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Corrective Action Plans

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Finding 35586 (2022-018)
Significant Deficiency 2022
Commonwealth of Virginia
VA
Eligibility Significant Deficiency Internal Control / Segregation of Duties
Responsible Contact Person(s): Sarah Hatton, Deputy Director of Administration Cindy Olson, Eligibility and Enrollment Division Director Corrective Action Planned: The final tally of the master out of state report listed 16,930 members. Of the 16,930 members, 11,719 members were closed (69%). The ...
Responsible Contact Person(s): Sarah Hatton, Deputy Director of Administration Cindy Olson, Eligibility and Enrollment Division Director Corrective Action Planned: The final tally of the master out of state report listed 16,930 members. Of the 16,930 members, 11,719 members were closed (69%). The remaining members were either already closed or validly open with an out of state address. The staff dedicated to this project have been reviewing the APA identified list of approximately 6,927 members with out of state addresses. The team has reviewed 98% of the cases, with only 1% requiring case action. When action to close a case is taken, standard notice requirements are followed. On February 6, 2023, the team also began reviewing the newest Out of State Data Match Report provided by the DMAS Office of Data Analytics. This new report includes approximately 7,261 individuals for review, with a targeted completion date of April 28, 2023. This report will continue to be generated quarterly to ensure that individuals no longer residing in Virginia are accurately closed out of their Virginia Medicaid coverage. Estimated Completion Date: 4/30/2023
View Audit 36377
Finding 35582 (2022-003)
Significant Deficiency 2022
Cornerstones Inc, Cornerstones Housing Corporation & Rihc Partners, Lp
VA
Eligibility
Pending client
Pending client
View Audit 33333
Finding 35579 (2022-001)
Significant Deficiency 2022
Ingleside Homes, INC
DE
HUD Housing Programs Eligibility Equipment & Real Property Management
Ingleside Homes, Inc.?s responsible staff will properly verify all income, assets, and deductions. The responsible staff will document attempts to obtain third-party verification and keep this record in the resident?s file. Responsible Person(s): Facility HUD Bookkeeper Anticipated Completion Date: ...
Ingleside Homes, Inc.?s responsible staff will properly verify all income, assets, and deductions. The responsible staff will document attempts to obtain third-party verification and keep this record in the resident?s file. Responsible Person(s): Facility HUD Bookkeeper Anticipated Completion Date: Completion of the documented attempts for third-party verification for the 5 residents noted in the finding will be accomplished by April 30, 2023.
View Audit 32776
Finding 35526 (2022-017)
Significant Deficiency 2022
Commonwealth of Virginia
VA
Special Tests & Provisions Eligibility Significant Deficiency
Responsible Contact Person(s): Gena Boyle, Deputy Commissioner for Policy and Administration Angela Morse, Director of Benefit Programs Corrective Action Planned: Proposed changes to the Code of Virginia will be submitted for the next General Assembly session's consideration. Estimated Completion Da...
Responsible Contact Person(s): Gena Boyle, Deputy Commissioner for Policy and Administration Angela Morse, Director of Benefit Programs Corrective Action Planned: Proposed changes to the Code of Virginia will be submitted for the next General Assembly session's consideration. Estimated Completion Date: 7/1/2024
View Audit 36377
Finding 35511 (2022-001)
Significant Deficiency 2022
Housing Authority of the City of Huntsville
MD
HUD Housing Programs Eligibility Significant Deficiency
Recommendation: We recommend that the Authority reviews its internal controls over obtaining and maintaining income and expense tenant file documentation to ensure compliance with eligibility requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit findi...
