Corrective Action Plans

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Corrective Action: NTU will improve processes to ensure proper maintenance of source documentation supporting student eligibility determinations. Additionally, staff will receive comprehensive training sessions on eligibility determination and documentation requirements. Person Responsible: Gary Seg...
Corrective Action: NTU will improve processes to ensure proper maintenance of source documentation supporting student eligibility determinations. Additionally, staff will receive comprehensive training sessions on eligibility determination and documentation requirements. Person Responsible: Gary Segaye, Financial Aid Director and Dr. Delores Becenti, Director of Enrollment Estimated Completion Date: July 31, 2024
Audit Finding Number: 2023-001-Enrollment Reporting: Management concurs with the finding. The College submitted enrollment reports over the past year according to our approved submission schedule, but the reports were rejected due to configuration issues with our student information system (SIS). W...
Audit Finding Number: 2023-001-Enrollment Reporting: Management concurs with the finding. The College submitted enrollment reports over the past year according to our approved submission schedule, but the reports were rejected due to configuration issues with our student information system (SIS). We worked diligently to resolve these issues with assistance from Anthology and the National Student Clearinghouse. All the reporting configuration issues that prevented timely and accurate reporting have been resolved and verified by the National Student Clearinghouse. The College has implemented a process whereby the Registrar reports graduation statuses at the conclusion of each term to the College's SIS for upload to the National Student Clearinghouse and subsequent transmission to NSLDS. The Registrar will create a separate report of students who have completed a program yet are continuing their education at the College. In addition, the Registrar will generate a weekly report from the College's SIS listing the last date of attendance for drops/withdrawals, leaves of absence, and standard periods of non-enrollment and upload to the National Student Clearinghouse with subsequent transmission to NSLDS monthly. As an internal control, submitting the report will be a joint venture between the Registrar, the Financial Aid Manager, and the Associate Vice President of Education. These individuals have completed all the required training to ensure accurate reporting. To ensure timely reporting, all will receive transmission and error reports, and submission dates will be set on outlook calendars as a constant reminder. Successful report submission will be a required report at the College's bi-weekly operations meeting. William H. Dindy, Associate Vice President of Education
Corrective Action: Nambe Pueblo Housing Entity (NPHE) will develop comprehensive policies and procedures for maintaining and retaining applications for assistance, as well as all other source documentation necessary to support the eligibility determination process. This initiative aims to ensure acc...
Corrective Action: Nambe Pueblo Housing Entity (NPHE) will develop comprehensive policies and procedures for maintaining and retaining applications for assistance, as well as all other source documentation necessary to support the eligibility determination process. This initiative aims to ensure accuracy, transparency, and compliance with regulatory requirements throughout the eligibility assessment. The enhanced documentation process will provide a robust framework to verify applicant eligibility, maintain records for auditing purposes, and improve overall operational efficiency. Person Responsible: Christine Brock, Interim Executive Director Estimated Completion Date: July 31, 2024
Finding 404938 (2023-001)
Significant Deficiency 2023
Federal Agency: U.S. Department of Health and Human Services Federal Program: 93.568 Low Income Home Energy Assistance Responsible Official Jennifer Beloff, Chief Program Officer Plan Detail Action is in the process of taking the LIHEAP Operators Guide and creating an Action Policy/Procedure manual ...
Federal Agency: U.S. Department of Health and Human Services Federal Program: 93.568 Low Income Home Energy Assistance Responsible Official Jennifer Beloff, Chief Program Officer Plan Detail Action is in the process of taking the LIHEAP Operators Guide and creating an Action Policy/Procedure manual updating /highlighting findings from current and past audits for staff to keep current and for new staff to review when they start working in the LIHEAP program. At the start of the LIHEAP program year, the Energy Director will meet with all staff and review program highlights, changes and new instructions and have staff signoff having participated in the meeting. Anticipated Completion Date June 30, 2024
While the entry of the poverty tables into our case management system is largely an administrative matter, LAWV will engage in review of this process in the future. Both LAWV’s Grants and Trainings Manager and LAWV’s Access to Services Manager will review the poverty tables following import in the c...
While the entry of the poverty tables into our case management system is largely an administrative matter, LAWV will engage in review of this process in the future. Both LAWV’s Grants and Trainings Manager and LAWV’s Access to Services Manager will review the poverty tables following import in the coming years. Furthermore, Legal Server has issued guidance that their case management system can import this information automatically as it serves numerous programs that are recipients of LSC funding. By using Legal Server’s automatic import feature to annually update the poverty tables and by adding the review by two LAWV managers, we believe that this will address the issue prospectively so that an incident such as this will not be repeated.
Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Financial Assistance Listing #93.498 Finding Summary: The Hospital’s final expenditure listing identified as eligible and claimed under ...
Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Financial Assistance Listing #93.498 Finding Summary: The Hospital’s final expenditure listing identified as eligible and claimed under the Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution program (the program) was not reviewed and approved by a separate individual outside of the preparer. Additionally, the Hospital claimed mortgage reimbursements as expenditures under the program. Responsible Individuals: Renae Karst, Chief Financial Officer Corrective Action Plan: A Grant Award Policy and Procedure Manual was established which includes, but not limited to, outlined internal controls around the review, approval, and tracking of grants/awards allowable expenses and reporting. Anticipated Completion Date: June 30, 2024
View Audit 311195 Questioned Costs: $1
Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: The Hospital’s requests for reimbursement under the Community Facilities Grant Agreement were not reviewed and approved by a sep...
Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: The Hospital’s requests for reimbursement under the Community Facilities Grant Agreement were not reviewed and approved by a separate individual. Responsible Individuals: Renae Karst, Chief Financial Officer Corrective Action Plan: Hospital personnel will compile the initial requests for reimbursement with the help of Management to provide proof of invoices and payments. The final request for reimbursement will then be verified by Management prior to requesting reimbursement to the Communities Facilities Grant Coordinator. Anticipated Completion Date: June 30, 2024
Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend the County maintain a list of all individuals at the top of the waiting list. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response t...
Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend the County maintain a list of all individuals at the top of the waiting list. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: As recommended, we will seek a method to keeping, and maintaining, a list of those on top of the Wait List. Name(s) of the contact person(s) responsible for corrective action: Kenneth Stratemeyer Planned completion date for corrective action plan: 10/1/2024
The finding identified in the sample is consistent with the Section Eight Management Assessment Program (SEMAP) score submitted at the end of Fiscal Year 22-23. JHA did not claim any points under the Adjusted Income indicator. Consistent with the corrective action plan, JHA’s HCV staff has undergo...
The finding identified in the sample is consistent with the Section Eight Management Assessment Program (SEMAP) score submitted at the end of Fiscal Year 22-23. JHA did not claim any points under the Adjusted Income indicator. Consistent with the corrective action plan, JHA’s HCV staff has undergone extensive training. During April 2024, HCV staff received training through Nan McKay in the following areas: Housing Choice Voucher Specialist Housing Choice Voucher Rent Calculation Specialist Twenty-two (22) Housing Counselors took the class and seventeen (17) passed and will receive certification in this area. The JHA restructured the HCV Department to designate a Quality and Training Manager and currently over 2,000 files have been reviewed to determine compliance with all 14 SEMAP indicators. JHA continues to improve the overall processes and procedures in the HCV department and has already taken corrective action regarding the identified deficiency.
The following steps have been and are being taken regarding tenant certifications: 1. Staff has attended HOTMA training: An In-Depth Review of Programmatic Changes on 5/21/24 2. A new position was created at the Authority. Our most senior Manager is now our dedicated Quality Control Specialist and ...
The following steps have been and are being taken regarding tenant certifications: 1. Staff has attended HOTMA training: An In-Depth Review of Programmatic Changes on 5/21/24 2. A new position was created at the Authority. Our most senior Manager is now our dedicated Quality Control Specialist and will be responsible for reviewing 100% of our files yearly.
PLAN OF ACTION RESPONSE TO FY23 FINDINGS & QUESTIONED COSTS SIGNIFICANT DEFICIENCY Action Timeframe Responsible Person Training will be provided to staff on a quality control protocol, specifically, the importance of proper calculations; obtaining necessary documentation; and the importance and p...
