Corrective Action Plans

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Name of Contact Person: Autumn Grim, Director. Recommendation: We recommend the Center verify a vendor's status by checking the System for Award Management (SAM) maintained by the General Services Administration before making purchases expected to exceed $25,000 and to keep all supporting documen...
Name of Contact Person: Autumn Grim, Director. Recommendation: We recommend the Center verify a vendor's status by checking the System for Award Management (SAM) maintained by the General Services Administration before making purchases expected to exceed $25,000 and to keep all supporting documentation of the verification of the vendor's status. Corrective Action: We will verify all vendors' status using the System for Award Management (SAM) maintained by the General Services Administration before making purchases expected to exceed $25,000. Proposed Completion Date: Immediately.
2024-001 Condition: Deficiencies Noted in the Examination of Procurement Steps to resolve: We will review staffing requirements for procurement compliance needs and review all HUD requirements and policies to ensure complete compliance for all procurement. Timeframe: By FYE June 30, 2025 Indiv...
2024-001 Condition: Deficiencies Noted in the Examination of Procurement Steps to resolve: We will review staffing requirements for procurement compliance needs and review all HUD requirements and policies to ensure complete compliance for all procurement. Timeframe: By FYE June 30, 2025 Individual responsible for correction: Ms. Rosetta Washington, Executive Director
Finding 537237 (2024-002)
Material Weakness 2024
LearningWorks has been working with an external accounting consultant since July of 2024. This seasoned CPA with valuable experience in nonprofit financial management has offered counsel and support with various issues. Moving forward, her support will include developing and executing a monthly revi...
LearningWorks has been working with an external accounting consultant since July of 2024. This seasoned CPA with valuable experience in nonprofit financial management has offered counsel and support with various issues. Moving forward, her support will include developing and executing a monthly review process in order to meet industry and Uniform Guidance standards. Additionally, we are willing to institute further recommended practices that will remediate this finding.
Finding 537236 (2024-001)
Material Weakness 2024
LearningWorks is utilizing a temporary plan that engages existing staff in aspects of segregation. The recently revised Finance Manual includes a full matrix that explicitly includes additional finance staff to ensure segregation of duties through the transaction cycle. LearningWorks is committed to...
LearningWorks is utilizing a temporary plan that engages existing staff in aspects of segregation. The recently revised Finance Manual includes a full matrix that explicitly includes additional finance staff to ensure segregation of duties through the transaction cycle. LearningWorks is committed to and engaged in hiring a Finance Associate. The agency will incorporate these criteria and the matrix in our routine operations. Additionally, we are willing to institute further recommended practices that will remediate this finding.
Appendix B – Corrective Action Plan To: PKF O’Connor Davies, LLP, U.S. Department of Education From: Brian Kirkpatrick, Vice President of Administration and Finance Date: March XX, 2025 RE: New Jersey City University Foundation, Inc. and Affiliate Corrective Action Plan 2024-001 – Grant Agreem...
Appendix B – Corrective Action Plan To: PKF O’Connor Davies, LLP, U.S. Department of Education From: Brian Kirkpatrick, Vice President of Administration and Finance Date: March XX, 2025 RE: New Jersey City University Foundation, Inc. and Affiliate Corrective Action Plan 2024-001 – Grant Agreements Federal Assistance Listing Number: 84.031 Name of Program or Cluster: 84.031 Higher Education Institutional Aid: Opening the Gate: Improving Math Success for STEM Careers (Endowment Corpus)--84.031C, Closing the Completion Gap for HIS Community-College Graduate (Endowment Corpus)--84.031C, Picking Up the Pace: Ensuring Hispanic Degree Completion (Endowment Corpus)--84.031S, Proyecto Stem: Evidence-Based Approaches to STEM Enrollment (Endowment Corpus)--84.031C Agency: U.S. Department of Education Name of Passed-Through Entity: New Jersey City University (the “University”) Criteria: Per federal regulation CFR 624.41 paragraph (a) (1), an institution that the Secretary selects to receive an endowment challenge grant shall enter into an agreement with the Secretary to administer the endowment challenge grant. Condition: New Jersey City University Foundation, Inc. and Affiliate, (the “Organization”), was unable to present a formalized subrecipient agreement entered into at the inception of the endowment between the University and the Organization. Cause: Programs were initiated between the years 2013 through 2018 and were audited as part of the University’s audits in accordance with Uniform Guidance. The Organization’s staff have been unable to locate the subrecipient agreement which were entered into several years ago. Effect: Noncompliance with federal regulation over grant compliance requirements. Questioned Costs: None. Repeat Finding: Yes, see finding 2023-001. Recommendation: The Organization should maintain all records for Endowment Challenge Grants in accordance with federal regulation over grant compliance requirements. Views of Responsible Official: Although the Organization had provided a memorandum of understanding to the auditors which provided details of the endowment challenge grants, the Organization will coordinate with the University to establish a formal subrecipient agreement that is approved by each of their respective boards.
