Corrective Action Plans

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Findings Related to the Financial Statements Reported in Accordance with Government Auditing Standards None Findings Related to Federal Awards 2023-001 Activities Allowed or Unallowed and Allowable Costs/Cost Principles Federal Agency: U.S. Department of Homeland Security: Passed through the Sta...
Findings Related to the Financial Statements Reported in Accordance with Government Auditing Standards None Findings Related to Federal Awards 2023-001 Activities Allowed or Unallowed and Allowable Costs/Cost Principles Federal Agency: U.S. Department of Homeland Security: Passed through the State of New Jersey, Department of Law and Public Safety Program Titles and Assistance Listing Numbers (ALN): Disaster Grants – Public Assistance (Presidentially Declared Disasters) – ALN 97.036 Federal Grant Numbers: State of New Jersey pass-through number: UH1WX, Project Worksheet #1822 – Award Year 2023 (Application 553330) Contact Person: Donna Wilser, Deputy Executive Director, 732-750-5300 Corrective Action: Management agrees with the finding. We are committed to strengthening our processes to ensure that all physical timesheets related to FEMA-declared disaster events are properly maintained and readily accessible. To achieve this, we will implement enhanced procedures and controls to ensure full compliance with the Uniform Guidance requirements. Anticipated Completion Date: December 1st, 2024
The Pickens County Board of Education will ensure that controls are in place to ensure the Davis-Bacon Act wage rate requirements are included in all construction contracts.
The Pickens County Board of Education will ensure that controls are in place to ensure the Davis-Bacon Act wage rate requirements are included in all construction contracts.
View Audit 310036 Questioned Costs: $1
The payroll department will be trained on the proper calculation of salary and compensation rates.
The payroll department will be trained on the proper calculation of salary and compensation rates.
The payroll department will be trained on the proper calculation of salary and compensation rates.
The payroll department will be trained on the proper calculation of salary and compensation rates.
The board will ensure the schools and central office departments are aware of and follow the federal procurement codes for federal funds.
The board will ensure the schools and central office departments are aware of and follow the federal procurement codes for federal funds.
View Audit 309995 Questioned Costs: $1
Finding 2023-014 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Expenditure Processing for Medical Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has been working since 2018 to ensure correct eligibil...
Finding 2023-014 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Expenditure Processing for Medical Payments Management Views MDHHS agrees with the finding. Planned Corrective Action 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 correctly routed. MDHHS originally expected to have all cases corrected at the end of the PHE unwind (July 2024), however, due to some of the mitigation strategies that 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, as MDHHS completes renewals for existing cases. MDHHS identified and updated its manual process of transferring expenditures from the Medicaid Cluster to the Children’s Health Insurance Program (CHIP) in June 2021; and will continue this manual process, on a quarterly basis, by completing a summary-level adjustment determined by analyzing the Community Health Automated Medicaid Processing System (CHAMPS) payment data and Bridges eligibility data until all existing cases have been updated. Anticipated Completion Date May 2025 Responsible Individual(s) Brant Cole, MDHHS Logan Dreasky, MDHHS Erin Emerson, MDHHS
Finding 402737 (2023-046)
Significant Deficiency 2023
Finding 2023-046 Temporary Assistance for Needy Families, ALN 93.558 - MARS User Access Management Views The Department of Labor and Economic Opportunity (LEO) agrees with the finding. The Management of Awards to Recipients System (MARS) is an older legacy system that does not automatically deactiv...
Finding 2023-046 Temporary Assistance for Needy Families, ALN 93.558 - MARS User Access Management Views The Department of Labor and Economic Opportunity (LEO) agrees with the finding. The Management of Awards to Recipients System (MARS) is an older legacy system that does not automatically deactivate user accounts after 60 days of inactivity. The LEO Finance unit continues to experience challenges related to staffing shortages and competing priorities. Accordingly, the LEO Internal Controls unit will assist the LEO Finance unit in the interim with implementing corrective action until this legacy application is replaced, and new procedures are implemented. Planned Corrective Action LEO has received a Technical Review Board exception from SOM Technical Standard 1340.00.020.01 (Access Control Standard). The exception allows MARS inactive accounts to remain open for up to 90 days - an interval at which Michigan Works! Agency administrators make quarterly approvals (sometimes their only activity on the system). The exception was granted on April 12, 2024, and is valid through October 9, 2024, but may be extended. LEO staff has begun manually pulling an inactive users report monthly and manually deactivating accounts that were not accessed during the previous 90-day period. LEO is currently working on a request for proposal to replace MARS and anticipates that the new system will be able to automatically deactivate user accounts in accordance with the SOM Technical Standard. The LEO Finance unit has updated its procedures to reflect its interim process and will further revise them once the MARS replacement system goes live. Anticipated Completion Date September 30, 2026 Responsible Individual(s) Lora MacKay, LEO Allen Williams, LEO
Finding 402645 (2023-041)
Significant Deficiency 2023
Finding 2023-041 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - ADP Security Program Management Views MDHHS agrees with part a. of the finding. MDHHS and DTMB disagree with part b. of the finding. For part b., although MDHHS agrees that system security plans were not updated timely for the sys...
