Corrective Action Plans

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CORRECTIVE ACTION PLAN June 28, 2023 U.S. Department of Health and Human Services Muskingum Valley Health Centers (the Organization) respectfully submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Blue & Co., LLC...
CORRECTIVE ACTION PLAN June 28, 2023 U.S. Department of Health and Human Services Muskingum Valley Health Centers (the Organization) respectfully submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Blue & Co., LLC 9200 Worthington Road, Suite 200 Westerville, OH 43082 Audit period: Year ended December 31, 2022 The finding from the schedule of findings and questioned costs for the year ended December 31, 2022, is discussed below. The finding is numbered consistently with the number assigned in the Schedule. FINDING ?FEDERAL AWARD PROGRAM AUDITS 2022-001 Assistance Listing #: 93.498 Title: Reporting Condition: The completion of period 4 reporting was completed and submitted without consideration of other allowable options and the inclusion of certain allowable expenses. Action: The completion of period 4 reporting was based on guidance received from the organization?s independent public accounting firm. Management communicated with HRSA regarding a potential portal reopening for the effected reporting period to correct methods and expenses. As there were no anticipated changes in retention of funds, the portal was not reopened. Management will proceed with seeking guidance from the organization?s independent public accounting firm along with other organizations with expertise in federal funding. Anticipated Completion Date: Completed Responsible Contact Person: Paula Schlosser
Comments on the Finding and Each Recommendation: The Corporation did not file the data collection form SF-SAC as of and for the year ended July 31, 2021 with the Federal Audit Clearinghouse by the required date of April 30, 2022. Pursuant to Section 18 of the Regulatory Agreement, non-profit borrow...
Comments on the Finding and Each Recommendation: The Corporation did not file the data collection form SF-SAC as of and for the year ended July 31, 2021 with the Federal Audit Clearinghouse by the required date of April 30, 2022. Pursuant to Section 18 of the Regulatory Agreement, non-profit borrowers are to follow audit requirements specified in the OMB Compliance Supplement. The OMB Compliance Supplement requires the data collection form SF-SAC to be filed with the Federal Audit Clearinghouse in a timely manner, as required by 2 CFR 200.512. The required timeframe specified by 2 CFR 200.512 is the earlier of 30 calendar days after receipt of the auditor's report or nine months after the end of the audit period. The deadline to file the data collection form SF-SAC was April 30, 2022. Due to administrative delays, the Corporation did not file the data collection form SF-SAC by April 30, 2022. The Corporation was not in compliance with the Regulatory Agreement or the OMB Compliance Supplement. Action(s) Taken and Planned on the Finding: Management concurs with the finding and agrees with the recommendation. The data collection form SF-SAC as of and for the year ended July 31, 2021, was filed with the Federal Audit Clearinghouse on May 4, 2022. No further action is required.
Finding 41746 (2022-006)
Significant Deficiency 2022
Finding 2022-006 Name of contact person: Lyn Saunders- IMC Supervisor II Corrective Action: Training to be provided to all caseworkers to include review of SSI Medicaid- County DSS Responsibility Policy Section MA-1100 during November 2022 monthly meeting and caseworker s...
Finding 2022-006 Name of contact person: Lyn Saunders- IMC Supervisor II Corrective Action: Training to be provided to all caseworkers to include review of SSI Medicaid- County DSS Responsibility Policy Section MA-1100 during November 2022 monthly meeting and caseworker sign off sheet for timely review of SSI Termination. Proposed completion date: Ongoing ? Management will continue to monitor progress of SSI Termination Review process.
Finding 41745 (2022-005)
Significant Deficiency 2022
Finding 2022-005 Name of contact person: Melissa McDaniels ? IMC Supervisor III Corrective Action: "Training to be provided to all caseworkers to include TWN and OVS learning gateway webinars. Review of policy for exparte process and system reviews. Training to include re...
Finding 2022-005 Name of contact person: Melissa McDaniels ? IMC Supervisor III Corrective Action: "Training to be provided to all caseworkers to include TWN and OVS learning gateway webinars. Review of policy for exparte process and system reviews. Training to include retaining manual OLV hits. Including covering in detail the documentation template that is required to be completed for each case. Target 2nd parties will be complete at 2 per worker per week of cases processed within the month. Feedback shared with worker to ensure training was effective" Proposed completion date: Training will occur Nov. 2022, once the training is provided the additional 2nd parties of cases will begin and continue for 2 months into Jan 2023.
