Corrective Action Plans

Finding 480065 (2023-003)

Significant Deficiency 2023

Jericho Road Ministries D/b/a Jericho Road Community Health Center

NY

Eligibility

The Sliding Fee Discount Program policy was updated in March 2024, by Magdalena Nichols, the Chief Operating Officer, to add that the Billing Manager or his/her designee will review all Sliding Fee Scale (SFS) applications on a monthly basis for accuracy. To reduce clerical errors associated with th...

The Sliding Fee Discount Program policy was updated in March 2024, by Magdalena Nichols, the Chief Operating Officer, to add that the Billing Manager or his/her designee will review all Sliding Fee Scale (SFS) applications on a monthly basis for accuracy. To reduce clerical errors associated with the entry of data into the billing system, the SFS calculation was also added to the SFS application to ensure that we are offering the right SFS rate so that it can be verified at a later point.

View Audit 316348

Finding 480040 (2023-004)

Material Weakness 2023

Cornerstones Inc, Cornerstones Housing Corporation & Rihc Partners, Lp

VA

Eligibility Material Weakness Internal Control / Segregation of Duties

Cornerstones acknowledges that our files were incomplete. It is our position that the COVID-19 pandemic created immense need to which Cornerstones responded by expanding rapidly and mobilizing funding and program requests that did not receive the benefit of comprehensive planning; the focus was on h...

Cornerstones acknowledges that our files were incomplete. It is our position that the COVID-19 pandemic created immense need to which Cornerstones responded by expanding rapidly and mobilizing funding and program requests that did not receive the benefit of comprehensive planning; the focus was on health prevention, isolation and quarantine activities, and temporary shelter for homeless and other low-income, vulnerable seniors and disabled persons. We served those in need and our intake processes and recordkeeping processes did not keep pace. Additionally, given the time that has passed since the services in question, it is possible that records that did exist were misplaced. Staff turnover, resulting from the pandemic burden, made it challenging to go back to the work that had been done. Due to the timing of receiving this finding we were not able to make necessary adjustments to FY23 practices, but Cornerstones has since further emphasized the compliance and documentation needs of the case management process, and we have filled turned-over positions with experienced staff that also understand intake and documentation requirements. We have also hired a Senior Director, Finance with over 20 years of federal contracts experience that is an integral part of increased program compliance and operational oversight responsibilities within the Finance/Operations function. This Senior Director and Cornerstones’ Chief Financial & Operating Officer, Executive Vice President of Housing and Community Programs, and other program leaders and staff, will all work together to ensure that the file construction process is complete and timely for all participants. Due to timing of receiving this finding, remediation processes began in fiscal year 2024 and will be applied fully to the fiscal year 2025, beginning 7/1/2024, files.

View Audit 316337

Finding 479996 (2023-006)

Material Weakness 2023

Idaho State University

ID

Matching / Level of Effort / Earmarking Eligibility Material Weakness § 200.303

2023-006: Eligibility Federal Program Title: Student Financial Assistance Cluster Assistance Listing Number: Various Type of Finding: Material Weakness Other Matters Recommendation: ISU should evaluate its procedure...

2023-006: Eligibility Federal Program Title: Student Financial Assistance Cluster Assistance Listing Number: Various Type of Finding: Material Weakness Other Matters Recommendation: ISU should evaluate its procedures around disbursement of loans and ensure that notifications of disbursements are sent and contain all of the required elements outline in the FSA handbook. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To meet requirements outlined in 34 CFR 668.165, ISU includes information in a student’s award notification email and in their MyISU portal of pertinent Direct Loan information including their “Award Payment Schedule” and what steps to take to accept, decline or modify their award offers. Additionally, in July 2023, ISU implemented an automated email notification in our daily job scheduler, AppWorx, that is sent on each date of disbursement to student Direct Loan borrowers and parent borrowers of Direct Parent PLUS (added Feb 2024) notifying them of the disbursement and reminding them what they need to do to revise or cancel the loan disbursement. Name(s) of the contact person(s) responsible for corrective action: James Martin, Director of Financial Aid Planned completion date for corrective action plan: Implemented in December 2023.

