Corrective Action Plans

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Contact Person Brent Tucker, Interim Executive Director Corrective Action Plan Management has implemented a new software program that provides rent reasonableness documentation. Staff have been trained on the proper way to utilize the software and are also now aware of when to run a rent reasonablen...
Contact Person Brent Tucker, Interim Executive Director Corrective Action Plan Management has implemented a new software program that provides rent reasonableness documentation. Staff have been trained on the proper way to utilize the software and are also now aware of when to run a rent reasonableness comparison. Planned Completion Date for CAP March 1, 2024
Identifying #: 2023-001 and 2023-004 Finding: The finding refers to a number of adjustments to the SEFA and SESA as originally provided by the Town of Greenwich. Fifteen (15) federal programs and five (5) state programs required adjustments to the reported expenditures. Two (2) programs included o...
Identifying #: 2023-001 and 2023-004 Finding: The finding refers to a number of adjustments to the SEFA and SESA as originally provided by the Town of Greenwich. Fifteen (15) federal programs and five (5) state programs required adjustments to the reported expenditures. Two (2) programs included on the SEFA did not have assistance listing numbers, which resulted in the programs being reported as being from the incorrect oversight agency. One program was missing from the SEFA. One program was reported as a state program that was a passthrough of a federal program. The SEFA and SESA balances are required to be reconciled to the basic financial statements prepared in accordance with generally accepted accounting principles in the United States (U.S. GAAP). The Town has failed to adequately perform such reconciliation. Corrective Actions Taken or Planned: Due to a large turnover rate at the Greenwich Public Schools over recent years in key positions, a lack of adequate oversight existed. The Town’s Finance Department was working with the new Chief Operations Officer (COO) at the Greenwich Public Schools and was in the process of assuming more responsibility and oversight in the reconciliation of the SEFA and SESA to the Town’s financial systems (MUINIS). Unfortunately, the staff turnover continues, and the new COO has resigned leaving another potential void in accurate accounting and reporting. The Town Finance Department is still striving to centralize grants accounting to ensure proper accounting and reporting. Name and Phone # of Person Responsible for Implementation:Mr. Peter Mynarski, Comptroller 203-622-2226
Management will deposit $14,004 into the reserve for replacement account unless a retroactive suspension of deposits is granted.
Management will deposit $14,004 into the reserve for replacement account unless a retroactive suspension of deposits is granted.
View Audit 303128 Questioned Costs: $1
Finding Number: 2023-01 Bank Reconciliations Condition: As of June 30, 2023, the University had only completed bank reconciliations and approvals through October 2022. Planned Corrective Action: The University concurs with the finding and has already remedied the condition and bank reconciliations...
Finding Number: 2023-01 Bank Reconciliations Condition: As of June 30, 2023, the University had only completed bank reconciliations and approvals through October 2022. Planned Corrective Action: The University concurs with the finding and has already remedied the condition and bank reconciliations are now current and being completed and reviewed on a monthly basis. Contact person responsible for corrective action: Crystal Wilcox, Director of Finance Completion Date: October 10, 2023
Special Education Cluster – Assistance Listing No. 84.027 & 84.173 Recommendation: We recommend the District reviews its procedures and controls over procurement to ensure that all procurements are documented such that a third party can clearly see and understand the detailed history of the procurem...
Special Education Cluster – Assistance Listing No. 84.027 & 84.173 Recommendation: We recommend the District reviews its procedures and controls over procurement to ensure that all procurements are documented such that a third party can clearly see and understand the detailed history of the procurement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will work with their departments utilizing federal dollars to ensure the proper procurement method is utilized for all procurements and that documentation of that process is retained so its clear what considerations were made in the procurement decision. Name of the contact person responsible for corrective action: Shari Thompson Planned completion date for corrective action plan: June 30, 2024.
