Corrective Action Plans

Finding 422814 (2022-051)

Significant Deficiency 2022

State of Alaska

AK

Allowable Costs / Cost Principles Eligibility Subrecipient Monitoring

Finding: 2022-051 - DHSS staff claimed inaccurate federal reimbursement for behavioral health costs.Questioned Costs: Assistance Listing 93.767: Indeterminate; Assistance Listing 93.778: IndeterminateAssistance Listing Number: 93.767; 93.775, 93.777, 93 .778Assistance Listing Title: CHIP; Medicaid C...

Finding: 2022-051 - DHSS staff claimed inaccurate federal reimbursement for behavioral health costs.Questioned Costs: Assistance Listing 93.767: Indeterminate; Assistance Listing 93.778: IndeterminateAssistance Listing Number: 93.767; 93.775, 93.777, 93 .778Assistance Listing Title: CHIP; Medicaid ClusterViews of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH agrees with the finding.Corrective Action (corrective action planned): The Division of Behavioral Health (DBH) is working with the ASO to ensure accurate member eligibility file load and claims processing issues under a corrective action plan to resolve issues that led to inaccurate federal reimbursement.Completion Date (list anticipated completion date): DOH anticipates an interim resolution will be in place during FY2023 followed with a full system resolution in FY2024.Agency Contact (name of person responsible for corrective action): Josephine Stern, Assistant Commissioner

View Audit 312347

Finding 422811 (2022-046)

Significant Deficiency 2022

State of Alaska

AK

Questioned Costs Eligibility Significant Deficiency

Finding: 2022-046 - Three (5 percent) of 60 Low-Income Home Energy Assistance Program (LIHEAP) applicant case files tested had eligibility errors.Questioned Costs: $6,490Assistance Listing Number: 93.568Assistance Listing Title: LIHEAPViews of Responsible Officials (state whether your agency agrees ...

Finding: 2022-046 - Three (5 percent) of 60 Low-Income Home Energy Assistance Program (LIHEAP) applicant case files tested had eligibility errors.Questioned Costs: $6,490Assistance Listing Number: 93.568Assistance Listing Title: LIHEAPViews of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH agrees with the finding.Corrective Action (corrective action planned): The Division of Public Assistance (DPA) plans to implement random sample testing for LIHEAP cases using the Program Integrity and Analysis Unit. This would reflect current processes in place for similar public assistance programs that the division administers.Completion Date (list anticipated completion date): DOH anticipates the finding will be resolved in FY2024.Agency Contact (name of person responsible for corrective action): Josephine Stern, Assistant Commissioner

View Audit 312347 Questioned Costs: $1

Finding 422808 (2022-045)

Significant Deficiency 2022

State of Alaska

AK

Allowable Costs / Cost Principles Eligibility

Finding: 2022-045 - DHSS?s information technology staff did not properly limit user access to DPA?s EIS during FY22.Questioned Costs: NoneAssistance Listing Number: 93.558; 93.775, 93.777, 93.778Assistance Listing Title: TANF; Medicaid ClusterViews of Responsible Officials (state whether your agency...

Finding: 2022-045 - DHSS?s information technology staff did not properly limit user access to DPA?s EIS during FY22.Questioned Costs: NoneAssistance Listing Number: 93.558; 93.775, 93.777, 93.778Assistance Listing Title: TANF; Medicaid ClusterViews of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH agrees with the finding.Corrective Action (corrective action planned): The Division is implementing protocols to reconcile users in every eligibility system at a minimum of twice yearly. These protocols will be used to identify and deactivate user accounts that are no longer needed but have not been reported via the established formal process.Completion Date (list anticipated completion date): DOH anticipates the finding will be resolved in FY2024.Agency Contact (name of person responsible for corrective action): Josephine Stern, Assistant Commissioner

View Audit 312347

Finding 422800 (2022-038)

Material Weakness 2022

State of Alaska

AK

Eligibility Special Tests & Provisions Subrecipient Monitoring

Finding: 2022-038 - Ten of 25 Temporary Assistance for Needy Families (TANF) recipient case files tested lacked documentation supporting the request and use of income and benefit information through the Income Eligibility and Verification System (IEVS) for determining eligibility and benefits. Furth...

