Corrective Action Plans

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Federal Assistance Listing Number 93.917
Federal Assistance Listing Number 93.917
During our audit, we selected a sample of 60 clients receiving assistance under the Ryan White HIV/AIDS Program Part B (RWB) program to ascertain whether those clients met program eligibility requirements and whether costs charged to the RWB program were allowable. We noted two instances where HHHR...
During our audit, we selected a sample of 60 clients receiving assistance under the Ryan White HIV/AIDS Program Part B (RWB) program to ascertain whether those clients met program eligibility requirements and whether costs charged to the RWB program were allowable. We noted two instances where HHHRC determined that the clients were ineligible; however, certain costs associated with these clients were charged to the RWB program. Specifically, we found that:
·         For one of the 60 clients selected, the client exceeded income threshold to be considered low-income, as defined by the state.
·         For one of the 60 clients selected, the client exceeded income threshold to be considered low-income, as defined by the state.
·         For one of the 60 client files selected, no intake documents were collected.
·         For one of the 60 client files selected, no intake documents were collected.
Clients receiving assistance under the RWB program are subject to eligibility requirements contained in the Health Resources and Services Administration’s HIV/AIDS Bureau Policy Clarification Notice No. 13-02 Clarifications on Ryan White Program Client Eligibility Determinations and Recertification ...
Clients receiving assistance under the RWB program are subject to eligibility requirements contained in the Health Resources and Services Administration’s HIV/AIDS Bureau Policy Clarification Notice No. 13-02 Clarifications on Ryan White Program Client Eligibility Determinations and Recertification Requirements. To be eligible, clients must have a medical diagnosis of HIV/AIDS and be (a) a low-income individual, (b) a resident of the state, and (c) uninsured or underinsured, as defined by the state. Eligibility determination is required before participation in the RWB program during the in-take process. Re-assessments are performed at least once every 6 months thereafter.
Per HHHRC’s Ryan White Eligibility Policy, these eligibility criteria are to be documented in their Annual Certification forms. HIV status must be documented by a written statement from a medical provider. Lab results may only be used on an interim basis. Residency must be documented with a State...
Per HHHRC’s Ryan White Eligibility Policy, these eligibility criteria are to be documented in their Annual Certification forms. HIV status must be documented by a written statement from a medical provider. Lab results may only be used on an interim basis. Residency must be documented with a State ID card or a driver’s license, lease agreement, utility bill, official government mail, bank statement, pay stub, or a verification letter from an agency providing the client with housing. Income levels must be documented with the most recent pay stubs covering 30 consecutive days, benefit statements, IRS tax transcripts, or a signed statement from the client attesting to no income or very low income. For the payer of last resort criteria, HHHRC’s policy states that they must, at a minimum, assess and re-assess the client’s eligibility for benefits such as MedQuest. In addition, HHHRC must make reasonable efforts to secure funding, besides the Ryan White program, including pursuing enrollment into health care coverage.
Additionally, costs associated with clients determined to be ineligible to receive assistance under the RWB program are unallowable.
Additionally, costs associated with clients determined to be ineligible to receive assistance under the RWB program are unallowable.
HHHRC did not adhere to established policies and procedures requiring that the client meet all eligibility requirements during the in-take and re-assessment process before costs are charged to the RWB program.
HHHRC did not adhere to established policies and procedures requiring that the client meet all eligibility requirements during the in-take and re-assessment process before costs are charged to the RWB program.
HHHRC did not comply with the RWB program allowable cost requirements for the two instances noted above. As a result, $379 of unallowed costs were erroneously billed to the RWB program.
HHHRC did not comply with the RWB program allowable cost requirements for the two instances noted above. As a result, $379 of unallowed costs were erroneously billed to the RWB program.
We recommend that HHHRC adhere to established policies and procedures requiring that only allowable costs associated with clients determined to be eligible to receive benefits be charged to the RWB program.
We recommend that HHHRC adhere to established policies and procedures requiring that only allowable costs associated with clients determined to be eligible to receive benefits be charged to the RWB program.
In addition, we recommend that HHHRC follow up with the State to determine the appropriate action for any costs erroneously billed to the RWB program.
In addition, we recommend that HHHRC follow up with the State to determine the appropriate action for any costs erroneously billed to the RWB program.
Views of Responsible Officials and Planned Corrective Action
Views of Responsible Officials and Planned Corrective Action
HHHRC agrees that policies and procedures must be followed so that only allowable costs with clients documented to be eligible are processed. HHHRC is working with the State to determine the best process for ensuring there were no other billings for ineligible clients. HHHRC will be instituting a ...
