Corrective Action Plans

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Finding 2024-005 By April 30, 2025, HCEB will engage ACE Housing Group to complete a file audit for the 10 units of supportive housing for persons with disabilities in Fremont in accordance with HUD Handbook 4350.3, Chapter 7, Section 1, 7-4A. All missing documents will be completed, reviewed, and s...
Finding 2024-005 By April 30, 2025, HCEB will engage ACE Housing Group to complete a file audit for the 10 units of supportive housing for persons with disabilities in Fremont in accordance with HUD Handbook 4350.3, Chapter 7, Section 1, 7-4A. All missing documents will be completed, reviewed, and signed by the households.
Finding # 2024-004 Type: Significant deficiency over eligibility A.L. 14.218 U.S. Department of Housing and Urban Development Significant Deficiency Case file intake forms reviewed did not have documentation of required eligibility requirements for 7 of 35 case files selected. Corrective Action...
Finding # 2024-004 Type: Significant deficiency over eligibility A.L. 14.218 U.S. Department of Housing and Urban Development Significant Deficiency Case file intake forms reviewed did not have documentation of required eligibility requirements for 7 of 35 case files selected. Corrective Action: We were able to substantiate the eligibility of all participants however we agree improvement is needed in providing additional training for onboarding staff on eligibility criteria as well as ensuring onboarding forms are complete and accurate. We will also implement a formal manager review and approval of intake forms which includes validating eligibility criteria have been met. Anticipated Completion Date May 30, 2025
Going forward, Edison Local Schools Eligibility process to determine Free/Reduced/Denied Status of applications submitted for the National School Lunch Program are: All applications collected at Edison Local School will be reviewed prior to the data entered into pay schools to ensure the application...
Going forward, Edison Local Schools Eligibility process to determine Free/Reduced/Denied Status of applications submitted for the National School Lunch Program are: All applications collected at Edison Local School will be reviewed prior to the data entered into pay schools to ensure the applications have all the information and data to make the correct determination. The income eligibility criteria is established by the Ohio Department of Education. The eligibility for paper applications will be made by the food service director and the superintendent is the determining official and each application is reviewed prior to entering this into the POS system, and a free/reduced and benefits issuance reports is compared to ensure all information is correct after it is entered to ensure the determination is correct, additionally annual verification is also done on free/reduced applications.
Views of Responsible Officials: CVT will add to a comprehensive sub-recipient checklist timely FFATA reporting and review training with Finance staff working with sub-recipient.
Views of Responsible Officials: CVT will add to a comprehensive sub-recipient checklist timely FFATA reporting and review training with Finance staff working with sub-recipient.
2024-005 – Coronavirus State and Local Fiscal Recovery Funds – Procurement, Suspended, Debarred – The Village is aware it has not verified contractors eligibility to work on Federally funded projects and will create policies to ensure the Village is compliant going forward. Responsible Official – Ja...
2024-005 – Coronavirus State and Local Fiscal Recovery Funds – Procurement, Suspended, Debarred – The Village is aware it has not verified contractors eligibility to work on Federally funded projects and will create policies to ensure the Village is compliant going forward. Responsible Official – James Healy – Administrator Anticipated Completion Date – The Village intends to work towards resolving this finding in the following year.
View Audit 353554 Questioned Costs: $1
Health Center Program Cluster (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) -Assistance Listing No. 93.224 /93.527 Recommendation: A test should be performed in the billing software annually when the updated Sliding Fee Discount Sch...
Health Center Program Cluster (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) -Assistance Listing No. 93.224 /93.527 Recommendation: A test should be performed in the billing software annually when the updated Sliding Fee Discount Schedule is put into place to ensure that slides are being calculated properly at the effective date of the new schedule. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: CHWP will test for irregularities periodically throughout the year Name(s) of the contact person(s) responsible for corrective action: Jeff Forman, CFO. Planned completion date for corrective action plan: March 21, 2025.
The District has contacted the EPA regarding buses replaced and the new buses purchased in the 2022 Clean School Bus Rebate. As of April 2, 2025, we are still waiting on their instructions for our next actions. The District uploaded all required documentation to the EPA portal in the close out pro...
The District has contacted the EPA regarding buses replaced and the new buses purchased in the 2022 Clean School Bus Rebate. As of April 2, 2025, we are still waiting on their instructions for our next actions. The District uploaded all required documentation to the EPA portal in the close out process. Contact person responsible for corrective action: Kim Foster. Anticipated completion date of corrective action: The EPA was contacted on February 3, 2025.
View Audit 353537 Questioned Costs: $1
Child Nutrition implemented a new policy/procedure for handling free and reduced applications effective July 1, 2024.
Child Nutrition implemented a new policy/procedure for handling free and reduced applications effective July 1, 2024.
Management has corrected all audited recertifications with correct information. For those tenants where the corrections had an impact on the tenant rent and housing assistance payments, management has notified and conducted meetings with the residents. Management will also insert file clarification ...
