Corrective Action Plans

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2023-001: Section 811, Assistance Listing No. 14.181 Three tenant files were selected for testing and the required documentation to determine eligibility, as required by the HUD regulations, could not be located as follows: • Two of the files were missing Form HUD-50059, Owner’s Certification of Com...
2023-001: Section 811, Assistance Listing No. 14.181 Three tenant files were selected for testing and the required documentation to determine eligibility, as required by the HUD regulations, could not be located as follows: • Two of the files were missing Form HUD-50059, Owner’s Certification of Compliance. Recommendation: We recommend the Corporation establish procedures to ensure that the annual recertifications are completed on a timely basis in accordance with HUD requirements. Action Taken: Management agrees with the recommendation and the Corporation’s Board of Directors has made the decision to change property managing agents effective January 1, 2024. It is anticipated that the change to a new property managing agent will allow the Corporation to establish procedures to ensure all recertifications are performed and maintained in accordance with the regulatory agreement. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Dr. Seanelle Hawkins at (585) 325-6530.
2023-001: Section 202, Assistance Listing No. 14.157 One tenant file was selected for testing and the required documentation to determine eligibility, as required by HUD regulations, could not be located as follows: • The file was missing Form HUD-50059, Owner’s Certification of Compliance. Recommen...
2023-001: Section 202, Assistance Listing No. 14.157 One tenant file was selected for testing and the required documentation to determine eligibility, as required by HUD regulations, could not be located as follows: • The file was missing Form HUD-50059, Owner’s Certification of Compliance. Recommendation: We recommend the Corporation establish procedures to ensure that the annual recertifications are completed on a timely basis in accordance with HUD requirements. Action Taken: Management agrees with the condition and the Corporation’s Board of Directors has made the decision to change property managing agents effective January 1, 2024. It is anticipated that the change to a new property managing agent will allow the Corporation to establish procedures to ensure all recertifications are performed and maintained in accordance with the regulatory agreement. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Seanelle Hawkins at 585-325-6530.
2023-001: Section 811, Assistance Listing No. 14.181 One tenant file was selected for testing. However, this tenant file could not be located. As a result, the following documentation could not be located to determine eligibility, as required by HUD regulations: • Form HUD-50059, Owner’s Certificati...
2023-001: Section 811, Assistance Listing No. 14.181 One tenant file was selected for testing. However, this tenant file could not be located. As a result, the following documentation could not be located to determine eligibility, as required by HUD regulations: • Form HUD-50059, Owner’s Certification of Compliance • A completed and signed application • The signed lease agreement • The move-in and move-out inspection forms Recommendation: We recommend the Corporation establish procedures for maintaining tenant files to comply with HUD requirements for verification of tenant information, as required. Action Taken: Management agrees with the recommendation and the Corporation’s Board of Directors has made the decision to change property managing agents effective January 1, 2024. It is anticipated that the change to a new property managing agent will allow the Corporation to establish procedures to ensure all tenant files are properly maintained to comply with HUD regulations. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Seanelle Hawkins at 585-325-6530.
2023-001: Section 202, Assistance Listing No. 14.157 Two tenant files were selected for testing and the required documentation to determine eligibility, as required by the HUD Regulatory Agreement, could not be located as follows: • One file was missing Form HUD-50059, Owner’s Certification of Compl...
2023-001: Section 202, Assistance Listing No. 14.157 Two tenant files were selected for testing and the required documentation to determine eligibility, as required by the HUD Regulatory Agreement, could not be located as follows: • One file was missing Form HUD-50059, Owner’s Certification of Compliance Recommendation: We recommend the Corporation establish procedures to ensure that the annual recertifications are performed on a timely basis in accordance with HUD requirements. Action Taken: Management agrees with the recommendation and the Corporation’s Board of Directors has made the decision to change property managing agents effective January 1, 2024. It is anticipated that the change to a new property managing agent will allow the Corporation to establish procedures to ensure all recertifications are performed and maintained in accordance with the regulatory agreement. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Seanelle Hawkins at 585-325-6530.
