Corrective Action Plans

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Federal Agency Review *Significant Deficiency in Internal Controls over Compliance; Noncompliance Federal Program - CFDA 10.555 – National School Lunch Program ASDOE School Lunch Program (SLP) continues to work with the representative who oversees civil rights for the USDA Western region. SLP co...
Federal Agency Review *Significant Deficiency in Internal Controls over Compliance; Noncompliance Federal Program - CFDA 10.555 – National School Lunch Program ASDOE School Lunch Program (SLP) continues to work with the representative who oversees civil rights for the USDA Western region. SLP continues to have training to correct the issues in their USDA FNS report. POC  SLP Assistant Director Christina Fualaau
Corrective Action Plan Finding: 2023-002-Inadequate Administration of Facets of Programs-Allowable Costs/Principles Condition: (a) and (b)-It appears the enrollment, progress of participants to meet the established goals, and potential earning and disbursement of FSS and Set Aside funds have b...
Corrective Action Plan Finding: 2023-002-Inadequate Administration of Facets of Programs-Allowable Costs/Principles Condition: (a) and (b)-It appears the enrollment, progress of participants to meet the established goals, and potential earning and disbursement of FSS and Set Aside funds have been inadequately monitored for at least the last two years. (c)-Without both of these requested items noted above, we are unable to determine if the SEP contribution terms were adequately complied with. Corrective Action Planned: We will comply with the auditor’s recommendation. I do note that we were short of personnel for the entire audit period. I believe that I have staff presently that can do most of the assigned duties. I admit that not all of the deficiencies noted were due to being understaffed, but lack of training (being new to HUD) and understanding. But we will also correct those errors to the best of our ability. Person responsible for corrective action: Mary Grace Saenz, Executive Director Telephone: (915) 886-4650 Housing Authority of the Town of Anthony, Texas Fax: (915) 886-2296 1007 Franklin Anthony, TX 79821 Anticipated Completion Date: September 30, 2024
VIEWS OF RESPONSIBLE OFFICIALS AND PLANNED CORRECTIVE ACTION Management is responsible for designing and maintaining internal controls over financial reporting that is sufficient to provide reasonable assurance that management can prepare the financial statement and the Uniform Guidance Audit Report...
VIEWS OF RESPONSIBLE OFFICIALS AND PLANNED CORRECTIVE ACTION Management is responsible for designing and maintaining internal controls over financial reporting that is sufficient to provide reasonable assurance that management can prepare the financial statement and the Uniform Guidance Audit Report in conformity with US GAAP and federal regulations. Management will improve accounting and financial reporting policies and procedures to include timely issuance of the financial statement and the uniform guidance report. IMPLEMENTATION DATE March 31, 2025 RESPONSIBLE PERSON Jamille Muriente, CFO, Marjuli, David Mateo, Contract Coordinator Officer
Management plans on starting the June 2024 audit by December 1, 2024, which should give us enough time to complete the Uniform Guidance audit by March 31, 2025.
Management plans on starting the June 2024 audit by December 1, 2024, which should give us enough time to complete the Uniform Guidance audit by March 31, 2025.
Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing # FCDA 93.498 Finding Summary: Eide Bailly LLP identified that the method used for reporting lost revenue was inaccurate. Method 2 wa...
Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing # FCDA 93.498 Finding Summary: Eide Bailly LLP identified that the method used for reporting lost revenue was inaccurate. Method 2 was reported, when it should’ve been method 3. Responsible Individuals: Dara Bartels, CEO Corrective Action Plan: Mile Bluff Medical Center has not had a lot of experience with a single audit prior to COVID grant funds. This year we experienced turnover in our CFO role, leaving the process to be re-created. We pulled together most of the information that was required but needed assistance/guidance from our auditors on how to pull the information together and report them on the required forms. We will continue to learn the layout and review the Schedule of Expenditures of Federal Awards prior to sending or addressing this with the Auditors. Anticipated Completion Date: Ongoing
Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing # FCDA 93.498 Finding Summary: Eide Bailly LLP identified the lack of documentation of review processes surrounding the expenditures ...
Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing # FCDA 93.498 Finding Summary: Eide Bailly LLP identified the lack of documentation of review processes surrounding the expenditures of the federal award. Responsible Individuals: Dara Bartels, CEO Corrective Action Plan: We have a process that requires the Grant “owners” to review and sign off on the expenditures related to any Federal Awards and other expenditure in the organization. We will add a quarterly review in the Grants office to verify the expected purpose, compliance with federal statutes, regulations and conditions of the federal award. This will also be reviewed by the CFO to create checks and balances. Anticipated Completion Date: Ongoing
Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing # FCDA 93.498 Finding Summary: Eide Bailly LLP assisted in the Preparation of Schedule of Expenditures of Federal Awards Responsible ...
Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing # FCDA 93.498 Finding Summary: Eide Bailly LLP assisted in the Preparation of Schedule of Expenditures of Federal Awards Responsible Individuals: Dara Bartels, CEO Corrective Action Plan: Mile Bluff Medical Center has not had a lot of experience with a single audit prior to COVID grant funds. This year we experienced turnover in our CFO role, leaving the process to be re-created. We pulled together most of the information that was required but needed assistance/guidance from our auditors on how to pull the information together and report them on the required forms. We will continue to learn the layout and review the Schedule of Expenditures of Federal Awards prior to sending or addressing this with the Auditors. Anticipated Completion Date: Ongoing
The Department of Behavioral Health (DBH) agrees with the findings. The 425 reports will be reviewed by both the Accounting Supervisor and the Accounting Officer prior to entering in the Payment and Management System (PMS) and will appropriately be signed by either one of the two. Documentation fro...
The Department of Behavioral Health (DBH) agrees with the findings. The 425 reports will be reviewed by both the Accounting Supervisor and the Accounting Officer prior to entering in the Payment and Management System (PMS) and will appropriately be signed by either one of the two. Documentation from PMS will provide a history of the approval flow. Accountants will not have the authority to certify the reports in PMS. The HSSC Comptroller, the Accounting Manager, the AFO and the Budget Staff will perform a detailed review and walk through of the SEFA to confirm the expenditures are correctly categorized by fund and grant, and appropriately identify expenditures for subrecipients, if applicable. Additionally, DBH is working with OCP (Office of Contracting and Procurement), to attach to DC Health’s contract to implement a grants management system that is on the Salesforce platform. The system will automate workflow and enable “alerts” to notify users when reports are due. If the notification is not acted on, the system will automatically escalate the alert to senior management. In the interim, DBH is working through the Districts Grants Management Advisory Board to identify DIFS reports (e.g., DIFS report for FFATA, Subrecipient Grant Report R071). To note, all programmatic data that was used for the PPR was available to the auditors. The supporting documentation for the chart that included spending for administrative and data costs had not been saved, which was the source of the finding. Contact - FAPIIS and FFATA: Renee Evans Jackman, Director of Grants Management, FFR (SF-425) and SEFA: Barbara Roberson, HSSC Accounting Officer, PPR: Sharon Hunt, State Opioid Treatment Authority Estimated Completion Date - Grants Management System is due to be implemented on January 1, 2025. See Corrective Action Plan for chart/table
The Department of Behavioral Health (DBH) concurs with the finding. The Accounting Supervisor will require additional documentation upon the presentation of a draw request for all federal grants prior to submitting the request in the federal system. The accountant will be required to submit a repor...
The Department of Behavioral Health (DBH) concurs with the finding. The Accounting Supervisor will require additional documentation upon the presentation of a draw request for all federal grants prior to submitting the request in the federal system. The accountant will be required to submit a report reflecting summary and detailed reports for all draw requests. This report will include detailed payroll information as well as confirmation that all non-personal services expenditures have been disbursed. Contact - Adran Reid, DBH Agency Fiscal Officer Estimated Completion Date - July 1, 2024 See Corrective Action Plan for chart/table
The Economic Security Administration (ESA) concurs with this finding. As a corrective action, ESA will provide refresher training and reinforce oversight controls to ensure caseworkers and supervisors are processing applications within federally required timeframes. Contact - Melisa Byrd, Senior D...
The Economic Security Administration (ESA) concurs with this finding. As a corrective action, ESA will provide refresher training and reinforce oversight controls to ensure caseworkers and supervisors are processing applications within federally required timeframes. Contact - Melisa Byrd, Senior Deputy Director and Medicaid Director Estimated Completion Date - June 18, 2024 See Corrective Action Plan for chart/table
The Department of Health Care Finance (DHCF) agrees with the finding. The drug rebate vendor’s IT staff will test the calculation to see if there would have been interest calculated or if there is a system glitch that requires further attention. If additional interest should be billed for this invo...
