Corrective Action Plans

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It should be noted that distribution of funds under this program terminated on December 31, 2024; no new loans will be originated. The Foundation will implement the recommended actions as appropriate in future programs that may be similar to this one.
It should be noted that distribution of funds under this program terminated on December 31, 2024; no new loans will be originated. The Foundation will implement the recommended actions as appropriate in future programs that may be similar to this one.
View Audit 370140 Questioned Costs: $1
Planned Corrective Action: To ensure compliance with federal reporting standards, the Organization will require a secondary review of all federal reports submitted to granting agencies. The designated secondary reviewer shall be an individual that has strong knowledge of the reporting requirements. ...
Planned Corrective Action: To ensure compliance with federal reporting standards, the Organization will require a secondary review of all federal reports submitted to granting agencies. The designated secondary reviewer shall be an individual that has strong knowledge of the reporting requirements. Additionally, the Organization will implement policies and procedures surrounding file retention of the underlying data that supports federal reports submitted. Anticipated Completion Date: 12/31/2025 Responsible Contact Person: Angelita Thomas, Chief Financial Officer
Corrective Action Plan Cognizant or Oversight Agency for Audit: U.S. Department of Health and Human Services Center for Asbestos Related Disease, Inc respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm...
Corrective Action Plan Cognizant or Oversight Agency for Audit: U.S. Department of Health and Human Services Center for Asbestos Related Disease, Inc respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Rudd & Company, PLLC 3805 Valley Commons Drive, Ste. 7 Bozeman, MT 59718 Audit Period: January 1, 2024 – December 31, 2024 The findings from the 2024 schedule of findings and questioned costs are discussed below: Federal Award Findings and Questioned Costs Finding 2024-001 Department of Health and Human Services Libby, Montana’s Public Health Emergency, Asbestos Health Screening, CFDA #93.534 5NU61TS000295-05 Finding Summary: Final Financial report for the grant period end was not submitted by the due date. Responsible Individuals: Executive Director, Tracy McNew and Financial Officer, Janine Price Corrective Action Plan: Management has added all report due dates to their calendars beginning two weeks before the due dates to ensure reports are filed in a timely manner even if difficulties are encountered with the filing process. In addition, case numbers with PMS’s help desk will be recorded and other communications will be saved to ensure that proper documentation is maintained for any reports rejected and refiled at a later date. Anticipated Completion Date: Ongoing
To: FY2024 Uniform Guidance Reporting Package From: David Noble, Director, Grant Administration RE: 2024 Uniform Guidance Audit Corrective Action Plan Date: September 25, 2025 Finding: 2024-001 Activities Allowed or Unallowed/Allowable Costs Federal Program: Medicaid Assistance Program/Medicaid Clus...
To: FY2024 Uniform Guidance Reporting Package From: David Noble, Director, Grant Administration RE: 2024 Uniform Guidance Audit Corrective Action Plan Date: September 25, 2025 Finding: 2024-001 Activities Allowed or Unallowed/Allowable Costs Federal Program: Medicaid Assistance Program/Medicaid Cluster ALN: 93.778 Grady Memorial Hospital Corporation’s CFO and VP of Fiscal Services/Controller have reviewed the reporting from KPMG relating to the Uniform Guidance. We understand the recommendation set forth by KPMG and will update our controls and processes to include additional review of expenses incurred during the relevant audit period. Grady’s corrective action plan: During the FY 2024 single audit, one unallowable payroll disbursement totaling $1,988 was reimbursed by the federal agency. The disbursement was associated with a rarely used payroll code that is routinely excluded from reimbursement requests. Internal controls over the review process for payroll charges exist and will be strengthened to ensure only allowable charges are charged to the grant. Contact person/s responsible for the corrective action: David Noble, Director, Grant Administration Anticipated Completion Date: Consistent with 2025 Financial Audit Reporting
Finding 2024-008 I. Procurement and Suspension and Debarment Information on the federal program: Grantor: Grantor: Department of Agriculture, Department of Defense, Department of Labor, National Aeronautics and Space Administration, Promotion of the Arts Grants to Organizations and Individuals, Nati...
