Corrective Action Plans

Finding 33801 (2022-003)

Significant Deficiency 2022

CT

Cash Management Questioned Costs HUD Housing Programs

Finding Number 2022-003 ? Description ? Program staff do not prepare a reconciliation of amounts received for a given month with what was actually disbursed on a monthly basis. ? Views of Responsible Officials and Planned Corrective Action ? We agree with the finding. We will create an Excel...

Finding Number 2022-003 ? Description ? Program staff do not prepare a reconciliation of amounts received for a given month with what was actually disbursed on a monthly basis. ? Views of Responsible Officials and Planned Corrective Action ? We agree with the finding. We will create an Excel spreadsheet with each of the provider names and amount the provider requested and the actual amount paid each month. If there is a difference, it will be noted on the spreadsheet. ? Names and Title of Responsible Official ? Kathy Sabitsky, Finance Manager. ? Anticipated Completion Date ? October 2023.

View Audit 35487

Finding 33799 (2022-001)

Material Weakness 2022

Saugatuck Child Care Services Inc.

CT

Questioned Costs Material Weakness Reporting

Finding Number 2022-001 ? Description ? Not all of the revenue and expenses associated with the program was being recorded on the general ledger by the client and amounts were not readily determinable. ? Views of Responsible Officials and Planned Corrective Action ? We agree with the finding. We w...

Finding Number 2022-001 ? Description ? Not all of the revenue and expenses associated with the program was being recorded on the general ledger by the client and amounts were not readily determinable. ? Views of Responsible Officials and Planned Corrective Action ? We agree with the finding. We will record actual revenue and expenses each month in the general ledger and reconcile the activity to the bank account. ? Names and Title of Responsible Official ? Cathy Donahue, SON Director and Kathy Sabitsky, Finance Manager. ? Anticipated Completion Date ? September 2023.

View Audit 35487

Finding 33795 (2022-005)

Material Weakness 2022

Howard Area Community Center

IL

Special Tests & Provisions Questioned Costs Eligibility

2022-005 Head Start Cluster, Federal Assistance Listing No. 93.600 Special Tests and Provisions Recommendation: The auditors recommend that the Organization should establish policies and procedures to ensure all applicable special tests and provisions are completed accurately and timely. Actions ...

2022-005 Head Start Cluster, Federal Assistance Listing No. 93.600 Special Tests and Provisions Recommendation: The auditors recommend that the Organization should establish policies and procedures to ensure all applicable special tests and provisions are completed accurately and timely. Actions Taken or Planned: The Organization has created a written plan to provide appropriate training and technical assistance on the Head Start performance standards that is sufficient to ensure that the governing body and policy council can fulfill their responsibilities under the Head Start Act. Training is to take place within 180 days of the beginning of the term of a new governing body or policy council. The training: i) includes methods on how to collect complete and accurate eligibility information from families and third party sources; ii) explains program policies and procedures that describe actions taken against staff, families, or participants who attempt to provide or intentionally provide false information; and, iii) incorporates strategies for treating families with dignity and respect and dealing with possible issues of domestic violence, stigma, and privacy. Person Responsible: The Howard Area Community Center Executive Director, Jason Kaiser, Early Childhood Education Director Nancy Salvador, and ERSEA Tech Maria Hernandez. Estimated Date of Completion: The Organization?s Board of Directors received training for FY23 on July 28, 2022. The next training for the policy council will be completed on March 16, 2023 and the HACC Board Training for FY24 is scheduled to be completed by March 30, 2024.

View Audit 34716

Finding 33794 (2022-004)

Material Weakness 2022

Howard Area Community Center

IL

Allowable Costs / Cost Principles Questioned Costs § 200.430

2022-004 Head Start Cluster, Federal Assistance Listing No. 93.600 Allowable Payroll Costs and Controls Over Payroll (Repeat) Recommendation: The auditors recommend that the Organization establish policies and procedures to support a system of internal controls, which provides a reasonable assuran...

