Corrective Action Plans

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Oxnard Pathway to Educated Nutrition, Inc. respectfully submits the following corrective action plan for the fiscal year ending September 30, 2024. Findings: 2024-001 CACFP-Administrative Budget Exceeded our approved budget in the Communications Category. Although a budget increase (revision) was re...
Oxnard Pathway to Educated Nutrition, Inc. respectfully submits the following corrective action plan for the fiscal year ending September 30, 2024. Findings: 2024-001 CACFP-Administrative Budget Exceeded our approved budget in the Communications Category. Although a budget increase (revision) was requested and approved for the above budget category, the amount of the increase was not sufficient to cover the total administrative costs at year’s ending. Note: Our agency did not exceed our total FY 23-24 Budget.As reflected on the UFAP DCH07, a total of $19,190.80 in unused funds were returned to CDSS in December 2024 Action Taken: Our organization will now track our administrative expenses monthly instead of quarterly. This will ensure there is enough time to request Specific Prior Written Approva/ timely budget revision, to any categories that may need to be increased or adjusted. If there are any questions regarding this plan, please call Angelita Barron at (805) 642-2720.
View Audit 360493 Questioned Costs: $1
Person(s) responsible for corrective action: Lucy Yanez, Contract Specialist, Tracy Johnson, Accounts Payable, Tina Hurtado Controller, NWIFC staff and supervisors engaged in procurement and contracting. Management’s Response/Corrective Action Plan: The NWIFC implemented corrective measures relat...
Person(s) responsible for corrective action: Lucy Yanez, Contract Specialist, Tracy Johnson, Accounts Payable, Tina Hurtado Controller, NWIFC staff and supervisors engaged in procurement and contracting. Management’s Response/Corrective Action Plan: The NWIFC implemented corrective measures related to procurement in March of 2024. See FY23 Corrective Action Plan. However, the one procurement sample that was cited as not including “documentation of bidding, alternative price quotes or sole source documentation” contained a sole source justification that was developed before implementation of the FY23 Corrective Action Plan. The sole source justification was based on the specialized knowledge and specific expertise. Procurement samples for purchases or contracts after the implementation of the FY23 Corrective Action Plan, show compliance of adequate bidding, price quotes or sole source documentation consistent with 2 CFR 200. The NWIFC will continue to implement the FY23 Corrective Action Plan, by requiring NWIFC managers and their staff to be responsible for soliciting bids or developing sole source justifications for procurements and contracts consistent with 2 CFR 200. The Contract Specialist will ensure that bid solicitations and sole source justifications are properly documented and filed with each contract. Similarly, the audit noted that certain suspension and debarment samples selected, before the FY23 Corrective Action Plan was implemented in March 2024, lacked documentation of a suspension and debarment review prior to doing business with vendors. In response, the FY23 Corrective Action Plan, put into effect in March 2024, included measures to ensure that both new vendor and annual reviews are documented. The Accounts Payable department will continue to conduct suspension and debarment reviews for all new vendors before conducting business and perform annual reviews of all vendors, in line with the FY23 Corrective Action Plan. Anticipated completion date: Completed March 2024.
View Audit 360492 Questioned Costs: $1
Expenditures submitted for the Alabama Medicaid Administrative Claiming Program included expenditures suppported by federal funds and undocumented costs. Contact Person: Dr. Brock Nolin, Superintendent ...
Expenditures submitted for the Alabama Medicaid Administrative Claiming Program included expenditures suppported by federal funds and undocumented costs. Contact Person: Dr. Brock Nolin, Superintendent Corrective Action: Claims will be adjusted to correct the duplication of federal funds and undocumented costs. Policies and procedures will be implemented according to the recommendations found in the Schedule of Findings and Questioned Costs. Proposed Completion Date: Prior the submission of the July-September 2025 claim.
View Audit 360487 Questioned Costs: $1
As already indicated, income from tenant payments were not being properly applied to the correct revenue streams, all monies received were being coded to dwelling rents and not extra utility and cable charges as applicable. See response to 2024-001. Also, we have raised the fee charged to the tena...
As already indicated, income from tenant payments were not being properly applied to the correct revenue streams, all monies received were being coded to dwelling rents and not extra utility and cable charges as applicable. See response to 2024-001. Also, we have raised the fee charged to the tenants for cable to ensure that the expense is being adequately covered.
