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Corrective Action Plans

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Finding 393842 (2023-001)
Significant Deficiency 2021
Hospital Comunitario Buen Samaritano, Inc.
PR
Questioned Costs Eligibility Subrecipient Monitoring
As discussed during the past couple of weeks we are lacking some detailed information that could have helped us clarify some of, or all of the questions and/ or doubts that you have raised, but unfortunately key people that generated the list are no longer employees (Finance Director, Human Resource...
As discussed during the past couple of weeks we are lacking some detailed information that could have helped us clarify some of, or all of the questions and/ or doubts that you have raised, but unfortunately key people that generated the list are no longer employees (Finance Director, Human Resource Director, and Payroll Manager). In regards to whom was eligible, this is a more difficult question to answer primarily due to the same reasons expressed above. But asking the team members that are still employed, they indicated that most of areas during this stage of the pandemic had direct or indirect contact with the patients visiting us, reason being that a significant percentage of our employees at the time were diagnosticated with COVID-19. In order to significantly improve future Federal funds receipts management processes, we will take the following steps: 1. Discuss, document and safe guard documentations regarding meetings that take place with all responsible parties on Federal requirements that must be followed to ensure compliance (Signatures required of all participants) 2. Depending on the nature of the funds and its intended utilization, the responsible parties will designate whom (Position/Department) will be the custodian of all the documentation 3. Ensure that each step of the implementation processes is well documented, with clear instructional details that are required to comply with the Federal requirements 4. Before submitting the required information, the responsible parties must meet to ensure that all requirements have been met, and that all required documentation is safe guarded for future reference (Signatures required of all participants) The plan will be approved by the Board and implemented no later than April 26th, 2024.
View Audit 304036 Questioned Costs: $1
Finding 393787 (2021-004)
Material Weakness 2021
Housing Authority of the City of Pueblo
CO
Eligibility Material Weakness Internal Control / Segregation of Duties
U.S. Department of Housing and Urban Development – CFDA #14.850 Public and Indian Housing – 2021 Eligibility Material Weakness in Internal Control over Compliance Finding Summary: Testing indicated that there was an error in a tenant’s rent calculation that was not detected by the Authority’s intern...
U.S. Department of Housing and Urban Development – CFDA #14.850 Public and Indian Housing – 2021 Eligibility Material Weakness in Internal Control over Compliance Finding Summary: Testing indicated that there was an error in a tenant’s rent calculation that was not detected by the Authority’s internal controls. In addition, there was no review of the rent calculation by another individual. Responsible Individual: Steven Trujillo, Executive Director Corrective Action Plan: We have implemented a process to ensure eligibility requirements are being followed and that another person reviews the rent calculations once they are determined. Anticipated Completion Date: January 2023
View Audit 303983
Finding 393783 (2021-011)
Significant Deficiency 2021
Housing Authority of the City of Pueblo
CO
HUD Housing Programs Eligibility Significant Deficiency
U.S. Department of Housing and Urban Development – CFDA #14.182/14.856 Section 8 Project-based Cluster– 2021 Eligibility Significant Deficiency in Internal Control over Compliance Finding Summary: The Authority could not find a tenant file from 2021. In addition, there was 1 participant file that di...
U.S. Department of Housing and Urban Development – CFDA #14.182/14.856 Section 8 Project-based Cluster– 2021 Eligibility Significant Deficiency in Internal Control over Compliance Finding Summary: The Authority could not find a tenant file from 2021. In addition, there was 1 participant file that did not have a signed HUD-50059 form that was signed by the participant or the Authority. Responsible Individual: Steven Trujillo, Executive Director Corrective Action Plan: We have established procedures to ensure that all files are maintained and that all forms are signed by both the tenant and the Authority. Anticipated Completion Date: January 2023
View Audit 303983
Community Development Partnership
MA
Subrecipient Monitoring Eligibility
Upon the completion of the annual audits for FY21, FY22 and FY23 management will file Form SF-SAC with the Federal Audit Clearing House (FAC). Thereafter the annual audit will be completed on a timely basis which will allow for the timely filing of the Form SF-SAC with the FAC.Anticipated Completio...
