Corrective Action Plans

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Finding 2022-014 U.S. Department of Health and Human Services AL No. 93.568 Total Low-Income Home Energy Assistance Significant Deficiency over Eligibility Repeat Finding: No Auditee?s Corrective Action Plan: The Office of Home and Energy Programs (OHEP) bureau of The Mayors Office of Childr...
Finding 2022-014 U.S. Department of Health and Human Services AL No. 93.568 Total Low-Income Home Energy Assistance Significant Deficiency over Eligibility Repeat Finding: No Auditee?s Corrective Action Plan: The Office of Home and Energy Programs (OHEP) bureau of The Mayors Office of Children and Family Success (MOCFS) agency has implemented a plan to locate needed files from previous and current fiscal years. The agency has implemented a scanning and uploading Standard Operating Procedure (SOP) that requires each case file to be digitally attached to its application and supporting documents. This will remedy this finding in its totality. Contact Person: OHEP Director ? Rigel Moore Completion Date: March 10, 2023
View Audit 23759 Questioned Costs: $1
Finding 2022-019 U.S. Department of Health and Human Services AL No. 93.778 Medical Assistance Program (Medicaid; Title XIX) Significant Deficiency and Internal Control Deficiency over Reporting Repeat Finding: Yes Auditee?s Corrective Action Plan: BCHD will implement controls to maintain co...
Finding 2022-019 U.S. Department of Health and Human Services AL No. 93.778 Medical Assistance Program (Medicaid; Title XIX) Significant Deficiency and Internal Control Deficiency over Reporting Repeat Finding: Yes Auditee?s Corrective Action Plan: BCHD will implement controls to maintain compliance with reporting requirements. BCHD will continue to work with the Department of Finance to ensure parameters for generating reports are the same and there is an agreed upon reconciliation when the parameters for reporting are not the same. Policies and procedures will be updated to ensure what is reported on Federal Financial Reports are reconciled to general ledger details in addition to ensuring all submitted reports have proper approvals documented. Accounting staff will be trained appropriately. Contact Person: Chief Financial Officer ? Unyime Ekpa Completion Date: December 2023
CORRECTIVE ACTION PLAN 2022-001 - Special Tests & Provisions- HQS Enforcement Auditee's Response and Planned Corrective Action The period of the inspections was during Covid and the files audited were Enhanced vouchers leased at Orchard Hill Estates. The development had several issues with retain...
CORRECTIVE ACTION PLAN 2022-001 - Special Tests & Provisions- HQS Enforcement Auditee's Response and Planned Corrective Action The period of the inspections was during Covid and the files audited were Enhanced vouchers leased at Orchard Hill Estates. The development had several issues with retaining maintenance to correct the deficiencies. The development also struggled with receiving parts in a timely manner. The Oxford Housing Authority had been in contact with the development throughout the period of held HAP to maintain that these units were to be corrected. The Oxford housing Authority withheld HAP payments until the units were corrected, then released payment. The Oxford Housing Authority bas revised its Ad.min Plan to include the corrective procedure for abated units, along with a revised notice to the landlord. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Barry Nadon Jr.
View Audit 22730 Questioned Costs: $1
Finding 2022-002 Responsible Party Name: Fred Gibbs Position: President ? Management Agent Telephone Number: 913-709-1811 Federal Agency U.S. Department of Housing and Urban Development Federal Program Mortgage Insurance for Purchase or Refinancing of Existing Multifamily Rental Housing (Section 207...
