Corrective Action Plans

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Finding 561177 (2024-003)
Significant Deficiency 2024
Finding no.: 2024-003 Contact person(s) responsible: Kymberly Horner, Executive Director for PCRI and Radha Mehrotra, Controller for Cascade Management Corrective action planned: The monthly deposits to the replacement reserve account have been reinstated after the lapse which was due to a peri...
Finding no.: 2024-003 Contact person(s) responsible: Kymberly Horner, Executive Director for PCRI and Radha Mehrotra, Controller for Cascade Management Corrective action planned: The monthly deposits to the replacement reserve account have been reinstated after the lapse which was due to a period of transition of management in the property management department. The funding processes have been reestablished and procedures are in place to ensure there are no unplanned lapses in funding the reserve going forward. Anticipated completion date: February 2025
Finding 561176 (2024-002)
Significant Deficiency 2024
Finding no.: 2024-002 Contact person(s) responsible: Kymberly Horner, Executive Director for PCRI and Radha Mehrotra, Controller for Cascade Management Corrective action planned: The improvements in processes mentioned in the plan to address Fining no. 2024-001 will serve to accelerate closing ...
Finding no.: 2024-002 Contact person(s) responsible: Kymberly Horner, Executive Director for PCRI and Radha Mehrotra, Controller for Cascade Management Corrective action planned: The improvements in processes mentioned in the plan to address Fining no. 2024-001 will serve to accelerate closing procedures and help the audit to be completed on schedule allowing for the required calculation and deposit of the residual receipt reserve funds within the required time frame. Anticipated completion date: October 2025
Finding 561175 (2024-001)
Significant Deficiency 2024
Finding no.: 2024-001 Contact person(s) responsible: Kymberly Horner, Executive Director for PCRI and Radha Mehrotra, Controller for Cascade Management Corrective action planned: The closing of books and preparation for audit procedures is being addressed via improvements in internal controls r...
Finding no.: 2024-001 Contact person(s) responsible: Kymberly Horner, Executive Director for PCRI and Radha Mehrotra, Controller for Cascade Management Corrective action planned: The closing of books and preparation for audit procedures is being addressed via improvements in internal controls related to property accounting, month and year end closing procedures which include a new property management accounting software package. It is also being addressed via the hiring of more experienced staff during fiscal year 2024-2025. The organization anticipates that these improvements will allow for the audit to be completed within the required timeframe in the upcoming cycle. Anticipated completion date: October 2025
The Agency has attempted to segregate accounting duties by having a person who does not initiate, prepare or post disbursements review the bank statements and co-sign all checks. The Agency will continue to monitor its policies and procedures in an effort to improve control efficiencies, however, a...
The Agency has attempted to segregate accounting duties by having a person who does not initiate, prepare or post disbursements review the bank statements and co-sign all checks. The Agency will continue to monitor its policies and procedures in an effort to improve control efficiencies, however, at this time, the Agency has determined that the cost of eliminating this material weakness in internal control would exceed its benefit.
The Authority has attempted to segregate accounting duties by having a person who does not initiate, prepare or post disbursements review the bank statements and co-sign all checks. The Authority will continue to monitor its policies and procedures in an effort to improve control efficiencies, howe...
The Authority has attempted to segregate accounting duties by having a person who does not initiate, prepare or post disbursements review the bank statements and co-sign all checks. The Authority will continue to monitor its policies and procedures in an effort to improve control efficiencies, however, at this time, the Authority has determined that the cost of eliminating the deficiency would exceed its benefit.
Finding Reference Number: 2024-003 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director and the Treasurer will review internal controls to ensure the proper segregation of duties. The Finance Director and the Executive Director will review job...
