Corrective Action Plans

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Auditor Recommendation Recommendation: We recommend that the Organization verifies that payments are recorded in the correct period and not changed in the general ledger after the checks are written. Corrective Action Plan (CAP) 1. Explanation of Disagreement with Audit Finding There is no...
Auditor Recommendation Recommendation: We recommend that the Organization verifies that payments are recorded in the correct period and not changed in the general ledger after the checks are written. Corrective Action Plan (CAP) 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Action Planned in Response to Finding Sara Wohlers and Josh Warner (management agent) will establish a review process that will include making sure all payments are recorded within the proper period. 3. Official Responsible for Insuring CAP Sara Wohlers is the official responsible for insuring corrective action of the deficiency. 4. Planned Completion Date for CAP This plan will be implemented for the September 30, 2024 audit. 5. Plan to Monitor Completion of CAP Julie Baruch (board chair) and Sara Wohlers will be monitoring this plan.
Auditor Recommendation Recommendation: We recommend that the Organization verifies all necessary adjustments are made to the financial statements prior to the audit process. Corrective Action Plan (CAP) 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit findi...
Auditor Recommendation Recommendation: We recommend that the Organization verifies all necessary adjustments are made to the financial statements prior to the audit process. Corrective Action Plan (CAP) 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Action Planned in Response to Finding Sara Wohlers (management agent) will establish a review process to ensure that all necessary adjustments are made to the financial statements prior to the audit process. 3. Official Responsible for Ensuring CAP Sara Wohlers is the official responsible for ensuring corrective action of the deficiency. 4. Planned Completion Date for CAP This plan will be implemented for the September 30, 2024 audit. 5. Plan to Monitor Completion of CAP Julie Baruch (board chair) and Sara Wohlers will be monitoring this plan.
Finding 7948 (2023-002)
Significant Deficiency 2023
Auditor Recommendation Recommendation: We recommend that the Organization verifies all requests for reimbursements are received in a timely manner. We also recommend that the Organization verifies that payments are recorded in the correct period and not changed in the general ledger after the check...
Auditor Recommendation Recommendation: We recommend that the Organization verifies all requests for reimbursements are received in a timely manner. We also recommend that the Organization verifies that payments are recorded in the correct period and not changed in the general ledger after the checks are written. Corrective Action Plan (CAP) 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Action Planned in Response to Finding Sara Wohlers and Josh Warner (management agent) will establish a review process that will include making sure all payments are recorded within the proper period. It will also include ensuring all HUD/HAP funds are received in full during that period and any short falls or overages are identified within the proper period. 3. Official Responsible for Ensuring CAP Sara Wohlers is the official responsible for ensuring corrective action of the deficiency. 4. Planned Completion Date for CAP This plan will be implemented for the September 30, 2024 audit. 5. Plan to Monitor Completion of CAP John Frank (board chair) and Sara Wohlers will be monitoring this plan.
Auditor Recommendation Recommendation: We recommend that the Organization verifies all necessary adjustments are made to the financial statements prior to the audit process. Corrective Action Plan (CAP) 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit fin...
Auditor Recommendation Recommendation: We recommend that the Organization verifies all necessary adjustments are made to the financial statements prior to the audit process. Corrective Action Plan (CAP) 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Action Planned in Response to Finding Sara Wohlers (management agent) will establish a review process to ensure that all necessary adjustments are made to the financial statements prior to the audit process. 3. Official Responsible for Ensuring CAP Sara Wohlers is the official responsible for ensuring corrective action of the deficiency. 4. Planned Completion Date for CAP This plan will be implemented for the September 30, 2024 audit. 5. Plan to Monitor Completion of CAP John Frank (board chair) and Sara Wohlers will be monitoring this plan.
Auditor Recommendation Recommendation: We recommend that the Organization ensure that the required deposit to the reserve for replacements account be made on a timely basis. Corrective Action Plan (CAP) 1. Explanation of Disagreement with Audit Finding There are no disagreements with the audit fin...
Auditor Recommendation Recommendation: We recommend that the Organization ensure that the required deposit to the reserve for replacements account be made on a timely basis. Corrective Action Plan (CAP) 1. Explanation of Disagreement with Audit Finding There are no disagreements with the audit finding. 2. Action Planned in Response to Finding Sara Wohlers, or Josh Warner, (management agent) will ensure that deposits to reserve for replacements account are made on a timely basis when cash allows. They will ensure the final deposit will be made prior to September 30. 3. Official Responsible for Ensuring CAP Sara Wohlers is the official responsible for ensuring corrective action of the deficiency. 4. Planned Completion Date for CAP This plan will be implemented for the September 30, 2024 Audit. 5. Plan to Monitor Completion of CAP Nick Kandoll (board chair) and Sara Wohlers will be monitoring this plan.
