Corrective Action Plans

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Finding 2022-001 Finding: CACFP requires that non-Federal entities receiving Federal Awards establish and maintain internal control designed to reasonably ensure compliance with Federal Statutes, regulations, and the terms and conditions of the Federal award. The Club was unable to replicate exact...
Finding 2022-001 Finding: CACFP requires that non-Federal entities receiving Federal Awards establish and maintain internal control designed to reasonably ensure compliance with Federal Statutes, regulations, and the terms and conditions of the Federal award. The Club was unable to replicate exact payroll expenses that were reported to the state monthly for the program. This is due to a lack of payroll documentation retained monthly. This documentation took time to replicate during the audit. No fraud is suspected related to payroll reporting issues for the program. Response: Adjustments were made to the payroll process to retain all supporting documentation and to replicate any prior period paperwork. The Club switched to a new payroll processor which has enabled improved payroll reporting.
Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program to ensure that established internal control policies are being followed on a timely basis. Melody Joh...
Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program to ensure that established internal control policies are being followed on a timely basis. Melody Johnson-Williams, Executive Director, is responsible for implementing this corrective action by December 31, 2023.
View Audit 289566 Questioned Costs: $1
Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers Program to ensure that established internal control policies are being followed on a timely basis. M...
Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers Program to ensure that established internal control policies are being followed on a timely basis. Melody Johnson-Williams, Executive Director, is responsible for implementing this corrective action by December 31, 2023.
View Audit 289566 Questioned Costs: $1
Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight on the maintenance of the waiting list and process of housing applicants to better monitor adequacy with compliance requirements. Melody Johns...
Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight on the maintenance of the waiting list and process of housing applicants to better monitor adequacy with compliance requirements. Melody Johnson-Williams, Executive Director, is responsible for implementing this corrective action by December 31, 2023.
View Audit 289566 Questioned Costs: $1
Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers Program to ensure that established internal control policies are being followed on a timely basis. Me...
Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers Program to ensure that established internal control policies are being followed on a timely basis. Melody Johnson-Williams, Executive Director, is responsible for implementing this corrective action by December 31, 2023.
View Audit 289566 Questioned Costs: $1
The District continues to review its control procedures to obtain the maximum internal control possible under the circumstances.
The District continues to review its control procedures to obtain the maximum internal control possible under the circumstances.
Warwick Public Schools is in the process of hiring an assistant controller responsible for grants finance. This individual will reconcile expenses monthly, record revenues, receivables and reimbursements on a monthly basis. This will prevent the amount of year-end cleanup going forward.
Warwick Public Schools is in the process of hiring an assistant controller responsible for grants finance. This individual will reconcile expenses monthly, record revenues, receivables and reimbursements on a monthly basis. This will prevent the amount of year-end cleanup going forward.
Finding 366494 (2022-001)
Significant Deficiency 2022
HABcore will follow-up with NJ HMFA to determine if the $150 quarterly deposits are still necessary, and if so, will catch up and comply.
HABcore will follow-up with NJ HMFA to determine if the $150 quarterly deposits are still necessary, and if so, will catch up and comply.
INSURANCE POLICY CO-OBLIGEE Criteria: The Organization is responsible for having the USDA Rural Development listed as a co-obligee on fidelity bonds or mortgagee (loss payee) on the property insurance policy....
INSURANCE POLICY CO-OBLIGEE Criteria: The Organization is responsible for having the USDA Rural Development listed as a co-obligee on fidelity bonds or mortgagee (loss payee) on the property insurance policy. Condition: During our review of internal control procedures for the Community Facilities Loans & Grants Cluster, we identified the USDA Rural Development was not listed as a co-obligee on the fidelity bonds or mortgagee (loss payee) on the property insurance policy. Cause: The requirement was not met due to managements? oversight of the requirement to update the property insurance policy. Potential Effect: As a result, the Agency reserves the right to withdraw Agency funding. Recommendation: The Organization should review current procedures to ensure that they are complying with all requirements of the USDA Rural Development loan. Client Response: The Organization will review their monitoring procedures to ensure that they follow loan requirements and also update the insurance policy to include USDA Rural Development as the mortgagee (loss payee).
