Corrective Action Plans

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Condition Found: The Organization has not applied sliding fee discounts to patient charges consistent with its sliding fee discount program. Individual(s) Responsible for Corrective Action: Tina Gerlack, Billing Manager Planned Corrective Action: HealthFirst will continue to provide training on sl...
Condition Found: The Organization has not applied sliding fee discounts to patient charges consistent with its sliding fee discount program. Individual(s) Responsible for Corrective Action: Tina Gerlack, Billing Manager Planned Corrective Action: HealthFirst will continue to provide training on sliding fee eligibility to all staff related to sliding fee enrollment. HealthFirst will also continue to do monthly audits on all patients who receive a sliding fee discount. The monthly audits will include verifying the correct fee was applied based on documents received during the patients sliding fee enrollment. If any errors are found they will be immediately corrected. Anticipated Completion Date: 1/1/2024
Finding Number: 2023-002 Condition: Out of 60 allowability samples that were tested, one expenditure tested was determined to be incorrectly charged to this grant. Planned Corrective Action: The College of Cooperative Education and Professional Studies (CCPS) has instituted several reforms to prev...
Finding Number: 2023-002 Condition: Out of 60 allowability samples that were tested, one expenditure tested was determined to be incorrectly charged to this grant. Planned Corrective Action: The College of Cooperative Education and Professional Studies (CCPS) has instituted several reforms to prevent future instances of this nature. The Program Director is now required to review and sign-off on all transactions before they are charged to the project, to ensure all charges are appropriate. New staff have been assigned to the project to process transactions, and the CCPS business office is now meeting monthly to review project activity, discuss any questions, and address any concerns regarding financial activities. Additionally, the university is drafting a new policy to review and, if needed, provide additional administrative support for large, complex grant projects. This policy will require that grant proposals above a certain dollar threshold are reviewed by the Office of Research prior to submission to ensure proper resources will be available to manage the project if awarded. In cases where the Office of Research determines additional resources may be needed, they will be authorized to require additional support be included in the grant proposal, or else provide additional administrative help to the unit at the time of award. Contact person responsible for corrective action: CCPS: Jeremy Harvey, Jodi Sleyo, and Bailey Bartels. Office of Research: Patrick Clark Anticipated Completion Date: CCPS changes have been implemented as of 10/11/2023; policy changes to be completed by 6/30/2024.
View Audit 293505 Questioned Costs: $1
Finding Number: 2023-001 Condition: Out of 28 payments to subrecipients that were tested, 12 were made after the 30 calendar day requirement. Planned Corrective Action: Accounts Payable personnel will review all vendor invoices to determine whether an invoice is related to a federal award expendit...
Finding Number: 2023-001 Condition: Out of 28 payments to subrecipients that were tested, 12 were made after the 30 calendar day requirement. Planned Corrective Action: Accounts Payable personnel will review all vendor invoices to determine whether an invoice is related to a federal award expenditure. For federal award expenditures, Accounts Payable will manually change the payment terms to 30 calendar days or less, to ensure compliance. Periodically, Accounts Payable will review open federal award payables to verify payment terms have been properly set for the 30-day compliance requirement. The Controller’s and Accounts Payable Offices will also explore creating a more efficient long-term solution, whereby the 30-day terms could be automatically set during the purchase order creation process. This would eliminate any manual updates to the payment terms by Accounts Payable personnel. The Sponsored Research Services Accounting Office will send reminders to all college business officers and Principal Investigators (PIs) to highlight the need for prompt review and approval of Federal award invoices. This language will be incorporated into the SRS Best Grant Practices training classes, as well as the university’s Fundamentals of Sponsored Administration training courses. Contact person responsible for corrective action: Accounts Payable: Erik Sager; Purchasing: Tom Guerin; Sponsored Research Services Accounting: John Ungruhe Anticipated Completion Date: Initial corrective action, including review of invoices, reminders and modifications to training, will be completed by 10/31/2023. Additional solutions to eliminate manual updates, if possible, will be completed within 12 months.
