Corrective Action Plans

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Since taking over the financial management of ELFHCC in December 2022, sliding fee schedule policy has been updated and training has been implemented and ongoing to assure accurate sliding fee discounts are appropriately distributed onto a patients account. Check lists of what is required from each ...
Since taking over the financial management of ELFHCC in December 2022, sliding fee schedule policy has been updated and training has been implemented and ongoing to assure accurate sliding fee discounts are appropriately distributed onto a patients account. Check lists of what is required from each patient applying for a sliding fee discount have been prepared and staff trained on how to enter the proof requirement into ELFHCC’s patient record.
Finding 310 (2022-012)
Significant Deficiency 2022
Finding: 2022-012: Inadequate Request for information Name of Contact Person: Laurie Potter, DSS Director Corrective Action: (Adult Medicaid) All cases are now being reviewed to make sure all the correct information is being requested from the client. Information that was unknown to the agency prev...
Finding: 2022-012: Inadequate Request for information Name of Contact Person: Laurie Potter, DSS Director Corrective Action: (Adult Medicaid) All cases are now being reviewed to make sure all the correct information is being requested from the client. Information that was unknown to the agency previously has been addressed by OST thru multiple training sessions. (MAGI) New supervisor will be hired & trained on what is needed to be entered into the system. New supervisor will complete 2nd party reviews & training as needed. Standard Operating Procedure put in place for both units. Proposed Completion Date: 10/31/23.
Finding 309 (2022-011)
Significant Deficiency 2022
Finding: 2022-011: IV-D Child Support Non-Cooperation Name of Contact Person: Laurie Potter, DSS Director Corrective Action: Temporary Supervisor has been providing one-on-one support to the MAGI workers & completing 2nd party reviews on cases. A new supervisor is going to be hired who will be provi...
Finding: 2022-011: IV-D Child Support Non-Cooperation Name of Contact Person: Laurie Potter, DSS Director Corrective Action: Temporary Supervisor has been providing one-on-one support to the MAGI workers & completing 2nd party reviews on cases. A new supervisor is going to be hired who will be provided with training for themselves, will complete 2nd party reviews & training with the staff. Standard Operating Procedure put in place. Proposed Completion Date: 10/31/23.
Finding 308 (2022-010)
Significant Deficiency 2022
Finding: 2022-010: Inaccurate Resource Calculation Name of Contact Person: Laurie Potter, DSS Director Corrective Action: (Adult Medicaid) New caseworker brought into county from another county on 11/1/2022 who had more training provided from previous county of employment. She immediately begain rev...
Finding: 2022-010: Inaccurate Resource Calculation Name of Contact Person: Laurie Potter, DSS Director Corrective Action: (Adult Medicaid) New caseworker brought into county from another county on 11/1/2022 who had more training provided from previous county of employment. She immediately begain reviewing cases & correcting as needed. In addition, all cases are now being 2nd partied to ensure nothing is being missed. Tool now used to make sure resources are not being missed during interview is the 5202D. Worker uses resources such as policy, online data to ask the proper questions to the client. (MAGI) New supervisor will be hired & trained on what is needed to be entered into the system. New supervisor will complete 2nd party reviews & training as needed. Standard Operating Procedure put in place for both units. Proposed Completion Date: 10/31/23.
Finding 307 (2022-009)
Significant Deficiency 2022
Finding: 2022-009: Inaccurate Information Entry Name of Contact Person: Laurie Potter, DSS Director Corrective Action: (Adult Medicaid) New caseworker brought into county from another county on 11/1/2022 who had more training provided from previous county of employment. She immediately begain review...
Finding: 2022-009: Inaccurate Information Entry Name of Contact Person: Laurie Potter, DSS Director Corrective Action: (Adult Medicaid) New caseworker brought into county from another county on 11/1/2022 who had more training provided from previous county of employment. She immediately begain reviewing cases & correcting as needed. In addition, all cases are now being 2nd partied to ensure nothing is being missed. New caseworker scans in documents immediately & uploads to case once completed to avoid hardcopies being lost. (MAGI) New supervisor will be hired & trained on what is needed to be entered into the system. New supervisor will complete 2nd party reviews & training as needed. Standard Operating Procedure put in place for both units. Proposed Completion Date: 10/31/23.