Recommendation: We recommend that the Authority reviews its internal controls over obtaining and maintaining income and expense tenant file documentation to ensure compliance with eligibility requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Huntsville Housing Authority (HHA) is restructuring the Assisted Housing Department to add additional management positions, implement comprehensive standard operating procedures, which will include clearly defined eligibility processes and enhanced quality control measures, to include, provisions to appropriately determine dependent allowances. Management will conduct oversight of key functions, data entry, and maintain a consistent review of regulatory compliance. Management will complete more targeted and a higher number of internal quality control audits. Additionally, HHA will increase staff training on income, assets, expenses, deductions and rent calculations. This approach will also include obtaining and maintaining the correct backup and support documentation. HHA will also contract with a Housing Choice Voucher (HCV) consultant to provide additional training to the Assisted Housing management team. HHA is committed to ensuring that all employees have proper training in all components of the HCV program Name(s) of the contact person(s) responsible for corrective action: Turkessa Coleman Lacey, Deputy Executive Director
View Audit 27131
Finding 35467 (2022-110)
Material Weakness 2022
Commonwealth of Virginia
VA
Eligibility Material Weakness Matching / Level of Effort / Earmarking § 200.303 § 200.501
Responsible Contact Person(s): Danielle Robertson, Fiscal Officer Corrective Action Planned: The Emergency Rental Assistance federal grant program is winding down and near close out. As a result, the agency plans to create and implement procedures to retroactively test eligibility in order to docum...
Responsible Contact Person(s): Danielle Robertson, Fiscal Officer Corrective Action Planned: The Emergency Rental Assistance federal grant program is winding down and near close out. As a result, the agency plans to create and implement procedures to retroactively test eligibility in order to document and confirm program compliance with federal statutes, regulations, and terms and conditions of the federal award. Procedures are currently being written and DHCD anticipates this process to be complete on or prior to March 31, 2023. Estimated Completion Date: 3/31/2023
View Audit 36377
Finding 35459 (2022-108)
Significant Deficiency 2022
Commonwealth of Virginia
VA
Internal Control / Segregation of Duties Procurement, Suspension & Debarment Eligibility § 200.300
Responsible Contact Person(s): Timothy O. Kestner, EIA Director Corrective Action Planned: EIA Management has developed a reporting schedule outlining the frequency, responsible party, and due date of all required reports. This is a collaborative effort across several business units; therefore, pol...
Responsible Contact Person(s): Timothy O. Kestner, EIA Director Corrective Action Planned: EIA Management has developed a reporting schedule outlining the frequency, responsible party, and due date of all required reports. This is a collaborative effort across several business units; therefore, policies and procedures have been updated and communicated to all users to ensure compliance. Estimated Completion Date: 2/15/2023
View Audit 36377
Finding 35448 (2022-101)
Significant Deficiency 2022
Commonwealth of Virginia
VA
Eligibility Significant Deficiency
Responsible Contact Person(s): Paula Garrett, WIC Director Corrective Action Planned: The Remote Services Policy was updated and sent to local agency staff on January 21st. The updated policy included clarifying information about scanning in the affidavit so it is viewable in the record. An additi...
Responsible Contact Person(s): Paula Garrett, WIC Director Corrective Action Planned: The Remote Services Policy was updated and sent to local agency staff on January 21st. The updated policy included clarifying information about scanning in the affidavit so it is viewable in the record. An additional update to the policy will include a requirement for documentation as to why the affidavit is needed. Once in-person services resume, the normal policies and procedures for required affidavits will resume. Estimated Completion Date: 8/31/2023
View Audit 36377
Finding 35377 (2022-005)
Significant Deficiency 2022
Meeker County
MN
Eligibility Significant Deficiency Internal Control / Segregation of Duties
ELIGIBILITY Recommendation: The County should implement additional procedures to provide reasonable assurance that necessary documentation is properly input in MAXIS. Case file reviews should be performed. Explanation of disagreement with audit finding: There is no disagreement with the audit findin...
ELIGIBILITY Recommendation: The County should implement additional procedures to provide reasonable assurance that necessary documentation is properly input in MAXIS. Case file reviews should be performed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Supervisor will sample and perform a quality review on a quarterly basis to ensure case workers are accurately assessing eligibility. Review will be documented. Supervisor will review at least 1 casefile for each caseworker per quarter and randomly pull additional cases from new caseworkers. Name of the contact person responsible for corrective action: LoAnn Shepard, Eligibility Supervisor Planned completion date for corrective action plan: December 31, 2023
View Audit 26710
Finding 35340 (2022-004)
Significant Deficiency 2022
Marshfield Clinic Health System, Inc.
