Corrective Action Plans

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Views of Responsible Officials QHS agrees with the finding and accepts the recommendation.
Views of Responsible Officials QHS agrees with the finding and accepts the recommendation.
View Audit 318521 Questioned Costs: $1
Finding 2022‐002: Eligibility‐(Material weakness in Compliance, Internal Control, and Service Provision within the APA (Assistance Program) Program) Effect: The Organization provided APA/R&P program funding to ineligible refugees and lawful permanent residents due to inadequate verification and inco...
Finding 2022‐002: Eligibility‐(Material weakness in Compliance, Internal Control, and Service Provision within the APA (Assistance Program) Program) Effect: The Organization provided APA/R&P program funding to ineligible refugees and lawful permanent residents due to inadequate verification and inconsistent documentation practices. Auditor's Recommendation: The Organization should enhance its eligibility verification process to ensure that only enrolled refugees receive funding. Implementing regular training for staff and updating guidelines will help maintain accurate and complete documentation, ensuring compliance and maximizing the effectiveness of the APA/R&P program. Management Response: We agree with the recommendation and have also submitted the following response: Ensuring refugee eligibility as a sub-recipient of HIAS involves a comprehensive and diligent process. Staff are trained in verification and eligibility as required by the funder and follow an enhanced eligibility verification process. Screening is completed at the funder level to ensure refugee eligibility and program placement. Once approved, a referral is sent to the designated providers. Eligibility: The referral number designates the refugee to a program; even though the Funder system lists “None,” the referral is eligible. For the 7 in the sample, each refugee had a designated approved number from HIAS Verification: In the one exception where a refugee was a lawful permanent resident, JFSSV conducted its due diligence in the verification process and identified the client. This was immediately reported to the funder and rectified as required by the funder. Documentation: During the fiscal year 21/22, amidst the wrap-up of COVID-19, intake was conducted via telehealth processes, and verbal approval was accepted. Additionally, not all services required forms to be signed, such as “providing information on accessing legal permanent resident status, family reunification procedures, assisting school-age children.” These services were verbally discussed during the intake process and updated in the refugees' case notes in the funder system. JFSSV has provided Harshwal & Company LLP with detailed explanations on all samples and provided testing requirements with refugee backup during the audit. JFSSV ensures proper documentation and support as required by the grantor's requirements, and JFSSV adheres to all monitoring visits and grant program reviews To address the specific concerns raised regarding internal controls over compliance and eligibility verification, JFSSV will: Enhance the Eligibility Verification Process: JFSSV will continue to review and strengthen its eligibility verification process to ensure that only enrolled refugees receive funding. Regular Staff Training: JFSSV will ensure continuous training to ensure they are well-versed in the updated guidelines and best practices for eligibility verification and documentation required from the Funder. Improve Documentation Practices: JFSSV will continue best practices in validating eligibility determinations and related documentation to be complete, accurate, and current. This includes maintaining thorough records in the case note log within the Funder’s system.
Upon the completion of the annual audits for FY22 – FY24 management will file Form SF-SAC with the USDA. Thereafter the annual audit will be completed on a timely basis which will allow for the timely filing of the Form SF-SAC with the USDA. The SAC filing for FY 21 has been completed. Anticipat...
Upon the completion of the annual audits for FY22 – FY24 management will file Form SF-SAC with the USDA. Thereafter the annual audit will be completed on a timely basis which will allow for the timely filing of the Form SF-SAC with the USDA. The SAC filing for FY 21 has been completed. Anticipated Completion Date-11/30/2024.Responsible Contact Person-Kathleen Boyce, CFAO
Finding 485451 (2022-005)
Significant Deficiency 2022
2022-005 Temporary Aid for Needy Families (TANF) Federal Financial Assistance Listing Number: 93.558 Federal Grantor: U.S. Department of Health and Human Services Pass-Through: California Department of Social Services Award No. and Year: 1946001347-A7 2022 Compliance Requirements: Eligibility ...
