Corrective Action Plans

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Health Care Services agrees with the recommendation and implemented corrective action by October 31, 2022. Health Care Services, or DHCS, published Behavioral Health Information Notice (BHIN) 22-045 which outlines Health Care Services sanctions policy. The BHIN states “Under state and federal law D...
Health Care Services agrees with the recommendation and implemented corrective action by October 31, 2022. Health Care Services, or DHCS, published Behavioral Health Information Notice (BHIN) 22-045 which outlines Health Care Services sanctions policy. The BHIN states “Under state and federal law DHCS must enforce compliance with the terms of the DHCS’ contracts with Mental Health Plans and Drug Medi-Cal Organized Delivery System counties, as well as ensure compliance with applicable state and federal laws and regulations, in accordance with its authority and obligations under state and federal requirements.” Lastly, under the section titled ‘Exhibit A - Attachment 3’ of the County Mental Health Plan Contract counties are required to submit cost reports timely which would allow Health Care Services to impose sanctions on counties who do not submit cost reports in a timely manner. This BHIN resolves the finding. Additionally, Health Care Services will not be collecting cost reports for dates of service after State Fiscal Year 2022-23. Under the California Advancing and Innovating Medi-Cal (CalAIM) initiative, and pursuant to Welfare and Institutions Code, Section 14184.403(b), Health Care Services will replace the current Certified Public Expenditures (CPE) reimbursement methodology with an intergovernmental transfer (IGT) reimbursement methodology. The IGT reimbursement methodology will make a single and final payment for services provided to the county, which includes the non-federal portion of the claims. This change will eliminate the requirement for the county submission of cost reports. Estimated Implementation Date: October 31, 2022 Contact: Wendy Griffe, Chief Internal Audits California Department of Health Care Services
Given the unprecedented volume of unemployment insurance claims during the federal disaster -approximately 20 million claims compared to 3.8 million during the Great Recession - EDD took action to speed payments to eligible claimants whenever possible. For example, EDD launched in July 2021 a Condit...
Given the unprecedented volume of unemployment insurance claims during the federal disaster -approximately 20 million claims compared to 3.8 million during the Great Recession - EDD took action to speed payments to eligible claimants whenever possible. For example, EDD launched in July 2021 a Conditional Payment Program to speed payments to claimants who certified for benefits and already received at least one week of benefits in the past but whose payments were later pending for more than two weeks. EDD also boosted its capacity to process workloads, prioritized timely payments, and employed automation among other measures. As reported in Reference Number 2020-006 in fiscal year 2019-2020, EDD began automatically cross-matching EDD wage records and Franchise Tax Board (FTB) records in November 2020 to assist in verifying the income of PUA claimants. Claimants who could not be automatically verified through the FTB wage record match were required to submit additional documentation to EDD for a manual review. Regarding the manual processing of the income documents to substantiate the PUA weekly benefit amounts that have been increased above the minimum California weekly benefit amount (WBA) of $167, in June 2022, the EDD submitted a blanket waiver application to the U.S. Department of Labor (DOL), pursuant to the DOL Unemployment Insurance Program Letter 20-21, Change 1. EDD’s application is pending the DOL’s determination. If approved, our blanket waiver application would cover any overpayments for claimants who, through no fault of their own, failed to provide proof of income substantiation to support the increase or whose WBA will be decreased because the proof they provided was insufficient. Regarding the verification of employment or self-employment substantiation (known in California as “Self-employment/Employment Substantiation” or “SEES”), this verification process is being implemented in two phases. Phase 1 of the SEES effort was implemented on November 10, 2021, and involved notifying claimants registered in California’s UI Online (UIO) system by email and text of their requirement to provide SEES documentation. Phase 2 will involve notifying claimants who did not respond to the UIO request for SEES documentation, and those who are not registered in UIO, via a paper notice mailed through the United States Postal Service (USPS). EDD submitted a blanket overpayment waiver application in June 2022 to DOL regarding this issue. EDD will assess further implementation based on the DOL’s decision. If approved, our blanket waiver application would cover any overpayments for claimants who, through no fault of their own, provided insufficient documentation or did not provide any documentation. Estimated Implementation Date: To be determined once the DOL provides a decision on the waiver application. Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California Employment Development Department
View Audit 309913 Questioned Costs: $1
Since fiscal year 2020-21, EDD has implemented dozens of strict anti-fraud measures to continue to evaluate and enhance its fraud detection. These measures, described in last year’s response to finding Reference Number 2020-005, included, but were not limited to, cross matching claimant information ...
