Corrective Action Plans

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Finding 2025-001- Public Housing Internal Control over Waiting List - Eligibility Noncompliance and Significant Deficiency Low Rent Public Housing - Subsidy ALN 14.850 Corrective Action Plan: The Great Falls Housing Authority printed out waiting lists on the date of the audit finding. We will keep n...
Finding 2025-001- Public Housing Internal Control over Waiting List - Eligibility Noncompliance and Significant Deficiency Low Rent Public Housing - Subsidy ALN 14.850 Corrective Action Plan: The Great Falls Housing Authority printed out waiting lists on the date of the audit finding. We will keep notes on the list and at periodic times when adding or deleting applicants we will maintain all lists in a binder for historical review. Person Responsible: Donna Halbleib, Program Supervisor Anticipated Completion Date: Already implemented and will be continuously kept - March 31, 2026
Response to FY2025 Audit Finding: Impact: "Lack of policy enforcement may have resulted in the Organization providing discounted services greater to or less than the appropriate amounts to beneficiaries" Why: 1. Were staff not consistently collecting the required income and family size documentation...
Response to FY2025 Audit Finding: Impact: "Lack of policy enforcement may have resulted in the Organization providing discounted services greater to or less than the appropriate amounts to beneficiaries" Why: 1. Were staff not consistently collecting the required income and family size documentation? 2. Was training not comprehensive enough or did staff turnover lead to a knowledge gap? 3. Is the Organizations policy or process for documenting income unclear or not consistently enforced? 4. Was there a system in place to audit patient files internally to catch documentation errors? 5. Is the culture of compliance not strong enough to prioritize consistent documentation? Action: 1. Update/Revise sliding fee policy and procedure to clearly define acceptable documentation process for income verification and annual re-evaluation 2. Create and deliver comprehensive training to all relevant staff (front desk, enrollment specialist, and billing) 3. Implement ongoing monitoring – • Establish a new scheduled internal audit process to regularly review a sample of patient documentation for sliding fee documentation compliance. • Establish metrics to track progress, such as percentage of patient files with complete sliding fee documentation, for new and annual sliding fee applications. 4. Once all actions are complete and the issue is resolved, document these improvements to continue the cycle of compliance 5. Continue to audit files at random to ensure documentation compliance continues
Finding 2025-001 Federal assistance listing number and name: 10.415 Rural Rent Housing Loans Awards numbers and years: 2025 Federal agency: United States Department of Agriculture Compliance Requirement: Activities allowed or unallowed, allowable costs/ cash management, eligibility, equipment, perio...
Finding 2025-001 Federal assistance listing number and name: 10.415 Rural Rent Housing Loans Awards numbers and years: 2025 Federal agency: United States Department of Agriculture Compliance Requirement: Activities allowed or unallowed, allowable costs/ cash management, eligibility, equipment, period of performance, procurement, program income, reporting, special tests Questioned Costs: None Name of contact person and title: Pat Bishop, President Condition and Context: The auditee did not submit the required audit reports to the Federal Audit Clearinghouse (FAC) and Rural Development (RD) in a timely manner. Specifically:  The 2023 Audit Report was not submitted to the FAC as required under 2 CFR Part 200, Subpart F.  The 2024 Audit Report was submitted past the regulatory deadline to both the FAC and RD. Management Response: Management plans to develop and implement an internal audit compliance calendar with clearly defined submission deadlines for all audit-related deliverables, including due dates for the FAC and RD and Create an internal checklist and sign-off process to confirm that each audit deliverable has been submitted to all required agencies and portals. Status: In progress Anticipated Completion Date: Estimated 2025
Management of Miami-Cass REMC and Subsidiary will implement procedures to prevent unallowable costs. In addition, the State of Indiana Office of Community and Rural Affairs will be alerted of the questioned costs. Management agrees with this finding.
Management of Miami-Cass REMC and Subsidiary will implement procedures to prevent unallowable costs. In addition, the State of Indiana Office of Community and Rural Affairs will be alerted of the questioned costs. Management agrees with this finding.
