Corrective Action Plans

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Finding 395193 (2023-031)
Significant Deficiency 2023
Finding 2023-031 – Corrective Action Plan RIDOH agrees with the finding and recommendation. The RI WIC Program was cited by USDA for this issue over a year ago. The issue was caused by the Crossroads MIS system rounding up the calculation for converting formula upon issuance, resulting in over iss...
Finding 2023-031 – Corrective Action Plan RIDOH agrees with the finding and recommendation. The RI WIC Program was cited by USDA for this issue over a year ago. The issue was caused by the Crossroads MIS system rounding up the calculation for converting formula upon issuance, resulting in over issuance in certain situations. RI WIC immediately changed the calculation and responded to the USDA finding with implementing an updated policy and changes to the system. On December 15, 2023, RI WIC received a response from USDA stating that the finding was closed. Anticipated Completion Date: Completed December 15, 2023 Contact Person: Anthony Manzi, WIC Fiscal Manager, Rhode Island Department of Health anthony.manzi@health.ri.gov
View Audit 305097 Questioned Costs: $1
Management acknowledges noncompliance in the current fiscal year and has addressed all of the health and safety issues as of January 25, 2023
Management acknowledges noncompliance in the current fiscal year and has addressed all of the health and safety issues as of January 25, 2023
Management acknowledges noncompliance in the current fiscal year and has addressed all of the health and safety issues as of February 1, 2024
Management acknowledges noncompliance in the current fiscal year and has addressed all of the health and safety issues as of February 1, 2024
2023-002 Special Rest; Graduation Cohort Recommendation: We recommend that the schools develop internal controls and procedures to ensure the documentation is consistently maintained to support compliance with grantor’s requirements. Action planned/taken in response to finding: 1. City Schools will ...
2023-002 Special Rest; Graduation Cohort Recommendation: We recommend that the schools develop internal controls and procedures to ensure the documentation is consistently maintained to support compliance with grantor’s requirements. Action planned/taken in response to finding: 1. City Schools will draft guidance to schools reminding them of their obligation to maintain documentation for all student transfers as per the MSDE Student Records Manual, P.32. The initial guidance will remind schools that all documentation needs to be saved as part of a student’s transfer packet. For SY24-25, the guidance will be updated to instruct schools to save all transfer requests in Person Documents in Infinite Campus (IC). This will be a collaboration between the Office of Achievement and Accountability (OAA) and the Schools Office. 2. City Schools will create a new data cleansing report (DCR) to ensure that all transfer codes entered in Infinite Campus have transfer documentation uploaded to IC to support the transfer request. The above guidance will be shared with schools as part of the launch of the new DCR report in SY24-25. This will be a collaboration between OAA and the Office of Information Technology (OIT). 3. City Schools’ School Managers will monitor the new DCR to ensure schools are uploading documentation for every transfer into IC. Name(s) of the contact person(s) responsible for corrective action: Holly Bedwell (OAA) and Sabree Barnes (Schools Office) Planned completion date for corrective action plan: September 9, 2024.
This finding is related to activities on our VOCA grants. As was the case in Finding #005, the majority of the exceptions were related to either finding #2 above or were related to the process in place prior to May 2023. Again, in May 2023 FRLS added an electronic transaction approval process via te...
This finding is related to activities on our VOCA grants. As was the case in Finding #005, the majority of the exceptions were related to either finding #2 above or were related to the process in place prior to May 2023. Again, in May 2023 FRLS added an electronic transaction approval process via teams, that documents approvals for all our AP, AR and other transactions initiated by our accounting staff. These are reviewed and approved by the CFO before being posted into the GL. It was also noted that our process of allocating costs from our overhead cost centers to our various grants, was not fully documented. The CFO will undertake a review of this process to ensure that we are in compliance with allowable cost documentation requirements. We will also review and update our documentation of allocations and ensure that each month’s allocation is properly approved. This review will be completed within the next 90 days.
View Audit 304969 Questioned Costs: $1
FRLS shared that as part of the corrective action plan, improved PAI services by changing pro bono coordinators from paralegals to attorneys to better work with private attorneys and respective bar associations throughout our service areas. FRLS has also reestablished connections with our respective...
