Corrective Action Plans

Finding 1157795 (2022-035)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Questioned Costs Eligibility Matching / Level of Effort / Earmarking § 200.303

The Government concurs with the auditor's findings and recommendations. The agency has commenced reviewing the agency retention policies and training with staff on keeping records and files in a systematic sequence. In the third quarter of FY2025, the agency will be launching an electronic record ke...

The Government concurs with the auditor's findings and recommendations. The agency has commenced reviewing the agency retention policies and training with staff on keeping records and files in a systematic sequence. In the third quarter of FY2025, the agency will be launching an electronic record keeping system for claims files that will provide a more comprehensive and structured mechanism for record retention. VIDOL staff will also be engaging with USDOL to have programmatic technical assistance with record retention. The agency is also engaging with USDOL to implement data validation in the operations which is intended to verify that eligibility and records are maintained. The agency’s Integrity unit will commence regular compliance reviews for claimant eligibility in the 2nd quarter of FY2025, this review will assist in mitigating past errors and provide feedback on corrective actions that will assist in proper record retention.

View Audit 369907 Questioned Costs: $1

Finding 1155085 (2022-003)

Material Weakness 2022

Hill Country Community Clinic, Inc.

CA

Special Tests & Provisions Eligibility

Management acknowledges the finding. We will conduct mandatory training sessions for all relevant personnel to ensure a clear understanding of the Sliding Fee Discount Program requirements and policy. Training will include proper documentation practices, eligibility verification, and procedures for ...

Management acknowledges the finding. We will conduct mandatory training sessions for all relevant personnel to ensure a clear understanding of the Sliding Fee Discount Program requirements and policy. Training will include proper documentation practices, eligibility verification, and procedures for applying discounts consistently. We will review and update our sliding fee discount policy to ensure clarity, consistency, and compliance with regulatory requirements. We will provide an annual review and obtain board approval of the Sliding Fee Discounting Program scheduled on an annual basis. Regular internal audits will be conducted to review the application of sliding fee discounts and identify any discrepancies before external audits. Results of internal audits will be shared with management, and corrective actions will be taken as necessary. We will assess the feasibility of implementing system controls or automated alerts within our electronic health record (EHR) and billing systems to reduce errors in discount applications. Additional oversight measures may be introduced to ensure all eligible patients receive the correct discount in accordance with policy guidelines. The above corrective actions are currently being implemented.

View Audit 367389

Finding 574043 (2022-002)

Material Weakness 2022

County of Rockingham

NH

Questioned Costs Allowable Costs / Cost Principles Eligibility § 200.303 § 200.334

Audit Finding Reference: 2022-002 Corrective Action Taken or Planned: 1. Formalized Record Retention Policies: A formal record retention policy specific to federal grant programs will be implemented to ensure full compliance with 2 CFR 200.334. This policy will apply regardless of whether documentat...

Audit Finding Reference: 2022-002 Corrective Action Taken or Planned: 1. Formalized Record Retention Policies: A formal record retention policy specific to federal grant programs will be implemented to ensure full compliance with 2 CFR 200.334. This policy will apply regardless of whether documentation is stored internally or by third-party systems. Any documentation downloaded or transferred from third-party systems will be subject to a review process to verify completeness and accuracy before being finalized for County retention. The County shall also take steps to ensure that information downloads and exports from third-party systems represent omplete and accurate records. 2. Audit Timing Advocacy and Preparedness: The County will continue to maintain timely documentation and preparedness for audits and will also advocate for timely initiation and completion of future audits. Significant delays in the audit process, through no fault of the County, as observed during the FY2022 audit, substantially impacted the County's ability to access necessary documentation and demonstrate compliance. Although the County made every effort to retain records in accordance with federal requirements, the timing of the audit fieldwork occurred well after the program had concluded in May 2023. Had the audit been conducted in a timely manner, full access to the third-party platform used for program administration would have been available, along with all supporting documentation. However, by the time the audit took place, the program had been closed for over 18 months, and access to the external software system had lapsed in accordance with the expiration of the service agreement. 3. Internal Audit Readiness Reviews: Beginning with FY2025, the County will conduct internal audit readiness reviews shortly after fiscal year-end to ensure all documentation for closed federal programs is centralized, archived, and accessible for future audit purposes, even if conducted years later. Anticipated Completion Date: October 15, 2025 Contact Person Responsible for Corrective Action: Charles Nickerson, Senior Director of Finance

View Audit 364627 Questioned Costs: $1

Finding 570442 (2022-008)

Material Weakness 2022

Consortium of Universities for the Advancement of Hydrologic Science, Inc.

