Corrective Action Plans

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Corrective Action Planned: Management has replaced the property manager with a more experienced property manager who has a full and complete understanding of the HUD regulations and processes. Management has developed policies and procedures to establish a timely database of all recertification dat...
Corrective Action Planned: Management has replaced the property manager with a more experienced property manager who has a full and complete understanding of the HUD regulations and processes. Management has developed policies and procedures to establish a timely database of all recertification dates. Name(s) of Contact Person(s) Responsible for Corrective Action: Marcia Drake, Property Manager, Ashley Kratzer, Corporate Controller
Clinic management team acknowledges that from the audit selection made of 60 patients, 22 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. A de...
Clinic management team acknowledges that from the audit selection made of 60 patients, 22 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. A detail plan of correction has been developed and is listed below. With the exception of the last bullet below, these corrections were implemented in the fourth quarter of 2023 as a result of the 2022 finding. The last bullet was implemented in the first quarter of 2024. • 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) – Supervisor, 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-Supervisor 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-Supervisor and Assistant Manager monitor retention of all patient 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. Contact Person: Rajesh Mehta, Chief Financial Officer, Peter Ho Memorial Clinic Expected Completion Date: September 30, 2024
Finding 485421 (2023-002)
Significant Deficiency 2023
Corrective Action Plan - Finding 2023-002 Internal Control over Eligibility Department of Health and Human Services Foster Care Title IV-E - ALN #93.658 and Adoption Assistance Title IV-E - ALN #93.659. The County has reimplemented the previously performed procedure of completion and a sign off of a...
Corrective Action Plan - Finding 2023-002 Internal Control over Eligibility Department of Health and Human Services Foster Care Title IV-E - ALN #93.658 and Adoption Assistance Title IV-E - ALN #93.659. The County has reimplemented the previously performed procedure of completion and a sign off of a checklist of the documents reviewed in the Tile IV-E eligibility file. This review will be performed by an independent employee. This will typically be the TANF eligibility employee. A check mark will be placed on the check list beside each document that is reviewed and will include the initials of the employee completing the review. Any questions or concerns will be directed back to the original employee that performed the initial verification. Anticipated Completion Date: August 9, 2024. Person Responsible for Corrective Action: William Kepple Financial Operations Officer Human Services Department County of Butler PO Box 1208 Butler, PA 16003-1208. 724-284-5120. wkepple@co.butler.pa.us
We are currently in the process of retraining staff on the sliding fee scale procedures and required documentation.
We are currently in the process of retraining staff on the sliding fee scale procedures and required documentation.
With the newly hired staff as of October 2022, the process of selecting eligible tenants from the list has been accomplished by identifying the preference and verifying in writing th ereason for such preference to move forward with the housing the applicant. All verification is kep tin the eligible ...
With the newly hired staff as of October 2022, the process of selecting eligible tenants from the list has been accomplished by identifying the preference and verifying in writing th ereason for such preference to move forward with the housing the applicant. All verification is kep tin the eligible tenant file. The existing staff has had 10-15 years' experience maintaining Federal program waiting list.
City’s Corrective Action Plan: At the time of Emergency Rental Assistance Program (ERAP) implementation, the guidance provided by U.S. Treasury was continuously evolving and the ERAP team was navigating a complex social and economic crisis. Residents became unemployed, had income reductions as direc...
City’s Corrective Action Plan: At the time of Emergency Rental Assistance Program (ERAP) implementation, the guidance provided by U.S. Treasury was continuously evolving and the ERAP team was navigating a complex social and economic crisis. Residents became unemployed, had income reductions as direct result of the pandemic, and/or had limited access to technology to complete application documents. Prior to official guidance recommending the use of an attestation form, some applicants provided written statements that they did not have any income. Furthermore, these applications were accompanied by eviction notices. These households were clearly at risk of experiencing homelessness or housing instability, which constitutes an “eligible household” as defined by 15 USC 9058a (k)(3)(A)(ii). This section of the U.S. Code states that a “household can demonstrate a risk of experiencing homelessness or housing instability” by providing a “past due utility or rent notice or eviction notice.” While the portal used to intake, review, and approve applications shows occasional inconsistencies with income verification boxes not checked off, all of the sampled cases were verified to be under the income threshold, provided an eviction notice, past due rent notice, and/or signed a written statement that they had zero income. Although certain boxes were not checked within the portal, all cases were verified through diligent and compassionate coordination with households requesting support. Furthermore, a risk assessment by the State's Housing & Community Development for the 2021 Program Year evaluated the City's risk profile as Low Risk. All program expenditures were concluded in fiscal year 2022-23. This was one-time funding. There will be some administrative costs related to the grant in fiscal year 2023-24, but no additional funding was received, therefore eligibility requirements will not be direct material in fiscal year 2023-24. Responsible Person: Jordan Peterson (Deputy Director of Redevelopment), Carrie Wright (Director of Economic Development) Expected Implementation Date: July 2023
Center for Family Services acknowledges that its files lacked consistent documentation. Procedures have been revised to address this issue going forward. Recommendation: The Organization should continue to be vigilant in adhering to documentation requirements, even during inactive program periods, t...