REPORTING Criteria: The Organization is responsible for maintaining proper controls over programs to submit complete and accurate quarterly financial statements within 20 days of the quarte...
REPORTING Criteria: The Organization is responsible for maintaining proper controls over programs to submit complete and accurate quarterly financial statements within 20 days of the quarter end, and the annual budget must be submitted to the Agency 30 days prior to the beginning of the borrower?s fiscal year. Condition: During our review of internal control procedures for the Community Facilities Loans & Grants Cluster, we identified the quarterly financial statements were not submitted timely for the third quarter of 2021 and fourth quarter of 2021, the annual budget was not submitted timely, and the first quarter of 2022 financial statement was not submitted accurately. Cause: The submission of timely and complete reports was not met due to managements? oversight of the requirement to submit quarterly financials. Potential Effect: As a result, the Agency reserves the right to withdraw Agency funding. Recommendation: The Organization should review current processes and ensure the financial reports are reviewed for accuracy and submitted timely by someone who did not prepare the reports. Client Response: The Organization will modify the process to include review by another individual and monitor due dates to submit future reports accurately and on time.
Finding 316358 (2022-078)
Significant Deficiency 2022
(A) CDOT will work with various divisions to devise a plan that will comply with this finding and the recommendations noted within. This plan shall include identifying a centralized location for all policies and procedures related to subrecipient monitoring. We will look at all policies and procedur...
(A) CDOT will work with various divisions to devise a plan that will comply with this finding and the recommendations noted within. This plan shall include identifying a centralized location for all policies and procedures related to subrecipient monitoring. We will look at all policies and procedures to ensure they clearly identify responsibilities and requirements for non-compliance. (B) CDOT will work with various divisions to devise a plan that will comply with this finding and the recommendations noted within. This plan shall include establishing a process by which an analysis of contracted entities will be performed to identify and properly record entities as a vendor or subrecipient.
(B) The Department revised its training model which is on track and will be fully rolled out to all eligibility sites by July 2022. (D) The Department disagrees with the auditor?s findings and questioned costs related to capitation payments under the Eligibility Issues Identified through Data Analy...
(B) The Department revised its training model which is on track and will be fully rolled out to all eligibility sites by July 2022. (D) The Department disagrees with the auditor?s findings and questioned costs related to capitation payments under the Eligibility Issues Identified through Data Analyses section. These costs are related to cases that were ?not eligible? in CBMS but were showing as ?eligible? in Colorado interChange that were already identified by the Department. The Department was actively working to resolve these cases with CMS prior to the Public Health Emergency (PHE). The Department developed and implemented a reconciliation report that is used to research and resolve CBMS and Colorado interChange interface mismatches. Members identified on the reconciliation reports were being manually updated until March 2020. CMS instructed the Department to cease work on these cases when the PHE was implemented. During the PHE the Department was not allowed to terminate benefits for anyone receiving benefits prior to March 2020, even if eligibility was determined incorrectly prior to the PHE. During this unprecedented time, the authority and operations regarding these cases was not immediately available. The auditors? retrospective review fails to address the uncertainty that occurred during this period of the PHE. The Department agrees to resume work on the manual reconciliation process when authorized by CMS.
(A) The Department agrees with the audit recommendation to develop and implement formal written policies and procedures. Prior to this audit, the Department began creating formal written policies and procedures for site case reviews, maintenance of supporting documentation, timely training for faile...
