Corrective Action Plans

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Finding: 2022-001 Name of contact person: Rick Tipton, DSS Director Corrective Action: Medicaid Programs Supervisor at Yancey DSS oversees the second party review process. Second party reviews are conducted by supervisors and lead workers on Adult Medicaid and Family & Children?s Medicaid cases on a...
Finding: 2022-001 Name of contact person: Rick Tipton, DSS Director Corrective Action: Medicaid Programs Supervisor at Yancey DSS oversees the second party review process. Second party reviews are conducted by supervisors and lead workers on Adult Medicaid and Family & Children?s Medicaid cases on a quarterly basis in accordance with policy. The date of review, program type, and any issues found are documented on the DHB-7078 form, which is subsequently attached on the case in NC FAST. Quarterly training is conducted to address any identified issues and is documented. Yancey DSS will begin keeping a spreadsheet with a list of the cases on which second party reviews are conducted beginning July 1, 2022 and going forward. This will further demonstrate the agency?s compliance with the second party review requirement. The spreadsheet will be completed with cases that have been reviewed July 2022 through February 2023 for FY 2022-23 by March 6, 2023. Cases will be added as reviews are completed each quarter. Proposed Completion Date: March 6, 2023
Finding No. 2022-002 ? Preparation of Financial Statements Jeff Cottingham, Management agent and Wes Clanton, board president of project will continue to monitor financial reports and accounting information as correction is not practical.
Finding No. 2022-002 ? Preparation of Financial Statements Jeff Cottingham, Management agent and Wes Clanton, board president of project will continue to monitor financial reports and accounting information as correction is not practical.
Finding No. 2022-001 ? Segregation of Duties Jeff Cottingham, Management agent and Wes Clanton, board president of project will be responsible for monitoring monthly financial results and accounting information as correction is not practical.
Finding No. 2022-001 ? Segregation of Duties Jeff Cottingham, Management agent and Wes Clanton, board president of project will be responsible for monitoring monthly financial results and accounting information as correction is not practical.
2022-003 Written Procedures of Internal Control over Compliance (Significant Deficiency) Department of Housing and Urban Development Section 811 Supportive Housing for Person with Disabilities, Assistance Listing Number 14.181 Recommendation: The Organization should develop written policies for ...
2022-003 Written Procedures of Internal Control over Compliance (Significant Deficiency) Department of Housing and Urban Development Section 811 Supportive Housing for Person with Disabilities, Assistance Listing Number 14.181 Recommendation: The Organization should develop written policies for the internal control over compliance of federal awards. Action Taken (Unaudited): Management is in the process of updating its control procedures to include proper written policies for the internal control over compliance of federal awards John Griffin, CFO of COF Training Services, Inc. (Management Agent of Integrated Living, Inc.) is responsible for this corrective action. Anticipated completion date is June 30, 2023.
Finding No. 2022-002 ? Preparation of Financial Statements Jeff Cottingham, Management agent, and Father Elia, sponsor of the project, will continue to monitor financial reports and accounting information as correction is not practical.
Finding No. 2022-002 ? Preparation of Financial Statements Jeff Cottingham, Management agent, and Father Elia, sponsor of the project, will continue to monitor financial reports and accounting information as correction is not practical.
Finding No. 2022-001 ? Segregation of Duties Jeff Cottingham, Management agent, and Father Elia, sponsor of the project, will be responsible for monitoring monthly financial results and accounting information as correction is not practical
Finding No. 2022-001 ? Segregation of Duties Jeff Cottingham, Management agent, and Father Elia, sponsor of the project, will be responsible for monitoring monthly financial results and accounting information as correction is not practical
Recommendation: We recommend the Organization enforce its policies and procedures around review of reports. Corrective Action: Management agrees with the recommendation. Program management will review existing process to ensure adequate review and documentation of review of funder reports. Person(s)...
Recommendation: We recommend the Organization enforce its policies and procedures around review of reports. Corrective Action: Management agrees with the recommendation. Program management will review existing process to ensure adequate review and documentation of review of funder reports. Person(s) Responsible for Corrective Action: Associate Director, Ending Poverty Anticipated Completion Date: March 31, 2023
Recommendation: We recommend the organization enforce its policies for retention and review of records for each person enrolled in the program and strengthen review of payroll for the underlying records. Corrective Action: Management agrees with the recommendation. Corrective action taken includes p...
