Corrective Action Plans

Browse how organizations respond to audit findings

Total CAPs
59,925
In database
Filtered Results
5,845
Matching current filters
Showing Page
180 of 234
25 per page

Filters

Clear
Active filters: Eligibility
Finding 2022-002Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionFederal Financial Assistance Listing #93.498Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Princi...
Finding 2022-002Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionFederal Financial Assistance Listing #93.498Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles and ReportingFinding Summary: During testing, the following were identified:- Expenses were claimed under the program which were incurred prior to the Organization preparing, preventing, and responding to COVID. Actual costs of $51,160.- Payroll expenses claimed under the program were calculated for three employees with the current hourly wage rate rather than the hourly wage rate effective during the period of time COVID hours were claimed under the program. Actual costs of $3,360 with projected costs of $9,751.- One employee?s specific COVID related hours were claimed twice under the program. Actual costs of $24,096.- FICA payroll expenses were claimed twice under the program. Actual costs of $3,685.- Additional COVID payroll expenses were identified by management; however, due to a clerical error, these payroll expenses were not included in the special report submitted to HHS for Period 2 TIN #460233030 totaling $135,096.- The Organization included these expenses in the special reports submitted to the Department of Health and Human Services (HHS) for Period 2 TIN #460233030 and TIN #237072116 which caused the reports to be inaccurate. The Organization?s special reports submitted to HHS had no formal documentation of a secondary review or approval.Responsible Individuals: Stephan Wilson, Chief Financial Officer, Carol Peterson, Director of Finance, Stacy Flahaven, Accounting ManagerCorrective Action Plan: More time and attention will be given to calculating, gathering, and reporting amounts for future awards. Review and approval of federal reports will be performed by separate individuals. Both the review and approval will be formally documented by signing and dating upon completion. There are no future reporting requirements under this federal award.Anticipated Completion Date: June 30, 2023
Finding 409863 (2022-001)
Significant Deficiency 2022
Finding 2022-001 ? Special Tests and ProvisionsThe auditee acknowledges the findings of the auditors. It has been noted that two patients were billedat discounts above eligibility levels and one patient was billed at a discount below the eligible amount.Review of the samples noted revealed that one ...
Finding 2022-001 ? Special Tests and ProvisionsThe auditee acknowledges the findings of the auditors. It has been noted that two patients were billedat discounts above eligibility levels and one patient was billed at a discount below the eligible amount.Review of the samples noted revealed that one of the 3 individuals included in the finding occurredas a result of staff inputting the incorrect salary information into the system for those patients and/ornot selecting the proper frequency for patient income, i.e., monthly, weekly, biweekly, annually, etc.These are simple human errors that occur when staff are inundated with tasks during registrationmissing detailed steps as they enter the patient?s income.Another instance of the noted error existed as a result of the staff failing to include the income for allindividuals in the household income calculation which provided a greater than applicable discount.The final error occurred as a result of failure to follow up and adjust patient accounts for those patientswho present and apply for the sliding fee. This patient applied for the sliding fee discount at the timeof the visit, but because he did not have the income verification, he was listed as self-pay and givena 30 day notice to provide the information. The patient paid toward the balance and once he providedinformation it was determined that his payment on the day of the visit exceeded the required paymentper the sliding fee. Supervisors failed to adjust the account and provide the patient with a refund, asa result patient?s account did not reflect the proper discount.Plan of Action:Management reviewed the findings and began to rationalize the reasons that these findings occurredand measures that will help to reduce these errors. The course of action to be taken includes thefollowing to be implemented immediately:? Reduction of Turnover in PAR. A contributing factor to the errors with sliding fees is turnoverin the department. There is a considerably high percentage of turnover average of 6%. Errorsare existing due to the turnover of staff, and the constant training.? Strengthened procedures for Supervisors of employees registering patients are nowcompleting audits of patients? charts to review the sliding fee scale and the attacheddocumentation. The audits are conducted on the patient account as they present for service.Because of the nature of the Sliding Fee Program, the documentation required toparticipated, and the setup of our Patient Management System (Athena), these areperformance audits and are based on how accurate each employee enters information intothe system.? Training to reiterate avoiding common mistakes while registering patients and workingwith patient information.? Also, as recommended, we have scheduled a date to renew the annual sliding fee scaleand notify patients. As an added measure, we will also commit to documenting the effectivedates for any leniency in the corresponding Board minutes.
