Corrective Action Plans

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Finding 402642 (2023-038)
Significant Deficiency 2023
Finding 2023-038 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Payments on Behalf of Ineligible Beneficiaries Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS developed a prior report review process to ensure impacted records that do not get corrected with the C...
Finding 2023-038 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Payments on Behalf of Ineligible Beneficiaries Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS developed a prior report review process to ensure impacted records that do not get corrected with the CHAMPS retrigger are addressed. MDHHS continues to work with DTMB on the underlying issues in Bridges causing synchronization problems between Bridges and CHAMPS, as well as developing mitigation strategies to temporarily address the overpayment concerns while the more permanent system solutions are developed. MDHHS expects all remaining synchronization issues to be resolved once the remaining larger system changes are implemented in March 2025. Anticipated Completion Date March 31, 2025 Responsible Individual(s) Jamy Hengesbach, MDHHS
View Audit 309982 Questioned Costs: $1
Finding 2023-013 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Beneficiary Eligibility Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS continues to pursue other data sources for income verification and other s...
Finding 2023-013 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Beneficiary Eligibility Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS continues to pursue other data sources for income verification and other system enhancements so that all case data is available to all reviewers. In addition, MDHHS will continue to determine where additional training or enhancements to training are needed to ensure eligibility is accurately determined and documentation is properly maintained and loaded to the electronic case file. Once this is completed, MDHHS will develop mandatory training protocols for eligibility workers. Lastly, MDHHS has been working since 2018 to ensure correct eligibility classifications in Bridges at the time of payment and a system change was implemented in April 2021 to correct the issue. All new cases are being correctly routed. MDHHS originally expected to have all cases corrected at the end of the public health emergency (PHE) unwind (July 2024), however, due to some of the mitigation strategies that the Centers for Medicare and Medicaid Services (CMS) developed to ensure children did not lose eligibility, not all cases had their coding updated when they were renewed. MDHHS expects that all existing cases will be updated by May 2025. Anticipated Completion Date May 2025 Responsible Individual(s) Logan Dreasky, MDHHS Brant Cole, MDHHS Mariah Schaefer, MDHHS
View Audit 309982 Questioned Costs: $1
Finding 402593 (2023-036)
Significant Deficiency 2023
Finding 2023-036 CCDF Cluster, ALN 93.575 and 93.596 - Provider Health and Safety Requirements Management Views The Department of Licensing and Regulatory Affairs (LARA) and MiLEAP agree with the finding. The Child Care and Development Fund (CCDF) Cluster transferred from MDE to MiLEAP, and the chi...
Finding 2023-036 CCDF Cluster, ALN 93.575 and 93.596 - Provider Health and Safety Requirements Management Views The Department of Licensing and Regulatory Affairs (LARA) and MiLEAP agree with the finding. The Child Care and Development Fund (CCDF) Cluster transferred from MDE to MiLEAP, and the child care licensing responsibilities transferred from LARA to MiLEAP per Executive Order No. 2023-6 on December 1, 2023. Planned Corrective Action LARA and MiLEAP have been working to expand child care capacity across the State to meet the growing demand for care, which significantly increases the workload of licensing consultants. Also, more duties have been placed on licensing consultants to meet federal health and safety standards and monitoring requirements. Federal standards require the ratio of licensing consultants to child care providers and facilities is maintained at a level sufficient to enable the State to conduct effective inspections on a timely basis. To adhere to these federal ratio standards, health and safety standards, and timeliness of annual inspections, best practices recommend limiting each consultant’s caseload to a goal of 50 to 60 licensed facilities. The fiscal year 2025 executive budget recommendation includes an additional 30 Full-Time Equivalent positions as a significant step toward reaching case load best practices. After the audit period, the Child Care Licensing Bureau completed inspections of all facilities that were due by September 30, 2023, where the applicable health and safety requirements were reviewed. Additionally, LARA and MiLEAP launched the Child Care Hub Information Records Portal (CCHIRP) information technology system in September 2023. CCHIRP allows consultants to access information in a mobile format during onsite inspections, make real time updates to records, and confirm all applicable information with the provider while onsite. The new system supports a streamlined licensing process and additional efficiency for inspectors to perform inspections timely. Anticipated Completion Date October 1, 2025 Responsible Individual(s) Emily Laidlaw, MiLEAP
Finding 402592 (2023-035)
Significant Deficiency 2023
Finding 2023-035 CCDF Cluster, ALN 93.575 and 93.596 - Client Eligibility Management Views MiLEAP and MDHHS agree with the finding. Planned Corrective Action MDHHS Public Assistance Operations (PAO), within ESA, will continue assisting the local office staff and Business Service Center (BSC) staf...
