Corrective Action Plans

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Condition - During the compliance testing of the Uniform Guidance "Special Tests and Provisions - Sliding Fee Discounts" two (2) selections out of a sample size of twenty-five (25) did not obtain proper proof of income prior to applying the sliding fee discount. In addition, two (2) selections out ...
Condition - During the compliance testing of the Uniform Guidance "Special Tests and Provisions - Sliding Fee Discounts" two (2) selections out of a sample size of twenty-five (25) did not obtain proper proof of income prior to applying the sliding fee discount. In addition, two (2) selections out of a sample size of twenty-five (25) used the incorrect calculation of income from the proof of income and applied the incorrect sliding fee. Plan - Management will ensure that all information is collected and input into the billing system correctly in order to avoid patients getting charged incorrect amounts for services. Anticipated Date of Completion - March 31, 2024. Name of Contact Person - Lori Sanson, CFO. Management's Response - Management is implementing weekly chart auditing of encounters from the prior week. These reviews will include a review of the client's financial information which includes assessment of the sliding fee scale paperwork completed, whether we have obtained proof of income, if the sliding fee was entered into the billing system, if the sliding fee adjustments are applied, if payment was collected, insurance information, and the client's balance. These audits will be sent to front office staff for corrections (if needed) or the CFO for review on a monthly basis. In addition, MCPHD billing supervisors will be obtain a weekly report of client's that have not turned in proof of income in order to proactively reach out and attempt to obtain the information.
2023-002 Special Rest; Graduation Cohort Recommendation: We recommend that the schools develop internal controls and procedures to ensure the documentation is consistently maintained to support compliance with grantor’s requirements. Action planned/taken in response to finding: 1. City Schools will ...
2023-002 Special Rest; Graduation Cohort Recommendation: We recommend that the schools develop internal controls and procedures to ensure the documentation is consistently maintained to support compliance with grantor’s requirements. Action planned/taken in response to finding: 1. City Schools will draft guidance to schools reminding them of their obligation to maintain documentation for all student transfers as per the MSDE Student Records Manual, P.32. The initial guidance will remind schools that all documentation needs to be saved as part of a student’s transfer packet. For SY24-25, the guidance will be updated to instruct schools to save all transfer requests in Person Documents in Infinite Campus (IC). This will be a collaboration between the Office of Achievement and Accountability (OAA) and the Schools Office. 2. City Schools will create a new data cleansing report (DCR) to ensure that all transfer codes entered in Infinite Campus have transfer documentation uploaded to IC to support the transfer request. The above guidance will be shared with schools as part of the launch of the new DCR report in SY24-25. This will be a collaboration between OAA and the Office of Information Technology (OIT). 3. City Schools’ School Managers will monitor the new DCR to ensure schools are uploading documentation for every transfer into IC. Name(s) of the contact person(s) responsible for corrective action: Holly Bedwell (OAA) and Sabree Barnes (Schools Office) Planned completion date for corrective action plan: September 9, 2024.
2023-003 Allowable Cost- Payroll Recommendation We recommend that the schools develop internal controls and procedures to ensure the documentation is consistently maintained and readily available to support compliance with grantor’s requirements. Explanation of disagreement with audit finding: There...
2023-003 Allowable Cost- Payroll Recommendation We recommend that the schools develop internal controls and procedures to ensure the documentation is consistently maintained and readily available to support compliance with grantor’s requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: 1. Requirements to support documentation of payroll expenditures will be reviewed with school staff annually as part of grant support visits, resource materials provided and other technical assistance sessions. 2. As part of Spring 2024 site visits to be completed prior to June 30, 2024, Title I specialists will review with school staff requirements for documentation to support payroll expenditures using Title I funds. Documentation of stipend and temporary staff payroll will be collected and saved in the school’s grant monitoring folder. This activity will also occur in September 2024 for summer stipend/temp staff payments. 3. Charter schools utilizing Title II and/or Title IV funds will continue to participate in twice annual monitoring by the Office of Data Monitoring and Compliance to review support documentation for any stipend/temporary staff payments. 4. Schools leveraging ESSER funds in SY23/24 for stipend/temporary staff payments will be requested to upload support documentation to a district established SharePoint site prior to June 30, 2024. 5. By April 30, 2024 requirements for payroll expenditure documentation will be reviewed with district offices implementing grant funded district initiatives. These meetings include Title I, Title II, Title III, Title IV, Perkins and COVID relief grant funds. All district offices will be required to save support documentation for stipend and temporary staff payments for district level and/or district coordinated activities to a SharePoint folder to ensure accessibility for future monitoring activities. The district staff person from the Office of Data Monitoring and Compliance assigned to support the federal grant will review uploaded materials to ensure the documentation supports payroll expenditures. Name(s) of the contact person(s) responsible for corrective action: Kimberly Hoffmann Planned completion date for corrective action plan: June 2024.