Upon the completion of the annual audits for FY21, FY22 and FY23 management will file Form SF-SAC with the Federal Audit Clearing House (FAC). Thereafter the annual audit will be completed on a timely basis which will allow for the timely filing of the Form SF-SAC with the FAC.Anticipated Completion Date October 15, 2024.Responsible Contact Person-Kathleen Boyce, CFAO
View Audit 303856
Finding 393335 (2021-009)
Significant Deficiency 2021
Village of North Syracuse Housing Authority
NY
HUD Housing Programs Eligibility
Finding # 2021-009 HCV Waiting List Tenant Selection Corrective Action Plan: With the newly hired staff as of October 2022, the process of selecting eligible tenants from the list has been accomplished by identifying the preference and verifying in writing the reason for such preference to move for...
Finding # 2021-009 HCV Waiting List Tenant Selection Corrective Action Plan: With the newly hired staff as of October 2022, the process of selecting eligible tenants from the list has been accomplished by identifying the preference and verifying in writing the reason for such preference to move forward with the housing the applicant. All verification is kept in the eligible tenant file. The existing staff has had 10-15 years' experience maintaining Federal program waiting list.
View Audit 303605
Finding 392607 (2021-007)
Material Weakness 2021
Fairbanks Rescue Mission, Inc.
AK
Questioned Costs HUD Housing Programs Subrecipient Monitoring
Federal Award Finding: 2021-007 Material Weakness in Internal Control over Compliance and Noncompliance - Eligibility Requirement. Name and Contact Person: Pete Kelly, Chief Executive Officer. Corrective Action: The Fairbanks Rescue Mission's Board of Directors created a Finance Committee with exte...
Federal Award Finding: 2021-007 Material Weakness in Internal Control over Compliance and Noncompliance - Eligibility Requirement. Name and Contact Person: Pete Kelly, Chief Executive Officer. Corrective Action: The Fairbanks Rescue Mission's Board of Directors created a Finance Committee with extensive banking and accounting experience to create a higher level of scrutiny and oversite of the Missions finances. We contracted a professional accounting/bookkeeping firm {Midnight Sun Bookkeeping Services) and empowered them to establish procedures and practices consistent with GAAP {Generally Accepted Accounting Principles) as well as track and participate in day to day activities of Accounting; thereby, assuring accuracy of financial data and assuring compliance. We have formalized check writing, money handling, and credit card control procedures. Switched to an online time tracking system for employees and digitized all employee documents. Created an online filing system for all grant expenses Proposed Completion Date: January 01, 2024
View Audit 302911 Questioned Costs: $1
Finding 392595 (2021-001)
Significant Deficiency 2021
Self Regional Healthcare and Affiliates
SC
Questioned Costs Internal Control / Segregation of Duties Eligibility
Contact Person: Timothy Evans Managements Response: Management had claimed pharmacy costs for drugs that were reimbursed by insurance plans. We incorrectly made an assumption that all drug related expenditures for treating the coronavirus virus were allowable expenditures. We have changed o...
Contact Person: Timothy Evans Managements Response: Management had claimed pharmacy costs for drugs that were reimbursed by insurance plans. We incorrectly made an assumption that all drug related expenditures for treating the coronavirus virus were allowable expenditures. We have changed our processes for inclusion of only expenditures that have not been reimbursed. Similarly we included costs of COVID testing expenditures however, some of those costs were either billed to patients or reimbursed from other sources. We have corrected that process also. Completion Date: January 2024.
View Audit 302889 Questioned Costs: $1
Finding 392586 (2021-004)
Material Weakness 2021
The Jackson County Health Care Authority
AL
Questioned Costs Allowable Costs / Cost Principles Eligibility
Finding 2021-004- Material Weakness and Material Noncompliance over Allowable Cost and Reporting Contact Person: Andrew Wenning Managements Response: During a review of expenses related to the COVID pandemic, the audit identified payroll and non-payroll expenses that management first thought eligibl...
