Corrective Action Plans

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Responsible Person: Tim Bergsma, CFO - West Michigan Partnership for Children (WMPC). Management View: Management agrees with the finding and is in the process of implementing the recommendation. Corrective Action: WMPC will create a Compensation Adjustement Policy. This policy will reference the co...
Responsible Person: Tim Bergsma, CFO - West Michigan Partnership for Children (WMPC). Management View: Management agrees with the finding and is in the process of implementing the recommendation. Corrective Action: WMPC will create a Compensation Adjustement Policy. This policy will reference the compensation policy, connect to the budget approval process, and identify clear directions regarding the approval process for compensation adjustments. Anticipated Completion Date: August 15, 2024
Finding 404541 (2023-002)
Significant Deficiency 2023
2CFR 320, Methods of Procurement Standards are to be followed by each department requesting federal award. The County Auditor has instructed our employees and admin people of the changes made to our system to be followed for methods of procurements. County Auditors have provided an easy sheet to be ...
2CFR 320, Methods of Procurement Standards are to be followed by each department requesting federal award. The County Auditor has instructed our employees and admin people of the changes made to our system to be followed for methods of procurements. County Auditors have provided an easy sheet to be followed and dated to be turned into the auditor's office to be approved prior to purchases as to see all steps have been completed of the procurement policy prior of purchasing items on any federal award. All items by County Auditor will be processed and looked at again prior to a check written.
View Audit 311060 Questioned Costs: $1
Reference Number: 2023-003 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Title: Section 8 Housing Choice Vouchers Federal Catalog Number: 14.871 Federal Grant Number: Not Applicable Category of Finding: Special Tests and Provisions HQS Enforcement Classification o...
Reference Number: 2023-003 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Title: Section 8 Housing Choice Vouchers Federal Catalog Number: 14.871 Federal Grant Number: Not Applicable Category of Finding: Special Tests and Provisions HQS Enforcement Classification of Finding: Significant Deficiency in Internal Control over Compliance Instance of Noncompliance The Authority has made significant progress in addressing the backlog of annual inspections since outsourcing the programmatic functions of the HCV program to third-party contractors. The Authority acknowledges that more progress in this area is required and continues to work diligently with the third-party HCV contractors to ensure this occurs. The Authority uses the Emphasys Elite software to schedule, record, and enforce HQS inspections. The Authority also uses its Customer Relations Management (CRM) system to track units that have failed an HQS inspection. The HCV contractors have implemented a daily review process of units that have failed and/or no-showed two or more consecutive inspections. The inspection department will use this process to accurately review the letter generation and notification process for HQS deficiencies and notices of abatement. The inspection department will manually review and generate both letters to their respective parties (landlord/owner and tenant). In addition to the daily morning review, at the close of business day, the HCV contractors will review the emergency failed inspections and will schedule any emergency re-inspections to ensure compliance with HQS enforcement rules and regulations. Anticipated Implementation Date September 30, 2024 Name(s) and Title(s) of Contact Person(s) Responsible for Correction Action HCV Contractors Kendra Crawford, Director of Housing Operations
View Audit 311041 Questioned Costs: $1
Reference Number: 2023-002 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Title: Housing Choice Cluster Federal Catalog Number: 14.871 and 14.879 Federal Grant Number: Not Applicable Category of Finding: Special Tests and Provisions (Housing Quality Standards Inspec...
