Corrective Action Plans

Finding 59942 (2022-002)

Material Weakness 2022

Housing Authority of the City of Greenville

NC

HUD Housing Programs Subrecipient Monitoring Eligibility

Finding 2022-002 - Continuum of Care Tenant Files - Eligibility - Internal Control over Tenant Files - Noncompliance and Material Weakness Corrective Action Plan: The Housing Authority of the City of Greenville (HACG) has implemented and/or will implement the following by our fiscal year-end...

Finding 2022-002 - Continuum of Care Tenant Files - Eligibility - Internal Control over Tenant Files - Noncompliance and Material Weakness Corrective Action Plan: The Housing Authority of the City of Greenville (HACG) has implemented and/or will implement the following by our fiscal year-end September 30, 2023: a. Program Coordinators will maintain all Continuum of Care Tenant files in individual file folders designated by special purpose voucher program. All loose documents will be anchored in tenant files. b. An action plan has been developed for the Continuum of Care programs to ensure that all program files are HUD, State, and GHA compliant starting with October 1, 2022, files through the current. c. Continuum of Care fiscal year 2023 (October 2022-September 2023) re- exams and interims will be caught up and complete as they become effective. All tenant files will be reviewed and compliant by FYE2023 . d. All late/overdue re-exams will be compliant by FYE2023. e. During FYE2023, the Deputy Executive Director/COO or designee will perform quality controls on all Continuum of Care tenant files processed each month prior to initialization. f. File checklist sheets will be placed in each file upon quality control review to be signed off by the Deputy Executive Director/COO or designee. g. Additional training will be required and ongoing for Program Coordinators. h. Other internal control measures will be implemented to eliminate future audit findings. Person Responsible: Shanetta Moye, Deputy Executive Director/COO Anticipated Completion Date: September 30, 2023

View Audit 51971

Finding 59941 (2022-001)

Significant Deficiency 2022

Housing Authority of the City of Greenville

NC

Questioned Costs HUD Housing Programs Subrecipient Monitoring

Finding 2022-001 - Low Rent Public Housing Tenant Files - Eligibility - Internal Control over Tenant Files - Noncompliance and Significant Deficiency Corrective Action Plan: The Housing Authority of the City of Greenville (HACG) has implemented and/or will implement the following by our fisca...

Finding 2022-001 - Low Rent Public Housing Tenant Files - Eligibility - Internal Control over Tenant Files - Noncompliance and Significant Deficiency Corrective Action Plan: The Housing Authority of the City of Greenville (HACG) has implemented and/or will implement the following by our fiscal year-end September 30, 2023: a. Low Rent Public Housing tenant files will be reviewed and quality controlled each month prior to initialization (25th of each month) by the Senior Property Manager and the AMP Property Manager. b. An action plan has been developed for Low Rent Public Housing to ensure that all Public Housing files are HUD and GHA compliant starting with October 1, 2022, files through the current. c. Low Rent Public Housing calendar-year 2023 (October 2022-September 2023) re-exams are substantially complete, as they become effective. All tenant files will be reviewed and HUD-compliant by FYE2023. d. During FYE2023, the Senior Property Manager will perform 25% quality control of the monthly re-exams processed by the AMP Property Managers. Additionally, the AMP Property Managers will perform 50% quality controls of the monthly re-exams and interims processed by the Assistant Property Managers. e. File checklist sheets will be placed in each file upon quality control review to be signed off by the Senior Property Manager and the AMP Property Managers. A copy of the completed checklist with signatures will be forwarded to the Deputy Executive Director/COO. f. Additional training will be made available as necessary. g. Other internal control measures will be implemented as deemed necessary by the Deputy Executive Director/COO, to eliminate future audit findings. Person Responsible: Shanetta Moye, Deputy Executive Director/COO Anticipated Completion Date: September 30, 2023

View Audit 51971 Questioned Costs: $1

Finding 59936 (2022-001)

Significant Deficiency 2022

New Jersey Housing and Mortgage Finance Agency

NJ

Eligibility Significant Deficiency Internal Control / Segregation of Duties

U.S. Department of Treasury New Jersey Housing and Mortgage Finance Agency respectfully submits the following corrective action plan for the year ended December 31, 2022. Audit period: January 1, 2022 ? December 31, 2022 The finding from the schedule of findings and questioned costs is discussed be...

