Corrective Action Plans

Finding 1160034 (2022-007)

Material Weakness 2022

DC

Eligibility

Views of Responsible Officials and Corrective Action: To address this issue and ensure future compliance, we have implemented the following measures: • Eligibility Verification Protocols: We have developed and implemented standardized eligibility screening procedures for all HHS-funded programs. The...

Views of Responsible Officials and Corrective Action: To address this issue and ensure future compliance, we have implemented the following measures: • Eligibility Verification Protocols: We have developed and implemented standardized eligibility screening procedures for all HHS-funded programs. These protocols include: • Clear definitions of eligibility criteria based on program guidelines. • Required documentation (e.g., income verification, residency, age, or disability status). • A checklist to ensure all required documents are collected and reviewed. • Documentation Standards: All eligibility determinations are now documented and retained in participant files. We have adopted a secure digital system to store and manage these records, ensuring they are accessible for audit and monitoring purposes . • Staff Training: Program staff have received training on eligibility requirements and documentation standards. Training materials include examples of acceptable documentation and instructions for handling incomplete or missing information. Monitoring and Oversight • We have instituted periodic internal audits to review participant files for compliance with eligibility documentation requirements. • Supervisors are required to review and approve eligibility determinations before services are rendered. Policy Updates Our program policies have been updated to include: • Mandatory eligibility screening and documentation procedures. • Retention requirements aligned with 2 CFR § 200.334. • Procedures for handling exceptions and documenting justifications. Commitment to Compliance We are committed to ensuring that all participants in HHS-funded programs meet the required eligibility criteria and that our documentation practices fully comply with Federal regulations. We appreciate the audit team's diligence and will continue to cooperate fully to resolve this finding.

View Audit 370488

Finding 1159822 (2022-006)

Material Weakness 2022

Republic of Palau

PW

Questioned Costs Subrecipient Monitoring Eligibility

We concur with the finding. Beginning in FY25, claimants have been required to come in and correct errors on their weekly claim forms. Regarding the overpayment, the claimant has been provided with a completed overpayment waiver form covering the two weeks of paid benefits.

View Audit 370385 Questioned Costs: $1

Finding 1157880 (2022-077)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Special Tests & Provisions Eligibility Matching / Level of Effort / Earmarking § 200.303

The Government concurs with the auditor's findings and recommendations. DHS has onboarded a Director of Program Integrity who will be responsible for establishing The Quality Control Unit, which will work with the Medical Eligibility Quality Control (MFCU) on behalf of the Medicaid Program.

View Audit 369907

Finding 1157878 (2022-075)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Internal Control / Segregation of Duties Eligibility Reporting § 200.303

The Government concurs with the auditor's findings and recommendations. DHS staff will work with PMO, hired to assist with the Public Health Emergency Unwind and establish Standard Operating Policies and Procedures (SOPPs) on certification and recertification processes and procedures. DHS is also in...

The Government concurs with the auditor's findings and recommendations. DHS staff will work with PMO, hired to assist with the Public Health Emergency Unwind and establish Standard Operating Policies and Procedures (SOPPs) on certification and recertification processes and procedures. DHS is also in the process of hiring a Program Integrity Director and Medical Eligibility Quality Control (MEQC) staff, whose responsibility will be to review completed case files.

View Audit 369907

Finding 1157866 (2022-069)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Matching / Level of Effort / Earmarking Special Tests & Provisions Subrecipient Monitoring § 200.303

The Government concurs with the auditor's findings and recommendations. An internal audit process is in place and is being utilized. Specifically, this includes exchanging caseloads between workers and having the eligibility and subsidy determinations cross-checked by the different worker based on t...

The Government concurs with the auditor's findings and recommendations. An internal audit process is in place and is being utilized. Specifically, this includes exchanging caseloads between workers and having the eligibility and subsidy determinations cross-checked by the different worker based on the federally and locally established policies.

View Audit 369907

Finding 1157865 (2022-068)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Special Tests & Provisions Subrecipient Monitoring Eligibility § 200.303

The Government concurs with the auditor's findings and recommendations. While DHS remains in compliance with this finding from previously audited years, the untimely submission resulted in this finding. Moving forward, a shared file will be established to ensure that the requisite information for ea...

The Government concurs with the auditor's findings and recommendations. While DHS remains in compliance with this finding from previously audited years, the untimely submission resulted in this finding. Moving forward, a shared file will be established to ensure that the requisite information for each year is readily available for audit purposes.

View Audit 369907

Finding 1157861 (2022-064)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Subrecipient Monitoring Eligibility Matching / Level of Effort / Earmarking § 200.303

The Government concurs with the auditor's findings and recommendations. The DHS has implemented a checklist as an added internal control step to comply with the Federal requirements for review of provider enrollment applications by the provider relations staff.

