Corrective Action Plans

Finding 558070 (2024-002)

Significant Deficiency 2024

Sanilac County Community Mental Health Authority

MI

Questioned Costs Internal Control / Segregation of Duties Subrecipient Monitoring

FINDING NUMBER: 2024-002 Condition: The CMHSP included all contract costs, including amounts over $25,000, in the modified total direct costs. Recommendation: We recommend that the CMHSP review/update policies and procedures to ensure that amounts used to calculate indirect costs charged to the gr...

FINDING NUMBER: 2024-002 Condition: The CMHSP included all contract costs, including amounts over $25,000, in the modified total direct costs. Recommendation: We recommend that the CMHSP review/update policies and procedures to ensure that amounts used to calculate indirect costs charged to the grant properly exclude contract amounts over the allowed limit. Planned Corrective Action: Going forward the Authority will calculate the indirect costs based on up to $25,000 per contract employee. Contact Person: Anthony Shaver, Chief Financial Officer Anticipated Completion Date: 9/30/2025

View Audit 354928 Questioned Costs: $1

Finding 558043 (2024-029)

Significant Deficiency 2024

State of Georgia/state Accounting Office-Ein Noted

GA

Questioned Costs Allowable Costs / Cost Principles Period of Performance § 200.303 § 200.403 § 200.77

Federal Fund Source liquidation is monitored monthly via the Fund Source Reconciliation Report and the Provider Utilization Report. Requests to close purchase orders associated with expiring federal fund sources are submitted to OPC accordingly. The Federal Financial Reporting Group will now have th...

Federal Fund Source liquidation is monitored monthly via the Fund Source Reconciliation Report and the Provider Utilization Report. Requests to close purchase orders associated with expiring federal fund sources are submitted to OPC accordingly. The Federal Financial Reporting Group will now have the right to close purchase orders with federal fund sources to expedite this process. Also, the Provider Utilization Report has been updated with Key Performance Indicators (KPIs), Contract End Date Exceeds Period of Performance and Payments Exceed Period of Performance, that specifically address the period of performance as of December 2024.

View Audit 354902 Questioned Costs: $1

Finding 557725 (2024-028)

Significant Deficiency 2024

State of Georgia/state Accounting Office-Ein Noted

GA

Questioned Costs Allowable Costs / Cost Principles Eligibility § 200.303

DCH will review MO 598348 within the Gateway system to ensure the established interface process is functioning properly. DCH will draft additional guidance through a policy memo to revise DHS policy 2750 as it relates to the processing of Ex-Parte members. The DCH policy memo will clarify that upon ...

DCH will review MO 598348 within the Gateway system to ensure the established interface process is functioning properly. DCH will draft additional guidance through a policy memo to revise DHS policy 2750 as it relates to the processing of Ex-Parte members. The DCH policy memo will clarify that upon the completion of the determination by DHS, Gateway will notify GAMMIS of A/R's approval or denial thorough daily interface files sent from Gateway to GAMMIS. The non-confirmation report will be reviewed to determine SOP and validate that the file has been received. Additionally, the DCH policy memo will require Gateway to complete the DMA-962 and submit to Gainwell for manual processing if the file has not been received. DCH is also reviewing current policy to determine if the infinity date established for Ex-Parte members can be revised to a time-limited date.

View Audit 354902 Questioned Costs: $1

Finding 557719 (2024-023)

Significant Deficiency 2024

State of Georgia/state Accounting Office-Ein Noted

GA

Special Tests & Provisions Subrecipient Monitoring Significant Deficiency

DCH is implementing a comprehensive risk analysis framework utilizing the ServiceNow GRC module. This framework will systematically assess risks across all relevant systems and evaluate the effectiveness of existing controls in mitigating identified risks. While DCH has historically obtained and le...

