Corrective Action Plans

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Name of auditee: Hollywood West Tenant Action Committee HUD auditee identification number: 122-44641 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2024 CAP prepared by Name: Noel Sweitzer Position: President, HDSI Management, Inc. Telephone number...
Name of auditee: Hollywood West Tenant Action Committee HUD auditee identification number: 122-44641 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2024 CAP prepared by Name: Noel Sweitzer Position: President, HDSI Management, Inc. Telephone number: (323) 231-1104 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Statement of condition 2024-003: The Corporation did not furnish HUD with a complete annual financial report within ninety (90) days following the year ended June 30, 2024. Recommendation: The Corporation should ensure the annual financial report is filed within 90 days of year end. Action(s) taken or planned on the finding: The audited financial statements have been submitted to HUD. No further action is required.
Name of auditee: Hollywood West Tenant Action Committee HUD auditee identification number: 122-44641 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2024 CAP prepared by Name: Noel Sweitzer Position: President, HDSI Management, Inc. Telephone number...
Name of auditee: Hollywood West Tenant Action Committee HUD auditee identification number: 122-44641 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2024 CAP prepared by Name: Noel Sweitzer Position: President, HDSI Management, Inc. Telephone number: (323) 231-1104 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Statement of condition 2024-002: The Corporation has not submitted audited financial statements to the Federal Audit Clearinghouse after the receipt of the auditor's reports. Recommendation: The Corporation should submit audited financial statements to the Federal Audit Clearinghouse within the time frames required. Action(s) taken or planned on the finding: The audited financial statements will be submitted to the Federal Audit Clearinghouse on a go forward basis.
Name of auditee: Hollywood West Tenant Action Committee HUD auditee identification number: 122-44641 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2024 CAP prepared by Name: Noel Sweitzer Position: President, HDSI Management, Inc. Telephone number...
Name of auditee: Hollywood West Tenant Action Committee HUD auditee identification number: 122-44641 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2024 CAP prepared by Name: Noel Sweitzer Position: President, HDSI Management, Inc. Telephone number: (323) 231-1104 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Statement of condition 2024-001: During the year ended June 30, 2024, the Corporation did not make the required deposits to the reserve for replacements in the amount of $12,747. Recommendation: Management should request approval from HUD for a transfer from the residual receipt account to the reserve for replacement account in the amount of $8,498 to correct the error. Management should also make the additional deposit of $4,249 or request a suspension of deposits from HUD. Action(s) taken or planned on the finding: Management has requested approval from HUD to transfer the funds to the reserve for replacement account and will make the additional deposit during the year ended June 30, 2025.
Management acknowledges that this finding was also reported in the prior fiscal year. Due to staffing changes within the finance department and competing operational priorities, the corrective actions previously planned were not fully implemented in time to ensure timely filing of the required repor...
Management acknowledges that this finding was also reported in the prior fiscal year. Due to staffing changes within the finance department and competing operational priorities, the corrective actions previously planned were not fully implemented in time to ensure timely filing of the required reports. Management recognized the importance of timely regulatory filings and has taken additional steps to strengthen internal processes and oversight. Significant staff turnover within the finance department during and after the audit period resulted in delays in preparing audit schedules and supporting documentation required for the completion of the related regulatory filings. In addition, formalized procedures and a compliance calendar for regulatory reporting deadlines were not fully implemented during the prior year. Finance Management will implement a financial compliance calendar to track all required regulatory reporting deadlines, including IRS Form 990, single audit and other financial reports. The calendar will include preparation, review, and submission deadlines to ensure reports are completed and filed in time. Finance management will coordinate with external auditors and tax preparers to support timely completion of filings. Responsible party: Finance Management Target Completion Date: June 30, 2026 Monitoring: The Finance Director will maintain and review the compliance calendar monthly to monitor upcoming deadlines and filing status. The CFDO will periodically review compliance with reporting requirements to ensure filings are completed within required timeframes.
Management acknowledges this finding and recognizes the importance of maintaining adequate internal control over the preparation and review of accounting records. This finding was also reported in the prior fiscal year, however due to turnover within key finance leadership roles and limited staff ca...
