Corrective Action Plans

Finding 479063 (2023-001)

Significant Deficiency 2023

MI

Eligibility HUD Housing Programs Significant Deficiency

The Corporation contacted the local Continuum of Care and regional HUD office in an effort to verify the required number of units occupied by individuals meeting the definition of "homeless". The local Continuum of Care had no record of the original grant agreement or required number of "homeless" t...

The Corporation contacted the local Continuum of Care and regional HUD office in an effort to verify the required number of units occupied by individuals meeting the definition of "homeless". The local Continuum of Care had no record of the original grant agreement or required number of "homeless" to be served. The Corporation contacted three staff in the regional HUD office, including the staff that had been our representative for annually renewed operation and support service grants for the two projects. Regional HUD staff were not able to provide a copy of the original grant agreements which would indicate the number of persons to be served by each project. HUD staff stated that they do not keep copies of grant agreements longer than seven years. Corporation management will continue to work with HUD personnel to determine the continuing compliance requirements of the Continuum of Care funding received for initial construction or rehabilitation. Corporation management will continue to serve individuals meeting the definition of homelessness at its two projects and document evidence in the file.

View Audit 315585

Finding 479055 (2023-002)

Material Weakness 2023

Evergreen Youth & Family Services, Inc.

MN

Eligibility Material Weakness Internal Control / Segregation of Duties

Transitional Living for Homeless Youth – Assistance Listing No. 93.550 Recommendation: It is recommended that the Organization implement controls to ensure that proper documentation and support for eligibility is obtained and reviewed by a qualified individual. Explanation of disagreement with audit...

Transitional Living for Homeless Youth – Assistance Listing No. 93.550 Recommendation: It is recommended that the Organization implement controls to ensure that proper documentation and support for eligibility is obtained and reviewed by a qualified individual. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Program Director will conduct Weekly Document Reviews for new and ongoing clients and will also verify eligibility as staff submit weekly request forms for clients to receive services. Weekly Review Schedule: • The Program Director will conduct a review of all documentation once a week. Verification Process: • During the review, the Program Director will verify that all required documents for eligibility is being completed accurately, processed, and documented. Documentation of Review: • The results of this review will be documented on each client’s initial intake form and in Apricot. • The Program Director will sign the intake form to indicate verification and completion of the review and will also document this in Apricot. • By adhering to this procedure, we ensure that all documentation is thoroughly checked and validated on a consistent basis, maintaining the integrity and accuracy of our eligibility process. Name(s) of the contact person(s) responsible for corrective action: Elena Guerra, EYS Program Director. Planned completion date for corrective action plan: ongoing

View Audit 315565

Finding 479054 (2023-001)

Significant Deficiency 2023

Evergreen Youth & Family Services, Inc.

MN

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Transitional Living for Homeless Youth – Assistance Listing No. 93.550 Recommendation: It is recommended that the Organization implement controls to ensure that clients meet eligibility requirements before being enrolled in the program. This could include verifying age at the time of enrollment and ...

Transitional Living for Homeless Youth – Assistance Listing No. 93.550 Recommendation: It is recommended that the Organization implement controls to ensure that clients meet eligibility requirements before being enrolled in the program. This could include verifying age at the time of enrollment and periodically re-verifying eligibility for on-going clients. Additionally, the Organization should review its policies and procedures to ensure that they are in compliance with program requirements and make any necessary updates. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Clearly define eligibility requirements for staff conducting intakes, along with the intake process. Staff and Program Director will reverify eligibility when doing check requests. Two opportunities will be provided for staff each year to revisit eligibility requirements and to provide staff with refresher training. Intake Process: At the time of intake into the program, client’s will be asked for their driver’s license, state ID, permit, tribal ID, or birth certificate. If the client doesn't have any Identification, staff will calculate the client's age using the client's reported date of birth. Staff will then attempt to help the client secure personal vital documents and add copies to the client file for verification. The Program Director will also verify eligibility. Training: Staff to be trained in the spring and fall of each year to revisit eligibility requirements, intake processes, along with agency core values, mission and vision. Name(s) of the contact person(s) responsible for corrective action: Elena Guerra, EYS Program Director Planned completion date for corrective action plan: • Clearly define eligibility requirements for staff by July 1, 2024. • Host trainings by September 30, 2024, and March 31, 2025. • Verify eligibility for new clients and current clients on an ongoing basis.

