Corrective Action Plans

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Management agrees with the finding and recommendation. The University will implement a process that ensures notification from the Registrar when a student drops from any course or from the University. A review of R2T4 will be completed at that time if deemed necessary. The process will be reviewed a...
Management agrees with the finding and recommendation. The University will implement a process that ensures notification from the Registrar when a student drops from any course or from the University. A review of R2T4 will be completed at that time if deemed necessary. The process will be reviewed annually by the University to ensure compliance.
FINDING 2024-002 Finding Subject: PPHF Geriatric Education Centers - Subrecipient Monitoring Summary of Finding: Audit Finding 2024-002 states that the University of Southern Indiana did not establish a system of internal controls to ensure that subrecipient audit reports are received and reviewed, ...
FINDING 2024-002 Finding Subject: PPHF Geriatric Education Centers - Subrecipient Monitoring Summary of Finding: Audit Finding 2024-002 states that the University of Southern Indiana did not establish a system of internal controls to ensure that subrecipient audit reports are received and reviewed, when required, to ensure that subrecipients are properly monitored in accordance with Federal regulations. Contact Person Responsible for Corrective Action: Jina Platts, Assistant Vice President for Finance and Administration and Assistant Treasurer Contact Phone Number and Email Address: 812-465-7090; jlplatts@usi.edu Views of Responsible Officials: We concur with the finding that the University should have ensured that subrecipient audit reports were received and reviewed, when required, to ensure that subrecipients are properly monitored in accordance with Federal regulations. The University had other controls in place related to subrecipient monitoring including the review of financial reports and requests for reimbursement for subrecipient expenses. One purpose of collecting and reviewing subrecipient audit reports is to determine the level of monitoring required as high, medium, or low. Although the University treats all subrecipients as high risk, we are unable to issue a formal management decision to subrecipients within six months of acceptance of the audit report by the Federal Audit Clearinghouse without assurance that audit reports are received and reviewed in a timely manner. Description of Corrective Action Plan: The University will update subrecipient monitoring procedures as follows: 1. Upon issuance of a subaward, the Business Office will verify if a subrecipient is subject to single audit according to OMB Uniform Guidance. If so, the subrecipient must provide a complete copy of their most recent independent audit used to meet their OMB Uniform Guidance requirement or a link to their record on the Federal Audit Clearinghouse. 2. The Business Office will review the report to verify that there are no findings that may impact the proposed subaward. In the event there are such findings, the Business Office will notify the Office of Sponsored Projects & Research. Together the two offices will determine an appropriate plan of action and issue a Management Decision Letter as required by Uniform Guidance. 3. The Business Office will identify subrecipients receiving payments quarterly and verify that their most recent audit reports have been received and reviewed. Any audit reports completed after issuance of a subaward will be reviewed as described in #2 above. Anticipated Completion Date: Planned corrective actions to be implemented in January 2025.
Finding 2024-001: The Property received a score of 58c* on a physical inspection of the Property performed on June 7, 2023 by a representative of HUD. By reference, the REAC inspection is included as a statement of condition. Comments on the Finding and Each Recommendation: Management should ensu...
Finding 2024-001: The Property received a score of 58c* on a physical inspection of the Property performed on June 7, 2023 by a representative of HUD. By reference, the REAC inspection is included as a statement of condition. Comments on the Finding and Each Recommendation: Management should ensure all necessary repairs have been made. Management should continue to conduct routine unit and general property inspections and deficiencies should be corrected in a timely manner. Action(s) taken or planned on the finding: Agree. Management has responded to HUD in regards to this inspection report and has addressed all health and safety issues. Management will continue to correct all remaining deficiencies noted and will implement a process of self-inspection of units and common areas. Management will request a new physical inspection of the property.
Finding 524629 (2024-003)
Significant Deficiency 2024
Management will review the FY 24 FISAP report concerning the accuracy of the SEOG drawdown and whether any portion of the drawdown should have been reported as carryover funds. Any overdraw determined as part of this reconciliation will be returned to the U.S. Department of Education. The College ...