HHHRC agrees that policies and procedures must be followed so that only allowable costs with clients documented to be eligible are processed. HHHRC is working with the State to determine the best process for ensuring there were no other billings for ineligible clients. HHHRC will be instituting a fiscal review to ensure any errors are caught prior to processing billings.
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 ...
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 Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the eligibility compliance requirement. Context: During the testing of internal controls over eligibility determinations for free and reduced meals, we noted there was no formal review control in place for 26 of the 60 applications selected for testing. Additionally, for one of the 60 selections, the student was improperly classified as free when the annual income per the student's application exceeded the corresponding threshold for that determination. Corrective Action Plan: The School Corporation will implement a system of internal controls to ensure that the applications are being formally reviewed by the Food Services Director and the Corporation Treasurer. Person responsible for implementation and projected implementation date: The Food Services Director and the Corporation Treasurer will be responsible for implementing the corrective action, which will begin with applications for the 2025-2026 school year.
View Audit 347315 Questioned Costs: $1
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-Throug...
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 Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the eligibility compliance requirement. Context: During testing over controls for eligibility, for 16 of the 60 applications selected, we noted there was no formal evidence that the applications had been reviewed and further, the application did not specify if the student was eligible for free or reduced lunch. We also noted for 2 of the 60 selections, management was unable to provide support for the student that was selected. Corrective Action Plan: The Food Services Director and the Treasurer will both sign off on the applications once they have completed their review to determine if the application was accurately denied or approved for free or reduced meals. The completed and reviewed applications will be maintained in a safe and secure location, so they are easily accessible in an instance where they would need to be referenced. Person responsible for implementation and projected implementation date: The Food Services Director and the Corporation Treasurer will implement the corrective action plan starting with applications received for the 2025-2026 school year.
Description of Finding: Criteria or Specific Requirement: The lead agencies, who are subrecipients under the Federal Awards, are required to have clients sign the Form 502045-A CSFP Sub-Agency Monthly Participant Sign-in Sheet to self-declare program eligibility before food is disbursed. Issue and C...
Description of Finding: Criteria or Specific Requirement: The lead agencies, who are subrecipients under the Federal Awards, are required to have clients sign the Form 502045-A CSFP Sub-Agency Monthly Participant Sign-in Sheet to self-declare program eligibility before food is disbursed. Issue and Cause: There were three instances out of 40 distributions tested where this signoff was not completed. Due to the hectic environment at the lead agencies during food distribution day, oversights have occurred when obtaining the required client signoff. Statement of Concurrence or Nonconcurrence: PARF management has reviewed the 2024-001 finding and concurs with the recommendations as stated. Corrective Action: PARF has an extensive training process in place for lead agencies, in relation to grant award compliance requirements, which includes the provision of training manuals and monthly phone calls to review matters. In addition, PARF provides updates to the lead agencies as new or amended requirements are enacted. Further, PARF does periodic reviews of the lead agencies and completes the biennial review Form 502035 CSFP Management Evaluation. PARF will continue to reiterate the required signoff process with the lead agencies during phone calls, training session and reviews. In addition for FY 2025 PARF will be conducting a mandatory webinar to ensure all the lead agencies are understanding the procedure and why it is important for 100 percent accuracies -https://docs.google.com/presentation/d/1YZgcq7SY4DmvhYrKZE8sp-NDhpuzn827PZDZ0xAKDw/edit?usp=sharing
Finding 529242 (2024-009)
Significant Deficiency 2024
Corrective Action Plan For the Year Ended June 30, 2024 Finding 2024-009 Inadequate Request for Information Name of contact person: Corrective Action: Proposed completion date: Section III - Federal Award Findings and Question Costs (continued) Develop and implement standardized request forms or tem...
