Corrective Action Plans

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Finding 2023-004: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants Federal Financial Assistance Listing Number: 10.766 Finding Summary: The Medical Center excluded adjustments from t...
Finding 2023-004: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants Federal Financial Assistance Listing Number: 10.766 Finding Summary: The Medical Center excluded adjustments from the lost revenue calculation. Responsible Individuals: Mark Wall, CFO Response: The Medical Center agrees with the findings. We will utilize our outside accounting firm for guidance to ensure appropriateness of calculations going forward. Completion Date: Ongoing
Name of contact person: Deqa Essa, Chief Financial Officer Corrective Action: The Organization changed management companies after June 30, 2023. The new management company has written policies and procedures and will ensure unit inspections are maintained in the tenant files. Proposed completion d...
Name of contact person: Deqa Essa, Chief Financial Officer Corrective Action: The Organization changed management companies after June 30, 2023. The new management company has written policies and procedures and will ensure unit inspections are maintained in the tenant files. Proposed completion date: The Organization plans to complete the plan by June 30, 2024.
CKHA will implement an internal quality control function which will review the income calculations for one hundred (100) percent of all move-ins and ten (10) percent of monthly recertifications by site to determine that incomes are correctly included int he Family Reports in accordance with the ACOP...
CKHA will implement an internal quality control function which will review the income calculations for one hundred (100) percent of all move-ins and ten (10) percent of monthly recertifications by site to determine that incomes are correctly included int he Family Reports in accordance with the ACOP and 24 CFR 960.259. Moving forward, Tammy Edelman, Director of Housing Management, will be responsible for assuring this function is completed in an accurate and timely manner. Anticipated Completion Date: This new function with be implemented January 1, 2024, and this will be an on-going function.
View Audit 8188 Questioned Costs: $1
Finding 6227 (2023-003)
Significant Deficiency 2023
2023-003 U.S. Department of the Treasury COVID-19: Coronavirus State and Local Fiscal Recovery Funds, Assistance Listing #21.027 Reporting Significant Deficiency Finding Summary: The City of Sparks did not have adequate internal controls to ensure Project and Expenditure Reports were prepared in acc...
2023-003 U.S. Department of the Treasury COVID-19: Coronavirus State and Local Fiscal Recovery Funds, Assistance Listing #21.027 Reporting Significant Deficiency Finding Summary: The City of Sparks did not have adequate internal controls to ensure Project and Expenditure Reports were prepared in accordance with governing requirements. The City reported current obligations for the amount the City recognized as a payable, rather than the obligations (i.e., contracts) that were entered into during the reporting period. Responsible Person: Jeff Cronk, CPA, Chief Financial Officer Corrective Action Planned: Financial Services staff will correct the Project and Expenditure Report current obligations for the period ended December 31, 2023 to ensure only the obligations that were entered into during the reporting period are reported. Does the City Agree with the finding: Yes If No or Partial, please explain the reason(s) why: Anticipated completion date: 1/31/2024
Finding 6157 (2023-001)
Significant Deficiency 2023
Finding 2023-001 Federal Agency Name: US Department of Health & Human Services, California Department of Social Services Program Name: Child Care and Development Fund Cluster CFDA #93.575 Finding Summary: The Commission has not established written procedures for determining allowability of costs in...
Finding 2023-001 Federal Agency Name: US Department of Health & Human Services, California Department of Social Services Program Name: Child Care and Development Fund Cluster CFDA #93.575 Finding Summary: The Commission has not established written procedures for determining allowability of costs in accordance with Subpart E- Cost principles or the conditions of the Federal award. Responsible Individuals: Debora Dickerson-Sims, Chief Financial Officer Corrective Action Plan: Review current policies and procedures to revise or develop new procedures for determining allowability of costs in accordance with Subpart E – Cost principles or the conditions of the Federal award. Anticipated Completion Date: June 30, 2024
U.S. Department of Health and Human Services Cedar County Memorial Hospital (“Organization”) respectfully submits the following corrective action plan for the year ended January 31, 2023. Audit period: February 1, 2022 – January 31, 2023 The findings from the schedule of findings and questioned cos...