View Audit 303104 Questioned Costs: $1
Finding 392742 (2023-001)
Significant Deficiency 2023
Finding 2023-001 - Mortgage Insurance for the Purchase or Refinancing of Existing #14.155 Concur or Do Not Concur with this Finding Concur Agree or Disagree with auditor recommendations Agree Completion Date or Proposed Completion Date March 31, 2024 Actions Taken or Planned on the Finding Managemen...
Finding 2023-001 - Mortgage Insurance for the Purchase or Refinancing of Existing #14.155 Concur or Do Not Concur with this Finding Concur Agree or Disagree with auditor recommendations Agree Completion Date or Proposed Completion Date March 31, 2024 Actions Taken or Planned on the Finding Management will either get HUD approval or refund the distributions made. Contact Person First Name Dawn Contact Person Last Name Cole
Finding 2023-001 - Supportive Housing for the Elderly, AL # 14.157 Concur or Do Not Concur with this Finding Concur Agree or Disagree with auditor recommendations Agree Completion Date or Proposed Completion Date January 5, 2024 Actions Taken or Planned on the Finding Management has refunded the dis...
Finding 2023-001 - Supportive Housing for the Elderly, AL # 14.157 Concur or Do Not Concur with this Finding Concur Agree or Disagree with auditor recommendations Agree Completion Date or Proposed Completion Date January 5, 2024 Actions Taken or Planned on the Finding Management has refunded the distribution made in error. Contact Person First Name Dawn Contact Person Last Name Cole
The District will implement a process to track the submission time of the data collection form and audit package.
The District will implement a process to track the submission time of the data collection form and audit package.
Finding Number: 2023-001, 2022-001, 2021-001: Material Weakness and Material Noncompliance - Sliding Fee Recommendation: We recommend that sliding fee applications be completed for each sliding fee patient. Procedures should be implemented to verify applications are completed before the encounter i...
Finding Number: 2023-001, 2022-001, 2021-001: Material Weakness and Material Noncompliance - Sliding Fee Recommendation: We recommend that sliding fee applications be completed for each sliding fee patient. Procedures should be implemented to verify applications are completed before the encounter is billed. Sliding fee discounts per policy should be agreed in the billing system to ensure the proper discounts are entered and updated. In addition, the Center could consider increasing its internal sampling throughout the year to verify sliding fee applications are obtained, completed, and agree to the discount applied. Action Taken: CHASS management concurs with the audit finding and will put the following corrective action plan in place to mitigate this finding in the future: During Sliding Fee Testing it was found that the actual charge to patient (after slidingfee applied) did not match the actual discount that patient should have had. We have reviewed all process on how EPIC loads up charges (table with applied slidingfee tiers) and found that no one had a master list of the charges, when Billing requests a CPT to be added they just go to accounting and gets added as well as when they request changes on charges for CPT code. There is not one set of approved CPT charges/discount creating discrepancies in patients accounts. In response to these audit findings, CHASS has developed and implemented a comprehensive series of improvements. First, implementation of key improvements involves the implementation of a one person only authorized to request changes on table of charges to EPIC. Second, implementation of a verification process for every patient receiving a sliding fee discount. To achieve this, the Center's Customer Service team now generates personalized labels for each eligible patient and cross-checks their entries by the end of each day. This process ensures each item is diligently reviewed to ensure if any errors are made within this process they are rectified immediately via a Supervisor/Team Leader. Through this process the Supervisor/Team Leader now conducts a second review of the labels to ensure accuracy of the Center's labeling system for each patient utilizing the sliding scale discount program. This review also includes the actual charges on EPIC and Discount being verified with CPI Tables. Third implementation, the Center's Billing Department is now responsible for performing regular weekly audits. During these audits, the Billing Department will now randomly select five claims with sliding fee discounts and examine the applied fees and the corresponding discounts applied to the patient's account (using the approved CPT Table). Through these improvements CHASS aims to ensure that the Sliding Fee Discount Policy is used accurately and appropriately. These methods have been incorporated into the Center's Sliding Fee Discount Policy to guarantee their utilization and accuracy, and to further strengthen the Center's initiatives in providing access to needed health care services. Responsible Parties: Angela Salgado, Chief Operating Officer
2023-001 — Late Submission of the Annual Federal Reporting Package Corrective Action: The City has successfully filled the critical vacancies in the accounting department and is looking to add one additional position before the end of the fiscal year. To address the need for financial reporting cont...
