Corrective Action Plans

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Suspension and Debarment Recommendation: We recommend that current policies and procedures over covered transactions be updated to include one of the following procedures related to suspension and debarment: • Searching for the person or entity within the Excluded Parties List System; Collecting ce...
Suspension and Debarment Recommendation: We recommend that current policies and procedures over covered transactions be updated to include one of the following procedures related to suspension and debarment: • Searching for the person or entity within the Excluded Parties List System; Collecting certification from the person or entity; or • Adding a clause or condition to the covered transaction with that person or entity Views of Responsible Officials: There is no disagreement with the audit finding. Action taken in response to finding: Enlace Chicago is committed to ensuring the policies and procedures are being followed in relation to suspension and debarment. The current policy is to search a person or entity within the Excluded Parties List System on an ongoing basis. In addition to the search, moving forward, documentation will include the date of the search and saved within each contractual package. Contract language will also be added to include a clause to cover this internal control requirement. Name of the contact person responsible for corrective action: Laura Velazques, Director of Finance
Procurement Recommendation: We recommend that the Organization follow the current policies and procedures over covered transactions to maintain documentation supporting the procurement for 5 years following the end of the contract. Views of Responsible Officials: There is no disagreement with this ...
Procurement Recommendation: We recommend that the Organization follow the current policies and procedures over covered transactions to maintain documentation supporting the procurement for 5 years following the end of the contract. Views of Responsible Officials: There is no disagreement with this finding. Action taken in response to finding: Enlace Chicago is committed to following the procurement process and requirements outlined within the policies and procedures. Name of the contact person responsible for corrective action: Laura Velazquez, Director of Finance Planned completion date for corrective action plan: June 30, 2024.
Finding 390216 (2023-003)
Significant Deficiency 2023
Reporting Recommendation: We recommend that management follow established policies and procedures for timely preparation of reports under program requirements financial reports. Documented timing of preparation and approval should be maintained and documented. Views of Responsible Officials: There ...
Reporting Recommendation: We recommend that management follow established policies and procedures for timely preparation of reports under program requirements financial reports. Documented timing of preparation and approval should be maintained and documented. Views of Responsible Officials: There is no disagreement with this finding. Action taken in response to finding: Enlace Chicago is committed to timely completion of report submissions. Enlace Chicago has continued to review and approve reports prior to submission as required by the state agency. We will continue to put forth best efforts to take a step further and document preparation and review on the report form to satisfy the internal process requirement. Name of the contact person responsible for corrective action: Laura Velazquez, Director of Finance Planned completion date for corrective action plan: June 30, 2024.
The University will review and enhance its procedures and internal controls to ensure reporting requirements related to the HEERF grants are met and information is reported timely and accurately.
The University will review and enhance its procedures and internal controls to ensure reporting requirements related to the HEERF grants are met and information is reported timely and accurately.
The University will further review and refine the policies and procedures to strengthen internal controls and to ensure the timely and accurate reporting to NSLDS.
The University will further review and refine the policies and procedures to strengthen internal controls and to ensure the timely and accurate reporting to NSLDS.
The Superintendent, Iruis Voiron, Jt, has mandated that all contracts entered into by the District follour the Uniform Guidance for federal procurement. The exact langu€e has been shared with staff and is being used in all contracts.
The Superintendent, Iruis Voiron, Jt, has mandated that all contracts entered into by the District follour the Uniform Guidance for federal procurement. The exact langu€e has been shared with staff and is being used in all contracts.
2023-003 -Return of the Title IV R2T4 Calculation Cluster: Student Financial Assistance Sponsoring Agency: Department of Education Award Names: Federal Pell Grant Program and Federal Direct Student Loans Award Numbers: Not applicable Assistance Listing Titles: Federal Pell Grant Program and Federal ...
2023-003 -Return of the Title IV R2T4 Calculation Cluster: Student Financial Assistance Sponsoring Agency: Department of Education Award Names: Federal Pell Grant Program and Federal Direct Student Loans Award Numbers: Not applicable Assistance Listing Titles: Federal Pell Grant Program and Federal Direct Student Loans Assistance Listing Numbers: 84.063 and 84.268 Award Year: 2022-2023 Pass-through entity: Not applicable The Network agrees with the finding, and will make the following enhancement to the process: A review of the R2T4 calculation will be evidenced to ensure the calculation is prepared completely and accurately to determine whether a refund is required as well as to verify any post-withdrawal disbursements. The Network is implementing this process beginning in Q4 of FY2024. For inquiries regarding this finding, please contact Lisa Storck, Senior Associate Dean, and Joe Zelasko, Senior Financial Aid Coordinator, who are responsible for the corrective action.
