Corrective Action Plans

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Finding 547981 (2024-003)
Significant Deficiency 2024
Management response: • Nuestra Escuela’s Program Director will adopt automated data collection software to ensure the timely availability of participants information, thereby preventing delays in report submission. • Nuestra Escuela will enhance its internal controls to ensure adherence to all req...
Management response: • Nuestra Escuela’s Program Director will adopt automated data collection software to ensure the timely availability of participants information, thereby preventing delays in report submission. • Nuestra Escuela will enhance its internal controls to ensure adherence to all required reporting deadlines, promoting timely and accurate submissions under the TANF program strengthen internal controls to ensure the compliance with the reporting. • Nuestra Escuela will conduct regular audits to verify data accuracy, maintaining open and consistent communication with all relevant parties to address potential reporting bottlenecks. • Nuestra Escuela Management staff will receive specialized training on participant qualification and proper requirements and efficient time management practices to improve reporting compliance. • The Executive President will develop and implement a contingency plan to address unforeseen circumstances that could otherwise hinder timely submission of reports. Corrective action plan: Action Date of Compliance Involved areas Adopt automated data collection software Jun 25 - 2025 Executive President Program Director Schedule of internal monitoring for compliance with Special Conditions Monthly Program Director Specialized training on participant qualification and proper requirements May 22 - 2025 External Consultant Program Director Directors in charge of Programs Develop a contingency plan to address unforeseen circumstances Apr 10 - 2025 Executive President External Consultant Actions to complete monthly: ● Internal monitoring by the Program Director with the automated data collection software. ● Meeting between the Program Director and the Directors of each of the Programs to validate the correct status of the reports. Actions to complete quarterly: ● Meeting between the Program Director and the Executive President for a physical review of the files. Contact Person: Ana Yris Guzmán – Executive President|
Finding 547968 (2024-002)
Significant Deficiency 2024
Management response: • Nuestra Escuela will design and implement internal controls specifically addressing the accounting of conditional advances. These controls will include developing a clear rubric to assess whether grants and contracts meet the criteria for conditional contributions under ASU 2...
Management response: • Nuestra Escuela will design and implement internal controls specifically addressing the accounting of conditional advances. These controls will include developing a clear rubric to assess whether grants and contracts meet the criteria for conditional contributions under ASU 2018-08. • The accounting staff will undergo specialized training on the proper recognition of conditional advances. Regular reviews will be conducted to ensure ongoing compliance with ASU 2018-08 and to maintain accurate financial reporting. • Recognizing the need to meet both agency (cash basis) and GAAP (accrual basis), Nuestra Escuela will prepare management reports on both bases. This approach will facilitate accurate grant reporting while ensuring compliance with generally accepted accounting principles. Corrective action plan: Action Date of Compliance Involved areas Developing a clear rubric to assess whether grants and contracts meet the criteria for conditional contributions under ASU 2018-08. Apr 21 - 2025 External Consultant Executive President Administrative Director Directors in charge of Programs Create a “Model reports” on both bases, to use monthly. Monthly Executive President Administrative Director Specialized training on the proper recognition of conditional advances. Jun 10 - 2025 External Consultant Executive President Administrative Director Directors in charge of Programs Actions to complete monthly: • To prepare management reports on both bases Actions to complete quarterly: • Use the rubric to assess whether grants and contracts meet the criteria for conditional contributions under ASU 2018-08. Contact Person: Ana Yris Guzmán – Executive President
Finding 547967 (2024-001)
Significant Deficiency 2024
Management response: • Nuestra Escuela will strengthen its processes to ensure that all grants and accrued expenses are recorded promptly and that services rendered are accounted for in the correct period accurately. • The Administrative Director will perform regular reconciliations of accounts to...