MA

Cash Management Allowable Costs / Cost Principles Eligibility § 200.307

Finding Reference Number: MW2022-008 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2022: External contract accounting staff in place during audit year 2022 failed to declare program incom...

Finding Reference Number: MW2022-008 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2022: External contract accounting staff in place during audit year 2022 failed to declare program income in advance of the deadline specified by NSF. Program income for 2022 was filed was filed on 3 December 2022, approximately three weeks late. Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI continues to use a single payment gateway for events and registration fees which supports segregation of payments per event and per grant. Program income has been reported to NSF accurately and on time as of audit year 2023 and appropriate staff and policies are in place to ensure continued future compliance. Name of Contact Person: • Maureen S. Ako, Director of Finance • Telephone: (339)221-5400 • Email: msabino@cuahsi.org Projected Completion Date: NA; is complete

View Audit 361411

Finding 567969 (2022-002)

Material Weakness 2022

Community Action Partnership of Providence County

RI

Eligibility

Policies for all programs are being developed by each department and will include random, periodic file audits to ensure eligibility documentation and other mandatory paperwork is maintained for all programs.

View Audit 360314

Finding 565761 (2022-007)

Material Weakness 2022

Detroit Central City Cmh, Inc.

MI

Eligibility

To address this finding, the Finance Department along with the Revenue Cycle department will take the following actions: * An Executive Director of Revenue Cycle has been hired to manage all aspects of revenue cycle (including the Sliding Fee Discount Program). * The Director will implement a target...

To address this finding, the Finance Department along with the Revenue Cycle department will take the following actions: * An Executive Director of Revenue Cycle has been hired to manage all aspects of revenue cycle (including the Sliding Fee Discount Program). * The Director will implement a targeted training program for staff involved in administering the program, focusing on a sliding fee approach. This traning will include identifying patients who are eligible for the sliding fee discount. * The Director has created a Standard Operating Procedure (SOP) for each EHR system to ensure that all staff administering sliding fees understand the Sliding Fee process. This will also include monitoring the program for compliance and the appropriate application of any sliding fee discount transactions. * Update the sliding fee scale annually using the Federal Poverty Guidelines.

View Audit 359454

Finding 565179 (2022-012)

Material Weakness 2022

City of Paterson

NJ

Questioned Costs Procurement, Suspension & Debarment Cash Management

City was delayed due to staff shrotages. City is catching up and has controls set

View Audit 359090 Questioned Costs: $1

Finding 565178 (2022-007)

Material Weakness 2022

City of Paterson

NJ

Questioned Costs Procurement, Suspension & Debarment Cash Management

City was delayed due to staff shrotages. City is catching up and has controls set

View Audit 359090 Questioned Costs: $1

Finding 565177 (2022-009)

Material Weakness 2022

City of Paterson

NJ

Questioned Costs Procurement, Suspension & Debarment Eligibility

City was delayed due to staff shrotages. City is catching up and has controls set

View Audit 359090 Questioned Costs: $1

Finding 565176 (2022-008)

Material Weakness 2022

City of Paterson

NJ

Questioned Costs Procurement, Suspension & Debarment Cash Management

City was delayed due to staff shrotages. City is catching up and has controls set

View Audit 359090 Questioned Costs: $1

Finding 565174 (2022-010)

Material Weakness 2022

City of Paterson

NJ

Questioned Costs Procurement, Suspension & Debarment Cash Management

City was delayed due to staff shrotages. City is catching up and has controls set

View Audit 359090 Questioned Costs: $1

Finding 565074 (2022-002)

Material Weakness 2022

United Way of Marion County, Inc.

FL

Cash Management Eligibility Material Weakness

United of Marion County, Inc. experienced staff turnover during the ERA 1 & ERA2 which may have contributed to data not being regularly reconciled to the third-party grant tracking system. The United Way of Marion County, Inc has hired a full-time accounting professional to improve internal controls...

United of Marion County, Inc. experienced staff turnover during the ERA 1 & ERA2 which may have contributed to data not being regularly reconciled to the third-party grant tracking system. The United Way of Marion County, Inc has hired a full-time accounting professional to improve internal controls. Management as the time utilized the resources available to ensure residents received timely housing assistance.

View Audit 359012

Finding 564774 (2022-004)

Significant Deficiency 2022

American Society for Engineering Education

DC

Eligibility

ASEE is working with the Program directors to ensure that proper and sufficient documentation is stored and retained for all federal awards. In addition, the organization is providing the proper tools to assist the Program Directors store and retain all documents safely for a long time.

