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Corrective Action Plans

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Finding 40170 (2022-007)
Significant Deficiency 2022
The Howard University
DC
Equipment & Real Property Management Procurement, Suspension & Debarment Internal Control / Segregation of Duties
Name of Responsible Individual: Brenda Willis - Senior Director of Financial Grants and Contracts Corrective Action: The University experienced challenges from the cyber-attack in September 2021 that impacted the transition to the Workday ERP. Equipment purchased with federal funds will be maintaine...
Name of Responsible Individual: Brenda Willis - Senior Director of Financial Grants and Contracts Corrective Action: The University experienced challenges from the cyber-attack in September 2021 that impacted the transition to the Workday ERP. Equipment purchased with federal funds will be maintained in the Workday property management system by Procurement and Grants and Contracts. Procurement will tag equipment when initially received at Howard University Central Receiving. An additional process will be implemented to ensure equipment delivered directly to departments will be timely tagged. Workday property records include fields for the equipment description, relevant identification numbers, source, title information, acquisition date and cost, percentage of Federal participation in the cost, location, condition, and ultimate disposition data. Anticipated Completion Date: August 31, 2023
View Audit 37632
Finding 40169 (2022-006)
Significant Deficiency 2022
The Howard University
DC
Procurement, Suspension & Debarment
Name of Responsible Individual: Rawle Howard - Assistant Vice President and Chief Procurement Officer Corrective Action: The Office of Procurement and Contracting (OPC) leadership attended a procurement with Federal Grants Seminar in November 2022. All OPC team members will be required to take manda...
Name of Responsible Individual: Rawle Howard - Assistant Vice President and Chief Procurement Officer Corrective Action: The Office of Procurement and Contracting (OPC) leadership attended a procurement with Federal Grants Seminar in November 2022. All OPC team members will be required to take mandatory foundational procurement training to close the knowledge gap and promote standardization and consistency. Procurement Managers will review all purchase orders over $25,000 prior to issuance to ensure the procurement record is complete to ensure that procurement is in alignment with the University?s Procurement Policy and procedures. OPC revised the University?s Procurement & Contracting Policies, Procedures & Guidelines in September 2022 to include Uniform Guidance requirements to clearly define the procurement steps to take when processing requests at various dollar value thresholds. Also, a procurement checklist was developed to provide guidance pursuant to Uniform Guidance. Training for Research Administrators and Principal Investigators is scheduled for April and May 2023. Anticipated Completion Date: June 30, 2023
View Audit 37632
The Howard University
DC
Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking
Name of Responsible Individual: Benjamin Carmichael, Compliance Officer and Roderick Johnson, Assistant Director for Compliance Corrective Action: There was one credit balance in the sample (from September 2021) that was not processed within 14 days. It was completed on the 20th day after the refund...
Name of Responsible Individual: Benjamin Carmichael, Compliance Officer and Roderick Johnson, Assistant Director for Compliance Corrective Action: There was one credit balance in the sample (from September 2021) that was not processed within 14 days. It was completed on the 20th day after the refund was created on the student?s account. Note that the record identified in the sample was during the time of the cyberattack. While this does not absolve Howard of demonstration of administrative capability, the bursar team could not have performed their function during this time. Anticipated Completion Date: December 31, 2021
View Audit 37632
The Howard University
DC
Cash Management Student Financial Aid Internal Control / Segregation of Duties
Name of Responsible Individual: Roderick Johnson, Assistant Director for Compliance Corrective Action: The finance and financial aid divisions will collaborate to improve the internal controls that are in place to ensure there is a three-day turnaround for draws and refunds. The policies and procedu...
Name of Responsible Individual: Roderick Johnson, Assistant Director for Compliance Corrective Action: The finance and financial aid divisions will collaborate to improve the internal controls that are in place to ensure there is a three-day turnaround for draws and refunds. The policies and procedures for cash management were updated in July 2022. Anticipated Completion Date: June 30, 2023
View Audit 37632
Finding 40166 (2022-003)
Significant Deficiency 2022
The Howard University
DC
Internal Control / Segregation of Duties Student Financial Aid Matching / Level of Effort / Earmarking
Name of Responsible Individual: Benjamin Carmichael, Compliance Officer Corrective Action: Loan disbursement notifications are now the responsibility of the Office of Financial Aid (Financial Aid). Notifications are now being sent out through Ellucian Banner (Banner) when a student has been awarded....
