Corrective Action Plans

Finding 433258 (2022-008)

None 2022

LA

Allowable Costs / Cost Principles Eligibility HUD Housing Programs

Dear Mr. Waguespack:The Department of Children and Family Services has reviewed the finding ?Improper Employee Activity in Federal Program?. The Department concurs with the finding and continues to prioritize prevention and detection of improper activity associated with programs it administers. Each...

Dear Mr. Waguespack:The Department of Children and Family Services has reviewed the finding ?Improper Employee Activity in Federal Program?. The Department concurs with the finding and continues to prioritize prevention and detection of improper activity associated with programs it administers. Each employee of the Department of Children and Family Services (DCFS), as a new hire and annually, must sign and date form DCFS CS 4 Acknowledgement of Agreement to Comply with DCFS Policy Regarding Prohibited Activities and Employees Working on Cases of Relatives, Friends, Acquaintances, and/or Oneself.The Department?s Fraud and Recovery Unit initiates a review of each employee receiving benefits under the programs administered. An automated monthly report identifies all DCFS employees receiving assistance in the Supplemental Nutrition Assistance Program (SNAP) and all new cases are reviewed for eligibility by parish office staff. Any cases identified by parish office staff as suspect are submitted to the Fraud and Recovery Unit for investigation. Through their reviews, the Fraud and Recovery Unit identified improper activity by a DFCS employee. The employee was subsequently terminated and is required to repay the ineligible SNAP benefits. Additionally, the employee is barred from future employment with DCFS.DCFS reported this finding to the United States Department of Agriculture, Food and Nutrition Service, on the FNS 366B, as required. The Fraud and Recovery Unit has collected $78.00 of the debt and will continue to pursue recovery of the remaining $3,890.00 balance. Should the household cease to repay the balance the case will be referred to the Treasury Offset Program once the due process prerequisites are met.The Fraud and Recovery Unit also investigated two employees for payroll fraud. Both employees were determined to have received wages from DCFS and a secondary employer for the same hours worked. One of the employees was terminated from DCFS and the other employee resigned prior to the receipt of a termination letter. DCFS has recovered $11,349 from one former employee and is seeking recovery of the amount owed by the other former employee.DCFS will continue to investigate improper employee activities and emphasize the consequences of illegal acts. If you have any questions, please contact Rhonda Brown, Fraud and Recovery Unit Director, at Rhonda.Brown.DCFS@LA.GOV.

View Audit 312391

Finding 425828 (2022-006)

Material Weakness 2022

Commonspirit Health

IL

Eligibility Internal Control / Segregation of Duties Material Weakness § 200.303

REFERENCE: 2022-006 ? EligibilityHIV Emergency Relief Project Grants (Assistance listing No. 93.914)Federal Grantor: Health Resources and Services AdministrationFacility: St. Mary?s Medical Center ? San FranciscoSt. Mary Medical Center ? Long BeachFinding: St. Mary Medical Center ? Long Beach and St...

REFERENCE: 2022-006 ? EligibilityHIV Emergency Relief Project Grants (Assistance listing No. 93.914)Federal Grantor: Health Resources and Services AdministrationFacility: St. Mary?s Medical Center ? San FranciscoSt. Mary Medical Center ? Long BeachFinding: St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco did notconsistently retain evidence of their internal controls over the requirement to review eligibility requirements prior toadministering services in accordance with the grant agreements.Corrective Action Plan: This finding has been corrected. The 6 month eligibility check is no longer required. Forthe annual eligibility checks at St. Mary?s Medical Center ? San Francisco, all HIV patients are listed on an Excelspreadsheet that is on a shared drive. Both the Social Worker and Case Manager are responsible for monitoring andupdating patient information contained on the spreadsheet. The spreadsheet is monitored and updated daily. Hardcopies of eligibility documents are kept in a locked file cabinet located in the Social Worker?s office. Along with thehard copies, a face sheet listing eligibility documents, patient name and medical record number and name of personwho received the documents is documented. Electronic copies of eligibility documents are kept on the CaseManager?s password protected computer hard drive. The disposition and status of each patient is documented on thespreadsheet. The date documents were last collected is listed in the first column on the eligibility spreadsheet.Patients not participating on the ADAP program are contacted at least 15 days prior to the expiration of eligibilitydocuments on file. Patient contact attempts are documented in the patient?s medical record. In the event the patientdoes not respond to phone calls the patient is sent a certified letter. Patients may be contacted via secure email withthe address on file. The spreadsheet is reviewed weekly. Outreach attempts are documented in the patient?smedical chart. Corrective action was implemented in July 2022.At St. Mary Medical Center ? Long Beach, In April 2022 management implemented a more robust and electronicfile for each client to make it easy to ensure appropriate tracking of eligibility requirements validation. Files arereviewed monthly to ensure compliance.Person Responsible: Toni Luckett, Manager of Nursing, St. Mary?s San FranciscoSharon McNealy, CFO ? St. Mary Long BeachCompletion: April 30, 2022

