Corrective Action Plans

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We gave instructions to the Finance Department Director to strengthen internal procedures and controls to ensure accurate preparation and submission of financial reports within the required timeframe. Implementation Date: April 1, 2025. Responsible Person: Mrs. Rosa J. La Torre Santiago, Executive...
We gave instructions to the Finance Department Director to strengthen internal procedures and controls to ensure accurate preparation and submission of financial reports within the required timeframe. Implementation Date: April 1, 2025. Responsible Person: Mrs. Rosa J. La Torre Santiago, Executive Director
View of Responsible Officials - The questioned costs were immaterial and relate to a pay period that was split across the fiscal year (6/26/23 to 7/9/23, with a pay date of 7/14/23). Reports to the funder for the year ending 6/30/23 were due on 7/10/23, before all payroll information and supporting ...
View of Responsible Officials - The questioned costs were immaterial and relate to a pay period that was split across the fiscal year (6/26/23 to 7/9/23, with a pay date of 7/14/23). Reports to the funder for the year ending 6/30/23 were due on 7/10/23, before all payroll information and supporting documentation for this pay period was available. Therefore, the full pay period was included in the July reimbursement report. This practice was approved by the funder and the funder will not seek to recoup out of period costs. Moving forward, the Organization will be more cognizant of accrual dates for payroll reporting and submit a true-up as needed to ensure that payroll costs are correctly allocated at the end of the fiscal year
CCS transitioned to a new payroll system during the fiscal year ended June 30, 2024. The payroll system had deficiencies with reporting and allocation capabilities that are being resolved. Manual processes to track and record payroll allocations have been cumbersome and inefficient. These systems ...
CCS transitioned to a new payroll system during the fiscal year ended June 30, 2024. The payroll system had deficiencies with reporting and allocation capabilities that are being resolved. Manual processes to track and record payroll allocations have been cumbersome and inefficient. These systems are being updated to create accurate and timely reports to facilitate more efficient allocation processes. This is the responsibility of the CCS Executive Director of Human Resources. Additionally, internal review requirements are being enhanced and reinforced. This is the responsibility of the CCS Chief Financial Officer. Enhanced oversight has been implemented to ensure proper payroll approvals, documentation, tracking and allocations, and additional training is being provided as needed. This is the responsibility of the CCS Controller and is expected to be completed by June 30, 2025.
CCS discovered this and self-reported it to the appropriate agencies. The former employee mentioned and his immediate supervisor were terminated by CCS immediately upon its discovery of the conflict of interest and not following CCS’s procurement procedures. CCS refined its Conflict-of-Interest an...
CCS discovered this and self-reported it to the appropriate agencies. The former employee mentioned and his immediate supervisor were terminated by CCS immediately upon its discovery of the conflict of interest and not following CCS’s procurement procedures. CCS refined its Conflict-of-Interest and Procurement procedures. Conflict-of-Interest and procurement policy training sessions were conducted with all levels of staff and will continue to be conducted on a recurring basis. CCS is implementing additional layers of oversight and compliance monitoring. This is the responsibility of the CCS Chief Financial Officer. CCS is committed to continuous improvement, conducting regular internal audits and reviews to verify adherence to federal procurement standards. This is the responsibility of the CCS Revenue Cycle Manager. We are working to ensure that every vendor has a contract on file and all procurement policies are strictly followed. This is the responsibility of the CCS Controller and is expected to be completed by June 30, 2025.
Finding 547917 (2024-003)
Significant Deficiency 2024
2024-003 – Enrollment Reporting (Significant Deficiency) Department of Education, SFA Cluster, Special Tests and Provisions Condition: The College did not report student enrollment data to the National Student Clearinghouse within the minimum required timeframe. Criteria: Based on requirements set f...
2024-003 – Enrollment Reporting (Significant Deficiency) Department of Education, SFA Cluster, Special Tests and Provisions Condition: The College did not report student enrollment data to the National Student Clearinghouse within the minimum required timeframe. Criteria: Based on requirements set forth by 34 CFR Section 685.309(b)(2), the College is responsible for notifying the National Student Loan Data System (NSLDS) to changes to student’s enrollment data within minimum required timeframes. Cause: The College does not have adequate procedures in place to ensure changes in students’ enrollment statuses are identified and reported in a timely manner. Context: From a population of 26 students that withdrew officially and unofficially during a term, we tested 3 students and noted those students’ withdrawals were not reported timely or accurately. Effect: Enrollment data was not reported timely or accurately to the Department of Education thus, the Department could not properly service the student’s loans. The accuracy of Title IV student loan records depends heavily on the accuracy of the enrollment information reported by institutions. Recommendation: We recommend that a review process be put in place to ensure timely and accurate enrollment reporting to NSLDS and additional training on the reporting requirements as needed. Management Response: Management is working with the Registrar’s Office to determine why there was an issue and provide a process that will eliminate any untimely reporting to Clearinghouse moving forward. If the Federal Audit Clearinghouse has questions regarding this plan, please call Angie Edmondson, CFO, 276-944-6755, aedmonds@emoryhenry.edu
1. Immediate General Ledger Reconciliation: By April 30th, the outsourced accounting / bookkeeping vendor will review and reconcile all YTD general ledger accounts. 2. Conduct Thorough Review of Finance and Accounting Policies and Procedures: By May 31st, the Director of Administrative Operations wi...
