Corrective Action Plans

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2024-002 C. Cash Management; L. Reporting Evidence and Review and Approval of the Reported Expenditures and Timely Report Submission Assistance Listing 93.959: Block Grants for Substance Use Prevention, Treatment, and Recovery Services Federal Agency: Department of Health and Human Services Recommen...
2024-002 C. Cash Management; L. Reporting Evidence and Review and Approval of the Reported Expenditures and Timely Report Submission Assistance Listing 93.959: Block Grants for Substance Use Prevention, Treatment, and Recovery Services Federal Agency: Department of Health and Human Services Recommendation: Management should reassess the design of its controls to ensure submissions to BHSB are made timely within the required 15-day period and that documentation is retained that evidences the review and approval of expenditures submitted to BHSB for reimbursement. Explanation of disagreement with audit finding: There is no disagreement with the finding and recommendations. Action planned/taken in response to finding: The Corporation went live on its new ERP system in April 2024. Since go-live, management has continued to optimize the system and find ways to strengthen our internal controls, including automating certain processes. Management will continue educating grant managers on capabilities within the system that can be utilized in the execution of review and approval of grant expenditures prior to timely submission to the relevant granting agencies for reimbursement. Centralized repositories have been set up for grant managers to extract specific monthly financial reports for use in the execution of their controls, as well as to retain their review and approval evidence. Additionally, management will develop a federal grant policy that includes the requirements for compliance and internal controls for federal grants. The policy will acknowledge that for controls to be designed and operate effectively, there must always be a segregation of duties between the preparer of the control vs. reviewer and that clear documentation must be retained to evidence the execution of the controls. Anticipated Completion Date – June 30, 2026 Name(s) of the contact person(s) responsible for corrective action: Jeff Chadwick, Financial Reporting Director, jeff.chadwick@umm.edu
University of Maryland Medical System Corporation and Subsidiaries Corrective Action Plan Year Ended June 30, 2024 University of Maryland Medical System Corporation and Subsidiaries (the Corporation) considers the implementation and monitoring of effective internal controls to be one of its most i...
University of Maryland Medical System Corporation and Subsidiaries Corrective Action Plan Year Ended June 30, 2024 University of Maryland Medical System Corporation and Subsidiaries (the Corporation) considers the implementation and monitoring of effective internal controls to be one of its most important responsibilities. The Corporation respectfully submits the following corrective action plan regarding the Schedule of Findings and Questioned Costs for the year ended June 30, 2024. Audit period: July 1, 2023 to June 30, 2024 FINDINGS—FEDERAL AWARD PROGRAMS AUDITS 2024-001 A. Activities Allowed or Unallowed; B. Allowable Costs/Cost Principles Review and Approval of Purchase Orders Assistance Listing 93.959: Block Grants for Substance Use Prevention, Treatment, and Recovery Services Federal Agency: Department of Health and Human Services Recommendation: Management should obtain documentation that evidences the review and approval of expenditures submitted to Behavioral Health System Baltimore (BHSB). Explanation of disagreement with audit finding: There is no disagreement with the finding and recommendations. Action planned/taken in response to finding: The Corporation went live on its new ERP system in April 2024. Since go-live, management has continued to optimize the system and find ways to strengthen our internal controls, including automating certain processes. Management will continue educating grant managers on system capabilities that can be utilized in the execution of review and approval of grant expenditures prior to submission to the relevant granting agencies for reimbursement. Centralized repositories have been set up for grant managers to extract specific monthly financial reports for use in the execution of their controls, as well as retain their review and approval evidence. For the specific vendor noted in Finding 2024-001, a grant input field has been added to the group purchasing orders to allow for enhanced tracking and review of expenditures associated with grants. Additionally, management is working with the vendor to ensure the requisition and approval configuration is properly maintained to prevent an approver in the from approving their own requisitions. Anticipated Completion Date – June 30, 2026 Name(s) of the contact person(s) responsible for corrective action: Jeff Chadwick, Financial Reporting Director, jeff.chadwick@umm.edu
Finding 542001 (2024-002)
Significant Deficiency 2024
Fiscal Policies and Procedure Alignment with Uniform Guidance Management at NAMI Chicago agrees with this finding and has already taken steps to address this recommendation through the following: • The implementation of expense management platform, Ramp to track and electronically maintain a system...