Finding 41744 (2022-004)
Significant Deficiency 2022
Finding 2022-004 Name of contact person: Melissa McDaniels ? IMC Supervisor III Corrective Action: "Training to be provided to cover IV-D Referral Policy and Process, this will include OVS ACTS review, review of policy to know when a referral is required to include if a c...
Finding 2022-004 Name of contact person: Melissa McDaniels ? IMC Supervisor III Corrective Action: "Training to be provided to cover IV-D Referral Policy and Process, this will include OVS ACTS review, review of policy to know when a referral is required to include if a client requests to be referred. A laminated desk reference will be provided at the time of training, this will have examples of when a referral is needed along with how to enter the referral within NCFAST. Update documentation template to ensure IV-D referral reason is documented within case notes as to why the referral was needed or not. This will be shared with staff at the training provided and guidelines presented as to how this is a required documentation addition. Medicaid Supervisor, Team Leads and Staff Development will complete target 2nd parties on 2 cases per worker per week that have been processed within the same month to ensure each worker is following the process of reviewing ACTs and submitting IV-D referrals when required. " Proposed completion date: Training will occur Nov. 2022, once the training is provided the additional 2nd parties of cases will begin and continue for 2 months into Jan 2023.
Finding 41743 (2022-003)
Significant Deficiency 2022
Finding 2022-003 Name of contact person: Lyn Saunders- IMC Supervisor II Corrective Action: "Training to be provided to all caseworkers to include AVS and OVS learning gateway webinars. Training will also include Financial Resources Policy and will be provided during Nov....
Finding 2022-003 Name of contact person: Lyn Saunders- IMC Supervisor II Corrective Action: "Training to be provided to all caseworkers to include AVS and OVS learning gateway webinars. Training will also include Financial Resources Policy and will be provided during Nov. 2022 monthly meeting for evidence entry on the dashboard. Accuracy check point will be completed by the caseworker by reviewing the case determinations to ensure correct tax value and liquid resource balance are entered and counted correctly prior to redetermination/application processing is completed. Second Party reviews will continue to be completed to monitor continued progress by caseworkers. " Proposed completion date: Ongoing ? Management will continue to monitor progress of inaccurate information entry.
Finding 41742 (2022-002)
Significant Deficiency 2022
Finding 2022-002 Name of contact person: Melissa McDaniels ? IMC Supervisor III, Lyn Saunders- IMC Supervisor II Corrective Action: "Training to be provided to all caseworkers to include TWN and OVS learning gateway webinars. Review of policy for exparte process and syste...
Finding 2022-002 Name of contact person: Melissa McDaniels ? IMC Supervisor III, Lyn Saunders- IMC Supervisor II Corrective Action: "Training to be provided to all caseworkers to include TWN and OVS learning gateway webinars. Review of policy for exparte process and system reviews. Training to also include Income Policy, how to review for self-employment income and utilize the income wizard to enter weekly, bi-weekly and monthly income amounts so the system will calculate the income and leave less room for user error. Documentation of what income is being evaluated to also include why certain incomes are not counted. Training to include review of Household Composition, tax filing status and how to review the determinations of each case before completing/ releasing auto holds. Target 2nd parties will be complete at 2 per worker per week of cases processed within the month. Feedback shared with worker to ensure training was effective. Training to be provided to all caseworkers to include TWN and OVS learning gateway webinars. Training will also include Income Policy and updated Job Aids will be provided during Nov. 2022 monthly meeting for evidence entry on the dashboard. Accuracy check point will be completed by the caseworker by reviewing the case determinations to ensure correct income are entered and counted correctly prior to redetermination/application processing is completed. Second Party reviews will continue to be completed to monitor continued progress by caseworkers. " Proposed completion date: Training will occur Nov. 2022, once the training is provided the additional 2nd parties of cases will begin and continue for 2 months into Jan 2023. Management will continue to monitor progress of inaccurate information entry.
Finding 41737 (2022-004)
Significant Deficiency 2022
2022-004 Eligibility ? Assistance Listing No. 84.063 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit fin...