View Audit 358839

Finding 561489 (2022-007)

Material Weakness 2022

Sayre Health Center

PA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Finding No. 2022-007: Inadequate Documentation and Records for Application of Sliding Fee Discounts We have incorporated a policy that establishes the basis for the sliding fee policy to assure affordable access to care for uninsured and underinsured patients of the organization. The policy will rec...

Finding No. 2022-007: Inadequate Documentation and Records for Application of Sliding Fee Discounts We have incorporated a policy that establishes the basis for the sliding fee policy to assure affordable access to care for uninsured and underinsured patients of the organization. The policy will recognize a “full discount” for individuals and families with annual incomes at or below 100% Federal poverty level (FPL) with only nominal fees charged, three levels of discount between 100% and 200%, and no discounts for copays for individuals and families earning over 200% FPL. This policy will be in accordance with Section 330(k)(3)(G) of the PHS Act and 42 CFR Part 51c.303(f) and 42 CFR Part 51c.303(u) which are incorporated herewith. We will charge a nominal fee to individuals and families with annual incomes at or below 100% of the FPL. Patients whose incomes are above 100% or below 200% of the FPL will be charged according to our sliding fee scale based on income and family size. Discounts will be provided to patients with incomes up to 200% of the FPL for medical visits. Discounts will be provided to patients with incomes up to 250% of the FPL for family planning visits. Staff will assess patients’ incomes based upon a sliding fee scale and no patient will be denied care based upon their inability to pay. The organization also has a policy of nondiscrimination in the delivery of health care as stated in its Patient Bill of Rights. Also, the Board of Directors define the income and family size, and has defined the family size to be all parents, minors or guardians that are financially responsible for the household. The tracking and documentation of sliding fees is now maintained with the deposit record of each fee received in the shared file for immediate availability and reference.

View Audit 357068 Questioned Costs: $1

Finding 560504 (2022-010)

Material Weakness 2022

Orutsararmiut Native Council

AK

Allowable Costs / Cost Principles Eligibility Material Weakness

Name of Contact: Brian Henry, Executive Director Corrective Action Plan: Vacant positions within the accounting and program departments have been filled to ensure that the Council follows internal control policies over grant reporting. Proposed Completion Date: Complete as of June 30, 2024

View Audit 356419

Finding 560149 (2022-016)

Material Weakness 2022

Oregon Coast Community Action

AL

Cash Management Subrecipient Monitoring Allowable Costs / Cost Principles

The Energy program has been current on the required reporting since the referenced audit period. The program is aware of the grants' requirements now. Additionally, ORCCA plans to utilize grant tracker system with the ability to send reminders for important dates to avoid future delinquent reporting...

The Energy program has been current on the required reporting since the referenced audit period. The program is aware of the grants' requirements now. Additionally, ORCCA plans to utilize grant tracker system with the ability to send reminders for important dates to avoid future delinquent reporting that was experienced during the audit period. The system will be utilized by the program directors as well as finance team (Finance Director, Accounting Manager, Program Fiscal Compliance Coordinator) working with grants/directors. ORCCA's current process at the Energy program level has already improved to ensure proper documentation of eligibility. The Energy program director and staff are implementing this internal control at the program level to review the supporting documents and information and proper coding to the correct period. Responsible party: Bonnie Foroudi, Finance Director Estimated completion date: December 31, 2025

View Audit 356132

Finding 560144 (2022-015)

Material Weakness 2022

Oregon Coast Community Action

AL

Questioned Costs Matching / Level of Effort / Earmarking Subrecipient Monitoring

ORCCA's current process at the Energy program level has already improved to ensure proper documentation of eligibility. The Energy program director and staff are currently implementing this internal control at the program level to document the information and proper coding to the correct period. Re...

ORCCA's current process at the Energy program level has already improved to ensure proper documentation of eligibility. The Energy program director and staff are currently implementing this internal control at the program level to document the information and proper coding to the correct period. Responsible party: Bonnie Foroudi, Finance Director Estimated completion date: December 31, 2025

View Audit 356132 Questioned Costs: $1

Finding 560138 (2022-013)

Material Weakness 2022

Oregon Coast Community Action

AL

Allowable Costs / Cost Principles Eligibility Period of Performance § 200.303

ORCCA's current process at the program level has improved to ensure proper documentation of eligibility. The Housing director and staff have implemented this internal control at the program level. The finance department's internal control (as noted earlier) is in place to ensure the payment requests...

