Corrective Action Plans

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Finding 2025-002 Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Auditee’s Comment on Finding We agree with the auditors’ finding. Corrective Action Pending Anticipated Completion Date July 15, 2025
Finding 2025-002 Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Auditee’s Comment on Finding We agree with the auditors’ finding. Corrective Action Pending Anticipated Completion Date July 15, 2025
CORRECTIVE ACTION PLAN FOR THE YEAR ENDED FEBRUARY 28, 2025 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee t...
CORRECTIVE ACTION PLAN FOR THE YEAR ENDED FEBRUARY 28, 2025 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee to prepare a corrective action plan to address each audit finding included in the current year auditor’s reports. The Corrective Action Plan for Current Year Findings present our corrective action plan for the Financial Statement and/or Federal Award Findings described in the accompanying Schedule of Findings and Questioned Costs for the period ended February 28, 2025. Responsible Party Name: Tamara Wallace Position: Executive Director – Management Agent Telephone Number: 816-233-4250 Federal Agency U.S. Department of Housing and Urban Development Federal Program Mortgage Insurance for Rental and Cooperative Housing (Section 221(d)(4)) Finding 2025-001 Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Auditee’s Comment on Finding We agree with the auditors’ finding. Corrective Action We will ensure that the accounts reconcile to source documents as part of our month-end closing process. Anticipated Completion Date August 31, 2025
Finding 2025-007 Compliance Requirements A/B Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Type Federal Awards Auditee’s Comment on Finding We agree with the auditor’s finding. Corrective Action Management will ask HUD for retroactive permission for these expenditures. ...
Finding 2025-007 Compliance Requirements A/B Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Type Federal Awards Auditee’s Comment on Finding We agree with the auditor’s finding. Corrective Action Management will ask HUD for retroactive permission for these expenditures. Anticipated Completion Date July 31, 2025
View Audit 370220 Questioned Costs: $1
Finding 2025-005 Compliance Requirements A/B Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Type Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action Management will follow its policies and procedures immediately. Anticipated Completio...
Finding 2025-005 Compliance Requirements A/B Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Type Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action Management will follow its policies and procedures immediately. Anticipated Completion Date July 1, 2025
View Audit 370220 Questioned Costs: $1
Finding 2025-003 Compliance Requirements N – Special Tests and Provisions Finding Type Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action We will contact HUD to discuss resolution of this matter within 30 days. Anticipated Completion Date September 30, 2025
Finding 2025-003 Compliance Requirements N – Special Tests and Provisions Finding Type Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action We will contact HUD to discuss resolution of this matter within 30 days. Anticipated Completion Date September 30, 2025
View Audit 370220 Questioned Costs: $1
Finding 2025-002 Compliance Requirements N – Special Tests and Provisions Finding Type Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action We will deposit $732 into the residual receipts account within 30-days. Anticipated Completion Date July 31, 2025
Finding 2025-002 Compliance Requirements N – Special Tests and Provisions Finding Type Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action We will deposit $732 into the residual receipts account within 30-days. Anticipated Completion Date July 31, 2025
View Audit 370220 Questioned Costs: $1
Finding 2025-001 Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action Management will follow its policies and procedures to ensure accounting records are accurate and com...
Finding 2025-001 Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action Management will follow its policies and procedures to ensure accounting records are accurate and complete. Anticipated Completion Date September 30, 2025
Condition: We noted no indication that certified payrolls were obtained and reviewed by Township officials prior to payment being made to a contractor for construction work performed in one instance. Planned Corrective Action: While controls are in place to ensure payments to vendors are not made wi...
