Corrective Action Plans

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U.S. Department of Health and Human Services Great River Health System, Inc. and Subsidiaries respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 – June 30, 2023 The finding from the schedule of findings and questioned costs is discu...
U.S. Department of Health and Human Services Great River Health System, Inc. and Subsidiaries respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 – June 30, 2023 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDING—FEDERAL AWARD PROGRAMS AUDITS MATERIAL WEAKNESS U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 2023-003 Provider Relief Fund – Assistance Listing No. 93.498 Recommendation: We recommend the Organization put in place controls over compliance that mitigate the risk of errors in reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We added an additional management review for future submissions prior to filing and submission. Name(s) of the contact person(s) responsible for corrective action: Jeremy Alexander, CFO Planned completion date for corrective action plan: 7/01/2024 If the Department of Health and Human Services has questions regarding this plan, please call Jeremy Alexander at 319-768-3280.
View Audit 315911 Questioned Costs: $1
Develop a comprehensive policy outlining the procedures for reviewing the monthly payroll grant summary. Provide training and guidance to the designated reviewer on the policies and procedures outlined in the new policy. Maintain thorough documentation of the review activities conducted, including a...
Develop a comprehensive policy outlining the procedures for reviewing the monthly payroll grant summary. Provide training and guidance to the designated reviewer on the policies and procedures outlined in the new policy. Maintain thorough documentation of the review activities conducted, including any corrective actions taken in response to identified issues.
Maintain detailed documentation of the review process, including any findings or discrepancies identified during the review of drawdowns. Establish clear review procedures for the drawdowns prepared by the Assistant Controller. Continuously monitor the effectiveness of the review process and identif...
Maintain detailed documentation of the review process, including any findings or discrepancies identified during the review of drawdowns. Establish clear review procedures for the drawdowns prepared by the Assistant Controller. Continuously monitor the effectiveness of the review process and identify areas for improvement. Implement any necessary changes or enhancements to the review procedures to ensure thorough compliance with grant requirements.
The County's system of internal control detected this error prior to commencement of audit procedures for 2023 and was corrected during the grant reporting process for the quarter ended March 31, 2024.
The County's system of internal control detected this error prior to commencement of audit procedures for 2023 and was corrected during the grant reporting process for the quarter ended March 31, 2024.
Views of Responsible Officials and Planned Corrective Actions We agree with this finding. NWCH was successful in adding needed staff in 2023, but was unable to hire a degreed accountant or controller, or to contract with an accounting firm for oversight of the accounting function. Bookkeeper trainin...
Views of Responsible Officials and Planned Corrective Actions We agree with this finding. NWCH was successful in adding needed staff in 2023, but was unable to hire a degreed accountant or controller, or to contract with an accounting firm for oversight of the accounting function. Bookkeeper training was provided from Shelter Resources Financial Manager in February 2023. NWCH is researching CPA firms in order to contract a qualified controller with expertise in real estate holdings relevant to NWCH. NWCH has been actively searching for a qualified CPA to hire or contract with since 2021, however, due to capacity constraints and overwhelmed CPA firms, NWCH has been unsuccessful. Efforts to hire experienced accounting personnel continues.
Finding 2023-002: Special Tests and Provisions The Corporation has three properties secured by CDBG loans. The properties are known as Mid-City, AppleTree Housing, Inc. (“ATH”), and Center West. The Corporation was unable to support that at least fifty-one percent (51%) of the tenants at the ATH pro...