Recommendation: We recommend the organization enforce its policies for retention and review of records for each person enrolled in the program and strengthen review of payroll for the underlying records. Corrective Action: Management agrees with the recommendation. Corrective action taken includes preparation of and communication of standard operating procedures for enrollment, payroll set up, and member service agreement document review and retention. In addition, program management staff will conduct a secondary review of biweekly program payroll prior to submission, to ensure wage rate compliance with member service agreements. Person(s) Responsible for Corrective Action: Associate Director, Human Resources; Associate Director, Ending Poverty Anticipated Completion Date: March 31, 2023
Finding No. 2022-002 ? Preparation of Financial Statements Jeff Cottingham, Management agent and Father Elia, sponsor of project will continue to monitor financial reports and accounting information as correction is not practical.
Finding No. 2022-002 ? Preparation of Financial Statements Jeff Cottingham, Management agent and Father Elia, sponsor of project will continue to monitor financial reports and accounting information as correction is not practical.
Finding No. 2022-001 ? Segregation of Duties Jeff Cottingham, Management agent and Father Elia, sponsor of project, will be responsible for monitoring monthly financial results and accounting information as correction is not practical.
Finding No. 2022-001 ? Segregation of Duties Jeff Cottingham, Management agent and Father Elia, sponsor of project, will be responsible for monitoring monthly financial results and accounting information as correction is not practical.
Finding 61668 (2022-001)
Significant Deficiency 2022
Finding 2022-001 Federal Agency Name: U.S. Department of Housing and Urban Development Program Name: Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects ? Section 223f Federal Financial Assistance Listing #14.155 Finding Summary: Tenant file testing identifie...
Finding 2022-001 Federal Agency Name: U.S. Department of Housing and Urban Development Program Name: Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects ? Section 223f Federal Financial Assistance Listing #14.155 Finding Summary: Tenant file testing identified one exception where a tenant?s medical expenses were incorrectly calculated. Responsible Individuals: Shane Knutson, Director, Senior Living Operations Corrective Action Plan: We will review our procedures with applicable employees to ensure compliance with designed controls. Anticipated Correction Date: April 30, 2023
Finding 61633 (2022-002)
Significant Deficiency 2022
2022-002: Significant Deficiency ? Reporting ? Relating to the Emergency Food Assistance Program ? Commodities (10.569) ? this is a repeat finding of prior year finding 2021-002 This deficiency is primarily due to vacancies of certain key positions within Operations, compounded by a general lack of...
2022-002: Significant Deficiency ? Reporting ? Relating to the Emergency Food Assistance Program ? Commodities (10.569) ? this is a repeat finding of prior year finding 2021-002 This deficiency is primarily due to vacancies of certain key positions within Operations, compounded by a general lack of necessary cross-training hampered by those vacancies. Because of this in-part, full workloads of our existing Operations staff are common, and in order for our Operations staff to have and be assured the necessary time to successfully perform and complete their day-to-day operational responsibilities, these particular monthly reporting deadlines have unfortunately been missed on occasion. Additionally, because of our desire to submit accurate reports, several times the reconciliation of inventory took greater than 10 days. We continually attempt to submit all of our monthly reporting to the Tennessee Department of Agriculture prior to the 10-business day deadline and consider any missed deadlines as undesirable. It is the responsibility of the COO to fill key open positions, train and cross-train Operations staff to ensure that this particular reporting, and Operations reporting in general, is performed timely and accurately.Anticipated completion date: The corrective controls and procedures were collectively completed, which includes having one staff member responsible for filing the report monthly, checked for accuracy by the COO, and have two additional staff members trained as backups, and put in place February 1, 2023 and are ready for the next fiscal year close. Responsible Official: Scott Fortin, COO (901-373-0437)
Finding 61622 (2022-004)
Significant Deficiency 2022
Finding 2022-004 Activities Allowed or Unallowed and Allowable Costs/Cost Principles ? Significant Deficiency in Internal Control Over Compliance Planned Corrective Actions: The Association will ensure that the proper internal control procedures over timesheets review and approval process are in pla...
