Corrective Action Plans

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Finding 2023-002 Payroll and Personnel Files Significant Deficiency in Internal Control over Payroll and Personnel Files - Accurate and Completeness of Personnel Files The PRDOH agrees with the finding. However, PRDOH has implemented several corrective actions. The PRDOH established an internal c...
Finding 2023-002 Payroll and Personnel Files Significant Deficiency in Internal Control over Payroll and Personnel Files - Accurate and Completeness of Personnel Files The PRDOH agrees with the finding. However, PRDOH has implemented several corrective actions. The PRDOH established an internal control to ensure that the required documents are recorded in the files. The Director of Human Resources presented a work plan, in order to implement an effective procedure for reviewing files. A control sheet of documents required to the active records was established in which the Human Resources Officers of the regions and Hospital were requested to verify the employee’s files for the require documentation that is need it in the files. Responsible Official Lcdo. Luis Rivera Villanueva Secretario Auxiliar de Recursos Humanos 787-765-2929 ext. 4273 Mrs. Luz S. Ramos Pedroza Specialist 787-765-2929 ext. 4273 Mrs. Maribel Zayas Payroll Officer Director 787-765-2929 ext. 4209 Estimated Completion Date Implementation is expected to be completed on or before the end of October 2024.
Finding 2023-001 Financial Administration- Standards for Financial Management System Financial Internal Control Weakness and Noncompliance The PRDOH agrees with the finding. However, PRDOH has implemented various corrective actions. Regarding Project Costing Module, the PRDOH already has implemente...
Finding 2023-001 Financial Administration- Standards for Financial Management System Financial Internal Control Weakness and Noncompliance The PRDOH agrees with the finding. However, PRDOH has implemented various corrective actions. Regarding Project Costing Module, the PRDOH already has implemented the Travel and Expenses Module, Payment Management System, which integrates with the Account Receivable to streamline revenue records and Payroll Solutions. The effectiveness of these will be observed during the fiscal year 2024-2025. Also, the PRDOH and Central Government are currently working on ERP implementation in all Government Agencies. This new ERP will be in place in the fiscal year 2024-2025. Furthermore, the PRDOH has established control in order for all program to ensure the timely performed reconciliations between the finance office, the federal affair office, this procedure has started since august 2022. In the other hand the State Department of Treasury has begun a series of training with regard the new ERP that will, be in place by October 2024. This new system in order to close the monthly period all programs will need to reconcile first before closing of the period. Responsible Official Mrs. Velmary Martinez Yace Finance Director Tel. 787-765-2929 ext. 3291 Mrs. Mayra Reyes Accounting Office Supervisor Tel. 787-765-2929 ext. 3294 Estimated Completion Date Implementation is expected to be completed on or before the end of October 2024.
Finding Number: 2023-003 Finding Title: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Program: 93.563 Child Support Enforcement Name of Contact Person Responsible for Corrective Action: Kevin Venenga, Finance Manager Corrective Action Planned: All impacted employees have been r...
Finding Number: 2023-003 Finding Title: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Program: 93.563 Child Support Enforcement Name of Contact Person Responsible for Corrective Action: Kevin Venenga, Finance Manager Corrective Action Planned: All impacted employees have been reviewed and system adjustments in payroll have been completed. In addition, a review will be done at the start of every quarter to ensure that all allocations are being distributed correctly by the payroll system to ensure that reports are accurately completed. Anticipated Completion Date: 2023 amounts will be corrected by 7/31/2024. The quarterly payroll systems review will start prior to the first payroll of the 3rd quarter of 2024.
Finding Number: 2023-002 Finding Title: Child Support Non-Cooperation Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: DeAnn Boney, Income and Healthcare Assistance Manager Corrective Action Planned: The agency will take the following ...
