Corrective Action Plans

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Finding Number: 2024-003 Finding Title: Eligibility - MAXIS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: John Stepien, Financial Assistance Supervisor Corrective Action Planned: •Citizenship verification continues to be an error prone area. As ...
Finding Number: 2024-003 Finding Title: Eligibility - MAXIS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: John Stepien, Financial Assistance Supervisor Corrective Action Planned: •Citizenship verification continues to be an error prone area. As an automated system process, the majority of our cases successfully complete the interface with SSA to determine citizenship. Determining the root cause of these errors is not always simple, but some contributing factors are failed interface links between MAXIS and SSA. Citizenship details on the MEMI panel which isn’t part of the normal review workflow for recertifications as it holds “additional” member information that typically doesn’t change from year to year. Also, human error plays a role as this type of verification is typically requested at the time a case opens and normally doesn’t change throughout the life of the case. Despite reminders and manual reviews, cases are still being missed. System modernization would go a long way to mitigate these types of error. In addition to continuing the reminders for staff, and periodically checking cases for failed interface verifications, the financial assistance supervisor will request ad-hoc reports from DHS specifically for healthcare cases that have a missing citizenship verification field or coded as “N” for no verification on the MEMI panel in MAXIS. This report will be shared with staff to target cases with missing citizenship verifications. In addition, it has been determined that the use of SMI to verify citizenship has been approved, however this verification has not been added to the case file in some instances which results in an error finding. •Asset verification rules have changed over the past year and a half and although the previous CAP stated we would hold reviews of this policy during regular unit meetings, the financial assistance supervisor has only held one review. This area will be revisited using state training in Trainlink and staff will be reminded that any information reported on an application or renewal needs to be compared to the information recorded in MAXIS and conflicting information needs to be verified. In addition, the process of receiving verifications will be reviewed. Currently, verification documents must be accepted from the client by any means, including mail, fax, paper, or email. Email containing verifications may be sent to the primary Financial Assistance email (recommended) but also may be sent to the agency’s primary email or the primary worker’s personal work email (not recommend). This puts the responsibility of moving those verifications to the case file on several different people. This process may lead to verifications being received but not added to the case files. Best practices will be shared with staff. Anticipated Completion Date: Trainlink training was shared and reviewed at the next in person unit meeting, September 4th. Ad-Hoc reports will be requested for the next quarter, October 6th Reviewing receipt of verification procedures will occur over the next several months and modifications (if necessary) or best practices will be shared January 2026.
Finding Number: 2024-002 Finding Title: Eligibility - METS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: John Stepien, Financial Assistance Supervisor Corrective Action Planned: The Financial Assistance supervisor will run BOBI report MNCM 220A ...
Finding Number: 2024-002 Finding Title: Eligibility - METS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: John Stepien, Financial Assistance Supervisor Corrective Action Planned: The Financial Assistance supervisor will run BOBI report MNCM 220A at least 2 times per month to identify outstanding verifications for MA cases in METS. This will identify specific cases missing SSN verifications. Anticipated Completion Date: The MNCM 220A reported is generated quarterly. The anticipated completion date is October 6th for the next quarterly report.
This serves as a response to your audit memo regarding Finding 2024-001 Allowable Costs - Significant deficiency in internal controls over compliance in Section II - Federal Award Findings and Questioned Costs. The organization concurs with the finding and has made corrective actions effective immed...
This serves as a response to your audit memo regarding Finding 2024-001 Allowable Costs - Significant deficiency in internal controls over compliance in Section II - Federal Award Findings and Questioned Costs. The organization concurs with the finding and has made corrective actions effective immediately to ensure the deficiency no longer occurs. Specifically, an active confirmation of billing amounts matching the general ledger from the CPA to the CEO has been added to our internal controls. Previously, the CPA only contacted the CEO if there was a need for correction. As stated in the audit report, this error occurred during the transition time between our contracted CPA and the new CFO beginning. Neither the CPA nor the CFO informed the CEO of the discrepancy between the billing and general ledger amounts, and therefore no correction was made or even looked for. This finding identified a flaw in our existing internal controls if the CPA does not complete the final validation process. Below are the internal control procedures for grant billing that were in place at the time of the error with the new addition in red: • All time sheets are forwarded to the CPA. • The CPA, or their designee, develops a payroll report utilizing the timesheets to allocate payroll by work function. • The payroll report is forwarded to the CEO for approval and billing purposes. • The detailed monthly billing is sent to the CPA for verification that the billing matches the general ledger. • The CPA will send an email to the CEO either confirming the amounts billed match the general ledger or identifying the need for a billing/general ledger correction. • Any discrepancies between billing and the general ledger are corrected via a corrected billing being submitted or a general ledger journal entry being made to reallocate costs. The organization is confident the above augmented internal control procedures will provide the necessary oversight and quality control measures needed to ensure the identified deficiency from recurring. The CEO is responsible for monitoring and ensuring compliance with the revised internal control measures.
