Corrective Action Plans

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3. Finding 2023-003. Fund Balance Management Corrective Action: Previous audit year expenses were classified as “General” funds when they should have classified as “Food Service”. This, in aggregate, has led to an excess fund balance. Management, will work with the state on how to transfer the large...
3. Finding 2023-003. Fund Balance Management Corrective Action: Previous audit year expenses were classified as “General” funds when they should have classified as “Food Service”. This, in aggregate, has led to an excess fund balance. Management, will work with the state on how to transfer the large arrear fund balances between accounts. Management will also endeavor to assure that all ongoing expenses are allocated to the correct fund. Responsible Person/Position: Rod Iberg/COO and Linda Heidrich/Staff Accountant
Community Health Services, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: December 31, 2023 The findings from the December 31, 2023 schedule of findings and questioned costs are...
Community Health Services, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: December 31, 2023 The findings from the December 31, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS Section Ill- Federal Award Findings and Questioned Costs Health Center Program Cluster, Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), COVID - 19 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), Grants for New and Expanded Services under the Health Center Program and COVID-19 Grants for New and Expanded Services under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 Item 2023-00.1 - Special Tests Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated based on family size and income. Repeat Finding Yes Action Taken The Center implemented internal controls to mitigate the risk of missing sliding fee discount documentation. The creation of this control consisted of designing a report that would identify all sliding fee discount applicants for the specified timeframe, as well as identify whether supporting documentation had been scanned into the patient's electronic health record. The Director of Development, Grants and Outreach or the Director of Finance and Grants Administration reviews all slide applications before they are scanned and entered into the electronic health record and applied to the patient's account. The Center will continue monthly internal auditing procedures where an Eligibility Specialist haphazardly selects slide applications from the previous month to ensure compliance. As a result of the repeated finding, the Center created an excel template that will accurately calculate and feed the slide result in effort to minimize manual calculation errors. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Dianna Kulmacz, CFO at (860) 808-8765.
Section Ill- Federal Award Findings and Questioned Costs Health Center Program Cluster, Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), COVID - 19 Health Center Program (Community Health Centers, Migrant Health...
Section Ill- Federal Award Findings and Questioned Costs Health Center Program Cluster, Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), COVID - 19 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), Grants for New and Expanded Services under the Health Center Program and COVID-19 Grants for New and Expanded Services under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 Item 2023-001 - Special Tests Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated based on family size and income. Repeat Finding Yes Action Taken In 2023, IHC implemented each IHC site auditing five accounts per front office staff twice per month that will be reviewed by the Office Manager, Practice Manager, and Director of Operations, with any sliding issues being addressed with the respective front office staff with re­ education. As this has not resolved all the sliding fee issues, IHC will be implementing two-person verification for sliding fees provided for any eligible IHC patient. The following process will be followed for EVERY patient that presents with Proof of Income (POI). A. When a patient presents to the clinic and provides POI upon checking in or completing an Intake appointment, the Front Office Staff (FOS) will make a copy of the documents provided. B. The FOS will then calculate the income based on the POI provided, showing the work on the copy. C. The FOS will initial the document where the calculations were completed. D. They will then get a second person to verify the calculations were completed correctly and initial the document. E. The initial FOS employee will enter the information into the SFS section of the pt's chart. F. There will be a FOS SFS Two-Person Verification Log to track who verified each patients POI. G. The FOS SFS Two-Person Verification Log will be kept in the LMT Teams file for each site. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Mr. Tracy Nagel, CFO at (317) 576-1335. Sincerely yours, Mr. Tracy Nagel, Chief Financial Officer
Establishing a better process for federal contract procurement and prevailing wage requirements. Working with outside consultant to ensure vendors meet the federal compliance requirements as well.
Establishing a better process for federal contract procurement and prevailing wage requirements. Working with outside consultant to ensure vendors meet the federal compliance requirements as well.
Finding No. 2023-003 21.027: COVID - 19: Coronavirus State and Local Fiscal Recovery Funds Personnel Responsible for Corrective Action: Name: Edith Robles Department: Finance Title: Director of Finance Anticipated Completion Date: June 30, 2024 Corrective Action Plan: An adequate subrecipient risk a...
Finding No. 2023-003 21.027: COVID - 19: Coronavirus State and Local Fiscal Recovery Funds Personnel Responsible for Corrective Action: Name: Edith Robles Department: Finance Title: Director of Finance Anticipated Completion Date: June 30, 2024 Corrective Action Plan: An adequate subrecipient risk assessment policy will be put in place to evaluate and monitor subrecipients. Southwest Organizing Project will provide subrecipients with all required Federal awards identifiers. Edith Robles will ensure that Federal award identifiers are included in subrecipients grant agreements.