View Audit 369907

Finding 1157824 (2022-054)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

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

The Government concurs with the auditor's findings and recommendations. VIDE acknowledges the findings related to the participation of private school children in the COVID-19 Education Stabilization Fund (ESF-SEA) program. VIDE is committed to rectifying these issues and enhancing our systems to ens...

The Government concurs with the auditor's findings and recommendations. VIDE acknowledges the findings related to the participation of private school children in the COVID-19 Education Stabilization Fund (ESF-SEA) program. VIDE is committed to rectifying these issues and enhancing our systems to ensure equitable services for private school children. OMB will develop and implement a formal policy and procedures that outline the process for ensuring the participation of private school children in compliance with federal regulations. This will include guidelines for timely consultation with nonpublic schools and documentation of services provided. OMB will create a consultation schedule to ensure that timely consultations with nonpublic schools are conducted each fiscal year. The schedule will outline key dates for initiating and completing consultations to meet compliance requirements. OMB will collaborate with the Department of Education to develop control measure to ensure that all private schools expenditures are equal on a per-pupil basis to the expenditures for participating public school children and their teachers and other educational personnel.

View Audit 369907

Finding 1157798 (2022-038)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Special Tests & Provisions Subrecipient Monitoring Eligibility § 200.303

The Government concurs with the auditor's findings and recommendations. VIDOL will be implementing a RESEA case management system for reporting and program services. This case management system is currently in configuration phase of the project. Live production is expected by the 2nd quarter 2025. T...

The Government concurs with the auditor's findings and recommendations. VIDOL will be implementing a RESEA case management system for reporting and program services. This case management system is currently in configuration phase of the project. Live production is expected by the 2nd quarter 2025. This system will be the official system of record for recording all services for RESEA claimants that participate in the program.

View Audit 369907

Finding 1157795 (2022-035)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Questioned Costs Eligibility Matching / Level of Effort / Earmarking § 200.303

The Government concurs with the auditor's findings and recommendations. The agency has commenced reviewing the agency retention policies and training with staff on keeping records and files in a systematic sequence. In the third quarter of FY2025, the agency will be launching an electronic record ke...

The Government concurs with the auditor's findings and recommendations. The agency has commenced reviewing the agency retention policies and training with staff on keeping records and files in a systematic sequence. In the third quarter of FY2025, the agency will be launching an electronic record keeping system for claims files that will provide a more comprehensive and structured mechanism for record retention. VIDOL staff will also be engaging with USDOL to have programmatic technical assistance with record retention. The agency is also engaging with USDOL to implement data validation in the operations which is intended to verify that eligibility and records are maintained. The agency’s Integrity unit will commence regular compliance reviews for claimant eligibility in the 2nd quarter of FY2025, this review will assist in mitigating past errors and provide feedback on corrective actions that will assist in proper record retention.

View Audit 369907 Questioned Costs: $1

Finding 1155085 (2022-003)

Material Weakness 2022

Hill Country Community Clinic, Inc.

CA

Special Tests & Provisions Eligibility

Management acknowledges the finding. We will conduct mandatory training sessions for all relevant personnel to ensure a clear understanding of the Sliding Fee Discount Program requirements and policy. Training will include proper documentation practices, eligibility verification, and procedures for ...

Management acknowledges the finding. We will conduct mandatory training sessions for all relevant personnel to ensure a clear understanding of the Sliding Fee Discount Program requirements and policy. Training will include proper documentation practices, eligibility verification, and procedures for applying discounts consistently. We will review and update our sliding fee discount policy to ensure clarity, consistency, and compliance with regulatory requirements. We will provide an annual review and obtain board approval of the Sliding Fee Discounting Program scheduled on an annual basis. Regular internal audits will be conducted to review the application of sliding fee discounts and identify any discrepancies before external audits. Results of internal audits will be shared with management, and corrective actions will be taken as necessary. We will assess the feasibility of implementing system controls or automated alerts within our electronic health record (EHR) and billing systems to reduce errors in discount applications. Additional oversight measures may be introduced to ensure all eligible patients receive the correct discount in accordance with policy guidelines. The above corrective actions are currently being implemented.

View Audit 367389

Finding 574043 (2022-002)

Material Weakness 2022

County of Rockingham

NH

Questioned Costs Allowable Costs / Cost Principles Eligibility § 200.303 § 200.334

Audit Finding Reference: 2022-002 Corrective Action Taken or Planned: 1. Formalized Record Retention Policies: A formal record retention policy specific to federal grant programs will be implemented to ensure full compliance with 2 CFR 200.334. This policy will apply regardless of whether documentat...

