Corrective Action Plans

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Response and Corrective Action Plan: The District will review current processes for identifying, coding and reporting federal expenditures and implement processes to ensure amounts reported are supported by the District’s general ledger.
Response and Corrective Action Plan: The District will review current processes for identifying, coding and reporting federal expenditures and implement processes to ensure amounts reported are supported by the District’s general ledger.
We will implement procedures to ensure correct labor rates and fleet asset usage are used in calculating reimbursements.
We will implement procedures to ensure correct labor rates and fleet asset usage are used in calculating reimbursements.
The Authority agrees with finding 2024-002 • The Authority did not ensure that all financial institutions required to collateralize had pledged identifiable U.S. Government or Agency securities. o The Authority has corrected this issue and will ensure in the future that all pledges meet HUD requirem...
The Authority agrees with finding 2024-002 • The Authority did not ensure that all financial institutions required to collateralize had pledged identifiable U.S. Government or Agency securities. o The Authority has corrected this issue and will ensure in the future that all pledges meet HUD requirements.
In Finding 2024-001, a condition was noted in which the Organization did not verify that certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Management recognizes the importance of complying with pro...
In Finding 2024-001, a condition was noted in which the Organization did not verify that certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Management recognizes the importance of complying with procurement, debarments, and suspension guidelines. In response to Finding 2024-001, procedures will be implemented to ensure debarment searches are completed and properly documented.
The grant team, led by Michelle DeFrance, Senior Manager of Grant Finance (michelle.defrance@upbring.org) has implemented personal calendar reminders to ensure that the mistake is not repeated. Additionally, the finance department led by Chad Seveland, CFO (chad.seveland@upbring.org) has created a d...
The grant team, led by Michelle DeFrance, Senior Manager of Grant Finance (michelle.defrance@upbring.org) has implemented personal calendar reminders to ensure that the mistake is not repeated. Additionally, the finance department led by Chad Seveland, CFO (chad.seveland@upbring.org) has created a deadlines calendar that is shared with the entire finance team. We feel that these two actions will support the team and ensure future compliance. These steps have been completed.
2024-002 Student Financial Aid – 84.268 – Federal Direct Loan Program, 84.063 – Federal Pell Grant Program, 84.007 – Federal Supplemental Educational Opportunity Grant Program, 84.033 – Federal Work-Study Program Recommendation: We recommend the review process for awarding be documented and retain...
2024-002 Student Financial Aid – 84.268 – Federal Direct Loan Program, 84.063 – Federal Pell Grant Program, 84.007 – Federal Supplemental Educational Opportunity Grant Program, 84.033 – Federal Work-Study Program Recommendation: We recommend the review process for awarding be documented and retained as support for the review and approval process. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Director of Financial Aid will document each change to an award by printing a new award offer and saving to document tracking. As this is the final year in which Lincoln Christian University will have academic operations, we believe this corrective action to be sufficient for the remainder of the year. Name of the contact person responsible for corrective action: Margie Martin, Director of Accounting Planned completion date for corrective action plan: May 31, 2024.
2024-001 Material Adjustments and Financial Statement Preparation Recommendation: We recommend that the University establish internal procedures to adjust all account balances at year-end and evaluate their internal staff capacity. Explanation of disagreement with audit finding: There is no disagr...
2024-001 Material Adjustments and Financial Statement Preparation Recommendation: We recommend that the University establish internal procedures to adjust all account balances at year-end and evaluate their internal staff capacity. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: This was the final year in which Lincoln Christian University provided degree-earning education. These material entries and assistance with financial statement preparation are not expected in future years. Name of the contact person responsible for corrective action: Margie Martin, Director of Accounting Planned completion date for corrective action plan: May 31, 2025
VALLEY FAMILY HEALTH CARE, INC. (VFHC) BELIEVES THE SIGNIFICANT DEFICIENCIES NOTED IN THE SCHEDULE OF FINDINGS AND QUESTIONED COSTS WERE A COMBINATION OF INSUFFICIENT USER TRAINING ISSUES, SYSTEM (EPIC) ISSUES AND INADEQUATE REVIEW AND INTERNAL AUDITING. TO ADDRESS THE SYSTEM ISSUES, WE HAVE REQ...
