Corrective Action Plans

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Finding 7857 (2022-002)
Significant Deficiency 2022
U.S. Department of Housing and Urban Development CFDA # 14.239 HOME Investment Partnerships Program Applicable Federal Award Number and Year – 2022 Eligibility Significant Deficiency in Internal Control over Compliance Finding Summary: The Organization does not retain documentation that supports the...
U.S. Department of Housing and Urban Development CFDA # 14.239 HOME Investment Partnerships Program Applicable Federal Award Number and Year – 2022 Eligibility Significant Deficiency in Internal Control over Compliance Finding Summary: The Organization does not retain documentation that supports the internal controls in place over the review of the annual certifications for the HOME units. Responsible Individuals: Steve Kuehneman, Executive Director and Jacki Kurchinski, Director of Property Management and Operations Corrective Action Plan: Management agrees with the finding. The Organization added steps to the annual certification process to document the approval of the annual certifications of HOME units. Anticipated Completion Date: 2024
Finding 2022-001 ...
Finding 2022-001 Mercy Church was a new agency in 2022 and signed all agreements July 20, 2022. The annual mandatory Recertification training for all agencies occurs at the end of July and the first of August each year. Therefore, there is an approximate six-week period before the new fiscal year begins October 1. Following recertification, all agencies are activated in CERES for the new year and as a result, Mercy Church was also activated and placed their first order in September shortly before the new fiscal year began. They have been compliant ever since, it was just a matter of timing. Our Community Impact team will ensure that new agencies that are brought on prior to the fiscal year are not activated in our systems until the new fiscal year begins to prevent this in the future. All agencies are trained and monitored for federal compliance on a regular basis. Person responsible: Amy Breitmann...10/1/23 completion date
Finding 7604 (2022-004)
Significant Deficiency 2022
The Housing Services Development District (HSDD) had previously been attempting to reconstruct, where feasible, the client files received from the previous management contractor. We have continued on this effort in an attempt to eliminate the audit finding moving forward. It should be noted, that fi...
The Housing Services Development District (HSDD) had previously been attempting to reconstruct, where feasible, the client files received from the previous management contractor. We have continued on this effort in an attempt to eliminate the audit finding moving forward. It should be noted, that files effected under the HSDD Management did not contain this deficiency. As such, audit files selected for the 2023 audit year will contain all relevant monitoring documentation.
Finding 7380 (2022-005)
Significant Deficiency 2022
We have developed an internal auditing process that includes a staff member external to the participant files reviews to ensure all participant eligibility forms are signed.
We have developed an internal auditing process that includes a staff member external to the participant files reviews to ensure all participant eligibility forms are signed.
Finding: The Organization had contradicting support for the income eligibility documentation for two clients. All documentation supported the conclusion that the client was eligible based on their income, however the lack of consistent evidence results in the conclusion that proper review and appro...
Finding: The Organization had contradicting support for the income eligibility documentation for two clients. All documentation supported the conclusion that the client was eligible based on their income, however the lack of consistent evidence results in the conclusion that proper review and approval of this documentation is not occurring. Corrective Action Taken or Planned: An Eligibility and Retention Specialist was hired March 10, 2023, whose sole responsibilities pertain to eligibility. Name of Contact Person: Jacob Ducey, Grants Manager Phone Number of Contact Person: (540) 907-4555 Projected Completion Date: October 31, 2023
FINDING NO. 2022-003: Ineffective Internal Controls over Sliding Fee Revenues Condition: During the compliance testing of the Uniform Guidance “Special Tests and Provisions – Sliding Fee Applications” requirements, we noted the following exceptions: • Three (3) out of thirty-four (34) were miss...
FINDING NO. 2022-003: Ineffective Internal Controls over Sliding Fee Revenues Condition: During the compliance testing of the Uniform Guidance “Special Tests and Provisions – Sliding Fee Applications” requirements, we noted the following exceptions: • Three (3) out of thirty-four (34) were missing applications. • Fourteen (14) out of thirty-four (34) sliding fee adjustments were calculated incorrectly based on the sliding fee schedule. • One (1) out of thirty-four (34) sliding fee adjustments were not properly applied to the patient’s account. Plan: CHESI has implemented a new workflow process to ensure compliance with the program requirements of the sliding fee program. CHESI has developed a new sliding fee procedure and trained all staff to ensure the applications are complete and signed by the patient, income is verified, the proper discount is calculated based on the sliding fee schedule, the proper amount of discount is applied to the patient’s account, and the application is approved and signed by the Billing Manager. All sliding fee applications will also be scanned into the patient’s chart once completed and approved. Anticipated Date of Completion: December 31, 2023 Name of Contact Person: Kanci Houston, CEO
Assistance listing number and program name: 93.658 Foster Care – Title IV-E Agency: Department of Child Safety Name of contact person and title: Tanya Abdellatif, Assistant Director Anticipated completion date: June 30, 2025 Agency’s Response: Concur Department will ensure background checks for ch...
