Corrective Action Plans

Finding 522298 (2024-003)

Significant Deficiency 2024

NM

Subrecipient Monitoring Reporting Procurement, Suspension & Debarment

2024-003 Reporting (original finding 2021-001) (Significant Deficiency in Internal Controls over Compliance) What Action(s) Will be Done: ASD staff form the Contracts and Procurement and Grant Management Bureau will work together to monitor any new activity that will need to be reported on the Feder...

2024-003 Reporting (original finding 2021-001) (Significant Deficiency in Internal Controls over Compliance) What Action(s) Will be Done: ASD staff form the Contracts and Procurement and Grant Management Bureau will work together to monitor any new activity that will need to be reported on the Federal Funding Accountability and Transparency Act (FFATA). ASD established and implemented a new contract/agreement system called Bonfire in January 2024. This system is an automated system that includes all the information that was entered on the Contract Request Form (CRF) that was previously used in the Contracts and Procurement Bureau and a copy of the proposed contract/agreement. Now, there is a specific field that can be used to track if any new contact/agreement must be reported on the FFATA. These contracts/agreements are reviewed and pre-approved in Bonfire by many HSD staff which include the Contract and Procurement Bureau Chief and the ASD Director/CFO. We can monitor the FFATA field as we review and provide information to the Grants Management Bureau Chief in real time. We can also run monthly reports to review and track this field to ensure that any new contracts/agreements were not missed to ensure timely FFATA reporting. Who Will Act: Grants Bureau Chief & Contracts and Procurement Bureau Chief When Will Action(s) be Completed: ASD will ensure that a FFATA sub-award report is submitted by the of the month following the month in which HSD awards any sub-grants greater than or equal to $30,000.

View Audit 341573

Finding 522297 (2024-006)

Significant Deficiency 2024

Commonspirit Health

IL

Allowable Costs / Cost Principles § 200.303 § 200.430

REFERENCE: 2024-006 – Allowable Costs/Cost Principles COVID-19 Coronavirus State and Local Fiscal Recovery Funds (Assistance Listing No. 21.027) Federal Grantor: Department of Treasury Facility: St. Mary Medical Center – Long Beach Finding: At St. Mary Medical Center – Long Beach, controls over th...

REFERENCE: 2024-006 – Allowable Costs/Cost Principles COVID-19 Coronavirus State and Local Fiscal Recovery Funds (Assistance Listing No. 21.027) Federal Grantor: Department of Treasury Facility: St. Mary Medical Center – Long Beach Finding: At St. Mary Medical Center – Long Beach, controls over the required allowability criteria with regard to payroll expense were not performed and/or documented throughout the year. Corrective Action Plan: At St. Mary Medical Center – Long Beach, the leadership team implemented a timecard review process to ensure timecards are properly signed off and approved each pay period, with exceptions confirmed via email from the appropriate manager. Person Responsible: Vo Phay Sin, Controller – St. Mary Medical Center, Long Beach Completion: April 2024

View Audit 341568

Finding 522295 (2024-005)

Significant Deficiency 2024

Commonspirit Health

IL

Student Financial Aid Special Tests & Provisions Reporting § 200.303

REFERENCE: 2024-005 – Special Tests and Provision – Enrollment Reporting Student Financial Assistance Cluster (Assistance listing No. 84.007, 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science Finding: Good Samaritan College...

