Corrective Action Plans

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The Division will contact each unit distributing TEFAP assistance and communicate the requirement to retain documentation regarding the determination of client eligibility. This was also reviewed during the NW Division’s Social Service conference in April 2025. Anticipated Completion Date: 10/1/25...
The Division will contact each unit distributing TEFAP assistance and communicate the requirement to retain documentation regarding the determination of client eligibility. This was also reviewed during the NW Division’s Social Service conference in April 2025. Anticipated Completion Date: 10/1/25. Responsible Contact Person: Julie Luft, NW Social Services Director
The Division will enhance controls to ensure timely submission of reports and that there is segregation of duties between the report preparer and reviewer. Reports will be reviewed prior to submission and the review and submission of reports to granting agencies will be documented. A schedule of re...
The Division will enhance controls to ensure timely submission of reports and that there is segregation of duties between the report preparer and reviewer. Reports will be reviewed prior to submission and the review and submission of reports to granting agencies will be documented. A schedule of reports will be added to the TSAMM during the review and approval of new contracts. We will also work with our funders to extend reporting due dates. Anticipated Completion Date: 12/31/25. Responsible Contact Person: Yohannes Gedlu, NW Divisional Finance Director & Julie Luft, NW Social Services Director
Management acknowledges the importance of maintaining accessible and complete documentation to support all transactions charged to federal grants. The inability to provide the requested approvals for certain transactions was due to the challenging security conditions in some country offices during t...
Management acknowledges the importance of maintaining accessible and complete documentation to support all transactions charged to federal grants. The inability to provide the requested approvals for certain transactions was due to the challenging security conditions in some country offices during the audit period. To strengthen documentation access and retention, the Organization has transitioned to NetSuite, where backup documentation for transactions is now stored centrally on the cloud and can be easily accessed by headquarters staff. This change enhances our ability to ensure timely review, approval, and audit readiness, regardless of field conditions. We remain committed to continuous improvement of our internal controls and documentation practices. Responsible Person: Country Finance Directors
FINDINGS— FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL PROGRAMS DEPARTMENT OF AGRICULTURE 2024 – 002 Community Facilities Loans and Grants Recommendation: Management should continue to focus on making operational improvements to achieve the minimum level of Historical Debt Service Coverage of 1.25...
FINDINGS— FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL PROGRAMS DEPARTMENT OF AGRICULTURE 2024 – 002 Community Facilities Loans and Grants Recommendation: Management should continue to focus on making operational improvements to achieve the minimum level of Historical Debt Service Coverage of 1.25, as required. Action taken in response to finding: The Hospital will continue to make operational improvements to achieve the minimum level of Historical Debt Service Coverage of 1.25 . Name of the contact person responsible for corrective action: Carli Taylor, Chief Financial Officer. Planned completion date for corrective action plan: December 31, 2025 If the Department of Health and Human Services has questions regarding this plan, please call Carli Taylor, Chief Financial Officer at 660.385.8716 .
CORRECTIVE ACTION PLAN Name of auditee: Bellflower Oak Street Manor Name of audit firm: Propp Christensen Caniglia LLP Period covered by the audit: October 1, 2023 through September 30, 2024 CAP prepared by: Name: Sean Calendar Position: Director of Accounting Telephone: (916) 357-5300 Comments: Man...
CORRECTIVE ACTION PLAN Name of auditee: Bellflower Oak Street Manor Name of audit firm: Propp Christensen Caniglia LLP Period covered by the audit: October 1, 2023 through September 30, 2024 CAP prepared by: Name: Sean Calendar Position: Director of Accounting Telephone: (916) 357-5300 Comments: Management agrees with the 2024-001 finding. Actions: Management will implement policies and procedures to ensure the monthly deposit to the replacement reserve is made in accordance with HUD regulations. Additionally, management will fund $19,824 of additional reserve deposits to make the account whole; $9,912 for the current period’s unfunded deposits and an additional $9,912 for unfunded deposits from prior period, as reported in finding 2023-01.
Description of Finding: Pass-through grant agreements required quarterly reconciliation reports to be filed with the grantor within 5 days after the conclusion of the quarter. Four quarterly reports were not filed with the grantor, resulting in noncompliance with one grant agreement. We acknowled...
