Corrective Action Plans

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CORRECTIVE ACTION PLAN Finding 2022-001 Internal Control over Bank Reconciliation and Vendor Invoice Management Response: Management agrees with this recommendation and have taken steps to implement proper review and documentation for bank reconciliations and vendor invoice approvals. Person Resp...
CORRECTIVE ACTION PLAN Finding 2022-001 Internal Control over Bank Reconciliation and Vendor Invoice Management Response: Management agrees with this recommendation and have taken steps to implement proper review and documentation for bank reconciliations and vendor invoice approvals. Person Responsible: President/CEO, Finance Officer, and Program Managers Finding 2022-02 Debarred and Suspended Vendors Management Response: Management agrees with this recommendation and have taken steps to develop and implement proper internal controls. Person Responsible: Finance Officer and Program Managers Finding 2022-03 Monitoring Subcontractor Performance Management response: Management agrees with the recommendation and have scheduled training for key personnel. Person Responsible: Program Managers Finding 2022-04 Written Approval of Subcontractors Management Response: Management agrees with this recommendation and have scheduled training for key personnel. Person Responsible: President/CEO and Program Managers Finding 2022-005 Indirect Cost Allocation ? Questioned Costs Management Response: Management agrees with the need for additional grant training, especially as it applies to calculating and allocating indirect costs. However, we do have issues with the classification of expenses within the original contract and hope we can reconcile those prior to the finalization of the grant award. Person Responsible: President/CEO Finance Officer
Finding: Thirteen reports within three quarters were submitted after the required deadline. We recommend reviewing the controls in place to ensure that all future reports are submitted on time and in accordance with grant requirements. If the Organization expects that there will be a delay in the su...
Finding: Thirteen reports within three quarters were submitted after the required deadline. We recommend reviewing the controls in place to ensure that all future reports are submitted on time and in accordance with grant requirements. If the Organization expects that there will be a delay in the submission of the reports, they should obtain permission to extend the submission date from the awarding agency. Statement of Concurrence or Non-Concurrence Statement of Concurrence: HopeWorks concurs with the finding and recommendation listed above. Corrective Action HopeWorks has implemented a number of streamlined processes in which to expedite the availablity of information needed to file the funder reports more timely. These processes are not limited to electronic import of payroll and benefit entries, implementation and consistent use of Bill.com for expenditures, and prioritization of recording credit card activity. Fifteen days is a strict deadline and if for some reason reporting will be late, HopeWorks will communicate to the funder and document that communication. In FY23, we are also working to streamline the technology and our internal and departmental grant reporting processes to ensure that we are being as efficient as possible with our existing resources, both technological and human.
Finding 32304 (2022-001)
Significant Deficiency 2022
Finding 2022-001 Procurement and Suspension and Debarment AL #21.027 Coronavirus State and Local Fiscal Recovery Funds The Township has reviewed all contracts with their solicitors and added appropriate language to mitigate the risk of entering a contract with a suspended or debarred entity. ...
Finding 2022-001 Procurement and Suspension and Debarment AL #21.027 Coronavirus State and Local Fiscal Recovery Funds The Township has reviewed all contracts with their solicitors and added appropriate language to mitigate the risk of entering a contract with a suspended or debarred entity. Responsible Official: David Pribulka and Jill Lovett Anticipated Resolution Date: Immediately
Finding 32303 (2022-004)
Significant Deficiency 2022
REPRESENTATION OF CITY OF NASHWAUK CORRECTIVE ACTION PLAN Year Ended December 31, 2022 Finding Number: 2022-004 Finding Title: SEGREGATION OF DUTIES Name of Contact Person Responsible for Correcti...
REPRESENTATION OF CITY OF NASHWAUK CORRECTIVE ACTION PLAN Year Ended December 31, 2022 Finding Number: 2022-004 Finding Title: SEGREGATION OF DUTIES Name of Contact Person Responsible for Corrective Action April Kurtock, Clerk/Treasurer Corrective Action Planned The City Council will attempt to monitor transactions and structure the duties of office personnel to help ensure as much segregation of duties as possible within the City's staffing limitations and funding constraints Anticipated Completion Date Ongoing.
Finding 2022-001 Significant Deficiency in Internal Control Over Compliance ? U.S. Department of Treasury ? Coronavirus Relief Fund City Municipal Assistance ? (CFDA No. 21.019) ? Reporting (continued) Passed Through Commonwealth of Massachusetts Executive Office of Administration and Finance Nam...
