Corrective Action Plans

Finding 32975 (2022-002)

Significant Deficiency 2022

IL

Subrecipient Monitoring Eligibility School Nutrition Programs

United States Department of Agriculture 2022-002 Emergency Food Assistance Program ? Assistance Listing Number #10.569 During the year ended March 31, 2022, Nourishing Hope did not follow USDA Signature Sheet Guidelines and retain addresses from guests or their income eligibility. Recommendation No...

United States Department of Agriculture 2022-002 Emergency Food Assistance Program ? Assistance Listing Number #10.569 During the year ended March 31, 2022, Nourishing Hope did not follow USDA Signature Sheet Guidelines and retain addresses from guests or their income eligibility. Recommendation Nourishing Hope should enhance their eligibility record keeping procedures in accordance with the program guidelines. Action Taken Nourishing Hope conducted this requirement in accordance with Greater Chicago Food Depository (?GCFD?) program regulations and collected and submitted all required documentation to GCFD for review on a monthly basis. Nourishing Hope did not keep a copy of the documentation in the past since Nourishing Hope was not subject to a single audit requirement and was required to send all of the documents to GCFD. In fiscal year 2023, a new process was implemented to now scan a copy of these documents to be in compliance with USDA regulations. With this new process in place, Nourishing Hope considers the control and compliance matter remediated in fiscal year 2023.

View Audit 33699

Finding 32957 (2022-001)

Significant Deficiency 2022

N.e.w. Community Clinic, Ltd.

WI

Subrecipient Monitoring Eligibility Internal Control / Segregation of Duties

2022-001 ? Special Tests and Provision ? Sliding Fee Scale Discounts Condition: The Health Center's sliding fee scale policy provides for the application of discounts to eligible patients based on the ability to pay. The Health Center has designed an internal control to provide a review and approv...

2022-001 ? Special Tests and Provision ? Sliding Fee Scale Discounts Condition: The Health Center's sliding fee scale policy provides for the application of discounts to eligible patients based on the ability to pay. The Health Center has designed an internal control to provide a review and approval of eligibility determinations within the established sliding fee scale based on income and family size. During our testing of participants, it was noted that four out of the 40 individuals sampled and tested did not have evidence that the internal control designed had been applied to the determination of eligibility within the sliding fee scale framework. Corrective Action Plan: N.E.W. Community Clinic, Ltd. (NEWCC) is implementing an internal audit process for qualifying persons for Sliding Fee Discount Program {SFDP). In addition, NEWCC is implementing a staffing change for separation of duties. The receptionist job duties will be split into three separate job duties of scheduling/call center, patient intake at receptionist desk, and financial counselor. The financial counselor position will be solely responsible for the approval of the SFDP applications. In addition, NEWCC is implementing an SFDP Application process. {Please see attachments for sample). Person(s) Responsible: Keith Szerkins, CFO Timing for Implementation: 1. Internal audit for 2023 SFDP is in currently in place as of September 29, 2023. 2. Separation of job duties will be done by November 30, 2023. 3. Sliding fee application to be implemented by October 31, 2023. September 29, 2023

View Audit 37864

Finding 32952 (2022-001)

Material Weakness 2022

Center for Inclusive Child Care

MN

Cash Management Eligibility Material Weakness

SECTION II - FINDINGS AND QUESTIONED COSTS - FINANCIAL STATEMENTS AUDIT Name of Contact person ? Amy Petersen, Finance Manager Corrective action ? CICC will develop a process to track expenses incurred. Before the accounting records are closed for the year, a review should be performed to ensure exp...

SECTION II - FINDINGS AND QUESTIONED COSTS - FINANCIAL STATEMENTS AUDIT Name of Contact person ? Amy Petersen, Finance Manager Corrective action ? CICC will develop a process to track expenses incurred. Before the accounting records are closed for the year, a review should be performed to ensure expenses incurred prior to year-end are captured in the accounting records. Any expenses noted that required accrual will be reviewed for reimbursement eligibility and, if applicable, the related revenue will be accrued. Proposed completion date ? Management and the Board of Directors will implement the above procedures immediately.

View Audit 34223

Finding 32946 (2022-001)

Significant Deficiency 2022

Share

WA

Period of Performance Subrecipient Monitoring Allowable Costs / Cost Principles § 200.308 § 200.309 § 200.403

Contracts charged for expenses outside of the period of performance have been credited for ineligible expenses. Share's Director of Finance, Christopher Brox will provide training to accounting staff responsible for expense entry, expense review and approval, and invoicing by June 30, 2023 that incl...

