Corrective Action Plans

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Finding 9455 (2023-003)
Significant Deficiency 2023
Insert a clause into the contract stating the contractor is not suspended or debarred.
Insert a clause into the contract stating the contractor is not suspended or debarred.
Finding 9455 (2023-003)
Significant Deficiency 2023
Note: If you go this route, including a suspension and debarment clause in your request for proposal is insufficient. The clause must be part of the contract. Its possible language included on a purchase order would work, but you should check with your grantor first to determine if this would be acc...
Note: If you go this route, including a suspension and debarment clause in your request for proposal is insufficient. The clause must be part of the contract. Its possible language included on a purchase order would work, but you should check with your grantor first to determine if this would be acceptable. If so, the contractor must sign the purchase order.
Finding 9455 (2023-003)
Significant Deficiency 2023
Check the contractor's status on the U.S. General Administration's website before contracting or purchasing. Type your contractor's name into the search bar to find exclusion records.
Check the contractor's status on the U.S. General Administration's website before contracting or purchasing. Type your contractor's name into the search bar to find exclusion records.
Finding 9455 (2023-003)
Significant Deficiency 2023
Note: Be sure you keep documentation that demonstrates you performed the search, including the date. For example, you might save a screen shot that includes the date you performed the search.
Note: Be sure you keep documentation that demonstrates you performed the search, including the date. For example, you might save a screen shot that includes the date you performed the search.
Finding 9454 (2023-002)
Significant Deficiency 2023
All front desk staff will complete comprehensive training on applying the Sliding Fee Discount Policy to patient fees. Supervisors will conduct a competency check with each staff member and retain a signed competency form on the Sliding Fee Discount Schedule (SFDS) policy in their personnel file. Th...
All front desk staff will complete comprehensive training on applying the Sliding Fee Discount Policy to patient fees. Supervisors will conduct a competency check with each staff member and retain a signed competency form on the Sliding Fee Discount Schedule (SFDS) policy in their personnel file. This will be complete by the end of January 2024 and incorporated into onboarding and orientation for new hires moving forward (to be completed within two weeks of the start date).
Finding 9454 (2023-002)
Significant Deficiency 2023
Front desk supervisors at all clinic sites will be responsible for doing a weekly audit of fee collection amounts to ensure that visit fees are being collected appropriately according to the Sliding Fee Discount Policy. We will work to re-institute a regular copay report which will improve the flow ...
Front desk supervisors at all clinic sites will be responsible for doing a weekly audit of fee collection amounts to ensure that visit fees are being collected appropriately according to the Sliding Fee Discount Policy. We will work to re-institute a regular copay report which will improve the flow of information between the front desk, IT / data, and the fiscal teams, allowing for more timely
Assistance Listing Number: 84.027, 84.027X, 84.173, and 84.173X – Special Education Recommendation: We recommend the District implement procedures and controls to ensure vendors are not suspended or debarred Explanation of disagreement with audit finding: There is no disagreement with the audit fi...
Assistance Listing Number: 84.027, 84.027X, 84.173, and 84.173X – Special Education Recommendation: We recommend the District implement procedures and controls to ensure vendors are not suspended or debarred Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will work to implement procedures so vendors are verified to the suspensions and debarred list. Name(s) of the contact person(s) responsible for corrective action: Jackie Paradis, Business Manager and Patrick Gordon, Executive Director. Planned completion date for corrective action plan: June 30, 2024.
Finding 9445 (2023-004)
Significant Deficiency 2023
Finding No. 2023-004: Suspension and Debarment Responsible Individuals: Trista Olney, Business Manager Corrective Action Plan: The Business Manager will compare vendors against the list of suspended and debarred vendors. Anticipated Completion Date: Current fiscal year
Finding No. 2023-004: Suspension and Debarment Responsible Individuals: Trista Olney, Business Manager Corrective Action Plan: The Business Manager will compare vendors against the list of suspended and debarred vendors. Anticipated Completion Date: Current fiscal year
Finding No. 2023-003: SEFA Adjustments Responsible Individuals: Trista Olney, Business Manager Corrective Action Plan: The District will make efforts to accurately track and present grant funding. Anticipated Completion Date: Current fiscal year
Finding No. 2023-003: SEFA Adjustments Responsible Individuals: Trista Olney, Business Manager Corrective Action Plan: The District will make efforts to accurately track and present grant funding. Anticipated Completion Date: Current fiscal year
Lexington Housing Authority (LHA) did fail to determine excess receipts were due to HUD when its PRAC renewed November 1, 2022. Amount due is $5,292.34. LHA is preparing to ask HUD if we can use some of the excess receipts to fix the smoke alarm system as well as a couple other items. If LHA is not...