U.S. Department of Health and Human Services Cedar County Memorial Hospital (“Organization”) respectfully submits the following corrective action plan for the year ended January 31, 2023. Audit period: February 1, 2022 – January 31, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS— FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL PROGRAMS DEPARTMENT OF HEALTH AND HUMAN SERVICES 2023 – 003 COVID-19 Provider Relief Funding and American Rescue Plan Rural Distribution Recommendation: We recommend the Hospital design controls to ensure that reporting is completing in accordance with latest HHS guidelines. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Management misunderstood the input of the information to be on fiscal vs. calendar year end. Name of the contact person responsible for corrective action: Carla Gilbert, CFO. Planned completion date for corrective action plan: November 1, 2023 If the Department of Health and Human Services has questions regarding this plan, please call Carla Gilbert, CFO at (417) 876-3097.
Finding #2023-003 - Major Federal Award Finding - Reporting Significant Deficiency-in Internal Controls over Compliance Corrective Action Plan: Procedure(s) were drafted covering data collection, storage, and reporting of HEERF data, including setting alerts to comply with the reporting due dates, h...
Finding #2023-003 - Major Federal Award Finding - Reporting Significant Deficiency-in Internal Controls over Compliance Corrective Action Plan: Procedure(s) were drafted covering data collection, storage, and reporting of HEERF data, including setting alerts to comply with the reporting due dates, however, the VP of Finance did not adhere to them. The VP of Finance will meet with the Executive Vice President to set up an accountability structure to ensure that quarterly reports are reviewed and filed on or before the due date. A revised annual report for calendar 2022 will be submitted to the Department of Education.
Inaccurate and Untimely Returns of Title IV Funds (R2T4) Planned Corrective Action: In conjunction with the Registrar’s Office, we have implemented the following corrective actions to improve our processes/timeframe for withdrawals: 1) This summer, the Financial Aid Office was added to the workfl...
Inaccurate and Untimely Returns of Title IV Funds (R2T4) Planned Corrective Action: In conjunction with the Registrar’s Office, we have implemented the following corrective actions to improve our processes/timeframe for withdrawals: 1) This summer, the Financial Aid Office was added to the workflow in Etrieve (document management system used by CIU) so that 2 of our counselors (one for UG trad and one for online) now receive notifications directly of every withdrawal received by the Registrar’s Office. This allows our office to begin the process of returning funds without the reliance of emails forwarded from the Registrar’s Office. 2) Director and Associate Directors of Financial Aid met with the Registrar and Assistant Registrar on 10/31/23 to discuss how communication and processes could improve between offices. The following are several action items the Registrar will complete on their end that can assist in accomplishing this goal. • Registrar will ask Deans to explain to their faculty that when a student completes an assignment after their module is complete, the date to be entered must be the last date of that module so that our reports will capture the date needed for the return to process correctly. • Registrar will review their current procedures for processing official withdrawals and tighten their turn around time so that the Financial Aid Office can return aid within the required 45 days. 3) CIU made the decision to convert all 5-week UG online classes to 8-week classes starting the 23-24 academic year. These modules now fall within our standard academic calendar which should greatly improve our ability to monitor and process withdrawals for this student population. Person Responsible for Corrective Action Plan: Patty Hix, Director of Financial Aid; Lynsay Shumpert, Associate Director for Online Studies; Elizabeth Haselden, Registrar Anticipated Date of Completion: A follow-up meeting has been set before the end of fall semester to discuss the progress of our action plans with the Registrar.
Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: 1. The security program documentation will be updated to reflect actions required by the June 2023 GLBA legislative changes. 2. The information and technology risk management activities logged and captured in supplemental docume...
Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: 1. The security program documentation will be updated to reflect actions required by the June 2023 GLBA legislative changes. 2. The information and technology risk management activities logged and captured in supplemental documentation will be included in the master security program documentation going forward. 3. Active technology projects and roadmap initiatives that impact GLBA compliance will be expedited. Person Responsible for Corrective Action Plan: Tirrell Howell, Vice President of Information Technology Anticipated Date of Completion: May 31, 2024
Finding Summary: Ascent Academies of Utah is required to submit an annual performance report to the State of Utah detailing GEER and ESSER expenditures by subgrant fund, expenditure category, object code, number of specific positions supported with GEER and ESSER funds, allocation of GEER and ESSER ...
Finding Summary: Ascent Academies of Utah is required to submit an annual performance report to the State of Utah detailing GEER and ESSER expenditures by subgrant fund, expenditure category, object code, number of specific positions supported with GEER and ESSER funds, allocation of GEER and ESSER funds and criteria used and number of full-time equivalent positions for all GEER & ESSER funds received from the USBE during the period of July 1, 2021 to June 30, 2022. Ascent Academies of Utah reported ESSER II expenditures incorrectly. Responsible Individuals: Accountant and Lead Director Corrective Action Plan: Management has communicated with the State of Utah regarding what they believe to be deficiencies in the reporting mechanism that was provided by the State to report annual GEER and ESSER expenditures. These deficiencies include the absence of adequate means for management to prevent and detect typographical errors, and the absence of documentation for the submitted report. The reporting error has been corrected and management will use mitigating controls to prevent future errors. Anticipated Completion Date: The Corrective Action Plan has been implemented.
Finding 5785 (2023-003)
Significant Deficiency 2023
GEAR UP Program In-Kind Match Planned Corrective Action: The corrective action plan is to review In-Kind Match monthly, to ensure we there are no missing documentation & review for accuracy. Person Responsible for Corrective Action Plan: Shelley Belong Anticipated Date of Completion: December 1, ...
GEAR UP Program In-Kind Match Planned Corrective Action: The corrective action plan is to review In-Kind Match monthly, to ensure we there are no missing documentation & review for accuracy. Person Responsible for Corrective Action Plan: Shelley Belong Anticipated Date of Completion: December 1, 2023
Finding 5784 (2023-002)
Significant Deficiency 2023
Need Analysis Planned Corrective Action: The University recognizes the federal regulations regarding over‐awarding and has implemented the use of a delivered report through the Student Information System to address this concern. Person Responsible for Corrective Action Plan: Shondra Dickson, Direc...
Need Analysis Planned Corrective Action: The University recognizes the federal regulations regarding over‐awarding and has implemented the use of a delivered report through the Student Information System to address this concern. Person Responsible for Corrective Action Plan: Shondra Dickson, Director of Financial Aid Anticipated Date of Completion: Implemented
2023-006 Special Tests and Provisions Recommendation: We recommend that management implements journal entry review process for Workforce Council Executive Director indirect cost allocations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action pl...
2023-006 Special Tests and Provisions Recommendation: We recommend that management implements journal entry review process for Workforce Council Executive Director indirect cost allocations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: MVACs executive director will review WFCs executive director timesheet for approval. Name of the contact person responsible for corrective action: Amanda Mackie Planned completion date for corrective action plan: We plan to implement by the 12.01.2023 payroll.
2023-001 Activities Allowed or Unallowed Recommendation: We recommend obtaining documentation of approval for all invoices. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Staff will be retrained to ensu...
2023-001 Activities Allowed or Unallowed Recommendation: We recommend obtaining documentation of approval for all invoices. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Staff will be retrained to ensure they are following procedures and collecting the appropriate signatures and documentation prior to dispersing funds. Name of the contact person responsible for corrective action: Amanda Mackie Planned completion date for corrective action plan: This has been completed.
Finding 5746 (2023-005)
Significant Deficiency 2023
Finding 2023-005: Reporting of disbursement dates to the Common Origination and Disbursement system Contact person responsible for correction action – Mitzi Suhler, Vice President of Enrollment Services Anticipated completion date – June 30, 2023 Corrective action Sterling College agrees with t...
