Corrective Action Plans

Finding 25485 (2022-001)

None 2022

NE

Eligibility Allowable Costs / Cost Principles

2022-001 - U.S. Department of Health and Human Services - Nebraska Department of Labor ? Temporary Assistance for Needy Families ? 93.558 Criteria or Specific Requirement ? Management is responsible for implementing and effectively operating internal controls over compliance to mitigate the risk of...

2022-001 - U.S. Department of Health and Human Services - Nebraska Department of Labor ? Temporary Assistance for Needy Families ? 93.558 Criteria or Specific Requirement ? Management is responsible for implementing and effectively operating internal controls over compliance to mitigate the risk of misuse of the Organization?s federal funds and ensure participating students are eligible based on financial need. The Temporary Assistance for Needy Families (TANF) funds may be used for expenses related to Job?s for America?s Graduates (JAG) Program, which helps low-income students with additional resources in middle and/or high school to help the students graduate. To be eligible for the JAG Program, which is funded by the TANF funds, the students must be low-income, evidenced by qualification for free or reduced lunch. Planned Corrective Actions (Management's Response) - United Way of the Midlands (UWM) has reviewed and updated its policies, procedures and training within the JAG Program to improve retention of eligibility documentation and, in the event such documentation is no longer available, document the validation of eligibility requirements used to support Management?s decision on the applicant?s eligibility. This is fully documented in our Quality Assurance SOP (Standard Operating Procedures). UWM also implemented an additional detective internal control in our JAG Nebraska Invoicing SOP that requires a UWM Finance member independent of the eligibility onboarding process to audit monthly a small sampling of students for proper documentation and eligibility related to TANF invoicing. Management will monitor this regularly throughout the year to ensure procedures are being followed as documented. All changes have been implemented. Anticipated Completion Date - October 15th, 2022

View Audit 22058

Finding 25413 (2022-001)

Significant Deficiency 2022

Housing Authority of the County of Santa Cruz

CA

Questioned Costs HUD Housing Programs Eligibility

The findings from the June 30, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Findings ? Federal Award Program Audit Finding 2022-001 Federal Agency: U.S. Department of Housing and Urban Develo...

The findings from the June 30, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Findings ? Federal Award Program Audit Finding 2022-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers and Mainstream Vouchers Programs Federal Catalog Numbers: 14.871 and 14.879 Noncompliance ? E. Eligibility ? Tenant Files Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance for Eligibility Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). These files are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority?s files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Context: There are approximately 5,068 units. Of a sample size of fifty-nine (59) tenant files, the following was noted: - HUD 9887 Form was missing in 4 files - Annual HUD 50058 recertification form and verification of income and assets was missing in 1 file - Lead based paint disclosure form was missing in 1 file Our sample size is statistically valid. Known Questioned Costs: $59,947 Cause: There is a significant deficiency in compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority has not properly maintained tenant files in compliance with program requirements following the expiration of HUD waivers as a result of insufficient staffing. Effect: The Section 8 Housing Choice Vouchers and Mainstream Vouchers Programs are in non-compliance with the eligibility type of compliance related to the maintenance of tenant files. Recommendation: We recommend the Authority design and implement a corrective action plan that will assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. Following the expiration of the COVID-19 HUD regulatory waivers, the Authority experienced a large backlog of reexaminations along with higher than usual rates of staff turnover and other staff capacity challenges related to the pandemic. Authority management has developed and implemented a plan to rapidly work through the backlog, bringing the program into compliance. Current HUD SEMAP data reflects that 96% of reexaminations have been completed in a timely manner, which is high enough to provide full points for this SEMAP indicator. Authority management will continue to monitor and strive towards 100% timely recertifications by the end of this fiscal year. Aaron Pomeroy, Finance Director, will be responsible to implement this corrective action by June 30, 2023.

View Audit 25622 Questioned Costs: $1

Finding 25373 (2022-009)

Significant Deficiency 2022

Donnelly College

KS

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.407

Finding Reference 2022-009 Contact Person: Gerald Moench, Interim CFO (or Emily Buckley, VP of Advancement) Views of Responsible Officials and Planned Corrective Action: In including the questioned indirect cost as a HEERF expense, management only considered the per unit cost threshold, rather than ...