Name of Responsible Individual: Benjamin Carmichael, Compliance Officer Corrective Action: Loan disbursement notifications are now the responsibility of the Office of Financial Aid (Financial Aid). Notifications are now being sent out through Ellucian Banner (Banner) when a student has been awarded. The disbursement notification documentation is now electronic and does not require manual actions from Howard University employees to be completed. The following areas identified in the audit have been addressed: ? Notifications are immediately sent out electronically when the student is awarded, allowing Howard to meet the required notification timeline for notification. ? Each notification is addressed to the specific person (i.e., parent, student) who is responsible for paying back the loan. ? The name of the student, exact amount of the disbursement and the date of disbursement is generated on the notification as well. Bi-semester reviews have been completed by the Associate Director for Compliance (Financial Aid) to ensure the loan disbursement notifications are being generated in the required timeline and includes all federally required information listed above in each notification. Spring 2022, Summer 2022, and Fall 2022 reviews have been completed thus far with no significant issues identified. The policies and procedures for loan disbursement notifications were updated in April 2022. These will be reviewed annually. Anticipated Completion Date: April 30, 2022
View Audit 37632
Finding 40164 (2022-002)
Significant Deficiency 2022
The Howard University
DC
Student Financial Aid Special Tests & Provisions Reporting
Name of Responsible Individual: Benjamin Carmichael, Compliance Officer and Roderick Johnson, Assistant Director for Compliance Corrective Action: The Enrollment Reporting process is supervised by the Office of the Registrar (Registrar), which is responsible for providing enrollment reports to Howar...
Name of Responsible Individual: Benjamin Carmichael, Compliance Officer and Roderick Johnson, Assistant Director for Compliance Corrective Action: The Enrollment Reporting process is supervised by the Office of the Registrar (Registrar), which is responsible for providing enrollment reports to Howard University?s third-party servicer, National Student Clearinghouse (NSC), who then submits the report to the National Student Loan Data System (NSLDS). The departure of a key registrar personnel resulted in miscommunication and neglect of the enrollment reporting duties. The issue has since been remedied, but due to the time lag, will take an additional fiscal year for improvements to be observed. Anticipated Completion Date: March 31, 2023
View Audit 37632
Finding 40163 (2022-011)
Significant Deficiency 2022
The Howard University
DC
Cash Management Internal Control / Segregation of Duties
Name of Responsible Individual: Brenda Willis - Senior Director of Financial Grants and Contracts Corrective Action: The original lost revenue calculation was completed by the Deputy Chief Financial Officer in August 2021. The calculation was reviewed by the Controller and Assistant Treasurer prior ...
Name of Responsible Individual: Brenda Willis - Senior Director of Financial Grants and Contracts Corrective Action: The original lost revenue calculation was completed by the Deputy Chief Financial Officer in August 2021. The calculation was reviewed by the Controller and Assistant Treasurer prior to drawing funds. The lost revenue calculation was compiled by management before the draw was completed on 09/09/2021. Deloitte was contracted for an additional review of the lost revenue increasing the lost revenue from $23M to $29M. Howard University will continue to comply with cash management policies and procedures in accordance with ALN: 84.915A. Anticipated Completion Date: June 30, 2023
View Audit 37632
Finding 40157 (2022-001)
Significant Deficiency 2022
Gateway Public Schools
CA
Name of Contact Person: Chris Hero (COO) Corrective Action: To address the issue of our journal entries not being signed off on by our COO we will implement the following process beginning with the journal entries for the December 2022 month-end accounting close: Going forward, the Controller will ...
