Corrective Action Plans

Finding 51385 (2022-002)

Significant Deficiency 2022

Durham County

NC

Eligibility HUD Housing Programs Significant Deficiency

Finding 2022-002 Significant Deficiency in Internal Controls over Compliance, Nonmaterial Noncompliance Name of Contact Person(s): Rhonda Stevens and Lynn Thomas QAT will provide refresher training to staff to reiterate the importance of correcting case errors timely and reports available to assist ...

Finding 2022-002 Significant Deficiency in Internal Controls over Compliance, Nonmaterial Noncompliance Name of Contact Person(s): Rhonda Stevens and Lynn Thomas QAT will provide refresher training to staff to reiterate the importance of correcting case errors timely and reports available to assist in managing deadlines. Proposed completion date: December 31, 2022 FEI Supervisors will review QAT cases cited in error within 10 days of receipt to verify correction/rebuttal. Supervisors are to key the date corrected in the QC tool within 30 days of the review date. FEI Supervisors are to document this expectation has been reviewed in the weekly check-in meeting minutes. Proposed completion date: December 31, 2022

View Audit 47801

Finding 51356 (2022-003)

Significant Deficiency 2022

Bethel University and Affiliates

MN

Questioned Costs Student Financial Aid Eligibility

Student Financial Assistance Cluster Recommendation: We recommend the University review its procedures to ensure the students' academic level is correctly reported to ensure proper awarding. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken...

Student Financial Assistance Cluster Recommendation: We recommend the University review its procedures to ensure the students' academic level is correctly reported to ensure proper awarding. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Financial Aid Director and Associate Director reviewed the student?s file associated with this finding. The error in certifying was associated with a one-time deviation from normal business practices in certifying loans. Financial aid staff involved in certifying loans were reminded, by the Associate Director, of the need to follow established business practices so these types of errors do not occur. Name of the contact person responsible for corrective action: Jeffrey Olson, Director of Financial Aid Planned completion date for corrective action plan: February 20, 2023

View Audit 42899 Questioned Costs: $1

Finding 51325 (2022-002)

None 2022

Harmony Community Development Corporation, Inc.

TX

Questioned Costs Allowable Costs / Cost Principles Eligibility

Lack of Documentation to Prove Eligibility Planned Corrective Action: The steps taken were a thorough review of the current documentation process. During the process specific areas were shown where the documentation was missing. A revised (SOP) standard operating procedure was developed that ensur...

Lack of Documentation to Prove Eligibility Planned Corrective Action: The steps taken were a thorough review of the current documentation process. During the process specific areas were shown where the documentation was missing. A revised (SOP) standard operating procedure was developed that ensured staff reviewed and verified all the necessary information was collected. Part of the new SOP was how to properly store them and retrieve them in a secondary place outside of the internal housing portal. Training is ongoing as the staff has changed in recent weeks. The process will be regularly reviewed to ensure that the SOP is being followed and identify any new gaps that may emerge. Regular internal audits will also be followed to ensure that documentation is being correctly collected and stored. Person Responsible for Corrective Action Plan: Ayn Llopis, Finance Director Anticipated Date of Completion: June 1, 2023 and ongoing internal audits quarterly

View Audit 51090 Questioned Costs: $1

Finding 51308 (2022-001)

None 2022

Mississippi Home Corporation

MS

Eligibility

2022 -001 Eligibility Program: Emergency Rental Assistance (ERA) Program Assistance Listing Number 21.023 Name of Contact Person: Lisa Coleman, Senior Vice President of Federal Grants Corrective Action: In addition to following the Corporation's policies and procedures developed in accordance with E...