FINDING 2024-005: Finding Subject: COVID 19 – Coronavirus State and Local Fiscal Recovery Funds –Suspension and Debarment Contact Person Responsible for Corrective Action: Toni Loper, Town Clerk-Treasurer Contact Phone Number and Email Address: 765-857-2377 / ridgevilleclerk@gmail.com Views of Respo...
FINDING 2024-005: Finding Subject: COVID 19 – Coronavirus State and Local Fiscal Recovery Funds –Suspension and Debarment Contact Person Responsible for Corrective Action: Toni Loper, Town Clerk-Treasurer Contact Phone Number and Email Address: 765-857-2377 / ridgevilleclerk@gmail.com Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The town attorney will draft a standard contract that will apply to any contractors that are paid $25,000.00 or more from federal funds, prior to entering a covered transaction ensuring that their respective contractor is not suspended or debarred. The council president will review and sign the contract ensuring the suspension and debarment clause is included in all respective contracts. The town has put controls and procedures in place to ensure timely documentation of suspension and debarment checks in regard to federal awards. For purchases procured outside of a contractual agreement, the town will require all vendors to self certify prior to entering into a transaction. Anticipated Completion Date: Policies and procedures to be documented and adopted by March 18, 2026. Full implementation and testing to be in place for the 2025 fiscal year reporting cycle.
FINDING 2024-003: Finding Subject: COVID 19 – Coronavirus State and Local Fiscal Recovery Funds – Reporting Contact Person Responsible for Corrective Action: Toni Loper, Town Clerk-Treasurer Contact Phone Number and Email Address: 765-857-2377 / ridgevilleclerk@gmail.com Views of Responsible Officia...
FINDING 2024-003: Finding Subject: COVID 19 – Coronavirus State and Local Fiscal Recovery Funds – Reporting Contact Person Responsible for Corrective Action: Toni Loper, Town Clerk-Treasurer Contact Phone Number and Email Address: 765-857-2377 / ridgevilleclerk@gmail.com Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: In regards to the current finding over the reporting period under audit all pertinent issues will be corrected in the following annual project and expenditure report, due in April, 2026. The town will contract with Local Government Services to prepare the annual project and expenditure report, develop a procedure where the Clerk-Treasurer or any Town employee with proper training and knowledge will review the report prior to submission for accuracy and completeness before final filing. The Clerk-Treasurer or respective town employee who will review the report, will receive the proper training over the respective program. Any correspondence between Local Government Services and the Town of Ridgeville will be documented accordingly. Anticipated Completion Date: Policies and procedures to be documented and adopted by March 18, 2026. Full implementation and testing to be in place for the 2025 fiscal year reporting cycle.
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Housing Authority of Asotin County January 1, 2024 through December 31, 2024 This schedule presents the corrective action the Housing Authority is planning to take for findings included in this report in accordance with Title 2 U.S....