View Audit 367301 Questioned Costs: $1
Condition –The Organization determines the sliding fee discount charged to the patients based on their annual gross income and household size. During our testing of sliding fee discounts, we found two encounters where the patients were charged incorrect copays. Recommendation – The Organization shou...
Condition –The Organization determines the sliding fee discount charged to the patients based on their annual gross income and household size. During our testing of sliding fee discounts, we found two encounters where the patients were charged incorrect copays. Recommendation – The Organization should strengthen processes surrounding the monitoring of the program to ensure the Organization’s policies are consistently and properly applied. Views of Responsible Officials and Planned Corrective Actions – Management agrees with the finding. The Organization has developed a plan for addressing this issue that includes updated procedures, training, and auditing. All teams engaged in the patient collection, enrollment, and eligibility process will be retrained on the process with emphasis on proper documentation and provide feedback and retraining as necessary to staff as needed. Anticipated Date of Completion – By October 31, 2025. Action Taken – Management has scheduled time at front desk/billing meetings to retrain staff on processes that ensure appropriate sliding fee rates are utilized for each sliding fee encounter. Specifically, training will focus on encounters with both an office visit and lab are properly identified so that the lab co-pay is adjusted appropriately. Person Responsible for Corrective Action Plan – Steven Leazer, Chief Financial Officer.
View Audit 366550 Questioned Costs: $1
Corrective Action Plan Year Ended April 30, 2025 To Health Resources and Services Administration United Methodist Western Kansas Mexican-American Ministries, Inc. d/b/a Genesis Family Health respectfully submits the following corrective action plan for the year ended April 30, 2025. CohnReznick LLP ...
Corrective Action Plan Year Ended April 30, 2025 To Health Resources and Services Administration United Methodist Western Kansas Mexican-American Ministries, Inc. d/b/a Genesis Family Health respectfully submits the following corrective action plan for the year ended April 30, 2025. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: April 30, 2025 The findings from the April 30, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Financial Statement Findings: Finding 2025.001 - Sliding Fee Scale Documentation Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken GFH implemented an O&E Department (Onboarding and Enrollment) July 2023. This has been a timely process, but it has been implemented across all clinic sites. The purpose of this department is to ensure all required documentation is current, accurate, scanned in chart and applied to patients EMR. This process includes current registration, slide application, POIs, IDs and insurance verification for coverage. All patients are required to complete an onboarding and enrollment appointment to ensure required information is added to the patient’s account and the sliding fee discount is accurately applied. The slide application with the incorrect discount was completed on 06/27/2023 and the patient returned to the clinic for a follow-up appointment on 6/17/2024 (10 days prior to the annual O&E update appointment). All other accounts audited were after the O&E implementation in July 2023 and no errors or deficiencies were identified. Additionally, Genesis Family Health has implemented a mandatory annual review process for all staff with electronic acknowledgement of the staff member's understanding of the Sliding Fee Discount Policy. If there are any questions regarding this plan, please contact Amanda Vaughan at: Amanda.Vaughan@genesisfh.org Sincerely, Amanda Vaughan (electronically signed 7/31/2025) Amanda Vaughan - Chief Financial Officer
Recommendation Management should enhance and strengthen procedures to ensure tenant income certifications are completed within 90 days of the tenant being entered into the HUD TRACS system. Finding Resolution Status: Resolved Views of Responsible Officials Management agrees with the finding and reco...
Recommendation Management should enhance and strengthen procedures to ensure tenant income certifications are completed within 90 days of the tenant being entered into the HUD TRACS system. Finding Resolution Status: Resolved Views of Responsible Officials Management agrees with the finding and recommendation and will ensure timely income verifications going forward.
Management concurs with the findings and had already commenced corrective actions prior to the issuance of this report. These actions were initiated to address deficiencies resulting from the inadequate performance of the former property manager, who resigned from the position. Additionally, a new p...
Management concurs with the findings and had already commenced corrective actions prior to the issuance of this report. These actions were initiated to address deficiencies resulting from the inadequate performance of the former property manager, who resigned from the position. Additionally, a new property manager has been hired to ensure compliance with established procedures and to oversee the continued implementation of corrective measures.
