Corrective Action Plans

Finding 58471 (2022-002)

None 2022

MA

Student Financial Aid Eligibility Reporting

Finding No. 2022-002 Enrollment reporting Cluster: Student Financial Assistance Cluster Grantor: Department of Education Award Name: Federal Direct Student Loans Award Year: July 1, 2021 ? June 30, 2022 Award Number: Not applicable Assistance Listing Number: 84.268 The College agrees with the find...

Finding No. 2022-002 Enrollment reporting Cluster: Student Financial Assistance Cluster Grantor: Department of Education Award Name: Federal Direct Student Loans Award Year: July 1, 2021 ? June 30, 2022 Award Number: Not applicable Assistance Listing Number: 84.268 The College agrees with the finding noting that this exception is an unusual occurrence as a result of improper recording of the leave status in Colleague, the student information system. The record in Colleague should have had hiatus data entered on April 11, 2022, the date in which the College was aware of the student?s enrollment change, which would allow the change in enrollment information to be queried and transmitted to the National Student Clearinghouse (?NSC?) in in the May 17, 2022 submission. As this hiatus data was not updated, the student?s enrollment record was reported as enrolled at that time, which is attributed to an error in data entry of the multiple fields required in Colleague to reflect a leave from the College. The student?s transcript was correctly marked as ?W? as of April 8, 2022. However, the effective date was not correctly reported to the NSLDS. Management is in the process of correcting the effective date reporting to the NSLDS. The College has since implemented Workday Student, the College?s new student information system, in August of 2022. New business processes for entering student leaves have been documented and staff have been trained. The Office of Student Affairs initiates the leave process and a system process prompts records, financial aid, and billing to review the student record. The leave is updated within the student information system once all of the relevant offices have completed their processing. Training was done as a part of the implementation and testing process. The NSC enrollment reporting in Workday is automated. Jesse Barba, Director of Institutional Research and Registrar Services, is responsible for the implemented corrective action plan.

View Audit 55292

Finding 58446 (2022-003)

Significant Deficiency 2022

Volunteer Homes for Elderly

TN

HUD Housing Programs Internal Control / Segregation of Duties Eligibility

CORRECTIVE ACTION PLAN Volunteer Homes for Elderly, Inc. respectfully submits the following corrective action plan for the year ended September 30, 2022. Purkey, Carter, Compton, Swann, & Carter, PLLC PO. Box 727 Morristown, Tennessee 37815 Audit period: October 1, 2021 - September 30, 2022 ...

CORRECTIVE ACTION PLAN Volunteer Homes for Elderly, Inc. respectfully submits the following corrective action plan for the year ended September 30, 2022. Purkey, Carter, Compton, Swann, & Carter, PLLC PO. Box 727 Morristown, Tennessee 37815 Audit period: October 1, 2021 - September 30, 2022 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDINGS-FINANCIAL STATEMENT AUDIT None Finding No. 2022 ? 003: Ineffective oversight and operation of internal controls over compliance by management Volunteer Homes for Elderly, Inc's managers did not follow all HUD requirements when going through the tenant recertification process. The tenant files tested for internal controls over compliance contained multiple deficiencies including missing copy of social security card in order to verify social security number; missing income verification; missing Ethnic and Racial Data conformation; incorrect calculation of tenant assets; incorrect income used on HUD Form 50059, and missing tenant signature and date on Resident Rights and Responsibilities acknowledgment. Criteria: According to HUD Handbook 4350.3: 1. All applicant and tenant household members must disclose and provide verification of the complete and accurate social security number assigned to them except for those individuals who do not contend eligible immigration status. Owners must include verification documentation in the tenant file. Owners must gather data about the race and ethnicity of applicants and tenants so that HUD can easily spot possible discrimination, track racial or ethnic concentrations, and focus enforcement actions on owners with racially or ethnically identifiable properties. 4. Owners must verify all income assets, expenses, deductions, family characteristics, and circumstances that affect family eligibility or level of assistance: for savings accounts, use the current balance and for checking accounts. use the average balance for the last six months. 5. Annual income is defined as all amounts anticipated to be received from a source outside the family during the 12?month period following admission or annual recertification and owner calculates projected annual income by annualizing current income. 6. Owners must provide applicants and tenants with a copy of the Resident Rights and Responsibilities brochure at move-in and annual recertification and all family members at least 18 years of age must acknowledge receipt of brochure by signing and dating the acknowledgement. Cause of Condition: The management agent did not have systems in place to ensure managers know of and are complying with ail HUD requirements pursuant to the HUD Handbook 4350.3. Recommendation: Auditor recommends management review HUD Handbook 4350.3 and put proper procedures in place to ensure managers know of applicable HUD requirements and are complying with HUD requirements. Action Taken: Management agent will provide additional training on HUD requirements to managers during their annual manager's training and implement procedures to ensure managers are complying with requirements pursuant to' HUD Handbook 4350.3.

View Audit 56038

Finding 58441 (2022-101)

Significant Deficiency 2022

B J Enterprises, Inc.

