Corrective Action Plans

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Ineligible Student Received Title IV Funding Auditor Description of Condition and Effect. During our testing, we noted that a student successfully appealed their academic dismissal in the Summer 2022–2023 semester. The student did not receive Title IV funding during that term and subsequently failed...
Ineligible Student Received Title IV Funding Auditor Description of Condition and Effect. During our testing, we noted that a student successfully appealed their academic dismissal in the Summer 2022–2023 semester. The student did not receive Title IV funding during that term and subsequently failed both attempted courses. Despite the lack of demonstrated academic improvement following the appeal, the student was awarded Title IV funding in the Spring 2024–2025 semester based on the appeal granted during the 2022–2023 academic year. As a result of this condition, one student received Title IV funding that who was not eligible based on the criteria outlined in the College's satisfactory academic policy (SAP). Auditor Recommendation. We recommend the College implement a formal review process to verify that students who were previously dismissed and granted an appeal in a prior academic year have demonstrated the required academic improvement before receiving subsequent Title IV funding, or alternatively, obtain a new appeal determination. Corrective Action. Management acknowledges this finding and is implementing strengthened Satisfactory Academic Progress (SAP) review procedures to ensure students who previously appealed an academic dismissal are properly evaluated before receiving Title IV funding. The Financial Aid Office is now working closely with the Registrar to ensure both Title‑IV and non‑Title‑IV students undergo appropriate SAP monitoring. Information Technology is developing a report that identifies students by financial‑aid track status, allowing Financial Aid to review aid‑receiving students while the Registrar evaluates all others. Students who require SAP follow‑up are contacted by the appropriate office, and SAP appeal forms are reviewed under updated criteria to ensure students demonstrate academic improvement before additional aid is awarded. These steps ensure the College remains compliant with federal SAP requirements and prevents ineligible students from receiving Title IV funds. Responsible Person. Jennifer Stimson, Director of Financial Aid Anticipated Completion Date. June 30, 2026
Student Financial Aid Cluster: TEACH Grant – Assistance Listing No. 84.379 Recommendation: We recommend the University review and update current procedures to ensure that students meet eligibility requirements prior to receiving the TEACH Grant. Explanation of disagreement with audit finding: There ...
Student Financial Aid Cluster: TEACH Grant – Assistance Listing No. 84.379 Recommendation: We recommend the University review and update current procedures to ensure that students meet eligibility requirements prior to receiving the TEACH Grant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has updated procedures to ensure verification of student GPA prior to disbursement of TEACH Grant funding. Name(s) of the contact person(s) responsible for corrective action: Ms. Nacasaw Coppage, Director of Office of Financial Aid and Ms. Courtney Youngblood, Assistant Director of Financial Aid Planned completion date for corrective action plan: September 2025
Federal Program: U.S. Department of Education Student Financial Assistance Cluster: Federal Direct Student Loans, Federal Assistance Listing 84.268 Criteria: The University must comply with 34 CFR 668.165(a). Condition: During our eligibility testing, 10 of 38 students who received Direct Loans were...
Federal Program: U.S. Department of Education Student Financial Assistance Cluster: Federal Direct Student Loans, Federal Assistance Listing 84.268 Criteria: The University must comply with 34 CFR 668.165(a). Condition: During our eligibility testing, 10 of 38 students who received Direct Loans were not notified of their disbursements timely by the University. Cause: The University did not have controls in place to ensure students were being notified of Direct Loan disbursements in a timely manner (within 30 days before or 30 days after crediting the students' account). Effect: The provisions of 34 CFR 668.165(a) were not followed and thus a total of 10 students were not notified of Direct Loan disbursements in a timely manner. Questioned Costs: There were no questioned costs associated with this finding. Recommendation: We recommend that the University update their internal controls related to Direct Loan disbursements and send required communications prior to crediting the students' accounts. Corrective Actions Taken or Planned: We agree with this finding and recommendation. The financial aid office has automated the process to send disbursement notifications. Disbursement notifications are sent the day after loans are posted to a student’s account. Responsible Parties: Daniel Donner, Director of Financial Aid Completion Date: November 05, 2025
2025-001 Pell Grant Under Award Recommendation: We recommend the University implement a review process that compares enrolled credits to Pell awards to ensure all students receive the correct Pell Grant amounts. Explanation of disagreement with audit finding: There is no disagreement with the audit ...
