Corrective Action Plans

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2022-001 Gross Patient Revenues Included in Lost Revenue Calculation Corrective action planned: Ensure independent audit of financial statements is performed and finalized prior to Provider Relief Fund or other relevant filing deadlines to ensure completeness of revenue calculation. Anticipated comp...
2022-001 Gross Patient Revenues Included in Lost Revenue Calculation Corrective action planned: Ensure independent audit of financial statements is performed and finalized prior to Provider Relief Fund or other relevant filing deadlines to ensure completeness of revenue calculation. Anticipated completion date: 12/31/2023 Contact person responsible for corrective action: Anthonie Zimmermann, CFO
Ensure that the Organization's tenant compliance policies are strictly adhered to, complying with FHA Guidance and that proper procurement documentation maintained.
Ensure that the Organization's tenant compliance policies are strictly adhered to, complying with FHA Guidance and that proper procurement documentation maintained.
Finding 2022-02: Late Submission of Financial Statements to FAC and REAC (Significant Deficiency) Corrective Action Plan: Lack of leadership and structure within the Finance department along with the ripple effects from a previous waiver submission requirement under COVID for delayed audit submissio...
Finding 2022-02: Late Submission of Financial Statements to FAC and REAC (Significant Deficiency) Corrective Action Plan: Lack of leadership and structure within the Finance department along with the ripple effects from a previous waiver submission requirement under COVID for delayed audit submissions lead to missed deadlines for the delivery of the financial statements to REAC. To remedy this finding, RRHA’s new CFO has implemented an earlier internal deadline for Unaudited FDS submissions. RRHA’s Unaudited FDS is due November 30th. However, the new internal deadline date will be scheduled before Thanksgiving each year. We will also work with our auditors to establish an audit schedule that will allow us to submit the Audited FDS prior to the June 30th deadline. Name of Responsible Person: Precious Washington, Senior Vice President/Chief Financial Officer Expected Completion Date: September 30, 2024
2022-005 Control Documentation Recommendation: We recommend that the District review its procedures and controls over time and effort documentation for wages charged to Federal programs to ensure all documentation accurately reflets the work performed and that the time and effort documentation agree...
2022-005 Control Documentation Recommendation: We recommend that the District review its procedures and controls over time and effort documentation for wages charged to Federal programs to ensure all documentation accurately reflets the work performed and that the time and effort documentation agrees with how the employee’s wages are allocated to the grant in the finance system Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will make necessary modifications to its time and effort documentation and control process to ensure all wages charged to Federal programs accurately reflect the work performed. Name(s) of the contact person(s) responsible for corrective action: Tariro Chapinduka, Director of Business Services Planned completion date for corrective action plan: December 31, 2023
Controls, such as a calendar tracker, should be implemented to monitor timely completion and submission of required reports. In addition, there should be a documented review of the report data before submission. The Organization will fully utilize the spreadsheet /database that is in place with key...
Controls, such as a calendar tracker, should be implemented to monitor timely completion and submission of required reports. In addition, there should be a documented review of the report data before submission. The Organization will fully utilize the spreadsheet /database that is in place with key federal contract requirements and deadlines. This document will be reviewed monthly by the program and finance team to ensure reports and submitted on a timely basis. Additional tools will be utilized to facilitate roles and responsibilities and reporting requirements.
Finding 857 (2022-001)
Significant Deficiency 2022
2022-01 Technical Name of contact person: Annie Murrell, Director of Social Services Corrective Action: Forced Eligibility Supervisors will ensure that staff are utilizing dictation templates that was implemented in January 2022. This template addresses Admin letters when needed and training was com...