Finding No. 2023-002 93.391, Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crises Personnel Responsible for Corrective Action: Name: Edith Robles Department: Finance Title: Director of Finance Anticipated Completion Date: ...
Finding No. 2023-002 93.391, Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crises Personnel Responsible for Corrective Action: Name: Edith Robles Department: Finance Title: Director of Finance Anticipated Completion Date: June 30, 2024 Corrective Action Plan: An adequate subrecipients risk assessment policy will be put in place to evaluate and monitor subrecipients. Southwest Organizing Project will provide subrecipients with all required Federal awards identifiers. Subrecipients will be required to provide a single audit when applicable and a signed statement if not applicable. Edith Robles will monitor receipt of single audits during the budgeting process and when closing out programs as well as record keeping for audit and reporting evidence.
The person responsible for corrective action is Rick Martinez, Superintendent. Procedures have been implemented to assure the District has no significant deficiencies in internal controls or noncompliance in the future. The District has hired new personnel in key areas and have sought outside help f...
The person responsible for corrective action is Rick Martinez, Superintendent. Procedures have been implemented to assure the District has no significant deficiencies in internal controls or noncompliance in the future. The District has hired new personnel in key areas and have sought outside help from the Region Service Center. 79
Institutional Comments on Findings and Recommendations: Compliance Requirements – Applicable After a Student Begins Attendance: The institution agrees with the auditors on this finding in which there were two (2) cases where the auditors noted that the institution failed to determine that the stud...
Institutional Comments on Findings and Recommendations: Compliance Requirements – Applicable After a Student Begins Attendance: The institution agrees with the auditors on this finding in which there were two (2) cases where the auditors noted that the institution failed to determine that the students withdrew within fourteen (14) days after the student’s last day of attendance. In one (1) of the two (2) cases the Date of Determination was twenty-two (22) days after the Last Day of Attendance and in the second case, the Date of Determination was Three (3) days after the Last Day of Attendance. All funds due to the Department, (for the first case $682.00 of Unsub. Direct Loan funds and in the second case $974.22 of Federal Pell Grant funds), were returned within the forty-five (45) days required timeframe as of the Date of Determination of each case. This process was evidenced to the auditors for their records. Actions Taken or Planned: The institution is fully aware of the Return of Title IV funds (R2T4) reporting requirements and deadlines. The issue related to this finding was identified as a lack in some Faculty notifying student absences within the fourteen (14) day timeframe to process an R2T4 in a timely manner as required. Although this issue was already discussed with them by the Dean of Academic Affairs, an additional follow up meeting would be held to remind them of the importance in monitoring student attendance and notifying student absences to the Registrar office within the required timeframes to fully comply with the R2T4 reporting requirements. Status of Corrective Actions on Prior Findings: The issue as related to this finding occurred in the past audit.
View Audit 305178 Questioned Costs: $1
Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to disbursing loans within aggregate loan limits. Responsible Administrators: Director of Financial Aid Effective: Immediately and ongoing
Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to disbursing loans within aggregate loan limits. Responsible Administrators: Director of Financial Aid Effective: Immediately and ongoing
Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to competing and submitting the audit. The College has a new CFO and Controller. These measures will ensure stability and a timely audit. Responsible Administ...
Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to competing and submitting the audit. The College has a new CFO and Controller. These measures will ensure stability and a timely audit. Responsible Administrators: Director of Financial Aid & Chief Financial Officer Effective immediately and ongoing
Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to calculating and awarding Pell. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid & Chief Fin...
Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to calculating and awarding Pell. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid & Chief Financial Officer Effective: Immediately and ongoing
View Audit 305169 Questioned Costs: $1
Management concurs with this finding. The College will review and adhere to its practices, policies, and procedures along with federal guidelines as it relates to disbursing and administering federal aid. The College will return any ineligible funds accordingly. Responsible Administrators: Direct...
Management concurs with this finding. The College will review and adhere to its practices, policies, and procedures along with federal guidelines as it relates to disbursing and administering federal aid. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid, Chief Financial Officer & V.P. of Academic Affairs Effective: Immediately and ongoing
View Audit 305169 Questioned Costs: $1
Management concurs with this finding. The College will set policies, procedures and practices in place and adhere to ensure that changes in students’ enrollment are reported accurately and timely as defined in the Federal guidelines. Responsible Administrators: Director of Financial Aid & Regist...
