Corrective Action Plans

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7. If necessary, conduct additional revision to the policies and procedures. November 2024 Executive Director & Management Team Revise Budget Development and Fiscal Monitoring Policies and Procedures Head Start Performance Standards 45 CFR Part 1302.101 (a)(3) Management system (Implementation) and ...
7. If necessary, conduct additional revision to the policies and procedures. November 2024 Executive Director & Management Team Revise Budget Development and Fiscal Monitoring Policies and Procedures Head Start Performance Standards 45 CFR Part 1302.101 (a)(3) Management system (Implementation) and Uniform Guidance 45 CFR Part 75.302(b)(2) Financial Report and 75.341 Reporting Requirements
8. Conduct follow-up monitoring to ensure fully implementation. December 2024 Executive Director Revise Budget Development and Fiscal Monitoring Policies and Procedures Head Start Performance Standards 45 CFR Part 1302.101 (a)(3) Management system (Implementation) and Uniform Guidance 45 CFR Part 75...
8. Conduct follow-up monitoring to ensure fully implementation. December 2024 Executive Director Revise Budget Development and Fiscal Monitoring Policies and Procedures Head Start Performance Standards 45 CFR Part 1302.101 (a)(3) Management system (Implementation) and Uniform Guidance 45 CFR Part 75.302(b)(2) Financial Report and 75.341 Reporting Requirements
9. Complete Summary Schedule January 2025 Executive Director Summary Schedule Uniform Guidance 45 CFR Part 75.511 Audit findings follow-up
9. Complete Summary Schedule January 2025 Executive Director Summary Schedule Uniform Guidance 45 CFR Part 75.511 Audit findings follow-up
Finding 478310 (2021-007)
Significant Deficiency 2021
Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The City Controller drafted a grants policy which is currently under review by the City Manager, that includes succession planning in case of staff turnover and parameter...
Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The City Controller drafted a grants policy which is currently under review by the City Manager, that includes succession planning in case of staff turnover and parameters for grant reporting compliance. Planned Implementation Date: December 31, 2024 Responsible Person(s): City Manager, Grants Manager
Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The City Controller's Office drafted a grants policy that is currently under review by City Management. Community development staff will ensure a succession plan is in pl...
Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The City Controller's Office drafted a grants policy that is currently under review by City Management. Community development staff will ensure a succession plan is in place for any staff turnover and for report preparation compliance. Planned Implementation Date: December 31, 2024 Responsible Person(s): City Manager, Community Development Director, and City Controller
In response to the negative finding of the 2019, 2020 and 2021 audits, immediate actions have been taken by L2020 to address the issues and prevent reoccurrence in the future. The individuals who were previously responsible for financial reporting and cash management during the audit are no longer e...
In response to the negative finding of the 2019, 2020 and 2021 audits, immediate actions have been taken by L2020 to address the issues and prevent reoccurrence in the future. The individuals who were previously responsible for financial reporting and cash management during the audit are no longer employed at L2020. Going forward, Rebecca “Kawehi” Inaba, appointed as the Executive Director in late 2021, will take charge of ensuring that L2020 remains compliant with all financial requirements, including conducting audits in a timely manner. The organization expresses confidence in her ability to keep L2020 up to date with all financial obligations. In an effort to enhance control and oversight, L2020 will be instituting a quality control review process for all forthcoming report submissions. This measure aims to identify any discrepancies or delays in submissions, enabling corrective actions to be taken promptly. L2020 remains dedicated to upholding transparency and accountability in their financial practices. These proactive steps are crucial in enhancing processes and performance. The organization appreciates understanding and support as they strive for improved financial management practices at L2020.
The College will ensure that all grant reports are reviewed in detail and information reported will be traced to the source reports by the reviewer. The College also implemented policies and procedures to ensure all grant reports are submitted prior to the due date.
The College will ensure that all grant reports are reviewed in detail and information reported will be traced to the source reports by the reviewer. The College also implemented policies and procedures to ensure all grant reports are submitted prior to the due date.
