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Corrective Action Plans

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Finding 2024 (2023-003)
Significant Deficiency 2023
South Heartland District Health Department
NE
Procurement, Suspension & Debarment Subrecipient Monitoring
Program: AL 21.027 – COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension & Debarment Corrective Action Planned: SHDHD will add a clause to each Agreement covered by Federal funds, certifying that the recipient of the funds is eligible to receive such funds. SHDHD will also clar...
Program: AL 21.027 – COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension & Debarment Corrective Action Planned: SHDHD will add a clause to each Agreement covered by Federal funds, certifying that the recipient of the funds is eligible to receive such funds. SHDHD will also clarify the certification process in our Procurement Policy. Anticipated Completion Date: Ongoing, re Agreements. January 31, 2024, re policy change. Responsible Party: Michele Bever, Kelly Derby, Brooke Wolfe
View Audit 3537
Finding 2019 (2023-001)
Significant Deficiency 2023
University of San Diego
CA
Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking
October 24, 2023 Corrective Action Plan for University of San Diego Audit finding 2023-001 FINDING 2023-001 – Special Tests and Provisions – Borrower Data Transmission and Reconciliation: Significant Deficiency in Internal Control Over Compliance Criteria –34 CFR section 685.300(b)(5): On a monthly ...
October 24, 2023 Corrective Action Plan for University of San Diego Audit finding 2023-001 FINDING 2023-001 – Special Tests and Provisions – Borrower Data Transmission and Reconciliation: Significant Deficiency in Internal Control Over Compliance Criteria –34 CFR section 685.300(b)(5): On a monthly basis, the University of San Diego must reconcile institutional records with Direct Loan funds received from the Secretary and Direct Loan disbursement records submitted to and accepted by the Secretary. Condition/Context – The University of San Diego operates a law school and an undergraduate and graduate school. A sample of 6 direct loan reconciliations were selected from the population of all reconciliations performed by the University, under both schools during the year ended June 30, 2023. We obtained the supporting schedules used to reconcile the disbursed direct loan funds to the federal government’s records. The University did not complete reconciliations of its direct loan program disbursements for the law school between December 2022 and June 2023. Cause – There was turnover in the position responsible for reconciling this data, and the responsibility did not transfer to another individual, and as a result, the reconciliations were not completed. Effect – There is a chance that the University of San Diego’s records may not match the federal government’s records of direct loan disbursement. Recommendation – The auditors recommend the University of San Diego revise the existing policies and procedures to ensure when a change in personnel occurs, responsibilities appropriately transfer to a new individual. Corrective action plan – Management concurs with this finding. This exception was due to the monthly reconciliation not being part of the established policies and procedures for the Law School Financial Aid Office. As a result, during staff turnover the interim staff were unaware of the responsibilities and requirements for the monthly reconciliation. Management updated the direct lending servicing system reconciliation procedures for the Law School to clearly delineate the responsible parties. Management believes these enhancements will be sufficient to prevent future errors. Anticipated completion date: October 2023 Persons responsible: Mike Chavez, Director of JD Admissions, Financial Aid & Diversity Initiatives
View Audit 3531
Finding 2006 (2023-001)
Significant Deficiency 2023
Casa Otonal Housing Corporation
CT
HUD Housing Programs Eligibility
The following is a recommended format to be followed by the auditee for preparing a corrective action plan: A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2023-001 a. Comments on the Finding and Each Recommendation Management has reviewed finding 202...