Management will review the FY 24 FISAP report concerning the accuracy of the SEOG drawdown and whether any portion of the drawdown should have been reported as carryover funds. Any overdraw determined as part of this reconciliation will be returned to the U.S. Department of Education. The College has also strengthened controls and trained staff to ensure compliance with cash management practices for future federal awards.
View Audit 344059 Questioned Costs: $1
Finding 524616 (2024-004)
Significant Deficiency 2024
Research and Development Cluster – Assistance Listing Numbers 47.070, 47.076, 47.084, and 93.846 Recommendation: We recommend the University review its internal controls around the reimbursement process for all federal grants to ensure the necessary review and approval controls are in place and per...
Research and Development Cluster – Assistance Listing Numbers 47.070, 47.076, 47.084, and 93.846 Recommendation: We recommend the University review its internal controls around the reimbursement process for all federal grants to ensure the necessary review and approval controls are in place and performed by an individual other than the one performing the drawdown calculation and request from the federal agency. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Midway through the fiscal year, we introduced a new process involving multiple layers of approval before a drawdown is executed. The drawdown calculation is done either by the Senior Accountant or Grant Manager and sent to either the Grant Manager (if prepared by the Senior Accountant), or Controller (if prepared by the Grant Manager) for review and approval. If additional information is needed, the approver sends the request back for updating and recalculation. Name(s) of the contact person(s) responsible for corrective action: Mutale Sokoni, Associate Vice President for Finance, 703-284-1496 Planned completion date for corrective action plan: Action taken during April 2024
Finding 524608 (2024-002)
Significant Deficiency 2024
Student Financial Aid Cluster – Assistance Listing Numbers 84.007, 84.033, 84.038, 84.063, and 84.268 Recommendation: We recommend that the University engage a third party or perform the risk assessment for the areas required by the Gramm-Leach-Bliley Act and ensure that there are documented safegu...
Student Financial Aid Cluster – Assistance Listing Numbers 84.007, 84.033, 84.038, 84.063, and 84.268 Recommendation: We recommend that the University engage a third party or perform the risk assessment for the areas required by the Gramm-Leach-Bliley Act and ensure that there are documented safeguards for identified risks. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has prepared a separate Corrective Action Plan document in response to this finding due to the sensitivity. Each requirement noted as a deficiency within the finding is address separately and appropriate response is being taken. Name(s) of the contact person(s) responsible for corrective action: Carl Whitman, Associate Vice President and Chief Information Officer (703-526-6901) Planned completion date for corrective action plan: Action plan completed on February 18, 2025.
Our Agency has included activities as a joint force’s initiative with other agencies and entities in an outreach task. We have been authorized to use the distribution waiver of percentages to have a better or bigger span for our youth populations. We also signed a memorandum of understanding with at...
Our Agency has included activities as a joint force’s initiative with other agencies and entities in an outreach task. We have been authorized to use the distribution waiver of percentages to have a better or bigger span for our youth populations. We also signed a memorandum of understanding with attractive entities like the PR National Guard and have planned activities reaching youth from school programs to communities without school youths. Our alliances with DDEC, Azore and the Department of Education will contribute to an increase in youth program expenses. We have strategically created an initiative that targets in-school youths where we’ll provide workshops focused on elevating their skills and creating real-time experiences. The memorandum we have with the Department of Education has facilitated this strategy. The Individual Training account (ITA) program will also be promoted in our school district to identify candidates with barriers that can be served through our program. As part of our outreach strategy, we plan to visit foster homes alongside the Department of the Family, which we have signed a memorandum to target this group of disadvantaged youths, as well as projects we have signed with the vocational schools in our district providing real time and paid work experience. With the nine municipalities comprising our area will develop summer work experience targeting our in-and-out school youth (TSY, OSY) populations. The estimated expenses for these initiatives, based on last year's outcome, will reach the goal parameters of programs under WIOA Act. IMPLEMENTATION DATE June 2025 RESPONSIBLE PERSONS Budget Director, Executive Director, Directors of Programmatic and Operations
Management's Corrective Action Plan: Due to changes in departmental management and responsibilities submission was not timely. We have now implemented policies and procedures to ensure grant activity is reported in accordance with the grant requirements. This matter was resolved subsequent to June 3...