WE HAVE REVIEWED AND ARE FAMILIAR WITH THE REQUIRED COMPLIANCE REQUIREMENTS UNDER THE COMPLIANCE STATEMENT WHICH GOVERNS THE ARP ESSER PROGRAM. WE HAVE REQUESTED AND RECEIVED DOCUMENTATION FROM EACH VENDOR THAT ATTESTS THAT THEY ARE CONFORMING TO DAVIS-BACON PREVAILING WAGE REQUIREMENTS.
WE HAVE REVIEWED AND ARE FAMILIAR WITH THE REQUIRED COMPLIANCE REQUIREMENTS UNDER THE COMPLIANCE STATEMENT WHICH GOVERNS THE ARP ESSER PROGRAM. WE HAVE REQUESTED AND RECEIVED DOCUMENTATION FROM EACH VENDOR THAT ATTESTS THAT THEY ARE CONFORMING TO DAVIS-BACON PREVAILING WAGE REQUIREMENTS.
View Audit 293502 Questioned Costs: $1
Finding #2023-001 -Limited Segregation of Duties (Prior Year Finding #2022-001) Condition: The available office staff precludes a proper segregation of duties in the control areas reviewed. Effect: Because of the lack of segregation of duties, errors or irregularities could occur and not be detected...
Finding #2023-001 -Limited Segregation of Duties (Prior Year Finding #2022-001) Condition: The available office staff precludes a proper segregation of duties in the control areas reviewed. Effect: Because of the lack of segregation of duties, errors or irregularities could occur and not be detected on a timely basis. Cause: The condition is due to limited staff available. Criteria: Internal controls should be in place that provide adequate segregation of duties. Generally, a system of internal control contemplates separation of duties such that no individual has responsibility to execute a transaction, have physical access to the related assets, and have responsibility or authority to record the transaction. Recommendation: Procedures should be implemented segregating duties among different employees. Management should continue to maintain a working knowledge of matters relating to the district's operations. Response: We agree with this finding and continue to work to achieve segregation of duties whenever cost effective. The cash disbursements process includes approval of purchase orders and matching of approved purchase orders with invoices. Review of account coding is perfo1med by the district accounting staff. The payroll disbursement process includes approval of timesheets and review of coding on an ongoing basis. The Board of Education reviews budget to actual information along with disbursement information monthly.
Condition: The District claimed $136,026 of capital expenditures between their March 31, 2023 and June 30, 2023 reimbursement claim submitted to the Illinois State Board of Education that could not be supported by documentation. Plan: The District is in the process of restructuring finance and opera...
Condition: The District claimed $136,026 of capital expenditures between their March 31, 2023 and June 30, 2023 reimbursement claim submitted to the Illinois State Board of Education that could not be supported by documentation. Plan: The District is in the process of restructuring finance and operations to align roles and responsibilities. We will implement additional procedures for review and approval of reimbursement claims prior to submission to ensure that expenditures are claimed within a reasonable period of time in relation to when a reimbursement claim is submitted. Anticipated Date of Completion: 6/30/2024 Name of Contact Person: Sheila Johnson, Assistant Superintendent of Finance and Operations
View Audit 293479 Questioned Costs: $1
The lead maintenance person was out on long term disability which created a staffing shortage and a delay in our normal semi annual unit inspections. This position is now filled and unit inspections are scheduled for October 19th. Multifamily Select Inc will monitor unit inspections to insure semi a...
The lead maintenance person was out on long term disability which created a staffing shortage and a delay in our normal semi annual unit inspections. This position is now filled and unit inspections are scheduled for October 19th. Multifamily Select Inc will monitor unit inspections to insure semi annual inspections are conducted regularly
Finding 372171 (2023-002)
Significant Deficiency 2023
2023-002 Program: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Financial Assistance Listing Number: 21.027 Federal Agency: U.S. Department of Treasury Award Year: 2021 Grant Award Number: N/A Compliance Requirement: Suspension and Debarment Type of Finding: Significant Deficiency in ...