The Capital District YMCA reviewed the vendor used for our project when the auditors brought this to our attention and we did not find any suspension or disbarment information. We will incorporate this vendor review into our process for all programs or activities related to Federal contracts. This w...
The Capital District YMCA reviewed the vendor used for our project when the auditors brought this to our attention and we did not find any suspension or disbarment information. We will incorporate this vendor review into our process for all programs or activities related to Federal contracts. This will be done in conjunction with the procurement policy and be in place by July 31, 2025. The SVP/CFO Mary Maziejka will be responsible for development and implementation of the policy.
Eligibility – Foster Grandparent/Senior Companion Programs ECS is strengthening its existing review procedures by implementing a more structured and documented secondary review process. Income eligibility determinations will be reviewed for completeness and mathematical accuracy, including proper an...
Eligibility – Foster Grandparent/Senior Companion Programs ECS is strengthening its existing review procedures by implementing a more structured and documented secondary review process. Income eligibility determinations will be reviewed for completeness and mathematical accuracy, including proper annualization of income and inclusion of applicable income sources. Program staff responsible for preparing and reviewing eligibility determinations will receive training regarding calculation procedures, required supporting documentation, document retention, and evidence of review and approval. The SVP Director will serve as the second level of review for all completed income eligibility forms. A Director’s signature line has been added to the income eligibility form to provide documented evidence that the secondary review was completed. Periodic file reviews will be performed to verify that eligibility calculations are accurate, required supporting documentation is maintained, and Director review is appropriately documented. A formal annual completion timeline will be incorporated into departmental procedures to establish deadlines for completion, secondary review, approval, and retention of annual income eligibility documentation.
The Town will establish written procedures requiring documentation of suspension and debartment verification for all applicable federally funded procurements. Verification will be completed through a SAM.gov search, vendor certification, or inclusion of required contract language. Responsibility for...
The Town will establish written procedures requiring documentation of suspension and debartment verification for all applicable federally funded procurements. Verification will be completed through a SAM.gov search, vendor certification, or inclusion of required contract language. Responsibility for performing and retaining documentation will be assigned within the procurement workflow.
We agree with this Finding. We have updated our Sliding fee scale using the US Federal poverty guideline for year 2026, it has been approved by our board of directors as of 04/10/26. This new sliding fee scale is applied in the new ECW Electronic Health Records system that we are currently in the pr...
We agree with this Finding. We have updated our Sliding fee scale using the US Federal poverty guideline for year 2026, it has been approved by our board of directors as of 04/10/26. This new sliding fee scale is applied in the new ECW Electronic Health Records system that we are currently in the process of completing and instituting into our health centers. This new system is presumed to go live in September 2026 and will be able to accommodate our need to capture accurate demographic data that is needed to determine whether a patient is eligible for the discount or not, it will be able to automatically place each individual patient under the different sliding fee scale categories that they fall under based on their income once they register to see a doctor. So to correct our finding for 2023 and 2024, this is what we have been working on to improve our health center and build a system in place that will be able to capture the data we need, we will also be updating our sliding fee scale in the system every year based on the yearly US federal poverty guideline.
The Town will ensure that department heads receive the necessary guidance and procedures for the current grant process, including requirements for verifying suspension and debarment status. The Town will develop procedures requiring verification before grant funds are obligated, contracts are execut...
The Town will ensure that department heads receive the necessary guidance and procedures for the current grant process, including requirements for verifying suspension and debarment status. The Town will develop procedures requiring verification before grant funds are obligated, contracts are executed, or payments are processed. Verification will include reviewing the applicable federal exclusion records, documenting the date and results of the review, and maintaining the supporting documentation with the grant file. Department heads will be reminded to review and follow each grant’s requirements before submission and processing to support ongoing compliance and prevent grant-related oversights.
Finding: 2024-004 - Inadequate Controls Over Federal Procurement and Suspension and Debarment Finding Type: Material weakness in internal control over compliance. Repeat Finding: Yes; prior-year finding 2023-003. Federal Award: ALN 21.027 - Coronavirus State and Local Fiscal Recovery Funds (SLFRF). ...