Assistance listing number and program name: 93.658 Foster Care – Title IV-E Agency: Department of Child Safety Name of contact person and title: Tanya Abdellatif, Assistant Director Anticipated completion date: June 30, 2025 Agency’s Response: Concur Department will ensure background checks for childcare institutions’ employees are completed prior to their hire date by: • Reviewing and amending DCS 15-32 Background Checks – Child Welfare Agency Staff policy and procedures to clarify that Child Welfare Agencies shall request and receive results for DCS Central Registry background checks prior to employment/date of hire. • Revising the Personnel File Monitoring Tool for licensing to include language that background checks need to be completed prior to hire and ensure all Child Welfare Licensing staff are utilizing the updated checklist. • Implementing, as part of the Quarterly Site Visit Process for childcare institutions, a process to review backgrounds checks to identify opportunities for improvement, trends and establish actions (countermeasures) to resolve any areas of concern. Hiring processes for each agency will also be reviewed during the quarterly site visits. • Providing updates related to policies and procedures during Quarterly Provider Meetings for childcare institutions, implementing monthly provider calls/meetings and conducting monthly unit/team meetings for Department. • Presenting the safety requirement expectations related to background checks for employees to childcare institutions and how the safety requirements are necessary for foster care maintenance payments at a quarterly meeting. • Conducting monthly monitoring of childcare institutions’ compliance with safety requirement expectations (background checks) for new and existing employees for fiscal year 2023.
Finding 5930 (2022-126)
Significant Deficiency 2022
Assistance listing number and program name: 84.425E COVID-19 Education Stabilization Fund—Higher Education Emergency Relief Fund (HEERF)—Student Portion Student Financial Assistance Cluster 84.007 Federal Supplemental Educational Opportunity Grants 84.033 Federal Work-Study 84.038 Federal Perkins L...
Assistance listing number and program name: 84.425E COVID-19 Education Stabilization Fund—Higher Education Emergency Relief Fund (HEERF)—Student Portion Student Financial Assistance Cluster 84.007 Federal Supplemental Educational Opportunity Grants 84.033 Federal Work-Study 84.038 Federal Perkins Loan Program—Federal Capital Contributions 84.063 Federal Pell Grant Programs 84.268 Federal Direct Student Loans 84.379 Teacher Education Assistance for College and Higher Education Grants (TEACH Grants) 93.364 Nursing Student Loans 93.925 Scholarships for Health Professions Students from Disadvantaged Backgrounds—Scholarships for Disadvantaged Students (SDS) Agency: Northern Arizona University (NAA) Name of contact person and title: Bradley Miner, Interim Associate Vice President and Comptroller Anticipated completion date: November 30, 2023 Agency’s Response: Concur See University response section at the end of this report for the corrective action response for finding 2022-126.
View Audit 7884 Questioned Costs: $1
Assistance listing number and program name: 17.225 COVID-19 Unemployment Insurance Agency: Department of Economic Security Name of contact person and title: Sandra Canez, Unemployment Insurance Program Administrator Jacqueline Butera, Quality Assurance and Integrity Administrator Anticipated comple...
Assistance listing number and program name: 17.225 COVID-19 Unemployment Insurance Agency: Department of Economic Security Name of contact person and title: Sandra Canez, Unemployment Insurance Program Administrator Jacqueline Butera, Quality Assurance and Integrity Administrator Anticipated completion date: July 16, 2023 Agency’s Response: Concur The Department of Economic Security took the following actions to remediate finding 2022-110 and prior year finding 2021-108. In July 2023, the Department completed the wage evaluation of the claimants determined eligible to receive above the $117-minimum weekly UI benefit amount, as noted in the finding. Any resulting overpayment for the federal CARES Act programs was established by the Department, and where appropriate, waivers were considered and allowed following federal regulations and the state overpayment policy. As noted in the finding, the Department addressed the 7 sampled cases and will continue to follow well-established overpayment and recovery policy and procedures.
