Corrective Action Plans

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Corrective Action Plan: CBHA updated its process to assign current year cases to patients under the sliding fee program. Previous cases are now closed at the end of the benefit year preventing staff from selecting an incorrect case under the sliding fee program. This alerts staff that the patient's ...
Corrective Action Plan: CBHA updated its process to assign current year cases to patients under the sliding fee program. Previous cases are now closed at the end of the benefit year preventing staff from selecting an incorrect case under the sliding fee program. This alerts staff that the patient's coverage is expiring and needs to be renewed. In addition, an electronic audit is performed on all sliding fee appointments that identifies any discrepancy between the active billing profile and the sliding fee profile applied to a visit.
2022-006 Higher Education Emergency Relief Fund (HEERF) ? Cash Management Recommendation: We recommend that the College review their policies surrounding federal grants and ensure a review process is in place to ensure that all necessary compliance requirements are met. Explanation of disagreement w...
2022-006 Higher Education Emergency Relief Fund (HEERF) ? Cash Management Recommendation: We recommend that the College review their policies surrounding federal grants and ensure a review process is in place to ensure that all necessary compliance requirements are met. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Reporting will be reviewed for compliance and accuracy by FA Solutions, the student accounts coordinator, student aid coordinator and VP of Student Services. Name(s) of the contact person(s) responsible for corrective action: Mariel Lee, Melissa Hennessy, Shannon Stoughton and Matt Payne Planned completion date for corrective action plan: This change will take place immediately.
2022-004 Higher Education Emergency Relief Funds (HEERF) Reporting Recommendation: We recommend that the College review their policies surrounding federal grants and ensure a review process is in place to ensure that all necessary compliance requirements are met. Explanation of disagreement with aud...
2022-004 Higher Education Emergency Relief Funds (HEERF) Reporting Recommendation: We recommend that the College review their policies surrounding federal grants and ensure a review process is in place to ensure that all necessary compliance requirements are met. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Reporting will be reviewed for compliance and accuracy by FA Solutions, the student accounts coordinator, student aid coordinator and VP of Student Services. Name(s) of the contact person(s) responsible for corrective action: Mariel Lee, Melissa Hennessy, Shannon Stoughton and Matt Payne. Planned completion date for corrective action plan: This change will take place immediately.
2022-003 COD Reporting Recommendation: We recommend the College evaluate its procedures and policies around reporting Pell disbursements to COD to ensure that student information is reported accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audi...
2022-003 COD Reporting Recommendation: We recommend the College evaluate its procedures and policies around reporting Pell disbursements to COD to ensure that student information is reported accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Pell disbursements will be reviewed by the Student Aid Coordinator and then by the VP of Student Services to ensure accuracy and timeliness. Name(s) of the contact person(s) responsible for corrective action: Mariel Lee, Shannon Stoughton, Matt Payne Planned completion date for corrective action plan: This change will take place immediately.
Federal Award Findings Finding 2023-003 Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Nancy Shewfelt, Business Manager Corrective Action Plan: YFSD has hired a new grant director to manage all grants. She is devising systems and timelines to streamline the ...
Federal Award Findings Finding 2023-003 Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Nancy Shewfelt, Business Manager Corrective Action Plan: YFSD has hired a new grant director to manage all grants. She is devising systems and timelines to streamline the process and submit in a timely fashion. Once this is in place, we will be compliant. Proposed Completion Date: Implemented July 1, 2022
Finding 48316 (2022-008)
Significant Deficiency 2022
2022 ? 008 Reporting (Significant Deficiency and Noncompliance) Management Response: The City agrees with the finding. The City will implement controls to ensure compliance with federal financi...
