Corrective Action Plans

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Finding 520633 (2024-002)
Significant Deficiency 2024
Inaccurate Information Entry Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor C...
Inaccurate Information Entry Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: New process changes made 11/2022. Addition of Internal Quality Assurance employee by 1/6/25. Section IV - State Award Findings and Questioned Costs Finding: 2024-002 Inaccurate Resource Calculation In the past (prior to employment of the curent Medicaid Supervisor), staff were improperly trained on using replacement value of property vs. tax value. This is not current practice and values have been changed to tax value on all cases worked/supervised by Medicaid Supervisor. Current Recipient Eligibility Audits show the correct value is being used as there have been no findings. New process changes made 11/2022. Addition of Internal Quality Assurance employee by 1/6/25. Corrective actions for findings 2024-001, 2024-002, 2024-003, 2024-004 also apply to the State Awards findings. Finding: 2024-003 Inadequate Request for information The agency has experienced changes in staffing since the period that the error occured. New procedures have been put in place and training is ongoing. Additional Quality Assurance efforts will continue to ensure staff are sending the correct forms and accurately addressing employment results found in the system. New process changes made 11/2022. Addition of Internal Quality Assurance employee by 1/6/25. No corrective action will be implemented going forward as this policy is no longer required as of August 2023. The error for untimely IV-D (child support) referral was made under old policy. New policy effective August 2023 under Admin Letter 13-23 no longer requires post eligibility referrals to Child Support. Finding: 2024-004 Non-Cooperation With Child Support Procedures Finding: 2024-001 Workers will actively check eligibility for household size and income. An active Second Party process is in place that involves reviewing the eligibility check for accuracy. Since November 2022, the new Medicaid Supervisor has provided training and put quality control in place to help eliminate these type of errors. Further, the Agency is currently reorganizing by placing another employee in place to perform Quality Assurance/Internal Audit duties. The work of that employee will be to mirror all audits and randomly review cases checking for any recurrence of specific previous findings.
Finding 520632 (2024-001)
Significant Deficiency 2024
Inaccurate Information Entry Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor C...
Inaccurate Information Entry Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: New process changes made 11/2022. Addition of Internal Quality Assurance employee by 1/6/25. Section IV - State Award Findings and Questioned Costs Finding: 2024-002 Inaccurate Resource Calculation In the past (prior to employment of the curent Medicaid Supervisor), staff were improperly trained on using replacement value of property vs. tax value. This is not current practice and values have been changed to tax value on all cases worked/supervised by Medicaid Supervisor. Current Recipient Eligibility Audits show the correct value is being used as there have been no findings. New process changes made 11/2022. Addition of Internal Quality Assurance employee by 1/6/25. Corrective actions for findings 2024-001, 2024-002, 2024-003, 2024-004 also apply to the State Awards findings. Finding: 2024-003 Inadequate Request for information The agency has experienced changes in staffing since the period that the error occured. New procedures have been put in place and training is ongoing. Additional Quality Assurance efforts will continue to ensure staff are sending the correct forms and accurately addressing employment results found in the system. New process changes made 11/2022. Addition of Internal Quality Assurance employee by 1/6/25. No corrective action will be implemented going forward as this policy is no longer required as of August 2023. The error for untimely IV-D (child support) referral was made under old policy. New policy effective August 2023 under Admin Letter 13-23 no longer requires post eligibility referrals to Child Support. Finding: 2024-004 Non-Cooperation With Child Support Procedures Finding: 2024-001 Workers will actively check eligibility for household size and income. An active Second Party process is in place that involves reviewing the eligibility check for accuracy. Since November 2022, the new Medicaid Supervisor has provided training and put quality control in place to help eliminate these type of errors. Further, the Agency is currently reorganizing by placing another employee in place to perform Quality Assurance/Internal Audit duties. The work of that employee will be to mirror all audits and randomly review cases checking for any recurrence of specific previous findings.
Views of responsible officials and planned corrective action: We changed our processes to ensure that expenditures reimbursed by grants are recorded as such when incurred, not when reimbursed. This will ensure when an accrual is booked, it will be included in the grant totals for the SEFA.
Views of responsible officials and planned corrective action: We changed our processes to ensure that expenditures reimbursed by grants are recorded as such when incurred, not when reimbursed. This will ensure when an accrual is booked, it will be included in the grant totals for the SEFA.