Finding 2022-004 Activities Allowed or Unallowed and Allowable Costs/Cost Principles ? Significant Deficiency in Internal Control Over Compliance Planned Corrective Actions: The Association will ensure that the proper internal control procedures over timesheets review and approval process are in place before the timesheets are submitted to payroll for processing. Individual(s) Responsible for Corrective Action Plan Angela Joule HR Director 907-442-7899 Anticipated Completion Date: March 31, 2023
MANY FARMS COMMUNITY SCHOOL, INC. CORRECTIVE ACTION PLAN FOR THE YEAR ENDED JUNE 30, 2022 2022-001 Internal Control over Financial Close and Reporting (Material Weakness) - Repeated &Modified (Prior Year Finding 2021-001) Federal program information Funding agencies: U.S. Department of the Inter...
MANY FARMS COMMUNITY SCHOOL, INC. CORRECTIVE ACTION PLAN FOR THE YEAR ENDED JUNE 30, 2022 2022-001 Internal Control over Financial Close and Reporting (Material Weakness) - Repeated &Modified (Prior Year Finding 2021-001) Federal program information Funding agencies: U.S. Department of the Interior; U.S. Department of Education Title: Indian school equalization program (ISEP); Administrative Cost Grants for Indian Schools; Indian Education Facilities; Title I Grants to Local Agencies; Coronavirus Response and Relief Assistance Listing Numbers: 15.042 Award year: 07/01/2021 - 06/30/2022 Award number: A19AV00941 Management Response: The School did not have a Business Manager or Principal for the full fiscal year and has experienced turnover in other positions as well. The school has hired two (2) Business Managers on a short-term contract and full time contract. During the interim period, the Business Manager position was vacant until December 19, 2022. The administration agrees with the finding and with the newly hired Business Manager will devote time to evaluate adequate internal controls and procedures to ensure timely and accurate financial statements and supporting schedules and to ensure timely financial compliance requirements are met. ? All liability accounts will be reconciled at year end. ? Cash deposits will be made into the correct cash accounts and accounts reconciled. ? The School?s financial policy, updated in December of 2021, will be revised annually to ensure internal controls are identified and procedures are in place for timely and accurate recording of revenue and expenditures. ? The Organizational Structure will be revised to ensure the internal controls are met within the Business Office. ? The Principal and key staff will establish ad team to review and update the School's financial policies. Anticipated Completion Date: June 2023 Responsible Party: School Principal, Leon Oosahwe; Business Manager, Ernest Sakeva
SEGREGATION OF DUTIES: The Organization concurs with the findings. The Organization has determined it is staffed appropriately given the resources available and will continue to look for new opportunities to address these findings.
SEGREGATION OF DUTIES: The Organization concurs with the findings. The Organization has determined it is staffed appropriately given the resources available and will continue to look for new opportunities to address these findings.
Management's Response and Planned Corrective Action: The Health Department of Northwest Michigan will review and follow any instructions and guidance available in any instances we are required to file within the Provider Relief Funding Portal. Responsible Party for Corrective Action: Shannon Klownow...
Management's Response and Planned Corrective Action: The Health Department of Northwest Michigan will review and follow any instructions and guidance available in any instances we are required to file within the Provider Relief Funding Portal. Responsible Party for Corrective Action: Shannon Klownowski, Chief Financial and Administrative Officer Anticipated Completion Date: January 2023
Supportive Housing for Persons With Disabilities ? Assistance Listing No. 14.181 Criteria or Specific Requirement: According to the client's internal control over payroll disbursements, hourly employees must maintain timesheets which are approved and signed by the property manager. Condition: Upon...
Supportive Housing for Persons With Disabilities ? Assistance Listing No. 14.181 Criteria or Specific Requirement: According to the client's internal control over payroll disbursements, hourly employees must maintain timesheets which are approved and signed by the property manager. Condition: Upon performing testing over payroll disbursements, we noted that there was no approval of the timesheet for one of the payroll disbursements tested. Questioned costs: None Context: The timesheet for 1 out of 5 payroll disbursements tested was not properly approved by the property manager. Cause: Turnover of property manager at the property management company and weaknesses in internal controls over payroll disbursements. Effect: There is no evidence of proper approval of payroll disbursement. Repeat Finding: No Recommendation: We recommend that management strengthen controls over review of payroll. Views of Responsible Officials: There is no disagreement with the audit finding. Action taken in response to finding: Property manager is implementing review prior to payroll disbursement. Name of the contact person responsible for corrective action: Angela Westwood, CFO Planned completion date for corrective action plan: Already implemented as of 7/1/23
Supportive Housing for Persons With Disabilities ? Assistance Listing No. 14.181 Criteria or Specific Requirement: All disbursements from the reserve must be approved by HUD and made for the approved purpose (24 CFR section 891.405). Condition: Upon performing testing over replacement reserve disb...
