Corrective Action Plans

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A scope limitation qualified opinion was issued for Assistance Listing 10.557 as the auditors were unable to obtain sufficient documentation supporting the compliance of the Corporation regarding eligibility. The Corporation uses a paperless system as supported by the State of Indiana and the U.S. D...
A scope limitation qualified opinion was issued for Assistance Listing 10.557 as the auditors were unable to obtain sufficient documentation supporting the compliance of the Corporation regarding eligibility. The Corporation uses a paperless system as supported by the State of Indiana and the U.S. Department of Agriculture. Third-party documentation is reviewed by the Corporation at the time the initial eligibility determination of a WIC participant is made. However, due to the paperless system implemented in 2007, these records are not retained. The Corporation’s process for eligibility determination is as follows: 1. A (potential) participant comes into the WIC clinic 2. A clerk verifies information (by looking and checking the appropriate boxes on the screen) a. Proof of identification (driver’s license, birth certificate, hospital birth record, etc.) b. Proof of residence (bill, lease, driver’s license, etc.) c. Proof of income i. Working – 30 days of pay stubs ii. Medicaid – card needed 3. All of the above information is entered into the State of Indiana’s system a. System automatically determines eligibility i. If yes – they continue with appointment ii. If no – they get a letter explaining reason why (over income, etc.) Compliance with State of Indiana participant eligibility requirements is the responsibility of Leslie Miller, WIC Coordinator. As the Corporation follows the State of Indiana’s paperless system as described above, no further corrective action will be taken.
Recommendation: Our auditors recommended that we provide training to those making eligibility calculations and implementation in the new billing software. Action Taken: We are currently in the process of retraining staff on the sliding fee scale procedures and implementation in the new billing soft...
Recommendation: Our auditors recommended that we provide training to those making eligibility calculations and implementation in the new billing software. Action Taken: We are currently in the process of retraining staff on the sliding fee scale procedures and implementation in the new billing software. Name of Contact Person Responsible for Corrective Action: Kimberly Osborne, President/Chief Executive Officer, (607) 753-3797. Anticipated Completion Date: June 2024
Recommendation: We recommend procedures be strengthened to ensure that all requests for reimbursement are for expenditures that have been incurred and paid/disbursed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Name(s) of the contact person(s) res...
Recommendation: We recommend procedures be strengthened to ensure that all requests for reimbursement are for expenditures that have been incurred and paid/disbursed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Name(s) of the contact person(s) responsible for corrective action: Nick Robertson, Town Accountant Planned completion date for corrective action plan: The reconciliation meetings were reintroduced in December 2022 upon Nick Robertson’s hiring as Town Accountant. There have been monthly and/or as needed meetings since to reconcile ledgers before grant reimbursements are submitted. Action taken in response to finding: Prior to the turnover in the Finance Department which occurred during the FY22 to early FY23 period, there were consistent meetings between Finance/Accounting and Jacobs Engineering (they manage the Airport projects and prepare the reimbursement requests) to confirm that the Town’s accounting software matched the expenses on the reimbursement requests. These meetings reconciling the ledgers did not occur when this reimbursement request was submitted by Jacobs. These meetings have been reinstated on a monthly basis and occasionally more frequently as needed.
2023-002 Missing Eligibility Information - ALN# 14.181 Section 811 Supportive Housing for Persons with Disabilities – Year Ended June 30, 2023 Condition Found During the eligibility testing of the audit, the following deficiencies were identified – certain tenant files are not kept on file within...
2023-002 Missing Eligibility Information - ALN# 14.181 Section 811 Supportive Housing for Persons with Disabilities – Year Ended June 30, 2023 Condition Found During the eligibility testing of the audit, the following deficiencies were identified – certain tenant files are not kept on file within the required compliance timeframe. We consider this finding to be a material weakness with the Eligibility Compliance Requirement. Corrective Action Plan A new Finance Department position will be created that is responsible for working with residents and programmatic staff in order to ensure that tenant files are kept on file within the required compliance timeframe. Responsible Person for Corrective Action Plan Lore Baker, President & CEO Implementation Date of Corrective Action Plan September 2024
2023-002 Missing Eligibility Information - ALN# 14.181 Section 811 Supportive Housing for Persons with Disabilities – Year Ended June 30, 2023 Condition Found During the eligibility testing of the audit, the following deficiencies were identified – certain tenant files are not kept on file within...
