Corrective Action Plans

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Finding 571941 (2024-001)
Significant Deficiency 2024
To mitigate this risk in the future, management intends to hire an additional Accounting Manager in the Summer 2025 that will in part be tasked with ensuring that development-related transactions are properly recorded between CHN and its affiliated entities.
To mitigate this risk in the future, management intends to hire an additional Accounting Manager in the Summer 2025 that will in part be tasked with ensuring that development-related transactions are properly recorded between CHN and its affiliated entities.
2024-002 - Internal Control over Eligibility Major Program: AL#93.569 - Community Service Block Grant Corrective Action Plan Staff has undergone extensive training on eligibility determination since mid-June. All forms and applications have been updated with specific language related to needed docum...
2024-002 - Internal Control over Eligibility Major Program: AL#93.569 - Community Service Block Grant Corrective Action Plan Staff has undergone extensive training on eligibility determination since mid-June. All forms and applications have been updated with specific language related to needed documentation, and a portable scanner has been purchased so documents can be scanned wherever clients are engaged. After application review, there will be additional communication regarding appointment confirmation as well as a reminder of documentation required when clients arrive. Person(s) Responsible: Monica Pettengill, Development Director Timing for Implementation: July 1, 2025 LeeAnn Horowitz, Chief Financial Officer" Corrective Action Plan for Current Year Findings 2024-001- Internal Control over Payroll Major Program: AL#93.569 - Community Service Block Grant Corrective Action Plan DONNA M. KELLEY, LCSW President & CEO Waldo CAP was finally able to hire an additional Human Resources staff member in May of 2025, who will complement our current payroll review process by adding a second layer to ensure not only the accuracy of the Wage Change of Status form (among other enhanced review duties) but to also ensure the completeness of the form including required signatures. Person(s) Responsible: Katie Bagley, Human Resources Director Timing for Implementation: August 1, 2025 2024-002 - Internal Control over Eligibility Major Program: AL#93.569 - Community Service Block Grant Corrective Action Plan Staff has undergone extensive training on eligibility determination since mid-June. All forms and applications have been updated with specific language related to needed documentation, and a portable scanner has been purchased so documents can be scanned wherever clients are engaged. After application review, there will be additional communication regarding appointment confirmation as well as a reminder of documentation required when clients arrive. Person(s) Responsible: Monica Pettengill, Development Director Timing for Implementation: July 1, 2025 LeeAnn Horowitz, Chief Financial Officer P.O. Box 130, 9 Field Street, Belfast, ME 04915 I Phone: (207) 338-6809 I Fax: (207) 338-6812 I www.waldocap.org
Corrective Action Plan for Current Year Findings 2024-001 - Internal Control over Payroll Major Program: AL#93.569 - Community Service Block Grant Corrective Action Plan DONNA M. KELLEY, LCSW President & CEO Waldo CAP was finally able to hire an additional Human Resources staff member in May of 2025...
Corrective Action Plan for Current Year Findings 2024-001 - Internal Control over Payroll Major Program: AL#93.569 - Community Service Block Grant Corrective Action Plan DONNA M. KELLEY, LCSW President & CEO Waldo CAP was finally able to hire an additional Human Resources staff member in May of 2025, who will complement our current payroll review process by adding a second layer to ensure not only the accuracy of the Wage Change of Status form (among other enhanced review duties) but to also ensure the completeness of the form including required signatures. Person(s) Responsible: Katie Bagley, Human Resources Director Timing for Implementation: August 1, 2025
Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend the City revise its policies and procedures to ensure that documentation related to suspension and debarment be presented with the procurement action prior to approval. Explanation of disag...
Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend the City revise its policies and procedures to ensure that documentation related to suspension and debarment be presented with the procurement action prior to approval. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: City staff conducted a review of newly contracted vendors associated with STP Urban funds. These contracts were recently executed with various engineering firms. None of these firms appear on the federal debarment list as maintained on System for Award Management (SAM). Documentation of these reviews is recorded within the respective project files in the City’s enterprise business software. Management is establishing a monthly review procedure to cross-reference the vendor list against the SAM debarment database. The anticipated implementation date is July 31, 2025. To further mitigate risk and ensure continued compliance, Management recommends incorporating a Certification of Non-Debarment or Suspension Status into the City’s contract execution process. This document will be completed, signed, and submitted by any contractor receiving $25,000 or more in payments. Name(s) of the contact person(s) responsible for corrective action: Jennifer Selenske, Finance Director Planned completion date for corrective action plan: July 31, 2025
The Community Development Division took corrective actions regarding submission of HUDs Integrated Disbursement and Information System (IDIS) Cash on Hand Quarterly Reports (formerly known as Federal Financial Report /Standard Form SF-425). Moving forward, the Cash on Hand Quarterly Reports will be ...