NONCOMPLIANCE WITH PROCUREMENT AND SUSPENSION AND DEBARMENT REQUIREMENTS, CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS, ASSISTANCE LISTING No. 21.027, Direct Allocation, YEAR ENDED JUNE 30, 2024 Name of contact person: City Manager Corrective Action: Employee training has been completed w...
NONCOMPLIANCE WITH PROCUREMENT AND SUSPENSION AND DEBARMENT REQUIREMENTS, CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS, ASSISTANCE LISTING No. 21.027, Direct Allocation, YEAR ENDED JUNE 30, 2024 Name of contact person: City Manager Corrective Action: Employee training has been completed with all department heads to ensure future compliance with federal debarment requirements. We will do annual staff training on this and will work with our engineers to make sure they too are complying with the requirements. Proposed Completion Date: Ongoing
Corrective Action Plan: The University has developed a project plan to identify all assets that require inventory to meet Uniform Guidance requirements. Tasks, milestones, and deliverables will drive completion of the project, with the imperative to meet federal regulations and alignment with ope...
Corrective Action Plan: The University has developed a project plan to identify all assets that require inventory to meet Uniform Guidance requirements. Tasks, milestones, and deliverables will drive completion of the project, with the imperative to meet federal regulations and alignment with operational procedures taking priority. Contemporaneous reporting will be enhanced to include aged inventory dates and allow for setting of inventory tasks across a continuum. Meeting Uniform Guidance requirements will take precedence when completing inventory of all federally sponsored equipment, and if in conflict with internal operations and/or processes. UT Southwestern Medical Center’s Asset Management procedure manual(s) will be revised to include the new process, controls, and reports established to consistently and repeatedly meet Uniform Guidance requirements. Further, UT Southwestern’s Sponsored Program Administration and Internal Audit teams will coordinate to perform ad hoc internal reviews to assure the respective project plan has been completed and new process continues to meet the requirements of Uniform Guidance respective asset management inventory requirements. Implementation of this plan will commence February 1, 2025, with asset inventory being fully compliant with Uniform Guidance prior to July 31, 2025. Internal reviews will continue for a minimum period of two fiscal years, through FY27. Implementation Date: February 1, 2025 Responsible Person: Megan G. Marks, PhD, Associate Vice President, Sponsored Programs Administration Sharonda Lawson, Director, Sourcing and Contract Management Timothy Martin, Director, Purchasing
Corrective Action Plan: UTMB will conduct a review of asset property records to ensure the serial numbers and locations are correct. UTMB Finance will coordinate with UTMB Supply Chain to evaluate and strengthen controls related to assets in Surplus warehouse. Implementation Date: November 1, 20...
Corrective Action Plan: UTMB will conduct a review of asset property records to ensure the serial numbers and locations are correct. UTMB Finance will coordinate with UTMB Supply Chain to evaluate and strengthen controls related to assets in Surplus warehouse. Implementation Date: November 1, 2025 Responsible Person: Mike Linton, Sr. Finance Manager
Corrective Action Plan: The Red Hat Enterprise Linux (RHEL) Extended Life Cycle Support license for UTMB’s 51 PeopleSoft RHEL7 servers was received on Friday 10/4/2024 for service dates through 6/30/2025. Furthermore, these servers will be updated to RHEL9 in the first half of 2025. Implementati...