2022 -001 Eligibility Program: Emergency Rental Assistance (ERA) Program Assistance Listing Number 21.023 Name of Contact Person: Lisa Coleman, Senior Vice President of Federal Grants Corrective Action: In addition to following the Corporation's policies and procedures developed in accordance with ERA Program guidelines established by the Treasury, the Corporation implemented additional procedures related to fraud prevention and detection. The Corporation began independent property ownership searches, added additional application review requirements for large tenant-paid payments, and added additional recertification requirements including proof of payment to landlord. Effective August 15, 2022, Governor Reeves directed Mississippi Home Corporation to stop accepting new applications for assistance through the ERA Program. All applications received prior to August 15, 2022, would continue to be processed in accordance with federal law and program rules and regulations. After such applications are processed, the remaining federal funds, if any, will be returned to the United States Department of Treasury. Anticipated Completion Date: June 30, 2023

View Audit 43679

Finding 51229 (2022-021)

Material Weakness 2022

State of Delaware

DE

Internal Control / Segregation of Duties Special Tests & Provisions Subrecipient Monitoring § 200.303

Reference Number: 2022-021 Prior Year Finding: 2021-015 Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Medicaid and Medical Assistance Federal Program: Children?s Health Insurance Program M...

Reference Number: 2022-021 Prior Year Finding: 2021-015 Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Medicaid and Medical Assistance Federal Program: Children?s Health Insurance Program Medicaid Cluster Assistance Listing Number: 93.767, 93.775, 93.777, 93.778 Award Number and Year: 2105DE5021 (10/1/2020 ? 9/30/2022), 2205DE5021 (10/1/2021 ? 9/30/2023) 2105DE5MAP (10/1/2020 ? 9/30/2021), 2205DE5MAP (10/1/2021 ? 9/30/2022) Compliance Requirement: Special Tests ? Provider Eligibility Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Recommendation: The Division should reevaluate its current process and perform additional training for determining and monitoring provider eligibility. More thorough reviews and supervision should be placed around the provider eligibility processes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Division is reevaluating the current process for validating non-Par provider eligibility. This includes developing additional training for determining and monitoring provider eligibility and researching best practices in this area. The Division will also complete more thorough reviews and exercise increased supervisory oversight around the provider eligibility processes. Name(s) of the contact person(s) responsible for corrective action: Kathleen Dougherty Planned completion date for corrective action plan: September 30, 2023

View Audit 43524

Finding 51207 (2022-032)

Significant Deficiency 2022

State of Delaware

DE

Student Financial Aid Eligibility Matching / Level of Effort / Earmarking § 200.303

No Reference Number: 2022-032 Prior Year Finding: No Federal Agency: U.S. Department of Education State Department Name: Delaware Technical Community College Federal Program: Student Financial Assistance Cluster Assistance Listing Number: 84.007, 84.033, 84.063, 84.268 Award Period: July 1, 2021 to ...

No Reference Number: 2022-032 Prior Year Finding: No Federal Agency: U.S. Department of Education State Department Name: Delaware Technical Community College Federal Program: Student Financial Assistance Cluster Assistance Listing Number: 84.007, 84.033, 84.063, 84.268 Award Period: July 1, 2021 to June 30, 2022 Compliance Requirement: Eligibility Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend that DTCC review procedures and controls pertaining to the eligibility of students for financial aid regarding the SAP 150% credit threshold. We further recommend that DTCC reviews the eligibility of other students enrolled during the 2022 and 2023 academic years and properly adjusts student accounts as necessary. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The financial aid office worked with members of our IT Applications and Web Services department to discover a failure in the script being run within Banner to identify the full student population related to the maximum credits allowed within a program of study. A system patch to the processing script is currently being developed and we anticipate this process to be in good working order April 2023 after testing. In order to remedy the error, the financial aid office audited all Fiscal Year 2022 activity. Of the 13,333 students enrolled Title IV aid eligible programs during the 2021-22 academic year, five students (.0003%) received federal aid erroneously without the opportunity to submit an appeal. The amount of Pell and Direct Loans disbursed for these students totaled $15,725, which reflects .0004% of the total Pell and Direct loan funds disbursed during the 2021-22 academic year by the college. We are currently taking corrective action on each student identified and will be returning all funds disbursed in error to the U.S. Dept. of Education. In addition, we are currently reassessing all Fiscal Year 2023 student records to identify and correct any student accounts not recognized in our reporting. Name(s) of the contact person(s) responsible for corrective action: Brian Keister, Collegewide Director of Financial Aid Brandi Niezgoda, Applications Manager ? IT Applications and Web Services Michael Rasberry, Senior Applications Development Specialist ? IT Applications and Web Services Planned completion date for corrective action plan: April 2023