Finding: 2022-038 - Ten of 25 Temporary Assistance for Needy Families (TANF) recipient case files tested lacked documentation supporting the request and use of income and benefit information through the Income Eligibility and Verification System (IEVS) for determining eligibility and benefits. Further, the following eligibility errors were identified:? Eight TANF applicants did not have eligibility redetermined within 12 months and eligibility was automatically extended.? Three TANF applications were not reviewed within 30 days of receipt.? Three applications either did not fill out the felony conviction disclosures or the section was not retained in the case file.? Three applications did not have adequate income verification support.? Three benefit payment amounts were not calculated accurately.? One application did not include child support documentation in the case file.? One renewal application was not reviewed for an eligibility redetermination.Additionally, 24 of the TANF recipient cases received Pandemic Emergency Assistance Fund (PEAF) payments, of which 20 did not have IEVS documentation to support the eligibility determination prior to DHSS making the PEAF payments.Questioned Costs: $138,024Assistance Listing Number: 93.558Assistance Listing Title: TANFViews of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why):DOH agrees with the finding.Corrective Action (corrective action planned): The agency continues to work through priorities and mandates implemented due to the ending of the public health emergency, which has increased the workload beyond what the division had experienced in the prior year. This has impacted the ability to meaningfully execute the corrective action plan. The Division is currently implementing strategies, which includes increasing staffing, to address the increased workload and upcoming PHE unwinding efforts. The agency will continue moving forward with corrective actions.Completion Date (list anticipated completion date): DOH anticipates the finding will be resolved in FY2024.Agency Contact (name of person responsible for corrective action): Josephine Stern, Assistant Commissioner

View Audit 312347

Finding 422766 (2022-032)

Material Weakness 2022

State of Alaska

AK

Allowable Costs / Cost Principles Eligibility Special Tests & Provisions § 200.303

Finding: 2022-032 - Testing of5l SNAP recipient cases to verify the accuracy of EIS benefit calculations found five (10 percent) were incorrect. Testing of 26 SNAP recipient cases to verify the adequacy of case information stored in EIS and the DHSS `s document management system, ILINX, found 11(42 ...

Finding: 2022-032 - Testing of5l SNAP recipient cases to verify the accuracy of EIS benefit calculations found five (10 percent) were incorrect. Testing of 26 SNAP recipient cases to verify the adequacy of case information stored in EIS and the DHSS `s document management system, ILINX, found 11(42 percent) had insufficient information in ILINX or inaccurate data input into EIS, and four (15 percent) recipients? applications or report of changes were not processed within federally required timeframes.Questioned Costs: Assistance Listing 10.55 1: $2,636Assistance Listing Number: 10.55 1, 10.561Assistance Listing Title: SNAP ClusterViews of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH agrees with the finding.Corrective Action (corrective action planned): The Division of Public Assistance (DPA) continues to strengthen its procedures. Refresher trainings for staff are being offered and case work continues to be reviewed. The agency is also redesigning business processes to meet timeliness measures set by federal partners, to include applications and reports of change.Completion Date (list anticipated completion date): DOH anticipates the finding will be resolved in FY2024.Agency Contact (name of person responsible for corrective action): Josephine Stern, Assistant Commissioner

View Audit 312347

Finding 422764 (2022-031)

Material Weakness 2022

State of Alaska

AK

Eligibility Special Tests & Provisions Allowable Costs / Cost Principles § 200.303

Finding: 2022-031 - The Division of Public Assistance (DPA) Eligibility Information System (EIS) did not automatically cut off households from receiving Supplemental Nutrition Assistance Program (SNAP) benefits at the end of the certification period during FY 22.Questioned Costs: Assistance Listing ...

Finding: 2022-031 - The Division of Public Assistance (DPA) Eligibility Information System (EIS) did not automatically cut off households from receiving Supplemental Nutrition Assistance Program (SNAP) benefits at the end of the certification period during FY 22.Questioned Costs: Assistance Listing 10.551: IndeterminateAssistance Listing Number: 10.55 1, 10.561Assistance Listing Title: SNAP ClusterViews of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH agrees with the finding.Corrective Action (corrective action planned): The Division is reestablishing recertification processes for SNAP and mailing of recertification packets to clients has resumed. The agency is also ensuring previously programmed auto closure protocols are in place, so that SNAP ends when recertification packets are not submitted by households. System-generated extensions of SNAP certification periods have ceased.Completion Date (list anticipated completion date): DOH anticipates the finding will be resolved in FY2024.Agency Contact (name of person responsible for corrective action): Josephine Stern, Assistant Commissioner

View Audit 312347

Finding 421967 (2022-002)

Material Weakness 2022

Surry County

NC

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

The County will develop a 2nd Party Review form that will be used to check completed applications for accuracy in applying policy and to assure all verifications have been uploaded to the NCFAST System.

