Corrective Action Plans

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Corporación La Fondita de Jesús Corrective Action Plan December 27, 2024 Finding number: 2024-001 Federal program: 14.267 Continuum of Care Category: Compliance/internal control Condition: An immediate family member of the Executive Director was promoted to Director of Services, and the safeguard me...
Corporación La Fondita de Jesús Corrective Action Plan December 27, 2024 Finding number: 2024-001 Federal program: 14.267 Continuum of Care Category: Compliance/internal control Condition: An immediate family member of the Executive Director was promoted to Director of Services, and the safeguard measures established in the Conflict-of-Interest policy and the new organizational protocol were not followed. The following instances were noted: • The Employment Agreement was signed exclusively by the Executive Director and the Director of Services. • The Reasonable Accommodation of the Supervisory Role of the Director of Services Agreement was signed exclusively by the Executive Director and the Director of Services. In addition, another immediate family member of the Director of Services was hired as a professional contractor. At the time of the recruitment, the document establishing the relationship was not signed. Subsequently, the referred document was signed, but it did not specify the existing conflicts between the Director of Services and the Executive Director. Views of responsible officials: Management agrees with the audit findings and is committed to addressing the issues identified to ensure compliance with CFR 200.318, our Conflict-of- Interest policy, and new organizational protocols. We would like to bring to your attention that effective on November 30, 2024, the Executive Director resigned from his position with Corporacion La Fondita de Jesus. We will review and revise our Conflict-of-Interest policy and protocols to ensure they are comprehensive and clear. This includes detailing the steps to be followed when hiring or promoting individuals with familial relationships within the organization. We will establish an independent review and approval process for all employment and promotion agreements involving immediate family members of senior management. This process will include an additional review by a member of the executive committee of the Board of Directors to ensure objectivity and compliance with policies. We will review all contracts to ensure that they comply with the conflict-of-interest clause. Names of the contact persons responsible for the corrective action plan: Geraldine Bayron, Interim Executive Director, and Javier Fraguela, Board of Directors Anticipated completion date: March 31, 2025
We have reviewed procedures and plan to make the necessary changes to improve reporting timeliness. Staff will update its internal policy to submit the FFATA with 30 days of execution of the CDBG annual budget, Annual Action Plan, and subaward agreements, along with any amendments to these agreement...
We have reviewed procedures and plan to make the necessary changes to improve reporting timeliness. Staff will update its internal policy to submit the FFATA with 30 days of execution of the CDBG annual budget, Annual Action Plan, and subaward agreements, along with any amendments to these agreements.
ASPIRA will put in place a process for monitoring the certification of the audit reporting package and ensure to submit the audit reporting package before the deadline.
ASPIRA will put in place a process for monitoring the certification of the audit reporting package and ensure to submit the audit reporting package before the deadline.
Condition: The Organization lacked sufficient controls to ensure consistent reviews/approvals of monthly reimbursement requests and tenant rent calculations throughout the year. Planned Corrective Action: - The Rent Analyst will complete the rent calculations and sign off. - The Director of Account...
Condition: The Organization lacked sufficient controls to ensure consistent reviews/approvals of monthly reimbursement requests and tenant rent calculations throughout the year. Planned Corrective Action: - The Rent Analyst will complete the rent calculations and sign off. - The Director of Accounting will review and approve the checklist in writing. Contact person responsible for corrective action: The Director of Accounting will oversee all rent calculations. Anticipated Completion Date: Effective 01-13-2025.
FINDING 2024-001 Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (or Other Identifying Numbers): FY 22-23,...
