Corrective Action Plans

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Finding 29101 (2022-003)
Material Weakness 2022
Finding 2022-003 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution CFDA #93.498 Finding Summary: The Organization had a lost revenue calculation error of $141,573 on the HHS special repor...
Finding 2022-003 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution CFDA #93.498 Finding Summary: The Organization had a lost revenue calculation error of $141,573 on the HHS special reports causing a difference to the actual lost revenues (i.e. there were more lost revenues reported on the HHS special report). There were no questioned costs. Responsible Individuals: Darin Ohe, CFO Corrective Action Plan: All tracking documents that have calculations will be reviewed by the Vice President of Finance if the CFO compiles for accuracy and vice versa. The reviewer will sign off by email that they have reviewed and agree with the calculations. The calculation of lost revenues was updated on the period 4 report which was submitted to HHS. Anticipated Completion Date: 3/31/23
2022-002 Material Weakness - Davis-Bacon Act Planned Corrective Action Proper documentation not maintained by the Authority to verify compliance with Davis Bacon, due to the lack of monitoring of contractor compliance and adequate records retention by project management. A new system of checks and b...
2022-002 Material Weakness - Davis-Bacon Act Planned Corrective Action Proper documentation not maintained by the Authority to verify compliance with Davis Bacon, due to the lack of monitoring of contractor compliance and adequate records retention by project management. A new system of checks and balance was created between Finance, Capital Project, and Procurement Departments to reconcile, evaluate, and manage construction projects on a monthly basis to ensure proper documentation and tracking. Management will add an additional requirement to include this as part of the accounts payable process. Anticipated Completion Date Complete by September 30, 2022 Responsible Contact Person Rico Owens, Senior Accountant
Issue ?Reporting is completed by submitting a Uses of Award Report by answering a series of questions on the CDFI Fund?s AMIS webpage. For the Uses of Award Report which was due on March 31, 2022, the submission did not occur until June 28, 2022. When initially submitting the Uses of Award Report ...
Issue ?Reporting is completed by submitting a Uses of Award Report by answering a series of questions on the CDFI Fund?s AMIS webpage. For the Uses of Award Report which was due on March 31, 2022, the submission did not occur until June 28, 2022. When initially submitting the Uses of Award Report in March 2022, the on-line submission through AMIS was not properly completed. Action Plan 1? The report will be completed a minimum of two weeks before the deadline. This will be documented in the form of a screenshot and retained in records. Action Plan 2? Upon submission the credit union will verify the report was received. This will be documented in the form of a screenshot and retained in records. Contact: Michael Daugherty, President/CEO, manager@cplusfcu.org Anticipated completion date: 12/15/2022
Finding 2022.001 PREVAILING WAGE REQUIREMENTS Contact person: Kelley Terry, Business Manager Corrective action planned: 1) MCISD requested Collier Construction to provide the weekly certified payroll reports that are in compliance with 29 CFR 5.5(a)(3) around December 8, 2022. They provided us...
Finding 2022.001 PREVAILING WAGE REQUIREMENTS Contact person: Kelley Terry, Business Manager Corrective action planned: 1) MCISD requested Collier Construction to provide the weekly certified payroll reports that are in compliance with 29 CFR 5.5(a)(3) around December 8, 2022. They provided us the Wage survey information that we forwarded to the Auditor. 2) MCISD administration had a meeting to discuss Internal Controls. Effective immediately, any future Construction projects MCISD will include in our contracts the Wage Rate and the DOL requirements. Anticipated completion date: MCISD will follow up with Collier Construction when they open back up on Tuesday, January 17, 2023, to let them know we are expecting the certified weekly payroll reports as soon as possible.
Single Audit Finding 2022-003 Material Weakness and Nonmaterial Noncompliance ? Allowable Costs and Eligibility See Co...
Single Audit Finding 2022-003 Material Weakness and Nonmaterial Noncompliance ? Allowable Costs and Eligibility See Corrective Action Plan for chart / table.