1. Immediate General Ledger Reconciliation: By April 30th, the outsourced accounting / bookkeeping vendor will review and reconcile all YTD general ledger accounts. 2. Conduct Thorough Review of Finance and Accounting Policies and Procedures: By May 31st, the Director of Administrative Operations will have reviewed all internal policies and processes expected by the vendor to ensure all account balances and transactions are periodically reviewed for proper treatment in accordance with accounting principles generally accepted in the US. 3. Increase Vendor FTE Support: By June 1st, expand FTE allocation with the outsourced accounting and bookkeeping vendor to enhance financial reporting and audit readiness. 4. Bring in a Director of Finance: By July 15th, begin recruitment of a Director of Finance to oversee accounting, finance, and improving internal controls and reporting.
Finding 547915 (2024-004)
Significant Deficiency 2024
2024-004 – U.S. Department of Education, SFA Cluster, Special Tests and Provisions - Return of Title IV Refunds (Significant Deficiency) Condition: Title IV refunds for the two students tested were calculated incorrectly. Criteria: When the recipient of Title IV grant or loan assistance withdraws fr...
2024-004 – U.S. Department of Education, SFA Cluster, Special Tests and Provisions - Return of Title IV Refunds (Significant Deficiency) Condition: Title IV refunds for the two students tested were calculated incorrectly. Criteria: When the recipient of Title IV grant or loan assistance withdraws from an institution during a payment period or period of enrollment in which the recipient began attendance, the institution must determine the amount of Title IV grant or loan assistance that the student earned as of the student’s withdrawal date in accordance with 34 CFR 668.22. The institution must return the lesser of the total amount of unearned Title IV assistance or an amount equal to the total institutional charges incurred by the student for the payment period or period of enrollment multiplied by the percentage of Title IV grant or loan assistance that has not been earned by the student. Cause: Controls are not functioning properly. Effect: The amount returned was incorrect for the two students that required refund calculations. Context: From a population of 60 students that official or unofficially withdrew from a payment period, we tested nine and noted that two students required refund calculations. Repeat Finding from a Prior Year: No Recommendation: We recommend the College put procedures in place for accurate preparation and calculation of Title IV refunds. Management Response: We agree the institution must return the lesser of the total amount of unearned Title IV assistance or an amount equal to the total institutional charges incurred by the student for the payment period or period of enrollment multiplied by the percentage of Title IV grant or loan assistance that has not been earned by the student. This issue arose from a lack of leadership and staff training in the Financial Aid Office over the past several years. As a result, proper procedures for calculating and returning unearned Title IV assistance were not consistently. Currently, staff are undergoing comprehensive training in all areas of Title IV and Higher Education Act (HEA) regulations. In the 2024-2025 academic year, the institution hired a new director of financial aid, who has implemented a system to process withdrawals online through Common Origination and Disbursement (COD) and has been working to maintain necessary documentation for accurate refund calculations. Additionally, an updated policies and procedures manual is being finalized to ensure that all staff members have access to the necessary resources and guidelines for compliance. If the Federal Audit Clearinghouse has questions regarding this plan, please call Danielle Pfaff, Controller at 1-336-316-2140 or dpfaff@guilford.edu.
FY24 interest in the amount of$331.01 was returned to USDHHS PS Program Suppmi Center on 1/30/2025. We are keeping a smaller balance in the Federal Funds bank account to lessen the amount of interest earned on the account. Any amount over $500 at the end of the fiscal year will be returned through t...
FY24 interest in the amount of$331.01 was returned to USDHHS PS Program Suppmi Center on 1/30/2025. We are keeping a smaller balance in the Federal Funds bank account to lessen the amount of interest earned on the account. Any amount over $500 at the end of the fiscal year will be returned through the same process as prior years. Responsible Person for Correction Action Plan: Deana Rogers, Vice President of Administration & Finance Implementation Date/or Corrective Action Plan: 01/30/25
View Audit 351835 Questioned Costs: $1
Identification and Review • Students clocked in during scheduled class times. Blackburn did not initially educate nor send reminders to students and faculty about students not being able to clock in during class times. • During the 2023-2024 fiscal year, there was a transition in the Dean of Work ro...
