Corrective Action Plans

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Views of Responsible Officials and Planned Corrective Actions: Reexaminations have been completed for tenants who were not recertified during FY 2020. Current staff have received additional training on the recertification process and documentation. During recertification, if Upper-management will re...
Views of Responsible Officials and Planned Corrective Actions: Reexaminations have been completed for tenants who were not recertified during FY 2020. Current staff have received additional training on the recertification process and documentation. During recertification, if Upper-management will review a minimum of 20% of all tenants recertification and recertifications, selected randomly by the management designee from tenant files due for recertification within the current month to ensure all required documents are present and correct. Interim recertifications were completed for residents that had a decrease in income during this time period. Additionally, residents who were recertified at a later date or will be certified at a later date and found to have been over charged for rent, will be credited for the amount of overpayment retro to the start of the overpayment or the due date of the recertification. Responsible Parties: Audra Butler, Interim Deputy Director and Tara West, Property Manager. Timeline: Recertifications: Completed Compliance Review beginning January 2022.
2020-004 – REPORTING MATERIAL WEAKNESS/NONCOMPLIANCE Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority will ensure annual audits are conducted and timely electronic submissions of GAAP-based unaudited a...
2020-004 – REPORTING MATERIAL WEAKNESS/NONCOMPLIANCE Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority will ensure annual audits are conducted and timely electronic submissions of GAAP-based unaudited and audited financial information to HUD through the FASS-PH system. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director
2020-003 – ELIGIBILITY MATERIAL WEAKNESS/NONCOMPLIANCE Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority provided training to necessary staff and will discuss with the third party management company to ...
2020-003 – ELIGIBILITY MATERIAL WEAKNESS/NONCOMPLIANCE Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority provided training to necessary staff and will discuss with the third party management company to ensure compliance with 24 CFP 982.516 in the future. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director
2020-002 – INTERNAL CONTROLS OVER COMPLIANCE MATERIAL WEAKNESS Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority will maintain proper monitoring, communication and control activities to ensure adherence...
2020-002 – INTERNAL CONTROLS OVER COMPLIANCE MATERIAL WEAKNESS Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority will maintain proper monitoring, communication and control activities to ensure adherence to the Authority’s key administrative policies including procurement, occupancy and the HCV administrative plan. Additionally, management will have the Board approve all policies and procedures adopted and communicate them with the third party company that manages the Authority’s Housing Choice Voucher and Mainstream Voucher programs. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director
2020-108 Lack of Controls over Costs Submitted for Reimbursement Condition: The Organization included an invoice for reimbursement under the program for which a vendor credit memo for the full amount of the invoice had been received due to miscoding of the credit memo to the correct COVID-19 class ...
2020-108 Lack of Controls over Costs Submitted for Reimbursement Condition: The Organization included an invoice for reimbursement under the program for which a vendor credit memo for the full amount of the invoice had been received due to miscoding of the credit memo to the correct COVID-19 class on the general ledger. In addition, the Organization did not include an applicable invoice for COVID-19 expenses for reimbursement due to the same miscoding of the COVID-19 class to the general ledger. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. Management understands the importance of reviewing the posting of credit memos or applicable invoices to ensure they are posted correctly. We will update our policy to include a process for review of credit memos prior to posting. The planned corrective action for this finding is currently in the process of development, approval, and implementation. Person Responsible for Corrective Action: Robert Thompson, Chief Operating Officer Anticipated Completion Date: March 1, 2023
2020-107 Lack of ACH Payment Review and Approval Condition: Payments are not reviewed prior to ACH payments. The Organization has no documented policies and procedures for handling the processing and review of ACH payments. Corrective Action Planned: : The Organization has hired a new Chief Finan...
2020-107 Lack of ACH Payment Review and Approval Condition: Payments are not reviewed prior to ACH payments. The Organization has no documented policies and procedures for handling the processing and review of ACH payments. Corrective Action Planned: : The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. Management understands the importance of reviewing the posting of credit memos or applicable invoices to ensure they are posted correctly. We will update our policy to include a process for review of credit memos prior to posting. The planned corrective action for this finding is currently in the process of development, approval, and implementation. Person Responsible for Corrective Action: Robert Thompson, Chief Operating Officer Anticipated Completion Date: March 1, 2023
2020-106 Use of Budgeted Versus Actual Costs for Reimbursements Condition: The Organization made drawdowns after month-end based on budgeted period expenses. Insufficient documentation was kept to clearly document that the amount requested was reviewed for accuracy. Corrective Action Planned: The ...