The Department of Health Care Finance (DHCF) agrees with the finding. The drug rebate vendor’s IT staff will test the calculation to see if there would have been interest calculated or if there is a system glitch that requires further attention. If additional interest should be billed for this invoice, the vendor will add the interest that should have been billed. Currently, the drug rebate vendor calculates interest every Tuesday. The system is also calibrated to calculate interest on invoices that were paid in full that had outstanding balances based on the postmark date applied in the system. Contact - Melisa Byrd, Senior Deputy Director and Medicaid Director Estimated Completion Date - November 30, 2024 See Corrective Action Plan for chart/table
The Economic Security Administration (ESA) concurs with this finding. As a corrective action, ESA will provide refresher training and reinforce oversight controls to ensure caseworkers and supervisors are processing applications within federally required timeframes. Contact- Melisa Byrd, Senior De...
The Economic Security Administration (ESA) concurs with this finding. As a corrective action, ESA will provide refresher training and reinforce oversight controls to ensure caseworkers and supervisors are processing applications within federally required timeframes. Contact- Melisa Byrd, Senior Deputy Director and Medicaid Director Estimated Completion Date - June 18, 2024 See Corrective Action Plan for chart/table
The Child and Family Services Agency (CFSA) concurs with the findings. The Business Services Administration will install correspondence protocols whereby the invoicing/cost reporting team will acknowledge the review and acceptance of quarterly cost reports from the provider community. Contact - Ja...
The Child and Family Services Agency (CFSA) concurs with the findings. The Business Services Administration will install correspondence protocols whereby the invoicing/cost reporting team will acknowledge the review and acceptance of quarterly cost reports from the provider community. Contact - James J. Murphy, Director, Business Services Administration Estimated Completion Date - September 30, 2024 See Corrective Action Plan for chart/table
The Department of Energy and Environment (DOEE) agrees with the conditions and recommendations of this finding. DOEE personnel perform initial reviews of individual applications before, during, and after certification. Supervisory level reviews of 5 applications are performed per processor per mont...
The Department of Energy and Environment (DOEE) agrees with the conditions and recommendations of this finding. DOEE personnel perform initial reviews of individual applications before, during, and after certification. Supervisory level reviews of 5 applications are performed per processor per month, which is documented in the Operations Manual. On a semi-annual basis, program personnel will conduct an inventory of applications to ensure a 25% threshold of secondary reviews is being met. Additionally, DOEE will conduct and require staff participation in system demonstration and refresher trainings in order to strengthen existing policies and procedures. Contact - Danielle Wright, Deputy Director Estimated Completion Date - September 30, 2024 See Corrective Action Plan for chart/table
The Department of Human Services (DHS) agrees with the findings. Economic Security Administration (ESA) agrees with the documentation issue, which is compounded by the lack of interface between the reporting data systems. This requires collaboration efforts between multiple units within ESA that in...
The Department of Human Services (DHS) agrees with the findings. Economic Security Administration (ESA) agrees with the documentation issue, which is compounded by the lack of interface between the reporting data systems. This requires collaboration efforts between multiple units within ESA that includes the Division of Customer Workforce Employment & Training (DCWET), the Department of Program Operations (DPO), and the Division of Innovation and Change Management (DICM). ESA needs to enhance DCAS to tie the income evidence in the income support case to the employment evidence in the person record to allow the employment hours to end date once the income evidence is end dated. The Office of Performance Monitoring (OPM) has a process in place to monitor and confirm the hours reported from CATCH; however, the process to monitor and verify the hours received from DCAS needs to be strengthened to capture and resolve discrepancies in work hours. During the monthly Q5I reviews, we found multiple discrepancies from the data received from DCAS showing that the customer was not employed during the sample month or fiscal year; but hours were reported in Q5i. When OPM conducts their review of DCAS hours, and identifies income and hour differences, the DPO is informed and/or the Office of Work Opportunity (OWO) requests their assistance with resolving the discrepancy. While this was a temporary fix for the problem, however, a permanent solution would require a multi-faceted approach: (1) Training (re-training) all DPO SSR on the DCAS screens which require action to confirm employment. This means that the DPO should dedicate resources to provide adequate training to SSRs involved in updating customers’ employment information in DCAS. While this would be a short-term solution it will go a long way to resolving some of the discrepancies in reported work hours that are being transmitted to Q5i. (2) Requiring DICM to enhance DCAS to tie the income evidence in the income support case to the employment evidence in the person record to allow the employment hours to end date once the income evidence is end dated. Her suggestion is to have Brian initiate the meetings between DCWET, DPO, and DICM. This would be automating the process by connecting the 2- step process into one task. This would be a permanent solution to curbing stale and unsubstantiated hours from migrating to Q5i. (3) Continuing to randomly select and review a sample of 40 cases from Q5i each month. OPM monitors will randomly generate 40 sample cases from Q5i, review them and if they find any discrepancies would refer them to either OWO, DPO, or TEP Providers for resolution. (4) Continuing to cross-reference all customers assigned to a vendor to verify that each customer’s DCAS hours are confirmed by OPM during its participation audit process. OPM will continue to ensure that all customers’ participation documents are uploaded in Fileshare during each bi-weekly audit cycle. Contact - Christian Okonkwo, Program Manager, Office of Performance Monitoring, DHS/ESA Estimated Completion Date - DICM will create a Jira ticket to enhance DCAS to tie the income evidence in the income support case to the employment evidence in the person record to allow the employment hours to end date once the income evidence is end dated. This process will take four (4) months, September 30, 2024, to complete. DPO will train (retrain) all DPO SSR on the DCAS screens which require action to confirm employment. The training will last up to six (6) months, March 30, 2025. See Corrective Action Plan for chart/table
The Department of Human Services (DHS) concurs with the findings. DHS Budget and Accounting staff will meet on a quarterly basis to review and walk through the ACF-196R and ACF-196P reports and the backup supporting documentation, to ensure the expenditure reported reconciles with the expenditures ...