View Audit 312373

Finding 425677 (2022-012)

Material Weakness 2022

Commonspirit Health

IL

Eligibility Material Weakness Matching / Level of Effort / Earmarking § 200.303

REFERENCE: 2022-012 ? EligibilityMedicaid Cluster (93.778)Federal Grantor: U.S. Department of Health and Human ServicesFacility: Dignity Health Medical FoundationDignity Health Connected LivingFinding: The Dignity Health Medical Foundation and Dignity Health Connected Living did not retain evidence ...

REFERENCE: 2022-012 ? EligibilityMedicaid Cluster (93.778)Federal Grantor: U.S. Department of Health and Human ServicesFacility: Dignity Health Medical FoundationDignity Health Connected LivingFinding: The Dignity Health Medical Foundation and Dignity Health Connected Living did not retain evidence of Medicaid eligibility being reviewed prior to patient services being provided.Corrective Action Plan: For the Medical Assistance Program eligibility is validated through a Medi-Cal system website. Dignity Health Medical Foundation personnel have implemented procedures to ensure documentation of eligibility checks are retained. The Clinic Operations manager has instructed staff and supervisors to save proof of eligibility for all months. The Clinic Operations manager checks for retention of eligibility documentation on a random basis and an internal audit will be performed to check for compliance with the documentation retention.At Connected Living the staff will identify participants who may be ineligible for continued services at the beginning of each service month. The Medi-Cal eligibility report is produced on the first business day of each month. The list includes all eligible and ineligible participants. This report will be saved each month for tracking purposes. The report will be reviewed each month for ineligible participants or factors that may impact eligibility for the coming month. Steps will be taken to obtain proof of eligibility or being termination proceedings.Person Responsible: Nicole Hill, Clinic Operations Manager, Dignity Health Medical Foundation.Kristina Devan, Dignity Health Connected LivingCompletion: July 1, 2022

View Audit 312373

Finding 423468 (2022-005)

Significant Deficiency 2022

State System of Higher Education, Commonwealth of Pennsylvania

PA

Student Financial Aid Eligibility Significant Deficiency

California: Recommendation: We recommend the Institute review its policies and procedures around sending entrance and exit counseling information to students to ensure students are receiving proper counseling and ensure entrance counseling is documented before loans disbursements are made.Explanatio...

California: Recommendation: We recommend the Institute review its policies and procedures around sending entrance and exit counseling information to students to ensure students are receiving proper counseling and ensure entrance counseling is documented before loans disbursements are made.Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A process in banner is run to catch any new students that need RRAAREQ updates with exit counseling. This will get students who have withdrawn, less than 1/2-time attendance, not enrolled, graduated or schedule to graduate. Once the requirement is on the account, then another process is run to get all of the students with the EXIT code still outstanding and send an e-mail to campus and personal e-mail. Students will receive emails every 30 days to complete the requirement until it is satisfied.Name(s) of the contact person(s) responsible for corrective action: Financial Aid Office, California, Clarion and Edinboro- Kelly Vitelli, Sue Bloom or Traci NecciaiPlanned completion date for corrective action plan: Plan is currently being employed.

View Audit 312353

Finding 422819 (2022-056)

Significant Deficiency 2022

State of Alaska

AK

Allowable Costs / Cost Principles Special Tests & Provisions Eligibility

Finding: 2022-056 - Certain behavioral health providers were not screened and enrolled in accordance with federal eligibility requirements.Questioned Costs: Assistance Listing 93.767: $1,669; Assistance Listing 93.778: $425,224Assistance Listing Number: 93.767; 93.775, 93.777, 93 .778Assistance List...