Contracts charged for expenses outside of the period of performance have been credited for ineligible expenses. Share's Director of Finance, Christopher Brox will provide training to accounting staff responsible for expense entry, expense review and approval, and invoicing by June 30, 2023 that include the following topics: - Allowability of expenses based on both contract criteria and the period of performance. - key identifiers that could flag an exception in allowability based on period of performance, and how to catch this in the review of expenses. - General ledger transactions that require further review for period of performance allowability during monthly review of expenses prior to preparing invoices. This training will highlight this being a specific area of focus for review during periods when a contract terms and a new contract starts. This training will happen with all new accounting staff responsible for expense entry and review and will be incorporated as refresher trainings if contract and grant administrator expense reviews identify this as being a continued issue by staff performing expense data entry.

View Audit 31554

Finding 32907 (2022-001)

Material Weakness 2022

Regional Health Reach, Inc.

NY

Eligibility

Management agrees with the finding. Deficiencies in the Sliding Fee Discount program for year ending December 31, 2022 are a direct result of several misfortunes. On top of the COVID pandemic, the organization experienced Unionization, de-Unionization, high staff turnover, including multiple chan...

Management agrees with the finding. Deficiencies in the Sliding Fee Discount program for year ending December 31, 2022 are a direct result of several misfortunes. On top of the COVID pandemic, the organization experienced Unionization, de-Unionization, high staff turnover, including multiple changes in Senior Leadership, a death of an Executive Director, and an office relocation. Since January 2023, significant improvements have been implemented; the office settled into the new location, new staff and senior leaders have been hired, the organization is flourishing post-pandemic, and policies and procedures have been reviewed and updated. After review of the Sliding Fee Discount Program policies and office process, it was clear that previous controls were ineffective and identified gaps in the Sliding Fee Discount program structure. A major gap was the lack of knowledge related to who was in the current program and who continues to be eligible a year after acceptance. This gap was directly related to missing documentation, lack of EMR tracking, and lack of reporting. The previous corrective action for shelter, Street Medicine and Dental teams remains in place; providers who see patients? offsite were trained on the required documentation, which will be submitted to the clinic daily. Additional staff have been assigned to shelters to facilitate the registration process and transportation of the completed forms back to the Clinic for scanning. In mid-February 2023, an audit was completed on the Sliding Fee Discount program to determine clinic compliance. Additional gaps were identified which led to a secondary process of checks and balances. In addition to the current corrective action, a secondary corrective action was implemented. The Clinic staff would collect the application, review eligibility, and enter the approval/denial status, along with the date into the patients EMR, as well as entering the data on a spreadsheet to track yearly eligibility review. In addition, each team is equipped with a draft application that identifies the necessary information for a complete application. The controls currently in place are performed to identify eligibility at each appointment. If no change, the application is then filed until the next appointment or annual review date, whichever occurs first. If a patients income has changed, prior to the yearly review, a new application is completed at the time of visit, the EMR and spreadsheet are updated accordingly, and the application is filed. The current controls are reviewed daily in order to identify eligibility review and compliance.

View Audit 29396

Finding 32887 (2022-005)

Significant Deficiency 2022

State of South Carolina

SC

Subrecipient Monitoring Eligibility Significant Deficiency

Department of Health & Human Services Centers for Medicare & Medicaid Services 31 Forsyth Street, SW, Room 4T20 Atlanta, Georgia 30303-8909 The South Carolina Department of Health and Human Services respectfully submits the following corrective action plan for the year ended June 30, 2022. The fin...