Condition: We noted no indication that certified payrolls were obtained and reviewed by Township officials prior to payment being made to a contractor for construction work performed in one instance. Planned Corrective Action: While controls are in place to ensure payments to vendors are not made without completed review of certified payrolls, staff acknowledges records kept did not provide adequate backup to verify these controls. Going forward, staff will not only be sure to keep copies of certified payrolls with related invoices, they will also maintain records that confirm invoices without certified payrolls did not include labor that is subject to Davis-Bacon wage requirements. These records will likely come in the form of detailed invoice cost breakdowns (showing absence of labor costs) or correspondence affirming no labor costs were included in the invoice. Contact person responsible for corrective action: Matthew Wallace Anticipated Completion Date: Immediately
Condition: We noted no formal evidence that the stated control to ensure performance of required inspections prior to contract approval had been implemented effectively in one instance. We also noted no formal evidence that the stated control to verify inspections were performed upon project complet...
Condition: We noted no formal evidence that the stated control to ensure performance of required inspections prior to contract approval had been implemented effectively in one instance. We also noted no formal evidence that the stated control to verify inspections were performed upon project completion to ensure that work was carried out in accordance with contract specifications had been implemented effectively in one instance. Planned Corrective Action: Staff will review folders at various stages of the project to ensure all records of inspections at both the beginning and end of the project are in the file. Staff has already set up either bi-weekly or monthly meetings (depending on project activity levels) to report on the status of ongoing projects. These meetings were intended to help staff keep current projects in line with the overall project budget (i.e. not obligating funds beyond what’s available). Using these same meetings to check project files for all necessary records will be an adjustment of negligible effort. In instances where there is a sizable gap between portions of a project (e.g. part of the project can’t be completed until spring) staff will consider closing out the completed portion of the project and completing a final inspection on the balance of the job at a later date. Contact person responsible for corrective action: Edwin Manninen, Matthew Wallace Anticipated Completion Date: Immediately
Finding Number: 2025-006 Condition: The Township did not have the appropriate processes and controls in place to ensure FFATA reports were appropriately submitted. Planned Corrective Action: The Township will put processes and controls in place to ensure FFATA reports are submitted as needed. Contac...
Finding Number: 2025-006 Condition: The Township did not have the appropriate processes and controls in place to ensure FFATA reports were appropriately submitted. Planned Corrective Action: The Township will put processes and controls in place to ensure FFATA reports are submitted as needed. Contact person responsible for corrective action: Finance Director Anticipated Completion Date: 3/31/2026
Finding Number: 2025-005 Condition: The Township did not have the appropriate controls in place to ensure reports and reimbursement requests that were required to be submitted under the grant were complete and accurate as well as ensuring the matching requirement was properly reviewed. Planned Corre...
Finding Number: 2025-005 Condition: The Township did not have the appropriate controls in place to ensure reports and reimbursement requests that were required to be submitted under the grant were complete and accurate as well as ensuring the matching requirement was properly reviewed. Planned Corrective Action: The Township will update the Grant Policy to include a requirement for dual review on all grant reporting. Contact person responsible for corrective action: Finance Director Anticipated Completion Date: 3/31/2026
Finding 2025-002 See response to finding 2025-001.
Finding 2025-002 See response to finding 2025-001.
View Audit 367580 Questioned Costs: $1
2025-001 Application of Sliding Fee Discounts Corrective action planned: The CFO, Revenue Cycle Manager, Revenue Cycle Coordinator, and billing staff will begin to implement a peer review process of the sliding fee scale applications monthly. Management will develop a peer review form, train the sta...