WI
Questioned Costs Allowable Costs / Cost Principles Eligibility § 200.303
Finding 2022-004 Name of Contact Person: Dan Fischer, Internal Consultant (former Controller) Corrective Action Plan: In early 2022, the team calculating physician compensation costs eligible for reporting in the HRSA portal experienced turnover of staff and thorough review of new staff?s work wa...
Finding 2022-004 Name of Contact Person: Dan Fischer, Internal Consultant (former Controller) Corrective Action Plan: In early 2022, the team calculating physician compensation costs eligible for reporting in the HRSA portal experienced turnover of staff and thorough review of new staff?s work was not completed for several months. Although expenses were overstated in the portal, the grant was not overcharged as lower expenses reported for physician compensation costs would have been replaced by increasing the amount related to additional eligible lost revenues. Management will implement review procedures for eligible physician compensation costs to ensure expenditures to the portal are accurate. Proposed Completion Date: December 31, 2023
View Audit 24187 Questioned Costs: $1
Finding 35327 (2022-003)
Significant Deficiency 2022
Pennsauken Lutheran Housing, INC
NJ
Subrecipient Monitoring Eligibility HUD Housing Programs
Planned Corrective Actions: We will re-enforce the use of the mov in/recertification file checklist as a tool for project managers to utilize. We will also conduct at a minimum, semiannual in-house refresher sessions. In addition, we will conduct file reviews for move ins and perform random file aud...
Planned Corrective Actions: We will re-enforce the use of the mov in/recertification file checklist as a tool for project managers to utilize. We will also conduct at a minimum, semiannual in-house refresher sessions. In addition, we will conduct file reviews for move ins and perform random file audits on annual recertifications.
View Audit 24060
Finding 35284 (2022-001)
Significant Deficiency 2022
Aspirus, Inc.
WI
Internal Control / Segregation of Duties Cash Management Eligibility
Response: At the time of sending the claim to HRSA the patient did not have other insurance coverage. Subsequently we received information that the patient had other coverage. This information was received by the Financial Clearance department but there was a lack of communication to the Credit Ba...
Response: At the time of sending the claim to HRSA the patient did not have other insurance coverage. Subsequently we received information that the patient had other coverage. This information was received by the Financial Clearance department but there was a lack of communication to the Credit Balance Manager as provided for in our process. Although the Credit Balance team would have found and refunded the money to HRSA after the other insurance paid through their normal credit review process, this was not yet completed at the time of the audit. There is an opportunity to increase the timeliness of the refunding process as addressed in our action plan. Corrective Action Plan: ? Refund HRSA for overpayments found during audit ? Completed on 3/13/2023 and 3/15/2023, respectively. ? Reeducation to Financial Clearance team to notify Credit Balance Manager of change of coverage for HRSA accounts as soon as receive information. ? Education and process change with Initial Claims Team, who also reviews coverage changes, to notify Credit Balance Manager of change of coverage for HRSA accounts as soon as they receive. ? Explore Epic build to route accounts with HRSA coverage change to a Credit Balance WQ to be promptly worked.
View Audit 24698
Finding 35186 (2022-002)
Material Weakness 2022
Eastwick II Section 811 Housing Corporation
PA
HUD Housing Programs Subrecipient Monitoring Eligibility
Views of Responsible Officials and Planned Corrective Actions: Staffing turnover limited ability for portfolio property managers to effectively manage tenant files at each building location. Inglis has contracted with an external expert regarding implementation and process training for Yardi, the ne...
Views of Responsible Officials and Planned Corrective Actions: Staffing turnover limited ability for portfolio property managers to effectively manage tenant files at each building location. Inglis has contracted with an external expert regarding implementation and process training for Yardi, the new property management system. Once fully implemented there are several key internal controls within the system that will alert property management team to tenant issues regarding rent and recertifications. Items such as documenting extenuating circumstances in TRACS and updating the form 50059 will occur more timely once Inglis has successfully implemented Yardi property management system for each property.