AZ

Procurement, Suspension & Debarment Cash Management Eligibility § 200.303

B J ENTERPRISES, INC. CORRECTIVE ACTION PLAN SEPTEMBER 30, 2022 REFERENCE: 2022-101 REPEAT FINDING REFERENCE: 2021-001 CFDA NUMBER: 10.558 ? CHILD AND ADULT CARE FOOD PROGRAM U.S. DEPARTMENT OF AGRICULTURE - FOOD AND NUTRITION - 2022 PASSED THROUGH ARIZONA STATE DEPARTMENT OF EDUCATION GRANT NUMBE...

B J ENTERPRISES, INC. CORRECTIVE ACTION PLAN SEPTEMBER 30, 2022 REFERENCE: 2022-101 REPEAT FINDING REFERENCE: 2021-001 CFDA NUMBER: 10.558 ? CHILD AND ADULT CARE FOOD PROGRAM U.S. DEPARTMENT OF AGRICULTURE - FOOD AND NUTRITION - 2022 PASSED THROUGH ARIZONA STATE DEPARTMENT OF EDUCATION GRANT NUMBER 6AZ300003 CLIENT RESPONSE AND CORRECTIVE ACTION PLAN We concur with the condition. 1. Name of the contact person responsible for corrective action: Katie O'Neill, Director 2. Corrective action planned: a. For 2 of 40 providers files tested, menus were clerically inaccurate and did not support the meals claimed. The Area Coordinators will be retrained to double check their meal counting on their menus at least once before they submit their meal counts and one time after they submit their meal counts. See BJ Enterprises Procedures for Reading Menus, Section D, #6. b. For 1 of 40 provider files tested, meals were claimed for the provider's own child, when the provider was not eligible for free/reduced price meals. The menu reader must use the most current "Claiming Own" report while they are menu reading. The income applications have to be approved by the Assistant Director or Director prior to the menus being read. The menu reader will use this list, as well as the Master List when reading the menus. The Area Coordinators will be retrained to ensure that the provider who is claiming their own children qualify to do so. See BJ Enterprises Procedures for Reading Menus, Section C, #5. c. For 2 of 40 provider files tested meals were claimed when the provider's children were the only children present. This occurred when the day care children were disallowed. The Area Coordinators will be re-trained to disallow the day care providers own children when meals are disallowed for all of the day care children. See BJ Enterprises Procedures for Reading Menus, Section C, #5. d. For 1 of 40 provider files tested, meals were claimed outside of the current claim month. The Area Coordinators will be re-trained to disallow meals on the front end or the back end of the month. See BJ Enterprises Procedures for Reading Menus, Section B, #2. e. For 1 of 40 provider files tested, meals were claimed when the child was not indicated as being present for the meal. The times in and out were not on the day that was claimed. The Area Coordinators will be re-trained to disallow meals when the time in and outs are not written on the menu. See 8 J Enterprises Procedures for Reading Menus, Section C, #4. f. For 1 of 40 provider files tested, meals were claimed when no menu components were listed on the menu. The Area Coordinators will be re-trained to disallow meals when thy have no components listed on the menu. See BJ Enterprises Procedures for Reading Menus, Section B, #3. All of the menu mistakes were on paper menus. We are encouraging everyone to start claiming on computerized menus (KidKare) because there are less or no mistakes on those menus. 3. Anticipated completion date: June 30, 2023

View Audit 55181

Finding 58430 (2022-001)

Material Weakness 2022

The Harry and Jeanette Weinberg Gardens at Bedford, INC

MD

Eligibility HUD Housing Programs Subrecipient Monitoring

Finding 2022-1 a. Comments on the Finding and Each Recommendation Management agrees with the finding. b. Action(s) Taken or Planned on the Finding In 2022 we hired additional oversight staff at the corporate level and changed the procedure for reviewing and approving annual certifications as well as...

Finding 2022-1 a. Comments on the Finding and Each Recommendation Management agrees with the finding. b. Action(s) Taken or Planned on the Finding In 2022 we hired additional oversight staff at the corporate level and changed the procedure for reviewing and approving annual certifications as well as monitoring EIV reporting. We have implanted new EIV procedures to ensure

View Audit 55113

Finding 58424 (2022-001)

Significant Deficiency 2022

Carroll Community College

MD

Eligibility Reporting Matching / Level of Effort / Earmarking § 200.303

Action taken in response to finding: After management was re-notified of the reporting errors in the HEERF reports on the college website, management has decided to completely reorganize the college webpage for HEERF reports. This will allow management and the reader to better understand the spendin...

Action taken in response to finding: After management was re-notified of the reporting errors in the HEERF reports on the college website, management has decided to completely reorganize the college webpage for HEERF reports. This will allow management and the reader to better understand the spending history of institutional and student portions of these grants. When the website is reorganized, quarterly reports will be reviewed and verified that student data is verified and reported correctly in the narrative of the reports. Name(s) of the contact person(s) responsible for corrective action: Ms. Karen Pelton, Mr. Timothy League and Mr. John Gay. Planned completion date for corrective action plan: Adjustments to the website and the review and correction of these reports, if needed, is currently in process and is expected to be completed no later than January 31, 2023.

