Corrective Action Plans

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During the period of April 2023 through September 2023, the turnover in staff put too many accounting functions on Program Manager I. The Organization hired additional staff and restructured accounting functions to Program manager II that eliminated the segregation of duties.
During the period of April 2023 through September 2023, the turnover in staff put too many accounting functions on Program Manager I. The Organization hired additional staff and restructured accounting functions to Program manager II that eliminated the segregation of duties.
Finding 395833 (2023-006)
Significant Deficiency 2023
Finding:  2023‐006:  Significant Deficiency over Eligibility  Name of Contact Person: Daphine Little, Director of Bertie County Department of Social Services Corrective Action/Management's Response: Recommended Improvement:  Immediate re‐training of specific policy on child support  Post eligibil...
Finding:  2023‐006:  Significant Deficiency over Eligibility  Name of Contact Person: Daphine Little, Director of Bertie County Department of Social Services Corrective Action/Management's Response: Recommended Improvement:  Immediate re‐training of specific policy on child support  Post eligibility training after application disposition on child support procedures  ACTS data is viewed on all parent‐child cases at recertification and application  Make sure all single parent cases with children have compliance addressed with child support  Make sure all child support referrals are done at all applicable recertifications of determining eligibility and post eligibility for applications  Make sure on how to do referral for child support by job aid through NC Fast help Goal:  Decrease technical errors with child support by 100%  Request online data for ACTS at all recertifications and applications  Recheck all evidences on dashboard pertaining to child support enforcement for accuracy  Supervisors  and  Caseworkers  retain  all  Fast  Help,  Learning  Gateway  Trainings,  Administrative  Letter,  Change Notices, and Medicaid Manual Information to properly complete their job requirements Training Information:  Medicaid Manual and Policy Training (MA‐3365 Child Support)  Child Support Post Eligibility (MA‐3205 Post Eligibility Verification)  DHB  Administrative  Letter  No:  2‐20,  Child  Support  Guidance  Eligibility  Verification  During  COVID‐19(Guidance During This Audit)  DHB‐22000 Absent Parent Information Form  Current Guidance Child Support During CCU. DHB Administrative Letter No: 13‐23, Child Support Cooperation and Applying For Other Monetary Benefits Post Eligibility Benefits During The CCU Period  Child Support (IV‐D) Referrals for MA, CA, & MAGI Cases (Job Aid from NC Fast Help) Corrective Action Plan  Additional Training on Child Support Policy and Procedures for Recertification and Applications  Additional Training on Child Support Referral Job Aid and How to Complete it in NC Fast System  Staff training will be conducted monthly during staff conferences which will include child support training on child support referrals and how to key them in the NC Fast system  Sign in sheet for caseworkers attending training and staff conference Proposed Completion Date: February 29, 2024
Finding 395832 (2023-005)
Significant Deficiency 2023
Finding: 2023‐005: Significant Deficiency over Activities Allowed and Unallowed and Allowable Costs/Cost Principles Name of Contact Person: Daphine Little, Director of Bertie County Department of Social Services Corrective Action/Management's Response: DSS agrees that there were some discrepanc...
Finding: 2023‐005: Significant Deficiency over Activities Allowed and Unallowed and Allowable Costs/Cost Principles Name of Contact Person: Daphine Little, Director of Bertie County Department of Social Services Corrective Action/Management's Response: DSS agrees that there were some discrepancies found in two out of twenty‐three employee daysheets vs. timesheets resulting in more program time reported on the daysheets than the approved timesheets. Supervisors  are  responsible  for  ensuring  that  time  reported  on  employee  daysheets  matches  the  timesheets.  Bertie  County DSS utilizes an Excel spreadsheet provided by Bertie County Government that is completed by each employee monthly to report time worked. As it is the Supervisor’s responsibility to verify and approve the accuracy of employee daysheets, the Supervisor is expected to reconcile time reported on employee daysheets to time reported on employee timesheets. Plan of Action:  Provide  employees  with  a  copy  of  Power  Point  Training ‐Day  Sheets:  Time  Reporting  and  Reimbursement  for County DSS (2022).  Reiterate the importance of employees reporting the same amount of time on the daysheet vs. the timesheet.  Communicate with Supervisors the importance of reconciling employee daysheets vs. timesheets. Proposed Completion Date:  March 1, 2024
National Council for Behavioral Health (d/b/a National Council for Mental Wellbeing) Corrective Action Plan Department of Health and Human Services The National Council for Mental Wellbeing respectfully submits the following corrective action plan for the year ended September 30, 2023. Name and a...
