Corrective Action Plans

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Monitoring Procedures and Risk Assessment Process ? 93.958 Block Grants for Community Mental health Services Corrective Action Plan: CAMHD will have a dedicated accountant to any grant program above $750,000 in contract reimbursements to over see the monitoring procedures and process. Implementati...
Monitoring Procedures and Risk Assessment Process ? 93.958 Block Grants for Community Mental health Services Corrective Action Plan: CAMHD will have a dedicated accountant to any grant program above $750,000 in contract reimbursements to over see the monitoring procedures and process. Implementation Date: April 1, 2023 Responding Official: Scott Shimabukuro, Acting Administrative Chief and Janet Ledoux, Administrative Officer/Child and Adolescent Mental Health Division
Reporting - FFR and FSRS ? 93.958 Block Grants for Community Mental Health Services Corrective Action Plan: AMHD plans on contracting with an accountant to assist with grant activities including preparation of FFRs. If FFRs will not be available to submit withfn 90 days after the close of the statu...
Reporting - FFR and FSRS ? 93.958 Block Grants for Community Mental Health Services Corrective Action Plan: AMHD plans on contracting with an accountant to assist with grant activities including preparation of FFRs. If FFRs will not be available to submit withfn 90 days after the close of the statutory grant period, a submission extension will be requested. AMHD's first-tier subawards of $30,000 or more are being currently being reported to FSRS. CAMHD has one dedicated accountant to monitor each federal grant and will ensure that the FFR includes all 1st tier sub-awards and is submitted in a timely manner. Implementation Date: AMHD - June 1, 2023 CAMHD - April 1, 2023 Responding Official: Amy Curtis, Administrative Chief and Amy Yamaguchi, Administrative Officer/Adult Mental health Division; Scott Shimabukuro, Acting Administrative Chief and Janet Ledoux, Administrative Officer/Children
Reporting - FSRS ? 93.155 SHIP COVID Testing and Mitigation Corrective Action Plan: Program management will take more care in understanding the requirements of grant agreements and seek out further instruction and training on reporting to the FSRS. Implementation Date: Immediately Responding Offi...
Reporting - FSRS ? 93.155 SHIP COVID Testing and Mitigation Corrective Action Plan: Program management will take more care in understanding the requirements of grant agreements and seek out further instruction and training on reporting to the FSRS. Implementation Date: Immediately Responding Officials: William Aakhus, Administrative Officer/Family Health Services Division
University of Maryland Medical System Corporation and Subsidiaries Corrective Action Plan Year Ended June 30, 2022 University of Maryland Medical System Corporation and Subsidiaries (the Corporation) respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit ...
University of Maryland Medical System Corporation and Subsidiaries Corrective Action Plan Year Ended June 30, 2022 University of Maryland Medical System Corporation and Subsidiaries (the Corporation) respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 2021 to June 30, 2022 FINDINGS?FEDERAL AWARD PROGRAMS AUDITS CONTROL DEFICIENCY 2022-001 Incomplete Federal Requirements Within Procurement Policies COVID-19 ? Coronavirus State and Local Fiscal Recovery Funds (Assistance Listing # 21.027) Recommendation: The Corporation should update its procurement policy to include the provisions required by the Uniform Guidance for purchasing goods and/or services with federal funds Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Updated Corporation Procurement Policies are drafted to satisfy the federal requirements and working through the necessary reviews. Planned completion date for corrective action plan: September 30, 2023 Name(s) of the contact person(s) responsible for corrective action: Jeff Chadwick, Financial Reporting Director, jeff.chadwick@umm.edu.
2022-004 - ESSER Condition/Finding: During the audit, the District was unable to provide the original teacher's contracts to support the salaries paid which are relied upon to properly support the expenditures in the federal programs. Corrective steps: The district has already hired and outside age...
2022-004 - ESSER Condition/Finding: During the audit, the District was unable to provide the original teacher's contracts to support the salaries paid which are relied upon to properly support the expenditures in the federal programs. Corrective steps: The district has already hired and outside agency to handle personnel files and to maintain these files.
Pinnacles agrees that an expense was double claimed. The only mitigating factor was that the e-rate funding decision took over a year to be received. The corrective action below has already been implemented. Moving forward, the contracted accounting firm will mark all items submitted for reimbursem...
