Corrective Action Plans

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Finding Number: 2023-001 Condition: Two reimbursement requests submitted during 2023 did not have documentation available to indicate that the reimbursement request was reviewed by a supervisor for accuracy before submission. Planned Corrective Action: Staff turnover in early 2023 resulted in a temp...
Finding Number: 2023-001 Condition: Two reimbursement requests submitted during 2023 did not have documentation available to indicate that the reimbursement request was reviewed by a supervisor for accuracy before submission. Planned Corrective Action: Staff turnover in early 2023 resulted in a temporary lapse of documentation proving that the internal control process was followed. The Society follows its internal review process and is maintaining documentation that appropriate approvals are in place. Contact person responsible for corrective action: Dharshni Sabapathy, Senior Director of Accounting Anticipated Completion Date: April 25, 2024
Sliding Fee Discount: Criteria: The health center must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient's ability to pay. Condition: During compliance testing, it was identified...
Sliding Fee Discount: Criteria: The health center must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient's ability to pay. Condition: During compliance testing, it was identified that the sliding fee discount was not accurately applied to one patient out of a sample of 25. An additional patient did not have any support on file for the discount they received. Context: Some patients did not receive the proper discount based on the approved sliding fee schedule. Effect: As a result of the condition, some patients received incorrect bills. Cause: The billing system utilized by the Organization does not automatically apply the discount, therefore requiring the Organization's billing team to review and manually adjust patient bills. Repeat Finding: This is a repeat finding. Recommendation: In the future, the Organization should work with the billing system vendor to automate the billing within the system. Additionally, the Organization should implement appropriate processes and controls to ensure a review is performed prior to sending patient bills. Contact: Stuart May, Chief Executive Officer Corrective Actions Taken or Planned: An employee from the revenue cycle management team has been assigned to work with our vendor to determine why the slide calculation does not work correctly and what steps are needed to correct the calculation. The corrections will then be made to the system.
Section 202 Capital Advance – Assistance Listing No. 14.157 Recommendation: Accounting staff should reconcile the Replacement Reserve account on a periodic (monthly or quarterly) basis to ensure the monthly transfers are being made. Management should also make the deposit to fully fund the replaceme...
Section 202 Capital Advance – Assistance Listing No. 14.157 Recommendation: Accounting staff should reconcile the Replacement Reserve account on a periodic (monthly or quarterly) basis to ensure the monthly transfers are being made. Management should also make the deposit to fully fund the replacement reserve as soon as possible. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management is in agreement with the finding and has since corrected the issue. Name(s) of the contact person(s) responsible for corrective action: Chuck Armstrong, Director Independent & Affordable Living Planned completion date for corrective action plan: September 30, 2023
View Audit 307011 Questioned Costs: $1
Name of auditee: Adirondack Community Action Programs, Inc. TIN: 14-1490418 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: June 1, 2022 - May 31, 2023 CAP prepared by: Alan Jones ajones@acapinc.org Finding 2023-001 Adirondack Community Action Programs Inc. (ACAP) is committed to...
Name of auditee: Adirondack Community Action Programs, Inc. TIN: 14-1490418 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: June 1, 2022 - May 31, 2023 CAP prepared by: Alan Jones ajones@acapinc.org Finding 2023-001 Adirondack Community Action Programs Inc. (ACAP) is committed to addressing the finding highlighted in the Independent Auditor's Report on Compliance regarding late filing of the Data Collection Form. We recognize the importance of timely reporting for organizational compliance. We were fortunate to receive significant additional unexpected financial resources in the year in question to assist with COVID recovery and support for our work in Child Care. These additional resources were welcomed, but created a temporary significant increase in the workload for our business office. We pride ourselves on our internal controls and comprehensive financial procedures and expect this delay to be isolated to the year in question. As in the past, ACAP will: • Ensure adequate staffing levels given the increases we have been experiencing in annual revenue. • Continue to review our internal processes related to financial reporting and filing deadlines. Identify any bottlenecks or inefficiencies contributing to the delays. • Continue to foster effective communication channels among team members responsible for financial reporting. Continue to ensure everyone understands their roles and responsibilities in meeting filing deadlines. • As always encourage training and development opportunities for staff. • Consider engaging external consultants or advisors to provide guidance around best practices. • Continue to foster a culture of continuous improvement within the organization. Encourage feedback from staff members on ways to streamline processes and identify opportunities for improvement. By implementing these corrective actions, ACAP is confident that we can address this late filing finding and strengthen our financial reporting practices moving forward. We are committed to ensuring timely and accurate reporting to uphold the trust and confidence of our stakeholders.