National Council for Behavioral Health (d/b/a National Council for Mental Wellbeing) Corrective Action Plan Department of Health and Human Services The National Council for Mental Wellbeing respectfully submits the following corrective action plan for the year ended September 30, 2023. Name and address of independent public accounting firm: Marcum LLP 1899 L Street NW Suite 850 Washington DC 20036 The finding from the September 30, 2023, schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. Finding No. 2023-002: Inadequate Review of Subsidiary Ledger – Material Weakness Recommendation We recommend that the Council enhance its internal control over reconciliation and review to ensure that its subsidiary ledgers only include proper and valid transactions. Management’s Response: When uncashed checks were reissued in the previous accounting system, there were occurrences that we did not fully complete a second step needed to void these checks. This resulted in recording duplicate expense and accounts payable in these occurrences. The error was not discovered due to the subsidiary ledger not being fully scanned for content by preparers and reviewers in the previous system. For our ongoing financial reconciliation process, several internal controls are already in place to catch such errors. One, this two-step error is no longer possible in our new accounting system that when live on October 1, 2022. Two, a continuation of ongoing comprehensive reconciliations of all balance sheet accounts, to include accounts payable, a proper segregation of duties, where staff/senior accountants prepare reconciliations and accounting management reviews. Going forward the preparers and reviewers procedure is to fully review the contents of the accounts payable subsidiary ledger just the same as we do with every other balance sheet account. Regarding the monies owed on closed federal awards, staff are currently reaching out to those federal project officials to facilitate reimbursement. Contact Person Responsible for Corrective Action: Jonathan Hutchins Expected Completion Date: 5/31/2024
View Audit 305464 Questioned Costs: $1
Finding 2023-103 Allowable Costs/Cost Principles/Reporting (Material Weakness, Compliance Finding) Repeat Finding. Responsible Individuals: William Bridgeman, Chief Fiscal Officer Natalie Alvarez, Chief Operating Officer- Head Start Director Corrective Action Plan: Greater Phoenix Urban League (Dele...
Finding 2023-103 Allowable Costs/Cost Principles/Reporting (Material Weakness, Compliance Finding) Repeat Finding. Responsible Individuals: William Bridgeman, Chief Fiscal Officer Natalie Alvarez, Chief Operating Officer- Head Start Director Corrective Action Plan: Greater Phoenix Urban League (Delegate Agency) will continue its on- going collaborate with the City of Phoenix (Grantee) in evaluating the process and effectiveness of inserting and updating the “quarterly administrative reporting package”, relatively to its use and the accuracy of the content that flows within the excel workbooks. Anticipated Completion Date: On going throughout the contract period on an annualized basis. July 1, 2024
Finding 2023-102 – Allowable Costs/Cost Principle (Material Weakness, Compliance Finding) Responsible Individual: William Bridgeman-Chief Fiscal Officer Corrective Action Plan: The organization tracks all revenue and expenses specifically and directly related to the Head Start Program CFDA 93.600 by...