PLAN OF ACTION RESPONSE TO FY23 FINDINGS & QUESTIONED COSTS SIGNIFICANT DEFICIENCY Action Timeframe Responsible Person Training will be provided to staff on a quality control protocol, specifically, the importance of proper calculations; obtaining necessary documentation; and the importance and process for following up on inspections July 31, 2024 Beth Ochs Rent Assistance Director Quality control by manager will be performed on all files assigned to probationary employees July 31, 2024 Beth Ochs Rent Assistance Director Establish an updated checklist for staff to follow to ensure proper documentation is obtained on each file September 30, 2024 Beth Ochs Rent Assistance Director Pull reports out of the EIV/PIC system, on a monthly basis, such as the Identity Verification Report, SSA Screening Deficiencies Report and place them in a centrally located OneNote for staff follow up. Note: This has been on pause due to the conversion to new software July 31, 2024 Beth Ochs Rent Assistance Director Establish a plan to schedule overdue inspections and complete inspections December 31, 2024 Beth Ochs Rent Assistance Director Assigned caseworker staff will correct the tenant files that were cited in the “other matter” finding in the FY 23 Audit August 30, 2024 Beth Ochs Rent Assistance Director Randomly select tenant files on a monthly basis for review. Note: This has been on pause due to the conversion to new software and will resume in July 2024 July 31, 2024 Beth Ochs Rent Assistance Director Randomly select an additional 50 HCV tenant files beyond the FY 23 audit sample of 86 and review them for the following compliance finding, to test: 1. Income calculations 2. 214 declarations for all members 3. ID documentation for all members 4. Unit inspections 5. Proof of dependents in Household August 30, 2024 Beth Ochs Rent Assistance Director
The Authority had instances of missing income verification, incorrect utility allowance and incorrect payment standard. Gardner Housing Authority has established a system of internal control over the participant recertification process that meets HUD’s requirements. Seven (7) to ten (10) files will ...
The Authority had instances of missing income verification, incorrect utility allowance and incorrect payment standard. Gardner Housing Authority has established a system of internal control over the participant recertification process that meets HUD’s requirements. Seven (7) to ten (10) files will be reviewed fiscally for quality assurance.
Upon discovering issues related to eligibility requirements, Valle del Sol, Inc. addressed and fixed the issues to ensure all patients who are eligible to be covered under the Mercy Care City of Phoenix ARPA award are appropriately charged for services. We implemented a training for all front offic...
Upon discovering issues related to eligibility requirements, Valle del Sol, Inc. addressed and fixed the issues to ensure all patients who are eligible to be covered under the Mercy Care City of Phoenix ARPA award are appropriately charged for services. We implemented a training for all front office staff to include a better understanding of the Mercy Care City of Phoenix ARPA program, scripts for frequently asked questions from patients, and worksheets for staff to complete to ensure all required documents are received, to ensure proper application of eligibility of the Mercy Care City of Phoenix ARPA program. Our staff were fully retrained on the Mercy Care City of Phoenix ARPA program. We feel confident that the re-training to the front office staff and managers will ensure the the accurate application of the policy and accurate discounts are given to our patients. Valle del Sol, Inc. will track and monitor compliance through our QA/QI Committee on a regular basis.
Finding 404732 (2023-011)
Significant Deficiency 2023
Finding number: 2023-011 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance listing #: 84.063 & 84.268 Award year: 2023 Corrective Action Plan: College Unbound has implemented a process to review eligibility for all new students. The Finan...
Finding number: 2023-011 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance listing #: 84.063 & 84.268 Award year: 2023 Corrective Action Plan: College Unbound has implemented a process to review eligibility for all new students. The Financial Aid Office works closely with Admissions/Recruiting to ensure proper documentation of all new students before the first disbursement. Timeline for Implementation of Corrective Action Plan: Ongoing. Started 8/22/24, fully implemented by the end of FY24. Contact Person: Diana Perdomo, Vice President for Institutional and Student Sustainability/CFO
View Audit 311103 Questioned Costs: $1
Finding 404731 (2023-010)
Significant Deficiency 2023
Finding number: 2023-010 Federal agency: U.S. Department of Education Programs: Federal Direct Student Loans Assistance listing #: 84.268 Award year: 2023 Corrective Action Plan: The college has implemented controls in place to ensure that exit counseling is conducted with Direct Loan borro...
Finding number: 2023-010 Federal agency: U.S. Department of Education Programs: Federal Direct Student Loans Assistance listing #: 84.268 Award year: 2023 Corrective Action Plan: The college has implemented controls in place to ensure that exit counseling is conducted with Direct Loan borrowers following changes in enrollment as required. As of FY24, this finding has been corrected. Exit interviews have been sent for FY24 and we will continue to work with our borrowers to understand their loan repayment options. Timeline for Implementation of Corrective Action Plan: Completed Contact Person: Diana Perdomo, Vice President for Institutional and Student Sustainability/CFO
Finding 404721 (2023-003)
Significant Deficiency 2023
Finding number: 2023-003 Federal agency: U.S. Department of Education Programs: Federal Pell Grants Assistance listing #: 84.063 Award year: 2023 Corrective Action Plan: College Unbound has increased its administrative capacity and has implemented internal controls to properly monitor stude...
