Corrective Action Plans

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SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION – COVID-19 – EDUCATION STABILIZATION FUND (FEDERAL ALN 84.425) 2023-003 Internal Control Over Compliance With Equipment and Real Property Management Requirements Finding Summary 2 CFR § ...
SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION – COVID-19 – EDUCATION STABILIZATION FUND (FEDERAL ALN 84.425) 2023-003 Internal Control Over Compliance With Equipment and Real Property Management Requirements Finding Summary 2 CFR § 200.313(d)(1) requires the Academy to designate fixed assets purchased under federal programs and to maintain related property records, including a description of the property, a serial number or other unique identification number, the source of funding for the property (including the federal Assistance Listing Number), who holds title, the acquisition date, cost of the property, percentage of federal participation in the project costs for the federal award under which the property was acquired, the location, use, and condition of the property, and any ultimate disposition data, including the date of disposal and sale price of the property. During our audit, we noted that the Academy did not have sufficient controls in place within the COVID-19 – Education Stabilization Fund federal program to specifically identify federally-funded fixed assets and maintain the required records as noted above to assure compliance with federal equipment and real property management requirements. Corrective Action Plan Actions Planned – The Academy plans to review its internal control procedures to ensure future compliance with the federal compliance requirements specific to equipment and real property management for the COVID-19 – Education Stabilization Fund federal program. Official Responsible – The Academy’s Executive Director, Farhiya Einte. Planned Completion Date – June 30, 2024. Disagreement With or Explanation of Finding – The Academy agrees with this finding. Plan to Monitor – The Academy’s Executive Director, Farhiya Einte, will ensure that federally-funded fixed assets are distinguishable within the Academy’s finance system. The Academy also intends to review its control procedures relating to equipment and real property management requirements to ensure compliance for future federal awards expenditures.
Management concurs with this finding. We will implement a formal review process to ensure timely submissions.
Management concurs with this finding. We will implement a formal review process to ensure timely submissions.
PCHS is in the process of training all reception staff to ensure that sliding fee scale applications are provided to patients and that completed applications are correctly filed and stored to support patients' sliding fee receipts. PCHS will implement quarterly reviews of appropriate support to just...
PCHS is in the process of training all reception staff to ensure that sliding fee scale applications are provided to patients and that completed applications are correctly filed and stored to support patients' sliding fee receipts. PCHS will implement quarterly reviews of appropriate support to justify patients' receipt of sliding fee discounts.
Grantee Response and Corrective Action Plan: We concur with this finding and have implemented measures to mitigate the repetition of additional occurrences. In July 2023, a new policy was implemented that requires employees to record their time as a percentage across all grants in which they work....
Grantee Response and Corrective Action Plan: We concur with this finding and have implemented measures to mitigate the repetition of additional occurrences. In July 2023, a new policy was implemented that requires employees to record their time as a percentage across all grants in which they work. The employee records this allocation at least weekly within a time keeping software system. Employees and supervisors are now required to review and acknowledge payroll allocations across grants by signing weekly timesheets. Timesheets will be retained and used as backup by the Grants Department when invoicing the Grantor for expense reimbursement. In addition, we have updated our Policy and Procedures Manual to reflect this policy. Responsible Parties: Kimberly Yoo, CFO Whitney Gillis, Director of RD Mary Guzman, Accounting Supervisor Date Corrected: 7/1/2023
View Audit 316202 Questioned Costs: $1
DEPARTMENT OF HEALTH AND HUMAN SERVICES 2023 – 003 COVID-19 Provider Relief Funding and American Rescue Plan Rural Payments Recommendation: We recommend the Medical Center design controls to ensure documentation is completed timely and sufficiently on how costs are necessary to respond to COVID-19....
DEPARTMENT OF HEALTH AND HUMAN SERVICES 2023 – 003 COVID-19 Provider Relief Funding and American Rescue Plan Rural Payments Recommendation: We recommend the Medical Center design controls to ensure documentation is completed timely and sufficiently on how costs are necessary to respond to COVID-19. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Management has identified that the Medical Center has more than a sufficient amount of lost revenues related to COVID-19 to offset this difference. Action taken in response to finding: The Medical Center will ensure that controls are put into place to capture Covid specific costs in accordance with HHS guidelines. Name of the contact person responsible for corrective action: Kayla Chamberlin, Controller Planned completion date for corrective action plan: July 1, 2023
CONDITION: During my review of the District’s compliance with the requirements for noncompetitive procurement, I noted the District did not document its rationale for purchases made from ‘Associates in Counseling’. CRITERIA: In accordance with Section 2 CFR 200.318(i) of the Uniform Guidance, the...
