Corrective Action Plans

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Finding Number: 2023‐001, 2022‐002 Program Name/Assistance Listing Titles: COVID‐19 Education Stabilization Fund, COVID‐19 Emergency Connectivity Fund Program Assistance Listing Numbers: 84.425C, 84.425D, 84.425U, 84.425W, 32.009 Contact Person: Ricky Hernández, Chief Financial Officer Anticipated C...
Finding Number: 2023‐001, 2022‐002 Program Name/Assistance Listing Titles: COVID‐19 Education Stabilization Fund, COVID‐19 Emergency Connectivity Fund Program Assistance Listing Numbers: 84.425C, 84.425D, 84.425U, 84.425W, 32.009 Contact Person: Ricky Hernández, Chief Financial Officer Anticipated Completion Date: December 31, 2024 Planned Corrective Action: The physical inventory that was to be completed by June 30, 2022, was only partially completed, and only included technology equipment and no other assets. The District will begin a full physical inventory on or by June 1, 2024, with a planned completion date of December 31, 2024.
Finding 2023‐002 Federal Agency Name: U.S. Department of Health and Human Services Pass‐Through Entity: Federal Financial Assistance Listing 93.423 Assistance Listing Number: 1332 State Innovation Waivers Program Name: Maine Guaranteed Access Reinsurance Association (MGARA) Finding Summary: The Asso...
Finding 2023‐002 Federal Agency Name: U.S. Department of Health and Human Services Pass‐Through Entity: Federal Financial Assistance Listing 93.423 Assistance Listing Number: 1332 State Innovation Waivers Program Name: Maine Guaranteed Access Reinsurance Association (MGARA) Finding Summary: The Association’s existing controls over their IT environment for reviewing and reimbursing carriers for claims was not able to detect and prevent a claim from being reimbursed twice.Corrective Action Plan: The duplicate payment to Aetna was requested back to the program and will be received in April 2024. Going forward, the administrator will run reports at the beginning of each calendar year to ensure that all insurance carrier exception reports are generated. This will ensure that whenever claims are processed that all duplicate claims will be identified and denied. Responsible Individual(s): Diane Kopecky, administrator Anticipated Completion Date: April 2024
Condition and Context: The Housing Authority City of Kennewick's (KHA) audit was performed when the agency was going through a major software accounting conversion. The trial balance conversion had an unexpected delay which caused a delay in submitting financial reports and records to the auditors. ...
Condition and Context: The Housing Authority City of Kennewick's (KHA) audit was performed when the agency was going through a major software accounting conversion. The trial balance conversion had an unexpected delay which caused a delay in submitting financial reports and records to the auditors. The Housing Authority submitted documents requested between the sixth and seventh month after the fiscal year end. Auditors reviewed records submitted on the eighth month after the fiscal year end. This did not allow KHA enough time to upload additional information requested. The audit was not able to be completed by the due date and the report was not submitted to the Federal Clearinghouse which was due nine months after the fiscal year end. Recommendation: The Auditors recommended that the Authority develop a process or a procedure to ensure the preparation year-end financial records and draft financial statements is completed timely to allow sufficient time for the audit of such information to occur prior to all deadlines for audit submission. Plan for Corrective Action: Management addressed the internal control accounting deficiencies by establishing a year-end check list procedure to ensure that the financial statements and records are ready during audit timing. Additionally, now that the software conversion has been completed, management is acquiring a third-party consultant to assist with the accounting reporting settings and clearing up any pending software conversion issues. Actions Taken: KHA is now submitting the audit report to the Federal Clearinghouse as of the date of this report. Management has reached out to a third-party consultant to help clear out pending software issues and to ensure that accounting reports are correct for future audits.
Community Health Services, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: December 31, 2023 The findings from the December 31, 2023 schedule of findings and questioned costs are...
