Corrective Action Plans

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Finding 3157 (2023-002)
Significant Deficiency 2023
Lisa Chaney, Mandy Edwards, Nicole Victory and Debbie McGuire Management will review cases internally to ensure proper documentation is in place for eligibility. Staff will be provided with refresher training on what information should be included in case files and the importance of this being compl...
Lisa Chaney, Mandy Edwards, Nicole Victory and Debbie McGuire Management will review cases internally to ensure proper documentation is in place for eligibility. Staff will be provided with refresher training on what information should be included in case files and the importance of this being complete and accurate. Management will review and revise current procedures in place to ensure that all eligibility determination criteria is completed such as online verifications, documented resources and amounts are accurately reflected and retained in the case file within the NC FAST Case Management System. Training will be completed by November 17th, 2023
Finding 3156 (2023-001)
Significant Deficiency 2023
Lisa Chaney, Mandy Edwards, Nicole Victory and Debbie McGuire Management will review cases internally to ensure proper documentation is in place for eligibility. Staff will be provided with refresher training on what information should be included in case files and the importance of this being compl...
Lisa Chaney, Mandy Edwards, Nicole Victory and Debbie McGuire Management will review cases internally to ensure proper documentation is in place for eligibility. Staff will be provided with refresher training on what information should be included in case files and the importance of this being complete and accurate. Management will review and revise current procedures in place to ensure that all eligibility determination criteria is completed such as online verifications, documented sources of income/resources and amounts are accurately reflected and retained in the case file within the NC FAST Case Management System. Training will be completed by November 17th, 2023
Finding 3155 (2023-005)
Significant Deficiency 2023
Finding: 2023-005 Name of contact person: Corrective Action: Proposed Completion Date: YCHSA has revamped onboarding of new Medicaid staff to include individual staffing's with employee and their supervisor at least three times each week for a minimum of four months. These staffing's would include d...
Finding: 2023-005 Name of contact person: Corrective Action: Proposed Completion Date: YCHSA has revamped onboarding of new Medicaid staff to include individual staffing's with employee and their supervisor at least three times each week for a minimum of four months. These staffing's would include direct education on when Child Support referrals are necessary and how to document. YCHSA is in the process of hiring an Eligibility Trainer to assist with onboarding of new staff, provide refresher trainings for established staff and conduct second party reviews. When issues are noted by the Trainer, they will notify the respective supervisor and provide follow-up training as needed (either in an individual or group setting). Knowledge checks will be administered following group training to determine if knowledge has increased. If not, supervisors will follow up with individual training on appropriate Child Support referrals. YCHSA will continue to utilize policy portal for needed clarification on policy interpretation. YCHSA will send training requests to the Operational Support Team at least quarterly. The onboarding process for YCHSA is an ongoing process. A training will be provided on the Single County Audit findings before 11/30/23. YCHSA will begin the hiring process for the Eligibility Trainer during the week of 10/30/23.
Finding 3154 (2023-004)
Significant Deficiency 2023
Finding: 2023-004 Name of contact person: Corrective Action: Proposed Completion Date: Jessica Wall, Director YCHSA has revamped onboarding of new Medicaid staff to include individual staffing's with employee and their supervisor at least three times each week for a minimum of four months. These sta...
Finding: 2023-004 Name of contact person: Corrective Action: Proposed Completion Date: Jessica Wall, Director YCHSA has revamped onboarding of new Medicaid staff to include individual staffing's with employee and their supervisor at least three times each week for a minimum of four months. These staffing's would include direct education on what information should be used to accurately determine eligibility and how to document said information. YCHSA is in the process of hiring an Eligibility Trainer to assist with onboarding of new staff, provide refresher trainings for established staff and conduct second party reviews. When issues are noted by the Trainer, they will notify the respective supervisor and provide follow-up training as needed (either in an individual or group setting). Knowledge checks will be administered following group training to determine if knowledge has increased. If not, supervisors will follow up with individual training on appropriate requests for information. YCHSA will continue to utilize policy portal for needed clarification on policy interpretation. YCHSA will send training requests to the Operational Support Team at least quarterly. The onboarding process for YCHSA is an ongoing process. A training will be provided on the Single County Audit findings before 11/30/23. YCHSA will begin the hiring process for the Eligibility Trainer during the week of 10/30/23.
Finding 3153 (2023-003)
Significant Deficiency 2023
Finding: 2023-003 Name of contact person: Corrective Action: Proposed Completion Date: Jessica Wall, Director YCHSA has revamped onboarding of new Medicaid staff to include individual staffing's with employee and their supervisor at least three times each week for a minimum of four months. These sta...