2020-106 Use of Budgeted Versus Actual Costs for Reimbursements Condition: The Organization made drawdowns after month-end based on budgeted period expenses. Insufficient documentation was kept to clearly document that the amount requested was reviewed for accuracy. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization. Person Responsible for Corrective Action: Robert Thompson, Chief Operating Officer Anticipated Completion Date: Implemented
2020-104 Lack of Documentation Related to Reporting and Lack of Controls Related to Filing Reports Condition: The Organization did not maintain proper documentation in support of reporting requirements and there was no review of the reports prior to submission to the grantor, other than the review...
2020-104 Lack of Documentation Related to Reporting and Lack of Controls Related to Filing Reports Condition: The Organization did not maintain proper documentation in support of reporting requirements and there was no review of the reports prior to submission to the grantor, other than the review done by the preparer. Corrective Action Planned: Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization has reviewed and updated its reporting policy and implemented the changes. The corrective action for this finding has been approved and implemented by the Organization. Person Responsible for Corrective Action: Robert Thompson, Chief Operating Officer Anticipated Completion Date: Implemented
2020-101 Lack of Internal Controls Over the Application of the Sliding Fee Scale Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale ...
2020-101 Lack of Internal Controls Over the Application of the Sliding Fee Scale Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization’s policies for the sliding fee scale were recently updated during fiscal year 2022, by management, based on findings during the monitoring by HRSA performed in 2022, but management will consider discussing potential improvements to their policy with the grantor to potentially update it to allow for certain exceptions. The Organization will also consider discussing the agreement with the local school district in more detail with the grantor to either structure their policies to allow for these visits to have different requirements or to see if the grantor would be willing to provide a waiver with regards to theses visits not being technically in compliance with other regular clinic visits. The planned corrective action for this finding is currently in the process of development, approval, and implementation. The Organization expects to have the corrective action implemented by March 1, 2023. The Organization will continue to engage the consulting services of the professional certified accounting firm to assist in this process through completion. Person Responsible for Corrective Action: Robert Thompson, Chief Operating Officer Anticipated Completion Date: March 1, 2023
The audited financial statements have been filed with HUD via its REAC system. If thereare any questions regarding this plan, please call Yulia Garcia, Controller, at 508-778-5040.
The audited financial statements have been filed with HUD via its REAC system. If thereare any questions regarding this plan, please call Yulia Garcia, Controller, at 508-778-5040.
FINDINGS -FINANCIAL STATEMENT AUDIT Finding Number: 2020-002 Finding Type: Material Weakness Condition: During the audit, it was noted: • Third Party Accounts Receivable accounts were not analyzed prior to the start of the audit and resulted in significant adjustments to properly state those acco...
FINDINGS -FINANCIAL STATEMENT AUDIT Finding Number: 2020-002 Finding Type: Material Weakness Condition: During the audit, it was noted: • Third Party Accounts Receivable accounts were not analyzed prior to the start of the audit and resulted in significant adjustments to properly state those accounts. • Grants Receivable and Grant Revenue accounts were not reviewed prior to the audit to ensure the accounts were properly stated. • General Ledger expense accounts were not reviewed in detail and adjustments were made after the start of the audit to reclassify certain expenses to the proper sub-accounts. Management response: DCCCMH is committed to ensuring compliance with all regulatory requirements. DCCCMH has hired a grant accountant who will be tasked with reconciling all grant-related activities and accounts. In addition, DCCCMH intends on hiring a General Ledger Accountant who will be responsible for reconciling all Balance Sheet accounts for accuracy monthly.
FINDINGS - FINANCIAL STATEMENT AUDIT Finding Number: 2020-003 Finding Type: Material weakness -Financial Management Condition: Expenditures reported in the general ledger for the Continuum of Care Grant of $960,405 did not agree with the expenditures reported to HUD of $1,071,510 and for which H...
