Corrective Action Plans

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Views of Responsible Officials and Corrective Action Planned: The Seminary hired a third-party financial aid servicer, Financial Aid Services, LLC (?FAS?) who will do the enrollment reporting as part of their contract. The FAS contract was signed May 2022 for the upcoming fiscal year 2022 to 2023. T...
Views of Responsible Officials and Corrective Action Planned: The Seminary hired a third-party financial aid servicer, Financial Aid Services, LLC (?FAS?) who will do the enrollment reporting as part of their contract. The FAS contract was signed May 2022 for the upcoming fiscal year 2022 to 2023. This contract was approved by the Administrative Council in May 2022. The Seminary?s current part-time financial aid coordinator sent out the April 2022 enrollment roster which included student status changes on October 17, 2022.
Corrective Action Plan for Finding 2022-001 The City did not have adequate controls or procedures in place to identify the applicable reporting requirement and ensure the information was filed accurately and timely. Views of Responsible Officials and Planned Corrective Actions: Management agrees...
Corrective Action Plan for Finding 2022-001 The City did not have adequate controls or procedures in place to identify the applicable reporting requirement and ensure the information was filed accurately and timely. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding. Finance Department has implemented a new process that requires reports to be completed by the 15th of the following month. Reports from Community Development Manager are to be submitted to Comptroller for review and sign off to be reported timely by the report due date. Responsible Party: The Comptroller is responsible to follow-up and ensure report is completed. Implementation Date: March 15, 2023
Finding 16534 (2022-001)
Significant Deficiency 2022
Caritas Villa respectfully submits the following corrective action plan for the year ended June 30, 2022. Name & address of public accounting firm: Jones & Roth CPAs 260 Country Club Rd. Ste. 100 Eugene OR 97401 Audit Period: June 30, 2022 Major Federal Award Findings: Finding Reference #: 2022-001 ...
Caritas Villa respectfully submits the following corrective action plan for the year ended June 30, 2022. Name & address of public accounting firm: Jones & Roth CPAs 260 Country Club Rd. Ste. 100 Eugene OR 97401 Audit Period: June 30, 2022 Major Federal Award Findings: Finding Reference #: 2022-001 Significant deficiency Recommendation: We recommend management review the current internal control procedures and implement additional procedures to ensure annual recertifications are performed as required by HUD. Corrective Action: Management will work with Cascade Management to improve the internal control procedures to ensure annual recertifications are performed as required by December 31, 2022. Questions regarding this corrective action plan may be directed to Marci Pierce, Chief Financial and Administrative Officer, at (503) 688-2646.
Views of Responsible Officials: During an audit process of our federal fund expenditures on October 19,2022. The auditors found our district is not keeping records to specifically track property and equipment acquired with Federal Awards, nor is an inventory performed as required. On October 20, 202...
Views of Responsible Officials: During an audit process of our federal fund expenditures on October 19,2022. The auditors found our district is not keeping records to specifically track property and equipment acquired with Federal Awards, nor is an inventory performed as required. On October 20, 2022 and October 21, 2022 an inventory was developed to include all capital projects and a notation for items purchased with Federal Awards. The spreadsheet was created by Superintendent Tara Lewis and with the document shared with Bookkeeper Julie Cragen. Previous to the audit finding our district used a video inventory to capture visual evidence of items purchased for insurance purposes. Additionally, invoices were reviewed from Stewart Refrigeration and found that the invoices did not breakdown the bill for supplies and wages/labor. In the bidding process the Prevailing Wage order was used, but it is not documented on the bid nor the invoice. As of December 1, 2022 we will insure all bids and invoices are specific when prevailing wage is required.
Finding 2022-001 Sea Mar will retrain medical, dental and behavioral health department staff at all sites who conduct and/or oversee the patient registration and income verification process. This includes Health Center Administrators, Front Desk Supervisors, Dental Supervisors, Financial Specialist...