View Audit 360281 Questioned Costs: $1
Finding 2024-055 Low-Income Home Energy Assistance, ALN 93.568 - Eligibility Determinations Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS implemented quarterly case reads beginning in fiscal year 2023, and during April 2023, MDHHS began monthly meetings with the B...
Finding 2024-055 Low-Income Home Energy Assistance, ALN 93.568 - Eligibility Determinations Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS implemented quarterly case reads beginning in fiscal year 2023, and during April 2023, MDHHS began monthly meetings with the BSC analyst team to discuss common errors, answer questions, provide guidance, and on a quarterly basis discuss the results of the State Emergency Relief (SER) case reads. During April 2024, MDHHS SER program policy management and staff began attending BSC leadership meetings to discuss SER case read data findings, policy changes, and communicate common errors found during audits. In addition to updating verification requirements on October 1, 2023, SER program policy management and staff added copay verification requirements on October 1, 2024. MDHHS completed system updates during April 2024 to allow specialists access to directly upload verification documentation to the electronic case file instead of providing the documentation to other areas to process and upload. MDHHS will provide annual training directly to counties that fail to meet the state average for SER case reads relating to verification of the client's income, client contribution payment, and proof of energy crisis. MDHHS will continue to communicate with BSCs and local offices regarding the requirements to obtain adequate verification and maintain sufficient documentation to support SER processing. MDHHS will also continue to provide direct SER guidance and clarification through the SER mailbox. Anticipated Completion Date September 30, 2025 Responsible Individual(s) Bethany Cabanaw, MDHHS Kent Schulze, MDHHS Julie McLaughlin, MDHHS
View Audit 360209 Questioned Costs: $1
Finding 2024-050 Refugee and Entrant Assistance State/Replacement Designee Administered Programs, ALN 93.566 - Assistance to Ineligible Refugees Management Views LEO and MDHHS agree with the finding. Planned Corrective Action MDHHS, in conjunction with LEO, will provide mandatory training for all ...
Finding 2024-050 Refugee and Entrant Assistance State/Replacement Designee Administered Programs, ALN 93.566 - Assistance to Ineligible Refugees Management Views LEO and MDHHS agree with the finding. Planned Corrective Action MDHHS, in conjunction with LEO, will provide mandatory training for all specialists that determine eligibility for refugee cash assistance payments by September 30, 2025. MDHHS also will implement ongoing management and peer-to-peer spot checks of cases to ensure that documentation is maintained to support the client’s eligibility beginning October 2025. In addition, MDHHS will determine if technical changes are needed to help ensure the proper documentation is in the electronic case file by December 31, 2025. If potential system modifications are needed, the Bridges technical team will follow the Departmental Work Intake Process for prioritization and determine an anticipated completion date for implementation. Anticipated Completion Date MDHHS has not yet determined an anticipated completion date because the date is dependent on the determination of whether system modifications are necessary. Responsible Individual(s) Benjamin Cabanaw, LEO Nicole Adams, LEO Bethany Cabanaw, MDHHS Kent Schutz, MDHHS Mariah Schaefer, MDHHS
View Audit 360209 Questioned Costs: $1
Finding 567837 (2024-046)
Significant Deficiency 2024
Finding 2024-046 Temporary Assistance for Needy Families, ALN 93.558 - Inappropriate TANF- Funded Emergency Foster Care Assistance Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS redetermined the Foster Care Title IV-E (Title IV-E) program eligibility after the bi...
Finding 2024-046 Temporary Assistance for Needy Families, ALN 93.558 - Inappropriate TANF- Funded Emergency Foster Care Assistance Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS redetermined the Foster Care Title IV-E (Title IV-E) program eligibility after the birth certificate was identified and the youth was determined to be Title IV-E eligible. MDHHS will reclassify the funds to the appropriate funding source, allowing the department to claim Title IV-E for the eligible placement. For those cases in which Title IV-E funding is denied initially based on lack of a birth certificate or other documentation of citizenship, the Child Welfare Funding Specialists will continue to monitor the case for updated documentation in order to complete a redetermination of funding. Child Welfare Funding Specialists will be reminded to monitor cases for updated documentation during a Child Welfare Funding conference call in June 2025. Anticipated Completion Date June 30, 2025 Responsible Individual(s) Nancy Berger, MDHHS
View Audit 360209 Questioned Costs: $1
Finding 567836 (2024-045)
Significant Deficiency 2024
Finding 2024-045 Temporary Assistance for Needy Families, ALN 93.558 - Non-Financial Eligibility Documentation Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS ESA policy staff will work with the MDHHS Bridges technical team to determine the reason for the incomplet...
