Corrective Action Plans

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Findings- Federal Award Audit. Department of Health and Human Services.2022-001 Nutrition Services Assistance Listing Number 93.045. See Finding 2022-001. Recommendation: All procedures and policies that are exercised in the accounting function should be written in an accounting manual. Action Taken...
Findings- Federal Award Audit. Department of Health and Human Services.2022-001 Nutrition Services Assistance Listing Number 93.045. See Finding 2022-001. Recommendation: All procedures and policies that are exercised in the accounting function should be written in an accounting manual. Action Taken: Laura Edwards and Diane Stevens of Senior Nutrition Program compiled a Finance Policy detailing company financial policies and procedures.
CORRECTIVE ACTION PLAN Finding No. 2022-01: Surplus Cash existing at December 31, 2021 was not deposited into a separate residual receipts account. Recommendation: Management should deposit the amount or request HUD's approval for a waiver. Action Taken or Planned: Due to pending cash requirements, ...
CORRECTIVE ACTION PLAN Finding No. 2022-01: Surplus Cash existing at December 31, 2021 was not deposited into a separate residual receipts account. Recommendation: Management should deposit the amount or request HUD's approval for a waiver. Action Taken or Planned: Due to pending cash requirements, we requested HUD's approval to waive the deposit requirement, however an answer was not obtained. We will again seek w waiver for the current year and, if not approved, we will follow the HUD Account Executive?s instructions on how to resolve the matter. Responsible Person: James Watt, Senior Vice President, Management Company Completion Date: July 31, 2023
View Audit 18784 Questioned Costs: $1
Finding 2022-002 Planned Corrective Action: Montgomery County concurs with the finding. Based on the information included in 2 CFR ? 200.331 through 2 CFR ? 200.333, the Department of Finance will produce a written communication that outlines the requirements and responsibilities related to subreci...
Finding 2022-002 Planned Corrective Action: Montgomery County concurs with the finding. Based on the information included in 2 CFR ? 200.331 through 2 CFR ? 200.333, the Department of Finance will produce a written communication that outlines the requirements and responsibilities related to subrecipient disclosures and monitoring. The requirements and responsibilities will further be discussed in a targeted training session, to include the County?s Department of Health and Human Services. Name of Contact Person: Michael Lee, General Accounting Manager Anticipated Completion Date: June 30, 2023
Finding 2022-001 Planned Corrective Action: Montgomery County concurs with the finding. The County will update its existing processes and documentation over its reviews of grant awards to ensure Federal Funding Accountability and Transparency Act (FFATA) reporting requirements are addressed. The Co...
Finding 2022-001 Planned Corrective Action: Montgomery County concurs with the finding. The County will update its existing processes and documentation over its reviews of grant awards to ensure Federal Funding Accountability and Transparency Act (FFATA) reporting requirements are addressed. The County will also perform a one-time review of its existing Federal grants with subawards to ensure there are no additional FFATA reporting oversights. Name of Contact Person: Michael Lee, General Accounting Manager Anticipated Completion Date: June 30, 2023
Finding Reference Number: 2022-002 Concur or Do Not Concur: Concur Agree or Disagree with Auditor Recommendations: Agree Actions Taken or Planned on the Finding: Management agrees with the finding. The residual receipts account deficiency will be funded in the amount of $25,122. Management will e...
Finding Reference Number: 2022-002 Concur or Do Not Concur: Concur Agree or Disagree with Auditor Recommendations: Agree Actions Taken or Planned on the Finding: Management agrees with the finding. The residual receipts account deficiency will be funded in the amount of $25,122. Management will ensure that the residual receipts account is properly funded in the future. Completion Date: August 31, 2022
Finding Reference Number: 2022-001 Concur or Do Not Concur: Concur Agree or Disagree with Auditor Recommendations: Agree Actions Taken or Planned on the Finding: Management agrees with the finding. The replacement reserve deficiency will be funded in the amount of $70. Management will ensure that...
Finding Reference Number: 2022-001 Concur or Do Not Concur: Concur Agree or Disagree with Auditor Recommendations: Agree Actions Taken or Planned on the Finding: Management agrees with the finding. The replacement reserve deficiency will be funded in the amount of $70. Management will ensure that the replacement reserve deposits are made on a timely basis in the future. Completion Date: August 31, 2022
2022-02: Significant Deficiency ? Program income compliance and controls Federal Agency: Department of Health and Human Services Program: Certified Community Behavioral Health Clinic Demonstration Grant Assistance Listing Number: 93.829 Management agrees that during the year ended December 31, 20...
