Corrective Action Plans

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Name of Contact Person – Margaret Quintrall, Business Manager Corrective Action Carbon County School District #1 established a district folder for information used to complete all state and federal reporting requirements. Proposed Completion Date: July 5, 2023
Name of Contact Person – Margaret Quintrall, Business Manager Corrective Action Carbon County School District #1 established a district folder for information used to complete all state and federal reporting requirements. Proposed Completion Date: July 5, 2023
Views of responsible officials and planned corrective actions: The County does not have available funding to hire a grant compliance officer, however, the County plans to seek training resources for current staff responsible for grant administration
Views of responsible officials and planned corrective actions: The County does not have available funding to hire a grant compliance officer, however, the County plans to seek training resources for current staff responsible for grant administration
View Audit 13148 Questioned Costs: $1
To United States Department of Health and Human Services Heartland Community Health Center respectfully submits the following corrective action plan for the year ended April 30, 2023. CohnReznick, LLP 350 Church Street Hartford, CT 06103 Audit Period: April 30, 2023 The findings from the April 3...
To United States Department of Health and Human Services Heartland Community Health Center respectfully submits the following corrective action plan for the year ended April 30, 2023. CohnReznick, LLP 350 Church Street Hartford, CT 06103 Audit Period: April 30, 2023 The findings from the April 30, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Federal Awards Findings: Finding 2023.001 - Sliding Fee Scale Discount Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken • Monthly Audits o The Front Office Coordinators at each location will routinely audit sliding fee verification on a monthly basis to verify that information has been captured and recorded correctly and all proof of income documentation is received. These monthly audits will be adopted as standard protocol and procedure for front office operations, effective January 2024. Any findings through the audit process will be reported to the COO. At least five patien.t charts will be audited monthly. o In addition, the billing manager will also review audit findings or summaries to ensure adequate adjustment to patient accounts to correlate with the patient's eligibility status. • Staff Training o Although Heartland has offered periodic sliding fee scale procedure training, administration will be scheduling additional training with a focus on required documentation and proper set up of sliding fee discounts. o Health Center Practice Administrator will review and implement and update standard operating procedure for sliding fee scale verification. o Employees will receive a copy of the sliding fee scale policy and sign that they have read the material. o Front office employees at all locations will complete a sliding fee schedule competency check-off sheet that will be reviewed by the Front Office Coordinators and billing manager. If there are any question regarding this plan, please e-mail Regina Oxford at roxford@heartlandhealth.org. Sincerely,
Finding 9481 (2023-001)
Significant Deficiency 2023
Corrective Action Plan: The Finance Division will add calendar reminders to confirm all subsequent reporting on the audited financial statements and federal grants are completed by the various deadlines. Person Responsible: Yvonne Herrera, Finance Division Director Estimated Completion Date: June ...
Corrective Action Plan: The Finance Division will add calendar reminders to confirm all subsequent reporting on the audited financial statements and federal grants are completed by the various deadlines. Person Responsible: Yvonne Herrera, Finance Division Director Estimated Completion Date: June 30, 2024
District Administration was originally made aware of the specific requirements/documentation necessary for contracts let with federal ESSER funds during our FY22 state audit. School Districts are usually not required to pay prevailing wages (state/local funds). The District had not used federal fu...
District Administration was originally made aware of the specific requirements/documentation necessary for contracts let with federal ESSER funds during our FY22 state audit. School Districts are usually not required to pay prevailing wages (state/local funds). The District had not used federal funds for construction in the past and was unaware of the requirement. On 9/27/22, the District policy (DJF), regarding purchasing procedures, was updated to include the Davis-Bacon requirements. The purchase orders for the $24,605 flooring project in question were created on 8/18/22 and checks were issued on 12/15/22, prior to our FY22 audit being completed and a corrective action plan being in place. The District intends to closely follow internal controls pertaining to federal grant management in order to prevent future issues as described in Finding 2023-001.