(A) The Department agrees with the audit recommendation to develop and implement formal written policies and procedures. Prior to this audit, the Department began creating formal written policies and procedures for site case reviews, maintenance of supporting documentation, timely training for failed workers, and performance of timely re-certification of presumptive eligibility sites (PE site). This finding had no known questionable cost associated with it. (B) The Department agrees with the audit recommendation to develop an effective tracking mechanism to identify and monitor PE sites that are due for re-certification every two years and ensuring that the recertifications are performed. Prior to this audit, the Department began developing a tracking mechanism for PE site re-certifications. This finding had no known questionable cost associated with it. (C) The Department fixed enrollment information for Fiscal Year 2020 and 2021 in CBMS for beneficiaries who were no longer eligible for presumptive eligibility and have either had their benefits terminated or were moved to the regular Medicaid and Children?s Basic Health Plan programs. The Department is currently performing regular reviews to appropriately terminate applicants? presumptive eligibility in CBMS when appropriate. However, the Department has not addressed the programming and system issues in CBMS. The Department plans to fully implement this recommendation by December 2022.
(B) The Department will review and revise, as necessary, its taxi claim billing requirements and rates to ensure that they are consistent. In addition, the Department will devise controls to ensure that taxi claims are paid in accordance with established requirements and rates and explore controls t...
(B) The Department will review and revise, as necessary, its taxi claim billing requirements and rates to ensure that they are consistent. In addition, the Department will devise controls to ensure that taxi claims are paid in accordance with established requirements and rates and explore controls to ensure that only permitted providers bill as a taxi. The Department is working on reductions in the max fee and unit limits for taxi claim billing codes, which it will have completed by the end of October 2021. In addition, the Department is considering systematically pricing the code at each taxi provider?s specific Public Utilities Commission (PUC) rate. This change, if pursued, will require a system change request, which will take a year or more, which is why the Department has selected an implementation date of December 2022. If this proves infeasible, alternate controls will be implemented. HCPF has met with DORA PUC. The Department is trying to establish a process to decide if the PUC taxi rate still applies or an internal rate can be created. Because of these discussions and needed system changes the implementation date has been moved to December 2023. (D) The Department intends to define in rule the types of documentation that NEMT providers must keep on hand and make clear that they must furnish records to the Department upon request. The July 2022 date will allow for the completion of formal rulemaking. The Department further intends to develop and implement a process to perform regular risk-based provider file reviews with a focus on noncompliant providers. These reviews will ensure, at a minimum, that the providers? paid claims are supported with appropriate documentation and represent the least costly option appropriate to meet each recipient?s needs. The Department met with the RAC team on February 22, 2023 to come up with a process to perform small audits for claims from providers that are outside the Intelliride service area. New systems will be implemented which has pushed the anticipated completion date to December 2023. (E) The Department will amend its contract with its NEMT broker by adding a mandatory annual audit so that it can reconcile trip scheduling data with paid claims data. This will help ensure that the Department pays accurately, pays for NEMT services, and pays for the least costly transportation option appropriate for each recipient. The Department chose July 2022 to add the audit through its annual contract amendment and renewal processes. The contract amendment was completed and signed June 30, 2022 that included a clause for an annual audit of claims. (F) The Department will develop a data review process to reconcile interChange data on NEMT trip claims to interChange data on Medicaid medical claims. This process will entail periodic reviews of NEMT claims to see if members have corresponding medical claims on those dates. If they do not, the Department will follow up with the appropriate NEMT provider to investigate. The July 2022 implementation date reflects the potential need for system changes. This is implemented, the Department has been pulling claims data and where corresponding medical claims are not found HCPF is investigating on a case by case basis to find the cause. (G) Department staff will work with the Department?s Program Integrity (PI) staff on processes to investigate and recover, as appropriate, the overpayments and inappropriate payments that the audit identified as known or likely questioned costs, and repay the federal portion, as appropriate. The December 2022 implementation date reflects the time needed to investigate and when appropriate, recover any overpayments. This has been implemented and the federal portion has been returned to CMS. (H) The Department will develop a process to track staff time and productivity to ensure that it has sufficient staff assigned to oversee and administer NEMT. This process will include documenting time spent each week on various tasks to get a sense of where help is needed, and which tasks take up the most staff resources. Based on its findings, the Department will explore staffing options, as needed. The Department selected the July 2022 implementation date to allow for data collection through the end of State Fiscal Year 2021-22. This has been implemented. New NEMT staff was hired November 1, 2022 to act as the liaison to the counties and clients in the 55 counties outside of the Intelliride service area.