View Audit 43524

Finding 51205 (2022-030)

Significant Deficiency 2022

State of Delaware

DE

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

Reference Number: 2022-030 Prior Year Finding: No Federal Agency: U.S. Department of Education State Department Name: Delaware Technical Community College Federal Program: Student Financial Assistance Cluster Assistance Listing Number: 84.007, 84.033, 84.063, 84.268 Award Period: July 1, 2021 to Jun...

Reference Number: 2022-030 Prior Year Finding: No Federal Agency: U.S. Department of Education State Department Name: Delaware Technical Community College Federal Program: Student Financial Assistance Cluster Assistance Listing Number: 84.007, 84.033, 84.063, 84.268 Award Period: July 1, 2021 to June 30, 2022 Compliance Requirement: Special Tests and Provisions: Return of Title IV Funds Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend that DTCC review its procedures and controls pertaining to the return of Title IV funds to ensure that refunds are properly calculated on a timely basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Please note there is no monetary value related to this finding. The above-mentioned finding is a result of DTCC not completing an R2T4 calculation for one student that had their academic record updated after the semester in question had ended through a hardship withdrawal process. Our spring 2022 semester ended on May 14, 2022. On June, 21, 2022, the student was granted a hardship withdrawal for all courses registered and the student record was backdated to update the college?s decision. While there are no changes to a student?s federal aid eligibility in these instances, we are aware a calculation should have been completed to acknowledge the update within the student academic record. In response to the finding, DTCC will extend the time period for when reports are ran that identify adjustments. In addition, the member of the college?s hardship withdrawal committee representing the financial aid office will notify individuals responsible for R2T4 calculations when committee approvals are decided. Name(s) of the contact person(s) responsible for corrective action: Brian Keister, Collegewide Director of Financial Aid Veronica Oney, Financial Aid Officer Planned completion date for corrective action plan: March 2023 (immediately)

View Audit 43524

Finding 51196 (2022-009)

Significant Deficiency 2022

State of Delaware

DE

Eligibility Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Reference Number: 2022-009 Prior Year Finding: No Federal Agency: U.S. Department of Labor State Department Name: Department of Labor State Division Name: Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 ? Unemployment Insurance Assistance Listing Number: 17.225 A...

Reference Number: 2022-009 Prior Year Finding: No Federal Agency: U.S. Department of Labor State Department Name: Department of Labor State Division Name: Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 ? Unemployment Insurance Assistance Listing Number: 17.225 Award Number and Year: UI340502055A10 (10/1/2019 ? 12/31/2022), UI347072055A10 (4/1/2020 ? 6/30/2023), UI372152255A10 (10/1/2021 ? 12/31/2024) Compliance Requirement: Eligibility Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend the Division review and enhance procedures and controls to ensure that it retains documentation for claimant eligibility and that benefit payments are accurate in accordance with program requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We will continue to utilize and enhance of customer service management tools and centralize where documentation is retained. We will continue to review program requirements and ensure they are reviewed, and implemented, and processed correctly. We will review and ask for clarity regarding UIPLs when there is a discrepancy. We are also looking to modernization our systems to house all our documentations. Name(s) of the contact person(s) responsible for corrective action: Shannon Lolley ? UI Administrator Planned completion date for corrective action plan:

View Audit 43524

Finding 51119 (2022-003)

Material Weakness 2022

Russellville Housing Authority

AR

Questioned Costs HUD Housing Programs Eligibility

2022-001 - Internal Control over Financial Statements. Condition ? The financial statements and the Financial Data Schedule submitted to REAC had several material misstatements and were not prepared in accordance with Generally Accepted Accounting Principles (GAAP). Cause ? During the current fiscal...