Corrective Action Plan: The Red Hat Enterprise Linux (RHEL) Extended Life Cycle Support license for UTMB’s 51 PeopleSoft RHEL7 servers was received on Friday 10/4/2024 for service dates through 6/30/2025. Furthermore, these servers will be updated to RHEL9 in the first half of 2025. Implementation Date: October 4, 2024 Responsible Person: Darwin VanDyke, IT Services – Director of Administrative & Research Information Systems
Corrective Action Plan: UT Health-San Antonio’s Property Control group will continue to stress the importance of updating equipment locations in a timely manner. The University’s Property Control practices will be enhanced to emphasized compliance with our property policies. The Property Control ...
Corrective Action Plan: UT Health-San Antonio’s Property Control group will continue to stress the importance of updating equipment locations in a timely manner. The University’s Property Control practices will be enhanced to emphasized compliance with our property policies. The Property Control Office will continue to perform more rigorous spot audit reviews subsequent to the annual inventory process for respective departments with federally funded assets. Implementation Date: February 2025 Responsible Person: Yvette Martinez, Senior Director of Financial Affairs
Corrective Action Plan: The University has taken steps to identify and correct the deficiencies in Inventory’s processes and external knowledge base. Inventory Services has reviewed their website and made the necessary updates to their inventory trainings and guides. In the near future, Inventory...
Corrective Action Plan: The University has taken steps to identify and correct the deficiencies in Inventory’s processes and external knowledge base. Inventory Services has reviewed their website and made the necessary updates to their inventory trainings and guides. In the near future, Inventory Services will create a web-based training module that will be required for departmental inventory contacts. Inventory will still offer individual training sessions to departmental inventory contacts. Implementation Date: August 2025 Responsible Person: Christopher Ochoa, Inventory Manager
Corrective Action Plan: TEES Property Management will continue working with departments to increase their awareness regarding the updating of location information in a timely manner. Departments will also be reminded regularly to notify property management of missing and/or stolen property when d...
Corrective Action Plan: TEES Property Management will continue working with departments to increase their awareness regarding the updating of location information in a timely manner. Departments will also be reminded regularly to notify property management of missing and/or stolen property when discovered and to submit the appropriate forms. Property Management will increase communication to departments regarding the replacement of asset tags that have been damaged and/or are missing. A listserv has been established by TEES to effectively and efficiently communicate this information to the departments. Implementation Date: February 2025 Responsible Person: Jennifer Caddel, Inventory & Property Control Coordinator
Corrective action plan: The Purchasing and Historically Underutilized Business Services (PHS) unit within PCS will provide additional mandatory training to staff responsible for vendor compliance checks. PHS will also revise the current Vendor Compliance Checks Procedure to include the evidence re...
Corrective action plan: The Purchasing and Historically Underutilized Business Services (PHS) unit within PCS will provide additional mandatory training to staff responsible for vendor compliance checks. PHS will also revise the current Vendor Compliance Checks Procedure to include the evidence required to document compliance, including the run date. Furthermore, PHS management will establish a process for reviewing and approving the Form 1400 Procurement Checklist, regardless of the monetary value, to guarantee that vendor compliance checks are executed accurately and timely and in advance of covered transactions. Implementation dates: March 31, 2025 Responsible persons: Sonya Bebley, Director of Purchasing and Historically Underutilized Business Services, Procurement and Contract Services Department
Corrective action plan: IT has updated Standard Operating Procedure 742-Promoting Code to Production, to clarify IT policy on separation of duties for staff who develop code and those that promote code. Implementation dates: February 10, 2025 Responsible persons: Thomas Beckley, Scheduled Releases...
Corrective action plan: IT has updated Standard Operating Procedure 742-Promoting Code to Production, to clarify IT policy on separation of duties for staff who develop code and those that promote code. Implementation dates: February 10, 2025 Responsible persons: Thomas Beckley, Scheduled Releases Director and Richard Yashewski, Maintenance & Operations Director
Corrective action plan: N/A Implementation dates: N/A Responsible persons: Tim Urbanovsky, Director of Accounting & Financial Reporting Services
Corrective action plan: N/A Implementation dates: N/A Responsible persons: Tim Urbanovsky, Director of Accounting & Financial Reporting Services
Corrective action plan: TVC’s will ensure that all VES’s approved grant documents are retained not only in TVC’s Finance Department but also in the TVC’s VES program in the event of management turnover. Implementation dates: February 2025 Responsible persons: Michelle Nall, Chief Financial Office...