2023-002 Missing Eligibility Information - ALN# 14.181 Section 811 Supportive Housing for Persons with Disabilities – Year Ended June 30, 2023 Condition Found During the eligibility testing of the audit, the following deficiencies were identified – certain tenant files are not kept on file within the required compliance timeframe. We consider this finding to be a material weakness with the Eligibility Compliance Requirement. Corrective Action Plan A new Finance Department position will be created that is responsible for working with residents and programmatic staff in order to ensure that tenant files are kept on file within the required compliance timeframe. Responsible Person for Corrective Action Plan Lore Baker, President & CEO Implementation Date of Corrective Action Plan September 2024
2023-002 Missing Eligibility Information - ALN# 14.181 Section 811 Supportive Housing for Persons with Disabilities – Year Ended June 30, 2023 Condition Found During the eligibility testing of the audit, the following deficiencies were identified – certain tenant files are not kept on file within...
2023-002 Missing Eligibility Information - ALN# 14.181 Section 811 Supportive Housing for Persons with Disabilities – Year Ended June 30, 2023 Condition Found During the eligibility testing of the audit, the following deficiencies were identified – certain tenant files are not kept on file within the required compliance timeframe. We consider this finding to be a material weakness with the Eligibility Compliance Requirement. Corrective Action Plan A new Finance Department position will be created that is responsible for working with residents and programmatic staff in order to ensure that tenant files are kept on file within the required compliance timeframe. Responsible Person for Corrective Action Plan Lore Baker, President & CEO Implementation Date of Corrective Action Plan September 2024
2023-002 Missing Eligibility Information - ALN# 14.181 Section 811 Supportive Housing for Persons with Disabilities – Year Ended June 30, 2023 Condition Found During the eligibility testing of the audit, the following deficiencies were identified – certain tenant files are not kept on file within...
2023-002 Missing Eligibility Information - ALN# 14.181 Section 811 Supportive Housing for Persons with Disabilities – Year Ended June 30, 2023 Condition Found During the eligibility testing of the audit, the following deficiencies were identified – certain tenant files are not kept on file within the required compliance timeframe. We consider this finding to be a material weakness with the Eligibility Compliance Requirement. Corrective Action Plan A new Finance Department position will be created that is responsible for working with residents and programmatic staff in order to ensure that tenant files are kept on file within the required compliance timeframe. Responsible Person for Corrective Action Plan Lore Baker, President & CEO Implementation Date of Corrective Action Plan September 2024
Oversight Agency for Audit, Retired Steelworkers Housing and Health Development Corporation respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Sui...
Oversight Agency for Audit, Retired Steelworkers Housing and Health Development Corporation respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067 Audit period: January 1, 2023 through December 31, 2023 The findings from the December 31, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. SECTION III – FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING No. 2023-001: Section 236 Mortgage Restructuring Note, ALN 14.103 Recommendation: The Project should implement procedures to ensure the Project verifies tenant eligibility through the EIV system in a timely manner. Action Taken: Staff training has been provided and included in monthly reporting procedures.
Finding 2023-002 – Budget to Actual Analysis Cluster: Research and Development Agency: Department of Commerce, Department of Energy, and Department of Health and Human Services Award Names: Standards/Guidance for Rapid Qualification of Metal-Based Additive Manufacturing, Accelerating Commercial Mari...
