Corrective Action Plans

Finding 25133 (2022-001)

Significant Deficiency 2022

Westchester Jewish Community Services, Inc.

NY

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Persons Responsible: Irene Math, Chief Financial Officer, Karen Rosenthal Controller Comment: The federal program 93.829 requires that the distribution of salary and wages charged to federal awards be based on actual employee activity as reflected in personal activity reports (timesheets), prepared ...

Persons Responsible: Irene Math, Chief Financial Officer, Karen Rosenthal Controller Comment: The federal program 93.829 requires that the distribution of salary and wages charged to federal awards be based on actual employee activity as reflected in personal activity reports (timesheets), prepared after-the-fact, that include the total activity for which employees were compensated Response: WJCS implemented weekly manual timesheets to track staff time and attendance on Federal contracts. These timesheets are used to appropriately allocate salaries and wages to federal awards. However, these timesheets are not integrated into a standard agency-wide payroll processing system. In automated systems, timesheets are embedded in an organization?s time and attendance and payroll system. In the first quarter of 2023 WJCS commenced the process of building and implementing an agency-wide time and attendance system for all WJCS employees. This includes working with our existing payroll processor, and engaging payroll consultants to ensure comprehensive timekeeping, including maintaining the allocation of hours worked by program for all employees. Utilizing these enhancements to payroll tracking will allow WJCS to completely and accurately allocate payroll costs with fewer mechanical steps which increase the risk of miscalculations, and therefore, less errors in Federal reporting. Estimated Completion Date: The agency-wide time and attendance system will be implemented by December 31, 2023.

View Audit 23650

Finding 25079 (2022-005)

Material Weakness 2022

Independent School District 2164

MN

Allowable Costs / Cost Principles Material Weakness

Finding 2022-005 Activities Allowed or Unallowed ? Education Stabilization Fund Material Weakness in Internal Control Over Compliance Finding Summary: The District has no procedure in place for review of pay rates paid to employees under the Education Stabilization Fund. Responsible Individuals: Sha...

Finding 2022-005 Activities Allowed or Unallowed ? Education Stabilization Fund Material Weakness in Internal Control Over Compliance Finding Summary: The District has no procedure in place for review of pay rates paid to employees under the Education Stabilization Fund. Responsible Individuals: Shannon Hunstad, Superintendent Corrective Action Plan: The District will review and strengthen the controls surrounding the review and approval of allowable costs in the Education Stabilization Fund to ensure they are supported, approved, and accurate. Anticipated Completion Date: June 30, 2023

View Audit 23716

Finding 25075 (2022-004)

Material Weakness 2022

Independent School District 2164

MN

Allowable Costs / Cost Principles Material Weakness School Nutrition Programs

Finding 2022-004 Activities Allowed or Unallowed ? Child Nutrition Cluster Material Weakness in Internal Control Over Compliance Finding Summary: The District has no procedure in place for review of pay rates paid to employees under federal programs in the Child Nutrition Cluster. Responsible Indivi...

Finding 2022-004 Activities Allowed or Unallowed ? Child Nutrition Cluster Material Weakness in Internal Control Over Compliance Finding Summary: The District has no procedure in place for review of pay rates paid to employees under federal programs in the Child Nutrition Cluster. Responsible Individuals: Shannon Hunstad, Superintendent Corrective Action Plan: The District will review and strengthen the controls surrounding the review and approval of allowable costs in the Child Nutrition Cluster to ensure they are supported, approved, and accurate. Anticipated Completion Date: June 30, 2023

View Audit 23716

Finding 25010 (2022-006)

Significant Deficiency 2022

Tri Valley Health System

NE

Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.303

Finding 2022-006 Department of Health and Human Services Federal Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year ? Period 1 TIN #476028103 Activities Allowed or Unallowed and Allowable Costs/Cost Prin...

Finding 2022-006 Department of Health and Human Services Federal Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year ? Period 1 TIN #476028103 Activities Allowed or Unallowed and Allowable Costs/Cost Principles and Reporting Significant Deficiency in Internal Control Over Compliance and Noncompliance Finding Summary: The Health System claimed expenses that were incurred prior to when the Health System began to prepare for, prevent and respond to the coronavirus. This resulted in the incorrect treatment of expenses on the special report submitted to the Department of Health and Human Services (HHS) for Period 1. Responsible Individuals: Diana Swindler, CFO Corrective Action Plan: Tri Valley Health System will enhance internal control policies to ensure expenditures claimed under a federal program meet the terms and conditions of the award and are properly included in the reports required to be submitted to the federal agency. Anticipated Completion Date: 02/28/2023

View Audit 23714

Finding 25009 (2022-005)

Significant Deficiency 2022

Tri Valley Health System

NE

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Cash Management § 200.303

Finding 2022-005 Department of Health and Human Services Federal Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year ? Period 1 TIN #476028103 Activities Allowed or Unallowed and Allowable Costs/Cost Prin...