Corrective action plan: TVC’s will ensure that all VES’s approved grant documents are retained not only in TVC’s Finance Department but also in the TVC’s VES program in the event of management turnover. Implementation dates: February 2025 Responsible persons: Michelle Nall, Chief Financial Officer, and Anna Baker, Director of Veteran Employment Services
Corrective action plan: TVC’s Finance Department hired a dedicated Budget Analyst to the VES program in October 2024. Both the Chief Financial Officer and the Deputy Chief Financial Officer will review and approve all Forecast and Payroll reports related to the VES grant program to ensure there is...
Corrective action plan: TVC’s Finance Department hired a dedicated Budget Analyst to the VES program in October 2024. Both the Chief Financial Officer and the Deputy Chief Financial Officer will review and approve all Forecast and Payroll reports related to the VES grant program to ensure there is proper documentation and approvals as well as to be familiar with procedures in the event of employee and/or management turnover. During the review process, the Chief Financial Officer or the Deputy Financial Officer will also validate that VES’s indirect revenues are being accurately calculated against VES’s payroll costs (salaries and benefits only) and well documented each month. There will also be an annual review conducted for additional verification. Implementation dates: November 2024 Responsible persons: Michelle Nall, Chief Financial Officer, Lawrence Cruz, Deputy Financial Officer, and Julie Pusan ,VES Budget Analyst
View Audit 348386 Questioned Costs: $1
Corrective action plan: The VES Budget Analyst will continue to review the monthly Forecast and Payroll reports with the VES’s Director or Operations Manager. Upon review, the Director or Operations Manager will sign-off on both the monthly Forecast and the monthly Payroll Report which identifies ...
Corrective action plan: The VES Budget Analyst will continue to review the monthly Forecast and Payroll reports with the VES’s Director or Operations Manager. Upon review, the Director or Operations Manager will sign-off on both the monthly Forecast and the monthly Payroll Report which identifies each employee’s payroll costs and operation costs approved to be charged to the grant. VES’s Director or Operations Manger will also sign-off on the VES Annual State Plan which identifies employees and operating costs approved to be charged to the grant for the grant period, prior to submitting to the U.S. Department of Labor. Implementation dates: January 2025 Responsible persons: Anna Baker, Director of Veteran Employment Services and Julie Pusan, VES Budget Analyst,
Corrective action plan: TxDOT AVN will implement procedures to ensure FFATA reports are reviewed and approved by a separate individual and submitted in a timely manner. Implementation dates: The procedure has been partially implemented, including the addition of the screen shots. A full implementa...
Corrective action plan: TxDOT AVN will implement procedures to ensure FFATA reports are reviewed and approved by a separate individual and submitted in a timely manner. Implementation dates: The procedure has been partially implemented, including the addition of the screen shots. A full implementation will be completed by March 1, 2025. Responsible persons: Michelle Burcham, AVN Grant & Admin Section Director, Allison Martin, Grant Manager Lead, Cassandra Moore, Grant Manager
Corrective action plan: TxDOT Aviation has modified the procedures for the SF-425 report preparation to require the subrecipient share of the expenditures to be properly reported when the match is from a local source. A Checklist will be created to include this amount when the document is reviewed...
Corrective action plan: TxDOT Aviation has modified the procedures for the SF-425 report preparation to require the subrecipient share of the expenditures to be properly reported when the match is from a local source. A Checklist will be created to include this amount when the document is reviewed by the Grant & Admin Section Director. TxDOT AVN will explore the consideration of including the local share in its accounting system which would allow identification of the local amount. Implementation dates: February 15, 2025 Responsible persons: Michelle Burcham, AVN Grant & Admin Section Director, Allison Martin, Grant Manager Lead
Corrective action plan: The current application lacks a notification feature for discrepancies between the requested and approved payment amounts. A software enhancement is expected to be implemented by April 30th, 2025, that will display a warning message if the requested and approved amounts do ...