2025-001 Pell Grant Under Award Recommendation: We recommend the University implement a review process that compares enrolled credits to Pell awards to ensure all students receive the correct Pell Grant amounts. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: 1) The Office of Financial Aid will continue to run monthly or bi-monthly enrollment reports for Pell Grant recipients to ensure awards are accurately determined based on enrollment status. 2) Financial Aid Counselors will continue to review the daily and weekly Hour Change Reports for each payment period to ensure Pell Grant awards are adjusted appropriately in response to enrollment status changes. 3) The Director and Assistant Director of Financial Aid will continue providing Banner (student information system) training to staff to ensure Pell Grant amounts are updated accurately within the system. Name(s) of the contact person(s) responsible for corrective action: Vanesa Teran-Martinez, Jennifer Monroy Planned completion date for corrective action plan: June 30, 2026
Corrective Action: Imperial Beach Community Clinic will immediately take steps to correct processes and workflows to meet future year Sliding Fee documentation requirements. In conjunction, the Revenue Cycle team including the CFO and Billing Manager will work with the Patient Services Manager to pu...
Corrective Action: Imperial Beach Community Clinic will immediately take steps to correct processes and workflows to meet future year Sliding Fee documentation requirements. In conjunction, the Revenue Cycle team including the CFO and Billing Manager will work with the Patient Services Manager to put together training for all Staff in Patient Services and Revenue Cycle on all issues identified. Training will encompass program requirements and proper identification and implementation of the sliding fee program. The team will also institute monthly Sliding Fee Chart Audits to assess staff knowledge, provide feeback and offer guidance to all staff.
Recommendation: The Department of Social Services should provide the necessary resources and institute procedures to ensure that it uses all information from eligibility, income, and death matches to ensure that it correctly issues benefits to or on behalf of eligible clients. DSS should return fede...
Recommendation: The Department of Social Services should provide the necessary resources and institute procedures to ensure that it uses all information from eligibility, income, and death matches to ensure that it correctly issues benefits to or on behalf of eligible clients. DSS should return federal reimbursements for unallowable expenditures claimed under Medicaid and SNAP. Corrective Action Plan as Reported by the Department of Social Services: The Department agrees with this finding. DSS staff is in the development phase of implementing new automated procedures to ensure timely and accurate action is taken to discontinue benefits of deceased clients when date of death information is received and matched to the Connecticut Department of Public Health’s State Vital Records Office. Action has been taken to correct the errors cited, including discontinuing the benefits of the individuals that were verified as deceased, and recouping the overpayments as appropriate. Anticipated Completion Date: December 31, 2026 Department of Social Services Contact Person: Dan Giacomi, Program Division Director (860) 424-5080
Recommendation: The Department of Social Services should strengthen internal controls to ensure that only eligible recipients receive Medicaid services in accordance with federal laws and the Medicaid State Plan. Corrective Action Plan as Reported by the Department of Social Services: The Department...
Recommendation: The Department of Social Services should strengthen internal controls to ensure that only eligible recipients receive Medicaid services in accordance with federal laws and the Medicaid State Plan. Corrective Action Plan as Reported by the Department of Social Services: The Department agrees with this finding. The Department identified cases where overrides that were applied during the public health emergency were not removed. This resulted in individuals remaining enrolled inappropriately. Our Business Systems Division is implementing a tiered resolution approach, beginning with individuals enrolled in the Medicare Savings Program and HUSKY-C coverage. Please note: The Department will not be returning the questioned costs associated with this finding. According to federal regulations, recoveries based on eligibility errors can only be pursued when identified by programs operating under CMS’ Payment Error Rate Measurement program, per section 1903(u) of the Social Security Act and regulations at Title 42 CFR Part 431, Subpart Q. Anticipated Completion Date: December 31, 2026 Department of Social Services Contact Person: Dan Giacomi, Program Division Director (860) 424-5080
Recommendation: The Department of Social Services should strengthen internal controls to ensure that only eligible recipients receive Money Follows the Person Rebalancing Demonstration services in accordance with federal laws, award terms and conditions, and the Money Follows the Person Operational ...