Department of Health & Human Services Centers for Medicare & Medicaid Services 31 Forsyth Street, SW, Room 4T20 Atlanta, Georgia 30303-8909 The South Carolina Department of Health and Human Services respectfully submits the following corrective action plan for the year ended June 30, 2022. The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS ? FEDERAL AWARD PROGRAM AUDIT DEPARTMENT OF HEALTH AND HUMAN SERVICES 2022-005 Medicaid Cluster; Children?s Health Insurance Program (CHIP) ? Assistance Listing No. 93.775, 93.777, 93.778; 93.767 Recommendation: We recommend the Department strengthen controls over eligibility determinations to ensure documentation is maintained and reviewed in accordance with its State plan and federal regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The agency continues to implement an Eligibility Performance and Remediation process, which includes internal Eligibility Quality Assurance (EQA) monthly case reviews, as well as third party case reviews conducted by the University of South Carolina Core for Applied Research and Evaluation (USC CARE). Eligibility Policies and Procedures provide instructions for a worker to ensure the case file is complete for all eligibility criteria based on policy, prior to making a determination. The policy is included in staff training and is evaluated as part of quality assurance activities. Supervisors are responsible for monitoring staff daily by using data available via system of record, the electronic document management system (OnBase), workload management software, as well as through case spot reviews. Supervisors meet monthly with each staff member to review Eligibility Quality Assurance (EQA) findings to identify and address issues that impact performance, as well as to facilitate corrections to incorrect determinations identified through the EQA process. Errors are identified via error codes and descriptions. EQA reviews are conducted and housed in a state-developed tool to allow for creation of reports that can be generated based on supervisor, worker, work type, error code or overall accuracy. The state compares errors identified through audits and federal reviews such as payment error rate measurement with internal and third party EQA error trends and use this monitoring method to identify trends, develop mitigation strategies and to determine impact of those strategies on these errors. During the 4th quarter of calendar year 2022, 15,716 cases were reviewed by EQA with the following results pertaining to missing documentation: Error Description, Q1 CY2022 % Cases Reviewed, Q2 CY2022 % Cases Reviewed, Q3 CY2022 % Cases Reviewed, Q4 CY2022 % Cases Reviewed: The application was not signed, 0.03%, 0.01%, 0.02%, 0.30%; The application could not be located in the case file, 0.02%, 0.03%, 0.01%, 0.03%; Level of care was not in the case file or in Phoenix, 0.02%, 0.01%, 0.01%, 0.01%; The case record was missing SSN or proof of application for SSN, 0.25% 0.36%, 0.26%, 0.00%; In response to these findings, the Eligibility department will conduct email and face-to-face communication with managers, supervisors and staff regarding these findings and a reminder of documentation requirements in policy, as well as to ensure supervisors are assessing for this requirement in casefile spot checks. This will also be discussed on an upcoming Eligibility Supervisor call and shared in the Eligibility, Enrollment, and Member Services Newsletter. These requirements will also continue to be emphasized in new worker and staff refresher training. Name(s) of the contact person(s) responsible for corrective action: Lori Risk Planned completion date for corrective action plan: Email, face-to-face and newsletter communications: June 2023; EQA Procedures, staff training ? Ongoing.

View Audit 28588

Finding 32886 (2022-004)

Material Weakness 2022

State of South Carolina

SC

Subrecipient Monitoring Eligibility Material Weakness

Department of Health & Human Services Centers for Medicare & Medicaid Services 31 Forsyth Street, SW, Room 4T20 Atlanta, Georgia 30303-8909 The South Carolina Department of Health and Human Services respectfully submits the following corrective action plan for the year ended June 30, 2022. The fin...

Department of Health & Human Services Centers for Medicare & Medicaid Services 31 Forsyth Street, SW, Room 4T20 Atlanta, Georgia 30303-8909 The South Carolina Department of Health and Human Services respectfully submits the following corrective action plan for the year ended June 30, 2022. The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS ? FEDERAL AWARD PROGRAM AUDIT DEPARTMENT OF HEALTH AND HUMAN SERVICES 2022-004 Medicaid Cluster; Children?s Health Insurance Program (CHIP) ? Assistance Listing No. 93.775, 93.777, 93.778; 93.767 Recommendation: We recommend eligibility reviews be performed annually in accordance with the South Carolina Medicaid Policies and Procedures Manual. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The agency will resume standard review processing in April 2023 in response to requirements outlined in the Consolidated Appropriations Act 2023. The state has developed a comprehensive operational plan for completing this work including: ? Policy and procedure updates ? Hiring additional staff in response to attrition during the public health emergency (PHE) and staffing levels needed to complete the anticipated work ? Additional staff augmentation through a third party vendor to assist with specific data entry tasks associated with review processing ? Staff refresher training on eligibility review policies and procedures ? A comprehensive Communication Plan for sharing relevant information regarding unwinding activities with stakeholders such as beneficiaries, agency staff, call centers, providers, managed care plans and community organizations ? Outreach to inform beneficiaries about the review process and how to contact the agency with changes to contact information and questions they may have ? Distribution of reviews. The state has 12 months during the unwinding period to initiate reviews and 14 months to complete the work. ? Workload management plan to react to staffing needed for both application and review processing. Name(s) of the contact person(s) responsible for corrective action: Lori Risk Planned completion date for corrective action plan: June 2024 (End of Unwinding Period)

View Audit 28588

Finding 32816 (2022-005)

Significant Deficiency 2022

Yadkin County

NC

Eligibility

Finding: 2022-005 Name of contact person: Jessica Wall, DSS Director Corrective Action: YCHSA continues to provide training on The Work Number. This is also checked during the second party review process. Additionally, The Work Number is now located within NCFast...