FINDING 2024-001 Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (or Other Identifying Numbers): FY 22-23, FY 23-24 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Eligibility Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the eligibility compliance requirement. Context: During the testing of internal controls over eligibility determinations for free and reduced meals, we noted there was no formal review control in place. There is no documented, secondary review for the applications entered in the food service software which determines eligibility. Additionally, there was no documented review by School Corporation personnel of the Income Eligibility Guidelines used by the food service software which are updated on annual basis. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Management will formally sign off on the Mosaic income guidelines annually prior to each school year. Responsible Party and Timeline for Completion: Shane Hacker, Assistant Superintendent of Operations; Corey Ebert, Director of Finance; Jordan Ryan, Director of Nutrition Services Anticipated Completion Date: February 1, 2025
Management's Response: Management concurs with the above finding and will ensure that human resources, fiscal services and Title Ill all have proper approvals, budgets and written authorization of anything that deviates from the approved budget. The corrective action will be implemented immediately ...
Management's Response: Management concurs with the above finding and will ensure that human resources, fiscal services and Title Ill all have proper approvals, budgets and written authorization of anything that deviates from the approved budget. The corrective action will be implemented immediately and completed by June 2025.
View Audit 338909 Questioned Costs: $1
Inadequate Segregation of Duties Actions Planned - The District has implemented a plan to mitigate this finding for federal programs by distiributing duties, and adding additional oversight. Program managers have been assigned to mon...
Inadequate Segregation of Duties Actions Planned - The District has implemented a plan to mitigate this finding for federal programs by distiributing duties, and adding additional oversight. Program managers have been assigned to monitor and give oversight approval for federal fund expenses and budgets. Program managers sign off on all receipts and disbursements. A principal will act as a program manager for Title funds, and the Superintendent will act as program manager for all other federal funds. Request for reimbursement and receipting will be completed by the Business Manager with oversight by the Superintendent. The key action to eliminate inadequate segregation of duties is developing strong contols over the review and approval of adjusting journal entries. This will involve detailed review by the program manager and the Superintendent. Adjusting journal entries are discussed and signed off on each month to timely detect misstatements. Official Responsible - Business Manager and Superintendent of Schools. Planned Completion date - Discussed with School Board December 30, 2024. This is considered ongoing to to current staffing available. Disagreement with Finding - None. ISD #695 - Chisholm concurs with the finding. Plan to Monitor - The Distirct is aware of the situation and will monitor, as it deems appropriate. Monitoring will include educating program managers to provide additional oversight for the interim and year end reporting.
Planned Corrective Action: I acknowledge the identified instance where supervisory approval was not obtained for a documented personnel expense. We have taken immediate steps to address this issue by implementing a more robust process to ensure that all personnel expense documentation is reviewed an...
Planned Corrective Action: I acknowledge the identified instance where supervisory approval was not obtained for a documented personnel expense. We have taken immediate steps to address this issue by implementing a more robust process to ensure that all personnel expense documentation is reviewed and approved by a supervisory-level employee before submission. Additionally, we will reinforce this practice through staff training and remind supervisors of their responsibility to approve all personnel expense reports. We are committed to maintaining strong internal controls, and we will monitor the implementation of this process to ensure compliance and reduce the risk of unallowable costs in the future. Anticipated Completion Date: Immediately Responsible Contact Person: Danielle Devoll
Finding Number: 2024-001 Planned Corrective Action: Towpath Trail High School will comply with all federal grant compliance requirements – including reporting requirements and deadlines. Anticipated Completion Date: 2/14/2025 Responsible Contact Person: Dave Massa, Treasurer
Finding Number: 2024-001 Planned Corrective Action: Towpath Trail High School will comply with all federal grant compliance requirements – including reporting requirements and deadlines. Anticipated Completion Date: 2/14/2025 Responsible Contact Person: Dave Massa, Treasurer
Finding Number: 2024-004 Condition: The College does not have a written cash management policy related to federal awards. Planned Corrective Action: In accordance with 2 CFR 200.302(b)(6), the College will establish a written cash management policy, including written procedures related to fed...
Finding Number: 2024-004 Condition: The College does not have a written cash management policy related to federal awards. Planned Corrective Action: In accordance with 2 CFR 200.302(b)(6), the College will establish a written cash management policy, including written procedures related to federal payments/awards in order to implement the requirements of 200.305. Contact person responsible for corrective action: David Cummins, Vice President for Administrative Services and College Treasurer Anticipated Completion Date: As soon as possible moving forward starting December 18, 2024.