Response. Agreed. Where feasible, the Housing Trust will aim to improve management of all federal grants. A process of documentation verification prior to any requests made for financial draws will include employee, supervisor, business operations manager, and executive director level approvals to e...
Response. Agreed. Where feasible, the Housing Trust will aim to improve management of all federal grants. A process of documentation verification prior to any requests made for financial draws will include employee, supervisor, business operations manager, and executive director level approvals to ensure compliance and availability of funds. A monthly federal request for reimbursements with all grantee information will be used and reconciled monthly with QuickBooks. This report will mirror the SEFA form so auditors will receive the information in a timely manner. For any quarterly reports, the three months of reporting will again be reconciled prior to submission. All new processes and compliance will be updated in the policies and procedure manual. As the Executive Director prepares the 2024 budget, a reorganization of the business operations department will be sought. A new position to prepare and work on all federal grant tasks will be hired and report to the Business Operations Manager. In the meantime, the Business Operations Manager has started to develop checks and balances. Corrective Action Plan Timeline: Immediately Designation Of Employee Position Responsible For Meeting Deadline: Business Operations Manager
2022-002 Reporting Recommendation: Our auditors recommend that we review and strengthen current procedures regarding review of reporting by an appropriate level of management prior to submission. As well as that we work with HRSA to take corrective action to rectify this reporting matter. Action Tak...
2022-002 Reporting Recommendation: Our auditors recommend that we review and strengthen current procedures regarding review of reporting by an appropriate level of management prior to submission. As well as that we work with HRSA to take corrective action to rectify this reporting matter. Action Taken: The accounting department had a significant turnover during 2022 which cause reporting errors go unreviewed. Since 2023, the appropriate accounting team has been assembled and proper policies, procedures, authorization, segregation of duties and reviews have been put in place so that going forward this will not be an issue. All reporting is now being reviewed prior to submission so that reporting requirements including proper period and proper information is reported correctly. We have proactively reached out to the PRF Reporting Help Desk to correct the reporting and communicated the noted reporting corrections needed. Name(s) of Contact Person(s) Responsible for Corrective Action: John Milligan, CFO, (315) 430-1708. Anticipated Completion Date: October 2023
2022-001 Internal Control Over Financial Close Process Name of Contact Person: Chief Financial Officer: Amber Curley Corrective Action: The Center agrees with this finding and recommendations. The Center went through a change in CFO leadership throughout this fiscal year and our full-time p...
2022-001 Internal Control Over Financial Close Process Name of Contact Person: Chief Financial Officer: Amber Curley Corrective Action: The Center agrees with this finding and recommendations. The Center went through a change in CFO leadership throughout this fiscal year and our full-time permanent CFO started in January 2022, who then immediately expanded the Center’s finance department and implemented corrective procedures and greatly improved accounting processes and accounting operations, including all balance sheet accounts being reviewed and reconciled in a timely manner. In order to ensure we are fully compliant, two new positions were created and filled – a 1.0 FTE Controller hired in July 2022 and a 1.0 FTE Staff Accountant hired in January 2023. Additionally, our CFO overhauled our financial policies and procedures manual which was approved by the Center’s Board of Directors in July 2022. These policies and procedures were also reviewed by our HRSA consultants during our three-day operational site visit which took place in July 2022. Specific process improvements were made and included more specific segregation of duties, enhanced communication across all departments to address program items around budgetary and resource planning, transactional accuracy, and transparency. Moreover, the five-member finance department is working collaboratively with program management to advise and support the finance department on continued process improvements and maintaining open communication with program staff for effective feedback on program monitoring systems essential to strengthening internal control over financial close and reporting process. Proposed Completion Date: June 30, 2023
Finding Numbers 2022-005 and 2022-006 Planned Corrective Action: Management plans to offer additional trainings, reminders to the Financial Screening Department, and institute a quarterly audit of completed applications to ensure compliance. Anticipated Completion Date: December 31, 2023 Responsib...
Finding Numbers 2022-005 and 2022-006 Planned Corrective Action: Management plans to offer additional trainings, reminders to the Financial Screening Department, and institute a quarterly audit of completed applications to ensure compliance. Anticipated Completion Date: December 31, 2023 Responsible Contact Persons: Jillian Hudspeth, CEO Christopher Bernardi, CFO
I am the New Executive Director of Bridgeton Housing Authority, I started on February 13th, 2023. Resident files were found to be in a state of extreme disarray from years of not conducting file maintenance. Office was not organized. Pertinent tenant information was not filed properly as required...
