Corrective Action Plans

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Finding 1313 (2023-001)
Significant Deficiency 2023
JM Apartments agrees with the audit finding identified as part of the FY23 Annual Audit performed by Marcum, Inc. The inconsistencies occurred during a transition of personnel and is believed to be an isolated incident associated with orientation. Going forward, controls will be put in place to ass...
JM Apartments agrees with the audit finding identified as part of the FY23 Annual Audit performed by Marcum, Inc. The inconsistencies occurred during a transition of personnel and is believed to be an isolated incident associated with orientation. Going forward, controls will be put in place to assure compliance, including, but not limited to, centralization of files, improved orientation procedures and periodic internal reviews conducted by Finance staff.
View Audit 2464 Questioned Costs: $1
The superintendent will verify with the staff member in charge of the verification process that the verification process is completed according to the proper timeline; review the income verification information provided by families and ensure the proper status has been redetermined; ensure families ...
The superintendent will verify with the staff member in charge of the verification process that the verification process is completed according to the proper timeline; review the income verification information provided by families and ensure the proper status has been redetermined; ensure families are timely notified of the confirmed or changed status; verify necessary status changes have been updated in the nutrition program software.
View Audit 2430 Questioned Costs: $1
When District staff learns o facts that could affect eligibility determination, they will request households submit a new application with the updated information rather than altering the original application.
When District staff learns o facts that could affect eligibility determination, they will request households submit a new application with the updated information rather than altering the original application.
View Audit 2430 Questioned Costs: $1
FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS SIGNIFICANT DEFICIENCY 2023.001 – Sliding Fee Scale Discount Recommendation The Center should implement a system of controls to ensure all sliding fee discounts are properly supported. Action Taken All the Practice Managers (PM) and Director of Practice M...
FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS SIGNIFICANT DEFICIENCY 2023.001 – Sliding Fee Scale Discount Recommendation The Center should implement a system of controls to ensure all sliding fee discounts are properly supported. Action Taken All the Practice Managers (PM) and Director of Practice Management have been and will continue to review and monitor the sliding fee discount (SFD) on a daily basis on all slides for internal control. StayWell’s Patent Intake solution, ‘Phreesia’ has a dashboard in which this tool is being utilized effective November 1st, 2022 to monitor internal controls at the front desk operations with regard to accuracy of registration, patient demographic, insurance verification and most importantly the application of the Sliding Fee Discount Program and ensuring there is proper documentation to support (POI). Monthly random audits on the sliding fee discount program will continue to be performed by the PM’s and the Director of Practice Management. Director of Practice Management will also continue to perform SFD program compliance education to all Patients Service Associates (PSA) and all Practice Managers (PM) on a as needs basis.
View of Responsible Official: The Agency agrees with the finding. The Agency will terminate ineligible participant immediately and will conduct an internal audit of all current participants to be in compliance with financial reporting and single audit reporting requirements. Planned Implementation D...
View of Responsible Official: The Agency agrees with the finding. The Agency will terminate ineligible participant immediately and will conduct an internal audit of all current participants to be in compliance with financial reporting and single audit reporting requirements. Planned Implementation Date of Corrective Action : 10/31/2023 Person Responsible for Corrective Action: Andrew Boozer, Executive Director, Marcus Hunter, Director of Finance and Operations, and Beverly Breuer, Director of FGP/SCP Programs.
Views of Responsible Official and Planned Corrective Actions: The District agrees with this recommendation. Brian Bartlett, School Business Administrator, will be responsible for ensuring the maintenance of effort (MOE) calculation is completed within the required timeline provided by NYSED. The MOE...
Views of Responsible Official and Planned Corrective Actions: The District agrees with this recommendation. Brian Bartlett, School Business Administrator, will be responsible for ensuring the maintenance of effort (MOE) calculation is completed within the required timeline provided by NYSED. The MOE calculation for 2022-23 was submitted to NYSED and evidenced that the District was in compliance with the grant regulations. This will be corrected by June 30, 2024.
Segregation of Duties Supportive Housing for the Elderly – Assistance Listing No. 14.157 Recommendation: The Project should continue to evaluate its staffing in order to segregate incompatible duties whenever possible. Explanation of disagreement with audit finding: There is no disagreement with the...
