Corrective Action Plans

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Finding 20271 (2022-002)
Significant Deficiency 2022
Finding 2022-002 ? Considered a significant deficiency in internal control over compliance/immaterial non-compliance Federal Grant ? ALN 93.958 Condition ? During testing it was noted that FICA costs were overcharged by $14,047. Corrective Action ? HealthWest will review its methods for determini...
Finding 2022-002 ? Considered a significant deficiency in internal control over compliance/immaterial non-compliance Federal Grant ? ALN 93.958 Condition ? During testing it was noted that FICA costs were overcharged by $14,047. Corrective Action ? HealthWest will review its methods for determining allocations of fringe benefits to their grants. Review and, any necessary, updates to daily procedures and processes are occurring. All finance staff and any HealthWest staff assigned to grants will be required to obtain grants specific training annually. Finally, monthly monitoring of all expenses will be reviewed. Contract Person ? Brandy Carlson, Chief Financial Officer Anticipated Completion Date ? June 30, 2023
View Audit 21044 Questioned Costs: $1
Finding Number: 2022-015 ? Reporting Corrective Action Plan: A process has been put in place for the school principal to review all RFRs prior to submission to the grantor. Approval is evidenced by email sent by principal to the Director of Grant Management, which is saved with the RFR as support. R...
Finding Number: 2022-015 ? Reporting Corrective Action Plan: A process has been put in place for the school principal to review all RFRs prior to submission to the grantor. Approval is evidenced by email sent by principal to the Director of Grant Management, which is saved with the RFR as support. Responsible Individuals: Nachum Golodner, Director of Accounting Anticipated Completion Date: June 30, 2023
Finding 2022-001: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Reporting Cluster: Not applicable Federal Agency: Department of Health and Human Services (?HHS?) Award Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing #:...
Finding 2022-001: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Reporting Cluster: Not applicable Federal Agency: Department of Health and Human Services (?HHS?) Award Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing #: 93.498 Assistance Listing Title: COVID-19 - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution ? Period 4 Award Year(s): January 1, 2020 ? December 31, 2022 Management acknowledges the identified issue and concurs with the suggested course of action. A comprehensive analysis of the inputs utilized in the computation of lost revenue will be undertaken by Management. This meticulous review aims to guarantee the precision and completeness of the calculation. A thorough documentation of this review process will be conducted, ensuring the establishment of a comprehensive audit trail and accuracy of the detailed computation. Furthermore, Management is actively pursuing the rectification of the previous submissions in the HRSA portal to accurately reflect the necessary corrections stemming from the clerical error. The anticipated timeline for the review and subsequent filing is set for completion by September 30, 2023.
CORRECTIVE ACTION PLAN May 22, 2023 United States Department of Health and Human Services Community Health Services, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2022. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: December 31...
CORRECTIVE ACTION PLAN May 22, 2023 United States Department of Health and Human Services Community Health Services, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2022. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: December 31, 2022 The findings from the December 31, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS SIGNIFICANT DEFICIENCY 2021.001 ? Sliding Fee Scale Discount Recommendation The Center should implement controls to ensure proper slide fee discounts are provided. Action Taken The Center implemented internal controls to mitigate the risk of missing sliding fee discount documentation. The creation of this control consisted of designing a report that would identify all sliding fee discount applicants for the specified timeframe, as well as identify whether supporting documentation had been scanned into the patient?s electronic health record. As a result of the repeated finding, the Center added an additional layer of review. The Director of Development, Grants and Outreach reviews all slide applications before they are scanned and entered into the electronic health record and applied to the patient?s account. The Center will continue monthly internal auditing procedures where an Eligibility Specialist haphazardly selects slide applications from the previous month to ensure compliance. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Dianna Kulmacz, CFO at (860) 808-8765. Sincerely yours, Dianna Kulmacz Chief Financial Officer
Significant Deficiency in Internal Control 2022-004 Reporting Repeat finding from prior year: No Finding Summary: ? The Program requires the Authority to prepare and provide quarterly financial status reports to the granting agency. During our testing over reporting, we noted that quarterly reports ...