Finding 2023-035 CCDF Cluster, ALN 93.575 and 93.596 - Client Eligibility Management Views MiLEAP and MDHHS agree with the finding. Planned Corrective Action MDHHS Public Assistance Operations (PAO), within ESA, will continue assisting the local office staff and Business Service Center (BSC) staff by providing guidance on updated policies and processes. ESA will inform the local office staff and BSC staff of policy changes or noted trends during PAO’s Bridges Bits and Bytes communications sessions. ESA and MDE implemented a checklist on May 9, 2023, for local office staff to ensure documentation supports eligibility determinations. MDHHS will continue to use the finalized checklist at eligibility determination. Also, MDE launched a Child Development and Care case review SharePoint site on May 1, 2023, to share information with MDE and MDHHS staff, reduce errors, and promote integrity efforts for the program. These practices will continue to be carried out by MDHHS and MiLEAP moving forward, including the continuation of monthly meetings to discuss Child Development and Care errors. Anticipated Completion Date MDHHS assistance and guidance for local office and BSC staff is ongoing. Responsible Individual(s) Mariah Schaefer, MDHHS Gayle Vail, MDHHS Lisa Brewer-Walraven, MiLEAP
View Audit 309982 Questioned Costs: $1
Finding 402558 (2023-033)
Significant Deficiency 2023
Finding 2023-033 Title I Grants to Local Educational Agencies, ALN 84.010 - Supplement Not Supplant Monitoring Procedures Management Views MDE agrees with the finding. Planned Corrective Action For fiscal year 2024, MDE’s Office of Educational Supports resumed its full federal programs monitoring ...
Finding 2023-033 Title I Grants to Local Educational Agencies, ALN 84.010 - Supplement Not Supplant Monitoring Procedures Management Views MDE agrees with the finding. Planned Corrective Action For fiscal year 2024, MDE’s Office of Educational Supports resumed its full federal programs monitoring of LEAs to ensure they have a written methodology to demonstrate compliance with Title I, Part A supplement not supplant requirements. From February 2024 through May 2024, MDE conducted 29 on-site monitoring reviews with LEAs across the State and will continue completing the remaining on-site monitoring reviews, including close out activities, with the remaining LEAs. Anticipated Completion Date June 30, 2025 Responsible Individual(s) Michael Powell, MDE Shoua Vang, MDE
Finding 402528 (2023-024)
Significant Deficiency 2023
Finding 2023-024 Fish and Wildlife Cluster, ALN 15.605, 15.611, and 15.626 - Inappropriate Telecommunication Expenditures Management Views DNR agrees with the finding. Planned Corrective Action DNR sent an email communication on May 7, 2024, to the Department Budget Control Team as a reminder to u...
Finding 2023-024 Fish and Wildlife Cluster, ALN 15.605, 15.611, and 15.626 - Inappropriate Telecommunication Expenditures Management Views DNR agrees with the finding. Planned Corrective Action DNR sent an email communication on May 7, 2024, to the Department Budget Control Team as a reminder to use the monthly DTMB telecom billing detail to verify all employees coded to fish and wildlife activities are valid. The monitoring of these charges will continue to occur as part of the interim quarterly assessments. Anticipated Completion Date Completed Responsible Individual(s) Jennifer Houle, DNR
Cambridge Public Schools' CFO or Grants Coordinator will review and sign-off on all tuition requisitions that will be charged to grants to confirm the grant approval date and compliance with the period of performance.
