Corrective Action Plans

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Finding 399 (2023-001)
Significant Deficiency 2023
OKEMOS PUBLIC SCHOOLS FOR THE YEAR ENDED JUNE 30, 2023 Okemos Public Schools respectfully submits the following corrective action plan for the year ended June 30, 2023. Auditor: Maner Costerisan 2425 E. Grand River Avenue, Suite 1 Lansing, MI 48912 Audit Period Year ended June 30, 2023 District Con...
OKEMOS PUBLIC SCHOOLS FOR THE YEAR ENDED JUNE 30, 2023 Okemos Public Schools respectfully submits the following corrective action plan for the year ended June 30, 2023. Auditor: Maner Costerisan 2425 E. Grand River Avenue, Suite 1 Lansing, MI 48912 Audit Period Year ended June 30, 2023 District Contact Person: Liz Lentz, Executive Director of Finance Finding 2023-001: Considered a significant deficiency in internal control over compliance. Recommendation: The District should consistently utilize a point-of-sale system to track and claim the number of meals served. Action to be Taken: Management agrees with the finding and had already changed procedures during the school year to better track and claim meals.
I have reached out to the Nebraskaland Bank regarding alternate collateralization. If this bank cannot provide appropriate collateral, a new banking institution will be found.
I have reached out to the Nebraskaland Bank regarding alternate collateralization. If this bank cannot provide appropriate collateral, a new banking institution will be found.
Recommendation: JTCHS should review federal procurement guidelines and revise its procurement policy to be in compliance with the federal procurement guidelines. Responsible Official’s Response: Management will review adopt a procurement policy in accordance with the Uniform Guidance. Planned Implem...
Recommendation: JTCHS should review federal procurement guidelines and revise its procurement policy to be in compliance with the federal procurement guidelines. Responsible Official’s Response: Management will review adopt a procurement policy in accordance with the Uniform Guidance. Planned Implementation Date of Corrective Action Plan: Management has started revising its policy and expects to have a revised procurement policy during fiscal year ending January 31, 2024.
Name of Responsible Individual: Sarah Christoffersen, Interim Director of Financial Aid Corrective Action: This finding affected a mere 2 of 40 records tested. Corrective action has been taken. The financial aid office has set up daily disbursement record submissions through its financial aid proce...
Name of Responsible Individual: Sarah Christoffersen, Interim Director of Financial Aid Corrective Action: This finding affected a mere 2 of 40 records tested. Corrective action has been taken. The financial aid office has set up daily disbursement record submissions through its financial aid processing system, Jenzabar Financial Aid, which will simplify the process and prevent reporting delays. Anticipated Completion Date: Completed
The Center will be creating new general ledger accounts that reference the budget categories for the CCBHC grant. Each month there will be a reconciliation performed between the trial balance and amounts submitted to be drawn down for the grant. The expenses included in the general ledger will be re...
The Center will be creating new general ledger accounts that reference the budget categories for the CCBHC grant. Each month there will be a reconciliation performed between the trial balance and amounts submitted to be drawn down for the grant. The expenses included in the general ledger will be reviewed thoroughly to ensure they are allowable expenses. Additionally, all expenses will be coded to the account associated with the category they are budgeted in to allow for easier expense tracking when drawing down funds for the grant.
Finding 323 (2023-001)
Significant Deficiency 2023
Management agrees with the finding and will begin an independent review of each tenant file to include examination of EIV reports to determine if there are any discrepancies and take corrective measures. Leasing office staff will undergo additional HUD 202 training regarding the initial and recertif...
Management agrees with the finding and will begin an independent review of each tenant file to include examination of EIV reports to determine if there are any discrepancies and take corrective measures. Leasing office staff will undergo additional HUD 202 training regarding the initial and recertification process. Additionally, management is staffing the property with a dedicated property manager that will be responsible for reviewing tenant files for compliance with HUD procedures including uses of EIV reports and ensure supporting documentation is maintained in each tenant’s file prior to signing new or amended leases.
Finding 236 (2023-003)
Significant Deficiency 2023
Recommendation: Our auditors recommended the Organization review internal controls in regards to the determination, recording and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilitzed for each sliding fee encounter. Explanation of disagreement wi...