View Audit 305063 Questioned Costs: $1
Action item - Title 2023-001 – Updated Information Report Date Identified: March 2023 Status: (Open; In-process) Corrected Description: The University failed to upload the financial report related to the quarter ended March 31, 2023, within the ten days provided by the Department of Education. Grant...
Action item - Title 2023-001 – Updated Information Report Date Identified: March 2023 Status: (Open; In-process) Corrected Description: The University failed to upload the financial report related to the quarter ended March 31, 2023, within the ten days provided by the Department of Education. Grantee Required Action: Upload required reports before due date. Follow up with all service providers to ensure compliance with federal compliance requirements. Identified Root Cause: The University administration did not properly oversee the website’s administrator’s compliance process, which failed to meet the required guidelines and regulations by the scheduled deadline. Grantee resolution plan: Once the reports are sent to the person in charge of uploading the information to the institution's website, they will be followed up to corroborate that the task is completed and the institution is in compliance with all agencies. In addition, a copy of the report will be sent to the Department before the due date. Completion date: March 2023 Name and Title of contact person responsible for corrective action: Pablo Salom Portela- Director, Federal and State Funds Administration Office Phone: 787-622-8000 ext. 683 Email: psalom@pupr.edu
U.S. Department of Housing and Urban Development (“HUD”) Norwood Life Society respectfully submits the following corrective action plan for the year ended December 31, 2023. Audit period: January 1, 2023 – December 31, 2023 The findings from the schedule of findings and questioned costs are discusse...
U.S. Department of Housing and Urban Development (“HUD”) Norwood Life Society respectfully submits the following corrective action plan for the year ended December 31, 2023. Audit period: January 1, 2023 – December 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 Department of Housing and Urban Development 2023-001 Mortgage Insurance_Nursing Homes, Intermediate Care Facilities, Board and Care Homes and Assisted Living Facilities – Assistance Listing No. 14.129 Recommendation: We recommended to Management that they continue to monitor related party transactions and request prior approval before any advances are made or considered to be made in support of other related parties in the future. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Rick Steffens, the CFO, will oversee this plan, and the plan has been implemented and fully resolved. The unauthorized loan was due to an increasing intercompany balance due from an affiliated nursing home (“Bethesda”) who was losing money and unable to reimburse Norwood Crossing for shared bills for items including benefits and insurance. Due to the size of the losses, we realized this issue was unable to be resolved without disposing of Bethesda and began working on selling Bethesda in the second quarter of 2022. Bethesda was supposed to close on the sale on November 30, 2022, which would have solved the intercompany issue during the 2022 audit year, which was our plan. However, the sale was continuously delayed due to numerous serious issues pushing the actual sale date all the way back to July 1, 2023. The audit finding for the unauthorized intercompany loan was for $1,724,731.69, and was a finding on the 2022 audit. However, the intercompany balance continued to grow in 2023 and had an additional $574,583.86 of expenses that built up in 2023 before the sale occurred. This made a grand total of $2,299,315.55 that needed to be repaid from Bethesda to Norwood Crossing for the unauthorized intercompany loans through the sale date. Bethesda worked to repay the intercompany loans the best it could during 2023 before the sale occurred, and completely paid down the remaining balance on the unauthorized intercompany loans shortly after the sale of Bethesda occurred. The following payments were made from Bethesda to Norwood Crossing: Payment Dates Payment Amounts 5/8/2023 $675,000.00 5/23/2023 $350,000.00 7/17/2023 $1,274,315.55 Total $2,299,315.55 These repayments above fully resolved the unauthorized intercompany loans that were 1) in the 2022 Audit as a finding, 2) increases that occurred in 2023 after the 2022 year end, and 3) the resolutions occurred before the 2022 audit was issued and only are a finding in the 2023 audit because the loans were not fully paid off as of 2022. Furthermore, Bethesda has officially been sold as of July 1, 2023 and is no longer causing this issue to continue to occur going forward. Name(s) of the contact person(s) responsible for corrective action: Rick Steffens Planned completion date for corrective action plan: July 17, 2023 If the Oversight Agency for Audit has questions regarding this plan, please call Rick Steffens at 773-577-5334.
