Corrective Action Plans

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SharePoint is being utilized to track reporting requirements to ensure timely filings. The Department will continue to explore ways to streamline the process. However, final numbers for the prior month are typically not available until the second week after the close of the month. This is complicate...
SharePoint is being utilized to track reporting requirements to ensure timely filings. The Department will continue to explore ways to streamline the process. However, final numbers for the prior month are typically not available until the second week after the close of the month. This is complicated by the need for controls in place to ensure the final numbers are correct.
The Department has instituted a policy to maintain electronic back-ups of all documentation utilized to submit all federal reports. The electronic copies are backed up on a SharePoint service. Additionally, the Finance Staff will review the FFR prior to submission.
The Department has instituted a policy to maintain electronic back-ups of all documentation utilized to submit all federal reports. The electronic copies are backed up on a SharePoint service. Additionally, the Finance Staff will review the FFR prior to submission.
The Department has instituted a policy that FFRs must be submitted within 30 days of the end of the quarter. This will allow for any unforeseen circumstances that may delay submission.
The Department has instituted a policy that FFRs must be submitted within 30 days of the end of the quarter. This will allow for any unforeseen circumstances that may delay submission.
The Department has instituted a policy to maintain electronic back-ups of all documentation utilized in the submission of both the UDS and FFR. The electronic copies are backed up on a SharePoint service. Additionally, the Finance Staff will review the FFR prior to submission. Furthermore, the Healt...
The Department has instituted a policy to maintain electronic back-ups of all documentation utilized in the submission of both the UDS and FFR. The electronic copies are backed up on a SharePoint service. Additionally, the Finance Staff will review the FFR prior to submission. Furthermore, the Health Center has recently adopted a new EHR with UDS functionality built into the system allowing us to streamline submission.
The finance department will review Form SF-425 compared to financial reports prior to submittals. Quarterly reminders have been initiated to ensure timely reporting moving forward.
The finance department will review Form SF-425 compared to financial reports prior to submittals. Quarterly reminders have been initiated to ensure timely reporting moving forward.
2023-008 Health Centers Cluster – Assistance Listing No. 93.2242/93.527 Recommendation: We recommend implementing a formal policy and procedure where there is a review of all required reporting by an individual that did not prepare the report. Documentation should be retained to support the review/a...
2023-008 Health Centers Cluster – Assistance Listing No. 93.2242/93.527 Recommendation: We recommend implementing a formal policy and procedure where there is a review of all required reporting by an individual that did not prepare the report. Documentation should be retained to support the review/approval occurrence. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will implement a formal review process for reporting and retain documentation of review. This has been incorporated in subsequent reporting years. Name(s) of the contact person(s) responsible for corrective action: Bobby Royal Planned completion date for corrective action plan: December 2025
2023-007 Health Centers Cluster – Assistance Listing No. 93.2242/93.527 Recommendation: We recommend in the future the Organization retain documentation of key control processes occurring for a reasonable retention period to be able to support control activities around grant compliance and financial...
2023-007 Health Centers Cluster – Assistance Listing No. 93.2242/93.527 Recommendation: We recommend in the future the Organization retain documentation of key control processes occurring for a reasonable retention period to be able to support control activities around grant compliance and financial reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will retain timesheet documentation moving forward to support control process in place. Name(s) of the contact person(s) responsible for corrective action: Bobby Royal Planned completion date for corrective action plan: December 2025
Corrective Action Plan: To address this issue and prevent recurrence, the Town has implemented the following measures: 1. Reconciliation Procedures: Finance Department staff will reconcile all expenditures reported on USDA Form E – RD Project Budget/Cost Certification Reporting to the general ledger...
Corrective Action Plan: To address this issue and prevent recurrence, the Town has implemented the following measures: 1. Reconciliation Procedures: Finance Department staff will reconcile all expenditures reported on USDA Form E – RD Project Budget/Cost Certification Reporting to the general ledger, ensuring both the accuracy of amounts and the correct vendor attribution. 2. Vendor Verification: A vendor cross-check process will be added to the review, requiring staff to match each reported expenditure to the appropriate invoice, purchase order, and vendor record before submission. 3. Review & Approval Controls: A supervisory review will be conducted prior to submission of Form E reports to verify vendor accuracy, in addition to ensuring no duplicate or misclassified expenditures are reported. The Town is committed to ensuring compliance with all USDA reporting requirements. By strengthening reconciliation, vendor verification, and review processes, we will reduce the risk of reporting errors and maintain accurate, reliable financial reporting moving forward.