Finding 306 (2022-008)
Significant Deficiency 2022
Finding: 2022-008: SSI Terminations Name of Contact Person: Laurie Potter, DSS Director Corrective Action: Adult Medicaid IMC's now have access to the queue. In the past workers didn't have access to these queues which left them unable to react timely. In addition employees have been training on Med...
Finding: 2022-008: SSI Terminations Name of Contact Person: Laurie Potter, DSS Director Corrective Action: Adult Medicaid IMC's now have access to the queue. In the past workers didn't have access to these queues which left them unable to react timely. In addition employees have been training on Medicaid Verification Reports, explained the importance of working these reports timely, if case has a shared Income Support, the importance of sharing information across the agency & a new form put into place for reporting changes. Proposed Completion Date: Training on reports was 3/8/23 & workers are still cleaning up old reports. Expected completion date is 6/30/23.
Finding 2022-00 I - COCC deficit and the use of LIPH funds in violation of HUD Rule Auditee's Response and Planned Corrective Action The Authority is working to gather the information necessary to complete an analysis of the benefits charged to each AMP and COCC for the above referenced finding. T...
Finding 2022-00 I - COCC deficit and the use of LIPH funds in violation of HUD Rule Auditee's Response and Planned Corrective Action The Authority is working to gather the information necessary to complete an analysis of the benefits charged to each AMP and COCC for the above referenced finding. There is a meeting scheduled for October 16, 2023. HUD has been informed regarding the status of the finding. Planned Implementation Date of Corrective Action: December 2023 Person Responsible for Corrective Action: Ed Cumming, Executive Director
Staff meetings held in 2022 with the Permanent Supportive Housing Team, identified challenges reinstituting consistent home visits and therefore updating documents. The telephone check-in and visits instituted early in the pandemic had become a preference for some clients and readjusting to former p...
Staff meetings held in 2022 with the Permanent Supportive Housing Team, identified challenges reinstituting consistent home visits and therefore updating documents. The telephone check-in and visits instituted early in the pandemic had become a preference for some clients and readjusting to former participation requirements was met with resistance. Internal audits of the records conducted by Shelter of Flint indetified deficiencies and other mechanisms such as written requests, unannounced visits, etc, were conducted to attempt contact and completion of required documents. These attempts were documented in client files. Over the course of 2023, reconnecting clients with staff members in consistent face-to-face meetings had improved. We have also restructured the procedure of reconfirming eligibility, and annual review of other documents, which has had a positive impact on obtaining required documentation. Recent reviews of client files show siginificant improvement. These procedures will be maintained with continuation of improvement being expected into the future.
The County is in the final stages of implementing grant policies, which will cover reimbursement procedures for all departmental grants. The County will work with the pass-through grantor to repay the amounts the County received in excess. The County will work with the Health Department director a...
The County is in the final stages of implementing grant policies, which will cover reimbursement procedures for all departmental grants. The County will work with the pass-through grantor to repay the amounts the County received in excess. The County will work with the Health Department director and staff to review grant policies and procedures.
View Audit 240 Questioned Costs: $1
Participant files will be monitored and reviewed monthly by the Program Manager or others in the organization with the requisite experience and stature to guarantee consistency and content. Regular technical assistance and staff training will be conducted on both the standardized filing process and ...
Participant files will be monitored and reviewed monthly by the Program Manager or others in the organization with the requisite experience and stature to guarantee consistency and content. Regular technical assistance and staff training will be conducted on both the standardized filing process and compliance requirements. Going forward, electronic copies of all files will be digitized and stored on SharePoint and in the state database to improve efficiency and for better accessibility.
In response to Finding 2021-002, the following corrective action will be taken: 1. Streamlining of enrollment to a singular assigned staff who has been trained specifically around enrollment/eligibility criteria. 2. Review of every enrollment by CRWDB leadership staff directly after enrollment to id...
In response to Finding 2021-002, the following corrective action will be taken: 1. Streamlining of enrollment to a singular assigned staff who has been trained specifically around enrollment/eligibility criteria. 2. Review of every enrollment by CRWDB leadership staff directly after enrollment to identify and correct any missing information. 3. CRWDB leadership staff will add a casenote into electronic record confirming review and accuracy of enrollment or to note missing items and plan to correct.
The Crater Regional Workforce Development Board obtained a waiver beginning in PY24 to service the WIOA Title 1 Program (instead of using an outside service provider as was the case for PY21) which has led to additional internal controls including but not limited to: 1. Streamlining of enrollment to...