The following is a recommended format to be followed by the auditee for preparing a corrective action plan: A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2023-001 a. Comments on the Finding and Each Recommendation Management has reviewed finding 2023-001 and is in agreement that one instance where management failed to have an accurate HUD form 50059 in their lease file. b. Action(s) Taken or Planned on the Finding Documentation was submitted showing that the 50059 was corrected to include accurate information. Management will monitor compliance with its established procedures to ensure tenant eligibility is correctly determined and that the tenant lease files are properly maintained in accordance with the requirements of HUD Handbook 4350.3, Occupancy Requirements of Subsidized Multifamily Housing Programs. Sincerely yours, Elmer Rivera Bello, Board President
View Audit 3459
Finding 2005 (2023-001)
Significant Deficiency 2023
Bellefaire Jewish Children's Bureau
OH
Cash Management Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.305
The Agency is updating its process to calculate the indirect costs in accordance with the revised notice of award (NOA) dated March 10, 2023. Additionally, the Agency will provide further training to all individuals involved in the financial management of federal awards. On a monthly basis, the ca...
The Agency is updating its process to calculate the indirect costs in accordance with the revised notice of award (NOA) dated March 10, 2023. Additionally, the Agency will provide further training to all individuals involved in the financial management of federal awards. On a monthly basis, the calculation of indirect costs eligible for reimbursement under this award will be compared to the indirect costs allowed for in the NOA. This calculation will be secondarily reviewed by an individual having financial oversight on federal awards to ensure that any reimbursement request is computed in accordance with the NOA. The reimbursement request will then be submitted only after this verification has been completed. Contact person responsible for corrective action: Scott Moore, Chief Financial Officer Anticipated completion date: December 31, 2023
View Audit 3451
Finding 2001 (2023-001)
Material Weakness 2023
Robertson Hill Apartments, Inc.
NC
Recommendation: CASA should take all possible steps to ensure its leasing department is adequately staffed. Additionally, CASA should ensure new staff are being properly trained on the requirements of this program. Views of Responsible Officials and Planned Corrective Actions: CASA has hired additio...
Recommendation: CASA should take all possible steps to ensure its leasing department is adequately staffed. Additionally, CASA should ensure new staff are being properly trained on the requirements of this program. Views of Responsible Officials and Planned Corrective Actions: CASA has hired additional employees and the leasing department is now fully staffed. In addition, one employee is devoted to this program and is currently in the process of conducting all of the required tenant recertifications. This is expected to be completed by November 2023. Lastly, all new leasing employees have gone through the required training.
View Audit 3444
Finding 2000 (2023-001)
Material Weakness 2023
Oak Hill Apartments, Inc.
NC
Recommendation: CASA should take all possible steps to ensure its leasing department is adequately staffed. Additionally, CASA should ensure new staff are being properly trained on the requirements of this program. Views of Responsible Officials and Planned Corrective Actions: CASA has hired additio...
Recommendation: CASA should take all possible steps to ensure its leasing department is adequately staffed. Additionally, CASA should ensure new staff are being properly trained on the requirements of this program. Views of Responsible Officials and Planned Corrective Actions: CASA has hired additional employees and the leasing department is now fully staffed. In addition, one employee is devoted to this program and is currently in the process of conducting all of the required tenant recertifications. This is expected to be completed by November 2023. Lastly, all new leasing employees have gone through the required training.
View Audit 3443
Finding 1989 (2023-001)
Material Weakness 2023
St. Croix Regional Family Health Center
ME
Reporting
Finding Number: 2023-001 Condition Found: In a nonstatistical sample, one annual Federal Financial Report (FFR) tested included certain amounts which were not supported by underlying accounting records. The report was to be completed on the accrual basis of accounting; however, based on our procedur...
Finding Number: 2023-001 Condition Found: In a nonstatistical sample, one annual Federal Financial Report (FFR) tested included certain amounts which were not supported by underlying accounting records. The report was to be completed on the accrual basis of accounting; however, based on our procedures, we determined the report was completed on the cash basis of accounting. The "Federal share of expenditures" reported on line 10.e. represented cumulative cash draws in the amount of $2,794,799. Upon review of the underlying accounting records, the Organization had cumulative federal grant expenditures for the period of $2,932,394. As a result, the Organization underreported the "Federal share of expenditures" on line 10.e. and overstated the "Unobligated balance of Federal Funds" on line 10.h. by $137,595. lndividual(s) Responsible for Corrective Action: Corinne LaPlant, Executive Director Corrective Action Planned: Management has ensured that staff have received clarity as to the filing issues and education as to how to complete the federal expenditure reports. Policies & procedures will be updated accordingly. Anticipated Completion Date: Completed, 7/28/2023.