Finding 9460 (2023-001)
Significant Deficiency 2023
Gramm Leach Bliley Act Planned Corrective Action: The current Information Security Program was created using Capin's template last year and was acceptable. Moving forward, we will document the safeguards we're putting in place by including them in the Information Security Program and documenting th...
Gramm Leach Bliley Act Planned Corrective Action: The current Information Security Program was created using Capin's template last year and was acceptable. Moving forward, we will document the safeguards we're putting in place by including them in the Information Security Program and documenting the decreased mitigated risk level. We have a legacy on­ premise legacy SIS application software that doesn't have the capacity for MFA. We will attempt to either move our on-premise application software and database to our vendor's location where MFA is required to get into their network, or we will source a third-party vendor that will work with a legacy application without MFA capacity and require MFA on the front-end before calling the application. We will also consider application software on University-owned computer workstations and laptops that require MFA upon logging into our campus network. We will source an outside company for penetration testing and vulnerability scanning. Then, review the results and put in a plan to address the critical items and track progress. We will document each vendor that hosts PII data. We will collect SOC reports, privacy statements, GLBA compliance documents, and other related documents. We will provide the Board of Trustees - Business/Finance Committee a written report on the current status of the Information Security Program document. Person Responsible for Corrective Action Plan: Kelvin D Tohme, Senior Director of Information Technology Anticipated Date of Completion: Spring 2024
Name of Contact Person: Matt Lacy, Chief Financial Officer; Recommendation: We recommend the District verify a vendor's status by checking the System for Award Management (SAM) maintained by the General Services Administration before making purchases expected to exceed $25,000; Corrective Action: ...
Name of Contact Person: Matt Lacy, Chief Financial Officer; Recommendation: We recommend the District verify a vendor's status by checking the System for Award Management (SAM) maintained by the General Services Administration before making purchases expected to exceed $25,000; Corrective Action: We will verify all vendors' status using the System for Award Management (SAM) maintained by the General Services Administration before making purchases expected to exceed $25,000.
Planned Corrective Action: We agree with the auditor’s comments, and the following action will be taken to improve the condition. Director Will Triplett and Manager Clarissa Lostaunau will implement a written policy included in the HSP Policy and Procedure Manual outlining accurate process and comp...
Planned Corrective Action: We agree with the auditor’s comments, and the following action will be taken to improve the condition. Director Will Triplett and Manager Clarissa Lostaunau will implement a written policy included in the HSP Policy and Procedure Manual outlining accurate process and completion of the HSP 14 monthly reporting. The manual will include written steps on obtaining, verifying and storing all backup documentation for all data on the HSP 14. The team will also include a verification process before the submission of the report where two employees approve the monthly report as an internal control, one being from management. This will be completed by December 31, 2023 and led by Director of Transformational Services, Will Triplett.
Finding: 2023-001 Name of contact person: Jacob Joyner, Director of Financial Services Corrective Action: The City will add review steps to ensure that all applicable reporting requirements are met. Proposed Completion Date: February 1, 2024
Finding: 2023-001 Name of contact person: Jacob Joyner, Director of Financial Services Corrective Action: The City will add review steps to ensure that all applicable reporting requirements are met. Proposed Completion Date: February 1, 2024
Name of Contact Person :Wannaa Chavis, Chief Finance Officer ...
Name of Contact Person :Wannaa Chavis, Chief Finance Officer Corrective Acrtion Plan: The finding resulted primarily from significant turnover within the Finance Department. Management has established procedures to ensure that all bank account and other required reconciliations are prepared on a timely basis going forward. The Finance department will also strive to keep key positions filled at all times and ensure that staff receives appropriate training regarding reconciliations. Proposed Completion Date: Immediately
U.S. Department of Education 2023-001 NSLDS Enrollment Reporting Student Financial Aid Cluster – Assistance Listing No. 84.063, 84.268 Condition: During testing of enrollment status reporting, we noted that the incorrect enrollment status, effective date, and program begin date was reported to N...