Management's Corrective Action Plan: Due to changes in departmental management and responsibilities submission was not timely. We have now implemented policies and procedures to ensure grant activity is reported in accordance with the grant requirements. This matter was resolved subsequent to June 30, 2024.
Statement of Condition 2024-002 (Assistance Listing 14.181): The Property received a Management Occupancy Review (MOR) rating of Below Average and is unable to locate a response to HUD correcting the findings in the MOR. Recommendation: Management should clear all findings from the MOR and follow u...
Statement of Condition 2024-002 (Assistance Listing 14.181): The Property received a Management Occupancy Review (MOR) rating of Below Average and is unable to locate a response to HUD correcting the findings in the MOR. Recommendation: Management should clear all findings from the MOR and follow up with HUD to request a close-out letter. Management Response: Agree. On January 24, 2025, management responded to the MOR findings and believes they have adequately addressed all deficiencies. No further action is required.
Statement of Condition 2024-001 (Assistance Listing 14.181): The Corporation did not make all of the HUD required reserve for replacement deposits for the year ended October 31, 2024. Recommendation: Management should transfer $19,200 from the operating cash account to the reserve for replacements ...
Statement of Condition 2024-001 (Assistance Listing 14.181): The Corporation did not make all of the HUD required reserve for replacement deposits for the year ended October 31, 2024. Recommendation: Management should transfer $19,200 from the operating cash account to the reserve for replacements fund or request a suspension of monthly deposits from HUD. Management Response: Agree. On January 9, 2025, management transferred $19,200 from the operating account to the reserve for replacements fund.
View Audit 343963 Questioned Costs: $1
Finding 524537 (2024-002)
Significant Deficiency 2024
The College continues to document the policies and procedures and implement any outstanding requirements to become fully compliant with GLBA. Where necessary the College will reach out to third parties for assistance. Anticipated completion during late FY 2025 to mid FY 2026.
The College continues to document the policies and procedures and implement any outstanding requirements to become fully compliant with GLBA. Where necessary the College will reach out to third parties for assistance. Anticipated completion during late FY 2025 to mid FY 2026.
FINDING 2024-002 Finding Subject: COVID-19 - Education Stabilization Fund – Activities Allowed or Unallowed; Allowable Costs/Cost Principles Summary of Finding: An effective internal control system was not designed at the School Corporation to ensure compliance with requirements related to the grant...
FINDING 2024-002 Finding Subject: COVID-19 - Education Stabilization Fund – Activities Allowed or Unallowed; Allowable Costs/Cost Principles Summary of Finding: An effective internal control system was not designed at the School Corporation to ensure compliance with requirements related to the grant agreement and the Activities Allowed or Unallowed and Allowable Costs/Cost Principles compliance requirements. The School Corporation had designed a system of internal controls to ensure payroll expenditures charged to the grant fund were allowable. However, 2 of the 44 expenditures tested did not show have documentation that the control had been applied and operated effectively. The State Board of Accounts recommends that the School Corporation’s management establish a system of internal controls related to the federal award and the Activities Allowed or Unallowed and Allowable Costs/Cost Principles compliance requirements and apply the controls consistently to all transactions. Contact Person Responsible for Corrective Action: Kerri Powers-Hoffman, Payroll Specialist Contact Phone Number and Email Address: hoffmank@franklinschools.org, 317-346-8738 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Payroll Specialist will ensure the files posted to the shared drive for the monthly board meetings contain all payroll claims necessary for approval each month. The Payroll Specialist also will review the prior months file to ensure no payroll claims were skipped, which is what resulted in this finding. Anticipated Completion Date: This corrective action has already been implemented.
FINDING 2024-001 Finding Subject: COVID-19 - Education Stabilization Fund - Reporting Summary of Finding: The School Corporation had not designed, nor implemented a system of internal controls, to ensure the annual Elementary and Secondary School Emergency Relief (ESSER) annual Data Collection repor...