Management response: • Nuestra Escuela will strengthen its processes to ensure that all grants and accrued expenses are recorded promptly and that services rendered are accounted for in the correct period accurately. • The Administrative Director will perform regular reconciliations of accounts to detect, identify, and correct, any discrepancies that may indicate cut-off errors. • The administrative staff and accounting team will receive additional training on the best practices and proper cut-off procedures, emphasizing the importance of timely and accurate recognition of liabilities and receivables and the impact of errors on financial reporting. • Nuestra Escuela will reinforce its internal audit processes to periodically review compliance with cut-off procedures. This practice will involve analyzing the impact of contractual clauses on the period of receipt and use of funds. • Nuestra Escuela will Create documentation of its cut-off policies and procedures to ensure consistent application and understanding among all relevant staff and ensure that they are strictly enforced. • Nuestra Escuela is committed to preventing cut-off errors through a proactive approach from accountants. This involves a combination of robust procedures, leveraging technology, and fostering a culture of accuracy and compliance within the accounting department. By following these best practices, accountants can help ensure the integrity of the financial reporting process. Corrective action plan: Action Date of Compliance Involved areas Reconciliations of each account to identify any discrepancies that may indicate cut-off errors. Monthly Executive President Administrative Director Analyze the impact of contractual clauses on the period of receipt and use of funds. Apr 15 – 2025 Jul 15 -2025 Oct 15 – 2025 Ene 15 - 2026 Executive President Administrative Director Training on the best practices and proper cut-off procedures May 8 - 2025 External Consultant Executive President Administrative Director Directors in charge of Programs Complete file with cut-off policies and procedures Jun 20 - 2025 Administrative Director Directors in charge of Programs   Actions to complete monthly: • Reconciliations of each account to identify any discrepancies that may indicate cut-off errors. Actions to complete quarterly: • Analyze the impact of contractual clauses on the period of receipt and use of funds. • Training on the best practices and proper cut-off procedures • Complete file with cut-off policies and procedures Contact Person: Ana Yris Guzmán – Executive President
Condition: During audit procedures, we noted expenditures were charged to the program via adjusting journal entry for which adequate supporting documentation could not be provided. Corrective Actions: Going forward, the Organization will implement procedures requiring supporting documentation for a...
Condition: During audit procedures, we noted expenditures were charged to the program via adjusting journal entry for which adequate supporting documentation could not be provided. Corrective Actions: Going forward, the Organization will implement procedures requiring supporting documentation for all journal entries made to the program to ensure that amount charged to the program are actual expenses/expenditure of the program. Employee Responsible for Corrective Action: Michelle Clarke Completion Date: March 31, 2025
View Audit 351890 Questioned Costs: $1
Condition: During the audit several adjusting journal entries were proposed. These entries would have a material effect on the financial statements if not proposed and recorded. Corrective Actions: Going forward, the Organization will implement procedures to perform a more comprehensive monthly clo...
Condition: During the audit several adjusting journal entries were proposed. These entries would have a material effect on the financial statements if not proposed and recorded. Corrective Actions: Going forward, the Organization will implement procedures to perform a more comprehensive monthly closing, especially at year end, to ensure that all general ledger accounts are reviewed and reconciled to arrive at a complete and accurate set of books and records to be audited. Employee Responsible for Corrective Action: Michelle Clarke Completion Date: March 31, 2025
Condition: During audit procedures, it was noted total reimbursements received exceeded expenditures. The Organization has charged costs to the program and received reimbursement; however, the products cost charged to the program had not been received prior to June 30, 2024. Corrective Actions: Goi...
Condition: During audit procedures, it was noted total reimbursements received exceeded expenditures. The Organization has charged costs to the program and received reimbursement; however, the products cost charged to the program had not been received prior to June 30, 2024. Corrective Actions: Going forward, the Organization will review all vouchers being charged to the program to make sure costs have been incurred before being charged to the program. Employee Responsible for Corrective Action: Michelle Clarke Completion Date: March 31, 2025
View Audit 351890 Questioned Costs: $1
Reference Number: 2024-001 Name of Contact Person: Kelly Nakamura Phone: 530-642-7167 Email: Kelly.nakamura@edcgov.us Corrective Action: • Increasing Staffing Levels: o By April 1, 2025, the County will have 11 newly trained Eligibility Specialists who are fully trained to proces...