Identification and Review • Students clocked in during scheduled class times. Blackburn did not initially educate nor send reminders to students and faculty about students not being able to clock in during class times. • During the 2023-2024 fiscal year, there was a transition in the Dean of Work role. There was not as much oversight of student payroll reports Corrective Actions • The Work Office and Provost Office has increased communication and education about students not being able to work during scheduled class times. Reminders have also been sent out. • The Work Office now has a Dean of Work who is educated about how to run student payroll. Process and Policy Improvements • Starting in the Fall 2024 semester, the Work Office and Provost Office increased awareness and communication regarding students not being allowed to work during scheduled class times. • Student Communication- Student managers communicated with student employees at monthly department meetings and through electronic communication that students are not allowed to clock in during scheduled class times. The exception is when their class is cancelled, and students must send the class cancellation notice (email from Professor or screenshot of Learning Management System announcement) to the Work Office before clocking in during the cancelled class time. Once the cancelled claim information is received, it is added to a spreadsheet maintained jointly by the Provost and Work Office. Professor Communication- The Provost sent an electronic communication to all professors notifying them they must communicate with the Provost and Work Office when they cancel a class. Once the cancelled class information is received, it is added to a spreadsheet maintained jointly by the Provost and Work Office. • Additionally, the Work Office reached out to our time tracking and payroll software vendor to identify a solution to limit students' ability to clock in during scheduled class times. Monitoring and Compliance • The Work Office and Provost Office will dedicate time to educate and remind students and faculty that students are not allowed to work during scheduled class time, and how to report a cancelled class. • The Work Office will dedicate time to double check the student payroll reports before sending them to Human Resources. • The Dean of Work will ensure students are educated in department meetings and through electronic communication that they are not allowed to clock in to work during scheduled class times, and how to report a cancelled class. • The Dean of Work will coordinate with the Provost Office to ensure faculty are educated about students not being able to clock in during scheduled class times, and how to report a class cancellation. • The Dean of Work will randomly select 10 students each payroll to ensure they are not clocking in during their scheduled class times. • The Dean of Work will also ensure that the student payroll is double checked before sending to Human Resources. Reporting and Documentation • Fall 2024 o Student managers educated students during their first department meeting And students also received electronic communication that they could not work during a scheduled class time, and informed them how to report a cancelled class. o The Provost Office sent electronic communication to faculty on the importance of reporting a class cancellation. • Spring 2025 o Student managers educated students during their first department meeting and students also received electronic communication that they could not work during a scheduled class time, and informed them how to report a cancelled class. o The Provost Office sent electronic communication to faculty on the importance of reporting a class cancellation. o The Work Office is facilitating monthly Supervisor trainings. In the February training, supervisors were informed verbally and in writing about students not being able to work during scheduled class times, and what documentation is needed when a class is cancelled. • Fall 2025 o The Work Office will facilitate a Supervisor training before the academic year begins. In the training, we will review policies and procedures with one of them being students not being able to clock in during scheduled class times. Responsible Person for Correction Action Plan: Leslie Johnson, Dean of Work Implementation Date for Corrective Action Plan: 09/03/24
View Audit 351835 Questioned Costs: $1
Identification and Review • Conduct an internal audit to identify all students who failed all courses and determine the last date of attendance for each. • Review institutional records (For example, faculty attendance records, Learning Management or participation records) to establish when students ...
Identification and Review • Conduct an internal audit to identify all students who failed all courses and determine the last date of attendance for each. • Review institutional records (For example, faculty attendance records, Learning Management or participation records) to establish when students stopped engaging academically • Verify whether R2T4 calculations should have been performed Corrective Actions • Process R2T4 calculations for affected students based on their last date of attendance • Return any unearned Title IV funds • Update students file to reflect accurate withdrawal dates and notify them of any financial obligations resulting from the adjustment • If students are still enrolled in future terms, ensure they understand satisfactory academic progress (SAP) implications Process and Policy Improvements • Implement an early alert system to identify students who cease attendance before the end of the term. • Strengthen collaboration between academic departments, the registrar, and the financial aid office to improve withdrawal tracking • Run monthly withdrawal reports to see when students earn all failing grades. Monitoring and Compliance • Conduct regular audits to ensure compliance with R2T4 regulations and timely student withdrawals • Provide staff training on withdrawal procedures and the importance of accurately tracking last dates of attendance. • Establish a set time to review withdrawal policies and ensure adherence to federal regulations. Reporting and Documentation • Maintain detailed records of all identified cases, R2T4 calculations, and funds returned. • Document all policy and procedural updates made to prevent recurrence. • If required, submit a report to the U.S. Department of Education outlining corrective actions taken. Responsible Person for Correction Action Plan: Alexis Brown, Director of Financial Aid Implementation Date for Corrective Action Plan: 2/25/25
View Audit 351835 Questioned Costs: $1
Identification and Review • Conduct a comprehensive audit of enrollment records to identify instances of inaccurate or delayed reporting • Verify the accuracy of enrollment statuses (e.g., full-time, half-time, withdrawn, graduated) for all affected students • Determine the root cause of reporting d...