The Department of Human Services (DHS) concurs with the findings. DHS Budget and Accounting staff will meet on a quarterly basis to review and walk through the ACF-196R and ACF-196P reports and the backup supporting documentation, to ensure the expenditure reported reconciles with the expenditures on the supporting documentation. A copy of the TANF MOE schedule and the submitted ACF-204 reports will be provided to the program staff. Budget and accounting staff will schedule a meeting with the program staff responsible for completing and submitting the ACF-204 reports to review and ensure the expenditures reported on reconciles with the expenditures on the backup supporting documentation. Contact - Hayden Bernard, Agency Fiscal Officer, DHS Estimated Completion Date - July 1, 2024 See Corrective Action Plan for chart/table
The Office of State Superintendent of Education (OSSE) concurs with the auditor’s finding and recommendations. OSSE will further strengthen its internal controls for its FFATA reporting process to enhance operational efficiency and accuracy by increasing the frequency and rigor of agency review an...
The Office of State Superintendent of Education (OSSE) concurs with the auditor’s finding and recommendations. OSSE will further strengthen its internal controls for its FFATA reporting process to enhance operational efficiency and accuracy by increasing the frequency and rigor of agency review and checks on the collection and submission. Contact - Carol D’Avilar-Etkins, Program Officer Estimated Completion Date - October 2024 See Corrective Action Plan for chart/table
The Office of the State Superintendent (OSSE) agrees with the conditions and recommendations of this finding. The OSSE corrective action plan includes the following: • The OCFO budget team will ensure that every budgeted federal award has a corresponding equivalent Federal Notice of Grant Award (...
The Office of the State Superintendent (OSSE) agrees with the conditions and recommendations of this finding. The OSSE corrective action plan includes the following: • The OCFO budget team will ensure that every budgeted federal award has a corresponding equivalent Federal Notice of Grant Award (NOGA). • Grant reconciliations done to determine carryover balances and subsequent budget modifications will incorporate cash as well as accrued expenditures. • Quarterly financial reviews will be conducted to properly review and support expenditures. • During the year-end close process, the accounting team will compare total awarded amount and total expenditures. Contact - Keith Fletcher, Agency Fiscal Officer, OSSE, Crosby Boyd, Controller, Education Cluster Estimated Completion Date - February 1, 2025 See Corrective Action Plan for chart/table
The Department of Energy and Environment (DOEE), Office of Neighborhood Safety and Engagement (ONSE) and various other District agencies agree with the conditions and recommendations of this finding. DOEE: The agency will add a section regarding a subrecipient’s prior year audit report to the risk ...
The Department of Energy and Environment (DOEE), Office of Neighborhood Safety and Engagement (ONSE) and various other District agencies agree with the conditions and recommendations of this finding. DOEE: The agency will add a section regarding a subrecipient’s prior year audit report to the risk analysis conducted by program staff. For any prior year audit findings, the agency will request a copy of the subrecipient’s corrective action plan. ONSE: The agency will conduct and review, on a monthly and quarterly basis, site visits/reports and will follow up with subrecipients to submit reports on a timely basis. Various Other District Agencies: The agencies will review the details of subrecipients amount generated from the system and perform a vendor or subrecipient analysis to ensure accuracy of amounts to be reported in SEFA. Contact - Lisa Mae Crawford, Associate Director, Residential Services Division, DOEE, Yasha Williams, Chief Operating Officer, ONSE, Various District Cluster Controllers Estimated Completion Date - September 30, 2024; March 1, 2025 See Corrective Action Plan for chart/table
The Department of Human Services (DHS) OCFO concurs with the finding. Expenditures were inadvertently categorized to the incorrect fund. Moving forward, a meeting will be scheduled with the HSSC Comptroller, the Accounting Officer, the AFO and the Budget Staff for a detailed review and walk through...