Finding Reference Number: 2024-003 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director and the Treasurer will review internal controls to ensure the proper segregation of duties. The Finance Director and the Executive Director will review job duties of the Finance Director and appropriate staff will be trained as back-up. We have a third party outside accountant that prepares quarterly and annual reporting. All reports are reviewed by the Executive Director, the Finance Director and the third-party accountant to ensure that the reports are accurate. After the initial review, the third-party accountant is present at the finance committee when the reports are presented. Name of Contact Person: Susan Dana, Finance Director Projected Completion Date: June 30, 2025
Finding Reference Number: 2024-002 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director reviewed the internal controls requiring all expenditures above $2,000 requiring dual signatures with the Office Administrator. If the Office Administrator ...
Finding Reference Number: 2024-002 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director reviewed the internal controls requiring all expenditures above $2,000 requiring dual signatures with the Office Administrator. If the Office Administrator is not in the office when checks are to be mailed, the staff mailing checks will refer to the procedures filed in the front office prior to processing checks. Name of Contact Person: Susan Dana, Finance Director Projected Completion Date: March 28, 2025
Finding Reference Number: 2024-001 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director will review personnel files for all raises to ensure that the required documentation supports the raise amount approved by the Executive Director. Name o...
Finding Reference Number: 2024-001 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director will review personnel files for all raises to ensure that the required documentation supports the raise amount approved by the Executive Director. Name of Contact Person: Susan Dana, Finance Director Projected Completion Date: May 31, 2025
Finding 561095 (2024-001)
Significant Deficiency 2024
Finding 2024-001 Condition: The federal awards expenditure data compiled by the County to prepare the SEFA was found to be incomplete and inaccurate. Plan: The County should consider the costs and benefits of establishing a financial management system that provides for the identification, in its...
Finding 2024-001 Condition: The federal awards expenditure data compiled by the County to prepare the SEFA was found to be incomplete and inaccurate. Plan: The County should consider the costs and benefits of establishing a financial management system that provides for the identification, in its accounts, of all Federal awards received and expended and the Federal programs for which they are received for all County Departments receiving federal awards. Name of Contact Person: Nikki Lohman, Treasurer Management Response: In the 2025 Budget, the County has a new separate fund, Fund 385, established to deal solely with the grant money that comes into Montgomery County. The County has transferred coal money to begin the fund and all Haz Mat, DCEO, Elections, etc. will go through this fund to keep it separate from regular budgeted money. Expenses will be paid out and revenue will return to this fund. This is for General Fund accounts, the Health Department will still be on their own process. Anticipated Date of Completion: Completed in 2025 prior to the issuance of financial statements.
Finding 561094 (2024-003)
Significant Deficiency 2024
Finding 2024-003 Condition: The County incorrectly reported expenditures on their annual Project and Expenditure (P&E) report for the fiscal year ended November 30, 2024. There were excluded expenditures for one project and overstated expenditures for various projects related to prior year exclusi...
Finding 2024-003 Condition: The County incorrectly reported expenditures on their annual Project and Expenditure (P&E) report for the fiscal year ended November 30, 2024. There were excluded expenditures for one project and overstated expenditures for various projects related to prior year exclusions, which are now reported correctly in total. Plan: The County should ensure all expenditures incurred within the fiscal year are included on the annual report. Name of Contact Person: Nikki Lohman, Treasurer Management Response: The County will work closer with Bellwether to ensure the expenditures are matching and included in the report. Anticipated Date of Completion: November 2025, anticipated date of ARPA funds being fully expensed.
CORRECTIVE ACTION PLAN (UNAUDITED) Name of Auditee: Union Congregational Church Homes, Inc. HUD Project No.: 023-35372 Audit Firm: Kahn, Litwin, Renza & Co., Ltd. Period Covered by the Audit: Year ended December 31, 2024 Corrective Action Plan Prepared By: Name: Ronald Gates Position: Executive Dire...