2022-004 Head Start Cluster, Federal Assistance Listing No. 93.600 Allowable Payroll Costs and Controls Over Payroll (Repeat) Recommendation: The auditors recommend that the Organization establish policies and procedures to support a system of internal controls, which provides a reasonable assurance that the charges to federal awards for salaries and other payroll related costs are accurate, allowable and properly allocated. Documentation of all employees? approved pay rates, hours worked and support for the allocation percentages (or actual hours worked) should be maintained. Actions Taken or Planned: The Organization terminated our professional relationship with our financial services provider in FY23, Quatrro BSS. We established a financial services contract with Metropolitan Family Services (MFS) that began July 1, 2022. MFS manages over 130 million dollars in revenue each year and the current finance team has over 50+ years of combined experience managing government and private contracts. MFS is a Professional Employer Organization (PEO) for five organizations averaging four million dollars in annual revenue and has established back-office and finance service contracts with those organizations. MFS has policies and procedures to support a system of internal controls which provides a reasonable assurance that charges to federal awards for payroll related costs are accurate, allowable, and properly allocated. Budget estimates are used for interim accounting purposes provided the estimates produce reasonable approximations of activity performed. The MFS finance team and the Organization's executive team review payroll allocations each quarter. Allocations are supported by an after-the-fact accounting of employee time and effort in a Personal Activity Report (PAR), significant changes in work activity are identified and entered into the record, and the after-the-fact review is completed to make all necessary adjustments to the final amount charged to the Organization's federal awards to help ensure charges are accurate, allowable, and properly allocated. Person Responsible: The Howard Area Community Center Executive Director, Jason Kaiser and the Metropolitan Family Services finance team including CFO James Baldwin, Controller Kelly Kelly, Director of Budget Don Pzynarski, and Assistant Budget Director Emilia Vargas. Estimated Date of Completion: April 2023.

View Audit 34716 Questioned Costs: $1

Finding 33791 (2022-003)

Material Weakness 2022

Howard Area Community Center

IL

Questioned Costs Reporting Internal Control / Segregation of Duties

2022-003 Crime Victims Assistance, Federal Assistance Listing No. 16.575 Late Financial Reporting and Limited Controls Over Timely Reporting Recommendation: The auditors recommend management to communicate periodically with the federal agency and design and implement effective controls to ensure ...

2022-003 Crime Victims Assistance, Federal Assistance Listing No. 16.575 Late Financial Reporting and Limited Controls Over Timely Reporting Recommendation: The auditors recommend management to communicate periodically with the federal agency and design and implement effective controls to ensure timely submission of future reports. Also, all past due reports should be submitted to the grantor as soon as possible. Actions Taken or Planned: The Organization terminated our professional relationship with our financial services provider in FY23, Quatrro BSS. We established a financial services contract with Metropolitan Family Services (MFS) that began July 1, 2022. MFS has not had any late submission findings in the past ten years of audits. We have created a calendar with all necessary reporting deadlines for all funding agencies. The calendar is reviewed by the finance team, the executive team, and a government contracts and grants manager to ensure accurately recorded deadlines are reflected. The Director of Budgets reviews monthly deadlines and ensures timely submission of reports. Person Responsible: The Howard Area Community Center Executive Director, Jason Kaiser, Government Contracts and Grants Manager Kasey Muhammad and the Metropolitan Family Services finance team including CFO James Baldwin, Controller Kelly Kelly, Director of Budgets Don Pzynarski, and Assistant Budget Director Emilia Vargas. Estimated Date of Completion: June 30, 2023

View Audit 34716

Finding 33790 (2022-002)

Material Weakness 2022

Advocates for A Healthy Community, Inc. D/b/a Jordan Valley Community

MO

Allowable Costs / Cost Principles Cash Management Questioned Costs

February 21, 2023 To Whom It May Concern: RE: Grants for Capital Development in Health Centers Assistance Listing # 93.526, Finding 2022-002 Corrective Action Plan During our fiscal year 2022 audit, the Organization drew down grant funds under this award and spent them on expenditures that w...