Name of Contact Person: Chris Hero (COO) Corrective Action: To address the issue of our journal entries not being signed off on by our COO we will implement the following process beginning with the journal entries for the December 2022 month-end accounting close: Going forward, the Controller will prepare the full package of journal entries for the COO to review and sign off on each month. This will include all the recurring and standard monthly entires. Proposed Completion Date: January 10, 2023
View Audit 37424
Finding 40156 (2022-001)
Significant Deficiency 2022
B-K Health Center, Inc. (d/b/a Nepa Community Health Care)
PA
Reporting Internal Control / Segregation of Duties Significant Deficiency
B-K Health Center Inc. d/b/a NEPA Community Health Care (the Organization) respectfully submits the following corrective action plan for the year ending September 30, 2022. Audit Finding Reference: 2022-001 ? Significant Deficiency in Internal Control ? Reporting Condition/Context: The Organizat...
B-K Health Center Inc. d/b/a NEPA Community Health Care (the Organization) respectfully submits the following corrective action plan for the year ending September 30, 2022. Audit Finding Reference: 2022-001 ? Significant Deficiency in Internal Control ? Reporting Condition/Context: The Organization was required to submit the Annual Federal Financial Report by July 30, 2022 and the report was submitted on September 1, 2022. This is not a statistically valid sample. Recommendation: The Organization should implement procedures to identify and ensure compliance with all reporting requirements for the program. Planned Corrective Action: Both the CEO and CFO will add the reporting deadlines to their calendars to ensure timely filing. The CFO will prepare the document for reporting and the CEO will certify documents. A monthly update will be given to the finance committee as to reports filed for the prior month. Name of Contact Person: Kristen Follert, CEO Anticipated Completion Date: 1/19/2023
View Audit 37315
Finding 40155 (2022-003)
Significant Deficiency 2022
Virginia Union University
VA
Student Financial Aid Matching / Level of Effort / Earmarking
See corrective action plan for chart/table.
See corrective action plan for chart/table.
View Audit 53516
Finding 40154 (2022-002)
Significant Deficiency 2022
Virginia Union University
VA
Student Financial Aid Reporting Matching / Level of Effort / Earmarking
See corrective action plan for chart/table.
See corrective action plan for chart/table.
View Audit 53516
Finding 40153 (2022-001)
Material Weakness 2022
Virginia Union University
VA
Student Financial Aid Cash Management Reporting
See corrective action plan for chart/table.
See corrective action plan for chart/table.
View Audit 53516
Finding 40152 (2022-004)
Material Weakness 2022
Virginia Union University
VA
Questioned Costs Student Financial Aid Eligibility
See corrective action plan for chart/table.
See corrective action plan for chart/table.
View Audit 53516 Questioned Costs: $1
Finding 40149 (2022-001)
Material Weakness 2022
Hope Family Health Services, Inc.
TN
Special Tests & Provisions Internal Control / Segregation of Duties
In Finding 2022-001, it was reported that the Organization did not properly substantiate that proper documentation was obtained and that proper sliding fee discounts were applied for certain patients for the year ended December 31, 2022. During the pandemic, the Organization has experienced signif...
In Finding 2022-001, it was reported that the Organization did not properly substantiate that proper documentation was obtained and that proper sliding fee discounts were applied for certain patients for the year ended December 31, 2022. During the pandemic, the Organization has experienced significant turnover of staff, especially in those personnel who are responsible for obtaining documentation for sliding fee discounts and calculating the discounts. Employees will be given proper training to document and apply the sliding fee discounts, and the Organization will ensure that the sliding fee discounts are reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. This review and training will be completed by July 31, 2023.
View Audit 53069
Finding 40148 (2022-002)
Significant Deficiency 2022
Chippewa Lutheran Housing Corporation
PA
Questioned Costs Internal Control / Segregation of Duties HUD Housing Programs
2022-002 Federal agency: U.S. Department of Housing and Urban Development Federal program title: Supportive Housing for the Elderly Section 202 CFDA Number: 14.157 Criteria or specific requirement: Unapproved replacement reserve withdrawal. Condition: The Corporation mistakenly withdrew an unapprove...
