Corrective Action Plans

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Name of auditee: The Pavilion Housing Development Fund Corporation HUD auditee identification number: 012-EE247 Name of audit firm: WithumSmith+Brown, PC Period covered by the audit: Year Ended September 30, 2024 CAP prepared by: Name: Father Ronald Giannone Position: Executive Director Telephone: 6...
Name of auditee: The Pavilion Housing Development Fund Corporation HUD auditee identification number: 012-EE247 Name of audit firm: WithumSmith+Brown, PC Period covered by the audit: Year Ended September 30, 2024 CAP prepared by: Name: Father Ronald Giannone Position: Executive Director Telephone: 646-996-4234 1. Current Findings on the Schedule of Findings, and Questioned Costs a. Finding 2024-001. Delinquent deposits into the replacement reserve account. i. Comments on the Finding and Each Recommendation: Management concurs with the finding and the auditor’s recommendation to transfer the funds to the replacement reserve account. ii. Actions Taken on the Finding: Management will transfer the funds as soon as cash flow permits. b. Finding 2024-002. Special Tests and Provisions – Project Funds. i. Comments on the Finding and Each Recommendation: Management concurs with the finding and the auditor’s recommendation to utilize an interest-bearing account for project funds. ii. Actions Taken on the Finding: Management is in the process of evaluating the recommendation to determine that appropriate course of action. 2. Status of Corrective Actions on Findings Reported in the Prior Audit Schedule of Findings, and Questioned Costs. Finding 2023-001 for delinquent deposits in the aggregated amount of $54,061 were funded in 2024.
Finding Number: 2024-004 Condition: The College does not have a written cash management policy related to federal awards. Planned Corrective Action: In accordance with 2 CFR 200.302(b)(6), the College will establish a written cash management policy, including written procedures related to fed...
Finding Number: 2024-004 Condition: The College does not have a written cash management policy related to federal awards. Planned Corrective Action: In accordance with 2 CFR 200.302(b)(6), the College will establish a written cash management policy, including written procedures related to federal payments/awards in order to implement the requirements of 200.305. Contact person responsible for corrective action: David Cummins, Vice President for Administrative Services and College Treasurer Anticipated Completion Date: As soon as possible moving forward starting December 18, 2024.
Finding Number: 2024-003 Condition: There was a lack of internal controls in place related to the review of the FISAP that was submitted by the College in September 2023. Planned Corrective Action: The College will establish the proper controls to ensure that the information included in the FISAP...
Finding Number: 2024-003 Condition: There was a lack of internal controls in place related to the review of the FISAP that was submitted by the College in September 2023. Planned Corrective Action: The College will establish the proper controls to ensure that the information included in the FISAP is accurate, including implementing an additional level of review of the report. Contact person responsible for corrective action: David Cummins, Vice President for Administrative Services and College Treasurer Anticipated Completion Date: As soon as possible moving forward starting December 18, 2024.
Finding Number: 2024-002 Condition: There was a lack of internal controls in place related to the return of Title IV funds. Planned Corrective Action: The College will implement controls related to returns of Title IV funds, to ensure the related calculations are complete and accurate, and the fun...
Finding Number: 2024-002 Condition: There was a lack of internal controls in place related to the return of Title IV funds. Planned Corrective Action: The College will implement controls related to returns of Title IV funds, to ensure the related calculations are complete and accurate, and the funds are returned in a timely manner. Contact person responsible for corrective action: David Cummins, Vice President for Administrative Services and College Treasurer Anticipated Completion Date: As soon as possible moving forward starting December 18, 2024.
The District and campus staff will work together to develop processes to capture proper and relevant time and effort activities. This will ensure documentation can be provided regarding personnel expenses to identify employee costs charged to federal programs.
The District and campus staff will work together to develop processes to capture proper and relevant time and effort activities. This will ensure documentation can be provided regarding personnel expenses to identify employee costs charged to federal programs.
View Audit 338758 Questioned Costs: $1
Processes will be implemented to review, update and verify data captured by NSLDS and ensure such data has been accurately reported in a timely manner.
Processes will be implemented to review, update and verify data captured by NSLDS and ensure such data has been accurately reported in a timely manner.
Employment Contracts Corrective Action Plan (CAP): 1. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding: The Executive Director is working with staff to ensure that all necessary documentation is maintained appr...