View Audit 56029

Finding 58418 (2022-001)

None 2022

Quartz Valley Indian Reservation

CA

Eligibility Internal Control / Segregation of Duties

2022-001 Sufficient documentation of eligibility not maintained for all items selected for testing. Contact Person Trisha Braswell Anticipated Completion Date 12/31/2023 Action Plan: Due to large turnover in staff at the front desk , we were not able to fully correct this finding this year. Th...

2022-001 Sufficient documentation of eligibility not maintained for all items selected for testing. Contact Person Trisha Braswell Anticipated Completion Date 12/31/2023 Action Plan: Due to large turnover in staff at the front desk , we were not able to fully correct this finding this year. The Clinic Manager will ensure all new staff are trained and that it is part of the of the orientation.

View Audit 55048

Finding 58303 (2022-003)

Significant Deficiency 2022

College Dreams, INC

OR

Eligibility Significant Deficiency

Finding # 2022-003 Immaterial Noncompliance U.S. Department of Labor 17.249 WIOA Youth Activities Finding: One case file out of fifteen tested did not meet eligibility criteria Recommendation: Procedures should be in place to ensure eligibility is properly documented and exceptions are obtained. ...

Finding # 2022-003 Immaterial Noncompliance U.S. Department of Labor 17.249 WIOA Youth Activities Finding: One case file out of fifteen tested did not meet eligibility criteria Recommendation: Procedures should be in place to ensure eligibility is properly documented and exceptions are obtained. Corrective Action: Management understands exceptions are allowed with explicit approval and that document is maintained Anticipated Completion Date: June 30, 2023

View Audit 54075

Finding 58140 (2022-001)

Material Weakness 2022

East River Road Housing Development Fund Company,inc.

NY

Eligibility HUD Housing Programs Reporting

2022-001: Section 202, Assistance Listing No. 14.157 Two tenant files were selected for testing and the required documentation to determine eligibility, as required by the HUD Regulatory Agreement, could not be located as follows: ? 2 files were missing Form HUD-50059, Owner?s Certification of Com...

2022-001: Section 202, Assistance Listing No. 14.157 Two tenant files were selected for testing and the required documentation to determine eligibility, as required by the HUD Regulatory Agreement, could not be located as follows: ? 2 files were missing Form HUD-50059, Owner?s Certification of Compliance ? 1 file was missing the move-in and move-out inspection forms Recommendation: We recommend the Corporation establish procedures for maintaining tenant files to comply with HUD requirements for verification of tenant information, as required. Action Taken: Management agrees with the recommendation and will establish procedures with the managing agent to ensure all tenant files are maintained in accordance with HUD regulations.

View Audit 54291

Finding 58138 (2022-001)

Significant Deficiency 2022

Amesbury Housing Authority

MA

Special Tests & Provisions Eligibility HUD Housing Programs

Finding #2022-001 ? Special Tests and Provisions: Selection from the Waiting List The Authority acknowledges that waiting list documentation could not be located for two (2) new admissions during the audit period. The Authority experienced significant staff turnover in recent years that resulted in ...

Finding #2022-001 ? Special Tests and Provisions: Selection from the Waiting List The Authority acknowledges that waiting list documentation could not be located for two (2) new admissions during the audit period. The Authority experienced significant staff turnover in recent years that resulted in lacking internal controls. The Authority has effectively corrected this deficiency by contracting with the Chelsea Housing Authority for administration of the Authority?s Section 8 Housing Choice Voucher Program. The Chelsea Housing Authority has staff capacity, experience, and certifications to effectively administer all aspects of this program including selections from the waiting list. Implementation Date of Corrective Action: February 7, 2022 Person Responsible for Correction Action: Adam Garvey, Executive Director

View Audit 54100

Finding 58124 (2022-005)

Material Weakness 2022

County of San Joaquin

CA

Eligibility Material Weakness Internal Control / Segregation of Duties

Program: Medicaid Cluster CFDA No.: 93.778 Federal Agency: U.S. Department of Health and Human Services Passed-through: California Department of Health Care Services Award Year: 2021-2022 Compliance Requirement: Eligibility Grant Award Number: In-Home Supportive Services (IHSS) Type of Finding: Mat...

Program: Medicaid Cluster CFDA No.: 93.778 Federal Agency: U.S. Department of Health and Human Services Passed-through: California Department of Health Care Services Award Year: 2021-2022 Compliance Requirement: Eligibility Grant Award Number: In-Home Supportive Services (IHSS) Type of Finding: Material Noncompliance and Material Weakness in Internal Control over Compliance Repeat Finding from Prior Year: Yes, prior year finding 2021-06. Management?s or Department?s Response: With the 2021-2022 budget, the County allocated an additional seven Social Worker positions to assist in maintaining compliance with the redetermination backlog of cases. With the 2022-2023 budget, the County requested one additional unit of seven Social Worker positions to comply with this requirement. The County also continues to use overtime and part-time Social Workers to ensure compliance with the 12-month requirement. Views of Responsible Officials and Corrective Action: The County will continue to process the backlog of redetermination cases to comply with the 12-month requirement. Name of Responsible Person: Renee Smith, IHSS Program Manager Name of Department Contact: Renee Smith, IHSS Program Manager Projected Implementation Date: The County hired additional staff to assist with the processing of the redetermination of eligible cases.