Cambridge Public Schools' CFO or Grants Coordinator will review and sign-off on all tuition requisitions that will be charged to grants to confirm the grant approval date and compliance with the period of performance.
The Finance department will document the reconciliation of the City's GL ARPA expenditures and obligations to the Department of Treasury ARPA reporting portal report both quarterly and annually. All reconciling adjustments and GL report documentation will be properly retained.
The Finance department will document the reconciliation of the City's GL ARPA expenditures and obligations to the Department of Treasury ARPA reporting portal report both quarterly and annually. All reconciling adjustments and GL report documentation will be properly retained.
The City will use a subrecipient audit certification form and a subrecipient risk assessment questionnaire to evaluate a subrecipient's risk/experience with federal funds as well as assess their federal funding threshold for having a single audit.
The City will use a subrecipient audit certification form and a subrecipient risk assessment questionnaire to evaluate a subrecipient's risk/experience with federal funds as well as assess their federal funding threshold for having a single audit.
The City will ensure that subrecipient contracts will include language about suspension and debarment. The City will also download a PDF copy of the subrecipients registration on SAM.GOV showing the subrecipient's Exclusion Summary Status.
The City will ensure that subrecipient contracts will include language about suspension and debarment. The City will also download a PDF copy of the subrecipients registration on SAM.GOV showing the subrecipient's Exclusion Summary Status.
The City will work with all HOPWA subrecipients to ensure that a complete and accurate CAPER is completed in the appropriate format as required by HUD. This will include a focus on inputting the correct (eg, actual expended vs. award amount) funding amount.
The City will work with all HOPWA subrecipients to ensure that a complete and accurate CAPER is completed in the appropriate format as required by HUD. This will include a focus on inputting the correct (eg, actual expended vs. award amount) funding amount.
The two individuals determined to have incomes in excess of HOME Program limits were noted in our FY23 monitoring of properties assisted with HOME funds. The HOME Program allows for a unit to be occupied by a household who was initially eligible and whose income later increases, but requires that a ...
The two individuals determined to have incomes in excess of HOME Program limits were noted in our FY23 monitoring of properties assisted with HOME funds. The HOME Program allows for a unit to be occupied by a household who was initially eligible and whose income later increases, but requires that a comparable unit be designated as a HOME unit and leased to an eligible household when one is available. Owners of each property were made aware of the circumstance when City monitoring was completed. Each will designate comparable units to be HOME units when available and lease them to eligible households.
Based on prior year (FY22) findings, the City established the following procedures to ensure payment requests received from subrecipients are paid within 30 days of receipt of a complete request for reimbursement: 1. Department of Human Service Programs (DHSP) Contract Manager reviews invoices withi...
Based on prior year (FY22) findings, the City established the following procedures to ensure payment requests received from subrecipients are paid within 30 days of receipt of a complete request for reimbursement: 1. Department of Human Service Programs (DHSP) Contract Manager reviews invoices within 5 business days of receipt of request for reimbursement from subrecipient. a. If invoice is complete, original date of receipt is recorded. b. If invoice is incomplete, subrecipient is notified of items or documentation that is missing and receipt date is updated to reflect date of receipt of complete invoice. 2. Contract Manager approves payment request and submits to DHSP Fiscal staff for processing. 3. Fiscal staff processes and submits to Auditing Department as Priority payment. Four of the 19 sampled payment requests were received or processed after receipt of the FY22 audit findings, and all of those requests for reimbursement were paid within 30 days of receipt.
Management commits to documenting processes and procedures - in this case specifically for the endowment spending policy; instituting regular reviews for effectiveness and compliance and better defining the responsibilities and accountabilities of employee and outsourced staff.
Management commits to documenting processes and procedures - in this case specifically for the endowment spending policy; instituting regular reviews for effectiveness and compliance and better defining the responsibilities and accountabilities of employee and outsourced staff.
Corrective Action Plan: The Executive Director will advise the CPA of all purchases that exceed the capitalization threshold when they occur. Copies of the check(s) and invoice(s) will be scanned into the month they are paid (into the Laserfiche electronic storage system). The CPA will review the pa...
