Corrective Action Plans

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2024-104 Lack of Controls Related to Filing Reports Condition: The Organization did not maintain proper documentation to support the review of the report prior to submission to the grantor, other than the review done by the preparer. Corrective Action Planned: The Organization has hired a new Chie...
2024-104 Lack of Controls Related to Filing Reports Condition: The Organization did not maintain proper documentation to support the review of the report prior to submission to the grantor, other than the review done by the preparer. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The accounting staff was restructured in November 2024 with the addition of a Finance Manager and Senior Accountant to strengthen internal controls and facilitate segregation of duties best practices for day-to-day activities. In addition to review of month-end journal entries, reporting requirements with additional review was also implemented in 2025 Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: Implemented
U.S. Department of Health and Human Services (HHS) SIGNIFICANT DEFICIENCY 2024-002 93.224/93.527 - Consolidated Health Centers (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, Public Housing Primary Care, and School Based Health Centers); (HHS Community Health Center...
U.S. Department of Health and Human Services (HHS) SIGNIFICANT DEFICIENCY 2024-002 93.224/93.527 - Consolidated Health Centers (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, Public Housing Primary Care, and School Based Health Centers); (HHS Community Health Center Program) Recommendation: We recommend that management hold additional training for front desk staff regarding the collection and verification of patient information for each patient. We also recommend enhancing your sliding fee status feature in your billing system to be completed for all patients to identify if the patient is insured, an application is pending, an application was received, an application was approved by finance for adjustment, and if an application was waived, to enable better tracking of the eligibility of each patient. We also recommend reviewing outstanding patient balances over 180 days to determine if follow up with a patient is required to collect the outstanding balance or to see if something has been collected by the front desk but not communicated to the finance team. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Management agrees with the recommendations identified above. During April 2025, NHA started a project to review Self Pay balances with service dates prior to January 1, 2025 to follow up on why the balance is still outstanding. This would have caught the error identified above. In addition to this project, they have held additional trainings for front desk staff and will continue to do so and will continue to improve their methods of tracking patient eligibility. Name(s) of the contact person(s) responsible for corrective action: Doni Miller Planned completion date for corrective action plan: November 30, 2025 If the Department of Health and Human Services has questions regarding this plan, please call Doni Miller, CEO at 419-720-7883.
Finding Number: 2024-001 ...
Finding Number: 2024-001 Equipment and Real Property Management (Internal Control and Compliance) Condition Our testing of the expenditures of Airport Improvement Program funds identified $192,000 of equipment purchased as part of the rehabilitation of the air traffic control tower. This equipment was recorded in the Authority's property records. However, the property records did not contain the required data elements noted above. Response/Planned Corrective Action We agree with the auditor’s findings and have already taken corrective measures to ensure compliance. Specifically, we conducted a full review of the Authority’s property records and updated the equipment entries associated with this project to include all required data elements. To strengthen compliance moving forward, we have created a Standard Operating Procedure (SOP) that mandates completion of all required data elements before any asset record is finalized. In addition, the SOP establishes a protocol for conducting periodic internal audits of property records to confirm accuracy, completeness, and adherence to federal requirements. These corrective actions have already been implemented, and the Authority will maintain ongoing oversight to prevent recurrence. Responsible Contact Person: Courtney K. Pittman Interim Executive Director, St. Johns County Airport Authority
Finding 2024-001 - Housing Choice Voucher Tenant Files - Eligibility- Rent Calculations Noncompliance & Significant Deficiency Section 8 Housing Choice Voucher Cluster - ALN 14.871 Corrective Plan: 1. Income Verification Vanette Greer (please state tenant in audit for privacy act) - Stated that she...