Finding: 2022-056 - Certain behavioral health providers were not screened and enrolled in accordance with federal eligibility requirements.Questioned Costs: Assistance Listing 93.767: $1,669; Assistance Listing 93.778: $425,224Assistance Listing Number: 93.767; 93.775, 93.777, 93 .778Assistance Listing Title: CHIP; Medicaid ClusterViews of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH agrees with the finding.Corrective Action (corrective action planned): The department is assessing the issues identified in the fmdmg and collaborating internally on the necessary corrective action. It is anticipated multiple courses of action may be necessary and include, among others, strengthening the provider enrollment grid and policies.Completion Date (list anticipated completion date): DOH anticipates the finding will be resolved in FY2025.Agency Contact (name of person responsible for corrective action): Josephine Stern, Assistant Commissioner

View Audit 312347

Finding 422818 (2022-055)

Significant Deficiency 2022

State of Alaska

AK

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Finding: 2022-055 - Seven of 30 (23 percent) Medicaid eligibility cases and two of 20 (10 percent) CHIP eligibility cases tested were sent written eligibility notices that contained inconsistent or incorrect information regarding the eligibility period and application date.Questioned Costs: NoneAssi...

Finding: 2022-055 - Seven of 30 (23 percent) Medicaid eligibility cases and two of 20 (10 percent) CHIP eligibility cases tested were sent written eligibility notices that contained inconsistent or incorrect information regarding the eligibility period and application date.Questioned Costs: NoneAssistance Listing Number: 93.767; 93.775, 93.777, 93.778Assistance Listing Title: CHIP; Medicaid ClusterViews of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH agrees with the finding.Corrective Action (corrective action planned): The Division of Public Assistance (DPA) continues to strengthen online staff development and training offerings available in the department?s electronic training portal which include courses on MAGIICHIP Medicaid and ARIES. The agency continues to streamline the Statewide Case Review Team and the case review guidelines reflecting the team?s requirement to spend 80 percent of their time reviewing cases with the goal of increasing timeliness and accuracy. A contractor was secured to serve as the primary resource in addressing Alaska Resource for Integrated Eligibility Services (ARIES) system defects and is assisting in the system?s maintenance and operations. The contractor started defect resolution activities and pushed the first round of defect fixes (Release) into the ARIES Production Environment, 7/8/2022. Defect resolution is an ongoing activity, the Contractor will continue to review and fix existing, as well as any new defects encountered. Completion Date (list anticipated completion date): DOH anticipates the finding will be resolved in FY2024.Agency Contact (name of person responsible for corrective action): Josephine Stern, Assistant Commissioner

View Audit 312347

Finding 422817 (2022-052)

Significant Deficiency 2022

State of Alaska

AK

Eligibility Significant Deficiency

Finding: 2022-052 - An examination of the Alaska Resource for Integrated Eligibility Services system during FY 22 identified significant intemal control deficiencies.Questioned Costs: NoneAssistance Listing Number: 93.767; 93.775, 93.777, 93.778Assistance Listing Title: CHIP; Medicaid ClusterViews o...

Finding: 2022-052 - An examination of the Alaska Resource for Integrated Eligibility Services system during FY 22 identified significant intemal control deficiencies.Questioned Costs: NoneAssistance Listing Number: 93.767; 93.775, 93.777, 93.778Assistance Listing Title: CHIP; Medicaid ClusterViews of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH agrees with the finding.Corrective Action (corrective action planned): A contractor was secured to serve as the primary resource in addressing Alaska Resource for Integrated Eligibility Services (ARIES) system defects and is assisting in the system?s maintenance and operations. The contractor started defect resolution activities and pushed the first round of defect fixes (Release) into the ARIES Production Environment, 7/8/2022. Defect resolution is an ongoing activity, the Contractor will continue to review and fix existing, as well as any new defects encountered.Completion Date (list anticipated completion date): The audit finding was fixed in FY2023.Agency Contact (name of person responsible for corrective action): Josephine Stern, Assistant Commissioner

View Audit 312347

Finding 422816 (2022-054)

Material Weakness 2022

State of Alaska

AK

Eligibility Material Weakness

Finding: 2022-054 - Thirty Medicaid and 20 CHIP recipients with paid medical claims during FY 22 were randomly selected for eligibility testing. Auditors found inaccurate or unsupported eligibility determinations by DPA staff for 33 percent of Medicaid cases tested and 10 percent of CHIP cases teste...