The Department did not have strong enough controls for the initial checks on the financial data reporting templates. This process has been updated and will be rectified in coming cycles. The Department has modified its templates in order to address the concerns provided by the auditors including sig...
The Department did not have strong enough controls for the initial checks on the financial data reporting templates. This process has been updated and will be rectified in coming cycles. The Department has modified its templates in order to address the concerns provided by the auditors including signatures and supplemental reporting. Written policies and procedures for the validation and audit of the templates are being developed currently and will be in place and effective in December 2022. The Department will be correcting this error by posting the audit results along with other quality and audit reports on the following site: https:hcpf.colorado.gov/quality-and-healthimprovement-reports.
(A) The MLR report template has been updated and will now be reviewed at least yearly by the Department. In addition, new written policies and procedures are being developed and will be implemented before the submission of the next MLR for review. (B) The Department will add contract language and e...
(A) The MLR report template has been updated and will now be reviewed at least yearly by the Department. In addition, new written policies and procedures are being developed and will be implemented before the submission of the next MLR for review. (B) The Department will add contract language and enforcement mechanisms in order to receive accurate information in a timely manner. This includes specific timelines for correcting incomplete or inaccurate information in order to submit the MLR report timely to the Centers for Medicare & Medicaid Services.
(A) CDHS agrees that it needs to it needs to correct the automated reporting process from the eClearance system used to gather data needed for our FFATA reporting. The department thought that the reports obtained from eClearance were complete and relied on them as the basis of our reporting. Upon in...
(A) CDHS agrees that it needs to it needs to correct the automated reporting process from the eClearance system used to gather data needed for our FFATA reporting. The department thought that the reports obtained from eClearance were complete and relied on them as the basis of our reporting. Upon investigation we found that an internal process change enacted during the implementation of another system at the start of the pandemic was the cause of the data discrepancy. This occurred because the new system made the routing in eClearance after a certain point unnecessary for internal processing so this stopped. It was unknown that this further routing to archive files in eClearance was the trigger for eClearance to push out FFATA report data. Since the department has been able to identify the cause we are able to immediately remedy the problem and ensure that all processes are in sync to ensure accurate and complete FFATA data is contained in automated reporting processes. The department will catch up on FFATA reporting that was missed during this time frame. (B) The department agrees that it needs to implement procedures to validate that data derived from automated processes used as a basis for FFATA reporting should be periodically validated against another data source. To do this the department will create and implement procedures to use CORE reports of encumbrance data referencing subrecipient object codes and tie this to information received from the automated eClearance report. Doing this will validate that the data provided from eClearance is a complete listing of all FFATA reportable subrecipient awards, and thus is a valid source to base FFATA reporting on. This will also help us monitor the process in case any future inadvertent changes are made to processes that could cause data validity issues. (C) CDHS agrees that a supervisory review is needed over the FFATA reporting process in order to ensure more consistency, accuracy and timeliness in reporting processes and standards. The department is currently developing procedures that will allow for more oversight of the FFATA reporting through supervisory reviews and cross training staff on FFATA reporting duties. Supervisory reviews will help ensure that reporting is completed in line with reporting procedures and timeframes and can be a second set of eyes to ensure that information appears accurate and adds analytical judgement value (example - a supervisor might see that July typically has high volume, but this July volume is low, why). In addition, the department is taking this opportunity to cross train other staff on the process so that more individuals can be involved which leads to more transparency over processes allowing various individuals to notice if something isn't working as designed. These new procedures are being developed and implemented as the department catches up on reporting subrecipient awards that were missed since the automated process stopped working.
(B) The Department agrees to develop and implement policies and procedures requiring Department staff to perform reconciliations of recipient agencies? and Regional Food Banks? physical inventories to the Web-based Supply Chain Management system to ensure inventory records are complete and accurate....
