Corrective Action Plans

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Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and will take the following corrective action. The ESSER annual Data Collection reports will need to be reviewed more closely to ensure that they are matching to the disbursement detail in the accountin...
Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and will take the following corrective action. The ESSER annual Data Collection reports will need to be reviewed more closely to ensure that they are matching to the disbursement detail in the accounting software. Once the superintendent has entered numbers into the report, there should be a second review of those numbers to the accounting software numbers by the corporation treasurer. In addition, detail of full-time equivalent employees needs to be documented by the deputy treasurer and retained with each report going forward. Responsible party and timeline for completion: Responsible party is Theresa Robbins, Corporation Treasurer. The timeline for completion is spring of 2025.
Agency: Happy Camp Community Services District Responsible person: Becky Aubrey District Secretary/Bookkeeper Anticipated completion date: 12/31/2025 Corrective Action Plan: The Happy Camp Community Services District's Secretary will contract with an outside accountant to write the policies for c...
Agency: Happy Camp Community Services District Responsible person: Becky Aubrey District Secretary/Bookkeeper Anticipated completion date: 12/31/2025 Corrective Action Plan: The Happy Camp Community Services District's Secretary will contract with an outside accountant to write the policies for compliance with the requirements of 2 CFR 200 Subpart D - post Federal Award Requirements and Subpart E- Cost Principles.
The finding was the result of a data entry oversight made by human error in the Oral Health service category for the September 2024 Ryan White billing to Dallas County. While our Dallas County Ryan White billings are currently calculated under a unit cost method, effective March 1, 2025 our contract...
The finding was the result of a data entry oversight made by human error in the Oral Health service category for the September 2024 Ryan White billing to Dallas County. While our Dallas County Ryan White billings are currently calculated under a unit cost method, effective March 1, 2025 our contracts will be on cost reimbursement. Although we will implement the action plan to ensure our records of units are accurate, beginning March 1st there will be no financial correlation between the number of units we report to, and the amount of the reimbursement we receive from, Dallas County. New data validity review points designed to identify possible anomalies will be incorporated into the agency’s procedures with increased review by the Ryan White Program Director. The number of per‐client services received will be compared to parameters established with program managers as representing an unusual number of units received per client/patient per service date and per month. Units exceeding these parameters will be reviewed and corrected, if necessary. The review will be conducted monthly and prior to submission of Dallas County billings. The Ryan White Program Director, Del Wilson, will be in charge of implementing the corrective action plan changes. We hope to implement this plan by March 10, 2025, but before any further billings of service units to Dallas County.
View Audit 345415 Questioned Costs: $1
Finding 526492 (2024-002)
Significant Deficiency 2024
Finding 2024-002 Federal Departments: Corporation for National and Community Service Assistance Listing #: 94.006 Federal Departments: Department of Labor Assistance Listing #: 17.274 Internal Controls Significant Deficiency Category of Finding – Eligibility Finding Summary: Change, Inc. has an in...
Finding 2024-002 Federal Departments: Corporation for National and Community Service Assistance Listing #: 94.006 Federal Departments: Department of Labor Assistance Listing #: 17.274 Internal Controls Significant Deficiency Category of Finding – Eligibility Finding Summary: Change, Inc. has an internal control process designed to review and sign the eligibility forms, but the controls did not operate as designed. Personnel at Change Inc. were unable to produce documentation supporting the review of participant files for participant eligibility. Responsible Individuals: Jill Johnson, Executive Director Corrective Action Plan: We are working to formalize this process by creating a written participant file review policy and procedure. It will be implemented by February 1, 2025. Anticipated Completion Date: February 1, 2025
Finding Number Planned Corrective Action Anticipated Completion Date Responsible Contact Person 2024- 001 The District has extensive controls to monitor the expenditure and FER process related to Federal programs. Expenditures were reported accurately in totality. There were no funds that were not r...