DCH is implementing a comprehensive risk analysis framework utilizing the ServiceNow GRC module. This framework will systematically assess risks across all relevant systems and evaluate the effectiveness of existing controls in mitigating identified risks. While DCH has historically obtained and leveraged independent security assessments—including SOC Type II reports, Security Assessment Reports, and HITRUST validations—to inform its security posture, we recognize the need for enhanced documentation and a formalized assessment process. To address this finding, DCH has taken the following corrective actions: • Standardized Documentation Procedures: Implemented a formalized process to document the receipt, review, and analysis of SOC Type II reports, Complementary User Entity Controls (CUECs), and other relevant security assessments. • Automated Assessment Framework: Leveraging the ServiceNow GRC module to establish a structured, repeatable process for evaluating the effectiveness of implemented controls and their role in mitigating identified risks. • Training & Process Integration: Conducted staff training on the importance of documentation and the new assessment framework to ensure consistent execution and compliance. We remain committed to strengthening our security posture and refining our processes to enhance compliance and risk management. While the SSP approval occurred outside the audit period, DCH has since ensured that approved SSPs for critical Medicaid systems—including Georgia Medicaid Management Information System (GAMMIS), Gateway, and the Enterprise Analytics Solution for Everyone (EASE) are in place. DCH has already begun implementing these corrective actions and anticipates full implementation by April 30, 2025

View Audit 354902

Finding 557716 (2024-026)

Significant Deficiency 2024

State of Georgia/state Accounting Office-Ein Noted

GA

Internal Control / Segregation of Duties Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

At the end of the Low Income Home Energy Assistance Program (LIHEAP) season, the State Program Office and other applicable areas such as Grant Administration, Office of Information Technology, etc. (Team) will attend the annual training completed by the Office of Community Services (OCS). The OCS Ho...

At the end of the Low Income Home Energy Assistance Program (LIHEAP) season, the State Program Office and other applicable areas such as Grant Administration, Office of Information Technology, etc. (Team) will attend the annual training completed by the Office of Community Services (OCS). The OCS Household Report training is typically scheduled in November of each year. After the training session, the team will discuss any changes to the new Household Report. The State Program Office will contact the Georgia Environmental Finance Authority (GEFA) to request information about their annual household report. The Household Report will be printed from the Online Data Collection (OLDC) system for review, discussion, and completion by the team, usually around the middle of December to finalize the draft report. Upon completion of the review and approval by the necessary areas, the State Program Office will submit the Household Report to OLDC for approval and acceptance.

View Audit 354902

Finding 557401 (2024-018)

Significant Deficiency 2024

State of Georgia/state Accounting Office-Ein Noted

GA

Subrecipient Monitoring Cash Management Student Financial Aid § 200.303

The monthly student reconciliations for the Direct Loan programs, including the SAS files, have resumed starting with the October 2024 SAS file. These reconciliations will continue on a monthly basis by the financial aid office, as required, and will be conducted without interruption. The reconcilia...

The monthly student reconciliations for the Direct Loan programs, including the SAS files, have resumed starting with the October 2024 SAS file. These reconciliations will continue on a monthly basis by the financial aid office, as required, and will be conducted without interruption. The reconciliation process will be closely monitored, reviewed, and approved monthly by management to ensure ongoing compliance. The loan processing team has been trained on the SAS file import process and direct loan reconciliation. They have also been provided with the necessary system resources to identify variances between Common Origination and Disbursement (COD) and Banner at the student level. Additionally, the direct loan reconciliation process documentation will undergo continuous review and monitoring by the loan processing team, with oversight from the Director of Student Financial Aid and Scholarships, to ensure accuracy and adherence to established policies with each new academic year. The loan processing team will have annual refresher training at the beginning of each academic year. Confirmation of employees, date of training, and current training process will be documented.

View Audit 354902

Finding 557389 (2024-017)

Significant Deficiency 2024

State of Georgia/state Accounting Office-Ein Noted

GA

Student Financial Aid Special Tests & Provisions Allowable Costs / Cost Principles § 200.303

On July 29, 2024, Georgia State University (GSU) was made aware of a National Student Loan Data System (NSLDS) reporting defect in our student information system related to program level reporting. A system correction was installed on November 25, 2024. GSU will enhance monitoring procedures to ensu...