Finding Reference 2022-009 Contact Person: Gerald Moench, Interim CFO (or Emily Buckley, VP of Advancement) Views of Responsible Officials and Planned Corrective Action: In including the questioned indirect cost as a HEERF expense, management only considered the per unit cost threshold, rather than both the per unit cost and the expected life of the items. The audit clarified the regulations and Donnelly promptly notified our program officer, posted a corrected quarterly report and refunded the funds to the Department of Education. Anticipated Completion Date: October 2022

View Audit 25035 Questioned Costs: $1

Finding 25370 (2022-007)

Significant Deficiency 2022

Donnelly College

KS

Questioned Costs Student Financial Aid Eligibility

Finding Reference 2022-007 Contact Person: Stephani Berry Views of Responsible Officials and Planned Corrective Action: These Pell recipients are from the 2nd Chance Pell Grant Experiment and guidance has been inconsistent in the awarding process, resulting from staffing issues and high turnover. St...

Finding Reference 2022-007 Contact Person: Stephani Berry Views of Responsible Officials and Planned Corrective Action: These Pell recipients are from the 2nd Chance Pell Grant Experiment and guidance has been inconsistent in the awarding process, resulting from staffing issues and high turnover. Student credit hours are now determined using the correct Pell Grant Payment Schedule and awarded accordingly. Verification process includes reviewing student's maximum lifetime Pell award percentage of 600%. Anticipated Completion Date: July 1, 2022

View Audit 25035 Questioned Costs: $1

Finding 25341 (2022-002)

Significant Deficiency 2022

City of Chicago

IL

Eligibility Internal Control / Segregation of Duties Procurement, Suspension & Debarment

FINDING 2022-002 As a result of the 2022 Single Audit, the Department of Housing (DOH) received an audit finding with respect to potential unallowable rental assistance payments made because of an internal control failure in the case management workflow that did not adequately segregate reviewer and...

FINDING 2022-002 As a result of the 2022 Single Audit, the Department of Housing (DOH) received an audit finding with respect to potential unallowable rental assistance payments made because of an internal control failure in the case management workflow that did not adequately segregate reviewer and approver duties. As a corrective action, DOH terminated its contractual agreement with its program administrator effective May 12, 2023. To disburse the remaining emergency rental assistance dollars, DOH has entered into a contractual agreement with the Illinois Housing Development Authority to be its new program administrator effective June 30, 2023. DOH is actively investigating questionable cases to quantify the total population and dollar amount of ineligible payments made. In addition, DOH is reviewing its case management workflow procedures to ensure clear segregation of duties in any future rental assistance program. Daniel Kay Hertz, DOH Director of Policy, will be responsible for ensuring that this corrective action plan is fully implemented by January 1, 2024.

View Audit 21083

Finding 25270 (2022-002)

None 2022

Barrier Free Living Holding, Inc.

NY

Eligibility

Finding 2022-002 - Management will continue to accumulate proper supporting documentation to support their compliance with the eligibility compliance requirement and to provide such documentation, when legally possible.

View Audit 22152

Finding 25259 (2022-004)

Material Weakness 2022

Brodstone Memorial Hospital D/b/a Brodstone Healthcare and Affiliate

NE

Allowable Costs / Cost Principles Eligibility Material Weakness § 200.303

Finding No. 2022-004 Criteria: The terms and conditions of the CARES Act Provider Relief Fund (PRF) distributions state that funds are to only be used to prevent, prepare for, and respond to coronavirus, and that funds may only be used for healthcare related expenses or lost revenue that is attribu...