2023-001: Section 202, Assistance Listing No. 14.157 Two tenant files were selected for testing and the required documentation to determine eligibility, as required by the HUD Regulatory Agreement, could not be located as follows: • One file was missing Form HUD-50059, Owner’s Certification of Compl...
2023-001: Section 202, Assistance Listing No. 14.157 Two tenant files were selected for testing and the required documentation to determine eligibility, as required by the HUD Regulatory Agreement, could not be located as follows: • One file was missing Form HUD-50059, Owner’s Certification of Compliance Recommendation: We recommend the Corporation establish procedures for maintaining tenant files to comply with HUD requirements for verification of tenant information, as required. Action Taken: Management agrees with the recommendation and the Corporation’s Board of Directors has made the decision to change property managing agents effective January 1, 2024. It is anticipated that the change to a new property managing agent will allow the Corporation to establish procedures to ensure all recertifications are performed and maintained in accordance with the regulatory agreement. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Seanelle Hawkins at 585-325-6530.
Corrective Action Plan (CAP) The Ozark Housing Authority (Housing Authority) To the Department of Housing and Urban Development, During the Fiscal Year 2023 audit, the Housing Authority could not locate two tenant files along with one HUD 50058 Reexamination form, two HUD 9886 Authorization forms ...
Corrective Action Plan (CAP) The Ozark Housing Authority (Housing Authority) To the Department of Housing and Urban Development, During the Fiscal Year 2023 audit, the Housing Authority could not locate two tenant files along with one HUD 50058 Reexamination form, two HUD 9886 Authorization forms and three third party verification documents. The Housing Authority’s Executive Director, Dannie Walker, is responsible for implementing the corrective action plan. CAP developed to resolve audit finding: Finding 2023-001 – Tenant Eligibility and Reexaminations We were aware of the tenant file deficiencies before audit fieldwork began and had begun implementing the recommendation of strengthening internal controls over eligibility requirements in addition to having made personnel changes to the eligibility department. The deficiency that led to this finding will be corrected by March 31, 2024.
#2023-004 Material Weakness related internal controls and compliance with Special Tests and Provisions – Verifications: The District did not perform verification of free/reduced meal applications until March 2023. Recommendation: Auditor recommends the District maintain close communication wit...
#2023-004 Material Weakness related internal controls and compliance with Special Tests and Provisions – Verifications: The District did not perform verification of free/reduced meal applications until March 2023. Recommendation: Auditor recommends the District maintain close communication with the Department of Education, particularly during any period when there is a change in manner in which the food service program operates. Action Taken: The Bandon School District will maintain close communication with the Department of Education, particularly during any period when there is a change in the manner in which the food service program operates. The Director of Food Services will also reach out to the verification team to make sure verifications are done promptly. They will also check regularly for incoming applications that also must be verified promptly. Effective May 2023.
#2023-002 Material Weakness related to eligibility for free and reduced price meals: During a transitional year where all meals were being provided free to all students under various funding sources, the District did not actively solicit applications from households and did not process those appli...
#2023-002 Material Weakness related to eligibility for free and reduced price meals: During a transitional year where all meals were being provided free to all students under various funding sources, the District did not actively solicit applications from households and did not process those applications that were received until nearly six months later. Recommendation: Auditor recommends the District maintain close communication with the Department of Education, particularly during any period when there is a change in manner in which the food service program operates. Action Taken: The Bandon School District will maintain in close communication with the Department of Education, particularly during any period when there is a change in the manner in which the food service program operates. Director of Food Services will also regularly reach out to ODE’s assigned Nutrition Specialist to verify the certification of students’ classification on free, reduced and paid students is correct. Effective May of 2023.
Finding 3543 (2023-001)
Significant Deficiency 2023
Corrective Action Plan: While the student was not initially identified, the record was corrected within the appropriate term and the student received the full proceeds of their aid eligibility. The Office of Financial Aid will be notified of grade changes on a weekly basis, if applicable, by the O...