View Audit 315565

Finding 479030 (2023-003)

Material Weakness 2023

West Central Nebraska Joint Housing Authority

NE

Internal Control / Segregation of Duties Special Tests & Provisions Eligibility

Finding 2023-003: We agree with the finding. The Authority is relatively small with limited administrative staff. Further, the Board of Commissioners is a volunteer oversight board and not a managing board and does not have the time or expertise to provide the necessary services to correct the inte...

Finding 2023-003: We agree with the finding. The Authority is relatively small with limited administrative staff. Further, the Board of Commissioners is a volunteer oversight board and not a managing board and does not have the time or expertise to provide the necessary services to correct the internal control deficiencies noted. The Board had reviewed the issue and determined that there are no additional procedures which can be reasonably done to eliminate the deficiencies and accepts them.

View Audit 315549

Finding 478972 (2023-029)

Significant Deficiency 2023

Commonwealth of Massachusetts

MA

Questioned Costs Eligibility Special Tests & Provisions § 200.303

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES 2023-029 Medicaid Cluster, COVID-19 – Medicaid Cluster - Assistance Listing No. 93.775, 93.777, 93.778 Action taken in response to the finding: Dental: In response to the finding MassHealth required DentaQuest to: • Implement a corrective action plan to...

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES 2023-029 Medicaid Cluster, COVID-19 – Medicaid Cluster - Assistance Listing No. 93.775, 93.777, 93.778 Action taken in response to the finding: Dental: In response to the finding MassHealth required DentaQuest to: • Implement a corrective action plan to review and improve internal controls for the retention of provider enrollment documentation. • Ensure that all required documents are obtained and retained during validation and revalidation (i.e., “provider eligibility recertification”) processes for both individual dental providers and dental group practices. • Provide additional training to its provider enrollment staff on document retention. DentaQuest has implemented the above requirements to ensure provider license and revalidation dates are verified and maintained in MassHealth’s Medicaid Management Information System (MMIS) upon enrollment and subsequent revalidation. However, MassHealth anticipates that due to a backlog in the dental group practice revalidation process, dental group practice revalidation will not be complete January 2025. In the event that a MassHealth-enrolled provider or group practice does not timely respond to MassHealth revalidation requests, MassHealth initiates the process of terminating the provider’s MassHealth contract. BSS: For the one out of state provider that MassHealth did not revalidate, once identified, the provider was immediately put into a revalidation process. The provider did not respond to requests from MassHealth to revalidate and the provider’s MassHealth contract was terminated effective 1/21/2024 for failure to revalidate. MassHealth and BSS will continue to review and ensure that all providers who are required to revalidate are completed within the CMS required timeframes. Name of the contact person responsible for corrective action: Tuyen Vu, Deputy Director, Dental Janice Wadsworth, Director of Provider Operations Planned completion date for corrective action plan: Dental: January 1, 2025 BSS: January 21, 2024

View Audit 315520 Questioned Costs: $1

Finding 478930 (2023-016)

Significant Deficiency 2023

Commonwealth of Massachusetts

MA

Questioned Costs Eligibility Significant Deficiency § 200.303

EXECUTIVE OFFICE OF HOUSING AND LIVABLE COMMUNITIES 2023-016 COVID-19 – Emergency Rental Assistance Program – Assistance Listing No. 21.023 Action taken in response to the finding: EOHLC has notified Nan McKay of the income ineligibility. Nan McKay and EOHLC agreed with the finding. In February 202...

EXECUTIVE OFFICE OF HOUSING AND LIVABLE COMMUNITIES 2023-016 COVID-19 – Emergency Rental Assistance Program – Assistance Listing No. 21.023 Action taken in response to the finding: EOHLC has notified Nan McKay of the income ineligibility. Nan McKay and EOHLC agreed with the finding. In February 2024 Nan McKay sent payment recoupment letters to the landlord and the utility company to attempt to recoup the funds paid on behalf of an ineligible household. EOHLC met with Nan McKay leadership staff on 04/18/2024 to review income eligibility steps for emergency rental assistance programs. Name of the contact person responsible for corrective action: Amy Mullen Planned completion date for corrective action plan: April 18, 2024

View Audit 315520 Questioned Costs: $1

Finding 478723 (2023-009)

Significant Deficiency 2023

Hyde County

NC

Eligibility Significant Deficiency

Finding: 2023-009 Inadequate Request for information New Medicaid Supervisor started 6/1/23 & has put new procedures in place & training of staff to eliminate the errors that occurred during the audit. All cases are reviewed before being processed to make sure the worker has worked the case properly...