February 21, 2023 To Whom It May Concern: RE: Grants for Capital Development in Health Centers Assistance Listing # 93.526, Finding 2022-002 Corrective Action Plan During our fiscal year 2022 audit, the Organization drew down grant funds under this award and spent them on expenditures that were not allowable. This was a clerical error as finance staff thought they were drawing down funds under the Community Health Center grant instead of this capital grant. The draw was used to pay salaries instead of capital items that this grant was intended for. We have self-reported this issue to HRSA and have been approved to transfer these funds to the appropriate award so they could be spent properly. Although controls are in place to help prevent these types of errors to occur and were effective for the Organization?s other Federal awards, they were not effective for this award. We have reviewed our grant drawdown procedures and have discussed this error internally with finance staff and provided training as appropriate. Our audit partner has discussed this issue with the Organization?s Chief Executive Officer (CEO) and the Board of Directors. A robust discussion occurred in our February board meeting about this issue, how it occurred and what measures need to be taken to help prevent this type of error in the future. At this time, all corrective actions have been taken. We are currently without a Chief Financial Officer but K. Brooks Miller, CEO supervised these corrections and took responsibility to make sure these corrective actions were taken.

View Audit 32657 Questioned Costs: $1

Finding 33789 (2022-002)

None 2022

H-Cap, Inc. (healthcare Career Advancement Program)

NY

Questioned Costs

Key Personnel: Danielle Copeland ? H-CAP will alert their Grant Program Officer (completed 5/23) ? H-CAP will cease drawing down funds unt il shortfall is recouped (completed 8/23) ? Each drawdown will b...

Key Personnel: Danielle Copeland ? H-CAP will alert their Grant Program Officer (completed 5/23) ? H-CAP will cease drawing down funds unt il shortfall is recouped (completed 8/23) ? Each drawdown will be reviewed to ensure all invoices are new and payable (started 5/23 and ongoing) ? Each invoice will be reviewed by two parties to ensure proper back up documentation (Started 5/23 and ongoing) ? No invoice will be paid without proper backup documentation (Started 5/23 and ongoing)

View Audit 31216 Questioned Costs: $1

Finding 33783 (2022-001)

None 2022

Almont Community Schools

MI

School Nutrition Programs Questioned Costs Subrecipient Monitoring

See Corrective Action Plan for chart/table

View Audit 35867

Finding 33773 (2022-002)

Significant Deficiency 2022

Village Cooperative of Hutchinson

MN

Questioned Costs Reporting Internal Control / Segregation of Duties

Housing and Urban Development Village Cooperative of Hutchinson respectfully submits the following corrective action plan for the year ended April 30, 2022. Westberg Eischens, PLLP 2630 1st Street South P.O. Box 362 Willmar, MN 56201 Audit Period: April 30, 2022 The findings from the April 30...

Housing and Urban Development Village Cooperative of Hutchinson respectfully submits the following corrective action plan for the year ended April 30, 2022. Westberg Eischens, PLLP 2630 1st Street South P.O. Box 362 Willmar, MN 56201 Audit Period: April 30, 2022 The findings from the April 30, 2022, schedule of findings and questioned costs and the summary schedule of prior audit findings are discussed below. The findings are numbered consistently with the numbers assigned in the schedules. Summary of audit results does not include findings and is not addressed. Finding 2022-002 Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance or responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperative will continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Planned Completion Date: Not Applicable.

View Audit 34564

Finding 33768 (2022-001)

Material Weakness 2022

Lemko Housing Corporation

MD

Questioned Costs HUD Housing Programs

Statement Of Condition: The Corporation is delinquent in making deposits to the Reserve for Replacements as required by the Section 8 Contract. There are sixteen delinquent deposits totaling $32,000 as of September 30, 2022. Comments on the Findings and Recommendation: Management intends to make all...

Statement Of Condition: The Corporation is delinquent in making deposits to the Reserve for Replacements as required by the Section 8 Contract. There are sixteen delinquent deposits totaling $32,000 as of September 30, 2022. Comments on the Findings and Recommendation: Management intends to make all delinquent deposits by October 31, 2023. Status: The Corporation has requested that HUD suspend the required monthly deposits to the Reserve for Replacements. If approved, the Corporation will make two deposits of $2,000 per month until October 2023, when all delinquent deposits will have been paid. If the suspension is not approved, the Corporation will make three deposits of $2,000 per month until October 2023, when all delinquent deposits will have been paid and will then return to making the minimum required monthly deposit.

