Corrective Action Plans

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Finding 478311 (2021-008)
Significant Deficiency 2021
Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The general accounting policy will be updated for the accountant to check the payroll register to accrue retroactive pay changes to the correct period. The payroll policy...
Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The general accounting policy will be updated for the accountant to check the payroll register to accrue retroactive pay changes to the correct period. The payroll policy will also be updated to require that timecards be updated with supervisor signature if changes are made to change allocation to another fund. Planned Implementation Date: June 30, 2024 Responsible Person(s): City Controller
Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The City Controller's Office drafted a grants policy that is currently under review by City Management. Community development staff will ensure a succession plan is in pl...
Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The City Controller's Office drafted a grants policy that is currently under review by City Management. Community development staff will ensure a succession plan is in place for any staff turnover and for report preparation compliance. Planned Implementation Date: December 31, 2024 Responsible Person(s): City Manager, Community Development Director, and City Controller
Finding 406040 (2021-003)
Significant Deficiency 2021
Finding No. 2021-003 – Reporting - Late filing of data collection form and reporting package Corrective Action Plan Commencing immediately, Mr. José R. Rodríguez, Accounting Manager, will be the designated officer in charge of concluding all necessary procedures, including the audit of financial sta...
Finding No. 2021-003 – Reporting - Late filing of data collection form and reporting package Corrective Action Plan Commencing immediately, Mr. José R. Rodríguez, Accounting Manager, will be the designated officer in charge of concluding all necessary procedures, including the audit of financial statements and single audit, for the Hospital to file its reporting package within it´s due date, as required by the CFR. Also, Mr. Julio Colón, Chief Financial Officer, will be the designated officer in charge of supervising and monitoring compliance with timely submittance each year. Name (s) of the Contact Person (s) Responsible for Corrective Action Mr. Julio Colón, Chief Financial Officer Anticipated Completion Date December 2024
Finding 406039 (2021-002)
Significant Deficiency 2021
Finding No. 2021-002 - Reporting Corrective Action Plan On July 29, 2022, all pending reports were submitted to AAFAF. Also, commencing immediately, Mr. José R. Rodríguez, Accounting Manager, will be de designated officer in charge of submitting the report by its due date and Mr. Julio Colón, Chief ...
Finding No. 2021-002 - Reporting Corrective Action Plan On July 29, 2022, all pending reports were submitted to AAFAF. Also, commencing immediately, Mr. José R. Rodríguez, Accounting Manager, will be de designated officer in charge of submitting the report by its due date and Mr. Julio Colón, Chief Financial Officer, will be de designated officer in charge of supervising and monitoring compliance with timely submittance each month. Name (s) of the Contact Person (s) Responsible for Corrective Action Julio Colón, Chief Financial Officer Anticipated Completion Date Completed on July 29, 2022
Finding 406038 (2021-001)
Significant Deficiency 2021
Finding No. 2021-001 - Activities Allowed or Unallowed - Hazard Pay Eligibility Corrective Action Plan On March 2, 2022, payments to ineligible employees were recharacterized as additional compensation paid from the Entity’s own resources, instead of federal awards. Such federal awards remain availa...
Finding No. 2021-001 - Activities Allowed or Unallowed - Hazard Pay Eligibility Corrective Action Plan On March 2, 2022, payments to ineligible employees were recharacterized as additional compensation paid from the Entity’s own resources, instead of federal awards. Such federal awards remain available for use under other assistance programs provided by the CARES Act through December 2020. Name (s) of the Contact Person (s) Responsible for Corrective Action Julio Colón, Chief Financial Officer Anticipated Completion Date Completed on March 2, 2022
County Judge/Executive’s Response: The Fiscal Court has contracted with Compass to ensure are compliant.
County Judge/Executive’s Response: The Fiscal Court has contracted with Compass to ensure are compliant.
