Corrective Action Plans

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Program(s): Health Center Program Cluster Assistance Listing Number 93.224 / 93.527 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matter Condition: During our testing, we noted the following two instances of noncompliance in the sample of forty patient files t...
Program(s): Health Center Program Cluster Assistance Listing Number 93.224 / 93.527 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matter Condition: During our testing, we noted the following two instances of noncompliance in the sample of forty patient files tested: • In one patient file selected for testing, the sliding fee discount applied was incorrect due to the patient’s income not being entered correctly in Epic, resulting in an inaccurate FPL calculation and associated discount classification. • In one patient file selected for testing, based on support provided and the SFDS, an incorrect discount class was applied, and the County was not able to provide documentation demonstrating how annual income/household size supported the applied discount classification. Hennepin County’s Corrective Action Planned in Response to Finding: Develop a required form for all case aides to use and uniformly determine “annual income”. The EPIC Financial Assistance Module (FAM) recently implemented will maintain record of patient financial calculations / conversations and will include upload of the financial income form. Determination of the proper patient discount is automated in FAM and will reduce chance of incorrect rate setting. Hennepin County Employee Responsible for the CAP: Baye D Diouf, Chief Financial Officer Planned Completion Date for CAP: September 30, 2026
Current policy and procedure in place will be followed. The Daily meal count sheets will be reconciled to the dummary spreadsheet and the reimburement claims, including a second review prior to submitting the claim for reinburement.
Current policy and procedure in place will be followed. The Daily meal count sheets will be reconciled to the dummary spreadsheet and the reimburement claims, including a second review prior to submitting the claim for reinburement.
Current policy and precedure in place will be followed. The Executive Director of Nutrition Services and the Food Compliance Officer will review Summer Food Service Program sited and serving windows prior to the start of the program as well as reinbursements prior to the completion of the SFSP progr...
Current policy and precedure in place will be followed. The Executive Director of Nutrition Services and the Food Compliance Officer will review Summer Food Service Program sited and serving windows prior to the start of the program as well as reinbursements prior to the completion of the SFSP program period each year.
View of Responsible Officials and Planned Corrective Actions: We plan on verifying that the submission to the Federal Audit Clearinghouse is completed in a timely manner moving forward.
View of Responsible Officials and Planned Corrective Actions: We plan on verifying that the submission to the Federal Audit Clearinghouse is completed in a timely manner moving forward.
U.S. Department of Housing and Urban Development MATERIAL WEAKNESS Segregation of Duties Recommendation: When this condition exists, management’s and the board’s close supervision and review of accounting information is the best means of preventing or detecting errors and fraud. Explanation of disag...
U.S. Department of Housing and Urban Development MATERIAL WEAKNESS Segregation of Duties Recommendation: When this condition exists, management’s and the board’s close supervision and review of accounting information is the best means of preventing or detecting errors and fraud. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We agree and will continue to monitor financial results and accounting information as hiring additional employees is not practical. Name(s) of the contact person(s) responsible for corrective action: Donald Bly Planned completion date for corrective action plan: In process
Corrective Action Plan – December 31, 2025 Audit Findings 2025-001 Condition: Deficiencies Noted in Examination of Housing Choice Voucher Program Participant Files Auditor Recommendation: The Authority should review its internal control procedures over tenant file re-certifications and documentation...