Description of Finding: Pass-through grant agreements required quarterly reconciliation reports to be filed with the grantor within 5 days after the conclusion of the quarter. Four quarterly reports were not filed with the grantor, resulting in noncompliance with one grant agreement. We acknowledge that, purely due to oversight, quarterly reports were not filed for one pass-through grant. We did, however, provide progress reports on the funded project when we submitted reimbursement and advance payment requests to the grantor towards the end of the year, resulting in payment without question or feedback regarding quarterly report omission. Corrective Action: The Charleston Area Alliance is committed to timely and accurate grant reporting and grant compliance. We will promptly submit all past due grant reports, and will review our grant administration process, creating reminders to ensure future grant reports are submitted on a timely basis. Contact Persons: Debra S. James, CPA, Chief Financial Officer 304-340-4253 djames@charlestonareaalliance.org Mara C. Boggs, Chief Executive Officer 304-340-4253 mboggs@charlestonareaalliance.org Anticipated Completion Date: July 5, 2025
Description of Finding: The audit team noted insufficient supervisory review and approval procedures related to the grant reporting function, specifically, a lack of documented supervisory review and approval prior to submission of grant reports which increases the risk of grant reporting errors or...
Description of Finding: The audit team noted insufficient supervisory review and approval procedures related to the grant reporting function, specifically, a lack of documented supervisory review and approval prior to submission of grant reports which increases the risk of grant reporting errors or omissions. As previously noted, 2024 was a year of transition with respect to executive leadership of the Charleston Area Alliance. Grant reporting previously handled at the executive level was delegated to experienced financial and program leaders within the organization who prepared grant reports collaboratively and reviewed reports prior to their submission. We acknowledge that approval of reports may not have been documented in writing other than in emails, and that reports were at times approved verbally prior to submission. Corrective Action: We will maintain written documentation of review and approval of future grant reports prior to submission. Contact Persons: Debra S. James, CPA, Chief Financial Officer 304-340-4253 djames@charlestonareaalliance.org Mara C. Boggs, Chief Executive Officer 304-340-4253 mboggs@charlestonareaalliance.org Anticipated Completion Date: July 1, 2025
Finding 2024-001 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting ...
Finding 2024-001 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting Name of Contact Person: Cynthia Beatus, IGAP Coordinator Corrective action plan: The IGAP Coordinator will ensure that the annual federal financial report (FFR) will be submitted within the 120 day timeframe of the end of the project period. Proposed Completion Date: September 30, 2025
South Landry Parish Housing Authority P.O. Drawer E Grand Coteau, LA 70541 Phone: (337) 662-3573 Fax: (337) 662-3583 HOUSING AUTHORITY OF SOUTH LANDRY PARISH, LOUISIANA CORRECTIVE ACTION PLAN YEAR ENDED DECEMBER 31, 2024 Corrective Action Plan Finding: Finding 2024-001-Re-examination Of Tena...
South Landry Parish Housing Authority P.O. Drawer E Grand Coteau, LA 70541 Phone: (337) 662-3573 Fax: (337) 662-3583 HOUSING AUTHORITY OF SOUTH LANDRY PARISH, LOUISIANA CORRECTIVE ACTION PLAN YEAR ENDED DECEMBER 31, 2024 Corrective Action Plan Finding: Finding 2024-001-Re-examination Of Tenant Eligibility and Rent Not Timely Done-Special Tests Condition: Tenant eligibility and rent should be examined on an annual basis, as required by federal regulations. Corrective Action Planned: I am Denise Moore, Executive Director and Designated Person to answer this audit finding. We will do as the auditor recommends and timely do the re-exams in the future. Person responsible for corrective action: Denise Moore, Executive Director Telephone: (337) 662-3573 South Landry Parish Housing Authority Fax: (337) 662-3583 P.O. Drawer E Grand Coteau, LA 70541 Anticipated Completion Date: December 31, 2025
As already indicated, income from tenant payments were not being properly applied to the correct revenue streams, all monies received were being coded to dwelling rents and not extra utility and cable charges as applicable. See response to 2024-001. Also, we have raised the fee charged to the tena...
As already indicated, income from tenant payments were not being properly applied to the correct revenue streams, all monies received were being coded to dwelling rents and not extra utility and cable charges as applicable. See response to 2024-001. Also, we have raised the fee charged to the tenants for cable to ensure that the expense is being adequately covered.
View Audit 360281 Questioned Costs: $1
Another turnover in staff occurred in March 2025, since new staff has been in place, bank reconciliations have been done and properly recorded. The rent registers have been reconciled and “adjusted” to match tenant management software. Deposit breakdowns were not being reported correctly – all rec...
