Corrective Action Plans

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Responsible Individuals: Mary R. Duncan, CPA, CGMA, Chief Financial Officer Corrective Action Plan: The Organization has implemented practices for timely account reconciliations and oversight review of those reconciliations. Appropriate adjustments will be made during the fiscal year and the year-en...
Responsible Individuals: Mary R. Duncan, CPA, CGMA, Chief Financial Officer Corrective Action Plan: The Organization has implemented practices for timely account reconciliations and oversight review of those reconciliations. Appropriate adjustments will be made during the fiscal year and the year-end close by the Organization. Anticipated Completion Date: Current fiscal year 2022, as CFO was hired in October 2021.
Responsible Individuals: Mary R. Duncan, CPA, CGMA, Chief Financial Officer Corrective Action Plan: The Organization has accepted the risk associated with requesting the auditors to prepare the financial statements and SEFA and continues to plan for the auditors to prepare the reports. Anticipated C...
Responsible Individuals: Mary R. Duncan, CPA, CGMA, Chief Financial Officer Corrective Action Plan: The Organization has accepted the risk associated with requesting the auditors to prepare the financial statements and SEFA and continues to plan for the auditors to prepare the reports. Anticipated Completion Date: Current fiscal year 2022, as CFO was hired in October 2021.
Management Response: The District will review cafeteria operations throughout 2022-2023 and ensure any excess funds be used to provide additional support to the cafeteria program, including the utilization of excess funds for equipment and operational efficiencies.
Management Response: The District will review cafeteria operations throughout 2022-2023 and ensure any excess funds be used to provide additional support to the cafeteria program, including the utilization of excess funds for equipment and operational efficiencies.
Findings and Recommendations - 2022 ? 001: Finding Type: Noncompliance with Laws and Regulations. Condition: The Academy?s NSFSA?s fund balance exceeded the allowable three months? average expenditures at June 30, 2022. The Academy had approximately 5.81 months of expenditures as fund balance at ...
Findings and Recommendations - 2022 ? 001: Finding Type: Noncompliance with Laws and Regulations. Condition: The Academy?s NSFSA?s fund balance exceeded the allowable three months? average expenditures at June 30, 2022. The Academy had approximately 5.81 months of expenditures as fund balance at June 30, 2022. Recommendation: The Academy should submit a spend down plan and obtain Michigan Department of Education?s prior approval to improve the food quality or take other action to improve the program in accordance with 7 CFR 210.19(a)(2). Corrective Action Plan - The Academy is aware of the finding and is implementing procedures in order to prevent further noncompliance in the future. The Academy will be creating and implementing a spend down plan once approval of the plan is received by Michigan Department of Education. Responsible Department - Business department and Food Service department. Responsible Person - Tammy Visger (Director of Food Service). Planned Completion Date (TBD or Date) - Spend-down plan to be implemented and expected completion prior to June 30, 2023.
Finding 2022-03 - Cash Management Recommendation: The University should implement controls and processes to ensure that all expenses are properly identified and documented before any drawdowns are made. Action Taken: The funding was drawn down as the result of news publications from various sources ...
Finding 2022-03 - Cash Management Recommendation: The University should implement controls and processes to ensure that all expenses are properly identified and documented before any drawdowns are made. Action Taken: The funding was drawn down as the result of news publications from various sources in August 2021 indicating that the infrastructure package threatened to take away unused relief funds. At the time, no creditable source was able to confirm whether this meant the University would lose unused HEERF II and III funds. To safeguard the student funding, the University drew down the remaining balance for HEERF II, knowing they would have students to award the funds to shortly thereafter. All other HEERF awards were drawn down on a reimbursement basis. Responsible Individual for Corrective Action: Sr. Associate VP / Deputy CFO ? Jennifer Ginnetti Anticipated Completion Date: December 31, 2022
Finding 2022-02 ? Enrollment Reporting Recommendation: The University should revise its procedures to ensure accurate enrollment information is sent to the NSLDS within the required timeframe for all students and that notifications between departments are communicated timely. Action Taken: As of the...
