Corrective Action Plans

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Finding 2023-002, 2022-022 - Material Weakness in Internal Control over Financial Reporting and Material Noncompliance - Chart of Accounts Corrective Action Plan: The corrective action plan is to hire additional staff with expertise in the Uniform Budget and Accounting Act. All finance staff will b...
Finding 2023-002, 2022-022 - Material Weakness in Internal Control over Financial Reporting and Material Noncompliance - Chart of Accounts Corrective Action Plan: The corrective action plan is to hire additional staff with expertise in the Uniform Budget and Accounting Act. All finance staff will be required to take training in this area before December 31, 2023 and the CFO will initiate this action.
Finding 1118 (2023-001)
Significant Deficiency 2023
Drake University respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 to June 30, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assign...
Drake University respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 to June 30, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FINANCIAL STATEMENT AUDIT No findings to report. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS Department of Education 2023-001 Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the University reevaluate its procedures and review policies surrounding reporting status changes to NSLDS to put a process in place to ensure the student status changes are being reported timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Subsequent to the final submission of the enrollment file to the NSC, the Registrar’s Office will manually update the enrollment status in the NSC for any student whose enrollment status was determined to have changed immediately upon the discovery of that change. This ensures that the enrollment status is updated for “unofficial withdrawals”, since the University’s date of determination that the student withdrew occurs after the end of the spring semester and often after the submission of the first enrollment file for the next semester. Prior to the 60-day reporting deadline (starting at the school’s date of determination that the student’s status changed) the Assistant Director for New Student Programs will verify that the enrollment status change is correctly reflected in NSLDS. In addition, the Financial Aid and Registrar’s Offices are exploring reports that are available from NSLDS to assist in identifying any discrepancies between University and NSLDS records. Name(s) of the contact person(s) responsible for corrective action: Kevin Moenkhaus, Associate Registrar Planned completion date for corrective action plan: September 30, 2023. If the Department of Education has questions regarding this plan, please call Ryan Zantingh at 515-271-3048.
Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: Management has policies and plans in place that are being updated to meet the specific requirements of the GLBA no later than December 31, 2023. The internal policies were updated to perform risk assessment and documentation immedi...
Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: Management has policies and plans in place that are being updated to meet the specific requirements of the GLBA no later than December 31, 2023. The internal policies were updated to perform risk assessment and documentation immediately upon completion of any new system or program implementation. The Seminary has implemented multi-factor authentication (MFA) across 95% of all applications and systems and the remaining 5% have other safeguards in place, therefore management believes we meet this specific requirement. To ensure the formal employee training program is fully implemented the IT policy will be modified to reflect that all new employees be trained individually by IT Helpdesk employees. The Seminary's continuous monitoring process or establishment of periodic vulnerability assessments and penetration testing will be completed no later than December 31, 2023. The Seminary will present to the board of trustees at its March 2024 meeting the Annual Report on Information Security Programs to include all the required details. Person Responsible for Corrective Action Plan: Robert Riggs, Senior Vice President for Operations and Institutional Efficiency/COO Anticipated Date of Completion: December 31, 2023
Contact Name: Judy Southall, CFO Contact Phone Number: 870-798-4064 Audit Period Ending: March 31, 2023 Audit Firm: FORVIS, LLP Federal Program: Health Center Program, Assistance Listing Number: 93.224, 93.527 Federal Agency: U.S. Department of Health and Human Services Plan of action to correct fur...
Contact Name: Judy Southall, CFO Contact Phone Number: 870-798-4064 Audit Period Ending: March 31, 2023 Audit Firm: FORVIS, LLP Federal Program: Health Center Program, Assistance Listing Number: 93.224, 93.527 Federal Agency: U.S. Department of Health and Human Services Plan of action to correct further UDS issues. 1. Table 5, Line 8, Column b2 - Total number of Physician virtual visits were reported as 140. The support provided indicated a total of 141. a. Additional reports will be run to verify the number produced by the system on for virtual visits by providers. b. Totals will be verified against the canned report, additional reports, and what is entered into the HRSA handbook. 2. Table 5, Line 10a, Column b - Total number of NPs, PAs, and CNMs virtual visits were reported as 0, while the support provided indicated a total of 26. a. The report produced shows virtual encounters of 26 which could have been included under the billing provider (MD/DO) instead of performing provider (NP/PA) since the total visits were only 1 short. b. Additional reports will be run to verify the canned report produced by the PMS c. Totals of the canned reports, additional reports, and the HRSA entry will be verified for accuracy. 3. Table 5, Line 10a, Column b - Total clinic visits were reported as 21,494 rather than 21,495 based on the support. a. Additional reports will be run to verify the number produced by the system on the total clinic visits. b. Totals will be verified against the canned reports, additional reports and what is entered into the HRSA handbook.
Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: 16 CFR 314.4(c)(1-8) – The university currently secures a large majority of its systems and data following best practice guidelines including Single Sign On (SSO), Multifactor Authentication (MFA), and Passwordless Authentication. H...
Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: 16 CFR 314.4(c)(1-8) – The university currently secures a large majority of its systems and data following best practice guidelines including Single Sign On (SSO), Multifactor Authentication (MFA), and Passwordless Authentication. However, there are a few systems remaining that have not yet been fully protected by these systems. The University will work to identify and migrate all systems containing PII to its authentication security systems. 16 CFR 314.(e) – The university currently provides security training through several avenues throughout the year. However, there is not currently a formal training plan. The university will create a formal training plan to include in-person and online annual training as well as smaller and more frequent refresher training throughout the year. 16 CFR 314.4(i) – The university currently advises the Cabinet on all matters concerning security effectiveness, however, no formal presentation has been given to the Board of Trustees. The university will create a formal report to present to the Board of Trustees beginning with their Fall 2023 meeting. Other finding: Moving forward, the university will enforce its data retention policies and dispose of all PII once the retention date has been reached. Person Responsible for Corrective Action Plan: (Dr. John Eberle, Chief Information Officer) Anticipated Date of Completion: May 2024
View of Responsible Officials and Corrective Action Plan – Upon receiving notification from the management company that the accounting department had inadvertently invoiced the academy for a duplicate amount dissimilar to an invoice provided in a previous month, the academy conducted a detailed revi...
View of Responsible Officials and Corrective Action Plan – Upon receiving notification from the management company that the accounting department had inadvertently invoiced the academy for a duplicate amount dissimilar to an invoice provided in a previous month, the academy conducted a detailed review in collaboration with the finance team. 1. Root Cause Analysis: The academy conducted a root cause analysis to identify the underlying factors contributing to the finding. This analysis helped pinpoint that the management company was experiencing unexpected internal staffing issues throughout the conclusion of the fiscal year within their accounting department. 2 Action Plan: The issue has been reconciled as of August 30, 2023. The academy, in collaboration with the management company, has developed a comprehensive action plan outlining the specific steps that will be taken to prevent this issue from happening again. 3 Implementation: The management company has notified the academy that it has begun the implementation of the action plan, including process improvements and staff reconfigurations. 4. Monitoring and Oversight: The academy, along with the management company, has established an improved monitoring and oversight method to ensure internal audits and management reviews will be conducted periodically to ensure sustained compliance and effectiveness. 5. Preventive Measures: To prevent similar issues from arising in the future, additionally, the management company is implementing preventive measures, including additional staffing, staff training, process enhancements, and increased oversight. The academy is committed to resolving this finding promptly and effectively, and values the recommendations provided by the audit team and views this process as an opportunity to strengthen internal controls and enhance overall operations in collaboration with the management company.
Advance Community Health's CFO resigned and did not prepare the 3/31/2023 FFR prior to leaving in April 2023. The new CFO had to pick up where the former CFO left off with no transitional communication. The new CFO usually perform drawdowns along with the bi-weekly payroll which leaves no unobligate...
Advance Community Health's CFO resigned and did not prepare the 3/31/2023 FFR prior to leaving in April 2023. The new CFO had to pick up where the former CFO left off with no transitional communication. The new CFO usually perform drawdowns along with the bi-weekly payroll which leaves no unobligated balances at the end of the budget year. The New CFO assumed that the former CFO had done the same. The new CFO was not aware that a drawdown in the new fiscal year was for the prior fiscal year and prepared the FFR report with no unobligated balance. This should not pose an impact on any future FFR reporting due to the New CFO's practice of drawing down funds during the payroll week and having no unobligated balances at the end of the budget period. Tiffany Robertson, the CFO will be responsible for and will continue to assess our reporting processes for accuracy. We consider this issue to be fully resolved effective 10/27/2023.
