Corrective Action Plans

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Statement of condition 2023-001: During the year ended September 30, 2023, the Project paid expenses totaling $695 on behalf of an entity under common management without HUD approval. Recommendation: Management should have the other project reimburse $695. Action(s) taken or planned on the findi...
Statement of condition 2023-001: During the year ended September 30, 2023, the Project paid expenses totaling $695 on behalf of an entity under common management without HUD approval. Recommendation: Management should have the other project reimburse $695. Action(s) taken or planned on the finding: On December 18, 2023, the finding was cleared as $695 was repaid to the Project. Completion date: December 18, 2023
View Audit 13940 Questioned Costs: $1
Finding 10248 (2023-007)
Significant Deficiency 2023
2023-007 – Special Tests and Provisions - Enrollment Reporting – Significant Deficiency in Internal Controls over Compliance Recommendation: The auditors recommend the University follow and enhance existing policies to ensure all student changes in status are identified timely and submitted accu...
2023-007 – Special Tests and Provisions - Enrollment Reporting – Significant Deficiency in Internal Controls over Compliance Recommendation: The auditors recommend the University follow and enhance existing policies to ensure all student changes in status are identified timely and submitted accurately within the required time frame. The auditors also recommend the University establish a formal internal monitoring control whereby a designated individual with NSLDS access, on a sample basis, spot checks the status updates on NSLDS so to internally audit the National Student Clearinghouse submissions. Planned corrective actions: The University will adhere to current regulations and improve them if necessary to guarantee that all student status changes are recognized promptly and filed correctly within the allotted period. In order to internally audit the National Student Clearinghouse submissions, the University established a formal internal monitoring system wherein a designated individual with NSLDS access, on a sample basis, spot-checks the status updates on NSLDS. Name of Responsible Party: 1. Mary Neal, Registrar 2. Financial Aid Director 3. Melissa Hill, Provost 4. VP of Administration/CFO 5. Dr. Andrew Sund, President Anticipated completion date: 6/30/2024
Internal Control over Major Federal Program Compliance Program : Education Stabilization Fund CFDA 84.425 Condition: Lack of policies and procedures for verifying and monitoring Wage Rate Requirements. Material Weakness Corrective Action Plan: The District will adopt policies to ensure...
Internal Control over Major Federal Program Compliance Program : Education Stabilization Fund CFDA 84.425 Condition: Lack of policies and procedures for verifying and monitoring Wage Rate Requirements. Material Weakness Corrective Action Plan: The District will adopt policies to ensure prevailing wage payments for contractor employees on federally funded projects. The District will adopt policies requiring contractors on federally funded projects provide certified payroll reports to the District to ensure compliance with Wage Rate Requirements. The District will mimplement procedures to verify contractor compliance with Wage Rate Requirements. Planned Completion Date: March 31, 2024 Responsible Contact person: Aaron Dalton, Superintendent (417) 683-4717)
2023-02 – Gramm Leach Bliley Missing Elements. Auditor Description of Conditional and Effect. The most recent written security policy fails to address how the College will evaluate and adjust its information security program for any changes in the College's operations or the results of risk assessme...
2023-02 – Gramm Leach Bliley Missing Elements. Auditor Description of Conditional and Effect. The most recent written security policy fails to address how the College will evaluate and adjust its information security program for any changes in the College's operations or the results of risk assessments. Auditor Recommendation. We recommend that the College implement procedures to ensure that all Gramm Leach Bliley policies are met and confirmed by a second individual. Corrective Action. GOCC will require all procedures and policies are updated and reviewed on an annual basis to make sure we are incompliance with the requirements. Responsible Party. Chief Financial Officer/Controller and IT Director. Anticipated Completion Date. June 30, 2024.
Findings and Questioned Costs Related to Federal Awards Finding Number: 2023‐001 Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425U Contact Person: Diana Fitzpatrick, Director of Finance Anticipated Completion Date: April 30, 2024 Planned Correctiv...
Findings and Questioned Costs Related to Federal Awards Finding Number: 2023‐001 Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425U Contact Person: Diana Fitzpatrick, Director of Finance Anticipated Completion Date: April 30, 2024 Planned Corrective Action: When notified by the audit firm of the error in procurement procedures, district employees were notified of the correct procedures. This information has been and will continue to be made known to district employees who are delegated authority to procure goods and services during monthly leadership meetings. During this spring’s annual budget workshop with district staff, a brief training session will be held on Federal, State, and Board procurement policies and procedures. Also, a record of vetting vendors has been implemented this current fiscal year via the Sam.gov website.
Management agrees and will implement procedures to verify and ensure all vendors have not been suspended or debarred prior to doing business with the entity.
Management agrees and will implement procedures to verify and ensure all vendors have not been suspended or debarred prior to doing business with the entity.