Corrective Action Plan: While the student was not initially identified, the record was corrected within the appropriate term and the student received the full proceeds of their aid eligibility. The Office of Financial Aid will be notified of grade changes on a weekly basis, if applicable, by the Office of the Registrar who is responsible for documenting and recording corrections to grading. The Office of Financial Aid will recalculate, if appropriate, the student Satisfactory Academic Progress status and make any necessary awarding and disbursement updates to the student’s record. Implementation: The responsible parties include the Office of Financial Aid and the Office of the Registrar with initial submissions within the month of November 2023 and continuing forward until such further efficiencies have been identified.
View Audit 5557 Questioned Costs: $1
After discussion with the auditor, senior management understands the importance of having a properly functioning monitoring system in place to ensure that controls that are properly designed are in fact placed in operation and functioning as intended. The compliance manager responsible for implement...
After discussion with the auditor, senior management understands the importance of having a properly functioning monitoring system in place to ensure that controls that are properly designed are in fact placed in operation and functioning as intended. The compliance manager responsible for implementing the controls over compliance has been terminated, and senior management will institute monitoring procedures to ensure that controls over compliance are both properly designed and functioning as intended.
Management agrees with the recommendation of the auditor, and will ensure that evidence of certification review and approval is documented with a approval stamp or some other documentary evidence.
Management agrees with the recommendation of the auditor, and will ensure that evidence of certification review and approval is documented with a approval stamp or some other documentary evidence.
Finding 3159 (2023-004)
Significant Deficiency 2023
Lisa Chaney, Nicole Victory and Debbie McGuire Management will provide refresher training to staff on what process to follow in regards to making Child Support IV-D referrals. Management will review and revise current procedures in place to ensure that all required referrals are completed, accurate,...
Lisa Chaney, Nicole Victory and Debbie McGuire Management will provide refresher training to staff on what process to follow in regards to making Child Support IV-D referrals. Management will review and revise current procedures in place to ensure that all required referrals are completed, accurate, sent timely and reflected in the case file within the NC Fast Case Management System Training will be completed by November 17th, 2023
Finding 3158 (2023-003)
Significant Deficiency 2023
Lisa Chaney, Mandy Edwards, Nicole Victory and Debbie McGuire Management will review cases internally to ensure proper documentation is in place for eligibility. Staff will be provided with refresher training on what information should be included in case files and the importance of this being compl...
Lisa Chaney, Mandy Edwards, Nicole Victory and Debbie McGuire Management will review cases internally to ensure proper documentation is in place for eligibility. Staff will be provided with refresher training on what information should be included in case files and the importance of this being complete and accurate. Management will review and revise current procedures in place to ensure that all eligibility determination criteria is completed such as online verifications, documented sources of income/resources and amounts are accurately reflected and retained in the case file within the NC FAST Case Management System. Training will be completed by November 17th, 2023
Finding 3157 (2023-002)
Significant Deficiency 2023
Lisa Chaney, Mandy Edwards, Nicole Victory and Debbie McGuire Management will review cases internally to ensure proper documentation is in place for eligibility. Staff will be provided with refresher training on what information should be included in case files and the importance of this being compl...
Lisa Chaney, Mandy Edwards, Nicole Victory and Debbie McGuire Management will review cases internally to ensure proper documentation is in place for eligibility. Staff will be provided with refresher training on what information should be included in case files and the importance of this being complete and accurate. Management will review and revise current procedures in place to ensure that all eligibility determination criteria is completed such as online verifications, documented resources and amounts are accurately reflected and retained in the case file within the NC FAST Case Management System. Training will be completed by November 17th, 2023
Finding 3156 (2023-001)
Significant Deficiency 2023
Lisa Chaney, Mandy Edwards, Nicole Victory and Debbie McGuire Management will review cases internally to ensure proper documentation is in place for eligibility. Staff will be provided with refresher training on what information should be included in case files and the importance of this being compl...