Finding 2022-005 Department of Health and Human Services Federal Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year ? Period 1 TIN #476028103 Activities Allowed or Unallowed and Allowable Costs/Cost Principles and Reporting Significant Deficiency in Internal Control Over Compliance Finding Summary: Tri Valley Health System calculated the reimbursement rate from the total expenses, but also calculated the reimbursemeone on an individual expense in duplicate. Responsible Individuals: Diana Swindler, CFO Corrective Action Plan: Tri Valley Health System will implement procedures to ensure the reduction for reimbursement of expenditures are calculated and reported correctly for all future federal awards. Anticipated Completion Date: 02/28/2023

View Audit 23714

Finding 24984 (2022-001)

Significant Deficiency 2022

Access to Independence, Inc.

WI

Allowable Costs / Cost Principles Cash Management Reporting

Finding 2022-001 ? Corrective Action Plan Federal program and specific federal award Identification: 93.958 Block Grants for Community Mental Health Services and 93.959 Block Grants for Prevention and Treatment of Substance Abuse Passed through Wisconsin Department of Health Services Peer Speciali...

Finding 2022-001 ? Corrective Action Plan Federal program and specific federal award Identification: 93.958 Block Grants for Community Mental Health Services and 93.959 Block Grants for Prevention and Treatment of Substance Abuse Passed through Wisconsin Department of Health Services Peer Specialist CARS 531057 Grant Contract October 1, 2021 - September 30, 2022 Responsible Party: Jason Beloungy, Executive Director Expected Completion Date: April 1, 2023 Corrective Action Planned: Management has already taken action on this situation by replacing the internal finance position with an outsourced accounting firm who specializes in nonprofits and grant accounting. The firm is expected to monitor the status of each cost reimbursement grant to ensure spending is in line with grant awards. This monitoring will be done each month in conjunction with closing the books and communicated with the responsible party.

View Audit 22491

Finding 24982 (2022-001)

Significant Deficiency 2022

Orleans Central Supervisory Union

VT

Allowable Costs / Cost Principles § 200.430

December 20, 2022 Finding: 2022-001 Allowable Cost/Cost Principal Agency: U.S. Department of Education AL Number: 84.425D Grant: Education Stabilization Fund Under the Coronavirus Aid, Relief and Economic Security Act Name of contact person and title: Crista Perkins, Business Manager Anticipate...

December 20, 2022 Finding: 2022-001 Allowable Cost/Cost Principal Agency: U.S. Department of Education AL Number: 84.425D Grant: Education Stabilization Fund Under the Coronavirus Aid, Relief and Economic Security Act Name of contact person and title: Crista Perkins, Business Manager Anticipated completion date: 06/30/2023 Agency's response: Concur The Department agrees with this finding and will implement the following: ? ?Review policies and procedures that require time and effort records for employees working in federal grants are properly documents according to grant requirements ? ?Distribute policies and procedures ? ?Train/Update staff on the policies and procedures ? ?Grant manager will review and approve time and effort records to be sure they are covering a six month period per the Compliance Supplement

View Audit 22389

Finding 24930 (2022-008)

Material Weakness 2022

Ojai Unified School District

CA

Allowable Costs / Cost Principles

The Executive Director of Fiscal Services will implement forms and procedures to ensure the Federal Time and Effort reporting requirement for salary and wage is documented to accurately reflect the work performed.

View Audit 24025

Finding 24923 (2022-009)

Material Weakness 2022

Ojai Unified School District

CA

Allowable Costs / Cost Principles

The Executive Director of Fiscal Services has implemented forms and procedures to ensure the Federal Time and Effort reporting requirement for salary and wage is documented to accurately reflect the work performed for employees who are working in multiple federal programs.

