Corrective Action Plans

Finding 1168772 (2021-005)

Material Weakness 2021

ND

Cash Management School Nutrition Programs Significant Deficiency

Contact Person Jackie Cordie, Business Manager Corrective Action Plan The District plans to implement the auditor's recommendation. Planned Completion Date for CAP Fiscal year beginning July 1, 2024

View Audit 380881

Finding 1165510 (2021-001)

Material Weakness 2021

New Directions, Inc.

CA

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

Management concurs that there were staffing and turnover challenges for the Organization. Adequate policies and procedures are in place to ensure timeliness of data requested. Additionally, we will establish milestones to ensure future audits progress within the Uniform Guidance timeline.

View Audit 376224

Finding 1165035 (2021-007)

Material Weakness 2021

Pima Council on Aging

AZ

Allowable Costs / Cost Principles Cash Management Significant Deficiency

Finding Number 2021-007: No Review of Reimbursement Requests Before Submission (Allowable Costs/Cost Principles), July 1, 2020 through June 30,2021. Statement of Condition: PCOA did not review reimbursement requests before submission PCOA personnel responsible for enacting corrective action plan: Ja...

Finding Number 2021-007: No Review of Reimbursement Requests Before Submission (Allowable Costs/Cost Principles), July 1, 2020 through June 30,2021. Statement of Condition: PCOA did not review reimbursement requests before submission PCOA personnel responsible for enacting corrective action plan: Jay Huffstutler, Finance Director, jhuffstutler@pcoa.org The corrective action plan:  Reimbursement requests now undergo formal internal review prior to submission.  A checklist-based review process was developed with assistance from the Director of Contracts, and compliance is enforced by the Finance Director.  Additional accounting staff are being hired to support the month-end closing process and ensure reimbursement requests are reconciled and supported appropriately. Completion Date: July 31, 2025

View Audit 375125

Finding 1165034 (2021-006)

Material Weakness 2021

Pima Council on Aging

AZ

Allowable Costs / Cost Principles Significant Deficiency

Finding Number 2021-006: Missing or Inaccurate Personnel Action Notices (Allowable Costs/Cost Principles), July 1, 2020 through June 30,2021. Statement of Condition: PCOA had missing or inaccurate personnel action notices PCOA personnel responsible for enacting corrective action plan: Jay Huffstutle...

Finding Number 2021-006: Missing or Inaccurate Personnel Action Notices (Allowable Costs/Cost Principles), July 1, 2020 through June 30,2021. Statement of Condition: PCOA had missing or inaccurate personnel action notices PCOA personnel responsible for enacting corrective action plan: Jay Huffstutler, Finance Director, jhuffstutler@pcoa.org; Jennifer Billa, Human Resources Director, Jbilla@pcoa.org The corrective action plan:  PCOA has standardized its personnel documentation process, including personnel action notices (PAN) and approval workflows.  HR and finance implemented policy and procedures to align pay rate documentation with payroll data.  All personnel changes are now signed off by the Finance and HR Director  Additional skilled personnel are being recruited to ensure accuracy and control around personnel changes. Completion Date: July 31, 2025

View Audit 375125

Finding 1165033 (2021-005)

Material Weakness 2021

Pima Council on Aging

AZ

Allowable Costs / Cost Principles Significant Deficiency

Finding Number 2021-005: Payroll Registers Not Approved by CFO (Allowable Costs/Cost Principles), July 1, 2020 through June 30,2021. Statement of Condition: PCOA did not have payroll registers reviewed by the CFO PCOA personnel responsible for enacting corrective action plan: Jay Huffstutler, Financ...