Significant Deficiency in Internal Control 2022-004 Reporting Repeat finding from prior year: No Finding Summary: ? The Program requires the Authority to prepare and provide quarterly financial status reports to the granting agency. During our testing over reporting, we noted that quarterly reports were not prepared during 2022. Responsible Individuals: Housing and Community Investment Director, Housing Compliance Manager, Accounting Supervisor Corrective Action Plan: Quarterly reports were completed during the audit. We have setup calendar appointments and added this reporting to our compliance calendar. Anticipated Completion Date: May 31, 2023
MATERIAL WEAKNESS IN INTERNAL CONTROL OVER COMPLIANCE AND MATERIAL NONCOMPLIANCE ? U.S. DEPARTMENT OF EDUCATION ? PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, COVID-19 ? EDUCATION STABILIZATION FUND, FEDERAL ALN 84.425 2022-002 Internal Control Over Compliance and Material Noncompliance With E...
MATERIAL WEAKNESS IN INTERNAL CONTROL OVER COMPLIANCE AND MATERIAL NONCOMPLIANCE ? U.S. DEPARTMENT OF EDUCATION ? PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, COVID-19 ? EDUCATION STABILIZATION FUND, FEDERAL ALN 84.425 2022-002 Internal Control Over Compliance and Material Noncompliance With Equipment and Real Property Management Requirements Finding Summary 2 CFR ? 200.313 (c)(1) and (d)(1) requires that Aurora Charter School (the School) obtain approval from the federal funding agency or pass-through agency prior to the purchase of equipment with federal funding. During our audit, we noted the School did not have sufficient controls in place within the COVID-19 ? Education Stabilization Fund federal program to assure compliance with federal equipment and real property management requirements, resulting in material noncompliance. Corrective Action Plan Actions Planned ? This condition and the resulting material noncompliance was caused by a misunderstanding of the cost threshold at which federal equipment and real property management compliance requirements must be applied, due to the School?s adopted internal capitalization threshold being lower than the federal threshold. The School intends to revise its internal capitalization threshold to align with the federal threshold, and to review its other control procedures relating to equipment and real property management requirements to ensure compliance for future federal awards expenditures. Official Responsible ? Matthew Cisewski, Executive Director. Planned Completion Date ? June 30, 2023. Disagreement With or Explanation of Finding ? The School agrees with this finding. Plan to Monitor ? The School?s Executive Director, Matthew Cisewski, will oversee the implementation of proposed corrective actions and verify that appropriate controls are in place and understood by individuals responsible for federal program oversite at the School to ensure future compliance with federal equipment and real property management requirements.
The School District acknowledges this requirement and will make corrective procedures going forward to make sure the Davis-Bacon Act language will be included in any construction project contracts over $2,000.
The School District acknowledges this requirement and will make corrective procedures going forward to make sure the Davis-Bacon Act language will be included in any construction project contracts over $2,000.
District Response and Corrective Action Plan: With the transition of the entire business office, it was discovered that grant budgets were not submitted and claims were not filed. The current business office updated the grant budgets and submitted claims to the best of their ability with the informa...
District Response and Corrective Action Plan: With the transition of the entire business office, it was discovered that grant budgets were not submitted and claims were not filed. The current business office updated the grant budgets and submitted claims to the best of their ability with the information that they had. Grants will be maintained by the business manager, the curriculum director, and the student services director. Weekly meetings are in place to review grant budgets and submit the appropriate claims quarterly after purchases have been made.
District Response and Corrective Action Plan: The Business Office has implemented new procedures requiring requisitions prior to every purchase. All purchases for the 2022-2023 school will have approval. Timecards are approved in Skyward via the Organizational Chart by each employee?s supervisor.
District Response and Corrective Action Plan: The Business Office has implemented new procedures requiring requisitions prior to every purchase. All purchases for the 2022-2023 school will have approval. Timecards are approved in Skyward via the Organizational Chart by each employee?s supervisor.
District Response and Corrective Action Plan: The district will perform the sampling prior to November 15th to meet the reporting deadline.
District Response and Corrective Action Plan: The district will perform the sampling prior to November 15th to meet the reporting deadline.
District Response and Corrective Action Plan: The Business Office will monitor the list at SAM.gov monthly and will check new vendors against the suspendered and debarment list. The District will not work with debarred vendors.
District Response and Corrective Action Plan: The Business Office will monitor the list at SAM.gov monthly and will check new vendors against the suspendered and debarment list. The District will not work with debarred vendors.
PRPHA has a provider with vast experience in this program and is currently serving other government authorities in the mainland that are entitled with this program. We have assured that they are following the regulations that are set forth by the Treasury Department. However, because of the shor...