Finding: 2023-003 Name of contact person: Corrective Action: Proposed Completion Date: Jessica Wall, Director YCHSA has revamped onboarding of new Medicaid staff to include individual staffing's with employee and their supervisor at least three times each week for a minimum of four months. These staffing's would include direct education on what resources are used to accurately determine eligibility and how to document said resources. YCHSA is in the process of hiring an Eligibility Trainer to assist with onboarding of new staff, provide refresher trainings for established staff and conduct second party reviews. When issues are noted by the Trainer, they will notify the respective supervisor and provide follow-up training as needed (either in an individual or group setting). Knowledge checks will be administered following group training to determine if knowledge has increased. If not, supervisors will follow up with individual training on inaccurate resource entry. YCHSA will continue to utilize policy portal for needed clarification on policy interpretation. YCHSA will send training requests to the Operational Support Team at least quarterly. The onboarding process for YCHSA is an ongoing process. A training will be provided on the Single County Audit findings before 11/30/23. YCHSA will begin the hiring process for the Eligibility Trainer during the week of 10/30/23.
Finding 3152 (2023-002)
Significant Deficiency 2023
Finding: 2023-002 Name of contact person: Corrective Action: Proposed Completion Date: Jessica Wall, Director The Yadkin County Human Services Agency (YCHSA) has revamped onboarding of new Medicaid staff to include individual staffing's with employee and their supervisor at least three times each we...
Finding: 2023-002 Name of contact person: Corrective Action: Proposed Completion Date: Jessica Wall, Director The Yadkin County Human Services Agency (YCHSA) has revamped onboarding of new Medicaid staff to include individual staffing's with employee and their supervisor at least three times each week for a minimum of four months. These staffing's would include direct education on what information is used to accurately determine eligibility and how to document said actions. YCHSA is in the process of hiring an Eligibility Trainer to assist with onboarding of new staff, provide refresher trainings for established staff and conduct second party reviews. When issues are noted by the Trainer, they will notify the respective supervisor and provide follow-up training as needed (either in an individual or group setting). Knowledge checks will be administered following group training to determine if knowledge has increased. If not, supervisors will follow up with individual training on inaccurate information entry. YCHSA will continue to utilize policy portal for needed clarification on policy interpretation. YCHSA will send training requests to the Operational Support Team at least quarterly. The onboarding process for YCHSA is an ongoing process. A training will be provided on the Single County Audit findings before 11/30/23. YCHSA will begin the hiring process for the Eligibility Trainer during the week of 10/30/23.
Item 2023-001: Compliance with Client Placement on the Sliding Fee Scale for the Health Center Cluster Program Corrective Active Plan: Implementation of Phreesia software will flag any placement discrepancies. Front Desk Staff has completed and signed off of an intensive two-week training. All front...
Item 2023-001: Compliance with Client Placement on the Sliding Fee Scale for the Health Center Cluster Program Corrective Active Plan: Implementation of Phreesia software will flag any placement discrepancies. Front Desk Staff has completed and signed off of an intensive two-week training. All front desk has been properly trained and will have ongoing and refresher training as needed. Front Desk Staff are required to check their work at the end of the day. We have a dedicated staff member who double checks each SFS registration. The corrected registration packet is returned to the corresponding Office Manager who reviews the corrections with the Front Desk staff member. The Front Desk staff member will make the noted corrections themselves. Front Desk will experience disciplinary action for continued incorrect placements such as write ups, or termination. We conduct an Eligibility Audit on a monthly basis. A report consisting of errors by facility as well as the employee responsible for the errors will be given to office managers and key administrative staff. The information collected is reported during our monthly CPI Committee meetings. Estimated Completion Date: Ongoing Responsible Party Contact Information: Jolene Busby Jbusby@hcmtx.org 936-591-8380 Ext 109
Finding 2023-003: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Voucher Assistance Listing Number: 14.871 Noncompliance – N. Special Tests and Provisions – Housing Quality Standards Non Compliance Material to the Financial Statemen...
