Corrective Action Plans

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Finding 1681 (2023-003)
Significant Deficiency 2023
Finding 2023-003 ELIGIBILITY - INACCURATE RESOURCE ENTRY Name of contact person: "Stacy Ragsdale, Adult Medicaid Supervisor" Corrective Action: One on one training with worker that did not mark vehicles property and reminder at an Adult Medicaid unit meeting to all worker...
Finding 2023-003 ELIGIBILITY - INACCURATE RESOURCE ENTRY Name of contact person: "Stacy Ragsdale, Adult Medicaid Supervisor" Corrective Action: One on one training with worker that did not mark vehicles property and reminder at an Adult Medicaid unit meeting to all workers. Proposed Completion Date: 10/31/2023. Will be checked on monthly 2nd party reviews.
Finding 1680 (2023-002)
Significant Deficiency 2023
Finding 2023-002 ELIGIBILITY - INACCURATE INFORMATION ENTRY Name of contact person: "Robin Huneycutt, Family and Children's Medicaid Supervisor" Corrective Action: Unit meeting to discuss the importance/requirement to enter all information correctly into NCFast. P...
Finding 2023-002 ELIGIBILITY - INACCURATE INFORMATION ENTRY Name of contact person: "Robin Huneycutt, Family and Children's Medicaid Supervisor" Corrective Action: Unit meeting to discuss the importance/requirement to enter all information correctly into NCFast. Proposed Completion Date: Meeting will be held on 10/31/2023. Will be checked during monthly 2nd party reviews.
Finding 1678 (2023-004)
Significant Deficiency 2023
Finding 2023-004 ELIGIBILITY - NON-COOPERATION WITH CHILD SUPPORT PROCEDURES Name of contact person: "Catherine Lytch, DSS Director" Corrective Action: "The department incorrectly interpreted the policy which required the department to send a post-eligibility 5097 form, a...
Finding 2023-004 ELIGIBILITY - NON-COOPERATION WITH CHILD SUPPORT PROCEDURES Name of contact person: "Catherine Lytch, DSS Director" Corrective Action: "The department incorrectly interpreted the policy which required the department to send a post-eligibility 5097 form, at the time of the determination, counties could not terminate an individual's Medicaid for non-cooperation with child support. However, under new guidance published in Admin Letter 13-23 on August 18, 2023, due to the unwinding period the request for absent parent information is no longer required, therefore this will no longer be an issue going forward. " Proposed Completion Date: "DHHS updated policy in Admin Letter 13-23 on August 18, 2023, this will no longer be an issue going forward. "
Finding 1677 (2023-003)
Significant Deficiency 2023
Finding 2023-003 ELIGIBILITY - INADEQUATE REQUEST FOR INFORMATION Name of contact person: "Catherine Lytch, DSS Director" Corrective Action: "The department will conduct refresher training on running and reviewing electronic sources and checking all resources. Additional...
Finding 2023-003 ELIGIBILITY - INADEQUATE REQUEST FOR INFORMATION Name of contact person: "Catherine Lytch, DSS Director" Corrective Action: "The department will conduct refresher training on running and reviewing electronic sources and checking all resources. Additionally, the department will conduct targeted case reads for the next three months to ensure the agency is following policy. " Proposed Completion Date: 1/31/2024
Finding 1676 (2023-002)
Significant Deficiency 2023
Finding 2023-002 ELIGIBILITY - INACCURATE RESOURCE ENTRY Name of contact person: "Catherine Lytch, DSS Director" Corrective Action: "The department supervisors will remind staff to double-check casework to ensure dates and amounts are entered correctly prior to processing...
Finding 2023-002 ELIGIBILITY - INACCURATE RESOURCE ENTRY Name of contact person: "Catherine Lytch, DSS Director" Corrective Action: "The department supervisors will remind staff to double-check casework to ensure dates and amounts are entered correctly prior to processing the case during monthly conferences, team meetings, and trainings. " Proposed Completion Date: 1/31/2024
Finding 1675 (2023-001)
Significant Deficiency 2023
Finding 2023-001 ELIGIBILITY - INACCURATE INFORMATION ENTRY Name of contact person: "Catherine Lytch, DSS Director" Corrective Action: "The department will conduct refresher training on reading and reviewing electronic sources. Additionally, the department will conduct ta...
