Corrective Action Plans

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Finding 2023.003 Response: When reporting for Federal awards moving forward, before submitting the final report, payroll will review all payroll data that was submitted to the CFO. The human resources department will double check to ensure accuracy of the employees being reported. Responsible Par...
Finding 2023.003 Response: When reporting for Federal awards moving forward, before submitting the final report, payroll will review all payroll data that was submitted to the CFO. The human resources department will double check to ensure accuracy of the employees being reported. Responsible Party: Kim Gentner, CFO at Marlette Regional Hospital Estimated Completion: 01/01/2024
The Chicago Lighthouse will implement processes to address material weakness for internal controls in relation to reviewing and approving time spent by personnel working on government funded programs. Staff dedicating time and effort to activities that are multi-grant funded will prepare Personnel ...
The Chicago Lighthouse will implement processes to address material weakness for internal controls in relation to reviewing and approving time spent by personnel working on government funded programs. Staff dedicating time and effort to activities that are multi-grant funded will prepare Personnel Activity Reports (PAR) monthly and submit them to the Accounting Department once approved by the manager over the program. Charges to awards for salaries, wages, and benefits will be based on documented PAR approved by a responsible official(s) of the organization. PAR submissions will contain the breakdown of time dedicated by staff to activities and awards across all programs they support. In the event a staff member is dedicated to only one program or cost objective, the recurrence of the PAR will be at least twice a year. Each Program Director must ensure that all grant-funded employees are familiar with time documentation guidelines and are complying with these requirements. The Director of Grants and Contracts will review the time and effort report (PAR) and confirm appropriate verification. As part of the recurring vouchering process, the Director of Grants and Contracts will reconcile actual hours worked and percentage of hours worked per program as reported on the time reporting forms to actual charges within the accounting system. The Director of Grants and Contracts will work with the Program Director/Administrator to resolve any discrepancies. The Program Director/Administrator must initial any corrections that are made to the forms. Name of the contact person responsible for corrective action: Rosa Carrillo, CFO Anticipated completion date for corrective action: 07/01/2023
Finding 2023-004- Eligibility- Reimbursements Request Auditor Description of Condition: The School District's support for the number of meals served did not agree to the meals requested on the reimbursement requests. The District should request reimbursement for the actual number of meals served an...
Finding 2023-004- Eligibility- Reimbursements Request Auditor Description of Condition: The School District's support for the number of meals served did not agree to the meals requested on the reimbursement requests. The District should request reimbursement for the actual number of meals served and should maintain support for the number of meals served for each reimbursement request. The School District maintained records from a point-of-sale system, but those meals served could not be reconciled or agreed to the reimbursement requests for our sample of 3 claims. The lack of reconciliation or other records to explain the differences could have resulted in the School District over or under requesting reimbursement from Michigan Department of Education. Corrective Action Plan: The Business Office will work with the Food Service Director to implement procedures to ensure meals service data is retained and communicated to the entity requesting reimbursement for meals served. Responsible Person: Director of Finance and Director of Food Service. Anticipated Completion Date: June 30, 2024
Finding 9216 (2023-001)
Significant Deficiency 2023
Catholic Charities respectfully submits the following corrective action plan for the year ended June 30, 2023. Name & address of public accounting firm: Kernutt Stokes 1600 Executive Parkway, Suite 110 Eugene OR 97401 Audit Period: June 30, 2023 Major Federal Award Findings: Finding Reference #: 202...
Catholic Charities respectfully submits the following corrective action plan for the year ended June 30, 2023. Name & address of public accounting firm: Kernutt Stokes 1600 Executive Parkway, Suite 110 Eugene OR 97401 Audit Period: June 30, 2023 Major Federal Award Findings: Finding Reference #: 2023-001 Significant deficiency Recommendation: We recommend management design and implement internal controls over compliance to ensure the amount of $873 is deposited monthly into the Replacement Reserve account as required by HUD. Corrective Action: Management will work with Cascade Management to improve the internal control procedures to ensure the amount of $873 is deposited monthly into the Replacement Reserve account as required by HUD. Questions regarding this corrective action plan may be directed to Marci Pierce, Chief Financial and Administrative Officer, at (503) 688-2646.