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Housing Authority of Asotin County January 1, 2024 through December 31, 2024 This schedule presents the corrective action the Housing Authority is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2024-002 Finding caption:The Housing Authority did not have adequate internal controls and did not comply with Housing Quality Standards enforcement requirements of its Housing Voucher Cluster program. Name, address, and telephone number of Housing Authority contact person: KayLee Rosgen, Manager, Business and Finance 1212 Fair St., Clarkston, WA 99403 (509) 758-5751 ext. 4 Corrective action the auditee plans to take in response to the finding: The Housing Authority does concur with the State Auditor’s Office finding that the Housing Quality Standards (HQS) requirements are to follow up with the landlord if any life-threatening deficiencies are identified during an inspection. The requirement states that “If a deficiency is life-threatening, the owner (landlord) must correct the deficiency within 24 hours of notification” (24 CFR 982.404(a)(3)). Although this finding was also included in the prior year’s audit, the Housing Authority acknowledges that the corrective action did not start until September 2024. When the Housing Authority was notified of this finding, a corrective action plan was immediately prepared and implemented. Additionally, the U.S. Department of Housing and Urban Development (HUD) followed up on this finding in June 2025 and the Housing Authority provided the corrective action plan along with supporting documentation to HUD. On June 23, 2025, the Housing Authority received a letter from the HUD Seattle Field Office acknowledging that the Housing Authority had taken the appropriate actions to resolve the finding and avoid the same error in the future. Below is the Housing Authority’s corrective action plan that was implemented in September 2024: - Review HQS/NSPIRE standards with current staff assigned to performing and processing Section 8 inspections during a monthly meeting - Implemented internal controls that ensure life-threatening deficiencies are identified and all required notifications are made - Review of all parts of the Code of Federal Regulations (CFR) and PIH Notices distributed by HUD monthly that pertain to HQS/NSPIRE inspection standards - All pertinent staff have taken the NSPIRE Inspection Standards training (all inspectors and Section 8 Occupancy Specialist) - Updated our process to include the use of a new inspection checklist that separately identifies life-threatening deficiencies, as well as using a new form to document attempts to contact the landlord and track the date that the deficiency was resolved The Housing Authority acknowledges that we lacked the appropriate internal controls prior to September 2024 to identify and notify the landlords of any life-threatening deficiencies that must be corrected within 24 hours. This corrective action plan has been in place since September 2024, and the Housing Authority feels that it is now fully in compliance with the applicable inspection requirements set forth by HUD and any relevant CFRs. Anticipated date to complete the corrective action: September 2024
dLCV has refined our policies regarding review of timesheets to ensure that all timesheets are timely submitted and are reviewed and approved by designated staff. The policy revisions will be effective as of October 1, 2025
dLCV has refined our policies regarding review of timesheets to ensure that all timesheets are timely submitted and are reviewed and approved by designated staff. The policy revisions will be effective as of October 1, 2025
Finding #2024-002 – Significant Deficiency and Other Noncompliance. Condition and context: Same as finding reported as #2024-001. Recommendation: Same as finding reported as #2024-001. Planned corrective action: Year-end closing policies and procedures will be modified to ensure grant transactions a...
Finding #2024-002 – Significant Deficiency and Other Noncompliance. Condition and context: Same as finding reported as #2024-001. Recommendation: Same as finding reported as #2024-001. Planned corrective action: Year-end closing policies and procedures will be modified to ensure grant transactions are reviewed, reconciled, and include applicable accruals. Management will review grant reports monthly to ensure transactions are properly recorded. Responsible officer: Amber Newman, CEO. Estimated completion date: October 1, 2025.
The findings from the December 31, 2024, Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Finding 2024-001 U.S. Department of Housing and Urban Development Moving to Work Demonstration Program - ALN 14.881...
The findings from the December 31, 2024, Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Finding 2024-001 U.S. Department of Housing and Urban Development Moving to Work Demonstration Program - ALN 14.881 Eligibility and Reporting Repeat Finding from 2021(2021-001), 2022(2022-001), and 2023 (2023-001) Maher Duessel Finding Condition: During our review of 40 tenant files prepared by the Housing Authority of the City of Pittsburgh (Authority) as part of the biennial reexamination process, we noted a lack of functioning internal controls which led to the below exceptions in our testing. We noted four instances where a tenant recertification using the HUD-50058, Family Report (Form) (which provides eligibility and reporting information) was not completed, on a timely basis. We also noted one instance where other documentation to support the reporting and eligibility assessment as part of completion of the HUD-50058 was not provided. This includes items such as support for income calculation and medical deductions. These exceptions indicate a lack of functioning internal controls and oversight to ensure compliance with HUD requirements related to timely and accurate tenant recertifications. HACP Management Response/Action Taken: Action Taken: The HACP will continue to monitor and train staff regarding processes and procedures, to include and not limited to the Housing and Urban Development's (HUD) hierarchy of income verification. As noted in previous responses, the HACP continues to experience challenges in hiring and retaining staff as a result of the complexity of the Housing Choice Voucher (HCV) Program. In fiscal year (FY) 2024, the HCV Department had a significant turnover in both line and managerial staff. The HACP promoted an aggressive hiring plan to attract new talent to fill vacant positions due to the great resignation that the HACP, along with other national Agencies, continue to experience. In addition, the HACP has adopted the policy of hiring more staff than needed in the event of turnover. The HACP will continue to utilize the Internal Compliance (IC) Department to review recertifications and compile audit report cards based on the accuracy of recertifications reviewed. The audit report cards are used as an additional management tool to determine whether additional training is needed for staff and the department in general. The HACP continues to: • Send notices regarding re-certifications 120 days in advance of the due date, o Send 10-day notices for missing AR documents o Send 30-day notices when there is no or insufficient response to the 10 day notice sent • Require Managers to review reports to assure timely submission of re-certifications, • Utilize the IC Department to review and sample files from the Occupancy and the HCV portfolio, • Offer periodic staff training on re-certification, • Offer participants the use of technology to complete paperwork In addition to the above noted internal controls, the HACP will institute Bob.ai in FY 2026 as an additional tool to notify both the participant and the HACP staff when the recertifications are due and provide notification of missing documents. The One Stop Shop (OSS) is staffed with three (3) full-time staff members to receive information from participants and landlords to provide timely customer service. In July of 2024, the OSS was equipped with computers for the public to access HACP staff virtually. The use of the computers allows staff to interact with participants regarding minor issues without having the staff physically come to the OSS, thus saving time and money for both the external customer and the Authority. The opening of the One Stop Shop has been successful in receiving the public and responding to concerns.