View Audit 312326

Finding 421965 (2022-001)

None 2022

Surry County

NC

Questioned Costs Eligibility Program Income

The County will review internal policies and procedures to ensure consistent documentation retention policy. Training will occur with staff involved all income verification within this program. Additional oversight protocols will be put into place to review and verify documentation is retained for e...

The County will review internal policies and procedures to ensure consistent documentation retention policy. Training will occur with staff involved all income verification within this program. Additional oversight protocols will be put into place to review and verify documentation is retained for each applicant. The time period and funds for this program have been exhausted. New funds will not be available until next SFY 2023-2024. We have a plan to this program under the supervision of the Economics Services Division and repurpose and existing position. We will complete the training once the position has been filled.

View Audit 312326 Questioned Costs: $1

Finding 421963 (2022-003)

Significant Deficiency 2022

Surry County

NC

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

The County created a 2nd Party Review Error Summary Log. This will be used to record all 2nd Party Reviews that require corrections to a case. 2nd Party Review forms will be completed and handed out to caseworkers as previously with the exception that the Reviewer will log the ones that need correct...

The County created a 2nd Party Review Error Summary Log. This will be used to record all 2nd Party Reviews that require corrections to a case. 2nd Party Review forms will be completed and handed out to caseworkers as previously with the exception that the Reviewer will log the ones that need corrections. Once the form is returned to the Reviewer, they will check to verify the needed corrections have been completed and documented. Once they have done this, they will enter the needed dates on the 2nd Party Review Error Summary Log. A meeting was held to implement this new procedure on 2/16/2023 and was placed in effect for the action month of January 2023, since this is the current month being reviewed at time of reported findings and needed CAP.

View Audit 312326

Finding 421519 (2022-006)

Material Weakness 2022

Blackford County Schools

IN

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

FINDING 2022-006Subject: Title I Grants to Local Educational Agencies - EligibilityFederal Agency: Department of EducationFederal Program: Title I Grants to Local Educational AgenciesAssistance Listing Number: 84.010Federal Award Numbers and Years: FY18, FY19, FY20, FY21Pass-Through Entity: Indiana ...

FINDING 2022-006Subject: Title I Grants to Local Educational Agencies - EligibilityFederal Agency: Department of EducationFederal Program: Title I Grants to Local Educational AgenciesAssistance Listing Number: 84.010Federal Award Numbers and Years: FY18, FY19, FY20, FY21Pass-Through Entity: Indiana Department of EducationCompliance Requirement: EligibilityAudit Findings: Material WeaknessContact Person Responsible for Corrective Action: Michelle Gross, Data Specialist, Shelly Kemp FoodService Director and Lindsay Cagle, ECA TreasurerContact Phone Number: 765-348-7550Views of Responsible Official: We agree with the finding of the AuditorsDescription of Corrective Action Plan:The ECA Treasurer provides Textbook Assistance Applications to each building for dispersal. The applications arereturned to the ECA Treasurer. These applications are given to the Food Services Director who manually enters the datainto Skyward. When complete, the applications are given back to the ECA Treasurer for filing and verification thestudent has been updated in Skyward to the correct status. (Free/Reduced, Medicaid or Paid)The Food Service Director pulls direct certified students from the state and uploads those students into the SIS(Skyward) program. Currently the ECA Treasurer will compare old and new invoices in Skyward to check for anychanges.Going forward the Food Service Director will provide a report (email when only 1 or 2 students) to the ECA Treasurer ofall direct cert. students as well as students that have completed a Textbook Assistance Application for her review. Thesereports will be run every 2-4 weeks as needed. The treasurer will compare the data in Skyward for accuracy. Both theFood Service Director and the ECA Treasurer will sign off on the report as confirmation.Anticipated Completion Date: May 2023

View Audit 312304

Finding 420276 (2022-003)

Material Weakness 2022

Community Youth Services

WA

Questioned Costs Subrecipient Monitoring Eligibility

Finding: 2021-003CFDA: 21.023 Department of the Treasury, Agency Rental AssistancePass-Through Entity: WA Department of Commerce 2021-ComTRAP-CYS-RAAgency: Community Youth ServicesName of contact person and title: Derek Harris, CEOAnticipated completion date: completed on 09/30/2022Agency?s response...