Finding 2023-005: Reporting of disbursement dates to the Common Origination and Disbursement system Contact person responsible for correction action – Mitzi Suhler, Vice President of Enrollment Services Anticipated completion date – June 30, 2023 Corrective action Sterling College agrees with the finding regarding the disbursement dates of two students who were reported incorrectly to the COD system. We will provide continued training to those who are responsible for compliance of reporting accurate disbursement dates. We will review processes and internal controls and make any necessary changes to prevent and/or detect issues so that they can be corrected in a timely manner.
Finding 2023-001 – Housing Choice Voucher Tenant Files – Eligibility – Rent Calculations Noncompliance & Significant Deficiency Section 8 Housing Choice Voucher Cluster – ALNs 14.871 and 14.879 Corrective Action Plan: Finding: Somerville Housing Authority (SHA) received the authority’s Single Audi...
Finding 2023-001 – Housing Choice Voucher Tenant Files – Eligibility – Rent Calculations Noncompliance & Significant Deficiency Section 8 Housing Choice Voucher Cluster – ALNs 14.871 and 14.879 Corrective Action Plan: Finding: Somerville Housing Authority (SHA) received the authority’s Single Audit for the year ended March 31, 2023, indicating that SHA received a finding of Significant Deficiencies identified not considered to be material weaknesses. Auditors noted three files missing documentation of the action, as well as four missing income verification or outdated income verification. Auditors recommend that SHA conduct a file audit to determine the extent of deficiencies. They also recommend that SHA implement a quality control review to monitor the maintenance of tenant files. PHA Response: The SHA has implemented a corrective action plan to address noted deficiencies. The SHA has had significant staffing turnover in the last year. As a result, until all vacant positions are filled, the SHA has contracted with Nan McKay Associates (NMA) to complete all Annual Recertifications. NMA has assigned four full-time staff to complete all recertifications and has assigned one additional full-time staff person to conduct a monthly Qualify Control Review of all recertifications completed by NMA. During NMA’s contract, SHA has focused on refilling positions and training new staff. SHA has hired a new Director of Leased Housing, a new Leased Housing Supervisor, and one Leasing Coordinator. Two additional Leasing Coordinator positions are still vacant, and interviews are ongoing. SHA plans to hire two more staffers for that role. The Director and Supervisor have been providing one-on-one training and support to all new staff in addition to enrollment in training opportunities provided by outside vendors. At weekly staff meetings, the Director reviews Administrative Plan policies, and corrections needed for any quality control issues found before they become systemic. Besides the Nan McKay monthly quality control review, the SHA has begun conducting internal quality control audits every month for SEMAP. Additionally, SHA has implemented an electronic file storage system, utilizing PHA Web’s online system to better organize, track, and maintain client files. PHA Goal: Based on the SHA’s monthly quality control sample of tenant files: (A) The SHA obtains third party verification of reported family annual income, the value of assets totaling more than $5,000, expenses related to deductions from annual income, and other factors that affect the determination of adjusted income, and uses the verified information in determining adjusted income, and/or documents tenant files to show why third party verification was not available; (B) The SHA properly attributes and calculates allowances for any medical, child care, and/or disability assistance expenses; and (C) The SHA uses the appropriate utility allowances to determine gross rent for the unit leased, (D) The SHA applies the appropriate payment standard in accordance with 24 CFR 982.505. PHA Strategies: Target completion date 1) The SHA will review its current quality control tracking system to record the results of random sampling of files as required in 985.2. The SHA will revise this system on an ongoing basis if necessary. 12/31/2023 2) Confirm that 90% or more files sampled contain proper third party written verification (or equivalent) of income and assets, proper calculation of appropriate deductions and allowances and that appropriate utility allowance were used in the calculation of tenant rent. 80% 12/31/2023 Person Responsible: Matt Lincoln, Director of Leased Housing David Hospedales, Leased Housing Supervisor Anticipated Completion Date: The SHA anticipates completing all hiring and training of new Leased Housing staff no later than 04/01/2024.
