Corrective Action Plans

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Finding 7072 (2023-005)
Significant Deficiency 2023
Finding 2023-005 Name of contact person: Corrective Action: Proposed completion date: For Adult - Training to be provided to all caseworkers to include OVS learning gateway webinar, Mastering Medicaid Policy Webinar, and Recertification & Continuous Coverage Unwinding training. Review of MA Policy S...
Finding 2023-005 Name of contact person: Corrective Action: Proposed completion date: For Adult - Training to be provided to all caseworkers to include OVS learning gateway webinar, Mastering Medicaid Policy Webinar, and Recertification & Continuous Coverage Unwinding training. Review of MA Policy Section Financial Resources. Bi-weekly 3-hour staffing sessions with caseworkers. For Family and Children - Training to be provided to all caseworkers to include TWN and OVS learning gateway webinars. Review of policy for exparte process and system reviews. Training to include retaining manual OLV hits. Including covering in detail the documentation template that is required to be completed for each case. Target 2nd parties will be completed at 2 per worker per week of cases processed within the month. Feedback shared with worker to ensure training was effective. For Adult - Training will occur December 2023, once the training is provided the additional 2nd parties of cases will begin and continue for 2 months into Feb 2024. For Family and Children - Training will occur Nov.30th 2023.
Finding 7071 (2023-004)
Significant Deficiency 2023
Finding 2023-004 Name of contact person: Corrective Action: Proposed completion date: Finding 2023-005 Name of contact person: Corrective Action: Proposed completion date: For Adult - Training to be provided to all caseworkers to include OVS learning gateway webinar, Mastering Medicaid Policy Webina...
Finding 2023-004 Name of contact person: Corrective Action: Proposed completion date: Finding 2023-005 Name of contact person: Corrective Action: Proposed completion date: For Adult - Training to be provided to all caseworkers to include OVS learning gateway webinar, Mastering Medicaid Policy Webinar, and Recertification & Continuous Coverage Unwinding training. Review of MA Policy Section Financial Resources. Bi-weekly 3-hour staffing sessions with caseworkers. For Family and Children - Training to be provided to all caseworkers to include TWN and OVS learning gateway webinars. Review of policy for exparte process and system reviews. Training to include retaining manual OLV hits. Including covering in detail the documentation template that is required to be completed for each case. Target 2nd parties will be completed at 2 per worker per week of cases processed within the month. Feedback shared with worker to ensure training was effective. For Adult - Training will occur December 2023, once the training is provided the additional 2nd parties of cases will begin and continue for 2 months into Feb 2024. For Family and Children - Training will occur Nov.30th 2023. Section III - Federal Award Findings and Questioned Costs (continued) Lyn Saunders - Adult Medicaid Supervisor, Melissa McDaniels – Family and Children's Medicaid Supervisor Melissa McDaniels –Family and Children's Medicaid Supervisor Training to be provided to cover IV-D Referral Policy and Process, this will include OVS ACTS review, review of policy to know when a referral is required to include if a client requests to be referred. A laminated desk reference will be provided at the time of training, this will have examples of when a referral is needed along with how to enter the referral within NCFAST. Training will occur Nov. 30th 2023.
Finding 7070 (2023-003)
Significant Deficiency 2023
Finding 2023-003 Name of contact person: Corrective Action: Proposed completion date: Section II - Financial Statement Findings Section III - Federal Award Findings and Questioned Costs For the Year Ended June 30, 2023 Corrective Action Plan Immediately and ongoing Donna Wood, Finance Director Train...