Finding Number Planned Corrective Action Anticipated Completion Date Responsible Contact Person 2024- 001 The District has extensive controls to monitor the expenditure and FER process related to Federal programs. Expenditures were reported accurately in totality. There were no funds that were not record or not represented on the FER, total spent by the district was reported. There was a clerical error when sorting the report to process the information; a salary account (object 100) was sorted in the middle of the benefits (objects 200), exhibit of what occurred is below. Unfortunately this error was not recognized at the time the FER was being completed and the incorrectly sorted totals were used to complete the FER. FER’s are submitted annually and do have to be approved by the Department of Education. This FER was approved with no errors identified. It was not the final FER of the award remaining unused funds did carryover form the 2023 grant year to 2024. 6/30/2025 Katherine Henes, Treasurer
Condition: The University did not return Title IV aid in a timely manner during the fiscal year. Planned Corrective Action: The University resolved immediately upon identification. The University checked all students and found no other student affected. It was an isolated incident that led to the mo...
Condition: The University did not return Title IV aid in a timely manner during the fiscal year. Planned Corrective Action: The University resolved immediately upon identification. The University checked all students and found no other student affected. It was an isolated incident that led to the modification of controls for accurate reporting going forward. Contact person responsible for corrective action: Cassie Tennant Anticipated Completion Date: The university completed this action on June 24, 2024
Condition: The University did not report certain students' status to the NSLDS in an accurate and timely manner during the fiscal year. Planned Corrective Action: Financial aid identified all the students who were not reported accurately to NSLDS. The University has also put a control in place to en...
Condition: The University did not report certain students' status to the NSLDS in an accurate and timely manner during the fiscal year. Planned Corrective Action: Financial aid identified all the students who were not reported accurately to NSLDS. The University has also put a control in place to ensure that all subsequent enrollment changes are reported accurately and timely. Contact person responsible for corrective action: Cassie Tennant Anticipated Completion Date: Action was completed on August 15, 2024
SECTION III - FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2024-002 – ACTIVITIES ALLOWED OR UNALLOWED AUDITEE’S RESPONSE AND CORRECTIVE ACTION TAKEN Management reviewed the authorized signatories on all accounts, updating them and retired the manual stamp as of March 2024. The contact person for this...
SECTION III - FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2024-002 – ACTIVITIES ALLOWED OR UNALLOWED AUDITEE’S RESPONSE AND CORRECTIVE ACTION TAKEN Management reviewed the authorized signatories on all accounts, updating them and retired the manual stamp as of March 2024. The contact person for this finding is John McKeown, Executive Director, and can be reached at 781-293-3088. Completion date of corrective action was March 2024.
Finding 526392 (2024-002)
Significant Deficiency 2024
Student Financial Assistance Cluster - Assistance Listing No. Various. Recommendation: We recommend that the University review its procedures related to outstanding student refund checks that have been outstanding for more than 240 days and return them to the Department. Explanation of disagreement ...
Student Financial Assistance Cluster - Assistance Listing No. Various. Recommendation: We recommend that the University review its procedures related to outstanding student refund checks that have been outstanding for more than 240 days and return them to the Department. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the finding: Waldorf University is developing an ACH for student refunds and conducting a quarterly review of outstanding checks that cannot be ACH. The business office has been given additional help, which will help with timely refunds to the Department. Name(s) of the contact person(s) responsible: Duane Polsdofer at 641-585-8121. Planned completion date for a corrective action plan: March 1, 2025. If the Department of Education has questions regarding this plan, please call Dr. Daisy Halvorson at 641-585-8496 or Duane Polsdofer at 641-585-8121.
Finding 526389 (2024-001)
Significant Deficiency 2024
Finding No. 2024-001 Corrective Action Plan: The University concurs with this finding. The Financial Aid Office has updated procedures and ensures all student files have a thorough examination of all documents prior to document retention review. All MPNs and Perkins-related documents are now identif...
