Corrective Action Plans

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Corrective action plan: In December 2021, the Texas Health and Human Services Commission (HHSC) implemented the Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment Management System (PEMS), an automated system that is the single tool for provider enrollment, re-enrollment, revalidat...
Corrective action plan: In December 2021, the Texas Health and Human Services Commission (HHSC) implemented the Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment Management System (PEMS), an automated system that is the single tool for provider enrollment, re-enrollment, revalidation, and maintenance requests (maintaining and updating provider enrollment record information). Medicaid provider enrollment, revalidation, and re-enrollment documentation, including risk-based screenings, are tracked in PEMS. Additionally, the relevant federal databases are checked at least monthly for all providers currently enrolled in Medicaid. HHSC continues efforts to enroll Medicaid providers, including LTC providers, through the PEMS. HHSC continued to operate under the public health emergency (PHE) waiver through May 11, 2023. As a result of the PHE end date and provider revalidation requirements, the projected end date for required revalidation of Medicaid providers is January 11, 2027. Of the Medicaid providers requested during the fiscal year 2024 Statewide Single Audit, the listed exceptions only apply to two LTC providers. The PEMS automated disenrollment process for providers who did not complete their revalidation was disabled during the PHE and had not yet been reenabled at the time these providers were due for revalidation. Manual disenrollment batches occurred through July 2024 with approved disenrollment exclusions based on a providers in-flight application, receipt of paid claims, and missing revalidation reminder notifications. The PEMS automatic disenrollment process was re-enabled in August 2024. Implementation dates: December 2021, PEMS implementation (Implemented) January 2027, provider enrollment and revalidation completed Responsible persons: Jordan Nichols, Deputy Associate Commissioner, Medicaid and CHIP Services Operations Management
Corrective action plan: Since fiscal year 2022, Access and Eligibility Services (AES) has focused on hiring initiatives, strategic workload strategies, system improvements, and training to improve workload capacity to enable AES to reallocate workforce resources to applications waiting the longest...
Corrective action plan: Since fiscal year 2022, Access and Eligibility Services (AES) has focused on hiring initiatives, strategic workload strategies, system improvements, and training to improve workload capacity to enable AES to reallocate workforce resources to applications waiting the longest to be processed. In addition, AES has reviewed regular monitoring and reporting mechanisms to track application processing times and identify any delays. HHSC conducted a comprehensive review of application processing workflows to identify strategies to increase capacity and/or reduce workload. The review identified more than 40 strategies to improve end-user function, eliminating unnecessary actions and interactions, improving client experience, and promoting timely workflow. As of January 31, 2025, procedural improvements implemented have resulted in most Medicaid applications being processed within three days of receipt, allowing for a greater amount of the full processing timeframe (45 days) being available to establish proper eligibility. AES began implementing identified strategies in September 2024 and ongoing efforts will continue to focus on workforce and workload balance to meet the needs of timeliness of applicable programs. AES will continue to evaluate effectiveness of procedures through feedback loops, ensuring changes made result in sustained improvements and compliance with all relevant regulations. Implementation dates: December 31, 2028 Responsible persons: Molly Regan, Deputy Executive Commissioner, AES Rachel Patton, Associate Commissioner, AES Operations
Corrective action plan: HHSC has enacted changes to policies and timelines to ensure SOC 1 Type 2 reports are completed in a timely manner each year. HHSC will evaluate language in new and/or amending contracts to ensure contractual language supports these efforts. Implementation date: September ...
Corrective action plan: HHSC has enacted changes to policies and timelines to ensure SOC 1 Type 2 reports are completed in a timely manner each year. HHSC will evaluate language in new and/or amending contracts to ensure contractual language supports these efforts. Implementation date: September 30, 2025 Responsible persons: Michael Blood, Deputy Associate Commissioner, Contract Administration and Provider Monitoring
Name of Contact Person: Sara Graul Corrective Action: Case File Oversight: • The Program Director has always reviewed case files but previously failed to sign the checklists. This has now been corrected and checklists are being signed upon review. • This process will continue to ensure proper docu...
