Corrective Action Plans

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Finding: 2024-004 Written Financial Policies- Activitities Allowable, Allowable Cost Name of responsible official: Melissa Spear -Treasurer Corrective action: Adopt suggested policies as outlined by auditor. Anticipated completion date: June 30, 2025
Finding: 2024-004 Written Financial Policies- Activitities Allowable, Allowable Cost Name of responsible official: Melissa Spear -Treasurer Corrective action: Adopt suggested policies as outlined by auditor. Anticipated completion date: June 30, 2025
Finding 553616 (2024-001)
Significant Deficiency 2024
This letter is in response to finding 2024-001 Federal Awards2024-001 Preparation of the Financial Statements. We have separated duties to the largest extent as possible and have implemented compensating controls to monitor the accounting activities. Candace Machado Mayor Town of Evansville, Wyomin...
This letter is in response to finding 2024-001 Federal Awards2024-001 Preparation of the Financial Statements. We have separated duties to the largest extent as possible and have implemented compensating controls to monitor the accounting activities. Candace Machado Mayor Town of Evansville, Wyoming
We have reviewed procedures and plan to make the necessary changes to improve internal control.
We have reviewed procedures and plan to make the necessary changes to improve internal control.
The corrective action plan was documented in our response to the auditor’s comment. See the Schedule of Findings and Questioned Costs.
The corrective action plan was documented in our response to the auditor’s comment. See the Schedule of Findings and Questioned Costs.
The corrective action plan was documented in our response to the auditor’s comment. See the Schedule of Findings and Questioned Costs.
The corrective action plan was documented in our response to the auditor’s comment. See the Schedule of Findings and Questioned Costs.
U.S DEPARTMENT OF COMMMERCE COVID-19-Economic Development Administration- CARES RLF - Assistance Listing No. 11.307, Grant period - Year ended June 30, 2024. See finding 2024-002 – listed below. ALLOWANCE FOR UNCOLLECTIBLE LOANS Recommendation: When management determines a loan is uncollectible, the...
U.S DEPARTMENT OF COMMMERCE COVID-19-Economic Development Administration- CARES RLF - Assistance Listing No. 11.307, Grant period - Year ended June 30, 2024. See finding 2024-002 – listed below. ALLOWANCE FOR UNCOLLECTIBLE LOANS Recommendation: When management determines a loan is uncollectible, they should ensure an allowance is recorded. Management Response: Management concurs with finding. Planned Corrective Action: The Finance Department will include the Fiscal Manager and Fiscal Controller in any communications regarding problematic loans to ensure proper reporting. Persons Responsible: Jamie Carnes, Fiscal Controller Anticipated Completion Date: March 31, 2025.
Federal Award Finding Finding 2024-001 Federal Agency Name: Department of Housing and Urban Development Assistance Listing Number: Federal Financial Assistance Listing 14.195 Program Name: Section 8 Project-Based Cluster – Project Based Rental Assistance (PBRA) – Section 8 Housing Assistance Payment...
Federal Award Finding Finding 2024-001 Federal Agency Name: Department of Housing and Urban Development Assistance Listing Number: Federal Financial Assistance Listing 14.195 Program Name: Section 8 Project-Based Cluster – Project Based Rental Assistance (PBRA) – Section 8 Housing Assistance Payment Program Finding Summary: Material Weakness in internal control over compliance was found in relation to owner’s performance of housing quality inspections. Annual housing quality inspections did not occur at one of the properties operating under Section 8 during 2024. The cause was turnover at the property management level and incomplete monitoring controls. Corrective Action Plan: The Housing Company will enhance its inspection process to ensure annual inspections are completed and reported for all properties. The plan includes the following steps: 1. Regional Managers will collect inspection data and enter it into a centralized tracking system. 2. The Operations Manager and/or Director of The Housing Company will review the tracker semi-annually to verify completeness. 3. Any incomplete inspections will be promptly identified and addressed to maintain annual inspection compliance. 4. The centralized tracker will be stored in an easily accessible location for authorized personnel. 5. Follow-up actions will be taken to complete any outstanding inspections in a timely manner. Responsible Individual: Erin Anderson, Director Anticipated Completion Date: Immediately – March 27, 2025. Very truly yours, Erin Anderson Director The Housing Company
Finding 2024-03: Cash Management Approval Views of Responsible Officials Management agrees with the findings and recommendations. Through the merger with Old Dominion University, additional controls have adopted around the processes and controls around the review and approval of cash drawdown reque...