Finding 9215 (2023-003)
Significant Deficiency 2023
Finding: Reporting The Organization is required to prepare and submit annual SF-425 Federal Financial Reports. During the fiscal year, one SF-425 annual report was required to be filed for the September 30, 2021 to September 29, 2022 grant period. We noted that the Cash Receipts and Disbursements on...
Finding: Reporting The Organization is required to prepare and submit annual SF-425 Federal Financial Reports. During the fiscal year, one SF-425 annual report was required to be filed for the September 30, 2021 to September 29, 2022 grant period. We noted that the Cash Receipts and Disbursements on lines 10a and b, and the Federal share of expenditures on line 10e and unobligated balance of Federal funds on line 10h were incorrectly reported and not in agreement with the actual amounts reported in the Organization’s underlying accounting records. We did test Federal draw requests as part of our Uniform Guidance testing and noted that expenditures reported on the Schedule of Expenditures of Federal Awards and cash received and disbursed for this federal award were correct and supported by underlying documentation. No discrepancies in expenditures or cash activity were identified in the Organization’s accounting system but, rather, just the reporting of the figures in SF-425 was incorrect. Views of Responsible Officials and Planned Corrective Actions: Management is in agreement with this finding. We worked with our grants management specialist to correct the error on the SF-425. We have implemented a process for preparing and reviewing the SF-425 to ensure that the cash and expenditures activity for the grant period being reported on agrees with our underlying account systems balances and activity. Responsible Official: Casey Pauly Completion Date: 12/12/2023
Views of the Responsible Officials and Planned Corrective Actions: The Business Administrator will work closely with the new Food Service Director to verify and record any company/vendor that is paid with Federal money.
Views of the Responsible Officials and Planned Corrective Actions: The Business Administrator will work closely with the new Food Service Director to verify and record any company/vendor that is paid with Federal money.
Corrective Action Plan Recommendation 1: The University Registrar will review the NSC Reject Detail Report every 45 days and will use the NSC error description resources to resolve any errors noted. For files rejected due to a discrepancy with a student’s SSN, the University Registrar will attempt t...
Corrective Action Plan Recommendation 1: The University Registrar will review the NSC Reject Detail Report every 45 days and will use the NSC error description resources to resolve any errors noted. For files rejected due to a discrepancy with a student’s SSN, the University Registrar will attempt to verify the students’ SSN via the Social Security Administration’s verification site (https://www.ssa.gov/employer/ssnv.htm). If the SSN cannot be verified using the link above, the University Registrar will provide the NSC Reject Detail Report to USA’s Office of Financial Aid to verify the students’ SSN. If the SSN is unable to be verified by Financial Aid, the Registrar’s Office will send an email to the student’s university email account notifying them that there is an issue with the SSN reported for them to NSC. The notification will encourage students to provide documentation to the Registrar’s Office to verify their SSN. Students will be given the option to provide their documentation directly to NSC if they prefer that option. After the student provides documentation of their SSN, we will notify NSC to have the student’s records corrected and updated to the NSLDS. Recommendation 2: The University Registrar's Office will submit student status enrollment changes every 30 days based on the date the enrollment file was submitted. Anticipated Completion Date 11/27/2023 Name of Contact Person for Corrective Action Ashley Suggs, University Registrar
Corrective Action Plan Inaccurate Vendor Invoice Calculations Communication was made by USA Health Director of Accounting to the USA Health Accounting Department on 11/4/23 and sent via email to all USA Health Department Managers on 11/6/2023 reiterating the procedures for submission, review, and ap...