VALLEY FAMILY HEALTH CARE, INC. (VFHC) BELIEVES THE SIGNIFICANT DEFICIENCIES NOTED IN THE SCHEDULE OF FINDINGS AND QUESTIONED COSTS WERE A COMBINATION OF INSUFFICIENT USER TRAINING ISSUES, SYSTEM (EPIC) ISSUES AND INADEQUATE REVIEW AND INTERNAL AUDITING. TO ADDRESS THE SYSTEM ISSUES, WE HAVE REQUESTED VERIFICATION FROM OUR 3RD PARTY BILLING SYSTEM ON HOW THE EFFECTIVE AND EXPIRATION DATES ENTERED IN THE SYSTEM FOR THE FEDERAL POVERTY LEVEL (FPL) DATA IMPACT THE CALCULATION. IN ADDITION, IN DECEMBER OF 2023, VFHC IMPLEMENTED A NEW FEE SCHEDULE THAT INCREASED THE NUMBER OF SLIDING FEE DISCOUNTS THAT COULD BE AUTOMATICALLY CALCULATED BY THE SYSTEM, TO REMOVE THE OPPORTUNITY FOR USER ERROR. TO ADDRESS USER ERRORS, WE REINSTATED OUR FRONT OFFICE MANAGER POSITION RESPONSIBLE FOR TRAINING FRONT DESK STAFF WHO ASSIST PATIENTS WITH THE COMPLETION OF THE SLIDING FEE DISCOUNT APPLICATION. THE HANDBOOK AND TRAINING MATERIALS HAVE BEEN ENHANCED. IN ADDITION, WE ARE CREATING LOGIC IN THE EPIC SYSTEM TO IDENTIFY MISSING OR INCONSISTENT INFORMATION AND DIRECT THESE ISSUES TO A WORK QUE THAT WILL BE REVIEWED BY STAFF. WE ARE IMPLEMENTING AN INTERNAL AUDIT PROCESS OF THE SLIDING FEE DISCOUNTS. THE FRONT OFFICE MANAGER OR DESIGNEE WILL AUDIT A STATISTICALLY MEANINGFUL RANDOM SAMPLE OF NEW SLIDING FEE DISCOUNT APPLICATIONS FOR COMPLETENESS AND ACCURACY. IN ADDITION, WE WILL AUDIT A STATISTICALLY MEANINGFUL NUMBER OF PATIENT ACCOUNTS WHERE A SLIDING FEE DISCOUNT WAS TAKEN TO ENSURE THE ACCURACY OF THE CALCULATION. WE REVIEWED EACH OF THE AUDIT EXCEPTIONS AND DETERMINED THAT IN TWO OF THE FIVE INSTANCES; WE GAVE A LARGER DISCOUNT THAN THE PATIENT QUALIFIED FOR. WE WILL NOT MAKE ACCOUNT ADJUSTMENTS TO COLLECT. IN ONE INSTANCE, WE GAVE A SMALLER DISCOUNT BY $45.50 AND THE BILLING TEAM IS CORRECTING THIS ACCOUNT TO ISSUE A REFUND FOR THE ADDITIONAL DISCOUNT. IN ONE INSTANCE, NO SLIDING FEE DISCOUNT WAS GIVEN AND THE VERIFICATION RETAINED IN THE SYSTEM INDICATED THAT THIS WAS CORRECT. HOWEVER, IT IS POSSIBLE THAT HAD STAFF REQUESTED ADDITIONAL INCOME VERIFICATION; THE PATIENT MAY HAVE HAD A DIFFERENT FPL ASSIGNED. IN ONE INSTANCE, IT APPEARS THE APPROPRIATE SLIDE FEE DISCOUNT WAS APPLIED BUT THE SUPPORTING DOCUMENTATION WAS NOT RETAINED IN THE PATIENT CHART. VFHC TAKES THESE ISSUES VERY SERIOUSLY AND WILL BEGIN CORRECTIVE ACTIONS IMMEDIATELY. PROPOSED COMPLETION DATE: WE ANTICIPATE THESE ACTIONS TO BE COMPLETED BY THE END OF THE 3RD QUARTER.
Section 232 Mortgage Insurance for Nursing Homes – Assistance Listing No. 14.157 Recommendation: The auditor recommends that management increase their coverage amount to come into compliance with HUD requirements, as well as develop policies and procedures to monitor required coverage minimums to e...