View Audit 7804 Questioned Costs: $1
Finding 5733 (2023-001)
Significant Deficiency 2023
Management utilized the HRSA FAQ guidelines and interpreted the reporting guidance, to the best extent possible, based on how it was presented. The reporting guidance was somewhat convoluted; however, Management acknowledges the overstatement amounting to $723,754 and the fact that the error does no...
Management utilized the HRSA FAQ guidelines and interpreted the reporting guidance, to the best extent possible, based on how it was presented. The reporting guidance was somewhat convoluted; however, Management acknowledges the overstatement amounting to $723,754 and the fact that the error does not jeopardize the PRF amount received. Management will support staff in continuing professional education, specifically tied to Yellow book training. Furthermore, management will hire a subject matter expert and/or organically facilitate the creation of this expertise within the existing talent pool. Contact individual responsible for the corrective action plan is Kimberly Myers, Director of Accounting and Financial Reporting.
Finding 5707 (2023-005)
Significant Deficiency 2023
Management’s Response and Planned Corrective Actions: 1. The name of the contact person(s) responsible for the corrective action a. Kathleen Broadhurst, Sr. Director of Finance/ShelterCare 2. The corrective action planned: a. ShelterCare, as new managing agent, will be utilizing the same AP invoice ...
Management’s Response and Planned Corrective Actions: 1. The name of the contact person(s) responsible for the corrective action a. Kathleen Broadhurst, Sr. Director of Finance/ShelterCare 2. The corrective action planned: a. ShelterCare, as new managing agent, will be utilizing the same AP invoice naming conventions that we currently utilize for ShelterCare’s books to ensure we do not duplicate a payment to a vendor. 3. The anticipated completion date: a. 5/1/2023 – when ShelterCare took over as new managing agent.
Finding 5706 (2023-004)
Significant Deficiency 2023
Management’s Response and Planned Corrective Actions: 1. The name of the contact person(s) responsible for the corrective action a. Kathleen Broadhurst, Sr. Director of Finance/ShelterCare 2. The corrective action planned: a. ShelterCare, as new managing agent, will ensure that monthly required depo...
Management’s Response and Planned Corrective Actions: 1. The name of the contact person(s) responsible for the corrective action a. Kathleen Broadhurst, Sr. Director of Finance/ShelterCare 2. The corrective action planned: a. ShelterCare, as new managing agent, will ensure that monthly required deposits are completed to the replacement reserve account. 3. The anticipated completion date: a. 7/1/2023 – new managing agent is now responsible for monthly required deposits.
Finding 5705 (2023-003)
Significant Deficiency 2023
Management’s Response and Planned Corrective Actions: 1. The name of the contact person(s) responsible for the corrective action a. Kathleen Broadhurst, Sr. Director of Finance/ShelterCare 2. The corrective action planned: a. ShelterCare, as new managing agent, will ensure that any surplus cash (if ...
Management’s Response and Planned Corrective Actions: 1. The name of the contact person(s) responsible for the corrective action a. Kathleen Broadhurst, Sr. Director of Finance/ShelterCare 2. The corrective action planned: a. ShelterCare, as new managing agent, will ensure that any surplus cash (if any) is deposited within 60 days following year-end. Prior Managing agent failed at following this requirement. 3. The anticipated completion date: a. August 29, 2023 (60 days after fiscal year-end)
Finding 5704 (2023-002)
Significant Deficiency 2023
Management’s Response and Planned Corrective Actions: 1. The name of the contact person(s) responsible for the corrective action a. Kathleen Broadhurst, Sr. Director of Finance/ShelterCare 2. The corrective action planned: a. ShelterCare, as managing agent, has hired a new property accountant which ...
