Corrective Action Plans

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2023‐005 – Year Ended June 30, 2023 Department of Health and Human Services Federal Assistance Listing/# 93.498 Activities Allowed or Unallowed and Allowable Costs/Cost Principles and Reporting Significant Deficiency in Internal Control over Compliance Finding Summary: 2 CFR 200.303(a) establis...
2023‐005 – Year Ended June 30, 2023 Department of Health and Human Services Federal Assistance Listing/# 93.498 Activities Allowed or Unallowed and Allowable Costs/Cost Principles and Reporting Significant Deficiency in Internal Control over Compliance Finding Summary: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. The Facilities claimed equipment costs under the Provider Relief Fund program for a project that was not complete at the end of the period of availability, or December 31, 2022. Costs were improperly included within the Period 4 report and caused the reporting submitted to the Department of Health and Human Services to be inaccurate. Responsible Individual: Perry Howell, CFO Corrective Action Plan: The Facilities will enhance internal control policies to ensure all amounts are adequately documented and properly recorded in the reports required to be submitted to the federal agency. The Facilities will enhance internal control policies to ensure that the required reports are properly reviewed prior to submission to ensure all key line items are necessary, correct, meet the requirements of the federal program, and are properly recorded in the reports required to be submitted to the federal agency. Anticipated Completion Date: June 2024
View Audit 305361 Questioned Costs: $1
2023‐004 – Year Ended June 30, 2023 Department of Health and Human Services Federal Assistance Listing/# 93.498 Reporting Material Weakness in Internal Control Over Compliance and Material Noncompliance Finding Summary: 2 CFR 200.303(a) establishes that the auditee must establish and maintain eff...
2023‐004 – Year Ended June 30, 2023 Department of Health and Human Services Federal Assistance Listing/# 93.498 Reporting Material Weakness in Internal Control Over Compliance and Material Noncompliance Finding Summary: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. The Facilities did not consider the impact of the year-end audit adjustments on the quarters applicable to Period 4 when reporting lost revenue. Key line items for reporting related to lost revenue were materially misstated. No lost revenue was claimed during the current period. Responsible Individual: Perry Howell, CFO Corrective Action Plan: The Facilities will enhance internal control policies to ensure all amounts are adequately documented and properly recorded in the reports required to be submitted to the federal agency. The Hospital will enhance internal control policies to ensure that the required reports are properly reviewed prior to submission to ensure all key line items are necessary, correct, meet the requirements of the federal program, and are properly recorded in the reports required to be submitted to the federal agency. Anticipated Completion Date: June 2024
Finding 395728 (2023-001)
Significant Deficiency 2023
Name of auditee: Luther Crest, Inc.; HUD auditee identification number: HUD Project No. 074-EE033-WAH; Name of audit firm: Carter & Company, CPA; Period covered by the audit year: January 1, 2023 through December 31, 2023; CAP prepared by: Name: Trey Knight, Position: Operations Analyst, Telephon...
Name of auditee: Luther Crest, Inc.; HUD auditee identification number: HUD Project No. 074-EE033-WAH; Name of audit firm: Carter & Company, CPA; Period covered by the audit year: January 1, 2023 through December 31, 2023; CAP prepared by: Name: Trey Knight, Position: Operations Analyst, Telephone number: 913-947-3131; 1. Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations: Finding 2023-001 - Pursuant to the requirements of the regulatory agreement the Organization is required to comply with all HUD regulations and other requirements. The Regulatory Agreement establishes the requirement to fund a replacement reserve in an amount determined by HUD. (1) Comments on the Finding and Each Recommendation. The project encountered cash flow issues during 2023. (2) Actions Taken on the Finding. Management is preparing documentation to submit for a Budget Based Rent increase to alleviate cash flow issues and fund the Reserve.
View Audit 305353 Questioned Costs: $1
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to retaining the completed sliding fee applications in the patients record to support the sliding fee discount pr...