Name of Contact Person: Jay Toland, Associate Superintendent of Business Operations The finding resulted 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 go...
Name of Contact Person: Jay Toland, Associate Superintendent of Business Operations The finding resulted 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
1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding The District will evaluate current procedures for accurately monitoring, recording, and reporting the number and type of meals served. 3. Official Responsible ...
1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding The District will evaluate current procedures for accurately monitoring, recording, and reporting the number and type of meals served. 3. Official Responsible Dr. Jeff Ridlehoover, Superintendent, is the official responsible for ensuring corrective action. 4. Planned Completion Date June 30, 2024 5. Plan to Monitor Completion The Board of Education will be monitoring this Corrective Action Plan.
Finding 9873 (2023-001)
Significant Deficiency 2023
Finding Reference Number: 2023-001 Description of Finding: The City has not implemented the proper controls to ensure all required Federal Funding Accountability and Transparency Act (FFATA) reports are submitted to the federal agency timely. Statement of Concurrence or Nonconcurrence: The City...
Finding Reference Number: 2023-001 Description of Finding: The City has not implemented the proper controls to ensure all required Federal Funding Accountability and Transparency Act (FFATA) reports are submitted to the federal agency timely. Statement of Concurrence or Nonconcurrence: The City concurs with this finding. Corrective Action: FFATA reports for subawards awarded during the year ending June 30, 2023 were submitted on 12/11/2023. The Housing and Community Development Division will also submit FFATA reports for all subaward expenditures from prior program years included on the Schedule of Expenditures of Federal Awards for the year ended June 30, 2023. This process has been added to the Division’s checklist for processing funding agreements with subrecipients to avoid recurrence in the future. In addition, this task has been added to monthly tracking. Projected Completion Date: January 16, 2024 Name of Contact Person: Sheila Giorgetti, Grants Manager, Housing & Community Services Division
Finding: 2023-004 – Written Policies Required by the Uniform Grant Guidance Auditor Description of Condition and Effect: Although the District has processes in place to cover these areas, there are no formal written policies covering payments, allowability of costs, and compensation. As a result of...
Finding: 2023-004 – Written Policies Required by the Uniform Grant Guidance Auditor Description of Condition and Effect: Although the District has processes in place to cover these areas, there are no formal written policies covering payments, allowability of costs, and compensation. As a result of this condition, the District did not fully comply with the Uniform Guidance applicable to the above noted grants. Auditor Recommendation: We are aware that the District is evaluating options using internal and external resources to take corrective action. We recommend that the District proceed with its selected option as soon as practical, but no later than the end of the next fiscal year. Corrective Action: As noted, the District has processes in place that cover all grant guidelines related to federal funds. However, upon bringing it to our attention that these policies should be in writing, we are making every endeavor to comply. The District is currently working on drafting policies that will meet the criteria set out in the Uniform Guidance and plan to have those in place by the end of the fiscal year. Responsible Person: Mike Beltnick, CFO Anticipated Completion Date: June 30, 2024
Finding Number: 2023-002 Condition: In a monitoring visit performed by U.S. Department of Housing and Urban Development (HUD), the grantor found that the supporting documentation submitted does not enable a third-party reviewer to make a clear determination that match requirements were met. Planned ...
Finding Number: 2023-002 Condition: In a monitoring visit performed by U.S. Department of Housing and Urban Development (HUD), the grantor found that the supporting documentation submitted does not enable a third-party reviewer to make a clear determination that match requirements were met. Planned Corrective Action: The Organization established a policy and procedure to calculate the match requirement, compare it with the required total, and proactively identify actions to address any shortages at the end of each month. The Organization also ensured that all matches were supported by documents in a format that third parties could verify. Contact person responsible for corrective action: Chiyoko Yokota, Chief Financial Officer & Angel Hurtado, VP of Programs Anticipated Completion Date: 1/31/2023
Finding Number: 2023-001 Condition: In a monitoring visit performed by HUD, the grantor found that rent reasonableness determination was not completed on five of the six files reviewed. In our testing we found that six of ten participants we tested did not have a rent reasonableness determination da...
Finding Number: 2023-001 Condition: In a monitoring visit performed by HUD, the grantor found that rent reasonableness determination was not completed on five of the six files reviewed. In our testing we found that six of ten participants we tested did not have a rent reasonableness determination dated prior to the grant funds being expended Planned Corrective Action: The Organization revised the program policy to compare the rent reasonableness of at least three similar units using the Rent Reasonableness Comparison worksheet before any lease-up and document the test with evidence that is reviewed and verified with a supervisor signature prior to execution of the lease. The Organization will repeat this process annually as long as the participant remains in the same unit. The Organization also hired an extra full-time program quality control staff to monitor the compliance with the procedures. Moreover, The Organization will have an internal audit by the finance department at the halfway point of the grant year. Contact person responsible for corrective action: Chiyoko Yokota, Chief Financial Officer & Angel Hurtado, VP of Programs Anticipated Completion Date: 1/31/2023
Finding Number: 2023-003 Condition: Participant files selected for testing did not include complete information to support the participant's income to determine the level of benefits provided. Planned Corrective Action: The Housing Choice Voucher Program will work towards and maintain program compli...