View Audit 316332

Finding 479706 (2023-005)

Significant Deficiency 2023

United Way of West Florida, INC

FL

Reporting Subrecipient Monitoring Allowable Costs / Cost Principles

Procedures have been established to run program financial statements to monitor spending monthly. Form 1037 is being added to the comprehensive year-end checklist to ensure that the reports are completed in time.

View Audit 316262

Finding 479687 (2023-004)

Significant Deficiency 2023

Housing Authority of Newberry

SC

Eligibility HUD Housing Programs Internal Control / Segregation of Duties

2023-004 ALN 14.871 – Housing Voucher Cluster – Eligibility Management acknowledges the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Jessica Holcomb, Executive Director Projected Comple...

2023-004 ALN 14.871 – Housing Voucher Cluster – Eligibility Management acknowledges the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Jessica Holcomb, Executive Director Projected Completion Date: December 31, 2024

View Audit 316234

Finding 479686 (2023-003)

Significant Deficiency 2023

Housing Authority of Newberry

SC

Eligibility HUD Housing Programs Internal Control / Segregation of Duties

2023-003 ALN 14.850 - Public & Indian Housing Program - Eligibility Management acknowledges the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Jessica Holcomb, Executive Director Projecte...

2023-003 ALN 14.850 - Public & Indian Housing Program - Eligibility Management acknowledges the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Jessica Holcomb, Executive Director Projected Completion Date: December 31, 2024

View Audit 316234

Finding 479582 (2023-001)

Material Weakness 2023

Care Alliance Health Center

CT

Special Tests & Provisions Subrecipient Monitoring Eligibility

To Health Resources and Services Administration Care Alliance Health Center, Inc. respectfully submits the following corrective action plan for the year ended October 31, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: October 31, 2023 The findings from the October 31, 202...

To Health Resources and Services Administration Care Alliance Health Center, Inc. respectfully submits the following corrective action plan for the year ended October 31, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: October 31, 2023 The findings from the October 31, 2023, schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Federal Award Findings: Finding 2023.001 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken We will invest the time and resources into improving all areas related to the Sliding Fee Scale. We will implement the following steps to our process to ensure all federal guidelines and requirements are met. 1. Documented Process: Design and implement an internal control process to ensure sliding fee discounts are accurately calculated based on family size and income. 2. Documented Procedures: Establish clear procedures and guidelines for front desk staff to follow when determining discounts, including appropriate documentation requirements, eligibility criteria, and fee structure. These procedures will be aligned with our written policy to ensure consistency and accuracy in discount calculations. 3. Training and Education: Provide training to front desk staff members responsible for determining eligibility and applying sliding fee discounts to ensure they understand the process. 4. Regular Reviews: Implement regular reviews and monthly audits to verify that all discounts are properly supported and documented. Quarterly reviews will be conducted to verify compliance, identify areas for improvement, and evaluate the effectiveness of the sliding scale fee program to ensure it meets our patients' needs and complies with all federal guidelines. Responsible Parties: 1. The Controller and revenue cycle staff will develop the written procedure. 2. The Clinical Support Supervisor and revenue cycle staff will overseE3 the training. 3. The Revenue Cycle Manager_will monitor adherence to the procedure, conduct regular monthly audits, and report results to the Controller. 4. The Controller will conduct quarterly documentation reviews of the internal audit results. Timeline: 1. Procedure draft completion: Completed 2. Review and approval by senior management: July 24, 2024 3. Initial staff training session: July 25, 2024 4. Follow-up training sessions: As needed 5. Monthly compliance audits: Starting September 1, 2024

View Audit 316128

Finding 479533 (2023-005)

Significant Deficiency 2023

Worker Education & Resource Center INC

CA

Questioned Costs Eligibility Subrecipient Monitoring

During the period being audited internal controls for program participants documents were not reviewed by the former Executive Director. The new Executive Director has implemented a check and balance procedure that requires the Case Manager, Program Manager, and Executive Director to review and sign...