Recommendation: The Department of Social Services should strengthen internal controls to ensure that only eligible recipients receive Money Follows the Person Rebalancing Demonstration services in accordance with federal laws, award terms and conditions, and the Money Follows the Person Operational Protocol. Corrective Action Plan as Reported by the Department of Social Services: The Department agrees in part with this finding. Condition #1: DSS agrees that participation end dates were not updated timely due to cross-system manual entry limitations. Reconciliation procedures and supervisory oversight will be strengthened. Condition #2: DSS agrees that participation suspensions were not consistently reflected across systems due to timing delays. Monitoring and real-time reconciliation controls will be enhanced. Condition #3: DSS agrees approved costs exceeded institutional thresholds in limited cases. Variances were clinically justified, reviewed, and authorized. DSS will strengthen documentation and internal protocols to ensure clearer policy alignment. Condition #4: DSS agrees that the documentation was incomplete in one instance. Internal review standards will be reinforced to ensure comparative cost analyses are consistently documented. Please note, the Department will not be returning the questioned costs associated with this finding. According to federal regulations, recoveries based on eligibility errors can only be pursued when identified by programs operating under Centers for Medicare and Medicaid Services’ (CMS) Payment Error Rate Measurement program, per section 1903(u) of the Social Security Act and regulations at Title 42 CFR Part 431, Subpart Q. Anticipated Completion Date: December 31, 2026 Department of Social Services Contact Person: Christine Weston, Program Division Director (860) 424-5012
Recommendation: The Department of Social Services should strengthen internal controls to ensure that each Children’s Health Insurance Program recipient is eligible for the program according to the state plan and federal regulations. Corrective Action Plan as Reported by the Department of Social Serv...
Recommendation: The Department of Social Services should strengthen internal controls to ensure that each Children’s Health Insurance Program recipient is eligible for the program according to the state plan and federal regulations. Corrective Action Plan as Reported by the Department of Social Services: The Department agrees with this finding. Condition #1: This was a processing error and was independently addressed. Condition #2: The findings were for cases that were granted prior to the implementation of the Department’s manual review process, which includes updating third-party information in the Health Insurance Exchange (HIX) system after verifying policy information. This process was officially started in May 2025. It is a post-enrollment function since it is permissible for clients to self-attest to having third-party liability (TPL) at the time of application. We expect to see a reduction in this type of error in future audits. There is an inevitable delay in DSS being notified of any discrepancies with TPL details due to the timing of that information being updated from carriers and then provided to DSS. With our new process, we can close these cases as soon as that information is available to us. Condition #3: There are multiple root causes related to this finding, including Premium Payment Module file transaction issues, reversing system functionality that was temporarily implemented during the COVID-19 Public Health Emergency which resulted in lingering enrollment issues, and staff processing errors. DSS regularly reviews age-out cases to take the necessary actions to close. Please note, the Department will not be returning the questioned costs associated with this finding. According to federal regulations, recoveries based on eligibility errors can only be pursued when identified by programs operating under Centers for Medicare and Medicaid Services’ (CMS) Payment Error Rate Measurement program, per section 1903(u) of the Social Security Act and regulations at Title 42 CFR Part 431, Subpart Q. Anticipated Completion Date: December 31, 2026 Department of Social Services Contact Person: Dan Giacomi, Program Division Director (860) 424-5080
Recommendation: The Department of Social Services should strengthen internal controls over sanctions to ensure compliance with Temporary Assistance for Needy Families child support enforcement requirements. Corrective Action Plan as Reported by the Department of Social Services: The Department agree...
Recommendation: The Department of Social Services should strengthen internal controls over sanctions to ensure compliance with Temporary Assistance for Needy Families child support enforcement requirements. Corrective Action Plan as Reported by the Department of Social Services: The Department agrees with the finding. DSS Economic Security and Office of Child Support Services implemented a new child support non-cooperation referral process on November 25, 2025. It is task based, assures an accurate and complete universe of sanction notices for child support non-cooperation are provided, and assures staff process and document all required sanctions. Anticipated Completion Date: November 25, 2025 Department of Social Services Contact Person: Tricia Morelli, Program Administrative Manager (860) 424-5519
Recommendation: The Department of Social Services should strengthen internal controls to ensure that only eligible recipients receive temporary family assistance in accordance with federal laws and the Temporary Assistance for Needy Families State Plan. Corrective Action Plan as Reported by the Depa...
