Corrective Action Plans

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2024-005 – Reporting (Repeat Finding) Auditor Description of Condition and Effect. While the City performed the required Coronavirus State and Local Fiscal Recovery Funds expenditure reporting for each quarter of 2024, the Project and Expenditure reports for the first three quarters of 2024 did not ...
2024-005 – Reporting (Repeat Finding) Auditor Description of Condition and Effect. While the City performed the required Coronavirus State and Local Fiscal Recovery Funds expenditure reporting for each quarter of 2024, the Project and Expenditure reports for the first three quarters of 2024 did not report any current period expenditures. Rather, the cumulative expenditures for the year were included in the fourth quarter Project and Expenditure report. In addition, the Project and Expenditure reports for the third and fourth quarters of 2024 were not filed within the required timeframe. As a result of this condition, the City did not comply completely with the reporting requirements of the Coronavirus State and Local Fiscal Recovery Funds grant. Auditor Recommendation. We recommend that the City review the reporting requirements for each grant and complete all required reporting as required under the terms of the grant agreement. Corrective Action. City staff has accessed these reports and attempted to submit all required reports. Ongoing reports have been submitted on time. Assistance will be sought with federal agencies as necessary. Responsible Person. Finance Director Anticipated Completion Date. December 31, 2025
Finding Number: 2024-002 Finding Title: Eligibility - METS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: John Stepien, Financial Assistance Supervisor Corrective Action Planned: The Financial Assistance supervisor will run BOBI report MNCM 220A ...
Finding Number: 2024-002 Finding Title: Eligibility - METS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: John Stepien, Financial Assistance Supervisor Corrective Action Planned: The Financial Assistance supervisor will run BOBI report MNCM 220A at least 2 times per month to identify outstanding verifications for MA cases in METS. This will identify specific cases missing SSN verifications. Anticipated Completion Date: The MNCM 220A reported is generated quarterly. The anticipated completion date is October 6th for the next quarterly report.
This serves as a response to your audit memo regarding Finding 2024-001 Allowable Costs - Significant deficiency in internal controls over compliance in Section II - Federal Award Findings and Questioned Costs. The organization concurs with the finding and has made corrective actions effective immed...
This serves as a response to your audit memo regarding Finding 2024-001 Allowable Costs - Significant deficiency in internal controls over compliance in Section II - Federal Award Findings and Questioned Costs. The organization concurs with the finding and has made corrective actions effective immediately to ensure the deficiency no longer occurs. Specifically, an active confirmation of billing amounts matching the general ledger from the CPA to the CEO has been added to our internal controls. Previously, the CPA only contacted the CEO if there was a need for correction. As stated in the audit report, this error occurred during the transition time between our contracted CPA and the new CFO beginning. Neither the CPA nor the CFO informed the CEO of the discrepancy between the billing and general ledger amounts, and therefore no correction was made or even looked for. This finding identified a flaw in our existing internal controls if the CPA does not complete the final validation process. Below are the internal control procedures for grant billing that were in place at the time of the error with the new addition in red: • All time sheets are forwarded to the CPA. • The CPA, or their designee, develops a payroll report utilizing the timesheets to allocate payroll by work function. • The payroll report is forwarded to the CEO for approval and billing purposes. • The detailed monthly billing is sent to the CPA for verification that the billing matches the general ledger. • The CPA will send an email to the CEO either confirming the amounts billed match the general ledger or identifying the need for a billing/general ledger correction. • Any discrepancies between billing and the general ledger are corrected via a corrected billing being submitted or a general ledger journal entry being made to reallocate costs. The organization is confident the above augmented internal control procedures will provide the necessary oversight and quality control measures needed to ensure the identified deficiency from recurring. The CEO is responsible for monitoring and ensuring compliance with the revised internal control measures.
Finding #2024-003 – Significant Deficiency and Other Noncompliance. Condition and context: Boys & Girls Club was unable to produce a report from its general ledger system that supported the expenditures reported in the schedule of expenditures of federal awards. Recommendation: Establish policies an...
Finding #2024-003 – Significant Deficiency and Other Noncompliance. Condition and context: Boys & Girls Club was unable to produce a report from its general ledger system that supported the expenditures reported in the schedule of expenditures of federal awards. Recommendation: Establish policies and procedures to record all federal expenditures in the general ledger system by class code in order to generate a report of expenditures by grant. Planned corrective action: Government funded transactions will be recorded in our general ledger in a manner which facilitates reporting by federal award. Management will review grant reports monthly to ensure transactions are properly recorded. Responsible officer: Amber Newman, CEO. Estimated completion date: October 1, 2025.