Finding No. 2022-004 Criteria: The terms and conditions of the CARES Act Provider Relief Fund (PRF) distributions state that funds are to only be used to prevent, prepare for, and respond to coronavirus, and that funds may only be used for healthcare related expenses or lost revenue that is attributable to the coronavirus. The Health Resources and Services Administration (HRSA) provided guidance on how an organization was to report usage of PRF distributions received. Period 1 and Period 2 reporting required an organization to illustrate how PRF funds received were used. An organization was allowed to include eligible expenditures from January 1, 2020 through December 31, 2021 depending on the period reporting. Condition: During the process of identifying expenses that were incurred to prevent, prepare for, or respond to the coronavirus pandemic, management included expenses incurred in January 2020 and February 2020 which were not supported by management in relation to prepare, prevent, or respond to coronavirus as these were incurred prior to when the Hospital began to prepare for coronavirus. Planned Corrective Action: Management will continue to refine processes to review reporting requirements and the accumulation of eligible expenditures per the terms and conditions of the PRF and reporting guidance provided by HRSA. However, the Hospital also incurred and reported sufficient unreimbursed expenditures attributable to coronavirus in the PRF reporting portal that if the noted item were not to be reported, the Hospital would have satisfactorily incurred eligible expenses in excess of PRF funds received, including interest earned on such funds. Planned Completion Date: Ongoing Person Responsible: Crystal Wyatt, CFO

View Audit 22532

Finding 25137 (2022-001)

None 2022

Community Action Resource & Development, Inc.

OK

Questioned Costs Eligibility

September 14, 2023 Corrective Action Notice Community Action Resource & Development, Inc. FISCAL YEAR END DATE: 12/31/22 The audit citation of a staff incident wherein net rather than gross income was utilized is most regrettable and an obvious error. Appropriately, the staff person was notified and...

September 14, 2023 Corrective Action Notice Community Action Resource & Development, Inc. FISCAL YEAR END DATE: 12/31/22 The audit citation of a staff incident wherein net rather than gross income was utilized is most regrettable and an obvious error. Appropriately, the staff person was notified and the error was corrected. Retraining and relevant corrective action was taken. All persons who figure income eligibility received training and notifications regarding this failure to follow instructions. I and my staff feel certain that no further incidences of this outcome will happen in the future. Measures have also been placed on persons reviewing files and entering data for reporting purposes will double check the income eligibility to ensure correctness. Please know that our good intentions and continued efforts to accomplish clean and reliable audits is paramount.

View Audit 22624 Questioned Costs: $1

Finding 25132 (2022-002)

Significant Deficiency 2022

Overlake Hospital Medical Center

WA

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring § 200.403

ALN No. 97.036, Disaster Grants ? Public Assistance (Presidentially Declared Disasters); Award Number: 033-UECF5-00; Award Year: January 1, 2020 to July 1, 2022; Pass-Through Entity: State of Washington Military Department Emergency Medicine Division; Award Number: D20-368 Finding: Activities Allow...

ALN No. 97.036, Disaster Grants ? Public Assistance (Presidentially Declared Disasters); Award Number: 033-UECF5-00; Award Year: January 1, 2020 to July 1, 2022; Pass-Through Entity: State of Washington Military Department Emergency Medicine Division; Award Number: D20-368 Finding: Activities Allowed or Unallowed ? The controls were not sufficient to ensure that purchase orders issued for capital purchases were fully fulfilled and paid prior to submission for program reimbursement. Status: Corrective action in progress. Corrective Action: Internal controls will be strengthened in future periods to ensure that costs are incurred prior to submission for program reimbursement. Instead of tracking purchase orders issued we will utilize general ledger details ensuring only purchase orders with receipts and subsequent invoices are included in reimbursement requests. The accounting team will pull invoice and payment support which will be reviewed by the Director of Finance prior to submission to ensure all expenditures have been paid prior to submitting a request for reimbursement. Person(s) Responsible for Implementing: Jenna Bevilacqua, Director of Finance and Lindsey Soboloski, Controller Implementation Date: March 20, 2023

View Audit 23649 Questioned Costs: $1

Finding 25131 (2022-001)

Significant Deficiency 2022

Overlake Hospital Medical Center

WA

Questioned Costs Cash Management Eligibility

ALN No. 93.498, Provider Relief Fund; Award Year: Periods 2 and 3: July 1, 2020 to June 30, 2021 Finding: Activities Allowed or Unallowed ? The controls were not sufficient to ensure that depreciation expense for capital purchases were excluded when the capital expense was also submitted for progra...

