Corrective Action Plans

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Corrective Action Plan for Finding 2024-003 Community Care agrees with this finding. The homeless youth service sector of our organization has significant report requirements that could not be supported by existing resources. A recent effort to improve report timing was to hire an administrative...
Corrective Action Plan for Finding 2024-003 Community Care agrees with this finding. The homeless youth service sector of our organization has significant report requirements that could not be supported by existing resources. A recent effort to improve report timing was to hire an administrative person to specifically focus on these reports. This individual began employment in February 2025. The primary purpose of this position will be to organize data and complete reports on schedule. Responsible Official: David McCluskey, Executive Director Date of Corrective Action: New employee hired in February 2025
Corrective Action Plan for Finding 2024-002 Community Care agrees with this finding. There are three bullets in the finding. Although we agree with the findings, the first two are not fully related to a problem of service delivery from Community Care These timeframes are highly dependent on the De...
Corrective Action Plan for Finding 2024-002 Community Care agrees with this finding. There are three bullets in the finding. Although we agree with the findings, the first two are not fully related to a problem of service delivery from Community Care These timeframes are highly dependent on the Department of Health and Human Services to ensure parents and family members have reliable transportation. Approximately 6 months ago, Community Care discussed with DHHS that we would be willing to transport parents and were told by DHHS the funding cannot be used for that part of the service. Community Care will continue to hiring employees to fulfill the contract and arranging visits efficiently as soon as parents and families members who are visiting have transportation. We have seen improvements in the area. Because these two measurements are not fully in our control we will be advocating for this measurement to be removed in future contract language. The third bullet has been improved since 2024. In Feb of 2025 we made significant efforts and dedicated significant resources in employee to move closer to this goal. Currently we are within 7-10 days from date of service making entries into the Katahdin system rather than two months. Responsible Official: David McCluskey, Executive Director Date of Corrective Action: Hiring activities/efforts are on-going
2024-004 Eligibility U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement policies and procedures to ensure that the necessary controls are in place to properly verify the eligibility of all Youth Activities participants. Act...
2024-004 Eligibility U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement policies and procedures to ensure that the necessary controls are in place to properly verify the eligibility of all Youth Activities participants. Action Taken: The Board has established policies and procedures to strengthen eligibility verification for the Youth program participants. These policies outline clear documentation requirements, verification steps, and staff responsibilities. Staff involved in eligibility determination have been trained on the new procedures to ensure consistency and compliance with federal and state guidelines and will receive ongoing training and technical assistance. The Board has implemented internal controls, including multi-level verification and supervisory review to ensure the accuracy and completeness of participant eligibility determinations.
View Audit 350052 Questioned Costs: $1
2024-003 Subrecipient Monitoring U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement its recently adopted policies and procedures and commit the appropriate personnel to subrecipient monitoring to ensure that the Board is in ...
2024-003 Subrecipient Monitoring U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement its recently adopted policies and procedures and commit the appropriate personnel to subrecipient monitoring to ensure that the Board is in compliance with all federal requirements. Action Taken: The Board has formally integrated the new adopted policies and procedures into our operational framework to ensure consistency and adherence to federal guidelines. Specific staff members have been designated to subrecipient monitoring responsibilities, ensuring adequate oversight and compliance. Executive staff will conduct period internal reviews to assess the effectiveness of our monitoring processes and make improvements as needed.
View Audit 350052 Questioned Costs: $1
2024-002 Reporting U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board design and implement controls to ensure that all required reporting is submitted accurately and in a timely fashion. Action Taken: Region III will establish cle...
2024-002 Reporting U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board design and implement controls to ensure that all required reporting is submitted accurately and in a timely fashion. Action Taken: Region III will establish clear documentation checklist with requirements for each report to ensure completeness and accuracy. Assign specific roles and responsibilities for report preparation, review and approval before submission to ensure that multiple levels of review are in place.
View Audit 350052 Questioned Costs: $1
2024-001 Activities Allowed or Unallowed U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board design and implement controls to ensure that all charges to federal programs are adequately reviewed and approved prior to payment. Action T...
