Corrective Action Plans

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2020-003 – ELIGIBILITY MATERIAL WEAKNESS/NONCOMPLIANCE Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority provided training to necessary staff and will discuss with the third party management company to ...
2020-003 – ELIGIBILITY MATERIAL WEAKNESS/NONCOMPLIANCE Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority provided training to necessary staff and will discuss with the third party management company to ensure compliance with 24 CFP 982.516 in the future. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director
2020-002 – INTERNAL CONTROLS OVER COMPLIANCE MATERIAL WEAKNESS Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority will maintain proper monitoring, communication and control activities to ensure adherence...
2020-002 – INTERNAL CONTROLS OVER COMPLIANCE MATERIAL WEAKNESS Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority will maintain proper monitoring, communication and control activities to ensure adherence to the Authority’s key administrative policies including procurement, occupancy and the HCV administrative plan. Additionally, management will have the Board approve all policies and procedures adopted and communicate them with the third party company that manages the Authority’s Housing Choice Voucher and Mainstream Voucher programs. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director
2020-107 Lack of ACH Payment Review and Approval Condition: Payments are not reviewed prior to ACH payments. The Organization has no documented policies and procedures for handling the processing and review of ACH payments. Corrective Action Planned: : The Organization has hired a new Chief Finan...
2020-107 Lack of ACH Payment Review and Approval Condition: Payments are not reviewed prior to ACH payments. The Organization has no documented policies and procedures for handling the processing and review of ACH payments. Corrective Action Planned: : The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. Management understands the importance of reviewing the posting of credit memos or applicable invoices to ensure they are posted correctly. We will update our policy to include a process for review of credit memos prior to posting. The planned corrective action for this finding is currently in the process of development, approval, and implementation. Person Responsible for Corrective Action: Robert Thompson, Chief Operating Officer Anticipated Completion Date: March 1, 2023
2020-106 Use of Budgeted Versus Actual Costs for Reimbursements Condition: The Organization made drawdowns after month-end based on budgeted period expenses. Insufficient documentation was kept to clearly document that the amount requested was reviewed for accuracy. Corrective Action Planned: The ...
2020-106 Use of Budgeted Versus Actual Costs for Reimbursements Condition: The Organization made drawdowns after month-end based on budgeted period expenses. Insufficient documentation was kept to clearly document that the amount requested was reviewed for accuracy. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization. Person Responsible for Corrective Action: Robert Thompson, Chief Operating Officer Anticipated Completion Date: Implemented
2020-101 Lack of Internal Controls Over the Application of the Sliding Fee Scale Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale ...
2020-101 Lack of Internal Controls Over the Application of the Sliding Fee Scale Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization’s policies for the sliding fee scale were recently updated during fiscal year 2022, by management, based on findings during the monitoring by HRSA performed in 2022, but management will consider discussing potential improvements to their policy with the grantor to potentially update it to allow for certain exceptions. The Organization will also consider discussing the agreement with the local school district in more detail with the grantor to either structure their policies to allow for these visits to have different requirements or to see if the grantor would be willing to provide a waiver with regards to theses visits not being technically in compliance with other regular clinic visits. The planned corrective action for this finding is currently in the process of development, approval, and implementation. The Organization expects to have the corrective action implemented by March 1, 2023. The Organization will continue to engage the consulting services of the professional certified accounting firm to assist in this process through completion. Person Responsible for Corrective Action: Robert Thompson, Chief Operating Officer Anticipated Completion Date: March 1, 2023
The audited financial statements have been filed with HUD via its REAC system. If thereare any questions regarding this plan, please call Yulia Garcia, Controller, at 508-778-5040.
The audited financial statements have been filed with HUD via its REAC system. If thereare any questions regarding this plan, please call Yulia Garcia, Controller, at 508-778-5040.
FINDINGS -FINANCIAL STATEMENT AUDIT Finding Number: 2020-002 Finding Type: Material Weakness Condition: During the audit, it was noted: • Third Party Accounts Receivable accounts were not analyzed prior to the start of the audit and resulted in significant adjustments to properly state those acco...