Lexington Housing Authority (LHA) did fail to determine excess receipts were due to HUD when its PRAC renewed November 1, 2022. Amount due is $5,292.34. LHA is preparing to ask HUD if we can use some of the excess receipts to fix the smoke alarm system as well as a couple other items. If LHA is not able to, then they will be remitted back to HUD. LHA agrees with the finding and the planned corrective action follows. LHA should have answers back from HUD in regards to using the funds within the next two weeks. LHA Procedure for the future: When Annual Contract is renewed, check balance of Residual Receipts and if over the $4500 limit, remit the amount back to HUD.
Name of Contact Person: Matt Lacy, Chief Financial Officer; Recommendation: We recommend the District verify a vendor's status by checking the System for Award Management (SAM) maintained by the General Services Administration before making purchases expected to exceed $25,000; Corrective Action: ...
Name of Contact Person: Matt Lacy, Chief Financial Officer; Recommendation: We recommend the District verify a vendor's status by checking the System for Award Management (SAM) maintained by the General Services Administration before making purchases expected to exceed $25,000; Corrective Action: We will verify all vendors' status using the System for Award Management (SAM) maintained by the General Services Administration before making purchases expected to exceed $25,000.
Name of Contact Person: Matt Lacy, Chief Financial Officer; Recommendation: We recommend the District monitor the Child Nutrition profit made and ensure all expenditures used to operate the program are properly charged to the program; Corrective Action: We will ensure that all eligible costs are ...
Name of Contact Person: Matt Lacy, Chief Financial Officer; Recommendation: We recommend the District monitor the Child Nutrition profit made and ensure all expenditures used to operate the program are properly charged to the program; Corrective Action: We will ensure that all eligible costs are charged to the program and modernize the equipment to reduce the accumulated carry-over; Proposed Completion Date: Immediately.
2023-001 Level of Effort (Maintenance of Effort) Recommendation: The District should monitor operations to ensure that it is maintaining the required level of expenditures of local funds for the education of children with disabilities. Action Taken: The District will monitor operations to ens...
2023-001 Level of Effort (Maintenance of Effort) Recommendation: The District should monitor operations to ensure that it is maintaining the required level of expenditures of local funds for the education of children with disabilities. Action Taken: The District will monitor operations to ensure that it is maintaining the required level of expenditures of local funds for the education of children with disabilities. Anticipated Completion Date: Throughout Fiscal Year Ending August 31, 2024
View Audit 12908 Questioned Costs: $1
COVID-19 – American Rescue Plan Act – Assistance Listing No. 21.027 Recommendation: Design controls to ensure an adequate review process is in place to review potential contractors to determine they are not suspended or debarred. Explanation of disagreement with audit finding: There is no disagree...
COVID-19 – American Rescue Plan Act – Assistance Listing No. 21.027 Recommendation: Design controls to ensure an adequate review process is in place to review potential contractors to determine they are not suspended or debarred. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Town has created a form to be completed by Town departments for every contract and purchase made with ARPA funds. The form requires the department to identify the selected vendor, as well as the method used to select the vendor. The form is submitted to the Director of Finance who confirms the vendor is not suspended or debarred. Name(s) of the contact person(s) responsible for corrective action: Jennifer Charneski Planned completion date for corrective action plan: July 24, 2023
Finding Summary: When a recipient of Title IV grant or loan assistance withdraws from an institution during a payment period or period of enrollment in which the recipient began attendance, the institution must calculate the correct amount of Title IV grant or loan assistance that the student earned...
Finding Summary: When a recipient of Title IV grant or loan assistance withdraws from an institution during a payment period or period of enrollment in which the recipient began attendance, the institution must calculate the correct amount of Title IV grant or loan assistance that the student earned based on the student's withdrawal date and allocation of Title IV funds. During 2023, one student that withdrew during the period of enrollment and required a return of funds had an amount refunded that was in excess of the amount calculated by the University. Corrective Action Plan (CAP): For 2023-2024, all Return to Title IV Processes will be completed by Debra McGee, Director of Financial Aid, and then reviewed by Ron Anderson, AVP Student Financial Services. We will ensure all scheduled University time off will be included in the calculations, and all regulations followed. Anticipated Completion Date: The procedures will be implemented for the 2023-2024 Financial Aid Year. Responsible Parties: Debra McGee, Ron Anderson
View Audit 12902 Questioned Costs: $1
Responsible Official’s Response: In this particular finding, the decision was made to undertake a project using organizational reserves. Subsequent to the project taking place additional review indicated it would qualify as permissible under the American Rescue Plan and Federal Funding could potenti...