CONDITION: During my review of the District’s compliance with the requirements for noncompetitive procurement, I noted the District did not document its rationale for purchases made from ‘Associates in Counseling’. CRITERIA: In accordance with Section 2 CFR 200.318(i) of the Uniform Guidance, the District must maintain records sufficient to detail the history of procurement. These records include but are not limited to the rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. Furthermore, Section 2 CFR 200.320(c’) of the Uniform Guidance details five (5) circumstances in which noncompetitive procurement can be used. RECOMMENDATION: I recommend that for all future purchases involving noncompetitive procurement, that the District adhere to the requirements of 1) the District’s Procurement Policy for Federal Programs (#626), and 2) Section 2 CFR 200.320(c) of the Uniform Guidance. MANAGEMENT’S PLANNED CORRECTIVE ACTION: For noncompetitive procurement, the District will maintain records sufficient to detail the history of procurement. These records will include but are not limited to the rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. The District’s timeframe for implementation is effective immediately.
View Audit 316135 Questioned Costs: $1
CONDITION: The Moniteau School District contracted with a third-party vendor (Smart Solutions Technologies) for technology equipment (Smart Boards and Mobile Carts) for the District which exceeded the threshold for competitive procurement. The District was unable to provide documentation to verify ...
CONDITION: The Moniteau School District contracted with a third-party vendor (Smart Solutions Technologies) for technology equipment (Smart Boards and Mobile Carts) for the District which exceeded the threshold for competitive procurement. The District was unable to provide documentation to verify that the third-party procurement contract was competitively procured, such as a bid evaluation and public solicitation. CRITERIA: 24 Pa. Statutes 751 of the Public-School Code and Section 2 CFR 200.318(i) of the Uniform Guidance prescribes the bidding requirements for equipment, supplies, and work of any nature made by a school district whereby the cost exceeds certain dollar thresholds as adjusted annually for an inflation index. As specified in 2 CFR 200. 318(i) of the Uniform Guidance, the District must maintain records sufficient to detail the history of procurement. These records will include, but are not necessarily limited to, the following: rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. RECOMMENDATION: I am recommending that the management of the School District review and update as necessary its procurement policies to ensure retention of the appropriate procurement documentation, in all instances, so as to comply with all applicable sections of the Uniform Guidance, in specifically, Section 2 CFR 200.318(i) of the Uniform Guidance. In addition, I am recommending that management contact the PA Department of Education, and explain the circumstances and oversight, and seek direction as to the allowability of this program cost in writing for their permanent files. MANAGEMENT’S CORRECTIVE ACTION PLAN: Management will review and update as necessary, it’s current procurement policies and procedures to ensure compliance with all applicable sections of the Uniform Guidance, in specifically, Section 2 CFR 200.318(i) of the Uniform Guidance. The timeframe for completion of this process will be finalized during the District’s 2024-2025 fiscal year and will be revised on an ongoing basis as required by new policy directives from oversight agencies.
View Audit 316135 Questioned Costs: $1
To Health Resources and Services Administration Care Alliance Health Center, Inc. respectfully submits the following corrective action plan for the year ended October 31, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: October 31, 2023 The findings from the October 31, 202...
To Health Resources and Services Administration Care Alliance Health Center, Inc. respectfully submits the following corrective action plan for the year ended October 31, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: October 31, 2023 The findings from the October 31, 2023, schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Federal Award Findings: Finding 2023.001 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken We will invest the time and resources into improving all areas related to the Sliding Fee Scale. We will implement the following steps to our process to ensure all federal guidelines and requirements are met. 1. Documented Process: Design and implement an internal control process to ensure sliding fee discounts are accurately calculated based on family size and income. 2. Documented Procedures: Establish clear procedures and guidelines for front desk staff to follow when determining discounts, including appropriate documentation requirements, eligibility criteria, and fee structure. These procedures will be aligned with our written policy to ensure consistency and accuracy in discount calculations. 3. Training and Education: Provide training to front desk staff members responsible for determining eligibility and applying sliding fee discounts to ensure they understand the process. 4. Regular Reviews: Implement regular reviews and monthly audits to verify that all discounts are properly supported and documented. Quarterly reviews will be conducted to verify compliance, identify areas for improvement, and evaluate the effectiveness of the sliding scale fee program to ensure it meets our patients' needs and complies with all federal guidelines. Responsible Parties: 1. The Controller and revenue cycle staff will develop the written procedure. 2. The Clinical Support Supervisor and revenue cycle staff will overseE3 the training. 3. The Revenue Cycle Manager_will monitor adherence to the procedure, conduct regular monthly audits, and report results to the Controller. 4. The Controller will conduct quarterly documentation reviews of the internal audit results. Timeline: 1. Procedure draft completion: Completed 2. Review and approval by senior management: July 24, 2024 3. Initial staff training session: July 25, 2024 4. Follow-up training sessions: As needed 5. Monthly compliance audits: Starting September 1, 2024
Internal controls for proper vetting and approval of spreadsheets are being implemented to safeguard the accuracy of payroll report totals that tie back to labor percentages allocated to individual employee labor totals, billed to the grant.