Finding 2022-001 Sea Mar will retrain medical, dental and behavioral health department staff at all sites who conduct and/or oversee the patient registration and income verification process. This includes Health Center Administrators, Front Desk Supervisors, Dental Supervisors, Financial Specialists and Receptionists. This training will be conducted via Relias (web-based training and testing). This training will be required for all staff including new hires to ensure compliance and consistency. A competency test will be administered after the training, which requires a score of I 00% to pass. If an employee does not pass the competency test, they will be retrained and will retake the test. We will track and run reports for all staff that are required to complete these tasks to ensure compliance. This log will demonstrate that staff at the sites were trained and have passed the competency test. Sea Mar will conduct an audit to determine the accuracy of income verifications. The audit will select a random sample of patients to test and verify accuracy and completeness. Sea Mar has set a goal to achieve accuracy percentage of 95%-100% and will conduct monthly audits to monitor accuracy and improvement. Sea Mar will also implement a process that will require supervisors to review and sign off on employee's income verifications to ensure they are accurate. Supervisors will be expected to ensure this process is being conducted accurately at their sites and to retrain staff who are not accurately verifying income. This review and sign off process will be verified during the quarterly audit. The quarterly audit will also identify sites and staff who need additional training. The contact person for the corrective action plan is Sea Mar's Chief Compliance Officer, Kristina Hoeschen, Kristina Hoeschen@seamarchc.org ,and the anticipated completion date of November 30, 2022.
The District has implemented new procedures related to the retention of production records in the Child Nutrition Program. The procedures include, but are not limited to: 1) Detailed instructions as to which documents are to be retained and where they are to be filed 2) Review of the production reco...
The District has implemented new procedures related to the retention of production records in the Child Nutrition Program. The procedures include, but are not limited to: 1) Detailed instructions as to which documents are to be retained and where they are to be filed 2) Review of the production records daily by the on-site supervisors 3) Training and retraining of employees when necessary 4) Evaluation of the overall procedures on a triennial basis 5) Disposition guidelines once the retention period has passed. The Director of FNs is responsible for the implementation and oversight of document retention procedures. The new procedures will be implemented on October 18, 2022.
Finding: 2022-003 Corrective Action Plan: While the District did get signed certification from the vendor that the organization had not been suspended or debarred, the District did not take the further step to check the government website for verification. The District will ensure that this step wi...
Finding: 2022-003 Corrective Action Plan: While the District did get signed certification from the vendor that the organization had not been suspended or debarred, the District did not take the further step to check the government website for verification. The District will ensure that this step will be taken in the future. Also, the vendor in question was checked as of 4/18/23 on the government website and did not appear as debarred or suspended. Anticipated Completion Date: Completed Contact Person: Amanda Raymond, Director of Finance
Finding: 2022-004 Corrective Action Plan: The District?s payroll process is significantly lacking proper control procedures. With the hiring of a new financial manager, policies, procedures and controls will be implemented immediately, including the proper tracking of time and effort for employees...
Finding: 2022-004 Corrective Action Plan: The District?s payroll process is significantly lacking proper control procedures. With the hiring of a new financial manager, policies, procedures and controls will be implemented immediately, including the proper tracking of time and effort for employees charged to federal grants as required. Anticipated Completion Date: September 1, 2023 Contact Person: Amanda Raymond, Director of Finance
#2022-004 - Compliance Finding - Procurement Recommendations: We recommend that Grand Rapids Christian Schools establish and follow written procurement standards that comply with the requirements of Uniform Guidance and 2 CFR 200.320. ...
#2022-004 - Compliance Finding - Procurement Recommendations: We recommend that Grand Rapids Christian Schools establish and follow written procurement standards that comply with the requirements of Uniform Guidance and 2 CFR 200.320. Views of Responsible Officials and Planned Corrective Actions: ? The GRCMS kitchen renovation needed to be completed quickly over the summer of 2022, and in time for the start of the 2022-23 school year (August 16, 2022). As a result, Grand Rapids Christian did not solicit quotes and contracted with Rockford Construction, who was the contractor for the GRCMS building renovation in 2014. ? GRCS will develop established written procurement standards and, when appropriate, will follow them for future projects. GRCS will utilize the resources from Uniform Guidance and 2 CFR 200 to develop a policy that is in compliance with those requirements prior to June 30, 2023.
