Corrective Action Plans

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Views of responsible officials and planned corrective actions Quivira Coalition has made efforts to fully comply with federal allowable cost rules, including implementing a compliant time and expense system, implementing a compliant accounting system, consulting with federal program officers, and re...
Views of responsible officials and planned corrective actions Quivira Coalition has made efforts to fully comply with federal allowable cost rules, including implementing a compliant time and expense system, implementing a compliant accounting system, consulting with federal program officers, and requesting budget revisions when necessary. However, management agrees that despite its efforts it did not correctly attribute allowable non-personnel and personnel costs to the grants, resulting in errors on the Schedule of Expenditures of Federal Awards (SEFA). Management has analyzed the errors and determined the root causes. Management agrees that the root cause of finding 2024-001 is the discrepancy between the accounting system and time and expenses software system, and that this is material to grant management. After reconciling these discrepancies, as discussed below, management believes the estimated amount for Beginning Farmer and Rancher Development Program; Award: BFRDP - 2023 - 49400 - 40894 (AL 10.311) to be $7,002 and for Partnerships for Climate-Smart Commodities; Award: USDA/NR243A750004G005 (AL 10.937) to be $10,169. Non-Personnel Costs Discrepancies in non-personnel costs were primarily caused by human errors. Management conducted a post-audit reconciliation between the expense tracking system (Harvest) and the general ledger (QuickBooks) which identified the 2024 discrepancies, and Quivira has corrected them. Personnel Costs Discrepancies in labor costs were due to three factors: 1) Quivira Coalition personnel are paid for holidays and paid time off (PTO) and therefore personnel costs include PTO and holiday costs in QuickBooks. However, Quivira’s timekeeping system (Harvest) does not burden federal award personnel costs with PTO and holiday costs making it difficult to reconcile. 2) To allocate personnel costs to a grant, Quivira used the Harvest system. This system calculates a fixed cost rate for each person based on their total annual compensation and expected work capacity and then multiplies this fixed cost rate by the number of hours worked on each grant (as recorded in the Harvest System). However, using fixed cost rates can result in misallocation in situations where personnel work over capacity (e.g. overtime) or under capacity. The appropriate cost allocation approach for salaried employees is to allocate actual personnel costs for a task based on the percentage of total hours worked. 3) Quivira calculated personnel fringe costs based on an estimated hourly fringe rate rather than identifying and allocating actual fringe expenses from QuickBooks. To correct for this material weakness, Quivira Coalition will: Action Step Detail Date Responsible Party Develop a new, compliant method to allocate personnel costs for federal billing and reporting. Stop using the timekeeping system (Harvest) for allocation. The new method must properly reflect actual paid salaries, paid fringe, and actual time spent. 12/31/2025 Accounting Firm Update reporting process to reconcile all costs reported on the SF-425 to the general ledger (instead of the timekeeping system) using the new federal grants billing process. Keep detailed records of the reconciliation. 12/31/2025 Accounting Firm Implement a monthly reconciliation process between the time and expense system (Harvest) and the QuickBooks general ledger to reconcile all non-personnel expenses. 1/31/2026 Operations Director Document the grant management process, including new reporting processes, required reconciliations, monitoring policies, and allowable cost management to ensure consistency across the organization. 2/28/2026 Operations Director Update policies and procedures to require that expenses reported on the SEFA form come directly from the accounting system to ensure this continues. 1/31/2026 Operations Director Update policies and procedures to require an annual reconciliation between the SF-425 and SEFA reports to ensure this continues. This occurs before submitting the SEFA report. 1/31/2026 Operations Director Reconcile all grant programs active in 2024 and 2025 using updated processes and resolve any discrepancies with federal reports or billing. 2/28/2026 Initial Review - Operations Director & Grants Manager Secondary Review & Corrections (if needed) - Accounting Firm Develop a plan to ensure regular and sufficient training on Uniform Guidance tracking regulatory changes, and how to implement changes. Update policies and procedures. 11/30/2025 Operations Director & Executive Director Update policies and procedures to require an additional level of review and approval for SF-425 and SEFA reports and reconciliations for accuracy and completeness before they are submitted. 12/31/2025 Operations Director with final approval from the Executive Director
View Audit 369852 Questioned Costs: $1
Views of Responsible Officials and Planned Corrective Action Management agrees with the recommendation. Quivira Coalition will: Action Step Detail Date Responsible Party Update its subrecipient and contractor agreement templates to include information outlined in 2 CFR § 200.332, including more spec...