Finding No. 2024-001 Corrective Action Plan: The University concurs with this finding. The Financial Aid Office has updated procedures and ensures all student files have a thorough examination of all documents prior to document retention review. All MPNs and Perkins-related documents are now identified in this review and subsequently stored separately in secure fireproof storage. The files relating to this finding were not appropriately retained and the current procedure would have identified these for continued records retention. Responsible Official: Dane Fuhrman, CFO Anticipated Completion Date: June 2025
Contact Person Responsible for Corrective Action: Dr. Tammy Rowshandel, Chief Accountability Officer Contact Phone Number: 812-462-4224 Views of Responsible Official: The School Corporation's management will establish an effective system of internal control to ensure compliance and comply with the g...
Contact Person Responsible for Corrective Action: Dr. Tammy Rowshandel, Chief Accountability Officer Contact Phone Number: 812-462-4224 Views of Responsible Official: The School Corporation's management will establish an effective system of internal control to ensure compliance and comply with the grant agreement and the Special Tests and Provisions - Annual Report Card, High School Graduation Rate compliance requirement. Description of Corrective Action Plan: A system will be put in place that ensures compliance with the Special Tests and Provisions-Annual Report Card, High School Graduation Rate requirements. Records will be retained for audit so that appropriate documentation is available to substantiate all future reporting. Building registrars will enter state exit codes for students and upload documentation to substantiate the exit codes that are chosen. Once the documents are uploaded, the registrars will place the word “AUDIT” in the withdrawal comments. This indicates the exit is now audit ready. Schools will conduct regular internal cohort audits. Comparisons of IDOE cohort data and withdrawal information in Skyward will be done. The registrar, assistant principal, and data counselor in each building will work together to check the original uploads of documentation done by the registrar and keep record of this work. One final internal audit will take place at the school level by head counselors and assistant principals to indicate all graduates are correctly identified and all exits have proper documentation on file. The CFO and superintendent will digitally sign off on these records during IDOE July certification. Anticipated Completion Date: March 1, 2025
Action Plan: CCC’s managerial and quality assurance review processes include reviews of all client files to ensure appropriate documentation of eligibility, services rendered, and client progress. These reviews happen at intake and periodic intervals to ensure the accuracy and quality of the client ...
Action Plan: CCC’s managerial and quality assurance review processes include reviews of all client files to ensure appropriate documentation of eligibility, services rendered, and client progress. These reviews happen at intake and periodic intervals to ensure the accuracy and quality of the client record. We acknowledge that in some cases, management did not specifically document the management review of eligibility documentation, however the review process did ensure that all files did include appropriate documentation of client eligibility. Moving forward, we will ensure that all client files specifically evidence managerial confirmation of client eligibility with one or more of the following: 1. a signed checklist containing potential eligibility documents 2. a signature on the actual eligibility document or referral 3. an electronic case note to the file confirming review and presence of eligibility documentation. We have already begun working with relevant departments to implement these improvements and will monitor the implemented changes to ensure their effectiveness as we are committed to maintaining and enhancing our internal controls environment and the quality of services provided to the individuals and families we serve.
Responsible Contact Person(s): Naveen Abraham, Chief Core Infrastructure Services Corrective Action Planned: Ensuring that infrastructure suppliers fulfill all contractual requirements with respect to Commonwealth security policies and standards necessitates a programmatic, continuous improvement ap...
Responsible Contact Person(s): Naveen Abraham, Chief Core Infrastructure Services Corrective Action Planned: Ensuring that infrastructure suppliers fulfill all contractual requirements with respect to Commonwealth security policies and standards necessitates a programmatic, continuous improvement approach. VITA has made improved cybersecurity a primary goal and major initiatives have completed and are underway. Based on the improved SLAs and with the improved tools previously implemented, VITA will continue to monitor and improve the security of infrastructure services through ongoing governance, including the requirements of architecture documentation, system security plans, and audit reports. VITA’s infrastructure services group will work with our security group to confirm that the current state achieves security standards compliance. VITA will also continue to work with agencies to drive continued vulnerability remediation and access to log data and to further refine documentation regarding SOPs of the security program and regarding the responsibilities of VITA vs the responsibilities of agencies and suppliers. Estimated Completion Date: 6/30/2025
Responsible Contact Person(s): Barry Davis, Chief Information Security Officer Karen Holt, Human Resource Business Process Consultant Corrective Action Planned: An agency-wide work group will be established to determine the exact processes need to implement the controls necessary to address this fi...