Finding 2023-003: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Voucher Assistance Listing Number: 14.871 Noncompliance – N. Special Tests and Provisions – Housing Quality Standards Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance for Special Tests and Provisions Criteria: Housing Quality Standards Inspections. The PHA must inspect the unit leased to a family at least annually to determine if the unit meets the Housing Quality Standards (HQS) and the PHA must conduct quality control re-inspections. The PHA must prepare a unit inspection report (24 CFR sections 982.158(d) and 982.405(b)). For units that fail inspection the PHA must correct all life threatening HQS deficiencies within 24 hours and all other deficiencies within 30 days. Condition: Based upon inspection of the Authority’s files and on discussions with management, the Authority did not properly abate thirteen (13) out of twenty-five (25) annual failed inspections selected for testing. Context: The Authority did not properly abate thirteen (13) out of twenty-five (25) failed inspections selected for testing. As a result, the Authority was not in compliance with the HQS as required by 24 CFR sections 982.158(d) and 982.405(b). Known Questioned Costs: $66,242 Cause: There is a material weakness in internal controls over compliance for the special tests and provisions type of compliance related to HQS inspections. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that assures the program is in compliance. Effect: The Section 8 Housing Choice Vouchers Program is in material non-compliance with the special tests and provisions type of compliance related to HQS inspections. Recommendation: We recommend the Authority design and implement internal control procedures that will assure compliance with the Uniform Guidance and the compliance supplement. Authority Response: We agree with the Auditor’s observations on the re-inspection of the failed units. Based on the auditor’s recommendation, the Authority will implement a more stringent oversight to ensure that internal control policies are being followed in a timely manner to show improvement in this area. In addition, the Authority has recently hired a HQS inspector in the Leasing and Occupancy department, which will assist to improve the quality control component of the program. Further the Authority is actively seeking to fill the vacant Director and Supervisor positions in the L&O department, to improve the entire operation function of this department.
View Audit 5108 Questioned Costs: $1
Finding 2023-002: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Emergency Housing Vouchers Assistance Listing Number: 14.EHV Noncompliance – E. Eligibility - Tenant Files Non Compliance Material to the Financial Statements: No Significant deficiency in Int...
Finding 2023-002: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Emergency Housing Vouchers Assistance Listing Number: 14.EHV Noncompliance – E. Eligibility - Tenant Files Non Compliance Material to the Financial Statements: No Significant deficiency in Internal Control over Compliance for Eligibility Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). Condition: Based upon inspection of the Authority’s files and on discussions with management there were documents that were unavailable for examination at the time of audit. Context: Of a sample size of six (6) tenant files, the following information was unavailable for examination at the time of audit: • Annual 50058 form • Annual inspection form Our sample size is statistically valid. Known Questioned Costs: $1,775 Cause: There is a significant deficiency in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority has not properly considered and designed a system of internal controls that reasonably assures the program is in compliance. Effect: The Emergency Housing Vouchers Program is in non-compliance with the eligibility type of compliance related to the maintenance of tenant files. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. Authority Response: We agree with the Auditor’s observations on the inspection of the tenant files and will implement internal control procedures that will assure tenant file compliance. Views of responsible officials and planned corrective action: The PHA has taken into consideration the Auditor’s recommendation in regards to Emergency Housing Vouchers (EHV) program. During the audit period, the staff assigned to the EHV program changed three times, resulting in program deficiencies. Currently a more skilled tenant interviewer is responsible for voucher processing, therefore program compliance will be in line with HUD requirement.
View Audit 5108 Questioned Costs: $1
2023-005 PROCUREMENT/SUSPENSION AND DEBARMENT Federal agency: U.S. Department of Agriculture Federal program title: Child Nutrition Cluster CFDA Number: 10.553, 10.555, and 10.559 Pass-Through Agency: Minnesota Department of Education Pass-Through Number(s): 1-0381-000 Award Period: July 1, 2022 – ...
2023-005 PROCUREMENT/SUSPENSION AND DEBARMENT Federal agency: U.S. Department of Agriculture Federal program title: Child Nutrition Cluster CFDA Number: 10.553, 10.555, and 10.559 Pass-Through Agency: Minnesota Department of Education Pass-Through Number(s): 1-0381-000 Award Period: July 1, 2022 – June 30, 2023 Type of Finding: • Material Weakness in Internal Control over Compliance and Compliance CORRECTIVE ACTION PLAN (CAP): Recommendation: We recommend the District complete the proposal process when contracts expire to ensure they are in compliance with procurement requirements. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to the Finding: The District will continue to work on establishing a process to ensure the proposal process is completed when contracts expire. Official Responsible for Ensuring CAP: Tanner Spawn, Business Manager. Planned Completion Date for CAP: June 30, 2024.
Finding: 2023-001 Estimated Completion Date: Year Ended June 30, 2023 November 15, 2023 Pennsylvania College of Health Sciences is committed to meeting all regulatory policies and procedures related to student financial aid. Below are the changes that were implemented in March 2023 and communicat...