Finding: 2021-003CFDA: 21.023 Department of the Treasury, Agency Rental AssistancePass-Through Entity: WA Department of Commerce 2021-ComTRAP-CYS-RAAgency: Community Youth ServicesName of contact person and title: Derek Harris, CEOAnticipated completion date: completed on 09/30/2022Agency?s response: ConcurThe organization agrees with this finding and implemented the following:We developed program guidelines in addition to the guidelines provided by the Pass-Through Entity in order to ensure internal controls are in place to mitigate fraud and/or misuse of rental assistance funds.The program personnel implemented a file checklist starting October 1, 2022, to ensure all compliance components included in the file documentation meet the criteria required for the program. The checklist and forms are reviewed prior to payment. When digital signatures cannot be obtained, verbal verification of agreement by the applicant will be documented by the program staff to include date, time, method of communication.A supervisor (Program Director, Deputy Director, or CEO) reviews the files to ensure compliance with the program guidelines, ensure third party evidence exists and that all applicable documentation is in the file to support the rental assistance request.The files will also be reviewed by the Finance Coordinator prior to submitting the payment request to the Accounting Associate to ensure eligibility is adequately documented and that third party evidence exists before funds are released to the landlord.Sincerely,Derek R. HarrisChief Executive OfficerCommunity Youth Services

View Audit 312253 Questioned Costs: $1

Finding 412048 (2022-001)

Significant Deficiency 2022

El Camino Community College District

CA

Student Financial Aid Eligibility Significant Deficiency

2022 ? 001: Student Financial Aid Cluster - Student Eligibility and Awarding: Exit Counseling ?Program Number 84.268Recommendation: We recommend the college review its policies and procedures around disbursingexit counseling information to students to ensure students are receiving proper counseling ...

2022 ? 001: Student Financial Aid Cluster - Student Eligibility and Awarding: Exit Counseling ?Program Number 84.268Recommendation: We recommend the college review its policies and procedures around disbursingexit counseling information to students to ensure students are receiving proper counseling and ensureentrance counseling is documented before loans disbursements are made.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: The Financial Aid Office recognized that the exit loan counselingrule was not being met prior to the commencement of the 2021-2022 audit. The following action planwas already taking shape during the annual audit of 2021-2022 to ensure compliance rule would bemet for the 2022-2023 aid year.Process: Use SIS Colleague system to run query to identify current loan borrowers at beginning andend of term to identify those who have ceased half-time enrollment. Send communication via email andphysical letter notification to ensure student receive important information about loan repaymentresponsibilities, including Department of Education links and contact information.Procedure: Created documentation with step by step procedures for assigned staff to run query toidentify students, request exit loan counseling communication, and run batch posting of communication.Communication: Loan borrowers will receive an email on Day 1 run, a second email on Day 14 run, anda paper letter on Day 30 run.Staff Training: Staff assigned to the Loan program have been trained to run process by ourSystems/Programmer. Financial Aid Staff have been provided information about policy and proceduresto assist students who may contact our office for assistance after receiving exit loan counselingcommunication.Quality Assurance: Two additional staff members have been assigned to help with the Loan program.Name(s) of the contact person(s) responsible for corrective action: Chau Dao - Director ofFinancial AidPlanned completion date for corrective action plan: November 2022.

View Audit 312129

Finding 412032 (2022-001)

Significant Deficiency 2022

University Prep Public Charter Schools

NY

Allowable Costs / Cost Principles Cash Management Eligibility

The school has implemented an electronic timecard system for tutors that will automatically generate timesheets and eliminate or significantly reduce the possibility for human error. All tutors for the school are required to use this computer-based clock in/out system for all shifts.

View Audit 312127

Finding 411725 (2022-004)

Material Weakness 2022

Ohio Institute of Allied Health, Inc.

IL

Student Financial Aid Eligibility Matching / Level of Effort / Earmarking

Finding 2022-04 Late Notification to NSLDS - see corrective action plan submitted with the audit report.