FINDINGS - FINANCIAL STATEMENT AUDIT Finding Number: 2020-003 Finding Type: Material weakness -Financial Management Condition: Expenditures reported in the general ledger for the Continuum of Care Grant of $960,405 did not agree with the expenditures reported to HUD of $1,071,510 and for which HUD provided reimbursement. This condition resulted in the Organization being required to make an adjustment to reduce grant reported revenue and record an amount due to HUD for excess funds received. Expenditures reported in the general ledger for the noted HRSA grant exceeded the amount reported and requested for reimbursement. DCCCMH elected to use non-Federal funds to cover the excess expenditures. Management response: DCCCMH has hired a grant accountant who will ensure expenses claimed are accurately reflected in the books and records of DCCCMH. In addition, DCCCMH is hiring a General Ledger Accountant who will ensure all Balance Sheet accounts are reconciled monthly.
Finding # 2020-009 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 forw...
Finding # 2020-009 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. Anticipated Completion Date: Currently in progress
Finding # 2020-008 Utility Allowance Calculation Corrective Action Plan: When the new director, Robert Weismore, was hired on September 7, 2022, he replaced the former director and 3 staff members. In October he hired the current staff of Ms. Schaefer, Ms. Lynn. Ms. Filipski was hired as a part time...
Finding # 2020-008 Utility Allowance Calculation Corrective Action Plan: When the new director, Robert Weismore, was hired on September 7, 2022, he replaced the former director and 3 staff members. In October he hired the current staff of Ms. Schaefer, Ms. Lynn. Ms. Filipski was hired as a part time employee in the middle of September 2022. For the next 2 months the staff reviewed each file and recalculated the figures using the correct payment standards for the necessary period and also used the September 1, 2022 approved utility schedule installed by the current staff. The recalculations caused the North Syracuse Housing Authority to reimburse $25,463 to previously miscalculated tenants. Also, had to repay HUD $23,000. The current payment standards are up to date and the current utility schedule was updated effective 7/1/2023 and will be updated effective 7 /1/24 and each July thereafter. Anticipated Completion Date: Currently in progress
Finding # 2020-007 Rent Reasonableness and Depository Agreement Corrective Action Plan: Please see 2020-008 regarding payment standards and utility schedules. The current staff updated the current rent reasonableness comparisons during the summer of 2023. This was accomplished by completing a survey...
Finding # 2020-007 Rent Reasonableness and Depository Agreement Corrective Action Plan: Please see 2020-008 regarding payment standards and utility schedules. The current staff updated the current rent reasonableness comparisons during the summer of 2023. This was accomplished by completing a survey of area wide rents and amenities for comparable units. Each folder has a rent re asonableness form showing the com parables and justifying the rent being changed is eligible and within reason. Anticipated Completion Date: Currently in progress
Finding # 2020-006 Housing Quality Standards lnspection/HQS Enforcement Corrective Action Plan: When the current director, Robert Weismore was appointed his first obligation was to inspect 51 units that had been neglected by the former staff. As documentation in the files all previ ous inspections h...
Finding # 2020-006 Housing Quality Standards lnspection/HQS Enforcement Corrective Action Plan: When the current director, Robert Weismore was appointed his first obligation was to inspect 51 units that had been neglected by the former staff. As documentation in the files all previ ous inspections have been completed. The current staff, Sarah Schaefer, has become a certified inspector after completing the necessary course and passing the exam. All inspections whether annual or bi-annually are all completed within the time frame directed by HUD. The director currently will complete the supervisory inspections based on the percentage of program participation directed by HUD regulations. Anticipated Completion Date: Currently in progress
Finding # 2020-005 Report Submission Corrective Action Plan: The new director and staff know that SEMAP reports are due annually. They also know that the report is the responsibility of the director to complete the SEMAP filing. The director who was in place during the 2019-2020-2021 should have fil...