Corrective Action Plan Inaccurate Vendor Invoice Calculations Communication was made by USA Health Director of Accounting to the USA Health Accounting Department on 11/4/23 and sent via email to all USA Health Department Managers on 11/6/2023 reiterating the procedures for submission, review, and approval of contract labor invoices. Specific instructions to recalculate each contract employees’ timesheet(s) and agree the totals to the related invoice prior to approval were included and outlined for department managers, accountants, and accounts payable staff. Duplicate Grant Expenditures and Proper Approvals The manager charged with approval of grant related transactions and transfers in 2022/2023 has since left USA. The process for reviewing and approving grant expenditures has since been enhanced. Specifically, employees responsible for processing grant transfer documentation will ensure documents contain management approval(s), grants and contracts accounting approval, and appropriate documentation prior to keying and uploading documentation into the general ledger (Banner system). The new practice will help compensate for employee turnover as documentation of historical review will be available to successors. Additional process enhancements will include the following: • Expenses cannot be transferred to a grant until payment has been processed. • Entries must contain a transaction line item for each invoice transferred to the Grant (not subtotals). • Accounting records will be reviewed prior to approval to ensure expenditures have not been previously transferred to a grant. • Expense transfer supporting documentation must contain a detailed schedule of all invoices, include a reference to the foapal and document number originally charged, name of vendor, date of initial payment, and amount. USA Health Accounting is currently working with Grants & Contracts Accounting and the USA Campus Business Office to document the process and effectively communicate this process with all responsible parties. Anticipated Completion Date 01/31/2024 Name of Contact Person for Corrective Action Becky Schaffer, USA Health Director of Accounting
View Audit 12556 Questioned Costs: $1
Finding 2023-002 Cash Management Internal Controls (Significant Deficiency) Responsible Persons: Debbie Rapier, Chief Financial Officer Corrective Action Plan: All monthly billing information for the FPP and MST programs is sent by the Director of Revenue Cycle to the FPP/MST supervisor for review...
Finding 2023-002 Cash Management Internal Controls (Significant Deficiency) Responsible Persons: Debbie Rapier, Chief Financial Officer Corrective Action Plan: All monthly billing information for the FPP and MST programs is sent by the Director of Revenue Cycle to the FPP/MST supervisor for review and comparison. The Outpatient Services Manager then prepares the monthly invoice. The invoice is forwarded to finance and reviewed by the Chief Financial Officer or Accounting Manager, in the absence of the CFO. Once approved, it is submitted to the Department of Community Based Services for payment. Once payment is received, it is compared against the receivable for accuracy. Anticipated Completion Date: Throughout fiscal year ending and beyond June 30, 2024
The District will monitor vendors to ensure they are able to accept federal monies. By Ashley Simmons, Accounts Payable clerk by 6/30/2024.
The District will monitor vendors to ensure they are able to accept federal monies. By Ashley Simmons, Accounts Payable clerk by 6/30/2024.
The District will work to collect federal certifications for all employees paid from grants. By Dawn Mead, Treasurer by 6/30/2024.
The District will work to collect federal certifications for all employees paid from grants. By Dawn Mead, Treasurer by 6/30/2024.
U.S. Department of Education 2023-001 NSLDS Enrollment Reporting Student Financial Aid Cluster – Assistance Listing No. 84.063, 84.268 Condition: During testing of enrollment status reporting, we noted that the incorrect enrollment status, effective date, and program begin date was reported to N...