Responsible Contact Person(s): Barry Davis, Chief Information Security Officer Karen Holt, Human Resource Business Process Consultant Corrective Action Planned: An agency-wide work group will be established to determine the exact processes need to implement the controls necessary to address this finding. Estimated Completion Date: 6/30/2025
Responsible Contact Person(s): Kevin Platea, Chief Information Officer Stephen Schleck, Associate Director of Enterprise Business Solutions Angela Morse, Benefit Programs Corrective Action Planned: A Change Request (CR), for the management system was developed 2 years ago and DSS is reviewing the CR...
Responsible Contact Person(s): Kevin Platea, Chief Information Officer Stephen Schleck, Associate Director of Enterprise Business Solutions Angela Morse, Benefit Programs Corrective Action Planned: A Change Request (CR), for the management system was developed 2 years ago and DSS is reviewing the CR to determine a status. It was agreed by Line of Business and ITS EBS and the O&M provider that there will be an iterative approach to completing the record retention and purge rules for implementation in the management system. DSS anticipates the first of a series of changes to address this finding to be implemented in the February 2024 Information Technology Services release. DSS is planning for the final phase of Purge by quarter three of 2025 and will include the following scope: • Scope of change is 150 EDBC tables across all programs beyond a defined cut-off date. • A one-time purge process and on-going purge process will be developed to purge the Uncertified/Unauthorized, Non-current Eligibility Determination. • Develop ongoing purge process for the Phase 1 and Phase 2 tables. • Purge Data files and Data logs App/Batch server. Estimated Completion Date: 12/30/2025
Responsible Contact Person(s): Kevin Platea, Chief Information Officer Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under §2.2-3705.2 (9.) of the Code of Virginia. Fede...
Responsible Contact Person(s): Kevin Platea, Chief Information Officer Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under §2.2-3705.2 (9.) of the Code of Virginia. Federal awarding agencies and pass-through entities, please see the Appendix titled “Applicable Management Contacts for Findings and Questioned Costs” to request the corrective action planned from the applicable entity. Estimated Completion Date: 12/31/2025
Responsible Contact Person(s): Barry Davis, Chief Information Security Officer and Director of Information Security & Risk Management Corrective Action Planned: DSS Information Security and Risk Management security awareness and training assets will develop role based training for system administrat...
Responsible Contact Person(s): Barry Davis, Chief Information Security Officer and Director of Information Security & Risk Management Corrective Action Planned: DSS Information Security and Risk Management security awareness and training assets will develop role based training for system administrators and data custodians. Estimated Completion Date: 6/30/2025
Responsible Contact Person(s): Barry Davis, Chief Information Security Officer and Director of Information Security & Risk Management John Vosper, Assistant Director of Information Security & Risk Management Corrective Action Planned: DSS has contracted external IT auditors to perform IT audits once...
Responsible Contact Person(s): Barry Davis, Chief Information Security Officer and Director of Information Security & Risk Management John Vosper, Assistant Director of Information Security & Risk Management Corrective Action Planned: DSS has contracted external IT auditors to perform IT audits once every three years on an ongoing rotating basis in accordance with yellow book audit standards. Estimated Completion Date: 12/15/2025
Responsible Contact Person(s): Mike Jones, Chief Information Officer Steve Hanoka, Information Security Officer Corrective Action Planned: Vulnerability Management policies and procedures exist. These include scanning for both vulnerabilities and baseline configuration. They are being tracked acco...
Responsible Contact Person(s): Mike Jones, Chief Information Officer Steve Hanoka, Information Security Officer Corrective Action Planned: Vulnerability Management policies and procedures exist. These include scanning for both vulnerabilities and baseline configuration. They are being tracked according to SEC530 resolution standards. Goal is to ensure that all vulnerabilities are remediated within the SLA or have approved exceptions by May 30, 2025. In addition, DMAS has gained guidance from VITA on acceptable alternatives to penetration testing and are tracking completion. Estimated Completion Date: 5/30/2025
Responsible Contact Person(s): Kevin Platea, Chief Information Officer Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under §2.2-3705.2 (9.) of the Code of Virginia. Fede...