The District will contact DESE to determine if further steps are needed. The Assistant Superintendent of Student Services will facilitate this action.
The District will contact DESE to determine if further steps are needed. The Assistant Superintendent of Student Services will facilitate this action.
The District has made several attempts to secure weekly certified payrolls for construction projects on-going since July 2023 once notified of this deficiency for the 2022-2023 audit. We will continue to request certified payrolls for the months prior to April 2024 and will request the payroll info...
The District has made several attempts to secure weekly certified payrolls for construction projects on-going since July 2023 once notified of this deficiency for the 2022-2023 audit. We will continue to request certified payrolls for the months prior to April 2024 and will request the payroll information for current and future construction projects from this point forward. Documentation of attempts to collect the information will be maintained. This will be monitored by the Comptroller and Business Manager for the District.
Management concurs with this recommendation. GII Mission Team plans to complete the FFATA reporting on its Subaward Reporting System (FSRS) for the Federal Communications Commission grant (FCC). The team will provide training to relevant staff on GII’s New Grant Start Up checklist from the GII Grant...
Management concurs with this recommendation. GII Mission Team plans to complete the FFATA reporting on its Subaward Reporting System (FSRS) for the Federal Communications Commission grant (FCC). The team will provide training to relevant staff on GII’s New Grant Start Up checklist from the GII Grant Management Toolkit that requires a review of Grant Terms and Conditions including the FFATA reporting requirement for federal grants, and training on the process for reporting the FFATA on FSRS. This includes collection of required elements, such as the UEI number, congressional districts zip codes, and level of Federal grants received from subrecipients. Additionally, the supervisor must review and approve the report before submission. Confirmation of successful submission is required for the grant records. GII will review grant startup checklist within 30 days of receipt of grant with program manager and grant accounting staff to ensure all required activities are completed. The team will ensure that the grant start up process is followed with all new federal grants. With the described action plan, GII will strengthen supervision and review controls over evaluating subawards for reporting requirements under FFATA and tracking whether reporting occurs timely and accurately. Persons Responsible for Corrective Action: Martin Scaglione Kristin Pratt Chief Mission Officer Sr. Director Grant Operations and Administration Implementation of the Correction Action Plan: All corrective actions will be completed by June 30, 2024.
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Cheney School District No. 360 September 1, 2022 through August 31, 2023 This schedule presents the corrective action planned by the District for findings reported in this report in accordance with Title 2 U.S. Code of Federal Regu...
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Cheney School District No. 360 September 1, 2022 through August 31, 2023 This schedule presents the corrective action planned by the District for findings reported in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2023-001 Finding caption: The District’s internal controls were inadequate for ensuring compliance with federal procurement, suspension and debarment requirements. Name, address, and telephone of District contact person: Jamie Reed, Director of Finance & Operations 12414 S. Andrus Road (509) 559-4501 Corrective action the auditee plans to take in response to the finding: We acknowledge the importance of robust internal controls and adherence to federal procurement requirements. In response to the recommendations, we are committed to taking the following actions: 1) Training and Education: We will implement a comprehensive training program for all staff involved in procurement to ensure they have a clear understanding of both federal procurement requirements and our district’s policies and procedures. 2) Policy Review and Update: Our procurement policies and procedures will be reviewed and updated to align with the latest federal regulations. We will ensure these policies are easily accessible and communicated to all relevant staff members. 3) Verification Process: Before engaging with any contractor for services amounting to $25,000 or more, we will establish a verification process to check whether the contractors are in good standing and not suspended or debarred from participating in federal programs. We appreciate the diligence of the audit that led to these recommendations and are dedicated to upholding the highest standards of integrity and compliance in our procurement processes. Anticipated date to complete the corrective action: 2024
CORRECTIVE ACTION - FINDING 2023-004 - SEGREGATION OF DUTIES Anticipated Date of Completion: June 1, 2024 Name of Contact Person: Robin Vail, Business Manager Management Response: Management acknowledges the repeated finding concerning the segregation of duties within the accounting and bookkeeping ...