2022-001 - Internal Control over Financial Statements. Condition ? The financial statements and the Financial Data Schedule submitted to REAC had several material misstatements and were not prepared in accordance with Generally Accepted Accounting Principles (GAAP). Cause ? During the current fiscal year, the Housing Authority inexperienced staff was not aware of the year end documentation that was required to complete the financial statement preparation. In addition, the fee accountant was not specific in explaining the necessary items for Year End. Plan of Action ? The Housing Authority will conduct a monthly review of all financial data to ensure that all financial activities have been properly recorded. The Housing Authority will coordinate the Year End Process as outlined in the Year End checklist provided by Lindsey. In addition, in the future the financial statement preparation will be conducted on the Housing Authority?s server which enable the Housing Authority to retain records within the actual accounting system. Person Responsible: Ms. Donna Smith (Executive Director) Period of Action: The review will be conducted monthly and in coordination with MRI Software. 2022-002 Activities Allowed or Unallowed ? Capital Fund Program. Condition ? The Authority expended ineligible funds from the Capital fund Program that were not supported for the use of and administration of the program. Cause ? The Housing Authority misinterpreted the information regarding CARES and CFP sent from HUD and after reviewing with fee accountant, fee accountant misinterepreted the information provided, as well, thus providing inaccurate information on how to expense funds. Plan of Action ? The Housing Authority will review all disbursements monthly and consult with the fee accountant as to the purpose and nature of any costs that could be deemed as questionable or allowable under the Capital fund Program. In addition, the Housing Authority will ensure that all disbursements are adequately supported and can be easily traced to any LOCCS draw. We will also be requesting a budget revision. Person Responsible: Ms. Donna Smith (Executive Director)

View Audit 48079 Questioned Costs: $1

Finding 51112 (2022-001)

Significant Deficiency 2022

Olivet Nazarene University

IL

Student Financial Aid Matching / Level of Effort / Earmarking Eligibility § 200.303

The University understands the importance of accurate verification. It was missed by the verification specialist, and not a matter of process. The specialist simply missed the line on the tax document that listed the education credits. This caused the student to receive $200 less Pell funding than t...

The University understands the importance of accurate verification. It was missed by the verification specialist, and not a matter of process. The specialist simply missed the line on the tax document that listed the education credits. This caused the student to receive $200 less Pell funding than the eligibility. The student should have received $200 in additional Pell Grant funds, so the school contacted the student and applied $200 in university funding to offset that loss. On November 21st, Tim Schultz (verification specialist) was instructed about this important process. The Executive Director of Student Finance, Tiffany McCann, will help monitor those verification materials and process, which should reduce the chances of a repeat mistake and ensure compliance.

View Audit 42623

Finding 51065 (2022-002)

Significant Deficiency 2022

Blue Earth County

MN

Eligibility Significant Deficiency Matching / Level of Effort / Earmarking

Recommendation: We recommend the County management establish internal controls over eligibility. Case files should be reviewed to ensure proper documentation exists to support the eligibility determination. Explanation of disagreement with audit finding: There is no disagreement with the audit find...

Recommendation: We recommend the County management establish internal controls over eligibility. Case files should be reviewed to ensure proper documentation exists to support the eligibility determination. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement additional review procedures. Name of the contact person responsible for corrective action: Lisa Malinski, Finance Director

View Audit 49837

Finding 50989 (2022-002)

Material Weakness 2022

Union County

NC

Questioned Costs Eligibility Material Weakness

Finding 2022-002-Repeat Finding, Material Weakness and Nonmaterial Noncompliance-Eligibility Response/Corrective Action: Since 2017, the Medicaid program has seen a 25% increase in the caseload volume. In addition to the increase in caseload, we currently have 12 Eligibility Specialist positions vac...

