Corrective Action Plans

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Finding 35848 (2022-001)
Significant Deficiency 2022
United States Department of Health and Human Services Infinity Health respectfully submits the following corrective action plan for the year ended November 30, 2022. Audit period: December 1, 2021 ? November 30, 2022 The findings from the schedule of findings and questioned costs are discussed be...
United States Department of Health and Human Services Infinity Health respectfully submits the following corrective action plan for the year ended November 30, 2022. Audit period: December 1, 2021 ? November 30, 2022 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS?FINANCIAL STATEMENT AUDIT None FINDINGS?FEDERAL AWARD PROGRAMS AUDITS United States Department of Health and Human Services 2022-001 Reporting ? Assistance Listing No. 93.224/93.527 Recommendation: We recommend that multiple members of management be involved in the preparation and review process of the UDS report, and that supporting documentation, which agrees to the amounts in the report, be saved in a manner which allows for easy access and recovery if needed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We believe the inability to provide sufficient supporting documentation for the 2021 UDS report to be an anomaly due to the extenuating circumstance of a flood that closed Infinity Health?s main administrative building during the preparation of the 2021 UDS report. The preparation of the 2022 UDS report was completed by the CEO, CFO, COO and Director of Quality and Efficiency. All supporting documentation has been reviewed and saved on a network drive that allows for easy access, recovery and back up retrieval if necessary. Name(s) of the contact person(s) responsible for corrective action: Samantha Cannon, CEO, and Michelle Leonard, CFO. Planned completion date for corrective action plan: 4/26/2023
The Agency has attempted to segregate accounting duties by having a person who does not initiate, prepare or post disbursements review the bank statements and co-sign all checks. The Agency will continue to monitor its policies and procedures in an effort to improve control efficiencies, however, a...
The Agency has attempted to segregate accounting duties by having a person who does not initiate, prepare or post disbursements review the bank statements and co-sign all checks. The Agency will continue to monitor its policies and procedures in an effort to improve control efficiencies, however, at this time, the Agency has determined that the cost of eliminating this material weakness in internal control would exceed its benefit.
Finding 35839 (2022-003)
Significant Deficiency 2022
Finding 2022-003 Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants CFDA # 10.766 Finding Summary: The Health Center?s FY2023 operating budget and prior year audited financial statements were not submitted to USDA within the submission timeframe. Res...
Finding 2022-003 Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants CFDA # 10.766 Finding Summary: The Health Center?s FY2023 operating budget and prior year audited financial statements were not submitted to USDA within the submission timeframe. Responsible Individuals: Crystal Richter, Chief Financial Officer Corrective Action Plan: Once the operating budget is approved by the Board of Directors at the June quarterly meeting, the approved budget will be submitted to USDA in a timely manner. Audited financial statements will be submitted to USDA in a timely manner after the audit is presented to the Board of Directors. Anticipated Completion Date: June 2023
Finding 2022-004 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grant Cluster Federal Financial Assistance Listing #10.766 Special Tests and Provisions: Material Weakness in Internal Control over Compliance Finding Summary: The Medical Center did not h...
Finding 2022-004 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grant Cluster Federal Financial Assistance Listing #10.766 Special Tests and Provisions: Material Weakness in Internal Control over Compliance Finding Summary: The Medical Center did not have an internal control process in place to ensure a secondary level of review is being performed on the required minimum for the reserve account and financial covenants. Responsible Individuals: Sandra Schlechter, Chief Financial Officer, and Bradley Burris, Chief Executive Officer Corrective Action Plan: Within the monthly board packet, we will include the calculation of days on hand, the debt service covenant ratio, the balance of the reserve along with the required minimum requirements for each of these items. This packet is presented monthly to the board of directors for approval. Anticipated Completion Date: February 2023
Finding 2022-003 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grant Cluster Federal Financial Assistance Listing #10.766 Reporting: Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: The fiscal year 2021...
Finding 2022-003 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grant Cluster Federal Financial Assistance Listing #10.766 Reporting: Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: The fiscal year 2021 audit report was either not submitted to USDA or submitted to USDA with no retained documentation to support when the report was submitted. The FY 2023 operating budget was not submitted to USDA during the period under audit. Responsible Individuals: Sandra Schlechter, Chief Financial Officer, and Bradley Burris, Chief Executive Officer Corrective Action Plan: There will be internal reminders set up in management?s yearly calendar for information to be sent to USDA for submission of the annual audited financial statements and operating budget for the next fiscal year. Anticipated Completion Date: February 2023
SEGREGATION OF DUTIES Name of Contact Person: Roger Heimbigner Corrective Action: The duties will be separated as much as possible and alternative controls will be used to compensate for lack of separation. The governing board will continue to be involved in providing some of these controls. Pro...
