Corrective Action Plans

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Finding No.: 2023-008 Recommendation The College acknowledges the finding and is committed to addressing the gaps identified in enrollment reporting to the National Student Loan Data System (NSLDS). We recognize that accurate and timely reporting at both the Campus Level and Program Level is critica...
Finding No.: 2023-008 Recommendation The College acknowledges the finding and is committed to addressing the gaps identified in enrollment reporting to the National Student Loan Data System (NSLDS). We recognize that accurate and timely reporting at both the Campus Level and Program Level is critical to maintaining compliance with U.S. Department of Education Title IV requirements and ensuring that students’ federal financial aid records are correctly reflected. Response 1. The College will retain the FAO as the lead unit responsible for NSLDS enrollment reporting, in alignment with Title IV compliance functions. However, the College will strengthen interdepartmental collaboration by establishing a formal partnership with the Registrar’s Office, which maintains the official record of enrollment data. 2. A shared workflow and communication protocol between the FAO and Registrar’s Office will be developed to ensure timely, accurate updates of both campus-level and program-level data. The Registrar’s Office will be responsible for updating student enrollment data, which serves as the source data for NSLDS reporting. The FAO will extract and upload these reports via the Enrollment Reporting Roster (ERR) on the NSLDS Professional Access portal. 3. The College will implement internal controls to track and verify changes in student enrollment status, program information, and key data elements. These controls will include but by no means limited to: a. A monthly reconciliation process between SIS data and NSLDS records. b. Use of exception reports to flag and resolve inconsistencies or delays. c. Documentation of all update logs for audit purposes. Periodic reviews will be conducted at least once per term to assess the accuracy and completeness of enrollment reporting. Any discrepancies will be promptly addressed and procedures updated as necessary to prevent recurrence. Relevant staff in both the FAO and Registrar’s Office will receive regular training on NSLDS reporting requirements, including proper use of record types (Campus vs. Program Level), enrollment status codes, and certification timelines. Training will emphasize the implications of noncompliance and best practices for accurate reporting. Training logs will be maintained by both the FAO and Registrar’s Office to support accountability and audit-readiness. Contact: VPEMSS Completion Date: September 30, 2025
Finding 2023-07 - Special Tests and Provisions: Disbursements to or on Behalf of Students Recommendation The College should implement a comprehensive communication strategy to ensure that all students receive clear and timely notifications regarding their Title IV funds. This should include the deve...
Finding 2023-07 - Special Tests and Provisions: Disbursements to or on Behalf of Students Recommendation The College should implement a comprehensive communication strategy to ensure that all students receive clear and timely notifications regarding their Title IV funds. This should include the development of award letter of college financing plans that outline the amount and type of funds, as well as the disbursement schedule. Additionally, the College should establish a monitoring system to ensure that credit balances are disbursed within the required 14-day time frame to maintain compliance with federal records. Response The College acknowledges the finding and has initiated a process to address them. A formal request has been submitted to the SIS program developer for the implementation of a notification feature. The SIS vendor has confirmed development will be completed by July 1, 2025. This feature will ensure that students receive email notifications when they are awarded and reimbursed for any overpayments. Furthermore, we will establish an enhanced level of monitoring to ensure that credit balances are disbursed within the designated 14-day timeframe. Contact: Comptroller Completion Date: September 30, 2025
Finding 2023-06 – Special Tests and Provisions: Gramm-Leach-Bliley Act–Student Information Security Recommendation The College should develop and implement a comprehensive GLBA information security program that includes risk assessments, safeguards, and regular testing and monitoring of the effectiv...