Finding 2024-008 I. Procurement and Suspension and Debarment Information on the federal program: Grantor: Grantor: Department of Agriculture, Department of Defense, Department of Labor, National Aeronautics and Space Administration, Promotion of the Arts Grants to Organizations and Individuals, National Science Foundation, Department of Veteran Affairs, Environment Protection Agency, Department of Energy, Department of Health and Human Services, U.S. Agency for International Development Program Name: Research and Development Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees with the finding described above. Due to a system failure, vendor payment files from January through September 2024 were not transmitted to Mount Sinai’s sanction screening vendor. Mount Sinai has taken corrective actions to address this issue. All current vendors in our vendor master file, as well as all new vendors added through our new vendor credentialing process, are now processed through our sanction screening vendor on a monthly basis. In addition, a new manual control has been implemented to review, confirm, and reconcile to ensure that the vendor master file has been transmitted successfully, and all vendors are screened for sanctions, and a report thereof is provided each month. Our process will also document and maintain evidence that unverified vendors or those that were indicated as excluded were investigated and evaluated by the Health System. We will also periodically perform independent sanction screening checks on a sample of our vendors to validate the accuracy of the results of our third-party sanction screening vendor. Name of responsible official: Franco Sagliocca Corporate Director, Supply Chain Franco.sagliocca@mountsinai.org Projected completion date: Our vendor credentialing process was establishing with our ERP implementation on October 7, 2024. Our enhanced procedures to reconcile our file transmissions to our independent third-party and perform screening checks on samples of vendors verified by our independent third-party is expected to be implemented by December 31, 2025.
View Audit 370128 Questioned Costs: $1
Finding 2024-007 I. Procurement and Suspension and Debarment Information on the federal program: Grantor: Grantor: Department of Agriculture, Department of Defense, Department of Labor, National Aeronautics and Space Administration, Promotion of the Arts Grants to Organizations and Individuals, Nati...
Finding 2024-007 I. Procurement and Suspension and Debarment Information on the federal program: Grantor: Grantor: Department of Agriculture, Department of Defense, Department of Labor, National Aeronautics and Space Administration, Promotion of the Arts Grants to Organizations and Individuals, National Science Foundation, Department of Veteran Affairs, Environment Protection Agency, Department of Energy, Department of Health and Human Services, U.S. Agency for International Development Program Name: Research and Development Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees with the finding described above. In October 2024, Mount Sinai transitioned to Oracle Cloud for its Enterprise Resource Planning (ERP) and general ledger system. During this transition, Deputy Buyer transactions of $10,000 and above were not routed to the Purchasing Team for review, allowing purchase orders to be completed without the required documentation, including Sole Source Justifications, Directed Source Justifications, or multiple quotes as required under Uniform Guidance. Corrective actions, including a system enhancement, have been implemented to remediate this issue. Mount Sinai’s enhanced process ensures Deputy Buyer transactions of $10,000 and above are routed appropriately to the Purchasing Team for validation and documentation review. In addition, a quarterly manual review process, supported by reports developed in partnership with Mount Sinai’s technology team, will be fully implemented as a compensating control in the fourth quarter of 2025. Name of responsible official: Franco Sagliocca Corporate Director, Supply Chain Franco.sagliocca@mountsinai.org Projected completion date: Our enhanced procedures for ensuring the necessary documentation is completed on Deputy Buyer transactions of $10,000 and above is expected to be implemented by December 31, 2025.
View Audit 370128 Questioned Costs: $1
Finding 2024-006 L. Reporting Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees with the finding that FISAP was not c...
Finding 2024-006 L. Reporting Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees with the finding that FISAP was not correctly populated. Management has since corrected the data and submitted a revised FISAP. Management notes there was turnover in the PSON’s Office of Student Financial Aid during the year and an employee was not properly trained on the FISAP preparation. Training has since been implemented and new employees in the department will be trained accordingly. Names of responsible official: Denis Donegan Vice President of Finance, Mount Sinai Health System Denis.donegan@mountsinai.org Projected completion date: The project is expected to complete by December 31, 2025.
Finding 2024-005 N. Special Tests and Provisions - Disbursement to or on Behalf of Students Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective ac...
Finding 2024-005 N. Special Tests and Provisions - Disbursement to or on Behalf of Students Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees with the finding that certain credit refunds were not issued timely. PSON and ISMMS’ Offices of Student Financial will implement a control that ensures communication related to refunds is enhanced when a student withdraws. ISMMS has ensured compliance with the Department of Education’s 14-day credit balance requirement by contracting with Nelnet, an external financial management vendor, to administer the credit refund process, supported by ongoing monitoring and periodic internal reviews. The control will ensure that all credit refunds are issued timely. Names of responsible official: Denis Donegan Vice President of Finance, Mount Sinai Health System Denis.donegan@mountsinai.org LaVerne Walker Director of Student Financial Services, Icahn School of Medicine at Mount Sinai Laverne.walker@mssm.edu Projected completion date: The project is expected to complete by December 31, 2025.