2022-005 Temporary Aid for Needy Families (TANF) Federal Financial Assistance Listing Number: 93.558 Federal Grantor: U.S. Department of Health and Human Services Pass-Through: California Department of Social Services Award No. and Year: 1946001347-A7 2022 Compliance Requirements: Eligibility Type of Finding: Significant Deficiency Management’s or Department’s Response: Imperial County Department of Social Services agrees with the finding. Views of Responsible Officials and Corrective Action Plan: The Count of Imperial, Department of Social Services, is committed to maintaining robust monitoring and oversight controls in place to ensure that applicant eligibility is thoroughly reviewed and approved. The Department will continue to monitor compliance with policies to ascertain that eligibility technicians follow guidelines for redetermination of recipients of need and amount of assistance, including to retain acceptable documentation to support the determinations. The Department will implement enhances training and guidance to include refresher training that will be developed based on needs identified during this review. The training will address any changes in regulations and/or internal processes. Name of Responsible Person: Paula S. Llanas, County of Imperial – Department of Social Services Director Implementation Date: September 1, 2024
With the newly hired staff as of October 2022, the process of selecting eligible tenants from the list has been accomplished by identifying the preference and verifying in writing th ereason for such preference to move forward with the housing the applicant. All verification is kep tin the eligible ...
With the newly hired staff as of October 2022, the process of selecting eligible tenants from the list has been accomplished by identifying the preference and verifying in writing th ereason for such preference to move forward with the housing the applicant. All verification is kep tin the eligible tenant file. the existing staff has had 10-15 years' experience maintaining Federal program waiting list.
Management agrees that in order to maintain the integrity of the accounting and financial reporting system, and to ensure timely reporting, an adequate system of internal controls should be designed and implemented to ensure effective operation. Management is aware of the reconciliation issue betwee...
Management agrees that in order to maintain the integrity of the accounting and financial reporting system, and to ensure timely reporting, an adequate system of internal controls should be designed and implemented to ensure effective operation. Management is aware of the reconciliation issue between the receivables in Sewer and Solid Waste Funds which, in part, is due to inherent limitation in the system used for utility billings. Staff is working diligently to perform the reconciliations or to develop a different methodology of accurately reporting receivables in both Funds. The complete and accurate reconciliations between these two funds should take place during FY 2024-25. Earlier reconciliation is possible. Management agrees to the adjustments related to OPEB and other liabilities, writing off significant uncollectible interfund receivables, amounts due from other governments, and capital assets. Management and staff are preparing a detailed and comprehensive schedule of accounting duties for the year-end closing process, to include individuals responsible for completing each task along with completion dates and sign-off elements. The OPEB and other liabilities, writing off significant uncollectible interfund receivables, amounts due from other governments, and capital assets are corrected during FY 2022-23. Timely issuance of audit reports involves collaboration and teamwork between auditor and auditee. The finance staff worked diligently and promptly responded to the auditors’ requests for information and documentation. The timeliness of reconciliations related to the Sewer and Solid Waste funds were delayed but were not associated with the rest of the funds. However, the audit of all financial information of the Town was suspended for more than a year when the lack of reconciliations for these two funds was brought to the attention of the auditors. Name of Responsible Person: Emad Gewaily, Director of Finance Implementation Date: June 30, 2025
The Project will adhere to the HUD rent subsidy program in accepting applications, determining eligibility, calculating the tenant's contribution toward rent and utilities, and calculating subsidy in accordance with HUD.
The Project will adhere to the HUD rent subsidy program in accepting applications, determining eligibility, calculating the tenant's contribution toward rent and utilities, and calculating subsidy in accordance with HUD.
Management Response #2022-014: Due to software update with DC Department of Health, the January 1 – March 31, 2022, records were not available, nor were internal reviews of eligibility requirements support available as required. Corrective Action Plan: • The Grants program management team will expa...