Another turnover in staff occurred in March 2025, since new staff has been in place, bank reconciliations have been done and properly recorded. The rent registers have been reconciled and “adjusted” to match tenant management software. Deposit breakdowns were not being reported correctly – all receipts except repayments and vending machine income was being recorded as dwelling rent. Extra utility charges and cable charges were not being recorded correctly. A new procedure has been put in place regarding rent receipts and payments are now being allocated correctly. Regarding payroll tax reports, we have changed payroll processing providers and are now receiving monthly reports and quarterly tax reports.
Finding Number: 2024-001 Condition: The City lacked adequate controls to verify that expenditures charged to the grant were incurred within the proper period of performance. Transactions were processed without sufficient review or procedures around the period of performance, resulting in expenditur...
Finding Number: 2024-001 Condition: The City lacked adequate controls to verify that expenditures charged to the grant were incurred within the proper period of performance. Transactions were processed without sufficient review or procedures around the period of performance, resulting in expenditures being charged from outside the allowable timeframe. Planned Corrective Action: The City has worked with the State to identify expenses outside the period of performance. The City has sent the money back to the State that was before the performance start date. All balances are properly stated as of November 30. 2024. Contact person responsible for corrective action: Connie Kumpula Anticipated Completion Date: 5/23/2025
Finding No. 2024-004: Financial Statement Preparation Responsible Individuals: Ona Arnold, Director of Operations and Finance Corrective Action Plan: The Organization will establish and maintain documentation to support in-kind/matching balances. Anticipated Completion Date: September 30, 2025
Finding No. 2024-004: Financial Statement Preparation Responsible Individuals: Ona Arnold, Director of Operations and Finance Corrective Action Plan: The Organization will establish and maintain documentation to support in-kind/matching balances. Anticipated Completion Date: September 30, 2025
Finding 567893 (2024-005)
Significant Deficiency 2024
Hips
DC
Views of Responsible Officials: Prior to receiving this finding in the prior year, HIPS was not in the practice of saving documentation of financial or programmatic reporting submission. Staff responsible for submissions are now documenting submission of reports as of 2024. HIPS Finance Manager has ...
Views of Responsible Officials: Prior to receiving this finding in the prior year, HIPS was not in the practice of saving documentation of financial or programmatic reporting submission. Staff responsible for submissions are now documenting submission of reports as of 2024. HIPS Finance Manager has been tasked with checking all spreadsheet calculations prior to submissions of financial reporting.
Finding 567892 (2024-004)
Significant Deficiency 2024
Hips
DC
Views of Responsible Officials: This deficiency was noted internally even before the auditors flagged it in April 2024. Effective April 2024, the allocation of salaries and wages to different grants was transferred back to the Finance Manager who has more information regarding the grants timing, emp...
Views of Responsible Officials: This deficiency was noted internally even before the auditors flagged it in April 2024. Effective April 2024, the allocation of salaries and wages to different grants was transferred back to the Finance Manager who has more information regarding the grants timing, employees involved, % of time spent et al. In addition, the salaries and wages allocation is now a prerequisite for the invoicing process every month. HIPS have already seen significant improvements in both accuracy in seeking salaries and wages reimbursement as well as in wages reconciliations against paychex reports. COLA adjustments will be recorded more accurately and approval documented. As of 2024, HIPS has also updated our HR policy to provide written documentation by the Operations Manager of COLA increases to each staff member when they are implemented.
Park City has implemented a secure, digital document management protocol requiring that all income verification forms and re-examination documents be scanned and stored within Yardi, our newly adopted digital management system. This transition ensures that all records are accurately maintained, secu...
Park City has implemented a secure, digital document management protocol requiring that all income verification forms and re-examination documents be scanned and stored within Yardi, our newly adopted digital management system. This transition ensures that all records are accurately maintained, securely stored, and readily accessible for audits and inspections. By digitizing these critical documents, we are enhancing regulatory compliance, reducing administrative inefficiencies, and strengthening data integrity. This approach aligns with best practices for record retention and enables swift retrieval of documentation to meet oversight and inspection requirements Contact: Jillian Baldwin Email & Phone Number : jbaldwin@oarkcitycommunities.org (203) 337-8900
A memo relating to HUD and PHA verification requirements has been issued to staff. Utility allowance schedule set up in software has been confirmed for accuracy. Staff has been reminded to ensure appropriate Utility Schedule is applied during processing of transactions. Internal quarterly Qualit...
