Corrective Action Plans

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FINDING 2023-006 Finding Subject: Education Stabilization Fund - Reporting Summary of Finding: Management had not developed or implemented a system of internal control that would have ensured compliance with the grant agreement and the Reporting compliance requirement. The failure to establish an ef...
FINDING 2023-006 Finding Subject: Education Stabilization Fund - Reporting Summary of Finding: Management had not developed or implemented a system of internal control that would have ensured compliance with the grant agreement and the Reporting compliance requirement. The failure to establish an effective internal control system enabled material noncompliance to go undetected. Noncompliance with the grant agreement and the Reporting compliance requirement could result in the loss of future federal funds to the School Corporation. We recommended that the School Corporation's management establish internal controls to ensure compliance and comply with the grant agreement and the Reporting compliance requirement. Contact Person Responsible for Corrective Action: Andrea Miller Contact Phone Number and Email Address: 765-564-2100, millera@delphi.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The treasurer will prepare all required reports, and the grant administrator will verify the information on the reports. Reports will be signed and dated by both parties. Anticipated Completion Date: July 2024
FINDING 2023-005 Finding Subject: Child Nutrition Cluster - Procurement and Suspension and Debarment Summary of Finding: Management had not developed a system of internal controls that would have ensured compliance with the grant agreement and the Procurement and Suspension and Debarment compliance ...
FINDING 2023-005 Finding Subject: Child Nutrition Cluster - Procurement and Suspension and Debarment Summary of Finding: Management had not developed a system of internal controls that would have ensured compliance with the grant agreement and the Procurement and Suspension and Debarment compliance requirement. The failure to establish an effective internal controls system enabled material noncompliance to go undetected. Noncompliance with the grant agreement and the Procurement and Suspension and Debarment compliance requirement could result in the loss of future federal funds to the School Corporation. We recommended that the School Corporation's management establish a system of internal controls to ensure compliance with the Procurement and Suspension and Debarment compliance requirement. Contact Person Responsible for Corrective Action: Andrea Miller Contact Phone Number and Email Address: 765-564-2100, millera@delphi.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Food Service Director will obtain 3 quotes for any purchase over $10,000 from different vendors, in addition if the purchase is over $50,000 a contract will be awarded. Vendors will be verified by SAM.gov for suspension and disbarment, a record of these searches will be printed and kept in the vendor file. In addition, a vendor list will be provided annually to the school board for approval. Anticipated Completion Date: July 2024
Finding 2023-001 Special Tests and Provisions - Sliding Fee Scale Recommendation Kalihi-Palama Health should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated, and patients receive the correct sliding fee discount. Action Taken: We implemented...
Finding 2023-001 Special Tests and Provisions - Sliding Fee Scale Recommendation Kalihi-Palama Health should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated, and patients receive the correct sliding fee discount. Action Taken: We implemented a new EHR system AthenaOne and it includes a sliding fee scale calculation tool. By March 18, 2024 we will have completed doing all of the testing and training of all current Patient Services/Front Desk staff. Effective April 1 2024, we will implement the following changes to ensure clients are appropriately charged according to the sliding fee scale: • Update recurring sliding fee scale employee training sessions to quarterly. • Update training process documentation and reference materials for sliding fee scale. • Implement monthly review and spot check procedures to ensure compliance with the sliding fee scale requirements and guidelines. Based on the results of the reviews and spot checks, individualized training will be provided staff. • Onboarding new Patient Services/Front Desk staff will be based on the updated training and reference materials. Should you need additional information or have questions, you can reach me at ekintu@kphc.org or (808) 791-6315. Emmuel Kintu, D. Mgt, MBA Chief Executive Office & Executive Director
Finding 372673 (2023-003)
Significant Deficiency 2023
Recommendation: We recommend that the Organization review its monitoring process for the annual reporting of SF-425 reports, and ensure reports are filed timely within the requirements of the reporting deadlines. If an extension is necessary for any instances of reporting, a request for extension sh...