Finding 2023-102 – Allowable Costs/Cost Principle (Material Weakness, Compliance Finding) Responsible Individual: William Bridgeman-Chief Fiscal Officer Corrective Action Plan: The organization tracks all revenue and expenses specifically and directly related to the Head Start Program CFDA 93.600 by individual general ledger. Each revenue and expenses account are supported with documentation. Classes within QuickBooks are available within the platform. However, using classes is optional and with the purchase of the more advance version of QuickBooks “QuickBooks Enterprise Platinum” it’s the intent of the organization to move to enhanced detail general ledger accounts (which will provide detail data relating to each individual transaction). As it relates to Assistance Listing No 93.185 National Urban League Vaccine Equity 2021-22 in the amount of $40,000 and Assistance Listing no. 10-551 in the amount of $52,129 is not affiliated with Head Start from a program perspective. No staff time or expenses of the two grants are related to the Head Start Program. Each of the reference programs are stand-alone funded through a third-party pass through grantee and not a direct grant from a federal agency. However, the organization will establish separate classes within QuickBooks Enterprise Platinum for each federal and state contract. The implementation of the vertical classes within the QuickBooks Enterprise Platinum platform will consist of the reconciliation of cost reimbursements with a separate and dedicated “in kind” calculation of 25% within the class where applicable as per grantee requirement. Implementation Date: July 1, 2024
View Audit 305459 Questioned Costs: $1
Finding 2023-101 Allowable Costs/Cost Principle and Reporting (Material Weakness Compliance Finding) Repeat Finding Responsible Individuals: William Bridgeman Chief Fiscal Officer Natalie Alvarez- Chief Operating Officer Head Start Director Corrective Action Plan: Greater Phoenix Urban League has r...
Finding 2023-101 Allowable Costs/Cost Principle and Reporting (Material Weakness Compliance Finding) Repeat Finding Responsible Individuals: William Bridgeman Chief Fiscal Officer Natalie Alvarez- Chief Operating Officer Head Start Director Corrective Action Plan: Greater Phoenix Urban League has received great support from our community partners by providing in-kind space in 4 school districts and the abundance of parent volunteer support for our Head Start program, however, the program struggles to identify the in-kind match during the turn to full on campus instruction. COVID19 has had a considerable impact on the programs ’s ability to meet the non-federal share obligation as families and community volunteers are not allowed fully back onto Head Start Campuses and enrollment has declined. The program was unable to open several classrooms due to lack of qualified staff and low enrollment. In the past, Greater Phoenix Urban League Head Start has relied heavily on in-kind Space as the main source of program match and with the closing of classrooms in-kind was very difficult to collect. We believe we have worked towards meeting the challenge of program in-kind match. We have used ARPA funds to develop “A grow your own program.” Greater Phoenix Urban League Head Start has recruited parents and the community to participant in a workforce development program to train and hire new Head Start staff as classroom aides and teacher assistances. We also have contracted with an organization to provided contracted instructional support to open up temporarily closed classrooms. The program will continue to identify non-federal share to meet the obligations of the grant award. COVID will continue to have an impact on the programs ’s ability to meet non-federal share but it certainly opens new channels of identifying non-federal share. The following steps are in progress of being implemented in fiscal year 23-24 within the grantee: • An internal control process has been developed to review the current system to document the resources for non-federal share. A Data Assistant will review and analyze at our process in collecting in kind. • Revised Policies and procedures will be developed to assisted instructional staff to collect parent volunteer hours. • Parent Policy Committee will be trained on the non-federal share in-kind as it relates to their important role within the Head Start Program. • Greater Phoenix Urban League Head Start will continue to review the internal control process annually to ensure compliance with the Head Start Program Performance Standards, federal regulations, and City of Phoenix Grantee regulations. • Greater Phoenix Urban League Chief Fiscal Officer, fiscal staff, Program Director and Grantee Fiscal and Program staff will meet monthly to review fiscal reporting and requirements, to ensure grant obligations are on track. • Greater Phoenix Urban League will continue their efforts to identify citywide partners that can provide non-federal share to the Head Start Program. • Greater Phoenix Urban League Chief Fiscal Officer, fiscal staff, Program Director and Grantee Fiscal and Program staff will meet monthly to review fiscal reporting and requirements, to ensure grant obligations are on track. • All third-party appraisals will be conducted in May 2024 to reflect the current market value of space and real property. • The activities mentioned above will assist the Greater Phoenix Urban League-Head Start Program in meeting its obligations in the coming years. Anticipated Completion Date: Ongoing throughout the contract period on an annualized basis. May 1, 2024
View Audit 305459 Questioned Costs: $1
Accounting leadership will review general Federal guidelines for allowable costs with directors and supervisors. Additionally, directors and supervisors will be reminded of their responsibility for, and the importance of, carefully reviewing coding of individual program expenditures to align with Fe...