View Audit 312103

Finding 410380 (2022-004)

Material Weakness 2022

Madelia Health

MN

Allowable Costs / Cost Principles Cash Management Eligibility

Finding 2022-004Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionFederal Financial Assistance Listing #93.498Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Princi...

Finding 2022-004Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionFederal Financial Assistance Listing #93.498Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles and ReportingFinding Summary: During testing, we identified the following:- No formal documentation of review and approval of the Hospital's final expenditures listing identified as eligible and claimed under the Provider Relief Fund and American Rescue Plan (ARP} Rural Distribution program (the program) was retained.- Payroll reports to support the COVID-related bonuses based on hours worked were not retained and were not able to be recreated.- Some expenses claimed under the program were incurred before the Hospital started preparing, preventing, and responding to COVID. Net costs of $36,540.- Equipment and information technology expenses claimed under other sources of funding were claimed under the program. Net actual costs of $6,080.- Utility expenses and personnel expenses were overclaimed under the program based on a review of supporting documentation. Net costs of $2,985 with projected net costs of $3,827.- No formal documentation of review and approval of the Hospital's lost revenue calculation and the Hospital's special report submitted to HHS for Period 1 TIN #410758512 was retained.- The lost revenue narrative to describe the option iii calculation did not agree with the supporting calculation performed for January and February 2021. The narrative indicated a comparison to January and February of 2019, but the calculation was done based on January and February 2020 trended revenue.- Expenses claimed under the program and included within the Hospital's special report submitted to the Department of Health and Human Services (HHS} for Period 1 TIN #410758512 were reported at gross cost and did not consider the Hospital's Medicare Cost Reimbursement percentage. Net costs of $880,880.Responsible Individuals: Bruce Craven, CFOCorrective Action Plan: Management has formally documented the review and approval process for expense data and federal agency reporting for funds received by federal agencies. This review process ensures compliance of allowable expense data federal agency reporting. Full implementation of this documented process is expected to be completed within the next month.Anticipated Completion Date: March 2023

View Audit 311963

Finding 410371 (2022-003)

Significant Deficiency 2022

Alamo Area Resource Center, Inc.

TX

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Finding 2022-003EligibilityManagement Response: Management agrees with auditor recommendations and a plan is in place to increase the effectiveness of reviews to ensure the completeness of client certification requirements.Action Plan: 1) Identify the departments that had eligibility errors. 2) Prov...

Finding 2022-003EligibilityManagement Response: Management agrees with auditor recommendations and a plan is in place to increase the effectiveness of reviews to ensure the completeness of client certification requirements.Action Plan: 1) Identify the departments that had eligibility errors. 2) Provide comprehensive training to ensure a clear understanding of Ryan White eligibility requirements among departments.Enacted: June 2023Responsible Person: Director of Case ManagementFinalized: July 2023Action Plan: 3) The programs use a new platform, e2SanAntonio, that has a built-in feature that flags clients that are out of compliance. Will perform monthly audits of Ryan White eligibility using the new eligibility platform reporting.Enacted: April 2023Responsible Person: Director of Case ManagementFinalized: June 2023

View Audit 311961

Finding 410365 (2022-002)

Material Weakness 2022

South Dakota Achieve

SD

Allowable Costs / Cost Principles Eligibility Material Weakness

Finding 2022-002Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionFederal Financial Assistance Listing #93.498Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Princi...

Finding 2022-002Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionFederal Financial Assistance Listing #93.498Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles and ReportingFinding Summary: During testing, the following were identified:- Expenses were claimed under the program which were incurred prior to the Organization preparing, preventing, and responding to COVID. Actual costs of $51,160.- Payroll expenses claimed under the program were calculated for three employees with the current hourly wage rate rather than the hourly wage rate effective during the period of time COVID hours were claimed under the program. Actual costs of $3,360 with projected costs of $9,751.- One employee?s specific COVID related hours were claimed twice under the program. Actual costs of $24,096.- FICA payroll expenses were claimed twice under the program. Actual costs of $3,685.- Additional COVID payroll expenses were identified by management; however, due to a clerical error, these payroll expenses were not included in the special report submitted to HHS for Period 2 TIN #460233030 totaling $135,096.- The Organization included these expenses in the special reports submitted to the Department of Health and Human Services (HHS) for Period 2 TIN #460233030 and TIN #237072116 which caused the reports to be inaccurate. The Organization?s special reports submitted to HHS had no formal documentation of a secondary review or approval.Responsible Individuals: Stephan Wilson, Chief Financial Officer, Carol Peterson, Director of Finance, Stacy Flahaven, Accounting ManagerCorrective Action Plan: More time and attention will be given to calculating, gathering, and reporting amounts for future awards. Review and approval of federal reports will be performed by separate individuals. Both the review and approval will be formally documented by signing and dating upon completion. There are no future reporting requirements under this federal award.Anticipated Completion Date: June 30, 2023