Section 232 Mortgage Insurance for Nursing Homes – Assistance Listing No. 14.157 Recommendation: The auditor recommends that management increase their coverage amount to come into compliance with HUD requirements, as well as develop policies and procedures to monitor required coverage minimums to ensure that actual coverage amount is kept at least at that level. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Fidelity Bond insurance coverage was immediately increased from $1,135,927 to $1,182,615 to be above the minimum required threshold of $1,164,177 when identified. The new process implemented will assess potential organizational revenue growth ahead of insurance renewal to maintain at least the minimum required coverage threshold. Name(s) of the contact person(s) responsible for corrective action: Edward Forfa Planned completion date for corrective action plan: 8/12/2024
In Finding 2024-002, it was reported that time and activity reports were not maintained for salaried employees. Although the Organization’s policies require that time records be maintained by salaried employees, current operating procedures are not in place to ensure the time records are completed. ...
In Finding 2024-002, it was reported that time and activity reports were not maintained for salaried employees. Although the Organization’s policies require that time records be maintained by salaried employees, current operating procedures are not in place to ensure the time records are completed. Procedures will be established to require all salaried employees to maintain time and effort certifications that coincide with the Organization’s payroll cycle (at least on a monthly basis) in accordance with the Organization’s policies.
In Finding 2024-001, it was reported that the Organization did not obtain and properly document all necessary elements required by the Organization’s sliding fee policy, resulting in sliding fee discounts that were not properly calculated for certain sliding fee patients. Management recognizes th...
In Finding 2024-001, it was reported that the Organization did not obtain and properly document all necessary elements required by the Organization’s sliding fee policy, resulting in sliding fee discounts that were not properly calculated for certain sliding fee patients. Management recognizes the importance of complying with sliding fee guidelines and the Organization’s sliding fee discount policy. In response to Finding 2024-001, proper training will be given to employees, and sliding fee discounts will be reviewed by a supervisor on a periodic basis to ensure compliance with the Organization’s sliding fee policy.
This finding is due to the Village not having control procedures in place to submit the annual Project and Expenditure Report for the reporting period ended March 31, 2024, accurately or within 30 days of the close of the reporting period. In the future, the Village will have controls in place to en...
This finding is due to the Village not having control procedures in place to submit the annual Project and Expenditure Report for the reporting period ended March 31, 2024, accurately or within 30 days of the close of the reporting period. In the future, the Village will have controls in place to ensure accurate and timely filing of the report. The person responsible for the corrective action is the Village Manager. The anticipated completion date of the corrective action plan is before the end of the 2025 fiscal year. The plan for adherence is the Council will build a timeline for preparation and completion of the report to ensure timely and accurate filing.
This finding is due to the Village not having control procedures in place for ensuring contractors performing work on federal projects were not suspended or debarred. Subsequently, the Village’s engineer, Wade Trim, has searched the state procurement office webpage to check if any vendor for a feder...
This finding is due to the Village not having control procedures in place for ensuring contractors performing work on federal projects were not suspended or debarred. Subsequently, the Village’s engineer, Wade Trim, has searched the state procurement office webpage to check if any vendor for a federal project is on the debarment list, which they are not. In the future, the Village will have controls in place to ensure that vendors are not debarred or suspended from federal funding awards. The person responsible for the corrective action is the Village Manager. The anticipated completion date of the corrective action plan is before the end of the 2025 fiscal year. The plan for adherence is the Council will review implement controls to ensure that vendors are not suspended, debarred, or otherwise excluded.
This finding is due to the Village not having formal written policies in place required by Uniform Guidance. The Village is now aware that these policies are required and will adopt all necessary policies. The Village does not believe that there were any actual nonallowable costs or transactions bec...
This finding is due to the Village not having formal written policies in place required by Uniform Guidance. The Village is now aware that these policies are required and will adopt all necessary policies. The Village does not believe that there were any actual nonallowable costs or transactions because of the lack of written policies as required by Uniform Guidance. The Village will adopt all necessary policies to be in compliance. The person responsible for the corrective action is the Village Manager. The anticipated completion date of the corrective action plan is before the end of the 2025 fiscal year. The plan for adherence is the Council will review all proposed policies and adopt them, the Council will also monitor any changes to policy requirements to ensure that they are in compliance in the future.
This finding is due to the Village not having formal written policies in place required by Uniform Guidance. The Village is now aware that these policies are required and will adopt all necessary policies. The Village does not believe that there were any actual nonallowable costs or transactions bec...