View Audit 367447 Questioned Costs: $1
The Administrator and Fiscal Officer will work to ensure all reports for grant funding are completed.
The Administrator and Fiscal Officer will work to ensure all reports for grant funding are completed.
FINDING 2024-005 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Catherine MM Lane Contact Phone Number and Email Address: 812-882-6426 clane@vincennes.in.gov Views of Responsible Officials: We concur with th...
FINDING 2024-005 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Catherine MM Lane Contact Phone Number and Email Address: 812-882-6426 clane@vincennes.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: All reports will be prepared by the clerk’s treasurer’s office and will be reviewed by someone who is knowledgeable about the reporting requirements prior to submission. They will review reports for errors and omissions. After this additional review, the report will be submitted. Anticipated Completion Date: This corrective action plan will go into effect immediately.
FINDING 2024-004 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Contact Person Responsible for Corrective Action: Catherine MM Lane Contact Phone Number and Email Address: 812-882-6426 clane@vincennes.in.gov Views of Responsible Officials: We...
FINDING 2024-004 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Contact Person Responsible for Corrective Action: Catherine MM Lane Contact Phone Number and Email Address: 812-882-6426 clane@vincennes.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Clerks office will verify that vendors are not excluded or disqualified by checking the SAM’s website, collecting information from the vendor, or adding a clause or condition to the contract to be signed by the vendor. This documentation of verification will be retained in the City’s grant files. Anticipated Completion Date: This corrective action plan will go into effect immediately.
FINDING 2024-005 Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Federal Agency: Department of Treasury Federal Program: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Number and Year (or Other Identifyin...
FINDING 2024-005 Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Federal Agency: Department of Treasury Federal Program: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Number and Year (or Other Identifying Numbers): 2024 Compliance Requirement: Reporting Audit Findings: Material Weakness Contact Person Responsible for Corrective Action: Hans Eilbracht Contact Phone Number and Email Address: 812-358-6161, auditor@jacksoncounty.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: A corrective action plan will be created that will design and implement a proper system of internal controls that will be e􀆯ective in preventing, or detecting and correcting, noncompliance related to the P&E report. - Internal controls will create a documented secondary review of the information to ensure compliance related to the P&E report also ensure what is reported is accurate and correct. Anticipated Completion Date: 1/31/2026
Finding Number 2024-006: Special Tests and Provisions – Material Weakness in Internal Control Over Compliance and Noncompliance Corrective Action: Management will enhance and enforce policies to ensure HUD-compliant rent reasonableness, conduct thorough reviews of tenant files with landlords and pro...
Finding Number 2024-006: Special Tests and Provisions – Material Weakness in Internal Control Over Compliance and Noncompliance Corrective Action: Management will enhance and enforce policies to ensure HUD-compliant rent reasonableness, conduct thorough reviews of tenant files with landlords and property managers, and implement additional oversight procedures for accounting and documentation of tenant rents. FJV compliance staff will perform quarterly checks with sub-recipients, and rent reasonableness forms will be reviewed and updated annually. These measures aim to strengthen controls, ensure compliance, and prevent incorrect charges to federal programs. Name of Responsible Individual(s): Jason Brenier, Maria Rafanan, Jesse Casement, Christina Madriles, Tatyana Gavino and Judy Bokhari Anticipated Completion Date: June 2025
View Audit 367408 Questioned Costs: $1
We will continue to enforce and refine the internal controls implemented in April 2024. Records will be reviewed regularly to ensure compliance. This will be added to the finance and operation manual
We will continue to enforce and refine the internal controls implemented in April 2024. Records will be reviewed regularly to ensure compliance. This will be added to the finance and operation manual
Finding No. 2024-004: Compliance Controls Responsible Individuals: Cheryl Fox, Director of Finance Corrective Action Plan: The Organization is continuing to evaluate its internal control systems to ensure proper segregation of duties surrounding various compliance requirements with grant programs. W...
