Corrective Action Plans

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The County concurs with this finding and will be working to improve the timeliness of Medicaid eligibility determinations by using the COGNOS reports to determine which cases are approaching the due date. Ongoing cases will be reviewed to verify continued eligibility.
The County concurs with this finding and will be working to improve the timeliness of Medicaid eligibility determinations by using the COGNOS reports to determine which cases are approaching the due date. Ongoing cases will be reviewed to verify continued eligibility.
Finding 2024-05 Inadequate System of Internal Controls over Benefit Limitation Condition: The Organization is required by the federal grant award to limit eligible client families to a maximum of eleven diapering supply "package" distributions per participating child over the course of the grant ag...
Finding 2024-05 Inadequate System of Internal Controls over Benefit Limitation Condition: The Organization is required by the federal grant award to limit eligible client families to a maximum of eleven diapering supply "package" distributions per participating child over the course of the grant agreement period. While the program design includes efforts to control this requirement, the eligibility database lacks the capability to assign or track unique participant identifiers needed to reliably enforce this limit. Additionally, there is no documentation to demonstrate that processes related to benefit limits are periodically reviewed or monitored. Due to the nature of recordkeeping in this area, testing compliance is challenging. Although no instances of noncompliance were identified in the sample tested, the Organization has not implemented an adequate system of internal controls to ensure consistent compliance with this grant criterion. Corrective Actions Taken or Planned: The Organization will transition to Pantry Soft a new CRM to track benefit limitation and mandatory documentation. We will include mandatory eligibility fields and document upload requirements before service can be recorded. We will develop a standardized eligibility checklist to be completed for all new and returning participants. Staff will be trained on Pantry Soft usage, eligibility requirements and document retention stands.
Finding 2024-04 Insufficient Documentation Supporting Eligibility Determination Condition: The Organization uses a database to collect and store documentation related to eligibility determinations for program participants. While this tool was used consistently throughout the year, the audit identif...
Finding 2024-04 Insufficient Documentation Supporting Eligibility Determination Condition: The Organization uses a database to collect and store documentation related to eligibility determinations for program participants. While this tool was used consistently throughout the year, the audit identified a lack of documented review procedures to verify that eligibility criteria were appropriately assessed and that all required documentation was obtained and retained. There is no established process to review or confirm the completeness and accuracy of eligibility documentation within the database. As a result, three of the sixty transactions tested did not include sufficient documentation to support eligibility determinations, representing instances of noncompliance with the eligibility requirements under the federal program. Corrective Actions Taken or Planned: The Organization will transition to Pantry Soft, a new CRM to centralize client records, eligibility documentation and service dates. We will include mandatory eligibility fields and document upload requirements before service can be recorded. We will develop a standardized eligibility checklist to be completed for all new and returning participants. Staff will be trained on Pantry Soft usage, eligibility requirements and document retention stands.
View Audit 365678 Questioned Costs: $1
The Center will - Provide immediate re-training to staff on issues identified, and - Continues to provide ongoing training to current and new staff involved in Sliding Fee Discount Program (SFDP) on program requirements and proper implementation of sliding fee determination and billing, and - Ha...
The Center will - Provide immediate re-training to staff on issues identified, and - Continues to provide ongoing training to current and new staff involved in Sliding Fee Discount Program (SFDP) on program requirements and proper implementation of sliding fee determination and billing, and - Has updated procedures for the Sliding Fee Discount Program approval process in which all sliding fee required documents are first reviewed and approved by a Clinic Supervisor or Center Manager for program compliance. This process was implemented in July 2025, which was at the mid-point of the current fiscal year and will assist in addressing any issues and training proactively, and - Will continue ongoing Sliding Fee Audit Tracers and Chart Audits to assess staff knowledge, provide feedback, and offer guidance, as needed
Tenant Filing Documentation Processes Recommendation: Implement processes to ensure that all required documentation is properly maintained for every tenant. Response/Action Taken: HALC has standardized the documentation process through updated SOPs and training modules. All staff are now required ...