We have implemented the following protocol to ensure the accuracy of the Form 801A State Attendance Reporting: The site supervisor prepares a Monthly Attendance Form from the daily Attendance Sign-in Sheets and submits it to the ECE Director of Programs, with a copy to the Enrollment Coordinator. ...
We have implemented the following protocol to ensure the accuracy of the Form 801A State Attendance Reporting: The site supervisor prepares a Monthly Attendance Form from the daily Attendance Sign-in Sheets and submits it to the ECE Director of Programs, with a copy to the Enrollment Coordinator. The Enrollment Coordinator reviews the accuracy of the report based on a re-comparison to source sign-in/sign-out sheets, as well as other source information, and submits the report, corrected as necessary, to the ECE Director of Programs. The ECE Director of Programs will review and approve to submit for reporting and invoicing. Once approved, the monthly forms are submitted to the finance department by the site supervisor. GFS’s finance team will complete one more review of the totals before submitting to the CDE and CDSS.
Recommendation – We recommend the Center provide proper training to employees to ensure that the sliding fee discounts are being properly applied and documented. In addition to implementing policies and procedures to ensure the sliding fee discounts are being properly monitored and supervised on a ...
Recommendation – We recommend the Center provide proper training to employees to ensure that the sliding fee discounts are being properly applied and documented. In addition to implementing policies and procedures to ensure the sliding fee discounts are being properly monitored and supervised on a periodic basis to ensure compliance. Action Taken – We concur with the audit finding. While the Center has a policy that meets the compliance requirements, management is responsible for the implementation and monitoring of those processes and procedures. Additional staff training on slide fee discounts is in place and monthly review and testing of compliance with Center sliding fee discount policy will be done.
A comprehensive schedule for all sites for the entire year has been created. Responsible staff are assigned to visit the site on the dates outlined and then submit monitoring forms to the department secretary within 3 days. The Director of Nutrition Services will review all monitoring forms monthly ...
A comprehensive schedule for all sites for the entire year has been created. Responsible staff are assigned to visit the site on the dates outlined and then submit monitoring forms to the department secretary within 3 days. The Director of Nutrition Services will review all monitoring forms monthly with a review of corrective action plans within 45 days. In the event of staff absence or turnover, a backup staff member is assigned to conduct the site visit.
Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: To address the GLBA finding regarding sufficient vendor management policies and reviews, we are actively enhancing our oversight process by collecting security attestations (SOC or HECVAT) from all vendors. These attestations are ...
Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: To address the GLBA finding regarding sufficient vendor management policies and reviews, we are actively enhancing our oversight process by collecting security attestations (SOC or HECVAT) from all vendors. These attestations are being evaluated and translated into our newly developed risk matrix, which aligns with our broader risk management framework. This approach allows us to systematically assess each vendor's security posture and assign corresponding risk levels, ensuring compliance with GLBA requirements and supporting informed decision-making in vendor relationships Person Responsible for Corrective Action Plan: Eric Riddering, Chief Information Officer Anticipated Date of Completion: June 30, 2025
Title III – Assistance Listing No. 84.364 Recommendation: We recommend that the Board reevaluate its current process, implement proper controls, and perform additional training over time and effort reporting. The Board should not seek federal reimbursement unless it can substantiate that the time an...
Title III – Assistance Listing No. 84.364 Recommendation: We recommend that the Board reevaluate its current process, implement proper controls, and perform additional training over time and effort reporting. The Board should not seek federal reimbursement unless it can substantiate that the time and effort was dedicated to the federal program. Documentation should be readily available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Director of Multilingual Achievement will ensure that Time and Effort Statements are completed two times each year. These documents will be completed and signed on January 6 and July 6 of each year. Name of the contact person responsible for corrective action: Sonja Bloetner, Director of Multilingual Achievement Planned completion date for corrective action plan: For immediate implementation and ongoing.
