Corrective Action Plans

Finding 394729 (2023-014)

Material Weakness 2023

MI

Procurement, Suspension & Debarment Subrecipient Monitoring Eligibility § 200.501

Finding Number: 2023-014 Federal Program: 10.557, U.S. Department of Agriculture – WIC Special Supplemental Nutrition Program for Women, Infants, and Children Condition Per Auditor: Controls in place were not adequate to ensure the County maintained responsibility for compliance with eligibility sta...

Finding Number: 2023-014 Federal Program: 10.557, U.S. Department of Agriculture – WIC Special Supplemental Nutrition Program for Women, Infants, and Children Condition Per Auditor: Controls in place were not adequate to ensure the County maintained responsibility for compliance with eligibility standards when eligibility determinations are made by the contractor. Planned Corrective Action: Management has fully implemented a process, as of January 2024, by which a county representee preforms review of contractor eligibility determinations. Anticipated Completion Date: 1/31/24 Responsible Contact Person: Nataline Dean-Woods

View Audit 304593

Finding 394334 (2023-002)

Significant Deficiency 2023

Winter Grove, Inc.

CT

Eligibility HUD Housing Programs Subrecipient Monitoring

2. Finding 2023-002 c. Comments on the Finding and Each Recommendation The Enterprise Income Verification (EIV) was not completed within the 90 days period due to staffing changes. d. Action(s) Taken or Planned on the Finding The compliance monitoring report has now been completed. Staff reviewed th...

2. Finding 2023-002 c. Comments on the Finding and Each Recommendation The Enterprise Income Verification (EIV) was not completed within the 90 days period due to staffing changes. d. Action(s) Taken or Planned on the Finding The compliance monitoring report has now been completed. Staff reviewed the policies and procedures to prevent future occurrences.

View Audit 304344

Finding 394330 (2023-001)

Significant Deficiency 2023

Opportunity Resource Fund

MI

Eligibility Reporting Significant Deficiency

OPPORTUNITY RESOURCE FUND CORRECTIVE ACTION PLAN YEAR ENDED DECEMBER 31, 2023 Opportunity Resource Fund respectfully submits the following corrective action plan for the year ended December 31, 2023. Auditor: Maner Costerisan 2425 E. Grand River Avenue, Suite 1 Lansing, MI 48912 Audit period: Year e...

OPPORTUNITY RESOURCE FUND CORRECTIVE ACTION PLAN YEAR ENDED DECEMBER 31, 2023 Opportunity Resource Fund respectfully submits the following corrective action plan for the year ended December 31, 2023. Auditor: Maner Costerisan 2425 E. Grand River Avenue, Suite 1 Lansing, MI 48912 Audit period: Year ended December 31, 2023. Contact Person: Kevin Fitzerald, Vice President of Finance & CFO The findings from December 31, 2023, schedule of findings and questioned are discussed below. The findings are numbered consistently with the number assigned in the schedule. Finding: Federal Award Finding: Finding 2023-001 Recommendation: We recommend Opportunity Resource Fund, in the future, implement a review process of applicant information to ensure that all data input into the loan system is accurate. Action to be taken: Opportunity Resource Fund (OppFund) will be implementing a review process to ensure that application information properly input it into the loan servicing system accurately. OppFund will be doing this in a two-part process first by hiring a loan closing position, (starts April 1st) one of their responsibilities will be to review the application and loan servicing software to ensure accuracy. The other part will be to automate the process to ensure that the manual errors do not occur.

View Audit 304338

Finding 394329 (2023-001)

Significant Deficiency 2023

Haverstock Hills Apartments Tx24m000183

TX

HUD Housing Programs Eligibility

Finding Reference Number: 2023-1 View of Responsible Officials and Corrective Actions: Management agrees with the finding. Management will establish procedures and monitor compliance with those procedures to ensure that the determination of tenant eligibility and the maintenance of lease files a...

Finding Reference Number: 2023-1 View of Responsible Officials and Corrective Actions: Management agrees with the finding. Management will establish 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 guidelines specified by HUD. Contact Person Responsible: Flynann Janisse, Executive Director, Equality Community Housing Corporation Joshua Allen, President, J. Allen Management Co. Inc. Completion Date: Open

View Audit 304335

Finding 394241 (2023-001)

Significant Deficiency 2023

Peak Vista Community Health Centers, INC

CO

Questioned Costs Eligibility Subrecipient Monitoring

Condition – Peak Vista (“the Organization”) determines the sliding fee discount charged to patients based on the patient’s annual gross income and household size. We found two encounters where applications were not retained. Therefore, we could not determine if the sliding fee discount applied was i...