Finding: 2022-005 Name of contact person: Jessica Wall, DSS Director Corrective Action: YCHSA continues to provide training on The Work Number. This is also checked during the second party review process. Additionally, The Work Number is now located within NCFast so there is no need for staff to run this in an older program outside the NCFast system. Staff utilize a checklist to ensure the correct application of Medicaid policy and adequate information being used to determine eligibility. A training will be held on this checklist to ensure staff are knowledgeable to its intended use and it is being used correctly and consistently. Eligibility Supervisors will complete knowledge checks with Medicaid staff to evaluate the effectiveness of recent trainings. This will be done in a group setting and will use active applications/cases as a guide to determine if information has been requested accurately. Following the knowledge checks, Medicaid staff will be given anonymous surveys to complete in an effort to discern improvements or continued areas of need. Due to the age of the cases pulled (many of these being from 2019) the staff involved in these cases are no longer here. Proposed Complinace Date: Training on The Work Number has already been provided to staff and the new checklist is already in use. YCHSA will continue to conduct second party reviews at a higher amount compared to the state mandate. Training will occur by 12/31/22.

View Audit 29375

Finding 32815 (2022-004)

Significant Deficiency 2022

Yadkin County

NC

Eligibility

Finding: 2022-004 Name of contact person: Jessica Wall, DSS Director Corrective Action: YCHSA will provide training to staff on the review of checklists that have previously been provided. A training will be held on this checklist to ensure staff are knowledgeabl...

Finding: 2022-004 Name of contact person: Jessica Wall, DSS Director Corrective Action: YCHSA will provide training to staff on the review of checklists that have previously been provided. A training will be held on this checklist to ensure staff are knowledgeable to its intended use and it is being used correctly and consistently. Second party reviews will continue to ensure that resources are being entered correctly in NCFast. Eligibility Supervisors will complete knowledge checks with Medicaid staff to evaluate the effectiveness of recent training on resources. This will be done in a group setting and will use active applications/cases as a guide to determine if resources have been evaluated accurately. Following the knowledge checks, Medicaid staff will be given anonymous surveys to complete in an effort to discern improvements or continued areas of need. Due to the age of the cases pulled (many of these being from 2019) the staff involved in these cases are no longer here. Proposed Complinace Date: Training will occur by 12/31/22 and second party reviews will continue indefinitely.

View Audit 29375

Finding 32814 (2022-003)

Significant Deficiency 2022

Yadkin County

NC

Eligibility Internal Control / Segregation of Duties

Finding: 2022-003 Name of contact person: Jessica Wall, DSS Director Corrective Action: YCHSA continues to second party Medicaid cases with at least 100 cases being viewed each quarter (more than the state requirement of 76). YCHSA will provide training to staff ...

Finding: 2022-003 Name of contact person: Jessica Wall, DSS Director Corrective Action: YCHSA continues to second party Medicaid cases with at least 100 cases being viewed each quarter (more than the state requirement of 76). YCHSA will provide training to staff on the review of checklists that have previously been provided. A training will be held on this checklist to ensure staff are knowledgeable to its intended use and it is being used correctly and consistently. Eligibility Supervisors will complete knowledge checks with Medicaid staff to evaluate the effectiveness of recent trainings. This will be done in a group setting and will use active applications/cases as a guide to determine if information has been entered accurately. Following the knowledge checks, Medicaid staff will be given anonymous surveys to complete in an effort to discern improvements or continued areas of need. Due to the age of the cases pulled (many of these being from 2019) the staff involved in these cases are no longer here. Proposed Complinace Date: Increased second party reviews are in place currently and will continue with at least 100 cases being second-party reviewed each quarter. Training will occur by 12/31/22 around how to properly enter information and which information should be included.

View Audit 29375

Finding 32806 (2022-004)

Significant Deficiency 2022

Sherburne County

MN

Eligibility Significant Deficiency Internal Control / Segregation of Duties

2022-004 SPECIAL PROVISIONS Federal Agency: U.S. Department of Agriculture Federal Program Name: Supplemental Nutrition Assistance Program Assistance Listing Number: 10.561 Federal Award Identification Number and Year: 222MN127Q7503 & 222MN101S2514 - 2022 Award Period: October 1, 2021 through Septe...