2022-01 Technical Name of contact person: Annie Murrell, Director of Social Services Corrective Action: Forced Eligibility Supervisors will ensure that staff are utilizing dictation templates that was implemented in January 2022. This template addresses Admin letters when needed and training was completed with staff. Supervisors have implemented reviewing the task that caseworkers are receiving. Completing these reviews will allow supervisors to monitor timeliness regarding medical forced/recertifications. Supervisors for all Medicaid programs will complete a review of all transfer cases prior to accepting the transfer to identify possible errors in the case. If needed supervisors will reach out to the transferring county. This change will be effective October 2023. Income - Total Countable Income CMA implemented recertification checklist in September 2022 that will assist workers in completing steps during the recertification process and second partying their work as well. Proposed Completion Date: October 31, 2023
Condition: During testing of tenant files, there were 5 instances where inspection documentation or HQS documentation was missing. Corrective Action: Management has established the proposed controls included in the Recommendations outlined in the Federal Awards Findings and Questioned Costs documen...
Condition: During testing of tenant files, there were 5 instances where inspection documentation or HQS documentation was missing. Corrective Action: Management has established the proposed controls included in the Recommendations outlined in the Federal Awards Findings and Questioned Costs document: Management created a review tool checklist of all required forms for the frontline staff to use as reference, for the Housing Coordinator to review assistance requests and client charts; and for leadership to conduct randomized internal audits; updated the training curriculum for Housing Department staff; new frontline staff has been hired, and trained to include clarification of compliance elements, the rationale and their importance, and which forms satisfy each one. WNCAP recognizes that the deficiency appears to persist, but this is due to the corrective actions being implemented in the first quarter of 2023, which is when the final audit report for FY 2020-21 was completed, and which time period is not covered by this audit. After implementation, internal review of client records confirms that they addressed this deficiency, as evidenced by the complete, compliant files. This will be reflected in the next Single Audit for FY 2022-23, and going forward.
Condition: During the testing of tenant files, certain documentation deficiencies noted as summarized below: 14 – Missing Release of Information documentation. 9 – Missing documentation of client and/or landlord participation agreements. 4 – Missing documentation of current income or verification...
Condition: During the testing of tenant files, certain documentation deficiencies noted as summarized below: 14 – Missing Release of Information documentation. 9 – Missing documentation of client and/or landlord participation agreements. 4 – Missing documentation of current income or verification of 0 income. 3 – Missing documentation of housing plan or assessment. Corrective Action: Management has established the proposed controls included in the previous audit, which match the Recommendations outlined in the Federal Awards Findings and Questioned Costs document: created a review tool checklist of all required forms for management to review assistance requests and client charts; updated the training curriculum for Housing Department staff, new frontline staff has been hired and trained to include clarification of compliance elements, the rationale and their importance, and which forms satisfy each one. Management also decided to overhaul all department forms and has begun a review process. WNCAP recognizes that the deficiency appears to persist, but this is due to the corrective actions being implemented in the first quarter of 2023, which is when the final audit report for FY 2020-21 was completed, and which time period is not covered by this audit. After implementation, internal review of client records confirms that they addressed this deficiency, as evidenced by the complete, compliant files. This will be reflected in the next Single Audit for FY 2022-23, and going forward.
Condition: The WNCAP Single Audit was not submitted to the Federal Audit Clearinghouse within the prescribed period. Corrective Action: The key position of Director of Finance was filled in October 2022, and will remain appropriately staffed going forward. The main cause for this delay was the dela...
Condition: The WNCAP Single Audit was not submitted to the Federal Audit Clearinghouse within the prescribed period. Corrective Action: The key position of Director of Finance was filled in October 2022, and will remain appropriately staffed going forward. The main cause for this delay was the delay of the previous Single Audit, since it extended into this fiscal year’s timeline. The Director of Finance was able to complete the SEFSA for this audit in a timely manner, and the audit progressed at a reasonable pace. Management will continue to refine internal processes for efficiency; and WNCAP is on track to submit the next Single Audit (FY 2022-23) by the standard deadline of March 31, 2024. In addition, management created a risk assessment policy and procedure to be initiated any time there is turnover in key personnel who play a role in the finance-related activities of the organization. The process includes the following steps: naming an assessor/monitor to lead the effort, who must be the staff member at the highest level of financial responsibility; creation of a monitoring plan that identifies risks, their potential impacts, the actionable steps to mitigate said impacts, and assigns actionable steps to specific staff. The assessor/monitor decides the duration of the monitoring period, and is tasked with routinely meeting with responsible staff to ensure mitigation activities are implemented, and update the monitoring plan as needed. One of the potential impacts named in the policy is “past-due submission of the Single Audit into the FAC”.
