Corrective Action Plans

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Actions Taken on the Finding.
Actions Taken on the Finding.
Management will offer annual training to all Resident Councils, prepare a standard of operational procedures for resident council.
Management will offer annual training to all Resident Councils, prepare a standard of operational procedures for resident council.
Capital Fund Program Expenses
Capital Fund Program Expenses
There was one (1) instance out of twenty (20) transactions selected for testing whereby, the payment to the Vendor was not processed within 3 business days of the funds being deposited into the bank account.
There was one (1) instance out of twenty (20) transactions selected for testing whereby, the payment to the Vendor was not processed within 3 business days of the funds being deposited into the bank account.
Comments on the Finding and Each Recommendation. Management concurs with the finding and the auditor’s recommendation that Springfield MHA, disburse Capital Funds received, within 3 business days of funds being deposited into Authority’s bank account from LOCCS.
Comments on the Finding and Each Recommendation. Management concurs with the finding and the auditor’s recommendation that Springfield MHA, disburse Capital Funds received, within 3 business days of funds being deposited into Authority’s bank account from LOCCS.
Actions Taken on the Finding.
Actions Taken on the Finding.
Management has a Standard of Operation for this process. All new staff will be trained on this procedure.
Management has a Standard of Operation for this process. All new staff will be trained on this procedure.
Security Deposit – Contra Account
Security Deposit – Contra Account
During the conversion process, there were numerous negative balances brought forward. There was no reconciliation performed to properly state the security deposit – contra account balance as of September 30, 2025.
During the conversion process, there were numerous negative balances brought forward. There was no reconciliation performed to properly state the security deposit – contra account balance as of September 30, 2025.
(1) Comments on the Finding and Each Recommendation. Management concurs with the finding and the auditor’s recommendation that Springfield Metropolitan Housing Authority, should perform a reconciliation of the security deposit liability account on a monthly basis.
(1) Comments on the Finding and Each Recommendation. Management concurs with the finding and the auditor’s recommendation that Springfield Metropolitan Housing Authority, should perform a reconciliation of the security deposit liability account on a monthly basis.
Comments on the Finding and Each Recommendation. Management concurs with the finding and the auditor’s recommendation that Springfield Metropolitan Housing Authority, should perform a reconciliation of the security deposit liability account on a monthly basis.
Comments on the Finding and Each Recommendation. Management concurs with the finding and the auditor’s recommendation that Springfield Metropolitan Housing Authority, should perform a reconciliation of the security deposit liability account on a monthly basis.
Actions Taken on the Finding
Actions Taken on the Finding
Management will reconcile accounts monthly to insure of this action.
Management will reconcile accounts monthly to insure of this action.
Item: 2025-003 Assistance Listing Number: 93.958 Program: Block Grants for Community Mental Health Services Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: Arizona Complete Health - North (Care1st) Contract Number: Unknown Award Year: October 1, 2024 – September 3...
Item: 2025-003 Assistance Listing Number: 93.958 Program: Block Grants for Community Mental Health Services Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: Arizona Complete Health - North (Care1st) Contract Number: Unknown Award Year: October 1, 2024 – September 30, 2025 Compliance Requirement: Reporting Criteria: In accordance with the grant agreements, the Organization is required to submit periodic financial and programmatic reports for each contract within certain prescribed timeframes. Documentation should be maintained to support that the reports required were submitted to the granting agencies and that the submissions were submitted timely. Condition: In a nonstatistical sample of 7 programmatic reports, we noted 5 programmatic reports were not submitted to the granting agency within the prescribed reporting deadlines. Additionally, we noted that the Organization was not able to provide documentation supporting that one report was completed and submitted to the granting agency. Name of Contact Person: Ramon Dominguez, CFO Phone Number: (480) 831-7566 x4909 Anticipated Completion Date: September 30, 2026 Views of Responsible Officials and Corrective Actions: Management concurs with the finding and will determine whether the missing report was completed and submitted to the granting agency and take appropriate follow-up action, including submission if necessary. To prevent recurrence, management will strengthen the reporting control environment by assigning clear ownership for each required report, implementing written procedures, and establishing a system to track internal due dates. The Organization will also provide periodic training, implement cross-training to reduce key person dependency, and perform a retrospective review to address process inefficiencies. Policies and procedures will be updated to reflect these enhancements, and management will implement ongoing monitoring, with results reported to governance.
Assistance Listing Number: 93.788 Program: Opioid STR Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: Mercy Care Contract Number: YH22-0061R-01 Award Year: October 1, 2024 – September 30, 2025 Compliance Requirement: Reporting Criteria: In accordance with the gran...