Finding: 2022-054 - Thirty Medicaid and 20 CHIP recipients with paid medical claims during FY 22 were randomly selected for eligibility testing. Auditors found inaccurate or unsupported eligibility determinations by DPA staff for 33 percent of Medicaid cases tested and 10 percent of CHIP cases tested.Questioned Costs: Assistance Listing 93.767: $20,115; Assistance Listing 93.778: $16,945Assistance Listing Number: 93.767; 93.775, 93.777, 93.778Assistance Listing Title: CHIP; Medicaid Cluster Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DHSS concurs with the finding but not the questioned costs. CMS has notified the state that financial recoveries based on eligibility errors can only be pursued when identified by programs operating under CMS? Payment Error Rate Measurement (PERM) program, under section 1903(u) of the Social Security Act and regulations at 42 CFR Part 431, Subpart Q.Corrective Action (corrective action planned): The Division of Public Assistance (DPA) continues to strengthen online staff development and training offerings available in the department?s electronic training portal which include courses on MAGI/CHIP Medicaid and ARIES. The agency continues to streamline the Statewide Case Review Team and the case review guidelines reflecting the team?s requirement to spend 80 percent of their time reviewing cases with the goal of increasing timeliness and accuracy.Completion Date (list anticipated completion date): DOH anticipates the finding will be resolved in FY2023.Agency Contact (name of person responsible for corrective action): Josephine Stern, Assistant Commissioner

View Audit 312347

Finding 422815 (2022-053)

Material Weakness 2022

State of Alaska

AK

Eligibility Subrecipient Monitoring Cash Management

Finding: 2022-053 - Thirty Medicaid and 20 CHIP recipients with paid medical claims during FY 22 were randomly selected for eligibility testing. Auditors found DPA staff did not process applications in a timely manner or redetermine eligibility when required for 87 percent of Medicaid cases and 90 p...

Finding: 2022-053 - Thirty Medicaid and 20 CHIP recipients with paid medical claims during FY 22 were randomly selected for eligibility testing. Auditors found DPA staff did not process applications in a timely manner or redetermine eligibility when required for 87 percent of Medicaid cases and 90 percent of CHIP cases tested.Questioned Costs: NoneAssistance Listing Number: 93.767; 93.775, 93.777, 93.778Assistance Listing Title: CHIP; Medicaid ClusterViews of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH agrees with the finding.Corrective Action (corrective action planned): The Division of Public Assistance (DPA) continues to streamline internal processes, including staff training on the use of the electronic document management system (ILINX) and the Instant Eligibility Verification System (IEVS) to increase accurate and timely eligibility renewals. The department also completed a procurement during FY22 to secure a contractor, who is serving as the primary resource in implementing an automated renewal process. The contract became effective 03/01/2022.Completion Date (list anticipated completion date): DOH anticipates the finding will be resolved in FY2023.Agency Contact (name of person responsible for corrective action): Josephine Stern, Assistant Commissioner

View Audit 312347

Finding 422814 (2022-051)

Significant Deficiency 2022

State of Alaska

AK

Allowable Costs / Cost Principles Eligibility Subrecipient Monitoring

Finding: 2022-051 - DHSS staff claimed inaccurate federal reimbursement for behavioral health costs.Questioned Costs: Assistance Listing 93.767: Indeterminate; Assistance Listing 93.778: IndeterminateAssistance Listing Number: 93.767; 93.775, 93.777, 93 .778Assistance Listing Title: CHIP; Medicaid C...

Finding: 2022-051 - DHSS staff claimed inaccurate federal reimbursement for behavioral health costs.Questioned Costs: Assistance Listing 93.767: Indeterminate; Assistance Listing 93.778: IndeterminateAssistance Listing Number: 93.767; 93.775, 93.777, 93 .778Assistance Listing Title: CHIP; Medicaid ClusterViews of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH agrees with the finding.Corrective Action (corrective action planned): The Division of Behavioral Health (DBH) is working with the ASO to ensure accurate member eligibility file load and claims processing issues under a corrective action plan to resolve issues that led to inaccurate federal reimbursement.Completion Date (list anticipated completion date): DOH anticipates an interim resolution will be in place during FY2023 followed with a full system resolution in FY2024.Agency Contact (name of person responsible for corrective action): Josephine Stern, Assistant Commissioner

View Audit 312347

Finding 422811 (2022-046)

Significant Deficiency 2022

State of Alaska

AK

Questioned Costs Eligibility Significant Deficiency

Finding: 2022-046 - Three (5 percent) of 60 Low-Income Home Energy Assistance Program (LIHEAP) applicant case files tested had eligibility errors.Questioned Costs: $6,490Assistance Listing Number: 93.568Assistance Listing Title: LIHEAPViews of Responsible Officials (state whether your agency agrees ...