Finding: 2024-004 - Inadequate Controls Over Federal Procurement and Suspension and Debarment Finding Type: Material weakness in internal control over compliance. Repeat Finding: Yes; prior-year finding 2023-003. Federal Award: ALN 21.027 - Coronavirus State and Local Fiscal Recovery Funds (SLFRF). Auditor Description of Condition and Effect: During the audit, we noted that the Organization had not established and implemented sufficient controls over procurements charged to the federal program. The Organization could not provide sufficient documentation demonstrating that: • The rationale for the procurement method and contractor selection was documented; • Potential conflicts of interest were evaluated; • Applicable contractors were verified as not suspended, debarred, or otherwise excluded; • Required federal provisions were included in applicable contracts; and • Contractor performance and compliance with contract terms were appropriately monitored. The absence of appropriately designed and implemented controls creates a reasonable possibility that material noncompliance with federal procurement or suspension and debarment requirements could occur and not be prevented, or detected and corrected, on a timely basis. This could result in unsupported procurement decisions, transactions with excluded or otherwise ineligible contractors, contracts that omit required federal provisions, or inadequate oversight of contractor performance. Auditor Recommendation: Management should adopt written federal procurement procedures and implement a standardized review process for procurements charged to federal awards. The process should address and document the procurement method and contractor selection, potential conflicts of interest, contractor eligibility, required federal contract provisions, and oversight of contractor performance. Documentation should be retained with each procurement file and be subject to appropriate management review and approval. Management Response and Corrective Action Planned: The Organization agrees with the finding. Management will adopt written federal procurement procedures and use a standardized checklist for each procurement charged to a federal award. The checklist will document the procurement method, contractor selection and price basis, evaluation of potential conflicts of interest, contractor eligibility verification, applicable federal contract provisions, and contractor oversight. A designated management reviewer will approve the completed procurement file, and the supporting records will be retained in accordance with the applicable award requirements.
Finding: 2024-003 - Late Completion of the Single Audit and Submission of the Reporting Package and Data Collection Form Finding Type: Noncompliance. Repeat Finding: Yes; prior-year finding 2023-002. Auditor Description of Condition and Effect: The Organization’s Single Audit for the six-month perio...
Finding: 2024-003 - Late Completion of the Single Audit and Submission of the Reporting Package and Data Collection Form Finding Type: Noncompliance. Repeat Finding: Yes; prior-year finding 2023-002. Auditor Description of Condition and Effect: The Organization’s Single Audit for the six-month period ended June 30, 2024, was not completed by the March 31, 2025 deadline. The audit was completed on May 12, 2025, 42 days late; consequently, the reporting package and data collection form were not submitted to the Federal Audit Clearinghouse within the timeframe required by 2 CFR § 200.512(a)(1). The delay resulted from the fiscal year-end change and the absence of a sufficiently detailed transition, closing, reconciliation, and audit-readiness plan. Auditor Recommendation: Management should establish and monitor a formal year-end closing and audit-readiness plan that assigns responsible individuals and interim completion dates for account reconciliations, financial reporting schedules, federal award information, and other audit support. Progress should be monitored, delays addressed promptly, and significant matters communicated to those charged with governance and the auditors sufficiently in advance of the Federal Audit Clearinghouse filing deadline. Management Response and Corrective Action Planned: Management concurs with the finding and recommendation. Now that June 30 is the Organization’s recurring fiscal year-end, management will implement a formal annual closing, audit-readiness, and Federal Audit Clearinghouse submission process as follows: • Maintain a written calendar beginning before fiscal year-end that identifies each close, financial-reporting, Schedule of Expenditures of Federal Awards, audit-support, governance, and Federal Audit Clearinghouse task; the assigned preparer and reviewer; and interim and final due dates. • Complete and independently review account reconciliations, year-end entries, grant schedules, and other requested audit support according to the calendar, with unresolved items tracked in a centralized open-items log. • Meet with the external auditors before year-end to establish the audit timeline and requested-information deadlines, and update the plan promptly when significant transactions, staffing changes, or other risks to timely completion arise. • Monitor progress at least biweekly after year-end. Missed interim dates and unresolved matters that could affect the filing deadline will be escalated to senior management and those charged with governance, together with a recovery plan. • Assign a senior-level management representative to review and certify the data collection form, authorize submission of the reporting package, and verify and retain evidence of Federal Audit Clearinghouse acceptance by the earlier of 30 calendar days after receipt of the auditor’s reports or nine months after the end of the audit period, as required by 2 CFR § 200.512(a)(1). Management will retain documentation supporting implementation and will periodically evaluate whether the corrective action is operating as designed.