Finding 2024-045 Temporary Assistance for Needy Families, ALN 93.558 - Non-Financial Eligibility Documentation Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS ESA policy staff will work with the MDHHS Bridges technical team to determine the reason for the incomplete application by September 30, 2025, and implement a solution to correct the issue, if needed. If potential system modifications are needed, MDHHS will follow the Departmental Work Intake Process for prioritization and determine an anticipated completion date for implementation. MDHHS will also send a memo and template of the application to the local offices to highlight the required questions on the application to help ensure all required questions are appropriately answered. Anticipated Completion Date MDHHS has not yet determined an anticipated completion date because the date is dependent on the potential solution identified. Responsible Individual(s) Bethany Cabanaw, MDHHS Kenton Schulze, MDHHS Brian Sanborn, MDHHS
View Audit 360209 Questioned Costs: $1
Finding 567769 (2024-043)
Significant Deficiency 2024
Finding 2024-043 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 2024-043 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 was implemented during March 2025 to address several issues. This upgraded interface removed the existing limitations to mitigate the occurrence of retroactive disenrollment. Anticipated Completion Date Completed Responsible Individual(s) Latina McCausey, MDHHS Alexis Bond, MDHHS
View Audit 360209 Questioned Costs: $1
Finding 567768 (2024-042)
Significant Deficiency 2024
Finding 2024-042 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Ineligible Home Help Assistance Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS added the Electronic Document Management system (EDM) to MiAIMS in March 2023 and issued an Adult Services Notificatio...
Finding 2024-042 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Ineligible Home Help Assistance Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS added the Electronic Document Management system (EDM) to MiAIMS in March 2023 and issued an Adult Services Notification to adult services staff, communicating that medical needs forms should be uploaded into EDM. MDHHS issued an Adult Services Notification to adult services staff during May 2025 to communicate the exceptions identified and remind them of the medical needs form requirements. MDHHS will develop a procedure to monitor the expiration of medical needs forms using the MiAIMS Plan of Care by August 2025. In addition, MDHHS will research potential options to automate monitoring of the medical needs forms in MiAIMS and determine if any necessary system changes are needed by December 2026. Anticipated Completion Date December 2026 Responsible Individual(s) Elaina Brown, MDHHS
View Audit 360209 Questioned Costs: $1
Finding 567767 (2024-041)
Significant Deficiency 2024
Finding 2024-041 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Ineligible HHP Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS generates a monthly hospitalization report and distributes to adult services workers as part of the post-payment review proce...
Finding 2024-041 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Ineligible HHP Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS generates a monthly hospitalization report and distributes to adult services workers as part of the post-payment review process. MDHHS enhanced the report query to improve the data used to identify overlaps in services and timely recover payments. MDHHS implemented the updated query during June 2025. Also, MDHHS issued an Adult Services Notification to managers and directors during February 2025, informing them of the audit finding and reminding local office management of the expectation to thoroughly monitor and review the hospitalization reports to ensure timely and accurate action is taken by adult services workers. In addition, MDHHS reissued the Home Help Recoupment Process training and procedural resources during February 2025 to adult services workers who manage Home Help cases to ensure process steps are consistently followed. Anticipated Completion Date Completed Responsible Individual(s) Elaina Brown, MDHHS Michelle Martin, MDHHS
View Audit 360209 Questioned Costs: $1
Finding 567766 (2024-040)
Significant Deficiency 2024
Finding 2024-040 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 continues to work with DTMB on the underlying issues in Bridges causing these overpayment issues, as we...
Finding 2024-040 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 continues to work with DTMB on the underlying issues in Bridges causing these overpayment issues, 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 December 2025. Anticipated Completion Date December 31, 2025 Responsible Individual(s) Jamy Hengesbach, MDHHS
View Audit 360209 Questioned Costs: $1
Finding 567765 (2024-039)
Significant Deficiency 2024
Finding 2024-039 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Transitional Medicaid Eligibility Management Views MDHHS agrees with the finding. MDHHS recognizes there are opportunities for improvement to ensure renewals are processed on a timely basis for beneficiaries receiving transitional ...