During weekly meetings, the importance of timely reporting will be discussed with employees responsible for completion and submittal of reports to ensure that all requirements to the Government, including financial audits, are identified, and submitted in a timely manner. Reporting deadlines specifi...
During weekly meetings, the importance of timely reporting will be discussed with employees responsible for completion and submittal of reports to ensure that all requirements to the Government, including financial audits, are identified, and submitted in a timely manner. Reporting deadlines specified in the cooperative agreement for monthly financial reports are under discussion with the Federal Government. This is estimated to be completed by December 31, 2023.
Sliding Scale Assessment Planned Corrective Action: (Patients accounts were tested for eligibility for the sliding scale and found that the patient was not eligible for the discount. We are training staff to follow guidelines during their assessment. Sliding fee discounts will be approved by Sanara...
Sliding Scale Assessment Planned Corrective Action: (Patients accounts were tested for eligibility for the sliding scale and found that the patient was not eligible for the discount. We are training staff to follow guidelines during their assessment. Sliding fee discounts will be approved by Sanara Leake. Person Responsible for Corrective Action Plan: (Sanara Leake, Revenue Cycle Manager) Anticipated Date of Completion: 10/30/2023
Management’s Response The key fiscal point of contact for HAPCAP was on medical leave for a significant portion of time during the work of the audit. This led to delays in the compilation of required reports. Additionally, near the submission deadline, there was a discrepancy in the financials that ...
Management’s Response The key fiscal point of contact for HAPCAP was on medical leave for a significant portion of time during the work of the audit. This led to delays in the compilation of required reports. Additionally, near the submission deadline, there was a discrepancy in the financials that was ultimately resolved, but took time to research and also contributed to the late submission. All items within the audit were accurate. HAPCAP now has multiple staff that have been involved in the process of building audit reports. This will allow for timely audit completion for all future audits. We will also work with our audit firm to begin the work of the audit earlier in the calendar year for the 2023 audit. Contact Person Responsible for Corrective Action: Kelly Hatas, Executive Director Anticipated Completion Date: 10/24/2023 Management’s Response The key fiscal point of contact for HAPCAP was on medical leave for a significant portion of time during the work of the audit. This led to delays in the compilation of required reports. Additionally, near the submission deadline, there was a discrepancy in the financials that was ultimately resolved, but took time to research and also contributed to the late submission. All items within the audit were accurate. Finding 2022-001: Late Filing of Audit Report Management’s Response The key fiscal point of contact for HAPCAP was on medical leave for a significant portion of time during the work of the audit. This led to delays in the compilation of required reports. Additionally, near the submission deadline, there was a discrepancy in the financials that was ultimately resolved, but took time to research and also contributed to the late submission. All items within the audit were accurate. HAPCAP now has multiple staff that have been involved in the process of building audit reports. This will allow for timely audit completion for all future audits. We will also work with our audit firm to begin the work of the audit earlier in the calendar year for the 2023 audit. Contact Person Responsible for Corrective Action: Kelly Hatas, Executive Director Anticipated Completion Date: 10/24/2023
Finding 408 (2022-004)
Significant Deficiency 2022
Federal Agency Name: U.S. Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: There was no formal documented review over the reserve fund reconciliation for the federal program. Re...