The Treasurer or designee will periodically, but not less than three times annually, conduct a review of the meal counts manually entered into the point of sale system and the CRRS and verify the counts entered manually into the CRRS system. Patrick Higley, Dawn Johnson, and Jim Fadel will be the pa...
The Treasurer or designee will periodically, but not less than three times annually, conduct a review of the meal counts manually entered into the point of sale system and the CRRS and verify the counts entered manually into the CRRS system. Patrick Higley, Dawn Johnson, and Jim Fadel will be the parties responsible for ensuring the accuracy of the counts.
2024-001 Assistance Listing Number(s), Federal Agency and Program Name: 84.063, 84.007, 84.033, and 84.268; United States Department of Education (DOE), Student financial assistance cluster. Finding Type: Noncompliance and material weakness in internal control over compliance relating to special tes...
2024-001 Assistance Listing Number(s), Federal Agency and Program Name: 84.063, 84.007, 84.033, and 84.268; United States Department of Education (DOE), Student financial assistance cluster. Finding Type: Noncompliance and material weakness in internal control over compliance relating to special tests. Criteria: The Institute is responsible for designing, implementing, and maintaining internal control over compliance for special tests and provisions and for accurately and timely reporting significant data elements under the Campus-Level and Program-Level records within the National Student Loan Data System (NSLDS) that DOE considers high risk. Statement of Condition: Management implemented controls that specifically addressed the some of the circumstances surrounding prior year finding 2023-001. Management's review of the enrollment reporting did not detect errors on certain student Program-Level data elements or timely reporting. Certain student records within the NSLDS were identified with inaccurate Program-Level data elements and not timely reported. Questioned Costs: There were no questioned costs. Context: 9 students were identified with inaccurate Program-Level data elements and not timely reported out of a total of 27 student statuses tested. The Campus-Level data elements were accurately and timely reported. Cause: The Institute’s internal control over compliance did not detect and correct the errors. The preparer incorrectly reported graduate file impacting the student's effective dates and statuses during submission process to NSLDS resulting in inaccuracies in significant Program-Level enrollment data elements that ED considers high risk. The Institute’s internal control over compliance did not detect and correct the error. Effect: The Institute incorrectly reported certain Program-Level records in NSLDS which is information that DOE considers high risk and the Institute’s internal controls over compliance did not detect and correct the errors. Recommendation: We recommend management review policies and procedures surrounding enrollment reporting submissions to ensure the accuracy of Program-Level data elements reported to DOE. A review performed by an appropriate individual separate from the preparer prior to the submission of the enrollment reports to NSLDS may improve the accuracy of enrollment reporting. Management’s Response: Management agrees with the finding. Through internal investigation, it was determined that the date field issues found in 2023 also impacted “special” files, which include graduate data files and are processed differently in-house. This error has been fixed so that both fields will always be the same and accurate using the same method as the 2023-001 finding. The registrar will now confirm both the student-level and program-level data fields upon submission to NSC. Status: Completed January 2024 Contact: Mark Fetherston Vice President for Enrollment Management 414-847-3215 markfetherston@miad.edu
Finding 2024-001: Financial Data Schedule; Housing Choice Voucher-14.871 Material Weakness/Noncompliance Reporting We agree with the finding and have struggled to get back financial information from our fee accountants in a timely fashion which then causes the unaudited submissions to not be able ...
Finding 2024-001: Financial Data Schedule; Housing Choice Voucher-14.871 Material Weakness/Noncompliance Reporting We agree with the finding and have struggled to get back financial information from our fee accountants in a timely fashion which then causes the unaudited submissions to not be able to be performed in a proper submission time line. The housing authority has already taken steps to be sure the information is sent to the fee accountant in a proper time period at the end of the month. Currently, we are following up monthly with the fee accountant head to ask how getting monthly’s caught up is going. The most recent attempt also requested that extra staff be added to get Housing Partner’s monthly reports caught up. We are actively taking steps to keep following up with the fee accountant. This is a problem that is going to need to be resolved or the housing authority may be forced to look for a new fee accountant.
Santa Cruz COE will ensure current ledger reports are generated from the financial system at the time reports are submitted.
Santa Cruz COE will ensure current ledger reports are generated from the financial system at the time reports are submitted.
