Corrective Action Plans

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Powell Boulevard Apartments, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024 Name and address of independent accounting firm: CohnReznick LLP 350 Granite Street Suite 1200 Braintree MA 02184 Audit period: January 1 – December 31, 2024 The fi...
Powell Boulevard Apartments, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024 Name and address of independent accounting firm: CohnReznick LLP 350 Granite Street Suite 1200 Braintree MA 02184 Audit period: January 1 – December 31, 2024 The findings from the December 31, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Federal Award Findings and Questioned Costs Item 2024-001 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for Persons with Disabilities (Section 811) Program Federal Assistance Listing: Number 14.181 Recommendation: Management should establish procedures and monitor compliance with those procedures to ensure that recertifications are performed timely and signed, tenant eligibility is correctly determined and that tenant lease files are properly maintained in accordance with the requirements of HUD Handbook 4350.3, Occupancy Requirements of Subsidized Multifamily Housing Programs. Action Taken: Management reviewed the AR in question and confirmed that all documentation, including EIV, was performed and obtained in January 2024. The 50059 was not signed until 3/13/24 for a 3/1/24 effective date because the tenant was unavailable due to sickness. Property staff were reminded it is REACH policy to receive all documentation and signatures by the effective date to be considered complete. Completion Date: May 23, 2025. If the Department of the Housing and Urban Development has questions regarding this plan, please contact Margaret Salazar at (503) 231-0682 or by email at msalazar@reachcdc.org Sincerely, Margaret Salazar Chief Executive Officer May 23, 2025
United States Department of Housing and Urban Development The Housing Authority of the County of Butler respectfully submits the following corrective action plan for the year ended December 31, 2024. Finding 2024-001 - Special Tests and Provisions Statement of Condition: During the testing of new...
United States Department of Housing and Urban Development The Housing Authority of the County of Butler respectfully submits the following corrective action plan for the year ended December 31, 2024. Finding 2024-001 - Special Tests and Provisions Statement of Condition: During the testing of new participants for compliance with HUD's waiting list selection requirements, two waiting lists were not available for review. These lists assist in documenting that the participant was selected from the waiting list in accordance with established policies and procedures. Action taken: The Authority has already taken steps to address the issue by adjusting their policy so that waiting lists are now scanned and saved electronically, which ensures their availability for review at a later time, if necessary.
View Audit 362013 Questioned Costs: $1
Finding 571009 (2024-001)
Material Weakness 2024
Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend that Home Forward reviews the controls in place to ensure that recertifications are performed timely and the income is supported. Explanation of disagreement with audit finding: There is no disagreement...
Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend that Home Forward reviews the controls in place to ensure that recertifications are performed timely and the income is supported. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Prior to COVID, we had software controls in place that did not allow staff to override the next re-exam dates. We removed those restrictions during COVID. Since this audit finding we have now put those controls back in place. We also have training scheduled to discuss income calculations and to reiterate processes related to review schedules. The training will focus on correct income calculation procedures and documentation and will highlight maintaining effect dates for reviews when they are not completed on time due to resident failure to provide documentation. Name(s) of the contact person(s) responsible for corrective action: Elise Anderson (software controls) and Suzanne Couttouw (income/ exam date training) Planned completion date for corrective action plan: • Software controls back in place 6/1/2025 • Income Calculation training 7/16/2025
2024-003 Temporary Assistance for Needy Families Program (TANF) (Assistance Listing #93.558) Award #2401MNTANF, Passed through Minnesota Department of Human Services: Grant Period Year Ended December, 31, 2024: Eligibility Requirement Recommendation: It is recommended the County implement procedure...
2024-003 Temporary Assistance for Needy Families Program (TANF) (Assistance Listing #93.558) Award #2401MNTANF, Passed through Minnesota Department of Human Services: Grant Period Year Ended December, 31, 2024: Eligibility Requirement Recommendation: It is recommended the County implement procedures to ensure all required documentation is maintained in the file and that there are procedures in place to review files for errors and omissions in eligibility documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will review their process for data input and recording and remind staff to verify all eligibility requirements are documented for verbal interviews. Name of contact person responsible for corrective action plan: Rick Gieseke, Deputy Administrator Community Services and Deb Purfeerst, Public Health Director. Planned completion date for corrective action plan: December 31, 2025
Corrective Action Condition Identified: The Organization did not verify whether vendors were suspended or debarred during the year. Cause: The Organization did not have formal procedures in place to ensure vendors were checked against the SAM.gov exclusions list. Corrective Action Taken: The O...