Corrective Action Plan: The Executive Director will advise the CPA of all purchases that exceed the capitalization threshold when they occur. Copies of the check(s) and invoice(s) will be scanned into the month they are paid (into the Laserfiche electronic storage system). The CPA will review the payments scanned monthly and also scan the disbursements for any that could have been missed. At the end of the fiscal year, the disbursements that meet the capitalization requirements of HAHC and RTS will be entered into the depreciation schedule. Person(s) responsible: Executive Director- Connie Stewart CPA- Barfield and Kinkead LLC Completion Date: Fiscal year ending September 30, 2024
We agree with the finding and provide below the corrective action plan. Corrective action plan: We will provide additional training to staff responsible for tracking federal and state awards and utilize another member of management to review and approve the grant tracking spreadsheets routinely. Add...
We agree with the finding and provide below the corrective action plan. Corrective action plan: We will provide additional training to staff responsible for tracking federal and state awards and utilize another member of management to review and approve the grant tracking spreadsheets routinely. Additionally, reconciliations will be performed monthly between the grant spreadsheets and the financial reporting software.
Finding 402308 (2023-001)
Significant Deficiency 2023
Allowable Activities and Costs – Assistance Listing No. 93.224/93.527 Recommendation: CLA recommends that the Organization consider completing time and effort attestation forms electronically to ensure none get lost or misplaced and are returned timely. Explanation of disagreement with audit finding...
Allowable Activities and Costs – Assistance Listing No. 93.224/93.527 Recommendation: CLA recommends that the Organization consider completing time and effort attestation forms electronically to ensure none get lost or misplaced and are returned timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Infinity Health’s current policy to support compliance with time and effort requirements is to obtain a statement from each employee with any time allocated for a grant, certifying the time spent on grant activities on a quarterly basis. Beginning 12/1/2023, Infinity Health has implemented a new electronic document management system which will improve our ability to track and monitor timely completion of time and effort statements each quarter. Name(s) of the contact person(s) responsible for corrective action: Kyle Ahlenstorf, CEO, and Michelle Leonard, CFO. Planned completion date for corrective action plan: June 30, 2024
Finding: For a portion of the year, expenditures for certain services exceeding the simplified acquisition threshold were made, and an approved procurement method was not utilized within Assistance Listing #84.027, #84.027X, #84.173 and #84.173X. Response: During the year, the Board utilized an ap...
Finding: For a portion of the year, expenditures for certain services exceeding the simplified acquisition threshold were made, and an approved procurement method was not utilized within Assistance Listing #84.027, #84.027X, #84.173 and #84.173X. Response: During the year, the Board utilized an approved procurement method for these services. Completion Date: May 2023
Views of Responsible Officials: As of 7/1/204, NEW's accounting has been outsourced and a new accounting system will be utilized. The accounting department has been restructured to ensure accounts are properly reconciled each month.
Views of Responsible Officials: As of 7/1/204, NEW's accounting has been outsourced and a new accounting system will be utilized. The accounting department has been restructured to ensure accounts are properly reconciled each month.
Finding No. 2023-002 Tenant Files: Eligibility Program: U.S. Department of HUD: Section 8 Housing Choice Vouchers (CFDA 14.871) Type of Finding: Material non-compliance and Material Weakness in Internal Control over Compliance This is a repeat finding of 2022-002 from September 30, 2022 (Origi...