Recommendation: Our auditors recommended the Organization review internal controls in regards to the determination, recording and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilitzed for each sliding fee encounter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization's enrollment and billing department will work together to identify when any errors occur based on the documentation the patient provides. The enrollment team will verify the rate, and the billing and coding team will begin checking to ensure the rate that the patient was screened for is the rate the patient is being charged for and that the correct discoutn applies.
Management agrees with the finding and will begin an independent review of each tenant file to include examination of EIV reports to determine if there are any discrepancies and take corrective measures. Leasing office staff will undergo additional HUD 811 training regarding the initial and recertif...
Management agrees with the finding and will begin an independent review of each tenant file to include examination of EIV reports to determine if there are any discrepancies and take corrective measures. Leasing office staff will undergo additional HUD 811 training regarding the initial and recertification process. Additionally, management is staffing the property with a dedicated property manager that will be responsible for reviewing tenant files for compliance with HUD procedures including uses of EIV reports and ensure supporting documentation is maintained in each tenant’s file prior to signing new or amended leases. Estimated completion date is November 30, 2023.
Name of Responsible Individual: Ruth Casper & Stephanie Furlough Corrective Action: The University Financial Aid Office has restructured the disbursement process as noted below: • Staff members will be retrained on the importance of timely reporting and record compliance. • A disbursement and docum...
Name of Responsible Individual: Ruth Casper & Stephanie Furlough Corrective Action: The University Financial Aid Office has restructured the disbursement process as noted below: • Staff members will be retrained on the importance of timely reporting and record compliance. • A disbursement and documentation process will be created to track, manage and reconcile the disbursement requests sent to COD. This process will aidin recognizing approved disbursements, rejected requests, and posting of disbursements. • The disbursement and reconciliation log will be reviewed by the Asst. Vice President for Student Financial Services as well as the Asst Vice President for Analytics & Audit. Anticipated Completion Date: The disbursement procedures will be monitored on an ongoing basis.
The enrollment reporting issue specifically relates to the integrated BS/PharmD degree program. The University's primary operating system, Jenzabar, reports concurrent enrollment status for P1 students and students who have graduated from the bachelor's degree component of the program. Since the N...
The enrollment reporting issue specifically relates to the integrated BS/PharmD degree program. The University's primary operating system, Jenzabar, reports concurrent enrollment status for P1 students and students who have graduated from the bachelor's degree component of the program. Since the National Student Clearinghouse's (NSC's) system automatically overrides the graduation data in the University's Jenzabar report without notifying the University, a two-step corrective action plan has been initiated. The modified reporting process to improve internal controls consists of the following steps: 1. Upload the initial Jenzabar enrollment reporting into the NSC system which will show full-time enrollment for both the bachelor's degree and the PharmD program; 2. File a second report reflecting the date of completion of the bachelor's degree for all students in the integrated program to remedy the NSC system override of graduation data in the initial Jenzabar report; and 3. Conduct a manual verification of graduation data in the National Student Loan Data System to ensure complete, accurate and timely reporting of graduation information from NSC. The modified reporting process is expected to be fully implemented at the conclusion of the 2023-2024 academic year in conjunction with completion of commencement, which is scheduled to occur in May 2024.
The Organization has implemented a facility monitoring program that incorporates all of the facility visit requirements as described in the grant agreement.
The Organization has implemented a facility monitoring program that incorporates all of the facility visit requirements as described in the grant agreement.
REFERENCE # 2022-008 ELIGIBILITY– MATERIAL WEAKNESS – MATERIAL NONCOMPLIANCE Program Name/ALN The Food Distribution Cluster Corrective Action Plan: The Division will take steps to ensure sub-recipient agreements are retained and the distribution sites maintain sign-in sheets requiring participants t...
REFERENCE # 2022-008 ELIGIBILITY– MATERIAL WEAKNESS – MATERIAL NONCOMPLIANCE Program Name/ALN The Food Distribution Cluster Corrective Action Plan: The Division will take steps to ensure sub-recipient agreements are retained and the distribution sites maintain sign-in sheets requiring participants to self-certify that they meet the grant eligibility requirements. Action Date: Ongoing Final Implementation Date: 09/30/2026 Name and Phone # Of Person Responsible for Implementation: Claudia Pardo, Captain, Divisional Finance Secretary (916) 563-3745
REFERENCE # 2022-007 ALLOWABLE COST– MATERIAL WEAKNESS - NONCOMPLIANCE Program Name/ALN The Food Distribution Cluster Corrective Action Plan: The Division will take steps to ensure that proper evidence of review is maintained for the food distribution reports and the sign-in sheets . The division wi...