Accounting leadership will review general Federal guidelines for allowable costs with directors and supervisors. Additionally, directors and supervisors will be reminded of their responsibility for, and the importance of, carefully reviewing coding of individual program expenditures to align with Federal guidelines. Accountants currently meet monthly with directors and supervisors to review the financial status of each program, including unreasonable budget variances and the reasonableness of current expenditure levels. Going forward, they will also review the individual expenditures in categories deemed most likely to have unallowable transactions
Finding 395808 (2023-001)
Significant Deficiency 2023
Person responsible for corrective action Emily Allen, SVP Programs Corrective Action The Foundation concurs with this finding. We have worked with the U.S. Department of Labor and the matter is now closed. In February 2024, the Foundation repaid the $435,289 identified in this finding, and a mod...
Person responsible for corrective action Emily Allen, SVP Programs Corrective Action The Foundation concurs with this finding. We have worked with the U.S. Department of Labor and the matter is now closed. In February 2024, the Foundation repaid the $435,289 identified in this finding, and a modified final report has been filed. The Foundation will design and implement additional processes to ensure that earmarking requirements are monitored on a continuous basis by SCSEP staff. In the meantime, the Foundation has implemented additional controls to address the risks of noncompliance with earmarking requirements. Beginning with the March 2024 quarterly report (which was filed on April 9, 2024), all such reports will be reviewed by the Group Controller and Assistant National Director, SCSEP, with specific reference to the earmarking requirements. In the event of any report identifying a risk of noncompliance with the earmarking requirements, the Foundation will immediately raise the matter with our colleagues at the U.S. Department of Labor. Anticipated Completion Date Initial implementation completed, with further control enhancements to be in place by June 30, 2024
View Audit 305433 Questioned Costs: $1
Replacement Reserve Deposits Unexpected ...
Replacement Reserve Deposits Unexpected delays were encountered due to the change in the Managing Agent at the end of the fiscal year and the transfer of cash accounts were delayed The Entity has reviewed the replacement reserve account and will deposit the shortfall of funds upon receipt of HUD Monthly subsidy payments to ensure the account is properly funded.
Timely submission of Required Reporting Packages Management understands the need to...
Timely submission of Required Reporting Packages Management understands the need to be in compliance with the filing requirements and will ensure that these reports are filed timely. Unexpected delays were encountered due to the change in the Managing Agent at the end of the fiscal year and the transition took longer than expected. The filings have been subsequently completed with FAC and REAC.
Keeping a close eye on the dates, making sure the deadlines aren't being missed. See full Corrective Action Plan on district letterhead.
Keeping a close eye on the dates, making sure the deadlines aren't being missed. See full Corrective Action Plan on district letterhead.
Monitoring the grant and what is being purchased using grant account numbers, making sure that only approved expenditures are being purchased and approved with the grant. See full Corrective Action Plan on district letterhead.
Monitoring the grant and what is being purchased using grant account numbers, making sure that only approved expenditures are being purchased and approved with the grant. See full Corrective Action Plan on district letterhead.
View Audit 305425 Questioned Costs: $1
Keeping a close eye on the dates, making sure the deadlines aren't being missed. See full Corrective Action Plan on district letterhead.
Keeping a close eye on the dates, making sure the deadlines aren't being missed. See full Corrective Action Plan on district letterhead.
Monitoring dates closely to ensure the deadlines are being met. See full Corrective Action Plan on district letterhead.
Monitoring dates closely to ensure the deadlines are being met. See full Corrective Action Plan on district letterhead.
Plan is to have the board vote to lower the bonding requirement to 10% from the current 25% in the board policy. We plan to leave the bond amount the same to ensure the district is covered at all times. See full Corrective Action Plan on district letterhead.
Plan is to have the board vote to lower the bonding requirement to 10% from the current 25% in the board policy. We plan to leave the bond amount the same to ensure the district is covered at all times. See full Corrective Action Plan on district letterhead.