Corrective Action Condition Identified: The Organization did not verify whether vendors were suspended or debarred during the year. Cause: The Organization did not have formal procedures in place to ensure vendors were checked against the SAM.gov exclusions list. Corrective Action Taken: The Organization put a procedure in place that will check vendors against the exclusion list. Anticipated Completion Date: Procedure was put in place in May 2025 Views of Responsible Officials: Management concurs with the finding and has implemented procedures to document vendor eligibility verification via SAM.gov.
U.S. Department of Health and Human Services Passed-through the Colorado Department of Human Services FFAL #93.778 Medicaid Cluster Eligibility Significant Deficiency in Internal Control Noncompliance Criteria: The Federal requirement related to processing of an application requires the State to pro...
U.S. Department of Health and Human Services Passed-through the Colorado Department of Human Services FFAL #93.778 Medicaid Cluster Eligibility Significant Deficiency in Internal Control Noncompliance Criteria: The Federal requirement related to processing of an application requires the State to provide notice of its decision concerning eligibility and provide timely and adequate notice of the basis for denial or termination of assistance (42 USC 1320c-7(d)). According to the Colorado Department of Health Care Policy and Financing (HCPF), processing standards 8.100.3.D, the City and County is required to process an initial application for any program not requiring a disability determination no later than 45 days following receipt of application. Condition: We tested eligibility determination and controls over this process for sixty case files. We noted the following in our testing: Four instances of non-compliance in which the City and County did not complete the eligibility determination and approve/deny the case within 45 days and no notice of action was sent to the client within the required timeframe. Cause: Due to the City and County’s ineffective monitoring, eligibility determinations were not completed in a timely manner and within the 45-day deadline. Effect: Failure to process applications timely could result in participants that are delayed approval of Medicaid services. Questioned Costs: None to report. Context/Sampling: A nonstatistical sample of 60 participants were selected for eligibility testing. Repeat Finding from Prior Years: Yes. Recommendation: We recommend the County utilize available COGNOS reports to determine which cases are nearing the exceeding processing guidelines. Views of Responsible Officials: Agree
Plan: • Ensure all applications are saved in files on the computer and paper copies if needed for backup. • Work for Success manager and VP will work with DCF to determine clear eligibility qualifications. It will be determined whether or not 18-24 year olds involved in the juvenile or foster care ...
Plan: • Ensure all applications are saved in files on the computer and paper copies if needed for backup. • Work for Success manager and VP will work with DCF to determine clear eligibility qualifications. It will be determined whether or not 18-24 year olds involved in the juvenile or foster care system are eligible. • Proper documentation showing that a participant does qualify will be obtained and kept in the file with the application. • Staff will ensure the participant and staff working with participant completing the application sign off on the application. Management will then review and sign off on the application and note appropriate funding stream. • If a change appears to be made on an application the staff member shall note the change on the appropriate application and initial the change. Implementation Date: Beginning of Fiscal Year 26- July 1, 2025 Responsible Party: Melissa Goodman, VP of Reentry Services will oversee the manager of the Work for Success program and ensure that these internal controls are taking place.
Plan: • Implement a policy to ensure appropriate review process and documentation for each application is obtained. • Implement internal control that management signs off on all applications, verifying that appropriate documentation is present and noting what funding the applicant qualifies for. ...
Plan: • Implement a policy to ensure appropriate review process and documentation for each application is obtained. • Implement internal control that management signs off on all applications, verifying that appropriate documentation is present and noting what funding the applicant qualifies for. Implementation Date: Beginning of Fiscal Year 26- July 1, 2025 Responsible Party: Melissa Goodman, VP of Reentry Services will oversee the manager of the Work for Success program and ensure that these internal controls are taking place.
Management will continue to accumulate proper supporting documentation to support the organization’s compliance with the eligibility compliance requirement and to provide such documentation, when legally possible. Responsible parties: Cynthia Amodeo, Chief Executive Officer Myra Ricard, Program Dire...