2022-004 Eligibility ? Assistance Listing No. 84.063 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Policy and Procedures of reporting deadlines and requires has been put into action by the director of financial aid. Name(s) of the contact person(s) responsible for corrective action: Grant Pollard, Director of Financial Aid Planned completion date for corrective action plan: 11/1/2022
View Audit 38581 Questioned Costs: $1
Finding 41735 (2022-009)
Significant Deficiency 2022
2022-009 Eligibility ? Assistance Listing No. 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit fin...
2022-009 Eligibility ? Assistance Listing No. 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Policy and Procedures of reporting deadlines and requires has been put into action by the director of financial aid. Name(s) of the contact person(s) responsible for corrective action: Grant Pollard, Director of Financial Aid Planned completion date for corrective action plan: 11/1/2022
Finding 41734 (2022-008)
Significant Deficiency 2022
2022-008 Inadequate Schedule of Federal Expenditures Reporting ? Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit fi...
2022-008 Inadequate Schedule of Federal Expenditures Reporting ? Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: CFO prepared the FY 21 SEFA in advance of the 3/31/2022 Single Audit deadline. CFO will prepare the FY 22 SEFA in advance of the 3/31/2023 Single Audit deadline. Name(s) of the contact person(s) responsible for corrective action: Ashley Chancellor, CFO Planned completion date for corrective action plan: 11/1/2022
Finding 41733 (2022-007)
Significant Deficiency 2022
2022-007 Special Tests and Provisions ? Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. After year end, the College engaged CLA to assist with the GLBA pr...
2022-007 Special Tests and Provisions ? Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. After year end, the College engaged CLA to assist with the GLBA process for the next fiscal year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: College IT department is currently working with outside consultants to perform a risk assessment. Name(s) of the contact person(s) responsible for corrective action: Ashley Chancellor, CFO Planned completion date for corrective action plan: 11/1/2022
Finding 41732 (2022-006)
Significant Deficiency 2022
2022-006 Special Tests and Provisions ? Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagr...
2022-006 Special Tests and Provisions ? Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The director of financial aid works with the third-party servicer to ensure accurate student programs and program beginning dates reported to NSLDS. The financial aid office cross-references program information within the student information system. Name(s) of the contact person(s) responsible for corrective action: Grant Pollard, Director of Financial Aid Planned completion date for corrective action plan: 11/1/2022
Finding 41731 (2022-005)
Significant Deficiency 2022
2022-005 Special Tests and Provisions ? Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagr...
2022-005 Special Tests and Provisions ? Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The director of financial aid works with the third-party servicer to ensure accurate and timely enrollment updates to NSLDS. Name(s) of the contact person(s) responsible for corrective action: Grant Pollard, Director of Financial Aid Planned completion date for corrective action plan: 11/1/2022
Finding 41730 (2022-003)
Material Weakness 2022
2022-003 Eligibility ? Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College provide additional resources to ensure all compliance requirements are met. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response ...
2022-003 Eligibility ? Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College provide additional resources to ensure all compliance requirements are met. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The director of financial aid reviews the funding estimate (award package) put together by the third party servicer and signs/e-signs it to document his review. Name(s) of the contact person(s) responsible for corrective action: Grant Pollard, Director of Financial Aid Planned completion date for corrective action plan: 11/1/2022
Federal Audit Clearinghouse: CommQuest Services, Inc. and Subsidiaries. respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 2021 through June 30, 2022. The findings from the schedule of findings and questioned costs are discussed below. T...
Federal Audit Clearinghouse: CommQuest Services, Inc. and Subsidiaries. respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 2021 through June 30, 2022. The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS?FEDERAL AWARD PROGRAMS AUDITS Department of Health and Human Services 2022-001 Provider Relief Funds ? Assistance Listing No. 93.498 Recommendation: CommQuest Services, Inc. and subsidiaries management request that HHS re-open the portal so as to re-submit based on the lost revenue calculation versus based on the original reporting method which used expenditures as a basis. If unable to re-open the portal, verify for next submission to HHS, if applicable, that the organization submits report based on the lost revenue calculation. It was also recommended that CommQuest Services, Inc. and subsidiaries management review this reporting submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management agreed with the above finding and attempted to re-open the HHS portal to accurately report based on the lost revenue calculation, but given the timing of the request, were denied by HHS. Name(s) of the contact person(s) responsible for corrective action: Melissa Hoch, CFO Planned completion date for corrective action plan: October 2022 If the Federal Audit Clearinghouse or Department of Health and Human Services has questions regarding this plan, please call Melissa Hoch at 330-445-2672.