U.S. Department of Treasury New Jersey Housing and Mortgage Finance Agency respectfully submits the following corrective action plan for the year ended December 31, 2022. Audit period: January 1, 2022 ? December 31, 2022 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS?FEDERAL AWARD PROGRAMS AUDITS SIGNIFCANT DEFICIENCY U.S. Department of Treasury 2022-001 Eligibility ? Homeowners Assistance Fund? Assistance Listing No. 21.026 Recommendation: The Agency should evaluate the steps it takes to ensure that any required documentation not gathered from the client is obtained prior to finalizing an application and providing housing assistance. Any changes in this methodology should be documented in the program policies and procedures and communicated to all employee who engage in the application process. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: ERMA applicants can submit required documentation with the assistance of a contracted Housing Counseling Agency or via the application portal directly. The two examples that caused this recommendation can be attributed to applicant error, as well as a missed review by the processing vendor. To ensure that required documentation not gathered from the applicant is followed-up on and obtained timely and to minimize future occurrences, the Agency has (1) revised the required documentation list to simplify the documentation gathering process for the applicant, and (2) provided additional training on the required documentation process to the Housing Counseling Agencies, processing/underwriting vendor and ERMA program staff. All approvals are reviewed by a supervisor, or their designee, to ensure all required documents pertinent to the applicant?s eligibility are present prior to providing ERMA assistance. Name(s) of the contact person(s) responsible for corrective action: William Schmidt (Assistant Director of HAF); James Abrams (HAF Program Manager); Tina White (HAF Program Manager) Planned completion date for corrective action plan: Both the training and the changes to the required documentation list were completed in May of 2023. If the U.S. Department of Treasury has questions regarding this plan, please call Kimberly A. Sked at 609- 278-7669.

View Audit 55339

Finding 59906 (2022-001)

None 2022

Oakton Community College District Number 535

IL

Student Financial Aid Eligibility Internal Control / Segregation of Duties

2022-001 Incorrect Pell Disbursement - Student Financial Aid Cluster Assistance Listing Number 84.007, 84.033, 84.063, 84.268, Grant Period - Year Ended June 30, 2022 Condition Found: During ou...

2022-001 Incorrect Pell Disbursement - Student Financial Aid Cluster Assistance Listing Number 84.007, 84.033, 84.063, 84.268, Grant Period - Year Ended June 30, 2022 Condition Found: During our student file testing we noted one student out of forty had was not disbursed the correct Pell Grant award. Based on the student?s enrollment status and need, the College under awarded the student by $680. We consider this to be an instance of noncompliance relating to the Eligibility Compliance Requirement. Corrective Action Plan: In response to this finding, Oakton Community College had already updated the student's federal Pell grant award, disbursed the additional Pell to the student, and reported the subsequent adjustment to COD on May 4, 2022. The Financial Aid Manager also met with the financial aid advisors to share the finding. Responsible Person for Corrective Action Plan: Jamie Peterson, Manager of Student Financial Assistance Dr. Cheryl Warmann, Registrar/Director of Student Financial Support Implementation Date of Corrective Action Plan: May 4, 2022- Student Record Adjustment June 14, 2022 - Internal training with financial aid advisors

View Audit 55252

Finding 59878 (2022-002)

Significant Deficiency 2022

Northbay Healthcare Corporation

CA

Eligibility Reporting Significant Deficiency

As required by OMB Uniform Guidance, we have provided below our response and corrective action plan addressing the findings in the ?Report on Federal Awards in Accordance with the OMB Uniform Guidance? for the year ended December 31, 2022. Management?s Views and Corrective Action Plan Finding 2022...