Tenant Filing Documentation Processes Recommendation: Implement processes to ensure that all required documentation is properly maintained for every tenant. Response/Action Taken: HALC has standardized the documentation process through updated SOPs and training modules. All staff are now required to follow a uniform documentation checklist during intake and recertification. Additionally, file reviews are conducted quarterly by supervisors to ensure compliance and identify any gaps in documentation.
Federal Assistance Listing Numbers: 93.224 and 93.527 2024.001 Recommendation The Center should establish a system of internal controls to ensure that all patients receive the correct sliding fee discount. Action Taken Upon review it was determined that a single CDT code within ConnextCare’s practic...
Federal Assistance Listing Numbers: 93.224 and 93.527 2024.001 Recommendation The Center should establish a system of internal controls to ensure that all patients receive the correct sliding fee discount. Action Taken Upon review it was determined that a single CDT code within ConnextCare’s practice management system was not set-up with the proper procedure class and was omitted from the Sliding Fee Program maintenance schedule. The procedure class was corrected in the system. ConnextCare has audited all CDT codes and has determined that there were no other instances. Additionally, ConnextCare audit all D0274 charges back to January 1st, 2024, and determine there were no other occurrences. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Tracy Wimmer, CFO at (315) 298-6569 ext. 2020. Sincerely yours, Tracy Wimmer Chief Financial Officer
The Town is in the process of reviewing Policies and Procedures as they relate to Federal Awards.
The Town is in the process of reviewing Policies and Procedures as they relate to Federal Awards.
2024-001 Sliding Fee Discount Determination Name of Contact Person: Chief Financial Officer: Ahmed Zibare Corrective Action: Community Medical Wellness Centers USA: • Is providing immediate re-training to staff on issues identified beginning September 1, 2025. • Continues to provide ongoing training...
2024-001 Sliding Fee Discount Determination Name of Contact Person: Chief Financial Officer: Ahmed Zibare Corrective Action: Community Medical Wellness Centers USA: • Is providing immediate re-training to staff on issues identified beginning September 1, 2025. • Continues to provide ongoing training to current and new staff involved in Sliding Fee Discount Program (SFDP) on program requirements and proper implementation of sliding fee determination and billing. • Will continue ongoing Sliding Fee Audits to assess staff knowledge, provide feedback, and offer guidance, as needed. Proposed Completion Date: October 31, 2025
Management Response and Corrective Action: HACLA's Housing Services Department appreciates the work taken to review these files and to point out areas of improvement. While Housing Services regularly trains staff on the importance of reviews being conducted on time as well as accurately and require...
Management Response and Corrective Action: HACLA's Housing Services Department appreciates the work taken to review these files and to point out areas of improvement. While Housing Services regularly trains staff on the importance of reviews being conducted on time as well as accurately and requires Assistant Managers to Quality Control 100% of annual reviews prior to being approved for transmission, mistakes do still occur - whether it be from oversight or misfiling of documents. Additionally, the auditor noted staffing as an issue. At Jordan Downs which has been under transition, there has been staffing challenges as the occupied units decrease and residents are transitioned to new units. HACLA will ensure that the Assistant Manager continues to Quality Control 100% of the annual reviews prior to transmission. We will continue to reiterate the importance of these issues during our Annual Occupancy training as well as during bi-monthly Manager and Assistant Manager meetings and will continue to conduct any necessary and ad-hoc trainings throughout the year as issues are identified. Housing Services performs a bi-yearly audit of 10% of tenant files and the staff person conducting this audit meets with each site staff to review the errors found so that that staff know where they need to improve. As this internal audit was just completed in June, the cumulative results are being compiled and will be reviewed with all occupancy staff in a training that we are aiming to conduct in late October/early November 2025. These results will also be reviewed at the next Manager and Assistant Manager meeting. HACLA's Asset Management Department oversees the performance of the 3rd party property management companies. Although all HACLA staff and the 3rd party property managers have been trained on the public housing program requirements, Asset Management will implement an annual training to reinforce the key elements of the program requirements. Additionally, during our routine annual compliance monitoring, we will expand our file audits to 20% of the tenant files. All current year's audit observations will be reviewed with the Asset Management compliance team and our property managers, and a program training will be conducted by the end of October/early November 2025. Person Responsible: Director of Housing Services
Management Response and Corrective Action: Section 8 Management acknowledges the findings and remains committed to strengthening internal controls to ensure full compliance with HUD requirements for timely, complete, and accurate tenant files. To address the identified deficiencies and prevent futu...