Finding 2021-004- Material Weakness and Material Noncompliance over Allowable Cost and Reporting Contact Person: Andrew Wenning Managements Response: During a review of expenses related to the COVID pandemic, the audit identified payroll and non-payroll expenses that management first thought eligible but on further review, (and subsequent to the submission to the portal) determined were unallowable per the Coronavirus Relief Fund grant terms and conditions. Management has put into place a policy for an individual in the accounting department to review all COVID expenses on a monthly basis going forward. In addition, management will further investigate the total likely questioned cost in order to determine the complete known questioned cost in the period 1 payroll and non-payroll expenditure population by June 30, 2024. For payroll expenses, the policy includes that a review and approval of the expenditures will be performed by an individual in accounting to ensure that the hours and wages calculated meet the terms and conditions of the CRF. If any non-eligible payroll expenses are identified during the review process, they will be removed. For all other expenses, we will obtain and retain approved copies of all invoices or other documentation to support expenses and review for eligibility. If any non-eligible expenses are identified during the review process, they will be removed. Completion Date: April 5, 2024
View Audit 302859 Questioned Costs: $1
Finding 392585 (2021-003)
Material Weakness 2021
The Jackson County Health Care Authority
AL
Questioned Costs Allowable Costs / Cost Principles Eligibility
Finding 2021-003- Material Weakness and Material Noncompliance over Allowable Cost and Reporting Contact Person: Andrew Wenning Managements Response: During a review of expenses related to the COVID pandemic, the audit identified payroll and non-payroll expenses that management first thought eligibl...
Finding 2021-003- Material Weakness and Material Noncompliance over Allowable Cost and Reporting Contact Person: Andrew Wenning Managements Response: During a review of expenses related to the COVID pandemic, the audit identified payroll and non-payroll expenses that management first thought eligible but on further review, (and subsequent to the submission to the portal) determined were unallowable per the Provider Relief Fund grant and Coronavirus Relief Fund grant terms and conditions. Management has put into place a policy for an individual in the accounting department to review all COVID expenses on a monthly basis going forward. In addition, management will further investigate the total likely questioned cost in order to determine the complete known questioned cost in the period 1 payroll and non-payroll expenditure population by June 30, 2024. For payroll expenses, the policy includes that a review and approval of the expenditures will be performed by an individual in accounting to ensure that the hours and wages calculated meet the terms and conditions of the PRF. If any non-eligible payroll expenses are identified during the review process, they will be removed. For all other expenses, we will obtain and retain approved copies of all invoices or other documentation to support expenses and review for eligibility. If any non-eligible expenses are identified during the review process, they will be removed. Completion Date: April 5, 2024
View Audit 302859 Questioned Costs: $1
Finding 392156 (2021-003)
Significant Deficiency 2021
Housing Authority of the City of Renton
WA
HUD Housing Programs Allowable Costs / Cost Principles Eligibility
Finding 2021-003 a. Comments on the Finding and Each Recommendation: Management agrees with both the finding and recommendations. b. Action(s) Taken or Planned on the Finding The management overseeing the process has been completely replaced to ensure a fresh perspective and unwavering dedication to...
Finding 2021-003 a. Comments on the Finding and Each Recommendation: Management agrees with both the finding and recommendations. b. Action(s) Taken or Planned on the Finding The management overseeing the process has been completely replaced to ensure a fresh perspective and unwavering dedication to implementing robust internal controls. To address the shortcomings identified in Finding 2021-003, the Authority commits to a targeted action plan aimed at ensuring timely compliance with reporting requirements. Central to our approach is the engagement of a fee accountant, recognized for expertise in HUD reporting and public housing financial management. This specialist will be tasked with overseeing and streamlining our reporting processes. By leveraging this expertise, we aim to quickly rectify past reporting lapses and ensure future submissions are timely and compliant with HUD requirements. The new fee accountant will conduct a comprehensive review of our current reporting mechanisms, identify bottlenecks, and implement best practices tailored to our operations. This decisive action, centered around the expertise of the newly appointed fee accountant, demonstrates our commitment to enhancing our financial management practices and aligning with HUD's reporting expectations. Through these measures, we anticipate not only meeting HUD's deadlines but also setting a new standard for operational excellence within our Authority.
View Audit 302365
Finding 392079 (2021-004)
Material Weakness 2021
Lss Housing Jamestown, Inc.
ND
Allowable Costs / Cost Principles Eligibility Special Tests & Provisions § 200.334
US Department of Housing and Urban Development Federal Financial Assistance Listing #14.157 Supportive Housing for the Elderly (Section 202) Finding Summary: As a result of management transition, supporting documentation for expense transactions and tenant eligibility were destroyed and were unable ...