Reference Number: 2023-002 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Title: Housing Choice Cluster Federal Catalog Number: 14.871 and 14.879 Federal Grant Number: Not Applicable Category of Finding: Special Tests and Provisions (Housing Quality Standards Inspections) Classification of Finding: Material Weakness in Internal Control over Compliance Material Noncompliance The Authority has made considerable progress in addressing the backlog of annual inspections that resulted from the implementation of HUD waivers during the national pandemic. The Authority acknowledges that more progress in this area is required and continues to work diligently with its third-party HCV contractors to ensure completion of this ongoing work. The Authority understands the importance of and is committed to ensuring all units under contract are beyond safe, sanitary, and decent in accordance with HQS requirements and the Authority's Administrative Plan. The Authority uses the Emphasys Elite software to check against HUD's PIH Information Center (PIC) system to identify units with outstanding Housing Quality Standards (HQS) Inspections. The Authority has scheduled HQS Inspections for the units identified to be out of compliance. Some key strategies and controls in place are as follows: Review the report of outstanding HQS Inspections on a weekly basis. Schedule outstanding HQS Inspections in order of aging date. Conduct HQS Inspections prior to anniversary date of previously completed inspection. Run a monthly report of failed inspections and compare them with future scheduled inspections to ensure that a second inspection has been scheduled. Run a monthly report to identify units with two failed inspections to ensure all have been abated correctly. Implement weekly monitoring to ensure all units are properly abated and lifted timely when units pass inspections and contracts are properly terminated after being in abatement for 180 days without a cure. During the pandemic, units were not inspected and legally permitted based upon available HUD regulations. As a result, the Authority has implemented a 100% Annual Inspection requirement for all contracted project-based vouchers (PBVs) and tenant-based vouchers (TBVs) units starting with the 10/1/2023 HUD Section Eight Management Assessment Program (SEMAP) Year. To that end, the HCV contractors have implemented a daily review process for all failed inspections to ensure timely rescheduling and will accurately note inspection extension requests exceeding the 30-day HQS enforcement requirement to bring a unit up to standard. Anticipated Implementation Date September 30, 2024 Name(s) and Title(s) of Contact Person(s) Responsible for Correction Action HCV Contractors Kendra Crawford, Director of Housing Operations
View Audit 311041 Questioned Costs: $1
Management’s Response: We will establish centralized controls that include identifying all required reports and implementing effective controls over report preparation. We will also implement a monitoring function to ensure that these controls are in place and operating effectively for timely and ac...
Management’s Response: We will establish centralized controls that include identifying all required reports and implementing effective controls over report preparation. We will also implement a monitoring function to ensure that these controls are in place and operating effectively for timely and accurate report submission. In addition, we are in the process of implementing a new ERP/Accounting system that will help us with our reporting process. This new system will provide us with better tools for identifying required reports and implementing effective controls over report preparation. It will also enable us to establish more effective monitoring functions to ensure timely and accurate report submission. Anticipated Completion Date: September 30, 2024 Responsible Party: Keterah Mitchell, Accountant Tony Gutierrez, Consultant – Moss Adams
United States Department of the Treasury Programs Jackson Park Hospital (“The Hospital”) respectfully submits the following corrective action plan for the year ended March 31, 2023. Audit period: April 1, 2022 – March 31, 2023 The findings from the schedule of findings and questioned costs are disc...
United States Department of the Treasury Programs Jackson Park Hospital (“The Hospital”) respectfully submits the following corrective action plan for the year ended March 31, 2023. Audit period: April 1, 2022 – March 31, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Treasury 2023 – 002 Coronavirus State and Local Fiscal Recovery Funds Recommendation: We recommend the Hospital design controls to ensure that reporting is completing in accordance with U.S. Department of Treasury guidelines. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Hospital will ensure that controls are put into place to report timely on future grants. Name of the contact person responsible for corrective action: Barry Mandell, VP Special Projects. Planned completion date for corrective action plan: July 1, 2024. If the U.S. Department of Treasury has questions regarding this plan, please call Barry Mandell at 773-947-7701.
Management has established and implemented written procedures to ensure future compliance. Management will increase the detail of the review process over the tracking of meals, including both the financial function and those with direct knowledge and supervision of the services being performed. Mana...
Management has established and implemented written procedures to ensure future compliance. Management will increase the detail of the review process over the tracking of meals, including both the financial function and those with direct knowledge and supervision of the services being performed. Management will also offer additional training for program staff.
Response and Corrective Action Plan: The District (Kevin Baccam) will implement a process to review and retain meal claim reporting documentation as outlined by the Iowa Department of Education and Office of Management and Budget.
Response and Corrective Action Plan: The District (Kevin Baccam) will implement a process to review and retain meal claim reporting documentation as outlined by the Iowa Department of Education and Office of Management and Budget.
Finding Number: 2023-002 Condition: The County did not track WIC interest income earned throughout the fiscal year, resulting in the County not refunding the Department of Health and Human Services the excess of $500 earned during the year. Planned Corrective Action: The financial analyst assigned t...
Finding Number: 2023-002 Condition: The County did not track WIC interest income earned throughout the fiscal year, resulting in the County not refunding the Department of Health and Human Services the excess of $500 earned during the year. Planned Corrective Action: The financial analyst assigned to the grant will review interest income earned throughout the fiscal year and ensure any amount exceeding $500 is returned to the Department of Health and Human Services. Contact person responsible for corrective action: Vanessa Barker Anticipated Completion Date: 06/30/2024
View Audit 310975 Questioned Costs: $1
Finding Number: 2023-001 Condition: During testing, it was noted that although there was a process in place to review eligibility criteria received by both programs, there was not an independent review or control to ensure eligibility was accurate. Planned Corrective Action: WIC: After the initial r...