Finding number: 2023-003 Federal agency: U.S. Department of Education Programs: Federal Pell Grants Assistance listing #: 84.063 Award year: 2023 Corrective Action Plan: College Unbound has increased its administrative capacity and has implemented internal controls to properly monitor student enrollment status and recalculate Pell Grant awards as required by the Federal Government. We will continue to review these processes to mitigate any further redundancies or mistakes. Timeline for Implementation of Corrective Action Plan: Corrected. Contact Person: Diana Perdomo, Vice President for Institutional and Student Sustainability/CFO
View Audit 311103 Questioned Costs: $1
CORRECTIVE ACTION PLAN (CAP) Since the end of audit period 9/30/2023 the Richmond Redevelopment and Housing Authority (RRHA) has accomplished a series of activities to improve the quality and accuracy of tenant file information and has created Corrective Action Plans (CAP) for continuous improvement...
CORRECTIVE ACTION PLAN (CAP) Since the end of audit period 9/30/2023 the Richmond Redevelopment and Housing Authority (RRHA) has accomplished a series of activities to improve the quality and accuracy of tenant file information and has created Corrective Action Plans (CAP) for continuous improvement, as outlined below: FY 2023 Activity to date: RRHA requested a review of RRHA policies and procedures regarding rent collection and tenant file management from Nan McKay Consultants. Nan McKay issued a memorandum certifying compliance of the agency’s policies and procedures with all related HUD requirements. CAP: RRHA will update its Standard Operating Procedures regarding tenant file management to comply with Admission and Continued Occupancy and Administrative Plan revisions that were part of the agency’s Annual Plans. FY 2023 Activity to date: Staff attended a Nan McKay Consultants rent calculation training September 26-28, 2023. In addition, RRHA staff attended a six-week training course that included a two-week skills development. In addition, a Corporate Trainer position has been budgeted and will be filled early in the first quarter of FY2025. CAP: RRHA will ensure quarterly refresher training for current staff and comprehensive training for new staff. FY 2023 Activity to date: The RRHA created a Chief Compliance Officer Position that coordinates and reports on all RRHA compliance activities. CAP: The RRHA will develop a Standard Operating Procedure for that Compliance Office that will include more extensive quality control reviews and statistically significant Internal Audit reviews of tenant files. NAME OF RESPONSIBLE PERSON: Tonise Webb, Associate Lead Counsel and Chief Compliance Officer EXPECTED COMPLETION DATE FOR CORRECTIVE ACTION PLANS: September 30, 2024
Corrective Action Plan: Atrium Health CMHA management will address the gap in SFA transactional review and approval internal controls, arising due to the SFA program size and limited number of subject matter experts, by implementing mitigating controls and policies to ensure accuracy and completene...
Corrective Action Plan: Atrium Health CMHA management will address the gap in SFA transactional review and approval internal controls, arising due to the SFA program size and limited number of subject matter experts, by implementing mitigating controls and policies to ensure accuracy and completeness of transactions. Proposed Completion Date: Management will complete the corrective action plan by October 2024.
Corrective Action Plan: As part of the audit planning for 2024, Atrium Health CMHA management will ensure that the internal controls within the SFA IT Systems are documented and tested, or compensating controls implemented. Proposed Completion Date: In November of 2024, management would intend ...
Corrective Action Plan: As part of the audit planning for 2024, Atrium Health CMHA management will ensure that the internal controls within the SFA IT Systems are documented and tested, or compensating controls implemented. Proposed Completion Date: In November of 2024, management would intend to incorporate and complete this IT systems controls testing into the planning phase of the December 31, 2024 reporting period audit.
Finding Number: 2023-001 Condition: During testing, it was noted that although there was a process in place to review eligibility criteria received by both programs, there was not an independent review or control to ensure eligibility was accurate. Planned Corrective Action: WIC: After the initial r...
Finding Number: 2023-001 Condition: During testing, it was noted that although there was a process in place to review eligibility criteria received by both programs, there was not an independent review or control to ensure eligibility was accurate. Planned Corrective Action: WIC: After the initial review for eligibility, a second employee will verify that eligibility was properly determined and provide a signoff to document review. Food Distribution Cluster: After the initial review and input of participant applications into the system, a new procedure will be introduced prior to distribution. Each client will undergo two verifications. The first verification will involve an employee verifying the client's information both manually against eligibility guidelines and electronically with program software. If the information is found to meet eligibility, a document will be signed and provided to the participant. The second verification will involve the client giving the signed documents to a second employee, who will also provide confirmation of eligibility and approve distribution. Contact person responsible for corrective action: WIC: Lucy Rosenberg and Michelle Estell Food Distribution Cluster: Karen Moton Anticipated Completion Date: 06/30/2024
Park City's Response Rent Adjustment Letters Park City has implemented the requirement that all residents are to complete and sign their annual recertification forms within thirty days of receipt. This policy aims to streamline our administrative processes and ensure that all resident information re...
