Corrective Action Plans

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The main reason for the discrepancy in income was a result of using actual units/services billed (from the billing software) and not what is recorded in the financials because, usually what is recorded every month in the financials is based on estimates and later adjusted based on actual billing and...
The main reason for the discrepancy in income was a result of using actual units/services billed (from the billing software) and not what is recorded in the financials because, usually what is recorded every month in the financials is based on estimates and later adjusted based on actual billing and payments for services received. With this approach we were comfortable that, if necessary, we could trace the income to the actual service rather than an estimate. An unintended consequence was that income received in a year for a service in a prior year was not accounted for. While, immaterial, this resulted in discrepancies. We are committed that in the future, we would take additional steps to review the information by other employees who are not involved in the process in order to get a different perspective, and seek outside help, like a CPA, if necessary.
We will update our written policies to include the required written policies under Uniform Guidance.
We will update our written policies to include the required written policies under Uniform Guidance.
Reporting Federal Agency Name: Department of Hea lth and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center claimed lost revenues that were incorrectly calculated or not supp...
Reporting Federal Agency Name: Department of Hea lth and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center claimed lost revenues that were incorrectly calculated or not supported. These were improperly included within the HHS Report Period 4 and caused the Report to be inaccurate. Responsible Individuals: Corey Ulmer, CFO Corrective Action Plan: We will implement internal control policies to ensure that the required reports are properly reviewed prior to submission to ensure all key line items are necessary, correct, meet the requirements of the federal program, and are properly recorded in the reports required to be submitted to the federal agency. Anticipated Completion Date: 6/30/2024
Activities Allowed or Unallowed, Allowable Costs/Costs Principles Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center selected lo...
Activities Allowed or Unallowed, Allowable Costs/Costs Principles Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center selected lost revenue ca lculation option i which is actual to actual methodology of calculating lost revenues attributable to coronavirus. The Medical Center did not incorporate the financial audit adjustments into the actual revenue amounts reported within the HHS special report for the fiscal years 2019, 2020, and 2021. Responsible Individuals: Corey Ulmer, CFO Corrective Action Plan: We will implement internal control policies to ensure the lost revenue calculation is supported by internal financia ls. We will also implement control policies to ensure a secondary review and approval over the final lost revenue calculation. Anticipated Completion Date: 6/30/2024
Activities Allowed or Unallowed, Allowable Costs/Costs Principles, and Reporting Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Cen...
Activities Allowed or Unallowed, Allowable Costs/Costs Principles, and Reporting Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center's final expenditure listing, lost revenue calculation identified as eligible and claimed under the Provider Relief Fund program, and special report submitted to the Department of Health and Human Services for Period 4 did not have evidence of being reviewed and approved by a separate individual outside of the preparer. Responsible Individuals: Cory Ulmer, CFO Corrective Action Plan: We will implement internal control policies to ensure all invoices are reviewed and approved to ensure all expenses claimed under the federal program are necessary, correct, and meet the requirements of the federal program. We will also implement a control process which includes a secondary review and approval of the final expenditure listing and lost revenue calculation used to claim the allowable costs under the federal program and that there is documented evidence of the review and approval. In addition, the Report submitted to HHS will have a secondary review and approval that is documented. Anticipated Completion Date: 6/30/2024
Activities Allowed or Unallowed, Allowable Costs/Costs Principles Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center does not ha...
Activities Allowed or Unallowed, Allowable Costs/Costs Principles Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center does not have an adequate internal control policy in place to ensure review and approval of cash disbursements claimed under the federal programs were documented and to ensure that expenses claimed in the Report were complete, accurate, and reduced by other funding sources. Responsible Individuals: Corey Ulmer, CFO Corrective Action Plan: We will implement internal control policies to ensure all amounts reimbursed by other funding sources are adequately documented and reduced from the eligible expenditure listing and are properly recorded in the Report required to be submitted to the federal agency. We will also implement internal control policies to ensure that the required Report are properly reviewed prior to submission to ensure all key line items are necessary, correct, meet the requirements of the federal program, and are properly recorded in the Report required to be submitted to the federal agency. Anticipated Completion Date: 6/30/2024
Finding 391307 (2023-008)
Significant Deficiency 2023
Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.038, 84.063, 84.268, 84.379 Recommendation: The College should develop and implement an approved written information security program and verify there is a risk management section that describes how the College is identifying,...
Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.038, 84.063, 84.268, 84.379 Recommendation: The College should develop and implement an approved written information security program and verify there is a risk management section that describes how the College is identifying, assessing and communicating risks. In addition, there should be a description on the evaluation of safeguard sufficiency in mitigating risks. The information security program should also include the following: • IT Security Policy • Acceptable Use Policy • Incident Response Policy • Data Classification Policies • Vendor Management Policy • Patch Management Policy • Data Disposal Policy • Risk Assessment Policy • Logical Access and User Access Review Policies • Evidence of Review by CIO/CISO and responsibility of program Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The college will develop and implement an information security program to verify our risk management efforts. This plan will identify how we are identifying, assessing and communicating risks. Name(s) of the contact person(s) responsible for corrective action: Jossie Johnson - Director of Financial Aid and Scott Seidman – Director of IT Planned completion date for corrective action plan: September 30, 2024
Finding 391303 (2023-007)
Significant Deficiency 2023
Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.063, 84.268, 84.379 Recommendation: We recommend the College evaluate its procedures and policies around reporting to the COD to ensure that student information is reported timely. Explanation of disagreement with audit finding: There...
Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.063, 84.268, 84.379 Recommendation: We recommend the College evaluate its procedures and policies around reporting to the COD to ensure that student information is reported timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The college will evaluate our procedures and review regulations to ensure the appropriate enrollment information is reported, timely. In the summer of 2023, the financial aid office implemented weekly COD mismatch updates and real time R2T4 adjustments. In doing so, we are ensuring that COD has the most accurate information and adjustments are reported in a timely manner. Name(s) of the contact person(s) responsible for corrective action: Jossie Johnson – Director of Financial Aid and Michael Reig – Registrar. Planned completion date for corrective action plan: June 30, 2024
Finding 391301 (2023-006)
Significant Deficiency 2023
Student Financial Aid Cluster – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College evaluate its procedures and review regulations set by the Department of Education around NSLDS to ensure the College understands the definitions for each enrollment information that gets re...
Student Financial Aid Cluster – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College evaluate its procedures and review regulations set by the Department of Education around NSLDS to ensure the College understands the definitions for each enrollment information that gets reported. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The college will evaluate our procedures and review regulations to ensure the appropriate enrollment information is reported, timely. Name(s) of the contact person(s) responsible for corrective action: Jossie Johnson – Director of Financial Aid and Michael Reig – Registrar. Planned completion date for corrective action plan: June 30, 2024
Finding 391297 (2023-005)
Significant Deficiency 2023
Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.063, 84.268, 84.379 Recommendation: We recommend reviewing the report that is run to identify withdrawn students to understand why these students were not included, as well as implement a compensating control to ensure future students...
Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.063, 84.268, 84.379 Recommendation: We recommend reviewing the report that is run to identify withdrawn students to understand why these students were not included, as well as implement a compensating control to ensure future students are not missed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Office fully understands federal requirements surrounding the completion of R2T4s and strive to remain up to date with R2T4 best practice. We are fully committed to identifying the root cause, implementing corrective actions, and improving the system to prevent similar issues in the future. Name(s) of the contact person(s) responsible for corrective action: Jossie Johnson – Director of Financial Aid and Michael Reig – Registrar. Planned completion date for corrective action plan: April 30, 2024
Finding 391296 (2023-004)
Significant Deficiency 2023
Student Financial Aid Cluster – Assistance Listing No. 84.268 Recommendation: We recommend the College review its policies and procedures around sending exit counseling information to students to ensure students are receiving proper counseling. Explanation of disagreement with audit finding: There i...