2022 ? 008 Reporting (Significant Deficiency and Noncompliance) Management Response: The City agrees with the finding. The City will implement controls to ensure compliance with federal financial management regulations. The City recognizes that it needs to improve its procedures for preparing quarterly report for Treasury funds. Going forward, the Family and Community Services Department will work with the Grants Section to develop and implement standardized procedures for identifying and documenting expenditures, and for reviewing quarterly reports prior to submission. Timeline and Responsible Position: June 2023 ? City Controller/DFAS Deputy Director and Director of Family & Community Services
Eligibility, Nonmaterial Noncompliance, Significant Deficiency Per Title 24 of the Code of Federal Regulations parts 880 through 883, only eligible individuals should participate and the program and there should be evidence of eligibility determinations. The Authority has established a move-in and ...
Eligibility, Nonmaterial Noncompliance, Significant Deficiency Per Title 24 of the Code of Federal Regulations parts 880 through 883, only eligible individuals should participate and the program and there should be evidence of eligibility determinations. The Authority has established a move-in and re-examination checklist to be used during the eligibility determination process to ensure that all required documents are maintained in the tenant?s file. Of the forty (40) tenants selected for testing, we noted the following: Seventeen (17) tenants were missing the re-examination checklist. Three (3) tenants were missing documentation that they were selected from the waiting list. Two (2) tenants were missing documentation of inspections and tenant certifications. The Authority has had a significant amount of turnover in their staffing who complete eligibility determinations, and the staff who were completing the eligibility determinations did not properly include the completed checklists in the file to evidence their review that all required documents were included in the file. The Authority did not have documentation of compliance with the eligibility requirement for one (1) tenant for the year ended June 30, 2022. Response: Within the next thirty days the Housing Program Compliance Analyst will complete a random audit at each complex of new admissions to confirm all HUD required forms have been completed, and will review random files to confirm the re-examination checklists have been completed. A report will be provided to the Director of Housing once the analyst has completed the review. Target Date: April 2023 Responsible Party: Director of Housing
Eligibility, Nonmaterial Noncompliance, Significant Deficiency Per Title 24 of the Code of Federal Regulations parts 5, 902, 960, 966, and 990, only eligible individuals should participate and the program and there should be evidence of eligibility determinations. The Authority has established an a...
Eligibility, Nonmaterial Noncompliance, Significant Deficiency Per Title 24 of the Code of Federal Regulations parts 5, 902, 960, 966, and 990, only eligible individuals should participate and the program and there should be evidence of eligibility determinations. The Authority has established an application and re-examination checklist to be used during the eligibility determination process to ensure that all required documents are maintained in the tenant?s file. Of the forty (40) tenants selected for testing, we noted the following: One (1) tenant where the Authority was unable to locate the tenant file to document their eligibility to participate in the program. Twelve (12) tenants were missing the re-examination checklist. Five (5) tenants were missing documentation that their income was accurately calculated and verified. For the one tenant whose file was unable to be located moved out of the program during fiscal year 2022, the Authority believes the file was moved to storage but was unable to locate it. For the missing checklists and other documentation, the Authority has had a significant amount of turnover in their staffing who complete eligibility determinations, and the staff who were completing the eligibility determinations did not properly include the completed checklists and other supporting documentation of eligibility in the file to evidence their review that all required documents were included in the file. Response: The Authority will have the Housing Program Compliance Analyst audit a sample of tenant files based on the latest re-examinations to ensure that the calculated income agrees with the supporting documentation, the checklist is completed in its entirety and is maintained in the tenant files. Target Date: April 2023 Responsible Party: Director of Housing
Finding 48283 (2022-001)
Significant Deficiency 2022
Inaccurate and Untimely Return of Title IV Funds (R2T4) Planned Corrective Action: The implementation of the new student information system was completed in October 2022. This will assist in extracting timely data related to course drops and reporting LDAs. The Registrar has implemented a review o...
