Corrective Action Plans

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Finding 2024-003 Material Weakness in Internal Control Over Special Tests and Provisions Assistance Listing Numbers 93.224 Health Center Program 93.527 Affordable Care Act (ACA) for New and Expanded Services Under the Health Center Program Federal Agency U.S. Department of Health and Human Services,...
Finding 2024-003 Material Weakness in Internal Control Over Special Tests and Provisions Assistance Listing Numbers 93.224 Health Center Program 93.527 Affordable Care Act (ACA) for New and Expanded Services Under the Health Center Program Federal Agency U.S. Department of Health and Human Services, Health Resources and Services Administration Passthrough Agency N/A Award Number/Year 2024 Criteria FFHC is responsible for keeping adequate supporting documentation of the calculation of patient service fees for those patients who qualify for discounted fees based on family size and household income. FFHC is also required to apply discounted fees accurately based on an approved sliding fee scale that meets federal compliance requirements.Views of Responsible Officials and Planned Corrective Actions Friend Family Health Center Inc. and Affiliates (Organization) will implement the following corrective actions for the fiscal year ending June 30, 2024 to remediate the finding and address the cause of the finding. The Organization will implement the following corrective actions for fiscal year 2024 to remediate the finding and address the cause of the finding. • The Chief Financial Officer (CFO) will be responsible for the implementation of the corrective action plan and will oversee all related finance activities. • FFHC will enforce its current policy and related internal control procedures to ensure that supporting documentation of family size and household income is maintained for all patients that receive discounted patient service fees in relation to the Health Centers Program and Affordable Care Act (ACA) for New and Expanded Services Under the Health Center Program. • FFHC will enforce its current policy and related internal control procedures to ensure that discounted patient service fees are properly calculated and charged based on the applicable approved sliding fee scale. The target date for full implementation of these corrective actions is December 30, 2025. The responsible party for the planned resources will be Wendy Thompson, Chief Executive Officer (312) 682-6110. Our address is 340 E. 51st St., Chicago, IL 60615.
Finding 2024-002 Material Weakness in Internal Control Over Reporting Assistance Listing Numbers 93.224 Health Center Program 93.527 Affordable Care Act (ACA) for New and Expanded Services Under the Health Center Program Federal Agency U.S. Department of Health and Human Services, Health Resources a...
Finding 2024-002 Material Weakness in Internal Control Over Reporting Assistance Listing Numbers 93.224 Health Center Program 93.527 Affordable Care Act (ACA) for New and Expanded Services Under the Health Center Program Federal Agency U.S. Department of Health and Human Services, Health Resources and Services Administration Passthrough Agency N/A Award Number/Year 2024 Criteria FFHC is responsible for preparing and submitting its annual Universal Report and Federal Financial Reports in a timely manner. Views of Responsible Officials and Planned Corrective Actions Friend Family Health Center Inc. and Affiliates (Organization) will implement the following corrective actions for the fiscal year ending June 30, 2024 to remediate the finding and address the cause of the finding. The Organization will implement the following corrective actions for fiscal year 2024 to remediate the finding and address the cause of the finding. The Organization has hired staff with higher technical accounting skills than the previous staff. The following staff have been hired full-time or will be hired soon: Payroll and Benefits Specialist, Grant Accountant, Senior Staff Accountant, Accounts Payables and Receivables Specialist, and a Purchasing Specialist.• The Organization has implemented a new accounting system – Sage Intacct. Additionally, we have implemented a grants project tracking module to better help with grants and contracts reporting and compliance. • All grant related year-end audit procedures have been transitioned to the Grant Accountant who has experience with financial audits and compliance and reporting for City, State, and Federal grants. • The Organization will ensure that Finance personnel receive a minimum of twenty-five (25) hours of training annually of relevant accounting topics including updates to generally accepted accounting principles, generally accepted government accounting principles, nonprofit and governmental financial reporting, and other related accounting trainings. • The Organization will ensure that any personnel involved in financial reporting have the technical expertise to help with the preparation, review, and analysis of the Federal Financial Reports and the Universal Report. The target date for full implementation of these corrective actions is December 30, 2025. The responsible party for the planned resources will be Wendy Thompson, Chief Executive Officer (312) 682-6110. Our address is 340 E. 51st St., Chicago, IL 60615. • The Chief Financial Officer (CFO) will be responsible for the implementation of the corrective action plan and will oversee all related finance activities. • To ensure timely submission of Federal Financial Reports (FFR) to HRSA, Friend Health will implement a robust internal calendar that includes all HRSA reporting deadlines along with earlier internal due dates for preparation and review. Designated financial and grants management staff will be responsible for compiling and verifying the required data well in advance of the submission deadline. Friend Health will conduct regular internal reviews to ensure accuracy, completeness, and compliance with HRSA guidelines. Additionally, staff will be provided with ongoing training on HRSA reporting requirements and utilizing reporting tools or software that streamline the FFR preparation process. These proactive measures will help maintain compliance and prevent future delays. • The Organization will document accounting policies and procedures to reflect the new month-end processes and provide training to staff on current and future policies.