2022-02: Significant Deficiency ? Program income compliance and controls Federal Agency: Department of Health and Human Services Program: Certified Community Behavioral Health Clinic Demonstration Grant Assistance Listing Number: 93.829 Management agrees that during the year ended December 31, 2022, Flushing did not have a formal control in place to identify, monitor and report program income collected from providing mental health counseling services to patients under the grant. Management has contacted The Department of Health and Human Services to inform them of this finding. Medisys Health Network, which includes Jamaica Hospital and Flushing, is the recipient of various federal grants, including another grant with program income requirements which was identified as a result of management?s review of the awards and for which controls have been designed and implemented to ensure compliance with the requirement. We believe our oversight of this compliance requirement was an isolated situation because the NoA only included one brief sentence regarding program income. Flushing will implement the following process to formalize controls related to the program income compliance requirement for the grant. 1) Management will review monthly charge/income reports for each clinician hired under the grant to keep track of the program income related to the grant. Management has started reviewing the program revenue and will set up quarterly reviews with the program director. 2) Management will keep track of all program income related to the grant and compare the income to the current expenses, and retain documentation supporting how the program income was used to further eligible project objectives prior to requesting reimbursement from the agency under the grant. 3) These controls and procedures will be implemented by the end of the 3rd quarter of 2023. Management responsible for corrective action plan: Gina Aharonoff, Program Director (gaharono@jhmc.org) Manzar Sassani, Vice President of Finance (msassani@jhmc.org)
View Audit 25996 Questioned Costs: $1
2022-001: Untimely and Incomplete Submission of Federal Financial Report Federal Agency: Department of Health and Human Services (?HHS?) Program: Certified Community Behavioral Health Clinic Demonstration Grant Assistance Listing Number: 93.829 Management agrees that during the year ended December...
2022-001: Untimely and Incomplete Submission of Federal Financial Report Federal Agency: Department of Health and Human Services (?HHS?) Program: Certified Community Behavioral Health Clinic Demonstration Grant Assistance Listing Number: 93.829 Management agrees that during the year ended December 31, 2022, the Federal Financial Report (?FFR?) was not submitted timely and that it did not include the required program income information. Flushing Hospital Medical Center (?Flushing?) will implement the following controls and procedures to avoid any future untimely and incomplete submissions of the FFR. 1) Management will review all grant reporting requirements and create a checklist to ensure the completeness of each report. 2) A formal review process will be established before the report is submitted to ensure multiple layers of review prior to submission. 3) A formal calendar will be prepared with report due dates to ensure the timely filing of each report. 4) These controls and procedures will be implemented by the end of the 3rd quarter of 2023. Management responsible for corrective action plan: Gina Aharonoff, Program Director (gaharono@jhmc.org) Manzar Sassani, Vice President of Finance (msassani@jhmc.org)
Finding 2022-001: U.S. Department of Health and Human Services - Technical and Non-Financial Assistance to Health Centers - Assistance Listing No. 93.129. Reporting, Significant Deficiency Auditor Recommendation: We recommend that the Association review its procedures to ensure reports are remitte...
Finding 2022-001: U.S. Department of Health and Human Services - Technical and Non-Financial Assistance to Health Centers - Assistance Listing No. 93.129. Reporting, Significant Deficiency Auditor Recommendation: We recommend that the Association review its procedures to ensure reports are remitted on time in accordance with the terms outlined by the agreement. Corrective Action: The late filling stated on the deficiency was due to the transition period when directors changed. The Association has not had a late submission in the past. The Association Current Director and the Accountant will form a more collaborative approach to the timely filing of the FFR. This will ensure that a timely filing will occur with-out exception basis. Responsible Party: Brent Dolence Accountant and Tracy Woodhouse Brosius Anticipated Completion Date: 06/20/2023
Corrective Action Plan Haven Towers Development Corporation For the Year Ended June 30, 2022 Haven Towers Development Corporation respectfully submits the following Corrective Action Plan for the year ended June 30, 2022. Name and address of the independent public accounting firm who conducted th...