Pinnacles agrees that an expense was double claimed. The only mitigating factor was that the e-rate funding decision took over a year to be received. The corrective action below has already been implemented. Moving forward, the contracted accounting firm will mark all items submitted for reimbursement with the appropriate class code in the accounting system. This will prevent double claiming as the accounting system will already demarcate which expenses were submitted for reimbursement. This finding was also already communicated to the CSP grantor and an eligible expense was submitted and accepted to replace the double claimed expense.
Pinnacles agrees that suspension and debarment checks were not completed. Moving forward, the CEO and Director of Operations will ensure that suspension and debarment checks are completed moving forward by (1) reviewing the procurement policies each Spring; and (2) sharing purchase plans with the ...
Pinnacles agrees that suspension and debarment checks were not completed. Moving forward, the CEO and Director of Operations will ensure that suspension and debarment checks are completed moving forward by (1) reviewing the procurement policies each Spring; and (2) sharing purchase plans with the contracted-CFO prior to purchases being made. Plans shared will include: funding source and any required bids or RFPs as well as screenshots of suspension and debarment look up prior to placing the order.
Pinnacles agrees that appropriate time and effort reports were not kept. The reports were created but never signed. Moving forward, the School will implement procedures to ensure that these reports are signed in a timely manner.
Pinnacles agrees that appropriate time and effort reports were not kept. The reports were created but never signed. Moving forward, the School will implement procedures to ensure that these reports are signed in a timely manner.
Pinnacles agrees that appropriate claim packets with documentation that tie exactly to the amounts claimed for reimbursement were not kept. The contracted CFO did keep records, but due to not copying and pasting correctly, could not get back exactly to the amounts claimed. Moving forward, the contr...
Pinnacles agrees that appropriate claim packets with documentation that tie exactly to the amounts claimed for reimbursement were not kept. The contracted CFO did keep records, but due to not copying and pasting correctly, could not get back exactly to the amounts claimed. Moving forward, the contracted CFO will keep a list of what exactly was claimed for reimbursement at each claim.
Finding 43124 (2022-005)
Significant Deficiency 2022
2022 ? 005 Allowable Activities and Costs/Cost Principals (Significant Deficiency and Noncompliance) Management Response: Management agrees with the finding. The grants distributed by the Economic Development Department were a lifeline to small busine...
2022 ? 005 Allowable Activities and Costs/Cost Principals (Significant Deficiency and Noncompliance) Management Response: Management agrees with the finding. The grants distributed by the Economic Development Department were a lifeline to small businesses that were just holding on. While a strong program was set up in a very short timeframe some reviews and follow-up were not completed. Additionally, the Family & Community Services Department will ensure timesheets are signed timely. Additionally, the department will work with the Grants Section to ensure timesheets, Kronos and Peoplesoft agree. Timeline and Responsible Position: June 2023 ? Department Directors, Economic Development, Family & Community Services and Transit
Finding 43122 (2022-009)
Significant Deficiency 2022
2022 ? 009 Special Tests and Provisions ? Housing Quality Standards (Significant Deficiency and Noncompliance) Management Response: The City concurs with the finding. The City did complete 20% of the program files however one unit was not inspected due to the client testing positive for COVID -19. I...
2022 ? 009 Special Tests and Provisions ? Housing Quality Standards (Significant Deficiency and Noncompliance) Management Response: The City concurs with the finding. The City did complete 20% of the program files however one unit was not inspected due to the client testing positive for COVID -19. In the future if a home in not able to be inspected, another tenant will be notified and a HQS inspection will occur at another residence at a later date. This action will be corrected by updating the Monitoring Checklist to ensure that staff knows the proper of units to be inspected. This will be reviewed with supervisor prior to monitoring. The City was not aware of the requirement that, in the case of HOME projects with between one and four units, all units needed to be inspected; the City typically looks at the project as a whole and inspects 10% or 20% depending on the Risk Assessment. This will be corrected in the future by updating the Monitoring Checklist to ensure staff knows the proper number of HOME units that need to be inspected. Timeline and Responsible Position: June 2023 ? Director of Family & Community Services
Finding 43121 (2022-002)
Significant Deficiency 2022
The Director of Financial Aid will ensure that a process is created to identify students that are scheduled to graduate, withdraw, or drop below half-time in order for them all to complete exit counseling. Students will be notified at the time of withdrawal by phone, email, and a certified letter wi...
