Corrective Action Plans

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Views of Responsible Officials and Corrective Action: The District will strive to implement the water shut-off policy consistently.
Views of Responsible Officials and Corrective Action: The District will strive to implement the water shut-off policy consistently.
Views of Responsible Officials and Corrective Action: The District will strive to gain necessary knowledge needed to prepare a full set of financial statements. The District will appoint a competent individual who possesses the skill knowledge and experience to review and approve the draft reports a...
Views of Responsible Officials and Corrective Action: The District will strive to gain necessary knowledge needed to prepare a full set of financial statements. The District will appoint a competent individual who possesses the skill knowledge and experience to review and approve the draft reports and assume all relevant management responsibilities.
Views of Responsible Officials and Corrective Action: The District will strive to segregate as many accounting functions as practical with the limited staff available.
Views of Responsible Officials and Corrective Action: The District will strive to segregate as many accounting functions as practical with the limited staff available.
Medical Assistance Program – Assistance Listing No. 93.778 Recommendation: CLA recommends the County develop and implement a process to require review and approval of the WIMCR reports prior to the submission of the report to the state to help ensure that the data reported are accurate, complete and...
Medical Assistance Program – Assistance Listing No. 93.778 Recommendation: CLA recommends the County develop and implement a process to require review and approval of the WIMCR reports prior to the submission of the report to the state to help ensure that the data reported are accurate, complete and supporting documentation is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Annual WIMCR reporting to be completed by Waushara County DHS Finance team; Financial Manager and/or Financial Assistant. If both positions are fully employed both positions need to review and sign off on data prior to submission. If one of the positions is vacant a second review of data and signoff needs to be done by someone else within DHS – likely the DHS Director. Name(s) of the contact person(s) responsible for corrective action: Peder Culver, Finance Manager, Clara Voigtlander, DHS Director Planned completion date for corrective action plan: Action plan in place 2025 reporting in 2026.
Finding 2024-005: PERIOD OF PERFORMANCE Description of Finding: Capital Funds identified in the PHA's CFP 5-Year Action Plan to be transferred to operations are obligated by the PHA once the funds have been budgeted and drawn down by the PHA. Capital Funds transferred to operations (BLI 1406) are no...
Finding 2024-005: PERIOD OF PERFORMANCE Description of Finding: Capital Funds identified in the PHA's CFP 5-Year Action Plan to be transferred to operations are obligated by the PHA once the funds have been budgeted and drawn down by the PHA. Capital Funds transferred to operations (BLI 1406) are not considered obligated until the PHA has budgeted and drawn down the funds. To meet this requirement, the funds must be budgeted in line BLI 1406 (Operations) and the PHA must submit the voucher request in LOCCS. (24 CFR Section 905.314(I)). Statement of Concurrence or NonConcurrence: The Authority had obligated capital funds related to operations (BLI 1406) for Capital Fund years 2020 and 2022 prior to the voucher request date for these draws. The Authority had six open capital fund grants during fiscal year 2024 (Capital Fund years 2019-2024). The Authority obligated the BLI 1406 funding for Capital Fund 2020 in March 2024 and Capital Fund 2022 in May 2024. The Authority submitted the voucher requests in February 2025. Corrective Action: Funds in 1406 will be drawn down directly after obligation. Name of Contact Person: Cheryl Thibeault Projected Completion Date: 09/30/2025
Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2024 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2024-001 – Reporting: Federal Funding Accountability and Transparency Act (“FFATA”) Description of Finding: Th...
Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2024 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2024-001 – Reporting: Federal Funding Accountability and Transparency Act (“FFATA”) Description of Finding: The FFATA subawards were not submitted timely to the Federal Funding Accountability and Transparency Act Subaward Reporting System (“FSRS”). The review and approval occurred after the FFATA subaward was submitted to the FSRS. Statement of Concurrence: We concur with the finding above. Corrective Action: BCHN has created a policy regarding the FFATA reporting process. In this process the Electronic Handbook (EHB) is reviewed weekly to ensure that if new awarded funding is released, BCHN is alerted to the need to complete the FFATA report. BCHN has created a spreadsheet to track all the awarded funding and due dates for FFATA reports. Every month, at the board meeting, the spreadsheet is presented to the board with any new awarded funding and when the FFATA report is completed. BCHN has begun a process where the FFATA report is put together by the Finance Manager and reviewed and signed off by the CFO before submitting the report. Completion Date: October 2024. Name of Contact Person: Alicia Tenny Chief Financial Officer Tel. No.: (917) 364-1156 E-mail: atenny@bchnhealth.org If HRSA has questions regarding this Corrective Action Plan, please call Alicia Tenny at (917) 364-1156. Sincerely yours, _________________________ Alicia Tenny Chief Financial Officer
Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2024 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2024-004 – Period of Performance Description of Finding: There was no evidence, such as a signature, evidencin...
Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2024 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2024-004 – Period of Performance Description of Finding: There was no evidence, such as a signature, evidencing review and approval by a direct supervisor of the timesheets. Time and effort reports were not done. Statement of Concurrence: We concur with the finding above. Corrective Action: BCHN has put together a training program for employees to ensure that timecards are reviewed and approved by both the employee and the supervisor on a bi-weekly basis. Before payroll is processed, approvals by employees and supervisors will be checked. HR will provide a monthly time and effort report to the finance team. This report will provide total number of hours worked by each employee for each assigned cost center. Completion Date: October 2024. Name of Contact Person: Alicia Tenny Chief Financial Officer Tel. No.: (917) 364-1156 E-mail: atenny@bchnhealth.org If HRSA has questions regarding this Corrective Action Plan, please call Alicia Tenny at (917) 364-1156. Sincerely yours, _________________________ Alicia Tenny Chief Financial Officer
The Director of Finance and Accounting Manager began implementing process and procedures to ensure all invoices are filed in a timely manner to funders in July 2024. The importance of understanding the requirements of the agreements has been stressed to the finance team. The team has also been instr...
The Director of Finance and Accounting Manager began implementing process and procedures to ensure all invoices are filed in a timely manner to funders in July 2024. The importance of understanding the requirements of the agreements has been stressed to the finance team. The team has also been instructed to save on SharePoint all communication with funders regarding changes of when invoices are to be filed when the instructions differ from the agreement. EPHC has been behind on financial statements and previously were not able to submit the semi-annual financial statements. As of June 30, 2025, the first semi-annual financial statements was submitted.
The Director of Finance and Accounting Manager began implementing process and procedures to ensure all invoices are filed in a timely manner to funders in July 2024. The importance of understanding the requirements of the agreements has been stressed to the finance team. The team has also been instr...
The Director of Finance and Accounting Manager began implementing process and procedures to ensure all invoices are filed in a timely manner to funders in July 2024. The importance of understanding the requirements of the agreements has been stressed to the finance team. The team has also been instructed to save on SharePoint all communication with funders regarding changes of when invoices are to be filed when the instructions differ from the agreement. To ensure timely submission of the performance reports, EPHC will use Sales Force software to track all due dates. This system will send reminders and will record submission dates. To ensure review of all performance reports, procedures will be put in place outlining roles and responsibilities of report preparation by managers and review by Program Directors.
EPHC has long term employees that joined the organization when it was a program of Catholic Charities. EPHC does not maintain these records for employees that began with Catholic Charities. In early FY2026, EHPC will complete background checks on long term employees to ensure we maintain the proper ...
EPHC has long term employees that joined the organization when it was a program of Catholic Charities. EPHC does not maintain these records for employees that began with Catholic Charities. In early FY2026, EHPC will complete background checks on long term employees to ensure we maintain the proper documentation.
The delegates from the board did receive the 40-hour training prior to entering the board but were unable to provide certification proof. Moving forward a new process of policy with record keeping guidance will be implemented to ensure the documentation is kept on file. For training courses that do ...
The delegates from the board did receive the 40-hour training prior to entering the board but were unable to provide certification proof. Moving forward a new process of policy with record keeping guidance will be implemented to ensure the documentation is kept on file. For training courses that do not provide a completion certificate, Board members will prepare a memo with self-attestation of completion for our records.
Moving forward a new process of policy with record keeping guidance will be implemented to ensure the documentation is kept on file. For training courses that do not provide a completion certificate, staff will prepare a memo with self-attestation of completion for our records.
Moving forward a new process of policy with record keeping guidance will be implemented to ensure the documentation is kept on file. For training courses that do not provide a completion certificate, staff will prepare a memo with self-attestation of completion for our records.
Finding Number: 2024-004 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Erin Marks, Accounting & Support Services Supervisor - Main Contact Persons involved: Kim Giese, Fiscal Officer and Joan Stordalen, Social Services S...