Finding 2024-001 Noncompliance with Federal and State Reporting Requirements Assistance Listing Numbers 93.224 Health Centers Program 93.527 Affordable Care Act Grants (ACA) for New and Expanded Services Under the Health Center Program Federal Agency U.S. Department of Health and Human Services Pass...
Finding 2024-001 Noncompliance with Federal and State Reporting Requirements Assistance Listing Numbers 93.224 Health Centers Program 93.527 Affordable Care Act Grants (ACA) for New and Expanded Services Under the Health Center Program Federal Agency U.S. Department of Health and Human Services Passthrough Agency N/A Award Number/Year 2024 Criteria Uniform Guidance requires that single audits be completed, and the reporting package submitted to the Federal Audit Clearinghouse within the earlier of thirty (30) calendar days after receipt of the auditor’s report or nine (9) months after the end of the audit period. Views of Responsible Officials and Planned Corrective Actions Friend Family Health Center Inc. and Affiliates (Organization) will implement the following corrective actions for the fiscal year ending June 30, 2024 to remediate the finding and address the cause of the finding. The Organization will implement the following corrective actions for fiscal year 2024 to remediate the finding and address the cause of the finding. The Organization has hired staff with higher technical accounting skills than the previous staff. The following staff have been hired full-time or will be hired soon: Payroll and Benefits Specialist, Grant Accountant, Senior Staff Accountant, Accounts Payables and Receivables Specialist, and a Purchasing Specialist. • The Chief Financial Officer (CFO) will be responsible for the implementation of the corrective action plan, and will oversee all related finance activities. To ensure compliance with timely submission of financial and Single audit reports, Friend Health will implement a structured timeline that aligns with all regulatory deadlines and includes internal checkpoints to monitor progress. The audit engagement will begin within sixty (60) days of fiscal year-end. Key staff members will be assigned clear responsibilities, and regular status meetings will be held to track report preparation and address any issues promptly. Friend Health will also enhance coordination with its external auditors by providing them with all necessary documentation in advance to avoid delays. Additionally, further investment will be made to train relevant team members on audit requirements and reporting standards to improve accuracy and efficiency. These steps will ensure that all deadlines are met and full compliance is maintained moving forward. • The Organization has implemented procedures for staff accountants to prepare balance sheet reconciliations monthly with a monthly review performed by the CFO. All balance sheet accounts are reconciled to external data for verification on a monthly basis. All revenue accounts will be reconciled to external data for verification on a monthly basis. • The Organization has implemented a new accounting system – Sage Intacct. Additionally, we have implemented a grants project tracking module to better help with grants and contracts reporting and compliance. • The Organization has implemented a month-end checklist for all monthly entries to be completed by assigned finance personnel. We are ensuring that all staff are trained adequately to handle any assigned task. All monthly entries are required to be reviewed and approved by the CFO prior to posting to the general ledger within our new accounting software. All appropriate backup documentation will be saved and stored within the accounting software. • All grant related year-end audit procedures have been transitioned to the Grant Accountant who has experience with financial audits and compliance and reporting for City, State, and Federal grants. • The Organization will ensure that Finance personnel receive a minimum of twenty-five (25) hours of training annually of relevant accounting topics including updates to generally accepted accounting principles, generally accepted government accounting principles, nonprofit and governmental financial reporting, and other related accounting trainings. • The Organization will ensure that any personnel involved in financial reporting have the technical expertise to help with the preparation, review, and analysis of the financial statements and supplementary information. The target date for full implementation of these corrective actions is December 30, 2025. The presponsible party for the planned resources will be Wendy Thompson, Chief Executive Officer (312) 682-6110. Our address is 340 E. 51st St., Chicago, IL 60615.