I am the New Executive Director of Bridgeton Housing Authority, I started on February 13th, 2023. Resident files were found to be in a state of extreme disarray from years of not conducting file maintenance. Office was not organized. Pertinent tenant information was not filed properly as required. Resident documentation had not been filed since 2019-2020. The following steps have been implemented to address the material weakness. 1. Retrained on proper tenant file compliance and management, purging and file retention. An audit and purge of every low-income public housing file is being conducted. Missing documents are being replaced, all needed documentation being completed. 2. A retention policy will be implemented ensuring that yearly purging is conducted, and proper file management is maintained. 3. Regular monitoring and auditing of tenant files will be conducted to enure ongoing compliance. 4. Monitoring of monthly recertifcations to ensure on time submission and compliance.
Children and Youth Programs Assistance Listing 93.090 Guardianship Assistance Assistance Listing 93.645 Stephanie Tubbs Jones Child Welfare Services Program Assistance Listing 93.658 Foster Care Title IV-E Assistance Listing 93.659 Adoption Assistance Assistance Listing 93.778 Medical Assistance Pro...
Children and Youth Programs Assistance Listing 93.090 Guardianship Assistance Assistance Listing 93.645 Stephanie Tubbs Jones Child Welfare Services Program Assistance Listing 93.658 Foster Care Title IV-E Assistance Listing 93.659 Adoption Assistance Assistance Listing 93.778 Medical Assistance Program Assistance Listing 93.556 MaryLee Allen Promoting Safe and Stable Families Program Act 148 Pennsylvania Department of Human Services Views of the Responsible Officials and Corrective Action Plan: After a recent discussion with the [PA] Office of Children, Youth, and Families (OCYF), DHS was informed that compensation plans for FY21 and FY22 were on file and under review. However, approval was pending. OCYF explained that the State reviews plans on a calendar-year basis. However, city pay plans change during a July-June fiscal year. Therefore, the possibility of overages can occur because of salary increases or other personnel changes. The process is that once the new compensation plan is received, the reviewing authority would flag any items that are in excess of the existing approved rates. At that time, DHS would be permitted to submit a waiver for the items in question. Contact Person: Landuleni Shipanga, Controller, Department of Human Services, 215-683-6366.
View Audit 5296 Questioned Costs: $1
Finding 3009 (2022-031)
Significant Deficiency 2022
Findinq No.: 2022-031 Eligibility Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Arthur San Augustin, Director (DPHSS) The agency agrees with the findings. Moving fonrvard, DPHSS will develop an SOP and checklist to ensure that all applicants submi...
Findinq No.: 2022-031 Eligibility Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Arthur San Augustin, Director (DPHSS) The agency agrees with the findings. Moving fonrvard, DPHSS will develop an SOP and checklist to ensure that all applicants submit the proper documentation within a certain number of days.
View Audit 4883 Questioned Costs: $1
Finding 3001 (2022-029)
Significant Deficiency 2022
Findinq No.:2022-029 Eligibility Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Arthur San Augustin, Director (DPHSS) The agency disagrees with the findings. The grant eligibility criteria in question are the CAPS21 Grant. All grantees demonstrated...
Findinq No.:2022-029 Eligibility Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Arthur San Augustin, Director (DPHSS) The agency disagrees with the findings. The grant eligibility criteria in question are the CAPS21 Grant. All grantees demonstrated compliance with the eligibility criteria in the attached GY21 GU APRA Stabilization Notice of Award Supplemental Terms and Conditions on page 6 item 2 that was provided to EY.
View Audit 4883 Questioned Costs: $1
Findins No.:2022-027 Eligibility Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Arthur San Augustin, Director (DPHSS) The agency agrees with the findings. Moving forward, DPHSS will develop an SOP and evaluation to ensure that the minimum requireme...
Findins No.:2022-027 Eligibility Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Arthur San Augustin, Director (DPHSS) The agency agrees with the findings. Moving forward, DPHSS will develop an SOP and evaluation to ensure that the minimum requirements are met for references for family foster homes, and that they can be easily identified.