Finding 2024-03: Cash Management Approval Views of Responsible Officials Management agrees with the findings and recommendations. Through the merger with Old Dominion University, additional controls have adopted around the processes and controls around the review and approval of cash drawdown requests. Corrective Action Plan Effective July 1, 2024, EVMS merged with ODU and the ODU Research Foundation became the fiscal and administrative agent for EVMS’s transferring sponsored programs on behalf of ODU. As per ODU’s Memorandum of Understanding (MOU) with the ODU Research Foundation, the ODU Research Foundation has policies and processes in place to manage the review and approval of cash drawdown requests. The ODU Research Foundation uses its own system of internal controls for the review and approval of cash drawdown requests with no reliance on ODU systems for those processes and are audited separately. As a corrective action moving forward, ODU management will notify the ODU Research Foundation management of the audit findings, so they are aware of the internal control deficiencies. ODU will request the Research Foundation to provide a copy of their single audit report to monitor continued compliance with Uniform Guidance. The corrective action plan will be completed by March 31, 2025 and the contact person for this finding is Victoria Dean.
Finding 2024-02: Indirect Costs (IDC) Views of Responsible Officials Management agrees with the finding and recommendations. Through the merger with Old Dominion University, additional controls have adopted around the processes and controls around the accuracy of the review over indirect costs calcu...
Finding 2024-02: Indirect Costs (IDC) Views of Responsible Officials Management agrees with the finding and recommendations. Through the merger with Old Dominion University, additional controls have adopted around the processes and controls around the accuracy of the review over indirect costs calculation requirements. Corrective Action Plan Effective July 1, 2024, EVMS merged with ODU and the ODU Research Foundation became the fiscal and administrative agent for EVMS’s transferring sponsored programs on behalf of ODU. As per ODU’s Memorandum of Understanding (MOU) with the ODU Research Foundation, the ODU Research Foundation has policies and processes in place to manage how the indirect costs are calculated. The ODU Research Foundation uses its own system of internal controls for IDC calculation with no reliance on ODU systems for those processes and are audited separately. As a corrective action moving forward, ODU management will notify the ODU Research Foundation management of the audit findings, so they are aware of the internal control deficiencies. ODU will request the Research Foundation to provide a copy of their single audit report to monitor continued compliance with Uniform Guidance. The corrective action plan will be completed by March 31, 2025 and the contact person for this finding is Victoria Dean.
View Audit 352191 Questioned Costs: $1
Finding 553590 (2024-002)
Significant Deficiency 2024
Finding 2024-002 Significant Deficiency and Noncompliance - Lack of Required Uniform Guidance Policies and Procedures Condition: The City did not update their federal policies and procedures to be in full compliance with Uniform Guidance. Anticipated Completion Date: September 30, 2025 Corrective Ac...
Finding 2024-002 Significant Deficiency and Noncompliance - Lack of Required Uniform Guidance Policies and Procedures Condition: The City did not update their federal policies and procedures to be in full compliance with Uniform Guidance. Anticipated Completion Date: September 30, 2025 Corrective Action: The City will implement a new policy document specifically for Uniform Grant Compliance to have one document to ensure compliance.
Management’s Response: North Nelson Water District has made every effort to comply with purchasing requirements. In addition to these efforts, North Nelson Water District will be adopting a formal procurement policy.
Management’s Response: North Nelson Water District has made every effort to comply with purchasing requirements. In addition to these efforts, North Nelson Water District will be adopting a formal procurement policy.