Finding 2022-02 ? Enrollment Reporting Recommendation: The University should revise its procedures to ensure accurate enrollment information is sent to the NSLDS within the required timeframe for all students and that notifications between departments are communicated timely. Action Taken: As of the date that this student withdrew, the Registrar's office was working with the Information Technology (IT) department to implement a process of receiving automatic email notifications when a student has been determined as withdrawn in the student management system (Colleague). At the beginning of calendar year 2022, these notifications were implemented and are now sent to the Registrar?s Office, Student Billing Office, Residence Life Office, and the Financial Aid Office, notifying them when a student is withdrawn from all of their courses. These notifications will now help mitigate the risk of untimely reporting. Additionally, the University has created a weekly report that is pulled by the Registrar?s Office to find students who are active but not enrolled or listed as on Leave Of Absence (LOA) but are not enrolled in a future class. Responsible Individual for Corrective Action: Registrar ? Joanna Raudenbush Anticipated Completion Date: June 30, 2022
Finding 2022-001: Gramm-Leach Bliley Act (GLBA) Recommendation: The University should perform and document an annual risk assessment to determine the University's specific risks relevant to protecting consumer nonpublic personal information. At a minimum, the University should have at least one risk...
Finding 2022-001: Gramm-Leach Bliley Act (GLBA) Recommendation: The University should perform and document an annual risk assessment to determine the University's specific risks relevant to protecting consumer nonpublic personal information. At a minimum, the University should have at least one risk statement aligned or referenced to each of the three required areas noted in the GLBA law at 16 CFR 314.4 (b). Finally, the University should identify and document at least one safeguard (i.e., control) for each of the risks identified and document in the risk assessment. Each control should be aligned or referenced to the risk(s) to which the safeguard applies. Action Taken: The University has taken the following steps to address the risks identified during the audit: 1. Employee Training and Management a. The University deployed the Knowbe4 Security Awareness Program to all full time staff. The program provides training for managing user data and email messages. To date the University has distributed two campaigns to combat email phishing attempts. 2. Information systems, including network and software design, as well as information processing, storage, transmission and disposal a. The University has formulated a digital transformation strategy to reduce on premises systems and applications. All the critical business systems are hosted at a colocation or are SaaS solutions. b. The University performs backups of all on premises systems using technology that creates immutable storage. c. The University leverages the cybersecurity experience of resellers and manufacturers to ensure all core network technology is installed and configured to minimize any attack surface. 3. Detecting, preventing, and responding to attacks, intrusions, or other systems failures and document safeguards for identified risks as required by the Gramm-Leach Bliley Act (GLBA). a. The University has deployed a redundant pair of Fortinet Advanced Firewalls to monitor and block traffic with suspicious payloads. b. The University has updated to the latest version of Microsoft Advanced Threat Defender to serve as optimal end point protection for managing email traffic. c. The University contracted with the Cybersecurity and Infrastructure Security Agency (CISA) to perform vulnerability scans and penetration testing. The IT department evaluates the weekly reports and remediates highlighted deficiencies. d. The University has removed all admin rights from school managed computers, eliminating the ability to install local software. e. The University has deployed an updated VPN client to all school managed computers providing a secure tunnel for access network services. f. The University manages web browsers of all school managed computers. The University will take the results of the security assessment that was completed and draft the GLBA policy in conformity with the DOE requirements by June 2023. Responsible Individual for Corrective Action: Chief Information Officer ? Gregg Chottiner Anticipated Completion Date: June 30, 2023
FINDING 2022-001 Contact Person Responsible for Corrective Action: Adam C. Minth, Assistant Superintendent Contact Phone Number: 219-374-3504 Views of Responsible Official: The school corporation concurs with the finding and will be implementing corrective procedures by the end of this fiscal year. ...
FINDING 2022-001 Contact Person Responsible for Corrective Action: Adam C. Minth, Assistant Superintendent Contact Phone Number: 219-374-3504 Views of Responsible Official: The school corporation concurs with the finding and will be implementing corrective procedures by the end of this fiscal year. Description of Corrective Action Plan: The Corporation Treasurer and the Assistant Superintendent of Business and Operations are going to perform an analysis on the identified employee who is currently splitting her duties between the Child Nutrition Cluster and other non-federal duties. The analysis will be used to determine what percentage of her workload is directly related to the Child Nutrition Cluster, and what percentage is directly related to non-federal duties. Once the analysis has been completed, the Assistant Superintendent of Business and Operations will direct the Payroll Specialist in regard to what percentage of her pay should go to the Child Nutrition Cluster, and what percentage should go to the Operations Fund. Anticipated Completion Date: 4/30/2023
View Audit 50200 Questioned Costs: $1
Finding Reference Number: 2022-002 Concur or Do Not Concur: Concur Agree or Disagree with Auditor Recommendations: Agree Actions Taken or Planned on the Finding: Management agrees with the finding. The residual receipts account deficiency will funded in the amount of $18,738 and $1,515. Management...