View Audit 32803 Questioned Costs: $1

Finding 33737 (2022-004)

Significant Deficiency 2022

Crete Public Schools No 2

NE

Questioned Costs Subrecipient Monitoring

The Crete Public Schools District No. 2 Board of Education continually evaluates the distribution of duties to employees and closely monitors finances. The Executive Director of Finance and Superintendent will work with the Director of Federal Programs to ensure compliance monitoring is in place wh...

The Crete Public Schools District No. 2 Board of Education continually evaluates the distribution of duties to employees and closely monitors finances. The Executive Director of Finance and Superintendent will work with the Director of Federal Programs to ensure compliance monitoring is in place when using federal funds for construction related projects.

View Audit 32710 Questioned Costs: $1

Finding 33736 (2022-002)

None 2022

Fulton Gardens II Corporation

TX

Questioned Costs Reporting

Audit Finding 2022-002: Cash will be transferred from the operating account into the tenant security deposit account in an amount sufficient to cover the tenant security deposit liability.

View Audit 33347

Finding 33735 (2022-001)

None 2022

Fulton Gardens II Corporation

TX

Questioned Costs HUD Housing Programs Reporting

Audit Finding 2022-001 Cash will be transferred from the operating account to the reserve for replacement account to replenish the $6,000 withdrawn without prior HUD approval.

View Audit 33347

Finding 33729 (2022-001)

Significant Deficiency 2022

Children's Hospital & Medical Center and Affiliates

NE

Questioned Costs Period of Performance Reporting

Finding 2022-001: Reporting Recommendation: The Hospital should strengthen their system of internal controls around the review of HRSA guidance to ensure that all reporting is consistent with requirements and instructions as provided by regulatory agencies. Views of Responsible Officials: Manageme...

Finding 2022-001: Reporting Recommendation: The Hospital should strengthen their system of internal controls around the review of HRSA guidance to ensure that all reporting is consistent with requirements and instructions as provided by regulatory agencies. Views of Responsible Officials: Management agrees with the finding. Although reported in the incorrect quarter, the Hospital did incur expenses in excess of the amount of ARPA funds received. In addition, the Hospital also suffered lost revenues in excess of the ARPA funds received. Management will refine its review process of HRSA guidance and data entry into the portal to ensure appropriate designation between reporting periods. Children?s Hospital & Medical Center and Affiliates Corrective Action Plan: Management inadvertently reported expenses in the incorrect quarter of the Period 4 report submission. Although reported incorrectly, reported expenses were still above the total ARPA payments received. For future reporting, management will reinforce the reporting of activities in the proper quarter prior to submission. Completion Date: Completed Contact Person: Mindy Stetson 402-955-6765

View Audit 32489

Finding 33728 (2022-001)

Significant Deficiency 2022

Fox-Wolf Watershed Alliance INC

WI

Questioned Costs

2022-001 Lack of Adequate Segregation of Duties Corrective Action Plan: The Organization is working to separate responsibilities among additional staff to work towards increased segregation of duties. At this time,...

2022-001 Lack of Adequate Segregation of Duties Corrective Action Plan: The Organization is working to separate responsibilities among additional staff to work towards increased segregation of duties. At this time, the cost/benefit of hiring the additional support staff needed to obtain complete segregation of duties is not possible due to budget constraints. Anticipated Completion Date: Ongoing

View Audit 32486

Finding 33707 (2022-005)

Significant Deficiency 2022

Tusculum University

TN

Questioned Costs Student Financial Aid Reporting

2022-005 Significant Deficiency: Return to Title IV Funds (U.S. Department of Education, William D. Ford Direct Loan Program, CFDA #84.268; Federal Pell Grant Program, CFDA #84.063; Federal Supplemental Opportunity Grant Program, CFA #84.007; and TEACH Grant Program, CFDA #84.379) Name of Contact P...