Finding Number: 2023-002 Finding Title: Child Support Non-Cooperation Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: DeAnn Boney, Income and Healthcare Assistance Manager Corrective Action Planned: The agency will take the following steps to come into compliance: 1 Correct the cases that were found to be in error. 2 Establish an internal case review process. 3 Provide training and review the policy areas where deficiencies were identified with the family team. 4 Require family team to take new DHS training on assets. 5 Use DHS TANF case reviews as learning tools and share results with the family team. Anticipated Completion Date: Cases will be corrected, and the review process will be in place by 7/31/2024
Finding Number: 2023-001 Finding Title: Eligibility Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: DeAnn Boney, Income and Healthcare Assistance Manager Corrective Action Planned: The agency will take the following steps to come into...
Finding Number: 2023-001 Finding Title: Eligibility Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: DeAnn Boney, Income and Healthcare Assistance Manager Corrective Action Planned: The agency will take the following steps to come into compliance: 1. Correct the cases that were found to be in error. 2. Establish an internal case review process. 3. Provide training and review the policy areas where deficiencies were identified with the family team. 4. Require family team to take new DHS training on assets. 5. Use DHS TANF case reviews as learning tools and share results with the family team. Anticipated Completion Date: Cases will be corrected, and the review process will be in place by 7/31/2024.
Management has prepared an outstanding Replacement Reserve Deposit worksheet and this tool will be used to track monthly deposits into the Replacement Reserve Account. Deposits will begin in June 2024 and older outstanding balances will be paid first. On a go forward basis, St. Cat's will make at le...
Management has prepared an outstanding Replacement Reserve Deposit worksheet and this tool will be used to track monthly deposits into the Replacement Reserve Account. Deposits will begin in June 2024 and older outstanding balances will be paid first. On a go forward basis, St. Cat's will make at least one monthly deposit into the Replacement Reserve, and depending on cash flow will strive to make additional monthly deposits to lower the total amount outstanding.
Management has prepared an outstanding Replacement Reserve Deposit worksheet and this tool will be used to track monthly deposits into the Replacement Reserve Account. Deposits will begin in June 2024 and older outstanding balances will be paid first. On a go forward basis, St. Ann's will make at le...
Management has prepared an outstanding Replacement Reserve Deposit worksheet and this tool will be used to track monthly deposits into the Replacement Reserve Account. Deposits will begin in June 2024 and older outstanding balances will be paid first. On a go forward basis, St. Ann's will make at least one monthly deposit into the Replacement Reserve, and depending on cash flow will strive to make additional monthly deposits to lower the total amount outstanding.
BCCYF Program and Fiscal departments have updated the policy and procedure to adequately track yearly reviews for TANF eligible files. The fiscal department will track dates in QuickBooks. This will be used as a tickler system for notifying the fiscal department that a redetermination and review mus...
BCCYF Program and Fiscal departments have updated the policy and procedure to adequately track yearly reviews for TANF eligible files. The fiscal department will track dates in QuickBooks. This will be used as a tickler system for notifying the fiscal department that a redetermination and review must be completed. Prior to reporting of TANF, this tracking system will be used to ensure that all redeterminations and reviews are completed prior to submission. Timetable for Implementation: Implementation of the TANF policy and procedure will take effect FY 24/25 Quarter 1. Monitoring to Be Performed: A report will be saved in Excel of all TANF determinations/redeterminations and reviews per quarter. Name of Person(s) with Title and Scope of Responsibility: Name: Mindy Hostetler Title: Fiscal Officer. Corrective Action - Approved by: Tiffany Treese Position: Administrator Date: June 28, 2024.
Name of Auditee: Town of Alexander, New York Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended December 31, 2023 CAP Prepared by: David Miller, Supervisor Phone: 585-591-2455 (3) Audit Finding 2023-003 - The engineering services for the construction of water district...
Name of Auditee: Town of Alexander, New York Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended December 31, 2023 CAP Prepared by: David Miller, Supervisor Phone: 585-591-2455 (3) Audit Finding 2023-003 - The engineering services for the construction of water district #6 was not procured. (a) Implementation Plan of Actions - The Town will procure engineering services in the future. (b) Implementation Date - This will be implemented for the year ended December 31, 2024. (c) Persons Responsible for Implementation - The Town Board and Supervisor of the Town of Alexander.
