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Corrective Action Plans

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Finding 1223694 (2024-002)
Material Weakness 2024
145 SO. 3RD STREET HOUSING DEVELOPMENT FUND CORPORATION
NY
HUD Housing Programs Eligibility
Management has implemented the following corrective actions to address the deficiencies noted in tenant file maintenance and eligibility determinations: A. Strengthening Recertification Compliance 1. Implementation of a Recertification Tracking System: a. A digital tracking log will be used to monit...
Management has implemented the following corrective actions to address the deficiencies noted in tenant file maintenance and eligibility determinations: A. Strengthening Recertification Compliance 1. Implementation of a Recertification Tracking System: a. A digital tracking log will be used to monitor upcoming recertifications with alerts at 90, 60, and 30 days before due dates. b. The Senior Housing Specialist will oversee timely completion and issue weekly progress reports to the Director of Asset Management. c. Non-compliant files will be flagged for immediate follow-up with tenants. d. PMCS, a third-party group, will assist with recertifications. 2. Enforcing Timely Recertifications: a. Recertifications must be completed no later than 30 days before expiration. b. Staff will receive monthly reminders, and escalation measures will be implemented for delays. 3. Quarterly Internal Audits: a. PMCS and internal staff will conduct random file audits every three months to ensure adherence. b. Deficiencies will be addressed in real-time, and corrective steps will be logged. B. Ensuring EIV System Compliance 1. Standardizing EIV Compliance Procedures: a. A formal checklist will be created for EIV report reviews, ensuring all required reports are generated before lease renewals. b. EIV data will be cross-referenced with tenant files every quarter to ensure completeness. 2. Internal Monthly EIV Reviews: a. The Senior Housing Specialist will generate and review EIV reports on the 1st of each month. b. The Director of Asset Management, Third-Party Compliance Officer (PMCS), and Senior Housing Specialist will verify compliance before reports are finalized. 3. Quarterly Compliance Reports: a. The Compliance Officer will submit a quarterly compliance report documenting completion rates and deficiencies. C. Enhancing Staff Training and Accountability 1. Mandatory Quarterly Training: a. Staff will undergo quarterly compliance training covering HUD Handbook 4350.3, recertifications, and EIV compliance. b. Training sessions will be documented, and staff performance assessed. 2. Clarification of Responsibilities: a. Staff roles will be clearly outlined in a Standard Operating Procedure (SOP) document. b. Staff will be required to acknowledge their roles in compliance processes. 3. PMCS Involvement for Training Support: a. PMCS will offer supplementary training sessions as needed. D. Documentation and Oversight Enhancements 1. Maintaining Complete and Auditable Files: a. All lease and EIV documentation will be stored both physically and digitally. b. A real-time compliance dashboard will track completion rates. 2. Routine Management Reviews: a. The Senior Housing Specialist and Director of Asset Management will conduct monthly spot checks to verify document accuracy and completion. b. Non-compliance will result in formal corrective actions.
View Audit 407198
Finding 1223693 (2024-001)
Material Weakness 2024
145 SO. 3RD STREET HOUSING DEVELOPMENT FUND CORPORATION
NY
HUD Housing Programs Material Weakness Matching / Level of Effort / Earmarking
Management will immediately reimburse the property’s operating account for the unauthorized $10,000 distribution. Procedures will be implemented to ensure that all future loan repayments and cash distributions comply with HUD surplus cash requirements and the regulatory agreement. Surplus cash calcu...
Management will immediately reimburse the property’s operating account for the unauthorized $10,000 distribution. Procedures will be implemented to ensure that all future loan repayments and cash distributions comply with HUD surplus cash requirements and the regulatory agreement. Surplus cash calculations will be reviewed and approved prior to authorizing any distributions. Staff responsible for financial oversight will receive additional training on HUD surplus cash rules to prevent recurrence.
View Audit 407198
Finding 1223690 (2024-001)
Material Weakness 2024
WHITE BUFFALO, INC.
CT
Allowable Costs / Cost Principles Internal Control / Segregation of Duties Subrecipient Monitoring
Action Taken: The Organization has re-evaluated its internal controls related to grant budgeting with Federal agencies and cost billing expectations. The updated controls will be implemented in the next fiscal year.