Finding: 2023-001 Estimated Completion Date: Year Ended June 30, 2023 November 15, 2023 Pennsylvania College of Health Sciences is committed to meeting all regulatory policies and procedures related to student financial aid. Below are the changes that were implemented in March 2023 and communicated to all staff members involved with student financial services: 1. Require the Student Account Specialist to run the Batch Assign Transmittal Communication process in the student information system immediately following each transmittal of financial aid. This will ensure communication will occur within the regulated timeframe. 2. Request that the Student Financial Services Coordinator note when loan disbursement notification e-mails are sent and alert the Student Account Specialist if notifications are not pulling in communications. These steps are monitored by the Director of Student Financial Services to ensure all updates and communication are occurring in a timely manner and in compliance with all regulations.
Management agrees with the finding. The Medical Center’s secondary review control will ensure allowable expenses are being claimed.
Management agrees with the finding. The Medical Center’s secondary review control will ensure allowable expenses are being claimed.
Management agrees with the finding. Controls will be put into place to ensure the lost revenue calculation reported properly includes and excludes all relevant information.
Management agrees with the finding. Controls will be put into place to ensure the lost revenue calculation reported properly includes and excludes all relevant information.
Finding 2023-002 - School Breakfast Program No. 10.553; Grant Period: Year Ended June 30, 2023 and National School Lunch Program - Assistance Listing No. 10.555; Grant Period: Year Ended June 30, 2023 Recommendation: The School should ensure that processes are in place to review and approve of invoi...
Finding 2023-002 - School Breakfast Program No. 10.553; Grant Period: Year Ended June 30, 2023 and National School Lunch Program - Assistance Listing No. 10.555; Grant Period: Year Ended June 30, 2023 Recommendation: The School should ensure that processes are in place to review and approve of invoices for purchases related to the breakfast and lunch program. Also, the meal counts and monthly claim reimbursements should be reviewed and confirmed by someone other than the person compiling the counts. These processes should be documented. Action Taken: Purchase orders for food and supply purchases will be filled out by the Cafeteria Manager and approved by the Chief Operating Officer (COO). Once the food is delivered, the Cafeteria Manager will submit the invoice to the COO and he will match it to the invoice and review and sign the invoice. On a monthly basis, the COO will review and approve the monthly meal counts, compiled by the Cafeteria Manager and submit the meal claim reimbursement. The COO, Craig Eichmann, will be responsible for implementing this updated process and it will be fully implemented by October 31, 2023.
Corrective Action: The Executive Director of Finance and Coordinator of Testing and Accountability & State/Federal Programs will do additional training on Title I plans and how to claim money.  We will monitor the claims quarterly to track spending for each quarter to make sure we are meeting the pe...
Corrective Action: The Executive Director of Finance and Coordinator of Testing and Accountability & State/Federal Programs will do additional training on Title I plans and how to claim money.  We will monitor the claims quarterly to track spending for each quarter to make sure we are meeting the percentages that are required by the state department. The Coordinator of Testing and Accountability & State/Federals will meet monthly with the Grants Accountant to monitor Title I.
We had used the Impact Aid Coronavirus Relief Act when submitting FY2022 and FY2023 application so had not completed a survey for several years. We will add procedures and formulas in the source census files to ensure children count of each category agrees to the application.
We had used the Impact Aid Coronavirus Relief Act when submitting FY2022 and FY2023 application so had not completed a survey for several years. We will add procedures and formulas in the source census files to ensure children count of each category agrees to the application.
Finding 2023-003 Finding Title: Student Financial Assistance Cluster Name of Contact Person: Traci Boeve, Director of Financial Aid Corrective Action: Hastings College will add additional staff as a control to the current process. The Assistant Registrar and the Office of Financial Aid will be inclu...
Finding 2023-003 Finding Title: Student Financial Assistance Cluster Name of Contact Person: Traci Boeve, Director of Financial Aid Corrective Action: Hastings College will add additional staff as a control to the current process. The Assistant Registrar and the Office of Financial Aid will be included in the receipt of the graduation file. The Assistant Registrar will confirm in NSC (National Student Clearinghouse) the file was uploaded with no errors. The Office of Financial Aid will also request a report from NSLDS, which can be compared to the file that was directly uploaded to NSC. Anticipated Date of Completion: In place for 2023-2024 school year.
Corrective Action Plan: The University has a previously established detailed policy and procedure in place to process and to accurately report status changes timely via the National Student Clearinghouse (NSC) to NSLDS. The reporting of the Initial Submission along with the Subsequent Submissions oc...