U.S. Department of Education 2023-001 NSLDS Enrollment Reporting Student Financial Aid Cluster – Assistance Listing No. 84.063, 84.268 Condition: During testing of enrollment status reporting, we noted that the incorrect enrollment status, effective date, and program begin date was reported to NSLDS. Recommendation: The College should evaluate their procedures and policies related to reporting status changes to NSLDS and enhance as deemed necessary to ensure that accurate information is reported to NSLDS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Cause-Enrollment Status Reporting: Montgomery College utilizes the National Student Clearinghouse (NSC) as a third-party provider in order to submit student information to the NSLDS. Student enrollment status corrections were uploaded to NSC timely, however, monitoring of the upload through success was inconsistent, resulting in error reports preventing the accurate and timely update to the enrollment statuses. No review was completed to ensure the upload was completed in NSLDS. Cause for Effective Date Reporting - Inaccurate Student withdrawal effective dates were not identified timely due to delays in the review of student withdrawal status. Cause for Program Start Date Reporting - Inaccurate Student program begin dates were due to a programming issue with the file transmission software. Program start date was updating each semester to the latest semester start date. There was insufficient review to identify the problem and recommend a solution to resolve. The following actions have been implemented to resolve the deficiencies: Review of error reports by an employee not responsible for correcting the errors to ensure completeness and timeliness of the corrections submitted. Use of internal weekly reports to identify students who dropped below half time status or withdrew entirely from a semester. Use of the NSC online error reporting tool to correct errors monthly. Errors are corrected using this tool within eight days of receipt of the error report, which provides the NSC two days to resubmit the information and meet the ten-day resolution requirement. Utilize the Enrollment Reporting Summary Report (SCHER1) to ensure completeness and timeliness of error correction submissions. The Dept of Enrollment Services has coordinated with the Office of Information Technology to adjust the programming on the file transmission to NSC to ensure accuracy and minimize discrepancies. Manually submit corrections directly to NSLDS on an as-needed basis. Name(s) of the contact person(s) responsible for corrective action: Director of Enrollment Services- Earnest Cartledge Planned completion date for corrective action plan: December 2023
The District will append the notes field in our inventory records to include the grant funding year and source, for example, "22-23 ESSER, 989".
The District will append the notes field in our inventory records to include the grant funding year and source, for example, "22-23 ESSER, 989".
Finding 9151 (2023-001)
Significant Deficiency 2023
United States Department of Commerce 2023-001 Connecticut State Technology Extension Program – Assistance Listing No. 11.611 Recommendation: We recommend that if employees are being allocated to multiple programs throughout the year, personnel activity reports must be prepared at minimum, on a mo...
United States Department of Commerce 2023-001 Connecticut State Technology Extension Program – Assistance Listing No. 11.611 Recommendation: We recommend that if employees are being allocated to multiple programs throughout the year, personnel activity reports must be prepared at minimum, on a monthly basis and be reviewed and signed off on by both the employee and their immediate supervisor. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will implement a policy to require employees to prepare activity reports on a least a monthly basis that are signed by the employee and the supervisor. Name of the contact person responsible for corrective action: Robert Blakey, Controller Planned completion date for corrective action plan: December 2023.
Finding: 2023-002 – Special Tests and Provisions – Wage Rate Requirements U.S. Department of Education – COVID-19 - Education Stabilization Fund (ALN 84.425D and 84.425U); Passed through the Michigan Department of Education; All project numbers. Auditor Description of Condition and Effect: Two of ...
Finding: 2023-002 – Special Tests and Provisions – Wage Rate Requirements U.S. Department of Education – COVID-19 - Education Stabilization Fund (ALN 84.425D and 84.425U); Passed through the Michigan Department of Education; All project numbers. Auditor Description of Condition and Effect: Two of the contracts selected for testing that were subject to the Wage Rate Requirements did not include the required provision, and the District did not obtain the required certified payrolls. The District did not follow federal requirements to include the prevailing wage rate provision in its contract. Auditor Recommendation: We recommend that the District reviews its policies to ensure that applicable prevailing wage requirements are included in construction contracts whenever federal funds are used and certified payrolls are obtained. Corrective Action: District officials will ensure that construction contracts contain these requirements during the bid process. Responsible Person: Christine Robinson, Superintendent and Melissa Butler, LEA Business Manager Anticipated Completion Date: June 30, 2024
View Audit 12522 Questioned Costs: $1
View of Responsible Officials and Planned Corrective Actions: Management is reviewing their written procurement policy and will enhance it to include all elements required by Uniform Guidance including ensuring vendors and providers are not suspended, debarred, or otherwise disqualified.
View of Responsible Officials and Planned Corrective Actions: Management is reviewing their written procurement policy and will enhance it to include all elements required by Uniform Guidance including ensuring vendors and providers are not suspended, debarred, or otherwise disqualified.
By bringing the payroll back into the District from FEH BOCES, allows better oversight of the payroll functions. The District continues to work on improving and developing systems to enhance the payroll disbursements which are supported by documentation and approvals. It is the goal of the District ...