Recommendation: We recommend that management timely submit annual audit report to the Federal Audit Clearinghouse. To do this, management should develop and implement a clear timeline with internal milestones for completing audit preparation and review. Management should also establish internal cont...
Recommendation: We recommend that management timely submit annual audit report to the Federal Audit Clearinghouse. To do this, management should develop and implement a clear timeline with internal milestones for completing audit preparation and review. Management should also establish internal control procedures that assign specific responsibilities to staff to ensure that all federal reporting deadlines are met. Views of Responsible Official: Management of the Organization concurs with the audit finding and will immediately implement the auditors’ recommendations. Internal control procedures will be put into place to establish milestones and overseen by the Executive director
FINDING No. 2024-002: Recommendation: The Project’s management should redeposit the funds into the Security Deposit bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the security account in 2025.
FINDING No. 2024-002: Recommendation: The Project’s management should redeposit the funds into the Security Deposit bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the security account in 2025.
FINDING No. 2024-001: Recommendation: The Project’s management should redeposit the funds into the Replacement Reserve bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the replacement reserve account i...
FINDING No. 2024-001: Recommendation: The Project’s management should redeposit the funds into the Replacement Reserve bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the replacement reserve account in 2025.
FINDING No. 2024-001: Recommendation: The Project’s management should redeposit the funds into the Security Deposit bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the Security Deposit account in 2025...
FINDING No. 2024-001: Recommendation: The Project’s management should redeposit the funds into the Security Deposit bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the Security Deposit account in 2025.
FINDING No. 2024-001: Recommendation: The Project’s management should redeposit the funds into the Replacement Reserve bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the replacement reserve account i...
FINDING No. 2024-001: Recommendation: The Project’s management should redeposit the funds into the Replacement Reserve bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the replacement reserve account in 2025.
Recommendation: The Project’s management should redeposit the funds into the Security Deposit bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the security account in 2025.
Recommendation: The Project’s management should redeposit the funds into the Security Deposit bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the security account in 2025.
Recommendation: The Project’s management should redeposit the funds into the Replacement Reserve bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the replacement reserve account in 2025.
Recommendation: The Project’s management should redeposit the funds into the Replacement Reserve bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the replacement reserve account in 2025.
FINDING No. 2024-002: Recommendation: The Project’s management should redeposit the funds into the Security Deposit bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the security account in 2025.
FINDING No. 2024-002: Recommendation: The Project’s management should redeposit the funds into the Security Deposit bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the security account in 2025.
FINDING No. 2024-001: Recommendation: The Project’s management should redeposit the funds into the Replacement Reserve bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the replacement reserve account i...
FINDING No. 2024-001: Recommendation: The Project’s management should redeposit the funds into the Replacement Reserve bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the replacement reserve account in 2025.
FINDING No. 2024-002: Recommendation: The Project’s management should redeposit the funds into the Security Deposit bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the security account in 2025.
FINDING No. 2024-002: Recommendation: The Project’s management should redeposit the funds into the Security Deposit bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the security account in 2025.
FINDING No. 2024-001: Recommendation: The Project’s management should redeposit the funds into the Replacement Reserve bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the replacement reserve account i...
FINDING No. 2024-001: Recommendation: The Project’s management should redeposit the funds into the Replacement Reserve bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the replacement reserve account in 2025.
The City agrees with this finding. Having recognized this deficiency prior to commencement of this audit, the City implemented additional internal review requirements during FY25.
The City agrees with this finding. Having recognized this deficiency prior to commencement of this audit, the City implemented additional internal review requirements during FY25.