As established in the SA 2020 Corrective Action Plan, the OPPEA established a process to adapt to the reality of the office. The OPPEA implemented a Risk Assessment System. The actions taken by management regarding monitoring are based on a review of the policies and processes to carry out the monit...
As established in the SA 2020 Corrective Action Plan, the OPPEA established a process to adapt to the reality of the office. The OPPEA implemented a Risk Assessment System. The actions taken by management regarding monitoring are based on a review of the policies and processes to carry out the monitoring of subrecipients. Risk monitoring will be carried out to minimize evaluation efforts in the follow-up. With the purpose of streamlining their process and ensuring that they are completed effectively in less time. Some Risk categories were established so that in the event that a Monitor finds as a result of its evaluation that said project represents a risk in the management of funds, a more in-depth Monitoring can be carried out.
Public Health agrees with the recommendation. We will establish formal procedures for conducting risk assessments of our subrecipients. Public Health will also develop and implement specific subrecipient monitoring procedures and establish a process for obtaining single audit reports from out subrec...
Public Health agrees with the recommendation. We will establish formal procedures for conducting risk assessments of our subrecipients. Public Health will also develop and implement specific subrecipient monitoring procedures and establish a process for obtaining single audit reports from out subrecipients. Finally, we will develop a monitoring mechanism to track subrecipients' compliance with the single audit mandate. Estimated Implementation Date: December 2024 Contact: Melissa Relles, Assistant Deputy Director Division of Operations Center for Preparedness and Response California Department of Public Health
Finding 402375 (2021-013)
Significant Deficiency 2021
Health Care Services understands the finding that amounts identified in the single audit as Medicaid and CHIP “pass through payments to subrecipients” could be subject to the FFATA. Pursuant to Office of Management and Budget (OMB) Guidance, Title 2 of the CFR, Parts 170 and 200.1, and the OMB Comp...
Health Care Services understands the finding that amounts identified in the single audit as Medicaid and CHIP “pass through payments to subrecipients” could be subject to the FFATA. Pursuant to Office of Management and Budget (OMB) Guidance, Title 2 of the CFR, Parts 170 and 200.1, and the OMB Compliance Supplement, a subrecipient is an entity “that receives a subaward from a pass-through entity to carry out part of a Federal award,” and a subaward “does not include payments to a contractor or payments to an individual that is a beneficiary of a Federal Program.” Health Care Services will review current practices for managing subawards and payment classifications to ensure payments subject to FFATA are appropriately reported and update current practices as applicable by June 2024. Estimated Implementation Date: June 2024 Contact: Wendy Griffe, Chief Internal Audits California Department of Health Care Services
Finding 402372 (2021-012)
Significant Deficiency 2021
The Department of Aging (Aging) is committed to rectifying this issue and coming into compliance with this reporting requirement effective now. Aging has reworked the roles and responsibilities within the Budget Operations Bureau to ensure that there is a dedicated staff person to enter all FFATA re...
The Department of Aging (Aging) is committed to rectifying this issue and coming into compliance with this reporting requirement effective now. Aging has reworked the roles and responsibilities within the Budget Operations Bureau to ensure that there is a dedicated staff person to enter all FFATA reporting within the required timeframe. This individual has been trained and made aware of the expectations. Aging has begun updating the FFATA records and will continue this effort through the month of March until all reporting has been completed. Moving forward, the dedicated staff person will update the FFATA for each new federal funding award within the required timeframe. Estimated Implementation Date: March 2023 Contact: Kim Elliott, Chief Budget Officer Division of Administrative Services California Department of Aging
The Office of AIDS (OA) agrees with the finding and recommendation. OA developed and implemented additional, internal quality assurance (QA) processes in April of 2022 to ensure that secondary reviews of AIDS Drug Assistance Program (ADAP) applications are consistently enforcing the existing guideli...