Segregation of Duties Supportive Housing for the Elderly – Assistance Listing No. 14.157 Recommendation: The Project should continue to evaluate its staffing in order to segregate incompatible duties whenever possible. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The board of directors will continue to closely monitor the financial operations of the Project. Name(s) of the contact person(s) responsible for corrective action: Mary Gilberts, Management Agent Planned completion date for corrective action plan: June 2024
During the 2023 audit of PrairieStar Health Center, FORVIS found two issues with the sliding fee set up. The first issue was that CPT code 73610 was attached to the wrong slide level due to a change in price. The CPT code was attached to the Radiology 2 group which is for CPTs between $100.00 and ...
During the 2023 audit of PrairieStar Health Center, FORVIS found two issues with the sliding fee set up. The first issue was that CPT code 73610 was attached to the wrong slide level due to a change in price. The CPT code was attached to the Radiology 2 group which is for CPTs between $100.00 and $114.99. The price of the CPT had been changed from $102.00 to $120.00 and should have been moved to the Radiology 3 group which is for CPTs between $115.00 and $169.99. The second issue was that CPT code 90620 was not set up to slide. In the six and one-half years that I have been at PrairieStar, we have made great strides in identifying CPT codes that were not attached to a sliding fee group and correcting them. I feel that this is a rare CPT code that has been missed in our review. Plan to Correct Finding Multiple steps have or will be taken to correct this finding. • Both of the errors above have been corrected in our EMR. • We are getting ready to update pricing. As part of this update, I will review the slide group attached to each CPT code to make sure that the correct slide is attached. • We will continue to randomly review sliding fee calculations each month to help identify any errors in sliding fee calculations or setup. Date of Completion Both of the errors described above have been corrected. There is no completion date for the monthly review. This is a part of our monthly routine. Responsible Party Shandi Stallman, Chief Financial Officer, is the party that has overall responsibility for this corrective action.
October 24, 2023 Finding Number: 2023-003 – Significant Deficiency in Internal Control – Eligibility Condition: Of the 22 applications for reduced meals that were selected for testing, 3 did not document evidence of review by staff. Responsible Person: Kim Gagne – Director of Food Service Imple...
October 24, 2023 Finding Number: 2023-003 – Significant Deficiency in Internal Control – Eligibility Condition: Of the 22 applications for reduced meals that were selected for testing, 3 did not document evidence of review by staff. Responsible Person: Kim Gagne – Director of Food Service Implementation Date: 10-24-2023 This year we have a 2-person checking system, Kim Gagne initially completes the applications with a signature and Jody King double checks every application for errors and oversites and adds her signature also. Both have been through the MDE training on the applications and the required information they need. Sincerely, Stephen Grubaugh Director of Business Services
Public and Indian Housing AL #14.850 Material Weakness Internal Control Over Compliance Eligibility Checklists 2023-003 Condition: The Commission uses internal control checklists to demonstrate compliance with the various eligibility requirements. During audit fieldwork, we identified two instances...
Public and Indian Housing AL #14.850 Material Weakness Internal Control Over Compliance Eligibility Checklists 2023-003 Condition: The Commission uses internal control checklists to demonstrate compliance with the various eligibility requirements. During audit fieldwork, we identified two instances in which the checklists were used, but steps related to background checks were not complete. In addition, there was no documentation maintained to prove these checks were performed. Criteria: All eligibility requirements must be verified prior to determining tenant eligibility. Repeat of Prior Year Finding: No Auditor’s Recommendation: We recommend the Commission provide further training for program staff and implement periodic reviews of tenant files to ensure internal control processes are followed and eligibility documentation is maintained. Management’s Response: The Commission has provided training for program staff and performs periodic reviews of tenant files to ensure internal control processes are followed and eligibility documentation is maintained. Anticipated Completion Date: Periodic reviews began January 2023. Staff training and periodic reviews are ongoing.
In Finding 2023-001, it was noted that the Organization had found 1 of the 15 patients tested were not in the proper slide category based on the income backup received for the patient. We also found 1 of the 15 patients tested did not have backup for income on file for the sliding fee scale but was ...
In Finding 2023-001, it was noted that the Organization had found 1 of the 15 patients tested were not in the proper slide category based on the income backup received for the patient. We also found 1 of the 15 patients tested did not have backup for income on file for the sliding fee scale but was on the scale and had visits that were applied to the scale. Management recognizes the importance of complying with grant guidelines. In response to Finding 2023-001, Management has taken the necessary steps to ensure full compliance with the provisions of the program, identified specifically as Sliding Fee Discount Program (SFDP) within our organization. These steps include: a.       Implementing a new process for adding the sliding fee discount to patient accounts. Each patient that applies for the slide will be scheduled under “eligibility” with an appointment. After the patient has completed the application, the information will be entered into Athena, and then the plan will be calculated. The paperwork will then be uploaded as an attachment to the Sliding Fee Discount Policy. Each week, a report will be generated in Athena and sent to the Clinical Services Manager. This report will list all patients that had an appointment with eligibility for the prior week. The Clinical Services Manager will then use that report and verify that all information is uploaded and entered correctly. b.       Training on the new process will occur. All support staff responsible for entering and uploading the Sliding Fee Discount will go through thorough training of the new process. Additionally, the Clinical Services Manager will complete peer-to-peer training on the verification process.