Finding: 2023-009 Inadequate Request for information New Medicaid Supervisor started 6/1/23 & has put new procedures in place & training of staff to eliminate the errors that occurred during the audit. All cases are reviewed before being processed to make sure the worker has worked the case properly & if not immediate feedback, staffing & 2nd party review form is provided to the worker. Due to COVID & the State continuing cases this resulted in 15 of 35 of our errors. Of the 20 left, one is from 2018 due to the claim being paid in 2023 for a date of service of 2018. The other 19 relate to a current recert, however, review shows these were still worked prior to new supervisor & new procedures put into place. New staff has been brought in & are being trained one-on-one. It is anticipated that it will take 6 months - 1 year to get the new workers completely trained in their program. Team also has a pending new hire. Staffing cases & 2nd party reviews will continue indefinitely. Lots of errors came from the worker not running TWN. New process includes when the recert is started the workers is to run OVS, AVS & TWN. This is checked during 2nd party that all were started the same day. Workers are being taught that they are to upload their documents in NCFast at review/app & hard copy files are being eliminated to risk being lost.

View Audit 315389

Finding 478722 (2023-008)

Significant Deficiency 2023

Hyde County

NC

Eligibility Significant Deficiency

Finding: 2023-008 Inaccurate Resource Calculation New Medicaid Supervisor started 6/1/23 & has put new procedures in place & training of staff to eliminate the errors that occurred during the audit. All cases are reviewed before being processed to make sure the worker has worked the case properly & ...

Finding: 2023-008 Inaccurate Resource Calculation New Medicaid Supervisor started 6/1/23 & has put new procedures in place & training of staff to eliminate the errors that occurred during the audit. All cases are reviewed before being processed to make sure the worker has worked the case properly & if not immediate feedback, staffing & 2nd party review form is provided to the worker. Due to COVID & the State continuing cases this resulted in 15 of 35 of our errors. Of the 20 left, one is from 2018 due to the claim being paid in 2023 for a date of service of 2018. The other 19 relate to a current recert, however, review shows these were still worked prior to new supervisor & new procedures put into place. New staff has been brought in & are being trained one-on-one. It is anticipated that it will take 6 months - 1 year to get the new workers completely trained in their program. Team also has a pending new hire. Staffing cases & 2nd party reviews will continue indefinitely. For cases related to property resource entered incorrectly, previous supervisor instructed staff to enter the replacement value & not the tax value. This is being fixed as cases are being touched by the worker. New workers are being taught to review eligibility check to make sure income/resources are calcuating properly before processing.

View Audit 315389

Finding 478721 (2023-007)

Significant Deficiency 2023

Hyde County

NC

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Finding: 2023-007 New Medicaid Supervisor started 6/1/23 & has put new procedures in place & training of staff to eliminate the errors that occurred during the audit. All cases are reviewed before being processed to make sure the worker has worked the case properly & if not immediate feedback, staff...

Finding: 2023-007 New Medicaid Supervisor started 6/1/23 & has put new procedures in place & training of staff to eliminate the errors that occurred during the audit. All cases are reviewed before being processed to make sure the worker has worked the case properly & if not immediate feedback, staffing & 2nd party review form is provided to the worker. Due to COVID & the State continuing cases this resulted in 15 of 35 of our errors. Of the 20 left, one is from 2018 due to the claim being paid in 2023 for a date of service of 2018. The other 19 relate to a current recert, however, review shows these were still worked prior to new supervisor & new procedures put into place. New staff has been brought in & are being trained one-on-one. It is anticipated that it will take 6 months - 1 year to get the new workers completely trained in their program. Team also has a pending new hire. Staffing cases & 2nd party reviews will continue indefinitely. It was recently determined that workers were not reviewing the eligibility check for correct income/household size. Training has the workers checking this now. Section III - Federal Award Findings and Questioned Costs (continued) 6 months - 1 year

View Audit 315389

Finding 478692 (2023-002)

Significant Deficiency 2023

The San Diego Lgbt Community Center

CA

Eligibility Program Income § 200.307

2) Finding 2023-002 a. Program Information: 14.267 Continuum of Care Program b. Criteria: In accordance with 2 CFR 200.307, program income (in this case, tenant rent) must be correctly determined and properly recorded in the accounting records. Eligibility and rent determination evaluations are perf...