Corrective Action Plan – December 31, 2025 Audit Findings 2025-001 Condition: Deficiencies Noted in Examination of Housing Choice Voucher Program Participant Files Auditor Recommendation: The Authority should review its internal control procedures over tenant file re-certifications and documentation. Response: The audit indicates there were egregious errors with the participants’ files. We agree. Even though 50058 were processed, for over 95% of the participants, there were two issues which made the 50058 submissions inadequate. 1. The 50058’s were submitted through Yardi MTCS files, but often records were rejected by PIC. We did not review and resolve the PIC errors in a timely manner. These errors were due to our change in operating programs, from Lindsey to Yardi. In Yardi, we complete biannual inspections and annual recertifications. However, if there were any issues with dates of submissions relative to date either transaction was processed, they often failed in the PIC submission. It takes a great deal of work and effort to go back and fix these issues, and we got very behind and finally hired a consultant to assist us with the cleanup. 2. The second issue is more concerning. Our two Section 8 analysts completed 50058 for recertifications and interims but often did not include the back up in the electronic file or the paper file for the participant. They also made many calculation issues, rule issues, and would forget to process the 50058 all the way through. Even when the system showed there might be an error of some type, they did not clear those errors before submitting. a. As background, we implemented Yardi in August 2024. It took several months to a year to clean the data that was put into the system by the Yardi implementation team. b. Our Section 8 analysts had over 15 days of on-site personal training with Yardi trainers and provided a great deal of documentation for each module/class. c. Our Section 8 analysts have both completed a Section 8 Certification course with industry leaders like Nan McKay. d. We are a four-person office, so our Section 8 analyst have access to two other people in the office as well as a contractor who has 25 years of housing experience with Fort Lauderdale Housing and Yardi implementation a year before us. The contractor is on site for 4 ½ hours on Wednesday and available via email and phone. She has provided process documents, instructions, and sometimes multiple times for the same issue. e. The workload on both Section 8 analysts has been reduced. Each analyst is responsible for approximately 235 files, interims and recertifications. The inspections are mostly outsourced, and analysts only get involved with placing abatements. f. The failure to complete the recertifications when they are incorrect relative to information and calculations, and not maintaining the backup documentation is inexcusable. g. These issues were discovered before the auditor came on site, when we started up our file audits and we shared our findings with the auditor when they came on site. The auditor came to the same opinion as us. 38 Therefore, to correct this situation, we are taking the following steps and implementing several processes to ensure the files are in line with HUD’s standards. 1. Every 50058 processed will have to be printed, and management will review the 50058, changes made, calculations, and all pertinent information including family composition, answers on recertification packages, et. The manager will sign and date and file the record. 2. The agency will continue to randomly select 15 – 25 files for spot audit each month relative to last interim and annual recertification. The sample will depend on the number of files processed for the month. 3. The Housing Authority will run recertification and inspection reports at least twice a month to ensure all recertifications and inspections due are being completed timely and not processed as late transactions. 4. The agency will continue training and retraining for all employees. This has been ongoing for several years including HOTMA, NSpire, calculating HAP, verifying eligibility, reviewing deductions, processing reasonable accommodations requests to name a few. 5. We have implemented a no override policy for any information in Yardi including dates, payment standards, etc. without Executive Director approval. 6. We have implemented that all reasonable accommodation requests must be signed by the Assistant Executive Director or the Executive Director. 7. We are looking at purchasing licensing software solutions such as Monday which helps manage daily tasks. 8. We have already documented some of the egregious transactions for each analyst and will continue to do so. If there is no improvement over time, counseling may include termination of employment. We hope these steps will reverse the errors with the files immediately. If there is time available, we plan to start a review of every file to make corrections. We are currently doing that with about forty participants who appeared in the EIV/IVT report. We have been meeting with each head of household and correcting records or executing a repayment agreement. Timeframe: By FYE December 31, 2026 Individual responsible for correction: Ms. Anne Castro, Executive Director
In Finding 2025-001, it was reported that the Organization did not properly apply the sliding fee discounts for certain patients with visits to the Organization during the year ended December 31, 2025. Management recognizes the importance of complying with sliding fee guidelines and the Organization...
In Finding 2025-001, it was reported that the Organization did not properly apply the sliding fee discounts for certain patients with visits to the Organization during the year ended December 31, 2025. Management recognizes the importance of complying with sliding fee guidelines and the Organization’s sliding fee policy. In response to Finding 2025-001, proper training will be given to employees, and sliding fee discounts will be reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee policy.
Allegations of Fraud Contact: Katie Queen Dossinger Title: Chief Operating Officer Phone Number: 202-785-0072 Estimated Completion Date: Ongoing Corrective Action HealthXP manages fraud risk through a combination of preventative, detective, and monitoring controls, and reinforces its expectations re...