Finding 2022-002-Repeat Finding, Material Weakness and Nonmaterial Noncompliance-Eligibility Response/Corrective Action: Since 2017, the Medicaid program has seen a 25% increase in the caseload volume. In addition to the increase in caseload, we currently have 12 Eligibility Specialist positions vacant. Many of these vacancies have occurred within the last year, which has caused an additional substantial increase in the workload of the Eligibility staff. Like most counties across the state, we are struggling to fill the vacancies, but are working diligently to recruit and hire new staff. We currently have less than 30% of staff with more than 1- 2 years of experience in the program. In response to the errors cited, Union County provided education training for staff on citizenship codes in OVS on November 8th and 10th 2022. Responsible Parties: Michelle Lancaster, Deputy County Manager / Human Services Director Beverly Liles, Finance Director

View Audit 45126 Questioned Costs: $1

Finding 50954 (2022-004)

Significant Deficiency 2022

City of Baton Rouge - Parish of East Baton Rouge

LA

Questioned Costs Eligibility

2022-004) Allowable Activities Management?s response and corrective action is as follows: After reviewing the project scope, along with the U. S. Treasury Final Rule, the City-Parish believes that the bridge replacement is an allowable use of funds. Twin Oaks bridge was closed in 2015 in a very ...

2022-004) Allowable Activities Management?s response and corrective action is as follows: After reviewing the project scope, along with the U. S. Treasury Final Rule, the City-Parish believes that the bridge replacement is an allowable use of funds. Twin Oaks bridge was closed in 2015 in a very rural area. During the pandemic it became evident that citizens were unable to access healthcare quickly with the bridge closure. In addition, the bridge is causing major drainage issues in the Baker Canal. The replacement bridge will use watertight expansion joints so that all surface water can drain off the structure and collect in inlets placed at the bridge ends. The downstream ends of bridges need special attention which will collect and concentrate the stormwater away from the bridge. The concentrated flow will be directed into a low-risk erosion area. All runoff shall be directed away from wing walls, fill slopes, and embankments, so that no material is susceptible to erosion. Bridge drains are designed to reduce the amount of concentrated flows off a structure. The replacement of the bridge allows the Parish to address the subsurface drainage issues as well as respond to the public health and negative economic impacts of the pandemic. U.S. Treasury has specifically enumerated the flexibility provided under this expenditure category in the Final Rule excerpt: (second paragraph on the page 4411) ?Although the meaning of water and sewer infrastructure for purposes of sections 602(c)(1)(D) and 603(c)(1)(D) of the Social Security Act does not include all water-related uses, Treasury has made clear in this final rule that investments to infrastructure include a wide variety of projects. Treasury interprets the word ``infrastructure?? in this context broadly to mean the underlying framework or system for achieving the given public purpose, whether it be provision of drinking water or management of wastewater or stormwater. As discussed below, this can include not just storm drains and culverts for the management of stormwater, for example, but also bioretention basins and rain barrels implemented across a watershed, including on both public and private property, that together reduce the amount of runoff that needs to be managed by traditional infrastructure.? Expected Implementation Date: June 2023 Contact person: Tom Stephens, Chief Engineer, Transportation and Drainage Department Angie Savoy, Assistant Director, Finance Department

View Audit 53428 Questioned Costs: $1

Finding 50945 (2022-001)

Material Weakness 2022

Garrett Regional Medical Center

MD

Questioned Costs Allowable Costs / Cost Principles Special Tests & Provisions § 200.303

Finding 2022-001- Allowable Costs, Activities Allowed and Special Tests and Provisions Contact Person: Lori Dixon Management?s Response: GRMC management will implement the following processes/procedures as a result of the finding of the 2022 Single Audit. During the audit review, FEMA hours we...