Finding No. 2023-002 Tenant Files: Eligibility Program: U.S. Department of HUD: Section 8 Housing Choice Vouchers (CFDA 14.871) Type of Finding: Material non-compliance and Material Weakness in Internal Control over Compliance This is a repeat finding of 2022-002 from September 30, 2022 (Originally reported as finding 2019-001 from September 30, 2019) Statement of Condition: Out of a total tenant population of approximately 1,142 vouchers, 25 files were selected for testing, and the following errors were discovered. • 1 tenant file had the following error: o The utility allowance was miscalculated by $32 (overstatement). The two-bedroom column utility rates were used when the 1-bedroom column utility rates should have been used. Correcting this error would cause which the HAP rent to decrease from $762 to $731. • 1 tenant file had the following error: o An EIV form was either not run or has been misplaced for the tenant’s annual recertification period. • 1 tenant file had the following error: o The utility allowance was miscalculated by $23 (understatement). The 2022 utility allowance schedule was used when the 2023 utility allowance schedule should have been used. Correcting this error would cause the HAP rent to increase from $494 to $517. • 1 tenant file had the following error: o The tenant did not check the checkbox on the 214-affidavit form indicating that they are a U.S. Citizen. However, based on the birth certificate the tenant is a U.S. citizen. • 1 tenant file had the following error: o An EIV form was either not run or has been misplaced for the tenant’s annual recertification period. • 1 tenant file had the following error: o The tenant’s asset income was miscalculated. Correcting this error would increase the HAP rent by $4. • 1 tenant file had the following error: o The 50058-form reported childcare income support of $6,000, however, the support for the childcare income showed $5,800. Correcting this error had no effect on the HAP rent. • 1 tenant file had the following error: o No support for the tenant’s wage income of $23,296 on the 50058 form. Appears to be reported correctly, since the EIV shows an amount that approximates the tenant’s wage income of $23,296. Nonetheless, there needs to be support in the tenant file for the wage income. o Missing HAP contract. • 1 tenant file had the following error: o The utility allowance was miscalculated by $19 (understatement). Correcting this error would cause the HAP rent to increase from $924 to $943. In addition to the above, we noted the following during our new admissions testing (out of a total of 161 new admissions, 17 files were selected for testing.): • 1 tenant file had the following error: o The tenant did not check the checkbox on the 214-affidavit form indicating that they are a U.S. Citizen. However, based on the birth certificate the tenant is a U.S. citizen. • 1 tenant file had the following error: o HAP contract was not executed timely (within 60 days). • 1 tenant file had the following error: o The voucher extension date was not documented on the voucher. • 1 tenant file had the following error: o The request for tenancy addendum was executed (dated) two days after the voucher extended due date. o The unit size on the voucher did not agree to the family voucher size on the 50058 and the wrong payment standard was applied to the tenant. Recommendation: The Authority should correct the deficiencies noted in the tested files and utilize an ongoing quality control review process on the entire tenant population to ensure proper compliance with the requirements related to tenant eligibility. Ongoing staff training and timely management reviews should be utilized to ensure staff is aware of acceptable procedures. In addition, the Authority should review staffing levels, skill sets and case load. Action Taken: The Authority concurs with this finding. The Authority has an established review, oversight and training process and will continue to improve its review, oversight, and training process to ensure proper procedures are being followed. All audit findings of the files tested have been corrected. The Authority has implemented a quality control system so that every file receives a quality review for appropriate third-party verification and upfront income, and assistance is determined. The agency has created a Family Worksheet and an HCV Computation Worksheet to help staff identify errors in calculations and to check for accuracy prior to completing Annual Reexaminations and Interim Recertifications. The agency has changed its filing system to enable staff to thoroughly review all forms prior to admission and during regular recertification and interim adjustment processing. The agency created an “Other Adult” packet to ensure 214 forms and other pertinent are completed for all adult household members. The HCV Counselor caseloads have been distributed equitably amongst Counselors to promote efficiency and accuracy while working on each HCV participant's file. The Counselor's caseload is divided alphabetically and assigned by multifamily developments to track and monitor counselors' strength and weaknesses and to determine if additional training and/or monitoring is needed. A Counselor has been assigned to only handle specialty vouchers (EHV, VASH, Homeownership, and FUP). The FSS Coordinator is responsible for the full management of HCV FSS participants. The Authority has hired an Intake Housing Counselor/Portability Specialist to focus on determining eligibility of new applicants pulled from the waitlist and to manage the waitlist. This Counselor also determines eligibility and compiles document packet for portability clients. Internal file reviews are being completed and management will continue to conduct a 10% review for each Counselor's processing of annual recertifications. This percentage may increase if work product indicates a need for more stringent review. To further ensure compliance and accuracy, the HCV Program Manager will review at least 1 out of every 5 intake files. All new admissions move-in files are now being to the Housing Programs Director for review prior to approval. A sample size of 15% is now being reviewed at the end of month by the Compliance Director and Housing Programs Director for compliance. The Authority has had a significant turnover in the HCV department over the past 24 months. All HCV Counselors, except the new Intake Counselor, have attended Voucher Specialist training and Nan McKay HCV Rental Calculation Certification training and successfully passed the certification exam. Effective Date: June 21, 2024 Contact Information Gwendolyn B. Dawson, CEO Ocala Housing Authority 1629 NW 4th Street Ocala, Florida 34475 (352) 369-2636
May 7, 2024 U.S. Department of Education American Academy McAllister Institute of Funeral Services, Inc. respectfully submits the following corrective action plan for the year ended September 30, 2023. Auditors: CohnReznick 1301 Avenue of the Americas New York, NY 10019 Audit period: October 1...
