Corrective Action Plans

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Views of responsible officials and planned corrective actions: The Clinic will seek professional consultation and guidance to create a work schedule compliant with reporting deadlines and submissions and provide oversight to ensure those deadlines are met. Personnel responsible for implementation: ...
Views of responsible officials and planned corrective actions: The Clinic will seek professional consultation and guidance to create a work schedule compliant with reporting deadlines and submissions and provide oversight to ensure those deadlines are met. Personnel responsible for implementation: Deborah Lerner, CEO and Board of Directors Date of implementation: July 1, 2025
Views of responsible officials and planned corrective actions: The Clinic will be seeking professional consultation and guidance on a process to support and enforce monthly reconciliations of the amounts submitted for the grant with the amounts booked within the system, using appropriate grant-track...
Views of responsible officials and planned corrective actions: The Clinic will be seeking professional consultation and guidance on a process to support and enforce monthly reconciliations of the amounts submitted for the grant with the amounts booked within the system, using appropriate grant-tracking schedules. Relevant staff will be retrained, and a monthly review will be completed by an appropriate professional and submitted to the Chief Executive Officer (CEO). Personnel responsible for implementation: Deborah Lerner, CEO and Board of Directors Date of implementation: July 1, 2025
Finding 2024-002: Common Origination and Disbursement (COD) Reporting Cluster Name: Student Financial Assistance Federal Awarding Agency: Department of Education Award Name: Federal Pell Grant Program, Federal Direct Loans Award Number: Various Award Year: 10/1/2023-9/30/2024 Assistance Listing Tit...
Finding 2024-002: Common Origination and Disbursement (COD) Reporting Cluster Name: Student Financial Assistance Federal Awarding Agency: Department of Education Award Name: Federal Pell Grant Program, Federal Direct Loans Award Number: Various Award Year: 10/1/2023-9/30/2024 Assistance Listing Title: Federal Pell Grant Program, Federal Direct Student Loans Assistance Listing Number: 84.063, 84.268 Pass-Through Entities: Not applicable As described in finding 2024-002, 1 of the 25 selections was not reported to the COD system within 15 calendar days of the disbursement to the student. The noted disbursement was reported 5 calendar days late. Caltech confirmed it had additional instances of late reporting beyond the audit selection. To address this finding, Caltech created a Disbursement Checklist to ensure that all steps in the process are followed, including generating common record files of disbursement information and transmitting those files to COD the same day as the funds are disbursed to the student accounts. The checklist was created in May 2025. Malina Chang, Director, Financial Aid Office, is responsible for this corrective action plan. Caltech also performs Pell monthly reconciliations to capture discrepancies between internal information and that which is reported by COD. Any discrepancies are investigated via this monthly reconciliation process, and errors are corrected. In addition, Caltech requests Pell funds from the Department of Education on a quarterly basis (quarterly EDCAPS draws), significantly reducing the risk of the Institute needing to return funds.
Finding 2024-001: E-Sign Act Cluster Name: Student Financial Assistance Federal Awarding Agency: Department of Education Award Name: Federal Supplemental Educational Opportunity Grant, Federal Work Study Program, Federal Pell Grant Program, Federal Perkins Loan, Federal Direct Loans Award Number: ...
Finding 2024-001: E-Sign Act Cluster Name: Student Financial Assistance Federal Awarding Agency: Department of Education Award Name: Federal Supplemental Educational Opportunity Grant, Federal Work Study Program, Federal Pell Grant Program, Federal Perkins Loan, Federal Direct Loans Award Number: Various Award Year: 10/1/2023-9/30/2024 Assistance Listing Title: Federal Supplemental Educational Opportunity Grants, Federal Work-Study Program, Federal Pell Grant Program, Federal Perkins Loan Program, Federal Direct Student Loans Assistance Listing Number: 84.007, 84.033, 84.063, 84.038, 84.268 Pass-Through Entities: Not applicable As described in finding 2024-001, in examining 25 student records, a statement prompting voluntarily consent to participate in electronic transactions was not included in the list of terms and conditions. To address this finding, in March 2025, Caltech revised the Financial Aid Terms and Conditions, found under the student portal, which students must agree to before accepting their financial aid, to include language about voluntarily consenting to participate in electronic transactions. Malina Chang, Director, Financial Aid Office, is responsible for this corrective action plan.
Management’s Comments and Corrective Action Plan: Management has reviewed finding 2024-001 related to timely Single Audit report submission to the Federal Audit Clearinghouse and has developed the following plan to address this finding and ensure compliance going forward. 1. Root Cause Analysis...
