Corrective Action Plans

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The newly hired CFO will update the policies and procedures and oversee the Finance Department and will develop procedures to ensure there are proper segregation of duties over key cycles, taking into consideration the size and complexity of the Organization. These procedures will strengthen the exp...
The newly hired CFO will update the policies and procedures and oversee the Finance Department and will develop procedures to ensure there are proper segregation of duties over key cycles, taking into consideration the size and complexity of the Organization. These procedures will strengthen the expense and accounts payable processes to ensure compliance with the provisions of 2 CFR § 200.302.
Management’s Response and Planned Corrective Actions: 1. The corrective action planned: a. Internal control document and procedure that is consistent with the compliance requirement for: i. CFR §200.318, General procurement standards identify all requirements which the offerors must fulfill and all ...
Management’s Response and Planned Corrective Actions: 1. The corrective action planned: a. Internal control document and procedure that is consistent with the compliance requirement for: i. CFR §200.318, General procurement standards identify all requirements which the offerors must fulfill and all other factors to be used in evaluating bids or proposals i. §200.319, Competition requirements will be met with documented procurement actions using strategic sourcing, shared services, and other similar procurement arrangements ii. §200.320 Methods of procurement to be followed. 2. The name of the contact person(s) responsible for the corrective action a. Kathleen Broadhurst, Sr. Director of Finance, ShelterCare 3. The anticipated completion date: a. The written policies will be updated by 05/01/2024.
Management’s Response and Planned Corrective Actions: 1. The corrective action planned: a. ShelterCare, as managing agent, has hired a new property accountant which should help with keeping the books current and ShelterCare prepared to start audit work mid-July and be ready to submit the audit to HU...
Management’s Response and Planned Corrective Actions: 1. The corrective action planned: a. ShelterCare, as managing agent, has hired a new property accountant which should help with keeping the books current and ShelterCare prepared to start audit work mid-July and be ready to submit the audit to HUD within 90 days of the fiscal year end. 2. The name of the contact person(s) responsible for the corrective action a. Kathleen Broadhurst, Sr. Director of Finance, ShelterCare 3. The anticipated completion date: a. New property accountant was hired in August of 2023.
II. FEDERAL FINDINGS AND QUESTIONED COSTS 2023-001 50000 - ELIGIBILITY Management's Response: We concur. View of Responsible Officials and Corrective Action Plan In the 2023-24 school year, Nutrition Services has implemented an additional step when processing meal applications to improve accuracy. M...
II. FEDERAL FINDINGS AND QUESTIONED COSTS 2023-001 50000 - ELIGIBILITY Management's Response: We concur. View of Responsible Officials and Corrective Action Plan In the 2023-24 school year, Nutrition Services has implemented an additional step when processing meal applications to improve accuracy. Meal applications are verified a total of three times. The Nutrition Specialist is the Determining Official, the Director is the Confirming Official, and either the Secretary or Clerk is the Verifying official. Each official reviews the application for accuracy. Name of responsible individual: Brenda Zarate Implementation Date: 7/1/2023
Supportive Housing for Persons With Disabilities – Assistance Listing No. 14.181 Criteria or Specific Requirement: According to the client's internal control over payroll disbursements, hourly employees must maintain timesheets which are approved and signed by the property manager. Condition: Upon...
Supportive Housing for Persons With Disabilities – Assistance Listing No. 14.181 Criteria or Specific Requirement: According to the client's internal control over payroll disbursements, hourly employees must maintain timesheets which are approved and signed by the property manager. Condition: Upon performing testing over payroll disbursements, we noted that there was no approval of the timesheet for the payroll disbursements tested. Questioned costs: None Context: The timesheet for 4 out of 4 payroll disbursements tested was not properly approved by the property manager. Cause: Turnover of property manager at the property management company and weaknesses in internal controls over payroll disbursements. Effect: There is no evidence of proper approval of payroll disbursement. Repeat Finding: Yes Recommendation: We recommend that management strengthen controls over review of payroll. Views of Responsible Officials: There is no disagreement with the audit finding. Action taken in response to finding: Although other controls and reviews around compensation help safeguard and mitigate compensation errors, the property manager will ensure that all time sheets are properly approved prior to payment as a first line of internal controls. Name of the contact person responsible for corrective action: Angela Westwood, CFO Planned completion date for corrective action plan: May 30, 2024.