Action Taken: The Organization has re-evaluated its internal controls related to grant budgeting with Federal agencies and cost billing expectations. The updated controls will be implemented in the next fiscal year.
View Audit 407180
Finding 1223616 (2024-002)
Material Weakness 2024
City of Akutan
AK
Reporting Material Weakness § 200.512
Finding 2024-002 Late Reporting And Noncompliance With Reporting Requirements Name of Contact Person: Robin Stepetin, Finance Manager Corrective Action: The city has retained an audit preparation accountant to assist with year-end closing activities and audit preparation. Management will implement a...
Finding 2024-002 Late Reporting And Noncompliance With Reporting Requirements Name of Contact Person: Robin Stepetin, Finance Manager Corrective Action: The city has retained an audit preparation accountant to assist with year-end closing activities and audit preparation. Management will implement a reporting calendar that identifies key deadlines, assigns responsibilities, and includes periodic monitoring to ensure information requested by the auditors and other required financial reports are completed and submitted on time. Proposed Completion Date: December 31, 2026
View Audit 407114
Finding 1223593 (2024-002)
Material Weakness 2024
North Baltimore Local School District
OH
Procurement, Suspension & Debarment § 200.110 § 200.320
The Treasurer's Office will review all contracts and expenditures funded with Federal awards to ensure compliance with applicable procurement requirements under 2 CFR §200. Prior to entering into agreements with the Educational Service Center that will be paid from Federal funds, the District will e...
The Treasurer's Office will review all contracts and expenditures funded with Federal awards to ensure compliance with applicable procurement requirements under 2 CFR §200. Prior to entering into agreements with the Educational Service Center that will be paid from Federal funds, the District will either: • Conduct the appropriate competitive procurement process and maintain supporting documentation, or • Complete and retain the Ohio Department of Education and Workforce's Noncompetitive Proposal Request for Educational Service Center Services, when applicable.
View Audit 407040
Finding 1223589 (2024-001)
Material Weakness 2024
John Stark Regional High School
NH
Subrecipient Monitoring Reporting Significant Deficiency
We created a procedure and ensured the appropriate staff members know their responsibilities in filing time and effort documentation
We created a procedure and ensured the appropriate staff members know their responsibilities in filing time and effort documentation
View Audit 407020
Finding 1223571 (2024-004)
Material Weakness 2024
County of Imperial
CA
Reporting Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303
2024-004 Program: WIOA Cluster Federal Financial Assistance Listing Number: 17.258, 17.259, 17.277, 17.278 Federal Grantor: U.S. Department of Labor Pass-Through: California Department of Employment Development Award No. and Year: AA111008 and 2021 Compliance Requirements: Reporting Type of Finding:...
2024-004 Program: WIOA Cluster Federal Financial Assistance Listing Number: 17.258, 17.259, 17.277, 17.278 Federal Grantor: U.S. Department of Labor Pass-Through: California Department of Employment Development Award No. and Year: AA111008 and 2021 Compliance Requirements: Reporting Type of Finding: Significant Deficiency Management’s or Department’s Response: Imperial County Workforce Development Office (ICWDO) agrees with the finding. Views of Responsible Officials and Corrective Action Plan: ICWDO acknowledges the recommendation and is actively working on a remedy and on the development of formal policies as recommended, which will assist ICWDO’s fiscal team in ensuring that all reports are appropriately reconciled. ICWDO acknowledges the recommendations from finding 2021-010 related to a formalization of the Administrative/fiscal processes and protocols to ensure that procedures are consistently followed to guarantee that reports agree to the amounts recorded in the general ledger and SEFA. Additionally, the recommendation specifics that protocols to ensure the separation of duties are featured in the policy. ICWDO operates under WIOA guidelines and follows County fiscal/administrative policies. Internal policies that include formal controls and procedures to ensure that monthly reports and general ledgers are consistent, with clear segregation of duties will be formally adopted. Aspects of these policies will include: • Protocol for preparation of monthly reports by the fiscal manager, and approval and signature by ICWDO Director • Protocol for preparation of closeouts that will provide the hierarchy of development, review, and approval for future reference. • Schedule monthly closeout meetings with the fiscal department and administration to ensure that documents are reviewed separately, and issues are addressed promptly. • Protocol for Policy Committee review, comment and direction, and approval for implementation by vote of the full workforce development board. ICWDO anticipates to implement the corrective action by December 31, 2025. Name of Responsible Person: Priscilla A Lopez, ICWDB Director Implementation Date: December 31, 2025
View Audit 406996
Finding 1223570 (2024-003)
Material Weakness 2024
County of Imperial
CA
Subrecipient Monitoring § 200.1 § 200.303 § 200.331 § 200.332 § 200.414
2024-003 Program: WIOA Cluster Federal Financial Assistance Listing Number: 17.258, 17.259, 17.277, 17.278 Federal Grantor: U.S. Department of Labor Pass-Through: California Department of Employment Development Award No. and Year: AA011008 and 2019 Compliance Requirements: Subrecipient Monitoring Ty...