Center for Family Services acknowledges that its files lacked consistent documentation. Procedures have been revised to address this issue going forward. Recommendation: The Organization should continue to be vigilant in adhering to documentation requirements, even during inactive program periods, to maintain compliance standards. Response: The Center for Family Services has reviewed and revised its procedures to ensure future adherence to documentation standards.
Audit Period: December 31, 2023 2023-001 Missing voucher documentation, U.S. Department of Labor Criteria: Internal controls over Federal awards must be designed and implemented to provide reasonable assurance of compliance with applicable Federal statutes, regulations, and the terms and conditions ...
Audit Period: December 31, 2023 2023-001 Missing voucher documentation, U.S. Department of Labor Criteria: Internal controls over Federal awards must be designed and implemented to provide reasonable assurance of compliance with applicable Federal statutes, regulations, and the terms and conditions of the Federal award. Condition: During our testing, we noted one instance, in a sample of 68 expenditures tested, in which supporting documentation could not be provided. Action Taken: Finance staff reviewed internal controls and the overall process with team members responsible for providing supporting documentation for all expenditures as well as those who receive and review documentation prior to processing expenses for reimbursement. In addition to this training, additional review for all supporting documents has been added prior to billing for expenses. Responsible Party: Accountant responsible for billing expenditures Point of Contact: Stephanie Smoot – VP of Finance – ssmoot@goodwillvalleys.com. Expected date of correction: End of May 2024 once made aware of missing documentation.
Status: Completed Corrective Action: The City disagrees with the finding. BDO’s review of the ERA2 administration costs should consider the timing of the static report submission. The report was prior to monthly close/reconciliation for March 2023 administrative expenses, which occurs the following ...
Status: Completed Corrective Action: The City disagrees with the finding. BDO’s review of the ERA2 administration costs should consider the timing of the static report submission. The report was prior to monthly close/reconciliation for March 2023 administrative expenses, which occurs the following month. The correct administration costs for Q2 is $40,484.26. We make every attempt to coincide the grant reporting requirements however, if there are updates/changes needed we make those adjustments in future reports. Person(s) Responsible for Implementing: Melissa Thate, HOST HSHR Director Implementation Date: N/A- the City disagrees with the finding
2023-002 Missing Eligibility Information - ALN# 14.181 Section 811 Supportive Housing for Persons with Disabilities – Year Ended June 30, 2023 Condition Found During the eligibility testing of the audit, the following deficiencies were identified – certain tenant files are not kept on file within...
2023-002 Missing Eligibility Information - ALN# 14.181 Section 811 Supportive Housing for Persons with Disabilities – Year Ended June 30, 2023 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 A new Finance Department position will be created that is responsible for working with residents and programmatic staff in order to ensure that tenant files are kept on file within the required compliance timeframe. Responsible Person for Corrective Action Plan Lore Baker, President & CEO Implementation Date of Corrective Action Plan September 2024
For Assistance Listing 93.011, the auditors were unable to obtain sufficient documentation supporting the compliance of the Corporation regarding eligibility. Participants are eligible to participate in the program and receive a gift card if they received a COVID-19 vaccine. The Corporation screene...