Finding 553586 (2024-002)
Significant Deficiency 2024
Name of contact person: Melissa Labra, Income Maintenance Administrator II Case workers will receive additional training on countable/non-countable resources. Workers will be reminded of the procedures and policies that should be followed at time of application and recertification processes. Superv...
Name of contact person: Melissa Labra, Income Maintenance Administrator II Case workers will receive additional training on countable/non-countable resources. Workers will be reminded of the procedures and policies that should be followed at time of application and recertification processes. Supervisors will conduct second party reviews on applications and recertification’s to determine that proper policies and procedures are being followed. Workers will be retrained on NCFAST evidence for resources to ensure procedures are being followed for evidence on dashboard to match the supporting documentation used as verifications. Supervisors will review cases to verify that evidence in NC FAST and supporting documentation match. Proposed Completion Date: January 31, 2026
View Audit 352178 Questioned Costs: $1
Finding 553585 (2024-001)
Significant Deficiency 2024
Name of contact person: Melissa Labra, Income Maintenance Administrator II Corrective Action: Caseworkers will receive additional training on complete documentation in case files, application of NCFAST evidence including accurate needs unit, precise resource calculations and countable/non-countable ...
Name of contact person: Melissa Labra, Income Maintenance Administrator II Corrective Action: Caseworkers will receive additional training on complete documentation in case files, application of NCFAST evidence including accurate needs unit, precise resource calculations and countable/non-countable resources. Caseworkers will receive additional training in regards to the proper procedures and policies that should be followed at time of application and recertification process. Supervisors will conduct second party reviews on applications and recertification’s to determine that the correct procedures are being followed. Caseworkers will receive training on the work number (TWN) in NCFAST learning gateway. Caseworkers will receive training on income and budgeting policy (MA 3300). Caseworkers will receive training on third party insurance and inputting such into NC FAST. Supervisors will review cases to verify evidence and supporting documentation match and cases show consistency. Supervisors will review cases to ensure evidence is inputted correctly and accurate needs units is used in determination of benefits. Proposed Completion Date: January 31, 2026
Management’s Response/Corrective Action Plan: This program received significantly more distributions in 2024 than the City had received in the past. The funds initially were not considered to be federal since the source was private companies, but staff has since taken required grant agency training...
Management’s Response/Corrective Action Plan: This program received significantly more distributions in 2024 than the City had received in the past. The funds initially were not considered to be federal since the source was private companies, but staff has since taken required grant agency training. The City is implementing workflow for purchasing and credit card transactions which will provide electronic approvals and the ability to attach receipts.
Management’s Response/Corrective Action Plan: Management will have staff prepare monthly personnel activity reports for time worked on grants and will review and adjust budgeted payroll allocations accordingly. Monthly budget report have already been set up on the Google Drive for management and sta...
Management’s Response/Corrective Action Plan: Management will have staff prepare monthly personnel activity reports for time worked on grants and will review and adjust budgeted payroll allocations accordingly. Monthly budget report have already been set up on the Google Drive for management and staff to access and review.
Management’s Response/Corrective Action Plan: Management will reconcile reimbursement requests to general ledger detail and review available grant amounts before submitting the drawdown.
Management’s Response/Corrective Action Plan: Management will reconcile reimbursement requests to general ledger detail and review available grant amounts before submitting the drawdown.
View Audit 352169 Questioned Costs: $1
Management’s Response/Corrective Action Plan: The Director and Operations Manager abruptly left in spring of 2024, leaving the Finance Department to take over all financial functions. The City contracted with Greater Portland Metro to run the service until we could determine next steps. The City Co...
Management’s Response/Corrective Action Plan: The Director and Operations Manager abruptly left in spring of 2024, leaving the Finance Department to take over all financial functions. The City contracted with Greater Portland Metro to run the service until we could determine next steps. The City Council approved joining Greater Portland Metro in September 2024, effective January 2025. The City no longer has a bus service.
Management’s Response/Corrective Action Plan: The Director and Operations Manager abruptly left in spring of 2024 and the City contracted with Greater Portland Metro to run the service until we could determine next steps. The City Council approved joining Greater Portland Metro in September 2024, e...