REFERENCE: 2024-005 – Special Tests and Provision – Enrollment Reporting Student Financial Assistance Cluster (Assistance listing No. 84.007, 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science Finding: Good Samaritan College of Nursing & Health Science did not have internal controls over enrollment reporting. Student enrollment information, including enrollment status changes and campus level and program level information, was not reported accurately and/or timely to the NSLDS for certain students. Corrective Action Plan: Beginning Spring of 2024, Good Samaritan College changed their reporting cycle to include five submissions per semester. This change was encouraged as a best practice from the American Association of Collegiate Registrars and Admission Officers (AACRAO). Reporting five times within a traditional semester creates an approximate 30-day cycle from first submission to the next, keeping reporting to NSLDS well below the 60-day reporting minimum. Evidence of this will be shared in the College’s monthly Compliance Committee Meetings. To address the issues of reporting “less than half time” for students who were enrolled in zero hours, Good Samaritan College has contacted the Student Information System vendor, Ellucian, to identify a technological solution allowing the reporting of students with zero hours correctly. Until a technological solution can be found, the College Registrar will run a report to cross check against each enrollment transmission for National Student Clearinghouse identifying all students who drop to zero hours and report them as withdrawn to NSC. In turn, NSC will correctly report to NSLDS the status of withdrawn. Reporting is signed off and evidence of this will be shared in the College’s monthly Compliance Committee meetings. Person Responsible: Judy Kronenberger, President Good Samaritan College of Nursing and Health Science Expected Completion: February 2025

View Audit 341568

Finding 522294 (2024-004)

Material Weakness 2024

Commonspirit Health

IL

Eligibility Matching / Level of Effort / Earmarking § 200.303

REFERENCE: 2024-004 – Eligibility HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: U.S. Department of Health and Human Services Facility: Bailey-Boushay House Finding: The Bailey-Boushay House did not retain evidence of eligibility being reviewed prior to patie...

REFERENCE: 2024-004 – Eligibility HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: U.S. Department of Health and Human Services Facility: Bailey-Boushay House Finding: The Bailey-Boushay House did not retain evidence of eligibility being reviewed prior to patient services being provided. Corrective Action Plan: Bailey-Boushay House Administrative staff will send out upcoming Eligibility expirations occurring in the next 90 days to the Clinical Supervisor and Director of Outpatient Programs. The Clinical Supervisor will forward a list to each care manager/social worker for clients on their caseload. The Clinical Supervisor will discuss the status of these updates during meetings with care manager/social worker. Notes will be made on the caseload list to document the discussion of status. The Clinical Supervisor will send a list to the care management team for clients who are within 30 days of their expiration, in order to identify clients who may be out of contact or less engaged in the program. A note will be provided with these clients' medications to remind them that they need to complete this eligibility update with a care manager or social worker. Quarterly and monthly emails of eligibility expirations will be retained for documentation purposes. Person Responsible: Katie Hara, Director of Outpatient Programs – Bailey Boushay House Expected Completion: February 2025

View Audit 341568

Finding 522293 (2024-003)

Significant Deficiency 2024

Commonspirit Health

IL

Student Financial Aid Matching / Level of Effort / Earmarking Special Tests & Provisions § 200.303

REFERENCE: 2024-003 – Special Tests and Provisions – Return of Title IV Funds SFA Cluster (Assistance Listing No. 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science Finding: Good Samaritan College of Nursing and Health Science did no...

REFERENCE: 2024-003 – Special Tests and Provisions – Return of Title IV Funds SFA Cluster (Assistance Listing No. 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science Finding: Good Samaritan College of Nursing and Health Science did not calculate and return Title IV funds in a timely manner to the U.S. Department of Education, within 45 days after the date the institution determined that a student withdrew. Good Samaritan College of Nursing & Health Science did not provide evidence of an effective review process to ensure the timely calculation and return of Title IV funds to the U.S. Department of Education. Corrective Action Plan: Beginning in April 2024, Financial Aid Services incorporated an additional step to the return disbursement process to ensure timely returns. The additional step occurs after each return to ensure the Common Origination and Disbursement (COD) system shows the return successfully processed for the student. Financial Aid Services reviews the student’s disbursement detail history in COD to confirm the return credit adjustment has been applied to the appropriate record and it shows an applied date at ED within the appropriate timeframe for the return. To document this process has been completed, Financial Aid Services maintains a spreadsheet for all returns. The spreadsheet documents the student, amount of the return, date processed in Financial Aid and Student Accounts, date processed in G5, and date applied at ED per COD. If any issues arise during this review where the return did not successfully apply at ED, Financial Aid Services reviews and resolves rejects immediately so the record can move forward and process successfully within the required timeframe. The Dean of Financial Services validates the report submitted by Financial Aid Services on a monthly basis and submits the document to the President. Both review and sign the documentation. This documentation is presented to the GSC Compliance Oversight Committee to ensure monthly verification of time return of Title IV funds. Person Responsible: Judy Kronenberger, President Good Samaritan College of Nursing and Health Science Completion: April 2024