PRPHA has a provider with vast experience in this program and is currently serving other government authorities in the mainland that are entitled with this program. We have assured that they are following the regulations that are set forth by the Treasury Department. However, because of the short period of time that we have had this program in Puerto Rico we have had to adapt the practices that have been adopted in the other agencies as the formal procedures as a start up implementation. We are establishing more procedures as the program evolves in the island. This is an on going action plan.
Corrective Action: A two-person team has been developed to ensure USDA terms and conditions are followed. Both team members will be responsible for reviewing and understanding the terms and conditions of the USDA loans, including the reporting requirements and applicable deadlines. Each team member ...
Corrective Action: A two-person team has been developed to ensure USDA terms and conditions are followed. Both team members will be responsible for reviewing and understanding the terms and conditions of the USDA loans, including the reporting requirements and applicable deadlines. Each team member will be assigned to complete a specific requirement and the other member will independently review and acknowledge prior to submission. Person Responsible: Janet Soper, VP/CFO, Labette Health (620} 820-5251 janets@labettehealth.com Proposed Completion Date: July 20, 2023
2022-001 Allowable Costs/Cost Principles The ESSER Coordinator, Shane Patrick, Assistant Superintendent of Operations and the Chief Financial Officer, Terri Raskiewicz, are reviewing all actual expenses that pertain to COVID-19-Education Stabilization Fund. Shane Patrick did reach out to DESE and D...
2022-001 Allowable Costs/Cost Principles The ESSER Coordinator, Shane Patrick, Assistant Superintendent of Operations and the Chief Financial Officer, Terri Raskiewicz, are reviewing all actual expenses that pertain to COVID-19-Education Stabilization Fund. Shane Patrick did reach out to DESE and DESE provided our district with a letter stating these expenses would have been approved had we sent in a justification form. This item was approved by DESE in our overall ESSER plan. We implemented on July 1, 2022
View Audit 19455 Questioned Costs: $1
Finding 20136 (2022-007)
Significant Deficiency 2022
Finding: 2022-007 Untimely Review of SSI Termination Name of contact person: Virginia Ewuell, & Angel Joyner/Adult Medicaid Supervisors Corrective Action: Automatic verification will be made available to caseworkers on the computer. The caseworker will verify...
Finding: 2022-007 Untimely Review of SSI Termination Name of contact person: Virginia Ewuell, & Angel Joyner/Adult Medicaid Supervisors Corrective Action: Automatic verification will be made available to caseworkers on the computer. The caseworker will verify their manual calculations with the automated calculations. The automated verification will also check the calculated family?s income against the State-provided income standard. A printout of the verifications will accompany the caseworker?s records in the file to be reviewed by a supervisor. "Proposed Completion Date: Training and corrections will be completed by January15, 2023. Case record reviews are currently being conducted and will be ongoing. "
Finding 20135 (2022-006)
Significant Deficiency 2022
Finding: 2022-006 Inadequate Request for Information Name of contact person: Veronica Lyons, Tina Radford, Virginia Ewuell, and Angel Joyner/ Medicaid Supervisors Corrective Action: Files will be reviewed internally by the Medicaid Supervisors and Quality Contr...
Finding: 2022-006 Inadequate Request for Information Name of contact person: Veronica Lyons, Tina Radford, Virginia Ewuell, and Angel Joyner/ Medicaid Supervisors Corrective Action: Files will be reviewed internally by the Medicaid Supervisors and Quality Control workers to ensure that the proper requests are made for information needed. Workers have been given an agency/State approved checklist that included everything that is needed for a case to be dispositioned. This checklist should eliminate the inadequate request for information. Case notes will be documented using an agency/State approved narrative template that will include everything that should be requested for a case. "Proposed Completion Date: Training and corrections will be completed by January15, 2023. Case record reviews are currently being conducted and will be ongoing. "
Finding 20134 (2022-005)
Significant Deficiency 2022
Finding: 2022-005 Inaccurate Resource Calculation Name of contact person: Veronica Lyons, Tina Radford, Virginia Ewuell, and Angel Joyner/ Medicaid Supervisors Corrective Action:Files will be reviewed internally by Medicaid Supervisors and Quality Control worke...