Finding Reference Number: 2022-002 Concur or Do Not Concur: Concur Agree or Disagree with Auditor Recommendations: Agree Actions Taken or Planned on the Finding: Management agrees with the finding. The residual receipts account deficiency will funded in the amount of $18,738 and $1,515. Management will ensure that the residual receipts account is properly funded in the future. Completion Date: August 25, 2022
Finding Reference Number: 2022-001 Concur or Do Not Concur: Concur Agree or Disagree with Auditor Recommendations: Agree Actions Taken or Planned on the Finding: Management agrees with the finding. The excess funds were accrued to submit to HUD. Completion Date: August 25, 2022
Finding Reference Number: 2022-001 Concur or Do Not Concur: Concur Agree or Disagree with Auditor Recommendations: Agree Actions Taken or Planned on the Finding: Management agrees with the finding. The excess funds were accrued to submit to HUD. Completion Date: August 25, 2022
FINDING NO: 2022-002 CONDITION THE OCTOBER, 2021 AND THE MARCH, 2022 CLAIM SUBMITTED FOR NATIONAL SCHOOL LUNCH AND SCHOOL BREAKFAST PROGRAM DID NOT AGREE TO THE SUPPORTING DOCUMENTATION. PLAN THE INCORRECT NUMBERING ON THE COUNT SHEETS HAVE BEEN CORRECTED. WE WILL ALSO CREATE A SEPARATE MONTHLY S...
FINDING NO: 2022-002 CONDITION THE OCTOBER, 2021 AND THE MARCH, 2022 CLAIM SUBMITTED FOR NATIONAL SCHOOL LUNCH AND SCHOOL BREAKFAST PROGRAM DID NOT AGREE TO THE SUPPORTING DOCUMENTATION. PLAN THE INCORRECT NUMBERING ON THE COUNT SHEETS HAVE BEEN CORRECTED. WE WILL ALSO CREATE A SEPARATE MONTHLY SUMMARY SHEET TO CHECK MEAL COUNTS AGAINST WINS. THE FOOD SERVICE DIRECTOR AND SECRETARY WILL REVIEW THE DAILY COUNT SHEETS BEFORE THE MONTHLY CLAIM FOR REIMBURSEMENT IS FILED. ANTICIPATED DATE OF COMPLETION: IMMEDIATELY UPON LEARNING OF THE OVERSIGHT. NAME OF CONTACT PERSON: RYAN SWAN, SUPERINTENDENT
View Audit 55313 Questioned Costs: $1
Financial Services Response: Management agrees with this finding. Corrective Action(s): Year-end Internal Service Fund Accruals were posted on time and there were no audit issues for Fiscal Year 2022. Grant drawdowns were performed regularly as funds were expended.
Financial Services Response: Management agrees with this finding. Corrective Action(s): Year-end Internal Service Fund Accruals were posted on time and there were no audit issues for Fiscal Year 2022. Grant drawdowns were performed regularly as funds were expended.
The following action items are currently being put into place by the People, Culture & Learning Department: -Reviewing and updating policies, procedures, and language in the Employee Handbook that meets the requirements of the Colorado Healthy Families Workplace Act -Communicate and train supervisor...
The following action items are currently being put into place by the People, Culture & Learning Department: -Reviewing and updating policies, procedures, and language in the Employee Handbook that meets the requirements of the Colorado Healthy Families Workplace Act -Communicate and train supervisors and managers on the updated policies, procedures, and language including the requirement for supervisors to be aware of the employee?s use of the specific leave codes and ensuring the leave code is being used appropriately before approving timecards -Implementing a new HRIS/Payroll system that will require justification/documentation from the employee for specific paid leave codes such as use of Extended Leave Bank or COVID. CLIENT RESPONSIBLE PARTY: Jaime Engle, Director of Total Rewards and HR Operations COMPLETION DATE: August 1, 2023 with implementation of ADP payroll system
View Audit 55410 Questioned Costs: $1
Tri-County North will make sure that we follow the proper controls on wage requirements and standards to make sure that the contractor is in compliance with prevailing wage rate.
Tri-County North will make sure that we follow the proper controls on wage requirements and standards to make sure that the contractor is in compliance with prevailing wage rate.
2022-001 - Deposit of Surplus Cash into a Residual Receipts Account Corrective Action Plan No later than 60 days past the end of the fiscal year, we will identify surplus cash in the project funds account and deposit into the residual receipts account. Person(s) Responsible: Greg Shinn, Agency CPA T...