Recommendation: The Department of Social Services should strengthen internal controls to ensure that only eligible recipients receive temporary family assistance in accordance with federal laws and the Temporary Assistance for Needy Families State Plan. Corrective Action Plan as Reported by the Department of Social Services: The Department agrees with this finding. The error occurred due to a system issue that did not trigger the discontinuance of benefits for a household that had received 60 months of time-limited benefits. The Department will take action to correct the system functionality to ensure incorrect payments are not made to households that have received 60 months of time-limited benefits. An overpayment has been created, and the recovery of the error amount is in process. Anticipated Completion Date: December 31, 2026 Department of Social Services Contact Person: Dan Giacomi, Program Division Director (860) 424-5080
Recommendation: The Department of Mental Health and Addiction Services should strengthen internal controls to ensure providers maintain sufficient and current documentation to support the reasonableness of rent for the Continuum of Care Program. Corrective Action Plan as Reported by the Department o...
Recommendation: The Department of Mental Health and Addiction Services should strengthen internal controls to ensure providers maintain sufficient and current documentation to support the reasonableness of rent for the Continuum of Care Program. Corrective Action Plan as Reported by the Department of Mental Health and Addiction Services: DMHAS Housing and Homeless Services Unit verbally instructed providers that they must complete, prior to client move-in, accurately, sign and retain documentation regarding the comparable units when completing the Rent Reasonableness on December 17, 2024. On December 24, 2024 and December 19, 2025, these instructions were sent to the providers via email. On February 4, 2025, DMHAS updated the CoC Operations Guide with the full instructions for completing the Rent Reasonableness and the retention of supporting documentation. DMHAS will continue to randomly review a sample of Rent Reasonable documents throughout the year and will provide training and technical assistance to providers on the completion and retention of Rent Reasonableness documentation. Anticipated Completion Date: June 30, 2026 Department of Mental Health and Addiction Services Contact Person: Alice Minervino, Director, Housing and Homeless Services Alice.minervino@ct.gov (860) 418-6942
Recommendation: The Department of Mental Health and Addiction Services should strengthen internal controls to ensure providers maintain sufficient documentation to support participant eligibility and accurately calculate client income and rental assistance payments in the Continuum of Care Program. ...
Recommendation: The Department of Mental Health and Addiction Services should strengthen internal controls to ensure providers maintain sufficient documentation to support participant eligibility and accurately calculate client income and rental assistance payments in the Continuum of Care Program. Corrective Action Plan as Reported by the Department of Mental Health and Addiction Services: In 2026, DMHAS will continue to conduct trainings on CoC Fiscal Requirements. As in the past, these trainings will be recorded and available for viewing on the Connecticut Balance of State Continuum of Care (CTBOS) website. DMHAS Housing and Homeless Services Unit staff conduct mandatory in-person and virtual Technical Assistance visits for the funded agencies to provide guidance and training on the United States Department of Housing and Urban Development (HUD) required eligibility regulations Income Calculation and Documentation. On November 1, 2023, DMHAS implemented a Microsoft Excel Workbook that is fully inclusive of the DMHAS required paperwork, including the income calculation, lease, contract, as well as initial and recertification which standardizes the documents for each participant. On December 19, 2025, the workbook was updated to enhance internal controls over the use of Rent Reasonableness forms and calculations of client income and rental assistance payments. The DMHAS Housing and Homeless Services Unit will continue to work with the DMHAS Fiscal Services Bureau to ensure payments are made accurately, correctly and on-time. Anticipated Completion Date: June 30, 2026 Department of Mental Health and Addiction Services Contact Person: Alice Minervino, Director, Housing and Homeless Services Alice.minervino@ct.gov (860) 418-6942
Recommendation: The Department of Social Services should strengthen internal controls to identify the agency responsible for each client’s eligibility determination and document benefit iteration approvals for the Summer Electronic Benefits Transfer Program for Children. Corrective Action Plan as Re...