Corrective Action Plan: The University has a previously established detailed policy and procedure in place to process and to accurately report status changes timely via the National Student Clearinghouse (NSC) to NSLDS. The reporting of the Initial Submission along with the Subsequent Submissions occurs approximately 5 business days prior to the month for which the report is due. This then ensures that NSC has the opportunity to transmit the data to NSLDS within 14 days of the 1st of the month. Submission of additional rosters would not change anything as NSC only submits once per month to NSLDS. The University will continue to submit on time to NSC and will continue to monitor when NSC transmit to NSLDS. Timeline for Implementation of Corrective Action Plan: The corrective action plan was implemented as of October 2023. Contact Person Mark Powers, Registrar Finding number: 2023-001 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster CFDA #: 84.063 and 84.268 Award year: 2023
The Institute has implemented procedures to ensure all documents to support the salaries and wages charged to federal programs are prepared in accordance with the SCDE requirements.
The Institute has implemented procedures to ensure all documents to support the salaries and wages charged to federal programs are prepared in accordance with the SCDE requirements.
The Institute has implemented procedures to ensure all budget estimates used for salaries and wages are reviewed quarterly and adjustments will be made to reflect actual cost for the activity performed in accordance with the SCDE requirements.
The Institute has implemented procedures to ensure all budget estimates used for salaries and wages are reviewed quarterly and adjustments will be made to reflect actual cost for the activity performed in accordance with the SCDE requirements.
Response to Finding 2023-003 - Schedule of Expenditures of Federal Awards (SEFA) Preparation The district will strive for monthly requests for reimbursement for all applicable federal funds, thus creating awareness of the funds and potential issues before they arise. The District Director of Finance...
Response to Finding 2023-003 - Schedule of Expenditures of Federal Awards (SEFA) Preparation The district will strive for monthly requests for reimbursement for all applicable federal funds, thus creating awareness of the funds and potential issues before they arise. The District Director of Finance will be responsible for overseeing the implementation of these responses and anticipates corrective dates to be immediate. Person(s) responsible for action: Lanell Farmer/Director of Finance
Client Response: The District has started a review process to ensure all expenditures are properly documented, especially those from federally funded grants, with purchase orders and will ensure that all additional documentation to support the decisions made within the purchase order are included in...
Client Response: The District has started a review process to ensure all expenditures are properly documented, especially those from federally funded grants, with purchase orders and will ensure that all additional documentation to support the decisions made within the purchase order are included in the file for support.
As a result of the deficiency noted, the Business Services and Procurement Departments have revoked all purchasing privileges from the Magnet Program Office for a period of 90 days. All purchases, including school level purchases, must be approved by Business Services or Procurement directly. During...
As a result of the deficiency noted, the Business Services and Procurement Departments have revoked all purchasing privileges from the Magnet Program Office for a period of 90 days. All purchases, including school level purchases, must be approved by Business Services or Procurement directly. During this time, the MSAP program office personnel will undergo specific training related to federal compliance including procurement, suspension and debarment. Following this 90-Day period, the District will implement additional monitoring procedures to ensure transactions that do not qualify as “small-purchases” be performed by the District Procurement Department.
The District will implement additional internal control procedures to require the MSAP Director complete a request for reimbursement based off general ledger expenditures similar to other federal programs at the District. In addition, the District will implement additional monitoring procedures to e...
The District will implement additional internal control procedures to require the MSAP Director complete a request for reimbursement based off general ledger expenditures similar to other federal programs at the District. In addition, the District will implement additional monitoring procedures to ensure requests for reimbursement are received and reflect general ledger transactions prior to performing any drawdown of federal funds.
Accuracy of Reporting: Criteria: Management was responsible for reporting COVID-related expenditures based on the terms of the grant agreement. Condition: During compliance testing, it was identified that certain expenditures included in the final report were not accurate based on the amounts re...
Accuracy of Reporting: Criteria: Management was responsible for reporting COVID-related expenditures based on the terms of the grant agreement. Condition: During compliance testing, it was identified that certain expenditures included in the final report were not accurate based on the amounts recorded within the Organization's general ledger. Context: The COVID-related expenditures reported for the period were not accurate. Cause: Certain COVID-related expenditures had inaccuracies in the expenditures reported for Period 3 and Period 4. Effect: As a result of the condition, the Organization's required reporting for this grant was misstated, however the Organization was able to recalculate the appropriate COVID-related expenditures and, in conclusion, report that there were enough expenditures to charge to this federal award to support the propriety of all funds received. Further, the expenditures reported on the Period filings were limited to the amount of funding received. Recommendation: In the future, the Organization should ensure it implements appropriate processes and controls to ensure a review is performed prior to submission to the awarding agency. Contact: David Hildenbrand, Chief Financial Officer. Corrective Actions Taken or Planned: Management acknowledges the finding and will ensure controls are implemented to prevent this error from reoccurring. Anticipated Completion Date: By December 31, 2023.
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