Finding 2024-039 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Transitional Medicaid Eligibility Management Views MDHHS agrees with the finding. MDHHS recognizes there are opportunities for improvement to ensure renewals are processed on a timely basis for beneficiaries receiving transitional medical assistance (TMA) Medicaid coverage, however due to time constraints, it was not feasible to manually review and validate all 1,802 beneficiaries queried to ensure they should be terminated from TMA. Also, although beneficiaries might not be eligible for TMA, they may be eligible for other Medicaid aid categories, and this will be determined as part of the department’s corrective action. Planned Corrective Action MDHHS implemented a system enhancement during May 2023 that generates redetermination requests one month in advance to allow additional time for processing and help ensure renewals are processed timely. MDHHS is continuing to update the backlog of cases following the end of the PHE, including those identified in the finding, to determine if the beneficiary should remain on Medicaid or if coverage should be terminated, and expects all existing cases will be reviewed and updated by July 2025. MDHHS will evaluate potential underlying system issues related to the timeliness of TMA renewals and will implement system enhancements if necessary by December 2026. Anticipated Completion Date December 2026 Responsible Individual(s) Logan Dreasky, MDHHS Brant Cole, MDHHS
View Audit 360209 Questioned Costs: $1
Finding 2024-012 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 identified exceptions for parts a. and c. of the finding. However, MDHHS disagrees that 3 Medicaid cases and 20 Chil...
Finding 2024-012 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 identified exceptions for parts a. and c. of the finding. However, MDHHS disagrees that 3 Medicaid cases and 20 Children’s Health Insurance Program (CHIP) cases with MAGI determinations cited in part b. did not have case file documentation supporting the beneficiary eligibility determination. The Centers for Medicare and Medicaid Services (CMS) has determined that a reasonable compatibility indicator can be used for CMS audit purposes to determine if the attested income information was electronically verified for MAGI cases and MDHHS disagrees that documentation was not maintained to support the eligibility determination. The SOM MiIntegrate system communicates with various State and federal electronic trusted data sources and sends the information from these sources, along with the beneficiaries’ attested income, to the SOM MAGI Rules Engine where the MAGI eligibility determination is made. As part of the MAGI eligibility determination, a reasonable compatibility test is completed to determine if beneficiary/applicant attested income is within a specified percentage of the electronic trusted data sources or if the attested and verified income are below the threshold for the applicable program. The results of the MAGI eligibility determination are sent back to MiIntegrate using an Account Transfer (AT) packet that contains the results. MiIntegrate then communicates the results to the SOM MAGI Viewer and Bridges using an AT packet and Bridges stores the AT packet number only that can be used to view the details of the AT packet within the SOM MAGI Viewer. The version of the AT packet within the MAGI Viewer also contains a reasonable compatibility indicator that documents the outcome of the reasonable compatibility test and supports the SOM MAGI Rules Engine eligibility decision. MDHHS stores the AT packet information, including facts essential to the eligibility determination, within MiIntegrate and the MAGI Viewer instead of Bridges to help protect and secure the federal income tax data and unemployment data used for the determination. The AT packet for each individual determination can be retrieved from the MAGI Viewer using the AT packet number stored in each beneficiary’s case file within Bridges. MDHHS is not aware of any federal regulations that preclude MDHHS from storing this information in a separate system to help secure the data and restrict access as required by federal and state law. Planned Corrective Action To address the exceptions identified that are not related to MAGI-based income verification results, MDHHS has developed mandatory training protocols for eligibility workers and expects to have the first Medicaid audit focused mandatory training implemented by July 2025. 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 within the electronic case file. MDHHS disagrees it did not maintain case file documentation that supports the beneficiary eligibility determination for MAGI cases and does not intend to take further action. Anticipated Completion Date MDHHS will implement the first Medicaid audit focused training by July 2025. Responsible Individual(s) Logan Dreasky, MDHHS Mariah Schaefer, MDHHS
View Audit 360209 Questioned Costs: $1
Finding 567724 (2024-033)
Significant Deficiency 2024
Finding 2024-033 CCDF Cluster, ALN 93.575 and 93.596 - Client Eligibility Management Views MiLEAP and MDHHS agree with the finding. Planned Corrective Action MiLEAP and MDHHS ESA will continue to work together to help ensure compliance with client eligibility requirements by providing guidance on ...
