Corrective Action Plans

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Finding Number: 2022-001 Condition: The Hospital's controls in place for reporting submissions did not identify that General and Targeted Distribution Post-Payment Notice of Reporting Requirements guidelines were not followed related to the lost revenue calculations. The Hospital's Period 1 and Pe...
Finding Number: 2022-001 Condition: The Hospital's controls in place for reporting submissions did not identify that General and Targeted Distribution Post-Payment Notice of Reporting Requirements guidelines were not followed related to the lost revenue calculations. The Hospital's Period 1 and Period 2 reporting submissions for lost revenue did not follow the acceptable options provided by HHS Planned Corrective Action: The Hospital will review its processes surrounding the methodologies used to report lost revenue and will implement additional levels of review to ensure that the proper lost revenue methodology is used in future reporting periods. Contact person responsible for corrective action: Andrew Poole, Chief Financial Officer Anticipated Completion Date: 3/31/2023
Finding 37415 (2022-006)
Significant Deficiency 2022
Finding: 2022-006 Name of contact person: Brittany Majors (Program Manager), Meredith Farmer (Leadworker) Corrective Action: In this instance, the work number was being ran manually on their website and this informaiton was housed in the County's former document managem...
Finding: 2022-006 Name of contact person: Brittany Majors (Program Manager), Meredith Farmer (Leadworker) Corrective Action: In this instance, the work number was being ran manually on their website and this informaiton was housed in the County's former document management system, Compass. This verification was lost and was unable to be recovered from the Cyber Incident in 2020. The State has since updated NCFAST functionality to include the running of work number through the NCFAST website. Therefore, moving forward all results will already be housed in that State supported system. The County would like to State that results returned recently support the action taken. Unit meeting was held to remind the workers to run work number in NCFAST. Proposed Completion Date: 9/30/2022
Finding 37414 (2022-005)
Significant Deficiency 2022
Finding: 2022-005 Name of contact person: Brittany Majors (Program Manager), Donna Rimmer (AM Supervisor), Joanna Thompson (Leadworker) Corrective Action: Due to a higher volume of vacancies and new hires with no previous Income Maintenance experience it has taken the A...
Finding: 2022-005 Name of contact person: Brittany Majors (Program Manager), Donna Rimmer (AM Supervisor), Joanna Thompson (Leadworker) Corrective Action: Due to a higher volume of vacancies and new hires with no previous Income Maintenance experience it has taken the Adult Medicaid unit some time to get all positions filled and staff trained adequately enough to assist with the processing of cases. During the time of extreme turnover the case workers in place prioritized cases which resulted in the client receiving a greater benefit as advised by the administrative letters issued by DHB given due to the PHE continuity of beneifts was in place. During this time frame the State only allowed specific reduction of benefits/terminiations. Therefore, these individuals would have continued to recieve the same benefit regardless of the SSI review being completed or not. The County has since filled all IMC II positions in that unit and hired a contracted trainer to assist with training in the Adult Medicaid unit. Workloads have been evaluated and specialized based off of program to reduce/eliminate processing errors moving forward. Proposed Completion Date: 9/23/2022
Finding 37413 (2022-004)
Significant Deficiency 2022
Finding: 2022-004 Name of contact person: Brittany Majors (Program Manager), Donna Rimmer (AM Supervisor), Joanna Thompson and Meredith Farmer (Leadworkers) Corrective Action: Adult Medicaid Supervisor updated the cover sheet/ checklist and documentation outline utilize...
Finding: 2022-004 Name of contact person: Brittany Majors (Program Manager), Donna Rimmer (AM Supervisor), Joanna Thompson and Meredith Farmer (Leadworkers) Corrective Action: Adult Medicaid Supervisor updated the cover sheet/ checklist and documentation outline utilized by all caseworkers when making their determination of eligibility in hopes of reducing/eliminating any oversight which occurred during the past evaluations. The County would like to state that although data entry data occured in regards to resource evidence there where no benefits granted in error. Proposed Completion Date: 10/20/2022
Finding 37412 (2022-003)
Significant Deficiency 2022
Finding: 2022-003 Name of contact person: Brittany Majors (Program Manager), Donna Rimmer (AM Supervisor), Joanna Thompson and Meredith Farmer (Leadworkers) Corrective Action: Some of the verifications missing were lost in the County 2020 Cyber Incident. The County cons...