Finding 2023-003 Name of contact person: Corrective Action: Proposed completion date: Section II - Financial Statement Findings Section III - Federal Award Findings and Questioned Costs For the Year Ended June 30, 2023 Corrective Action Plan Immediately and ongoing Donna Wood, Finance Director Training will occur Nov. 30th 2023. Team meeting will be held to discuss findings of audit, errors cited to include Household Composition, income calculation and TWN calls for each household member age 14 or old on an application or Recertification. Finance Director will review year end salary accrual along with the Payroll Specialist to ensure correct salary accruals. The Finance Director will work with the Accountant to calculate and update the EMS net receivables each year to ensure proper posting to the General Ledger, working with information from the County’s billing and collection agency. Melissa McDaniels –Family and Children's Medicaid Supervisor Training to be provided to all caseworkers to include TWN and OVS learning gateway webinars. Review of policy for exparte process and system reviews. Training to also include Income Policy, how to review for self-employment income and utilize the income wizard to enter weekly, bi-weekly and monthly income amounts so the system will calculate the income and leave less room for user error. Documentation of what income is being evaluated to also include why certain incomes are not counted. Training to include review of Household Composition, tax filing status and how to review the determinations of each case before completing/ releasing auto holds. Lyn Saunders - Adult Medicaid Supervisor Training to be provided to caseworkers to include review of Job Aids for Adding Evidence to an application, Adding Evidence to a Case, and Adding Verifications. Review of MA Policy Financial Resources. Bi-weekly 3-hour staffing sessions with caseworkers. Target 2nd parties will be completed at 2 per worker per week of cases processed within the month. Feedback shared with worker to ensure training was effective. Training will occur December 2023, once the training is provided the additional 2nd parties of cases will begin and continue for 2 months into Feb 2024.
Finding 7069 (2023-002)
Significant Deficiency 2023
Finding 2023-002 Name of contact person: Corrective Action: Proposed completion date: Finding 2023-003 Name of contact person: Corrective Action: Proposed completion date: Section II - Financial Statement Findings Section III - Federal Award Findings and Questioned Costs For the Year Ended June 30, ...
Finding 2023-002 Name of contact person: Corrective Action: Proposed completion date: Finding 2023-003 Name of contact person: Corrective Action: Proposed completion date: Section II - Financial Statement Findings Section III - Federal Award Findings and Questioned Costs For the Year Ended June 30, 2023 Corrective Action Plan Immediately and ongoing Donna Wood, Finance Director Training will occur Nov. 30th 2023. Team meeting will be held to discuss findings of audit, errors cited to include Household Composition, income calculation and TWN calls for each household member age 14 or old on an application or Recertification. Finance Director will review year end salary accrual along with the Payroll Specialist to ensure correct salary accruals. The Finance Director will work with the Accountant to calculate and update the EMS net receivables each year to ensure proper posting to the General Ledger, working with information from the County’s billing and collection agency. Melissa McDaniels –Family and Children's Medicaid Supervisor Training to be provided to all caseworkers to include TWN and OVS learning gateway webinars. Review of policy for exparte process and system reviews. Training to also include Income Policy, how to review for self-employment income and utilize the income wizard to enter weekly, bi-weekly and monthly income amounts so the system will calculate the income and leave less room for user error. Documentation of what income is being evaluated to also include why certain incomes are not counted. Training to include review of Household Composition, tax filing status and how to review the determinations of each case before completing/ releasing auto holds.
Finding 7068 (2023-006)
Significant Deficiency 2023
Finding 2023-006 Name of contact person: Corrective Action: Proposed completion date: Jessica Hill, Food and Nutrition Services Supervisor Training will be conducted in December 2023 in the following noted areas: Reviewing OVS ESC tab for all household members and related quarters to question each e...
Finding 2023-006 Name of contact person: Corrective Action: Proposed completion date: Jessica Hill, Food and Nutrition Services Supervisor Training will be conducted in December 2023 in the following noted areas: Reviewing OVS ESC tab for all household members and related quarters to question each employer listed in related quarters. Training of documentation of termination wages and verification sources to verify earned income. Conduct a documentation training exercise to ensure verification of all expenses given as a deduction. Review acceptable forms of verification for deductions given. Conduct an earned income exercise to review base period requirements and calculation of correct gross amount to determine correct earned income for the FNS unit. Review of documentation procedures and referencing to The Work Number verifying employment terminations for applicable employers. Review of policy sections 305, 300, and 310. Second party reviews focused around income calculations, verifications, correct base period used and documentation, and verification of deductions given to FNS unit. Ensure staff understands base period for earned income, the importance of documenting case file and providing correct verification to support action taken on case file. December 2023 Section IV - State Award Findin
Federal Program TRIO Cluster Compliance requirements Reporting Condition During testing, we identified errors in certain data elements reported during the year for TRIO participants. Recommendation We recommend that the College review its controls to ensure that accurate data is reported. Com...