Finding 7945 (2023-002)
Significant Deficiency 2023
Auditor Recommendation Recommendation: We recommend that the Organization ensure that the appropriate controls established over the federal program compliance requirements are being followed. Corrective Action Plan (CAP) 1. Explanation of Disagreement with Audit Finding There is no disagreement ...
Auditor Recommendation Recommendation: We recommend that the Organization ensure that the appropriate controls established over the federal program compliance requirements are being followed. Corrective Action Plan (CAP) 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Action Planned in Response to Finding Sara Wohlers, management agent, will establish a review process to ensure that all established controls over the federal program compliance requirements are being followed and all reserve deposits are being met. 3. Official Responsible for Ensuring CAP Sara Wohlers, management agent, is the official responsible for ensuring corrective action of the deficiency. 4. Planned Completion Date for CAP This plan will be implemented for the September 30, 2024 audit. 5. Plan to Monitor Completion of CAP Nick Kandoll, board chair, and Sara Wohlers, management agent, will be monitoring this plan.
Auditor Recommendation Recommendation: We recommend that the Organization verifies all necessary adjustments are made to the financial statements prior to the audit process. Corrective Action Plan (CAP) 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit fi...
Auditor Recommendation Recommendation: We recommend that the Organization verifies all necessary adjustments are made to the financial statements prior to the audit process. Corrective Action Plan (CAP) 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Action Planned in Response to Finding Sara Wohlers, or Josh Warner, (management agent) will establish a review process to ensure that all necessary adjustments are made to the financial statements prior to the audit process. 3. Official Responsible for Ensuring CAP Sara Wohlers is the official responsible for ensuring corrective action of the deficiency. 4. Planned Completion Date for CAP This plan will be implemented for the September 30, 2024 audit. 5. Plan to Monitor Completion of CAP Nick Kandoll (board chair) and Sara Wohlers will be monitoring this plan.
Finding 2023-005 Department of Health and Human Services Federal Financial Assistance Listing #93.697 COVID-19 Testing and Mitigation for Rural Health Clinics Procurement, Suspension, and Debarment Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: The ...
Finding 2023-005 Department of Health and Human Services Federal Financial Assistance Listing #93.697 COVID-19 Testing and Mitigation for Rural Health Clinics Procurement, Suspension, and Debarment Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: The Health System did not obtain quotes from multiple vendors as it relates to the procurement and purchasing of flooring which was over the micro-purchase threshold. In addition, the Health System did not have a written procurement policy or written standards of conduct policy related to procurement. Responsible Individuals: Diana Swindler, CFO Corrective Action Plan: Tri Valley Health System will implement a procurement policy and standards of conduct policy related to procurement, implement internal control processes to ensure compliance with their procurement policy, and retain documentation to support procurement, suspension and debarment procedures performed. Anticipated Completion Date: 01/31/2024
Department of Health and Human Services Federal Financial Assistance Listing #93.697 COVID-19 Testing and Mitigation for Rural Health Clinics Activities Allowed or Unallowed and Allowable Costs/Cost Principles Material Weakness in Internal Control over Compliance Period of Performance Material Wea...
Department of Health and Human Services Federal Financial Assistance Listing #93.697 COVID-19 Testing and Mitigation for Rural Health Clinics Activities Allowed or Unallowed and Allowable Costs/Cost Principles Material Weakness in Internal Control over Compliance Period of Performance Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: The Health System’s expense tracking spreadsheet, which identified the expenses claimed under the federal program as allowable costs included three expenses which were subsequent to December 31, 2022, and therefore, outside the period of performance. Although invoices were approved for payment, only one invoice included documentation relating to specific approval as allowable costs related to the grant. Likewise, the Health System’s expense tracking spreadsheet did not include a documented secondary review and approval by someone other than the preparer. Responsible Individuals: Diana Swindler, CFO Corrective Action Plan: Tri Valley Health System will implement a control process which includes an independent review and approval of the expense tracking spreadsheet which identifies the expenses claimed under the federal program as allowable costs and retain documentation of the review process. The expenses referenced as being outside of the period of performance were costs to a vendor whom was contracted/engaged prior to the period of performance. Due to supply chain/vendor demand issues, the work was completed subsequent to the period of performance. It was our understanding that these are eligible expenses under the program, as the work and payment was delayed due to supply chain/vendor demand issues. However, if necessary, we have identified other qualifying expenditures incurred within the period of performance we can submit which will satisfy allowable costs claimed for the period of performance. Anticipated Completion Date: 01/31/2024
View Audit 10349 Questioned Costs: $1
2023-003 Material Weakness over Subrecipient Monitoring; Emergency Rental Assistance Program (ERAP), Assistance Listing Number 21.023, U.S. Department of Treasury Recommendation: We recommend that the County create a subrecipient monitoring policy to monitor federal awards in accordance with th...