REFERENCE # 2022-007 ALLOWABLE COST– MATERIAL WEAKNESS - NONCOMPLIANCE Program Name/ALN The Food Distribution Cluster Corrective Action Plan: The Division will take steps to ensure that proper evidence of review is maintained for the food distribution reports and the sign-in sheets . The division will ensure proper documentation of the weight of items distributed is retained. Action Date: Ongoing Final Implementation Date: 09/30/2026 Name and Phone # Of Person Responsible for Implementation: Claudia Pardo, Captain, Divisional Finance Secretary (916) 563-3745
REFERENCE # 2022-005 PERIOD OF PERFORMANCE – SIGNIFICANT DEFICIENCY- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Compliance Supplement Requirement: A non-federal entity may charge only allowable costs incurred during the approved budget p...
REFERENCE # 2022-005 PERIOD OF PERFORMANCE – SIGNIFICANT DEFICIENCY- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Compliance Supplement Requirement: A non-federal entity may charge only allowable costs incurred during the approved budget period of a federal award’s period of performance and any costs incurred before the federal awarding agency or pass-through entity made the federal award that were authorized by the federal awarding agency or pass-through entity (2 CFR sections 200.308 200.309 and 200.403(h)). A period of performance may contain one or more budget periods. Condition/Context: Division receive Emergency Food and Shelter National Board Program funds from the U.S. Department Homeland security/FEMA and various pass-through entities. The Division’s pass-through Contract requires period of performance and also requires funds must be expended by certain date. Of the Sixty (60) files selected for testing We noted that the Division: • For 4 samples, we noted that Division program expenses were recorded prior to Contract starting date. Questioned Costs: Cannot be determined Recommendation: We recommend Division charge only allowable costs incurred during the approved budget period of a pass-through award’s period of performance and any costs incurred before the pass-through entity made the federal award that were authorized by the pass-through entity. Corrective Action Plan: The Division will charge only allowable costs incurred during the approved budget period of a pass-through award’s period of performance and any costs incurred before the pass-through entity made the federal award that were authorized by the pass-through entity. Step 1 Action Date: Ongoing Final Implementation Date: 12/31/2023 Name and Phone # Of Person Responsible for Implementation: Jeanne Stromberg, Major, Divisional Finance Secretary (916) 563-3710
REFERENCE # 2022-004 CASH MANAGEMENT – MATERIAL WEAKNESS- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Non-Federal Entities Other Than States- Non-federal entities must minimize the time elapsing between the transfer of funds from the US T...
REFERENCE # 2022-004 CASH MANAGEMENT – MATERIAL WEAKNESS- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Non-Federal Entities Other Than States- Non-federal entities must minimize the time elapsing between the transfer of funds from the US Treasury or pass-through entity and disbursement by the non-federal entity for direct program or project costs and the proportionate share of allowable indirect costs, whether the payment is made by electronic funds transfer, or issuance or redemption of checks, warrants, or payment by other means (2 CFR section 200.305(b)). What constitutes minimized elapsed time for funds transfer will depend on what payment system/method a non-federal entity uses. Under the advance payment method, federal awarding agency or pass-through entity payment is made to the non-federal entity before the non-federal entity disburses the funds for program purposes (2 CFR section 200.3). A non-federal entity must be paid in advance provided that it maintains, or demonstrates the willingness to maintain, both written procedures that minimize the time elapsing between the transfer of funds from the US Treasury and disbursement by the non-federal entity, as well as a financial management system that meets the specified standards for fund control and accountability (2 CFR section 200.305(b)(1)). Condition/Context: Division receive Emergency Food and Shelter National Board Program funds from the U.S. Department Homeland security/FEMA and various pass-through entities. Division receives advance funds from the pass-through agency and incurred program expenditures. Of the Sixty (60) files selected for testing We noted that the Division: (1) Does not have written procedures that minimize the time elapsing between the transfer of funds from the Pass-through entity and disbursement by the Division. Questioned Costs: Cannot be determined Recommendation: We recommend Division minimize the time elapsing between the transfer of funds from the Pass-through entity and disbursement by the Division. Corrective Action Plan: The Division will strive to minimize the time elapsing between the transfer of funds from the Pass-through entity and disbursement by the Division. Step 1 Action Date: Ongoing Final Implementation Date: 12/31/2023 Name and Phone # Of Person Responsible for Implementation: Jeanne Stromberg, Major, Divisional Finance Secretary (916) 563-3710
REFERENCE # 2022-003 OTHER - BASIS OF ACCOUNTING – SIGNIFICANT DEFICIENCY- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Basis of Accounting —Uniform Guidance states the basis of accounting used may be a special purpose framework. However, ...