2024-001 Activities Allowed or Unallowed U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board design and implement controls to ensure that all charges to federal programs are adequately reviewed and approved prior to payment. Action Taken: Region III will create a detailed workflow of the approval process that includes the following: Initial request, review by finance department, and approval by designated individuals. Ensure that no single individual has control over all aspects of the charge approval process. We will schedule quarterly internal audits to review samples of transactions for compliance.
View Audit 350052 Questioned Costs: $1
FINDING 2024-004: Impact Aid Application Controls (Repeated 2023-004) Response: The District has implemented that the documentation for the Impact Aid application will be kept in the Business Manager office rather than the Superintendent office to ensure that this documentation is maintained for fut...
FINDING 2024-004: Impact Aid Application Controls (Repeated 2023-004) Response: The District has implemented that the documentation for the Impact Aid application will be kept in the Business Manager office rather than the Superintendent office to ensure that this documentation is maintained for future years.
Finding 2024-001 Subrecipient Monitoring, Non-Compliance (Significant Deficiency) Finding Summary: The subawards did not include the required federal provisions or list the assistance listing numbers. Corrective Action Plan for Subrecipient Contracts: Revise all subrecipient contracts to include...
Finding 2024-001 Subrecipient Monitoring, Non-Compliance (Significant Deficiency) Finding Summary: The subawards did not include the required federal provisions or list the assistance listing numbers. Corrective Action Plan for Subrecipient Contracts: Revise all subrecipient contracts to include the federal provisions and list the assistance listing numbers. All LIFT 2.0 contracts will end on December 31, 2024. For those renewed contracts the aforementioned information will be included. All other existing contracts are currently being updated to include this information. The procurement policy will be updated to include this control as well as all other requirements per 2 CFR Section 200.303(a). A reviewer’s checklist will be created using this section to ensure that all future contracts are in compliance. Responsible Individual: Santanna Johnson, Director of Accounting and Contracts Anticipated Completion Date: December 2024
Health Resources and Services Administration Jacquelyn Kilmer, Harlem United Community AIDS Center, Inc.’s CEO respectfully submits the following corrective action plan for the year ended June 30, 2024: CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: June 30, 2024 The...
Health Resources and Services Administration Jacquelyn Kilmer, Harlem United Community AIDS Center, Inc.’s CEO respectfully submits the following corrective action plan for the year ended June 30, 2024: CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: June 30, 2024 The findings from the June 30, 2024, schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS – FINANCIAL STATEMENT AUDIT Material Weakness Item 2024-001 - Accounting for Leases The Organization adopted Financial Accounting Standards Board ("FASB") Accounting Standards Update ("ASU") 2016-02 (as amended), Leases (Topic 842), on July 1, 2020. Topic 842 required lessees to recognize a right-of-use asset and a corresponding lease liability for virtually all leases. The Organization did not apply Topic 842 for approximately 300 lease agreements for scatter sites that are part of the Organization's Housing Assistance Program. Recommendation We recommend that the Organization read and review all of its lease agreements to ensure that they are properly accounted for under Topic 842. Action Taken We agree with the finding. Management has already implemented a review of all of its existing lease agreements to ensure that we are accounting for them properly under Topic 842. We are also in the process of reviewing our accounting policies in relation to leases. Effectivity Date: July 2024 FINDINGS FEDERAL AWARD PROGRAM AUDITS Significant Deficiency Item 2024-002 - Procurement, Suspension and Debarment - U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Projects of Regional and National Significance (Assistance Listing Number 93.243) Notice of Award Number 1H79SP082826 for 2023-2025 and Notice of Award Number 5H79TI085189 for 2023 to 2024 The Center did not maintain documentation of its verification of two sample employees and two sample vendors to ascertain if they are suspended or debarred. Recommendation: We recommend that the Organization implement a policy requiring proper documentation of their verification of employees and vendors for suspension and debarment. Action Taken: Management agrees that evidence of exclusion search was not maintained or kept on file. Management has already established a policy in relation to performing verification for suspension and debarment and the Organization will be training all the personnel involved to ensure that proper documentation is kept on file. Effectivity Date: March 2025 Sincerely yours, Signature:  Jacquelyn Kilmer, CEO Harlem United Community AIDS Center, Inc.