Finding #2024-004 – Significant Deficiency and Other Noncompliance. Condition and context: In a sample of 30 vendor payments, we found one instance of reimbursement by the grantor approximately five months before payment was made to the vendor. Recommendation: Strengthen controls to ensure that invo...
Finding #2024-004 – Significant Deficiency and Other Noncompliance. Condition and context: In a sample of 30 vendor payments, we found one instance of reimbursement by the grantor approximately five months before payment was made to the vendor. Recommendation: Strengthen controls to ensure that invoices are paid in a timely manner to ensure federal reimbursements are not being held for an excess period of time. Planned corrective action: As part of our enhanced review of government transactions, we will be mindful that federal reimbursement requests should only include expenses that have been disbursed or have been accrued with expectation of disbursement in a timely manner. Responsible officer: Amber Newman, CEO. Estimated completion date: October 1, 2025.
Finding #2024-002 – Significant Deficiency and Other Noncompliance. Condition and context: Same as finding reported as #2024-001. Recommendation: Same as finding reported as #2024-001. Planned corrective action: Year-end closing policies and procedures will be modified to ensure grant transactions a...
Finding #2024-002 – Significant Deficiency and Other Noncompliance. Condition and context: Same as finding reported as #2024-001. Recommendation: Same as finding reported as #2024-001. Planned corrective action: Year-end closing policies and procedures will be modified to ensure grant transactions are reviewed, reconciled, and include applicable accruals. Management will review grant reports monthly to ensure transactions are properly recorded. Responsible officer: Amber Newman, CEO. Estimated completion date: October 1, 2025.
Finding 2024-003 Condition: As part of our audit of the Federal Aviation Administration Program, it was noted that the Airport did not adopt written policies/procedures surrounding certain areas to comply with the requirements of the Uniform Guidance Corrective Action Plan: Corrective Action Planned...
Finding 2024-003 Condition: As part of our audit of the Federal Aviation Administration Program, it was noted that the Airport did not adopt written policies/procedures surrounding certain areas to comply with the requirements of the Uniform Guidance Corrective Action Plan: Corrective Action Planned: Airport Finance department has adopted written policies and procedures to satisfy Uniform Guidance Name(s) of Contact Person(s) Responsible for Corrective Action: Director of Finance Anticipated Completion Date: August 1, 2025
Finding 1155070 (2024-003)
Material Weakness 2024
FINDING 2004-003 Finding Subject: CDBG – Entitlement Grants Cluster – Internal Control – Reporting Contact Person Responsible for Corrective Action: LaTrea Reed Contact Phone Number and Email Address: 219-881-5085 View of Responsible Officials: We Concur Description of Corrective Action Plan: Respon...
FINDING 2004-003 Finding Subject: CDBG – Entitlement Grants Cluster – Internal Control – Reporting Contact Person Responsible for Corrective Action: LaTrea Reed Contact Phone Number and Email Address: 219-881-5085 View of Responsible Officials: We Concur Description of Corrective Action Plan: Response to Finding: Segregation of Duties and Oversight of Required FFATA Reporting To address the finding related to segregation of duties and the lack of an established oversight or review process for required reports submitted under the Federal Funding Accountability and Transparency Act (FFATA), the Department of Community Development will implement a formalized review process. This process will include the use of a signature form to document the roles of the: • Preparer – responsible for compiling the report, • Reviewer – responsible for independently verifying the report’s accuracy, and • Submitter – responsible for final submission of the verified report. All parties will be required to sign the form upon completion of their respective responsibilities, ensuring accountability, verification of data accuracy, and compliance with FFATA reporting requirements. Anticipated Completion Date: February 2026
Management will implement the following corrective actions to address the root causes and prevent recurrence: • Policy Clarification – Categories A–D of the sliding fee schedule apply only to patients at or below 200% FPG. Category E is designated as a deposit/minimum payment category for patients a...
