Corrective Action Plans

Finding 392943 (2023-007)

Significant Deficiency 2023

Navajo Health Foundation - Sage Memorial Hospital Inc.

AZ

Eligibility Procurement, Suspension & Debarment

Management’s Response: The Purchase Referred Care (PRC) Team of the PRC Supervisor and PRC staff are responsible for implementing proper processes and procedures for ensuring proper eligibility verification and documentation prior to payment of PRC claims. PRC staff attended a PRC training regarding...

Management’s Response: The Purchase Referred Care (PRC) Team of the PRC Supervisor and PRC staff are responsible for implementing proper processes and procedures for ensuring proper eligibility verification and documentation prior to payment of PRC claims. PRC staff attended a PRC training regarding eligibility verification on August 2-3, 2023, conducted Indian Health Service. Since, staff have increased their knowledge of eligibility requirements. Estimated Completion Date: September 30, 2024 Responsible Position: Chief Financial Officer, Purchase Referred Care (PRC) Supervisor, and Prior Authorization and Claims Technician

View Audit 303220

Finding 392938 (2023-001)

Significant Deficiency 2023

Northwestern University

IL

Student Financial Aid Eligibility Period of Performance § 200.303

Federal Award Findings and Questions Costs Corrective Action Plan Year Ended August 31, 2023 Finding No. 2023-001: Inaccurate Enrollment Reporting CFDA Numbers: Various Program: Student Financial Assistance Cluster Corrective Action: Students will be required to request spe...

Federal Award Findings and Questions Costs Corrective Action Plan Year Ended August 31, 2023 Finding No. 2023-001: Inaccurate Enrollment Reporting CFDA Numbers: Various Program: Student Financial Assistance Cluster Corrective Action: Students will be required to request special permission to re-enroll, thus ensuring that their graduation is reported before any additional enrollment or withdrawal. Additionally, a thorough assessment of the management review process will be performed to identify areas that will help ensure the accurate submission of data to the NSLDS. We anticipate revised processes in the Spring of 2024. Contact Person: Jaci Casazza Expected Implementation: April 30, 2024

View Audit 303217

Finding 392908 (2023-002)

Significant Deficiency 2023

Rosemont College of the Holy Child Jesus

PA

Student Financial Aid Procurement, Suspension & Debarment Allowable Costs / Cost Principles

When SAP is run in the spring, students will be notified of their academic standing. Students who are suspended will have an opportunity to appeal their suspension. If the appeal of suspension is approved, students will meet with their academic advisor to be placed on an academic plan. The academic ...

When SAP is run in the spring, students will be notified of their academic standing. Students who are suspended will have an opportunity to appeal their suspension. If the appeal of suspension is approved, students will meet with their academic advisor to be placed on an academic plan. The academic plan must be signed by both the student and advisor. The academic plan must be submitted to the Office of Financial Aid via the teams. A financial aid hold will be placed on the student's account until the signed academic plan is received. Once received, the Office of Financial Aid will remove the hold so the student can be awarded.

View Audit 303193

Finding 392898 (2023-001)

Significant Deficiency 2023

North Providence Housing Authority

RI

HUD Housing Programs Eligibility Significant Deficiency

The North Providence Housing Authority will be creating a check list which will include Income Verification as part of the participants file to be used for examinations, and reexaminations of income. This check list will be completed by the Housing Authority staff member, signed, and dated, showing ...

The North Providence Housing Authority will be creating a check list which will include Income Verification as part of the participants file to be used for examinations, and reexaminations of income. This check list will be completed by the Housing Authority staff member, signed, and dated, showing that all required documents have been obtained and used for a successful processing of the tenants rent. Additionally, due to being a small housing authority, with only one HCV staff member, we have hired an HCV Assistant to help the HCV Coordinator in obtaining all information needed to comply with HUD’s regulations. Planned Implementation Date of Corrective Action: January 1, 2024 Planned Implementation Date of Corrective Action: Eileen Reyes/Michael McMahon/ Cheryl Lonardo

View Audit 303175

Finding 392869 (2023-002)

Significant Deficiency 2023

Sioux Falls Housing and Redevelopment Commission

SD

HUD Housing Programs Eligibility Significant Deficiency

Contact Person Brent Tucker, Interim Executive Director Corrective Action Plan Management has begun the process of creating a quality control plan to ensure that all files are accurate and follow all local, state and federal compliance guidelines. An Independent entity has also been hired to review ...

