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Corrective Action Plans

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Finding 403107 (2022-003)
Material Weakness 2022
State of California
CA
Eligibility Allowable Costs / Cost Principles HUD Housing Programs § 200.303
The California Department of Public Health (Public Health) Women, Infants, and Children (WIC) Division had agreed that the WIC Web Information System Exchange (WISE) system does not currently store eligibility history that should be included in the “Cert History Report,” and the initial eligibility ...
The California Department of Public Health (Public Health) Women, Infants, and Children (WIC) Division had agreed that the WIC Web Information System Exchange (WISE) system does not currently store eligibility history that should be included in the “Cert History Report,” and the initial eligibility data is overwritten when subsequent eligibility information is keyed into WIC WISE. However, WIC WISE does include preventative internal stops or checkpoints that do not allow ineligible individuals to be certified and issued benefits (e.g., over income, not a California resident, no nutrition risk factor, etc.). User acceptance testing vetted these items prior to system implementation in 2019/20. The certification history condition discussed was remediated via a system Defect Correction to WIC WISE that was in user acceptance testing for implementation in Fall 2023. Public Health/WIC has entered Defect Correction #6972 in TFS (Team Foundation Services), the tracking system previously used to capture system changes and defects. The defect correction supports a system change to ensure initial eligibility information is retained when subsequent eligibility information is entered into WIC WISE. Estimated Implementation Date: August 2023 Contact: William Welch, Assistant Division Chief, Operations Women, Infants, and Children Division California Department of Public Health
View Audit 310237
Finding 401579 (2022-008)
Significant Deficiency 2022
Martin University
IN
Questioned Costs Eligibility Significant Deficiency § 200.303
2022-008 Eligibility – Pell Awarding Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the University implement policies to review all student award packages at the start of the academic year to ensure no over and under awards exist. E...
2022-008 Eligibility – Pell Awarding Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the University implement policies to review all student award packages at the start of the academic year to ensure no over and under awards exist. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has begun to restructure all accounting and reconciliation functions. The University is implementing financial internal controls to improve the internal financial reporting process. Names of the contact persons responsible for corrective action: E. ZeNai Savage, CPA, CFO and Executive VP of Finance and Administration, and Qiana Hall, Associate VP of Enrollment Services Planned completion date for corrective action plan: June 30, 2024
View Audit 309593 Questioned Costs: $1
Finding 401561 (2022-006)
Significant Deficiency 2022
Martin University
IN
Special Tests & Provisions Student Financial Aid Subrecipient Monitoring § 200.303
2022-006 Special Tests and Provisions – Return of Title IV Funding Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the institution maintain proper documentation in accordance with federal grantor requirements and ensure that the docu...
2022-006 Special Tests and Provisions – Return of Title IV Funding Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the institution maintain proper documentation in accordance with federal grantor requirements and ensure that the documents are readily available for review upon request, including monitoring of students with triggering events that require a return to Title IV calculation to be completed, reviewed, and approved. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has implemented policy and procedures that require a review of all official and unofficial withdrawals to have R2T4 calculations on a real time basis to ensure compliance with the Department of Education guidelines on a consistent and regular basis. Internal audits of the process will also be implemented for continuous improvement. Names of the contact persons responsible for corrective action: E. ZeNai Savage, CPA, CFO and Executive VP of Finance and Administration, and Qiana Hall, Associate VP of Enrollment Services Planned completion date for corrective action plan: June 30, 2024
View Audit 309593
Finding 401536 (2022-001)
Material Weakness 2022
K'ima:w Medical Center
CA
Eligibility Subrecipient Monitoring Material Weakness
Management’s Response – To ensure that K'ima:w Medical Center has all supporting documentation to confirm Native American eligibility, we will update our PRC policies to reflect a more standardized and robust procedure for collecting and storing patient eligibility documentation, including periodic ...
Management’s Response – To ensure that K'ima:w Medical Center has all supporting documentation to confirm Native American eligibility, we will update our PRC policies to reflect a more standardized and robust procedure for collecting and storing patient eligibility documentation, including periodic review of our patient records in compliance with IHS standards and requirements. Additionally, we have some understanding in our Medical Records Department, which we plan to fill by next fiscal year.
View Audit 309572
Finding 401182 (2022-001)
Material Weakness 2022
Walla Walla County
WA
Subrecipient Monitoring Eligibility
We appreciate the auditor's assessment, analysis, and recommendations. However, we disagree with the conclusion reached and the finding. The auditor, during oral conversation discussing context, indicated the quantity of program beneficiaries reviewed for eligibility did not reach the auditor's expe...
