Corrective Action Plans

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Corrective Action The initial eligibility determinations are currently handled by the HCV department and are centralized. It has been determined that considerable investment in staff training has been made during the past twelve months. As a result, there has been staff turnover, some at the decisio...
Corrective Action The initial eligibility determinations are currently handled by the HCV department and are centralized. It has been determined that considerable investment in staff training has been made during the past twelve months. As a result, there has been staff turnover, some at the decision of TGHA, and some at the decision of staff. Initial eligibility is currently being restructured with an emphasis on new admissions. All procedures and processes are being evaluated for accuracy, with emphasis on the noted area of noncompliance and includes a complete review and update to the Administrative Plan. There will be increased staff training and file review. In July 2024, TGHA transitioned project-based files from a property management team to the Housing Choice Voucher Department. The files had not been electronically stored. Evidence pointed to deficiencies in file maintenance. TGHA has hired temporary staff for an extended period to focus on file organization and to correct documentation deficiencies. All HCV staff have completed Rent Calculation courses provided by NAHRO or Nan McKay during the fiscal year. There have been two managers hired for the department, one exclusively for project-based vouchers. Both attended NAHRO supervisory training in September. There will be an intensive focus on program integrity throughout the programs, including staff capability, training and monitoring. TGHA has contracted with a professional recruiter to assist in hiring a Director of the HCV and MTW programs. Recertification transactions will be monitored on a monthly basis. This will include validation of calculations and verification of correct documentation. It is anticipated that TGHA files will be fully in order by July 2025.
Finding No. 2023-002 Personnel Responsible For the Corrective Action: Eric Keith, Director of Finance Anticipated Completion Date December 31, 2024 Corrective Action Plan: LSEM will immediately begin time stamping all checks against the System for Awards Management (SAM). LSEM will deve...
Finding No. 2023-002 Personnel Responsible For the Corrective Action: Eric Keith, Director of Finance Anticipated Completion Date December 31, 2024 Corrective Action Plan: LSEM will immediately begin time stamping all checks against the System for Awards Management (SAM). LSEM will develop and implement a written policy, within 60 days, that outlines the procedures for verifying suspension and debarment status, including: • Regular checks against SAM. • Requirements for obtaining certifications from vendors. • Inclusion of debarment clauses in contracts. LSEM will conduct training sessions for procurement staff on the new policy, emphasizing the importance of verifying vendor eligibility and maintaining documentation within 90 days. LSEM will implement, within 90 days, a regular monitoring process to ensure compliance with suspension and debarment requirements, including: • Periodic audits of procurement transactions to verify adherence to the policy. • Review of the documentation repository for completeness and accuracy.
Finding No. 2023-001 Personnel Responsible For the Corrective Action: Eric Keith, Director of Finance Anticipated Completion Date December 31, 2024 Corrective Action Plan: All necessary FFATA will be filed within 30 days. Legal Services of Eastern Missouri (LSEM) will develop policies...
Finding No. 2023-001 Personnel Responsible For the Corrective Action: Eric Keith, Director of Finance Anticipated Completion Date December 31, 2024 Corrective Action Plan: All necessary FFATA will be filed within 30 days. Legal Services of Eastern Missouri (LSEM) will develop policies and procedures within 60 days to ensure that all FFATA reports are submitted in a timely manner. LSEM will provide training regarding all grant compliance for all staff involved in grant management and compliance within 90 days.
FINDING 2023-005 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Reporting Summary of Finding: Material Weakness Contact Person Responsible for Corrective Action: Mary Fletcher Contact Phone Number and Email Address: (765) 998-7439, mfletcher@uplandindiana.com Views of R...
FINDING 2023-005 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Reporting Summary of Finding: Material Weakness Contact Person Responsible for Corrective Action: Mary Fletcher Contact Phone Number and Email Address: (765) 998-7439, mfletcher@uplandindiana.com Views of Responsible Officials: We concur with the finding Explanation and Reasons for Disagreement: Description of Corrective Action Plan: The Town of Upland will implement an oversight system to review the P&E Report before submission to the Federal Government. Anticipated Completion Date: Upon the submission of our next report due April 30, 2025
FINDING 2023-04 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Suspension and Debarment Summary of Finding: Material Weakness, Noncompliance Contact Person Responsible for Corrective Action: Mary Fletcher Contact Phone Number and Email Address: (765) 998-7439, mfletcher...