Supportive Housing for Persons With Disabilities – Assistance Listing No. 14.181 Recommendation: We recommend that management establish the residual receipt account and make the required deposit as soon as possible. Explanation of disagreement with audit finding: There is no disagreement with the ...
Supportive Housing for Persons With Disabilities – Assistance Listing No. 14.181 Recommendation: We recommend that management establish the residual receipt account and make the required deposit as soon as possible. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A residual receipt account has been established. Required deposit will be made by May 30, 2024. Name of the contact person responsible for corrective action: Angela Westwood, CFO Planned completion date for corrective action plan: Required deposit will be made by May 30, 2024.
II. FEDERAL FINDINGS AND QUESTIONED COSTS 2023-001 Special Tests and Provisions Management's Response: We concur. View of Responsible Officials and Corrective Action Plan The District reviewed past practices and implemented revised procedures to ensure accurate student enrollment information is...
II. FEDERAL FINDINGS AND QUESTIONED COSTS 2023-001 Special Tests and Provisions Management's Response: We concur. View of Responsible Officials and Corrective Action Plan The District reviewed past practices and implemented revised procedures to ensure accurate student enrollment information is reported to the National Student Loan Data System. Additionally, the District consulted with the National Student Clearinghouse and prior semesters’ enrollment information was revised and resubmitted. Name of responsible individual: John Cooney Implementation Date: October 26, 2023
Corrective Action Plan For the Year Ended May 31, 2023 Finding 2023-002 Assistance Listing Number(s), Federal Agency and Program Name: 84.063, 84.007, 84.033, and 84.268; United States Department of Education (DOE), Student financial assistance cluster. Finding Type: Noncompliance and significant de...
Corrective Action Plan For the Year Ended May 31, 2023 Finding 2023-002 Assistance Listing Number(s), Federal Agency and Program Name: 84.063, 84.007, 84.033, and 84.268; United States Department of Education (DOE), Student financial assistance cluster. Finding Type: Noncompliance and significant deficiency in control over compliance relating to special tests. Criteria: The Institute is responsible for designing, implementing, and maintaining internal control over compliance for special tests and provisions and for safeguarding sensitive data under the Gramm-Leach-Bliley Act, including performing an annual risk assessment that addresses three required areas noted in 16 Code of Federal Regulations (CFR) 314.4 (b). Statement of Condition: The Institute performed a risk assessment however the safeguards for the risks identified were not formally documented through a policy. A formal policy was not reviewed in fiscal year 2023 which would have addressed required areas noted in 16 CFR 314.4 (b). Questioned Costs: Questioned costs could not be determined. Context: A policy and documentation linking the safeguards to the risk assessment was not formally written. The internal controls over compliance at the Institute did not identify the noncompliance. However, the Institute performed risk assessments and has appropriate safeguards for each area identified within 16 CFR 314.4(b). Cause: The Institute did not have internal controls in place to identify the need for the policy documenting the safeguards required by the Gramm-Leach-Bliley Act. Effect: The Institute has no verifiable evidence of the policy and the related safeguards for each risk identified. Recommendation: We recommend management review 16 CFR 314.4 (b) to create a policy that addresses the three required areas, which are (1) employee training and management; (2) information systems, including network and software design, as well as information processing, storage, transmission and disposal; and (3) detecting, preventing and responding to attacks, intrusions, or other systems failures. This policy should be formalized and reviewed annually. We recommend that the Institute document the approval and acceptance of the policy. In addition, we recommend management review internal control processes for special tests and provisions on an annual basis. Status: In progress, anticipated completion September 2024 Corrective Action: Management agrees with the finding. We are currently developing a comprehensive cybersecurity policy to address 16 CFR 314.4 (b), which will be formalized, approved by Senior Staff, and reviewed annually. We are now conducting annual penetration tests, the most recent in December 2023, to address internal control processes. We have contracted with a planning team at CDW to determine best practices and perform training. We have begun providing a quarterly GLBA Compliance update to our board, with an annual comprehensive GLBA review to the board. Contact Matt Ogden Director of Technology 414.847.3223 mattogden@miad.edu Submitted Feb 23, 2024
Finding 2023-001 – Housing Opportunities for Persons with AIDS Tenant Files – Eligibility – Rent Calculations Noncompliance & Significant Deficiency Housing Opportunities for Persons with AIDS Program – ALN 14.241, Grant Year 2022 & 2023 Corrective Action Plan: The two tenant files with income c...