Corrective Action Plan For the Year Ended June 30, 2024 Finding 2024-009 Inadequate Request for Information Name of contact person: Corrective Action: Proposed completion date: Section III - Federal Award Findings and Question Costs (continued) Develop and implement standardized request forms or templates to ensure all required information is consistently requested. Requests should explicitly list the documents or details needed, including examples (e.g., “bank statements for the last 3 months,” “proof of income,” or “vehicle registration”). Conduct targeted training sessions focused on requesting information accurately and comprehensively, including case scenarios and examples of complete and incomplete requests. Ensure staff are familiar with the guidelines on what information is required based on program eligibility rules. Reinforce these guidelines in regular meetings. Require staff to use an Eligibility Request Checklist before sending information requests to ensure all necessary items are included and accurately described. Incorporate checklists into second-party reviews to catch errors or omissions before client communication is sent. Supervisors should review outgoing requests during second-party or random audits to ensure they meet the standards of completeness and clarity. Use case management systems to track and audit requests for adequacy and timeliness. Access the Inbox/Task Dashboard in NC FAST to review pending tasks and notifications. Focus on tasks related to requests for information to ensure timely follow-up. Set reminders for staff to address tasks nearing their deadlines. Use the Verification Report in NC FAST to identify cases where requested information is still missing. This report helps staff track what verifications are outstanding. Run O&M reports to monitor applications, recertifications, and requests for information that are incomplete or overdue. Use these reports to identify cases where staff may have issued inadequate or untimely requests. Filter reports by due dates to ensure that cases are progressing within program timeframes (e.g., 45-day processing deadlines). Access the Evidence Dashboard in NC FAST to confirm whether evidence entries match the requested documents. Check if all evidence has been appropriately documented, verified, and updated within the system. Ensure that staff are documenting details of all requests for information in the case notes, including: What was requested. When it was requested. How it was communicated (e.g., mail, phone, email). Case notes should also reflect follow-up actions. Create a Compliance Log: Maintain a log of cases flagged for inadequate or late requests for information. Use this log to track resolution and identify recurring staff training needs. Management monitor daily to track progress of this issue and modify the controls as needed. Tiffiany Walton, Interim Director Melissa Castelow, F&C Medicaid Supervisor Anetre Vaughan, Adult Medicaid Supervisor BUILD YOUR FUTURE ON OUR FOUNDATION 115 Justice Drive  Suite 1  Winton, North Carolina 27986 Office 252.358.7805  Facsimile 252.358.0198  www.HerfordCountyNC.gov 126
Finding 529241 (2024-008)
Significant Deficiency 2024
Corrective Action Plan For the Year Ended June 30, 2024 Finding 2024-008 Inaccurate Resources Entry Name of contact person: Corrective Action: Proposed completion date: Ensure staff are well-versed in the policy guidelines, such as MA-2230 Financial Resources, which define what constitutes a resourc...
Corrective Action Plan For the Year Ended June 30, 2024 Finding 2024-008 Inaccurate Resources Entry Name of contact person: Corrective Action: Proposed completion date: Ensure staff are well-versed in the policy guidelines, such as MA-2230 Financial Resources, which define what constitutes a resource and what is countable. Use real-world scenarios and examples of correct and incorrect resource entries during staff training sessions. Encourage staff to complete or revisit relevant training modules to strengthen their understanding. Implement resource-specific checklists to guide staff through the entry process, ensuring all required data is verified and documented before submission. Require staff to confirm that resource amounts match the verification provided (e.g., bank statements, property valuations, vehicle assessments). Staff should routinely check determination history to ensure consistency and prevent duplicate or conflicting entries. Encourage staff to validate that resource entries align with other evidence in NC FAST. Require staff to compare manual budget calculations against NC FAST results to ensure accuracy. Conduct regular second-party reviews of resource entries to identify and correct errors before case authorization. Emphasize the importance of accuracy during staff meetings and coaching sessions. Hold staff accountable for errors by requiring signed checklists or certifications of reviewed work for each case. Ensure staff follow up on incomplete or unclear resource verifications in a timely manner to avoid delays or incorrect determinations. Require staff to consistently monitor inbox tasks, Medicaid Verification Reports, and other system alerts to address resource discrepancies promptly. Supervisors will provide one-on-one coaching for staff struggling with resource accuracy, using specific examples from their cases as teaching opportunities. Implement knowledge checks or mini-quizzes after training sessions to reinforce critical points about accurate resource entry. Share common errors and their solutions in unit meetings to create a learning environment focused on improvement. By combining training, tools, oversight, and accountability, the likelihood of inaccurate resource entry can be minimized effectively. Management monitor daily to track progress of this issue and modify the controls as needed. Section III - Federal Award Findings and Question Costs (continued) Tiffiany Walton, Interim Director Melissa Castelow, F&C Medicaid Supervisor Anetre Vaughan, Adult Medicaid Supervisor BUILD YOUR FUTURE ON OUR FOUNDATION 115 Justice Drive  Suite 1  Winton, North Carolina 27986 Office 252.358.7805  Facsimile 252.358.0198  www.HerfordCountyNC.gov 125
Finding 529240 (2024-007)
Significant Deficiency 2024
Corrective Action Plan For the Year Ended June 30, 2024 Finding 2024-007 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed completion date: Section III - Federal Award Findings and Question Costs (continued) Management monitor daily to track progress of this issue and ...