Finding 2024-001 - Housing Choice Voucher Tenant Files - Eligibility- Rent Calculations Noncompliance & Significant Deficiency Section 8 Housing Choice Voucher Cluster - ALN 14.871 Corrective Plan: 1. Income Verification Vanette Greer (please state tenant in audit for privacy act) - Stated that she did not have one of her weekly check stubs due to being out with Covid. The Specialist processed the following: She totaled three (3) check stubs, then divided by 4 with one being at zero. She then annualized. Upon further review, it was determined that the YTD included an additional pay week (which she stated that she was out with Covid). An interim will be completed with a Retroactive Agreement offered. 2. Income Verification Lola Garrett (please state tenant in audit for privacy act) -A student credit was given but failed to acquire the necessary source document. No retro necessary. 3. Late Reexaminations (4). Four reexaminations were processed late due to insufficient information provided. The Executive Director approved the late reexams to preserve and grow the lease-up rate (at 86%} prior to HUD's declaration of insufficient funds (May 2025} for the remaining calendar year of 2025. 4. Inspections - We did have one inspection overlooked at an elderly site since 2020. The other tenants within the complex did receive inspections including SEMAP. We are now utilizing the PIC report going forward (instead of in-house system) to prevent such an oversight again. Person Responsible: Jeff Trahan, Executive Director Anticipated Completion Date: July 14, 2025 Note: It is the Auditee's position that such an oversight constitutes a "deficiency" (oversight flaw) rather than a Significant Deficiency leading to a Material Weakness in Internal Control.
Corrective Action Plan Year Ended June 30, 2024 Identifying Number: 2024-001- Late Audit Reporting Finding: The audit, data collection form and reporting package for the Organization for the year ended June 30, 2024, should have been submitted to the Federal Audit Clearinghouse by March 31, 2025. Co...
Corrective Action Plan Year Ended June 30, 2024 Identifying Number: 2024-001- Late Audit Reporting Finding: The audit, data collection form and reporting package for the Organization for the year ended June 30, 2024, should have been submitted to the Federal Audit Clearinghouse by March 31, 2025. Corrective Actions Planned or Taken: The Organization will schedule and complete future external audits in a manner that will allow timely reporting. Responsible Official: Rebecca Leininger, Executive Director Anticipated Completion Date: March 31, 2026
Finding 574901 (2024-005)
Significant Deficiency 2024
The County agrees with this finding. The questioned costs are related to eligible payroll costs that were reported on the current year SEFA in error, rather than in the fiscal year in which they were incurred. The County recommends training for payroll and accounting staff related to proper recognit...
The County agrees with this finding. The questioned costs are related to eligible payroll costs that were reported on the current year SEFA in error, rather than in the fiscal year in which they were incurred. The County recommends training for payroll and accounting staff related to proper recognition of expenses on the SEFA and documentation standards of the COVID-19 Coronavirus State and Local Fiscal Recovery Funds program.
View Audit 365155 Questioned Costs: $1
Contact Person Jan Kamstra, Executive Director Corrective Action Plan The Authority will review its procedures over utility allowances to ensure a secondary review of the schedule is performed. Planned Completion Date for CAP Immediately
Contact Person Jan Kamstra, Executive Director Corrective Action Plan The Authority will review its procedures over utility allowances to ensure a secondary review of the schedule is performed. Planned Completion Date for CAP Immediately
Finding 574705 (2024-002)
Significant Deficiency 2024
The housing division has conducted a thorough review of their procedures and upgraded their internal Standard Operating Procedure documents to include detailed step-by-step instructions designed to ensure compliance with rent reasonableness requirements. Additionally, the PHA contracts the service...
The housing division has conducted a thorough review of their procedures and upgraded their internal Standard Operating Procedure documents to include detailed step-by-step instructions designed to ensure compliance with rent reasonableness requirements. Additionally, the PHA contracts the services of McCright & Associates LLC, a reputable HQS servicing company, to assist with rent reasonableness requirements. McCright now conducts all rent reasonableness comparables for all new units and staff confirm that a copy is stored in the participant file. Staff believe that with the implementation of these procedures appropriate steps have been taken to address this concern
Finding 574704 (2024-001)
Significant Deficiency 2024
PHA staff understand that income verification is essential to ensure that only eligible participants are provided with housing assistance benefits. The housing division has conducted a thorough review of their procedures and upgraded their internal Standard Operating Procedure documents to include d...
PHA staff understand that income verification is essential to ensure that only eligible participants are provided with housing assistance benefits. The housing division has conducted a thorough review of their procedures and upgraded their internal Standard Operating Procedure documents to include detailed step-by-step instructions designed to ensure compliance with EIV requirements. Additionally, staff have been in contact with their software provider about system enhancements such as the software producing a warning/error if an employee attempts to process an EIV reexamination without updating the EIV date. Such enhancements would further help to ensure compliance with federal program requirements. Staff have also been attending training to ensure sufficient knowledge of program EIV requirements. Staff believe these efforts should address this concern.