Finding 2024-004 N. Special Tests and Provisions - Enrollment Reporting Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management ag...
Finding 2024-004 N. Special Tests and Provisions - Enrollment Reporting Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees with the finding described above. PSON and ISSMS’ Offices of Student Financial will ensure that all NSLDS submissions are made timely and with the correct status of each student. The respective Offices are implementing enhanced monitoring, staff training, and periodic internal reviews to confirm compliance. Names of responsible official: Denis Donegan Vice President of Finance, Mount Sinai Health System Denis.donegan@mountsinai.org LaVerne Walker Director of Student Financial Services, Icahn School of Medicine at Mount Sinai Laverne.walker@mssm.edu Projected completion date: The project is expected to complete by December 31, 2025.
Finding 2024-003 N. Special Tests and Provisions - Verification Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees wit...
Finding 2024-003 N. Special Tests and Provisions - Verification Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees with the finding described above. PSON’s Office of Student Financial Aid will implement a process that ensures all required documentation is retained. Employees of the Student Financial Aid Office will be trained and PSON will be in compliance with the requirements in the Federal Student Aid Handbook. Name of responsible official: Denis Donegan Vice President of Finance, Mount Sinai Health System Denis.donegan@mountsinai.org Projected completion date: The project is expected to complete by December 31, 2025.
Management acknowledges the audit finding regarding timely submission of reports and retaining documentation of submissions. We will implement a new combined monitoring and record retention internal control process for financial, performance, and special reporting requirements, to ensure timely subm...
Management acknowledges the audit finding regarding timely submission of reports and retaining documentation of submissions. We will implement a new combined monitoring and record retention internal control process for financial, performance, and special reporting requirements, to ensure timely submission and retention of supporting documentation for required sponsor reporting. This process will be implemented by December 31, 2025.
Management acknowledges the audit finding regarding deficiencies in the reporting of student status changes to COD. These discrepancies were primarily due to limitations in our staffing and review procedures. We are revising our enrollment reporting policies to clearly define roles, responsibilities...
Management acknowledges the audit finding regarding deficiencies in the reporting of student status changes to COD. These discrepancies were primarily due to limitations in our staffing and review procedures. We are revising our enrollment reporting policies to clearly define roles, responsibilities, and timelines for processing student status changes. This includes an additional layer of review to verify the accuracy of effective dates prior to COD submission. These additional policies and procedures will be implemented by December 31, 2025.
Management acknowledges the findings related to compliance with GLBA requirements. The missing elements were primarily due to existing policies and procedures not specifically covering the information technology system utilized by the School of Nursing. Management will update their information techn...
Management acknowledges the findings related to compliance with GLBA requirements. The missing elements were primarily due to existing policies and procedures not specifically covering the information technology system utilized by the School of Nursing. Management will update their information technology policies and procedures to ensure full compliance with the 7 required elements outlined by the GLBA. This will include updating risk assessment procedures, designing safeguards based on risk assessments procedures, monitoring these safeguards, and documenting the results. These policy and procedure updates will be implemented by December 31, 2025.
Management acknowledges the findings related to Common Origination and Disbursement (COD) reporting as identified. These discrepancies were primarily due to limitations in our current review procedures. We are revising our internal policies and procedures to include detailed guidance on verifying an...
Management acknowledges the findings related to Common Origination and Disbursement (COD) reporting as identified. These discrepancies were primarily due to limitations in our current review procedures. We are revising our internal policies and procedures to include detailed guidance on verifying and documenting disbursement and enrollment dates, academic year parameters, and cost of attendance calculations prior to COD submission. This will include additional layers of review to ensure timely and accurate reporting. These policies and procedures will be implemented by December 31, 2025.
Management concurs with KPMG’s assessment that the risk assessment and monitoring control activities were not sufficiently designed to ensure adequate segregation of duties or to provide evidence of control operation. These gaps were primarily due to limited staffing and processes that have not evol...
Management concurs with KPMG’s assessment that the risk assessment and monitoring control activities were not sufficiently designed to ensure adequate segregation of duties or to provide evidence of control operation. These gaps were primarily due to limited staffing and processes that have not evolved to meet all compliance requirements. Management will implement new control policies and procedures that ensure proper segregation of duties and introduce review mechanisms at a sufficient level of precision to detect and prevent noncompliance. These policies and procedures will be implemented by December 31, 2025.