FINDING 2023-04 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Suspension and Debarment Summary of Finding: Material Weakness, Noncompliance Contact Person Responsible for Corrective Action: Mary Fletcher Contact Phone Number and Email Address: (765) 998-7439, mfletcher@uplandindiana.com Views of Responsible Officials: We concur with this finding Description of Corrective Action Plan: Although we do have a federal grant consultant that does check the suspension and debarment status of contractors, the Town of Upland will adopt a Suspension and Debarment policy to issue that no contractor being paid with Federal funds are Suspended or Debarred. Anticipated Completion Date: 11/15/2024
FINDING 2023-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Activities Allowed and Unallowed. Summary of Finding: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Mary Fletcher Contact Phone Number and Email Address: (765) 998-74...
FINDING 2023-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Activities Allowed and Unallowed. Summary of Finding: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Mary Fletcher Contact Phone Number and Email Address: (765) 998-7439, mfletcher@uplandindiana.com Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: Although the funds were transferred to utilities and not paid directly from ARPA Funds, the funds were used to make necessary investments in utility infrastructure during 2023. We have been fully informed of the guidelines for the use of the ARPA funds since this transfer occurred and will use the remaining funds according to the ARPA guidelines. The Clerk-Treasurer has contacted the Department of the Treasury to get guidance on what can be done to rectify our misuse of the funds. Anticipated Completion Date: Unknown- When a resolution is reached with the Federal Government.
View Audit 322658 Questioned Costs: $1
FINDING 2023-002 (Auditor Assigned Reference Number) Finding Subject: Coronavirus State and Local Fiscal Recovery Funds – Suspension and Debarment Summary of Finding: Material Weakness, Other Matters – no policy to check for suspension and debarment prior to entering into transactions with vendors C...
FINDING 2023-002 (Auditor Assigned Reference Number) Finding Subject: Coronavirus State and Local Fiscal Recovery Funds – Suspension and Debarment Summary of Finding: Material Weakness, Other Matters – no policy to check for suspension and debarment prior to entering into transactions with vendors Contact Person Responsible for Corrective Action: Dustin Dillard, Chief Contact Phone Number and Email Address: 812-331-1906; ddillard@monroefd.org Views of Responsible Officials: “We concur with the finding.” Description of Corrective Action Plan: The District will adopt a policy related to State and Local Fiscal Recovery Funds (SLFRF) suspension and debarment requirements, and develop a system of internal controls that addresses the need to verify suspension, debarment, or other exclusions prior to entering into transactions with vendors who may have transactions equal to or exceeding $25,000 of federal funds in one year. Policy will include verification by checking the Excluded Parties List System (ELPS), collecting a certification from that vendor, or adding a clause or condition to the covered transaction with that vendor. Anticipated Completion Date: December 31, 2024
Corrective Action Plan - VMS not reconciled with FDS. Contact person - Executive Director. Corrective action planned - The current year VMS will be adjusted as needed and future VMS reports will be reonciled with the FDS. Anticipated completion date - Within the next fiscal year.
Corrective Action Plan - VMS not reconciled with FDS. Contact person - Executive Director. Corrective action planned - The current year VMS will be adjusted as needed and future VMS reports will be reonciled with the FDS. Anticipated completion date - Within the next fiscal year.
Finding 499789 (2023-002)
Significant Deficiency 2023
Condition: We reviewed all four subawards associated with the program during the audit period and noted that sub-award information for all four subrecipients was not submitted to the FSRS by the required submission deadline. Although all other compliance requirements were met, the late submission r...
Condition: We reviewed all four subawards associated with the program during the audit period and noted that sub-award information for all four subrecipients was not submitted to the FSRS by the required submission deadline. Although all other compliance requirements were met, the late submission represents a deficiency in reporting controls. Correction action: FSRS were submitted to the FFATA site. Responsible Person: Interim Co-CEO Anticipated completion date: Complete. Reports were submitted November 2023
Our CCI Trip Report System has been modified to automatically send to USDA-FAS Trip Report/s submitted by the traveler/s in the System.