View Audit 305038 Questioned Costs: $1
Condition: Obligations were overstated by approximately $800,000 on the March 31, 2023 Project and Expenditure report. Corrective Action Planned: Will adjust on March 31, 2024 Project and Expenditure report. Anticipated Completion Date: April 30, 2024 Contact: Nicole Pearsall, Town Accountant
Condition: Obligations were overstated by approximately $800,000 on the March 31, 2023 Project and Expenditure report. Corrective Action Planned: Will adjust on March 31, 2024 Project and Expenditure report. Anticipated Completion Date: April 30, 2024 Contact: Nicole Pearsall, Town Accountant
Since taking over the financial management of ELFHCC in December 2022, the sliding fee schedule policy has been updated and training has been implemented and ongoing to assure accurate sliding fee discounts are appropriately distributed onto a patient’s account. Check lists of what is required from ...
Since taking over the financial management of ELFHCC in December 2022, the sliding fee schedule policy has been updated and training has been implemented and ongoing to assure accurate sliding fee discounts are appropriately distributed onto a patient’s account. Check lists of what is required from each patient applying for a sliding fee discount have been prepared and staff trained on how to enter the proof requirement into ELFHCC’s patient record
Since taking over the financial management of ELFHCC in December 2022 we have reorganized the financial reporting process and have been able to ensure meaningful analysis on a regular and continual basis. Policies and procedures have been created, changed, updated and Board approved. All financial r...
Since taking over the financial management of ELFHCC in December 2022 we have reorganized the financial reporting process and have been able to ensure meaningful analysis on a regular and continual basis. Policies and procedures have been created, changed, updated and Board approved. All financial reporting is prepared, analyzed and presented each month without delay.
Management’s Response/Corrective Action Plan: Discrepancies noted above are due to the timing of transactions posting in the accounting system where period transactions are not posted until after the data is gathered for the report or even after the reporting period, but still has an effective dat...
Management’s Response/Corrective Action Plan: Discrepancies noted above are due to the timing of transactions posting in the accounting system where period transactions are not posted until after the data is gathered for the report or even after the reporting period, but still has an effective date within the period, so it is not picked up when reports are filed. They are corrected in the following quarterly report. For TRUCK/LFVNT, the amounts were correct but just not in the period reported, and were corrected in subsequent reports. We can try to have another person duplicate the calculation of amounts for the reporting, which will depend on staffing level and time of year. The reporting site is also difficult and in order to be able to file on time, we really need to start mid-month to make sure it’s working and allow time for contacting the helpdesk to resolve any technical issues.
Management’s Response/Corrective Action Plan: The School Department has had turnover in positions that have had oversight and direct involvement in this process. In some cases, the established process was followed as constructed; however, in others, gaps in coverage are clearly exposed. The School D...
Management’s Response/Corrective Action Plan: The School Department has had turnover in positions that have had oversight and direct involvement in this process. In some cases, the established process was followed as constructed; however, in others, gaps in coverage are clearly exposed. The School Department agrees that the management of important documents has been inconsistent. In the future, the School Department will be assigning the management of these documents to positions where turnover is less likely to occur and a more consistent process is maintained.