During the period being audited internal controls for program participants documents were not reviewed by the former Executive Director. The new Executive Director has implemented a check and balance procedure that requires the Case Manager, Program Manager, and Executive Director to review and sign off on participant application forms and to be documented on the participants application before the participant can move forward in the program.

View Audit 316070 Questioned Costs: $1

Finding 479531 (2023-003)

Significant Deficiency 2023

Worker Education & Resource Center INC

CA

Eligibility Subrecipient Monitoring Significant Deficiency § 200.303

During the period being audited internal controls for program participants documents were not reviewed by the former Executive Director. The new Executive Director has implemented a check and balance procedure that requires the Case Manager, Program Manager, and Executive Director to review and sign...

During the period being audited internal controls for program participants documents were not reviewed by the former Executive Director. The new Executive Director has implemented a check and balance procedure that requires the Case Manager, Program Manager, and Executive Director to review and sign off on participant application forms and to be documented on the participants application before the participant can move forward in the program.

View Audit 316070

Finding 479500 (2023-003)

Material Weakness 2023

Stoddard County Public Health Center

MO

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Subrecipient Monitoring

Name of Contact Person: Ben Godwin, Director. Recommendation: We recommendthe Center verify a vendor's status by checking the System for Award Management (SAM) maintained by the General Services Administration before making purchases expected to exceed $25,000. Corrective Action: We will verify...

Name of Contact Person: Ben Godwin, Director. Recommendation: We recommendthe Center verify a vendor's status by checking the System for Award Management (SAM) maintained by the General Services Administration before making purchases expected to exceed $25,000. Corrective Action: We will verify all vendors' status using the System for Award Management (SAM) maintained by the General Services Administration before making purchases expected to exceed $25,000. Proposed Completion Date: Immediately.

View Audit 316025

Finding 479493 (2023-001)

Significant Deficiency 2023

Summit Community Care Clinic, Inc.

CO

Internal Control / Segregation of Duties Subrecipient Monitoring Eligibility

Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee ra...

Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization acknowledges the error identified in the sliding fee discount. To address this issue and prevent future occurrences, the following corrective actions will be implemented: • Internal Audit Procedure o An internal audit procedure will be established to review 10% of the applications processed by each eligibility worker. This review will include verification of application accuracy, calculation correctness, and appropriate selection of sliding fee scales. • Identification of Errors o During the internal audit, if any errors are found, immediate action will be taken to rectify the identified mistakes. • Retraining and Testing o In cases where errors are detected, affected staff will undergo retraining. This retraining will cover all relevant processes and guidelines to ensure a thorough understanding. o Post-retraining, the staff will be subjected to a period of testing to confirm their competence in handling the sliding fee discount applications accurately. These steps will help ensure the integrity and accuracy of the Sliding Fee Discount program moving forward. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Dan Becker, CEO, at 970-423-8833.

View Audit 316020

Finding 479422 (2023-001)

Significant Deficiency 2023

Metropolitan Council of the Twin Cities Area

MN

HUD Housing Programs Eligibility Significant Deficiency § 200.303

Finding Number: 2023-001 Finding Title: Eligibility – Source Documentation Program: 14.871 Section 8 Housing Choice Vouchers 14.879 Mainstream Vouchers Name of Contact Person Responsible for Corrective Action: Terri Smith, Director Metro HRA Corrective Action Planned: HRA staff has developed a check...

Finding Number: 2023-001 Finding Title: Eligibility – Source Documentation Program: 14.871 Section 8 Housing Choice Vouchers 14.879 Mainstream Vouchers Name of Contact Person Responsible for Corrective Action: Terri Smith, Director Metro HRA Corrective Action Planned: HRA staff has developed a checklist form and update procedures for all staff to ensure signatures and forms are not missing in case files, this includes but is not limited to criminal background checks performed, citizenship forms, members of the household forms, and debts owed forms. The checklist will be completed for each case and stored in each participant file as part of the quality control process. The quality control process that was implemented in June 2023 had not been in place for a full year when the 2023 audit was completed. All files are being checked at Annual Recertification. Once this has been in place for a full year, all files will have been checked for the appropriate forms and signatures. Anticipated Completion Date: This process will be in place effective July 2024.