We appreciate the auditor's assessment, analysis, and recommendations. However, we disagree with the conclusion reached and the finding. The auditor, during oral conversation discussing context, indicated the quantity of program beneficiaries reviewed for eligibility did not reach the auditor's expected quantity for adequate monitoring. As a management team, we assessed risk and determined the level of appropriate monitoring to consist of: 1) financial monitoring through review of reimbursement requests, which contained eligibility information necessary for oversight; 2) execution of regularly scheduled status and reporting meetings wherein we obtained ongoing programmatic data; and 3) review of audit reports, where applicable. We note neither our award agreement nor applicable federal regulations require a specific quantity of files to be reviewed as part of subrecipient monitoring. Accordingly, we do not concur with the presence of a finding. In addition, no instances of ineligible beneficiaries were identified by the auditor such that a material weakness classification does not appear reasonable or appropriate. That being said, we will assess our procedures and add greater clarity to help better tell this story going forward. We will also consider whether testing a specific number of beneficiaries is necessary and may be conducted efficiently.
View Audit 309209
Finding 400600 (2022-003)
Material Weakness 2022
Tca Health, Inc.
IL
Eligibility Material Weakness Internal Control / Segregation of Duties
The COO at TCA Health will address the Special Provisions weakness by coaching and training front desk staff members. Specifically, staff will be trained in the sliding fee scale and its requirements. Staff will become proficient in the collection of data from patients, properly storing and recordin...
The COO at TCA Health will address the Special Provisions weakness by coaching and training front desk staff members. Specifically, staff will be trained in the sliding fee scale and its requirements. Staff will become proficient in the collection of data from patients, properly storing and recording it in the EMR, and the calculation of the slide according to the Federal Poverty Guidelines. Lastly, the team will be updated on the latest EMR module that experienced an upgrade and taught how to effectively apply the slide. TCA will also assess the current staff to ensure the proper personnel is in in place.
View Audit 308641
Finding 400450 (2022-004)
Significant Deficiency 2022
Reach Community Development, Inc.
OR
Eligibility HUD Housing Programs
Finding No. 2022-004 - Low Income Housing Preservation and Resident Homeownership Act of 1990) Federal Assistance Listing Number #99.999 Statement of Condition: Our testing procedures noted that the owner did not perform certifications and recertifications timely, did not maintain tenant files i...
Finding No. 2022-004 - Low Income Housing Preservation and Resident Homeownership Act of 1990) Federal Assistance Listing Number #99.999 Statement of Condition: Our testing procedures noted that the owner did not perform certifications and recertifications timely, did not maintain tenant files in compliance with HUD Rules in Code of Federal Regulations at 24 CFR Part 92, and did not select tenants from the waitlist appropriately. Corrective Action: Management has policies and procedures in place, compliance has been impacted by being understaffed while recovering from covid-related social distancing/limited on site presence. This resulted in recertification and move-in compliance issues. Compliance team and the new HUD Portfolio Manager have been providing trainings for the HUD managers in 2023 and will continue to do so in 2024. In 2022 and 2023, Compliance Manager ensured that all staff who needed access to EIV took the appropriate steps (Cyber Awareness Training, updated EIV authorizations) to access EIV for their properties to run the reports timely. In 2023, The HUD Portfolio Manager created an EIV workflow training for the HUD managers. Both the Compliance team and HUD managers were present. One Compliance Specialist with HUD experience has been filling in and assisting at the HUD properties where we continue to be understaffed. As a Below Market Interest Rate (“BMIR”), we do not receive HUD subsidy or oversight from HUD. Because both properties are due for Affirmative Fair Housing Marketing Plan (“AFHMP”) updates, we will submit an updated plan to HUD for review and approval in 2024. Management is aware and has been performing Move-out inspections with tenants whenever possible.
View Audit 308469
Finding 400449 (2022-003)
Significant Deficiency 2022
Reach Community Development, Inc.
OR
Eligibility HUD Housing Programs
Finding No. 2022-003 - HUD HOME Investment Partnerships Program, Federal Assistance Listing Number #14.239 Statement of Condition: The owner did not make available to HOME tenants the contracted number and type of HOME units. Corrective Action: A unit will be re-classified the next time there is ...
Finding No. 2022-003 - HUD HOME Investment Partnerships Program, Federal Assistance Listing Number #14.239 Statement of Condition: The owner did not make available to HOME tenants the contracted number and type of HOME units. Corrective Action: A unit will be re-classified the next time there is a vacant unit of the corresponding size/type.