Assistance Listing Number: 93.788 Program: Opioid STR Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: Mercy Care Contract Number: YH22-0061R-01 Award Year: October 1, 2024 – September 30, 2025 Compliance Requirement: Reporting Criteria: In accordance with the grant agreements, the Organization is required to submit periodic financial for each contract within certain prescribed timeframes. Documentation should be maintained to support that the reports required were submitted to the granting agencies and that the submissions were submitted timely. Condition: In a nonstatistical sample of 9 financial reports, we noted one financial report was not submitted to the granting agency within the prescribed reporting deadlines. Name of Contact Person: Ramon Dominguez, CFO Phone Number: (480) 831-7566 x4909 Anticipated Completion Date: September 30, 2026 Views of Responsible Officials and Corrective Actions: To prevent recurrence, management will strengthen the reporting control environment by assigning clear ownership for each required report, implementing written procedures, and establishing a system to track internal due dates. The Organization will provide periodic training on reporting requirements, implement cross-training to mitigate turnover risks, and conduct a retrospective review to address process inefficiencies. Policies and procedures will be updated accordingly, and management will implement ongoing monitoring, with results reported to governance.
Item: 2025-001 Assistance Listing Number: 21.027 Program: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Federal Agency: U.S. Department of the Treasury Pass-Through Agencies: City of Phoenix; Arizona Department of Economic Security Contract Number: CTR062832; 157666-005; 163621-0; 159...
Item: 2025-001 Assistance Listing Number: 21.027 Program: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Federal Agency: U.S. Department of the Treasury Pass-Through Agencies: City of Phoenix; Arizona Department of Economic Security Contract Number: CTR062832; 157666-005; 163621-0; 159341 Award Year: October 1, 2024 – September 30, 2025 Compliance Requirement: Reporting Criteria: In accordance with the grant agreements, the Organization is required to submit periodic financial and programmatic reports for each contract within certain prescribed timeframes. Documentation should be maintained to support that the reports required were submitted to the granting agencies and that the submissions were submitted timely. Condition: In a nonstatistical sample of 14 financial reports and 40 programmatic reports, we noted one financial report and seven programmatic reports were not submitted to the granting agency within the prescribed reporting deadlines. Name of Contact Person: Ramon Dominguez, CFO Phone Number: (480) 831-7566 x4909 Anticipated Completion Date: September 30, 2026 Views of Responsible Officials and Corrective Actions: Management concurs with the finding and will strengthen the reporting control environment to ensure timely and accurate submission of required reports. Corrective actions include assigning clear ownership for each report, implementing formal written procedures, and establishing a system to track internal due dates. The Organization will provide periodic training on reporting requirements, implement cross-training to reduce reliance on key staff, and conduct a retrospective review to identify and address process bottlenecks. Policies and procedures will be updated to reflect these enhancements, and management will implement ongoing monitoring, with results reported to governance.
Reporting – Federal Funding Accountability and Transparency Act Management’s Views and Corrective Action Plan Management’s Views and Opinion Sunset Park Health Council, Inc. acknowledges the finding related to Federal Funding Accountability and Transparency Act (FFATA) reporting for subaward actions...