Community Health Services, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: December 31, 2023 The findings from the December 31, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS Section Ill- Federal Award Findings and Questioned Costs Health Center Program Cluster, Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), COVID - 19 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), Grants for New and Expanded Services under the Health Center Program and COVID-19 Grants for New and Expanded Services under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 Item 2023-00.1 - Special Tests Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated based on family size and income. Repeat Finding Yes Action Taken The Center implemented internal controls to mitigate the risk of missing sliding fee discount documentation. The creation of this control consisted of designing a report that would identify all sliding fee discount applicants for the specified timeframe, as well as identify whether supporting documentation had been scanned into the patient's electronic health record. The Director of Development, Grants and Outreach or the Director of Finance and Grants Administration reviews all slide applications before they are scanned and entered into the electronic health record and applied to the patient's account. The Center will continue monthly internal auditing procedures where an Eligibility Specialist haphazardly selects slide applications from the previous month to ensure compliance. As a result of the repeated finding, the Center created an excel template that will accurately calculate and feed the slide result in effort to minimize manual calculation errors. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Dianna Kulmacz, CFO at (860) 808-8765.
Section Ill- Federal Award Findings and Questioned Costs Health Center Program Cluster, Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), COVID - 19 Health Center Program (Community Health Centers, Migrant Health...
Section Ill- Federal Award Findings and Questioned Costs Health Center Program Cluster, Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), COVID - 19 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), Grants for New and Expanded Services under the Health Center Program and COVID-19 Grants for New and Expanded Services under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 Item 2023-001 - Special Tests Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated based on family size and income. Repeat Finding Yes Action Taken In 2023, IHC implemented each IHC site auditing five accounts per front office staff twice per month that will be reviewed by the Office Manager, Practice Manager, and Director of Operations, with any sliding issues being addressed with the respective front office staff with re­ education. As this has not resolved all the sliding fee issues, IHC will be implementing two-person verification for sliding fees provided for any eligible IHC patient. The following process will be followed for EVERY patient that presents with Proof of Income (POI). A. When a patient presents to the clinic and provides POI upon checking in or completing an Intake appointment, the Front Office Staff (FOS) will make a copy of the documents provided. B. The FOS will then calculate the income based on the POI provided, showing the work on the copy. C. The FOS will initial the document where the calculations were completed. D. They will then get a second person to verify the calculations were completed correctly and initial the document. E. The initial FOS employee will enter the information into the SFS section of the pt's chart. F. There will be a FOS SFS Two-Person Verification Log to track who verified each patients POI. G. The FOS SFS Two-Person Verification Log will be kept in the LMT Teams file for each site. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Mr. Tracy Nagel, CFO at (317) 576-1335. Sincerely yours, Mr. Tracy Nagel, Chief Financial Officer
Staff members have received updated training to become more familiar with the inventory process to ensure equipment is properly tracked.
Staff members have received updated training to become more familiar with the inventory process to ensure equipment is properly tracked.
Establishing a better process for federal contract procurement and prevailing wage requirements. Working with outside consultant to ensure vendors meet the federal compliance requirements as well.
Establishing a better process for federal contract procurement and prevailing wage requirements. Working with outside consultant to ensure vendors meet the federal compliance requirements as well.
During fiscal year 2023, the Medical Center dealt with multiple challenges including the implementation of a new accounting system and the loss of a key employee within the accounting department of the Medical Center that led the implementation of said new accounting system. Unfortunately, these cha...
During fiscal year 2023, the Medical Center dealt with multiple challenges including the implementation of a new accounting system and the loss of a key employee within the accounting department of the Medical Center that led the implementation of said new accounting system. Unfortunately, these challenges resulted in unfavorable conditions for the accounting department, as they had to learn the new accounting system without guidance from the employee that led the implementation. Moving forward, the Medical Center is focused on adequately training employees to use the new accounting system properly and delegating tasks including monthly reconciliations and closing procedures across the team. Additionally, the accounting department has already hired an additional accountant to help complete monthly reconciliations and closing procedures on a more timely basis. Lastly, we are implementing monthly check point meetings for the entire accounting team to help hold team members accountable for accomplishing their assigned tasks and responsibilities as efficiently as possible. Stuart Hill, CFO, is responsible for the implementation of this corrective action plan. As of 4/23/2024, the corrective actions have been fully implemented.
Finding No. 2023-003 21.027: COVID - 19: Coronavirus State and Local Fiscal Recovery Funds Personnel Responsible for Corrective Action: Name: Edith Robles Department: Finance Title: Director of Finance Anticipated Completion Date: June 30, 2024 Corrective Action Plan: An adequate subrecipient risk a...
