Corrective Action Plans

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We agree. The reimbursement has been processed in the Voucher for the month of August 2024. Procedures have been established improving the reviewing and monitoring process in order to detect and help to identify errors before vouchers processed.
We agree. The reimbursement has been processed in the Voucher for the month of August 2024. Procedures have been established improving the reviewing and monitoring process in order to detect and help to identify errors before vouchers processed.
View Audit 315891 Questioned Costs: $1
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to retaining the completed sliding fee applications in the patients record to support the sliding fee discount p...
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to retaining the completed sliding fee applications in the patients record to support the sliding fee discount provided to the patient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization is aware of the importance of properly applying the sliding fee scale to all eligible patients. We feel that we have strong policies and procedures to ensure this is performed accurately. However, the process is dependent on many individuals and is susceptible to human error. We will implement the following process to mitigate this risk. We will increase our internal audit procedures to audit sliding fee applications on a more frequent basis for any Enrollment Specialist who fails to maintain a 5% error rate. We will increase the number of Sliding Fee Discount applications to 5 every month. We will also conduct a retraining with the team to ensure all documents are uploaded into the document management system correctly for each patient. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Brian Johnston, CFO at 303-665-3036.
Colfax County agreed to be the fiscal agent for a collaborative project involving several state and federal agencies within NM, CO, and KS along with private corporations including BNSF and AMTRAK. Colfax County did not have the staffing or cash flow necessary to facilitate such a large project. Cou...
Colfax County agreed to be the fiscal agent for a collaborative project involving several state and federal agencies within NM, CO, and KS along with private corporations including BNSF and AMTRAK. Colfax County did not have the staffing or cash flow necessary to facilitate such a large project. County Manager and Financial Specialist were not trained in Railroad project management. Changes in staff within the County Manager’s Office and private corporations as well as state and federal agencies resulted in change in requirements, poor communication, and delay in reporting ultimately resulting in disruption of reimbursement to the County. Colfax County worked with NM Department of Transportation and Federal Railroad Administration to collect project status information and submit all outstanding progress reports. To date Colfax County has been successful in maintaining open communication and receiving support from NMDOT and FRA. All reporting requirements are current and reimbursement has been issued to the County.
The Organization hired a new grant and partnership specialist. This specialist attaches all relevant support for expenditure to the internal monthly grant reporting and ensures that all expenditures are fully supported by appropriate detail. This detail is on a shared drive with finance and is revie...
The Organization hired a new grant and partnership specialist. This specialist attaches all relevant support for expenditure to the internal monthly grant reporting and ensures that all expenditures are fully supported by appropriate detail. This detail is on a shared drive with finance and is reviewed by the vice president of finance.
Finding 2023-008 – Eligibility – Material Weakness in Internal Controls over Compliance and Instance of Noncompliance Low-Income Home Energy Assistance ALN# 93.568 (Repeat 2022-015) US Department of Health and Human Services Passed through Oregon Housing and Community Services Federal Grant/Contract...
Finding 2023-008 – Eligibility – Material Weakness in Internal Controls over Compliance and Instance of Noncompliance Low-Income Home Energy Assistance ALN# 93.568 (Repeat 2022-015) US Department of Health and Human Services Passed through Oregon Housing and Community Services Federal Grant/Contract Number: 2302ORLIEA, 2202ORLIEA Grant period – 2022 & 2023 ORCCA is aware of lack of documentation and internal control during the audit period due to various reasons, mainly short staffing and staff turnover and has been working hard to prevent such occurrences. The Finance staff (Finance Director, Accounting Manager, Program Fiscal Compliance Coordinator) have already started communicating with program directors if any such issues are observed. The Energy program has been current on the required reporting since the referenced audit period. The program is aware of the grants’ requirements now. Additionally, ORCCA plans to utilize grant tracker system with the ability to send reminders for important dates to avoid future delinquent reporting that was experienced during the audit period. The system will be utilized by the program directors as well as finance team (Finance Director, Accounting Manager, Program Fiscal Compliance Coordinator) working with grants/directors. The estimated date of completion of this process is January 31, 2026. ORCCA’s current process at the Energy program level has already improved to ensure proper documentation of eligibility. The Energy program director and staff are implementing this internal control at the program level to review the supporting documents and information and proper coding to the correct period.
Federal Agency Name Department of Agriculture Federal Assistance Listing #10.766 Program Name Community Facilities Loan and Grants Cluster Finding Summary The Medical Center does not ensure that the required USDA Accounts (General Account, Construction Account, Debt Service Account, and Reserve Acco...