Management acknowledges this finding and recognizes the importance of maintaining adequate internal control over the preparation and review of accounting records. This finding was also reported in the prior fiscal year, however due to turnover within key finance leadership roles and limited staff capacity and expertise during the audit period, the previously planned corrective actions were not fully implemented. While improvement began toward the end of Fiscal Year 2025 (FY25), management acknowledges that the implementation of strengthened internal control procedures will continue into Fiscal Year 2026 (FY26), as the newly established finance team further develops and formalizes these processes. The Finance Department experienced turnover within key finance leadership roles, which limited the department's capacity and expertise necessary to implement the corrective actions and process improvements identified in the prior year audit. The organization has since strengthened the finance department by hiring additional staff to support the implementation of improved internal controls, formalized procedures, and regulatory reporting processes. Finance leadership has implemented additional review procedures over the preparation of the accounting records including supervisory review of journal entries, documented monthly account reconciliations and a standardized month-end checklist. These procedures will help ensure accounting records are accurate, complete and reviewed timely. While improvements begin during the end of FY25, full implementation of these process improvements will continue into FY26 to ensure sustainable internal control practices and timely regulator reporting. Responsible party: Finance Management Target Completion Date: June 30, 2026 Monitoring: Management reviews the month end close calendar monthly to ensure all reconciliation, journal entries, and reporting are completed and documented. Finance management also reviews monthly financials with the program leaders during soft close.
Finding Number: 2024-002 Finding Title: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Program: 21.027 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Daniel Rahkola, Division Director Finance Corrective Acti...
Finding Number: 2024-002 Finding Title: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Program: 21.027 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Daniel Rahkola, Division Director Finance Corrective Action Planned: The County will review program-related costs to ensure compliance with applicable grant requirements and to confirm that all costs are allowable, allocable, and properly supported. Supporting documentation must sufficiently demonstrate the allowability of each cost. This review will include the following: • Submitted payroll reports that detail individual hours worked, descriptions of work performed, and a clear link between the work performed and allowable grant program activities. • General ledger reports that support each cost and clearly document the relationship between the expenditure and allowable grant program expenses. Anticipated Completion Date: June 30, 2026
FINDING 2024-004 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Pamela J. Beck Flora Clerk-Treasurer Contact Phone Number and Email Address: 574-967-4844 clerktreasurer@townofflora.org Views of Responsible O...
FINDING 2024-004 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Pamela J. Beck Flora Clerk-Treasurer Contact Phone Number and Email Address: 574-967-4844 clerktreasurer@townofflora.org Views of Responsible Officials: Option 1: “We concur with the finding.” . Description of Corrective Action Plan: Follow internal controls to obtain a second internal signature for Federal reports. Anticipated Completion Date: 12-1-2025
FINDING 2024-003 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Contact Person Responsible for Corrective Action: Pamela J Beck- Flora Clerk-Treasurer Contact Phone Number and Email Address: 574-967-4844 clerktreasurer@townofflora.org Views o...
FINDING 2024-003 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Contact Person Responsible for Corrective Action: Pamela J Beck- Flora Clerk-Treasurer Contact Phone Number and Email Address: 574-967-4844 clerktreasurer@townofflora.org Views of Responsible Officials: Option 1: “We concur with the finding.” Description of Corrective Action Plan: I will going forward use the verification of the System for Award management Excluded parties List System or include appropriate provisions in the contract. Anticipated Completion Date: Effective 12/2/2025, I will verify, as needed, to make sure vendors have not been suspended or disbarred via the SAM EPLS database.
The Academy learned of deficiencies pertaining to allowable indirect costs during the 2024 calendar year, at which time, after consultation with the funder, changes were made to the policies for calculation of indirect costs for the grant.
The Academy learned of deficiencies pertaining to allowable indirect costs during the 2024 calendar year, at which time, after consultation with the funder, changes were made to the policies for calculation of indirect costs for the grant.
The Corporation will take the following corrective actions: • Compliance Calendar Implementation - Develop a formal compliance calendar including all Uniform Guidance reporting deadlines. • Designated Reporting Oversight - Assign a responsible management-level individual to monitor timely submission...