View Audit 24749
Finding 35185 (2022-002)
Significant Deficiency 2022
Alvernia University
PA
Allowable Costs / Cost Principles Cash Management Eligibility
Federal Program Corporation of National and Community Service - AmeriCorps Seniors Foster Grandparent Program, ALN 94.011, Award No. 21SFBPA002, Period 7/1/21 - 6/30/24 Condition/Cause Due to turnover in program staff, management was unable to locate certain requested documentation for audit testin...
Federal Program Corporation of National and Community Service - AmeriCorps Seniors Foster Grandparent Program, ALN 94.011, Award No. 21SFBPA002, Period 7/1/21 - 6/30/24 Condition/Cause Due to turnover in program staff, management was unable to locate certain requested documentation for audit testing. Recommendation We recommend that the University revisit and revise their documentation filing system for timecards, mileage reimbursement, and other documentation that would support amounts paid for stipends under the program. This would also include a complete inventory of all clearances/criminal background checks for current staff and volunteers working in the program and obtain updated background checks for any that are not on file. We also recommend the University revisit the process of replacing a director after their departure to ensure program compliance continues. Management Response We agree with the auditors' finding. The instance of non-compliance occurred during a period when the University had a vacancy in both the Grant Specialist and Program Director positions. These roles carry duties to includes design and oversight of the internal control environment regarding the compliance of the federal program. As of August 2022, both vacant positions have been appointed to provide oversight for program compliance. To mitigate deficiencies in controls regarding change management, personnel status change forms involving federally funded programs will be circulated to the Program Director, Grant Specialist, and Business Affairs office. The University will implement the auditors? recommendation to invest in a documentation and approval system for credentials and allowable costs. The Program Director will also perform routine maintenance over personnel files and required documentation.
View Audit 24786
Finding 35173 (2022-007)
Material Weakness 2022
City of Woonsocket
RI
Procurement, Suspension & Debarment Eligibility HUD Housing Programs
Name of Contact Person: Veronicka Vega Corrective Action Plan: The City of Woonsocket has developed policies and procedures in order to facilitate the proper standards for documentation of income eligibility. The department will ensure that proper approvals will be solicited from the HOME Program ...
Name of Contact Person: Veronicka Vega Corrective Action Plan: The City of Woonsocket has developed policies and procedures in order to facilitate the proper standards for documentation of income eligibility. The department will ensure that proper approvals will be solicited from the HOME Program Compliance Officer after thorough review. Written agreement documentation will be revised to include the requirements from the new compliance manual. The City of Woonsocket plans to procure grant management software which will streamline the application process and allow for improved recordkeeping to ensure compliance with all policies and procedures. Proposed Completion Date: 06/30/2023
View Audit 29946
Finding 35172 (2022-002)
Material Weakness 2022
City of Woonsocket
RI
Reporting Subrecipient Monitoring Eligibility
Name of Contact Person: Veronicka Vega Corrective Active Plan: In the past year, the City has worked to develop an updated record of all HOME assisted projects. Staff thoroughly catalogued all program files creating separate documents for files that are discharged or still active. The documents ca...
Name of Contact Person: Veronicka Vega Corrective Active Plan: In the past year, the City has worked to develop an updated record of all HOME assisted projects. Staff thoroughly catalogued all program files creating separate documents for files that are discharged or still active. The documents can be reviewed to add monitoring information. The document contains the period of affordability and the amount due at payoff. Proposed Completion Date: 6/30/23
View Audit 29946
Finding 35167 (2022-006)
Significant Deficiency 2022
City of Woonsocket
RI
Equipment & Real Property Management Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.303
Name of Contact Person: Alyssa McDermott Corrective Action Plan: The City of Woonsocket has experienced significant turnover over the past years. With the division of housing and community development fully staffed, a thorough review of project files has occurred. Properties that were funded throu...