Recommendation: We recommend that the Organization review its monitoring process for the annual reporting of SF-425 reports, and ensure reports are filed timely within the requirements of the reporting deadlines. If an extension is necessary for any instances of reporting, a request for extension should be filed with the federal agency, along with a justified explanation for the additional time needed. Otherwise, all annual reports should be filed timely no later than 60 days after the end of each fiscal year.Views of Responsible Officials and Planned Corrective Action: Move United will put in place a three tier redundancy plan for ensuring that filings, both within the VA Salesforce system and within the Payment Management System, are filed prior to or on time each quarter. The Chief Financial Officer, Programs Director and Grants Administrator will work collaboratively to complete the necessary data compilation at least one week prior to the filing deadline. All three individuals will be trained on and have access to the two systems. In the event one individual is incapacitated at the time of filing, one of the other two will complete the filing on time. Person Responsible: Chief Financial & Operating Officer, Programs Director. Planned Completion Date: Immediately.
Finding 2023‐002 Finding Subject: COVID‐19 ‐ Education Stabilization Fund ‐ Reporting Summary of Finding: The School Corporation was required to submit an annual data report to the Indiana Department of Education (IDOE) via JotForm, a form/report builder. Data to be submitted included, but was not l...
Finding 2023‐002 Finding Subject: COVID‐19 ‐ Education Stabilization Fund ‐ Reporting Summary of Finding: The School Corporation was required to submit an annual data report to the Indiana Department of Education (IDOE) via JotForm, a form/report builder. Data to be submitted included, but was not limited to, current period expenditures, prior period expenditures, and expenditures per activity. The School Corporation submitted two reports during the audit period; however, a single employee prepared and submitted the reports without evidence of a review or oversight process in place to prevent or detect and correct errors for the first report submission. Additionally, for the ESSER I Year 2 reporting, the ‘Total Mandatory Subgrant Amount Expended in Current Reporting Period’ was not supported by the School Corporation's records. Actual expenditures from a provided report did not agree to the amount submitted for the Annual Performance Reporting. The key line item ‘Total Mandatory Subgrant Amount Expended in Current Reporting Period’ for the ESSER I Year 2 report was determined to be overstated by $80,342. Contact Person Responsible for Corrective Action: Whitney Kuszmaul, District Treasurer & Tiffany Grant, Grant Coordinator Contact Phone Number and Email Address: (765) 342‐6641 Whitney.Kuszmaul@msdmartinsville.org & Tiffany.Grant@msdmartinsville.org Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Grant Coordinator works to collect the data from a couple different sources. The staff report information comes from our Payroll/HR department, the CE information comes from our Reporting Specialist and the financial data comes from District Treasurer. The Grant Coordinator requests a detailed report for the appropriate period and break down the detailed report by project/report categories. All of this information is then recorded in the DOE data sheet and is reviewed and tied back to the detailed reports provided by the District Treasurer. After review, the Grant Coordinator and the District Treasurer initial/sign off on the DOE data sheets. The Jot Form confirmation is retained with the DOE data sheets and supporting reports/documentation. Anticipated Completion Date: February 2024
Finding 2023‐001 Finding Subject: COVID‐19 ‐ Education Stabilization Fund ‐ Allowable Costs/Cost Principles Summary of Finding: The School Corporation paid security contractors without an invoice. Costs charged to grant funds must be adequately documented. The School Corporation had an accounts paya...
Finding 2023‐001 Finding Subject: COVID‐19 ‐ Education Stabilization Fund ‐ Allowable Costs/Cost Principles Summary of Finding: The School Corporation paid security contractors without an invoice. Costs charged to grant funds must be adequately documented. The School Corporation had an accounts payable voucher signed by the contractor, but there was no invoice supporting the accounts payable voucher. Costs charged to grant funds must be adequately supported with documentation. Contact Person Responsible for Corrective Action: Tiffany Grant, Grant Coordinator Contact Phone Number and Email Address: 765‐342‐6641 ‐ Tiffany.Grant@msdmartinsville.org Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: A contract is on file with the Martinsville City Police Department for the contracted police officers that work for the MSD of Martinsville. Going forward, contracted police officers will submit their timesheets directly to the MSD of Martinsville Assistant Police Chief. The Assistant Police Chief will verify hours worked and submitted to the schedule. The Assistant Police Chief will review and initial/sign the vouchers before submitting those to the Grant Coordinator for review and signature. Anticipated Completion Date: February 2024
The Section 8 Program will improve its internal controls and monitoring procedures to assure the correction of income included in the 50058-Family Report. Implementation Date: During the fiscal year 2023-2024 Responsible Persons: Mr. Job Bonilla Federal Program Director
The Section 8 Program will improve its internal controls and monitoring procedures to assure the correction of income included in the 50058-Family Report. Implementation Date: During the fiscal year 2023-2024 Responsible Persons: Mr. Job Bonilla Federal Program Director
2023-001 Audit Adjustments and Oversight of the Financial Reporting Process Name of contact person – Laura Straw, Director of Finance Corrective action – Management has developed and implemented a new financial review process that includes a daily checklist for all accounting functions, includi...