Finding 2023-002: Special Tests and Provisions The Corporation has three properties secured by CDBG loans. The properties are known as Mid-City, AppleTree Housing, Inc. (“ATH”), and Center West. The Corporation was unable to support that at least fifty-one percent (51%) of the tenants at the ATH property were leased to and occupied by low or very low-income persons as determined by the Federal “Section 8” Income Standards with completed tenant certifications and recertifications. At ATH, 6 of 6 occupied unit’s certifications were not completed during the year ended June 30, 2023. This was an initial finding during the year ended June 30, 2020. Planned Corrective Action: It is the goal of the Corporation to maintain compliance with regulatory requirements. Where hardships are encountered the Corporation remains in ongoing communication with respective regulatory agencies to promote transparency and mitigate risk of loss in fundings or default. Mark Deitcher, CFO, is responsible for the corrective action plan. If the U.S Department of Housing and Urban Development has questions regarding this plan, please call Mark Deitcher at 1-215-557-8414.
The District has instituted an internal control that requires the preparation, review and retention of documentation as evidence that coding changes have not only been made but also made in a timely manner. The District will ensure that a contract is executed for every full-time employee included in...
The District has instituted an internal control that requires the preparation, review and retention of documentation as evidence that coding changes have not only been made but also made in a timely manner. The District will ensure that a contract is executed for every full-time employee included in the human resources module in eFinance by reconciling employee and contract counts.
View Audit 315830 Questioned Costs: $1
In our test of disbursements, we identified unallowable costs totaling $4,458 for football kicking lessons ($2,250) and student t-shirts to be worn at sporting events ($2,208) were paid from Education Stabilization Funds.
In our test of disbursements, we identified unallowable costs totaling $4,458 for football kicking lessons ($2,250) and student t-shirts to be worn at sporting events ($2,208) were paid from Education Stabilization Funds.
View Audit 315830 Questioned Costs: $1
COIVD-19: Coronavirus State and Local Fiscal Recovery – Assistance Listing No. 21.027 Recommendation: We recommend that the Organization consider implementing a process that documents review and approval of submitted indirect cost claims by someone other than the preparer of such claims. Documentat...
COIVD-19: Coronavirus State and Local Fiscal Recovery – Assistance Listing No. 21.027 Recommendation: We recommend that the Organization consider implementing a process that documents review and approval of submitted indirect cost claims by someone other than the preparer of such claims. Documentation of contemporaneous review should also be maintained. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: The organization will review this finding and current methodology and propose corrections as part of a broader review of its technologies. Name of the contact person responsible for corrective action: Silvia Zelaya, Finance Director Planned completion date for corrective action plan: January 2025
Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization update its derivative income allocation method, policy and procedures to reflect the method described in the federal regulations. Explanation of disagreement with audit finding: ...
Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization update its derivative income allocation method, policy and procedures to reflect the method described in the federal regulations. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: The Organization will reach out to LSC to understand if our current method is acceptable. If not, the Organization will implement corrections to comply with applicable standards. Name of the contact person responsible for corrective action: Silvia Zelaya, Finance Director Planned completion date for corrective action plan: January 2025
Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization review its case file review internal controls to ensure that they are designed in a manner to detect and prevent noncompliance with this requirement. Explanation of disagreement ...
Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization review its case file review internal controls to ensure that they are designed in a manner to detect and prevent noncompliance with this requirement. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: The Organization has robust training for case handlers around when a retainer is required. The Organization will keep these measures in place and also plan to provide additional training for all case handlers on our case handler standards, which we will make sure also covers retainer agreements and managers’ review of case files. Name of the contact person responsible for corrective action: Silvia Zelaya, Finance Director Planned completion date for corrective action plan: January 2025
Finding 2023-005 Medical Assistance Program Special Test and Provisions- ADP Risk Analysis and System Security Review Material Weakness and Noncompliance The DOH disagrees with this finding as they believe the MCO should have received a SOC 1 Type 1 and Type 2 Report. The DOH has requested this ...
Finding 2023-005 Medical Assistance Program Special Test and Provisions- ADP Risk Analysis and System Security Review Material Weakness and Noncompliance The DOH disagrees with this finding as they believe the MCO should have received a SOC 1 Type 1 and Type 2 Report. The DOH has requested this information from the MCO however it has not been provided yet due to the short time frame for gathering the requested information. Responsible Officials Dinorah Collazo Ortiz Executive Director 787-765-2929 ext. 3402 Felmarie Cruz Morales Fiscal Director 787-765-2929 ext. 6721 Marcia Berrios De La Torre Financial Advisor 787-765-2929 ext. 6746 Estimated Completion Date Implementation is expected to be completed on or before the end of the year 2025.