The Division will contact each unit distributing TEFAP assistance and communicate the requirement to retain documentation regarding the determination of client eligibility. Anticipated Completion Date: June 2024. Responsible Contact Person: Julie Luft, Northwest Division Social Services Director
The Division will contact each unit distributing TEFAP assistance and communicate the requirement to retain documentation regarding the determination of client eligibility. Anticipated Completion Date: June 2024. Responsible Contact Person: Julie Luft, Northwest Division Social Services Director
We are in receipt of the findings required to be reported by the single audit for COVID19 Claims Reimbursement for the Uninsured Program and the COVID19 Coverage Assistance Fund specifically, regarding discrepancies in funding received under a different employer identifier number. Management does no...
We are in receipt of the findings required to be reported by the single audit for COVID19 Claims Reimbursement for the Uninsured Program and the COVID19 Coverage Assistance Fund specifically, regarding discrepancies in funding received under a different employer identifier number. Management does not dispute the finding. The District is in it’s second year after going through an asset purchase transaction, whereby the physical assets were retained by the District, but the operations of the hospital were sold. As the District moves forward, we will work to develop policies and procedures over financial reporting to ensure they only request reimbursement for federal grants for programs with the correct employer identification number. Lynn Lindsey, Chief Financial Officer, will be responsible to ensure that this is accomplished and will begin to implement new procedures. The corrective action plan will be implemented by September 30, 2024.
Public Health’s Office of Aids (OA) agrees with the finding and recommendation. OA developed and implemented additional internal quality assurance (QA) processes in April of 2022 to ensure that secondary reviews of AIDS Drug Assistance Program (ADAP) applications are consistently enforcing the exist...
Public Health’s Office of Aids (OA) agrees with the finding and recommendation. OA developed and implemented additional internal quality assurance (QA) processes in April of 2022 to ensure that secondary reviews of AIDS Drug Assistance Program (ADAP) applications are consistently enforcing the existing guidelines, including acceptable supporting documentation and accurate eligibility requirements. Prior to this audit period, and through December 2021, ADAP had issued multiple policy memos to respond to the COVID-19 pandemic, which enabled staff and enrollment workers to defer documentation collection, when necessary, to remain flexible and ensure clients impacted by the pandemic, and associated site closures, did not lose eligibility and access to life-saving medications and comprehensive healthcare. These flexibilities in our guidelines were implemented based on guidance received from our federal funder, the Health Resources and Services Administration, which encouraged ADAP to reassess its organization's eligibility and recertification policies and procedures, and remove any barriers that may impede social distancing, or other public health strategies, necessary to minimize COVID-19 transmission. This documentation deferral was terminated on December 31, 2021, and since January 1, 2022, full documentation and eligibility requirements have been enforced. This, combined with ongoing QA efforts, will help mitigate future findings in ADAP applications. Estimated Implementation Date: Implemented as of April 2022 Contact: Joseph Lagrama, Branch Chief AIDS Drug Assistance Program Branch California Department of Public Health
The EDD resumed adjudicating all potential eligibility issues as of January 2021 and completed the retroactive determination workload on April 30, 2023. Estimated Implementation Date: April 2023 Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California Em...
The EDD resumed adjudicating all potential eligibility issues as of January 2021 and completed the retroactive determination workload on April 30, 2023. Estimated Implementation Date: April 2023 Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California Employment Development Department
View Audit 310237 Questioned Costs: $1
Given the unprecedented volume of unemployment insurance claims during the federal disaster—approximately 20 million claims compared to 3.8 million during the Great Recession—EDD took action to speed payments to eligible claimants whenever possible. For example, EDD launched in July 2021 a Condition...