View Audit 341568

Finding 522292 (2024-002)

Significant Deficiency 2024

Commonspirit Health

IL

Allowable Costs / Cost Principles § 200.303 § 200.430

REFERENCE: 2024-002 – Allowable Costs/Cost Principles Medicaid Cluster (Assistance Listing No. 93.778) Federal Grantor: Health Resources and Services Administration Facility: California Hospital and Medical Center Finding: At California Hospital and Medical Center, controls over the required allo...

REFERENCE: 2024-002 – Allowable Costs/Cost Principles Medicaid Cluster (Assistance Listing No. 93.778) Federal Grantor: Health Resources and Services Administration Facility: California Hospital and Medical Center Finding: At California Hospital and Medical Center, controls over the required allowability criteria with regard to payroll expense were not performed and/or documented throughout the year. Corrective Action Plan: Emails are sent to the supervisor on the Monday after the pay period ends reminding them to sign-off on their direct reports' timecards by the deadline. If the supervisor does not sign off by the deadline a subsequent email is sent. In the email, they are asked to attest that the timecard is approved as is or corrections will be submitted. Payroll stores the overdue timecard approval attestations in Google drive. Person Responsible: Lynn Christopher, System Director Payroll Delivery Completion: July 2024

View Audit 341568

Finding 522285 (2024-001)

Material Weakness 2024

Commonspirit Health

IL

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.430

REFERENCE: 2024-001 – Allowable Costs/Cost Principles HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: Health Resources and Services Administration Facility: St. Mary Medical Center – Long Beach Bailey-Boushay House Finding: At St. Mary Medical Center – Long...

REFERENCE: 2024-001 – Allowable Costs/Cost Principles HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: Health Resources and Services Administration Facility: St. Mary Medical Center – Long Beach Bailey-Boushay House Finding: At St. Mary Medical Center – Long Beach and Bailey-Boushay House, controls over the required allowability criteria with regard to payroll expense were not performed and/or documented throughout the year. At Bailey-Boushay House, one employee’s salary that was charged to the grant was not supported by the underlying timesheet for the respective pay period and the related expenditures should not have been charged to the grant and requested for reimbursement. Corrective Action Plan: At St. Mary Medical Center – Long Beach, the leadership team implemented a timecard review process to ensure timecards are properly signed off and approved each pay period, with exceptions confirmed via email from the appropriate manager. At Bailey-Boushay House, each Friday and Monday prior to running payroll, approval reminders are sent to all staff with the time-keeping policy attached. At least two different leaders and/or the scheduling coordinator send these reminders. Staff have been educated on the two-step approval system and it will impact their performance evaluation if there is continued non-compliance. The executive director ensures supervisory follow-up with each name that shows up in the audit report each pay period by Kronos Reports. The Finance Manager reviews the timecard allocations and populates the hours charged to the grant per the timecard on to the salary allocation spreadsheet. The salary allocation spreadsheet is utilized in completing the reimbursement request. The salary allocation spreadsheet is reviewed by the Director of Outpatient Programs as part of the reimbursement request approval process. The questioned costs will be refunded by Bailey-Boushay House to the grantor in February 2025. Person Responsible: Vo Phay Sin, Controller – St. Mary Medical Center, Long Beach Rob Hays, Executive Director – Bailey Boushay House Completion: April 2024 (control implementation) Expected Completion: February 2025 (compliance corrective action)

View Audit 341568 Questioned Costs: $1

Finding 522263 (2024-003)

Material Weakness 2024

Hall County Housing Authority

NE

Subrecipient Monitoring Eligibility HUD Housing Programs

Corrective Action Plan Contact Person Artena Thompson 1834 W 7th Street Grand Island, NE 68803 (308) 385-5530 Finding 2024-001 Management has recognized the finding and will familiarize themselves with the requirements of these documents to ensure the proper procedures are followed and the proper do...