Our CCI Trip Report System has been modified to automatically send to USDA-FAS Trip Report/s submitted by the traveler/s in the System.
Finding 499785 (2023-004)
Significant Deficiency 2023
Finding 2023-004 Condition The 2023 Project and Expenditure Reports for quarters selected for testing were not reviewed by an independent person before submission of the report. Corrective Action Plan Corrective Action Planned: The reporting process has been updated to ensure proper documentatio...
Finding 2023-004 Condition The 2023 Project and Expenditure Reports for quarters selected for testing were not reviewed by an independent person before submission of the report. Corrective Action Plan Corrective Action Planned: The reporting process has been updated to ensure proper documentation of formal review prior to submission. Name(s) of Contact Person(s) Responsible for Corrective Action: Samantha Fenske, Finance Director Anticipated Completion Date: December 31, 2024
Finding 2023-002: Section 8 Project-Based Cluster Federal Assistance Number: 14.182 and 14.195 U.S. Department of Housing and Urban Development (Repeat of Finding 2022-002) Compliance Requirements: Cash Management, El...
Finding 2023-002: Section 8 Project-Based Cluster Federal Assistance Number: 14.182 and 14.195 U.S. Department of Housing and Urban Development (Repeat of Finding 2022-002) Compliance Requirements: Cash Management, Eligibility, Reporting, Special Tests and Provisions Type of finding: Internal Control Over Compliance (significant deficiency) Recommendation: The Organization should strengthen its internal controls with adopted policies and procedures to ensure a review process is established through adequate segregation of duties. The Organization should consider assessing and realigning the duties and responsibilities of administrative staff allowing the administrator to act in a more supervisory position. Action Taken: The Operation Administrator is overall responsible the operation of Tri-County Senior Center and Housing; working together with the bookkeeping staff and Executive Director as partners to maintain financial records and budgets. The Executive Director will sporadically review tenant eligibility of new certifications and re-certifications, HAP Contracts, samples of monthly HAP Assistance Payment requests, and her presence when auditors are in-house as well any other assistance requested by Administrator. To ensure the health, safety, and well-being of the residents and staff, the Administrator oversees the responsibilities and duties of all other staff in their roles, (Administration Assistant/Program Administrator-Senior Center Activities; Administration Assistant-Membership, monthly newsletters, answer phones and any other duties requested by the Administrator), to guide them in their specific roles so they understand their duties and responsibilities as administrative staff, and ensuring the facility meets all regulatory compliance standards. If there are questions regarding this plan, please call the responsible party at (719) 852-5778. Sincerely yours, Monica Wolfe Executive Director Tri-County Senior Citizens and Housing, Inc.
Per Choggiung-Nushagak Subaward Agreement dated 1/16/23, Choggiung Limited as the Recipient prepares and submits NTIA required reporting. Choggiung has submitted annual and semi-annual reporting as required under NTIA grant terms and provided documentation supporting timely filing of required repor...
Per Choggiung-Nushagak Subaward Agreement dated 1/16/23, Choggiung Limited as the Recipient prepares and submits NTIA required reporting. Choggiung has submitted annual and semi-annual reporting as required under NTIA grant terms and provided documentation supporting timely filing of required reports. Considered corrected.
NETC and Choggiung followed up with Meridian on appropriate documentation (SAM.gov dated screenshots, etc.) to ensure appropriate documentation going forward. Considered corrected. The Comptroller will be the person responsible for implementing the corrective action plan.
NETC and Choggiung followed up with Meridian on appropriate documentation (SAM.gov dated screenshots, etc.) to ensure appropriate documentation going forward. Considered corrected. The Comptroller will be the person responsible for implementing the corrective action plan.
NETC will review procurement guidelines, internal procurement policies and processes, as well as recipient Choggiung Limited procurement policies and discuss with Meridian (project management) as needed to ensure compliance going forward. The Comptroller will be the person responsible for implementi...
NETC will review procurement guidelines, internal procurement policies and processes, as well as recipient Choggiung Limited procurement policies and discuss with Meridian (project management) as needed to ensure compliance going forward. The Comptroller will be the person responsible for implementing the corrective action plan.