ALN No. 93.498, Provider Relief Fund; Award Year: Periods 2 and 3: July 1, 2020 to June 30, 2021 Finding: Activities Allowed or Unallowed ? The controls were not sufficient to ensure that depreciation expense for capital purchases were excluded when the capital expense was also submitted for program reimbursement. Status: Corrective action in progress. Corrective Action: Internal controls will be strengthened in future periods to ensure that ledger details are appropriately filtered to exclude depreciation expense for costs already considered during the review of capital expenditures. The Director of Finance will review ledger details prior to submission to ensure only appropriate ledger accounts are included in requests for reimbursement. Person(s) Responsible for Implementing: Jenna Bevilacqua, Director of Finance and Lindsey Soboloski, Controller Implementation Date: March 20, 2023

View Audit 23649 Questioned Costs: $1

Finding 25130 (2022-002)

Significant Deficiency 2022

The Housing Authority of the City of Bessemer, Alabama

AL

HUD Housing Programs Eligibility Significant Deficiency

The Housing Authority of the City of Bessemer recognizes the need for satisfactory internal controls. The Housing Authority has hired a compliance officer to conduct file review and audits on all program files. Reports are prepared and submitted to executive management upon completion. This process ...

The Housing Authority of the City of Bessemer recognizes the need for satisfactory internal controls. The Housing Authority has hired a compliance officer to conduct file review and audits on all program files. Reports are prepared and submitted to executive management upon completion. This process was instituted January 1, 2023 and has proved to be an upgrade in our internal control environment.

View Audit 22621

Finding 25129 (2022-001)

Significant Deficiency 2022

The Housing Authority of the City of Bessemer, Alabama

AL

HUD Housing Programs Eligibility Significant Deficiency

The Housing Authority of the City of Bessemer agrees with the identified deficiencies and a plan or action has been developed to strengthen internal controls. The Housing Authority of the City of Bessemer recognizes the need for satisfactory internal controls. The identified deficiency was a result ...

The Housing Authority of the City of Bessemer agrees with the identified deficiencies and a plan or action has been developed to strengthen internal controls. The Housing Authority of the City of Bessemer recognizes the need for satisfactory internal controls. The identified deficiency was a result of interruption in inspections due to an unprecedented pandemic. Although, inspections were reinstated, the Housing Authority failed to complete all catch-up inspections. The Housing Authority hired a third-party vendor to conduct all inspections as a result of this deficiency. We have also hired a compliance officer to conduct file audits and confirm that all HUD required policies are met in all programs. We believe that these adjustments will ensure that our internal control environment is greatly improved.

View Audit 22621

Finding 25009 (2022-005)

Significant Deficiency 2022

Tri Valley Health System

NE

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Cash Management § 200.303

Finding 2022-005 Department of Health and Human Services Federal Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year ? Period 1 TIN #476028103 Activities Allowed or Unallowed and Allowable Costs/Cost Prin...

Finding 2022-005 Department of Health and Human Services Federal Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year ? Period 1 TIN #476028103 Activities Allowed or Unallowed and Allowable Costs/Cost Principles and Reporting Significant Deficiency in Internal Control Over Compliance Finding Summary: Tri Valley Health System calculated the reimbursement rate from the total expenses, but also calculated the reimbursemeone on an individual expense in duplicate. Responsible Individuals: Diana Swindler, CFO Corrective Action Plan: Tri Valley Health System will implement procedures to ensure the reduction for reimbursement of expenditures are calculated and reported correctly for all future federal awards. Anticipated Completion Date: 02/28/2023

View Audit 23714

Finding 24955 (2022-009)

Significant Deficiency 2022

Marian University, Inc.

WI

Eligibility Significant Deficiency

2022-009: Student Financial Aid Cluster ? Assistance Listing No. 84.268 Recommendation: We recommend that the University update its processes and procedures related to reviewing Pell awarded and not disbursed. Explanation of disagreement with audit finding: There is no disagreement with the audit f...

2022-009: Student Financial Aid Cluster ? Assistance Listing No. 84.268 Recommendation: We recommend that the University update its processes and procedures related to reviewing Pell awarded and not disbursed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University is completing an internal review of Pell grant recipients to ensure the finding is an isolated instance. Name(s) of the contact person(s) responsible for corrective action: Benjamin Soman Planned completion date for corrective action plan: 05/01/2023

View Audit 25226

Finding 24941 (2022-008)

Significant Deficiency 2022

Marian University, Inc.