Finding Number: 2024-004 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Erin Marks, Accounting & Support Services Supervisor - Main Contact Persons involved: Kim Giese, Fiscal Officer and Joan Stordalen, Social Services Supervisor Corrective Action Planned: Regarding the DHS-3220.3 Local Collaborative Time Study (LCTS) Cost Schedule, it was discovered that the Sexual Reproductive Health Services Grant Award was not accurately reported on the LCTS Cost Schedule due to the misguidance from MN Department of Health (MDH) and the interpretation of Watonwan County. After clarification from MDH, all SRHS funds will be reported as state funds only and should not be reflected on the LCTS reporting. Fiscal Officer will amend the last 4 quarters of the LCTS reporting to reflect that change. Moving forward, we will retain documentation from MDH showing SRHS funds are state only funds, regardless of what our grant agreement shows, and ensure that this funding source is not reported on the LCTS reporting in the future. Fiscal Officer will continue to complete the quarterly LCTS reporting, while the Accounting & Support Services Supervisor will review and sign off on it. Regarding the late submission of the 2024 Annual Collaborative Report. This report is emailed and completed by the LCTS Coordinator. Watonwan County's LCTS Coordinator is our Social Services Supervisor. To ensure on time submission of the Annual Collaborative Report, that is due on April 30 each year, a reminder will be added to both the Social Services Supervisor and the Accounting & Support Services Supervisor's Outlook calendars for a reminder beginning April ist giving time to complete and submit the report prior to April 30th. Anticipated Completion Date: 9/12/2025 - Reporting 4/30/2026 - Late Submission
Finding Number: 2024-003 Finding Title: Eligibility - MAXIS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Jodi Halvorson Corrective Action Planned: Verification of Citizenship/assets: We will have discussions at our next unit meeting about makin...
Finding Number: 2024-003 Finding Title: Eligibility - MAXIS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Jodi Halvorson Corrective Action Planned: Verification of Citizenship/assets: We will have discussions at our next unit meeting about making sure all health care cases have their citizenship verified. We will also have training on the policy regarding verifying vehicles if there is more than one in the household. Anticipated Completion Date: 9/15/25 we will have the unit meeting
Finding Number: 2024-002 Finding Title: Eligibility - METS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Jodi Halvorson Corrective Action Planned: Timelines: This error occurred from a worker that is no longer in our agency. It was discovered af...
Finding Number: 2024-002 Finding Title: Eligibility - METS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Jodi Halvorson Corrective Action Planned: Timelines: This error occurred from a worker that is no longer in our agency. It was discovered after the worker left that the application was filed away without processing. This is not our policy, and we will be discussing the importance of program timelines in our unit meeting. Verification of Citizenship status (error with SSN entry): This case was received from a previous county. The SSN was entered incorrectly which did not produce citizenship verification in the system. It was noted that there was a birth certificate on file, but METS case files do not get transferred between counties, so we did not have the birth certificate. The SSN was corrected which was able to ping the verification of the citizenship. Going forward, for the next 3 months we will be looking at each case that is transferred into our county to make sure the citizenship has been verified and if not, request the birth certificate or other verification. After the initial 3 months, we plan to do random case checks. Anticipated Completion Date: 9/15/25 we will have the unit meeting and discuss timelines 12/31/25 will be our 3-month goal of checking transferred in cases for citizenship
2024-003: Water and Waste Disposal Systems for Rural Communities Reporting Corrective Action Plan: The Village is actively working with USDA personnel to submit the required reporting documents. Going forward, these will be submitted once available. Reponsible person: Sheila Schreiner Anticipated co...
2024-003: Water and Waste Disposal Systems for Rural Communities Reporting Corrective Action Plan: The Village is actively working with USDA personnel to submit the required reporting documents. Going forward, these will be submitted once available. Reponsible person: Sheila Schreiner Anticipated completetion date: Ongoing
CASEFILE REVIEW (2023-005) Recommendation: It is recommended the County review case files on a periodic basis throughout the year and document the reviews. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County...
CASEFILE REVIEW (2023-005) Recommendation: It is recommended the County review case files on a periodic basis throughout the year and document the reviews. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will continue to work at this area and internal controls to achieve the overall goal. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2025
SSIS ACTIVITIES ALLOWED/ALLOWABLE COSTS (2023-009) Recommendation: It is recommended that the County implement procedures to document review of disbursements when not able to show an electronic approval in the SSIS system. Explanation of disagreement with audit finding: There is no disagreement with...
SSIS ACTIVITIES ALLOWED/ALLOWABLE COSTS (2023-009) Recommendation: It is recommended that the County implement procedures to document review of disbursements when not able to show an electronic approval in the SSIS system. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement procedures to document review for all SSIS disbursements. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2025
FOSTER CARE REPORTING (2023-008) Recommendation: It is recommended that the County implement procedures to review the foster care report and retain evidence of the review on file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in respons...
FOSTER CARE REPORTING (2023-008) Recommendation: It is recommended that the County implement procedures to review the foster care report and retain evidence of the review on file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will start printing a coversheet for the Fiscal Supervisor to sign and retain physical evidence of the review being done. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2025
SLFRF SUSPENSION AND DEBAREMENT (2023-011) Recommendation: It is recommended that the County ensure properly language related to suspension and debarment is included in the contract, or other records are kept on file to support a verification was done. Explanation of disagreement with audit finding:...