Finding 2023-001 ELIGIBILITY - INACCURATE INFORMATION ENTRY Name of contact person: "Catherine Lytch, DSS Director" Corrective Action: "The department will conduct refresher training on reading and reviewing electronic sources. Additionally, the department will conduct targeted case reads for the next three months to ensure the agency is following policy. " Proposed Completion Date: 1/31/2024
Finding 2023-003 – Allowable Costs and Activities, Eligibility – Compliance Federal Award. No. 21.026 Homeowner Assistance Fund – COVID 19 Corrective Action Plan: The Commission was made aware of the sophisticated fraudulent entity through its contacts with the National Council of State Housing Agen...
Finding 2023-003 – Allowable Costs and Activities, Eligibility – Compliance Federal Award. No. 21.026 Homeowner Assistance Fund – COVID 19 Corrective Action Plan: The Commission was made aware of the sophisticated fraudulent entity through its contacts with the National Council of State Housing Agencies (NCSHA). Staff remains active in those groups, participating in weekly and monthly calls and will adopt further preventative measures that have been shown to be effective in other states. Staff has implemented a more rigorous servicer onboarding process, whereby questionable items or documentation deemed to be suspicious or potentially altered will be presented to the program director, finance staff, compliance staff, or other internal staff for further investigation. Staff does not anticipate further issues with falsified information with the enhanced onboarding procedures implemented. In addition, balances owed are verified by loan servicers, and funds are paid directly to the servicer and never to individual homeowners. Completion Date: The Commission implemented additional compliance review procedures during fiscal year 2023 and completed its investigation of the identified case. Contact Person: Steve Whitson, Director of Community Programs
View Audit 2908 Questioned Costs: $1
Finding 2023-002 – Allowable Costs and Activities, Eligibility – Compliance and Control Finding Federal Award No. 21.023 Emergency Rental Assistance Program – COVID 19 Corrective Action Plan: The Commission administered direct assistance according to the program rules and regulations. The Commission...
Finding 2023-002 – Allowable Costs and Activities, Eligibility – Compliance and Control Finding Federal Award No. 21.023 Emergency Rental Assistance Program – COVID 19 Corrective Action Plan: The Commission administered direct assistance according to the program rules and regulations. The Commission collected the required information and documentation to review and approve applications. Applicants submitted certified applications meeting the requirements of the program. However, the Commission staff discovered through its noncompliance review and identification processes that some program applicants provided false information and fraudulent documentation that continues to be investigated and reported to the proper authorities. Internal controls have been enhanced to mitigate and help prevent further exposure to noncompliance. Past and ongoing measures implemented to ensure eligibility of all funds disbursed include: the adoption of a formal fraud, waste, and abuse policy in July 2021 as well as providing additional training to employees and third parties that were responsible for reviewing and approving applications in order to better detect invalid applicants to prevent funding these applicants. In May 2021, the Commission hired an Internal Compliance Manager and created an Internal Compliance Department who has engaged a third party law firm and a consulting group to provide consultative assistance to improve processes and to assist in investigating applications deemed to be questionable. Further, internal staffing capacity was expanded with the creation of the Community Programs Processes Department in fall 2021 and the Data and Analytics Department in early 2022. Additional investigative techniques such as “mass denial metrics” and tiered level reviews were implemented into weekly application processing. Commission staff set regular internal coordination meetings to improve communication and aid in the identification of new indicators. Internal compliance staff actively participates in national groups administering similar programs, and explores and adopts new preventative or other review measures demonstrated to be effective in other states. As program funds for direct rental and utility assistance have been expended and direct assistance applications no longer accepted, additional internal metrics and compliance review processes are being developed to apply a consistent process for examining any outstanding questioned costs and to make a final determination regarding the eligibility of disbursed funds. Completion Date: The Commission implemented additional compliance review procedures during fiscal years 2021 and 2022 and expects to conclude its investigation of the fiscal year identified cases during calendar year 2024. Contact Person: Steve Whitson, Director of Community Programs
View Audit 2908 Questioned Costs: $1
Finding 2023-001 – Allowable Costs and Activities – Compliance and Control Finding Federal Award No. 14.231 Emergency Solutions Grant Program – COVID 19 Corrective Action Plan: The Commission administered direct assistance according to the program rules and regulations. The Commission collected the ...
