Corrective Action Plans

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Return of Title IV (R2T4) Unearned Funds Planned Corrective Action: A process will be implemented to run a 0-credit report at the end of each semester. This will ensure withdrawals are followed up on and that R2T4s are completed in a timely manner, if required. A process will be implanted to track s...
Return of Title IV (R2T4) Unearned Funds Planned Corrective Action: A process will be implemented to run a 0-credit report at the end of each semester. This will ensure withdrawals are followed up on and that R2T4s are completed in a timely manner, if required. A process will be implanted to track student attendance in classes. Person Responsible for Corrective Action Plan: Lori Larsh, Vice President for Business Services Anticipated Date of Completion: 07/31/2026
Common Origination and Disbursement (COD) Reporting and Reconciliations Planned Corrective Action: Procedures will be implemented to monthly reconcile FDL and Pell disbursements to student accounts with disbursements reported to COD. Person Responsible for Corrective Action Plan: Lori Larsh, Vice Pr...
Common Origination and Disbursement (COD) Reporting and Reconciliations Planned Corrective Action: Procedures will be implemented to monthly reconcile FDL and Pell disbursements to student accounts with disbursements reported to COD. Person Responsible for Corrective Action Plan: Lori Larsh, Vice President for Business Services Anticipated Date of Completion: 07/31/2026
Need Analysis Planned Corrective Action: All scholarships will be marked as estimated financial assistance and an awarding check for need will be done accurately before final distribution. Person Responsible for Corrective Action Plan: Lori Larsh, Vice President for Business Services Anticipated Dat...
Need Analysis Planned Corrective Action: All scholarships will be marked as estimated financial assistance and an awarding check for need will be done accurately before final distribution. Person Responsible for Corrective Action Plan: Lori Larsh, Vice President for Business Services Anticipated Date of Completion: 07/31/2026
Enrollment Reporting to NSLDS Planned Corrective Action: A system will be put into place to ensure that enrollment is reported in a timely and accurate manner. Additionally, the College will complete a series of spot checks of NSLDS enrollment statuses throughout the year. Person Responsible for Cor...
Enrollment Reporting to NSLDS Planned Corrective Action: A system will be put into place to ensure that enrollment is reported in a timely and accurate manner. Additionally, the College will complete a series of spot checks of NSLDS enrollment statuses throughout the year. Person Responsible for Corrective Action Plan: Lori Larsh, Vice President for Business Services Anticipated Date of Completion: 07/31/2026
Satisfactory Academic Progress Planned Corrective Action: The SAP policy will be reviewed or created as needed and a procedure will be implemented based on that policy. Person Responsible for Corrective Action Plan: Lori Larsh, Vice President for Business Services Anticipated Date of Completion: 07/...
Satisfactory Academic Progress Planned Corrective Action: The SAP policy will be reviewed or created as needed and a procedure will be implemented based on that policy. Person Responsible for Corrective Action Plan: Lori Larsh, Vice President for Business Services Anticipated Date of Completion: 07/31/2026
Lack of Administrative Capability Planned Corrective Action: The financial aid officer will participate in training(s) specific to knowledge gaps. In addition, monthly entries will be made in the general ledger for financial aid activity and monthly balances will be reconciled between the general le...
Lack of Administrative Capability Planned Corrective Action: The financial aid officer will participate in training(s) specific to knowledge gaps. In addition, monthly entries will be made in the general ledger for financial aid activity and monthly balances will be reconciled between the general ledger and financial aid software. Person Responsible for Corrective Action Plan: Lori Larsh, Vice President for Business Services Anticipated Date of Completion: 07/31/2026
Recommendation: The Organization should reinforce its policies and procedures in regards to accurately classifying receivables and deposits. Responsible Officials' Response: We agree and will make sure that all invoices are received and recorded accurately with proper authorization, and upon deposit...
Recommendation: The Organization should reinforce its policies and procedures in regards to accurately classifying receivables and deposits. Responsible Officials' Response: We agree and will make sure that all invoices are received and recorded accurately with proper authorization, and upon deposit of those invoices, the confirmation of deposit will be attached to the invoice and the invoices stored in a central location in the administrative offices.
Recommendation: The Organization should reinforce its policies and procedures in regards to record keeping. Responsible Officials' Response: We agree and will make sure that all percentage allocations are properly verified and maintained in a separate ledger for reconciliations.
Recommendation: The Organization should reinforce its policies and procedures in regards to record keeping. Responsible Officials' Response: We agree and will make sure that all percentage allocations are properly verified and maintained in a separate ledger for reconciliations.