Action Plan for Enrollment Reporting Audit Finding 2023-001 Issue - It was discovered that there was a Colleague system update that occurred that caused the Standard Reporting Flag to change from Yes to No, which resulted in inaccurate reporting to NSC. For all terms that a student can attend, the...
Action Plan for Enrollment Reporting Audit Finding 2023-001 Issue - It was discovered that there was a Colleague system update that occurred that caused the Standard Reporting Flag to change from Yes to No, which resulted in inaccurate reporting to NSC. For all terms that a student can attend, the flag must be set to Yes for the reporting to be accurate. The following action plans will be put into place, to ensure that reporting is accurate: Action Plan 1 - A self-audit will be completed monthly when National Student Clearinghouse enrollment reporting is completed. This self-audit is to verify the students' enrollment status is accurate. To verify the accuracy, a sample of students will be pulled from the self-audit who have withdrawn, graduated, or had enrollment changes. Action Plan 2 - Admissions and Records and Financial Aid will work closely with the IT department any time there is a Colleague system update to fully comprehend the implications of the system update and how that could impact reporting and documented procedures.
Identifying Number: 2023-005 Finding: The College did not apply the appropriate clock to credit hour conversion formula for certain applicable financial aid eligible programs. The College also did not have sufficient evidence of controls being in place to ensure compliance with this requirement. ...
Identifying Number: 2023-005 Finding: The College did not apply the appropriate clock to credit hour conversion formula for certain applicable financial aid eligible programs. The College also did not have sufficient evidence of controls being in place to ensure compliance with this requirement. Corrective Action Planned: Moraine Valley Community College will evaluate all certificates that are standalone programs. Financial Aid will receive a list of these programs and work with IT to identify students enrolled in those programs. Financial Aid will also update our policies and procedures to ensure that all clock to credit hour conversion formulas are being applied and documented per Uniform Grant Guidance (34 CFR 688.8). Anticipated Completion Date: June 30, 2024 Responsible Person: Tasha Campbell, Director of Financial Aid campbellt68@morainevalley.edu
The accounting department, under direction of the CFO, will conduct monthly audits of random patients' accounts for whom the sliding fee schedule has been applied, as well as training for receptionist to minimize errors. Receptionists have been mandated, along with assistance from internal billing s...
The accounting department, under direction of the CFO, will conduct monthly audits of random patients' accounts for whom the sliding fee schedule has been applied, as well as training for receptionist to minimize errors. Receptionists have been mandated, along with assistance from internal billing staff, to review all patients' accounts (including income verification) at least annually.
Completed corrective action: Manager completed correction and new HUD 50059A recertification's corrected for July 31, 2023. Ongoing Corrective Action: Additional file review after recertifications and move-ins. Additional trainings for Income VS Assets for all managers.
Completed corrective action: Manager completed correction and new HUD 50059A recertification's corrected for July 31, 2023. Ongoing Corrective Action: Additional file review after recertifications and move-ins. Additional trainings for Income VS Assets for all managers.
Completed corrective action: Manager completed correction and new HUD 50059A recertification's corrected for June 30, 2023. Ongoing Corrective Action: Additional file review after recertifications and move-ins. Additional trainings for Income VS Assets for all managers.
Completed corrective action: Manager completed correction and new HUD 50059A recertification's corrected for June 30, 2023. Ongoing Corrective Action: Additional file review after recertifications and move-ins. Additional trainings for Income VS Assets for all managers.
Completed corrective action: Manager completed correction and new HUD 50059A recertification's corrected for June 30, 2023. Ongoing Corrective Action: Additional file review after recertifications and move-ins. Additional trainings for Income VS Assets for all managers.
Completed corrective action: Manager completed correction and new HUD 50059A recertification's corrected for June 30, 2023. Ongoing Corrective Action: Additional file review after recertifications and move-ins. Additional trainings for Income VS Assets for all managers.
Finding 2023-003 The Authority agrees with the finding and responds by stating that our project is relatively small with only one administrative staff. The Board has reviewed this issue and determined there are no additional procedures which can reasonably be done to eliminate these deficiencies a...