Federal Agency Name Department of Agriculture Federal Assistance Listing #10.766 Program Name Community Facilities Loan and Grants Cluster Finding Summary The Medical Center does not ensure that the required USDA Accounts (General Account, Construction Account, Debt Service Account, and Reserve Account) were reconciled on a timely basis. This increases the possibility that errors related to the USDA Accounts and other accounts impacted by the USDA Accounts, including construction in progress, are not properly stated in the financial statements. In addition, there could be amounts expended from the USDA Accounts that do not meet the requirements and those expenditures would not be identified in a timely manner. Corrective Action Plan Internal controls will be updated to have a formalized process established to ensure timely reconciliation of the USDA Accounts as well as a review process of those reconciliations each month Responsible Individuals Judy Monson, CFO; Nikki Lindsey, CEO; Jasen Walker, Controller Anticipated Completion Date Complete.
Federal Agency Name Department of Agriculture Federal Assistance Listing #10.766 Program Name Community Facilities Loan and Grants Cluster Federal Agency Name Department of Health and Human Services Federal Assistance Listing #93.697 Program Name COVID 19 Testing and Mitigations for Rural Health Cli...
Federal Agency Name Department of Agriculture Federal Assistance Listing #10.766 Program Name Community Facilities Loan and Grants Cluster Federal Agency Name Department of Health and Human Services Federal Assistance Listing #93.697 Program Name COVID 19 Testing and Mitigations for Rural Health Clinics Federal Agency Name Department of Health and Human Services Federal Assistance Listing #93.301 Program Name COVID 19 Small Rural Hospital Improvement Grants Finding Summary Eide Bailly assisted in the preparation of our draft consolidated schedule of expenditures and federal awards and accompanying notes to the consolidated schedule of expenditures and federal awards. Corrective Action Plan It is not cost effective to have an internal control system designed to provide for a complete and accurate schedule of expenditures and federal awards. We requested that our auditors, Eide Bailly LLP, assist in the preparation of the schedule of expenditures. We have designated a member of management to review the drafted schedule of expenditures. Responsible Individuals Judy Monson, CFO; Nikki Lindsey, CEO Anticipated Completion Date Ongoing
CMSU WILL SUBMIT YEARLY AUDITS WITHIN THE NIN MONTH REQUIREMENT UPON THE COMPLETION OF THE FISCAL YEAR
CMSU WILL SUBMIT YEARLY AUDITS WITHIN THE NIN MONTH REQUIREMENT UPON THE COMPLETION OF THE FISCAL YEAR
Reference Number: 2023-014 Finding: Housing Quality Standards Inspections for the HOME Program Name of Contact Person: Lara Auclair Corrective Active Plan: The division of housing and community development is now fully staffed, which will ensure that proper monitoring is completed annually. Current ...
Reference Number: 2023-014 Finding: Housing Quality Standards Inspections for the HOME Program Name of Contact Person: Lara Auclair Corrective Active Plan: The division of housing and community development is now fully staffed, which will ensure that proper monitoring is completed annually. Current staff has completed HUD training modules on monitoring to ensure that monitoring that takes place will follow all guidelines. With the updated catalogue of all HOME loans, the division of housing and community development can have an accurate list of properties that are in the period of affordability and subject to monitoring. Staff will refer to monitoring files from previous years to create documents and letters to be sent to homeowners. Proposed Completion Date: 6/30/26
Reference Number: 2023-013 Finding: Eligibility Determinations for the HOME Program Name of Contact Person: Lara Auclair Corrective Active Plan: The City of Woonsocket has developed policies and procedures in order to facilitate the proper standards for documentation of income eligibility. The depar...
Reference Number: 2023-013 Finding: Eligibility Determinations for the HOME Program Name of Contact Person: Lara Auclair Corrective Active Plan: The City of Woonsocket has developed policies and procedures in order to facilitate the proper standards for documentation of income eligibility. The department will ensure that proper approvals will be solicited from the HOME Program Compliance Officer after thorough review. Written agreement documentation will be revised to include the requirements from the new compliance manual. The City of Woonsocket plans to procure grant management software which will streamline the application process and allow for improved recordkeeping to ensure compliance with all policies and procedures. Proposed Completion Date: 6/30/26
Reference Number: 2023-012 Finding: Recordkeeping and Documentation for the HOME Investment Partnerships Program Name of Contact Person: Lara Auclair Corrective Active Plan: In the past year, the City has worked to develop an updated record of all HOME assisted projects. Staff thoroughly catalogued ...
Reference Number: 2023-012 Finding: Recordkeeping and Documentation for the HOME Investment Partnerships Program Name of Contact Person: Lara Auclair Corrective Active Plan: In the past year, the City has worked to develop an updated record of all HOME assisted projects. Staff thoroughly catalogued all program files creating separate documents for files that are discharged or still active. The documents can be reviewed to add monitoring information. The document contains the period of affordability and the amount due at payoff. Proposed Completion Date: 3/31/26
Reference Number: 2023-004 Finding: Improve Internal Controls over the Preparation of the Schedule of Expenditures of Federal Awards (SEFA) Name of Contact Person: James Lathrop, CPA Corrective Active Plan: The City will implement comprehensive procedures and internal controls to ensure the SEFA is ...