Contact Person Brent Tucker, Interim Executive Director Corrective Action Plan Management has begun the process of creating a quality control plan to ensure that all files are accurate and follow all local, state and federal compliance guidelines. An Independent entity has also been hired to review all current files and all corrections have been made. Planned Completion Date for CAP April 30, 2024

View Audit 303161

Finding 392770 (2023-001)

Material Weakness 2023

Edgewood Seniors Preservation Corporation

DC

HUD Housing Programs Eligibility Reporting

Management was made aware of instances where timely recertifications were not being performed. To ensure these situations do not continue to occur, Management made the following improvements to their internal processes: 1. Recertification reminder letters are being consistently sent to residents at...

Management was made aware of instances where timely recertifications were not being performed. To ensure these situations do not continue to occur, Management made the following improvements to their internal processes: 1. Recertification reminder letters are being consistently sent to residents at 120, 90, 60, and 30 days prior to recertification date. 2. Incentives were put in place to encourage site associates to complete recertification tasks timely including staff lunches. After working hour sessions are also being held. 3. Third party consultants are being utilized when necessary. 4. Site associates are going door to door and enlisting help from Resident Services teams to engage residents. Management is aware of the required use of the EIV system reports. Management believes the instance in which noncompliance occurred was due to lack of training and experience of certain individuals and has further addressed this condition by implementing additional training for all associates.

View Audit 303124

Finding 392600 (2023-003)

Material Weakness 2023

Chugachmiut

AK

Eligibility Internal Control / Segregation of Duties Material Weakness

Finding 2023-003: Material Weakness in Internal Control over Compliance – Eligibility. Name of Contact Person: Phyllis Wimberley, Deputy Director. Corrective Action: The Heritage program will create and implement a checklist of required documentation to ensure all participants are eligible to partic...

Finding 2023-003: Material Weakness in Internal Control over Compliance – Eligibility. Name of Contact Person: Phyllis Wimberley, Deputy Director. Corrective Action: The Heritage program will create and implement a checklist of required documentation to ensure all participants are eligible to participate in the program. Proposed Completion Date: June 2024

View Audit 302897

Finding 392580 (2023-003)

Significant Deficiency 2023

Bristol Bay Area Health Corporation and Subsidiary

AK

Eligibility Significant Deficiency

Finding 2023-003 Eligibility – Noncompliance and Significant Deficiency in Internal Control over Compliance. Planned Corrective Actions: The Organization provided documentation of beneficiary status for 38 of the 40 patients being tested. The remaining two patients were treated in remote villages an...

Finding 2023-003 Eligibility – Noncompliance and Significant Deficiency in Internal Control over Compliance. Planned Corrective Actions: The Organization provided documentation of beneficiary status for 38 of the 40 patients being tested. The remaining two patients were treated in remote villages and there was no documentation in their records. Management has reinforced the policy requiring documentation of beneficiary status and the Patient Access Manager has developed a registration performance improvement plan. Anticipated Completion Date: June 30, 2024.

View Audit 302857

Finding 392487 (2023-007)

Material Weakness 2023

Roosevelt County

MT

Procurement, Suspension & Debarment Eligibility § 200.214

CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS, ASSISTANCE LISTING No. 21.027, PROCUREMENT AND SUSPENSION AND DEBARMENT Name of contact person: County Commissioners Corrective Action: Roosevelt County will follow the procedure of verifying contractors through SAM or GSA Websites when using SLFR...

CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS, ASSISTANCE LISTING No. 21.027, PROCUREMENT AND SUSPENSION AND DEBARMENT Name of contact person: County Commissioners Corrective Action: Roosevelt County will follow the procedure of verifying contractors through SAM or GSA Websites when using SLFRF funds. Proposed Completion Date: Immediately.

View Audit 302827

Finding 392257 (2023-001)

Material Weakness 2023

Home Share 092-Hd017

MN

Internal Control / Segregation of Duties Eligibility HUD Housing Programs § 200.303

Finding: 2023-001 – Compliance and Controls over Compliance – Eligibility Supportive Housing for Persons with Disabilities (Section 811), CFDA No. 14.181 Material Weakness & Noncompliance In 2023, Home Share did not have controls in place to ensure that eligibility criteria and rent calculations w...

