Corrective Action Plans

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Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter and that the support for the...
Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter and that the support for the sliding fee discounts is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization recognizes the deficiency of internal controls regarding determination, recording, and monitoring of the sliding fee process from application through adjustment. The Organization has acknowledged that along with our Finance Team being new to the position for all of 2023 along with the realization that our electronic medical record was making an automatic adjustment on the Federal Poverty Level. This automatic adjustment issue has been resolved. We also reviewed the monthly adjustments and have implemented a monthly oversight process to review adjustments made to patient accounts. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Tricia Lippert, Comptroller at 970-327-0537.
Finding #2024-001 Comments on Findings and Recommendation: During the year ended March 31, 2024, deposits to the reserve for replacements account were $236 less than the required amount. Management should transfer $236 from the operating account to the reserve for replacements account. Action(s) tak...
Finding #2024-001 Comments on Findings and Recommendation: During the year ended March 31, 2024, deposits to the reserve for replacements account were $236 less than the required amount. Management should transfer $236 from the operating account to the reserve for replacements account. Action(s) taken or planned on the finding: Management concurs with the finding and recommendation.
View Audit 310491 Questioned Costs: $1
Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperati...
Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperative will continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Planned Completion Date: Not Applicable
Management will correct the next voucher
Management will correct the next voucher
View Audit 305045 Questioned Costs: $1
Management has corrected the errors
Management has corrected the errors
Colfax County agreed to be the fiscal agent for a collaborative project involving several state and federal agencies within NM, CO, and KS along with private corporations including BNSF and AMTRAK. Colfax County did not have the staffing or cash flow necessary to facilitate such a large project. Cou...
Colfax County agreed to be the fiscal agent for a collaborative project involving several state and federal agencies within NM, CO, and KS along with private corporations including BNSF and AMTRAK. Colfax County did not have the staffing or cash flow necessary to facilitate such a large project. County Manager and Financial Specialist were not trained in Railroad project management. Changes in staff within the County Manager’s Office and private corporations as well as state and federal agencies resulted in change in requirements, poor communication, and delay in reporting ultimately resulting in disruption of reimbursement to the County. Colfax County worked with NM Department of Transportation and Federal Railroad Administration to collect project status information and submit all outstanding progress reports. To date Colfax County has been successful in maintaining open communication and receiving support from NMDOT and FRA. All reporting requirements are current and reimbursement has been issued to the County.
The Organization hired a new grant and partnership specialist. This specialist attaches all relevant support for expenditure to the internal monthly grant reporting and ensures that all expenditures are fully supported by appropriate detail. This detail is on a shared drive with finance and is revie...
The Organization hired a new grant and partnership specialist. This specialist attaches all relevant support for expenditure to the internal monthly grant reporting and ensures that all expenditures are fully supported by appropriate detail. This detail is on a shared drive with finance and is reviewed by the vice president of finance.
Federal Agency Name Department of Agriculture Federal Assistance Listing #10.766 Program Name Community Facilities Loan and Grants Cluster Finding Summary The Medical Center does not ensure that the required USDA Accounts (General Account, Construction Account, Debt Service Account, and Reserve Acco...
Federal Agency Name Department of Agriculture Federal Assistance Listing #10.766 Program Name Community Facilities Loan and Grants Cluster Finding Summary The Medical Center does not ensure that the required USDA Accounts (General Account, Construction Account, Debt Service Account, and Reserve Account) were reconciled on a timely basis. This increases the possibility that errors related to the USDA Accounts and other accounts impacted by the USDA Accounts, including construction in progress, are not properly stated in the financial statements. In addition, there could be amounts expended from the USDA Accounts that do not meet the requirements and those expenditures would not be identified in a timely manner. Corrective Action Plan Internal controls will be updated to have a formalized process established to ensure timely reconciliation of the USDA Accounts as well as a review process of those reconciliations each month Responsible Individuals Judy Monson, CFO; Nikki Lindsey, CEO; Jasen Walker, Controller Anticipated Completion Date Complete.
Reference Number: 2023-014 Finding: Housing Quality Standards Inspections for the HOME Program Name of Contact Person: Lara Auclair Corrective Active Plan: The division of housing and community development is now fully staffed, which will ensure that proper monitoring is completed annually. Current ...