Internal controls for proper vetting and approval of spreadsheets are being implemented to safeguard the accuracy of payroll report totals that tie back to labor percentages allocated to individual employee labor totals, billed to the grant.
View Audit 316070 Questioned Costs: $1
During the period being audited internal controls for program participants documents were not reviewed by the former Executive Director. The new Executive Director has implemented a check and balance procedure that requires the Case Manager, Program Manager, and Executive Director to review and sign...
During the period being audited internal controls for program participants documents were not reviewed by the former Executive Director. The new Executive Director has implemented a check and balance procedure that requires the Case Manager, Program Manager, and Executive Director to review and sign off on participant application forms and to be documented on the participants application before the participant can move forward in the program.
View Audit 316070 Questioned Costs: $1
The approved account coding that was changed in the "condition" section mentioned above was done by the former Fiscal Consultant that was replaced by the current Director of Finance. Knowledge of that change with no documentation was not noticed until it was a selection picked during the audit. The ...
The approved account coding that was changed in the "condition" section mentioned above was done by the former Fiscal Consultant that was replaced by the current Director of Finance. Knowledge of that change with no documentation was not noticed until it was a selection picked during the audit. The current Director of Finance was not the manager of the Fiscal Consultant, the Executive Director was, and the current Director of Finance was not given any authority over the Fiscal Consultant. Currently the internal control implemented requires that no changes to grant coding are allowed to be done unless the Director of Finance deploys an accounting department team member to make the change by written request, it is then signed by the staff members in the accounting department making the change. If the Director of Finance makes the reclassification it is documented on the original invoice and signed off by the Director of Finance.
During the period being audited internal controls for program participants documents were not reviewed by the former Executive Director. The new Executive Director has implemented a check and balance procedure that requires the Case Manager, Program Manager, and Executive Director to review and sign...
During the period being audited internal controls for program participants documents were not reviewed by the former Executive Director. The new Executive Director has implemented a check and balance procedure that requires the Case Manager, Program Manager, and Executive Director to review and sign off on participant application forms and to be documented on the participants application before the participant can move forward in the program.
Finding 2023-003 – Reporting U.S. Department of Treasury COVID-19 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF)- ALN 21.027 Reporting – Missoula County has implemented a dual control process over CSLFRF reporting. As part of the month end process the accountant in finance will review al...
Finding 2023-003 – Reporting U.S. Department of Treasury COVID-19 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF)- ALN 21.027 Reporting – Missoula County has implemented a dual control process over CSLFRF reporting. As part of the month end process the accountant in finance will review all expenditures related to obligated ARPA programs and reconcile this activity with each department. At the end of the quarter after all months have closed and prior to Treasury reporting an additional review of quarter will occur by the Senior Accountant in finance. This documentation will be reconciled to the Treasury quarterly reports to ensure accurate reporting. Contact Person Responsible for the Corrective Action: Michelle Denman, Deputy Financial Services Director Anticipated Completion Date of the Corrective Action: June 30, 2024
View Audit 316058 Questioned Costs: $1
Condition and Cause: Due to staff turnover in Finance and the level of workload there were difficulties creating financial statements on a timely basis. Status: The Coalition is implementing a process to prepare, review, and approve financial statements to ensure that financials are reviewed and...