Federal Program TRIO Cluster Compliance requirements Reporting Condition During testing, we identified errors in certain data elements reported during the year for TRIO participants. Recommendation We recommend that the College review its controls to ensure that accurate data is reported. Comments on the Finding Recommendation The College agrees with the determination that certain reporting items were entered in error. We have determined that these items were not material to the College’s overall annual report. Action Taken As of November 30, 2023, and in conjunction with preparing the 2022-2023 Annual Performance Reports, all Barton TRIO programs will implement a systematic and detailed review of the participant eligibility and program acceptance information for TRIO participants. This review will include focused use of each program’s version of their “student eligibility checklist” that will ensure the systematic review and double check of the eligibility information before entry into each program’s specific participant database.
Finding 7039 (2023-004)
Significant Deficiency 2023
Training will be conducted on the Non-Cooperation with Child Support Procedures topic with staff specifically concerning the finding areas and ensuring all child support procedures are followed in accordance with policy requirements. Second party reviews will be enhanced to ensure those conducting t...
Training will be conducted on the Non-Cooperation with Child Support Procedures topic with staff specifically concerning the finding areas and ensuring all child support procedures are followed in accordance with policy requirements. Second party reviews will be enhanced to ensure those conducting the review ensure that proper procedures are being followed with regard to these policies.
Finding 7038 (2023-003)
Significant Deficiency 2023
Training will be conducted on the Inadequate Request for Information topic with staff specifically concerning the finding areas and ensuring all required requests for information are sent via 5097/20020 where applicable. Second party reviews will be enhanced to ensure those conducting the review ens...
Training will be conducted on the Inadequate Request for Information topic with staff specifically concerning the finding areas and ensuring all required requests for information are sent via 5097/20020 where applicable. Second party reviews will be enhanced to ensure those conducting the review ensure that proper procedures are being followed with regard to these policies.
Finding 7037 (2023-002)
Significant Deficiency 2023
Training will be conducted on the Inaccurate Resource topic with staff specifically concerning the finding areas and ensuring all verified resources are appropriately updated in the NC FAST evidence. Second party reviews will be enhanced to ensure those conducting the review ensure that proper proce...
Training will be conducted on the Inaccurate Resource topic with staff specifically concerning the finding areas and ensuring all verified resources are appropriately updated in the NC FAST evidence. Second party reviews will be enhanced to ensure those conducting the review ensure that proper procedures are being followed with regard to these policies.
Finding 7036 (2023-001)
Significant Deficiency 2023
Training will be conducted on the Inaccurate information entry topic with staff specifically concerning the finding areas and ensuring all verified information is appropriately updated in the NC FAST evidence. Second party reviews will be enhanced to ensure those conducting the review verify that pr...
Training will be conducted on the Inaccurate information entry topic with staff specifically concerning the finding areas and ensuring all verified information is appropriately updated in the NC FAST evidence. Second party reviews will be enhanced to ensure those conducting the review verify that proper procedures are being followed with regard to these policies.
The Authority failed to complete annual recertifications in accordance with its Administrative Plan and HUD regulations. The overall cause was a lack of management oversight and quality control over this program. Corrective Action: The Authority will reexamine family income and composition every twe...