Lisa Chaney, Mandy Edwards, Nicole Victory and Debbie McGuire Management will review cases internally to ensure proper documentation is in place for eligibility. Staff will be provided with refresher training on what information should be included in case files and the importance of this being complete and accurate. Management will review and revise current procedures in place to ensure that all eligibility determination criteria is completed such as online verifications, documented sources of income/resources and amounts are accurately reflected and retained in the case file within the NC FAST Case Management System. Training will be completed by November 17th, 2023
Finding 3155 (2023-005)
Significant Deficiency 2023
Finding: 2023-005 Name of contact person: Corrective Action: Proposed Completion Date: YCHSA has revamped onboarding of new Medicaid staff to include individual staffing's with employee and their supervisor at least three times each week for a minimum of four months. These staffing's would include d...
Finding: 2023-005 Name of contact person: Corrective Action: Proposed Completion Date: YCHSA has revamped onboarding of new Medicaid staff to include individual staffing's with employee and their supervisor at least three times each week for a minimum of four months. These staffing's would include direct education on when Child Support referrals are necessary and how to document. YCHSA is in the process of hiring an Eligibility Trainer to assist with onboarding of new staff, provide refresher trainings for established staff and conduct second party reviews. When issues are noted by the Trainer, they will notify the respective supervisor and provide follow-up training as needed (either in an individual or group setting). Knowledge checks will be administered following group training to determine if knowledge has increased. If not, supervisors will follow up with individual training on appropriate Child Support referrals. YCHSA will continue to utilize policy portal for needed clarification on policy interpretation. YCHSA will send training requests to the Operational Support Team at least quarterly. The onboarding process for YCHSA is an ongoing process. A training will be provided on the Single County Audit findings before 11/30/23. YCHSA will begin the hiring process for the Eligibility Trainer during the week of 10/30/23.
Finding 3154 (2023-004)
Significant Deficiency 2023
Finding: 2023-004 Name of contact person: Corrective Action: Proposed Completion Date: Jessica Wall, Director YCHSA has revamped onboarding of new Medicaid staff to include individual staffing's with employee and their supervisor at least three times each week for a minimum of four months. These sta...
Finding: 2023-004 Name of contact person: Corrective Action: Proposed Completion Date: Jessica Wall, Director YCHSA has revamped onboarding of new Medicaid staff to include individual staffing's with employee and their supervisor at least three times each week for a minimum of four months. These staffing's would include direct education on what information should be used to accurately determine eligibility and how to document said information. YCHSA is in the process of hiring an Eligibility Trainer to assist with onboarding of new staff, provide refresher trainings for established staff and conduct second party reviews. When issues are noted by the Trainer, they will notify the respective supervisor and provide follow-up training as needed (either in an individual or group setting). Knowledge checks will be administered following group training to determine if knowledge has increased. If not, supervisors will follow up with individual training on appropriate requests for information. YCHSA will continue to utilize policy portal for needed clarification on policy interpretation. YCHSA will send training requests to the Operational Support Team at least quarterly. The onboarding process for YCHSA is an ongoing process. A training will be provided on the Single County Audit findings before 11/30/23. YCHSA will begin the hiring process for the Eligibility Trainer during the week of 10/30/23.
Finding 3153 (2023-003)
Significant Deficiency 2023
Finding: 2023-003 Name of contact person: Corrective Action: Proposed Completion Date: Jessica Wall, Director YCHSA has revamped onboarding of new Medicaid staff to include individual staffing's with employee and their supervisor at least three times each week for a minimum of four months. These sta...