Allegations of Fraud Contact: Katie Queen Dossinger Title: Chief Operating Officer Phone Number: 202-785-0072 Estimated Completion Date: Ongoing Corrective Action HealthXP manages fraud risk through a combination of preventative, detective, and monitoring controls, and reinforces its expectations regarding ethical behavior through training and communications. HealthXP proactively reports and investigates allegations of fraud and raises awareness of the actions to be taken when fraud is suspected. The HealthXP Global Internal Audit and Investigations team shares lessons learned from its work. Given the challenging operating environments in which HealthXP implements its programs, fraud remains an ongoing risk that HealthXP actively monitors, investigates, and mitigates.
Internal Control over Compliance and Compliance with Cash Management Requirements Contact: Aida Awaj Title: Assistant Controller Phone Number: 202-785-0072 Estimated Completion Date: August 31, 2026 Corrective Action Transition to interest-bearing accounts and move advance Federal balances into inte...
Internal Control over Compliance and Compliance with Cash Management Requirements Contact: Aida Awaj Title: Assistant Controller Phone Number: 202-785-0072 Estimated Completion Date: August 31, 2026 Corrective Action Transition to interest-bearing accounts and move advance Federal balances into interest-bearing accounts. Also, establish a process to track interest earned on Federal advances and remit annually any interest above the $500 de minimis threshold to the federal agency per §200.305(b)(11), retaining records of calculation and remittance.
Internal Control over Compliance and Compliance with the Reporting Compliance Requirement Contact: Aida Awaj Title: Assistant Controller Phone Number: 202-785-0072 Estimated Completion Date: August 31, 2026 Corrective Action The results of the 2025 audit will be shared with appropriate EGPAF staff a...
Internal Control over Compliance and Compliance with the Reporting Compliance Requirement Contact: Aida Awaj Title: Assistant Controller Phone Number: 202-785-0072 Estimated Completion Date: August 31, 2026 Corrective Action The results of the 2025 audit will be shared with appropriate EGPAF staff and reinforced through training to ensure adequate attention and clear guidance on the FFATA reporting threshold and the requirement to file first-tier subaward reports in SAM.gov by the end of the month following the month in which the subaward is executed.
Internal Controls over Compliance and Compliance with the Period of Performance Compliance Requirement Contact: Katie Queen Dossinger Title: Chief Operating Officer Phone Number: 202-785-0072 Estimated Completion Date: Ongoing Corrective Action The results of the 2025 audit will be shared with appro...
Internal Controls over Compliance and Compliance with the Period of Performance Compliance Requirement Contact: Katie Queen Dossinger Title: Chief Operating Officer Phone Number: 202-785-0072 Estimated Completion Date: Ongoing Corrective Action The results of the 2025 audit will be shared with appropriate PSI and EGPAF staff and reinforced through training to ensure adequate attention and clear guidance on the allowability of trailing costs and the unallowability of newly incurred costs.
Internal Control over Compliance and Compliance with Activities Allowed or Unallowed and Allowable Costs and Cost Principles Contact: Katie Queen Dossinger Title: Chief Operating Officer Phone Number: 202-785-0072 Estimated Completion Date: Ongoing Corrective Action The results of the 2025 audit wil...
Internal Control over Compliance and Compliance with Activities Allowed or Unallowed and Allowable Costs and Cost Principles Contact: Katie Queen Dossinger Title: Chief Operating Officer Phone Number: 202-785-0072 Estimated Completion Date: Ongoing Corrective Action The results of the 2025 audit will be shared with appropriate staff and reiterated in training to ensure that adequate attention and guidance is provided on recording expenses within the correct accounting period. HealthXP delivers in person training to its global finance and program staff and will continue to offer training during 2026 to address such issues.
Action To Be Taken: To ensure federal compliance for the Corona virus Relief Fund (ALN 21.019), the organization will implement a secondary review process. After the Executive Director prepares the federal financial reports, a designated member of the Board Finance Committee will review the supporti...
Action To Be Taken: To ensure federal compliance for the Corona virus Relief Fund (ALN 21.019), the organization will implement a secondary review process. After the Executive Director prepares the federal financial reports, a designated member of the Board Finance Committee will review the supporting documentation (General Ledger and invoices) for accuracy before the report is submitted to the granting agency.•Responsible Party: Executive Director and Board Finance Committee. Anticipated Completion Date: February 28, 2026.