Findings and Questioned Costs Related to Federal Awards Finding Number: 2024‐001 Program Name/Assistance Listing Title: Child Nutrition Cluster Assistance Listing Numbers: 10.553, 10.555, 10.559 Contact Person: Anita Percell, Executive Director of Business Services Anticipated Completion Date: June ...
Findings and Questioned Costs Related to Federal Awards Finding Number: 2024‐001 Program Name/Assistance Listing Title: Child Nutrition Cluster Assistance Listing Numbers: 10.553, 10.555, 10.559 Contact Person: Anita Percell, Executive Director of Business Services Anticipated Completion Date: June 30, 2025 Planned Corrective Action: The District acknowledges the findings regarding the overcharging of indirect costs and is committed to ensuring full compliance with the federal cost principles and guidelines established by USDA and ADE. We will implement strengthened procedures, provide targeted training for relevant staff, and promptly reimburse the questioned costs.
View Audit 340268 Questioned Costs: $1
The County will implement a prodedure immediately of checking SAM.gov to verify that an entity has not been suspended, debarred before entering into a covered transaction. Reasonable completion date: March 31, 2025. Responsible Party: Micki Gilfry, Dodge County Clerk and Dodge County Finance Comm...
The County will implement a prodedure immediately of checking SAM.gov to verify that an entity has not been suspended, debarred before entering into a covered transaction. Reasonable completion date: March 31, 2025. Responsible Party: Micki Gilfry, Dodge County Clerk and Dodge County Finance Committee.
Action Taken: Management agrees with the recommendations. The management team involved with grants will work to modify and improve the current procedures and will implement the controls surrounding grant compliance, from the application process through final reporting. The team will also continue to...
Action Taken: Management agrees with the recommendations. The management team involved with grants will work to modify and improve the current procedures and will implement the controls surrounding grant compliance, from the application process through final reporting. The team will also continue to work to enhance our grant monitoring, including resuming management team meetings to keep everyone abreast of the status of grants. In addition, we will begin to gradually involve the new business office employee in grant reporting to improve on compliance with grant reporting requirements.
Action Taken: Management agrees with the recommendations. The procedures surrounding purchases will be modified and internal controls followed to ensure that bids or quotes are obtained for goods/supplies and services, as required. Management and any staff involved in the purchasing process will be ...
Action Taken: Management agrees with the recommendations. The procedures surrounding purchases will be modified and internal controls followed to ensure that bids or quotes are obtained for goods/supplies and services, as required. Management and any staff involved in the purchasing process will be informed of the federal and state thresholds for bids and quotes, including the District’s own policy. Controls will include a two-person monitoring of purchases.
Action Taken: Management agrees with the recommendations. The procedures in the business office will be modified and internal controls followed to ensure that payments based on quotes are prohibited. The business office staff will be more involved in the cash/accounts payable function and will be ed...
Action Taken: Management agrees with the recommendations. The procedures in the business office will be modified and internal controls followed to ensure that payments based on quotes are prohibited. The business office staff will be more involved in the cash/accounts payable function and will be educated on proper accounting principles. If an error is discovered by the staff, the business manager will be notified and the error documented and corrected in a timely manner. Controls will include a two-person monitoring of cash/accounts payable.
Action Taken: Management agrees with the recommendations. The unique situation with the COVID-19 funding, coupled with shifts in the business manager’s duties over the last few years and the staff retirement has resulted in grant report filings becoming a lower priority. The management team will wor...
Action Taken: Management agrees with the recommendations. The unique situation with the COVID-19 funding, coupled with shifts in the business manager’s duties over the last few years and the staff retirement has resulted in grant report filings becoming a lower priority. The management team will work together and will resume management team meetings to determine and monitor the duties for which each is responsible. Strides have been made in this regard, as the principals have become involved in Federal program training, budgeting, and scheduling. Although the aforementioned report submissions are delinquent and funding was suspended, some filings have been completed, and certain payments are forthcoming. However, management will begin to gradually involve the new business office employee in grant reporting to improve on compliance with grant reporting requirements.
Action Taken: Management agrees with the recommendation, and personnel involved in purchasing, especially those in the business office, will obtain a better understanding of the federal and state procurement thresholds, ensuring that bids or quotes will be obtained, as necessary. The Pennsylvania bu...
