Corrective Action Plans

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To United States Department of Health and Human Services Heartland Community Health Center respectfully submits the following corrective action plan for the year ended April 30, 2023. CohnReznick, LLP 350 Church Street Hartford, CT 06103 Audit Period: April 30, 2023 The findings from the April 3...
To United States Department of Health and Human Services Heartland Community Health Center respectfully submits the following corrective action plan for the year ended April 30, 2023. CohnReznick, LLP 350 Church Street Hartford, CT 06103 Audit Period: April 30, 2023 The findings from the April 30, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Federal Awards Findings: Finding 2023.001 - Sliding Fee Scale Discount Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken • Monthly Audits o The Front Office Coordinators at each location will routinely audit sliding fee verification on a monthly basis to verify that information has been captured and recorded correctly and all proof of income documentation is received. These monthly audits will be adopted as standard protocol and procedure for front office operations, effective January 2024. Any findings through the audit process will be reported to the COO. At least five patien.t charts will be audited monthly. o In addition, the billing manager will also review audit findings or summaries to ensure adequate adjustment to patient accounts to correlate with the patient's eligibility status. • Staff Training o Although Heartland has offered periodic sliding fee scale procedure training, administration will be scheduling additional training with a focus on required documentation and proper set up of sliding fee discounts. o Health Center Practice Administrator will review and implement and update standard operating procedure for sliding fee scale verification. o Employees will receive a copy of the sliding fee scale policy and sign that they have read the material. o Front office employees at all locations will complete a sliding fee schedule competency check-off sheet that will be reviewed by the Front Office Coordinators and billing manager. If there are any question regarding this plan, please e-mail Regina Oxford at roxford@heartlandhealth.org. Sincerely,
Finding 9505 (2023-001)
Significant Deficiency 2023
January 19, 2024 Department of Education Corrective Action Plan for Finding 2023-001 Hendrix College concurs with audit finding related to missing MPN documents under the Perkins Loan program as a repeat finding (previously 2022-002). The College offers the corrective actions as outlined below. For ...
January 19, 2024 Department of Education Corrective Action Plan for Finding 2023-001 Hendrix College concurs with audit finding related to missing MPN documents under the Perkins Loan program as a repeat finding (previously 2022-002). The College offers the corrective actions as outlined below. For any further questions or requests for further information, please contact Mr. Shawn Mathis, Associate VP and Controller for the College at 501-450-1474, or email mathis@hendrix.edu In response to Reference Number: 2022-002, In April 2023 the college performed an inventory of all documents onsite in the designated file cabinets related to Perkins loans. That information has been updated subsequent to May 31, 2023, to include all documents that exist electronically. Below is a summary of our findings as of November 30, 2023. As of November 30, 2023, there are 220 active Perkins Loans with balances greater than zero. Below is a summary of the loans. We were able to locate 182 (83%) of the loans Master Promissory Notes (“MPN”), with management unable to find the MPN for the remaining 38. Signed MPN 182 82.73% No MPN on file 38 220 For the 38 loans that the college did not have the MPN, were researched further to determine that 30 of those accounts contained student-initiated activity that substantiates the debt and the remaining eight loans will be purchased by the College for collection.
For the 2022-23 School Year, the District failed to correctly allocate expenditures to the CACFP accounts. In order to correct this action for the 2023-24 school year, the Director of Fiscal services will work with the Director of Child nutrition to reconcile each program and complete the cost alloc...
For the 2022-23 School Year, the District failed to correctly allocate expenditures to the CACFP accounts. In order to correct this action for the 2023-24 school year, the Director of Fiscal services will work with the Director of Child nutrition to reconcile each program and complete the cost allocation worksheet. The District utilizes a direct cost vending agreement, which will allocate the costs in an allowable manner. The Director of Fiscal Services will be responsible for making the transfer of expenditures from NSLP accounts to the CACFP accounts. The Director of Child Nutrition will verify the transfers have been completed correctly before the books are closed
View Audit 13071 Questioned Costs: $1
Finding 9481 (2023-001)
Significant Deficiency 2023
Corrective Action Plan: The Finance Division will add calendar reminders to confirm all subsequent reporting on the audited financial statements and federal grants are completed by the various deadlines. Person Responsible: Yvonne Herrera, Finance Division Director Estimated Completion Date: June ...