Management’s Response/Corrective Action Plan: The School Department has had turnover in positions that have had oversight and direct involvement in this process. In some cases, the established process was followed as constructed; however, in others, gaps in coverage are clearly exposed. The School D...
Management’s Response/Corrective Action Plan: The School Department has had turnover in positions that have had oversight and direct involvement in this process. In some cases, the established process was followed as constructed; however, in others, gaps in coverage are clearly exposed. The School Department agrees that the management of important documents has been inconsistent. In the future, the School Department will be assigning the management of these documents to positions where turnover is less likely to occur and a more consistent process is maintained.
The City will ensure all contactors of federal funds are not suspended or debarred in accordance with federal guidelines, including adding a clause to federal contracts. The City will also follow its procurement policy and ensure all contractor have a proper procurement.
The City will ensure all contactors of federal funds are not suspended or debarred in accordance with federal guidelines, including adding a clause to federal contracts. The City will also follow its procurement policy and ensure all contractor have a proper procurement.
View Audit 305002 Questioned Costs: $1
CORRECTIVE ACTION PLAN (UNAUDITED) Name of Auditee: Union Congregational Church Homes, Phase II, Inc. HUD Project No.: 023-EH217 Audit Firm: Kahn, Litwin, Renza & Co., Ltd. Period Covered by the Audit: Year ended December 31, 2023 Corrective Action Plan Prepared By: Name: Ronald Gates Position: Exec...
CORRECTIVE ACTION PLAN (UNAUDITED) Name of Auditee: Union Congregational Church Homes, Phase II, Inc. HUD Project No.: 023-EH217 Audit Firm: Kahn, Litwin, Renza & Co., Ltd. Period Covered by the Audit: Year ended December 31, 2023 Corrective Action Plan Prepared By: Name: Ronald Gates Position: Executive Director Telephone No.: (781) 335-2667 A. Current Findings on the Schedule of Findings and Questioned Costs Finding 2023-001: Replacement Reserve Deposits a. Comments on Finding and Recommendations: Management concurs with the finding and agrees with the recommendation. b. Actions Taken or Planned: Management concurs with the finding and a deposit of $6,428 was made to the replacement reserve account on February 21, 2024 to correct the underfunding. Supporting documentation for the deposit to the replacement reserve account will be furnished to HUD upon request. Name of Responsible Person: Ronald Gates, Executive Director Projected Implementation Date: February 21, 2024
View Audit 304991 Questioned Costs: $1
Identifying Number: Finding No. 2023-003: Documentation of Internal Controls Internal Control over Compliance Material Weakness Finding: Audit procedures noted controls identified by management over material compliance requirements lacked sufficient documentation to conclude application of contro...
Identifying Number: Finding No. 2023-003: Documentation of Internal Controls Internal Control over Compliance Material Weakness Finding: Audit procedures noted controls identified by management over material compliance requirements lacked sufficient documentation to conclude application of controls is in place. Corrective Actions Taken or Planned: Responsible Official: T.J. Snowden (Director of Financial Aid), Walter Brown (CFO) Anticipated Completion Date: 05/30/2024 View of Responsible Individuals: Management agrees with the assessment and the finding. Management will identify what controls need to be in place to ensure federal compliance requirements for Student Financial Aid are in place. These controls will include manual or electronic signoff to exhibit proper execution of controls.
Identifying Number: Finding No. 2023-002: Special Tests – Enrollment Reporting and Gramm-Leach-Bliley Act Compliance/Material Weakness Finding: Instances of noncompliance have been identified around major compliance requirements Enrollment Reporting and Gramm-Bleach-Bliley Act, which are both part...