Management has implemented policies and procedures to ensure the timely submission of single audit reporting package.
Management has implemented policies and procedures to ensure the timely submission of single audit reporting package.
Finding 406447 (2021-006)
Significant Deficiency 2021
Corrective Action: The Chief Financial Officer will oversee efforts to close out the old accounts in a timely manner and make sure all systems are reconciled. Internal controls have been set into place to ensure future compliance. The Municipal Comptroller will train and continue to work closely wi...
Corrective Action: The Chief Financial Officer will oversee efforts to close out the old accounts in a timely manner and make sure all systems are reconciled. Internal controls have been set into place to ensure future compliance. The Municipal Comptroller will train and continue to work closely with personnel in charge of reporting and processing IDIS and vouchers drawdowns. The Division of Accounts & Control will continue to maintain a sub-ledger to ensure IDIS and the City’s financial system tie out prior to the processing of any payments, and each payment request will require an IDIS activity reference number in order to be processed. Monthly reconciliation of funds has been implemented and copies are sent to US HUD on a monthly basis. In addition, the City has hired a 3rd party grant consultant to help navigate and strengthen our overall processes. Implementation Date: Ongoing
Finding 406040 (2021-003)
Significant Deficiency 2021
Finding No. 2021-003 – Reporting - Late filing of data collection form and reporting package Corrective Action Plan Commencing immediately, Mr. José R. Rodríguez, Accounting Manager, will be the designated officer in charge of concluding all necessary procedures, including the audit of financial sta...
Finding No. 2021-003 – Reporting - Late filing of data collection form and reporting package Corrective Action Plan Commencing immediately, Mr. José R. Rodríguez, Accounting Manager, will be the designated officer in charge of concluding all necessary procedures, including the audit of financial statements and single audit, for the Hospital to file its reporting package within it´s due date, as required by the CFR. Also, Mr. Julio Colón, Chief Financial Officer, will be the designated officer in charge of supervising and monitoring compliance with timely submittance each year. Name (s) of the Contact Person (s) Responsible for Corrective Action Mr. Julio Colón, Chief Financial Officer Anticipated Completion Date December 2024
Finding 406039 (2021-002)
Significant Deficiency 2021
Finding No. 2021-002 - Reporting Corrective Action Plan On July 29, 2022, all pending reports were submitted to AAFAF. Also, commencing immediately, Mr. José R. Rodríguez, Accounting Manager, will be de designated officer in charge of submitting the report by its due date and Mr. Julio Colón, Chief ...
Finding No. 2021-002 - Reporting Corrective Action Plan On July 29, 2022, all pending reports were submitted to AAFAF. Also, commencing immediately, Mr. José R. Rodríguez, Accounting Manager, will be de designated officer in charge of submitting the report by its due date and Mr. Julio Colón, Chief Financial Officer, will be de designated officer in charge of supervising and monitoring compliance with timely submittance each month. Name (s) of the Contact Person (s) Responsible for Corrective Action Julio Colón, Chief Financial Officer Anticipated Completion Date Completed on July 29, 2022
County Judge/Executive’s Response: The Fiscal Court has contracted with Compass to ensure are compliant.
County Judge/Executive’s Response: The Fiscal Court has contracted with Compass to ensure are compliant.
The CFO of Iroquois Memorial Hospital and Resident Home worked in fiscal year 2024 to catch up past audits and is working to catch-up account reconciliations and have proper support for balances within the general ledger and financial statements. This will also allow for timely filing of Uniform Gui...
The CFO of Iroquois Memorial Hospital and Resident Home worked in fiscal year 2024 to catch up past audits and is working to catch-up account reconciliations and have proper support for balances within the general ledger and financial statements. This will also allow for timely filing of Uniform Guidance audits in the future. The audits for the years ended September 30, 2023, 2022, and 2021, were completed and dated June 28, 2024; whereas under prior management of the hospital the last financial statement for the year ended September 30, 2020 was completed by the current management team in 2023 as was left uncompleted by prior hospital management. The team at the Organization plans to continue to be timely with audits in the future.