2025-001 Application of Sliding Fee Discounts Corrective action planned: The CFO, Revenue Cycle Manager, Revenue Cycle Coordinator, and billing staff will begin to implement a peer review process of the sliding fee scale applications monthly. Management will develop a peer review form, train the staff on the form, and process to review each application to ensure compliance with the approved policy. The following actions will be taken: 1. Develop a formal peer review form and process for reviewing sliding fee scale applications. a. Responsible Party: Revenue Cycle Manager and Revenue Cycle Coordinator b. Completion Date: August 11, 2025 2. Provide training to all billing staff for peer review process and forms. Implementation of the process after training. a. Responsible Party: Revenue Cycle Manager and Revenue Cycle Coordinator b. Completion Date: August 12, 2025 and September 1, 2025 3. Monitor for effectiveness. After completion of peer review, the two managers will review and provide feedback to each employee monthly. Billing staff will be responsible for completing reviews and feedback on process and form structure. a. Responsible Party: Revenue Cycle Manager and Revenue Cycle Coordinator b. Completion Date: September 18, 2025 4. Verify effectiveness. The CFO and Revenue Cycle Manager will conduct a random audit of the peer review forms and ensure compliance with the policy for slide applications and ensure the peer review forms are completed, signed and dated. Anticipated completion date: March 1, 2026 Contact person responsible for corrective action: Evan Condelario, CFO
In Finding 2025-001, it was reported that the Organization did not maintain proper documentation of all necessary elements of sliding fee discounts as required by the Organization’s policy. This was a result of sliding fee applications being incomplete, expired, or missing. In addition, one patient ...
In Finding 2025-001, it was reported that the Organization did not maintain proper documentation of all necessary elements of sliding fee discounts as required by the Organization’s policy. This was a result of sliding fee applications being incomplete, expired, or missing. In addition, one patient who qualified for a discount did not receive a discount. Management recognizes the importance of complying with federal sliding fee guidelines and the Organization’s sliding fee policy. In response to Finding 2025-001, procedures will be established to ensure employees are trained to maintain the required documentation, including sliding fee applications, for sliding fee discounts provided. The Organization will establish procedures to ensure that selected patient records are reviewed by a supervisor on a periodic basis to ensure that the required documentation is properly maintained and that the patients receive the proper discount in accordance with the Organization’s policies.
2025-004 Cash Management (repeat of finding 2024-008) Corrective action planned: Beginning April 1, 2025, when the organization was made aware of this finding in last year’s audit, OMC took immediate corrective action. The CFO/Designee monitors expenses and prepares a detailed report of expenditures...
2025-004 Cash Management (repeat of finding 2024-008) Corrective action planned: Beginning April 1, 2025, when the organization was made aware of this finding in last year’s audit, OMC took immediate corrective action. The CFO/Designee monitors expenses and prepares a detailed report of expenditures claimed for reimbursement and retains this documentation along with supporting invoices. A qualified, knowledgeable CFO will continue to ensure compliance with these requirements. Anticipated completion date: Corrective Action taken on April 1, 2025. Contact person responsible for corrective action: Allen Boyd, Director of Fiscal Operations
Management agrees with the finding and will establish the internal control recommendations outlined in the Schedule of Findings and Questioned Costs. Internal control procedures will be developed and implemented by September 2025.
Management agrees with the finding and will establish the internal control recommendations outlined in the Schedule of Findings and Questioned Costs. Internal control procedures will be developed and implemented by September 2025.
August 08, 2025 RE: FYE 2025 Audit Finding Contact Name: Brenda Wise, Director of Accounting Section III – Federal Award Findings and Questioned Costs: Finding 2025-001 The Authority agrees with finding 2025-001 • The Authority did not follow HUD’s published instructions in Notice PIH-2023-25 reg...
August 08, 2025 RE: FYE 2025 Audit Finding Contact Name: Brenda Wise, Director of Accounting Section III – Federal Award Findings and Questioned Costs: Finding 2025-001 The Authority agrees with finding 2025-001 • The Authority did not follow HUD’s published instructions in Notice PIH-2023-25 regarding required reference year for financial data used in preparing HUD Form 52723. o Each year prior to submission of HUD form 52723, the Authority will review all relevant PIH notices regarding calculation of the Public Housing Operating Subsidy, will adhere to the most current requirements, and will update its internal control documents and procedures to ensure consistency with current HUD guidance. Specifically, formula income, audit costs, and PILOT will be based on the Financial Data Schedule defined by HUD.