Finding 2022-001 Significant Deficiency in Internal Control Over Compliance ? U.S. Department of Treasury ? Coronavirus Relief Fund City Municipal Assistance ? (CFDA No. 21.019) ? Reporting (continued) Passed Through Commonwealth of Massachusetts Executive Office of Administration and Finance Name of Person Responsible: Marie T. Laflamme, Treasurer Sharyn Riley, Auditor John Miarecki, School Director of Budget & Finance Corrective Action Planned: The City will immediately review all expenses related to the Coronavirus Relief Funds. The City will take steps to reconcile the Coronavirus Report to our General Ledger. Anticipated Completion Date: May 30, 2023
Response: Management notes that, as this is their first time receiving significant federal funding and this was one-time emergency funding rather than an ongoing award, they do not have procurement procedures in writing which adhere to 2 CFR Part 200.318(a). However, they adhered to their internal...
Response: Management notes that, as this is their first time receiving significant federal funding and this was one-time emergency funding rather than an ongoing award, they do not have procurement procedures in writing which adhere to 2 CFR Part 200.318(a). However, they adhered to their internal written procurement procedures and conflict of interest policies, followed the award guidelines, and obtained multiple bids in the selection of vendors for contracted services. Action to be taken: Management notes that, as this was one-time emergency funding rather than an ongoing award, they do not anticipate receiving federal funding in the future. As such, they do not intend to document these procedures in writing at this point. However, if they apply for federal funding again in the future, they will develop written procedures at that point. Responsible Person: Andrew Edwards, Executive Director
Response: Management notes that, as this is their first single audit and this was one-time emergency funding rather than an ongoing award, they do not have these procedures in writing. However, they followed SBA/SVOG guidelines for allowability of costs, which were researched early in the grant pr...
Response: Management notes that, as this is their first single audit and this was one-time emergency funding rather than an ongoing award, they do not have these procedures in writing. However, they followed SBA/SVOG guidelines for allowability of costs, which were researched early in the grant process, and assigned costs in accordance with those guidelines. The budget, which included all assigned costs and was approved by the Lakewood Board of Directors, was also submitted and cleared by the SVOG Compliance Team and they inquired about the allowability of any items over which the guidelines were unclear. Action to be taken: Management notes that, as this was one-time emergency funding rather than an ongoing award, they do not anticipate receiving federal funding in the future. As such, they do not intend to document these procedures in writing at this point. However, if they apply for federal funding again in the future, they will develop written procedures at that point. Responsible Person: Andrew Edwards, Executive Director
See Corrective Action Plan for chart/table.
See Corrective Action Plan for chart/table.
See Corrective Action Plan for chart/table.
See Corrective Action Plan for chart/table.
Finding 32277 (2022-001)
Significant Deficiency 2022
Department of Commerce Finding: 2022-001 Department of Commerce Response/Corrective Action Plan: The Department of Commerce agrees with this finding. These grants were conducted outside of our normal scope of operations and new grant processes had to be designed and implemented to manage this ...
Department of Commerce Finding: 2022-001 Department of Commerce Response/Corrective Action Plan: The Department of Commerce agrees with this finding. These grants were conducted outside of our normal scope of operations and new grant processes had to be designed and implemented to manage this grant programmatically and fiscally. These grant payments were paid by a batch file process through the Office of Management and Budget and not fiscally managed by the agency?s fiscal department. The agency does not intend to manage grant processes programmatically or fiscally with these processes again. Of the eight duplicate grant payments identified two of the payments were voided, two payments have been returned to the department and turned back to the Office of Management and Budget, and the remaining payments the department has either been in contact with the beneficiary on returning the funds or the beneficiaries have been turned over to the Attorney General?s Office for further follow-up. The department will turn over the remainder of the beneficiaries to the Attorney?s General?s Office if payment is not made timely. Contact Person Shawn Kessel, COO/Deputy Commissioner Anticipated Completion Date There is no anticipated completion date for enhancing our internal controls to ensure duplicated payments are not made to the recipients of federal funds due to the fact the agency does not intend to manage a grant within our department programmatically or fiscally with these processes again.
View Audit 36677 Questioned Costs: $1
Finding 32272 (2022-020)
Significant Deficiency 2022
Finding: 2022-020 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. These services were provided by a contracted vendor in two separate sites in different cities for over ten years. In October 2018, due to staffing performance concerns...