The CFO and accounting team at Iroquois Memorial Hospital and Resident Home worked with its financial statement auditors and the HRSA audit support desk for Provider Relief Funds to identify a plan to update its documentation as well as update its internal records to reflect allowable costs under th...
The CFO and accounting team at Iroquois Memorial Hospital and Resident Home worked with its financial statement auditors and the HRSA audit support desk for Provider Relief Funds to identify a plan to update its documentation as well as update its internal records to reflect allowable costs under the program. One of the updates included utilization of additional lost revenue to cover nonallowable expenses under the first phases of reporting for Provider Relief Funds due to elimination of some expenses and reduction for Medicare cost reimbursement against expenses. Management developed a more detailed expense log and review those against current terms and conditions prior to any future portal submissions and took into account the use of additional lost revenue. The worksheets were mocked up internally as if these were submitted in the portal in Phase I reporting so that in the future for the next phases of reporting, these lost revenues are not utilized toward future Provider Relief Funding. One additional control being added for this reporting is that the CEO and CFO will be also completing a detailed review of the spreadsheets for entry into the portal and comparing this to the Compliance Supplement which governs the use of the Provider Relief Funds as to allowable costs as well as the Frequently Asked Questions (FAQs) available on HRSAs website. This may impact future reports, so management will ensure to take these updates into account on any future provider relief funds are they are released or future grant receipts if the Organization receives new grants in the future.
Compliance Finding 2021‐007 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan Rural Distribution Finding Summary: The Authority did not have internal controls established over the federa...
Compliance Finding 2021‐007 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan Rural Distribution Finding Summary: The Authority did not have internal controls established over the federal award to ensure the federal award has been managed in compliance with federal, states, regulations and conditions of the federal award. Corrective Action Plan: We will modify internal control policies to ensure there is an understanding of reporting requirements to ensure that reports are accurate and amounts are not inadvertently claimed that are considered unallowable. Responsible Individual: Doran Hammett, Chief Financial Officer Anticipated Completion Date: June 2024
Preparation of Schedule of Expenditures of Federal Awards Finding 2021‐006 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan Rural Distribution Finding Summary: The Authority does not ha...
Preparation of Schedule of Expenditures of Federal Awards Finding 2021‐006 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan Rural Distribution Finding Summary: The Authority does not have an internal control system designed to provide for a complete and accurate schedule of expenditures of federal awards being audited. We were requested to draft the schedule Corrective Action Plan: Due to cost considerations, we will continue to have our auditor prepare our draft schedule of expenditures of federal awards. Responsible Individual: Doran Hammett, Chief Financial Officer Anticipated Completion Date: Ongoing
As we mentioned in the SA 2020 Corrective Action Plan, we expected to finish SA 2021 in FY 2023, as well as SA 2022. We were not able to achieve this goal as face-to-face work had not yet been fully normalized due to a Pandemic Covid-19.Normality in terms of face-to-face work was fully implemented i...
As we mentioned in the SA 2020 Corrective Action Plan, we expected to finish SA 2021 in FY 2023, as well as SA 2022. We were not able to achieve this goal as face-to-face work had not yet been fully normalized due to a Pandemic Covid-19.Normality in terms of face-to-face work was fully implemented in 2022-2023. We currently have a contract to achieve the SA 2022 which will start in April 2024. We will continue to enter into a unified contract to achieve SA 2023 and SA 2024 completion on or before December 31, 2024. We have worked hard planning for this goal.
2021-008—Reporting Corrective Action: FCCH shall implement its Grants/Contracts Submission and Management Policies and Procedures and educate staff to ensure all program reports are properly completed and submitted by the required due dates. Person Responsible: Shawna Gonzales, Chief Financial Offic...