Finding 2024-033 CCDF Cluster, ALN 93.575 and 93.596 - Client Eligibility Management Views MiLEAP and MDHHS agree with the finding. Planned Corrective Action MiLEAP and MDHHS ESA will continue to work together to help ensure compliance with client eligibility requirements by providing guidance on updated policies, processes, and noted trends to local office and BSC staff. On October 1, 2024, MDHHS ESA distributed an ESA memo to BSCs and local offices requiring a Child Development and Care eligibility checklist to be completed and uploaded to the electronic case file at the time of each Child Development and Care application and redetermination to help ensure the authorized hours of care in Bridges does not exceed the client's documented need for hours of childcare services. The ESA memo also requires local offices that have not yet achieved compliance to review a sample of cases monthly and ensure the Child Development and Care eligibility checklist is properly uploaded to the electronic case file. The BSCs receive the monthly results from the local offices and also monitor progress to help ensure compliance. Anticipated Completion Date Ongoing Responsible Individual(s) Lisa Brewer-Walraven, MiLEAP Mariah Schaefer, MDHHS Gayle Vail, MDHHS
View Audit 360209 Questioned Costs: $1
Finding 2024-058 Unemployment Insurance, ALN 17.225 See Department of Labor and Economic Opportunity, Unemployment Insurance Agency - Unemployment Compensation Fund, Report on Expenditure of Federal Awards, Year Ended September 30, 2024, Corrective Action Plan, Finding 2024-001.
Finding 2024-058 Unemployment Insurance, ALN 17.225 See Department of Labor and Economic Opportunity, Unemployment Insurance Agency - Unemployment Compensation Fund, Report on Expenditure of Federal Awards, Year Ended September 30, 2024, Corrective Action Plan, Finding 2024-001.
View Audit 360209 Questioned Costs: $1
Finding 2024-005 Income Eligibility and Verification System Management Views MDHHS agrees with parts a., b., d., f., and g. of the finding. MDHHS disagrees with parts c. and e. of the finding. For part c., MDHHS disagrees that a process is not fully established to monitor the electronic notificat...
Finding 2024-005 Income Eligibility and Verification System Management Views MDHHS agrees with parts a., b., d., f., and g. of the finding. MDHHS disagrees with parts c. and e. of the finding. For part c., MDHHS disagrees that a process is not fully established to monitor the electronic notifications provided to county/district office caseworkers to ensure they utilized the Income Eligibility and Verification System (IEVS) information to determine the recipients’ eligibility. MDHHS had policies and procedures in effect during fiscal year 2024 to help ensure monitoring of electronic notifications was taking place. Review of IEVS information is fully incorporated into the case read procedure governed by Bridges Administrative Manual 301 and detailed further in desk aids and reading guides. The MDHHS Economic Stability Administration (ESA) provides regular direction and reminders of case read requirements via ESA Memos. For part e., MDHHS disagrees that IEVS information is required to be requested and obtained for modified adjusted gross income (MAGI) based recipients since eligibility is verified upon determination through the MAGI eligibility determination process and then granted for a 12-month continuous eligibility period. Requesting and obtaining IEVS information throughout the eligibility period would be irrelevant since eligibility is continuous. Planned Corrective Action For parts a. and b., MDHHS ESA will continue to provide guidance and trainings to the local office specialists on utilizing the IEVS data timely and appropriately if the data is critical for current eligibility determinations. MDHHS ESA will also continue to review any technical automated solutions of the IEVS data to help ensure its proper utilization and timeliness. For parts c. and e., MDHHS disagrees with the finding and does not intend to take further action. For part d., MDHHS is collaborating with other work areas to identify potential solutions to establish and implement IEVS interfaces for adoption subsidies recipients funded by Temporary Assistance for Needy Families (TANF). For part f., MDHHS worked with the Social Security Administration (SSA) to resolve a discrepancy in how the file was reported to DTMB by SSA and processed the fiscal year 2024 file during February 2025. For part g., MDHHS worked with the National Technical Information Service (NTIS) to regain access to the data during February 2024 and resume receiving the data monthly. Once access was re-established, NTIS sent a complete base file containing the data for the three months identified and the file exceeded the normal processing limit. MDHHS will work with DTMB to identify potential solutions and will process the complete file base by September 30, 2025. Anticipated Completion Date a. and b. Ongoing c. Not applicable d. MDHHS has not yet determined an anticipated completion date because the date is dependent on the potential solutions identified. e. Not applicable f. Completed g. September 30, 2025 Responsible Individual(s) a., b., and c. Veronica Maxson, MDHHS d. Kathonya Rice, MDHHS e. Logan Dreasky, MDHHS f. Brant Cole, MDHHS g. Brant Cole, MDHHS Nathan Buckwalter, DTMB
View Audit 360209 Questioned Costs: $1
Finding-002 Eligibility – Significant deficiency in internal control over compliance (Unit Inspection Documentation) Management Response Management acknowledges that this finding resulted in part from an over-reliance on partner organizations for performing initial and annual unit inspections, witho...