View Audit 24025

Finding 24913 (2022-003)

Material Weakness 2022

Westview School Corporation

IN

Allowable Costs / Cost Principles Subrecipient Monitoring

FINDING 2022-003 Information on the federal program: Subject: Title I Grants to Local Educational Agencies -Allowable Costs/Cost Principles Federal Agency: Department of Education Federal Program: Title I Grants to Local Educational Agencies Assistance Listing Number: 84.010 Pass-Through Entit...

FINDING 2022-003 Information on the federal program: Subject: Title I Grants to Local Educational Agencies -Allowable Costs/Cost Principles Federal Agency: Department of Education Federal Program: Title I Grants to Local Educational Agencies Assistance Listing Number: 84.010 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Allowable Costs/Cost Principles Audit Finding: Material Weakness Condition: The School Corporation had not established an effective internal control system related to the grant agreement and the Allowable Costs/Cost Principles compliance requirement. The School Corporation failed to comply with the allowable costs/cost principle requirements that employees who work 100 percent of their time on a federal award maintain semiannual certifications as required by the pass-through agency, and that employees who work on a federal award and a non-federal award have Program Activity Reports or equivalent documentation to support the distribution of their salaries or wages. Additionally, the School Corporation failed to properly document review and approval of all payroll distribution reports prior to salaries being paid. Context: Semiannual certifications are required by the pass-through agency. The required supporting documentation (Personnel Activity Reports, Semi-Annual Certifications, or equivalent documentation} for 37 of 40 payroll transactions selected for testing was not maintained properly. Payroll expenditures account for approximately $1.063 million of total program expenditures of $1.098 million. Additionally, support for review of payroll distribution reports for 1 of 7 pay dates selected for testing was not properly maintained. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and will take the following corrective action ... Responsible party and timeline for completion: Morgan Stout, Director of Curriculum has established the record keeping system for Time and Effort logs required by the Federal Grant. Completion Date 03/31/2023.

View Audit 20598

Finding 24909 (2022-004)

Significant Deficiency 2022

Westview School Corporation

IN

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.208 § 200.303 § 200.403

FINDING 2022-004 Information on the federal program: Subject: Special Education Cluster - Earmarking Federal Agency: Department of Education Federal Program: Special Education Grants to States, Special Education Preschool Grants Assistance Listings Numbers: 84.027, 84.173 Federal Award Number an...

FINDING 2022-004 Information on the federal program: Subject: Special Education Cluster - Earmarking Federal Agency: Department of Education Federal Program: Special Education Grants to States, Special Education Preschool Grants Assistance Listings Numbers: 84.027, 84.173 Federal Award Number and Year (or Other Identifying Numbers): 19611-042-PN01, 19619-042-PN01, 20611-042-PN01, 20619-042-PN01, 21611-042-PN01, 20619-042-PN01 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Matching, Level of Effort, Earmarking Audit Finding: Significant Deficiency Condition: The School Corporation is a member of the Northeast Indiana Special Education Cooperative (Cooperative). During fiscal year 2021-2022, the Cooperative operated the special education programs and spent the federal money on behalf of all its members. As the grant agreements were between the Indiana Department of Education {IDOE) and each member school, the School Corporation was responsible for ensuring and providing oversight of the Cooperative. However, there was inadequate oversight performed by the School Corporation in order to ensure compliance with the Matching, Level of Effort, Earmarking compliance requirement. The School Corporation did not have internal controls in place to ensure that the Cooperative complied with the earmarking requirements. The Cooperative did not have adequate procedures in place to ensure that the required level of expenditures for non-public students with disabilities was met for each member school. The Cooperative did not have effective internal controls to ensure non-public school expenditures were appropriately identified and reported. Context: The Non-Public Proportionate Share expenditures for 19611-042-PN01, 19619-042-PN01, 20611-042-PN01, 20619-042-PN01, 21611-042-PN01, 20619-042-PN01 grant awards could not be verified for the individual schools to verify the minimum amount per the grant awards was expended and properly reported to IDOE as required. The lack of internal controls and noncompliance were isolated to the 19611-042-PN01, 19619-042-PN0l, 20611-042-PN01, 20619-042-PN01, 21611-042-PN01, 20619-042-PN01 grant awards. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and will take the following corrective action ... Responsible party and timeline for completion: Brian L Christner, director of finance, will follow-up with the Northeast Indiana Special Education Cooperative to ensure that nonpublic expenditures are properly reported. Completion date will be April 30, 2023.