Recommendation The Board and management should hire an accountant with HUD experience to help correct the books and records in order to comply with HUD regulations and to conform with generally accepted accounting principles. Management/Owner Response The Board agrees with the findings is taking act...
Recommendation The Board and management should hire an accountant with HUD experience to help correct the books and records in order to comply with HUD regulations and to conform with generally accepted accounting principles. Management/Owner Response The Board agrees with the findings is taking action to correct the findings and implement the recommendations.
Recommendation Management must perform the corrective actions as required by the MOR by the target completion date. Management/Owner Response The Board agrees with the findings is taking action to correct the findings and implement the recommendations.
Recommendation Management must perform the corrective actions as required by the MOR by the target completion date. Management/Owner Response The Board agrees with the findings is taking action to correct the findings and implement the recommendations.
Action Taken: Housing Authority of the County of Chester agrees with the above recommendations and has already instituted policies and procedures designed to address the findings. Please see the list of procedures. HACC Recertification & Documentation Checklist (Quick Reference – 1 Page) 1. Recertif...
Action Taken: Housing Authority of the County of Chester agrees with the above recommendations and has already instituted policies and procedures designed to address the findings. Please see the list of procedures. HACC Recertification & Documentation Checklist (Quick Reference – 1 Page) 1. Recertification Timeline • Annual: Start process 120 days before due date. • Interim: Complete within 30 days of household change. • Missed/Delayed: Notify Program Manager immediately and document reason. 2. Required Documentation • Income verification (pay stubs, benefits, child support). • Asset verification (bank/retirement statements). • Family composition docs (birth certificates, SSNs). • HUD-required forms. • Use EIV when available; seek third-party verification first. • All docs must be collected within 60 days of effective date. 3. File Standards • Use Resident File Checklist for each household. • Files must include all signed forms & verifications. • Store in approved secure system (electronic or paper). • Retain files 3 years after end of participation (longer if litigation/audit pending). 4. Internal Controls • Supervisory Review: 10% of files checked monthly. • Maintain clear audit trail (date notices, interviews, verifications). • Correct any deficiencies within 30 days. 5. Staff & Training • Staff handling certifications = annual HUD/HACC compliance training. • Document training completion in personnel file. 6. Monitoring • Quarterly compliance report on timeliness & file completeness. • Issues shared with Executive Director and Board. • Policies reviewed annually for updates. Roles • Housing Specialists: Complete recerts & file docs. • Supervisors: Monitor timeliness & review files. • Compliance Officer: Audit & reporting. • Executive Director: Oversight & resources. n Follow this checklist to ensure timely recertifications, complete documentation, and avoid audit findings.
Action Taken: Housing Authority of the County of Chester agrees with the above recommendations and has already instituted policies and procedures designed to address the findings. Please see the list of procedures. HACC Recertification & Documentation Checklist (Quick Reference – 1 Page) 1. Recertif...
Action Taken: Housing Authority of the County of Chester agrees with the above recommendations and has already instituted policies and procedures designed to address the findings. Please see the list of procedures. HACC Recertification & Documentation Checklist (Quick Reference – 1 Page) 1. Recertification Timeline • Annual: Start process 120 days before due date. • Interim: Complete within 30 days of household change. • Missed/Delayed: Notify Program Manager immediately and document reason. 2. Required Documentation • Income verification (pay stubs, benefits, child support). • Asset verification (bank/retirement statements). • Family composition docs (birth certificates, SSNs). • HUD-required forms. • Use EIV when available; seek third-party verification first. • All docs must be collected within 60 days of effective date. 3. File Standards • Use Resident File Checklist for each household. • Files must include all signed forms & verifications. • Store in approved secure system (electronic or paper). • Retain files 3 years after end of participation (longer if litigation/audit pending). 4. Internal Controls • Supervisory Review: 10% of files checked monthly. • Maintain clear audit trail (date notices, interviews, verifications). • Correct any deficiencies within 30 days. 5. Staff & Training • Staff handling certifications = annual HUD/HACC compliance training. • Document training completion in personnel file. 6. Monitoring • Quarterly compliance report on timeliness & file completeness. • Issues shared with Executive Director and Board. • Policies reviewed annually for updates. Roles • Housing Specialists: Complete recerts & file docs. • Supervisors: Monitor timeliness & review files. • Compliance Officer: Audit & reporting. • Executive Director: Oversight & resources. n Follow this checklist to ensure timely recertifications, complete documentation, and avoid audit findings.