The Office of AIDS (OA) agrees with the finding and recommendation. OA developed and implemented additional, internal quality assurance (QA) processes in April of 2022 to ensure that secondary reviews of AIDS Drug Assistance Program (ADAP) applications are consistently enforcing the existing guidelines, including acceptable supporting documentation and accurate eligibility requirements. During this audit period, and through December 2021, ADAP had issued multiple policy memos to respond to the COVID-19 pandemic, which enabled staff and enrollment workers to defer documentation collection, when necessary, to remain flexible and ensure clients impacted by the pandemic, and associated site closures, did not lose eligibility and access to life saving medications and comprehensive healthcare. These flexibilities in our guidelines were implemented based on guidance received from our federal funder, Health Resources and Services Administration (HRSA), which encouraged ADAPs to reassess their organization's eligibility and recertification policies and procedures, and remove any barriers that may impede social distancing, or other public health strategies, necessary to minimize COVID-19 transmission. This documentation deferral was terminated on December 31, 2021, and since January 1, 2022, full documentation and eligibility requirements have been enforced. This, combined with ongoing QA efforts, will help to mitigate future findings in ADAP applications dated January 1, 2022 onward. Estimated Implementation Date: Already implemented as of April 2022 Contact: Sharisse Kemp, Branch Chief AIDS Drug Assistance Program Branch California Department of Public Health
Reference No. 2021-010: Health Care Services agrees with the finding. The U.S. Centers for Medicare and Medicaid Services (CMS) has confirmed the continuous enrollment requirement is now delinked from the Public Health Emergency (PHE) in the Consolidation Appropriations Act of 2023, (enacted Decemb...
Reference No. 2021-010: Health Care Services agrees with the finding. The U.S. Centers for Medicare and Medicaid Services (CMS) has confirmed the continuous enrollment requirement is now delinked from the Public Health Emergency (PHE) in the Consolidation Appropriations Act of 2023, (enacted December 29, 2022), which ends on March 31, 2023. Health Care Services will begin the continuous coverage requirement unwinding activities, including the resumption of renewals, on April 1, 2023. Per the current county oversight timeline established within the California Advancing and Innovating Medi-Cal (CalAIM) implementation timeline, the resumption of oversight and monitoring activities shall begin 14 months after the onset of continuous coverage requirement unwinding activities; therefore, the new implementation date to initiate these activities is May 1, 2024. Estimated Implementation Date: May 1, 2024 Contact: Wendy Griffe, Chief Internal Audits California Department of Health Care Services
View Audit 309913 Questioned Costs: $1
Finding 402368 (2021-009)
Significant Deficiency 2021
Office of AIDS (OA) agrees with the finding and has implemented solutions to meet the auditor's recommendation. OA has already taken steps to remedy the issue by using its Support Branch to realign staff and responsibilities to allow for a greater focus on fiscal reporting and invoice processing. T...
Office of AIDS (OA) agrees with the finding and has implemented solutions to meet the auditor's recommendation. OA has already taken steps to remedy the issue by using its Support Branch to realign staff and responsibilities to allow for a greater focus on fiscal reporting and invoice processing. The Care Branch has also put an increased emphasis on tracking and reviewing invoices for payment to prevent similar delays. Subsequently, the Ryan White Grant closeouts had all invoices processed and paid prior to the Federal Financial Report closeout deadlines to ensure that drawn cash for invoices was not held for extended timeframes. Estimated Implementation Date: July 1, 2021 Contact: Joseph Gonzales, Branch Chief Office of AIDS Support Branch California Department of Public Health
Health Care Services agrees with the recommendation and implemented corrective action by October 31, 2022. Health Care Services, or DHCS, published Behavioral Health Information Notice (BHIN) 22-045 which outlines Health Care Services sanctions policy. The BHIN states “Under state and federal law D...