CONDITION: The Beaver County Career and Technical Center contracted with a third-party vendor – Huckstein Mechanical and Robovent for the electrical upgrades in the welding lab and welding equipment respectively. The contracts were procured through a cooperative purchasing group. The Center 1) was u...
CONDITION: The Beaver County Career and Technical Center contracted with a third-party vendor – Huckstein Mechanical and Robovent for the electrical upgrades in the welding lab and welding equipment respectively. The contracts were procured through a cooperative purchasing group. The Center 1) was unable to provide documentation from the cooperative purchasing group to verify that the technology procurement contracts were competitively procured, such as a bid evaluation and public solicitation and 2) did not obtain the adequate number of price or rate quotations.
VPI has merged with VARC and will evaluate their current way to allocate the time for personnel that are not directly charged to a specific program. VPI hasn't found a viable solution yet, but will continue to look for options. VPI will be changing managed IT partner as part of the merger and will s...
VPI has merged with VARC and will evaluate their current way to allocate the time for personnel that are not directly charged to a specific program. VPI hasn't found a viable solution yet, but will continue to look for options. VPI will be changing managed IT partner as part of the merger and will seek recommendations from them. VARC also uses a different time collection methold which may provide better information. Person Responsible: Jim Patten, CFO Timing for Implementation: This will continue to be evaluated going forward
The Authority will strengthen internal controls over the income determination process by enhancing review procedures, verifying income documentation, and providing additional staff training to ensure compliance with HUD requirements.
The Authority will strengthen internal controls over the income determination process by enhancing review procedures, verifying income documentation, and providing additional staff training to ensure compliance with HUD requirements.
The Authority will establish controls to ensure all certifications are completed timely and in accordance with requirements.
The Authority will establish controls to ensure all certifications are completed timely and in accordance with requirements.
Recommendation: We recommend that the Authority develop, approve, and implement comprehensive written policies for federal fund spending that address cost allowability, procurement, approvals, documentation retention, subrecipient or vendor oversight, reimbursement requests, and periodic management ...
Recommendation: We recommend that the Authority develop, approve, and implement comprehensive written policies for federal fund spending that address cost allowability, procurement, approvals, documentation retention, subrecipient or vendor oversight, reimbursement requests, and periodic management review. In addition, the Authority should train relevant personnel on these policies and perform ongoing monitoring to confirm that federal expenditures are reviewed and documented in accordance with applicable grant requirements. Management’s Response: Management acknowledges the recommendation. The Authority will evaluate its existing processes and controls over the use of federal funds and consider whether additional written guidance and/or enhancements to current procedures are warranted to address, as applicable, cost allowability, procurement requirements, approval responsibilities, documentation and record retention, subrecipient or vendor oversight, reimbursement request preparation and review, and periodic management review of federal expenditures. Based on the results of this evaluation, the Authority will communicate any clarifications, reminders, and/or targeted training to relevant personnel involved in administering, approving, recording, or requesting reimbursement for federal expenditures, as deemed necessary. Management will also consider whether additional monitoring activities are warranted to help confirm that federal expenditures are reviewed, approved, and supported by appropriate documentation in accordance with applicable grant requirements.
The Company will review its procedures for submitting financial reports to the pass-through entity to ensure timely submission.
The Company will review its procedures for submitting financial reports to the pass-through entity to ensure timely submission.
FINDINGS—FEDERAL AWARD PROGRAMS AUDITS U.S Department of Health and Human Services 2025-001 Medicaid Cluster – Assistance Listing No. 93.778 Recommendation: We recommend that there is an appropriate reviewer of the WIMCR cost report and CLTS annual reconciliation. Explanation of disagreement with au...