The Community Development Division took corrective actions regarding submission of HUDs Integrated Disbursement and Information System (IDIS) Cash on Hand Quarterly Reports (formerly known as Federal Financial Report /Standard Form SF-425). Moving forward, the Cash on Hand Quarterly Reports will be submitted within IDIS every quarter and no later than 30 days after the last day of each reporting quarter and will be reviewed by a supervisor prior to submission. As the grantee, we understand HUDs Cash On Hand Quarterly Report is required every quarter, regardless of whether expenses were incurred or not, once the project(s) has begun.
Finding 571930 (2024-004)
Significant Deficiency 2024
U. S. Department of Housing and Urban Development. Heritage Grove, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of independent public accounting firm: MCK CPAs & Advisors, Decatur, Illinois. Audit period: Year ended June 30, 2024...
U. S. Department of Housing and Urban Development. Heritage Grove, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of independent public accounting firm: MCK CPAs & Advisors, Decatur, Illinois. Audit period: Year ended June 30, 2024. The findings from the June 30, 2024 Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Findings and Questioned Costs - Federal Award Programs Audit: Department of Housing and Urban Development: Supportive Housing for Persons with Disabilities Program (Section 811), Assistance Listing # 14.181: 2024 - 004 Recommendation: Management agent and sponsor will continue to recertify and update the tenant files to make sure it includes current required documentation. If the Department of Housing and Urban Development has questions regarding this plan, please call Mary Garrison, Heritage Grove, Inc. at (217) 362-6262.
Finding 571929 (2024-003)
Significant Deficiency 2024
U. S. Department of Housing and Urban Development. Heritage Grove, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of independent public accounting firm: MCK CPAs & Advisors, Decatur, Illinois. Audit period: Year ended June 30, 2024...
U. S. Department of Housing and Urban Development. Heritage Grove, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of independent public accounting firm: MCK CPAs & Advisors, Decatur, Illinois. Audit period: Year ended June 30, 2024. The findings from the June 30, 2024 Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Findings and Questioned Costs - Federal Award Programs Audit: Department of Housing and Urban Development: Supportive Housing for Persons with Disabilities Program (Section 811), Assistance Listing # 14.181: 2024 - 003 Recommendation: Finding is closed as of June 30, 2024. If the Department of Housing and Urban Development has questions regarding this plan, please call Mary Garrison, Heritage Grove, Inc. at (217) 362-6262.
Finding: Allowable Activities & Allowable Costs and Eligibility (Reference Number: 2024-001) Criteria or Specific Requirement: Funds may be expended for foster care maintenance payments on behalf of eligible children, in accordance with the Title IV-E agency’s foster care maintenance payment rate ...