Management Response #2022-014: Due to software update with DC Department of Health, the January 1 – March 31, 2022, records were not available, nor were internal reviews of eligibility requirements support available as required. Corrective Action Plan: • The Grants program management team will expand upon our current process to ensure eligibility determination is verified and documented. • Training will be provided to staff on performing income eligibility verification to include taking a screen shot of the eligibility and storing it on a protected shared drive with a de-identified naming convention. This will allow us to have a warehouse of the eligibility verification that can be referenced when needed. It shall be maintained by the WIC Director with limited access and password protection. Policy/procedure manuals for the WIC Dept will be updated to reflect this new requirement and ensure compliance. Responsible Party: Tracy Harrison, COO
The Houston Housing Authority agrees with this finding. The Houston Housing Authority has for the past several months undertaken a program to review all voucher files for purposes of getting all deficiencies corrected. During this process if other required documents are found to be missing steps ...
The Houston Housing Authority agrees with this finding. The Houston Housing Authority has for the past several months undertaken a program to review all voucher files for purposes of getting all deficiencies corrected. During this process if other required documents are found to be missing steps are being taken to complete the missing documentation and make sure that the files are complete. This review is substantially completed with final completion expected in the third quarter of 2024. Procedures have been implemented with regards to preventing this situation from recurring. Where needed staff will be provided the necessary training to make sure that all HCVP staff have the skills needed to successfully complete their job tasks. To facilitate this training, the Houston Housing Authority has created a training center that is made available to not only Houston Housing Authority staff but also others to provide a wide variety of training classes. Current leadership at the Houston Housing Authority is committed to having a competent trained staff working in the HCVP as well as other departments with the agency. This work is handled by the Voucher Program Operations department. The VP of this department and the Director of this department are primarily responsible for making sure the necessary corrections are made and the fill review is completed within the third quarter of 2024.
The Houston Housing Authority agrees with this finding. The Houston Housing Authority has for the past several months undertaken a program to review all voucher files for purposes of getting all delinquent recertifications completed. During this process if other required documents are found to be...
The Houston Housing Authority agrees with this finding. The Houston Housing Authority has for the past several months undertaken a program to review all voucher files for purposes of getting all delinquent recertifications completed. During this process if other required documents are found to be missing steps are being taken to complete the missing documentation and make sure that the files are complete. This review is substantially completed with final completion expected in the third quarter of 2024. Procedures have been implemented with regards to preventing this situation from recurring. Where needed staff will be provided the necessary training to make sure that a HCVP staff have the skills needed to successfully complete their job tasks. To facilitate this training, the Houston Housing Authority has created a training center that is made available to not only Houston Housing Authority staff but also others to provide a wide variety of training classes. Current leadership at the Houston Housing Authority is committed to having a competent trained staff working in the HCVP as well as other departments with the agency. This work is handled by the Voucher Program Operations department. The VP of this department and the Director of this department are primarily responsible for making sure the necessary corrections are made and the fill review is completed within the third quarter of 2024.
The Houston Housing Authority agrees with this finding. The Houston Housing Authority has for the past several months undertaken a program to review all voucher files for purposes of getting all delinquent recertifications completed. During this process if other required documents are found to be...
The Houston Housing Authority agrees with this finding. The Houston Housing Authority has for the past several months undertaken a program to review all voucher files for purposes of getting all delinquent recertifications completed. During this process if other required documents are found to be missing steps are being taken to complete the missing documentation and make sure that the files are complete. This review is substantially completed with final completion expected in the third quarter of 2024. Procedures have been implemented with regards to preventing this situation from recurring. Where needed staff will be provided the necessary training to make sure that all HCVP staff have the skills needed to successfully complete their job tasks. To facilitate this training, the Houston Housing Authority has created a training center that is made available to not only Houston Housing Authority staff but also others to provide a wide variety of training classes. Current leadership at the Houston Housing Authority is committed to having a competent trained staff working in the HCVP as well as other departments with the agency. This work is handled by the Voucher Program Operations department. The VP of this department and the Director of this department are primarily responsible for making sure the necessary corrections are made and the fill review is completed within the third quarter of 2024.