View Audit 315951

Finding 479358 (2023-001)

None 2023

Chemung County Treasurer

NY

Eligibility

Views of Responsible Officials and Planned Corrective Actions: Please accept the following corrective action plan from Chemung County Department of Social Services (DSS) regarding the audit findings shared with Chemung County DSS. In this audit, it was identified Chemung DSS had 1 of 40 HEAP cases w...

Views of Responsible Officials and Planned Corrective Actions: Please accept the following corrective action plan from Chemung County Department of Social Services (DSS) regarding the audit findings shared with Chemung County DSS. In this audit, it was identified Chemung DSS had 1 of 40 HEAP cases where an incorrect eligibility determination was made causing a negative impact to a client denying their case when indeed they were eligible. Chemung County DSS will take the following actions to address this deficiency: The HEAP Supervisor will hold an inservice refresher training by August 15th for all eligibility workers. This training will include budgeting income and determining eligibility for HEAP benefits. The examiner who made the error on this audit finding will be scheduled to take the HEAP eligibility and certification training course again with a target completion date of August 31st. The County is confident these two actions will help prevent this type of incorrect determination from happening again in the future and it will support reinforcing program knowledge for all involved.

View Audit 315856

Finding 479248 (2023-002)

Significant Deficiency 2023

Minnesota Prairie County Alliance

MN

Eligibility Significant Deficiency Internal Control / Segregation of Duties § 200.303

Finding Number: 2023-002 Finding Title: Child Support Non-Cooperation Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: DeAnn Boney, Income and Healthcare Assistance Manager Corrective Action Planned: The agency will take the following ...

Finding Number: 2023-002 Finding Title: Child Support Non-Cooperation Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: DeAnn Boney, Income and Healthcare Assistance Manager Corrective Action Planned: The agency will take the following steps to come into compliance: 1 Correct the cases that were found to be in error. 2 Establish an internal case review process. 3 Provide training and review the policy areas where deficiencies were identified with the family team. 4 Require family team to take new DHS training on assets. 5 Use DHS TANF case reviews as learning tools and share results with the family team. Anticipated Completion Date: Cases will be corrected, and the review process will be in place by 7/31/2024

View Audit 315808

Finding 479247 (2023-001)

Significant Deficiency 2023

Minnesota Prairie County Alliance

MN

Eligibility Significant Deficiency Internal Control / Segregation of Duties § 200.303

Finding Number: 2023-001 Finding Title: Eligibility Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: DeAnn Boney, Income and Healthcare Assistance Manager Corrective Action Planned: The agency will take the following steps to come into...

Finding Number: 2023-001 Finding Title: Eligibility Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: DeAnn Boney, Income and Healthcare Assistance Manager Corrective Action Planned: The agency will take the following steps to come into compliance: 1. Correct the cases that were found to be in error. 2. Establish an internal case review process. 3. Provide training and review the policy areas where deficiencies were identified with the family team. 4. Require family team to take new DHS training on assets. 5. Use DHS TANF case reviews as learning tools and share results with the family team. Anticipated Completion Date: Cases will be corrected, and the review process will be in place by 7/31/2024.

View Audit 315808

Finding 479213 (2023-002)

Material Weakness 2023

County of Blair

PA

Eligibility Internal Control / Segregation of Duties

BCCYF Program and Fiscal departments have updated the policy and procedure to adequately track yearly reviews for TANF eligible files. The fiscal department will track dates in QuickBooks. This will be used as a tickler system for notifying the fiscal department that a redetermination and review mus...

BCCYF Program and Fiscal departments have updated the policy and procedure to adequately track yearly reviews for TANF eligible files. The fiscal department will track dates in QuickBooks. This will be used as a tickler system for notifying the fiscal department that a redetermination and review must be completed. Prior to reporting of TANF, this tracking system will be used to ensure that all redeterminations and reviews are completed prior to submission. Timetable for Implementation: Implementation of the TANF policy and procedure will take effect FY 24/25 Quarter 1. Monitoring to Be Performed: A report will be saved in Excel of all TANF determinations/redeterminations and reviews per quarter. Name of Person(s) with Title and Scope of Responsibility: Name: Mindy Hostetler Title: Fiscal Officer. Corrective Action - Approved by: Tiffany Treese Position: Administrator Date: June 28, 2024.