Finding No. 2024-004: Compliance Controls Responsible Individuals: Cheryl Fox, Director of Finance Corrective Action Plan: The Organization is continuing to evaluate its internal control systems to ensure proper segregation of duties surrounding various compliance requirements with grant programs. With the implementation of the Purchase Request Document, multiple levels of review will be formally documented, and supporting documentation will be enhanced. Additionally, the Organization has adopted a new payroll platform, which will be administered by a third-party provider. This platform will incorporate multiple levels of approval, maintain documentation of approved pay rates, and improve the overall quality and accessibility of payroll-related records. Anticipated Completion Date: December 31, 2025
View Audit 367398 Questioned Costs: $1
Contact Person Tawnya Taylor, Executive Director Corrective Action Plan The Authority recognizes the deficiency and plans to implement the auditor's recommendations. Planned Completion Date for CAP Immediately.
Contact Person Tawnya Taylor, Executive Director Corrective Action Plan The Authority recognizes the deficiency and plans to implement the auditor's recommendations. Planned Completion Date for CAP Immediately.
Finding 1155073 (2024-006)
Material Weakness 2024
FINDING 2004-006 Finding Subject: COVID-19-Coronavirus State and Local Fiscal Recovery Funds Reporting Contact Person Responsible for Corrective Action: Celita Green, City Controller Contact Phone Number and Email Address: 219-881-5085 Views of Responsible Officials: We concur with the finding that ...
FINDING 2004-006 Finding Subject: COVID-19-Coronavirus State and Local Fiscal Recovery Funds Reporting Contact Person Responsible for Corrective Action: Celita Green, City Controller Contact Phone Number and Email Address: 219-881-5085 Views of Responsible Officials: We concur with the finding that Total Cumulative Expenditures reported for Quarter 2 report (April 1, 2024 to June 30, 2024) and Quarter 3 report (July 1, 2024 to September 30, 2024) were understated. However, there is no mechanism to file corrective to the State and Local Fiscal Recovery Funds (“SLFRF”) Compliance Quarterly Reports with the Treasury reporting system once they are submitted. The City did make cumulative adjustments in the Quarter 4 report (October 1, 2024 to December 31, 2024) to agree with Cumulative Expenditures in the Report with the City’s accounting records, once the City determined the cumulative totals were inaccurate prior to being audited. Description of Corrective Action Plan: As stated above, the City did make cumulative adjustments in the Quarter 4 report (October 1, 2024 to December 31, 2024) to agree with Cumulative Expenditures with the City’s accounting records, in accordance with the periodic updates to the “Compliance and Reporting Guidance for State and Local Fiscal Recovery Funds” issued by the U.S. Department of the Treasury, which indicates how to make cumulative adjustments in the current quarter’s report. Since the 4th Quarter 2024 Compliance Report, the City’s totals agree with Treasury Quarterly Reports to date. . Anticipated Completion Date: Actions were completed on January 30, 2025
Finding 1155072 (2024-005)
Material Weakness 2024
FINDING 2004-005 Finding Subject: Congressional Recommended Awards - Internal Control – Reporting Contact Person Responsible for Corrective Action: Police Chief Derrick Cannon Contact Phone Number and Email Address: 219-881-1214 View of Responsible Officials: We Concur Description of Corrective Acti...
FINDING 2004-005 Finding Subject: Congressional Recommended Awards - Internal Control – Reporting Contact Person Responsible for Corrective Action: Police Chief Derrick Cannon Contact Phone Number and Email Address: 219-881-1214 View of Responsible Officials: We Concur Description of Corrective Action Plan: The Gary Police Department intends to make the following corrections moving forward with the effective internal control system: A proper system of Internal Controls, including segregation of duties ensuring the accuracy of the semiannual performance reports and quarterly financial reports. The Roles within the JustGrants portal have been outlined and identified. The department will move forward with having two others to assist after the person responsible for completing the reporting has provided all the necessary information. Once the work has been completed the Authorized Representative will review the printout of the work before initialing and returning for submission. In partnership, Chief Derrick Cannon Chief Derrick Cannon City of Gary Anticipated Completion Date: February 2026
Finding 1155070 (2024-003)
Material Weakness 2024
FINDING 2004-003 Finding Subject: CDBG – Entitlement Grants Cluster – Internal Control – Reporting Contact Person Responsible for Corrective Action: LaTrea Reed Contact Phone Number and Email Address: 219-881-5085 View of Responsible Officials: We Concur Description of Corrective Action Plan: Respon...