Name of Contact Person: Alyssa McDermott Corrective Action Plan: The City of Woonsocket has experienced significant turnover over the past years. With the division of housing and community development fully staffed, a thorough review of project files has occurred. Properties that were funded through CDBG or HOME Entitlement funds are fully documented. Properties that are not owned by the City of Woonsocket or received funding from CDBG or HOME entitlement funds are not documented in this office. Properties owned by the Redevelopment Agency of Woonsocket, Woonsocket Housing Authority, or properties that HUD have foreclosed on are not documented by this office. Proposed Completion Date: 06/30/2023
View Audit 29946
Finding 35146 (2022-001)
Material Weakness 2022
Goodwill Industries of Middle Georgia, Inc. and Affiliates
GA
Student Financial Aid Special Tests & Provisions Eligibility
Audit Finding Number: 2022-001-Enrollment Reporting: Management concurs with the finding. As noted by the auditors, a corrective action plan was established to ensure that timely enrollment data be coordinated between the Registrar's Office and the Financial Aid Office. This plan was developed in Au...
Audit Finding Number: 2022-001-Enrollment Reporting: Management concurs with the finding. As noted by the auditors, a corrective action plan was established to ensure that timely enrollment data be coordinated between the Registrar's Office and the Financial Aid Office. This plan was developed in August 2022 along with additional corrective actions efforts to ensure that admission and financial aid data was internally audited prior to enrolling a student. As the audit was conducted, it was evident that the corrective action could not be examined for effectiveness and accuracy as the students examined were from periods prior to the implementation of the corrective action plan and then, as noted by the auditors, the government's NSLDS was not working from July 2022-February 2023, so records could not be shared. The corrective action plan was implemented when the HSLDS because available to submit reports in February 2023. Additionally, the Helms College Registrar, Director of Education and Compliance and Financial Aid Manager will complete free enrollment reporting training courses offered by the National Student Clearinghouse, and continue to submit the enrollment status reports to the National Student Clearinghouse according to the required reporting schedule. Luke Schultheis, Executive Vice President of Education 6/13/23
View Audit 38022
Finding 35137 (2022-003)
Significant Deficiency 2022
Community Action Services and Food Bank
UT
Eligibility Reporting School Nutrition Programs
Finding 2022-003 Finding Summary: The Organization did not have adequate controls to ensure household income was properly certified and may have allowed ineligible households to receive USDA Foods. Responsible Individuals: Administrative assistant (Wendy Matheney) and Front Desk Supervisor (Shannon ...
Finding 2022-003 Finding Summary: The Organization did not have adequate controls to ensure household income was properly certified and may have allowed ineligible households to receive USDA Foods. Responsible Individuals: Administrative assistant (Wendy Matheney) and Front Desk Supervisor (Shannon Thackeray) Corrective Action Plan: Signature paperwork will be verified individually for each client by the front desk staff. The Admin Assistant will supervise data collection and integrity from a big picture standpoint. Anticipated Completion Date: 1/15/2023
View Audit 35378
Finding 35105 (2022-003)
Material Weakness 2022
The Housing Authority of the City of Slidell
LA
HUD Housing Programs Internal Control / Segregation of Duties Eligibility
Action Taken: In December 2022, HACS staff (maintenance and Interim Executive Director) attended NSPIRE inspection standards training. NSPIRE standards are due to go live in 2023. The HUD Recovery Administrators are providing a HUD engineer on site to provide Technical assistance. Additionally, HACS...
Action Taken: In December 2022, HACS staff (maintenance and Interim Executive Director) attended NSPIRE inspection standards training. NSPIRE standards are due to go live in 2023. The HUD Recovery Administrators are providing a HUD engineer on site to provide Technical assistance. Additionally, HACS management is drafting, and will provide to its board and its audit firm prior to March 31, 2023, a schedule of Public Housing inspections to be completed in the coming calendar year.
View Audit 31989
Finding 35090 (2022-004)
Material Weakness 2022
School District of Sevastopol
WI
School Nutrition Programs Internal Control / Segregation of Duties Special Tests & Provisions
2022-004 Special Tests and Provisions ? Verification of Free and Reduced Price Applications Federal Assistance Listing Number: 10.CNC District is in the process of establishing procedures and controls by the Business Manager to oversee the retention of verification documentation and information ...