View Audit 29366 Questioned Costs: $1
Single Audit Finding 2022-002 Non-Material Non-Compliance ? Allowable Costs See Corrective Action Plan for chart / t...
Single Audit Finding 2022-002 Non-Material Non-Compliance ? Allowable Costs See Corrective Action Plan for chart / table.
2022 ? 001 ALN 14.850 Public and Indian Housing ? Special Tests & Provisions ? Wage Rate Requirements The Executive Director acknowledges the findings and the Authority?s ...
2022 ? 001 ALN 14.850 Public and Indian Housing ? Special Tests & Provisions ? Wage Rate Requirements The Executive Director acknowledges the findings and the Authority?s management is currently implementing the necessary changes to remediate these noncompliance instances. Person Responsible for Correction of Finding: Pauline Sturgill, Executive Director Projected Completion Date: June 30, 2023
Finding 2022-003 ARPA Reporting Significant Deficiency ? Internal Control over Financial Reporting Description of Finding Controls over Project and Expenditure Reports did not exist to ensure accuracy of submitted data. Statement of Concurrence or NonConcurrence Management agrees with the finding. ...
Finding 2022-003 ARPA Reporting Significant Deficiency ? Internal Control over Financial Reporting Description of Finding Controls over Project and Expenditure Reports did not exist to ensure accuracy of submitted data. Statement of Concurrence or NonConcurrence Management agrees with the finding. Corrective Action The City will institute proper controls to ensure any reporting is prepared and reviewed by different individuals. Name of Contact Person Robin Stanziale Projected Completion Date June 30, 2023
2022-001, 2021-001 - MATERIAL WEAKNESS AND MATERIAL NONCOMPLIANCE - SLIDING FEE - Contact Person - Patricia Fournier, CFO Completion Date - 11/01/2022. Finding ? We tested 60 sliding fee encounters and noted that 3 of 60 sliding fee encounters tested did not have sliding fee applications, 13 out of ...
2022-001, 2021-001 - MATERIAL WEAKNESS AND MATERIAL NONCOMPLIANCE - SLIDING FEE - Contact Person - Patricia Fournier, CFO Completion Date - 11/01/2022. Finding ? We tested 60 sliding fee encounters and noted that 3 of 60 sliding fee encounters tested did not have sliding fee applications, 13 out of 60 patients were discounted the wrong amount, 2 out of 60 patients sliding fee applications could not be located. We recommend the Organization continue with the corrective action plan implemented in the prior year in response to audit finding 2021-001 to ensure sliding fee applications are completed before encounters are billed. We recommend that management continue to review and monitor the internal sliding fee application auditing process for further improvements and consider increasing sample sizes. Response and Resolution: RESOLUTION: 1. Staff Training. The onset of COVID, staff turnover, and the abrupt implementation of Telehealthcaused some gaps in the adherence of processes such as sliding fee application updates. Honordeveloped and implemented an in-depth monthly training for front-end processes. The trainingincludes patient check-in, insurance verification, and sliding fee application completion. Participantscomplete a test to ensure the necessary knowledge and skills were obtained during the training. If theparticipant?s score is under our benchmark, they will complete the training again. This training isrequired for all front-end staff and practice managers. Staff will complete the training as part of newemployee on-boarding. Staff will also be required to complete an annual update training. 2. Dashboard Reporting & Sample Testing. A need for more immediate accountability was determinedin review of the clinic site infrastructure. Honor developed and implemented a daily dashboard to beused by the Practice Manager to monitor prior day visits to ensure that all patient check-in, insuranceverification, and sliding fee applications information is input correctly. In addition, the dailydashboards are audited by our Risk Management team weekly and the number of reviews will beincreased to 25% of the total weekly charts. These audits include verifying the sliding fee applicationis completed correctly with a signature, the slide was input correctly in the EHR, and a proof of incomeis attached. These weekly audits are accumulated monthly and reported to management for review.A new workflow process will be developed to ensure that appropriate on-site staff view the slideinformation in the EHR to ensure it matches the sliding fee application and proof of income. 3. Review Current Policy and Application ? Honor will review the current sliding fee application and policy. The review will include a patient survey to determine if our application is appropriate for our patient population to complete. Honor will also determine if requiring proof of income is a barrier to care for our patients. Management will explore all Federal, State and local regulations and guidelines to ensure our policy stays within these regulations.