Finding Number 2021-005: Payroll Registers Not Approved by CFO (Allowable Costs/Cost Principles), July 1, 2020 through June 30,2021. Statement of Condition: PCOA did not have payroll registers reviewed by the CFO PCOA personnel responsible for enacting corrective action plan: Jay Huffstutler, Finance Director, jhuffstutler@pcoa.org The corrective action plan: Background: Previous CFO established this control in collaboration with PCOA leadership.  Approval controls over payroll have been reinstated. All payroll registers are now reviewed and approved prior to submission.  Oversight of payroll controls will be led by the new Finance Director  New staff are being hired to support payroll processing and ensure adherence to internal protocols. Completion Date: July 31, 2025

View Audit 375125

Finding 1165031 (2021-003)

Material Weakness 2021

Pima Council on Aging

AZ

Allowable Costs / Cost Principles Cash Management Reporting

Finding Number 2021-003: Lack of Review of Meal Sign-In Sheets (Allowable Costs/Cost Principles) , July 1, 2020 through June 30,2021. Statement of Condition: The Meal Sign-in Sheets were not regularly and consistently attached to proper documentation. PCOA personnel responsible for enacting correcti...

Finding Number 2021-003: Lack of Review of Meal Sign-In Sheets (Allowable Costs/Cost Principles) , July 1, 2020 through June 30,2021. Statement of Condition: The Meal Sign-in Sheets were not regularly and consistently attached to proper documentation. PCOA personnel responsible for enacting corrective action plan: Francine McGetrick, Contracts Director, Fmcgetrick@pcoa.org The corrective action plan: 1. PCOA has implemented procedures requiring internal review of all client sign-in sheets related to meals billed for reimbursement. 2. While the required sign-in documentation was completed and retained, it was stored in the contracts area and not submitted with the DES files. A new process has been established to ensure that sign-in sheets are filed along with the corresponding summary information at the time of submission. 3. PCOA has designed the updated process and trained staff to ensure proper documentation is verified prior to billing. 4. Ongoing compliance is now overseen by the Director of Contracts, and operational staff have been re-trained to ensure consistent execution. Completion Date: June 30th, 2025

View Audit 375125

Finding 1164243 (2021-007)

Material Weakness 2021

Portsmouth Redevelopment and Housing Authority

VA

Questioned Costs HUD Housing Programs Significant Deficiency

Housing Choice Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority review its controls over reasonable rent determinations to ensure that they are performed timely, files are maintained, and the approved rent is properly carried forward to the HUD-50058. Explan...

Housing Choice Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority review its controls over reasonable rent determinations to ensure that they are performed timely, files are maintained, and the approved rent is properly carried forward to the HUD-50058. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority has reinforced internal controls and accountability procedures to ensure that reasonable rent determinations are consistently performed and properly documented in compliance with HUD regulations. The HCV Director has assumed responsibility for reviewing and approving all reasonable rent determinations and will continue to monitor compliance until the Compliance Manager is hired in January 2026. Name(s) of the contact person(s) responsible for corrective action Keva Newsome, Director of Housing Choice Voucher Program Planned completion date for corrective action plan: 12/1/25

View Audit 373527 Questioned Costs: $1

Finding 1164242 (2021-006)

Material Weakness 2021

Portsmouth Redevelopment and Housing Authority

VA

HUD Housing Programs Significant Deficiency Matching / Level of Effort / Earmarking

Housing Choice Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority to designate an individual to ensure accurate HUD-50058 information is inputted into the PIC system timely. Explanation of disagreement with audit finding: There is no disagreement with the audi...

Housing Choice Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority to designate an individual to ensure accurate HUD-50058 information is inputted into the PIC system timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority will hire a Compliance staff person for the HCV Program in January 2026 to provide dedicated oversight of eligibility determinations, quality control, and ongoing staff training. Name(s) of the contact person(s) responsible for corrective action: Keva Newsome, Director of Housing Choice Voucher Program Planned completion date for corrective action plan: 1/31/26

View Audit 373527

Finding 1164240 (2021-004)

Material Weakness 2021

Portsmouth Redevelopment and Housing Authority

VA

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency

Housing Choice Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority review its internal controls over allowable costs to ensure all documentation is maintained at the time expenses are paid. Explanation of disagreement with audit finding: There is no disagreemen...

