SEFA RECONCILIATION CONTROL MATRIX DOCUMENTATION, MONITORING AND TRAINING
IMPLEMENT SEFA RECONCILIATION CONTROL MATRIX DOCUMENTATION, MONITORING AND TRAINING
US Department of Homeland Security (DHS), Federal Emergency Management Agency 2023-005 Hazard Mitigation Grant Program – Assistance Listing No. 97.039 Recommendation: We recommend management implement procedures requiring documented review and approval of all grant reports prepared by outside consul...
US Department of Homeland Security (DHS), Federal Emergency Management Agency 2023-005 Hazard Mitigation Grant Program – Assistance Listing No. 97.039 Recommendation: We recommend management implement procedures requiring documented review and approval of all grant reports prepared by outside consultants prior to submission. Documentation should be retained to demonstrate management's oversight and review. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management understands the importance of reviewing the progress reports. Management believes that the one instance out of the four tested was an isolated instance. The Township implemented policies and procedures to ensure that the Township will comply going forward. These policies include management review of the statements and a clear notation of the approval. Name(s) of the contact person(s) responsible for corrective action: Timothy Tieperman, Township Manager Planned completion date for corrective action plan: June 2026
US Department of Treasury 2023-003 American Rescue Plan Act/Coronavirus State and Local Fiscal Recovery Funds (ARPA) – Assistance Listing No. 21.027 Recommendation: We recommend the Township strengthen its internal controls over federal grant reporting by assigning responsibility for monitoring gran...
US Department of Treasury 2023-003 American Rescue Plan Act/Coronavirus State and Local Fiscal Recovery Funds (ARPA) – Assistance Listing No. 21.027 Recommendation: We recommend the Township strengthen its internal controls over federal grant reporting by assigning responsibility for monitoring grant requirements, maintaining a centralized calendar of reporting deadlines, implementing supervisory review procedures prior to report due dates, and retaining documentation evidencing the preparation, review, and submission of required reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Township adopted written policies and procedures governing federal funds. These policies include review of the reporting requirements of the grant upon the grant award to ensure reporting compliance and maintaining a centralized calendar of reporting deadlines. Name(s) of the contact person(s) responsible for corrective action: Timothy Tieperman, Township Manager Planned completion date for corrective action plan: June 2026
Views of responsible officials and corrective action planned: Findings: The Hospital did not have a documented procurement policy in place that complied with the Uniform Guidance requirements. Management agrees with the findings. Corrective action planned: Management will develop, adopt and implemen...
Views of responsible officials and corrective action planned: Findings: The Hospital did not have a documented procurement policy in place that complied with the Uniform Guidance requirements. Management agrees with the findings. Corrective action planned: Management will develop, adopt and implement a documented procurement policy that complies with the Uniform Guidance requirements. Management to establish procedures to ensure procurement transactions are documented and performed in accordance with federal requirements. Anticipated completion date: December 31, 2026 Contact person responsible for corrective action: Roger Russell, CFO
2023-004 – Provider Relief Fund Reporting of Lost Revenue Views of responsible officials and corrective action planned: Findings: Patient service revenues were not reported net of contractual adjustments and bad debt. Management agrees with the findings. Corrective action planned: Management to corr...
2023-004 – Provider Relief Fund Reporting of Lost Revenue Views of responsible officials and corrective action planned: Findings: Patient service revenues were not reported net of contractual adjustments and bad debt. Management agrees with the findings. Corrective action planned: Management to correctly report lost revenue for any future reporting needs. Anticipated completion date: Future reporting needs. Contact person responsible for corrective action: Roger Russell, CFO
The Institute has engaged an auditor to complete the December 31, 2022, 2023, 2024, and 2025 Single Audits concurrently, and will submit each reporting package and data collection form to the Federal Audit Clearinghouse as each audit is completed. Thereafter, the Institute will complete the audit an...
The Institute has engaged an auditor to complete the December 31, 2022, 2023, 2024, and 2025 Single Audits concurrently, and will submit each reporting package and data collection form to the Federal Audit Clearinghouse as each audit is completed. Thereafter, the Institute will complete the audit and submit the reporting package within nine months after year end. Anticipated completion date: December 31, 2026. Responsible contact person: Kathy Walker, Executive Director.
Significant Deficiency Finding No. 2023-007: Reporting U.S. Department of Housing and Urban Development Passed Through the State of Hawaii Department of Human Services Emergency Solutions Grant Program Coronavirus Federal Assistance Listing Number 14.231 Criteria A non-Federal entity that expends $7...
Significant Deficiency Finding No. 2023-007: Reporting U.S. Department of Housing and Urban Development Passed Through the State of Hawaii Department of Human Services Emergency Solutions Grant Program Coronavirus Federal Assistance Listing Number 14.231 Criteria A non-Federal entity that expends $750,000 or more in Federal awards during the year must have a single audit conducted in accordance with 2 CFR §200.514. Pursuant to 2 CFR §200.512, the audit must be completed and Form SF-SAC: Data Collection Form and reporting package must be submitted within the earlier of 30 calendar days after receipt of the auditors’ report(s), or nine months after year end of the audit period. Condition We noted that KMNH has not submitted the single audit reports required by the Uniform Guidance, including the Data Collection Form to the Federal Audit Clearinghouse for the year ended December 31, 2023, within the stipulated nine months after the end of the audit period. Cause KMNH is not in compliance with the Uniform Guidance terms and conditions regarding the submission dates of the single audit report and Data Collection Form for the year ended December 31, 2023. Effect KMNH is not in compliance with the Uniform Guidance terms and conditions regarding the submission dates of the single audit report and Data Collection Form for the year ended December 31, 2023. Identification of a Repeat Finding This finding was reported as a federal award finding in the immediate previous audit as Finding No. 2022- 005. Recommendation We again recommend that KMNH incorporate internal controls to ensure compliance with the Uniform Guidance with respect to the submission deadline of single audit reports and the Data Collection Form. Corrective Action Responsible Party: Executive Director KMNH agrees with the finding and recommendation and have updated internal controls to monitor audit submissions to the Federal Audit Clearinghouse.
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