2023-002 – Reporting to the Common Origination and Disbursement (COD) System Cluster: Student Financial Assistance Sponsoring Agency: Department of Education Award Names: Federal Pell Grant Program and Federal Direct Student Loans Award Numbers: Not applicable Assistance Listing Titles: Federal Pell...
2023-002 – Reporting to the Common Origination and Disbursement (COD) System Cluster: Student Financial Assistance Sponsoring Agency: Department of Education Award Names: Federal Pell Grant Program and Federal Direct Student Loans Award Numbers: Not applicable Assistance Listing Titles: Federal Pell Grant Program and Federal Direct Student Loans Assistance Listing Numbers: 84.063 and 84.268 Award Year: 2022-2023 Pass-through entity: Not applicable The Network agrees with the finding, and will make the following enhancements to the process: A reconciliation between the amounts of St. Luke’s School of Nursing disbursements compared to COD disbursement records will be completed monthly starting Q4 2024 by downloading the SAS file from COD. Starting FY 2024, these reconciliations will be completed monthly. After Originating a PELL Grant or a Direct Loan, the Financial Aid Office will check COD to ensure that the Origination came back with an “Accepted” value before any disbursement can be made. The student will be notified of the error and Direct Loan proceeds will be refunded to the Department of Education. This will ensure the student was properly reported and sent a direct loan disbursement notification as required to notify the student of the date and amount of disbursement, the right to cancel and procedures to cancel. The Network is implementing this process beginning in Q4 of FY2024. All disbursement records for PELL Grant and Direct Loan payments will be sent to COD on the disbursement date and no later than 15 days of the disbursement occurring. Starting Q4 of FY 2024, all PELL Grant and Direct Loan payments will be checked to ensure that they are sent to COD within this acceptable date range. For inquiries regarding this finding, please contact Lisa Storck, Senior Associate Dean, and Joe Zelasko, Senior Financial Aid Coordinator, who are responsible for the corrective action.
2023-001 – Gaps in General Controls for SFA/COD Process (Significant Deficiency) Cluster: Student Financial Assistance Sponsoring Agency: Department of Education Award Names: Federal Pell Grant Program and Federal Direct Student Loans Award Numbers: Not applicable Assistance Listing Titles: Federal ...
2023-001 – Gaps in General Controls for SFA/COD Process (Significant Deficiency) Cluster: Student Financial Assistance Sponsoring Agency: Department of Education Award Names: Federal Pell Grant Program and Federal Direct Student Loans Award Numbers: Not applicable Assistance Listing Titles: Federal Pell Grant Program and Federal Direct Student Loans Assistance Listing Numbers: 84.063 and 84.268 Award Year: 2022-2023 Pass-through entity: Not applicable The Network has controls for the student financial aid program, monitored by the Student Financial Aid Office. The Network agrees with the finding regarding the retention of support and documentation of the reviews and approvals in the financial aid process. Going forward the Network will enhance the documentation and retention of support of proper review and approval that will evidence the appropriate segregation of duties. The Network is implementing this process beginning in Q4 of FY2024. For inquiries regarding this finding, please contact Lisa Storck, Senior Associate Dean, and Joe Zelasko, Senior Financial Aid Coordinator, who are responsible for the corrective action.
Finding # 2023-004: Significant deficiency over preparation of schedule of expenditures of federal awards (SEFA). 93.677 Social Services Block Grant Department of Health and Human Services Finding: The Organization should have systems in place to prepare a complete and accurate SEFA. The Organizati...
Finding # 2023-004: Significant deficiency over preparation of schedule of expenditures of federal awards (SEFA). 93.677 Social Services Block Grant Department of Health and Human Services Finding: The Organization should have systems in place to prepare a complete and accurate SEFA. The Organization did not identify all federal awards and adjustments were made to the SEFA prepared by management. Recommendation: The Organization should implement additional procedures and controls to accurately capture all activity under federal awards in preparing the SEFA. Corrective Action: The Executive Director and Business Manager will use a grant and contract tracking log to ensure they are aware of all federal awards. Anticipated Completion Date: June 30, 2024
Finding 390196 (2023-003)
Significant Deficiency 2023
Finding # 2023-003: Significant deficiency over reporting Immaterial noncompliance over reporting U.S. Department of Education 84.044A TRIO Programs Cluster: TRIO – Talent Search Finding: An annual report is due within 90 days after end of the budget period. The annual performance report was not ...