Fiscal Policies and Procedure Alignment with Uniform Guidance Management at NAMI Chicago agrees with this finding and has already taken steps to address this recommendation through the following: • The implementation of expense management platform, Ramp to track and electronically maintain a system of authorization and approval for all expenses. This system was piloted from September 1, 2024 – December 31, 2024 and implemented as of January 1, 2025. • The hiring of new fiscal staff with expertise in nonprofit financial management and standards, completed by June 30, 2024. • Updates to our fiscal policies and procedures to ensure alignment with Uniform Guidance requirements completed on December 1, 2024.
Finding ref number: 2024-001 Finding caption: The Potato Commission lacked adequate internal controls over and did not comply with federal suspension and debarment requirements. Name, address, and telephone of Commission contact person: Brandy Tucker Washington State Potato Commission 108 ...
Finding ref number: 2024-001 Finding caption: The Potato Commission lacked adequate internal controls over and did not comply with federal suspension and debarment requirements. Name, address, and telephone of Commission contact person: Brandy Tucker Washington State Potato Commission 108 Interlake Rd Moses Lake, WA 98837 509-765-8845 Corrective action the auditee plans to take in response to the finding: The Washington State Potato Commission (WSPC) acknowledges the audit finding and appreciates the recommendations provided by the auditors. Moving forward, we are committed to ensuring full compliance with federal requirements for the Specialty Crop Block Grant Program (SCBGP). To address this issue, the WSPC will implement stronger internal controls to verify that all contractors paid $25,000 or more, either fully or partially with federal funds, are not suspended or debarred from federal programs prior to entering into contracts. This will include: - Regularly checking exclusion records in the U.S. General Services Administration’s System for Award Management (SAM.gov) before performing work with contractors included in SCBGP contracts. By adopting these measures, we are confident in preventing any future noncompliance and ensuring proper stewardship of federal funds. Anticipated date to complete the corrective action: We have already taken action and reviewed our current contractors and plan to do so after each annual report is submitted to WSDA/USDA to ensure they are still not suspended or debarred from federal programs.
2024-001: Financial Reporting Management agrees with the finding and has taken immediate steps to address the issue and ensure timely submissions. Grand Street Settlement and BTQ Financial, Inc. will jointly oversee and ensure the timely submission of all progress reports. All agreements will be re...
2024-001: Financial Reporting Management agrees with the finding and has taken immediate steps to address the issue and ensure timely submissions. Grand Street Settlement and BTQ Financial, Inc. will jointly oversee and ensure the timely submission of all progress reports. All agreements will be reviewed in detail to fully understand compliance and reporting requirements, ensuring that all conditions are met, and submissions are made on time. A detailed timeline will be established for each reporting period, with regular check-ins to ensure that progress reports are completed and submitted on schedule. All deadlines will be closely monitored to prevent any future delays. Status of Finding: Management is expected to resolve the finding during fiscal year 2025 and will continue to work on resolving the finding. Managements Response: Management agrees with the finding. The issue will be corrected and resolved by the Grand Street Settlement Director of Administration, Program Director, and BTQ Financial during the fiscal year 2025.
Finding No. 2024-004: Segregation of Duties and Oversight – Material Weakness in Internal Control over Financial Reporting Contact for Corrective Action: Matt Bergheiser, President The finance department will institute a monthly financial reporting package to be sent to the President of the organi...
Finding No. 2024-004: Segregation of Duties and Oversight – Material Weakness in Internal Control over Financial Reporting Contact for Corrective Action: Matt Bergheiser, President The finance department will institute a monthly financial reporting package to be sent to the President of the organization which will include the monthly financial statements, general ledger detail, a listing of all journal entries made, significant accounts reconciliations, aged payables and receivables, and any significant adjustments in the previous period. Report will also include an update to the Schedule of Federal Awards and other significant grant reporting done in conjunction with the development team. President will review and approve the packet monthly. Expected Completion Date: 3/31/2025
Finding No. 2024-003: Procurement – Material Weakness in Internal Control Over Compliance Contact for Corrective Action: Matt Bergheiser, President The procurement policy for the organization will be updated to include a search of the suspension and debarment list as a first step towards complianc...
