Corrective Action Plans

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Finding 2024-003: Physical Inventory Observation Synopsis of Finding CAPSC has not performed a physical inventory in the last two years. Management’s Response We have implemented an annual schedule of Physical Inventory being taken every July, while classrooms are closed for the summer. This will be...
Finding 2024-003: Physical Inventory Observation Synopsis of Finding CAPSC has not performed a physical inventory in the last two years. Management’s Response We have implemented an annual schedule of Physical Inventory being taken every July, while classrooms are closed for the summer. This will be conducted by our Facility and Operations team members with support from Head Start leadership. Contact Person Responsible for Corrective Action: Kate Devine, Director of Operations and Change Management Anticipated Completion Date: 7/15/25
Finding 2024-002: Tri-Partite Board Composition Synopsis of Finding Condition: Less than 1/3 of the members of the board of directors of CAPSC were representative of the government sector in accordance with Community Services Block Grant (CSBG) requirements. Management’s Response We have already rec...
Finding 2024-002: Tri-Partite Board Composition Synopsis of Finding Condition: Less than 1/3 of the members of the board of directors of CAPSC were representative of the government sector in accordance with Community Services Block Grant (CSBG) requirements. Management’s Response We have already recruited new board members to fulfill this requirement as of January’s board meeting. Recruiting has been established as a standing agenda item for the Governance Committee of the board, and ongoing efforts are being made to continuously develop future board members to account for turnover. Contact Person Responsible for Corrective Action: Cynthia King, CEO Anticipated Completion Date: 1/27/25
Finding 2024-001: Late Audit Submission Synopsis of Finding The fiscal year audit and reporting package is being submitted after the required due date. Management’s Response Sonoma CAN has contracted with One Abacus to support design and implementation of procedures to maintain real time reconciliat...
Finding 2024-001: Late Audit Submission Synopsis of Finding The fiscal year audit and reporting package is being submitted after the required due date. Management’s Response Sonoma CAN has contracted with One Abacus to support design and implementation of procedures to maintain real time reconciliation and improve accuracy of data as it is entered into the general ledger. Additionally, we have replaced several internal roles with more qualified individuals for the coming year. Contact Person Responsible for Corrective Action: Johnny Nolen, COO + CFO Anticipated Completion Date: 7/1/2025
Finding #2024-001: During the year ended September 30, 2024, the Corporation did not make the HUD required number of deposits to the reserve for replacements. Recommendation: Management should transfer $6,060 from the operating account to the reserve for replacements account. Action(s) taken or pl...
Finding #2024-001: During the year ended September 30, 2024, the Corporation did not make the HUD required number of deposits to the reserve for replacements. Recommendation: Management should transfer $6,060 from the operating account to the reserve for replacements account. Action(s) taken or planned on the finding: Management concurs with the finding and recommendation. Management deposited $6,060 into the replacement reserve on December 18, 2024, and has begun making monthly deposits to the reserve to ensure compliance.
View Audit 355345 Questioned Costs: $1
Name of contact person: Jennifer Santerre, Chief Financial Officer Corrective Action: The Organization was fortunate to have sufficient cash on hand in order to continue to provide the highestquality of care to its residents during the COVID-19 pandemic, primarily as a result of federal and state st...
Name of contact person: Jennifer Santerre, Chief Financial Officer Corrective Action: The Organization was fortunate to have sufficient cash on hand in order to continue to provide the highestquality of care to its residents during the COVID-19 pandemic, primarily as a result of federal and state stimulus funds, which were restricted in usage, received during 2020 and 2021. The Organization made it a priority to ensure that its staff continued to be compensated throughout the pandemic. Accordingly, the Organization kept cash on hand in order to meet the needs of the residents cared for daily and the dedicated staff who serve them. The Organization was not expecting a surplus cash situation at December 31, 2020 or June 30, 2021. Had the Organization not received stimulus funds through programs such as the Provider Relief Fund and Paycheck Protection Program, the Organization would not have had surplus cash at both December 31, 2020 and June 30, 2021. The required deposit due to the residual receipt account for the year ended December 31, 2020 was made on May 31, 2022. The Organization is currently in the process of discussing repayment terms for the deposit due for the period June 30, 2021 with its asset manager which includes discussions for the repayment of $1,660,755 in frontline costs that were funded by the Parent Organization back to the Parent. Proposed Completion Date: No later than December 31, 2025
Name of contact person: Jennifer Santerre, Chief Financial Officer Corrective Action: The Organization is a community based non-profit and considers supporting local businesses, including a bank, a worthwhile business practice. The Organization is currently in the process of reviewing its banking re...
