Corrective Action Plans

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7. These improvements were reviewed during the 2025 HRSA Verification Site Visit and contributed to clearance of relevant conditions under Chapter 21 of the HRSA Health Center Compliance Manual.
7. These improvements were reviewed during the 2025 HRSA Verification Site Visit and contributed to clearance of relevant conditions under Chapter 21 of the HRSA Health Center Compliance Manual.
Corrective Action Plan:
Corrective Action Plan:
1. Continue weekly updates of the 12-month rolling cash flow forecast.
1. Continue weekly updates of the 12-month rolling cash flow forecast.
2. Maintain twice-weekly internal cash reviews to align disbursements with available cash and grant timing.
2. Maintain twice-weekly internal cash reviews to align disbursements with available cash and grant timing.
3. Monitor operating accounts against internal minimum thresholds and refine automated alerts as needed.
3. Monitor operating accounts against internal minimum thresholds and refine automated alerts as needed.
4. Reassess account structure annually and maintain contingency agreements with the bank.
4. Reassess account structure annually and maintain contingency agreements with the bank.
5. Require refresher training in cash flow management for new financial staff and Finance Committee members at least once annually.
5. Require refresher training in cash flow management for new financial staff and Finance Committee members at least once annually.
6. Maintain Finance Committee oversight of liquidity metrics, with trends tracked in monthly dashboards.
6. Maintain Finance Committee oversight of liquidity metrics, with trends tracked in monthly dashboards.
7. Review internal controls annually to ensure continued alignment with 45 CFR § 75.302(b)(4) and evolving HRSA guidance.
7. Review internal controls annually to ensure continued alignment with 45 CFR § 75.302(b)(4) and evolving HRSA guidance.
We will implement policies and procedures to ensure compliance with applicable grant requirements.
We will implement policies and procedures to ensure compliance with applicable grant requirements.
View Audit 362988 Questioned Costs: $1
Planned Corrective Action: A Uniform Guidance policy and Procedure document has been adopted. Planned Implementation Date of Corrective Action: The policy was effective 03/21/2025. Person Responsible for Corrective Action: Finance Director
Planned Corrective Action: A Uniform Guidance policy and Procedure document has been adopted. Planned Implementation Date of Corrective Action: The policy was effective 03/21/2025. Person Responsible for Corrective Action: Finance Director
2021-002 Reserve Account Category: Significant Deficiency in Internal Control and Noncompliance Condition: The Authority has a deposit deficiency of $40,416 in the Reserve Account. The balance of the debt service reserve as of June 30, 2021, shall be $90,936. Management’s Response: Starting in FY 20...
2021-002 Reserve Account Category: Significant Deficiency in Internal Control and Noncompliance Condition: The Authority has a deposit deficiency of $40,416 in the Reserve Account. The balance of the debt service reserve as of June 30, 2021, shall be $90,936. Management’s Response: Starting in FY 2024-2025, the Finance Department will initiate the necessary transfers to the Reserve Account to rectify the deposit deficiency. Additionally, we will establish a plan for regular monitoring of the account to prevent future deficiencies. To ensure ongoing compliance and to identify any potential issues early, we will schedule more frequent internal audits. Person in charge: Juan C. Rodriguez Rivera Accounting Official 787-705-7188 Juan.rodriguez@lra.pr.gov Implementation Date: FY 2024-2025
Item 2021.006 – Cash Management Recommendation The Center should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Prepare written proced...
Item 2021.006 – Cash Management Recommendation The Center should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Prepare written procedures to document the process for Drawdown requests, including the initial review, documented approval proves, submission to the funding agency, and the recoding of the drawdown in the accounting system immediately after submission. • Maintain detailed records of all drawdown requests, supporting documentation, approvals, and correspondence. • Conduct regular internal reviews of drawdown activities to ensure compliance with procedures and maintain audit trail. • Review drawdown procedures annually to ensure they remain current with funding agency guidelines and best practices.
Item 2021.006 – Cash Management Recommendation The Center should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Prepare written proced...
Item 2021.006 – Cash Management Recommendation The Center should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Prepare written procedures to document the process for Drawdown requests, including the initial review, documented approval proves, submission to the funding agency, and the recoding of the drawdown in the accounting system immediately after submission. • Maintain detailed records of all drawdown requests, supporting documentation, approvals, and correspondence. • Conduct regular internal reviews of drawdown activities to ensure compliance with procedures and maintain audit trail. • Review drawdown procedures annually to ensure they remain current with funding agency guidelines and best practices.
Audit Finding Reference: Federal Award Findings and Questioned Costs: 2021-03 (Single audit submission) Planned Corrective Action: The Kanawha Valley Collective, Inc. will develop internal policies and procedures designed to ensure a timely annual financial statement closing which will allow the req...
Audit Finding Reference: Federal Award Findings and Questioned Costs: 2021-03 (Single audit submission) Planned Corrective Action: The Kanawha Valley Collective, Inc. will develop internal policies and procedures designed to ensure a timely annual financial statement closing which will allow the required single audit to be completed in a timelier manner. Name of Contact Person: Traci Strickland Anticipated completion date: June 30, 2025
Audit Finding Reference: Federal Award Findings and Questioned Costs: 2021-02 (Reporting) Planned Corrective Action: The Kanawha Valley Collective, Inc. will implement enhanced reconciliation and documentation procedures that timely identify and allow for the correction of differences between the ac...