Health Care Services agrees with the recommendation and implemented corrective action by October 31, 2022. Health Care Services, or DHCS, published Behavioral Health Information Notice (BHIN) 22-045 which outlines Health Care Services sanctions policy. The BHIN states “Under state and federal law DHCS must enforce compliance with the terms of the DHCS’ contracts with Mental Health Plans and Drug Medi-Cal Organized Delivery System counties, as well as ensure compliance with applicable state and federal laws and regulations, in accordance with its authority and obligations under state and federal requirements.” Lastly, under the section titled ‘Exhibit A - Attachment 3’ of the County Mental Health Plan Contract counties are required to submit cost reports timely which would allow Health Care Services to impose sanctions on counties who do not submit cost reports in a timely manner. This BHIN resolves the finding. Additionally, Health Care Services will not be collecting cost reports for dates of service after State Fiscal Year 2022-23. Under the California Advancing and Innovating Medi-Cal (CalAIM) initiative, and pursuant to Welfare and Institutions Code, Section 14184.403(b), Health Care Services will replace the current Certified Public Expenditures (CPE) reimbursement methodology with an intergovernmental transfer (IGT) reimbursement methodology. The IGT reimbursement methodology will make a single and final payment for services provided to the county, which includes the non-federal portion of the claims. This change will eliminate the requirement for the county submission of cost reports. Estimated Implementation Date: October 31, 2022 Contact: Wendy Griffe, Chief Internal Audits California Department of Health Care Services
Finding 402363 (2021-007)
Significant Deficiency 2021
California Business, Consumer Services and Housing Agency (BCSH) The California Interagency Council on Homelessness (Cal ICH), an entity under the BCSH, would like to acknowledge a finding from the fiscal year 2020-21 Statewide Federal Compliance Audit of the State of California. This audit finding...
California Business, Consumer Services and Housing Agency (BCSH) The California Interagency Council on Homelessness (Cal ICH), an entity under the BCSH, would like to acknowledge a finding from the fiscal year 2020-21 Statewide Federal Compliance Audit of the State of California. This audit finding identifies lack of communication of required subaward information to Cal ICH subrecipients of the Coronavirus Relief Fund (CRF) program at the time of the subaward, or when the State became aware of changes in subaward information, including identification that the subaward funds represented federal funding. Cal ICH agrees with this finding and the recommendation to review all subawards provided which were funded using CRF program funds and determine whether the subrecipients properly reported their CRF awards and related expenditures in their respective schedule of expenditures of federal awards pursuant to Title 2 Code of the Federal Regulations 200.502. Additionally, while formal communication identifying that the subaward fund represented federal funding was not provided, many informal conversations were had with CRF grantees. These conversations were held during bi-weekly online Office Hours and through one-on-one calls with individual subrecipients and discussions of the substitution of federal awards with grantees originally provided with State funds could have occurred. Cal ICH will conduct review of the CRF subawards during mandatory desk reviews to verify that subrecipients properly reported their CRF awards and that expenditures of the federal awards were made pursuant to Title 2 Code of Federal Regulations 200.502. Additionally, Cal ICH has developed an improved communication system between leadership and program staff that will ensure changes are clearly communicated. This will also ensure the Council’s subrecipients are notified in a timely manner upon any changes in subaward information, such as identifying if subaward funds represent federal funding so that expenditures are spent in accordance with Federal statutes, regulations, and the terms and conditions of federal awards. Additionally, if in the future funding is changed, CDE will provide updated information to all recipients; this will ensure that expenditures are in line with the terms and conditions of the grant and/or funding source. Estimated Implementation Date: May 2023 Contact: Ellen Meuchel, Monitoring Unit Cal ICH Grant Operations and Suppor California Department of Education Concur. Education will review the relevant subawards funded under the CRF program and determine whether the subrecipients properly reported their CRF awards pursuant to 2 CFR 200.501. Estimated Implementation Date: July 31, 2023 Contact: Kelly Levario, External Audits Coordinator Audits and Investigations Division California Department of Social Services The California Department of Social Services (CDSS) acknowledges the Single Audit finding regarding the delayed communication of subaward information to the Department’s subrecipients of the Coronavirus Relief Fund (CRF) program. On December 21, 2022, CDSS released County Fiscal Letter 22/23-31 on the subject of “Federal Coronavirus