Corrective Action Plan Contact Person Artena Thompson 1834 W 7th Street Grand Island, NE 68803 (308) 385-5530 Finding 2024-001 Management has recognized the finding and will familiarize themselves with the requirements of these documents to ensure the proper procedures are followed and the proper documents are retained in the tenant files. Finding 2024-002 Management will familiarize themselves with the requirements and guidelines of their ACOP to better ensure that the Authority is operating and maintaining its policies. Finding 2024-003 See Finding 2024-001.

View Audit 341542

Finding 522255 (2024-003)

None 2024

The Open Door/cape Ann Food Pantry, Inc.

MA

HUD Housing Programs Reporting

Item # 2024-003 Reporting (Compliance Finding) Criteria: Per the grant agreement with the Department of Housing and Urban Development (HUD) the Organization must submit semi-annual performance and financial reports within 30 days of the reporting period end. Condition: Management did not submit the ...

Item # 2024-003 Reporting (Compliance Finding) Criteria: Per the grant agreement with the Department of Housing and Urban Development (HUD) the Organization must submit semi-annual performance and financial reports within 30 days of the reporting period end. Condition: Management did not submit the reports within the time period specified. Cause: Management was unaware of the thirty day deadline submit the required reports. Effect: The Organization is not in compliance with the federal award reporting requirements. Recommendation: The Organization should update its procedures to submit federal reports within the time period specified in the grant agreement. Views of Responsible Officials and Planned Corrective Actions: Management has been making updates to its policies and procedures throughout fiscal year 2025 to be in full compliance with federal award agreements and the Uniform Guidance. This exercise is anticipated to be complete by the end of fiscal year 2025.

View Audit 341522

Finding 522254 (2024-002)

Significant Deficiency 2024

The Open Door/cape Ann Food Pantry, Inc.

MA

Significant Deficiency Internal Control / Segregation of Duties

Item # 2024-002 Prepaid Expenses (Significant Deficiency in Internal Control) Criteria: Under U.S. GAAP, expenses prepaid during the fiscal year should be recorded as an asset on the statement of financial position and amortized through the remainder of the fiscal year to ensure that they are prope...

Item # 2024-002 Prepaid Expenses (Significant Deficiency in Internal Control) Criteria: Under U.S. GAAP, expenses prepaid during the fiscal year should be recorded as an asset on the statement of financial position and amortized through the remainder of the fiscal year to ensure that they are properly stated under the accrual basis of accounting. Condition: During the year under audit, the Organization did not properly reconcile the ending balance of prepaid expenses in the general ledger. Cause: Management did not take the necessary measures to reconcile prepaid expense amounts through the fiscal year to the general ledger to ensure that the ending balance of prepaid expenses was properly stated. Effect: Failure to update internal controls to comply with the requirements of U.S. GAAP could result in material misstatements of prepaid expense balances. Recommendation: The Organization should strengthen its internal control practices by updating its policies and procedures to comply with U.S. GAAP. Views of Responsible Officials and Planned Corrective Actions: Management has been making updates to its policies and procedures throughout fiscal year 2025 to be in full compliance with U.S. GAAP and the Uniform Guidance. This exercise is anticipated to be complete by the end of fiscal year 2025.

View Audit 341522

Finding 522253 (2024-001)

Significant Deficiency 2024

The Open Door/cape Ann Food Pantry, Inc.

MA

Significant Deficiency Internal Control / Segregation of Duties

Item # 2024-001 Valuation of Pledge Receivables (Significant Deficiency in Internal Control) Criteria: Under U.S. GAAP, long term pledge receivables are required to be discounted to net present value to ensure that they are properly stated under the accrual basis of accounting. Condition: During ...