Management concurs with this finding. The College will set policies, procedures and practices in place and adhere to ensure that changes in students’ enrollment are reported accurately and timely as defined in the Federal guidelines. Responsible Administrators: Director of Financial Aid & Registrar Effective: Immediately and ongoing
Management concurs with this finding. The College will review and adhere to its practices, policies, and procedures along with federal regulations as it relates to resolving credit balances. The College will resolve credit balances timely and within the 14-day period as defined in the Federal guid...
Management concurs with this finding. The College will review and adhere to its practices, policies, and procedures along with federal regulations as it relates to resolving credit balances. The College will resolve credit balances timely and within the 14-day period as defined in the Federal guidelines. Responsible Administrators: Director of Financial Aid & Chief Financial Officer Effective: Immediately and ongoing
Views of Responsible Officials and Planned Corrective Action: May 2023 was when FY22 audit was completed and the food service provider had already been selected and utilized by the District. FY24 the District has received food service management company contract. The contract has been board approve...
Views of Responsible Officials and Planned Corrective Action: May 2023 was when FY22 audit was completed and the food service provider had already been selected and utilized by the District. FY24 the District has received food service management company contract. The contract has been board approved.
The Center did not retain the eligibility documentation for one student and there was an incorrect computation for one student. Response and Planned Corrective Action: The Center acknowledges this finding, and will take the steps necessary to ensure that the information in the system is updated regu...
The Center did not retain the eligibility documentation for one student and there was an incorrect computation for one student. Response and Planned Corrective Action: The Center acknowledges this finding, and will take the steps necessary to ensure that the information in the system is updated regularly. Planned Corrective Action: to be implemented immediately. o The Director of Food Service will review the controls currently in place and revise accordingly to ensure that accuracy and completeness of data is maintained. o Proper documentation will be maintained by school staff and will be reviewed regularly by the Director of Food Services and or the Business Manager/Asst. Business Manager.
View Audit 305132 Questioned Costs: $1
Condition: The Center did not receive proper approval for the purchase of capital equipment purchased with grant funds in the current year. Response and Planned Corrective Action: The Center acknowledges this finding, and has since revised its permission process to include the requisite steps as re...
Condition: The Center did not receive proper approval for the purchase of capital equipment purchased with grant funds in the current year. Response and Planned Corrective Action: The Center acknowledges this finding, and has since revised its permission process to include the requisite steps as required by the US DoE (ED) Uniform Grant Guidance (UGG) in its subsequent purchases with Federal Funds. It is also noted that most if not all of these purchases were made after the receipt of delayed guidance from PA Department of Education’s Federal Programs Office. When alerted to the guidance, the Center implemented the proper procedures. Planned Corrective Action: to be implemented immediately. o The Business Manager/Asst. Business Manager will review all federally funded capital requests to ensure that the proper processes are followed in the procurement of bids and quotes.
The Center did not follow the appropriate procedures to comply with Uniform Grant Guidance. During testing, it was noted that the Center made procurements through noncompetitive procurement arrangements. Consistent with 2 CFR § 200.320(c)(3), an LEA may determine that its response to the COVID-19 p...
The Center did not follow the appropriate procedures to comply with Uniform Grant Guidance. During testing, it was noted that the Center made procurements through noncompetitive procurement arrangements. Consistent with 2 CFR § 200.320(c)(3), an LEA may determine that its response to the COVID-19 pandemic qualifies as a public exigency or emergency that does not permit the delay that would result from competitive bidding. Under these circumstances, and to the degree doing so is consistent with its own policies and procedures, the Center could use noncompetitive procurement. The Center should consult with the Pennsylvania Department of Education before using this authority. Subsequently, the Center paid for this purchase utilizing the Education Stabilization Fund and Career and Technical Education monies. In using federal funds to pay for these items, the Center inadvertently did not follow its procurement policy. Response and Planned Corrective Action: The Center acknowledges this finding, and has since revised its procurement process to include the requisite items as required by the US DoE (ED) Uniform Grant Guidance (UGG) in its subsequent purchases with Federal Funds. It is also noted that most if not all of these purchases were made in response to the COVID-19 Pandemic, and with delayed guidance from PA Department of Education’s Federal Programs Office. When alerted to the guidance, the Center implemented the proper procedures. Planned Corrective Action: • When using federal funds, the Business Manager/Asst. Business Manager will ensure that cooperative purchasing programs or noncompetitive purchasing arrangements comply with the UGG procurement policy. • The Business Manager/Asst. Business Manager will document the process and how it complied with the procurement standards and keep such documentation with Federal Award budget/procurement documents.