Reference Number: 2023-014 Finding: Housing Quality Standards Inspections for the HOME Program Name of Contact Person: Lara Auclair Corrective Active Plan: The division of housing and community development is now fully staffed, which will ensure that proper monitoring is completed annually. Current staff has completed HUD training modules on monitoring to ensure that monitoring that takes place will follow all guidelines. With the updated catalogue of all HOME loans, the division of housing and community development can have an accurate list of properties that are in the period of affordability and subject to monitoring. Staff will refer to monitoring files from previous years to create documents and letters to be sent to homeowners. Proposed Completion Date: 6/30/26
Reference Number: 2023-013 Finding: Eligibility Determinations for the HOME Program Name of Contact Person: Lara Auclair Corrective Active Plan: The City of Woonsocket has developed policies and procedures in order to facilitate the proper standards for documentation of income eligibility. The depar...
Reference Number: 2023-013 Finding: Eligibility Determinations for the HOME Program Name of Contact Person: Lara Auclair Corrective Active Plan: The City of Woonsocket has developed policies and procedures in order to facilitate the proper standards for documentation of income eligibility. The department will ensure that proper approvals will be solicited from the HOME Program Compliance Officer after thorough review. Written agreement documentation will be revised to include the requirements from the new compliance manual. The City of Woonsocket plans to procure grant management software which will streamline the application process and allow for improved recordkeeping to ensure compliance with all policies and procedures. Proposed Completion Date: 6/30/26
Reference Number: 2023-010 Finding: Improve Controls and Compliance with Reporting Name of Contact Person: Lorina Esposito Corrective Active Plan: In the past year, the City has fully staffed the division of housing and community development which has led to the successful submission of the 2024 CAP...
Reference Number: 2023-010 Finding: Improve Controls and Compliance with Reporting Name of Contact Person: Lorina Esposito Corrective Active Plan: In the past year, the City has fully staffed the division of housing and community development which has led to the successful submission of the 2024 CAPER. The staff worked diligently to find all required data for the report and participated in training courses to prepare for future CAPERs. Proposed Completion Date: 3/31/26
Reference Number: 2023-008 Finding: Improve Controls and Compliance with Reporting Name of Contact Person: Christine Chamberland Corrective Active Plan: The City will develop and implement formal written procedures for preparing, submitting, and retaining all required quarterly performance and evalu...
Reference Number: 2023-008 Finding: Improve Controls and Compliance with Reporting Name of Contact Person: Christine Chamberland Corrective Active Plan: The City will develop and implement formal written procedures for preparing, submitting, and retaining all required quarterly performance and evaluation reports in compliance with program requirements. Designated staff will be responsible for tracking reporting deadlines, ensuring timely submissions, and maintaining thorough documentation of all reports. Management will conduct regular reviews to monitor compliance and address any deficiencies promptly. Proposed Completion Date: 6/30/26
Reference Number: 2023-006 Finding: Improve Segregation of Duties over Expenditure Approvals Name of Contact Person: Christine Chamberland Corrective Active Plan: The City will establish formal procedures to ensure that the responsibilities for approving purchase orders and invoices are assigned to ...
Reference Number: 2023-006 Finding: Improve Segregation of Duties over Expenditure Approvals Name of Contact Person: Christine Chamberland Corrective Active Plan: The City will establish formal procedures to ensure that the responsibilities for approving purchase orders and invoices are assigned to different individuals, thereby maintaining effective segregation of duties. In instances where staffing limitations make segregation impractical, management will implement compensating controls, including independent review and approval of these transactions. Documentation of all reviews and approvals will be maintained for audit purposes. Training will be provided to relevant staff to ensure understanding and compliance with these procedures. Proposed Completion Date: 6/30/26
Highway Planning and Construction – Assistance Listing No. 20.205 Recommendation: We recommend that the County of Lassen strengthen its internal controls to ensure that all required documentation supporting the implementation of its Quality Assurance Program is retained and readily available for aud...
Highway Planning and Construction – Assistance Listing No. 20.205 Recommendation: We recommend that the County of Lassen strengthen its internal controls to ensure that all required documentation supporting the implementation of its Quality Assurance Program is retained and readily available for audit purposes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We were unaware the auditor’s office needed documentation for the quality assurance program. We have notified public works to forward us the information. Name(s) of the contact person(s) responsible for corrective action: Pete Heimbigner Planned completion date for corrective action plan: September 18, 2025
Finding 1174193 (2023-001)
Material Weakness 2023
Description of Finding: GBAPP, Inc. was unable to prepare financial statements, a schedule of federal awards and a schedule of state financial assistance that complied with Generally Accepted Accounting Principles (GAAP) and governmental professional standards on a timely basis. Significant adjustme...