Corrective Action Plan Haven Towers Development Corporation For the Year Ended June 30, 2022 Haven Towers Development Corporation respectfully submits the following Corrective Action Plan for the year ended June 30, 2022. Name and address of the independent public accounting firm who conducted the related audit: Comer, Nowling And Associates, P.C. 10475 Crosspoint Boulevard, Suite 200 Indianapolis, Indiana 46256 Finding 2022-001 Corrective Action Planned ? Management will provide the auditors with all audit documentation in a matter timely enough to complete the audit fieldwork and file the audit in the REAC system within 90 days of year-end. Contact Person(s) Responsible ? Jim Beemster, Controller Anticipated Completion Date ? January 17, 2023 Auditee Disagreements ? Management maintains the request for documentation was not received with enough time to turn around the documents. This corrective action plan was prepared by Evergreen Real Estate Services, the management company, on behalf of Haven Towers Development Corporation. __________________________ _____________________ Jim Beemster, Controller Date Evergreen Real Estate Services 566 West Lake Street, Suite 400 Chicago, IL 60661 312-234-9400
Condition: The audited financial statements, reports and supplemental information for the year ended December 31, 2021 were not submitted to the REAC within 90 days of the Corporation?s fiscal year end, and was not submitted to the Federal Audit Clearinghouse within nine months of the fiscal year e...
Condition: The audited financial statements, reports and supplemental information for the year ended December 31, 2021 were not submitted to the REAC within 90 days of the Corporation?s fiscal year end, and was not submitted to the Federal Audit Clearinghouse within nine months of the fiscal year end. Recommendation: Gethsemane Manor Apartments should implement controls to ensure necessary information is available for timely completion of the audit and submission of the audited financial statements to the REAC and the Federal Audit Clearinghouse within the required timeframe. Action Taken: Management of Gethsemane Manor Apartments will make every effort going forward to ensure timely submission to the REAC and Federal Audit Clearinghouse within the required timeframe.
Corrective Action Plan #2022-001 ? Tenant Rents ? The Housing Authority will have another employee review tenant files during their annual recertification to make sure the files are being maintained properly and tenant rents are being calculated properly. Responsible official: Sue Weis? Executiv...
Corrective Action Plan #2022-001 ? Tenant Rents ? The Housing Authority will have another employee review tenant files during their annual recertification to make sure the files are being maintained properly and tenant rents are being calculated properly. Responsible official: Sue Weis? Executive Director Anticipated completion date: 6/30/2023
Account reconciliations of balances Recommendation: The Center should reconcile all balance sheet accounts at the end of each month and evaluate the need for revisions in estimates such as the receivable allowances. This process should include a monthly update to the fixed asset and depreciation rec...
Account reconciliations of balances Recommendation: The Center should reconcile all balance sheet accounts at the end of each month and evaluate the need for revisions in estimates such as the receivable allowances. This process should include a monthly update to the fixed asset and depreciation records. Action Taken: We concur with the recommendation. The Center will reconcile balance sheet accounts monthly in partnership with the new third-party bookkeeping company.
HRSA Notice of Awards Recommendation: The Center should record (unconditional) grants in full at the time that they receive notice of the grant, rather than the time at which payment is received. Action Taken: We concur with the recommendation and the Center will continue to follow policy of recogni...
HRSA Notice of Awards Recommendation: The Center should record (unconditional) grants in full at the time that they receive notice of the grant, rather than the time at which payment is received. Action Taken: We concur with the recommendation and the Center will continue to follow policy of recognizing NOAs when received. There was one NOA that was not recognized during the year ended June 30, 2022 due an oversight by a former employee.
Reconcile cash at the end of the month Recommendation: The Center should timely resolve bank reconciliation differences on a monthly basis and should evaluate its payroll accrual at the end of each month. Action Taken: We concur with the recommendation and we are reconciling the bank statement to th...
Reconcile cash at the end of the month Recommendation: The Center should timely resolve bank reconciliation differences on a monthly basis and should evaluate its payroll accrual at the end of each month. Action Taken: We concur with the recommendation and we are reconciling the bank statement to the general ledger and evaluating the payroll accrual at the end of each month during FY23. We have hired a new third-party bookkeeping company to provide this reconciliation and assist with the evaluation of the payroll accrual each month.
Federal HRSA Grant Income Recommendation: Management should continue to recognize Federal HRSA grant income upon the Notice of Award and should continue to relieve the receivable in conjunction with funding; management should discontinue the second adjustment in conjunction with funding which serves...
Federal HRSA Grant Income Recommendation: Management should continue to recognize Federal HRSA grant income upon the Notice of Award and should continue to relieve the receivable in conjunction with funding; management should discontinue the second adjustment in conjunction with funding which serves to overstate grant income and decrease net assets. Action Taken: We concur with the recommendation. Starting in FY23 we are going to continue to recognize Federal HRSA grant income upon the Notice of Award and relieve the receivable each time a draw is taken. We will discontinue the adjustment which serves to overstate grant income and decrease net assets.
Finding 21554 (2022-001)
Significant Deficiency 2022
CORRECTIVE ACTION PLAN YEAR ENDED: JUNE 30, 2022 U.S. Department of Treasury Trilogy, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 2021 ? June 30, 2022 The findings from the schedule of findings and questioned costs are d...