Federal Agency Name: U.S. Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: There was no formal documented review over the reserve fund reconciliation for the federal program. Responsible Individuals: Nathan Johnson, CEO and Dan Stone, CFO Corrective Action Plan: We have adopted a policy to enhance internal control to ensure the reserve fund reconciliation has a secondary review and approval that is documented. Anticipated Completion Date: August 31, 2023
RE: Single Audit Corrective Action Plan The City of Hartwell, Georgia respectfully submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Williamson and Company, CPAs 611 N Tennessee Street ...
RE: Single Audit Corrective Action Plan The City of Hartwell, Georgia respectfully submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Williamson and Company, CPAs 611 N Tennessee Street Cartersville, GA 30120 Audit Period: Year ended December 31, 2022 The findings from the December 31, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule of findings and questioned costs. Findings – Financial Statement Audit MATERIAL WEAKNESS None Reported SIGNIFICANT DEFICIENCY None Reported Findings – Federal Award Programs Audit MATERIAL WEAKNESS None Reported SIGNIFICANT DEFICIENCY None Reported 2022-001 Clean Water State Revolving Fund – ALN: 66.458 Finding: Schedule of Expenditures of Federal Awards Preparation Recommendation: Procedures should be implemented to ensure completion of an entry to the Schedule of Federal Expenditures of Federal Awards to achieve a reliable reporting of total expenditures for an audit period. Action Taken: We acknowledge our responsibility to present the Schedule of Expenditures of Federal Awards and related notes in accordance with Uniform Guidance requirements. To ensure future implementation of this requirement, the City of Hartwell will record all expenditures on the schedule of federal expenditures going forward on for all federally funded projects. Please call or write if there are any questions/suggestions that you may have to help us further enhance the City’s operations. Sincerely, Audrey Segars Finance Director City of Hartwell, Georgia
Federal Award Finding: 2022-003 Significant Deficiency in Compliance and Internal Controls over Compliance - Reporting -Monitoring of Grant Budget and Expenditures Name and Contact Person: Heather Grato, Controller Corrective Action: The Controller with the help with of a hired consultant will gener...
Federal Award Finding: 2022-003 Significant Deficiency in Compliance and Internal Controls over Compliance - Reporting -Monitoring of Grant Budget and Expenditures Name and Contact Person: Heather Grato, Controller Corrective Action: The Controller with the help with of a hired consultant will generate a new policies and procedure that will help ensure the accounting is reviewed monthly and quarterly, and any errors are corrected before submission of grant reports. Once grant activity is adequately reviewed the Controller will create budget vs. actual financial reports to present to management and program managers or the Board. The accounting staff will file quarterly grant reports and drawdown funding before the deadline after transactions are prepared and reviewed. Proposed Completion Date: 6/30/2024
Finding 310 (2022-012)
Significant Deficiency 2022
Finding: 2022-012: Inadequate Request for information Name of Contact Person: Laurie Potter, DSS Director Corrective Action: (Adult Medicaid) All cases are now being reviewed to make sure all the correct information is being requested from the client. Information that was unknown to the agency prev...
Finding: 2022-012: Inadequate Request for information Name of Contact Person: Laurie Potter, DSS Director Corrective Action: (Adult Medicaid) All cases are now being reviewed to make sure all the correct information is being requested from the client. Information that was unknown to the agency previously has been addressed by OST thru multiple training sessions. (MAGI) New supervisor will be hired & trained on what is needed to be entered into the system. New supervisor will complete 2nd party reviews & training as needed. Standard Operating Procedure put in place for both units. Proposed Completion Date: 10/31/23.
Finding 309 (2022-011)
Significant Deficiency 2022
Finding: 2022-011: IV-D Child Support Non-Cooperation Name of Contact Person: Laurie Potter, DSS Director Corrective Action: Temporary Supervisor has been providing one-on-one support to the MAGI workers & completing 2nd party reviews on cases. A new supervisor is going to be hired who will be provi...