Recommendation: The Department of Social Services should strengthen internal controls to identify the agency responsible for each client’s eligibility determination and document benefit iteration approvals for the Summer Electronic Benefits Transfer Program for Children. Corrective Action Plan as Reported by the Department of Social Services: The Department disagrees with this finding. Condition #1: Eligibility for the Summer EBT program is established through multiple pathways: receipt of Supplemental Nutrition Assistance Program (SNAP) benefits, Temporary Family Assistance (TFA), or HUSKY A coverage, and through applying for and receiving an eligibility determination for either the National School Lunch Program or the Summer EBT program itself. Determining eligibility is a shared responsibility between DSS and the State Department of Education (SDE), and children qualify through multiple pathways simultaneously. DSS maintains a record within its eligibility system and compiles reports of all eligible children. When eligibility is established through any additional means, the child’s record is then analyzed against all previous issuances to ensure duplicate participation and double issuance does not occur. Title 7 CFR Part 292.16 (a)(5)(i) requires the Summer EBT agency to establish a master issuance file which contains all information needed to identify eligible children, issue Summer EBT benefits, record the participation activity for each household and supply all information necessary to fulfill reporting requirements. The agency is not required to specify which program(s) were used to determine eligibility, which is reasonable given that there may be multiple overlapping avenues of eligibility. The implication that DSS is somehow not compliant or able to identify the source of eligibility is inaccurate. DSS can identify this information on an individual basis through reviewing the child’s receipt of SNAP, TFA, HUSKY A, or through its ongoing coordination and communication with SDE. Condition #2: It is not a requirement of the business systems division to request approval for each issuance. Each year the Department issues benefits for this program in a consistent manner. Since there were no changes to the process during the audit period, approval was not sought for the issuances. Business systems would only seek approval if there was a change to the process. Anticipated Completion Date: N/A Department of Social Services Contact Person: Dan Giacomi, Program Division Director 860-424-5080
Reference Number: 2025-024 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Medicaid and Medical Assistance Federal Program: Medicaid Cluster Assistance Listing Number:...
Reference Number: 2025-024 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Medicaid and Medical Assistance Federal Program: Medicaid Cluster Assistance Listing Number: 93.775, 93.777, 93.778 Award Number and Year: 2405DE5MAP (10/1/2023 – 9/30/2024) 2505DE5MAP (10/1/2024 – 9/30/2025) Compliance Requirement: Eligibility Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: The Division should implement procedures and controls to ensure that it maintains documentation supporting participant eligibility and this documentation should be readily available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Division of Medicaid and Medical Assistance (DMMA) in partnership with the Division of Social Services (DSS) will provide training for determination member eligibility. DSS will also ensure supporting participant eligibility documentation is properly maintained. Name(s) of the contact person(s) responsible for corrective action: Kathleen Mahoney, Social Service Sr. Administrator, DMMA Carolyn Kincaid, Social Service Chief Administrator, DSS Marcella Spady, Deputy Principal Assist, DSS Planned completion date for corrective action plan: September 2026
Reference Number:2025-022 Prior Year Finding:2024-023 Federal Agency:U.S. Department of Health and Human Services State Department Name:Department of Health and Social Services State Division Name:Division of Medicaid and Medical Assistance Federal Program:Medicaid Cluster Assistance Listing Number:...
Reference Number:2025-022 Prior Year Finding:2024-023 Federal Agency:U.S. Department of Health and Human Services State Department Name:Department of Health and Social Services State Division Name:Division of Medicaid and Medical Assistance Federal Program:Medicaid Cluster Assistance Listing Number:93.775, 93.777, 93.778 Award Number and Year: 2405DE5MAP (10/1/2023 – 9/30/2024) 2505DE5MAP (10/1/2024 – 9/30/2025) Compliance Requirement:Special Tests and Provisions – Provider Health and Safety Standards Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Recommendation: The Division should reevaluate its current process and perform additional training to ensure documentation is maintained in accordance with program requirements and that all providers are compliant with required health and safety standards. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: DMMA will review the process of storing all data for provider’s screening and credentialing information. In addition, when a provider enrolls or revalidates into DMAP, they will be required to submit updated credentials and license information. Name(s) of the contact person(s) responsible for corrective action: Mei Johnson, Chief of Admin. IT Unit Planned completion date for corrective action plan: September 2026
Reference Number: 2025-019 Prior Year Finding: 2024-020 Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Social Services Federal Program: CCDF Cluster Assistance Listing Number: 93.575. 93.59...