Identification and Review • Conduct a comprehensive audit of enrollment records to identify instances of inaccurate or delayed reporting • Verify the accuracy of enrollment statuses (e.g., full-time, half-time, withdrawn, graduated) for all affected students • Determine the root cause of reporting delays or errors, whether due to system malfunctions, manual processing errors, or lack of oversight Corrective Actions • Submit corrected enrollment data to NSLDS for all affected students using our National Student Clearinghouse. • Ensure that all errors identified during the audit are addressed, and follow up to confirm the corrections are reflected in NSLDS. • Notify any impacted students of any changes in their enrollment status and provide necessary support if their loan repayment terms are affected. Process and Policy Improvements • Develop and implement clear policies to ensure accurate and timely submission of enrollment data within the required 30-day reporting window or in accordance with scheduled reporting intervals. • Automate the enrollment reporting process where possible to minimize manual data entry errors. • Establish cross-departmental communication protocols to ensure timely updates on student withdrawals, graduations, and status changes. • Create detailed documentation of reporting procedures for staff training and compliance purposes. Monitoring and Compliance • Implement regular reconciliation checks between our student information system (SIS) and NSLDS to ensure data accuracy • Conduct periodic internal audits to identify discrepancies before external audits occur • Designate staff to oversee enrollment reporting and ensure adherence to federal regulations. Staff Training • Provide comprehensive training for staff responsible for enrollment reporting on NSLDS requirements, deadlines, and best practices • Offer training sessions as regulations change or system updates occur. Reporting and Documentation • Maintain records of all corrected data submissions, audit results, and communications with NSLDS • Document procedural changes and staff training efforts Responsible Person for Correction Action Plan: Dianna Ruyle, Director of Records, Registration and Advising Implementation Date for Corrective Action Plan: Immediately and ongoing
Identification and Review • Conduct an internal audit of all financial aid awards for the affected students to determine the extent of the overaward • Identify the sources of aid contributing to the excess amount and whether any adjustments can be made within the same academic year. • Review packagi...
Identification and Review • Conduct an internal audit of all financial aid awards for the affected students to determine the extent of the overaward • Identify the sources of aid contributing to the excess amount and whether any adjustments can be made within the same academic year. • Review packaging procedures to pinpoint the cause of the discrepancy (e.g., late outside scholarships, system errors, or manual adjustments Student Award Adjustments • Reduce or cancel institutional or federal aid (such as loans, Federal Work-Study, or certain grants) in accordance with federal regulations and institutional policies. • Notify students of any changes to their financial aid package and provide guidance on alternative funding options if needed. Process and Policy Improvements • Implement a cross-check system for all financial aid components and strengthen internal controls to ensure total aid does not exceed COA before disbursement • Implement additional system checks and alerts in the financial aid management system to flag overawards automatically. • Require timely reporting of external scholarships and third-party payments to prevent adjustments after disbursement Monitoring and Compliance • Conduct periodic reconciliation of student aid packages throughout the academic year to prevent overawards • Train financial aid staff on COA regulations and best practices for awarding aid Responsible Person for Correction Action Plan: Alexis Brown, Director of Financial Aid Implementation Date for Corrective Action Plan: 2/25/25
View Audit 351835 Questioned Costs: $1
Identification and Review • Identify all students who received incorrect loan amounts (Completed) • Make appropriate adjustments to loan disbursements (Completed) • Notify affected students and provide guidance on next steps (Completed) Policy and Procedure Enhancements • Develop clear, written proc...
Identification and Review • Identify all students who received incorrect loan amounts (Completed) • Make appropriate adjustments to loan disbursements (Completed) • Notify affected students and provide guidance on next steps (Completed) Policy and Procedure Enhancements • Develop clear, written procedures for verifying loan amounts prior to disbursement • Implement a two-step verification process for loan packaging System Controls • Collaborate with IT to implement automated system checks to flag discrepancies • Enhance reporting tools for regular audits and monitoring Staff Training • Conduct comprehensive training sessions for financial aid staff on federal regulations regarding Direct Loans • Provide ongoing refresher courses and updates as federal policies change Monitoring Continuous Improvement • Establish a quarterly audit process to ensure compliance • Monitor loan discrepancies detected and correct as needed • Conduct regular audits to confirm compliance with federal loan regulations. • Collect feedback from staff on the effectiveness of training Responsible Person for Correction Action Plan: Alexis Brown, Director of Financial Aid Implementation Date for Corrective Action Plan: 03/03/25
Identification and Review • Immediately review and recalculate the subsidized need for the affected students. (Completed) • Identify the sources of aid contributing to the excess amount and whether any adjustments can be made within the same academic year • Adjust the loan amounts as necessary and r...
