Corrective Action Plans

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Finding 2024-004 Notices and Authorizations: (Significant Deficiency) Federal Agency: Department of Education Program: Federal Direct Student Loans AL #: 84.268 Award Year: 2023-2024 Condition: The written notifications were not provided to students for the periods October 2, 2023 through October 26...
Finding 2024-004 Notices and Authorizations: (Significant Deficiency) Federal Agency: Department of Education Program: Federal Direct Student Loans AL #: 84.268 Award Year: 2023-2024 Condition: The written notifications were not provided to students for the periods October 2, 2023 through October 26, 2023 and December 19, 2023 through February 9, 2024. Corrective Action Planned: Corrective actions were taken to resolve the automated notification process. Additional failures were discovered, which led to these deficiencies, and subsequent corrections were made to the system. Based on the possibility of future failures in the automatic process, an additional safeguard procedure has been added to the Financial Aid Office at two levels to verify that the required notices are communicated timely. Responsible Party: Mark Messingschlager, Director of Financial Aid Anticipated Completion Date: Immediately
Condition: The School does not have a documented Direct Loan quality assurance program. Planned Corrective Action: The Iliff School of Theology has contracted with a professional, third-party processing company to administer its student aid programs. The school will coordinate with this third-party...
Condition: The School does not have a documented Direct Loan quality assurance program. Planned Corrective Action: The Iliff School of Theology has contracted with a professional, third-party processing company to administer its student aid programs. The school will coordinate with this third-party processor to ensure that there is a documented quality assurance program that is regularly exercised for compliance purposes. All documentation will be maintained. Contact person responsible for corrective action: Jason Warr, VP for Business, Controller Anticipated Completion Date: June 2024
Condition: The School submitted a FISAP to the U.S. Department of Education that reported inaccurate information in several data fields within the report. In addition, there was no evidence that an individual other than the preparer reviewed the report. Planned Corrective Action: The Iliff School o...
Condition: The School submitted a FISAP to the U.S. Department of Education that reported inaccurate information in several data fields within the report. In addition, there was no evidence that an individual other than the preparer reviewed the report. Planned Corrective Action: The Iliff School of Theology has contracted with a professional, third-party processing company to administer its student aid programs. Preparation and submission of the FISAP will be completed with coordination between the VP of Business and the third-party processor. This includes a quality review process for accuracy. Contact person responsible for corrective action: Jason Warr, VP for Business, Controller Anticipated Completion Date: June 2024
Condition: Our audit procedures identified instances of untimely reporting of enrollment information to NSLDS. Planned Corrective Action: The Iliff School of Theology has contracted with a professional, third-party processing company to administer its student aid programs. The School has also ensur...
Condition: Our audit procedures identified instances of untimely reporting of enrollment information to NSLDS. Planned Corrective Action: The Iliff School of Theology has contracted with a professional, third-party processing company to administer its student aid programs. The School has also ensured that this third-party processor is properly coordinated with the registrar’s office to meet federal requirements for NSLDS enrollment reporting. Contact person responsible for corrective action: Jason Warr, VP for Business, Controller Anticipated Completion Date: June 2024
Contact Person – Cassandra Heide, City Administrator Corrective Action Plan – Will establish a procedure to review certified payrolls. Completion Date – Immediately
Contact Person – Cassandra Heide, City Administrator Corrective Action Plan – Will establish a procedure to review certified payrolls. Completion Date – Immediately
Finding 554954 (2024-003)
Significant Deficiency 2024
Contact Person – Cassandra Heide, City Administrator Corrective Action Plan – Will establish a procedure to ensure all reporting is filed timely. Completion Date – Immediately
Contact Person – Cassandra Heide, City Administrator Corrective Action Plan – Will establish a procedure to ensure all reporting is filed timely. Completion Date – Immediately
2024-005 – Coronavirus State and Local Fiscal Recovery Funds – Procurement, Suspended, Debarred – The Village is aware it has not verified contractors eligibility to work on Federally funded projects and will create policies to ensure the Village is compliant going forward. Responsible Official – Ja...
2024-005 – Coronavirus State and Local Fiscal Recovery Funds – Procurement, Suspended, Debarred – The Village is aware it has not verified contractors eligibility to work on Federally funded projects and will create policies to ensure the Village is compliant going forward. Responsible Official – James Healy – Administrator Anticipated Completion Date – The Village intends to work towards resolving this finding in the following year.