Views of Responsible Officials and Planned Corrective Action Management agrees with the recommendation. Quivira Coalition will: Action Step Detail Date Responsible Party Update its subrecipient and contractor agreement templates to include information outlined in 2 CFR § 200.332, including more specific federal award identification. 10/31/25 Operations Director Add a clause to the subrecipient and contractor agreement templates to include a requirement to report any significant developments to Quivira Coalition. 10/31/25 Operations Director Build a procedure for evaluating a subrecipient’s fraud risk and risk of non-compliance with the federal awards (as outlined in 2 CFR § 200.332 (c)) during the grant application phase or before engaging in agreements & work with subrecipient. It will continue to follow-up annually with the recipients on fraud risk and risk of non-compliance until the end of the federal award period. 10/31/25 Operations Director; CRI Director & Grants Manager Monitor sub-recipients as required by 2 CFR 200.332(e) 1/31/2026 Operations Director If a subrecipient has significant development during the course of monitoring, institute a tailored monitoring plan as outlined in 2 CFR § 200.332 (e) & (f) and resolve any findings listed as its responsibility under 2 CFR § 200.332 (e). 10/31/25 Operations Director; CRI Director & Grants Manager
Recommendation: Block grant reports should be completed prior to the accounting record close process to ensure the expenditures reported are supported by the underlying accounting records. Controls over reporting should include records for the basis of reporting submissions should be reviewed as par...
Recommendation: Block grant reports should be completed prior to the accounting record close process to ensure the expenditures reported are supported by the underlying accounting records. Controls over reporting should include records for the basis of reporting submissions should be reviewed as part of the report approval process prior to submission. Supporting documentation and reconciliations should be filed for reference purposes. Action Taken: The Department of Human Services received approval from the PA DHS in February 2025 for its 2021–2022 HSBG Income & Expenditure (I&E) Report, Revision 3, which had been submitted in January 2025. At the State’s request, the Agreed Upon Procedures report was submitted in August 2025 for fiscal year 2021-2022 and has since been approved. The journal entries reconciling the underlying expenditure detail in the County’s accounting system to the expenditures reported have been submitted, and the final reconciliation is in process. Retained Earnings Plans were submitted to the State in February and March 2024. The County completed submission of the 2022–2023 HSBG I&E Report in March 2025, with a revised version submitted in September 2025. The State is currently reviewing the report. Upon approval, the AUP will be completed, and the County will reconcile the detailed expenditures in the accounting system to the amounts reported, ensuring accuracy and compliance. The 2023–2024 HSBG I&E Report was submitted in September 2025. The County is finalizing the 2024–2025 HSBG I&E Report and anticipates submission by October 2025. Responsible Individual for Corrective Action: Gaston Gonzalez, County of Delaware Department of Human Services Chief Financial Officer Completion Date: December 31, 2025
Finding 2024-001: Reporting – Recordkeeping Planned Corrective Action: The Chicago Park District will implement the following strategies to improve the management of the Summer Food Service Program (SFSP).  Review and analyze audit findings with staff, Area Managers, and Administration in order to ...