Finding: 2023-001 – Compliance and Controls over Compliance – Eligibility Supportive Housing for Persons with Disabilities (Section 811), CFDA No. 14.181 Material Weakness & Noncompliance In 2023, Home Share did not have controls in place to ensure that eligibility criteria and rent calculations were being reviewed and/or approved by someone other than the individual making the initial determination or annual recertification. Actions Taken or Planned: Management agrees with this finding. Beginning in September 2023, management has changed the contractor they work with for the eligibility determination process. Management is working with the contractor to include a second individual in this process so that there will be a review performed by someone other than the individual making the initial determination or annual recertification. Contact Persons: Robert Pickering, Chief Financial Officer

View Audit 302523

Finding 392153 (2023-007)

Material Weakness 2023

City of Baldwin Park

CA

Subrecipient Monitoring Eligibility HUD Housing Programs

2023-007 - Special Tests – Internal Control and Compliance over Housing Quality Standards Inspections (Material Weakness) Condition: We found five (5) instances out of 9 in which the City did not conduct the HQS failed inspection follow up in a timely manner. We also noted three (3) instances out of...

2023-007 - Special Tests – Internal Control and Compliance over Housing Quality Standards Inspections (Material Weakness) Condition: We found five (5) instances out of 9 in which the City did not conduct the HQS failed inspection follow up in a timely manner. We also noted three (3) instances out of 40 samples for eligibility testing has HQS inspections that are over a year apart, which shows that the City did not conduct the HQS biennial inspection in a timely manner. Management concurs. Corrective Actions: Management has directed staff to abide by the PHA policy and HUD regulations for the HQS inspection process. Management will continue to enforce HUD regulations and the use of the PHA’s administrative plan to ensure staff will conduct the HQS biennial inspection in a timely manner. Name of Responsible Person: Ron Garcia, Director of Community Development Imelda Delgado, Housing Manager Projected Implementation Date: Immediately implemented.

View Audit 302364

Finding 392102 (2023-001)

Significant Deficiency 2023

Child Nutrition, INC

VA

Subrecipient Monitoring Eligibility Internal Control / Segregation of Duties

Corrective Action Taken or Planned: Child Nutrition, Inc. is in contact with the Virginia Department of Health (VDH) awaiting official written notification of the requirement that the three visits per year take place within the fiscal year. Immediately, for the current fiscal year (FY2024), the Ex...

Corrective Action Taken or Planned: Child Nutrition, Inc. is in contact with the Virginia Department of Health (VDH) awaiting official written notification of the requirement that the three visits per year take place within the fiscal year. Immediately, for the current fiscal year (FY2024), the Executive Director analyzed the Review History Report for all active providers to ensure compliance within the current fiscal year. The Executive Director drafted and finalized Reports Required to ensure Monitor Compliance within Fiscal Year (October – September) on March 11, 2024 and trained all Organization staff on March 14, 2024. Reports Required to ensure Monitor Compliance within Fiscal Year (October – September) • Review History Report: Executive Director and Field Specialist Manager are to review quarterly and communicate with Field Specialist if there are any discrepancies or required action. Field Specialists are required to run report for their case load and review quarterly. • Provider Due Reviews: Executive Director and Field Specialist Manager are to review monthly and communicate with Field Specialist if there are any discrepancies or required action. Field Specialists are required to run report for their case load and review monthly • Providers Not Trained: Executive Director and Field Specialist Manager are to review monthly and communicate with Field Specialist if there are any discrepancies or required action. Field Specialists are required to run report for their case load and review monthly • Sponsor Review Worksheet – Past Review History Executive Director and Program Manager will review the past review history on the Sponsor Review Worksheet as reports are received and entered into Minute Menu. The Program Manager will update Review# in Minute Menu. The Executive Director will edit next review due date as necessary. Name of Contact Person: Elizabeth Wittusen, Executive Director Phone Number of Contact Person: (540) 347-3767 Projected Completion Date: March 2024

View Audit 302252

Finding 392088 (2023-003)

Significant Deficiency 2023

Housing Authority of Prince George's County

MD

HUD Housing Programs Eligibility Significant Deficiency

Recommendation: We recommend the Authority review their process and internal controls for new tenants to ensure compliance with HUD requirements and their administrative plan. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response t...

Recommendation: We recommend the Authority review their process and internal controls for new tenants to ensure compliance with HUD requirements and their administrative plan. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Under the leadership of the newly appointed Executive Director, HAPGC will develop and implement to internal control policies to ensure waiting list selection notices are properly documented in client files, and voucher forms and HAP contracts are appropriately executed. Additional efforts will be placed on increasing the number internal quality control reviews performed of re-examination transactions to ensure adherence to the above listed compliance items. Name(s) of the contact person(s) responsible for corrective action: Jessica Anderson-Preston Planned completion date for corrective action plan: November 30, 2024.