Finding-002 Eligibility – Significant deficiency in internal control over compliance (Unit Inspection Documentation) Management Response Management acknowledges that this finding resulted in part from an over-reliance on partner organizations for performing initial and annual unit inspections, without ensuring that full inspection documentation was consistently maintained in internal records. To address this, the following corrective actions have been implemented: •The Leasing Department and Support Services teams are now required to collect and retain copies of all unit inspection documentation (both initial move-in inspections and annual reinspection), even when performed by partner organizations. •A centralized tracking log for unit inspections has been created and will be maintained by the Program Director to monitor inspection status and ensure document retention for each client. •Program staff are required to upload inspection documents to a secure central drive and log inspection completion in the client case management database. •Quarterly reviews will be conducted by the Compliance team to ensure all required inspection documentation is properly retained and accessible. Training on these updated procedures will be conducted on June 10, 2025, with quarterly refresher trainings planned. Responsible Staff: Program Directors and Leasing Manager Implementation Date: June 2, 2025
View Audit 360187 Questioned Costs: $1
Finding-001 Allowable Activities – Significant deficiency in internal controls over compliance (HOPWA Payroll Allocation) Management Response The organization recognizes the importance of ensuring that payroll allocations are properly supported by approved documentation. To address this finding, the...
Finding-001 Allowable Activities – Significant deficiency in internal controls over compliance (HOPWA Payroll Allocation) Management Response The organization recognizes the importance of ensuring that payroll allocations are properly supported by approved documentation. To address this finding, the agency has implemented the following corrective actions: • Annual training on grant-specific timekeeping and payroll allocation requirements hasbeen instituted for all employees whose salaries are charged to grants. • Updated Standard Operating Procedures (SOPs) have been issued to program directorsand payroll administrators outlining the necessary approval and documentation processfor payroll allocations. • Supervisory review and certification of payroll allocation reports have been implementedto ensure compliance with approved grant allocations prior to payroll processing. Training sessions will be held on: June 10, 2025 • June 10, 2025 (initial training session for all HOPWA-funded staff) • Refresher training will be scheduled annually each June going forward. Responsible Staff: Controller and Program Directors Implementation Date: June 2, 2025
View Audit 360187 Questioned Costs: $1
Corrective Action Plan Corrective Action Plan – Uniform Guidance Audit Finding Organization: Scripps Health and Affiliates Federal Agency: U.S. Department of Homeland Security Pass-Through Agency: California Governor’s Office of Emergency Services UEI Number: JJRCL53EXL36 Audit Period: Year Ended S...
Corrective Action Plan Corrective Action Plan – Uniform Guidance Audit Finding Organization: Scripps Health and Affiliates Federal Agency: U.S. Department of Homeland Security Pass-Through Agency: California Governor’s Office of Emergency Services UEI Number: JJRCL53EXL36 Audit Period: Year Ended September 30, 2024 Finding Reference Number: 2024-001 Federal Program: COVID-19 – Disaster Grants – Public Assistance (Presidentially Declared Disasters) Assistance Listing Number: 97.036 Finding Summary: The organization did not employ an adequate internal control review of expenditures to support activities allowed or unallowed, allowable costs/cost principles, reporting and special tests and provisions related to amounts reimbursed for the project worksheet as it relates to the FEMA disposition requirements for COVID-19 related supplies. As a result, Management was reimbursed by FEMA for expenditures that were not in compliance with the FEMA disposition requirements which resulted in a questioned costs of $480,606. Corrective Action Plan: Management will develop and implement an additional layer of review in future FEMA project worksheet submissions to ensure expenditures reporting for reimbursement in the FEMA project worksheet comply with the FEMA disposition requirements. Management will work with FEMA to refund the questioned costs and discuss the extent of the additional courses of action. Management will ensure this is performed through the closeout process of the project worksheet with FEMA. Responsible Officials & Contact Person: Brett Tande, Executive Vice President & Chief Financial Officer Scripps Health and Affiliates Expected Completion Date: June 30, 2025
View Audit 360181 Questioned Costs: $1
Finding 2024-003 Lack of Internal Control over Activities Allowed or Unallowable and Allowable Costs/Cost Principles Name of Contact Person: Alexis Russell, Human Resources Corrective Action: The Human Resources Department will conduct an internal audit of active employee documentation for all maj...