Finding 2022-002 Responsible Party Name: Fred Gibbs Position: President ? Management Agent Telephone Number: 913-709-1811 Federal Agency U.S. Department of Housing and Urban Development Federal Program Mortgage Insurance for Purchase or Refinancing of Existing Multifamily Rental Housing (Section 207/223(F)) Compliance Requirements N ? Special Tests and Provisions Finding Type Federal Awards Auditee?s Comment on Finding We agree with the auditor?s finding. Corrective Action We will deposit the shortfall of $868 into the reserve for replacement account, as soon as possible. We will also deposit the shortfall for 2019, 2020, and 2021 once funds become available. We will follow our process to deposit and reconcile the reserve for replacement account on a monthly basis. Anticipated Completion Date June 30, 2023
View Audit 19875 Questioned Costs: $1
Finding 2022-024 U.S. Department of Health and Human Services AL No. 93.977 Totally Sexually Transmitted Diseases (STD) Prevention and Control Grants Significant Deficiency in Compliance and Internal Control over Period of Performance Repeat Finding: No Auditee?s Corrective Action Plan: B...
Finding 2022-024 U.S. Department of Health and Human Services AL No. 93.977 Totally Sexually Transmitted Diseases (STD) Prevention and Control Grants Significant Deficiency in Compliance and Internal Control over Period of Performance Repeat Finding: No Auditee?s Corrective Action Plan: BCHD will implement controls to allow only costs within the period of performance to be charged to the correct grant period within the general ledger. BCHD will ensure that if there are any exceptions that allow for costs to be charged outside the period of performance, the proper supporting documents will be kept. Baltimore City's new financial system, Workday, allows for all supporting documentation to be kept electronically in one system. Policies and procedures for internal controls will be updated to incorporate processes in Workday and the accounting staff will be trained appropriately. Contact Person: Chief Financial Officer ? Unyime Ekpa Completion Date: December 2023
View Audit 23759 Questioned Costs: $1
2021-004 Housing Voucher Cluster ? Assistance Listing No. 14.871 Recommendation: The Authority should review their HQS inspection policies to ensure that all repairs are made timely and if not, that the necessary actions are taken by the Authority. Explanation of disagreement with audit finding: The...
2021-004 Housing Voucher Cluster ? Assistance Listing No. 14.871 Recommendation: The Authority should review their HQS inspection policies to ensure that all repairs are made timely and if not, that the necessary actions are taken by the Authority. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: NOHA has reviewed its updated HQS policies, including its HQS enforcement policies. NOHA continues to refine software functionality and reporting to monitor HQS repair due dates, and to take action when necessary. Name(s) of the contact person(s) responsible for corrective action: Sandra Soucie, HCV Manager, HCVManager@nwoha.org Planned completion date for corrective action plan: 3/31/2023
2022-002 Housing Voucher Cluster ? Assistance Listing No. 14.871 Recommendation: The Authority should review their policies to ensure all required documentation is maintained for all individuals who are on the waiting list. Explanation of disagreement with audit finding: There is no disagreement wi...
2022-002 Housing Voucher Cluster ? Assistance Listing No. 14.871 Recommendation: The Authority should review their policies to ensure all required documentation is maintained for all individuals who are on the waiting list. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: NOHA has reviewed its policies regarding documentation maintenance for all individuals on the waiting list. Quality control review of waiting list data entry was put in place after October 2020. The oldest application on the current waiting list is dated 2018. NOHA anticipates this finding will continue until the waiting list application dates reach 10/2020. Name(s) of the contact person(s) responsible for corrective action: Sandra Soucie, HCV Manager, HCVManager@nwoha.org Planned completion date for corrective action plan: 3/31/2023
2022-001 Housing Voucher Cluster ? Assistance Listing No. 14.871 Recommendation: The Authority should review their processes for eligibility determination and documentation to ensure all information is properly documented and maintained in the files. Explanation of disagreement with audit finding: T...