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to retaining the completed sliding fee applications in the patients record to support the sliding fee discount provided to the patient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization agrees that this is a clerical error and an isolated incident. Currently, eligibility staff receives completed applications, scans them into the electronic health record, and discards the hard copy. To minimize error, the procedure will be changed, whereby staff maintains hard copies for the week, and at the end of the week verifies that all applications have been scanned into the system. This will act as a double check of the scanning process. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Jeremy Carroll, CFO at 832-443-7395.
Recommendation: The City used grant funds to pay expenditures that were already requested for reimbursement from the LCDBG grant and Clean Water State Revolving Funds. The City should implement policies and procedures to ensure that expenditures are not charged to multiple federal programs. Corre...
Recommendation: The City used grant funds to pay expenditures that were already requested for reimbursement from the LCDBG grant and Clean Water State Revolving Funds. The City should implement policies and procedures to ensure that expenditures are not charged to multiple federal programs. Corrective Action Plan: The City agrees with the finding and has established policies and procedures to ensure that expenditures are only charged to one federal program.
Recommendation: The City did not obtain bids for the purchase of equipment totaling $268,640. The City should implement policies and procedures to ensure compliance. Corrective Action Plan: The City agrees with the finding and has established policies and procedures to ensure compliance.
Recommendation: The City did not obtain bids for the purchase of equipment totaling $268,640. The City should implement policies and procedures to ensure compliance. Corrective Action Plan: The City agrees with the finding and has established policies and procedures to ensure compliance.
View Audit 305307 Questioned Costs: $1
Recommendation: The City used grant funds to pay expenditures that were already requested for reimbursement from the LCDBG grant and Clean Water State Revolving Funds. The City should implement policies and procedures to ensure that expenditures are not charged to multiple federal programs. Corre...
Recommendation: The City used grant funds to pay expenditures that were already requested for reimbursement from the LCDBG grant and Clean Water State Revolving Funds. The City should implement policies and procedures to ensure that expenditures are not charged to multiple federal programs. Corrective Action Plan: The City agrees with the finding and has established policies and procedures to ensure that expenditures are only charged to one federal program.
View Audit 305307 Questioned Costs: $1
None necessary – REAC filed January 2024
None necessary – REAC filed January 2024
View Audit 305290 Questioned Costs: $1
Finding 2023‐002 Federal Agency Name: U.S. Department of Health and Human Services Pass‐Through Entity: Federal Financial Assistance Listing 93.423 Assistance Listing Number: 1332 State Innovation Waivers Program Name: Maine Guaranteed Access Reinsurance Association (MGARA) Finding Summary: The Asso...
Finding 2023‐002 Federal Agency Name: U.S. Department of Health and Human Services Pass‐Through Entity: Federal Financial Assistance Listing 93.423 Assistance Listing Number: 1332 State Innovation Waivers Program Name: Maine Guaranteed Access Reinsurance Association (MGARA) Finding Summary: The Association’s existing controls over their IT environment for reviewing and reimbursing carriers for claims was not able to detect and prevent a claim from being reimbursed twice.Corrective Action Plan: The duplicate payment to Aetna was requested back to the program and will be received in April 2024. Going forward, the administrator will run reports at the beginning of each calendar year to ensure that all insurance carrier exception reports are generated. This will ensure that whenever claims are processed that all duplicate claims will be identified and denied. Responsible Individual(s): Diane Kopecky, administrator Anticipated Completion Date: April 2024
Condition and Context: The Housing Authority City of Kennewick's (KHA) audit was performed when the agency was going through a major software accounting conversion. The trial balance conversion had an unexpected delay which caused a delay in submitting financial reports and records to the auditors. ...
Condition and Context: The Housing Authority City of Kennewick's (KHA) audit was performed when the agency was going through a major software accounting conversion. The trial balance conversion had an unexpected delay which caused a delay in submitting financial reports and records to the auditors. The Housing Authority submitted documents requested between the sixth and seventh month after the fiscal year end. Auditors reviewed records submitted on the eighth month after the fiscal year end. This did not allow KHA enough time to upload additional information requested. The audit was not able to be completed by the due date and the report was not submitted to the Federal Clearinghouse which was due nine months after the fiscal year end. Recommendation: The Auditors recommended that the Authority develop a process or a procedure to ensure the preparation year-end financial records and draft financial statements is completed timely to allow sufficient time for the audit of such information to occur prior to all deadlines for audit submission. Plan for Corrective Action: Management addressed the internal control accounting deficiencies by establishing a year-end check list procedure to ensure that the financial statements and records are ready during audit timing. Additionally, now that the software conversion has been completed, management is acquiring a third-party consultant to assist with the accounting reporting settings and clearing up any pending software conversion issues. Actions Taken: KHA is now submitting the audit report to the Federal Clearinghouse as of the date of this report. Management has reached out to a third-party consultant to help clear out pending software issues and to ensure that accounting reports are correct for future audits.