Reference Number: 2023-004 Finding: Improve Internal Controls over the Preparation of the Schedule of Expenditures of Federal Awards (SEFA) Name of Contact Person: James Lathrop, CPA Corrective Active Plan: The City will implement comprehensive procedures and internal controls to ensure the SEFA is both complete and accurate. This will include establishing a formal process for reconciling all reported federal expenditures with supporting documentation such as the general ledger and grant reports. Additionally, the SEFA will undergo a documented review by a qualified individual who was not involved in its preparation prior to finalization and submission. Proposed Completion Date: 3/31/26
During 2020 – 2022, HOMECorp’s management team was significantly impacted by COVID and despite PPP loan retention efforts we lost all our staff and transitioned our HUD Certified Housing Counselor to Property Manager. Due to staffing shortages and restricted to access to apartments as a result of he...
During 2020 – 2022, HOMECorp’s management team was significantly impacted by COVID and despite PPP loan retention efforts we lost all our staff and transitioned our HUD Certified Housing Counselor to Property Manager. Due to staffing shortages and restricted to access to apartments as a result of health concerns, our property manager was unable to perform Housing Quality Standards Inspections. The new Executive Director has contracted with a General Contractor to help assist our property manager with Housing Quality Standards Inspections. These inspections are conducted annually with detailed inspection logs for HVAC, Painting, Fire Safety, and major unit renovations maintained and tracked in our digital database. These logs are reviewed and updated on a quarterly basis to ensure timeliness in compliance and maintenance requests.
The new VIP processing system and accompanying spreadsheet is now used to complete a more thorough list for the Board for approval.
The new VIP processing system and accompanying spreadsheet is now used to complete a more thorough list for the Board for approval.
Timesheets will be signed off on by the Health Commissioner or by the department director (Nursing, Environmental Health, Community Health, Administration). Staff will be required to present the timesheets to their supervisor before turning them in for processing. All unsigned timesheets will be ret...
Timesheets will be signed off on by the Health Commissioner or by the department director (Nursing, Environmental Health, Community Health, Administration). Staff will be required to present the timesheets to their supervisor before turning them in for processing. All unsigned timesheets will be returned to the department director and will not be processed until signed.
The department will adopt written policies with the Uniform Guidance for Federally Funded Grant Programs accepted by the department.
The department will adopt written policies with the Uniform Guidance for Federally Funded Grant Programs accepted by the department.
RMIPA will strictly enforce contractors to submit wage-rate compliance documentation as a condition for invoice payment. This reporting requirement will be formally integrated into contract oversight practices.
RMIPA will strictly enforce contractors to submit wage-rate compliance documentation as a condition for invoice payment. This reporting requirement will be formally integrated into contract oversight practices.
RMIPA will update its processes to better track obligations alongside expenses for more accurate financial reporting and compliance. This includes obtaining additional Microix modules to enhance internal tracking and compliance.
RMIPA will update its processes to better track obligations alongside expenses for more accurate financial reporting and compliance. This includes obtaining additional Microix modules to enhance internal tracking and compliance.
2023 – 008: Activities Allowed and Unallowed, Allowable Costs, Period of Performance (Compliance; Internal Controls Over Compliance) (Repeat Finding: 2018-006, 2019-008, 2020-008, 2021-007 and 2022-009) Significant Deficiency ALN 93.441 Indian Self Determination ALN 20.205 Highway Planning & Constru...
2023 – 008: Activities Allowed and Unallowed, Allowable Costs, Period of Performance (Compliance; Internal Controls Over Compliance) (Repeat Finding: 2018-006, 2019-008, 2020-008, 2021-007 and 2022-009) Significant Deficiency ALN 93.441 Indian Self Determination ALN 20.205 Highway Planning & Construction ALN 93.575 Child Care and Development Block Grant Condition: During compliance requirement testing for Activities Allowed and Unallowed, Allowable Costs and Period of Performance for the above noted major programs, the auditors selected 120 transactions for testing from each major program. The following number of transactions were not provided for review during the audit: ALN 93.441 – Indian Self Determination – 18 transactions ALN 20.205 – Highway Planning and Construction – 16 transactions ALN 93.575 – Child Care and Development Block Grant – 7 transactions Corrective Action Plan: The Finance Department will become familiar with the requirements of 2 CFR, Part §200.313(a) and establish appropriate internal control policies and procedures to ensure compliance with the requirements of Uniform Guidance and each major program. In addition, all staff will be trained on those policies and procedures, so they are familiar with the requirements. The Finance Department will not process payment for disbursements that does not contain sufficient, appropriate supporting documentation and necessary approvals. The Finance Department will implement and execute an internal audit, by pulling random vouchers packets to test for compliance mid-year. An internal audit process is being developed and personnel assigned. Forms will be developed to assist with the internal audit process to ensure a timely and consistent process will be followed.