#2022-003 - Significant Deficiency in Controls over Compliance: Lack of Review over Reporting Recommendations: We understand that many, if not all locations participating in the meal programs have since either reverted back to using the electronic system for counting students, or plan to do so in th...
#2022-003 - Significant Deficiency in Controls over Compliance: Lack of Review over Reporting Recommendations: We understand that many, if not all locations participating in the meal programs have since either reverted back to using the electronic system for counting students, or plan to do so in the near term. We recommend that any remaining manual reports/tally sheets be reviewed prior to submitting counts for reimbursement. Views of Responsible Officials and Planned Corrective Actions: ? Because student meals are no longer free in the 2022-23 school year, GRCS is returning to the electronic system for counting student meals.
#2022-002: Material Weakness in Controls over Compliance: Administrative Requirements of Uniform Guidance -Administrative Policies Recommendations: Grand Rapids Christian Schools should consider the following written policy additions or updates: ? Financial Management (2 CFR 200.302) The financial m...
#2022-002: Material Weakness in Controls over Compliance: Administrative Requirements of Uniform Guidance -Administrative Policies Recommendations: Grand Rapids Christian Schools should consider the following written policy additions or updates: ? Financial Management (2 CFR 200.302) The financial management policy should include records documenting compliance, and the tracking of funds to determine that expenditures are in accordance with the terms and conditions of the federal awards. The financial management and reporting system must provide the following : ? Identification - Title of the award, CFDA number ? Complete disclosure of accurate and current financial results of each federal award ? Source and application of funds for federal award activity ? Record retention and access - define the time period for which records must be kept (can vary by grant agreement), and who has the ability access the records (?200.333 - ?200.337) ? Written procedure to implement cash management requirements (see below) ? Written procedures for determining the allowability of costs (see below) ? Cash Management (2 CFR 200.305) A written policy is required by Uniform Guidance detailing the Organization's procedures to minimize the time that elapses between draw and expenditure of federal dollars. ? Allowable Costs (2 CFR 200.302(b)(7)) The Organization must have written procedures for determining the allowability of costs in accordance with Subpart E - Cost Principles of Uniform Guidance and the terms and conditions of the Federal award. This includes the determination of allowable costs and the review of this determination. The standard assumes policies and procedures are in place for disbursements, and the allowable cost policy will demonstrate how the Organization ensures compliance. The criteria for costs to be considered allowable are documented within 2 CFR 200.403. ? Procurement Standards (2 CFR 200.317 - 200.326) The Organization must have a written policy that promotes full and open vendor competition, conflict of interest policies should cover employees as well as the organization, and general purchase requirements with specific thresholds as set forth by the Uniform Guidance. There are five allowable procurement methods as described in ?200.320, depending upon the dollar value of the purchase or contract. Views of Responsible Officials and Planned Corrective Actions: ? Grand Rapids Christian Schools follows procurement and record retention standards provided by the USDA. ? GRCS does not have actual written policies and procedures for Financial Management, Cash Management, Allowable Costs, and Procurement Standards, but do have practices in place to follow USDA guidelines. In the case of cash management, the only location that takes cash is GRCHS. In that instance, along with Meal Magic, cash registers are zeroed out and balanced to Meal Magic and cash deposits are made daily. ? GRCS Business Office will work with the Food Service Director to begin formulating written policies and procedures specific to Grand Rapids Christian Schools. GRCS will utilize the resources from Uniform Guidance and Code of Federal Regulations (CFR) to develop policies that are compliant with those requirements prior to June 30, 2023.
Identifying Number: 2022-002 Finding: Late Issuance of the 2022 Single Audit Reporting Package The District?s fiscal year 2022 Single Audit package was not submitted to the Federal Audit Clearinghouse within the required time period. The Single Audit package for the District?s fiscal year ended J...