Finding No. 2024-003: Procurement – Material Weakness in Internal Control Over Compliance Contact for Corrective Action: Matt Bergheiser, President The procurement policy for the organization will be updated to include a search of the suspension and debarment list as a first step towards compliance. UCD will implement and adhere to a strict protocol for verifying suspension and debarment status and conduct an open and competitive bidding process prior to awarding any contracts or subawards under federal programs as is outlined in our procurement policy document. All of the results of the process will be documented and submitted to the Finance department prior to the selection of a new vendor, in order to remain in compliance. Expected Completion Date: 3/31/2025
2024-002. Allowable Costs/Cost Principles: Final Expenditure Report for a Federal or State Project (FS-10-F) United States Department of Education, Passed Through New York State, Department of Education: Twenty-First Century Community Learning Centers ALN: 84.287 Condition: Testing of the expenditur...
2024-002. Allowable Costs/Cost Principles: Final Expenditure Report for a Federal or State Project (FS-10-F) United States Department of Education, Passed Through New York State, Department of Education: Twenty-First Century Community Learning Centers ALN: 84.287 Condition: Testing of the expenditures charged to the grant, determined that costs were in excess of the adjusted budget amount because the actual number of students served was less than the target number of students to be served. Planned Corrective Action: The District should monitor performance indicators for the grant and review final expenditures charged to grants prior to submitting final cost reports to the New York State Education Department for reimbursement. Responsible Contact Person: Peter Daly Interim School Business Administrator Bridgehampton Union Free School District 2685 Montauk Highway Bridgehampton, New York 11932 Anticipated Completion Date: June 30, 2025.
2024-001. Allowable Costs/Cost Principles: Compensation – Personal Services United States Department of Education, Passed Through New York State, Department of Education: Twenty-First Century Community Learning Centers ALN: 84.287 Condition: Subpart E, 2 CFR §200.430 of the Uniform Guidance requires...
2024-001. Allowable Costs/Cost Principles: Compensation – Personal Services United States Department of Education, Passed Through New York State, Department of Education: Twenty-First Century Community Learning Centers ALN: 84.287 Condition: Subpart E, 2 CFR §200.430 of the Uniform Guidance requires that charges to “Federal awards for salaries and wages must be based on records that accurately reflect the work performed.” The documentation should support the distribution of the employee's compensation among specific activities if the employee works on more than one federal award, or a federal award and non-federal award. The preparation of personnel activity reports (PARs) or periodic certifications or the equivalent is the most effective way to comply with this requirement. During the current year, the District had not prepared periodic certification equivalents for all employees. Planned Corrective Action: The District will monitor procedures to ensure that documentation to support salaries and wages charged to federal awards is in a format that complies with the requirements of the Uniform Guidance Subpart E, 2 CFR §200.430. Responsible Contact Person: Peter Daly Interim School Business Administrator Bridgehampton Union Free School District 2685 Montauk Highway Bridgehampton, New York 11932 Anticipated Completion Date: June 30, 2025.
Finding 541990 (2024-004)
Significant Deficiency 2024
Federal agency: U.S. Department of Education Programs: Federal Direct Student Loans Assistance listing #: 84.268 Award year: 2024 Corrective Action Plan: Previously, this was an ancillary work task for a staff member in a different department. CU has since hired an experienced Registrar and ...
Federal agency: U.S. Department of Education Programs: Federal Direct Student Loans Assistance listing #: 84.268 Award year: 2024 Corrective Action Plan: Previously, this was an ancillary work task for a staff member in a different department. CU has since hired an experienced Registrar and begun training an Associate Registrar. The dedicated department now updates Clearinghouse on the required monthly basis. All previous records have been corrected. Timeline for Implementation of Corrective Action Plan: Completed Contact Person: Mark Hartonchik, CFO
Finding 541988 (2024-002)
Significant Deficiency 2024
Finding number: 2024-002 Federal agency: U.S. Department of Education Programs: Federal Direct Student Loans Assistance listing #: 84.268 Award year: 2024 Corrective Action Plan: These findings are from Fall 2023. College Unbound has corrected this as of Spring 2024. The new practice, start...