Corrective Action Plan For the Year Ended June 30, 2024 Finding 2024-007 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed completion date: Section III - Federal Award Findings and Question Costs (continued) Management monitor daily to track progress of this issue and modify the controls as needed. Monthly second-party reviews will continue to be conducted to ensure accuracy in case processing. Peer-to-peer second-party reviews will be implemented monthly to encourage collaborative oversight. Staff will be required to perform second-party reviews of their own recertifications to reinforce attention to detail. Application checklists will be utilized for all applications and recertifications to verify that staff collect and verify the correct data needed for processing. Staff will complete and sign checklists for every application and recertification, holding them accountable for accuracy and thoroughness. All staff have been and will continue to be trained on MA-2230 Financial Resources, including identifying resources and determining which are countable. Facilitated trainings on properties, resources, and vehicles will continue to be conducted. Staff will revisit Learning Gateway trainings as needed to reinforce understanding and compliance. Knowledge checks will be incorporated into all trainings to evaluate staff comprehension. Staff will be trained on the importance of completing and utilizing vehicle forms during both applications and recertifications. Staff are encouraged to consistently review determination history prior to case authorization to ensure household composition and income are accurate. NC FAST will be reviewed during applications and recertifications to verify vehicle information and other resources. Staff will confirm that all case files include online verifications, documented resources and income, and that the amounts agree with information in NC FAST. Documentation in case notes will clearly indicate the actions performed and their results. Supervisors will continue to meet with staff individually for coaching sessions to address findings and collaboratively discuss areas for improvement. Supervisors will emphasize the importance of accuracy and accountability in case processing during regular team discussions. Staff will now be held to a higher level of accountability with signed checklists serving as verification of completed work. This plan will ensure consistent improvement in case accuracy and processing while fostering accountability and professional growth among staff. Tiffiany Walton, Interim Director Melissa Castelow, F&C Medicaid Supervisor Anetre Vaughan, Adult Medicaid Supervisor BUILD YOUR FUTURE ON OUR FOUNDATION 115 Justice Drive  Suite 1  Winton, North Carolina 27986 Office 252.358.7805  Facsimile 252.358.0198  www.HerfordCountyNC.gov 124
Finding 529239 (2024-006)
Significant Deficiency 2024
Corrective Action Plan For the Year Ended June 30, 2024 Finding 2024-006 Untimely Review of SSI Termination Name of contact person: Corrective Action: Proposed completion date: Access and review the SSI Medicaid Termination Report daily in NC FAST. Assign staff or a designated point person to monito...
Corrective Action Plan For the Year Ended June 30, 2024 Finding 2024-006 Untimely Review of SSI Termination Name of contact person: Corrective Action: Proposed completion date: Access and review the SSI Medicaid Termination Report daily in NC FAST. Assign staff or a designated point person to monitor and act on SSI terminations flagged in the system. Set up system alerts or reminders in NC FAST to notify staff of pending SSI terminations requiring immediate review. Develop a log or tracker (manual or digital) to record SSI termination cases, including review dates, actions taken, and deadlines. Use NC FAST or a supplemental tool to track cases through the review process, ensuring no cases fall through the cracks. Retrain staff on Ex Parte Reviews for SSI terminations, including the process for reviewing and evaluating ongoing eligibility. Reinforce the importance of timely action to avoid benefit gaps or unnecessary terminations. Provide clear, step-by-step instructions for handling SSI terminations, including where to find relevant information in NC FAST and how to document actions in case notes. Conduct second-party reviews of SSI termination cases to ensure timely and accurate action is taken. Supervisors should periodically audit a sample of cases to identify delays or errors. Contact clients as soon as an SSI termination is flagged, requesting updated information and notifying them of the potential impact on their benefits. Provide clear instructions on what documents are needed to reassess eligibility. Use NC FAST to track follow-ups with clients, ensuring they respond within required timeframes. Ensure staff are completing Ex Parte Reviews as required, utilizing existing evidence and verifications to determine continued eligibility without unnecessary delays. Develop workflow efficiencies to handle SSI terminations more effectively, such as batching similar cases for quicker review. Run O&M and Medicaid reports to monitor the timeliness of SSI termination reviews. Share progress and findings during staff meetings to promote transparency and improvement. Review reports to identify recurring issues or barriers causing delays and address them promptly. By establishing a system of regular monitoring, staff training, and supervisory oversight, the issue of untimely SSI termination reviews can be effectively addressed and prevented in the future. Management monitor daily to track progress of this issue and modify the controls as needed. Tiffiany Walton, Interim Director Anetre Vaughan, Adult Medicaid Supervisor Melissa Castelow, F&C Medicaid Supervisor Section III - Federal Award Findings and Question Costs BUILD YOUR FUTURE ON OUR FOUNDATION 115 Justice Drive  Suite 1  Winton, North Carolina 27986 Office 252.358.7805  Facsimile 252.358.0198  www.HerfordCountyNC.gov 123
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