Special Provisions Federal Agency: US Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2205MN5ADM, 2024 Award Period: January 1, 2024 through December 31, 2024 Type of Finding: Material We...
Special Provisions Federal Agency: US Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2205MN5ADM, 2024 Award Period: January 1, 2024 through December 31, 2024 Type of Finding: Material Weakness in Internal Control over Compliance Recommendation: We recommend the County puts in place the proper procedures to ensure it has proper controls in place to properly document the review of all the LCTS reports submitted by each collaborative member each quarter for accuracy. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will ensure there are proper financial procedures and controls in place to properly document the review of all required reports for the program. Name(s) of the contact person(s) responsible for corrective action: Angie Larson, Auditor-Treasurer / Chief Financial Officer Planned completion date for corrective action plan: December 31, 2026
Reporting Federal Agency: US Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2205MN5ADM, 2024 Award Period: January 1, 2024 through December 31, 2024 Type of Finding: Material Weakness in...
Reporting Federal Agency: US Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2205MN5ADM, 2024 Award Period: January 1, 2024 through December 31, 2024 Type of Finding: Material Weakness in Internal Control over Compliance Recommendation: We recommend the County puts in place the proper procedures to ensure it has proper controls in place to properly document the review of all required reports for the program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will ensure there are proper financial procedures and controls in place to properly document the review of all required reports for the program. Name(s) of the contact person(s) responsible for corrective action: Angie Larson, Auditor-Treasurer / Chief Financial Officer Planned completion date for corrective action plan: December 31, 2026
Allowable Costs - Quarterly Review of State Time Study Listings Federal Agency: US Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2205MN5ADM, 2024 Award Period: January 1, 2024 through D...
Allowable Costs - Quarterly Review of State Time Study Listings Federal Agency: US Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2205MN5ADM, 2024 Award Period: January 1, 2024 through December 31, 2024 Type of Finding: Material Weakness in Internal Control over Compliance Recommendation: We recommend the County puts in place the proper procedures to ensure it has proper controls in place to properly document the review of the state time study listings each quarter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will ensure there are proper financial procedures and controls in place to properly document the review of the state time study listings each quarter. Name(s) of the contact person(s) responsible for corrective action: Angie Larson, Auditor-Treasurer / Chief Financial Officer Planned completion date for corrective action plan: December 31, 2026
Finding 2024-058- Special Tests and Provisions – Subgrant Awards (Pass-through Requirement) Auditor's Summary of the Finding The auditors concluded that DEM did not maintain sufficient internal controls to ensure compliance with the statutory requirement that at least 80 percent of State Homeland Se...
Finding 2024-058- Special Tests and Provisions – Subgrant Awards (Pass-through Requirement) Auditor's Summary of the Finding The auditors concluded that DEM did not maintain sufficient internal controls to ensure compliance with the statutory requirement that at least 80 percent of State Homeland Security Program (SHSP) funds were obligated to local units of government within the required timeframe or that written consent was obtained when funds were retained by the State Administrative Agency (SAA). As a result, the auditors recommended that DEM strengthen internal controls to document compliance with the statutory passthrough requirement. DEM Response DEM respectfully disagrees with the conclusion that it lacked internal controls over compliance with the SHSP 80 percent pass-through requirement. DEM maintains an established governance process that provides multiple levels of review before Homeland Security Grant Program funding recommendations are submitted to FEMA. All HSGP applications are initially reviewed by DEM staff for compliance with the annual Notice of Funding Opportunity (NOFO), applicable federal statutes, FEMA guidance, and program eligibility requirements. Applications and proposed funding allocations are then reviewed through a transparent public process by the Nevada Resilience Advisory Committee (NRAC), the Urban Area Working Group (UAWG), the Homeland Security Finance Committee, and