Corrective Action Plan: The Finance Division will add calendar reminders to confirm all subsequent reporting on the audited financial statements and federal grants are completed by the various deadlines. Person Responsible: Yvonne Herrera, Finance Division Director Estimated Completion Date: June 30, 2024
Corrective Action Plan: Management is in the process of updating Policies and Procedures to help ensure that calculations are run correctly and timely. The Financial Aid office and the Finance Office will work together each semester to ensure Banner setup is correct, updated, and working properly pr...
Corrective Action Plan: Management is in the process of updating Policies and Procedures to help ensure that calculations are run correctly and timely. The Financial Aid office and the Finance Office will work together each semester to ensure Banner setup is correct, updated, and working properly prior to any calculations being performed. Anticipated Completion Date: January 31, 2024
Finding 9460 (2023-001)
Significant Deficiency 2023
Gramm Leach Bliley Act Planned Corrective Action: The current Information Security Program was created using Capin's template last year and was acceptable. Moving forward, we will document the safeguards we're putting in place by including them in the Information Security Program and documenting th...
Gramm Leach Bliley Act Planned Corrective Action: The current Information Security Program was created using Capin's template last year and was acceptable. Moving forward, we will document the safeguards we're putting in place by including them in the Information Security Program and documenting the decreased mitigated risk level. We have a legacy on­ premise legacy SIS application software that doesn't have the capacity for MFA. We will attempt to either move our on-premise application software and database to our vendor's location where MFA is required to get into their network, or we will source a third-party vendor that will work with a legacy application without MFA capacity and require MFA on the front-end before calling the application. We will also consider application software on University-owned computer workstations and laptops that require MFA upon logging into our campus network. We will source an outside company for penetration testing and vulnerability scanning. Then, review the results and put in a plan to address the critical items and track progress. We will document each vendor that hosts PII data. We will collect SOC reports, privacy statements, GLBA compliance documents, and other related documents. We will provide the Board of Trustees - Business/Finance Committee a written report on the current status of the Information Security Program document. Person Responsible for Corrective Action Plan: Kelvin D Tohme, Senior Director of Information Technology Anticipated Date of Completion: Spring 2024
2023-001 Level of Effort (Maintenance of Effort) Recommendation: The District should monitor operations to ensure that it is maintaining the required level of expenditures of local funds for the education of children with disabilities. Action Taken: The District will monitor operations to ens...
2023-001 Level of Effort (Maintenance of Effort) Recommendation: The District should monitor operations to ensure that it is maintaining the required level of expenditures of local funds for the education of children with disabilities. Action Taken: The District will monitor operations to ensure that it is maintaining the required level of expenditures of local funds for the education of children with disabilities. Anticipated Completion Date: Throughout Fiscal Year Ending August 31, 2024
View Audit 12908 Questioned Costs: $1
Finding Summary: When a recipient of Title IV grant or loan assistance withdraws from an institution during a payment period or period of enrollment in which the recipient began attendance, the institution must calculate the correct amount of Title IV grant or loan assistance that the student earned...