2022-002 - MATERIAL WEAKNESS AND MATERIAL NONCOMPLIANCE - FRINGE BENEFITS Contract Person - Patricia Fournier, CFO Completion Date - 10/01/2022 Finding - We noted fringe benefits were charged based on a flat budgeted percentage rather than actual expenses. We recommend that fringe benefits be charge...
2022-002 - MATERIAL WEAKNESS AND MATERIAL NONCOMPLIANCE - FRINGE BENEFITS Contract Person - Patricia Fournier, CFO Completion Date - 10/01/2022 Finding - We noted fringe benefits were charged based on a flat budgeted percentage rather than actual expenses. We recommend that fringe benefits be charged to grants based on the actual expenses to ensure costs are allowable and do not result in a potential takeback of funds. Response and Resolution: RESOLUTION: Honor revised the process for allocating and recording fringe benefits in our accounting system. Incoming vendor invoices for fringe benefits are posted to a pre-paid account until the time for the cost to be recognized as an expense. Actual fringe benefit costs are recognized as an expense with each payroll. The fringe benefit cost is allocated by employee to the appropriate location and funding source at the time of payroll. These actual expenses are then reported on all funder financial summary reports.
The Corporation contacted the local Continuum of Care and regional HUD office in an effort to verify the required number of units occupied by individuals meeting the definition of "homeless". The local Continuum of Care had no record of the original grant agreement or required number of "homeless" t...
The Corporation contacted the local Continuum of Care and regional HUD office in an effort to verify the required number of units occupied by individuals meeting the definition of "homeless". The local Continuum of Care had no record of the original grant agreement or required number of "homeless" to be served. The Corporation contacted three staff in the regional HUD office, including the staff that had been our representative for annually renewed operation and support service grants for the two projects. Regional HUD staff were not able to provide a copy of the original grant agreements which would indicate the number of persons to be served by each project. HUD staff stated that they do not keep copies of grant agreements longer than seven years. Corporation management will continue to work with HUD personnel to determine the continuing compliance requirements of the Continuum of Care funding received for initial construction or rehabilitation. Corporation management will continue to serve individuals meeting the definition of homelessness at its two projects and document evidence in the file.
2022-002 Internal Control over Compliance and Compliance ? Special Tests and Provisions Contact: Reginald Gregory Title: Executive Director/Controller Phone Number: 202-772-4300 Estimated completion date: June 30, 2023 Corrective Action: Program management will ensure that Case Management te...
2022-002 Internal Control over Compliance and Compliance ? Special Tests and Provisions Contact: Reginald Gregory Title: Executive Director/Controller Phone Number: 202-772-4300 Estimated completion date: June 30, 2023 Corrective Action: Program management will ensure that Case Management team and staff who are responsible for selecting housing units for the Fortitude MD program receive training on how to determine if the proposed rent meets the fair market rent (FMR). For leases that include utilities within the base rent, Case Management will make sure that there is a breakdown of the total proposed rent that shows the Base Rent Rate, Utility Portion, and Other miscellaneous expenses is appropriately documented. At time of sign off on the Lease Up packet, the Fortitude MD Sr. Program Manager will review the lease and confirm that the proposed rent does not exceed the FMR. The completed Lease-up Packet will be submitted to HHS management for final review, approval and submission to Finance for processing Monthly, the Sr. Program Manager will review the rent roster that will include a column for the current FMR and confirm that the rent being paid does not exceed the FMR.
Management Response/Corrective Action Plan: The Business Manager is working with the new Buildings, Grounds, and Transportation Director, as well as the vendors directly to ensure that we include this in any projects moving forward. The Business Manager has requested to be involved in any projects o...