Reference Number: 2024-001 Name of Contact Person: Kelly Nakamura Phone: 530-642-7167 Email: Kelly.nakamura@edcgov.us Corrective Action: • Increasing Staffing Levels: o By April 1, 2025, the County will have 11 newly trained Eligibility Specialists who are fully trained to process Medi-Cal applications. o Ongoing recruitment efforts will continue to fill vacant positions, including the hiring additional trainees to build capacity for timely eligibility determinations. • Improving Internal Processes: o The County is conducting a review of workflows to identify inefficiencies and implement streamlined processes that eliminate bottlenecks. o Digital tools and automation are being introduced to enhance efficiency and accuracy case processing. • Providing Additional Support: o Overtime opportunities are being offered to eligibility specialists to expedite the processing of pending cases. o Applications are being assigned to Eligibility Specialists on a weekly basis to ensure consistent progress in reducing the backlog. • Enhancing Monitoring and Reporting: o Administrative staff are generating weekly reports from CalSAWS to track the status Medi-Cal pending applications and monitor progress. o Weekly meetings are being held with supervisors to review performance, discuss challenges, and adjust strategies as needed. • Strengthening Internal Controls: o The County is improving its internal controls to prevent future delays, including increased use of system reports to identify applications nearing the 45-day processing requirement, regular audits of the eligibility determination process and enhanced compliance training for staff. • Ongoing Evaluation and Adaptation: o Progress will be assessed weekly to ensure the implemented measures are effective. Adjustments will be made as needed to maintain compliance with the 45-day requirement. Proposed Completion Date: The county has already implemented this process and expects it to be completed by July 31, 2026.
Reporting - FSRS Block Grants for Prevention & Treatment of Substance Abuse - FSRS were not timely submitted resulting in noncompliance with the reporting requirement. Corrective Action Plan: ADAD will meet with the program staff to complete the implementation of the policies and procedures relating...
Reporting - FSRS Block Grants for Prevention & Treatment of Substance Abuse - FSRS were not timely submitted resulting in noncompliance with the reporting requirement. Corrective Action Plan: ADAD will meet with the program staff to complete the implementation of the policies and procedures relating to the reporting of subawards to the new FSRS system to comply with the Federal reporting requirements. Implementation Date: July 1, 2025 Responding Official: John Valera and Melanie Muraoka, Administrative Officer/Alcohol and Drug Abuse Division
Subrecipient Monitoring Non-compliance with its inconsistent documented monitoring procedures. Corrective Action Plan: AMHD will review and revise their monitoring procedures to ensure that subrecipient expenditures are monitored and single audit reports are reviewed, as applicable. Implementation D...
Subrecipient Monitoring Non-compliance with its inconsistent documented monitoring procedures. Corrective Action Plan: AMHD will review and revise their monitoring procedures to ensure that subrecipient expenditures are monitored and single audit reports are reviewed, as applicable. Implementation Date: July 1, 2025 Responding Official: Chanel Daluddung, Performance, Information, Evaluation and Research Branch Chief, Adult Mental Health Division
Earmarking Earmarking requirement was not met. Corrective Action Plan: State Procurement rules occasionally make it difficult to spend the earmark by the deadline. In the future, the committee that governs these earmarks will be more proactive about monitoring planned procurements to ensure they are...
Earmarking Earmarking requirement was not met. Corrective Action Plan: State Procurement rules occasionally make it difficult to spend the earmark by the deadline. In the future, the committee that governs these earmarks will be more proactive about monitoring planned procurements to ensure they are moving through the process so funds can be spent. In addition, vacancies contributed to falling short of the earmarking requirement, since those personnel funds were not spent. Vacancies will be monitored quarterly for re-allocation opportunities, and workforce development strategies will be developed and implemented to address shortages. Implementation Date: July 1, 2025 Responding Official: Keli, Acquaro, Administrator, Child & Adolescent Mental Health Division
Reporting - FSRS Opioid STR - FSRS were not timely submitted resulting in noncompliance with the reporting requirement. Corrective Action Plan: ADAD will meet with the program staff to complete the implementation of the policies and procedures relating to the reporting of subawards to the new FSRS s...