Finding Summary: When a recipient of Title IV grant or loan assistance withdraws from an institution during a payment period or period of enrollment in which the recipient began attendance, the institution must calculate the correct amount of Title IV grant or loan assistance that the student earned based on the student's withdrawal date and allocation of Title IV funds. During 2023, one student that withdrew during the period of enrollment and required a return of funds had an amount refunded that was in excess of the amount calculated by the University. Corrective Action Plan (CAP): For 2023-2024, all Return to Title IV Processes will be completed by Debra McGee, Director of Financial Aid, and then reviewed by Ron Anderson, AVP Student Financial Services. We will ensure all scheduled University time off will be included in the calculations, and all regulations followed. Anticipated Completion Date: The procedures will be implemented for the 2023-2024 Financial Aid Year. Responsible Parties: Debra McGee, Ron Anderson
View Audit 12902 Questioned Costs: $1
Responsible Official’s Response: In this particular finding, the decision was made to undertake a project using organizational reserves. Subsequent to the project taking place additional review indicated it would qualify as permissible under the American Rescue Plan and Federal Funding could potenti...
Responsible Official’s Response: In this particular finding, the decision was made to undertake a project using organizational reserves. Subsequent to the project taking place additional review indicated it would qualify as permissible under the American Rescue Plan and Federal Funding could potentially cover the project costs. The contract for the work, however, was not further reviewed at the time. After subsequent review, it appears that the contract may not meet the standards for Federal Funding, Management, therefore, has removed the Federal funding revenue from it’s financial statements and has not requested funding for this project under the American Rescue Plan. As a regular course of business, the organization does require any contracts subject to Federal funding requirements meet Federal Funding requirements, including those requirements associated with prevailing wages. Going forward, a comprehensive contract review will be performed for any project retroactively deemed a potentially permissible use of Federal funds
Finding 9401 (2023-002)
Significant Deficiency 2023
Finding 2023-002 Response Type of Finding: Significant deficiency in internal control over compliance and instance of immaterial noncompliance. Criteria: DHI’s regulatory agreement with HUD and the HUD Uniform Financial Reporting Standards (24 CFR §5.801) require audited financial statements to be s...
Finding 2023-002 Response Type of Finding: Significant deficiency in internal control over compliance and instance of immaterial noncompliance. Criteria: DHI’s regulatory agreement with HUD and the HUD Uniform Financial Reporting Standards (24 CFR §5.801) require audited financial statements to be submitted to HUD within 90 days of the fiscal year end. HUD may authorize an extension to the 90 day due date. Management’s Response and Planned Corrective Actions: 1. The name of the contact person(s) responsible for the corrective action a. Kathleen Broadhurst, Sr. Director of Finance/ShelterCare 2. The corrective action planned: a. ShelterCare, as managing agent, has hired a new property accountant which should help with keeping the books current and ShelterCare prepared to start audit work mid-July and be ready to submit the audit to HUD within 90 days of the fiscal year end. 3. The anticipated completion date: a. New property accountant was hired in August of 2023.
Finding Number: 2023-005 – Review and Approval of the Schedule of Expenditures of Federal Awards (SEFA) Corrective Action Plan: While there was a review of the SEFA, the documentation of said review did not occur properly. Management has put in place a process to document preparation/review of the ...
Finding Number: 2023-005 – Review and Approval of the Schedule of Expenditures of Federal Awards (SEFA) Corrective Action Plan: While there was a review of the SEFA, the documentation of said review did not occur properly. Management has put in place a process to document preparation/review of the SEFA evidenced by signature and date. Personnel Responsible for Corrective Action: Nachum Golodner, Academica Director of Accounting Anticipated Completion Date: June 30, 2024
Finding Number: 2023-004 Approval Of Expense Transactions Corrective Action Plan: A process was put in place in May 2023 to ensure that all principal approvals are documented in writing or electronic approval in the system which can be date stamped by the system. Payroll will not be run, nor grant...
Finding Number: 2023-004 Approval Of Expense Transactions Corrective Action Plan: A process was put in place in May 2023 to ensure that all principal approvals are documented in writing or electronic approval in the system which can be date stamped by the system. Payroll will not be run, nor grants submitted, until proper approval is received. Personnel Responsible for Corrective Action: Nachum Golodner, Academica Director of Accounting Anticipated Completion Date: June 30, 2024
Finding Number: 2023-003 – Review and Approval of the Schedule of Expenditures of Federal Awards (SEFA) Corrective Action Plan: While there was a review of the SEFA, the documentation of said review did not occur properly. Management has put in place a process to document preparation/review of the ...