Finding 2023-06 – Special Tests and Provisions: Gramm-Leach-Bliley Act–Student Information Security Recommendation The College should develop and implement a comprehensive GLBA information security program that includes risk assessments, safeguards, and regular testing and monitoring of the effectiveness of these safeguards. A qualified individual with the necessary expertise and authority to oversee the GLBA information security program should also be designated. Provide training to relevant staff on GLBA requirements and the importance of information security. Conduct periodic reviews and updates of the information security program to ensure ongoing compliance with GLBA requirements. Response The college acknowledges the finding and will strengthen its student information security by implementing the following: 1) Designate a qualified Information Security Officer from within the IT Division or recruit externally if internal capacity is limited. 2) Develop a GLBA compliance program that includes: • Annual risk assessments • Implementation of administrative, technical, and physical safeguards • Staff training on data privacy • Annual testing of the security protocols Contact: Vice President for Institutional Effectiveness & Quality Assurance (VPIEQA) Completion Date: September 30, 2025
Property and Equipment Management Federal Agency: Various Federal Program Name: Research and Development Cluster Assistance Listing Number: Various Recommendation: We recommend management implement procedures for physical inventory to be taken within a two‐year time frame as well as maintain evide...
Property and Equipment Management Federal Agency: Various Federal Program Name: Research and Development Cluster Assistance Listing Number: Various Recommendation: We recommend management implement procedures for physical inventory to be taken within a two‐year time frame as well as maintain evidence of assets possession such as photos of the property and equipment. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Led by the Director of Capital Planning and Facilities Management, KSU has hired an inventory specialist to improve physical inventory documentation and maintenance. In addition, The Controller is in the process of reevaluating and designing internal controls surrounding capital and non‐capital inventory in conjunction with the President. Name(s) of the contact person(s) responsible for corrective action: Melissa Hicks – Controller in coordination with Jennifer Linton, Director of Capital Planning and Facilities Management. Planned completion date for corrective action plan: June 30, 2026
Suspension and Debarment Federal Agency: Various Federal Program Name: Research and Development Cluster Assistance Listing Number: Various Recommendation: We recommend the University review its policies relating to the retention of records to ensure support regarding the debarment status of vender...
Suspension and Debarment Federal Agency: Various Federal Program Name: Research and Development Cluster Assistance Listing Number: Various Recommendation: We recommend the University review its policies relating to the retention of records to ensure support regarding the debarment status of venders is maintained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Although Banner cannot currently add the W‐9 or debarment information in Banner Document Management, the University has implemented additional procedures and buyers have been trained in checking SAM.gov for each federally funded Purchase Order. All W‐9 documents are currently stored on a shared drive for retrieval. Name(s) of the contact person(s) responsible for corrective action: Fran Pinkston, Director of Purchasing & Procurement Planned completion date for corrective action plan: December 31, 2025
Our Organization has developed a Monitoring Policy to have better oversight of our sub-recipients. Our Chief Executive Office will implement this Monitoring Policy. The Grant Coordinator, will oversee the direct communications related to sub-recipients monitoring. The implementation of enhanced m...
Our Organization has developed a Monitoring Policy to have better oversight of our sub-recipients. Our Chief Executive Office will implement this Monitoring Policy. The Grant Coordinator, will oversee the direct communications related to sub-recipients monitoring. The implementation of enhanced monitoring tools and documentation standards will be completed by June 30, 2025
Finding 2023-006 – Federal Funding Accountability and Transparency Act Name of contact person and title: Jennifer Houck, Interim Chief Financial Officer Anticipated completion date: 6/30/25 Organization’s response: Concur Management agrees with this finding an...
Finding 2023-006 – Federal Funding Accountability and Transparency Act Name of contact person and title: Jennifer Houck, Interim Chief Financial Officer Anticipated completion date: 6/30/25 Organization’s response: Concur Management agrees with this finding and provided the following response for corrective action Plan of Action: To improve FFATA compliance, mandatory reconciliations for grants have been implemented to ensure timely identification and correction of reporting errors. Additionally, a reporting tracker has been established to monitor deadlines and ensure all required submissions are completed accurately and on time.