Given the unprecedented volume of unemployment insurance claims during the federal disaster—approximately 20 million claims compared to 3.8 million during the Great Recession—EDD took action to speed payments to eligible claimants whenever possible. For example, EDD launched in July 2021 a Conditional Payment Program to speed payments to claimants who certified for benefits and already received at least one week of benefits in the past but whose payments were later pending for more than two weeks. EDD also boosted its capacity to process workloads, prioritized timely payments, and employed automation among other measures. As reported in Reference Number 2020-006 in fiscal year 2019-2020, EDD began automatically cross-matching EDD wage records and Franchise Tax Board records in November 2020 to assist in verifying the income of PUA claimants who could not be automatically verified through these procedures. Such claimants were required to submit additional documentation to EDD for a manual review. Regarding the manual processing of the income documents to substantiate the PUA weekly benefit amounts that have been increased above the minimum California WBA of $167, and the verification of employment or self-employment substantiation (known in California as “Self-employment/Employment Substantiation” or “SEES”), on February 6, 2024, in accordance with the U.S. Department of Labor (DOL) Unemployment Insurance Program Letter 05-24, the California Employment Development Department (EDD) identified that the processing of PUA income documents and the SEES workloads must be considered resolved due to California’s finality laws. The EDD is prohibited by law from resolving these items by California Unemployment Insurance Code section 1376, which provides that EDD cannot establish overpayments more than one year after the close of the benefit year in which the overpayment was made unless the overpayment is found to be a result of fraud, misrepresentation, or willful nondisclosure. Given that there is no fraud or fault on the part of the individuals identified in these populations, EDD is unable to take the required actions to resolve the workload due to California’s finality law provisions. EDD is expecting a response from DOL agreeing with the application of California’s finality laws to the PUA income verification and the SEES workloads. Estimated Implementation Date: Upon DOL response, to be determined Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California Employment Development Department
View Audit 310237 Questioned Costs: $1
As reported in the prior year’s response, since fiscal year 2020-21, the Employment Development Department (EDD) has implemented dozens of strict anti-fraud measures and has continued to evaluate and enhance its fraud detection. EDD has also developed internal fraud working groups and a multiagency ...
As reported in the prior year’s response, since fiscal year 2020-21, the Employment Development Department (EDD) has implemented dozens of strict anti-fraud measures and has continued to evaluate and enhance its fraud detection. EDD has also developed internal fraud working groups and a multiagency fraud task force that reviews fraud data and fraud reports on a continual basis and recommends adjustments to filters and tools as necessary. EDD has successfully halted two large fraud scheme attempts over the previous two years and continues to work towards immediate detection and prevention of fraud attempts. EDD will continue to analyze and assess our processes to stay ahead of the ever-evolving fraud landscape. As previously described, EDD implemented the following measures to address the nationwide fraud attempts perpetrated against the new emergency federal benefit programs in 2020-21: • Implemented additional cross-matches in September 2020 to detect multiple claims per address. • Ceased automatically backdating PUA claims under federal rules in September 2020. • Strengthened identity verification procedures in October 2020 by implementing ID.me. • Implemented additional cross-matches in November 2020 against state inmate information. • Vetted applications against law enforcement databases and other tools provided by Thomson Reuters in December 2020 to further curb identity and non-identity fraud. • Established a 1099-G call center to help victims of identity theft deal with any tax-related questions. • Ceased printing Social Security numbers on mailed documents to reduce identity theft risk. • Enhanced benefit card security with Bank of America. • Partnered with state, local and federal law enforcement agencies to support thousands of criminal investigations, arrests, prosecutions and convictions. The EDD has and will continue to evaluate and enhance the fraud detection/prevention tools that have been put in place. Estimated Implementation Date: Annual reassessment to be completed September 2024 Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California Employment Development Department
View Audit 310237 Questioned Costs: $1
The California Department of Public Health (Public Health) Women, Infants, and Children (WIC) Division had agreed that the WIC Web Information System Exchange (WISE) system does not currently store eligibility history that should be included in the “Cert History Report,” and the initial eligibility ...