As required by OMB Uniform Guidance, we have provided below our response and corrective action plan addressing the findings in the ?Report on Federal Awards in Accordance with the OMB Uniform Guidance? for the year ended December 31, 2022. Management?s Views and Corrective Action Plan Finding 2022-002 ? Reporting ? Significant Deficiency in Internal Control Over Compliance NorthBay Healthcare Corporation and its Affiliates dba NorthBay Health agree with the finding and management has implemented a corrective action plan. Management has implemented a more precise review control over future federal award reporting submissions to ensure all reported expenditures comply with the terms and conditions of the federal award. Further, NorthBay Healthcare Corporation and its Affiliates dba NorthBay Health had sufficient unused lost revenues of approximately $114,915,000 and $133,021,000 from the Periods 3 and 4 Provider Relief Fund reporting to fully cover the Provider Relief Fund distributions for Periods 3 and 4, respectively. Date of Corrective Action: September 15, 2023 Party Responsible for Corrective Action: Theo Rallis, Assistant Vice President of Finance

View Audit 55328

Finding 59854 (2022-054)

None 2022

State of Nebraska

NE

Questioned Costs Allowable Costs / Cost Principles Eligibility § 200.303

Program: AL 21.026 ? COVID-19 Homeowner Assistance Fund ? Allowability & Eligibility Corrective Action Plan: Coaching has been provided to the appropriate review staff. Contact: Major General Bohac Anticipated Completion Date: Completed

View Audit 55212 Questioned Costs: $1

Finding 59852 (2022-052)

None 2022

State of Nebraska

NE

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303 § 200.403 § 200.516

Program: AL 21.023 ? COVID-19 Emergency Rental Assistance ? Allowability & Eligibility Corrective Action Plan: N/A Contact: Lee Will Anticipated Completion Date: N/A

View Audit 55212 Questioned Costs: $1

Finding 59846 (2022-047)

None 2022

State of Nebraska

NE

Reporting Special Tests & Provisions Allowable Costs / Cost Principles § 200.514

Program: AL 17.225 ? Unemployment Insurance ? Admin ? Special Tests & Provisions Corrective Action Plan: The corrective action plan has been completed and approved by USDOL. Contact: Andi Bridgmon, UI Director Anticipated Completion Date: N/A

View Audit 55212

Finding 59844 (2022-046)

Material Weakness 2022

State of Nebraska

NE

Questioned Costs Eligibility

Program: AL 17.225 ? COVID-19 ? Unemployment Insurance ? Federal; AL 17.225 ? Unemployment Insurance ? State ? Allowability & Eligibility Corrective Action Plan: NDOL will work to ensure that investigations are appropriately set and timely resolved. Contact: Andi Bridgmon, UI Director Anticipated...

Program: AL 17.225 ? COVID-19 ? Unemployment Insurance ? Federal; AL 17.225 ? Unemployment Insurance ? State ? Allowability & Eligibility Corrective Action Plan: NDOL will work to ensure that investigations are appropriately set and timely resolved. Contact: Andi Bridgmon, UI Director Anticipated Completion Date: June 30, 2023

View Audit 55212 Questioned Costs: $1

Finding 59835 (2022-040)

Significant Deficiency 2022

State of Nebraska

NE

Questioned Costs Eligibility Matching / Level of Effort / Earmarking

Program: AL 93.778 ? Medical Assistance Program; AL 93.778 ? COVID-19 Medical Assistance Program ? Allowability and Eligibility Corrective Action Plan: The agency will review training materials and tip sheets regarding these topics. The agency will review the errors with the staff who made them an...

Program: AL 93.778 ? Medical Assistance Program; AL 93.778 ? COVID-19 Medical Assistance Program ? Allowability and Eligibility Corrective Action Plan: The agency will review training materials and tip sheets regarding these topics. The agency will review the errors with the staff who made them and provide any additional training needed. Contact: Catherine Gekas Steeby Anticipated Completion Date: 10/31/2023

View Audit 55212 Questioned Costs: $1

Finding 59834 (2022-039)

Significant Deficiency 2022

State of Nebraska

NE

Questioned Costs Allowable Costs / Cost Principles Eligibility

Program: AL 93.778 ? Medical Assistance Program; AL 93.778 ? COVID-19 Medical Assistance Program ? Allowability Corrective Action Plan: Training materials will continue to be updated and made available to assist providers with EVV and for submitting accurate billing. Training will be at least annua...