Finding: 2023-003 Name of contact person: Corrective Action: Proposed Completion Date: Jessica Wall, Director YCHSA has revamped onboarding of new Medicaid staff to include individual staffing's with employee and their supervisor at least three times each week for a minimum of four months. These staffing's would include direct education on what resources are used to accurately determine eligibility and how to document said resources. YCHSA is in the process of hiring an Eligibility Trainer to assist with onboarding of new staff, provide refresher trainings for established staff and conduct second party reviews. When issues are noted by the Trainer, they will notify the respective supervisor and provide follow-up training as needed (either in an individual or group setting). Knowledge checks will be administered following group training to determine if knowledge has increased. If not, supervisors will follow up with individual training on inaccurate resource entry. YCHSA will continue to utilize policy portal for needed clarification on policy interpretation. YCHSA will send training requests to the Operational Support Team at least quarterly. The onboarding process for YCHSA is an ongoing process. A training will be provided on the Single County Audit findings before 11/30/23. YCHSA will begin the hiring process for the Eligibility Trainer during the week of 10/30/23.
Finding 3152 (2023-002)
Significant Deficiency 2023
Finding: 2023-002 Name of contact person: Corrective Action: Proposed Completion Date: Jessica Wall, Director The Yadkin County Human Services Agency (YCHSA) has revamped onboarding of new Medicaid staff to include individual staffing's with employee and their supervisor at least three times each we...
Finding: 2023-002 Name of contact person: Corrective Action: Proposed Completion Date: Jessica Wall, Director The Yadkin County Human Services Agency (YCHSA) has revamped onboarding of new Medicaid staff to include individual staffing's with employee and their supervisor at least three times each week for a minimum of four months. These staffing's would include direct education on what information is used to accurately determine eligibility and how to document said actions. YCHSA is in the process of hiring an Eligibility Trainer to assist with onboarding of new staff, provide refresher trainings for established staff and conduct second party reviews. When issues are noted by the Trainer, they will notify the respective supervisor and provide follow-up training as needed (either in an individual or group setting). Knowledge checks will be administered following group training to determine if knowledge has increased. If not, supervisors will follow up with individual training on inaccurate information entry. YCHSA will continue to utilize policy portal for needed clarification on policy interpretation. YCHSA will send training requests to the Operational Support Team at least quarterly. The onboarding process for YCHSA is an ongoing process. A training will be provided on the Single County Audit findings before 11/30/23. YCHSA will begin the hiring process for the Eligibility Trainer during the week of 10/30/23.
Item 2023-001: Compliance with Client Placement on the Sliding Fee Scale for the Health Center Cluster Program Corrective Active Plan: Implementation of Phreesia software will flag any placement discrepancies. Front Desk Staff has completed and signed off of an intensive two-week training. All front...
Item 2023-001: Compliance with Client Placement on the Sliding Fee Scale for the Health Center Cluster Program Corrective Active Plan: Implementation of Phreesia software will flag any placement discrepancies. Front Desk Staff has completed and signed off of an intensive two-week training. All front desk has been properly trained and will have ongoing and refresher training as needed. Front Desk Staff are required to check their work at the end of the day. We have a dedicated staff member who double checks each SFS registration. The corrected registration packet is returned to the corresponding Office Manager who reviews the corrections with the Front Desk staff member. The Front Desk staff member will make the noted corrections themselves. Front Desk will experience disciplinary action for continued incorrect placements such as write ups, or termination. We conduct an Eligibility Audit on a monthly basis. A report consisting of errors by facility as well as the employee responsible for the errors will be given to office managers and key administrative staff. The information collected is reported during our monthly CPI Committee meetings. Estimated Completion Date: Ongoing Responsible Party Contact Information: Jolene Busby Jbusby@hcmtx.org 936-591-8380 Ext 109
Finding 2023-002: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Emergency Housing Vouchers Assistance Listing Number: 14.EHV Noncompliance – E. Eligibility - Tenant Files Non Compliance Material to the Financial Statements: No Significant deficiency in Int...