Finding # 2023-003: Significant deficiency over reporting Immaterial noncompliance over reporting U.S. Department of Education 84.044A TRIO Programs Cluster: TRIO – Talent Search Finding: An annual report is due within 90 days after end of the budget period. The annual performance report was not submitted timely. Recommendation: Management should keep track of due dates for reports to avoid late submission. Corrective Action: We will have the Executive Director, Business Manager and College+ Program Manager monitor and ensure reports are remitted timely. Anticipated Completion Date: June 30, 2024
Finding 390195 (2023-002)
Significant Deficiency 2023
Finding # 2023-002: Significant deficiency over eligibility Immaterial noncompliance over period of performance U.S. Department of Education 84.044A TRIO Programs Cluster: TRIO – Talent Search Finding: Applications to the program should be reviewed and approved prior to acceptance into the program...
Finding # 2023-002: Significant deficiency over eligibility Immaterial noncompliance over period of performance U.S. Department of Education 84.044A TRIO Programs Cluster: TRIO – Talent Search Finding: Applications to the program should be reviewed and approved prior to acceptance into the program. Twenty applications out of 40 tested did not have proof of either initial or secondary review. Recommendation: Applications should have advisors or college prep specialists sign off and review prior to the program manager doing secondary review and acceptance. Corrective Action: We will have the Executive Director and College+ Program Manager ensure that all advisors review applications before sending to the College+ Program Manager for approval and acceptance. Anticipated Completion Date: June 30, 2024
Finding # 2023-001 Material weakness over allowable costs U.S. Department of Education 84.044A TRIO Programs Cluster: TRIO – Talent Search Finding: Only allowable costs may be charged to the contract for reimbursement. One out of six invoices charged to the contract was an unallowable expense (sc...
Finding # 2023-001 Material weakness over allowable costs U.S. Department of Education 84.044A TRIO Programs Cluster: TRIO – Talent Search Finding: Only allowable costs may be charged to the contract for reimbursement. One out of six invoices charged to the contract was an unallowable expense (scholarships). Recommendation: Expenses charged to contract should be reviewed thoroughly and be in compliance with contract agreement. Management should have understanding of what costs are considered allowable and unallowable. Corrective Action: We will have the Executive Director, Business Manager and College+ Program Manager thoroughly review the monthly Talent Search billing before completing a drawdown to ensure that all expenses billed are allowable costs. Anticipated Completion Date: June 30, 2024
Finding 2023-002: (L) Reporting of Unreimbursed Expenses Attributable to Coronavirus and Lost Revenues within the Health Resources Services Administration (HRSA) Provider Relief Fund Portal Program: COVID-19 - Provider Relief Fund (PRF) and American Rescue Plan (ARP) Distribution Assistance Listing ...
Finding 2023-002: (L) Reporting of Unreimbursed Expenses Attributable to Coronavirus and Lost Revenues within the Health Resources Services Administration (HRSA) Provider Relief Fund Portal Program: COVID-19 - Provider Relief Fund (PRF) and American Rescue Plan (ARP) Distribution Assistance Listing Number: 93.498 Agency: Department of Health and Human Services (HHS) Award Year: 1/1/2023-3/31/2023 Award Number: Not available Management’s Response to Finding: Management acknowledges the Period 4 HRSA Reporting portal submission errors noted. The personnel and supply costs identified at St. James Hospital and Memorial Hospital of William F and Gertrude F Jones Inc. were all allowable and reported in Period 4, but were over- or under-stated in a particular quarter. Management acknowledges that St. James Hospital understated its lost revenue in Reporting Period 4. Management’s Corrective Action Plan: The University is unable to amend the Reporting Period 4 submissions. HRSA has only provided guidance to providers with respect to how to account for unallowable expenses identified in prior reporting periods. The portal submission expense items identified were all allowable expenses, but under- or over- reported in a particular quarter of the Period 4 Reporting. The lost revenue calculation for St. James Hospital was an error in reporting. Since there is no ability to amend the Period 4 reporting for either of these entities, the University will ensure that it documents these corrections in case of future inquiries from the HRSA. As noted above, the URMC Office of the Chief Financial Officer, in support with the Office of University Audit, the Controller’s Office, and the University of Rochester Medical Center (URMC) Office of Integrity and Compliance, conducted enterprise-wide reviews of the HRSA Reporting portal submissions of all University affiliates in FY23 prior to submission to the HRSA. The University will continue to conduct enhanced reviews with respect to its future required portal submissions. Contact person: Adam Anolik, URMC Senior Vice President and CFO, Adam_Anolik@URMC.Rochester.edu
Finding 2023-001: (A) (B) Unallowed COVID-19 expenditures reported within the Health Resources Services Administration (HRSA) Provider Relief Fund Portal Program: COVID-19 - Provider Relief Fund (PRF) and American Rescue Plan (ARP) Distribution Assistance Listing Number: 93.498 Agency: Department of...