A memo relating to HUD and PHA verification requirements has been issued to staff. Utility allowance schedule set up in software has been confirmed for accuracy. Staff has been reminded to ensure appropriate Utility Schedule is applied during processing of transactions. Internal quarterly Quality Control reviews are also in place. Contact: Jillian Baldwin Email & Phone Number : jbaldwin@oarkcitycommunities.org (203) 337-8900
View of Responsible Officials and Corrective Actions: The following steps have been and are being taken regarding tenant certifications: 1. We issued a Request for Proposals for a third-party Contractor to perform all recertifications. We intend to award this Contract in July 2025. 2. All Manager...
View of Responsible Officials and Corrective Actions: The following steps have been and are being taken regarding tenant certifications: 1. We issued a Request for Proposals for a third-party Contractor to perform all recertifications. We intend to award this Contract in July 2025. 2. All Managers and assistant Managers will use the third-party Contractor to learn proper recertification and documentation procedures.
Finding 567882 (2024-057)
Significant Deficiency 2024
Finding 2024-057 Disaster Grants - Public Assistance (Presidentially Declared Disasters), ALN 97.036 - FFATA Reporting Management Views MSP agrees with the finding. The exception occurred due to an oversight during the transition to a new grant system. MSP immediately filed the report upon identifi...
Finding 2024-057 Disaster Grants - Public Assistance (Presidentially Declared Disasters), ALN 97.036 - FFATA Reporting Management Views MSP agrees with the finding. The exception occurred due to an oversight during the transition to a new grant system. MSP immediately filed the report upon identification. Planned Corrective Action MSP will review and update procedures for additional monitoring of the FFATA reporting process. Anticipated Completion Date September 30, 2025 Responsible Individual(s) Penny Burger, MSP
Finding 567881 (2024-056)
Significant Deficiency 2024
Finding 2024-056 Disaster Grants - Public Assistance (Presidentially Declared Disasters), ALN 97.036 - EM Grants Manager Security Management and Access Controls Management Views MSP agrees with the finding. MSP implemented the EM Grants Manager system in November 2023 and did not fully establish pr...
Finding 2024-056 Disaster Grants - Public Assistance (Presidentially Declared Disasters), ALN 97.036 - EM Grants Manager Security Management and Access Controls Management Views MSP agrees with the finding. MSP implemented the EM Grants Manager system in November 2023 and did not fully establish procedures for maintaining documentation of user access forms, reviewing privileged access, and disabling inactive users due to the number of current disasters and limited staff. Planned Corrective Action For part a., MSP implemented an access approval process in November 2023 to maintain documentation of access request forms within the EM Grants Manager system. For parts b. and c., MSP will create procedures to help ensure the timely completion of privileged user reviews and inactive user deactivation. MSP will perform the required user reviews and deactivate applicable accounts by September 30, 2025. Anticipated Completion Date September 30, 2025 Responsible Individual(s) Penny Burger, MSP
Finding 2024-013 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Expenditure Processing for Medical Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has been working to ensure correct eligibility classif...
Finding 2024-013 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Expenditure Processing for Medical Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has been working to ensure correct eligibility classifications in Bridges at the time of payment and a system change was implemented in April 2021 to correct the issue. All new cases are correctly routed. MDHHS is continuing to update cases following the end of the public health emergency (PHE) and expects that all existing cases will be updated by July 2025, as MDHHS completes a mass update and renewals for existing cases. MDHHS identified and updated its manual process of transferring expenditures from the Medicaid Cluster to the Children’s Health Insurance Program in June 2021; and will continue this manual process, on a quarterly basis, by completing a summary-level adjustment determined by analyzing CHAMPS payment data and Bridges eligibility data until all existing cases have been updated. Anticipated Completion Date July 2025 Responsible Individual(s) Brant Cole, MDHHS Logan Dreasky, MDHHS Crystal Kline, MDHHS
Finding 2024-055 Low-Income Home Energy Assistance, ALN 93.568 - Eligibility Determinations Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS implemented quarterly case reads beginning in fiscal year 2023, and during April 2023, MDHHS began monthly meetings with the B...