Item # 2024-001 Valuation of Pledge Receivables (Significant Deficiency in Internal Control) Criteria: Under U.S. GAAP, long term pledge receivables are required to be discounted to net present value to ensure that they are properly stated under the accrual basis of accounting. Condition: During the year under audit, the Organization did not record the appropriate discount for long term pledge receivables. Cause: Management did not follow the requirements under U.S. GAAP for long term pledge receivables and did not take the necessary measures to ensure that the ending balance of long term pledge receivables was properly stated. Effect: Failure to update internal controls to comply with the requirements of U.S. GAAP could result in material misstatements of receivable balances. Recommendation: The Organization should strengthen its internal control practices by updating its policies and procedures to comply with U.S. GAAP. Views of Responsible Officials and Planned Corrective Actions: Management has been making updates to its policies and procedures throughout fiscal year 2025 to be in full compliance with U.S. GAAP and the Uniform Guidance. This exercise is anticipated to be complete by the end of fiscal year 2025.

View Audit 341522

Finding 522252 (2024-003)

Material Weakness 2024

Southeast Iowa Regional Housing Authority

IA

HQS Quality Control inspections are to be done at separate time of initial inspection, the director doing them at follow up if any issues were found at initial inspection, the director will now correct that and has made a sheet to ensure it is done correctly and will do a separate inspection after t...

HQS Quality Control inspections are to be done at separate time of initial inspection, the director doing them at follow up if any issues were found at initial inspection, the director will now correct that and has made a sheet to ensure it is done correctly and will do a separate inspection after the inspector does the initial inspection, to ensure he is following HQS standards.

View Audit 341512

Finding 522252 (2024-003)

Material Weakness 2024

Southeast Iowa Regional Housing Authority

IA

A HUD Depository agreement was not filed with our financial institution, the director has sent that to the financial institution to sign and will file that properly.

View Audit 341512

Finding 522251 (2024-001)

Significant Deficiency 2024

Central Valley Senior Housing Corporation

CA

HUD Housing Programs Internal Control / Segregation of Duties Cash Management

1. Finding 2024-001 a. Comments on the Finding and Each Recommendation Management concurs that it failed to make required deposits into the Residual Receipt account in the amount of $12,574 for the year ended June 30, 2023, and acknowledges that there was no HUD approval for non-payment. b. Action(s...

1. Finding 2024-001 a. Comments on the Finding and Each Recommendation Management concurs that it failed to make required deposits into the Residual Receipt account in the amount of $12,574 for the year ended June 30, 2023, and acknowledges that there was no HUD approval for non-payment. b. Action(s) Taken or Planned on the Finding Management has initiated a transfer of funds into the Residual Receipt account as of 9/23/2024. The General Partner has also assigned a permanent Asset Manager to ensure required payments are made in accordance with agreements.

View Audit 341509

Finding 522250 (2024-001)

Significant Deficiency 2024

San Leandro Supportive Housing, Inc.

CA

Questioned Costs HUD Housing Programs Cash Management

1. Finding 2024-001 a. Comments on the Finding and Each Recommendation Management concurs that the Project withdrew from the residual receipts reserve in the amount of $8,409 without HUD approval. Management is in agreement with the recommendation to deposit $8,409 into the residual receipts reserve...

1. Finding 2024-001 a. Comments on the Finding and Each Recommendation Management concurs that the Project withdrew from the residual receipts reserve in the amount of $8,409 without HUD approval. Management is in agreement with the recommendation to deposit $8,409 into the residual receipts reserve. b. Action(s) Taken or Planned on the Finding Management has made changes to internal controls to prevent and detect unauthorized withdrawals from reserves. Management further notes that they have re-trained staff, and reaffirmed the review and approval process to ensure required residual receipt reserve withdrawals are completed with proper HUD authorization. Management will complete the required reimbursement to the residual receipts reserve by October 31, 2024.

View Audit 341508 Questioned Costs: $1

Finding 522248 (2024-005)

Significant Deficiency 2024

Nash County

NC

Eligibility Significant Deficiency

For the Year Ended June 30, 2024 Corrective Action Plan Finding 2024-003 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-004 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-005 Name of contact person: Corrective Action: Adult - Trai...