Name of contact person: Jennifer Santerre, Chief Financial Officer Corrective Action: The Organization is a community based non-profit and considers supporting local businesses, including a bank, a worthwhile business practice. The Organization is currently in the process of reviewing its banking relationships, and looking at other scenarios which would involve transferring funds to another institution. Proposed Completion Date: No later than December 31, 2025.
Finding 559054 (2024-002)
Material Weakness 2024
Identifying Number: 2024-002 Finding: Late submission of the Single Audit to the Federal Auditing Clearinghouse The Single Audit package for the College’s fiscal year ended June 30, 2024 should have been submitted to the Federal Audit Clearinghouse by March 31, 2024. The College’s fiscal year 2024 ...
Identifying Number: 2024-002 Finding: Late submission of the Single Audit to the Federal Auditing Clearinghouse The Single Audit package for the College’s fiscal year ended June 30, 2024 should have been submitted to the Federal Audit Clearinghouse by March 31, 2024. The College’s fiscal year 2024 Single Audit package was not submitted to the Federal Audit Clearinghouse within the required time frame. Corrective Actions Taken or Planned: The College will work with its outside auditors to develop an appropriate timeline for the completion of future audits on a schedule that allows for timely filing of the Single Audit Person Responsible: Alexander Guroff, aguroff@knox.edu Anticipated completion date: May 2025
Finding 559052 (2024-005)
Significant Deficiency 2024
Identifying Number: 2024-005 Finding: Disbursements to or on Behalf of Students (Credit Balances) The College did not pay the Title IV credit balance to the student directly for one student within the required timeline noted above. Out of the 40 students tested, we noted one student (2.5%) who’s cr...
Identifying Number: 2024-005 Finding: Disbursements to or on Behalf of Students (Credit Balances) The College did not pay the Title IV credit balance to the student directly for one student within the required timeline noted above. Out of the 40 students tested, we noted one student (2.5%) who’s credit balance was not paid directly to the student within the required timeframe noted above. The incorrect timing did not have an effect on the total award given to students (timing only). The College did not have formally documented controls related to the process associated with disbursements to or on behalf of students (credit balances), which is required under Uniform Grant Guidance. Corrective Actions Taken or Planned: The College has consistently worked to streamline the refund process in Student Financial Services and coordination with the Business Office. This process will be further enhanced by process improvements with the transition from CX to J1 in July 2025. Person Responsible: Leigh Brinson, lbrinson@knox.edu Anticipated completion date: July 2025
Finding 559051 (2024-004)
Significant Deficiency 2024
Identifying Number: 2024-004 Finding: Common Origination and Disbursement Reporting The College incorrectly reported the COA to COD for 3 students. Out of the 34 students tested, we noted 3 students (8.8%) whose COA was incorrectly reported to COD. The incorrect reporting did not have an effect on ...
Identifying Number: 2024-004 Finding: Common Origination and Disbursement Reporting The College incorrectly reported the COA to COD for 3 students. Out of the 34 students tested, we noted 3 students (8.8%) whose COA was incorrectly reported to COD. The incorrect reporting did not have an effect on the total award given to students (reporting only). The College did not have formally documented controls related to the processes of enrollment reporting and reporting, which is required under Uniform Grant Guidance. Corrective Actions Taken or Planned: The College has moved Financial Aid packaging for all students from CX to PowerFAIDS. This transition has removed the manual processes that caused this error. Person Responsible: Leigh Brinson, lbrinson@knox.edu Anticipated completion date: September 2024
Finding 559050 (2024-003)
Significant Deficiency 2024
Identifying Number: 2024-003 Finding: Error in Reporting for National Student Loan Data System (NSLDS) The College did not properly report the student enrollment change for students who received federal student aid to the NSLDS. The College did not timely report three students’ Program-Level or C...
Identifying Number: 2024-003 Finding: Error in Reporting for National Student Loan Data System (NSLDS) The College did not properly report the student enrollment change for students who received federal student aid to the NSLDS. The College did not timely report three students’ Program-Level or Campus-Level enrollment status change to NSLDS. Out of the 11 students tested, we noted 3 students (28%) whose status change at the Program-Level and Campus-Level was not timely reported to NSLDS. The College did not have formally documented controls related to the process of enrollment reporting, which is required under Uniform Grant Guidance. Corrective Actions Taken or Planned: The Registrar’s office is implementing new processes to provide timely filing of clearing house data. This process will be further improved with the transition from CX to J1 in summer 2025. Person Responsible: Patrick Hathaway, phathaway@knox.edu Anticipated completion date: March 2025
Finding 559045 (2024-006)
Material Weakness 2024
Identifying Number: 2024-006 Finding: Graham Leach Bliley Act – Student Information Security The College’s written information security program did not include the following elements required by regulation as agreed to in the PPA.  The College has performed a risk assessment utilizing internal reso...