View Audit 311959

Finding 409863 (2022-001)

Significant Deficiency 2022

Health Services, Inc.

AL

Special Tests & Provisions Eligibility

Finding 2022-001 ? Special Tests and ProvisionsThe auditee acknowledges the findings of the auditors. It has been noted that two patients were billedat discounts above eligibility levels and one patient was billed at a discount below the eligible amount.Review of the samples noted revealed that one ...

Finding 2022-001 ? Special Tests and ProvisionsThe auditee acknowledges the findings of the auditors. It has been noted that two patients were billedat discounts above eligibility levels and one patient was billed at a discount below the eligible amount.Review of the samples noted revealed that one of the 3 individuals included in the finding occurredas a result of staff inputting the incorrect salary information into the system for those patients and/ornot selecting the proper frequency for patient income, i.e., monthly, weekly, biweekly, annually, etc.These are simple human errors that occur when staff are inundated with tasks during registrationmissing detailed steps as they enter the patient?s income.Another instance of the noted error existed as a result of the staff failing to include the income for allindividuals in the household income calculation which provided a greater than applicable discount.The final error occurred as a result of failure to follow up and adjust patient accounts for those patientswho present and apply for the sliding fee. This patient applied for the sliding fee discount at the timeof the visit, but because he did not have the income verification, he was listed as self-pay and givena 30 day notice to provide the information. The patient paid toward the balance and once he providedinformation it was determined that his payment on the day of the visit exceeded the required paymentper the sliding fee. Supervisors failed to adjust the account and provide the patient with a refund, asa result patient?s account did not reflect the proper discount.Plan of Action:Management reviewed the findings and began to rationalize the reasons that these findings occurredand measures that will help to reduce these errors. The course of action to be taken includes thefollowing to be implemented immediately:? Reduction of Turnover in PAR. A contributing factor to the errors with sliding fees is turnoverin the department. There is a considerably high percentage of turnover average of 6%. Errorsare existing due to the turnover of staff, and the constant training.? Strengthened procedures for Supervisors of employees registering patients are nowcompleting audits of patients? charts to review the sliding fee scale and the attacheddocumentation. The audits are conducted on the patient account as they present for service.Because of the nature of the Sliding Fee Program, the documentation required toparticipated, and the setup of our Patient Management System (Athena), these areperformance audits and are based on how accurate each employee enters information intothe system.? Training to reiterate avoiding common mistakes while registering patients and workingwith patient information.? Also, as recommended, we have scheduled a date to renew the annual sliding fee scaleand notify patients. As an added measure, we will also commit to documenting the effectivedates for any leniency in the corresponding Board minutes.

View Audit 311953

Finding 404506 (2022-005)

Material Weakness 2022

The Salvation Army Northwest Division

WA

Subrecipient Monitoring Eligibility Material Weakness

The Division will contact each unit distributing TEFAP assistance and communicate the requirement to retain documentation regarding the determination of client eligibility. Anticipated Completion Date: June 2024. Responsible Contact Person: Julie Luft, Northwest Division Social Services Director

View Audit 311047

Finding 403696 (2022-003)

None 2022

Nacogdoches Memorial Hospital District

TX

Allowable Costs / Cost Principles Special Tests & Provisions Cash Management

We are in receipt of the findings required to be reported by the single audit for COVID19 Claims Reimbursement for the Uninsured Program and the COVID19 Coverage Assistance Fund specifically, regarding discrepancies in funding received under a different employer identifier number. Management does no...