Finding Number: 2023-001 Condition: During testing, it was noted that although there was a process in place to review eligibility criteria received by both programs, there was not an independent review or control to ensure eligibility was accurate. Planned Corrective Action: WIC: After the initial review for eligibility, a second employee will verify that eligibility was properly determined and provide a signoff to document review. Food Distribution Cluster: After the initial review and input of participant applications into the system, a new procedure will be introduced prior to distribution. Each client will undergo two verifications. The first verification will involve an employee verifying the client's information both manually against eligibility guidelines and electronically with program software. If the information is found to meet eligibility, a document will be signed and provided to the participant. The second verification will involve the client giving the signed documents to a second employee, who will also provide confirmation of eligibility and approve distribution. Contact person responsible for corrective action: WIC: Lucy Rosenberg and Michelle Estell Food Distribution Cluster: Karen Moton Anticipated Completion Date: 06/30/2024
Finding 404195 (2023-002)
Significant Deficiency 2023
A new HUD lease will be prepared, presented, and signed at the time of the annual recertification for every tenant.
A new HUD lease will be prepared, presented, and signed at the time of the annual recertification for every tenant.
A new HUD lease will be prepared, presented and signed at the time of the annual recertification for every tenant.
A new HUD lease will be prepared, presented and signed at the time of the annual recertification for every tenant.
Action Taken: NFFCMH plans to implement changes overall to the Federation’s timekeeping processes to ensure that payroll costs accurately reflect the work performed, and to reconcile and true up any budget estimates on a consistent basis.
Action Taken: NFFCMH plans to implement changes overall to the Federation’s timekeeping processes to ensure that payroll costs accurately reflect the work performed, and to reconcile and true up any budget estimates on a consistent basis.
Action Plan: Upon learning of this finding during the FY2022 audit, we worked with our external consultant, our Council auditors and our external auditor to reperform and review the base year and subsequent year calculations of revenue, using financial information in our final audit reports. These...
Action Plan: Upon learning of this finding during the FY2022 audit, we worked with our external consultant, our Council auditors and our external auditor to reperform and review the base year and subsequent year calculations of revenue, using financial information in our final audit reports. These corrected calculations of lost revenue have been clearly documented and will be reported going forward. We will continue to work to ensure that all controls for grants be documented with written procedures. The procedures will include the title of the positions responsible for each control (preparation, review, reconciliation, etc.) and will require that the performance of the controls be documented in a clear, reperformable manner including the name of each responsible individual, the specific control they performed over compliance for the grant and the date(s) the controls were performed. Contact Names responsible for the plan – Marcia Saulo Anticipated completion date of the plan – September 30, 2024
Action Plan: Upon learning of this finding during the FY2022 audit, we worked with the Neighborhoods Department to ensure wage rate requirement compliance was prioritized going forward. Considering this finding was presented near the completion of the FY2023 year, we expect this finding to be resolv...
Action Plan: Upon learning of this finding during the FY2022 audit, we worked with the Neighborhoods Department to ensure wage rate requirement compliance was prioritized going forward. Considering this finding was presented near the completion of the FY2023 year, we expect this finding to be resolved in FY2024. We will continue to work with our departments to ensure that all controls for grants are documented with written procedures. The procedures will include the title of the positions responsible for each control (preparation, review, reconciliation, etc.) and will require that the performance of the controls be documented in a clear, reperformable manner including the name of each responsible individual, the specific control they performed over compliance for the grant and the date(s) the controls were performed. Contact Names responsible for the plan – Marcia Saulo Anticipated completion date of the plan – September 30, 2024
Finding 2023-003: Reporting Condition: The College’s publicly available Higher Education Emergency Relief Funds reports for the institutional and student expenditures overstated the total amount of expenditures the College incurred during the fiscal year ending June 30, 2023. The College overstated...