Finding 2024-008 – Late Single Audit Filing Submission Contact Person: Gary Kloosterman, Village Manager Planned Corrective Action: The Village will implement a compliance calendar and internal procedures to monitor audit timelines, ensure timely year-end close, and support future on-time Single Aud...
Finding 2024-008 – Late Single Audit Filing Submission Contact Person: Gary Kloosterman, Village Manager Planned Corrective Action: The Village will implement a compliance calendar and internal procedures to monitor audit timelines, ensure timely year-end close, and support future on-time Single Audit filing. Anticipated Completion Date: March 31, 2026
2024-003 Sliding Fee Discount Determination Name of Contact Person: Beth Chumley, CEO Corrective Action: The Organization agrees with the recommendation and has taken steps to correct these errors. Additional training will be provided to billing and front office staff. Sliding fee transactions will ...
2024-003 Sliding Fee Discount Determination Name of Contact Person: Beth Chumley, CEO Corrective Action: The Organization agrees with the recommendation and has taken steps to correct these errors. Additional training will be provided to billing and front office staff. Sliding fee transactions will be audited internally for compliance. Proposed Completion Date: December 31, 2026
• The Compliance Director will be responsible for maintaining updated records and ensuring accessibility during audits. • Implement checklists for each compliance area (reporting, Eligibility, Procurement) to confirm all documents are gathered before deadlines. • Schedule quarterly internal mini aud...
• The Compliance Director will be responsible for maintaining updated records and ensuring accessibility during audits. • Implement checklists for each compliance area (reporting, Eligibility, Procurement) to confirm all documents are gathered before deadlines. • Schedule quarterly internal mini audits to test readiness and correct gaps before the annual audit. • Maintain written standard operating procedures for how documentation should be completed, stored and updated. • Assign responsibility for each compliance area (waiting lists, who oversees procurement, who handles reporting) • Implement the use of audit readiness templates that outline exactly what needs to be prepared for each compliance requirement. Name of Responsible Person: Housing Director, Compliance Director Projected Completion Date: By the end of the current fiscal year.
• Implement a new review process, 2 nd review of files and quarterly internal audit of tenant files. • Improvement of the tenant file checklist to ensure all required documents are consistently filed. • Corrections will be made to the tenant ledgers and HAP payments will be adjusted retroactively if...
• Implement a new review process, 2 nd review of files and quarterly internal audit of tenant files. • Improvement of the tenant file checklist to ensure all required documents are consistently filed. • Corrections will be made to the tenant ledgers and HAP payments will be adjusted retroactively if necessary. • Revise the operations procedures for rent calculations, payment processing, and ledger reconciliations • Conduct refresher training for the HCV staff • Conduct refresher training for inspection staff on timely inspection requirements • Implement an automated tracking system with alerts for upcoming and overdue inspections. • Increase staff and adjust workload to meet inspection timelines. Name of Responsible Person: Inspections Coordinator, Housing Director and Compliance Director. Projected Completion Date: By the end of the current fiscal year.
Organization’s response: The Organization concurs with the finding and will implement our recommendation immediately. Corrective Action Plan: The Organization will implement enhanced internal controls over compliance with federal award requirements by establishing a formal compliance calendar that i...