Finding 2024-003 – Capital Fund Grant Reconciliations – Special Tests – Significant Deficiency Capital Fund Program – ALN #14.872 Corrective Action Plan: The Housing Authority has brough forward all schedules related to Capital Fund Grant as of March 2025. Person Responsible: Sheila Crisp, Executi...
Finding 2024-003 – Capital Fund Grant Reconciliations – Special Tests – Significant Deficiency Capital Fund Program – ALN #14.872 Corrective Action Plan: The Housing Authority has brough forward all schedules related to Capital Fund Grant as of March 2025. Person Responsible: Sheila Crisp, Executive Director Anticipated Completion Date: June 2025
Finding 2024-002 – Low Income Public Housing Tenant Files – Eligibility – Noncompliance & Material Weakness – Public and Indian Housing – ALN #14.850 Corrective Action Plan: The Housing Authority has contracted with US Inspections to continue pre-inspecting units in preparation for NSPIRE inspecti...
Finding 2024-002 – Low Income Public Housing Tenant Files – Eligibility – Noncompliance & Material Weakness – Public and Indian Housing – ALN #14.850 Corrective Action Plan: The Housing Authority has contracted with US Inspections to continue pre-inspecting units in preparation for NSPIRE inspections. Additionally, staff is coordinating Income Calculation training with Zeffert University. Lastly, the Housing Authority has implemented a 100% file compliance review, which took effect on January 1, 2025. Person Responsible: Tammy Bradshaw, Admissions & Compliance Manager Anticipated Completion Date: June 2025
Finding 2024-001 – Accounting Controls – Internal Controls over Financial Statement Preparation ALN 14.850 – Noncompliance and Material Weakness Corrective Action Plan: The Housing Authority is working with new personnel to ensure processes are documented and proper training is taking place. The...
Finding 2024-001 – Accounting Controls – Internal Controls over Financial Statement Preparation ALN 14.850 – Noncompliance and Material Weakness Corrective Action Plan: The Housing Authority is working with new personnel to ensure processes are documented and proper training is taking place. The Housing Authority has contracted with BDO to assist with year-end processes and training. Person Responsible: Sheila Crisp, Executive Director Anticipated Completion Date: June 2025
Finding 539480 (2024-010)
Significant Deficiency 2024
Cash Management – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit...
Cash Management – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Director will ensure that when processes are completed, they are verifiable through documentation. Credit Balance refunds as well as drawdowns will be tracked for proper compliance requirements. Name(s) of the contact person(s) responsible for corrective action: Levi Powell, Student Financial Aid Director Planned completion date for corrective action plan: 6/30/2025
Finding 539478 (2024-009)
Significant Deficiency 2024
Special Tests and Provisions Direct Loan Reconciliation – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding:...
Special Tests and Provisions Direct Loan Reconciliation – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid director will institute a documented review of the Direct Loan reconciliations prepared by Campus Ivy or future third-party processors. Name(s) of the contact person(s) responsible for corrective action: Levi Powell, Student Financial Aid Director Planned completion date for corrective action plan: 6/30/2025
Finding 539476 (2024-008)
Significant Deficiency 2024
Special Tests and Provisions 240 Day Checks – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no...
Special Tests and Provisions 240 Day Checks – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid office along with Student Accounts and the Business Office at Urshan University will collaborate on an SOP which will establish a process of reviewing any outstanding Title IV checks. Checks will be reissued as necessary to ensure the university stays compliant with all Title IV regulations. Name(s) of the contact person(s) responsible for corrective action: Levi Powell, Student Financial Aid Director Planned completion date for corrective action plan: 6/30/2025
Finding 539474 (2024-007)
Significant Deficiency 2024
Eligibility – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit fin...
Eligibility – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid office will be implementing an SOP which will document a review process of work done by the third-party processor, to include COD reporting, and Verification procedures. We will also be implementing a process to review students who need to complete their exit counseling. Name(s) of the contact person(s) responsible for corrective action: Levi Powell, Student Financial Aid Director Planned completion date for corrective action plan: 6/30/2025
View Audit 350009 Questioned Costs: $1
Finding 539472 (2024-006)
Significant Deficiency 2024
Special Tests and Provisions Gramm-Leach-Bliley Act– Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: Ther...