2023-001 Audit Adjustments and Oversight of the Financial Reporting Process Name of contact person – Laura Straw, Director of Finance Corrective action – Management has developed and implemented a new financial review process that includes a daily checklist for all accounting functions, including, but not limited to bank reconciliations, balance sheet account reconciliations, depreciation schedules, etc. through month end close. This check list includes the responsible party, date to be completed and reviewer. It is reviewed weekly by the accounting staff as a team. Completion date – Management and the Board of Directors implemented the above as of February 1, 2024.
Federal Program Title: Research and Development Cluster ALN: Various Recommendation: We recommend the University evaluate its procedures and implement an additional control to review and approve the subrecipient reimbursements timely. Explanation of disagreement with audit finding: There is no di...
Federal Program Title: Research and Development Cluster ALN: Various Recommendation: We recommend the University evaluate its procedures and implement an additional control to review and approve the subrecipient reimbursements timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Boise State University continues to review and enhance its internal subrecipient payment processes to find ways to identify and prevent untimely subrecipient payments, and to reduce the potential for human error. The University will implement additional internal measures to address inefficiencies related to the current multi-department review, approval, and payment process. Name(s) of the contact person(s) responsible for corrective action: Jen Lutke, Assistant Director, Post Award: jenniferlutke@boisestate.edu Planned completion date for corrective action plan: February 2024
GLBA non-compliance Finding: The University does not meet the compliance requirements outlined in the GLBA Safeguards Rule. Discrepancies were identified in requirement B.6 which addresses how the institution how the institution will oversee its information system service providers. The University ...
GLBA non-compliance Finding: The University does not meet the compliance requirements outlined in the GLBA Safeguards Rule. Discrepancies were identified in requirement B.6 which addresses how the institution how the institution will oversee its information system service providers. The University did not have a Vendor Management Program with standards in place to oversee critical system service providers regarding due diligence, risk assessments, and annual reviews as related to 3rd party service providers. Auditors' Recommendation: The University needs to review the updated GLBA requirements and ensure their WISP includes all required elements. School Response: The school agrees with this finding. Corrective Action Plan: The school's director of IT is reviewing the school's Written Information Security Plan (WISP) to ensure GLBA Compliance. A vendor management plan has been added to the WISP which specifies that any information technology vendors and products will be subjected to an IT Acquisition Process prior to use by the University. In the IT Acquisition Process, the vendors and products will be evaluated by the Information Technology Advisory Committee and the Office of Information Technology to determine impact on the current infrastructure and data systems as well as any security concerns that should be addressed prior to implementation. Name(s) of the contact person{s) responsible for corrective action: Point University Director of IT, Bill Dorminy Planned completion date for corrective action plan: • WISP and review of GLBA requirements is ongoing with completion of the current review expected by June 1, 2024.
The filing of the Data Collection Form will be submitted by the required due date. In the prior year, the audit report was submitted after the Federal Audit Clearinghouse deadline. The current audit will be submitted with sufficient time to meet the Federal Audit Clearinghouse submission date requir...
The filing of the Data Collection Form will be submitted by the required due date. In the prior year, the audit report was submitted after the Federal Audit Clearinghouse deadline. The current audit will be submitted with sufficient time to meet the Federal Audit Clearinghouse submission date requirement. Responsible party(ies) for corrective action(s): Chief Financial Officer Corrective action(s) timeline: March 15, 2024
Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and will establish procedures to ensure compliance with guidelines and policies outlining the time and effort reporting and documentation requirements that department heads must adhere with to ensure co...
Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and will establish procedures to ensure compliance with guidelines and policies outlining the time and effort reporting and documentation requirements that department heads must adhere with to ensure compliance with federal and state time and effort reporting requirements. Management will also implement proper training to ensure that the program managers fully understand the time and effort reporting requirements. Management intends to implement these procedures in fiscal 2024.
FINDING No. 2023-004: Section 207/223(f) Mortgage Insurance for the Refinancing of Existing Multifamily Housing Projects, ALN 14.155 Recommendation: The Project should improve monitoring of the payroll disbursement process to ensure the appropriate approved wages are paid. Action Taken: Additio...
FINDING No. 2023-004: Section 207/223(f) Mortgage Insurance for the Refinancing of Existing Multifamily Housing Projects, ALN 14.155 Recommendation: The Project should improve monitoring of the payroll disbursement process to ensure the appropriate approved wages are paid. Action Taken: Additional payroll controls are being evaluated and implemented in 2024. This will include establishing procedures to ensure the completeness and accuracy of payroll and related oversight. If the audit Oversight Agency has questions regarding these plans, please call Irene Phillips at 954-835-9200. Sincerely yours, Irene Phillips, CFO Irene Phillips CFO
View Audit 293594 Questioned Costs: $1
During the Fiscal 2023 financial statement audit, Schneider Downs communicated the following finding from their Uniform Guidance procedures: The Food Bank did not obtain and or retain agency monitoring forms for 15 out of our sample of 25. Our response to the finding was: COVID-19 risk mitigation st...
During the Fiscal 2023 financial statement audit, Schneider Downs communicated the following finding from their Uniform Guidance procedures: The Food Bank did not obtain and or retain agency monitoring forms for 15 out of our sample of 25. Our response to the finding was: COVID-19 risk mitigation strategies employed by our Food bank and our partner agencies restricted our ability to directly monitor partner sites. The team responsible for monitoring and compliance also experienced staffing inconsistencies that have since been rectified; the team is now able to monitor at full capacity. Moving forward, new tools and processes for scheduling and tracking agency monitoring will provide better real-time insight into our progress and compliance. Finally, agencies are expected to renew their agreement with our Food Bank at 2024 calendar year-end, which will reassert our monitoring requirements to all partner agencies in our network. Update as of February 23, 2024 The Food Bank has taken the following actions: • The annual contract renewal process has been initiated, including reassertion of our monitoring requirements. • Additional compliance staff have started the regular monitoring process. • A system has been put in place to provide compliance progress updates to the Controller.
In recent years, due to staff turnover and a long period in between replacement, the City’s procedure for fulfilling FFATA reporting requirements has been missed. The City has already begun compiling the data for submission of the FFATA reporting for the 2023 year. We will work with resources from ...
In recent years, due to staff turnover and a long period in between replacement, the City’s procedure for fulfilling FFATA reporting requirements has been missed. The City has already begun compiling the data for submission of the FFATA reporting for the 2023 year. We will work with resources from the Federal Subaward Reporting System (FSRS) to get current with prior reporting years for which we may be obligated. Prior to submission, the reports will be reviewed and approved. The FFATA reporting will become a regular part of our process going forward now that we are adequately staffed.
Corrective Action Plan Year Ended June 30, 2023 Finding 2023-001: Procurement: Suspension and Debarment Condition Found: In the auditor’s testing over suspension and debarment, they identified two covered transactions, both with the same vendor, in a sample of 40 procurement transactions for wh...