Management has corrected all audited recertifications with correct information. For those tenants where the corrections had an impact on the tenant rent and housing assistance payments, management has notified and conducted meetings with the residents. Management will also insert file clarification notes in those corrected files that the tenant files were corrected to ensure transparency and note that an administrative correction was conducted. Management will continue to utilize internal control procedures to ensure that information are calculated accurately and reported correctly in the future.
View Audit 353506 Questioned Costs: $1
Corrective Action: The Organization agrees with the finding. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Management is working with the new property managers to ensure they have procedures in place to document and maintain tenant fil...
Corrective Action: The Organization agrees with the finding. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Management is working with the new property managers to ensure they have procedures in place to document and maintain tenant files in accordance with HUD and will have routine internal audits of tenant files to ensure compliance with HUD regulations. For properties not transitioning to new property management, management believes the reduced volume of properties at one property manager will reduce staff turnover and more efficiently provide the proper training to existing staff to improve compliance with tenant files. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2025. Name of contact person: Jennifer Anderson, Interim CFO
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, management has assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications...
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, management has assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications and hired a team of additional roving property management/compliance teams to cover open property management positions and to support site staff in completing tenant recertifications. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2025. Name of contact person: Jennifer Anderson, Interim CFO
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, management has assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications...
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, management has assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications and hired a team of additional roving property management/compliance teams to cover open property management positions and to support site staff in completing tenant recertifications. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2025. Name of contact person: Jennifer Anderson, Interim CFO
Corrective Action: The Organization agrees with the finding. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Management is working with the new property managers to ensure they have procedures in place to document and maintain tenant fil...
Corrective Action: The Organization agrees with the finding. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Management is working with the new property managers to ensure they have procedures in place to document and maintain tenant files in accordance with HUD and will have routine internal audits of tenant files to ensure compliance with HUD regulations. For properties not transitioning to new property management, management believes the reduced volume of properties at one property manager will reduce staff turnover and more efficiently provide the proper training to existing staff to improve compliance with tenant files. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2025. Name of contact person: Jennifer Anderson, Interim CFO
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, management has assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications...
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, management has assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications and hired a team of additional roving property management/compliance teams to cover open property management positions and to support site staff in completing tenant recertifications. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2025. Name of contact person: Jennifer Anderson, Interim CFO
Corrective Action: The Organization agrees with the finding. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Management is working with the new property managers to ensure they have procedures in place to document and maintain tenant fil...
Corrective Action: The Organization agrees with the finding. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Management is working with the new property managers to ensure they have procedures in place to document and maintain tenant files in accordance with HUD and will have routine internal audits of tenant files to ensure compliance with HUD regulations. For properties not transitioning to new property management, management believes the reduced volume of properties at one property manager will reduce staff turnover and more efficiently provide the proper training to existing staff to improve compliance with tenant files. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2025. Name of contact person: Jennifer Anderson, Interim CFO
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, management has assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications...
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, management has assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications and hired a team of additional roving property management/compliance teams to cover open property management positions and to support site staff in completing tenant recertifications. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2025. Name of contact person: Jennifer Anderson, Interim CFO
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, management has assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications...
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, management has assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications and hired a team of additional roving property management/compliance teams to cover open property management positions and to support site staff in completing tenant recertifications. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2025. Name of contact person: Jennifer Anderson, Interim CFO
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, management has assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications...
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, management has assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications and hired a team of additional roving property management/compliance teams to cover open property management positions and to support site staff in completing tenant recertifications. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2025. Name of contact person: Jennifer Anderson, Interim CFO
Corrective Action: The Organization agrees with the finding. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Management is working with the new property managers to ensure they have procedures in place to document and maintain tenant fil...
Corrective Action: The Organization agrees with the finding. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Management is working with the new property managers to ensure they have procedures in place to document and maintain tenant files in accordance with HUD and will have routine internal audits of tenant files to ensure compliance with HUD regulations. For properties not transitioning to new property management, management believes the reduced volume of properties at one property manager will reduce staff turnover and more efficiently provide the proper training to existing staff to improve compliance with tenant files. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2025. Name of contact person: Jennifer Anderson, Interim CFO
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, management has assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications...
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, management has assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications and hired a team of additional roving property management/compliance teams to cover open property management positions and to support site staff in completing tenant recertifications. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2025. Name of contact person: Jennifer Anderson, Interim CFO
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, management has assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications...
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, management has assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications and hired a team of additional roving property management/compliance teams to cover open property management positions and to support site staff in completing tenant recertifications. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2025. Name of contact person: Jennifer Anderson, Interim CFO
Condition – Peak Vista (“the Organization”) determines the sliding fee discount charged to the patients based on their annual gross income and household size. During our testing of sliding fee discounts, we found that two encounters selected where the patients were charged incorrect copays. Recommen...