Learning and understanding the way specific account numbers work and why/when journal entries need to be made. See full Corrective Action Plan on district letterhead.
Learning and understanding the way specific account numbers work and why/when journal entries need to be made. See full Corrective Action Plan on district letterhead.
CORRECTIVE ACTION PLAN Federal Award Findings and Questioned Costs Finding 2023-001 Student Financial Aid Cluster: Assistance Listing #84.007 Federal Supplemental Educational Opportunity Grants Assistance Listing #84.033 Federal Work-Study Program Assistance Listing #84.063 Federal Pell Grant Progra...
CORRECTIVE ACTION PLAN Federal Award Findings and Questioned Costs Finding 2023-001 Student Financial Aid Cluster: Assistance Listing #84.007 Federal Supplemental Educational Opportunity Grants Assistance Listing #84.033 Federal Work-Study Program Assistance Listing #84.063 Federal Pell Grant Program Assistance Listing #84.268 Federal Direct Student Loans Assistance Listing #93.364 Nursing Student Loans Federal agency – U.S. Department of Education Grant Period – Year ended August 31, 2023 Compliance Requirement: Special Tests and Provisions Criteria: The Gramm-Leach-Bliley Act (Public Law 106-102) (GLBA) requires the College, on an annual basis, to identify reasonably foreseeable internal and external risks to the security, confidentiality, and integrity of customer (student) information that could result in the unauthorized disclosure, misuse, alteration, destruction, or other compromise of such information, and assess the sufficiency of any safeguards in place to control these risks. At a minimum, the GLBA risk assessment should include consideration of risk in each relevant area of operations, including: Employee training and management. Information systems, including network and software design, as well as information processing, storage, transmission, and disposal. Detecting, preventing, and responding to attacks, intrusions, or other system failures. Condition: During our testing, we noted the following: While the IT Systems Team is the assigned resource for information security matters, the College communicated that it does not have a single qualified individual designated with the responsibility for implementing and enforcing the College’s information security program. An annual IT risk assessment was not performed. A vendor management program is not in place. Mobile device management is not in place. Backup media is not encrypted. A full set of policies and procedures is not in place. Cause: The expected documentation supporting the required controls to adequately confirm compliance with GLBA safeguards was not complete. Effect: Without demonstrable, documented controls supporting compliance with the GLBA standards for safeguarding the protected data, compliance with the law and the requirements in the federal PPA may not be assured. Context: Inquiry and observation of the information received from the College related to compliance with GLBA. Recommendation: The College should review the GLBA safeguarding rules and as soon as practical implement and document the controls necessary for compliance with the rule, focusing on the completion of a documented, thorough, and standardized risk assessment and management reporting framework. The College should perform comprehensive risk assessments on a regular basis, which is suggested to be at least annually, and at any significant change in infrastructure or business process. Contact Person Responsible for Corrective Action Plan: Donna Rocap, Associate Vice President of Administration Corrective Action Plan: The College agrees with the findings and is in process of developing a corrective action plan to address. In addition, the College has made it a top priority to hire both a Chief Information Officer and a Chief Information Security Officer but has experienced difficulty getting a qualified pool of candidates. Timing of Planned Corrective Action: The College expects to resolve this finding during its August 31, 2024 fiscal year.
Views of Responsible Officials: SCC's Previous CFO was unaware of the G5 3 day calendar rule for drawdowns for non-financial aid funds. As of 6/30/23 there are no further G5 HEERF funds to draw down.
Views of Responsible Officials: SCC's Previous CFO was unaware of the G5 3 day calendar rule for drawdowns for non-financial aid funds. As of 6/30/23 there are no further G5 HEERF funds to draw down.