View Audit 53495

Finding 58122 (2022-004)

Material Weakness 2022

County of San Joaquin

CA

Questioned Costs Allowable Costs / Cost Principles Eligibility

Program: Adoption Assistance CFDA No.: 93.659 Federal Agency: U.S. Department of Health and Human Services Passed-through: California Department of Social Services Award Year: 2021-2022 Compliance Requirement: Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Eligibility Grant Aw...

Program: Adoption Assistance CFDA No.: 93.659 Federal Agency: U.S. Department of Health and Human Services Passed-through: California Department of Social Services Award Year: 2021-2022 Compliance Requirement: Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Eligibility Grant Award Number: N/A Type of Finding: Material Noncompliance and Material Weakness in Internal Control over Compliance Repeat Finding from Prior Year: Yes, prior year finding 2021-05. Management?s or Department?s Response: The County has implemented policies and procedures to ensure that all documentation required to support eligibility is properly maintained. The Eligibility Supervisor assigned to Foster Care/Adoptions Assistance will continue to review approximately 10% of all active cases when the annual Cost of Living Adjustment (COLA) is processed to ensure accuracy. Views of Responsible Officials and Corrective Action: The County continues to review all documentation required to support eligibility with the annual COLA process. Name of Responsible Person: Craig Pedrucci, Child Welfare Division Chief Name of Department Contact: Craig Pedrucci, Child Welfare Division Chief Projected Implementation Date: Reviewing active cases was implemented in 2018 and continues. The unit will continue the 10% review process.

View Audit 53495 Questioned Costs: $1

Finding 58055 (2022-003)

Significant Deficiency 2022

The Foundation for University Hospital

NJ

Questioned Costs Allowable Costs / Cost Principles Cash Management

2022-003 Finding: The Foundation requested and received reimbursement for payments made to an ineligible restaurant. Cause: This was primarily due to inadequate staffing for the Foundation as there was only one employee, Executive Director, who was responsible for daily operations and financial rec...

2022-003 Finding: The Foundation requested and received reimbursement for payments made to an ineligible restaurant. Cause: This was primarily due to inadequate staffing for the Foundation as there was only one employee, Executive Director, who was responsible for daily operations and financial record keeping. Questioned Costs: $12,850 Corrective Action: The Foundation has addressed this inadequacy by hiring a part time seasoned bookkeeper to be responsible for financial record keeping. Responsible Official: Jessica Backofen Completion Date: October 21, 2022

View Audit 56481 Questioned Costs: $1

Finding 58045 (2022-003)

None 2022

State of Missouri

MO

Eligibility Matching / Level of Effort / Earmarking

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2022 State Agency: Department of Social Services (DSS) ? MO HealthNet Division (MHD) and Family Support Division (FSD) Audit Finding Number: 2022-003 ? Medicaid and CHIP Eligibility Determination Timeliness Name...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2022 State Agency: Department of Social Services (DSS) ? MO HealthNet Division (MHD) and Family Support Division (FSD) Audit Finding Number: 2022-003 ? Medicaid and CHIP Eligibility Determination Timeliness Name of the contact person responsible for corrective action: Heather Atkins Anticipated completion date for corrective action: Completed Recommendation: The DSS through the MHD and the FSD ensure participant eligibility is determined within required timeframes. DSS Response: The DSS agrees with this finding. During SFY 2022, DSS experienced significant delays in completing determinations of eligibility at application, resulting in sizable backlogs and applications pending beyond the timeframes permitted in regulation. Due to this, Missouri collaborated with CMS to mitigate the backlog. As of September 30, 2022, DSS has completed processing of all overdue applications. The mitigation plan is located at https://www.medicaid.gov/medicaid/eligibility/downloads/missouri-mitigation-plan.pdf. Since DSS completed the processing of all overdue applications as of September 30, 2022, the DSS is completing applications within the established timeframes outlined in 42 CFR 435.912(c)(3) and 42 CFR 457.340(d) and continues to ensure participant eligibility is determined within the required timeframes. To remain in compliance with established processing timeframes, DSS is leveraging new and available technologies. These technologies are intended to assist the department and participants with necessary actions such as submitting applications, verifying income and resources, and providing required information. Corrective action planned is as follows: As noted above, as of September 30, 2022, DSS has completed processing of all overdue applications; therefore, no further corrective action is need.