Inaccurate and Untimely Return of Title IV Funds (R2T4) Planned Corrective Action: The implementation of the new student information system was completed in October 2022. This will assist in extracting timely data related to course drops and reporting LDAs. The Registrar has implemented a review of all data to ensure it is correct moving forward. Person Responsible for Corrective Action Plan: Derek Pritchett, Registrar and Jennifer Steed, Director of SFS Anticipated Date of Completion: Correction action steps are in place now and monitoring is ongoing.
View Audit 41825 Questioned Costs: $1
Finding No. 2022-001 Compliance Requirement ? Reporting ? Significant Deficiency and Noncompliance Planned Corrective Action The University will ensure that each report submission that is required to support spending under each of the Higher Education Emergency Relief Funds and other related fundi...
Finding No. 2022-001 Compliance Requirement ? Reporting ? Significant Deficiency and Noncompliance Planned Corrective Action The University will ensure that each report submission that is required to support spending under each of the Higher Education Emergency Relief Funds and other related funding programs has formal supporting documentation to evidence appropriate review of the report. This issue of how eligible students were determined and how the amounts distributed were determined was identified on the Q4 2021 Report due to the timing of the test work in the prior year Single Audit. This issue was corrected in the Q1 2022 Report and all available funding has been spent. The Assistant Vice President for Financial Aid has ensured that the total number of students eligible to receive a grant and the total number of students who receive grants is properly reviewed and documented. The Manager of Financial Planning, Budgeting and Analysis will ensure that all submitted Institutional Aid Reports are properly reconciled to actual expenditures rather than anticipated expenditures. The Q4 2021 Report was revised and reposted to reflect that expenditures were related to other costs rather than lost revenue. Each Student Aid Report and Institutional Aid Report will be reviewed and approved by the Associate Vice President for Finance. This review and approval will be documented in the file. The submitted Reports will also be provided to the CFO, Vice President for Finance and Treasurer. Timing of Completion This corrective action was implemented in FY22 and FY23.
Finding 48234 (2022-002)
Significant Deficiency 2022
Finding: 2022-002 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 HRSA Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund Federal Financial Assistance Listing #: #93.461 Finding Summary: Audit testing identified one instance ...
Finding: 2022-002 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 HRSA Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund Federal Financial Assistance Listing #: #93.461 Finding Summary: Audit testing identified one instance in which health services provided to a patient were reimbursed under the federal program, and the health services provided did not meet the terms and conditions of the federal program. Through the coding process, an incorrect diagnosis code was included in the system, and therefore, the patient?s health services flowed into Monument Health?s Uninsured Program workflow which resulted in $3,563 of health services being reimbursed under the federal program. As part of the audit, a sample of 60 patients were selected for testing, accounting for $1,659,497 of $4,344,728 of monies received from the federal agency. Responsible Individuals: Austin Willuweit, Vice President of Finance Jen Schmaltz, Corporate Controller Corrective Action Plan: Monument Health will develop a review process to identify claims that could have a diagnosis coding issue. A return of any excess reimbursement will be completed. Anticipated Completion Date: June 30, 2023
Finding 2022-007 Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants FFAL #10.766 Finding Summary: The fiscal year 2021 audit report was requited to be submitted to the federal agency by September 30th, 2022. We did not provide the 2021 audit report wi...
Finding 2022-007 Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants FFAL #10.766 Finding Summary: The fiscal year 2021 audit report was requited to be submitted to the federal agency by September 30th, 2022. We did not provide the 2021 audit report within the timeframe requested by the federal agency representative. Responsible Individuals: Amanda Soesbe, Chief Finance Officer Corrective Action Plan: The CFO will send the audited financial statements to USDA by the deadline. Anticipated Completion Date: 9-30-2023
The Program Coordinator will complete the Volunteer File Master Checklist for each new volunteer including the income verification and background checks as well as other required steps. The Program Coordinator will sign and date the form. The Program Supervisor will review the checklist for comple...