Recommendation: The Organization should reinforce its policies and procedures in regards to payroll expenses and note that when payroll is run, payment to the Internal Revenue Service should be rendered to decrease accrued payroll liabilities. Responsible Officials' Response: Payments were made to t...
Recommendation: The Organization should reinforce its policies and procedures in regards to payroll expenses and note that when payroll is run, payment to the Internal Revenue Service should be rendered to decrease accrued payroll liabilities. Responsible Officials' Response: Payments were made to the Internal Revenue Service for this payroll liability account beginning January 2025. It will continue to work with the Internal Revenue Service to continue paying off the remainder of the balance and all new accruals and penalties.
Recommendation: The Organization should reinforce its policies and procedures in regards to expenditures to ensure vendor invoices are retained in a secure, centralized location. Responsible Official 's Response: We agree and will make sure that all invoices are received and recorded accurately with...
Recommendation: The Organization should reinforce its policies and procedures in regards to expenditures to ensure vendor invoices are retained in a secure, centralized location. Responsible Official 's Response: We agree and will make sure that all invoices are received and recorded accurately with proper authorization, and upon payment of those invoices, the confirmation of payment will be attached to the invoice and the invoices stored in a central location in the administrative offices.
Recommendation: The Organization should reinforce its policies and procedures in regards to expenditures to ensure vendor invoices are retained in a secure, centralized location. Responsible Official 's Response: We agree and will make sure that all invoices are received and recorded accurately with...
Recommendation: The Organization should reinforce its policies and procedures in regards to expenditures to ensure vendor invoices are retained in a secure, centralized location. Responsible Official 's Response: We agree and will make sure that all invoices are received and recorded accurately with proper authorization, and upon payment of those invoices, the confirmation of payment will be attached to the invoice and the invoices stored in a central location in the administrative offices.
Management acknowledges the finding and commits to taking corrective action. A thorough review of the factors contributing to the late filing will be conducted, and procedural enhancements will be implemented to ensure timely compliance with the submission requirements outlined in the Uniform Guidan...
Management acknowledges the finding and commits to taking corrective action. A thorough review of the factors contributing to the late filing will be conducted, and procedural enhancements will be implemented to ensure timely compliance with the submission requirements outlined in the Uniform Guidance. Management will also establish monitoring mechanisms to prevent future occurrences of late filings and ensure ongoing compliance.
Management will implement enhanced year-end closing and audit coordination procedures, including earlier preparation timelines, improved tracking of audit deliverables and reporting deadlines, and increased coordination with outsourced accounting and audit partners to help ensure timely completion a...
Management will implement enhanced year-end closing and audit coordination procedures, including earlier preparation timelines, improved tracking of audit deliverables and reporting deadlines, and increased coordination with outsourced accounting and audit partners to help ensure timely completion and submission of future Single Audit reporting packages.
NAME OF CONTACT: Terri Brown, Director of Finance CORRECTIVE ACTION: Management acknowledges the finding. The delayed submission of the Data Collection Form and reporting package was primarily the result of an extended audit timeline caused by the transition to a new audit firm. In addition, delays ...
NAME OF CONTACT: Terri Brown, Director of Finance CORRECTIVE ACTION: Management acknowledges the finding. The delayed submission of the Data Collection Form and reporting package was primarily the result of an extended audit timeline caused by the transition to a new audit firm. In addition, delays associated with the completion of prior audit matters and the new auditor's initial review process contributed to the timing of the final audit report and subsequent FAC submission. Since that time, the Organization has hired a new auditor, improved internal closing procedures, and implemented enhanced monitoring of audit and federal reporting deadlines. Management is committed to timely compliance with all Uniform Guidance reporting requirements and believes these improvements will help prevent future delays. PROPOSED COMPLETION DATE: May 30, 2026
NAME OF CONTACT: Terri Brown, Director of Finance CORRECTIVE ACTION: Management acknowledges the finding; however, it is important to clarify that the circumstances leading to the deficiency were significantly impacted by delated and unresponsive actions from the federal agency. Specifically, the Or...