The Crater Regional Workforce Development Board obtained a waiver beginning in PY24 to service the WIOA Title 1 Program (instead of using an outside service provider as was the case for PY21) which has led to additional internal controls including but not limited to: 1. Streamlining of enrollment to a singular assigned staff who has been trained specifically around enrollment/eligibility criteria. 2. Review of every enrollment by CRWDB leadership staff directly after enrollment to identify and correct any missing information. 3. Audit of every file open during the course of a program year at least 2 times during that PY by staff other than the staff who completed the initial enrollment.
Finding 2021-004 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster and Public and Indian Housing Program Assistance Listing Numbers: 14.871, 14.879, and 14.850 Material Noncompliance Non Compliance Material to the Financial Statements: Y...
Finding 2021-004 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster and Public and Indian Housing Program Assistance Listing Numbers: 14.871, 14.879, and 14.850 Material Noncompliance Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance Criteria: The Authority must maintain complete and accurate accounts and other records for the program in accordance with HUD compliance requirements. Condition: The Authority did not maintain complete and accurate accounts and other records in accordance with HUD compliance requirements including Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Eligibility, Reporting, and Special Tests and Provisions. Context: The Authority was unable to provide requested documentation at the time of audit to properly test the HUD compliance requirements. Known Questioned Costs: Unknown Cause: There is a material weakness in internal controls over compliance related to the maintenance of tenant files, wait lists, inspection reports and other records. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that reasonably assures the program is in compliance. Effect: The Housing Voucher Cluster and Public and Indian Housing Program are in material non- compliance with the compliance requirements of the program. Recommendation: We recommend that the Authority implement a process whereby Authority documents are stored and safeguarded to ensure compliance with the Uniform Guidance and the compliance supplement. View of Responsible Officials and Corrective Actions: The Authority experienced significant turnover in employees during the year and as a result certain source documents were misplaced or destroyed. Management agrees with the Auditors' finding and has hired a new Executive Director who will implement the required safeguards and ensure that the Authority follows its internal control over compliance processes and procedures related to the Housing Voucher Cluster and Public and Indian Housing Programs to remedy the aforementioned deficiencies. Byran McClellan, CFO, will be responsible to implement this corrective action by December 31, 2022.
It is recommended that Management should verify that all participant files are maintained and contain all required documentation for eligibility. Corrective Action and Explanation - The City of Newark will comply with the Auditor's recommendation. Implementation - December 31, 2023.
It is recommended that Management should verify that all participant files are maintained and contain all required documentation for eligibility. Corrective Action and Explanation - The City of Newark will comply with the Auditor's recommendation. Implementation - December 31, 2023.
Department of Veterans Affairs Federal Program Name: VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 64.024 Recommendation: We recommend that management retain all documents including evidence of participant eligibility under the program until the latter of the legally re...
Department of Veterans Affairs Federal Program Name: VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 64.024 Recommendation: We recommend that management retain all documents including evidence of participant eligibility under the program until the latter of the legally required retention period or completion of required audits and have the records available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented enhanced record retention and documentation controls to ensure that all participant eligibility documentation, supporting records, and program files are retained in accordance with federal retention requirements and made available upon request for audit or monitoring purposes. The Organization has created standardized eligibility documentation checklists and file review procedures to ensure completeness of required records. Additionally, records are now maintained in a centralized and secure format (physical and/or electronic), with clear retention timelines and assigned staff accountability for ongoing compliance and periodic file reviews. Name(s) of the contact person(s) responsible for corrective action: Ryan Ross, Executive Director Planned completion date for corrective action plan: March 31, 2026
2021-007 Tenant Eligibility Material Weakness Recommendation: In general, we continue to recommend a review of the re-certification process to determine areas of weakness. Specifically, we recommend the use of a standard checklist in the re-certification process. We further recommend that each re-ce...
2021-007 Tenant Eligibility Material Weakness Recommendation: In general, we continue to recommend a review of the re-certification process to determine areas of weakness. Specifically, we recommend the use of a standard checklist in the re-certification process. We further recommend that each re-certification clerk’s work be routinely audited. We also recommend more standardization in resident files organization of information, and procedures established to make sure all files are maintained adequately in order to be compliant. Action Taken: The Housing Authority agrees with this finding and will implement this recommendation within 120 days of this audit report
The City agrees with the finding. Starting in the summer of 2024, procedures were implemented to begin monthly financial statements leading to being prepared for more timely year-end closings. These procedures included expenditure and revenue reports being prepared and reviewed, as well as checklist...