Finding Number: 2023-003 – Review and Approval of the Schedule of Expenditures of Federal Awards (SEFA) Corrective Action Plan: While there was a review of the SEFA, the documentation of said review did not occur properly. Management has put in place a process to document preparation/review of the SEFA evidenced by signature and date. Personnel Responsible for Corrective Action: Nachum Golodner, Academica Director of Accounting Anticipated Completion Date: June 30, 2024
Finding 9337 (2023-002)
Significant Deficiency 2023
Corrective Action Plan (Continued) Year Ended August 31, 2023 2023-02 Recommendations: Paris Junior College's management should implement additional controls and procedures to ensure compliance requirements are met regarding the posting of contracted arrangements with financial account providers to ...
Corrective Action Plan (Continued) Year Ended August 31, 2023 2023-02 Recommendations: Paris Junior College's management should implement additional controls and procedures to ensure compliance requirements are met regarding the posting of contracted arrangements with financial account providers to the Department of Education's database. Additionally, the College must establish a procedure to accomplish a due diligence review of the financial account provider's rates and fees. Action Plan: Paris Junior College management will ensure that a comprehensive procedure is established and implemented to ensure compliance requirements are met. Contact Person: Debra Craig, Controller Anticipated Completion Date: January 10, 2024
Finding 9335 (2023-007)
Significant Deficiency 2023
Management will ensure an effective review of reimbursement requests prior to submission to ensure all costs requested are legitimate and allowable. Contact Person: Mayor Leroy Sullivan and Sandra Williams. Anticipated Completion Date: Annual basis/as needed
Management will ensure an effective review of reimbursement requests prior to submission to ensure all costs requested are legitimate and allowable. Contact Person: Mayor Leroy Sullivan and Sandra Williams. Anticipated Completion Date: Annual basis/as needed
View Audit 12808 Questioned Costs: $1
Finding 9334 (2023-006)
Significant Deficiency 2023
Management will ensure that proper proceudres are followed to comply with federal reporting requirments. Contact Person: Mayor Leroy Sullivan and Sandra Williams. Anticipated Completion Date: Annual basis
Management will ensure that proper proceudres are followed to comply with federal reporting requirments. Contact Person: Mayor Leroy Sullivan and Sandra Williams. Anticipated Completion Date: Annual basis
In regard to 2023-002 COVID-19 Education Stabilization Fund, management will reinforce with staff the need to follow controls related to monitoring/approving grant disbursements. This action will be taken today, November 15, 2023. If the Kentucky Department of Education has questions regarding this ...
In regard to 2023-002 COVID-19 Education Stabilization Fund, management will reinforce with staff the need to follow controls related to monitoring/approving grant disbursements. This action will be taken today, November 15, 2023. If the Kentucky Department of Education has questions regarding this plan, please call Matthew Davenport
Planned Corrective Action: This was a repeat finding for Family First Health. Going forward future submissions will be reviewed for accuracy prior to submitting. Completion Date: 4/1/2024 Accounting Name of Contact Person: Jenny Englerth, President/CEO; Brent Doores, CFO
Planned Corrective Action: This was a repeat finding for Family First Health. Going forward future submissions will be reviewed for accuracy prior to submitting. Completion Date: 4/1/2024 Accounting Name of Contact Person: Jenny Englerth, President/CEO; Brent Doores, CFO
Finding: 2023-002 Name of contact person: Jacob Joyner, Director of Financial Services Corrective Action: The City will add oversight over the requests and reporting of grants to ensure that all steps are completed correctly. Proposed Completion Date: February 1, 2024
Finding: 2023-002 Name of contact person: Jacob Joyner, Director of Financial Services Corrective Action: The City will add oversight over the requests and reporting of grants to ensure that all steps are completed correctly. Proposed Completion Date: February 1, 2024
Finding: 2023-001 Name of contact person: Jacob Joyner, Director of Financial Services Corrective Action: The City will add review steps to ensure that all applicable reporting requirements are met. Proposed Completion Date: February 1, 2024
Finding: 2023-001 Name of contact person: Jacob Joyner, Director of Financial Services Corrective Action: The City will add review steps to ensure that all applicable reporting requirements are met. Proposed Completion Date: February 1, 2024
Corrective Action Plan Inaccurate Vendor Invoice Calculations Communication was made by USA Health Director of Accounting to the USA Health Accounting Department on 11/4/23 and sent via email to all USA Health Department Managers on 11/6/2023 reiterating the procedures for submission, review, and ap...