the Nevada Homeland Security Commission (NHSC), with full participation of all eligible applicants. These reviews evaluate project eligibility, funding priorities, and compliance with applicable statutory and program requirements prior to FEMA approval. The FY 2023 FEMA Preparedness Grants Manual describes FEMA's review of preparedness grant applications, investment justifications, and funding allocations prior to award. DEM's application review process complements FEMA's oversight through multiple levels of state and local review before funding recommendations are submitted. Likewise, FEMA reviews the State's HSGP application and proposed funding allocations for compliance with the applicable NOFO before issuing an award. The Manual does not prescribe a specific post-award methodology requiring recipients to maintain a cumulative statewide calculation of the pass-through requirement. During Nevada's application review process, any funding proposed to remain with DEM as the State Administrative Agency is openly discussed with participating jurisdictions and stakeholder groups. Those funding decisions are agreed upon through the public application review process and are documented through Memoranda of Understanding (MOUs) and executed subaward documents. These records document local government concurrence with funding allocations and provide evidence supporting compliance with statutory pass-through requirements. Accordingly, DEM believes its existing governance structure constitutes an effective preventive internal control over compliance with the SHSP pass-through requirement. Corrective Action Although DEM believes its existing internal controls provide reasonable assurance of compliance, DEM recognizes the benefit of enhancing documentation supporting those controls. DEM has revised its Internal Control Manual to strengthen grant administration and oversight and will implement the following additional procedures: • Maintain a grant file certification documenting compliance with the SHSP statutory pass-through requirement for each HSGP award. • Retain documentation demonstrating review of funding allocations through DEM staff, NRAC, UAWG, Homeland Security Finance Committee, and NHSC. • Retain all applicable Memoranda of Understanding, subaward agreements, and supporting documentation evidencing local jurisdiction concurrence regarding funds retained by DEM. • Document any FEMA approvals or written consents applicable to retained funding in the official grant file. • Continue annual review of internal controls and grant administration procedures to ensure continued compliance with FEMA guidance and federal requirements. These enhancements formalize documentation of controls that have historically existed throughout Nevada's HSGP governance and award process. Responsible Official(s): • Susan Coyote, Chief Grants Officer • Shealyne Slone, Preparedness Grants Supervisor Anticipated Completion Date: Implemented for FY 2026 HSGP awards; ongoing thereafter.
Date: July 24, 2026 U.S. Department of Health and Human Services Children’s Health Insurance Program (CHIP) Medicaid Cluster: State Medicaid Fraud Control Units State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare, Medical Assistance Program (Medicaid; Title X...
Date: July 24, 2026 U.S. Department of Health and Human Services Children’s Health Insurance Program (CHIP) Medicaid Cluster: State Medicaid Fraud Control Units State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare, Medical Assistance Program (Medicaid; Title XIX) 93.767/93.775/93.778 Finding Number: 2024-050 - Eligibility Material Weakness in Internal Control over Compliance. PARIS data was not utilized by the Nevada Health Authority (NVHA) or DSS to monitor residency changes to determine when managed care benefits needed to be terminated because a beneficiary had become a resident of another state for Medicaid purposes. Projected questioned costs of $16,257,975 (Medicaid) and $1,111,448 (CHIP) were identified. (Repeat of prior year finding 2023-054.) Corrective Action Taken or To Be Taken: The Division of Social Services (DSS) automated the PARIS process as of September 30, 2025. The automation is designed to streamline the quarterly PARIS process. Upon receipt of the file, the system generates initial requests for information to identified customers, requiring them to confirm Nevada residency. Customers are allowed 30 days to respond. Approximately five days after the initial request, reminder notices are issued by text message and email to customers who have not responded. Customers who fail to respond within the 30-day timeframe, or who confirm an out-of-state address, will be terminated in accordance with policy, while those confirming Nevada residency will retain eligibility. NVHA continues to implement processes to ensure that MMIS will receive