We are in receipt of the findings required to be reported by the single audit for COVID19 Claims Reimbursement for the Uninsured Program and the COVID19 Coverage Assistance Fund specifically, regarding discrepancies in funding received under a different employer identifier number. Management does not dispute the finding. The District is in it’s second year after going through an asset purchase transaction, whereby the physical assets were retained by the District, but the operations of the hospital were sold. As the District moves forward, we will work to develop policies and procedures over financial reporting to ensure they only request reimbursement for federal grants for programs with the correct employer identification number. Lynn Lindsey, Chief Financial Officer, will be responsible to ensure that this is accomplished and will begin to implement new procedures. The corrective action plan will be implemented by September 30, 2024.

View Audit 310696

Finding 403119 (2022-010)

Material Weakness 2022

State of California

CA

Eligibility Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.303

Public Health’s Office of Aids (OA) agrees with the finding and recommendation. OA developed and implemented additional internal quality assurance (QA) processes in April of 2022 to ensure that secondary reviews of AIDS Drug Assistance Program (ADAP) applications are consistently enforcing the exist...

Public Health’s Office of Aids (OA) agrees with the finding and recommendation. OA developed and implemented additional internal quality assurance (QA) processes in April of 2022 to ensure that secondary reviews of AIDS Drug Assistance Program (ADAP) applications are consistently enforcing the existing guidelines, including acceptable supporting documentation and accurate eligibility requirements. Prior to this audit period, and through December 2021, ADAP had issued multiple policy memos to respond to the COVID-19 pandemic, which enabled staff and enrollment workers to defer documentation collection, when necessary, to remain flexible and ensure clients impacted by the pandemic, and associated site closures, did not lose eligibility and access to life-saving medications and comprehensive healthcare. These flexibilities in our guidelines were implemented based on guidance received from our federal funder, the Health Resources and Services Administration, which encouraged ADAP to reassess its organization's eligibility and recertification policies and procedures, and remove any barriers that may impede social distancing, or other public health strategies, necessary to minimize COVID-19 transmission. This documentation deferral was terminated on December 31, 2021, and since January 1, 2022, full documentation and eligibility requirements have been enforced. This, combined with ongoing QA efforts, will help mitigate future findings in ADAP applications. Estimated Implementation Date: Implemented as of April 2022 Contact: Joseph Lagrama, Branch Chief AIDS Drug Assistance Program Branch California Department of Public Health

View Audit 310237

Finding 403113 (2022-006)

Material Weakness 2022

State of California

CA

Questioned Costs Eligibility Reporting § 200.303

The EDD resumed adjudicating all potential eligibility issues as of January 2021 and completed the retroactive determination workload on April 30, 2023. Estimated Implementation Date: April 2023 Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California Em...

The EDD resumed adjudicating all potential eligibility issues as of January 2021 and completed the retroactive determination workload on April 30, 2023. Estimated Implementation Date: April 2023 Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California Employment Development Department

View Audit 310237 Questioned Costs: $1

Finding 403111 (2022-005)

Material Weakness 2022

State of California

CA

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

Given the unprecedented volume of unemployment insurance claims during the federal disaster—approximately 20 million claims compared to 3.8 million during the Great Recession—EDD took action to speed payments to eligible claimants whenever possible. For example, EDD launched in July 2021 a Condition...

Given the unprecedented volume of unemployment insurance claims during the federal disaster—approximately 20 million claims compared to 3.8 million during the Great Recession—EDD took action to speed payments to eligible claimants whenever possible. For example, EDD launched in July 2021 a Conditional Payment Program to speed payments to claimants who certified for benefits and already received at least one week of benefits in the past but whose payments were later pending for more than two weeks. EDD also boosted its capacity to process workloads, prioritized timely payments, and employed automation among other measures. As reported in Reference Number 2020-006 in fiscal year 2019-2020, EDD began automatically cross-matching EDD wage records and Franchise Tax Board records in November 2020 to assist in verifying the income of PUA claimants who could not be automatically verified through these procedures. Such claimants were required to submit additional documentation to EDD for a manual review. Regarding the manual processing of the income documents to substantiate the PUA weekly benefit amounts that have been increased above the minimum California WBA of $167, and the verification of employment or self-employment substantiation (known in California as “Self-employment/Employment Substantiation” or “SEES”), on February 6, 2024, in accordance with the U.S. Department of Labor (DOL) Unemployment Insurance Program Letter 05-24, the California Employment Development Department (EDD) identified that the processing of PUA income documents and the SEES workloads must be considered resolved due to California’s finality laws. The EDD is prohibited by law from resolving these items by California Unemployment Insurance Code section 1376, which provides that EDD cannot establish overpayments more than one year after the close of the benefit year in which the overpayment was made unless the overpayment is found to be a result of fraud, misrepresentation, or willful nondisclosure. Given that there is no fraud or fault on the part of the individuals identified in these populations, EDD is unable to take the required actions to resolve the workload due to California’s finality law provisions. EDD is expecting a response from DOL agreeing with the application of California’s finality laws to the PUA income verification and the SEES workloads. Estimated Implementation Date: Upon DOL response, to be determined Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California Employment Development Department