View Audit 4883 Questioned Costs: $1
Finding 2997 (2022-026)
Significant Deficiency 2022
Findinq No.:2022-026 Eligibility Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Arthur San Augustin, Director (DPHSS) The agency agrees with the findings. Moving fonrvard they will develop SOP to make sure all proper documentation is in place prior...
Findinq No.:2022-026 Eligibility Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Arthur San Augustin, Director (DPHSS) The agency agrees with the findings. Moving fonrvard they will develop SOP to make sure all proper documentation is in place prior to the approval of cases.
View Audit 4883 Questioned Costs: $1
Finding 2984 (2022-016)
Significant Deficiency 2022
Findinq No.: 2022-016 Eligibility Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The agency does not agree with the questioned cost. The file in question does not match any amounts in said file. Additionally, ERA did not have a cost thre...
Findinq No.: 2022-016 Eligibility Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The agency does not agree with the questioned cost. The file in question does not match any amounts in said file. Additionally, ERA did not have a cost threshold in the cycle by the case number. The claimant's income was below the 30% threshold as per their documents submitted and therefore qualified for the program. Furthermore, any review and approval will have the program manager's signature as required by ERA's SOP.
View Audit 4883 Questioned Costs: $1
Finding 2982 (2022-014)
Significant Deficiency 2022
Findinq No.:2022-014 Eligibility Responding Agency: Department of Labor (DOL) Responsible Personnel: David Dell'lsola, Director (DOL) The agency agrees with the findings. The agency is currently working with both claimants to resolve the matter.
Findinq No.:2022-014 Eligibility Responding Agency: Department of Labor (DOL) Responsible Personnel: David Dell'lsola, Director (DOL) The agency agrees with the findings. The agency is currently working with both claimants to resolve the matter.
View Audit 4883 Questioned Costs: $1
Findinq No.:2022-011 ADP System for SNAP Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Arthur San Augustin, Director (DPHSS) DPHSS agrees with the finding. Effective 1011123 The Bureau of Economic Security, and Division of Public Welfare superviso...
Findinq No.:2022-011 ADP System for SNAP Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Arthur San Augustin, Director (DPHSS) DPHSS agrees with the finding. Effective 1011123 The Bureau of Economic Security, and Division of Public Welfare supervisors are verifying documents and making sure it is complete and uploaded into the system. A checklist will be created to ensure all vital documents are completed and uploaded.
View Audit 4883 Questioned Costs: $1
Corrective Action Plan: Training will include: Need to have supervisory signature on application/recertification.LDSS-3209 requires signature. Training will be completed by December 1, 2023. Principal SWEs and Sr. SWE examiners will, for 5 days following the training, review every application for si...
Corrective Action Plan: Training will include: Need to have supervisory signature on application/recertification.LDSS-3209 requires signature. Training will be completed by December 1, 2023. Principal SWEs and Sr. SWE examiners will, for 5 days following the training, review every application for signature when reviewing the case. Any errors will be logged and brought to the attention of the SWE. Those SWEs failing ensure signature will continue to be reviewed during case review by supervision. Signature review will be included in case review by Supervision. Responsible Party and Anticipated Complete Date: Kris Ruggeri, Director of Financial Assistance and PSWEs in the Financial Assistance Unit. Training, Close Review and Logging will be completed by December 31, 2023.
Staff responsible for fulfilling applicable compliance requirements was terminated for failture to perform job duties and replaced. In addition, a process to monitor performance of required procedures to complete annual eligibility verifications and income recertifications was implemented upon sta...
Staff responsible for fulfilling applicable compliance requirements was terminated for failture to perform job duties and replaced. In addition, a process to monitor performance of required procedures to complete annual eligibility verifications and income recertifications was implemented upon staff transition.
Condition: The City charged the same invoice to two separate federal awards. Corrective Action Planned: This issue has been remedied. The City has corrected this and reversed the charge to the federal grant, reimbursed the grant funder, and filed a revised final grant report. This was an oversigh...
Condition: The City charged the same invoice to two separate federal awards. Corrective Action Planned: This issue has been remedied. The City has corrected this and reversed the charge to the federal grant, reimbursed the grant funder, and filed a revised final grant report. This was an oversight in the management of high volume COVID related grants totaling $10.3M with over 1,000 transactions, and reclassifications had occurred between the two as expenditures became ineligible. Moving forward, the City will take steps to ensure direct expenditures and limit the need for reclassifications. Anticipated Completion Date: October 31, 2023 Contact: Edward M. Dunn, City Auditor
View Audit 3965 Questioned Costs: $1
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