Corrective Action Plans

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County Judge/Executive’s Response: The Fiscal Court has contracted with Compass to ensure that expenses for Federal Reimbursement are eligible for reimbursement.
County Judge/Executive’s Response: The Fiscal Court has contracted with Compass to ensure that expenses for Federal Reimbursement are eligible for reimbursement.
View Audit 311338 Questioned Costs: $1
The CFO and accounting team at Iroquois Memorial Hospital and Resident Home worked with its financial statement auditors and the HRSA audit support desk for Provider Relief Funds to identify a plan to update its documentation as well as update its internal records to reflect allowable costs under th...
The CFO and accounting team at Iroquois Memorial Hospital and Resident Home worked with its financial statement auditors and the HRSA audit support desk for Provider Relief Funds to identify a plan to update its documentation as well as update its internal records to reflect allowable costs under the program. One of the updates included utilization of additional lost revenue to cover nonallowable expenses under the first phases of reporting for Provider Relief Funds due to elimination of some expenses and reduction for Medicare cost reimbursement against expenses. Management developed a more detailed expense log and review those against current terms and conditions prior to any future portal submissions and took into account the use of additional lost revenue. The worksheets were mocked up internally as if these were submitted in the portal in Phase I reporting so that in the future for the next phases of reporting, these lost revenues are not utilized toward future Provider Relief Funding. One additional control being added for this reporting is that the CEO and CFO will be also completing a detailed review of the spreadsheets for entry into the portal and comparing this to the Compliance Supplement which governs the use of the Provider Relief Funds as to allowable costs as well as the Frequently Asked Questions (FAQs) available on HRSAs website. This may impact future reports, so management will ensure to take these updates into account on any future provider relief funds are they are released or future grant receipts if the Organization receives new grants in the future.
Compliance Finding 2021‐007 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan Rural Distribution Finding Summary: The Authority did not have internal controls established over the federa...
Compliance Finding 2021‐007 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan Rural Distribution Finding Summary: The Authority did not have internal controls established over the federal award to ensure the federal award has been managed in compliance with federal, states, regulations and conditions of the federal award. Corrective Action Plan: We will modify internal control policies to ensure there is an understanding of reporting requirements to ensure that reports are accurate and amounts are not inadvertently claimed that are considered unallowable. Responsible Individual: Doran Hammett, Chief Financial Officer Anticipated Completion Date: June 2024
We recommend the Clerk work more closely with the award agencies to ensure the elibility of all claims for reimbursement is understood by both parties.
We recommend the Clerk work more closely with the award agencies to ensure the elibility of all claims for reimbursement is understood by both parties.
The Office of AIDS (OA) agrees with the finding and recommendation. OA developed and implemented additional, internal quality assurance (QA) processes in April of 2022 to ensure that secondary reviews of AIDS Drug Assistance Program (ADAP) applications are consistently enforcing the existing guideli...
The Office of AIDS (OA) agrees with the finding and recommendation. OA developed and implemented additional, internal quality assurance (QA) processes in April of 2022 to ensure that secondary reviews of AIDS Drug Assistance Program (ADAP) applications are consistently enforcing the existing guidelines, including acceptable supporting documentation and accurate eligibility requirements. During this audit period, and through December 2021, ADAP had issued multiple policy memos to respond to the COVID-19 pandemic, which enabled staff and enrollment workers to defer documentation collection, when necessary, to remain flexible and ensure clients impacted by the pandemic, and associated site closures, did not lose eligibility and access to life saving medications and comprehensive healthcare. These flexibilities in our guidelines were implemented based on guidance received from our federal funder, Health Resources and Services Administration (HRSA), which encouraged ADAPs to reassess their organization's eligibility and recertification policies and procedures, and remove any barriers that may impede social distancing, or other public health strategies, necessary to minimize COVID-19 transmission. This documentation deferral was terminated on December 31, 2021, and since January 1, 2022, full documentation and eligibility requirements have been enforced. This, combined with ongoing QA efforts, will help to mitigate future findings in ADAP applications dated January 1, 2022 onward. Estimated Implementation Date: Already implemented as of April 2022 Contact: Sharisse Kemp, Branch Chief AIDS Drug Assistance Program Branch California Department of Public Health
Finding 402368 (2021-009)
Significant Deficiency 2021
Office of AIDS (OA) agrees with the finding and has implemented solutions to meet the auditor's recommendation. OA has already taken steps to remedy the issue by using its Support Branch to realign staff and responsibilities to allow for a greater focus on fiscal reporting and invoice processing. T...