2022-002 Federal agency: U.S. Department of Housing and Urban Development Federal program title: Supportive Housing for the Elderly Section 202 CFDA Number: 14.157 Criteria or specific requirement: Unapproved replacement reserve withdrawal. Condition: The Corporation mistakenly withdrew an unapproved amount from the replacement reserve account in February 2022. Questioned costs: 7,796 Context: Upon receiving proper HUD withdrawal approval, the Corporation mistakenly duplicated the amount of the withdrawal. Upon discover of this mistake, these funds were deposited back into the replacement reserve account in February 2022. Recommendation: The Corporation should ensure all replacement reserve amounts are properly reviewed and approved prior to withdrawal occurs. Action taken in response to finding: Managements acknowledges this finding and is taking steps to correct. Management has counseled HUD building management on the need for appropriate process for handling of the replacement reserve account funds in the future. Name of contact person responsible for corrective action: Jeffrey Carraway
View Audit 53437 Questioned Costs: $1
Finding 40147 (2022-001)
Significant Deficiency 2022
Chippewa Lutheran Housing Corporation
PA
HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties
2022-001 Federal agency: U.S. Department of Housing and Urban Development Federal program title: Supportive Housing for the Elderly Section 202 CFDA Number: 14.157 Criteria or specific requirement: Expired Project Rental Assistance Contract (PRAC). Condition: The Corporation did not renew the PRAC t...
2022-001 Federal agency: U.S. Department of Housing and Urban Development Federal program title: Supportive Housing for the Elderly Section 202 CFDA Number: 14.157 Criteria or specific requirement: Expired Project Rental Assistance Contract (PRAC). Condition: The Corporation did not renew the PRAC timely. Context: The PRAC expired September 30, 2021, and was not renewed until February 14, 2022. Recommendation: The Corporation should ensure the PRAC is renewed on a timely basis annually. Action taken in response to finding: Managements acknowledges this finding and is taking steps to correct. Management has counseled HUD building management on the need for timely submissions of proposed budgets and contract completion. A master schedule has been set up and all budget submissions will now be reviewed by the Finance Department prior to submission. Name of contact person responsible for corrective action: Jeffrey Carraway
View Audit 53437
Finding 40146 (2022-027)
Material Weakness 2022
State of North Carolina
NC
Subrecipient Monitoring
Inadequate Subrecipient Monitoring Department Name: Health and Human Services Contact Name / Telephone Number of Person Responsible for CAP: Curtis D. Terry - (984) 236-5355 The Division is updating and strengthening its subrecipient monitoring policy and process. Those updates will include, among o...
Inadequate Subrecipient Monitoring Department Name: Health and Human Services Contact Name / Telephone Number of Person Responsible for CAP: Curtis D. Terry - (984) 236-5355 The Division is updating and strengthening its subrecipient monitoring policy and process. Those updates will include, among other things, requesting federal prior approval to deviate from required processes and procedures. The Division will ensure appropriate monitoring during times of business interruption, such as a public health emergency based on guidance provided by the federal funding agency and during a period of high staff vacancies by reassigning monitoring activities to available qualified staff. Anticipated Completion Date: December 31, 2023.
View Audit 53638
Finding 40145 (2022-026)
Material Weakness 2022
State of North Carolina
NC
Subrecipient Monitoring Reporting
Errors in FFATA Reporting Department Name: Health and Human Services Contact Name / Telephone Number of Person Responsible for CAP: Sheryl Plummer - (984) 236-5353 The Division of Mental Health, Developmental Disabilities, and Substance Use Services (DMH/DD/SUS) is updating and strengthening its app...
Errors in FFATA Reporting Department Name: Health and Human Services Contact Name / Telephone Number of Person Responsible for CAP: Sheryl Plummer - (984) 236-5353 The Division of Mental Health, Developmental Disabilities, and Substance Use Services (DMH/DD/SUS) is updating and strengthening its approach to Federal Funding Accountability and Transparency Act (FFATA) reporting. DMH/DD/SUS is in the final phase of filling the vacant Business Manager position within the Budget and Finance section. The Business Manager will be responsible for developing formalized FFATA reporting policies and procedures, ensuring staff receive cross-training on FFATA reporting, and reviewing FFATA reports for accuracy before submission. Anticipated Completion Date: December 31, 2023.
View Audit 53638
Finding 40144 (2022-025)
Significant Deficiency 2022
State of North Carolina
NC
Questioned Costs Period of Performance Subrecipient Monitoring
Funds Spent After Award Ended Department Name: Health and Human Services Contact Name / Telephone Number of Person Responsible for CAP: Sheryl Plummer - (984) 236-5353 The Division of Mental Health, Developmental Disabilities, and Substance Use Services is in the final phase of filling the vacant Bu...