Management will implement the following corrective actions to address the root causes and prevent recurrence: • Policy Clarification – Categories A–D of the sliding fee schedule apply only to patients at or below 200% FPG. Category E is designated as a deposit/minimum payment category for patients above 200% FPG, with no discount applied. • Patient Reclassification – All previously misclassified patients are being reclassified to full-pay status. Prior balances will be reconciled in accordance with HRSA requirements and organizational policy. • Staff Training – Front office, billing, and eligibility staff will undergo mandatory refresher training on the Sliding Fee Discount Program, income verification, and proper application of the fee schedule. Additional refresher training on Self-Pay procedures will be led by the Director of Member Services. • Ongoing Monitoring – A quarterly compliance audit of the sliding fee program has been implemented. Results will be reviewed by management, with corrective actions taken as necessary. • Transparency & Communication – Patients will be notified in writing of their payment category. Appeals or questions will be addressed per organizational policy and HRSA guidelines. • Financial Remediation – Refunds will be issued to patients who were overcharged. For cases involving undercharges, the outstanding balance will be applied to the patient’s next visit. Personnel responsible for implementation: Jose Juarez, Director of Member Services Date of implementation: August 31, 2025
View Audit 367364 Questioned Costs: $1
Views of Responsible Officials and Corrective Action: The District will strive to implement the water shut-off policy consistently.
Views of Responsible Officials and Corrective Action: The District will strive to implement the water shut-off policy consistently.
Views of Responsible Officials and Corrective Action: The District will strive to gain necessary knowledge needed to prepare a full set of financial statements. The District will appoint a competent individual who possesses the skill knowledge and experience to review and approve the draft reports a...
Views of Responsible Officials and Corrective Action: The District will strive to gain necessary knowledge needed to prepare a full set of financial statements. The District will appoint a competent individual who possesses the skill knowledge and experience to review and approve the draft reports and assume all relevant management responsibilities.
Views of Responsible Officials and Corrective Action: The District will strive to segregate as many accounting functions as practical with the limited staff available.
Views of Responsible Officials and Corrective Action: The District will strive to segregate as many accounting functions as practical with the limited staff available.
Medical Assistance Program – Assistance Listing No. 93.778 Recommendation: CLA recommends the County develop and implement a process to require review and approval of the WIMCR reports prior to the submission of the report to the state to help ensure that the data reported are accurate, complete and...
Medical Assistance Program – Assistance Listing No. 93.778 Recommendation: CLA recommends the County develop and implement a process to require review and approval of the WIMCR reports prior to the submission of the report to the state to help ensure that the data reported are accurate, complete and supporting documentation is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Annual WIMCR reporting to be completed by Waushara County DHS Finance team; Financial Manager and/or Financial Assistant. If both positions are fully employed both positions need to review and sign off on data prior to submission. If one of the positions is vacant a second review of data and signoff needs to be done by someone else within DHS – likely the DHS Director. Name(s) of the contact person(s) responsible for corrective action: Peder Culver, Finance Manager, Clara Voigtlander, DHS Director Planned completion date for corrective action plan: Action plan in place 2025 reporting in 2026.
Finding 2024-005: PERIOD OF PERFORMANCE Description of Finding: Capital Funds identified in the PHA's CFP 5-Year Action Plan to be transferred to operations are obligated by the PHA once the funds have been budgeted and drawn down by the PHA. Capital Funds transferred to operations (BLI 1406) are no...
Finding 2024-005: PERIOD OF PERFORMANCE Description of Finding: Capital Funds identified in the PHA's CFP 5-Year Action Plan to be transferred to operations are obligated by the PHA once the funds have been budgeted and drawn down by the PHA. Capital Funds transferred to operations (BLI 1406) are not considered obligated until the PHA has budgeted and drawn down the funds. To meet this requirement, the funds must be budgeted in line BLI 1406 (Operations) and the PHA must submit the voucher request in LOCCS. (24 CFR Section 905.314(I)). Statement of Concurrence or NonConcurrence: The Authority had obligated capital funds related to operations (BLI 1406) for Capital Fund years 2020 and 2022 prior to the voucher request date for these draws. The Authority had six open capital fund grants during fiscal year 2024 (Capital Fund years 2019-2024). The Authority obligated the BLI 1406 funding for Capital Fund 2020 in March 2024 and Capital Fund 2022 in May 2024. The Authority submitted the voucher requests in February 2025. Corrective Action: Funds in 1406 will be drawn down directly after obligation. Name of Contact Person: Cheryl Thibeault Projected Completion Date: 09/30/2025
Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2024 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2024-001 – Reporting: Federal Funding Accountability and Transparency Act (“FFATA”) Description of Finding: Th...
Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2024 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2024-001 – Reporting: Federal Funding Accountability and Transparency Act (“FFATA”) Description of Finding: The FFATA subawards were not submitted timely to the Federal Funding Accountability and Transparency Act Subaward Reporting System (“FSRS”). The review and approval occurred after the FFATA subaward was submitted to the FSRS. Statement of Concurrence: We concur with the finding above. Corrective Action: BCHN has created a policy regarding the FFATA reporting process. In this process the Electronic Handbook (EHB) is reviewed weekly to ensure that if new awarded funding is released, BCHN is alerted to the need to complete the FFATA report. BCHN has created a spreadsheet to track all the awarded funding and due dates for FFATA reports. Every month, at the board meeting, the spreadsheet is presented to the board with any new awarded funding and when the FFATA report is completed. BCHN has begun a process where the FFATA report is put together by the Finance Manager and reviewed and signed off by the CFO before submitting the report. Completion Date: October 2024. Name of Contact Person: Alicia Tenny Chief Financial Officer Tel. No.: (917) 364-1156 E-mail: atenny@bchnhealth.org If HRSA has questions regarding this Corrective Action Plan, please call Alicia Tenny at (917) 364-1156. Sincerely yours, _________________________ Alicia Tenny Chief Financial Officer
Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2024 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2024-004 – Period of Performance Description of Finding: There was no evidence, such as a signature, evidencin...
Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2024 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2024-004 – Period of Performance Description of Finding: There was no evidence, such as a signature, evidencing review and approval by a direct supervisor of the timesheets. Time and effort reports were not done. Statement of Concurrence: We concur with the finding above. Corrective Action: BCHN has put together a training program for employees to ensure that timecards are reviewed and approved by both the employee and the supervisor on a bi-weekly basis. Before payroll is processed, approvals by employees and supervisors will be checked. HR will provide a monthly time and effort report to the finance team. This report will provide total number of hours worked by each employee for each assigned cost center. Completion Date: October 2024. Name of Contact Person: Alicia Tenny Chief Financial Officer Tel. No.: (917) 364-1156 E-mail: atenny@bchnhealth.org If HRSA has questions regarding this Corrective Action Plan, please call Alicia Tenny at (917) 364-1156. Sincerely yours, _________________________ Alicia Tenny Chief Financial Officer
The Director of Finance and Accounting Manager began implementing process and procedures to ensure all invoices are filed in a timely manner to funders in July 2024. The importance of understanding the requirements of the agreements has been stressed to the finance team. The team has also been instr...
The Director of Finance and Accounting Manager began implementing process and procedures to ensure all invoices are filed in a timely manner to funders in July 2024. The importance of understanding the requirements of the agreements has been stressed to the finance team. The team has also been instructed to save on SharePoint all communication with funders regarding changes of when invoices are to be filed when the instructions differ from the agreement. EPHC has been behind on financial statements and previously were not able to submit the semi-annual financial statements. As of June 30, 2025, the first semi-annual financial statements was submitted.
The Director of Finance and Accounting Manager began implementing process and procedures to ensure all invoices are filed in a timely manner to funders in July 2024. The importance of understanding the requirements of the agreements has been stressed to the finance team. The team has also been instr...
The Director of Finance and Accounting Manager began implementing process and procedures to ensure all invoices are filed in a timely manner to funders in July 2024. The importance of understanding the requirements of the agreements has been stressed to the finance team. The team has also been instructed to save on SharePoint all communication with funders regarding changes of when invoices are to be filed when the instructions differ from the agreement. To ensure timely submission of the performance reports, EPHC will use Sales Force software to track all due dates. This system will send reminders and will record submission dates. To ensure review of all performance reports, procedures will be put in place outlining roles and responsibilities of report preparation by managers and review by Program Directors.
EPHC has long term employees that joined the organization when it was a program of Catholic Charities. EPHC does not maintain these records for employees that began with Catholic Charities. In early FY2026, EHPC will complete background checks on long term employees to ensure we maintain the proper ...
EPHC has long term employees that joined the organization when it was a program of Catholic Charities. EPHC does not maintain these records for employees that began with Catholic Charities. In early FY2026, EHPC will complete background checks on long term employees to ensure we maintain the proper documentation.
The delegates from the board did receive the 40-hour training prior to entering the board but were unable to provide certification proof. Moving forward a new process of policy with record keeping guidance will be implemented to ensure the documentation is kept on file. For training courses that do ...
The delegates from the board did receive the 40-hour training prior to entering the board but were unable to provide certification proof. Moving forward a new process of policy with record keeping guidance will be implemented to ensure the documentation is kept on file. For training courses that do not provide a completion certificate, Board members will prepare a memo with self-attestation of completion for our records.