Housing Choice Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority review its internal controls over allowable costs to ensure all documentation is maintained at the time expenses are paid. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority is prioritizing completion of outstanding audits to ensure records can be located promptly when requested. All invoices will continue to require proper approval signatures prior to payment, and payment authorization will serve as an additional layer of verification to confirm compliance with internal control procedures. This instance involved only one of forty (40) accounts payable items that was not available in the document imaging system at the time of review so it needed to be recreated by printing off the invoice and it was paid online. The payment would have had to be pre-approved by CFO prior to payment. Name(s) of the contact person(s) responsible for corrective action: Shannon Sterling, CFO Planned completion date for corrective action plan: 12/1/25

View Audit 373527 Questioned Costs: $1

Finding 1164239 (2021-003)

Material Weakness 2021

Portsmouth Redevelopment and Housing Authority

VA

HUD Housing Programs Eligibility Significant Deficiency

Housing Choice Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority review its internal controls over the waiting list process to ensure all documentation is maintained at the time each applicant enters and is pulled from the waiting list. Explanation of disagre...

Housing Choice Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority review its internal controls over the waiting list process to ensure all documentation is maintained at the time each applicant enters and is pulled from the waiting list. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Files will not be placed in storage until after the agency audit is completed. Name(s) of the contact person(s) responsible for corrective action: Keva Newsome, Director of Housing Choice Voucher Program Planned completion date for corrective action plan: 12/1/2025

View Audit 373527

Finding 1164238 (2021-002)

Material Weakness 2021

Portsmouth Redevelopment and Housing Authority

VA

Questioned Costs HUD Housing Programs Significant Deficiency

Housing Choice Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority review its controls over HQS inspections and abatements to ensure the controls are properly implemented. Explanation of disagreement with audit finding: There is no disagreement with the audit f...

Housing Choice Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority review its controls over HQS inspections and abatements to ensure the controls are properly implemented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A new HCV Director has been appointed and will perform monthly compliance reviews of failed inspections to ensure timely abatement enforcement and documentation accuracy. Name(s) of the contact person(s) responsible for corrective action: Keva Newsome, Director of Housing Choice Voucher Program Planned completion date for corrective action plan: 12/1/2025

View Audit 373527 Questioned Costs: $1

Finding 1162168 (2021-007)

Material Weakness 2021

JOHN C. FREMONT HEALTHCARE DISTRICT

CA

Reporting Significant Deficiency Internal Control / Segregation of Duties

JCFHD experienced substantial leadership and staff turnover in key financial roles over multiple years, including the CEO, CFO, and finance team. As a result, the individuals who originally prepared the lost revenues calculation were no longer employed at the facility when the Uniform Guidance audit...

JCFHD experienced substantial leadership and staff turnover in key financial roles over multiple years, including the CEO, CFO, and finance team. As a result, the individuals who originally prepared the lost revenues calculation were no longer employed at the facility when the Uniform Guidance audit was conducted. This led to challenges in locating complete supporting documentation for the original calculation, resulting in additional calculations being necessary. Under new leadership, JCFHD has prioritized the development and implementation of robust policies and procedures to ensure that all relevant financial documentation is readily accessible for future Uniform Guidance audits. These measures are intended to strengthen internal controls and improve audit readiness. Corrective Action: 1. Provide additional training to finance staff on GAAP financial reporting and disclosure requirements to strengthen internal review and oversight. 2. Implement a documented review process for financial statements and footnotes prepared by external auditors, including CFO and Board-level approval prior to issuance. Completion Date: Within 120 days.

View Audit 371977

Finding 1162167 (2021-006)

Material Weakness 2021

JOHN C. FREMONT HEALTHCARE DISTRICT

CA

Reporting Significant Deficiency

JCFHD experienced significant turnover in CEO, CFO, and finance positions over multiple years resulting in delays in completing the Uniform Guidance audit. JCFHD is under new leadership and has prioritized implementing policies and procedures to ensure future uniform guidance audits are completed an...