Finding No. 2023-003 21.027: COVID - 19: Coronavirus State and Local Fiscal Recovery Funds Personnel Responsible for Corrective Action: Name: Edith Robles Department: Finance Title: Director of Finance Anticipated Completion Date: June 30, 2024 Corrective Action Plan: An adequate subrecipient risk assessment policy will be put in place to evaluate and monitor subrecipients. Southwest Organizing Project will provide subrecipients with all required Federal awards identifiers. Edith Robles will ensure that Federal award identifiers are included in subrecipients grant agreements.
Finding No. 2023-002 93.391, Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crises Personnel Responsible for Corrective Action: Name: Edith Robles Department: Finance Title: Director of Finance Anticipated Completion Date: ...
Finding No. 2023-002 93.391, Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crises Personnel Responsible for Corrective Action: Name: Edith Robles Department: Finance Title: Director of Finance Anticipated Completion Date: June 30, 2024 Corrective Action Plan: An adequate subrecipients risk assessment policy will be put in place to evaluate and monitor subrecipients. Southwest Organizing Project will provide subrecipients with all required Federal awards identifiers. Subrecipients will be required to provide a single audit when applicable and a signed statement if not applicable. Edith Robles will monitor receipt of single audits during the budgeting process and when closing out programs as well as record keeping for audit and reporting evidence.
Finding No. 2023-001 Schedule of Expenditures of Federal Awards Personnel Responsible for Corrective Action: Name: Edith Robles Department: Finance Title: Director of Finance Anticipated Completion Date: June 30, 2024 Corrective Action Plan: An adequate system of internal controls will be put in pla...
Finding No. 2023-001 Schedule of Expenditures of Federal Awards Personnel Responsible for Corrective Action: Name: Edith Robles Department: Finance Title: Director of Finance Anticipated Completion Date: June 30, 2024 Corrective Action Plan: An adequate system of internal controls will be put in place by the end of fiscal year 2024. To ensure SEFA will include accurate assisting listing numbers and accurate inclusion of all federal programs. Allowable and unallowable costs will be reviewed to ensure accurate federal expenditure reporting. Edith Robles will perform an exhaustive review of all grants to close out the fiscal year in preparation for the audit process. In addition to these, SWOP will work with a consultant to provide necessary training of finance personnel.
CORRECTIVE ACTION PLAN Auditee: CAAP Housing, Inc. HUD Project Number: 073-11685 Audit Firm: Agresta, Storms & O’Leary PC Audit Period Ended December 31, 2023 Corrective Action Plan Prepared by: Name: Chuck Pechette Position: President, Mark III Management A. Current Findings on ...
CORRECTIVE ACTION PLAN Auditee: CAAP Housing, Inc. HUD Project Number: 073-11685 Audit Firm: Agresta, Storms & O’Leary PC Audit Period Ended December 31, 2023 Corrective Action Plan Prepared by: Name: Chuck Pechette Position: President, Mark III Management A. Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Finding No. 2023-001 A. Comments on the Finding and Each Recommendation: Management agrees with the finding that the security deposit cash account was underfunded at December 31, 2023. B. Action Taken or Planned on the Finding: Management will transfer the required funds to the security deposit cash account when the funds are available. B. Status of Corrective Actions on Findings Reported in the Prior Audit Schedule of Findings, Questioned Costs, and Recommendations See Finding No. 2023-001 for status of Finding No. 2022-001. Respectfully Submitted, Chuck Pechette President Mark III Management
View Audit 305189 Questioned Costs: $1
Finding 395578 (2023-002)
Significant Deficiency 2023
Finding 2023-002 Condition/Context The Corporation used the Lost Revenues Reporting Method: Alternative Reasonable Methodology (Option 3) for measuring lost revenues. In the Corporation's Period 4 submission for Robert Packer Hospital, TIN 24-0795463, total lost revenues were incorrectly reported as...