2023-003 Material Weakness over Subrecipient Monitoring; Emergency Rental Assistance Program (ERAP), Assistance Listing Number 21.023, U.S. Department of Treasury Recommendation: We recommend that the County create a subrecipient monitoring policy to monitor federal awards in accordance with the contract and Uniform grant guidance. The subrecipient monitoring policy should include performing a risk assessment to determine the level of subrecipient monitoring required. Additionally, we recommend the County conduct site visits and/or perform a random sampling of charges based on the results of the risk assessment. Corrective Action: An organization-wide documented policy is being developed by the newly established Grants Management program officers. The new policy will meet current Federal guidance on subrecipient monitoring and will include resources and recommendations for County Departments to perform a risk assessment, internal control assessment, onsite visits, and desk reviews as applicable. Proposed Completion Date: Upon completion and approval of the new subrecipient monitoring policy the County will implement the procedures within 180 days. Name of Contact Person: Patrick Flanary, Chief Financial Officer
Finding 2023-002 Significant Deficiency over Eligibility, repeat finding; Medicaid Cluster (Medicaid), Assistance Listing Number 93.778, U.S. Department of Health and Human Services, passed through the N.C Department of Health and Human Services (NCDHHS), Division of Medical Assistance. Recommendat...
Finding 2023-002 Significant Deficiency over Eligibility, repeat finding; Medicaid Cluster (Medicaid), Assistance Listing Number 93.778, U.S. Department of Health and Human Services, passed through the N.C Department of Health and Human Services (NCDHHS), Division of Medical Assistance. Recommendation: We recommend that the County train and monitor employees on the eligibility determination process. We also recommend the County review and amend current policies and procedures in place to ensure that all eligibility determination documentation is completed and retained by the County. Corrective Action Plan: The county will complete a quarterly review of errors in income, resources, and social security number and citizenship verification. For those staff identified by the targeted review with errors in these areas, supervisors will provide refresher training on Medicaid policy requirements. Additional targeted reviews will be completed monthly until the deficiencies are corrected. Proposed Completion Date: 1/31/2023 for initial quarterly review 2/28/2023 for refresher training for identified staff 7/31/2023 for additional reviews as needed for identified staff Contact Person: Yolanda McInnis, Economic Services Division Director
Condition: Data submitted on the LEA Data Collection Form showed some key line-item expenditures categorized differently from previously filed expenditure reports. Plan: Management will implement procedures including reconciling amounts between underlying data, quarterly expenditure reports, and ann...
Condition: Data submitted on the LEA Data Collection Form showed some key line-item expenditures categorized differently from previously filed expenditure reports. Plan: Management will implement procedures including reconciling amounts between underlying data, quarterly expenditure reports, and annual data collection reports. Additionally, reports and supporting documentation will be reviewed by a second person. Anticipated Date of Completion: 6/30/24 Name of Contact Person: Robert Gold
College Response: In November 2023, in conjunction with the College’s annual external audit, errors were identified in Cuyahoga Community College’s timely Return to Title IV funds. After careful internal review of the student records, all applicable corrections to student records were made to ensure...
College Response: In November 2023, in conjunction with the College’s annual external audit, errors were identified in Cuyahoga Community College’s timely Return to Title IV funds. After careful internal review of the student records, all applicable corrections to student records were made to ensure compliance with federal regulations. All financial aid funds related to Return of Title IV funds had been returned to the U.S. Department of Education. In December 2023, the college completed a review of internal procedures and processes to mitigate untimely Return of Title IV funds in the future. Mitigation Strategy: The following process and procedural changes for the review of the Return of Title IV funds have been put in place to resolve the issue of late returns of funds as identified in the 2022-2023 external audit: 1. Retrained staff responsible for the Return of Title IV processing, including updates and revisions to the policies and procedure manual for this financial aid function to strengthen the internal quality check for manual review of the accuracy of returns 2. Identified and cross-train additional financial aid employees to support the high-volume financial aid process, including two team members to check and validate the timely processing and accuracy of the return of funds 3. Developed an enhanced report to compare completed calculations of the return of funds in Banner to the processed with the COD-generated report to verify the timely return of funds 4. Automated reports for Return of Title IV report to be delivered bi-weekly to the central mailbox, which will enable multiple employees to have access to the Return of Title IV reports and ensure more than one trained team member to timely process the return of funds to meet the 45-day federal requirement 5. Conduct a quality check of the Return of Title IV funds to assess the accuracy of the calculation and timely return of funds by conducting an internal Financial Aid Team review of 5-10% of the return of funds assessment every 60 days Anticipated Completion Date: 12/19/2023 Responsible Contact Person: Angela Johnson –VP of Enrollment Management
Finding 2023-005 Name of Responsible Individual: Tonya Kilpatrick, AVP Finance and Compliance Corrective Action: We experienced a system glitch resulting in records that remained in validation tables and did not move to the process reporting tables which prevented proper reporting of work hours pe...