Moving forward a new process of policy with record keeping guidance will be implemented to ensure the documentation is kept on file. For training courses that do not provide a completion certificate, staff will prepare a memo with self-attestation of completion for our records.
Moving forward a new process of policy with record keeping guidance will be implemented to ensure the documentation is kept on file. For training courses that do not provide a completion certificate, staff will prepare a memo with self-attestation of completion for our records.
Finding Number: 2024-004 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Erin Marks, Accounting & Support Services Supervisor - Main Contact Persons involved: Kim Giese, Fiscal Officer and Joan Stordalen, Social Services S...
Finding Number: 2024-004 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Erin Marks, Accounting & Support Services Supervisor - Main Contact Persons involved: Kim Giese, Fiscal Officer and Joan Stordalen, Social Services Supervisor Corrective Action Planned: Regarding the DHS-3220.3 Local Collaborative Time Study (LCTS) Cost Schedule, it was discovered that the Sexual Reproductive Health Services Grant Award was not accurately reported on the LCTS Cost Schedule due to the misguidance from MN Department of Health (MDH) and the interpretation of Watonwan County. After clarification from MDH, all SRHS funds will be reported as state funds only and should not be reflected on the LCTS reporting. Fiscal Officer will amend the last 4 quarters of the LCTS reporting to reflect that change. Moving forward, we will retain documentation from MDH showing SRHS funds are state only funds, regardless of what our grant agreement shows, and ensure that this funding source is not reported on the LCTS reporting in the future. Fiscal Officer will continue to complete the quarterly LCTS reporting, while the Accounting & Support Services Supervisor will review and sign off on it. Regarding the late submission of the 2024 Annual Collaborative Report. This report is emailed and completed by the LCTS Coordinator. Watonwan County's LCTS Coordinator is our Social Services Supervisor. To ensure on time submission of the Annual Collaborative Report, that is due on April 30 each year, a reminder will be added to both the Social Services Supervisor and the Accounting & Support Services Supervisor's Outlook calendars for a reminder beginning April ist giving time to complete and submit the report prior to April 30th. Anticipated Completion Date: 9/12/2025 - Reporting 4/30/2026 - Late Submission
Finding Number: 2024-003 Finding Title: Eligibility - MAXIS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Jodi Halvorson Corrective Action Planned: Verification of Citizenship/assets: We will have discussions at our next unit meeting about makin...
Finding Number: 2024-003 Finding Title: Eligibility - MAXIS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Jodi Halvorson Corrective Action Planned: Verification of Citizenship/assets: We will have discussions at our next unit meeting about making sure all health care cases have their citizenship verified. We will also have training on the policy regarding verifying vehicles if there is more than one in the household. Anticipated Completion Date: 9/15/25 we will have the unit meeting
Finding Number: 2024-002 Finding Title: Eligibility - METS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Jodi Halvorson Corrective Action Planned: Timelines: This error occurred from a worker that is no longer in our agency. It was discovered af...
Finding Number: 2024-002 Finding Title: Eligibility - METS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Jodi Halvorson Corrective Action Planned: Timelines: This error occurred from a worker that is no longer in our agency. It was discovered after the worker left that the application was filed away without processing. This is not our policy, and we will be discussing the importance of program timelines in our unit meeting. Verification of Citizenship status (error with SSN entry): This case was received from a previous county. The SSN was entered incorrectly which did not produce citizenship verification in the system. It was noted that there was a birth certificate on file, but METS case files do not get transferred between counties, so we did not have the birth certificate. The SSN was corrected which was able to ping the verification of the citizenship. Going forward, for the next 3 months we will be looking at each case that is transferred into our county to make sure the citizenship has been verified and if not, request the birth certificate or other verification. After the initial 3 months, we plan to do random case checks. Anticipated Completion Date: 9/15/25 we will have the unit meeting and discuss timelines 12/31/25 will be our 3-month goal of checking transferred in cases for citizenship
2024-003: Water and Waste Disposal Systems for Rural Communities Reporting Corrective Action Plan: The Village is actively working with USDA personnel to submit the required reporting documents. Going forward, these will be submitted once available. Reponsible person: Sheila Schreiner Anticipated co...
2024-003: Water and Waste Disposal Systems for Rural Communities Reporting Corrective Action Plan: The Village is actively working with USDA personnel to submit the required reporting documents. Going forward, these will be submitted once available. Reponsible person: Sheila Schreiner Anticipated completetion date: Ongoing
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