JCFHD experienced significant turnover in CEO, CFO, and finance positions over multiple years resulting in delays in completing the Uniform Guidance audit. JCFHD is under new leadership and has prioritized implementing policies and procedures to ensure future uniform guidance audits are completed and filed timely. Corrective Action: 1. Develop and implement written accounting policies and procedures aligned with GAAP and COSO principles. 2. Establish a monthly reconciliation calendar for all significant balance sheet accounts, with supervisory review and sign-off. 3. Provide training to accounting staff on new policies, reconciliation standards, and documentation requirements. 4. Assign the Accountant to monitor compliance and report quarterly to the CFO on reconciliation status and control improvements. Completion Date: Target completion within 90 days.

View Audit 371977

Finding 573470 (2021-003)

Significant Deficiency 2021

Development Bank of American Samoa

AS

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Significant Deficiency

Finding No.: 2021-003 Segregation of Duties Federal Agency: U.S. Department of Housing and Urban Development Federal Program Title: HOME Investment Partnerships Program Assistance Listing Number: 14.239 Name of Contact Persons: Faaeteete Sio and Ruth Matagi Corrective Action: Due to ...

Finding No.: 2021-003 Segregation of Duties Federal Agency: U.S. Department of Housing and Urban Development Federal Program Title: HOME Investment Partnerships Program Assistance Listing Number: 14.239 Name of Contact Persons: Faaeteete Sio and Ruth Matagi Corrective Action: Due to the COVID-19 pandemic, DBAS had to work a staggered schedule for the staff to include vulnerable employees who are 60+ year olds (management) to work remotely from home. Two of the signors fall under this category. DBAS will ensure and enforce proper segregation of duties will be followed. Loan approval and check signer controls will be reviewed and revised to ensure segregation of duties concerns are mitigated moving forward. This situation has since been addressed and corrected with the return of staff to the office.

View Audit 364205

Finding 571780 (2021-004)

Significant Deficiency 2021

Gunnison Valley Hospital Special Service District

UT

Reporting Significant Deficiency

Assistance Listing Number: #93.498 Program Name: Provider Relief Fund and American Rescue Plan {ARP} Rural Distribution Compliance Requirement: Other Finding Summary: The District does not have an internal control system designed to provide for a complete and accurate schedule of expenditures of f...

Assistance Listing Number: #93.498 Program Name: Provider Relief Fund and American Rescue Plan {ARP} Rural Distribution Compliance Requirement: Other Finding Summary: The District does not have an internal control system designed to provide for a complete and accurate schedule of expenditures of federal awards being audited. We were requested to draft the schedule of expenditures of federal awards Responsible Individuals: Brian Murray, Chief Financial Officer Corrective Action Plan: GVH will review its' internal controls related to grant tracking. It also assign a project or grant account number to each grant and code all expenditures to that account code. The items in this account will be logged and the appropriate back identified and maintained.

View Audit 362800

Finding 571778 (2021-002)

Significant Deficiency 2021

Gunnison Valley Hospital Special Service District

UT

Allowable Costs / Cost Principles Significant Deficiency § 200.303

Federal Agency Name: Department of Health and Human Services Assistance Listing Number: #93.498 Program Name: Provider Relief Fund and American Rescue Plan {ARP} Rural Distribution Compliance Requirement: Activities Allowed or Unallowed, Allowable Cost/Cost Principles Finding Summary: The District ...

Federal Agency Name: Department of Health and Human Services Assistance Listing Number: #93.498 Program Name: Provider Relief Fund and American Rescue Plan {ARP} Rural Distribution Compliance Requirement: Activities Allowed or Unallowed, Allowable Cost/Cost Principles Finding Summary: The District did not have adequate internal controls policy in place to ensure expenditures claimed were accurate and based upon underlying records and to ensure the records were retained to support the amounts. Responsible Individuals: Brian Murray, Chief Financial Officer Corrective Action Plan: GVH will review its internal controls related to grant tracking. It also assign a project or grant account number to each grant and code all expenditures to that account code. The items in this account will be logged and the appropriate back identified and maintained.