CORRECTIVE ACTION PLAN (UNAUDITED) Name of Auditee: Union Congregational Church Homes, Inc. HUD Project No.: 023-35372 Audit Firm: Kahn, Litwin, Renza & Co., Ltd. Period Covered by the Audit: Year ended December 31, 2024 Corrective Action Plan Prepared By: Name: Ronald Gates Position: Executive Director Telephone No.: (781) 335-2667 A. Current Findings on the Schedule of Findings and Questioned Costs Finding 2024-001: Unauthorized Distribution of Project Funds a. Comments on Finding and Recommendations: Management concurs with the finding and agrees with the recommendation. b. Actions Taken or Planned: Management concurs with the finding. On March 11, 2025, the Organization transferred $118,186 from its entity cash account into the Project’s operating account. On March 27, 2025, the Organization transferred $14,681 from its entity cash account to the Project’s property insurance escrow deposits account. Supporting documentation for these transfers will be furnished to HUD upon request. Name of Responsible Person: Ronald Gates, Executive Director Projected Implementation Date: March 11, 2025 and March 27, 2025
View Audit 356732 Questioned Costs: $1
2024-001 Significant deficiency related to preparation of the schedule of federal awards Recommendation: The auditor recommends implementing a documented SEFA preparation process, assigning a reviewer to ensure accuracy, and providing staff training on Uniform Guidance standards. A checklist or simi...
2024-001 Significant deficiency related to preparation of the schedule of federal awards Recommendation: The auditor recommends implementing a documented SEFA preparation process, assigning a reviewer to ensure accuracy, and providing staff training on Uniform Guidance standards. A checklist or similar tool could enhance consistency and completeness. Planned Corrective Action: Management agrees with the recommendation and will take necessary steps to address the issue. These steps include developing a formal SEFA preparation process, reconciling federal expenditures to the general ledger, training staff on Uniform Guidance requirements, and instituting a review process to ensure accuracy. Management anticipates implementing these corrective actions prior to the next audit cycle.
The Health System met with grant managers and reviewed the expectations and responsibilities to ensure appropriate reviews and sign offs prior to submitting reports to the granting agency. The Health System will implement a centralized process with dedicated resources that will establish consistent ...
The Health System met with grant managers and reviewed the expectations and responsibilities to ensure appropriate reviews and sign offs prior to submitting reports to the granting agency. The Health System will implement a centralized process with dedicated resources that will establish consistent policies for grant management, including a layered review process with executive sign off on reports prior to submission.
Management response: Warren Easton is reviewing and updating the procurement section of the policy manual to explicitly include procedures for verifying the suspension and debarment status of all vendors and contractors receiving federal funds. Documentation of each vendor's verification will be mai...
Management response: Warren Easton is reviewing and updating the procurement section of the policy manual to explicitly include procedures for verifying the suspension and debarment status of all vendors and contractors receiving federal funds. Documentation of each vendor's verification will be maintained in procurement files. A printed or PDF record from SAM.gov showing the vendor's status will be retained as audit evidence.
Auditor Description of Condition and Effect: During our audit, we noted a variance between amounts reported in the Form 5100-127 and amounts recorded in the general ledger and audit report for the related fiscal year. The report was amended during the audit to reflect the correct amounts. Auditor R...
Auditor Description of Condition and Effect: During our audit, we noted a variance between amounts reported in the Form 5100-127 and amounts recorded in the general ledger and audit report for the related fiscal year. The report was amended during the audit to reflect the correct amounts. Auditor Recommendation: We recommend that the Airport reconciles Form 5100-127 with amounts in the general ledger to ensure that all items on the report are correct. Corrective Action: Form 5100-127 was corrected during the audit and resubmitted with accurate information. Going forward, Management will reconcile between the amounts on the general ledger and amounts reported on Form 5100-127 to ensure accuracy. Management will also complete an independent review of the Form before submission. Responsible Person: James Canders, Airport Director Anticipated Completion Date: 12/31/2025
Recommendation: We recommend that the District segregate all duties to ensure no single employee has access to assets and record keeping of those assets. Because of limited staff, we realize segregation of the above duties is not practical, if not impossible. Therefore, the responsibility of the ...