NAME OF CONTACT: Terri Brown, Director of Finance CORRECTIVE ACTION: Management acknowledges the finding; however, it is important to clarify that the circumstances leading to the deficiency were significantly impacted by delated and unresponsive actions from the federal agency. Specifically, the Organization submitted required reports and sought timely guidance and approvals from the federal agency, but responses were not received within the federal deadlines. These delays were outside of the Organization’s control and directly affected the timely reconciliation and finalization of reported amounts. Notably, the federal government has acknowledged delayed reports and there were no findings in their FY24 audit. Management will continue to improve internal controls and documentation practices while also documenting all federal communications and follow-up efforts to document the impact of future federal delays. PROPOSED COMPLETION DATE: Implemented and Ongoing
The City will strengthen its process by requiring documented SAM.gov suspension and debarment checks for all applicable federally funded vendors by ensuring our grant requirements document is up to date and accessible to all staff. The City is currently compliant with suspension and debarment requir...
The City will strengthen its process by requiring documented SAM.gov suspension and debarment checks for all applicable federally funded vendors by ensuring our grant requirements document is up to date and accessible to all staff. The City is currently compliant with suspension and debarment requirements and will ensure the grants requirement document is updated and all federal contracts remain compliant going forward.
The agency proactively enacted rigorous internal controls and systemic enhancements for FY25 to ensure optimal oversight and adherence to federal guidelines. Management has addressed this recommendation by deploying a strict, comprehensive expense request process to ensure robust internal controls o...
The agency proactively enacted rigorous internal controls and systemic enhancements for FY25 to ensure optimal oversight and adherence to federal guidelines. Management has addressed this recommendation by deploying a strict, comprehensive expense request process to ensure robust internal controls over all Other Than Personal Services (OTPS) expenditures. To ensure full compliance with 2 CFR 200.303 and 200.403, Finance has deployed the following enhancements to our accounts payable workflows: • Strict Electronic Approval Workflow: Finance has established a stringent review and approval protocol that requires direct involvement from Program Directors and Department Heads. All OTPS expenditures are now routed through a formalized electronic workflow, which mandates documented review and secure electronic signatures from authorized leadership prior to any payment processing. • System-Integrated Documentation: The new process strictly requires that all supporting documentation-including invoices, receipts, and evidence of allowability-be provided upfront. These documents are now uploaded and attached directly to the specific transaction within the accounting program, creating a permanent, easily accessible, and audit-ready trail for every federal charge. • Targeted Training and Oversight: To support this modernized workflow, Finance is providing targeted training to all staff responsible for initiating and approving transactions, ensuring a clear understanding of Uniform Guidance requirements. Furthermore, Finance leadership conducts periodic supervisory reviews directly within the accounting system to verify that all electronic approvals are captured and source documents are properly attached.
Management has reviewed the finding regarding the documentation of program eligibility. We recognize the importance of maintaining clear, audit-ready files that explicitly demonstrate case ownership and supervisory approval. To ensure full alignment with 2 CFR § 200.300, we have drafted and institut...
Management has reviewed the finding regarding the documentation of program eligibility. We recognize the importance of maintaining clear, audit-ready files that explicitly demonstrate case ownership and supervisory approval. To ensure full alignment with 2 CFR § 200.300, we have drafted and instituted the following corrective actions: • Updated Internal Signature Policy: We have drafted a strict internal policy requiring the primary case manager-and any other staff actively working on a case-to sign and date all required enrollment documents. This explicitly includes signing intake forms and completing the interpreter sections, where applicable. This policy ensures there is never any ambiguity regarding who is handling the case. • Mandatory Supervisory Review: To enforce this new standard, our internal policy now requires Program Managers and Directors to systematically review each individual case file. Leadership must verify that all required staff signatures, interpreter sign-offs, and eligibility approvals are fully documented before a client's enrollment is considered complete. • Standardized Case Coversheet: To immediately resolve the issue of identifying case handlers, we are implementing a standardized enrollment coversheet for all new files. This document clearly assigns the primary case manager on day one and requires a final supervisory signature to formally authorize the eligibility review. • Targeted Training and Spot-Checks: We are conducting immediate refresher training for all program staff to clarify exactly which signatures are required on each document. Furthermore, leadership will conduct routine, random spot-checks of active case files each month to verify that staff are consistently adhering to this policy in real-time. By formalizing our signature requirements and mandating director-level reviews, we are confident this updated workflow establishes clear accountability and fully resolves the finding.
Management has reviewed the finding, noting the inherent complexity of time allocation in our operational environment. Because our personnel routinely serve multiple clients simultaneously across various federal grants, tracking exact hours per case presents a significant administrative challenge. F...