Supportive Housing for Persons With Disabilities ? Assistance Listing No. 14.181 Criteria or Specific Requirement: All disbursements from the reserve must be approved by HUD and made for the approved purpose (24 CFR section 891.405). Condition: Upon performing testing over replacement reserve disbursements, we noted that one invoice was included in two different disbursement requests to HUD. Questioned costs: $1,436 Context: One of the invoice tested of $1,436 was included in two different disbursement requests to HUD. Cause: Turnover of property manager at the property management company and weaknesses in internal controls over replacement reserve disbursement. Effect: Disbursements made out of the replacement reserve included an invoice of $1,436 that was already included in previous disbursement request and was reimbursed twice. Repeat Finding: No Recommendation: We recommend that management strengthen controls over review of replacement reserve disbursement requests. Views of Responsible Officials: There is no disagreement with the audit finding. Action taken in response to finding: Property management is increasing staff to properly comply with all regulations. Name of the contact person responsible for corrective action: Angela Westwood, CFO Planned completion date for corrective action plan: Immediate going forward.
Supportive Housing for Persons With Disabilities ? Assistance Listing No. 14.181 Criteria or Specific Requirement: As per 24 CFR 891.410 Selection and Admission of Tenants, the owner must reexamine the income and composition of the household at least every 12 months. Upon verification of the inform...
Supportive Housing for Persons With Disabilities ? Assistance Listing No. 14.181 Criteria or Specific Requirement: As per 24 CFR 891.410 Selection and Admission of Tenants, the owner must reexamine the income and composition of the household at least every 12 months. Upon verification of the information, the Owner must make appropriate adjustments in the total tenant payment in accordance with federal regulations and must determine whether the household unit size is still appropriate. Condition: Upon performing testing over tenant rent and eligibility, we noted that annual recertifications were not completed timely. Questioned costs: None Context: Annual recertifications for 3 out of 5 tenants tested were not performed. Cause: Turnover of property manager at the property management company and weaknesses in internal controls over timely completion of tenant annual recertifications. Effect: Untimely performance of required annual recertifications could affect the household?s eligibility for project rental assistance payments. Repeat Finding: Yes Recommendation: We recommend that all required annual recertifications be completed timely. Views of Responsible Officials: There is no disagreement with the audit finding. Action taken in response to finding: Sponsor has requested a meeting with senior property management team to discuss lack of transparency with problems in this area. We are in the process of obtaining a current list of clients and their recertification dates. We will monitor monthly and follow up with management company and help from case managers to work with tenants to provide the needed information. Property management has new hires in the pipeline that should be up and running no later than 4/1/2023 to help mitigate the issues. Name of the contact person responsible for corrective action: Angela Westwood, CFO Planned completion date for corrective action plan: Immediately
Finding 61605 (2022-003)
Significant Deficiency 2022
2022-003 Comprehensive Opioid, Stimulant, and Substance Abuse Program ? Assistance Listing No. 16.838 Recommendation: TASC should continue to follow the documented policy of documenting preparation and review of billings submitted to funders. Explanation of disagreement with audit finding: There is ...
2022-003 Comprehensive Opioid, Stimulant, and Substance Abuse Program ? Assistance Listing No. 16.838 Recommendation: TASC should continue to follow the documented policy of documenting preparation and review of billings submitted to funders. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management implemented segregation of duties for this situation shortly after conclusion of the FY21 audit. Management formulated a Segregation of Duties (BUS 123) that included segregation of preparation and review of billings effective July 1, 2022. Name(s) of the contact person(s) responsible for corrective action: Roy Fesmire, CFO Planned completion date for corrective action plan: June 30, 2022
Finding 61603 (2022-001)
Significant Deficiency 2022
2022-001 Comprehensive Opioid, Stimulant, and Substance Abuse Program ? Assistance Listing No. 16.838 Recommendation: We recommend that current time tracking policies and procedures be followed in timecard preparation to document review and subsequent approval including adjustments made by the CFO. ...