2022-001 - Deposit of Surplus Cash into a Residual Receipts Account Corrective Action Plan No later than 60 days past the end of the fiscal year, we will identify surplus cash in the project funds account and deposit into the residual receipts account. Person(s) Responsible: Greg Shinn, Agency CPA Timing for Implementation: Immediate
Finding 59698 (2022-005)
Significant Deficiency 2022
Finding: 2022-005 Name of contact person: LaGuana Holder, QA/PI Income Maintenance Supervisor Corrective Action: Universal template mandated by Agency Director. In-house audits to verify templates are being used. Proposed Completion Date: Templ...
Finding: 2022-005 Name of contact person: LaGuana Holder, QA/PI Income Maintenance Supervisor Corrective Action: Universal template mandated by Agency Director. In-house audits to verify templates are being used. Proposed Completion Date: Templates will be distributed and used by staff starting immediately.
Finding 59697 (2022-004)
Significant Deficiency 2022
Finding: 2022-004 Name of contact person: LaGuana Holder, QA/PI Income Maintenance Supervisor Corrective Action: A required Power Point training for manual section 2230, 2300, 2250 for all Medicaid staff. A universal template mandated by Agency Director. ...
Finding: 2022-004 Name of contact person: LaGuana Holder, QA/PI Income Maintenance Supervisor Corrective Action: A required Power Point training for manual section 2230, 2300, 2250 for all Medicaid staff. A universal template mandated by Agency Director. Proposed Completion Date: PowerPoint training will be completed by January 31, 2023. Templates will be distributed and used by staff starting immediately.
Finding 59696 (2022-003)
Significant Deficiency 2022
Finding: 2022-003 Name of contact person: LaGuana Holder, QA/PI Income Maintenance Supervisor Corrective Action: Universal template mandated by Agency Director. In-house audits to verify templates are being used. Proposed Completion Date: Templ...
Finding: 2022-003 Name of contact person: LaGuana Holder, QA/PI Income Maintenance Supervisor Corrective Action: Universal template mandated by Agency Director. In-house audits to verify templates are being used. Proposed Completion Date: Templates will be distributed and used by staff starting immediately.
Finding 59695 (2022-002)
Significant Deficiency 2022
Finding: 2022-002 Name of contact person: LaGuana Holder, QA/PI Income Maintenance Supervisor Corrective Action: A required Power Point training for manual section 3365 for all Medicaid staff. A universal template mandated by Agency Director. In-house audits to...
Finding: 2022-002 Name of contact person: LaGuana Holder, QA/PI Income Maintenance Supervisor Corrective Action: A required Power Point training for manual section 3365 for all Medicaid staff. A universal template mandated by Agency Director. In-house audits to verify that templates are being used. Proposed Completion Date: PowerPoint training will be completed by January 31, 2023. Templates will be distributed and used by staff starting immediately.
Finding: Reports of commodity activity were submitted to the pass-through entity that were not consistent with the underlying commodities records of RKCAA. Corrective Response: RKCAA management agrees with the finding. RKCAA is updating and revising policies and procedures, including additional sup...
Finding: Reports of commodity activity were submitted to the pass-through entity that were not consistent with the underlying commodities records of RKCAA. Corrective Response: RKCAA management agrees with the finding. RKCAA is updating and revising policies and procedures, including additional supervision, training and reconciliations to better track and report the commodities activity to the pass-through entity. This process is expected to be completed by June 30, 2023. 06/30/2023 CFO Laura Brown 262-637-8377 ext 104
Views of responsible officials and corrective action plan: Due to significant turnover at Rural Health Corporation of Northeastern Pennsylvania, several income verifications were not completed in time. Additional hiring and training are required to ensure that these processes are followed. The out...
Views of responsible officials and corrective action plan: Due to significant turnover at Rural Health Corporation of Northeastern Pennsylvania, several income verifications were not completed in time. Additional hiring and training are required to ensure that these processes are followed. The outsourced billing company is scheduled to participate with an onsite visit the first week of April?23. The CFO acknowledges and is responsible for this corrective action plan.
2022-001 ? Significant deficiency in documentation supporting Provider Relief Fund expenditures Cluster: Not applicable Federal Granting Agency: Health Resources and Services Administration (HRSA) Assistance Listing #: 93.498 Assistance Listing Title: COVID-19 Provider Relief Fund and American Resc...