Finding 2022-004 Department of Education Education Stabilization Fund - Higher Education Emergency Relief Fund - Student Portion Federal Financial Assistance Listing #84.425F P425F200756-20A and P425F200756-20B Procurement, Suspension and Debarment Finding Summary: Eide Bailly LLP found that the U...
Finding 2022-004 Department of Education Education Stabilization Fund - Higher Education Emergency Relief Fund - Student Portion Federal Financial Assistance Listing #84.425F P425F200756-20A and P425F200756-20B Procurement, Suspension and Debarment Finding Summary: Eide Bailly LLP found that the University's procurement policy did not include all of the required elements as outlined in Uniform Guidance. Additionally, the University did not retain documentation to support the procedures it performed to ensure compliance with procurement, suspension, and debarment. Responsible Individuals: Michael Van Surksum, Vice President for Business and Finance; Elizabeth Porteous, Accountant Corrective Action Plan: Management is reviewing the Uniform Guidance set out in 2 CFR 200.317 through 200.327. 2 CFR 200 Appendix II and 2 CFR 180 and will update their policies for detailed use going forward. Anticipated Completion Date: Management hopes to have the new policy in place by December 31, 2022.
Finding 2022-003 Department of Education Education Stabilization Fund - Higher Education Emergency Relief Fund - Student Portion Federal Financial Assistance Listing #84.425E P425E200919- 20B Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Summary: Eide Bailly LLP found...
Finding 2022-003 Department of Education Education Stabilization Fund - Higher Education Emergency Relief Fund - Student Portion Federal Financial Assistance Listing #84.425E P425E200919- 20B Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Summary: Eide Bailly LLP found that the University over-awarded Higher Education Emergency Relief Fund (HEERF) funding to one student based on its determination over eligibility of the student portion of HEERF funding, which is awarded based on (1) expected family contribution and (2) enrollment status. The student was awarded based on fulltime enrollment; however, the student's enrollment status was part-time. Responsible Individuals: Michael Van Surksum, Vice President for Business and Finance; Elizabeth Porteous, Accountant; Karrie Morgan, Director of Financial Aid; Anna Heckenliable, Registrar Corrective Action Plan: Responsible Individuals above will review credit hour reports pulled from the system for accuracy to ensure no hours are duplicated. Anticipated Completion Date: Management expects this finding to be resolved by January 31, 2023.
Management response/corrective action: We will provide training to grant funded employees and their supervisors on proper time keeping and federal grant recordkeeping requirements.
Management response/corrective action: We will provide training to grant funded employees and their supervisors on proper time keeping and federal grant recordkeeping requirements.
Finding 41722 (2022-001)
Significant Deficiency 2022
2022-001 Improve Controls and Compliance over Reporting PLANNED ACTION: The County has reviewed the finding and will submit the next annual report in accordance with the most recent edition of the Project and Expenditure Report User Guide, dated 29 December 2022. PLANNED IMPLEMENTATION DATE OF CO...
2022-001 Improve Controls and Compliance over Reporting PLANNED ACTION: The County has reviewed the finding and will submit the next annual report in accordance with the most recent edition of the Project and Expenditure Report User Guide, dated 29 December 2022. PLANNED IMPLEMENTATION DATE OF CORRECTIVE ACTION: April 30, 2023 RESPONSIBLE INDIVIDUAL: Derek Ferland, County Administrator
Management response/corrective action plan: Maine school districts are required to pay the MEPERS Unfunded Actuarial Liability (UAL) contribution plus a health insurance fee for wages paid from federal funds to Teachers and Educational Technicians. In the rush to quickly hire and onboard dozens of ...