WI

Eligibility Significant Deficiency Internal Control / Segregation of Duties

2022-008: Student Financial Aid Cluster ? Assistance Listing No. 84.007, 84.033, 84.038, 84.063, 84.268, 84.379 Recommendation: We recommend that the University update its processes and procedures related to the maintenance of the required verification support. Explanation of disagreement with audit...

2022-008: Student Financial Aid Cluster ? Assistance Listing No. 84.007, 84.033, 84.038, 84.063, 84.268, 84.379 Recommendation: We recommend that the University update its processes and procedures related to the maintenance of the required verification support. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University updated its training from verification and documentation of review of student identification to verification and requiring a copy of student identification. Written policy will be updated by the date indicated below. Name(s) of the contact person(s) responsible for corrective action: Benjamin Soman Planned completion date for corrective action plan: 05/01/2023

View Audit 25226

Finding 24922 (2022-001)

Significant Deficiency 2022

Housing Authority of Kansas City Kansas

RI

Eligibility HUD Housing Programs Significant Deficiency

Finding 2022-001 Significant Deficiency in Internal Control over Compliance Corrective Action Plan: The corrective plan is to examine all applicant and participant files for accuracy using a file checklist for forms such as Section 214 Declaration of Citizenship during the eligibility process and an...

Finding 2022-001 Significant Deficiency in Internal Control over Compliance Corrective Action Plan: The corrective plan is to examine all applicant and participant files for accuracy using a file checklist for forms such as Section 214 Declaration of Citizenship during the eligibility process and annual reexamination period. Management has decided not to purge tenant files for the current program participants. For the participants who are not in the program, the file will not be purged for a minimum of three years. In this specific instance, the participant entered the program in 2012 and ended program participation on March 31, 2022. The original file had been purged. Name of Responsible Person: Cherrie Escobar, Director of Section 8 Projected Completion Date: March 31, 2023

View Audit 20984

Finding 24792 (2022-020)

Material Weakness 2022

State of Michigan

MI

Cash Management Eligibility Material Weakness § 200.516

Finding 2022-020 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Expenditure Processing for Medical Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has been working since 2018 to ensure correct eligibil...

Finding 2022-020 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Expenditure Processing for Medical Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has been working since 2018 to ensure correct eligibility classifications in Bridges at the time of payment and a system change was implemented in April 2021 to correct the issue. All new cases are correctly routed. MDHHS expects that all existing cases will be updated during the 14-month period following the May 11, 2023 end date of the PHE, as MDHHS completes renewals for existing cases. MDHHS could not terminate Medicaid benefits during the PHE, and annual renewals have not been completed since the start of the PHE, resulting in most Medicaid cases not being touched until the 14-month unwind period allotted by the Centers for Medicare and Medicaid Services at the end of the PHE. MDHHS identified and updated its manual process of transferring expenditures from the Medicaid Cluster to the Children?s Health Insurance Program in June 2021; and will continue this manual process, on a quarterly basis, by completing a summary-level adjustment determined by analyzing CHAMPS payment data and Bridges eligibility data until all existing cases have been updated. Anticipated Completion Date July 31, 2024 Responsible Individual(s) Logan Dreasky, MDHHS Brant Cole, MDHHS Erin Emerson, MDHHS

View Audit 20093

Finding 24736 (2022-057)

Material Weakness 2022

State of Michigan

MI

Questioned Costs Eligibility Subrecipient Monitoring § 200.516

Finding 2022-057 Low-Income Home Energy Assistance, ALN 93.568 - Eligibility Determinations Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS will continue to communicate with BSCs and local offices regarding the requirements to obtain adequate verification and mainta...