US Department of Housing and Urban Development Federal Financial Assistance Listing #14.157 Supportive Housing for the Elderly (Section 202) Finding Summary: As a result of management transition, supporting documentation for expense transactions and tenant eligibility were destroyed and were unable to be recreated. The organization was lacking appropriate internal controls to ensure records were retained for the required period of time. Responsible Individual: Dawn Helmowski, Finance Director Corrective Action Plan: Subsequent to the audit period under review, the affiliated entity of Luther Social Services of North Dakota has been replaced with Beyond Shelter, Inc. Upon this change, the new LSS Jamestown Housing, Inc. Board of Directors, implemented a Document Retention and Destruction Policy that includes retention or required documents for the required time periods that will ensure documents are retained. This policy was put into place on April 19, 2023. Anticipated Completion Date: April 2023
View Audit 302211
Finding 382704 (2021-002)
Material Weakness 2021
University of Kansas Hospital Authority
KS
Questioned Costs Cash Management Eligibility
The Authority has performed a review of all patients who have had indications of additional health insurance on an account with a HRSA payment, and made appropriate refunds. A sample of HRSA paid claims were reviewed for ineligible diagnosis codes and appropriate refunds were made.
The Authority has performed a review of all patients who have had indications of additional health insurance on an account with a HRSA payment, and made appropriate refunds. A sample of HRSA paid claims were reviewed for ineligible diagnosis codes and appropriate refunds were made.
View Audit 296290 Questioned Costs: $1
Finding 375948 (2021-001)
Significant Deficiency 2021
Middle Tennessee Electric Membership Corporation
TN
Questioned Costs Cash Management Eligibility
Since the date of the deficiency was identified, the MTE Finance Department recalculated the allowable costs for the project worksheet #136175 and submitted a revised worksheet to FEMA. We met with the employees responsible for completion and filing of eligible costs with FEMA. We believe this was a...
Since the date of the deficiency was identified, the MTE Finance Department recalculated the allowable costs for the project worksheet #136175 and submitted a revised worksheet to FEMA. We met with the employees responsible for completion and filing of eligible costs with FEMA. We believe this was an isolated incident due to preparation and submittal on our behalf by an independent contractor. We will have an employee of the Finance Department perform a review of any future projects submitted for reimbursement.
View Audit 295000 Questioned Costs: $1
Finding 375454 (2021-003)
Material Weakness 2021
Hale County Hospital
AL
Reporting Cash Management Eligibility
We are implementing policies to address the audit finding 2021-003 as follows: We have implemented a policy to ensure that all future Provider Relief Fund reporting is reviewed prior to filing. Anticipated completion date: September 30, 2024
We are implementing policies to address the audit finding 2021-003 as follows: We have implemented a policy to ensure that all future Provider Relief Fund reporting is reviewed prior to filing. Anticipated completion date: September 30, 2024
View Audit 294509
Cleveland County
OK
Questioned Costs Allowable Costs / Cost Principles Eligibility
21.019 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Requirements - Coronavirus Relief Fund The Cleveland County Board of County Commissioners (BOCC) will implement policies and procedures to ensure compliance with applicable grant requirements. Specifically,...
21.019 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Requirements - Coronavirus Relief Fund The Cleveland County Board of County Commissioners (BOCC) will implement policies and procedures to ensure compliance with applicable grant requirements. Specifically, the BOCC will ensure grant funds are expended on allowed costs as set forth by the grant. Anticipated Completion Date: On Going April 2021 Responsible Contact Person: Rod Cleveland,Chairman BOCC
View Audit 294443 Questioned Costs: $1
Finding 371938 (2021-003)
Significant Deficiency 2021
Martin University
IN
Student Financial Aid Matching / Level of Effort / Earmarking Eligibility
Enrollment reporting procedures should be strengthened Corrective action: The University submitted a correction action plan that was acceptable by DOE. and implemented effective 9/1/2022. Person responsible: Qiana Hall, Associate VP of Enrollment Services Anticipated Completion Date: Completed
Enrollment reporting procedures should be strengthened Corrective action: The University submitted a correction action plan that was acceptable by DOE. and implemented effective 9/1/2022. Person responsible: Qiana Hall, Associate VP of Enrollment Services Anticipated Completion Date: Completed
View Audit 293212
Finding 370593 (2021-014)
Material Weakness 2021
Kickapoo Tribe in Kansas
KS
Eligibility Material Weakness Significant Deficiency
Finding 2021-014 Eligibility Individual(s) Responsible: Paul Austin, Program Director with supervision from Grace Ross, Tribal Treasurer Action: Will ensure that all patients provide eligibility documentation. Anticipated Completion Date: September 2024
Finding 2021-014 Eligibility Individual(s) Responsible: Paul Austin, Program Director with supervision from Grace Ross, Tribal Treasurer Action: Will ensure that all patients provide eligibility documentation. Anticipated Completion Date: September 2024
View Audit 292271
Finding 370054 (2021-009)
Material Weakness 2021
Delaware County
OK
Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.300 § 200.403
The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants.