Audit Finding Reference: Federal Award Findings and Questioned Costs: 2021-02 (Reporting) Planned Corrective Action: The Kanawha Valley Collective, Inc. will implement enhanced reconciliation and documentation procedures that timely identify and allow for the correction of differences between the accounting recordkeeping and the grant reporting documentation. Name of Contact Person: Traci Strickland
Finding Reference Number: MW2021-009 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2021: CUAHSI used a single payment gateway for registration on CUAHSI events and was able to accurately ...
Finding Reference Number: MW2021-009 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2021: CUAHSI used a single payment gateway for registration on CUAHSI events and was able to accurately document and produce grant-specific totals for audit year 2021 program income. CUAHSI staff missed the NSF filing deadline for declaring federal fiscal year 2021 program income by one day (submitted November 16th, 2021). Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI continues to use a single payment gateway for events and registration fees which supports segregation of payments per event and per grant. Program income has been reported to NSF accurately and on time beginning in 2023 and appropriate staff and policies are in place to ensure future compliance. Name of Contact Person: 􀁸 Maureen S. Ako, Director of Finance 􀁸 Telephone: (339)221-5400 􀁸 Email: msabino@cuahsi.org Projected Completion Date: NA; is complete
Finding Reference Number: MW2021-08 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2021: All advance draws in 2021 were properly recorded as deferred revenue in the accounting books, see S...
Finding Reference Number: MW2021-08 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2021: All advance draws in 2021 were properly recorded as deferred revenue in the accounting books, see Statement of Financial Position. Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI consider this finding resolved. As covered in the corrective action to MW2021-006, CUAHSI implemented the drawdown procedure as documented in company policy which includes twotiered preparation and review and requires review and approval by the Prime funder for working capital advances. CUAHSI stopped the non-compliance in 2023 by halting all draws against NSF awards in late March 2023 (when this non-compliance became known to the current Executive Director) until June 15th, 2023, at which time CUAHSI completed a draw from an NSF aligned with the current policies. The certified SF-270 and draw documentation was reviewed and approved by NSF. Name of Contact Person: 􀁸 Jordan S Read, Executive Director 􀁸 Telephone: (339)933-4660 􀁸 Email: jread@cuahsi.org Projected Completion Date: NA; is complete
Finding Reference Number: MW2021-006 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2021: CUAHSI was unable to produce supporting documentation substantiating expenses behind numerous cash...
Finding Reference Number: MW2021-006 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2021: CUAHSI was unable to produce supporting documentation substantiating expenses behind numerous cash draws from NSF during audit year 2021. Corrective actions to processes and responsibilities impacting subsequent years: As of June 15th, 2023, all CUAHSI draws from NSF awards include supporting documents for expenses and a certified SF-270. The SF-270 and documents are stored in a secure and organized document management system. Per CUAHSI’s updated policies, each draw follows segregation of duties and an internal review, approval, and certification process. CUAHSI’s Operations and Program Assistant reviews documents quarterly to ensure all certified draw requests are filed along with associated backup and reports status to Management and relevant CUAHSI Officers (e.g., Treasurer) to ensure policy adherence. Name of Contact Person: 􀁸 Maureen S. Ako, Director of Finance 􀁸 Telephone: (339)221-5400 􀁸 Email: msabino@cuahsi.org Projected Completion Date: NA; is complete
U.S. Department of Health and Human Services 2021-001 Provider Relief Fund – Assistance Listing No. 93.498 Recommendation: We recommend that management implement a system that allows for easy identification of any copies of invoices paid. Explanation of disagreement with audit finding: There is no d...
U.S. Department of Health and Human Services 2021-001 Provider Relief Fund – Assistance Listing No. 93.498 Recommendation: We recommend that management implement a system that allows for easy identification of any copies of invoices paid. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Huntsville Community Hospital, Inc. now operates under a full digitized accounting and payables system which allows them to pull any historical invoice copies as needed. Name(s) of the contact person(s) responsible for corrective action: Paul Hanson, CFO Planned completion date for corrective action plan: Huntsville Community Hospital, Inc. now operates under a full digitized accounting and payables system.
View Audit 348302 Questioned Costs: $1
We agree that surplus cash deposit was not made in FY2020, and the recommendations described above. Management will deposit any surplus cash required into the residual receipts in future periods.
We agree that surplus cash deposit was not made in FY2020, and the recommendations described above. Management will deposit any surplus cash required into the residual receipts in future periods.
We agree that surplus cash deposit was not made in FY2019, and the recommendations described above. Management will deposit any surplus cash required into the residual receipts in future periods.
We agree that surplus cash deposit was not made in FY2019, and the recommendations described above. Management will deposit any surplus cash required into the residual receipts in future periods.
The Accounting department has established policies and procedures to ensure that grant billing is done properly and reconciled monthly. Part of the CFO and Controller’s duty is to ensure that grant billing is reconciled monthly, and there are no variances or discrepancies with the billing, drawdowns...
The Accounting department has established policies and procedures to ensure that grant billing is done properly and reconciled monthly. Part of the CFO and Controller’s duty is to ensure that grant billing is reconciled monthly, and there are no variances or discrepancies with the billing, drawdowns, and expenses. Last, the CFO and Controller are currently working diligently to ensure grant billing is properly done in the period the expenses are incurred.
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