Columbus Neighborhood Health Center, Inc. dba PrimaryOne Health Corrective Action Plan Year Ended December 31, 2023 Contact Information: Charleta B. Tavares, Chief Executive Officer 614. 859. 1946 ctavares@primaryonehealth.org Audit period: January 1, 2023 – December 31, 2023 Finding 2023-001 –...
Columbus Neighborhood Health Center, Inc. dba PrimaryOne Health Corrective Action Plan Year Ended December 31, 2023 Contact Information: Charleta B. Tavares, Chief Executive Officer 614. 859. 1946 ctavares@primaryonehealth.org Audit period: January 1, 2023 – December 31, 2023 Finding 2023-001 – Allowable Costs (Time and Effort) Recommendation: Management should establish policies and procedures that are consistent with the Uniform Guidance administrative requirements with regards to compensation and allowable costs which includes ensuring time and effort charges are based on records that accurately reflect the work performed. Action planned/take in response to finding: 1. Implementation of Time and Effort Reporting System: The organization has begun to establish and implement a robust time and effort reporting system in compliance with 2 CFR 200.430. This system will: a. Accurately reflect the distribution of employee time across different federal grants. b. Track employee hours worked, allocate wages based on grant activities, and ensure the proper alignment of salaries to the work performed. c. Provide documentation supporting time allocation between different federal and non-federal activities. 2. Training for Payroll and Grants Management Staff: All payroll, human resources, and finance staff will undergo mandatory training on: a. Time and effort reporting requirements under federal guidelines. b. The correct procedures for allocating wages to federal grants, including compliance with Uniform Guidance (2 CFR 200). 3. Updating Policies and Procedures: The organization will update internal policies to reflect compliance with the Uniform Guidance, particularly regarding payroll documentation and time and effort allocation. This will include: a. Establishing written procedures on tracking employee work hours and effort reporting. b. Implementing monthly or quarterly reviews to ensure payroll costs are appropriately charged to federal awards. 4. Periodic Internal Audits: The organization will conduct periodic internal audits to ensure continued compliance with federal requirements, especially as it relates to payroll and time tracking. Any discrepancies will be promptly corrected to avoid future findings. Planned completion date for corrective action plan: December 31, 2024
View Audit 322621 Questioned Costs: $1
Management concurs with the finding and has updated the tenant waiting list for all projects in the Low Income Public Housing program. In addition, management established plans to provide additional training and review of the waiting lists going forward by the Director of Housing Management to ensur...
Management concurs with the finding and has updated the tenant waiting list for all projects in the Low Income Public Housing program. In addition, management established plans to provide additional training and review of the waiting lists going forward by the Director of Housing Management to ensure that waiting lists are maintained in accordance with the applicable regulations.
Management concurs with the finding and has established plans to provide additional training and review of tenant files going forward by the Director of Housing Management to ensure required tenant certifications are performed timely and completely, and all required tenant certification documentatio...
Management concurs with the finding and has established plans to provide additional training and review of tenant files going forward by the Director of Housing Management to ensure required tenant certifications are performed timely and completely, and all required tenant certification documentation is included in tenant files.
Management concurs with the finding and has established plans to provide additional training and review of tenant files going forward to ensure required inspections are performed and documentation is included in tenant files. Management will have certification schedules printed monthly, reviewed and...
Management concurs with the finding and has established plans to provide additional training and review of tenant files going forward to ensure required inspections are performed and documentation is included in tenant files. Management will have certification schedules printed monthly, reviewed and emailed to the third-party contractor who was hired to complete the annual inspections. In addition, all tenant files will be reviewed by management and approved.
Management intended to report the Provider Relief Funding in the HRSA reporting system for subsidiary entities with the parent entity, however, it has now come to our attention that the field did not appropriately populate despite having included the TIN of the subsidiary.  The Organization has indi...
Management intended to report the Provider Relief Funding in the HRSA reporting system for subsidiary entities with the parent entity, however, it has now come to our attention that the field did not appropriately populate despite having included the TIN of the subsidiary.  The Organization has indicated that there is more than enough lost revenue and eligible expenses in the appropriate period to claim this funding in its entirety as was our intention, therefore there is no risk that funding was inappropriately utilized.  The Organization will implement procedures and a responsible party to oversee the preparation of a complete Schedule of Expenditures of Federal Awards that reconciles to the general ledger and other external reporting.