Finding number: 2024-002 Federal agency: U.S. Department of Education Programs: Federal Direct Student Loans Assistance listing #: 84.268 Award year: 2024 Corrective Action Plan: These findings are from Fall 2023. College Unbound has corrected this as of Spring 2024. The new practice, started February 2024, is to run a weekly report every Friday of disbursements made during that week. Every student on that disbursement list receives and email that a disbursement has been made and instructions how to review their account in their online student portal. We have been replicating this process for over 12 months now and will continue to do so in the future. Timeline for Implementation of Corrective Action Plan: Completed Contact Person: Mark Hartonchik, CFO
Finding 541987 (2024-003)
Significant Deficiency 2024
Finding number: 2024-003 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance listing #: 84.063 and 84.268 Award year: 2024 Corrective Action Plan: This finding was the result of failure to fully...
Finding number: 2024-003 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance listing #: 84.063 and 84.268 Award year: 2024 Corrective Action Plan: This finding was the result of failure to fully execute a professional judgment (PJ) calculation. We processed a PJ on the now-closed FAA access but failed to import the updated EFC into our system. As FAA is now closed, we cannot show the updated EFC. College Unbound does regular monthly checks to ensure that no student exceeds cost of attendance or need. This one was a PJ done sloppily. Timeline for Implementation of Corrective Action Plan: Completed Contact Person: Mark Hartonchik, CFO
View Audit 350797 Questioned Costs: $1
U.S. Department of Housing and Urban Development Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: The Authority should designate an individual to review tenant files to ensure that rent reasonableness is properly performed before the effective date and maintained in the file...
U.S. Department of Housing and Urban Development Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: The Authority should designate an individual to review tenant files to ensure that rent reasonableness is properly performed before the effective date and maintained in the file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Tenant files will be reviewed prior to effective date to ensure rent reasonableness are done timely. Name of the contact person(s) responsible for corrective action: Albert Kirland Jr. Planned completion date for corrective action plan: April 1, 2025 If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Albert Kirland Jr. at 863 676-7414x12
View Audit 350795 Questioned Costs: $1
Corrective Action Plan: Please describe below how the situation in the finding will be corrected. What action(s) will be done (refer to finding recommendation and agency response) The SAWDB will strengthen the process in which it monitors compliance with the requirements of Section 129(a)(4)(A), W...
Corrective Action Plan: Please describe below how the situation in the finding will be corrected. What action(s) will be done (refer to finding recommendation and agency response) The SAWDB will strengthen the process in which it monitors compliance with the requirements of Section 129(a)(4)(A), WIOA, 128 Stat. 1506 and develop a strategy to exceed the minimum 75 percent of funds to out-of-school youth. Quarterly review and monitoring will take place during the Monitoring Committees meeting. The fiscal administrator will provide the report. A direct review of percentages of expenditures will be analyzed by fiscal administrator, Program Manager, Program Monitor, and WIOA Administrator prior to reporting to the monitoring committee. Who will act (name and title): Skylar Arnold, Fiscal Admin Glory Juarez, WIOA Admin Jaymi Simms WIOA Program Manager When will action(s) be completed (effective dates, timelines, etc.): SAWDB will ensure that Earmarking Compliance is reviewed and maintained at or over the minimum percentage allowed. This is start immediately and reported to Monitoring Committee Quarterly. These enhanced procedures will be performed to resolve this finding before June 30, 2025.
State and Local Fiscal Recovery Funds– Assistance Listing No. 21.027 Procurement – Material Weakness in Internal Control Over Compliance, Material Non-Compliance Recommendation: We recommend the Commission continue to follow the procurement policy now established and provide comprehensive training t...