View Audit 353554 Questioned Costs: $1
U.S. Department of Health and Human Services Refugee and Entrant Assistance Discretionary Grants – Assistance Listing No. 93.576 Recommendation: The Organization should review internal controls to ensure required filings are submitted timely and evidence of submission are retained as documentation...
U.S. Department of Health and Human Services Refugee and Entrant Assistance Discretionary Grants – Assistance Listing No. 93.576 Recommendation: The Organization should review internal controls to ensure required filings are submitted timely and evidence of submission are retained as documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management is reviewing is current standard operating procedures to ensure that timely submissions occur, and evidence of submissions is retained in a central repository. Name(s) of the contact person(s) responsible for corrective action: Christopher Paris Planned completion date for corrective action plan: June 30, 2025 and Ongoing
U.S. Department of Health and Human Services Refugee and Entrant Assistance State/Replacement Designee Administered Programs Assistance Listing No. 93.566 Recommendation: The Organization should review internal controls to ensure required filings are submitted timely. Explanation of disagreement...
U.S. Department of Health and Human Services Refugee and Entrant Assistance State/Replacement Designee Administered Programs Assistance Listing No. 93.566 Recommendation: The Organization should review internal controls to ensure required filings are submitted timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management is reviewing is current standard operating procedures to ensure that timely submissions occur, and evidence of submissions is retained in a central repository. Name(s) of the contact person(s) responsible for corrective action: Christopher Paris Planned completion date for corrective action plan: June 30, 2025 and Ongoing
U.S. Department of Health and Human Services Refugee and Entrant Assistance State/Replacement Designee Administered Programs Assistance Listing No. 93.566 Recommendation: It is recommended that the Organization design controls to ensure expenses are supported by source documentation and allowable...
U.S. Department of Health and Human Services Refugee and Entrant Assistance State/Replacement Designee Administered Programs Assistance Listing No. 93.566 Recommendation: It is recommended that the Organization design controls to ensure expenses are supported by source documentation and allowable costs under the grant or contract. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management is reviewing standard operating procedures with the program staff. All expenses will be supported with source documentation. Management will perform periodic reviews to ensure expenses are supported by source documentation and allowable expenses under the grant. Name(s) of the contact person(s) responsible for corrective action: Christopher Paris Planned completion date for corrective action plan: June 30, 2025
View Audit 353549 Questioned Costs: $1
Health Center Program Cluster (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) -Assistance Listing No. 93.224 /93.527 Recommendation: Reimbursement requests should be reviewed by the CFO for all grants before submission to the grantor ...
Health Center Program Cluster (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) -Assistance Listing No. 93.224 /93.527 Recommendation: Reimbursement requests should be reviewed by the CFO for all grants before submission to the grantor to ensure that employees charged to the grants are different, in addition, timesheets should be reviewed during the grant reimbursement process to ensure time supports the specific grant and allowable costs. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The CFO will review all grant submissions based on personnel costs each month and ensure that there are no duplicate billings and that timesheets appropriately reflect staff involvement. Name(s) of the contact person(s) responsible for corrective action: Jeff Forman, CFO. Planned completion date for corrective action plan: March 21, 2025
View Audit 353547 Questioned Costs: $1
Health Center Program Cluster (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) -Assistance Listing No. 93.224 /93.527 Recommendation: A test should be performed in the billing software annually when the updated Sliding Fee Discount Sch...
Health Center Program Cluster (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) -Assistance Listing No. 93.224 /93.527 Recommendation: A test should be performed in the billing software annually when the updated Sliding Fee Discount Schedule is put into place to ensure that slides are being calculated properly at the effective date of the new schedule. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: CHWP will test for irregularities periodically throughout the year Name(s) of the contact person(s) responsible for corrective action: Jeff Forman, CFO. Planned completion date for corrective action plan: March 21, 2025.
Health Center Program Cluster (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) -Assistance Listing No. 93.224 /93.527 Recommendation: Data compiled to prepare a report is saved with a final copy of the report to support the information...