The City agrees with the finding. Starting in the summer of 2024, procedures were implemented to begin monthly financial statements leading to being prepared for more timely year-end closings. These procedures included expenditure and revenue reports being prepared and reviewed, as well as checklists and reconciliations being prepared and reviewed. Retroactive review processes are underway regarding 2022 and 2023 years to be audited.
Section 8 Project Based Cluster – ALN #14.195 & 14.856 Recommendation: We recommend that management review their procedures for retrieving tenant information and establish a method that ensures compliance. We recommend that the Authority should review their examination policies to ensure that all ex...
Section 8 Project Based Cluster – ALN #14.195 & 14.856 Recommendation: We recommend that management review their procedures for retrieving tenant information and establish a method that ensures compliance. We recommend that the Authority should review their examination policies to ensure that all examinations are performed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A comprehensive audit of tenant files was completed to confirm accuracy of medical deductions, recertification timeliness, and documentation requirements. The Management Analyst now performs ongoing file audits and coordinates with property managers to correct discrepancies promptly. Recertification scheduling is now supported by workflow reminders and supervisory tracking to prevent future delays. Name(s) of the contact person(s) responsible for corrective action: Jason Epperson, Assistant Vice President Planned completion date for corrective action plan: December 31, 2025
The BOCC will be more diligent in their overview of grant applications to ensure that all federal grant application requests are not reimbursable through any other federal grant program. All transactions regarding federal grants will be required to be flagged with the grant information and will requ...
The BOCC will be more diligent in their overview of grant applications to ensure that all federal grant application requests are not reimbursable through any other federal grant program. All transactions regarding federal grants will be required to be flagged with the grant information and will require approval by the BOCC before any action can be taken. BOCC will determine the validity of each transaction to ensure compliance with grant requirements.
Corrective Action for Condition 1: The MCD has been sending notices to borrowers as a reminder to update or renew their homeowner insurance policy. We have created a monitoring spreadsheet to ensure that the insurance policies are being updated and that notices to homeowners are being sent to remind...
Corrective Action for Condition 1: The MCD has been sending notices to borrowers as a reminder to update or renew their homeowner insurance policy. We have created a monitoring spreadsheet to ensure that the insurance policies are being updated and that notices to homeowners are being sent to remind them of their insurance status. Moving forward, we will be sending out demand notices to those listed accounts that were affected. Corrective Action for Condition 2: This loan account is noted and being monitored to ensure that future policy coverage accurately reflects the loan amount as cited. Corrective Action for Condition 3: Property insurance coverage for HP-367, HNC-403 and HNC-534 were subsequently renewed on 4/28/2022, 8/30/2022 and 11/16/2021, respectively. MCD will ensure that these account policies are being monitored for subsequent updates and renewals. Corrective Action for Condition 4: MCD will ensure moving forward that these accounts are carefully monitored and in compliance with required annual recertifications. Corrective Action for Condition 5: The two loan accounts, HL-178 and HL-196 were underwritten twenty years ago; therefore, corrective action regarding these two accounts would not be applicable. MCD verified and confirmed that the required document was not in the respective files. It is also possible the document was received but might have been misplaced or got lost in the process. Corrective Action for Condition 6: MCD will be unable to perform any corrective action to obtain such document as account is nearly twenty years old. It should be noted that the account has been referred for collection. Corrective Action for Condition 7: MCD will be unable to perform any corrective action to obtain such document as nearly twenty years has lapsed (possible misfiling or misplaced).
Housing Choice Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority review its internal controls over the waiting list process to ensure all documentation is maintained at the time each applicant enters and is pulled from the waiting list. Explanation of disagre...
Housing Choice Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority review its internal controls over the waiting list process to ensure all documentation is maintained at the time each applicant enters and is pulled from the waiting list. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Files will not be placed in storage until after the agency audit is completed. Name(s) of the contact person(s) responsible for corrective action: Keva Newsome, Director of Housing Choice Voucher Program Planned completion date for corrective action plan: 12/1/2025
Corrective Action Plan for Finding 2021-004 We are in receipt of the finding required to be reported by Uniform Guidance, regarding other instance of noncompliance with respect to Reporting and Activities Allowed or Unallowed and Allowable Costs/Cost Principles Reporting. Management agrees with the ...