2022-001 Housing Voucher Cluster ? Assistance Listing No. 14.871 Recommendation: The Authority should review their processes for eligibility determination and documentation to ensure all information is properly documented and maintained in the files. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Northwest Oregon Housing Authority has reviewed eligibility determination and documentation processes. Staff have received training regarding proper documentation. NOHA has conducted quality control file reviews on approximately 10% of transactions between July 1, 2022, to January 31, 2023, to review and ensure file quality. QC reviews will continue on an ongoing basis. Name(s) of the contact person(s) responsible for corrective action: Sandra Soucie, HCV Manager, HCVManager@nwoha.org Planned completion date for corrective action plan: 1/31/2023
Finding 2022-023 U.S. Department of Health and Human Services AL No. 93.940 HIV Prevention Activities Health Department Based Significant Deficiency in Compliance and Internal Control Over Reporting Repeat Finding: No Auditee?s Corrective Action Plan: BCHD will implement controls to maint...
Finding 2022-023 U.S. Department of Health and Human Services AL No. 93.940 HIV Prevention Activities Health Department Based Significant Deficiency in Compliance and Internal Control Over Reporting Repeat Finding: No Auditee?s Corrective Action Plan: BCHD will implement controls to maintain compliance with reporting requirements. BCHD will continue to work with the Department of Finance to ensure parameters for generating reports are the same and there is an agreed upon reconciliation when the parameters for reporting are not the same. Policies and procedures will be updated to ensure what is reported on 440 Reports are reconciled to general ledger details in addition to ensuring all submitted reports have proper approvals documented. Accounting staff will be trained appropriately. Contact Person: Chief Financial Officer ? Unyime Ekpa Completion Date: December 2023
2021-001 Reporting and Written Policies and Procedures Corrective action planned: Middle Park Health (MPH) management agrees that quarterly financial reporting to USDA as required did not occur in 2022. Turnover in finance leadership during 2022 contributed to this oversight among other factors. At ...
2021-001 Reporting and Written Policies and Procedures Corrective action planned: Middle Park Health (MPH) management agrees that quarterly financial reporting to USDA as required did not occur in 2022. Turnover in finance leadership during 2022 contributed to this oversight among other factors. At no point did MPH receive communication from USDA surrounding lack of compliance with this requirement. Upon discovering this weakness, MPH promptly implemented corrective action. Reminders have been set following the approval of each quarter?s financial statements by the Board of Directors to submit quarterly financial reports to USDA contacts. The first set of quarterly financials for 2023 were submitted to the USDA on April 28, 2023 and USDA confirmed receipt of these documents as well as confirming that the distribution list used by MPH for this submission was appropriate. MPH does not anticipate further noncompliance with this requirement. MPH will also develop written policies and procedures for the required reporting. Anticipated completion date: April 27, 2023 Contact person responsible for corrective action: Emily Ebert, CFO & Mikealena Horner, Accountant
Finding 2022-011 US Department of Housing and Urban Development AL No. 14.241 Housing Opportunities for Persons with AIDS Significant Deficiency over Special Tests - Housing Quality Standards- Housing Opportunities for Persons with AIDS Repeat Finding: No Auditee?s Corrective Action Plan: MOH...
Finding 2022-011 US Department of Housing and Urban Development AL No. 14.241 Housing Opportunities for Persons with AIDS Significant Deficiency over Special Tests - Housing Quality Standards- Housing Opportunities for Persons with AIDS Repeat Finding: No Auditee?s Corrective Action Plan: MOHS follows a recordkeeping process for its inspections. Inspection checklists are maintained in the participant records by calendar year. In some cases, the inspection may fall outside of when the participants annual recertification is due. During reviews, MOHS management will ensure that the staff are clear about providing inspection checklist for both years identified in the review period and not just the inspection for the annual recertification year. Additionally, during the period of review, the Inspections team experienced challenges with connecting into the City?s VPN system. Due to the connectivity issues, MOHS was not able to perform its inspections as required. MOHS has started the process to correct the connectivity issues. MOHS will be upgrading its? housing database to the web-based version. The new version will not require VPN access through Baltimore City?s network. The inspections team will be able to connect to the housing database via the web. MOHS anticipates the new database upgrade to be in place by Summer 2023. Contact Person: Compliance Supervisor ? Donata Patrick Completion Date: July 2023
Finding 2022-008 U.S. Department of Housing and Urban Development (HUD) AL No. 14.241 Housing Opportunities for Persons with AIDS Significant Deficiency and Internal Control Deficiency over Eligibility Repeat Finding: No Auditee?s Corrective Action Plan: MOHS does have a written process in ...
