Corrective Action Plans

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Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, management has assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications...
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, management has assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications and hired a team of additional roving property management/compliance teams to cover open property management positions and to support site staff in completing tenant recertifications. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2025. Name of contact person: Jennifer Anderson, Interim CFO
Corrective Action: The Organization agrees with the finding. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Management is working with the new property managers to ensure they have procedures in place to document and maintain tenant fil...
Corrective Action: The Organization agrees with the finding. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Management is working with the new property managers to ensure they have procedures in place to document and maintain tenant files in accordance with HUD and will have routine internal audits of tenant files to ensure compliance with HUD regulations. For properties not transitioning to new property management, management believes the reduced volume of properties at one property manager will reduce staff turnover and more efficiently provide the proper training to existing staff to improve compliance with tenant files. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2025. Name of contact person: Jennifer Anderson, Interim CFO
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, management has assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications...
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, management has assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications and hired a team of additional roving property management/compliance teams to cover open property management positions and to support site staff in completing tenant recertifications. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2025. Name of contact person: Jennifer Anderson, Interim CFO
Corrective Action: The Organization agrees with the finding. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Management is working with the new property managers to ensure they have procedures in place to document and maintain tenant fil...
Corrective Action: The Organization agrees with the finding. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Management is working with the new property managers to ensure they have procedures in place to document and maintain tenant files in accordance with HUD and will have routine internal audits of tenant files to ensure compliance with HUD regulations. For properties not transitioning to new property management, management believes the reduced volume of properties at one property manager will reduce staff turnover and more efficiently provide the proper training to existing staff to improve compliance with tenant files. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2025. Name of contact person: Jennifer Anderson, Interim CFO
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, management has assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications...
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, management has assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications and hired a team of additional roving property management/compliance teams to cover open property management positions and to support site staff in completing tenant recertifications. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2025. Name of contact person: Jennifer Anderson, Interim CFO
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, management has assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications...
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, management has assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications and hired a team of additional roving property management/compliance teams to cover open property management positions and to support site staff in completing tenant recertifications. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2025. Name of contact person: Jennifer Anderson, Interim CFO
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, management has assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications...
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, management has assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications and hired a team of additional roving property management/compliance teams to cover open property management positions and to support site staff in completing tenant recertifications. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2025. Name of contact person: Jennifer Anderson, Interim CFO
Corrective Action: The Organization agrees with the finding. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Management is working with the new property managers to ensure they have procedures in place to document and maintain tenant fil...
Corrective Action: The Organization agrees with the finding. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Management is working with the new property managers to ensure they have procedures in place to document and maintain tenant files in accordance with HUD and will have routine internal audits of tenant files to ensure compliance with HUD regulations. For properties not transitioning to new property management, management believes the reduced volume of properties at one property manager will reduce staff turnover and more efficiently provide the proper training to existing staff to improve compliance with tenant files. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2025. Name of contact person: Jennifer Anderson, Interim CFO
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, management has assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications...
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, management has assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications and hired a team of additional roving property management/compliance teams to cover open property management positions and to support site staff in completing tenant recertifications. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2025. Name of contact person: Jennifer Anderson, Interim CFO
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, management has assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications...
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, management has assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications and hired a team of additional roving property management/compliance teams to cover open property management positions and to support site staff in completing tenant recertifications. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2025. Name of contact person: Jennifer Anderson, Interim CFO
Finding 554905 (2024-001)
Significant Deficiency 2024
U.S. Department of Education Year ended June 30, 2024 Student Financial Assistance Cluster: Federal Pell Grant Program (Assistance Listing #84.063) Federal Direct Student Loans (Assistance Listing #84.268) Compliance Requirement: Special Tests and Provisions Criteria: The Gramm-Leach-Bliley Act (Pub...