Finding: 2022-005 Inaccurate Resource Calculation Name of contact person: Veronica Lyons, Tina Radford, Virginia Ewuell, and Angel Joyner/ Medicaid Supervisors Corrective Action:Files will be reviewed internally by Medicaid Supervisors and Quality Control workers to ensure proper documentation is in place for eligibility. Workers will be retrained on what files should contain and the importance of complete and accurate record keeping. The workers have also been provided an agency/State approved checklist that includes everything that should be included in a case. All files will include online verifications, documented resources of income and those amounts will match information in NCFAST. The workers have been provided an agency/State approved automated budget that will be completed and compared to the information in NCFAST. The results found or documentation made in case notes will clearly indicate what actions were performed and the results of those actions. Workers have been provided a agency/State approved documentation template to use for each case. "Proposed Completion Date: Training and corrections will be completed by January15, 2023. Case record reviews are currently being conducted and will be ongoing. "
Finding 20133 (2022-004)
Significant Deficiency 2022
Finding: 2022-004 Inaccurate Information Entry Name of contact person: Veronica Lyons, Tina Radford, Virginia Ewuell, & Angel Joyner/Medicaid Supervisors Corrective Action: Files will be reviewed internally by Medicaid Supervisors and Quality Control workers t...
Finding: 2022-004 Inaccurate Information Entry Name of contact person: Veronica Lyons, Tina Radford, Virginia Ewuell, & Angel Joyner/Medicaid Supervisors Corrective Action: Files will be reviewed internally by Medicaid Supervisors and Quality Control workers to ensure proper documentation is in place for eligibility. Workers will be retrained on what files should contain and the importance of complete and accurate record keeping. The workers have also been provided an agency/State approved checklist that includes everything that should be included in a case. All files will include online verifications, documented resources of income and those amounts will match information in NCFAST. The workers have been provided a State approved automated budget that will be completed and compared to the information in NCFAST. The results found or documentation made in case notes will clearly indicate what actions were performed and the results of those actions. Workers have been provided an agency/State approved documentation template to use for each case. "Proposed Completion Date: Training and corrections will be completed by January 15, 2023. Case record reviews are currently being conducted and will be ongoing."
Finding 20132 (2022-003)
Significant Deficiency 2022
Finding: 2022-003 IV-D Non-Cooperation Name of contact person: Tina Radford & Veronica Lyons/Family & Children's Medicaid Supervisors Corrective Action: Tina Radford & Veronica Lyons will retrain all Family & Children's Medicaid staff on the importance of foll...
Finding: 2022-003 IV-D Non-Cooperation Name of contact person: Tina Radford & Veronica Lyons/Family & Children's Medicaid Supervisors Corrective Action: Tina Radford & Veronica Lyons will retrain all Family & Children's Medicaid staff on the importance of following MA-3365 Child Support in making referrals to Child Support to avoid issuing benefits to ineligible participants. Child Support referrals will be made on all cases in error and case notes documented in NCFAST. To prevent recurring errors in the future, caseworkers will check their work by using an agency/State approved checklist that includes everything that should be included in their case. Supervisors and Quality Control staff will review a monthly sample of cases to ensure proper information is in place and necessary procedures are taken when determining eligibility. "Proposed Completion Date: Training and corrections will be completed by January 15, 2023. Case record reviews are currently being conducted and will be ongoing."
Finding 20131 (2022-008)
Significant Deficiency 2022
Finding: 2022-008 Significant Deficiency over Eligibility Name of contact person: Lynda Kennedy and Narkeisha Bryant, TANF Supervisors Corrective Action: Files will be reviewed internally by TANF Supervisors and Quality Control Workers to ensure all required e...
Finding: 2022-008 Significant Deficiency over Eligibility Name of contact person: Lynda Kennedy and Narkeisha Bryant, TANF Supervisors Corrective Action: Files will be reviewed internally by TANF Supervisors and Quality Control Workers to ensure all required evidence is received and documented properly. Workers will be retrained on what files should contain and the importance of complete and accurate record keeping. Workers will be retrained to ensure that all files include verifications, documented sources of income and verify that those amounts will match information in NCFAST. The workers will be retrained to ensure that the results found or documentation in case notes will clearly indicate what actions were performed and the results of those actions. Proposed Completion Date: Training and corrections will be completed by March 1, 2023. Case record reviews are currently being conducted and will be ongoing.