Condition and Cause: Due to staff turnover in Finance and the level of workload there were difficulties creating financial statements on a timely basis. Status: The Coalition is implementing a process to prepare, review, and approve financial statements to ensure that financials are reviewed and approved by Management on a regular basis. Corrective Action: End Abuse will take the following corrective actions: (1) End Abuse will create a process that involves the creation, review, and approval of financial statements. (2) The Finance Director will create the financial statements; the Executive Director or the Associate Director will review and approve them. (3) The Finance Director is currently recruiting for a staff accountant to help ease the workload. (4) The Board of Directors will review financial statements and/or financial reports on a quarterly basis to ensure that proper procedures are followed. Expected Completion Date: September 30, 2024
Management agrees with the finding of the auditor's report concerning the failure to timely submit our 2023 single audit reporting package and data collection form in a timely manner. We have suffered changes in personnel which had a significant impact on our ability to gather information needed to ...
Management agrees with the finding of the auditor's report concerning the failure to timely submit our 2023 single audit reporting package and data collection form in a timely manner. We have suffered changes in personnel which had a significant impact on our ability to gather information needed to finalize our accounting records. New staff members who have taken on these responsibilities are in the process of learning those procedures and adapting to our organization's specific requirements. Additionally, there were some communication challenges during the audit process which led to misunderstandings and further delays. In addressing these challenges, we are providing additional training and support for our new staff members and reevaluating our financial closing processes to ensure that reporting deadlines are met in future periods. In addition, we were awaiting two significant financial transactions that will have a direct and substantial impact on our 2022-2023 financial reports. The most significant of those transactions was a very large estate gift that was pending at the close of the fiscal year (gift receivable). The value of this gift was difficult to assess because of the nature of the gift as part of a sizeable and complicated trust (as well as a very lengthy liquidation process). The gift finally arrived in April 2024 which provided us with the correct valuations (an increase in net assets without donor restrictions of over $4 million). A gift of this magnitude had such a substantial financial impact that we needed to wait for its completion in order to properly assess our financial position. The second transaction (a sale of unused property) closed in late May which enabled us to accurately reflect the impact of these previously pending items. Responsible Official: Chris Ronk, Chief Financial Officer (800) 937-5097
Finding Number: 2023-003 Sliding Scale Assessment Planned Corrective Action: CCHC has created a workflow for staff as a guide in processing the sliding fee scale. This workflow is approved by the Head Nurse Supervisor and signed. Please see attached workflow sheet. CCHC will verify with Athena EHR...
Finding Number: 2023-003 Sliding Scale Assessment Planned Corrective Action: CCHC has created a workflow for staff as a guide in processing the sliding fee scale. This workflow is approved by the Head Nurse Supervisor and signed. Please see attached workflow sheet. CCHC will verify with Athena EHR system to make sure that the most up to date poverty guidelines are in the system that is being used to calculate sliding fee discounts. Person Responsible for Corrective Action Plan: Pasue Mahan, Chief Clinic Officer Anticipated Date of Completion: 07/01/2024
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee ra...
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization acknowledges the error identified in the sliding fee discount. To address this issue and prevent future occurrences, the following corrective actions will be implemented: • Internal Audit Procedure o An internal audit procedure will be established to review 10% of the applications processed by each eligibility worker. This review will include verification of application accuracy, calculation correctness, and appropriate selection of sliding fee scales. • Identification of Errors o During the internal audit, if any errors are found, immediate action will be taken to rectify the identified mistakes. • Retraining and Testing o In cases where errors are detected, affected staff will undergo retraining. This retraining will cover all relevant processes and guidelines to ensure a thorough understanding. o Post-retraining, the staff will be subjected to a period of testing to confirm their competence in handling the sliding fee discount applications accurately. These steps will help ensure the integrity and accuracy of the Sliding Fee Discount program moving forward. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Dan Becker, CEO, at 970-423-8833.
Finding 2023-002 - Reporting (COVID-19 American Rescue Plan Act Local Fiscal Recovery) Significant Deficiency – Internal Control over Compliance Other Matters (Noncompliance) Description of Finding - Controls over Project and Expenditure Reports did not exist to ensure accuracy of submitted data. ...
Finding 2023-002 - Reporting (COVID-19 American Rescue Plan Act Local Fiscal Recovery) Significant Deficiency – Internal Control over Compliance Other Matters (Noncompliance) Description of Finding - Controls over Project and Expenditure Reports did not exist to ensure accuracy of submitted data. Statement of Concurrence or NonConcurrence - Management agrees with the finding. Corrective Action - The City has implemented additional processes and controls related to the review of treasury reporting. However, these were not in place for all of the current year. Name of Contact Person - John Monks, Comptroller Projected Completion Date - June 30, 2024
All future federal grant programs that require substantial lines of information and calculations to be submitted for reimbursement of allowable costs will be reviewed by at least two qualified persons before submission to the administering agency (e.g. IDHS)..