Management Response/Corrective Action Plan: The Business Manager is working with the new Buildings, Grounds, and Transportation Director, as well as the vendors directly to ensure that we include this in any projects moving forward. The Business Manager has requested to be involved in any projects over $2,000 to ensure we are compliant. In the past projects were started without the knowledge of the Business Manager and often vendors did not want to comply after the fact.
Management Response/Corrective Action Plan: RSU10 hired a Grant Writer that was assisting us with this grant who stopped working on the project without informing us. However, it is ultimately up to RSU 10 to make sure all forms and documents were completed on time. Due to this Grant being awarded r...
Management Response/Corrective Action Plan: RSU10 hired a Grant Writer that was assisting us with this grant who stopped working on the project without informing us. However, it is ultimately up to RSU 10 to make sure all forms and documents were completed on time. Due to this Grant being awarded right before COVID-19, it fell off the Business Managers radar and items like this were missed and overlooked. The Business Manager just let the Technology Director with the help of this Grant Writer just take control of the grant, due to being overwhelmed with all the CRF and ESSER grants that the school received, and she missed several items with this Grant. The Business Manager will ensure all future projects she is involved in all necessary steps.
Name of Contract Person: Liesel Weiland Matanuska-Susitna Borough Comptroller 350 E. Dahlia Avenue Palmer, AK 99645 Phone: (907) 861-8624 Finding 2022-002 Significant Deficiency in Internal Control over Compliance, Noncompliance ? Reporting Corrective Action: The Borough will ensure timely year end ...
Name of Contract Person: Liesel Weiland Matanuska-Susitna Borough Comptroller 350 E. Dahlia Avenue Palmer, AK 99645 Phone: (907) 861-8624 Finding 2022-002 Significant Deficiency in Internal Control over Compliance, Noncompliance ? Reporting Corrective Action: The Borough will ensure timely year end closing and review of audit schedules to ensure timely reporting. Expected completion date: Fiscal year 2023
U.S. Department of Health and Human Services Inspire Development Centers respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 01, 2021 to June 30, 2022. The finding from the schedule of findings and questioned costs are discussed below. The f...
U.S. Department of Health and Human Services Inspire Development Centers respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 01, 2021 to June 30, 2022. The finding from the schedule of findings and questioned costs are discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS? FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Health and Human Services 2022-001 Head Start Program ? Assistant Listing No. 93.600 Recommendation: CLA recommends that Inspire reconcile fixed assets semi-annually to ensure fixed assets reported on SF-429 are accurate. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Inspire will ensure that the fixed asset report is reconciled to the reported value on the SF 429 before submitting. Name of the contact person responsible for corrective action: Stephanie Mathews Planned completion date for corrective action plan: January 12, 2023 If the U.S. Department of Health and Human Services has questions regarding this plan, please call Stephanie Mathews at 509-839-8575.
Finding 28840 (2022-104)
Material Weakness 2022
Assistance Listings number: 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Fund Contact Person(s): Jayson Vowell, Finance Director Anticipated completion date: June 30, 2023 Concur. During the audit period, fiscal year 21-22, the only reportable expenditure to the grantor was the $...
Assistance Listings number: 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Fund Contact Person(s): Jayson Vowell, Finance Director Anticipated completion date: June 30, 2023 Concur. During the audit period, fiscal year 21-22, the only reportable expenditure to the grantor was the $10 million standard deduction for revenue loss claimed by the County. The remaining reports did not include reportable expenditures as the projects identified had not begun as construction contracts are currently being negotiated between the County and contractors. Therefore, the County either did not perform a review or did so verbally between staff. To ensure County policy and procedures are followed, the County will require that all future program reports are reviewed for accuracy, agree to County records, and contain only allowable expenditures before submitting them to the federal agency. In addition, the County will ensure that this review process is documented.