Contact Person – Krista Martin, Director of Finance and Administration, and Ryan Riesinger, Executive Director Corrective Action Plan – Review and update procedures over payment requests to ensure allowability accuracy. Completion Date –December 31, 2024
Contact Person – Krista Martin, Director of Finance and Administration, and Ryan Riesinger, Executive Director Corrective Action Plan – Review and update procedures over payment requests to ensure allowability accuracy. Completion Date –December 31, 2024
View Audit 305388 Questioned Costs: $1
Contact Person – Krista Martin, Director of Finance and Administration, and Ryan Riesinger, Executive Director Corrective Action Plan – Review and update procedures to ensure accurate reporting. Completion Date –December 31, 2024
Contact Person – Krista Martin, Director of Finance and Administration, and Ryan Riesinger, Executive Director Corrective Action Plan – Review and update procedures to ensure accurate reporting. Completion Date –December 31, 2024
Finding 395755 (2023-002)
Significant Deficiency 2023
Auditors’ Recommendation: We recommend the Agency implement control activities and monitoring procedures to ensure monthly reports that are submitted to the funding agencies are accurately reflecting allowable grant costs. Action Taken: We agree with the finding and have taken the actions as outlin...
Auditors’ Recommendation: We recommend the Agency implement control activities and monitoring procedures to ensure monthly reports that are submitted to the funding agencies are accurately reflecting allowable grant costs. Action Taken: We agree with the finding and have taken the actions as outlined in finding 2023‐001 to fully address and improve the control process. Specifically, Agency management has reviewed the internal processes and enhanced control activities to ensure the mechanic salaries are accurately reported in the monthly operating reports going forward.
View Audit 305387 Questioned Costs: $1
Finding 395754 (2023-001)
Significant Deficiency 2023
Auditors’ Recommendation: Agency management took immediate action to determine the effect for the entire year, communicated with the auditor, communicated with the Kansas Department of Transportation, and developed the plan to respond to the finding. As recommended by the Kansas Department of Transp...
Auditors’ Recommendation: Agency management took immediate action to determine the effect for the entire year, communicated with the auditor, communicated with the Kansas Department of Transportation, and developed the plan to respond to the finding. As recommended by the Kansas Department of Transportation, a check for $13,715 will be written to the Kansas Department of Transportation. The last six‐month amount of $20,781 will be reported on the February, 2024, operating report to reduce the Kansas Department of Transportation reimbursement provided to the Agency for the year ending June 30, 2024. Action Taken: We agree with the finding and have taken the following actions to fully address and correct the discrepancies. 1. Agency management reviewed all twelve months of 2023 billing to determine the total amount to return to the Kansas Department of Transportation. After this review, management determined that the overreporting discrepancies began in January, 2023, and occurred every month through December, 2023. 2. A meeting was held between Agency management and the Kansas Department of Transportation Program Administrator and Program Consultant to discuss the findings and determine a plan of action to correct the discrepancies. The action planned is outlined in the Recommendation section of this finding. 3. Monthly Operating Budget billings for January 2023 through December 2023, were reviewed and the appropriate amounts that should have been billed were determined and compared to the actual amount billed to KDOT. The net result is as identified in the Recommendation section of this finding. 4. Agency management has reviewed the internal processes and enhanced control activities to ensure the mechanic salaries are accurately reported in the monthly operating reports going forward.
View Audit 305387 Questioned Costs: $1
Name of the Contact Person Responsible for the Corrective Action Plan: Stacey Merritt, Interim Finance Director Corrective Action Plan: Management concurs with the finding. We will work to ensure that future reports are submitted timely and that evidence of submissions is retained for each report ...
Name of the Contact Person Responsible for the Corrective Action Plan: Stacey Merritt, Interim Finance Director Corrective Action Plan: Management concurs with the finding. We will work to ensure that future reports are submitted timely and that evidence of submissions is retained for each report filing. Anticipated Completion Date: June 30, 2024
Name of the Contact Person Responsible for the Corrective Action Plan: Stacey Merritt, Interim Finance Director Corrective Action Plan: Management concurs with the finding. We will work to ensure that future reports are submitted timely and that evidence of submissions is retained for each report ...
Name of the Contact Person Responsible for the Corrective Action Plan: Stacey Merritt, Interim Finance Director Corrective Action Plan: Management concurs with the finding. We will work to ensure that future reports are submitted timely and that evidence of submissions is retained for each report filing. Anticipated Completion Date: June 30, 2024
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