Finding: 2022-020 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. These services were provided by a contracted vendor in two separate sites in different cities for over ten years. In October 2018, due to staffing performance concerns and licensing investigations, the state ended the contract with this vendor in one city. In April 2019 the vendor ended the contract in the second city. Three Requests for Proposals have been issued since that date and no proposals were received. Market research was conducted with several potential providers and due to lack of interest, capacity concerns, workforce issues as well as the effects of the COVID-19 pandemic, the department has been unable to meet the expenditure requirements. The Department has met several times with the Federal Substance Abuse and Mental Health Services Administration regarding this issue. Currently the Department is requesting funding from the North Dakota Legislative Assembly to develop of a Pregnant and Parenting Women?s Residential Treatment Program within the Department. If approved, the Department will work to secure locations and renovate spaces that is not allowable with the Federal Funds. Contact Person: Lacresha Graham, Manager Addiction Treatment and Recovery Program and Policy Anticipated Completion Date: September 2023
View Audit 36677 Questioned Costs: $1
Finding 32267 (2022-011)
Significant Deficiency 2022
Finding: 2022-011 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. The department will work with NDIT to ensure they restart and maintain the access and security reviews. Contact Person: Tory Brabandt, Medicaid Enterprise Directo...
Finding: 2022-011 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. The department will work with NDIT to ensure they restart and maintain the access and security reviews. Contact Person: Tory Brabandt, Medicaid Enterprise Director Anticipated Completion Date: June 30, 2023
Finding 32266 (2022-010)
Significant Deficiency 2022
Finding: 2022-010 Department of Human Services Response/Corrective Action Plan: The Department agrees with the finding. When the Department had to re-procure the Medicaid Expansion MCO contract for a January 1, 2022, start date, the contract was overhauled and made much more specific in terms o...
Finding: 2022-010 Department of Human Services Response/Corrective Action Plan: The Department agrees with the finding. When the Department had to re-procure the Medicaid Expansion MCO contract for a January 1, 2022, start date, the contract was overhauled and made much more specific in terms of the MLR requirements, so we do not anticipate the same issues happening again. Below is contract language that addresses this finding. Appendix E, Article 1 10. Reporting requirements 1. MCO shall submit two reports to STATE that includes at least the following information for each MLR Reporting Year, one of which excludes the adjustments identified in (I) and (C)(3)(d) above: 1. Total incurred claims. 2. Expenditures on quality improving activities. 3. Expenditures related to activities compliant with program integrity requirements (42 C.F.R. ?438.608(a)(1) through (5), (7), (8) and (b)). 4. Non-claims costs. 5. Premium revenue. 6. Taxes, licensing, and regulatory fees. 7. Methodology(ies) for allocation of expenditures. 8. Any credibility adjustment applied. 9. The calculated MLR. 10. Any remittance owed to STATE, if applicable. 11. A comparison of the information reported in this paragraph with the audited financial report required under 42 C.F.R. ?438.3(m). 12. A description of the aggregation method used under paragraph (F) of this article. 13. The number of Member Months. 2. MCO must require any third-party vendor providing claims adjudication activities to provide all underlying data associated with MLR reporting to that MCO within 180 days of the end of the MLR Reporting Year or within 30 days of being requested by MCO whichever comes sooner, regardless of current contractual limitations, to calculate and validate the accuracy of MLR reporting. 3. Prior to ten (10) months following the applicable MLR Reporting Year, MCO must submit the report required in paragraph (I)(1) of this article based on data including eight (8) months of claims run out. 4. MCO shall attest to the accuracy of the calculation of the MLR in accordance with requirements of this article when submitting the report required under this paragraph. 2. Prior to eleven (11) months following the applicable MLR Reporting Year or a mutually agreed upon alternative date, STATE shall finalize the MLR Reporting Year with any balance due to STATE as required in paragraph (H) of this article within sixty (60) days. Contact Person: Jared Ferguson, Medicaid Expansion Administrator Anticipated Completion Date: Already Completed
Finding 32265 (2022-009)
Significant Deficiency 2022
Finding: 2022-009 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. The department will work with NDIT to ensure they restart and maintain the risk analysis and security review for MMIS. Contact Person: Tory Brabandt, Medicaid Enterpr...
Finding: 2022-009 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. The department will work with NDIT to ensure they restart and maintain the risk analysis and security review for MMIS. Contact Person: Tory Brabandt, Medicaid Enterprise Director Anticipated Completion Date: December 31, 2023
Finding 32264 (2022-008)
Significant Deficiency 2022
Department of Human Services Finding: 2022-008 Department of Human Services Response/Corrective Action Plan: The department agrees to recover payments made on unsupported claims. The department will recover payments made on unsupported claims. Contact Person: Corey Kjos, Enterprise Operations ...