Identifying Number: Finding No. 2023-002: Special Tests – Enrollment Reporting and Gramm-Leach-Bliley Act Compliance/Material Weakness Finding: Instances of noncompliance have been identified around major compliance requirements Enrollment Reporting and Gramm-Bleach-Bliley Act, which are both part of special tests identified in the 2023 Compliance Supplement. ¬ Corrective Actions Taken or Planned: Responsible Official: Iman Riddick, Registrar, Dean Lane, Chief Information Officer (CIO) Anticipated Completion Date: 06/30/2024 View of Responsible Individuals: Management agrees with the assessment and finding. Dean Lane, CIO, will review the annual updates to the Student Financial Assistance Cluster within the OMB Compliance Supplement to ensure the Institute has policies, procedures, and controls in place for all required compliance requirements. For the noncompliance identified around the Gramm-Leach Bliley Act, the Institute will ensure compliance by establishing a formal written policy that will be created by Dean Lane, CIO, that addresses all required elements for a written information security program listed in the OMB Compliance Supplement. The CFO will review the policy once completed to ensure all required elements within the Compliance Supplement are included. For the noncompliance identified around the Enrollment Reporting special test, the Institute plans to have the Registrar attend comprehensive trainings around enrollment reporting offered by the National Student Clearinghouse (NSC) to further educate and enhance their understanding around the enrollment reporting compliance requirement. In addition, the Institute will have each month’s enrollment data submission by the Registrar to the National Student Clearinghouse reviewed by the Director of Financial Aid to verify completeness, accuracy, and timeliness of reporting. This will allow the Institute to correct any inaccurate reporting and verify timely submissions.
Based on the review of utility rate data during FY24, the utility allowance schedule was updated and approved by the Board of Commissioners in February 2024.
Based on the review of utility rate data during FY24, the utility allowance schedule was updated and approved by the Board of Commissioners in February 2024.
Each caseworker has been issued an admin plan and refer to it often. Staff has been made aware that an increase in rent must be issued a 30 day notice. If the tenant rent decreases, the decrease is to take effect immediately. Administrator is also auditing files to help alleviate any errors.
Each caseworker has been issued an admin plan and refer to it often. Staff has been made aware that an increase in rent must be issued a 30 day notice. If the tenant rent decreases, the decrease is to take effect immediately. Administrator is also auditing files to help alleviate any errors.
Administrator will review with staff agency Administrative Plan in accordance to CFR 982.2(b) in regards to policies and procedures for application documentation of preferences.
Administrator will review with staff agency Administrative Plan in accordance to CFR 982.2(b) in regards to policies and procedures for application documentation of preferences.
This finding is related to activities on our Legal Services Corporation Basic Field Grant. For each new employee added to our organization, our onboarding process includes a requirement of a signed priority statement be placed in our employee’s personnel file. FRLS has also implemented a checklist o...
This finding is related to activities on our Legal Services Corporation Basic Field Grant. For each new employee added to our organization, our onboarding process includes a requirement of a signed priority statement be placed in our employee’s personnel file. FRLS has also implemented a checklist of required documentation before every case closure to be reviewed by the Regional Managing Attorneys and Advocacy Director. This includes the required priority statement Upon closure of a case file, the assigned advocate and Regional Managing Attorney will then attest that a case file contains all necessary documentation for compliance. A review of the checklist and case files will be done by the Advocacy Director on a regular basis to ensure compliance. FRLS will undertake a review of this process to ensure that we are in compliance with priority statements for employees involved with cases or other matters. This review will be completed within the next 90 days.
This finding is related to activities on our VOCA grants. As was the case in Finding #005, the majority of the exceptions were related to either finding #2 above or were related to the process in place prior to May 2023. Again, in May 2023 FRLS added an electronic transaction approval process via te...
This finding is related to activities on our VOCA grants. As was the case in Finding #005, the majority of the exceptions were related to either finding #2 above or were related to the process in place prior to May 2023. Again, in May 2023 FRLS added an electronic transaction approval process via teams, that documents approvals for all our AP, AR and other transactions initiated by our accounting staff. These are reviewed and approved by the CFO before being posted into the GL. It was also noted that our process of allocating costs from our overhead cost centers to our various grants, was not fully documented. The CFO will undertake a review of this process to ensure that we are in compliance with allowable cost documentation requirements. We will also review and update our documentation of allocations and ensure that each month’s allocation is properly approved. This review will be completed within the next 90 days.
View Audit 304969 Questioned Costs: $1
FRLS shared that as part of the corrective action plan, improved PAI services by changing pro bono coordinators from paralegals to attorneys to better work with private attorneys and respective bar associations throughout our service areas. FRLS has also reestablished connections with our respective...