FRLS shared that as part of the corrective action plan, improved PAI services by changing pro bono coordinators from paralegals to attorneys to better work with private attorneys and respective bar associations throughout our service areas. FRLS has also reestablished connections with our respective service partners throughout the pandemic, rebuilding and providing excellent services through our pro bono partners. PAI remains one of our top priorities in expanding our program services. Our program improvements, including pro bono assistance via virtual and courthouse clinics have resulted in more PAI services to our client communities. We have increased attendance at our annual bench and bar events to raise PAI awareness in our service communities. FRLS is in the process of creating a “low bono” program to expand our network of private attorneys and meet our required 12.5% spending requirement. FRLS will continue to evaluate its policies and procedures surrounding monitoring of PAI compliance to ensure that only allowable pro bono cases are accepted. This will be completed by December 31, 2024.
Upon review, FRLS had retainer agreements for both of the exceptions listed, but they were not readily available for review. FRLS has implemented a checklist of required documentation before every case closure to be reviewed by the Regional Managing Attorneys and Advocacy Director. Upon closure of a...
Upon review, FRLS had retainer agreements for both of the exceptions listed, but they were not readily available for review. FRLS has implemented a checklist of required documentation before every case closure to be reviewed by the Regional Managing Attorneys and Advocacy Director. Upon closure of a case file, the assigned advocate and Regional Managing Attorney will then attest that a case file contains all necessary documentation for compliance. A review of the checklist and case files will be done by the Advocacy Director on a regular basis to ensure compliance.
Prior to 2018, obtaining the simple agreement, when required by LSC regulations, was the responsibility of the managing attorney for the unit or office. In 2018, this responsibility was transferred to the Human Resources Administrator to ensure this document and others were timely obtained and place...
Prior to 2018, obtaining the simple agreement, when required by LSC regulations, was the responsibility of the managing attorney for the unit or office. In 2018, this responsibility was transferred to the Human Resources Administrator to ensure this document and others were timely obtained and placed in the employee’s personal file. Based on these findings, all current employees, for whom a simple agreement was not in the personnel file, were required to sign the agreement or submit a copy of the agreement they previously signed. All current employees, required to sign the simple agreement, have one on file. Human Resources will continue to obtain the agreements as part of the new employee onboarding process.
One of the two meeting minutes noted, January 30, 2023, was approved at the March 3, 2023 board meeting and submitted to LSC on May 9, 2023. The minutes of the May 22, 2023 meeting have not been approved and should not have been submitted on September 7, 2023. The minutes for the May 22, 2023 meetin...
One of the two meeting minutes noted, January 30, 2023, was approved at the March 3, 2023 board meeting and submitted to LSC on May 9, 2023. The minutes of the May 22, 2023 meeting have not been approved and should not have been submitted on September 7, 2023. The minutes for the May 22, 2023 meeting will be placed on the upcoming Executive Committee meeting agenda for review and approval as appropriate. Upon approval, the May 22, 2023 meeting minutes will be re‐submitted to LSC. CLS recently implemented a new process. If there is not a quorum at a full board meeting, the minutes that were on that meeting’s agenda for approval will be placed on the next scheduled Executive Committee meeting for review and approval. For example, if there is no quorum at the January full board meeting, all meeting minutes that were scheduled for review and approval at that meeting will be placed on the agenda for the Executive Committee meeting later that month for approval and reported out to the full board at its next regularly scheduled meeting in March. This will ensure timely review, approval and submission of minutes for board and committee meetings.
2023-006 Timely Submission of Quarterly Financial Status Reports The Director of Finance will ensure Financial Status Reports are filed timely. The deadlines will be added to a calendar that tracks deadlines, maintained by the Director of Finance.
2023-006 Timely Submission of Quarterly Financial Status Reports The Director of Finance will ensure Financial Status Reports are filed timely. The deadlines will be added to a calendar that tracks deadlines, maintained by the Director of Finance.
Finding 394997 (2023-001)
Significant Deficiency 2023
Views of responsible officials and planned corrective action: City Management takes grant compliance very seriously and corrective action has been taken. The City has created a checklist encompassing all grant-related tasks, and an Environmental Review Record (ERR) is part of that checklist and will...