Reporting Recommendation: Recommended Recovery Connections of Central Florida, Inc. submit its financial reporting as noted in the agreements and maintain documentation of the approval and submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Ac...
Reporting Recommendation: Recommended Recovery Connections of Central Florida, Inc. submit its financial reporting as noted in the agreements and maintain documentation of the approval and submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: We will review each agreement to confirm the reporting requirements, deadlines, and any specific formats or templates that must be followed. A designated team member will be responsible for preparing, reviewing, and submitting the required reports. We will track submission deadlines and ensure that reports are submitted on time. Name of the contact person responsible for corrective action: Joseph Dodi Planned completion date for corrective action plan: December 31, 2025
Reporting Recommendation: Recommended Recovery Connections of Central Florida, Inc. submit its financial and performance reporting as noted in the agreements and maintain documentation of the approval and submission. Explanation of disagreement with audit finding: There is no disagreement with the a...
Reporting Recommendation: Recommended Recovery Connections of Central Florida, Inc. submit its financial and performance reporting as noted in the agreements and maintain documentation of the approval and submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: We will review each agreement to confirm the reporting requirements, deadlines, and any specific formats or templates that must be followed. A designated team member will be responsible for preparing, reviewing, and submitting the required reports. We will track submission deadlines and ensure that reports are submitted on time. Name of the contact person responsible for corrective action: Joseph Dodi Planned completion date for corrective action plan: December 31, 2025
The Board of County Commissioners, with the cooperation and participation of all elected officials, reviews, develops and implements policies and procedures to create a strong internal control environment. The Board of County Commissioners will work with all elected officials, the new county grant a...
The Board of County Commissioners, with the cooperation and participation of all elected officials, reviews, develops and implements policies and procedures to create a strong internal control environment. The Board of County Commissioners will work with all elected officials, the new county grant administrator, and federal, state and local partners to develop policies, procedures, and internal controls designed to accurately track grants, including the application process, verification, oversight, and reporting of grant requirements. The Board of County Commissioners will work with the new county grant administrator to ensure proper grant administration.
2023-004 - (Noncompliance) Completion of Single Audit Federal Program: Assistance Listing #14.228 Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii, U.S. Department of Housing and Urban Development, Passed Through Pennsylvania Department of Community and Economi...
2023-004 - (Noncompliance) Completion of Single Audit Federal Program: Assistance Listing #14.228 Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii, U.S. Department of Housing and Urban Development, Passed Through Pennsylvania Department of Community and Economic Development and Pennsylvania Emergency Management Agency, Pass-Through Entity Identifying Numbers: C000073444, C000075689, C000082264, C000086078, and PEMA-2022-007 Assistance Listing #21.027, COVID-19 - Coronavirus State and Local Fiscal Recovery Funds, U.S. Department of Treasury, Passed Through Pennsylvania Department of Community and Economic Development, Pass-Through Entity Identifying Number: not available Assistance Listing #21.023, COVID-19 Emergency Rental Assistance Program, U.S. Department of Treasury, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: not available Assistance Listing #93.658, Foster Care - Title IV-E, U.S. Department of Treasury, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: not available Condition/Context: The County’s December 31, 2022 Single Audit was not completed and submitted within the required time period. Recommendation: We recommend that as the County gets up and running on the new accounting system, the audit be prioritized in future periods. Views of Responsible Officials and Planned Corrective Actions: The County is working with its fee accountant and external auditors to ensure a timely filing of the Single Audit going forward. Individual Responsible: Finance Department Timeline for corrective action: By December 31, 2026
2024-006 - Reporting - Significant Deficiency/Noncompliance Federal Program: Assistance Listing #21.027, COVID-19 - Coronavirus State and Local Fiscal Recovery Funds, U.S. Department of Treasury, Passed Through Pennsylvania Department of Community and Economic Development, Pass-Through Entity Identi...
2024-006 - Reporting - Significant Deficiency/Noncompliance Federal Program: Assistance Listing #21.027, COVID-19 - Coronavirus State and Local Fiscal Recovery Funds, U.S. Department of Treasury, Passed Through Pennsylvania Department of Community and Economic Development, Pass-Through Entity Identifying Number: not available Condition/Context: The County’s required reports for the quarters ended June 30, 2023, September 30, 2023, and December 31, 2023, were due to be filed by the end of the month after the report end date (July 31, 2023, October 31, 2023, and January 31, 2024, respectively). The County filed its report on August 23, 2023, November 17, 2023, and February 15, 2024 (23, 17, and 15 days, respectively), after the required due date. Views of Responsible Officials and Planned Corrective Actions: Management understands and will seek to implement procedures to ensure future reports are submitted timely. Individual Responsible: Finance Department Timeline for corrective action: By December 31, 2024
Finding 2023-001: The Organization did not timely submit audited financial statements to the Office of Management and Budget (OMB). YMCA of San Juan Response: The Organization agrees with the finding. Corrective action plan: During 2024, YMCA implemented a more timely process for closing its financi...