On July 29, 2024, Georgia State University (GSU) was made aware of a National Student Loan Data System (NSLDS) reporting defect in our student information system related to program level reporting. A system correction was installed on November 25, 2024. GSU will enhance monitoring procedures to ensure discrepancies in reporting to the NSLDS are identified and corrected in a timely manner.

View Audit 354902

Finding 557380 (2024-022)

Significant Deficiency 2024

State of Georgia/state Accounting Office-Ein Noted

GA

Questioned Costs Student Financial Aid Eligibility § 200.303

The student in question had a lengthy break in enrollment (2015-2024). When the student returned, CGTC’s Banner rules differed from his previous enrollment and his status was not accurately updated within the correct term. To correct the issue, CGTC has worked with colleagues at the Technical Coll...

The student in question had a lengthy break in enrollment (2015-2024). When the student returned, CGTC’s Banner rules differed from his previous enrollment and his status was not accurately updated within the correct term. To correct the issue, CGTC has worked with colleagues at the Technical College System of Georgia to identify and correct any discrepancies in the Banner rules for the Satisfactory Academic Progress (SAP) process to prevent future occurrences of this issue. The College’s Financial Aid office has identified the “cutoff” year for changes in SAP rules and has developed a procedure to manually review any students with long breaks in enrollment whose last enrollment occurred prior to the identified cutoff. This review process will help to ensure that students’ SAP status is accurately updated in the correct term.

View Audit 354902 Questioned Costs: $1

Finding 557379 (2024-021)

Significant Deficiency 2024

State of Georgia/state Accounting Office-Ein Noted

GA

Questioned Costs Student Financial Aid Subrecipient Monitoring § 200.303

The Financial Aid Office has worked with the Registrar's Office to streamline the collection, review and processing of student who are unofficial withdrawals. Streamlining the unofficial withdrawal process will allow for timely and accurate reporting, return to title IV, and reconciliation of funds ...

The Financial Aid Office has worked with the Registrar's Office to streamline the collection, review and processing of student who are unofficial withdrawals. Streamlining the unofficial withdrawal process will allow for timely and accurate reporting, return to title IV, and reconciliation of funds between Lanier Technical College and Common Origination and Disbursement (COD).

View Audit 354902 Questioned Costs: $1

Finding 557378 (2024-020)

Significant Deficiency 2024

State of Georgia/state Accounting Office-Ein Noted

GA

Student Financial Aid Subrecipient Monitoring Significant Deficiency

The University of Georgia acknowledges the need for increased monitoring over the return to Title IV aid for students withdrawn from the University. UGA has taken immediate corrective action and has filled key staffing vacancies and implemented additional internal controls to monitor and ensure comp...

The University of Georgia acknowledges the need for increased monitoring over the return to Title IV aid for students withdrawn from the University. UGA has taken immediate corrective action and has filled key staffing vacancies and implemented additional internal controls to monitor and ensure compliance. A self-audit of Fall 2024 revealed no non-compliance issues.

View Audit 354902

Finding 557377 (2024-019)

Significant Deficiency 2024

State of Georgia/state Accounting Office-Ein Noted

GA

Questioned Costs Student Financial Aid Subrecipient Monitoring § 200.303

To prevent future errors, staff will undergo training to ensure accurate processing of withdrawals that occur after the term has ended. Both official and unofficial withdrawals will be evaluated based on the student's last date of attendance when the withdrawal date is after the end of term. While...

