Corrective Action Plans

Finding 277 (2022-001)

Material Weakness 2022

MI

Eligibility

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.

View Audit 512

Finding 164 (2022-102)

Material Weakness 2022

Santa Cruz County

AZ

Questioned Costs Cash Management Eligibility § 200.303

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

Finding 18 (2022-003)

Material Weakness 2022

Region III Workforce Investment Board of Kanawha County, Inc.

WV

Eligibility

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.

View Audit 56

Finding 1217594 (2021-001)

Material Weakness 2021

The Arizona Partnership for Immunization

AZ

Cash Management Eligibility Matching / Level of Effort / Earmarking § 200.303

Recommendation: The Arizona Partnership for Immunization should formally document its eligibility determination and insurance verification processes to ensure consistent application and compliance with award requirements. In addition, the organization should implement documentation standards to evid...

Recommendation: The Arizona Partnership for Immunization should formally document its eligibility determination and insurance verification processes to ensure consistent application and compliance with award requirements. In addition, the organization should implement documentation standards to evidence eligibility determinations, particularly during periods of increased service volume, to support accurate and allowable program charges. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Corrective Action taken in response to finding: Effective 4/2022, management has taken deliberate steps to strengthen documentation and standardize eligibility determination and insurance verification processes. These efforts include the development and formalization of written policies and procedures to ensure consistent application, improved documentation standards, and sustained compliance with HRSA award requirements. Name(s) of the contact person(s) responsible for corrective action: James Washington, Executive Director and Bernie Soderberg, Program Manager. Planned completion date for corrective action plan: December 2023

View Audit 403738

Finding 1217410 (2021-002)

Material Weakness 2021

Crater Regional Workforce Investment Board

VA

Eligibility

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.

View Audit 403603

Finding 1217409 (2021-001)

Material Weakness 2021

Crater Regional Workforce Investment Board

VA

Eligibility Allowable Costs / Cost Principles

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.

View Audit 403603

Finding 1214952 (2021-004)

Material Weakness 2021

HOUSING AUTHORITY OF THE CITY OF LITTLE ROCK, ARKANSAS

CA

Allowable Costs / Cost Principles Special Tests & Provisions Eligibility

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.

View Audit 401726

Finding 1205884 (2021-004)

Material Weakness 2021

City of Newark

NJ

Eligibility

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.

View Audit 397668

Finding 1181989 (2021-007)

Material Weakness 2021

Open Door Ministries of High Point, Inc.

NC

Eligibility Material Weakness Matching / Level of Effort / Earmarking § 200.334 § 200.337

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

View Audit 393351

Finding 1177791 (2021-007)

Material Weakness 2021

St. Croix Chippewa Housing Authority

CA

Eligibility HUD Housing Programs Material Weakness

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

View Audit 391158

Finding 1176174 (2021-003)

Material Weakness 2021

City of Chester

PA

Eligibility Material Weakness Reporting

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.

View Audit 389991

Finding 1172424 (2021-004)

Material Weakness 2021

Housing Authority of the City of Tulsa

OK

HUD Housing Programs Eligibility Significant Deficiency

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

View Audit 385538

Finding 1169706 (2021-003)

Material Weakness 2021

Pittsburg County

OK

Allowable Costs / Cost Principles Subrecipient Monitoring Eligibility § 200.303

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.

View Audit 382719

Finding 1167846 (2021-002)

Material Weakness 2021

Northern Marianas Housing Corporation

FM

Subrecipient Monitoring Eligibility HUD Housing Programs

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).

View Audit 379196

Finding 1164239 (2021-003)

Material Weakness 2021

Portsmouth Redevelopment and Housing Authority

VA

HUD Housing Programs Eligibility Significant Deficiency

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

View Audit 373527

Finding 1162227 (2021-004)

Material Weakness 2021

Stonewall County Hospital District

TX

Questioned Costs Allowable Costs / Cost Principles Eligibility

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

Finding 1161493 (2021-002)

Material Weakness 2021

Bristow Housing Authority

OK

Eligibility HUD Housing Programs

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

View Audit 371390

Finding 571922 (2021-006)

None 2021

Choctaw County

OK

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

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

NC

Eligibility Significant Deficiency

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

View Audit 355385

Finding 559156 (2021-011)

Significant Deficiency 2021

Caswell County

NC

Eligibility Significant Deficiency

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

View Audit 355385

Finding 559155 (2021-010)

Significant Deficiency 2021

Caswell County

NC

Eligibility Significant Deficiency Internal Control / Segregation of Duties

CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694‐4193 Corrective Action Plan For the Year Ended June 30, 2021 Proposed Completion Date: Finding: 2021-010 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed Completion Date: 2/28/2022 ...

CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694‐4193 Corrective Action Plan For the Year Ended June 30, 2021 Proposed Completion Date: Finding: 2021-010 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed Completion Date: 2/28/2022 All workers have knowledge that Templates put in place are Mandatory. IV-D Referrals are addressed on template. All cases will be reviewed for IV-D Referrals or open/active I-VD cases. All children must have a referral if the parent is receiving Medical Benefits. 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) Heather Starr Thomas, Medicaid Supervisor A refresher training will be held to review errors. 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 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. The template that has been put in place for applications and recertification address all computer checks and documentation that is needed to accurately approve/deny/continue or terminate benefits. All other cases in NCFAST are to be reviewed to ensure we have the correct information. Weekly Communications and Changes are reviewed weekly at Unit Meeting to address any changes and NCFAST issues that may require a Help Desk Ticket or an 8020 to remove benefits client may not have been eligible for. OST has provided guidance on Changes in policy to remove a client that may continue during Covid that is not eligible for NC Medicaid. 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. 2/28/2022 127

View Audit 355385

Finding 559154 (2021-009)

Significant Deficiency 2021

Caswell County

NC

Eligibility Significant Deficiency

Finding: 2021-009 IV-D Non-Cooperation Name of contact person: Corrective Action: Section III - Federal Award Findings and Question Costs Referrals are being keyed to Child Support Enforcement Agency (IV-D) each case with dependent children must cooperate with IV-D unless there is good cause. County...