View Audit 338700 Questioned Costs: $1
Title I – Assistance Listing No. 84.010 Recommendation: We recommend that the Board reevaluate its current process, implement proper controls, and perform additional training over time and effort reporting. The Board should not seek federal reimbursement unless it can substantiate that the time and ...
Title I – Assistance Listing No. 84.010 Recommendation: We recommend that the Board reevaluate its current process, implement proper controls, and perform additional training over time and effort reporting. The Board should not seek federal reimbursement unless it can substantiate that the time and effort was dedicated to the federal program. Documentation should be readily available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Weekly payroll runs will be cross-referenced with Title I position logs. Any discrepancies will be investigated promptly. • Unauthorized Employees: Employees not listed on Title I position logs will be removed from payroll to ensure only sponsored employees are attributed to the grant. • Missing Sponsored Employees: Sponsored employees not appearing on payroll reports will be investigated to determine the cause and appropriate corrective actions will be taken. Names of the contact persons responsible for corrective action: Michele Stansbury, Director of Title I Deanna Ashenfelter, Accounting Manager Brent Harry, Fiscal Supervisor III Planned completion date for corrective action plan: Implemented September 17, 2024
View Audit 338700 Questioned Costs: $1
Inadequate Segregation of Duties Actions Planned - The school district has implemented a process for federal programs by distributing duties, and adding additional oversight. Program managers are assigned to monitor and give oversigh...
Inadequate Segregation of Duties Actions Planned - The school district has implemented a process for federal programs by distributing duties, and adding additional oversight. Program managers are assigned to monitor and give oversight approval for federal fund expenses and budgets. Program managers sign off on all receipts and disbursements. Monthly reports given to program managers to assist in the oversight. The Special Education Director acts as a program manager for special ed funds, a Principal acts as a program manager for Title funds, and the Superintendent acts as program manager for all other federal funds. Request for reimbursement and receipting is completed by the Administrative Assistant with oversight by the Business Manager and Superintendent. The key action to eliminate inadequate segregation of duties is developing strong controls over the review and approval of adjusting journal entires. This involves detailed review by the program manager and the Superintendent. Adjusting journal entries are discussed and signed off on each month to timely detect misstatements. Official Responsible - Business Manager and Superintendent of Schools Planned Completion Date - December 31, 2024 Disagreement with Finding - None - ISD #701 - Hibbing concurs with the finding. Plan to monitor - The District is aware of the situation and will monitor, as it deems appropriate. Monitoring will include educating program managers to provide additional oversight fo the interim and year end reportin. This finding will like be ongoing due to limited resources.
Finding 519539 (2024-004)
Significant Deficiency 2024
Individuals Responsible for Corrective Action Plan: Collections Coordinator (Victoria Beeston)- Responsible for initiating contact with the borrower, providing documentation instructions, and reviewing completed forms. Director of Student Accounts (Ti Jolly)- Responsible for ensuring compliance wi...
Individuals Responsible for Corrective Action Plan: Collections Coordinator (Victoria Beeston)- Responsible for initiating contact with the borrower, providing documentation instructions, and reviewing completed forms. Director of Student Accounts (Ti Jolly)- Responsible for ensuring compliance with all applicable regulations and reviewing the re-assignment documentation. ECSI (Angela Johnson)- Responsible for updating financial records and confirming the reassignment of collection rights. Condition: Federal regulation 34 CFR 674.19(e) and 34 CFR 674.31 indicates that the institution is responsible for creating and maintaining the Master Promissory Note to indicated specifications. The university has found that the existing Master Promissory Note (MPN) or equivalent documentation that acknowledges the debt is either incorrect, incomplete, or missing. Management’s Corrective Action Plan: The following steps outline the corrective actions that will be taken to resolve this issue: 1. Contact the Borrower - Life University will initiate contact with the borrower to inform them of the need to update or establish a new MPN or equivalent documentation. This will be done via the following communication channels: • Phone call (if available) • Email notification • Postal mail (if no response is received through other means) 2. Provide Clear Instructions for Documentation - The university will send a formal notice to the borrower detailing the need for a new MPN or equivalent documentation. This will include instructions on how to sign the new agreement, the importance of the MPN, and a clear explanation of the implications for the outstanding loan amount. 