Need Analysis Planned Corrective Action: A report was created in Populi (Subsidized Eligibility Report) that will capture the students’ Cost of Attendance, SAI and if the student has zero need. A separate report will be generated to capture subsidized loan disbursements. The two reports will be c...
Need Analysis Planned Corrective Action: A report was created in Populi (Subsidized Eligibility Report) that will capture the students’ Cost of Attendance, SAI and if the student has zero need. A separate report will be generated to capture subsidized loan disbursements. The two reports will be combined to identify students who were awarded the subsidized loan in error. These reports will be reviewed after each add/drop period. Management has made a request to our vendor to create a special report that will capture this data in a more time efficient manner. Person Responsible for Corrective Action Plan: Darla Hopper, VP of Enrollment Management Anticipated Date of Completion: 09/30/2025
Condition Friends of Family Health Center lacked adequate controls over its sliding fee discount program to ensure patients received the correct discount. In testing patients receiving discounts under Friends of Family Health Center's sliding fee schedule, we noted that for 1 of 40 patients selecte...
Condition Friends of Family Health Center lacked adequate controls over its sliding fee discount program to ensure patients received the correct discount. In testing patients receiving discounts under Friends of Family Health Center's sliding fee schedule, we noted that for 1 of 40 patients selected for testing Friends of Family Health Center incorrectly applied the discount or were put in the incorrect category based on income and family size. Response One error in calculating a patient’s income with 40 others is a minor 2.5% error margin. FOFHC will have a quarterly training course on how to properly use the various income level tables provided to the front office staff. Responsible Party Dawn Ta, CFO Estimated Completion Date December 31, 2025
Views of responsible officials and planned corrective action: Management has changed the process in place for grant expenditures where the expenditure does not go through the formal bidding process. This will ensure the County obtains attestation regarding federal suspension and debarment from all ...
Views of responsible officials and planned corrective action: Management has changed the process in place for grant expenditures where the expenditure does not go through the formal bidding process. This will ensure the County obtains attestation regarding federal suspension and debarment from all vendors working on projects funded by federal grant dollars.
Federal Agency Name: U.S Department of Housing and Urban Development Program Name: Housing Choice Vouchers CFDA # 14.871 Finding Summary: Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Responsible Individuals: Celia Rivas Director of Assisted Hous...
Federal Agency Name: U.S Department of Housing and Urban Development Program Name: Housing Choice Vouchers CFDA # 14.871 Finding Summary: Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Responsible Individuals: Celia Rivas Director of Assisted Housing Corrective Action Plan: The AHA Director of Assisted Housing and the Senior Housing Inspector are conducting monthly reviews of inspection reports to identify deficiencies and ensure inspections extensions are completed on time. This program management process will continue on an ongoing basis. Additionally, we have hired an additional inspector to help meet inspection deadlines and improve overall timeliness. Anticipated Completion Date: Ongoing
Federal Agency Name: U.S Department of Housing and Urban Development Program Name: Housing Choice Vouchers CFDA # 14.871 Finding Summary: Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Responsible Individuals: Celia Rivas Director of Assisted Hous...
Federal Agency Name: U.S Department of Housing and Urban Development Program Name: Housing Choice Vouchers CFDA # 14.871 Finding Summary: Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Responsible Individuals: Celia Rivas Director of Assisted Housing Corrective Action Plan: To strengthen our compliance oversight, we now have a total of two Compliance Managers on staff. We recently filled the previously vacant Compliance Manager position, which will enhance our capacity to monitor and ensure that annual recertifications are being processed every 12 months and support staff in adhering to HUD requirements and agency procedures. We have made progress in hiring and retaining staff, which is strengthening our operational capacity and will support the timely processing of annual recertifications in compliance with HUD requirements. Anticipated Completion Date: Ongoing
Finding Number: 2024-002 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Waylon Welvaert, Finance Manager Corrective Action Planned: All impacted employees have been reviewed and system adjustments in payroll have been com...