Office of AIDS (OA) agrees with the finding and has implemented solutions to meet the auditor's recommendation. OA has already taken steps to remedy the issue by using its Support Branch to realign staff and responsibilities to allow for a greater focus on fiscal reporting and invoice processing. The Care Branch has also put an increased emphasis on tracking and reviewing invoices for payment to prevent similar delays. Subsequently, the Ryan White Grant closeouts had all invoices processed and paid prior to the Federal Financial Report closeout deadlines to ensure that drawn cash for invoices was not held for extended timeframes. Estimated Implementation Date: July 1, 2021 Contact: Joseph Gonzales, Branch Chief Office of AIDS Support Branch California Department of Public Health
Health Care Services agrees with the recommendation and implemented corrective action by October 31, 2022. Health Care Services, or DHCS, published Behavioral Health Information Notice (BHIN) 22-045 which outlines Health Care Services sanctions policy. The BHIN states “Under state and federal law D...
Health Care Services agrees with the recommendation and implemented corrective action by October 31, 2022. Health Care Services, or DHCS, published Behavioral Health Information Notice (BHIN) 22-045 which outlines Health Care Services sanctions policy. The BHIN states “Under state and federal law DHCS must enforce compliance with the terms of the DHCS’ contracts with Mental Health Plans and Drug Medi-Cal Organized Delivery System counties, as well as ensure compliance with applicable state and federal laws and regulations, in accordance with its authority and obligations under state and federal requirements.” Lastly, under the section titled ‘Exhibit A - Attachment 3’ of the County Mental Health Plan Contract counties are required to submit cost reports timely which would allow Health Care Services to impose sanctions on counties who do not submit cost reports in a timely manner. This BHIN resolves the finding. Additionally, Health Care Services will not be collecting cost reports for dates of service after State Fiscal Year 2022-23. Under the California Advancing and Innovating Medi-Cal (CalAIM) initiative, and pursuant to Welfare and Institutions Code, Section 14184.403(b), Health Care Services will replace the current Certified Public Expenditures (CPE) reimbursement methodology with an intergovernmental transfer (IGT) reimbursement methodology. The IGT reimbursement methodology will make a single and final payment for services provided to the county, which includes the non-federal portion of the claims. This change will eliminate the requirement for the county submission of cost reports. Estimated Implementation Date: October 31, 2022 Contact: Wendy Griffe, Chief Internal Audits California Department of Health Care Services
Corrective Action Plan: All Bank Reconciliations will be reviewed for the Assistance and Clearing Fund. All unidentified adjustments will be researched, and adjustments will be made on the corresponding reports submitted to the Division of Family Development. Responsible Party: Accountant Anticip...
Corrective Action Plan: All Bank Reconciliations will be reviewed for the Assistance and Clearing Fund. All unidentified adjustments will be researched, and adjustments will be made on the corresponding reports submitted to the Division of Family Development. Responsible Party: Accountant Anticipated Completion Date: Immediately
The criteria for use of the Provider Relief Funds (PRF) changed subsequent to the receipt and expenditure by the Hospital. The Hospital utilized the best information available at the time, during the early days of the public health emergency, in its use of the funds. The Hospital consistently revi...
The criteria for use of the Provider Relief Funds (PRF) changed subsequent to the receipt and expenditure by the Hospital. The Hospital utilized the best information available at the time, during the early days of the public health emergency, in its use of the funds. The Hospital consistently reviews the frequently asked questions for PRF maintained by the Health Resources & Services Administration (HRSA) for guidance on changes and clarification to the rules surrounding the program. In October 2021 — long after most critical access hospitals (CAHs), including Selling, had expended their initial PRF distributions - HRSA added an FAQ addressing cost-based reimbursement, specifically, "How does cost-based reimbursement relate to my Provider Relief Fund payment?" HRSA subsequently has made minor modifications to the language of this FAQ — most recently on October 27, 2022 — but the substantive guidance has remained the same. Unlike E.H.R. capital equipment, where specific cost report guidance was provided, no such guidance was provided for assets purchased to prevent, prepare for, and respond to COVID-19. Neither Prospective Payment System (PPS) nor CAH facilities were required to offset the full amount of funds received because they were considered grants, consistent with the treatment of PRF. We disagree with the audit findings and believe that no corrective action is required.
View Audit 307896 Questioned Costs: $1
Finding 2021-010 Management agrees with the finding and is implementing the accompanying corrective action plan. Views of Responsible Officials: Jessica Martinez, Program Director Joel Rusco, Chief Financial and Administrative Officer Jacy Hyde, Executive Director Contact Person: Jessica Martinez, P...