Contact person responsible for corrective action: Holly M. Rogers Description of corrective action to be taken: A spreadsheet has been created to assist in project progression with appropriate expenditure calculations compared to total prior payments. Antcipated completion date of corrective action:...
Contact person responsible for corrective action: Holly M. Rogers Description of corrective action to be taken: A spreadsheet has been created to assist in project progression with appropriate expenditure calculations compared to total prior payments. Antcipated completion date of corrective action: 09/15/2025.
Personnel Responsible for Corrective Action: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City, Kansas Anticipated Completion Date: November 1, 2025 Views of Responsible Officials and Planned Corrective Action: The debarment check was not done with an ...
Personnel Responsible for Corrective Action: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City, Kansas Anticipated Completion Date: November 1, 2025 Views of Responsible Officials and Planned Corrective Action: The debarment check was not done with an updated contract for 2024. The 2025 contract renewal and debarment check are being finalized now. Purchasing reviews suspension/debarment checks for procurement over $50,000, but since this was a community partner agreement it was done separately from that process. Departments have now been trained this is required for contracts acquired through purchasing as well as partner agreements.
Personnel Responsible for Corrective Action: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City, Kansas Anticipated Completion Date: July 1, 2025 Views of Responsible Officials and Planned Corrective Action: Unfortunately, due to the late completion of ...
Personnel Responsible for Corrective Action: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City, Kansas Anticipated Completion Date: July 1, 2025 Views of Responsible Officials and Planned Corrective Action: Unfortunately, due to the late completion of the 2023 Single Audit and the hiring of the grants position in early 2025, many previous findings and contracts were not yet corrected in 2024. In the event of this finding, there were two vendors which had minimal expenditures in 2024 (under $5,000 which does not require competitive bids but in aggregate they exceeded that amount). The procurement department had not been consulted, and debarment checks were not completed when the work began in 2023, and final payments were issued in 2024. In the Grants Manual and training departments have been instructed that these procedures must be complied with for all grants.
View Audit 370644 Questioned Costs: $1
Personnel Responsible for Corrective Action: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City, Kansas Anticipated Completion Date: October 1, 2025 Views of Responsible Officials and Planned Corrective Action: The grants administrator has been developi...
Personnel Responsible for Corrective Action: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City, Kansas Anticipated Completion Date: October 1, 2025 Views of Responsible Officials and Planned Corrective Action: The grants administrator has been developing a master calendar and will ensure the departments file the required reports within the required timeframes of their funders and maintain copies in a centralized file.
Personnel Responsible for Corrective Action: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City, Kansas Anticipated Completion Date: October 1, 2025 Views of Responsible Officials and Planned Corrective Action: All subrecipients for all grant programs o...
Personnel Responsible for Corrective Action: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City, Kansas Anticipated Completion Date: October 1, 2025 Views of Responsible Officials and Planned Corrective Action: All subrecipients for all grant programs over $30,000 will be reported in the FSRS system. Departments will enter the subrecipients into this system, and our grant administrator will audit the files to ensure proper documentation is maintained to ensure compliance.
The Health Department agrees with the finding and will implement the following corrective actions: Grant Monitoring Procedures: Develop and implement procedures to identify and monitor grant agreement changes and their potential impacts on established grant requirements and internal procedures. Repo...
The Health Department agrees with the finding and will implement the following corrective actions: Grant Monitoring Procedures: Develop and implement procedures to identify and monitor grant agreement changes and their potential impacts on established grant requirements and internal procedures. Reporting Procedures: Establish specific procedures to track grant reporting deadlines, review submission progress, and confirm status of upcoming reports. Staff Training and Oversight: Assign responsibility for the report preparation and submission as well as management review and confirmation of report submission.
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