The Director of Financial Aid will ensure that a process is created to identify students that are scheduled to graduate, withdraw, or drop below half-time in order for them all to complete exit counseling. Students will be notified at the time of withdrawal by phone, email, and a certified letter with the steps to complete the exit counseling.
Finding 43120 (2022-001)
Significant Deficiency 2022
The Office of Financial Aid has created a process where they will check Common Origination Disbursement (COD) to ensure that each student has a valid entrance counseling. Each counselor will also make a notation in the Financial Aid system that the student borrower's entrance counseling has been re...
The Office of Financial Aid has created a process where they will check Common Origination Disbursement (COD) to ensure that each student has a valid entrance counseling. Each counselor will also make a notation in the Financial Aid system that the student borrower's entrance counseling has been reviewed.
FINDING 2022-001 Contact Person Responsible for Corrective Action: Dr. Eric Goggins Contact Phone Number: 812-385-4851 Views of Responsible Official: Agreement with Finding Description of Corrective Action Plan: North Gibson School Corporation will maintain an asset inventory to ensure an accurate r...
FINDING 2022-001 Contact Person Responsible for Corrective Action: Dr. Eric Goggins Contact Phone Number: 812-385-4851 Views of Responsible Official: Agreement with Finding Description of Corrective Action Plan: North Gibson School Corporation will maintain an asset inventory to ensure an accurate recording of all capital assets are maintained and accurately include the following: Description of Property Serial Number Source of Funding for the Property (including federal award number) Who Holds the Title Acquisition Date Cost of Property Percentage of Federal Participation in the Project Use and Condition of the Property Anticipated Completion Date: The corrective action plan will be implemented immediately and continue moving forward when a capital asset is purchased and/or dispositioned.
Finding 43114 (2022-003)
Significant Deficiency 2022
The Controller and Compliance Officers are working together to correct the previously filed reports to update the estimated total number of students at the institution that are eligible to receive Emergency Financial Aid Grants to Students under the CARES (a)(1) subprogram and the CRRSAA and ARP (a)...
The Controller and Compliance Officers are working together to correct the previously filed reports to update the estimated total number of students at the institution that are eligible to receive Emergency Financial Aid Grants to Students under the CARES (a)(1) subprogram and the CRRSAA and ARP (a)(1) subprograms. Completion Date: April 2023 Contact Person: Tom Corley, Controller and Director of Fiscal Operations and Carrie Stevens, Associate Vice President of Compliance
Finding 43105 (2022-002)
Significant Deficiency 2022
Student Accounts Receivable, Controller?s Office, and IT are working together to develop more real-time reporting and tracking for student account refund balances to identify student accounts with refund balances that remain undistributed more than seven days after being created to prioritize those ...
Student Accounts Receivable, Controller?s Office, and IT are working together to develop more real-time reporting and tracking for student account refund balances to identify student accounts with refund balances that remain undistributed more than seven days after being created to prioritize those accounts for refund processing. Completion Date: June 30, 2023 Contact Person: Heather Long, Director Student Accounts
Finding 43104 (2022-001)
Significant Deficiency 2022
The Registrar and the IT department are working together to ensure timely and accurate data is being transmitted on a regular schedule to the Clearinghouse as needed. When date determination exceptions occur (e.g., degrees being conferred after initial reporting or withdrawal dates being retroactive...
The Registrar and the IT department are working together to ensure timely and accurate data is being transmitted on a regular schedule to the Clearinghouse as needed. When date determination exceptions occur (e.g., degrees being conferred after initial reporting or withdrawal dates being retroactively determined for administrative purposes), the Registrar?s Office, IT, and Financial Aid will work together to determine the appropriate date adjustments needed to manually update the Clearinghouse with the correct information if needed as quickly as possible. Completion Date: June 30, 2023 Contact Person: Julie McAdoo, University Registrar
Finding 43103 (2022-002)
Significant Deficiency 2022
project Number: 21st Century - Project 553. Corrective steps: Procedures have been put in place to ensure employees are being paid in accordance with the District contracts with board approval. All extra duty contracts have been signed by the Varnum School Board. Completion date: 3-20-2023. Plan fo...
project Number: 21st Century - Project 553. Corrective steps: Procedures have been put in place to ensure employees are being paid in accordance with the District contracts with board approval. All extra duty contracts have been signed by the Varnum School Board. Completion date: 3-20-2023. Plan for monitoring adherence to the corrective action plan: The Varnum Schools Superintendent will monitor for compliance.