Finding: 2022-046 - Three (5 percent) of 60 Low-Income Home Energy Assistance Program (LIHEAP) applicant case files tested had eligibility errors.Questioned Costs: $6,490Assistance Listing Number: 93.568Assistance Listing Title: LIHEAPViews of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH agrees with the finding.Corrective Action (corrective action planned): The Division of Public Assistance (DPA) plans to implement random sample testing for LIHEAP cases using the Program Integrity and Analysis Unit. This would reflect current processes in place for similar public assistance programs that the division administers.Completion Date (list anticipated completion date): DOH anticipates the finding will be resolved in FY2024.Agency Contact (name of person responsible for corrective action): Josephine Stern, Assistant Commissioner

View Audit 312347 Questioned Costs: $1

Finding 422808 (2022-045)

Significant Deficiency 2022

State of Alaska

AK

Allowable Costs / Cost Principles Eligibility

Finding: 2022-045 - DHSS?s information technology staff did not properly limit user access to DPA?s EIS during FY22.Questioned Costs: NoneAssistance Listing Number: 93.558; 93.775, 93.777, 93.778Assistance Listing Title: TANF; Medicaid ClusterViews of Responsible Officials (state whether your agency...

Finding: 2022-045 - DHSS?s information technology staff did not properly limit user access to DPA?s EIS during FY22.Questioned Costs: NoneAssistance Listing Number: 93.558; 93.775, 93.777, 93.778Assistance Listing Title: TANF; Medicaid ClusterViews of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH agrees with the finding.Corrective Action (corrective action planned): The Division is implementing protocols to reconcile users in every eligibility system at a minimum of twice yearly. These protocols will be used to identify and deactivate user accounts that are no longer needed but have not been reported via the established formal process.Completion Date (list anticipated completion date): DOH anticipates the finding will be resolved in FY2024.Agency Contact (name of person responsible for corrective action): Josephine Stern, Assistant Commissioner

View Audit 312347

Finding 422800 (2022-038)

Material Weakness 2022

State of Alaska

AK

Eligibility Special Tests & Provisions Subrecipient Monitoring

Finding: 2022-038 - Ten of 25 Temporary Assistance for Needy Families (TANF) recipient case files tested lacked documentation supporting the request and use of income and benefit information through the Income Eligibility and Verification System (IEVS) for determining eligibility and benefits. Furth...

Finding: 2022-038 - Ten of 25 Temporary Assistance for Needy Families (TANF) recipient case files tested lacked documentation supporting the request and use of income and benefit information through the Income Eligibility and Verification System (IEVS) for determining eligibility and benefits. Further, the following eligibility errors were identified:? Eight TANF applicants did not have eligibility redetermined within 12 months and eligibility was automatically extended.? Three TANF applications were not reviewed within 30 days of receipt.? Three applications either did not fill out the felony conviction disclosures or the section was not retained in the case file.? Three applications did not have adequate income verification support.? Three benefit payment amounts were not calculated accurately.? One application did not include child support documentation in the case file.? One renewal application was not reviewed for an eligibility redetermination.Additionally, 24 of the TANF recipient cases received Pandemic Emergency Assistance Fund (PEAF) payments, of which 20 did not have IEVS documentation to support the eligibility determination prior to DHSS making the PEAF payments.Questioned Costs: $138,024Assistance Listing Number: 93.558Assistance Listing Title: TANFViews of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why):DOH agrees with the finding.Corrective Action (corrective action planned): The agency continues to work through priorities and mandates implemented due to the ending of the public health emergency, which has increased the workload beyond what the division had experienced in the prior year. This has impacted the ability to meaningfully execute the corrective action plan. The Division is currently implementing strategies, which includes increasing staffing, to address the increased workload and upcoming PHE unwinding efforts. The agency will continue moving forward with corrective actions.Completion Date (list anticipated completion date): DOH anticipates the finding will be resolved in FY2024.Agency Contact (name of person responsible for corrective action): Josephine Stern, Assistant Commissioner

View Audit 312347

Finding 422766 (2022-032)

Material Weakness 2022

State of Alaska

AK

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

Finding: 2022-032 - Testing of5l SNAP recipient cases to verify the accuracy of EIS benefit calculations found five (10 percent) were incorrect. Testing of 26 SNAP recipient cases to verify the adequacy of case information stored in EIS and the DHSS `s document management system, ILINX, found 11(42 ...