Identifying Number: 2024-006 Finding: Graham Leach Bliley Act – Student Information Security The College’s written information security program did not include the following elements required by regulation as agreed to in the PPA.  The College has performed a risk assessment utilizing internal resources but has not based the information security program on the results of this assessment, nor has the College included all required elements of internal and external risks to the security, confidentiality or integrity of customer information. The College’s risk assessment is missing an inventory of IT systems that process and store customer information and the compliance with information security elements related to multifactor authentication, access control, change management, logging and alerting and encryption.  The College has not identified, designed or implemented safeguards for all of the risks identified in the risk assessment. The safeguards do not include the identification of security events or detection and response capabilities to support incident response.  The College has not been able to test safeguards because safeguards have not been designed or implemented in response to the risk assessment.  The College has not developed written policies and procedures to ensure that personnel are able to enact the information security program. There is a lack of evidence of leadership being required to report to the board or an appropriate supervisory council to ensure those charged with governance are informed on the current state of the information security program. The College has not developed policies and procedures to oversee information service providers Corrective Actions Taken or Planned: For the past 2 years, the College has been systematically addressing its IT and IT Security needs. These practices were updated in January 2023 and the policies have been formalized in November 2024. Person Responsible: James Stevens, jstevens@knox.edu Anticipated completion date: November 2024
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 April 30, 2025, our accounting department is fully staffed and we are supporting accounting staff training needs. As of April 30, 2025, management has drafted updates to many of the policies and procedures referenced in the OIG report. Updated policies, including a revised Accounting Manual and an updated Personnel Manual will be presented to the Board, the Board Budget & Audit Committee, or 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: June 2, 2025 Responsible Person(s): Executive Director and Chief Financial Officer
Finding Number 2024-003– Enrollment Reporting Contact Person(s): Shanell Tilo, Financial Aid Officer Dr. Emilia Le’i, Dean of Student Services Dr. Letupu Moananu, Vice President of Academics, Community, and Student Affairs Explanation and specific reasons for disagreement with the audit finding or t...
Finding Number 2024-003– Enrollment Reporting Contact Person(s): Shanell Tilo, Financial Aid Officer Dr. Emilia Le’i, Dean of Student Services Dr. Letupu Moananu, Vice President of Academics, Community, and Student Affairs Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreement. Corrective actions taken/planned: The Financial Aid Office has strengthened the review process by reinforcing the dual- review control system. In this system:  Control #1 (Financial Aid Coordinator) is responsible for conducting the initial review of the NSLDS Enrollment Report roster, performing data entry, and updating the status.  Control #2 (Financial Aid Manager) performs a secondary review and signs off on all NSLDS roster files before submission. Additionally, a log of all NSLDS submissions will be maintained, with both reviewers' signatures, to ensure proper documentation and accountability. Action Plan: The anticipated completion date for Finding Number 2024-0003 is March 2025
Finding 2024-002 – Special Tests and Provisions – Return of Title IV Funds Contact Person(s): Shanell Tilo, Financial Aid Officer Dr. Emilia Le’i, Dean of Student Services Dr. Letupu Moananu, Vice President of Academics, Community, and Student Affairs Explanation and specific reasons for disagreemen...
Finding 2024-002 – Special Tests and Provisions – Return of Title IV Funds Contact Person(s): Shanell Tilo, Financial Aid Officer Dr. Emilia Le’i, Dean of Student Services Dr. Letupu Moananu, Vice President of Academics, Community, and Student Affairs Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreement. Corrective actions taken/planned: The Financial Aid Office has updated the Financial Aid Handbook, Standard Operating Procedures (SOP), and the R2T4 total days calculation chart to exclude scheduled breaks of five or more consecutive days. To ensure compliance with these updates, the Financial Aid Office conducted a policy review session with the financial aid staff. Additionally, mandatory training sessions were held to reinforce R2T4 calculation procedures, with a specific focus on the proper exclusion of scheduled breaks. The Financial Aid Manager is responsible for calculating the total days for R2T4 purposes each award year. The Financial Aid Officer performs a secondary review to verify the accuracy of these calculations. Action Plan: The anticipated completion date for Finding Number 2024-0002 is March 2025.
The Managing Agent has requested and received authorization from HUD for the expenditure of funds from the Operating Account related to the design and planning of the Seismic Retrofit. The Managing Agent restored the funds expended from the Replacement Reserve Account from the Operating Account in F...