Program: AL 93.778 ? Medical Assistance Program; AL 93.778 ? COVID-19 Medical Assistance Program ? Allowability Corrective Action Plan: Training materials will continue to be updated and made available to assist providers with EVV and for submitting accurate billing. Training will be at least annually for direct staff involved with assisting providers. EVV website to be kept updated with program guidelines and regulations. DHHS will engage the vendor to explore technical options to resolve any technical related issues identified in the report, and develop any additional quality assurance measures necessary when a technical solution is not achievable in the short term. Contact: Kathy Scheele Anticipated Completion Date: 06/30/2023

View Audit 55212 Questioned Costs: $1

Finding 59820 (2022-034)

Material Weakness 2022

State of Nebraska

NE

Questioned Costs Matching / Level of Effort / Earmarking Eligibility

Program: AL 93.575 and 93.596 ? CCDF Cluster ? Allowability & Eligibility Corrective Action Plan: The CCDF program team will continue to work with the training team and the program accuracy team to create `quick tips? and tools addressing these eligibility issues for field staff. CCDF program staf...

Program: AL 93.575 and 93.596 ? CCDF Cluster ? Allowability & Eligibility Corrective Action Plan: The CCDF program team will continue to work with the training team and the program accuracy team to create `quick tips? and tools addressing these eligibility issues for field staff. CCDF program staff are reviewing monthly reviews with high billed hours. Resource Developer (RD) staff will increase initial and annual billing trainings with subsidy providers. A new provider handbook is being created and slated to be completed and launched summer 2023. DHHS is also changing the current billing structure from hours and days to half-days and full-days. This should simplify billing and calculation errors. This is scheduled to be completed by May 2023. Contact: Nicole Vint Anticipated Completion Date: 06/30/2023

View Audit 55212 Questioned Costs: $1

Finding 59815 (2022-032)

Significant Deficiency 2022

State of Nebraska

NE

Questioned Costs Eligibility

Program: AL 93.568 ? COVID-19 ? Low-Income Home Energy Assistance (LIHEAP); AL 93.568 ? Low-Income Home Energy Assistance ? Eligibility Corrective Action Plan: The LIHEAP Desk Aid will be revised to a Standard Operating Procedure to assist in providing clear guidance to Eligibility Staff. Contact:...

Program: AL 93.568 ? COVID-19 ? Low-Income Home Energy Assistance (LIHEAP); AL 93.568 ? Low-Income Home Energy Assistance ? Eligibility Corrective Action Plan: The LIHEAP Desk Aid will be revised to a Standard Operating Procedure to assist in providing clear guidance to Eligibility Staff. Contact: Matt Thomsen Anticipated Completion Date: 06/30/2023

View Audit 55212 Questioned Costs: $1

Finding 59811 (2022-030)

None 2022

State of Nebraska

NE

Questioned Costs Eligibility

Program: AL 93.558 ? Temporary Assistance for Needy Families (TANF) ? Allowability & Eligibility Corrective Action Plan: The specific error that occurred does not appear to be widespread since only 1 out of 25 cases were identified to have this error. In addition, the TANF program has information o...

Program: AL 93.558 ? Temporary Assistance for Needy Families (TANF) ? Allowability & Eligibility Corrective Action Plan: The specific error that occurred does not appear to be widespread since only 1 out of 25 cases were identified to have this error. In addition, the TANF program has information on regulations and the policy log that provides guidance on this issue. The Program will follow up with the worker that made the error to ensure it does not happen again. Contact: Will Varicak Anticipated Completion Date: 1/29/2023

View Audit 55212 Questioned Costs: $1

Finding 59810 (2022-029)