Fiscal Year 2023 Single Audit Corrective Action Plan Finding Number: 2023-006 Cash Management Condition: The CMHSP has established internal controls relating to approvals of cash requests. However, during testing we noted that cash requests did not contain evidence of required approvals. Planned Cor...
Fiscal Year 2023 Single Audit Corrective Action Plan Finding Number: 2023-006 Cash Management Condition: The CMHSP has established internal controls relating to approvals of cash requests. However, during testing we noted that cash requests did not contain evidence of required approvals. Planned Corrective Action: The CFO or Finance Manager will ensure that all cash requests are approved by the proper individuals. Contact Person: Kevin Hartley, CFO 231.633.2171 Kevin.hartley@nlcmh.org Anticipated Completion Date: 10-1-24
Fiscal Year 2023 Single Audit Corrective Action Plan Finding Number: 2023-005 Reporting Condition: The CMHSP did not reconcile financial expenditures shown in the Federal Financial Report to the total disbursement and charges in PMS. Planned Corrective Action: The CFO or Finance Manager will ensure ...
Fiscal Year 2023 Single Audit Corrective Action Plan Finding Number: 2023-005 Reporting Condition: The CMHSP did not reconcile financial expenditures shown in the Federal Financial Report to the total disbursement and charges in PMS. Planned Corrective Action: The CFO or Finance Manager will ensure that the financial expenditures shown in the Federal Financial Report reconciles to the total disbursement and charges in PMS. Contact Person: Kevin Hartley, CFO 231.633.2171 Kevin.hartley@nlcmh.org Anticipated Completion Date: 10-1-24
Views of Responsible Officials and Planned Corrective Actions: Agree with recommendation. A draft procurement policy has been prepared. It will be modified to ensure compliance with procurement of property or services required under a Federal award. Employees with procurement responsibilities wil...
Views of Responsible Officials and Planned Corrective Actions: Agree with recommendation. A draft procurement policy has been prepared. It will be modified to ensure compliance with procurement of property or services required under a Federal award. Employees with procurement responsibilities will be required to follow the policy.
Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The recommendations are included in the new grants policy. The City Manager shall review and approve it for implementation by September 2025. Planned Implementation Date:...
Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The recommendations are included in the new grants policy. The City Manager shall review and approve it for implementation by September 2025. Planned Implementation Date: September 2025 Responsible Person(s): City Manager
Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The City Controller’s Office drafted a grants policy that is currently under review by City Management. Community development staff will ensure a succession plan is in pl...
Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The City Controller’s Office drafted a grants policy that is currently under review by City Management. Community development staff will ensure a succession plan is in place for any staff turnover and for report preparation compliance. Planned Implementation Date: September 2025 Responsible Person(s): City Manager, City Controller, and Community Development Director
CORRECTIVE ACTION PLAN Name of the Project: Baten Arms Apartments FHA/CONTACT NO. 114-11227 Audit Firm: M Group, LLP Audit Period: The year ended June 30, 2023 Compliance Review COMMENTS ON FINDINGS AND RECOMMENDATIONS We concur with the findings and recommendations of our auditors regarding ou...
CORRECTIVE ACTION PLAN Name of the Project: Baten Arms Apartments FHA/CONTACT NO. 114-11227 Audit Firm: M Group, LLP Audit Period: The year ended June 30, 2023 Compliance Review COMMENTS ON FINDINGS AND RECOMMENDATIONS We concur with the findings and recommendations of our auditors regarding our noncompliance as cited in the accompanying Schedule of Findings and Questioned Costs. ACTIONS TAKEN FINDING #2023-003: Section 8 Housing Assistance Payments Program, CFDA: 14.195 and Mortgage Insurance Section 223(f) Insured Loan, CFDA:14.155 CORRECTIVE ACTION TO BE COMPLETED: The Corporation will review and monitor documentation procedures to ensure compliance regarding cash disbursements. We have prepared the corrective action plan as required by the standards applicable to financial statements contained in Government Auditing Standards and by the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principals, and Audit Requirements for Federal Awards. Any questions regarding the above corrective action plan should be directed to Mr. Stewart Grounds.