To prevent future errors, staff will undergo training to ensure accurate processing of withdrawals that occur after the term has ended. Both official and unofficial withdrawals will be evaluated based on the student's last date of attendance when the withdrawal date is after the end of term. While the Financial Aid Office (FAO) staff have adhered to the current withdrawal procedures, we recognize the need for an update to address instances when the date a student initiates the official withdrawal process is earlier than when the withdrawal is completed. To address this, we will adopt the date the student begins the withdrawal process as the official withdrawal date, if this date precedes the completion of the withdrawal form. Additionally, we will implement automated and electronic system controls to ensure withdrawals are processed accurately and within the required timelines by monitoring the full withdrawal cycle. The withdrawal policy and administrative procedures documentation will be updated to reflect these changes. Staff will have annual refresher training at the beginning of each academic year. Confirmation of employees, date of training, and training process will be documented.

View Audit 354902 Questioned Costs: $1

Finding 557376 (2024-016)

Significant Deficiency 2024

State of Georgia/state Accounting Office-Ein Noted

GA

Student Financial Aid Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

Georgia State University (GSU) will ensure all team members are appropriately trained related to the return to title IV process. Procedures have been enhanced to ensure that unearned funds required to be returned to the program due to return to title IV calculations are immediately reconciled and re...

Georgia State University (GSU) will ensure all team members are appropriately trained related to the return to title IV process. Procedures have been enhanced to ensure that unearned funds required to be returned to the program due to return to title IV calculations are immediately reconciled and returned during the required window. GSU has established an Assistant Director over Electronic Processing to carry out these procedures.

View Audit 354902

Finding 557375 (2024-015)

Significant Deficiency 2024

State of Georgia/state Accounting Office-Ein Noted

GA

Questioned Costs Student Financial Aid Allowable Costs / Cost Principles § 200.303

Georgia State University (GSU) will ensure all team members are appropriately trained related to the process for locking student financial aid records and completing verifications after the term ends. Additionally, GSU has enhanced monitoring procedures to identify changes to institutional student i...

Georgia State University (GSU) will ensure all team members are appropriately trained related to the process for locking student financial aid records and completing verifications after the term ends. Additionally, GSU has enhanced monitoring procedures to identify changes to institutional student information records after term ends with a verification indicator to ensure these accounts are resolved in a timely manner.

View Audit 354902 Questioned Costs: $1

Finding 556722 (2024-036)

Significant Deficiency 2024

State of Georgia/state Accounting Office-Ein Noted

GA

Special Tests & Provisions Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

Effective November 16, 2024, GDOL restructured the Benefit Accuracy Measurement (BAM) unit to strengthen internal controls by incorporating a secondary review process prior to the final review by the supervisor. This process allows the reconciliation of discrepancies and validates the accuracy of th...

Effective November 16, 2024, GDOL restructured the Benefit Accuracy Measurement (BAM) unit to strengthen internal controls by incorporating a secondary review process prior to the final review by the supervisor. This process allows the reconciliation of discrepancies and validates the accuracy of the case findings prior to the supervisory review. If the reviewer identifies questionable items during the review, the case is returned to the auditor for corrections and updates. Once completed, it is returned back to the reviewer for an additional review, sign-off, and then submission to the supervisor for review and closure. Beginning April 2025, an initiative will be implemented to train staff to perform quality checks. Staff will review a sample of cases completed by other auditors in the previous quarter and provide feedback. This plan is being established to posture staff to supplement gaps in resources if the need arises and address challenges, such as, attrition. This allows staff to effectively fulfill the responsibility of reviewing cases and preparing them for official signoff in a timely manner. Summary: GDOL greatly appreciates the feedback and recommendations and has and will continue to take appropriate measures to ensure the established BAM procedures are followed.

View Audit 354902

Finding 556720 (2024-034)

Significant Deficiency 2024

State of Georgia/state Accounting Office-Ein Noted

GA

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.302 § 200.303

After the September 2023 quarter, controls were put in place to ensure accurate Federal quarterly reports. These controls included preparing the report based on our accounting records, e.g. the general ledger. Another control is that the Chief Financial Officer or her designee reviews all reports an...