Finding 2022-001- Allowable Costs, Activities Allowed and Special Tests and Provisions Contact Person: Lori Dixon Management?s Response: GRMC management will implement the following processes/procedures as a result of the finding of the 2022 Single Audit. During the audit review, FEMA hours were found to be unallowable on sample patients treated for COVID. Management reviewed the findings and identified additional patients/hours not covered by other funding sources to replace the unallowed data totaling $8,550. Completion Date: The steps above will be completed by October 31, 2023.

View Audit 52431 Questioned Costs: $1

Finding 50924 (2022-002)

Material Weakness 2022

Saint Michael's Clinics, Inc.

NJ

Internal Control / Segregation of Duties Eligibility Subrecipient Monitoring

FINDING 2022-002: Clinic management team acknowledges that from the audit selection made of 65 patients that 15 were not recertified during the six-month period and the supporting documentation was not retained related to income verification for 3 patients. A detail plan of correction has been deve...

FINDING 2022-002: Clinic management team acknowledges that from the audit selection made of 65 patients that 15 were not recertified during the six-month period and the supporting documentation was not retained related to income verification for 3 patients. A detail plan of correction has been developed and is listed below: ? Revamping the job titles and description to encourage better return on recruitment efforts of medical case managers position. ? A position of Certified Case Counselor (CCC) ? Supervisor, was created and filled to provide direct oversight over the medical case managers that perform the bi-annual certifications, and other daily tasks. ? Quality management process, where Clinic clients are called ahead of time to notify them of their recertification requirements. ? Data Analyst(s) will generate a report of patients due for recertification 60 days in advance of the due date. The CCC-Supervisor will be directly accountable to review the progress of the re-certification. This will be further monitored by the Assistant Manager of the clinic. The CCC-Supervisor and Assistant Manager will also monitor retention of income verification supporting documentation for patients. CONTACT PERSON: Raj Mehta, Chief Financial Officer, Peter Ho Memorial Clinic EXPECTED COMPLETION DATE: September 30, 2023

View Audit 43310

Finding 50758 (2022-002)

Material Weakness 2022

Afiya Apartments INC

OR

HUD Housing Programs Eligibility Material Weakness

Management?s Response and Planned Corrective Actions: 1. The name of the contact person(s) responsible for the corrective action a. Kathleen Broadhurst, Finance Director/ShelterCare 2. The corrective action planned: a. Pinehurst Management overseeing property through 4/30/2023. A new management agen...

Management?s Response and Planned Corrective Actions: 1. The name of the contact person(s) responsible for the corrective action a. Kathleen Broadhurst, Finance Director/ShelterCare 2. The corrective action planned: a. Pinehurst Management overseeing property through 4/30/2023. A new management agent will be identified to take over the property after 4/30/2023. b. Ensure that the new managing agent employs an onsite manager with HUD compliance experience. c. Currently prioritizing recertifications by oldest first. d. Monthly review of TRACS reports to ensure recertifications are being completed in a timely manner. 3. The anticipated completion date: a. New processes will be implemented by 5/1/2023.

View Audit 41842

Finding 50640 (2022-002)

Material Weakness 2022

City of Olathe, Kansas

KS

HUD Housing Programs Eligibility Material Weakness

Finding 2022-002 ? Assistance #14.871 ? Section 8 Housing Choice Vouchers ? Eligibility (Material Weakness): Condition: A secondary review or approval of eligibility documentation was not being performed. Recommendations: We recommend that the Housing Authority follow the new quality control policie...

Finding 2022-002 ? Assistance #14.871 ? Section 8 Housing Choice Vouchers ? Eligibility (Material Weakness): Condition: A secondary review or approval of eligibility documentation was not being performed. Recommendations: We recommend that the Housing Authority follow the new quality control policies and procedures implemented in the 4th quarter of 2022 to ensure that eligibility calculations are being reviewed by someone other than the preparer, and also that all required documentation is being maintained in tenant files. Corrective Action Plan: The plan was executed in October 2022 and has been followed since. Contact Person: Joyce DePriest, Interim Executive Director

View Audit 52358

Finding 50590 (2022-001)

Significant Deficiency 2022

Louisiana Housing Corporation

LA

Eligibility

LHC will review the current process used for verification and approval of applicant eligibility for the Home Investment Partnership Program/TBRA Program. Winona Connor will handle the review of the process and anticipates completion by October 31, 2022. Upon completion of this review, we will revise...