All future federal grant programs that require substantial lines of information and calculations to be submitted for reimbursement of allowable costs will be reviewed by at least two qualified persons before submission to the administering agency (e.g. IDHS)..
Finding 479448 (2023-001)
Significant Deficiency 2023
Criteria or Specific Requirement – Reporting (Reference number 2023-001) Recommendation – The Organization should continue to improve understanding of the guidance related to this type of reporting and work to identify areas for improvement prior to submission to the Provider Relief Fund reporting ...
Criteria or Specific Requirement – Reporting (Reference number 2023-001) Recommendation – The Organization should continue to improve understanding of the guidance related to this type of reporting and work to identify areas for improvement prior to submission to the Provider Relief Fund reporting portal. Management should ensure proper internal controls are put into place to ensure that allowable expenses reported are not reimbursed by other sources or in previous submission period. Views of Responsible Officials and Corrective Action Plan – Management agrees with the finding. The reporting discrepancy was due to a misunderstanding of how the cost portion of the report should have been presented. The presentation was submitted with the same methodology as the lost revenue presentation, which was on a cumulative basis vs. the incremental period required for costs. In addition, staff turnover, including the responsible official (CFO), during this period of time impacted the execution of the last repoting requirement and improper reporting to HHS. The Organization believes that it had sufficient lost revenues to justify retention of all PRF Period 4 funds. There is no expected future reporting for the Provider Relief Funds. Personnel Responsible – John Hydock, Interim CFO Timeline – There is no expected future PRF submissions, but in the event one is required, the Organization will have a quality control process in place to review reporting of expenses to ensure no duplication or carry-over of expenses occurs.
Management agrees with the finding. The Borough will implement procedures to ensure reports are filed in a timely manner. The implementation of this recommendation will be monitored by Allyson Bruce, Controller.
Management agrees with the finding. The Borough will implement procedures to ensure reports are filed in a timely manner. The implementation of this recommendation will be monitored by Allyson Bruce, Controller.
Finding 479420 (2023-001)
Significant Deficiency 2023
Special Tests and Provisions: HPP staff will follow written policy and procedures for ensuring all clients have a rent reasonableness form with new move ins and annual recertifications. The Director of Housing Programs will initial each document submitted for a new move in or an annual recertificati...
Special Tests and Provisions: HPP staff will follow written policy and procedures for ensuring all clients have a rent reasonableness form with new move ins and annual recertifications. The Director of Housing Programs will initial each document submitted for a new move in or an annual recertification to ensure all necessary documents are in each client file. Person Responsible for Corrective Action: Director of Housing Heather Ryan Figueroa Anticipated Date of Completion: June 7, 2024
No action needed. Required deposit of $1,971 was deposited into the residual reserve account on March 4, 2024.
No action needed. Required deposit of $1,971 was deposited into the residual reserve account on March 4, 2024.
View Audit 315935 Questioned Costs: $1
Management will undertake the following corrective actions to address the material weakness identified: 1. Will provide training to their personnel in the procedures for reporting expenditures on the SEFA. 2. Will implement internal controls to ensure financial information that is used to prepare th...
Management will undertake the following corrective actions to address the material weakness identified: 1. Will provide training to their personnel in the procedures for reporting expenditures on the SEFA. 2. Will implement internal controls to ensure financial information that is used to prepare the SEFA is complete and accurate.
View Audit 315922 Questioned Costs: $1
Name of Auditee: Empire Justice Center Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended December 31, 2023 CAP Prepared by: Kristin Brown Phone: 518-852-5766 (A) Current Finding on the Schedule of Findings and Responses (1) Audit Finding 2023-001 (a) Comments on the ...
Name of Auditee: Empire Justice Center Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended December 31, 2023 CAP Prepared by: Kristin Brown Phone: 518-852-5766 (A) Current Finding on the Schedule of Findings and Responses (1) Audit Finding 2023-001 (a) Comments on the finding and recommendation: Management agrees with the finding. (b) Actions Taken: Management has taken steps to ensure timely filing for the year ended December 31, 2023. (c) Anticipated Completion Date: Management anticipates this finding will be resolved for the year ending December 31, 2023.
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