After the September 2023 quarter, controls were put in place to ensure accurate Federal quarterly reports. These controls included preparing the report based on our accounting records, e.g. the general ledger. Another control is that the Chief Financial Officer or her designee reviews all reports and compares them to the general ledger prior to signature, approval and our submission to the grantor. Furthermore, periodic reviews by program fiscal staff during the performance period take place to closely monitor activity. GDOL will continue to follow the updated procedures and internal controls. As we transition to GA@Work, the system itself will control overspending and provide alerts.

View Audit 354902

Finding 556089 (2024-004)

Significant Deficiency 2024

Legal Services Alabama, INC

AL

Significant Deficiency

Corrective Action: LSA is committed to strengthening our policies and procedures concerning the management of case files. We will collaborate closely with our Managing Attorneys to ensure that all compliance requirements are met effectively. Regarding the failure to disclose an affirmative filing un...

Corrective Action: LSA is committed to strengthening our policies and procedures concerning the management of case files. We will collaborate closely with our Managing Attorneys to ensure that all compliance requirements are met effectively. Regarding the failure to disclose an affirmative filing under 64 CFR 1644 - LSA does acknowledge that in two cases (from 2022 and 2023), one employee who was new to LSA failed to enter the case information into Legal Server in a timely manner which led to it not being reported in our report. This issue was noted by the individuals Managing Attorney approximately one year ago and measures were put in place at that time to ensure that the information was entered timely. Additionally, the staff person was trained pursuant to the training in our Corrective Action plan last year regarding 1644. These two incidents predate that training. LSA will continue to monitor 1644 information in our system to ensure it is entered timely. Our goal is to ensure full compliance moving forward.

View Audit 354787

Finding 556016 (2024-002)

Significant Deficiency 2024

Legal Aid Chicago

IL

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Recommendation: We recommend that management implement a control to ensure complete documentation is maintained for all cases that require retainer agreement. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: Our Deput...

Recommendation: We recommend that management implement a control to ensure complete documentation is maintained for all cases that require retainer agreement. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: Our Deputy Director/General Counsel contacted the person who had failed to sign the retainer that was missing the staff signature to remind them of that requirement. She also held a training on LSC requirements in Q1 2025 in which she reminded staff of the retainer requirement. Name of the contact person responsible for corrective action: Teresa Sullivan, Deputy Director / General Counsel Planned completion date for corrective action plan: Already implemented

View Audit 354747

Finding 556015 (2024-001)

Significant Deficiency 2024

Legal Aid Chicago

IL

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Recommendation: We recommend that management implement a control to review PAI time entries to ensure they are accurate. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: In 2024, but after employees logged the two erro...

Recommendation: We recommend that management implement a control to review PAI time entries to ensure they are accurate. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: In 2024, but after employees logged the two erroneous PAI entries, we implemented a new PAI time entry system in LegalServer. Employees must now choose the nature of the PAI involvement when they log the time, which would have avoided both of the two erroneous entries, had that been in place. Additionally, our Deputy Director/General Counsel provided an LSC regulations training in Q1 2025 to remind employees of LSC regulations, including the regulation governing PAI time. Name of the contact person responsible for corrective action: Teresa Sullivan, Deputy Director / General Counsel Planned completion date for corrective action plan: Already implemented

View Audit 354747

Finding 555921 (2024-006)

Significant Deficiency 2024

School District of Osceola

WI

Reporting Special Tests & Provisions Significant Deficiency

The District acknowledges this finding. Due to its size, it is not cost effective to have more than one person in the transportation department reviewing bus logs. The District will assign someone in the District office to review all logs. Shannon Grindell Ongoing

View Audit 354588

Finding 555917 (2024-004)

Significant Deficiency 2024

School District of Osceola

WI

Allowable Costs / Cost Principles Reporting School Nutrition Programs

The District acknowledges this finding. Due to its size, it is not cost effective to have more than one person in the food service department working with the claims. The District will assign someone in the District office to review all claims. Shannon Grindell, Susan Mayer Ongoing

