Corrective Action Plans

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Management’s Response and Corrective Action Plan: Management agrees. Management has addressed this as follows: Responsible person: Lee Pliscou Since July 2024, management has required that accounting staff must request changes to the chart of accounts by completing a Google Form, which is reviewed a...
Management’s Response and Corrective Action Plan: Management agrees. Management has addressed this as follows: Responsible person: Lee Pliscou Since July 2024, management has required that accounting staff must request changes to the chart of accounts by completing a Google Form, which is reviewed and approved by the Executive Director. This policy is carried over into our new Accounting Manual, approved by MLSC’s Board in October 2025: • Accounting staff must request any changes to our GL account using this form: https://docs.google.com/forms/d/e/1FAIpQLSceN9Qaipv786HA5HH8VR2ayb6MmtW-aocJDYwHauU1RLC45w/viewform?usp=sf_link • The Executive Director will review these promptly, and approve as informed by our financial operations. • Records of the request and review are saved here: https://docs.google.com/spreadsheets/d/10__3CiYXwORgspzysd_xtnxYFovuPeDLbHSAN3A2JQE/edit?usp=sharing We have been using this form since July 2024. Anticipated completion date: Completed.
Management’s Response and Corrective Action Plan: Management agrees. Responsible person: Executive Director Lee Pliscou Corrective action planned: This has been corrected as of October 2025. MLSC Board of Directors approved a revised MLSC Accounting Manual with updates intended to comply with LSC’s ...
Management’s Response and Corrective Action Plan: Management agrees. Responsible person: Executive Director Lee Pliscou Corrective action planned: This has been corrected as of October 2025. MLSC Board of Directors approved a revised MLSC Accounting Manual with updates intended to comply with LSC’s Financial Guide on cost allocation. In particular, our new cost allocation policy addresses: ● Direct and indirect cost definitions ● Direct cost allocation methodology ● Indirect cost allocation methodology including allocation bases (total direct costs) ● Frequency of allocation (annual) ● Who conducts the allocation and who performs the review (Chief Fiscal Officer, Executive Director) ● Documentation requirements to support the allocation (calculation work papers) ● Reconciliation process related to salaries and wages directly charged to LSC grants and contracts ● Methodology to address “exception for certain indirect costs.” Anticipated completion date: Completed.
Management’s Response and Corrective Action Plan: MLSC management acknowledges the finding and concurs in part. MLSC has an established Fixed Asset and Physical Inventory Policy in accordance with LSC Financial Guide § 3.6.2. The policy requires that a complete physical inventory be conducted at lea...
Management’s Response and Corrective Action Plan: MLSC management acknowledges the finding and concurs in part. MLSC has an established Fixed Asset and Physical Inventory Policy in accordance with LSC Financial Guide § 3.6.2. The policy requires that a complete physical inventory be conducted at least once every two years, and MLSC has been performing these inventories regularly. However, management recognizes that the documentation of the most recent physical inventory was incomplete, specifically lacking the signatures, dates, and reconciliation notes required to demonstrate full compliance. Responsible person: Chief Fiscal Officer, Jocelyn Mallari Corrective action planned: To address this issue and ensure full adherence to the policy, MLSC, with the supervision of the Chief Fiscal Officer continued the implementation of Physical Inventory Procedures requiring a full physical inventory every two years, including proper documentation and reconciliation with the subsidiary ledger. To improve documentation, the Chief Fiscal Officer will conduct training to ensure that each future physical inventory count includes the date of the count, signature of personnel conducting the inventory, a witness and management reviewer, reconciliation records, and authorization and documentation for any write-offs or disposals. Anticipated completion date: June 30, 2026.
Management’s Response and Corrective Action Plan: MLSC management acknowledges the finding and concurs in part. MLSC has an established Fixed Asset and Capitalization Policy in accordance with LSC Financial Guide § 3.6.1, which includes maintaining a detailed subsidiary ledger and lapsing (depreciat...