View Audit 3424
Finding 1987 (2023-004)
Significant Deficiency 2023
Person County
NC
Eligibility
Finding: 2023-004 Name of contact person: "Brittany Majors (Program Manager), Meredith Farmer (Leadworker)" Corrective Action: "This informaiton was housed in the County's former document management system, Compass. This verification was lost and was unable to be recove...
Finding: 2023-004 Name of contact person: "Brittany Majors (Program Manager), Meredith Farmer (Leadworker)" Corrective Action: "This informaiton was housed in the County's former document management system, Compass. This verification was lost and was unable to be recovered from the Cyber Incident in 2020. As an agency and per State requirment all documents are now being uploaded into NCFAST. The State has since updated NCFAST functionality to include the running of work number through the NCFAST website however, once the functionality was implented the State guidance was that we no longer run TWN outside of NCFAST until May 30, 2023. Due to an NCFAST functionality error with TWN the State gave permission to go back and run them manually. Adult Medicaid has since had a unit meeting and revise the checklist that staff use to provide dates that it is sent and due back on the 5097. " Proposed Completion Date: 6/1/2020; 5/30/2023
View Audit 3410
Finding 1986 (2023-003)
Significant Deficiency 2023
Person County
NC
Eligibility Reporting
Finding: 2023-003 Name of contact person: "Brittany Majors (Program Manager), Donna Rimmer (AM Supervisor), Joanna Thompson (Leadworker)" Corrective Action: "Due to a higher volume of vacancies and new hires with no previous Income Maintenance experience it has taken th...
Finding: 2023-003 Name of contact person: "Brittany Majors (Program Manager), Donna Rimmer (AM Supervisor), Joanna Thompson (Leadworker)" Corrective Action: "Due to a higher volume of vacancies and new hires with no previous Income Maintenance experience it has taken the Adult Medicaid unit some time to get all positions filled and staff trained adequately enough to assist with the processing of cases. During the time of extreme turnover the case workers in place prioritized cases which resulted in the client receiving a greater benefit as advised by the administrative letters issued by DHB given due to the PHE continuity of beneifts was in place. During this time frame the State only allowed specific reduction of benefits/terminiations. Therefore, these individuals would have continued to recieve the same benefit regardless of the SSI review being completed or not. The County has since appointed an individual to assist'/complete those SDX cases in order to maintain timiliness. " Proposed Completion Date: 11/23/2022; 3/16/2023; 6/15/2023; 8/7/2023
View Audit 3410
Finding 1985 (2023-002)
Significant Deficiency 2023
Person County
NC
Eligibility
Finding: 2023-002 Name of contact person: "Brittany Majors (Program Manager), Donna Rimmer (AM Supervisor), Joanna Thompson and Meredith Farmer (Leadworkers)" Corrective Action: "Family and Children's conducted an MAF/M Deductible Training and resources were discussed. ...
Finding: 2023-002 Name of contact person: "Brittany Majors (Program Manager), Donna Rimmer (AM Supervisor), Joanna Thompson and Meredith Farmer (Leadworkers)" Corrective Action: "Family and Children's conducted an MAF/M Deductible Training and resources were discussed. Adult Medicaid Supervisor updated the cover sheet/ checklist and documentation outline utilized by all caseworkers when making their determination of eligibility in hopes of reducing/eliminating any oversight which occurred during the past evaluations. Supervisor had staff to go back and complete ABD Financial Resources in Learning Gateway, both units continue to conduct unit meeetings monthly. " Proposed Completion Date: 2/28/2023; 7/10/2023; 7/25/2023; 8/17/2023
View Audit 3410
Finding 1984 (2023-001)
Significant Deficiency 2023
Person County
NC
Eligibility Internal Control / Segregation of Duties
Finding: 2023-001 Name of contact person: "Brittany Majors (Program Manager), Donna Rimmer (AM Supervisor), Joanna Thompson and Meredith Farmer (Leadworkers)" Corrective Action: The County continues to revise the procedural requriement regarding document management and ...