Reporting - FSRS Opioid STR - FSRS were not timely submitted resulting in noncompliance with the reporting requirement. Corrective Action Plan: ADAD will meet with the program staff to complete the implementation of the policies and procedures relating to the reporting of subawards to the new FSRS system to comply with the Federal reporting requirements. Implementation Date: July 1, 2025 Responding Official: John Valera and Melanie Muraoka, Administrative Officer/Alcohol and Drug Abuse Division
Reporting - FSRS Substance Abuse and Mental Health Services - FSRS were not timely submitted resulting in noncompliance with the reporting requirement. Corrective Action Plan: Complete the implementation of the policies and procedures relating to the reporting of subawards to the new FSRS system to ...
Reporting - FSRS Substance Abuse and Mental Health Services - FSRS were not timely submitted resulting in noncompliance with the reporting requirement. Corrective Action Plan: Complete the implementation of the policies and procedures relating to the reporting of subawards to the new FSRS system to comply with the Federal reporting requirements. Implementation Date: April 1, 2025 Responding Official: John Valera and Melanie Muraoka, Administrative Officer/Alcohol and Drug Abuse Division
Reporting - Cash Management During the testing of the Department's cash management procedures, it was determined that eight out of sixty payments tested were not distributed within 21 days of the draw down of funds. For the items tested, the time elapsed between draw down and payment ranged from 22 ...
Reporting - Cash Management During the testing of the Department's cash management procedures, it was determined that eight out of sixty payments tested were not distributed within 21 days of the draw down of funds. For the items tested, the time elapsed between draw down and payment ranged from 22 to 44 days. Corrective Action Plan:WIC has developed a Quality Control Plan, procedures and a workflow to ensure invoices are timely released to ASO-Fiscal for processing. Implementation Date: April 1, 2025 Responding Official: Melanie Murakami, WIC Branch Chief
2024-003- Medical Assistance (Medicaid School Based Services) Criteria: For an agency to bill Wisconsin Medicaid for School Based Services (SBS), an IEP, and Consent to Bill Wisconsin Medicaid for Medically Related Special Education and Related Services (DPI Form M-5) must be current, signed, and d...
2024-003- Medical Assistance (Medicaid School Based Services) Criteria: For an agency to bill Wisconsin Medicaid for School Based Services (SBS), an IEP, and Consent to Bill Wisconsin Medicaid for Medically Related Special Education and Related Services (DPI Form M-5) must be current, signed, and dated by the parent or guardian of a student with an IEP before claims can be submitted. The School District must obtain parental consent before the District accesses Wisconsin Medicaid for the first time. Condition: There were two students tested that did not have signed consent to bill forms on file. The District received reimbursements for services provided to these two students from Medicaid SBS. Without the signed consent to bill forms, theses services are not eligible for reimbursement. Cause: The District had a transition in staffing and the process step to verify signed consent to bill forms was missed. Effect: A reimbursement request was made for services that were not eligible to be reimbursed and did not comply with Medicaid SBS requirements. Auditor's Recommendation: Establish controls to verify all student services billed to Medicaid SBS have a signed consent to bill on file. Grantee Response: The District will review Medicaid SBS consent to bill forms and verify signed copies are on file going forward. Contact Person: Jon Bosworth Anticipated Completion: On-going
Finding 547943 (2024-003)
Significant Deficiency 2024
City staff will reconcile the employee’s time records to ensure accurate reporting.
City staff will reconcile the employee’s time records to ensure accurate reporting.
