Corrective Action Plans

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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
Department of Veterans Affairs Federal Program Name: VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 64.024 Recommendation: We recommend the Organization design controls to ensure an adequate review process is in place to ensure that required reports are accurate and subm...
Department of Veterans Affairs Federal Program Name: VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 64.024 Recommendation: We recommend the Organization design controls to ensure an adequate review process is in place to ensure that required reports are accurate and submitted within the required timeframe. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented formal reporting controls to ensure all required reports are prepared accurately, reviewed appropriately, and submitted within the required timelines. These controls include a structured reporting calendar with submission deadlines, assignment of responsibility for report preparation and review, and a standardized review and approval process prior to submission. The Organization has also developed documentation procedures to retain evidence of supervisory review, validation of key data points, and confirmation of timely submission. These enhancements are intended to reduce risk of late submissions and improve the accuracy and consistency of program reporting. Name(s) of the contact person(s) responsible for corrective action: Ryan Ross, Executive Director Planned completion date for corrective action plan: March 31, 2026
The District hired a new Chief Financial Officer in 2023 and was able to catch the District up on three years of financials statements and all missing audits. The new CFO made the following changes to ensure compliance: 1. Update internal controls and monitoring. The new CFO created a Federal Fundin...
The District hired a new Chief Financial Officer in 2023 and was able to catch the District up on three years of financials statements and all missing audits. The new CFO made the following changes to ensure compliance: 1. Update internal controls and monitoring. The new CFO created a Federal Funding Monitoring and Reporting Policy that specifies that responsibilities over compliance, expenditures, and reporting. 2. Implement Process Improvements. The new CFO and Accounts Payable were able to identify grant fund expenditures and work closely to make sure all future grant expenditures are identified and tracked. 3. Communicate with External Audit Team. The new CFO communicates regularly with the external audit team to ensure they are aware of the grant funds received and the type of audit that is required and coordinate audits with plenty of time to complete the audit before deadlines.
The District hired a new Chief Financial Officer in 2023 and was able to catch the District up on three years of financials statements and all missing audits. The new CFO made the following changes to ensure compliance: 1. Update internal controls and monitoring. The new CFO created a Federal Fundin...
The District hired a new Chief Financial Officer in 2023 and was able to catch the District up on three years of financials statements and all missing audits. The new CFO made the following changes to ensure compliance: 1. Update internal controls and monitoring. The new CFO created a Federal Funding Monitoring and Reporting Policy that specifies that responsibilities over compliance, expenditures, and reporting. 2. Implement Process Improvements. The new CFO and Accounts Payable were able to identify grant fund expenditures and work closely to make sure all future grant expenditures are identified and tracked. 3. Communicate with External Audit Team. The new CFO communicates regularly with the external audit team to ensure they are aware of the grant funds received and the type of audit that is required and coordinate audits with plenty of time to complete the audit before deadlines.
The District hired a new Chief Financial Officer in 2023 and was able to catch the District up on three years of financials statements and all missing audits. The new CFO made the following changes to ensure compliance: 1. Update internal controls and monitoring. The new CFO created a Federal Fundin...
The District hired a new Chief Financial Officer in 2023 and was able to catch the District up on three years of financials statements and all missing audits. The new CFO made the following changes to ensure compliance: 1. Update internal controls and monitoring. The new CFO created a Federal Funding Monitoring and Reporting Policy that specifies that responsibilities over compliance, expenditures, and reporting. 2. Implement Process Improvements. The new CFO and Accounts Payable were able to identify grant fund expenditures and work closely to make sure all future grant expenditures are identified and tracked. 3. Communicate with External Audit Team. The new CFO communicates regularly with the external audit team to ensure they are aware of the grant funds received and the type of audit that is required and coordinate audits with plenty of time to complete the audit before deadlines.
2021-010 Inventory Significant Deficiency Recommendation: Management should use a quarterly physical count as a starting point, track purchases and uses of inventory throughout the quarter in order to calculate the inventory balance that should be on hand at the end of the quarter. Management should...