Finding 2023-002 Condition/Context The Corporation used the Lost Revenues Reporting Method: Alternative Reasonable Methodology (Option 3) for measuring lost revenues. In the Corporation's Period 4 submission for Robert Packer Hospital, TIN 24-0795463, total lost revenues were incorrectly reported as $13,011,879, rather than $12,930,176. Total lost revenues available to be used in this reporting period based on the adjusted amount was $7,142,168 on payments in the period of $7,142,168. This is not a statistically valid sample. Corrective Action Plan Corrective Action Planned: The Corporation agrees with the finding. Management increased the level of review over the lost revenue calculations for future reporting periods. Management did not believe that further corrections to the Period 4 report were necessary as the remaining available lost revenues after adjusting for the error were equal to the payments received in the period and there was no further submissions necessary for Robert Parker Hospital. Name(s) of Contact Person(s) Responsible for Corrective Action: Sean Monahan, Corporate Financial Controller and Fran Macafee, VP, CFO – Guthrie Lourdes Hospital. Anticipated Completion Date: September 30, 2023
Finding 395577 (2023-001)
Significant Deficiency 2023
Finding 2023-001 Condition/Context The Corporation’s review process failed to detect errors in the calculation of amounts related to the pay for event program that were applied to the Federal award. Errors were discovered in 8 of the 44 items tested for the pay for event program which would have inc...
Finding 2023-001 Condition/Context The Corporation’s review process failed to detect errors in the calculation of amounts related to the pay for event program that were applied to the Federal award. Errors were discovered in 8 of the 44 items tested for the pay for event program which would have increased the allowable costs eligible for reimbursement under the Federal award by $671. This is not a statistically valid sample. Corrective Action Plan Corrective Action Planned: The Corporation agrees with the finding. Management implemented an enhanced review process to validate all amounts reported on the PRF Reporting Portal Submission, and to ensure compliance with existing policies and terms and conditions of the Provider Relief Funds. Further action was not considered necessary as the errors would result in increased costs eligible for reimbursement under the Federal award and no further funding is available. Name(s) of Contact Person(s) Responsible for Corrective Action: Kristen Maffei, Manager – Nursing Administration, Sean Monahan, Corporate Financial Controller and Fran Macafee, VP, CFO – Guthrie Lourdes Hospital. Kristen Maffei, Manager – Nursing Administration, Sean Monahan, Corporate Financial Controller and Fran Macafee, VP, CFO – Guthrie Lourdes Hospital. Anticipated Completion Date: This was corrected as of June 30, 2023, and the pay for event program was phased-out after the final Provider Relief Funds were released.
The person responsible for corrective action is Rick Martinez, Superintendent. Procedures have been implemented to assure the District has no significant deficiencies in internal controls or noncompliance in the future. The District has hired new personnel in key areas and have sought outside help f...
The person responsible for corrective action is Rick Martinez, Superintendent. Procedures have been implemented to assure the District has no significant deficiencies in internal controls or noncompliance in the future. The District has hired new personnel in key areas and have sought outside help from the Region Service Center. 79
The person responsible for corrective action is Rick Martinez, Superintendent. Procedures have been implemented to assure the District has no significant deficiencies in internal controls or noncompliance in the future. The District has hired new personnel in key areas and have sought outside help f...
The person responsible for corrective action is Rick Martinez, Superintendent. Procedures have been implemented to assure the District has no significant deficiencies in internal controls or noncompliance in the future. The District has hired new personnel in key areas and have sought outside help from the Region Service Center. 79
The person responsible for corrective action is Rick Martinez, Superintendent. Procedures have been implemented to assure the District has no significant deficiencies in internal controls or noncompliance in the future. The District has hired new personnel in key areas and have sought outside help f...
The person responsible for corrective action is Rick Martinez, Superintendent. Procedures have been implemented to assure the District has no significant deficiencies in internal controls or noncompliance in the future. The District has hired new personnel in key areas and have sought outside help from the Region Service Center. 79
Institutional Comments on Findings and Recommendations: The institution agrees with the auditor on this finding in that there were (3) three cases where the enrollment status was not reported correctly. Although as was observed by the auditor, the enrollment status for the three students in questio...