FINDING 2004-003 Finding Subject: CDBG – Entitlement Grants Cluster – Internal Control – Reporting Contact Person Responsible for Corrective Action: LaTrea Reed Contact Phone Number and Email Address: 219-881-5085 View of Responsible Officials: We Concur Description of Corrective Action Plan: Response to Finding: Segregation of Duties and Oversight of Required FFATA Reporting To address the finding related to segregation of duties and the lack of an established oversight or review process for required reports submitted under the Federal Funding Accountability and Transparency Act (FFATA), the Department of Community Development will implement a formalized review process. This process will include the use of a signature form to document the roles of the: • Preparer – responsible for compiling the report, • Reviewer – responsible for independently verifying the report’s accuracy, and • Submitter – responsible for final submission of the verified report. All parties will be required to sign the form upon completion of their respective responsibilities, ensuring accountability, verification of data accuracy, and compliance with FFATA reporting requirements. Anticipated Completion Date: February 2026
Contact Person Tawnya T, Executive Director Corrective Action Plan The Authority will review its policies and procedures over program compliance requirements and continue to provide occupancy training to staff to prevent future exceptions. Planned Completion Date for CAP December 31, 2025.
Contact Person Tawnya T, Executive Director Corrective Action Plan The Authority will review its policies and procedures over program compliance requirements and continue to provide occupancy training to staff to prevent future exceptions. Planned Completion Date for CAP December 31, 2025.
The Board of County Commissioners will work with all elected officials, the new county grant administrator, and federal, state and local partners to develop policies, procedures, and internal controls designed to accurately track grants, including the application process, verification, oversight, an...
The Board of County Commissioners will work with all elected officials, the new county grant administrator, and federal, state and local partners to develop policies, procedures, and internal controls designed to accurately track grants, including the application process, verification, oversight, and reporting of grant requirements.
Management will implement the following corrective actions to address the root causes and prevent recurrence: • Policy Clarification – Categories A–D of the sliding fee schedule apply only to patients at or below 200% FPG. Category E is designated as a deposit/minimum payment category for patients a...
Management will implement the following corrective actions to address the root causes and prevent recurrence: • Policy Clarification – Categories A–D of the sliding fee schedule apply only to patients at or below 200% FPG. Category E is designated as a deposit/minimum payment category for patients above 200% FPG, with no discount applied. • Patient Reclassification – All previously misclassified patients are being reclassified to full-pay status. Prior balances will be reconciled in accordance with HRSA requirements and organizational policy. • Staff Training – Front office, billing, and eligibility staff will undergo mandatory refresher training on the Sliding Fee Discount Program, income verification, and proper application of the fee schedule. Additional refresher training on Self-Pay procedures will be led by the Director of Member Services. • Ongoing Monitoring – A quarterly compliance audit of the sliding fee program has been implemented. Results will be reviewed by management, with corrective actions taken as necessary. • Transparency & Communication – Patients will be notified in writing of their payment category. Appeals or questions will be addressed per organizational policy and HRSA guidelines. • Financial Remediation – Refunds will be issued to patients who were overcharged. For cases involving undercharges, the outstanding balance will be applied to the patient’s next visit. Personnel responsible for implementation: Jose Juarez, Director of Member Services Date of implementation: August 31, 2025
View Audit 367364 Questioned Costs: $1
Recommendation: The Organization should follow established controls to ensure timely submission of the Data Collection Form. This should include assignment of responsibility to a designated official and be monitored by management. Corrective Actions: Our accounting department is now fully in-house a...
Recommendation: The Organization should follow established controls to ensure timely submission of the Data Collection Form. This should include assignment of responsibility to a designated official and be monitored by management. Corrective Actions: Our accounting department is now fully in-house and all partnerships with the outside accounting firm, Wipfli, have been terminated. This year and moving into the future, we do not anticipate having any issues with completing our audit on time. This audit for 2024 will be completed in a timely manner.
When federal compliance issues arise, the City Finance Officer will communicate them to the Mayor
When federal compliance issues arise, the City Finance Officer will communicate them to the Mayor
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