Finding 2022-008 U.S. Department of Housing and Urban Development (HUD) AL No. 14.241 Housing Opportunities for Persons with AIDS Significant Deficiency and Internal Control Deficiency over Eligibility Repeat Finding: No Auditee?s Corrective Action Plan: MOHS does have a written process in place for review of participant eligibility. The Housing Coordinator performs quality assurance reviews of participant eligibility and verifies documentation is maintained in the records. During the review period, the Housing Coordinator position was vacant. MOHS has started the process to fill the position. MOHS anticipates the Housing Coordinator position will be filled by Summer 2023. Contact Person: Compliance Supervisor ? Donata Patrick Completion Date: July 2023
Finding 2022-007 Programs: All Significant Deficiency and Noncompliance over Reporting Repeat Finding: No Auditee?s Corrective Action Plan: The City has purchased Workday, an Enterprise Resource Planning (ERP) system, and implemented the software with the assistance of Accenture consultants. ...
Finding 2022-007 Programs: All Significant Deficiency and Noncompliance over Reporting Repeat Finding: No Auditee?s Corrective Action Plan: The City has purchased Workday, an Enterprise Resource Planning (ERP) system, and implemented the software with the assistance of Accenture consultants. Although Workday is ?live? as of August 2022, the City is currently working to refine the software and fully utilize functionality. The Workday grants modules requires the grant funding source be defined prior to grant approval and fields are available for the AL titles and numbers and sub-recipients? information. The implementation of the Workday grants modules centralizes much of the grant management function by requiring the agencies to upload the grant documents into Workday. Prior to the completion of the SEFA, the City will hold training sessions with the agencies to ensure that the reporting is understood by the agencies, with special emphasis on subrecipient payments being reported properly. Additionally, the City will give access to the grant report upon which the SEFA is based. The City will keep a check list to ensure that all agencies respond to the grant certification to ensure that all agencies review the grant data. Contact Person: Michael Moiseyev, Chief Financial Officer, Baltimore City Completion Date: December 2024
2022-002. Preparation of Financial Statements and Related Footnotes Recommendation: This control deficiency is not unusual in a small company. However, it is the responsibility of management and the board of directors to decide whether to accept the degree of risk associated with this condition base...
2022-002. Preparation of Financial Statements and Related Footnotes Recommendation: This control deficiency is not unusual in a small company. However, it is the responsibility of management and the board of directors to decide whether to accept the degree of risk associated with this condition based on the cost of correction and other considerations. Management?s Response and Actions Planned: The Company?s management is aware of this significant deficiency. Management reviews and approves the draft annual audited financial statements and distributes them to the users. For entities of this size, it generally is not practical to obtain the internal expertise needed to handle all aspects of the external financial reporting. Management recognizes this and feels it is effectively handling its reporting responsibilities with the procedures described above.
Finding 23702 (2022-001)
Significant Deficiency 2022
Finding 2022-001 Confidential Information in SIGMA Management Views The Department of Military and Veterans Affairs (DMVA) and MSP disagree that confidential information was included in SIGMA. Follow-up with DTMB confirmed that user ID is not considered confidential data at the DTMB enterprise lev...
Finding 2022-001 Confidential Information in SIGMA Management Views The Department of Military and Veterans Affairs (DMVA) and MSP disagree that confidential information was included in SIGMA. Follow-up with DTMB confirmed that user ID is not considered confidential data at the DTMB enterprise level. Planned Corrective Action DTMB revised DTMB Administrative Policy 900.01 effective June 16, 2023. Anticipated Completion Date Completed Responsible Individual(s) Christine Apostol, DMVA Amanda Baker, MSP
Unaudited REAC Reporting Recommendation: CLA recommends the CDA develops an internal control monitoring system to ensure unaudited REAC filings are submitted on time. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding:...