View Audit 315756

Finding 479164 (2023-002)

Material Weakness 2023

Housing Authority of Aitkin County

NE

HUD Housing Programs Internal Control / Segregation of Duties Subrecipient Monitoring

Moving forward, a supervisory review of the move in files will be performed by a different staff member for the Authority than the staff member who initially determined eligibility. This will ensure that the Authority continues compliance with eligibility requirements.

View Audit 315674

Finding 479063 (2023-001)

Significant Deficiency 2023

Genesis Nonprofit Housing Corporation

MI

Eligibility HUD Housing Programs Significant Deficiency

The Corporation contacted the local Continuum of Care and regional HUD office in an effort to verify the required number of units occupied by individuals meeting the definition of "homeless". The local Continuum of Care had no record of the original grant agreement or required number of "homeless" t...

The Corporation contacted the local Continuum of Care and regional HUD office in an effort to verify the required number of units occupied by individuals meeting the definition of "homeless". The local Continuum of Care had no record of the original grant agreement or required number of "homeless" to be served. The Corporation contacted three staff in the regional HUD office, including the staff that had been our representative for annually renewed operation and support service grants for the two projects. Regional HUD staff were not able to provide a copy of the original grant agreements which would indicate the number of persons to be served by each project. HUD staff stated that they do not keep copies of grant agreements longer than seven years. Corporation management will continue to work with HUD personnel to determine the continuing compliance requirements of the Continuum of Care funding received for initial construction or rehabilitation. Corporation management will continue to serve individuals meeting the definition of homelessness at its two projects and document evidence in the file.

View Audit 315585

Finding 479055 (2023-002)

Material Weakness 2023

Evergreen Youth & Family Services, Inc.

MN

Eligibility Material Weakness Internal Control / Segregation of Duties

Transitional Living for Homeless Youth – Assistance Listing No. 93.550 Recommendation: It is recommended that the Organization implement controls to ensure that proper documentation and support for eligibility is obtained and reviewed by a qualified individual. Explanation of disagreement with audit...

Transitional Living for Homeless Youth – Assistance Listing No. 93.550 Recommendation: It is recommended that the Organization implement controls to ensure that proper documentation and support for eligibility is obtained and reviewed by a qualified individual. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Program Director will conduct Weekly Document Reviews for new and ongoing clients and will also verify eligibility as staff submit weekly request forms for clients to receive services. Weekly Review Schedule: • The Program Director will conduct a review of all documentation once a week. Verification Process: • During the review, the Program Director will verify that all required documents for eligibility is being completed accurately, processed, and documented. Documentation of Review: • The results of this review will be documented on each client’s initial intake form and in Apricot. • The Program Director will sign the intake form to indicate verification and completion of the review and will also document this in Apricot. • By adhering to this procedure, we ensure that all documentation is thoroughly checked and validated on a consistent basis, maintaining the integrity and accuracy of our eligibility process. Name(s) of the contact person(s) responsible for corrective action: Elena Guerra, EYS Program Director. Planned completion date for corrective action plan: ongoing

View Audit 315565

Finding 479054 (2023-001)

Significant Deficiency 2023

Evergreen Youth & Family Services, Inc.

MN

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Transitional Living for Homeless Youth – Assistance Listing No. 93.550 Recommendation: It is recommended that the Organization implement controls to ensure that clients meet eligibility requirements before being enrolled in the program. This could include verifying age at the time of enrollment and ...

