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Corrective Action Plans

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Finding 32302 (2022-001)
Significant Deficiency 2022
City of Chicopee, Massachusetts
MA
Questioned Costs Subrecipient Monitoring Reporting
Finding 2022-001 Significant Deficiency in Internal Control Over Compliance ? U.S. Department of Treasury ? Coronavirus Relief Fund City Municipal Assistance ? (CFDA No. 21.019) ? Reporting (continued) Passed Through Commonwealth of Massachusetts Executive Office of Administration and Finance Nam...
Finding 2022-001 Significant Deficiency in Internal Control Over Compliance ? U.S. Department of Treasury ? Coronavirus Relief Fund City Municipal Assistance ? (CFDA No. 21.019) ? Reporting (continued) Passed Through Commonwealth of Massachusetts Executive Office of Administration and Finance Name of Person Responsible: Marie T. Laflamme, Treasurer Sharyn Riley, Auditor John Miarecki, School Director of Budget & Finance Corrective Action Planned: The City will immediately review all expenses related to the Coronavirus Relief Funds. The City will take steps to reconcile the Coronavirus Report to our General Ledger. Anticipated Completion Date: May 30, 2023
View Audit 31097
Lakewood Theatre Company
OR
Procurement, Suspension & Debarment Allowable Costs / Cost Principles Questioned Costs § 200.318
Response: Management notes that, as this is their first time receiving significant federal funding and this was one-time emergency funding rather than an ongoing award, they do not have procurement procedures in writing which adhere to 2 CFR Part 200.318(a). However, they adhered to their internal...
Response: Management notes that, as this is their first time receiving significant federal funding and this was one-time emergency funding rather than an ongoing award, they do not have procurement procedures in writing which adhere to 2 CFR Part 200.318(a). However, they adhered to their internal written procurement procedures and conflict of interest policies, followed the award guidelines, and obtained multiple bids in the selection of vendors for contracted services. Action to be taken: Management notes that, as this was one-time emergency funding rather than an ongoing award, they do not anticipate receiving federal funding in the future. As such, they do not intend to document these procedures in writing at this point. However, if they apply for federal funding again in the future, they will develop written procedures at that point. Responsible Person: Andrew Edwards, Executive Director
View Audit 35785
Lakewood Theatre Company
OR
Allowable Costs / Cost Principles Questioned Costs § 200.302
Response: Management notes that, as this is their first single audit and this was one-time emergency funding rather than an ongoing award, they do not have these procedures in writing. However, they followed SBA/SVOG guidelines for allowability of costs, which were researched early in the grant pr...
Response: Management notes that, as this is their first single audit and this was one-time emergency funding rather than an ongoing award, they do not have these procedures in writing. However, they followed SBA/SVOG guidelines for allowability of costs, which were researched early in the grant process, and assigned costs in accordance with those guidelines. The budget, which included all assigned costs and was approved by the Lakewood Board of Directors, was also submitted and cleared by the SVOG Compliance Team and they inquired about the allowability of any items over which the guidelines were unclear. Action to be taken: Management notes that, as this was one-time emergency funding rather than an ongoing award, they do not anticipate receiving federal funding in the future. As such, they do not intend to document these procedures in writing at this point. However, if they apply for federal funding again in the future, they will develop written procedures at that point. Responsible Person: Andrew Edwards, Executive Director
View Audit 35785
Finding 32280 (2022-001)
Material Weakness 2022
Spotswood Reformed Church Senior Citizen's Housing Corp.
NJ
Questioned Costs
See Corrective Action Plan for chart/table.
See Corrective Action Plan for chart/table.
View Audit 31700
Finding 32278 (2022-001)
Material Weakness 2022
Older American Housing in Spotswood, Inc.
NJ
Questioned Costs
See Corrective Action Plan for chart/table.
See Corrective Action Plan for chart/table.
View Audit 28205
Finding 32277 (2022-001)
Significant Deficiency 2022
State of North Dakota
ND
Questioned Costs Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303
Department of Commerce Finding: 2022-001 Department of Commerce Response/Corrective Action Plan: The Department of Commerce agrees with this finding. These grants were conducted outside of our normal scope of operations and new grant processes had to be designed and implemented to manage this ...