For the Year Ended June 30, 2024 Corrective Action Plan Finding 2024-003 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-004 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-005 Name of contact person: Corrective Action: Adult - Training to be provided to all Adult Medicaid workers to include adequate request for info: Property Checks, Vehicle Rebuttals, Resolution of Vehicles, 1/3 Reduction evaluation, policy section MA-2261and FL2; MA-2270, SA-3200. Targeted second parties will be completed for all workers for error trends. Family and Children's - Training to be provided to all caseworkers to include TWN and OVS learning gateway webinars, along with a review of Magi Budgeting (Household Composition, Income Determination & Introduction to Magi Budgeting). Reminding caseworkers on the importance of documentation and if notes are not documented it didn’t happen, including detailing information out, the documentation template needs to be completed on each case. Target checks on correct income, household composition and completed documentation will be completed monthly. Section III - Federal Award Findings and Questioned Costs (continued) Angel Carpenter –Family and Children's Medicaid Supervisor; Goldie Davis - Adult Medicaid Supervisor Goldie Davis - Adult Medicaid Supervisor Training to be provided to all Adult Medicaid workers to include resource entry/documentation: Policy Section MA-2230, Liquid Resources, Life Insurance CV, Property tax value, and Vehicle tax values. Documentation Long-term care/Private Living Arrangement (PLA) template provided to workers and will be implemented at the county level to be required for all case files. PLA will implement a check list to be attached to all case files as a requirement. Targeted second parties will be completed for all workers for error trends. 12/2/2024 Angel Carpenter –Family and Children's Medicaid Supervisor Medicaid caseworkers will receive refresher training to include how to process an IV-D referral at the request of the Child Support caseworker according to policy. Caseworker will receive the DHB Admin Letter No. 13-23 “Child Support Cooperation and Applying for Other Monetary Benefits Post Eligibility Benefits During the Continuous Coverage Unwinding (CCU) handouts for review. 12/13/2024 Claude Mayo Jr. Administration Building • 120 West Washington Street, Suite 3072 • Nashville, NC 27856 Phone (252) 459-9800 • Fax (252) 459-9817 190

View Audit 341498

Finding 522247 (2024-004)

Significant Deficiency 2024

Nash County

NC

Eligibility Significant Deficiency

For the Year Ended June 30, 2024 Corrective Action Plan Finding 2024-003 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-004 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-005 Name of contact person: Corrective Action: Adult - Trai...

For the Year Ended June 30, 2024 Corrective Action Plan Finding 2024-003 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-004 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-005 Name of contact person: Corrective Action: Adult - Training to be provided to all Adult Medicaid workers to include adequate request for info: Property Checks, Vehicle Rebuttals, Resolution of Vehicles, 1/3 Reduction evaluation, policy section MA-2261and FL2; MA-2270, SA-3200. Targeted second parties will be completed for all workers for error trends. Family and Children's - Training to be provided to all caseworkers to include TWN and OVS learning gateway webinars, along with a review of Magi Budgeting (Household Composition, Income Determination & Introduction to Magi Budgeting). Reminding caseworkers on the importance of documentation and if notes are not documented it didn’t happen, including detailing information out, the documentation template needs to be completed on each case. Target checks on correct income, household composition and completed documentation will be completed monthly. Section III - Federal Award Findings and Questioned Costs (continued) Angel Carpenter –Family and Children's Medicaid Supervisor; Goldie Davis - Adult Medicaid Supervisor Goldie Davis - Adult Medicaid Supervisor Training to be provided to all Adult Medicaid workers to include resource entry/documentation: Policy Section MA-2230, Liquid Resources, Life Insurance CV, Property tax value, and Vehicle tax values. Documentation Long-term care/Private Living Arrangement (PLA) template provided to workers and will be implemented at the county level to be required for all case files. PLA will implement a check list to be attached to all case files as a requirement. Targeted second parties will be completed for all workers for error trends. 12/2/2024 Angel Carpenter –Family and Children's Medicaid Supervisor Medicaid caseworkers will receive refresher training to include how to process an IV-D referral at the request of the Child Support caseworker according to policy. Caseworker will receive the DHB Admin Letter No. 13-23 “Child Support Cooperation and Applying for Other Monetary Benefits Post Eligibility Benefits During the Continuous Coverage Unwinding (CCU) handouts for review. 12/13/2024 Claude Mayo Jr. Administration Building • 120 West Washington Street, Suite 3072 • Nashville, NC 27856 Phone (252) 459-9800 • Fax (252) 459-9817 190

View Audit 341498

Finding 522246 (2024-003)

Significant Deficiency 2024

Nash County

NC

Eligibility Significant Deficiency

For the Year Ended June 30, 2024 Corrective Action Plan Finding 2024-003 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-004 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-005 Name of contact person: Corrective Action: Adult - Trai...