Park City's Response Rent Adjustment Letters Park City has implemented the requirement that all residents are to complete and sign their annual recertification forms within thirty days of receipt. This policy aims to streamline our administrative processes and ensure that all resident information remains up to date. Also, as PCC transitions to Rent Café for recertifications, we anticipate this will make the process easier for residents and staff. Income Verification Forms Park City requires all income verification forms and re-examination documents to be scanned and securely stored in Yardi, our new digital management system. Storing documents digitally helps us maintain compliance with regulatory requirements by ensuring that all records are accurately maintained and readily available for audits and inspections.
Park City's Response Park City has contracted with an outside firm to manage, staff and run the Housing Choice Voucher program. In the twenty instances where the utility allowance amount does not agree with HUD Form 50058, there are sixteen cases where the utility allowance does not agree with the...
Park City's Response Park City has contracted with an outside firm to manage, staff and run the Housing Choice Voucher program. In the twenty instances where the utility allowance amount does not agree with HUD Form 50058, there are sixteen cases where the utility allowance does not agree with the HUD Form 50058 reviewed and four cases where the incorrect utility allowance year was used in HUD Form 50058. In the sixteen cases where the utility allowance does not agree with HUD Form 50058 reviewed, it appears that the incorrect structure type was used in the calculation. The contractor has established structure type definitions and distributed them to staff. The contractor has conducted an internal training about how to determine structure type to ensure the accuracy of the utility allowance. In the four cases where the incorrect utility allowance year was used, these transactions were completed prior to the establishment of the 2023 utility allowances. The transactions should have been corrected after they were approved. The contractor will establish a listing of all applicable transactions completed with an effective date of November 1, 2024. Any transactions submitted prior to the approval date of the utility allowances will be reviewed and corrected.
Action Taken: The Senior Programs have undergone significant improvements in the last 6 months following an audit by the federal funder which resulted in a corrective action plan (CAP) and a repayment of $54,228. Plans were implemented during the spring of 2024 in response to the CAP which resulted...
Action Taken: The Senior Programs have undergone significant improvements in the last 6 months following an audit by the federal funder which resulted in a corrective action plan (CAP) and a repayment of $54,228. Plans were implemented during the spring of 2024 in response to the CAP which resulted in an overhaul of the processes in place to properly develop the volunteer checklists and assure all records for staff and volunteers are now compliant. Our Quality and Compliance and Finance team worked closely with the new Program Manager to assure that we will be fully compliant and remain so.
View Audit 310898 Questioned Costs: $1
Finding 2023-003 Ineligible fees for lawn service care and pest control charged and paid by resident of Authority Units The Authority immediately stopped the charge for the lawn care and pest control when the HUD Review was conducted. The amount of the reimbursement has only been recently determin...
Finding 2023-003 Ineligible fees for lawn service care and pest control charged and paid by resident of Authority Units The Authority immediately stopped the charge for the lawn care and pest control when the HUD Review was conducted. The amount of the reimbursement has only been recently determined. The Authority will begin the reimbursement process before September 30, 2024. Date of Completion: September 30, 2024
View Audit 310841 Questioned Costs: $1
Finding 2023-002 Internal Controls over Documentation in Tenant Files The auditors chose 40 files to review but have NOT and did NOT provide the listing of issues and missing documentation by tenant so the Authority could verify the auditors' issues. Until this information is provided to the Aut...
Finding 2023-002 Internal Controls over Documentation in Tenant Files The auditors chose 40 files to review but have NOT and did NOT provide the listing of issues and missing documentation by tenant so the Authority could verify the auditors' issues. Until this information is provided to the Authority a corrective action plan cannot be formulated. The Authority has already reviewed all 163 tenant files as a result of the HUD Review conducted by the Atlanta Field Office. The Field Office report was received by the Authority in late December 2023. Date of Completion: Awaiting information from auditors so any revision to the procedures currently in place can be updated.
View Audit 310841 Questioned Costs: $1
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