Corrective Action Plan Year Ended June 30, 2023 Finding 2023-001: Procurement: Suspension and Debarment Condition Found: In the auditor’s testing over suspension and debarment, they identified two covered transactions, both with the same vendor, in a sample of 40 procurement transactions for which the University was unable to provide supporting documentation that they verified the vendor was not suspended or debarred prior to entering into the procurement transaction with the vendor. It was determined that the related vendor was not suspended or debarred. Recommendation: The auditors recommend the University enhance its internal control over compliance with the federal regulations related to suspension and debarment to ensure covered transactions are not entered into with parties that have been suspended or debarred. University of Delaware Corrective Action Plan: The University agrees with the finding. The University has taken additional measures to ensure a clause with suspension and debarment language is included within the contracts of all new covered transactions entered into on or after July 1, 2023. The finding relates to a legacy contract and has prompted a review of open purchase orders to address suspension/debarment requirements. Additionally, the University will begin utilizing a third-party verification software to screen existing and potential vendors against the System for Award Management (SAM.gov) Exclusions list daily, with an expected implementation by June 30, 2024. Anticipated Completion Date: Suspension and Debarment: Contract Clause – July 1, 2023 Suspension and Debarment: SAM.gov Verification – June 30, 2024 Contact Persons: Jeff Friedland, Associate Vice President for Research David Fenkel, Associate Vice President & Chief Procurement Officer
Condition Found: The Organization has not applied sliding fee discounts to patient charges consistent with its sliding fee discount program. Individual(s) Responsible for Corrective Action: Tina Gerlack, Billing Manager Planned Corrective Action: HealthFirst will continue to provide training on sl...
Condition Found: The Organization has not applied sliding fee discounts to patient charges consistent with its sliding fee discount program. Individual(s) Responsible for Corrective Action: Tina Gerlack, Billing Manager Planned Corrective Action: HealthFirst will continue to provide training on sliding fee eligibility to all staff related to sliding fee enrollment. HealthFirst will also continue to do monthly audits on all patients who receive a sliding fee discount. The monthly audits will include verifying the correct fee was applied based on documents received during the patients sliding fee enrollment. If any errors are found they will be immediately corrected. Anticipated Completion Date: 1/1/2024
Finding Number: 2023-002 Condition: Out of 60 allowability samples that were tested, one expenditure tested was determined to be incorrectly charged to this grant. Planned Corrective Action: The College of Cooperative Education and Professional Studies (CCPS) has instituted several reforms to prev...
Finding Number: 2023-002 Condition: Out of 60 allowability samples that were tested, one expenditure tested was determined to be incorrectly charged to this grant. Planned Corrective Action: The College of Cooperative Education and Professional Studies (CCPS) has instituted several reforms to prevent future instances of this nature. The Program Director is now required to review and sign-off on all transactions before they are charged to the project, to ensure all charges are appropriate. New staff have been assigned to the project to process transactions, and the CCPS business office is now meeting monthly to review project activity, discuss any questions, and address any concerns regarding financial activities. Additionally, the university is drafting a new policy to review and, if needed, provide additional administrative support for large, complex grant projects. This policy will require that grant proposals above a certain dollar threshold are reviewed by the Office of Research prior to submission to ensure proper resources will be available to manage the project if awarded. In cases where the Office of Research determines additional resources may be needed, they will be authorized to require additional support be included in the grant proposal, or else provide additional administrative help to the unit at the time of award. Contact person responsible for corrective action: CCPS: Jeremy Harvey, Jodi Sleyo, and Bailey Bartels. Office of Research: Patrick Clark Anticipated Completion Date: CCPS changes have been implemented as of 10/11/2023; policy changes to be completed by 6/30/2024.
View Audit 293505 Questioned Costs: $1
Finding Number: 2023-001 Condition: Out of 28 payments to subrecipients that were tested, 12 were made after the 30 calendar day requirement. Planned Corrective Action: Accounts Payable personnel will review all vendor invoices to determine whether an invoice is related to a federal award expendit...