2023-002 Program: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Financial Assistance Listing Number: 21.027 Federal Agency: U.S. Department of Treasury Award Year: 2021 Grant Award Number: N/A Compliance Requirement: Suspension and Debarment Type of Finding: Significant Deficiency in Internal Control Over Compliance Views of Responsible Officials: The City will revise it’s policies and procedures to perform verification of suspension or debarment status for each vendor before the City enters into a covered transaction with the vendor. Name of Responsible Person: Karen Ogawa, Director of Finance Implementation Date: February 21, 2024
Finding 372170 (2023-001)
Significant Deficiency 2023
2023-001 Program: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Financial Assistance Listing Number: 21.027 Federal Agency: U.S. Department of Treasury Award Year: 2021 Grant Award Number: N/A Compliance Requirement: Reporting Type of Finding: Significant Deficiency in Internal Contro...
2023-001 Program: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Financial Assistance Listing Number: 21.027 Federal Agency: U.S. Department of Treasury Award Year: 2021 Grant Award Number: N/A Compliance Requirement: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance Views of Responsible Officials: The City will revise its policies and procedures to incorporate an appropriate level of review prior to report submission. The Finance Manager will review all program reporting for Coronavirus State and Local Fiscal Recovery Funds and the Director of finance will approve and submit all program reporting. Name of Responsible Person: Karen Ogawa, Director of Finance Implementation Date: February 21, 2024
Going forward, we plan to implement robust policies and procedures to ensure the proper documention is obtained and maintained for each student who is removed from the adjusted cohort. This will involve establishing clear guidelines for confirming student transfers and ensuring that official written...
Going forward, we plan to implement robust policies and procedures to ensure the proper documention is obtained and maintained for each student who is removed from the adjusted cohort. This will involve establishing clear guidelines for confirming student transfers and ensuring that official written documentation is obtained and retained accordingly. Furthermore, we will conduct trainging sessions for relevant staff members involved in the documentation process to ensure understanding and adherence to the updated procedures. THis will help prevent similar issues from arising in the future and contribute to the accuracy and reliability of our graduation rate calculations.
ACOE updated the purchasing procurement policy and offered agency-wide training.
ACOE updated the purchasing procurement policy and offered agency-wide training.
View Audit 293447 Questioned Costs: $1
ACOE updated the procurement and statement temp to match the requirements.
ACOE updated the procurement and statement temp to match the requirements.
View Audit 293447 Questioned Costs: $1
ACOE updated the new Time and Effort policy and offered agency-wide training.
ACOE updated the new Time and Effort policy and offered agency-wide training.
View Audit 293447 Questioned Costs: $1
Finding 2023‐002 Material weakness in internal controls over compliance for earmarking and material noncompliance for earmarking in the U.S. Refugee Admissions Program. Contact Person(s): Nicholas Lee, Chief Financial Officer Corrective action planned: The accounting team will work alongside the pro...
Finding 2023‐002 Material weakness in internal controls over compliance for earmarking and material noncompliance for earmarking in the U.S. Refugee Admissions Program. Contact Person(s): Nicholas Lee, Chief Financial Officer Corrective action planned: The accounting team will work alongside the program management to develop and maintain a client tracker. Monthly meetings will be established to review spend, and resolve any questions. The client tracker will be established for the entire FYE June 30, 2024, and completed by August 31, 2024. The meetings will be established prior to the FYE June 30, 2024. Anticipated completion date: August 31, 2024
The quarterly closing checklist will include required reporting to be verified by the Accounting Manager and Executive Director of Accounting no later than 30days after the end of the quarter. Quarterly grant meetings will be held to maintain quarterly progress reporting.
The quarterly closing checklist will include required reporting to be verified by the Accounting Manager and Executive Director of Accounting no later than 30days after the end of the quarter. Quarterly grant meetings will be held to maintain quarterly progress reporting.