2022-001 ? Significant deficiency in documentation supporting Provider Relief Fund expenditures Cluster: Not applicable Federal Granting Agency: Health Resources and Services Administration (HRSA) Assistance Listing #: 93.498 Assistance Listing Title: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Year: 1/1/20 - 6/30/22 Pass-through entity: Not applicable Management has reassessed its internal controls over the review and approval of allowable expenditures under this program. HRSA reporting periods 4 and 5 are supported by lost revenues and will not include any expenditures. Management has updated its documentation for this program and is in the process of updating other documentation related to period 4 and 5 for the FY23 audit. Leadership Responsible: Steve Warren, Network Grants Management Manager; Melissa Laurie, Network VP/Corporate Controller Anticipated Completion Date: 9/30/2023
2022-002 ? Material weakness over amounts reported on the Schedule of Expenditures of Federal Awards (SEFA) Cluster: Not applicable Federal Granting Agency: Health Resources and Services Administration (HRSA) Award Year: 10/1/21 ? 9/30/22 Assistance Listing #: 93.461 Assistance Listing Title: HRSA ...
2022-002 ? Material weakness over amounts reported on the Schedule of Expenditures of Federal Awards (SEFA) Cluster: Not applicable Federal Granting Agency: Health Resources and Services Administration (HRSA) Award Year: 10/1/21 ? 9/30/22 Assistance Listing #: 93.461 Assistance Listing Title: HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund Pass-through entity: Not applicable Management notes that this program is complete, and expenditures will not be incurred or present on the Schedule of Expenditures of Federal Awards (SEFA) in future years. Management is working toward a centralized process for grant tracking. Blackbaud?s Financial Edge NXT software was implemented at UVM Medical Center, CVMC, PMC, and AHMC in 2021, ECH in 2022 and is scheduled to complete for CVPH on October 1, 2023. The system still needs to be implemented at HHH with a goal date of sometime in FY24. The system has the capability to track all grant related expenses and income by organization but currently only being used for grant tracking at UVMMC. This change in process is in its later stages. The intent of this work is to ensure that all grants are tracked centrally, with consistent oversight and monitoring. This will allow for centralized compilation of the SEFA for the Uniform Guidance audit. Currently the process is disparate across several entities with not a single point of contact. Management has added an additional FTE within the Network Grants Management Finance team beginning at the end of July 2023 to engage in this work to centralize grant tracking, which will continue to enhance our controls to ensure completeness and accuracy of the consolidated Network SEFA. Leadership Responsible: Steve Warren, Network Grants Management Manager; Melissa Laurie, Network VP/Corporate Controller Anticipated Completion Date: 12/31/2023
Finding 59687 (2022-001)
Significant Deficiency 2022
Finding 2021-001 Reporting ? Internal Control Finding ? Significant Deficiency in Internal Control 93.498 Provider Relief Fund (PRF) Condition and Effect: Bancroft incorrectly reported lost revenues in the Health Resources and Services Administration (?HRSA?) portal Period 3 submission for quarters ...
Finding 2021-001 Reporting ? Internal Control Finding ? Significant Deficiency in Internal Control 93.498 Provider Relief Fund (PRF) Condition and Effect: Bancroft incorrectly reported lost revenues in the Health Resources and Services Administration (?HRSA?) portal Period 3 submission for quarters in which there was no lost revenues. There were no questioned costs identified as result of this error. View of Responsible Officials and Planned Corrective Action: Management reported lost revenue in the HRSA portal for quarters in which such reporting was not required; however, the attachment submitted with the HRSA input was correct. Management will check for updates to guidance and make necessary changes as appropriate. Name of Contract Person: Jennifer Cripps Chief Financial Officer Bancroft (856) 348-1196 Jennifer.Cripps@Bancroft.org Completion Date: December 1, 2022
Finding: 2022-002 ? Material Weakness, Internal Control Over Compliance, Eligibility and Special Tests ? ALN 93.778 Medicaid Cluster Personnel Responsible for Corrective Action: Pam Noonan, Mesa County Finance Director Anticipated Completion Date: 09/29/2023 Cause: Internal controls over the el...
Finding: 2022-002 ? Material Weakness, Internal Control Over Compliance, Eligibility and Special Tests ? ALN 93.778 Medicaid Cluster Personnel Responsible for Corrective Action: Pam Noonan, Mesa County Finance Director Anticipated Completion Date: 09/29/2023 Cause: Internal controls over the eligibility determinations are the responsibility of management. Mesa County did not follow its formal process in place for reviews of eligibility determinations. View of Responsible Officials and Planned Corrective Action: Mesa County agrees with the finding and has put together a corrective action plan for the finding. Corrective Action Plan: Mesa County was aware that they were not meeting their internal or Health Care Policy and Financing (HCPF) and Colorado Department of Human Services (CDHS) review requirements for 2022. Mesa County created a new quality control case reviews policy and procedure effective June 2023. The new policy included internal, HCPF and CDHS review requirement for all programs. In addition, MCDHS quality assurance team will be providing oversight using a tool they create to ensure review requirements are being met for each program.
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