Action Taken: Management agrees with the recommendation, and personnel involved in purchasing, especially those in the business office, will obtain a better understanding of the federal and state procurement thresholds, ensuring that bids or quotes will be obtained, as necessary. The Pennsylvania bulletin has been provided by the auditor, and we will use that as a reference, in addition to the District’s own policy.
View Audit 340240 Questioned Costs: $1
Action Taken: Management agrees with the recommendations and will obtain a better understanding of encumbrances, especially with regard to grant programs, and will record expenditures only for items or services received.
Action Taken: Management agrees with the recommendations and will obtain a better understanding of encumbrances, especially with regard to grant programs, and will record expenditures only for items or services received.
View Audit 340240 Questioned Costs: $1
U.S. Department of Health and Human Services, Pass-through Programs from: Nebraska Department of Health and Human Services and the Iowa Department of Health and Human Services HIV Care Formula Grants, AL #93.917 Award No. 24X07HA00042, 24X07HA00041, 5884HC14 Award Periods: April 1, 2023 to March 31,...
U.S. Department of Health and Human Services, Pass-through Programs from: Nebraska Department of Health and Human Services and the Iowa Department of Health and Human Services HIV Care Formula Grants, AL #93.917 Award No. 24X07HA00042, 24X07HA00041, 5884HC14 Award Periods: April 1, 2023 to March 31, 2024 and April 1, 2024 to March 31, 2025 Eligibility: Significant Deficiency in Internal Control over Compliance Finding Summary: For 1 of 25 program participants selected for testing from the State of Nebraska, the participant file was missing documentation of HIV status. For 1 of 13 program participants selected for testing from the State of Iowa, the participant file was missing documentation for the annual recertification. Responsible Individuals: Brent Koster, Executive Director Corrective Action Plan: Procedures will be developed to ensure proper eligibility determinations are maintained in the file. Additionally, recertifications will be completed timely and documentation maintained in the file. Anticipated Completion Date: June 2025
1) Community Teamwork, Inc. has enhanced the verification process by introducing mandatory second-level reviews for all income and asset calculations for new employees. An extensive staff training program has been initiated that focuses on HUD and EOHLC requirements, with specific attention to the v...
1) Community Teamwork, Inc. has enhanced the verification process by introducing mandatory second-level reviews for all income and asset calculations for new employees. An extensive staff training program has been initiated that focuses on HUD and EOHLC requirements, with specific attention to the verification and documentation procedures. New employees will undergo a tiered review process where the new employees’ work will be audited by experienced staff until they have met the error compliance threshold. In addition, Community Teamwork, Inc. has updated their internal training protocols to focus on acceptable verification methods, accurate income reporting, and the correct completion of Form HUD-50058 MTW. As part of new protocols, program representatives are required to review the utility breakdown located in the tenant files to confirm that the utility allowance given to the tenant during the annual certification matches with the utility allowance in the tenant file. 2) Director of Intake and Leasing will ensure that the 120-day report is being run in a timely manner.
View Audit 340186 Questioned Costs: $1
Community Teamwork, Inc. has enhanced the verification process by introducing mandatory second-level reviews for all income and asset calculations for new employees. An extensive staff training program has been initiated that focuses on HUD and EOHLC requirements, with specific attention to the veri...
Community Teamwork, Inc. has enhanced the verification process by introducing mandatory second-level reviews for all income and asset calculations for new employees. An extensive staff training program has been initiated that focuses on HUD and EOHLC requirements, with specific attention to the verification and documentation procedures. New employees will undergo a tiered review process where the new employees’ work will be audited by experienced staff until they have met the error compliance threshold. In addition, Community Teamwork, Inc. has updated their internal training protocols to focus on acceptable verification methods, accurate income reporting, and the correct completion of form HUD-50058.
DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT ASI Freeport Senior Housing, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of independent public accounting firm: Baker Meinz & Associates, Ltd. 1000 Shelard Parkway, Suite 110 Minneapoli...
DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT ASI Freeport Senior Housing, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of independent public accounting firm: Baker Meinz & Associates, Ltd. 1000 Shelard Parkway, Suite 110 Minneapolis, MN 55426 Audit Period: June 30, 2024; The findings from the June 30, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDINGS - FINANCIAL STATEMENT AUDIT- None; FINDINGS - FEDERAL AWARD PROGRAMS AUDIT - DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2024-001: SECTION 202, ASSISTANCE LISTING NUMBER 14.157 The Project overpaid management fees to the management company. Recommendation: The management company should repay the $944 to the Project. Action Taken: The Project agrees with the finding. The management company will repay the overpaid management fees as soon as possible. If the Department of Housing and Urban Development has questions regarding this plan, please call Les Russo at 847-424-5601.