COVID-19 Provider Relief Funding and American Rescue Plan Rural Distribution Recommendation: We recommend the Medical Center design controls to ensure that expenses are reported in accordance with latest HHS guidelines. Explanation of disagreement with audit finding: There is no disagreement with th...
COVID-19 Provider Relief Funding and American Rescue Plan Rural Distribution Recommendation: We recommend the Medical Center design controls to ensure that expenses are reported in accordance with latest HHS guidelines. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Management has identified that the Medical Center has more than a sufficient amount of lost revenues related to COVID-19 to offset this difference. Action taken in response to finding: The Medical Center will ensure that controls are put into place to capture Covid specific costs in accordance with HHS guidelines. Name of the contact person responsible for corrective action: Megan Shank, COF. Planned completion date for corrective action plan: February 1, 2024
Finding 1063 (2023-001)
Significant Deficiency 2023
COVID-19 Provider Relief Funding and American Rescue Plan Rural Distribution Recommendation: We recommend the Medical Center design controls to ensure that lost revenues are reported in accordance with latest HHS guidelines. Explanation of disagreement with audit finding: There is no disagreement wi...
COVID-19 Provider Relief Funding and American Rescue Plan Rural Distribution Recommendation: We recommend the Medical Center design controls to ensure that lost revenues are reported in accordance with latest HHS guidelines. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Management has identified that the Medical Center has more than a sufficient amount of lost revenues related to COVID-19 to offset this difference. Action taken in response to finding: The Medical Center will ensure that controls are put into place to report lost revenues in accordance with HHS guidelines. Name of the contact person responsible for corrective action: Megan Shank, DOF. Planned completion date for corrective action plan: February 1, 2024
Finding 1046 (2023-001)
Significant Deficiency 2023
Gramm-Leach-Bliley Act Planned Corrective Action: 1. Erskine College will review all vendors who have access to personal identifiable information on an annual basis in addition to contract initiation. Erskine College will review vendors to make sure they are following Graham Leach Bliley Act standar...
Gramm-Leach-Bliley Act Planned Corrective Action: 1. Erskine College will review all vendors who have access to personal identifiable information on an annual basis in addition to contract initiation. Erskine College will review vendors to make sure they are following Graham Leach Bliley Act standards. Erskine College IT department will maintain a list of all active vendors and access levels of such vendors. 2. An annual security report will be generated, written, and presented to our Board of Trustees on an annual basis moving forward. This report will be generated by the Information Technology department and will be submitted to the Vice President of Operations to report at the Board of Trustees meeting. 3. Erskine College will update our Information Security Program to address the components from 16 CFR 314.3 and 16 CFR 314.4 and have a new version approved by our Board of Trustees. Person Responsible for Corrective Action Plan: Stephanie Hudson. Director of Information Technology Anticipated Date of Completion: End of quarter 1, 2023
Finding 1045 (2023-001)
Material Weakness 2023
Arts Impact has created a new timesheet with columns for each class of xpense (Programs: Voices from the Field, Creative Impact, or Fee for Service, G&A, Fundraising). Employees are tracking their hours spent on work in each class daily and recording it on the new timesheet every pay period. Supervi...
Arts Impact has created a new timesheet with columns for each class of xpense (Programs: Voices from the Field, Creative Impact, or Fee for Service, G&A, Fundraising). Employees are tracking their hours spent on work in each class daily and recording it on the new timesheet every pay period. Supervisors check their reporting staff’s hours against their knowledge of the employee’s work before signing their timesheets (on the 15th and last day of each month). The bookkeeper will upload each employee’s hours by class into QuickBooks online. Employees received the new timesheet templates October 23, 2023. These new timesheets will be used going forward from now on. Employees will also retroactively record their hours by class from the start of FY 23-24 (July 1, 2023) through October 31, 2023 to complete the transition.
The project had insufficient cash to make the required deposit. Management is in consultation with the HUD representative for an acceptable solution.
The project had insufficient cash to make the required deposit. Management is in consultation with the HUD representative for an acceptable solution.