Management has reviewed the finding, noting the inherent complexity of time allocation in our operational environment. Because our personnel routinely serve multiple clients simultaneously across various federal grants, tracking exact hours per case presents a significant administrative challenge. Furthermore, the delayed receipt of the FY23 audit-delivered post-FY24-precluded the implementation of procedural adjustments during the audited timeframe. To address our operational realities and ensure strict, ongoing adherence to 2 CFR § 200.430, the agency immediately instituted systemic enhancements for FY25. The Organization has transitioned all time tracking to a streamlined, system-driven process within our UKG platform: • Integrated UKG Time Tracking and Approvals: All employees are now required to punch in and out directly through the UKG system, efficiently assigning their actual hours worked to specific program and grant codes to generate functional, after-the-fact timesheets. To further streamline this documentation, the Organization is gradually transitioning our existing supervisory reviews into UKG’s electronic sign-off workflow, which will centralize our approval records and ensure accurate distribution across federal awards.
Management has reviewed the finding and recommendations. We note that this item was identified as a repeat issue primarily due to the timing of the prior year's audit. Because the FY23 findings were delivered after FY24 had already concluded, the Organization did not have the opportunity to incorpor...
Management has reviewed the finding and recommendations. We note that this item was identified as a repeat issue primarily due to the timing of the prior year's audit. Because the FY23 findings were delivered after FY24 had already concluded, the Organization did not have the opportunity to incorporate the auditors' feedback during the FY24 audited period. However, the Organization took immediate, proactive steps to deploy enhanced internal controls for FY25 to ensure continuous alignment with federal standards. To ensure strict adherence to 2 CFR § 200.302(a), we are actively implementing a more regular reconciliation process between government grant revenue claimed and actual revenue earned. As a key part of this initiative, the Organization has developed and deployed new internal financial tools designed to incorporate automation into our daily workflows. By utilizing these automated tools-such as standardized templates for recording cash receipts and systematically clearing Accounts Receivable-we have significantly enhanced the accuracy of our data entries and reduced the risk of manual misstatements. Our ongoing objective is to leverage these tools to establish clear, standardized documentation procedures, ensuring that all financial reports and claims are consistently generated from a reconciled general ledger. Management remains fully committed to dedicating the necessary time and resources to mature these financial controls and ensure robust compliance with federal regulations.
Recommendation We recommend that Management enhance its internal control structure, to include milestones for submitting the Single Audit Reporting Package. Management Response Corrective Action Corrective Action: DNA will comply with the recommendation. DNA will ensure processes are in place to com...
Recommendation We recommend that Management enhance its internal control structure, to include milestones for submitting the Single Audit Reporting Package. Management Response Corrective Action Corrective Action: DNA will comply with the recommendation. DNA will ensure processes are in place to comply with the due date of nine months after year end. Due Date of Completion: September 30, 2026. Responsible Party(ies) Chief Financial Officer
Recommendation We recommend DNA formally respond, in detail, to all deficiencies reported in the OIG Report, including Accounting Policies and other Policies such as the Vehicle Use Policy. As the Board needs to formally adopt all revised policies as noted in the OIG Report, we recommend: • DNA prov...
Recommendation We recommend DNA formally respond, in detail, to all deficiencies reported in the OIG Report, including Accounting Policies and other Policies such as the Vehicle Use Policy. As the Board needs to formally adopt all revised policies as noted in the OIG Report, we recommend: • DNA provide the Board a redline copy of the changes for each revised policy, • correlate each revised policy to each finding in the OIG report and • provide the Board each related policy section guidance in the LSC Financial Guide. Management Response Corrective Action As of January 15, 2026, our accounting department is short one person and we are supporting accounting staff training needs As of January 15, 2026, management has drafted updates and received acceptance by the OIG to all but one of the policies and procedures referenced in the OIG report. Updated policies, including a revised Accounting Manual and an updated Personnel Manual presented to the Board, the Board Budget & Audit Committee and the Board Executive Committee prior to the June 2, 2025 OIG response deadline. Management acknowledges that during the 2024 audit period the Legal Services Corporation Office of Inspector General (OIG) issued a final report on December 2, 2024 noting inadequate accounting policies, practices, and oversight for the period of January 1, 2022 through April 30, 2023. Also, while many of the policies noted in the OIG report have been updated, the policies mentioned in the OIG report have not been reviewed or adopted by the Board. Three primary causes contributed to the deficiencies noted during the period under review by the OIG (January 1, 2022 through April 30, 2023), and before the issuance of the final LSC OIG report in December 2024: • Staffing shortages. For most of the January 1, 2022 to April 30, 2023 review period DNA had three vacancies in our five-person accounting operation. Additionally, our Chief Financial Officer was hired during the middle of the period under review, and even though he has extensive legal services accounting experience, he just started learning about DNA’s organizational structure and accounting practices, and refamiliarizing himself with LSC accounting policies and financial guidelines. • A change in LSC accounting standards applicable to nonprofit LSC funded organizations was implemented during the period under review which made some of our policies and procedures outdated. • Management made a strategic decision to wait for the issuance of the final OIG report to ensure that updates to policies and practices would fully align with the OIG's expectations, rather than implementing piecemeal or interim measures that might have required further revision. Due Date of Completion: February 28, 2026. Responsible Person(s) Executive Director and Chief Financial Officer
The District acknowledges the failure to submit the Single Audit data collection form for the fiscal year ended June 30, 2023 to the Federal Audit Clearinghouse within the required 30-day post-opinion deadline. The form was never submitted for that fiscal year. Additionally, for the fiscal year ende...