Description of Finding: GBAPP, Inc. was unable to prepare financial statements, a schedule of federal awards and a schedule of state financial assistance that complied with Generally Accepted Accounting Principles (GAAP) and governmental professional standards on a timely basis. Significant adjustments, subsequent to year end, were required to conform the financial statements and schedules to professional standards in all material respects. Accordingly, the Federal Data Collection Form and the Connecticut EARS filings were not submitted timely. Statement of Concurrence or Nonconcurrence: GBAPP, Inc. concurs with this audit finding. Corrective Action: Management has since retained additional personnel to assist in performing these duties and is in the process of implementing additional policies and procedures. GBAPP supplemented its accounting personnel with an external CPA with extensive experience in accounting and reporting for non-profit organizations that receive federal and state funding, and who also possesses the suitable skills, knowledge and experience in financial, government and grants management reporting to ensure that this finding will not be repeated. Name of Contact Person: Nancy Kingwood President/Executive Director 203-366-8255 nkingwood@gbapp.org Projected Completion Date: Immediately
During 2020 – 2022, HOMECorp’s management team was significantly impacted by COVID and despite PPP loan retention efforts we lost all our staff and transitioned our HUD Certified Housing Counselor to Property Manager. Due to staffing shortages and restricted to access to apartments as a result of he...
During 2020 – 2022, HOMECorp’s management team was significantly impacted by COVID and despite PPP loan retention efforts we lost all our staff and transitioned our HUD Certified Housing Counselor to Property Manager. Due to staffing shortages and restricted to access to apartments as a result of health concerns, our property manager was unable to perform Housing Quality Standards Inspections. The new Executive Director has contracted with a General Contractor to help assist our property manager with Housing Quality Standards Inspections. These inspections are conducted annually with detailed inspection logs for HVAC, Painting, Fire Safety, and major unit renovations maintained and tracked in our digital database. These logs are reviewed and updated on a quarterly basis to ensure timeliness in compliance and maintenance requests.
Finding Number: 2023-003 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Taylor Spilde Corrective Action Planned: Taylor has been receiving supporting documents and reports since 1/1/2024. Taylor received notification sinc...
Finding Number: 2023-003 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Taylor Spilde Corrective Action Planned: Taylor has been receiving supporting documents and reports since 1/1/2024. Taylor received notification since 2024 and has been reporting since receiving notification. Anticipated Completion Date: 1/1/2024
Finding Number: 2023-002 Finding Title: Eligibility - MAXIS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Teri Taylor Corrective Action Planned: Implementation of quarterly internal auditing of cases Annual Public Assistance Program review/train...
Finding Number: 2023-002 Finding Title: Eligibility - MAXIS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Teri Taylor Corrective Action Planned: Implementation of quarterly internal auditing of cases Annual Public Assistance Program review/trainings for staff Anticipated Completion Date: Quarterly internal audits anticipated start date: April 2026 Anticipated completion date of ongoing program training: July 2026
Coryell County Memorial Hospital Authority implemented enhanced financial reporting procedures effective November 1, 2024. These procedures include the use of more detailed reports with sub-categories of expenses rather than reliance solely on the Authority’s summarized income statement when aggrega...
Coryell County Memorial Hospital Authority implemented enhanced financial reporting procedures effective November 1, 2024. These procedures include the use of more detailed reports with sub-categories of expenses rather than reliance solely on the Authority’s summarized income statement when aggregating data. Although corrective action was implemented prior to issuance of the audit report, the finding is reported because the condition existed during the audit period. Management believes these procedures have been operating effectively since implementation and will prevent recurrence.
December 23, 2025 The City of Colonial Heights respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Brown, Edwards & Company, L.L.P. 3906 Electric Road Roanoke, VA 24018 Audit period: June 30, 2023 The fin...