May 7, 2024 U.S. Department of Education American Academy McAllister Institute of Funeral Services, Inc. respectfully submits the following corrective action plan for the year ended September 30, 2023. Auditors: CohnReznick 1301 Avenue of the Americas New York, NY 10019 Audit period: October 1, 2022 to September 30, 2023 The findings from the fiscal year 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS-FINANCIAL STATEMENT AUDIT SIGNIFICANT DEFICIENCY 2023-001 Federal Direct Loan Program Student Recommendation: We recommended in the prior year that the Institute review and revise its procedures to put controls in place to ensure required notifications regarding Federal Direct Loan Program proceeds are provided to par-ticipating students. Action Plan: We agree with both the finding and the recommendation. In the Summer 2023 semester, a system was implemented to send out the required notifications regarding Federal Direct Loan Program proceeds that have been applied to a participating student's account. If the U.S. Department of Education has questions regarding this plan, please call Robert Graber at 732-547-9549.
Response/Views: We agree with the finding as it is stated. Corrective Action Planned: We shall comply accordingly for future federal fund projects requiring Davis-Bacon reporting. Anticipated Completion Date: NIA. The project has already taken place Contact Person(s): Cassandra Allen 334.864.9343
Response/Views: We agree with the finding as it is stated. Corrective Action Planned: We shall comply accordingly for future federal fund projects requiring Davis-Bacon reporting. Anticipated Completion Date: NIA. The project has already taken place Contact Person(s): Cassandra Allen 334.864.9343
View Audit 309744 Questioned Costs: $1
The Alliance has reinstituted an hourly timesheet format in order to account for positions with multiple funding sources.
The Alliance has reinstituted an hourly timesheet format in order to account for positions with multiple funding sources.
We concur. According to previous findings, daily expenditures have been recorded into the general ledger as they occur and reconciled in a timely manner monthly. Adjustments will be recorded into the general accounting system daily, after a review by the Executive Director on completion of entries b...
We concur. According to previous findings, daily expenditures have been recorded into the general ledger as they occur and reconciled in a timely manner monthly. Adjustments will be recorded into the general accounting system daily, after a review by the Executive Director on completion of entries by the Office Manager. In corrective action steps already in place from the previous year’s findings, adjustments have been recorded in the general accounting system and accounts have been reconciled in a timely manner.
Internal Control over Compliance and Compliance with Activities Allowed or Unallowed and Allowable Costs and Cost Principles   Contact: Chris Holmes   Title: Controller  Phone Number: 202-235-1938  Estimated Completion Date – ongoing  Corrective Action  The results of the 2023 audit will be ...
Internal Control over Compliance and Compliance with Activities Allowed or Unallowed and Allowable Costs and Cost Principles   Contact: Chris Holmes   Title: Controller  Phone Number: 202-235-1938  Estimated Completion Date – ongoing  Corrective Action  The results of the 2023 audit will be shared with appropriate staff and reiterated in training to ensure that adequate attention and guidance is provided on recording expenses within the correct accounting period. During 2023, PSI resumed delivering in person training to its global finance and program staff and will continue to offer training during 2024 to address such issues.
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