Management’s Comments and Corrective Action Plan: Management has reviewed finding 2024-001 related to timely Single Audit report submission to the Federal Audit Clearinghouse and has developed the following plan to address this finding and ensure compliance going forward. 1. Root Cause Analysis – Previous to 2023, the last time the Y was required to have a Single Audit was the year ended December 31, 2012. Because this was a new process to the Y, we were unaware that we needed to submit the Single Audit to the Federal Audit Clearinghouse. In past years, the independent audit firm initiated the e-filing process on our behalf. 2. Action Steps – The Y will develop a year-end Federal Awards checklist to include all necessary preparation steps including but not limited to preparation of the Schedule of Expenditures of Federal Awards (SEFA); corresponding audit documentation; and procedures for filing the completed Single Audit to the Federal Audit Clearinghouse including confirmation that independent auditors have reviewed and certified the submission to the Clearinghouse. 3. Responsible Parties – The Controller will complete the checklist and perform the filing to the Federal Audit Clearinghouse and the CFO will review and approve. 4. Timeline – Submission of the Single Audit to the Federal Audit Clearinghouse as well as completion, review, and approval of the checklist will be done within 30 days of receipt of the final Single Audit report. 5. Monitoring & Evaluation – The checklist and approval process will be monitored on an annual basis to ensure ongoing compliance and effectiveness of this corrective action plan.
Finding 563657 (2024-002)
Significant Deficiency 2024
Preparation of Financial Statements and Related Footnotes
Preparation of Financial Statements and Related Footnotes
Finding 563657 (2024-002)
Significant Deficiency 2024
Recommendation: This control deficiency is not unusual in a small city. However, it is the responsibility of management and the Council to decide whether to accept the degree of risk associated with this condition based on the cost of correction and other considerations.
Recommendation: This control deficiency is not unusual in a small city. However, it is the responsibility of management and the Council to decide whether to accept the degree of risk associated with this condition based on the cost of correction and other considerations.
Finding 563657 (2024-002)
Significant Deficiency 2024
Management’s Response and Actions Planned: The City’s management is aware of this significant deficiency. Management reviews and approves the draft annual audited financial statements and distributes them to the users. For entities of this size, it generally is not practical to obtain the internal e...
Management’s Response and Actions Planned: The City’s management is aware of this significant deficiency. Management reviews and approves the draft annual audited financial statements and distributes them to the users. For entities of this size, it generally is not practical to obtain the internal expertise needed to handle all aspects of the external financial reporting. Management recognizes this and feels it is effectively handling its reporting responsibilities with the procedures described above.
Finding 563656 (2024-001)
Significant Deficiency 2024
Segregation of Duties
Segregation of Duties
Finding 563656 (2024-001)
Significant Deficiency 2024
Recommendation: While we recognize the City’s office staff is not large enough to permit an adequate segregation of duties in all respects for an effective internal control structure, it is important that the City be aware of this condition and look for opportunities to improve segregation of duties...
Recommendation: While we recognize the City’s office staff is not large enough to permit an adequate segregation of duties in all respects for an effective internal control structure, it is important that the City be aware of this condition and look for opportunities to improve segregation of duties or add mitigating controls to prevent material misstatement of the financial statements.
Finding 563656 (2024-001)
Significant Deficiency 2024
Management’s Response and Actions Planned: The City’s management is aware of this condition and believes that it is not economically feasible to attain the ideal segregation of duties. Management attempts to mitigate the associated risks by doing the following:
Management’s Response and Actions Planned: The City’s management is aware of this condition and believes that it is not economically feasible to attain the ideal segregation of duties. Management attempts to mitigate the associated risks by doing the following:
Finding 563656 (2024-001)
Significant Deficiency 2024
1.      Identifies areas where the lack of segregation of duties exists and where there are higher risks of errors or fraud occurring.
1.      Identifies areas where the lack of segregation of duties exists and where there are higher risks of errors or fraud occurring.
Finding 563656 (2024-001)
Significant Deficiency 2024
2.      Implements limited segregation to the extent possible to reduce risks without impairing efficiency.
2.      Implements limited segregation to the extent possible to reduce risks without impairing efficiency.
Finding 563656 (2024-001)
Significant Deficiency 2024
3.      Uses the knowledge that management and the Board of Directors have of operations by having them review certain accounting records and reports.
3.      Uses the knowledge that management and the Board of Directors have of operations by having them review certain accounting records and reports.
Finding 563656 (2024-001)
Significant Deficiency 2024
Monitors the effectiveness of the above actions and makes changes as considered appropriate.
Monitors the effectiveness of the above actions and makes changes as considered appropriate.
Internal Control Over Compliance Recommendation: We recommend that the organization implement additional review process over the rate determination to ensure it is being calculated correctly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action t...
Internal Control Over Compliance Recommendation: We recommend that the organization implement additional review process over the rate determination to ensure it is being calculated correctly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Daycare Director will review all parent fee calculations with signed approval, beginning upon enrollment of the student and, annually, for as long as they remain enrolled at AELC. Name(s) of the contact person(s) responsible for corrective action: Michelle James Planned completion date for corrective action plan: May 23, 2025 f the State has questions regarding this plan, please call Michelle James at (203) 744-4700.