Finding 2023-001 – Allowable Costs and Activities – Compliance and Control Finding Federal Award No. 14.231 Emergency Solutions Grant Program – COVID 19 Corrective Action Plan: The Commission administered direct assistance according to the program rules and regulations. The Commission collected the required information and documentation to review and approve applications. Applicants submitted certified applications meeting the requirements of the program. However, the Commission staff discovered through its noncompliance review and identification processes that some program applicants provided false information and fraudulent documentation that continues to be investigated and reported to the proper authorities. Internal controls have been enhanced to mitigate and identify instances of potential noncompliance. The use of program funds for direct rental assistance under this program was concluded and the final disbursements made in early May 2021. Past and ongoing measures implemented to ensure eligibility of all funds disbursed include: The Commission hiring an Internal Compliance Manager and establishing an internal compliance department in May 2021 who engaged a third party law firm and a consulting group to provide consultative assistance to improve processes and to assist in investigating applications deemed to be questionable. A formal fraud, waste and abuse policy was adopted in July 2021. During fiscal year 2022, the Commission undertook extensive efforts to detect instances of ineligible applicants and documentation irregularities, which resulted in identification of these instances of applicant noncompliance. As program funds for direct rental assistance have been expended, additional internal metrics and compliance review processes are being developed to apply a consistent process for examining any outstanding questioned costs and to make a final determination regarding the eligibility of disbursed funds. Completion Date: The Commission implemented additional compliance review procedures during fiscal years 2021 and 2022, reviewed applications to identify potentially fraudulent applications during fiscal years 2022 and 2023 and expects to conclude its investigation of identified cases during fiscal year 2024. Contact Person: Steve Whitson, Director of Community Programs
View Audit 2908 Questioned Costs: $1
Plan: A procedure will be implemented to ensure that all tenant income and expenses are calculated correctly. Anticipated Completion Date: 7/31/2023. Contact Duska Noel, Director of Housing and Michael Tabory, Chief Operating Officer.
Plan: A procedure will be implemented to ensure that all tenant income and expenses are calculated correctly. Anticipated Completion Date: 7/31/2023. Contact Duska Noel, Director of Housing and Michael Tabory, Chief Operating Officer.
As a result of this audit, Kearney Public Schools Bearcat Diner employees (2) will each be responsible for entering the free and reduced applications and sign off on their completed applications. Each, will then be responsible for verifying the accuracy of their co-worker’s data entry. The person wh...
As a result of this audit, Kearney Public Schools Bearcat Diner employees (2) will each be responsible for entering the free and reduced applications and sign off on their completed applications. Each, will then be responsible for verifying the accuracy of their co-worker’s data entry. The person who originally completes the application will be the determining official and both employees will sign the application. Director of Nutrition Services will create a daily checklist to include: Application checked by co-worker, data entered into nutrition software and SIS, letters have been mailed a hard copy and an email, and list of families emailed to FSD daily to verify completion. Additionally, the Bearcat Diner Systems Analyst will complete the verification process and the FSD will review responses of the verification and check for accuracy, family notification of status and that data has been entered into nutrition software and SIS before submitting verification data to the state website. The Director will be responsible for reviewing and verifying the data entered and that all other recommendations provided are met with timeliness and accuracy.
View Audit 2825 Questioned Costs: $1
Need Analysis Planned Corrective Action: The financial aid staff has reporting available within PowerFAIDS to monitor and check for oversights related to need analysis. The team will review the reports to ensure that they are set up properly to identify such issues created by human error, as well a...