2) Finding 2023-002 a. Program Information: 14.267 Continuum of Care Program b. Criteria: In accordance with 2 CFR 200.307, program income (in this case, tenant rent) must be correctly determined and properly recorded in the accounting records. Eligibility and rent determination evaluations are performed for new tenants before move-in and annually for existing tenants to determine their portion of rent to pay via the Tenant Income Certification or Re-certification or Permanent Supportive Housing – Eligibility and Rent Determination forms which are approved by the San Diego Housing Commission. Housing program tenants are required to pay up to 30% of their income for rent. c. Condition: For one out of 12 transactions tested, The Center collected $344.40 which could not be directly traced to an individual tenant. Because it could not be directly traced, the Tenant Income Certification or Re-certification or Permanent supportive Housing – Eligibility and Rent Determination forms could not be identified and tested for accuracy or completeness and compliance with the tenant’s share of the rental payment could not be determined.

View Audit 315339

Finding 478668 (2023-003)

Significant Deficiency 2023

Houston Area Women's Center

TX

Eligibility Significant Deficiency

Finding #2023-003 – Significant Deficiency. U. S. Department of the Treasury, Passed through Texas Department of Housing and Community Affairs, Emergency Rental Assistance Program, Assistance Listing #: 21.023, Contract #: 20220000030, Contract period: 03/01/22 – 07/31/25. Condition and context: ...

Finding #2023-003 – Significant Deficiency. U. S. Department of the Treasury, Passed through Texas Department of Housing and Community Affairs, Emergency Rental Assistance Program, Assistance Listing #: 21.023, Contract #: 20220000030, Contract period: 03/01/22 – 07/31/25. Condition and context: HAWC’s policies and procedures for verifying the completeness of eligibility documentation includes the completion of a client file review with an internal reviewer’s signature evidencing their review. In our testing of a sample of 40 clients, we noted one client file for services provided that did not have the signature of an internal reviewer. We noted that the eligibility files did not include the required documentation. Recommendation: Provide additional staff training to ensure that HAWC’s internal control procedures that require review of client files are followed. Planned corrective action: Management will conduct additional refresher training for staff. An updated policy was put in place in March 2024 during the Apricot Database Migration. The implementation of Apricot has resolved this issue. Responsible officer: Nike Blue, Chief Quality Officer. Estimated completion date: August 30, 2024

View Audit 315284

Finding 478608 (2023-003)

Significant Deficiency 2023

Rice County, Minnesota

MN

Eligibility Significant Deficiency Internal Control / Segregation of Duties

FEDERAL AWARD PROGRAMS AUDITS 2023-003 Temporary Assistance for Needy Families Program (TANF) (Assistance Listing #93.558) Award #2301MNTANF, Passed through Minnesota Department of Human Services: Grant Period Year Ended December, 31, 2023; Eligibility Requirement Recommendation: It is recommended...

FEDERAL AWARD PROGRAMS AUDITS 2023-003 Temporary Assistance for Needy Families Program (TANF) (Assistance Listing #93.558) Award #2301MNTANF, Passed through Minnesota Department of Human Services: Grant Period Year Ended December, 31, 2023; Eligibility Requirement Recommendation: It is recommended the County implement procedures to ensure all required documentation is maintained in the file and that there are procedures in place to review files for errors and omissions in eligibility documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will review their process for data input and recording and remind staff to verify all eligibility requirements are documented for verbal interviews. Name of contact person responsible for corrective action plan: Rick Gieseke, Deputy Administrator Community Services Planned completion date for corrective action plan: December 31, 2024

View Audit 315237

Finding 478603 (2023-011)

Significant Deficiency 2023

Hertford County

NC

Eligibility

Finding 2023-011 Non-cooperation with Child Support Procedures Name of contact person: Corrective Action: Proposed completion date: Corrective Action Plan for Finding 2023-007, 2023-008, 2023-009, 2023-010 and 2023-011 also apply to the State Awards Findings. Section IV - State Award Findings and Qu...