Condition – Peak Vista (“the Organization”) determines the sliding fee discount charged to patients based on the patient’s annual gross income and household size. We found two encounters where applications were not retained. Therefore, we could not determine if the sliding fee discount applied was in accordance with the guideline. Recommendation – We recommend that the Organization's procedures be strengthened to ensure income is properly verified and adequately documented and retained. The Organization should strengthen processes surrounding monitoring of the program to ensure the Organization’s policies are consistently and properly applied. Views of Responsible Officials and Planned Corrective Actions – Management agrees with the finding. Peak Vista has developed a plan for addressing this issue that includes updated procedures, training, and auditing. All teams engaged in the enrollment and eligibility process, including our Enrollment, Reception, and Billing teams will be retrained on the process with emphasis on proper documentation. The Organization management plans to incorporate into our quality assurance audits the documentation for single service date discount applications and provide feedback and retraining as necessary to staff as needed. Anticipated Date of Completion – In progress. Action Taken – We have reviewed the recommendation and have developed a plan for addressing this issue. Person Responsible for Corrective Action Plan – Ryan Spillane, Chief Financial Officer Corrective Action Plan – Ryan Spillane, Deputy Chief Financial Officer

View Audit 304236 Questioned Costs: $1

Finding 393950 (2023-002)

Significant Deficiency 2023

Columbia Gorge Community College

OR

Allowable Costs / Cost Principles Eligibility Significant Deficiency

2023-002 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles – Significant Deficiency in Internal Controls over Compliance Federal Agency Name: Department of Education Federal Assistance Listing Number: 84.425E Federal Program Name: Higher Education Emergency Relief Funds (HEERF) S...

2023-002 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles – Significant Deficiency in Internal Controls over Compliance Federal Agency Name: Department of Education Federal Assistance Listing Number: 84.425E Federal Program Name: Higher Education Emergency Relief Funds (HEERF) Student Aid Portion Finding Summary: The College did not have consistent controls in place to formerly approve a plan for distribution of funds that was documented and circulated to the College. The lack of a documented plan for distribution of funds to students increases the risk that funds were inappropriately disbursed to students at the wrong amounts. In addition, it increases the risk that the disbursements were not equitable across the student population. Responsible Individuals: Dr. Lorelle Davies, Chief Financial Officer Michael N. Espinoza, Vice President of Student Services Corrective Action Plan: HEERF procedures and processes were adopted and provided to the auditors during the audit process. Three independent outreach efforts were implemented to contact, support, and release funding to students. Limited staffing and a sense of urgency in emergency disbursements contribute less than perfect execution. Documentation was provided for all sample disbursements with a few instances of missing documentation. The Rubric for disbursement through Student Services based on a Pell and enrollment need evaluation was not available to auditors. The college can reproduce criteria to support disbursement. All HEERF funding was distributed to students that met eligibility requirements withing the June 30, 2023, disbursement deadline. Ongoing efforts include the following:  The college will continue to archive and document all disbursement records.  Continued implementation of processes and procedures for all aid disbursement to prevent future instances. Anticipated Completion Date: Completed June 30, 2023

View Audit 304126

Finding 393941 (2023-008)

Material Weakness 2023

Columbia Gorge Community College

OR

Questioned Costs Student Financial Aid Procurement, Suspension & Debarment

2023-008 – Eligibility – Material Weakness in Internal Controls over Compliance and Material Noncompliance Student Financial Assistance Cluster U.S Department of Education Federal Assistance Listing Number: 84.063, 84.268, 84.007, 84.033, 84.379 Federal Program Name: Federal Pell Grant Program, Fede...

2023-008 – Eligibility – Material Weakness in Internal Controls over Compliance and Material Noncompliance Student Financial Assistance Cluster U.S Department of Education Federal Assistance Listing Number: 84.063, 84.268, 84.007, 84.033, 84.379 Federal Program Name: Federal Pell Grant Program, Federal Direct Student Loans, Federal Supplemental Educational Opportunity Grants, Federal Work-Study Program Finding Summary: The College did not have adequate controls in place to ensure the appropriate and reasonable amounts were included in each eligible cost of attendance category for its students, that awards were properly calculated, refunds were disbursed timely and student records were accurate. The auditors were not able to conclude that the College is in compliance with eligibility requirements in the OMB compliance supplement. Repeat finding: No Responsible Individuals: Michael N. Espinoza, Vice President of Student Services Views of responsible officials and planned corrective actions: The college entered into a third-party contract to manage financial aid packaging and awarding. Calculation and reporting completed by prior Financial Director submitted national average as the college calculations instead of college service area specific calculations. The college worked with the third-party provider to ensure policies and processes adopted in July 2023 to ensure cost of attendance (COA) reporting and calculations are complete and accurate going forward. Corrective Action: The College will review their policies, procedures and controls to ensure that annually a cost of attendance schedule is approved, and that the approved schedule is used in packaging student financial aid. Rationale for adjustments made to the budgeted cost of attendance for individual students should be documented and support maintained. The College will review all processes and procedures related to eligibility to ensure controls are well documented and to properly adhere to requirements for eligibility of Title IV aid. Anticipated Completion Date: to be completed by June 30, 2024

View Audit 304126 Questioned Costs: $1

Finding 393938 (2023-005)

Material Weakness 2023

Columbia Gorge Community College

OR

Questioned Costs Student Financial Aid Special Tests & Provisions

2023-005 – Special Tests and Provisions – Return of Title IV Funds (R2T4) – Material Weakness in Internal Controls over Compliance and Material Noncompliance Student Financial Assistance Cluster Department of Education Finding Summary: This occurred because of lack of controls and processes in place...