View Audit 302221

Finding 392086 (2023-002)

Significant Deficiency 2023

Housing Authority of Prince George's County

MD

Questioned Costs HUD Housing Programs Eligibility

Recommendation: We recommend the Authority review their process and internal controls over eligibility to ensure compliance with HUD requirements and their administrative plan. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response t...

Recommendation: We recommend the Authority review their process and internal controls over eligibility to ensure compliance with HUD requirements and their administrative plan. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Under the leadership of the newly appointed Executive Director, HAPGC will assess the overall operations of the Housing Choice Voucher Program. The assessment will include the following: a review of the overall effectiveness of the current voucher department management, a review and comprehensive update of the Administrative Plan; comprehensive staff training on the proper implementation and correct calculation and documentation of HUD program eligibility requirements including but not limited to income, assets, and expenses related to deductions from annual income and other factors that affect the determination of adjusted income. HAPGC will also implement policies to ensure the timely completion of annual re-examinations, and the proper retainage of supporting documentation for re-examination actions. Additional efforts will be placed on increasing the number internal quality control reviews performed of re-examination transactions to ensure adherence to the above listed compliance items. Efforts will also be place on increasing staffing levels and decreasing the amount of time required to fill vacant positions. Name(s) of the contact person(s) responsible for corrective action: Jessica Anderson-Preston Planned completion date for corrective action plan: November 30, 2024.

View Audit 302221 Questioned Costs: $1

Finding 392083 (2023-004)

Material Weakness 2023

Lss Housing Jamestown, Inc.

ND

Allowable Costs / Cost Principles Eligibility Special Tests & Provisions § 200.334

US Department of Housing and Urban Development Federal Financial Assistance Listing #14.157 Supportive Housing for the Elderly (Section 202) Finding Summary: As a result of management transition, supporting documentation for expense transactions and tenant eligibility were destroyed and were unable ...

US Department of Housing and Urban Development Federal Financial Assistance Listing #14.157 Supportive Housing for the Elderly (Section 202) Finding Summary: As a result of management transition, supporting documentation for expense transactions and tenant eligibility were destroyed and were unable to be recreated. The organization was lacking appropriate internal controls to ensure records were retained for the required period of time. Responsible Individual: Dawn Helmowski, Finance Director Corrective Action Plan: Subsequent to the audit period under review, the affiliated entity of Luther Social Services of North Dakota has been replaced with Beyond Shelter, Inc. Upon this change, the new LSS Jamestown Housing, Inc. Board of Directors, implemented a Document Retention and Destruction Policy that includes retention or required documents for the required time periods that will ensure documents are retained. This policy was put into place on April 19, 2023. Anticipated Completion Date: April 2023

View Audit 302214

Finding 391964 (2023-002)

Significant Deficiency 2023

Presbyterian College

SC

Student Financial Aid Internal Control / Segregation of Duties Special Tests & Provisions

Individuals Responsible for Corrective Action Plan: Daniel Hall (Interim Vice President for Finance and Administration) Libby Shull, CPA (Controller) April Baur (Director of Student Financial Aid) Kevin Crider (Chief Information Officer) Vicky Wilson (Registrar) Finding 2023-002 For 2 of 2 mid-y...

Individuals Responsible for Corrective Action Plan: Daniel Hall (Interim Vice President for Finance and Administration) Libby Shull, CPA (Controller) April Baur (Director of Student Financial Aid) Kevin Crider (Chief Information Officer) Vicky Wilson (Registrar) Finding 2023-002 For 2 of 2 mid-year transfer students tested, the school did not actively add these students to the NSLDS transfer monitoring list. Corrective Action Plan: While the college experienced significant turnover in its staffing in fiscal years 2021 and 2022, the college has historically reviewed the NSLDS history of transfer students to ensure they were not enrolled or receiving a disbursement for the current term at another institution. Any student that showed a pending disbursement on COD would be notified to inform their previous college and request the pending disbursement be removed. Starting in the fall 2023, the transfer monitoring tool was utilized along with reviewing NSLDS history.