Federal Funding Accountability and Transparency Act (FFATA) Filing for Subawards. Assistance Listing No. 93.493 Congressional Directives: Kupuna Support Navigator Program (KSNP) The KSNP project manager and senior management reviewed and submitted the FFATA required reporting, which included the sub...
Federal Funding Accountability and Transparency Act (FFATA) Filing for Subawards. Assistance Listing No. 93.493 Congressional Directives: Kupuna Support Navigator Program (KSNP) The KSNP project manager and senior management reviewed and submitted the FFATA required reporting, which included the subrecipient's name, subaward date, and subaward amount on SAM.gov website prior to the completion of this federal grant, which ended on June 30, 2025. The funder confirmed receipt of our reporting and did not specify any implications for late submission. As recommended by the auditors, HIPHI has developed a process to help identify the subawards subject to the FFATA reporting requirements prior to the start of the grant, and to ensure that reporting is reviewed, approved for completeness and accuracy, and filed in a timely manner. The Director of Finance, Finance and Accounting Manager, Program Managers and contract signers will be responsible for implementing these corrective actions by the end of 2025.
Finding 2025-003: Campus Crime Awareness Requirements Not Met Comments on Finding and Recommendation(s): Statement of Concurrence: We concur with the finding of 1. a burglary crime was reported in the Annual Security Report when it should have been reported as a motor vehicle theft. The issue was du...
Finding 2025-003: Campus Crime Awareness Requirements Not Met Comments on Finding and Recommendation(s): Statement of Concurrence: We concur with the finding of 1. a burglary crime was reported in the Annual Security Report when it should have been reported as a motor vehicle theft. The issue was due to error entry, neighboring lines. 2. motor vehicle theft and a weapons violation was not reported to the Department of Education. The issue was due to carelessness. These were correctly reported in the Annual Security Report. Usually, the Annual Security Report and report to the Department of Education is prepared and completed by the Student Services Coordinator and the Administrative Dean based on the statistic report from the school and the Police Department in August/September. Because the college was engaged in the self-study for accreditation, everyone was extremely busy at that time. Errors might occur when doing things in a hassle way. Actions Taken or Planned: 1. Corrections were made in the Annual Security Report and in the report to the Department of Education. Two corrections were made in the DOE website: Criminal Offenses - Public Property: For 2023, line J (motor vehicle theft) was changed from 0 to 1. Arrests - Public Property: For 2023, line a (weapon) was changed from 0 to 2 2. New Hire: The college is in the process of hiring a new Student Services Coordinator. This individual will work with the Administrative Dean for ensuring the accuracy and timelines of reporting moving forward. 3. A strengthen double-check system will be established to ensure the accuracy of all reporting. Completion Date: Ongoing 9/26/2025 Dong-Hua Yang MD, PhD Date Title: Administrative Dean Telephone: 516-739-1545 Email: administrative_dean@nyctcm.edu
Finding 2025-002: Untimely Paid Credit Balance Comments on Finding and Recommendation: Statement of Concurrence: We concur with the finding of Untimely Paid Credit Balance The delay in issuing the credit balance was due to a timing oversight related to the award year dates. Although the Credit Balan...
Finding 2025-002: Untimely Paid Credit Balance Comments on Finding and Recommendation: Statement of Concurrence: We concur with the finding of Untimely Paid Credit Balance The delay in issuing the credit balance was due to a timing oversight related to the award year dates. Although the Credit Balance Authorization Form was on file, the refund was processed after the award year had ended, rather than within the required timeframe. In the past, students were always allowed to keep funds in their Populi accounts for future use regardless of the loan award year, and it had not previously been indicated that this practice was not allowed. Actions Taken or Planned: We have reviewed our internal procedures and will strengthen oversight of award year deadlines to ensure that all credit balances are refunded within the required timeframe. Moving forward, the financial aid and accounting teams will implement a compliance checklist and establish calendar reminders to prevent similar delays. Additionally, we will revise the wording on our Credit Balance Authorization Form to read: “Leave the funds in my account and any remaining funds from the current award year in my account up to the end of the loan period.” Completion Date: Ongoing 9/26/2025 Dong-Hua Yang MD, PhD Date Title: Administrative Dean Telephone: 516-739-1545 Email: administrative_dean@nyctcm.edu
View Audit 370123 Questioned Costs: $1
Finding 2025-001: Inaccurate and Untimely Enrollment Status Reporting Comments on Finding and Recommendations: Statement of Concurrence: We concur with the finding of Inaccurate and Untimely Enrollment Status Reporting The inaccuracies and delays were mainly the result of our scheduling process. Cur...