Finding 2023-001: (A) (B) Unallowed COVID-19 expenditures reported within the Health Resources Services Administration (HRSA) Provider Relief Fund Portal Program: COVID-19 - Provider Relief Fund (PRF) and American Rescue Plan (ARP) Distribution Assistance Listing Number: 93.498 Agency: Department of Health and Human Services (HHS) Award Year: 1/1/2020-6/30/2023 Award Number: Not available Management’s Response to Finding: Management acknowledges that certain COVID-19 expenditures were overstated in the Period 4 Reporting period HRSA portal submissions by the University of Rochester and Related Entities (“the University”). Management’s Corrective Action Plan: As provided in HRSA’s FAQs regarding Auditing and Reporting Requirements for Provider Relief Fund Payments, a provider is allowed to replace its unallowable expenses with its unreimbursed lost revenues in the reporting period in question if a provider is not required to report in subsequent reporting periods. None of the related entities with findings have future required HRSA portal submission. Both UR Medicine Home Care and Nicholas H. Noyes Memorial Hospital had unreimbursed lost revenue that exceeded the identified unallowable expenses in Reporting Period 4. In accordance with HRSA’s guidance, UR Medicine Home Care and Nicholas H. Noyes Memorial Hospital will replace the unallowable expenses with unreimbursed lost revenue. St. James Hospital did not report enough unreimbursed lost revenue to replace the unallowable expenses. However, St. James Hospital has identified additional allowable expenses and a miscalculated lost revenue amount for Reporting Period 4 that would exceed the identified unallowable expenses. Further, enterprise-wide, the University had unreimbursed lost revenue that far exceeded the identified unallowable expenses. As the University is unable to amend Reporting Period 4 for St. James Hospital, the University will document the additional allowable expenses and miscalculated lost revenue amount in case of future inquiries. The URMC Office of the Chief Financial Officer, in support with the Office of University Audit, the Controller’s Office, and the University of Rochester Medical Center (URMC) Office of Integrity and Compliance, distributed enterprise-wide guidelines in FY23 to assist each entity with respect to allowable COVID-19 expenditures to help ensure reporting was complete and accurate. The University also conducted enterprise-wide reviews of the HRSA Reporting portal submissions of all University affiliates prior to submission to the HRSA. The University will continue to conduct enhanced reviews with respect to its future required portal submissions.
The Business Services Department will ensure reports are submitted in a timely manner. • The Director and Senior Accountant will work with Grants Accountant with any issues that may arise that prevents timely submission. Timeline: Effective immediately Personnel Responsible: Naquisha Larks, Grants A...
The Business Services Department will ensure reports are submitted in a timely manner. • The Director and Senior Accountant will work with Grants Accountant with any issues that may arise that prevents timely submission. Timeline: Effective immediately Personnel Responsible: Naquisha Larks, Grants Accountant
The Early Childhood Director retired in February. The new Director will work with daycare/childcare facilities to ensure the Memorandum of Understanding is completed and approved. Early Childhood Department will keep a copy for their records. Timeline: Effective immediately Personnel Responsible: Dr...
The Early Childhood Director retired in February. The new Director will work with daycare/childcare facilities to ensure the Memorandum of Understanding is completed and approved. Early Childhood Department will keep a copy for their records. Timeline: Effective immediately Personnel Responsible: Dr. Moquita Winey
The Supply Chain Depa11ment will ensure appropriate consideration to competitors are given and adequate documentation is obtained with respect to procurement of professional services and sole source products in accordance with the Uniform Guidance 2 CFR section 200.320(t). • Additionally, the docume...