Unaudited REAC Reporting Recommendation: CLA recommends the CDA develops an internal control monitoring system to ensure unaudited REAC filings are submitted on time. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will work closely with our outside accountant to ensure timely REAC reporting, securing a submission confirmation email. Management will also further confirm submission via HUD online systems. Name(s) of the contact person(s) responsible for corrective action: Betty Noel, Assistant Director Planned completion date for corrective action plan: April 18, 2023
Finding 23646 (2022-003)
Significant Deficiency 2022
2022-003 Research and Development Cluster ? Assistance Listing No. 93.310 Recommendation: We recommend the Blood Bank implement procedures to ensure only allowable charges outlined within 200 CFR 200.68 are included in the Modified Total Direct Costs (MTDC) subject ...
2022-003 Research and Development Cluster ? Assistance Listing No. 93.310 Recommendation: We recommend the Blood Bank implement procedures to ensure only allowable charges outlined within 200 CFR 200.68 are included in the Modified Total Direct Costs (MTDC) subject to the indirect cost rate. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Blood Bank added review and approval processes to ensure only allowable charges are included in the MTDC subject to the indirect cost rate. Names of the contact persons responsible for corrective action: Bryan Eleazar, CFO; Lisa Alexander, Direct of Grant Accounting; Jeanette Lysse, Controller Planned completion date for corrective action plan: October 29, 2021
View Audit 19755 Questioned Costs: $1
Finding 23645 (2022-002)
Significant Deficiency 2022
2022-002 Research and Development Cluster ? Assistance Listing No. 93.310 Recommendation: We recommend the Blood Bank implement procedures to ensure all personnel charges to the program are supported by the minimum time and effort documentation outlined within 200 CFR 200.430. Explanation of disagr...
2022-002 Research and Development Cluster ? Assistance Listing No. 93.310 Recommendation: We recommend the Blood Bank implement procedures to ensure all personnel charges to the program are supported by the minimum time and effort documentation outlined within 200 CFR 200.430. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Blood Bank added review and approval processes to compare actual vs budgeted vs allowable time and effort. Names of the contact persons responsible for corrective action: Bryan Eleazar, CFO; Lisa Alexander, Direct of Grant Accounting; Jeanette Lysse, Controller Planned completion date for corrective action plan: October 29, 2021
View Audit 19755 Questioned Costs: $1
Management concurs with the finding. The year-end closing process has improved significantly over the past years and we will continue to strengthen controls over financial reporting to reduce the time required to perform year-end analyses and the closing process. Specifically, analyses and adjustmen...
Management concurs with the finding. The year-end closing process has improved significantly over the past years and we will continue to strengthen controls over financial reporting to reduce the time required to perform year-end analyses and the closing process. Specifically, analyses and adjustments to contract obligations and purchase orders will be performed on a quarterly basis to complete the reconciliation of year-end balances and transactions in July, within the time constraint. In addition, the Municipality immediately implemented a three-step quality control to the quarterly report?s submission (Preparer / Reviewer / Approval) to ensure that the amounts reported are in accordance with the accounting records. IMPLEMENTATION DATE Ongoing Process RESPONSIBLE PERSON Finance Department
The Municipality will be evaluating possible training alternatives so that personnel from different Offices such as the Planning Office, Municipal Secretary, Internal Audit and Department of Housing can take them. In turn, the following link will be provided: https://www. Hudexchange.infor/trainings...