SLFRF SUSPENSION AND DEBAREMENT (2023-011) Recommendation: It is recommended that the County ensure properly language related to suspension and debarment is included in the contract, or other records are kept on file to support a verification was done. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will continue to work at this area and internal controls to achieve the overall goal. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2025
Condition: The Organization did not have the appropriate controls in place over FFATA reporting and did not file the required reports. Further, while the Organization had written procedures over cash management, they were outdated and did not reflect the current staffing model. Planned Corrective Ac...
Condition: The Organization did not have the appropriate controls in place over FFATA reporting and did not file the required reports. Further, while the Organization had written procedures over cash management, they were outdated and did not reflect the current staffing model. Planned Corrective Action: Reporting was completed in SAM.gov in May 2025 for subrecipient subaward amount based on the award period running from calendar periods of July to June. Written internal MMTC procedures regarding cash management will be updated and will include the current staff. Contact person responsible for corrective action: Alan Kowalewski Anticipated Completion Date: 10/31/2025
Auditee’s Response and Planned Corrective Action The Adams Housing Authority has received approval for HUD to switch banks for the HCV program. The Authority will obtain a signed depository agreement from the new bank Planned Implementation Date of Corrective Action: September 1, 2025 Person Respons...
Auditee’s Response and Planned Corrective Action The Adams Housing Authority has received approval for HUD to switch banks for the HCV program. The Authority will obtain a signed depository agreement from the new bank Planned Implementation Date of Corrective Action: September 1, 2025 Person Responsible for Corrective Action: William Schrade, Executive Director
Auditee’s Response and Planned Corrective Action The Adams Housing Authority will be providing training from a 3rd party for all employees on proper documentation and checklists needed for all voucher files. Planned Implementation Date of Corrective Action: September 8, 2025 Person Responsible for C...
Auditee’s Response and Planned Corrective Action The Adams Housing Authority will be providing training from a 3rd party for all employees on proper documentation and checklists needed for all voucher files. Planned Implementation Date of Corrective Action: September 8, 2025 Person Responsible for Corrective Action: William Schrade, Executive Director
The property manager attended a couple of multifamily housing specialist training courses and received certification. The required update to the gross rents, annually based on the OCAF, will be corrected in tenants' files moving forward. The Housing Authority has put a quality control system in plac...
The property manager attended a couple of multifamily housing specialist training courses and received certification. The required update to the gross rents, annually based on the OCAF, will be corrected in tenants' files moving forward. The Housing Authority has put a quality control system in place to ensure the tenants' files are in compliance. We expect to be in compliance moving forward.
The outstanding balance currently reflected in the books represents unreconciled funds resulting from the transfer of assets and liabilities during the conversion of the Public Housing Program to the RAD Project-Based Rental Assistance (PBRA) Program. These funds were carried forward following the t...
The outstanding balance currently reflected in the books represents unreconciled funds resulting from the transfer of assets and liabilities during the conversion of the Public Housing Program to the RAD Project-Based Rental Assistance (PBRA) Program. These funds were carried forward following the transition of ownership and operations from the PHA to Athens Housing Management, LLC, as the new ownership entity. By HUD RAD guidance, including the RAD Notice Revision 4 (H-2019-09/PIH-2019-23), when a public housing project converts to PBRA under RAD, the PHA is required to transfer assets and liabilities to the new ownership entity to ensure continuity and financial integrity of the property. Specifically, Attachment 1A to the RAD Notice outlines the obligation to transfer project-specific assets and liabilities from the public housing ledger to the new entity, including cash, receivables, and project-level obligations. The amounts in question were initially anticipated to be reconciled as part of that process. However, due to the complexity of the transition and lack of adequate internal controls at the time, the residual balance has remained unreconciled for the past five fiscal years. These amounts are not expected to be repaid or resolved in FY 2025. As such, this is a one-time, non-recurring issue, and corrective action is underway. Staff will formally seek HUD’s approval and submit a resolution to the Boards of both the Housing Authority (the management entity) and Athens Housing Management LLC (the ownership entity), requesting that the outstanding balance be written off. This action will appropriately clear the books of legacy items tied to the conversion and align the accounting records of both entities. This write-off recommendation aligns with best practices in governmental accounting for long-standing inter-entity balances that are no longer collectible or relevant to current operations. Additional internal controls have since been implemented to prevent recurrence, including improved cash management oversight, inter-entity reconciliation protocols, and timely financial reporting.
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