Department of Commerce Finding: 2022-001 Department of Commerce Response/Corrective Action Plan: The Department of Commerce agrees with this finding. These grants were conducted outside of our normal scope of operations and new grant processes had to be designed and implemented to manage this grant programmatically and fiscally. These grant payments were paid by a batch file process through the Office of Management and Budget and not fiscally managed by the agency?s fiscal department. The agency does not intend to manage grant processes programmatically or fiscally with these processes again. Of the eight duplicate grant payments identified two of the payments were voided, two payments have been returned to the department and turned back to the Office of Management and Budget, and the remaining payments the department has either been in contact with the beneficiary on returning the funds or the beneficiaries have been turned over to the Attorney General?s Office for further follow-up. The department will turn over the remainder of the beneficiaries to the Attorney?s General?s Office if payment is not made timely. Contact Person Shawn Kessel, COO/Deputy Commissioner Anticipated Completion Date There is no anticipated completion date for enhancing our internal controls to ensure duplicated payments are not made to the recipients of federal funds due to the fact the agency does not intend to manage a grant within our department programmatically or fiscally with these processes again.
View Audit 36677 Questioned Costs: $1
Finding 32272 (2022-020)
Significant Deficiency 2022
State of North Dakota
ND
Matching / Level of Effort / Earmarking Questioned Costs Reporting
Finding: 2022-020 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. These services were provided by a contracted vendor in two separate sites in different cities for over ten years. In October 2018, due to staffing performance concerns...
Finding: 2022-020 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. These services were provided by a contracted vendor in two separate sites in different cities for over ten years. In October 2018, due to staffing performance concerns and licensing investigations, the state ended the contract with this vendor in one city. In April 2019 the vendor ended the contract in the second city. Three Requests for Proposals have been issued since that date and no proposals were received. Market research was conducted with several potential providers and due to lack of interest, capacity concerns, workforce issues as well as the effects of the COVID-19 pandemic, the department has been unable to meet the expenditure requirements. The Department has met several times with the Federal Substance Abuse and Mental Health Services Administration regarding this issue. Currently the Department is requesting funding from the North Dakota Legislative Assembly to develop of a Pregnant and Parenting Women?s Residential Treatment Program within the Department. If approved, the Department will work to secure locations and renovate spaces that is not allowable with the Federal Funds. Contact Person: Lacresha Graham, Manager Addiction Treatment and Recovery Program and Policy Anticipated Completion Date: September 2023
View Audit 36677 Questioned Costs: $1
Finding 32267 (2022-011)
Significant Deficiency 2022
State of North Dakota
ND
Questioned Costs Eligibility Matching / Level of Effort / Earmarking
Finding: 2022-011 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. The department will work with NDIT to ensure they restart and maintain the access and security reviews. Contact Person: Tory Brabandt, Medicaid Enterprise Directo...
Finding: 2022-011 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. The department will work with NDIT to ensure they restart and maintain the access and security reviews. Contact Person: Tory Brabandt, Medicaid Enterprise Director Anticipated Completion Date: June 30, 2023
View Audit 36677
Finding 32266 (2022-010)
Significant Deficiency 2022
State of North Dakota
ND
Questioned Costs Reporting Matching / Level of Effort / Earmarking
Finding: 2022-010 Department of Human Services Response/Corrective Action Plan: The Department agrees with the finding. When the Department had to re-procure the Medicaid Expansion MCO contract for a January 1, 2022, start date, the contract was overhauled and made much more specific in terms o...
Finding: 2022-010 Department of Human Services Response/Corrective Action Plan: The Department agrees with the finding. When the Department had to re-procure the Medicaid Expansion MCO contract for a January 1, 2022, start date, the contract was overhauled and made much more specific in terms of the MLR requirements, so we do not anticipate the same issues happening again. Below is contract language that addresses this finding. Appendix E, Article 1 10. Reporting requirements 1. MCO shall submit two reports to STATE that includes at least the following information for each MLR Reporting Year, one of which excludes the adjustments identified in (I) and (C)(3)(d) above: 1. Total incurred claims. 2. Expenditures on quality improving activities. 3. Expenditures related to activities compliant with program integrity requirements (42 C.F.R. ?438.608(a)(1) through (5), (7), (8) and (b)). 4. Non-claims costs. 5. Premium revenue. 6. Taxes, licensing, and regulatory fees. 7. Methodology(ies) for allocation of expenditures. 8. Any credibility adjustment applied. 9. The calculated MLR. 10. Any remittance owed to STATE, if applicable. 11. A comparison of the information reported in this paragraph with the audited financial report required under 42 C.F.R. ?438.3(m). 12. A description of the aggregation method used under paragraph (F) of this article. 13. The number of Member Months. 2. MCO must require any third-party vendor providing claims adjudication activities to provide all underlying data associated with MLR reporting to that MCO within 180 days of the end of the MLR Reporting Year or within 30 days of being requested by MCO whichever comes sooner, regardless of current contractual limitations, to calculate and validate the accuracy of MLR reporting. 3. Prior to ten (10) months following the applicable MLR Reporting Year, MCO must submit the report required in paragraph (I)(1) of this article based on data including eight (8) months of claims run out. 4. MCO shall attest to the accuracy of the calculation of the MLR in accordance with requirements of this article when submitting the report required under this paragraph. 2. Prior to eleven (11) months following the applicable MLR Reporting Year or a mutually agreed upon alternative date, STATE shall finalize the MLR Reporting Year with any balance due to STATE as required in paragraph (H) of this article within sixty (60) days. Contact Person: Jared Ferguson, Medicaid Expansion Administrator Anticipated Completion Date: Already Completed
View Audit 36677
Finding 32265 (2022-009)
Significant Deficiency 2022
State of North Dakota
ND
Questioned Costs Eligibility Matching / Level of Effort / Earmarking
Finding: 2022-009 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. The department will work with NDIT to ensure they restart and maintain the risk analysis and security review for MMIS. Contact Person: Tory Brabandt, Medicaid Enterpr...