2022-005 Significant Deficiency: Return to Title IV Funds (U.S. Department of Education, William D. Ford Direct Loan Program, CFDA #84.268; Federal Pell Grant Program, CFDA #84.063; Federal Supplemental Opportunity Grant Program, CFA #84.007; and TEACH Grant Program, CFDA #84.379) Name of Contact Person Melissa White, Director of Financial Aid is responsible for R2T4 calculations. Corrective Action Planned During the audit, it was noted that the University used the incorrect number of total days in the payment period or period of enrollment in calculating the percentage of payment period and/or period of enrollment completed. To correct this measure, Financial Aid has created a two-step measure where the Director of Financial Aid creates the calendar and the Associate Director of Financial Aid checks the calendar. In addition, when performing each R2T4, the Director of Financial Aid shall perform the initial calculation on the R2T4 form found in the student aid handbook. Then, the Associate Director of Financial Aid will also perform the calculation within Colleague independently of the hand done calculation by the Director of Financial Aid. Once finished with the preliminary calculation in Colleague, the Associate Director will then compare the calculation to the hand done calculation on paper by the Director of Financial Aid. If the information matches, then the Associate Director will process the changes in Colleague to the student?s account. If both do not match, both Director and Associate Director will review the calculation a third time and determine where the difference is coming from. Only once both Associate Director and Director of Financial Aid have matching numbers will the account by adjusted by the Associate Director of Financial Aid. Anticipated Completion Date The R2T4 calendar was fixed for fall in fall 2022 and the spring 2023 calendar was fixed in spring 2023.

View Audit 36350 Questioned Costs: $1

Finding 33698 (2022-002)

Material Weakness 2022

City of Oakland

CA

Questioned Costs Special Tests & Provisions HUD Housing Programs

In relation to the City of Oakland?s single audit for the year ended June 30, 2022, the City hereby submits a corrective action plan for finding number 2022-002 for the Home Investment Partnerships Program (Assistance Listing Number 14.239) The City will adopt the recommendation from the auditor to...

In relation to the City of Oakland?s single audit for the year ended June 30, 2022, the City hereby submits a corrective action plan for finding number 2022-002 for the Home Investment Partnerships Program (Assistance Listing Number 14.239) The City will adopt the recommendation from the auditor to ensure the City perform HQS inspections are conducted in a timely manner. The City has resumed inspections during the current fiscal year ending June 30, 2023, and is on course to complete the 3-year inspection cycle of all 38 HOME projects by March 2025. Contact person responsible for corrective action: Meghan Horl Anticipated completion date: March 2025

View Audit 35082

Finding 33691 (2022-012)

Significant Deficiency 2022

Chester Community Unit School District No. 139

IL

Allowable Costs / Cost Principles Period of Performance Questioned Costs

Condition: We noted that the District reported expenditures to ISBE on the June 30, 2022 expenditure report when they were not incurred and paid for until July 2022 for the Education Stabilization Fund. Recommendation: We recommend that expenditures incurred by the District be reported in the prope...

Condition: We noted that the District reported expenditures to ISBE on the June 30, 2022 expenditure report when they were not incurred and paid for until July 2022 for the Education Stabilization Fund. Recommendation: We recommend that expenditures incurred by the District be reported in the proper period in the reports to ISBE. Management Response: The District will ensure that expenditures are reported in the proper period in the reports to ISBE. Anticipated Date of Completion: June 30, 2023

View Audit 32975

Finding 33689 (2022-008)

Significant Deficiency 2022

Chester Community Unit School District No. 139

IL

Reporting Internal Control / Segregation of Duties Questioned Costs

Condition: We noted that 9 of the quarterly expenditure reports for the Education Stabilization Fund were not filed in a timely manner. Recommendation: We recommend that steps are taken, including oversight by a second employee, to ensure that all quarterly expenditure reports are filed by the due ...

Condition: We noted that 9 of the quarterly expenditure reports for the Education Stabilization Fund were not filed in a timely manner. Recommendation: We recommend that steps are taken, including oversight by a second employee, to ensure that all quarterly expenditure reports are filed by the due date. Management Response: The District will take the necessary steps to file all quarterly expenditure reports on time in the future. Anticipated Date of Completion: June 30, 2023

View Audit 32975

Finding 33685 (2022-010)

Significant Deficiency 2022

Chester Community Unit School District No. 139

IL

Period of Performance Questioned Costs

Condition: We noted that expenditures incurred for the Federal Special Education Cluster were not reported in the proper periods on the expenditure reports submitted to ISBE. Recommendation: We recommend that the expenditures incurred by the District be reported in the proper quarter in the reports...