2023-005 – Special Tests and Provisions – Return of Title IV Funds (R2T4) – Material Weakness in Internal Controls over Compliance and Material Noncompliance Student Financial Assistance Cluster Department of Education Finding Summary: This occurred because of lack of controls and processes in place to ensure supporting documentation is maintained for student’s withdrawal dates, and a lack of understanding of compliance requirements. This resulted in a failure to properly identify students requiring calculation for return of funds to the federal government, or eligibility for post withdrawal disbursement. As a result, the auditors were unable to determine if the College is remitting unearned funds to the federal government, or offering eligible students post withdrawal disbursements if available to them. Responsible Individuals: Michael N. Espinoza, Vice President of Student Services Corrective Action Plan: The college entered into a third-party contract to manage financial aid packaging and awarding. Integration and processes for the R2T4 calculation with the third-party processer was not completed correctly. New integrations, policies, and processes to be adopted in fiscal year 2023-24.  Develop and implement ongoing tracking and reporting for all financial aid reporting.  Financial Aid and Student Accounts work to regularly review and action student account files.  Continue to work with third-party service to review and promptly return Title IV funding in compliance with federal rulings. Anticipated Completion Date: to be completed by June 30, 2024

View Audit 304126 Questioned Costs: $1

Finding 393769 (2023-001)

None 2023

Pepperdine University

CA

Student Financial Aid Eligibility Reporting

Enrollment Reporting Cluster: Student Financial Assistance Federal Awarding Agency: Department of Education (ED) Award Name: Federal Pell Grant Program, Federal Direct Student Loans Award Number: Not applicable Award Year: 2022-2023 Assistance Listing Title: Federal Pell Grant Program, Federal Direc...

Enrollment Reporting Cluster: Student Financial Assistance Federal Awarding Agency: Department of Education (ED) Award Name: Federal Pell Grant Program, Federal Direct Student Loans Award Number: Not applicable Award Year: 2022-2023 Assistance Listing Title: Federal Pell Grant Program, Federal Direct Student Loans Assistance Listing Number: 84.063 and 84.268 Pass-through entities: Not applicable Facts of Finding: The University uses National Student Clearinghouse (NSC) to help report enrollment status changes to National Student Loan Data System (NSLDS). For students that had a gap in enrollment and were no longer with the University, the NSC system recognized these students as “withdrawn” regardless of whether they were reported as “withdrawn” or “graduated.” The University confirmed these students were properly reported to NSC as “graduated”; however, when the reporting from NSC to NSLDS occurred, it was based on the information recognized by NSC, and as such these students were reported as “withdrawn.” Acceptance of Finding: We agree with the above finding and will implement the corrective plan of action as described below: Corrective Plan of Action: After submission of enrollment information to the NSLDS, the University has not historically verified that the NSLDS has updated students’ enrollment status accurately. The University will formalize a process and establish procedures to regularly identify students whose enrollment status is improperly reported to NSLDS, particularly those reported as “withdrawn” instead of “graduated.” To the extent there are discrepancies between the University’s records and these students’ enrollment status in NSLDS, the University will correct the enrollment status of such students in NSLDS accordingly. This process and related procedures will be established and implemented by the close of the current fiscal year, July 31, 2024.

View Audit 303962

Finding 393714 (2023-001)

Significant Deficiency 2023

Pasquotank County

NC

Eligibility

The State provided and updated the DHB-7078 - 2nd Pa1ty Review Worksheet which separated evaluation for appl ications and recertifications. The internal worksheet which was expanded to include a weighted score for monitoring error trends and patterns for individual staff and the unit as a whole was ...

The State provided and updated the DHB-7078 - 2nd Pa1ty Review Worksheet which separated evaluation for appl ications and recertifications. The internal worksheet which was expanded to include a weighted score for monitoring error trends and patterns for individual staff and the unit as a whole was updated as well. The enhanced review sheet allows for measuring improvement and determining where additional training is needed. Supervisors complete second party reviews monthly for all staff, conduct targeted reviews for errors identified and hold individual worker conferences monthly to review discrepancies discovered and provide instruction as needed. Targeted training/instruction is also provided during monthly team meetings to review errors and provide guidance and instruction to staff for policy and NC FAST functionality updates. Based on the summary of fi ndings for this fiscal years' audit, a Single County Audit (SCA) Findings Checklist will be created and utilized to address worker processes and functiona lity concerns in NC FAST. The enhanced second party review worksheet will continue to be incorporated as an ongoing practice with review of findings to be conducted individually with staff and at each monthly unit meeting. Review of audit errors and specific instruction surrounding the errors discovered in regards to income, household composition, resources and requesting information wi II be provided to all Medicaid workers ind ividually and during the monthly unit meetings scheduled in November 2023. Following the un it meeting, targeted reviews using the SCA Findings Checkl ist focusing on these errors will be completed during the months of December 2023, January and February of 2024. Results will be compiled and shared with staff during the month ly unit meetings in March 2024 to recognize improvement and engage workers in the resolution process moving forward.