Identification and Review • Immediately review and recalculate the subsidized need for the affected students. (Completed) • Identify the sources of aid contributing to the excess amount and whether any adjustments can be made within the same academic year • Adjust the loan amounts as necessary and return any excess funds to the Department of Education. (Completed) • Review packaging procedures to pinpoint the cause of the discrepancy (e.g., late outside scholarships, system errors, or manual adjustments Student Award Adjustments • Reduce or cancel institutional or federal aid (such as loans, Federal Work-Study, or certain grants) in accordance with federal regulations and institutional policies • If the excess aid cannot be adjusted within the same academic year, follow federal guidelines to return any over awarded federal funds through the Common Origination and Disbursement (COD) system • Notify students of any changes to their financial aid package and provide guidance on alternative funding options if needed System Enhancements • Implement system-level edits and warnings in the financial aid software to flag over-awards before disbursement. • Schedule regular audits of loan disbursements to ensure ongoing compliance Policy and Procedure Update • Update the financial aid packaging policy to include stricter controls for verifying subsidized need calculations. • Implement a cross-check system for all financial aid components before loan disbursement • Require timely reporting of external scholarships and third-party payments to prevent adjustments after disbursement Monitoring and Compliance • Conduct training sessions for financial aid staff on loan eligibility calculations. • Conduct periodic reconciliation of student aid packages throughout the academic year to prevent over awards • Provide guidance on using the financial aid management system's tools to avoid over-awards Responsible Person for Correction Action Plan: Alexis Brown, Director of Financial Aid Implementation Date for Corrective Action Plan: 02/25/25
View Audit 351835 Questioned Costs: $1
FINDING 2024-005 – Allowable Costs; Significant Deficiency in Internal Control over Compliance Views of responsible officials and planned corrective actions: Management agrees with the assessment and understands the importance of strong controls surrounding payroll allocation. The Organization has w...
FINDING 2024-005 – Allowable Costs; Significant Deficiency in Internal Control over Compliance Views of responsible officials and planned corrective actions: Management agrees with the assessment and understands the importance of strong controls surrounding payroll allocation. The Organization has worked hard to bring the new payroll so􀅌ware in line with the complex requirements of grant accounting and at the time of this audit issuance the error has been resolved. The Organization will complete employee level reviews each payroll to ensure that salaries and benefits continue to be allocated accurately according to hours charged to programs. The Organization is in the process of revising the accounting policy manual with the full revision expected to be completed by December 2025. Individual policies will be submited to the board for approval as they are revised. Contact Persons: Ryan Berendsen, Chief Operating Officer Delana Kromer, Controller
View Audit 351833 Questioned Costs: $1
FINDING 2024-004 – Reporting; Material Weakness in Internal Control over Compliance and Instance of Material Noncompliance Views of responsible officials and planned corrective actions: Management agrees with the assessment and has implemented corrective action. The Organization has implemented a re...
FINDING 2024-004 – Reporting; Material Weakness in Internal Control over Compliance and Instance of Material Noncompliance Views of responsible officials and planned corrective actions: Management agrees with the assessment and has implemented corrective action. The Organization has implemented a review and documentation control surrounding the timely submission of all financial reports, special reports, and performance reports. Reports required by contract must be submitted timely and must have two levels of documented review. All financial reports required by contract must have a documented review by a member of the fiscal department. Additionally, report backup and proof of timely submission must be retained. Contact Persons: Ryan Berendsen, Chief Operating Officer Delana Kromer, Controller
FINDING 2024-003 – Reporting; Significant Deficiency in Internal Control over Compliance Views of responsible officials and planned corrective actions: Management agrees with the assessment and has implemented corrective action. The Organization has implemented a review and documentation control sur...
FINDING 2024-003 – Reporting; Significant Deficiency in Internal Control over Compliance Views of responsible officials and planned corrective actions: Management agrees with the assessment and has implemented corrective action. The Organization has implemented a review and documentation control surrounding the timely submission of all financial reports, special reports, and performance reports. Reports required by contract must be submited timely and must have two levels of documented review. All financial reports required by contract must have a documented review by a member of the fiscal department. Additionally, report backup and proof of timely submission must be retained. Contact Persons: Ryan Berendsen, Chief Operating Officer Delana Kromer, Controller
FINDING 2024-002 – Equipment & Real Property Management; Material Weakness in Internal Control over Compliance and Instance of Material Noncompliance Views of responsible officials and planned corrective actions: Management agrees with the assessment and understands the importance of regular physica...
FINDING 2024-002 – Equipment & Real Property Management; Material Weakness in Internal Control over Compliance and Instance of Material Noncompliance Views of responsible officials and planned corrective actions: Management agrees with the assessment and understands the importance of regular physical inventories. The Organization has designed and implemented controls to ensure that all equipment purchased with federal funds is tagged and inventoried every two years. The process includes documentation of when the inventory takes place as well as procedures to ensure all additions and disposals are tracked and recorded on a timely basis. Contact Persons: Ryan Berendsen, Chief Operating Officer Delana Kromer, Controller
NCHE implemented a new policy in January 2025 regarding missing receipts. In January 2024, a new policy was instituted requiring receipt of vendor invoice before payment approval by the Accountant and Executive Director. All copies of approvals, receipts, and invoices, are now attached to each expen...
NCHE implemented a new policy in January 2025 regarding missing receipts. In January 2024, a new policy was instituted requiring receipt of vendor invoice before payment approval by the Accountant and Executive Director. All copies of approvals, receipts, and invoices, are now attached to each expense transaction in QuickBooks Online. In January 2025, NCHE required email documentation for any missing receipts, sent to the accountant for inclusion in QBO.