Finding: 2022-003 Name of contact person: Brittany Majors (Program Manager), Donna Rimmer (AM Supervisor), Joanna Thompson and Meredith Farmer (Leadworkers) Corrective Action: Some of the verifications missing were lost in the County 2020 Cyber Incident. The County consulted with State Medicaid Reps who advised the County would be in error to request information previously used to make those determination of eligibility which were lost due to not being able to 100% recover from the Cyber Incident. Therefore, the County implemented a new procedural requirement regarding document management and retention of verification used to determine eligibility. Effective January 2022, all economic benefit programs at Person County DSS were required to upload all verifications used in determining eligiblity into NCFAST. In regards to incorrect data being entered as evidence the Management team conducted individual and unit meeting/trainings to inform parties of the errors discovered and how to reduce/eliminate in future processing. The County would like for it to be notated that eligibility would not have been affected due to the data entry level. Proposed Completion Date: 9/30/2022
Corrective action plan: HHSC ? Medicaid and CHIP Services - FRAC identified the missing requirements and updated the MLR report template and instructions in August 2022. Unfortunately, work was not completed in time for the Managed Care Organizations (MCO) to use the new template for reports subm...
Corrective action plan: HHSC ? Medicaid and CHIP Services - FRAC identified the missing requirements and updated the MLR report template and instructions in August 2022. Unfortunately, work was not completed in time for the Managed Care Organizations (MCO) to use the new template for reports submitted in August 2022. MCOs will use the new template with reports submitted in August 2023. Implementation date(s): Fully implemented August 2022. Responsible persons: Director, Medicaid and CHIP Services ? FRAC
Corrective action plan: TDA maintains an internal policy that requires SOC reports to be reviewed annually and document complementary user entity controls included in each SOC report. TDA?s contract with Colyar LLC requires the vendor to produce a SOC report annually. The vendor was late in provid...
Corrective action plan: TDA maintains an internal policy that requires SOC reports to be reviewed annually and document complementary user entity controls included in each SOC report. TDA?s contract with Colyar LLC requires the vendor to produce a SOC report annually. The vendor was late in providing the SOC report as a 2022 contract deliverable. TDA took actions to ensure vendor accountability for submitting the late contract deliverable and the vendor was required to complete a corrective action plan. TDA will review and assess the SOC report as soon as it is delivered by the vendor to ensure CLA?s recommendations can be followed and will consider additional procedures to ensure internal controls are assessed in the absence of a SOC report. Implementation date(s): June 2023 Responsible persons: Chief Information Officer and the Director for Food and Nutrition Program Support
Corrective action plan: The Federal Funds Instruction Guide will be revised to require that PCAs associated with closed grants are inactivated by the end of the approved close-out period. Budget and Planning management will discuss the revised guidance with staff to ensure proper implementation. TCE...
Corrective action plan: The Federal Funds Instruction Guide will be revised to require that PCAs associated with closed grants are inactivated by the end of the approved close-out period. Budget and Planning management will discuss the revised guidance with staff to ensure proper implementation. TCEQ will implement the Centralized Accounting and Payroll/Personnel System (CAPPS) in September of 2023; grant numbers will include beginning and ending dates at the time the grant is created and will not require inactivation. TCEQ will ensure thorough documentation of its internal controls and the associated staff roles and responsibilities and will conduct periodic reviews of its controls. Implementation date(s): April 11. 2023 for update of the Federal Funds Instruction Guide and training staff. CAPPS: September 1, 2023. Responsible Persons: TBD, Federal Funds Section Manager; Stephanie Robinson, Assistant Deputy Director of Budget and Planning Division; Jene Bearse, Deputy Director of Budget and Planning Division
Corrective action plan: TCEQ will provide refresher training to staff and supervisors and review its standard operating procedures to ensure that staff record time and charge to grants accurately, and that calculated allocations of staff time are accurate. The overall objective will be to ensure tha...