Finding: 2022-009 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. The department will work with NDIT to ensure they restart and maintain the risk analysis and security review for MMIS. Contact Person: Tory Brabandt, Medicaid Enterprise Director Anticipated Completion Date: December 31, 2023
View Audit 36677
Finding 32264 (2022-008)
Significant Deficiency 2022
State of North Dakota
ND
Allowable Costs / Cost Principles Questioned Costs Matching / Level of Effort / Earmarking
Department of Human Services Finding: 2022-008 Department of Human Services Response/Corrective Action Plan: The department agrees to recover payments made on unsupported claims. The department will recover payments made on unsupported claims. Contact Person: Corey Kjos, Enterprise Operations ...
Department of Human Services Finding: 2022-008 Department of Human Services Response/Corrective Action Plan: The department agrees to recover payments made on unsupported claims. The department will recover payments made on unsupported claims. Contact Person: Corey Kjos, Enterprise Operations Manager Anticipated Completion Date: June 30, 2023
View Audit 36677 Questioned Costs: $1
Finding 32263 (2022-019)
Significant Deficiency 2022
State of North Dakota
ND
Eligibility Questioned Costs Cash Management
Finding: 2022-019 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. Due to Medicaid continuous enrollment requirements ending on March 30, 2023, the SPACES system will be converted back to its normal rules and this issue should not hap...
Finding: 2022-019 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. Due to Medicaid continuous enrollment requirements ending on March 30, 2023, the SPACES system will be converted back to its normal rules and this issue should not happen again. The Department will do a review of CHIP eligibility to ensure incorrect claims are identified and corrected. Claims paid in error will be adjusted to reflect the proper category of eligibility, so the applicable fund code is applied, which will apply the correct FMAP. Contact Person: Erik Elkins, Assistant Director, Medical Services Anticipated Completion Date: April 30, 2023
View Audit 36677 Questioned Costs: $1
Finding 32258 (2022-013)
Significant Deficiency 2022
State of North Dakota
ND
Questioned Costs Subrecipient Monitoring Matching / Level of Effort / Earmarking
Finding: 2022-013 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. The Child Care Licensing System (CCL) went live Dec. 2022, CCL will add upcoming unannounced visits to Licensing Specialist?s work que. Licensing Supervisors and the L...
Finding: 2022-013 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. The Child Care Licensing System (CCL) went live Dec. 2022, CCL will add upcoming unannounced visits to Licensing Specialist?s work que. Licensing Supervisors and the Licensing Administrator will run a monthly report to assure unannounced visits are being completed by the Licensing Specialists. Contact Person: Carmen Traeholt, Child Care Licensing Administrator Anticipated Completion Date: Completed January 2023
View Audit 36677
Finding 32257 (2022-012)
Significant Deficiency 2022
State of North Dakota
ND
Questioned Costs Subrecipient Monitoring Matching / Level of Effort / Earmarking
Finding: 2022-012 Department of Human Services Response/Corrective Action Plan: The Department of Health and Human Service agrees with this recommendation. The Department has been working with a developer to create a Child Care Licensing Data System to replace a paper process and multiple sprea...
Finding: 2022-012 Department of Human Services Response/Corrective Action Plan: The Department of Health and Human Service agrees with this recommendation. The Department has been working with a developer to create a Child Care Licensing Data System to replace a paper process and multiple spreadsheets. The system allows each licensing specialist to see their workflow when they log into the system. It also notifies when a reinspection is needed and will escalate the notice if the reinspection is not done timely. Contact Person: Carmen Traeholt, Child Care Licensing Administrator Anticipated Completion Date: The data system launched in December 2022.