U.S. Department of Education Year ended June 30, 2024 Student Financial Assistance Cluster: Federal Pell Grant Program (Assistance Listing #84.063) Federal Direct Student Loans (Assistance Listing #84.268) Compliance Requirement: Special Tests and Provisions Criteria: The Gramm-Leach-Bliley Act (Public Law 106-102) (GLBA) requires the BOCES, on an annual basis, to identify reasonably foreseeable internal and external risks to the security, confidentiality, and integrity of customer (student) information that could result in the unauthorized disclosure, misuse, alteration, destruction, or other compromise of such information, and assess the sufficiency of any safeguards in place to control these risks. At a minimum, the GLBA risk assessment should include consideration of risk in each relevant area of operations, including: 􀀄 Employee training and management. 􀀄 Information systems, including network and software design, as well as information processing, storage, transmission, and disposal. 􀀄 Detecting, preventing, and responding to attacks, intrusions, or other system failures. Condition: During our testing, we noted the following: 􀀄 A periodic inventory of data, noting where it is collected, stored, and transmitted was not performed. 􀀄 Vulnerability scanning and penetration testing is not completed annually. 􀀄 A written information security program is not fully in place. Policies surrounding risk management have not been implemented. 􀀄 Unsupported operating systems in use. Cause: The expected documentation supporting the required controls to adequately confirm compliance with GLBA safeguards was not complete. Effect: Without demonstrable, documented controls supporting compliance with the GLBA standards for safeguarding the protected data, compliance with the law and the requirements in the federal PPA may not be assured. Context: Inquiry and observation of the information received from the BOCES related to compliance with GLBA. Auditor’s Recommendation: The BOCES should review the GLBA safeguarding rules and as soon as practical implement and document the controls necessary for compliance with the rule, focusing on the completion of a documented, thorough, and standardized risk assessment and management reporting framework. The BOCES should perform comprehensive risk assessments on a regular basis, which is suggested to be at least annually, and at any significant change in infrastructure or business process. Contact Period Responsible for Corrective Action Plan: Warren Taylor, Chief Financial Officer Corrective Action Plan and Timing of Planned Corrective Action Plan: The BOCES is actively engaged in a formal Request for Proposals (RFP) process to procure a qualified vendor for the design and implementation of a comprehensive Information Security Program aligned with GLBA requirements. The selected vendor will conduct a full assessment of existing controls, help develop required policies and procedures, and assist in ensuring full compliance with GLBA mandates, including employee training, information systems safeguards, and incident response protocols. This process will be completed by December 2025. As part of the upcoming vendor engagement, a complete data inventory and structured risk assessment will be conducted. This will identify where sensitive data is collected, stored, transmitted, and processed, and will form the basis for implementing technical and administrative safeguards. This process will be completed by March 2026. In the past several years the BOCES has reviewed several student systems and was unable to identify a system that met all of their needs due to the differences between requirements applicable to school districts and those appropriate to the unique needs of a BOCES. The organization is on track to discontinue the use of all unsupported operating systems by June 30, 2026.
A new website is under development for Pocomoke City, which will allow for the audio of the Mayor and Council meetings to be immediately uploaded and available for the public viewing. Meeting minutes will be uploaded to the website once they have been approved at the next available Mayor and Council...
A new website is under development for Pocomoke City, which will allow for the audio of the Mayor and Council meetings to be immediately uploaded and available for the public viewing. Meeting minutes will be uploaded to the website once they have been approved at the next available Mayor and Council meeting. In addition to the City’s website, meeting minutes will we scanned and archived into the City’s electronic file cabinet ShoreScan. In fiscal year 2025, the finance department has begun using the electronic file cabinet ShoreScan to scan in all expenditures and expense reimbursements with supporting documentation. This will help alleviate misfiled and/or misplaced supporting documentation and expense reports.
Finding Number: 2024-001 Reporting – Noncompliance (Control Deficiency) Programs: U.S. Department of Housing and Urban Development - Project Based Rental Assistance (PBRA) (Section 8 Project-Based Cluster), Award Listing Number 14.195. Planned Corrective Action: The Corporation acknowledges that the...
Finding Number: 2024-001 Reporting – Noncompliance (Control Deficiency) Programs: U.S. Department of Housing and Urban Development - Project Based Rental Assistance (PBRA) (Section 8 Project-Based Cluster), Award Listing Number 14.195. Planned Corrective Action: The Corporation acknowledges that the 2024 data collection form and REAC filing were not filed timely. The planned correction plan is to file the 2024 data collection form and REAC filing upon the issuance of the Uniform Guidance financial statements and ensure that future data collection forms and REAC filing are submitted timely. Person Responsible: A’isha Torrence, Chief Financial Officer Expected Completion Date: June 2025
Finding 554902 (2024-001)
Significant Deficiency 2024
CORRECTIVE ACTION PLAN 3/27/2025 US Department of Health and Human Services CARES of NY, Inc. respectfully submits the following corrective action plan for the year ended April 30, 2024. Name and address of independent public accounting firm: Wojeski & Company CPAs, PC 159 Wolf Road Albany, NY 1...