View Audit 20598

Finding 24908 (2022-004)

Material Weakness 2022

City of West Lafayette

IN

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring § 200.1 § 200.303

Finding 2022-004 Contact Person: Peter Gray Contact Phone: 765-775-5150 Views of Responsible Official: 1. There were no material cost issues in the overall report. There was a categorization error. This was discussed in Finding 2022-003. 2. The Revenue Loss expenditures were all valid personnel cost...

Finding 2022-004 Contact Person: Peter Gray Contact Phone: 765-775-5150 Views of Responsible Official: 1. There were no material cost issues in the overall report. There was a categorization error. This was discussed in Finding 2022-003. 2. The Revenue Loss expenditures were all valid personnel costs. Over 80% of the costs are police & fire. Other various city departments comprise the balance of the expenditure. We concur with the finding. Corrective Action: A. An additional layer of review has been initiated. The Director of Development is familiar with the requirements of the SLFRF guidance and will review and sign off on future reports. Anticipated Completion Date: 30 June 2022

View Audit 22376

Finding 24907 (2022-003)

Material Weakness 2022

City of West Lafayette

IN

Questioned Costs Allowable Costs / Cost Principles Procurement, Suspension & Debarment § 200.112 § 200.303 § 200.318 § 200.403

Finding 2022-003 Contact Person: Peter Gray Contact Phone: 765-775-5150 Views of Responsible Official: 1. The US Treasury uses the term ?Subrecipient? in multiple ways. It has multiple meanings in the SLFRF reporting structure. ?Beneficiary?, ?Contractor?, and ?Subrecipient? are all entity types und...

Finding 2022-003 Contact Person: Peter Gray Contact Phone: 765-775-5150 Views of Responsible Official: 1. The US Treasury uses the term ?Subrecipient? in multiple ways. It has multiple meanings in the SLFRF reporting structure. ?Beneficiary?, ?Contractor?, and ?Subrecipient? are all entity types under the broader category of ?Subrecipient?. In the ?Expenditures? area, the only field to record the entity that receives funds is labeled as ?Subrecipient Name?. 2. The City did prepare a letter concerning the employees over the threshold. When the SBOA was asked where the letter should be sent, the response was that they did not have an address, so to keep the letter on file and be prepared to present it during an audit. We concur with the finding. Corrective Action: A. An additional layer of review has been initiated. The Director of Development is familiar with the requirements of the SLFRF guidance and will review and sign off on future reports. Anticipated Completion Date: 30 June 2022

View Audit 22376 Questioned Costs: $1

Finding 24850 (2022-001)

Material Weakness 2022

The Center for Conflict Resolution

IL

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

Finding 2022 ? 001 Fiscal year in which the finding occurred: 2022 Pass-Through Entity, if pass-through or Federal Grantor Agency, if direct: Chicago Bar Foundation Contact Person(s) Responsible for Corrective Action: Whitney Trumble and Cassandra Lively Contact Phone Number: 312-922-6464 Status ...

Finding 2022 ? 001 Fiscal year in which the finding occurred: 2022 Pass-Through Entity, if pass-through or Federal Grantor Agency, if direct: Chicago Bar Foundation Contact Person(s) Responsible for Corrective Action: Whitney Trumble and Cassandra Lively Contact Phone Number: 312-922-6464 Status of Audit Finding: At the time of the audit, CCR had not received funds for three months of work as a subgrantee on the large federal grant that is the subject of this plan. The grantor was awaiting the federal contract extension and funds, and so did not have the funds to release. CCR received communication from the grantor that the extension and funds would be available soon, so we prepared a check for a vendor. Then, there was an extensive additional delay in receiving the funds, and CCR did not send the check because the contract had not yet been signed and funds could not be dispersed. The expense had been approved by the grantor and the work was underway during the delay in mailing the check. Corrective Action: As of June 2022, stricter internal controls have been implemented to ensure that any reimbursements listed on a grant invoice have been sent out to the vendor before submitting the report. A more formal review process has been implemented: CCR?s Executive Director will review and approve monthly grant reports via email. She will also review and approve supporting documentation for reach grant report. Approval (sent via email) will be kept with in a digital file with the reporting documentation. An additional internal control has been implemented to ensure that expenditures submitted for reimbursement are within the period of performance for the grant agreement. The Executive Director will monitor the grant expenses against the grant agreement, paying specific attention to the invoices at the end of the grant period, in order to ensure that the invoice is dated prior to the end of the grant agreement or most current amendment.