2022-004 SPECIAL PROVISIONS Federal Agency: U.S. Department of Agriculture Federal Program Name: Supplemental Nutrition Assistance Program Assistance Listing Number: 10.561 Federal Award Identification Number and Year: 222MN127Q7503 & 222MN101S2514 - 2022 Award Period: October 1, 2021 through September 30, 2022 Type of Finding: ? Significant Deficiency in Internal Control over Compliance ? Other Matters Recommendation: We recommend that the County ensure for casefile review that the cases are reviewed by a separate person that the determining worker. In cases of heightened sensitivity when the lead makes the determination, the case should be reviewed by their supervisor. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement the recommendation immediately. Name of the contact person responsible for corrective action plan: Diane Arnold, Sherburne County Auditor-Treasurer Planned completion date for corrective action plan: Already corrected

View Audit 29346

Finding 32800 (2022-001)

Significant Deficiency 2022

Housing Authority of Lincoln County

OR

Allowable Costs / Cost Principles Eligibility HUD Housing Programs

Finding 2022-001 - Ineffective Internal Controls (Significant Deficiency) Recommendation: We recommend the Authority retain copies of properly approved invoices and journal vouchers to support allowable costs related to the Housing Voucher Program expenditures. We recommend the Housing Manager retai...

Finding 2022-001 - Ineffective Internal Controls (Significant Deficiency) Recommendation: We recommend the Authority retain copies of properly approved invoices and journal vouchers to support allowable costs related to the Housing Voucher Program expenditures. We recommend the Housing Manager retain each internal review file conducted during the year as support the Authority completed the programs required self-audit related to recertifications of participants. We further recommend the Authority document and retain managements review of the waiting list following the pull for top of the list letters. Action Taken: The agency has implemented stronger internal controls regarding oversight and approval of invoices and journal vouchers. Effective October 1, 2023, Managers will be initialing all invoices prior to entering in the system. The Finance Manager will approve the bills to pay from a list of approved invoices generated from the accounting system, and the Account Coordinator will generate the payments/collate with invoices and forward them to the ED for final review against the approved invoices and signature. The Housing Programs Manager has implemented a quarterly random sampling of files to ensure oversight of the requirements of documentation and certifications. These quarterly reviews are saved on our server for future reference and utilize spreadsheets for HALC for tracking and compliance purposes and using a random sampling app online. In regard to documenting the oversight of the waiting list, effective September 1, 2023, the Housing Programs Manager is now coordinating this process. The Administrative Assistant pulls the waiting list, signs it and then turns it in to the Housing Programs Manager for review for accuracy and to verify that applicants are being pulled in the correct order according to HALC policy. The Housing Programs Manager then signs the list and uploads it into a file on the HALC server. The Housing Manager will then quarterly process a random sampling and pull the applicant file to review on a quarterly basis. This will be documented for future review.

View Audit 29345

Finding 32772 (2022-003)

None 2022

Oklahoma Wesleyan University

OK

Student Financial Aid Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles

FINDING 2022-003 ? Subsidized Loan Allocation Condition Found: The amount of Subsidized and Unsubsidized Federal Direct Loans awarded was incorrect for one of the fifty-four students in our sample that received Federal Direct Loans. Corrective Action Plan: The Financial Aid Director updated r...

FINDING 2022-003 ? Subsidized Loan Allocation Condition Found: The amount of Subsidized and Unsubsidized Federal Direct Loans awarded was incorrect for one of the fifty-four students in our sample that received Federal Direct Loans. Corrective Action Plan: The Financial Aid Director updated reallocated $1,407 of unsubsidized loan funds as subsidized loan funds on August 3, 2022. Procedures will be improved to ensure that subsidized loan eligibility is reviewed before awarding unsubsidized loans. Anticipated Completion Date: The corrective action was completed on August 3, 2022. Contact Person Tirzah Knight, Director of Financial Aid 918-335-6252

View Audit 32138

Finding 32723 (2022-002)

None 2022

Beulah Heights University

GA

Questioned Costs Student Financial Aid Subrecipient Monitoring

Finding 2022-002 - U.S. Department of Education (USDEJ. Title IV Student Financial Aid Programs (deficiency}: We observed the following conditions in connection with our testing of the various U.S. Department of Education, Title IV, Student Financial Assistance Programs: 1. One (1) out of 10 student...