2021-008—Reporting Corrective Action: FCCH shall implement its Grants/Contracts Submission and Management Policies and Procedures and educate staff to ensure all program reports are properly completed and submitted by the required due dates. Person Responsible: Shawna Gonzales, Chief Financial Officer Completion Date: September 30, 2024
2021-009—Late Audit Report Corrective Action: FCCH shall implement its approved policies and procedures that govern year-end reconciliations and closing procedures so that records are maintained in an audit-ready manner. Person Responsible: Shawna Gonzales, Chief Financial Officer Completion Date:...
2021-009—Late Audit Report Corrective Action: FCCH shall implement its approved policies and procedures that govern year-end reconciliations and closing procedures so that records are maintained in an audit-ready manner. Person Responsible: Shawna Gonzales, Chief Financial Officer Completion Date: September 30, 2024
Finding 402380 (2021-015)
Significant Deficiency 2021
Health Care Services agrees with the recommendation. Effective September 1, 2021, System Development Notice (SDN) 20039 made updates to the Claims Processing Accounts Receivable System, requiring the Fiscal Intermediary (FI) to record the FFP rate including the Budget Program (i.e., Medicaid Assista...
Health Care Services agrees with the recommendation. Effective September 1, 2021, System Development Notice (SDN) 20039 made updates to the Claims Processing Accounts Receivable System, requiring the Fiscal Intermediary (FI) to record the FFP rate including the Budget Program (i.e., Medicaid Assistance Program vs. Children’s Health Insurance Program) for each overpayment account receivable set up after the effective date. The FFP rate and Budget Program information for each overpayment is provided on the Action Notices to the FI. The SDN also made updates to the California Omnibus Budget Reconciliation Act of 1985 (COBRA) system to enable the system to receive the FFP rate and Budget Program information for each overpayment set up by the FI and updated COBRA reports, thereby allowing Health Care Services to report the correct FFP rate for overpayments on the CMS-64 and CMS-21. Estimated Implementation Date: September 30, 2021 Contact: Wendy Griffe, Chief Internal Audits California Department of Health Care Services
View Audit 309913 Questioned Costs: $1
Finding 402375 (2021-013)
Significant Deficiency 2021
Health Care Services understands the finding that amounts identified in the single audit as Medicaid and CHIP “pass through payments to subrecipients” could be subject to the FFATA. Pursuant to Office of Management and Budget (OMB) Guidance, Title 2 of the CFR, Parts 170 and 200.1, and the OMB Comp...
Health Care Services understands the finding that amounts identified in the single audit as Medicaid and CHIP “pass through payments to subrecipients” could be subject to the FFATA. Pursuant to Office of Management and Budget (OMB) Guidance, Title 2 of the CFR, Parts 170 and 200.1, and the OMB Compliance Supplement, a subrecipient is an entity “that receives a subaward from a pass-through entity to carry out part of a Federal award,” and a subaward “does not include payments to a contractor or payments to an individual that is a beneficiary of a Federal Program.” Health Care Services will review current practices for managing subawards and payment classifications to ensure payments subject to FFATA are appropriately reported and update current practices as applicable by June 2024. Estimated Implementation Date: June 2024 Contact: Wendy Griffe, Chief Internal Audits California Department of Health Care Services
Finding 402372 (2021-012)
Significant Deficiency 2021
The Department of Aging (Aging) is committed to rectifying this issue and coming into compliance with this reporting requirement effective now. Aging has reworked the roles and responsibilities within the Budget Operations Bureau to ensure that there is a dedicated staff person to enter all FFATA re...