The California Department of Public Health (Public Health) Women, Infants, and Children (WIC) Division had agreed that the WIC Web Information System Exchange (WISE) system does not currently store eligibility history that should be included in the “Cert History Report,” and the initial eligibility data is overwritten when subsequent eligibility information is keyed into WIC WISE. However, WIC WISE does include preventative internal stops or checkpoints that do not allow ineligible individuals to be certified and issued benefits (e.g., over income, not a California resident, no nutrition risk factor, etc.). User acceptance testing vetted these items prior to system implementation in 2019/20. The certification history condition discussed was remediated via a system Defect Correction to WIC WISE that was in user acceptance testing for implementation in Fall 2023. Public Health/WIC has entered Defect Correction #6972 in TFS (Team Foundation Services), the tracking system previously used to capture system changes and defects. The defect correction supports a system change to ensure initial eligibility information is retained when subsequent eligibility information is entered into WIC WISE. Estimated Implementation Date: August 2023 Contact: William Welch, Assistant Division Chief, Operations Women, Infants, and Children Division California Department of Public Health
Finding 401579 (2022-008)
Significant Deficiency 2022
2022-008 Eligibility – Pell Awarding Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the University implement policies to review all student award packages at the start of the academic year to ensure no over and under awards exist. E...
2022-008 Eligibility – Pell Awarding Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the University implement policies to review all student award packages at the start of the academic year to ensure no over and under awards exist. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has begun to restructure all accounting and reconciliation functions. The University is implementing financial internal controls to improve the internal financial reporting process. Names of the contact persons responsible for corrective action: E. ZeNai Savage, CPA, CFO and Executive VP of Finance and Administration, and Qiana Hall, Associate VP of Enrollment Services Planned completion date for corrective action plan: June 30, 2024
View Audit 309593 Questioned Costs: $1
Finding 401561 (2022-006)
Significant Deficiency 2022
2022-006 Special Tests and Provisions – Return of Title IV Funding Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the institution maintain proper documentation in accordance with federal grantor requirements and ensure that the docu...
2022-006 Special Tests and Provisions – Return of Title IV Funding Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the institution maintain proper documentation in accordance with federal grantor requirements and ensure that the documents are readily available for review upon request, including monitoring of students with triggering events that require a return to Title IV calculation to be completed, reviewed, and approved. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has implemented policy and procedures that require a review of all official and unofficial withdrawals to have R2T4 calculations on a real time basis to ensure compliance with the Department of Education guidelines on a consistent and regular basis. Internal audits of the process will also be implemented for continuous improvement. Names of the contact persons responsible for corrective action: E. ZeNai Savage, CPA, CFO and Executive VP of Finance and Administration, and Qiana Hall, Associate VP of Enrollment Services Planned completion date for corrective action plan: June 30, 2024
Management’s Response – To ensure that K'ima:w Medical Center has all supporting documentation to confirm Native American eligibility, we will update our PRC policies to reflect a more standardized and robust procedure for collecting and storing patient eligibility documentation, including periodic ...
Management’s Response – To ensure that K'ima:w Medical Center has all supporting documentation to confirm Native American eligibility, we will update our PRC policies to reflect a more standardized and robust procedure for collecting and storing patient eligibility documentation, including periodic review of our patient records in compliance with IHS standards and requirements. Additionally, we have some understanding in our Medical Records Department, which we plan to fill by next fiscal year.
We appreciate the auditor's assessment, analysis, and recommendations. However, we disagree with the conclusion reached and the finding. The auditor, during oral conversation discussing context, indicated the quantity of program beneficiaries reviewed for eligibility did not reach the auditor's expe...