We concur with the finding and are implementing procedures to address all issues. The SF-428 is completed by Logistics utilizing data from ORMS. The report is meant to include only federally owned assets. Assets purchased by CAP with federal funds are not federally owned and should not be included i...
We concur with the finding and are implementing procedures to address all issues. The SF-428 is completed by Logistics utilizing data from ORMS. The report is meant to include only federally owned assets. Assets purchased by CAP with federal funds are not federally owned and should not be included in the report. Items are entered into ORMS manually and the funding source is chosen from a drop-down menu. Two vehicles were entered in fiscal year 2024, and the incorrect funding source was chosen from the drop-down menu. The correct option was right below the option chosen. The items were corrected when found during the audit. FM will work with Logistics to ensure all capitalized assets added during the fiscal year are reviewed for the correct funding source. We will review this as part of the cost review throughout the year. We will also request that a pop up or some other messaging be added to ORMS to alert the individual entering items to double check that the correct fund source has been chosen. We will implement the reviews in May 2025.
2024-002 • Material Weakness in Internal Control over Compliance Condition: During our eligibility assessment, we examined 40 files from Community Umbrella Agency 3 (CUA) foster care children to ensure they contained required documents by the City of Philadelphia and Pennsylvania's Department of H...
2024-002 • Material Weakness in Internal Control over Compliance Condition: During our eligibility assessment, we examined 40 files from Community Umbrella Agency 3 (CUA) foster care children to ensure they contained required documents by the City of Philadelphia and Pennsylvania's Department of Human Services (DHS). Our review found missing documents, time gaps between submissions, or untimely paperwork, including the following: (a) 29 CUA Safety Assessments, (b) 30 CUA Safety Plans, (c) 7 CUA PA Model Risk Assessments, (d) 3 CUA Documented Client Visits (Structure Case Notes), (e) FAST Family Advocacy Forms, (f) 17 Life Skills Assessment/ Biopsychosocial Evaluation/ IEP or Ages & Stages Questionnaire (ASQ), (g) 11 School Aged Report Cards, (h) 6 CUA Authorization to Release Information, (i) 9 CUA Immunizations, (j) 3 DHS Court Order Sheets, (k) 14 Child’s Photo, (l) 10 Initial CUA Single Case Plan, (m) 7 Monthly Updates to CUA Single Case Plan, (n) 17 Initial CUA Case Service Conference Summary Report, and (o) 16 Six Month Ongoing CUA Services Conference Summary Report. Furthermore, each child's file needed to contain specific documents from the DHS, which had to be supplied by the department or shown evidence of request by the CUA. Missing documents consisted of: (a) 34 DHS Service Authorization Forms, (b) 21 DHS CUA Provider Referral Forms, and (c) 30 DHS CUA In-Home Services Referral Forms. Recommendation: We recommend that management continue to develop policies and procedures in order to properly include all pertinent documentation within each client file as required by the City of Philadelphia, Department of Human Services. In addition, we recommend that program leadership and/or quality control department performs periodic audits of the client files to ensure all required documentation is included. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. FINDINGS – FEDERAL AWARD PROGRAM AUDITS (CONTINUED) Action taken in response to finding: 1. Hiring of Chief Compliance Officer to oversee Concilio Quality Assurance and Compliance process 2. Staffing of Quality Assurance department 3. Monthly review of client files for accuracy and completeness 4. Additional training of staff to review audit findings and implement corrective action Name of the contact person responsible for corrective action: Albert Essilfie, Chief Financial Officer albert.essilfie@elconcilio.net (215) 627-3100 Planned completion date for corrective action plan: June 30, 2025
Ensure that the Organization's tenant compliance policies are strictly adhered to, complying with FHA Guidance and that proper procurement documentation maintained.
Ensure that the Organization's tenant compliance policies are strictly adhered to, complying with FHA Guidance and that proper procurement documentation maintained.
Management’s Response: The University has undertaken several initiatives to enhance compliance and accuracy: (1) Collaboration with External Financial Aid Experts a. In 2025, the University engaged an external financial aid contractor to optimize system usage within its database, ensuring more accu...
Management’s Response: The University has undertaken several initiatives to enhance compliance and accuracy: (1) Collaboration with External Financial Aid Experts a. In 2025, the University engaged an external financial aid contractor to optimize system usage within its database, ensuring more accurate and timely reporting. (2) Appointment of a New Financial Aid Director a. A new Financial Aid Director has been hired, commencing their role on March 1, 2025. This leadership is expected to prioritize and address the issues identified in the audit finding. (3) Process Enhancement and Staff Training a. A comprehensive assessment of current enrollment reporting procedures has been conducted to identify and rectify gaps. b. Staff members in the Registrar’s Office have undergone targeted training to ensure accurate and timely updates to the National Student Loan Data System (NSLDS). (4) Policy and Procedure Development a. New policies and procedures have been established to verify that correct effective dates and status changes are reported to NSLDS within the required timeframes. b. Regular audits and reviews are now in place to ensure ongoing compliance and to promptly address any discrepancies. These initiatives demonstrate the University’s commitment to maintaining accurate student enrollment records and ensuring compliance with federal regulations, thereby safeguarding the interests of its students and the institution.