View Audit 359650 Questioned Costs: $1
Management concurs with the recommendation as proposed and is implementing policies and procedures to track and monitor reporting requirements. Management will file the reporting package and data collection form.
Management concurs with the recommendation as proposed and is implementing policies and procedures to track and monitor reporting requirements. Management will file the reporting package and data collection form.
Management agrees with the auditors' finding and will take action to implement controlling procedures over federal programs. Name(s) of Contact Person(s) Responsible for Corrective Action: Nhia Xiong, Accounting Specialist, Alex Sukalski, Chief Financial Officer
Management agrees with the auditors' finding and will take action to implement controlling procedures over federal programs. Name(s) of Contact Person(s) Responsible for Corrective Action: Nhia Xiong, Accounting Specialist, Alex Sukalski, Chief Financial Officer
FINDING 2023-003 Finding Subject: COVID-19 – State and Local Fiscal Recovery Funds – Suspension and Debarment Contact Person Responsible for Corrective Action: Bob G. Courtney, Mayor Contact Phone Number and Email Address: 812-265-8300/mayor@madison-in.gov Views of Responsible Officials: We concur w...
FINDING 2023-003 Finding Subject: COVID-19 – State and Local Fiscal Recovery Funds – Suspension and Debarment Contact Person Responsible for Corrective Action: Bob G. Courtney, Mayor Contact Phone Number and Email Address: 812-265-8300/mayor@madison-in.gov Views of Responsible Officials: We concur with the finding regarding the lack of policies or procedures in place related to the SLRF suspension and debarment requirements. Description of Corrective Action Plan: Historically, the city has not had a centralized position who would be responsible for grant and compliance management which created an inferior process of internal controls. A new Project & Grant Manager position was created in the Mayor’s office in April 2025. When contracts for goods or services equal or exceed the required amount, verification will be done by checking the Excluded Parties List System (EPLS), collecting a certification from that person, or adding a clause or condition to the transaction with that person. Proper education on the process is already underway. Anticipated Completion Date: The new position referenced above has been filled and is in operation as of April 8th 2025.
Action to be taken – Future internal approval of all timesheets will include first approval by the immediate supervisor, reviewing total hours worked per week, grants billed, and total hours worked. There will be a second approval by an outside financial management firm when they process the payroll...
Action to be taken – Future internal approval of all timesheets will include first approval by the immediate supervisor, reviewing total hours worked per week, grants billed, and total hours worked. There will be a second approval by an outside financial management firm when they process the payroll to prevent errors in overpayments. Estimated completion date – In September 2024 the new executive director mandated her approval or that of the board treasurer for any expenses. We are in the process of onboarding with the new financial management company with the anticipated start date of October 1, 2025 (the beginning of 2026 fiscal year).With this addition to our process, payroll will be processed off site by a third party. Responsible person – Carla Filkins, Executive Director and Julie Rushing, Board Treasurer
View Audit 359118 Questioned Costs: $1
Action to be taken – Immediately upon discovering the 2023 audit had not been completed, the Organization reached out to Weinlander Fitzhugh to schedule completion of the audit. As soon as the September 30, 2023 audit is complete, we have engaged with a new audit firm to begin the September 30, 2024...
Action to be taken – Immediately upon discovering the 2023 audit had not been completed, the Organization reached out to Weinlander Fitzhugh to schedule completion of the audit. As soon as the September 30, 2023 audit is complete, we have engaged with a new audit firm to begin the September 30, 2024 audit immediately. The Data Collection Forms will be submitted to the Federal Audit Clearinghouse within 30 days of the completion of each audit. Estimated completion date – The outstanding September 30, 2023 and September 30, 2024 fiscal year end audits are anticipated to both be completed by August 31, 2025. The September 30, 2025 audit will be scheduled timely after completion of the fiscal year. Responsible person – Carla Filkins, Executive Director and Julie Rushing, Board Treasurer
Action to be taken – Internal controls have been adjusted to reflect double approval of all transactions by the direct supervisor and the executive director or treasurer. This will include coding of bills, approval of all transactions and the processing of transactions. All approved transactions wil...