We appreciate the audit team’s diligence and acknowledge the reporting finding. This appears to reflect a difference in interpretation around when “final adjustments” to Weatherization Assistance Program contracts may occur. Based on our longstanding experience with the program and past guidance, we...
We appreciate the audit team’s diligence and acknowledge the reporting finding. This appears to reflect a difference in interpretation around when “final adjustments” to Weatherization Assistance Program contracts may occur. Based on our longstanding experience with the program and past guidance, we understood that adjustments could be made within the active contract period and up to 60 days after contract closeout. In this case, NWBCCC made an adjustment in 2024 to an active multi-year contract with a September 2025 end date, which we believed to be within allowable guidelines. However, based on the auditor’s definition of “final adjustment”, which is that every monthly voucher is a final adjustment, our action resulted in a finding. Going forward as a corrective measure, NWBCCC will treat each monthly voucher as a final submission for that period and enhance internal review processes to avoid retroactive changes. Where adjustments are necessary, we will coordinate with HCR to ensure proper documentation and compliance.
2024-006 Program: Equitable Sharing Program Federal Financial Assistance Listing Number: 16.922 Federal Grantor: U.S. Department of Justice Award No. and Year: 2024 Compliance Requirements: Allowable Costs/Cost Principles Type of Finding: Significant Deficiency in Internal Control Over Compliance an...
2024-006 Program: Equitable Sharing Program Federal Financial Assistance Listing Number: 16.922 Federal Grantor: U.S. Department of Justice Award No. and Year: 2024 Compliance Requirements: Allowable Costs/Cost Principles Type of Finding: Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance Criteria: 2 CFR Section 200.303(a), Internal Controls, states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. 2 CFR Section 200.430, Compensation – Personal Services, states that charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal control that provides reasonable assurance that the charges are accurate, allowable and properly allocated. Condition: During our testing of the Sheriff Department’s compliance with allowable costs/cost principles requirements, we noted that thirty-three (33) of forty (40) overtime cost calculations were miscalculated. Cause: Equitable sharing funds may not be used for salaries, except under certain provisions outlined in Section V.B.3 of the Equitable Sharing Guide including overtime. The Sheriff’s Department calculates the allowable portion of personnel salaries using a separate template that contained a formula error which inaccurately calculated the total salaries costs allocated to the program. The Sheriff’s department did not have internal controls in place to ensure that the allowed salaries were being calculated correctly. However, the error was detected after the 5th out of 6 months in which these types of costs were allocated to the program. Effect: Salary costs were allocated to the program in an incorrect amount. Questioned Costs: Our testing resulted in questioned costs in the amount of $3,550. However, the total questioned costs for the total population was $23,409. Context/Sampling: A sample of forty (40) individuals were selected from a population consisting of (840) payroll transactions. Repeat Finding from Prior Years: No. Recommendation: We recommend the Sheriff’s Department establish and maintain internal controls to ensure the overtime calculations are being accurately allocated to the program. Management Response and Corrective Action: 1. Person Responsible: Tiffany Mui, Fiscal Administrator 2. Corrective Action Plan: a. Staff corrected the formula error in the Overtime (OT) calculation workpapers. Detailed workpapers, including formulas, will be reviewed by Fiscal Administrator. b. Updated desk procedures for Sheriff’s Narcotics task will include updated OT calculation change. Procedures will be reviewed and initialed by Fiscal Administrator and Sr. Fiscal Manager. 3. Anticipated Implementation date: March 2025
View Audit 351824 Questioned Costs: $1
2024-005 Program: Equitable Sharing Program Federal Financial Assistance Listing Number: 16.922 Federal Grantor: U.S. Department of Justice Award No. and Year: 2024 Compliance Requirements: Procurement and Suspension and Debarment Type of Finding: Significant Deficiency in Internal Control Over Comp...