Name of Contact Person: Sara Graul Corrective Action: Case File Oversight: • The Program Director has always reviewed case files but previously failed to sign the checklists. This has now been corrected and checklists are being signed upon review. • This process will continue to ensure proper documentation and compliance. • The Department structure is currently being reviewed with additional staff likely to add capacity and oversight. Financial Review & Approval Process: • The Finance team will continue preparing projection worksheets reconciled to the general ledger. • The Program Director will formally review and approve these financial documents before reimbursement requests are submitted. • We resolved this deficiency in April 2024 and have put the following additional controls in place to prevent this deficiency from recurring. Training & Standardization: • All program staff, including case managers and finance personnel, will receive training on compliance and proper documentation. • A standardized process and accountability measures will be in place to maintain adherence to these corrective actions. Monitoring & Reporting: • Quarterly internal audits will be conducted to verify compliance with the updated review and approval process. • An internal compliance officer or manager will oversee adherence to the new protocols. Completion Date: Full compliance with these measures is expected by the end of the next reporting quarter.
FINDING 2024-005 – Child Nutrition Cluster - Eligibility Context: During sample testing of 60 students for eligibility, we noted 5 instances where there was no documented review by someone other than the individual making the eligibility determination. Additionally, we noted 4 instances where the ...
FINDING 2024-005 – Child Nutrition Cluster - Eligibility Context: During sample testing of 60 students for eligibility, we noted 5 instances where there was no documented review by someone other than the individual making the eligibility determination. Additionally, we noted 4 instances where the School Corporation was unable to provide the application. The issues were isolated to paper applications Contact Person Responsible for Corrective Action: Michelle L. Keene Contact Phone Number: (812) 384-4386 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The treasurer will formally review a sample of applications and the School Corporation will ensure all supporting applications and reviews are maintained. Anticipated Completion Date: March 2025
FINDING 2024-003 - Child Nutrition Cluster - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Context: During testing we noted the following issues in a sample of forty child nutrition cluster payroll claims: ● 6 of 40 payroll transactions where a timecard was not completed by the ...
FINDING 2024-003 - Child Nutrition Cluster - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Context: During testing we noted the following issues in a sample of forty child nutrition cluster payroll claims: ● 6 of 40 payroll transactions where a timecard was not completed by the employee to validate their hours worked and the time charged to food service. ● 19 of 40 payroll transactions where the School Corporation was unable to provide supporting documentation for approval of the hourly rate paid to employee. The noncompliance was isolated to the payroll periods through August 4, 2023. The School Corporation corrected the issues starting with the next payroll period. Contact Person Responsible for Corrective Action: Michelle L. Keene Contact Phone Number: (812) 384-4386 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: In FY24, the issue was corrected to ensure all employees were only paid for time supported by a time a card and a board approved rate schedule. Anticipated Completion Date: August 19, 2023
View Audit 348324 Questioned Costs: $1
2024-003 Adult Education - Assistance Listing Number 84.002 Recommendation: We recommend procedures to maintain records related to eligibility determinations be implemented/strengthened. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken ...
2024-003 Adult Education - Assistance Listing Number 84.002 Recommendation: We recommend procedures to maintain records related to eligibility determinations be implemented/strengthened. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Adult Education department will now scan in the physical intake form that Adult ESL students self-report their eligibility status for MA DESE ACLS as well as have the student sign that form. This form will be stored electronically in addition to the information from the form being entered into the Adult ESL Access database and LACES . Name(s) of the contact person(s) responsible for corrective action: Dr. Kevin O’Connor, Claudia Castro Alves and Kate Fiore Planned completion date for corrective action plan: Effective as of 08/01/2024
FINDING 2024-003 Information on the federal program: Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (or...
FINDING 2024-003 Information on the federal program: Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (or Other Identifying Numbers): FY2023, FY2024 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Eligibility Audit Finding: Material Weakness Context: During sample testing of 60 students for eligibility, we noted 14 instances where there was no documented review by someone other than the individual making the eligibility determination. The lack of review was isolated to paper applications. Contact Person Responsible for Corrective Action: Joyce Hulsman Contact Phone Number: 812-678-2781 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: A procedure has been established to ensure dual validation and paper copies are in compliance. Anticipated Completion Date: Already completed.
Finding 530181 (2024-032)
Significant Deficiency 2024
Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. For Sample Item 17, the screening activities associated with the revalidation were completed prior to the revalidation date through the Provider Enrollment, Chain, and Ownership System (PECOS). The provider ...
Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. For Sample Item 17, the screening activities associated with the revalidation were completed prior to the revalidation date through the Provider Enrollment, Chain, and Ownership System (PECOS). The provider submitted their revalidation application timely, but during the revalidation process the agency requested corrections and clarifications of administrative and tax information. This delayed the final component of the screening, the site visit, until July 15, 2024. For Sample Item 22, DMS confirms there was no W-9 dated prior to February 7, 2024. The primary function of the W-9 form is to confirm the providers name, address, and tax information. This information was already listed in MMIS during the date in question. The W-9 submitted by the provider on April 4, 2024, confirmed the accuracy of the information in MMIS that the provider has used since its initial enrollment on July 20, 1981. DMS is developing a mechanism to obtain information provided on W-9’s by utilizing an electronic process through the provider portal during enrollment. Anticipated Completion Date: June 30, 2025 Contact Person: Elizabeth Pitman Director, Division of Medical Services Department of Human Services 700 Main Street Little Rock, AR 72201 (501) 244-3944 Elizabeth.Pitman@dhs.arkansas.gov
Finding 530180 (2024-031)
Significant Deficiency 2024
Views of Responsible Officials and Planned Corrective Action: DMS concurs with this finding. For Sample Item 15, DMS has implemented an automated process to notify providers of pending revalidations and to terminate them when revalidation is not completed within five years. For Sample Item 21, DMS ...
Views of Responsible Officials and Planned Corrective Action: DMS concurs with this finding. For Sample Item 15, DMS has implemented an automated process to notify providers of pending revalidations and to terminate them when revalidation is not completed within five years. For Sample Item 21, DMS has implemented automated processes utilizing data transfers from licensing boards that will now terminate providers when their license lapses. In addition, DMS is developing a mechanism to obtain information provided on W-9’s by utilizing an electronic process through the provider portal during enrollment. This provider was terminated on 10/2/23. For Sample Item 40, DMS has coordinated with Division of Provider Services and Quality Assurance (DPSQA) to interface with their certification tracking system and to provide additional notifications to providers when their certification period is nearing expiration. Notifications are being sent 30 days prior to the lapse of certification. DMS confirmed with DPSQA that there were no adverse events that lead to the termination of the provider’s certification. Anticipated Completion Date: June 30, 2025 Contact Person: Elizabeth Pitman Director, Division of Medical Services Department of Human Services 700 Main Street Little Rock, AR 72201 (501) 244-3944 Elizabeth.Pitman@dhs.arkansas.gov
View Audit 348267 Questioned Costs: $1
Finding 530177 (2024-028)
Significant Deficiency 2024
Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. The first two deficiencies occurred prior to implementation of the agency’s current integrated eligibility system (ARIES). The date of death for the beneficiary did not cross over from the prior eligibility ...
Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. The first two deficiencies occurred prior to implementation of the agency’s current integrated eligibility system (ARIES). The date of death for the beneficiary did not cross over from the prior eligibility system to MMIS. The agency has implemented a process to monitor and address when eligibility updates do not cross over successfully from the ARIES system to MMIS. For the second case, the missing documentation was likely the result of a failure to scan or appropriately index the document in the prior eligibility system. The agency will continue its practice of reviewing a sample of eligibility cases for accuracy. For the third case, the coverage did not close properly at the end of the month due to a system defect. The correction for this defect was deployed in ARIES on 3/31/24. Anticipated Completion Date: Complete Contact Person: Mary Franklin Director, Division of County Operations Department of Human Services 700 Main Street Little Rock, AR 72201 (501) 681-8377 Mary.Franklin@dhs.arkansas.gov
View Audit 348267 Questioned Costs: $1
Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. Since June 2023, DYS has made multiple changes to improve monitoring of suspension and reinstatement of Medicaid eligibility for incarcerated juveniles. For juveniles with SSI Medicaid, the Social Security A...
Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. Since June 2023, DYS has made multiple changes to improve monitoring of suspension and reinstatement of Medicaid eligibility for incarcerated juveniles. For juveniles with SSI Medicaid, the Social Security Administration (SSA) is responsible for suspending Medicaid coverage. All incarcerations for cases noted in the findings involving SSI Medicaid were reported timely to SSA by the agency. DYS closely monitors these cases and continues to send closure requests to SSA until the cases are closed out. SSI cases account for 76% of the total questioned costs noted in the finding. The Division of Medical Services (DMS) implemented an MMIS change in September 2024 that automatically updates member profiles to accurately reflect incarceration dates. This change will resolve the remaining deficiencies noted in the finding. All payments noted as questioned costs were capitated payments made for the PASSE, Dental Managed Care, and NET programs. The agency currently has a reconciliation process for all three programs that identifies payments made after the member’s incarceration date that should be recouped. Any uncollected overpayments noted in the findings will be recouped as part of the next reconciliation process. Anticipated Completion Date: Complete Contact Person: Elizabeth Pitman Director, Division of Medical Services Department of Human Services 700 Main Street Little Rock, AR 72201 (501) 244-3944 Elizabeth.Pitman@dhs.arkansas.gov
View Audit 348267 Questioned Costs: $1
Views of Responsible Officials and Planned Corrective Action: DHS concurs with the finding. For Sample Item 32, the agency’s revalidation date was set for March 27, 2024, and the provider submitted their application for revalidation prior to that date. System updates and monitoring controls have bee...
Views of Responsible Officials and Planned Corrective Action: DHS concurs with the finding. For Sample Item 32, the agency’s revalidation date was set for March 27, 2024, and the provider submitted their application for revalidation prior to that date. System updates and monitoring controls have been implemented to ensure correct revalidation dates are entered in MMIS. For Sample Item 15, the provider submitted a revalidation application prior to their scheduled termination date. Since there was an active application in the system, the provider was not terminated. The revalidation was successfully completed. For Sample Item 21, the provider submitted their revalidation application on October 16, 2023, which was prior to the November 11, 2023 deadlines. Multiple follow-ups and requests for additional information from the provider resulted in completion of the revalidation after the deadline date. Anticipated Completion Date: Complete Contact Person: Elizabeth Pitman Director, Division of Medical Services Department of Human Services 700 Main Street Little Rock, AR 72201 (501) 244-3944 Elizabeth.Pitman@dhs.arkansas.gov
View Audit 348267 Questioned Costs: $1
Finding 530170 (2024-022)
Significant Deficiency 2024
Views of Responsible Officials and Planned Corrective Action: DHS concurs with the finding. The agency updated its documented controls in March 2024 to require confirmation that agreements are signed by all parties before processing adoption subsidy packets and that all adoption files contain comple...
Views of Responsible Officials and Planned Corrective Action: DHS concurs with the finding. The agency updated its documented controls in March 2024 to require confirmation that agreements are signed by all parties before processing adoption subsidy packets and that all adoption files contain complete documentation. All findings occurred prior to the agency updating its documented controls. Anticipated Completion Date: Complete Contact Person: Tiffany Wright Director, Division of Children and Family Services Department of Human Services 700 Main Street Little Rock, AR 72201 (501) 396-6477 Tiffany.wright@dhs.arkansas.gov
View Audit 348267 Questioned Costs: $1
Finding 530169 (2024-021)
Significant Deficiency 2024
Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. The DHS Accounts Receivables Unit is developing documented procedures and controls addressing the process for entering adoption subsidy overpayments into the agency’s accounts receivable system (AROPTS) and ...
Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. The DHS Accounts Receivables Unit is developing documented procedures and controls addressing the process for entering adoption subsidy overpayments into the agency’s accounts receivable system (AROPTS) and DCFS is updating documented procedures and training on reporting of collected overpayments to the Accounts Receivable Unit. System changes are also in process for AROPTS that will pull the adjusted balance for overpayments when a notice is being created. Anticipated Completion Date: April 30, 2025 Contact Person: Renee Ikard Chief Financial Officer Department of Human Services 700 Main Street Little Rock, AR 72201 (501) 682-8985 Renee.Ikard@dhs.arkansas.gov
View Audit 348267 Questioned Costs: $1
Finding 530161 (2024-013)
Significant Deficiency 2024
Views of Responsible Officials and Planned Corrective Action: ARS Discussion The Agency acknowledges the lack of adequate internal controls necessary to ensure accurate maintenance of supporting documentation during our migration to our new case management system (CMS). ARS Action Taken The Agency h...