Finding 2023-001: The Organization did not timely submit audited financial statements to the Office of Management and Budget (OMB). YMCA of San Juan Response: The Organization agrees with the finding. Corrective action plan: During 2024, YMCA implemented a more timely process for closing its financial statements. Additionally, financial information is now presented to the Finance Committee of the Board of Directors on a quarterly basis. As part of these improvements and to prevent this finding in the future, the 2024 financial audit was initiated in March 2025, with the goal of completing both the 2024 financial audit and single audit by June 2025. Name (s) of person (s) responsible for corrective action: Lysbell Araujo, Finance Director YMCA Accounting Department Anticipated completion date: June 2025
Finding Number 2023-020 Subject Heading (Financial) or AL no. and program name (Federal) 93.778 Medicaid Cluster Planned Corrective Action To improve accuracy and timeliness of expenditure reporting, OHCA plans to schedule internal meetings between Long Term Services and Supports (LTSS) staff, finan...
Finding Number 2023-020 Subject Heading (Financial) or AL no. and program name (Federal) 93.778 Medicaid Cluster Planned Corrective Action To improve accuracy and timeliness of expenditure reporting, OHCA plans to schedule internal meetings between Long Term Services and Supports (LTSS) staff, financial management team, and federal reporting team, at a minimum, quarterly. The team will discuss project progress and review budget to actual expenditures to be reported in the quarterly spending plan. As needed, OHCA will request the Center for Medicare and Medicaid (CMS) Technical Assistance (TA) to ensure OHCA is reporting in the manner CMS requires. Prior to submitting an American Rescue Plan Act of 2021 (ARPA) spending plan, the completed document will be circulated to the internal team for review and approved by the LTSS Senior Director. Because the amount reported is cumulative, the error self-corrects in future spending plans; therefore, OHCA does not plan to re-submit previously reported spending plans. Anticipated Completion Date 10/31/2024 Responsible Contact Person David Ward, Senior Director of Sooner Care Operations
Finding Number 2023-016 Subject Heading (Financial) or AL no. and program name (Federal) 93.778 Medicaid Cluster Planned Corrective Action Program Integrity was actively implementing corrective action to ensure that all overpayments were reported within 12 months from identification when these cases...
Finding Number 2023-016 Subject Heading (Financial) or AL no. and program name (Federal) 93.778 Medicaid Cluster Planned Corrective Action Program Integrity was actively implementing corrective action to ensure that all overpayments were reported within 12 months from identification when these cases were closed. The errors associated with this finding were first reported on January 21, 2023 (Finding 2022-039) which resulted in OHCA developing corrective action to evaluate past cases and ensure all cases were reviewed and all overpayments were reported during the initial corrective action cycle. In all three instances related to late reporting of overpayments, all cases were reported on CMS-64.9c1 during implementation of corrective action plan as a result of the previous audit finding. One case was erroneously excluded during the corrective action plan. This finalized case was reported and refunded on the CMS-64.9OFWA, Line 1B for the quarter ending September 30, 2024 utilizing an average FMAP for all impacted programs. Internal procedures have been evaluated to ensure Service Quality Review overpayments are timely reported and refunded to the Center for Medicare and Medicaid Services (CMS). The cost of $4,007 questioned were reported on the CMS 64.9P line 10A on Cost of Service (COS) line 5 for the quarter ending March 31, 2025. Anticipated Completion Date 3/31/2025 Responsible Contact Person Kristine West, Senior Director of Program Integrity and Accountability
View Audit 367158 Questioned Costs: $1
Finding Number 2023-008 Subject Heading (Financial) or AL no. and program name (Federal) 93.778 Medicaid Cluster Planned Corrective Action The Schedule of Expenditures of Federal Awards (SEFA) errors were corrected on October 16, 2024. To ensure the support for the Schedule of Expenditures of Federa...