Finding 2023-041 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - ADP Security Program Management Views MDHHS agrees with part a. of the finding. MDHHS and DTMB disagree with part b. of the finding. For part b., although MDHHS agrees that system security plans were not updated timely for the systems cited and the authority to operate expired for both systems, MDHHS disagrees that effective controls were not implemented to ensure confidentiality, integrity, and availability of its automated data processing (ADP) information systems. MDHHS also disagrees that the security of critical systems was at risk by failing to mitigate potential vulnerabilities as described above. MDHHS has compensating controls in place to ensure confidentiality, integrity, and availability of its ADP information systems in addition to mitigating potential vulnerabilities. MDHHS monitors remediation of Plans of Actions and Milestones for all information systems even after expiration of the authority to operate. The ADP systems cited for not having an updated risk assessment are reviewed biennially through the Internal Control Evaluation process where control evidence is updated to demonstrate effectiveness of controls. For one system cited, MDHHS is required to audit the system as part of the responsibilities related to the Affordable Care Act and the Medicaid Expansion marketplace. Those audits are conducted to show compliance with federal information security and privacy requirements related to data stored in those systems. The other system cited did not have any significant changes and implemented controls are still working as expected. Planned Corrective Action For part a., MDHHS will perform annual reviewing and testing of the business continuity plan (BCP). MDHHS has completed annual review and testing of the BCP as of April 22, 2024. For part b., MDHHS and DTMB will complete the necessary updates to the system security plans, including updating the risk assessments, and anticipate completion for both systems by December 31, 2024. MDHHS and DTMB anticipate that authority to operate renewals will be attained for both systems by December 31, 2024. Anticipated Completion Date December 31, 2024 Responsible Individual(s) Jim Bowen, MDHHS Nathan Buckwalter, DTMB Heather Frick, DTMB Karen Scott, MDHHS Keelie Honsowitz, MDHHS
Finding 402644 (2023-040)
Significant Deficiency 2023
Finding 2023-040 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Practitioner Reimbursement Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has determined the primary remaining source for overlaps between fee-for-service and capitation payments is due to retroact...
Finding 2023-040 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Practitioner Reimbursement Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has determined the primary remaining source for overlaps between fee-for-service and capitation payments is due to retroactive removal of Medicaid eligibility within Bridges. An upgraded interface fix is being implemented that will address several issues. This upgraded interface will remove the existing limitations to mitigate the occurrence of retroactive disenrollment. The interface fix is scheduled for March 2025 implementation. Anticipated Completion Date March 31, 2025 Responsible Individual(s) Latina McCausey, MDHHS Alexis Bond, MDHHS
View Audit 309982 Questioned Costs: $1
Finding 402643 (2023-039)
Significant Deficiency 2023
Finding 2023-039 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Ineligible HHP Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS presented the audit findings and planned corrective action to local office workers, managers, and staff at an Adult Services ...
Finding 2023-039 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Ineligible HHP Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS presented the audit findings and planned corrective action to local office workers, managers, and staff at an Adult Services statewide meeting during March 2024. During the meeting, MDHHS reviewed recoupment policies and procedures and the importance of reviewing work for accuracy. MDHHS issued an Adult Services Notification to managers and directors during April 2024 informing them of the recent recoupment audit findings and reminding local office management of the expectation to review hospitalization reports to ensure timely and accurate action is taken. Anticipated Completion Date Completed Responsible Individual(s) Elaina Brown-Mingo, MDHHS Michelle Martin, MDHHS
View Audit 309982 Questioned Costs: $1
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
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