Responsible Official’s Response: In this particular finding, the decision was made to undertake a project using organizational reserves. Subsequent to the project taking place additional review indicated it would qualify as permissible under the American Rescue Plan and Federal Funding could potentially cover the project costs. The contract for the work, however, was not further reviewed at the time. After subsequent review, it appears that the contract may not meet the standards for Federal Funding, Management, therefore, has removed the Federal funding revenue from it’s financial statements and has not requested funding for this project under the American Rescue Plan. As a regular course of business, the organization does require any contracts subject to Federal funding requirements meet Federal Funding requirements, including those requirements associated with prevailing wages. Going forward, a comprehensive contract review will be performed for any project retroactively deemed a potentially permissible use of Federal funds
The Rochester Schools will implement a plan which will eliminate discrepancies between meal counting at the homeroom level, reporting at the school level, and claims made at the state and federal levels. This implementation plan includes a heighten responsibility with data collection, multiple quali...
The Rochester Schools will implement a plan which will eliminate discrepancies between meal counting at the homeroom level, reporting at the school level, and claims made at the state and federal levels. This implementation plan includes a heighten responsibility with data collection, multiple quality checks and data transfer. Procedures to prevent reoccurrence in the future are listed below:
Finding 9401 (2023-002)
Significant Deficiency 2023
Finding 2023-002 Response Type of Finding: Significant deficiency in internal control over compliance and instance of immaterial noncompliance. Criteria: DHI’s regulatory agreement with HUD and the HUD Uniform Financial Reporting Standards (24 CFR §5.801) require audited financial statements to be s...
Finding 2023-002 Response Type of Finding: Significant deficiency in internal control over compliance and instance of immaterial noncompliance. Criteria: DHI’s regulatory agreement with HUD and the HUD Uniform Financial Reporting Standards (24 CFR §5.801) require audited financial statements to be submitted to HUD within 90 days of the fiscal year end. HUD may authorize an extension to the 90 day due date. Management’s Response and Planned Corrective Actions: 1. The name of the contact person(s) responsible for the corrective action a. Kathleen Broadhurst, Sr. Director of Finance/ShelterCare 2. The corrective action planned: a. ShelterCare, as managing agent, has hired a new property accountant which should help with keeping the books current and ShelterCare prepared to start audit work mid-July and be ready to submit the audit to HUD within 90 days of the fiscal year end. 3. The anticipated completion date: a. New property accountant was hired in August of 2023.
Finding 2023-001 Response Type of Finding: Material weakness in internal control over compliance and noncompliance. Criteria: In accordance with DH, Incorporated’s regulatory agreement with HUD for its HUD Section 223(f) Insured Mortgage and HUD Section 8 Housing Assistance Payments contract, DH, In...
Finding 2023-001 Response Type of Finding: Material weakness in internal control over compliance and noncompliance. Criteria: In accordance with DH, Incorporated’s regulatory agreement with HUD for its HUD Section 223(f) Insured Mortgage and HUD Section 8 Housing Assistance Payments contract, DH, Incorporated is required to annually recertify its tenants. It is the responsibility of management to design and implement internal controls to ensure the tenants are recertified within the applicable timeframe required by HUD. Additionally, HUD requires minimum security deposits of $50 to be collected for all tenants. Management’s Response and Planned Corrective Actions: 1. The name of the contact person(s) responsible for the corrective action: a. Kathleen Broadhurst, Sr. Director of Finance/ShelterCare b. Amanda Smith, Property Development Manager/ShelterCare 2. The corrective action planned: a. Pinehurst Management was overseeing property through 4/30/2023. ShelterCare was assigned as new managing agent 5/1/2023. b. ShelterCare is working to ensure that the onsite manager will be trained in HUD compliance. Training started in October 2023. c. We are currently prioritizing recertifications by oldest first so we are able to catch them up and get the property certifications back on track. d. Monthly review of Tenant Rental Assistance Certification System (TRACS) reports to ensure recertifications are being completed in a timely manner. 3. The anticipated completion date: a. New training was started in October 2023 and to be completed by 12/31/2023. Monthly review of TRACS reports was implemented 10/1/2023.
The findings identified for the current year of an excess cash balance in the lunchroom fund will be reviewed by the Superintendent, Business Manager, and the Board of Trustees. The review will include determining the District’s current needs for equipment, amounts charged for student meals, and oth...
The findings identified for the current year of an excess cash balance in the lunchroom fund will be reviewed by the Superintendent, Business Manager, and the Board of Trustees. The review will include determining the District’s current needs for equipment, amounts charged for student meals, and other food service expenditures to determine the best course of action for the District to reduce the excess cash balance in the food service program.
The District agrees with the finding and will institute the additional training and review process recommended.
The District agrees with the finding and will institute the additional training and review process recommended.
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