Finding: Allowable Activities & Allowable Costs and Eligibility (Reference Number: 2024-001) Criteria or Specific Requirement: Funds may be expended for foster care maintenance payments on behalf of eligible children, in accordance with the Title IV-E agency’s foster care maintenance payment rate schedule and in accordance with 45 CFR section 1356.21, to individuals serving as foster family homes, to childcare institutions, or public/private child-placement or child-care agencies. In accordance with Code of Colorado Regulations (CCR) section 7.302.2, for each child, Jefferson County Human Services (JCHS) must have an agreement with the provider which details the daily maintenance payments. JCHS agreement to purchase services must be signed by the provider and JCHS. Additionally, in accordance with CCR section 7.301.3, the Family Services Plan shall be reviewed in conference with the caseworker and supervisor every 90 calendar days. Condition: • Two instances out of 40 where there was no signed agreement in place to support revised maintenance payments following a child’s 9th birthday. The correct maintenance amount was paid to the provider in accordance with the State of Colorado rates published in IM-CW–2024-0028 and IM-CW-2023-0021. • One instance out of 40 where the required 90-day review was not completed on time. The review was conducted 15 days late. Cause: The state's Foster Care system did not automatically generate a notice that a new agreement to purchase services was needed based on the child's birthday. Additionally, JCHS lacks an effective control mechanism to proactively identify when a 90-day review is approaching or overdue. Corrective Action Plan: We agree with the finding. The Integrated Case Management System (ICM) is designed to generate an email notification to Collaborative Foster Care Program (CFCP) staff when a child turns 9 or 14 years of age while in foster care. This email notification instructs CFCP staff to generate a new Child Specific Addendum (SS23-B) due to the increase of the child maintenance rate. This email instructs and standard procedure requires CFCP staff to verify the child maintenance rate in Trails after an SS23-B is generated. The IT Systems Support Team responsible for the maintenance of ICM determined that ICM has failed to notify CFCP staff when a child turned 9 or 14 years of age while in foster care: • The IT Systems Support Team responsible for the maintenance of ICM has been asked to ensure that ICM is generating an email notification when a child turns 9 or 14 years of age while in foster care. • While this issue is being addressed in ICM, the CFCP requested a report that included the birthdays for all children in foster care. CFCP staff have generated new Child Specific Addendums (SS23-B) for children that have turned 9 or 14 years old while in foster care. CFCP staff will utilize this report to generate new Child Specific Addendums for future birthdays. • After a new Child Specific Addendum is generated, staff will verify the child maintenance rate in Trails. • The CFCP has determined that it can no longer rely on ICM and has decided to migrate its functionality over to the ancillary system supported by Jefferson County known as the Caseworker Application Timesaver (CAT). With this migration, the email notifications will resume so that CFCP staff are properly notified of the need to generate the new SS23-B and verify the child maintenance rate. • Migration is scheduled to occur on Friday, June 20, 2025. • On Monday, June 23, 2025, the CFCP will meet with the Jefferson County Application Program Analyst to ensure the migration was successful. • Additionally, the CFCP and the Jefferson County Application Program Analyst have scheduled a second meeting for July 9, 2025, to ensure the successful migration from ICM to CAT. • To ensure 90-Day Reviews are completed timely, the Division of Children, Youth, Families, and Adult Protection (CYFAP) will continue to utilize the 90-Day Review compliance feature of CAT. Additionally, CYFAP leadership will emphasize this requirement with supervisors and casework staff and ensure their compliance. Person(s) Responsible for Implementation: Barb Weinstein, Director, Division of Children, Youth, Families and Adult Protection Implementation Date: July 1, 2025
Finding 571927 (2024-003)
Significant Deficiency 2024
The City of Athens has reviewed the findings of ODOD and has modified subrecipient monitoring procedures to detect these types of issues in the future.
The City of Athens has reviewed the findings of ODOD and has modified subrecipient monitoring procedures to detect these types of issues in the future.
Classes of financial transactions have been segregated to the extent possible among the existing employees. However, due to the limited number of individuals involved in the accounting and bookkeeping functions, a corrective action plan to fully remedy the lack of segregation of duties is not cost j...
Classes of financial transactions have been segregated to the extent possible among the existing employees. However, due to the limited number of individuals involved in the accounting and bookkeeping functions, a corrective action plan to fully remedy the lack of segregation of duties is not cost justified. Instead, each level of management, the Board of Directors, and the Administrator remain aware of the principles of segregation of duties and the potential risks that exist when full segregation is not achievable. Because of this awareness, management is responsible for ongoing review and follow-up on any transactions or circumstances that appear unusual. This oversight is considered a mitigating control to reduce the risk of undetected errors or irregularities. Contact person: Tim Nichols Anticipated completion date: Unknown
Name of auditee: Dolan Manor II HUD auditee identification number: FHA/Contract 053-EE072 Name of audit firm: O. Douglas Covington, C.P.A., P.A. Period covered by the audit: January 1, 2024 thru December 31, 2024 CAP Prepared By: Name: Kenya Owens Position: Vice President of Operations Teleph...
Name of auditee: Dolan Manor II HUD auditee identification number: FHA/Contract 053-EE072 Name of audit firm: O. Douglas Covington, C.P.A., P.A. Period covered by the audit: January 1, 2024 thru December 31, 2024 CAP Prepared By: Name: Kenya Owens Position: Vice President of Operations Telephone: 336-944-5847 1. Finding 2024-001 a. Comments on the Finding and Each Recommendation At the time of audit, we are in agreement with the findings. b. Action(s) Taken or planned on the finding Due to an oversight on management duplicate invoices was submitted and approve through HUD. We have since corrected and returned the duplicated funds in the amount of $2,077.59 from the operating account back to the reserves account. *Regional Compliance Manager will review prior RFR previously submitted.