View Audit 23988

Finding 24848 (2022-001)

Significant Deficiency 2022

Shelby County Health Care Corporation

TN

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Finding No. 2022-001 Corrective Action Plan 1. Name of the contact person responsible for corrective action Brooks Champion- Controller 2. Corrective action planned Regional One Health will implement controls and processes to ensure all costs are manually reviewed and approved to ensure allowab...

Finding No. 2022-001 Corrective Action Plan 1. Name of the contact person responsible for corrective action Brooks Champion- Controller 2. Corrective action planned Regional One Health will implement controls and processes to ensure all costs are manually reviewed and approved to ensure allowability under the grant and that evidence of review is maintained. 3. Completion date November 1, 2022 4. If the client does not agree with the audit findings or believes corrective action is not required, include an explanation and specific reasons We agree with Finding No. 2022-001 5. The reference numbers the auditors assigned to the audit findings in the schedule of findings and questioned costs Finding No. 2022-001

View Audit 22190

Finding 24767 (2022-001)

Significant Deficiency 2022

Clackamas County Childrens Commission

OR

Allowable Costs / Cost Principles Significant Deficiency

Finding 2022-001: Review of expense allocations CFDA. 93.600 Agency. Department of Health and Human Services Significant Deficiency: There was inconsistent documentation of allocation rates for invoices charged to the grant. Allocations other than the rates determined by management were used on f...

Finding 2022-001: Review of expense allocations CFDA. 93.600 Agency. Department of Health and Human Services Significant Deficiency: There was inconsistent documentation of allocation rates for invoices charged to the grant. Allocations other than the rates determined by management were used on five out of forty nonpayroll expenses. Recommendation: System allocations should be reviewed regularly by an appropriate member of management and invoice allocations should be consistent with the approved allocations. Corrective Action: Clackamas County Children?s Commission (CCCC) agrees with the auditors? findings, and the following action will be taken to improve the situation. Allocations, and the supporting documentation for how those were derived will be periodically printed to PDF format for historical recording of changes, and the dates any changes were made. We will review the allocation codes of the accounting system monthly and deactivate those that we are not going to use in order to avoid errors in the allocation of expenses. Additionally, we will continue to review the transactions prior to posting in the accounting system to correct any errors. Anticipated Completion Date: September 2022

View Audit 21470

Finding 24718 (2022-054)

Material Weakness 2022

State of Michigan

MI

Questioned Costs Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.516

Finding 2022-054 Temporary Assistance for Needy Families, ALN 93.558 - Non-Financial Eligibility Documentation Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS?s ESA will continue to emphasize the importance of maintaining eligibility documentation through ongoing st...

Finding 2022-054 Temporary Assistance for Needy Families, ALN 93.558 - Non-Financial Eligibility Documentation Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS?s ESA will continue to emphasize the importance of maintaining eligibility documentation through ongoing staff training and a memorandum sent out to the local offices. ESA leadership will reach out to the managers of the individual specialists regarding the issues identified and provide additional guidance. Anticipated Completion Date Training will be ongoing. ESA will issue the memorandum and address the specific issues with local office management and specialists by August 31, 2023. Responsible Individual(s) Kenton Schulze, MDHHS Lana Karadsheh, MDHHS Brian Sanborn, MDHHS

View Audit 20093 Questioned Costs: $1

Finding 24716 (2022-003)

Significant Deficiency 2022

Alfred Saliba Family Services Center, Inc.

AL

Reporting Allowable Costs / Cost Principles § 200.303

Item 2022-003 Reporting ? Management?s Response ? The Agency will implement controls to ensure proper review and approval is obtained on required grant reports prior to submission to the grantor. Anticipated Completion: September 30, 2023 Responsible Party: Belinda Mitchell, Executive Director

View Audit 21276

Finding 24634 (2022-015)

Material Weakness 2022

The City of New York

NY

Questioned Costs Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Finding No. 2022-015 Department(s) New York City Administration for Children?s Services New York City Human Resources Administration Program(s) Assistance Listing Number 93.575, Child Care and Development Block Grant Corrective Action(s) HRA HRA will convene a small workgroup to meet bi-weekly to r...