Finding 2021-010 Management agrees with the finding and is implementing the accompanying corrective action plan. Views of Responsible Officials: Jessica Martinez, Program Director Joel Rusco, Chief Financial and Administrative Officer Jacy Hyde, Executive Director Contact Person: Jessica Martinez, Program Director Joel Rusco, Chief Financial and Administrative Officer Corrective Action Plan: • Clark Nuber has reviewed CFSC’s cash management policies and procedures. Clark Nuber’s proposed updates and revisions will be reviewed and approved by CFSC management and thereafter implemented by all CFSC staff. • CFSC will ensure the amount of advance payments requested from the funder are limited to the minimum amounts of funding needed and are timed to distribute in accordance with the actual cash requirements of CFSC or the subrecipient to carry out the approved program or project. • CFSC will review their subrecipient monitoring policy to determine and update where appropriate to ensure compliance with eh Unform Guidance. Payments made to subrecipients will be on a cost reimbursement basis unless subrecipients can show they have an adequate cash management policy in place. At that time, CFSC will make payments to subrecipients based on requests for advances; however, CFSC will continue to monitor the subrecipient to ensure it is minimizing the time lapse between the advance request by the subrecipient and the distribution of the grant funds. Anticipated Completion Date: CFSC will implement the above corrective actions by the end of Quarter 2 of 2024.
View Audit 305892 Questioned Costs: $1
Finding #SA2021-005: Cash Management Assistance Listing Number: 14.218 Assistance Listing Title: COVID-19 - Community Development Block Grants/Entitlement Grants Name of Federal Agency: Department of Housing and Urban Development Pass Through Entity: San Joaquin County Community Development Departme...
Finding #SA2021-005: Cash Management Assistance Listing Number: 14.218 Assistance Listing Title: COVID-19 - Community Development Block Grants/Entitlement Grants Name of Federal Agency: Department of Housing and Urban Development Pass Through Entity: San Joaquin County Community Development Department Federal Award Identification Number: A-93-916 • Name(s) of the contact person: Shay Narayan, Director of Finance; Carmen Gusman, Deputy Director of Finance • Corrective Action Plan: The City will develop procedures to ensure all grant-funded expenditures are included on drawdown request and prepared quarterly. • Anticipated Completion Date: 06/30/2024
Finding 396189 (2021-004)
Significant Deficiency 2021
Finding #SA2021-004: Allowable Subrecipient and Contract Costs Assistance Listing Number: 14.218 Assistance Listing Title: COVID-19 - Community Development Block Grants/Entitlement Grants Name of Federal Agency: Department of Housing and Urban Development Pass Through Entity: San Joaquin County Comm...
Finding #SA2021-004: Allowable Subrecipient and Contract Costs Assistance Listing Number: 14.218 Assistance Listing Title: COVID-19 - Community Development Block Grants/Entitlement Grants Name of Federal Agency: Department of Housing and Urban Development Pass Through Entity: San Joaquin County Community Development Department Federal Award Identification Number: A-93-916 • Name(s) of the contact person: Shay Narayan, Director of Finance; Carmen Gusman, Deputy Director of Finance • Corrective Action Plan: The City will develop procedures for grant management, accounting and reporting to ensure that only allowable subrecipient costs are claimed and are supported by contract. • Anticipated Completion Date: 06/30/24
View Audit 305817 Questioned Costs: $1
2021-004 Charges to cost pools that are allocated wholly or partially to Federal awards Management Response: The Tribe has indirect cost agreements through 12.31.2024 and will book the indirect cost according to the rate for audited fiscal years going forward Anticipated Completion Date: 12/31/2024 ...
2021-004 Charges to cost pools that are allocated wholly or partially to Federal awards Management Response: The Tribe has indirect cost agreements through 12.31.2024 and will book the indirect cost according to the rate for audited fiscal years going forward Anticipated Completion Date: 12/31/2024 Responsible Party: Treasurer, Comptroller, Accounting Manager and Federal Programs Accounting Manager
2021-003 Costs must be adequately documented Management Response: The Tribe recently went through administrative changes and we now have a Finance Department that will ensure we address this concern and correct it in a timely manner. We will revisit our current controls and use updated technology to...