View Audit 308469
Finding 400448 (2022-002)
Significant Deficiency 2022
Reach Community Development, Inc.
OR
Eligibility HUD Housing Programs
Finding No. 2022-002 - HUD HOME Investment Partnerships Program, Federal Assistance Listing Number #14.239 Statement of Condition: In connection with our lease file review we noted one instance of eight tenants tested where management did not perform a 3rd party income verification in accordance ...
Finding No. 2022-002 - HUD HOME Investment Partnerships Program, Federal Assistance Listing Number #14.239 Statement of Condition: In connection with our lease file review we noted one instance of eight tenants tested where management did not perform a 3rd party income verification in accordance with policy. Corrective Action: Community Manager reviewed file noting 2017 and 2018 were both done as self-certifications. REACH is currently doing full reviews for all HOME units during 2023.
View Audit 308469
Finding 399999 (2022-009)
Material Weakness 2022
Lincoln-King Adams-Young Academy
MI
Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management
The Academy signed a Promissory Note with Washington Parks Academy on February 8, 2024, to return all the ESSER dollars transferred to the Academy plus interest back to Washington Parks Academy over the next 60 months.
The Academy signed a Promissory Note with Washington Parks Academy on February 8, 2024, to return all the ESSER dollars transferred to the Academy plus interest back to Washington Parks Academy over the next 60 months.
View Audit 308166
Finding 399998 (2022-008)
Material Weakness 2022
Lincoln-King Adams-Young Academy
MI
Questioned Costs Eligibility
The Academy has put in place a Title I Coordinator to work with the Human Resources Department to ensure that the assigned staff meets the teacher’s eligibility standards for Title I.
The Academy has put in place a Title I Coordinator to work with the Human Resources Department to ensure that the assigned staff meets the teacher’s eligibility standards for Title I.
View Audit 308166 Questioned Costs: $1
Finding 399952 (2022-005)
Significant Deficiency 2022
The International Institute of Akron, Inc.
OH
Eligibility
Management has reaffirmed their commitment to following and enforcing current policies.
Management has reaffirmed their commitment to following and enforcing current policies.
View Audit 308108
Finding 398980 (2022-004)
Material Weakness 2022
Coastal Harvest
WA
Special Tests & Provisions Subrecipient Monitoring Cash Management § 200.303
Corrective Action: Coastal Harvest will implement formal internal control procedures, including independent reviews or other checks and balances, for all significant compliance requirements for its federal programs. Anticipated Completion Date: June 30, 2024
Corrective Action: Coastal Harvest will implement formal internal control procedures, including independent reviews or other checks and balances, for all significant compliance requirements for its federal programs. Anticipated Completion Date: June 30, 2024
View Audit 307582
Finding 397018 (2022-003)
Significant Deficiency 2022
Mobile Housing Authority
AL
Eligibility HUD Housing Programs Significant Deficiency
MHA will review and enhance as necessary the program’s existing quality control (QC) daily data validation reports to include a measure that crosschecks existing reports in the Yardi system of record and aids in validating data routinely submitted to HUD’s PIC system. In 2023, MHA implemented a Hous...
MHA will review and enhance as necessary the program’s existing quality control (QC) daily data validation reports to include a measure that crosschecks existing reports in the Yardi system of record and aids in validating data routinely submitted to HUD’s PIC system. In 2023, MHA implemented a Housing Specialist-II team lead to oversee staff processing annual reexaminations in accordance with 24 CFR 982.516. This team member is responsible for ensuring families are notified in a timely manner and if they do not comply with the annual reexamination requirement, they receive termination notices in compliance with HUD and MHA Administrative Plan requirements. MHA also implemented two compliance analysts in 2023; these staff persons currently report to the Program Management Analyst who monitors HUD’s PIC system and analyzes discrepancies between PIC data and MHA data housed in the Yardi system of record. This information is maintained in the program file. Responsible Person: Magdalene Watkins, Program Administrator Projected Completion Date: April 30, 2024
View Audit 306404
Finding 397009 (2022-003)
Material Weakness 2022
North Central Housing Authority
ND
HUD Housing Programs Eligibility Material Weakness
Contact Person Tim Greene, Executive Director Corrective Action Plan The Authority will continue to provide occupancy training to staff to prevent future exceptions. Planned Completion Date for CAP Immediately
Contact Person Tim Greene, Executive Director Corrective Action Plan The Authority will continue to provide occupancy training to staff to prevent future exceptions. Planned Completion Date for CAP Immediately
View Audit 306400
Finding 396478 (2022-005)
Significant Deficiency 2022
Agape Community Health Center, Inc.