Institutional Comments on Findings and Recommendations: The institution agrees with the auditor on this finding in that there were (3) three cases where the enrollment status was not reported correctly. Although as was observed by the auditor, the enrollment status for the three students in question were corrected in the next enrollment report that was submitted. During the audit period, the institution was unable to update, submit or complete in a timely manner Enrollment reports for the period of July through December 2022. This was mainly due to problems with the implementation of a new format for enrollment reporting through the NSLDS Modernized Website. The institution has on file, multiple inquiries to the NSLDS Customer Support Center in relation to this issue. The Department of Education also posted various Electronic Announcements updating and giving continued guidance to institutions on this issue. The auditors were provided with copies of all of ED’s posting and updates as related to this issue. Nevertheless, during the subsequent months from January 2023 to June 2023 covered in this audit period, the institution was able to complete and report the current enrollment status of students to the NSLDS platform. Actions Taken or Planned: The matter as related to this finding has already been discussed with the Registrar who is responsible for the completion and submission of the Enrollment Reports to the Department of Education To continue to improve on the reporting to student’s enrollment status, the institution would continue to submit its Enrollment Reports monthly instead of every two months as schedule. Status of Corrective Actions on Prior Findings: The issue as related to this finding occurred in the past audit.
Institutional Comments on Findings and Recommendations: Compliance Requirements – Applicable After a Student Begins Attendance: The institution agrees with the auditors on this finding in which there were two (2) cases where the auditors noted that the institution failed to determine that the stud...
Institutional Comments on Findings and Recommendations: Compliance Requirements – Applicable After a Student Begins Attendance: The institution agrees with the auditors on this finding in which there were two (2) cases where the auditors noted that the institution failed to determine that the students withdrew within fourteen (14) days after the student’s last day of attendance. In one (1) of the two (2) cases the Date of Determination was twenty-two (22) days after the Last Day of Attendance and in the second case, the Date of Determination was Three (3) days after the Last Day of Attendance. All funds due to the Department, (for the first case $682.00 of Unsub. Direct Loan funds and in the second case $974.22 of Federal Pell Grant funds), were returned within the forty-five (45) days required timeframe as of the Date of Determination of each case. This process was evidenced to the auditors for their records. Actions Taken or Planned: The institution is fully aware of the Return of Title IV funds (R2T4) reporting requirements and deadlines. The issue related to this finding was identified as a lack in some Faculty notifying student absences within the fourteen (14) day timeframe to process an R2T4 in a timely manner as required. Although this issue was already discussed with them by the Dean of Academic Affairs, an additional follow up meeting would be held to remind them of the importance in monitoring student attendance and notifying student absences to the Registrar office within the required timeframes to fully comply with the R2T4 reporting requirements. Status of Corrective Actions on Prior Findings: The issue as related to this finding occurred in the past audit.
View Audit 305178 Questioned Costs: $1
Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to disbursing loans within aggregate loan limits. Responsible Administrators: Director of Financial Aid Effective: Immediately and ongoing
Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to disbursing loans within aggregate loan limits. Responsible Administrators: Director of Financial Aid Effective: Immediately and ongoing
Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to competing and submitting the audit. The College has a new CFO and Controller. These measures will ensure stability and a timely audit. Responsible Administ...
Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to competing and submitting the audit. The College has a new CFO and Controller. These measures will ensure stability and a timely audit. Responsible Administrators: Director of Financial Aid & Chief Financial Officer Effective immediately and ongoing
Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to calculating and awarding Pell. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid & Chief Fin...
Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to calculating and awarding Pell. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid & Chief Financial Officer Effective: Immediately and ongoing
View Audit 305169 Questioned Costs: $1
Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to over awarding students. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid & Chief Financial ...
Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to over awarding students. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid & Chief Financial Officer Effective: Immediately and ongoing
View Audit 305169 Questioned Costs: $1
Management concurs with this finding. The College will review and adhere to its practices, policies, and procedures along with federal guidelines as it relates to students meeting satisfactory academic progress. The College has an SAP appeal committee in place to enforce and abide by the College's...
Management concurs with this finding. The College will review and adhere to its practices, policies, and procedures along with federal guidelines as it relates to students meeting satisfactory academic progress. The College has an SAP appeal committee in place to enforce and abide by the College's policy. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid Effective: Immediately and ongoing
View Audit 305169 Questioned Costs: $1
Management concurs with this finding. The College will review and adhere to its practices, policies, and procedures along with federal guidelines as it relates to disbursing and administering federal aid. The College will return any ineligible funds accordingly. Responsible Administrators: Direct...
Management concurs with this finding. The College will review and adhere to its practices, policies, and procedures along with federal guidelines as it relates to disbursing and administering federal aid. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid, Chief Financial Officer & V.P. of Academic Affairs Effective: Immediately and ongoing
View Audit 305169 Questioned Costs: $1
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