2021-010 Inventory Significant Deficiency Recommendation: Management should use a quarterly physical count as a starting point, track purchases and uses of inventory throughout the quarter in order to calculate the inventory balance that should be on hand at the end of the quarter. Management should then compare the calculated ending inventory against the related quarterly physical count and determine if there are any large variances that require further investigation. Written policies and procedures should be adopted accordingly. Action Taken: The Housing Authority agrees with this finding and will implement this recommendation within 120 days of this audit report.
2021-001 Segregation of Duties – Loan Program Significant Deficiency Recommendation: The Housing Authority’s fiscal policies should be revised to ensure that preventive controls are in place over check disbursements for loan disbursements, such that checks must be signed with live signatures at leas...
2021-001 Segregation of Duties – Loan Program Significant Deficiency Recommendation: The Housing Authority’s fiscal policies should be revised to ensure that preventive controls are in place over check disbursements for loan disbursements, such that checks must be signed with live signatures at least the signature of one Tribal Council member. Further, individuals who benefit from the loan program should not have complete discretion over recording and processing of advances and repayment. We recommend a complete list of outstanding balances be presented to the Tribal Council, or its designee, for continued monitoring. Action Taken: The SCCHA discontinued the Loan Program as of November 2019. A complete list of balances owed has been submitted to the Tribal Council with the outstanding balances of those whom had signatory authority forwarded to the St. Croix Tribal Court for further repayment actions.
Section 8 Project Based Cluster – ALN #14.195 & 14.856 Recommendation: We recommend that management review their procedures for reviewing and monitoring the required deposit amounts to ensure that each Project deposits the correct amount each month. Explanation of disagreement with audit finding: Th...
Section 8 Project Based Cluster – ALN #14.195 & 14.856 Recommendation: We recommend that management review their procedures for reviewing and monitoring the required deposit amounts to ensure that each Project deposits the correct amount each month. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority completed a reconciliation of required monthly replacement reserve deposit amounts for all affected properties and updated automated accounting system entries to reflect correct deposit levels. A monitoring checklist and monthly financial review process have been established to verify ongoing compliance. Finance staff received targeted training regarding reserve funding requirements and contract documentation. Name(s) of the contact person(s) responsible for corrective action: Julie Ward, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2025
Section 8 Project Based Cluster – ALN #14.195 & 14.856 Recommendation: We recommend that management review their procedures for retrieving tenant information and establish a method that ensures compliance. We recommend that the Authority should review their examination policies to ensure that all ex...
Section 8 Project Based Cluster – ALN #14.195 & 14.856 Recommendation: We recommend that management review their procedures for retrieving tenant information and establish a method that ensures compliance. We recommend that the Authority should review their examination policies to ensure that all examinations are performed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A comprehensive audit of tenant files was completed to confirm accuracy of medical deductions, recertification timeliness, and documentation requirements. The Management Analyst now performs ongoing file audits and coordinates with property managers to correct discrepancies promptly. Recertification scheduling is now supported by workflow reminders and supervisory tracking to prevent future delays. Name(s) of the contact person(s) responsible for corrective action: Jason Epperson, Assistant Vice President Planned completion date for corrective action plan: December 31, 2025
Section 8 Project Based Cluster – ALN #14.195 & 14.856 Recommendation: We recommend that management review their procedures for ensuring that contract rent changes are implemented and evidenced timely and accurately, and establish a method that ensures compliance. Explanation of disagreement with au...
Section 8 Project Based Cluster – ALN #14.195 & 14.856 Recommendation: We recommend that management review their procedures for ensuring that contract rent changes are implemented and evidenced timely and accurately, and establish a method that ensures compliance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority reviewed and updated procedures for implementing contract rent increases and configured automated financial system flags to ensure that rent adjustments are applied on their effective dates. The Management Analyst now verifies contract rent changes during monthly internal reviews, and staff were retrained on rent adjustment documentation and approval workflows. Name(s) of the contact person(s) responsible for corrective action: Jason Epperson, Assistant Vice President Planned completion date for corrective action plan: December 31, 2025
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