Finding: 2022-032 - Testing of5l SNAP recipient cases to verify the accuracy of EIS benefit calculations found five (10 percent) were incorrect. Testing of 26 SNAP recipient cases to verify the adequacy of case information stored in EIS and the DHSS `s document management system, ILINX, found 11(42 percent) had insufficient information in ILINX or inaccurate data input into EIS, and four (15 percent) recipients? applications or report of changes were not processed within federally required timeframes.Questioned Costs: Assistance Listing 10.55 1: $2,636Assistance Listing Number: 10.55 1, 10.561Assistance Listing Title: SNAP ClusterViews of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH agrees with the finding.Corrective Action (corrective action planned): The Division of Public Assistance (DPA) continues to strengthen its procedures. Refresher trainings for staff are being offered and case work continues to be reviewed. The agency is also redesigning business processes to meet timeliness measures set by federal partners, to include applications and reports of change.Completion Date (list anticipated completion date): DOH anticipates the finding will be resolved in FY2024.Agency Contact (name of person responsible for corrective action): Josephine Stern, Assistant Commissioner

View Audit 312347

Finding 422764 (2022-031)

Material Weakness 2022

State of Alaska

AK

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

Finding: 2022-031 - The Division of Public Assistance (DPA) Eligibility Information System (EIS) did not automatically cut off households from receiving Supplemental Nutrition Assistance Program (SNAP) benefits at the end of the certification period during FY 22.Questioned Costs: Assistance Listing ...

Finding: 2022-031 - The Division of Public Assistance (DPA) Eligibility Information System (EIS) did not automatically cut off households from receiving Supplemental Nutrition Assistance Program (SNAP) benefits at the end of the certification period during FY 22.Questioned Costs: Assistance Listing 10.551: IndeterminateAssistance Listing Number: 10.55 1, 10.561Assistance Listing Title: SNAP ClusterViews of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH agrees with the finding.Corrective Action (corrective action planned): The Division is reestablishing recertification processes for SNAP and mailing of recertification packets to clients has resumed. The agency is also ensuring previously programmed auto closure protocols are in place, so that SNAP ends when recertification packets are not submitted by households. System-generated extensions of SNAP certification periods have ceased.Completion Date (list anticipated completion date): DOH anticipates the finding will be resolved in FY2024.Agency Contact (name of person responsible for corrective action): Josephine Stern, Assistant Commissioner

View Audit 312347

Finding 421967 (2022-002)

Material Weakness 2022

Surry County

NC

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

The County will develop a 2nd Party Review form that will be used to check completed applications for accuracy in applying policy and to assure all verifications have been uploaded to the NCFAST System.

View Audit 312326

Finding 421965 (2022-001)

None 2022

Surry County

NC

Questioned Costs Eligibility Program Income

The County will review internal policies and procedures to ensure consistent documentation retention policy. Training will occur with staff involved all income verification within this program. Additional oversight protocols will be put into place to review and verify documentation is retained for e...

The County will review internal policies and procedures to ensure consistent documentation retention policy. Training will occur with staff involved all income verification within this program. Additional oversight protocols will be put into place to review and verify documentation is retained for each applicant. The time period and funds for this program have been exhausted. New funds will not be available until next SFY 2023-2024. We have a plan to this program under the supervision of the Economics Services Division and repurpose and existing position. We will complete the training once the position has been filled.

View Audit 312326 Questioned Costs: $1

Finding 421963 (2022-003)

Significant Deficiency 2022

Surry County

NC

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

The County created a 2nd Party Review Error Summary Log. This will be used to record all 2nd Party Reviews that require corrections to a case. 2nd Party Review forms will be completed and handed out to caseworkers as previously with the exception that the Reviewer will log the ones that need correct...

The County created a 2nd Party Review Error Summary Log. This will be used to record all 2nd Party Reviews that require corrections to a case. 2nd Party Review forms will be completed and handed out to caseworkers as previously with the exception that the Reviewer will log the ones that need corrections. Once the form is returned to the Reviewer, they will check to verify the needed corrections have been completed and documented. Once they have done this, they will enter the needed dates on the 2nd Party Review Error Summary Log. A meeting was held to implement this new procedure on 2/16/2023 and was placed in effect for the action month of January 2023, since this is the current month being reviewed at time of reported findings and needed CAP.

View Audit 312326

Finding 421519 (2022-006)

Material Weakness 2022

Blackford County Schools

IN

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

FINDING 2022-006Subject: Title I Grants to Local Educational Agencies - EligibilityFederal Agency: Department of EducationFederal Program: Title I Grants to Local Educational AgenciesAssistance Listing Number: 84.010Federal Award Numbers and Years: FY18, FY19, FY20, FY21Pass-Through Entity: Indiana ...