The Corporation will take the following corrective actions: • Compliance Calendar Implementation - Develop a formal compliance calendar including all Uniform Guidance reporting deadlines. • Designated Reporting Oversight - Assign a responsible management-level individual to monitor timely submission of federal reporting requirements. • Financial Close Acceleration - Improve internal financial close timelines to meet audit deadlines. • Monitoring and Reporting - Provide periodic updates to executive management regarding compliance status. • Staffing Structure Enhancement – Continue strengthening the finance and budget department structure to improve compliance. Jesús A. Rodríguez Avilés – Financial Planning and Analysis Director Anticipated Completion date June 30, 2026
Corrective Action Plan • Policies and Procedures Reinforcement – Review and reinforce procurement policies to ensure all purchases are supported by approved requisitions and required quotations. • Documentation Retention Controls - Implement controls to ensure all procurement documentation is proper...
Corrective Action Plan • Policies and Procedures Reinforcement – Review and reinforce procurement policies to ensure all purchases are supported by approved requisitions and required quotations. • Documentation Retention Controls - Implement controls to ensure all procurement documentation is properly filed and retrievable. • Staff Training and Development – Provide training on procurement requirements under uniform guidance. This training will focus on compliance with policies and procedures and emphasize the importance of require documentation for each process and best practices. • Monitoring and Compliance Review - Establish periodic internal review procedures to ensure adherence to procurement policies. Name of the contact person responsible for corrective action plan Jesús A. Rodríguez Avilés – Financial Planning and Analysis Director Anticipated Completion date June 30, 2025
Corrective Action Plan The Corporation will take the following corrective actions: • Financial Close Acceleration – The Corporation is aligning its accounting closing expectations for the issuance of its financial statements according to the Secretary of the Department of Treasury deadlines. Therefo...
Corrective Action Plan The Corporation will take the following corrective actions: • Financial Close Acceleration – The Corporation is aligning its accounting closing expectations for the issuance of its financial statements according to the Secretary of the Department of Treasury deadlines. Therefore, the accounting close processes are being improved in order to be completed by September of each fiscal year and issue the Single Audit on or before March 31 of the following fiscal year (nine months after each year end). • Compliance Calendar Implementation – Develop a formal compliance calendar to close its accounting books on September 30 and issuing the financial statements by March 31. Name of the contact person responsible for corrective action plan Jesús A. Rodríguez Avilés – Financial Planning and Analysis Director Anticipated Completion date March 31, 2027
Finding Number: 2024-003 Planned Corrective Action: Medina County acknowledges the deficiencies identified related to procurement documentation and suspension and debarment compliance under the Federal Transit Cluster. To address these issues, the County has implemented the following corrective acti...
Finding Number: 2024-003 Planned Corrective Action: Medina County acknowledges the deficiencies identified related to procurement documentation and suspension and debarment compliance under the Federal Transit Cluster. To address these issues, the County has implemented the following corrective actions: 1. Suspension and Debarment Verification Controls Effective immediately, prior to execution of any covered transaction funded in whole or in part with federal funds that is expected to equal or exceed $25,000, the Transit Department will verify vendor eligibility by performing a search of the System for Award Management (SAM.gov). Evidence of the SAM search, including the date performed and results, will be retained in the procurement file. In addition, all federally funded procurement contracts will include a standard suspension and debarment certification clause, or alternatively, a signed vendor certification will be obtained and retained when applicable. 2. Standardized Procurement Documentation The County will implement a standardized procurement checklist to be completed for all Transit procurements. This checklist will require documentation of: o The rationale for the method of procurement o The basis for contractor selection or rejection o The selection of contract type o The basis for contract price Completed checklists and supporting documentation will be maintained as part of the official procurement file in accordance with 2 CFR § 200.318 and the Medina County Transit Purchasing Policies and Procedures Manual. 3. Supervisory Review and Oversight The Transit Director, or designee, will perform a documented supervisory review of each procurement file prior to contract execution to ensure all required federal and County documentation is complete. No procurement will proceed without evidence of this review. 4. Training and Accountability Staff involved in Transit procurement activities will receive refresher training on federal procurement requirements, including suspension and debarment and procurement documentation standards. Compliance with these procedures will be monitored on an ongoing basis. Anticipated Completion Date: Implemented immediately and fully operational by March 31, 2026 Responsible Contact Person: Shannon Rine, Transit Director
H. Period of Performance Timely Payment of Financial Obligations Assistance Listing 93.959: Block Grants for Substance Use Prevention, Treatment, and Recovery Services Federal Agency: Department of Health and Human Services Recommendation: As the grant period has ended, we recommend that the Corpora...