2024-003 Program: WIOA Cluster Federal Financial Assistance Listing Number: 17.258, 17.259, 17.277, 17.278 Federal Grantor: U.S. Department of Labor Pass-Through: California Department of Employment Development Award No. and Year: AA011008 and 2019 Compliance Requirements: Subrecipient Monitoring Type of Finding: Material Weakness Management’s or Department’s Response: Imperial County Workforce Development Office (ICWDO) agrees with the finding. Views of Responsible Officials and Corrective Action Plan: The questions from finding 2021-008 relate to a formalization of the fiscal processes and protocols. ICWDO operates under WIOA guidelines and follows Imperial County’s fiscal policies. Internal policy will be formally updated to reflect compliance with WIOA regulations, as well as Imperial County policies. These policies will include formal controls and procedures to evaluate each subrecipient’s risk of noncompliance. Once the formal procedure is drafted, it will go through the ICWDO Policy Committee for comment and direction, and then finally reviewed and approved for implementation by the full Workforce Development Board. Additionally, for any future Memorandums of Understanding (MOUs) between this Imperial County department and any outside agency, there will be an additional step to include review by Imperial County Counsel to reflect that recital around the funding source will specify the following required information: • Federal Award Identification Number • Federal award date of award to recipient by the Federal agency • Name of Federal awarding agency • CFDA Number • Specific identification of whether the award is research and development ICWDO will develop internal policies for formalizing all subrecipient monitoring process. ICWDO operates under WIOA guidelines for monitoring; therefore a formal internal policy for future contracts will be developed and implemented using the usual review and approval procedures followed by the department. ICWDO will develop a formal internal documentation system, with appropriate checks and signatures, for the evaluation and assessment of each subrecipient’s risk of noncompliance. ICWDO will utilize this formal process to properly document the risk assessment of all subrecipients. ICWDO anticipates to implement the corrective action by December 31, 2025. Name of Responsible Person: Priscilla A Lopez, ICWDB Director Implementation Date: December 31, 2025
View Audit 406996
Finding 1223557 (2024-001)
Material Weakness 2024
MUNICIPALITY OF HARRISBURG
SD
Internal Control / Segregation of Duties Procurement, Suspension & Debarment
The City of Harrisburg's Mayor, Derick Wenck, is the contact person responsible for the corrective action plan for these findings. The City of Harrisburg will develop and adopt comprehensive written policies and procedures governing the administration of federal awards including CSLFRF and future fe...
The City of Harrisburg's Mayor, Derick Wenck, is the contact person responsible for the corrective action plan for these findings. The City of Harrisburg will develop and adopt comprehensive written policies and procedures governing the administration of federal awards including CSLFRF and future federally funded programs. Policies will address procurement standards, allowable costs, financial management, dovumentation retention, subrecipient and contractor oversight, reporting requirements, and monitoring responsibilities consistent with applicable federal regulations. Key personnel involved in grant administration, accounting, and procurement will receive periodic training regarding federal compliance requirements and internal control responsibilities. Because of the size of the City of Harrisburg, the municipality can't support hiring additional staff that would be sufficient to support the internal controls needed to properly segregate duties. The Mayor, City Council members and Finance employees are aware of the problem. A full physical inventory was conducted by the department heads and compared to the 2023 inventory count. Records were updated and reported to the finance officer. A complete inventory count will be conducted at the end of each year and reported to the finance officer. Expenditures will be reviewed and the budget updated based on actuals and a budget amendment approved by City Council if necessary.