2023-001 — Late Submission of the Annual Federal Reporting Package Corrective Action: The City has successfully filled the critical vacancies in the accounting department and is looking to add one additional position before the end of the fiscal year. To address the need for financial reporting continuity, the City will cross-train accounting personnel to help ensure all financial reporting duties, including the preparation of capital asset records, are adequately covered. This will help ensure that the annual federal reporting package is completed and submitted within nine months after the end of the audit period. Person Responsible: Michael Anne Antonucci, Clerk/Treasurer Estimated Completion Date: March 31, 2024
The River Valley Board of Education acknowledges that the Federal government requires school districts to get approval for any purchases with a unit cost of $5,000 or more from the federal awarding agency or pass-through entity. The Board and Administration have implemented processes and procedures,...
The River Valley Board of Education acknowledges that the Federal government requires school districts to get approval for any purchases with a unit cost of $5,000 or more from the federal awarding agency or pass-through entity. The Board and Administration have implemented processes and procedures, which require approval from both the awarding agency or pass-through entity and the Board of Education prior to purchasing any unit at or above the $5,000 threshold.
View Audit 302921 Questioned Costs: $1
March 26, 2024 Healthcare Account Executive U.S. Department of Housing and Urban Development 451 7th Street, S.W. Washington, DC 20410 Mississippi Methodist Senior Services, Inc. respectfully submits the following corrective action plan for Hattiesburg Area Senior Services, Inc. (the "Company") ...
March 26, 2024 Healthcare Account Executive U.S. Department of Housing and Urban Development 451 7th Street, S.W. Washington, DC 20410 Mississippi Methodist Senior Services, Inc. respectfully submits the following corrective action plan for Hattiesburg Area Senior Services, Inc. (the "Company") for the year ended December 31, 2023. The Correction Plan was necessitated by findings reported by the independent public accounting firm of: HORNE LLP 661 Sunnybrook Road Suite 100 Ridgeland, MS 39157 Current Findings on the Schedule of Findings and Questioned Costs Audit Finding #2023-001 / ALN 14.157 – Equal Housing Opportunity Logo Auditors Recommendation: HORNE recommends that all current marketing materials without the equal housing opportunity logo be corrected and any future materials produced include the equal housing opportunity logo. Action Taken: To be cost effective, the current video advertisements are run for a period of time and then updated when the commercial run has ended. Controls have been put in place to ensure the logo is placed on all future marketing materials, especially commercial advertisements. Status of Corrective Actions on the Schedule of Prior Year Audit Findings Audit Finding #2022-001 / ALN 14.157 – Equal Housing Opportunity Logo Action Taken: To be cost effective, the current video advertisements are run for a period of time and then updated when the commercial run has ended. Controls have been put in place to ensure the logo is placed on all future marketing materials, especially commercial advertisements. Should you need anything further or have any questions regarding management's plan of correction response, you may contact me at Mississippi Methodist Senior Services, Inc. (662-844-8977) or by email at jim.zuelzke@mss.org. Sincerely, Jim Zuelzke, CFO Mississippi Methodist Senior Services, Inc.
March 26, 2024 Healthcare Account Executive U.S. Department of Housing and Urban Development 451 7th Street, S.W. Washington, DC 20410 Mississippi Methodist Senior Services, Inc. respectfully submits the following corrective action plan for Lauderdale Senior Services, Inc. (the "Company") for th...