Responsible Contact Person(s): Kevin Platea, Chief Information Officer Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under §2.2-3705.2 (9.) of the Code of Virginia. Federal awarding agencies and pass-through entities, please see the Appendix titled “Applicable Management Contacts for Findings and Questioned Costs” to request the corrective action planned from the applicable entity. Estimated Completion Date: 6/30/2025
Responsible Contact Person(s): Kavansa Gardner, IT Manager Corrective Action Planned: DSS performed an annual access review of user accounts for the system. As of December 20, 2024, the DSS projected completion date for the 2024 system Annual Review was December 31, 2024. The IT Manager is waiting f...
Responsible Contact Person(s): Kavansa Gardner, IT Manager Corrective Action Planned: DSS performed an annual access review of user accounts for the system. As of December 20, 2024, the DSS projected completion date for the 2024 system Annual Review was December 31, 2024. The IT Manager is waiting for eight more FIPs to submit screenshots of roles that have been removed or changed. The IT Manager has been in contact with all noncompliant agencies and has meetings scheduled to ensure all necessary documentation is obtained prior to the cutoff point. DSS will be reviewing final documents to certify the accuracy of the review before deadline. Estimated Completion Date: 1/31/2025
Responsible Contact Person(s): Angela Morse, Director of Benefit Programs Kavansa Gardner, IT Manager Corrective Action Planned: DSS will perform and document a conflicting access review for the management system to identify the combinations of roles that could pose separation of duties conflicts an...
Responsible Contact Person(s): Angela Morse, Director of Benefit Programs Kavansa Gardner, IT Manager Corrective Action Planned: DSS will perform and document a conflicting access review for the management system to identify the combinations of roles that could pose separation of duties conflicts and ensure compensating controls are in place to mitigate risks arising from those conflicts. Additionally, DSS will work with the vendor to update the role-based security access documentation to reflect all system changes from prior case management system related releases when there are proposed changes to the roles matrix. Estimated Completion Date: 12/31/2025
Responsible Contact Person(s): Kevin Platea, Chief Information Officer Dwayne Sneade, Director of Cybersecurity Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under §2.2-3...
Responsible Contact Person(s): Kevin Platea, Chief Information Officer Dwayne Sneade, Director of Cybersecurity Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under §2.2-3705.2 (9.) of the Code of Virginia. Federal awarding agencies and pass-through entities, please see the Appendix titled “Applicable Management Contacts for Findings and Questioned Costs” to request the corrective action planned from the applicable entity. Estimated Completion Date: 12/31/2025
Responsible Contact Person(s): Barry Davis, Chief Information Security Officer and Director of Information Security & Risk Management John Vosper, Assistant Director of Information Security & Risk Management Sam Owusu, IT Risk Manager of Information Security & Risk Management Corrective Action Plann...
Responsible Contact Person(s): Barry Davis, Chief Information Security Officer and Director of Information Security & Risk Management John Vosper, Assistant Director of Information Security & Risk Management Sam Owusu, IT Risk Manager of Information Security & Risk Management Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under §2.2-3705.2 (9.) of the Code of Virginia. Federal awarding agencies and pass-through entities, please see the Appendix titled “Applicable Management Contacts for Findings and Questioned Costs” to request the corrective action planned from the applicable entity. Estimated Completion Date: 12/31/2026
Responsible Contact Person(s): Mike Jones, Chief Information Officer Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under §2.2-3705.2 (9.) of the Code of Virginia. Federa...
Responsible Contact Person(s): Mike Jones, Chief Information Officer Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under §2.2-3705.2 (9.) of the Code of Virginia. Federal awarding agencies and pass-through entities, please see the Appendix titled “Applicable Management Contacts for Findings and Questioned Costs” to request the corrective action planned from the applicable entity. Estimated Completion Date: 4/30/2025
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