Community Health Services, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: December 31, 2023 The findings from the December 31, 2023 schedule of findings and questioned costs are...
Community Health Services, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: December 31, 2023 The findings from the December 31, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS Section Ill- Federal Award Findings and Questioned Costs Health Center Program Cluster, Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), COVID - 19 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), Grants for New and Expanded Services under the Health Center Program and COVID-19 Grants for New and Expanded Services under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 Item 2023-00.1 - Special Tests Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated based on family size and income. Repeat Finding Yes Action Taken The Center implemented internal controls to mitigate the risk of missing sliding fee discount documentation. The creation of this control consisted of designing a report that would identify all sliding fee discount applicants for the specified timeframe, as well as identify whether supporting documentation had been scanned into the patient's electronic health record. The Director of Development, Grants and Outreach or the Director of Finance and Grants Administration reviews all slide applications before they are scanned and entered into the electronic health record and applied to the patient's account. The Center will continue monthly internal auditing procedures where an Eligibility Specialist haphazardly selects slide applications from the previous month to ensure compliance. As a result of the repeated finding, the Center created an excel template that will accurately calculate and feed the slide result in effort to minimize manual calculation errors. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Dianna Kulmacz, CFO at (860) 808-8765.
Section Ill- Federal Award Findings and Questioned Costs Health Center Program Cluster, Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), COVID - 19 Health Center Program (Community Health Centers, Migrant Health...
Section Ill- Federal Award Findings and Questioned Costs Health Center Program Cluster, Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), COVID - 19 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), Grants for New and Expanded Services under the Health Center Program and COVID-19 Grants for New and Expanded Services under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 Item 2023-001 - Special Tests Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated based on family size and income. Repeat Finding Yes Action Taken In 2023, IHC implemented each IHC site auditing five accounts per front office staff twice per month that will be reviewed by the Office Manager, Practice Manager, and Director of Operations, with any sliding issues being addressed with the respective front office staff with re­ education. As this has not resolved all the sliding fee issues, IHC will be implementing two-person verification for sliding fees provided for any eligible IHC patient. The following process will be followed for EVERY patient that presents with Proof of Income (POI). A. When a patient presents to the clinic and provides POI upon checking in or completing an Intake appointment, the Front Office Staff (FOS) will make a copy of the documents provided. B. The FOS will then calculate the income based on the POI provided, showing the work on the copy. C. The FOS will initial the document where the calculations were completed. D. They will then get a second person to verify the calculations were completed correctly and initial the document. E. The initial FOS employee will enter the information into the SFS section of the pt's chart. F. There will be a FOS SFS Two-Person Verification Log to track who verified each patients POI. G. The FOS SFS Two-Person Verification Log will be kept in the LMT Teams file for each site. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Mr. Tracy Nagel, CFO at (317) 576-1335. Sincerely yours, Mr. Tracy Nagel, Chief Financial Officer
Finding No. 2023-001 Schedule of Expenditures of Federal Awards Personnel Responsible for Corrective Action: Name: Edith Robles Department: Finance Title: Director of Finance Anticipated Completion Date: June 30, 2024 Corrective Action Plan: An adequate system of internal controls will be put in pla...
Finding No. 2023-001 Schedule of Expenditures of Federal Awards Personnel Responsible for Corrective Action: Name: Edith Robles Department: Finance Title: Director of Finance Anticipated Completion Date: June 30, 2024 Corrective Action Plan: An adequate system of internal controls will be put in place by the end of fiscal year 2024. To ensure SEFA will include accurate assisting listing numbers and accurate inclusion of all federal programs. Allowable and unallowable costs will be reviewed to ensure accurate federal expenditure reporting. Edith Robles will perform an exhaustive review of all grants to close out the fiscal year in preparation for the audit process. In addition to these, SWOP will work with a consultant to provide necessary training of finance personnel.