Management’s Response/Corrective Action Plan: The Director and Operations Manager abruptly left in spring of 2024 and the City contracted with Greater Portland Metro to run the service until we could determine next steps. The City Council approved joining Greater Portland Metro in September 2024, effective January 2025. The City no longer has a bus service.
Management’s Views and Corrective Action Plan Management response to finding 2024-004: Review over cost transfers of subrecipient expenditures Cluster Name: Research and Development Federal Awarding Agency: Various Award Name: Various Award Number: Various Award Years: Various Assistance Listing T...
Management’s Views and Corrective Action Plan Management response to finding 2024-004: Review over cost transfers of subrecipient expenditures Cluster Name: Research and Development Federal Awarding Agency: Various Award Name: Various Award Number: Various Award Years: Various Assistance Listing Title: Various Assistance Listing Number: Various Pass-through entities: Various As described in Finding 2024-004, and as a result of improper training related to the implementation of the university’s new financial system in FY22, the university lacked adequate controls to identify the proper application of indirect costs as it relates to subrecipient expenses when using the cost transfer process to make corrections. Additionally, the university failed to properly apply its policy for the classification of subawards versus direct expenditures. As such, while cost transfers are a small percentage of overall transfer activity, an update to training materials will be made by June 2025 to educate cost transfer initiators on the proper method to use for this subset of subrecipient expenditures. Since February 2025, the Sponsor Projects Accounting (SPA) representative responsible for central office review of cost transfers now reviews to ensure that all intended grant related attributes are in effect before approving any subrecipient cost transfers. Additionally, as of February 2025, the university reinforced its policy regarding the classification of subawards versus direct expenditures with both the Procurement department and the SPA staff to ensure the proper expenditure classification is set up during the onboarding process of a contractor. The SPA team has completed its analysis and review of all previous subrecipient cost transfers to verify and correct the improper application of indirect cost limits and expenditure classifications. As of March 2025, all subrecipient cost transfer errors have been identified and corrected, resulting in questioned costs of approximately $587,000. Separately, this resulted in an under-recovery of $306,000 of indirect costs that were not charged to the original award. As all awards impacted are still open and active, the correcting expenditure adjustments were applied to the awards impacted that will affect future draw downs. Contact Person: Cindy Lee, Director, Sponsored Projects Accounting, cmlee@usc.edu
Management’s Views and Corrective Action Plan Management response to finding 2024-003: Unallowable costs – Cost transfers based on budgeted amounts Cluster Name: Research and Development Federal Awarding Agency: Department of Health and Human Services Award Name: Leveraging natural phenotypic vari...
Management’s Views and Corrective Action Plan Management response to finding 2024-003: Unallowable costs – Cost transfers based on budgeted amounts Cluster Name: Research and Development Federal Awarding Agency: Department of Health and Human Services Award Name: Leveraging natural phenotypic variations of heterogenous ALS populations-in-a-dish to enable scalable drug discovery Award Number: 5R01NS131409-03 Award Years: 2022-2025 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders Assistance Listing Number: 93.853 Pass-through entities: Not applicable As described in finding 2024-003, the university inadvertently processed a cost transfer moving expenses from one grant to another based on budgeted figures instead of actual expenses incurred. This resulted in an amount transferred that was greater than the actual costs incurred. The administrator in question has been identified and further review of this administrator’s work has been performed to determine if additional instances occurred. Upon review of the administrator’s work, it was determined that no additional corrections were required as no other instances of this nature were identified outside of the total questioned costs. As part of the department’s efforts to minimize further cost transfer errors, training was provided to all their grant administrators beginning November 1, 2024. This training will now be held annually to ensure the department responsible for administering the award is current on the University’s existing compliance policies. Furthermore, to support accuracy and transparency, the department will allocate separate time commitments during weekly administration meetings to review any required cost transfers. This time will be dedicated to ensuring proper documentation is in place, confirming the appropriateness of the transfer, and ensuring full compliance of the transaction(s). This updated review process involves representatives from Grant Administration, Keck School of Medicine Finance Office, and Purchasing, to ensure a full comprehensive review of each transfer. As such, beginning November 2024, a cost transfer will not move forward until it has been reviewed by the group. Contact Person: Andres Chan, Director, FBS Financial Analysis, andres.chan@usc.edu
View Audit 352166 Questioned Costs: $1
Management’s Views and Corrective Action Plan Management response to finding 2024-002: Unallowable costs over the NIH salary cap Cluster Name: Research and Development Federal Awarding Agency: Department of Health and Human Services Award Name: Alzheimer's Clinical Trial Consortium Award Number: ...