FINDINGS -FINANCIAL STATEMENT AUDIT Finding Number: 2020-002 Finding Type: Material Weakness Condition: During the audit, it was noted: • Third Party Accounts Receivable accounts were not analyzed prior to the start of the audit and resulted in significant adjustments to properly state those accounts. • Grants Receivable and Grant Revenue accounts were not reviewed prior to the audit to ensure the accounts were properly stated. • General Ledger expense accounts were not reviewed in detail and adjustments were made after the start of the audit to reclassify certain expenses to the proper sub-accounts. Management response: DCCCMH is committed to ensuring compliance with all regulatory requirements. DCCCMH has hired a grant accountant who will be tasked with reconciling all grant-related activities and accounts. In addition, DCCCMH intends on hiring a General Ledger Accountant who will be responsible for reconciling all Balance Sheet accounts for accuracy monthly.
FINDINGS - FINANCIAL STATEMENT AUDIT Finding Number: 2020-003 Finding Type: Material weakness -Financial Management Condition: Expenditures reported in the general ledger for the Continuum of Care Grant of $960,405 did not agree with the expenditures reported to HUD of $1,071,510 and for which H...
FINDINGS - FINANCIAL STATEMENT AUDIT Finding Number: 2020-003 Finding Type: Material weakness -Financial Management Condition: Expenditures reported in the general ledger for the Continuum of Care Grant of $960,405 did not agree with the expenditures reported to HUD of $1,071,510 and for which HUD provided reimbursement. This condition resulted in the Organization being required to make an adjustment to reduce grant reported revenue and record an amount due to HUD for excess funds received. Expenditures reported in the general ledger for the noted HRSA grant exceeded the amount reported and requested for reimbursement. DCCCMH elected to use non-Federal funds to cover the excess expenditures. Management response: DCCCMH has hired a grant accountant who will ensure expenses claimed are accurately reflected in the books and records of DCCCMH. In addition, DCCCMH is hiring a General Ledger Accountant who will ensure all Balance Sheet accounts are reconciled monthly.
Finding Type: Material weakness -Financial Management Condition: During our audit we noted that the expenditures reported in the general ledger for the Continuum of Care grant did not agree with the expenditures reported to HUD of $1,071,510, and for which HUD provided reimbursement. This condit...
Finding Type: Material weakness -Financial Management Condition: During our audit we noted that the expenditures reported in the general ledger for the Continuum of Care grant did not agree with the expenditures reported to HUD of $1,071,510, and for which HUD provided reimbursement. This condition resulted in the Organization being required to make an adjustment to reduce grant reported revenue and record an amount due to HUD for the excess funds received. Expenditures reported in the general ledger for the noted HRSA grant exceeded the amount reported and requested for reimbursement. DCCCMH elected to use non-Federal funds to cover the excess expenditures. Management response: DCCCMH has hired a grant accountant who will ensure expenses claimed are accurately reflected in the books and records of DCCCMH. In addition, DCCCMH is hiring a General Ledger Accountant who will ensure all Balance Sheet accounts are reconciled monthly and tie to amounts reported to grant funders.
QCHC's transition from paper charting to electronic health record Athena Health as ofMarch 14, 2023, will improve our calculations and document retention process to support individuals who receive sliding fee discount. The inconsistency among the application of the sliding fee discount program by fr...
QCHC's transition from paper charting to electronic health record Athena Health as ofMarch 14, 2023, will improve our calculations and document retention process to support individuals who receive sliding fee discount. The inconsistency among the application of the sliding fee discount program by front desk staff has been corrected with ongoing training. In addition to training, we have continued to update our Sliding Fee Discount Program on an annual basis. The Chief Medical Officer, Chief Dental Officer, Director of Operations and Business Development, Office Managers and front desk associates have received the Federal Poverty Guidelines for 2024 and the updated Sliding Fee Discount Program approved by the Board of Directors as of January 24, 2024. QCHC has a scheduled training via technical assistance in April 2024. We will also attend training through our membership with Pennsylvania Association of Community Health Centers.
QCHC was unable to provide adequate documentation to support the nature of the services provided to patients at Fiscal Year End July 31,2020. Subsequent to July 31, 2020, QCHC's Chief Financial Officer, Accounting Manager and Billing Supervisor have worked together on the operation process to improv...