Enrollment certifications will be sent to the National Student Clearninghouse on a monthly basis, no later than 10 days following the end of the month. The final degree file will be submitted no later than 30 days after the last day of class, with additional awards submitted individually. The Financ...
Enrollment certifications will be sent to the National Student Clearninghouse on a monthly basis, no later than 10 days following the end of the month. The final degree file will be submitted no later than 30 days after the last day of class, with additional awards submitted individually. The Financial Aid Director will review all NSLDS errors.
Doane has reviewed the finding and is researching ways to improve the process.
Doane has reviewed the finding and is researching ways to improve the process.
The Financial Aid team is conducting staff training regarding return to Title IV calculations and compliance led by the Financial Aid Director. This includes all return to Title IV calculations being reviewed by the Financial Aid Director before final submission.
The Financial Aid team is conducting staff training regarding return to Title IV calculations and compliance led by the Financial Aid Director. This includes all return to Title IV calculations being reviewed by the Financial Aid Director before final submission.
View Audit 293420 Questioned Costs: $1
SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF AGRICULTURE, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, CHILD NUTRITION CLUSTER – FEDERAL ALN 10.553, 10.555, AND 10.556 2023-003 Internal Control Over Compliance With Federal Suspension and Debarment Requiremen...
SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF AGRICULTURE, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, CHILD NUTRITION CLUSTER – FEDERAL ALN 10.553, 10.555, AND 10.556 2023-003 Internal Control Over Compliance With Federal Suspension and Debarment Requirements Finding Summary 2 CFR § 180 requires the District to establish and maintain effective internal control over compliance with requirements applicable to federal program expenditures, including suspension and debarment requirements applicable to the child nutrition cluster federal program. The District did not have sufficient controls in place within its child nutrition cluster federal program to assure that it was not contracting for goods or services with parties that are suspended or debarred, or whose principals are suspended or debarred from participating in contracts involving the expenditures of federal program funds. Corrective Action Plan Actions Planned – The District will review policies and procedures relating to suspension and debarment for its federal programs and will ensure that all parties with which it contracts for goods or services are eligible to participate in contracts involving the expenditures of federal program funding. Official Responsible – Kerstin Quigley, Business Manager. Planned Completion Date – June 30, 2024. Disagreement With or Explanation of Finding – The District agrees with this finding. Plan to Monitor – The District’s Business Manager and the Superintendent will ensure appropriate controls are in place to verify that any vendor with which the District contracts for federal program goods or services exceeding $25,000 is not listed as suspended or debarred on the federal Excluded Parties List System website.
Finding #2023-002 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Treasury, Assistance Listing #21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds, Passed through Harris County, Texas, Contract #220163, Contract year: 12/01/22 – 12...
Finding #2023-002 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Treasury, Assistance Listing #21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds, Passed through Harris County, Texas, Contract #220163, Contract year: 12/01/22 – 12/31/24, U. S. Department of Health and Human Services:, Assistance Listing #93.243, Substance Abuse and Mental Health Services Projects of Regional and National Significance, Contract #5H79TI080624-03, Contract year: 09/30/21 – 09/29/22, Contract #5H79TI080624-04, Contract year: 09/30/22 – 09/29/23, Passed through the City of Houston Health Department, Contract #H79SP080300, Contract years: 11/01/21 – 10/31/22, 11/01/22 – 10/31/23 and 06/08/21 – 06/30/23, Assistance Listing #93.788, Opioid STR, Passed through the Texas Health and Human Services Commission, Contract #HHS000357900001, Contract years: 09/01/21 – 08/31/22 and 09/01/22 – 08/31/23, Passed through the University of Texas Health Science Center, San Antonio, Contract #HHS000561800001, Contract year: 09/01/21 – 08/31/22, Assistance Listing #93.959, Block Grants for Prevention and Treatment of Substance Abuse, Passed through the Texas Health and Human Services Commission, Contract #HHS000130500019, Contract years: 09/01/21 – 08/31/22 and 09/01/22 – 08/31/23. Condition and context: Houston Recovery Center is required to submit monthly reimbursement requests for five of its federal programs; one program requires reimbursement requests based on achievement of certain milestones rather than time. Out of a sample of 17 requests, we found six did not have evidence of review and approval as required by Houston Recovery Center’s policies and procedures. Recommendation: Training should be provided to ensure that policies and procedures regarding independent review and approval are followed. Planned corrective action: Houston Recovery Center will strengthen its internal control policies and procedures over independent review and approval of grant payment requests by shifting the primary review and approval process from the Chief Executive Officer (CEO) to the Chief Operating Officer (COO). The COO has full knowledge of allowable costs and has more availability than the CEO, which will make it easier to ensure that our policies and procedures are followed on a consistent basis. The CEO will continue in this role as backup to the COO to ensure immediate access for needed approval. We believe we have a strong system in place used by our accounting department to ensure all expenses underlying the grant payment requests are reviewed, checked for accuracy, and properly approved which further supports the reimbursement policies and procedures. Responsible officer: Leonard Kincaid, Executive Director. Estimated completion date: November 1, 2023.