Finding 28835 (2022-103)
Material Weakness 2022
Assistance Listings number: 17.258 WIOA Adult Program; Assistance Listings number: 17.259 WIOA Youth Activities; and Assistance Listings number: 17.258 WIOA Dislocated Worker Formula Grants Contact Person(s): Jeremy Flowers, WIOA Executive Director and Lisa Grannis, WIOA Board Clerk and Complia...
Assistance Listings number: 17.258 WIOA Adult Program; Assistance Listings number: 17.259 WIOA Youth Activities; and Assistance Listings number: 17.258 WIOA Dislocated Worker Formula Grants Contact Person(s): Jeremy Flowers, WIOA Executive Director and Lisa Grannis, WIOA Board Clerk and Compliance Specialist Anticipated completion date: June 30, 2023 Concur. To help ensure the County meets the WIOA Cluster?s earmarking requirement to spend no less than 20 percent of WIOA Youth Activities funds allocated to the County to provide in-school and out-of-school youth with paid and unpaid work experiences (WEX), the County has revised its process for tracking work experience expenditures. The County will utilize the revised process and provide technical assistance to the sub-recipient, Chicanos Por La Causa (CPLC) to implement procedures that will lead to an increase in Youth enrollments and placement into WEX to ensure at least 20 percent of the WIOA Youth Activities funds allocated to the County are used to provide in-school and out-of-school youth with paid and unpaid WEX. County staff is currently working with CPLC staff to implement a different approach to attaining the WEX requirements. The recommended solutions include improved tracking and monitoring of the WIOA Youth WEX activities to include both paid and unpaid work experiences, increasing all youth outreach, partnering with other local youth programs, and enrolling youth with barriers pursuant to current policy. The County will be tracking Youth progress and will be revising strategies as needed. The County?s goal is to see a significant increase in Youth WEX program activities by the end of fiscal year 22-23.
View Audit 28884 Questioned Costs: $1
Finding 28834 (2022-102)
Material Weakness 2022
Assistance Listings number: 17.258 WIOA Adult Program; Assistance Listings number: 17.259 WIOA Youth Activities; and Assistance Listings number: 17.258 WIOA Dislocated Worker Formula Grants Contact Person(s): Jeremy Flowers, WIOA Executive Director and Lisa Grannis, WIOA Board Clerk and Complia...
Assistance Listings number: 17.258 WIOA Adult Program; Assistance Listings number: 17.259 WIOA Youth Activities; and Assistance Listings number: 17.258 WIOA Dislocated Worker Formula Grants Contact Person(s): Jeremy Flowers, WIOA Executive Director and Lisa Grannis, WIOA Board Clerk and Compliance Specialist Anticipated completion date: June 30, 2023 Concur. The nonprofit organization was created in part to serve as the administrative arm of the Local Board and to provide a location for a resource center where WIOA services would be provided. The County did not distinguish fiscal responsibilities between parties and therefore assumed that certain expenditures of the Local Board and nonprofit would be allowable and could be paid directly by the County. The County considered the expenditures of the nonprofit to be program related, even though they were not directly incurred by the County. The County will improve its accounts payable policies and procedures for processing invoices using established process within the Finance Department, including ensuring all invoices are addressed to the County prior to payment. In addition, the County will establish clear contractual agreements that establish fiscal responsibilities that follow the program?s requirements. Finally, the County will coordinate with the pass-through grantor for the repayment of the unallowable costs identified in the finding.
View Audit 28884 Questioned Costs: $1
Finding 28833 (2022-101)
Material Weakness 2022
Assistance Listings number: 10.665 Schools and Roads ? Grants to States Contact Person(s): Catrina Jenkins, Emergency Management Manager Anticipated completion date: June 30, 2023 Concur. County staff has been educated on the 45-day comment period and proposal to the Resource Advisory Committee...