The Center did not file the required quarterly reports for June 2023 and had a late filing for September 2022 report for grant #224-21-1161. Also, the Center did not file quarterly reports for June 2023 and September 2022 for grant #380-23-0039 and #381-23-0014. Response and Planned Corrective Actio...
The Center did not file the required quarterly reports for June 2023 and had a late filing for September 2022 report for grant #224-21-1161. Also, the Center did not file quarterly reports for June 2023 and September 2022 for grant #380-23-0039 and #381-23-0014. Response and Planned Corrective Action: The Center has implemented a series of reminders in the email and calendar system for the Business Manager, the Assistant Business Manager, and the Administrative Director to ensure that timely submission of the quarterly reporting is completed. Planned Corrective Action: To be implemented immediately. ·         The Business Manager/Asst. Business Manager will establish additional procedures to ensure that the Center files all quarterly cash on hand within 10 days of quarter ending and final expenditure reports within 30 days after the funds are expended, but no later than 30 days after the ending date of the project. ·         This included calendar reminders and follow up and accountability to supervisors at the Center.
Finding 395384 (2023-034)
Significant Deficiency 2023
2023-034 Oregon Department of Emergency Management Fully implement subrecipient risk assessments MANAGEMENT RESPONSE: We agree with this recommendation. ODEM will undertake the following corrective actions to address the recommendations made by the Secretary of State’s Audits Division: a. ODEM wi...
2023-034 Oregon Department of Emergency Management Fully implement subrecipient risk assessments MANAGEMENT RESPONSE: We agree with this recommendation. ODEM will undertake the following corrective actions to address the recommendations made by the Secretary of State’s Audits Division: a. ODEM will continue to develop the risk assessment policy and procedures, including monitoring controls to identify and follow-up with subrecipients that have not completed a risk assessment. b. ODEM will develop an agency wide subrecipient monitoring policy in accordance with 2 CFR 200. This policy will include discussion on how ODEM prioritizes subrecipient monitoring based on the results of the risk assessment. Anticipated Completion Date: December 31, 2024 Contact person: Jeff Flowers, Chief Financial Officer
2023-033 Oregon Department of Emergency Management Implement controls over FFATA reporting MANAGEMENT RESPONSE: We agree with this recommendation. ODEM has undertaken the following corrective actions to address the recommendations made by the Secretary of State’s Audits Division: a. ODEM has dev...
2023-033 Oregon Department of Emergency Management Implement controls over FFATA reporting MANAGEMENT RESPONSE: We agree with this recommendation. ODEM has undertaken the following corrective actions to address the recommendations made by the Secretary of State’s Audits Division: a. ODEM has developed procedures for capturing necessary information and ensuring FFATA reports are filed in compliance with federal criteria. b. ODEM has identified all awards since July 1st 2023 and is working to ensure 100% compliance from that date forward. c. ODEM will continue to review older awards to determine what actions should be taken. Anticipated Completion Date: December 30, 2024. Contact person: Jeff Flowers, Chief Financial Officer
2023-020 Oregon Health Authority Implement controls to ensure subrecipients are appropriately identified and monitored MANAGEMENT RESPONSE: We agree with this recommendation. Contracts and program staff have piloted and implemented tools to help administrators determine if the NFP is a contractor...