The Project will have procedures in place to complete Income Verification for Form HUD-50059 accurately.
The Project will have procedures in place to complete Income Verification for Form HUD-50059 accurately.
Cornerstones acknowledges that our files were incomplete. It is our position that the COVID-19 pandemic created immense need to which Cornerstones responded by expanding rapidly and mobilizing funding and program requests that did not receive the benefit of comprehensive planning; the focus was on h...
Cornerstones acknowledges that our files were incomplete. It is our position that the COVID-19 pandemic created immense need to which Cornerstones responded by expanding rapidly and mobilizing funding and program requests that did not receive the benefit of comprehensive planning; the focus was on health prevention, isolation and quarantine activities, and temporary shelter for homeless and other low-income, vulnerable seniors and disabled persons. We served those in need and our intake processes and recordkeeping did not keep pace. Additionally, given the time that has passed since the services in question, it is possible that records that did exist were misplaced. Staff turnover, resulting from the pandemic burden, made it challenging to go back to the work that had been done. In the time since these events Cornerstones has further emphasized the compliance and documentation needs of the case management process, and we have filled turned-over positions with experienced staff that also understand intake and documentation requirements. We have also hired a Senior Director, Finance with over 20 years of federal contracts experience that is an integral part of increased program compliance and operational oversight responsibilities within the Finance/Operations function. This Senior Director and Cornerstones’ Chief Financial & Operating Officer, Executive Vice President of Housing and Community Programs, and other program leaders and staff, will all work together to ensure that the file construction process is complete and timely for all participants. Due to timing of receiving this finding, remediation processes began in fiscal year 2024 and will be applied fully to the fiscal year 2025, beginning 7/1/2024, files.
Management agrees with the recommendation and will implement stronger processes to ensure that all records are organized and maintained for ease of timely and complete review and consultation when needed. The processes to organize and secure files will be executed by program staff, with oversight by...
Management agrees with the recommendation and will implement stronger processes to ensure that all records are organized and maintained for ease of timely and complete review and consultation when needed. The processes to organize and secure files will be executed by program staff, with oversight by the Vice President of Community Building and Neighborhood Resources, Executive Vice President of Housing and Community Programs, Vice President of Family Empowerment and Self Sufficiency, Chief Financial & Operating Officer, and Sr. Director of Finance. Due to timing of receiving this finding, remediation processes began in fiscal year 2024 and will be applied fully to the fiscal year 2025, beginning 7/1/2024, files.
2022-006 – ELIGIBILITY Material Weakness/Material Noncompliance Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority provided training to necessary staff. Planned Implementation Date of Corrective Action: ...
2022-006 – ELIGIBILITY Material Weakness/Material Noncompliance Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority provided training to necessary staff. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director
2022-003 – ELIGIBILITY Material Weakness/Material Noncompliance Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority provided training to necessary staff and will discuss with the third party management co...
2022-003 – ELIGIBILITY Material Weakness/Material Noncompliance Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority provided training to necessary staff and will discuss with the third party management company to ensure compliance with 24 CFP 982.516 in the future. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director
2022-006 Housing Voucher Cluster – Assistance Listing Nos. 14.871/14.879 Recommendation: We recommend the Authority implements controls to ensure that documentation is maintained for new tenants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Acti...
2022-006 Housing Voucher Cluster – Assistance Listing Nos. 14.871/14.879 Recommendation: We recommend the Authority implements controls to ensure that documentation is maintained for new tenants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken or planned in response to finding: The HCVP is implementing a monthly quality control protocol to review new applicant files for completeness. A new Program Director was assigned to oversee this quality control process. The Program Director will also monitor the new tenant checklist which will be created to ensure that all new tenant documentation is accurately maintained. The OAC shall monitor and collaborate with the HCVP to ensure that the checklist is accurate and available for auditing. Name of the contact person responsible for corrective action: Starr Lane. Planned completion date for corrective action plan: 7/31/24.