Need Analysis Planned Corrective Action: The financial aid staff has reporting available within PowerFAIDS to monitor and check for oversights related to need analysis. The team will review the reports to ensure that they are set up properly to identify such issues created by human error, as well as ensuring that these reports are being monitored more regularly. The team is also investigating what additional information can be added to the PowerFAIDS student financial aid portal to help students better understand the benefits of accepting a subsidized loan over an unsubsidized loan. Person Responsible for Corrective Action Plan: Cindi Patterson, Director for Financial Aid Anticipated Date of Completion: December 2023
Disbursements to Ineligible Students Planned Corrective Action: While the Office of Financial Aid sought to replicate controls that were in place within the legacy system, the noted disbursements to ineligible students were a direct result of the system conversion to Workday. The following measures ...
Disbursements to Ineligible Students Planned Corrective Action: While the Office of Financial Aid sought to replicate controls that were in place within the legacy system, the noted disbursements to ineligible students were a direct result of the system conversion to Workday. The following measures have been or will be taken to prevent such disbursements in the future. Transfer credit evaluation (prior degree and TEACH grant) To ensure students with prior bachelor’s degrees are not awarded incorrectly, the office will coordinate with the Registrar’s Office to ensure that all undergraduate students with a prior degree are flagged immediately after transcript evaluation. The transfer credit coordinator will notify the Office of Financial Aid. If the student’s ISIR does not reflect they have earned a prior bachelor’s degree the student will be notified and the ISIR will be corrected. Existing award programming prevents students with ISIRs indicating a prior degree from being awarded aid for which they are ineligible. To ensure transfer students with GPAs that do not meet the requirements to receive TEACH grant are not awarded incorrectly, the office will conduct a review of all transfer students awarded TEACH grant once all their transcripts have been received to ensure they meet transfer GPA eligibility requirements. Loans in excess of limits To ensure students are not awarded loans in excess of their aggregate limits, the financial aid operations department has begun to proactively review NSLDS data for any student that is seen to be approaching loan limits. When an ISIR indicates an eligibility amount that is less than a single year’s maximum award, the operations department reviews NSLDS and overrides aggregate totals as needed to ensure students are not awarded over their limits. We are going to work with our post-implementation consulting partner, Alchemy, to determine other best practices within Workday. Pell Grant awarded for courses that do not apply to student’s program of study To ensure students are not awarded Pell grant for courses that do not apply to their program of study, the office developed reports to compare the financial aid load used to calculate the award with the financial aid loan within the student’s program of study. While these reports were in use during the 2022-2023 award year, there were some academic programs that had to be updated because of issues with their initial setup. Those changes have abated in this second academic year, but the financial aid technician will conduct a final check in the last week of the 7A and 7B terms so any changes to program of study load status can be reevaluated. Person Responsible for Corrective Action Plan: Michael Sapienza, Associate Vice President of Enrollment Services Anticipated Date of Completion: Necessary reports and calculations will be developed prior to December 1, 2023. Review will continue on a continuous basis.
View Audit 2820 Questioned Costs: $1
FINDING NO. 2023-002: Section 207/223(f) Mortgage Insurance for the Refinancing of Existing Multifamily Housing Projects, ALN 14.155 Recommendation: The Project should maintain all required tenant documentation including proper signatures on applications, support for security deposit collections, ev...
FINDING NO. 2023-002: Section 207/223(f) Mortgage Insurance for the Refinancing of Existing Multifamily Housing Projects, ALN 14.155 Recommendation: The Project should maintain all required tenant documentation including proper signatures on applications, support for security deposit collections, evidence that tenants meet the age or disability requirements, and verification of tenant income through the EIV system. Action Taken: The compliance department will provide additional training with the manager on screening policies and procedures. Compliance will also conduct periodic file reviews ensuring screenings were performed and that a copy of the report was put into the tenant file.
Finding 1315 (2023-001)
Significant Deficiency 2023
Wentworth Corporation agrees with the audit finding identified as part of the FY23 Annual Audit performed by Marcum, Inc. The inconsistencies occurred during a transition of personnel and is believed to be an isolated incident associated with orientation. Going forward, controls will be put in place...