December 23, 2025 The City of Colonial Heights respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Brown, Edwards & Company, L.L.P. 3906 Electric Road Roanoke, VA 24018 Audit period: June 30, 2023 The findings from the June 30, 2023 Schedule of Findings and Questioned Costs (the “Schedule”) are discussed below. The findings are numbered consistently with the number assigned in the Schedule. FINDINGS – FINANCIAL STATEMENT AUDIT 2023-001: Fund Balance Adjustments (Material Weakness) Condition: During our review of beginning fund balances, we noted that several fund balances did not agree to the ending amounts on the previous year’s annual comprehensive financial report due to issues with a financial software conversion during the fiscal year. As a result, adjustments were made to beginning fund balances during the audit. Criteria: Due to the financial software conversion, various fund balances were misstated due to the way the software was converting the fold balances and posting some new transactions. Cause: The financial software conversion lead to errors in fund balance reporting. Effect: Fund balance for several funds was materially misstated. Recommendation: We recommend correcting software issues and reconciling the prior year ending fund balances from the annual comprehensive financial report to the current year general ledger prior to fiscal year- end. Corrective Action: Management has noted the software issues for prior year ending fund balance reconciliation. The department has worked with the software vendor to resolve the underlying issues for prior year end fund balances and will continue to monitor for the following fiscal year audit to ensure the issue is fully resolved.. The software vendor also showed management a report to run on a monthly basis to check for any imbalances. Management will run this report at least monthly to check for imbalances going forward. FINDINGS – FINANCIAL STATEMENT AUDIT (CONTINUED) 2023-002: Audit Adjustments (Material Weakness) Condition: During the audit, we noted material year-end audit adjustments were required due to software conversion issues. These audit adjustments were required to ensure that the financial statements were prepared in accordance with accounting principles generally accepted in the United States of America. The adjustments were related to fund balance, trial balance discrepancies, and governmental account receivables. Criteria: Fund balance, various trial balance accounts, and governmental accounts receivables were initially materially misstated before audit adjustments were made. Cause: The financial software conversion lead to errors in financial reporting for some accounts. Effect: The ending balance for several accounts were materially misstated. Recommendation: We recommend establishing procedures in which qualified supervisors are reviewing year-end workpapers and reconciliations that feed into the final general ledger and focusing on the accuracy of year-end balances. We also recommend correcting any issues caused by the software conversion. Corrective Action: Management is working to establish procedures for qualified supervisors to review year-end workpapers and reconciliations that feed into the final general ledger. The department continues to correct issues caused by the software conversion. In addition, management has contracted with a consultant who is fully focused on audit work and will consider pre-audit engagements in the future. FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAM AUDIT 2023-003: COVID-19 Elementary and Secondary School Emergency Relief (ESSER) Fund – ALN #84.425D and COVID-19 American Rescue Plan Elementary and Secondary School Emergency Relief Fund (ARP ESSER) – ALN #84.425U, Special Tests and Provisions – Wage Rate (Material Noncompliance) Condition: During our review of the 1 applicable contract related to a federally funded project, we noted that the contract did not include the Wage Rate (Davis Bacon Act) and DOL regulations. Criteria: Federally funded projects under ESSER must comply with the Davis Bacon Act in the written contract. Cause: The omission of this clause was due to oversight. Effect: The written contract was not in compliance with required disclosures related to the Davis Bacon Act. Recommendation: We recommend that a process be put in place that ensures that all contracts related to federally funded projects include necessary DOL regulations. Corrective Action: Management will implement processes to ensure that any future contracts for federally funded projects will include the Wage Rate (Davis Bacon Act) and DOL regulations to ensure compliance. 2023-004: Highway Planning and Construction – ALN # 20.205, COVID-19 Coronavirus State and Local Fiscal Recovery Funds – ALN # 21.027, Special Education - Grants to States – ALN # 84.027, Special Education - Preschool Grants – ALN # 84.173, COVID-19 Elementary and Secondary School Emergency Relief (ESSER) Fund – ALN # 84.425D, and COVID-19 American Rescue Plan Elementary and Secondary School Emergency Relief Fund (ARP ESSER) – ALN # 84.425U, Late Filling of Data Collection Form Condition: The City did not submit the data collection form for the year ended June 30, 2023 timely. For June 30, 2023 year-end audits, under the requirements in the Uniform Guidance and the Office of Management and Budget (OMB), all entities are required to submit the annual data collection form with the Federal Audit Clearinghouse the earlier of either 30 days after the issuance of the entity’s annual audit or nine months after the entity’s fiscal year-end. FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAM AUDIT (CONTINUED) 2023-004: Highway Planning and Construction – ALN # 20.205, COVID-19 Coronavirus State and Local Fiscal Recovery Funds – ALN # 21.027, Special Education - Grants to States – ALN # 84.027, Special Education - Preschool Grants – ALN # 84.173, COVID-19 Elementary and Secondary School Emergency Relief (ESSER) Fund – ALN # 84.425D, and COVID-19 American Rescue Plan Elementary and Secondary School Emergency Relief Fund (ARP ESSER) – ALN # 84.425U, Late Filling of Data Collection Form Criteria: The City is required to submit the annual data collection form with the Federal Audit Clearinghouse the earlier of either 30 days after the issuance of the City’s annual audit or nine months after the City’s fiscal year-end. Cause: The data collection for was not filed timely due to the timing of the issuance of the City’s ACFR. Effect: The data collection form was not filed timely. Recommendation: Management should take steps to ensure that the firm is filed in a timely manner. Corrective Action: Management will work to complete the annual audit in a more timely manner, which is necessary to submit the annual data collection form in a more timely manner in future years. If the Federal Audit Clearinghouse has questions regarding this plan, please call Christina Sadler, Director of Finance at 804-520-9261. Sincerely yours, Christina E Sadler Director of Finance
The new VIP processing system and accompanying spreadsheet is now used to complete a more thorough list for the Board for approval.