Student Financial Aid Cluster – Assistance Listing No. 84.268 Recommendation: We recommend the College review its policies and procedures around sending exit counseling information to students to ensure students are receiving proper counseling. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Action taken in response to finding: We have conducted a thorough review of our exit counseling procedures and have identified areas of opportunity. Our team is committed to making the necessary corrections to ensure compliance with regulatory requirements. Our goal is to enhance our exit counseling program to better support students in understanding their rights and responsibilities regarding their federal student loans. We will execute this plan by including exit notices in our biweekly notifications, emailing students once an R2T4 is completed and notifying students that are less than halftime students the day after add/ period of each semester. For graduating students, we will host an event leading up to graduation where students can learn about the repayment process and an opportunity for students to complete their exit counseling. . Name(s) of the contact person(s) responsible for corrective action: Jossie Johnson – Director of Financial Aid Planned completion date for corrective action plan: April 30, 2024
Finding 391294 (2023-003)
Significant Deficiency 2023
Student Financial Aid Cluster – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College evaluate its procedures and policies around reporting to the COD to ensure that student information is reported timely. Explanation of disagreement with audit finding: There is no disagreem...
Student Financial Aid Cluster – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College evaluate its procedures and policies around reporting to the COD to ensure that student information is reported timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Financial Aid policies and procedures will be reviewed and amended as necessary. In conjunction with the Registrar’s Office all student changes and information will be reported and reconciled timely. Name(s) of the contact person(s) responsible for corrective action: Jossie Johnson – Director of Financial Aid Planned completion date for corrective action plan: September 30, 2024
Finding 391289 (2023-002)
Significant Deficiency 2023
Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268, 84.379 Recommendation: We recommend the College review its policies and procedures related to Title IV outstanding checks to ensure they are being returned to the Department of Education after 240 days. Explanatio...
Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268, 84.379 Recommendation: We recommend the College review its policies and procedures related to Title IV outstanding checks to ensure they are being returned to the Department of Education after 240 days. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The office of Financial Aid and Accounting will review outstanding checks on a monthly basis. In addition, any checks related to financial aid returns or refunds will be sent to the Department of Education within the required time frame. Name(s) of the contact person(s) responsible for corrective action: Larz Jeter – Controller and Jossie Johnson – Financial Aid Director Planned completion date for corrective action plan: September 30, 2024.
View Audit 301881 Questioned Costs: $1
The corrective action plan was documented in our response to the auditor’s comment. See the Schedule of Findings and Questioned Costs.
The corrective action plan was documented in our response to the auditor’s comment. See the Schedule of Findings and Questioned Costs.
The corrective action plan was documented in our response to the auditor’s comment. See the Schedule of Findings and Questioned Costs.
The corrective action plan was documented in our response to the auditor’s comment. See the Schedule of Findings and Questioned Costs.
Identifying Number: 2023-001 – Activities Allowed or Unallowed; Allowable Costs/Costs Principles Finding: The Code of Federal Regulations (CFR) Section 200.403(g) states that for costs to be allowable under federal awards, they must be adequately documented and there must be sufficient documentation...