Audit Finding Reference: 2022-002 Corrective Action Taken or Planned: 1. Formalized Record Retention Policies: A formal record retention policy specific to federal grant programs will be implemented to ensure full compliance with 2 CFR 200.334. This policy will apply regardless of whether documentation is stored internally or by third-party systems. Any documentation downloaded or transferred from third-party systems will be subject to a review process to verify completeness and accuracy before being finalized for County retention. The County shall also take steps to ensure that information downloads and exports from third-party systems represent omplete and accurate records. 2. Audit Timing Advocacy and Preparedness: The County will continue to maintain timely documentation and preparedness for audits and will also advocate for timely initiation and completion of future audits. Significant delays in the audit process, through no fault of the County, as observed during the FY2022 audit, substantially impacted the County's ability to access necessary documentation and demonstrate compliance. Although the County made every effort to retain records in accordance with federal requirements, the timing of the audit fieldwork occurred well after the program had concluded in May 2023. Had the audit been conducted in a timely manner, full access to the third-party platform used for program administration would have been available, along with all supporting documentation. However, by the time the audit took place, the program had been closed for over 18 months, and access to the external software system had lapsed in accordance with the expiration of the service agreement. 3. Internal Audit Readiness Reviews: Beginning with FY2025, the County will conduct internal audit readiness reviews shortly after fiscal year-end to ensure all documentation for closed federal programs is centralized, archived, and accessible for future audit purposes, even if conducted years later. Anticipated Completion Date: October 15, 2025 Contact Person Responsible for Corrective Action: Charles Nickerson, Senior Director of Finance

View Audit 364627 Questioned Costs: $1

Finding 570442 (2022-008)

Material Weakness 2022

Consortium of Universities for the Advancement of Hydrologic Science, Inc.

MA

Cash Management Allowable Costs / Cost Principles Eligibility § 200.307

Finding Reference Number: MW2022-008 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2022: External contract accounting staff in place during audit year 2022 failed to declare program incom...

Finding Reference Number: MW2022-008 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2022: External contract accounting staff in place during audit year 2022 failed to declare program income in advance of the deadline specified by NSF. Program income for 2022 was filed was filed on 3 December 2022, approximately three weeks late. Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI continues to use a single payment gateway for events and registration fees which supports segregation of payments per event and per grant. Program income has been reported to NSF accurately and on time as of audit year 2023 and appropriate staff and policies are in place to ensure continued future compliance. Name of Contact Person: • Maureen S. Ako, Director of Finance • Telephone: (339)221-5400 • Email: msabino@cuahsi.org Projected Completion Date: NA; is complete

View Audit 361411

Finding 567969 (2022-002)

Material Weakness 2022

Community Action Partnership of Providence County

RI

Eligibility

Policies for all programs are being developed by each department and will include random, periodic file audits to ensure eligibility documentation and other mandatory paperwork is maintained for all programs.

View Audit 360314

Finding 565761 (2022-007)

Material Weakness 2022

Detroit Central City Cmh, Inc.

MI

Eligibility

To address this finding, the Finance Department along with the Revenue Cycle department will take the following actions: * An Executive Director of Revenue Cycle has been hired to manage all aspects of revenue cycle (including the Sliding Fee Discount Program). * The Director will implement a target...

To address this finding, the Finance Department along with the Revenue Cycle department will take the following actions: * An Executive Director of Revenue Cycle has been hired to manage all aspects of revenue cycle (including the Sliding Fee Discount Program). * The Director will implement a targeted training program for staff involved in administering the program, focusing on a sliding fee approach. This traning will include identifying patients who are eligible for the sliding fee discount. * The Director has created a Standard Operating Procedure (SOP) for each EHR system to ensure that all staff administering sliding fees understand the Sliding Fee process. This will also include monitoring the program for compliance and the appropriate application of any sliding fee discount transactions. * Update the sliding fee scale annually using the Federal Poverty Guidelines.

View Audit 359454

Finding 565179 (2022-012)

Material Weakness 2022

City of Paterson

NJ

Questioned Costs Procurement, Suspension & Debarment Cash Management

City was delayed due to staff shrotages. City is catching up and has controls set

View Audit 359090 Questioned Costs: $1

Finding 565178 (2022-007)

Material Weakness 2022

City of Paterson

NJ

Questioned Costs Procurement, Suspension & Debarment Cash Management

City was delayed due to staff shrotages. City is catching up and has controls set

View Audit 359090 Questioned Costs: $1

Finding 565177 (2022-009)

Material Weakness 2022

City of Paterson

NJ

Questioned Costs Procurement, Suspension & Debarment Eligibility

City was delayed due to staff shrotages. City is catching up and has controls set

View Audit 359090 Questioned Costs: $1

Finding 565176 (2022-008)

Material Weakness 2022

City of Paterson

NJ

Questioned Costs Procurement, Suspension & Debarment Cash Management

City was delayed due to staff shrotages. City is catching up and has controls set

View Audit 359090 Questioned Costs: $1

Finding 565174 (2022-010)

Material Weakness 2022

City of Paterson

NJ

Questioned Costs Procurement, Suspension & Debarment Cash Management

City was delayed due to staff shrotages. City is catching up and has controls set

View Audit 359090 Questioned Costs: $1

Finding 565074 (2022-002)

Material Weakness 2022

United Way of Marion County, Inc.