H. Period of Performance Timely Payment of Financial Obligations Assistance Listing 93.959: Block Grants for Substance Use Prevention, Treatment, and Recovery Services Federal Agency: Department of Health and Human Services Recommendation: As the grant period has ended, we recommend that the Corporation works with the funding agency to remedy the period of performance noncompliance. In addition, we recommend that the Corporation reassess the design of its period of performance controls to identify where enhancement or additional controls are needed over liquidation of financial obligations subsequent to the end of a grant award. Explanation of disagreement with audit finding: There is no disagreement with the finding and recommendation. Action planned/taken in response to finding: The Corporation went live on its new ERP system in April 2024. Since go-live, management has continued to optimize the system and find ways to strengthen our internal controls, including automating certain processes. Management will continue to educate all grant managers on (1) the reporting capabilities within the system that can be utilized in the execution of monitoring payment status on individual invoices that have been submitted to granting agencies for reimbursement, and (2) the requirement to use their grant specific general ledger coding when orders are placed with vendors that are set up under the Corporation’s group purchasing process. For the specific vendor noted in Finding 2024-003, a grant number input field has been added to the group purchasing orders to allow for enhanced tracking and review of expenditures associated with grants and the monitoring of payment of those expenditures. The use of the accurate grant general ledger coding by grant managers when orders are placed will reduce the time between placement of order and payment of the invoice. The grant manager responsible for oversight of BHSB grants will work with BHSB to remedy the period of performance noncompliance noted in Finding 2024-003. Anticipated Completion Date – June 30, 2026 Name(s) of the contact person(s) responsible for corrective action: Jeff Chadwick, Financial Reporting Director, jeff.chadwick@umm.edu
C. Cash Management; L. Reporting Evidence and Review and Approval of the Reported Expenditures and Timely Report Submission Assistance Listing 93.959: Block Grants for Substance Use Prevention, Treatment, and Recovery Services Federal Agency: Department of Health and Human Services Recommendation: M...
C. Cash Management; L. Reporting Evidence and Review and Approval of the Reported Expenditures and Timely Report Submission Assistance Listing 93.959: Block Grants for Substance Use Prevention, Treatment, and Recovery Services Federal Agency: Department of Health and Human Services Recommendation: Management should reassess the design of its controls to ensure submissions to BHSB are made timely within the required 15-day period and that documentation is retained that evidences the review and approval of expenditures submitted to BHSB for reimbursement. Explanation of disagreement with audit finding: There is no disagreement with the finding and recommendation. Action planned/taken in response to finding: The Corporation went live on its new ERP system in April 2024. Since go-live, management has continued to optimize the system and find ways to strengthen our internal controls, including automating certain processes. Management will continue educating grant managers on capabilities within the system that can be utilized in the execution of review and approval of grant expenditures prior to timely submission to the relevant granting agencies for reimbursement. Centralized repositories have been set up for grant managers to extract specific monthly financial reports for use in the execution of their controls, as well as to retain their review and approval evidence. Additionally, management is developing standard operating procedures and policies that include the requirements for compliance and internal controls for federal grants. The policies will acknowledge that for controls to be designed and operate effectively, there must always be a segregation of duties between the preparer of the control vs. reviewer and that clear documentation must be retained to evidence the execution of the controls. Anticipated Completion Date – June 30, 2027 Name(s) of the contact person(s) responsible for corrective action: Jeff Chadwick, Financial Reporting Director, jeff.chadwick@umm.edu
The Morgan County Economic Development Office acknowledges the status and final reports for the CDBG and Home grant programs must be submitted by the required due dates. The office will actively monitor all deadlines and ensure that all reports are completed and submitted in a timely manner in accor...
The Morgan County Economic Development Office acknowledges the status and final reports for the CDBG and Home grant programs must be submitted by the required due dates. The office will actively monitor all deadlines and ensure that all reports are completed and submitted in a timely manner in accordance with those requirements.
Finding reference: 2024-007 - 93.137 – Community Programs to Improve Minority Health Grant Program Material Weakness and Noncompliance over Subrecipient Monitoring Recommendation: Program management should revise subaward agreements to specifically note the requirements and regulations of the Unifor...