Finding 2023-001 – Housing Opportunities for Persons with AIDS Tenant Files – Eligibility – Rent Calculations Noncompliance & Significant Deficiency Housing Opportunities for Persons with AIDS Program – ALN 14.241, Grant Year 2022 & 2023 Corrective Action Plan: The two tenant files with income calculation errors resulting in the tenant overpaying. This has been corrected on both files and tenants have had a HAP payment in excess of their rental amount to provide a credit. The tenant file with no recertification in 2022. We have no idea how this could have happened unless a wrong date prior to this. The recertification was done in July 2023 and scheduled to be done for July 2024, so we are going forward. Additional file reviews will be done in the future. Person Responsible: Joseph Beasley and Connie Howard Anticipated Completion Date: Everything except the additional file reviews has already occurred (2/5/24).
Head Start - AL #93.6000 Recommendation: The Organization should review and approve the related to the indirect costs that are automatically allocated by the system and retain support of this review and approval. Explanation of disagreement with audit finding: There is no disagreement with the audit...
Head Start - AL #93.6000 Recommendation: The Organization should review and approve the related to the indirect costs that are automatically allocated by the system and retain support of this review and approval. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We implement a policy to ensure review and approval of cost allocations. Name(s) of the contact person(s) responsible for corrective action: Rita Zilka, Fiscal Director Planned completion date for corrective action plan: September 30, 2024
Action taken in response to finding: Esperanza reviewed the current year’s HRSA drawdown sheet and updated all personnel salaries. We will also revise the draw down sheet so each person’s current salary is visible each month, and apply conditional formatting to highlight any person making in excess ...
Action taken in response to finding: Esperanza reviewed the current year’s HRSA drawdown sheet and updated all personnel salaries. We will also revise the draw down sheet so each person’s current salary is visible each month, and apply conditional formatting to highlight any person making in excess of the salary cap. Name(s) of the contact person(s) responsible for corrective action: Ryan Gadia Planned completion date for corrective action plan: May 31, 2024. If there are any questions regarding this plan, please call Ryan Gadia at (773) 640-5792.
View Audit 295147 Questioned Costs: $1
Corrective Action Plan Payroll will need send out a reminder email to Directors and Coordinators with a list of employees with timesheets not yet approved as of 2:45pm on the date approvals are due. Automatic approval will be delayed util 4:00pm to allow the payroll accountant more time to follow-up...
Corrective Action Plan Payroll will need send out a reminder email to Directors and Coordinators with a list of employees with timesheets not yet approved as of 2:45pm on the date approvals are due. Automatic approval will be delayed util 4:00pm to allow the payroll accountant more time to follow-up with Directors/Coordinators, if employees remain unapproved at 3pm. Directors and Coordinators will review, have time sheets corrected and approved by 3pm on the date approvals are due. Responsible Person for Corrective Action Plan Amanda Knight, Director of Finance, and Brandon Meline, Director of Maternal & Child Health. Implementation Date of Corrective Action Plan 02/09/2024
Federal Agency Name: Department of Health and Human Services Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN #420868216 Federal Financial Assistance Listing #93.498 Compliance Requirement: Preparati...