FL
Eligibility Special Tests & Provisions
Actions Planned: Proper training will be given to employees and sliding fee discounts will be reviewed by a supervisor on a periodic basis to ensure compliance with the Organization’s sliding fee policies and procedures.
Actions Planned: Proper training will be given to employees and sliding fee discounts will be reviewed by a supervisor on a periodic basis to ensure compliance with the Organization’s sliding fee policies and procedures.
View Audit 306052
The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments
FL
Special Tests & Provisions Allowable Costs / Cost Principles Eligibility § 200.303
The Authority expects to issue its 2023 financial statements prior to June 2024
The Authority expects to issue its 2023 financial statements prior to June 2024
View Audit 305996
The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments
FL
Allowable Costs / Cost Principles Eligibility Matching / Level of Effort / Earmarking § 200.303
The Authority expects to issue its 2023 financial statements prior to June 2024
The Authority expects to issue its 2023 financial statements prior to June 2024
View Audit 305996
Finding 395982 (2022-008)
Significant Deficiency 2022
Bakersfield, American Indian Health Project INC
CA
Eligibility
Create eligibility verification checklist, policy and procedures
Create eligibility verification checklist, policy and procedures
View Audit 305605
Finding 395878 (2022-006)
Significant Deficiency 2022
County of Columbus
NC
Eligibility
Name of Contact Person: Darlene Jenkins-Parks/Income Maintenance Administrator Denise Branch/ Family & Children Medicaid Supervisor Corrective Action Plan: The County will complete a quarterly review or errors in income and resources. For those staff identified by the targeted review with...
Name of Contact Person: Darlene Jenkins-Parks/Income Maintenance Administrator Denise Branch/ Family & Children Medicaid Supervisor Corrective Action Plan: The County will complete a quarterly review or errors in income and resources. For those staff identified by the targeted review with errors in these areas, supervisors will provide refresher training on Medicaid policy requirements. Additional targeted reviews will be completed monthly until the deficiencies are corrected. The agency has already had staff unit meetings to discuss all Audit findings. Supervisors and/or leadworkers complete 2nd party reviews monthly on all staff. Proposed Completion Date: 8/22/2022 email sent to Adult staff in reference to Register of Deed requirements 8/24/2022 & 9/28/2022 Adult Medicaid Staff Meetings discussed all Audit Findings 1/26/2023 F&C Medicaid Staff Meeting discussed all Audit Findings 1/31/2023 Quarterly review of all 2nd party cases 2/28/2023 Refresher training for identified staff Continuous quarterly review of all 2nd party cases as needed for identified staff.
View Audit 305506
Finding 395811 (2022-002)
Material Weakness 2022
City of Anaheim
CA
Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303
Finding 2022-002, ALN 21.027 Coronavirus State and Local Fiscal Recovery Funds Following the comprehensive audit conducted on the CWWAPP 1.0 disbursement Year Ended June 30, 2022, the following exceptions have been identified that require immediate attention. Below is a summary of the exceptions obs...
Finding 2022-002, ALN 21.027 Coronavirus State and Local Fiscal Recovery Funds Following the comprehensive audit conducted on the CWWAPP 1.0 disbursement Year Ended June 30, 2022, the following exceptions have been identified that require immediate attention. Below is a summary of the exceptions observed: Summary of Exceptions: 1.Credits applied for electric and secondary water disbursements exceeded the prescribed 60-day timeframe. 2.Recalculation of eligible credits for three out of sixty samples resulted in awarded amounts surpassing the calculated eligibility, leading to questioned costs (i.e., over award). Corrective Action Plan: 1.In order to ensure adherence to the stipulated 60-day window for credit applications, for the upcoming CWWAPP arrearage funding we have initiated immediate testing of bill notices upon receipt of the CWWAPP 2.0 disbursement check. Simultaneously, a secondary query has been implemented to validate consistency between the initial query and the present data. Should any discrepancies or technical issues arise, we will promptly seek extension from the State Water Resources Control Board (SWRCB) to facilitate timely funding. 2.To mitigate the risk of over awarding eligible customers, a final query will be conducted prior to disbursement to confirm the accuracy of awarded amounts for each eligible account. We are committed to implementing these corrective measures swiftly and effectively to uphold compliance standards and improve efficiency within the framework of the SWRCB and CWWAPP. Responsible Official: Jeff Sparks Assistant Customer Service Manager Corrective Action Plan Implementation Date: May 17th, 2024
View Audit 305456 Questioned Costs: $1
Finding 395810 (2022-001)
Material Weakness 2022
City of Anaheim
CA
Questioned Costs Subrecipient Monitoring Matching / Level of Effort / Earmarking
Finding #2022-001 Eligibility Program: Home Investment Partnership Program (CFDA # 14.239) Condition: During the test work over continuing eligibility requirements for loan recipients of the program, it was noted that the City did not have sufficient controls in place nor were adequate records maint...