Relief Funds That Replaced General Fund for COVID-19 Related Activities for Fiscal Years 2019-20 and 2020-21” to County Welfare Departments (CWDs) and federally recognized Tribal governments in California. This letter served as a formal documentation of the portion of expenditures that were funded with federal CRF. Additionally, although formal notice was not provided until December 21, 2022, informal notices and conversations took place between CDSS and the County Welfare Directors Association, as well as with CWDs, regarding possible situations in which the substitution of federal awards with grants originally provided with State funds could occur. On September 21, 2021, CDSS sent a notice to subrecipients requesting for their Data Universal Number System for the purpose of CRF federal subawards; thereby, communicating the use of CRF on the subrecipients’ behalf. CDSS will conduct a review of the CRF subawards during on-site fiscal monitoring reviews to verify that subrecipients properly reported their CRF awards and that expenditures of the federal awards were made pursuant to Title 2 Code of Federal Regulations 200.502. Moreover, CDSS will ensure that the Department’s subrecipients are notified in a timely manner upon any changes in subaward information, such as identifying if subaward funds represent federal funding so that expenditures are spent in accordance with Federal statutes, regulations, and the terms and conditions of federal awards. Estimated Implementation Date: April 2023 through June 2024 Contact: Elisa Tsujihara, Chief Fiscal Policy and Analysis Bureau
Public Health’s Accounting Office will generate the FI$Cal Year End Close report (KK_12 expenditure) and collaborate with the ELC program to ensure that all expenditures captured are complete and accurate, ensuring timely reporting of the SEFA data for FY 2023-24 and beyond. Additionally, we will up...
Public Health’s Accounting Office will generate the FI$Cal Year End Close report (KK_12 expenditure) and collaborate with the ELC program to ensure that all expenditures captured are complete and accurate, ensuring timely reporting of the SEFA data for FY 2023-24 and beyond. Additionally, we will update the procedures to document the SEFA reporting for the ELC program.
Recommendation: We recommend the College implement a suspension and debarment policy and corresponding procedures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College currently follows its internal control ...
Recommendation: We recommend the College implement a suspension and debarment policy and corresponding procedures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College currently follows its internal control policies to document verification of vendors who may be listed in SAM for suspension and debarment. The College approved an updated procurement policy effective November 7, 2020, to adhere to Uniform Guidance. The College will strengthen (include) the suspension and debarment section to include a policy specific to Debarment and Suspension. Name of the contact person responsible for corrective action: Reatha Tom, Accounts Payable Specialist, and Clarissa Salhus, Finance Manager Planned completion date for corrective action plan: December 31, 2024
Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority will ensure annual audits are conducted and timely electronic submissions of GAAP-based unaudited and audited financial information to HUD through the F...
Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority will ensure annual audits are conducted and timely electronic submissions of GAAP-based unaudited and audited financial information to HUD through the FASS-PH system. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director
Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority provided training to necessary staff and will discuss with the third party management company to ensure compliance with 24 CFP 982.516 in the future. Pl...
Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority provided training to necessary staff and will discuss with the third party management company to ensure compliance with 24 CFP 982.516 in the future. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director
Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority will maintain proper monitoring, communication and control activities to ensure adherence to the Authority’s key administrative policies including procu...
Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority will maintain proper monitoring, communication and control activities to ensure adherence to the Authority’s key administrative policies including procurement, occupancy and the HCV administrative plan. Additionally, management will have the Board approve all policies and procedures adopted and communicate them with the third party company that manages the Authority’s Housing Choice Voucher and Mainstream Voucher programs. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director
Finding 2021-001 – Reporting - Submission of the Data Collection Form Contact: Terry L. Weaver, CFO Telephone Number: (301) 539-3629 Estimated Completion Date: June, 2024 Charles County Nursing and Rehabilitation Center, Inc. hereby acknowledges the Organization’s audit reporting package was not ...