The Program Coordinator will complete the Volunteer File Master Checklist for each new volunteer including the income verification and background checks as well as other required steps. The Program Coordinator will sign and date the form. The Program Supervisor will review the checklist for completeness and sign and date the form. The completed form will be filed in the volunteer?s file. This practice is being implemented currently.
Catholic Charities West Michigan agrees that a separate review of both semi-annual reports and the quarterly Payment Management Services reports for Foster Grandparents/Senior Companion Cluster needs to occur and we have made those changes June 2022 as noted in the recommendations for this item.
Catholic Charities West Michigan agrees that a separate review of both semi-annual reports and the quarterly Payment Management Services reports for Foster Grandparents/Senior Companion Cluster needs to occur and we have made those changes June 2022 as noted in the recommendations for this item.
An Administrative Financial Management Policy is being written to address proper identification, grant relationship, and allowable costs of federal grants. This policy should be in place by June 2023. Catholic Charities West Michigan adopted a cash management policy in February 2023 supporting pro...
An Administrative Financial Management Policy is being written to address proper identification, grant relationship, and allowable costs of federal grants. This policy should be in place by June 2023. Catholic Charities West Michigan adopted a cash management policy in February 2023 supporting procedures to follow to assure timely draw and expenditures of federal dollars.
Finding 2022-002 Federal Agency Name: Department of Education Program Name: Student Financial Aid Cluster CFDA # 84.268 - Federal Direct Student Loans Special Tests and Provisions ? Return of Title IV Funds Finding Summary: 1 of 30 students tested for return of Title IV had a withdrawal determina...
Finding 2022-002 Federal Agency Name: Department of Education Program Name: Student Financial Aid Cluster CFDA # 84.268 - Federal Direct Student Loans Special Tests and Provisions ? Return of Title IV Funds Finding Summary: 1 of 30 students tested for return of Title IV had a withdrawal determination date outside of the 30-day requirement. For a student who withdraws without providing notification from a school that is not required to take attendance, the school much determine the withdrawal date no later than 30 days after the end of the earlier of 1) the payment period or the period of enrollment, 2) the academic year, or 3) the student?s educational program. Responsible Individuals: Eric Schultz, Director of Enrollment and Marlene Seeklander, Director of Financial Aid Corrective Action Plan: The Registrar?s Office will take the following action: For all programs that have SOE/Internship/Clinical experiences, a roster will be generated, and the instructors will be required to verify that the student has been placed and is actively participating in the SOE/Internship/Clinical. Moving forward, this will be a reminder that is emphasized on a regular basis. At the instructor in-service sessions in August, the Director or Enrollment and Director of Financial Aid present a session which is a series of reminders and other important information that instructors need to know. While we already address the need to notify the Registration Office that a student is no longer attending, we plan to expand on that topic. We will include a slide with the audit finding as outlined so they can see the audit ramifications it has on LATC. We will also explain that this is an institutional responsibility, which includes all staff, all program instructors and all adjuncts. Anticipated Completion Date: Ongoing
Finding 48181 (2022-004)
Significant Deficiency 2022
2021-004 COVID-19 HEERF Student Aid Portion and COVID-19 HEERF Institutional Portion Recommendation: We recommend the Organization establish a system to track due dates of reports to ensure timely submission and retain documents to support the submission and accuracy of the reports. Explanation of d...
2021-004 COVID-19 HEERF Student Aid Portion and COVID-19 HEERF Institutional Portion Recommendation: We recommend the Organization establish a system to track due dates of reports to ensure timely submission and retain documents to support the submission and accuracy of the reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: I do not disagree with this finding, however it is important to clarify that this is not a repeat finding from 2021, but rather, this is the exact same incident of the 2021 finding. The 2021 audit was not conducted until February 2022 which happens to also fall into our FY2022. As a result, this finding was corrected immediately following the FY21 discovery and the corrective action was put into place at that time and remains in place and effective. That corrective action was and is as follows: Summit did and continues to have the due dates for the various reporting deadlines, and we did meet those deadlines, however the issue remains that once our reports were updated to the website as required, there exists no audit log of the dates of the changes. As a solution to this issue, we have created a due date log that will be updated with the change date and the log will be signed by the originator of the report as well as the overseer of the website. This signed log will be preserved for review. Names of the contact persons responsible for corrective action: Reports will continue to be filed by the CFO (Marc Carrier) and the Digital Marketing Specialist (Rachel Prost) will be responsible for the website update. This was implemented March 31,2022 and remains in place.