View Audit 362800

Finding 570096 (2021-001)

Significant Deficiency 2021

County of Belknap, New Hampshire

NH

Subrecipient Monitoring Allowable Costs / Cost Principles Procurement, Suspension & Debarment

Planned Corrective Action: A Uniform Guidance policy and Procedure document has been adopted. Planned Implementation Date of Corrective Action: The policy was effective 03/21/2025. Person Responsible for Corrective Action: Finance Director

View Audit 361369

Finding 570040 (2021-002)

Significant Deficiency 2021

Local Redevelopment Authority of the Lands and Facilities of Naval Station Roosevelt Roads

PR

Internal Control / Segregation of Duties Cash Management Significant Deficiency

2021-002 Reserve Account Category: Significant Deficiency in Internal Control and Noncompliance Condition: The Authority has a deposit deficiency of $40,416 in the Reserve Account. The balance of the debt service reserve as of June 30, 2021, shall be $90,936. Management’s Response: Starting in FY 20...

2021-002 Reserve Account Category: Significant Deficiency in Internal Control and Noncompliance Condition: The Authority has a deposit deficiency of $40,416 in the Reserve Account. The balance of the debt service reserve as of June 30, 2021, shall be $90,936. Management’s Response: Starting in FY 2024-2025, the Finance Department will initiate the necessary transfers to the Reserve Account to rectify the deposit deficiency. Additionally, we will establish a plan for regular monitoring of the account to prevent future deficiencies. To ensure ongoing compliance and to identify any potential issues early, we will schedule more frequent internal audits. Person in charge: Juan C. Rodriguez Rivera Accounting Official 787-705-7188 Juan.rodriguez@lra.pr.gov Implementation Date: FY 2024-2025

View Audit 361347

Finding 566957 (2021-001)

Significant Deficiency 2021

California Labor Federation

CA

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.512

In July 2022, I assumed leadership as the Chief Officer of the California Labor Federation, AFL-CIO. My election was the organization’s first leadership transition since 1996. Upon taking over this role, it became immediately obvious that internal affairs of the organization needed a serious overhau...

In July 2022, I assumed leadership as the Chief Officer of the California Labor Federation, AFL-CIO. My election was the organization’s first leadership transition since 1996. Upon taking over this role, it became immediately obvious that internal affairs of the organization needed a serious overhaul, including additional oversight and reforms to internal policies and procedures. Though I cannot speak to why single audits were not completed timely, once the issue came to my attention, I immediately required that staff seek out a firm to complete its outstanding audits as soon as possible. Once prior year audits have been completed, single audits are to be completed annually, with the anticipation that all outstanding single audits will be completed by December 31, 2025.

View Audit 359825

Finding 559157 (2021-012)

Significant Deficiency 2021

Caswell County

NC

Eligibility Significant Deficiency

CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694‐4193 Corrective Action Plan For the Year Ended June 30, 2021 Finding: 2021-011 Inaccurate Resource Calculation Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2021-012 Inadequate Requ...

CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694‐4193 Corrective Action Plan For the Year Ended June 30, 2021 Finding: 2021-011 Inaccurate Resource Calculation Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2021-012 Inadequate Request for Information Name of contact person: Corrective Action: Heather Starr Thomas, Medicaid Supervisor Files will be reviewed internally to ensure proper documentation is in place for eligibility. Workers will be retrained on what files should contain and the importance of complete and accurate record keeping. All files will include online verifications, documented resources and income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. Templates have been put in place to address request for information. All avenues available to caseworker must be exhausted before requesting information from client, unless information provided and information obtained is questionable. We will continue to train on this issue, and it will also be addressed in new worker Trainings. Training in the learning gateway is also available. Section III - Federal Award Findings and Question Costs (continued) 2/28/2022 Heather Starr Thomas, Medicaid Supervisor Files will be reviewed internally to ensure proper documentation is in place for eligibility. Workers should be retrained on what files should contain and the importance of complete and accurate record keeping. All files must include online verifications, documented resources of income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. Resources have been readdressed at Unit Meeting. Templates have been put in place to address programs in which resources are countable. We will continue to train on this issue, and it will also be addressed in new worker Trainings. Training in the learning gateway is also available. 128