Finding #2023-001 – Material Weakness and Material Noncompliance. Major programs: U. S. Department of Health and Human Services:, Assistance Listing #93.243, Substance Abuse and Mental Health Services Projects of Regional and National Significance, Contract #5H79TI080624-03, Contract year: 09/30/2...
Finding #2023-001 – Material Weakness and Material Noncompliance. Major programs: U. S. Department of Health and Human Services:, Assistance Listing #93.243, Substance Abuse and Mental Health Services Projects of Regional and National Significance, Contract #5H79TI080624-03, Contract year: 09/30/21 – 09/29/22, Contract #5H79TI080624-04, Contract year: 09/30/22 – 09/29/23, Assistance Listing #93.959, Block Grants for Prevention and Treatment of Substance Abuse, Passed through the Texas Health and Human Services Commission, Contract #HHS000130500019, Contract years: 09/01/21 – 08/31/22 and 09/01/22 – 08/31/23, Passed through the City of Houston Health Department, Contract #H79SP080300, Contract years: 11/01/21 – 10/31/22, 11/01/22 – 10/31/23 and 06/08/21 – 06/30/23. Other federal programs: U. S. Department of Treasury, Assistance Listing #21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds, Passed through Harris County, Texas, Contract #220163, Contract year: 12/01/22 – 12/31/24, Assistance Listing #93.788, Opioid STR, Passed through the Texas Health and Human Services Commission, Contract #HHS000357900001, Contract years: 09/01/21 – 08/31/22 and 09/01/22 – 08/31/23, Passed through the University of Texas Health Science Center, San Antonio, Contract #HHS000561800001, Contract year: 09/01/21 – 08/31/22. Condition and context: Houston Recovery Center has personnel funded by more than one grant award. The responsibilities for each position are examined and an assessment of time needed to perform each assigned task is made. The time allotment is then converted to a percentage of salary, documented on the personnel action form for each employee, and used to create the personnel section of each grant budget. Each grant is charged based on the percentages documented on the personnel action forms. In fiscal 2022, quarterly time studies were utilized to support that the budgeted estimates per the personnel action forms were reasonable and, if needed, adjustments were made in the general ledger. On July 1, 2022, Houston Recovery Center changed third-party payroll processors and the new processor did not provide the capability to charge time to more than one cost center. Therefore, while allocations are still made in the general ledger based on the percentages documented on the employee’s personnel action form, actual time worked by grant/cost center was not tracked. Additionally, a time study was not performed in the year ended June 30, 2023 to evaluate the reasonableness of time charged to the grants. Recommendation: Houston Recovery Center should establish policies and procedures to ensure that grants are charged based on actual time and effort expended. Planned corrective action: Management believes that the grants were reasonably charged in all material respects although the payroll provider was unable to allow us to use actual time and effort. Comparison of fiscal year 2022 actual time and effort with the fiscal year 2022 time studies revealed very small differences. However, Houston Recovery Center is in the process of changing to a payroll software provider where actual time can be tracked to each grant as supported by a timesheet. In addition, Houston Recovery Center is using Time Distribution Sheets (TDSs) where the employee is required to record their hours worked by grants. Training on the TDSs will be completed by November 1, 2023 for all employees on multiple awards as appropriate. TDSs will be turned in weekly and utilized until the payroll conversion is completed and is working as needed. Responsible officer: Leonard Kincaid, Executive Director. Estimated completion date: November 1, 2023.