ORCCA's current process at the program level has improved to ensure proper documentation of eligibility. The Housing director and staff have implemented this internal control at the program level. The finance department's internal control (as noted earlier) is in place to ensure the payment requests have sufficient supporting documentation. As for record retention, ORCCA hired additional temp workers to ensure completed transactions are filed timely with the goal of going paperless in the near future. Responsible party: Bonnie Foroudi, Finance Director Estimated completion date: December 31, 2025

View Audit 356132

Finding 559160 (2022-014)

Significant Deficiency 2022

Caswell County

NC

Eligibility Significant Deficiency

CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2022 Finding: 2022-014 Inadequate Request for Information Name of contact person: Corrective Action: Proposed Completion Date: Corrective Action for Findings...

CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2022 Finding: 2022-014 Inadequate Request for Information Name of contact person: Corrective Action: Proposed Completion Date: Corrective Action for Findings 2022-012, 2022-013, 2022-014 also apply to the State Award findings. Section IV - State Award Findings and Question Costs April 11, 2024 Heather Starr Thomas, Medicaid Supervisor Cases will be reviewed internally to ensure proper documentation is in place for eligibility. Workers will be retrained on what cases should contain and the importance of complete and accurate record keeping. All cases will include online verifications ran timely, documented resources, income and make certain those amounts agree to information input into NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed by the caseworker and the results of those actions. Information must be updated at every application/recertification and change in circumstance adhering to Medicaid Policy. Templates have been updated to address request for information, income verifications, reasonable compatibility and to include electronic resources are ran with verification of date ran. Help Desk tickets should be submitted timely if information or functionality is not working properly. All avenues available to caseworker must be exhausted before requesting information from client, unless information provided and information obtained is questionable. We will continue to train on this issue, and it will also be addressed in new worker Trainings. Training in the learning gateway is also available. Section III - Federal Award Findings and Question Costs (continued) 137

View Audit 355386

Finding 559159 (2022-013)

Significant Deficiency 2022

Caswell County

NC

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Proposed Completion Date: Finding: 2022-013 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid Supervisor A refresher training will be held to review errors. Files will be reviewed internally to ensure proper documentation...

Proposed Completion Date: Finding: 2022-013 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid Supervisor A refresher training will be held to review errors. Files will be reviewed internally to ensure proper documentation is in place for eligibility. Workers will be retrained on what files should contain and the importance of complete and accurate record keeping. All files include accurate household members, online verifications, documented sources and verifications of income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. An updated template has been put in place for applications and recertification to address household members, tax filing status, electronic checks/verifications and documentation that is needed to accurately approve/deny/continue or terminate benefits. Caseworkers will need to review Determinations to ensure all eligibility is calculated accurately. All active cases regardless of program in NCFAST are to be reviewed to ensure we have the correct information. Weekly Communications and Changes will be reviewed weekly at Unit Meeting to address any changes and NCFAST issues that may require a Help Desk Ticket. We will continue to train on this issue, and it will also be addressed in new worker Trainings. Training in the learning gateway is also available. April 11, 2024 Section III - Federal Award Findings and Question Costs (continued) N/A - Caseworkers will adhere to the policy in Administrative Letter 13-23.

View Audit 355386

Finding 559158 (2022-012)

Significant Deficiency 2022

Caswell County

NC

Eligibility Significant Deficiency

Finding: 2022-012 IV-D Non-Cooperation Name of contact person: Corrective Action: Section II - Financial Statement Findings (continued) As noted in Findings 2022-001 and 2022-006, the county finance staff is diligently working to improve the timeliness of transaction processing and anticipates timel...

Finding: 2022-012 IV-D Non-Cooperation Name of contact person: Corrective Action: Section II - Financial Statement Findings (continued) As noted in Findings 2022-001 and 2022-006, the county finance staff is diligently working to improve the timeliness of transaction processing and anticipates timely completion of the FY24 audit which will resolve this finding. Melissa Miller, Interim Finance Officer Heather Starr Thomas, Medicaid Supervisor At the time the determinations under audit were completed this was a requirement. However, under current policy referrals are not being enforced for cooperation with the Child Support Enforcement Agency (IV-D). This became effective August 18, 2023. Please see Administrative Letter 13-23.Proposed Completion Date: Finding: 2022-013 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid Supervisor A refresher training will be held to review errors. Files will be reviewed internally to ensure proper documentation is in place for eligibility. Workers will be retrained on what files should contain and the importance of complete and accurate record keeping. All files include accurate household members, online verifications, documented sources and verifications of income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. An updated template has been put in place for applications and recertification to address household members, tax filing status, electronic checks/verifications and documentation that is needed to accurately approve/deny/continue or terminate benefits. Caseworkers will need to review Determinations to ensure all eligibility is calculated accurately. All active cases regardless of program in NCFAST are to be reviewed to ensure we have the correct information. Weekly Communications and Changes will be reviewed weekly at Unit Meeting to address any changes and NCFAST issues that may require a Help Desk Ticket. We will continue to train on this issue, and it will also be addressed in new worker Trainings. Training in the learning gateway is also available. April 11, 2024 Section III - Federal Award Findings and Question Costs (continued) N/A - Caseworkers will adhere to the policy in Administrative Letter 13-23.