FRLS shared that as part of the corrective action plan, improved PAI services by changing pro bono coordinators from paralegals to attorneys to better work with private attorneys and respective bar associations throughout our service areas. FRLS has also reestablished connections with our respective service partners throughout the pandemic, rebuilding and providing excellent services through our pro bono partners. PAI remains one of our top priorities in expanding our program services. Our program improvements, including pro bono assistance via virtual and courthouse clinics have resulted in more PAI services to our client communities. We have increased attendance at our annual bench and bar events to raise PAI awareness in our service communities. FRLS is in the process of creating a “low bono” program to expand our network of private attorneys and meet our required 12.5% spending requirement. FRLS will continue to evaluate its policies and procedures surrounding monitoring of PAI compliance to ensure that only allowable pro bono cases are accepted. This will be completed by December 31, 2024.
Upon review, FRLS had retainer agreements for both of the exceptions listed, but they were not readily available for review. FRLS has implemented a checklist of required documentation before every case closure to be reviewed by the Regional Managing Attorneys and Advocacy Director. Upon closure of a...
Upon review, FRLS had retainer agreements for both of the exceptions listed, but they were not readily available for review. FRLS has implemented a checklist of required documentation before every case closure to be reviewed by the Regional Managing Attorneys and Advocacy Director. Upon closure of a case file, the assigned advocate and Regional Managing Attorney will then attest that a case file contains all necessary documentation for compliance. A review of the checklist and case files will be done by the Advocacy Director on a regular basis to ensure compliance.
This finding is related to activities on our VOCA grants. As was the case in Finding #004, the majority of the exceptions were related to either finding #2 above or were related to the process in place prior to May 2023. Again, in May 2023 FRLS added an electronic transaction approval process via te...
This finding is related to activities on our VOCA grants. As was the case in Finding #004, the majority of the exceptions were related to either finding #2 above or were related to the process in place prior to May 2023. Again, in May 2023 FRLS added an electronic transaction approval process via teams, that documents approvals for all our AP, AR and other transactions initiated by our accounting staff. These are reviewed and approved by the CFO before being posted into the GL. It was also noted that our process of allocating costs from our overhead cost centers to our various grants, was not fully documented. The CFO will undertake a review of this process to ensure that we are in compliance with allowable cost documentation requirements. We will also review and update our documentation of allocations and ensure that each month’s allocation is properly approved. This review will be completed within the next 90 days.
This finding is related to activities in our Legal Services Basic Field Grant. In reviewing the testing for this finding, the majority of the exceptions were related to either finding #2 above or were related to the process in place prior to May 2023. Again, in May 2023 FRLS added an electronic tran...
This finding is related to activities in our Legal Services Basic Field Grant. In reviewing the testing for this finding, the majority of the exceptions were related to either finding #2 above or were related to the process in place prior to May 2023. Again, in May 2023 FRLS added an electronic transaction approval process via teams, that documents approvals for all our AP, AR and other transactions initiated by our accounting staff. These are reviewed and approved by the CFO before being posted into the GL. The CFO will undertake a review of this process to ensure that we are in compliance with allowable cost documentation requirements. This review will be completed within the next 90 days.
View Audit 304969 Questioned Costs: $1
Prior to 2018, obtaining the simple agreement, when required by LSC regulations, was the responsibility of the managing attorney for the unit or office. In 2018, this responsibility was transferred to the Human Resources Administrator to ensure this document and others were timely obtained and place...
Prior to 2018, obtaining the simple agreement, when required by LSC regulations, was the responsibility of the managing attorney for the unit or office. In 2018, this responsibility was transferred to the Human Resources Administrator to ensure this document and others were timely obtained and placed in the employee’s personal file. Based on these findings, all current employees, for whom a simple agreement was not in the personnel file, were required to sign the agreement or submit a copy of the agreement they previously signed. All current employees, required to sign the simple agreement, have one on file. Human Resources will continue to obtain the agreements as part of the new employee onboarding process.
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