Reporting – Federal Funding Accountability and Transparency Act Management’s Views and Corrective Action Plan Management’s Views and Opinion Sunset Park Health Council, Inc. acknowledges the finding related to Federal Funding Accountability and Transparency Act (FFATA) reporting for subaward actions under the Community Health Centers, Section 330, Federally Qualified Health Center Program, Assistance Listing Number 93.224. Management agrees that FFATA reporting requirements apply to subaward actions that obligate $30,000 or more in federal funds and that applicable subaward actions should be reported in the Federal Subaward Reporting System (FSRS) by the end of the month following the month in which the subaward obligation occurs. Management notes that the finding resulted from a process limitation in which FFATA review procedures focused primarily on newly executed subaward agreements and did not fully capture subsequent funding obligations, amendments, or continuation funding actions under existing subaward agreements. Management further notes that there were no questioned costs and that this is not a repeat finding. Sunset Park is committed to strengthening its FFATA identification, review, documentation, and reporting process to ensure that all applicable subaward actions, including those under existing agreements, are evaluated and reported timely in accordance with FFATA and 2 CFR Part 170. Corrective Action Plan To address this finding, Sunset Park will implement the following corrective actions: 1. FFATA Applicability Review for All Subaward Actions The Grants Fiscal Department will review all federally funded subaward agreements, amendments, continuations, and funding obligation actions to determine whether the FFATA reporting threshold has been met. This review will include both newly executed subaward agreements and funding actions under existing subaward agreements. 2. FFATA Reporting Checklist A standardized FFATA checklist will be implemented for each federal subaward action. The checklist will document the Assistance Listing Number, federal award identification, subrecipient name, subaward amount, obligation date, reporting threshold determination, and FSRS reporting status. 3. Monthly Subaward Obligation Review The Director of Grants and assigned Grant Accountant will conduct a monthly review of federal subaward activity to identify any subaward obligation, amendment, or continuation action that requires FFATA reporting. Any reportable action will be submitted in FSRS by the end of the month following the month in which the obligation occurred. 4. Coordination With Contracting and Program Staff Grants Fiscal will coordinate with contracting, program leadership, and finance staff to ensure that Grants Fiscal is notified timely of any new subaward agreement, amendment, budget modification, continuation funding, or other action that may create or modify a federal subaward obligation. 5. Documentation and Retention Evidence of FFATA review and FSRS submission will be retained with the applicable subaward file. Documentation will include the completed FFATA checklist, supporting award or subaward documentation, FSRS confirmation, and evidence of management review. 6. Retrospective FY2025 FFATA Review Sunset Park will complete a retrospective review of the FY2025 Section 330 subaward actions identified in the finding and will complete any required FFATA reporting, to the extent permitted by FSRS and applicable reporting requirements. Responsible Parties: • Director of Grants • Grant Accountants • Contracting Department, as applicable • Program Leadership, as applicable Implementation Timeline: Full implementation of corrective actions by August 31, 2026. Training: Grants Fiscal staff will receive training on FFATA reporting requirements, including the identification of reportable subaward actions, timing of FSRS submissions, documentation standards, and the distinction between new subaward agreements and subsequent obligating actions under existing agreements. Training will be incorporated into onboarding for new Grants Fiscal staff. Conclusion: These corrective actions will strengthen Sunset Park’s internal controls over FFATA reporting by ensuring that all applicable federal subaward actions are identified, reviewed, documented, and reported timely. Management believes these actions will address the root cause of the finding and support ongoing compliance with FFATA and Uniform Guidance requirements. Responsible Individual Leonardo Arias
SEFA Reporting Significant Deficiency - Ryan White HIV/AIDS Program Parts A and B Management’s Views and Opinion Sunset Park Health Council, Inc. acknowledges the finding and agrees that the Ending the HIV Epidemic: A Plan for America — Ryan White HIV/AIDS Program Parts A and B grant should have bee...
SEFA Reporting Significant Deficiency - Ryan White HIV/AIDS Program Parts A and B Management’s Views and Opinion Sunset Park Health Council, Inc. acknowledges the finding and agrees that the Ending the HIV Epidemic: A Plan for America — Ryan White HIV/AIDS Program Parts A and B grant should have been identified and reported as a federal award on the Schedule of Expenditures of Federal Awards (“SEFA”) beginning with the applicable award period. Management notes that the omission resulted from the Assistance Listing Number (“ALN”) not being identified at the time of the initial grant setup, which impacted the subsequent classification of the award for SEFA reporting purposes. Once identified during the FY2025 audit process, management corrected the matter by including the cumulative federal expenditures under the award on the FY2025 SEFA. Management also notes that there were no questioned costs and that the omission did not impact the prior-year major program determinations. Sunset Park is committed to strengthening its grant setup, award identification, and SEFA review controls to ensure that all federal awards, including federal pass-through awards, are accurately identified, classified, and reported in accordance with Uniform Guidance. The corrective actions described below are intended to improve the completeness and accuracy of federal award reporting and to prevent similar omissions in future reporting periods. Corrective Action Plan: To mitigate this risk, the following controls and procedures will be implemented: 1. Quarterly Grant Review All active and new grants will be reviewed on a quarterly basis by the Director of Grants and Grant Accountants to ensure completeness and accuracy of key award data, including CFDA/ALN identification. Any discrepancies will be identified and corrected timely. 2. AAW (Award Authorization Workflow) Control All Award Authorization Work (AAW) forms submitted to NYU Research Data Management (RDM) will require review and initial approval by the Director of Grants prior to submission, confirming that all required fields, including CFDA/ALN, are complete. 3. RDM Submission Verification Each submission to RDM will require confirmation and acknowledgment that all award data has been properly entered and recorded for both new and existing grants. 4. Chartstring Verification Control As part of the chartstring distribution process, Grant Accountants will confirm that all relevant grant attributes, including CFDA/ALN numbers, have been accurately established and communicated to program teams. 5. SEFA and Interim Review Procedures During interim reviews and annual SEFA preparation, each Grant Accountant will verify that all assigned grants are properly classified as federal or non-federal and that all applicable CFDA/ALN numbers are included and accurately reported. Responsible Parties: • Director of Grants • Grant Accountants • NYU Research Data Management (RDM) Implementation Timeline: Full implementation of corrective actions by August 31, 2026 Training: Grants Fiscal staff will undergo CFDA/ALN identification and SEFA reporting training by August 31, 2026. Training will be recorded and incorporated into onboarding for new staff. Conclusion: These corrective actions strengthen internal controls over grant setup and reporting, ensuring accurate identification of federal funding sources and completeness of SEFA reporting in compliance with Uniform Guidance. Responsible Individual Leonardo Arias Email: Leonardo.Arias@nyulangone.org
Management’s Response and Corrective Action: Management acknowledges that the Organization did not submit its fiscal year 2025 single audit reporting package to the Federal Audit Clearinghouse within the required nine-month deadline. This delay was primarily due to turnover in key finance personnel,...