Management Response and Corrective Action: Section 8 Management acknowledges the findings and remains committed to strengthening internal controls to ensure full compliance with HUD requirements for timely, complete, and accurate tenant files. To address the identified deficiencies and prevent future occurrences, the Housing Authority has taken the following corrective actions and implemented several operational and structural improvements: 1. Process Improvement and Oversight In mid-2022, the Housing Authority engaged Guidehouse, Inc., a national consulting firm specializing in public sector housing, to conduct a comprehensive review of Section 8 program operations. The recommendations from Guidehouse have been implemented. As part of HACLA’s transition to a new tenant software system in 2025, the department continues to make additional process improvements to further enhance accuracy, efficiency, and compliance. Key initiatives completed and sustained include: • Program Tracking and Performance Indicators Implemented a set of 30 program and performance indicators, a new Quality Control reporting system, and a Program Tracking and Performance Management Plan. Status: Completed and ongoing. • Housing Policy and Program Alignment Conducted benchmarking with peer agencies and academic institutions to identify 13 best practices across six strategic areas. These informed updates to policy and procedure. Status: Completed. • Workforce and Workload Optimization Assessed workload distribution and processing times, leading to the creation of a new generalist job classification. This has improved workload balance and increased staffing flexibility. Status: Completed; ongoing assessment continues for current classifications as they become vacant. HACLA evaluates and identifies when the new generalist position is appropriate based on program needs. • Training Program Development Identified training gaps and implemented a Training Program Implementation Plan that includes a structured training schedule, development of new materials, and outcome evaluations to ensure consistent and effective staff development. Status: Completed and ongoing. 2. File Corrections and Monitoring For all file-specific deficiencies noted in the audit sample, HACLA has contacted the families and either corrected the errors or will complete corrections within 30 days. Supervisory staff will verify completion and ensure updates are reflected in the system of record. 3. Enhanced Oversight and Accountability Section 8 leadership — including the Deputy Director and Assistant Directors — are providing ongoing oversight through managers and supervisors to ensure continued adherence to program requirements. This includes regular monitoring, corrective actions when necessary, and administrative accountability measures.   4. Timeframe and Responsible Parties These corrective actions are either completed or ongoing as part of our broader operational plan. Oversight for implementation and monitoring is the responsibility of the Deputy Director of Section 8, in coordination with Assistant Directors, managers, and supervisors across the program. Person Responsible: Director of Section 8
2024-002 ALN# 14.181 Supportive Housing for Persons with Disabilities, June 30, 2024 Eligibility - Missing Documentation Condition Found During the eligibility testing of the audit, the following deficiencies were identified – certain tenant files are not kept on file within the required compliance ...
2024-002 ALN# 14.181 Supportive Housing for Persons with Disabilities, June 30, 2024 Eligibility - Missing Documentation Condition Found During the eligibility testing of the audit, the following deficiencies were identified – certain tenant files are not kept on file within the required compliance timeframe. We consider this finding to be a material weakness with the Eligibility Compliance Requirement. Corrective Action Plan Additional staff have been hired to ensure all tenant files are kept current. A monthly review will be performed by the AVP of Asset Management to ensure accuracy. Responsible Person for Corrective Action Plan The Associate Vice President of Asset Management. Implementation Date of Corrective Action Plan December 2025
2024-002 ALN# 14.181 Supportive Housing for Persons with Disabilities, June 30, 2024 Eligibility - Missing Documentation Condition Found During the eligibility testing of the audit, the following deficiencies were identified – certain tenant files are not kept on file within the required compliance ...