2022-003 Housing Voucher Cluster – Assistance Listing Nos. 14.871/14.879 Recommendation: We recommend that DCHA staff review the controls in place to ensure that required eligibility determination documentation is complete, accurate, and available for audit. Explanation of disagreement with audit ...
2022-003 Housing Voucher Cluster – Assistance Listing Nos. 14.871/14.879 Recommendation: We recommend that DCHA staff review the controls in place to ensure that required eligibility determination documentation is complete, accurate, and available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken or planned in response to finding: The HCVP has a program eligibility team that processes applications. Once completed, the file will be reviewed monthly by an HCVP quality control staff and quarterly by the OAC to ensure that documentation is complete, accurate, and available for audit. Name of the contact person responsible for corrective action: Khaliah Payne. Planned completion date for corrective action plan: 9/30/24.
2022-002 Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend that DCHA staff review the controls in place to ensure that required eligibility determination documentation is complete, accurate, and available for audit. Explanation of disagreement with a...
2022-002 Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend that DCHA staff review the controls in place to ensure that required eligibility determination documentation is complete, accurate, and available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken or planned in response to finding: The HCVP has a program eligibility team that processes applications, and once complete, the file is reviewed by a quality control and compliance officer for compliance. The Office of Audit and Compliance (OAC) shall periodically monitor this process to ensure that eligibility determination documentation is complete, accurate, and available for audit. Name of the contact person responsible for corrective action: Khaliah Payne. Planned completion date for corrective action plan: 9/30/24.
Finding 454357 (2022-001)
Significant Deficiency 2022
2022-001 EligibilityName of contact person: Kathy Ford, Director and Jennifer Forlines, Income Maintenance Program AdministratorCorrective Action: The State provided DHB-7078 - 2nd Party Review Worksheet was expanded to include a weighted score for monitoring error trends and patterns for individual...
2022-001 EligibilityName of contact person: Kathy Ford, Director and Jennifer Forlines, Income Maintenance Program AdministratorCorrective Action: The State provided DHB-7078 - 2nd Party Review Worksheet was expanded to include a weighted score for monitoring error trends and patterns for individual staff and the unit as a whole. The enhanced review sheet allows for measuring improvement and determining where additional training is needed. Supervisors complete second party reviews monthly for all staff, conduct targeted reviews for errors identified and hold individual worker conferences monthly to review discrepancies discovered during review and provide instruction as needed. Training will be conducted during team meetings to review errors and provide guidance and instruction to staff for policy and NC FAST functionality updates.Proposed Completion Date: The enhanced second party review worksheet has been incorporated as an ongoing practice. Specific instruction surrounding the errors discovered with income, residency, household composition, resources and requesting information will be provided to all Medicaid workers during the January 2023 unit meetings set up by the supervisors for these units. Following the January 2023 meeting, targeted second party reviews focusing on these errors during the months of February, March and April 2023. Results will be compiled and shared with staff to recognize improvement and engage workers in the resolution process moving forward.
Finding 453787 (2022-002)
Significant Deficiency 2022
2022-002 Coronavirus State and Local Recovery Funds (CSLRF) ? Assistance Listing No. 21.027Recommendation: We recommend that the city review and evaluate procedures to ensure that the procedures over safeguarding assets, maintenance of records, and reconciliation of activity are consistently perform...
2022-002 Coronavirus State and Local Recovery Funds (CSLRF) ? Assistance Listing No. 21.027Recommendation: We recommend that the city review and evaluate procedures to ensure that the procedures over safeguarding assets, maintenance of records, and reconciliation of activity are consistently performed.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: Management concurs with the recommendation. The accounts will be reconciled prior to the program ending on a regular cycle during the program to ensure appropriate accounts and the accuracy of the supporting documentation is provided going forward.Described action planned or taken: The Standard Operating Procedures that provide additional detail will be followed to document the process of reconciling the account on a timely basis. Online applications programs are being created by the department of technology to assist in the program documentation gathering in order to ensure applicants can provide all necessary support for the program in a secure environment.Name(s) of the contact person(s) responsible for corrective action: Kyera Pope, Accounting Administrator, Gloria Taylor, Interim Chief Financial OfficerPlanned completion date for corrective action plan: 7/1/2022.If the Auditor of Public Accounts has questions regarding this plan, please call Mimi Terry, Interim City Manager.