Management’s Response and Corrective Action: Management acknowledges that the Organization did not submit its fiscal year 2025 single audit reporting package to the Federal Audit Clearinghouse within the required nine-month deadline. This delay was primarily due to turnover in key finance personnel, which impacted the timely completion of the year-end close process and preparation of the Schedule of Expenditures of Federal Awards (SEFA). To remediate this issue and ensure compliance with federal reporting requirements going forward, management has implemented the following corrective actions: • Staffing and Capacity Building: Key finance positions have been filled, and cross-training is being implemented to ensure continuity and reduce reliance on individual staff members. • Formalized Reporting Timeline: A comprehensive year-end close and single audit preparation timeline has been established, incorporating interim deadlines for financial statement preparation and SEFA completion to ensure timely submission to auditors. • Enhanced Monitoring and Oversight: Management will conduct regular status meetings during the audit preparation period to monitor progress and address potential delays proactively. • Process Improvements and Documentation: Policies and procedures related to financial reporting and federal award tracking have been formalized and documented to improve accuracy and efficiency. • Early Coordination with Auditors: The Organization will engage with external auditors earlier in the fiscal year-end process to align expectations and timelines. Management is committed to full compliance with federal reporting deadlines and will ensure timely submission of future single audit reporting packages. Contact Person: Lucina Patterson, Chief Financial Officer Nathan Robinson, Interim Director of Finance Anticipated Completion Date: March 31, 2027
Recommendation: The Department of Social Services should provide the necessary resources and institute procedures to ensure that it uses all information from eligibility, income, and death matches to ensure that it correctly issues benefits to or on behalf of eligible clients. DSS should return fede...
Recommendation: The Department of Social Services should provide the necessary resources and institute procedures to ensure that it uses all information from eligibility, income, and death matches to ensure that it correctly issues benefits to or on behalf of eligible clients. DSS should return federal reimbursements for unallowable expenditures claimed under Medicaid and SNAP. Corrective Action Plan as Reported by the Department of Social Services: The Department agrees with this finding. DSS staff is in the development phase of implementing new automated procedures to ensure timely and accurate action is taken to discontinue benefits of deceased clients when date of death information is received and matched to the Connecticut Department of Public Health’s State Vital Records Office. Action has been taken to correct the errors cited, including discontinuing the benefits of the individuals that were verified as deceased, and recouping the overpayments as appropriate. Anticipated Completion Date: December 31, 2026 Department of Social Services Contact Person: Dan Giacomi, Program Division Director (860) 424-5080
Recommendation: The Department of Social Services should amend the contract with its Medicaid recovery audit contractor to comply with federal regulations. Corrective Action Plan as Reported by the Department of Social Services: The Department agrees with this finding. The Department will review the...
Recommendation: The Department of Social Services should amend the contract with its Medicaid recovery audit contractor to comply with federal regulations. Corrective Action Plan as Reported by the Department of Social Services: The Department agrees with this finding. The Department will review the payment methodology at the next contract renewal. Anticipated Completion Date: October 1, 2027 Department of Social Services Contact Person: John Jakubowski, Director of Quality Assurance (860) 424-5855
Recommendation: The Department of Public Health should strengthen internal controls to ensure compliance with federal Medicare and Medicaid survey requirements. Corrective Action Plan as Reported by the Department of Public Health: The Facility Licensing and Investigations Section (FLIS) continues t...