Views of responsible officials and planned corrective action: City Management takes grant compliance very seriously and corrective action has been taken. The City has created a checklist encompassing all grant-related tasks, and an Environmental Review Record (ERR) is part of that checklist and will be completed for every property and program.
Finding 394962 (2023-001)
Significant Deficiency 2023
2023-001-Reporting Federal Agency: U.S. Department of the Treasury Federal Program Name: Covid-19 Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Recommendation: We recommend corrections to quarterly reports be made in subsequent quarterly reports to ensure obliga...
2023-001-Reporting Federal Agency: U.S. Department of the Treasury Federal Program Name: Covid-19 Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Recommendation: We recommend corrections to quarterly reports be made in subsequent quarterly reports to ensure obligations match actuality. We recommend timely reconciliation of accounting transactions to allow for accurate reporting of expenditures through the quarter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The findings noted on the FY 22/23 audit regarding expenditures and obligations were in direct correlation with the findings noted on the FY 21/22 audit. At the close of the FY 21/22 audit, quarter one and quarter two reports had been filed with Treasury. Leading into quarter three, corrections to reporting obligations were being addressed and corrected. As of the fourth quarter reporting cycle, all expenses and obligation issues were corrected. Name(s) of the contact person(s) responsible for corrective action: Christia Johnson, Budget and Management Services Director Planned completion date for corrective action plan: As mentioned above, this has already been addressed as part of the FY 21/22 audit that was finalized in April 2023, 7 months into FY 2022/23. The Budget Office will continue to follow the procedures that were put into place more than halfway through FY 22/23.
Finding 394961 (2023-002)
Significant Deficiency 2023
Federal Agency: Department of Homeland Security Federal Program Name: Hazard Mitigation Grant Assistance Listing Number: 97.039 Recommendation: We recommend that the quarterly reports be reviewed by an appropriate member of management. That review should be documented to ensure a complete audit trai...
Federal Agency: Department of Homeland Security Federal Program Name: Hazard Mitigation Grant Assistance Listing Number: 97.039 Recommendation: We recommend that the quarterly reports be reviewed by an appropriate member of management. That review should be documented to ensure a complete audit trail. In addition, all reports should be stored in a centralized location for easy future access. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County is working on implementing a review by management for all HMGP Grant quarterly reports. In addition, this review will be documented and stored in a centralized location for easy future access. The County is looking into creating a policy that would require divisions to save their grant information on a shared drive, while we are also looking at purchasing a grant management software as a repository for all related grant documents. Name(s) of the contact person(s) responsible for corrective action: These HMGP grants are in several divisions, so the directors over those divisions should be responsible for the corrective actions. This would include Tamara Richardson, Utilities Director; Gaye Sharpe, Parks and Natural Resources Director; Jay Jarvis, Roads and Drainage Director; and Keith Tate, Facilities Management Director. Planned completion date for corrective action plan: September 30, 2024
Finding 394945 (2023-002)
Significant Deficiency 2023
Recommendation: We recommend that management review its policies and procedures surrounding cut-off around the end of reporting periods to ensure disbursements are recorded in the correct reporting period. Views of Responsible Official: There is no disagreement with this finding. Action taken in r...
Recommendation: We recommend that management review its policies and procedures surrounding cut-off around the end of reporting periods to ensure disbursements are recorded in the correct reporting period. Views of Responsible Official: There is no disagreement with this finding. Action taken in response to finding: The Organization will continue to enhance our grant-end and year-end transaction monitoring to ensure appropriate treatment of expenses. Additionally, the organization will enhance communication with staff across the Organization to share grant and fiscal-year related deadlines
Finding 394944 (2023-001)
Significant Deficiency 2023
Recommendation: We recommend that management implement a control to review PAI time entries to ensure they are accurate. Views of Responsible Official: There is no disagreement with this finding. Action taken in response to finding: On a monthly basis, the Deputy Director/General Counsel will run ...