LHC will review the current process used for verification and approval of applicant eligibility for the Home Investment Partnership Program/TBRA Program. Winona Connor will handle the review of the process and anticipates completion by October 31, 2022. Upon completion of this review, we will revise policy if necessary to ensure compliance with the terms of the grant. Self-certification is currently allowed for program participants to self-report all sources of income. Going forward, we will ensure such self-certification documents are included in the participant file per our policy. Final review and approval of applicant income verification and program eligibility will be evidenced by the signature of a program supervisor and/or manager in each file.

View Audit 43150

Finding 50560 (2022-001)

Significant Deficiency 2022

Community Health Systems, Inc.

CA

Allowable Costs / Cost Principles Cash Management Eligibility

Finding 2022-001 PROGRAM INCOME ? CFD #93.224 (Significant Deficiency in Internal Control over Compliance) Response: Corrective Action Plan The Operation Department will conduct a verification of the sliding fee scale. In their internal monthly Sliding Fee Discount audit process, the Site Manager is...

Finding 2022-001 PROGRAM INCOME ? CFD #93.224 (Significant Deficiency in Internal Control over Compliance) Response: Corrective Action Plan The Operation Department will conduct a verification of the sliding fee scale. In their internal monthly Sliding Fee Discount audit process, the Site Manager is to review and verify each patient application, to the current Federal Poverty Level, to ensure patient is receiving the correct discount. Attached is a copy of policy and procedure for this corrective action plan.

View Audit 53034

Finding 50530 (2022-006)

Material Weakness 2022

Warren County, North Carolina

NC

Questioned Costs Eligibility Material Weakness

Finding: 2022-6 Name of contact person: Dyani Lynch, Supervisor Crisis & Medicaid Transportation Dept. Corrective Action: The Crisis Department will do a monthly review of Crisis and LIEAP policies to stay on top of any changes that may occur between fiscal years and to ensure we are implementing...

Finding: 2022-6 Name of contact person: Dyani Lynch, Supervisor Crisis & Medicaid Transportation Dept. Corrective Action: The Crisis Department will do a monthly review of Crisis and LIEAP policies to stay on top of any changes that may occur between fiscal years and to ensure we are implementing correct procedures. We will also perform self-audits monthly. We will randomly pull two applications from each caseworker to ensure that we are improving on where we?ve made errors and that we are correctly documenting/processing applications. Based on any findings/questions we have during these self-audits, we will contact our state representative for clarifications. Proposed Completion Date: March 31, 2023

View Audit 47077 Questioned Costs: $1

Finding 50528 (2022-004)

Material Weakness 2022

Warren County, North Carolina

NC

Questioned Costs Eligibility Material Weakness

Finding: 2022-4 Name of contact person: Renae Alston Corrective Action: The County will continue to train employees on a monthly basis and as needed when new and updated policies are received. Supervisors and lead workers will continue to conduct second party reviews and utilizing any findings...