View Audit 406953
Finding 1223549 (2024-001)
Material Weakness 2024
City of Pekin
IL
Cash Management Material Weakness Reporting
Finding 2024 – 001: Restatement to Fund Balance Condition: During audit fieldwork, our testing resulted in a restatement of fund balance in order to implement GASB 96 and correct buildings, land improvements and equipment categories of capital assets that were improperly recorded in the prior year. ...
Finding 2024 – 001: Restatement to Fund Balance Condition: During audit fieldwork, our testing resulted in a restatement of fund balance in order to implement GASB 96 and correct buildings, land improvements and equipment categories of capital assets that were improperly recorded in the prior year. Plan: The City will implement internal controls to properly record leases and capital assets on a timely basis prior to audit fieldwork. Anticipated Date of Completion: Updated Capital Assets Policy adopted on May 27, 2025, and applied retroactively to May 1, 2022. Name of Contact Person: Eric Dubrowski, Finance Director Management Response: As part of its internal review of capital assets, the City implemented a revised Capital Assets Policy. The revised policy significantly reduced the number of assets required to be tracked while retaining the vast majority of capital assets on the City's books, improving compliance and increasing administrative efficiency. The City also reviews the implementation of new GASB pronouncements with its external auditors in advance of each applicable reporting period to help ensure new accounting standards are implemented accurately and timely. The GASB 96 implementation has been completed, and no additional fund balance restatements related to GASB 96 are anticipated.
View Audit 406926
Finding 1223547 (2024-005)
Material Weakness 2024
Alabama Coalition Against Domestic Violence
AL
Cash Management Internal Control / Segregation of Duties
• Formalization of grant cash receipt procedures requiring all federal drawdowns and reimbursement receipts to include supporting documentation, grant reports, reimbursement calculations, and deposit verification.• Implementation of grant-specific reconciliation procedures between reimbursement requ...
• Formalization of grant cash receipt procedures requiring all federal drawdowns and reimbursement receipts to include supporting documentation, grant reports, reimbursement calculations, and deposit verification.• Implementation of grant-specific reconciliation procedures between reimbursement requests, accounting records, bank deposits, and general ledger activity. • Centralized electronic retention of grant draw documentation and supporting financial records. • Increased supervisory review of federal revenue transactions and reimbursement support prior to recording within the accounting system. • Enhanced monitoring of grant receivable activity and reimbursement timelines. • Strengthened communication protocols between program management, grant administration, and accounting personnel to ensure accurate documentation retention. • Ongoing compliance training focused on federal award management, grant documentation standards, and internal control responsibilities. ACADV believes the corrective actions implemented significantly strengthen the organization's federal grant compliance environment and financial accountability processes.
View Audit 406922
Finding 1223546 (2024-004)
Material Weakness 2024
Alabama Coalition Against Domestic Violence
AL
Internal Control / Segregation of Duties
Development of standardized Request for Funds (RFF) procedures requmng complete supporting documentation prior to reimbursement processing. • Implementation of centralized grant file management protocols to ensure participant requests, invoices, receipts, approvals, funding justifications, and suppo...
Development of standardized Request for Funds (RFF) procedures requmng complete supporting documentation prior to reimbursement processing. • Implementation of centralized grant file management protocols to ensure participant requests, invoices, receipts, approvals, funding justifications, and supporting documentation are retained together within organized electronic grant files. • Creation of grant-specific tracking systems to monitor reimbursement requests, supporting documentation status, approval workflow completion, and payment processing. • Increased accounting and management review of federally funded disbursements to verify allowab ility, allocability, reasonableness, and documentation completeness prior to payment approval. • Enhanced coordination between program staff and accounting personnel to ensure participant support documentation is submitted timely and maintained appropriately.• Implementation of additional compliance monitoring procedures aligned with 2 CFR Part 200 requirements. • Expanded training efforts related to federal grant compliance, documentation retention, and reimbursement processing standards.• Establishment of supervisory review controls to ensure disbursement support is reconciled to accounting records and grant reimbursement activity. ACADV is committed to maintaining stronger internal controls surrounding federally funded expenditures and ensuring future grant activity is supported by complete and accessible documentation.