For Assistance Listing 93.011, the auditors were unable to obtain sufficient documentation supporting the compliance of the Corporation regarding eligibility. Participants are eligible to participate in the program and receive a gift card if they received a COVID-19 vaccine. The Corporation screened applicants for eligibility, however, they did not retain supporting documentation to support that the participants in the program had a COVID-19 vaccine. Compliance with the eligibility requirements is the responsibility of Kimberly Green Reeves, Executive Director of Community Impact and the grant coordinator. As grants G32HS42634C6 and U3SHS45317C6 ended May 31, 2023, and July 31, 2023, respectively, no further correction action will be taken. However effective August 15th, 2023, the Corporation has implemented the following changes, which we believe would address future internal control considerations. The below procedures were added to the grant checklist which is required on all grants applied for by the Corporation entities. Responsible parties are required to document all procedures and sign off on these procedures. The requirements formalize reporting and data management procedures, which include proper management approval and retention of these records. The grant checklist is additionally approved by the grant applicant and Vice President or Executive Director overseeing the grant. Determine if there are any eligibility requirements. If so, please list the requirements and how these requirements will be documented. • All eligibility requirements should be documented and signed off on at the time the eligibility is confirmed. • All documentation of these procedures should be retained and readily available upon request.
View Audit 317761 Questioned Costs: $1
A scope limitation qualified opinion was issued for Assistance Listing 10.557 as the auditors were unable to obtain sufficient documentation supporting the compliance of the Corporation regarding eligibility. The Corporation uses a paperless system as supported by the State of Indiana and the U.S. D...
A scope limitation qualified opinion was issued for Assistance Listing 10.557 as the auditors were unable to obtain sufficient documentation supporting the compliance of the Corporation regarding eligibility. The Corporation uses a paperless system as supported by the State of Indiana and the U.S. Department of Agriculture. Third-party documentation is reviewed by the Corporation at the time the initial eligibility determination of a WIC participant is made. However, due to the paperless system implemented in 2007, these records are not retained. The Corporation’s process for eligibility determination is as follows: 1. A (potential) participant comes into the WIC clinic 2. A clerk verifies information (by looking and checking the appropriate boxes on the screen) a. Proof of identification (driver’s license, birth certificate, hospital birth record, etc.) b. Proof of residence (bill, lease, driver’s license, etc.) c. Proof of income i. Working – 30 days of pay stubs ii. Medicaid – card needed 3. All of the above information is entered into the State of Indiana’s system a. System automatically determines eligibility i. If yes – they continue with appointment ii. If no – they get a letter explaining reason why (over income, etc.) Compliance with State of Indiana participant eligibility requirements is the responsibility of Leslie Miller, WIC Coordinator. As the Corporation follows the State of Indiana’s paperless system as described above, no further corrective action will be taken.
Recommendation: Our auditors recommended that we provide training to those making eligibility calculations and implementation in the new billing software. Action Taken: We are currently in the process of retraining staff on the sliding fee scale procedures and implementation in the new billing soft...
Recommendation: Our auditors recommended that we provide training to those making eligibility calculations and implementation in the new billing software. Action Taken: We are currently in the process of retraining staff on the sliding fee scale procedures and implementation in the new billing software. Name of Contact Person Responsible for Corrective Action: Kimberly Osborne, President/Chief Executive Officer, (607) 753-3797. Anticipated Completion Date: June 2024
Recommendation: We recommend procedures be strengthened to ensure that all requests for reimbursement are for expenditures that have been incurred and paid/disbursed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Name(s) of the contact person(s) res...
Recommendation: We recommend procedures be strengthened to ensure that all requests for reimbursement are for expenditures that have been incurred and paid/disbursed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Name(s) of the contact person(s) responsible for corrective action: Nick Robertson, Town Accountant Planned completion date for corrective action plan: The reconciliation meetings were reintroduced in December 2022 upon Nick Robertson’s hiring as Town Accountant. There have been monthly and/or as needed meetings since to reconcile ledgers before grant reimbursements are submitted. Action taken in response to finding: Prior to the turnover in the Finance Department which occurred during the FY22 to early FY23 period, there were consistent meetings between Finance/Accounting and Jacobs Engineering (they manage the Airport projects and prepare the reimbursement requests) to confirm that the Town’s accounting software matched the expenses on the reimbursement requests. These meetings reconciling the ledgers did not occur when this reimbursement request was submitted by Jacobs. These meetings have been reinstated on a monthly basis and occasionally more frequently as needed.
2023-002 Missing Eligibility Information - ALN# 14.181 Section 811 Supportive Housing for Persons with Disabilities – Year Ended June 30, 2023 Condition Found During the eligibility testing of the audit, the following deficiencies were identified – certain tenant files are not kept on file within...