Finding # 2020-005 Report Submission Corrective Action Plan: The new director and staff know that SEMAP reports are due annually. They also know that the report is the responsibility of the director to complete the SEMAP filing. The director who was in place during the 2019-2020-2021 should have filed the SEMAP report. Anticipated Completion Date: Currently in progress
Effective 11/1/2022 all recommendations are completed with up to 90 days notice to prospective tenant, with notification as the propoer verification needed to complete the recret to completion. Notification is also sent to the owner of the recertification. Once the proper verificatio is completed c...
Effective 11/1/2022 all recommendations are completed with up to 90 days notice to prospective tenant, with notification as the propoer verification needed to complete the recret to completion. Notification is also sent to the owner of the recertification. Once the proper verificatio is completed calculations are compelted the tenant and owner are mailed an addeum starting new rnetal breakdown. The new current staff has between 10 and 154 years expeirence completing recertifiations Please see item 2020-008 regarding utilities and payment standards.
Finding Type: Material weakness -Financial Management Condition: During our audit we noted that the expenditures reported in the general ledger for the Continuum of Care grant did not agree with the expenditures reported to HUD of $1,071,510, and for which HUD provided reimbursement. This condit...
Finding Type: Material weakness -Financial Management Condition: During our audit we noted that the expenditures reported in the general ledger for the Continuum of Care grant did not agree with the expenditures reported to HUD of $1,071,510, and for which HUD provided reimbursement. This condition resulted in the Organization being required to make an adjustment to reduce grant reported revenue and record an amount due to HUD for the excess funds received. Expenditures reported in the general ledger for the noted HRSA grant exceeded the amount reported and requested for reimbursement. DCCCMH elected to use non-Federal funds to cover the excess expenditures. Management response: DCCCMH has hired a grant accountant who will ensure expenses claimed are accurately reflected in the books and records of DCCCMH. In addition, DCCCMH is hiring a General Ledger Accountant who will ensure all Balance Sheet accounts are reconciled monthly and tie to amounts reported to grant funders.
QCHC's transition from paper charting to electronic health record Athena Health as ofMarch 14, 2023, will improve our calculations and document retention process to support individuals who receive sliding fee discount. The inconsistency among the application of the sliding fee discount program by fr...
QCHC's transition from paper charting to electronic health record Athena Health as ofMarch 14, 2023, will improve our calculations and document retention process to support individuals who receive sliding fee discount. The inconsistency among the application of the sliding fee discount program by front desk staff has been corrected with ongoing training. In addition to training, we have continued to update our Sliding Fee Discount Program on an annual basis. The Chief Medical Officer, Chief Dental Officer, Director of Operations and Business Development, Office Managers and front desk associates have received the Federal Poverty Guidelines for 2024 and the updated Sliding Fee Discount Program approved by the Board of Directors as of January 24, 2024. QCHC has a scheduled training via technical assistance in April 2024. We will also attend training through our membership with Pennsylvania Association of Community Health Centers.
QCHC was unable to provide adequate documentation to support the nature of the services provided to patients at Fiscal Year End July 31,2020. Subsequent to July 31, 2020, QCHC's Chief Financial Officer, Accounting Manager and Billing Supervisor have worked together on the operation process to improv...
QCHC was unable to provide adequate documentation to support the nature of the services provided to patients at Fiscal Year End July 31,2020. Subsequent to July 31, 2020, QCHC's Chief Financial Officer, Accounting Manager and Billing Supervisor have worked together on the operation process to improve document retention. As of March 14, 2023, QCHC has transitioned from paper medical Explanation of Benefits (EOB) to electronic. QCHC has also contracted with Athena Health to provide full cycle medical billing as of November 1, 2023. Currently, QCHC has about 95% of all claims, medical and dental EOB's in an electronic format via Dentrix and Athena Health. In addition to Dentrix the transition to Athena Health with full cycle billing, will allow QCHC to maintain adequate patient service billing records. Any paper records received are scanned upon arrival and are housed in billing and accounting file storage. All electronic documents are saved on the QCHC network and are backed up daily.
QCHC experienced a ransomware attack against all servers resulting in loss of information across all databases (Centricity, Dentrix and Sage Accpac). There will be a reoccurrence of late audit submission for FYl9, FY20, and FY21. As ofFY22 to date, the Chief Financial Officer has coordinated with th...