Significant Deficiency 2022

State of Nebraska

NE

Questioned Costs Eligibility Matching / Level of Effort / Earmarking

Program: AL 93.558 ? Temporary Assistance for Needy Families (TANF) ? Allowability & Eligibility Corrective Action Plan: DHHS will review the underlying coding that pulls this report and make any changes based on findings. Contact: Andrew Keck Anticipated Completion Date: 6/30/2023

View Audit 55212 Questioned Costs: $1

Finding 59799 (2022-049)

Significant Deficiency 2022

State of Nebraska

NE

Procurement, Suspension & Debarment Subrecipient Monitoring Eligibility

Program: AL 12.400 ? Military Construction, National Guard ? Suspension and Debarment Corrective Action Plan: Contracting Officers are logging into SAM website, looking up the Contractor or A&E to ensure that they are not barred. We are taking a screen shot of the web site printing it off and attac...

Program: AL 12.400 ? Military Construction, National Guard ? Suspension and Debarment Corrective Action Plan: Contracting Officers are logging into SAM website, looking up the Contractor or A&E to ensure that they are not barred. We are taking a screen shot of the web site printing it off and attaching it to our digital/hard copy files. Contact: MAJ Justin Portenier Anticipated Completion Date: The Corrective Action Plan has already been implemented and will be updated in the Standard Operating Procedure Manual (SOP) no later than 30-May-2023.

View Audit 55212

Finding 59768 (2022-001)

Significant Deficiency 2022

East Detroit Area Non-Profit Housing Corporation

MI

Allowable Costs / Cost Principles Eligibility HUD Housing Programs

2022-001 ? Eligibility - Tenant File Documentation Finding Type. Immaterial noncompliance, Significant deficiency in internal controls over compliance (Eligibility) Federal programs U.S. Department of Housing and Urban Development ? Supportive Housing for the Elderly (ALN# 14.157) Condition. Out...

2022-001 ? Eligibility - Tenant File Documentation Finding Type. Immaterial noncompliance, Significant deficiency in internal controls over compliance (Eligibility) Federal programs U.S. Department of Housing and Urban Development ? Supportive Housing for the Elderly (ALN# 14.157) Condition. Out of a sample of 6 tenant files, it was noted: 1. Two out of six instances where the resident's cash balance was verified using the ending balance; however, the 6-month average balance should have been used; 2. One out of six instances where the resident's medical expenses were improperly calculated; 3. One out of six instances where the tenant's security deposit and/or prorated rent were not disbursed to them in the required 30 days; 4. One out of six instances where there was no verification of pension income performed on the most recent recertification. Effect. As a result of this condition, certain tenant files did not contain all required supporting documentation. In addition, employees did not follow HUD guideline procedures, and/or did not properly calculate the tenant subsidy in HUD Form 50059. While there were no significant differences in the amount of subsidies allowed compared to subsidies received, the lack of effective internal controls could lead to future significant noncompliance. Plan. Management agrees with finding 2022-001. All files are to be inspected in the current fiscal year to ensure compliance with HUD regulations. File maintenance will be competed following each move in and annual recertification. In addition to one-on-one training, the housing administrator has signed up for additional training including a WebEx on annual recertification and a basic EIV course. Additional training sessions are forthcoming. Contact Person Responsible for This Corrective Action: Laura Maisevich, Senior Housing Manager Anticipated completion date: December 31, 2022

View Audit 50452

Finding 59716 (2022-001)

Significant Deficiency 2022

Gwynedd Mercy University

PA

Student Financial Aid Subrecipient Monitoring Eligibility

Finding 2022-001: Gramm-Leach Bliley Act (GLBA) Recommendation: The University should perform and document an annual risk assessment to determine the University's specific risks relevant to protecting consumer nonpublic personal information. At a minimum, the University should have at least one risk...