Finding 2023-001 Financial Administration- Standards for Financial Management System Financial Internal Control Weakness and Noncompliance The PRDOH agrees with the finding. However, PRDOH has implemented various corrective actions. Regarding Project Costing Module, the PRDOH already has implemente...
Finding 2023-001 Financial Administration- Standards for Financial Management System Financial Internal Control Weakness and Noncompliance The PRDOH agrees with the finding. However, PRDOH has implemented various corrective actions. Regarding Project Costing Module, the PRDOH already has implemented the Travel and Expenses Module, Payment Management System, which integrates with the Account Receivable to streamline revenue records and Payroll Solutions. The effectiveness of these will be observed during the fiscal year 2024-2025. Also, the PRDOH and Central Government are currently working on ERP implementation in all Government Agencies. This new ERP will be in place in the fiscal year 2024-2025. Furthermore, the PRDOH has established control in order for all program to ensure the timely performed reconciliations between the finance office, the federal affair office, this procedure has started since august 2022. In the other hand the State Department of Treasury has begun a series of training with regard the new ERP that will, be in place by October 2024. This new system in order to close the monthly period all programs will need to reconcile first before closing of the period. Responsible Official Mrs. Velmary Martinez Yace Finance Director Tel. 787-765-2929 ext. 3291 Mrs. Mayra Reyes Accounting Office Supervisor Tel. 787-765-2929 ext. 3294 Estimated Completion Date Implementation is expected to be completed on or before the end of October 2024.
Finding Number: 2023-002 Finding Title: Child Support Non-Cooperation Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: DeAnn Boney, Income and Healthcare Assistance Manager Corrective Action Planned: The agency will take the following ...
Finding Number: 2023-002 Finding Title: Child Support Non-Cooperation Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: DeAnn Boney, Income and Healthcare Assistance Manager Corrective Action Planned: The agency will take the following steps to come into compliance: 1 Correct the cases that were found to be in error. 2 Establish an internal case review process. 3 Provide training and review the policy areas where deficiencies were identified with the family team. 4 Require family team to take new DHS training on assets. 5 Use DHS TANF case reviews as learning tools and share results with the family team. Anticipated Completion Date: Cases will be corrected, and the review process will be in place by 7/31/2024
Finding Number: 2023-001 Finding Title: Eligibility Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: DeAnn Boney, Income and Healthcare Assistance Manager Corrective Action Planned: The agency will take the following steps to come into...
Finding Number: 2023-001 Finding Title: Eligibility Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: DeAnn Boney, Income and Healthcare Assistance Manager Corrective Action Planned: The agency will take the following steps to come into compliance: 1. Correct the cases that were found to be in error. 2. Establish an internal case review process. 3. Provide training and review the policy areas where deficiencies were identified with the family team. 4. Require family team to take new DHS training on assets. 5. Use DHS TANF case reviews as learning tools and share results with the family team. Anticipated Completion Date: Cases will be corrected, and the review process will be in place by 7/31/2024.
Finding 479219 (2023-002)
Significant Deficiency 2023
The City has determined the benefit of adequately segregating duties is less than the cost. Based on this assessment, the City is accepting the risk posed by the deficiency while also evaluating mitigating controls that will help reduce the risk of material misstatement of the financial statements. ...
The City has determined the benefit of adequately segregating duties is less than the cost. Based on this assessment, the City is accepting the risk posed by the deficiency while also evaluating mitigating controls that will help reduce the risk of material misstatement of the financial statements. Management is attempting to mitigate the associated risks by doing the following: Identifying areas lacking segregation of duties and where there are higher risks of fraud occurring. Implementing limited segregation to the extent possible to reduce risks without impairing efficiency. Using the knowledge of management and the City Council to review accounting records and reports.