Transitional Living for Homeless Youth – Assistance Listing No. 93.550 Recommendation: It is recommended that the Organization implement controls to ensure that clients meet eligibility requirements before being enrolled in the program. This could include verifying age at the time of enrollment and periodically re-verifying eligibility for on-going clients. Additionally, the Organization should review its policies and procedures to ensure that they are in compliance with program requirements and make any necessary updates. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Clearly define eligibility requirements for staff conducting intakes, along with the intake process. Staff and Program Director will reverify eligibility when doing check requests. Two opportunities will be provided for staff each year to revisit eligibility requirements and to provide staff with refresher training. Intake Process: At the time of intake into the program, client’s will be asked for their driver’s license, state ID, permit, tribal ID, or birth certificate. If the client doesn't have any Identification, staff will calculate the client's age using the client's reported date of birth. Staff will then attempt to help the client secure personal vital documents and add copies to the client file for verification. The Program Director will also verify eligibility. Training: Staff to be trained in the spring and fall of each year to revisit eligibility requirements, intake processes, along with agency core values, mission and vision. Name(s) of the contact person(s) responsible for corrective action: Elena Guerra, EYS Program Director Planned completion date for corrective action plan: • Clearly define eligibility requirements for staff by July 1, 2024. • Host trainings by September 30, 2024, and March 31, 2025. • Verify eligibility for new clients and current clients on an ongoing basis.

View Audit 315565

Finding 479030 (2023-003)

Material Weakness 2023

West Central Nebraska Joint Housing Authority

NE

Internal Control / Segregation of Duties Special Tests & Provisions Eligibility

Finding 2023-003: We agree with the finding. The Authority is relatively small with limited administrative staff. Further, the Board of Commissioners is a volunteer oversight board and not a managing board and does not have the time or expertise to provide the necessary services to correct the inte...

Finding 2023-003: We agree with the finding. The Authority is relatively small with limited administrative staff. Further, the Board of Commissioners is a volunteer oversight board and not a managing board and does not have the time or expertise to provide the necessary services to correct the internal control deficiencies noted. The Board had reviewed the issue and determined that there are no additional procedures which can be reasonably done to eliminate the deficiencies and accepts them.

View Audit 315549

Finding 478972 (2023-029)

Significant Deficiency 2023

Commonwealth of Massachusetts

MA

Questioned Costs Eligibility Special Tests & Provisions § 200.303

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES 2023-029 Medicaid Cluster, COVID-19 – Medicaid Cluster - Assistance Listing No. 93.775, 93.777, 93.778 Action taken in response to the finding: Dental: In response to the finding MassHealth required DentaQuest to: • Implement a corrective action plan to...

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES 2023-029 Medicaid Cluster, COVID-19 – Medicaid Cluster - Assistance Listing No. 93.775, 93.777, 93.778 Action taken in response to the finding: Dental: In response to the finding MassHealth required DentaQuest to: • Implement a corrective action plan to review and improve internal controls for the retention of provider enrollment documentation. • Ensure that all required documents are obtained and retained during validation and revalidation (i.e., “provider eligibility recertification”) processes for both individual dental providers and dental group practices. • Provide additional training to its provider enrollment staff on document retention. DentaQuest has implemented the above requirements to ensure provider license and revalidation dates are verified and maintained in MassHealth’s Medicaid Management Information System (MMIS) upon enrollment and subsequent revalidation. However, MassHealth anticipates that due to a backlog in the dental group practice revalidation process, dental group practice revalidation will not be complete January 2025. In the event that a MassHealth-enrolled provider or group practice does not timely respond to MassHealth revalidation requests, MassHealth initiates the process of terminating the provider’s MassHealth contract. BSS: For the one out of state provider that MassHealth did not revalidate, once identified, the provider was immediately put into a revalidation process. The provider did not respond to requests from MassHealth to revalidate and the provider’s MassHealth contract was terminated effective 1/21/2024 for failure to revalidate. MassHealth and BSS will continue to review and ensure that all providers who are required to revalidate are completed within the CMS required timeframes. Name of the contact person responsible for corrective action: Tuyen Vu, Deputy Director, Dental Janice Wadsworth, Director of Provider Operations Planned completion date for corrective action plan: Dental: January 1, 2025 BSS: January 21, 2024

View Audit 315520 Questioned Costs: $1

Finding 478930 (2023-016)

Significant Deficiency 2023

Commonwealth of Massachusetts

MA

Questioned Costs Eligibility Significant Deficiency § 200.303

EXECUTIVE OFFICE OF HOUSING AND LIVABLE COMMUNITIES 2023-016 COVID-19 – Emergency Rental Assistance Program – Assistance Listing No. 21.023 Action taken in response to the finding: EOHLC has notified Nan McKay of the income ineligibility. Nan McKay and EOHLC agreed with the finding. In February 202...