March 26, 2024 Healthcare Account Executive U.S. Department of Housing and Urban Development 451 7th Street, S.W. Washington, DC 20410 Mississippi Methodist Senior Services, Inc. respectfully submits the following corrective action plan for Lauderdale Senior Services, Inc. (the "Company") for the year ended December 31, 2023. The Correction Plan was necessitated by findings reported by the independent public accounting firm of: HORNE LLP 661 Sunnybrook Road Suite 100 Ridgeland, MS 39157 Current Findings on the Schedule of Findings and Questioned Costs Audit Finding #2023-001 / ALN 14.155 – Equal Housing Opportunity Logo Auditors Recommendation: HORNE recommends that all current marketing materials without the equal housing opportunity logo be corrected, and any future materials produced include the equal housing opportunity logo. Action Taken: To be cost effective, the current video advertisements are run for a period of time and then updated when the commercial run has ended. Controls have been put in place to ensure the logo is placed on all future marketing materials, especially commercial advertisements. Status of Corrective Actions on Findings on the Schedule of Prior Year Audit Schedule of Findings and Questions Costs Audit Finding #2022-001 / ALN 14.155 – Equal Housing Opportunity Logo Action Taken: To be cost effective, the current video advertisements are run for a period of time and then updated when the commercial run has ended. Controls have been put in place to ensure the logo is placed on all future marketing materials, especially commercial advertisements. Should you need anything further or have any questions regarding management's plan of correction response you may contact me at Mississippi Methodist Senor Services, Inc. (662-844-8977) or by email at jim.zuelzke@mss.org. Sincerely, Jim Zuelzke, CFO Mississippi Methodist Senior Services, Inc.
Management fees and bookkeeping fees for the year ended December 31, 2023 were overpaid. By $120. Management repaid the $120 on 04/04/2024 by deducting $120 from the management fee for April. Name and Title of contact person responsible for corrective action: Steve Colella, Making a Difference in ...
Management fees and bookkeeping fees for the year ended December 31, 2023 were overpaid. By $120. Management repaid the $120 on 04/04/2024 by deducting $120 from the management fee for April. Name and Title of contact person responsible for corrective action: Steve Colella, Making a Difference in Property Management, LLC; Management Agent; 6800 Park Ten Blvd, Ste 184-W; San Antonio, TX 78213
View Audit 302860 Questioned Costs: $1
Finding 2023-003 Eligibility – Noncompliance and Significant Deficiency in Internal Control over Compliance. Planned Corrective Actions: The Organization provided documentation of beneficiary status for 38 of the 40 patients being tested. The remaining two patients were treated in remote villages an...
Finding 2023-003 Eligibility – Noncompliance and Significant Deficiency in Internal Control over Compliance. Planned Corrective Actions: The Organization provided documentation of beneficiary status for 38 of the 40 patients being tested. The remaining two patients were treated in remote villages and there was no documentation in their records. Management has reinforced the policy requiring documentation of beneficiary status and the Patient Access Manager has developed a registration performance improvement plan. Anticipated Completion Date: June 30, 2024.
Action Taken: A perfect storm of the CFO vacancy (however the organization believed the CFO was coming back soon). It was believed the Controller could handle a short period of absence from the CFO. The extended delay of hiring a competent CFO proved too taxing on the Controller which contributed to...
Action Taken: A perfect storm of the CFO vacancy (however the organization believed the CFO was coming back soon). It was believed the Controller could handle a short period of absence from the CFO. The extended delay of hiring a competent CFO proved too taxing on the Controller which contributed to the Controller’s resignation. A third‐party software conversion in March 2023, a payroll conversion which began in August 2023, and recent turnover of staff in the A/P and A/R positions had placed an enormous load on the controller’s position which is the reason for the late audit and other reports. None of the above is currently an issue and the necessary functions of the accounting and finance areas are performing in a timely manner with the understanding that areas requiring additional analyzes and training will be addressed as we progress into the future. Future reports and audits will be performed in a timely manner.