Finding Number: 2024-002 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Waylon Welvaert, Finance Manager Corrective Action Planned: All impacted employees have been reviewed and system adjustments in payroll have been completed. We have completed and submitted updated 2556 reports to the State on June 25, 2025, for the two quarterly reports that were affected. In addition, a review will be done at the start of every quarter to ensure that all allocations are being distributed correctly by the payroll system to ensure that reports are accurately completed. Anticipated Completion Date: We completed doing a full payroll system review on July 10, 2025 of account code classifications for the start of the 3rd quarter.
Finding Number: 2024-001 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: DeAnn Boney, Income and Healthcare Assistance Manager Corrective Action Planned: The results of the MA audit will be shared with all eligibility wo...
Finding Number: 2024-001 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: DeAnn Boney, Income and Healthcare Assistance Manager Corrective Action Planned: The results of the MA audit will be shared with all eligibility workers at a full team meeting. We will review the findings of the cases found in error and retrain workers on the expectation that the system will be updated when documentation is received on a case. The case findings will be reviewed directly with the individual workers that made the mistake on the case. They will update the case in the METS system to reflect the information in the case files. Anticipated Completion Date: Our full eligibility meeting is scheduled for July 29, 2025.
2024-002 Significant Deficiency-Procurement Fremont County Response. Julie Freese Fremont County Clerk. While the county does not have an independent "Procurement Policy", we have been following our Capital Revolving Procedures which include bidding criteria based on pricing and types of bids being ...
2024-002 Significant Deficiency-Procurement Fremont County Response. Julie Freese Fremont County Clerk. While the county does not have an independent "Procurement Policy", we have been following our Capital Revolving Procedures which include bidding criteria based on pricing and types of bids being sought. A Procurement policy has been obtained from another county to review. It is the intent of the county to prepare its own "Procurement Policy" during a policy work session, coming up this fall. Treasurer Anderson and Clerk Freese also toll a 2-day Procurement training put on by the Federal Grants Training Program this summer. In the meantime, the county will continue to follow all federal regulations for every grant we receive as per each particular project dictates.
Finding 2024-001: Significant Deficiency - Audit Completion and Submission to the Federal Government Compliance Area: Reporting (L) Based on the finding in the fiscal year 2023 audited financial report, the county commissioners set aside $100,000 in their budget to hire or contract with a CPA to as...
Finding 2024-001: Significant Deficiency - Audit Completion and Submission to the Federal Government Compliance Area: Reporting (L) Based on the finding in the fiscal year 2023 audited financial report, the county commissioners set aside $100,000 in their budget to hire or contract with a CPA to assist with audit preparation. This was in addition to $30,000 set aside in the county treasurer's budget for audit consulting. The county commissioners hired an individual in September 2024. That individual left employement with the county in November 2024 and the position was not refilled through the end of fiscal year 2025. The remainder of the FY2024 audit preparation was completed in-house. Due to reductions in revenue and budget constraints, both the $100,000 allocation for a new employee and the $30,000 for consulting services were cut from the commissioners' and treasurer's budgets, so the county is pivoting on audit preparation resposibilities and expanding the number of in-house employees working on different facets of the preparation. With the exception of the CPA that was on staff for two months, the rest of the finance staff has been stable for at least two years and have grown in their knowledge of county finances. We are utilizing 6-7 different staff members on parallel tasks with oversight and assistance from the county treasurer and clerk. We are confident that the audit preparation for FY2025 will be completed months earlier such that trial balances and supporting documentation will be available to our auditors in time to meet the federal submission deadline.
We are working in implementing adequate extaernal and internal control procedures in order to comply with the submission of all required information for the Single Audit for Fiscal Year 2025.
We are working in implementing adequate extaernal and internal control procedures in order to comply with the submission of all required information for the Single Audit for Fiscal Year 2025.
We are working in implementing adequate external and internal control procedures in order to comply with the submission of all required information for the Single Audit for Fiscal Year 2025.
We are working in implementing adequate external and internal control procedures in order to comply with the submission of all required information for the Single Audit for Fiscal Year 2025.
Rent Reasonableness Calculations Corrective Action Plan (CAP): Recommendation: We recommend, the entity develop a process to verify that rent reasonableness calculations are completed and maintained in the files. Explanation of disagreement with audit finding: There is no disagreement with the audit...