Finding 2023-003: Reporting Condition: The College’s publicly available Higher Education Emergency Relief Funds reports for the institutional and student expenditures overstated the total amount of expenditures the College incurred during the fiscal year ending June 30, 2023. The College overstated the total amount of student expenditures by $3,301,290 and overstated institutional expenditures by $1,127,289. Criteria: As described under Section 314 (e) of the Coronavirus Response and Relief Supplemental Appropriations Act of 2021 (CRRSAA), Public Law 116-260, and defined by the United States Education Department, an institution shall submit a quarterly expense report documenting the expenditures for both the student portion of HEERF money as well as institutional use of the HEERF money. These reports should be posted to the College’s website in a timely and accurate manner for the previously ended quarter. Cause: The College did not reconcile the reports posted to their publicly facing website with the underlying accounting records including the schedule of expenditures of federal awards. Effect of the Condition: Failure to comply with HEERF reporting requirements could jeopardize future federal funding. Action Taken: The College will review and reconcile the reports to the underlying accounting records including the schedule of expenditures of federal awards to ensure the reports reflect the activity that occurred during the reporting period. Name(s) of Contact Person(s) Responsible for Corrective Action: Patricia Smallacombe, Interim Associate Dean, Academic Partnerships Anticipated Completion Date: July 31, 2024
Finding 2023-002: Special Tests and Provisions Condition: The College has approximately 140 student financial assistance checks that were outstanding at year end that were over 240 days old and they have not been returned to the federal government. The College has also escheated uncashed student fi...
Finding 2023-002: Special Tests and Provisions Condition: The College has approximately 140 student financial assistance checks that were outstanding at year end that were over 240 days old and they have not been returned to the federal government. The College has also escheated uncashed student financial assistance checks to the state of Pennsylvania. Criteria: As outlined under 34 CFR 668.164 (1), an institution must have a process that ensures student financial assistance funds outstanding are returned to the federal government within 240 days. They may not be escheated to a state or revert to the institution or any other third party. Cause: The College did not have a process in place to monitor outstanding student financial assistance checks or to prevent these funds from escheating to the Commonwealth of Pennsylvania. Effect of the Condition: The College is not following required Federal Student Assistance regulations in maintaining an appropriate administrative capability to administer funds. Action Taken: The College will develop a process and procedures to ensure monitoring of outstanding student financial assistance checks and ensure that those checks are treated in accordance with Federal Student Assistance regulations. Name(s) of Contact Person(s) Responsible for Corrective Action: Niels Christensen, Chief Financial Officer Anticipated Completion Date: July 31, 2024
Park City's Response Rent Adjustment Letters Park City has implemented the requirement that all residents are to complete and sign their annual recertification forms within thirty days of receipt. This policy aims to streamline our administrative processes and ensure that all resident information re...
Park City's Response Rent Adjustment Letters Park City has implemented the requirement that all residents are to complete and sign their annual recertification forms within thirty days of receipt. This policy aims to streamline our administrative processes and ensure that all resident information remains up to date. Also, as PCC transitions to Rent Café for recertifications, we anticipate this will make the process easier for residents and staff. Income Verification Forms Park City requires all income verification forms and re-examination documents to be scanned and securely stored in Yardi, our new digital management system. Storing documents digitally helps us maintain compliance with regulatory requirements by ensuring that all records are accurately maintained and readily available for audits and inspections.
Park City's Response Park City has contracted with an outside firm to manage, staff and run the Housing Choice Voucher program. In the twenty instances where the utility allowance amount does not agree with HUD Form 50058, there are sixteen cases where the utility allowance does not agree with the...
Park City's Response Park City has contracted with an outside firm to manage, staff and run the Housing Choice Voucher program. In the twenty instances where the utility allowance amount does not agree with HUD Form 50058, there are sixteen cases where the utility allowance does not agree with the HUD Form 50058 reviewed and four cases where the incorrect utility allowance year was used in HUD Form 50058. In the sixteen cases where the utility allowance does not agree with HUD Form 50058 reviewed, it appears that the incorrect structure type was used in the calculation. The contractor has established structure type definitions and distributed them to staff. The contractor has conducted an internal training about how to determine structure type to ensure the accuracy of the utility allowance. In the four cases where the incorrect utility allowance year was used, these transactions were completed prior to the establishment of the 2023 utility allowances. The transactions should have been corrected after they were approved. The contractor will establish a listing of all applicable transactions completed with an effective date of November 1, 2024. Any transactions submitted prior to the approval date of the utility allowances will be reviewed and corrected.
Management agrees with the finding and has taken corrective action by purchasing and implementing software which will track the employee’s actual time spent. This software was placed in service on October 1, 2023.
Management agrees with the finding and has taken corrective action by purchasing and implementing software which will track the employee’s actual time spent. This software was placed in service on October 1, 2023.