2021-003 Costs must be adequately documented Management Response: The Tribe recently went through administrative changes and we now have a Finance Department that will ensure we address this concern and correct it in a timely manner. We will revisit our current controls and use updated technology to improve our processes. Anticipated Completion Date: 12/31/2024 Responsible Party: Treasurer, Comptroller, Accounting Manager and Federal Programs Accounting Manager
View Audit 305423 Questioned Costs: $1
2021-004 Cash Management Federal Program – All federal programs Criteria – Advances received on federal awards should be expended within 30 days of being drawn down to comply with relevant cash management requirements. Condition and Context – During the performance of our audit, we noted that th...
2021-004 Cash Management Federal Program – All federal programs Criteria – Advances received on federal awards should be expended within 30 days of being drawn down to comply with relevant cash management requirements. Condition and Context – During the performance of our audit, we noted that the Organization had a significant amount of refundable advances on federal awards and had cash on hand that exceeded the anticipated expenses over the next 30 days. As a result of a conversion to a new accounting system, the impact of COVID-19, cash advances were not routinely reconciled during the year ended December 31, 2021. Questioned Costs – None. Effect – The Organization was not in compliance with the Uniform Guidance cash management requirements. Cause – With the conversion to a new accounting system, combined with the COVID-19, new accounting staff, refundable advances were not reconciled timely. Recommendation – The refundable advances of the Organization should be reconciled on a monthly basis, which will permit more accurate draws on federal awards. Views of Responsible Officials and Planned Corrective Actions Management partially agrees with this finding as, in certain instances, the Organization must comply with the payment schedules of our grantors, which typically are on a quarterly basis. In some cases, there are strict schedules of draws in our grant agreements and no requests to draw funds are made. In situations when the Organization has the ability to draw funds, we agree not to make additional draw requests until the Organization has expended the funds already received. In 2021, due to the pandemic and the uncertainty of when programs would continue, many programs were suspended while waiting for travel restrictions to be lifted so that the Organization’s programs could be implemented. We will take the following steps: We will improve procedures to ensure that the drawdown of funds, from those grantors who require drawdowns will not exceed the Organization’s immediate use and we will develop additional procedures, as necessary, to assist in monitoring cash management. Anticipated Completion Date: December 31, 2022 Contact Person: Natalia Arno, President, 202-549-2417
Lack of Documentation Related to Reporting Condition: The Organization did not maintain proper documentation in support of reporting requirements. Corrective Action Planned: The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within th...
Lack of Documentation Related to Reporting Condition: The Organization did not maintain proper documentation in support of reporting requirements. Corrective Action Planned: The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization. Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: Implement
Lack of Documentation for Expenses Submitted for Reimbursement Condition: The Organization submitted costs for reimbursement of medical supplies which could not be supported with related invoices. Corrective Action Planned: The Organization has hired a new Chief Financial Officer, as of March 2022...
Lack of Documentation for Expenses Submitted for Reimbursement Condition: The Organization submitted costs for reimbursement of medical supplies which could not be supported with related invoices. Corrective Action Planned: The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization. Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: Implemented
View Audit 304417 Questioned Costs: $1
Use of Budgeted Versus Actual Costs for Reimbursements Condition: The Organization made drawdowns after month-end based on budgeted period expenses rather than actual salary expenses to support the amounts being requested for reimbursement. Corrective Action Planned: The Organization has hired a n...
Use of Budgeted Versus Actual Costs for Reimbursements Condition: The Organization made drawdowns after month-end based on budgeted period expenses rather than actual salary expenses to support the amounts being requested for reimbursement. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization. Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: Implemented
Lack of Cash Management Documentation Condition: The Organization made drawdowns after month-end based on budgeted period expenditures. Insufficient documentation was kept to clearly document that the amount requested was reviewed for accuracy. Corrective Action Planned: The Organization has hire...
Lack of Cash Management Documentation Condition: The Organization made drawdowns after month-end based on budgeted period expenditures. Insufficient documentation was kept to clearly document that the amount requested was reviewed for accuracy. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organizations policy and procedures related to support documentation retention has been evaluated and updated. Supporting documentation for all drawdown requests are retained by grant. The corrective action for this finding has been approved and implemented by the Organization. Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: Implemented
Given the complexity of the reporting requirements, including changing FAQ's, reporting deadline extensions, and the inability to update reporting to reflect expenses incurred within the guidelines such as lost revenue the Authority will apply such expenses as offsets to its provider relief fund dis...
Given the complexity of the reporting requirements, including changing FAQ's, reporting deadline extensions, and the inability to update reporting to reflect expenses incurred within the guidelines such as lost revenue the Authority will apply such expenses as offsets to its provider relief fund distributions. The Authority will continue to monitor the Health and Human Resources Provider Relief Fund General and Targeted Distribution Post-Payment Notice of Reporting Requirements and the most recently distributed Provide Relief Fund frequently asked questions which provide details on requirements related to the program.