Finding 2023-011 Non-cooperation with Child Support Procedures Name of contact person: Corrective Action: Proposed completion date: Corrective Action Plan for Finding 2023-007, 2023-008, 2023-009, 2023-010 and 2023-011 also apply to the State Awards Findings. Section IV - State Award Findings and Question Costs Management monitor daily to track progress of this issue and modify the controls as needed. Section III - Federal Award Findings and Question Costs (continued) Staff are also trained on how to key IV-D referrals effectively, ensuring accurate and timely data entry. Training sessions focus on specific deficiencies noted in previous audits, teaching staff how to avoid similar mistakes through correct practices and awareness. Staff are encouraged and reminded daily to utilize checklists to verify their work. Supervisors will conduct monthly reviews of policies, or more frequently if needed, based on errors identified in audits and second-party reviews. Brenda Brown, Director; Melissa Castelow, Medicaid Supervisor; Satonya Gonzales, Medicaid Supervisor

View Audit 315224

Finding 478602 (2023-010)

Significant Deficiency 2023

Hertford County

NC

Eligibility

Finding 2023-009 Inaccurate Resources Entry Name of contact person: Corrective Action: Proposed completion date: Finding 2023-010 Inadequate Request for Information Name of contact person: Corrective Action: Proposed completion date: Caseworkers will undergo periodic retraining sessions to refresh t...

Finding 2023-009 Inaccurate Resources Entry Name of contact person: Corrective Action: Proposed completion date: Finding 2023-010 Inadequate Request for Information Name of contact person: Corrective Action: Proposed completion date: Caseworkers will undergo periodic retraining sessions to refresh their understanding and ensure compliance with form 5097 usage guidelines. The Medicaid Supervisors and Quality Assurance (QA) staff will review denial at least 3 days each week. Caseworkers are to use the application checklist for every application processed. Caseworkers are reminded to continue following the guidelines outlined in MA-2300: Section XI, which deals with requesting information from applicants, with specific attention is given to parts A.1-5 of the section, focusing on the procedures and documentation required when information is requested from applicants. Management monitor daily to track progress of this issue and modify the controls as needed. Section III - Federal Award Findings and Question Costs (continued) Brenda Brown, Director; Melissa Castelow, Medicaid Supervisor; Satonya Gonzales, Medicaid Supervisor Brenda Brown, Director; Melissa Castelow, Medicaid Supervisor; Satonya Gonzales, Medicaid Supervisor Caseworkers will undergo periodic retraining sessions to refresh their understanding and ensure compliance with form 5097 usage guidelines. The Adult Medicaid Supervisor and Quality Assurance (QA) staff will review denial at least 3 days each week. Caseworkers are to use the application checklist for every application processed. Caseworkers are reminded to continue following the guidelines outlined in MA-2300: Section XI, which deals with requesting information from applicants, with specific attention is given to parts A.1-5 of the section, focusing on the procedures and documentation required when information is requested from applicants. Management monitor daily to track progress of this issue and modify the controls as needed.

View Audit 315224

Finding 478601 (2023-009)

Significant Deficiency 2023

Hertford County

NC

Eligibility

Finding 2023-009 Inaccurate Resources Entry Name of contact person: Corrective Action: Proposed completion date: Finding 2023-010 Inadequate Request for Information Name of contact person: Corrective Action: Proposed completion date: Caseworkers will undergo periodic retraining sessions to refresh t...

Finding 2023-009 Inaccurate Resources Entry Name of contact person: Corrective Action: Proposed completion date: Finding 2023-010 Inadequate Request for Information Name of contact person: Corrective Action: Proposed completion date: Caseworkers will undergo periodic retraining sessions to refresh their understanding and ensure compliance with form 5097 usage guidelines. The Medicaid Supervisors and Quality Assurance (QA) staff will review denial at least 3 days each week. Caseworkers are to use the application checklist for every application processed. Caseworkers are reminded to continue following the guidelines outlined in MA-2300: Section XI, which deals with requesting information from applicants, with specific attention is given to parts A.1-5 of the section, focusing on the procedures and documentation required when information is requested from applicants. Management monitor daily to track progress of this issue and modify the controls as needed. Section III - Federal Award Findings and Question Costs (continued) Brenda Brown, Director; Melissa Castelow, Medicaid Supervisor; Satonya Gonzales, Medicaid Supervisor Brenda Brown, Director; Melissa Castelow, Medicaid Supervisor; Satonya Gonzales, Medicaid Supervisor Caseworkers will undergo periodic retraining sessions to refresh their understanding and ensure compliance with form 5097 usage guidelines. The Adult Medicaid Supervisor and Quality Assurance (QA) staff will review denial at least 3 days each week. Caseworkers are to use the application checklist for every application processed. Caseworkers are reminded to continue following the guidelines outlined in MA-2300: Section XI, which deals with requesting information from applicants, with specific attention is given to parts A.1-5 of the section, focusing on the procedures and documentation required when information is requested from applicants. Management monitor daily to track progress of this issue and modify the controls as needed.