View Audit 302137

Finding 391953 (2023-002)

Significant Deficiency 2023

Interdenominational Theological Center

GA

Questioned Costs Student Financial Aid Subrecipient Monitoring

We observed the following conditions in connection with our testing of the various U.S. Department of Education, Title IV, Student Financial Assistance Programs: a. Two (2) out of 21 students did not complete exit counseling requirements upon graduating or dropping below half-time status. 34 CFR 685...

We observed the following conditions in connection with our testing of the various U.S. Department of Education, Title IV, Student Financial Assistance Programs: a. Two (2) out of 21 students did not complete exit counseling requirements upon graduating or dropping below half-time status. 34 CFR 685.304(b)(1) b. One (1) out of 21 students was awarded Federal Direct Loans at less than half-time status. 34 CFR 685.200 (a)(1)(i). Attributable questioned cost: $3,000 c. Documentation to support the Center’s reconciliation of the Federal Direct Loan program between Common Origination and Disbursement (COD) and the Office of Financial aid was not available. 34 CFR 685.300(b)(5) d. Documentation to support the Center’s reconciliation of the Federal Work-Study program was not available. 34 CFR Part 668 Subpart L e. One (1) out of 21 students did not have timely or accurate enrollment reporting to the National Student Loan Data System (NSLDS). 34 CFR685.309(b) f. Documentation to conduct Federal Work-Study compliance testing was not provided. 34 CFR Part 675 g. Documentation to support testing for withdrawals and the return of Title IV funds compliance was not provided. HEA Section 484B & 34 CFR 668.22 h. Documentation to support credit balance (student refund) testing was not provided. 34 CFR 668.164(h)(1) i. Two (2) out of 21 students were paid Federal Direct Loans and did not make satisfactory academic progress (SAP) for the academic year. Additionally, the school did not provide updated documents supporting successful appeals. 34 CFR 668.34. Attributable questioned cost: $30,730 j. One (1) out of 21 students did not have an undergraduate transcript to prove eligibility for the program they were enrolled within the institution. HEA Section 484(d) and 34 CFR 668.32. Attributable questioned cost: $20,500. Auditor's Recommendation – The Center should implement corrective actions to ensure that the above findings are resolved and do not recur in future periods. Moreover, internal controls over compliance with federal program regulations should be revisited to ensure adequate supervisory controls, quality assurance reviews of compliance steps, technical training of staff, and adequate procedures are being followed for compliance purposes. View of Responsible Officials – Management agrees.

View Audit 302135 Questioned Costs: $1

Finding 391930 (2023-002)

Material Weakness 2023

Michigan Works! Southeast Consortium

MI

Eligibility Material Weakness

March 27, 2024 2023-002: Material Weakness in Internal Control/Material Noncompliance- Eligibility Condition: The Consortium did not provide documentation of eligibility for each participant selected for testing. Corrective Action: We agree with the finding. The consortium recognizes the importance ...

March 27, 2024 2023-002: Material Weakness in Internal Control/Material Noncompliance- Eligibility Condition: The Consortium did not provide documentation of eligibility for each participant selected for testing. Corrective Action: We agree with the finding. The consortium recognizes the importance of having support documentation for all eligibility determinations. During COVID-19 staff were allowed to work from home, as a result two staff were not following document saving protocol and saved vital documentation on their local drive (desktop). Upon the transition back into the office, those individuals did not follow protocol and ensure all files were backed up/saved to the networked database. Once of the individuals no longer worked for MWSE and the other employee as well as their manager both were made aware of the issue. After further conversations with the manager, management was assured this will not happen again. A process for spot checking and compliance sign-off by managers has been implemented to work to ensure this issue does not arise again. Contact Person: Shamar Herron: Sherron@mwse.org Anticipated Completion Date: Completed January 2024 Respectfully, Shamar Herron

View Audit 302123

Finding 391866 (2023-004)

Significant Deficiency 2023

Michigan Works! Southeast Consortium

MI

Eligibility Significant Deficiency Internal Control / Segregation of Duties

March 27, 2024 2023-004: Material Weakness in Internal Control/Material Noncompliance- Eligibility Condition: The Consortium did not provide documentation that all eligibility related conditions were met for each participant selected for testing. Corrective Action: We agree with the finding. The con...