Management’s Response and Corrective Action Plan: MLSC management acknowledges the finding and concurs in part. MLSC has an established Fixed Asset and Capitalization Policy in accordance with LSC Financial Guide § 3.6.1, which includes maintaining a detailed subsidiary ledger and lapsing (depreciation) schedule. During the audit, the lapsing schedule was provided to the auditors upon request. However, the master fixed asset record (which includes itemized property details, funding source, and location) was not submitted because it was not requested during the audit process. Responsible person: Chief Fiscal Officer, Jocelyn Mallari Corrective action planned: To further ensure full compliance and to strengthen documentation and transparency, MSLC, with the supervision of the Chief Fiscal Officer, MLSC continues to enforce the existing Fixed Asset and Capitalization Policy and ensures that all property records are maintained in accordance with LSC Financial Guide 3.6.1. MLSC ensures to conduct periodic internal review of fixed assets registry and continues to maintain these records and made them readily available and provided to auditors, even if not specifically requested. Anticipated completion date: Completed.
Management’s Response and Corrective Action Plan: MLSC management would like to provide the following clarification regarding the finding that MLSC did not use the prior-year end fund balance before expending the current year’s LSC grant. Just in the first month of 2024, we already have a substantia...
Management’s Response and Corrective Action Plan: MLSC management would like to provide the following clarification regarding the finding that MLSC did not use the prior-year end fund balance before expending the current year’s LSC grant. Just in the first month of 2024, we already have a substantial deficit from the funding that we received. We have started using the fund balance that is in our bank account. There was no other source of funds for us but the fund balance. Being non-profit, whatever is on hand is used first and whatever is received last is the actual cash on hand at the end of the year. It is also important to note that MLSC’s local funder's grants are not received on a regular monthly basis. Some are disbursed quarterly, and FSM is received only once—typically toward the end of the fiscal year. The appearance of using current-year funds first is due to the timing and presentation in the audit schedule, not the actual fund flow. Responsible person: Chief Fiscal Officer, Jocelyn Mallari Corrective action planned: None Anticipated completion date: Completed.
Management’s Response and Corrective Action Plan: MLSC acknowledges the finding and concurs with the auditor’s recommendation. Management is committed to maintaining accurate, timely, and reliable financial reporting in accordance with Government Auditing Standards and the LSC Financial Guide. Respo...
Management’s Response and Corrective Action Plan: MLSC acknowledges the finding and concurs with the auditor’s recommendation. Management is committed to maintaining accurate, timely, and reliable financial reporting in accordance with Government Auditing Standards and the LSC Financial Guide. Responsible person: Exec. Director, Lee Pliscou Corrective action planned: MLSC currently has a Financial Management and Internal Control Policy. This policy is strictly being enforced and fully implemented to ensure compliance with both the LSC Financial Guide and Government Auditing Standards. • MLSC has established a financial oversight and audit committee, and identifies the duties of the committee in writings. • The financial oversight and audit committee is required to review quarterly the management report prepared by the Chief Fiscal Officer. • The Chief Fiscal Officer will review and reconcile the subsidiary ledger after the month-end close and before the submission of monthly report to the Board of Directors. • To ensure that internal controls are strengthened and that future financial statements are properly prepared, the Chief Fiscal Officer will conduct an annual training with all accounting staff on reconciliation procedures before the year-end close. Anticipated completion date: Dec. 31, 2026
Views of Responsible Officials: We agree with the auditor’s findings and recommendations. We are going to review, strengthen, and more closely supervise all of our accounting procedures including response time to the Development Team’s requests for reports. We are also engaging in discussions about ...
Views of Responsible Officials: We agree with the auditor’s findings and recommendations. We are going to review, strengthen, and more closely supervise all of our accounting procedures including response time to the Development Team’s requests for reports. We are also engaging in discussions about how and when the Development Team requests information for the needed reports. A Grant Manager has been hired and we hope that Grantseeker, our grant tracking program, can be utilized more effectively which include tracking reporting timelines.
Finding 1162698 (2024-002)
Material Weakness 2024
Finding Number: 2024-002 Closing Process (Significant Deficiency) Planned Corrective Action: The auditors noted issues related to the timeliness of the financial statement close process, additional entries to finalize the trial balance, and a lack of segregation of duties which led to journal entrie...