2024-002 ALN# 14.181 Supportive Housing for Persons with Disabilities, June 30, 2024 Eligibility - Missing Documentation Condition Found During the eligibility testing of the audit, the following deficiencies were identified – certain tenant files are not kept on file within the required compliance timeframe. We consider this finding to be a material weakness with the Eligibility Compliance Requirement. Corrective Action Plan Additional staff have been hired to ensure all tenant files are kept current. A monthly review will be performed by the AVP of Asset Management to ensure accuracy. Responsible Person for Corrective Action Plan The Associate Vice President of Asset Management. Implementation Date of Corrective Action Plan December 2025
2024-002 ALN# 14.181 Supportive Housing for Persons with Disabilities, June 30, 2024 Eligibility - Missing Documentation Condition Found During the eligibility testing of the audit, the following deficiencies were identified – certain tenant files are not kept on file within the required compliance ...
2024-002 ALN# 14.181 Supportive Housing for Persons with Disabilities, June 30, 2024 Eligibility - Missing Documentation Condition Found During the eligibility testing of the audit, the following deficiencies were identified – certain tenant files are not kept on file within the required compliance timeframe. We consider this finding to be a material weakness with the Eligibility Compliance Requirement. Corrective Action Plan Additional staff have been hired to ensure all tenant files are kept current. A monthly review will be performed by the AVP of Asset Management to ensure accuracy. Responsible Person for Corrective Action Plan The Associate Vice President of Asset Management. Implementation Date of Corrective Action Plan December 2025
2024-002 ALN# 14.181 Supportive Housing for Persons with Disabilities, June 30, 2024 Eligibility - Missing Documentation Condition Found During the eligibility testing of the audit, the following deficiencies were identified – certain tenant files are not kept on file within the required compliance ...
2024-002 ALN# 14.181 Supportive Housing for Persons with Disabilities, June 30, 2024 Eligibility - Missing Documentation Condition Found During the eligibility testing of the audit, the following deficiencies were identified – certain tenant files are not kept on file within the required compliance timeframe. We consider this finding to be a material weakness with the Eligibility Compliance Requirement. Corrective Action Plan Additional staff have been hired to ensure all tenant files are kept current. A monthly review will be performed by the AVP of Asset Management to ensure accuracy. Responsible Person for Corrective Action Plan The Associate Vice President of Asset Management. Implementation Date of Corrective Action Plan December 2025
2024-002 ALN# 14.181 Supportive Housing for Persons with Disabilities, June 30, 2024 Eligibility - Missing Documentation Condition Found During the eligibility testing of the audit, the following deficiencies were identified – certain tenant files are not kept on file within the required compliance ...
2024-002 ALN# 14.181 Supportive Housing for Persons with Disabilities, June 30, 2024 Eligibility - Missing Documentation Condition Found During the eligibility testing of the audit, the following deficiencies were identified – certain tenant files are not kept on file within the required compliance timeframe. We consider this finding to be a material weakness with the Eligibility Compliance Requirement. Corrective Action Plan Additional staff have been hired to ensure all tenant files are kept current. A monthly review will be performed by the AVP of Asset Management to ensure accuracy. Responsible Person for Corrective Action Plan The Associate Vice President of Asset Management. Implementation Date of Corrective Action Plan December 2025
U.S. Department of Health and Human Services (HHS) SIGNIFICANT DEFICIENCY 2024-002 93.224/93.527 - Consolidated Health Centers (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, Public Housing Primary Care, and School Based Health Centers); (HHS Community Health Center...
U.S. Department of Health and Human Services (HHS) SIGNIFICANT DEFICIENCY 2024-002 93.224/93.527 - Consolidated Health Centers (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, Public Housing Primary Care, and School Based Health Centers); (HHS Community Health Center Program) Recommendation: We recommend that management hold additional training for front desk staff regarding the collection and verification of patient information for each patient. We also recommend enhancing your sliding fee status feature in your billing system to be completed for all patients to identify if the patient is insured, an application is pending, an application was received, an application was approved by finance for adjustment, and if an application was waived, to enable better tracking of the eligibility of each patient. We also recommend reviewing outstanding patient balances over 180 days to determine if follow up with a patient is required to collect the outstanding balance or to see if something has been collected by the front desk but not communicated to the finance team. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Management agrees with the recommendations identified above. During April 2025, NHA started a project to review Self Pay balances with service dates prior to January 1, 2025 to follow up on why the balance is still outstanding. This would have caught the error identified above. In addition to this project, they have held additional trainings for front desk staff and will continue to do so and will continue to improve their methods of tracking patient eligibility. Name(s) of the contact person(s) responsible for corrective action: Doni Miller Planned completion date for corrective action plan: November 30, 2025 If the Department of Health and Human Services has questions regarding this plan, please call Doni Miller, CEO at 419-720-7883.