Finding 2022-002 - U.S. Department of Education (USDEJ. Title IV Student Financial Aid Programs (deficiency}: We observed the following conditions in connection with our testing of the various U.S. Department of Education, Title IV, Student Financial Assistance Programs: 1. One (1) out of 10 students tested did not have timely or accurate enrollment reporting to the National Student Loan Data System (NSLDS). 2. One (1) out of 60 students tested was overpaid Pell funds. The over awarded funds were subsequently returned. 3. One (1) out of 60 students tested was not eligible for but was awarded Federal Supplemental Educational Opportunity Grant (FSEOG). The University subsequently returned the ineligible grant amount. 4. One (1) out of 60 students tested showed a discrepancy during verification testing where we observed tax documents submitted with an incorrect social security number. The questioned cost is $5,195. 5. Two (2) out of Five (S) students tested did not show the returned amount on the student's statement of account during R2T4 testing. Both statements of account were subsequently updated with the returned amounts. Corrective Actions - 1. NSLDS reporting is actively reconciled monthly with our financial aid servicer and, as of August 18, 2022, the University confirmed 97.18% reported. The University will continue to actively monitor this reporting to ensure accuracy and timeliness. 2. The University will monitor and review the process of enrollment more thoroughly with the third-party financial aid processor to ensure all non-enrolled students are not included in payment batches. The University has moved to a new third-party financial aid processor in a further effort to ensure compliance with Title IV regulations. 3. The University will monitor and review the process of enrollment more thoroughly with the third-party financial aid processor to ensure all non-enrolled students are not included in payment batches. The University has moved to a new third-party financial aid processor in a further effort to ensure compliance with Title IV regulations. 4. The University will monitor and review the process of verification more thoroughly with the third-party financial aid processor to ensure all applicable steps are taken and that all information is accurate. The University has moved to a new third-party financial aid processor in a further effort to ensure compliance with Title IV regulations. 5. The University has implemented a new student information system, as well as processes to ensure that Title IV transactions are applied timely to student ledgers. The University also notes that, in the case of this finding, the Title IV funds were returned timely and accurately.

View Audit 29382 Questioned Costs: $1

Finding 32713 (2022-001)

None 2022

Webber International University, Inc.

FL

Questioned Costs Student Financial Aid Eligibility

A. Comments on Findings and Recommendations: We agree with the finding and recommendation. B. Actions Taken or Planned: By November, the Vice President of Financial Aid will update the Withdrawal Checklist to include a final enrollment field to notate the number of hours enrolled. The Withdrawal Ch...

A. Comments on Findings and Recommendations: We agree with the finding and recommendation. B. Actions Taken or Planned: By November, the Vice President of Financial Aid will update the Withdrawal Checklist to include a final enrollment field to notate the number of hours enrolled. The Withdrawal Checklist will also include a checkbox to notate that all financial aid has been updated to the proper enrollment status prior to completing the R2T4 calculation.

View Audit 27736 Questioned Costs: $1

Finding 32707 (2022-001)

None 2022

Stevenson University, Inc.

MD

Student Financial Aid Matching / Level of Effort / Earmarking Eligibility

Name of Responsible Individual: Melanie Mason, Director of Student Financial Aid Corrective Action: The University will transition from a manual review process to an automated electronic process utilizing a combination of both Informer and Colleague reports. The process will compare components of t...

Name of Responsible Individual: Melanie Mason, Director of Student Financial Aid Corrective Action: The University will transition from a manual review process to an automated electronic process utilizing a combination of both Informer and Colleague reports. The process will compare components of the Cost of Attendance to the student?s current billing as of the census date. Each Financial Aid counselor will run the automated report for their students and freeze each student?s award budget. This freeze process will prevent any further changes to the award budget for the student. Confirmation of this review will be provided to the Director of Financial Aid by each counselor. The Director will verify the process has been completed. Anticipated Completion Date: March 31, 2023

View Audit 36678

Finding 32512 (2022-001)

Material Weakness 2022

Uc Healthcare System

OH

Allowable Costs / Cost Principles Eligibility Special Tests & Provisions

Corrective Action Plan Federal Award Findings and Questioned Costs For the Fiscal Year Ended June 30, 2022 Finding 2022-001 ? A. Activities Allowed or Unallowed; B. Allowable Costs/Cost Principles; E. Eligibility; N. Special Tests and Provisions Federal program information: Federal Program: ...

Corrective Action Plan Federal Award Findings and Questioned Costs For the Fiscal Year Ended June 30, 2022 Finding 2022-001 ? A. Activities Allowed or Unallowed; B. Allowable Costs/Cost Principles; E. Eligibility; N. Special Tests and Provisions Federal program information: Federal Program: 93.461, HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund (COVID-19 Uninsured Program) Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Locations: Various Award Numbers: Various Award Period: July 1, 2021 through June 30, 2022 Summary of finding: UC Health did not design or appropriately document internal controls to monitor the terms and conditions and underlying HRSA COVID-19 Uninsured Program regulations during the COVID-19 pandemic. Additionally, UC Health did not have internal controls in place to formally document its compliance with the HRSA COVID-19 Uninsured Program?s allowability and eligibility requirements. While management has processes in place to review claims for potential insurance coverage before initial billing, evidence of insurance reviews and subsequent verification of lack of coverage was not retained. Refunds required to be made to the HRSA COVID-19 Uninsured Program were not identified timely. Planned corrective action: Management has reviewed claims submitted to the HRSA COVID-19 Testing for the Uninsured Program for potential payments for ineligible services and timely processed refunds as appropriate. In March 2022, HRSA announced the discontinuance of the HRSA COVID-19 Testing for the Uninsured program and, therefore, remediation of internal controls in no longer applicable. Completion date: December 31, 2022 Responsible contact person: Crag Cain, Vice President of Revenue Cycle Management