View Audit 303866

Finding 393703 (2023-002)

Significant Deficiency 2023

Planned Parenthood North Central States

MN

Internal Control / Segregation of Duties Eligibility Significant Deficiency

Title X – Assistance Listing No. 93.217Recommendation: We recommend management review its patient intake process to ensure income and household size is properly verified, adequately documented, and retained for each patient in accordance with organizational policies and program requirements. Explana...

Title X – Assistance Listing No. 93.217Recommendation: We recommend management review its patient intake process to ensure income and household size is properly verified, adequately documented, and retained for each patient in accordance with organizational policies and program requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PPNCS has put a process in place to ensure patient income and household size is accurately identified and documented. Patients report their income and household size to the health center staff, who enter the information into the electronic medical record system (NextGen). After the information is entered, a registration form (B209) is printed and given to the patient to review, verify, and sign. Name of the contact person responsible for corrective action: Randy Drager, CFO Planned completion date for corrective action plan: April 15, 2024

View Audit 303852

Finding 393554 (2023-007)

Significant Deficiency 2023

Scotland County of North Carolina

NC

Eligibility

Finding: 2023-006 Name of contact person: Corrective action: Proposed completion date: Finding: 2023-007 Name of contact person: Corrective action: Proposed completion date: Corrective Actions for Finding 2023-003, 2023-004, 2023-005, 2023-006 and 2023-007 also apply to the State findings. Shaneall ...

Finding: 2023-006 Name of contact person: Corrective action: Proposed completion date: Finding: 2023-007 Name of contact person: Corrective action: Proposed completion date: Corrective Actions for Finding 2023-003, 2023-004, 2023-005, 2023-006 and 2023-007 also apply to the State findings. Shaneall Kollock, Medicaid Program Manager Adult and Family Medicaid Supervisors will train staff on the importance of entering the correct information, so that the case is processed correctly. Targeted reviews will be completed by both Medicaid Supervisors for 3 months, 2 reviews for each staff member. Section IV - State Award Findings and Question Costs Training was completed on 12/5/2023 for Adult Medicaid and 12/6/2023 for Family & Children's Medicaid. Training logs are availalbe. Targeted reviews began on 12/1/2023 and will end on 2/28/2024 if improvements are noted and no further errors noted. Review logs will document those targeted reviews. Quality Assurance staff will review findngs, recommendations, and make any adjustments needed to 2nd party forms. Training was completed on 12/5/2023 for Adult Medicaid and 12/6/2023 for Family & Children's Medicaid. Training logs are availalbe. Targeted reviews began on 12/1/2023 and will end on 2/28/2024 if improvements are noted and no further errors noted. Review logs will document those targeted reviews. Quality Assurance staff will review findngs, recommendations, and make any adjustments needed to 2nd party forms. Shaneall Kollock, Medicaid Program Manager Adult and Family Medicaid Supervisors will train staff on the importance of entering the correct information, so that the case is processed correctly. Targeted reviews will be completed by both Medicaid Supervisors for 3 months, 2 reviews for each staff member.

View Audit 303698

Finding 393553 (2023-006)

Significant Deficiency 2023

Scotland County of North Carolina

NC

Eligibility Reporting

Finding: 2023-006 Name of contact person: Corrective action: Proposed completion date: Finding: 2023-007 Name of contact person: Corrective action: Proposed completion date: Corrective Actions for Finding 2023-003, 2023-004, 2023-005, 2023-006 and 2023-007 also apply to the State findings. Shaneall ...

Finding: 2023-006 Name of contact person: Corrective action: Proposed completion date: Finding: 2023-007 Name of contact person: Corrective action: Proposed completion date: Corrective Actions for Finding 2023-003, 2023-004, 2023-005, 2023-006 and 2023-007 also apply to the State findings. Shaneall Kollock, Medicaid Program Manager Adult and Family Medicaid Supervisors will train staff on the importance of entering the correct information, so that the case is processed correctly. Targeted reviews will be completed by both Medicaid Supervisors for 3 months, 2 reviews for each staff member. Section IV - State Award Findings and Question Costs Training was completed on 12/5/2023 for Adult Medicaid and 12/6/2023 for Family & Children's Medicaid. Training logs are availalbe. Targeted reviews began on 12/1/2023 and will end on 2/28/2024 if improvements are noted and no further errors noted. Review logs will document those targeted reviews. Quality Assurance staff will review findngs, recommendations, and make any adjustments needed to 2nd party forms. Training was completed on 12/5/2023 for Adult Medicaid and 12/6/2023 for Family & Children's Medicaid. Training logs are availalbe. Targeted reviews began on 12/1/2023 and will end on 2/28/2024 if improvements are noted and no further errors noted. Review logs will document those targeted reviews. Quality Assurance staff will review findngs, recommendations, and make any adjustments needed to 2nd party forms. Shaneall Kollock, Medicaid Program Manager Adult and Family Medicaid Supervisors will train staff on the importance of entering the correct information, so that the case is processed correctly. Targeted reviews will be completed by both Medicaid Supervisors for 3 months, 2 reviews for each staff member.