Finding 2022-057 Low-Income Home Energy Assistance, ALN 93.568 - Eligibility Determinations Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS will continue to communicate with BSCs and local offices regarding the requirements to obtain adequate verification and maintain sufficient documentation to support State Emergency Relief (SER) processing. MDHHS will also continue to provide direct SER guidance and clarification through the SER mailbox. Beginning in fiscal year 2023, MDHHS implemented quarterly case reads and during April 2023, MDHHS began monthly meetings with BSCs to discuss the results of quarterly SER case reads. In addition, MDHHS will update SER policy to include additional verification sources. Anticipated Completion Date MDHHS will update policy by September 30, 2023. All other corrective action is ongoing. Responsible Individual(s) Nicole Denson-Sogbaka, MDHHS Kent Schulze, MDHHS

View Audit 20093 Questioned Costs: $1

Finding 24718 (2022-054)

Material Weakness 2022

State of Michigan

MI

Questioned Costs Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.516

Finding 2022-054 Temporary Assistance for Needy Families, ALN 93.558 - Non-Financial Eligibility Documentation Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS?s ESA will continue to emphasize the importance of maintaining eligibility documentation through ongoing st...

Finding 2022-054 Temporary Assistance for Needy Families, ALN 93.558 - Non-Financial Eligibility Documentation Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS?s ESA will continue to emphasize the importance of maintaining eligibility documentation through ongoing staff training and a memorandum sent out to the local offices. ESA leadership will reach out to the managers of the individual specialists regarding the issues identified and provide additional guidance. Anticipated Completion Date Training will be ongoing. ESA will issue the memorandum and address the specific issues with local office management and specialists by August 31, 2023. Responsible Individual(s) Kenton Schulze, MDHHS Lana Karadsheh, MDHHS Brian Sanborn, MDHHS

View Audit 20093 Questioned Costs: $1

Finding 24714 (2022-002)

Material Weakness 2022

Isanti County

MN

Eligibility Material Weakness Internal Control / Segregation of Duties

Finding Number: 2022-002 Finding Title: Eligibility Program: 93.778 Medicaid Cluster Name of Contact Person Responsible for Corrective Action: Penny Messer, Health and Human Services Division Leader, and Karrie Kolb, Financial Assistance Supervisor Corrective Action Planned: The errors from this rev...

Finding Number: 2022-002 Finding Title: Eligibility Program: 93.778 Medicaid Cluster Name of Contact Person Responsible for Corrective Action: Penny Messer, Health and Human Services Division Leader, and Karrie Kolb, Financial Assistance Supervisor Corrective Action Planned: The errors from this review will be thoroughly discussed at the next all unit meeting. The Income Maintenance Supervisor plans to meet with each worker independently to review the errors and ensure understanding of policy and requirements, and a coaching plan will be implemented with each employee that had two or more case errors. Additionally, the Income Maintenance unit will conduct an average of 15 case reviews on a quarterly basis. Anticipated Completion Date: These actions were implemented on June 6, 2023, and the case reviews will begin in the third quarter of 2023, and be completed on an ongoing basis thereafter.

View Audit 21275

Finding 24681 (2022-008)

Significant Deficiency 2022

State of Michigan

MI

Internal Control / Segregation of Duties Eligibility Student Financial Aid

Finding 2022-008 MiSACWIS Security Management and Access Controls Management Views MDHHS agrees with parts a., b., d., and e. of the finding. DTMB disagrees with part c. of the finding. For part c., although MDHHS and DTMB had not fully documented all database specific configuration standards unti...