View Audit 355386

Finding 556195 (2022-003)

Material Weakness 2022

Benton County

WA

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

Thank you for bringing this to our attention. There were several factors that contributed to the difficulties we encountered submitting the required quarterly reports and have since remedied those issues. The Human Services Department has worked with Treasury on the challenges we encountered uploa...

Thank you for bringing this to our attention. There were several factors that contributed to the difficulties we encountered submitting the required quarterly reports and have since remedied those issues. The Human Services Department has worked with Treasury on the challenges we encountered uploading the required reporting templates and we now has multiple people with access to the reporting portal and in the event of staff turnover we can continue to submit required reports. The Human Services Manager and the Budget and Finance Analyst have created reminders on their calendars to ensure reporting is completed on time and with accurate data.

View Audit 354873

Finding 555649 (2022-008)

Significant Deficiency 2022

Town of Coventry, Rhode Island

RI

Procurement, Suspension & Debarment Subrecipient Monitoring Eligibility § 200.213 § 200.303

Significant Deficiency in Internal Control over Compliance, Other Matters Description of Finding The Town does not have policies and procedures in place to ensure that they do not contract with or make subawards to parties that are suspended or debarred. Statement of Concurrence or Nonconcurrence ...

Significant Deficiency in Internal Control over Compliance, Other Matters Description of Finding The Town does not have policies and procedures in place to ensure that they do not contract with or make subawards to parties that are suspended or debarred. Statement of Concurrence or Nonconcurrence Management concurs with the finding. Corrective Action The Town will review the district’s suspension and debarment policy and make sure that it is following the criteria as set out in the 2 CFR sections 200.213. The policy will then be updated and communicated to all personnel involved in the procurement process. Name of Contact Person Robert J. Civetti, CPA, Finance Director Projected Completion Date June 30, 2025

View Audit 354246

Finding 554717 (2022-003)

Material Weakness 2022

Passaic County Board of Social Services

NJ

Eligibility

Temporary Assistance for Needy Families (TANF), CFDA #93.558, Grant Period 1/1/22-12/31/22. There were multiple instances where eligibility files selected for review were either incomplete, or unable to be presented for audit review. Recommendation: As per Federal OMB Uniform Guidance Circular Compl...

Temporary Assistance for Needy Families (TANF), CFDA #93.558, Grant Period 1/1/22-12/31/22. There were multiple instances where eligibility files selected for review were either incomplete, or unable to be presented for audit review. Recommendation: As per Federal OMB Uniform Guidance Circular Compliance Supplement, each individual who receives benefits under the TANF Program, should have a completed eligibility determination on file which is available for audit review. Corrective Action: PCBSS have created a DIMS unit, where files are scanned and stored in DIMS. Implementation Date: Commenced 2022 and ongoing.

View Audit 353335

Finding 554716 (2022-002)

Material Weakness 2022

Passaic County Board of Social Services

NJ

Eligibility

Medical Assistance Program (Medicaid, Title IXI), CFDA #93.778, Grant Period 1/1/22-12/31/22. There were multiple instances where eligibility files selected for review were either incomplete, or unable to be presented for audit review. Recommendation: As per Federal OMB Uniform Guidance Circular Com...

Medical Assistance Program (Medicaid, Title IXI), CFDA #93.778, Grant Period 1/1/22-12/31/22. There were multiple instances where eligibility files selected for review were either incomplete, or unable to be presented for audit review. Recommendation: As per Federal OMB Uniform Guidance Circular Compliance Supplement, each individual who receives benefits under the Medicaid Program, should have a completed eligibility determination on file which is available for audit review. Corrective Action: PCBSS have created a DIMS unit, where files are scanned and stored in DIMS. Implementation Date: Commenced 2022 and ongoing.

View Audit 353335

Corrective Action Plans

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