Finding 2023-002 – Budget to Actual Analysis Cluster: Research and Development Agency: Department of Commerce, Department of Energy, and Department of Health and Human Services Award Names: Standards/Guidance for Rapid Qualification of Metal-Based Additive Manufacturing, Accelerating Commercial Maritime Demonstration Projects for Advanced Nuclear Reactor Technologies, Safety and Health Risks in Energy Transition for the Commercial Fishing Industry Award Numbers: 70NANB21H038, DE-NE0009226, and U01OH012502 Assistance Listing Title: National Institute of Standards and Technology, Office of Nuclear Energy, Advanced Research Projects Agency, Office of Energy Efficiency and Renewable Energy, Center for Disease Control and Prevention (CDC) Assistance Listing Number: 11.609, 81.121, 81.135, 81.087, 93.262 Award Year: FY 2023 In response to FY 2022 Single Audit, ABS updated its internal policy to establish and maintain effective controls over budget to actual expense reviews. Current ABS policy, which was implemented in 2024, requires grant project managers to review budget to actuals on at least a quarterly basis, and a budget spreadsheet will be maintained and signed as proof of verification. To ensure consistency and formality in carrying out this requirement, ABS has begun utilizing a standardized template to facilitate reviews and track completion by process owners.
Finding 484529 (2023-058)
Significant Deficiency 2023
ALN: 93.558, Corrective Action Plan: Potential Risk of Inaccurate ACF 199 Reports - TANF - DPHHS - The Montana Department of Public Health and Human Services developed procedures in February 2023 for the Temporary Assistance for Needy Families program and is currently working to create a tool to b...
ALN: 93.558, Corrective Action Plan: Potential Risk of Inaccurate ACF 199 Reports - TANF - DPHHS - The Montana Department of Public Health and Human Services developed procedures in February 2023 for the Temporary Assistance for Needy Families program and is currently working to create a tool to better document the review and approval of the report. However, a comprehensive review of the data prior to submission is not possible, due to the type of data being submitted. The data is submitted in code (i.e., strings of numbers) to be read by the Administration for Children and Families (ACF) system. A review will be done to the extent possible to ensure expectations are met about file sizes and numbers of rows. Review results will be documented in a review checklist, which will include a notation of the file review and signature. Person(s) Responsible for Corrective Measures: Chappell Smith, Administrator, Montana Department of Public Health and Human Services, Target Date: 11/30/2024
ALN: 21.023, Corrective Action Plan: Inadequate Eligibility Documentation - ERA - DOC - The Montana Department of Commerce has modified the program's payment platform to ensure compliance with federal requirements. Person(s) Responsible for Corrective Measures: Ingrid Mallo, Chief Financial Off...
ALN: 21.023, Corrective Action Plan: Inadequate Eligibility Documentation - ERA - DOC - The Montana Department of Commerce has modified the program's payment platform to ensure compliance with federal requirements. Person(s) Responsible for Corrective Measures: Ingrid Mallo, Chief Financial Officer, Montana Department of Commerce, Target Date: Completed
View Audit 317490 Questioned Costs: $1
ALN: 84.371, Corrective Action Plan: Noncompliant Eligibility Determinations - Literacy - OPI - The Montana Office of Public Instruction does not concur with finding 2023-041. The Office notes that the United States Department of Education approved the application eligibility requirements. Perso...
ALN: 84.371, Corrective Action Plan: Noncompliant Eligibility Determinations - Literacy - OPI - The Montana Office of Public Instruction does not concur with finding 2023-041. The Office notes that the United States Department of Education approved the application eligibility requirements. Person(s) Responsible for Corrective Measures: April Grady, Chief Financial Officer, Montana Office of Public Instruction, Target Date: N/A
View Audit 317490 Questioned Costs: $1
ALN: 93.767, Corrective Action Plan: Inadequate Provider Eligibility Controls - CHIP - DPHHS - The Montana Department of Public Health and Human Services processes Service Organizational Control (SOC) reports at the agency level. But the Children's Health Insurance Program (CHIP) will work with it...
ALN: 93.767, Corrective Action Plan: Inadequate Provider Eligibility Controls - CHIP - DPHHS - The Montana Department of Public Health and Human Services processes Service Organizational Control (SOC) reports at the agency level. But the Children's Health Insurance Program (CHIP) will work with its contractor to ensure it is clearly identified in future SOC reports to ensure receipt of assurances about provider screening and enrollment. Person(s) Responsible for Corrective Measures: Shellie McCann, Medicaid Systems Administrator, Montana Department of Public Health and Human Services, Target Date: 03/31/2025
View Audit 317490 Questioned Costs: $1
ALN: 93.775, 93.777, 93.778, Corrective Action Plan: Inadequate Medicaid ADP System Reviews - DPHHS - The Montana Department of Public Health and Human Services acknowledges that staff turnover contributed to the department's non-compliance. The department will reinstitute applicable controls. P...