Finding: 2021-009 IV-D Non-Cooperation Name of contact person: Corrective Action: Section III - Federal Award Findings and Question Costs Referrals are being keyed to Child Support Enforcement Agency (IV-D) each case with dependent children must cooperate with IV-D unless there is good cause. County will review cases for a referral keyed or to ensure a new child support referral is keyed. On 11/15/2021 eligibility workers refreshed on IV-D policy and reviewed the job aid in NCFAST help for IVD referrals. Second Party reviews are reviewed internally to ensure proper information is in place and necessary procedures are followed after eligibility is determined and documented in case notes. Documentation will clearly state what actions were performed and the outcome of those actions. The County has developed a mandatory verification check list enforced 11/15/2021 to ensure all criteria has been meet according to policy of the state. Since template has been in place we have noticed a significant drop in IV-D referral issues in Second Party Reviews.CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694‐4193 Corrective Action Plan For the Year Ended June 30, 2021 Proposed Completion Date: Finding: 2021-010 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed Completion Date: 2/28/2022 All workers have knowledge that Templates put in place are Mandatory. IV-D Referrals are addressed on template. All cases will be reviewed for IV-D Referrals or open/active I-VD cases. All children must have a referral if the parent is receiving Medical Benefits. 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) Heather Starr Thomas, Medicaid Supervisor A refresher training will be held to review errors. 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 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. The template that has been put in place for applications and recertification address all computer checks and documentation that is needed to accurately approve/deny/continue or terminate benefits. All other cases in NCFAST are to be reviewed to ensure we have the correct information. Weekly Communications and Changes are reviewed weekly at Unit Meeting to address any changes and NCFAST issues that may require a Help Desk Ticket or an 8020 to remove benefits client may not have been eligible for. OST has provided guidance on Changes in policy to remove a client that may continue during Covid that is not eligible for NC Medicaid. 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. 2/28/2022 127

View Audit 355385

Finding 558149 (2021-003)

Significant Deficiency 2021

Hill Country Community Clinic, Inc.

CA

Special Tests & Provisions Eligibility

Management acknowledges the finding. We will conduct mandatory training sessions for all relevant personnel to ensure a clear understanding of the Sliding Fee Discount Program requirements and policy. Training will include proper documentation practices, eligibility verification, and procedures for ...

Management acknowledges the finding. We will conduct mandatory training sessions for all relevant personnel to ensure a clear understanding of the Sliding Fee Discount Program requirements and policy. Training will include proper documentation practices, eligibility verification, and procedures for applying discounts consistently. We will review and update our sliding fee discount policy to ensure clarity, consistency, and compliance with regulatory requirements. We will provide an annual review and obtain board approval of the Sliding Fee Discounting Program scheduled on an annual basis. Regular internal audits will be conducted to review the application of sliding fee discounts and identify any discrepancies before external audits. Results of internal audits will be shared with management, and corrective actions will be taken as necessary. We will assess the feasibility of implementing system controls or automated alerts within our electronic health record (EHR) and billing systems to reduce errors in discount applications. Additional oversight measures may be introduced to ensure all eligible patients receive the correct discount in accordance with policy guidelines. The above corrective actions are currently being implemented.

View Audit 355035

Finding 554366 (2021-003)

Material Weakness 2021

Kanawha Valley Collective Inc.

WV

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management

Audit Finding Reference: Federal Award Findings and Questioned Costs: 2021-03 (Single audit submission) Planned Corrective Action: The Kanawha Valley Collective, Inc. will develop internal policies and procedures designed to ensure a timely annual financial statement closing which will allow the req...

Audit Finding Reference: Federal Award Findings and Questioned Costs: 2021-03 (Single audit submission) Planned Corrective Action: The Kanawha Valley Collective, Inc. will develop internal policies and procedures designed to ensure a timely annual financial statement closing which will allow the required single audit to be completed in a timelier manner. Name of Contact Person: Traci Strickland Anticipated completion date: June 30, 2025

View Audit 352974

Finding 554365 (2021-002)

Material Weakness 2021

Kanawha Valley Collective Inc.

WV

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management

Audit Finding Reference: Federal Award Findings and Questioned Costs: 2021-02 (Reporting) Planned Corrective Action: The Kanawha Valley Collective, Inc. will implement enhanced reconciliation and documentation procedures that timely identify and allow for the correction of differences between the ac...

Audit Finding Reference: Federal Award Findings and Questioned Costs: 2021-02 (Reporting) Planned Corrective Action: The Kanawha Valley Collective, Inc. will implement enhanced reconciliation and documentation procedures that timely identify and allow for the correction of differences between the accounting recordkeeping and the grant reporting documentation. Name of Contact Person: Traci Strickland

View Audit 352974

Corrective Action Plans

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