Special Tests and Provisions Gramm-Leach-Bliley Act– Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The IT department continues to improve its processes; an annual review of the WISP has been started and will continue. The Financial Aid Office will work with IT to make sure that the WISP is improved to include and provide secure disposal of customer information and make sure the review is documented. Name(s) of the contact person(s) responsible for corrective action: Levi Powell, Student Financial Aid Director Planned completion date for corrective action plan: 6/30/2025
View Audit 350009 Questioned Costs: $1
Special Tests and Provisions R2T4 – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreeme...
Special Tests and Provisions R2T4 – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid office will be crafting a new SOP to address R2T4 audit findings. The team will work more closely with the Registrar and Academic Deans when determining the withdrawal status of a student and make sure that the R2T4 documentation is accurately completed, a review of completed R2T4s will also be conducted. Name(s) of the contact person(s) responsible for corrective action: Levi Powell, Student Financial Aid Director Planned completion date for corrective action plan: 6/30/2025
View Audit 350009 Questioned Costs: $1
Finding 539468 (2024-004)
Significant Deficiency 2024
Special Tests and Provisions Enrollment Reporting – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College provide additional resources to ensure all compliance requirements are met. Explanation of disagreement with audit finding: There is no disagreement with the audit find...
Special Tests and Provisions Enrollment Reporting – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College provide additional resources to ensure all compliance requirements are met. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A new Standard Operating Procedure (SOP) is being created, which will address enrollment reporting concerns. The Financial Aid office will work with the Registrar to increase communication between offices and eliminate enrollment reporting errors. The Financial Aid office will also improve reporting to the third-party processor, so that timely and accurate information is uploaded to NSLDS. Furthermore, a recurring review of the third-party’s reporting to NSLDS will be instituted. Name(s) of the contact person(s) responsible for corrective action: Levi Powell, Director of Financial Aid Planned completion date for corrective action plan: 6/30/2025
Finding 539464 (2024-001)
Significant Deficiency 2024
Management's Response/Planned Corrective Action: The Organization has established and implemented a new procedure to ensure the correct allocation of substitute teachers. This change has already been made effective as of July 1, 2024 to meet the auditor's recommendations. The Organization will now b...
Management's Response/Planned Corrective Action: The Organization has established and implemented a new procedure to ensure the correct allocation of substitute teachers. This change has already been made effective as of July 1, 2024 to meet the auditor's recommendations. The Organization will now bill substitutes exclusively to the appropriate site and program, which will enhance financial tracking and accountability. Substitutes will no longer be included in any distribution tables. Currently, substitutes are assigned to a System of Support (SOS) as their direct supervisor. The SOS is responsible for scheduling substitutes, entering their schedules into Paycor, and assigning them to school sites. Additionally, the Payroll Coordinator, Joanna Qualls, is required to add a billing code to these substitutes. The Payroll Department follows a procedure every pay period to run a report on substitutes, ensuring they are coded correctly. This process has been established as a step for every payroll run. The Director of Finance, Juana Sierra-Perez, also does a final audit of payroll to ensure transactions are being coded properly.
View Audit 350003 Questioned Costs: $1
We will update our cost allocation plan to address the issues as outlined in our response above. We will also implement a formal quarterly review of cost allocations to contracts under the guidance of our outside accountant (Capalbo, Mather Dougherty). Finally, we will use improved grant accounting ...
We will update our cost allocation plan to address the issues as outlined in our response above. We will also implement a formal quarterly review of cost allocations to contracts under the guidance of our outside accountant (Capalbo, Mather Dougherty). Finally, we will use improved grant accounting worksheets as a final check that our contract billing and accounting records are fully consistent.
While the audit notes improvements in this area, we continued to face some challenges in properly allocating indirect costs and fringe benefits to individual contracts. We will close the remaining gap between the costs properly billed to individual contracts and the process of reflecting these costs...