Finding 2022-008 MiSACWIS Security Management and Access Controls Management Views MDHHS agrees with parts a., b., d., and e. of the finding. DTMB disagrees with part c. of the finding. For part c., although MDHHS and DTMB had not fully documented all database specific configuration standards until after the audit period, DTMB disagrees that during the audit period the system contained potentially vulnerable database configurations and disagrees that DTMB cannot ensure the security of the data. DTMB has been and continues to implement the manufacturer?s recommendations regarding security configurations. In addition, the databases reside in restricted trusted internal security zones, protected by firewalls, which are specific to each application and database, in conjunction with intrusion protection, antivirus software, and SOM standard security safeguards. Planned Corrective Action For parts a. and e., MDHHS will continue to provide training for LOSCs via quarterly webinars to emphasize the proper procedures for granting access and how to review and compare access to DSA approved requests. For part b., MDHHS will add an Incompatible Role form into the DSA Michigan Statewide Automated Child Welfare Information System (MiSACWIS) request with automated routing for appropriate approval. This would ensure that documentation was maintained, and appropriate approvals secured in all situations. For part c., DTMB developed an organization-wide framework for database security configuration management. For part d., MDHHS has implemented a quarterly report in MiSACWIS that will identify any financial authorization that was approved by the same person that created the authorization. Anticipated Completion Date a. and e. Corrective action is ongoing. b. MDHHS has not yet determined an anticipated completion date because implementation is dependent on funding, approval, and prioritization of proposed system changes. c. DTMB anticipates having compliance documentation by September 30, 2023. d. MDHHS will receive the first quarterly report on September 30, 2023, and will perform a review of the transactions identified on that report during October 2023. Responsible Individual(s) a., b., and e. Alana Lowe and Deon Nelson, MDHHS c. Heather Frick and Nathan Buckwalter, DTMB d. Alana Lowe, MDHHS

View Audit 20093

Finding 24666 (2022-053)

Material Weakness 2022

State of Michigan

MI

Special Tests & Provisions Procurement, Suspension & Debarment Subrecipient Monitoring

Finding 2022-053 Immunization Cooperative Agreements, ALN 93.268 - Control, Accountability, and Safeguarding of Vaccine and Record of Immunization Management Views MDHHS disagrees with the finding. Site visits were not conducted for all Vaccines for Children providers during the review period beca...

Finding 2022-053 Immunization Cooperative Agreements, ALN 93.268 - Control, Accountability, and Safeguarding of Vaccine and Record of Immunization Management Views MDHHS disagrees with the finding. Site visits were not conducted for all Vaccines for Children providers during the review period because the Centers for Disease Control and Prevention (CDC) allowed jurisdictions to temporarily suspend these visits during the COVID-19 pandemic. MDHHS reached out to the CDC for clarification on conducting site visits and was informed that site visit activities may be suspended based on COVID-19 activity in MDHHS?s jurisdiction and capacity within MDHHS?s organization. Information supporting this decision was provided to the audit team. Planned Corrective Action MDHHS informed all site visit reviewers of CDC?s requirement to return to full compliance of site visit requirements beginning with the new cycle from July 1, 2022 through June 30, 2023. This was relayed verbally on monthly calls, in writing, and through online training sessions. Anticipated Completion Date MDHHS anticipates that all site visits will be completed by June 30, 2023. Responsible Individual(s) Heather Barnes, MDHHS Heidi Loynes, MDHHS Terri Adams, MDHHS

View Audit 20093

Finding 24634 (2022-015)

Material Weakness 2022

The City of New York

NY

Questioned Costs Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Finding No. 2022-015 Department(s) New York City Administration for Children?s Services New York City Human Resources Administration Program(s) Assistance Listing Number 93.575, Child Care and Development Block Grant Corrective Action(s) HRA HRA will convene a small workgroup to meet bi-weekly to r...

Finding No. 2022-015 Department(s) New York City Administration for Children?s Services New York City Human Resources Administration Program(s) Assistance Listing Number 93.575, Child Care and Development Block Grant Corrective Action(s) HRA HRA will convene a small workgroup to meet bi-weekly to review the details and history of the cases identified to try to isolate the cause of the errors, and once we determine the cause, will work with the necessary parties/stakeholders to develop an approach to avoid the situation from repeating itself. First meeting will be 2nd week of April to identify the appropriate parties to include and come up with meeting goal and agenda. ACS Case No. 1 The audit reviewed a child care case relating to an older Fair Hearing which had not been closed timely per the original State Fair Hearing decision, which had been issued prior to FY22. ACS' Child and Family Well-Being (CFWB) division had previously instituted a new Quality Assurance review of pending Fair Hearing cases and through this QA review had already identified and closed the case. However, the auditors reviewed an earlier State FY22 claim prior to ACS' identification of the case. Per the new QA protocol, CFWB will be reviewing HRA/DSS systems reports on a monthly basis, identify any questioned cases and take appropriate follow-up action. CFWB is also preparing new written guidelines. Case No. 2 In one child care case, ACS was not able to provide eligibility documentation. Further ACS research determined a systems coding inconsistency. ACS procedure is to run reports to identify inconsistencies with programmatic codes and review any flagged cases prior to submission of claims to the State. However, in this instance, the case was not identified in the report. ACS will propose creation of a new exception report with a more refined level of detail to identify any case coding inconsistencies and allow follow up to ensure complete case eligibility support for any flagged cases. ACS will work with HRA/DSS on report development. Anticipated Completion Date HRA Beginning Q2 2023 ? Convene workgroup Beginning Q3 2023 ? Completion date ACS Initiated in FY 2022 ? New quality assurance (QA) review To be completed in FY 2023 ? New written guidelines and refined reporting Person(s) Responsible for Implementation HRA Ramon E. Flores Assistant Deputy Commissioner, Family Independence Administration (FIA) FloresRa@hra.nyc.gov ACS For new QA and guidelines Isabel Villegas Executive Director, Policy & Compliance Division of Child and Family Well-Being (212) 393-5325 For refined reporting Pauline Young Assistant Commissioner for Claiming and Revenue Division of Finance (212) 676-8803