View Audit 56478

Finding 58044 (2022-002)

Significant Deficiency 2022

State of Missouri

MO

Allowable Costs / Cost Principles Eligibility Procurement, Suspension & Debarment

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2022 State Agency: Department of Social Services (DSS) ? MO HealthNet Division (MHD) and Family Support Division (FSD) Audit Finding Number: 2022-002 ? Medicaid and CHIP MAGI-Based Participant Eligibility Name o...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2022 State Agency: Department of Social Services (DSS) ? MO HealthNet Division (MHD) and Family Support Division (FSD) Audit Finding Number: 2022-002 ? Medicaid and CHIP MAGI-Based Participant Eligibility Name of the contact person responsible for corrective action: Heather Atkins Anticipated completion date for corrective action: N/A Recommendation: The DSS through the MHD and the FSD review and correct cases for participants with manual overrides in the MEDES, ensure redeterminations are completed for these participants as required, and close the cases of any ineligible participants. In addition, the DSS should ensure system controls are functioning as designed for these participants. DSS Response: The DSS disagrees with this finding. The DSS disagrees that there is a significant deficiency in internal controls. As noted in the finding, from the 60 participants selected, the SAO did not identify any participants with previously-established overrides; therefore, no incorrect payments were cited. Section 6008 of the Families First Coronavirus Response Act (FFCRA) requires states to provide continuous coverage, through the end of the month in which the PHE period ends, to all Medicaid beneficiaries who were enrolled in Medicaid on or after March 18, 2020, regardless of any changes in eligibility unless the individual voluntarily terminates eligibility, is deceased, or moves out of state. As required by the Centers for Medicaid and Medicare Services (CMS) during the PHE, the DSS has processes in place to terminate eligibility for individuals who are deceased, voluntarily request closure, or report they have moved out of state when a current change is reported. The Consolidated Appropriations Act, 2023, signed on December 29, 2022, amends section 6008 of the FFCRA such that the continuous enrollment condition ended on March 31, 2023. During the PHE, the DSS did not conduct reviews of cases that did not report current changes. In accordance with CMS guidance, effective April 1, 2023, Missouri is unwinding from the PHE by completing annual reviews for all MO HealthNet cases over twelve months. At the time of the review of each case, the DSS will appropriately end MO HealthNet eligibility for all individuals determined to no longer be eligible.

View Audit 56478

Finding 58032 (2022-005)

Significant Deficiency 2022

State of Missouri

MO

Questioned Costs School Nutrition Programs Matching / Level of Effort / Earmarking § 200.303

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2022 State Agency: Department of Social Services (DSS) ? Family Support Division (FSD) Audit Finding Number: 2022-005 ? Pandemic Electronic Benefit Transfer Food Benefits Name of the contact person responsible ...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2022 State Agency: Department of Social Services (DSS) ? Family Support Division (FSD) Audit Finding Number: 2022-005 ? Pandemic Electronic Benefit Transfer Food Benefits Name of the contact person responsible for corrective action: Elizabeth Roberts-Smith Anticipated completion date for corrective action: Completed Recommendation: The DSS through the FSD strengthen internal controls to ensure P-EBT program benefit issuances are in accordance with the state plan, and review and correct the overpayments for the children identified in this finding. DSS Response: The DSS agrees with this finding. The DSS agrees that the two children identified in the report were incorrectly issued benefits. Recognizing the complexity for families seeking to appropriately access the benefit, the process by which school children are determined eligible and issued P-EBT benefits was modified in the state plan submitted by the State of Missouri to the Food and Nutrition Service (FNS) for the 2021-2022 school year. The P-EBT state plan for the 2021-2022 school year was approved by FNS on June 6, 2022. Eligibility for P-EBT is now determined at the individual child level based on COVID-related absences and qualification for federal free and reduced lunch benefits. For the 2021-2022 school year, local education authorities (LEA?s) submit lists of students determined eligible to the Missouri Department of Elementary and Secondary Education (DESE). DESE then submits the approved eligibility file to DSS with the name of each eligible child and the amount of benefit to be issued on a P-EBT card. DSS then issues the benefit. Corrective Action is as follows: DSS has reviewed the overpayments and referred the children identified in this finding to the Missouri Program Integrity Unit (PIU) for claims processing, if the funds can be recovered. This is outlined in the FNS approved Missouri P-EBT state plan.

View Audit 56478 Questioned Costs: $1

Finding 58015 (2022-002)

None 2022

Visible Music College

TN

Student Financial Aid Matching / Level of Effort / Earmarking Eligibility

AUDIT FINDING Finding 2022-002 NSLDS Status Reporting Error MANAGEMENT'S COMMENTS ON FINDINGS AND RECOMMENDATIONS We concur with the auditor?s finding and identification of a deficiency in our internal controls. MANAGEMENT'S CORRECTIVE ACTION PLAN We will enact stronger controls to ensure that all...