Corrective action plan: TCEQ will provide refresher training to staff and supervisors and review its standard operating procedures to ensure that staff record time and charge to grants accurately, and that calculated allocations of staff time are accurate. The overall objective will be to ensure that salaries and wages are based on records that correctly reflect the work performed. Implementation date(s): March 1,2023 Responsible persons: Yolanda Davis, Deputy Director of Financial Administration Division
View Audit 28519 Questioned Costs: $1
Corrective action plan: The Texas Workforce Commission will initiate a formal and documented review procedure to ensure that FFATA reports are submitted timely. Implementation date(s): March 1, 2023 Responsible persons: Teri Goodwin, Financial Reporting Manager
Corrective action plan: The Texas Workforce Commission will initiate a formal and documented review procedure to ensure that FFATA reports are submitted timely. Implementation date(s): March 1, 2023 Responsible persons: Teri Goodwin, Financial Reporting Manager
Corrective action plan: DPS will update the profile setup process in CAPPS to ensure the Service/Receipt Date Indicator box is checked in CAPPS on all profile setups relating to Grants. DPS Grants staff will receive training on how to fill out a Profile Setup Form to ensure the Service/Receipt Dat...
Corrective action plan: DPS will update the profile setup process in CAPPS to ensure the Service/Receipt Date Indicator box is checked in CAPPS on all profile setups relating to Grants. DPS Grants staff will receive training on how to fill out a Profile Setup Form to ensure the Service/Receipt Date Indicator Box is checked at the time the project is setup in CAPPS. The Grants staff will run a monthly report from CAPPS to see if all active projects have the service date indicator box checked. Implementation date(s): March 1, 2023 Responsible persons: Grants Manager, Deputy Administrator, Financial Reporting
View Audit 28519 Questioned Costs: $1
Corrective action plan: In December 2022, the Federal Funds Office (FFO) identified all prime awards with a potential subaward action date of 10/1/2021 or later. FFO is in the process of determining which of these have issued subawards for which no Federal Funding Accountability and Transparency A...
Corrective action plan: In December 2022, the Federal Funds Office (FFO) identified all prime awards with a potential subaward action date of 10/1/2021 or later. FFO is in the process of determining which of these have issued subawards for which no Federal Funding Accountability and Transparency Act (FFATA) reporting has been received from the program areas. In addition, FFO has revised the subaward reporting templates for programs. The goal of the revised templates is to 1) clearly state instructions for the information requested and 2) delineate between a) earlier subawards that are being reported late and b) subawards that fall into the current reporting period. These changes will assist FFO in maintaining current reporting and bringing all past due reporting up to date. The goal is to have all past due subawards from 10/1/2021 forward submitted to FFATA Subaward Reporting System (FSRS) by 12/31/2023. Implementation date(s): December 1, 2022 Responsible persons: Director, Federal Funds
Corrective action plan: HHSC Accounting has implemented the reporting of Early Childhood Intervention (ECI) expenditures on Line 16 of the Administration for Children and Families (ACF) 196R. The HHSC Accounting policies and procedures related to the ACF 196R were revised and corrected for all ope...
Corrective action plan: HHSC Accounting has implemented the reporting of Early Childhood Intervention (ECI) expenditures on Line 16 of the Administration for Children and Families (ACF) 196R. The HHSC Accounting policies and procedures related to the ACF 196R were revised and corrected for all open years. Implementation date(s): August 31, 2022 Responsible persons: Manager, State and Federal Reporting
Corrective action plan: DFPS will revise its policies and procedures related to the ACF-196R report review process to ensure all expenditure amounts are being properly classified. Implementation date(s): May 31, 2023 Responsible persons: Maura Flores
Corrective action plan: DFPS will revise its policies and procedures related to the ACF-196R report review process to ensure all expenditure amounts are being properly classified. Implementation date(s): May 31, 2023 Responsible persons: Maura Flores
EA Application/Determination Corrective action plan: DFPS will ensure that INV/AR staff receive ongoing communication/training regarding EA and how to correctly document and record income within the IMPACT. DFPS will update the current EA policy and publishing a new resource guide for staff. DFPS ...