Finding Number 2023-008 Subject Heading (Financial) or AL no. and program name (Federal) 93.778 Medicaid Cluster Planned Corrective Action The Schedule of Expenditures of Federal Awards (SEFA) errors were corrected on October 16, 2024. To ensure the support for the Schedule of Expenditures of Federal Awards is transferred accurately from the calculation worksheets and the other GAAP packages, we will implement a GAAP Package Z – SEFA Reviewer Checklist that will be included with the backup data of the GAAP Z. This will ensure the sources of data for the Schedule of Expenditures of Federal Awards are transferred correctly and tied back to their original source. Anticipated Completion Date 10/31/2024 Responsible Contact Person Calvin Cole, Financial Manager III
Finding Number 2023-009 Subject Heading (Financial) or AL no. and program name (Federal) 93.767 Children’s Health Insurance Program Planned Corrective Action The Schedule of Expenditures of Federal Awards (SEFA) errors were corrected on October 16, 2024. To ensure the support for the Schedule of Exp...
Finding Number 2023-009 Subject Heading (Financial) or AL no. and program name (Federal) 93.767 Children’s Health Insurance Program Planned Corrective Action The Schedule of Expenditures of Federal Awards (SEFA) errors were corrected on October 16, 2024. To ensure the support for the Schedule of Expenditures of Federal Awards is transferred accurately from the calculation worksheets and the other GAAP packages, we will implement a GAAP Package Z – SEFA Reviewer Checklist that will be included with the backup data of the GAAP Z. This will ensure the sources of data for the Schedule of Expenditures of Federal Awards are transferred correctly and tie back to their original source. Anticipated Completion Date 10/31/2024 Responsible Contact Person Calvin Cole, Financial Manager III
Finding Number 2023-074 Subject Heading (Financial) or AL no. and program name (Federal) 93.575 – CCDF Cluster Planned Corrective Action Child Care Services has continually inspected child care programs for compliance with health and safety requirements according to the Oklahoma Child Care Facilitie...
Finding Number 2023-074 Subject Heading (Financial) or AL no. and program name (Federal) 93.575 – CCDF Cluster Planned Corrective Action Child Care Services has continually inspected child care programs for compliance with health and safety requirements according to the Oklahoma Child Care Facilities Licensing Act and Oklahoma Administrative Code. Our inspection monitoring checklist that was used for a significant part of the time this was audited contained health inspection as a work step, but the checklist did not require the worker to specifically mark it as performed. The checklist did specifically state that the worker performed all steps and only exceptions would be further documented. The Oklahoma State Auditor and Inspectors took the position that our process did not provide enough assurance for them to validate that health inspections were performed, and they wanted a specific tick mark on the inspection. We do not agree on this point as one additional tick mark on a form does not provide any more assurance than the employee’s signature stating that all of the steps were performed. We did however agree to change the form to resolve this issue with the auditors. As previously stated in our 2022 audit findings, Child Care Services is aware this would be a repeat due to the audit timeframe including monitoring inspections that were prior to our form update. On January 30th, 2023; Child Care Services implemented the “Go-Live” phase of updating the monitoring checklists and summaries to include visual verification that all health and safety requirements are observed during inspections. Licensing specialists indicate on each health and safety item; compliance, noncompliance, or not reviewed while completing inspections. Quality review audits are also being conducted annually with each supervisory group in Child Care Services to address errors or inconsistencies when monitoring child care programs. Child Care Services professional development unit has included a new training module regarding documentation requirements. Anticipated Completion Date January 30, 2023 Responsible Contact Person Dione Smith
Finding Number 2023-100 Subject Heading (Financial) or AL no. and program name (Federal) 93.568 - LIHEAP Planned Corrective Action Detail eligibility data is not used to complete the Household Report. OKDHS uses system-generated summary reports and eligibility data to complete the Household Report. ...
Finding Number 2023-100 Subject Heading (Financial) or AL no. and program name (Federal) 93.568 - LIHEAP Planned Corrective Action Detail eligibility data is not used to complete the Household Report. OKDHS uses system-generated summary reports and eligibility data to complete the Household Report. The reports are EN600R02, EN600R03, EN600R04, and EN601R. OKDHS provided SAI copies of these reports for both FFY 2022 and 2023 on January 15, 2025. An image of the email is attached below: Anticipated Completion Date N/A Responsible Contact Person Caleb Turner
Finding Number 2023-084 Subject Heading (Financial) or AL no. and program name (Federal) 93.568 - LIHEAP Planned Corrective Action DHS agrees that improvements are needed in documentation and coordination to support the accurate identification and tracking of ARPA payments. While all recipients of t...