View Audit 36677
Finding 32252 (2022-002)
Material Weakness 2022
Metropolitan Boston Housing Partnership, Inc.
MA
Questioned Costs Subrecipient Monitoring Eligibility
2022-002 Recertifications 14.881 Moving to Work Demonstration Program ? Award No. OCD26401344019MTW 14.871 Housing Choice Voucher Program (Housing Voucher Cluster) ? Award No. OCD26401344019HCV Responsible Official John Hillis Director of Inspections & Property Owner Services, Systems, and Com...
2022-002 Recertifications 14.881 Moving to Work Demonstration Program ? Award No. OCD26401344019MTW 14.871 Housing Choice Voucher Program (Housing Voucher Cluster) ? Award No. OCD26401344019HCV Responsible Official John Hillis Director of Inspections & Property Owner Services, Systems, and Compliance Plan Detail After a detailed RFP process, Metro Housing has selected an outside vendor (Nan McKay) to assist with completing a backlog of regular reexaminations amassed during calendar years 2020 and 2021. The contract was signed on September 27, 2022. By clearing up this backlog of work, Metro Housing staff working on the completion of regular re-exams for the Section 8 HCVP and MTW programs will be able to renew their focus on completing current work timely and accurately. Metro Housing is also making changes to decrease caseload sizes for Program Specialists while also streamlining workflows to better internal and external communication needed to complete our tasks. The roll-out of this new setup should be complete before the end of the current calendar year. Anticipated Completion Date June 30, 2023 ? All reexaminations will be current, and past due percentages will be lowered to acceptable levels.
View Audit 32287
Finding 32250 (2022-003)
Material Weakness 2022
Greater Tucson Lions Senior Citizen Foundation Inc.
AZ
Questioned Costs Internal Control / Segregation of Duties
When director reviews invoice will initial. Director will continue to work on invoice retention.
When director reviews invoice will initial. Director will continue to work on invoice retention.
View Audit 32172 Questioned Costs: $1
Finding 32246 (2022-002)
Significant Deficiency 2022
Minot Vocational Adjustment Workshop, Inc. Dba: Kalix
ND
Internal Control / Segregation of Duties Questioned Costs
2022-002: Contact Person: Misty Wanner, CFO Corrective Action Plan: Management will retain all documentation as required by the federal agency. Completion Date: The Organization will implement immediately.
2022-002: Contact Person: Misty Wanner, CFO Corrective Action Plan: Management will retain all documentation as required by the federal agency. Completion Date: The Organization will implement immediately.
View Audit 31347
Finding 32245 (2022-001)
Significant Deficiency 2022
Minot Vocational Adjustment Workshop, Inc. Dba: Kalix
ND
Internal Control / Segregation of Duties Questioned Costs
2022-001: Contact Person: Misty Wanner, CFO Corrective Action Plan: Management will retain all documentation as required by the federal agency. Completion Date: The Organization will implement immediately.
2022-001: Contact Person: Misty Wanner, CFO Corrective Action Plan: Management will retain all documentation as required by the federal agency. Completion Date: The Organization will implement immediately.
View Audit 31347
Finding 32240 (2022-002)
Significant Deficiency 2022
Regina Coeli Child Development Center
LA
Equipment & Real Property Management Questioned Costs Procurement, Suspension & Debarment
2022-002 - Equipment and Real Property Management- Failure to Obtain Approval for Disposition of Property Acquired with Federal Awards- The Center concurs with the finding. The Center has implemented procedures to ensure approval for disposition of property acquired with federal funds. New personnel...
2022-002 - Equipment and Real Property Management- Failure to Obtain Approval for Disposition of Property Acquired with Federal Awards- The Center concurs with the finding. The Center has implemented procedures to ensure approval for disposition of property acquired with federal funds. New personnel have been hired who are being adequately trained regarding this process.
View Audit 35779 Questioned Costs: $1
Finding 32239 (2022-001)
Significant Deficiency 2022
Schi Early Intervention Program
NJ
Questioned Costs
Views of Responsible Officials and Planned Corrective Action: Management and the Board of SCHI EIP have increased their efforts to collect the outstanding debt from the related party. A significant portion of the monies have been repaid. As of the date of the independent auditors? report, the balanc...