Clinic management team acknowledges that from the audit selection made of 60 patients, 14 were not recertified during the six-month period and the supporting documentation was not always obtained or retained related to income verification, household size, residency, and health insurance status. The ...
Clinic management team acknowledges that from the audit selection made of 60 patients, 14 were not recertified during the six-month period and the supporting documentation was not always obtained or retained related to income verification, household size, residency, and health insurance status. The corrective action plan as developed for CY 2023 will be continued to be reinforced and followed. The plan did result in lower findings than in prior years. A new bullet was added in the fourth quarter of 2024 to further assist in meeting the compliance guidance. The addition is the last bullet listed below. • Revamped the job titles and description to encourage better return on recruitment efforts of medical case manager positions. • A position of Certified Case Counselor (CCC) – Lead, was created and filled to provide direct oversight over the medical case managers that perform the bi-annual certifications, and other daily tasks. • Added a quality management process, where Clinic clients are called ahead of time to notify them of their recertification requirements. • Data Analyst(s) generate a report of patients due for recertification 60 days in advance of the due date. The CCC-Lead is directly accountable to review the progress of the re-certification, and the process is monitored by the Assistant Manager of the clinic. The CCC-Lead and Assistant Manager monitor retention of all patients required supporting documentation in the patients’ medical records. • Patients that do not provide the required supporting documentation showing compliance with program eligibility as outlined in the grant agreement or are otherwise not able to be recertified six months after certification will be classified as inactive in the database used to submit invoices to the Ryan White HIV/AIDS Program. • CCC-Lead has been assigned to preview charts on the daily appointment book in EPIC and sending a list of the documentation required via email to case management staff as they meet with the patients. Contact Person: Mark Brown, Office Manager, Peter Ho Memorial Clinic Expected Completion Date: September 30, 2025
Finding 2024-001 - Housing Choice Voucher Tenant Files - Eligibility- Rent Calculations Noncompliance & Significant Deficiency Section 8 Housing Choice Voucher Cluster - ALN 14.871 Corrective Plan: 1. Income Verification Vanette Greer (please state tenant in audit for privacy act) - Stated that she...
Finding 2024-001 - Housing Choice Voucher Tenant Files - Eligibility- Rent Calculations Noncompliance & Significant Deficiency Section 8 Housing Choice Voucher Cluster - ALN 14.871 Corrective Plan: 1. Income Verification Vanette Greer (please state tenant in audit for privacy act) - Stated that she did not have one of her weekly check stubs due to being out with Covid. The Specialist processed the following: She totaled three (3) check stubs, then divided by 4 with one being at zero. She then annualized. Upon further review, it was determined that the YTD included an additional pay week (which she stated that she was out with Covid). An interim will be completed with a Retroactive Agreement offered. 2. Income Verification Lola Garrett (please state tenant in audit for privacy act) -A student credit was given but failed to acquire the necessary source document. No retro necessary. 3. Late Reexaminations (4). Four reexaminations were processed late due to insufficient information provided. The Executive Director approved the late reexams to preserve and grow the lease-up rate (at 86%} prior to HUD's declaration of insufficient funds (May 2025} for the remaining calendar year of 2025. 4. Inspections - We did have one inspection overlooked at an elderly site since 2020. The other tenants within the complex did receive inspections including SEMAP. We are now utilizing the PIC report going forward (instead of in-house system) to prevent such an oversight again. Person Responsible: Jeff Trahan, Executive Director Anticipated Completion Date: July 14, 2025 Note: It is the Auditee's position that such an oversight constitutes a "deficiency" (oversight flaw) rather than a Significant Deficiency leading to a Material Weakness in Internal Control.