Finding No. 2022-015 Department(s) New York City Administration for Children?s Services New York City Human Resources Administration Program(s) Assistance Listing Number 93.575, Child Care and Development Block Grant Corrective Action(s) HRA HRA will convene a small workgroup to meet bi-weekly to review the details and history of the cases identified to try to isolate the cause of the errors, and once we determine the cause, will work with the necessary parties/stakeholders to develop an approach to avoid the situation from repeating itself. First meeting will be 2nd week of April to identify the appropriate parties to include and come up with meeting goal and agenda. ACS Case No. 1 The audit reviewed a child care case relating to an older Fair Hearing which had not been closed timely per the original State Fair Hearing decision, which had been issued prior to FY22. ACS' Child and Family Well-Being (CFWB) division had previously instituted a new Quality Assurance review of pending Fair Hearing cases and through this QA review had already identified and closed the case. However, the auditors reviewed an earlier State FY22 claim prior to ACS' identification of the case. Per the new QA protocol, CFWB will be reviewing HRA/DSS systems reports on a monthly basis, identify any questioned cases and take appropriate follow-up action. CFWB is also preparing new written guidelines. Case No. 2 In one child care case, ACS was not able to provide eligibility documentation. Further ACS research determined a systems coding inconsistency. ACS procedure is to run reports to identify inconsistencies with programmatic codes and review any flagged cases prior to submission of claims to the State. However, in this instance, the case was not identified in the report. ACS will propose creation of a new exception report with a more refined level of detail to identify any case coding inconsistencies and allow follow up to ensure complete case eligibility support for any flagged cases. ACS will work with HRA/DSS on report development. Anticipated Completion Date HRA Beginning Q2 2023 ? Convene workgroup Beginning Q3 2023 ? Completion date ACS Initiated in FY 2022 ? New quality assurance (QA) review To be completed in FY 2023 ? New written guidelines and refined reporting Person(s) Responsible for Implementation HRA Ramon E. Flores Assistant Deputy Commissioner, Family Independence Administration (FIA) FloresRa@hra.nyc.gov ACS For new QA and guidelines Isabel Villegas Executive Director, Policy & Compliance Division of Child and Family Well-Being (212) 393-5325 For refined reporting Pauline Young Assistant Commissioner for Claiming and Revenue Division of Finance (212) 676-8803

View Audit 22749 Questioned Costs: $1

Finding 24617 (2022-012)

Material Weakness 2022

The City of New York

NY

Questioned Costs Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Finding No. 2022-012 Department(s) New York City Human Resources Administration Program(s) Assistance Listing Number 14.239, HOME Investment Partnerships Program Corrective Action(s) Response: ? HRA agrees that the Agency had challenges in retaining some recertification documentation during the COVI...

Finding No. 2022-012 Department(s) New York City Human Resources Administration Program(s) Assistance Listing Number 14.239, HOME Investment Partnerships Program Corrective Action(s) Response: ? HRA agrees that the Agency had challenges in retaining some recertification documentation during the COVID Public Health crisis when staff were working from home and then ultimately leaving the Agency prior to the return to office. ? The identified HOME TBRA tenants had been originally found eligible over five years ago and have been recertified annually every year following. ? This FY22 audit was conducted on the heels of the FY21 audit where the finding was the same and the recommended Corrective Action was the development of a Quality Assurance Checklist due by November 2022 and ongoing. ? HRA agrees to strengthen internal controls and have created and implemented a Quality Assurance Tool that ensure eligibility is accurately assessed, allowable cost is correctly calculated and appropriate evidence (i.e. Recertification Information Form, Proof of Income, Rent Reasonableness Information, Passed Inspection, Landlord Packet, Client Packet, RAC, Tenant Breakdown) that support annual approval is maintained. Also, the payment system already fully requires supervisor approval before annual payments can be set up. Absolutely no payment can go out without supervisor approval. Corrective Actions: ? Strengthen internal governance and future compliance. ? Hire an Executive Director for the TBRA ? Create and implement a Quality Assurance tool that includes information that supports eligibility. ? Provide refresher training for staff involved with TBRA. Anticipated Completion Date May 2023 and ongoing Person(s) Responsible for Implementation Dori Hopkins-Figeroux Director, TBRA (929) 252-6089 Dwana Abraham Assistant Deputy Commissioner (929) 221-6726

View Audit 22749 Questioned Costs: $1

Finding 24611 (2022-001)

Material Weakness 2022

Greene Acres Nursing Home Association, Inc.

AR

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303

Views of responsible officials and planned corrective actions: Management agrees with this finding and will ensure proper review is performed and evidenced.