FINDING 2024-001 Finding Subject: COVID-19 - Education Stabilization Fund - Reporting Summary of Finding: The School Corporation had not designed, nor implemented a system of internal controls, to ensure the annual Elementary and Secondary School Emergency Relief (ESSER) annual Data Collection reports (Reports) were complete and accurately submitted. The School Corporation Reports were reviewed by the Assistant Deputy Treasurer and submitted by the Chief Financial Officer; however, there was no documentation provided to verify that the oversight or review process to prevent, or detect and correct, errors were performed during the audit period. The State Board of Accounts recommends that the School Corporation’s management establish a system of internal controls related to the federal award and the Reporting compliance requirement which includes documentation of the operation of the controls. Contact Person Responsible for Corrective Action: Camilla Hoffman, Assistant Deputy Treasurer Contact Phone Number and Email Address: hoffmanca@franklinschools.org, 317-346-8748 Views of Responsible Officials: We concur with the finding, but we would like to emphasize that the review had been implemented. It just was not documented by the reviewer. Description of Corrective Action Plan: The Assistant Deputy Treasurer will begin documenting her review of the required ESSER reporting via email, so that this review can be verified by auditors or other inquirers. Anticipated Completion Date: This corrective action will be added to the district’s procedures immediately, but ESSER reporting is not anticipated until later in the Spring 2025.
Beginning March 2025, the City's Finance department will review and sign off on any annual financial reports submitted to the U.S. Department of Treasury. The City will provide training to appropriate staff that Finance Departmental review is required.
Beginning March 2025, the City's Finance department will review and sign off on any annual financial reports submitted to the U.S. Department of Treasury. The City will provide training to appropriate staff that Finance Departmental review is required.
Finding 524447 (2024-001)
Significant Deficiency 2024
MANAGEMENT’S CORRECTIVE ACTION PLAN 2 CFR § 200.511(c) June 30, 2024 Finding Number: 2024-001 – Internal Control over Compliance and Compliance with Period of Performance Planned Corrective Action: The errors identified took place during September 2023, during a period when the financial managemen...
MANAGEMENT’S CORRECTIVE ACTION PLAN 2 CFR § 200.511(c) June 30, 2024 Finding Number: 2024-001 – Internal Control over Compliance and Compliance with Period of Performance Planned Corrective Action: The errors identified took place during September 2023, during a period when the financial management of Council’s grants, including subrecipient monitoring and allowable cost review, were under the purview of the program teams. In May 2024, these responsibilities were deemed to be more appropriately aligned with the Finance and Business Operations Team’s skill sets and brought under that team’s management. Additionally, in December 2023, the accounts payable process was automated, enabling a more thorough review of each reimbursement package. Anticipated Completion Date: May 6, 2024 Responsible Contact Person: Stan Harrell, Chief Financial Officer
View Audit 343772 Questioned Costs: $1
Finding 2024-001 Condition Finding 2024-001 – Significant Deficiency – Return of Title IV Federal Program – Federal Pell Grant Program, Federal Direct Student Loan Program Federal Agency – U.S. Department of Education Pass- Through Entity – Not Applicable ALN Number – 84.063, 84.268 Federal Award Y...
Finding 2024-001 Condition Finding 2024-001 – Significant Deficiency – Return of Title IV Federal Program – Federal Pell Grant Program, Federal Direct Student Loan Program Federal Agency – U.S. Department of Education Pass- Through Entity – Not Applicable ALN Number – 84.063, 84.268 Federal Award Year – May 31, 2024 Criteria: The Uniform Guidance requires recipients of federal awards to administer its federal programs with an adequate system of internal controls over applicable compliance requirements. In addition, when a recipient of Title IV grant or loan assistance withdraws from an institution during a payment period, Title IV regulations (34 CFR 668.22) require the College to determine, through a Return of Title IV Funds (R2T4) calculation, the amount of Title IV grant or loan assistance that the student earned as of the withdrawal date and return the unearned portion of the grant or loan to the Title IV programs as soon as possible but no later than 45 days after the withdrawal date. Corrective Action Plan Corrective Action Planned: {The College agrees with the finding and has taken immediate corrective action to address the finding related to R2T4 calculations. All R2T4 calculations for the related period have been recalculated and reviewed for accuracy. Any noted discrepancies related to the necessary return of funds have been addressed. Enhanced internal controls have been implemented to ensure that the dates entered in the Colleague system aligns with the academic calendar. The College will also institute an internal audit/compliance process for additional verification and monitoring. Identify the specific actions to be taken to eliminate or mitigate the recurrence of the finding. Name(s) of Contact Person(s) Responsible for Corrective Action: Kemia Himon, Financial Aid Director Anticipated Completion Date: 3.3.25
View Audit 343760 Questioned Costs: $1
The Municipality established internal control to maintain schedule of the due date reports in order to avoid this situation.