The District acknowledges the failure to submit the Single Audit data collection form for the fiscal year ended June 30, 2023 to the Federal Audit Clearinghouse within the required 30-day post-opinion deadline. The form was never submitted for that fiscal year. Additionally, for the fiscal year ended June 30, 2024, the District’s accounting records were not available until March 2026, causing the audit to extend well beyond the required nine-month completion deadline and resulting in further noncompliance with Single Audit reporting requirements. Current management has improved procedures related to the management of Single Audit compliance obligations. The District, in coordination with the third-party accounting firm and the external auditor, has established a compliance calendar that identifies all Single Audit submission deadlines and assigns responsibility for preparation, certification, and submission of the data collection form. Procedures have been implemented to ensure accounting records are available on a timely basis to support completion of the audit within the required nine-month window, starting with the fiscal year ending June 30, 2026. We plan to ensure that the fiscal year ended June 30, 2023 data collection form is submitted to the Federal Audit Clearinghouse and that the fiscal year ended June 30, 2024 Single Audit is completed and submitted within 30 days of the audit opinion date, and that all future Single Audit data collection forms are submitted in a timely manner. Estimated date of implementation of the corrective action plan: Ongoing Person responsible for implementation of the corrective action plan: Dr. Kirk Henwood
The District acknowledges the material correction of an error to the District’s financial statements. This situation occurred due to a material weakness in internal controls over compliance with federal award requirements for the Education Stabilization Fund (CFDA 84.425U), passed through the Colora...
The District acknowledges the material correction of an error to the District’s financial statements. This situation occurred due to a material weakness in internal controls over compliance with federal award requirements for the Education Stabilization Fund (CFDA 84.425U), passed through the Colorado Department of Education, for the fiscal year ended June 30, 2024. Specifically, the District lacked adequate segregation of duties over payroll and human resources processes, both of which were performed by a single employee without a secondary review. In addition, the District did not maintain adequate reimbursement request documentation or regularly reconcile ESSER grant expenditures to reimbursement requests, as required under 2 CFR 200.303. These conditions resulted in material audit 60 adjustments, significant audit delays, and the engagement of a third-party accounting firm to reconstruct grant records. Notwithstanding these control deficiencies, the District was in compliance with allowable activities, allowable costs, and cash management requirements, as allowable costs exceeded the amounts requested for reimbursement. Current management has improved procedures related to the oversight of federal grant compliance and payroll processes. The District has engaged a third-party accounting firm and hired new staff to assist with grants reconciliation, reimbursement request preparation, and internal controls over federal awards. A secondary review process has been established for payroll and human resources transactions to ensure that no single employee has unchecked control over these functions. Grant reconciliation responsibilities have been reassigned to incorporate segregation of duties, and a defined schedule for monthly ESSER reconciliations and reimbursement submissions has been implemented. We plan to have all ESSER grant activity fully reconciled, reimbursement documentation complete and available for review, and monthly reconciliation and secondary review procedures operational and documented for all applicable federal grant programs prior to the start of the audit process. Estimated date of implementation of the corrective action plan: June 30, 2026 Person responsible for implementation of the corrective action plan: Dr. Kirk Henwood
The duties will be segregated as much as possible. We understand that in most cases, the added cost of providing absolute segregation of duties will outweigh the projected benefits of the added internal controls and therefore, may be considered unjustified. Sistercare, Inc. will ensure that the Boar...
The duties will be segregated as much as possible. We understand that in most cases, the added cost of providing absolute segregation of duties will outweigh the projected benefits of the added internal controls and therefore, may be considered unjustified. Sistercare, Inc. will ensure that the Board of Directors will remain involved in the financial affairs of the Organization to provide oversight and independent review functions.
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