Management will continue to accumulate proper supporting documentation to support the organization’s compliance with the eligibility compliance requirement and to provide such documentation, when legally possible. Responsible parties: Cynthia Amodeo, Chief Executive Officer Myra Ricard, Program Director Anticipated Completion Date: Not Applicable as this is not correctable at this time due to New York State Executive Order 19-ADM-05; 19-OCFS-ADM-03.
Finding 2024-002: We agree with the finding. The Authority is relatively small with limited administrative staff. Further, the Board of Commissioners is a volunteer oversight board and not a managing board and does not have the time or expertise to provide the necessary services to correct the inte...
Finding 2024-002: We agree with the finding. The Authority is relatively small with limited administrative staff. Further, the Board of Commissioners is a volunteer oversight board and not a managing board and does not have the time or expertise to provide the necessary services to correct the internal control deficiencies noted. The Board had reviewed the issue and determined that there are no additional procedures which can be reasonably done to eliminate the deficiencies and accepts them.
Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will work with management to strengthen its document retention policies and processes and implement internal controls to ensure that all required grant reports are consistently ...
Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will work with management to strengthen its document retention policies and processes and implement internal controls to ensure that all required grant reports are consistently reviewed, approved, submitted, retained and retrievable for the required retention period. This includes quarterly reports, expense reimbursement packets submitted to the grantors, project expenditure reports, or other grant-related records necessary to demonstrate compliance with federal reporting and record retention standards under the federal programs.
Finding 570035 (2024-003)
Material Weakness 2024
Supportive Services for Veteran Families Assistance Listing No. 64.033 Recommendation: We recommend that the Corporation establish and enforce a standardized process for completing and reviewing intake forms, provide training to staff on the importance of maintaining proper documentation and the pr...
Supportive Services for Veteran Families Assistance Listing No. 64.033 Recommendation: We recommend that the Corporation establish and enforce a standardized process for completing and reviewing intake forms, provide training to staff on the importance of maintaining proper documentation and the procedures for completing and reviewing eligibility determinations, and implement periodic internal audits to ensure compliance with documentation requirements and to identify any areas needing improvement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: In fiscal year 2025, Passage Home implemented new programmatic policies and procedures ensuring that a Program Manager or the Program Director reviews and approves (by signature) all new client enrollments prior to case manager assignment. The Program Director will conduct related training for all program staff and will administer quarterly client record audits (peer or supervisor review) to verify ongoing compliance. Name of the contact person responsible for corrective action: Karen Harshman Planned completion date for corrective action plan: 03/26/2025
This finding resulted from a loan disbursement exceeding regulatory limits for one student. The issue was corrected before the audit report was finalized. The University will strengthen its review process prior to disbursement by ensuring additional loan eligibility is validated and documented. The ...
This finding resulted from a loan disbursement exceeding regulatory limits for one student. The issue was corrected before the audit report was finalized. The University will strengthen its review process prior to disbursement by ensuring additional loan eligibility is validated and documented. The Financial Aid Office will receive targeted training on aggregate loan monitoring. Corrective actions will be fully implemented by January 31, 2026.
View Audit 361246 Questioned Costs: $1
Name of Contact Person: Veronica Williams, Interim Executive DirectorCorrective Action:KHMA’s Board has approved new written policies and procedures and are in place now.Appropriate staff have begun taking proper safeguards for Capital Fund Program management to ensure proper accountability. This in...
Name of Contact Person: Veronica Williams, Interim Executive DirectorCorrective Action:KHMA’s Board has approved new written policies and procedures and are in place now.Appropriate staff have begun taking proper safeguards for Capital Fund Program management to ensure proper accountability. This includes the oversight of processing payments of CFP expenditures, which includes the following procedures for: 1) payment of invoices; 2) requisition of funds; 3) monitoring; and 4) reporting of CFP funds.payment of InvoicesAll CFP invoices will be reviewed and clearly marked as approved and documented to show that the source of funds for payment are CFP grant funds by the Executive Director prior to payment. The Executive Director will specify the general ledger code, including the BLI account to be used for payment processing on the invoice before providing the invoice to the accounts payable clerk.Under no circumstances will a payment be made if KMHA has not drawdown and received the respective CFP funds.With the exception of funds associated with BLI 1406 “Operations”, PHAs have three (3) business days to issue and mail the check once the CFP funds are received.The Executive Director/accounts payable clerk will specify the BLI account and CFP grant year on the check voucher prior to sending the check voucher to the fee accountant for financial statement processing.Requisition of FundsFor each drawdown, the Executive Director will print the associated eLOCCS Voucher Payment form from the eLOCCS system.The Executive Director will document the check number(s) and vendor(s) associated with each CFP draw (i.e., the eLOCCS Voucher Payment form). In addition, each individual draw shall be numbered for reference purposes.A copy of each draw shall be submitted to the fee accountant to ensure proper reporting of the grant drawdown.With the exception of funds associated with BLI 1406 “Operations”, in no case shall a draw be made without the proper approved invoices.MonitoringThe fee accountant's monthly financial statements will include a CFP report for each grant which will be reviewed by the Executive Director for proper coding and accuracy.Folder has been created to track all required information in the management of a CFP grant to include correspondence to and from HUD, expenses, grant reimbursements, budgets, closeout documentation and EPIC management.Proposed Completion Date: Immediately
The Jacksonville Housing Authority’s (JHA) Housing Choice Voucher (HCV) program is the largest rental assistance program in the City of Jacksonville. Through the Annual Contributions Contract (ACC), the program receives over $90M from the United States Department of Housing and Urban Development (HU...