Finding 2022-005 Procurement, Suspension and Debarment Material Weakness in Internal Control over Compliance Finding Summary: The College?s procurement policy did not include all the required elements as outlined in the Uniform Guidance. Additionally, two vendors were not verified against the centra...
Finding 2022-005 Procurement, Suspension and Debarment Material Weakness in Internal Control over Compliance Finding Summary: The College?s procurement policy did not include all the required elements as outlined in the Uniform Guidance. Additionally, two vendors were not verified against the central contractor registry prior to expenses incurred to ensure the vendor was not suspended or debarred. Responsible Individuals: Dr. Lane Azure, President Corrective Action Plan: Rarely does the college use unknown vendors that have been used by the college in the past. However, we will now check with SAM to determine if vendors have been debarred or suspended. Anticipated Completion Date: July 1, 2022
Finding 2022-004 Reporting Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: In our sample of reports selected for testing, we noted the following items; o No support could be provided to substantiate a secondary level of review was completed for stude...
Finding 2022-004 Reporting Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: In our sample of reports selected for testing, we noted the following items; o No support could be provided to substantiate a secondary level of review was completed for student and institutional portion quarterly reports for the quarters ended 12/31/2021 and 3/31/2022 and the year two annual report. o Student portion quarterly reports ending 12/31/2021 and 3/31/2022 reported cumulative expenditures incurred from the inception of the federal program rather than expenditures incurred within the quarter, resulting in an error of $105,202 in the first report and $165,154 in the second report. Responsible Individuals: Dr. Lane Azure, President Corrective Action Plan: o The reporting was completed by the Comptroller. The comptroller provided the president with the report to review the report, then the report was provided to the website staff member who uploaded the report on the website in the particular area designated specifically for COVID19 reporting. The College will ensure documentation of secondary level of review and approval is retained. o The errors occurred due to a misunderstanding of how to report this particular line item. A better understanding of proper reporting requirements has been attained. All of these items were items that were not deliberately conducted by any staff member at the college. SWC blames the ever-changing method of reporting and how to spend these funds. On several occasions, the president randomly selected other TCU to see how their reporting was being done and on more than several occasions, there was no reporting to view or compare and contrast to. Anticipated Completion Date: July 1, 2022
Finding 2022-003 Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: Through testing of operational expenditures of the College, it was determined; o Payroll expen...
Finding 2022-003 Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: Through testing of operational expenditures of the College, it was determined; o Payroll expenditures charged to the award were not for costs newly associated with the coronavirus, a requirement communicated within the supplemental guidance in the Higher Education Emergency Relief Fund III Frequently Asked Questions published May 11, 2021 and updated May 24, 2021. Through testing of disbursements to students, it was determined; o No support could not be provided to substantiate a secondary level of review was completed prior to disbursement of funds. o 26 instances identified in which the College directly controlled how student?s use their emergency financial aid grant. o 8 instances identified in which college discharged outstanding balance on student account for costs incurred prior to March 13, 2020. o 2 instances identified in which the College charged coronavirus vaccine incentive payments under the student portion of HEERF award. Responsible Individuals: Dr. Lane Azure, President Corrective Action Plan: o In response to the payroll finding, this was funded through MSI (no Student or Institutional funds were used for payroll). SWC president attended weekly meetings with American Indian Higher Education Consortium (AIHEC) who assisted and advocated for these HEERF monies for all Tribal Colleges and Universities (TCU). Handouts (attached) of slides were given to each institution and Payroll was an allowable cost with the exception of the President. The college president believed in order to allow the college to stay open and not lose students and staff, subsidies had to be included in payroll. There were no predictions on how long this world-wide pandemic was going to last or how much funds the government was going to give to IHE. SWC is a small tribal college where hiring and maintaining qualified personnel has been difficult long before the pandemic and now even more