Finding 2023-005 Name of Responsible Individual: Tonya Kilpatrick, AVP Finance and Compliance Corrective Action: We experienced a system glitch resulting in records that remained in validation tables and did not move to the process reporting tables which prevented proper reporting of work hours performed. The system did not generate the required certification reports to allow the selected employee to certify their effort. We are reviewing our processes to implement an automated comparison reports of individual employees paid from federal grants and the system generated effort certification report to ensure that the system generates the required effort report to allow the employee to properly certify their effort. We will also ensure that all employees approve/certify actual time worked allotted to federal funds within our time and attendance system to provide another level of certification. This report will be produced quarterly to ensure that system errors are corrected before the required semiannual effort reporting requirement. Anticipated Completion Date: March 1, 2024
View Audit 10337 Questioned Costs: $1
Finding 2023-004 Name of Responsible Individual: Demetrius Carmichael, AVP Finance and Controller Corrective Action: We understand the requirement of disbursing Title IV funding to eligible students and parents and the requirement to make disbursements as soon as administratively feasible, but no ...
Finding 2023-004 Name of Responsible Individual: Demetrius Carmichael, AVP Finance and Controller Corrective Action: We understand the requirement of disbursing Title IV funding to eligible students and parents and the requirement to make disbursements as soon as administratively feasible, but no later than 3 business days following the receipt of funds and eliminating excess cash balance within the next 7 calendar days. In this case, the School received funds from the student from unknown sources, and the School submitted the funds to the ED on behalf of the student at the student’s request to lower outstanding educational debt. We discuss the importance of lowering education debt during our debt counseling sessions and encourage students to return funds not needed due to subsequent scholarships or family support. We have not found guidance that will support the requirement to submit funds to the ED within the 3 business days plus 7 calendar days that are earned and provided by the student to submit to the ED under the cash management ruling. Anticipated Completion Date: March 1, 2024
Finding 2023-003 Name of Responsible Individual: Tonya Kilpatrick, AVP Finance and Compliance Corrective Action: We agree. We understand that annual reports must be submitted to the agency and quarterly reports uploaded on our website accurately and in a timely manner. We will review our procedur...
Finding 2023-003 Name of Responsible Individual: Tonya Kilpatrick, AVP Finance and Compliance Corrective Action: We agree. We understand that annual reports must be submitted to the agency and quarterly reports uploaded on our website accurately and in a timely manner. We will review our procedures to ensure proper monitoring to ensure report submissions are complete, accurate, and prepared in accordance with the established requirements. We are moving forward to separate grants and contract post-awards from Finance to the newly established Research Administration area. With this restructuring of the department and staffing, we are also establishing a compliance area that will be charged with ensuring reporting requirements are completed based on the required agency guidelines. This new structure will strengthen our review and monitoring of grant compliance. Additionally, review and monitoring of reports will take place to ensure timely and accurate submission for the entire grants and contract portfolio. Anticipated Completion Date: March 1, 2024
Finding 2023-002 Name of Responsible Individual: Cinnamon Bradley, Associate Dean of Student Affairs Corrective Action: We agree. We understand that status changes must be submitted, and errors must be corrected in the National Student Clearinghouse and NSLDS in a timely manner. We will review ...
Finding 2023-002 Name of Responsible Individual: Cinnamon Bradley, Associate Dean of Student Affairs Corrective Action: We agree. We understand that status changes must be submitted, and errors must be corrected in the National Student Clearinghouse and NSLDS in a timely manner. We will review our procedures to ensure proper recording of these changes by NSLDS based on our submission to the National Student Clearinghouse. Additionally, we will implement the following processes: • An automated monitoring notification system that will alert us within the established timeframe of status changes to ensure accuracy in both third-party systems. • Change in our submission process to the National Student Clearinghouse from 30 days to occur weekly to ensure timely reporting to NSLDS. Additionally, all student records contained in the NSLDS for the Academic Term will be reviewed every month and the student roster will be reviewed weekly for accuracy in both third-party systems. Anticipated Completion Date: March 1, 2024
Finding 2023-001 Name of Responsible Individual: Tonya Kilpatrick, AVP Finance and Compliance Corrective Action: We agree. The expenditures were reported on the schedule of expenditures for federal awards subsequent to the period of performance end date. These funds were not charged to the age...