The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants.
View Audit 291562 Questioned Costs: $1
Finding 369848 (2021-013)
Material Weakness 2021
Trinity Community Housing CORP
IL
Eligibility HUD Housing Programs
Corrective Action Plan: The Corporation plans has hired a management agent company that will ensure that all payroll records are available for examination purposes. Responsible party: Eric Dickerson, Chairman Planned completion date for corrective action plan: Already remediated.
Corrective Action Plan: The Corporation plans has hired a management agent company that will ensure that all payroll records are available for examination purposes. Responsible party: Eric Dickerson, Chairman Planned completion date for corrective action plan: Already remediated.
View Audit 291369
Finding 369835 (2021-022)
Material Weakness 2021
Trinity Acres Housing Corporation
IL
Eligibility HUD Housing Programs Internal Control / Segregation of Duties
Corrective Action Plan: The Corporation plans has hired a management agent company that will ensure that all payroll records are available for examination purposes. Responsible party: Eric Dickerson, Chairman
Corrective Action Plan: The Corporation plans has hired a management agent company that will ensure that all payroll records are available for examination purposes. Responsible party: Eric Dickerson, Chairman
View Audit 291368
Finding 369833 (2021-020)
Material Weakness 2021
Trinity Acres Housing Corporation
IL
Eligibility HUD Housing Programs Internal Control / Segregation of Duties
Corrective Action Plan: The Corporation plans has hired a management agent company that will ensure that all payroll records are available for examination purposes. Responsible party: Eric Dickerson, Chairman
Corrective Action Plan: The Corporation plans has hired a management agent company that will ensure that all payroll records are available for examination purposes. Responsible party: Eric Dickerson, Chairman
View Audit 291368
Finding 369832 (2021-019)
Material Weakness 2021
Trinity Acres Housing Corporation
IL
Eligibility HUD Housing Programs Internal Control / Segregation of Duties
Corrective Action Plan: The Corporation plans has hired a management agent company that will ensure that all payroll records are available for examination purposes. Responsible party: Eric Dickerson, Chairman
Corrective Action Plan: The Corporation plans has hired a management agent company that will ensure that all payroll records are available for examination purposes. Responsible party: Eric Dickerson, Chairman
View Audit 291368
Finding 369831 (2021-018)
Material Weakness 2021
Trinity Acres Housing Corporation
IL
HUD Housing Programs Internal Control / Segregation of Duties Eligibility
Corrective Action Plan: The Corporation plans has hired a management agent company that will ensure that all payroll records are available for examination purposes. Responsible party: Eric Dickerson, Chairman
Corrective Action Plan: The Corporation plans has hired a management agent company that will ensure that all payroll records are available for examination purposes. Responsible party: Eric Dickerson, Chairman
View Audit 291368
Finding 369830 (2021-017)
Material Weakness 2021
Trinity Acres Housing Corporation
IL
Eligibility HUD Housing Programs Internal Control / Segregation of Duties
Corrective Action Plan: The Corporation plans has hired a management agent company that will ensure that all payroll records are available for examination purposes. Responsible party: Eric Dickerson, Chairman
Corrective Action Plan: The Corporation plans has hired a management agent company that will ensure that all payroll records are available for examination purposes. Responsible party: Eric Dickerson, Chairman
View Audit 291368
Finding 369829 (2021-016)
Material Weakness 2021
Trinity Acres Housing Corporation
IL
Eligibility HUD Housing Programs
Corrective Action Plan: The Corporation plans has hired a management agent company that will ensure that all payroll records are available for examination purposes. Responsible party: Eric Dickerson, Chairman
Corrective Action Plan: The Corporation plans has hired a management agent company that will ensure that all payroll records are available for examination purposes. Responsible party: Eric Dickerson, Chairman
View Audit 291368
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