U.S. Department of Education 2023-001 NSLDS Enrollment Reporting Student Financial Aid Cluster – Assistance Listing No. 84.063, 84.268 Condition: During testing of enrollment status reporting, we noted that the incorrect enrollment status, effective date, and program begin date was reported to NSLDS. Recommendation: The College should evaluate their procedures and policies related to reporting status changes to NSLDS and enhance as deemed necessary to ensure that accurate information is reported to NSLDS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Cause-Enrollment Status Reporting: Montgomery College utilizes the National Student Clearinghouse (NSC) as a third-party provider in order to submit student information to the NSLDS. Student enrollment status corrections were uploaded to NSC timely, however, monitoring of the upload through success was inconsistent, resulting in error reports preventing the accurate and timely update to the enrollment statuses. No review was completed to ensure the upload was completed in NSLDS. Cause for Effective Date Reporting - Inaccurate Student withdrawal effective dates were not identified timely due to delays in the review of student withdrawal status. Cause for Program Start Date Reporting - Inaccurate Student program begin dates were due to a programming issue with the file transmission software. Program start date was updating each semester to the latest semester start date. There was insufficient review to identify the problem and recommend a solution to resolve. The following actions have been implemented to resolve the deficiencies: Review of error reports by an employee not responsible for correcting the errors to ensure completeness and timeliness of the corrections submitted. Use of internal weekly reports to identify students who dropped below half time status or withdrew entirely from a semester. Use of the NSC online error reporting tool to correct errors monthly. Errors are corrected using this tool within eight days of receipt of the error report, which provides the NSC two days to resubmit the information and meet the ten-day resolution requirement. Utilize the Enrollment Reporting Summary Report (SCHER1) to ensure completeness and timeliness of error correction submissions. The Dept of Enrollment Services has coordinated with the Office of Information Technology to adjust the programming on the file transmission to NSC to ensure accuracy and minimize discrepancies. Manually submit corrections directly to NSLDS on an as-needed basis. Name(s) of the contact person(s) responsible for corrective action: Director of Enrollment Services- Earnest Cartledge Planned completion date for corrective action plan: December 2023
November 27, 2023 United States Department of Health and Human Services Wood River Health Services, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: June 30, 2023 The findings from th...
November 27, 2023 United States Department of Health and Human Services Wood River Health Services, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: June 30, 2023 The findings from the June 30, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS SIGNIFICANT DEFICIENCY 2023.001 – Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly documented. Action Taken Wood River Health Services is committed to documenting the sliding fee discounts being applied. Actions we are taking: Re-education of the Sliding Fee Discount Schedule (SFDS) documentation process to all personnel in the Community Resources Area Create review cheat sheets for SFDS including the documentation needed for decision making Review of Community Resource approvals If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please contact Alison Croke acroke@wrhsri.org. Sincerely yours, Alison Croke, MHA President and Chief Executive Officer
Finding 9065 (2023-003)
Significant Deficiency 2023
Elementary and Secondary School Emergency Relief Assistance Listing Nos. 84.425D and 84.425U Recommendation: CLA recommends that the District implement a formal review process over the reporting requirement relating to ESSER annual reports. Explanation of disagreement with audit finding: There is no...
Elementary and Secondary School Emergency Relief Assistance Listing Nos. 84.425D and 84.425U Recommendation: CLA recommends that the District implement a formal review process over the reporting requirement relating to ESSER annual reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Annual ESSER reporting will be prepared by the bookkeeper, reviewed and signed off by the District Administrator, and be submitted Name(s) of the contact person(s) responsible for corrective action: Cari Guden, District Administrator Planned completion date for corrective action plan: July 1st 2023
Finding 9062 (2023-004)
Significant Deficiency 2023
Child Nutrition Cluster - Assistance Listing nos. 10.553 and 10.555 Recommendation: CLA recommends the District review and update policies and procedures over review of certain transactions to ensure that all federal grants with covered transaction have vendors reviewed for suspension and debarment ...