Views of Responsible Officials and Planned Corrective Action: ARS Discussion The Agency acknowledges the lack of adequate internal controls necessary to ensure accurate maintenance of supporting documentation during our migration to our new case management system (CMS). ARS Action Taken The Agency has taken the below steps to mitigate the lack of internal controls regarding supporting documentation, mainly attachments, located in our CMS in the future. • As the transfer of data to our new CMS platform concludes, that impediment has significantly diminished. The Agency has an appropriate method of control in place to detect any case file errors that may occur because of an incomplete retrieval or an insufficient data element input. In both instances, data analyst personnel from Program, Planning, Development and Evaluation (PPD&E) employ RSA’s edit check process that identifies specific errors prior to submission of the RSA 911 report. Those errors are then methodically corrected in our CMS ensuring the RSA 911 report is error free. • In instances where information is miscoded in the client case file, or is missing, the division’s Quality Assurance (QA) team identifies those errors and employes best practice training methods to ensure the case file complies with federal regulations. • Finally, our new CMS data hosted on an AR DIS platform is regularly backed up on a separate server to ensure that if anything were to happen to the primary CMS, we have a back up of all case data, including supporting documentation, and attachments. This data would be able to be accessed as a backup if data in the CMS was compromised in any way. Anticipated Completion Date: Complete Contact Person: Robert Trevino Associate Commissioner of PPD&E Arkansas Rehabilitation Services 1 Commerce Way Little Rock, AR 72202 (501) 296-1604 Robert.Trevino@Arkansas.gov
Finding 530152 (2024-004)
Significant Deficiency 2024
Views of Responsible Officials and Planned Corrective Action: The Arkansas Department of Education (ADE), Division of Elementary and Secondary Education (DESE), Health and Nutrition Unit (HNU), concur with the finding. The HNU implemented a new application and payment system that began in 2024. Du...
Views of Responsible Officials and Planned Corrective Action: The Arkansas Department of Education (ADE), Division of Elementary and Secondary Education (DESE), Health and Nutrition Unit (HNU), concur with the finding. The HNU implemented a new application and payment system that began in 2024. During implementation and subsequent operations, several issues with data transfers between the old and new system were identified and now corrected. The HNU Application and Finance staff will receive training to ensure that all criteria are met prior to the retroactive payment of claims. Anticipated Completion Date: April 1, 2025 Contact Person: Sheila Chastain Associate Director Arkansas Department of Education, DESE, Nutrition Services #4 Capitol Mall, Box #12 Little Rock, AR 72201 (501) 324-9502 Sheila.Chastain@ade.arkansas.gov Pamela Burton Director Arkansas Department of Education, DESE, Nutrition Services #4 Capitol Mall, Box #19 Little Rock, AR 72201 (501) 320-8978 Pamela.Burton@ade.arkansas.gov
View Audit 348267 Questioned Costs: $1
The Midland School District will ensure all criteria and specific requirements are met for the District in processing free and reduced price meals for the District’s child nutrition program and classify them in accordance with federal guidelines established by the U.S. Department of Agriculture. Ap...
The Midland School District will ensure all criteria and specific requirements are met for the District in processing free and reduced price meals for the District’s child nutrition program and classify them in accordance with federal guidelines established by the U.S. Department of Agriculture. Applications will include the required information to be considered for free and reduced price meals.
A.      The District will establish controls to ensure free and reduced price meal applications are properly completed by the applicant before processing.
A.      The District will establish controls to ensure free and reduced price meal applications are properly completed by the applicant before processing.
B.      The District will ensure that a complete application includes the names of children for whom the application is made.
B.      The District will ensure that a complete application includes the names of children for whom the application is made.
C.      A SNAP case number of the household for whom the application is made if person has SNAP.
C.      A SNAP case number of the household for whom the application is made if person has SNAP.
D.      The signature of an adult household member has been submitted on the paperwork. (this may be a foster parent or an official of a court or other agency with responsibility for the child.
D.      The signature of an adult household member has been submitted on the paperwork. (this may be a foster parent or an official of a court or other agency with responsibility for the child.
E.       The names of all household members.
E.       The names of all household members.
F.       The amount of current income by each member and the source of the income.
F.       The amount of current income by each member and the source of the income.
G.      The last four of the social security number of the adult household member who signs the application or an indication that the household member does not have a social security number (box checked for “no social security number”) Indication that the child is a foster child
G.      The last four of the social security number of the adult household member who signs the application or an indication that the household member does not have a social security number (box checked for “no social security number”) Indication that the child is a foster child
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