Finding Number: 2024-002 Closing Process (Significant Deficiency) Planned Corrective Action: The auditors noted issues related to the timeliness of the financial statement close process, additional entries to finalize the trial balance, and a lack of segregation of duties which led to journal entries being prepared, reviewed and posted by the same person in the general ledger system. The issues noted were largely the result of significant turnover within the Finance Department, including the departure of the former head of the department without a proper transfer of institutional knowledge to remaining staff or incoming leadership. Since that time, oversight has improved considerably, and key processes have been reviewed, updated, and formally documented. While the current size of the Finance Team necessitates that the same individual generally enters and posts journal entries, we have implemented compensating controls that we believe are appropriate given the assessed levels of risk and materiality. These controls include role-specific responsibilities for journal entries and reconciliations. For example, with respect to cash activity, different team members handle cash receipts, disbursements, and inter-account transfers. Additionally monthly bank reconciliations are formally reviewed and signed off by Fiscal Department management. Management remains committed to strengthening internal controls, maintaining adequate segregation of duties to the extent practicable, and continuing to enhance the overall financial close and reporting process. Person Responsible: The Executive Director and Chief Financial Officer Completion Date: July 2024
Insufficient Understanding of Federal Compliance Requirements The County will work to improve their understanding of federal compliance requirements for each grant award and documentation of procedures implemented to ensure compliance.
Insufficient Understanding of Federal Compliance Requirements The County will work to improve their understanding of federal compliance requirements for each grant award and documentation of procedures implemented to ensure compliance.
Finding Number: 2024-003 Finding Name: Data Collection Form Late Submission Finding Synopsis: The organization did not submit the December 31, 2024 data collection form and reporting package to the Federal Audit Clearinghouse in a timely matter. Action Steps: The late submission was due to switching...
Finding Number: 2024-003 Finding Name: Data Collection Form Late Submission Finding Synopsis: The organization did not submit the December 31, 2024 data collection form and reporting package to the Federal Audit Clearinghouse in a timely matter. Action Steps: The late submission was due to switching audit service providers. Systems and procedures are already in place to ensure timely completion of audit and submission of the audit package to the Federal Audit Clearinghouse. Management is now aware that when switching audit firms. we will have to allocate more time for the new firm to get familiar with the agency. Contact Person(s): William Chatman, Executive Director/CEO, 815-963-6236 Claudia Seijas, Director of Finance, 815-963-6236 Anticipated Completion Date: Continues
Condition: Suspension and debarment compliance was not verified for four covered transactions. Corrective Action Planned: The Town will implement procedures to include a suspension and debarment certification in all federal contracts that are considered covered transactions to ensure that the contra...
Condition: Suspension and debarment compliance was not verified for four covered transactions. Corrective Action Planned: The Town will implement procedures to include a suspension and debarment certification in all federal contracts that are considered covered transactions to ensure that the contractors are eligible to receive federal funds and not excluded or disqualified from doing business. Anticipated Completion Date: March 31, 2026 Contact: Bryan Sawyer, Town Administrator
Condition: The Town has not documented in writing its policies regarding federal awards. Corrective Action Planned: The Town will formally document procedures in writing to support compliance with applicable federal awards requirements. Anticipated Completion Date: March 31, 2026 Contact: Bryan Sawy...
Condition: The Town has not documented in writing its policies regarding federal awards. Corrective Action Planned: The Town will formally document procedures in writing to support compliance with applicable federal awards requirements. Anticipated Completion Date: March 31, 2026 Contact: Bryan Sawyer, Town Administrator
Compliance with Allowable Activities Planned Corrective Action: Heartland Alliance Health has partnered with an outside revenue cycle management firm to strengthen documentation oversight, billing accuracy, and compliance monitoring. Together with internal Revenue Cycle staff, the external firm now ...
Compliance with Allowable Activities Planned Corrective Action: Heartland Alliance Health has partnered with an outside revenue cycle management firm to strengthen documentation oversight, billing accuracy, and compliance monitoring. Together with internal Revenue Cycle staff, the external firm now generates and reviews weekly documentation and billing completeness reports to identify and resolve missing or incomplete encounter records. Clinic managers and providers receive weekly follow-ups to ensure that documentation is corrected promptly and that all billed services are properly supported. Person Responsible for Corrective Action Plan: Steve Knox, Controller Anticipated Date of Completion: Resolved
Action Taken: We agree with the findings and have established new written policies and procedures to ensure the SEFA is properly reconciled and reviewed prior to the start of the audit.