2023-002 Missing Eligibility Information - ALN# 14.181 Section 811 Supportive Housing for Persons with Disabilities – Year Ended June 30, 2023 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 A new Finance Department position will be created that is responsible for working with residents and programmatic staff in order to ensure that tenant files are kept on file within the required compliance timeframe. Responsible Person for Corrective Action Plan Lore Baker, President & CEO Implementation Date of Corrective Action Plan September 2024
2023-002 Missing Eligibility Information - ALN# 14.181 Section 811 Supportive Housing for Persons with Disabilities – Year Ended June 30, 2023 Condition Found During the eligibility testing of the audit, the following deficiencies were identified – certain tenant files are not kept on file within...
2023-002 Missing Eligibility Information - ALN# 14.181 Section 811 Supportive Housing for Persons with Disabilities – Year Ended June 30, 2023 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 A new Finance Department position will be created that is responsible for working with residents and programmatic staff in order to ensure that tenant files are kept on file within the required compliance timeframe. Responsible Person for Corrective Action Plan Lore Baker, President & CEO Implementation Date of Corrective Action Plan September 2024
2023-002 Missing Eligibility Information - ALN# 14.181 Section 811 Supportive Housing for Persons with Disabilities – Year Ended June 30, 2023 Condition Found During the eligibility testing of the audit, the following deficiencies were identified – certain tenant files are not kept on file within...
2023-002 Missing Eligibility Information - ALN# 14.181 Section 811 Supportive Housing for Persons with Disabilities – Year Ended June 30, 2023 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 A new Finance Department position will be created that is responsible for working with residents and programmatic staff in order to ensure that tenant files are kept on file within the required compliance timeframe. Responsible Person for Corrective Action Plan Lore Baker, President & CEO Implementation Date of Corrective Action Plan September 2024
2023-002 Missing Eligibility Information - ALN# 14.181 Section 811 Supportive Housing for Persons with Disabilities – Year Ended June 30, 2023 Condition Found During the eligibility testing of the audit, the following deficiencies were identified – certain tenant files are not kept on file within...
2023-002 Missing Eligibility Information - ALN# 14.181 Section 811 Supportive Housing for Persons with Disabilities – Year Ended June 30, 2023 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 A new Finance Department position will be created that is responsible for working with residents and programmatic staff in order to ensure that tenant files are kept on file within the required compliance timeframe. Responsible Person for Corrective Action Plan Lore Baker, President & CEO Implementation Date of Corrective Action Plan September 2024
Oversight Agency for Audit, Retired Steelworkers Housing and Health Development Corporation respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Sui...
Oversight Agency for Audit, Retired Steelworkers Housing and Health Development Corporation respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067 Audit period: January 1, 2023 through December 31, 2023 The findings from the December 31, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. SECTION III – FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING No. 2023-001: Section 236 Mortgage Restructuring Note, ALN 14.103 Recommendation: The Project should implement procedures to ensure the Project verifies tenant eligibility through the EIV system in a timely manner. Action Taken: Staff training has been provided and included in monthly reporting procedures.
Finding 2023-002 – Budget to Actual Analysis Cluster: Research and Development Agency: Department of Commerce, Department of Energy, and Department of Health and Human Services Award Names: Standards/Guidance for Rapid Qualification of Metal-Based Additive Manufacturing, Accelerating Commercial Mari...
Finding 2023-002 – Budget to Actual Analysis Cluster: Research and Development Agency: Department of Commerce, Department of Energy, and Department of Health and Human Services Award Names: Standards/Guidance for Rapid Qualification of Metal-Based Additive Manufacturing, Accelerating Commercial Maritime Demonstration Projects for Advanced Nuclear Reactor Technologies, Safety and Health Risks in Energy Transition for the Commercial Fishing Industry Award Numbers: 70NANB21H038, DE-NE0009226, and U01OH012502 Assistance Listing Title: National Institute of Standards and Technology, Office of Nuclear Energy, Advanced Research Projects Agency, Office of Energy Efficiency and Renewable Energy, Center for Disease Control and Prevention (CDC) Assistance Listing Number: 11.609, 81.121, 81.135, 81.087, 93.262 Award Year: FY 2023 In response to FY 2022 Single Audit, ABS updated its internal policy to establish and maintain effective controls over budget to actual expense reviews. Current ABS policy, which was implemented in 2024, requires grant project managers to review budget to actuals on at least a quarterly basis, and a budget spreadsheet will be maintained and signed as proof of verification. To ensure consistency and formality in carrying out this requirement, ABS has begun utilizing a standardized template to facilitate reviews and track completion by process owners.