AUDIT FINDING Finding 2022-002 NSLDS Status Reporting Error MANAGEMENT'S COMMENTS ON FINDINGS AND RECOMMENDATIONS We concur with the auditor?s finding and identification of a deficiency in our internal controls. MANAGEMENT'S CORRECTIVE ACTION PLAN We will enact stronger controls to ensure that all future enrollment reporting is submitted timely. EMPLOYEE/ DIVISION RESPONSIBLE Financial Aid Director TIMELINE AND ESTIMATED COMPLETION DATE Immediately

View Audit 54568

Finding 58003 (2022-001)

Material Weakness 2022

Accord

MN

Internal Control / Segregation of Duties Eligibility Material Weakness § 200.303

May 1, 2023 Corrective Action Plan Finding 2022-001 ? Compliance and Controls over Compliance ? Eligibility Home Investment Partnership Program, AL# 14.239 Material Weakness Accord did not have controls in place to ensure that eligibility criteria and rent calculations were being reviewed and/or app...

May 1, 2023 Corrective Action Plan Finding 2022-001 ? Compliance and Controls over Compliance ? Eligibility Home Investment Partnership Program, AL# 14.239 Material Weakness Accord did not have controls in place to ensure that eligibility criteria and rent calculations were being reviewed and/or approved by someone other than the individual performing the initial determination or annual reexamination. Actions Taken or Planned: Management agrees with this finding. Beginning in February 2022, management has contracted out the eligibility determination process to a third-party contractor with significant experience in affordable housing and similar processes. Management is working with the contractor to include a second individual in this process so that there will be a review performed by someone other than the individual making the initial determination or annual recertification. Contact Persons: Ernest Johnson, Housing Associate Director Robert Pickering, Chief Financial Officer

View Audit 54396

Finding 57887 (2022-001)

Material Weakness 2022

Northshore University Healthsystem

IL

Cash Management Eligibility Period of Performance

Corrective Action Plan Finding 2022-001 Assistance Listing #93.461 Internal Control over Compliance? Activities Allowed or Unallowed and Eligibility, Due to the evolving nature of the COVID-19 pandemic, and the rapid pace in which programs were implemented, documentation of controls related to the r...

Corrective Action Plan Finding 2022-001 Assistance Listing #93.461 Internal Control over Compliance? Activities Allowed or Unallowed and Eligibility, Due to the evolving nature of the COVID-19 pandemic, and the rapid pace in which programs were implemented, documentation of controls related to the reporting of COVID-19 uninsured patients was not maintained. However, controls were in place and proper submission of claims was accurate. As part of the prior year audit finding, NorthShore implemented a process as of January 2022 to document internal controls related to the quality review of claims to ensure patients meet the eligibility requirements. HRSA reviewed the documentation and determined that the finding had been satisfactorily resolved. Although the program has now ended, NorthShore will ensure the internal controls are documented should the HRSA program be reinstated. Responsible Official: John Skeans, Senior Vice President, Patient Financial Services.

View Audit 54355

Finding 53053 (2022-101)

Significant Deficiency 2022

State of Wisconsin

WI

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

CAP for Finding: 2022-101 Auditor Recommendation: Establish and implement written procedures for making updates to the benefit calculation parameters in the Home Energy (HE) Plus application. Planned Corrective Action: The Wisconsin Department of Administration (Department or DOA) will establish and...

CAP for Finding: 2022-101 Auditor Recommendation: Establish and implement written procedures for making updates to the benefit calculation parameters in the Home Energy (HE) Plus application. Planned Corrective Action: The Wisconsin Department of Administration (Department or DOA) will establish and implement written procedures for entering and updating the benefit calculation parameters related to the Wisconsin Home Energy Assistance Program (WHEAP) in the HE Plus (HE+) System. The Department?s procedures will reflect that it incorporated a module for determining the LIHEAP heating maximum benefit in the HE+ System and eliminated the use of an external Microsoft Access database for that purpose subsequent to the period under audit (i.e., in state fiscal year [SFY] 2022-23). Anticipated Completion Date: May 1, 2023 Auditor Recommendation: Reassess its existing procedures for performing a review of the benefit calculation parameters entered into the Home Energy (HE) Plus application, make adjustments to its existing procedures as necessary, and document the performance of each review. Planned Corrective Action: The Department necessarily reassessed its procedures for reviewing the entry of benefit calculation parameters into the HE+ System when it incorporated a module for determining the LIHEAP heating maximum benefit in the HE+ System and eliminated the use of an external Microsoft Access database for that purpose subsequent to the period under audit (i.e., in state fiscal year [SFY] 2022-23). The development and implementation of the new system functionality, which was used for the determining the federal fiscal year (FFY) 2023 WHEAP program benefits, improved program integrity through the elimination of manual data entry of end result benefit factors and proxy values. Program integrity will be further strengthened through the creation of a form to document the review of the benefit calculation parameters entered into HE+. The form will be created by May 1, 2023, and implemented with the FFY24 benefit formula calculation scheduled to be completed in July 2023. Anticipated Completion Date: May 1, 2023 Auditor Recommendation: Complete its review of the 605 households that were underpaid heating benefits due to the error and issue supplemental heating benefit payments. Planned Corrective Action: DOA completed its review of the households that were underpaid heating benefits and will issue the supplemental heating benefit payments as soon as practical. Anticipated Completion Date: June 30, 2023 Person responsible for corrective action: Susan Brown, Administrator Division of Energy, Housing and Community Resources susan.brown@wisconsin.gov

View Audit 44861

Finding 52676 (2022-001)

Significant Deficiency 2022

Long Island Fqhc, Inc.