Finding 2024-001: Reporting – Recordkeeping Planned Corrective Action: The Chicago Park District will implement the following strategies to improve the management of the Summer Food Service Program (SFSP).  Review and analyze audit findings with staff, Area Managers, and Administration in order to prevent findings.  2025 DMC, has a new line at the bottom of the page, that will have staff print their name and then second line for signature and date. See attached for example.  Hold a citation meeting of sites that received ISBE citations in 2024, prior to the start of summer. In 2025, electronically send ISBE citations in real time, once wellness receives the citation is emailed to Park Supervisor and Area Manager.  Continue train monitors to review SFSP binders, check food temperature, date of service and signature recorded on all invoices and DMC, and attendance. Ensure seasonal monitors will be onsite for the duration of meal service.  Mandate that at least three of staff members per site are trained in SFSP (pending number of staff at park location).  Provide multiple in person trainings before start of the season to all field staff emphasize the importance of accuracy and details when following the Policy and Procedures of the Summer Food Service Program. Name of the Contact Person Responsible for Corrective Action: Farah Tunks, Director of Programming Meghan O’Boyle, Wellness Manager Anticipated Completion Date: September 30, 2025
The Fulton County District Attorney's Office has maintained compliance with their policy and procedure regarding time and effort management since August 2024. The SAKI grant employees per policy complete activity reports which document their activities on a biweekly basis, reflect time worked, and t...
The Fulton County District Attorney's Office has maintained compliance with their policy and procedure regarding time and effort management since August 2024. The SAKI grant employees per policy complete activity reports which document their activities on a biweekly basis, reflect time worked, and then sign those reports. Those reports are then reviewed and signed by a supervisor with a knowledge of their work. Those reports are maintained and kept in the Fulton County District Attorney's Office.
View Audit 369827 Questioned Costs: $1
The Fulton County Department of Behavioral Health and Developmental Disabilities (DBHDD) performs continuous monitoring activities with program subrecipients by conducting weekly meetings, reviewing monthly reports, invoices, and conducts quarterly performance reviews. DBHDD will strengthen its subr...
The Fulton County Department of Behavioral Health and Developmental Disabilities (DBHDD) performs continuous monitoring activities with program subrecipients by conducting weekly meetings, reviewing monthly reports, invoices, and conducts quarterly performance reviews. DBHDD will strengthen its subrecipient monitoring internal controls by properly documenting these reviews in order to be incompliance with 2 CFR 200.331, and the County’s Subrecipient Monitoring Policy.
The Department of Senior Services follows the monitoring standards established by the pass-through entity and has implemented process improvements to ensure that all Program Year 2024-2025 compliance processes were met. The current period monitoring plan, risk assessments and monitoring have been co...
The Department of Senior Services follows the monitoring standards established by the pass-through entity and has implemented process improvements to ensure that all Program Year 2024-2025 compliance processes were met. The current period monitoring plan, risk assessments and monitoring have been completed. The Department will maintain an annual monitoring plan to ensure that all subrecipients are monitored in compliance with 2 CFR 200 requirements.
Finding 1157573 (2024-002)
Material Weakness 2024
Finding 2024-002 Program ALN: 21.027 Program Title: COVID-19 Coronavirus State and Local Fiscal Recovery Funds (SLFRF) Award Number/Year: Not applicable / 2021 Federal Agency: U.S. Department of Treasury Repeat of Finding 2023-004 Condition The County was not able to provide evidence that the suspen...
Finding 2024-002 Program ALN: 21.027 Program Title: COVID-19 Coronavirus State and Local Fiscal Recovery Funds (SLFRF) Award Number/Year: Not applicable / 2021 Federal Agency: U.S. Department of Treasury Repeat of Finding 2023-004 Condition The County was not able to provide evidence that the suspension and debarment verification was completed for the three contractors selected for testing. The sample was not statistically valid. Corrective Action Plan Corrective Action Planned: Training has been provided to the County’s Purchasing division regarding the requirement to review and record evidence that verification is completed on vendors prior to contracting. Name(s) of Contact Person(s) Responsible for Corrective Action: Kristin Vander Kooi, Rock County Finance Director Anticipated Completion Date: September 18, 2024
2024-003 Program: Crime Victim Assistance Federal Agency: Department of Justice AL #: 16.575 Federal Award Identification Number and Year: Various – See SEFA Pass-through Entity: Missouri Department of Social Services Type of Compliance Finding: I - Procurement, Suspension, & Debarment Internal Cont...