Finding Number 2023-084 Subject Heading (Financial) or AL no. and program name (Federal) 93.568 - LIHEAP Planned Corrective Action DHS agrees that improvements are needed in documentation and coordination to support the accurate identification and tracking of ARPA payments. While all recipients of the supplemental ARPA payments had documented arrearages and met general LIHEAP eligibility at the time of payment, we recognize the need for improved system documentation and reporting processes to support eligibility determinations and data integrity. It is also important to note that the ARPA funding was a onetime, temporary supplement to LIHEAP and is no longer active in the current program year. OKDHS is taking the following steps to strengthen system documentation, reporting accuracy, and cross-divisional reconciliation: • System and Reporting Enhancements: The Data Transformation Office (DTO) and Finance Division are collaborating to develop system functionality and reporting tools that clearly identify funding sources and improve the readability and completeness of payment data used for audit and program oversight. • Cross-Divisional Reconciliation Effort: AFS, Finance, and DTO are jointly working to establish a coordinated reconciliation process that ensures eligibility data aligns with payment records and federal reporting, including future SEFA submissions. • Process Documentation: OKDHS is documenting the updated processes and reporting requirements to ensure consistency in implementation and to support audit readiness going forward. • Internal Audit Oversight and Support: OKDHS has recently reorganized its Internal Audit division to enhance independence, improve reporting structure, and expand its capacity to support internal control consultation and program integrity reviews. Internal Audit will assist in evaluating reconciliation efforts, documentation standards, and data reporting controls as they are implemented. Anticipated Completion Date Ongoing Responsible Contact Person Kayla Urtz
Finding Number 2023-032 Subject Heading (Financial) or AL no. and program name (Federal) 93.568 - LIHEAP Planned Corrective Action The Oklahoma Department of Human Services will ensure data used to calculate LIHEAP Quarterly Performance Data and Management report is clearly documented regarding the ...
Finding Number 2023-032 Subject Heading (Financial) or AL no. and program name (Federal) 93.568 - LIHEAP Planned Corrective Action The Oklahoma Department of Human Services will ensure data used to calculate LIHEAP Quarterly Performance Data and Management report is clearly documented regarding the data is being used, how it was calculated for this report, and ensure this documentation saved at the time the report is created. Anticipated Completion Date 4/30/2025 Responsible Contact Person Matthew Conley
Finding Number 2023-078 Subject Heading (Financial) or AL no. and program name (Federal) 93.558 – TANF Planned Corrective Action As of 9/30/2023, changes were made to the CST750 Cost Allocation Report to capture the 34X expenditures that are the source of the data noted in the finding. This automate...
Finding Number 2023-078 Subject Heading (Financial) or AL no. and program name (Federal) 93.558 – TANF Planned Corrective Action As of 9/30/2023, changes were made to the CST750 Cost Allocation Report to capture the 34X expenditures that are the source of the data noted in the finding. This automated report allows both the report preparer and reviewer to validate that the information on the lines in question is complete and accurate going forward. A revision was made to the ACF 196R report on 3/31/25 to correct the errors noted above. Anticipated Completion Date 9/30/2023 Responsible Contact Person Kevin Haddock
Finding Number 2023-075 Subject Heading (Financial) or AL no. and program name (Federal) 93.558 – TANF Planned Corrective Action We have a comprehensive series of SharePoint pages dedicated to the preparation and documentation of this report. It is likely that the request was not directed to the app...
Finding Number 2023-075 Subject Heading (Financial) or AL no. and program name (Federal) 93.558 – TANF Planned Corrective Action We have a comprehensive series of SharePoint pages dedicated to the preparation and documentation of this report. It is likely that the request was not directed to the appropriate person or group, as this information has been and remains readily available. Additionally, case data is compared to IMS through automated processes, including various data scrapes and queries in Access that analyze file data against AllData. While cases are not manually reviewed in IMS, the data comparison in Access allows for a thorough analysis of all cases, rather than a limited manual review. Furthermore, the data in AllData originates from the same source as IMS (DB2), ensuring consistency and accuracy. Additional documents are attached to this email further documenting the process. Anticipated Completion Date N/A Responsible Contact Person Rhonda Archer
Finding Number 2023-055 Subject Heading (Financial) or AL no. and program name (Federal) 93.558 -TANF Planned Corrective Action It was determined that the incorrect number was entered into the report due to a typographical error. The correct value should have been 12, but 23 was mistakenly recorded....
Finding Number 2023-055 Subject Heading (Financial) or AL no. and program name (Federal) 93.558 -TANF Planned Corrective Action It was determined that the incorrect number was entered into the report due to a typographical error. The correct value should have been 12, but 23 was mistakenly recorded. Additional second party review procedures will be implemented to ensure accuracy prior to submission. Anticipated Completion Date 03/28/2025 Responsible Contact Person Rhonda Archer
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