Recommendation: We recommend that management implement a control to review PAI time entries to ensure they are accurate. Views of Responsible Official: There is no disagreement with this finding. Action taken in response to finding: On a monthly basis, the Deputy Director/General Counsel will run a LegalServer report on PAI time, including missing activity details, and will follow up with each person to correct their time records as needed. We will also provide additional training to staff on requirements for classifying time as PAI, and the importance of accuracy in timekeeping detail.
Management will implement an additional review step to evaluate the timing of when such costs are incurred in order to ensure accounts payable includes all applicable invoices.
Management will implement an additional review step to evaluate the timing of when such costs are incurred in order to ensure accounts payable includes all applicable invoices.
Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN #370645239 Activities Allowed or Unallowed and Allowable Costs/Cost Principles ...
Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN #370645239 Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Summary: During our testing, there was no documentation of review and approval of the expenditure listing or lost revenue calculation. The Organization also miscalculated the portion of an expense that was reimbursed by another source.Responsible Individuals: Paul Courtney, CFO Corrective Action Plan: Management will implement internal control policies and procedures to ensure the expenditure listing and lost revenue calculation are reviewed and approved to ensure that all payments are necessary, correct, meet the requirements of the federal program, and are properly recorded in the reports required to be submitted to the federal agency. Anticipated Completion Date: June 30, 2024
Finding 394867 (2023-003)
Significant Deficiency 2023
Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: The University will proceed with approval and implementation of draft policies and procedures and will expand the information security program to address identified issues. The University will allocate necessary resources and wil...
Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: The University will proceed with approval and implementation of draft policies and procedures and will expand the information security program to address identified issues. The University will allocate necessary resources and will contract with necessary third-party providers to meet existing resource and technology gaps. Person Responsible for Corrective Action Plan: Jeff Lundblad, AVP and Chief Information Officer Anticipated Date of Completion: October, 2024
Corrective Action Plan: I am in receipt of the draft finding letter for the audit that was recently conducted for the Housing Authority of McDonough County. Of the 15 tenant files randomly chosen to review, 7 were not in compliance. Discrepancies include: • Failing to gather proper income verificati...
Corrective Action Plan: I am in receipt of the draft finding letter for the audit that was recently conducted for the Housing Authority of McDonough County. Of the 15 tenant files randomly chosen to review, 7 were not in compliance. Discrepancies include: • Failing to gather proper income verification; • Failing to properly calculate annual income; • Failing to maintain EIV documentation; • Failing to maintain birth certificates or social security cards; and • Failing to maintain Declaration 214s. As I am Executive Director, I am responsible for the Corrective Action Plan that will include rental calculation and HOTMA training for a property managers and me. I am scheduled to attend a rent calc/HOTMA training seminar the week of March 18th. The managers are scheduled to attend a rent calc/HOTMA training seminar the week of April 3rd. In addition, a Quality Assurance program to monitor tenant files will be in effect by April 30, 2024. Anticipated Completion Date: April 30, 2024. Person Responsible: Annette Carper, Executive Director
The following represents the Corrective Action Plan related to the audit finding listed in the Schedule of Findings and Questioned Costs included in the December 31, 2023 audited financial statements of Machester Supportive Housing, Inc. d/b/a Page Place: Finding 2023-001: Failure to make the correc...
The following represents the Corrective Action Plan related to the audit finding listed in the Schedule of Findings and Questioned Costs included in the December 31, 2023 audited financial statements of Machester Supportive Housing, Inc. d/b/a Page Place: Finding 2023-001: Failure to make the correct required deposit into the Reserve for Replacement Account. Condition and Criteria: The Corporation failed to increase its monthly deposits into its Reserve for Replacement account based on a required increase in its monthly deposit. The incorrect deposit was made during the months September 2022 through January 2023. As a result, its reserve for replacement account has been underfunded by $4,750. Management Response and Corrective Action Plan: Management agrees with the finding. The Corporation will make an additional deposit in April 2024 to satisfy this deficiency.
The following represents the Corrective Action Plan related to the audit finding listed in the Schedule of Findings and Questioned Costs included in the December 31, 2023 audited financial statements of McDonald Presbyterian Senior Housing, Inc. d/b/a HaveLoch Commons: Finding 2023-001: Incorrect El...