2023-020 Oregon Health Authority Implement controls to ensure subrecipients are appropriately identified and monitored MANAGEMENT RESPONSE: We agree with this recommendation. Contracts and program staff have piloted and implemented tools to help administrators determine if the NFP is a contractor or sub-recipient using the determination checklist. Department managers have communicated expectations related to the use of this tool and guidance to ensure that contract administrators understand how to determine if an agency is a contractor or sub-recipient. If determination identifies a subrecipient relationship, controls are in place to ensure the Federal Funding Accountability and Transparency Act (FFATA) form, self-assessment, and monitoring plan are completed. Further, mental health block grant planners will assess each new or amended contract for appropriate designation. OHA management plans to establish a single training for all staff to complete before developing a contract. This training will also include necessary messaging to all staff about terminology, location of resources, expectations as an administrator, and compliance/verification processes. OHA will provide this messaging and training through agency-wide emails, newsletters, and all staff meetings. OHA will continue refining its onboarding to incorporate these trainings and messaging. Additionally, the Office of Financial Services reviews each contract to determine the correct coding for each contracted service/deliverable and accurate code, such in State Financial Management Accounting (SFMA) system. Risk assessment survey has been developed that allows for self-assessment and documentation of the process. Administrators are requested to keep a copy of the assessment in their administrative file. Contract administrators create regularly scheduled meetings with the sub-awardee to monitor for compliance, depending on the risk of the sub-awardee. OHA-HSD has created a planning and implementation document to systematically identify the process of self-assessment and monitoring plan. In addition to the 11-module contract administration training required for all administrators. OHA plans to create an accessible folder for download to include the Contract Administration Plan (CAP), RACI Matrix, Monitoring, and closeout activities. Once all of the resources are socialized throughout the Program and Leadership staff, controls are still necessary to get as close to 100% compliance by the administrators. Controls that will be implemented are: • DocuSign CLM- During the automated workflow for approvals, administrators must verify that the determination document and, if applicable, the self-assessment and monitoring plan is attached. If not, the request will be rejected until the proper documentation is provided. • Team audit- The program analyst will perform random audits of grant/contracts administrator folders to confirm documentation is complete for each grant/contract, including monitoring activities, reports, invoices, and grant compliance requirements. Anticipated Completion Date: September 1, 2024 Contact person: Amy Ashton-Williams, Adult Behavioral Health Director
Finding 395355 (2023-018)
Significant Deficiency 2023
2023-018 Oregon Housing and Community Services Ensure grant management report control is performed and documented MANAGEMENT RESPONSE: We agree with this recommendation. A dedicated staff resource has been trained and has brought grant reconciliations and reporting current. Additional training h...
2023-018 Oregon Housing and Community Services Ensure grant management report control is performed and documented MANAGEMENT RESPONSE: We agree with this recommendation. A dedicated staff resource has been trained and has brought grant reconciliations and reporting current. Additional training has been provided for awareness of the earmarking and obligation requirements as well. Anticipated Completion Date: June 30, 2024 Contact person: Dean Criscola, Controller
Finding 395341 (2023-042)
Significant Deficiency 2023
2023-042 Oregon Department of Education Retain support for pre-approval of equipment purchases MANAGEMENT RESPONSE: We agree with this recommendation. ODE has already developed and implemented updates to the capital expenditure request review and approval process to ensure equipment approvals are...
2023-042 Oregon Department of Education Retain support for pre-approval of equipment purchases MANAGEMENT RESPONSE: We agree with this recommendation. ODE has already developed and implemented updates to the capital expenditure request review and approval process to ensure equipment approvals are retained. Early ESSER capital project tag requests were split between a committee for large projects and the individual grant finance manager. Approvals were primarily sent via email from the grant finance manager. Some of those messages are archived in the ESSER.ODE inbox, however some went out directly from staff email. Records are available for the committee decisions. When the smaller approvals moved from the finance manager to an ESSER team, many of those decisions were made in conjunction with other meetings. Some records are available; however, the Capital Expenditure Tracker was the primary location of decisions. In October 2022, staffing changes allowed the committee and team structure to become more formalized. Committee meeting decisions shifted from a “minute”- style agenda to being more systematized in an online log. Team meeting decisions followed a similar process update in April 2023. The online agenda/log allows for consistent tracking of projects that are up for discussion and which approval are put on hold for elevation approval, correction, or clarification from the district. Committee and team meetings have been established weekly. When all information is received from a district, the project is placed on the appropriate agenda for that week. Approvals are sent out within 2 business days. A column was added to the Capital Expenditure Tracker, which remains the primary location of records, to track when the approval emails were sent. Corrections have already been developed and implemented as of April 2024. Anticipated Completion Date: April 30, 2024 Contact person: Cynthia Stinson, Senior Manager of Federal Investments and Pandemic Renewal Effort
Finding 395340 (2023-041)
Significant Deficiency 2023
2023-041 Oregon Department of Education Improve FFATA reporting controls MANAGEMENT RESPONSE: We agree with this recommendation. ODE will implement the following corrective action to ensure monthly FFATA reports are independently reviewed to ensure accurate and complete reporting. 1. Review and u...
2023-041 Oregon Department of Education Improve FFATA reporting controls MANAGEMENT RESPONSE: We agree with this recommendation. ODE will implement the following corrective action to ensure monthly FFATA reports are independently reviewed to ensure accurate and complete reporting. 1. Review and update list of all FFATA eligible federal awards monthly. 2. Implement a new query tool that will reduce manual processes. 3. Collaborate with ODE partners to access agency-collected unique entity identifier (UEI) information for sub awardees. 4. Monthly review of FFATA reporting by a second accountant. Anticipated Completion Date: June 30, 2024 Contact person: Kristie Miller, Accounting Director
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