View Audit 303698

Finding 393552 (2023-005)

Significant Deficiency 2023

Scotland County of North Carolina

NC

Eligibility Reporting

Finding: 2023-004 Name of contact person: Corrective action: Proposed completion date: Finding: 2023-005 Name of contact person: Corrective action: Proposed completion date: Shaneall Kollock, Medicaid Program Manager Adult and Family Medicaid Supervisors will train staff on the importance of enterin...

Finding: 2023-004 Name of contact person: Corrective action: Proposed completion date: Finding: 2023-005 Name of contact person: Corrective action: Proposed completion date: Shaneall Kollock, Medicaid Program Manager Adult and Family Medicaid Supervisors will train staff on the importance of entering the correct information, so that the case is processed correctly. Targeted reviews will be completed by both Medicaid Supervisors for 3 months, 2 reviews for each staff member. Section III - Federal Award Findings and Question Costs (continued) Shaneall Kollock, Medicaid Program Manager Adult Medicaid Supervisors will train staff on the importance of entering the correct information, so that the case is processed correctly. Targeted reviews will be completed by both Medicaid Supervisors for 3 months, 2 reviews for each staff member. Training was completed on 12/5/2023 for Adult Medicaid and 12/6/2023 for Family & Children's Medicaid. Training logs are availalbe. Targeted reviews began on 12/1/2023 and will end on 2/28/2024 if improvements are noted and no further errors noted. Review logs will document those targeted reviews. Quality Assurance staff will review findngs, recommendations, and make any adjustments needed to 2nd party forms. Training was completed on 12/5/2023 for Adult Medicaid. Training logs are availalbe. Targeted reviews began on 12/1/2023 and will end on 2/28/2024 if improvements are noted and no further errors noted. Review logs will document those targeted reviews. Quality Assurance staff will review findngs, recommendations, and make any adjustments needed to 2nd party forms.

View Audit 303698

Finding 393551 (2023-004)

Significant Deficiency 2023

Scotland County of North Carolina

NC

Eligibility Internal Control / Segregation of Duties

Finding: 2023-004 Name of contact person: Corrective action: Proposed completion date: Finding: 2023-005 Name of contact person: Corrective action: Proposed completion date: Shaneall Kollock, Medicaid Program Manager Adult and Family Medicaid Supervisors will train staff on the importance of enterin...

Finding: 2023-004 Name of contact person: Corrective action: Proposed completion date: Finding: 2023-005 Name of contact person: Corrective action: Proposed completion date: Shaneall Kollock, Medicaid Program Manager Adult and Family Medicaid Supervisors will train staff on the importance of entering the correct information, so that the case is processed correctly. Targeted reviews will be completed by both Medicaid Supervisors for 3 months, 2 reviews for each staff member. Section III - Federal Award Findings and Question Costs (continued) Shaneall Kollock, Medicaid Program Manager Adult Medicaid Supervisors will train staff on the importance of entering the correct information, so that the case is processed correctly. Targeted reviews will be completed by both Medicaid Supervisors for 3 months, 2 reviews for each staff member. Training was completed on 12/5/2023 for Adult Medicaid and 12/6/2023 for Family & Children's Medicaid. Training logs are availalbe. Targeted reviews began on 12/1/2023 and will end on 2/28/2024 if improvements are noted and no further errors noted. Review logs will document those targeted reviews. Quality Assurance staff will review findngs, recommendations, and make any adjustments needed to 2nd party forms. Training was completed on 12/5/2023 for Adult Medicaid. Training logs are availalbe. Targeted reviews began on 12/1/2023 and will end on 2/28/2024 if improvements are noted and no further errors noted. Review logs will document those targeted reviews. Quality Assurance staff will review findngs, recommendations, and make any adjustments needed to 2nd party forms.

View Audit 303698

Finding 393550 (2023-003)

Significant Deficiency 2023

Scotland County of North Carolina

NC

Eligibility Internal Control / Segregation of Duties

Finding: 2023-003 Name of contact person: Corrective action: Proposed completion date: Family Medicaid Supervisor has trained staff on when completing a child support referral is required. Targeted reviews will be completed by the Family Medicaid Supervisor for 3 months, 2 reviews for each staff mem...