SEGREGATION OF DUTIES Name of Contact Person: Roger Heimbigner Corrective Action: The duties will be separated as much as possible and alternative controls will be used to compensate for lack of separation. The governing board will continue to be involved in providing some of these controls. Proposed Completion Date: The governing board will implement the above procedure immediately.
Waubay School District Business Official, Marie J. Hlavacek, is the contact person responsible for the corrective action plan for this finding. The finding is due to limited staff employed within the Waubay School's Business Office. Staffing the office at an efficient and financially feasible leve...
Waubay School District Business Official, Marie J. Hlavacek, is the contact person responsible for the corrective action plan for this finding. The finding is due to limited staff employed within the Waubay School's Business Office. Staffing the office at an efficient and financially feasible level precludes the hiring of adequate personnel to provide an ideal environment for internal controls. Waubay School District has adopted an Internal Controls and Procedures policy in February 2018. We are aware of the weakness in our internal controls and will adhere to policies and procedures we have in place to try to reduce the risk. This will be an ongoing finding and we will continue to monitor our processes.
Finding Type: Significant Deficiency for 84.425D. Name of Contact Person: Greg Frehner, Superintendent. Recommendation: We recommend that the Superintendent review the quarterly expenditure reports and supporting documentation to ensure all costs are reported timely and accurately. Corrective ...
Finding Type: Significant Deficiency for 84.425D. Name of Contact Person: Greg Frehner, Superintendent. Recommendation: We recommend that the Superintendent review the quarterly expenditure reports and supporting documentation to ensure all costs are reported timely and accurately. Corrective Action: The Superintendent will review the quarterly reports submitted to ISBE and agree with the District's accounting software before they are submitted. Proposed Completion Date: Fiscal year 2023.
Responsible Contact Person(s): Naveen Abraham, Chief of Core Infrastructure Services Corrective Action Planned: 1. VITA, working with VITA multi-sourcing services integrator (MSI), opened a multi-supplier project to reduce and eliminate unpremeditated vulnerabilities. 2. With respect to agency acce...
Responsible Contact Person(s): Naveen Abraham, Chief of Core Infrastructure Services Corrective Action Planned: 1. VITA, working with VITA multi-sourcing services integrator (MSI), opened a multi-supplier project to reduce and eliminate unpremeditated vulnerabilities. 2. With respect to agency access to security log information, all logs are being monitored. VITA intends to further enhance services during the remainder of calendar year 2023. VITA is also working on additional tools and implementation of zero trust. Security compliance of enterprise IT services overall is assessed on an ongoing basis through System Security Plan (SSP) submission and review. Estimated Completion Date: 9/30/2023
Responsible Contact Person(s): Steve Hanoka, Chief Information Security Officer John Kissel, Deputy Director of Innovation and Technology Carla Bennett, Director of Procurement and Contract Management Susan Smith, Director of Internal Audit Corrective Action Planned: This finding was marked as FOIA ...
Responsible Contact Person(s): Steve Hanoka, Chief Information Security Officer John Kissel, Deputy Director of Innovation and Technology Carla Bennett, Director of Procurement and Contract Management Susan Smith, Director of Internal Audit Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under ?2.2-3705.2 (9.) of the Code of Virginia. Federal awarding agencies and pass-through entities, please see the Appendix titled ?Applicable Management Contacts for Findings and Questioned Costs? to request the corrective action planned from the applicable entity. Estimated Completion Date: 4/30/2023
Responsible Contact Person(s): Mark McCreary, Director Centralized IT Security Audit Services Corrective Action Planned: 1. Regularly monitor audit workplan to ensure audit staff complete all IT security audits by the required deadlines; and, 2. Evaluate staffing levels and assess need to contract ...
Responsible Contact Person(s): Mark McCreary, Director Centralized IT Security Audit Services Corrective Action Planned: 1. Regularly monitor audit workplan to ensure audit staff complete all IT security audits by the required deadlines; and, 2. Evaluate staffing levels and assess need to contract with an outside audit firm to aid in completing IT security audits. Estimated Completion Date: 9/30/2023
Responsible Contact Person(s): Kevin Platea, Deputy Chief Information Officer Stephen Schleck, Associate Director of Enterprise Business Solutions Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting correc...