Management’s Views and Corrective Action Plan Management response to finding 2024-002: Unallowable costs over the NIH salary cap Cluster Name: Research and Development Federal Awarding Agency: Department of Health and Human Services Award Name: Alzheimer's Clinical Trial Consortium Award Number: 5U24AG057437-07 Award Years: 2023-2025 Assistance Listing Title: Aging Research Assistance Listing Number: 93.866 Pass-through entities: Not applicable As described in finding 2024-002, the process for manually creating sub-grants within our financial systems required an attribute to be activated. In this instance the attribute in question was not activated, resulting in the NIH salary cap restriction not to be enforced within the payroll system. In November 2024, when this instance was identified, a correction was immediately made to stop any future amounts above the salary cap to be charged to the award and to avoid any further errors. To ensure any transactions that occurred while the incorrect system attribute was in place were properly addressed, corrective measures in the form of cost transfers were made during this period by the department to minimize inappropriate charges to the sponsor. As part of the university’s corrective action plan, the Sponsored Project Accounting (SPA) office has completed a full review of all awards and determined this to be an isolated event. As of March 2025, to further strengthen internal controls over compliance, the SPA office has implemented a revised approach for the creation of new manual sub-grants which will ensure the necessary NIH salary cap restrictions are applied. Additionally, training documents have been updated to reflect this revised approach, and all SPA staff have now received training on this new update. Contact Person: Cindy Lee, Director, Sponsored Projects Accounting, cmlee@usc.edu
View Audit 352166 Questioned Costs: $1
2024-001 Failure to comply with Reporong Requirements The grant was executed in October 2023, making the first reporong period to start January 2024. The City was unable to access the DRGR portal until late April 2024. During this period, the City maintained regular communica􀆟on with the HUD represe...
2024-001 Failure to comply with Reporong Requirements The grant was executed in October 2023, making the first reporong period to start January 2024. The City was unable to access the DRGR portal until late April 2024. During this period, the City maintained regular communica􀆟on with the HUD representa􀆟ve . A􀅌er gaining access the data was entered into the portal and the City has remained in communica􀆟ons with HUD representa􀆟ves. While the report was entered, there are addi􀆟onal steps to be able to submit. The City is ac􀆟vely working with DRGR staff to resolve a system issue that is not allowing us to complete the submi􀆫ng process. To date, the City has not received any no􀆟fica􀆟on from HUD indica􀆟ng that the performance reports are overdue, and they have been able to proceed with processing the reimbursement requests. The City has gained beter knowledge in rela􀆟on to the steps for full report submissions on the DRGR website and has strengthened internal controls on repor􀆟ng requirements, and grants management in general to avoid cases like this in the future Contact – Stephanie Hill, Administra􀆟ve Services Director Es􀆟mated Implementa􀆟on – June 30, 2025
Finding 553481 (2024-003)
Significant Deficiency 2024
"Finding 2024-003 – U. S. Department of Education (USDE), TRIO Programs (significant deficiency): Information on the federal programs – Upward Bound, FAL No. 84.047A, June 30, 2024; Student Support Services, FAL No. 84.042A, June 30, 2024 Criteria – Federal regulations regarding program requirements...