Finding: 2023-003 Name of contact person: Corrective action: Proposed completion date: Family Medicaid Supervisor has trained staff on when completing a child support referral is required. Targeted reviews will be completed by the Family Medicaid Supervisor for 3 months, 2 reviews for each staff member. Section III - Federal Award Findings and Question Costs These errors and the finding were reviewed with the Family & Children's Medicaid staff. There will be no training as this requirement is currently not required per Admin Letter 13-23. Shaneall Kollock, Medicaid Program Manager

View Audit 303698

Finding 393405 (2023-011)

Significant Deficiency 2023

Northampton County

NC

Eligibility Significant Deficiency

Finding 2023-011 Inaccurate Resources Entry Name of contact: Lisa Broady, Adult Medicaid Supervisor Corrective Action: Proposed Completion Date: Corrective Actions for finding 2023-008, 2023-009, 2023-010, and 2023-011 also apply to State Award findings. Section IV - State Award Findings and Questio...

Finding 2023-011 Inaccurate Resources Entry Name of contact: Lisa Broady, Adult Medicaid Supervisor Corrective Action: Proposed Completion Date: Corrective Actions for finding 2023-008, 2023-009, 2023-010, and 2023-011 also apply to State Award findings. Section IV - State Award Findings and Question Costs Unit meetings will be held during the week of March 4, 2024 with implementation effective immediately. Section III - Federal Award Findings and Question Costs (continued) Adult Medicaid supervisors will be meeting with staff to ensure that all resources have been updated, entered and documented correctly in NCFast and case files and NCFast are matching. A unit meeting will be scheduled to be held during the week of March 4, 2024 with implementation effective immediately.

View Audit 303645

Finding 393404 (2023-010)

Significant Deficiency 2023

Northampton County

NC

Eligibility Significant Deficiency

Finding 2023-008 IV-D Cooperation with Child Support Name of contact: Felicia Bullock, Family and Children’s Medicaid Supervisor Corrective Action: Proposed Completion Date: Finding 2023-009 Inaccurate Information Entry Name of contact: Corrective Action: Proposed Completion Date: Finding 2023-010 I...

Finding 2023-008 IV-D Cooperation with Child Support Name of contact: Felicia Bullock, Family and Children’s Medicaid Supervisor Corrective Action: Proposed Completion Date: Finding 2023-009 Inaccurate Information Entry Name of contact: Corrective Action: Proposed Completion Date: Finding 2023-010 Inadequate Request for Information Name of contact: Corrective Action: Family and Children's Medicaid with staff on making sure TWN and OVS is ran on every application and recert as well as paying attention to other information received. Adult Medicaid supervisors will meet with staff to ensure that the TWN is being run in NCFast for all applications/recerts and that all case files include online verifications and case documentation of all resources countable and non-countable for vehicles and property. Section III - Federal Award Findings and Question Costs Family and Children's Medicaid supervisors will be meeting with staff to ensure they are receiving correct information, counting and entering correct information into NCF. Supervisor will randomly check at least 10 cases a month to assure accuracy. Adult Medicaid supervisors will be meeting with staff to ensure that they are imputing and listing income correctly in NCFast on all applications/recerts. Also, will ensure that prior to case terminations, clients have been evaluated properly for all AMA programs and proper procedures have been followed before terminating a case. Unit meetings will be held during the week of March 4, 2024 with implementation effective immediately. Supervisor will continue to review 10 cases each month to assure correct information has been keyed and correct procedures has been done prior to case termination. Family and Children's Medicaid supervisors will meet with staff on IV-D referrals and discuss when to key them. A unit meeting with staff during the week of March 4, 2024.

View Audit 303645

Finding 393403 (2023-009)

Significant Deficiency 2023

Northampton County

NC

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Finding 2023-008 IV-D Cooperation with Child Support Name of contact: Felicia Bullock, Family and Children’s Medicaid Supervisor Corrective Action: Proposed Completion Date: Finding 2023-009 Inaccurate Information Entry Name of contact: Corrective Action: Proposed Completion Date: Finding 2023-010 I...

Finding 2023-008 IV-D Cooperation with Child Support Name of contact: Felicia Bullock, Family and Children’s Medicaid Supervisor Corrective Action: Proposed Completion Date: Finding 2023-009 Inaccurate Information Entry Name of contact: Corrective Action: Proposed Completion Date: Finding 2023-010 Inadequate Request for Information Name of contact: Corrective Action: Family and Children's Medicaid with staff on making sure TWN and OVS is ran on every application and recert as well as paying attention to other information received. Adult Medicaid supervisors will meet with staff to ensure that the TWN is being run in NCFast for all applications/recerts and that all case files include online verifications and case documentation of all resources countable and non-countable for vehicles and property. Section III - Federal Award Findings and Question Costs Family and Children's Medicaid supervisors will be meeting with staff to ensure they are receiving correct information, counting and entering correct information into NCF. Supervisor will randomly check at least 10 cases a month to assure accuracy. Adult Medicaid supervisors will be meeting with staff to ensure that they are imputing and listing income correctly in NCFast on all applications/recerts. Also, will ensure that prior to case terminations, clients have been evaluated properly for all AMA programs and proper procedures have been followed before terminating a case. Unit meetings will be held during the week of March 4, 2024 with implementation effective immediately. Supervisor will continue to review 10 cases each month to assure correct information has been keyed and correct procedures has been done prior to case termination. Family and Children's Medicaid supervisors will meet with staff on IV-D referrals and discuss when to key them. A unit meeting with staff during the week of March 4, 2024.