Health Center Program Cluster (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) -Assistance Listing No. 93.224 /93.527 Recommendation: Data compiled to prepare a report is saved with a final copy of the report to support the information is complete and accurate. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: CHWP has made enhancements to its financial reporting structure and used this in calculating the UOS data for CY 2024. We believe that we documented the numbers appropriately but will make sure that we continue to comply with this requirement in future UOS reporting, Name(s) of the contact person(s) responsible for corrective action: Jeff Forman, CFO. Planned completion date for corrective action plan: March 21, 2025.
MVCHS acknowledges that two of thirty patient accounts had miscalculated Sliding Fee Discount Schedule Program income, which resulted in the patients being placed on the wrong Slide. MVCHS Finance staff conducts periodic training with Front Office staff regarding the Sliding Fee Discount Program. Th...
MVCHS acknowledges that two of thirty patient accounts had miscalculated Sliding Fee Discount Schedule Program income, which resulted in the patients being placed on the wrong Slide. MVCHS Finance staff conducts periodic training with Front Office staff regarding the Sliding Fee Discount Program. The Sliding Fee Discount Schedule application process involves collecting income documents and calculating household income and family size. MVCHS Finance staff will enhance its periodic training, starting in April 2025 and quarterly thereafter, of the Sliding Fee Discount Schedule Program to ensure calculations are performed correctly. In addition, MVCHS Finance staff will develop an audit checklist and perform regular audits, starting in April 2025, of Sliding Fee Discount Schedule Program patient accounts in order to ensure accuracy and compliance. In addition to the above aforementioned error, MVCHS also acknowledges that the Sliding Fee Discount Schedule Program Application erroneously states that gross income is applied in calculating eligibility for the Sliding Fee Discount Schedule Program, when in fact, net income is applied. MVCHS appropriately applies net income when calculating eligibility for the Sliding Fee Discount Schedule Program. The Sliding Fee Discount Program Application has since been updated to indicate that net income will be applied. Front Office staff will receive updated training in order to ensure understanding and procedures for the Sliding Fee Discount Schedule Program.
The District had the three buses enrolled in the EPA Program crushed in entirety at Cunningham Metals in Russellville, AR. The motor was only to be drilled if the District was keeping the chassis on site. The receipt from the salvage was uploaded to the EPA portal in the close out process. Pictur...
The District had the three buses enrolled in the EPA Program crushed in entirety at Cunningham Metals in Russellville, AR. The motor was only to be drilled if the District was keeping the chassis on site. The receipt from the salvage was uploaded to the EPA portal in the close out process. Pictures taken at the salvage yard and a letter was provided by the salvage yard. As of April 2, 2025, we are waiting on instructions from the EPA for our next actions. Contact person responsible for corrective action: Kim Foster. Anticipated completion date of corrective action: The EPA was contacted on February 3, 2025.
The District has contacted the EPA regarding buses replaced and the new buses purchased in the 2022 Clean School Bus Rebate. As of April 2, 2025, we are still waiting on their instructions for our next actions. The District uploaded all required documentation to the EPA portal in the close out pro...
The District has contacted the EPA regarding buses replaced and the new buses purchased in the 2022 Clean School Bus Rebate. As of April 2, 2025, we are still waiting on their instructions for our next actions. The District uploaded all required documentation to the EPA portal in the close out process. Contact person responsible for corrective action: Kim Foster. Anticipated completion date of corrective action: The EPA was contacted on February 3, 2025.
View Audit 353537 Questioned Costs: $1
Child Nutrition implemented a new policy/procedure for handling free and reduced applications effective July 1, 2024.
Child Nutrition implemented a new policy/procedure for handling free and reduced applications effective July 1, 2024.
Audit period: January 1, 2024 – December 31, 2024 The finding from the 2024 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS – FINANCIAL STATEMENT AUDIT None FINDINGS – FEDERAL AWARD PROGRAM AUDI...
Audit period: January 1, 2024 – December 31, 2024 The finding from the 2024 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS – FINANCIAL STATEMENT AUDIT None FINDINGS – FEDERAL AWARD PROGRAM AUDIT Finding 2023-001 (Repeat Finding): Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects, Federal Assistance Listing Number 14.155 Recommendation: Our auditors recommended that we resume unit inspections and ensure those inspections are properly documented in the tenant files. Action Taken: We are currently in the process of completing and documenting unit inspections. Name of Contact Person Responsible for Corrective Action: Kyle Lyskawa, CFO, (315) 424-1821. Anticipated Completion Date: April 2025
Audit period: January 1, 2024 – December 31, 2024 The findings from the 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS – FINANCIAL STATEMENT AUDIT None FINDINGS – FEDERAL AWARD PROGRAM...