State and Local Fiscal Recovery Funds– Assistance Listing No. 21.027 Procurement – Material Weakness in Internal Control Over Compliance, Material Non-Compliance Recommendation: We recommend the Commission continue to follow the procurement policy now established and provide comprehensive training to all relevant staff on procurement policies and procedures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: In April 2024, the Commission implemented a federal funding procurement policy. The sources of grant funding have expanded extensively since the inception of expanding broadband service to underserved communities. The original primary source of funding was ReConnect, a federal grant from the USDA, and funding subsequently expanded to include the State of Maryland. The Commission received guidance from ReConnect, allowing the Commission to single source vendors for inventory for standardization within the system, both our existing and the new system. The Commission issued purchased orders to stockpile materials under that guidance starting in May 2021 to avoid construction delays due to long lead times experienced throughout the industry. Maryland grants agreements were signed August 2021, July 2022, and June 2023. The use of material procured using the methods allowed by the ReConnect grant had been discussed and agreed upon between the Commission’s Chief Financial Officer (at the time) and the Director of the Department of Housing and Community Development Office of Statewide Broadband; however, approval had not been memorialized in writing. The Commission also has contracts with vendors established under the ReConnect grant following their guidance. The Commission utilizes consistent and established vendors on this project as the project as a whole covers the entire county and some areas overlap or are intertwined. Vendors used are familiar with the entire project. Name of the contact person responsible for corrective action: Tracie Thomas Planned completion date for corrective action plan: Corrective action was taken April 2024.
State and Local Fiscal Recovery Funds– Assistance Listing No. 21.027 Suspension and Debarment - Significant Deficiency in Internal Control Over Compliance Recommendation: We recommend the Commission continue with the policies and procedures now established and require documentation be maintained t...
State and Local Fiscal Recovery Funds– Assistance Listing No. 21.027 Suspension and Debarment - Significant Deficiency in Internal Control Over Compliance Recommendation: We recommend the Commission continue with the policies and procedures now established and require documentation be maintained to verify vendors are not suspended or debarred prior to being paid with federal funds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: In April 2024, the Commission established a policy requiring documentation be maintained to verify vendors are not suspended or debarred prior to being paid with federal funds. Name of the contact person responsible for corrective action: Tracie Thomas Planned completion date for corrective action plan: Corrective action was taken April 2024.
State and Local Fiscal Recovery Funds– Assistance Listing No. 21.027 Allowable Activities and Costs - Significant Deficiency in Internal Control Over Compliance Recommendation: We recommend the Commission establish policies and procedures over internal controls to ensure review and approval of SEFA...
State and Local Fiscal Recovery Funds– Assistance Listing No. 21.027 Allowable Activities and Costs - Significant Deficiency in Internal Control Over Compliance Recommendation: We recommend the Commission establish policies and procedures over internal controls to ensure review and approval of SEFA preparation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Commission will implement a SEFA preparation policy. Name of the contact person responsible for corrective action: Tracie Thomas Planned completion date for corrective action plan: May 31, 2025
The sliding fee determination will be reviewed by the front desk staff thoughtfully to ensure the proper charge to the patient. Once the patient is screened and determined to be eligible for the Sliding Fee program by the front office, the patient will complete the Sliding Fee application and self ...
The sliding fee determination will be reviewed by the front desk staff thoughtfully to ensure the proper charge to the patient. Once the patient is screened and determined to be eligible for the Sliding Fee program by the front office, the patient will complete the Sliding Fee application and self declaration of income and family size. The front office will verify the application, determine the scale for which the patient qualifies, and verify with the Center's practice management system. The lead biller will review all uploaded documents and approve the sliding fee in real time. Additional traning will take place with front desk personnel.
The Controller will review the detailed information related ot the drawdown to ensure the amount charged to the specific grant is allowable, reasonable and properly supported prior to when the drawdown is requested.
The Controller will review the detailed information related ot the drawdown to ensure the amount charged to the specific grant is allowable, reasonable and properly supported prior to when the drawdown is requested.
Contact Responsible for the Corrective Action: District Manager & Board Treasurer Corrective Action to be Taken: The District has implemented the recommended action, requiring that all internal billing worksheets be reconciled to the QuickBooks general ledger prior to final District Manager approva...