Corrective Actions Planned To address the deficiency in internal controls over compliance with respect to procurement, CHC will implement the following corrective actions: CHC will develop and implement a written procurement policy that conforms to the Uniform Guidance.; CHC will ensure sta􀀁 receive ...
Corrective Actions Planned To address the deficiency in internal controls over compliance with respect to procurement, CHC will implement the following corrective actions: CHC will develop and implement a written procurement policy that conforms to the Uniform Guidance.; CHC will ensure sta􀀁 receive adequate training on the procurement policy and the required methods of procurement to be made when making procurements with federal awards. Responsible Person(s): CHC President, Rob Dibble as Primary; CHC Vice President Betsy Gordon as Backup Corrective Action Plan Dates: Schedule implementation starts: February 1, 2026; Staff training starts: March 1, 2026; Review process in effect starts: April 1, 2026
VITEMA concurs with this finding. This information is documented in BSIR as part of the submittal process and does not allow for the submittal of reporting if not verified to meet this requirement. VITEMA will also document this information when preparing the SF 425 report by including this informat...
VITEMA concurs with this finding. This information is documented in BSIR as part of the submittal process and does not allow for the submittal of reporting if not verified to meet this requirement. VITEMA will also document this information when preparing the SF 425 report by including this information in the notes section of this report. This will be conducted on a quarterly basis.
In accordance with 2CFR #200.303 federal recipients VITEMA/ODR must create internal controls that provide reasonable assurance that FFATA reporting requirements are met. Currently, internal controls have been established to ensure compliance with the Federal Funding Accountability and Transparency A...
In accordance with 2CFR #200.303 federal recipients VITEMA/ODR must create internal controls that provide reasonable assurance that FFATA reporting requirements are met. Currently, internal controls have been established to ensure compliance with the Federal Funding Accountability and Transparency Act (FFATA). On a monthly basis, the Disaster Program Administrative Assistant in responsible for obtaining the P5 report from the Grants Manager and entering all project with obligated funds exceeding $30,000 into the SAM.gov database, formerly FSRS.gov. The report must be submitted by the end of the following month. Once the data is entered, the Territorial Public Assistance Officer reviews the submission and, upon the verification, certifies that the information has been accurately reported in the federal database. The reports and associated certifications will be placed in a centralized database.
The ERP provides an overall expense report, a specific liquidation report has been developed to ensure that matching is completed with each report submission. Additionally, a program specific Federal Grants Financial Analyst with the sole focus on the Supplemental Nutrition Program. Lastly, a Direct...
The ERP provides an overall expense report, a specific liquidation report has been developed to ensure that matching is completed with each report submission. Additionally, a program specific Federal Grants Financial Analyst with the sole focus on the Supplemental Nutrition Program. Lastly, a Director of Audit and Compliance has been onboarded. Once the audit team is developed, support and compliance monitoring will be provided to ensure compliance.
Currently, a Standard Operating Policies and Procedures (SOPPs) for certification and recertification procedures is being updated. Additionally, DHS hired a Program Integrity Director in August 2023 and Medical Eligibility Quality Control (MEQC) Reviewer in June 2025 also tasked with the responsibil...
Currently, a Standard Operating Policies and Procedures (SOPPs) for certification and recertification procedures is being updated. Additionally, DHS hired a Program Integrity Director in August 2023 and Medical Eligibility Quality Control (MEQC) Reviewer in June 2025 also tasked with the responsibility of reviewing completed case files.
DHS is committed to strengthening internal controls and addressing the auditors’ concern related to the reconciliation process and the importance of clear, auditable reconciliation processes that fully support the preparation of the Schedule of Expenditures of Federal Awards (SEFA) and demonstrate c...
DHS is committed to strengthening internal controls and addressing the auditors’ concern related to the reconciliation process and the importance of clear, auditable reconciliation processes that fully support the preparation of the Schedule of Expenditures of Federal Awards (SEFA) and demonstrate compliance with internal control requirements. DHS will continue to collaborate closely with the auditors and other stakeholders in the reconciliation process and SEFA preparation to ensure all affected parties confirm receipt of required documentation so determination of compliance can be readily identified, confirming DHS’s commitment to federal funds stewardship. To achieve this, DHS will streamline communication between all parties through a designated point of contact, the Director of Audit & Compliance who onboarded in August 2025, to make certain that necessary documentation is distributed to all stakeholders involved.
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