CORRECTIVE ACTION PLAN Auditee: CAAP Housing, Inc. HUD Project Number: 073-11685 Audit Firm: Agresta, Storms & O’Leary PC Audit Period Ended December 31, 2023 Corrective Action Plan Prepared by: Name: Chuck Pechette Position: President, Mark III Management A. Current Findings on ...
CORRECTIVE ACTION PLAN Auditee: CAAP Housing, Inc. HUD Project Number: 073-11685 Audit Firm: Agresta, Storms & O’Leary PC Audit Period Ended December 31, 2023 Corrective Action Plan Prepared by: Name: Chuck Pechette Position: President, Mark III Management A. Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Finding No. 2023-001 A. Comments on the Finding and Each Recommendation: Management agrees with the finding that the security deposit cash account was underfunded at December 31, 2023. B. Action Taken or Planned on the Finding: Management will transfer the required funds to the security deposit cash account when the funds are available. B. Status of Corrective Actions on Findings Reported in the Prior Audit Schedule of Findings, Questioned Costs, and Recommendations See Finding No. 2023-001 for status of Finding No. 2022-001. Respectfully Submitted, Chuck Pechette President Mark III Management
View Audit 305189 Questioned Costs: $1
Finding 395578 (2023-002)
Significant Deficiency 2023
Finding 2023-002 Condition/Context The Corporation used the Lost Revenues Reporting Method: Alternative Reasonable Methodology (Option 3) for measuring lost revenues. In the Corporation's Period 4 submission for Robert Packer Hospital, TIN 24-0795463, total lost revenues were incorrectly reported as...
Finding 2023-002 Condition/Context The Corporation used the Lost Revenues Reporting Method: Alternative Reasonable Methodology (Option 3) for measuring lost revenues. In the Corporation's Period 4 submission for Robert Packer Hospital, TIN 24-0795463, total lost revenues were incorrectly reported as $13,011,879, rather than $12,930,176. Total lost revenues available to be used in this reporting period based on the adjusted amount was $7,142,168 on payments in the period of $7,142,168. This is not a statistically valid sample. Corrective Action Plan Corrective Action Planned: The Corporation agrees with the finding. Management increased the level of review over the lost revenue calculations for future reporting periods. Management did not believe that further corrections to the Period 4 report were necessary as the remaining available lost revenues after adjusting for the error were equal to the payments received in the period and there was no further submissions necessary for Robert Parker Hospital. Name(s) of Contact Person(s) Responsible for Corrective Action: Sean Monahan, Corporate Financial Controller and Fran Macafee, VP, CFO – Guthrie Lourdes Hospital. Anticipated Completion Date: September 30, 2023
Institutional Comments on Findings and Recommendations: Compliance Requirements – Applicable After a Student Begins Attendance: The institution agrees with the auditors on this finding in which there were two (2) cases where the auditors noted that the institution failed to determine that the stud...
Institutional Comments on Findings and Recommendations: Compliance Requirements – Applicable After a Student Begins Attendance: The institution agrees with the auditors on this finding in which there were two (2) cases where the auditors noted that the institution failed to determine that the students withdrew within fourteen (14) days after the student’s last day of attendance. In one (1) of the two (2) cases the Date of Determination was twenty-two (22) days after the Last Day of Attendance and in the second case, the Date of Determination was Three (3) days after the Last Day of Attendance. All funds due to the Department, (for the first case $682.00 of Unsub. Direct Loan funds and in the second case $974.22 of Federal Pell Grant funds), were returned within the forty-five (45) days required timeframe as of the Date of Determination of each case. This process was evidenced to the auditors for their records. Actions Taken or Planned: The institution is fully aware of the Return of Title IV funds (R2T4) reporting requirements and deadlines. The issue related to this finding was identified as a lack in some Faculty notifying student absences within the fourteen (14) day timeframe to process an R2T4 in a timely manner as required. Although this issue was already discussed with them by the Dean of Academic Affairs, an additional follow up meeting would be held to remind them of the importance in monitoring student attendance and notifying student absences to the Registrar office within the required timeframes to fully comply with the R2T4 reporting requirements. Status of Corrective Actions on Prior Findings: The issue as related to this finding occurred in the past audit.