Since fiscal year 2020-21, EDD has implemented dozens of strict anti-fraud measures to continue to evaluate and enhance its fraud detection. These measures, described in last year’s response to finding Reference Number 2020-005, included, but were not limited to, cross matching claimant information against law enforcement and government databases and implementing rigorous new identity verification procedures. As a result, EDD caught and stopped multiple fraud attempts starting in September 2020. As previously described, EDD implemented the following measures to address the nationwide fraud attempts perpetrated against the new emergency federal benefit programs in 2020-21: • Implemented additional cross-matches in September 2020 to detect multiple claims per address. • Ceased automatically backdating Pandemic Unemployment Assistance (PUA) claims under federal rules in September 2020. • Strengthened identity verification procedures in October 2020 by implementing ID.me. • Implemented additional cross-matches in November 2020 against state inmate information. • Vetted applications against law enforcement databases and other tools provided by Thomson Reuters in December 2020 to further curb identity and non-identity fraud. • Established a 1099-G call center to help victims of identity theft deal with any tax-related questions. • Ceased printing Social Security numbers on mailed documents to reduce identity theft risk. • Enhanced benefit card security with Bank of America. • Partnered with state, local and federal law enforcement agencies to support thousands of criminal investigations, arrests, prosecutions and convictions. The EDD will continue to evaluate and enhance the fraud detection/prevention tools that have been put in place. Estimated Implementation Date: September 2020 Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California Employment Development Department
View Audit 309913 Questioned Costs: $1
During 2023, the county implemented internal controls over the control environment, risk assessment, informaion, communication and monitoring over federal grants through meetings when a grant is received. We will ensure employees have the current compliance supplement and adequate documentation wil...
During 2023, the county implemented internal controls over the control environment, risk assessment, informaion, communication and monitoring over federal grants through meetings when a grant is received. We will ensure employees have the current compliance supplement and adequate documentation will be kept.
The size of the Organization prohibits hiring additional personnel. Duties have always been segregated where possible and currently another staff person is being trained in recording and summarizing transactions to further break out duties. The Board of Directors is involved where possible.
The size of the Organization prohibits hiring additional personnel. Duties have always been segregated where possible and currently another staff person is being trained in recording and summarizing transactions to further break out duties. The Board of Directors is involved where possible.
Recommendation: We recommend the College implement policies and procedures to ensure all property and equipment purchased with federal funds includes such information in the property records to comply with the requirement. Explanation of disagreement with audit finding: There is no disagreement with...
Recommendation: We recommend the College implement policies and procedures to ensure all property and equipment purchased with federal funds includes such information in the property records to comply with the requirement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College has begun to explore the Asset Module in the Jenzabar platform, with the goal that Procurement is the first stage of our property tracking. Work continues to be a challenge in this area as we are short staffed. The Business Office Staff will continue to work with the Purchasing staff to identify how best to proceed with this requirement. The College currently has Policies that speak to Assets and the recording of such. The College will strengthen the specifics of what an Asset listing is to include. Name of the contact person responsible for corrective action: Raquel Vigil, Chief Financial Officer, Clarissa Salhus, Finance Manager, Charles Roberts, Purchasing Manager, and Paul Roberts, Fiscal Technician/Receiving Planned completion date for corrective action plan: March 31, 2025
Department of Health and Human Services Presbyterian Homes of Tennessee, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2021. Audit period: January 1, 2021 through December 31, 2021 The finding from the schedule of findings and questioned costs is disc...
Department of Health and Human Services Presbyterian Homes of Tennessee, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2021. Audit period: January 1, 2021 through December 31, 2021 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS Department of Health and Human Services 2021-001 Provider Relief Funding – Assistance Listing No. 93.498 Recommendation: The organization updated the submission related to its Period 1 reporting, which included an updated lost revenue calculation to support all provider relief fund payments received. The organization should ensure the proper review procedures are in place for any future submissions to ensure accurate reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: An amended Period 1 submission report, using the lost revenues, was submitted. Appropriate review procedures will be put in place to ensure accurate reporting on any future submissions. Name of the contact person responsible for corrective action: Erik Hockman, CFO Planned completion date for corrective action plan: May 2, 2023 If the Department of Health and Human Services has questions regarding this plan, please call Erik Hockman at 865-243-3613.
Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority will ensure annual audits are conducted and timely electronic submissions of GAAP-based unaudited and audited financial information to HUD through the F...
Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority will ensure annual audits are conducted and timely electronic submissions of GAAP-based unaudited and audited financial information to HUD through the FASS-PH system. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director
Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority will maintain proper monitoring, communication and control activities to ensure adherence to the Authority’s key administrative policies including procu...
Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority will maintain proper monitoring, communication and control activities to ensure adherence to the Authority’s key administrative policies including procurement, occupancy and the HCV administrative plan. Additionally, management will have the Board approve all policies and procedures adopted and communicate them with the third party company that manages the Authority’s Housing Choice Voucher and Mainstream Voucher programs. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director
Corrective Action Plan: All Bank Reconciliations will be reviewed for the Assistance and Clearing Fund. All unidentified adjustments will be researched, and adjustments will be made on the corresponding reports submitted to the Division of Family Development. Responsible Party: Accountant Anticip...
Corrective Action Plan: All Bank Reconciliations will be reviewed for the Assistance and Clearing Fund. All unidentified adjustments will be researched, and adjustments will be made on the corresponding reports submitted to the Division of Family Development. Responsible Party: Accountant Anticipated Completion Date: Immediately
Corrective Action Plan: All Bank Reconciliations will be reviewed for the Assistance and Clearing Fund. All unidentified adjustments will be researched, and adjustments will be made on the corresponding reports submitted to the Division of Family Development. Responsible Party: Accountant Anticip...
Corrective Action Plan: All Bank Reconciliations will be reviewed for the Assistance and Clearing Fund. All unidentified adjustments will be researched, and adjustments will be made on the corresponding reports submitted to the Division of Family Development. Responsible Party: Accountant Anticipated Completion Date: Immediately
Corrective Action Plan: All Bank Reconciliations will be reviewed for the Assistance and Clearing Fund. All unidentified adjustments will be researched, and adjustments will be made on the corresponding reports submitted to the Division of Family Development. Responsible Party: Accountant Anticip...
Corrective Action Plan: All Bank Reconciliations will be reviewed for the Assistance and Clearing Fund. All unidentified adjustments will be researched, and adjustments will be made on the corresponding reports submitted to the Division of Family Development. Responsible Party: Accountant Anticipated Completion Date: Immediately
Condition The Health Center’s financial statement and compliance audits for the December 31, 2021 reporting period were not filed within the required timeline. Views of responsible officials and planned corrective actions Management will continue to monitor and enhance our internal controls to as...
Condition The Health Center’s financial statement and compliance audits for the December 31, 2021 reporting period were not filed within the required timeline. Views of responsible officials and planned corrective actions Management will continue to monitor and enhance our internal controls to assure all future reporting timelines are met. Anticipated completion date Ongoing
Condition Management should have a process in place to ensure the internal completion of the schedule of federal expenditures (SEFA) including all required disclosures. Views of responsible officials and planned corrective actions We will continue to monitor and, although we have limited personnel...
Condition Management should have a process in place to ensure the internal completion of the schedule of federal expenditures (SEFA) including all required disclosures. Views of responsible officials and planned corrective actions We will continue to monitor and, although we have limited personnel, we will continue to enhance our internal controls over the completion of the SEFA. Anticipated completion date Ongoing
Condition Management provided excel workbooks of costs they determined allowable under the PRF program. Although the workbook totals for some cost reporting categories did match the PRF reporting form, there were several categories that did not. Other reporting errors were also noted on the PRF po...
Condition Management provided excel workbooks of costs they determined allowable under the PRF program. Although the workbook totals for some cost reporting categories did match the PRF reporting form, there were several categories that did not. Other reporting errors were also noted on the PRF portal reporting document. Views of responsible officials and planned corrective actions We will review our current reporting processes and internal controls over PRF reporting to ensure all future reporting requirements are met. Anticipated completion date Ongoing
Seminole County strives to gain more understanding and knowledge of requirements and will continue to implement more internal controls to ensure we follow all fedreal grant requirements. This was the first time we had this kind of federal grant program and now we know and understand the grant requi...
Seminole County strives to gain more understanding and knowledge of requirements and will continue to implement more internal controls to ensure we follow all fedreal grant requirements. This was the first time we had this kind of federal grant program and now we know and understand the grant requirements and reporting better.
Finding 399397 (2021-007)
Material Weakness 2021
The County will establish policies and procedures to create better communication between the Emergency Manager and the County Officers.
The County will establish policies and procedures to create better communication between the Emergency Manager and the County Officers.
The criteria for use of the Provider Relief Funds (PRF) changed subsequent to the receipt and expenditure by the Hospital. The Hospital utilized the best information available at the time, during the early days of the public health emergency, in its use of the funds. The Hospital consistently revi...