By bringing the payroll back into the District from FEH BOCES, allows better oversight of the payroll functions. The District continues to work on improving and developing systems to enhance the payroll disbursements which are supported by documentation and approvals. It is the goal of the District to continue to improve on systems by which timesheets are obtained promptly and maintained. The District purchased a timesheet enhancement software that works in conjunction with WINCAP software through FEH BOCES that is waiting to be implemented by the FEH BOCES Shared Business. Brandon Pelkey, superintendent ofschools is responsible for implementing this corrective action plan. We plan to rectrify all action by June 30, 2024.
Finding 9142 (2023-003)
Significant Deficiency 2023
Responsible party: Loretta Trujillo; Finance will distribute the budget and accounting manual and provide training to all supervisors and directors; purchases such as this are not allowable and will not occur again
Responsible party: Loretta Trujillo; Finance will distribute the budget and accounting manual and provide training to all supervisors and directors; purchases such as this are not allowable and will not occur again
Finding: 2023-002 – Procurement, Suspension, and Debarment – Contract Bidding Auditor Description of Condition and Effect. The District did not obtain price or rate quotations for the purchase of services for one vendor that met the small purchase threshold. As a result of this condition, the Distr...
Finding: 2023-002 – Procurement, Suspension, and Debarment – Contract Bidding Auditor Description of Condition and Effect. The District did not obtain price or rate quotations for the purchase of services for one vendor that met the small purchase threshold. As a result of this condition, the District paid a vendor with federal funding that was not procured in accordance with federal regulations. Auditor Recommendation. We recommend that the District update its procedures to ensure that all services are appropriately procured in accordance with federal and state requirements. Corrective Action. Management concurs with finding. The District will only allocate costs to the food service program that have been properly bid out and obtain quotes for all services in excess of the Federal micropurchase threshold. Responsible Person: Emili Jones, Director of Business and Finance Anticipated Completion Date: November 1, 2023
View Audit 12482 Questioned Costs: $1
Finding: 2023-001 – Reporting – Meal Claim Reimbursement Noncompliance Auditor Description of Condition and Effect. Two of three meal claim reimbursement reports selected for testing did not agree to underlying meal count sheets and on all three reports tested, the District understated claims for o...
Finding: 2023-001 – Reporting – Meal Claim Reimbursement Noncompliance Auditor Description of Condition and Effect. Two of three meal claim reimbursement reports selected for testing did not agree to underlying meal count sheets and on all three reports tested, the District understated claims for one of its facilities. As a result of this condition, the District submitted inaccurate claims for reimbursement, resulting in a reimbursement less than what the District should have received. Auditor Recommendation. We recommend that the District thoroughly review its monthly reports to count sheets and familiarize itself with allowable reimbursement claims. Corrective Action. Management concurs with finding. The District will utilize a thorough review of entered data prior to certification of claims data. A secondary review of claims data will be reviewed by a District finance department staff to ensure proper claims data. Responsible Person: Emili Jones, Director of Business and Finance Anticipated Completion Date: November 1, 2023
Finding 9115 (2023-002)
Significant Deficiency 2023
Condition: During the testing of internal controls surrounding the child nutrition program claims reimbursement reporting, it was identified that review of the meal counts and monthly claims reports is not taking place. Planned Corrective Action: The 2022-23 school year returned to students having t...
Condition: During the testing of internal controls surrounding the child nutrition program claims reimbursement reporting, it was identified that review of the meal counts and monthly claims reports is not taking place. Planned Corrective Action: The 2022-23 school year returned to students having to pay for their school meals since COVID. The district had a FS bookkeeper who was hired in the spring of 2020. The 2022-23 school year was her first-time filing school meal claims based on if students were free, reduced, or full pay. She started by exporting student counts from Skyward then adjusting them for GSRP and Heartwood student meal claims. Since this was a manual process, a few errors occurred. This FS bookkeeper resigned in the spring of 2023. The district hired a new FS Bookkeeper. She will be exporting the count information directly from Skyward, then using an Excel spreadsheet to adjust for GSRP and Heartwood students. The FS Bookkeeper will enter the counts into School Meal Claims website. The counts will be reviewed by the FS Director who will complete the actual submission of the meal claims. The entire process will be audited by the district accountant monthly. Contact person responsible for corrective action: Tracey Wooden, CFO Anticipated Completion Date: 07/12/2023
November 27, 2023 United States Department of Health and Human Services Wood River Health Services, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: June 30, 2023 The findings from th...