(B) The Department agrees to develop and implement policies and procedures requiring Department staff to perform reconciliations of recipient agencies? and Regional Food Banks? physical inventories to the Web-based Supply Chain Management system to ensure inventory records are complete and accurate. Starting in January 2021 the Department began developing a position description for an Inventory Specialist with the focus of ensuring accurate and thorough accounting of all year-end inventory and reconciliations. The position was hired in April 2021. Due to the implementation of the inventory database and the timing of beginning and ending inventories, the Department anticipates being able to do a full reconciliation of inventories by December 2022. (C) The Department agrees to develop and implement a tracking system for food inventory at recipient agencies and Regional Food Banks using the Web Supply Chain Management system receipts as the basis of food received, including the maintenance of supporting documents. The Department is undertaking an inventory overhaul which includes implementing a new inventory database and creating and hiring an Inventory Specialist. The Department recognized the need for inventory software and started the process of obtaining it in June 2020. In May 2021, the Department received a signed licensing agreement for a new database which is expected to be implemented in six months per an OIT timeline. In addition to the database, the Department recently hired a new Inventory Specialist position. This position will lead the development of policies, procedures, inventory reconciliations, and monthly report management. Once the Inventory Specialist has a comprehensive understanding of federal and state policy and the new database software, the Department will develop policies and procedures, training for partner agencies, and roll out new requirements for the tracking and reconciliation of program inventories.
(A) CDHS agrees to enhance internal controls over monthly P-EBT reporting to better ensure accuracy. P-EBT is a new program derived from pandemic funding. Being a new program with a lack of federal guidance at implementation, and urgency to get the funds disbursed program staff had to learn about th...
(A) CDHS agrees to enhance internal controls over monthly P-EBT reporting to better ensure accuracy. P-EBT is a new program derived from pandemic funding. Being a new program with a lack of federal guidance at implementation, and urgency to get the funds disbursed program staff had to learn about the nuances of the program and the reporting requirements as it was being implemented. During implementation we recognized that there are some inherent differences with P-EBT from other benefit programs which caused processes to have to be adjusted slightly. Additionally, timing of federal report filing for the P-EBT program is not in synch with our other processes and associated federal reporting requirements and deadlines. This makes it impossible to ensure reconciliation procedures are performed before filing occurs, which is one of our typical internal controls. As a compensating internal control CDHS will ensure that supervisory review processes are performed over P-EBT reporting, and that P-EBT reporting is reconciled to other sources (CBMS and CFMS) as soon as possible after reporting is available. If changes are discovered CDHS will make adjustments to filed P-EBT reports as needed based on reconciliation findings, and communicate changes to necessary parties. (B) CDHS will work to ensure better coordination between program activities and the accounting section relating to federal reporting changes. Accounting will iterate the importance of timely informing the accounting staff when changes are made to program filed federal reports. This message will be delivered in periodic fiscal meetings and identified on the closing calendar. The P-EBT program will ensure that corrections are communicated to accounting on any updates completed on the FNS-292-B report upon discovery, and no later than 30 days after the reporting period. (C) CDHS will ensure that review and approval processes are occurring as designed at various points in the process leading up to entry into CORE. As part of the Requisition (RQS) approval process program and accounting staff independently approve that the correct direct or subrecipient object code is used. These approved RQS transactions are then transitioned into encumbrance documents that drive which object code future expenditures will be booked to. For CCDF transactions related to this finding, both the OEC and Accounting teams inadvertently approved an incorrect object code in 4 RQS's. Staffing shortages coupled with a large increase in workload related to pandemic funding contributed to this oversight. To correct OEC and Accounting will train new staff, periodically familiarize themselves with the appropriate object codes, and perform quality assurance review over object codes before applying approval in CORE. The K1 is compiled from balances derived from expenditure data recorded in CORE. The compilation of the K1 relies on the fact that expenditure balances are accurate, and that prior reviews and approvals of individual transactions have occurred as designed. The K1 currently goes through various levels of review focusing on balance level validation coupled with analytical procedures. To enhance the review process, CDHS will ensure analytical procedures include line level expenditure comparison at the direct and subrecipient levels.