Management’s Response and Planned Corrective Actions: 1. The name of the contact person(s) responsible for the corrective action a. Kathleen Broadhurst, Sr. Director of Finance/ShelterCare 2. 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. 3. The anticipated completion date: a. New property accountant was hired in August of 2023.
Our regular federal awards are being regularly submitted on a monthly basis by our bookkeeper. The finding is related to our newer grants that were awarded WYBILT specfically, and the ESSER III - ARP and were taken on by the business manager. We also had our GEER II award that had delays in cash req...
Our regular federal awards are being regularly submitted on a monthly basis by our bookkeeper. The finding is related to our newer grants that were awarded WYBILT specfically, and the ESSER III - ARP and were taken on by the business manager. We also had our GEER II award that had delays in cash requests. At different points in the year multiple changes in requirements in what to provide for documentation, caused a delay in doing cash requests. The business manager will work to shorten the amount of time this process takes in the upcoming year. We have fewer grants that will be tracked which will help in getting the time between expenditures and when cash is requested.
Finding 5661 (2023-001)
Significant Deficiency 2023
Department of Education Immaculata University respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 01, 2022 - June 30, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consist...
Department of Education Immaculata University respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 01, 2022 - June 30, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FINANCIAL STATEMENT AUDIT No findings over financial statement audit. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS Department of Education 2023-001 Student Financial Assistance Cluster – Federal Assistance Numbers 84.007, 84.063, 84.268 Recommendation: We recommend the University develop a process to ensure that all Title IV outstanding checks are returned back to the ED within the required timeframe and verify on a regular basis the process has been followed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University had an established monthly process for returning Title IV outstanding checks to the Department of Education. During the months of January, 2023 and May, 2023, the University did not follow this established monthly process. Beginning in August, 2023, the University began scheduling monthly meetings to ensure all Title IV outstanding checks are returned to the Department of Education within the required timeframe. Name(s) of the contact person(s) responsible for corrective action: Joanne Cristinzio Planned completion date for corrective action plan: August 15, 2023 If the Department of Education has questions regarding this plan, please call Joanne Cristinzio at 484- 323-3067.
View Audit 7583 Questioned Costs: $1
Action taken: Saint Martin’s University will review the requirements of 16 CFR 314.4, update our written policy to ensure that it addresses all the required elements 16 CFR 314.3(b), and perform an annual review of our updated policy to ensure that it continues to comply with all relevant regulation...
Action taken: Saint Martin’s University will review the requirements of 16 CFR 314.4, update our written policy to ensure that it addresses all the required elements 16 CFR 314.3(b), and perform an annual review of our updated policy to ensure that it continues to comply with all relevant regulations. The University is currently in the process of formally adopting a cybersecurity framework as well as securing a vendor to perform an IT security assessment. This ongoing work in the interest of the security, confidentiality, and integrity of student information will position us well to make the recommended updates to our policy Name of Responsible Party: Mary Donahoo, Chief Information Officer Anticipated completion date: 3/31/2024
Action taken: As of June 2023, the Financial Aid department has a full-time Director, who is responsible for the Return to Title IV (R2T4) determinations. Following the regulations set forth by the Department of Education on R2T4 calculations for schools not required to take attendance, we have revi...
Action taken: As of June 2023, the Financial Aid department has a full-time Director, who is responsible for the Return to Title IV (R2T4) determinations. Following the regulations set forth by the Department of Education on R2T4 calculations for schools not required to take attendance, we have reviewed procedures and controls to ensure they are properly designed and implemented to ensure calculations are occurring accurately and timely. Going forward, we will ensure maintenance of proper documentation on students requiring a calculation, including indication of withdrawal date. Potential R2T4 calculations audits are now run multiple times a week, and will continue to be, in order to address timely calculations. The Director plans to continue education in the area of R2T4 calculations to maintain the most accurate and updated information on the topic. Name of Responsible Party: Erin Schaffer, Director of Financial Aid Anticipated completion date: 12/31/2023
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