Finding 2021-001 – Reporting - Submission of the Data Collection Form Contact: Terry L. Weaver, CFO Telephone Number: (301) 539-3629 Estimated Completion Date: June, 2024 Charles County Nursing and Rehabilitation Center, Inc. hereby acknowledges the Organization’s audit reporting package was not submitted by the filing deadline of September 30, 2022. The Organization will file the reporting package shortly after issuance and ensure that any future audits are completed and filed timely, by working closely with our audit partner and frequently accessing the substantive status, stage of completion or any other pertinent aspect of the audit necessary to meet the filing deadline. Anticipated Completion Date The Organization anticipates submission of the audit and data collection form immediately upon completion on May 16, 2024.
Finding 399397 (2021-007)
Material Weakness 2021
The County will establish policies and procedures to create better communication between the Emergency Manager and the County Officers.
The County will establish policies and procedures to create better communication between the Emergency Manager and the County Officers.
Finding 2021-006 Compliance Requirement: Special Tests and Provisions – Sliding Fee Discounts Material Weakness Assistance Living Number 93.224 Health Center Programs Grant Award Number H80CS00112 U.S. Department of Human Services Condition: Supporting documents could not be located for four of...
Finding 2021-006 Compliance Requirement: Special Tests and Provisions – Sliding Fee Discounts Material Weakness Assistance Living Number 93.224 Health Center Programs Grant Award Number H80CS00112 U.S. Department of Human Services Condition: Supporting documents could not be located for four of the thirty patients selected for testing. As such, we were unable to determine eligibility. Action Planned in Response to the Finding: Effective immediately, the revenue cycle team will implement and monitor procedures to ensure that all supporting documents are kept for determining sliding fee discounts and patient eligibility. Official Responsible for Ensuring the CAP: Becky Howard Planned Completion Date: June 30th, 2024
MANAGEMENT’S CORRECTIVE ACTION PLANS Finding 2021-001: Noncompliance over Earmarking We agree with the auditors comments. Although much of the difficulty with establishing work-experience training for Youth was related to pandemic-driven restrictions on in-person work and slowdowns or freezes on ...
MANAGEMENT’S CORRECTIVE ACTION PLANS Finding 2021-001: Noncompliance over Earmarking We agree with the auditors comments. Although much of the difficulty with establishing work-experience training for Youth was related to pandemic-driven restrictions on in-person work and slowdowns or freezes on hiring that were commonplace during the period July 1, 2020 through June 30, 2021, our progress in improving performance against that target show it can be possible. (To that effect, note that Youth PY20 Total Program Expenditures at June 30, 2021 were $763,817 and Work Experience was $169,009 = 22.13%). Effective April 27, 2021, the Report Cards used by Local Board staff to evaluate sub-grantees and communicate their successes and deficiencies was modified to add Work Experience expenditures and make it worth 10/25 points in the financial section towards their final score. This made WEX spending part of the review every month and conversation every quarter and made it impossible to score in the top tier without also meeting the WEX target, which is set at 25% for each service provider. Additional technical assistance was provided June 24, 2021 for all youth service providers, led by EPG’s Director, Program Performance & Data Quality to clarify the requirements and provide guidance on how programs might be realigned to increase their focus on work experience activities. EPG believes these efforts will be reflected in program performance in fiscal year 2022. The above corrective action plans have been confirmed by management of Employ Prince George's, Inc. __________________________________ Jeffrey Dufresne Chief Financial Officer
View Audit 306272 Questioned Costs: $1
The School's SF 425 reports are currently up to date and are being submitted in a timely manner to our Superintendent for review then sent on to the BIE Grants Specialist.
The School's SF 425 reports are currently up to date and are being submitted in a timely manner to our Superintendent for review then sent on to the BIE Grants Specialist.
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