Corrective Action Plans

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Projected completion date: VAMHAR expects to submit all required grant reports timely for fiscal year 2025.
Projected completion date: VAMHAR expects to submit all required grant reports timely for fiscal year 2025.
Finding type: Significant deficiency.
Finding type: Significant deficiency.
Federal award: 93.912, Rural Health Care Services Outreach.
Federal award: 93.912, Rural Health Care Services Outreach.
Passthrough organization: Not applicable.
Passthrough organization: Not applicable.
Condition: Late submission of audit reporting package.
Condition: Late submission of audit reporting package.
Management concurrence: Management concurs with this finding.
Management concurrence: Management concurs with this finding.
Corrective action plan: VAMHAR has put into effect policies and internal controls to allow it to submit filings on time and in compliance going forward once the previous audits are filed.
Corrective action plan: VAMHAR has put into effect policies and internal controls to allow it to submit filings on time and in compliance going forward once the previous audits are filed.
Name of contact person: Daniel Franklin, Executive Director and Lisa Lord, Director of Operations.
Name of contact person: Daniel Franklin, Executive Director and Lisa Lord, Director of Operations.
Projected completion date: VAMHAR expects to submit the audit reporting package timely for the year ending June 30, 2025.
Projected completion date: VAMHAR expects to submit the audit reporting package timely for the year ending June 30, 2025.
Name of Auditee: City of Beacon, New York Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended December 31, 2023 CAP Prepared by: Susan Tucker, CPA, Director of Finance Phone: (845) 838-5006 (2) Audit Finding 2023-002 - The City did not submit its audited financial info...
Name of Auditee: City of Beacon, New York Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended December 31, 2023 CAP Prepared by: Susan Tucker, CPA, Director of Finance Phone: (845) 838-5006 (2) Audit Finding 2023-002 - The City did not submit its audited financial information for the year ended December 31, 2023, to the FAC by the required deadlines. (a) Implementation Plan of Actions - The City will reconcile its balance sheet accounts at year-end. (b) Implementation Date - This will be implemented for the year ending December 31, 2026. (c) Persons Responsible for Implementation - The Director of Finance and the City Council.
Views of responsible officials: Before the approval of budget and the contract petition, the legal department will very if the vendors are excluded as a authorized Federal contractor. The Company will establish a formal procedure to ensure that all vendors for federal funds are verified against the ...
Views of responsible officials: Before the approval of budget and the contract petition, the legal department will very if the vendors are excluded as a authorized Federal contractor. The Company will establish a formal procedure to ensure that all vendors for federal funds are verified against the excluded list at least once a year. This verification process will ensure compliance with federal regulations and avoid engaging with vendors who may be suspended or debarred. Additionally, this procedure will be recommended to be included in the review process for quotes or bidding requirements, further enhancing the company’s ability to comply with federal regulations and maintain responsible vendor relationships. Names of the contact persons responsible for the corrective action plan: Sra. Carmen Fernandez, Legal Advisory Director Completed date: This corrective action was implemented as of December 31, 2024.
Views of responsible officials: 6 days The Company will establish a clear and organized calendar for the submission of all required reports. This calendar will serve as a reference to ensure that all deadlines are met, helping to improve overall efficiency. By outlining specific dates for each repor...
Views of responsible officials: 6 days The Company will establish a clear and organized calendar for the submission of all required reports. This calendar will serve as a reference to ensure that all deadlines are met, helping to improve overall efficiency. By outlining specific dates for each report will avoid delays and ensure that all required reports and documentation are submitted on time, contributing to a more effective report delivery process. Names of the contact persons responsible for the corrective action plan: Nilsa Rodríguez Rivera (CFO -2025) Anticipated complete date: This corrective action was implemented as of December 31, 2024.
The Chief Financial Officer (CFO) is responsible for this task. The overview includes reviewing and submitting the information and data collected during the month. To ensure timely compliance, the CFO has implemented a shared calendar system with the administrative personnel that establishes clear d...