View Audit 406922
Finding 1223490 (2024-004)
Material Weakness 2024
Mesalands Community College
NM
Matching / Level of Effort / Earmarking Subrecipient Monitoring Reporting
The foundation is working on completing audits for FY21. The OSA included foundation audits for FY22, FY23, and now FY24. At the conclusion of the FY21 foundation audit, the foundation and Mesalands will meet with the OSA to determine next steps. The foundation and the college will work to reconcile...
The foundation is working on completing audits for FY21. The OSA included foundation audits for FY22, FY23, and now FY24. At the conclusion of the FY21 foundation audit, the foundation and Mesalands will meet with the OSA to determine next steps. The foundation and the college will work to reconcile the balance of this endowment and get the correct amount recorded. Responsible staff: Director of Finance and MCC Foundation Coordinator. Expected date of compliance: June 30, 2026.
View Audit 406851
Finding 1223489 (2024-005)
Material Weakness 2024
Mesalands Community College
NM
Subrecipient Monitoring Reporting
On completion of audits the college has made significant progress in reporting for the Federal Department of Education. The timeline of late submissions has grown shorter over the last 2 audits. Responsible staff: President and Director of Finance. Expected date of compliance: FY25 information due i...
On completion of audits the college has made significant progress in reporting for the Federal Department of Education. The timeline of late submissions has grown shorter over the last 2 audits. Responsible staff: President and Director of Finance. Expected date of compliance: FY25 information due in March, 2026 is expected to be on time.
View Audit 406851
Finding 1223484 (2024-004)
Material Weakness 2024
Henry County Board of Education
AL
Matching / Level of Effort / Earmarking Special Tests & Provisions
The Board should comply with Title 29, U. S. Code of Federal Regulations, Part 5, Sub-Part A Davis Bacon and Related Acts Provisions and Procedures (the “Davis-Bacon Act”) when using COVID-19 Education Stabilization Funds to fund construction contracts in excess of $2,000.00 with the use of mechanic...
The Board should comply with Title 29, U. S. Code of Federal Regulations, Part 5, Sub-Part A Davis Bacon and Related Acts Provisions and Procedures (the “Davis-Bacon Act”) when using COVID-19 Education Stabilization Funds to fund construction contracts in excess of $2,000.00 with the use of mechanics and laborers.
View Audit 406850
Finding 1223478 (2024-001)
Material Weakness 2024
Utah Navajo Health System, Inc.
UT
Reporting Significant Deficiency
Finding # 2024-001 Response - UNHS experienced turnover in a key position within the finance department, which resulted in delays in the completion of the annual financial statement audit and SF-SAC filing. UNHS will implement additional internal controls to prevent future late submissions to the SF...
Finding # 2024-001 Response - UNHS experienced turnover in a key position within the finance department, which resulted in delays in the completion of the annual financial statement audit and SF-SAC filing. UNHS will implement additional internal controls to prevent future late submissions to the SF-SAC. Responsible Party - Andrew Evans, Chief Financial Officer Estimated Completion Date - On or before June 30, 2026
View Audit 406837
Finding 1223468 (2024-003)
Material Weakness 2024
City of San Buenaventura
CA
Cash Management Matching / Level of Effort / Earmarking
The City concurs with the finding. The City is committed to updating its policies and procedures for the reimbursement/drawdown process for projects funded with multiple funding sources and is committed to improving its communication between departments to prevent duplicating reimbursement and drawd...
The City concurs with the finding. The City is committed to updating its policies and procedures for the reimbursement/drawdown process for projects funded with multiple funding sources and is committed to improving its communication between departments to prevent duplicating reimbursement and drawdown requests. In fact, the City has already begun doing so. At the beginning of the current fiscal year (FY 2026), the City began split funding the Ventura Water Pure multi-funded projects at the point of preparation of requisitions, purchase orders, and invoices instead of performing the analysis and allocation after the fact as was done in the past. It was the result of this process that enabled the Accounting Division to identify duplicate reimbursements during its review of WIFIA drawdown requests. Once noted, the Accounting Division immediately communicated this issue to the Water Department, who then immediately notified the City’s Environmental Protection Agency (EPA) representative to determine next steps. Since then, in collaboration with the City’s EPA representative, the City did not draw down any WIFIA funds until the City incurred expenditures in excess of the amount overdrawn. Since implementing the above process, no additional duplicate reimbursement of drawdown requests has been noted. The City is committed to further strengthening its internal controls over cash management to prevent any such duplication of draw-down requests in the future. Additionally, the City’s Finance Department will increase collaboration with the City’s Water Department to further strengthen its grant policies and procedures and to further strengthen communication between the two departments to prevent duplicating reimbursement and drawdown requests.