The Managing Agent has requested and received authorization from HUD for the expenditure of funds from the Operating Account related to the design and planning of the Seismic Retrofit. The Managing Agent restored the funds expended from the Replacement Reserve Account from the Operating Account in February 2025, subsequent to year-end. Management changes (including a revision of leadership) as well as a better understanding of HUD requirements will ensure this error does not happen again.
View Audit 355300 Questioned Costs: $1
Management agrees with the finding. The Managing Agent has, at its own expense, contracted with US Inspection Group to complete a full inspection of every unit before April 15, 2025. The Managing Agent has prepared a new internal tasking schedule for enhance tracking of unit inspections by the ma...
Management agrees with the finding. The Managing Agent has, at its own expense, contracted with US Inspection Group to complete a full inspection of every unit before April 15, 2025. The Managing Agent has prepared a new internal tasking schedule for enhance tracking of unit inspections by the maintenance, management and executive teams. The Managing Agent will reinforce the critical importance of annual unit inspection during its annual Maintenance Conference and its annual Management Conference.
Management agrees with the finding and is in process of developing and implementing the appropriate policies and procedures. Management expects to present the policies to the board for approval at the May 2025 board meeting.
Management agrees with the finding and is in process of developing and implementing the appropriate policies and procedures. Management expects to present the policies to the board for approval at the May 2025 board meeting.
The College will continue to adjust procedures as determined necessary to ensure that students are properly identified to provide them with exit counseling materials.
The College will continue to adjust procedures as determined necessary to ensure that students are properly identified to provide them with exit counseling materials.
The College is working to increase enrollment and adjusting the budget accordingly with available resources to reflect a positive net income from unrestricted operations.
The College is working to increase enrollment and adjusting the budget accordingly with available resources to reflect a positive net income from unrestricted operations.
The College will make the necessary correction to the student's award. Review procedures will be conducted for student awards and disbursements to ensure accuracy for the next fiscal year.
The College will make the necessary correction to the student's award. Review procedures will be conducted for student awards and disbursements to ensure accuracy for the next fiscal year.
Although procurement will be handled through several manager, MVRTD will implement a procedure that All procurements will be finalized and filed with the procurement manager. MVRTD will update it procurement policy to restate the timetable for operational procurements and define the filing of the do...
Although procurement will be handled through several manager, MVRTD will implement a procedure that All procurements will be finalized and filed with the procurement manager. MVRTD will update it procurement policy to restate the timetable for operational procurements and define the filing of the documentation of each operational procurement above a specific dollar value ( to be defined).
MVRTD is in the process of procuring and implementing software that will be managed regularly to ensure that the general ledger reflects the allocation and disbursements that will assist in reconciling the payroll costs with the grant budget. MVRTD will assign different individuals to handle payrol...
MVRTD is in the process of procuring and implementing software that will be managed regularly to ensure that the general ledger reflects the allocation and disbursements that will assist in reconciling the payroll costs with the grant budget. MVRTD will assign different individuals to handle payroll preparation, approval, and reconciliation.
Southeastern Indiana REMC is aware there were two invoices submitted in error totaling $55,705. The result of this error was an overstatement of the amount eligible for reimbursement. Southeastern Indiana REMC has invoices eligible for reimbursement that were not submitted which offsets these errors...
Southeastern Indiana REMC is aware there were two invoices submitted in error totaling $55,705. The result of this error was an overstatement of the amount eligible for reimbursement. Southeastern Indiana REMC has invoices eligible for reimbursement that were not submitted which offsets these errors. Southeastern Indiana REMC, given these circumstances, does not believe they have requested total funds in excess of eligible costs.
View Audit 355278 Questioned Costs: $1
Management is aware of the audit finding regarding a lack of segregation of duties. It would not be cost effective to hire additional employees to properly segregate responsibilities at this time. Management performs additional procedures to mitigate this risk. We do not have an anticipated time fra...
Management is aware of the audit finding regarding a lack of segregation of duties. It would not be cost effective to hire additional employees to properly segregate responsibilities at this time. Management performs additional procedures to mitigate this risk. We do not have an anticipated time frame for hiring additional employees to mitigate this risk.
2024-001 Audit Adjustments Corrective Action Plan: Management will review transactions after year-end to ensure proper accounting and financial reporting. Additionally, the Agency has hired a new Financial Comptroller to oversee this process, with an anticipated start date at the end of March 2025...
2024-001 Audit Adjustments Corrective Action Plan: Management will review transactions after year-end to ensure proper accounting and financial reporting. Additionally, the Agency has hired a new Financial Comptroller to oversee this process, with an anticipated start date at the end of March 2025. Anticipated Completion Date: December 31, 2025. Contact Information Natalie Abbadessa, Director of Operations The Agency Broome County LDC 5 South College Drive Binghamton, New York 13905
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