Finding 20129 (2022-009)
Significant Deficiency 2022
Finding: 2022-009 Significant Deficiency over Eligibility Name of contact person: Donna Barnes and Linda Jackson, FNS Supervisors Corrective Action: Files will be reviewed internally by FNS Supervisors an Quality Control Workers to ensure that records containt ...
Finding: 2022-009 Significant Deficiency over Eligibility Name of contact person: Donna Barnes and Linda Jackson, FNS Supervisors Corrective Action: Files will be reviewed internally by FNS Supervisors an Quality Control Workers to ensure that records containt all required evidence and is received and documented properly. Workers will be retrained on what files should contain and the importance of complete and accurate record keeping. Workers will be retrained to ensure all files will include verifications, documented sources of income and verify that those amounts will match information in NCFAST. The workers will be retrained to ensure that results found or documentation in case notes will clearly indicate what actions were performed and the results of those actions. Proposed Completion Date: Training and corrections will be completed by March 1, 2023. Case record reviews are currently being conducted and will be ongoing.
Views of Responsible Officials and Planned Corrective Actions ? AAPHC has evaluated the lost revenue calculation used in the period one Provider Relief Fund reporting and has determined that there would still have been sufficient lost revenue incurred to fully obligate the funds received if 340b pha...
Views of Responsible Officials and Planned Corrective Actions ? AAPHC has evaluated the lost revenue calculation used in the period one Provider Relief Fund reporting and has determined that there would still have been sufficient lost revenue incurred to fully obligate the funds received if 340b pharmacy revenue had been included in the calculation. Management intends to correct the lost revenue previously reported when completing the required reporting for the period four funding cycle. Responsible Official: Milton Jordan, Chief Financial Officer Anticipated completion date: March 31, 2023
Views of responsible officials: The project coordinator at the property management firm oversees all recurring projects and ensures deadlines aren't missed. Digital reminders are used to ensure budgets are started and submitted on-time. USDA budgets are required to be submitted 90-days before the en...
Views of responsible officials: The project coordinator at the property management firm oversees all recurring projects and ensures deadlines aren't missed. Digital reminders are used to ensure budgets are started and submitted on-time. USDA budgets are required to be submitted 90-days before the end of the project's fiscal year if a rent increase is being requested and 60-days prior to the end of the fiscal year if no rent increase is requested. The USDA budget submission consists of a hard copy submission comprised of a budget using form 3560-7, a budget narrative, rent increase notice to tenant's (if applicable), and utility allowance calculations (if applicable). Additionally, the budget is submitted electronically through USDA's MINC system. Confirmation of the submission of the USDA budget is provided to the Executive Director and Accounting & HR Technician at Mt. Si Senior Center. Confirmation of the submission of the USDA budget is provided to the Executive Director and Accounting & HR Technician at Mt. Si Senior Center. Confirmation of the submission of the USDA budget is provided to the Executive Director and Accounting & HR Technician at Mt. Si Senior Center.
Finding 2022-002 - Internal control deficiency and noncompliance over calculation of indirect costs The grants management team will be trained on the correct indirect cost calculation and requirements. Review of indirect calculation will be included in the Fund Transfer Request (FTR) review meetings...
Finding 2022-002 - Internal control deficiency and noncompliance over calculation of indirect costs The grants management team will be trained on the correct indirect cost calculation and requirements. Review of indirect calculation will be included in the Fund Transfer Request (FTR) review meetings. Contact person: Administrative Director, Grants ? Erasmo ?Tony? Cortez. Expected Completion Date: October 2023.
View Audit 20475 Questioned Costs: $1
Finding 2022-001 - Internal control deficiency and noncompliance over the allowable activities, allowable costs/cost principles, and reporting compliance requirements Adventist Health had several phone conversations with HRSA over allowable expenses for the ARP program. We explained we had been usi...
Finding 2022-001 - Internal control deficiency and noncompliance over the allowable activities, allowable costs/cost principles, and reporting compliance requirements Adventist Health had several phone conversations with HRSA over allowable expenses for the ARP program. We explained we had been using lost revenue method for prior period reporting. We asked specifically what we can use and not use. We were informed to take the values (in whole) to use as expenses. We were following the guidance we had received by the HRSA employees. The information was confirmed on our methodology for allowable expenses by 2 different employees. Contact Person: Manager, Tax & Audit ? David Dumitru. Expected Completion Date: October 2023
View Audit 20475 Questioned Costs: $1
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