Finding: 2022-011: IV-D Child Support Non-Cooperation Name of Contact Person: Laurie Potter, DSS Director Corrective Action: Temporary Supervisor has been providing one-on-one support to the MAGI workers & completing 2nd party reviews on cases. A new supervisor is going to be hired who will be provided with training for themselves, will complete 2nd party reviews & training with the staff. Standard Operating Procedure put in place. Proposed Completion Date: 10/31/23.
Finding 308 (2022-010)
Significant Deficiency 2022
Finding: 2022-010: Inaccurate Resource Calculation Name of Contact Person: Laurie Potter, DSS Director Corrective Action: (Adult Medicaid) New caseworker brought into county from another county on 11/1/2022 who had more training provided from previous county of employment. She immediately begain rev...
Finding: 2022-010: Inaccurate Resource Calculation Name of Contact Person: Laurie Potter, DSS Director Corrective Action: (Adult Medicaid) New caseworker brought into county from another county on 11/1/2022 who had more training provided from previous county of employment. She immediately begain reviewing cases & correcting as needed. In addition, all cases are now being 2nd partied to ensure nothing is being missed. Tool now used to make sure resources are not being missed during interview is the 5202D. Worker uses resources such as policy, online data to ask the proper questions to the client. (MAGI) New supervisor will be hired & trained on what is needed to be entered into the system. New supervisor will complete 2nd party reviews & training as needed. Standard Operating Procedure put in place for both units. Proposed Completion Date: 10/31/23.
Finding 307 (2022-009)
Significant Deficiency 2022
Finding: 2022-009: Inaccurate Information Entry Name of Contact Person: Laurie Potter, DSS Director Corrective Action: (Adult Medicaid) New caseworker brought into county from another county on 11/1/2022 who had more training provided from previous county of employment. She immediately begain review...
Finding: 2022-009: Inaccurate Information Entry Name of Contact Person: Laurie Potter, DSS Director Corrective Action: (Adult Medicaid) New caseworker brought into county from another county on 11/1/2022 who had more training provided from previous county of employment. She immediately begain reviewing cases & correcting as needed. In addition, all cases are now being 2nd partied to ensure nothing is being missed. New caseworker scans in documents immediately & uploads to case once completed to avoid hardcopies being lost. (MAGI) New supervisor will be hired & trained on what is needed to be entered into the system. New supervisor will complete 2nd party reviews & training as needed. Standard Operating Procedure put in place for both units. Proposed Completion Date: 10/31/23.
Finding 306 (2022-008)
Significant Deficiency 2022
Finding: 2022-008: SSI Terminations Name of Contact Person: Laurie Potter, DSS Director Corrective Action: Adult Medicaid IMC's now have access to the queue. In the past workers didn't have access to these queues which left them unable to react timely. In addition employees have been training on Med...
Finding: 2022-008: SSI Terminations Name of Contact Person: Laurie Potter, DSS Director Corrective Action: Adult Medicaid IMC's now have access to the queue. In the past workers didn't have access to these queues which left them unable to react timely. In addition employees have been training on Medicaid Verification Reports, explained the importance of working these reports timely, if case has a shared Income Support, the importance of sharing information across the agency & a new form put into place for reporting changes. Proposed Completion Date: Training on reports was 3/8/23 & workers are still cleaning up old reports. Expected completion date is 6/30/23.
Finding 304 (2022-002)
Significant Deficiency 2022
Condition Upon review of the indirect cost calculations throughout the fiscal year, it was noted that there was no documentation of review and approval of three of the seven calculations tested. The auditors were able to review the drawdown reconciliations performed by the Caminar Latino and determi...