We appreciate the auditor's assessment, analysis, and recommendations. However, we disagree with the conclusion reached and the finding. The auditor, during oral conversation discussing context, indicated the quantity of program beneficiaries reviewed for eligibility did not reach the auditor's expected quantity for adequate monitoring. As a management team, we assessed risk and determined the level of appropriate monitoring to consist of: 1) financial monitoring through review of reimbursement requests, which contained eligibility information necessary for oversight; 2) execution of regularly scheduled status and reporting meetings wherein we obtained ongoing programmatic data; and 3) review of audit reports, where applicable. We note neither our award agreement nor applicable federal regulations require a specific quantity of files to be reviewed as part of subrecipient monitoring. Accordingly, we do not concur with the presence of a finding. In addition, no instances of ineligible beneficiaries were identified by the auditor such that a material weakness classification does not appear reasonable or appropriate. That being said, we will assess our procedures and add greater clarity to help better tell this story going forward. We will also consider whether testing a specific number of beneficiaries is necessary and may be conducted efficiently.
The COO at TCA Health will address the Special Provisions weakness by coaching and training front desk staff members. Specifically, staff will be trained in the sliding fee scale and its requirements. Staff will become proficient in the collection of data from patients, properly storing and recordin...
The COO at TCA Health will address the Special Provisions weakness by coaching and training front desk staff members. Specifically, staff will be trained in the sliding fee scale and its requirements. Staff will become proficient in the collection of data from patients, properly storing and recording it in the EMR, and the calculation of the slide according to the Federal Poverty Guidelines. Lastly, the team will be updated on the latest EMR module that experienced an upgrade and taught how to effectively apply the slide. TCA will also assess the current staff to ensure the proper personnel is in in place.
Finding No. 2022-004 - Low Income Housing Preservation and Resident Homeownership Act of 1990) Federal Assistance Listing Number #99.999 Statement of Condition: Our testing procedures noted that the owner did not perform certifications and recertifications timely, did not maintain tenant files i...
Finding No. 2022-004 - Low Income Housing Preservation and Resident Homeownership Act of 1990) Federal Assistance Listing Number #99.999 Statement of Condition: Our testing procedures noted that the owner did not perform certifications and recertifications timely, did not maintain tenant files in compliance with HUD Rules in Code of Federal Regulations at 24 CFR Part 92, and did not select tenants from the waitlist appropriately. Corrective Action: Management has policies and procedures in place, compliance has been impacted by being understaffed while recovering from covid-related social distancing/limited on site presence. This resulted in recertification and move-in compliance issues. Compliance team and the new HUD Portfolio Manager have been providing trainings for the HUD managers in 2023 and will continue to do so in 2024. In 2022 and 2023, Compliance Manager ensured that all staff who needed access to EIV took the appropriate steps (Cyber Awareness Training, updated EIV authorizations) to access EIV for their properties to run the reports timely. In 2023, The HUD Portfolio Manager created an EIV workflow training for the HUD managers. Both the Compliance team and HUD managers were present. One Compliance Specialist with HUD experience has been filling in and assisting at the HUD properties where we continue to be understaffed. As a Below Market Interest Rate (“BMIR”), we do not receive HUD subsidy or oversight from HUD. Because both properties are due for Affirmative Fair Housing Marketing Plan (“AFHMP”) updates, we will submit an updated plan to HUD for review and approval in 2024. Management is aware and has been performing Move-out inspections with tenants whenever possible.
Finding No. 2022-003 - HUD HOME Investment Partnerships Program, Federal Assistance Listing Number #14.239 Statement of Condition: The owner did not make available to HOME tenants the contracted number and type of HOME units. Corrective Action: A unit will be re-classified the next time there is ...
Finding No. 2022-003 - HUD HOME Investment Partnerships Program, Federal Assistance Listing Number #14.239 Statement of Condition: The owner did not make available to HOME tenants the contracted number and type of HOME units. Corrective Action: A unit will be re-classified the next time there is a vacant unit of the corresponding size/type.