QCHC was unable to provide adequate documentation to support the nature of the services provided to patients at Fiscal Year End July 31,2020. Subsequent to July 31, 2020, QCHC's Chief Financial Officer, Accounting Manager and Billing Supervisor have worked together on the operation process to improve document retention. As of March 14, 2023, QCHC has transitioned from paper medical Explanation of Benefits (EOB) to electronic. QCHC has also contracted with Athena Health to provide full cycle medical billing as of November 1, 2023. Currently, QCHC has about 95% of all claims, medical and dental EOB's in an electronic format via Dentrix and Athena Health. In addition to Dentrix the transition to Athena Health with full cycle billing, will allow QCHC to maintain adequate patient service billing records. Any paper records received are scanned upon arrival and are housed in billing and accounting file storage. All electronic documents are saved on the QCHC network and are backed up daily.
QCHC experienced a ransomware attack against all servers resulting in loss of information across all databases (Centricity, Dentrix and Sage Accpac). There will be a reoccurrence of late audit submission for FYl9, FY20, and FY21. As ofFY22 to date, the Chief Financial Officer has coordinated with th...
QCHC experienced a ransomware attack against all servers resulting in loss of information across all databases (Centricity, Dentrix and Sage Accpac). There will be a reoccurrence of late audit submission for FYl9, FY20, and FY21. As ofFY22 to date, the Chief Financial Officer has coordinated with the Accounting Manager to enforce all financial Accounting and Financial Management procedures to ensure QCHC stays in compliance. A month-end close process has been implemented by the Accounting Manager to ensure account reconciliation and balances are properly stated at month-end. This will improve our financial reporting process to ensure the Single Audit Reporting Package can be submitted to the Federal Audit Clearinghouse no later than the earlier of 30 days after the reports are received from auditors or nine months after year­ end.
Subsequent to July 31, 2020, QCHC has hired a new fiscal team: Chief Financial Officer (2021), Accounting Manager (2023), Senior Accountant (2024) and Staff Accountant (2022). As of August 15, 2023, Health Resources and Services Administration (HRSA), Office of Federal Assistance Management's (OFAM)...
Subsequent to July 31, 2020, QCHC has hired a new fiscal team: Chief Financial Officer (2021), Accounting Manager (2023), Senior Accountant (2024) and Staff Accountant (2022). As of August 15, 2023, Health Resources and Services Administration (HRSA), Office of Federal Assistance Management's (OFAM) Division of Financial Integrity (DFI) provided Fiscal Technical Assistance (FTA) to Quality Community Health Care for six months. During the Fiscal Technical Assistance, DFI provided QCHC best practices and recommendations for improving weaknesses and internal control processes. The key topics discussed during the PTA that DFI recommended QCHC have an in-depth understanding and strengthen internal controls over were the following: Legislative Mandates, Delinquent Single Audit, Financial Management System, Cash Management, Compensation for Personal Services (Time and Effort Reporting) and Policies and Procedures. As a repeated finding, the Chief Financial Officer has been charged with reviewing past accounting procedures for posting, reconciling, and documentation. To date, all Financial Accounting and Financial Management procedures have been enforced by the Chief Financial Officer to ensure QCHC will be complainant. The Accounting Manager ensures the month-end close process is implemented and account reconciliations and balances are properly stated at month end. In the accounting system all federal awards are assigned a general ledger account number in which funds are recorded or disbursed. The Schedule of Expenditures for the Federal Awards will be completed by the Accounting Manager as part of the monthly close to ensure timely availability.
Explanation of Disagreement with Audit Findings: There is no disagreement with the audit findings. Actions Planned in Response to Findings: The Organization will work to continue to improve document retention in its medical record system to ensure an audit trail exists for all sliding fee applicatio...
Explanation of Disagreement with Audit Findings: There is no disagreement with the audit findings. Actions Planned in Response to Findings: The Organization will work to continue to improve document retention in its medical record system to ensure an audit trail exists for all sliding fee applications. Official Responsible for Ensuring CAP: Harold Minor, Finance Director, is the official responsible for ensuring the planned responses. Planned Completion Date for CAP: December 31, 2023. Plan to Monitor Completion of CAP: Becky Howard, Interim Chief Executive Officer, will ensure the Organization’s electronic medical record system is properly retaining documents related to the sliding fee application and process. She will do this through discussions with the Finance Director.
RESPONSE: FINDING 2020-007 Explanation of Disagreement with Audit Findings: There is no disagreement with the audit findings. Actions Planned in Response to Findings: The Organization has implemented a formal onboarding process for new employees supported by checklist to ensure all onboarding proces...