NY

Special Tests & Provisions Subrecipient Monitoring Eligibility

LIFQHC has implemented procedures to ensure that all patients are charged appropriately based on services, income and where they should be categorized on the LIFQHC sliding fee scale. Management is currently providing training to the registration staff across all sites. The objective of this trainin...

LIFQHC has implemented procedures to ensure that all patients are charged appropriately based on services, income and where they should be categorized on the LIFQHC sliding fee scale. Management is currently providing training to the registration staff across all sites. The objective of this training is to verify patients' information, such as income, in order to ensure that all patients are charged appropriately. All the above findings were happened before the training was provided. Management has also implemented a new process in which the sliding fee scale will be updated on a more timely basis. LIFQHC will update the sliding fee scale in the electronic medical record system as soon as the current year's poverty guidelines are available. Responsible Party: Savitree Pestano, Chief Financial Officer Estimated Time of Completion: December 31, 2022

View Audit 44098

Finding 52601 (2022-101)

Significant Deficiency 2022

Osborn Elementary School District No. 8

AZ

Eligibility Reporting Matching / Level of Effort / Earmarking § 200.61

REFERENCE: 2022-101 CFDA NUMBER: 84.027A ? SPECIAL EDUCATION ? GRANTS TO STATES CFDA NUMBER: 84.027X ? SPECIAL EDUCATION ? GRANTS TO STATES CFDA NUMBER: 84.173A ? SPECIAL EDUCATION ? PRESCHOOL GRANTS U.S. DEPARTMENT OF EDUCATION ? 2022 PASSED THROUGH ARIZONA STATE DEPARTMENT OF EDUCATION GRANT NUMBE...

REFERENCE: 2022-101 CFDA NUMBER: 84.027A ? SPECIAL EDUCATION ? GRANTS TO STATES CFDA NUMBER: 84.027X ? SPECIAL EDUCATION ? GRANTS TO STATES CFDA NUMBER: 84.173A ? SPECIAL EDUCATION ? PRESCHOOL GRANTS U.S. DEPARTMENT OF EDUCATION ? 2022 PASSED THROUGH ARIZONA STATE DEPARTMENT OF EDUCATION GRANT NUMBERS: H027A210007, H027X210007, H173A210003 CLIENT RESPONSE AND CORRECTIVE ACTION PLAN We concur with the condition. 1. Name of the contact person responsible for corrective action: Mariah Kelly-Hatcher, Director of Student Services 2. Corrective action planned: 1) Error 1: For 4 of 40 files tested, the Individualized education program (IEP) was not completed timely. The IEPs were between 2 and 54 days late. ? Internal procedure of prioritizing parent attendance will be adjusted and communicated to reflect documentation being completed timely prior to the expiration date. Completed August 2022. ? Internal procedure of school psychologist oversight of IEP calendaring and regular meetings to ensure deadline adherence implemented. Completed August 2022. ? Verbal corrective discipline warning, to be followed with a written corrective discipline for IEPs not completed timely. Completed October 2021, April 2022, May 2022. 2) Error 2: For 3 of 40 files tested, the primary disability category was not properly reported. A prior or secondary eligibility category was used rather than the current primary eligibility category. ? Internal procedure established for regular checks of eligibility alignment among documents and district reporting. Established August 2022. 3) Error 3: Although the District has established internal control processes and procedures to ensure student files include required documentation, the performance of these control activities was not documented for 1 of 40 provider files tested. ? Internal control processes were reviewed and will be tested with randomized files bimonthly. This process will continue to be completed through December 2022 to ensure fidelity. 3. Anticipated completion date: December 15, 2022.

View Audit 43764

Finding 52441 (2022-006)

Significant Deficiency 2022

Columbia Gorge Community College

OR

Questioned Costs Student Financial Aid Subrecipient Monitoring

Finding 2022-006 Federal Agency Name: Department of Education Program Name: Education Stabilization Fund ALN 84.425 Finding Summary: The College provided emergency grants to students with the student portion of the HEERF funding, but the College could not provide evidence that the student met the de...