Finding 392508 (2023-012)
Material Weakness 2023
NONCOMPLIANCE WITH GRANT TERMS AND CONDITIONS; FORMULA GRANTS FOR RURAL AREAS AND TRIBAL TRANSIT PROGRAM; AL No. 20.509, GRANT No 111604, YEAR ENDED JUNE 30, 2023 Name of contact person: Kristen Galbraith, GPC Corrective Action: The Grants Department will develop procedures that will provide reaso...
NONCOMPLIANCE WITH GRANT TERMS AND CONDITIONS; FORMULA GRANTS FOR RURAL AREAS AND TRIBAL TRANSIT PROGRAM; AL No. 20.509, GRANT No 111604, YEAR ENDED JUNE 30, 2023 Name of contact person: Kristen Galbraith, GPC Corrective Action: The Grants Department will develop procedures that will provide reasonable assurance that procurement of goods and services are made in compliance with applicable federal regulations and other procurement requirements specific to a federal award or subaward, and that no subaward, contract, or agreement for purchase of goods or services is made with any suspended or debarred party. Proposed Completion Date: Immediately
View Audit 302840 Questioned Costs: $1
NONCOMPLIANCE WITH REPORTING REQUIREMENTS, CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS; AL No. 21.027, GRANT No. Direct and AM-23-0287 Name of contact person: Kelly Strecker Corrective Action: The City commits to ensuring that a procurement policy be put in place that will allow it to comply...
NONCOMPLIANCE WITH REPORTING REQUIREMENTS, CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS; AL No. 21.027, GRANT No. Direct and AM-23-0287 Name of contact person: Kelly Strecker Corrective Action: The City commits to ensuring that a procurement policy be put in place that will allow it to comply with procurement standards outlined in the Uniform Guidance. Proposed Completion Date: December 1, 2024
Student Financial Aid Cluster – Assistance Listing No.: Various Recommendation: We recommend that the University review the updated GLBA requirements and ensure their WISP includes all required elements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding....
Student Financial Aid Cluster – Assistance Listing No.: Various Recommendation: We recommend that the University review the updated GLBA requirements and ensure their WISP includes all required elements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Sonoran University will implement the corrective action suggestions outlined in the audit findings, including: • Expansion of vulnerability mitigation to include the prescribed penetration and exploitation operations. • Complete migration of Sonoran servers vendor-supported versions (as of this writing, only two systems remaining). • Implementation of a phishing campaign education initiative for Sonoran University Employees. • Update WISP documents to meet the prescribed documentation requirements. • Build University-consistent data retention strategy. Name of the contact person responsible for corrective action: • Paul Collins, Senior Director of IT, Sonoran University. Planned completion date for corrective action plan: • Completion of all items by September 30, 2024.
Finding 392365 (2023-001)
Significant Deficiency 2023
Section 202 Supportive Housing for the Elderly – Assistance Listing No. 14.157 Recommendation: The Auditors recommend that the Organization obtain approval from HUD to repay the loan advances after the initial due date and to establish internal controls to monitor the repayment of loan advances to e...
Section 202 Supportive Housing for the Elderly – Assistance Listing No. 14.157 Recommendation: The Auditors recommend that the Organization obtain approval from HUD to repay the loan advances after the initial due date and to establish internal controls to monitor the repayment of loan advances to ensure compliance with HUD requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Procedures have been put in place that all replacement reserve requests due to cash shortfalls are elevated to the VP of Operations who will ensure a plan is in place for timely repayment. Name(s) of the contact person(s) responsible for corrective action: Steve Lodi Planned completion date for corrective action plan: March 21, 2024.
DUE TO THE NATURE OF THE CAUSE OF THIS FINDING, THERE IS NO OTHER SPECIFIC CORRECT ACTION CONSIDERED NECESSARY. THE ORGANIZATION WILL ENSURE THAT FUTURE CONSTRUCTION CONTRACTS, IF ANY, CONTAIN ANY APPLICABLE PREVAILING WAGE REQUIREMENT VERBIAGE AND CERTIFIED PAYROLLS WILL BE RECEIVED AND REVIEWED.