View Audit 315224

Finding 478600 (2023-008)

Significant Deficiency 2023

Hertford County

NC

Eligibility Internal Control / Segregation of Duties

Finding 2023-006 Untimely Adoption of Policy Name of contact person: Corrective Action: Proposed completion date: Finding 2023-007 Untimely Review of SSI Termination Name of contact person: Corrective Action: Proposed completion date: Finding 2023-008 Inaccurate Information Entry Name of contact per...

Finding 2023-006 Untimely Adoption of Policy Name of contact person: Corrective Action: Proposed completion date: Finding 2023-007 Untimely Review of SSI Termination Name of contact person: Corrective Action: Proposed completion date: Finding 2023-008 Inaccurate Information Entry Name of contact person: Corrective Action: Immediately Leslie Edwards, Finance Director The Finance Office is currently fully staffed, the Finance Director and the County Manager will work together to ensure proper policies are completed and up to date for federal awards. The fiance director will ensure that policies needed for federal grant awards are in place. The policies were adopted in FY2023 and the finding should be eliminated in FY24. Section III - Federal Award Findings and Question Costs (continued) Regular review intervals will be established to ensure that these critical tasks are being addressed promptly and efficiently, minimizing the risk of delays in case processing. Prioritizing tasks according to urgency and compliance requirements. Focusing on terminated cases to prevent any potential service disruption to clients. Regular reminders will be issued to staff to review and work on their tasks according to the established guidelines. Management monitor daily to track progress of this issue and modify the controls as needed. All staff must use the provided checklists to review their work prior to submission or finalization. Staff are required to review the determination history to verify accuracy in household composition and income details. After completing a manual budget, workers must compare their results with the NCFAST-generated budget to confirm accuracy in budgeting and program eligibility. Training sessions include knowledge checks to validate understanding and retention of correct income entry methods. Engaging in peer reviews where feasible to promote a culture of accuracy and mutual accountability. Brenda Brown, Director; Melissa Castelow, Medicaid Supervisor; Satonya Gonzales, Medicaid Supervisor Brenda Brown, Director; Melissa Castelow, Medicaid Supervisor; Satonya Gonzales, Medicaid Supervisor

View Audit 315224

Finding 478599 (2023-007)

Significant Deficiency 2023

Hertford County

NC

Internal Control / Segregation of Duties Eligibility Reporting

Finding 2023-006 Untimely Adoption of Policy Name of contact person: Corrective Action: Proposed completion date: Finding 2023-007 Untimely Review of SSI Termination Name of contact person: Corrective Action: Proposed completion date: Finding 2023-008 Inaccurate Information Entry Name of contact per...

Finding 2023-006 Untimely Adoption of Policy Name of contact person: Corrective Action: Proposed completion date: Finding 2023-007 Untimely Review of SSI Termination Name of contact person: Corrective Action: Proposed completion date: Finding 2023-008 Inaccurate Information Entry Name of contact person: Corrective Action: Immediately Leslie Edwards, Finance Director The Finance Office is currently fully staffed, the Finance Director and the County Manager will work together to ensure proper policies are completed and up to date for federal awards. The fiance director will ensure that policies needed for federal grant awards are in place. The policies were adopted in FY2023 and the finding should be eliminated in FY24. Section III - Federal Award Findings and Question Costs (continued) Regular review intervals will be established to ensure that these critical tasks are being addressed promptly and efficiently, minimizing the risk of delays in case processing. Prioritizing tasks according to urgency and compliance requirements. Focusing on terminated cases to prevent any potential service disruption to clients. Regular reminders will be issued to staff to review and work on their tasks according to the established guidelines. Management monitor daily to track progress of this issue and modify the controls as needed. All staff must use the provided checklists to review their work prior to submission or finalization. Staff are required to review the determination history to verify accuracy in household composition and income details. After completing a manual budget, workers must compare their results with the NCFAST-generated budget to confirm accuracy in budgeting and program eligibility. Training sessions include knowledge checks to validate understanding and retention of correct income entry methods. Engaging in peer reviews where feasible to promote a culture of accuracy and mutual accountability. Brenda Brown, Director; Melissa Castelow, Medicaid Supervisor; Satonya Gonzales, Medicaid Supervisor Brenda Brown, Director; Melissa Castelow, Medicaid Supervisor; Satonya Gonzales, Medicaid Supervisor

View Audit 315224

Finding 478393 (2023-005)

None 2023

Oregon College of Oriental Medicine

OR

Special Tests & Provisions Student Financial Aid Eligibility

Finding: 2023-005 Special Tests and Provisions Department’s Response: We concur Corrective Action: This issue occurred as employee files and onboarding are managed by the Human Resources department, which had also been running payroll. The matter has since been resolved as the accounting depart...