Contact Responsible for the Corrective Action: District Manager & Board Treasurer Corrective Action to be Taken: The District has implemented the recommended action, requiring that all internal billing worksheets be reconciled to the QuickBooks general ledger prior to final District Manager approval. However, to ensure proper documentation, the District will develop and implement a check-off spreadsheet to track when this reconciliation has been completed for each payment request. Additionally, an internal Standard Operating Procedure (SOP) for Billing Worksheet – General Ledger reconciliation will be created to formalize and document the process, ensuring it is retained. Anticipated Completion Date: June 30, 2025
Contact Responsible for the Corrective Action: District Manager & Board Treasurer Corrective Action to be Taken: At the March 27th, 2025 Board Meeting, the District addressed the issue of missing signatures on checks. As a result, the following actions were agreed upon: • The District Manager will ...
Contact Responsible for the Corrective Action: District Manager & Board Treasurer Corrective Action to be Taken: At the March 27th, 2025 Board Meeting, the District addressed the issue of missing signatures on checks. As a result, the following actions were agreed upon: • The District Manager will comply with District Policy 3140 at all times. • When possible, Board Members will sign checks at regularly scheduled Board meetings. • If waiting for the next meeting is not feasible, the District will implement the following internal control process, documented in an internal Standard Operating Procedure (SOP): 1. The District Manager will initiate payment and draft the check. 2. The Bookkeeper will log the relevant information into the internal Check Control Log. 3. The District Manager will contact the Board to obtain the necessary signatures. 4. Once signed, the District Manager will notify the Bookkeeper of the signatories, who will update the Check Control Log with their names or initials. 5. The Bookkeeper will verify the check and signatories once the check has cleared but before it is uploaded to the QuickBooks General Ledger. Anticipated Completion Date: June 30, 2025
Contact Responsible for the Corrective Action: District Manager & Board Treasurer Corrective Action to be Taken: The District has implemented the recommended action, requiring that all internal billing worksheets be reconciled to the QuickBooks general ledger prior to final District Manager approv...
Contact Responsible for the Corrective Action: District Manager & Board Treasurer Corrective Action to be Taken: The District has implemented the recommended action, requiring that all internal billing worksheets be reconciled to the QuickBooks general ledger prior to final District Manager approval. However, to ensure proper documentation, the District will develop and implement a check-off spreadsheet to track when this reconciliation has been completed for each payment request. Additionally, an internal Standard Operating Procedure (SOP) for Billing Worksheet – General Ledger reconciliation will be created to formalize and document the process, ensuring it is retained. Anticipated Completion Date: June 30, 2025
Recommendation: We recommend the College follow and properly execute its procedures it has in place relating to non-payroll expenditures. Action Taken: The Finance department will review and ensure all journal entries are properly documented prior to making posting payments. Finance is 90% fully sta...
Recommendation: We recommend the College follow and properly execute its procedures it has in place relating to non-payroll expenditures. Action Taken: The Finance department will review and ensure all journal entries are properly documented prior to making posting payments. Finance is 90% fully staffed and new staff have been trained on how to do journal entries.
View Audit 350766 Questioned Costs: $1
Recommendation: We recommend the College follow and properly execute its procedures it has in place relating to payroll expenditures. Action Taken: The Finance department will review and ensure all payroll entries and payroll corrections are properly documented prior to making journal entries.
Recommendation: We recommend the College follow and properly execute its procedures it has in place relating to payroll expenditures. Action Taken: The Finance department will review and ensure all payroll entries and payroll corrections are properly documented prior to making journal entries.
View Audit 350766 Questioned Costs: $1
Recommendation: We recommend the College set up a debt reserve fund in accordance with the loan agreement. Action Taken: The College met with the lending agency regarding debt reserve fund account and reporting process. A debt reserve account has been established in accordance with the loan agreemen...
Recommendation: We recommend the College set up a debt reserve fund in accordance with the loan agreement. Action Taken: The College met with the lending agency regarding debt reserve fund account and reporting process. A debt reserve account has been established in accordance with the loan agreement.
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