Finding 48176 (2022-003)
Significant Deficiency 2022
2022-003 COD Reporting Recommendation: We recommend the Academy evaluate its procedures and policies around reporting disbursements to COD to ensure that student information is reported accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit fin...
2022-003 COD Reporting Recommendation: We recommend the Academy evaluate its procedures and policies around reporting disbursements to COD to ensure that student information is reported accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: FA staff will research and receive more training on how to audit dates between our internal records system (CNS) and COD, and if adjustments are needed, how to correctly apply adjustments to disbursement dates. When disbursing Pell, FA staff will check through the expected dates (disbursement dates) in our system before exporting the Pell request to COD. In the event dates need adjusting after Pell has be received, the dates will be updated in CNS (Summit?s records system) prior to applying. The dates will also be checked, and if necessary, updated on COD to ensure they match, and both systems reflect the accurate disbursement date. Note: Due to late notification of 2020-2021 Audit Findings, we were unaware of deficiencies in our process, therefore; did not begin corrective action until near the end of 2021-2022 AY. Name of the contact person responsible for corrective action: Jennifer Haavisto Planned completion date for corrective action plan: 3/15/2023
Finding 48175 (2022-002)
Significant Deficiency 2022
2022-002 NSLDS Reporting Recommendation: We recommend the Organization reevaluate its procedure and review polies surrounding reporting status changes to NSLDS to ensure timely reporting as well as put a process in place to ensure the enrollment effective date reported to NSLDS is aligning with the ...
2022-002 NSLDS Reporting Recommendation: We recommend the Organization reevaluate its procedure and review polies surrounding reporting status changes to NSLDS to ensure timely reporting as well as put a process in place to ensure the enrollment effective date reported to NSLDS is aligning with the organizations last date of attendance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Financial Aid staff will utilize the most recent NSLDS Enrollment Reporting Guide, and the corresponding NSLDS Enrollment Reporting Guide Appendices in order to evaluate current procedures and improve upon where necessary in order to be in compliance. The guide and appendices will also be shared with the Registrar?s office for review. The Registrar?s Office and Financial Aid Office will work together to ensure both departments? tasks and processing concerning NSLDS enrollment reporting are done so in a timely manner. The data provided to Financial Aid staff will be reviewed uploaded to NSLDS within one week of receiving it from the Registrar to make certain the reporting is accurate and falling within the required timeframes. The Financial Aid staff and Registrar will revamp current reporting process to reduce risk on incorrect data being reported as well as to ensure all the correct data is being compiled and reviewed prior to reporting. Note: Due to late notification of 2020-2021 Audit Findings, we were unaware of deficiencies in our process, therefore; did not begin corrective action until near the end of 2021-2022 AY. Name of the contact person responsible for corrective action: Jennifer Haavisto Planned completion date for corrective action plan: 3/15/2023
OPSRC is now registered on the FSRS reporting system and staff are working with the federal Education Program Specialist to schedule report training and to clarify how to file reports. A policy and procedure will be approved by the OPSRC board of directors and adopted that ensures timely review of ...
OPSRC is now registered on the FSRS reporting system and staff are working with the federal Education Program Specialist to schedule report training and to clarify how to file reports. A policy and procedure will be approved by the OPSRC board of directors and adopted that ensures timely review of subrecipient reporting under the Federal Funding Accountability and Transparency Act. We anticipate the corrective action to be accomplished by May 2023. Eric Doss, Director, Quality Charter Schools and Pat McKinstry, Deputy Director will be responsible for ensuring compliance.