View Audit 363000 Questioned Costs: $1
U. S. Department of Housing and Urban Development; Heritage Fields III, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2024.; Name and address of independent public accounting firm: MCK CPAs & Advisors, Decatur, Illinois. Audit period: Year ended June 3...
U. S. Department of Housing and Urban Development; Heritage Fields III, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2024.; Name and address of independent public accounting firm: MCK CPAs & Advisors, Decatur, Illinois. Audit period: Year ended June 30, 2024. The findings from the June 30, 2024 Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Findings and Questioned Costs - Federal Award Programs Audit: Department of Housing and Urban Development: Supportive Housing for Persons with Disabilities Program (Section 811), Assistance Listing # 14.181: 2024 - 002 Recommendation: Finding is closed as of June 30, 2024. If the Department of Housing and Urban Development has questions regarding this plan, please call Mary Garrison, Heritage Grove, Inc. at (217) 362-6262.
Finding 571923 (2024-003)
Significant Deficiency 2024
U. S. Department of Housing and Urban Development. Heritage Fields, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of independent public accounting firm: MCK CPAs & Advisors, Decatur, Illinois. Audit period: Year ended June 30, 202...
U. S. Department of Housing and Urban Development. Heritage Fields, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of independent public accounting firm: MCK CPAs & Advisors, Decatur, Illinois. Audit period: Year ended June 30, 2024.The findings from the June 30, 2024 Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule.Department of Housing and Urban Development: Supportive Housing for Persons with Disabilities Program (Section 811), Assistance Listing # 14.181: 2024 - 003 Recommendation: Finding is closed as of June 30, 2024. If the Department of Housing and Urban Development has questions regarding this plan, please call Mary Garrison, Heritage Fields, Inc. at (217) 362-6262.
We will obtain written documentation of the period of performance for all applicable projects to ensure compliance.
We will obtain written documentation of the period of performance for all applicable projects to ensure compliance.
View Audit 362973 Questioned Costs: $1
Going forward, we will obtain and retain quotes via email and ensure that a sufficient number of qualified sources are solicited, in accordance with procurement guidelines.
Going forward, we will obtain and retain quotes via email and ensure that a sufficient number of qualified sources are solicited, in accordance with procurement guidelines.
View Audit 362973 Questioned Costs: $1
As with Finding 2024-002, employees will now use the time tracking software to log fleet assets with time entries. All submissions will be reviewed and approved by someone other than the submitter or Line Foreman.
As with Finding 2024-002, employees will now use the time tracking software to log fleet assets with time entries. All submissions will be reviewed and approved by someone other than the submitter or Line Foreman.
View Audit 362973 Questioned Costs: $1
We have implemented a time tracking software feature allowing employees to associate fleet assets with their time entries. Entries will be submitted by the employee or Line Foreman, then reviewed and approved by a separate supervisor or manager.
We have implemented a time tracking software feature allowing employees to associate fleet assets with their time entries. Entries will be submitted by the employee or Line Foreman, then reviewed and approved by a separate supervisor or manager.
For all future large-scale weather events, two employees will jointly pull materials and document quantities. Both will sign a material charge-out sheet. Any unused materials will be charged back to the appropriate work order.
For all future large-scale weather events, two employees will jointly pull materials and document quantities. Both will sign a material charge-out sheet. Any unused materials will be charged back to the appropriate work order.
View Audit 362973 Questioned Costs: $1
2024-004) Late Completion and Filing of Single Audit Assistance Listing Numbers Name of Federal Program or Cluster 97.036 Disaster Grants-Public Assistance (Presidentially Declared Disasters) Management will implement procedures referenced in Finding 2023-001 and 2023-003 that will help facil...
2024-004) Late Completion and Filing of Single Audit Assistance Listing Numbers Name of Federal Program or Cluster 97.036 Disaster Grants-Public Assistance (Presidentially Declared Disasters) Management will implement procedures referenced in Finding 2023-001 and 2023-003 that will help facilitate gathering information necessary for proper recording at year end to avoid this issue in the future and allow timely completion of the audit. Persons responsible: Dennis Bent, C.F.O.; Martha Witherwax, Director of Accounting Expected Completion date: July, 2025
2024-003) Preparation of Schedule of Expenditures and Federal Awards CFDA Listing Numbers Name of Federal Program or Cluster 97.036 Disaster Grants-Public Assistance (Presidentially Declared Disasters) Disaster Grants through FEMA are managed by rules and processes that are not easily acco...