Finding: 2023-005 Special Tests and Provisions Department’s Response: We concur Corrective Action: This issue occurred as employee files and onboarding are managed by the Human Resources department, which had also been running payroll. The matter has since been resolved as the accounting department reassumed responsibility for running payroll and is serving as a cross check to ensure that all necessary documentation has been verified as collected by the Human Resources department at the time of onboarding. The responsibility of the Human Resources department remains to ensure that all employee onboarding files are available for review while accounting as the payroll processor shall confirm that student work study hours have been documented and approved by the appropriate supervisor. Contact: Katrina Hitzeman Anticipated Completion Date: Immediately

View Audit 315065

Finding 478391 (2023-003)

None 2023

Oregon College of Oriental Medicine

OR

Student Financial Aid Eligibility Matching / Level of Effort / Earmarking

Finding: 2023-003 Reporting Department’s Response: We concur Corrective Action: This issue occurred while the Director of Financial Aid was out of the office on Leave. This issue was caused by an issue in Populi’s system and a replacement Financial Aid Officer did not know who all was supposed...

Finding: 2023-003 Reporting Department’s Response: We concur Corrective Action: This issue occurred while the Director of Financial Aid was out of the office on Leave. This issue was caused by an issue in Populi’s system and a replacement Financial Aid Officer did not know who all was supposed to be included in the disbursement batch. The process will be updated so that a list of all students who are meant to be in a batch will be listed on a report as their requests come in, then the report will be referenced when creating a disbursement batch to make sure no students are missing. Contact: Katrina Hitzeman Anticipated Completion Date: Summer 2024

View Audit 315065

Finding 478371 (2023-001)

Significant Deficiency 2023

Boston Tremont Housing Development Fund Corporation

NY

Eligibility HUD Housing Programs Reporting

Corrective Action Plan Project Legal Name: Boston Tremont Housing Development Fund Corporation HUD Project Nos.: NY 36L000080 and NY 36L000081 Audit Firm: CohnReznick LLP Period covered by the audit: December 31, 2023 Corrective Action Plan prepared by: Name: Lukeman Ogunyinka Position: Chief Financ...

Corrective Action Plan Project Legal Name: Boston Tremont Housing Development Fund Corporation HUD Project Nos.: NY 36L000080 and NY 36L000081 Audit Firm: CohnReznick LLP Period covered by the audit: December 31, 2023 Corrective Action Plan prepared by: Name: Lukeman Ogunyinka Position: Chief Financial Officer Telephone Number: (212) 243-9090 The following is a recommended format to be followed by the auditee for preparing a corrective action plan: A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2023-1 a. Comments on the Finding and Each Recommendation 4 out of 26 tenants tested did not have an annual tenant recertification Form HUD 50059 completed timely. Moving forward, management will follow established procedures and monitor compliance with those procedures to ensure that the determination of tenant eligibility and the maintenance of lease files are in accordance with the guidelines specified by HUD. b. Action(s) Taken or Planned on the Finding Management has addressed the issue by recertifying the tenant and does not expect a late recertification to occur again based on procedures in place.

View Audit 315050

Finding 478354 (2023-001)

Significant Deficiency 2023

Food Bank of South Jersey, INC

NJ

Subrecipient Monitoring Eligibility

The Organization has established procedures to set consistent dates for annual in-person trainings and signing of contracts. The Organization will set up a schedule in excel with expiring dates to ensure no TEFAP food is distributed without a contract.

View Audit 315000

Finding 478277 (2023-003)

Significant Deficiency 2023

Crookston Housing and Economic Development Authority

MN

HUD Housing Programs Eligibility Significant Deficiency

1. Correcting Plan CHEDA staff are aware of income eligibility documentation and will implement an internal control process. 2. Explanation of Disagreement with the Audit Finding There is essentially no disagreement with the finding. 3. Official Responsible for Ensuring CAP Karie Kirschbaum – Execut...