In response to the audit finding for fiscal year 2023, Wayne County Healthy Communities has implemented processes and procedures to address the finding. • Finding Number 2023-01 WCHC Management agrees with the finding and will conduct a review of the current process for data intake and application o...
In response to the audit finding for fiscal year 2023, Wayne County Healthy Communities has implemented processes and procedures to address the finding. • Finding Number 2023-01 WCHC Management agrees with the finding and will conduct a review of the current process for data intake and application of sliding fee calculations into eClinicalWorks (our Electronic Health Record [EHR] system) performed by front desk staff. Process improvement actions will be taken (including trainings) to ensure all front desk staff have full understanding of the process, address any concerns, and avoid future errors. Anticipated Completion Date: December 15, 2024 Individuals Responsible: Amaal Haimout, Chief Operating Officer Jawan Simpson, Chief Financial Officer
DEPARTMENT OF HEALTH AND HUMAN SERVICES 2023-002 Head Start Cluster- Federal Assistance Listing Number 93.600 - Significant Deficiency in Internal Control over Allowable Costs Recommendation: Internal Controls should be implemented around expense cutoff to ensure all expenses relate to the appropria...
DEPARTMENT OF HEALTH AND HUMAN SERVICES 2023-002 Head Start Cluster- Federal Assistance Listing Number 93.600 - Significant Deficiency in Internal Control over Allowable Costs Recommendation: Internal Controls should be implemented around expense cutoff to ensure all expenses relate to the appropriate period, or in this case, school year. Action taken: We concur with the recommendation. On May 30, 2024, HRCAP drafted Accounting Policy 3.10 to be reviewed for addition to the Finance Policy Manual. This policy would serve to provide internal control procedures for grant-related transactions in accordance with Generally Accepted Accounting Principles (GAAP). Specifically, it outlines precise year end and cut-off procedures tailored to grant revenue and expenses, emphasizing the critical importance of recording these transactions within the appropriate grant period. Sincerely yours, Audrea Lambert, Chief Financial Officer
View Audit 310907 Questioned Costs: $1
Action Taken: The Senior Programs have undergone significant improvements in the last 6 months following an audit by the federal funder which resulted in a corrective action plan (CAP) and a repayment of $54,228. Plans were implemented during the spring of 2024 in response to the CAP which resulted...
Action Taken: The Senior Programs have undergone significant improvements in the last 6 months following an audit by the federal funder which resulted in a corrective action plan (CAP) and a repayment of $54,228. Plans were implemented during the spring of 2024 in response to the CAP which resulted in an overhaul of the processes in place to properly develop the volunteer checklists and assure all records for staff and volunteers are now compliant. Our Quality and Compliance and Finance team worked closely with the new Program Manager to assure that we will be fully compliant and remain so.
View Audit 310898 Questioned Costs: $1
Name of Auditee: Rochester Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: September 30, 2023 CAP Prepared by: Shawn Burr, Executive Director Phone: (585) 697-6184 (A) Current Findings on the Schedule of Findings and Questioned Costs (2) Finding 2023-002 (a)...
Name of Auditee: Rochester Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: September 30, 2023 CAP Prepared by: Shawn Burr, Executive Director Phone: (585) 697-6184 (A) Current Findings on the Schedule of Findings and Questioned Costs (2) Finding 2023-002 (a) Comments on the finding and recommendation - The Authority agrees with the finding. The Authority also agrees with the recommendation, please see below for action taken. (b) Action taken - Procurement policies over record retention will be implemented. (c) Planned implementation date of corrective action - Completed by September 30, 2024.
View Audit 310889 Questioned Costs: $1
Name of Auditee: Rochester Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: September 30, 2023 CAP Prepared by: Shawn Burr, Executive Director Phone: (585) 697-6184 (A) Current Findings on the Schedule of Findings and Questioned Costs (3) Finding 2023-003 (a)...
Name of Auditee: Rochester Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: September 30, 2023 CAP Prepared by: Shawn Burr, Executive Director Phone: (585) 697-6184 (A) Current Findings on the Schedule of Findings and Questioned Costs (3) Finding 2023-003 (a) Comments on the finding and recommendation - The Authority agrees with the finding. The Authority also agrees with the recommendation, please see below for action taken. (b) Action taken - HQS inspections of Shelter Plus Care properties will be performed on an annual basis. (c) Planned implementation date of corrective action - Completed by September 30, 2024.
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