2024-003) Preparation of Schedule of Expenditures and Federal Awards CFDA Listing Numbers Name of Federal Program or Cluster 97.036 Disaster Grants-Public Assistance (Presidentially Declared Disasters) Disaster Grants through FEMA are managed by rules and processes that are not easily accounted for in traditional accounting systems. Procedures will be strengthened to fully and accurately identify all federal program expenditures and record in the appropriate accounting funds. Procedures will be implemented to prepare documentation necessary to support the information in the financial statements earlier and more accurately, for the information to be completed, available and provided to auditors for the audit. Persons responsible: Dennis Bent, C.F.O.; Martha Witherwax, Director of Accounting Expected Completion date: July, 2025
PRAC Budgets Recommendation: We recommend audits are completed timely to ensure the annual budget is submitted to HUD as required. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The process for submitting the budg...
PRAC Budgets Recommendation: We recommend audits are completed timely to ensure the annual budget is submitted to HUD as required. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The process for submitting the budget for 2025 has already begun. Management is monitoring the process to ensure timely submission. Name(s) of the contact person(s) responsible for corrective action: Alex Lueth, VP of Finance Planned completion date for corrective action plan: June 2025
Replacement Reserve Deposits Recommendation: We recommend management implement a control to ensure the monthly transfer is completed automatically and in accordance with the Regulatory Agreement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action ...
Replacement Reserve Deposits Recommendation: We recommend management implement a control to ensure the monthly transfer is completed automatically and in accordance with the Regulatory Agreement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization agrees with the finding and the recommendation will be implemented. Controls implemented include scheduling of automatic transfers to our reserve for replacement savings account as well as updating our treasury standard operating procedures to ensure funds are available for the transfer. Monthly bank reconciliation will also confirm that the transfer occurred. Name(s) of the contact person(s) responsible for corrective action: Alex Lueth, VP of Finance Planned completion date for corrective action plan: June 2025
View Audit 362961 Questioned Costs: $1
PRAC Budgets Recommendation: We recommend audits are completed timely to ensure the annual budget is submitted to HUD as required. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The process for submitting the budg...
PRAC Budgets Recommendation: We recommend audits are completed timely to ensure the annual budget is submitted to HUD as required. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The process for submitting the budget for 2025 has already begun. Management is monitoring the process to ensure timely submission. Name(s) of the contact person(s) responsible for corrective action: Alex Lueth, VP of Finance Planned completion date for corrective action plan: June 2025
Replacement Reserve Deposits Recommendation: We recommend management implement a control to ensure the monthly transfer is completed automatically and in accordance with the Regulatory Agreement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action ...
Replacement Reserve Deposits Recommendation: We recommend management implement a control to ensure the monthly transfer is completed automatically and in accordance with the Regulatory Agreement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization agrees with the finding and the recommendation will be implemented. Controls implemented include scheduling of automatic transfers to our reserve for replacement savings account as well as updating our treasury standard operating procedures to ensure funds are available for the transfer. Monthly bank reconciliation will also confirm that the transfer occurred. Name(s) of the contact person(s) responsible for corrective action: Alex Lueth, VP of Finance Planned completion date for corrective action plan: June 2025
View Audit 362958 Questioned Costs: $1
To ensure consistent completion of the Sliding Fee Discount Form for all patients, new procedures have been implemented to improve the collection and documentation of required information. Patient registration forms have been revised to reflect these updates. Clerical staff will now conduct schedule...
To ensure consistent completion of the Sliding Fee Discount Form for all patients, new procedures have been implemented to improve the collection and documentation of required information. Patient registration forms have been revised to reflect these updates. Clerical staff will now conduct schedule preparation and identify patients who are non-compliant with the Sliding Fee Discount Form requirements. Post visit audits will be conducted to confrim that all necessary data is being accurately captured. The Revenue Cycle Manager will continue to provide on-site training across all locations and will work in close collaboration with clerical support staff, Clinic Managers, the Director of Operations, and the Director of Quality to ensure successful implementation and ongoing compliance.
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