Recommendation: We recommend that the District segregate all duties to ensure no single employee has access to assets and record keeping of those assets. Because of limited staff, we realize segregation of the above duties is not practical, if not impossible. Therefore, the responsibility of the Business Manager is greatly increased because the Board must rely on her knowledge of the everyday operations to discover any material changes in the District’s financial position. Management’s Response: The District acknowledges this finding and has analyzed staffing; however, due to budget constraints finds it is not possible to hire the additional staff needed to put the controls in place to properly rectify this finding. Management’s Response: The District acknowledges this finding and, due to limited resources, cannot overcome this finding at this time but will put a plan in place to work towards improving controls to prevent or detect material misstatements in the preparation of the financial statements.
Finding 2024-001 – Special Tests and Provisions, SEMAP reporting – ALN 14.871 – Significant Deficiency & Other Matter Corrective Action Plan: Since the audit, I have completed a SEMAP training course provided by The Nelrod Company. I will draft a binder for each indicator. I will complete the anal...
Finding 2024-001 – Special Tests and Provisions, SEMAP reporting – ALN 14.871 – Significant Deficiency & Other Matter Corrective Action Plan: Since the audit, I have completed a SEMAP training course provided by The Nelrod Company. I will draft a binder for each indicator. I will complete the analysis for each indicator and provide verification of all findings. Person Responsible: Annette Carper, Executive Director Anticipated Completion Date: I have completed the SEMAP training. The FYE 2025 SEMAP is due to be submitted by July 31, 2025. I will prepare a binder that will show collected data from August 1, 2024-July 31, 2025.
We are reviewing all accounting procedures to determine changes to be implemented.
We are reviewing all accounting procedures to determine changes to be implemented.
2024-003: Reporting Compliance Requirement The City will review the current procedures for maintaining documentation for when quarterly project and expenditures reports are completed, reviewed and submitted. Contact Person: Rosie Cavazos, CFO Proposed implementation date: September 30, 2025
2024-003: Reporting Compliance Requirement The City will review the current procedures for maintaining documentation for when quarterly project and expenditures reports are completed, reviewed and submitted. Contact Person: Rosie Cavazos, CFO Proposed implementation date: September 30, 2025
Finding 561067 (2024-002)
Significant Deficiency 2024
2024-002: Procurement, Suspension and Debarment Compliance Requirement The City will review the current procedures for maintaining documentation for when vendors are verified that they are not suspended or debarred. Contact Person: Rosie Cavazos, CFO Proposed implementation date: September 30, 20...
2024-002: Procurement, Suspension and Debarment Compliance Requirement The City will review the current procedures for maintaining documentation for when vendors are verified that they are not suspended or debarred. Contact Person: Rosie Cavazos, CFO Proposed implementation date: September 30, 2025
Finding Number: 2024‐002 Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425 Contact Person: Arlene Laughter, Business Coordinator Anticipated Completion Date: September 30, 2025 Planned Corrective Action: The District will develop and implement stro...
Finding Number: 2024‐002 Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425 Contact Person: Arlene Laughter, Business Coordinator Anticipated Completion Date: September 30, 2025 Planned Corrective Action: The District will develop and implement stronger internal control procedures to ensure accountings and financial statements are free from misstatements and are in accordance with District policies and Federal and State requirements. Inventories of capital assets purchased with federal funds will be conducted every two years, as required.
Finding Number: 2024‐001 Program Names/Assistance Listing Titles: Assistance Listing Numbers: Title I Grants 84.010 Child Nutrition Cluster 10.553, 10.555, 10.559 Impact Aid 84.041 Education Stabilization Fund 84.425 Contact Person: Arlene Laughter, Business Coordinator Anticipated Completion Date: ...