View Audit 340169 Questioned Costs: $1
The College has promptly engaged with Federal Student Aid regarding proper corrective actions. The Financial Aid Office has conducted a review of disbursement policies and procedures to prevent future occurrences.
The College has promptly engaged with Federal Student Aid regarding proper corrective actions. The Financial Aid Office has conducted a review of disbursement policies and procedures to prevent future occurrences.
2024-003 Material Weakness – Eligibility Second Party Reviews The auditor recommends that the County abide by the State policies in terms of the frequency and amount of case reviews each month. They also recommend that policies and procedures are documented surrounding second party reviews and rei...
2024-003 Material Weakness – Eligibility Second Party Reviews The auditor recommends that the County abide by the State policies in terms of the frequency and amount of case reviews each month. They also recommend that policies and procedures are documented surrounding second party reviews and reinforced to ensure that reviews are completed and followed up on as necessary. There is no disagreement with this audit finding. The County’s Quality Assurance (QA) team will review 100% of all TANF re-certifications. Monthly, a report from NC FAST will be published to identify the audits needed to complete the required 25% expectation and assigned to members of the QA team. A contingency plan will be created so that enough staff will be able to backfill the QA team if members are temporarily re-assigned or are unable to complete audits. New reports will be created to confirm compliance by tracking audit completion rates and identify shortfalls immediately. Person responsible for correction action: Leigh Anderson, HHS Business Administrator Completion date: Immediate – Creation of new audit workflow 2/10/2025 – Establish audit contingency plan 2/28/2025 – Creation of monthly compliance reporting
Finding 520568 (2024-002)
Significant Deficiency 2024
2024-002 Significant Deficiency over Activities Allowed and Unallowed and Allowable Costs/Cost Principles The auditors recommend that the County implements a review control over weekly timesheets to ensure the timesheets include all program time coded on the day sheets. NCDHHS policy requires ...
2024-002 Significant Deficiency over Activities Allowed and Unallowed and Allowable Costs/Cost Principles The auditors recommend that the County implements a review control over weekly timesheets to ensure the timesheets include all program time coded on the day sheets. NCDHHS policy requires program salaries to be allocated and supported by payroll and attendance records for individuals. There is no disagreement with this audit finding.The County will develop and deliver day sheet training which will be required for all staff responsible for completing these reports. The County will also conduct random reviews monthly. Any discrepancies identified will be provided to staff leadership for support and correction. The County will implement additional reviews if errors are identified until corrections are made. New reporting will be created to track review findings and will be shared with the Quality and Performance Officer or their designee. Person responsible for correction action: Leigh Anderson, HHS Business Administrator Completion date: 1/31/2025 – Day sheet training 3/1/2025 – Begin review of random of day sheets and timesheets 4/25/2025 – Report tracking of review findings
Finding Type: Compliance. Name of Contact Person: Ronald Ferrell, Superintendent. Recommendation: We recommend that the Superintendent review all supporting documentation for the expenditure reports submitted to the Illinois State Board of Education to ensure all costs are correctly reported be...
Finding Type: Compliance. Name of Contact Person: Ronald Ferrell, Superintendent. Recommendation: We recommend that the Superintendent review all supporting documentation for the expenditure reports submitted to the Illinois State Board of Education to ensure all costs are correctly reported before he approves the reports. Corrective Action: The Superintendent will review all supporting documentation for the expenditure reports before he approves the reports going forward. The District has contacted the Illinois State Board of Education to re-open the report for correction.
Finance will review and participate in staff development and CPE opportunities relating to the implementation of new and complex accounting pronouncements.
Finance will review and participate in staff development and CPE opportunities relating to the implementation of new and complex accounting pronouncements.
Finance will meet with purchasing agents to communicate procurement requirements, including documentation requirements, to avoid future misinterpretations and noncompliance with the Board's approved procurement policy.
Finance will meet with purchasing agents to communicate procurement requirements, including documentation requirements, to avoid future misinterpretations and noncompliance with the Board's approved procurement policy.
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