Corrective Action Plan Inaccurate Vendor Invoice Calculations Communication was made by USA Health Director of Accounting to the USA Health Accounting Department on 11/4/23 and sent via email to all USA Health Department Managers on 11/6/2023 reiterating the procedures for submission, review, and approval of contract labor invoices. Specific instructions to recalculate each contract employees’ timesheet(s) and agree the totals to the related invoice prior to approval were included and outlined for department managers, accountants, and accounts payable staff. Duplicate Grant Expenditures and Proper Approvals The manager charged with approval of grant related transactions and transfers in 2022/2023 has since left USA. The process for reviewing and approving grant expenditures has since been enhanced. Specifically, employees responsible for processing grant transfer documentation will ensure documents contain management approval(s), grants and contracts accounting approval, and appropriate documentation prior to keying and uploading documentation into the general ledger (Banner system). The new practice will help compensate for employee turnover as documentation of historical review will be available to successors. Additional process enhancements will include the following: • Expenses cannot be transferred to a grant until payment has been processed. • Entries must contain a transaction line item for each invoice transferred to the Grant (not subtotals). • Accounting records will be reviewed prior to approval to ensure expenditures have not been previously transferred to a grant. • Expense transfer supporting documentation must contain a detailed schedule of all invoices, include a reference to the foapal and document number originally charged, name of vendor, date of initial payment, and amount. USA Health Accounting is currently working with Grants & Contracts Accounting and the USA Campus Business Office to document the process and effectively communicate this process with all responsible parties. Anticipated Completion Date 01/31/2024 Name of Contact Person for Corrective Action Becky Schaffer, USA Health Director of Accounting
View Audit 12556 Questioned Costs: $1
Finding 2023-002 Cash Management Internal Controls (Significant Deficiency) Responsible Persons: Debbie Rapier, Chief Financial Officer Corrective Action Plan: All monthly billing information for the FPP and MST programs is sent by the Director of Revenue Cycle to the FPP/MST supervisor for review...
Finding 2023-002 Cash Management Internal Controls (Significant Deficiency) Responsible Persons: Debbie Rapier, Chief Financial Officer Corrective Action Plan: All monthly billing information for the FPP and MST programs is sent by the Director of Revenue Cycle to the FPP/MST supervisor for review and comparison. The Outpatient Services Manager then prepares the monthly invoice. The invoice is forwarded to finance and reviewed by the Chief Financial Officer or Accounting Manager, in the absence of the CFO. Once approved, it is submitted to the Department of Community Based Services for payment. Once payment is received, it is compared against the receivable for accuracy. Anticipated Completion Date: Throughout fiscal year ending and beyond June 30, 2024
U.S. Department of Education 2023-001 NSLDS Enrollment Reporting Student Financial Aid Cluster – Assistance Listing No. 84.063, 84.268 Condition: During testing of enrollment status reporting, we noted that the incorrect enrollment status, effective date, and program begin date was reported to N...