Finding 2024-055 Low-Income Home Energy Assistance, ALN 93.568 - Eligibility Determinations Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS implemented quarterly case reads beginning in fiscal year 2023, and during April 2023, MDHHS began monthly meetings with the BSC analyst team to discuss common errors, answer questions, provide guidance, and on a quarterly basis discuss the results of the State Emergency Relief (SER) case reads. During April 2024, MDHHS SER program policy management and staff began attending BSC leadership meetings to discuss SER case read data findings, policy changes, and communicate common errors found during audits. In addition to updating verification requirements on October 1, 2023, SER program policy management and staff added copay verification requirements on October 1, 2024. MDHHS completed system updates during April 2024 to allow specialists access to directly upload verification documentation to the electronic case file instead of providing the documentation to other areas to process and upload. MDHHS will provide annual training directly to counties that fail to meet the state average for SER case reads relating to verification of the client's income, client contribution payment, and proof of energy crisis. MDHHS will continue to communicate with BSCs and local offices regarding the requirements to obtain adequate verification and maintain sufficient documentation to support SER processing. MDHHS will also continue to provide direct SER guidance and clarification through the SER mailbox. Anticipated Completion Date September 30, 2025 Responsible Individual(s) Bethany Cabanaw, MDHHS Kent Schulze, MDHHS Julie McLaughlin, MDHHS
View Audit 360209 Questioned Costs: $1
Finding 567854 (2024-054)
Significant Deficiency 2024
Finding 2024-054 Low-Income Home Energy Assistance, ALN 93.568 - Recertification of Clearance Patterns Management Views Treasury agrees with the finding. Planned Corrective Action Since the fall of 2024, the Treasury Financial Services Division (FSD) has gained a better understanding of the clear...
Finding 2024-054 Low-Income Home Energy Assistance, ALN 93.568 - Recertification of Clearance Patterns Management Views Treasury agrees with the finding. Planned Corrective Action Since the fall of 2024, the Treasury Financial Services Division (FSD) has gained a better understanding of the clearance pattern review process and updated its procedures through April 2025 to ensure compliance with federal regulations in future fiscal years. This included gaining an understanding of and documenting how the clearance patterns are determined for each program, which programs require clearance pattern review each year, how the SIGMA Business Intelligence (BI) queries function, and how to interpret the BI query results. Treasury FSD completed a post review of the fiscal year 2025 Treasury State Agreement using the updated procedures. Anticipated Completion Date Completed Responsible Individual(s) Melanie Alvord, Treasury Lauren Markwart, Treasury
Finding 2024-052 Refugee and Entrant Assistance State/Replacement Designee Administered Programs, ALN 93.566 - FFATA Reporting Management Views LEO agrees with the finding. Planned Corrective Action The LEO Finance Division updated its FFATA procedure effective March 2025 and has been working to c...
Finding 2024-052 Refugee and Entrant Assistance State/Replacement Designee Administered Programs, ALN 93.566 - FFATA Reporting Management Views LEO agrees with the finding. Planned Corrective Action The LEO Finance Division updated its FFATA procedure effective March 2025 and has been working to correct the inaccurate FFATA reporting for the Refugee and Entrant Assistance State/Replacement Designee Administered Programs subawards. All of LEO’s open subawards are reported correctly in SAM and LEO completed corrections to the closed subawards in April 2025. Going forward, LEO will ensure that future subawards are reported both accurately and timely in accordance with FFATA requirements. Anticipated Completion Date Completed Responsible Individual(s) Heidi Parker, LEO
Finding 2024-050 Refugee and Entrant Assistance State/Replacement Designee Administered Programs, ALN 93.566 - Assistance to Ineligible Refugees Management Views LEO and MDHHS agree with the finding. Planned Corrective Action MDHHS, in conjunction with LEO, will provide mandatory training for all ...
Finding 2024-050 Refugee and Entrant Assistance State/Replacement Designee Administered Programs, ALN 93.566 - Assistance to Ineligible Refugees Management Views LEO and MDHHS agree with the finding. Planned Corrective Action MDHHS, in conjunction with LEO, will provide mandatory training for all specialists that determine eligibility for refugee cash assistance payments by September 30, 2025. MDHHS also will implement ongoing management and peer-to-peer spot checks of cases to ensure that documentation is maintained to support the client’s eligibility beginning October 2025. In addition, MDHHS will determine if technical changes are needed to help ensure the proper documentation is in the electronic case file by December 31, 2025. If potential system modifications are needed, the Bridges technical team will follow the Departmental Work Intake Process for prioritization and determine an anticipated completion date for implementation. Anticipated Completion Date MDHHS has not yet determined an anticipated completion date because the date is dependent on the determination of whether system modifications are necessary. Responsible Individual(s) Benjamin Cabanaw, LEO Nicole Adams, LEO Bethany Cabanaw, MDHHS Kent Schutz, MDHHS Mariah Schaefer, MDHHS
View Audit 360209 Questioned Costs: $1
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