The Authority failed to complete annual recertifications in accordance with its Administrative Plan and HUD regulations. The overall cause was a lack of management oversight and quality control over this program. Corrective Action: The Authority will reexamine family income and composition every twelve (12) months and calculate tenant rents and housing assistance payments in accordance with 24 CFR 982.516. The Authority will implement greater oversight over the Housing Choice Voucher program to ensure that annual recertifications are completed timely and accurately. This will include utilizing a recertification checklist and management review. Person Responsible: Marc Starling, Marc.Starlling@hopewellrha.org
Finding No. 2023-001- Section 8 Housing Choice Vouchers Program CFDA#14.871 Eligibility: Tenant Compliance The agency acknowledges that all tenants are required to have their income verified with current EIV Income Reports, as required by HUD regulations. Due to new staff and management changes, all...
Finding No. 2023-001- Section 8 Housing Choice Vouchers Program CFDA#14.871 Eligibility: Tenant Compliance The agency acknowledges that all tenants are required to have their income verified with current EIV Income Reports, as required by HUD regulations. Due to new staff and management changes, all staff did not always have access to EIV. Going forward management will ensure that all staff members have appropriate access to EIV and income verification methods. The PHA will also implement greater oversight over HCV compliance and train employees on procedures mandated by HUD regarding tenant income verification and annual recertification. Planned Implementation Date of Corrective Action: 12/18/2023 Person responsible for corrective action plan implementation: Interim Housing Choice Voucher Program Manager, Janice Spellman and staff. Best Regards, Navonya Thomas Director of Property Management Charlottesville Redevelopment & Housing Authority.
We will review tenant’s files for the deficiencies identified above and implement new internal control procedures to correct these conditions. We will also provide increased supervision and training over this area. We anticipate a complete resolution of this type of error by February 29, 2024.
We will review tenant’s files for the deficiencies identified above and implement new internal control procedures to correct these conditions. We will also provide increased supervision and training over this area. We anticipate a complete resolution of this type of error by February 29, 2024.
Federal agency: U.S. Department of Housing and Urban Development Federal program title: Housing Choice Voucher Program ALN Number: 14.871 & 14.879 Award Period: April 1, 2022 through March 31, 2023 Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Recomme...
Federal agency: U.S. Department of Housing and Urban Development Federal program title: Housing Choice Voucher Program ALN Number: 14.871 & 14.879 Award Period: April 1, 2022 through March 31, 2023 Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Recommendation: We recommend management should designate one person to review a sample of the new files entering the program to determine if files were prepared and processed in accordance with internal policies and compliance requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The compliance officer will ensure that at least 3 of the 15 files selected for review each month are new intakes to determine if files were prepared and processed in accordance with internal policies and compliance requirements. Name(s) of the contact person(s) responsible for corrective action: Regla Exavier and Ruchelle Hobbs Planned completion date for corrective action plan: January 1, 2024.
View Audit 8875 Questioned Costs: $1
Federal agency: U.S. Department of Housing and Urban Development Federal program title: Housing Choice Voucher Program ALN Number: 14.871 & 14.879 Award Period: April 1, 2022 through March 31, 2023 Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Recomme...
Federal agency: U.S. Department of Housing and Urban Development Federal program title: Housing Choice Voucher Program ALN Number: 14.871 & 14.879 Award Period: April 1, 2022 through March 31, 2023 Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Recommendation: We recommend management should designate one person to review a sample of the files that have been recertified each month, to determine if the tenant files were prepared in accordance with internal policies and until the compliance deficiencies have been corrected. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The compliance officer will review at least 15 files monthly and 30 SEMAP files annually to determine if the participant files were prepared in accordance with internal policies and follow up until the compliance deficiencies have been corrected. The HCVP Director will ensure that HCV staff has corrected all files within 10 days of receipt. Name(s) of the contact person(s) responsible for corrective action: Regla Exavier and Ruchelle Hobbs Planned completion date for corrective action plan: No later than 1/1/2024
View Audit 8875 Questioned Costs: $1
Finding 6867 (2023-001)
Significant Deficiency 2023
FORCED ELIGIBILITY Supervisors/Lead Workers and staff will pull case management reports weekly to ensure all recertifications are actively being completed. Staff will proactively use desk or Microsoft calendar to keep up with all recertifications. Staff will complete refresher courses for timely not...