Condition: We noted that expenditures incurred for the Federal Special Education Cluster were not reported in the proper periods on the expenditure reports submitted to ISBE. Recommendation: We recommend that the expenditures incurred by the District be reported in the proper quarter in the reports to ISBE. Management Response: The District will ensure that expenditures are reported in the proper quarter in future expenditure reports. Anticipated Date of Completion: June 30, 2023

View Audit 32975

Finding 33684 (2022-009)

Significant Deficiency 2022

Chester Community Unit School District No. 139

IL

Reporting Questioned Costs

Condition: We noted that the general ledger account function used for nonpublic school pupil services did not agree with the function reported in the expenditure reports submitted to ISBE as well as the budget approved by ISBE for the Federal Special Education Cluster. Recommendation: We recommend ...

Condition: We noted that the general ledger account function used for nonpublic school pupil services did not agree with the function reported in the expenditure reports submitted to ISBE as well as the budget approved by ISBE for the Federal Special Education Cluster. Recommendation: We recommend that the general ledger account functions and objects used support what is reported to ISBE. Management Response: The District will ensure that correct general ledger account functions and objects are used in the future. Anticipated Date of Completion: June 30, 2023

View Audit 32975

Finding 33683 (2022-007)

Significant Deficiency 2022

Chester Community Unit School District No. 139

IL

Reporting Internal Control / Segregation of Duties Questioned Costs

Condition: We noted that 4 of the quarterly expenditure reports for the Federal Special Education Cluster were not filed in a timely manner. Recommendation: We recommend that steps are taken, including oversight by a second employee, to ensure that all quarterly expenditure reports are filed by the...

Condition: We noted that 4 of the quarterly expenditure reports for the Federal Special Education Cluster were not filed in a timely manner. Recommendation: We recommend that steps are taken, including oversight by a second employee, to ensure that all quarterly expenditure reports are filed by the due date. Management Response: The District will take the necessary steps to file all quarterly expenditure reports on time in the future. Anticipated Date of Completion: June 30, 2023

View Audit 32975

Finding 33681 (2022-003)

Material Weakness 2022

Winslow Memorial Hospital D/b/a Little Colorado Medical Center

AZ

Questioned Costs Material Weakness Reporting § 200.303

Finding 2022-003 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing #93.498 Compliance Requirement: Reporting Finding Summary: The Hospital did not consider the impact of the year-end...

Finding 2022-003 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing #93.498 Compliance Requirement: Reporting Finding Summary: The Hospital did not consider the impact of the year-end audit adjustments on the quarters applicable to Period 2 when reporting lost revenue. Responsible Individuals: John J Dempsey, Chief Executive Officer, Lona King, Chief Financial Officer Corrective Action Plan: Management will modify the lost revenue reported on future reports to reflect the yearend adjustments in the appropriate quarter. Anticipated Completion Date: March 31, 2023

View Audit 31569

Finding 33646 (2022-003)

Significant Deficiency 2022

State of Kansas

KS

Questioned Costs Matching / Level of Effort / Earmarking

Recommendation: We recommend the State train all staff members to properly verify providers are meeting the prescribed health and safety standards before making payments to those providers. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken...

Recommendation: We recommend the State train all staff members to properly verify providers are meeting the prescribed health and safety standards before making payments to those providers. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The KDHE Bureau of Facilities and Licensing respectfully submits the following corrective action plan, as it relates to planning, staffing, and CMS-MPD requirements. KDHE acknowledges the auditor?s recommendation to train staff of the need to verify providers are meeting H&S standards, prior to our permitting payments to those providers. Training will be incorporated into the following correction action plan, accompanied by additional steps we believe should be explored to further move our agency toward compliance. The KDHE-DHCF Audit Team will meet with appropriate State stakeholders to examine potential Medicaid program modifications that would assist our agency in establishing compliance with federal law. Teams to be engaged are 1) Bureau of Facilities/Licensing, 2) Policy, 3) KMMS, 4) KDADS, 5) Program Integrity, and 6) Quality. The intent of this conference is to investigate methods to ensure payments are not made to providers whose health and safety certifications are outdated, based on the annual CMS Mission and Priority Document (CMS MPD). A tentative meeting agenda is as follows: a. Educate staff on the cause of Finding 2022-002; b. Review federal regulations substantiating the need for policy/procedural changes; c. Brainstorm methods to become compliant with federal law; d. Research State law to identify any potential conflicts; e. Discuss drafting a new Medicaid policy requiring KDHE to have a current provider certification on file, prior to releasing payment to that provider; f. Examine the BOFL provider database and its potential to 1) notify surveyors of certifications nearing their expiration date and 2) interface with KMMS; g. Identify KMMS system changes needed to prevent payment to providers with outdated certifications, e.g., a system edit; h. Draft KMMS change order; i. Educate MCOs and providers (facilities); j. Assign follow-up duties among stakeholders Name(s) of the contact person(s) responsible for corrective action: Donna Wills Planned completion date for corrective action plan: Dates will vary dependent on our progress with tasks a-j, above. The initial planning meeting will be held no later than May 1, 2023.