View Audit 406822
Finding 1223466 (2024-001)
Material Weakness 2024
City of San Buenaventura
CA
Reporting § 200.327
The City staff will be stricter in following its established internal control procedures to ensure that all reporting requirements are met and submitted timely. The City will also establish access to the Integrated Disbursement and Information System (IDIS) for another member of the Finance Departme...
The City staff will be stricter in following its established internal control procedures to ensure that all reporting requirements are met and submitted timely. The City will also establish access to the Integrated Disbursement and Information System (IDIS) for another member of the Finance Department in a backup capacity. Where applicable, the City will request an extension from the funding agency and maintain a record of the approval when a report cannot be submitted by the due date.
View Audit 406822
Finding 1223451 (2024-103)
Material Weakness 2024
The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments
FL
Subrecipient Monitoring Procurement, Suspension & Debarment § 200.303 § 200.322 § 200.332 § 200.501 § 200.521
Concur: · 8 instances where the Government was unable to obtain Quarterly Progress Reports. As a result of the audit finding and in accordance with grant requirement, a Governor's Authorized Representative (GAR) Memo is being implemented, requiring Subrecipients to submit Quarterly Progress Reports ...
Concur: · 8 instances where the Government was unable to obtain Quarterly Progress Reports. As a result of the audit finding and in accordance with grant requirement, a Governor's Authorized Representative (GAR) Memo is being implemented, requiring Subrecipients to submit Quarterly Progress Reports within 10 days of quarter end. All reports are reviewed and retained in a centralized location for documentation and audit compliance. · 8 instances where the Government was unable to obtain completion/inspection certificate. Project inspection/certification report(s) are now required for all payment request federal fund drawdowns. The reports must now be uploaded to the Enterprise Resource Planning System (ERP) and retained in centralized location for documentation and record keeping purposes. · 8 subrecipients with no supporting documentation that VITEMA verified that subrecipients expected to be audited as required by 2 CFR part 200, subpart F. The Program will annually notify subrecipients of their audit responsibilities, monitor compliance, obtain required audit reports, and maintain documentation in a centralized location for audit and recordkeeping purposes.
View Audit 406809
Finding 1223450 (2024-102)
Material Weakness 2024
The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments
FL
Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking § 200.303
The Program agrees and has established internal controls to ensure that all Federal Funding Accountability and Transparency Act (FFATA) subaward reports exceeding 30,000 are submitted timely and reviewed by the Territorial Public Assistance Officer. Although the SAM.GOV system implemented in FY 2024...
The Program agrees and has established internal controls to ensure that all Federal Funding Accountability and Transparency Act (FFATA) subaward reports exceeding 30,000 are submitted timely and reviewed by the Territorial Public Assistance Officer. Although the SAM.GOV system implemented in FY 2024 does not track individual FFATA filing dates, VITEMA remains committed to submitting all required reports by the last day of the month following each award. A certification process has also been implemented to verify the date reports are filed and reviewed.
View Audit 406809
Finding 1223449 (2024-101)
Material Weakness 2024
The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments
FL
Special Tests & Provisions HUD Housing Programs Matching / Level of Effort / Earmarking § 200.303
The Program Integrity Unit has established SOPPs which identifies the method for identifying fraud cases, investigating cases, and developed procedures in collaborating and cooperating with legal authorities, for referring credible allegations of fraud cases to law enforcement officials.
The Program Integrity Unit has established SOPPs which identifies the method for identifying fraud cases, investigating cases, and developed procedures in collaborating and cooperating with legal authorities, for referring credible allegations of fraud cases to law enforcement officials.
View Audit 406809
Finding 1223448 (2024-100)
Material Weakness 2024
The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments
FL
Special Tests & Provisions Subrecipient Monitoring Eligibility § 200.303
To address these challenges and strengthen program integrity, DHS implemented the Provider Enrollment Application (PEA) Portal on March 2, 2026. The PEA Portal modernizes provider enrollment and revalidation by electronically collecting, storing, and maintaining required documentation in a centraliz...