Finding #2022-001 Eligibility Program: Home Investment Partnership Program (CFDA # 14.239) Condition: During the test work over continuing eligibility requirements for loan recipients of the program, it was noted that the City did not have sufficient controls in place nor were adequate records maintained to verify that the property was the principal residence of the homebuyer during the period of affordability described in the finding. Corrective Action: During fiscal year 2022, the Department underwent a reorganization as the City Council approved the establishment of two separate departments, Housing & Community Development and Economic Development. In April 2022, the Department contracted with Keyser Marston and Associates to train newly hired staff to assist the Department with Loan portfolio monitoring and to ensure on-going compliance. In addition, the Department will be implementing new procedures through a program called Neighborly to facilitate and streamline the process for all outstanding loans. The Neighborly program will assist with loan tracking, communicating with loan participants and obtaining annual compliance certifications. The Department will be focusing its resources to ensure ongoing compliance and plans to close this finding in fiscal year 2023. Contact Person: Andy Nogal, Deputy Director Anticipated Completion Date: June 2023
View Audit 305456 Questioned Costs: $1
Finding 395692 (2022-002)
Significant Deficiency 2022
Saleian Missions, Inc.
NY
Questioned Costs Subrecipient Monitoring Eligibility
Finding Number: 2022-002 - Eligibility Programs: U.S. State Department. Award Listing Number 19.517 Overseas Refugee Assistance Programs for Africa: Sunrise Project, Cairo Urban Refugees VI U.S. State Department. Award Listing Number 19.517 Overseas Refugee Assistance Programs for Africa: Sunrise...
Finding Number: 2022-002 - Eligibility Programs: U.S. State Department. Award Listing Number 19.517 Overseas Refugee Assistance Programs for Africa: Sunrise Project, Cairo Urban Refugees VI U.S. State Department. Award Listing Number 19.517 Overseas Refugee Assistance Programs for Africa: Sunrise Project, Cairo Urban Refugees VII. Planned Corrective Action: Management has adjusted its internal policy related to files maintained related to eligibility. Due to the timing of the finding the first full period that this can be implemented will be in fiscal 2024. Person Responsible: Daniel DeFilippis, Controller Expected Completion Date: December 31, 2024
View Audit 305324 Questioned Costs: $1
Finding 395593 (2022-007)
Material Weakness 2022
Sacramento Housing and Revelopment Agency
CA
HUD Housing Programs Eligibility Material Weakness
Public and Indian Housing – Assistance Listing No. 14.850 Recommendation: We recommend management to assign a person that verifies all the documents are in place before processing the determination of eligibility. Explanation of disagreement with audit finding: There is no disagreement with the audi...
Public and Indian Housing – Assistance Listing No. 14.850 Recommendation: We recommend management to assign a person that verifies all the documents are in place before processing the determination of eligibility. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A checklist will be created that staff will use to check off all relevant data that has come in. This list will be reviewed by the Intake team before files are sent to Public Housing. Name(s) of the contact person(s) responsible for corrective action: Myvy Ngo Planned completion date for corrective action plan: Immediately
View Audit 305205
Finding 395583 (2022-003)
Significant Deficiency 2022
Sacramento Housing and Revelopment Agency
CA
HUD Housing Programs Eligibility Reporting
Housing Choice Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend that the person assigned to submit the 50058s to PIC, assure the fatal errors and warnings are correctly in a reasonable time to avoid variances. Explanation of disagreement with audit finding: There is no di...
Housing Choice Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend that the person assigned to submit the 50058s to PIC, assure the fatal errors and warnings are correctly in a reasonable time to avoid variances. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Ken Olson, Senior Program Analyst, is responsible for submitting the 50058s to PIC. He will regularly review and correct errors and resubmit as needed. Name(s) of the contact person(s) responsible for corrective action: Ken Olson, Senior Program Analyst Planned completion date for corrective action plan: immediately
View Audit 305205
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