View Audit 29116

Finding 32455 (2022-007)

Significant Deficiency 2022

Commonwealth of Pennsylvania

PA

Questioned Costs Subrecipient Monitoring Reporting § 200.303

Similar to other DHS programs, DHS has implemented an after-action review of information submitted, using a contracted vendor. DHS faced challenges implementing a program with 67 counties and no central eligibility determination system. DHS has learned that implementing the supportive services and m...

Similar to other DHS programs, DHS has implemented an after-action review of information submitted, using a contracted vendor. DHS faced challenges implementing a program with 67 counties and no central eligibility determination system. DHS has learned that implementing the supportive services and multi-sector partnerships was challenging in the context of the global pandemic and workforce shortages. This made DHS dependent on local county reports to maintain program oversight and compile statewide data for submission to US Treasury. DHS plans to strengthen this control as we plan for future emergency or pandemic programs related to rental assistance. Anticipated Completion Date: 06/30/2023 Contact Person and Title: Joel O?Donnell, Director, Bureau of Program Support, OIM

View Audit 27724 Questioned Costs: $1

Finding 32382 (2022-003)

Material Weakness 2022

Intercare Community Health Network

MI

Eligibility

In Response to Federal Award Finding, Finding 2022-003 ? Material Weakness and Material Noncompliance ? Special Tests ? Sliding Fee. Health centers must obtain sliding fee applications so that amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient...

In Response to Federal Award Finding, Finding 2022-003 ? Material Weakness and Material Noncompliance ? Special Tests ? Sliding Fee. Health centers must obtain sliding fee applications so that amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient?s ability to pay. We tested 60 sliding fee encounters and noted that 1 of 60 sliding fee encounters tested received the wrong slide. We noted 6 of 60 sliding fee applications were missing an approving sign off. We noted 2 of 60 sliding fee applications were missing and not on file. We noted 1 out of 60 sliding fee applications did not properly document an extension in the slide eligibility period. We noted 1 out of 60 sliding fee encounters was not properly charged a lab visit fee in accordance with the policy. Lastly, we noted 1 out of 60 sliding fee encounters had a wrong correcting adjustment applied to the patient account. Responsible Person: Stephanie Smith, CPA, Chief Financial Officer Corrective Action Planned: Management will ensure sliding fee applications are completed and properly approved and that discounts for eligible patients are properly calculated, documented in files, processed and extended correctly when applicable, for each sliding fee patient. Management has carefully revised training materials for staff as well as new staff, and will work to ensure controls are followed to verify sliding fee discounts applied are correct based on the patient application. To help ensure compliance, the organization has already begun conducing sampling throughout the year to verify sliding fee applications are obtained, completed correctly, and applied accurately to accounts. Anticipated Completion Timeframe: To be completed by 3/31/23.

View Audit 27204

Finding 32366 (2022-004)

Significant Deficiency 2022

Beaufort County

NC

Eligibility

Finding 2022-004 Name of contact person: Amy Alligood, Income Maintenance Administrator Corrective Action: Supervisors will be second partying records internally to ensure accuracy of cases. Applications will be reviewed and recertifications will be monitored o...

Finding 2022-004 Name of contact person: Amy Alligood, Income Maintenance Administrator Corrective Action: Supervisors will be second partying records internally to ensure accuracy of cases. Applications will be reviewed and recertifications will be monitored on a rotation basis. Findings from second party reviews will be reviewed with the worker to monitor a pattern for errors and will review policy guidelines to ensure worker is knowledgeable of policy requirements. Training will also be provided to ensure all files include online verifications, work number searches, register of deeds search, documented resources of income, and ensure those amounts agree to information entered in NCF AST. Supervisors will provide training to ensure workers are aware of proper documentation required to support eligibility decisions. Proposed completion date: Training will be provided the week of November 7, 2022, to review findings and corrective action items. Trainings will continue every week to review policy changes, NCF AST updates as well as common errors that may be found during second party reviews. There were four (4) technical errors cited with a review date from a prior fiscal year.