View Audit 303645

Finding 393402 (2023-008)

Significant Deficiency 2023

Northampton County

NC

Eligibility Significant Deficiency

Finding 2023-008 IV-D Cooperation with Child Support Name of contact: Felicia Bullock, Family and Children’s Medicaid Supervisor Corrective Action: Proposed Completion Date: Finding 2023-009 Inaccurate Information Entry Name of contact: Corrective Action: Proposed Completion Date: Finding 2023-010 I...

Finding 2023-008 IV-D Cooperation with Child Support Name of contact: Felicia Bullock, Family and Children’s Medicaid Supervisor Corrective Action: Proposed Completion Date: Finding 2023-009 Inaccurate Information Entry Name of contact: Corrective Action: Proposed Completion Date: Finding 2023-010 Inadequate Request for Information Name of contact: Corrective Action: Family and Children's Medicaid with staff on making sure TWN and OVS is ran on every application and recert as well as paying attention to other information received. Adult Medicaid supervisors will meet with staff to ensure that the TWN is being run in NCFast for all applications/recerts and that all case files include online verifications and case documentation of all resources countable and non-countable for vehicles and property. Section III - Federal Award Findings and Question Costs Family and Children's Medicaid supervisors will be meeting with staff to ensure they are receiving correct information, counting and entering correct information into NCF. Supervisor will randomly check at least 10 cases a month to assure accuracy. Adult Medicaid supervisors will be meeting with staff to ensure that they are imputing and listing income correctly in NCFast on all applications/recerts. Also, will ensure that prior to case terminations, clients have been evaluated properly for all AMA programs and proper procedures have been followed before terminating a case. Unit meetings will be held during the week of March 4, 2024 with implementation effective immediately. Supervisor will continue to review 10 cases each month to assure correct information has been keyed and correct procedures has been done prior to case termination. Family and Children's Medicaid supervisors will meet with staff on IV-D referrals and discuss when to key them. A unit meeting with staff during the week of March 4, 2024.

View Audit 303645

Finding 393377 (2023-001)

Significant Deficiency 2023

Mi Residential Community, Inc. 023-11147

MA

HUD Housing Programs Eligibility Reporting

U.S. Department of Housing and Urban Development, passed through the Massachusetts Housing Finance Agency Section 8 Housing Assistance Payments Program – Assistance Listing No. 14.195 Significant Deficiencies 2023-001 Condition: 1) Housing assistance and tenant payments for 2 of the 40 tenant file...

U.S. Department of Housing and Urban Development, passed through the Massachusetts Housing Finance Agency Section 8 Housing Assistance Payments Program – Assistance Listing No. 14.195 Significant Deficiencies 2023-001 Condition: 1) Housing assistance and tenant payments for 2 of the 40 tenant files selected for testing were calculated incorrectly due to errors in the amounts used for income. 2) The asset values for 10 of the 40 tenant files and the interest income for 3 of the 40 tenant files selected for testing were not reported correctly on Form HUD-50059. This had no impact on the housing assistance and tenant payments. 3) There were no sufficient documentation for 2 of the 40 tenant files selected for testing to support the asset values reported on Form HUD-50059. 4) 1 of the 40 tenant files selected for testing was missing an Existing Tenant Search report. 5) The Existing Tenant Search report for 2 of the 40 tenant files selected for testing stated that the tenants may be receiving rental assistance at another housing agency, however there was no evidence to show that the Community had followed up with the tenant and/or the housing agency to avoid a double subsidy. Auditor's Recommendation: We recommend that an internal control procedure be implemented to ensure that all HUD-50059 forms are completed accurately and all required information is obtained and maintained within the tenant files. Action Taken: 1) Management will meet with tenants to properly investigate causation for the finding above. Management will correct the audited annual recertification with the expectation of correcting the income used to tabulate the tenants’ level of rental assistance. For the file where the tenant was overcharged, the tenant will be reimbursed for administrative error. For the file where the rental subsidy was being overcharged, HUD will be reimbursed for the subsidy accordingly. 2) Management will correct all audited annual recertifications with correct asset values and/or interest income. Management will also insert file clarification notes to all files that are edited to ensure transparency and notate that the corrected asset values and/or interest income will not affect the tenants’ level of rental assistance. Management will implement internal control procedures to ensure that all asset and interest income values are reported correctly in the future. 3) Management will meet with tenants to properly investigate causation for the finding above. Management will correct annual recertification reporting and properly document tenant files accordingly. Management will implement internal control procedures to ensure that staff is only accepting proper verifications per the HUD handbook in the future. 4) Management will ensure that the tenant has an Existing Tenant Search report in the file. Management has removed all tenant information that does not correspond to this tenant file. Management will implement internal control procedures to ensure that documents are not being misfiled. 5) Management will meet with tenants to properly investigate causation for the finding above. Management will determine if possible double subsidies exist. Management will follow up with respective PHA or owner if necessary to confirm if the tenant is being assisted at the other location. Management will properly document all contacts made or information obtained to determine if a household is receiving multiple subsidies or not. When the tenants’ multiple subsidies are discussed and resolved, management will ensure that all evidence is included within the tenant file.