Responsible Contact Person(s): Kevin Platea, Deputy Chief Information Officer Stephen Schleck, Associate Director of Enterprise Business Solutions Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under ?2.2-3705.2 (9.) of the Code of Virginia. Federal awarding agencies and pass-through entities, please see the Appendix titled ?Applicable Management Contacts for Findings and Questioned Costs? to request the corrective action planned from the applicable entity. Estimated Completion Date: 12/31/2024
Responsible Contact Person(s): Kevin Platea, Deputy Chief Information Officer Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under ?2.2-3705.2 (9.) of the Code of Virginia...
Responsible Contact Person(s): Kevin Platea, Deputy Chief Information Officer Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under ?2.2-3705.2 (9.) of the Code of Virginia. Federal awarding agencies and pass-through entities, please see the Appendix titled ?Applicable Management Contacts for Findings and Questioned Costs? to request the corrective action planned from the applicable entity. Estimated Completion Date: 12/31/2024
Responsible Contact Person(s): Barry Davis, Chief Information Security Officer Melinda Raines, Director of Human Resources Karen Holt, Human Resource Business Process Consultant Corrective Action Planned: An agency-wide work group will be established to determine the exact processes need to implemen...
Responsible Contact Person(s): Barry Davis, Chief Information Security Officer Melinda Raines, Director of Human Resources Karen Holt, Human Resource Business Process Consultant Corrective Action Planned: An agency-wide work group will be established to determine the exact processes need to implement the controls necessary to address this finding. Estimated Completion Date: 6/30/2023
Responsible Contact Person(s): Steven Hanoka, Chief Information Security Officer John Kissel, Deputy Director of Innovation and Technology Sarah Haggie, Strategic Initiatives Advisor Mike Alston, HCD Division Director Cat Pelletier, Operations Lead for Finance Cindy Olson, Eligibility and Enrollment...
Responsible Contact Person(s): Steven Hanoka, Chief Information Security Officer John Kissel, Deputy Director of Innovation and Technology Sarah Haggie, Strategic Initiatives Advisor Mike Alston, HCD Division Director Cat Pelletier, Operations Lead for Finance Cindy Olson, Eligibility and Enrollment Director Corrective Action Planned: DMAS IT Access Control Policy was revised January 2023 to be compliant with the COV security standard. IM Security will revise security training to also reflect this change. Training and reminders will be provided to ensure the divisions and managers understand the importance of the system workflow and timely notification to initiate the process for disabling access. DMAS is in the process of updating the off-boarding system requirements to ensure system access is removed timely. Additional staff was requested to have system access removal rights to support the system access administration and resolve workload and staffing issues. Estimated Completion Date: 2/28/2023
Responsible Contact Person(s): Kevin Platea, Deputy Chief Information Officer Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under ?2.2-3705.2 (9.) of the Code of Virginia...
Responsible Contact Person(s): Kevin Platea, Deputy Chief Information Officer Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under ?2.2-3705.2 (9.) of the Code of Virginia. Federal awarding agencies and pass-through entities, please see the Appendix titled ?Applicable Management Contacts for Findings and Questioned Costs? to request the corrective action planned from the applicable entity. Estimated Completion Date: 12/31/2023
Responsible Contact Person(s): Barry Davis, Chief Information Security Officer and Director of Information Security & Risk Management Dwayne Sneade, Assistant Director of Governance-ISRM Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller ...
Responsible Contact Person(s): Barry Davis, Chief Information Security Officer and Director of Information Security & Risk Management Dwayne Sneade, Assistant Director of Governance-ISRM Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under ?2.2-3705.2 (9.) of the Code of Virginia. Federal awarding agencies and pass-through entities, please see the Appendix titled ?Applicable Management Contacts for Findings and Questioned Costs? to request the corrective action planned from the applicable entity. Estimated Completion Date: 8/1/2023
Responsible Contact Person(s): Kevin Platea, Deputy Chief Information Officer Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under ?2.2-3705.2 (9.) of the Code of Virginia...
Responsible Contact Person(s): Kevin Platea, Deputy Chief Information Officer Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under ?2.2-3705.2 (9.) of the Code of Virginia. Federal awarding agencies and pass-through entities, please see the Appendix titled ?Applicable Management Contacts for Findings and Questioned Costs? to request the corrective action planned from the applicable entity. Estimated Completion Date: 12/31/2024
Responsible Contact Person(s): Steven Hanoka, Chief Information Security Officer John Kissel, Deputy Director of Innovation and Technology Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective act...