FINDING 2022-006Subject: Title I Grants to Local Educational Agencies - EligibilityFederal Agency: Department of EducationFederal Program: Title I Grants to Local Educational AgenciesAssistance Listing Number: 84.010Federal Award Numbers and Years: FY18, FY19, FY20, FY21Pass-Through Entity: Indiana Department of EducationCompliance Requirement: EligibilityAudit Findings: Material WeaknessContact Person Responsible for Corrective Action: Michelle Gross, Data Specialist, Shelly Kemp FoodService Director and Lindsay Cagle, ECA TreasurerContact Phone Number: 765-348-7550Views of Responsible Official: We agree with the finding of the AuditorsDescription of Corrective Action Plan:The ECA Treasurer provides Textbook Assistance Applications to each building for dispersal. The applications arereturned to the ECA Treasurer. These applications are given to the Food Services Director who manually enters the datainto Skyward. When complete, the applications are given back to the ECA Treasurer for filing and verification thestudent has been updated in Skyward to the correct status. (Free/Reduced, Medicaid or Paid)The Food Service Director pulls direct certified students from the state and uploads those students into the SIS(Skyward) program. Currently the ECA Treasurer will compare old and new invoices in Skyward to check for anychanges.Going forward the Food Service Director will provide a report (email when only 1 or 2 students) to the ECA Treasurer ofall direct cert. students as well as students that have completed a Textbook Assistance Application for her review. Thesereports will be run every 2-4 weeks as needed. The treasurer will compare the data in Skyward for accuracy. Both theFood Service Director and the ECA Treasurer will sign off on the report as confirmation.Anticipated Completion Date: May 2023

View Audit 312304

Finding 420276 (2022-003)

Material Weakness 2022

Community Youth Services

WA

Questioned Costs Subrecipient Monitoring Eligibility

Finding: 2021-003CFDA: 21.023 Department of the Treasury, Agency Rental AssistancePass-Through Entity: WA Department of Commerce 2021-ComTRAP-CYS-RAAgency: Community Youth ServicesName of contact person and title: Derek Harris, CEOAnticipated completion date: completed on 09/30/2022Agency?s response...

Finding: 2021-003CFDA: 21.023 Department of the Treasury, Agency Rental AssistancePass-Through Entity: WA Department of Commerce 2021-ComTRAP-CYS-RAAgency: Community Youth ServicesName of contact person and title: Derek Harris, CEOAnticipated completion date: completed on 09/30/2022Agency?s response: ConcurThe organization agrees with this finding and implemented the following:We developed program guidelines in addition to the guidelines provided by the Pass-Through Entity in order to ensure internal controls are in place to mitigate fraud and/or misuse of rental assistance funds.The program personnel implemented a file checklist starting October 1, 2022, to ensure all compliance components included in the file documentation meet the criteria required for the program. The checklist and forms are reviewed prior to payment. When digital signatures cannot be obtained, verbal verification of agreement by the applicant will be documented by the program staff to include date, time, method of communication.A supervisor (Program Director, Deputy Director, or CEO) reviews the files to ensure compliance with the program guidelines, ensure third party evidence exists and that all applicable documentation is in the file to support the rental assistance request.The files will also be reviewed by the Finance Coordinator prior to submitting the payment request to the Accounting Associate to ensure eligibility is adequately documented and that third party evidence exists before funds are released to the landlord.Sincerely,Derek R. HarrisChief Executive OfficerCommunity Youth Services

View Audit 312253 Questioned Costs: $1

Finding 412048 (2022-001)

Significant Deficiency 2022

El Camino Community College District

CA

Student Financial Aid Eligibility Significant Deficiency

2022 ? 001: Student Financial Aid Cluster - Student Eligibility and Awarding: Exit Counseling ?Program Number 84.268Recommendation: We recommend the college review its policies and procedures around disbursingexit counseling information to students to ensure students are receiving proper counseling ...

2022 ? 001: Student Financial Aid Cluster - Student Eligibility and Awarding: Exit Counseling ?Program Number 84.268Recommendation: We recommend the college review its policies and procedures around disbursingexit counseling information to students to ensure students are receiving proper counseling and ensureentrance counseling is documented before loans disbursements are made.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: The Financial Aid Office recognized that the exit loan counselingrule was not being met prior to the commencement of the 2021-2022 audit. The following action planwas already taking shape during the annual audit of 2021-2022 to ensure compliance rule would bemet for the 2022-2023 aid year.Process: Use SIS Colleague system to run query to identify current loan borrowers at beginning andend of term to identify those who have ceased half-time enrollment. Send communication via email andphysical letter notification to ensure student receive important information about loan repaymentresponsibilities, including Department of Education links and contact information.Procedure: Created documentation with step by step procedures for assigned staff to run query toidentify students, request exit loan counseling communication, and run batch posting of communication.Communication: Loan borrowers will receive an email on Day 1 run, a second email on Day 14 run, anda paper letter on Day 30 run.Staff Training: Staff assigned to the Loan program have been trained to run process by ourSystems/Programmer. Financial Aid Staff have been provided information about policy and proceduresto assist students who may contact our office for assistance after receiving exit loan counselingcommunication.Quality Assurance: Two additional staff members have been assigned to help with the Loan program.Name(s) of the contact person(s) responsible for corrective action: Chau Dao - Director ofFinancial AidPlanned completion date for corrective action plan: November 2022.