View Audit 355385

Finding 559156 (2021-011)

Significant Deficiency 2021

Caswell County

NC

Eligibility Significant Deficiency

CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694‐4193 Corrective Action Plan For the Year Ended June 30, 2021 Finding: 2021-011 Inaccurate Resource Calculation Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2021-012 Inadequate Requ...

CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694‐4193 Corrective Action Plan For the Year Ended June 30, 2021 Finding: 2021-011 Inaccurate Resource Calculation Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2021-012 Inadequate Request for Information Name of contact person: Corrective Action: Heather Starr Thomas, Medicaid Supervisor Files will be reviewed internally to ensure proper documentation is in place for eligibility. Workers will be retrained on what files should contain and the importance of complete and accurate record keeping. All files will include online verifications, documented resources and income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. Templates have been put in place to address request for information. All avenues available to caseworker must be exhausted before requesting information from client, unless information provided and information obtained is questionable. We will continue to train on this issue, and it will also be addressed in new worker Trainings. Training in the learning gateway is also available. Section III - Federal Award Findings and Question Costs (continued) 2/28/2022 Heather Starr Thomas, Medicaid Supervisor Files will be reviewed internally to ensure proper documentation is in place for eligibility. Workers should be retrained on what files should contain and the importance of complete and accurate record keeping. All files must include online verifications, documented resources of income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. Resources have been readdressed at Unit Meeting. Templates have been put in place to address programs in which resources are countable. We will continue to train on this issue, and it will also be addressed in new worker Trainings. Training in the learning gateway is also available. 128

View Audit 355385

Finding 559155 (2021-010)

Significant Deficiency 2021

Caswell County

NC

Eligibility Significant Deficiency Internal Control / Segregation of Duties

CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694‐4193 Corrective Action Plan For the Year Ended June 30, 2021 Proposed Completion Date: Finding: 2021-010 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed Completion Date: 2/28/2022 ...

CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694‐4193 Corrective Action Plan For the Year Ended June 30, 2021 Proposed Completion Date: Finding: 2021-010 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed Completion Date: 2/28/2022 All workers have knowledge that Templates put in place are Mandatory. IV-D Referrals are addressed on template. All cases will be reviewed for IV-D Referrals or open/active I-VD cases. All children must have a referral if the parent is receiving Medical Benefits. We will continue to train on this issue, and it will also be addressed in new worker Trainings. Training in the learning gateway is also available. Section III - Federal Award Findings and Question Costs (continued) Heather Starr Thomas, Medicaid Supervisor A refresher training will be held to review errors. Files will be reviewed internally to ensure proper documentation is in place for eligibility. Workers will be retrained on what files should contain and the importance of complete and accurate record keeping. All files include online verifications, documented resources of income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. The template that has been put in place for applications and recertification address all computer checks and documentation that is needed to accurately approve/deny/continue or terminate benefits. All other cases in NCFAST are to be reviewed to ensure we have the correct information. Weekly Communications and Changes are reviewed weekly at Unit Meeting to address any changes and NCFAST issues that may require a Help Desk Ticket or an 8020 to remove benefits client may not have been eligible for. OST has provided guidance on Changes in policy to remove a client that may continue during Covid that is not eligible for NC Medicaid. We will continue to train on this issue, and it will also be addressed in new worker Trainings. Training in the learning gateway is also available. 2/28/2022 127

View Audit 355385

Finding 559154 (2021-009)

Significant Deficiency 2021

Caswell County

NC

Eligibility Significant Deficiency

Finding: 2021-009 IV-D Non-Cooperation Name of contact person: Corrective Action: Section III - Federal Award Findings and Question Costs Referrals are being keyed to Child Support Enforcement Agency (IV-D) each case with dependent children must cooperate with IV-D unless there is good cause. County...