Responsible Contact Person(s): Steven Hanoka, Chief Information Security Officer John Kissel, Deputy Director of Innovation and Technology Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under ?2.2-3705.2 (9.) of the Code of Virginia. Federal awarding agencies and pass-through entities, please see the Appendix titled ?Applicable Management Contacts for Findings and Questioned Costs? to request the corrective action planned from the applicable entity. Estimated Completion Date: 6/30/2023
Responsible Contact Person(s): Barry Davis, Chief Information Security Officer and Director of Information Security & Risk Management Kevin Platea, Deputy Chief Information Officer Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has de...
Responsible Contact Person(s): Barry Davis, Chief Information Security Officer and Director of Information Security & Risk Management Kevin Platea, Deputy Chief Information Officer Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under ?2.2-3705.2 (9.) of the Code of Virginia. Federal awarding agencies and pass-through entities, please see the Appendix titled ?Applicable Management Contacts for Findings and Questioned Costs? to request the corrective action planned from the applicable entity. Estimated Completion Date: 8/1/2023
Responsible Contact Person(s): Sarah Hatton, Deputy Director of Administration Cindy Olson, Eligibility and Enrollment Division Director Corrective Action Planned: The final tally of the master out of state report listed 16,930 members. Of the 16,930 members, 11,719 members were closed (69%). The ...
Responsible Contact Person(s): Sarah Hatton, Deputy Director of Administration Cindy Olson, Eligibility and Enrollment Division Director Corrective Action Planned: The final tally of the master out of state report listed 16,930 members. Of the 16,930 members, 11,719 members were closed (69%). The remaining members were either already closed or validly open with an out of state address. The staff dedicated to this project have been reviewing the APA identified list of approximately 6,927 members with out of state addresses. The team has reviewed 98% of the cases, with only 1% requiring case action. When action to close a case is taken, standard notice requirements are followed. On February 6, 2023, the team also began reviewing the newest Out of State Data Match Report provided by the DMAS Office of Data Analytics. This new report includes approximately 7,261 individuals for review, with a targeted completion date of April 28, 2023. This report will continue to be generated quarterly to ensure that individuals no longer residing in Virginia are accurately closed out of their Virginia Medicaid coverage. Estimated Completion Date: 4/30/2023
Finding 35579 (2022-001)
Significant Deficiency 2022
Ingleside Homes, Inc.?s responsible staff will properly verify all income, assets, and deductions. The responsible staff will document attempts to obtain third-party verification and keep this record in the resident?s file. Responsible Person(s): Facility HUD Bookkeeper Anticipated Completion Date: ...
Ingleside Homes, Inc.?s responsible staff will properly verify all income, assets, and deductions. The responsible staff will document attempts to obtain third-party verification and keep this record in the resident?s file. Responsible Person(s): Facility HUD Bookkeeper Anticipated Completion Date: Completion of the documented attempts for third-party verification for the 5 residents noted in the finding will be accomplished by April 30, 2023.
Federal Agency: U.S. Department of Health and Human Services Federal Program Title: COVID-19 - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Assistance Listing Number: 93.498 Compliance Requirement: Reporting ...
Federal Agency: U.S. Department of Health and Human Services Federal Program Title: COVID-19 - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Assistance Listing Number: 93.498 Compliance Requirement: Reporting Views of Responsible Officials and Planned Corrective Actions: Procedures will be put in place to review accuracy of reporting prior to submission. Completion Date 2/1/23 Accounting Name of Contact Person: Jenny Englerth, President/CEO
We have made the required journal entries to correct the financial statements at September 30,2022 and for the year then ended. Additionally, management established system safeguards in accounting program that wont allow users to post entries to past years without authorization from Controller or Ch...
We have made the required journal entries to correct the financial statements at September 30,2022 and for the year then ended. Additionally, management established system safeguards in accounting program that wont allow users to post entries to past years without authorization from Controller or Chief Financial Officer.
Responsible Contact Person(s): Ida Witherspoon, Chief Financial Officer Corrective Action Planned: Prepare procedures that documents where the number of eligible individuals contained in the SSBG-Post expenditure are derived. Also include screen prints of the actual reports used to obtain the data ...
Responsible Contact Person(s): Ida Witherspoon, Chief Financial Officer Corrective Action Planned: Prepare procedures that documents where the number of eligible individuals contained in the SSBG-Post expenditure are derived. Also include screen prints of the actual reports used to obtain the data with the report as supporting documentation. Estimated Completion Date: 6/30/2023
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