2024-003 Program: Crime Victim Assistance Federal Agency: Department of Justice AL #: 16.575 Federal Award Identification Number and Year: Various – See SEFA Pass-through Entity: Missouri Department of Social Services Type of Compliance Finding: I - Procurement, Suspension, & Debarment Internal Control Impact: Material Weakness Finding: During our audit of the Organization’s fiscal year ended December 31, 2024 federal award program, we noted the Organization did not follow their documented procurement procedures for approving one contractor. Corrective Action Plan: All procurement procedures will be followed as documented in YWCA St. Joseph financial policies. Person(s) Responsible for Implementation: Danielle Brown, CEO, dbrown@ywcasj.org, 816-232-4481
2024-002 Program: Crime Victim Assistance Federal Agency: Department of Justice AL #: 16.575 Federal Award Identification Number and Year: Various – See SEFA Pass-through Entity: Missouri Department of Social Services Type of Compliance Finding: E - Eligibility Internal Control Impact: Material Weak...
2024-002 Program: Crime Victim Assistance Federal Agency: Department of Justice AL #: 16.575 Federal Award Identification Number and Year: Various – See SEFA Pass-through Entity: Missouri Department of Social Services Type of Compliance Finding: E - Eligibility Internal Control Impact: Material Weakness Finding: When a participant arrives at the Shelter, the admission checklist, procedures, and forms must be completed by program staff. During our audit of the Organization’s fiscal year ended December 31, 2024 federal award program, we noted the Organization did not have necessary supporting documentation, such as admission checklists for eligibility, to evaluate twenty-one out of twenty- five participants in their files. Corrective Action Plan: All supporting documentation for client eligibility will be maintained for the period required by the grant. Person(s) Responsible for Implementation: Danielle Brown, CEO, dbrown@ywcasj.org, 816-232-4481
Corrective Action: Procedures will be created as part of the subaward monitoring process to ensure that subrecipient information is received in a timely manner. Deadlines will be created to ensure that the subaward information is entered as part of FFATA reporting in Sam.gov with deadlines outlined ...
Corrective Action: Procedures will be created as part of the subaward monitoring process to ensure that subrecipient information is received in a timely manner. Deadlines will be created to ensure that the subaward information is entered as part of FFATA reporting in Sam.gov with deadlines outlined in 2 CFR 170.
Corrective Action: The risk assessment template and list of subaward terms to be downloaded. A new subaward agreement template to be developed which encompasses all aspects of 200.332(b). Contact Persons: Laurie Olson, Controller and Kevin Osborn, Interim Executive Director Implementation Timeline: ...
Corrective Action: The risk assessment template and list of subaward terms to be downloaded. A new subaward agreement template to be developed which encompasses all aspects of 200.332(b). Contact Persons: Laurie Olson, Controller and Kevin Osborn, Interim Executive Director Implementation Timeline: The risk assessment template and subaward terms were downloaded and distributed to key stakeholders on Friday, September 19, 2025. A new subaward agreement template will be created in a multi-department collaboration and is due to be completed by December 31, 2025.
Choice Neighborhood Incentive Grants – Assistance Listing No. 14.889 Recommendation: We recommend that HABC staff review the controls in place to ensure that required FFATA reporting documentation is complete, accurate, and available for audit. Explanation of disagreement with audit finding: There i...