To address these challenges and strengthen program integrity, DHS implemented the Provider Enrollment Application (PEA) Portal on March 2, 2026. The PEA Portal modernizes provider enrollment and revalidation by electronically collecting, storing, and maintaining required documentation in a centralized system. The portal supports retention of Medicaid Provider Agreements, screening documentation, ownership disclosures, licensure information, and other enrollment records within a single electronic repository. The PEA Portal improves document retention and accessibility, creates an electronic audit trail, and enables staff to retrieve enrollment and screening records more efficiently. It also strengthens oversight by standardizing enrollment workflows, reducing reliance on paper files, and improving documentation consistency. These enhancements better position DHS to demonstrate compliance during future audits and monitoring reviews. DHS recognizes the importance of maintaining complete, accurate, and accessible provider enrollment records. In addition to implementing the PEA Portal, DHS is strengthening policies and procedures related to provider file maintenance, document retention, and quality assurance reviews. Staff training and periodic monitoring will help ensure required enrollment documents and exclusion screening records are consistently maintained and available for inspection. DHS is committed to maintaining compliance with federal Medicaid and CHIP provider enrollment requirements and believes the corrective actions implemented, including deployment of the PEA Portal, will improve documentation controls, strengthen program integrity, and reduce the risk of similar findings in the future.
View Audit 406809
Finding 1223447 (2024-099)
Material Weakness 2024
The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments
FL
Special Tests & Provisions Subrecipient Monitoring Eligibility § 200.303
During the audit period, the Department did not complete the required ADP Risk Analysis and System Security Review for systems supporting the Medicaid Program, and certain monitoring controls were not operating at a sufficient level of precision to ensure compliance with federal requirements. To add...
During the audit period, the Department did not complete the required ADP Risk Analysis and System Security Review for systems supporting the Medicaid Program, and certain monitoring controls were not operating at a sufficient level of precision to ensure compliance with federal requirements. To address this finding, the Department recently issued Requests for Qualifications (RFQs) to seven qualified vendors to perform comprehensive security risk assessments of the Medicaid Enterprise Systems (MES), including the VIBES Eligibility and Enrollment System, Provider Enrollment Application (PEA), Pharmacy Benefit Management (PBM) solution, and related supporting systems. Vendor responses are due within three weeks, after which the Department will evaluate submissions and proceed with the procurement process. The selected vendor will conduct the required risk assessments, identify control deficiencies and security vulnerabilities, and provide recommendations to strengthen the Department's security posture and compliance framework. The Department will work collaboratively with its technology partners, system vendors, and oversight entities to implement corrective actions identified through the assessments and enhance monitoring controls to ensure ongoing compliance with applicable federal requirements.
View Audit 406809
Finding 1223446 (2024-098)
Material Weakness 2024
The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments
FL
Internal Control / Segregation of Duties Special Tests & Provisions Cash Management § 200.303
The Department has strengthened its oversight of Medicaid financial reporting through the establishment of a Director of Audits position in September 2025. The Director of Audits will work collaboratively with the Medicaid Program, Fiscal Office, and other applicable stakeholders to monitor complian...
The Department has strengthened its oversight of Medicaid financial reporting through the establishment of a Director of Audits position in September 2025. The Director of Audits will work collaboratively with the Medicaid Program, Fiscal Office, and other applicable stakeholders to monitor compliance with federal reporting requirements and ensure that adequate supporting documentation is maintained for Medicaid cost reporting activities.
View Audit 406809
Finding 1223445 (2024-097)
Material Weakness 2024
The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments
FL
Reporting Special Tests & Provisions
The purpose of this Action Plan is to establish internal controls and accountability measures to ensure the timely preparation, review, and submission of all Federal Financial Reports (FFRs) required under the Medicaid Fraud Control Unit (MFCU) grant awarded by the U.S. Department of Health and Huma...