The Chief Financial Officer (CFO) is responsible for this task. The overview includes reviewing and submitting the information and data collected during the month. To ensure timely compliance, the CFO has implemented a shared calendar system with the administrative personnel that establishes clear deadlines and reminders to prevent delays and improve efficiency, ensuring all submissions are received within the required timeframe. In addition to timeliness, the CFO will implement enhanced internal controls and quality assurance measures to guarantee that all data submitted is accurate, complete, and in full compliance with federal reporting requirements. This process will include: • Conducting a pre-submission review of all documents by the finance and compliance team to verify accuracy and consistency. • Establish a checklist of federal regulatory requirements to be applied before final submission of reporting packages. • Assigning a secondary reviewer independent of the preparer to ensure an additional level of oversight. • Documenting all reviews and approvals to create an audit trail that supports transparency and accountability. • Holding monthly coordination meetings with responsible personnel to address potential delays, clarify requirements, and provide corrective guidance in real time. By combining timely submission mechanisms with strengthened review and compliance controls, the CFO ensures that reporting packages meet the highest standards of accuracy, reliability, and federal regulatory compliance. Names of the contact persons responsible for the corrective action plan: Nilsa Rodríguez Rivera (CFO -2025) Anticipated completion date: This corrective action will be in place no more than November 30, 2025.
Finding 2023-008: This is for Pohnpei Community Health Centers. 1) For 2 of 2 items tested. We noted that total expenditures reported in documentary support submitted by the State for drawdown requests do not match the initial amounts requested, approved, and received by the awarding agency. We are ...
Finding 2023-008: This is for Pohnpei Community Health Centers. 1) For 2 of 2 items tested. We noted that total expenditures reported in documentary support submitted by the State for drawdown requests do not match the initial amounts requested, approved, and received by the awarding agency. We are aware that the expenditure reports furnished to us are not the originals that would have accompanied the State’s initial request for reimbursement from the awarding agency. It does not appear that the original supporting expenditure reports were retained. 2) The State does not appear to have a policy or adopted standard methodology for monitoring 93.224 programmatic cash needs and scheduling regular drawdowns. Root Cause Analysis 1) The State’s documentary retention controls over programmatic drawdowns need improvement 2) The State has not established a policy or standard operating procedure for monitoring 93.224 programmatic cash needs and scheduling regular drawdowns. Corrective Actions 1) Strengthen its controls over documentary retention for drawdowns. Retain expenditure reports for the basis of drawdowns at the time of filing and ensure there is appropriate explanatory documentation retained for any special reconciling items. 2) Establish clear policies and procedures for monitoring cash needs, performing drawdowns, and retaining documentation of drawdowns. Responsible Parties For CAP 1, Director of DOTA and the Chief of Finance For CAP 2, Director of DOTA and the Chief of Finance Timeline Verification of Effectiveness Conduct regular assessments to ensure the implementation of the aforementioned action plans.
Finding 2023-007: This is for Pohnpei Community Health Centers. The FFR (SF425’s) were submitted after the due dates. Root Cause Analysis The State’s monitoring controls over FFR reporting deadlines were ineffective Corrective Actions 1) Establish a tracking schedule for grant reporting deadlines up...
Finding 2023-007: This is for Pohnpei Community Health Centers. The FFR (SF425’s) were submitted after the due dates. Root Cause Analysis The State’s monitoring controls over FFR reporting deadlines were ineffective Corrective Actions 1) Establish a tracking schedule for grant reporting deadlines upon award or extension and 2) Retain copies of all submissions and supporting expenditure reports for audit purposes Responsible Parties For CAP 1, Executive Director of CHC and the Administrative officers For CAP 2, Director of DOTA and the Chief of Finance Timeline Verification of Effectiveness Conduct regular assessments to ensure the implementation of the aforementioned action plans.