Choice Neighborhood Incentive Grants – Assistance Listing No. 14.889 Recommendation: We recommend that HABC staff review the controls in place to ensure that required FFATA reporting documentation is complete, accurate, and available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Public Law 109-282, known as the Federal Funding Accountability and Transparency Act of 2006 (FFATA), mandates the public disclosure of all entities and organizations receiving federal funds through a single accessible website. Any subcontract exceeding $30,000 must be reported by the prime recipient of federal funds. However, this reporting requirement does not apply to the Housing Authority of Baltimore City (HABC), similar to the Moving to Work (MTW) block grants and their sub-recipient reporting to the Baltimore Regional Housing Partnership (BRHP). Both awards, the Choice Neighborhood Initiative (CNI) grant awards are not available in the dropdown menu for fulfilling this monthly reporting requirement. This issue was noted because HABC could not demonstrate to the auditors that we had made several unsuccessful attempts to meet this requirement. In response, HABC Finance has established a monthly workflow process to regularly check the website to document the attempts. In addition, we are currently awaiting a formal response from the Department of Housing and Urban Development (HUD) regarding the unavailability of these grants for sub-contracting monitoring & reporting on the SAMs website. Name(s) of the contact person(s) responsible for corrective action: Anu Francis, Chief Financial Officer. Planned completion date for corrective action plan: 12/31/2025
Finding No. 2024-001 –Significant Deficiency Personnel Responsible for Section 8 Director Corrective Action: Completion Date: January 31, 2025 Corrective Action Plan: We acknowledge that while reviews of moved-out individuals are occurring, there was insufficient documentation to support this proces...
Finding No. 2024-001 –Significant Deficiency Personnel Responsible for Section 8 Director Corrective Action: Completion Date: January 31, 2025 Corrective Action Plan: We acknowledge that while reviews of moved-out individuals are occurring, there was insufficient documentation to support this process. We understand the importance of maintaining clear and accessible records to demonstrate our compliance and due diligence. To address this finding and implement the best practice recommendations, we will take the following steps: 1. Documentation Protocol: • Implement a standardized documentation process for move-out reviews. • Create a digital log that records the date of review, the reviewer's name, and the outcome of each review. • Ensure all documentation is easily accessible for future audits and internal reviews. 2. Monthly Landlord Verification: • Establish a monthly process to contact a sample of 3-5 landlords. • Provide these landlords with a current tenant listing for their properties. • Request verification of occupancy status for each listed tenant. • Document all responses and follow up on any discrepancies identified. 3. Move-Out Tracking: • Strengthen our move-out tracking procedures to ensure timely submission of Form HUD-50058. • Implement a system of alerts or reminders to prompt staff when 50058 submissions are due. • Conduct regular internal audits to verify the timeliness of 50058 submissions. 4. Training: • Provide comprehensive training to all relevant staff on the new documentation and verification processes. • Emphasize the importance of timely 50058 submissions and accurate move-out tracking.
With the addition of personnel, the finance team has been restructured to allow for a more streamlined month-end process. As part of the month-end process we have implemented more collaborative and robust communication between the grants management and finance teams to ensure accuracy in our grant m...
With the addition of personnel, the finance team has been restructured to allow for a more streamlined month-end process. As part of the month-end process we have implemented more collaborative and robust communication between the grants management and finance teams to ensure accuracy in our grant management process.
We are taking immediate, multi-layered action to strengthen financial stability and restore a positive operating balance. The Board of Directors is establishing an emergency fundraising committee to raise $1 million over the next nine months. The committee is composed of current and former board mem...
We are taking immediate, multi-layered action to strengthen financial stability and restore a positive operating balance. The Board of Directors is establishing an emergency fundraising committee to raise $1 million over the next nine months. The committee is composed of current and former board members, as well as long-standing influential supporters, who have a provden ability to mobilize resources quickly. In parallel, we are convening a staff leadership committee composed of the organization's most experienced and innovative staff to design and advance high-quality proposals to private foundations, building on our strong track record of successful grant-making partnerships.
The untimely completion of bank reconcilations during the audit period was due to changes in staffing and a transition to a new credit card provider, which created delays in the reconcilation process. To address this, the organization has implemented a calendar-based tracking system to ensure that a...
The untimely completion of bank reconcilations during the audit period was due to changes in staffing and a transition to a new credit card provider, which created delays in the reconcilation process. To address this, the organization has implemented a calendar-based tracking system to ensure that all reconciliations are completed and documented promptly each month. In addition, reconcilation responsibilities have been reassigned and reinforced through updated financial procedures. Managment believes that these steps will ensure reconciliations are completed within the required timeframe moving forward and the risk of untimely reconciliations will be mitigated.