U.S. Department of Education 2023-001 NSLDS Enrollment Reporting Student Financial Aid Cluster – Assistance Listing No. 84.063, 84.268 Condition: During testing of enrollment status reporting, we noted that the incorrect enrollment status, effective date, and program begin date was reported to NSLDS. Recommendation: The College should evaluate their procedures and policies related to reporting status changes to NSLDS and enhance as deemed necessary to ensure that accurate information is reported to NSLDS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Cause-Enrollment Status Reporting: Montgomery College utilizes the National Student Clearinghouse (NSC) as a third-party provider in order to submit student information to the NSLDS. Student enrollment status corrections were uploaded to NSC timely, however, monitoring of the upload through success was inconsistent, resulting in error reports preventing the accurate and timely update to the enrollment statuses. No review was completed to ensure the upload was completed in NSLDS. Cause for Effective Date Reporting - Inaccurate Student withdrawal effective dates were not identified timely due to delays in the review of student withdrawal status. Cause for Program Start Date Reporting - Inaccurate Student program begin dates were due to a programming issue with the file transmission software. Program start date was updating each semester to the latest semester start date. There was insufficient review to identify the problem and recommend a solution to resolve. The following actions have been implemented to resolve the deficiencies: Review of error reports by an employee not responsible for correcting the errors to ensure completeness and timeliness of the corrections submitted. Use of internal weekly reports to identify students who dropped below half time status or withdrew entirely from a semester. Use of the NSC online error reporting tool to correct errors monthly. Errors are corrected using this tool within eight days of receipt of the error report, which provides the NSC two days to resubmit the information and meet the ten-day resolution requirement. Utilize the Enrollment Reporting Summary Report (SCHER1) to ensure completeness and timeliness of error correction submissions. The Dept of Enrollment Services has coordinated with the Office of Information Technology to adjust the programming on the file transmission to NSC to ensure accuracy and minimize discrepancies. Manually submit corrections directly to NSLDS on an as-needed basis. Name(s) of the contact person(s) responsible for corrective action: Director of Enrollment Services- Earnest Cartledge Planned completion date for corrective action plan: December 2023
Finding 9151 (2023-001)
Significant Deficiency 2023
United States Department of Commerce 2023-001 Connecticut State Technology Extension Program – Assistance Listing No. 11.611 Recommendation: We recommend that if employees are being allocated to multiple programs throughout the year, personnel activity reports must be prepared at minimum, on a mo...
United States Department of Commerce 2023-001 Connecticut State Technology Extension Program – Assistance Listing No. 11.611 Recommendation: We recommend that if employees are being allocated to multiple programs throughout the year, personnel activity reports must be prepared at minimum, on a monthly basis and be reviewed and signed off on by both the employee and their immediate supervisor. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will implement a policy to require employees to prepare activity reports on a least a monthly basis that are signed by the employee and the supervisor. Name of the contact person responsible for corrective action: Robert Blakey, Controller Planned completion date for corrective action plan: December 2023.
Finding: 2023-002 – Special Tests and Provisions – Wage Rate Requirements U.S. Department of Education – COVID-19 - Education Stabilization Fund (ALN 84.425D and 84.425U); Passed through the Michigan Department of Education; All project numbers. Auditor Description of Condition and Effect: Two of ...
Finding: 2023-002 – Special Tests and Provisions – Wage Rate Requirements U.S. Department of Education – COVID-19 - Education Stabilization Fund (ALN 84.425D and 84.425U); Passed through the Michigan Department of Education; All project numbers. Auditor Description of Condition and Effect: Two of the contracts selected for testing that were subject to the Wage Rate Requirements did not include the required provision, and the District did not obtain the required certified payrolls. The District did not follow federal requirements to include the prevailing wage rate provision in its contract. Auditor Recommendation: We recommend that the District reviews its policies to ensure that applicable prevailing wage requirements are included in construction contracts whenever federal funds are used and certified payrolls are obtained. Corrective Action: District officials will ensure that construction contracts contain these requirements during the bid process. Responsible Person: Christine Robinson, Superintendent and Melissa Butler, LEA Business Manager Anticipated Completion Date: June 30, 2024
View Audit 12522 Questioned Costs: $1
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