Finding 2023-001 Name of Responsible Individual: Tonya Kilpatrick, AVP Finance and Compliance Corrective Action: We agree. The expenditures were reported on the schedule of expenditures for federal awards subsequent to the period of performance end date. These funds were not charged to the agency and are considered cost share for the grant as the work on the grant continued past the grant end date. We will review our grant close-out procedures to ensure that grants are closed out in a timely manner based on the grant end date preventing subsequent charges to the grant award. Anticipated Completion Date: March 1, 2024
View Audit 10337 Questioned Costs: $1
Views of Responsible Officials: New program staff was hired to provide added capacity and trained on the invoicing process and the bill.com system. Furthermore, the Program Director is developing and implementing a clear, written procedural protocol that will eliminate this issue in the future.
Views of Responsible Officials: New program staff was hired to provide added capacity and trained on the invoicing process and the bill.com system. Furthermore, the Program Director is developing and implementing a clear, written procedural protocol that will eliminate this issue in the future.
3. Finding 2023-003 e. Comments on the Finding and Each Recommendation Management agrees with the finding and the recommendations as stated. f. Action(s) Taken or Planned on the Finding Management will review tenant files at the time a tenant moves out to ensure proper documentation is retained ...
3. Finding 2023-003 e. Comments on the Finding and Each Recommendation Management agrees with the finding and the recommendations as stated. f. Action(s) Taken or Planned on the Finding Management will review tenant files at the time a tenant moves out to ensure proper documentation is retained in the tenant file.
2. Finding 2023-002 c. Comments on the Finding and Each Recommendation Management agrees with the finding and the recommendations as stated. d. Action(s) Taken or Planned on the Finding Management will review all tenant files before lease signing and after annual recertifications to ensure prope...
2. Finding 2023-002 c. Comments on the Finding and Each Recommendation Management agrees with the finding and the recommendations as stated. d. Action(s) Taken or Planned on the Finding Management will review all tenant files before lease signing and after annual recertifications to ensure proper procedures were completed and documented in each tenant file.
1. Finding 2023-001 a. Comments on the Finding and Each Recommendation Management agrees with the finding and the recommendations as stated. b. Action(s) Taken or Planned on the Finding All findings in the REAC Physical Inspection Report were corrected and evidence submitted to HUD for its revie...
1. Finding 2023-001 a. Comments on the Finding and Each Recommendation Management agrees with the finding and the recommendations as stated. b. Action(s) Taken or Planned on the Finding All findings in the REAC Physical Inspection Report were corrected and evidence submitted to HUD for its review. Additional property inspections by on-site employees and management will be completed throughout the year to ensure compliance.
Condition: Data submitted on the LEA Data Collection Form showed some key line-item expenditures categorized differently from previously filed expenditure reports. Plan: Management will implement procedures including reconciling amounts between underlying data, quarterly expenditure reports, and ann...
Condition: Data submitted on the LEA Data Collection Form showed some key line-item expenditures categorized differently from previously filed expenditure reports. Plan: Management will implement procedures including reconciling amounts between underlying data, quarterly expenditure reports, and annual data collection reports. Additionally, reports and supporting documentation will be reviewed by a second person. Anticipated Date of Completion: 6/30/24 Name of Contact Person: Brian Stachacz
Rainier School District #13 respectfully submits the following corrective action plan in response to deficiencies reported in our audit of fiscal year ended June 30, 2023 the audit was completed by the independent auditing firm Pauley Rogers and reported the deficiencies listed below. The deficien...
Rainier School District #13 respectfully submits the following corrective action plan in response to deficiencies reported in our audit of fiscal year ended June 30, 2023 the audit was completed by the independent auditing firm Pauley Rogers and reported the deficiencies listed below. The deficiencies are listed below, including the adopted plan of action and timeframe for each.1. Single Audit Finding a. Type of deficiency (Single Audit Finding) – During our testing of ESSER for the Single audit, we noted certified payroll reports were not obtained for construction projects before the expense was paid. b. All projects will be reviewed and discussed with contractors to assure proper reporting is done. c. Timeframe Implementation: January 1, 2024
Management will meet with the grant Program Manager(s) to review and ensure all of the City’s Federal Grants Management Policies are being adhered to.
Management will meet with the grant Program Manager(s) to review and ensure all of the City’s Federal Grants Management Policies are being adhered to.
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