Finding # 2025-001 Type: Immaterial noncompliance U.S. Department of Commerce, National Oceanic and Atmospheric Administration Assistance Listing #11.441 Finding: The Organization’s fiscal policies and procedures do not meet the required federal standards for procurement set out at 2 CFR sections 20...
Finding # 2025-001 Type: Immaterial noncompliance U.S. Department of Commerce, National Oceanic and Atmospheric Administration Assistance Listing #11.441 Finding: The Organization’s fiscal policies and procedures do not meet the required federal standards for procurement set out at 2 CFR sections 200.318 through 200.327. The Organization's procurement policy must have documented procurement procedures, consistent with state, local, and tribal laws and regulations for the acquisition of property or services required under a federal award or subaward. The Organization should maintain records sufficient to detail the history of procurement. Corrective Action: Management will work on revising the Organization’s procurement policies to incorporate the necessary provisions. Anticipated Completion Date December 2025
The Organization recognizes that subrecipient agreements must include all elements required by 2 CFR 200.332(b)(1). To address this, management will update the standard subrecipient agreement template to incorporate each required element and will adopt a checklist to be used during the agreement dra...
The Organization recognizes that subrecipient agreements must include all elements required by 2 CFR 200.332(b)(1). To address this, management will update the standard subrecipient agreement template to incorporate each required element and will adopt a checklist to be used during the agreement drafting and review process to ensure completeness. Staff responsible for preparing and executing subrecipient agreements will receive training on Uniform Guidance requirements. These steps will ensure that all subrecipient agreements fully comply with Federal regulations going forward.
U.S. Department of Justice 2024-005 Congressionally Mandated Awards – Assistance Listing No. 16.753 Recommendation: We recommend that the County develop internal controls and procedures to ensure drawdowns are performed in a manner to minimize the time between drawing and disbursing federal funds Ex...
U.S. Department of Justice 2024-005 Congressionally Mandated Awards – Assistance Listing No. 16.753 Recommendation: We recommend that the County develop internal controls and procedures to ensure drawdowns are performed in a manner to minimize the time between drawing and disbursing federal funds Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Fiscal Clerk has been trained on proper drawdown of grant funds and accurate recording of expenditures. Name of the contact person(s) responsible for corrective action: District Attorney Fiscal Clerk Planned completion date for corrective action plan: 12/31/25
U.S. Department of Housing and Urban Development 2024-004 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that the County develop internal controls and procedures to ensure that FFATA reporting requirements are met and ensure that all required subaward...
U.S. Department of Housing and Urban Development 2024-004 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that the County develop internal controls and procedures to ensure that FFATA reporting requirements are met and ensure that all required subawards are reported accurately and timely to FSRS or SAM.gov. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All of our 2024 grants have been entered into FFATA and our 2025 grants and going forward will be entered when awarded. Name of the contact person(s) responsible for corrective action: Director of Community Development Planned completion date for corrective action plan: 5/22/25
Federal Program: Head Start – ALN 93.600 / 93.356 Awarding Agency: U.S. Department of Health and Human Services (DHHS), Administration for Children and Families (ACF) Finding Reference Number: 2024-001 Condition The SF-425 Federal Financial Report for the period ending December 31, 2024, which was d...