Finding No. 2022-002 - HUD HOME Investment Partnerships Program, Federal Assistance Listing Number #14.239 Statement of Condition: In connection with our lease file review we noted one instance of eight tenants tested where management did not perform a 3rd party income verification in accordance ...
Finding No. 2022-002 - HUD HOME Investment Partnerships Program, Federal Assistance Listing Number #14.239 Statement of Condition: In connection with our lease file review we noted one instance of eight tenants tested where management did not perform a 3rd party income verification in accordance with policy. Corrective Action: Community Manager reviewed file noting 2017 and 2018 were both done as self-certifications. REACH is currently doing full reviews for all HOME units during 2023.
The Academy signed a Promissory Note with Washington Parks Academy on February 8, 2024, to return all the ESSER dollars transferred to the Academy plus interest back to Washington Parks Academy over the next 60 months.
The Academy signed a Promissory Note with Washington Parks Academy on February 8, 2024, to return all the ESSER dollars transferred to the Academy plus interest back to Washington Parks Academy over the next 60 months.
The Academy has put in place a Title I Coordinator to work with the Human Resources Department to ensure that the assigned staff meets the teacher’s eligibility standards for Title I.
The Academy has put in place a Title I Coordinator to work with the Human Resources Department to ensure that the assigned staff meets the teacher’s eligibility standards for Title I.
View Audit 308166 Questioned Costs: $1
Management has reaffirmed their commitment to following and enforcing current policies.
Management has reaffirmed their commitment to following and enforcing current policies.
Corrective Action: Coastal Harvest will implement formal internal control procedures, including independent reviews or other checks and balances, for all significant compliance requirements for its federal programs. Anticipated Completion Date: June 30, 2024
Corrective Action: Coastal Harvest will implement formal internal control procedures, including independent reviews or other checks and balances, for all significant compliance requirements for its federal programs. Anticipated Completion Date: June 30, 2024
MHA will review and enhance as necessary the program’s existing quality control (QC) daily data validation reports to include a measure that crosschecks existing reports in the Yardi system of record and aids in validating data routinely submitted to HUD’s PIC system. In 2023, MHA implemented a Hous...
MHA will review and enhance as necessary the program’s existing quality control (QC) daily data validation reports to include a measure that crosschecks existing reports in the Yardi system of record and aids in validating data routinely submitted to HUD’s PIC system. In 2023, MHA implemented a Housing Specialist-II team lead to oversee staff processing annual reexaminations in accordance with 24 CFR 982.516. This team member is responsible for ensuring families are notified in a timely manner and if they do not comply with the annual reexamination requirement, they receive termination notices in compliance with HUD and MHA Administrative Plan requirements. MHA also implemented two compliance analysts in 2023; these staff persons currently report to the Program Management Analyst who monitors HUD’s PIC system and analyzes discrepancies between PIC data and MHA data housed in the Yardi system of record. This information is maintained in the program file. Responsible Person: Magdalene Watkins, Program Administrator Projected Completion Date: April 30, 2024
Contact Person Tim Greene, Executive Director Corrective Action Plan The Authority will continue to provide occupancy training to staff to prevent future exceptions. Planned Completion Date for CAP Immediately
Contact Person Tim Greene, Executive Director Corrective Action Plan The Authority will continue to provide occupancy training to staff to prevent future exceptions. Planned Completion Date for CAP Immediately
Actions Planned: Proper training will be given to employees and sliding fee discounts will be reviewed by a supervisor on a periodic basis to ensure compliance with the Organization’s sliding fee policies and procedures.
Actions Planned: Proper training will be given to employees and sliding fee discounts will be reviewed by a supervisor on a periodic basis to ensure compliance with the Organization’s sliding fee policies and procedures.
The Authority expects to issue its 2023 financial statements prior to June 2024
The Authority expects to issue its 2023 financial statements prior to June 2024
« 1 178 179 181 182 234 »