Identification of the federal program: Federal Agency: U.S. Department of Homeland Security (DHS) Assistance Listing: 97.036 Disaster Grants – Public Assistance (Presidentially Declared Disasters) Pass-Through Grantor: Michigan State Police Emergency Management and Homeland Security Division Pass-Th...
Identification of the federal program: Federal Agency: U.S. Department of Homeland Security (DHS) Assistance Listing: 97.036 Disaster Grants – Public Assistance (Presidentially Declared Disasters) Pass-Through Grantor: Michigan State Police Emergency Management and Homeland Security Division Pass-Through Award Number: 4494-DR-MI Pass-Through Award Period: 7/1/2022-4/30/2023 Summary of Finding: The Personal Protective Equipment (PPE) and other COVID related supplies were not used within the period of performance outlined within the project worksheet. There were three FEMA obligations during FY 2024. An overstatement of expenditures in one of the projects (project 10) was identified with an obligation amount of $6,732,507. The period of performance as specified within the project 10 application is July 2, 2022 to April 30, 2023 and $1,077,759 of costs were not used by April 30, 2023. The overstatement represents approximately 16% of the amounts reported in the project 10 application and 14% of the total FEMA obligations in FY 2024. The total federal expenditures for FEMA for FY 2024 were $7,795,530. Corrective Action Plan: Management agrees that a thorough review of the claim was not completed prior to submitting the Request for Reimbursement to the State of Michigan, thus causing a control deficiency. In the future management will perform, document, and sign off on a thorough claim review to validate that all final adjustments have been submitted prior to submitting the Request for Reimbursement to the State. Individuals responsible for corrective action: Brittany Kruse, Vice President Finance and Assistant Controller Cindy Brink, Director, System Accounting and Reporting. Timing of corrective action: September 1, 2025 and going forward.
View Audit 365058 Questioned Costs: $1
Finding 574704 (2024-001)
Significant Deficiency 2024
PHA staff understand that income verification is essential to ensure that only eligible participants are provided with housing assistance benefits. The housing division has conducted a thorough review of their procedures and upgraded their internal Standard Operating Procedure documents to include d...
PHA staff understand that income verification is essential to ensure that only eligible participants are provided with housing assistance benefits. The housing division has conducted a thorough review of their procedures and upgraded their internal Standard Operating Procedure documents to include detailed step-by-step instructions designed to ensure compliance with EIV requirements. Additionally, staff have been in contact with their software provider about system enhancements such as the software producing a warning/error if an employee attempts to process an EIV reexamination without updating the EIV date. Such enhancements would further help to ensure compliance with federal program requirements. Staff have also been attending training to ensure sufficient knowledge of program EIV requirements. Staff believe these efforts should address this concern.
Need Analysis Planned Corrective Action: A report was created in Populi (Subsidized Eligibility Report) that will capture the students’ Cost of Attendance, SAI and if the student has zero need. A separate report will be generated to capture subsidized loan disbursements. The two reports will be c...
Need Analysis Planned Corrective Action: A report was created in Populi (Subsidized Eligibility Report) that will capture the students’ Cost of Attendance, SAI and if the student has zero need. A separate report will be generated to capture subsidized loan disbursements. The two reports will be combined to identify students who were awarded the subsidized loan in error. These reports will be reviewed after each add/drop period. Management has made a request to our vendor to create a special report that will capture this data in a more time efficient manner. Person Responsible for Corrective Action Plan: Darla Hopper, VP of Enrollment Management Anticipated Date of Completion: 09/30/2025
Federal Agency Name: U.S Department of Housing and Urban Development Program Name: Housing Choice Vouchers CFDA # 14.871 Finding Summary: Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Responsible Individuals: Celia Rivas Director of Assisted Hous...