Employment Contracts Corrective Action Plan (CAP): 1. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding: The Executive Director is working with staff to ensure that all necessary documentation is maintained appropriately. 3. Official Responsible for Ensuring CAP: Heather Ebnet, Executive Director, is the official responsible for ensuring corrective action. 4. Planned Completion Date for CAP: Continuous. 5. Plan to Monitor Completion of CAP: The Academy will continue to review its procedures to determine if any improvements can be made. Heather Ebnet Executive Director
We have implemented the following protocol to ensure the accuracy of the Form 801A State Attendance Reporting: The site supervisor prepares a Monthly Attendance Form from the daily Attendance Sign-in Sheets and submits it to the ECE Director of Programs, with a copy to the Enrollment Coordinator. ...
We have implemented the following protocol to ensure the accuracy of the Form 801A State Attendance Reporting: The site supervisor prepares a Monthly Attendance Form from the daily Attendance Sign-in Sheets and submits it to the ECE Director of Programs, with a copy to the Enrollment Coordinator. The Enrollment Coordinator reviews the accuracy of the report based on a re-comparison to source sign-in/sign-out sheets, as well as other source information, and submits the report, corrected as necessary, to the ECE Director of Programs. The ECE Director of Programs will review and approve to submit for reporting and invoicing. Once approved, the monthly forms are submitted to the finance department by the site supervisor. GFS’s finance team will complete one more review of the totals before submitting to the CDE and CDSS.
Recommendation – We recommend the Center provide proper training to employees to ensure that the sliding fee discounts are being properly applied and documented. In addition to implementing policies and procedures to ensure the sliding fee discounts are being properly monitored and supervised on a ...
Recommendation – We recommend the Center provide proper training to employees to ensure that the sliding fee discounts are being properly applied and documented. In addition to implementing policies and procedures to ensure the sliding fee discounts are being properly monitored and supervised on a periodic basis to ensure compliance. Action Taken – We concur with the audit finding. While the Center has a policy that meets the compliance requirements, management is responsible for the implementation and monitoring of those processes and procedures. Additional staff training on slide fee discounts is in place and monthly review and testing of compliance with Center sliding fee discount policy will be done.
Management concurs with this finding. Management has taken steps to review and revise its procurement policies to comply with state and local laws, the standards of the CFO, as well as current operating procedures. The fining relates to contracts that were originally procured prior to the change in ...
Management concurs with this finding. Management has taken steps to review and revise its procurement policies to comply with state and local laws, the standards of the CFO, as well as current operating procedures. The fining relates to contracts that were originally procured prior to the change in policies, with only renewals in the financial statement periods. Going forward, Management will document basis for procurement for renewals of contracts that originated prior to the new policies and procedures implementation.
The following corrective measures will be implemented to ensure compliance with Title 2, Code of Federal Regulations, Part 200.313(d)(2), as well as Board Policy 3270 Management of District Assets and Administrative Regulation 3440 Inventories: 1. Procedure: a. The District defines a Fixed Asset as ...
The following corrective measures will be implemented to ensure compliance with Title 2, Code of Federal Regulations, Part 200.313(d)(2), as well as Board Policy 3270 Management of District Assets and Administrative Regulation 3440 Inventories: 1. Procedure: a. The District defines a Fixed Asset as any tangible asset purchased for a school/department in the day-to-day operation of the District from which an economic benefit will be derived over a period greater than one year and has a value of $500 or more (Education Code 35168). The District capitalizes assets valued at $5,000 or above and tracks all assets over $500. b. Every every two years, the Business Services Department will provide an inventory count sheet to each school site and department. The count sheets will contain the equipment for each room. Sites shall designate staff to perform a physical count as follows: i. In performing a physical inventory, sites and departments will check every room, closet, locked cabinet, and open area, including items checked out to staff members. ii. When the site completes the physical inventory, the inventory report will be returned to the purchasing department with the signature of the site or department administrator and the names of the staff members who performed the inventory check. c. When the Purchasing Department receives the inventory listing from the site, the items will be checked for accuracy. If there are any discrepancies between the site's inventory and the master listing held in purchasing, the Purchasing Department will perform a physical inventory at the site to locate items. Once purchasing has completed its inventory check, the master list will be updated in the Fixed Assets Module. d. A form will be completed by sites and departments for assets that are transferred from one location to another, retired, etc., and submitted to the Purchasing Department for proper recording of the location change or retirement of an asset. 2. Warehouse Procedures: a. All electronic assets ($100 or greater), as well as all other items purchased with state and/or federal funds that have a useful life of more than one year with a value of $500 or greater (Education Code 35168) are to be asset tagged once received by the warehouse. b. Asset tag procedure: The Warehouse will tag and record all asset-tagged items into the Master Asset Tag form. The following information will be added to the completed form: i. Item type/description ii. Model/name iii. Serial number or other identification number iv. Title holder v. Funding source vi. Acquisition date vii. Cost viii. Percentage of federal participation in the cost of the property ix. Location x. Current condition (fair, good, poor) xi. Transfer, replacement or disposition of obsolete or unusable equipment c. Timelines: From the 1st to the 15th of February 2025, repeated every two years.