Finding Number: 2023-001 Condition: Out of 28 payments to subrecipients that were tested, 12 were made after the 30 calendar day requirement. Planned Corrective Action: Accounts Payable personnel will review all vendor invoices to determine whether an invoice is related to a federal award expenditure. For federal award expenditures, Accounts Payable will manually change the payment terms to 30 calendar days or less, to ensure compliance. Periodically, Accounts Payable will review open federal award payables to verify payment terms have been properly set for the 30-day compliance requirement. The Controller’s and Accounts Payable Offices will also explore creating a more efficient long-term solution, whereby the 30-day terms could be automatically set during the purchase order creation process. This would eliminate any manual updates to the payment terms by Accounts Payable personnel. The Sponsored Research Services Accounting Office will send reminders to all college business officers and Principal Investigators (PIs) to highlight the need for prompt review and approval of Federal award invoices. This language will be incorporated into the SRS Best Grant Practices training classes, as well as the university’s Fundamentals of Sponsored Administration training courses. Contact person responsible for corrective action: Accounts Payable: Erik Sager; Purchasing: Tom Guerin; Sponsored Research Services Accounting: John Ungruhe Anticipated Completion Date: Initial corrective action, including review of invoices, reminders and modifications to training, will be completed by 10/31/2023. Additional solutions to eliminate manual updates, if possible, will be completed within 12 months.
WE HAVE REVIEWED AND ARE FAMILIAR WITH THE REQUIRED COMPLIANCE REQUIREMENTS UNDER THE COMPLIANCE STATEMENT WHICH GOVERNS THE ARP ESSER PROGRAM. WE HAVE REQUESTED AND RECEIVED DOCUMENTATION FROM EACH VENDOR THAT ATTESTS THAT THEY ARE CONFORMING TO DAVIS-BACON PREVAILING WAGE REQUIREMENTS.
WE HAVE REVIEWED AND ARE FAMILIAR WITH THE REQUIRED COMPLIANCE REQUIREMENTS UNDER THE COMPLIANCE STATEMENT WHICH GOVERNS THE ARP ESSER PROGRAM. WE HAVE REQUESTED AND RECEIVED DOCUMENTATION FROM EACH VENDOR THAT ATTESTS THAT THEY ARE CONFORMING TO DAVIS-BACON PREVAILING WAGE REQUIREMENTS.
View Audit 293502 Questioned Costs: $1
Going forward, we plan to implement robust policies and procedures to ensure the proper documention is obtained and maintained for each student who is removed from the adjusted cohort. This will involve establishing clear guidelines for confirming student transfers and ensuring that official written...
Going forward, we plan to implement robust policies and procedures to ensure the proper documention is obtained and maintained for each student who is removed from the adjusted cohort. This will involve establishing clear guidelines for confirming student transfers and ensuring that official written documentation is obtained and retained accordingly. Furthermore, we will conduct trainging sessions for relevant staff members involved in the documentation process to ensure understanding and adherence to the updated procedures. THis will help prevent similar issues from arising in the future and contribute to the accuracy and reliability of our graduation rate calculations.
ACOE updated the purchasing procurement policy and offered agency-wide training.
ACOE updated the purchasing procurement policy and offered agency-wide training.
View Audit 293447 Questioned Costs: $1
ACOE updated the new Time and Effort policy and offered agency-wide training.
ACOE updated the new Time and Effort policy and offered agency-wide training.
View Audit 293447 Questioned Costs: $1
The quarterly closing checklist will include required reporting to be verified by the Accounting Manager and Executive Director of Accounting no later than 30days after the end of the quarter. Quarterly grant meetings will be held to maintain quarterly progress reporting.
The quarterly closing checklist will include required reporting to be verified by the Accounting Manager and Executive Director of Accounting no later than 30days after the end of the quarter. Quarterly grant meetings will be held to maintain quarterly progress reporting.
Finding 372099 (2023-001)
Significant Deficiency 2023
Enrollment information was not submitted accurately or within the required timeframe by the University. Personnel Responsible for Corrective Action: Tonya Mourning, Chief Financial Officer, and Mike Pepple, Student Financial Services Director. Anticipated Completion Date: Corrective action plan will...
Enrollment information was not submitted accurately or within the required timeframe by the University. Personnel Responsible for Corrective Action: Tonya Mourning, Chief Financial Officer, and Mike Pepple, Student Financial Services Director. Anticipated Completion Date: Corrective action plan will be implemented by June 30, 2024. Corrective Action Plan: Management has hired a new Student Financial Services Director and is aware of the federal regulations surrounding enrollment information that must be reported to the NSLDS. Given the complexity of the reporting, management has established additional policies and procedures to address the errors related to enrollment reporting to the NSLDS in a timely and accurate manner.
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