RESPONSE: FINDING 2020-007 Explanation of Disagreement with Audit Findings: There is no disagreement with the audit findings. Actions Planned in Response to Findings: The Organization has implemented a formal onboarding process for new employees supported by checklist to ensure all onboarding processes and procedures are completed. The processes include obtaining W-4 and I-9 forms in addition to other required documents that are to be kept in each personnel file, along with the checklist. Background checks and credential verification are conducted on all new personnel and a copy of the support along with a copy of the applicants resume or application are stored in the file. In addition, Organization will review all current employees’ personnel file to verify all required documentation is included in each employee’s file. Official Responsible for Ensuring CAP: Nichole Thomas, Human Resources Manager, is the official responsible for ensuring the planned responses. Planned Completion Date for CAP: December 31, 2023. Plan to Monitor Completion of CAP: Becky Howard, Interim Chief Executive Officer, will ensure the process and documentation retention has been completed. She will do this through discussions with the Human Resources Manager.
View Audit 292911 Questioned Costs: $1
Finding: 2020-002 - Allowable Costs & Period of Performance Material Weakness in Internal Controls Over Compliance and Instances of Noncompliance Recommendation: The Organization should implement controls to ensure accurate recordkeeping and document retention to substantiate expenditures allocate...
Finding: 2020-002 - Allowable Costs & Period of Performance Material Weakness in Internal Controls Over Compliance and Instances of Noncompliance Recommendation: The Organization should implement controls to ensure accurate recordkeeping and document retention to substantiate expenditures allocated to grants. Corrective Action Plan: In working with HighPoint CPA, the WWBC has implemented the online accounting system DEXT: all invoices, receipts, bank statements and deposits are loaded in the program and the Executive Director is responsible for categorizing the data, ensuring proper fiscal grant management and is reviewed by the HighPoint CPA team and is reconciled with QuickBooks. The finance committee, which meets the 2nd Tuesday of every month reviews the past month’s financials to ensure compliance. Paper copies are also printed out and filed. Anticipated Completion: January 2021 Responsible Party: Executive Director
View Audit 9815 Questioned Costs: $1
Special Tests and Provisions Material Weakness in Internal Controls over Compliance Federal Agency Name: Department of Education Program Name: Impact Aid CFDA #84.041 Finding Summary: In 2020, information was not obtained to support wage rate requirements for construction expenditures in accor...
Special Tests and Provisions Material Weakness in Internal Controls over Compliance Federal Agency Name: Department of Education Program Name: Impact Aid CFDA #84.041 Finding Summary: In 2020, information was not obtained to support wage rate requirements for construction expenditures in accordance with Section 7007. Responsible Individuals: Jean Callahan, Superintendent Corrective Action Plan: The School District has implemented corrective action for reporting in fiscal year 2024. Anticipated Completion Date: 2024
Reporting Material Weakness in Internal Controls over Compliance Federal Agency Name: Department of Education Program Name: Impact Aid CFDA #84.041 Finding Summary: In the 2020 Impact Aid application, information on construction expenditures were not accurately submitted. Responsible Indiv...
Reporting Material Weakness in Internal Controls over Compliance Federal Agency Name: Department of Education Program Name: Impact Aid CFDA #84.041 Finding Summary: In the 2020 Impact Aid application, information on construction expenditures were not accurately submitted. Responsible Individuals: Jean Callahan, Superintendent Corrective Action Plan: The School District has implemented corrective action for reporting in fiscal year 2023. Anticipated Completion Date: 2023
Management analyzed the amounts submitted for reimbursement and compared to the applicable terms and conditions of this grant. As part of this review, management assessed whether any internal control gaps existed and confirmed the completeness and accuracy of reimbursement claims that were flagged ...
Management analyzed the amounts submitted for reimbursement and compared to the applicable terms and conditions of this grant. As part of this review, management assessed whether any internal control gaps existed and confirmed the completeness and accuracy of reimbursement claims that were flagged within its patient accounting system. Refunds were issued in the amount of $144,355.56 for accounts that were identified to have insurance as the result of this review
Management analyzed the amounts submitted for reimbursement and compared to the applicable terms and conditions of this grant. As part of this review, management assessed whether any internal control gaps existed and confirmed the completeness and accuracy of reimbursement claims that were flagged ...