Finding 479184 (2023-001)
Significant Deficiency 2023
Finding 2023-001 Internal Control Over Allowable Costs/Activities Name of Contact Person: Joy Stein, Chief Financial Officer Corrective Action Plan: An error occurred when a workaround in the workflow approval process caused a raise to be missed for one employee. A Compensation Change form was re-...
Finding 2023-001 Internal Control Over Allowable Costs/Activities Name of Contact Person: Joy Stein, Chief Financial Officer Corrective Action Plan: An error occurred when a workaround in the workflow approval process caused a raise to be missed for one employee. A Compensation Change form was re-routed from the customary workflow established in the BambooHR system because an approver was out on Paid Time Off (PTO). The workaround removed the change from reflecting on the Bamboo reports used during the processing payroll. The result was that the pay raise was missed, and the employee was underpaid until the time of audit and test sample review. A telephone meeting was held the afternoon of March 27, 2024, with the CFO, CHRO, and Payroll Specialist. It was identified that when the workflow is worked-around the change does not appear on the Bamboo change report. Therefore, it was decided that the best practice will be to use an alternate approver which is the Senior Accountant at present. If this position is vacant or not available, then the workflow will remain intact. If items are urgent and cannot wait, HR will contact the approver via telephone and request the item to be processed. Proposed Completion Date: March 27, 2024, action was completed. Corrective action was identified and completed on same day the error was identified.
To ensure compliance with grant regulations the school district will implement the following: ● Conduct a comprehensive assessment of existing procedures to identify gaps that led to non-compliance with grant regulations. ● Ensure timely submission of grant applications. ● Maintain detailed document...
To ensure compliance with grant regulations the school district will implement the following: ● Conduct a comprehensive assessment of existing procedures to identify gaps that led to non-compliance with grant regulations. ● Ensure timely submission of grant applications. ● Maintain detailed documentation of all award dates and expenditures to provide a clear compliance record. ● Ensure all documentation is easily accessible and systematically organized for audit purposes. ● Ensure pre-award costs are allowable only to the extent they would have been allowable if incurred after the effective date and ONLY with written approval from the Federal awarding agency (as per 2 CFR 200.458). ● Establish a process for obtaining and documenting written approval for pre-award costs. ● Provide comprehensive training on compliance with Uniform Grant Guidance to all relevant staff. ● Review and update policies and procedures related to grant expenditures regularly to ensure they are current and compliant with federal regulations. ● Assign accountability for monitoring and reporting compliance to specific roles within the organization. This implementation of this plan shall be the responsibility of the Russ Kaubris, Business Manager. Starting with the Fiscal Year 2025 grant cycle, procedures to comply will be implemented.
Cause: Miskeying of information from paperwork to calculate the sliding fee discounts resulted in errors in the application of the sliding fee under the previous EHR. Planned Corrective Action: The issues around manual inputs have been greatly reduced under the new EHR and billing software. Sliding...
Cause: Miskeying of information from paperwork to calculate the sliding fee discounts resulted in errors in the application of the sliding fee under the previous EHR. Planned Corrective Action: The issues around manual inputs have been greatly reduced under the new EHR and billing software. Sliding fee information is now input in real time, allowing for confirmation of information from applicants. In addition, regular reviews and audit samplings are taken monthly to assure for accuracy. Anticipated Completion Date: 7/31/2024 Responsible Contact Person: Yammah Morgan, Chief Operations Officer
Finding 479160 (2023-001)
Significant Deficiency 2023
Finding 2023‐001 Federal Agency Name: U.S. Department of the Treasury Program Name: COVID‐19 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Finding Summary: The County’s quarterly performance reports submitted to the Department of Treasury were not revie...