so. SWC could not afford to hire new staff even if it was feasible to find someone to fill new positions. Therefore, SWC used HEERF to make payroll on many employees whose job duties changed so they could assist the college in staying open and transition to a completely different method of delivering education to SWC students. SWC president was told by the Department of Education and AIHEC that these funds had to be exhausted in a limited amount of time. In addition, there was a limited number of items that the funds could be spent on, but it was changing every day to be more liberal. In March 2020, SWC had to begin offering courses via distance delivery which was a completely new method for this college. In summer 2020, the college did not offer classes and in fall 2020 SWC had to begin offering a hybrid method of delivery. Every single employee of this college had to do their day to day duties differently in order to support the new delivery method for education ranging from contact tracing, hyflex delivery, social distancing, hygiene, masking up, staff meetings, parking, teaching, and etc. The range of employees went from admissions, student services, academic staff, faculty, and the business office. All employees were coming in at different shifts, and/or working remotely, while social distancing. o The College will ensure documented secondary level of review and approval is retained. o For grant payments funded by institutional portion, Grant payments were applied to student accounts and if no outstanding balance, a check was given to the student. For grants funded by MSI, a formula was used to distribute $125 per credit and an allowance for books and fees. The COARS was a financial aid grant to the student who applied for the relief. o Any debt relief provided for students was for those students who could not attend the current academic year because of a prior balance. In order to attend college during the pandemic, MSI funds were used to discharge the student?s balance at the discretion of the student. o The checks for these instances were given directly to the student to defray costs of going to get the vaccine, for transportation, for cost of the office visit, or whatever it may have been they needed in order to get the vaccine. It was emergency aid to the student. Anticipated Completion Date: July 1, 2022
View Audit 48700 Questioned Costs: $1
Views of Responsible Officials and Planned Corrective Actions: Based on our payment practice prior to and after this occurrence, the organization believes that it has demonstrated and has sufficient controls in place to ensure continued adherence to the criteria.
Views of Responsible Officials and Planned Corrective Actions: Based on our payment practice prior to and after this occurrence, the organization believes that it has demonstrated and has sufficient controls in place to ensure continued adherence to the criteria.
CORRECTIVE ACTION PLAN RESPONSE: The delinquent submissions have been approved by HUD. The Agency will ensure timely filing going forward. Anticipated completion date: 3-31-2023 Responsible party: Vicky Pritchett, Finance Director Please contact Vicky Pritchett, Finance Director at 573-213-4811...
CORRECTIVE ACTION PLAN RESPONSE: The delinquent submissions have been approved by HUD. The Agency will ensure timely filing going forward. Anticipated completion date: 3-31-2023 Responsible party: Vicky Pritchett, Finance Director Please contact Vicky Pritchett, Finance Director at 573-213-4811 extension #10102 with questions regarding this plan.
Views of Responsible Officials and Planned Corrective Action: The Home disagrees with the disallowance and maintains that the ACF made legal and factual errors in taking the disallowance and that expenses incurred were necessary, reasonable, allocable and allowable. The Home is working with a consul...
Views of Responsible Officials and Planned Corrective Action: The Home disagrees with the disallowance and maintains that the ACF made legal and factual errors in taking the disallowance and that expenses incurred were necessary, reasonable, allocable and allowable. The Home is working with a consultant to establish standard operating procedures and workflows relating to the accounting function.
View Audit 45290 Questioned Costs: $1
Views of Responsible Officials and Planned Corrective Action: The Home agrees with the finding. The funds were drawn down from the grant due to human error. Shortly after discovering this mistake, The Home has developed a process in which the drawn down amounts is reviewed and approved before proce...
Views of Responsible Officials and Planned Corrective Action: The Home agrees with the finding. The funds were drawn down from the grant due to human error. Shortly after discovering this mistake, The Home has developed a process in which the drawn down amounts is reviewed and approved before processing the drawdown. The amounts overdrawn were used to pay grant expenditures during FY2023, which still covers the grant budget period.
View Audit 45290 Questioned Costs: $1
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