The City will continue to review and approve adjusting journal entries as proposed by the auditor, as well as taking responsibility for the audited financial statements.
The City will continue to review and approve adjusting journal entries as proposed by the auditor, as well as taking responsibility for the audited financial statements.
Management has prepared an outstanding Replacement Reserve Deposit worksheet and this tool will be used to track monthly deposits into the Replacement Reserve Account. Deposits will begin in June 2024 and older outstanding balances will be paid first. On a go forward basis, St. Cat's will make at le...
Management has prepared an outstanding Replacement Reserve Deposit worksheet and this tool will be used to track monthly deposits into the Replacement Reserve Account. Deposits will begin in June 2024 and older outstanding balances will be paid first. On a go forward basis, St. Cat's will make at least one monthly deposit into the Replacement Reserve, and depending on cash flow will strive to make additional monthly deposits to lower the total amount outstanding.
Management has prepared an outstanding Replacement Reserve Deposit worksheet and this tool will be used to track monthly deposits into the Replacement Reserve Account. Deposits will begin in June 2024 and older outstanding balances will be paid first. On a go forward basis, St. Ann's will make at le...
Management has prepared an outstanding Replacement Reserve Deposit worksheet and this tool will be used to track monthly deposits into the Replacement Reserve Account. Deposits will begin in June 2024 and older outstanding balances will be paid first. On a go forward basis, St. Ann's will make at least one monthly deposit into the Replacement Reserve, and depending on cash flow will strive to make additional monthly deposits to lower the total amount outstanding.
BCCYF Program and Fiscal departments have updated the policy and procedure to adequately track yearly reviews for TANF eligible files. The fiscal department will track dates in QuickBooks. This will be used as a tickler system for notifying the fiscal department that a redetermination and review mus...
BCCYF Program and Fiscal departments have updated the policy and procedure to adequately track yearly reviews for TANF eligible files. The fiscal department will track dates in QuickBooks. This will be used as a tickler system for notifying the fiscal department that a redetermination and review must be completed. Prior to reporting of TANF, this tracking system will be used to ensure that all redeterminations and reviews are completed prior to submission. Timetable for Implementation: Implementation of the TANF policy and procedure will take effect FY 24/25 Quarter 1. Monitoring to Be Performed: A report will be saved in Excel of all TANF determinations/redeterminations and reviews per quarter. Name of Person(s) with Title and Scope of Responsibility: Name: Mindy Hostetler Title: Fiscal Officer. Corrective Action - Approved by: Tiffany Treese Position: Administrator Date: June 28, 2024.
Finding 2023-001 Condition The College did not notify the National Student Loan Data System (NSLDS) in a timely manner for 24 students with status changes in our sample of 25 students. The sample was not a statistically valid sample. Corrective Action Plan Corrective Action Planned: The College has ...
Finding 2023-001 Condition The College did not notify the National Student Loan Data System (NSLDS) in a timely manner for 24 students with status changes in our sample of 25 students. The sample was not a statistically valid sample. Corrective Action Plan Corrective Action Planned: The College has updated its policies and procedures to ensure notifications to the National Student Loan Data System are performed timely. In addition, all members of the responsible team will undergo formalized training to ensure their knowledge and proficiency regarding all applicable rules and regulations are kept up to date. Name(s) of Contact Person(s) Responsible for Corrective Action: Jeremy Sivillo, Institutional Registrar Kevin A. Thomas, D.O., Assistant Dean of Institutional Enrollment Management Anticipated Completion Date: Policies and procedure update implementation has been completed. Training for existing staff is to be completed by April 30, 2024. Training material development for new employees will be completed by May 31, 2024
Planned Corrective Action: While we agree that the submission dates lagged the scheduled dates, we do not agree that this condition rises to the level of a material weakness in internal controls over reporting. BVCOG submitted their audited financial statements for fiscal year 2022 through the Feder...