Wentworth Corporation agrees with the audit finding identified as part of the FY23 Annual Audit performed by Marcum, Inc. The inconsistencies occurred during a transition of personnel and is believed to be an isolated incident associated with orientation. Going forward, controls will be put in place to assure compliance, including, but not limited to, centralization of files, improved orientation procedures and periodic internal reviews conducted by Finance staff.
Finding 1314 (2023-001)
Significant Deficiency 2023
Shore Courts, Inc. agrees with the audit finding identified as part of the FY23 Annual Audit performed by Marcum, Inc. The inconsistencies occurred during a transition of personnel and is believed to be an isolated incident associated with orientation. Going forward, controls will be put in place to...
Shore Courts, Inc. agrees with the audit finding identified as part of the FY23 Annual Audit performed by Marcum, Inc. The inconsistencies occurred during a transition of personnel and is believed to be an isolated incident associated with orientation. Going forward, controls will be put in place to assure compliance, including, but not limited to, centralization of files, improved orientation procedures and periodic internal reviews conducted by Finance staff.
Finding 1313 (2023-001)
Significant Deficiency 2023
JM Apartments agrees with the audit finding identified as part of the FY23 Annual Audit performed by Marcum, Inc. The inconsistencies occurred during a transition of personnel and is believed to be an isolated incident associated with orientation. Going forward, controls will be put in place to ass...
JM Apartments agrees with the audit finding identified as part of the FY23 Annual Audit performed by Marcum, Inc. The inconsistencies occurred during a transition of personnel and is believed to be an isolated incident associated with orientation. Going forward, controls will be put in place to assure compliance, including, but not limited to, centralization of files, improved orientation procedures and periodic internal reviews conducted by Finance staff.
View Audit 2464 Questioned Costs: $1
The superintendent will verify with the staff member in charge of the verification process that the verification process is completed according to the proper timeline; review the income verification information provided by families and ensure the proper status has been redetermined; ensure families ...
The superintendent will verify with the staff member in charge of the verification process that the verification process is completed according to the proper timeline; review the income verification information provided by families and ensure the proper status has been redetermined; ensure families are timely notified of the confirmed or changed status; verify necessary status changes have been updated in the nutrition program software.
View Audit 2430 Questioned Costs: $1
When District staff learns o facts that could affect eligibility determination, they will request households submit a new application with the updated information rather than altering the original application.
When District staff learns o facts that could affect eligibility determination, they will request households submit a new application with the updated information rather than altering the original application.
View Audit 2430 Questioned Costs: $1
FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS SIGNIFICANT DEFICIENCY 2023.001 – Sliding Fee Scale Discount Recommendation The Center should implement a system of controls to ensure all sliding fee discounts are properly supported. Action Taken All the Practice Managers (PM) and Director of Practice M...
FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS SIGNIFICANT DEFICIENCY 2023.001 – Sliding Fee Scale Discount Recommendation The Center should implement a system of controls to ensure all sliding fee discounts are properly supported. Action Taken All the Practice Managers (PM) and Director of Practice Management have been and will continue to review and monitor the sliding fee discount (SFD) on a daily basis on all slides for internal control. StayWell’s Patent Intake solution, ‘Phreesia’ has a dashboard in which this tool is being utilized effective November 1st, 2022 to monitor internal controls at the front desk operations with regard to accuracy of registration, patient demographic, insurance verification and most importantly the application of the Sliding Fee Discount Program and ensuring there is proper documentation to support (POI). Monthly random audits on the sliding fee discount program will continue to be performed by the PM’s and the Director of Practice Management. Director of Practice Management will also continue to perform SFD program compliance education to all Patients Service Associates (PSA) and all Practice Managers (PM) on a as needs basis.
View of Responsible Official: The Agency agrees with the finding. The Agency will terminate ineligible participant immediately and will conduct an internal audit of all current participants to be in compliance with financial reporting and single audit reporting requirements. Planned Implementation D...