Finding 2023-006: This is for Special Education Condition 1: For 4 of the transactions total question costs $512. The supporting documentations were not provided. Conditional 2: No departmental timecards or timesheets were provided to support compensation. Condition 3. Payroll with timecards, there ...
Finding 2023-006: This is for Special Education Condition 1: For 4 of the transactions total question costs $512. The supporting documentations were not provided. Conditional 2: No departmental timecards or timesheets were provided to support compensation. Condition 3. Payroll with timecards, there were no verification performed at the departments to ensure that what is being paid are correct. Root Cause Analysis a. Condition 1: Ineffective documentation retention at treasury, exacerbated by office relocation. b. Condition 2: Ineffective retention at departmental agencies where timesheets are held. c. Conditions 3(a) and 3(c): Weak internal controls over reconciliation between departmental timesheets and treasury uniform timesheets. Treasury does not regularly obtain departmental timesheets. d. Condition 3(b): Manual timecard errors from daily stamp-based systems. Corrective Actions 1. Strengthen documentation retention controls. 2. Enhance monitoring at the departmental level or implement a uniform timekeeping system to reduce reconciliation issues. 3. Require submission of departmental timekeeping reports to treasury for secondary reconciliation. 4. Ensure explanatory documentation is retained when uniform timesheets differ from departmental records. Responsible Parties For CAP 1. Director of DOTA and Payroll division For CAP 2. Special Education Administrator and his timekeepers For CAP 3. Director of DOTA and Payroll division For CAP 4. Both Department of DOTA and Special Ed Timeline Verification of Effectiveness Conduct regular assessments to ensure the implementation of the aforementioned action plans.
Finding 2023-005: Condition 1: The State’s capital asset register reflected no Compact Sector–funded capitalized infrastructure additions since FY 2016, despite completed contracts during 2016 through 2021. The State was unable to provide supporting documentation evidencing capitalizable values, pro...
Finding 2023-005: Condition 1: The State’s capital asset register reflected no Compact Sector–funded capitalized infrastructure additions since FY 2016, despite completed contracts during 2016 through 2021. The State was unable to provide supporting documentation evidencing capitalizable values, project ownership, or other required details. Conditional 2: Four (4) assets or batches of assets that met the State’s capitalization requirements were not capitalized until corrected through audit adjustments Root Cause Analysis For both conditions there is a lack of internal control monitoring over fixed asset capitalization. Corrective Actions 1. For Condition 1, the State should obtain documentation to support capitalizable values and confirm ownership. 2. For Condition 2, all assets related to health-sector acquisitions, the State should improve coordination between the Department of Health and Human Services and the State Treasury to ensure eligible items are capitalized at requisition or purchase order stage. Responsible Parties For Corrective Action Plan 1: Director of DOTA and Procurement Officer For Corrective Action Plan 2: Director of Health and his administrative officers Director of DOTA, Certification and Procurement officer Timeline Verification of Effectiveness Conduct regular assessments to ensure the implementation of the aforementioned action plans.
Finding 2023-004: For 1 (or 1%) of 60 transactions tested, aggregating $1,187,753 out of $19,516,462 in program expenditures, the State made an advance payment using sector grant funds. No documentation was provided to evidence prior grantor agency concurrence to waive the specific special provision...
Finding 2023-004: For 1 (or 1%) of 60 transactions tested, aggregating $1,187,753 out of $19,516,462 in program expenditures, the State made an advance payment using sector grant funds. No documentation was provided to evidence prior grantor agency concurrence to waive the specific special provision. For 11 (or 23%) of 49 personnel records tested under the Compact Sector Education and Supplemental Education grants, no documentation was available to show that the annual performance evaluation had been performed. Root Cause Analysis • For advance payments, either concurrence was not obtained, or documentation was not retained; and a lack of familiarity with specific grant conditions may have contributed to the noncompliance. • For evaluations, documentation retention controls over personnel files were inadequate. Corrective Actions • For the health grants, if advance payments are necessary, the State should (a) use general fund advances with later reimbursement; (b) establish a letter of credit; or (c) obtain prior OIA concurrence. • For the Education and Supplemental Education grants, the State should strengthen controls to ensure annual evaluations are completed and retained in personnel files. Responsible Parties For bullet point one: Director of Health and his administrative officers Director of DOTA, certification and payable section For bullet point two: Director of Education and Personnel Managers Timeline Verification of Effectiveness Conduct regular assessments to ensure the effective implementation of the aforementioned action plans.