The following represents the Corrective Action Plan related to the audit finding listed in the Schedule of Findings and Questioned Costs included in the December 31, 2023 audited financial statements of McDonald Presbyterian Senior Housing, Inc. d/b/a HaveLoch Commons: Finding 2023-001: Incorrect Eligibility Assessment Condition and Criteria: The Corporation made a data entry error for the annual medical expenses of a resident. Accurate financial information is essential in order to calculate the correct subsidy each resident is eligible for. Management Response and Corrective Action Plan: Management agrees with the finding. The Corporation will perform re-education to its existing members on the importance of this data entry, and update its standard review process over these calculations in order to detect errors on a timely basis.
Finding 394759 (2023-003)
Significant Deficiency 2023
Finding Number: 2023-003 Condition: The schedule of expenditures of federal awards (SEFA) was not complete. Planned Corrective Action: The College will ensure that the schedule of federal awards (SEFA is reviewed for completeness. Going forward, the SEFA will be compared with the prior year SEFA and...
Finding Number: 2023-003 Condition: The schedule of expenditures of federal awards (SEFA) was not complete. Planned Corrective Action: The College will ensure that the schedule of federal awards (SEFA is reviewed for completeness. Going forward, the SEFA will be compared with the prior year SEFA and a separate schedule of new awards for the current fiscal period. The results of this comparison will be reviewed by the grants office, the controller’s office and the Vice President’s office. This will increase the level of reviews to a three-tiered process which should address issues of completeness of the SEFA. Contact person responsible for corrective action: Ms. Jackie Brown, Ms. Deborah McKenzie, and Dr. Sharron T. Burnett Anticipated Completion Date: 06/30/2024
Finding 394755 (2023-002)
Significant Deficiency 2023
Finding Number: 2023-002 Condition: The College did not follow all the Tier Two arrangement requirements and disclosures. Planned Corrective Action: The College will ensure that regulations related to Tier Two arrangements are reviewed. On a semiannual basis, the College will review all arrangements...
Finding Number: 2023-002 Condition: The College did not follow all the Tier Two arrangement requirements and disclosures. Planned Corrective Action: The College will ensure that regulations related to Tier Two arrangements are reviewed. On a semiannual basis, the College will review all arrangements service providers for compliance with regulations. In addition, the College will review cash management regulations and references such as Dear Colleague letters on the subject matter to remain current with requirements. Contact person responsible for corrective action: Ms. Taranne Roberts and Dr. Sharron T. Burnett Anticipated Completion Date: 06/30/2024
Action Taken The Lending Department has recently onboarded a new Lending Operations Manager as well as a Lending Operations Analyst with the primary responsibility of submitting timely reports to the SBA and others. These individuals do not have client-facing responsibilities and are solely focused ...
Action Taken The Lending Department has recently onboarded a new Lending Operations Manager as well as a Lending Operations Analyst with the primary responsibility of submitting timely reports to the SBA and others. These individuals do not have client-facing responsibilities and are solely focused on the internal lending operations. Employee goal setting for FY2024 will include the timely report submission. Anticipated Completion Date: March 31, 2024 If there are any questions regarding this plan, please call Kevin Fryatt, Co-Interim CEO and Chief Financial & Operations Officer (CFOO) at 202-516-1156. Submitted by, Kevin Fryatt Co-Interim CEO Chief Financial & Operations Officer 12
Finding Number: 2023-017 Federal Program: 14.218, Department of Housing and Urban Development (HUD), CDBG – Entitlement Grants Cluster, Community Development Block Grants/Entitlement Grants Program (CDBG) Condition Per Auditor: The County filed the FFATA report seven months late Planned Corrective A...
Finding Number: 2023-017 Federal Program: 14.218, Department of Housing and Urban Development (HUD), CDBG – Entitlement Grants Cluster, Community Development Block Grants/Entitlement Grants Program (CDBG) Condition Per Auditor: The County filed the FFATA report seven months late Planned Corrective Action: Management agrees with this finding. The County will implement a notification process to include communication to the grants division once grant contracts are approved. Subsequent FFATA reports will be filed of notification of approval no later than the last day of the month following the month in which the subaward/subaward amendment obligation. Anticipated Completion Date: 6/30/25 Responsible Contact Person: Shauntika Bullard
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