November 27, 2023 United States Department of Health and Human Services Wood River Health Services, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: June 30, 2023 The findings from the June 30, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS SIGNIFICANT DEFICIENCY 2023.001 – Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly documented. Action Taken Wood River Health Services is committed to documenting the sliding fee discounts being applied. Actions we are taking: Re-education of the Sliding Fee Discount Schedule (SFDS) documentation process to all personnel in the Community Resources Area Create review cheat sheets for SFDS including the documentation needed for decision making Review of Community Resource approvals If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please contact Alison Croke acroke@wrhsri.org. Sincerely yours, Alison Croke, MHA President and Chief Executive Officer
Finding: 2023-002 – Special Tests and Provisions - Wage Rate Requirements U.S. Department of Education– COVID-19 - Education Stabilization Fund (ALN 84.425D and 84.425U); Passed through MDE; All project numbers. Auditor Description of Condition and Effect: One of the contracts selected for testing...
Finding: 2023-002 – Special Tests and Provisions - Wage Rate Requirements U.S. Department of Education– COVID-19 - Education Stabilization Fund (ALN 84.425D and 84.425U); Passed through MDE; All project numbers. Auditor Description of Condition and Effect: One of the contracts selected for testing that was subject to the Wage Rate Requirements did not include the required provision and the District did not obtain the required certified payrolls. The District did not follow federal requirements to include the prevailing wage rate provision in its contract. Auditor Recommendation: We recommend that the District reviews its policies to ensure that applicable prevailing wage requirements are included in construction contracts whenever federal funds are used and certified payrolls are obtained. Corrective Action: Management will work internally with the management team on all construction contracts greater than $2,000. At time of quote or contract Management will determine if the funding source is Federal and apply the appropriate Davis Bacon Act - Prevailing Wage Compliance Certification. Management will follow up with the vendor to obtain the required certified payrolls. Responsible Person: Kendra Leib, LEA Business Manager Anticipated Completion Date: June 30, 2024
View Audit 12452 Questioned Costs: $1
2023-002: Special Tests and Provisions – NSLDS Program-Level Reporting Student Financial Aid Cluster – Assistance Listing No. 84.063, 84.268 Condition: The associate degree programs were not reported as two years per the recommendation in the NSLDS enrollment reporting guide. Recommendation: We rec...
2023-002: Special Tests and Provisions – NSLDS Program-Level Reporting Student Financial Aid Cluster – Assistance Listing No. 84.063, 84.268 Condition: The associate degree programs were not reported as two years per the recommendation in the NSLDS enrollment reporting guide. Recommendation: We recommend the College report associate degree program length to NSLDS at two years. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Currently investigating ERP system configuration changes necessary to report associate degree program length to NSLDS at two years. Name(s) of the contact person(s) responsible for corrective action: Nanci A. Beier, Registrar Planned completion date for corrective action plan: Spring 2024
2023-001: Gramm-Leach-Bliley Act Student Financial Aid Cluster – Assistance Listing No. 84.063, 84.268, 84.007, 84.033 Condition: Certain elements of the College’s information security program were not maintained in written form. Recommendation: We recommend the College ensure its written informati...
2023-001: Gramm-Leach-Bliley Act Student Financial Aid Cluster – Assistance Listing No. 84.063, 84.268, 84.007, 84.033 Condition: Certain elements of the College’s information security program were not maintained in written form. Recommendation: We recommend the College ensure its written information security program addresses the required minimum elements as outlined in 16 CFR 314.4. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Prior to the conclusion of our audit the College documented in writing the required minimum elements. Name(s) of the contact person(s) responsible for corrective action: Dr. Richard C. Kralevich, Vice President, Information and Instructional Technology Planned completion date for corrective action plan: Completed
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