QCHC experienced a ransomware attack against all servers resulting in loss of information across all databases (Centricity, Dentrix and Sage Accpac). There will be a reoccurrence of late audit submission for FYl9, FY20, and FY21. As ofFY22 to date, the Chief Financial Officer has coordinated with the Accounting Manager to enforce all financial Accounting and Financial Management procedures to ensure QCHC stays in compliance. A month-end close process has been implemented by the Accounting Manager to ensure account reconciliation and balances are properly stated at month-end. This will improve our financial reporting process to ensure the Single Audit Reporting Package can be submitted to the Federal Audit Clearinghouse no later than the earlier of 30 days after the reports are received from auditors or nine months after year­ end.
Subsequent to July 31, 2020, QCHC has hired a new fiscal team: Chief Financial Officer (2021), Accounting Manager (2023), Senior Accountant (2024) and Staff Accountant (2022). As of August 15, 2023, Health Resources and Services Administration (HRSA), Office of Federal Assistance Management's (OFAM)...
Subsequent to July 31, 2020, QCHC has hired a new fiscal team: Chief Financial Officer (2021), Accounting Manager (2023), Senior Accountant (2024) and Staff Accountant (2022). As of August 15, 2023, Health Resources and Services Administration (HRSA), Office of Federal Assistance Management's (OFAM) Division of Financial Integrity (DFI) provided Fiscal Technical Assistance (FTA) to Quality Community Health Care for six months. During the Fiscal Technical Assistance, DFI provided QCHC best practices and recommendations for improving weaknesses and internal control processes. The key topics discussed during the PTA that DFI recommended QCHC have an in-depth understanding and strengthen internal controls over were the following: Legislative Mandates, Delinquent Single Audit, Financial Management System, Cash Management, Compensation for Personal Services (Time and Effort Reporting) and Policies and Procedures. As a repeated finding, the Chief Financial Officer has been charged with reviewing past accounting procedures for posting, reconciling, and documentation. To date, all Financial Accounting and Financial Management procedures have been enforced by the Chief Financial Officer to ensure QCHC will be complainant. The Accounting Manager ensures the month-end close process is implemented and account reconciliations and balances are properly stated at month end. In the accounting system all federal awards are assigned a general ledger account number in which funds are recorded or disbursed. The Schedule of Expenditures for the Federal Awards will be completed by the Accounting Manager as part of the monthly close to ensure timely availability.
Finding 2020-003: Section 223(f), CFDA 14.155 and Section 8, CFDA 14.195 a. Recommendation: The Company should ensure their procedures require the calculation of residual receipts and the transfer occur within 90 days of year end. b. Action(s) Taken/Planned: Management has acknowledged a breach in p...
Finding 2020-003: Section 223(f), CFDA 14.155 and Section 8, CFDA 14.195 a. Recommendation: The Company should ensure their procedures require the calculation of residual receipts and the transfer occur within 90 days of year end. b. Action(s) Taken/Planned: Management has acknowledged a breach in protocol and deposited the current year's surplus cash on February 5, 2021.
Finding 369609 (2020-001)
Material Weakness 2020
The EXCELth Finance Department was delayed in providing timely financial information to your audit firm and provide the financial statements by the filing deadline due to the COVID pandemic and subsequent problems this caused in difficulties hiring and maintaining qualified individuals in the depart...
The EXCELth Finance Department was delayed in providing timely financial information to your audit firm and provide the financial statements by the filing deadline due to the COVID pandemic and subsequent problems this caused in difficulties hiring and maintaining qualified individuals in the department. To prevent recurrence of the late filing of financial statements, we have contracted with a temporary staffing agency, Robert Half, for additional qualified accountants to provide the following services: to assist with preparing timely monthly financial information for presentation to the governing board; timely reconciliation of all bank statements to the general ledger each month; timely reconciliation of receivable and payables subsidiary ledgers to the general ledger each month; preparation any necessary adjusting entries for posting; attend the monthly board meeting when financial information is presented; and provide the necessary assistance to prepare audit financial statements on a timely basis.
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