Management agrees with the finding. Management will submit the forms for USDA's approval.
Management agrees with the finding. Management will submit the forms for USDA's approval.
View Audit 293412 Questioned Costs: $1
Management agrees with the finding. The replacement reserve deficiency will be funded in the amount of $12,000. Management will ensure that the replacement reserve deposits are made on a timely basis in the future.
Management agrees with the finding. The replacement reserve deficiency will be funded in the amount of $12,000. Management will ensure that the replacement reserve deposits are made on a timely basis in the future.
Internal Control over Compliance- Cash Management Recommendation: Internal controls are designed to ensure an adequate review and approval process is in place before submission of any drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding...
Internal Control over Compliance- Cash Management Recommendation: Internal controls are designed to ensure an adequate review and approval process is in place before submission of any drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Response by management to the finding: Management has implemented appropriate controls to ensure drawdowns are reviewed and approved by staff familiar with the purpose and operations of the contracts before requests are processed in the payment management system. Name of the contact person responsible for corrective action: David Rivera-Garcia, Executive Vice President/CFO Planned completion date for corrective action plan: June 2024
Federal Award Findings and Questioned Costs Reference Number: 2023‐001 Federal Agency Name: U.S. Department of Housing and Urban Development Program Name: Continuum of Care Program Federal Financial Assistance Listing: 14.267 Finding Summary: Program Income Significant Deficiency in Internal Control...
Federal Award Findings and Questioned Costs Reference Number: 2023‐001 Federal Agency Name: U.S. Department of Housing and Urban Development Program Name: Continuum of Care Program Federal Financial Assistance Listing: 14.267 Finding Summary: Program Income Significant Deficiency in Internal Control over Compliance Contact: Jillian Patterson, Deputy Director 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition: There was not a documented review by a separate individual outside of the preparer of the program income calculations. The Housing Authority had a review process in place over program income calculations. However, the review process was not documented. Corrective Action Plan: It is important to note that while we do have a process in place for program income calculations, we recognize that it was not adequately documented. To remedy this and ensure compliance with federal regulations, we have developed the following corrective action plan: Implementation of Controls Configure Yardi Voyager PHA software to enforce controls and workflows that ensure consistency and documentation of the review process. This may include setting up automated notifications for review assignments, establishing approval hierarchies, and creating standardized templates for documentation. Designation of Reviewer Utilize Yardi Voyager PHA software to assign designated reviewers for program income calculations, ensuring separation from the preparer. The software will facilitate clear identification of reviewers, their roles, and responsibilities within the review process. Documentation of Review Process Utilize Yardi Voyager PHA software to streamline and document the review process for program income calculations. The software will be configured to include a dedicated workflow specifically for documenting and tracking reviews conducted by separate individuals outside of the preparer. Periodic Monitoring and Evaluation Utilize the reporting and analytics features to monitor and evaluate the effectiveness of the review process. Generate regular reports to assess compliance with established procedures and identify any areas for improvement. Ongoing Compliance Monitoring Utilize Yardi Voyager PHA software to conduct ongoing compliance monitoring of internal controls and processes related to program income calculations. Set up automated alerts and notifications to flag any potential non‐compliance issues for timely resolution. By leveraging the capabilities of Yardi Voyager PHA software, the Housing Authority will enhance its ability to document, track, and monitor the review process for program income calculations, thereby strengthening internal controls and ensuring compliance with 2 CFR 200.303(a).
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