Recommendation: The Department of Public Health should strengthen internal controls to ensure compliance with federal Medicare and Medicaid survey requirements. Corrective Action Plan as Reported by the Department of Public Health: The Facility Licensing and Investigations Section (FLIS) continues to recruit and train surveyors to fill vacancies. DPH is working to ameliorate the backlog of recertification surveys before the end of FFY 2026, and the complaint project is continuing. The Department’s efforts are dependent on several staffing and training variables, including hiring, turnover, and other extenuating circumstances (e.g. the need to respond to emergent issues). Department of Public Health Anticipated Completion Date: September 30, 2026 Department of Public Health Contact Person: Jennifer Olsen-Armstrong, Section Chief, Facility Licensing and Investigation Section (860) 509-7520 Corrective Action Plan as Reported by the Department of Social Services: The Department agrees with this finding and the response provided by the Department of Public Health. Department of Social Services Anticipated Completion Date: December 31, 2026 Department of Social Services Contact Person: Nicole Godburn, Fiscal Administrative Manager 2 (860) 424-5393
Recommendation: The Department of Social Services should comply with the long-term care facility auditing procedures in the State Medicaid Plan. Corrective Action Plan as Reported by the Department of Social Services: The Department agrees with this finding. With more than 1,200 long-term care and b...
Recommendation: The Department of Social Services should comply with the long-term care facility auditing procedures in the State Medicaid Plan. Corrective Action Plan as Reported by the Department of Social Services: The Department agrees with this finding. With more than 1,200 long-term care and boarding home providers, the Department is unable to audit every facility on a biennial basis. Facilities are primarily chosen for audit based on the risk of misstatement. The Department operates with limited resources and while it is neither possible nor feasible to conduct a field examination for every facility, the benefit of utilizing the desk review process must be considered when discussing the risk of incorrect payments. The Department ensures that a desk review is conducted on each facility's cost report annually. During the desk review process the auditors submit requests to providers for additional information to resolve questions which arise from significant risk areas identified and follow up on prior year findings. These procedures are conducted to mitigate and reduce the risk of incorrect payments. Anticipated Completion Date: December 31, 2026 Department of Social Services Contact Person: Nicole Godburn, Fiscal Administrative Manager 2 (860) 424-5393
Recommendation: The Department of Social Services should strengthen internal controls to ensure that it accurately reports and adequately reviews revenues, expenditures, collections, and contingency fees prior to submitting Form CMS 64. The Department of Social Services should strengthen internal co...
Recommendation: The Department of Social Services should strengthen internal controls to ensure that it accurately reports and adequately reviews revenues, expenditures, collections, and contingency fees prior to submitting Form CMS 64. The Department of Social Services should strengthen internal controls to ensure that it tracks, reports, and returns the federal share of overpayments to corresponding federal and state medical assistance programs. The Department of Social Services should resolve the issues affecting the Medicaid receivable balances and file the proper adjustment to correct the errors, unsupported amounts, and corresponding federal reimbursements on Form CMS 64. Corrective Action Plan as Reported by the Department of Social Services: The Department agrees with this finding. The Department will review internal controls to identify possible corrective actions. Anticipated Completion Date: December 31, 2026 Department of Social Services Contact Person: Briana Mitchell, Chief Officer Fiscal Administrative Services 1 (860) 424-5471
Recommendation: The Department of Social Services should strengthen internal controls to ensure that only eligible recipients receive Medicaid services in accordance with federal laws and the Medicaid State Plan. Corrective Action Plan as Reported by the Department of Social Services: The Department...
Recommendation: The Department of Social Services should strengthen internal controls to ensure that only eligible recipients receive Medicaid services in accordance with federal laws and the Medicaid State Plan. Corrective Action Plan as Reported by the Department of Social Services: The Department agrees with this finding. The Department identified cases where overrides that were applied during the public health emergency were not removed. This resulted in individuals remaining enrolled inappropriately. Our Business Systems Division is implementing a tiered resolution approach, beginning with individuals enrolled in the Medicare Savings Program and HUSKY-C coverage. Please note: The Department will not be returning the questioned costs associated with this finding. According to federal regulations, recoveries based on eligibility errors can only be pursued when identified by programs operating under CMS’ Payment Error Rate Measurement program, per section 1903(u) of the Social Security Act and regulations at Title 42 CFR Part 431, Subpart Q. Anticipated Completion Date: December 31, 2026 Department of Social Services Contact Person: Dan Giacomi, Program Division Director (860) 424-5080
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