March 27, 2024 2023-004: Material Weakness in Internal Control/Material Noncompliance- Eligibility Condition: The Consortium did not provide documentation that all eligibility related conditions were met for each participant selected for testing. Corrective Action: We agree with the finding. The consortium recognizes the importance of having support documentation for all eligibility determinations. During COVID-19 staff were allowed to work from home, as a result two staff were not following document saving protocol and saved vital documentation on their local drive (desktop). Upon the transition back into the office, those individuals did not follow protocol and ensure all files were backed up/saved to the networked database. Once of the individuals no longer worked for MWSE and the other as well as their manager both were made aware of the issue. After further conversations with the manager, management was assured this will not happen again. A process for spot checking and compliance sign-off by managers has been implemented to work to ensure this issue does not arise again. Contact Person: Shamar Herron: Sherron@mwse.org Anticipated Completion Date: Completed January 2024 Respectfully, Shamar Herron

View Audit 302123

Finding 391693 (2023-002)

Material Weakness 2023

Laboure College of Healthcare

MA

Student Financial Aid Eligibility Reporting

Finding: As described in 34 CFR 668.171, the U.S. Department of Education (ED) requires institutions of higher education to report the occurance of specific events, known as triggering events, to them within ten days of the event. The notification of the vote by the Massachusetts Board of Registrati...

Finding: As described in 34 CFR 668.171, the U.S. Department of Education (ED) requires institutions of higher education to report the occurance of specific events, known as triggering events, to them within ten days of the event. The notification of the vote by the Massachusetts Board of Registration in Nursing (BORN) to withdraw the approval of the College's Associate Degree Nursing Program is a triggering event that should have been reported to the ED within ten days of occurance of the event. ED requirements for reporting triggering events. The triggering event occurred on June 20, 2023 and communication was not made to the ED until August 2023. Corrective Action Plan. The College has implemented procedures to ensure triggering events are identified and reported to the ED in a timely mannger. The Financial Aid Director: Erin Hanlon or VP of Administration and Finance: William McDonald is responsible for communicating triggering events once identified.

View Audit 302109

Finding 391690 (2023-005)

Material Weakness 2023

Department of Human Services

HI

Questioned Costs Special Tests & Provisions Eligibility

Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: The Supplemental Nutrition and Assistance Program office has worked with Statewide Branch and Staff Development offices to address refresher training ass...

Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: The Supplemental Nutrition and Assistance Program office has worked with Statewide Branch and Staff Development offices to address refresher training associated with budget calculations including the documentation and input of all data correctly. The Department is also in process of finalizing the new eligibility system – Benefit Eligibility Solution – slated to rollout statewide by late October 2024. As a condition of system rollout, all staff will be required to go through system training which will include a reinforcement of data entry practices and documentation requirements as a condition of eligibility determination. Expected Completion Date: October 31, 2024 Responding Officials: Ginet Hayes, Supplemental Nutrition and Assistance Administrator

View Audit 302108 Questioned Costs: $1

Finding 391681 (2023-007)

Significant Deficiency 2023

Department of Human Services

HI

Questioned Costs Special Tests & Provisions Eligibility

Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken of Planned: The Department has identified a gap in training and education, that caused a failure to enforce the contract requirements for plans to submit audited fin...

Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken of Planned: The Department has identified a gap in training and education, that caused a failure to enforce the contract requirements for plans to submit audited financial statements pursuant to 42 CFR 438.3(m). Training and education were completed. The Department has engaged with a vendor to implement our new online provider enrollment system HOKU on August 3, 2020 and started the process to have all providers re register their information in the new online system. All providers were given a deadline to do this by December 31, 2023 and if missed they would be terminated in 2024. Expected Completion Date: April 30, 2024 Responding Official: Marvin Malohi, Med-QUEST Division Supervising Contracts Specialist

View Audit 302108 Questioned Costs: $1

Finding 391679 (2023-016)

Material Weakness 2023

Department of Human Services

HI

Questioned Costs Eligibility Material Weakness

Views of Responding Officials: The Department agrees with the finding and will implement corrective action, however, notes the following: Letter dated April 29, 2022 was sent to ACF notifying of the temporary amendment to the Hawaii TANF State Plan, Part B, Section 10.1, suspending the interview re...