Child Nutrition Cluster - Assistance Listing nos. 10.553 and 10.555 Recommendation: CLA recommends the District review and update policies and procedures over review of certain transactions to ensure that all federal grants with covered transaction have vendors reviewed for suspension and debarment status. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All food service vendors will be checked for suspension and debarment on the Sam.gov website. Name(s) of the contact person(s) responsible for corrective action: Morgan Mueller, Bookkeeper Planned completion date for corrective action plan: July 1st 2023
CORRECTIVE ACTION PLAN (Concerning Finding 2023-001) December 21, 2023 Finding: 2023-001 Subrecipient Monitoring Federal Program Information: U.S. Department of Education Passed through the State of Vermont Agency of Education ALN: 84.425 - Education Stabilization Fund Contact Person Respons...
CORRECTIVE ACTION PLAN (Concerning Finding 2023-001) December 21, 2023 Finding: 2023-001 Subrecipient Monitoring Federal Program Information: U.S. Department of Education Passed through the State of Vermont Agency of Education ALN: 84.425 - Education Stabilization Fund Contact Person Responsible for Corrective Action: Cheryl Hammond, Business Manager Corrective Action: The Two Rivers Supervisory Union will take the following actions to address finding 2023-001:  Review 2 CFR 200.332(a)  Create a temple subreceipient form  Complete the form annually and create a new form with any chance to the sub granted amount  Begin this process immediately Anticipated Completion Date: December 21, 2023
Finding Number: 2023-001 Planned Corrective Action: The Dayton Early College Academy will comply with all federal grant compliance requirements – including reporting requirements and deadlines. Anticipated Completion Date: 07/01/2023 Responsible Contact Person: Steven Hinshaw, Treasurer
Finding Number: 2023-001 Planned Corrective Action: The Dayton Early College Academy will comply with all federal grant compliance requirements – including reporting requirements and deadlines. Anticipated Completion Date: 07/01/2023 Responsible Contact Person: Steven Hinshaw, Treasurer
With respect to the lack of performance of a risk assessment, formal, written subrecipient monitoring policies and procedures for the Trust are now in place and will cover the entire fiscal year period ending June 30, 2024. Management will strictly adhere to these policies and procedures with respec...
With respect to the lack of performance of a risk assessment, formal, written subrecipient monitoring policies and procedures for the Trust are now in place and will cover the entire fiscal year period ending June 30, 2024. Management will strictly adhere to these policies and procedures with respect to all new subrecipients and subrecipients that are still active and receiving reimbursements during the year. With respect to the lack of follow-up with findings in subrecipients’ audit reports, the Trust will update its subrecipient monitoring policies and procedures to include immediate follow-up and documentation of corrective actions taken by subrecipients to address audit findings in their single audit reports. Individual(s) Responsible for Corrective Action Plan: Denise Wise Vice President of Finance & Controller, NTHP 202-588-6192 John Chomiak Chief Financial & Administration Officer, NMSC 202-372-5617 Anticipated Completion Date: June 30, 2024
2023-002 - Noncompliance and Significant Deficiency in Internal Controls over Compliance for Subrecipient Monitoring Corrective Action Plan: Wellbeing Initiative has reviewed subrecipient monitoring criteria and updated the Internal Controls Policy and Procedure Manual to include the following...