Audit Finding Number: 2024-002 Reasonable Rent Agency: Department of Housing and Urban Development Responsible Person, Title: Dave Dunn, Housing Director Completion date: 5/15/2025 Agency Response: Concur Corrective Action Plan: An evaluation has been completed to determine the gaps in staff trai...
Audit Finding Number: 2024-002 Reasonable Rent Agency: Department of Housing and Urban Development Responsible Person, Title: Dave Dunn, Housing Director Completion date: 5/15/2025 Agency Response: Concur Corrective Action Plan: An evaluation has been completed to determine the gaps in staff training on this topic. For the staff struggling with this area, step-by-step instruction has been provided and on-going weekly mentoring with the Program Manager initiated. Significant improvement in this category is anticipated.
Audit Finding Number: 2024-001 Housing Quality Standards Inspections & Enforcement Agency: Department of Housing and Urban Development Responsible Person, Title: Dave Dunn, Housing Director Completion date: 5/15/2025 Agency Response: Concur Corrective Action Plan: Monthly reports for failed inspec...
Audit Finding Number: 2024-001 Housing Quality Standards Inspections & Enforcement Agency: Department of Housing and Urban Development Responsible Person, Title: Dave Dunn, Housing Director Completion date: 5/15/2025 Agency Response: Concur Corrective Action Plan: Monthly reports for failed inspections were set up in May of 2024 in response to the previous year’s finding. While these reports were helpful, they did not fully resolve the issue. Two additional changes have since been implemented: 1) Staffing changes including the removal of one Specialist that had a high frequency of missed follow-ups and the addition of a “Lead” Housing Specialist; 2) The Lead Housing Specialist is now receiving all-staff monthly reports on failed HQS inspections to ensure that follow-up is not only completed by completed timely. We expect a drastic improvement in this category.
Audit Finding Number: 2024-003 Cash Management Agency: Department of Housing and Urban Development Responsible Person, Title: Karla Strain, Assistant Controller Completion date: 5/15/2025 Agency Response: Concur Corrective Action Plan: In response to these findings, the Authority has reviewed and ...
Audit Finding Number: 2024-003 Cash Management Agency: Department of Housing and Urban Development Responsible Person, Title: Karla Strain, Assistant Controller Completion date: 5/15/2025 Agency Response: Concur Corrective Action Plan: In response to these findings, the Authority has reviewed and revised its Capital Fund cash management procedures to ensure full compliance with the Capital Fund Handbook. The updated procedures have been reviewed in collaboration with both the Housing Project Manager and the Housing Program Manager. Invoices will be organized to fulfil the monthly obligation and paid within three days of the fund draw. To prevent recurrence and ensure ongoing compliance, the Authority will hold monthly meetings to review project timelines and cash flow needs. Communication frequency will increase during complex, multi-phase projects to support effective oversight and coordination. Furthermore, updated policy and payment procedures will be clearly communicated to all current and future vendors to ensure alignment with federal regulations. These corrective actions reflect the Authority’s commitment to improved financial oversight and adherence to all applicable funding regulations.
Funds from COVID-19 Education Stabilization Fund (ESF) were used to fund construction contracts in excess of $2,000 without the inclusion of prevailing wage rate clauses as required by Title 29, U.S. Code of Federal Regulations, Part 5, Sub-Part A Davis Bacon and Related Acts Provisions and Procedur...
Funds from COVID-19 Education Stabilization Fund (ESF) were used to fund construction contracts in excess of $2,000 without the inclusion of prevailing wage rate clauses as required by Title 29, U.S. Code of Federal Regulations, Part 5, Sub-Part A Davis Bacon and Related Acts Provisions and Procedures (the “Davis-Bacon Act”). The Board did not have controls in place to ensure the Davis-Bacon Act wage rate requirements were included in construction contracts. Therefore, the construction project contract awarded during the fiscal year did not include prevailing wage rate clauses nor did the contractors submit weekly certified payrolls to the Board. Response: Management will implement controls to ensure future contracts funded with COVID-19 Education Stabilization Funds (ESF) in excess of $2,000 specify applicability of wage rate requirements.
View Audit 357874 Questioned Costs: $1
The office staff is currently working to segregate duties.
The office staff is currently working to segregate duties.
View Audit 357869 Questioned Costs: $1
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