Planned Corrective Action: While we agree that the submission dates lagged the scheduled dates, we do not agree that this condition rises to the level of a material weakness in internal controls over reporting. BVCOG submitted their audited financial statements for fiscal year 2022 through the Federal Audit Clearinghouse (FAC) on June 30, 2023, which is prior to June 30, 2023. BVCOG awaits receipt of their audited financial fiscal year 2023 in order to submit them to the FAC. The audited fiscal year 2022 financial statements were submitted separately to HUD on November 22, 2023. HUD approved our submission without notice of delay. Unaudited financial statements for the fiscal year ending 2023 were submitted and accepted by HUD, with no point score deduction penalties or requests for corrective action. The timing of HUD’s Real Estate Assessment Center (REAC) report submission depends on acceptance of the previous unaudited or audited financial statements. The REAC submissions require that each year’s unaudited submission be approved by HUD before the audited submission can be submitted; further, both submissions for a year must be accepted by HUD before the next year’s submissions can be completed. Due to various factors including the COVID-19 pandemic and Winter Storm Uri in 2021, the Fiscal Year 2020 unaudited submission process completed April 2022. Subsequent staff turnover delayed the submission of the audited 2020 submission until August 2023. Once that submission was approved by HUD, the 2021 and 2022 submissions were completed by the end of November 2023. BVCOG realizes its REAC submission procedures rely on institutional knowledge and addressed this risk by engaging an outside CPA firm with personnel knowledgeable of the REAC system. This arrangement ensures additional cross-training opportunities in the future for current finance staff such that, if a key staff person leaves, there will be others in the department who know and understand the procedures necessary for compliance with HUD deadlines. Contact Person Responsible for Corrective Action: Janet Dudding, MBA, CPA, CGFO, Director of Finance Anticipated Completion Date: July 2024
To ensure compliance with grant regulations the school district will implement the following: ● Conduct a comprehensive assessment of existing procedures to identify gaps that led to non-compliance with grant regulations. ● Ensure timely submission of grant applications. ● Maintain detailed document...
To ensure compliance with grant regulations the school district will implement the following: ● Conduct a comprehensive assessment of existing procedures to identify gaps that led to non-compliance with grant regulations. ● Ensure timely submission of grant applications. ● Maintain detailed documentation of all award dates and expenditures to provide a clear compliance record. ● Ensure all documentation is easily accessible and systematically organized for audit purposes. ● Ensure pre-award costs are allowable only to the extent they would have been allowable if incurred after the effective date and ONLY with written approval from the Federal awarding agency (as per 2 CFR 200.458). ● Establish a process for obtaining and documenting written approval for pre-award costs. ● Provide comprehensive training on compliance with Uniform Grant Guidance to all relevant staff. ● Review and update policies and procedures related to grant expenditures regularly to ensure they are current and compliant with federal regulations. ● Assign accountability for monitoring and reporting compliance to specific roles within the organization. This implementation of this plan shall be the responsibility of the Russ Kaubris, Business Manager. Starting with the Fiscal Year 2025 grant cycle, procedures to comply will be implemented.
Moving forward, a supervisory review of the move in files will be performed by a different staff member for the Authority than the staff member who initially determined eligibility. This will ensure that the Authority continues compliance with eligibility requirements.
Moving forward, a supervisory review of the move in files will be performed by a different staff member for the Authority than the staff member who initially determined eligibility. This will ensure that the Authority continues compliance with eligibility requirements.
It was discovered that our financial institution was pledging securities based on book value and not on market value which led to the deposits not being fully collateralized according to HUD requirements and State Statutes. The Authority will review the collateral reports at least quarterly to dete...
It was discovered that our financial institution was pledging securities based on book value and not on market value which led to the deposits not being fully collateralized according to HUD requirements and State Statutes. The Authority will review the collateral reports at least quarterly to determine that pledging requirements are adequate to ensure compliance in the future.
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