Identifying Number: 2022-002 Finding: Late Issuance of the 2022 Single Audit Reporting Package The District?s fiscal year 2022 Single Audit package was not submitted to the Federal Audit Clearinghouse within the required time period. The Single Audit package for the District?s fiscal year ended June 30, 2022 should have been submitted to the Federal Audit Clearinghouse by March 31, 2023. Corrective Action Taken or Planned: The District will schedule and complete future external audits in a manner that will allow timely reporting of the Single Audit. Anticipated Completion Date: June 2023 Responsible Person(s): John Gibson, Chief School Business Official
FINDING 2022-001: THE CITY OF CULLMAN, ALABAMA WILL DEVELOP A GRANTS MANUAL OR WRITTEN POLICIES TO INCORPORATE ALL REQUIREMENTS OF 2 CFR 200 AND ENSURE COMPLIANCE WITH GRANT REQUIREMENTS.
FINDING 2022-001: THE CITY OF CULLMAN, ALABAMA WILL DEVELOP A GRANTS MANUAL OR WRITTEN POLICIES TO INCORPORATE ALL REQUIREMENTS OF 2 CFR 200 AND ENSURE COMPLIANCE WITH GRANT REQUIREMENTS.
CORRECTIVE ACTION PLAN Name and Number of the Project: St. George?s Senior Housing, Inc. No. 115-EH057 Audit Firm: M Group, LLP Audit Period: The year ended September 30, 2022 Compliance Review A. COMMENTS ON FINDINGS AND RECOMMENDATIONS We concur with the findings and recommendations of our au...
CORRECTIVE ACTION PLAN Name and Number of the Project: St. George?s Senior Housing, Inc. No. 115-EH057 Audit Firm: M Group, LLP Audit Period: The year ended September 30, 2022 Compliance Review A. COMMENTS ON FINDINGS AND RECOMMENDATIONS We concur with the findings and recommendations of our auditors regarding our noncompliance as cited in the accompanying Schedule of Findings and Questioned Costs. ACTIONS TAKEN
View Audit 23155 Questioned Costs: $1
Finding Number 2022-005 Education Stabilization Fund: Elementary and Secondary School Emergency Relief (ESSER) Assistance Listing Number 84.425D Allowable Costs/Cost Principles ? Documentation of Employee Time and Effort Immaterial Noncompliance Criteria: Per Federal regulations 2 CFR section 200.43...
Finding Number 2022-005 Education Stabilization Fund: Elementary and Secondary School Emergency Relief (ESSER) Assistance Listing Number 84.425D Allowable Costs/Cost Principles ? Documentation of Employee Time and Effort Immaterial Noncompliance Criteria: Per Federal regulations 2 CFR section 200.430(i)(1)(vii), the School District must maintain time and effort distribution records for an employee who works in part on the consolidated administrative cost objective and in part on a federal program whose administrative funds have not been consolidated or on activities funded from other revenue sources. Condition: The School District did not maintain time and effort distribution records for employees who were partially funded with ESSER Federal funds. Cause: Oversight. Effect: Time and effort reports were not completed. Questioned Costs: None. Recommendation: Time and effort reports should be completed throughout the year listing the employees name, position or job title, and percentage of time spent on each Federal award and signed by the employee?s supervisor. Management's Response and Corrective Actions: The Director of Finance and Superintendent completed time and effort reports for the ESSER funds expended for fiscal year ending June 30, 2022 and will continue to complete time and effort reports going forward. Person Responsible for Corrective Action: Justin Weston, Director of Finance, and Amiee Erfourth, Superintendent Completion Date: November 21, 2022.
Allegany County HRDC agrees with the finding and will ensure that all reports are filed timely in the future.
Allegany County HRDC agrees with the finding and will ensure that all reports are filed timely in the future.
Management increased the security deposit bank account by $500 on September 15, 2022 to correct this finding.
Management increased the security deposit bank account by $500 on September 15, 2022 to correct this finding.
Contact Person Dawn Bacon, Executive Director Corrective Action Plan Staff will perform quality control review for the Public and Indian Housing program. Going forward a sample of files will be reviewed on a semi-annual basis. Planned Completion Date for CAP FY2023
Contact Person Dawn Bacon, Executive Director Corrective Action Plan Staff will perform quality control review for the Public and Indian Housing program. Going forward a sample of files will be reviewed on a semi-annual basis. Planned Completion Date for CAP FY2023
Contact Person Dawn Bacon, Executive Director Corrective Action Plan Error occurred due to lack of oversight in review of calculation of annual income and underlying support. We continue to confirm that all total tenant payment (TTP) calculations are matched to verification of income and deductions ...