Identifying Number: 2023-001 – Activities Allowed or Unallowed; Allowable Costs/Costs Principles Finding: The Code of Federal Regulations (CFR) Section 200.403(g) states that for costs to be allowable under federal awards, they must be adequately documented and there must be sufficient documentation. Additionally, CFR Section 200.430 states that charges to federal awards for salaries and wages must be based on records that accurately reflect the work performed and are supported by a system of internal control which provides reasonable assurance that the charges are accurate and allowable. The Florida’s Division of Accounting and Auditing Reference Guide for State Expenditures states that supporting documentation shall be maintained in support of expenditure payment requests for cost reimbursement contracts including that approved timesheets support the hours worked on the project or activity must be kept. During our testing of payroll disbursements, we noted that seven of the 120 payroll expenditures selected for testing did not have a properly approved timecard for the pay period selected. Corrective Actions Taken or Planned: All of the timecards noted in the finding above have been reviewed for accuracy and retroactively approved by the Chief Talent Officer. The following corrective actions are in the process of being implemented: • CHS’s Payroll and Talent teams will conduct a review of timecards completed after July 1, 2023. The accuracy of any unapproved timecards identified will be verified and retroactively approved by the designated supervisor, or the Chief Talent Officer if the designated supervisor is no longer available. • After each payroll period, a list of unapproved timecards will be provided to the Talent Team so the respective Talent Business Partner may follow up with corrective action with those supervisors who have two or more repeat occurrences. Such corrective action will include: o A thorough review with the supervisor of the CHS policies and practices relative to supervisory duties regarding the management and approval of employee timecards. o Mandatory refresher education and training on the supervisory timecard review and approval process in the CHS HRIS, Paylocity. In addition, CHS is formally implementing a new HRIS, UKG PRO, in July 2024. This system has advanced notification and tracking features that will assist supervisors in proper management and approval of timecards. Person(s) Responsible for Corrective Actions: Barbara McDonald, Chief Financial Officer and Chief Administrative Officer and Heather Vogel, Chief Talent Officer Anticipated Completion Date for Corrective Actions: Implementation of the Corrective Actions outlined above will begin immediately to be completed by June 30, 2024.
Identifying Number: 2023-002 – Eligibility Finding: The Code of Federal Regulations (CFR) Section 200.303(a) states the non-federal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal entity is managing the feder...
Identifying Number: 2023-002 – Eligibility Finding: The Code of Federal Regulations (CFR) Section 200.303(a) states the non-federal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). The State of Florida’s Department of Financial Services’ State Projects Compliance Supplement Part Five: Internal Controls Section D. Eligibility states that recipients should develop Control Objectives to provide reasonable assurance that only eligible individuals and organizations receive assistance under state projects, that subawards are made only to eligible subrecipients, and that amounts provided to or on behalf of eligibles were calculated in accordance with project requirements. During our testing of participant eligibility, we noted that supervisory personnel did not properly review and approve their eligibility documentation prior to the participant entering the program for ten of 80 participants selected for eligibility testing. Corrective Actions Taken or Planned: Corrective measures were taken with the Program Leadership responsible for the eligibility documentation noted above. The following corrective actions are in the process of being implemented: • CHS’s Program Leadership and their teams will conduct a review of respective intake forms completed after July 1, 2023 to ensure that all were properly reviewed and approved. Any unapproved intake forms identified will be verified and retroactively approved by the designated supervisor. • In cases where there are instances of unapproved intake forms, the Program Leadership will collaborate with the respective Talent Business Partner to follow up with formal corrective action. Such corrective action will include: o A thorough review of the CHS policies and practices relative to the management and approval of intake forms. o Mandatory refresher education and training with all staff to ensure they understand the steps required to document review and approval of the intake process, as well as the importance of maintaining evidence that the process was adequately performed. Person(s) Responsible for Corrective Actions: Barbara McDonald, Chief Financial Officer and Chief Administrative Officer and Heather Brungardt, Chief Program and Clinical Officer Anticipated Completion Date for Corrective Actions: Implementation of the Corrective Actions outlined above will begin immediately to be completed by June 30, 2024.
The Municipality will be implementing the internal controls and procedures to assure that the required reports are completed and be submitted as per program regulations on the 15th day of the following month; the expenses were incurred.
The Municipality will be implementing the internal controls and procedures to assure that the required reports are completed and be submitted as per program regulations on the 15th day of the following month; the expenses were incurred.
Finding 2023-003 Internal Controls over Compliance Description of Finding While the School Department has policies and procedures to ensure vendors are not suspended or debarred, the procedures were not retrospectively applied to contracts entered into before these policies were implemented. State...
Finding 2023-003 Internal Controls over Compliance Description of Finding While the School Department has policies and procedures to ensure vendors are not suspended or debarred, the procedures were not retrospectively applied to contracts entered into before these policies were implemented. Statement of Concurrence or Nonconcurrence Management concurs with the finding. Corrective Action The School Department will retrospectively review vendors to ensure they are not suspended or debarred, in accordance with the updated policies. Name of Contact Person John Welch Projected Completion Date 6/30/2024
Title V Grant Procurement Planned Corrective Action: The University will update and implement internal policies such that they align with the federal procurement requirements. Person Responsible for Corrective Action Plan: Jim Gerrish, Director of Facilities Anticipated Date of Completion: Apr...