Reference Number: 2025-019 Prior Year Finding: 2024-020 Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Social Services Federal Program: CCDF Cluster Assistance Listing Number: 93.575. 93.596 Award Number and Year: SAI5406 (10/1/2022 – 9/30/2025) SAI5788 (10/1/2023 – 9/30/2026) SAI6656 (10/1/2024 – 9/30/2028) SAI6306 (10/1/2024 – 9/30/2027) Compliance Requirement: Special Tests and Provisions – Health and Safety Requirements Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Recommendation: The Division should reevaluate its current process and perform additional training to ensure all providers are compliant with required health and safety requirements and that documentation is maintained and readily available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Department of Education, Early Childhood Excellence team will reevaluate its current process and perform additional training to ensure all providers are compliant with required health and safety requirements. Reporting will operate effectively in a new data system to ensure that documentation of providers’ compliance with health and safety requirements is maintained and readily available for audit. Name(s) of the contact person(s) responsible for corrective action: Caitlin Gleason – Department of Education Associate Secretary, Early Childhood Excellence Planned completion date for corrective action plan: Between July 1, 2026 and July 1, 2027.
Reference Number: 2025-018 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division: Division of Social Services Federal Program: CCDF Cluster Assistance Listing Number: 93.575. 93.596 Award Num...
Reference Number: 2025-018 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division: Division of Social Services Federal Program: CCDF Cluster Assistance Listing Number: 93.575. 93.596 Award Number and Year: SAI5406 (10/1/2022 – 9/30/2025) SAI5788 (10/1/2023 – 9/30/2026) SAI6656 (10/1/2024 – 9/30/2028) SAI6306 (10/1/2024 – 9/30/2027) Compliance Requirement: Eligibility Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance Recommendation: The Division should reevaluate its current process, implement proper controls, and perform additional training to ensure that participants receiving benefits under the program meet eligibility requirements. The Division should maintain documentation of participant eligibility and this documentation should be readily available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Division of Social Services (DSS) is currently conducting pilot sites to implement front-end scanning prior to case processing. Bi-weekly meetings with the vendor began in August 2024, and the first on-site visit to a pilot location took place in August 2025. Following successful implementation of the scanning process, a statewide rollout is planned for April–May 2026. The DSS Training Department has developed targeted mini training courses focusing on areas with high error rates. The Learning Innovation Team (LIT) will collect and analyze pre- and post-assessment data from child care training to measure effectiveness. Additionally, open lab sessions will be introduced to provide hands-on support, with a focus on accurately entering authorizations based on need for care and addressing other common error areas identified through Quality Control audits. Name(s) of the contact person(s) responsible for corrective action: Jacqueline Bensel – Social Service Senior Administrator Planned completion date for corrective action plan: June 30, 2026.
Reference Number: 2025-010 Prior Year Finding: 2024-004 Federal Agency: U.S. Department of Labor State Department Name: Department of Labor State Division Name: Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 – Unemployment Insurance Assistance Listing Number: 17...
Reference Number: 2025-010 Prior Year Finding: 2024-004 Federal Agency: U.S. Department of Labor State Department Name: Department of Labor State Division Name: Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 – Unemployment Insurance Assistance Listing Number: 17.225 Award Number and Year: UI372152255A10 (10/1/2021 – 12/31/2024) UI393142355A10 (10/1/2022 – 12/31/2025) 24A55UI000067 (10/1/2023 – 12/31/2026) 25A55UI000116 (1/1/2024 – 12/31/2027) Compliance Requirement: Eligibility Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: The Division should review and enhance procedures and controls to ensure that claimant eligibility is properly determined, that documentation supporting claimant eligibility is retained, and that documentation is readily available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: For 3 of 60 claimants, the Division was unable to provide documentation that the claimant provided weekly updates. These cases (sample 2,7 and 36) relate to claimant weekly certifications and their responses to required eligibility questions for the applicable benefit weeks. Due to existing mainframe system limitations, the Division does not have the ability to directly view all claimant responses within the system interface. In preparation for the CLA review, Application Support generated a comprehensive report capturing weekly certification responses for all sampled claimants, based on Social Security Numbers. However, three claimants did not appear on this report, and therefore their responses could not be verified at the time of review. The Division has identified both short-term and long-term corrective actions to address this discrepancy:  Short-term solution: A service ticket has been submitted to the Application Support team to investigate and resolve the issue that caused these claimants to be excluded from the report. Once resolved, future reports are expected to consistently capture all claimant responses associated with weekly certifications. * Long-term solution: The Division recognizes the need for a modernized system to improve the efficiency and reliability of claims processing and adjudication. Current case management systems are outdated and have limited functionality. Implementation of an updated system will allow for automated capture of weekly certification responses, improved data accessibility, and enhanced identification of potential compliance issues requiring investigation. Name(s) of the contact person(s) responsible for corrective action: Rachael Griffith, UI Administrator Planned completion date for corrective action plan: March 31, 2027
ENROLLMENT REPORTING PROCEDURES SHOULD BE STRENGTHENED. STUDENT FINANCIAL AID CLUSTER PROGRAM ALN# 84.268,84.007,84.033, 84.063, and 84.038 (Questioned Costs - None) Views of Responsible Officials and Planned Corrective Actions The university will strengthen coordination between the Registrar, Finan...