Finding: 2023-001 Name of contact person: "Brittany Majors (Program Manager), Donna Rimmer (AM Supervisor), Joanna Thompson and Meredith Farmer (Leadworkers)" Corrective Action: The County continues to revise the procedural requriement regarding document management and retention of verification used to determine eligibility. Each supervisor continues to conduct individual and unit meeting/trainings to inform parties of the errors discovered and how to reduce/eliminate in future processing. The County would like to notate that these errors discovered was during COVID where individuals could not be reduced/terninated. Staff has also completed the State Mastering Medicaid Policy Training that is provided monthly. The supervisor has also conducted an Income and Deductible training. Proposed Completion Date: 10/20/2023
View Audit 3410
MacOmb Community Unit School District #185
IL
School Nutrition Programs Eligibility
The District will implement an internal procedure to ensure that the eligibility verification is completed prior to the November 15th due date.
The District will implement an internal procedure to ensure that the eligibility verification is completed prior to the November 15th due date.
View Audit 3407
Finding 1982 (2023-001)
Significant Deficiency 2023
Kankakee County Housing Authority
IL
HUD Housing Programs
The Executive Director will start the budget process timely and present to the Board at the May meeting each year.
The Executive Director will start the budget process timely and present to the Board at the May meeting each year.
View Audit 3406
West House Corporation
RI
HUD Housing Programs Internal Control / Segregation of Duties
Management has reviewed all files, obtained the required information, and corrected calculations. Site staff will be trained in correct procedures.
Management has reviewed all files, obtained the required information, and corrected calculations. Site staff will be trained in correct procedures.
View Audit 3402
V. N. Housing Corporation
RI
HUD Housing Programs Internal Control / Segregation of Duties
Management has reviewed all files, obtained the required information, and corrected calculations. Site staff will be trained in correct procedures.
Management has reviewed all files, obtained the required information, and corrected calculations. Site staff will be trained in correct procedures.
View Audit 3401
Finding 1979 (2023-002)
Material Weakness 2023
Southeast Behavioral Health Group
CO
Planned Corrective Action: All staff is now reporting payroll through Paycom, which has a robust time and effort tracking tool where time and effort is tracked extensively in the time card. Staff time cards, both for salary and hourly, are reviewed and approved by their supervisor.
Planned Corrective Action: All staff is now reporting payroll through Paycom, which has a robust time and effort tracking tool where time and effort is tracked extensively in the time card. Staff time cards, both for salary and hourly, are reviewed and approved by their supervisor.
View Audit 3396
Finding 1979 (2023-002)
Material Weakness 2023
Southeast Behavioral Health Group
CO
Person Responsible for Corrective Action Plan: Javier Martinez, Chief Financial Officer
Person Responsible for Corrective Action Plan: Javier Martinez, Chief Financial Officer
View Audit 3396
Finding 1979 (2023-002)
Material Weakness 2023
Southeast Behavioral Health Group
CO
Anticipated Date of Completion: With the merger of Southeast Health Group with Valley-Wide, Valley-Wide already has existing controls in place to ensure time and effort is accurately captured.
Anticipated Date of Completion: With the merger of Southeast Health Group with Valley-Wide, Valley-Wide already has existing controls in place to ensure time and effort is accurately captured.
View Audit 3396
Finding 1974 (2023-001)
Significant Deficiency 2023
The School District of Greenville County
SC
Cash Management School Nutrition Programs
CONTACT PERSON: Robin Stack, Chief Finance Officer, rstack@greenville.k12.sc.us CORRECTIVE ACTION: The School District will review the food service and accounting software programs and interface to determine why meals served data did not transfer properly for certain locations. In the meantime, the...