Federal Agency Name: Department of Health and Human Services Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN #420868216 Federal Financial Assistance Listing #93.498 Compliance Requirement: Preparation of Schedule of Expenditures of Federal Awards ‐ Other Finding Summary: The Hospital does not have an internal control system designed to provide for a complete and accurate Schedule being audited. Eide Bailly, LLP, the auditors, were requested to draft the Schedule and notes to the Schedule. Responsible Individuals: Craig Carstens, CFO Corrective Action Plan: Management agrees with this finding. Management will develop and implement an internal control system tailored to ensure completeness and accuracy in auditing the Schedule. Management will clearly define the objectives of the internal control system to address gaps in auditing procedures. Management will set clear standards and protocols for auditing processes, ensuring adherence to regulatory requirements. Management will provide comprehensive training to staff involved in auditing processes to ensure they understand their roles and responsibilities. Management will conduct regular assessments and reviews of the internal control system's effectiveness and make adjustments as needed to improve accuracy and completeness. Anticipated Completion Date: 2/26/2024.
Federal Agency Name: Department of Health and Human Services Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN #420868216 Federal Financial Assistance Listing #93.498 Compliance Requirement: Reporting...
Federal Agency Name: Department of Health and Human Services Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN #420868216 Federal Financial Assistance Listing #93.498 Compliance Requirement: Reporting Finding Summary: There was no evidence retained that the Hospital’s special report submitted to the Department of Health and Human Services for Period 4 TIN #420868216 was reviewed or approved by an individual separate from the preparer prior to submission. Responsible Individuals: Craig Carstens, CFO Corrective Action Plan: Management agrees with this finding. Management will designate specific individuals to review HHS special report submissions before submission to HHS. Management will require documentation verifying independent review and approval prior to submission. Management will provide comprehensive training to staff on the importance of independent review processes. Management will set up automated workflow systems and checklists to enforce review procedures. Management will regularly audit the review process, gather feedback, and make necessary adjustments for enhancement. Anticipated Completion Date: 2/26/2024.
Federal Agency Name: Department of Health and Human Services Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN #420868216 Federal Financial Assistance Listing #93.498 Compliance Requirement: Activitie...
Federal Agency Name: Department of Health and Human Services Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN #420868216 Federal Financial Assistance Listing #93.498 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Summary: The Hospital claimed expenses in the HHS special report for Period 4 that were related to services to be performed after the period of availability. Responsible Individuals: Craig Carstens, CFO Corrective Action Plan: Management agrees with the findings. Management will ensure that all expenses claimed are properly documented and supported by appropriate documentation, including invoices, receipts, and service agreements. Management will provide training and education to relevant staff members responsible for preparing and submitting expense claims to ensure they understand the period of availability and the importance of accurate reporting. Management will implement controls and procedures to prevent similar errors in the future. This may include implementing a review process for expense claims to ensure compliance with reporting requirements. Management will communicate the importance of accurate reporting and adherence to reporting equirements to all relevant staff members. Emphasize the impact of inaccurate reporting on the hospital's reputation and compliance status. Management will Establish a system for ongoing monitoring and oversight of expense reporting processes to identify and address any issues or discrepancies in a timely manner. Anticipated Completion Date: 2/26/2024.
Responsible Contact Person(s): Kassandra Bullock, Director of Grants Management DeAndrea Williams, Grants Admin Supervisor Joseph Thompson, Grants Compliance Supervisor John Colligan, Director of Finance and Administration Corrective Action Planned: An internal compliance review has been implemented...