Funds Spent After Award Ended Department Name: Health and Human Services Contact Name / Telephone Number of Person Responsible for CAP: Sheryl Plummer - (984) 236-5353 The Division of Mental Health, Developmental Disabilities, and Substance Use Services is in the final phase of filling the vacant Business Manager position within the Budget and Finance section. This position will be responsible for updating policies and procedures to include a detailed review process for processing grant expenditures. The policy will include a process for grant expenditure review during the 90-day liquidation (closeout) period for the grant. This process will consist of verifying grant expenditures and/or grant payment reclassifications has sufficient supporting documentation to be processed. The Division?s Budget and Finance section will also implement secondary review and approval processes for expenditures paid during the grant closeout period. Anticipated Completion Date: December 31, 2023.
View Audit 53638 Questioned Costs: $1
Finding 40143 (2022-024)
Significant Deficiency 2022
State of North Carolina
NC
Questioned Costs Subrecipient Monitoring
Funds Not Used on Primary Prevention Programs Department Name: Health and Human Services Contact Name / Telephone Number of Person Responsible for CAP: Sheryl Plummer - (984) 236-5353 The Division of Mental Health, Developmental Disabilities, and Substance Use Services (DMH/DD/SUS) is in the final p...
Funds Not Used on Primary Prevention Programs Department Name: Health and Human Services Contact Name / Telephone Number of Person Responsible for CAP: Sheryl Plummer - (984) 236-5353 The Division of Mental Health, Developmental Disabilities, and Substance Use Services (DMH/DD/SUS) is in the final phase of filling the vacant Business Manager position within the Budget and Finance section. This position will be responsible for updating policies and procedures to include an Earmarking process in the Business and Finance section. This process will involve the Business Manager assigning a Budget and Finance staff member to determine the set aside amount for prevention services based on the terms of the award and capped amounts such as administrative services. The assigned staff member will track expenditures monthly and will also compare the DMH/DD/SUS tracking report to the DHHS Office of the Controller? Grant Inventory report. Discrepancies between the DMH/DD/SUS and Controller?s Office monthly reports will be reconciled based on the grant terms to ensure the 20% threshold is met during the period of the grant. Anticipated Completion Date: December 31, 2023.
View Audit 53638 Questioned Costs: $1
Finding 40142 (2022-021)
Significant Deficiency 2022
State of North Carolina
NC
Subrecipient Monitoring
Inadequate Subrecipient Monitoring Department Name: Health and Human Services Contact Name / Telephone Number of Person Responsible for CAP: Curtis D. Terry - (984) 236-5355 The Division is updating and strengthening its subrecipient monitoring policy and process. Those updates will include, among o...
Inadequate Subrecipient Monitoring Department Name: Health and Human Services Contact Name / Telephone Number of Person Responsible for CAP: Curtis D. Terry - (984) 236-5355 The Division is updating and strengthening its subrecipient monitoring policy and process. Those updates will include, among other things, requesting federal prior approval to deviate from required processes and procedures. The Division will ensure appropriate monitoring during times of business interruption, such as a public health emergency based on guidance provided by the federal funding agency and during a period of high staff vacancies by reassigning monitoring activities to available qualified staff. Anticipated Completion Date: December 31, 2023.
View Audit 53638
Finding 40141 (2022-020)
Significant Deficiency 2022
State of North Carolina
NC
Subrecipient Monitoring Reporting
FFATA Reporting Not Completed Department Name: Health and Human Services Contact Name / Telephone Number of Person Responsible for CAP: Lisa Allnutt - (919) 527-6854; Felicia Harris - (919) 527-6416; Curtis Terry - (984) 236-5355 Department-wide FFATA training was provided on August 12, 2022. In add...