EXECUTIVE OFFICE OF HOUSING AND LIVABLE COMMUNITIES 2023-016 COVID-19 – Emergency Rental Assistance Program – Assistance Listing No. 21.023 Action taken in response to the finding: EOHLC has notified Nan McKay of the income ineligibility. Nan McKay and EOHLC agreed with the finding. In February 2024 Nan McKay sent payment recoupment letters to the landlord and the utility company to attempt to recoup the funds paid on behalf of an ineligible household. EOHLC met with Nan McKay leadership staff on 04/18/2024 to review income eligibility steps for emergency rental assistance programs. Name of the contact person responsible for corrective action: Amy Mullen Planned completion date for corrective action plan: April 18, 2024

View Audit 315520 Questioned Costs: $1

Finding 478723 (2023-009)

Significant Deficiency 2023

Hyde County

NC

Eligibility Significant Deficiency

Finding: 2023-009 Inadequate Request for information New Medicaid Supervisor started 6/1/23 & has put new procedures in place & training of staff to eliminate the errors that occurred during the audit. All cases are reviewed before being processed to make sure the worker has worked the case properly...

Finding: 2023-009 Inadequate Request for information New Medicaid Supervisor started 6/1/23 & has put new procedures in place & training of staff to eliminate the errors that occurred during the audit. All cases are reviewed before being processed to make sure the worker has worked the case properly & if not immediate feedback, staffing & 2nd party review form is provided to the worker. Due to COVID & the State continuing cases this resulted in 15 of 35 of our errors. Of the 20 left, one is from 2018 due to the claim being paid in 2023 for a date of service of 2018. The other 19 relate to a current recert, however, review shows these were still worked prior to new supervisor & new procedures put into place. New staff has been brought in & are being trained one-on-one. It is anticipated that it will take 6 months - 1 year to get the new workers completely trained in their program. Team also has a pending new hire. Staffing cases & 2nd party reviews will continue indefinitely. Lots of errors came from the worker not running TWN. New process includes when the recert is started the workers is to run OVS, AVS & TWN. This is checked during 2nd party that all were started the same day. Workers are being taught that they are to upload their documents in NCFast at review/app & hard copy files are being eliminated to risk being lost.

View Audit 315389

Finding 478722 (2023-008)

Significant Deficiency 2023

Hyde County

NC

Eligibility Significant Deficiency

Finding: 2023-008 Inaccurate Resource Calculation New Medicaid Supervisor started 6/1/23 & has put new procedures in place & training of staff to eliminate the errors that occurred during the audit. All cases are reviewed before being processed to make sure the worker has worked the case properly & ...

Finding: 2023-008 Inaccurate Resource Calculation New Medicaid Supervisor started 6/1/23 & has put new procedures in place & training of staff to eliminate the errors that occurred during the audit. All cases are reviewed before being processed to make sure the worker has worked the case properly & if not immediate feedback, staffing & 2nd party review form is provided to the worker. Due to COVID & the State continuing cases this resulted in 15 of 35 of our errors. Of the 20 left, one is from 2018 due to the claim being paid in 2023 for a date of service of 2018. The other 19 relate to a current recert, however, review shows these were still worked prior to new supervisor & new procedures put into place. New staff has been brought in & are being trained one-on-one. It is anticipated that it will take 6 months - 1 year to get the new workers completely trained in their program. Team also has a pending new hire. Staffing cases & 2nd party reviews will continue indefinitely. For cases related to property resource entered incorrectly, previous supervisor instructed staff to enter the replacement value & not the tax value. This is being fixed as cases are being touched by the worker. New workers are being taught to review eligibility check to make sure income/resources are calcuating properly before processing.

View Audit 315389

Corrective Action Plans

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