2024-005 Program: Equitable Sharing Program Federal Financial Assistance Listing Number: 16.922 Federal Grantor: U.S. Department of Justice Award No. and Year: 2024 Compliance Requirements: Procurement and Suspension and Debarment Type of Finding: Significant Deficiency in Internal Control Over Compliance Criteria: 2 CFR section 200.303(a), Internal Controls, states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Title 2 CFR Section 200.214 of the Uniform Guidance states that the County must comply with 2 CFR part 180, which implements Executive Orders 12549 and 12689. The regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance programs or activities. Per 2 CFR Section 180.300, when a non-Federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration (GSA) and available at https://www.sam.gov/SAM/, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity. Condition: For three (3) of eight (8) vendors tested, we were not able to verify that the Sheriff Department followed their internal control to ensure the vendor was not suspended or debarred prior to entering the transaction. Cause: The Sheriff department did not follow their policy to verify the information described in the condition prior to entering the transactions. Effect: The County’s policy was not consistently followed, which required verification of suspension or debarment prior to entering the contract. The department subsequently verified that the vendor was not suspended or debarred. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: A nonstatistical sample of eight (8) out of thirty-three (33) procurement contracts were tested. The condition noted above was identified during our procedures related to procurement and suspension and debarment. Repeat Finding from Prior Years: No. Recommendation: We recommend that the Sheriff’s Department adhere to their procurement procedures requiring the suspension or debarment verification is performed prior to entering into a covered transaction. Management Response and Corrective Action: 1. Person Responsible: Yvette Torres, Procurement Contract Manager, Senior 2. Corrective Action Plan: The Sheriff’s Department acknowledges the audit finding and is committed to implementing a robust due diligence process to ensure compliance with procurement and suspension/debarment regulations. The following corrective actions will be taken: a. Policy Reinforcement and SAM.gov Checks: The department will reinforce adherence to existing procurement procedures that require suspension or debarment verification prior to entering into any contract by requiring all procurement staff to verify vendor status on the System for Award Management (SAM.gov) before executing any contracts. Proof of verification including the applicable date printed will be retained and included in the contract file to ensure compliance with federal regulations and internal policies. Additionally, as an added layer to ensure compliance with all federal, state and local laws, the County Procurement Office has required that all Deputy Purchasing Agents (DPA’s) conduct a Due Diligence check on all County Contracts which includes a SAM.gov check. b. Refresher Training: All procurement staff will participate in refresher training to reinforce the importance of compliance with 2 CFR section 180.300. This training will cover proper procedures for conducting suspension and debarment checks using SAM.gov and emphasize the documentation requirements to maintain compliance. c. Enhanced Internal Controls and Monitoring A secondary review process will be implemented, requiring a supervisor or manager to verify the suspension or debarment check documentation prior to contract execution. Additionally, periodic internal audits will be conducted to ensure compliance with federal regulations and internal policies. Any identified discrepancies will be promptly addressed with corrective actions to maintain robust internal controls. 3. Anticipated Implementation Date: April 2025
2024-011 Program: Disaster Grants – Public Assistance (Presidentially Declared Disasters) Federal Financial Assistance Listing Number: 97.036 Federal Grantor: U.S. Department of Homeland Security Pass Through: California Office of Emergency Services Award No. and Year: 059-00000 Compliance Requireme...
2024-011 Program: Disaster Grants – Public Assistance (Presidentially Declared Disasters) Federal Financial Assistance Listing Number: 97.036 Federal Grantor: U.S. Department of Homeland Security Pass Through: California Office of Emergency Services Award No. and Year: 059-00000 Compliance Requirements: Other - Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) §200.510(b) - Schedule of Expenditures of Federal Awards Type of Finding: Material Weakness in Internal Control Over Compliance Criteria: In accordance with the 2024 OMB Compliance Supplement, nonfederal entities must record expenditures on the Schedule of Expenditures of Federal Awards (SEFA) when (1) FEMA has approved the nonfederal entity’s Project, and (2) the nonfederal entity has incurred the eligible expenditures. FEMA’s approval of a subaward is indicated when FEMA obligates the federal share of the eligible project cost to the recipient. Federal awards expended in years subsequent to the fiscal year in which the Project is approved are to be recorded on the nonfederal entity’s SEFA in those subsequent years. In addition, section 200.303 of the Uniform Guidance states that recipients and subrecipients must establish effective internal control over the federal awards, including controls over the accuracy of program information and expenditure amounts. Condition: During our audit procedures performed over the Schedule of Expenditures of Federal Awards and expenditures reported for the Disaster Grants – Public Assistance (Presidentially Declared Disasters) we noted the County reported expenditures totaling $5,820,436 that should have been reported on the FY 2023 SEFA, as the granting agency approved the expenditures in FY 2023 and the County incurred the expenditures prior to June 30, 2023. Cause: The County lacks adequate internal controls to ensure the SEFA is completely and accurately stated. Effect: The initial FY 2024 SEFA provided was overstated by $5,820,436. However, we noted these expenditures would not have had a material effect on the FY 2023 SEFA. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: No sampling was used. Program expenditures on the SEFA were reconciled to supporting records. Repeat Finding from Prior Years: No. Recommendation: We the recommend that the County establish policies and implement internal controls to ensure that expenditures are reported on the SEFA in accordance with program requirements. Management Response and Corrective Action: 1. Person Responsible: Trevor Richardson, OCPW Emergency Manager 2. Corrective Action Plan: Due to the change in reporting guidance, we will now report the full amount of the award in the fiscal year it is approved, based on the obligation letter, instead of on a cash basis. 3. Anticipated Implementation date: Effective immediately for FY24-25.
2024-010 Program: Disaster Grants – Public Assistance (Presidentially Declared Disasters) Federal Financial Assistance Listing Number: 97.036 Federal Grantor: U.S. Department of Homeland Security Pass Through: California Office of Emergency Services Award No. and Year: 059-00000 and 2019 Compliance ...