View Audit 305178 Questioned Costs: $1
Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to disbursing loans within aggregate loan limits. Responsible Administrators: Director of Financial Aid Effective: Immediately and ongoing
Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to disbursing loans within aggregate loan limits. Responsible Administrators: Director of Financial Aid Effective: Immediately and ongoing
Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to competing and submitting the audit. The College has a new CFO and Controller. These measures will ensure stability and a timely audit. Responsible Administ...
Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to competing and submitting the audit. The College has a new CFO and Controller. These measures will ensure stability and a timely audit. Responsible Administrators: Director of Financial Aid & Chief Financial Officer Effective immediately and ongoing
Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to calculating and awarding Pell. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid & Chief Fin...
Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to calculating and awarding Pell. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid & Chief Financial Officer Effective: Immediately and ongoing
View Audit 305169 Questioned Costs: $1
Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to over awarding students. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid & Chief Financial ...
Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to over awarding students. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid & Chief Financial Officer Effective: Immediately and ongoing
View Audit 305169 Questioned Costs: $1
Management concurs with this finding. The College will review and adhere to its practices, policies, and procedures along with federal guidelines as it relates to students meeting satisfactory academic progress. The College has an SAP appeal committee in place to enforce and abide by the College's...
Management concurs with this finding. The College will review and adhere to its practices, policies, and procedures along with federal guidelines as it relates to students meeting satisfactory academic progress. The College has an SAP appeal committee in place to enforce and abide by the College's policy. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid Effective: Immediately and ongoing
View Audit 305169 Questioned Costs: $1
Management concurs with this finding. The College will review and adhere to its practices, policies, and procedures along with federal guidelines as it relates to disbursing and administering federal aid. The College will return any ineligible funds accordingly. Responsible Administrators: Direct...
Management concurs with this finding. The College will review and adhere to its practices, policies, and procedures along with federal guidelines as it relates to disbursing and administering federal aid. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid, Chief Financial Officer & V.P. of Academic Affairs Effective: Immediately and ongoing
View Audit 305169 Questioned Costs: $1
Management concurs with this finding. The College will set policies, procedures and practices in place and adhere to ensure that changes in students’ enrollment are reported accurately and timely as defined in the Federal guidelines. Responsible Administrators: Director of Financial Aid & Regist...
Management concurs with this finding. The College will set policies, procedures and practices in place and adhere to ensure that changes in students’ enrollment are reported accurately and timely as defined in the Federal guidelines. Responsible Administrators: Director of Financial Aid & Registrar Effective: Immediately and ongoing
Management concurs with this finding. The College will keep accurate attendance and participation records. The College will calculate R2T4s accurately and will return the funds in a timely manner. The College will review and adhere to its practices, policies, and procedures along with federal gui...
Management concurs with this finding. The College will keep accurate attendance and participation records. The College will calculate R2T4s accurately and will return the funds in a timely manner. The College will review and adhere to its practices, policies, and procedures along with federal guidelines as it relates to R2T4 regulations. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid & Chief Financial Officer Effective: Immediately and ongoing
View Audit 305169 Questioned Costs: $1
Finding 395409 (2023-002)
Significant Deficiency 2023
Person Responsible: Chief Operating Officer, Deirdre Bagley, will coordinate with the finance team Implementation Date: By August 30, 2024 Management’s response: In response to the recommendation that the Organization properly apply allowed indirect cost rates across its Federal awards, we concur wi...
Person Responsible: Chief Operating Officer, Deirdre Bagley, will coordinate with the finance team Implementation Date: By August 30, 2024 Management’s response: In response to the recommendation that the Organization properly apply allowed indirect cost rates across its Federal awards, we concur with the recommendation and are in the process of creating a single, succinct schedule and the supporting documentation on indirect cost rates and rationale to allow the auditors to easily verify that the costs have been charged appropriately.
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