Finding 2023-003: Test no 15 is for Department of Education and the rest are for Department of Health. • For test no. 15, obligation 361854 – Of 3 quotations obtained for a small purchase transaction, the highest quotation was selected, there was no documented justification to support the procuremen...
Finding 2023-003: Test no 15 is for Department of Education and the rest are for Department of Health. • For test no. 15, obligation 361854 – Of 3 quotations obtained for a small purchase transaction, the highest quotation was selected, there was no documented justification to support the procurement selection. • For test no. 16, obligation 372216 – The procurement was sourced from one vendor and lacks additional quotations. There was no documented justification to support the sole-source procurement. • For test no. 17, obligation 372215 – The procurement was sourced from one vendor and lacks additional quotations. There was no documented justification to support the sole-source procurement. • For test no. 22, obligation 334914 – The procurement file included 2 quotations and a justification form that did not relate to the transaction as it cites an explanation for purchasing goods from other vendors unrelated to the actual transaction. Of the 2 vendors included, there did not appear to be a notable difference in goods/services offered, however the higher of the 2 was selected. Consequently, we could not determine the ultimate basis for vendor selection. • For test no. 30, obligation 358537 – The procurement as sourced from one vendor and lacks additional quotations. There was no documented justification for the sole-source procurement. Root Cause Analysis Ineffective documentation filing and retention controls, further impacted by the relocation of the State Treasury office. Corrective Actions • Strengthen procurement documentation controls and ensure rationales and justifications for vendor selection are retained in procurement files. Responsible Parties Director of Education and its administrative officers Director of Health and administrative officers Director of DOTA, certification and payable section Timeline Verification of Effectiveness Periodically verify the department's purchases to ensure that no instances of noncompliance are still taking place.
Finding 2023-002: This finding is for Education Department Condition 1. Impact: For 3 or (5%) of 60 non-payroll transactions tested, (a) no financial records were available to substantiate allowability; or (b) the available procurement file documentation was insufficient to substantiate allowability...
Finding 2023-002: This finding is for Education Department Condition 1. Impact: For 3 or (5%) of 60 non-payroll transactions tested, (a) no financial records were available to substantiate allowability; or (b) the available procurement file documentation was insufficient to substantiate allowability, as follows: The noncompliance resulted in a total questioned cost of $604. Condition 2. For 13 or (20%) of 65 payroll transactions tested, no departmental timecards or timesheet documentation was provided to support compensation, taxes, and fringe benefits. Condition 3. Of the 49 payroll transactions tested where departmental timecards or timesheet support was provided, we identified the following: 1) For 1 employee, the uniform timesheet reported 16 hours of sick leave, while the departmental timesheet reported 80 hours of regular work. 2) For 1 employee, the uniform timesheet was not signed by all required authorized signatories. 3) For 1 employee, the uniform timesheet reported 56 regular hours, while the departmental timesheet reflected 43 regular hours; however, the employee was paid for 80 regular hours, resulting in an overpayment of approximately $76 (processed on May 2, 2023). Root Cause Analysis • For Condition 1, ineffective documentation filing and retention controls were exacerbated by the relocation of the State Treasury office during the audit period. • For Condition 2, ineffective documentation filing and retention controls existed at the departmental agency level, where timesheets or other timekeeping records were retained. • For Condition 3(a), insufficient internal controls at the departmental level failed to ensure reconciliation of departmental timesheets with uniform timesheets submitted to the State Treasury. The Treasury does not consistently receive departmental support and therefore relies on agency review and certification. • For Condition 3(b), required signatory authorization controls failed at both the departmental and treasury levels. • For Condition 3(c), existing controls failed to detect and prevent the overpayment. Corrective Actions 1) For Condition 1. Strengthen documentation filing and retention controls. 