The Jacksonville Housing Authority’s (JHA) Housing Choice Voucher (HCV) program is the largest rental assistance program in the City of Jacksonville. Through the Annual Contributions Contract (ACC), the program receives over $90M from the United States Department of Housing and Urban Development (HUD) and assist over 7,700 families each year. The ACC requires JHA to comply with federal regulations and HUD guidelines, as amended from time to time. Audit Findings Berman Hopkins Wright & LaHam, CPAs and Associates, LLP conducted the recent FY2024 JHA Audit (Period: October 1, 2023 – September 30, 2024) and identified continued material weakness findings within the JHA Housing Choice Voucher (HCV) program including but not limited to: Material Weaknesses in Internal Controls, Material Weaknesses in Non-Compliance and Material Weaknesses in the Housing Quality Standards (HQS) Inspection process. Berman Hopkins Wright & LaHam, CPAs and Associates, LLP previously conducted JHA’s FY2023 audit (Period: October 1, 2022 – September 30, 2023) and FY2022 audit (Period: October 1, 2021 – September 30, 2022) which disclosed consecutive historical material weaknesses in JHAs internal controls and noncompliance of the Housing Choice Voucher (HCV) program. Under new CEO leadership at JHA, a request to the JHA Board of Commissioners is in place for a vote on Friday, June 27, 2025, to authorize the following action of Nan McKay & Associates to Administer, Manage and Operate the JHA Housing Choice Voucher Program for an effective date of Monday July 7, 2025. Pending Resolution: AUTHORIZE THE AWARD OF THE MIAMI-DADE HOUSING & COMMUNITY DEVELOPMENT PIGGYBACK CONTRACT IN THE NOT-TO-EXCEED AMOUNT OF 72% OF THE ADMINISTRATIVE FEES CONCURRENT WITH THE EXISTING CONTRACT TERMS TO NAM MCKAY AND ASSOCIATES, FOR HOUSING CHOICE VOUCHER MANAGEMENT AND OPERATIONS. As evidenced by the increase in overall HCV audit findings, loss of federal revenues, inability to correctly serve existing and future HCV program participants, noncompliance on both a local and federal level for section 8 program funding for the administration and operations of the HCV program, immediate action is requested to authorize Nan McKay & Associates to administer and operate JHA’s HCV program immediately. Combined with a plethora of likely compliance issues and deteriorated financial condition, these concerns pose a significant threat to both the immediate and long-term success of Jacksonville’s HCV program. Responsible: Nan McKay & Associates POINT OF CONTACT: Steven Rosario, Sr. Director EMAIL: srosario@nanmckay.com JHA POC: Roslyn Phillips, Interim COO EMAIL: RPHILLIPS@JAXHA.ORG
The Jacksonville Housing Authority’s (JHA) Housing Choice Voucher (HCV) program is the largest rental assistance program in the City of Jacksonville. Through the Annual Contributions Development (HUD) and assist over 7,700 families each year. The ACC requires JHA to comply with federal regulations a...