This finding is due to the Village not having formal written policies in place required by Uniform Guidance. The Village is now aware that these policies are required and will adopt all necessary policies. The Village does not believe that there were any actual nonallowable costs or transactions because of the lack of written policies as required by Uniform Guidance. The Village will adopt all necessary policies to be in compliance. The person responsible for the corrective action is the Village President. The anticipated completion date of the corrective action plan is before the end of the 2025 fiscal year. The plan for adherence is the Council will review all proposed policies and adopt them, the Council will also monitor any changes to policy requirements to ensure that they are in compliance in the future.
Finding 485172 (2024-002)
Significant Deficiency 2024
Finding 2024-002 Personnel Responsible for Corrective Action: Cathy Gorrell, Registrar Anticipated Completion Date: September 30, 2024 Corrective Action Plan: The Office of the Registrar recognizes the systematic programming of a pseudo academic program after a pseudo course has been added with a ...
Finding 2024-002 Personnel Responsible for Corrective Action: Cathy Gorrell, Registrar Anticipated Completion Date: September 30, 2024 Corrective Action Plan: The Office of the Registrar recognizes the systematic programming of a pseudo academic program after a pseudo course has been added with a future date after the student’s current program has been inactivated or graduated. This process has been at the request of the Office of Student Accounts for the graduation fee. The Office of the Registrar will work with the Office of Student Accounts to move to the system Graduation Application process rather than the customized and manual process of pseudo courses. Further, the Office of the Registrar has increased its data quality checks on the pseudo programs and courses. In conjunction, this should eliminate the reporting of active programs when the student has graduated.
August 20, 2024 Department of Housing and Urban Development Washington DC East Central Kansas Economic Opportunity Corporation respectfully submits the following corrective action plan for the year ended March 31, 2024. SSC CPAs, PA 3320 Clinton Parkway Court, Suite 120 Lawrence, KS 66047 Audit ...
August 20, 2024 Department of Housing and Urban Development Washington DC East Central Kansas Economic Opportunity Corporation respectfully submits the following corrective action plan for the year ended March 31, 2024. SSC CPAs, PA 3320 Clinton Parkway Court, Suite 120 Lawrence, KS 66047 Audit Period: Year ended March 31, 2024 The finding from March 31, 2024, schedule of findings and questioned costs are discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS 2024-001 Compliance and Controls over Eligibility of the Section 8 Housing Choice Vouchers Program (Significant Deficiency) Federal Agency: U.S. Department of Housing and Urban Development Program Name: Section 8 Housing Choice Vouchers Assistance Listing Number: 14.871 Award Period: March 31, 2024 Recommendation: The Board of Directors and management review the controls over the eligibility process to ensure the process is being followed and implemented correctly. Action Taken (Unaudited): ECKAN will create a policy in its Admin Plan, using any new HOTMA rules that may apply, to require zero-income forms in client files for households claiming zero-income. This Admin Plan edit will be presented to the ECKAN Board of Trustees for approval. Effective immediately (as of date of file inspection) ECKAN will use the Zero Income Verification Form for any new families claiming zero income. This had been a practice within the department but had not been formalized or provided oversight. ECKAN will also take steps to ensure current client files are searched for any families who claimed zero income prior and either locate the form or initiate contact with the family to obtain a completed form. A tracking spreadsheet will be created to ensure a complete list of zero-income households is maintained and monitored by the ECKAN housing staff. Anticipated completion date is March 31, 2025. If the Department of Housing and Urban Development has questions regarding this plan, please call Crystal Anderson at 785-242-7450. Sincerely yours, Crystal Anderson Crystal Anderson CEO East Central Kansas Economic Opportunity Corporation
In Finding 2024-002, a condition was noted in which the Organization did not verify that certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Management recognizes the importance of complying with pro...
In Finding 2024-002, a condition was noted in which the Organization did not verify that certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Management recognizes the importance of complying with procurement, debarments, and suspension guidelines. In response to Finding 2024-002, procedures will be implemented to ensure debarment searches are completed and properly documented.
Management will implement a process of identifying any surplus cash to be deposited into its residual receipts reserve account and a timeline to provide reasonable assurance that the remittance of the required deposits are done within the specified timeframe set by HUD. Responsible party: Keith Gib...