A comprehensive schedule for all sites for the entire year has been created. Responsible staff are assigned to visit the site on the dates outlined and then submit monitoring forms to the department secretary within 3 days. The Director of Nutrition Services will review all monitoring forms monthly ...
A comprehensive schedule for all sites for the entire year has been created. Responsible staff are assigned to visit the site on the dates outlined and then submit monitoring forms to the department secretary within 3 days. The Director of Nutrition Services will review all monitoring forms monthly with a review of corrective action plans within 45 days. In the event of staff absence or turnover, a backup staff member is assigned to conduct the site visit.
To ensure that federal funds are used appropriately and to correct the unallowable charges, the following will be implemented: 1. In collaboration with California Department of Education (CDE), qualifying expenditures will be transferred in the identified amount. The unqualified expenditure will be ...
To ensure that federal funds are used appropriately and to correct the unallowable charges, the following will be implemented: 1. In collaboration with California Department of Education (CDE), qualifying expenditures will be transferred in the identified amount. The unqualified expenditure will be transferred to another resource. 2. A formal Standardized Operative Procedure will be developed to ensure federal compliance, including expenditure reviews. 3. Staff will be trained on federal requirements and allowable costs. Costs will be reviewed with CDE and our auditing consultant to ensure compliance. 4. Expenditure will be approved by the Senior Fiscal Director and the Director of Equity and Access. 5. The Senior Fiscal Director will ensure accurate posting of Indirect Costs to programs.
View Audit 338734 Questioned Costs: $1
Management concurs with the finding. Beginning in fiscal 2025, management will open an interest bearing account insured by the Federal Deposit Insurance Corporation (“FDIC”) and transfer funds to the account to comply with HUD requirements. Our policies and procedures manual will be updated to mor...
Management concurs with the finding. Beginning in fiscal 2025, management will open an interest bearing account insured by the Federal Deposit Insurance Corporation (“FDIC”) and transfer funds to the account to comply with HUD requirements. Our policies and procedures manual will be updated to more clearly specify this HUD compliance requirement. We will continuously monitor HUD’s overall requirements, in order to maintain compliance on an ongoing basis.
Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperativ...
Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperative will continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Planned Completion Date: Not Applicable.
U.S. Department of the Treasury 2024-001 COVID-19 American Rescue Plan Act Local Fiscal Recovery – Assistance Listing No. 21.027 Recommendation: We recommend that the Town review its formal procurement policies and make necessary revisions to formally include policies and procedures to meet the req...
U.S. Department of the Treasury 2024-001 COVID-19 American Rescue Plan Act Local Fiscal Recovery – Assistance Listing No. 21.027 Recommendation: We recommend that the Town review its formal procurement policies and make necessary revisions to formally include policies and procedures to meet the requirements for verification that an entity with which the Town plans to enter into a covered transaction is not debarred, suspended, or otherwise excluded. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Town has revised the purchasing policies and procedures documented in the Finance Department Policy and Procedures Manual to add the requirement that any entity with which the Town plans to enter into a covered transaction is not debarred, suspended, otherwise excluded. Name(s) of the contact person(s) responsible for corrective action: Tom DiStasio, Director of Finance Planned completion date for corrective action plan: July 1, 2024
Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: To address the GLBA finding regarding sufficient vendor management policies and reviews, we are actively enhancing our oversight process by collecting security attestations (SOC or HECVAT) from all vendors. These attestations are ...
Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: To address the GLBA finding regarding sufficient vendor management policies and reviews, we are actively enhancing our oversight process by collecting security attestations (SOC or HECVAT) from all vendors. These attestations are being evaluated and translated into our newly developed risk matrix, which aligns with our broader risk management framework. This approach allows us to systematically assess each vendor's security posture and assign corresponding risk levels, ensuring compliance with GLBA requirements and supporting informed decision-making in vendor relationships Person Responsible for Corrective Action Plan: Eric Riddering, Chief Information Officer Anticipated Date of Completion: June 30, 2025
Finding 519612 (2024-002)
Significant Deficiency 2024
Incorrect Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: A new Registrar was hired in late May of 2024. A new process was implemented for the Fall semester of 2024 to ensure timely and accurate processing of official and unofficial withdrawals. Outcom...