View of Responsible Official: The Agency agrees with the finding. The Agency will terminate ineligible participant immediately and will conduct an internal audit of all current participants to be in compliance with financial reporting and single audit reporting requirements. Planned Implementation Date of Corrective Action : 10/31/2023 Person Responsible for Corrective Action: Andrew Boozer, Executive Director, Marcus Hunter, Director of Finance and Operations, and Beverly Breuer, Director of FGP/SCP Programs.
Views of Responsible Official and Planned Corrective Actions: The District agrees with this recommendation. Brian Bartlett, School Business Administrator, will be responsible for ensuring the maintenance of effort (MOE) calculation is completed within the required timeline provided by NYSED. The MOE...
Views of Responsible Official and Planned Corrective Actions: The District agrees with this recommendation. Brian Bartlett, School Business Administrator, will be responsible for ensuring the maintenance of effort (MOE) calculation is completed within the required timeline provided by NYSED. The MOE calculation for 2022-23 was submitted to NYSED and evidenced that the District was in compliance with the grant regulations. This will be corrected by June 30, 2024.
Segregation of Duties Supportive Housing for the Elderly – Assistance Listing No. 14.157 Recommendation: The Project should continue to evaluate its staffing in order to segregate incompatible duties whenever possible. Explanation of disagreement with audit finding: There is no disagreement with the...
Segregation of Duties Supportive Housing for the Elderly – Assistance Listing No. 14.157 Recommendation: The Project should continue to evaluate its staffing in order to segregate incompatible duties whenever possible. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The board of directors will continue to closely monitor the financial operations of the Project. Name(s) of the contact person(s) responsible for corrective action: Mary Gilberts, Management Agent Planned completion date for corrective action plan: June 2024
During the 2023 audit of PrairieStar Health Center, FORVIS found two issues with the sliding fee set up. The first issue was that CPT code 73610 was attached to the wrong slide level due to a change in price. The CPT code was attached to the Radiology 2 group which is for CPTs between $100.00 and ...
During the 2023 audit of PrairieStar Health Center, FORVIS found two issues with the sliding fee set up. The first issue was that CPT code 73610 was attached to the wrong slide level due to a change in price. The CPT code was attached to the Radiology 2 group which is for CPTs between $100.00 and $114.99. The price of the CPT had been changed from $102.00 to $120.00 and should have been moved to the Radiology 3 group which is for CPTs between $115.00 and $169.99. The second issue was that CPT code 90620 was not set up to slide. In the six and one-half years that I have been at PrairieStar, we have made great strides in identifying CPT codes that were not attached to a sliding fee group and correcting them. I feel that this is a rare CPT code that has been missed in our review. Plan to Correct Finding Multiple steps have or will be taken to correct this finding. • Both of the errors above have been corrected in our EMR. • We are getting ready to update pricing. As part of this update, I will review the slide group attached to each CPT code to make sure that the correct slide is attached. • We will continue to randomly review sliding fee calculations each month to help identify any errors in sliding fee calculations or setup. Date of Completion Both of the errors described above have been corrected. There is no completion date for the monthly review. This is a part of our monthly routine. Responsible Party Shandi Stallman, Chief Financial Officer, is the party that has overall responsibility for this corrective action.
October 24, 2023 Finding Number: 2023-003 – Significant Deficiency in Internal Control – Eligibility Condition: Of the 22 applications for reduced meals that were selected for testing, 3 did not document evidence of review by staff. Responsible Person: Kim Gagne – Director of Food Service Imple...
October 24, 2023 Finding Number: 2023-003 – Significant Deficiency in Internal Control – Eligibility Condition: Of the 22 applications for reduced meals that were selected for testing, 3 did not document evidence of review by staff. Responsible Person: Kim Gagne – Director of Food Service Implementation Date: 10-24-2023 This year we have a 2-person checking system, Kim Gagne initially completes the applications with a signature and Jody King double checks every application for errors and oversites and adds her signature also. Both have been through the MDE training on the applications and the required information they need. Sincerely, Stephen Grubaugh Director of Business Services
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