CORRECTIVE ACTION - FINDING 2023-004 - SEGREGATION OF DUTIES Anticipated Date of Completion: June 1, 2024 Name of Contact Person: Robin Vail, Business Manager Management Response: Management acknowledges the repeated finding concerning the segregation of duties within the accounting and bookkeeping functions at the beginning of the audit period. We recognize the importance of segregating these duties to safeguard assets and ensure the accuracy of financial information. While we faced limitations in resources during that period, we have since hired additional staff to mitigate this risk. Moving forward, we remain committed to maintaining an appropriate segregation of duties to strengthen internal controls and mitigate potential risks.
CORRECTIVE ACTION FINDING 2023-003 -- CASH MANAGEMENT Anticipated Date of Completion: June 1, 2024 Name of Contact Person: Robin Vail, Business Manager Management Response: Management acknowledges the material weakness identified in our cash management practices related to federal grant programs. To...
CORRECTIVE ACTION FINDING 2023-003 -- CASH MANAGEMENT Anticipated Date of Completion: June 1, 2024 Name of Contact Person: Robin Vail, Business Manager Management Response: Management acknowledges the material weakness identified in our cash management practices related to federal grant programs. To address this, we will enhance internal controls and allocate additional resources to support grant management activities. Improved communication between departments involved in grant management and reducing reliance on interfund borrowings through better cash flow forecasting will be prioritized. Establishing regular monitoring and reporting systems will provide visibility into grant fund status and facilitate smoother accounting processes. These actions aim to strengthen our cash management practices and ensure timely drawdowns and reporting for federal grant programs, ultimately optimizing the utilization of grant funds for program expenditures.
CORRECTIVE ACTION FINDING 2023-002 - TIMELY DRAWDOWN GRANT REIMBURSEMENTS Anticipated Date of Completion: June 1, 2024 Name of Contact Person: Robin Vail, Business Manager Management Response: Management acknowledges the finding regarding delays in performing drawdowns and reporting for federal gran...
CORRECTIVE ACTION FINDING 2023-002 - TIMELY DRAWDOWN GRANT REIMBURSEMENTS Anticipated Date of Completion: June 1, 2024 Name of Contact Person: Robin Vail, Business Manager Management Response: Management acknowledges the finding regarding delays in performing drawdowns and reporting for federal grant programs. To address this, we will implement a control process for timely drawdowns and reporting, ensuring adequate resource allocation and support for the Business Manager. Responsibilities will be delegated among the business office staff, and regular monthly reports on drawdown status will be provided to enhance transparency and accountability. These actions aim to improve the District's grant administration processes and ensure timely reimbursement for program expenditures.
18. Deficiency #18 SA-2023-005 a. Significant Deficiency - Recipients and sub-recipients that use ESF funds for remodeling, renovation or construction projects that are over $2,000 and use laborers and mechanics must meet Davis-Bacon prevailing wage requirements. b. Proper documentation was not rece...
18. Deficiency #18 SA-2023-005 a. Significant Deficiency - Recipients and sub-recipients that use ESF funds for remodeling, renovation or construction projects that are over $2,000 and use laborers and mechanics must meet Davis-Bacon prevailing wage requirements. b. Proper documentation was not received before disbursement to show prevailing wage requirements in relation to Charter School payments. Documentation was received during the audit when requested by charter schools and no errors/issues were found. Documentation and notes for the future have been noted for future disbursements. c. This was implemented as of February 2024. Governing
17. Deficiency #17 SA-2023-004 a. Significant Deficiency - The grant should properly report items in correct categories of expenditures. b. With new staff, the SEFA report was incorrectly reporting expenditures in wrong categories. Once identified by auditors, the SEF A was corrected and submitted. ...
17. Deficiency #17 SA-2023-004 a. Significant Deficiency - The grant should properly report items in correct categories of expenditures. b. With new staff, the SEFA report was incorrectly reporting expenditures in wrong categories. Once identified by auditors, the SEF A was corrected and submitted. Additional documentation was noted for next fiscal year to ensure federal expenditures are reported accurately. c. This was implemented as of February 2024.
16. Deficiency #16 SA-2023-003 a. Significant Deficiency - The schedule of federal expenditures should report all expenditures related to a federal grant. b. With new staff, the SEF A report was incorrectly reporting IDEA expenditures in wrong groups. Once identified by auditors, the SEF A was corre...
16. Deficiency #16 SA-2023-003 a. Significant Deficiency - The schedule of federal expenditures should report all expenditures related to a federal grant. b. With new staff, the SEF A report was incorrectly reporting IDEA expenditures in wrong groups. Once identified by auditors, the SEF A was corrected and submitted. Additional documentation was noted for next fiscal year to ensure federal expenditures are reported accurately. c. This was implemented as of February 2024.