2022-004 Special Tests and Provisions ? Verification of Free and Reduced Price Applications Federal Assistance Listing Number: 10.CNC District is in the process of establishing procedures and controls by the Business Manager to oversee the retention of verification documentation and information obtained through the verification process. Responsible Official: Karl Volkmann, Business Manager Anticipated Completion Date: June 30, 2023
View Audit 24809
Finding 35005 (2022-003)
Significant Deficiency 2022
Housing Authority of the City of Norwalk
CT
Questioned Costs HUD Housing Programs Eligibility
Views of responsible officials and planned corrective action: The Authority will increase oversight in the Section 8 Housing Choice Vouchers program to ensure that established internal control policies are being followed on a timely basis. Adam Bovilsky, Executive Director, is responsible for implem...
Views of responsible officials and planned corrective action: The Authority will increase oversight in the Section 8 Housing Choice Vouchers program to ensure that established internal control policies are being followed on a timely basis. Adam Bovilsky, Executive Director, is responsible for implementing this corrective action by March 31, 2023.
View Audit 36679 Questioned Costs: $1
Finding 35004 (2022-002)
Material Weakness 2022
Housing Authority of the City of Norwalk
CT
Questioned Costs HUD Housing Programs Eligibility
Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers program to ensure that established internal control policies are being followed on a timely basis. A...
Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers program to ensure that established internal control policies are being followed on a timely basis. Adam Bovilsky, Executive Director, is responsible for implementing this corrective action by March 31, 2023.
View Audit 36679 Questioned Costs: $1
Finding 34976 (2022-001)
Significant Deficiency 2022
Westhampton Beach Union Free School District
NY
Eligibility Significant Deficiency Internal Control / Segregation of Duties
This corrective action plan is in response to the school district?s external auditor?s Single Audit report dated June 30, 2022 prepared by R.S. Abrams & Co, LLP. 1. Recommendation: We recommend the district develop a system of internal control to have the maintenance of effort calculator reviewed an...
This corrective action plan is in response to the school district?s external auditor?s Single Audit report dated June 30, 2022 prepared by R.S. Abrams & Co, LLP. 1. Recommendation: We recommend the district develop a system of internal control to have the maintenance of effort calculator reviewed and approved with all supporting documentation by a responsible administrator prior to submitting it to the State. We also recommend the district officials contact the State to verify procedures to file a revised MOE calculation, if considered necessary. Corrective Action: For the past five years the District has utilized a third party to process and submit its maintenance of effort calculations through the PPS office. Moving forward the business office will process, maintain and submit the maintenance of effort calculations to the State. Anticipated Completion Date: March 2023 with oversight from the Assistant Superintendent for Business.
View Audit 38144
Finding 34936 (2022-001)
Material Weakness 2022
Lebanon Community School Corporation
IN
Questioned Costs Internal Control / Segregation of Duties Cash Management § 200.303
Finding 2022-001 Subject: Medicaid ? Eligibility, Other Matters Audit Findings: Material Weakness Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the eligibility compliance...
Finding 2022-001 Subject: Medicaid ? Eligibility, Other Matters Audit Findings: Material Weakness Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the eligibility compliance requirements that are performed by the Special Education Cooperative on behalf of the School Corporation. Context: The School Corporation participates in a Special Education Co-op. In 2015, the Co-op provided an avenue through a third-party company, for the member school districts to obtain reimbursement for Medicaid services. It was discovered in 2021 that the yearly parental disclosure statements had not been completed for Medicaid eligibility compliance. Due to this oversight, each member school has had to voi transactions through the third-party company and pay back the amount of these transactions from August 9, 2015 through April 23, 2021. The School Corporation?s amount owed was $481,276 for the period identified during 2015-2021. The School Corporation completed a Voluntary Self-Disclosure of Provider of Overpayments Packet through the Indiana Family & Social Services Administration?s Office of Medicaid Policy and Planning Office to reimburse the amounts owed. The amount related to this period July 1, 2020 through June 30, 2022 was indeterminable. The full amount was paid back prior to June 30, 2021. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Parental disclosure statements are completed annually for Medicaid eligibility compliance. This has already been implemented. Responsible Party and Timeline for Completion: Madeline Sandberg, Director of BCNWH Joint Services, 7/1/2021
View Audit 32733 Questioned Costs: $1
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