Finding 2022-001: Gramm-Leach Bliley Act (GLBA) Recommendation: The University should perform and document an annual risk assessment to determine the University's specific risks relevant to protecting consumer nonpublic personal information. At a minimum, the University should have at least one risk statement aligned or referenced to each of the three required areas noted in the GLBA law at 16 CFR 314.4 (b). Finally, the University should identify and document at least one safeguard (i.e., control) for each of the risks identified and document in the risk assessment. Each control should be aligned or referenced to the risk(s) to which the safeguard applies. Action Taken: The University has taken the following steps to address the risks identified during the audit: 1. Employee Training and Management a. The University deployed the Knowbe4 Security Awareness Program to all full time staff. The program provides training for managing user data and email messages. To date the University has distributed two campaigns to combat email phishing attempts. 2. Information systems, including network and software design, as well as information processing, storage, transmission and disposal a. The University has formulated a digital transformation strategy to reduce on premises systems and applications. All the critical business systems are hosted at a colocation or are SaaS solutions. b. The University performs backups of all on premises systems using technology that creates immutable storage. c. The University leverages the cybersecurity experience of resellers and manufacturers to ensure all core network technology is installed and configured to minimize any attack surface. 3. Detecting, preventing, and responding to attacks, intrusions, or other systems failures and document safeguards for identified risks as required by the Gramm-Leach Bliley Act (GLBA). a. The University has deployed a redundant pair of Fortinet Advanced Firewalls to monitor and block traffic with suspicious payloads. b. The University has updated to the latest version of Microsoft Advanced Threat Defender to serve as optimal end point protection for managing email traffic. c. The University contracted with the Cybersecurity and Infrastructure Security Agency (CISA) to perform vulnerability scans and penetration testing. The IT department evaluates the weekly reports and remediates highlighted deficiencies. d. The University has removed all admin rights from school managed computers, eliminating the ability to install local software. e. The University has deployed an updated VPN client to all school managed computers providing a secure tunnel for access network services. f. The University manages web browsers of all school managed computers. The University will take the results of the security assessment that was completed and draft the GLBA policy in conformity with the DOE requirements by June 2023. Responsible Individual for Corrective Action: Chief Information Officer ? Gregg Chottiner Anticipated Completion Date: June 30, 2023

View Audit 50213

Finding 59702 (2022-001)

Material Weakness 2022

Summitstone Health Partners

CO

Questioned Costs Allowable Costs / Cost Principles Eligibility

The following action items are currently being put into place by the People, Culture & Learning Department: -Reviewing and updating policies, procedures, and language in the Employee Handbook that meets the requirements of the Colorado Healthy Families Workplace Act -Communicate and train supervisor...

The following action items are currently being put into place by the People, Culture & Learning Department: -Reviewing and updating policies, procedures, and language in the Employee Handbook that meets the requirements of the Colorado Healthy Families Workplace Act -Communicate and train supervisors and managers on the updated policies, procedures, and language including the requirement for supervisors to be aware of the employee?s use of the specific leave codes and ensuring the leave code is being used appropriately before approving timecards -Implementing a new HRIS/Payroll system that will require justification/documentation from the employee for specific paid leave codes such as use of Extended Leave Bank or COVID. CLIENT RESPONSIBLE PARTY: Jaime Engle, Director of Total Rewards and HR Operations COMPLETION DATE: August 1, 2023 with implementation of ADP payroll system

View Audit 55410 Questioned Costs: $1

Finding 59698 (2022-005)

Significant Deficiency 2022

Johnston County

NC

Eligibility Significant Deficiency

Finding: 2022-005 Name of contact person: LaGuana Holder, QA/PI Income Maintenance Supervisor Corrective Action: Universal template mandated by Agency Director. In-house audits to verify templates are being used. Proposed Completion Date: Templ...

Finding: 2022-005 Name of contact person: LaGuana Holder, QA/PI Income Maintenance Supervisor Corrective Action: Universal template mandated by Agency Director. In-house audits to verify templates are being used. Proposed Completion Date: Templates will be distributed and used by staff starting immediately.

View Audit 55433

Finding 59697 (2022-004)

Significant Deficiency 2022

Johnston County

NC

Eligibility Significant Deficiency

Finding: 2022-004 Name of contact person: LaGuana Holder, QA/PI Income Maintenance Supervisor Corrective Action: A required Power Point training for manual section 2230, 2300, 2250 for all Medicaid staff. A universal template mandated by Agency Director. ...