Responsible Contact Person(s): Kassandra Bullock, Director of Grants Management DeAndrea Williams, Grants Admin Supervisor Joseph Thompson, Grants Compliance Supervisor John Colligan, Director of Finance and Administration Corrective Action Planned: An internal compliance review has been implemented to ensure accuracy and timely reporting of FFATA data. Data is confirmed prior to upload by the Grants Compliance Team to address errors, missing information, and conflicting dates. Training has occurred via the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) by Grants Admin staff. Additionally all changes in statements of grant awards (SOGA) will be reviewed and reissued when needed and data re-entered to ensure FFATA correlates with SOGA. Estimated Completion Date: 1/26/2024
Responsible Contact Person(s): Ida Witherspoon, Chief Financial Officer Corrective Action Planned: Send periodic e-mail reminders to program staff responsible for submitting FFATA data to the Federal Reporting Unit for submission to the federal government. Additional time is needed to fully impleme...
Responsible Contact Person(s): Ida Witherspoon, Chief Financial Officer Corrective Action Planned: Send periodic e-mail reminders to program staff responsible for submitting FFATA data to the Federal Reporting Unit for submission to the federal government. Additional time is needed to fully implement an automated solution. Estimated Completion Date: 10/30/2024
Responsible Contact Person(s): Angela Morse, Director of Benefit Programs Frank Smith, Associate Director of Benefit Programs Corrective Action Planned: DSS will perform an analysis of identified reporting errors to determine causality and the appropriate actions to resolve reporting errors. Additio...
Responsible Contact Person(s): Angela Morse, Director of Benefit Programs Frank Smith, Associate Director of Benefit Programs Corrective Action Planned: DSS will perform an analysis of identified reporting errors to determine causality and the appropriate actions to resolve reporting errors. Additionally, DSS will create a systems modification request to correct errors that are identified as occurring as a result of inaccurate programming in the data modification phase of federal report creation. Estimated Completion Date: 12/31/2024
Responsible Contact Person(s): Angela Morse, Director of Benefit Programs Frank Smith, Associate Director Senior Benefit Programs Denise Surber, EAP Manager - Division of Benefit Programs Corrective Action Planned: DSS will work to provide additional training to local agency eligibility workers on h...
Responsible Contact Person(s): Angela Morse, Director of Benefit Programs Frank Smith, Associate Director Senior Benefit Programs Denise Surber, EAP Manager - Division of Benefit Programs Corrective Action Planned: DSS will work to provide additional training to local agency eligibility workers on how to properly determine and document eligibility determinations in the case management system. Additionally, DSS will consider monitoring local agency eligibility worker’s use of manual overrides to confirm that they properly document eligibility determinations in the case management system. Estimated Completion Date: 12/31/2024
View Audit 295106 Questioned Costs: $1
Responsible Contact Person(s): Steve Hanoka, Chief Information Security Officer Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under §2.2-3705.2 (9.) of the Code of Virgin...
Responsible Contact Person(s): Steve Hanoka, Chief Information Security Officer Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under §2.2-3705.2 (9.) of the Code of Virginia. Federal awarding agencies and pass-through entities, please see the Appendix titled “Applicable Management Contacts for Findings and Questioned Costs” to request the corrective action planned from the applicable entity. Estimated Completion Date: 4/1/2024
Responsible Contact Person(s): Kevin Platea, Chief Information Officer Corrective Action Planned: DSS has 15 plus applications that are in active oversight; IT Business Administration is in receipt of the required SOC 2, Type 2 reports. However, additional requirements to capture the SOC 1, Type 2 ...
Responsible Contact Person(s): Kevin Platea, Chief Information Officer Corrective Action Planned: DSS has 15 plus applications that are in active oversight; IT Business Administration is in receipt of the required SOC 2, Type 2 reports. However, additional requirements to capture the SOC 1, Type 2 reports have not yet been accomplished. Several SOC reports were not captured by VITA and then provided to DSS for review. Additional requirements to capture SOC 1, Type 2 reports have been identified and VITA is requesting this information of the providers. Estimated Completion Date: 12/31/2024
Responsible Contact Person(s): Naveen Abraham, Chief Core Infrastructure Services Corrective Action Planned: Ensuring that infrastructure suppliers fulfill all contractual requirements with respect to Commonwealth security policies and standards necessitates a programmatic, continuous improvement ap...