FORCED ELIGIBILITY Supervisors/Lead Workers and staff will pull case management reports weekly to ensure all recertifications are actively being completed. Staff will proactively use desk or Microsoft calendar to keep up with all recertifications. Staff will complete refresher courses for timely notices. Supervisors will disburse vacant caseload timely after employee leaves to ensure all recertifications are accounted for, distributed and worked. Supervisors will ensure that staff run eligibility checks even if the recertification is rolled over by the system/state. In an effort to prevent the system from automatically rolling the case over, staff will process (recertify and terminate) all cases by the 8110 cutoff date. Staff will implement these changes for the January 2024 recertification period. Staff will be informed on changes and changes will be implemented on December 4, 2023.
Finding Number: 2023-001 Condition: The Hospital's controls in place for submitting expenses did not identify that several invoices and related expense amounts were duplicated in the addendum to the period 1 submission. As a result, period 1 addendum submission included expenses that were deemed una...
Finding Number: 2023-001 Condition: The Hospital's controls in place for submitting expenses did not identify that several invoices and related expense amounts were duplicated in the addendum to the period 1 submission. As a result, period 1 addendum submission included expenses that were deemed unallowable as they had already been utilized to support funding received. Reimbursement for, the original period 1 submission contained retention bonus costs that exceeded 20% of total funds awarded. Planned Corrective Action: The Hospital will review its processes surrounding submission of expenses to MHA and implement additional layers of review. Contact person responsible for corrective action: Brenda Winn and Alex Roehling Anticipated Completion Date: 9/30/2023
2023-003 Condition: Deficiencies Noted in Examination of Low-Rent Public Housing Tenant Files Steps to resolve: We will review the internal control procedures over tenant file re-certifications and documents. Management has implemented procedures along with staffing changes in order to clear thi...
2023-003 Condition: Deficiencies Noted in Examination of Low-Rent Public Housing Tenant Files Steps to resolve: We will review the internal control procedures over tenant file re-certifications and documents. Management has implemented procedures along with staffing changes in order to clear this finding in FY 2023. Individual responsible for correction: Ms. Denise Brooks-Jones, Acting Executive Director Timeframe: As of March 31, 2024
2023-001 Condition: Deficit in COCC Steps to resolve: The Authority's continued conversion to private based ownership via tax credits and Rental Assistance Demonstration will ease the burden of capital need. Once all our properties are converted this issue will not exist. Individual responsibl...
2023-001 Condition: Deficit in COCC Steps to resolve: The Authority's continued conversion to private based ownership via tax credits and Rental Assistance Demonstration will ease the burden of capital need. Once all our properties are converted this issue will not exist. Individual responsible for correction: Ms. Denise Brooks-Jones, Acting Executive Director Timeframe: As of March 31, 2024
2023-101 Eligibility Recommendation: The Authority should establish policies and procedures to ensure that tenants' eligibility determinations will be reviewed and approved by an employee that is independent of the initial eligibility determination. Action Taken: Authority concurs and has implemente...
2023-101 Eligibility Recommendation: The Authority should establish policies and procedures to ensure that tenants' eligibility determinations will be reviewed and approved by an employee that is independent of the initial eligibility determination. Action Taken: Authority concurs and has implemented the recommendation. Anticipated Completion date: Fiscal year 2024
2023-01 - Section 223(f) Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects, ALN #14.155 Statement of Condition: The Project does not have sufficient internal controls in place over eligibility Response: Developac, Inc., Management Agent, will immediately im...
2023-01 - Section 223(f) Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects, ALN #14.155 Statement of Condition: The Project does not have sufficient internal controls in place over eligibility Response: Developac, Inc., Management Agent, will immediately implement the following corrective actions to cure said deficiency: 1. Management Agent will be solely responsible for updating housing software with the annual income limits provided by HUD 2. Management Agent will periodically review tenant move-in files for eligibility verification
2023-002 Contact Person Myra Pearson, (Acting) Director Corrective Action Plan An internal audit within the corporation will be conducted and reviewed quarterly until the finding is corrected and satisfactorily completed. Has been implemented with checkl.ist in each tenant file and will be noted a...