The Department of Aging (Aging) is committed to rectifying this issue and coming into compliance with this reporting requirement effective now. Aging has reworked the roles and responsibilities within the Budget Operations Bureau to ensure that there is a dedicated staff person to enter all FFATA reporting within the required timeframe. This individual has been trained and made aware of the expectations. Aging has begun updating the FFATA records and will continue this effort through the month of March until all reporting has been completed. Moving forward, the dedicated staff person will update the FFATA for each new federal funding award within the required timeframe. Estimated Implementation Date: March 2023 Contact: Kim Elliott, Chief Budget Officer Division of Administrative Services California Department of Aging
The Office of AIDS (OA) agrees with the finding and recommendation. OA developed and implemented additional, internal quality assurance (QA) processes in April of 2022 to ensure that secondary reviews of AIDS Drug Assistance Program (ADAP) applications are consistently enforcing the existing guideli...
The Office of AIDS (OA) agrees with the finding and recommendation. OA developed and implemented additional, internal quality assurance (QA) processes in April of 2022 to ensure that secondary reviews of AIDS Drug Assistance Program (ADAP) applications are consistently enforcing the existing guidelines, including acceptable supporting documentation and accurate eligibility requirements. During this audit period, and through December 2021, ADAP had issued multiple policy memos to respond to the COVID-19 pandemic, which enabled staff and enrollment workers to defer documentation collection, when necessary, to remain flexible and ensure clients impacted by the pandemic, and associated site closures, did not lose eligibility and access to life saving medications and comprehensive healthcare. These flexibilities in our guidelines were implemented based on guidance received from our federal funder, Health Resources and Services Administration (HRSA), which encouraged ADAPs to reassess their organization's eligibility and recertification policies and procedures, and remove any barriers that may impede social distancing, or other public health strategies, necessary to minimize COVID-19 transmission. This documentation deferral was terminated on December 31, 2021, and since January 1, 2022, full documentation and eligibility requirements have been enforced. This, combined with ongoing QA efforts, will help to mitigate future findings in ADAP applications dated January 1, 2022 onward. Estimated Implementation Date: Already implemented as of April 2022 Contact: Sharisse Kemp, Branch Chief AIDS Drug Assistance Program Branch California Department of Public Health
Health Care Services agrees with the recommendation and implemented corrective action by October 31, 2022. Health Care Services, or DHCS, published Behavioral Health Information Notice (BHIN) 22-045 which outlines Health Care Services sanctions policy. The BHIN states “Under state and federal law D...
Health Care Services agrees with the recommendation and implemented corrective action by October 31, 2022. Health Care Services, or DHCS, published Behavioral Health Information Notice (BHIN) 22-045 which outlines Health Care Services sanctions policy. The BHIN states “Under state and federal law DHCS must enforce compliance with the terms of the DHCS’ contracts with Mental Health Plans and Drug Medi-Cal Organized Delivery System counties, as well as ensure compliance with applicable state and federal laws and regulations, in accordance with its authority and obligations under state and federal requirements.” Lastly, under the section titled ‘Exhibit A - Attachment 3’ of the County Mental Health Plan Contract counties are required to submit cost reports timely which would allow Health Care Services to impose sanctions on counties who do not submit cost reports in a timely manner. This BHIN resolves the finding. Additionally, Health Care Services will not be collecting cost reports for dates of service after State Fiscal Year 2022-23. Under the California Advancing and Innovating Medi-Cal (CalAIM) initiative, and pursuant to Welfare and Institutions Code, Section 14184.403(b), Health Care Services will replace the current Certified Public Expenditures (CPE) reimbursement methodology with an intergovernmental transfer (IGT) reimbursement methodology. The IGT reimbursement methodology will make a single and final payment for services provided to the county, which includes the non-federal portion of the claims. This change will eliminate the requirement for the county submission of cost reports. Estimated Implementation Date: October 31, 2022 Contact: Wendy Griffe, Chief Internal Audits California Department of Health Care Services
Finding 402363 (2021-007)
Significant Deficiency 2021
California Business, Consumer Services and Housing Agency (BCSH) The California Interagency Council on Homelessness (Cal ICH), an entity under the BCSH, would like to acknowledge a finding from the fiscal year 2020-21 Statewide Federal Compliance Audit of the State of California. This audit finding...