The Jacksonville Housing Authority’s (JHA) Housing Choice Voucher (HCV) program is the largest rental assistance program in the City of Jacksonville. Through the Annual Contributions Development (HUD) and assist over 7,700 families each year. The ACC requires JHA to comply with federal regulations and HUD guidelines, as amended from time to time. Audit Findings Berman Hopkins Wright & LaHam, CPAs and Associates, LLP conducted the recent FY2024 JHA Audit (Period: October 1, 2023 – September 30, 2024) and identified continued material weakness findings within the JHA Housing Choice Voucher (HCV) program including but not limited to: Material Weaknesses in Internal Controls, Material Weaknesses in Non-Compliance and Material Weaknesses in the Housing Quality Standards (HQS) Inspection process. Berman Hopkins Wright & LaHam, CPAs and Associates, LLP previously conducted JHA’s FY2023 audit (Period: October 1, 2022 – September 30, 2023) and FY2022 audit (Period: October 1, 2021 – September 30, 2022) which disclosed consecutive historical material weaknesses in JHAs internal controls and noncompliance of the Housing Choice Voucher (HCV) program. Under new CEO leadership at JHA, a request to the JHA Board of Commissioners is in place for a vote on Friday, June 27, 2025, to authorize the following action of Nan McKay & Associates to Administer, Manage and Operate the JHA Housing Choice Voucher Program for an effective date of Monday July 7, 2025. Pending Resolution: AUTHORIZE THE AWARD OF THE MIAMI-DADE HOUSING & COMMUNITY DEVELOPMENT PIGGYBACK CONTRACT IN THE NOT-TO-EXCEED AMOUNT OF 72% OF THE ADMINISTRATIVE FEES CONCURRENT WITH THE EXISTING CONTRACT TERMS TO NAM MCKAY AND ASSOCIATES, FOR HOUSING CHOICE VOUCHER MANAGEMENT AND OPERATIONS. As evidenced by the increase in overall HCV audit findings, loss of federal revenues, inability to correctly serve existing and future HCV program participants, noncompliance on both a local and federal level for section 8 program funding for the administration and operations of the HCV program, immediate action is requested to authorize Nan McKay & Associates to administer and operate JHA’s HCV program. Combined with a plethora of likely compliance issues and deteriorated financial condition, these concerns pose a significant threat to both the immediate and long-term success of Jacksonville’s HCV program.
Berman Hopkins Wright & LaHam, CPAs and Associates, LLP recently identified in the FY2024 JHA Audit (Period: October 1, 2023 – September 30, 2024) material weakness findings and noncompliance findings for the JHA Public Housing Program. Please note that the JHA’s Public Housing Program was not teste...
Berman Hopkins Wright & LaHam, CPAs and Associates, LLP recently identified in the FY2024 JHA Audit (Period: October 1, 2023 – September 30, 2024) material weakness findings and noncompliance findings for the JHA Public Housing Program. Please note that the JHA’s Public Housing Program was not tested by the auditors in previous years. Note: JHA will have a finding in FY2025 due to existing months of the public housing program operations that have already commenced for the periods: October 1, 2024 – June 27, 2025. The audit period will end for FY2025 September 30, 2025. JHA will quickly evaluate each PH employee, train, hire skilled employees and streamline organizational inefficiencies, while implementing new internal process controls to address the findings identified in the FY2024 audit report for the Public Housing program. An evaluation of the current employee role structure and staff qualifications will commence July 2025. The entire public housing department will be assessed to ensure that JHA is efficient, productive, utilizes the technology system of record Yardi V7 to adhere to compliance, and works in a collaborative matter to better serve all existing a potential future client of the agency. The Public Housing organizational re-org will be implemented no later than September 1, 2025. Responsible: Jacksonville Housing Authority JHA POC: William Mitchell (a.k.a.Daniel/Danny), Deputy Chief EMAIL: dmitchell@jaxha.org JHA POC: Roslyn Phillips, Interim COO EMAIL: RPHILLIPS@JAXHA.ORG
Management Response: We will regularly review the recertification process to determine areas of weakness. We have created a standard re-certification plan, check list, and a monitor log and will routinely review the Authority’s Policy to ensure proper required eligibility documentations are provided...