Condition – Peak Vista (“the Organization”) determines the sliding fee discount charged to the patients based on their annual gross income and household size. During our testing of sliding fee discounts, we found that two encounters selected where the patients were charged incorrect copays. Recommendation – The Organization should strengthen processes surrounding the monitoring of the program to ensure the Organization’s policies are consistently and properly applied. Views of Responsible Officials and Planned Corrective Actions – Management agrees with the finding. The Organization has developed a plan for addressing this issue that includes updated procedures, training, and auditing. All teams engaged in the enrollment and eligibility process, including our Enrollment, Reception, and Billing teams will be retrained on the process with emphasis on proper documentation. The Organization management plans to incorporate into our quality assurance audits the documentation for single service date discount applications and provide feedback and retraining as necessary to staff as needed. Anticipated Date of Completion – In progress. Action Taken – We have reviewed the recommendation and have developed a plan for addressing this issue. Person Responsible for Corrective Action Plan – Ryan Spillane, Chief Financial Officer Corrective Action Plan – Ryan Spillane, Chief Financial Officer
View Audit 353387 Questioned Costs: $1
Planned Corrective Action: The Garland Housing Agency (GHA) relies on the certifications of the tenant and landlord, which states that there is not a familial relationship between the two parties. GHA will review applications for unusual items that could be indicative of a familial relationship and...
Planned Corrective Action: The Garland Housing Agency (GHA) relies on the certifications of the tenant and landlord, which states that there is not a familial relationship between the two parties. GHA will review applications for unusual items that could be indicative of a familial relationship and use online, public records to try to identify whether or not there is a familial relationship. GHA maintains a log of potential issues with the participants and will include potential familial relationships between the tenant and landlord in the log. Responsible officials: Steve Fitch, Director of Housing Planned completion date: September 30, 2025
View Audit 353380 Questioned Costs: $1
Finding 554757 (2024-017)
Significant Deficiency 2024
2024-017 Oregon Department of Human Services/Oregon Health Authority Strengthen internal controls over the ONE system Management Response: We agree with this recommendation. ODHS will continue to work with our vendor to secure a SOC 2 Type II audit of our processes and oversight of the ONE system in...
2024-017 Oregon Department of Human Services/Oregon Health Authority Strengthen internal controls over the ONE system Management Response: We agree with this recommendation. ODHS will continue to work with our vendor to secure a SOC 2 Type II audit of our processes and oversight of the ONE system in 2025. Additionally, ODHS will work on amending the ONE M&O agreement with Deloitte for them to obtain a scoped SOC 2 Type II audit related to their work within the ONE system. ODHS would expect to negotiate this additional audit requirement in 2025 with the first audit then happening in 2026. In addition, the agency will request reports that will allow reconciliation of transactions between ONE and the mainframe system. Anticipated Completion Date: December 31, 2026 Contact person: Jennifer Stallsworth, Chief of Staff, ODHS APD, April Gillette, OHA Medicaid Division, Strategic Operations & Improvement Director
Finding 554756 (2024-016)
Significant Deficiency 2024
2024-016 Oregon Department of Human Services/Oregon Health Authority Improve documentation for provider eligibility determinations and revalidations Management Response: We agree with this recommendation. OHA – Medicaid (Todd Howard) - At the next Provider Enrollment meeting on April 17, 2025, we wi...
2024-016 Oregon Department of Human Services/Oregon Health Authority Improve documentation for provider eligibility determinations and revalidations Management Response: We agree with this recommendation. OHA – Medicaid (Todd Howard) - At the next Provider Enrollment meeting on April 17, 2025, we will conduct an additional training on the ownership and disclosure form, in particular the requirement around the managing employee disclosure. We will also work with our CCO contract administrator, unit lead worker and staff that process the annual CCO ownership disclosure forms to ensure all disclosures and attachments are obtained. ODHS-Aging & People with Disabilities (Jennifer Stallsworth) The Office of Aging and People with Disabilities is committed to ensuring the Provider Enrollment Agreements and I-9 forms are on accurate and records are stored and retained properly. Corrective Actions Taken & In Progress • Improved Provider Enrollment & Renewal Forms – On or before March 31, all new and renewing providers will have the option to complete the Provider Enrollment Application and Agreement (PEAA), I-9, W-4 (federal and state), and HCW Guide Agreement Form through DocuSign and submit them electronically through email, which will assist in the accuracy of forms completion and mitigate human errors in completing forms. • Local Office Verification Step – An Action Request (AR) transmittal will require local offices to verify that a properly completed I-9 is on file during provider renewal process. • Training & Resources – We will develop a Quick Resource Guide (QRG) with clear instructions and visual examples to help staff verify employment documents accurately and store them appropriately. • Quality Assurance Enhancements – The Provider Relations Unit (PRU) will implement a Quality Assurance check for I-9 forms during provider enrollment and renewal process. • E-Verify – The department is developing a proposal with an implementation plan using the Department of Homeland Security’s E-Verify+ system as an electronic verification tool for employment eligibility. We will seek leadership approval by July 1, 2025, with a plan to implement by March 31, 2026. Resolution of Questioned Costs The department has obtained the missing I-9 documentation and will not reimburse the federal agency for the questioned costs. We are confident these measures will ensure full compliance and improve the accuracy and efficiency of our provider enrollment process. Anticipated Completion Date: March 31, 2026 Contact person: Jennifer Stallsworth, Chief of Staff, ODHS APD, April Gillette, OHA Medicaid Division, Strategic Operations & Improvement Director
View Audit 353343 Questioned Costs: $1
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