The criteria for use of the Provider Relief Funds (PRF) changed subsequent to the receipt and expenditure by the Hospital. The Hospital utilized the best information available at the time, during the early days of the public health emergency, in its use of the funds. The Hospital consistently reviews the frequently asked questions for PRF maintained by the Health Resources & Services Administration (HRSA) for guidance on changes and clarification to the rules surrounding the program. In October 2021 — long after most critical access hospitals (CAHs), including Selling, had expended their initial PRF distributions - HRSA added an FAQ addressing cost-based reimbursement, specifically, "How does cost-based reimbursement relate to my Provider Relief Fund payment?" HRSA subsequently has made minor modifications to the language of this FAQ — most recently on October 27, 2022 — but the substantive guidance has remained the same. Unlike E.H.R. capital equipment, where specific cost report guidance was provided, no such guidance was provided for assets purchased to prevent, prepare for, and respond to COVID-19. Neither Prospective Payment System (PPS) nor CAH facilities were required to offset the full amount of funds received because they were considered grants, consistent with the treatment of PRF. We disagree with the audit findings and believe that no corrective action is required.
View Audit 307896 Questioned Costs: $1
SEE RESPONSE AND CORRECTIVE ACTION PLAN AT II-A-21.
SEE RESPONSE AND CORRECTIVE ACTION PLAN AT II-A-21.
Management has submitted final audited financial statements for FY20-21.
Management has submitted final audited financial statements for FY20-21.
Finding 2021-001: Condition and Context: The Hospital included expenses in its filing that did not meet criteria of allowable expenses as defined by the U.S. Department of Health and Human Services guidance. The filing included various expenses associated with the facility that were not specificall...
Finding 2021-001: Condition and Context: The Hospital included expenses in its filing that did not meet criteria of allowable expenses as defined by the U.S. Department of Health and Human Services guidance. The filing included various expenses associated with the facility that were not specifically used to prevent, prepare for, and respond to the coronavirus. During our testing we noted exceptions on 7 of 40 samples. Upon further analysis of the entire population, we noted that the Hospital reported expenses associated with the facility that were not specifically used to prevent, prepare for, and respond to the coronavirus totaling $1,359,809. The Hospital received distributions totaling $3,736,717 and reported total expenses of $1,950,653. Our sample was not a statistically valid sample. Corrective Action Plan: Subsequent to the filing of the Period 1 report, the Hospital instituted new policies and procedures surrounding the use, tracking and reporting on federal funds, including the Provider Relief Fund and American Rescue Plan Act (ARP) Rural Distribution. Under the new policies and procedures, the usage of all funds is accumulated and reviewed on a periodic basis, and interpretive of most updated, published guidance, and all reporting is subjected to reviews by Kevin Gessler prior to reporting. Name of Contact Person Responsible for Corrective Action: Kevin Gessler, Chief Financial Officer Anticipated Completion Date: As guidance fluctuated, even through 2022, framework for updated procedures was instituted for subsequent submissions for increased accuracy. Updated policies and procedures, prospectively, have been updated by May 2023.
View Audit 306879 Questioned Costs: $1
The Organization will designate a knowledgeable person separate from the preparer of the reports to review all expenditures that go into the reports prior to submission.
The Organization will designate a knowledgeable person separate from the preparer of the reports to review all expenditures that go into the reports prior to submission.
Segregation of Duties over Reporting: The Department was in need of additional accounting personnel and as of December 2023 a new employee was hired so adequate oversight will be corrected going forward.
Segregation of Duties over Reporting: The Department was in need of additional accounting personnel and as of December 2023 a new employee was hired so adequate oversight will be corrected going forward.
Management has implemented new policy and procedures.
Management has implemented new policy and procedures.
Finding Reference Number #SA2021-003: Pro-Rating Annual Payroll Costs Charged to Grant Assistance Listing Number: 21.019 Assistance Listing Title: COVID-19 - Coronavirus Relief Fund Name of Federal Agency: Department of Treasury Pass Through Entity: California Department of Finance Federal Award Ide...
Finding Reference Number #SA2021-003: Pro-Rating Annual Payroll Costs Charged to Grant Assistance Listing Number: 21.019 Assistance Listing Title: COVID-19 - Coronavirus Relief Fund Name of Federal Agency: Department of Treasury Pass Through Entity: California Department of Finance Federal Award Identification Number: 390 • Name(s) of the contact person: Shay Narayan, Director of Finance; Carmen Gusman, Deputy Director of Finance • Corrective Action Plan: Now that payroll services and the budget unit are both fully staffed, the City will be able to develop procedures that will ensure personnel budgets and costs are accurately pro-rated to the appropriate funding source. Additionally, the City expects to have sufficient staffing to work more closely with grantors make certain the all eligible costs are accounted for. • Anticipated Completion Date: 06/30/24
View Audit 305817 Questioned Costs: $1
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