Management will implement a process of identifying any surplus cash to be deposited into its residual receipts reserve account and a timeline to provide reasonable assurance that the remittance of the required deposits are done within the specified timeframe set by HUD. Responsible party: Keith Gibson, Chief Financial Officer; (207) 373-1140 Anticipated completion date: Effective July 2024
View Audit 317846 Questioned Costs: $1
The Project deposited $272 into the reserve for replacement account.
The Project deposited $272 into the reserve for replacement account.
View Audit 317811 Questioned Costs: $1
Reporting views of responsible officials: The Company has already submitted the audit package to the Federal Audit Clearinghouse and the Company will timely file the audit package with the Federal Audit Clearinghouse in the future. Auditors' summary of auditee's comments on the findings and recommen...
Reporting views of responsible officials: The Company has already submitted the audit package to the Federal Audit Clearinghouse and the Company will timely file the audit package with the Federal Audit Clearinghouse in the future. Auditors' summary of auditee's comments on the findings and recommendations: The Company has already submitted the audit package to the Federal Audit Clearinghouse and the Company will timely file the audit package with the Federal Audit Clearinghouse in the future. Response indicator: Agree. Response: The Company has already submitted the audit package to the Federal Audit Clearinghouse and the Company will timely file the audit package with the Federal Audit Clearinghouse in the future. Completion date: March 25, 2024 Contact person: James Sweeney
Reporting views of responsible officials: The Company has already submitted the audit package to the Federal Audit Clearinghouse and the Company will timely file the audit package with the Federal Audit Clearinghouse in the future. Auditors' summary of auditee's comments on the findings and recommen...
Reporting views of responsible officials: The Company has already submitted the audit package to the Federal Audit Clearinghouse and the Company will timely file the audit package with the Federal Audit Clearinghouse in the future. Auditors' summary of auditee's comments on the findings and recommendations: The Company has already submitted the audit package to the Federal Audit Clearinghouse and the Company will timely file the audit package with the Federal Audit Clearinghouse in the future. Response indicator: Agree. Response: The Company has already submitted the audit package to the Federal Audit Clearinghouse and the Company will timely file the audit package with the Federal Audit Clearinghouse in the future. Completion date: March 25, 2024 Contact person: James Sweeney
Reporting views of responsible officials: The Company has already submitted the audit package to the Federal Audit Clearinghouse and the Company will timely file the audit package with the Federal Audit Clearinghouse in the future. Auditors' summary of auditee's comments on the findings and recommen...
Reporting views of responsible officials: The Company has already submitted the audit package to the Federal Audit Clearinghouse and the Company will timely file the audit package with the Federal Audit Clearinghouse in the future. Auditors' summary of auditee's comments on the findings and recommendations: The Company has already submitted the audit package to the Federal Audit Clearinghouse and the Company will timely file the audit package with the Federal Audit Clearinghouse in the future. Response indicator: Agree. Response: The Company has already submitted the audit package to the Federal Audit Clearinghouse and the Company will timely file the audit package with the Federal Audit Clearinghouse in the future. Completion date: March 25, 2024 Contact person: James Sweeney
Houston Heights Tower Corrective Action Plan May 31, 2024 - Audit Finding 2024-001: The regulatory agreement stipulates that all withdrawals exceeding $2,500 from the Reserve for Replacement Account need prior written consent of the lender. A withdrawal of $37,000 for emergency improvements was mad...
Houston Heights Tower Corrective Action Plan May 31, 2024 - Audit Finding 2024-001: The regulatory agreement stipulates that all withdrawals exceeding $2,500 from the Reserve for Replacement Account need prior written consent of the lender. A withdrawal of $37,000 for emergency improvements was made from the Reserve for Replacement account without prior approval from the lender. Response: Management had tried to get approval for the withdrawal from HUD, not realizing that the regulatory agreement required them to get approval from the lender. Management obtained retroactive approval from the lender on July 1, 2024 for the $37,000 withdrawal. Responsible Party: Linda G. Holder, Vice President/COO/Agent, Houston Housing Management Corporation, 2211 Norfolk, Suite 614, Houston, TX 77098
Jeff Cottingham, Management agent, and Patti Gratton, sponsor of project, will be responsible for monitoring monthly financial results and accounting information as correction is not practical.
Jeff Cottingham, Management agent, and Patti Gratton, sponsor of project, will be responsible for monitoring monthly financial results and accounting information as correction is not practical.
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