The purpose of this Action Plan is to establish internal controls and accountability measures to ensure the timely preparation, review, and submission of all Federal Financial Reports (FFRs) required under the Medicaid Fraud Control Unit (MFCU) grant awarded by the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG). This plan is intended to prevent future reporting delays, strengthen financial oversight, and protect continued federal funding. I. Background: The MFCU experienced delays in the completion and submission of several Federal Financial Reports due primarily to delayed financial reconciliations, untimely receipt of expenditure information, staffing limitations, and insufficient coordination between programmatic and financial personnel. To address these issues, the MFCU is implementing the following corrective actions and internal controls. II. Responsibilities: MFCU Director: The Director shall: •Maintain overall responsibility for grant compliance and FFR submission. •Conduct monthly financial status meetings. •Review all grant expenditures for consistency with approved budgets. •Monitor progress toward reporting deadlines. • Escalate unresolved issues to executive leadership. •Maintain communication with HHS-OIG regarding reporting requirements. Chief Financial Officer: The CFO shall: •Ensure grant expenditures are entered and reconciled timely. •Provide monthly expenditure reports to the MFCU. •Certify expenditure data used in FFR preparation. • Respond to requests for financial information within five business days. •Participate in monthly grant reconciliation meetings. MFCU Auditor/Analyst: The Auditor/Analyst shall: •Maintain monthly grant expenditure tracking. •Reconcile expenditures against accounting records. •Verify supporting documentation. •Maintain electronic FFR support files. •Prepare draft FFRs for management review. Program Assistant: The Program Assistant shall: •Maintain the grant compliance calendar. •Track reporting deadlines. •Schedule reconciliation meetings. •Maintain submission records and correspondence. III. Monthly Internal Control Process: No later than the 5th Business Day of Each Month: The CFO shall provide: •General ledger reports. • Detailed grant expenditure reports. •Payroll allocation reports. • Outstanding obligation reports. • Budget-to-actual expenditure summaries. No later than the 10th Business Day of Each Month: The Auditor/Analyst shall: •Reconcile all expenditures. •Identify discrepancies. •Prepare a written reconciliation memorandum. No later than the 15th Business Day of Each Month: The MFCU Director and CFO shall conduct a reconciliation meeting to: •Review expenditures. •Resolve discrepancies. •Review grant spending levels. • Identify budget concerns. •Document corrective actions. Meeting minutes shall be maintained in the grant file. IV. Quarterly FFR Preparation Schedule: Forty-Five (45) Days Before FFR Due Date: •Open FFR preparation file. •Confirm reporting period expenditures. •Review approved budget categories. •Identify outstanding obligations. •Verify personnel allocations. Thirty (30) Days Before Due Date: •Draft FFR completed. •CFO receives draft for review. •Supporting documentation assembled. Twenty-One (21) Days Before Due Date: •Director conducts management review. •All questioned expenditures resolved. Fourteen (14) Days Before Due Date: •CFO provides final expenditure certification. Ten (10) Days Before Due Date: •Final FFR completed. •Submission package reviewed. Five (5) Days Before Due Date: •FFR submitted to HHS-OIG. • Confirmation of submission retained. V. Escalation Procedures: If Required Financial Information Is Not Received: 15 Days Before Deadline: Written reminder from MFCU Director to CFO. 10 Days Before Deadline Written escalation to the Attorney General and Chief Deputy Attorney General. 45 Days Before Deadline: Executive-level meeting convened to resolve outstanding issues and document corrective actions. All escalation memoranda shall be retained in the grant compliance file. VI. Performance Measures: The following performance measures shall be monitored quarterly: •100% on-time submission rate for all FFRs. • Monthly reconciliations completed by the 15th business day. •Zero unresolved expenditure discrepancies at submission. •Complete supporting documentation maintained for all reported expenditures. • Quarterly compliance review completed and documented. VII. Quarterly Management Review: The Director shall conduct a quarterly review of: •Timeliness of financial reporting. •Accuracy of submitted FFRs. •Compliance with grant requirements. •Outstanding corrective actions. Findings and recommendations shall be documented and maintained in the grant compliance file. VIII. Corrective Action Status Reporting: Beginning immediately, the MFCU shall maintain a quarterly Corrective Action Tracking Log documenting: •Action item. •Responsible party. •Due date. • Completion date. •Status. •Supporting documentation. The log shall be reviewed during monthly financial meetings and made available to HHS-OIG upon request.
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