Corrective Action Plans

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Corrective Plan of Action: Silver Key Senior Services has had review and approval processes in place since early 2024; however, gaps arose in consistent documentation. Going forward, all compliance procedures will be followed and documented, including documenting verbal communications. All Controlle...
Corrective Plan of Action: Silver Key Senior Services has had review and approval processes in place since early 2024; however, gaps arose in consistent documentation. Going forward, all compliance procedures will be followed and documented, including documenting verbal communications. All Controller (new role in lieu of CFO) approvals will be maintained in writing, and transactions by the Controller will continue to be reviewed by the CEO. Quarterly spot checks will be conducted to confirm compliance. Anticipated Completion Date: Corrections were made as soon as the issue was identified; procedures are now in place to ensure consistent documentation
Views of Responsible Officials and Corrective Action: The District will strive to implement the water shut-off policy consistently.
Views of Responsible Officials and Corrective Action: The District will strive to implement the water shut-off policy consistently.
Views of Responsible Officials and Corrective Action: The District will strive to gain necessary knowledge needed to prepare a full set of financial statements. The District will appoint a competent individual who possesses the skill knowledge and experience to review and approve the draft reports a...
Views of Responsible Officials and Corrective Action: The District will strive to gain necessary knowledge needed to prepare a full set of financial statements. The District will appoint a competent individual who possesses the skill knowledge and experience to review and approve the draft reports and assume all relevant management responsibilities.
Views of Responsible Officials and Corrective Action: The District will strive to segregate as many accounting functions as practical with the limited staff available.
Views of Responsible Officials and Corrective Action: The District will strive to segregate as many accounting functions as practical with the limited staff available.
Finding: 2024-002 Improper Approvals of Payroll Name of contact person: Vince Collins, Executive Director Corrective Action: the Organization started its formal approval process for pay raises and pay changes during 2025. As a part of the Organization’s remediation they created formal agreements and...
Finding: 2024-002 Improper Approvals of Payroll Name of contact person: Vince Collins, Executive Director Corrective Action: the Organization started its formal approval process for pay raises and pay changes during 2025. As a part of the Organization’s remediation they created formal agreements and pay raise letters for approvals. Proposed Completion Date: Before September 30, 2025, the Organization’s 2024 audit period single audit submission deadline.
Finding: 2024-001 Single Audit Completion and Submission Name of contact person: Vince Collins, Executive Director Corrective Action: The Organization started its remediation of its accounting closing processes during 2025. Timely and accurate accounting records will ensure the timely completion of ...
Finding: 2024-001 Single Audit Completion and Submission Name of contact person: Vince Collins, Executive Director Corrective Action: The Organization started its remediation of its accounting closing processes during 2025. Timely and accurate accounting records will ensure the timely completion of future reporting requirements for the Organization. Proposed Completion Date: Before September 30, 2025, the Organization’s 2024 audit period single audit submission deadline.
Medical Assistance Program – Assistance Listing No. 93.778 Recommendation: CLA recommends the County develop and implement a process to require review and approval of the WIMCR reports prior to the submission of the report to the state to help ensure that the data reported are accurate, complete and...
Medical Assistance Program – Assistance Listing No. 93.778 Recommendation: CLA recommends the County develop and implement a process to require review and approval of the WIMCR reports prior to the submission of the report to the state to help ensure that the data reported are accurate, complete and supporting documentation is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Annual WIMCR reporting to be completed by Waushara County DHS Finance team; Financial Manager and/or Financial Assistant. If both positions are fully employed both positions need to review and sign off on data prior to submission. If one of the positions is vacant a second review of data and signoff needs to be done by someone else within DHS – likely the DHS Director. Name(s) of the contact person(s) responsible for corrective action: Peder Culver, Finance Manager, Clara Voigtlander, DHS Director Planned completion date for corrective action plan: Action plan in place 2025 reporting in 2026.
Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2024 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2024-004 – Period of Performance Description of Finding: There was no evidence, such as a signature, evidencin...
Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2024 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2024-004 – Period of Performance Description of Finding: There was no evidence, such as a signature, evidencing review and approval by a direct supervisor of the timesheets. Time and effort reports were not done. Statement of Concurrence: We concur with the finding above. Corrective Action: BCHN has put together a training program for employees to ensure that timecards are reviewed and approved by both the employee and the supervisor on a bi-weekly basis. Before payroll is processed, approvals by employees and supervisors will be checked. HR will provide a monthly time and effort report to the finance team. This report will provide total number of hours worked by each employee for each assigned cost center. Completion Date: October 2024. Name of Contact Person: Alicia Tenny Chief Financial Officer Tel. No.: (917) 364-1156 E-mail: atenny@bchnhealth.org If HRSA has questions regarding this Corrective Action Plan, please call Alicia Tenny at (917) 364-1156. Sincerely yours, _________________________ Alicia Tenny Chief Financial Officer
Lack of Procurement Policy – Procurement, Suspension and Debarment Federal Agency: U.S. Department of Treasury Federal Program Title: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: N/A Pass-Through Agency: N/A Pass-Th...