The Supply Chain Depa11ment will ensure appropriate consideration to competitors are given and adequate documentation is obtained with respect to procurement of professional services and sole source products in accordance with the Uniform Guidance 2 CFR section 200.320(t). • Additionally, the documentation will be approved by the Director of Special Education as well as the Supervisor of Supply Chain and retained as evidence of the internal controls over procurement. Timeline: Effective immediately Responsible Person:Amber Miller, Supply Chain Supervisor
View Audit 301090 Questioned Costs: $1
The Business Service Department will work with CSRS to ensure the FEMA funded projectes are reported correctly on the SEFA. Timeline: Immediately Responsible Person: Naquisha Larks, Grants Accountant
The Business Service Department will work with CSRS to ensure the FEMA funded projectes are reported correctly on the SEFA. Timeline: Immediately Responsible Person: Naquisha Larks, Grants Accountant
Lack of Internal Control over Reporting and Noncompliance Name of Contact: W. Scott Pegau Corrective Action Plan: A new section on contracts was added to our accounting manual that describes the steps to be taken when a new contract is established. It identifies the need for the FFATA reporting....
Lack of Internal Control over Reporting and Noncompliance Name of Contact: W. Scott Pegau Corrective Action Plan: A new section on contracts was added to our accounting manual that describes the steps to be taken when a new contract is established. It identifies the need for the FFATA reporting. A second procedure outlines how to complete the required reporting. All existing subcontracts over $30,000 were reported as required. Proposed completion date: December 15, 2023.
Management concurs with the audit finding. Capital Region Medical Center has sufficient unreimbursed lost revenues to replace the unallowable expenses reported. Capital Region Medical Center federal grant processes will begin to follow the University of Missouri grant policies beginning January 1,...
Management concurs with the audit finding. Capital Region Medical Center has sufficient unreimbursed lost revenues to replace the unallowable expenses reported. Capital Region Medical Center federal grant processes will begin to follow the University of Missouri grant policies beginning January 1, 2024.
View Audit 301083 Questioned Costs: $1
Altus Public Schools plans to meet the requirements of the Davis-Bacon Act on any future federal awards. Weekly payroll reports will be reviewed with vendors to ensure that federal rates and fringes are met. Items will be posted at the work site to ensure compliance with the Davis-Bacon Act.
Altus Public Schools plans to meet the requirements of the Davis-Bacon Act on any future federal awards. Weekly payroll reports will be reviewed with vendors to ensure that federal rates and fringes are met. Items will be posted at the work site to ensure compliance with the Davis-Bacon Act.
Altus Public Schools plans to meet the requirements of the Davis-Bacon Act on any future federal awards. Weekly payroll reports will be reviewed with vendors to ensure that federal rates and fringes are met. Items will be posted at the work site to ensure compliance with the Davis-Bacon Act.
Altus Public Schools plans to meet the requirements of the Davis-Bacon Act on any future federal awards. Weekly payroll reports will be reviewed with vendors to ensure that federal rates and fringes are met. Items will be posted at the work site to ensure compliance with the Davis-Bacon Act.
Name of Contact Person: Elena Begojevic, Business Manager Corrective Action Plan: Management will ensure that the system of internal controls over cash disbursements is designed appropriately and operates effectively to ensure all transactions are coded, reviewed, and approved before payment is mad...
Name of Contact Person: Elena Begojevic, Business Manager Corrective Action Plan: Management will ensure that the system of internal controls over cash disbursements is designed appropriately and operates effectively to ensure all transactions are coded, reviewed, and approved before payment is made. The Business manager and the Superintendent will conduct a review of claims to determine whether they are proper and valid charges. Once reviewed, all transactions will be authorized. DocuSign will be used for electronic signature approval. Accounts payable clerk will ensure that all transactions include copies of receipts for the goods or services purchased. Finally, the Finance department will work with the program directors to ensure that expenses are coded accurately and within reasonable timeframe to allow for timely submission of grant reports. Proposed Completion Date: March 31, 2024
Name of Contact Person: Elena Begojevic, Business Manager Corrective Action Plan: YFSD hired an experienced and independent contract grants specialist. She is using Outlook to set up reporting reminders to ensure timely submission of reports. In addition, the Business office started using a calenda...
Name of Contact Person: Elena Begojevic, Business Manager Corrective Action Plan: YFSD hired an experienced and independent contract grants specialist. She is using Outlook to set up reporting reminders to ensure timely submission of reports. In addition, the Business office started using a calendar developed by ALASBO which addresses all reporting requirements for the school districts in Alaska. Proposed Completion Date: March 31, 2024
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