Finding 2022-006 Federal Agency Name: Department of Education Program Name: Education Stabilization Fund ALN 84.425 Finding Summary: The College provided emergency grants to students with the student portion of the HEERF funding, but the College could not provide evidence that the student met the definition of ?eligible student?. The emergency grants were used to relieve the delinquent student accounts. There were 5 students identified in our testing that were not ?enrolled in an institution of higher education on or after the date of the declaration of the national emergency (March 13, 2020).? It appears the 5 students were not enrolled at the College on or after March 13, 2020, and the College did not obtain evidence that the students were enrolled on or after this date at another institution of higher education. Responsible Individuals: Courtney Judah, Director of Institutional Effectiveness Corrective Action Plan: Ongoing training was conducted with Enterprise Management Software support to develop reporting and process steps to prevent reporting errors and improve accuracy for student?s assistance. Prevention to include creation of reports for awards pending and detailed disbursement and reconciliations schedules. Develop ongoing student intervention processes to identify student with emergency financial need. Student Funding Committee formed that processes request includes verification of enrollment, number of credits, and financial aid standing. Committee includes representatives from Financial Aid, Advising, Foundation, and the Business Office. The College has entered into an agreement with a third-party financial aid provider to service and administer financial aid awards, reporting and reconciliation. Contracted services include award packaging, document collection and compliance review, disbursement logs, direct flow of federal funds, account reconciliation and exit process. The added third-party support reduced workload on Financial Aid and allowed for a more proactive engagement with student emergency funding needs. Contacted Department of Education grant administrator for guidance on program requirements and compliance. Completed and will continue to participate in ongoing Department of Education training. Anticipated Completion Date: June 30, 2023

View Audit 52798 Questioned Costs: $1

Finding 52399 (2022-004)

Material Weakness 2022

Carbon Cliff-Barstow School District No. 36

IL

Procurement, Suspension & Debarment Eligibility School Nutrition Programs

Response and Corrective Action Plan: The District will require the food service software to be used for verification data and selection of applications. The District will require documented supervisory approval of verification conclusions and reports submitted to the state of Illinois.

View Audit 47540

Finding 52384 (2022-001)

Significant Deficiency 2022

Wentworth Institute of Technology, Inc.

MA

Student Financial Aid Eligibility Reporting

Finding ? Eligibility ? Federal Direct Student Loan Program Assistance Listing Number 84.268 and Federal Pell Grant Program Assistance Listing Number 84.063; June 30, 2022 Award Year; U.S. Department of Education Criteria or Specific Requirement The annual maximum loan amount an undergraduate stud...

Finding ? Eligibility ? Federal Direct Student Loan Program Assistance Listing Number 84.268 and Federal Pell Grant Program Assistance Listing Number 84.063; June 30, 2022 Award Year; U.S. Department of Education Criteria or Specific Requirement The annual maximum loan amount an undergraduate student may receive must be prorated when the borrower is enrolled in a program that is shorter than a full academic year; or enrolled in a program that is one academic year or more in length but is in a remaining period of study that is shorter than a full academic year. (2021 - 2022 Student Financial Aid Bank Book, Volume 3, Chapter 5, Page 3-160, 34 CFR 685.203(a),(b),(c)) The amount of a student's Pell Grant for an academic year is based upon the payment and disbursement schedules published by the Secretary for each award year. (2021 - 2022 Student Financial Aid Handbook, Volume 3, Chapter 3, Page 3-68, 34 CFR 690.62) Condition Of the 40 students selected for eligibility testing, two students within the sample were incorrectly awarded aid based upon their specific circumstances. This was not a statistically valid sample. Views of Responsible Officials and Planned Corrective Actions The University concurs with the finding. The University will implement periodic quality control checks to ensure student aid is being appropriately calculated and awarded based upon relevant student enrollment and financial information. Names of Contact Persons Responsible for Corrective Action: Joan Romano, Registrar and Anne-Marie Caruso, Assistant Vice President/Director of Financial Aid Anticipated Completion Date: October 24, 2022

View Audit 45056

Finding 52383 (2022-002)

Significant Deficiency 2022

Wentworth Institute of Technology, Inc.

MA

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

Finding ? Special Tests and Provisions: Enrollment Reporting ? Federal Direct Student Loan Program, Assistance Listing Number 84.268; June 30, 2022 Award Year; U.S. Department of Education Criteria or Specific Requirement Enrollment information, including the effective date of separation from the ...

Finding ? Special Tests and Provisions: Enrollment Reporting ? Federal Direct Student Loan Program, Assistance Listing Number 84.268; June 30, 2022 Award Year; U.S. Department of Education Criteria or Specific Requirement Enrollment information, including the effective date of separation from the institution, must be accurately reported within 30 days whenever attendance changes for a student, unless a roster will be submitted within 60 days. The changes include reductions or increases in attendance levels, withdrawals, graduations, and approved leaves-of absence. It is the institution?s responsibility, as a participant in the Title IV aid programs, to monitor and report these changes to the National Student Loan Data System (?NSLDS?). (NSLDS Enrollment Reporting Guide September 2021, and 34 CFR 685.309(b)) Condition Of the 40 students selected for enrollment reporting testing, three students within the sample were reported to NSLDS outside the maximum 60-day window. This was not a statistically valid sample. Views of Responsible Officials and Planned Corrective Actions The University concurs with the finding. The University will continue to remain vigilant in its oversight over timely communication of enrollment reporting detail to NSC and from NSC to NSLDS. Names of Contact Persons Responsible for Corrective Action: Joan Romano, Registrar and Anne-Marie Caruso, Assistant Vice President/Director of Financial Aid Anticipated Completion Date: October 24, 2022

View Audit 45056

Corrective Action Plans

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