ALN: 93.775, 93.777, 93.778, Corrective Action Plan: Inadequate Medicaid ADP System Reviews - DPHHS - The Montana Department of Public Health and Human Services acknowledges that staff turnover contributed to the department's non-compliance. The department will reinstitute applicable controls. Person(s) Responsible for Corrective Measures: Shellie McCann, Medicaid Systems Administrator, Montana Department of Public Health and Human Services, Target Date: 09/30/2024
ALN: 14.195, 14.856, 14.871, 14.879, Corrective Action Plan: Inadequate Baseline Security Controls - Housing Assistance Payment System - DOC - The Montana Department of Commerce has updated password requirements to comply with statewide policies. The passwords are now sent through encrypted emails...
ALN: 14.195, 14.856, 14.871, 14.879, Corrective Action Plan: Inadequate Baseline Security Controls - Housing Assistance Payment System - DOC - The Montana Department of Commerce has updated password requirements to comply with statewide policies. The passwords are now sent through encrypted emails and users are required to change their passwords upon initial login. The department has also developed a process to conduct and document access reviews. Additionally, the department has developed a change control policy to address roles, responsibilities, and configuration management processes as well as procedures to adequately document the department’s understanding of change impact to the system. The department has provided training and support to the backup user access manager. Person(s) Responsible for Corrective Measures: Ingrid Mallo, Chief Financial Officer, Montana Department of Commerce, Target Date: 06/24/2024
ALN: 93.575, 93.596, Corrective Action Plan: Inadequate Documentation of Recipient Eligibility - CCDF - DPHHS - The Montana Department of Public Health and Human Services, Child Care and Development Fund programs are continuing to review questioned costs per the guidance received from Office of Ch...
ALN: 93.575, 93.596, Corrective Action Plan: Inadequate Documentation of Recipient Eligibility - CCDF - DPHHS - The Montana Department of Public Health and Human Services, Child Care and Development Fund programs are continuing to review questioned costs per the guidance received from Office of Child Care (OCC). The department documents the extent to which families receiving the 2021 Coronavirus Response and Relief Supplemental Appropriations Act (CRRSA) funded subsidies were eligible, including income-eligible or essential workers. The department additionally documents the extent to which providers who served families met applicable health and safety requirements. Program staff will enhance controls and training and will work with federal partners to ensure funding is in alignment with applicable terms and conditions. Person(s) Responsible for Corrective Measures: Tracy Moseman, Administrator, Montana Department of Public Health and Human Services, Target Date: 12/31/2024
View Audit 317490 Questioned Costs: $1
ALN: 93.575, 93.596, Corrective Action Plan: Inadequate Subrecipient Monitoring - CCDF - DPHHS - The Montana Department of Public Health and Human Services, Child Care and Development Fund programs will develop monitoring procedures to coordinate state plan requirements with contract requirements ...
ALN: 93.575, 93.596, Corrective Action Plan: Inadequate Subrecipient Monitoring - CCDF - DPHHS - The Montana Department of Public Health and Human Services, Child Care and Development Fund programs will develop monitoring procedures to coordinate state plan requirements with contract requirements and make amendments to contracts when State Plan changes. Person(s) Responsible for Corrective Measures: Tracy Moseman, Administrator, Montana Department of Public Health and Human Services, Target Date: 12/31/2024
Oversight Agency for Audit, NCSC/USA Housing Development Corporation Three, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral...
Oversight Agency for Audit, NCSC/USA Housing Development Corporation Three, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067. Audit period: January 1, 2023 through December 31, 2023 The findings from the December 31, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers in the schedule. SECTION III - FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING No. 2023-001: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should implement procedures to ensure that required documentation is obtained prior to acceptance and maintained in the tenant files. Action Taken: Further staff training has been completed and processes put in place to prevent moving forward.