View Audit 22749 Questioned Costs: $1

Finding 24620 (2022-014)

Significant Deficiency 2022

The City of New York

NY

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

Finding No. 2022-014 Department(s) New York City Human Resources Administration Program(s) Assistance Listing Number 14.241, Housing Opportunities for Persons with AIDS Corrective Action(s) The auditors selected a non-statistical sample of nineteen (19) units that were subject to an initial inspect...

Finding No. 2022-014 Department(s) New York City Human Resources Administration Program(s) Assistance Listing Number 14.241, Housing Opportunities for Persons with AIDS Corrective Action(s) The auditors selected a non-statistical sample of nineteen (19) units that were subject to an initial inspection by HRA during fiscal 2022 and noted that for three (3) selections, HRA was unable to provide a copy of the inspection checklist that was completed by the QA Inspector prior to assistance being provided for the unit. Unfortunately, during the height of the COVID-19 pandemic, many housing vendor staff were working remotely, and a few documents may have been mislaid. To ensure continual compliance with federal HOPWA grant requirements, HRA will enhance its efforts to confirm that housing vendors properly maintain a copy of inspection checklists completed prior to initial move in. Monitoring visits conducted by HRA will include a review of the checklists. Anticipated Completion Date April 2023 and ongoing Person(s) Responsible for Implementation Pamela Xiomara Farquhar Assistant Deputy Commissioner FarquharX@hra.nyc.gov

View Audit 22749

Finding 24619 (2022-013)

Material Weakness 2022

The City of New York

NY

Questioned Costs Internal Control / Segregation of Duties Eligibility § 200.303

Finding No. 2022-013 Department(s) New York City Human Resources Administration Program(s) Assistance Listing Number 14.241, Housing Opportunities for Persons with AIDS Corrective Action(s) Rental assistance payments made on behalf of tenants residing in supportive housing are calculated by contract...

Finding No. 2022-013 Department(s) New York City Human Resources Administration Program(s) Assistance Listing Number 14.241, Housing Opportunities for Persons with AIDS Corrective Action(s) Rental assistance payments made on behalf of tenants residing in supportive housing are calculated by contracted supportive housing vendors, not directly by HRA. On December 20, 2022, agency staff received a formal notice informing them that the agency will cease issuing to clients a notification of their rent payment responsibility for agency-contracted supportive housing programs, as this is the responsibility of the supportive housing vendor. To ensure continual compliance with federal HOPWA grant requirements, HRA will enhance its monitoring of contract vendors during annual monitoring visits. This includes sampling of rent payments made to verify calculation of rent payment is appropriate, payments made are timely, and tenant income documentation is appropriately budgeted in rent payment calculation. Monitoring visits will also include a review of each client?s Notice of Rights, which describes rent information, including the client?s share, as per the Local Law that went into effect May 9, 2022. Anticipated Completion Date April 2023 Person(s) Responsible for Implementation Pamela Xiomara Farquhar Assistant Deputy Commissioner FarquharX@hra.nyc.gov

View Audit 22749 Questioned Costs: $1

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