Responsible Contact Person(s): Naveen Abraham, Chief Core Infrastructure Services Corrective Action Planned: Ensuring that infrastructure suppliers fulfill all contractual requirements with respect to Commonwealth security policies and standards necessitates a programmatic, continuous improvement approach. VITA has made improved cybersecurity a primary goal and major initiatives have completed and are underway. VITA has established a scoring mechanism, based on the Common Vulnerability Scoring System (CVSS), that delineates the necessary response based on the criticality of the vulnerability (critical, high, and medium). For vulnerabilities with a CVSS score of (critical and high), service level agreement (SLA) 1.1.3 is now in place to measure supplier performance and adjust supplier compensation accordingly through SLA credits and RCDs. For vulnerabilities below the critical and high score, in Q4 of 2023, suppliers started providing data in a quarterly report to the MSI and VITA. The new SLAs combined with the reports of vulnerabilities below the critical and high score are used to ensure suppliers’ contractual compliance. VITA’s data shows that patches for software on the enterprise software list are being applied on an ongoing basis. VITA will work with agencies and suppliers if there are any new technical difficulties or questions about patching. New tools are now available to agencies so that they can monitor and verify the remediation of the vulnerabilities for which infrastructure suppliers are responsible. Dashboards have also been provided to the suppliers so that they can review a shared and common vulnerability list. VITA and the suppliers monitor and review enterprise level logs and security events on behalf of customer agencies through the system dashboard and a 24x7 Security Operations Center. The dashboard is available for access by agencies as of Q4 2023. VITA will continue to monitor and improve the security of infrastructure services through ongoing governance, including the requirements of architecture documentation, system security plans, and audit reports. VITA’s infrastructure services group will work with the VITA security group to confirm that the current state achieves security standards compliance. Estimated Completion Date: 6/30/2024
Responsible Contact Person(s): Kevin Platea, Chief Information Officer Stephen Schleck, Associate Director of Enterprise Business Solutions Corrective Action Planned: A Change Request for the case management system was developed 2 years ago and DSS is reviewing the change request to determine a stat...
Responsible Contact Person(s): Kevin Platea, Chief Information Officer Stephen Schleck, Associate Director of Enterprise Business Solutions Corrective Action Planned: A Change Request for the case management system was developed 2 years ago and DSS is reviewing the change request to determine a status. It was agreed by Line of Business and ITS EBS & a vendor (the systems provider) that there will be an iterative approach to completing the record retention and purge rules for implementation in the case management system. Estimated Completion Date: 12/31/2024
Responsible Contact Person(s): Diane Carnohan, Chief Information Security Officer Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under §2.2-3705.2 (9.) of the Code of Virg...
Responsible Contact Person(s): Diane Carnohan, Chief Information Security Officer Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under §2.2-3705.2 (9.) of the Code of Virginia. Federal awarding agencies and pass-through entities, please see the Appendix titled “Applicable Management Contacts for Findings and Questioned Costs” to request the corrective action planned from the applicable entity. Estimated Completion Date: 6/1/2024
Responsible Contact Person(s): Kevin Platea, Chief Information Officer Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under §2.2-3705.2 (9.) of the Code of Virginia. Fede...
Responsible Contact Person(s): Kevin Platea, Chief Information Officer Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under §2.2-3705.2 (9.) of the Code of Virginia. Federal awarding agencies and pass-through entities, please see the Appendix titled “Applicable Management Contacts for Findings and Questioned Costs” to request the corrective action planned from the applicable entity. Estimated Completion Date: 12/31/2024
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