Contact Person Dawn Bacon, Executive Director Corrective Action Plan Error occurred due to lack of oversight in review of calculation of annual income and underlying support. We continue to confirm that all total tenant payment (TTP) calculations are matched to verification of income and deductions documentation in tenant files. Planned Completion Date for CAP FY2023
Criteria: The Hospital must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Hospital is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. 2 CFR 200.327 and 2 CF...
Criteria: The Hospital must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Hospital is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. 2 CFR 200.327 and 2 CFR 200.328 require the auditee to collect financial information and monitor its activities under federal awards to assure compliance with applicable federal requirements and performance expectations are being achieved and report these items in accordance with program requirements. Terms and conditions of the federal award require the Hospital to maintain a reserve fund at specified balance levels. Condition: During 2022, the accounts that represented the reserve fund had a balance below that required by the loan resolution agreements and required deposits were not being made to restore the balances to required levels. Planned Corrective Action: Management agrees with the finding and will deposit required amounts into the reserve fund. Planned Completion Date: Ongoing Person Responsible: Jeremy Bauer, CEO
2022-007 Reserve Requirement not Met for the Sewerage System Mortgage Revenue Bond Condition: The District did not meet the reserve requirement for the bond issuance during the audit period. Criteria: The Sewerage System Mortgage Revenue Bond agreement, as outlined in Resolution No. 22-02, specie...
2022-007 Reserve Requirement not Met for the Sewerage System Mortgage Revenue Bond Condition: The District did not meet the reserve requirement for the bond issuance during the audit period. Criteria: The Sewerage System Mortgage Revenue Bond agreement, as outlined in Resolution No. 22-02, species that the District must maintain an amount equal to the least of (a) the amount required by the District ($86,500), (b) maximum annual debt service on the Bond in any Bond Year and (c) 125% of average annual debt service on the Bond, to ensure compliance with the terms and conditions of the bond issuance. Cause: The failure to meet the reserve requirement was primarily attributed to not transferring money to the reserve account. Effect: Failure to meet the reserve requirements could result in regulatory penalties. Auditor's Recommendation: We recommend the District develops a plan to replenish the reserve to meet the bond issuance requirements, implements a robust financial monitoring system to track compliance with bond issuance terms and ensure the reserve requirement is met on an ongoing basis, and conduct a comprehensive review of financial planning processes to prevent future reserve shortfalls. Management Response: The District acknowledges the audit finding and is committed to taking corrective measures in line with the recommendations provided. We will develop a detailed action plan to replenish the reserve and enhance financial monitoring and planning processes to prevent similar issues in the future. Contact Person: Dawn Bauer Anticipated Completion: December 31, 2023
2022-006 Late Submission of 2021 Data Collection Form with Federal Audit Clearinghouse Condition: The 2021 data collection form for the District was submitted after the prescribed nine month due date, as required by the Federal Audit Clearinghouse for the year ended December 31, 2021. Criteria: Th...
2022-006 Late Submission of 2021 Data Collection Form with Federal Audit Clearinghouse Condition: The 2021 data collection form for the District was submitted after the prescribed nine month due date, as required by the Federal Audit Clearinghouse for the year ended December 31, 2021. Criteria: The Federal Audit Clearinghouse requires that organizations submit their annual audit and the annual data collection form within nine months after the fiscal year-end. Cause: The delay in submitting the 2021 data collection form and the 2021 annual audit was primarily due to the audit was performed late. Effect: This delay in submission may hinder timely access to accurate financial information for decision-making and reporting. Auditor's Recommendation: We recommend that the District establishes a formalized process to track regulatory filing deadlines and responsibilities and conduct periodic reviews to ensure timely compliance with regulatory requirements. Management Response: The District acknowledges the audit finding and commits to implementing the recommended actions promptly to enhance compliance with regulatory requirements regarding data collection form submissions. Contact Person: Dawn Bauer Anticipated Completion: December 31, 2023
2022-005 Federal Procedure Manual Condition: Internal controls over federal grants should be in place to provide reasonable assurance that misstatement in the schedule of expenditures of federal awards would be prevented or detected. Criteria: Non-federal entities who receive federal or state gra...