Lack of Procurement Policy – Procurement, Suspension and Debarment Federal Agency: U.S. Department of Treasury Federal Program Title: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: N/A Pass-Through Agency: N/A Pass-Through Number(s): N/A Award Period: December 31, 2024 Type of Finding: Significant Deficiency in Internal Control Over Compliance Recommendation: We recommend the City adopt a procurement policy that includes procedures over suspension and debarment. Views of Responsible Officials: There is no disagreement with the audit finding. Action Taken in Response to Finding: The City will prepare a policy and have it adopted by the City Council. Name of the Contact Person Responsible for Corrective Action Plan: Emily Burns, Finance Manager Planned Completion Date for Corrective Action Plan: December 31, 2025.
Lack of Proper Review – Eligibility, Reporting, and Special Provisions Federal agency: U.S. Department of Housing and Urban Development Federal program Title: Housing Choice Voucher Program Assistance Listing Number: 14.871 and 14.879 Federal Award Identification Number and Year: N/A Pass-Through Ag...
Lack of Proper Review – Eligibility, Reporting, and Special Provisions Federal agency: U.S. Department of Housing and Urban Development Federal program Title: Housing Choice Voucher Program Assistance Listing Number: 14.871 and 14.879 Federal Award Identification Number and Year: N/A Pass-Through Agency: N/A Pass-Through Number(s): N/A Award Period: December 31, 2024 Type of Finding: Material Weakness in Internal Control Over Compliance Recommendation: We recommend the HRA implement controls over all areas of the federal program so that controls are in place and working. Views of Responsible Officials: There is no disagreement with the audit finding. Action Taken in Response to Finding: The HRA will assess the controls over the federal program and make changes as deemed necessary. Name of the Contact Person Responsible for Corrective Action Plan: Emily Burns, Finance Manager Planned Completion Date for Corrective Action Plan: December 31, 2025.
1. Policy Adoption: A formal disbursement approval policy was adopted in 2024. The policy defines required documentation, establishes tiered approval thresholds, and assigns authorization responsibility based on role.
1. Policy Adoption: A formal disbursement approval policy was adopted in 2024. The policy defines required documentation, establishes tiered approval thresholds, and assigns authorization responsibility based on role.
2. System Controls: SCMRC’s accounting system was configured to require digital documentation of disbursement approvals. All disbursements are now traceable to authorized personnel.
2. System Controls: SCMRC’s accounting system was configured to require digital documentation of disbursement approvals. All disbursements are now traceable to authorized personnel.
3. Routine Oversight: The CEO and contract accountant conduct quarterly sampling of disbursement activity to verify proper documentation and authorization.
3. Routine Oversight: The CEO and contract accountant conduct quarterly sampling of disbursement activity to verify proper documentation and authorization.
4. Board Involvement: SCMRC’s Finance Committee reviews disbursement policies and internal controls annually as part of the broader fiscal oversight process.
4. Board Involvement: SCMRC’s Finance Committee reviews disbursement policies and internal controls annually as part of the broader fiscal oversight process.
5. Staff Training: Finance and administrative staff received updated training in 2024 on disbursement procedures and documentation protocols.
5. Staff Training: Finance and administrative staff received updated training in 2024 on disbursement procedures and documentation protocols.
1. SCMRC will conduct internal audits twice per year to verify continued compliance with disbursement approval and documentation requirements.
1. SCMRC will conduct internal audits twice per year to verify continued compliance with disbursement approval and documentation requirements.
2. A dashboard tracking disbursement approval timeliness and compliance will be developed in FY26 to support real-time monitoring.
2. A dashboard tracking disbursement approval timeliness and compliance will be developed in FY26 to support real-time monitoring.
3. The Controller will maintain a master log of all disbursement approvals and provide quarterly updates to the CEO.
3. The Controller will maintain a master log of all disbursement approvals and provide quarterly updates to the CEO.
4. SCMRC’s Disbursement Approval Policy will be reviewed and updated annually, with proposed revisions presented to the Finance Committee.
4. SCMRC’s Disbursement Approval Policy will be reviewed and updated annually, with proposed revisions presented to the Finance Committee.
5. Refresher training on approval protocols will be incorporated into the annual finance team training calendar beginning Q1 FY26.
5. Refresher training on approval protocols will be incorporated into the annual finance team training calendar beginning Q1 FY26.
1. All CMS-838 Credit Balance Reports for the audit period and subsequent quarters were submitted in September 2024 and accepted by CMS.
1. All CMS-838 Credit Balance Reports for the audit period and subsequent quarters were submitted in September 2024 and accepted by CMS.
2. SCMRC updated its Medicare compliance protocols in 2025 and established centralized tracking of required federal reports in the CEO’s compliance calendar.
2. SCMRC updated its Medicare compliance protocols in 2025 and established centralized tracking of required federal reports in the CEO’s compliance calendar.
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