EA Application/Determination Corrective action plan: DFPS will ensure that INV/AR staff receive ongoing communication/training regarding EA and how to correctly document and record income within the IMPACT. DFPS will update the current EA policy and publishing a new resource guide for staff. DFPS staff will be provided training, tip sheets and ongoing support regarding the new policy and resource guide. The policy will be published by April 1, 2023. DFPS will continue to strengthen our internal quality assurance review of cases eligible for EA to ensure that INV/AR staff are complying with federal guidelines and internal policies. DFPS has submitted an IT ticket request to resolve the condition for the participant that had the incorrect income range of $0-$10,000 selected to the correct income range of $20,550 to $40,549 to align with the investigation report. The participant remains eligible for assistance regardless as the family unit makes less than $63,000. CPI will initiate a request for an IT project to conduct analysis of any limitations with verifying Emergency Assistance eligibility in the IMPACT system regarding why two of the three EA statements now show not answered. DFPS staff will be researching the issue to determine next steps by 2nd quarter FY 2024. Implementation date(s): Ongoing communication ? will vary, first communication by April 1, 2023; IMPACT research January 31, 2024. Responsible persons: Jerome Green PEAF Corrective action plan: DFPS uses an established recoupment process to address overpayments. A Kinship Development Worker writes a letter to the kinship caregiver regarding the overpayment and details the steps needed to return funds. This letter is also sent to accounting for follow up. DFPS maintains a proactive approach to strengthening/enhancing IMPACT limitations to ensure accurate data is maintained for accurate payments/disbursements through continuous program improvement. Implementation date(s): On January 13, 2023 ? staff initiated the above described recoupment process to recoup the second payment for the subject children. Responsible persons: Debbie Bouldin
View Audit 28519 Questioned Costs: $1
Corrective action plan: DSHS will continue to utilize the updated procedure and FFATA checklist that was implemented on March 1, 2022 to ensure the verification of FFATA reports are formally documented prior to submission. DSHS will continue to maintain all relevant documentation to support that t...
Corrective action plan: DSHS will continue to utilize the updated procedure and FFATA checklist that was implemented on March 1, 2022 to ensure the verification of FFATA reports are formally documented prior to submission. DSHS will continue to maintain all relevant documentation to support that the key data elements were reported within the required timeframes. Implementation date(s): March 1, 2022 Responsible persons: FFATA Coordinator
Corrective action plan: To strengthen requirements related to unique disaster funding, DSHS will amend DSHS Policy AA-3301: Monitoring and Management of the Operating Budget to establish roles and responsibilities for ensuring expenditures are reviewed and within grant parameters. We anticipate poli...
Corrective action plan: To strengthen requirements related to unique disaster funding, DSHS will amend DSHS Policy AA-3301: Monitoring and Management of the Operating Budget to establish roles and responsibilities for ensuring expenditures are reviewed and within grant parameters. We anticipate policy revisions to be drafted by July 31, 2023. Implementation date(s): July 31, 2023 Responsible persons: Chief Financial Officer
View Audit 28519 Questioned Costs: $1
Corrective action plan: To strengthen requirements related to unique disaster funding, DSHS will amend DSHS Policy AA-3301: Monitoring and Management of the Operating Budget to establish roles and responsibilities for ensuring expenditures are reviewed and within grant parameters. We anticipate poli...
Corrective action plan: To strengthen requirements related to unique disaster funding, DSHS will amend DSHS Policy AA-3301: Monitoring and Management of the Operating Budget to establish roles and responsibilities for ensuring expenditures are reviewed and within grant parameters. We anticipate policy revisions to be drafted by July 31, 2023. Implementation date(s): July 31, 2023 Responsible persons: Chief Financial Officer
View Audit 28519 Questioned Costs: $1
Corrective action plan: Program management adopted policies and procedures to ensure supporting documentation for federal submissions are maintained, including any reconciling calculations or adjustments to support information. Implementation date(s): Implemented as of February 8, 2023 Responsib...
Corrective action plan: Program management adopted policies and procedures to ensure supporting documentation for federal submissions are maintained, including any reconciling calculations or adjustments to support information. Implementation date(s): Implemented as of February 8, 2023 Responsible persons: Mariana Salazar, Texas Rent Relief Director
Corrective action plan: ? For Source Data, the program has developed policies and procedures to document source data. ? For Cumulative Calculations, auditors specifically requested from TDHCA reports submitted to the Treasury from different periods to specifically be able to calculate cumulative ...
Corrective action plan: ? For Source Data, the program has developed policies and procedures to document source data. ? For Cumulative Calculations, auditors specifically requested from TDHCA reports submitted to the Treasury from different periods to specifically be able to calculate cumulative figures for obligations and expenditures. TDHCA explained that the methodology the Treasury has requested for grantees to use will not allow the quarterly obligations and expenditures reported to be summed to equal the current cumulative amount due to adjustments for recaptured funds. This is an unavoidable reality of the Emergency Rental Assistance (ERA) program and federal reporting system and can only be rectified in the final report to Treasury. Certain aspects of the Treasury?s design of the program, most significantly the recapture of funds from beneficiaries, can cause the draw/transaction data for a given period, e.g. Q3 2022, to change after that quarter is complete. Per Treasury guidance, TDHCA will be able to resubmit expenditure and obligation figures for each quarter in the final report. For the December 2021 ERA 1 Monthly Compliance Report and November 2021 ERA 2 Monthly Compliance Report, the total number of households served were off by 0.4% and 0.05% due to inadvertently including households who were initially served but later had all of the funds recaptured and therefore should have been excluded. TDHCA has updated internal procedures for calculating these reports to ensure these are excluded from future reports. Implementation date(s): Implemented as of February 8, 2023 Responsible persons: David Johnson, Project Manager ? Process Mgmt. /Data Analytics
Corrective action plan: To prevent similar errors from occurring until program closure, TRR management shared these findings with the external application review vendor on January 26, 2023, reiterating the processes for reviewing and approving rental assistance according to all program policies an...