2023-002 - Noncompliance and Significant Deficiency in Internal Controls over Compliance for Subrecipient Monitoring Corrective Action Plan: Wellbeing Initiative has reviewed subrecipient monitoring criteria and updated the Internal Controls Policy and Procedure Manual to include the following policy. The appropriate measures have been taken to ensure these requirements are met in the coming years. Item 10.8.b.i-xv. Subrecipient monitoring requirements for pass-through entities, include the requirement that pass-through entities ensure that every subaward is clearly identified to the subrecipient as a subaward and includes the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass-through entity must provide the best information available to describe the Federal award and subaward. Required information includes but is not limited to: i. Subrecipient name (which must match the name associated with its unique entity identifier); ii. Subrecipient's unique entity identifier; iii. Federal Award Identification Number (FAIN); iv. Subaward Period of Performance Start and End Date; v. Subaward Budget Period Start and End Date; vi. Total Amount of Federal Funds Obligated to the subrecipient by the pass-through entity including the current financial obligation; vii. Total Amount of the Federal Award committed to the subrecipient by the pass-through entity; viii. Federal award project description, as required to be responsive to the Federal Funding Accountability and Transparency Act (FFATA); ix. Name of Federal awarding agency, pass-through entity, and contact information for awarding official of the Pass-through entity; x. Assistance Listings number and Title; the pass-through entity must identify the dollar amount made available under each Federal award and the Assistance Listings Number at time of disbursement; xi. Indirect cost rate for the Federal award (including if the de minimis rate is charged) per § 200.414. xii. All requirements imposed by the pass-through entity on the subrecipient so that the Federal award is used in accordance with Federal statutes, regulations and the terms and conditions of the Federal award; xiii. Any additional requirements that the pass-through entity imposes on the subrecipient in order for the pass-through entity to meet its own responsibility to the Federal awarding agency including identification of any required financial and performance reports; xiv. A requirement that the subrecipient permit the pass-through entity and auditors to have access to the subrecipient's records and financial statements as necessary for the pass-through entity to meet the requirements of this part; and xv. Appropriate terms and conditions concerning closeout of the subaward Anticipated Completion Date: Completed 11/16/2023 Responsible: Chief Executive Team: Danielle Smith and Sadie Thompson
2023-001 - Noncompliance and Significant Deficiency in Internal Controls over Compliance for Reporting Corrective Action Plan: Wellbeing Initiative has reviewed FFATA reporting requirements and has adopted a procedure to ensure such reporting is completed as required. Wellbeing Initiative, In...
2023-001 - Noncompliance and Significant Deficiency in Internal Controls over Compliance for Reporting Corrective Action Plan: Wellbeing Initiative has reviewed FFATA reporting requirements and has adopted a procedure to ensure such reporting is completed as required. Wellbeing Initiative, Inc.’s Internal Controls Policy and Procedure Manual includes the following policy. Procedures have been put in place by the Project Director for appropriate grants. Item 10.8.a. First-tier subaward reporting requirements under the Federal Funding Accountability and Transparency Act (FFATA), requires prime recipients to report first-tier subawards to non-Federal entities equal to or exceeding $30,000 within 30 days. Wellbeing Initiative will follow FFATA reporting requirements for qualifying sub-recipients. Anticipated Completion Date: Completed 11/16/2023 Responsible: Chief Executive Team - Danielle Smith and Sadie Thompson
Graduation Rate Cohort Finding-Action Plan The finding will be resolved on January 31, 2024. Sandra Bethley, Ph.D., Executive Director of Federal Programs will be responsible for the resolution of the finding. Effective January 4, 2024, the leadership team of the Office of Federal Programs will supe...
Graduation Rate Cohort Finding-Action Plan The finding will be resolved on January 31, 2024. Sandra Bethley, Ph.D., Executive Director of Federal Programs will be responsible for the resolution of the finding. Effective January 4, 2024, the leadership team of the Office of Federal Programs will supervise the Graduation Rate Cohort initiative for the East Baton Rouge Parish School System. A Graduation Rate Cohort team will be established. The Graduation Rate Cohort team will develop written procedures for identified school personnel and principals to follow. A contact person from each high school will be identified. A meeting will be conducted with identified school personnel to explain the criteria and procedures for maintaining documentation for students departing from the high schools. Failure to comply with the procedures will result in immobilizing schoolwide Title I funds.
Finding 8814 (2023-002)
Significant Deficiency 2023
The management team agrees with the auditor’s recommendation and has already implemented additional controls to address the stated concerns. These subawards were in place through another department at the time that the newly formed Grants department was created. In the transition of responsibility b...
The management team agrees with the auditor’s recommendation and has already implemented additional controls to address the stated concerns. These subawards were in place through another department at the time that the newly formed Grants department was created. In the transition of responsibility between departments, the FFATA reporting was delayed. Through the new grants management system, Monday.com, the department has set-up automations to ensure that FFATA reporting is done in a timely manner and contains an electronic audit record. The Grants Director is responsible for the corrective action as it relates to this finding.