closure information related to PARIS matches and report it to T-MSIS. Once DSS has determined that termination is needed within the timeframes outlined above, DSS will send a “Y” indicator to MMIS and proceed with the termination which will also terminate the member from managed care benefits. This enhancement was implemented in November 2025. In addition, another project which will update the PARIS indicator to include Concurrent Enrollment Matches (CEM) and Death Master File (DMF). Any terminations that are full under these will be reported with respective termination codes when this is implemented, which is currently estimated to be October 2026 but is subject to change. If to be taken, estimated date of completion: Completed (2025); ongoing quarterly operations. Agency Response Does the Agency agree with finding: Yes X No Partially Individual Responsible for Corrective Action Plan: Name, Title: Karen Stoycoff, Social Services Program Specialist Phone Number: 775-684-7436 Email: kstoycoff@dss.nv.gov Name, Title: Russell Steele, Nevada Health Authority Phone Number: 775-684-3609 Email: rsteele@nvha.nv.gov Name, Title: Jennifer Frischmann, Nevada Health Authority Phone Number: 775-684-3609 Email: j.frischmann@nvha.nv.gov
Finding Number 2024-050 U.S. Department of Health and Human Services Children’s Health Insurance Program (CHIP), 93.767 Medicaid Cluster: State Medicaid Fraud Control Units, 93.775 State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare, 93.777 Medical Assistance...
Finding Number 2024-050 U.S. Department of Health and Human Services Children’s Health Insurance Program (CHIP), 93.767 Medicaid Cluster: State Medicaid Fraud Control Units, 93.775 State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare, 93.777 Medical Assistance Program (Medicaid; Title XIX), 93.778 Summary of Finding for 2024 Audit: PARIS data was not utilized by the Nevada Health Authority (NVHA) or the Nevada Division of Social Services (DSS) to monitor residency changes to determine when managed care benefits needed to be terminated because the beneficiary was a resident of another state for Medicaid purposes. NVHA and DSS did not have internal controls in place to effectively communicate the PARIS data between the two agencies to ensure managed care benefits were terminated when appropriate. Individuals are enrolled in Medicaid (and CHIP) plans in multiple states and benefits are not being terminated timely. Therefore, the State of Nevada is paying capitation payments to managed care organizations, when the benefits should have been terminated. We recommend NVHA and DSS implement internal controls to effectively communicate the PARIS data between each other and to ensure managed care benefits are terminated when appropriate. NVHA Response: The Nevada Health Authority agrees with this finding. Contact Person(s): Russ Steele, Audit Manager Corrective Action Planned: The Division of Social Services (DSS), which conducts eligibility and enrollment on behalf of Nevada Medicaid, automated the PARIS process as of September 30, 2025. The automation is designed to streamline the quarterly PARIS process. Upon receipt of the file, the system generates initial requests for information to customers identified, requiring them to confirm Nevada residency. Customers are allowed 30 days to respond. Approximately five days after the initial request, reminder notices are issued by text message and email to customers who have not responded. Customers who fail to respond within the 30-day timeframe, or who confirm an out-of-state address, will be terminated in accordance with policy, while those confirming Nevada residency will retain eligibility. NVHA continues to implement processes to ensure that MMIS will receive closure information related to PARIS matches and report it to T-MSIS. Once DSS has determined that termination is needed within the timeframes outlined above, DSS will send a “Y” indicator to MMIS and proceed with the termination which will also terminate the member from managed care benefits. This enhancement was implemented in November 2025. In addition, another project which will update the PARIS indicator to include Concurrent Enrollment Matches (CEM) and Death Master File (DMF). Any terminations that fall under these will be reported with respective termination codes when this is implemented, which is currently estimated to be October 2026 but is subject to change. Anticipated Completion Date of Corrective Action Plan: This corrective action plan was implemented on September 30, 2025.
Finding Number 2024-048 U.S. Department of Health and Human Services Children’s Health Insurance Program (CHIP), 93.767 Summary of Finding: Amounts reported on the CMS-21 were not supported by the underlying accounting information. NVHA did not have adequate internal controls to ensure CMS-21 report...