Finding 2024-003 Lack of Internal Control over Activities Allowed or Unallowable and Allowable Costs/Cost Principles Name of Contact Person: Alexis Russell, Human Resources Corrective Action: The Human Resources Department will conduct an internal audit of active employee documentation for all major departments. All active employees within these departments will be required to submit updated voluntary deduction forms. Additionally, department directors will be responsible for submitting and renewing Personnel Action Forms for all employees under their supervision, with all renewals effective no later than October 1st of each year. Proposed Completion Date: The internal audit of documentation for all active employees within major MIC departments will be completed no later than August 31, 2025. All active employees in these departments will be required to submit updated voluntary deduction forms by August 31, 2025. Directors of major MIC departments will be responsible for the submission of Personnel Action Forms for all active employees under their supervision, with all renewals required to be effective no later than October 1, 2025.
View Audit 360172 Questioned Costs: $1
Finding 2024-006 The Authority has hired a new Executive Director in April of 2025. She is undertaking the process of learning the systems in place and adjusting them to meet the requirements of the program. The Authority has hired a consultant that has significant experience in HUD regulations to h...
Finding 2024-006 The Authority has hired a new Executive Director in April of 2025. She is undertaking the process of learning the systems in place and adjusting them to meet the requirements of the program. The Authority has hired a consultant that has significant experience in HUD regulations to help guide them to implement the appropriate systems. Planned corrective actions are to be implemented immediately. The Authority has also hired a fee accountant that will work closely with them to get them on the right track with their accounting records.
View Audit 360171 Questioned Costs: $1
2024-001 – ALN 14.850 – Public Housing Operating Fund – Activities Allowed, Unallowed The Authority has developed procedures to ensure that restricted funds are repaid to the Low Rent Program and to ensure that further restricted funds are not advanced. Upon notification from the Department of Housi...
2024-001 – ALN 14.850 – Public Housing Operating Fund – Activities Allowed, Unallowed The Authority has developed procedures to ensure that restricted funds are repaid to the Low Rent Program and to ensure that further restricted funds are not advanced. Upon notification from the Department of Housing and Urban Development to cease and desist of the Authority’s cost sharing agreement, the Authority immediately discontinued the advancement of funds to other programs operated by the Authority. Current management is actively pursuing collection efforts and understands these federal guidelines. Person Responsible for Correction of Finding: Chanosha Lawton, Executive Director Projected Completion Date: June 30, 2025
View Audit 360162 Questioned Costs: $1
Corrective Action: The Authority submitted corrective actions to HUD dated March 24, 2025, which included implementing HUD’s recommended corrective actions. Responsible Party: Darold Sterling, Executive Director, (256)329-2201. Anticipated Completion Date: September 30, 2025.
Corrective Action: The Authority submitted corrective actions to HUD dated March 24, 2025, which included implementing HUD’s recommended corrective actions. Responsible Party: Darold Sterling, Executive Director, (256)329-2201. Anticipated Completion Date: September 30, 2025.
View Audit 360138 Questioned Costs: $1
2024-005 – ALN 14.872 – Public Housing Capital Fund Program – Allowable Costs Planned Corrective Action: The Executive Director acknowledges the finding and is following the auditor’s recommendation as presented in the Audit Report. Issues are a result of prior management, and a corrective action pl...
2024-005 – ALN 14.872 – Public Housing Capital Fund Program – Allowable Costs Planned Corrective Action: The Executive Director acknowledges the finding and is following the auditor’s recommendation as presented in the Audit Report. Issues are a result of prior management, and a corrective action plan is in place to address these weaknesses and deficiencies. Person Responsible for Correction of Finding: Christy Amacher, Executive Director Anticipated Completion Date: September 30, 2025
View Audit 360091 Questioned Costs: $1
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