Department of Human Services Finding: 2022-008 Department of Human Services Response/Corrective Action Plan: The department agrees to recover payments made on unsupported claims. The department will recover payments made on unsupported claims. Contact Person: Corey Kjos, Enterprise Operations Manager Anticipated Completion Date: June 30, 2023
View Audit 36677 Questioned Costs: $1
Finding 32263 (2022-019)
Significant Deficiency 2022
Finding: 2022-019 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. Due to Medicaid continuous enrollment requirements ending on March 30, 2023, the SPACES system will be converted back to its normal rules and this issue should not hap...
Finding: 2022-019 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. Due to Medicaid continuous enrollment requirements ending on March 30, 2023, the SPACES system will be converted back to its normal rules and this issue should not happen again. The Department will do a review of CHIP eligibility to ensure incorrect claims are identified and corrected. Claims paid in error will be adjusted to reflect the proper category of eligibility, so the applicable fund code is applied, which will apply the correct FMAP. Contact Person: Erik Elkins, Assistant Director, Medical Services Anticipated Completion Date: April 30, 2023
View Audit 36677 Questioned Costs: $1
Finding 32258 (2022-013)
Significant Deficiency 2022
Finding: 2022-013 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. The Child Care Licensing System (CCL) went live Dec. 2022, CCL will add upcoming unannounced visits to Licensing Specialist?s work que. Licensing Supervisors and the L...
Finding: 2022-013 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. The Child Care Licensing System (CCL) went live Dec. 2022, CCL will add upcoming unannounced visits to Licensing Specialist?s work que. Licensing Supervisors and the Licensing Administrator will run a monthly report to assure unannounced visits are being completed by the Licensing Specialists. Contact Person: Carmen Traeholt, Child Care Licensing Administrator Anticipated Completion Date: Completed January 2023
Finding 32257 (2022-012)
Significant Deficiency 2022
Finding: 2022-012 Department of Human Services Response/Corrective Action Plan: The Department of Health and Human Service agrees with this recommendation. The Department has been working with a developer to create a Child Care Licensing Data System to replace a paper process and multiple sprea...
Finding: 2022-012 Department of Human Services Response/Corrective Action Plan: The Department of Health and Human Service agrees with this recommendation. The Department has been working with a developer to create a Child Care Licensing Data System to replace a paper process and multiple spreadsheets. The system allows each licensing specialist to see their workflow when they log into the system. It also notifies when a reinspection is needed and will escalate the notice if the reinspection is not done timely. Contact Person: Carmen Traeholt, Child Care Licensing Administrator Anticipated Completion Date: The data system launched in December 2022.
2022-002 Recertifications 14.881 Moving to Work Demonstration Program ? Award No. OCD26401344019MTW 14.871 Housing Choice Voucher Program (Housing Voucher Cluster) ? Award No. OCD26401344019HCV Responsible Official John Hillis Director of Inspections & Property Owner Services, Systems, and Com...
2022-002 Recertifications 14.881 Moving to Work Demonstration Program ? Award No. OCD26401344019MTW 14.871 Housing Choice Voucher Program (Housing Voucher Cluster) ? Award No. OCD26401344019HCV Responsible Official John Hillis Director of Inspections & Property Owner Services, Systems, and Compliance Plan Detail After a detailed RFP process, Metro Housing has selected an outside vendor (Nan McKay) to assist with completing a backlog of regular reexaminations amassed during calendar years 2020 and 2021. The contract was signed on September 27, 2022. By clearing up this backlog of work, Metro Housing staff working on the completion of regular re-exams for the Section 8 HCVP and MTW programs will be able to renew their focus on completing current work timely and accurately. Metro Housing is also making changes to decrease caseload sizes for Program Specialists while also streamlining workflows to better internal and external communication needed to complete our tasks. The roll-out of this new setup should be complete before the end of the current calendar year. Anticipated Completion Date June 30, 2023 ? All reexaminations will be current, and past due percentages will be lowered to acceptable levels.
2022-001 Unit Inspections 14.881 Moving to Work Demonstration Program ? Award No. OCD26401344019MTW 14.871 Housing Choice Voucher Program (Housing Voucher Cluster) ? Award No. OCD26401344019HCV Responsible Official John Hillis Director of Inspections & Property Owner Services, Systems, and Com...