The new VIP processing system and accompanying spreadsheet is now used to complete a more thorough list for the Board for approval.
Timesheets will be signed off on by the Health Commissioner or by the department director (Nursing, Environmental Health, Community Health, Administration). Staff will be required to present the timesheets to their supervisor before turning them in for processing. All unsigned timesheets will be ret...
Timesheets will be signed off on by the Health Commissioner or by the department director (Nursing, Environmental Health, Community Health, Administration). Staff will be required to present the timesheets to their supervisor before turning them in for processing. All unsigned timesheets will be returned to the department director and will not be processed until signed.
2023 – 005: Reporting (Compliance; Internal Controls Over Compliance) (Repeat Finding: 2021-005 and 2022-005) Material Weakness – 93.U01 Title V Condition: The Organization was unable to provide any of the required reports for the Title V program, including the financial report, activity narrative, ...
2023 – 005: Reporting (Compliance; Internal Controls Over Compliance) (Repeat Finding: 2021-005 and 2022-005) Material Weakness – 93.U01 Title V Condition: The Organization was unable to provide any of the required reports for the Title V program, including the financial report, activity narrative, third-party income report, GPRA/GPRAMA, urban data standards, and property inventory. Without these reports, we were unable to perform the necessary audit procedures to assess compliance with federal requirements. Corrective Action Plan: As of October 1, 2024, the start of FY25 QuickBooks has been the only software used and Revenue and Disbursements are being classed by Fund. General ledgers are reconciled monthly. Management has implemented procedures and training to assure financial report, activity narrative, third-party income report, GPRA/GPRAMA, urban data standards, and property inventory are completed and retained.
2023 – 003: Activities Allowed and Unallowed, Allowable Costs, Period of Performance (Compliance; Internal Controls Over Compliance) (Repeat Finding: 2021-003 and 2022-003) Material Weakness – 93.U01 Title V Condition: The Organization’s general ledger did not allow for sufficient identification of ...
2023 – 003: Activities Allowed and Unallowed, Allowable Costs, Period of Performance (Compliance; Internal Controls Over Compliance) (Repeat Finding: 2021-003 and 2022-003) Material Weakness – 93.U01 Title V Condition: The Organization’s general ledger did not allow for sufficient identification of transactions related to the major program, Title V. Title V expenditures were recorded through journal entries without supporting transaction-level detail. Because of this, the population of expenditures could not be tied to individual transactions, and pulling samples from this population would not provide a reasonable basis for drawing conclusions about the population tested. As a result, we were unable to select transactions for testing or perform the necessary audit procedures to assess compliance with federal requirements. Corrective Action Plan: As of October 1, 2024, the start of FY25, QuickBooks has been the only software used, and Revenue and Disbursements are being classed by Fund. General ledgers are reconciled monthly. Management is strengthening documentation and recordkeeping procedures to ensure compliance with federal record retention requirements, including improved tracking of Title V expenditures and retention of transaction-level support.
Contact Person – Benjamin Schafer, Executive Director Corrective Action Plan – The Cooperative will reconcile any grant reimbursements prior to submission. Completion Date – This is a current process.
Contact Person – Benjamin Schafer, Executive Director Corrective Action Plan – The Cooperative will reconcile any grant reimbursements prior to submission. Completion Date – This is a current process.
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