Incorrect Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: A new Registrar was hired in late May of 2024. A new process was implemented for the Fall semester of 2024 to ensure timely and accurate processing of official and unofficial withdrawals. Outcome: All student withdrawal requests both official and unofficial are processed daily and tracked in a shared workbook. This allows information about each individual withdrawal request to be captured and available for both the Business Office and Financial Aid. Date of Determination, Last Date of Attendance, Processed Date, withdrawal type, withdrawal reason, and credits impacted are all captured in the workbook to aid with R2T4 calculations. This workbook also serves as a document that can be audited in real-time to ensure accuracy of each student’s record. A Standard Operating Procedure was developed and used to train the team members effective on 8/12/2024. Person Responsible for Corrective Action Plan: Tonya Troka, University Registrar & Assistant Provost Anticipated Date of Completion: Completed and implemented for Fall 2024 Semester
Incorrect and Untimely Return of Title IV Funds Calculation (R2T4) Planned Corrective Action: See Below Cleary University identified compliance gaps in its Return of Title IV Funds (R2T4) reporting processes during the 2023-2024 award year. These issues stemmed from a lack of timely enforcement of ...
Incorrect and Untimely Return of Title IV Funds Calculation (R2T4) Planned Corrective Action: See Below Cleary University identified compliance gaps in its Return of Title IV Funds (R2T4) reporting processes during the 2023-2024 award year. These issues stemmed from a lack of timely enforcement of procedures and misinterpretation of R2T4 regulatory requirements, necessitating immediate corrective action and leadership changes. The Financial Aid Director was dismissed, and an experienced Assistant Vice President (AVP) of Financial Aid was hired to oversee compliance and ensure accurate implementation of federal regulations. Additional Financial Aid Data Specialists were hired to improve system efficiency and accuracy. An R2T4 Task force was established, meeting weekly to review Last Day of Attendance (LDA) data, monitor student drop processes, and ensure timely R2T4 calculations and funds returned. A structured process for R2T4 calculations was put in place, with cross-referencing from the Records Department, maintaining through documentation, and improving tracking and reporting. Cleary University has taken significant steps to address the issues and ensure compliance with R2T4 regulations. The revised process, implemented in July 2024, aims to prevent future delays and findings. Weekly checks and ongoing training will ensure that R2T4 processing is accurate, timely, and fully complaint with federal requirements, with a target processing completion of 20 days. Person Responsible for Corrective Action Plan: JoAnn Ross, Vice President of Financial Aid Anticipated Date of Completion: December 18, 2024
Title III – Assistance Listing No. 84.364 Recommendation: We recommend that the Board reevaluate its current process, implement proper controls, and perform additional training over time and effort reporting. The Board should not seek federal reimbursement unless it can substantiate that the time an...
Title III – Assistance Listing No. 84.364 Recommendation: We recommend that the Board reevaluate its current process, implement proper controls, and perform additional training over time and effort reporting. The Board should not seek federal reimbursement unless it can substantiate that the time and effort was dedicated to the federal program. Documentation should be readily available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Director of Multilingual Achievement will ensure that Time and Effort Statements are completed two times each year. These documents will be completed and signed on January 6 and July 6 of each year. Name of the contact person responsible for corrective action: Sonja Bloetner, Director of Multilingual Achievement Planned completion date for corrective action plan: For immediate implementation and ongoing.
View Audit 338700 Questioned Costs: $1
Title I – Assistance Listing No. 84.010 Recommendation: We recommend that the Board continue with established policies and procedures implemented in October 2023 to ensure that it obtains documentation to support student withdrawals and that this documentation is available for audit purposes. Explan...
Title I – Assistance Listing No. 84.010 Recommendation: We recommend that the Board continue with established policies and procedures implemented in October 2023 to ensure that it obtains documentation to support student withdrawals and that this documentation is available for audit purposes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: 1. A year-long induction and support program has been established for office professionals including those who serve as records secretaries and liaisons. All office professionals—regardless of job title and specific responsibilities— are strongly encouraged to participate in the induction and support program. Making the training available to all office professionals serves several purposes: a. addresses gaps in learning to maintain student records; b. corrects misunderstandings of enrollment and withdrawal practices and procedures; and c. supports integration of appropriate processes for the withdrawal practices and procedures (addition to training program 2025). Immediately following the training, the presentation, print materials, and video snippets will be made available to reinforce the learning outcomes and to be used throughout the year. 2. A procedural manual for records secretaries and liaisons will be developed, shared during training, and uploaded to Schoology for future reference. 3. Policy and Rule 5130 and 5150 will be shared with principals to support the processes for student withdrawal and the student record verification process. 4. Student Record Reviews will continue to take place. Student Record Reviews are conducted to ensure that students’ cumulative folders include the documentation required by MSDE and Policy/Rule 5150. 5. Policy and Rule 5150 will be reviewed with PPWs, residency investigators and principals to ensure that they are aware of the required documents necessary to approve an initial shared domicile application and renew a shared domicile application. Name of the contact person responsible for corrective action: Patricia Mustipher, Director of Department of Student Support Services Planned completion date for corrective action plan: Various dates beginning in October 2023 through March 2025.