REFERENCE # 2022-003 OTHER - BASIS OF ACCOUNTING – SIGNIFICANT DEFICIENCY- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Basis of Accounting —Uniform Guidance states the basis of accounting used may be a special purpose framework. However, it does state that the determination of when an award is expended must be based on when the activity related to the federal award occurs. Uniform Guidance also states for Grants, cost reimbursement contracts, cooperative agreements, and direct appropriation type of contracts, the federal expenditure or expense should be reported when the transaction occurs. Uniform Guidance further states, the auditee should also be able to reconcile amounts presented in the financial statements to related amounts in the schedule of expenditures of federal awards. Condition/Context: Division receive Emergency Food and Shelter National Board Program funds from the U.S. Department Homeland security/FEMA and various pass-through entities. Division report to the pass-through entity on an accrual basis. Division’s schedule of expenditures of federal awards is presented on the accrual basis of accounting. Of the Sixty (60) files selected for testing: • Five (5) prior year expenditures were included in Division’s current year schedule of expenditures of federal awards. Questioned Costs: Cannot be determined Recommendation: We recommend Division report program expenditures in the year expenditures were accrued. Corrective Action Plan: The Division will report program expenditures in the year expenditures were accrued. Step 1 Action Date: Ongoing Final Implementation Date:h 12/31/2023 Name and Phone # Of Person Responsible for Implementation: Jeanne Stromberg, Major, Divisional Finance Secretary (916) 563-3710
The Seminary has developed, with the assistance of our outsourced vCIO and vChief Security Officer, a comprehensive security plan which meets the standards required by the Gramm- Leach-Bliley Act.
The Seminary has developed, with the assistance of our outsourced vCIO and vChief Security Officer, a comprehensive security plan which meets the standards required by the Gramm- Leach-Bliley Act.
CORRECTIVE ACTION PLAN (Concerning Finding 2022-002) Contact Person Responsible for Corrective Action: Dana L. Gendreau, Interim County Administrator Corrective Action: The County of Aroostook has initiated corrective action to address Finding 2022-002. Subsequent to the audit period and notificatio...
CORRECTIVE ACTION PLAN (Concerning Finding 2022-002) Contact Person Responsible for Corrective Action: Dana L. Gendreau, Interim County Administrator Corrective Action: The County of Aroostook has initiated corrective action to address Finding 2022-002. Subsequent to the audit period and notification of the finding on January 15, 2026, the County developed a formal Subrecipient Monitoring Policy intended to ensure compliance with the requirements of 2 CFR 200.214 and 2 CFR 200.332. The policy establishes procedures for subrecipient versus contractor determination, required subaward agreement elements, Debarment and Suspension verification, risk assessment, ongoing monitoring activities, Single Audit determination and follow-up, and enforcement of corrective actions. The policy is scheduled to be presented for formal adoption at the next available County Commissioner meeting on February 18, 2026. Upon adoption and implementation, these measures are expected to strengthen internal controls over subrecipient monitoring and reduce the risk of future noncompliance with federal award requirements. Anticipated Completion Date: February 18, 2026
Item 2022.007 - Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this rec...
Item 2022.007 - Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Conduct a pre-approval of expenditures, verifying that the expense is allowable under the grant terms and falls within the period of performance • Utilize a pre-approval form that includes details of the proposed expenditure, its necessity, and confirmation in the form of authorized signatures, that it is within the grant period. • Require all relevant supporting documentation with the date the expense was incurred, ensuring it falls within the grant's period of performance. This is further reviewed by the CFO who will verify that the expenditure meets all requirements and is then able to record it in the accounting system. • Conduct regular reviews of expenditures to ensure compliance with the grant period and maintain audit trail • Review these procedures annually to ensure they ongoing compliance with the grant's period of performance FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Cynthia Mitchell, CEO at 508-627-5797.