CONTACT PERSON: Robin Stack, Chief Finance Officer, rstack@greenville.k12.sc.us CORRECTIVE ACTION: The School District will review the food service and accounting software programs and interface to determine why meals served data did not transfer properly for certain locations. In the meantime, the School District will manually review the meal count transfer totals for propriety and will notate differences and adjust for any significant differences. PROPOSED COMPLETION DATE: December 31, 2023
View Audit 3385
Elder Care Two, Inc.
RI
HUD Housing Programs Internal Control / Segregation of Duties
Management has corrected the error.
Management has corrected the error.
View Audit 3384
Elder Care Two, Inc.
RI
Questioned Costs
Management will offset the unpaid balance by the overcharge.
Management will offset the unpaid balance by the overcharge.
View Audit 3384 Questioned Costs: $1
Elder Care One, Inc.
RI
HUD Housing Programs Internal Control / Segregation of Duties
Management has moved funds to provide for full insurance coverage.
Management has moved funds to provide for full insurance coverage.
View Audit 3383
Elder Care One, Inc.
RI
HUD Housing Programs Internal Control / Segregation of Duties
Management has corrected the error.
Management has corrected the error.
View Audit 3383
City of Ionia
MI
Procurement, Suspension & Debarment
The City of Ionia agrees with the finding identified and respectfully submits the following Corrective Action Plan for the year ending June 30, 2023. The City did not document the part of the policy that is needed to show that the vendor was not suspended or debarred from the Federal Government thr...
The City of Ionia agrees with the finding identified and respectfully submits the following Corrective Action Plan for the year ending June 30, 2023. The City did not document the part of the policy that is needed to show that the vendor was not suspended or debarred from the Federal Government through SAM.gov before the contract was entered into. The City has discussed the procedure of policy and has identified that the review and documentation on the selected vendor needs to happen prior to approval of the contract by City Council. It will be the responsibility of the finance director and the city manager to adhere to the policy to document the review of the vendor through SAM.gov. if anyone has questions about the plan, please contact the city finance director at dirfinance@ci.ionia.mi.us.
View Audit 3365
Finding 1939 (2023-001)
Significant Deficiency 2023
Point Loma Nazarene University and Subsidiary
CA
Internal Control / Segregation of Duties Student Financial Aid Reporting
Return of Title IV (R2T4) Errors Planned Corrective Action: Our process for identifying unofficial withdrawals begins with a report from our Workday software to identify students who had unearned credits in a semester at the conclusion of that semester, after the grade due date. We then reach out to...
Return of Title IV (R2T4) Errors Planned Corrective Action: Our process for identifying unofficial withdrawals begins with a report from our Workday software to identify students who had unearned credits in a semester at the conclusion of that semester, after the grade due date. We then reach out to the individual professors of the courses and/or the Instructional Design team to determine if each student completed the semester or if (s)he had unearned credits having ceased attending at some point during the semester. If the student ceased attending, we would determine if a Return of Title IV (R2T4) calculation was needed and would complete it if necessary. The report was corrected for AY 2022/2023 to include No Credit (NC), Incomplete (I) and Failed (F) grades to enable PLNU to identify all the students who need to be reviewed going forward. In addition, we have added to our process instructions to run this report after the grades for module 1 are due, and after the grades for module 2 are due, rather than at the end of each semester. This was intended to ensure the review of any unofficial withdrawals in a timelier manner, meeting the 45-day deadline for any possible returns that must be made. The modified report, however, produced a far greater number of students for review, which was too broad of a selection and was unmanageable. We are working to refine the reporting criteria further to accurately identify students who require review and we have assigned additional staff for the review process. Person Responsible for Corrective Action Plan: Daniel Reed, Director of Financial Aid; Joanna Castro, Associate Director of Financial Aid; Jamie Asche, Director of Student Financial Services Business Analysis and Compliance Anticipated Date of Completion: 1/1/2024
View Audit 3361
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