For the Year Ended June 30, 2024 Corrective Action Plan Finding 2024-003 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-004 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-005 Name of contact person: Corrective Action: Adult - Training to be provided to all Adult Medicaid workers to include adequate request for info: Property Checks, Vehicle Rebuttals, Resolution of Vehicles, 1/3 Reduction evaluation, policy section MA-2261and FL2; MA-2270, SA-3200. Targeted second parties will be completed for all workers for error trends. Family and Children's - Training to be provided to all caseworkers to include TWN and OVS learning gateway webinars, along with a review of Magi Budgeting (Household Composition, Income Determination & Introduction to Magi Budgeting). Reminding caseworkers on the importance of documentation and if notes are not documented it didn’t happen, including detailing information out, the documentation template needs to be completed on each case. Target checks on correct income, household composition and completed documentation will be completed monthly. Section III - Federal Award Findings and Questioned Costs (continued) Angel Carpenter –Family and Children's Medicaid Supervisor; Goldie Davis - Adult Medicaid Supervisor Goldie Davis - Adult Medicaid Supervisor Training to be provided to all Adult Medicaid workers to include resource entry/documentation: Policy Section MA-2230, Liquid Resources, Life Insurance CV, Property tax value, and Vehicle tax values. Documentation Long-term care/Private Living Arrangement (PLA) template provided to workers and will be implemented at the county level to be required for all case files. PLA will implement a check list to be attached to all case files as a requirement. Targeted second parties will be completed for all workers for error trends. 12/2/2024 Angel Carpenter –Family and Children's Medicaid Supervisor Medicaid caseworkers will receive refresher training to include how to process an IV-D referral at the request of the Child Support caseworker according to policy. Caseworker will receive the DHB Admin Letter No. 13-23 “Child Support Cooperation and Applying for Other Monetary Benefits Post Eligibility Benefits During the Continuous Coverage Unwinding (CCU) handouts for review. 12/13/2024 Claude Mayo Jr. Administration Building • 120 West Washington Street, Suite 3072 • Nashville, NC 27856 Phone (252) 459-9800 • Fax (252) 459-9817 190

View Audit 341498

Finding 522245 (2024-002)

Significant Deficiency 2024

Nash County

NC

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Finding 2024-001 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-002 Name of contact person: Corrective Action: Proposed completion date: Section III - Federal Award Findings and Questioned Costs For the Year Ended June 30, 2024 Corrective Action Plan 01/10/2025 and...

Finding 2024-001 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-002 Name of contact person: Corrective Action: Proposed completion date: Section III - Federal Award Findings and Questioned Costs For the Year Ended June 30, 2024 Corrective Action Plan 01/10/2025 and 01/24/2025 Angel Carpenter –Family and Children's Medicaid Supervisor; Goldie Davis - Adult Medicaid Supervisor Medicaid caseworkers will receive additional and/or refresher training to include but not limited to running online data (OVS) when required, reviewing case determinations to ensure correct income and household size are being counted for each household member actively receiving on case(s), and accuracy of data entered onto dashboard. Second Party reviews will continue to be conducted to monitor continued progress and to ensure policies and procedures are correctly followed by caseworkers. Documentation templates have also been created and put into place to assist in ensuring cases are thoroughly documented. Case errors will be included on the Agenda for upcoming Staff Meetings and discussion will include review of accuracy/double checking determination decisions to ensure they are correct prior to authorizing or releasing determinations from hold on cases in NC FAST and ensuring correct income and household compositions are correct on determinations prior to authorizing or releasing cases from hold on cases in NC FAST and ensuring correct income and household compositions are correct on determinations prior to authorizing or releasing cases from hold. Training scheduled by 01/10/2025 for “Income & Deduction Wizard and by 01/24/2025 for “Mastering Medicaid Policy”, “Recertification & NC Fast 20020 (July 2023) “ and “ Recertification & CCU Training. Target checks on correct income, household composition and completed documentation will be completed monthly. Section II - Financial Statement Findings Dec 31, 2024. Mary Hogan, Finance Director The County agrees with the finding and will appropriately budget and make budget anendments for all leases in the future per GASB 87. Claude Mayo Jr. Administration Building • 120 West Washington Street, Suite 3072 • Nashville, NC 27856 Phone (252) 459-9800 • Fax (252) 459-9817 189