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Finding 32365 (2022-003)

Significant Deficiency 2022

Beaufort County

NC

Eligibility Reporting

Finding 2022-003 Name of contact person: Amy Alligood, Income Maintenance Administrator Corrective Action: "Staff will be trained on state communications as it relates to applicants' benefits and the importance of sharing information with all areas which the pa...

Finding 2022-003 Name of contact person: Amy Alligood, Income Maintenance Administrator Corrective Action: "Staff will be trained on state communications as it relates to applicants' benefits and the importance of sharing information with all areas which the participant receives benefits. Currently the lead worker manages the notifications received to ensure timely processing of SSI terminations. Agency processes have been reviewed to monitor SSI terminations to prevent recertifications from becoming overdue. " Proposed completion date: "Training will be provided the week of November 7, 2022, to review findings and corrective action items. State communications will continue to be monitored. One (1) technical error cited for an untimely SSI Exparte Review was for a prior fiscal year. "

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Finding 32364 (2022-002)

Significant Deficiency 2022

Beaufort County

NC

Eligibility

Finding 2022-002 Name of contact person: Amy Alligood, Income Maintenance Administrator Corrective Action: Supervisors will be second partying records internally to ensure accuracy of cases. Applications will be reviewed and recertifications will be monitored o...

Finding 2022-002 Name of contact person: Amy Alligood, Income Maintenance Administrator Corrective Action: Supervisors will be second partying records internally to ensure accuracy of cases. Applications will be reviewed and recertifications will be monitored on a rotation basis. Findings from second party reviews will be reviewed with the worker to monitor a pattern for errors and will review policy guidelines to ensure worker is knowledgeable of policy requirements. Training will also be provided to ensure all files include online verifications, documentation of resources of income, and ensuring those amounts match information entered into NCF AST. Supervisors will provide training to ensure workers are aware of proper documentation required to support eligibility decisions. Checklists have been established to include errors cited during audit. Checklists are to be completed at applications and recertifications. Proposed completion date: Training will be provided the week of November 7, 2022, to review findings and corrective action items. Trainings will continue every week to review policy changes, NCF AST updates as well as common errors that may be found during second party reviews. There were four (4) technical errors cited with a review date from a prior fiscal year.

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Finding 32363 (2022-001)

Significant Deficiency 2022

Beaufort County

NC

Eligibility Internal Control / Segregation of Duties

Finding 2022-001 Name of contact person: Amy Alligood, Income Maintenance Administrator Corrective Action: "Supervisors will be second partying records internally to ensure accuracy of cases. Applications will be reviewed and recertifications will be monitored ...

Finding 2022-001 Name of contact person: Amy Alligood, Income Maintenance Administrator Corrective Action: "Supervisors will be second partying records internally to ensure accuracy of cases. Applications will be reviewed and recertifications will be monitored on a rotation basis. Findings from second party reviews will be reviewed with the worker to monitor a pattern for errors and will review policy guidelines to ensure the worker is knowledgeable of policy requirements. Training will be provided to ensure all files have accurate information entry to include correct household composition and correct income calculations. Supervisors will provide training to ensure workers are aware of proper documentation required to support eligibility decisions. Checklists have been established to include errors cited during audit. Checklists are to be completed at applications and recertifications. " Proposed completion date: Training will be provided the week of November 7, 2022, to review findings and corrective action items. Trainings will continue every week to review policy changes, NCF AST updates as well as common errors that may be found during second party reviews. There were six ( 6) technical errors cited with a review date from a prior fiscal year.

View Audit 27610

Finding 32267 (2022-011)

Significant Deficiency 2022

State of North Dakota

ND

Eligibility Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Finding: 2022-011 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. The department will work with NDIT to ensure they restart and maintain the access and security reviews. Contact Person: Tory Brabandt, Medicaid Enterprise Directo...

Finding: 2022-011 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. The department will work with NDIT to ensure they restart and maintain the access and security reviews. Contact Person: Tory Brabandt, Medicaid Enterprise Director Anticipated Completion Date: June 30, 2023

View Audit 36677

Finding 32265 (2022-009)

Significant Deficiency 2022

State of North Dakota

ND

Eligibility Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Finding: 2022-009 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. The department will work with NDIT to ensure they restart and maintain the risk analysis and security review for MMIS. Contact Person: Tory Brabandt, Medicaid Enterpr...

Finding: 2022-009 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. The department will work with NDIT to ensure they restart and maintain the risk analysis and security review for MMIS. Contact Person: Tory Brabandt, Medicaid Enterprise Director Anticipated Completion Date: December 31, 2023

View Audit 36677

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