2024-010 Program: Disaster Grants – Public Assistance (Presidentially Declared Disasters) Federal Financial Assistance Listing Number: 97.036 Federal Grantor: U.S. Department of Homeland Security Pass Through: California Office of Emergency Services Award No. and Year: 059-00000 and 2019 Compliance Requirements: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance Criteria: 2 CFR Section 200.303(a), Internal Controls, states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Condition: For two (2) out of three (3) project application summary reports tested, the OCPW did not retain evidence to document the individual who reviewed and approved the required reports. Cause: The department’s procedures did not include documenting the review and approval of the reports prior to submission. Effect: Ineffective controls over this area of compliance could result in reports that are inaccurate or incomplete being submitted or disclosed to the granting agency. Questioned Costs: No questioned costs were identified as a result of our audit procedures. Context/Sampling: A non-statistical sample of three (3) of nine (9) Grant Project Application Summary Reports were selecting for testing. The condition above was identified during our procedures over reporting testing. Repeat Finding: No. Recommendation: We recommend the OCPW department revise its procedures to include evidence to document the individual who reviewed and approved required reports prior to submission. Management Response and Corrective Action: 1. Person Responsible: • FEMA Public Assistance Grants Coordinator – Responsible for completing reports, uploading documents to the FEMA Grants Portal, and ensuring accurate records. • OCPW Emergency Manager Responsible for reviewing, approving, and submitting project applications. 2. Corrective Action Plan: • Revised Procedures for Review and Approval: i. The FEMA Public Assistance Grants Coordinator will be responsible for completing the Project Application Summary Reports. ii. Upon completion, the Grants Coordinator will upload all supporting documents into the FEMA Grants Portal. The system automatically timestamps each document and records the name of the individual who uploaded it, ensuring clear documentation of the review process. iii. After all required documents are uploaded, the OCPW Emergency Manager will be notified that the project application is ready for review. iv. The OCPW Emergency Manager will then: 1. Review the submitted documents in the FEMA Grants Portal. 2. Confirm that the reported costs align with the information provided by the reporting County agency. 3. Approve and submit the project application to Cal OES and FEMA for project approval. • Retention of Documentation: i. The FEMA Grants Portal serves as the official system of record, ensuring all uploaded documents are timestamped and traceable. ii. All project application approvals, cost documentation, and required forms will be retained electronically within the system for audit and compliance purposes. • Training and Implementation: i. Staff responsible for grant reporting will receive training on the revised process, including proper document upload procedures and compliance expectations. ii. The updated process will be implemented immediately. • Monitoring and Compliance: i. The OCPW Emergency Manager will conduct semiannual internal reviews of project applications to ensure compliance with the updated procedures. ii. Any issues identified during internal reviews will be addressed through additional staff training and process improvements. 3. Anticipated Implementation date: Immediate, March 18, 2025 • Staff Training: Within 30 days • Semiannual Compliance Review: Beginning next quarter i. First review will take place May 1, 2025. Followed by another review in October 2025.
2024-008 Program: Medicaid Cluster Federal Financial Assistance Listing Number: 93.778 Federal Grantor: U.S. Department of Health and Human Services Pass-Through: California Department of Health Care Services Award No. and Year: Various Compliance Requirements: Eligibility Type of Finding: Significa...
2024-008 Program: Medicaid Cluster Federal Financial Assistance Listing Number: 93.778 Federal Grantor: U.S. Department of Health and Human Services Pass-Through: California Department of Health Care Services Award No. and Year: Various Compliance Requirements: Eligibility Type of Finding: Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance Criteria: Title 42 Chapter IV Subchapter C Part 435 Subpart J Section 435.916, Regularly Scheduled Renewals of Medicaid Eligibility, states that the agency must renew MAGI-based determination of eligibility once every 12 months and no more frequently than once every 12 months. For non- MAGI beneficiaries, entities must renew eligibility at least once every 12 months. Condition: During our testing of the Social Service Agency’s (SSA) provisions for eligibility requirements, we noted that for one (1) of sixty (60) samples tested the department did not suspend, or pause, program eligibility despite being over the income limit for MAGI. Cause: The SSA department did not ensure the department’s policies and procedures relating to eligibility determination were followed. We noted that when a participant is determined to be over the income limit for MAGI, the participant is placed on a “soft pause” until a determination of eligibility under non-MAGI or Covered California is made. The department had erroneously marked the application as complete rather than placing the account on “soft pause” which caused the case to auto-renew. Effect: The County’s control was not consistently followed which caused an inaccurate determination of eligibility. Questioned Costs: None noted. Context/Sampling: A non-statistical sample of sixty (60) out of all active program participants were selected for testing. The condition noted above was identified during our procedures related to eligibility. Repeat Finding: No. Recommendation: We recommend the SSA department adhere to their policies and procedures to ensure that participant eligibility determinations and redeterminations are performed accurately. Management Response and Corrective Action: 1. Person Responsible: Michael Ueda, Human Services Manager and Yesenia Zapien, Human Service Manager 2. Corrective Action Plan: SSA will add administrative controls to track cases in soft pause to ensure eligibility determinations and redeterminations are performed accurately. Additionally, staff will be reminded of the policy and procedures surrounding soft pause. 3. Anticipated Implementation date: May 2025
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