15. Deficiency #15 SA-2023-002 a. Significant Deficiency - The schedule of federal expenditures should report all expenditures related to a federal grant. b. With changes during the audit process to expenditures, this resulted in a misstatement of the original SEF A reported to auditors. Subsequent ...
15. Deficiency #15 SA-2023-002 a. Significant Deficiency - The schedule of federal expenditures should report all expenditures related to a federal grant. b. With changes during the audit process to expenditures, this resulted in a misstatement of the original SEF A reported to auditors. Subsequent changes were made once new expenditure information was recorded and the SEF A was appropriately updated. c. This was implemented as of February 2024.
14. Deficiency #14 SA-2023-001 a. Significant Deficiency - The District misstated the pass through amounts to sub-recipients for this program. The District made subsequent corrections. b. Proper documentation was not received by Charter Schools for payments made with federal ESSER dollars. Subsequen...
14. Deficiency #14 SA-2023-001 a. Significant Deficiency - The District misstated the pass through amounts to sub-recipients for this program. The District made subsequent corrections. b. Proper documentation was not received by Charter Schools for payments made with federal ESSER dollars. Subsequent documentation was received during the audit process. This documentation has been noted for any future disbursements to ensure proper documentation is received beforehand. c. This was implemented as of March 2024
In Finding 2023-003, the Organization made one draw of federal funds that was not disbursed in a timely manner for program expenditures. The Organization is required to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments fo...
In Finding 2023-003, the Organization made one draw of federal funds that was not disbursed in a timely manner for program expenditures. The Organization is required to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes. The Organization understands the requirements to disburse federal funds in a timely manner. Procedures will be established to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes by the Organization.
In Finding 2023-002, it was reported that time and activity report are not maintained for salaried employees. The Organization’s operating processes in place do not require salaried employees to certify time and efforts on a monthly basis. Procedures will be established to maintain time and effort ...
In Finding 2023-002, it was reported that time and activity report are not maintained for salaried employees. The Organization’s operating processes in place do not require salaried employees to certify time and efforts on a monthly basis. Procedures will be established to maintain time and effort certifications by all salaried employees. Procedures will be established to ensure that salaried employees certify time and effort that coincide with the Organization’s payroll cycle (at least on a monthly basis).
In Finding 2023-001, it was reported that the Organization did not properly substantiate that proper documentation was obtained and that proper sliding fee discounts were applied for certain patients for the year ended December 31, 2023. Employees will be properly trained to document and apply the...
In Finding 2023-001, it was reported that the Organization did not properly substantiate that proper documentation was obtained and that proper sliding fee discounts were applied for certain patients for the year ended December 31, 2023. Employees will be properly trained to document and apply the sliding fee discounts in accordance with the Organization’s sliding fee policy. Sliding fee discounts will be reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. This review and training will be completed by May 31, 2024.
MVCHS acknowledges the need to implement procedures to verify the suspension and debarment status of contractors prior to using federal funds. The Finance Department will develop a process to check for suspension and debarment prior to issuing a purchase order. This process will be completed by May ...
MVCHS acknowledges the need to implement procedures to verify the suspension and debarment status of contractors prior to using federal funds. The Finance Department will develop a process to check for suspension and debarment prior to issuing a purchase order. This process will be completed by May 6, 2024. Carla Melendez, Chief Financial Officer will be responsible for developing and implementing this process.
MVCHS recognizes that in 2023 income for 4 out of 30 patients was incorrectly entered into the system and the slide was improperly applied. 1. MVCHS will also ensure that required income documents are obtained and that the correct income (s) are applied. MVCHS will also ensure that patients who are ...
MVCHS recognizes that in 2023 income for 4 out of 30 patients was incorrectly entered into the system and the slide was improperly applied. 1. MVCHS will also ensure that required income documents are obtained and that the correct income (s) are applied. MVCHS will also ensure that patients who are unable to provide written verification at the time of their first appointment will complete the self-declaration portion of the SFDP application. 2. MVCHS will provide training to Front Office staff to ensure that income and family size are properly entered into the system and the Slide is properly applied. MVCHS will ensure that proper documentation is collected from patients and that accurate information is entered into the system, even during staff turnover. Finance/Billing staff will ensure oversite of documentation. 3. MVCHS reached out to the New Mexico Primary Care Association and was provided training for the Front Office Staff regarding the Sliding Fee Discount Program process in April 2024.