View Audit 33298

Finding 33645 (2022-002)

Significant Deficiency 2022

State of Kansas

KS

Questioned Costs Eligibility

Recommendation: We recommend that KDHE reviews the process of redeterminations being sent to the household and identify any problem areas in the process which could undermine the redetermination frequency. We also recommend that KDHE reviews the training materials to ensure that all staff who make e...

Recommendation: We recommend that KDHE reviews the process of redeterminations being sent to the household and identify any problem areas in the process which could undermine the redetermination frequency. We also recommend that KDHE reviews the training materials to ensure that all staff who make eligibility determinations are aware of the required supporting documentation to be saved for both initial eligibility determinations and redeterminations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Due to the current COVID-19 Public Health Emergency (PHE) and the continuous enrollment requirement mandated by CMS, no action has been taken on cases to correct the issue of annual redeterminations as it would cause adverse action with active recipients of Medicaid. At the conclusion of the continuous enrollment requirement, all active recipients will receive a redetermination and updated information based on changes in circumstances will be addressed to determine on-going eligibility. As redeterminations have not been conducted for the past three years, the State of Kansas has utilized the ?downtime? to enhance both KEES and training in preparation for the resumption of redeterminations. From a KEES perspective, numerous updates have been made to redetermination functionality/logic to ensure households receive the required redeterminations appropriately. Throughout the course of day-to-day activities, tickets can be submitted to Helpdesk when a potential problem area is identified in KEES. These tickets are then tracked, prioritized, and analyzed to determine the root cause. The State of Kansas has continued to utilize this information to fix on-going defects that prevent undermining the redetermination frequency. Additionally, validations have been implemented within KEES and visuals added to assist eligibility staff in how redeterminations are completed as part of the review process. A complete redesign has also been completed regarding the Transitional Medical program to ensure KEES is following policy. As mentioned in previous Corrective Action Plans, to prevent untimely redetermination processing in the future, enhancements have been made to the reviews batch and the reviews data available. This will be utilized as redeterminations resume in the State of Kansas. KDHE enhanced the reviews batch process to ensure beneficiaries are sent their review earlier. This allows more time to determine ongoing eligibility prior to the beneficiary losing coverage. Reporting enhancements were made that provide previously unavailable data. The enhanced data allows for greater analysis of mailed and return volumes, which is then used to allocate staff for reviews processing in a more effective manner. From a training perspective, all redetermination training materials were updated and sent through the approval process based on current policies and procedures. These materials are now housed on a document repository (KanShare) that is accessible by all eligibility staff. In February and March 2023, all eligibility staff who will be tasked with processing redeterminations when they resume in April 2023 attended redeterminations training to ensure their comprehension of policies and procedures. This training was divided into three (3) sections: Part 1 is the policy and procedures of determinations; Part 2 is the application of policy and procedures and Part 3 was a post-assessment to gauge the understanding of redeterminations. Lastly, due to the already made enhancements in KEES surrounding redeterminations, all eligibility staff completed `KEES Reviews Update? training in March 2023. This allows eligibility staff to put together redeterminations from beginning to end and ensure all required documentation is maintained with KEES. All active recipients will receive at minimum one annual redetermination by April 2024.This will allow the State of Kansas to gauge recent efforts to mitigate errors identified during the FY22 SSA. Name(s) of the contact person(s) responsible for corrective action: Donna Wills Planned completion date for corrective action plan: April 2024

View Audit 33298

Corrective Action Plans

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