Management analyzed the amounts submitted for reimbursement and compared to the applicable terms and conditions of this grant. As part of this review, management assessed whether any internal control gaps existed and confirmed the completeness and accuracy of reimbursement claims that were flagged within its patient accounting system. Refunds were issued in the amount of $144,355.56 for accounts that were identified to have insurance as the result of this review
We will perform the following to ensure only allowable costs are charged to the program: • Ensure all supporting vouchers are prepared and approved by different people • Ensure all supporting vouchers have the appropriate documentation including the invoice from each vendor and the underlying sup...
We will perform the following to ensure only allowable costs are charged to the program: • Ensure all supporting vouchers are prepared and approved by different people • Ensure all supporting vouchers have the appropriate documentation including the invoice from each vendor and the underlying support for what the gift card purchases were ultimately used to fulfill the grant purpose.
View Audit 3568 Questioned Costs: $1
Management concurs with the audit finding.
Management concurs with the audit finding.
Views of Responsible Officials: The Commission will review and enhance our policies and procedures over year end close, to ensure all adjustments are made timely. In addition, we create policy and procedures to perform an assessment for component unit determination of any new legally separate organi...
Views of Responsible Officials: The Commission will review and enhance our policies and procedures over year end close, to ensure all adjustments are made timely. In addition, we create policy and procedures to perform an assessment for component unit determination of any new legally separate organization that is established.
2020-002 Eligibility Housing Voucher Cluster Material Weakness in Internal Control Material Noncompliance Condition: Out of an approximate population of 17,476 tenants, 44 tenant files were tested and the following deficiencies were noted: • Nineteen files did not have annual recertifications per...
2020-002 Eligibility Housing Voucher Cluster Material Weakness in Internal Control Material Noncompliance Condition: Out of an approximate population of 17,476 tenants, 44 tenant files were tested and the following deficiencies were noted: • Nineteen files did not have annual recertifications performed during the year, • Seven files did not have correct utility allowance or documentation required to determine correct utility allowance, • Six files did not have 9886 release of information forms with 15 months of annual recertification, • Five files had HAP payments that did not agree to the HAP register, • Two files did not have rent reasonableness performed under a circumstance were it would be required to, • Two tenants did not have inspections performed during the year, • One file had an incorrect HAP calculation, and • One file did have the required forms of identification documented. Auditor’s Recommendations: The Authority should consider reevaluating their established procedures and controls in place to ensure full compliance in regards to eligibility and the timeliness of recertifications. The Authority needs to correct the deficiencies noted in the tested files and consider the impact to the rest of the population of tenant files that were not selected as part of the auditor’s sample. Action Taken: Leadership of the Houston Housing Authority acknowledges this issue and agrees with the finding. To eliminate the number of delinquent recertifications management of the HHA program has undertaken a project to eliminate all of the delinquencies and maintain the current status of those HCVP files where the recertification is not delinquent. An incentive plan has been created where certain HCVP staff will be granted overtime in the case of hourly employees and paid an incentive in the case of salaried employees to eliminate the existing backlog of delinquent recertifications. Each employee who works on this program is to be verified that they have the training necessary to work on the recertifications. In addition if recertifications are part of their normal work load they will have to maintain the pace that is necessary to not create additional delinquencies in order to participate in the incentive program. Hourly employees who are not successfully contributing to the project will be either be offered additional training or removed for eligibility to participate. Salaried employees will be compensated on a completed file basis with the HUD PIC acceptance of the data as the benchmark for completion and receipt of the incentive pay for the completed recertification. The HCVP management staff is confident that they can eliminate the backlog prior to the end of the 2023 calendar year.
2019-006 - Special Tests and Provisions - Material Weakness Recommendation: Management should obtain a HUD approved AFHMP and add the equal opportunity logo to marketing materials. Action Taken: Although it was believed that a HUD approved AFHMP was in place, documentation of this plan could not...
2019-006 - Special Tests and Provisions - Material Weakness Recommendation: Management should obtain a HUD approved AFHMP and add the equal opportunity logo to marketing materials. Action Taken: Although it was believed that a HUD approved AFHMP was in place, documentation of this plan could not be located by all parties. The Managing Agent will take steps to obtain a new HUD approved AFHMP and include the equal opportunity logo to marketing materials.
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