Management agrees with the assessment and will work to develop a procurement policy.
Management agrees with the assessment and will work to develop a procurement policy.
Finding 499766 (2023-003)
Significant Deficiency 2023
2023-003 Coronavirus State & Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: The auditor recommend the City design controls to ensure an adequate review, and update as necessary, of policies occurs when changes in practice or regulation occur. Action taken in response to...
2023-003 Coronavirus State & Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: The auditor recommend the City design controls to ensure an adequate review, and update as necessary, of policies occurs when changes in practice or regulation occur. Action taken in response to finding: The City has adopted an updated procurement policy that complies with current requirements of Uniform Guidance. Name(s) of the contact person(s) responsible for corrective action: Carol Stancato, Director of Finance Planned completion
Audit Finding Number: 2023-002 Responsible Person: Carrie Smith, AVP of Regulatory Response to Findings: The Accounting Team performed an internal review and agrees with the Uniform Guidance audit findings. An adjustment was recorded as of 12/31/2023. In addition, the finding was communicated to the...
Audit Finding Number: 2023-002 Responsible Person: Carrie Smith, AVP of Regulatory Response to Findings: The Accounting Team performed an internal review and agrees with the Uniform Guidance audit findings. An adjustment was recorded as of 12/31/2023. In addition, the finding was communicated to the State auditors. Corrective Action to be Taken: 1. VillageCare will continue to utilize project ID when recording grants revenue and grants expenses. 2. Only appropriate, non-duplicative, and verified invoices will be submitted by the Accounts Payable Department for reimbursement. The AVP of Regulatory will receive and review all invoices from AP prior to submission to the funding source. 3. For material reimbursement, the Procurement Department will ensure the goods are received. 4. The Accounting Team will maintain all potential reimbursement schedules and cross check against current and past grants to ensure no prior approved expenditures are resubmitted for reimbursement. 5. The Director of Accounting and Finance and/or Controller will only approve grants receivable accrual based on allowable, confirmed, and validated invoices. Completion Date or Anticipated Completion Date of the Action to be Taken: September 1, 2024.
View Audit 322588 Questioned Costs: $1
2023-001 Quality Control Inspections .00 Condition and Criteria: The Authority’s purpose for existence is providing decent safe and affordable housing to low-income persons. As such, HUD requires the Authority to comply with special tests and provisions relating to its...
2023-001 Quality Control Inspections .00 Condition and Criteria: The Authority’s purpose for existence is providing decent safe and affordable housing to low-income persons. As such, HUD requires the Authority to comply with special tests and provisions relating to its Housing Choice Voucher program. The Authority must inspect the unit leased to a family at least annually to determine if the unit meets Housing Quality Standards (HQS) and the Authority must conduct quality control re-inspections. The Authority must prepare a unit inspection report (24 CFR sections 982.158(d) and 982.405(b)). Population and Items Tested: During our testing of fifteen housing choice voucher tenant files, we noted the annual inspections were completed as required. However, during the current fiscal year, the PHA did not conduct the required quality control re-inspections. Auditor’s Recommendation: The Authority should perform housing quality control re-inspections according to HUD guidelines. Planned Corrective Action: We will complete the required quality control re-inspections. Anticipated Completion Date: December 31, 2024
Views of Responsible Officials: Management acknowledges that prior approval must be received before allocating any cost to an award that is incurred outside of the period of performance. While in this case approval was ultimately not granted, the cost was returned to the original project and removed...
Views of Responsible Officials: Management acknowledges that prior approval must be received before allocating any cost to an award that is incurred outside of the period of performance. While in this case approval was ultimately not granted, the cost was returned to the original project and removed from the affected project and subsequent drawdowns adjusted accordingly. To avoid incurring costs outside the period of performance, the following actions will be implemented:  Update the Global Center procurement guidelines to explicitly emphasize period of performance requirements when incurring expenses on grants and contracts.  Systematically confirm all purchase requests, vendor contracts, consulting agreements and subawards fall within the period of performance by including the start and end date of the grant or contract on all associated documentation. Responsible Officials: Daniel Grimshaw, Director of Finance Anticipated Completion Date: December 31, 2024
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