Finding: 2024-01 Federal Agency Name: Department of Education Assistance Listing Number: 84.063 Program Name: Student Financial Aid Cluster - Pell Finding Summary: During testing of students that were disbursed Pell Grants, three students out of a total of 40 that were tested did not receive th...
Finding: 2024-01 Federal Agency Name: Department of Education Assistance Listing Number: 84.063 Program Name: Student Financial Aid Cluster - Pell Finding Summary: During testing of students that were disbursed Pell Grants, three students out of a total of 40 that were tested did not receive the appropriate amount of Pell Grant. Corrective Action: The Pell amounts were reviewed when the error was found during the audit. Students with incorrect amounts were then awarded additional funding based on Title IV guideline. Going forward the following steps will be taken to ensure the error does not occur in the future: • Financial aid staff will review the Financial Aid awarding system prior to awarding and make sure the correct fields have been updated to show the correct Pell cost of attendance. • A second review will be conducted again at census prior to disbursing funds • A final review will be conducted at the end of the semester.Responsible Individual: Crystal Morris, Director, Financial Aid Anticipated Completion Date: March 2024
The County concurs with this finding and will be working to improve the timeliness of Medicaid eligibility determinations by using the COGNOS reports to determine which cases are approaching the due date.
The County concurs with this finding and will be working to improve the timeliness of Medicaid eligibility determinations by using the COGNOS reports to determine which cases are approaching the due date.
The County concurs with this finding and will be working to enhance documentation of the review of the Adoption Assistance eligibility determinations.
The County concurs with this finding and will be working to enhance documentation of the review of the Adoption Assistance eligibility determinations.
The County concurs with this finding and will be working to enhance documentation of the review of the IV-E eligibility determinations.
The County concurs with this finding and will be working to enhance documentation of the review of the IV-E eligibility determinations.
Housing Voucher Cluster – Assistance Listing Nos. 14.871/14.879 Recommendation: We recommend the Authority implements controls to ensure that documentation is maintained for new tenants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken ...
Housing Voucher Cluster – Assistance Listing Nos. 14.871/14.879 Recommendation: We recommend the Authority implements controls to ensure that documentation is maintained for new tenants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken or planned in response to finding: The HCVP is implementing a monthly quality control protocol to review new applicant files for completeness. A new Program Director was assigned to oversee this quality control process. The Program Director will also monitor the new tenant checklist which will be created to ensure that all new tenant documentation is accurately maintained. The OAC shall monitor and collaborate with the HCVP to ensure that the checklist is accurate and available for auditing. Name of the contact person responsible for corrective action: Starr Lane. Planned completion date for corrective action plan: 7/31/24.
Housing Voucher Cluster – Assistance Listing Nos. 14.871/14.879 Recommendation: We recommend that DCHA staff review the controls in place to ensure that required eligibility determination documentation is complete, accurate, and available for audit. Explanation of disagreement with audit finding: ...
Housing Voucher Cluster – Assistance Listing Nos. 14.871/14.879 Recommendation: We recommend that DCHA staff review the controls in place to ensure that required eligibility determination documentation is complete, accurate, and available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken or planned in response to finding: The HCVP has a program eligibility team that processes applications. Once completed, the file will be reviewed monthly by an HCVP quality control staff and quarterly by the OAC to ensure that documentation is complete, accurate, and available for audit. Name of the contact person responsible for corrective action: Khaliah Payne. Planned completion date for corrective action plan: 9/30/24
Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend that DCHA staff review the controls in place to ensure that required eligibility determination documentation is complete, accurate, and available for audit. Explanation of disagreement with audit find...
Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend that DCHA staff review the controls in place to ensure that required eligibility determination documentation is complete, accurate, and available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken or planned in response to finding: The HCVP has a program eligibility team that processes applications, and once complete, the file is reviewed by a quality control and compliance officer for compliance. The Office of Audit and Compliance (OAC) shall periodically monitor this process to ensure that eligibility determination documentation is complete, accurate, and available for audit. Name of the contact person responsible for corrective action: Khaliah Payne. Planned completion date for corrective action plan: 9/30/24
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