Corrective action plan: To prevent similar errors from occurring until program closure, TRR management shared these findings with the external application review vendor on January 26, 2023, reiterating the processes for reviewing and approving rental assistance according to all program policies and procedures and ensuring that appropriate documentation related to review of applications is maintained in the files. Eligibility errors are expected in all programs, and TRR has developed different processes to address errors when identified. For these particular cases, TRR management requested the vendor take corrective action for each case as applicable (e.g., by requesting a return of funds for overpayment or by requesting additional information from applicants). Implementation date(s): January 26, 2023 Responsible persons: Danny Shea, TRR Senior Program Manager
View Audit 28519 Questioned Costs: $1
Management's Corrective Action Plan - Finding 2022-001: Special Tests: Return of Title IV Funds - In our 2021-22 audit it was identified that a Return of Title IV funding (R2T4) occurred outside of the required 45 day window. During the 2021-22 year the Financial Aid Office was continually working o...
Management's Corrective Action Plan - Finding 2022-001: Special Tests: Return of Title IV Funds - In our 2021-22 audit it was identified that a Return of Title IV funding (R2T4) occurred outside of the required 45 day window. During the 2021-22 year the Financial Aid Office was continually working on finding the most accurate ways to ensure that all withdrawals were identified and reviewed for R2T4 processing within the necessary time frames. We were using multiple reports that were created and delivered from various departments to screen all enrollment status changes, however, these reports were not capturing all necessary information which caused us to not identify the student in question until we were outside of the 45 day window to return funds. We have since worked to create a new report that captures all enrollment changes for the semester within one report. The new report is now delivered on a weekly basis for review to ensure that all required R2T4 deadlines are met. - Contact Person: Chris, Preszler, Director of Financial Aid - Anticipated Completion Date: November 30, 2022.
For the Rockford Supportive Housing Facility FINDING 2022-003: SECTION 811, ASSISTANCE LISTING NUMBER 14.181 HUD SUBSIDY LOAN FROM REPLACEMENT RESERVES NOT REPAID Recommendation: The Project should repay the HUD subsidy loan as soon as funds are available...
For the Rockford Supportive Housing Facility FINDING 2022-003: SECTION 811, ASSISTANCE LISTING NUMBER 14.181 HUD SUBSIDY LOAN FROM REPLACEMENT RESERVES NOT REPAID Recommendation: The Project should repay the HUD subsidy loan as soon as funds are available. Action Taken: The Project agrees with the finding. A $15,000 transfer will be made once funds are available. Management will be reminded to carefully review HUD correspondence to make sure HUD subsidy loan terms are being followed. If the Department of Housing and Urban Development has questions regarding this plan, please call Les Russo at 847-424-5601.
View Audit 36617 Questioned Costs: $1
Over the Rainbow Association and Subsidiaries CORRECTIVE ACTION PLANS (CONTINUED) YEAR ENDED DECEMBER 31, 2022 FINDING 2022-002: SECTION 8, ASSISTANCE LISTING NUMBER 14.195 SPONSOR LOAN PAYMENT WITHOUT HUD APPROVAL Recommendat...
Over the Rainbow Association and Subsidiaries CORRECTIVE ACTION PLANS (CONTINUED) YEAR ENDED DECEMBER 31, 2022 FINDING 2022-002: SECTION 8, ASSISTANCE LISTING NUMBER 14.195 SPONSOR LOAN PAYMENT WITHOUT HUD APPROVAL Recommendation: The Sponsor should work with HUD to determine if the $130,019 needs to be paid back to the Project. Action Taken: The Sponsor will work with HUD to determine if the $130,019 needs to be paid back to the Project.
View Audit 36617 Questioned Costs: $1
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