Finding: 2022-4 Name of contact person: Renae Alston Corrective Action: The County will continue to train employees on a monthly basis and as needed when new and updated policies are received. Supervisors and lead workers will continue to conduct second party reviews and utilizing any findings to aid in training staff on any necessary policy information. The County added a Quality Control position effective January 1, 2021 to assist with conducting second party reviews and training. During Fiscal Year 2021 an experienced supervisor was hired for adult Medicaid with extensive knowledge of long-term care and SA policy. This has led to internal process changes for the department. The department will continue to implement changes as necessary to achieve the overall improvement of eligibility determinations. Proposed Completion Date: June 30, 2023

View Audit 47077 Questioned Costs: $1

Finding 50503 (2022-003)

Material Weakness 2022

Vigo County School Corporation

IN

Subrecipient Monitoring Special Tests & Provisions Matching / Level of Effort / Earmarking § 200.303 § 200.333 § 200.334

FINDING 2022-003 Contact Person Responsible for Corrective Action: Teresa Stuckey, Director of Elementary Education and Title I Contact Phone Number: 812-462-4228 Views of Responsible Official: The School Corporation will implement effective processes to ensure that the Special Tests and Provisions ...

FINDING 2022-003 Contact Person Responsible for Corrective Action: Teresa Stuckey, Director of Elementary Education and Title I Contact Phone Number: 812-462-4228 Views of Responsible Official: The School Corporation will implement effective processes to ensure that the Special Tests and Provisions ? Annual Report Card, High School Graduation Rate data is solicited and maintained for audit purposes. Description of Corrective Action Plan: The School Corporation will work to develop a more defined process that ensures compliance with procedures that were established, but have not always followed, to ensure that the Special Tests and Provisions ? Annual Report Card, High School Graduation Rate compliance requirement is met. Specific employees will be placed in charge of obtaining documentation from students leaving the district and others will be asked to review and approve the documentation. If documentation is not successfully garnered from parents, schools will maintain records indicating the school?s efforts to solicit the correct documentation from parents. Anticipated Completion Date: Immediately.

View Audit 53341

Finding 50502 (2022-002)

Material Weakness 2022

Vigo County School Corporation

IN

Subrecipient Monitoring Internal Control / Segregation of Duties Matching / Level of Effort / Earmarking § 200.303 § 200.333 § 200.334 § 200.77 § 200.78

FINDING 2022-002 Contact Person Responsible for Corrective Action: Teresa Stuckey, Director of Elementary Education and Title I Contact Phone Number: 812-462-4228 Views of Responsible Official: The School Corporation will work with non-public schools to make sure that their enrollment is properly re...

FINDING 2022-002 Contact Person Responsible for Corrective Action: Teresa Stuckey, Director of Elementary Education and Title I Contact Phone Number: 812-462-4228 Views of Responsible Official: The School Corporation will work with non-public schools to make sure that their enrollment is properly reported. Description of Corrective Action Plan: School Corporation personnel will work with non-public school representatives to secure accurate enrollment information and maintain the proper documentation for audit purposes. Additionally, enrollment data entered on the Title I application portal will be reviewed prior to submission to ensure that data entered agrees with supporting documentation. Anticipated Completion Date: During submission of the 23-24 Title I application.

View Audit 53341

Finding 50469 (2022-002)

Significant Deficiency 2022

Home Forward

OR

HUD Housing Programs Eligibility Significant Deficiency

2022-02 Moving to Work Demonstration Program ? Assistance Listing No. 14.881 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 findin...

2022-02 Moving to Work Demonstration Program ? Assistance Listing No. 14.881 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: The files in question were moved from one office to another using Home Forward?s contracted courier system. Moving forward, any file that must be transported from one office to another will require the signature of the individual who is receiving the file as well as the individual relinquishing the file. The department will develop a new policy and train staff on the new procedure. In addition, the department will be conducting an audit of each site to assure that all files are present and accounted for. Name(s) of the contact person(s) responsible for corrective action: Elise Anderson, Celeste King Planned completion date for corrective action plan: 12/31/2023.

View Audit 45210

Finding 50442 (2022-002)

Material Weakness 2022

Urban League of Rochester, Ny, Inc.

NY

Questioned Costs Eligibility

Views of Responsible Officials and Planned Corrective Actions Management agrees with the finding and will verify the eligibility of the assistance payments that could not be located. We will also continue to self-audit payments to ensure program eligibility.

View Audit 43329 Questioned Costs: $1

Corrective Action Plans

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