Finding reference: 2024-007 - 93.137 – Community Programs to Improve Minority Health Grant Program Material Weakness and Noncompliance over Subrecipient Monitoring Recommendation: Program management should revise subaward agreements to specifically note the requirements and regulations of the Uniform Guidance, as noted in Section 200.331(a). Additionally, program management should develop standardized procedures for selecting and granting subawards. These procedures should be formalized and maintained for future reference. Brief minutes of progress meetings should be taken to show that monitoring is taking place. All reporting by the subrecipient should be reviewed by management of the program. Action taken: The HHS Department will outline the selection process within the Notice of Funding Availability. Furthermore, a monitoring schedule will be created and program staff are required to review all reports submitted by the subrecipient.
Finding reference: 2024-006 - 93.137 – Community Programs to Improve Minority Health Grant Program Material Weakness and Noncompliance over Reporting - FFATA Recommendation: We recommend the City establish and implement controls to maintain compliance with reporting requirements. Action taken: In ad...
Finding reference: 2024-006 - 93.137 – Community Programs to Improve Minority Health Grant Program Material Weakness and Noncompliance over Reporting - FFATA Recommendation: We recommend the City establish and implement controls to maintain compliance with reporting requirements. Action taken: In addition to hiring a grant manager to oversee compliance, the City has purchased OpenGov grant software to ensure compliance, monitoring and the insurance of timely submissions in accordance with the grant. This system is designed to send notifications of reporting requirements prior to the due date.
The Fiscal Officer will improve tracking and reporting procedures by requesting a clear outline from all funding and liaising parties at the start of all future projects. As well as making sure all reporting and procedures are adhered to by those parties.
The Fiscal Officer will improve tracking and reporting procedures by requesting a clear outline from all funding and liaising parties at the start of all future projects. As well as making sure all reporting and procedures are adhered to by those parties.
CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Housing and Urban Development The Town of Oak Bluffs, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of independent public accounting firm: CBIZ CPAs P.C....
CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Housing and Urban Development The Town of Oak Bluffs, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of independent public accounting firm: CBIZ CPAs P.C. 53 State Street, 17th Floor Boston, MA 02109 Audit period: July 1, 2023 through June 30, 2024 The finding from the June 30, 2024, schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. Financial Statement Finding 2024-001 – Document Policies and Procedures Over Federal Awards Condition: During our audit, we noted that the Town did not have formal policies and procedures in place covering the requirements of Uniform Guidance as specified in 2 CFR Part 200. Certain elements, such as procurement standards, subrecipient monitoring, internal control, and other compliance areas, were not addressed in written policies or documented procedures. Criteria: Uniform Guidance (2 CFR Part 200) requires non-federal entities administering federal awards to establish and maintain written policies and procedures to address all requirements specified in the regulations, including but not limited to internal controls, determination of allowable costs, procurement, subrecipient monitoring, financial management, and reporting. Cause: The Town has not developed comprehensive written policies and procedures to address all compliance requirements under Uniform Guidance. Effect: The absence of written policies and procedures increases the risk of noncompliance with federal requirements, reduces consistency in federal program administration, and limits transparency and accountability. Recommendation The Town should develop and implement comprehensive written policies and procedures that address all major compliance requirements under Uniform Guidance (2 CFR Part 200). Periodic review and updates should be performed to ensure ongoing compliance. Views of Responsible Officials: We have been reviewing existing workflows, and unwritten procedures, relative to our management and oversight of federal awards either received directly from the federal or from another intermediary pass-through agency. Once our review is complete, we will commit those procedures to writing and present them to the Select Boad for approval. The anticipation is that we will have documented policies and procedures, that are compliant with the Uniform Guidance, in time for the FY2026 audit.
Management has registered with Sam.gov and obtained a Unique Entity ID (UEI) for the submission of the single audit report for the fiscal year ended June 30, 2024. The UEI does not expire and is therefore addressed for future single audits.
Management has registered with Sam.gov and obtained a Unique Entity ID (UEI) for the submission of the single audit report for the fiscal year ended June 30, 2024. The UEI does not expire and is therefore addressed for future single audits.
Management Responses: We acknowledge that prior to this audit, CASA relied on summary-level expense reports from subrecipients under the PCCD grant and did not consistently verify underlying invoices. The established oversight also included the following efforts: 1) the individual previously respons...