Federal Agency Name: U.S Department of Housing and Urban Development Program Name: Housing Choice Vouchers CFDA # 14.871 Finding Summary: Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Responsible Individuals: Celia Rivas Director of Assisted Housing Corrective Action Plan: To strengthen our compliance oversight, we now have a total of two Compliance Managers on staff. We recently filled the previously vacant Compliance Manager position, which will enhance our capacity to monitor and ensure that annual recertifications are being processed every 12 months and support staff in adhering to HUD requirements and agency procedures. We have made progress in hiring and retaining staff, which is strengthening our operational capacity and will support the timely processing of annual recertifications in compliance with HUD requirements. Anticipated Completion Date: Ongoing
Finding Number: 2024-002 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Waylon Welvaert, Finance Manager Corrective Action Planned: All impacted employees have been reviewed and system adjustments in payroll have been com...
Finding Number: 2024-002 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Waylon Welvaert, Finance Manager Corrective Action Planned: All impacted employees have been reviewed and system adjustments in payroll have been completed. We have completed and submitted updated 2556 reports to the State on June 25, 2025, for the two quarterly reports that were affected. In addition, a review will be done at the start of every quarter to ensure that all allocations are being distributed correctly by the payroll system to ensure that reports are accurately completed. Anticipated Completion Date: We completed doing a full payroll system review on July 10, 2025 of account code classifications for the start of the 3rd quarter.
Finding Number: 2024-001 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: DeAnn Boney, Income and Healthcare Assistance Manager Corrective Action Planned: The results of the MA audit will be shared with all eligibility wo...
Finding Number: 2024-001 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: DeAnn Boney, Income and Healthcare Assistance Manager Corrective Action Planned: The results of the MA audit will be shared with all eligibility workers at a full team meeting. We will review the findings of the cases found in error and retrain workers on the expectation that the system will be updated when documentation is received on a case. The case findings will be reviewed directly with the individual workers that made the mistake on the case. They will update the case in the METS system to reflect the information in the case files. Anticipated Completion Date: Our full eligibility meeting is scheduled for July 29, 2025.
June 26, 2025 JGD & Associates LLP 9191 Towne Centre Drive Suite 340 San Diego, California 92122 Re: Corrective Action Plan Dear JGD & Associates LLP, The following are responses to the program audit findings from the most recent audit of Adjoin. 1. Current Year Findings 2024-001 a. Program Name: Su...
June 26, 2025 JGD & Associates LLP 9191 Towne Centre Drive Suite 340 San Diego, California 92122 Re: Corrective Action Plan Dear JGD & Associates LLP, The following are responses to the program audit findings from the most recent audit of Adjoin. 1. Current Year Findings 2024-001 a. Program Name: Supportive Services for Veterans Families: CFDA 64.033 b. Criteria: Failure to comply with the grant agreement’s terms and applicable regulations: The Organization did not comply with grant compliance requirements such as tracking administrative expenses charged to the program outside of the general ledger and in other matters noted in licensing reviews. c. Condition: The Organization has failed to comply with grant requirements due to lack of proper tracking of administrative expenses, limited compliance policies including approval over supplemental pay wages, and lack of proper training over verification and documentation processes. d. Response: The organization has been successfully running the SSVF program for 11+ years and tracking/calculating administrative costs utilizing offline Excel spreadsheets since inception which provided a low cost and flexible solution for our accounting team. However, as an outcome of our last SSVF audit and due to the size and scope of our SSVF operations, the VA is requiring Adjoin to cease maintaining offline spreadsheets and ensure that all SSVF grant costs are logged in the general ledger. We're partnering with JMT Consulting (our Sage Intacct solution provider) for their assistance in implementing a new Dynamic Allocation Module to our Sage platform allowing click thru capabilities to all of the administrative costs that hit the grant (not to exceed 10%). We're committed to rolling out this functionality and are excited about the efficiencies it will bring to the team along with ensuring compliance with VA requirements. 2. Prior Year Finding 2023-001 None noted. Contact person responsible for corrective action: Pat Phelan, CFO Completion date: August 31, 2025 If you have any questions regarding this plan, please contact Pat Phelan, CFO, 858- 292-2030, pat.phelan@adjoin.org. Sincerely, Pat Phelan CFO Adjoin
View Audit 364796 Questioned Costs: $1
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