DUE TO THE NATURE OF THE CAUSE OF THIS FINDING, THERE IS NO OTHER SPECIFIC CORRECT ACTION CONSIDERED NECESSARY. THE ORGANIZATION WILL ENSURE THAT FUTURE CONSTRUCTION CONTRACTS, IF ANY, CONTAIN ANY APPLICABLE PREVAILING WAGE REQUIREMENT VERBIAGE AND CERTIFIED PAYROLLS WILL BE RECEIVED AND REVIEWED.
Finding: 2023-001 – Compliance and Controls over Compliance – Eligibility Supportive Housing for Persons with Disabilities (Section 811), CFDA No. 14.181 Material Weakness & Noncompliance In 2023, Home Share did not have controls in place to ensure that eligibility criteria and rent calculations w...
Finding: 2023-001 – Compliance and Controls over Compliance – Eligibility Supportive Housing for Persons with Disabilities (Section 811), CFDA No. 14.181 Material Weakness & Noncompliance In 2023, Home Share did not have controls in place to ensure that eligibility criteria and rent calculations were being reviewed and/or approved by someone other than the individual making the initial determination or annual recertification. Actions Taken or Planned: Management agrees with this finding. Beginning in September 2023, management has changed the contractor they work with for the eligibility determination process. Management is working with the contractor to include a second individual in this process so that there will be a review performed by someone other than the individual making the initial determination or annual recertification. Contact Persons: Robert Pickering, Chief Financial Officer
Finding 2023-001: The Corporation did not make all of the reserve for replacement deposits as required by HUD for the year ended June 30, 2023. Comments on the Finding and Each Recommendation: Management should transfer $14,000 from the operating cash account to the reserve for replacement fund. Act...
Finding 2023-001: The Corporation did not make all of the reserve for replacement deposits as required by HUD for the year ended June 30, 2023. Comments on the Finding and Each Recommendation: Management should transfer $14,000 from the operating cash account to the reserve for replacement fund. Action(s) taken or planned on the finding: On September 1, 2023, management transferred $10,000 from the operating cash account to the reserve for replacement fund. Management will transfer the remaining $4,000 from the operating account to the reserve for replacement fund as soon as possible.
View Audit 302490 Questioned Costs: $1
Finding 2023-002: During the year ended June 30, 2023, the Community paid for payroll expenditures on behalf of other communities managed by the Agent totaling $12,960. Comments on the Finding and Each Recommendation: The other communities managed by the Agent should reimburse the Community in the a...
Finding 2023-002: During the year ended June 30, 2023, the Community paid for payroll expenditures on behalf of other communities managed by the Agent totaling $12,960. Comments on the Finding and Each Recommendation: The other communities managed by the Agent should reimburse the Community in the amount of $12,960. Action(s) taken or planned on the finding: Agree. On September 6, 2023, the Agent has issued a credit to the Community of $12,960.
View Audit 302489 Questioned Costs: $1
Finding 2023-001: The required deposit per the June 30, 2022 Computation of Surplus Cash, Distributions and Residual Receipts was not deposited to the residual receipts fund within 90 days after the fiscal year end. Comments on the Finding and Each Recommendation: Management should ensure that surpl...
Finding 2023-001: The required deposit per the June 30, 2022 Computation of Surplus Cash, Distributions and Residual Receipts was not deposited to the residual receipts fund within 90 days after the fiscal year end. Comments on the Finding and Each Recommendation: Management should ensure that surplus cash is deposited to the residual receipts account within 90 days after the fiscal year end. Action(s) taken or planned on the finding: On June 6, 2023, management transferred $6,157 from operating cash to the residual receipts account. No further action is required.
View Audit 302489 Questioned Costs: $1
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