Management Responses: We acknowledge that prior to this audit, CASA relied on summary-level expense reports from subrecipients under the PCCD grant and did not consistently verify underlying invoices. The established oversight also included the following efforts: 1) the individual previously responsible for invoicing did review submissions for reasonableness against the approved budget, 2) subrecipients were advised to maintain detailed back-up for all expenses, and 3) the Coalition Director regularly visited subrecipient sites to observe work being completed and to meet and observe personnel covered by the grant. However, we acknowledge this process did not meet the full requirements of the Uniform Guidance. While prior audits were not performed under Government Auditing Standards , management notes that the agency has received federal funding since 2016 with no history of previous management-related findings. The identified grant in this finding was a pilot project and the first time the agency has managed subrecipients. Corrective Actions Already Taken: CASA has engaged a new contracted accounting firm with a wider breadth of experience and expertise. CASA has completed an internal restructuring to provide increased opportunity for oversight and review of contracted financial services. CASA has adopted a new review protocol requiring verification of all supporting documentation for subrecipient reimbursements. The Operations Manager now performs a detailed review of invoices, approvals, and alignment with allowable costs prior to releasing funds. Planned Actions: Subrecipient Monitoring Policy: CASA will implement a policy immediately that includes: A standardized invoice review checklist (verifying vendor, date, amount, and allowability). Documentation of management approvals and sign-offs. Monitoring visits or virtual reviews for subrecipients by Coalition Director or Operations Director. Communication: CASA will issue written guidance to all subrecipients outlining documentation requirements and timelines.
Scotland County’s response for issues found: 1. We will double check to make sure we didn’t miss something for the SEFA report. 2. We will update the 2024 SEFA for the corrected amounts. 3. The Highway Planning and Construction (MODOT Intermodal) included the railroad bridge that no one could tell u...
Scotland County’s response for issues found: 1. We will double check to make sure we didn’t miss something for the SEFA report. 2. We will update the 2024 SEFA for the corrected amounts. 3. The Highway Planning and Construction (MODOT Intermodal) included the railroad bridge that no one could tell us where the money was coming from. This accounted for $1,228,104.64. We will correct this on the SEFA. 4. The ARPA was the interest received in 2024. We didn’t receive any more money from the state in 2024. We will get this added to the SEFA. 5. The HAVA Election Security Grant was missed when we were putting them in the report. We will get this added to the SEFA.
Finding 2024-002 | Subrecipient Not Monitored — City of Laredo Across Three Programs Material Weakness in Internal Control over Compliance | Ryan White (93.917) | HOPWA (14.241) | State Services (HHS001317000004) | First-Time Finding Finding Number: 2024-002 Planned Completion Date: June 30, 2025 (r...
Finding 2024-002 | Subrecipient Not Monitored — City of Laredo Across Three Programs Material Weakness in Internal Control over Compliance | Ryan White (93.917) | HOPWA (14.241) | State Services (HHS001317000004) | First-Time Finding Finding Number: 2024-002 Planned Completion Date: June 30, 2025 (retroactive review and system implementation); ongoing thereafter Responsible Official(s): Josafat Saldivar, Finance Director (monitoring schedule and fiscal monitoring); Program Managers — Ryan White, State Services, HOPWA (programmatic coordination); Juan E. Rodriguez, Executive Director (oversight and quarterly review) Agency Response: STDC acknowledges the finding and recognizes the seriousness of the Material Weakness classification. During FY2024, STDC did not conduct the required annual monitoring of the City of Laredo under the Ryan White, State Services, or HOPWA programs. Combined subrecipient expenditures for the City of Laredo across these three programs totaled $1,162,418. STDC concurs that this constitutes a failure to meet the subrecipient monitoring requirements of 2 CFR 200.332 and the applicable contract terms for all three programs. Management acknowledges that the absence of a formal, documented annual monitoring schedule allowed this gap to go undetected. STDC notes that five of six Ryan White and State Services subrecipients and three of four HOPWA subrecipients were monitored during FY2024; the lapse was isolated to the City of Laredo across all three programs. STDC takes seriously its obligation to ensure all subrecipients are monitored on schedule and is committed to implementing a comprehensive corrective action that addresses both the immediate gap and the underlying control deficiency. STDC also notes that subrecipient monitoring policies and procedures were formally developed and adopted as part of the corrective action for Finding 2022-006. The recurrence of a monitoring gap in FY2024 underscores the need for a more structured scheduling and tracking mechanism to ensure those procedures are consistently applied across all programs and subrecipients each grant