Condition Upon review of the indirect cost calculations throughout the fiscal year, it was noted that there was no documentation of review and approval of three of the seven calculations tested. The auditors were able to review the drawdown reconciliations performed by the Caminar Latino and determine the reports were materially accurate; however, no evidence of a formal supervisory review and approval of the reconciliation was maintained on-file in these three instances. Correction action As of Q4 2022, the Atlanta-based Co-CEO and the Chief of Programs and Administration have instituted a process of review and approval of drawdown reconciliations prior to drawdown to review for accuracy of calculations and to ensure that previous drawdown amounts are accurately recorded. A Finance Manager was hired in April 2023, and the responsibility of ongoing drawdown reconciliation and calculation of invoice amounts has shifted to the Finance Manager position. Monthly invoices and drawdowns are being reviewed and approved by the Co-CEO and Chief of Programs and Administration prior to drawdown. Responsible Person Co-CEO and Chief of Programs and Administration Anticipated completion date Completed - This process is currently in place.
Finding 303 (2022-001)
Significant Deficiency 2022
Condition We reviewed all subawards made by the grantee during the audit period and found that 4 of them, totaling $224,000, were not reported to the FSRS. Correction action The FSRS will be submitted to the FFATA website. Responsible Person The Chief of Programs and Administration will submit the F...
Condition We reviewed all subawards made by the grantee during the audit period and found that 4 of them, totaling $224,000, were not reported to the FSRS. Correction action The FSRS will be submitted to the FFATA website. Responsible Person The Chief of Programs and Administration will submit the FSRS under the supervision of the Co-CEO. Anticipated completion date Within 30 days
Management concurs that there were staffing and turnover challenges for the Organization. Adequate policies and procedures are in place to ensure timeliness of data requested. Additionally, we will establish milestones to ensure future audits progress within the Uniform Guidance timeline.
Management concurs that there were staffing and turnover challenges for the Organization. Adequate policies and procedures are in place to ensure timeliness of data requested. Additionally, we will establish milestones to ensure future audits progress within the Uniform Guidance timeline.
Finding Number 2021-007: No Review of Reimbursement Requests Before Submission (Allowable Costs/Cost Principles), July 1, 2020 through June 30,2021. Statement of Condition: PCOA did not review reimbursement requests before submission PCOA personnel responsible for enacting corrective action plan: Ja...
Finding Number 2021-007: No Review of Reimbursement Requests Before Submission (Allowable Costs/Cost Principles), July 1, 2020 through June 30,2021. Statement of Condition: PCOA did not review reimbursement requests before submission PCOA personnel responsible for enacting corrective action plan: Jay Huffstutler, Finance Director, jhuffstutler@pcoa.org The corrective action plan:  Reimbursement requests now undergo formal internal review prior to submission.  A checklist-based review process was developed with assistance from the Director of Contracts, and compliance is enforced by the Finance Director.  Additional accounting staff are being hired to support the month-end closing process and ensure reimbursement requests are reconciled and supported appropriately. Completion Date: July 31, 2025
Finding Number 2021-006: Missing or Inaccurate Personnel Action Notices (Allowable Costs/Cost Principles), July 1, 2020 through June 30,2021. Statement of Condition: PCOA had missing or inaccurate personnel action notices PCOA personnel responsible for enacting corrective action plan: Jay Huffstutle...
Finding Number 2021-006: Missing or Inaccurate Personnel Action Notices (Allowable Costs/Cost Principles), July 1, 2020 through June 30,2021. Statement of Condition: PCOA had missing or inaccurate personnel action notices PCOA personnel responsible for enacting corrective action plan: Jay Huffstutler, Finance Director, jhuffstutler@pcoa.org; Jennifer Billa, Human Resources Director, Jbilla@pcoa.org The corrective action plan:  PCOA has standardized its personnel documentation process, including personnel action notices (PAN) and approval workflows.  HR and finance implemented policy and procedures to align pay rate documentation with payroll data.  All personnel changes are now signed off by the Finance and HR Director  Additional skilled personnel are being recruited to ensure accuracy and control around personnel changes. Completion Date: July 31, 2025
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