The Municipality established internal control to maintain schedule of the due date reports in order to avoid this situation.
Finding 2024-002 – Internal control deficiency and noncompliance over Reporting related to performance reports Connecting Minority Communities Pilot Program – Timeliness and Accuracy During testing over the Reporting compliance requirement, management did not have effective internal controls in pl...
Finding 2024-002 – Internal control deficiency and noncompliance over Reporting related to performance reports Connecting Minority Communities Pilot Program – Timeliness and Accuracy During testing over the Reporting compliance requirement, management did not have effective internal controls in place to ensure performance reports were submitted by the deadline and completed correctly. Management did not submit the required performance reports by the deadline and certain key line items were not completed correctly. Management Response and Action Plan: Management will meet with the Principal Investigator and provide additional training emphasizing the importance of timely submission and accuracy of grant documentation and reports. In addition, management will monitor submission deadlines and follow-up with the Principal Investigator to ensure timely filing. Responsible Person: Executive Director of Sponsored Project Administration Target Date: February 2025
FINDING 2024-003 Finding Subject: Education Stabilization - Reporting Summary of Finding: The School Corporation had not designed, nor implemented, a system of internal controls to ensure that the annual Elementary and Secondary School Emergency Relief (ESSER) Data Collection reports (Reports) were ...
FINDING 2024-003 Finding Subject: Education Stabilization - Reporting Summary of Finding: The School Corporation had not designed, nor implemented, a system of internal controls to ensure that the annual Elementary and Secondary School Emergency Relief (ESSER) Data Collection reports (Reports) were complete and accurately submitted. The Reports were prepared by one employee without a documented oversight, review, or approval process in place to prevent, or detect and correct, errors. Contact Person Responsible for Corrective Action: Trina Huff Contact Phone Number and Email Address: (812) 689-4114, thuff@jaccendel.k12.in.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: Moving forward treasurer will provide even more information to the reviewer specifically pertaining to the findings and any other pertinent information for that person to have a better idea of what they are looking for and will keep documentation of the review being done and signed off on. Anticipated Completion Date: This will be corrected with the next round of ESSER reporting due January 2025.
Corrective Action/Management Response: Supervisor responsible for submitting report has become more familiar with the due dates in which this report is due. In addition, a reminder has been placed on the Outlook calendar to ensure that the report is completed timely. This practice has seemed to ...
Corrective Action/Management Response: Supervisor responsible for submitting report has become more familiar with the due dates in which this report is due. In addition, a reminder has been placed on the Outlook calendar to ensure that the report is completed timely. This practice has seemed to work as the report submitted for the 1st quarter was submitted timely. Proposed Completion Date: 11/21/2024
Finding 2024-003 School Nutrition Program Meal Claims 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding The District has already begun evaluating current procedures for accurately monitoring, recording, and re...
Finding 2024-003 School Nutrition Program Meal Claims 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding The District has already begun evaluating current procedures for accurately monitoring, recording, and reporting the number and type of meals served. 3. Official Responsible Mr. Greg Johnson, Superintendent, is the official responsible for ensuring corrective action. 4. Planned Completion Date The planned completion date is June 30, 2025. 5. Plan to Monitor Completion The Board of Directors will be monitoring this Corrective Action Plan.
CONDITION: The South Cook Intermediate Service Center #4 had inadequate controls over grant compliance to ensure all grant reports during the fiscal year were timely reported and grant requirements were met. During testing of the South Cook Intermediate Service Center #4’s compliance with the grant...