View Audit 21261 Questioned Costs: $1

Finding 24575 (2022-050)

Significant Deficiency 2022

State of Michigan

MI

Questioned Costs Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles

Finding 2022-050 Medicaid Cluster, ALN 93.775, 93.777 and 93.778 - Practitioner Reimbursement Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has determined the primary remaining source of overlaps between fee-for-service and capitation payments is retroactive remov...

Finding 2022-050 Medicaid Cluster, ALN 93.775, 93.777 and 93.778 - Practitioner Reimbursement Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has determined the primary remaining source of overlaps between fee-for-service and capitation payments is retroactive removal of Medicaid eligibility within Bridges. In November 2019, MDHHS formed a multi-disciplinary work group within the Medical Services Administration to address the problems created when eligibility is removed retroactively. An interface fix is being implemented in December 2023 that will address several existing issues. This upgraded interface will remove existing limitations to mitigate the occurrence of retroactive disenrollment. In addition, the work group continues to evaluate whether any additional process and system changes are needed to further mitigate the occurrence of overlapping payments. Anticipated Completion Date The interface fix will be implemented by December 31, 2023, and evaluation of whether additional process and system changes are needed to further mitigate the occurrence of overlapping payments is ongoing. Responsible Individual(s) Alexis Bond, MDHHS Latina McCausey, MDHHS

View Audit 20093 Questioned Costs: $1

Finding 24574 (2022-049)

Significant Deficiency 2022

State of Michigan

MI

Questioned Costs Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.516

Finding 2022-049 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Home Help Payment Oversight Management Views MDHHS agrees with the finding. Planned Corrective Action Beginning in April 2022, MDHHS automated the payment methodology for ESV to ensure that payments to individual providers using E...

Finding 2022-049 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Home Help Payment Oversight Management Views MDHHS agrees with the finding. Planned Corrective Action Beginning in April 2022, MDHHS automated the payment methodology for ESV to ensure that payments to individual providers using ESV are based on tasks authorized and completed, and compared to approved authorizations before payment is issued. Also, individual caregiver verifications currently in ESV and Paper Service Verification (PSV) will be replaced with Electronic Visit Verification (EVV), which will help ensure payments are reflective of the services provided. MDHHS will continue to manually review PSVs until EVV is implemented. Anticipated Completion Date December 2024 Responsible Individual(s) Elaina Brown-Mingo, MDHHS Michelle Martin, MDHHS

View Audit 20093 Questioned Costs: $1

Finding 24573 (2022-048)

Significant Deficiency 2022

State of Michigan

MI

Questioned Costs Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.516

Finding 2022-048 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Ineligible HHP Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS made improvements to the monthly hospitalization reports to help capture all facility stays for Home Help Clients. MDHHS is no...

Finding 2022-048 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Ineligible HHP Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS made improvements to the monthly hospitalization reports to help capture all facility stays for Home Help Clients. MDHHS is now pulling reports by billing date instead of hospitalization dates to capture inpatient stays that are billed late. MDHHS also implemented a new policy on February 1, 2023, that allows payment for Home Help Program (HHP) services on the day an individual is admitted to the hospital. MDHHS changed the HHP payment process to an automated process during April 2022, tying payments to services on the Electronic Service Verification (ESV) prior to payment being made. In addition, MDHHS modified policy to begin recoupment by task instead of by daily rate for services provided on overlapping days. MDHHS provided a recoupment calculator and training for HHP staff to ensure the correct amount is recouped using the revised policy and procedure. Anticipated Completion Date Completed Responsible Individual(s) Elaina Brown-Mingo, MDHHS Michelle Martin, MDHHS

View Audit 20093 Questioned Costs: $1

Finding 24572 (2022-047)

Significant Deficiency 2022

State of Michigan

MI

Questioned Costs Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.516

Finding 2022-047 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Payments on Behalf of Ineligible Beneficiaries Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS implemented a system solution to identify out of sync records between CHAMPS and Bridges and retrigger ...

Finding 2022-047 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Payments on Behalf of Ineligible Beneficiaries Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS implemented a system solution to identify out of sync records between CHAMPS and Bridges and retrigger updates to CHAMPS. MDHHS is also developing a prior report review process to ensure impacted records that do not get corrected with the CHAMPS retrigger are addressed. Anticipated Completion Date The system solution was implemented as of August 31, 2022. The prior report review process will be implemented by September 30, 2023, and reviews will be ongoing. Responsible Individual(s) Jamy Hengesbach, MDHHS

View Audit 20093 Questioned Costs: $1

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