Finding 2022-005 Reporting Significant Deficiency ? Internal Control over Compliance Other Matters (Noncompliance) Description of Finding The Town's Program Status Reports were not reviewed separate from preparer prior to submission. Statement of Concurrence or NonConcurrence Management agrees wi...
Finding 2022-005 Reporting Significant Deficiency ? Internal Control over Compliance Other Matters (Noncompliance) Description of Finding The Town's Program Status Reports were not reviewed separate from preparer prior to submission. Statement of Concurrence or NonConcurrence Management agrees with this finding. Corrective Action The Town is in process of developing a formal policy. Name of Contact Person John Wilcox Projected Completion Date June 30, 2023
Finding 48111 (2022-003)
Significant Deficiency 2022
Finding: 2022-003 Name of contact person: Amy Seay - Director of Social Services Corrective Action: The Department will continue to provide more in-depth training to ensure cases requiring IV-D Cooperation are meeting policy guidelines. Proposed Completion Date: As soon as possible
Finding: 2022-003 Name of contact person: Amy Seay - Director of Social Services Corrective Action: The Department will continue to provide more in-depth training to ensure cases requiring IV-D Cooperation are meeting policy guidelines. Proposed Completion Date: As soon as possible
The Board of Directors is and will remain involved in the financial affairs of the Cooperative.
The Board of Directors is and will remain involved in the financial affairs of the Cooperative.
Finding 2022-001 ? Moving to Work Tenant Files ? Eligibility ? Annual Recertifications ? Noncompliance & Significant Deficiency ? CFDA #14.881 Corrective Action Plan: The Auburn Housing Authority (AHA) has implemented and/or will implement the following by FYE 2023: a. PBV case management is now ...
Finding 2022-001 ? Moving to Work Tenant Files ? Eligibility ? Annual Recertifications ? Noncompliance & Significant Deficiency ? CFDA #14.881 Corrective Action Plan: The Auburn Housing Authority (AHA) has implemented and/or will implement the following by FYE 2023: a. PBV case management is now administered in-house b. HCV has developed an action plan to ensure that all PBV files are HUD-compliant c. PBV calendar-year 2022 (January 2022-December 2022) re-exams are substantially complete. All files will be HUD-compliance by FYE2023. d. During FYE2023, the HCV Manager will perform quality controls by randomly selecting departmental files. e. Other internal control measures will be implemented to eliminate future audit findings. Person Responsible: Sharon Tolbert, CEO Anticipated Completion Date: June 30, 2023
Finding 2022-01: COVID1-19 Education Stabilization Fund, Higher Education Emergency Relief Funds ? Reporting Program: COVID-19 Education Stabilization Fund Federal Agency: U.S. Department of Education Pass Through Entity: Not Applicable Assistance Listing Number: 84.425E, 84.425F Federal Award Numb...
Finding 2022-01: COVID1-19 Education Stabilization Fund, Higher Education Emergency Relief Funds ? Reporting Program: COVID-19 Education Stabilization Fund Federal Agency: U.S. Department of Education Pass Through Entity: Not Applicable Assistance Listing Number: 84.425E, 84.425F Federal Award Number: P425E200445 Federal Award Year: June 30, 2022 Condition: The College did not post the required quarterly reports for the Student Portion. Additionally, during the audit, it was noted that the College was unable to provide a copy of the annual report and supporting documentation for the year ended December 31, 2021. Corrective Action Plan Management agrees with the finding, and is committed to strengthening its procedures to avoid similar issues in the future. Quarterly reports for the Student Portion have now been posted on the College website. Turnover in finance department staff resulted in difficulty locating copies of reports submitted by former staff. New staff will be trained on the Department?s HEERF requirements to ensure accurate and timely future reporting.
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