CONDITION: The South Cook Intermediate Service Center #4 had inadequate controls over grant compliance to ensure all grant reports during the fiscal year were timely reported and grant requirements were met. During testing of the South Cook Intermediate Service Center #4’s compliance with the grant requirements, we noted the following: For Public Safety Partnership and Community Policing Grants - • One of 2 (50%) quarterly federal financial reports were submitted 36 days late. • One of 1 (100%) semi-annual performance report was submitted 47 days late. For McKinney-Vento Education for Homeless Children and Youth - • Four of 4 (100%) quarterly expenditure reports and the Grant Accountability and Transparency Act (GATA) reports were submitted but the South Cook Intermediate Service Center #4 was unable to provide proof of submission; therefore, we were unable to determine if the required reports were submitted timely or at all. • South Cook Intermediate Service Center #4 did not formally establish a Community Advisory Group. PLAN: Management will develop more formal and comprehensive grant monitoring procedures that will include a checklist for all the necessary reporting and compliance requirements. Specifically for the Mc-Kinney Vento grant, formal documentation for the established Community Advisory Group will be obtained in consultation with the grantor. ANTICIPATED DATE OF COMPLETION: June 30, 2025 CONTACT PERSON: Dr. Anthony Marinello, Executive Director
Finding 524287 (2024-002)
Significant Deficiency 2024
Views of Responsible Officials: Historically, the Foundation has submitted all required documents per the grant agreement. GrantSolutions is a newer platform by which all documents must be uploaded. When the final financial reports were submitted, the grant was closed without the performance report ...
Views of Responsible Officials: Historically, the Foundation has submitted all required documents per the grant agreement. GrantSolutions is a newer platform by which all documents must be uploaded. When the final financial reports were submitted, the grant was closed without the performance report and the grant was removed from the dashboard. The performance report was prepared by the deadline, but the grant manager was not aware of the alternative dropdown to upload the file. Moving forward, everyone who has access to GrantSolutions, both in Finance and Development, must acquaint themselves with the site and crosscheck that the required documents are uploaded timely, especially prior to a grant closing.
2024.02 - Eligibility Recommendation We recommend that management provide training to those responsible for verifying eligibility to ensure that documentation and internal control over eligibility is maintained. Action Taken 1) To ensure patient eligibility is properly assigned to patients, the Dir...
2024.02 - Eligibility Recommendation We recommend that management provide training to those responsible for verifying eligibility to ensure that documentation and internal control over eligibility is maintained. Action Taken 1) To ensure patient eligibility is properly assigned to patients, the Director of Clinical Operations will perform random audits on a Monthly basis of patients that are assigned. 2) The Director of Clinical Operations will also ensure proper training to those that are assigning eligibility to ensure that proper documentation is obtained and properly stored. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Eric Newman, CFO at (203) 756-8021 x 3015. Sincerely yours, Eric Newman Chief Financial Officer
SIGNIFICANT DEFICIENCY 2024.001 - Sliding Fee Scale Discount Recommendation The Center should implement a system of controls to ensure all sliding fee discounts are properly supported. Action Taken 1) To ensure Sliding Fee Discounts are properly supported, the Director of Program Management will ass...
SIGNIFICANT DEFICIENCY 2024.001 - Sliding Fee Scale Discount Recommendation The Center should implement a system of controls to ensure all sliding fee discounts are properly supported. Action Taken 1) To ensure Sliding Fee Discounts are properly supported, the Director of Program Management will assign random audits on a Monthly basis of patients that are assigned a sliding fee. 2) Director of Program Management as well as Program Managers will monitor Phreesia dashboard to identify self-pay patients on the schedule and work to ensure that accounts are updated accordingly. a. For any accounts that need to be updated, they will inform the PSA who checked in the patient to make the updates as necessary and provide additional training if needed. b. Provide trainings to PSAs to ensure that they are offering the Sliding Fee Discount to all patients that may need to apply, and appropriately applying those slides. 3) If a Pt has had a visit and left prior to getting sliding fee information, PSAs are to call the patient to let them know that they may have to apply for a sliding fee (or receive insurance information over the phone). 4) Practice Managers will identify Self-pay accounts via Phreesia each morning that may need attention and send a list of accounts to the PSAs at the beginning of each day. PSA will then contact the patients to remind them to bring in proof of income to apply for the sliding fee if eligilble.
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