Finding Number: 2024‐001 Program Names/Assistance Listing Titles: Assistance Listing Numbers: Title I Grants 84.010 Child Nutrition Cluster 10.553, 10.555, 10.559 Impact Aid 84.041 Education Stabilization Fund 84.425 Contact Person: Arlene Laughter, Business Coordinator Anticipated Completion Date: December 30, 2025 Planned Corrective Action: The District will implement better controls over financial reporting and records retention to ensure all documents are prepared and available for the timely completion of the financial reports.
District will work closely with external auditors with an initial calendar to meet the required deadline for next year’s (fiscal year 2025) audit.
District will work closely with external auditors with an initial calendar to meet the required deadline for next year’s (fiscal year 2025) audit.
MANAGEMENT’S VIEWS AND CORRECTIVE ACTION PLAN For the year ended December 31, 2024 Finding 2024-001 - Non-Compliance with Accurate Student Enrollment Change Submissions to the National Student Loan Data System (Significant Deficiency) Grantor: U.S. Department of Education Program: Student Fina...
MANAGEMENT’S VIEWS AND CORRECTIVE ACTION PLAN For the year ended December 31, 2024 Finding 2024-001 - Non-Compliance with Accurate Student Enrollment Change Submissions to the National Student Loan Data System (Significant Deficiency) Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing #: 84.268, 84.063 Award Titles: Federal Direct Student Loan Program, Federal Pell Grant Program Award Years: 7/2023 – 6/2025 Management agrees with the finding and proposes the following corrective action plan: Corrective Action Plan: Due to non-compliance with timely and accurate student enrollment change submissions to the National Student Loan Data System (NSLDS), Brigham Young University – Hawaii (BYUH) Management proposes the following corrective action plan to mitigate reporting errors. The Registrar’s Office, in coordination with BYUH’s Enterprise Information Systems team, will review and enhance the processes used to extract student data from PeopleSoft and transmit it to the National Student Clearinghouse (NSC) and NSLDS. This includes: -Reviewing all relevant PeopleSoft updates and ensuring that corresponding changes are reflected in the data transmitted to NSLDS. -Testing and validating the reporting processes within PeopleSoft to confirm data accuracy and completeness. -Verifying that the correct data is being transmitted to NSLDS. -Testing the student data within NSLDS to ensure its integrity. -Documenting the entire process for future reference and ongoing quality assurance. In addition, the Registrar’s office has already added additional resources to run all reporting processes. The Registrar’s office has also reached out to Ensign College to learn about their reporting process. The University is considering contacting the PeopleSoft reporting specialist that Ensign used, although that decision will be made at a later date, and if necessary. These actions will enable the Registrar’s Office to more effectively review credit load determinations and accurately establish program begin dates for students. Daryl Whitford, Registrar, will remain responsible for enrollment reporting at BYUH. She will oversee the implementation of the revised process, provide training to all relevant staff members, and lead the development and implementation of a control mechanism to ensurefuture compliance with NSLDS reporting requirements within PeopleSoft. Timing: Daryl Whitford, Registrar, will be responsible for overseeing that all items noted in the corrective action plan will be implemented by September 1, 2025. Signed and Acknowledged Daryl Whitford, BYUH Registrar
Federal Agency: U.S. Department of Agriculture, Rural Development, CFDA #10.766 Community Facilities Loans and Grants Cluster Corrective Action Plan: Upon the discovery of the underfunding of the debt service reserve account, the Facility discussed the situation with the Facility’s USDA contact. ...
Federal Agency: U.S. Department of Agriculture, Rural Development, CFDA #10.766 Community Facilities Loans and Grants Cluster Corrective Action Plan: Upon the discovery of the underfunding of the debt service reserve account, the Facility discussed the situation with the Facility’s USDA contact. The USDA has approved an action plan for the Facility to replenish the debt service reserve account by February 2028 with $5,000 monthly deposits which began in December 2024. Responsible Party: Mariah Voeltz, Acting Administrator Estimated completion date: December 31, 2024
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