Finding 2023‐001 Federal Agency Name: U.S. Department of the Treasury Program Name: COVID‐19 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Finding Summary: The County’s quarterly performance reports submitted to the Department of Treasury were not reviewed and approved by a separate individual outside of the preparer. Responsible Individuals: Kent Reeves, County Auditor Corrective Action Plan: The County will continue to have the County Auditor prepare the performance reports, with a mechanical review of the report performed by an individual within the Auditor’s Office. Anticipated Completion Date: Fiscal year 2024
2023-001: Provider Relief Fund Reporting Federal Granting Agency: DHHS Health Resources and Services Administration (HRSA) Award Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing Number: 93.498 Assistance Listing Title: COVID-19 Provider Relief Fund and ...
2023-001: Provider Relief Fund Reporting Federal Granting Agency: DHHS Health Resources and Services Administration (HRSA) Award Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing Number: 93.498 Assistance Listing Title: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Management agrees with the auditor’s finding that management erroneously included other revenue in the AMG submission for reporting period 5 within the HRSA Reporting Portal. It was human error that may have been mitigated with a second review prior to submission. Management believes there is no corrective action needed to the reported submission. Reported revenue by quarter for the time period July 1, 2022 to June 30, 2023 had no impact to the total unused lost revenue reported in the Lost Revenue Summary as the actual revenue exceeded the budget. In addition, the lost revenue reported for fiscal year ending December 31, 2020 far exceeded the total PRF funds received by AMG from the initial distribution though Period 5 (which is the last distribution received by AMG). Management will ensure to exclude any non patient care revenue and to perform a second review of any future submissions that would be required if additional funds were to be distributed. Management responsible for the corrective action plan: Katharine Driebe, Vice President – Finance Kay.driebe@atlantichealth.org
Finding 2023-003: Allowable costs – significant deficiency in internal controls over compliance and compliance finding. Management Response All submissions of expenses reimbursed by grants will require review by the Controller or the COO, in the Controller’s absence, to ensure that expenditures char...
Finding 2023-003: Allowable costs – significant deficiency in internal controls over compliance and compliance finding. Management Response All submissions of expenses reimbursed by grants will require review by the Controller or the COO, in the Controller’s absence, to ensure that expenditures charged to the grants agree to the original documents (invoices or 􀆟mesheets) prior to submission or charging to a specific grant
Finding 2023-001: Allowable costs – material weakness in internal controls over compliance and compliance finding. Management Response All submissions of 􀆟mesheets and payroll reimbursed by grants will require review by the Controller or the COO, in the Controller’s absence, to ensure that expenditu...
Finding 2023-001: Allowable costs – material weakness in internal controls over compliance and compliance finding. Management Response All submissions of 􀆟mesheets and payroll reimbursed by grants will require review by the Controller or the COO, in the Controller’s absence, to ensure that expenditures charged to the grants agree to the original 􀆟mesheets or payroll prior to submission or charging to a specific grant
Views of responsible officials: There is no disagreement with the audit finding. A waiver of the funding requirement was obtained for the year ended August 31, 2023. Management will incorporate the funding calculation for the Replacement and Extension Account into the reconciliations to be performed...
Views of responsible officials: There is no disagreement with the audit finding. A waiver of the funding requirement was obtained for the year ended August 31, 2023. Management will incorporate the funding calculation for the Replacement and Extension Account into the reconciliations to be performed and reevaluated monthly.
Finding 479115 (2023-002)
Significant Deficiency 2023
Additional training will be provide to staff in the sliding fee discount application process and implement a review of sliding fee discount applications in the future at the management level.
Additional training will be provide to staff in the sliding fee discount application process and implement a review of sliding fee discount applications in the future at the management level.
View Audit 315615 Questioned Costs: $1
Finding 479065 (2023-003)
Significant Deficiency 2023
For the April 2023 financial report, an error was found with the amount of indirect costs reported. There was a transposition error in the submitted amount. In addition, the salaries and fringe benefits were not split out between FTE and PTE as all were included on the FTE lines in the submitted r...