Action to be taken – Internal controls have been adjusted to reflect double approval of all transactions by the direct supervisor and the executive director or treasurer. This will include coding of bills, approval of all transactions and the processing of transactions. All approved transactions will be handled by an offsite financial management service in the future. By eliminating the use of the credit card, this will significantly reduce the chance of not having proper supporting documentation in the future. Estimated completion date – In September 2024 the new executive director mandated her approval or that of the board treasurer for any expenses, including credit cards. In February 2025 we updated our internal controls and added an administrative assistant to provide an extra level of segregation of duties. We are in the process of onboarding with the new financial management company with the anticipated start date of October 1, 2025 (the beginning of 2026 fiscal year). Responsible person – Carla Filkins, Executive Director and Julie Rushing, Board Treasurer
Action to be taken – Since becoming aware of the discrepancies between the credit card statements and transactions recorded in Quickbooks, the Organization has been entering all charges, interest and fees into the accounting software to reflect true balances on the credit cards. Going forward, all e...
Action to be taken – Since becoming aware of the discrepancies between the credit card statements and transactions recorded in Quickbooks, the Organization has been entering all charges, interest and fees into the accounting software to reflect true balances on the credit cards. Going forward, all entries related to credit cards will be recorded by an outside financial management firm. The Organization has accepted a purchase agreement for the Organization's building at 118 S Mitchell Street. The outstanding balance of the credit cards owed will be paid from the proceeds of the sale. Since becoming aware of the credit card balances, the use of Organization credit cards has been significantly restricted by management. Going forward, all credit card charges, if there are any, are only approved by the discretion of the executive director and paid on the balance immediately. Estimated completion date – Credit card balances have been reviewed and are current in their posting to our accounting software through journal entries that have been recorded. All fees and interest have also been recorded. All open credit card balances will be paid off from the proceeds on the sale of our building. This is anticipated to be completed by June 2025. Responsible person – Carla Filkins, Executive Director and Julie Rushing, Board Treasurer
Action to be taken – The Organization has updated its internal controls to reflect incorporate segregation of duties over the disbursement process and payroll processing. For payroll the updated process includes one person approving timesheets, another person processing payroll, the executive direct...
Action to be taken – The Organization has updated its internal controls to reflect incorporate segregation of duties over the disbursement process and payroll processing. For payroll the updated process includes one person approving timesheets, another person processing payroll, the executive director and board treasurer approving payroll, and lastly include a final approval of payroll. For disbursements the director of operations will open the mail and code bills for expense accounts, the executive director will approve bills for payment, the director of operations will print checks, the executive director or board treasurer will sign checks, the community response coordinator will mail checks, and the board treasurer will review bank reconciliations completed by the director of operations. All reconciliations will be reviewed by the board treasurer. Payroll processing will be performed by an outside financial management firm moving forward. Estimated completion date – In September 2024 the new executive director mandated her approval or that of the board treasurer for any expenses, including credit cards. In February 2025 we updated our internal controls and added an administrative assistant to provide an extra level of segregation of duties. Responsible person – Carla Filkins, Executive Director and Julie Rushing, Board Treasurer
Action to be taken – The Organization has adjusted its internal controls to include a final approval of payroll and withholdings by the executive director and board treasurer. The newly contracted outside financial Organization will be responsible for the processing of all payroll withholdings. The ...