View Audit 354588

Finding 555793 (2024-005)

Significant Deficiency 2024

Rome Housing Authority

NY

HUD Housing Programs Reporting Significant Deficiency

The Executive Director has implemented procedures for the procurement of an auditor to ensure the Financia Data Schedule is filed within nine months after the conclusion of the fiscal year. Name of Responsible Person: Tami Lucia, Executive Director Implementation date: September 2024

View Audit 354468

Finding 555792 (2024-004)

Significant Deficiency 2024

Rome Housing Authority

NY

HUD Housing Programs Internal Control / Segregation of Duties Special Tests & Provisions

RHA has put in place comprehensive new procedures and controls for all the staff members, including Clerks, Housing Assistants, Housing Coordinators and Project Managers, concerning the management of the waiting list process. As of September 2024m a new waiting list will be generating following each...

RHA has put in place comprehensive new procedures and controls for all the staff members, including Clerks, Housing Assistants, Housing Coordinators and Project Managers, concerning the management of the waiting list process. As of September 2024m a new waiting list will be generating following each new move-in, and the previous waiting list will be appropriately filed and preserved. Name of Responsible Person: Entire Admin Staff lmplementatio_n Date: September 2024

View Audit 354468

Finding 555782 (2024-002)

Significant Deficiency 2024

Harvest Regional Food Bank, Inc.

AR

Special Tests & Provisions Reporting Significant Deficiency

All federal food commodities received will be entered into the SMF QuickBooks system and reported to the Arkansas Department of Education (ADE) within 48 hours of delivery by the Operations Manager or his assistant. All federal food receipts will be verified by a secondary employee monthly to ensure...

All federal food commodities received will be entered into the SMF QuickBooks system and reported to the Arkansas Department of Education (ADE) within 48 hours of delivery by the Operations Manager or his assistant. All federal food receipts will be verified by a secondary employee monthly to ensure ADE has received and properly processed the submission into their system. Any discrepancies will be discussed and corrected as necessary. Harvest will perform an inventory count quarterly and adjust inventory amounts as needed in the SMF QuickBooks system.

View Audit 354463

Finding 555772 (2024-001)

Significant Deficiency 2024

Alliance for Community Empowerment, Inc.

CT

Questioned Costs Allowable Costs / Cost Principles Period of Performance

CT Energy Assistance Program Assistance Listing No. 93.568 Recommendation: We recommend Alliance for Community Empowerment, Inc. design controls to ensure an adequate review process is in place to review the period of costs incurred to ensure costs are charged to grants in the proper period. Action...

CT Energy Assistance Program Assistance Listing No. 93.568 Recommendation: We recommend Alliance for Community Empowerment, Inc. design controls to ensure an adequate review process is in place to review the period of costs incurred to ensure costs are charged to grants in the proper period. Action taken in response to finding: All expenditures will be reviewed and recorded in the proper period of performance. The correction was put into place during the audit and all expenditures have been reviewed during entry and at the point of signature from the Finance Director. Name of the contact person responsible for corrective action: Indi Hayes, Finance Director Planned completion date for corrective action plan: March 21, 2025

View Audit 354453 Questioned Costs: $1

Finding 555742 (2024-001)

Significant Deficiency 2024

Nutley Senior Citizens Housing Corporation

NJ

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

Management has reviewed the audit finding and acknowledges the delay in depositing surplus cash. Management was under the impression that the surplus cash was going to be used for the reduction of a future HAP payment. Management believes this was an isolated incident and has taken corrective action...

Management has reviewed the audit finding and acknowledges the delay in depositing surplus cash. Management was under the impression that the surplus cash was going to be used for the reduction of a future HAP payment. Management believes this was an isolated incident and has taken corrective action by reinforcing internal procedures to ensure timely deposits in the future. Additional monitoring measures have been implemented to prevent recurrence.

View Audit 354370

Corrective Action Plans

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