View Audit 312129

Finding 412032 (2022-001)

Significant Deficiency 2022

University Prep Public Charter Schools

NY

Allowable Costs / Cost Principles Cash Management Eligibility

The school has implemented an electronic timecard system for tutors that will automatically generate timesheets and eliminate or significantly reduce the possibility for human error. All tutors for the school are required to use this computer-based clock in/out system for all shifts.

View Audit 312127

Finding 411725 (2022-004)

Material Weakness 2022

Ohio Institute of Allied Health, Inc.

IL

Student Financial Aid Eligibility Matching / Level of Effort / Earmarking

Finding 2022-04 Late Notification to NSLDS - see corrective action plan submitted with the audit report.

View Audit 312103

Finding 410380 (2022-004)

Material Weakness 2022

Madelia Health

MN

Allowable Costs / Cost Principles Cash Management Eligibility

Finding 2022-004Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionFederal Financial Assistance Listing #93.498Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Princi...

Finding 2022-004Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionFederal Financial Assistance Listing #93.498Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles and ReportingFinding Summary: During testing, we identified the following:- No formal documentation of review and approval of the Hospital's final expenditures listing identified as eligible and claimed under the Provider Relief Fund and American Rescue Plan (ARP} Rural Distribution program (the program) was retained.- Payroll reports to support the COVID-related bonuses based on hours worked were not retained and were not able to be recreated.- Some expenses claimed under the program were incurred before the Hospital started preparing, preventing, and responding to COVID. Net costs of $36,540.- Equipment and information technology expenses claimed under other sources of funding were claimed under the program. Net actual costs of $6,080.- Utility expenses and personnel expenses were overclaimed under the program based on a review of supporting documentation. Net costs of $2,985 with projected net costs of $3,827.- No formal documentation of review and approval of the Hospital's lost revenue calculation and the Hospital's special report submitted to HHS for Period 1 TIN #410758512 was retained.- The lost revenue narrative to describe the option iii calculation did not agree with the supporting calculation performed for January and February 2021. The narrative indicated a comparison to January and February of 2019, but the calculation was done based on January and February 2020 trended revenue.- Expenses claimed under the program and included within the Hospital's special report submitted to the Department of Health and Human Services (HHS} for Period 1 TIN #410758512 were reported at gross cost and did not consider the Hospital's Medicare Cost Reimbursement percentage. Net costs of $880,880.Responsible Individuals: Bruce Craven, CFOCorrective Action Plan: Management has formally documented the review and approval process for expense data and federal agency reporting for funds received by federal agencies. This review process ensures compliance of allowable expense data federal agency reporting. Full implementation of this documented process is expected to be completed within the next month.Anticipated Completion Date: March 2023

View Audit 311963

Finding 410371 (2022-003)

Significant Deficiency 2022

Alamo Area Resource Center, Inc.

TX

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Finding 2022-003EligibilityManagement Response: Management agrees with auditor recommendations and a plan is in place to increase the effectiveness of reviews to ensure the completeness of client certification requirements.Action Plan: 1) Identify the departments that had eligibility errors. 2) Prov...

Finding 2022-003EligibilityManagement Response: Management agrees with auditor recommendations and a plan is in place to increase the effectiveness of reviews to ensure the completeness of client certification requirements.Action Plan: 1) Identify the departments that had eligibility errors. 2) Provide comprehensive training to ensure a clear understanding of Ryan White eligibility requirements among departments.Enacted: June 2023Responsible Person: Director of Case ManagementFinalized: July 2023Action Plan: 3) The programs use a new platform, e2SanAntonio, that has a built-in feature that flags clients that are out of compliance. Will perform monthly audits of Ryan White eligibility using the new eligibility platform reporting.Enacted: April 2023Responsible Person: Director of Case ManagementFinalized: June 2023

View Audit 311961

Corrective Action Plans

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