Organization’s response: The Organization concurs with the finding and will implement our recommendation immediately. Corrective Action Plan: The Organization will implement enhanced internal controls over compliance with federal award requirements by establishing a formal compliance calendar that includes all key reporting deadlines, including audit and FAC submission requirements. Responsibilities for each compliance requirement will be clearly assigned to specific personnel. Management will monitor the calendar regularly to ensure all deadlines are met. Additionally, the Organization will implement a review process to ensure submissions are accurate, complete, and timely. Contact: BreNita Jackson, Executive Director
Person responsible for corrective action plan: Stacey Mike, Interim Tribal Chair Marjianne Yonge, Tribal Treasurer PO Box 747 Lone Pine, CA 93545 (760) 876-1038 Condition: During testing, we noted the following: 21.027 • The Tribe did not provide evidence that the required Annual Project and Expendi...
Person responsible for corrective action plan: Stacey Mike, Interim Tribal Chair Marjianne Yonge, Tribal Treasurer PO Box 747 Lone Pine, CA 93545 (760) 876-1038 Condition: During testing, we noted the following: 21.027 • The Tribe did not provide evidence that the required Annual Project and Expenditure report was prepared and submitted. 93.445 • The Tribe did not provide evidence that the required Quarterly Progress/Performance reports were prepared and submitted. Corrective Action: Documentation shall be kept to verify timely submission of the Annual Project and Expenditure Report as well as the Quarterly Progress/Performance Reports. Anticipated date of completion: November 30, 2026.
Waiting Listing Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend that the Authority designate an individual to maintain the waiting list and track all correspondence with potential tenants. Explanation of disagreement with audit finding: There is no dis...
Waiting Listing Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend that the Authority designate an individual to maintain the waiting list and track all correspondence with potential tenants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Housing Daytona Beach has a designated person to track waitlist activity and correspondence in Lead Housing Specialist, Tyvon Tobler. Name(s) of the contact person(s) responsible for corrective action: Vanessa L. Dunn Planned completion date for corrective action plan: Ms. Tobler has been assigned to manage the HCV Waitlist for the last three years. However, HDB has inserted an additional internal control measure as of FY 25-26, to include additional review by the HCV Manager.
Contact Name: Patrick Johndrow Contact Phone Number: 479-271-6781 Audit Firm: Forvis Mazars, LLP Audit Period: December 31, 2024 Finding #2024-002 – Statement of Condition: The quarterly performance reports did not agree to underlying data. Specifically, source records and supporting schedules used ...
Contact Name: Patrick Johndrow Contact Phone Number: 479-271-6781 Audit Firm: Forvis Mazars, LLP Audit Period: December 31, 2024 Finding #2024-002 – Statement of Condition: The quarterly performance reports did not agree to underlying data. Specifically, source records and supporting schedules used to compile reported information did not agree to the submitted report. Response: The Organization concurs with the finding. Management will implement additional controls related to reporting. The completion date for the above-mentioned corrective action was January 2026.
We have reviewed the sliding fee calculations calculated by the system and have implemented internal control procedures to ensure the discount fees are calculated and applied correctly. Implementation date: _June 16, 2026_
We have reviewed the sliding fee calculations calculated by the system and have implemented internal control procedures to ensure the discount fees are calculated and applied correctly. Implementation date: _June 16, 2026_
Corrective Action Plan Assistance Listing Number 21.029 COVID-19 Coronavirus Capital Projects Fund U.S. Department of the Treasury Missouri Department of Economic Development Program Year 2024 Finding #2024-002 – Statement of Condition: The Cooperative was unable to provide evidence that vendors use...
Corrective Action Plan Assistance Listing Number 21.029 COVID-19 Coronavirus Capital Projects Fund U.S. Department of the Treasury Missouri Department of Economic Development Program Year 2024 Finding #2024-002 – Statement of Condition: The Cooperative was unable to provide evidence that vendors used in covered transactions were not suspended, debarred, or otherwise excluded. Response: Due to the current year finding, management set a goal to ensure the Missouri ARPA Broadband Infrastructure Grant Program guidelines related to debarred or suspended vendors are being met. To meet these guidelines management has compared the current vendor list to Excluded Parties List System found on SAM.GOV and found none of the currently used vendors on the list. Management has added this verification step to its new vendor process and will conduct annual self-assessment to ensure vendor eligibility documentation is current and up to date. The completion date for the above-mentioned corrective action was February 10, 2026.
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