Corrective action plan: The current application lacks a notification feature for discrepancies between the requested and approved payment amounts. A software enhancement is expected to be implemented by April 30th, 2025, that will display a warning message if the requested and approved amounts do not match, prompting an additional review. During the developer review, the Grant Manager Lead will maintain a spreadsheet highlighting mismatched data, stored in the AVN Grant drive for reference. TxDOT AVN Grant Managers will be trained on this process, with updated instructions. Once the software is updated, further training and procedure updates will follow. Implementation dates: June 1, 2025 Responsible persons: Michelle Burcham, Grants & Admin Section Director, Allison Martin, Grant Manager Lead, Cassandra Moore, Grant Managers
Corrective action plan: CMS is in the process of training the Manager of Physical Inspection to review and assign properties for timely inspections to ensure multiple staff members have oversight of the process. In addition, CMS is utilizing a new process using Excel to ensure all HOME-rental prop...
Corrective action plan: CMS is in the process of training the Manager of Physical Inspection to review and assign properties for timely inspections to ensure multiple staff members have oversight of the process. In addition, CMS is utilizing a new process using Excel to ensure all HOME-rental properties are inspected within required federal timeframes and this process is completed by two staff members independently. Implementation dates: On February 6, 2025, the new process of reconciling travel using Excel tools by independent staff was implemented to ensure no HOME-rental properties are inspected late. Responsible persons: Wendy Quackenbush, Director of Multifamily Compliance, Manual Pena, Manager of Physical Inspections and Carolyn Metzger, Team Leader.
Corrective action plan: During discussions with HOME staff, it was determined that the IDIS system, used by the Single-Family Program division for HUD reporting, generates contract activity reports that should alleviate the discrepancy noted during this review. CMSM has requested read-only access ...
Corrective action plan: During discussions with HOME staff, it was determined that the IDIS system, used by the Single-Family Program division for HUD reporting, generates contract activity reports that should alleviate the discrepancy noted during this review. CMSM has requested read-only access to IDIS in order to generate a risk population. Implementation dates: The Department is pending review and approval of IDIS access for appropriate staff. Upon receiving IDIS access CMSM staff will coordinate with HOME staff for training. CMSM anticipates using IDIS in either the third or fourth quarter of the Department’s current fiscal year depending on HUD’s response. Responsible persons: Earnest Hunt, Director of Compliance Subrecipient Monitoring, Robert Moore, Manager of Compliance Subrecipient Monitoring and Ben Rose, Monitor.
Corrective action plan: Based on the recommendation above, HHSC Medicaid & CHIP Services (MCS) Financial Reporting and Audit Coordination (FRAC) has incorporated the suggested enhanced controls around the review of MLR report submissions to ensure they are complete and accurate. In order to enhan...
Corrective action plan: Based on the recommendation above, HHSC Medicaid & CHIP Services (MCS) Financial Reporting and Audit Coordination (FRAC) has incorporated the suggested enhanced controls around the review of MLR report submissions to ensure they are complete and accurate. In order to enhance existing controls, MCS FRAC has included a section for MLR reviewers to ensure Methodology(ies) for allocation of expenditures tab questions are complete. Likewise, specific instructions have been added to the review document to ensure the recommendations are met. These enhanced controls will be included in Fiscal Year (FY) 2025 and ongoing review of MLR report submissions. Implementation dates: November 2025 Responsible persons: Jason Mendl, Deputy Associate Commissioner, FRAC
Corrective action plan: HHSC's OIG has taken action to ensure timely reviews of the Centers for Medicare/Medicaid Services (CMS) Data Exchange Portal (DEX) reports. HHSC's OIG has multiple employees that have access to the systems necessary to retrieve the reports and has trained those employees o...
Corrective action plan: HHSC's OIG has taken action to ensure timely reviews of the Centers for Medicare/Medicaid Services (CMS) Data Exchange Portal (DEX) reports. HHSC's OIG has multiple employees that have access to the systems necessary to retrieve the reports and has trained those employees on the review process. Implementation dates: July 10, 2024 (Implemented) Responsible persons: Robin Bernard, Director, Financial Analysis and Case Management
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