Views of Responding Officials: The Department agrees with the finding and will implement corrective action, however, notes the following: Letter dated April 29, 2022 was sent to ACF notifying of the temporary amendment to the Hawaii TANF State Plan, Part B, Section 10.1, suspending the interview requirement for TANF applications and annual recertification. The temporary suspension of the interview requirement aligned with the waiver granted by the Food and Nutrition Service for the Supplemental Nutrition Assistance Program (“SNAP”). The letter also informed ACF the interview requirement will resume for new TANF applications by July 31, 2022. No date was provided as to when the interview requirement will resume for annual recertifications. The Department received a letter dated May 9, 2022 from ACF that acknowledged the temporary amendment to the Hawaii TANF State Plan. A subsequent letter dated March 16, 2023 was sent to inform ACF that the suspended interview resumed for TANF applications effective July 1, 2022, however, will continue to be suspended for annual eligibility recertifications for TANF recipients. The Department received a letter dated March 29, 2023 from ACF that acknowledged the temporary State Plan amendment. A letter dated July 25, 2023 informed ACF that TANF will continue to align with SNAP and extend its suspended interview requirement for annual recertifications until May 31, 2024. The Department received a letter dated August 3, 2023 from ACF that acknowledged the extended temporary amendment to the State Plan. The Department did not need guidance from ACF on whether a particular action is allowable under program requirements. Pursuant to section 402 of the Social Security Act, ACF has the authority to determine whether a state’s TANF State Plan is complete but does not have the authority to approve or disapprove a plan. ACF acknowledged the temporary amendments made to the Hawaii TANF State Plan and expressed no concerns or determined that the temporary amendments were not allowable. Corrective Action Taken or Planned: No corrective action. The temporary amendment to the Hawaii TANF State Plan will end effective June 1, 2024, as noted in the July 25, 2023 letter to ACF. Expected Completion Date: Not applicable Responding Officials: Catherine Scardino, Temporary Assistance for Needy Families Program Administrator

View Audit 302108 Questioned Costs: $1

Finding 391669 (2023-011)

Material Weakness 2023

Department of Human Services

HI

Questioned Costs Eligibility Special Tests & Provisions

Views of Responding Officials: The Department does not agree with this finding. According to 45 CFR section 205.55, it states, “…the State agency will request through the IEVS…”. However, the policy does not specify the State agency must “properly use IEVS information to evaluate benefit amounts…...

Views of Responding Officials: The Department does not agree with this finding. According to 45 CFR section 205.55, it states, “…the State agency will request through the IEVS…”. However, the policy does not specify the State agency must “properly use IEVS information to evaluate benefit amounts…” as notated in this finding under “Effect.” Unless IEVS provides the necessary information for the applicable benefit month(s) used to determine a TANF applicant’s or recipient’s (“client”) eligibility, information obtained will only validate whether a household received an income source, after the fact, but will not verify the dollar amount. Hard-copy verification is obtained from the client to verify income source and dollar amount, for the applicable benefit months, to determine eligibility in accordance with §17 676 51, Hawaii Administrative Rules. For example, if a client applied for TANF on January 31, 2024, and the Department processes the application on February 29, 2024 (current month), verification of the household’s income received in January 2024 and received thus far in February 2024, must be obtained to determine eligibility for the month of application (January 2024) and subsequent months (based on projected income). Data obtained from IEVS are not current. For example, wage information through SWICA becomes available on a quarterly basis. The most current SWICA information available would have been for quarter ending December 31, 2023, for an application that was processed on February 29, 2024. Eligibility determination would have been improperly made if SWICA information was applied. Corrective Action Taken or Planned: The Department will continue to conduct IEVS check and utilize information obtained to determine eligibility if the information is applicable, otherwise, IEVS information will continue to be used to validate any source of income. Expected Completion Date: Ongoing Responding Officials: Catherine Scardino, Temporary Assistance for Needy Families Program Administrator

View Audit 302108 Questioned Costs: $1

Finding 391668 (2023-006)

Significant Deficiency 2023

Department of Human Services

HI

Questioned Costs Special Tests & Provisions Eligibility

Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken of Planned: The Department has identified a gap in training and education, that caused a failure to enforce the contract requirements for plans to submit audited fin...

Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken of Planned: The Department has identified a gap in training and education, that caused a failure to enforce the contract requirements for plans to submit audited financial statements pursuant to 42 CFR 438.3(m). Training and education were completed. The Department has engaged with a vendor to implement our new online provider enrollment system HOKU on August 3, 2020 and started the process to have all providers re register their information in the new online system. All providers were given a deadline to do this by December 31, 2023 and if missed they would be terminated in 2024. Expected Completion Date: April 30, 2024 Responding Official: Marvin Malohi, Med-QUEST Division Supervising Contracts Specialist

View Audit 302108 Questioned Costs: $1

Corrective Action Plans

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