Management Response: We will regularly review the recertification process to determine areas of weakness. We have created a standard re-certification plan, check list, and a monitor log and will routinely review the Authority’s Policy to ensure proper required eligibility documentations are provided and placed in the client file. We will review clients’ files monthly with the results of these reviews being forwarded to the Housing Management Division Director and, if deficiencies are found, they will be corrected immediately. Deficiencies will also be tracked to determine if additional staff training is needed. The Housing Directors are charged with the responsibility of ensuring proper documentation of Public Rental and Homeownership folders at the time of move in, during the Annual Inspection and Annual/Interim Recertification process. Anticipated Completion Date: September 30, 2025 Responsible Party:  Housing Management Division - Division Director  Housing Management Office - Housing Directors  Housing Management Office - Housing Specialists  Housing Management Office - Housing Technicians  Housing Management Office - Administrative Assistants/Specialists
Finding: 2024-067 - Sixty Medicaid and 60 CHIP recipients were randomly selected for eligibility testing. Testing revealed the following errors: Medicaid - 22 of 60 cases lacked eligibility determination issues (note, some case had multiple deficiencies): • One of 60 files was approved by the federa...
Finding: 2024-067 - Sixty Medicaid and 60 CHIP recipients were randomly selected for eligibility testing. Testing revealed the following errors: Medicaid - 22 of 60 cases lacked eligibility determination issues (note, some case had multiple deficiencies): • One of 60 files was approved by the federally facilitated marketplace in 2015 and has been rolling forward ever since with no review and no documentation to support the case as an ongoing Medicaid eligible case. Electronic review did not have enough information so roll forward was cancelled as of June 30, 2024. In addition: • Ten of 60 cases, one of which was a behavioral health case, lacked documentation to indicate the participant submitted a signed Medicaid application. • Ten of 60 files, one of which was behavioral health, lacked documentation of facts supporting the eligibility determination. • Two of 60 cases were determined to not be part of one of the non-Modified Adjusted Gross Income (MAGI) covered groups and did not fit into one of the MAGI-exempted categories. • One of 60 participants did not meet income eligibility requirements. • Fifteen of 60 cases, five of which are behavioral health, lacked documentation to verify that IEVS was used to verify income eligibility. • Two of 60 cases lacked review by the appropriate staff/supervisor for manual overrides. CHIP - 23 of 60 cases lacked eligibility determination issues (note, some case had multiple deficiencies): • Three of 60 cases lacked adequate support to eligibility determinations redeterminations, one ofwhich was a behavioral health case. • Two of 60 cases were not covered groups, one of which was a behavioral health case. • One of 60 participant files did not contain a social security number. During testing it was noted that the application was denied once reviewed, but it was initially allowed through the federally facilitated marketplace. • Three of 60 participants received benefits after aging out of the program (age 19). One of these was a behavioral health case. • One of sixty behavioral health case files was missing a CHIP-specific application and support for determination. • Eighteen of 60 case files, four of which were behavioral health cases, lacked sufficient documentation to indicate that IEVS participation was verified. Questioned Costs: AL 93.778: $ 5,691 (known questioned costs); $762,897,131 (likely questioned costs); AL 93.767: $ 5,019 (known questioned costs); $ 2,537,251 (likely questioned costs) Assistance Listing Number: 93.767; 93.775, 93.777, 93.778 Assistance Listing Title: CHIP; Medicaid Cluster Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): The department agrees with the finding but does not concur with the questioned costs. CMS has notified the state that financial recoveries based on eligibility errors can only be pursued when identified by programs operating under CMS’ Payment Error Rate Measurement (PERM) program, under section 1903(u) of the Social Security Act and regulations at 42 CFR Part 431, Subpart Q Corrective Action (corrective action planned): Division of Public Assistance continues to leverage automated renewals for Medicaid and expects processing timeliness to continue improving. Staff will be coached on proper case documentation standards and procedures such as including appropriate information in case notes and uploading documentation in ILINX to support eligibility determinations. The Division intends to implement quality control and training efforts using the newly formed Staff Learning & Development team. Completion Date (list anticipated completion date): The department anticipates the finding will be resolved in FY2026. Agency Contact (name of person responsible for corrective action): Pam Halloran, Assistant Commissioner
Finding: 2024-066 - Sixty Medicaid and 60 Children’s Health Insurance Program (CHIP) recipients were randomly selected for eligibility testing. Testing revealed the following errors: Medicaid 24 of 60 cases had timing issues (note, some cases had multiple deficiencies): • Fifteen of the 60 cases, tw...