ENROLLMENT REPORTING PROCEDURES SHOULD BE STRENGTHENED. STUDENT FINANCIAL AID CLUSTER PROGRAM ALN# 84.268,84.007,84.033, 84.063, and 84.038 (Questioned Costs - None) Views of Responsible Officials and Planned Corrective Actions The university will strengthen coordination between the Registrar, Financial Aid, and the Business Office to ensure that SAP status is evaluated and communicated before financial aid is disbursed. Procedures will be implemented to ensure timely receipt of grade reporting and academic alerts from faculty and Academic Affairs. Financial Aid staff will review SAP eligibility after each academic evaluation period and maintain documentation of SAP determinations. Students who do not meet SAP requirements will be appropriately flagged to ensure financial aid eligibility is addressed prior to disbursement, strengthening compliance with federal financial aid regulations. Date to be implemented: On-going and completed by June 1, 2026. Persons responsible: Vice President of Business & Finance and Office of Financial Aid.
Recommendation We recommend implementing a Program Improvement Plan between the Title IV-E team and Fostering Connections to ensure that adoption cases potentially eligible for extended subsidies are processed promptly upon consideration, with the necessary agreements executed in a timely manner, i....
Recommendation We recommend implementing a Program Improvement Plan between the Title IV-E team and Fostering Connections to ensure that adoption cases potentially eligible for extended subsidies are processed promptly upon consideration, with the necessary agreements executed in a timely manner, i.e., before the children in question turn 18. Management Response Corrective Action The Office of Performance and Accountability Director will work with the Adoption and Kinship Unit Supervisor to establish a biannual review of payments to adoptive parents to verify if cases need to be closed. Due Date of Completion: June 30, 2026 Responsible Person(s) Office of Performance and Accountability Director
Recommendation We recommend a Program Improvement Plan with documentation retention and file checklist, training, implementation, and monitoring process. There should be accountability for non compliance with these requirements. Management Response Corrective Action Missing Documentation The CYFD Ad...
Recommendation We recommend a Program Improvement Plan with documentation retention and file checklist, training, implementation, and monitoring process. There should be accountability for non compliance with these requirements. Management Response Corrective Action Missing Documentation The CYFD Adoption Subsidy unit will continue to organize its filing system. The Eligibility Manager and Office of Performance and Accountability Director will work with the Adoption and Kinship Unit Supervisor to review and ensure appropriate checklists, training, and processes are in place. In addition, the Eligibility Manager, OPA Director, and Adoption and Kinship Unit will conduct an additional case review to ensure required documentation is present and establish a biannual cadence of self-assessment checks to ensure no missing documentation. Criminal Records Mitigation The agency continues to ensure that workers, supervisors, and managers follow proper procedures for mitigating criminal records checks. The agency addresses this by creating a supervisor checklist to ensure licensure documentation is complete and accurate. The supervisor will conduct an initial placement review; the checklist will include verification by the supervisor of the completed level of care documentation. Supervisors and Managers will address work performance with employees through corrective actions or employment evaluation. Due Date of Completion: June 30, 2026 Responsible Person(s) Office of Performance and Accountability Director
Management Plans to develop proper written policies and procedures over the elibility process that ensures indivdiuals are eligible and proper documentation is maintained
Management Plans to develop proper written policies and procedures over the elibility process that ensures indivdiuals are eligible and proper documentation is maintained
Finding 2025-001: Material Weakness in Internal Control Over Compliance and Non-Material Noncompliance Federal Awarding Agency: Department of Health and Human Services (HHS) Responsible Person: Deidra Bolden, Acting Director, Department of Family Services Estimated Completion: June 30, 2026 Correcte...