Finding 453168 (2022-005)
Significant Deficiency 2022
Finding: 2022-005Name of contact person: Lisa Chaney, Mandy Edwards, Nicole Victory and Debbie McGuireCorrective Action: "Management will review cases internally to ensure proper documentation is in place for eligibility. Staff will be provided with refresher training on what information should be ...
Finding: 2022-005Name of contact person: Lisa Chaney, Mandy Edwards, Nicole Victory and Debbie McGuireCorrective Action: "Management will review cases internally to ensure proper documentation is in place for eligibility. Staff will be provided with refresher training on what information should be included in case files and the importance of this being complete and accurate. Management will review and revise current procedures in place to ensure that all eligibility determination criteria is completed such as online verifications, documented sources of income/resources and amounts are accurately reflected and retained in the case file within the NC FAST Case Management System. "Proposed Completion Date: Training will be completed by October 28th, 2022
Finding 453167 (2022-004)
Significant Deficiency 2022
Finding: 2022-004Name of contact person: Lisa Chaney, Mandy Edwards, Nicole Victory and Debbie McGuireCorrective Action: "Management will provide refresher training to all staff on what processes to follow when changes are reported to ensure accurate and timely review of all benefits. Management w...
Finding: 2022-004Name of contact person: Lisa Chaney, Mandy Edwards, Nicole Victory and Debbie McGuireCorrective Action: "Management will provide refresher training to all staff on what processes to follow when changes are reported to ensure accurate and timely review of all benefits. Management will review and revise current procedures in place to ensure that all eligibility determination criteria and documentation is completed timely and accurately reflected in the case file within the NC Fast Case Management System. "Proposed Completion Date: Training will be completed by October 28th, 2022
Finding 453166 (2022-003)
Significant Deficiency 2022
Finding: 2022-003Name of contact person: Lisa Chaney, Mandy Edwards, Nicole Victory and Debbie McGuireCorrective Action: "Management will review cases internally to ensure proper documentation is in place for eligibility. Staff will be provided with refresher training on what information should be ...
Finding: 2022-003Name of contact person: Lisa Chaney, Mandy Edwards, Nicole Victory and Debbie McGuireCorrective Action: "Management will review cases internally to ensure proper documentation is in place for eligibility. Staff will be provided with refresher training on what information should be included in case files and the importance of this being complete and accurate. Management will review and revise current procedures in place to ensure that all eligibility determination criteria is completed such as online verifications, documented resources and amounts are accurately reflected and retained in the case file within the NC FAST Case Management System. "Proposed Completion Date: Training will be completed by October 28th, 2022
Finding 453165 (2022-002)
Significant Deficiency 2022
Finding: 2022-002Name of contact person: Lisa Chaney, Mandy Edwards, Nicole Victory and Debbie McGuireCorrective Action: "Management will review cases internally to ensure proper documentation is in place for eligibility. Staff will be provided with refresher training on what information should be ...
Finding: 2022-002Name of contact person: Lisa Chaney, Mandy Edwards, Nicole Victory and Debbie McGuireCorrective Action: "Management will review cases internally to ensure proper documentation is in place for eligibility. Staff will be provided with refresher training on what information should be included in case files and the importance of this being complete and accurate. Management will review and revise current procedures in place to ensure that all eligibility determination criteria is completed such as online verifications, documented sources of income/resources and amounts are accurately reflected and retained in the case file within the NC FAST Case Management System. "Proposed Completion Date: Training will be completed by October 28th, 2022
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