Finding: 2024-066 - Sixty Medicaid and 60 Children’s Health Insurance Program (CHIP) recipients were randomly selected for eligibility testing. Testing revealed the following errors: Medicaid 24 of 60 cases had timing issues (note, some cases had multiple deficiencies): • Fifteen of the 60 cases, two of which were behavioral health cases, had not gone through a renewal assessment within 12 months of the last determination. • Sixteen of the 60 cases’ eligibility determinations were not done timely (i.e., within 45 days), one of which was a behavioral health case. • One of the 60 cases’ eligibility effective date was earlier than 3 months prior to the month of application. CHIP 40 of 60 cases had timing issues (note, some cases had multiple deficiencies): • Twenty-eight of 60 cases’ eligibility determinations were not done timely (i.e., within 45 days), two of which were behavioral health cases. • Nineteen of 60 cases, four of which were behavioral health cases, had not gone through a renewal assessment within 12 months of the last determination. Questioned Costs: AL 93.778: $ 608 (known questioned costs); $81,540,436 (likely questioned costs); AL 93.767: $ 6,888 (known questioned costs); $ 3,482,307 (likely questioned costs) Assistance Listing Number: 93.767; 93.775, 93.777, 93.778 Assistance Listing Title: CHIP; Medicaid Cluster Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): The department agrees with the finding but does not concur with the questioned costs. CMS has notified the state that financial recoveries based on eligibility errors can only be pursued when identified by programs operating under CMS’ Payment Error Rate Measurement (PERM) program, under section 1903(u) of the Social Security Act and regulations at 42 CFR Part 431, Subpart Q. Corrective Action (corrective action planned): Division of Public Assistance continues to streamline and enhance internal processes and integrate systems to automate processes as much as possible. This includes (a) automated document ingestion into the electronic document repository (ILINX) from the online portal, e-mail, and other sources; (b) integrating the Division’s workload program (Current) with ILINX to improve workload management; and (c) continue using the approved E- 14 waiver authorized under section 1902(e)(14)(A) of the Social Security Act to increase ex parte renewal rates. Completion Date (list anticipated completion date): The department anticipates the finding will be resolved in FY2026. Agency Contact (name of person responsible for corrective action): Pam Halloran, Assistant Commissioner
Finding 569792 (2024-063)
Significant Deficiency 2024
Finding: 2024-063 - The State lacked sufficient documentation, as outlined in the federal requirements and the state plan, to clearly document what services one child was receiving and if they were authorized for services during the period under audit. Questioned Costs: None Assistance Listing Num...
Finding: 2024-063 - The State lacked sufficient documentation, as outlined in the federal requirements and the state plan, to clearly document what services one child was receiving and if they were authorized for services during the period under audit. Questioned Costs: None Assistance Listing Number: 93.575, 93.596 Assistance Listing Title: Child Care and Development Fund Cluster (CCDF) Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): The department agrees with the finding. Corrective Action (corrective action planned): Division of Public Assistance (DPA) will provide documentation and case note training to Child Care Assistance grantees. Grantees will provide similar training to their staff and increase internal case file review. DPA will verify grantee staff training occurred and that they’re maintaining compliance. Completion Date (list anticipated completion date): The department anticipates the finding will be resolved in FY2025. Agency Contact (name of person responsible for corrective action): Pam Halloran, Assistant Commissioner
Finding: 2024-061 - Each state shall participate in Income Eligibility and Verification System required by Section 1137 of the Social Security Act as amended. Fifteen of 60 cases tested lacked adequate documentation to indicate if all components of income verification were gathered and processed cor...
Finding: 2024-061 - Each state shall participate in Income Eligibility and Verification System required by Section 1137 of the Social Security Act as amended. Fifteen of 60 cases tested lacked adequate documentation to indicate if all components of income verification were gathered and processed correctly. Questioned Costs: None Assistance Listing Number: 93.558 Assistance Listing Title: TANF Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): The department agrees with the finding. Corrective Action (corrective action planned): Division of Public Assistance staff will be coached on proper case documentation standards and procedures such as including appropriate information in case notes and uploading documentation in ILINX to support eligibility determinations. Spot checks and case reviews will be performed for case completion and accuracy. Completion Date (list anticipated completion date): The department anticipates the finding will be resolved in FY2025. Agency Contact (name of person responsible for corrective action): Pam Halloran, Assistant Commissioner
Finding 569784 (2024-056)
Significant Deficiency 2024
Finding: 2024-056 - Three of 60 Temporary Assistance for Needy Families (TANF) recipient case files tested lacked adequate documentation to indicate that the participant met all eligibility criteria. The following errors were noted: • Two cases exceeded the 60-month benefit limit, which resulted in ...