Action to be taken – The Organization has adjusted its internal controls to include a final approval of payroll and withholdings by the executive director and board treasurer. The newly contracted outside financial Organization will be responsible for the processing of all payroll withholdings. The executive director and the treasurer will have online access to the accounts for oversight. Estimated completion date – In October 2024 the Executive Director began reviewing payroll and payroll withholdings during each pay period. Responsible person – Carla Filkins, Executive Director and Julie Rushing, Board Treasurer
Action to be taken – In September 2024 when the new executive director joined the Organization, the Organization immediately began to pay and file the payroll withholding. The late tax payments were brought to the attention of the executive director by the auditing firm during the audit. The board o...
Action to be taken – In September 2024 when the new executive director joined the Organization, the Organization immediately began to pay and file the payroll withholding. The late tax payments were brought to the attention of the executive director by the auditing firm during the audit. The board of directors immediately contacted tax attorney Patti O’Dell. The tax attorney has been communicating with the IRS and the State of Michigan on behalf of the Organization. Patti O’Dell has since joined the Organization's board of directors. The new internal controls in place and the new arrangement of contracting with an outside financial management firm will improve oversight in the future. The Organization has accepted a purchase agreement for the Organization's building at 118 S Mitchell Street. The balance of the payroll taxes owed will be paid from the proceeds of the sale. Estimated completion date – The sale of the building and payment of the outstanding payroll tax balances are anticipated to be completed by June 2025. The Organization will pay the total amount owed along with interest and penalties as soon as the sale of the building closes. All 2024-2025 fiscal year payroll taxes are current in processing and payment. Responsible person – Carla Filkins, Executive Director and Julie Rushing, Board Treasurer
Corrective Action Plan: 1. Created a detailed shared federal financial reporting calendar that includes all relevant deadlines and submission dates 2. Developed checklists for each report to ensure all required information is gathered and reviewed before submission 3. Designated a staff member who i...
Corrective Action Plan: 1. Created a detailed shared federal financial reporting calendar that includes all relevant deadlines and submission dates 2. Developed checklists for each report to ensure all required information is gathered and reviewed before submission 3. Designated a staff member who is responsible for tracking and managing federal financial reporting deadlines and ensuring timely submissions 4. Continuously evaluate the financial reporting process and make adjustments based on lessons learned from previous submissions and audits 5. Review and update internal policies and procedures to ensure that they reflect the latest federal reporting requirements and best practices Anticipated completion date: 1. Completed 2. Completed 3. Completed 4. Ongoing 5. Ongoing
Corrective Action Plan: 1. Standardize financial reporting procedures: • Accountant and ED will meet bi-weekly to review revenue and expenses • Accountant will meet with Donor Operations Manager monthly to confirm fund development revenue and expenses are properly allocated to the correct GL code • ...
Corrective Action Plan: 1. Standardize financial reporting procedures: • Accountant and ED will meet bi-weekly to review revenue and expenses • Accountant will meet with Donor Operations Manager monthly to confirm fund development revenue and expenses are properly allocated to the correct GL code • Accountant will send monthly financials to ED first for review • Once approved, ED will send monthly financials to Finance Committee Chair and BOD President • Finance Committee Chair will send to full board • Any questions will be addressed to the Finance Committee Chair • Budget will be reviewed at monthly leadership meetings • Regularly assess and refine, as applicable, financial reporting and closing processes to improve efficiency and accuracy 2. Finance Committee • Effective 9/2023, the finance committee was re-instituted to review financials and to implement stronger financial safeguards for TBS • Monthly meetings are held where financial performance and reports are reviewed in depth • Any anticipated risks will be reviewed • Finance Committee prepares annual budget with input from ED and BOD President 3. Board reporting • BOD members will receive monthly financial packet from Finance Committee Chair for review • Any questions will be directed to the Finance Committee Chair • Each quarterly board meeting will include a budget review highlighting projections and actuals vs budgeted • First board meeting of year will include comprehensive review of previous year Anticipated completion date: 1. Ongoing 2. Ongoing 3. Ongoing
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