Finding Number 2024-048 U.S. Department of Health and Human Services Children’s Health Insurance Program (CHIP), 93.767 Summary of Finding: Amounts reported on the CMS-21 were not supported by the underlying accounting information. NVHA did not have adequate internal controls to ensure CMS-21 reports were accurate or supporting documentation for reconciling items was maintained. A nonstatistical sample of two CMS-21 reports out of a population of four was selected for testing. NVHA was unable to provide Support for the following variances: December 31, 2023 CMS-21 Report Amount Reported Amount Supported Line 1a - Premiums Up to 150% of Poverty Level – Gross Premiums Paid $12,790,058 $10,620,925 Line 9 - Dental Services $603,625 $2,772,759 Line 18 – Screening Services $54,880 $57,168 March 31, 2024 CMS-21 Report Amount Reported Amount Supported Line 1a - Premiums Up to 150% of Poverty Level – Gross Premiums Paid $9,192.633 $7,629,522 Line 8 – Prescribed Drugs $295,759 $321,092 Line 9 - Dental Services $755,375 $2,318,487 We recommend NVHA enhance internal controls to ensure CMS-21 reports are accurate and supporting documentation is maintained. NVHA Response: The Nevada Health Authority agrees with this finding. Contact Person(s): Russ Steele, Audit Manager Corrective Action Planned: The Division has enhanced its internal controls to ensure the accuracy of CMS-21 reports and the proper maintenance of supporting documentation. The following measures have been implemented: 1.System of Record – DAWN: The state’s accounting system, DAWN, continues to serve as the Division’s official system of record for compiling CMS-21 reports. 2.Documentation of Transactions: The Division has transitioned to an electronic recordkeeping system for all financial transactions. This change enhances the accuracy, consistency, and accessibility of financial records while supporting improved internal controls. Electronic documentation is now maintained in accordance with established policies and is readily available for review, permitting more efficient audit processes and ensuring compliance with applicable record retention requirements. 3.Reporting Requirements for Certain Service Costs: Currently, several service costs are commingled within MMIS. To address this, the Division performs data downloads from MMIS to separate and identify these costs appropriately for CMS-21 reporting. The Federal Reporting Unit will ensure these MMIS reports are maintained to provide transparency and traceability. 4.Collaboration with Fiscal Agent: The Division is actively collaborating with its Fiscal Agent, Gainwell, to improve CMS-21 reporting. This includes the development of new “fiscal strings” designed to capture and isolate specific costs that must be reported separately. These efforts aim to enhance transparency and accuracy in federal reporting. These improvements reflect the Division’s commitment to strengthening financial reporting processes, ensuring compliance with federal requirements, and maintaining robust documentation standards. Anticipated Completion Date of Corrective Action Plan: September 2025
Finding Number: 2024-043 – Material Weakness in Internal Control over Compliance and Material Noncompliance Finding: DSS did not have adequate internal controls to ensure amounts reported on the LIHEAP Quarterly Performance and Management Report were appropriately supported. Corrective Action Taken ...
Finding Number: 2024-043 – Material Weakness in Internal Control over Compliance and Material Noncompliance Finding: DSS did not have adequate internal controls to ensure amounts reported on the LIHEAP Quarterly Performance and Management Report were appropriately supported. Corrective Action Taken or To Be Taken: The internal controls have been implemented to ensure the amounts are documented and reported accurately on the LIHEAP Quarterly Performance and Management Report. If to be taken, estimated date of completion: Corrective action in place. Agency Response Does the Agency agree with finding: Yes X No Partially Individual Responsible for Corrective Action Plan: Name, Title: Brooke Barlow, Administrative Services Officer III- Chief of Fiscal Services Phone Number: 775-684-0659 Email: bebarlow@dss.nv.gov
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