CORRECTIVE ACTION PLAN 3/27/2025 US Department of Health and Human Services CARES of NY, Inc. respectfully submits the following corrective action plan for the year ended April 30, 2024. Name and address of independent public accounting firm: Wojeski & Company CPAs, PC 159 Wolf Road Albany, NY 12205 Audit period: Year ending April 30, 2024 The findings from the April 30, 2024 schedule of findings and questions costs are discussed below. The findings are numbered consistent with the numbers assigned in the schedule. Finding 2024-0001 – Reporting of the Schedule of Expenditure of Federal Awards Recommendation: We recommend that the Organization implement additional processes and procedures to ensure that the SEFA is complete and accurate. Corrective Action plan taken: The corrective action taken was to notify Auditors as soon as the error was realized so that audits could be corrected. There is no need for further corrective action. This incident was isolated and not recurring. The grant for which this finding is associated was a temporary covid grant that has since ended. To prevent future errors for occurring, all new contracts will be reviewed prior to submitting the summary of federal awards to the auditor to ensure that any federally sourced funding is properly identified regardless of grantor. CARES of NY, Inc. will implement a check and balance procedure where the grants director will review the listing prior to audit submission for accuracy. Responsible Person for corrective action plan: Eileen Wiebicke, Chief Financial Officer Anticipated completion date for corrective action plan: 1/24/2025 (date auditors were notified of error) If the US Department of Health and Human Services has questions regarding this plan, please call Eileen Wiebicke at 518-489-4130 x 702.
2024‐001 Compliance Over Reporting Asian and Pacific Islander Wellness Center Inc. dba San Francisco Community Health Center [SFCHC] accepts this finding. A new CFO is hired in November 2024 with over 30 years of high‐level nonprofit experience in reporting compliance and finance and business operat...
2024‐001 Compliance Over Reporting Asian and Pacific Islander Wellness Center Inc. dba San Francisco Community Health Center [SFCHC] accepts this finding. A new CFO is hired in November 2024 with over 30 years of high‐level nonprofit experience in reporting compliance and finance and business operations. The new CFO has over 10 years as CFO/COO for two federally qualified health centers and immediately reviewed existing policies and procedures with focus on federal grants and compliance reporting. The next single audit submission for fiscal year ended March 31, 2025, will be submitted to the Federal Audit Clearinghouse [FAC] without delay. We are now planning timeline to commence independent review starting mid‐July. The estimated field audit will be completed by October 15. We are anticipating submission to FAC and other regulatory agencies no later than December 15, 2025, within 9 months from fiscal year [March 31]. At SFCHC, we re‐enforced the centralization of documents and records and secured sensitive information, reviewing access and rights of users to avoid compromising data. We also enabled the ‘attachment’ feature at MIP Fund Accounting. Accounting transactions along with documentation lived in digital files. A compliance calendar is now disseminated quarterly and shared with programs. We will be posting the same to SFCHC intra‐net and will be renewed each quarter. Anticipated Completion Date: At this time, the condition noted by our auditor is now addressed and will be tracked for progress. We are hiring additional staff to support grants and contracts administration, monitoring and reporting compliance. Responsible party: Rosalia Aquino Chief Financial & Compliance Officer April 9, 2025
This Corrective Action Plan is in response to Lancaster Bible College’s single audit report for the fiscal year ended June 30, 2024, prepared by Tait, Weller & Baker. Finding 2024-001 Recommendation: The College should review its procedures related to the request and disbursement of federal funds, i...
This Corrective Action Plan is in response to Lancaster Bible College’s single audit report for the fiscal year ended June 30, 2024, prepared by Tait, Weller & Baker. Finding 2024-001 Recommendation: The College should review its procedures related to the request and disbursement of federal funds, including controls over compliance, to ensure they are following the advance payment method and establish controls to ensure it complies with the federal requirement. Corrective Action: In July 2024, a new tracking system was implemented for daily reconciliation of award batch detail along with specific individual training to ensure staff follows compliance responsibilities and understand the requirements of the program. The Controller and Financial Aid Director meet monthly to discuss any potential gaps in compliance. Person Responsible for Corrective Action: Matthew Mason, Vice President of Finance Anticipated Completion Date: The Corrective Action Plan was corrected during July 2024.
View Audit 353450 Questioned Costs: $1
New management has taken over and will make the delinquent deposit to the replacement reserve of $770 and establish transfers for the monthly deposit amount.
New management has taken over and will make the delinquent deposit to the replacement reserve of $770 and establish transfers for the monthly deposit amount.
View Audit 353426 Questioned Costs: $1
Management agrees with the finding. Management has submitted the forms for HUD's approval.
Management agrees with the finding. Management has submitted the forms for HUD's approval.
View Audit 353416 Questioned Costs: $1
Management agrees with the finding. Management will ensure that the replacement reserve deposits are made on a timely basis in the future.
Management agrees with the finding. Management will ensure that the replacement reserve deposits are made on a timely basis in the future.