Assistance Listings number: 10.665 Schools and Roads ? Grants to States Contact Person(s): Catrina Jenkins, Emergency Management Manager Anticipated completion date: June 30, 2023 Concur. County staff has been educated on the 45-day comment period and proposal to the Resource Advisory Committee (RAC). The County has put into place corrective actions to negate these issues in the future. These actions have included a calendar reminder to publish the 45-day comment period in our paper of record and to submit the proposed use of fund to the local RAC prior to spending any funds. The County has reached out to the current coordinator of the local RAC to ensure the County will be able to coordinate our efforts efficiently in the future. The County will develop written policy and procedures for these funds to ensure that these action items are followed and will train all staff according to these policies as it is applicable.
A. Current Findings on the Schedule of Findings and Questioned Costs 1. Finding 2022-001 a. Comments on the Finding and Each Recommendation We agree with the finding and the auditor's recommendation has been adopted. b. Action(s) Taken or Planned on the Finding Management agrees with the finding. In...
A. Current Findings on the Schedule of Findings and Questioned Costs 1. Finding 2022-001 a. Comments on the Finding and Each Recommendation We agree with the finding and the auditor's recommendation has been adopted. b. Action(s) Taken or Planned on the Finding Management agrees with the finding. In addition to hiring a new Director of Compliance and rebuilding the compliance team in 2021 to review and approve certifications, we have increased our corporate operations team and they are now responsible for reviewing all certification due dates weekly with the site teams to ensure timely completion of certifications.
Finding 28816 (2022-001)
Significant Deficiency 2022
Name of Auditee: Waterbrook Place, Inc. HUD auditee identification Number: 085-HD044 Name of audit firm: Donovan CPAs Period covered by the audit: For the year ended December 31, 2022 Corrective action prepared by: Name: Cale Mitchell, Spectrum Health Care Position: Management Agent Telephone number...
Name of Auditee: Waterbrook Place, Inc. HUD auditee identification Number: 085-HD044 Name of audit firm: Donovan CPAs Period covered by the audit: For the year ended December 31, 2022 Corrective action prepared by: Name: Cale Mitchell, Spectrum Health Care Position: Management Agent Telephone number: (573) 514-7312 Email address: bacton@spectrumhealthcare.org 1) Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Corrective Action Not Started or in Process Finding 2022-001 ? Filing Annual Reports Timely Statement of Condition: Waterbrook violated the U.S. Department of Housing and Urban Development (HUD) Regulatory agreement by not filing 2022 audited financial statements on time. HUD regulatory agreement requires annual audited financial statements be submitted to Real Estate Assessment Center (REAC) using the Financial Assessment Subsystem (FASSUB) 90 days after year end. Corrective Action Plan: Waterbrook will file the 2022 audited financial statements with HUD and REAC using the FASSUB system. Status: In Process.
In Finding 2022-002, it was reported that the Uniform Data System report submitted to DHHS for the year ended December 31, 2021 contained incorrect data for patient revenue. The charges and payments were not correctly reported on Table 9D of the UDS report. The charges were understated by approxima...
In Finding 2022-002, it was reported that the Uniform Data System report submitted to DHHS for the year ended December 31, 2021 contained incorrect data for patient revenue. The charges and payments were not correctly reported on Table 9D of the UDS report. The charges were understated by approximately $2.4 million. Management recognizes the importance of complying with federal reporting guidelines. In response to Finding 2022-002, efforts will be made to ensure that the revenue and expenses recorded is reconciled to the revenue and expenses on the UDS report. This will be implemented by the Chief Executive Officer by October 31, 2022.
Finding 28789 (2022-005)
Significant Deficiency 2022
The City agrees with this finding and will work with Grant Administrators to ensure that reimbursement requests are in compliance with the guidelines set by state and federal agencies. Due to the City?s limited budget and restrictions set by Grant Agencies, the City and the Grant Administrators agr...
The City agrees with this finding and will work with Grant Administrators to ensure that reimbursement requests are in compliance with the guidelines set by state and federal agencies. Due to the City?s limited budget and restrictions set by Grant Agencies, the City and the Grant Administrators agreed to wait to submit invoices or group invoices to meet the required threshold for reimbursements. The Grant Agencies have not delayed or rejected payment of any invoices due to the delay in submissions.
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