CORRECTIVE ACTION PLAN YEAR ENDED: JUNE 30, 2022 U.S. Department of Treasury Trilogy, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 2021 ? June 30, 2022 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS?FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Treasury 2022-001 Allowable Costs (Allocation of payroll costs) ? Assistance Listing Number 21.027 Recommendation: Management should develop a process whereby payroll costs allocated to federal grants are supported by a system of internal controls which provides reasonable assurance that the charges are accurate, allowable and properly allocated, reasonably reflect the total activity for which the employee is compensated and support the distribution of the employee?s wages among specific activities or cost objectives if the employee works on more than one federal award. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Trilogy has an internal control process in place regarding the review of eligible grant related expenditures. This process has been led by the Grants Compliance Team (GCT), since FY2018. The GCT is the key control mechanism through which allowable salaries and wage expenses are identified. Staff enter hours into ADP with their immediate supervisor signing off on entries and ensuring that salaries/ wages are being distributed to correct cost centers that reflect their actual worked hours and effort reporting. All salary allocations are approved by higher level program staff, HR and Finance staff. As a regular part of the grant revenue analysis for the monthly financial close, the GCT communicates with programs to verify the accuracy and reasonableness of labor allocations that directly impact our grant reimbursable expenses. Trilogy does acknowledge that a further verification of this process can be added through the following points: 1. Have budget owners (ie. Program Managers and/or Clinical Directors) certify through electronic signature the accuracy and reasonableness of labor allocations, monthly as a requirement of the grant invoicing process. 2. Monthly reassessment by GCT of internal transfers, exits and new recruits to each grant program to ensure allocations are reasonable for labor cost and efforts to support each program. While this is part of the current process, this process can, once again, be bolstered through electronic certifications/ signatures. 3. GCT will reassess each program?s allocations as we enter the budget season for grant renewals with our funding sources. While this is part of the current process, this process can, once again, be bolstered through electronic certifications/ signatures. Name(s) of the contact person(s) responsible for corrective action: Rich Adelman, Chief Financial Officer, Katrina Wright, Chief Human Resources Officer, Kyu Yup Kim, Grants Compliance Manager Planned completion date for corrective action plan: Trilogy will implement these action plans by the onset of FY2023 Q4 (April 1, 2023) If there are any questions regarding this plan, please call Rich Adelman, CFO at (773) 382-4002.
Condition ? The Hospital?s Provider Relief Fund filing with HRSA for Reporting Period 4 did not consider COVID-19 costs that were potentially already reimbursed with a Paycheck Protection Program (PPP) loan. The PPP loan was subsequently forgiven. Recommendation ? We recommend that the Hospital impl...
Condition ? The Hospital?s Provider Relief Fund filing with HRSA for Reporting Period 4 did not consider COVID-19 costs that were potentially already reimbursed with a Paycheck Protection Program (PPP) loan. The PPP loan was subsequently forgiven. Recommendation ? We recommend that the Hospital implement review procedures for any future filings with HRSA that ensure consideration of all relevant rules and regulations. Views of Responsible Officials and Planned Corrective Actions ? Management agrees with the finding and has taken steps to ensure any future filings consider all relevant rules and regulations. Anticipated Date of Completion ? Completed June 21, 2023. Action Taken ? We have reviewed the recommendation and have taken steps to ensure any future filings consider all relevant rules and regulations. Person Responsible for Corrective Action Plan ? Calvin Carey, Chief Financial Officer
Department of Health General Requirements Services Kewaunee County agrees with the finding. Policy and procedures, as well as related documentation, are being revised as necessary to ensure complia...
Department of Health General Requirements Services Kewaunee County agrees with the finding. Policy and procedures, as well as related documentation, are being revised as necessary to ensure compliance with the requirements.
2022-006 Epidemiology and Laboratory Capacity for Infectious Diseases and Support of Immunization Initiative-Focusing on Childhood Vaccination Programs ? Assistance Listing No. 93.323 and 93.268 ? Allowable Costs Recommendation: We recommend the County review time and effort records to ensure overti...