Finding 2023-003 The Authority agrees with the finding and responds by stating that our project is relatively small with only one administrative staff. The Board has reviewed this issue and determined there are no additional procedures which can reasonably be done to eliminate these deficiencies and accepts them.
Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: A review is being completed by the Registrar’s Office to determine if something is in the student record that may prevent a student from being reported correctly. If a common factor can be determined, then ...
Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: A review is being completed by the Registrar’s Office to determine if something is in the student record that may prevent a student from being reported correctly. If a common factor can be determined, then it will be corrected. Until then, Enrollment reporting to NSC will be reviewed twice. Follow up will be done regarding last date of attendance reporting for those students who do fail to complete the semester. Person Responsible for Corrective Action Plan: Karen LaQuey, Director, Student Financial Aid Director; Wendy McNeeley, previous Registrar; Kristina Penland, Registrar Anticipated Date of Completion: 12/12/2023
Views of responsible officials and planned corrective actions: The Financial and Data Analytics Director conducts spot testing of each bi-weekly payroll expenditure report received from Human Resources for eligible PRF reporting. Evidence of testing is retained. Responsible Officials: Dean C. Cocchi...
Views of responsible officials and planned corrective actions: The Financial and Data Analytics Director conducts spot testing of each bi-weekly payroll expenditure report received from Human Resources for eligible PRF reporting. Evidence of testing is retained. Responsible Officials: Dean C. Cocchi, Vice President and CFO Completion Date: March 31, 2022
The Director has added to her monthly checklist to review quality control logs and follow up on any QC reviews that are not being conducted in a timely fashion.
The Director has added to her monthly checklist to review quality control logs and follow up on any QC reviews that are not being conducted in a timely fashion.
Finding 361 (2023-003)
Significant Deficiency 2023
Contact Person – Superintendent; Corrective Action Plan – The District has established a procedure for review of journal entries; Completion Date – Completed
Contact Person – Superintendent; Corrective Action Plan – The District has established a procedure for review of journal entries; Completion Date – Completed
Condition - The institution had the following changes that were required to be updated on their ECAR: • The V.P. of Finance (equivalent to a chief financial officer) was no longer active at the institution as of April 2022. • A Board Member was no longer serving the institution as of May 2021. •...
Condition - The institution had the following changes that were required to be updated on their ECAR: • The V.P. of Finance (equivalent to a chief financial officer) was no longer active at the institution as of April 2022. • A Board Member was no longer serving the institution as of May 2021. • A Board Member was added to the Board in October 2021. These changes to the institution’s ECAR information were not submitted until June 2023, subsequent to inquiry by auditors. Corrective Action Plan - The College will review current procedures and adjust accordingly to ensure timely ECAR updates. Contact Person, Title and Phone Number - Chris Scott, President, (815)-772-7218, Ext. 212 Anticipated Completion Date - August 1, 2023
Management agrees with the finding and will begin an independent review of each tenant file to include examination of proof of disability paperwork to determine if there are any discrepancies and take corrective measures. Leasing office staff will undergo additional HUD 811 training regarding the in...
Management agrees with the finding and will begin an independent review of each tenant file to include examination of proof of disability paperwork to determine if there are any discrepancies and take corrective measures. Leasing office staff will undergo additional HUD 811 training regarding the initial and recertification process. Additionally, management is staffing the property with a dedicated property manager that will be responsible for reviewing tenant files for compliance with HUD procedures including eligibility requirements and ensure supporting documentation is maintained in each tenant’s file prior to signing new or amended leases. Management has requested proof of disability from the tenant that satisfies HUD guidelines and will not renew lease if it is not received. The training and file review will be completed by November 30, 2023. If the tenant does not produce proof of disability their lease will not be renewed on May 11, 2024.
View Audit 460 Questioned Costs: $1
Finding 2023-002 Internal Control Structure Material Weakness – Eligibility, Reporting and Special Tests and provisions Repeat Finding 2022-02 I agree with finding The Authority is relatively small with limited administrative staff. Further, the Board of Commissioners is a volunteer oversight boar...
Finding 2023-002 Internal Control Structure Material Weakness – Eligibility, Reporting and Special Tests and provisions Repeat Finding 2022-02 I agree with finding The Authority is relatively small with limited administrative staff. Further, the Board of Commissioners is a volunteer oversight board and not a managing board and does not have the time or expertise to provide the necessary services to correct the internal control deficiencies noted. The Board has reviewed the issue and determined that there are no additional procedures which can be reasonably done to eliminate the deficiencies and accepts them.
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