Milwaukee Health Services, Inc. ("MHSI") submits the following corrective action plan for all identified findings and questioned costs for the year ending January 31, 2023. Finding 2023-002: Sliding Fee: External auditors reviewed 40 sliding fee charges to test if the amount charged, was calculat...
Milwaukee Health Services, Inc. ("MHSI") submits the following corrective action plan for all identified findings and questioned costs for the year ending January 31, 2023. Finding 2023-002: Sliding Fee: External auditors reviewed 40 sliding fee charges to test if the amount charged, was calculated properly based on the patients’ income level and in compliance with Milwaukee Health Services’ sliding fee policy. External auditors noted that 2 of the charges were not properly determined or information was not retained to determine if the charge was properly determined. Corrective Action: HRSA performed a site visit regarding the 330 Grant in May 2023. During that site visit, the Sliding Fee Discount program requirement was classified as “met”. The audited timeframe for this fiscal year was during the period when we transitioned, on June 21, 2023, from the Centricity Electronic Health Record (EHR) to the OCHIN Epic EHR. Of the 40 Sliding Fee charges tested, there were 2 failures. Both failures were from charges selected in the Centricity EHR. No fails were identified in the OCHIN Epic EHR, which has built in safeguards to assist in Sliding Fee calculation accuracy. Responsible current staff have been re-trained, and new staff are being trained as part of the on-boarding process. 100% of Sliding Fee accounts will be audited from February 1, 2023, and forward. Any required corrections will be made immediately. Any impacted accounts will be appropriately reprocessed when identified. All forms related to Sliding Fee determination will be scanned into the OCHIN Epic system and will be reviewed for quantity and quality, prior to disposing of any paper copies. Person Responsible for Corrective Action: Chief Financial Officer (Laurie Yake), Revenue Cycle Director (Leeann Stoiber) Anticipated Timing for Completion of Corrective Action: November 30, 2023.
Condition: The Section 8 program ended the year with a negative unrestricted equity of $6,810. A negative unrestricted equity balance is an indication that Housing Assistance Payments (HAP) funds are being spent on administration costs. Recommendation: The negative unrestricted equity balance should...
Condition: The Section 8 program ended the year with a negative unrestricted equity of $6,810. A negative unrestricted equity balance is an indication that Housing Assistance Payments (HAP) funds are being spent on administration costs. Recommendation: The negative unrestricted equity balance should be brought to a positive equity balance as soon as possible. Client Response and Corrective Action: The Executive Director will have the negative unrestricted equity balance corrected. Contact Person: Tammy Groover. Anticipated Date: March 31, 2024
CORRECTIVE ACTION PLAN October 2023 Section III: Federal Award Findings and Questioned Costs Findings and questioned costs related to Federal awards which are required to be reported in accordance with the Uniform Guidance 2 CFR 200.516(a): Significant Deficiency 2023-001 Child Nutrition Cluste...
CORRECTIVE ACTION PLAN October 2023 Section III: Federal Award Findings and Questioned Costs Findings and questioned costs related to Federal awards which are required to be reported in accordance with the Uniform Guidance 2 CFR 200.516(a): Significant Deficiency 2023-001 Child Nutrition Cluster - Procurement Views of the Responsible Officials and Planned Corrective Actions: The District has reviewed the requirements of 2 CFR Section 200.213. The District is in agreement with the recommendation to implement a procedure to document the process used to verify the eligibility of potential vendors to participate in Federal assistance programs. The verification of excluded parties will be accomplished by accessing the System for Award Management (SAM.gov) website and selecting the “Excluded Entity” filter on the “Exclusions” search page to search for exclusions by Unique Entity ID or CAGE/NCAGE code as follows: 1. Select “Search” from the header menu from any page on SAM.gov 2. In the filters, under “Select Domain”, select “Entity Information”, then select Exclusions 3. Use the filters or keyword box to enter the search criteria and view the results 4. Document the results in the vendor file. Other alternatives for verification may include collecting a certification from the entity or adding a clause or condition to the covered transaction or contract with that entity. The Purchasing Agent is charged with the responsibility of monitoring and ensuring compliance with the suspension and debarment procedures and maintaining documentation that contracts expected to equal or exceed $25,000 have been verified on the System for Award Management (SAM) website before purchases are made. Responsible Person(s): Matt Leon, Assistant Superintendent for Business & Operations and Michael DeSantis, Purchasing Agent Deadline for Completion: On or before 12/1/23 for covered transactions with contracts or purchase orders meeting the threshold during the time period 7/1/22 - 10/31/23. Prior to contract approval or purchase order issuance for contracts or purchase orders meeting the threshold on or after 11/1/23.
Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Coopera...
Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperative will continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Planned Completion Date: Not Applicable.
Recommendation: We recommend that the Cooperative continue to segregate incompatible duties as best it can within the limits of what the Cooperative considers to be cost beneficial. Action Taken: The Cooperative reviews and makes improvements to its internal controls on an ongoing basis and attem...
Recommendation: We recommend that the Cooperative continue to segregate incompatible duties as best it can within the limits of what the Cooperative considers to be cost beneficial. Action Taken: The Cooperative reviews and makes improvements to its internal controls on an ongoing basis and attempts to maximize the segregation of duties in all areas within the limits of the staff available. Planned Completion Date: Not Applicable.
Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Coopera...
Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperative will continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Planned Completion Date: Not Applicable.
Recommendation: We recommend that the Cooperative continue to segregate incompatible duties as best it can within the limits of what the Cooperative considers to be cost beneficial. Action Taken: The Cooperative reviews and makes improvements to its internal controls on an ongoing basis and attem...
Recommendation: We recommend that the Cooperative continue to segregate incompatible duties as best it can within the limits of what the Cooperative considers to be cost beneficial. Action Taken: The Cooperative reviews and makes improvements to its internal controls on an ongoing basis and attempts to maximize the segregation of duties in all areas within the limits of the staff available. Planned Completion Date: Not Applicable.
Recommendation: We recommend that the Cooperative file their annual audit with the Federal Audit Clearinghouse within nine months of their fiscal year-end. Action Taken: The Cooperative will file their annual audit with the Federal Audit Clearinghouse within nine months of their fiscal year-end. ...
Recommendation: We recommend that the Cooperative file their annual audit with the Federal Audit Clearinghouse within nine months of their fiscal year-end. Action Taken: The Cooperative will file their annual audit with the Federal Audit Clearinghouse within nine months of their fiscal year-end. Planned Completion Date: January 24,2023
Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Coopera...
Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperative will continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Planned Completion Date: Not Applicable.
Recommendation: We recommend that the Cooperative continue to segregate incompatible duties as best it can within the limits of what the Cooperative considers to be cost beneficial. Action Taken: The Cooperative reviews and makes improvements to its internal controls on an ongoing basis and attem...
Recommendation: We recommend that the Cooperative continue to segregate incompatible duties as best it can within the limits of what the Cooperative considers to be cost beneficial. Action Taken: The Cooperative reviews and makes improvements to its internal controls on an ongoing basis and attempts to maximize the segregation of duties in all areas within the limits of the staff available. Planned Completion Date: Not Applicable.
The newly contracted Accountant for Shared Business Services fully understands the requirements and rules related to the federal ESSER dollars and reporting requirements of the Final Expenditure Report and has already ensured that newly submitted FER’s under her direction do not exceed 10% of the ap...
The newly contracted Accountant for Shared Business Services fully understands the requirements and rules related to the federal ESSER dollars and reporting requirements of the Final Expenditure Report and has already ensured that newly submitted FER’s under her direction do not exceed 10% of the approved budget. She will continue to monitor all grants and their required reporting moving forward.
View Audit 1901 Questioned Costs: $1
The Shared Business Services employees will work with the Management Company of the Food Services program to ensure that in situations where missed meals are identified, that proper documentation (including original tally sheets) be maintained and kept on hand to support the additional meals being c...
The Shared Business Services employees will work with the Management Company of the Food Services program to ensure that in situations where missed meals are identified, that proper documentation (including original tally sheets) be maintained and kept on hand to support the additional meals being claimed. In addition, they will ensure that staff are properly trained to not recreate tally sheets, but to properly document on the original copies, to ensure that meal counts are not duplicated.
View Audit 1901 Questioned Costs: $1
Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperati...
Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperative will continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Planned Completion Date: Not Applicable.
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