View Audit 304032 Questioned Costs: $1
U.S. Department of Housing and Urban Development – CFDA #14.872 Capital Fund Program – 2021 Cash Management Material Weakness in Internal Control over Compliance Finding Summary: Testing identified differences in amounts drawn down for the Capital Fund program and amounts recorded in the general led...
U.S. Department of Housing and Urban Development – CFDA #14.872 Capital Fund Program – 2021 Cash Management Material Weakness in Internal Control over Compliance Finding Summary: Testing identified differences in amounts drawn down for the Capital Fund program and amounts recorded in the general ledger, resulting in material proposed audit adjustments. In addition, there was no review by another individual prior to the drawdown of funds. Responsible Individual: Steven Trujillo, Executive Director Corrective Action Plan It appears that the differences were mostly between projects and did not result in a material change in the financial statements. However, we recognize the importance of properly recording and documenting general ledger transactions and have review procedures in place to prevent such transactions in the future. Anticipated Completion Date: January 2023
Management Response: The current policy will be reviewed for changes necessary to ensure compliance with Section 330(k)(3)(E), (F), and (G) of the PHS Act; and 42 CFR 51c.303(e), (f), and (g) and 42 CFR 56.303(e), (f), and (g). We concur that we did not write off the receivables from the subsidiary ...
Management Response: The current policy will be reviewed for changes necessary to ensure compliance with Section 330(k)(3)(E), (F), and (G) of the PHS Act; and 42 CFR 51c.303(e), (f), and (g) and 42 CFR 56.303(e), (f), and (g). We concur that we did not write off the receivables from the subsidiary ledger monthly, which will be reviewed as to the efficiency of monthly write-off, with any necessary changes. We did make a bad debt allowance for those write-offs in a timely manner, thus meeting the essence of our policy #PS-06 entitled Billing, Collection and Debt Write-off.
Finding # 2021-008 Utility Allowance Calculation Corrective Action Plan: When the new director, Robert Weismore, was hired on September 7, 2022, he replaced the former director and 3 staff members. In October he hired the current staff of Ms. Schaefer, Ms. Lynn. Ms. Filipski was hired as a part tim...
Finding # 2021-008 Utility Allowance Calculation Corrective Action Plan: When the new director, Robert Weismore, was hired on September 7, 2022, he replaced the former director and 3 staff members. In October he hired the current staff of Ms. Schaefer, Ms. Lynn. Ms. Filipski was hired as a part time employee in the middle of September 2022. For the next 2 months the staff reviewed each file and recalculated the figures using the correct payment standards for the necessary period and also used the September 1, 2022 approved utility schedule installed by the current staff. The recalculations caused the North Syracuse Housing Authority to reimburse $25,463 to previously miscalculated tenants. Also, had to repay HUD $23,000. The current payment standards are up to date and the current utility schedule was updated effective 7/1/2023 and will be updated effective 7/1/24 and each July thereafter.
Finding # 2021-007 Rent Reasonableness Corrective Action Plan: Please see 2020-008 regarding payment standards and utility schedules. The current staff updated the current rent reasonableness comparisons during the summer of 2023. This was accomplished by completing a survey of area wide rents and ...
Finding # 2021-007 Rent Reasonableness Corrective Action Plan: Please see 2020-008 regarding payment standards and utility schedules. The current staff updated the current rent reasonableness comparisons during the summer of 2023. This was accomplished by completing a survey of area wide rents and amenities for comparable units. Each folder has a rent reasonableness form showing the comparables and justifying the rent being changed is eligible and within reason.
Finding # 2021-004 Voucher Re-Examination Corrective Action Plan: Effective 11/1/2022 all recommendations are completed with up to 90 days notice to prospective tenant, with notification as the proper verification needed to complete the recert to completion. Notification is also sent to the owner o...
Finding # 2021-004 Voucher Re-Examination Corrective Action Plan: Effective 11/1/2022 all recommendations are completed with up to 90 days notice to prospective tenant, with notification as the proper verification needed to complete the recert to completion. Notification is also sent to the owner of the recertification. Once the proper verification is completed calculations are completed the tenant and owner are mailed an addendum stating new rental breakdown. The new current staff has between 10 and 15 years' experience completing recertifications. Please see item 2020-008 regarding utilities and payment standards.
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