Title I – Assistance Listing No. 84.010 Recommendation: We recommend that the Board reevaluate its current process, implement proper controls, and perform additional training over time and effort reporting. The Board should not seek federal reimbursement unless it can substantiate that the time and ...
Title I – Assistance Listing No. 84.010 Recommendation: We recommend that the Board reevaluate its current process, implement proper controls, and perform additional training over time and effort reporting. The Board should not seek federal reimbursement unless it can substantiate that the time and effort was dedicated to the federal program. Documentation should be readily available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Weekly payroll runs will be cross-referenced with Title I position logs. Any discrepancies will be investigated promptly. • Unauthorized Employees: Employees not listed on Title I position logs will be removed from payroll to ensure only sponsored employees are attributed to the grant. • Missing Sponsored Employees: Sponsored employees not appearing on payroll reports will be investigated to determine the cause and appropriate corrective actions will be taken. Names of the contact persons responsible for corrective action: Michele Stansbury, Director of Title I Deanna Ashenfelter, Accounting Manager Brent Harry, Fiscal Supervisor III Planned completion date for corrective action plan: Implemented September 17, 2024
View Audit 338700 Questioned Costs: $1
Child Nutrition Cluster – Assistance Listing No. 10.553, 10.555, 10.559, and 10.582 Recommendation: We recommend that the Board enhance controls and procedures to ensure that it follows its procurement policies for all goods and services charged to the program. Documentation should be readily availa...
Child Nutrition Cluster – Assistance Listing No. 10.553, 10.555, 10.559, and 10.582 Recommendation: We recommend that the Board enhance controls and procedures to ensure that it follows its procurement policies for all goods and services charged to the program. Documentation should be readily available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Purchasing procedures and thresholds were discussed at a leadership meeting of the Department of Food and Nutrition Services. Specifically, the need for at least two quotes for purchases between $15,000 and $50,000 was reiterated. On an ongoing basis, expenditures by vendor will be reviewed to ensure compliance with the procurement policy. Name of the contact person responsible for corrective action: Jaime Hetzler, Director of Food and Nutrition Services Planned completion date for corrective action plan: For immediate implementation and ongoing.
While reviewing the follow up questions along regarding enrollment reporting, a discovery was made that there could have been issues with the query that was used to create the lists to be sent to National Student Clearinghouse. A new version of the query was created mid-July 2023. This query was lac...
While reviewing the follow up questions along regarding enrollment reporting, a discovery was made that there could have been issues with the query that was used to create the lists to be sent to National Student Clearinghouse. A new version of the query was created mid-July 2023. This query was lacking 3 current student statuses that would have prevented them from picked up transmitted/uploaded to National Student Clearinghouse. The original query was missing a status that was introduced in 2023, which was around summer/spring 2023, which is why the second query was created to pull that new status. Moving forward, we will create a new query for all future reports that use all current statuses.
U.S. Department of Mental Health 2024-001 Block Grants for Community Mental Health Services – Assistance Listing No. 93.958 Recommendation: It is recommended that the Organization design controls to ensure time and effort spent on programs are properly documented in accordance with Uniform Guidance...
U.S. Department of Mental Health 2024-001 Block Grants for Community Mental Health Services – Assistance Listing No. 93.958 Recommendation: It is recommended that the Organization design controls to ensure time and effort spent on programs are properly documented in accordance with Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Edinburg will be implementing procedures in accordance with 2 CFR 200.430(i) by collecting effort reports for exempt employees who are split across multiple federally funded contracts for each payroll period. Non-exempt employees will be required to complete their time and effort reporting within our payroll module, which will maintain the record and electronic signatures. Any corrections will be collected and reconciled before the contract period is closed. Name(s) of the contact person(s) responsible for corrective action: Debra Veth, Planned completion date for corrective action plan: 6/30/2025 If the U.S. Department of Mental Health has questions regarding this plan, please call Debra Veth at 781-761-5139 or email dveth@edinburgcenter.org
View Audit 338692 Questioned Costs: $1
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