year. Corrective Actions to Be Implemented: Action 1 (Target: April 30, 2025): Retroactive Monitoring Review — Conduct a desk review of the City of Laredo's FY2024 subrecipient expenditures, financial reports, and compliance documentation under Ryan White (ALN 93.917), State Services (HHS001317000004), and HOPWA (ALN 14.241), using the standardized monitoring tools and checklists established under STDC's existing Subrecipient Monitoring Policy. Document results and retain findings in the City of Laredo subrecipient monitoring files. Action 2 (Target: April 30, 2025): Develop a formal, written Annual Subrecipient Monitoring Schedule at the start of each grant year, covering all active programs and all subrecipients. The schedule will identify: subrecipient name, program(s), subaward amount, assigned monitoring staff, planned monitoring method (desk review or on-site), and planned and actual completion dates. The schedule must be reviewed and approved by the Executive Director. Action 3 (Target: May 15, 2025): Implement a Monitoring Tracking Log consistent with STDC's existing Subrecipient Monitoring Policy to be updated on an ongoing basis and reviewed weekly. The log will track monitoring visit dates, report draft and distribution dates, and status of any corrective actions required of subrecipients. Action 4 (Target: May 31, 2025): Implement a quarterly monitoring progress report to the Executive Director identifying: (a) subrecipients scheduled for monitoring, (b) monitoring completed to date, (c) any past-due monitoring, and (d) findings or corrective actions arising from completed monitoring activities. Action 5 (Target: Ongoing, beginning FY2025): At the start of each grant year, cross-reference the Annual Subrecipient Monitoring Schedule against all active subaward agreements and update the schedule whenever a new subaward is executed or a new subrecipient is added to any program, to ensure no subrecipient is omitted from the monitoring plan. Action 6 (Target: June 30, 2025): Conduct refresher training for all finance and program staff responsible for subrecipient monitoring on the requirements of 2 CFR 200.332, STDC's Subrecipient Monitoring Policy, and the use of the updated annual monitoring schedule and tracking log. Monitoring and Evaluation: Quarterly monitoring progress reports will be submitted to the Executive Director to verify that all subrecipients are monitored according to the annual schedule. The Annual Subrecipient Monitoring Schedule and Monitoring Tracking Log will be maintained in the subrecipient compliance files and available for audit review. Compliance with the Subrecipient Monitoring Policy will be reviewed annually, and any deviations will be addressed through staff corrective action plans as appropriate.
Finding Number 2024-002 Planned Corrective Action: CAMcare has implemented enhanced controls over the financial screening and sliding fee discount application process to ensure compliance with 42 CFR §56.303(g)(2). Prior to the application of any sliding fee discount, financial screening staff are n...
Finding Number 2024-002 Planned Corrective Action: CAMcare has implemented enhanced controls over the financial screening and sliding fee discount application process to ensure compliance with 42 CFR §56.303(g)(2). Prior to the application of any sliding fee discount, financial screening staff are now required to verify that the patient’s application rating (based on income and family size) aligns with the corresponding Federal Poverty Level (FPL) category and discount level configured within the Epic system. Discounts will not be applied unless this validation is completed. To address inconsistencies identified during the audit period, CAMcare has formalized procedures requiring that all updates to the sliding fee discount schedule, including changes to FPL thresholds or discount percentages, are communicated to registration, financial screening, and billing staff prior to implementation. Additionally, system-level updates within Epic must be validated by designated personnel to ensure that the updated fee schedule is accurately reflected before being used in patient billing. Supervisory review controls have also been strengthened. Financial screening supervisors will perform monthly spot checks of a defined sample of patient accounts to verify that sliding fee discounts have been applied correctly and are supported by complete and accurate patient application data. Any discrepancies identified will be documented, corrected, and escalated for follow-up training or process improvement as necessary. In addition, CAMcare will reinforce staff training on financial screening policies and procedures on a periodic basis and maintain documentation of completed training. Management will monitor compliance through ongoing supervisory review and periodic evaluation of screening and billing accuracy to ensure adherence to established policies. These corrective actions are designed to strengthen internal controls over financial screening and billing processes, ensure accurate application of sliding fee discounts, and reduce the risk of noncompliance in future reporting periods. Anticipated Completion Date: January 1st, 2025, with ongoing monthly monitoring and periodic training. Responsible Contact Persons: Eshan Singh, Vice President of Finance, Analytics & Technology
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