Title V Grant Procurement Planned Corrective Action: The University will update and implement internal policies such that they align with the federal procurement requirements. Person Responsible for Corrective Action Plan: Jim Gerrish, Director of Facilities Anticipated Date of Completion: April 30, 2024
Title V Grant Cash Management Planned Corrective Action: The University will implement and follow a formal process for making drawdowns when or after expenditures have been incurred and require that supporting documentation be retained to support compliance with cash management requirements. Perso...
Title V Grant Cash Management Planned Corrective Action: The University will implement and follow a formal process for making drawdowns when or after expenditures have been incurred and require that supporting documentation be retained to support compliance with cash management requirements. Person Responsible for Corrective Action Plan: Jim Pierce, Controller Anticipated Date of Completion: June 30th, 2024
Federal Direct Loans Reconciliations Planned Corrective Action: The University’s Financial Aid Office will review the reconciliations to ensure that the Direct Loan Program is reconciled. We will also refer the ED announcement DL-22-07 to maintain consistent and accurate reconciliations. Person ...
Federal Direct Loans Reconciliations Planned Corrective Action: The University’s Financial Aid Office will review the reconciliations to ensure that the Direct Loan Program is reconciled. We will also refer the ED announcement DL-22-07 to maintain consistent and accurate reconciliations. Person Responsible for Corrective Action Plan: Nicholas Capodice, Director of Financial Aid Anticipated Date of Completion: April 30, 2024
Unofficial Withdrawals Planned Corrective Action: The University will run zero credit reports at the end of each semester to ensure all potential unofficial withdrawals are followed up on so that R2T4’s are completed timely when required. Person Responsible for Corrective Action Plan: Nicholas Cap...
Unofficial Withdrawals Planned Corrective Action: The University will run zero credit reports at the end of each semester to ensure all potential unofficial withdrawals are followed up on so that R2T4’s are completed timely when required. Person Responsible for Corrective Action Plan: Nicholas Capodice, Director of Financial Aid Anticipated Date of Completion: June 30th, 2024
View Audit 301872 Questioned Costs: $1
Common Origination and Disbursement (COD) Reporting Planned Corrective Action: The University’s Financial Aid Office will update the anticipated disbursement date to reflect the actual disbursement for 2022-23. We will review the current award year to ensure that the anticipated disbursement dates...
Common Origination and Disbursement (COD) Reporting Planned Corrective Action: The University’s Financial Aid Office will update the anticipated disbursement date to reflect the actual disbursement for 2022-23. We will review the current award year to ensure that the anticipated disbursement dates reflect the actual disbursement date. Person Responsible for Corrective Action Plan: Nicholas Capodice, Director of Financial Aid Anticipated Date of Completion: April 30, 2024
Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: The University’s IT Department will work to update procedures and controls to ensure any federal regulations of the FTC Safeguards Rule (16 CFR § 314.4(b)(1) - 16 CFR § 314.4(i)) that were found to be in partial compliance are reme...
Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: The University’s IT Department will work to update procedures and controls to ensure any federal regulations of the FTC Safeguards Rule (16 CFR § 314.4(b)(1) - 16 CFR § 314.4(i)) that were found to be in partial compliance are remediated and brought into compliance. Some of these have already been remediated. We will work with other departments who administer third party vendor accounts to enforce MFA where there are gaps. A penetration test and the standing up of a tool to continuously monitor our network internally and those of third party vendors are already in startup phases Our information security program and risk assessment will be updated to reflect any recommendations offered by our auditors to fill any existing gaps in the 2023 audit. Person Responsible for Corrective Action Plan: Ron Loneker, Jr., Director, IT Special Projects Anticipated Date of Completion: May 31, 2024
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