Action Taken: We agree with the findings and have established new written policies and procedures to ensure the SEFA is properly reconciled and reviewed prior to the start of the audit.
Internal Controls Over Rent Reasonableness - Significant Deficiency Condition: The Organization did not have a documented procedure supporting how rent reasonableness is documented and maintained in the tenant files to provide documentation of compliance with the criteria. Corrective Action Plan: CH...
Internal Controls Over Rent Reasonableness - Significant Deficiency Condition: The Organization did not have a documented procedure supporting how rent reasonableness is documented and maintained in the tenant files to provide documentation of compliance with the criteria. Corrective Action Plan: CHP will be updating internal controls to include evidence of appropriate reviews and approvals of rent reasonableness.
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program to ensure that established internal control policies are being followed on a timely basis. Leonard Spicer, Execu...
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program to ensure that established internal control policies are being followed on a timely basis. Leonard Spicer, Executive Director, is responsible for implementing this corrective action by December 31, 2025.
View Audit 372175 Questioned Costs: $1
The Greening of Detroit has adjusted all indirect costs from being charged to the DNR grant for the current year 2025 and future years. The Greening of Detroit has also updated the grant budget to reflect the change to match the grant requirements.
The Greening of Detroit has adjusted all indirect costs from being charged to the DNR grant for the current year 2025 and future years. The Greening of Detroit has also updated the grant budget to reflect the change to match the grant requirements.
The Greening of Detroit will ensure that we plan and complete our audits on time. Next year, we will schedule audits earlier in the year and set defined date range with our auditors to avoid late audit reports in the future. Our audits will be completed 15 days before the audit report is due to the ...
The Greening of Detroit will ensure that we plan and complete our audits on time. Next year, we will schedule audits earlier in the year and set defined date range with our auditors to avoid late audit reports in the future. Our audits will be completed 15 days before the audit report is due to the clearing house.
Views of Responsible Officials and Planned Corrective Action: According to Appendix: American Rescue Plan CSLFRF HVAC Replacement and Improvement Grant Assurances of the 2021 CSLFRF HVAC Application it is stated the LEA/grantee assures: IX. It will submit such reports to the state educational agency...
Views of Responsible Officials and Planned Corrective Action: According to Appendix: American Rescue Plan CSLFRF HVAC Replacement and Improvement Grant Assurances of the 2021 CSLFRF HVAC Application it is stated the LEA/grantee assures: IX. It will submit such reports to the state educational agency as the state educational agency and Secretary may require to enable the state educational agency and the Secretary to perform their duties under the program; The LEA has also submitted an official correspondence to the Auditors from the Commonwealth of Virginia Department of Education’s Director of the Office of Federal Pandemic Relief Programs stating the following: On April 25, 2023, the Virginia Department of Education conducted monitoring to ensure that certain federally funded programs and activities supported with Elementary and Secondary School Emergency Relief (ESSER) formula grants; ESSER and Governor’s Emergency Education Relief (GEER) state setaside grants; and Coronavirus State and Local Fiscal Recovery Fund (CSLFRF) HVAC grants were implemented as stipulated by law. These federally funded programs were reviewed as operated by Richmond City Public Schools. Furthermore, RPS is a subrecipient. As such it is our stance that RPS was not required to create or submit quarterly financial activity reports to US Treasury. We were also not required to submit quarterly financial reports to the recipient (i.e. the Commonwealth of Virginia). Instead, RPS regularly submitted expenditures for reimbursement to VDOE on a nearly monthly basis via OMEGA. We also maintained financial records (invoices, GL transactions) via AS400 and LINQ and conducted annual single audits as required by the Single Audit Act & 2 CFR part 200, subpart F. We also complied with all monitoring activities conducted by VDOE. In turn, VDOE (the award recipient) used these artifacts to create and submit its quarterly financial reports to US Treasury, as required by statute. For more evidence of this "passthrough" structure of reporting, see the attached SLFRF Compliance and Reporting Guidance published by US Treasury and Updated October 2025 Part 2 Section B (p. 21-22) for a detail of which entities are required to submit quarterly reports. The following recipients are required to submit quarterly Project and Expenditure Reports: • States and U.S. territories • Tribal governments that are allocated more than $30 million in SLFRF funding • Metropolitan cities and counties with a population that exceeds 250,000 residents Coronavirus State and Local Fiscal Recovery Funds C • Metropolitan cities and counties with a population below 250,000 residents that are allocated more than $10 million in SLFRF funding • NEUs [Non-Entitlement Units of Government] that are allocated more than $10 million in SLFRF funding RPS does not fall into any of the aforementioned categories. We humble ask that you reconsider this finding.
Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Repeat Finding No Action Taken The health center will share one location to maintain all UDS files and ensure that the worksheet/and data...
Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Repeat Finding No Action Taken The health center will share one location to maintain all UDS files and ensure that the worksheet/and data that is prepared is locked so only the owner can make changes.
Recommendation We recommend that the Organization consistently enforce its internal controls over payroll to ensure that timesheets are reviewed and approved by the appropriate supervisor and ensure that they agree to the payroll register. Repeat Finding Yes Action Taken The staff accountant does th...
Recommendation We recommend that the Organization consistently enforce its internal controls over payroll to ensure that timesheets are reviewed and approved by the appropriate supervisor and ensure that they agree to the payroll register. Repeat Finding Yes Action Taken The staff accountant does the payroll. We save a backup timecard report each payroll that we are paying from the approved by the employee's supervisor. We also have an internal worksheet that we use to document any changes that are made. Once the accountant is done with her review the controller will do the second review before we finish processing the payroll enforcing internal controls that are in place and being followed.
Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Repeat Finding Yes Action Taken We will hold quarterly training on the Slide Fee process and share any relevant findings to support staff learnin...
Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Repeat Finding Yes Action Taken We will hold quarterly training on the Slide Fee process and share any relevant findings to support staff learning and development. The Slide Fee Coordinator will run a daily report to audit the slide fees entered the previous day to ensure accuracy.
Finding 2024.006 - Reporting Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Action Taken In response to the audit finding, I will develop and implement a formal internal control system...
Finding 2024.006 - Reporting Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Action Taken In response to the audit finding, I will develop and implement a formal internal control system to ensure that all Uniform Data System (UDS) related calculations are accurately documented and consistently maintained.
Finding 2024.003 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken This was also a find...
Finding 2024.003 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken This was also a finding in the 2023 Audit. In response to the audit finding, I worked directly with the Director of Clinical Operations and the Patient Service Representative Manager to conduct a comprehensive review of the health center's existing sliding fee scale policy to ensure alignment with federal guidelines and best practices, clarifying documentation requirements, including acceptable forms of income verification and the definition of family size. We developed and implemented a step-by-step standard operating procedure (SOP) for Patient Service Representatives (PSR) staff to consistently assess and apply sliding fee discounts. The SOP included clear instructions for verifying documentation, calculating discount eligibility, and recording determinations in the patient's record. The Clinical Operations Director's management team will conduct quarterly spot audits of a sample of sliding fee files to verify correct application and documentation. The managers will report the findings to leadership and provide corrective follow-up and provide training for PSR personnel on the updated policy and procedures needed. I reported all identified and assessed changes to the health center's board of directors or its audit committee for review and oversight. The board verified that appropriate corrective action was being taken regarding internal controls.
2024-003 Reporting over COVID-19 America Rescue Plan Act Recommendation: We recommend that the Town implement a control to ensure an independent review of the financial reports is performed by an individual other than the prepared to verify accuracy and completeness prior to the U.S. Department of t...
2024-003 Reporting over COVID-19 America Rescue Plan Act Recommendation: We recommend that the Town implement a control to ensure an independent review of the financial reports is performed by an individual other than the prepared to verify accuracy and completeness prior to the U.S. Department of the Treasury. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Town Manager will review filing prior to submission at next reporting deadline. Name of the contact person responsible for corrective action: Town Manager and Finance Director Planned completion date for corrective action plan: Since this report is overdue, the estimated implementation date is before the filing of the 2026 deadline
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