2) For Condition 2 & 3 a) Enhance monitoring controls at the departmental level or implementing a uniform timekeeping system to reduce reconciliation burdens b) Establish policies requiring submission of department timekeeping report to the State treasury to allow for secondary reconciliation c) Reinforcing the requirement that when changes are made affecting uniform timesheets but not departmental records, appropriate explanatory documentation be retained. Responsible Parties For Condition 1. • Director of DOTA/Payable Section - Strengthen documentation filing and retention controls. For Condition 2 & 3 • Director of Education/Timekeepers - Enhance monitoring controls at the departmental level or implementing a uniform timekeeping system to reduce reconciliation burdens • Director of DOTA and Payroll Section - Establish policies requiring submission of departmental timekeeping reports to the State treasury to allow for secondary reconciliation. • Director of DOTA and Payroll Section - Reinforce the requirement that when changes are made affecting uniform timesheets but not departmental records, appropriate explanatory documentation be retained. Timeline Verification of Effectiveness For condition 1, the State Treasury will perform routine inspections of the filing systems to verify compliance and address individuals who resist necessary changes. For Conditions 2 and 3, payroll will not be disbursed to any department that fails to adhere to the new action plan
Views of Responsible Officials: In the first quarter of 2023, management deployed a standardized platform across LCMC Health to enhance automated approval workflows. Automated enhancements included: • Automated approval routing based on predefined authorization hierarchies. • System-enforced approva...
Views of Responsible Officials: In the first quarter of 2023, management deployed a standardized platform across LCMC Health to enhance automated approval workflows. Automated enhancements included: • Automated approval routing based on predefined authorization hierarchies. • System-enforced approval checkpoints prior to payment processing. • Audit trail functionality that logs all approval actions and user activities. In addition, management conducts routine staff training and periodic reviews of authorization hierarchies to ensure on-going effectiveness and compliance with financial controls. These enhancements reflect LCMC Health’s proactive commitment to maintaining strong internal control processes
Hale County Health Care Authority respectfully submits the following corrective action plan for the year ended September 30, 2023. The finding from the September 30, 2023 Schedule of Findings and Questioned Costs is discussed below. The finding is numbered consistently with the numbers assigned in t...
Hale County Health Care Authority respectfully submits the following corrective action plan for the year ended September 30, 2023. The finding from the September 30, 2023 Schedule of Findings and Questioned Costs is discussed below. The finding is numbered consistently with the numbers assigned in the schedule. FEDERAL AWARD PROGRAMS AUDIT FINDING Significant Deficiency (2023-001) - Reporting (Late Filing) Recommendation: We recommend that the Authority complete its audit and submit the required by the deadline. Planned Corrective Action: We are continuining to institute processes and procedure to complete timely reconcilations to allow for future filings to be made prior to deadline. Contact Person: Shay Cherry
The Organization will be working with staff on retaining and obtaining all applicable, required forms in each client files for the 2024 calendar year end.
The Organization will be working with staff on retaining and obtaining all applicable, required forms in each client files for the 2024 calendar year end.
The Organization will be working to retain supporting documentation for all transactions for the 2024 calendar year audit.
The Organization will be working to retain supporting documentation for all transactions for the 2024 calendar year audit.
The Organization will be working to either follow their documented controls or update their documentation for their new controls for the 2024 calendar year audit.
The Organization will be working to either follow their documented controls or update their documentation for their new controls for the 2024 calendar year audit.
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