Finding: 2021-009 IV-D Non-Cooperation Name of contact person: Corrective Action: Section III - Federal Award Findings and Question Costs Referrals are being keyed to Child Support Enforcement Agency (IV-D) each case with dependent children must cooperate with IV-D unless there is good cause. County will review cases for a referral keyed or to ensure a new child support referral is keyed. On 11/15/2021 eligibility workers refreshed on IV-D policy and reviewed the job aid in NCFAST help for IVD referrals. Second Party reviews are reviewed internally to ensure proper information is in place and necessary procedures are followed after eligibility is determined and documented in case notes. Documentation will clearly state what actions were performed and the outcome of those actions. The County has developed a mandatory verification check list enforced 11/15/2021 to ensure all criteria has been meet according to policy of the state. Since template has been in place we have noticed a significant drop in IV-D referral issues in Second Party Reviews.CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694‐4193 Corrective Action Plan For the Year Ended June 30, 2021 Proposed Completion Date: Finding: 2021-010 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed Completion Date: 2/28/2022 All workers have knowledge that Templates put in place are Mandatory. IV-D Referrals are addressed on template. All cases will be reviewed for IV-D Referrals or open/active I-VD cases. All children must have a referral if the parent is receiving Medical Benefits. We will continue to train on this issue, and it will also be addressed in new worker Trainings. Training in the learning gateway is also available. Section III - Federal Award Findings and Question Costs (continued) Heather Starr Thomas, Medicaid Supervisor A refresher training will be held to review errors. Files will be reviewed internally to ensure proper documentation is in place for eligibility. Workers will be retrained on what files should contain and the importance of complete and accurate record keeping. All files include online verifications, documented resources of income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. The template that has been put in place for applications and recertification address all computer checks and documentation that is needed to accurately approve/deny/continue or terminate benefits. All other cases in NCFAST are to be reviewed to ensure we have the correct information. Weekly Communications and Changes are reviewed weekly at Unit Meeting to address any changes and NCFAST issues that may require a Help Desk Ticket or an 8020 to remove benefits client may not have been eligible for. OST has provided guidance on Changes in policy to remove a client that may continue during Covid that is not eligible for NC Medicaid. We will continue to train on this issue, and it will also be addressed in new worker Trainings. Training in the learning gateway is also available. 2/28/2022 127

View Audit 355385

Finding 530197 (2021-001)

Significant Deficiency 2021

Huntsville Memorial Hospital

TX

Questioned Costs Allowable Costs / Cost Principles Cash Management

U.S. Department of Health and Human Services 2021-001 Provider Relief Fund – Assistance Listing No. 93.498 Recommendation: We recommend that management implement a system that allows for easy identification of any copies of invoices paid. Explanation of disagreement with audit finding: There is no d...

U.S. Department of Health and Human Services 2021-001 Provider Relief Fund – Assistance Listing No. 93.498 Recommendation: We recommend that management implement a system that allows for easy identification of any copies of invoices paid. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Huntsville Community Hospital, Inc. now operates under a full digitized accounting and payables system which allows them to pull any historical invoice copies as needed. Name(s) of the contact person(s) responsible for corrective action: Paul Hanson, CFO Planned completion date for corrective action plan: Huntsville Community Hospital, Inc. now operates under a full digitized accounting and payables system.

View Audit 348302 Questioned Costs: $1

Finding 524400 (2021-007)

Material Weakness 2021

Quileute Tribal School

WA

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness § 200.303

Persons responsible for corrective action: Bob Harmon, Superintendent Corrective Action: During the 2021 fiscal year there were superintendent vacancies. The School currently has a superintendent that is knowledgeable of this requirement. Implementation date: June 30, 2025

View Audit 343636

Corrective Action Plans

Filters