Audit period: January 1, 2024 – December 31, 2024 The findings from the 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS – FINANCIAL STATEMENT AUDIT None FINDINGS – FEDERAL AWARD PROGRAM AUDIT Finding 2024-001: Mortgage Insurance – Rental Housing (Section 207), federal assistance listing number 14.134 Recommendation: East Main Street Apartments should ensure residual receipts are made within 60 days of year-end in accordance with the HUD Regulatory Agreement. Action Taken: East Main Street Apartments made the required payment was made after the 60-day timeline. Completion Date: March 2024 Name of Contact Person Responsible for Corrective Action: Kyle Lyskawa, CFO (315) 424-1821
Audit period: January 1, 2024 – December 31, 2024 The findings from the 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS – FINANCIAL STATEMENT AUDIT None FINDINGS – FEDERAL AWARD PROGRAM...
Audit period: January 1, 2024 – December 31, 2024 The findings from the 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS – FINANCIAL STATEMENT AUDIT None FINDINGS – FEDERAL AWARD PROGRAM AUDIT Finding 2024-001: Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects, Federal Assistance Listing Number 14.155 Recommendation: Our auditors recommended that we ensure documentation of unit inspections is maintained in all tenant files. Action Taken: We completed a review of tenant files and reinspected those units without appropriate documentation. Name of Contact Person Responsible for Corrective Action: Kyle Lyskawa, CFO, (315) 424-1821. Anticipated Completion Date: April 2025
Management will contact MassHousing and inform them of the incorrect utility allowance approval and provide supporting documentation to explain error. Management will follow guidance from MassHousing to resolve the discrepancy.
Management will contact MassHousing and inform them of the incorrect utility allowance approval and provide supporting documentation to explain error. Management will follow guidance from MassHousing to resolve the discrepancy.
1) Management will continue to work consistently to comply with performing all unit inspections within 30 days of lease date and properly document all unit inspections accordingly in the tenant file. 2) The maintenance supervisor will ensure that at completion of all work orders, the work order for...
1) Management will continue to work consistently to comply with performing all unit inspections within 30 days of lease date and properly document all unit inspections accordingly in the tenant file. 2) The maintenance supervisor will ensure that at completion of all work orders, the work order form must be filled out and signed by the maintenance technician. All complete work orders will be documented and filed at the Business Office each day. Before leaving the apartment, the maintenance staff will leave a carbon copy of the work order indicating what work was performed in the apartment. The maintenance supervisor will also ensure that all work orders coded as emergencies will be assigned to a technician in a timely manner and completed within 24 business hours.
Management has corrected all audited recertifications with correct information. For those tenants where the corrections had an impact on the tenant rent and housing assistance payments, management has notified and conducted meetings with the residents. Management will also insert file clarification ...
Management has corrected all audited recertifications with correct information. For those tenants where the corrections had an impact on the tenant rent and housing assistance payments, management has notified and conducted meetings with the residents. Management will also insert file clarification notes in those corrected files that the tenant files were corrected to ensure transparency and note that an administrative correction was conducted. Management will continue to utilize internal control procedures to ensure that information are calculated accurately and reported correctly in the future.
View Audit 353506 Questioned Costs: $1
Corrective Action: The Organization agrees with the finding. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Management is working with the new property managers to ensure they have procedures in place to document and maintain tenant fil...
Corrective Action: The Organization agrees with the finding. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Management is working with the new property managers to ensure they have procedures in place to document and maintain tenant files in accordance with HUD and will have routine internal audits of tenant files to ensure compliance with HUD regulations. For properties not transitioning to new property management, management believes the reduced volume of properties at one property manager will reduce staff turnover and more efficiently provide the proper training to existing staff to improve compliance with tenant files. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2025. Name of contact person: Jennifer Anderson, Interim CFO
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, management has assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications...
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, management has assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications and hired a team of additional roving property management/compliance teams to cover open property management positions and to support site staff in completing tenant recertifications. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2025. Name of contact person: Jennifer Anderson, Interim CFO
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