Management should establish and implement a robust tracking system to monitor reporting deadlines, ensure timely financial statement preparation, and improve coordination with external auditors. Additionally, assigning a compliance officer or designated staff member responsible for tracking audit pr...
Management should establish and implement a robust tracking system to monitor reporting deadlines, ensure timely financial statement preparation, and improve coordination with external auditors. Additionally, assigning a compliance officer or designated staff member responsible for tracking audit progress and submission deadlines can help prevent future delays.
Name: Community Services Office of Hot Springs and Garland County Arkansas Contact: Leslie P. Barnes Contact Phone Number: (501) 538-5626 Audit Period Ending: 05/31/2022 Anticipated Completion Date: May 5, 2025 Finding 2022-004: Management concurs with the finding. The Organization has implemented a...
Name: Community Services Office of Hot Springs and Garland County Arkansas Contact: Leslie P. Barnes Contact Phone Number: (501) 538-5626 Audit Period Ending: 05/31/2022 Anticipated Completion Date: May 5, 2025 Finding 2022-004: Management concurs with the finding. The Organization has implemented a process where a staff accountant will prepare the necessary reports and the chief financial officer will review such reports. Alternatively, if the chief financial officer must prepare such reports, the review will be performed by the executive director.
Condition and Context: ITCN did not file Form ACF-696T reports, required by the Child Care and Development Block Grant within the required timeframe. ITCN also did not file Form SF-429(A), required by the Head Start program within the required timeframe. Also, ITCN’s single audit reporting package f...
Condition and Context: ITCN did not file Form ACF-696T reports, required by the Child Care and Development Block Grant within the required timeframe. ITCN also did not file Form SF-429(A), required by the Head Start program within the required timeframe. Also, ITCN’s single audit reporting package for the fiscal year ended September 30, 2022, was not submitted to the Federal Audit Clearinghouse within nine months after ITCN’s year-end. Recommendation: The auditors recommended that ITCN devote the necessary resources to the financial reporting process and establish a system of monitoring for the filing of all required reporting and that the executive director review the monitoring list on a regular basis consistent with the timing of report filings. Contact Name: Deserea Quintana, Executive Director Corrective Action Planned: ITCN has created a federal reporting compliance calendar with automated reminders. Fiscal contractors continue to support timely submission of required reports. MIP/Microix will allow automated report generation and tracking. The training plan includes modules on reporting compliance and deadline monitoring. Anticipated Completion Date: The calendar was implemented in March 2024, with full automation and staff training to be completed by March 2026.
Finding 1175571 (2022-009)
Material Weakness 2022
The County will make sure that all federal documentation is maintained by each district for inspection and will ensure it is accurately reported on the SEFA.
The County will make sure that all federal documentation is maintained by each district for inspection and will ensure it is accurately reported on the SEFA.
Finding 1175569 (2022-007)
Material Weakness 2022
The County will include all federal grant discussion in our Officers’ meetings so that all Elected Officials are aware. We will discuss the Control Environment, Risk Assessment, Information and Communication, and Monitoring for all federal grants.
The County will include all federal grant discussion in our Officers’ meetings so that all Elected Officials are aware. We will discuss the Control Environment, Risk Assessment, Information and Communication, and Monitoring for all federal grants.
Finding 2022-017 Procurement Individual(s) Responsible: Tribal Council; Rona Johnson-Murillo, Accounting Director; Program Directors; Enterprise Managers; and Paula Vann, Grants Compliance Officer. Action: Will adhere to the most active Procurement Policy and will check for Debarment for all vendors...
Finding 2022-017 Procurement Individual(s) Responsible: Tribal Council; Rona Johnson-Murillo, Accounting Director; Program Directors; Enterprise Managers; and Paula Vann, Grants Compliance Officer. Action: Will adhere to the most active Procurement Policy and will check for Debarment for all vendors. Procurement procedures will be updated to clearly define vendor classification and SAM.gov requirements. Anticipated Completion Date: March 2026.
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