Finding 484529 (2023-058)
Significant Deficiency 2023
ALN: 93.558, Corrective Action Plan: Potential Risk of Inaccurate ACF 199 Reports - TANF - DPHHS - The Montana Department of Public Health and Human Services developed procedures in February 2023 for the Temporary Assistance for Needy Families program and is currently working to create a tool to b...
ALN: 93.558, Corrective Action Plan: Potential Risk of Inaccurate ACF 199 Reports - TANF - DPHHS - The Montana Department of Public Health and Human Services developed procedures in February 2023 for the Temporary Assistance for Needy Families program and is currently working to create a tool to better document the review and approval of the report. However, a comprehensive review of the data prior to submission is not possible, due to the type of data being submitted. The data is submitted in code (i.e., strings of numbers) to be read by the Administration for Children and Families (ACF) system. A review will be done to the extent possible to ensure expectations are met about file sizes and numbers of rows. Review results will be documented in a review checklist, which will include a notation of the file review and signature. Person(s) Responsible for Corrective Measures: Chappell Smith, Administrator, Montana Department of Public Health and Human Services, Target Date: 11/30/2024
ALN: 21.023, Corrective Action Plan: Inadequate Eligibility Documentation - ERA - DOC - The Montana Department of Commerce has modified the program's payment platform to ensure compliance with federal requirements. Person(s) Responsible for Corrective Measures: Ingrid Mallo, Chief Financial Off...
ALN: 21.023, Corrective Action Plan: Inadequate Eligibility Documentation - ERA - DOC - The Montana Department of Commerce has modified the program's payment platform to ensure compliance with federal requirements. Person(s) Responsible for Corrective Measures: Ingrid Mallo, Chief Financial Officer, Montana Department of Commerce, Target Date: Completed
View Audit 317490 Questioned Costs: $1
ALN: 84.371, Corrective Action Plan: Noncompliant Eligibility Determinations - Literacy - OPI - The Montana Office of Public Instruction does not concur with finding 2023-041. The Office notes that the United States Department of Education approved the application eligibility requirements. Perso...
ALN: 84.371, Corrective Action Plan: Noncompliant Eligibility Determinations - Literacy - OPI - The Montana Office of Public Instruction does not concur with finding 2023-041. The Office notes that the United States Department of Education approved the application eligibility requirements. Person(s) Responsible for Corrective Measures: April Grady, Chief Financial Officer, Montana Office of Public Instruction, Target Date: N/A
View Audit 317490 Questioned Costs: $1
ALN: 93.767, Corrective Action Plan: Inadequate Provider Eligibility Controls - CHIP - DPHHS - The Montana Department of Public Health and Human Services processes Service Organizational Control (SOC) reports at the agency level. But the Children's Health Insurance Program (CHIP) will work with it...
ALN: 93.767, Corrective Action Plan: Inadequate Provider Eligibility Controls - CHIP - DPHHS - The Montana Department of Public Health and Human Services processes Service Organizational Control (SOC) reports at the agency level. But the Children's Health Insurance Program (CHIP) will work with its contractor to ensure it is clearly identified in future SOC reports to ensure receipt of assurances about provider screening and enrollment. Person(s) Responsible for Corrective Measures: Shellie McCann, Medicaid Systems Administrator, Montana Department of Public Health and Human Services, Target Date: 03/31/2025
View Audit 317490 Questioned Costs: $1
ALN: 93.775, 93.777, 93.778, Corrective Action Plan: Inadequate Medicaid ADP System Reviews - DPHHS - The Montana Department of Public Health and Human Services acknowledges that staff turnover contributed to the department's non-compliance. The department will reinstitute applicable controls. P...
ALN: 93.775, 93.777, 93.778, Corrective Action Plan: Inadequate Medicaid ADP System Reviews - DPHHS - The Montana Department of Public Health and Human Services acknowledges that staff turnover contributed to the department's non-compliance. The department will reinstitute applicable controls. Person(s) Responsible for Corrective Measures: Shellie McCann, Medicaid Systems Administrator, Montana Department of Public Health and Human Services, Target Date: 09/30/2024
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