View Audit 341498

Finding 522229 (2024-001)

Material Weakness 2024

The Halifax - Warren Smart Start Partnership for Children, Inc.

NC

Questioned Costs Eligibility Subrecipient Monitoring

Going forward, all initial rosters submitted to HWSS will be reviewed by at least two different HWSS staff and compared to eligibility results to verify eligibility prior to entering rosters into NCPK KIDS. Any changes to a roster during the year will also be verified by at least two HWSS staff.

View Audit 341479 Questioned Costs: $1

Finding 522227 (2024-001)

None 2024

Cloville Homes, Inc.

MD

Reporting Internal Control / Segregation of Duties

Auditee has made an additional deposit of $111 on 9/23/2024 in order to fully fund the reserve for replacements and has established a system of automatic monthly payments in order to properly fund the account going forward. No further action is required.

View Audit 341473

Finding 522225 (2024-001)

None 2024

Greater Hamilton Homes, Inc.

MD

Reporting Internal Control / Segregation of Duties

Auditee has made an additional deposit of $351 on 9/23/2024 in order to fully fund the reserve for replacements and has established a system of automatic monthly payments in order to properly fund the account going forward. No further action is required.

View Audit 341472

Finding 522224 (2024-001)

None 2024

Hamilton Park Homes, Inc.

MD

Reporting Internal Control / Segregation of Duties

Auditee has made an additional deposit of $266 on 9/23/2024 in order to fully fund the reserve for replacements and has established a system of automatic monthly payments in order to properly fund the account going forward. No further action is required.

View Audit 341471

Finding 522222 (2024-001)

None 2024

Plymouth Homes, Inc.

MD

Reporting Internal Control / Segregation of Duties

Auditee has made an additional deposit of $365 on 9/23/2024 in order to fully fund the reserve for replacements and has established a system of automatic monthly payments in order to properly fund the account going forward. No further action is required.

View Audit 341470

Finding 522219 (2024-001)

Significant Deficiency 2024

Northwest Power & Conservation Council

OR

Questioned Costs Reporting

The Council’s managing officials accept and concur with the audit finding that two of the quarterly interim cost reports required by the RTF Grant for 2020-2024 were not submitted within 30 days after the end of the reporting period as required by the grant. We appreciate the auditor’s recommendati...

The Council’s managing officials accept and concur with the audit finding that two of the quarterly interim cost reports required by the RTF Grant for 2020-2024 were not submitted within 30 days after the end of the reporting period as required by the grant. We appreciate the auditor’s recommendation that the Council work to establish an internal tracking system to track reporting deadlines and the submission of required reports in accordance with the grant. We acknowledge the lack of an internal tracking system is a significant internal control deficiency requiring immediate correction. We will develop an internal tracking system for the RTF grant and implement the tracking system to track reporting deadlines and the submission of required reports no later than March 14, 2025 Starting with the quarter ending March 31, 2025, the filing of any quarterly reports due to Bonneville under the current RTF grant agreement will be tracked via this new system which will be developed and implemented by the Accounting Manager in consultation with the RTF Manager. The tracking system will be overseen by the Administrative Division Director and the Executive Director of the Council who will review the system each month to ensure the requirements of the RTF grant are being met.

View Audit 341456 Questioned Costs: $1

Corrective Action Plans

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