FFATA Reporting Not Completed Department Name: Health and Human Services Contact Name / Telephone Number of Person Responsible for CAP: Lisa Allnutt - (919) 527-6854; Felicia Harris - (919) 527-6416; Curtis Terry - (984) 236-5355 Department-wide FFATA training was provided on August 12, 2022. In addition, the Department will implement a FFATA Data Reporting Form and provide communication to all divisions regarding the use of the form. Anticipated Completion Date: March 31, 2023. Division of Social Services The Business Operations Budget section filled three positions, two of which are assigned responsibilities for the FFATA reporting process. The FFATA reporting procedures were updated to ensure segregation of the review and approval processes and to include step by step instructions. The Business Operations Budget section will continue to hire additional positions to ensure FFATA duties are reassigned in the event of employee turnover. Anticipated Completion Date: March 31, 2023. Division of Mental Health The Division is in the final phase of filling the vacant Business Manager position within the Budget and Finance section. This position will be responsible for assigning FFATA reporting responsibilities and confirming submitted reports are accurate. In addition, the Division will establish a contingency plan to ensure FFATA reporting is completed when essential staff turnover occurs. Anticipated Completion Date: March 31, 2023.
View Audit 53638
Finding 40140 (2022-019)
Significant Deficiency 2022
State of North Carolina
NC
Reporting
Inaccurate TANF Data on Families Was Submitted to the Federal Government Department Name: Health and Human Services Contact Name / Telephone Number of Person Responsible for CAP: Shauna Cuffee - (919) 527-6265; Heather Bohanan - (919) 527-6264 The Department will perform the following actions: ? A t...
Inaccurate TANF Data on Families Was Submitted to the Federal Government Department Name: Health and Human Services Contact Name / Telephone Number of Person Responsible for CAP: Shauna Cuffee - (919) 527-6265; Heather Bohanan - (919) 527-6264 The Department will perform the following actions: ? A table to capture participant months has been created by NC FAST. The Applications System Specialist from the Client Services Data Warehouse team will update the ACF-199 code to pull month counts from this table. ? The programming code will be corrected to ensure cases are only counted once per month. Anticipated Completion Date: June 30, 2023.
View Audit 53638
Finding 40139 (2022-018)
Significant Deficiency 2022
State of North Carolina
NC
Subrecipient Monitoring Reporting
FFATA Reporting Not Completed Department Name: Health and Human Services Contact Name / Telephone Number of Person Responsible for CAP: Lisa Allnutt - (919) 527-6854; Felicia Harris - (919) 527-6416; Candice Bailey - (919) 609-2100 Department-wide FFATA training was provided on August 12, 2022. In a...
FFATA Reporting Not Completed Department Name: Health and Human Services Contact Name / Telephone Number of Person Responsible for CAP: Lisa Allnutt - (919) 527-6854; Felicia Harris - (919) 527-6416; Candice Bailey - (919) 609-2100 Department-wide FFATA training was provided on August 12, 2022. In addition, the Department will implement a FFATA Data Reporting Form and provide communication to all divisions regarding the use of the form. Anticipated Completion Date: March 31, 2023. Division of Social Services The Business Operations Budget section filled three positions, two of which are assigned responsibilities for the FFATA reporting process. The FFATA reporting procedures were updated to ensure segregation of the review and approval processes and to include step by step instructions. The Business Operations Budget section will continue to hire additional positions to ensure FFATA duties are reassigned in the event of employee turnover. Anticipated Completion Date: March 31, 2023. Division of Child Development and Early Education DCDEE staff attended Department-wide FFATA training on August 12, 2022. DCDEE Contracts staff will be responsible for reporting TANF subawards administered through DCDEE contracts. Anticipated Completion Date: March 31, 2023.
View Audit 53638
Finding 40138 (2022-017)
Significant Deficiency 2022
State of North Carolina
NC
Questioned Costs Eligibility
Deficiencies in the TANF Eligibility Determination Process Department Name: Health and Human Services Contact Name / Telephone Number of Person Responsible for CAP: Allison Smith - (919) 527-6316 The Division of Social Services will provide targeted training and support for the two counties in error...
Deficiencies in the TANF Eligibility Determination Process Department Name: Health and Human Services Contact Name / Telephone Number of Person Responsible for CAP: Allison Smith - (919) 527-6316 The Division of Social Services will provide targeted training and support for the two counties in error and will continue to provide support to prevent future errors from occurring. Anticipated Completion Date: June 30, 2023.
View Audit 53638 Questioned Costs: $1
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