FL

Cash Management Eligibility Material Weakness

United of Marion County, Inc. experienced staff turnover during the ERA 1 & ERA2 which may have contributed to data not being regularly reconciled to the third-party grant tracking system. The United Way of Marion County, Inc has hired a full-time accounting professional to improve internal controls...

United of Marion County, Inc. experienced staff turnover during the ERA 1 & ERA2 which may have contributed to data not being regularly reconciled to the third-party grant tracking system. The United Way of Marion County, Inc has hired a full-time accounting professional to improve internal controls. Management as the time utilized the resources available to ensure residents received timely housing assistance.

View Audit 359012

Finding 564774 (2022-004)

Significant Deficiency 2022

American Society for Engineering Education

DC

Eligibility

ASEE is working with the Program directors to ensure that proper and sufficient documentation is stored and retained for all federal awards. In addition, the organization is providing the proper tools to assist the Program Directors store and retain all documents safely for a long time.

View Audit 358839

Finding 561489 (2022-007)

Material Weakness 2022

Sayre Health Center

PA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Finding No. 2022-007: Inadequate Documentation and Records for Application of Sliding Fee Discounts We have incorporated a policy that establishes the basis for the sliding fee policy to assure affordable access to care for uninsured and underinsured patients of the organization. The policy will rec...

Finding No. 2022-007: Inadequate Documentation and Records for Application of Sliding Fee Discounts We have incorporated a policy that establishes the basis for the sliding fee policy to assure affordable access to care for uninsured and underinsured patients of the organization. The policy will recognize a “full discount” for individuals and families with annual incomes at or below 100% Federal poverty level (FPL) with only nominal fees charged, three levels of discount between 100% and 200%, and no discounts for copays for individuals and families earning over 200% FPL. This policy will be in accordance with Section 330(k)(3)(G) of the PHS Act and 42 CFR Part 51c.303(f) and 42 CFR Part 51c.303(u) which are incorporated herewith. We will charge a nominal fee to individuals and families with annual incomes at or below 100% of the FPL. Patients whose incomes are above 100% or below 200% of the FPL will be charged according to our sliding fee scale based on income and family size. Discounts will be provided to patients with incomes up to 200% of the FPL for medical visits. Discounts will be provided to patients with incomes up to 250% of the FPL for family planning visits. Staff will assess patients’ incomes based upon a sliding fee scale and no patient will be denied care based upon their inability to pay. The organization also has a policy of nondiscrimination in the delivery of health care as stated in its Patient Bill of Rights. Also, the Board of Directors define the income and family size, and has defined the family size to be all parents, minors or guardians that are financially responsible for the household. The tracking and documentation of sliding fees is now maintained with the deposit record of each fee received in the shared file for immediate availability and reference.

View Audit 357068 Questioned Costs: $1

Finding 560504 (2022-010)

Material Weakness 2022

Orutsararmiut Native Council

AK

Allowable Costs / Cost Principles Eligibility Material Weakness

Name of Contact: Brian Henry, Executive Director Corrective Action Plan: Vacant positions within the accounting and program departments have been filled to ensure that the Council follows internal control policies over grant reporting. Proposed Completion Date: Complete as of June 30, 2024

View Audit 356419

Finding 560149 (2022-016)

Material Weakness 2022

Oregon Coast Community Action

AL

Cash Management Subrecipient Monitoring Allowable Costs / Cost Principles

The Energy program has been current on the required reporting since the referenced audit period. The program is aware of the grants' requirements now. Additionally, ORCCA plans to utilize grant tracker system with the ability to send reminders for important dates to avoid future delinquent reporting...

The Energy program has been current on the required reporting since the referenced audit period. The program is aware of the grants' requirements now. Additionally, ORCCA plans to utilize grant tracker system with the ability to send reminders for important dates to avoid future delinquent reporting that was experienced during the audit period. The system will be utilized by the program directors as well as finance team (Finance Director, Accounting Manager, Program Fiscal Compliance Coordinator) working with grants/directors. ORCCA's current process at the Energy program level has already improved to ensure proper documentation of eligibility. The Energy program director and staff are implementing this internal control at the program level to review the supporting documents and information and proper coding to the correct period. Responsible party: Bonnie Foroudi, Finance Director Estimated completion date: December 31, 2025

View Audit 356132

Corrective Action Plans

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