California Business, Consumer Services and Housing Agency (BCSH) The California Interagency Council on Homelessness (Cal ICH), an entity under the BCSH, would like to acknowledge a finding from the fiscal year 2020-21 Statewide Federal Compliance Audit of the State of California. This audit finding identifies lack of communication of required subaward information to Cal ICH subrecipients of the Coronavirus Relief Fund (CRF) program at the time of the subaward, or when the State became aware of changes in subaward information, including identification that the subaward funds represented federal funding. Cal ICH agrees with this finding and the recommendation to review all subawards provided which were funded using CRF program funds and determine whether the subrecipients properly reported their CRF awards and related expenditures in their respective schedule of expenditures of federal awards pursuant to Title 2 Code of the Federal Regulations 200.502. Additionally, while formal communication identifying that the subaward fund represented federal funding was not provided, many informal conversations were had with CRF grantees. These conversations were held during bi-weekly online Office Hours and through one-on-one calls with individual subrecipients and discussions of the substitution of federal awards with grantees originally provided with State funds could have occurred. Cal ICH will conduct review of the CRF subawards during mandatory desk reviews to verify that subrecipients properly reported their CRF awards and that expenditures of the federal awards were made pursuant to Title 2 Code of Federal Regulations 200.502. Additionally, Cal ICH has developed an improved communication system between leadership and program staff that will ensure changes are clearly communicated. This will also ensure the Council’s subrecipients are notified in a timely manner upon any changes in subaward information, such as identifying if subaward funds represent federal funding so that expenditures are spent in accordance with Federal statutes, regulations, and the terms and conditions of federal awards. Additionally, if in the future funding is changed, CDE will provide updated information to all recipients; this will ensure that expenditures are in line with the terms and conditions of the grant and/or funding source. Estimated Implementation Date: May 2023 Contact: Ellen Meuchel, Monitoring Unit Cal ICH Grant Operations and Suppor California Department of Education Concur. Education will review the relevant subawards funded under the CRF program and determine whether the subrecipients properly reported their CRF awards pursuant to 2 CFR 200.501. Estimated Implementation Date: July 31, 2023 Contact: Kelly Levario, External Audits Coordinator Audits and Investigations Division California Department of Social Services The California Department of Social Services (CDSS) acknowledges the Single Audit finding regarding the delayed communication of subaward information to the Department’s subrecipients of the Coronavirus Relief Fund (CRF) program. On December 21, 2022, CDSS released County Fiscal Letter 22/23-31 on the subject of “Federal Coronavirus Relief Funds That Replaced General Fund for COVID-19 Related Activities for Fiscal Years 2019-20 and 2020-21” to County Welfare Departments (CWDs) and federally recognized Tribal governments in California. This letter served as a formal documentation of the portion of expenditures that were funded with federal CRF. Additionally, although formal notice was not provided until December 21, 2022, informal notices and conversations took place between CDSS and the County Welfare Directors Association, as well as with CWDs, regarding possible situations in which the substitution of federal awards with grants originally provided with State funds could occur. On September 21, 2021, CDSS sent a notice to subrecipients requesting for their Data Universal Number System for the purpose of CRF federal subawards; thereby, communicating the use of CRF on the subrecipients’ behalf. CDSS will conduct a review of the CRF subawards during on-site fiscal monitoring reviews to verify that subrecipients properly reported their CRF awards and that expenditures of the federal awards were made pursuant to Title 2 Code of Federal Regulations 200.502. Moreover, CDSS will ensure that the Department’s subrecipients are notified in a timely manner upon any changes in subaward information, such as identifying if subaward funds represent federal funding so that expenditures are spent in accordance with Federal statutes, regulations, and the terms and conditions of federal awards. Estimated Implementation Date: April 2023 through June 2024 Contact: Elisa Tsujihara, Chief Fiscal Policy and Analysis Bureau
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