Finding 2025-001: Inaccurate and Untimely Enrollment Status Reporting Comments on Finding and Recommendations: Statement of Concurrence: We concur with the finding of Inaccurate and Untimely Enrollment Status Reporting The inaccuracies and delays were mainly the result of our scheduling process. Currently, we update enrollment maintenance every two months, typically on the day prior to the scheduled dates. We now understand that enrollment status updates must be completed within 15 days after the scheduled date. Actions Taken or Planned: We have reviewed the enrollment maintenance schedule and adjusted our process to ensure compliance with the requirement. Moving forward, enrollment status will be updated within 15 days after the scheduled date. This adjustment will be fully implemented starting from the next scheduled update on 09/30/2025. 9/26/2025 Dong-Hua Yang MD, PhD Date Title: Administrative Dean Telephone: 516-739-1545 Email: administrative_dean@nyctcm.edu
Planned Corrective Action: We will maintain a detailed listing of all real property and equipment purchased with federal funding. We will also continue to have executed agreements dictating the treatment of real property and equipment with beneficiaries of all items that ownership is transferred fro...
Planned Corrective Action: We will maintain a detailed listing of all real property and equipment purchased with federal funding. We will also continue to have executed agreements dictating the treatment of real property and equipment with beneficiaries of all items that ownership is transferred from the Organization to ensure compliance. Name of Contact Person: Rhonda Conn, Associate Director Anticipated Completion Date: October 1, 2025
Planned Corrective Action: The Organization will document and retain records of all bids and quotes solicited in keeping with their procurement policy to ensure compliance. Name of Contact Person: Rhonda Conn, Associate Director Anticipated Completion Date: October 1, 2025
Planned Corrective Action: The Organization will document and retain records of all bids and quotes solicited in keeping with their procurement policy to ensure compliance. Name of Contact Person: Rhonda Conn, Associate Director Anticipated Completion Date: October 1, 2025
Planned Corrective Action: We have implemented a process to monitor cost cash match including obtaining, reviewing, and retaining support for reported cost match amounts. Name of Contact Person: Rhonda Conn, Associate Director Anticipated Completion Date: In Process at 12/31/2024 with Remainder to b...
Planned Corrective Action: We have implemented a process to monitor cost cash match including obtaining, reviewing, and retaining support for reported cost match amounts. Name of Contact Person: Rhonda Conn, Associate Director Anticipated Completion Date: In Process at 12/31/2024 with Remainder to be Completed by October 1, 2025
Planned Corrective Action: We have implemented a cloud‐based platform that automates the AP process. All invoices are submitted to this platform and given to individuals for dual review and approval before being paid. This system was put in place in July 2024, there have been no noted issues of nonc...
Planned Corrective Action: We have implemented a cloud‐based platform that automates the AP process. All invoices are submitted to this platform and given to individuals for dual review and approval before being paid. This system was put in place in July 2024, there have been no noted issues of noncompliance since using this platform. Name of Contact Person: Rhonda Conn, Associate Director Anticipated Completion Date: Done ‐ July 31, 2024
Name of contact person responsible for corrective action plan: Justin Frank Corrective action planned: The Parish will review all policies and procedures to ensure that proper internal controls are in place, with an emphasis on Federal procurement guidelines. Anticipated Completion Date: December 31...
Name of contact person responsible for corrective action plan: Justin Frank Corrective action planned: The Parish will review all policies and procedures to ensure that proper internal controls are in place, with an emphasis on Federal procurement guidelines. Anticipated Completion Date: December 31, 2025
View Audit 370116 Questioned Costs: $1
Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the finding: The Authority has reviewed and updated its financial reporting and closing processes and controls he preparation of the final trial balances and related schedules...
Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the finding: The Authority has reviewed and updated its financial reporting and closing processes and controls he preparation of the final trial balances and related schedules. As part of this process, we will create a year-end checklist with deadlines established and set up status meetings to monitor the progress. Name(s) of the contact person(s) responsible for corrective action: Lowel Kruger, Executive Director. Planned completion date for corrective action plan: December 31, 2024
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