Finding: 2024-056 - Three of 60 Temporary Assistance for Needy Families (TANF) recipient case files tested lacked adequate documentation to indicate that the participant met all eligibility criteria. The following errors were noted: • Two cases exceeded the 60-month benefit limit, which resulted in excess benefits. • One case lacked documentation to verify one parent’s relational status to the children. Additionally, seven of 60 cases tested had documentation to support individual’s eligibility but lacked sufficient documentation to verify that the key control over compliance occurred. Questioned Costs: AL 93.558: $ 5,720 (known questioned costs); $173,417 (likely questioned costs) Assistance Listing Number: 93.558 Assistance Listing Title: TANF Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): The department agrees with the finding. Corrective Action (corrective action planned): Division of Public Assistance staff will be coached on proper case documentation standards and procedures such as including appropriate information in case notes and uploading documentation in ILINX to support eligibility determinations. Spot checks and case reviews will be performed for case completion and accuracy. Completion Date (list anticipated completion date): The department anticipates the finding will be resolved in FY2025. Agency Contact (name of person responsible for corrective action): Pam Halloran, Assistant Commissioner
View Audit 361087 Questioned Costs: $1
Finding: 2024-054 - Testing of 42 SNAP recipient cases to verify the completeness and accuracy of benefit calculations found 37 (88 percent) were incorrect or unsupported, including 24 (57 percent) in which the recipients’ application or reports of changes were not processed within federally require...
Finding: 2024-054 - Testing of 42 SNAP recipient cases to verify the completeness and accuracy of benefit calculations found 37 (88 percent) were incorrect or unsupported, including 24 (57 percent) in which the recipients’ application or reports of changes were not processed within federally required timeframes. Testing of 42 SNAP recipient cases to verify the adequacy of case information stored in EIS and DOH’s document management system, ILINX, found 18 (43 percent) had inadequate verifications of required information. Questioned Costs: AL 10.551: $59,073 Assistance Listing Number: 10.551, 10.561 Assistance Listing Title: SNAP Cluster Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): The department agrees with the finding. Corrective Action (corrective action planned): The Division of Public Assistance has reinstated SNAP interview requirements and verification procedures in FY2025. It will also review casework via supervisory case reviews to ensure accuracy and documentation standards are met. The division’s Learning & Development Team is creating training modules that will provide continuing education to existing staff. Completion Date (list anticipated completion date): The department anticipates the finding will be resolved in FY2026. Agency Contact (name of person responsible for corrective action): Pam Halloran, Assistant Commissioner
Finding: 2024-053 - The amount of FY 24 Supplemental Nutrition Assistance Program (SNAP) benefits reported to the United States Department of Agriculture (USDA) as issued by the State’s EBT contractor, FIS, was $2,628,951 more than the amount of authorized benefits reported in data from DPA’s Eligib...
Finding: 2024-053 - The amount of FY 24 Supplemental Nutrition Assistance Program (SNAP) benefits reported to the United States Department of Agriculture (USDA) as issued by the State’s EBT contractor, FIS, was $2,628,951 more than the amount of authorized benefits reported in data from DPA’s Eligibility Information System (EIS). Furthermore, FIS could not provide a reliable audit trail of issuances. Questioned Costs: AL 10.551: $2,628,951 Assistance Listing Number: 10.551, 10.561 Assistance Listing Title: SNAP Cluster Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): The department agrees with the finding, but not the questioned cost. The Division of Public Assistance performs monthly reconciliations and balancing efforts to ensure accuracy with routine FIS reports, EIS authorization and issuance reports, and federal reporting. However, the division agrees that a new ad hoc report created for this audit by the EBT contractor, FIS, does not match with issuances and reporting. Corrective Action (corrective action planned): The Division of Public Assistance will work with the EBT contractor, FIS, through the contract performance management process to address discrepancies found between a non standard ad hoc report and program issuances and reporting. The division will evaluate further ad hoc reports against previously established documents for accuracy. Completion Date (list anticipated completion date): The department anticipates the finding will be resolved in FY2026. Agency Contact (name of person responsible for corrective action): Pam Halloran, Assistant Commissioner
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