Federal Program: Head Start – ALN 93.600 / 93.356 Awarding Agency: U.S. Department of Health and Human Services (DHHS), Administration for Children and Families (ACF) Finding Reference Number: 2024-001 Condition The SF-425 Federal Financial Report for the period ending December 31, 2024, which was due on January 30, 2025, was submitted late on February 7, 2025. Corrective Action Plan Christian Military Academy, Inc. acknowledges this finding and has implemented corrective measures to ensure compliance with future reporting deadlines: 1. Enhanced Monitoring of PMS Submissions – A reporting calendar with reminders has been established to track all SF-425 deadlines and submission confirmations through the Payment Management System (PMS). 2. Secondary Reviewer – A second staff member has been assigned to review and confirm timely report submissions before each deadline. 3. System Contingency Plan – In the event of PMS malfunctions or access issues, management will immediately notify DHHS/ACF program officers in writing and retain evidence of the communication on or before the due date. 4. Staff Training – Fiscal staff responsible for federal reporting have been trained on the importance of timely submission and the procedures to follow in case of technical issues. Responsible Official Maribel Batista Marrero Christian Military Academy, Inc. Anticipated Completion Date The corrective actions have been implemented as of October 2025 and will remain in place on an ongoing basis.
Finding Number: 2024-001 Finding Title: Cash Management - WIC Reimbursement to Member Counties Program: Special Supplemental Nutrition Program for Women, Infants, and Children Name of Contact Person Responsible for Corrective Action : Brandon Nelson Corrective Action Planned: Set up an internal poli...
Finding Number: 2024-001 Finding Title: Cash Management - WIC Reimbursement to Member Counties Program: Special Supplemental Nutrition Program for Women, Infants, and Children Name of Contact Person Responsible for Corrective Action : Brandon Nelson Corrective Action Planned: Set up an internal policy where any payment remittance advices' must be responded to and completed within two weeks of receipt to ensure that payments are deposited, and member counties of the CHB are reimbursed for the expenses that were submitted for in a prompt manner. Anticipated Completion Date: August 15, 2025
FISCAL YEAR OF FINDING: December 31, 2024 AUDITOR FINDING: 2024-001 The Authority is responsible for determining client eligibility and entering data into the State of Colorado’s WIC COMPASS system. Although the Medicaid ID number is required for individuals with adjunct eligibility, it is not a man...
FISCAL YEAR OF FINDING: December 31, 2024 AUDITOR FINDING: 2024-001 The Authority is responsible for determining client eligibility and entering data into the State of Colorado’s WIC COMPASS system. Although the Medicaid ID number is required for individuals with adjunct eligibility, it is not a mandatory field in COMPASS. Therefore, eligibility can be processed without entering this number. Testing revealed that the Authority did not consistently follow established controls requiring documentation of the state case ID for individuals deemed eligible based on participation in other state programs. Since the Medicaid ID number is not a required field in the COMPASS system, eligibility determinations can be processed without it. The system lacks reporting capabilities to identify missing entries in this field. Additionally, due to a high caseload, the Authority does not have the capacity to conduct 100% case reviews for all clients served. It is recommended that the Authority expand existing case reviews to include five participant records per month per staff member. The results should be incorporated into annual performance evaluations. Additionally, we recommend enhanced training for all staff involved in eligibility determinations. CLIENT PLANNED ACTION: The Authority will implement the following corrective actions: • Denver Health WIC leadership will perform random record reviews of 5 participant records per month per staff member to ensure compliance with Colorado WIC Policies, including accurate income and eligibility documentation. • Include the results of the reviews, including adjunctive eligibility screen, from the 5 reviews per month in the annual employee performance evaluation and communicate the importance of documenting the Medicaid ID. • All Denver Health WIC staff will complete a new training on income determination and documentation. This training will be released by the state WIC office by the end of October 2025 and all staff should complete this training by the end of December 2025. Completion of this training will be documented with an acknowledgment signed by the WIC staff and maintained by the Denver Health WIC Program Manager. CLIENT RESPONSIBLE PARTY: Kate Bennett, WIC Program Manager COMPLETION DATE: 12/31/2025
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-005: • Heart City Health Center, Inc. will refine and change controls that deal with tracking of when expenses are incurred to confirm that no drawdown receipt is received before then...
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-005: • Heart City Health Center, Inc. will refine and change controls that deal with tracking of when expenses are incurred to confirm that no drawdown receipt is received before then or in the incorrect grant period
View Audit 369664 Questioned Costs: $1
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