2022-005 Federal Procedure Manual Condition: Internal controls over federal grants should be in place to provide reasonable assurance that misstatement in the schedule of expenditures of federal awards would be prevented or detected. Criteria: Non-federal entities who receive federal or state grants or have grant programs should have documented policies and procedures in place over grants and grant expenditures. Cause: The District does not have documented policies and procedures in place over grants and grant expenditures. Effect: Without documented policies and procedures, the internal control over federal grants is low, and the risk of misstatement in the schedule of expenditures of federal and state awards is high. Auditor's Recommendation: We recommend that the District works on written policies and procedures over grants and grant expenditures. Management Response: The District will work with their auditor to develop and adopt written grant procedures that are in accordance with the Uniform Guidance. Contact Person: Dawn Bauer Anticipated Completion: December 31, 2023
2022-004 Drafting Schedule of Expenditures of Federal Awards and Related Notes Condition: Like other entities of similar size, the District requires the assistance of the auditor to prepare the schedule of expenditures of federal awards in accordance with the Uniform Guidance. Criteria: Internal co...
2022-004 Drafting Schedule of Expenditures of Federal Awards and Related Notes Condition: Like other entities of similar size, the District requires the assistance of the auditor to prepare the schedule of expenditures of federal awards in accordance with the Uniform Guidance. Criteria: Internal controls over preparation of the schedule of expenditures of federal awards should be in place to provide reasonable assurance that a misstatement in the schedule of expenditures of federal awards would be prevented or detected. Cause: Management relies on the auditor to assist with the preparation of the schedule of expenditures of federal awards. Effect: The District's system of internal control may not prevent, detect, or correct misstatements in the schedule of expenditures of federal awards. Auditor's Recommendation: The auditor will continue to work with the District, providing information and training when necessary, to make the District?s personnel more knowledgeable about its responsibility for the schedule of expenditures of federal awards. Management Response: The control deficiency has been discussed with the District?s Board and they acknowledge their responsibility for the schedule of expenditures of federal awards. The District accepts responsibility for the schedule of expenditures of federal awards. Due to the technical nature of preparing the schedule of expenditures of federal awards, and due to limited resources, the District does not anticipate the need for this assistance to change in the foreseeable future. Contact Person: Dawn Bauer Anticipated Completion: Not Applicable
Reference Number: 22-02 Name of Award ? Project Number (794, 628, 770) (Federal Findings) Condition/Finding: The District's final expenditure reports with the Oklahoma State Department of Education and Oklahoma Cost Accounting System (OCAS), did not match the actual allowable expense for their p...
Reference Number: 22-02 Name of Award ? Project Number (794, 628, 770) (Federal Findings) Condition/Finding: The District's final expenditure reports with the Oklahoma State Department of Education and Oklahoma Cost Accounting System (OCAS), did not match the actual allowable expense for their program. Three programs (794, 628, 770) had OCAS coding errors when final reports were submitted to the Oklahoma State Department of Education. Corrective steps that have already been implemented and/or the steps that will be implemented: All OCAS data, both receiving and expenditures, will be correct and accurate. All OCAS data involving Federal Programs will be reported correctly and accurately to the Oklahoma State Department of Education. Completion Date: Immediately The plan for monitoring adherence to the corrective action plan: All Chisholm Public Schools central office personnel involved with purchase orders, and OCAS data, will seek professional development and training to improve professionally. Additionally, all Chisholm Public Schools central office personnel will work collaboratively to ensure that all OCAS data is correct and accurate on an ongoing basis. Finally, all finalized OCAS data will be completely accurate when submitting to the Oklahoma State Department of Education. If warranted, reasons why the district does not consider a Corrective Action necessary. Superintendent's Signature Date
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