2022-006 Epidemiology and Laboratory Capacity for Infectious Diseases and Support of Immunization Initiative-Focusing on Childhood Vaccination Programs ? Assistance Listing No. 93.323 and 93.268 ? Allowable Costs Recommendation: We recommend the County review time and effort records to ensure overtime is not charged to Federal grants on days in which vacation and sick time is used. More detailed reporting of the days in which the vacation and sick days are used and the overtime days would assist with this process. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The public health department is in the process of training new employees that are responsible for payroll and grant allocations. The Finance Manager has begun conversations with the new employee and the public health administrator on documentation and review. It was discussed that no benefit time such as vacation or sick be charged to a grant. If there are allowances within a grant for benefit time to be charged, there must be proper documentation and detailed approval by the public health board. This will be implemented immediately. Name of the contact persons responsible for corrective action: Jill Johnson, Finance Manager, and Department Heads and Elected Officials Planned completion date for corrective action plan: Immediate implementation
View Audit 26346 Questioned Costs: $1
2022-005 Coronavirus State and Local Fiscal Recovery Funds ? Assistance Listing No. 21.027 ? Reporting Recommendation: We recommend the County strengthen its review procedures over reports and ensure the review is documented. Explanation of disagreement with audit finding: There is no disagreement w...
2022-005 Coronavirus State and Local Fiscal Recovery Funds ? Assistance Listing No. 21.027 ? Reporting Recommendation: We recommend the County strengthen its review procedures over reports and ensure the review is documented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The American Rescue Plan Act annual report is completed by the Finance Manager. The annual report will then be taken to the finance committee for review and approval for submission. The fiscal year 2023 annual report will be requested for return in order to correct and will be implemented immediately. Name of the contact persons responsible for corrective action: Jill Johnson, Finance Manager, and Department Heads and Elected Officials Planned completion date for corrective action plan: March 31, 2024
View Audit 26346 Questioned Costs: $1
2022-004 Coronavirus State and Local Recovery Funds ? Assistance Listing No. 21.027 - Procurement Recommendation: We recommend the County carefully review federal procurement requirements for proper documentation needed. The County should consider use of a Federal procurement checklist. Explanation ...
2022-004 Coronavirus State and Local Recovery Funds ? Assistance Listing No. 21.027 - Procurement Recommendation: We recommend the County carefully review federal procurement requirements for proper documentation needed. The County should consider use of a Federal procurement checklist. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Finance Manager will implement a Federal Procurement Checklist. The Finance Manager will provide the checklist to the finance committee to complete and approve for federal spending. Name of the contact persons responsible for corrective action: Jill Johnson, Finance Manager, and Department Heads and Elected Officials Planned completion date for corrective action plan: December 1, 2023
Contact Person Responsible for the Corrective Action Plan: Mary W. Duncan, Finance Director Corrective Action Plan: We have discussed the finding and are currently implementing controls to ensure the timesheets are appropriately reviewed to match with daysheets. Anticipated Completion Date: June 30,...
Contact Person Responsible for the Corrective Action Plan: Mary W. Duncan, Finance Director Corrective Action Plan: We have discussed the finding and are currently implementing controls to ensure the timesheets are appropriately reviewed to match with daysheets. Anticipated Completion Date: June 30, 2023 179
Condition: The District did not include the necessary suspension and debarment language required for Child Nutrition Cluster related contractors with bids in excess of $25,000. Upon further review, it was determined that the vendors were not suspended or debarred. ...
Condition: The District did not include the necessary suspension and debarment language required for Child Nutrition Cluster related contractors with bids in excess of $25,000. Upon further review, it was determined that the vendors were not suspended or debarred. Plan: Procedures need to be implemented to ensure all vendors contracted with have the required suspension and debarment language will be included in the initial bidding documentation, prior to procuring their services. Anticipated Date of Completion: 6/30/2023 Name of Contact Person: Ron McCord, Superintendent Managements Response: There is no disagreement with this finding and procedures will be implemented to ensure all vendors contracted with have not been suspended or debarred or otherwise excluded from doing business, prior to procuring their services. Bidding documentation will include required suspension and debarment language.
FINDING 2022-002 Contact Person Responsible for Corrective Action: Food Service Director Billie Jo Russell Contact Phone Number: 812-755-4872 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: Procurement ? The School Corporation has established internal...
FINDING 2022-002 Contact Person Responsible for Corrective Action: Food Service Director Billie Jo Russell Contact Phone Number: 812-755-4872 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: Procurement ? The School Corporation has established internal controls to ensure compliance with the grant agreement and the Procurement and Suspension and Debarment requirement. The Food Service Director will obtain information from the Wilson Service Center for any necessary documentation pertaining to this requirement. The School Corporation has procured any food and supply purchases that exceed $150,000 and will maintain documentation for procurement procedures for purchases under $150,000. Suspension/Debarment ? Procedures will be implemented to ensure our procurement agent is an approved procurement agent. Anticipated Completion Date: Immediately
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