2023-002 Contact Person Myra Pearson, (Acting) Director Corrective Action Plan An internal audit within the corporation will be conducted and reviewed quarterly until the finding is corrected and satisfactorily completed. Has been implemented with checkl.ist in each tenant file and will be noted as incomplete until all steps are followed and listed as complete. Planned Completion Date for CAP Immediate utilization of CAP with completion date for the endoffiscal year if completed according to plan.
Responsible Party Name: Fred Gibbs Position: President, Management Agent Telephone Number: (913) 709-1811 Federal Agency U.S. Department of Housing and Urban Development Federal Program Supportive Housing for the Elderly (Section 202) Compliance Requirements E - Eligibility Finding Type Federal Awar...
Responsible Party Name: Fred Gibbs Position: President, Management Agent Telephone Number: (913) 709-1811 Federal Agency U.S. Department of Housing and Urban Development Federal Program Supportive Housing for the Elderly (Section 202) Compliance Requirements E - Eligibility Finding Type Federal Awards Auditee’s Comments on Finding We agree with the auditors’ finding. Corrective Action We will follow procedures to ensure tenant eligibility and establishing and maintaining security deposits for tenants moving out and we will review the accuracy / completeness of the documentation being processed in the tenant files on a periodic basis. Anticipated Completion Date December 31, 2023
Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers, Mainstream Vouchers, Emergency Housing Vouchers Assistance Listing Numbers: 14.871, 14.879, 14.EHV (the “Housing Voucher Cluster”) Noncompliance – E. Eligibility – Tenant File...
Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers, Mainstream Vouchers, Emergency Housing Vouchers Assistance Listing Numbers: 14.871, 14.879, 14.EHV (the “Housing Voucher Cluster”) Noncompliance – E. Eligibility – Tenant Files Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance for Eligibility Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). These files are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority’s files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Context: There are approximately 8,789 units. Of a sample size of eighty-seven (87) tenant files, the following was noted: • HUD-9886 Authorization for Release of Information was missing in 8 files • Annual 50058 form was missing in 7 files • Verification of income and assets was missing in 10 files • Annual inspection report was missing in 2 files Our sample size is statistically valid. Known Questioned Costs: $216,820 Cause: There is a material weakness in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that assures the program is in compliance. Effect: The Housing Voucher Cluster is in material non-compliance with the eligibility type of compliance related to the maintenance of tenant files. Recommendation: We recommend the Authority design and implement internal control procedures that will assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor on the inspection of tenant files and has made arrangements to comply with the compliance requirements of the Housing Voucher Cluster. The added controls will consist of additional training that will be completed by Continued Eligibility staff related to the Electronic File Protocol and the procurment of an IT vendor that will develop reports to identify missing SharePoint attachments within electronic tenant files. Ingrid Layne, the Director of Assisted Housing will be responsible to implement this corrective action by March 31, 2024.
View Audit 8726 Questioned Costs: $1
Finding 2023-007 Special Tests and Provision – Child Nutrition Cluster Material Weakness in Internal Control Over Compliance and Material Noncompliance Finding Summary: The District does not have an internal control system designed to review and maintain documentation for verification of eligibility...
Finding 2023-007 Special Tests and Provision – Child Nutrition Cluster Material Weakness in Internal Control Over Compliance and Material Noncompliance Finding Summary: The District does not have an internal control system designed to review and maintain documentation for verification of eligibility status. Responsible Individuals: Shannon Hunstad, Superintendent Corrective Action Plan: The District will review and strengthen the controls to ensure the required verification process is being completed and ensuring proper eligibility status for the Child Nutrition Cluster program. Anticipated Completion Date: June 30, 2024
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