View Audit 310237 Questioned Costs: $1

Finding 403109 (2022-004)

Material Weakness 2022

State of California

CA

Questioned Costs Eligibility Internal Control / Segregation of Duties § 200.303

As reported in the prior year’s response, since fiscal year 2020-21, the Employment Development Department (EDD) has implemented dozens of strict anti-fraud measures and has continued to evaluate and enhance its fraud detection. EDD has also developed internal fraud working groups and a multiagency ...

As reported in the prior year’s response, since fiscal year 2020-21, the Employment Development Department (EDD) has implemented dozens of strict anti-fraud measures and has continued to evaluate and enhance its fraud detection. EDD has also developed internal fraud working groups and a multiagency fraud task force that reviews fraud data and fraud reports on a continual basis and recommends adjustments to filters and tools as necessary. EDD has successfully halted two large fraud scheme attempts over the previous two years and continues to work towards immediate detection and prevention of fraud attempts. EDD will continue to analyze and assess our processes to stay ahead of the ever-evolving fraud landscape. As previously described, EDD implemented the following measures to address the nationwide fraud attempts perpetrated against the new emergency federal benefit programs in 2020-21: • Implemented additional cross-matches in September 2020 to detect multiple claims per address. • Ceased automatically backdating PUA claims under federal rules in September 2020. • Strengthened identity verification procedures in October 2020 by implementing ID.me. • Implemented additional cross-matches in November 2020 against state inmate information. • Vetted applications against law enforcement databases and other tools provided by Thomson Reuters in December 2020 to further curb identity and non-identity fraud. • Established a 1099-G call center to help victims of identity theft deal with any tax-related questions. • Ceased printing Social Security numbers on mailed documents to reduce identity theft risk. • Enhanced benefit card security with Bank of America. • Partnered with state, local and federal law enforcement agencies to support thousands of criminal investigations, arrests, prosecutions and convictions. The EDD has and will continue to evaluate and enhance the fraud detection/prevention tools that have been put in place. Estimated Implementation Date: Annual reassessment to be completed September 2024 Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California Employment Development Department

View Audit 310237 Questioned Costs: $1

Finding 403107 (2022-003)

Material Weakness 2022

State of California

CA

Eligibility Allowable Costs / Cost Principles HUD Housing Programs § 200.303

The California Department of Public Health (Public Health) Women, Infants, and Children (WIC) Division had agreed that the WIC Web Information System Exchange (WISE) system does not currently store eligibility history that should be included in the “Cert History Report,” and the initial eligibility ...

The California Department of Public Health (Public Health) Women, Infants, and Children (WIC) Division had agreed that the WIC Web Information System Exchange (WISE) system does not currently store eligibility history that should be included in the “Cert History Report,” and the initial eligibility data is overwritten when subsequent eligibility information is keyed into WIC WISE. However, WIC WISE does include preventative internal stops or checkpoints that do not allow ineligible individuals to be certified and issued benefits (e.g., over income, not a California resident, no nutrition risk factor, etc.). User acceptance testing vetted these items prior to system implementation in 2019/20. The certification history condition discussed was remediated via a system Defect Correction to WIC WISE that was in user acceptance testing for implementation in Fall 2023. Public Health/WIC has entered Defect Correction #6972 in TFS (Team Foundation Services), the tracking system previously used to capture system changes and defects. The defect correction supports a system change to ensure initial eligibility information is retained when subsequent eligibility information is entered into WIC WISE. Estimated Implementation Date: August 2023 Contact: William Welch, Assistant Division Chief, Operations Women, Infants, and Children Division California Department of Public Health

View Audit 310237

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