2022-001 Unit Inspections 14.881 Moving to Work Demonstration Program ? Award No. OCD26401344019MTW 14.871 Housing Choice Voucher Program (Housing Voucher Cluster) ? Award No. OCD26401344019HCV Responsible Official John Hillis Director of Inspections & Property Owner Services, Systems, and Compliance Plan Detail Metro Housing is converting all eligible inspections from an annual to a biennial cycle as allowed by the program. Due to the constraints of the pandemic waivers, Metro Housing was required to perform an inspection of every unit on its portfolio over a 12-month period instead of a 24-month period, which resulted in numerous delays. This shift should allow for all our inspections to be completed timely. Metro Housing also faced problems in implementing the COVID-waiver issued by HUD to allow for self-certifications of units?namely, if the owner did not provide said waiver, our only recourse would have been to terminate the HAP Contract and force the tenant to move, which was not a course of action deemed appropriate by Metro Housing leadership given the circumstances. We do not anticipate that self-certifications will be implemented again, and so this process should not be a factor moving forward with our ability to meet program requirements. Anticipated Completion Date July 1, 2023 ? All inspections will be in compliance and on a biennial schedule.
When director reviews invoice will initial. Director will continue to work on invoice retention.
When director reviews invoice will initial. Director will continue to work on invoice retention.
View Audit 32172 Questioned Costs: $1
August 5, 2022 Re: West House Corporation Project No. 016-EE-010 YE June 30, 2022 Finding 2022-001: Federal Program- Section 811: Criteria- HUD regulations require all bank accounts be fully insured up to the FDIC limit or that management monitor the bank ratings if an excess of the FDIC limit exist...
August 5, 2022 Re: West House Corporation Project No. 016-EE-010 YE June 30, 2022 Finding 2022-001: Federal Program- Section 811: Criteria- HUD regulations require all bank accounts be fully insured up to the FDIC limit or that management monitor the bank ratings if an excess of the FDIC limit exists. Corrective Action Plan: Management has transferred the excess to another bank account. Finding 2002-002: Federal program ? PRAC: Criteria ? the HUD Occupancy handbook specifies the nature and content of tenant income re/certifications. Corrective Action Plan: Management has reviewed all files, obtained required information, and corrected calculations. Site staff will be trained in correct procedures. Please let me know if you have any questions. Sincerely, Jennifer Y. Huynh Vice President
August 5, 2022 Re: West House Corporation Project No. 016-EE-010 YE June 30, 2022 Finding 2022-001: Federal Program- Section 811: Criteria- HUD regulations require all bank accounts be fully insured up to the FDIC limit or that management monitor the bank ratings if an excess of the FDIC limit exist...
August 5, 2022 Re: West House Corporation Project No. 016-EE-010 YE June 30, 2022 Finding 2022-001: Federal Program- Section 811: Criteria- HUD regulations require all bank accounts be fully insured up to the FDIC limit or that management monitor the bank ratings if an excess of the FDIC limit exists. Corrective Action Plan: Management has transferred the excess to another bank account. Finding 2002-002: Federal program ? PRAC: Criteria ? the HUD Occupancy handbook specifies the nature and content of tenant income re/certifications. Corrective Action Plan: Management has reviewed all files, obtained required information, and corrected calculations. Site staff will be trained in correct procedures. Please let me know if you have any questions. Sincerely, Jennifer Y. Huynh Vice President
August 5, 2022 Re: V.N. Housing Corporation Project No. 016-HD-013 YE June 30, 2022 Finding 2022-001: Federal Program- Section 811: Criteria- HUD regulations require all bank accounts be fully insured up to the FDIC limit or that management monitor the bank ratings if an excess of the FDIC limit exi...
August 5, 2022 Re: V.N. Housing Corporation Project No. 016-HD-013 YE June 30, 2022 Finding 2022-001: Federal Program- Section 811: Criteria- HUD regulations require all bank accounts be fully insured up to the FDIC limit or that management monitor the bank ratings if an excess of the FDIC limit exists. Corrective Action Plan: Management has transferred the excess to another bank. Please let me know if you have any questions. Sincerely, Jennifer Y. Huynh Vice President
2022-002: Contact Person: Misty Wanner, CFO Corrective Action Plan: Management will retain all documentation as required by the federal agency. Completion Date: The Organization will implement immediately.
2022-002: Contact Person: Misty Wanner, CFO Corrective Action Plan: Management will retain all documentation as required by the federal agency. Completion Date: The Organization will implement immediately.
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