Finding 2023-002: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Emergency Housing Vouchers Assistance Listing Number: 14.EHV Noncompliance – E. Eligibility - Tenant Files Non Compliance Material to the Financial Statements: No Significant deficiency in Internal Control over Compliance for Eligibility Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). Condition: Based upon inspection of the Authority’s files and on discussions with management there were documents that were unavailable for examination at the time of audit. Context: Of a sample size of six (6) tenant files, the following information was unavailable for examination at the time of audit: • Annual 50058 form • Annual inspection form Our sample size is statistically valid. Known Questioned Costs: $1,775 Cause: There is a significant deficiency in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority has not properly considered and designed a system of internal controls that reasonably assures the program is in compliance. Effect: The Emergency Housing Vouchers Program is in non-compliance with the eligibility type of compliance related to the maintenance of tenant files. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. Authority Response: We agree with the Auditor’s observations on the inspection of the tenant files and will implement internal control procedures that will assure tenant file compliance. Views of responsible officials and planned corrective action: The PHA has taken into consideration the Auditor’s recommendation in regards to Emergency Housing Vouchers (EHV) program. During the audit period, the staff assigned to the EHV program changed three times, resulting in program deficiencies. Currently a more skilled tenant interviewer is responsible for voucher processing, therefore program compliance will be in line with HUD requirement.
View Audit 5108 Questioned Costs: $1
Management will begin staff training with regular check ins, software upgrade for calculating income and qualifying patients within the practice management system and revising billing team procedures.
Management will begin staff training with regular check ins, software upgrade for calculating income and qualifying patients within the practice management system and revising billing team procedures.
Title: Student Financial Assistance Cluster – Assistance Listing Nos. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the University review its SAP review policies to ensure it is completed timely and before Title IV disbursements occur. Explanation of disagreement with audit finding: Th...
Title: Student Financial Assistance Cluster – Assistance Listing Nos. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the University review its SAP review policies to ensure it is completed timely and before Title IV disbursements occur. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Prior to this finding, in November 2022 our Registrar implemented a change in process to require a form when assigning either an L and I grade to a student. This ensures that the correct grade type is used in all cases depending on the nature of the work still outstanding. In doing so, it allows more accurate and timely assess a student’s GPA for SAP status on a regular schedule within the timeline expected for each type of grade when a final grade is determined. The Financial Aid office had also implemented an additional tracking mechanism outside of our ERP system to monitor the SAP status of each student to augment deficiencies in our ERP related to tracking the correct status over time. This tracking occurs regardless of the timing of a FAFSA being completed or the consistency of student enrollment from one semester to the next. This allows us to know the eligibility status of a student prior to awarding and disbursement, and require an appeal when appropriate. This was implemented May 2023. Regardless, as per policy and as we’ve been doing, we will continue to evaluate grade changes at the time of the next regular SAP evaluation period, and enforce the policy based on their status from that point forward. Name(s) of the contact person(s) responsible for corrective action: Dwight R Berreth Planned completion date for corrective action plan: August 2023
For the Special Aid and Food Service Funds, the System for Award Management will be checked in the fall and spring for the debarment of any vendors that we expect to pay over $25,000 for the fiscal year. Summary spreadsheets will be provided to the Auditors.
For the Special Aid and Food Service Funds, the System for Award Management will be checked in the fall and spring for the debarment of any vendors that we expect to pay over $25,000 for the fiscal year. Summary spreadsheets will be provided to the Auditors.
Action taken: The district entered into a shared services agreement with Capital Region BOCES in March of 2022 for management of the School Nutrition program. It was assumed that this was a procedure they followed; however, documentation was not provided and the external auditors inciuded it as a f...
Action taken: The district entered into a shared services agreement with Capital Region BOCES in March of 2022 for management of the School Nutrition program. It was assumed that this was a procedure they followed; however, documentation was not provided and the external auditors inciuded it as a finding. The School Nutrition Director resigned and was replaced by a new School Nutrition Director with BOCES (Greg Nalewjka) and he was unaware that this was necessary. He is working with his supervisors to provide documentation to the district that due diligence has been done to meet this requirement. Anticipated completion date: 11/10/2023
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