Management's Views and Corrective Action Plan Finding 2023-002 - Non-Compliance with Financial Need Requirements for Subsidized Direct Loans in Non-Standard Semesters Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing#: 84.268 Award Titles: Federa...
Management's Views and Corrective Action Plan Finding 2023-002 - Non-Compliance with Financial Need Requirements for Subsidized Direct Loans in Non-Standard Semesters Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing#: 84.268 Award Titles: Federal Direct Student Loan Program Program Award Years: 7/2022 - 6/2024 Management agrees with the finding and proposes the following corrective action plan: Corrective Action Plan: When a student attends a standard semester (Fall and Winter), PeopleSoft uses the Prorated Estimated Family Contribution (EFC) Methodology to determine the subsidized loan eligibility based on their EFC. When a student attends a non-standard term (Spring), PeopleSoft uses the Automatic Zero EFC Methodology and offers subsidized loans to all students rather than the subsidized loan eligibility based on their EFC. Tammie Fonoimoana, Financial Aid & Scholarships Senior Manager, will work to update the PeopleSoft system to use the Prorated EFC Methodology for calculating subsidized loan eligibility for both standard and non-standard terms. In addition, Tammie Fonoimoana, Financial Aid & Scholarships Senior Manager, who is responsible for packaging and awarding of Financial Aid at Brigham Young University- Hawaii will continue to provide training to the staff who administer Title IV aid to ensure they are aware of the changes in packaging and awarding subsidized loans for the non-standard term (Spring). Also, Tammie Fonoimoana will oversee the implementation of controls wherein the University will implement preventative mechanisms to verify financial aid packages are calculated correctly. Timing: Tammie Fonoimoana, Financial Aid & Scholarships Senior Manager, will be responsible for overseeing that the items as noted in the corrective action plan section above will be implemented by July 1, 2024. Signed and Acknowledged, Tammie Fonoimoana, Senior Manager BYU-Hawaii Financial Aid & Scholarships Tammie.fonoimoana@byuh.edu 808-675-4737
View Audit 306965 Questioned Costs: $1
Management's Views and Corrective Action Plan Finding 2023-001 - Non-Compliance with Timely and Accurate Student Enrollment Change Submissions to the National Student Loan Data System (Significant Deficiency) Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assis...
Management's Views and Corrective Action Plan Finding 2023-001 - Non-Compliance with Timely and Accurate Student Enrollment Change Submissions to the National Student Loan Data System (Significant Deficiency) Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing#: 84.268, 84.063 Award Titles: Federal Direct Student Loan Program, Federal Pell Grant Program A ward Years: 7 /2022 - 6/2024 Management agrees with the finding and proposes the following corrective action plan: Corrective Action Plan: The prior year's corrective action plan was successful in addressing two of three issues identified in previous audits in enrollment reporting. These additional steps will be taken to address the remaining issue noted during the 2023 audit, which resulted in a repeat finding of 2022-001. When a student returns from a leave of absence, PeopleSoft updates the students' program begin date for the student's return date rather than the original program begin date. Daryl Whitford, Registrar, will continue reviewing program begin dates for students returning from a leave of absence to ensure the proper program begin date is reported to NSLDS. In addition, we will review if any PeopleSoft enhancements can be made to provide additional comfort that the program begin elates are accurate in these circumstances. Daryl Whitdord, Registrar, who is responsible for enrollment reporting at Brigham Young University Hawaii will continue to provide training to staff who participate in enrollment reporting to ensure that they are aware of the campus and program enrollment changes to be reported, the details to be reported for each change, and the importance of submitting changes timely. Also, Daryl Whitford, Registrar, will oversee the implementation of a control wherein the University will review program begin dates for students returning from leave of absence to ensure the proper program begin date is reported to NSLDS. Timing: Daryl Whitford, Registrar, will be responsible for overseeing that the items as noted in the corrective action plan section above will be implemented by September 1, 2024. Signed and Acknowledged, Daryl Whitford, Registrar BYU-Hawaii daryl.whitford@byuh.edu 808-675-3730
The following corrective actions have been put into place in order to address these findings:
The following corrective actions have been put into place in order to address these findings:
•       The district will follow all guidelines outlined by the USDA during the verification process.
•       The district will follow all guidelines outlined by the USDA during the verification process.
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