View Audit 351875 Questioned Costs: $1
Management will work with Athena to correct the workflow to ensure slide fees are adjusted at the correct updated Federal Poverty Level at the beginning of the new year. Organization contact persons responsible for corrective action: Michele Sarrett Anticipated completion date: 12/31/2025
Management will work with Athena to correct the workflow to ensure slide fees are adjusted at the correct updated Federal Poverty Level at the beginning of the new year. Organization contact persons responsible for corrective action: Michele Sarrett Anticipated completion date: 12/31/2025
Management agrees with the auditors' recommendations. The UDS formulas were updated and the issues corrected for the 2024 UDS report. In the upcoming year it is expected that new accounting leadership and Grant Management will work together to ensure the accuracy of the UDS Report. Organization con...
Management agrees with the auditors' recommendations. The UDS formulas were updated and the issues corrected for the 2024 UDS report. In the upcoming year it is expected that new accounting leadership and Grant Management will work together to ensure the accuracy of the UDS Report. Organization contact persons responsible for corrective action: Michele Sarrett Anticipated completion date: 12/31/2025
Finding 2024-003: Allowable Costs – Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance Management agrees with the finding and the auditor’s recommendation. Contact Person responsible for corrective action: Elizabeth Comfort Finance Director ecomfort@clackamas.us...
Finding 2024-003: Allowable Costs – Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance Management agrees with the finding and the auditor’s recommendation. Contact Person responsible for corrective action: Elizabeth Comfort Finance Director ecomfort@clackamas.us 503-936-5345 Corrective Action Planned: Procedures will be incorporated into the County workflow to provide additional monitoring, and oversight. These will include: • Departments will ensure that all expenses are reviewed to confirm alignment with the specific terms and conditions of the grant before reallocating any charges. • Redistribution of Award expenses will be reviewed and approved by Division Director and/or Finance Grant Manager • Federal Awards quarterly reporting will be reviewed and approved by Finance Grant Manager prior to submission • Journal Entries will be for correcting entries and not move funded expenditures to other funding revenues • All Journal Entries will have complete supporting documentation reviewed and signed by Director level staff at the Division or by Finance Grant Management Anticipated Completion Date: Implementation of controls by March 24, 2025.
Finding 2024-002: Procurement, Suspension and Debarment – Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance Management agrees with the finding and the auditor’s recommendation. Contact Person responsible for corrective action: Elizabeth Comfort Finance Director...
Finding 2024-002: Procurement, Suspension and Debarment – Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance Management agrees with the finding and the auditor’s recommendation. Contact Person responsible for corrective action: Elizabeth Comfort Finance Director ecomfort@clackamas.us 503-936-5345 Corrective Action Planned: Procedures will be incorporated into the County workflow to provide additional monitoring, oversight, and record retention related to reporting. These will include: • Timely verification from SAM.gov to verify non-suspension or disbarment status • Procurement to download the timestamped report from SAM.gov • Retain documentation of verification from SAM.gov • Procurement to include appropriate language on all Federal funded awards Anticipated Completion Date: Implemented as a control by the Finance Procurement Division each award March 19, 2025.
Finding 2024-001: Reporting – Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance Management agrees with the finding and the auditor’s recommendation. Contact Person responsible for corrective action: Elizabeth Comfort Finance Director ecomfort@clackamas.us 503-9...
Finding 2024-001: Reporting – Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance Management agrees with the finding and the auditor’s recommendation. Contact Person responsible for corrective action: Elizabeth Comfort Finance Director ecomfort@clackamas.us 503-936-5345 Corrective Action Planned: Procedures will be incorporated into the County workflow to provide additional monitoring, oversight, and record retention related to reporting of subawards greater or equal to $30,000. These will include: • Timely monitoring for the status of FFATA subaward reporting • Receive the FFATA subaward report to SAM.gov confirmation from Sub Recipient contractor • Retain documentation of submission to SAM.gov • Include quarterly cash-on-hand reports to award checklist to be completed in the Finance office • Compile listing of current open subrecipient agreements for adherence to FFATA contractor award reporting to ensure compliance Anticipated Completion Date: Implemented as a control to the Finance Grant checklist for each award March 20, 2025.
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
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