While the audit notes improvements in this area, we continued to face some challenges in properly allocating indirect costs and fringe benefits to individual contracts. We will close the remaining gap between the costs properly billed to individual contracts and the process of reflecting these costs in our accounting system by refining our cost allocation plan. This revision will include consistent rules for allocating indirect and fringe plus a quarterly review by accounting staff and management. We will also use newly formatted grant worksheets shared with us by Whittlesey to help us identify and correct any allocation issues before closing out our accounting records for this fiscal year.
Finding 2024-002 – The Organization provided humanitarian assistance to migrants and asylum seekers turned over by Customs and Border Protection (CBP), including meals, transportation and shelter at hotels and the Organizations Respite Center. The Organization has intake procedures in place with res...
Finding 2024-002 – The Organization provided humanitarian assistance to migrants and asylum seekers turned over by Customs and Border Protection (CBP), including meals, transportation and shelter at hotels and the Organizations Respite Center. The Organization has intake procedures in place with respect to hotel shelter expenditures. However, the intake process was not consistently applied to all participants. The Organization was not able to provide supporting documentation for 5% of the requested sample of individuals who received shelter. Management's view: Management acknowledges this finding, and awareness has been brought to this area. The errors identified in this finding were made due to a lack of implementation of proper agency financial procedures by a former employee and occurred during a period of substantial influx in the number of non-citizen migrants being assisted. Authorization of credit card use was provided to one hotel vendor which led to unverified charges. This was identified and corrected by senior staff within three weeks. Proposed Corrective Action: The following measures were already taken to correct this finding: The organization has provided proper training to its program staff and accounting bookkeepers to improve the internal payment review process on all payment requests and has prohibited the use of credit cards to cover hotel stays for clients. All hotel payments are to be paid by check after reviewing the proper documentation submitted by the vendor, which includes an invoice with the non-citizen migrant's name as spelled in the Notice to Appear documentation provided by U.S. Customs and Border Protection. This documentation is then compared to the registration database maintained by the organization which includes name and A-number for all non-citizen migrants served. Any unauthorized payment will be immediately investigated and disputed on a timely basis. This policy has already been implemented successfully. An internal sample verification process was completed successfully with supporting evidence for all clients served after the previous unauthorized charges were identified within the period of three weeks. Anticipated Correction Date: These measures have been implemented.
View Audit 349994 Questioned Costs: $1
AAA will create a worksheet to show unpaid balances and will create A/P transactions for those to be reported on monthly financials. Completion date March 31 st, 2025 by fiscal dept
AAA will create a worksheet to show unpaid balances and will create A/P transactions for those to be reported on monthly financials. Completion date March 31 st, 2025 by fiscal dept
Finding 539419 (2024-001)
Significant Deficiency 2024
FINDING 2024-001 – SIGNIFICANT DEFICIENCY- PROCUREMENT AND SUSPENSION AND DEBARMENT- INTERNAL CONTROL OVER VERIFICATION AGAINST THE SYSTEM FOR AWARD MANAGEMENT (“SAM”) Description of Finding: 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awa...
FINDING 2024-001 – SIGNIFICANT DEFICIENCY- PROCUREMENT AND SUSPENSION AND DEBARMENT- INTERNAL CONTROL OVER VERIFICATION AGAINST THE SYSTEM FOR AWARD MANAGEMENT (“SAM”) Description of Finding: 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, (Uniform Guidance) requires compliance with provisions of procurement, suspension, and debarment. Non-federal entities are required to ensure that they do not award contracts or make subawards to any parties that are suspended or debarred from receiving federal funds. This verification may be accomplished by checking the System for Award Management (SAM). The Town does not have a process in place to check that vendors are not suspended or debarred by checking the System for Award Management (SAM). Statement of Concurrence or Nonconcurrence: The Town agrees with the audit finding. Corrective Action: The Town will establish policies and procedures to ensure vendors are not suspended or debarred by checking the System for Award Management (SAM) and maintain documentation showing that verification. Name of Contact Person: Thomas Sparkman, First Selectman, (860) 376-3400. Projected Completion Date: March 31, 2025.
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