FINDINGS—FEDERAL AWARD PROGRAMS AUDITS U.S Department of Health and Human Services 2025-001 Medicaid Cluster – Assistance Listing No. 93.778 Recommendation: We recommend that there is an appropriate reviewer of the WIMCR cost report and CLTS annual reconciliation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will evaluate their current processes and procedures during staffing transitions in fiscal year 2025 to ensure that proper review of the WIMCR cost report and the CLTS annual reconciliation. Name(s) of the contact person(s) responsible for corrective action: Hollie Viestenz and Tim Marzu Planned completion date for corrective action plan: December 31, 2026 If the State of Wisconsin has questions regarding this plan, please call Hollie Viestenz at (715) 732-7422.
Finding 2025-001 Capital Asset Accounting and Reporting-The town has a fixed asset file where we have researched recent fixed asset purchases. The cost benefit of researching costs as far back as 1913 is cost effective for all capital purchases. We will continue to work on updating the file for new ...
Finding 2025-001 Capital Asset Accounting and Reporting-The town has a fixed asset file where we have researched recent fixed asset purchases. The cost benefit of researching costs as far back as 1913 is cost effective for all capital purchases. We will continue to work on updating the file for new purchases so that the fixed asset value can be confirmed in the future.
Finding Reference Number: 2025-001 for U.S. Department of Housing and Urban Development: Assistance Listing 14.195 Project-Based Rental Assistance (PBRA) View of Responsible Officials and Corrective Actions: Management agrees with the finding. Management will establish procedures and monitor complia...
Finding Reference Number: 2025-001 for U.S. Department of Housing and Urban Development: Assistance Listing 14.195 Project-Based Rental Assistance (PBRA) View of Responsible Officials and Corrective Actions: Management agrees with the finding. Management will establish procedures and monitor compliance with those procedures to ensure that the determination of tenant eligibility and the maintenance of lease files are in accordance with guidelines specified by HUD. Contact Person Responsible: Flynann Skeen, President/Executive Director, Equality Community Housing Corporation Joshua Allen, President, J. Allen Management Co. Inc. Completion Date: Open
Finding No. 2025-003 – Late Filing of Single Audit Reporting Package Federal Program: Health Center Program Cluster, ALN 93.224 – U.S. Department of Health and Human Services (HHS) Contact Person Responsible for Corrective Action Guillermo J. Jiménez Ramos, Chief Financial Officer Views of Responsib...
Finding No. 2025-003 – Late Filing of Single Audit Reporting Package Federal Program: Health Center Program Cluster, ALN 93.224 – U.S. Department of Health and Human Services (HHS) Contact Person Responsible for Corrective Action Guillermo J. Jiménez Ramos, Chief Financial Officer Views of Responsible Officials Management concurs with the finding. Corrective Action Planned 1. The Hospital will establish an annual audit readiness timeline working backward from the Uniform Guidance submission deadline (the earlier of thirty (30) calendar days after receipt of the auditors’ reports or nine months after the end of the audit period, June 30). The timeline will include target dates for the completion of year-end closing procedures, the delivery of auditor-requested schedules and supporting documentation, audit fieldwork, review of the draft report, and submission of the reporting package and Data Collection Form to the Federal Audit Clearinghouse in advance of the deadline. 2. Monthly closing discipline will be maintained throughout the fiscal year so that year-end balances, account reconciliations (including patient accounts receivable aging, the allowance for credit losses, and grants receivable), and audit support schedules are substantially complete at year end and available for timely delivery to the auditors. 3. The Chief Financial Officer will monitor the status of the audit timeline monthly beginning in October of each fiscal year, and any delay against the established milestones will require a documented recovery plan to return the process to schedule. 4. The Single Audit Reporting Package and Data Collection Form for the year ended September 30, 2025 will be submitted to the Federal Audit Clearinghouse immediately upon issuance of the final audit report. Anticipated Completion Date October 31, 2026
Finding No. 2025-002 – Failure to Properly Apply Current Federal Poverty Guidelines in the Sliding Fee Discount Program (SFDP) Federal Program: Health Center Program Cluster, ALN 93.224 – U.S. Department of Health and Human Services (HHS) Contact Person Responsible for Corrective Action Guillermo J....