Finding: 2022-004 Name of contact person: LaGuana Holder, QA/PI Income Maintenance Supervisor Corrective Action: A required Power Point training for manual section 2230, 2300, 2250 for all Medicaid staff. A universal template mandated by Agency Director. Proposed Completion Date: PowerPoint training will be completed by January 31, 2023. Templates will be distributed and used by staff starting immediately.

View Audit 55433

Finding 59696 (2022-003)

Significant Deficiency 2022

Johnston County

NC

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Finding: 2022-003 Name of contact person: LaGuana Holder, QA/PI Income Maintenance Supervisor Corrective Action: Universal template mandated by Agency Director. In-house audits to verify templates are being used. Proposed Completion Date: Templ...

Finding: 2022-003 Name of contact person: LaGuana Holder, QA/PI Income Maintenance Supervisor Corrective Action: Universal template mandated by Agency Director. In-house audits to verify templates are being used. Proposed Completion Date: Templates will be distributed and used by staff starting immediately.

View Audit 55433

Finding 59695 (2022-002)

Significant Deficiency 2022

Johnston County

NC

Eligibility Significant Deficiency

Finding: 2022-002 Name of contact person: LaGuana Holder, QA/PI Income Maintenance Supervisor Corrective Action: A required Power Point training for manual section 3365 for all Medicaid staff. A universal template mandated by Agency Director. In-house audits to...

Finding: 2022-002 Name of contact person: LaGuana Holder, QA/PI Income Maintenance Supervisor Corrective Action: A required Power Point training for manual section 3365 for all Medicaid staff. A universal template mandated by Agency Director. In-house audits to verify that templates are being used. Proposed Completion Date: PowerPoint training will be completed by January 31, 2023. Templates will be distributed and used by staff starting immediately.

View Audit 55433

Finding 59685 (2022-002)

Material Weakness 2022

Mesa County, Colorado

CO

Subrecipient Monitoring Eligibility Material Weakness

Finding: 2022-002 ? Material Weakness, Internal Control Over Compliance, Eligibility and Special Tests ? ALN 93.778 Medicaid Cluster Personnel Responsible for Corrective Action: Pam Noonan, Mesa County Finance Director Anticipated Completion Date: 09/29/2023 Cause: Internal controls over the el...

Finding: 2022-002 ? Material Weakness, Internal Control Over Compliance, Eligibility and Special Tests ? ALN 93.778 Medicaid Cluster Personnel Responsible for Corrective Action: Pam Noonan, Mesa County Finance Director Anticipated Completion Date: 09/29/2023 Cause: Internal controls over the eligibility determinations are the responsibility of management. Mesa County did not follow its formal process in place for reviews of eligibility determinations. View of Responsible Officials and Planned Corrective Action: Mesa County agrees with the finding and has put together a corrective action plan for the finding. Corrective Action Plan: Mesa County was aware that they were not meeting their internal or Health Care Policy and Financing (HCPF) and Colorado Department of Human Services (CDHS) review requirements for 2022. Mesa County created a new quality control case reviews policy and procedure effective June 2023. The new policy included internal, HCPF and CDHS review requirement for all programs. In addition, MCDHS quality assurance team will be providing oversight using a tool they create to ensure review requirements are being met for each program.

View Audit 55777

Finding 59681 (2022-003)

Significant Deficiency 2022

Ashwaubenon School District

WI

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Recommendation: We recommend the District implement procedures to ensure that someone knowledgeable of the grant requirements reviews the prepared eligibility reports prior to submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned...

Recommendation: We recommend the District implement procedures to ensure that someone knowledgeable of the grant requirements reviews the prepared eligibility reports prior to submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: A procedure will be implemented to require a separate preparer and reviewer of the reports. Responsible official: Keith Lucius, Assistant Superintendent Anticipated completion date: June 30, 2023

View Audit 55305

Corrective Action Plans

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