2022-001 Comprehensive Opioid, Stimulant, and Substance Abuse Program ? Assistance Listing No. 16.838 Recommendation: We recommend that current time tracking policies and procedures be followed in timecard preparation to document review and subsequent approval including adjustments made by the CFO. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will modify its? Segregation of Duties (BUS 123) policy to include language requiring Supervisory sign-off of manual time charge adjustments that occur after time sheets have been approved as a result of incorrect time sheet submissions. Name(s) of the contact person(s) responsible for corrective action: Roy Fesmire, CFO Planned completion date for corrective action plan: June 30, 2023
Views of responsible officials and planned corrective action: We are in agreement with the finding. One of the Organization?s subrecipients was late in responding with necessary information, which resulted in the Organization being late in filing. Management is in the process of creating an updated ...
Views of responsible officials and planned corrective action: We are in agreement with the finding. One of the Organization?s subrecipients was late in responding with necessary information, which resulted in the Organization being late in filing. Management is in the process of creating an updated process/system to ensure compliance with this requirement moving forward.
Wabanaki Public Health and Wellness received our FY21 audit in April 2023, which did not allow for the changes to be made in time for FY22. The corrective action plan from FY21 continues to be our course of action and will be fully implementing the following to ensure compliance in FY23. Wabanaki P...
Wabanaki Public Health and Wellness received our FY21 audit in April 2023, which did not allow for the changes to be made in time for FY22. The corrective action plan from FY21 continues to be our course of action and will be fully implementing the following to ensure compliance in FY23. Wabanaki Public Health & Wellness is committed to having our Single audits completed in time for submission to the clearing house within the appropriate time frame. WPHW has obtained WIPFLI for the next five years and will schedule our audit as early in the season as possible. Wabanaki Public Health & Wellness will be prepared to provide all information that is requested prior to the auditors being within our offices by the designated date in which the items are requested. During the period in which the auditors are within house and the weeks following the Director of Finance and the Financial Quality and Compliance Manager will be available to answer any questions, provide documentation, and details for all requirements for WIPFLI to complete the audit for submission to the clearing house. Person(s) Responsible: Beth McLean Timing for Implementation: Summer 2023
Wabanaki Public Health and Wellness received our FY21 audit in April 2023, which did not allow for the changes to be made in time for FY22. The corrective action plan from FY21 continues to be our course of action and will be fully implementing the following to ensure compliance in FY23. Wabanaki ...
Wabanaki Public Health and Wellness received our FY21 audit in April 2023, which did not allow for the changes to be made in time for FY22. The corrective action plan from FY21 continues to be our course of action and will be fully implementing the following to ensure compliance in FY23. Wabanaki Public Health & Wellness has acquired a new accounting software, go live 2nd quarter of 2023, that allows the separation of access to items, accounts, lists, assets, etc. to be segregated by positions assignments. Each position has different limitations within the software and access to different levels of accounting limits. The new system has approval processes attached to different sections within the recording aspect of different transactions that requires separate staff to approve entries. Wabanaki Public Health & Wellness has also increased the number of staff to help in the separation amongst duties, to strengthen the internal controls within the accounting system and department. The organization is going through a restructure to ensure there are separations of duties, lack of single staff having full access to all items. The Director of Finance and the Financial Quality and Compliance Manager are two of the new positions that have been implemented to help work through the required changes to get the internal control structure and the separations of duties in place. The Financial Quality and Compliance Manager will continue to review processes and validate compliance within the department and suggest changes for processes as they arise within the accounting department. Person(s) Responsible: Beth McLean Timing for Implementation: Summer 2023
Wabanaki Public Health and Wellness received our FY21 audit in April 2023, which did not allow for the changes to be made in time for FY22. The corrective action plan from FY21 continues to be our course of action and will be fully implementing the following to ensure compliance in FY23. Wabanaki P...
Wabanaki Public Health and Wellness received our FY21 audit in April 2023, which did not allow for the changes to be made in time for FY22. The corrective action plan from FY21 continues to be our course of action and will be fully implementing the following to ensure compliance in FY23. Wabanaki Public Health & Wellness has been reviewing the year end close process as soon as we learned that there was a need for a stronger year end closing procedure. With the two new key roles being implemented the organization will have a full review of the internal control process and the yearend close process. A new full year end closing check list will be set forth to help designate appropriate steps to verify that all accounts have been review and reconciled with support from general ledger. The Director of Finance will review the processes as the accounting teams works through the checklist and once the Accounting team has determined that the process has been completed, the Financial Quality and Compliance Manager will complete a full review/audit of items to ensure that each have followed the year end closing check list and that the accounts have been reviewed and reconciled with the support of the general ledger accounts. Person(s) Responsible: Beth McLean Timing for Implementation: Summer 2023
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