Corrective Action Plan for Finding 2021-004 We are in receipt of the finding required to be reported by Uniform Guidance, regarding other instance of noncompliance with respect to Reporting and Activities Allowed or Unallowed and Allowable Costs/Cost Principles Reporting. Management agrees with the finding. Policies and procedures over federal grant reporting will be modified to ensure reports are prepared using complete and accurate information. We will increase compensating controls for introducing additional oversight and review for future federal funding reporting. Lewis Robbins, CFO, will be responsible to ensure this is accomplished. The District had enough lost revenues related to Period 1, as reported in the Period 4 reporting submission, that the error determined in Finding 2021-003 will not result in a conflict with funding received. The Corrective Action Plan will be implemented by September 30, 2025.
View Audit 372037 Questioned Costs: $1
Corrective Action Plan Finding: Finding 2021-002-Low Rent Tenant File Deficiencies-Eligibility Condition: We reviewed 18 files, 4 of which were audit year move-ins, and 14 were annual re-examinations. We noted the following exceptions: (a)-We were unable to find any annual inspections for the 14 re-...
Corrective Action Plan Finding: Finding 2021-002-Low Rent Tenant File Deficiencies-Eligibility Condition: We reviewed 18 files, 4 of which were audit year move-ins, and 14 were annual re-examinations. We noted the following exceptions: (a)-We were unable to find any annual inspections for the 14 re-examinations. We did note them for the 4 move-ins. (b)-We were unable to find the required annual review of the utility allowances. The January 27, 2020 Minutes discuss utility allowances and approve new ones. However, the minutes do not reflect for which period the new allowances covered. In addition, there was no documented analysis of whether utility rates had increased beyond the level which required revision, and whether the allowances changed or instead were a holdover from the old rates. (c)-We were unable to view the waiting list, and thus could not review whether the 4 move-ins reached the top of the list. (d)-One required Enterprise Income Verification (EIV} was not present in the proper time frame for the 18 files reviewed. (e)-Of the 14 re-examinations we reviewed, one was past-due when done. (f)-We were unable to review documentation of the review of flat rents. Corrective Action Planned As noted previously, we were not the management during this audit period. Our initial Cooperative Agreement was executed November 14, 2023. We believe we have corrected the noted deficiencies. Person responsible for corrective action: Diane Adams, Executive Director Telephone: (918) 367-5558 Housing Authority of Bristow, Oklahoma Fax: (918) 367-2341 1110 S. Chestnut Bristow, OK 74010 Anticipated Completion Date- June 30, 2026
We will implement policies and procedures to ensure compliance with applicable grant requirements.
We will implement policies and procedures to ensure compliance with applicable grant requirements.
View Audit 362988 Questioned Costs: $1
Finding 559157 (2021-012)
Significant Deficiency 2021
CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694‐4193 Corrective Action Plan For the Year Ended June 30, 2021 Finding: 2021-011 Inaccurate Resource Calculation Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2021-012 Inadequate Requ...
CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694‐4193 Corrective Action Plan For the Year Ended June 30, 2021 Finding: 2021-011 Inaccurate Resource Calculation Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2021-012 Inadequate Request for Information Name of contact person: Corrective Action: Heather Starr Thomas, Medicaid Supervisor Files will be reviewed internally to ensure proper documentation is in place for eligibility. Workers will be retrained on what files should contain and the importance of complete and accurate record keeping. All files will include online verifications, documented resources and income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. Templates have been put in place to address request for information. All avenues available to caseworker must be exhausted before requesting information from client, unless information provided and information obtained is questionable. We will continue to train on this issue, and it will also be addressed in new worker Trainings. Training in the learning gateway is also available. Section III - Federal Award Findings and Question Costs (continued) 2/28/2022 Heather Starr Thomas, Medicaid Supervisor Files will be reviewed internally to ensure proper documentation is in place for eligibility. Workers should be retrained on what files should contain and the importance of complete and accurate record keeping. All files must include online verifications, documented resources of income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. Resources have been readdressed at Unit Meeting. Templates have been put in place to address programs in which resources are countable. We will continue to train on this issue, and it will also be addressed in new worker Trainings. Training in the learning gateway is also available. 128
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