We have resolved the issue by identifying that our EMR system, EPIC, was not calculating the slides correctly. Due to this issue, we were utilizing an Excel spreadsheet to manually calculate the slides for our SFS patients. This process did work and calculated the correct slides as long as our front...
We have resolved the issue by identifying that our EMR system, EPIC, was not calculating the slides correctly. Due to this issue, we were utilizing an Excel spreadsheet to manually calculate the slides for our SFS patients. This process did work and calculated the correct slides as long as our front desk staff input the patient’s data correctly. In the instance of the samples that had incorrect slides calculated, it appears that it was an user error where they must not have adequately reviewed the patient’s information and entered it correctly into the spreadsheet. Our corrective action plan is that we are no longer going to use the spreadsheet for calculating SFS slides for our patients. This will be done in EPIC now that it is able to correctly calculate the slides. We will continue to use our internal trainer to work with the front desk staff to ensure they understand how to review the SFS applications and supporting documentation, as well as enter the patient data into EPIC to calculate the correct slides. Furthermore, each clinic manager will review the SFS applications on a daily basis to verify the correct slides were calculated for each patient.
Type of Finding: Other Finding Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to Finding: The health center will submit the May 31, 2025, Statements timely. A calendar of scheduled financial reports is active and has b...
Type of Finding: Other Finding Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to Finding: The health center will submit the May 31, 2025, Statements timely. A calendar of scheduled financial reports is active and has been implemented effectively with the submission of this Audit. Official Responsible for Ensuring CAP: Responsible Parties: Board of Directors (Althea Riddick, Chair), Chief Executive Officer (Rose Turner), Interim Chief Financial Officer (Dan Miles), Finance Director (Kelly Glover). Planned Completion Date for CAP: This is an ongoing requirement.
The District will implement a process to track the submission time of the data collection form and audit package.
The District will implement a process to track the submission time of the data collection form and audit package.
Condition – Peak Vista (“the Organization”) determines the sliding fee discount charged to the patients based on their annual gross income and household size. During our testing of sliding fee discounts, we found that two encounters selected where the patients were charged incorrect copays. Recommen...
Condition – Peak Vista (“the Organization”) determines the sliding fee discount charged to the patients based on their annual gross income and household size. During our testing of sliding fee discounts, we found that two encounters selected where the patients were charged incorrect copays. Recommendation – The Organization should strengthen processes surrounding the monitoring of the program to ensure the Organization’s policies are consistently and properly applied. Views of Responsible Officials and Planned Corrective Actions – Management agrees with the finding. The Organization has developed a plan for addressing this issue that includes updated procedures, training, and auditing. All teams engaged in the enrollment and eligibility process, including our Enrollment, Reception, and Billing teams will be retrained on the process with emphasis on proper documentation. The Organization management plans to incorporate into our quality assurance audits the documentation for single service date discount applications and provide feedback and retraining as necessary to staff as needed. Anticipated Date of Completion – In progress. Action Taken – We have reviewed the recommendation and have developed a plan for addressing this issue. Person Responsible for Corrective Action Plan – Ryan Spillane, Chief Financial Officer Corrective Action Plan – Ryan Spillane, Chief Financial Officer
View Audit 353387 Questioned Costs: $1
Monitoring Deposits over FDIC Limits Recommendation: We recommend that management develop procedures to ensure requirements are monitored, documented, and reviewed to ensure compliance with the HUD regulatory agreement. Explanation of disagreement with audit finding: There is no disagreement with ...
Monitoring Deposits over FDIC Limits Recommendation: We recommend that management develop procedures to ensure requirements are monitored, documented, and reviewed to ensure compliance with the HUD regulatory agreement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has designed internal controls to ensure deposits held over FDIC limits are monitored quarterly to ensure consistency with the minimally acceptable ratings as established by the Government National Association. Name(s) of contact person(s) responsible for corrective action: Nicole Chwala.
Replacement Reserve Deposits Recommendation: We recommend that management develop procedures to ensure replacement reserve deposits are updated timely to ensure compliance with the HUD regulatory agreement. Explanation of disagreement with audit finding: There is no disagreement with the audit fi...
Replacement Reserve Deposits Recommendation: We recommend that management develop procedures to ensure replacement reserve deposits are updated timely to ensure compliance with the HUD regulatory agreement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has developed processes to verify replacement reserve deposits are updated based on the regulatory agreement annually. Name(s) of contact person(s) responsible for corrective action: Nicole Chwala. Planned completion date for corrective action plan: Corrective action has been taken in March 2025.
View Audit 353384 Questioned Costs: $1
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