Views of Responsible Officials and Planned Corrective Action: Management and the Board of SCHI EIP have increased their efforts to collect the outstanding debt from the related party. A significant portion of the monies have been repaid. As of the date of the independent auditors? report, the balance has been paid off in its entirety.
View Audit 35776
Finding 32238 (2022-001)
Significant Deficiency 2022
Village Cooperative of the Northland
MO
Internal Control / Segregation of Duties Questioned Costs Significant Deficiency
The Board of Directors is and will remain involved in the financial affairs of the Cooperative.
The Board of Directors is and will remain involved in the financial affairs of the Cooperative.
View Audit 35774
Finding 32237 (2022-003)
Significant Deficiency 2022
Heal the Hero Foundation
AZ
Internal Control / Segregation of Duties Questioned Costs Cash Management § 200.303
Coronavirus State and Local Fiscal Recovery Funds ? Assistance Listing No. 21.027 Recommendation: We recommend that the Organization implement policies and procedures surrounding the cash disbursement process that ensures disbursements to the chief executive officer are reviewed and approved by a se...
Coronavirus State and Local Fiscal Recovery Funds ? Assistance Listing No. 21.027 Recommendation: We recommend that the Organization implement policies and procedures surrounding the cash disbursement process that ensures disbursements to the chief executive officer are reviewed and approved by a second, independent individual such as a board member. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will implement policies and procedures surrounding cash disbursement process ensuring disbursements to the chief executive officer are reviewed and approved by a second, independent individual such as a board member. Name(s) of the contact person(s) responsible for corrective action: Joseph Holmes Planned completion date for corrective action plan: 10/31/23
View Audit 34813
Finding 32235 (2022-001)
Material Weakness 2022
Fairfield Medical Center
OH
Questioned Costs Material Weakness Reporting
Fairfield Medical Center and Subsidiaries December 31, 2022 CORRECTIVE ACTION PLAN The finding from the schedule of findings and questioned costs for the year ended December 31, 2022 are discussed below. The findings are numbered consistently with the numbers assigned in the Schedule. Finding 2022-0...
Fairfield Medical Center and Subsidiaries December 31, 2022 CORRECTIVE ACTION PLAN The finding from the schedule of findings and questioned costs for the year ended December 31, 2022 are discussed below. The findings are numbered consistently with the numbers assigned in the Schedule. Finding 2022-001 Condition: The Organization does not have a review process in place relate to reviewing PRF submissions. The Organization calculated its period 4 payments applied toward lost revenue using option ii and attested to using budgets approved prior to March 27, 2020. Planned Corrective Action: Management has implemented a process to ensure review of the reporting submissions prior to finalization. Management has updated its method for calculating lost revenues in the period 5 submission by comparing 2020 budget to 2020 ? 2023 actual revenues. Management believes this is an allowable method under option iii. The period 5 filing was submitted September 19, 2023. Anticipated Completion Date: September 30, 2023 Responsible Contact Person: Julie Grow, Chief Financial Officer
View Audit 34812
Finding 32212 (2022-011)
Significant Deficiency 2022
The Boulevard of Chicago, Inc.
IL
Questioned Costs Allowable Costs / Cost Principles Cash Management
Views of responsible officials and planned corrective actions: There is no disagreement with the audit finding. All vouchers will be reviewed and approved by upper management before submission. These vouchers will be checked against a modified policy ensuring costs are reasonable, allowable, and all...
Views of responsible officials and planned corrective actions: There is no disagreement with the audit finding. All vouchers will be reviewed and approved by upper management before submission. These vouchers will be checked against a modified policy ensuring costs are reasonable, allowable, and allocable to a State, Federal, local, and private awards shall be charged to that award directly or indirectly. Name(s) of the contact person(s) responsible for corrective action: Shanan Egger, Chief Financial Officer Planned completion date for corrective action plan: September 2023
View Audit 31477
University of Saint Katherine
CA
Questioned Costs Reporting § 200.329
Education Stabilization Fund Reporting Planned Corrective Action: The University is no longer accepting HEERF Funding. 2021 HEERF (reported 2022) has been revised and will be resubmitted March 2023, during the US Department of Education?s submission window. All future applicable reporting will b...
Education Stabilization Fund Reporting Planned Corrective Action: The University is no longer accepting HEERF Funding. 2021 HEERF (reported 2022) has been revised and will be resubmitted March 2023, during the US Department of Education?s submission window. All future applicable reporting will be completed within the required timeframe(s). All required reports will be put on the University?s website. Person Responsible for Corrective Action Plan: Laurel Maguire, Controller Anticipated Date of Completion: March 2023
View Audit 27151
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