Management response/corrective action plan: Maine school districts are required to pay the MEPERS Unfunded Actuarial Liability (UAL) contribution plus a health insurance fee for wages paid from federal funds to Teachers and Educational Technicians. In the rush to quickly hire and onboard dozens of new employees who were hired in response to the pandemic, many newly hired teachers and educational technicians were not correctly coded as federally funded employees in the payroll system. The result was the requisite employer UAL contributions and health insurance fees were not paid until the error was discovered later. Procedures have been revised and the Director of Business Services now assigns payroll codes for all new hires to prevent a recurrence.
The Accounting Manager will work in conjunction with the Junior Staff Accountant and/or Grant Assistant to ensure monthly, quarterly, and semi-annual reconciliations have appropriate supporting documentation to reconcile to internal statistics and the reports include evidence of a preparer and revie...
The Accounting Manager will work in conjunction with the Junior Staff Accountant and/or Grant Assistant to ensure monthly, quarterly, and semi-annual reconciliations have appropriate supporting documentation to reconcile to internal statistics and the reports include evidence of a preparer and reviewer. Procedures will be revised as necessary and documented.
The Accounting Manger will review and revise current processes to ensure documented review of vendors and employees against Provider Trust prior to expending against federal awards. Updated procedures will be documented, and accounting staff will be trained on the new procedures.
The Accounting Manger will review and revise current processes to ensure documented review of vendors and employees against Provider Trust prior to expending against federal awards. Updated procedures will be documented, and accounting staff will be trained on the new procedures.
Written policy will be adopted to reflect the process being undertaken to minimize the time elapsing between the transfer of funds from the US Treasury. Current process of carrying out detailed analysis of anticipated expenses for the quarter will be reflected in the policy.
Written policy will be adopted to reflect the process being undertaken to minimize the time elapsing between the transfer of funds from the US Treasury. Current process of carrying out detailed analysis of anticipated expenses for the quarter will be reflected in the policy.
Finding 2022-004, Significant Deficiency and Non-Material Non-Compliance - Reporting Corrective Action Plan: Goal: To ensure US Treasury reports are submitted timely and accurately, the County will log into the US Treasury website to download and save copies of previously submitted ERAP reports. Pla...
Finding 2022-004, Significant Deficiency and Non-Material Non-Compliance - Reporting Corrective Action Plan: Goal: To ensure US Treasury reports are submitted timely and accurately, the County will log into the US Treasury website to download and save copies of previously submitted ERAP reports. Plan: The County will retain a repository with internally reviewed and uploaded reports. Performance Improvement Strategies: 1. Prior to March 10, 2023, reports that were submitted in the US Treasury website related to ERAP were not able to be saved/retained. 2. Leadership will log into the US Treasury website and download all prior reports submitted + will continue to download and save reports submitted henceforth. 3. All staff who participate in the submission of reports will sign and date the submitted report to verify internal review of information submitted. 4. Copies of reports will be stored in the shared Teams Channel for ERAP. 5. Supporting reports/documentation and meetings related to US Treasury reports will be retained via printed/signed copies. Responsible Parties: Mia Stockton, Economic Services Division Director Timeframes: Prior reports submitted will be downloaded and retained no later than 3/17/2023. Future reports/updates to reports will be retained upon submission.
Finding 2022-003, Significant Deficiency - Eligibility Corrective Action Plan: Goal: To ensure necessary Medicaid corrections are made by caseworkers in a timely manner and verified as completed by Medicaid management and/or Quality Assurance staff. Plan: The County will include a due date to the au...
Finding 2022-003, Significant Deficiency - Eligibility Corrective Action Plan: Goal: To ensure necessary Medicaid corrections are made by caseworkers in a timely manner and verified as completed by Medicaid management and/or Quality Assurance staff. Plan: The County will include a due date to the auditing tool so that correction tasks request can be tracked and monitored for completion and accurateness. Eligibility errors will be given five business days to be completed by workers and Internal Controls will be completed in 10 business days as they may require streamlining or revamping of internal processes. Performance Improvement Strategies: 1. Training will be given to supervisors, lead workers, and QA staff on proper usage and monitoring of due date requirements added to the audit tool. 2. Copies of reports will be stored in the shared Teams Channel for Medicaid Services. Responsible Parties: Marissa D. Adams, Medicaid Services Division Director Timeframes: Training for the usage of an audit tool is to be held no later than June 30, 2023, and usage of to begin immediately after is completed.
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