View Audit 303633

Finding 393358 (2023-008)

Significant Deficiency 2023

South Carolina State Housing Finance and Development Authority

SC

Questioned Costs Eligibility HUD Housing Programs

Housing Voucher Cluster – Assistance Listing Numbers 14.871/14.879 Recommendation: We recommend the Authority implements controls to ensure that tenant files contain all required documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action...

Housing Voucher Cluster – Assistance Listing Numbers 14.871/14.879 Recommendation: We recommend the Authority implements controls to ensure that tenant files contain all required documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Current processes in place require collection and review of documentation by individual HPC assigned to a particular file. Upon transfer to the associated administrative team member, a second review is to be conducted to verify all required documentation is present. Any omissions require the HPC to reach out and supply mission documentation before action can be processed. We also secured a contract with The Work Number solution to assist with third party income verifications. Name(s) of the contact person(s) responsible for corrective action: Entire HCVP team and management. Planned completion date for corrective action plan: Currently implemented and ongoing.

View Audit 303627 Questioned Costs: $1

Finding 393284 (2023-001)

Significant Deficiency 2023

Millennium - Janesville I, Inc.

IL

HUD Housing Programs Eligibility

Statement of condition #2023-001: During the year ended September 30, 2023, 1 of 2 resident files selected for testing under the HUD Consolidated Audit Guide was unable to be located by the Agent. Recommendation: The current Management Agent should ensure that all resident files are maintained at ...

Statement of condition #2023-001: During the year ended September 30, 2023, 1 of 2 resident files selected for testing under the HUD Consolidated Audit Guide was unable to be located by the Agent. Recommendation: The current Management Agent should ensure that all resident files are maintained at the site for each resident of the Property, and the Management Agent should ensure that the resident files include all properly executed and documented resident eligibility forms. Action(s) taken or planned on the finding: Management intends to update all resident files as needed to include all resident eligibility forms to ensure the Property is in compliance during the year ended September 30, 2024.

View Audit 303576

Finding 393253 (2023-027)

Significant Deficiency 2023

State of New Jersey

NJ

Internal Control / Segregation of Duties Special Tests & Provisions Procurement, Suspension & Debarment § 200.303

The audit finding noted one Consultative Examination (CE) provider where the qualified provider review was not completed timely and this was an oversight on the part of the Department of Labor and Workforce Development’s Division of Disability Services (DDS) due to attrition of staff. Going forward...

The audit finding noted one Consultative Examination (CE) provider where the qualified provider review was not completed timely and this was an oversight on the part of the Department of Labor and Workforce Development’s Division of Disability Services (DDS) due to attrition of staff. Going forward, each DDS Professional Relations Officer will be responsible for reviewing eight to 10 CE provider’s qualifications each month until the yearly review is completed for each vendor. The Chief of Professional Relations will submit a monthly report to the DDS Assistant Director detailing how many sites were visited that month and any findings that may have occurred. Each month, the report will detail how many reports remain outstanding in order to complete the yearly reviews. COMPLETION DATE/ CONTACT PERSON & PHONE# April 9, 2024 Theresa Vallely (609) 984-1779 Theresa.Vallely@dol.nj.gov

View Audit 303516

Finding 393192 (2023-003)

Material Weakness 2023

State of New Jersey

NJ

Special Tests & Provisions Eligibility Material Weakness § 200.303

The Department of Labor and Workforce Development (DLWD) will continue to review and enhance controls to ensure that BAM quality control case investigations are completed timely, that reviews are signed as required by appropriate staff, and that all required case review supporting documentation is m...

The Department of Labor and Workforce Development (DLWD) will continue to review and enhance controls to ensure that BAM quality control case investigations are completed timely, that reviews are signed as required by appropriate staff, and that all required case review supporting documentation is maintained in case files. DLWD corrective actions will be completed by September 30, 2024. COMPLETION DATE/ CONTACT PERSON September 30, 2024 Theresa Vallely (609) 984-1779 Theresa.Vallely@dol.nj.gov

View Audit 303516

Corrective Action Plans

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