Finding 2025-001: Material Weakness in Internal Control Over Compliance and Non-Material Noncompliance Federal Awarding Agency: Department of Health and Human Services (HHS) Responsible Person: Deidra Bolden, Acting Director, Department of Family Services Estimated Completion: June 30, 2026 Corrected Action: 1. The Department of Family Services has implemented a Medicaid-focused caseworker structure and a specialized intake-and-ongoing case management model. This model reduces task switching and allows staff to develop proficiency more quickly by focusing on Medicaid and progressing from simpler to more complex case types. It also improves consistency in case processing and allows supervisors to provide more targeted oversight. The Department has also completed a Medicaid Overdue Resolution Project, significantly reducing backlog and stabilizing renewal processing. These structural changes, combined with reduced caseloads and increased supervisory capacity, allow for more focused case management, improved oversight, and more consistent application of eligibility policy. 2. The Department has expanded training capacity and structure to address prior limitations. A second trainer position has been added, doubling internal training capacity and enabling more frequent onboarding, refresher training, and targeted instruction. This allows the Department to better support both new and tenured staff and respond more quickly to identified training needs. In addition, the Department is implementing a competency-based training model that establishes structured learning pathways for new staff, experienced workers, and supervisors. This model incorporates modular curriculum, scenario-based application, and targeted refreshers tied to error trends, supporting more consistent policy application and stronger staff development over time. 3. The Department is strengthening monitoring and case review practices to improve early detection of issues and reinforce consistent oversight. As supervisory capacity has increased and caseloads have begun to stabilize, supervisors are better positioned to conduct more frequent and targeted case reviews, particularly for high-risk and time-sensitive work. The Department is also strengthening case review capacity and moving toward a higher percentage of routine case review to improve early detection of errors and reinforce policy compliance. Trend analysis is being expanded to identify patterns across workers, supervisors, and case types, allowing for more targeted and timely corrective action. These enhancements, supported by improved staffing levels and more manageable caseloads, strengthen the Department’s ability to identify issues earlier, reinforce expectations consistently, and reduce the likelihood of overdue or noncompliant cases. 4. The Department is strengthening how it evaluates the effectiveness of corrective actions by conducting on going case reviews, monthly performance monitoring to track timeliness and accuracy trends, performing trend analysis over time to measure improvement and identify recurring issues, and conducting executive-level reporting to monitor progress and ensure accountability. These evaluation methods provide a structured approach to verifying that corrective actions are implemented effectively and produce sustained improvement. 5. The Department has onboarded additional staff, including supervisors, case managers, a case reviewer, and a trainer, improving both workload distribution and monitoring capacity. Continued investment in staffing, combined with ongoing efforts to right-size caseloads, is expected to further strengthen supervisory oversight, expand case review capacity, and sustain improvements in timeliness and compliance.
Management's Response: Management has created the following Corrective Action Plan: 1. Redwoods Rural Health Center (RRHC) will implement a monthly quality review process, to determine that only patients who correctly complete a SFDP application and provide supporting documentation receive any eligi...
Management's Response: Management has created the following Corrective Action Plan: 1. Redwoods Rural Health Center (RRHC) will implement a monthly quality review process, to determine that only patients who correctly complete a SFDP application and provide supporting documentation receive any eligible discounts. 2. Additionally, on a quarterly basis, a sample of Sliding Fee Discount Applications will be selected and reviewed for accuracy of the SFDP calculation. 3. Reviews will be performed by Revenue Cycle department staff and submitted to Patient Intake and Eligibility Staff as an on-going training agenda item. Reviews will be performed utilizing the Income Detail/Sliding Fee Schedule report which pulls data from the information entered within the specified timeframe. See related Board approved Sliding Fee Discount Policy. Responsible Party: Billing Manager, Front Desk Supervisor, Medical Operations Manager Completion Date: This plan has been created as of December 16th, 2025, and implementation will begin effective immediately.
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