3. Reassign Collection Rights - Once the borrower has completed the required documentation, Life University will work with ECSI to reassign the university’s right to collect on the remaining balance. 4. Documentation Review and Verification - After the MPN is completed by the borrower, Life University will review the new MPN for completeness and accuracy. This review will ensure that the terms are correctly documented, that the borrower’s consent is properly obtained, and that the right to collect on the outstanding amount is clearly assigned. 5. Update Financial Records - Life University will update its financial records to reflect the new MPN and the re-assigned collection rights. The university will also ensure that any outstanding amounts and repayment schedules are updated accordingly. 6. Ongoing Communication and Monitoring - The university will maintain communication with the borrower throughout the process, providing reminders if necessary. Verification of Effectiveness: Upon completion of the corrective actions, the university will verify that: • The borrower has submitted the new MPN or equivalent documentation. • The collection rights have been successfully reassigned. • Financial records have been updated accurately. The university will conduct a follow-up review in February 2025 to verify the effectiveness of the corrective action plan and to ensure that no further issues remain. Anticipated Completion Date: January 1st, 2025
As of the Spring 2025 semester all R2T4 calculations performed will then go through a secondary review by either the Assistant Director of Financial Aid or the Director of Financial Aid. This will ensure that R2T4 calculations have the correct Determination dates and that the correct amounts have be...
As of the Spring 2025 semester all R2T4 calculations performed will then go through a secondary review by either the Assistant Director of Financial Aid or the Director of Financial Aid. This will ensure that R2T4 calculations have the correct Determination dates and that the correct amounts have been returned In COD for both the Institutional and Student portion owed.
Subrecipient Monitoring Material Weakness in Internal Control Over Compliance and Material Noncompliance Federal Agency Name: Department of the Treasury Program Name: COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Finding Summary: The subrecipient ag...
Subrecipient Monitoring Material Weakness in Internal Control Over Compliance and Material Noncompliance Federal Agency Name: Department of the Treasury Program Name: COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Finding Summary: The subrecipient agreement requires the submission of quarterly performance reports by the subrecipient within fifteen days of quarter end. However, no quarterly performance reports were submitted by the subrecipient for the year ended June 30, 2024, as of August 1, 2024. Responsible Individuals: Stella Runde, Budget Director Corrective Action Planned: Dubuque County acknowledges the comment and has implemented a process to receive and review quarterly performance reports from the subrecipient. Anticipated Completion Date: June 30, 2025
2024-001 Federal Program - Federal Program AL # 93.224 and 93.527 Health Center Cluster Recommendation – Along with providing proper training to employees , we recommend that the Center develop a tool the eliminates manual calculations for the front desk staff to use in determining which fees to app...
2024-001 Federal Program - Federal Program AL # 93.224 and 93.527 Health Center Cluster Recommendation – Along with providing proper training to employees , we recommend that the Center develop a tool the eliminates manual calculations for the front desk staff to use in determining which fees to apply to vision patients. In addition to implementing policies and procedures to ensure the sliding fee discounts are being properly monitored and supervised on a periodic basis to ensure compliance. Action Taken – We concur with the audit finding. While the Center has a policy that meets the compliance requirements, management is responsible for the implementation and monitoring of those processes and procedures. Additional staff training on slide fee discounts is in place and quarterly review and testing of compliance with Center sliding fee discount policy is ongoing.
Finding 519401 (2024-001)
Significant Deficiency 2024
Management agrees with the auditors’ recommendation and will evaluate process improvements and additional employee training to ensure the youth intake file audit review process is fully implemented and executed going forward. The organization has already begun to train staff with the Contracts and C...