Finding #2023-002 Comments on the Finding and Each Recommendation: Statement of condition 2023-002: The Corporation did not make the required monthly deposits to the reserve for replacements account. The reserve for replacements is underfunded by $598 as of June 30, 2023. Recommendation: Manageme...
Finding #2023-002 Comments on the Finding and Each Recommendation: Statement of condition 2023-002: The Corporation did not make the required monthly deposits to the reserve for replacements account. The reserve for replacements is underfunded by $598 as of June 30, 2023. Recommendation: Management should deposit $598 into the reserve for replacement. Action(s) taken or planned on the finding: Management agrees with the finding and auditor's recommendation. On September 1, 2023, management transferred $598 to the reserve for replacements.
View Audit 12069 Questioned Costs: $1
Finding #2023-001 Comments on the Finding and Each Recommendation: Statement of condition #2023-001: For the year ended June 30, 2023, the Corporation did not have a HUD approved Project Owner's/Management Agent's Certification (HUD-9839-B). Recommendation: Management should continue to request t...
Finding #2023-001 Comments on the Finding and Each Recommendation: Statement of condition #2023-001: For the year ended June 30, 2023, the Corporation did not have a HUD approved Project Owner's/Management Agent's Certification (HUD-9839-B). Recommendation: Management should continue to request the executed Project Owner's/Management Agent's Certification (HUD-9839-B) from HUD. Management should not pay any management fees until the executed Project Owner's/Management Agent's Certification (HUD-9839-B) is received. Action(s) taken or planned on the finding: Agree. Management received email correspondence from HUD on August 12, 2021 that stated the Agent is approved to take over management immediately and the Project Owner's/Management Agent's Certification (HUD-9839-B) would be retroactively effective. Management has continued to seek the executed Project Owner's/Management Agent's Certification (HUD-9839-B) from HUD.
View Audit 12069 Questioned Costs: $1
Lamar State College Orange Response and Corrective Action Plan to FY 23 Federal Financial Aid Audit Finding 2023-001 Enrollment Reporting Views of Responsible Officials The College agrees with the auditor's findings and recommendations. Corrective Action Plan The College has identified three issues ...
Lamar State College Orange Response and Corrective Action Plan to FY 23 Federal Financial Aid Audit Finding 2023-001 Enrollment Reporting Views of Responsible Officials The College agrees with the auditor's findings and recommendations. Corrective Action Plan The College has identified three issues that delayed identification and reporting of changes in student enrollment status for reporting on the NSLDS component. In response, the college will implement the following corrective actions: 1.The Registrar will review the error resolution reports provided by National Student Clearinghouse (NSC) to ensure the correct enrollment information is being reported to NSLDS within 60 days of the determination date. Implementation Date Immediate 2.An advisor drop code will be implemented effective Spring 2024. This code will trigger an email to the Records Office, and at that point the Records Office will determine the student's enrollment status and update to withdrawn in Banner when it is determined the student has withdrawn from the semester. This will ensure the correct enrollment status is reported to NSLDS within 60 days of the determination date. Implementation Date 1/16/2024 3. LSCO will ensure a subsequent term report is submitted any time a late award is processed. This will ensure the correct enrollment status is reported to NSLDS within 60 days of the determination date. Implementation Date Immediate Individual Responsible Summer Rather, Registrar
What Action(S) Will be Done: ASD Staff from the Contracts and Procurement and Grants Management Bureau are working with Division Staff to gather the appropriate data to report and submit the Federal Funding Accountability and Transparency Act (FFATA). ASD did submit the FFATA report, however, we wil...
What Action(S) Will be Done: ASD Staff from the Contracts and Procurement and Grants Management Bureau are working with Division Staff to gather the appropriate data to report and submit the Federal Funding Accountability and Transparency Act (FFATA). ASD did submit the FFATA report, however, we will work to ensure that this report is submitted timely. Who Will Act: Grants Bureau Chief-Vacant Contracts and Procurement Bureau Chief When Will Action(s) be Completed: ASD will ensure that a FFATA sub-award report is submitted by theof the month following the month in which the Department awards any sub-grants greater than or equal to $30,000.
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