Finding No. 2025-002 – Failure to Properly Apply Current Federal Poverty Guidelines in the Sliding Fee Discount Program (SFDP) Federal Program: Health Center Program Cluster, ALN 93.224 – U.S. Department of Health and Human Services (HHS) Contact Person Responsible for Corrective Action Guillermo J. Jiménez Ramos, Chief Financial Officer Views of Responsible Officials Management concurs with the finding. Corrective Action Taken and Planned 1. Resolution of the two identified cases. The Hospital reviewed and resolved the two patient accounts identified in the audit sample in which an incorrect sliding fee discount percentage was applied: • In the first case, the discount applied resulted in a charge to the patient below the amount that corresponded under the correct Federal Poverty Guidelines discount tier, and a lower amount was collected from the patient. Management evaluated the account and determined not to retroactively bill the patient for the remaining difference, consistent with the Hospital’s mission and its policy of not creating barriers to care for patients eligible under the Sliding Fee Discount Program. • In the second case, the Hospital billed and collected from the patient an amount higher than the amount that corresponded under the correct discount tier. This case was resolved and the amount collected in excess of the correctly discounted amount was returned to the patient by check no. 95274, issued on May 29, 2026. Documentation of the refund is retained in the patient’s account file. 2. Questioned cost. The known questioned cost of $245.97 has been repaid and offset by the Hospital. Supporting documentation of the resolution is available for review by the awarding agency. 3. Current Federal Poverty Guidelines implementation. The Sliding Fee Discount Schedule will be updated to the current Federal Poverty Guidelines (FPG) issued annually by HHS, and a standing procedure will be established requiring that the updated schedule be approved and incorporated into the Hospital’s billing system (eClinicalWorks) within thirty (30) days of the annual publication of the FPG. 4. Review of sliding fee determinations. The review process over sliding fee discount determinations, which had previously been performed by the Billing Department and was later delegated to the information management staff, has been returned to the Billing Department to ensure that discounts are properly applied to patients in accordance with the Sliding Fee Discount Program policies and the updated fee schedule. 5. Strengthened internal controls. A secondary review control will be implemented under which a quarterly sample of new and renewed SFDP eligibility determinations will be re-verified by the Billing Department against the current FPG schedule, income documentation, and household size, with the results documented in a monitoring log subject to review by the Chief Financial Officer. 6. Training. Formal training on the SFDP policy, the current FPG schedule, and the related documentation requirements will be provided to all registration, billing, and eligibility staff, with attendance documented. Refresher training will be provided annually upon each FPG update. Anticipated Completion Date Items 1 and 2 – Completed. Items 3 through 6 – October 31, 2026.
Finding No. 2025-001 – Late Report Filing (SF-425) Federal Program: Health Center Program Cluster, ALN 93.224 – U.S. Department of Health and Human Services (HHS) Contact Person Responsible for Corrective Action Guillermo J. Jiménez Ramos, Chief Financial Officer Views of Responsible Officials Manag...
Finding No. 2025-001 – Late Report Filing (SF-425) Federal Program: Health Center Program Cluster, ALN 93.224 – U.S. Department of Health and Human Services (HHS) Contact Person Responsible for Corrective Action Guillermo J. Jiménez Ramos, Chief Financial Officer Views of Responsible Officials Management concurs with the finding. Corrective Action Planned 1. The Fiscal Department will implement a Federal Compliance Reporting Calendar covering all required federal financial reports, including the Federal Financial Report (SF-425) and Payment Management System (PMS) submissions, identifying for each report its due date, the individual responsible for its preparation, the reviewer, and the submission evidence to be retained. 2. Responsibility for the preparation of each SF-425 report will remain formally assigned to the Fiscal Department, under the oversight of the Chief Financial Officer (CFO). Each report will be subject to CFO review and approval prior to submission. Preparation of the reports will commence no later than thirty (30) days before the established due date, in accordance with internal control procedures and reporting timelines. 3. Automated reminders will be configured at thirty (30), fifteen (15), and five (5) days before each filing deadline, directed to both the preparer and the reviewer, to provide adequate oversight and prevent future delays. 4. Confirmation of each submission (PMS acknowledgment) will be retained and filed with the report workpapers as evidence of timely filing, and the status of federal reporting deadlines will be monitored monthly by the Chief Financial Officer. Anticipated Completion Date July 31, 2026
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