Rent Reasonableness Calculations Corrective Action Plan (CAP): Recommendation: We recommend, the entity develop a process to verify that rent reasonableness calculations are completed 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 Authority will train individuals doing the calculations to ensure calculations are done and maintained in the files and implement processes to verify rent reasonableness calculations are done. Name of the contact person responsible for corrective action: Bob Kazmierski Planned completion date for corrective action plan: December 31, 2024
Finding 574145 (2024-002)
Significant Deficiency 2024
Finding 2024-002: Significant deficiency in internal controls over compliance and immaterial non- compliance. Corrective Action Planned: Connected Lane County has updated internal control processes to ensure timely reporting and closing of the books and records are stored both electronically and in ...
Finding 2024-002: Significant deficiency in internal controls over compliance and immaterial non- compliance. Corrective Action Planned: Connected Lane County has updated internal control processes to ensure timely reporting and closing of the books and records are stored both electronically and in paper files in the finance department for easy access during the course of the audit. Person(s) Responsible: Mary Bell, Finance Manager Anticipated Completion Date: September 1, 2025
Reports were not sent in a way that does not show proof that they were received and reviewed. In the future all reports will be sent and approved through a channel that can be proven and pulled upon request at any time.
Reports were not sent in a way that does not show proof that they were received and reviewed. In the future all reports will be sent and approved through a channel that can be proven and pulled upon request at any time.
The Brockton Housing Authority {The Authority) has reviewed and agrees with finding 2024-01. The Authority has experienced a large turnover in staff who are responsible for the calculations of rents and Housing Assistance Payments. Through promotions, retirements, and resignations 7 of the 10 staff ...
The Brockton Housing Authority {The Authority) has reviewed and agrees with finding 2024-01. The Authority has experienced a large turnover in staff who are responsible for the calculations of rents and Housing Assistance Payments. Through promotions, retirements, and resignations 7 of the 10 staff primarily responsible for this function have left their positions in the last two years and have been replaced by staff new to the position. The Authority did increase quality control reviews due to the transition period. The finding does not identify a systemic issue rather it found various instances of noncompliance. Prior to the Audit the Authority scheduled a three-day onsite rent calculation training for all staff with Nan McKay inc that occurred the week of May 20, 2025. Finding 2024-001- Moving To Work Demonstration Tenant Files - Eligibility - Internal Control over Tenant Files - Noncompliance and Significant Deficiency Corrective Action Plan: The Authority will continue and enhance its training regimen for staff responsible for rent determination. Furthermore, the Authority has engaged the services of Edgemere Consulting. As part of this engagement Edgemere will conduct an independent quality control review of public housing and rental assistance files. From the information gathered from the file review Edgemere Consulting will develop specific training initiatives for the staff including enhanced quality control measures. Person Responsible: Bruna Campbell, Compliance officer Anticipated Completion Date: December 31, 2025 - Ongoing
View Audit 364699 Questioned Costs: $1
Finding 574080 (2024-002)
Significant Deficiency 2024
Finding Number: 2024-002 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Michelle Trulock, Financial Assistance Supervisor Corrective Action Planned: Cases where there was an income discrepancy have been reviewed and upd...
Finding Number: 2024-002 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Michelle Trulock, Financial Assistance Supervisor Corrective Action Planned: Cases where there was an income discrepancy have been reviewed and updated. Peacetime instructions used during COVID are no longer in place. MAXIS cases have reverted to pre-pandemic processing and will be reviewed and updated. Specific income calculations were reviewed with staff. Supervisor will promote annotation on documents for clarification, as well as clear and concise case noting. Desk reviews are completed periodically for review of income, assets and citizenship and all transfer in cases are reviewed for the like. Supervisor will request that each worker review citizenship (STAT/ MEMB/MEMI and imaging) at healthcare renewal month to ensure accuracy. Policy and procedure review for staff on reviewing forms for asset information. This also relates to the self-attestation of cash on the review forms. Anticipated Completion Date: On 06/03/2025, Supervisor met with staff to discuss the results of the audit and train and review policy and procedure on best practices for processing and maintenance of healthcare cases. This will be an ongoing agenda item at monthly unit meetings.
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