Finding Number: 2023-003 Condition: Participant files selected for testing did not include complete information to support the participant's income to determine the level of benefits provided. Planned Corrective Action: The Housing Choice Voucher Program will work towards and maintain program compliance to ensure we are meeting all regulatory requirements. We will do this through staff hiring and restructuring. Ongoing in- house as well as Industry training to stay current and skilled on all program rules and updates as it pertains to the HCV Program with monthly and weekly reporting and monitoring. DHC understands the challenges outlined above and we have implemented measures to improve, redefine, address, and resolve all items according to HUD best practices. We will continue our ongoing efforts and have measurable goals with set dates and timelines. That will show marked improvement over the next 6-12 months in the following areas.  Reduction of Annual recertifications.  Increased utilization.  Increased PBV potential/new RFP.  PIC error corrective actions.  Increased landlord outreach/landlord Fairs.  Customer Service improvement/Call Center Staffing.  Continued industry training for all HCV Housing Specialist.  HCV Department RFP contract proposal. Contact person responsible for corrective action: Felicia Burris, HCV Interim Director. Anticipated Completion Date: 06/30/2024
Finding Number: 2023-002 Condition: Participant files selected for testing did not include complete information to support participant eligibility Planned Corrective Action: Staff will be retrained on the compliance requirements under the standards of the HCV Program through the oversight of the Ren...
Finding Number: 2023-002 Condition: Participant files selected for testing did not include complete information to support participant eligibility Planned Corrective Action: Staff will be retrained on the compliance requirements under the standards of the HCV Program through the oversight of the Rental Assistance Department Manager and Continued Occupancy Supervisor. The Department Manager and Supervisor will continue to utilize all Yardi monitoring reports to ensure the Department is operating in accordance with industry standards. Reporting will be done and monitored monthly to meet set goals. We know and maintain we will work in accordance with HUD rules and regulations where Annual Recertification processes are concerned. Weekly; Department Manager will review the certification pipeline to ensure compliance and follow up with the Housing Specialist to ensure compliance and meeting set weekly and monthly goals and metrics. Contact person responsible for corrective action: Felicia Burris, HCV Program Manager Anticipated Completion Date: 6/30/2023
View Audit 13310 Questioned Costs: $1
Finding Number: 2023-001 Condition: DHC did not complete fiscal year 2023 recertification. Planned Corrective Action: Staff will be retrained on the compliance requirements under the standards of the HCV Program through the oversight of the Rental Assistance Department Manager and Continued Occupanc...
Finding Number: 2023-001 Condition: DHC did not complete fiscal year 2023 recertification. Planned Corrective Action: Staff will be retrained on the compliance requirements under the standards of the HCV Program through the oversight of the Rental Assistance Department Manager and Continued Occupancy Supervisor. The Department Manager and Supervisor will continue to utilize all Yardi monitoring reports to ensure the Department is operating in accordance with industry standards. Reporting will be done and monitored monthly to meet set goals. We know and maintain we will work in accordance with HUD rules and regulations where Annual Recertification processes are concerned. Weekly; Department Manager will review the certification pipeline to ensure compliance and follow up with the Housing Specialist to ensure compliance and meeting set weekly and monthly goals and metrics. Contact person responsible for corrective action: Felicia Burris, HCV Program Manager Anticipated Completion Date: 6/30/2023
Program Name/Assistance Listing Title: Special Education Cluster, Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 84.027A, 84.027X, 84.173A, 84.173X, 21.027 Contact Person: Tyler Moore, Chief Financial Officer Anticipated Completion Date: June 30, 2024 Planned Corrective...
Program Name/Assistance Listing Title: Special Education Cluster, Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 84.027A, 84.027X, 84.173A, 84.173X, 21.027 Contact Person: Tyler Moore, Chief Financial Officer Anticipated Completion Date: June 30, 2024 Planned Corrective Action: Higley Unified School District No. 60 has updated the procurement policies to align with federal rules to verify vendors are not suspended or debarred.  Applicable finance staff have been trained on the additional rules and regulations regarding federal funding.  For the vendors that have reached the federal grant threshold of $25,000 or meet certain other criteria as specified in 2 CFR section 180.220; a binder has been created alphabetically listing their SAM.GOV documentation.  All new vendors added to Visions will have SAM.GOV documentation pulled.  Federal grant account codes will be monitored by the Director and Assistant Director of Finance to track potential account code changes after the initial purchase order has been created. The Purchasing Manager will be alerted to any new expenses being charged to a federal program.
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
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