The Department of Human Services (DHS) OCFO concurs with the finding. Expenditures were inadvertently categorized to the incorrect fund. Moving forward, a meeting will be scheduled with the HSSC Comptroller, the Accounting Officer, the AFO and the Budget Staff for a detailed review and walk through of the SEFA to confirm the expenditures are correctly categorized by fund and grant, and expenditures reconcile to reports from the financial system. Contact - Barbara Roberson, Accounting Officer Estimated Completion Date - September 30, 2024 See Corrective Action Plan for chart/table
The Department of Employment Services (DOES) concurs to this finding. Management is committed to closely monitoring the PNG clearing account and implementing timely adjustments at the source as necessary. We will also evaluate and enhance internal controls pertaining to subledgers and the General L...
The Department of Employment Services (DOES) concurs to this finding. Management is committed to closely monitoring the PNG clearing account and implementing timely adjustments at the source as necessary. We will also evaluate and enhance internal controls pertaining to subledgers and the General Ledger (GL). Regular reconciliations, reviews, and adjustments will be conducted to ensure alignment between subledger and General Ledger amounts, and to maintain consistency between SEFA amounts and Federal reports. The fiscal year 2023 SEFA has been revised to accurately reflect federal expenditures, and management will ensure ongoing compliance with established controls to ensure the fair presentation of SEFA data moving forward. Contact - Shilonda Wiggins, Agency Fiscal Officer Estimated Completion Date - September 30, 2024 See Corrective Action Plan for chart/table
The Department of Housing and Community Development (DHCD) concurs with the conditions and recommendations of this finding. DHCD will input data into Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) for all Community Development Block Grants Section 108 Loan Guar...
The Department of Housing and Community Development (DHCD) concurs with the conditions and recommendations of this finding. DHCD will input data into Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) for all Community Development Block Grants Section 108 Loan Guarantees program subawards. Contact - Lesley Edmond, DHCD Housing Compliance Officer Estimated Completion Date - June 28, 2024 See Corrective Action Plan for chart/table
The Department of Human Services (DHS) and Department of Health Care Finance (DHCF) DC Access System (DCAS) Program Management Administration team agree with the findings. For the fifteen (15) findings, DHS/ESA has identified the description of the deficiencies, examined the magnitude and geographi...
The Department of Human Services (DHS) and Department of Health Care Finance (DHCF) DC Access System (DCAS) Program Management Administration team agree with the findings. For the fifteen (15) findings, DHS/ESA has identified the description of the deficiencies, examined the magnitude and geographic extent of the deficiencies, identified the actions completed to eliminate the deficiencies. The District will focus on efforts that will create the maximum impact, which includes creating new options for collaboration, streamlining current communication, and introducing cross-functional prioritization. These strategies will help the District move projects toward completion and are rooted in continuous quality improvement. To guide its strategic efforts and track its impact, DHS has outlined the following four phases of corrective action plans to be taken to ensure the deficiencies will be eliminated: • Review and Prioritization, • Design and Development, • Implementation, and • Monitor and Evaluation. Each phase has several process steps including a completion document that signals the permission to move to the next phase. The detailed process steps are documented under DHS’ Consolidated Semi-Annual SNAP Advance Warning Letter Corrective Action Plan and FFY2024 Quality Control Corrective Action Plan reports dated April 2024. The corrective action plan is facilitated by the Quality Improvement Program and since implementing this process in January 2021, the District has identified root causes for errors and gaps in internal auditing and evaluation processes. Therefore, the flow of the semi-annual corrective action plans reflects the District’s commitment to a collaborative corrective action plan - expanding the data analysis section to include data and analysis of internal methods, a complete summary of each phase completed, and a timeline for upcoming phase/project completion. Contact - Stephanie Bloch-Newman, Deputy Administrator for Innovation & Change Management Estimated Completion Date - September 30, 2025 See Corrective Action Plan for chart/table
The City will monitor federal awards totals more closely in the future
The City will monitor federal awards totals more closely in the future
The Airport has created additional internal notifications to prevent late submittals of annual Federal Aviation Administration SF 425 and SF 271 Reporting Forms.
The Airport has created additional internal notifications to prevent late submittals of annual Federal Aviation Administration SF 425 and SF 271 Reporting Forms.
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