For the April 2023 financial report, an error was found with the amount of indirect costs reported. There was a transposition error in the submitted amount. In addition, the salaries and fringe benefits were not split out between FTE and PTE as all were included on the FTE lines in the submitted report. Corrective Action Plan: As 2023 was the initial year of Provident, Inc. being considered a subrecipient under this grant, rather than a subcontractor as in prior years, the April 2023 reporting cycle was the initial reporting cycle completed by the Organization. As such, there was an experience curve for the initial reporting cycle. After the initial month of reporting, management had correspondence with Vibrant relating to changes going forward. In order to prevent clerical issues in future reports, management will implement additional reviews of the reports and supporting documentation prior to submission. This review will consist of review for clerical issues, comparison to supporting schedules, and comparison to report compliance requirements. Personnel Responsible for Corrective Action: Jamie Ilko, Senior Director, Finance & Administration; jilko@providentstl.org; 314-802-2607 Anticipated Completion Date: Change is in process and full adoption is anticipated by December 31, 2024.
The Corporation contacted the local Continuum of Care and regional HUD office in an effort to verify the required number of units occupied by individuals meeting the definition of "homeless". The local Continuum of Care had no record of the original grant agreement or required number of "homeless" t...
The Corporation contacted the local Continuum of Care and regional HUD office in an effort to verify the required number of units occupied by individuals meeting the definition of "homeless". The local Continuum of Care had no record of the original grant agreement or required number of "homeless" to be served. The Corporation contacted three staff in the regional HUD office, including the staff that had been our representative for annually renewed operation and support service grants for the two projects. Regional HUD staff were not able to provide a copy of the original grant agreements which would indicate the number of persons to be served by each project. HUD staff stated that they do not keep copies of grant agreements longer than seven years. Corporation management will continue to work with HUD personnel to determine the continuing compliance requirements of the Continuum of Care funding received for initial construction or rehabilitation. Corporation management will continue to serve individuals meeting the definition of homelessness at its two projects and document evidence in the file.
Transitional Living for homeless Youth – Assistance Listing No. 93.550 Recommendation: It is recommended that the Organization implement controls to monitor program income and ensure that the funds are being properly used before requesting additional federal funds. This could include regular reporti...
Transitional Living for homeless Youth – Assistance Listing No. 93.550 Recommendation: It is recommended that the Organization implement controls to monitor program income and ensure that the funds are being properly used before requesting additional federal funds. This could include regular reporting on the use of program income and conducting periodic reviews to ensure compliance with program requirements. Additionally, the Organization should review its policies and procedures to ensure they are in compliance with program requirements and make any necessary updates. Finally, the Organization should ensure that all staff members responsible for monitoring program income are properly trained and have a clear understanding of program requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: During each Payment Management System Draw process, the Finance Director will verify the draw amounts and run a program income and expense report to verify that the amount of miscellaneous expenses for the Transitional Living Program are more than the program income received. A copy of the income and expense statement will be saved in each draw file with the other verification documents. A column for verification initials of this process was added to the ACF Grant Balances Spreadsheet used for recording the draw amounts and dates of the draws. Name(s) of the contact person(s) responsible for corrective action: Julia Montebello, Finance Director Planned completion date for corrective action plan: 4/26/2024
Transitional Living for Homeless Youth – Assistance Listing No. 93.550 Recommendation: It is recommended that the Organization implement controls to ensure that proper documentation and support for eligibility is obtained and reviewed by a qualified individual. Explanation of disagreement with audit...
Transitional Living for Homeless Youth – Assistance Listing No. 93.550 Recommendation: It is recommended that the Organization implement controls to ensure that proper documentation and support for eligibility is obtained and reviewed by a qualified individual. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Program Director will conduct Weekly Document Reviews for new and ongoing clients and will also verify eligibility as staff submit weekly request forms for clients to receive services. Weekly Review Schedule: • The Program Director will conduct a review of all documentation once a week. Verification Process: • During the review, the Program Director will verify that all required documents for eligibility is being completed accurately, processed, and documented. Documentation of Review: • The results of this review will be documented on each client’s initial intake form and in Apricot. • The Program Director will sign the intake form to indicate verification and completion of the review and will also document this in Apricot. • By adhering to this procedure, we ensure that all documentation is thoroughly checked and validated on a consistent basis, maintaining the integrity and accuracy of our eligibility process. Name(s) of the contact person(s) responsible for corrective action: Elena Guerra, EYS Program Director. Planned completion date for corrective action plan: ongoing
Transitional Living for Homeless Youth – Assistance Listing No. 93.550 Recommendation: It is recommended that the Organization implement controls to ensure that clients meet eligibility requirements before being enrolled in the program. This could include verifying age at the time of enrollment and ...