"Finding 2024-003 – U. S. Department of Education (USDE), TRIO Programs (significant deficiency): Information on the federal programs – Upward Bound, FAL No. 84.047A, June 30, 2024; Student Support Services, FAL No. 84.042A, June 30, 2024 Criteria – Federal regulations regarding program requirements. 34-CFR 645.21 Condition – Non-compliances were noted as more fully described in the context below. Context – The College did not meet the two-thirds requirement for the Upward Bound Program. Per federal regulations, not less than two-thirds of the College's program participants will be lowincome individuals who are potential first-generation college students. Cause – Administrative oversight. Effect – The College’s participation in the Title III and TRIO Programs could be subject to USDE sanctions as applicable. Repeat Finding – Yes. Auditor’s Recommendation – We recommend the College monitor participation for the program to assure all requirements are met. View of Responsible Officials – Prior to the start of the Upward Bound FY2024 (September 1, 2024 - August 31, 2025), there was communication between the Program Director and her USDOE Program Officer regarding the current number of participants being served and the number of low-income & first-generation participants (2/3 requirement) as of August 2024. The Program Director explained that recruitment continues to be a challenge stemming from the Covid-19 pandemic, constant changes/turnover in target school personnel, and low student engagement. The monthly plan to increase participant numbers was shared with and approved by the Program Officer. With this, a Continuation Award was granted on September 5, 2024, without any reduction in funds or stipulations to allow the Program to continue to operate and serve students. Program Staff continue to work hard to increase the number of participants, which directly impacts the 2/3 requirement. Please note that decreased student engagement is a nationwide issue in TRIO.
Finding 553477 (2024-002)
Significant Deficiency 2024
"Finding 2024-002 – U.S. Department of Education (USDE), Title IV Student Financial Aid Programs Planning (significant deficiency) Information on the federal program – Federal Direct Student Loans, FAL No. 84.268, June 30, 2024; Federal Pell Grants Program, FAL No. 84.063, June 30, 2024; Federal Sup...
"Finding 2024-002 – U.S. Department of Education (USDE), Title IV Student Financial Aid Programs Planning (significant deficiency) Information on the federal program – Federal Direct Student Loans, FAL No. 84.268, June 30, 2024; Federal Pell Grants Program, FAL No. 84.063, June 30, 2024; Federal Supplemental Educational Opportunity Grant, FAL No. 84.007, June 30, 2024; Federal Work-Study Program, FAL No. 84.033, June 30, 2024 Criteria – Federal regulations governing Title IV programs. Condition – Non-compliances were noted, as more fully described in the context below. Questioned Costs – N/A Context – We observed the following conditions in connection with our testing of the various U.S. Department of Education, Title IV, Student Financial Assistance Programs 1) Three (3) out of 25 students had a credit balance on their account created by Title IV program funds longer than 14 days. 34 CFR 668.164(h)(1). Cause – Oversight by responsible employees. Effect – The College’s participation in the Title IV programs could be subject to USDE sanctions as applicable. Repeat Finding – No Auditor’s Recommendation – We strongly recommend the College refine the processes and procedures for the timely recording of disbursements in the general ledger allowing for more accuracy in financial reporting. View of Responsible Officials – The College has refined processes and procedures to ensure student refunds are processed within 14 days after the credit appears on the student account.
Views of Responsible Officials and Planned Corrective Actions The FFR report was submitted late due to the Director of Finance being new to the position and balancing vacancies in the Accounting Manager and Accounts Payable Clerk positions. There were many deadlines backlogged and the FFR report is ...
Views of Responsible Officials and Planned Corrective Actions The FFR report was submitted late due to the Director of Finance being new to the position and balancing vacancies in the Accounting Manager and Accounts Payable Clerk positions. There were many deadlines backlogged and the FFR report is one of those items. The Center has been experiencing stability in the key positions as well as expanding the department to include a Grants Administrator who will be responsible for grants reporting. Additionally, the Center is working on a Master Calendar of due dates to monitor and stay ahead of reporting deadlines. Person Responsible: Hector Zapeta Position of Responsible Party: Accounting Manager Anticipated Completion: June 30, 2025
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