1. Correcting Plan CHEDA staff are aware of income eligibility documentation and will implement an internal control process. 2. Explanation of Disagreement with the Audit Finding There is essentially no disagreement with the finding. 3. Official Responsible for Ensuring CAP Karie Kirschbaum – Executive Director 4. Planned Completion Date for CAP Immediately. 5. Plan to Monitor Completion of CAP The Executive Director will monitor completion of the CAP.

View Audit 314956

Finding 478275 (2023-001)

Significant Deficiency 2023

Watertown Housing Authority

MA

Eligibility HUD Housing Programs Allowable Costs / Cost Principles

Name of Auditee: Watertown Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: December 31, 2023 CAP Prepared by: Michael Lara, Executive Director Phone: (617) 923-3950 (A) Current Findings on the Schedule of Findings and Questioned Costs (1) Finding 2023-001 (a...

Name of Auditee: Watertown Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: December 31, 2023 CAP Prepared by: Michael Lara, Executive Director Phone: (617) 923-3950 (A) Current Findings on the Schedule of Findings and Questioned Costs (1) Finding 2023-001 (a) Comments on the finding and recommendation - The Authority agrees with the finding. The Authority also agrees with the recommendation, please see below for action taken. (b) Action taken - The Authority’s HCV program coordinator will review records in each tenant’s file to ensure all required documents are present. (c) Planned implementation date of corrective action - Completed by December 31, 2024.

View Audit 314952

Finding 478227 (2023-001)

Significant Deficiency 2023

Planned Parenthood of Greater Texas, Inc.

TX

Allowable Costs / Cost Principles Eligibility Significant Deficiency

Annual Title X training will be provided to staff Title X centers in early July 2024. The training will include expanded direction and provide clarity for the staff regarding the expectations around eligibility forms. This includes the need for eligibility forms for supply-only encounters. The Sr. ...

Annual Title X training will be provided to staff Title X centers in early July 2024. The training will include expanded direction and provide clarity for the staff regarding the expectations around eligibility forms. This includes the need for eligibility forms for supply-only encounters. The Sr. Grants Project Manager, Metzli Gonzales, performs bi-annual chart audits across all Title X sites to assess compliance with the Title X program. The audits review ten charts from each Title X center, chosen at random. The criteria include looking for evidence demonstrating compliance with the requirement that an eligibility Form is completed with income information and signed by the patient.

View Audit 314903

Finding 478187 (2023-003)

Material Weakness 2023

Jackson Housing Commission

MI

HUD Housing Programs Allowable Costs / Cost Principles Eligibility

Finding 2023-003 - Lack of Data Available to Audit Federal Compliance Requirements Applicable to the Section 8 Housing Choice Program (Material Weakness, Potential Material Noncompliance) Public Housing Program -Assistance Listing No. 14.871; Grant period - fiscal year ended March 31,2023 Condition:...

Finding 2023-003 - Lack of Data Available to Audit Federal Compliance Requirements Applicable to the Section 8 Housing Choice Program (Material Weakness, Potential Material Noncompliance) Public Housing Program -Assistance Listing No. 14.871; Grant period - fiscal year ended March 31,2023 Condition: We did not attain sufficient supporting data in order to audit the Commission's compliance with the Allowable Activities, Allowable Costs , Eligibility, Reporting and Special Tests and Provisions compliance requirements applicable to the Section 8 Housing Choice Voucher Program. Contact person responsible for corrective action: Arturo Puckerin Corrective action planned: The authority hired a new financial fee accountant to review the internal controls and the state of the Authority's financials as of fiscal year 2023 forward. The authority was able to correct the HUD REAC Financial Data Schedule for the audited financials for fiscal year 2023, record the pension and other post-retirement employment benefits balances and begin work on reconstructing the capital asset register. The authority has integrated proper financial and accounting internal controls through the accounts payable, cash receipts, payroll and accounting entries during fiscal year 2024. The authority has the financial fee accountant work with accounting and program staff to ensure the financials are materially stated monthly, hud reporting is completed on a timely basis with materially stated financial and operational information and the executive staff is reviewing the appropriate financial information. The board approved the fiscal year 2025 budget which was in balance and set the course for continued improvement of financial reporting and proper internal controls over financial reporting. The Authority has reconciled the (HCVP) activities to the account ledgers for program, housing assistance payments, subsidies received by type and other income through fiscal year-end 2024 and forward. Anticipated completion date: March 31, 2024

View Audit 314861

Corrective Action Plans

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