Transitional Living for Homeless Youth – Assistance Listing No. 93.550 Recommendation: It is recommended that the Organization implement controls to ensure that clients meet eligibility requirements before being enrolled in the program. This could include verifying age at the time of enrollment and periodically re-verifying eligibility for on-going clients. Additionally, the Organization should review its policies and procedures to ensure that they are in compliance with program requirements and make any necessary updates. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Clearly define eligibility requirements for staff conducting intakes, along with the intake process. Staff and Program Director will reverify eligibility when doing check requests. Two opportunities will be provided for staff each year to revisit eligibility requirements and to provide staff with refresher training. Intake Process: At the time of intake into the program, client’s will be asked for their driver’s license, state ID, permit, tribal ID, or birth certificate. If the client doesn't have any Identification, staff will calculate the client's age using the client's reported date of birth. Staff will then attempt to help the client secure personal vital documents and add copies to the client file for verification. The Program Director will also verify eligibility. Training: Staff to be trained in the spring and fall of each year to revisit eligibility requirements, intake processes, along with agency core values, mission and vision. Name(s) of the contact person(s) responsible for corrective action: Elena Guerra, EYS Program Director Planned completion date for corrective action plan: • Clearly define eligibility requirements for staff by July 1, 2024. • Host trainings by September 30, 2024, and March 31, 2025. • Verify eligibility for new clients and current clients on an ongoing basis.
2023-002 Planned Corrective Action: We agree with the need for updated policies and/or procedures to be codified in the Organization’s Accounting Manual to ensure compliance with the new 2023 LSC Financial Guide requirements. In 2022, 603 Legal Aid drafted a set of accounting policies based on the p...
2023-002 Planned Corrective Action: We agree with the need for updated policies and/or procedures to be codified in the Organization’s Accounting Manual to ensure compliance with the new 2023 LSC Financial Guide requirements. In 2022, 603 Legal Aid drafted a set of accounting policies based on the previous Financial Guide and operations at the time (which included different staffing positions to those in place at present). The Organization currently has a temporary consultant filling in for the Senior Accountant position while a permanent hire is found. Working with the Board Treasurer, he is in the process of updating the 603 Legal Aid 2022 draft of policies to reflect changes in the new LSC Financial Guide as well as operational changes at 603 Legal Aid. This work is expected to be handed off to the permanent Senior Accountant when hired, who will be responsible for ongoing oversight of the Organization’s Accounting Manual to ensure compliance. Responsible Person: Temporary Consultant, Senior Accountant Date of Completion: December 31, 2024
2023-001 Planned Corrective Action: The Organization has already taken the necessary corrective action steps to be in compliance with this regulation. In January 2024, 603 Legal Aid communicated with our LSC Program Officer to review the Board of Directors composition requirements and discuss the pl...
2023-001 Planned Corrective Action: The Organization has already taken the necessary corrective action steps to be in compliance with this regulation. In January 2024, 603 Legal Aid communicated with our LSC Program Officer to review the Board of Directors composition requirements and discuss the plan for bringing the Organization into compliance. A new McCollum attorney joined the Board in January 2024, bringing 603 Legal Aid into compliance. Additionally, the Chair of the Board Development Committee has agreed to create and maintain a running list of Board members for ongoing oversight throughout the year to ensure continued compliance. Responsible Person: Ariel Clemmer Date of Completion: Compliant as of January 2024
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