The Municipality will be evaluating possible training alternatives so that personnel from different Offices such as the Planning Office, Municipal Secretary, Internal Audit and Department of Housing can take them. In turn, the following link will be provided: https://www. Hudexchange.infor/trainings/cources/ffata-subaward-reporting-system-webinar-for-cdbg-grantees1/, which is a one hour training course that is on the HUD Exchange platform on the FFATA Reporting System. IMPLEMENTATION DATE During fiscal year 2023 RESPONSIBLE PERSON Zaid Diaz Isaac, Program Director
Significant Deficiency ? Item No. 2022-003 Criteria: The Hospital must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Hospital is managing the federal awards in compliance with federal statutes, regulations and terms and conditions o...
Significant Deficiency ? Item No. 2022-003 Criteria: The Hospital must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Hospital is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. 2 CFR 200.327 and 2 CFR 200.328 require the auditee to collect financial information and monitor its activities under federal awards to assure compliance with applicable federal requirements and performance expectations are being achieved and report these items in accordance with program requirements. Terms and conditions of the federal award require the audited financial statements to be provided to the federal agency annually within 9 months of fiscal year-end, as well as quarterly internal financial statements. Condition: The Hospital did not submit the audited financial statements within the prescribed period or request an extension and did not submit any quarterly reports to the federal agency. The Hospital was not asked for the information after they failed to submit it. The audit financial statements are readily available to the federal agency through the federal clearinghouse website. Planned Corrective Action: Management agrees with the finding and are implementing procedures to ensure that the required financial reports are submitted in a timely manner in accordance with the terms and conditions of the federal award. Planned Completion Date: June 30, 2023 Person Responsible: Nate Thompson, Chief Executive Officer
Views of Responsible Officials and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers program to ensure that established internal control policies are being followed on a timely basis. Joe...
Views of Responsible Officials and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers program to ensure that established internal control policies are being followed on a timely basis. Joel Johnson, Executive Director, is responsible for implementing this corrective action by December 31, 2023.
View Audit 19795 Questioned Costs: $1
The department of public works updated and put into effect its SOPs for electronic project billing in January 2021. DPW's action plan is to continue adhering to its updated process and procedures. Key individuals responsible: DPW Deputy Director Laupele Tilei, Civil Engineer Uaealesi Doris Faumuina...
The department of public works updated and put into effect its SOPs for electronic project billing in January 2021. DPW's action plan is to continue adhering to its updated process and procedures. Key individuals responsible: DPW Deputy Director Laupele Tilei, Civil Engineer Uaealesi Doris Faumuina-Sipelii; to be completed by September 30 2023
This finding has been addressed in fiscal year 2023. ASGDOE school lunch Is working with a representative who oversees civil rights for the USDA wester region. Civil rights training for all SLP staff continues yearly with sign-in sheets and agendas for documentation purposes. Reports are submitted t...
This finding has been addressed in fiscal year 2023. ASGDOE school lunch Is working with a representative who oversees civil rights for the USDA wester region. Civil rights training for all SLP staff continues yearly with sign-in sheets and agendas for documentation purposes. Reports are submitted to USDA for inventory and mean counts on the 15th of each month. Special dietary accomodations have since been rolled out and schools have been notified of the process should a student require accomodation. USDA has an on-site visit scheduled not that borders are open. Key individuals responsible: SLP Assistant Director Christina Fualaau. Will be completed and closed in 2023.
Finding 23361 (2022-006)
Significant Deficiency 2022
United States Department of Health and Human Services 2022-006 Medical Assistance ? Assistance Listing No. 93.778 Recommendation: The County should implement a review process over the LCTS Annual Collaborative Report. Explanation of disagreement with audit finding: There is no disagreement with the ...
United States Department of Health and Human Services 2022-006 Medical Assistance ? Assistance Listing No. 93.778 Recommendation: The County should implement a review process over the LCTS Annual Collaborative Report. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will enact a process to ensure the review of the annual collaborative report is documented. Name(s) of the contact person(s) responsible for corrective action: Heather Olson Auditor/Treasurer Planned completion date for corrective action plan: December 31, 2023
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