Management agrees with the auditors’ recommendation and will evaluate process improvements and additional employee training to ensure the youth intake file audit review process is fully implemented and executed going forward. The organization has already begun to train staff with the Contracts and Compliance Manager attending quarterly Program Director Meetings to report out on file compliance status. In addition, in the first quarter of Fiscal Year 2025, the Director of Practice Development incorporated the training curriculum for program file management into onboarding for new staff. Moving forward, the Director of Development and Compliance Manager will provide specific trainings during the agency-wide Intake Specialist meeting and the Program Manager meeting. These trainings will take place before the end of the calendar year.
Management Response/Corrective Action Plan: RSU #4 acknowledges the audit finding regarding the lack of documented evidence verifying contractors’ eligibility for federally funded projects. It is part of our process to check for suspension and debarment using the System for Award Management (SAM) da...
Management Response/Corrective Action Plan: RSU #4 acknowledges the audit finding regarding the lack of documented evidence verifying contractors’ eligibility for federally funded projects. It is part of our process to check for suspension and debarment using the System for Award Management (SAM) database; however, we did not retain sufficient evidence of these checks. Moving forward, we will ensure proper documentation is maintained to demonstrate compliance with federal guidelines. Corrective Action Plan: 1. Documentation Enhancement: ○ Action: Implement procedures to formally document SAM database checks for all vendors and contractors, ensuring that evidence of these checks is retained in procurement records. ○ Timeline: Effective immediately. ○ Responsible Party: Business Office Staff. 2. Training: ○ Action: Provide training to procurement staff on proper procedures for verifying and documenting vendor eligibility, including the importance of retaining evidence. ○ Timeline: Training completed within 30 days. ○ Responsible Party: Business Manager. 3. Monitoring and Review: ○ Action: Conduct periodic internal audits of vendor eligibility documentation to ensure compliance with updated procedures. ○ Timeline: Reviews conducted semi-annually starting January 1, 2025. ○ Responsible Party: Business Manager. Expected Outcome: These actions will ensure that RSU #4’s established process for verifying vendor eligibility is fully documented, thereby maintaining compliance with federal guidelines and safeguarding access to federal funding. We are committed to addressing this issue promptly and ensuring continued adherence to grant requirements.
All invoices received will be reviewed by the origional purchaser. The Purchaser will be responsible for verifying the validity of the invoice. All reimbursements and payments sumbitted will be approved by the Executive Director. Expenses paid with an MRC credit/debit card will be approved by the Ex...
All invoices received will be reviewed by the origional purchaser. The Purchaser will be responsible for verifying the validity of the invoice. All reimbursements and payments sumbitted will be approved by the Executive Director. Expenses paid with an MRC credit/debit card will be approved by the Executive Director and supported by a receipt indicating the vendor paid, date of transaction, amount of transaction and business purpose. The Executive Director's Credit/debit card purchases will be approved by the Board Treasurer. Recipts will be sumbitted for all employees reimbursements. If receipt is lost, employee shall sumbit a Lost Receipt Form, which will be approved by Executive Director. Reimbvursements to Executive Director will be approved by the Board Treasurer. Subrecipient Expenses will include approval by the Authorized individual from the subrecipient organization when sumbitted. The Organization strives to remain compliant with Uniform Guidance in all respective respects to present both accurate and transparent records. If Minnesota Department of Health or U.S. Department of Justice have questions regarding this plan, please call Cynthia Munguia at 612-584-4158 ext. 111
Finding 2024-001 – Child Nutrition Cluster – Eligibility Context: During testing over controls for eligibility, we noted there was no formal, secondary review for the applications entered in the food service software determining eligibility. Additionally, there was no documented annual review by Sch...
Finding 2024-001 – Child Nutrition Cluster – Eligibility Context: During testing over controls for eligibility, we noted there was no formal, secondary review for the applications entered in the food service software determining eligibility. Additionally, there was no documented annual review by School Corporation personnel of the income eligibility guidelines used by the food service software. Contact Person Responsible for Corrective Action: Tracy Wilson Contact Phone Number:317-408-1388 ext. 407 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Food Service Director will review and provide proof that multiple parties reviewed and confirmed the correct income eligibility guidelines in our software each year prior to making the applications available to parents. Anticipated Completion Date: Immediate
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