We have prepared the following corrective action plan as required by the standards applicable to financial audits contained in Government Auditing Standards and by the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and A...
We have prepared the following corrective action plan as required by the standards applicable to financial audits contained in Government Auditing Standards and by the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Specifically, for each finding we are providing you with the names of the contact people responsible for corrective action, the corrective action planned, and the anticipated completion date. Findings - Financial Statement Audit 2022-101: Eligibility Recommendation: The South Tucson Housing Authority should establish policies and procedures to ensure that tenants? eligibility determinations will be reviewed and approved by an employee that is independent of the initial eligibility determination. Action Taken: The South Tucson Housing Authority concurs and has implemented the recommendation. Completion date: Fiscal Year 2023
Finding 291593 (2022-073)
Significant Deficiency 2022
CDLE will continue to develop, formally document, and implement policies for completing its federal reports for the Unemployment Insurance program. These policies will require the workbooks used to prepare the reports to be protected, for the data to be substantiated, and will require supervisory re...
CDLE will continue to develop, formally document, and implement policies for completing its federal reports for the Unemployment Insurance program. These policies will require the workbooks used to prepare the reports to be protected, for the data to be substantiated, and will require supervisory review on a monthly basis prior to submitting the reports to the federal government.
(A) The Department agrees with this finding. The Department is moving all adjudication and investigation of program integrity holds into the MyUI+ system, so there will be one system of record. The Department will ensure that all program integrity holds have all documentation through adjudication an...
(A) The Department agrees with this finding. The Department is moving all adjudication and investigation of program integrity holds into the MyUI+ system, so there will be one system of record. The Department will ensure that all program integrity holds have all documentation through adjudication and investigation, including log notes. The Department anticipates this to be fully implemented by July 2024. (B) The Department agrees with this finding. The department has modified processes to ensure all holds are only routed to the appropriate team to be adjudicated. In addition the Department is working to have all claims identified as fraud delivered in a workflow process in MyUI+ rather than the various processes in place now. Further the department is working with our MyUI+ system experts to implement new technology to strengthen and streamline the fraud indicator escalation process and systems within MyUI+. In working with our MyUI+ system experts, the Department anticipates this to be fully implemented by July 2024. (C) The Department agrees with this finding. The Department will continue strengthening security in this area and internal procedures to periodically monitor the potential for internal fraud activities. Additionally, the Department will periodically monitor and review My UI+ access levels for appropriateness. In consultation with our MyUI+ systems experts, the Department anticipates this finding to be fully implemented by July 2024. (D) The Department agrees with this finding. The Department will reinforce and strengthen the ethics policies in yearly communication to staff and tighten escalation policies to ensure pressures and inappropriate requests are handled in accordance with guidelines. The Department anticipates this will be completed by July 2023. (E) When a PI hold is identified as being highly suspicious for criminally fraudulent activity, it is routed to a specialized unit for review, thereby leaving the standard adjudication process. This is handled by passing the review to the UI Investigations and/or Criminal Enforcement (ICE) unit. The investigator performs their investigation and if no actual fraudulent activity is found they will release the hold. The UI Division also performs several quality control reviews of claims and claim decisions via Benefits Payment Control (BPC), Benefits Accuracy Measurements (BAM), Benefits Timeliness and Quality (BTQ), and internal Quality Assurance (QA) reviews. Claims are reviewed for such criteria as adequate support documentation, benefit payment accuracy, timely processing, and correct claim decision determination on all program integrity holds. The Green Book states in Section 10.14, ? If segregation of duties is not practical within an operational process because of limited personnel or other factors, management designs alternative control activities to address the risk of fraud, waste, or abuse in the operational process.? CDLE believes the reviews represent adequate and sufficient compensating controls for the need for segregation of duties on fraud holds. Changing the current process would hinder our ability to deliver UI benefit services timely to our customers and would put us in jeopardy of fulfilling our federal and state payment timeliness requirements.
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