Corrective Action Plans

Finding 565475 (2024-034)

Significant Deficiency 2024

MA

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

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES 2024-034 Medicaid Cluster, COVID-19 – Medicaid Cluster - Assistance Listing No. 93.775, 93.777, 93.778 Recommendation: The Department should enhance its procedures and internal controls to ensure it properly monitors high-risk providers and that it maint...

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES 2024-034 Medicaid Cluster, COVID-19 – Medicaid Cluster - Assistance Listing No. 93.775, 93.777, 93.778 Recommendation: The Department should enhance its procedures and internal controls to ensure it properly monitors high-risk providers and that it maintains documentation that claims are paid only to eligible providers. Action taken in response to finding: Providers who are identified as high risk, are sent for fingerprinting. Once the fingerprinting results are received, they are scheduled for a site visit. Business Support Services have reinforced with staff that the site visit must follow the fingerprinting results. Additionally, a checklist will be created for all high-risk providers to ensure that all required steps in the process are completed at enrollment, revalidation or when they are identified as having a credible allegation of fraud or appropriate overpayment. Name(s) of the contact person(s) responsible for corrective action: Janice Wadsworth, MassHealth Director Provider Operations Keith West, Director Special Projects Business Support Services and Chris Silva, Manager Provider Enrollment Business Support Services. Planned completion date for corrective action plan: The checklist will be complete by July 2025.

View Audit 359283

Finding 565463 (2024-027)

Significant Deficiency 2024

Commonwealth of Massachusetts

MA

Eligibility Special Tests & Provisions Significant Deficiency § 200.303

DEPARTMENT OF TRANSITIONAL ASSISTANCE 2024-027 Temporary Assistance for Needy Families (TANF) - Assistance Listing No. 93.558 Recommendation: We recommend the Department evaluate its procedures and internal controls to ensure that information used to verify work participation is complete, accurate, ...

DEPARTMENT OF TRANSITIONAL ASSISTANCE 2024-027 Temporary Assistance for Needy Families (TANF) - Assistance Listing No. 93.558 Recommendation: We recommend the Department evaluate its procedures and internal controls to ensure that information used to verify work participation is complete, accurate, and agrees with supporting documentation. Action taken in response to finding: A. Program requirements on work hours self-attestation for self-employed The Department will work on guidance that complies with the federal rules and develop instructions for staff on how to determine hours of work for those who are self-employed. B. Accuracy of reported hours of work Quality Control (QC) managers will initial the unsubsidized hours field and the corresponding supporting documentation to indicate that a thorough review has been completed. The current procedure requires QC managers to review all cases, which 250 to 300 cases per month. Further, QC staff will also be reminded of the importance of accurately coding unsubsidized employment hours and will be instructed to double-check their work to minimize errors and maintain data integrity. QC management maintains the practice of reviewing a random 20% sample of all unsubsidized employment hours coded prior to quarterly transmission to ACF, to ensure ongoing accuracy and compliance. QC management will work with IT to explore the possibility of developing a management report or error report using backend BEACON data that would show specifics of errors corrected by QC managers or QC management to assist management in providing targeted training to QC staff. Name(s) of the contact person(s) responsible for corrective action: Megan Nicholls, Associate Commissioner of Family and Economic Assistance Carlos Rosado, Director of Quality Control | Quality Management Planned completion date for corrective action plan: September 30, 2025 – Issue instruction and guidance that complies with the federal rules October 30, 2025 – Implement enhanced procedures accuracy of reported work hours

View Audit 359283

Finding 565462 (2024-026)

Significant Deficiency 2024

Commonwealth of Massachusetts

MA

Questioned Costs Special Tests & Provisions Student Financial Aid § 200.303

DEPARTMENT OF TRANSITIONAL ASSISTANCE 2024-026 Temporary Assistance for Needy Families (TANF) - Assistance Listing No. 93.558 Recommendation: We recommend the Department evaluate its procedures and internal controls over Child Support Non-Cooperation to ensure that sanctions are applied timely. Acti...

DEPARTMENT OF TRANSITIONAL ASSISTANCE 2024-026 Temporary Assistance for Needy Families (TANF) - Assistance Listing No. 93.558 Recommendation: We recommend the Department evaluate its procedures and internal controls over Child Support Non-Cooperation to ensure that sanctions are applied timely. Action taken in response to finding: The Department will utilize existing training opportunities, including but not limited to new hire training, monthly supervisor webinars and ad hoc guest training from DOR to address this topic as needed. Further, the Department is working on building out a quality control program on sampling of TAFDC cases in the Quality Management organization. When built out, this program would include a sample review of child support non-cooperative cases to ensure sanctions are applied timely and appropriately. In the interim, ad hoc targeted reviews on this topic will be performed annually at minimum as a compensating control for risk mitigation. Reviews will be performed on a sample basis. Name(s) of the contact person(s) responsible for corrective action: Megan Nicholls, Associate Commissioner of Family and Economic Assistance - Training Lily Kuo, Director of Internal Controls – Ad hoc Targeted Reviews Planned completion date for corrective action plan: September 30, 2025 and forward – Facilitate training March 30, 2026 and forward – Perform ad hoc targeted reviews

View Audit 359283 Questioned Costs: $1

Finding 565461 (2024-025)

Significant Deficiency 2024

Commonwealth of Massachusetts

MA

Matching / Level of Effort / Earmarking Eligibility Reporting § 200.303

DEPARTMENT OF TRANSITIONAL ASSISTANCE 2024-025 Temporary Assistance for Needy Families (TANF) - Assistance Listing No. 93.558 Recommendation: We recommend the Department evaluate its procedures and internal controls over reporting to ensure that reports are supported by documentation and are submitt...

DEPARTMENT OF TRANSITIONAL ASSISTANCE 2024-025 Temporary Assistance for Needy Families (TANF) - Assistance Listing No. 93.558 Recommendation: We recommend the Department evaluate its procedures and internal controls over reporting to ensure that reports are supported by documentation and are submitted timely. Action taken in response to finding: The Department will evaluate, enhance, and document its procedures and internal controls over the ACF-209 reporting to ensure the data in the reports are supported by documentation. Specifically, participants with zero earned income should not have a blank field and the reported unsubsidized hours - Block 43 UnsubEmpHrsc - in BEACON QI and the ACF-209 reports should be supported by BEACON Program, where applicable. Further, the Department will submit the ACF-209 reports timely on a quarterly basis. This includes reviewing and correcting rejected submissions and the errors from the partially accepted submissions by ACF and resubmitting the reports until acceptance by ACF. Name(s) of the contact person(s) responsible for corrective action: Birabwa Kajubi, Associate Commission for Quality Management Roubina Panian, Quality Improvement Director | Quality Management Planned completion date for corrective action plan: October 30, 2025 – Implement enhanced procedures on data accuracy August 14, 2025 and forward – Timely submission of data reports

View Audit 359283

Finding 565422 (2024-006)

Significant Deficiency 2024

Commonwealth of Massachusetts

MA

Special Tests & Provisions Eligibility Reporting § 200.303

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT Unemployment Insurance, COVID-19 – Unemployment Insurance - Assistance Listing No. 17.225 Recommendation: We recommend the Department review and enhance procedures and controls to ensure that RESEA program requirements are met. We further recommend...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT Unemployment Insurance, COVID-19 – Unemployment Insurance - Assistance Listing No. 17.225 Recommendation: We recommend the Department review and enhance procedures and controls to ensure that RESEA program requirements are met. We further recommend the Department develop a formal process to review quarterly performance reports for accuracy prior to submission. Action taken in response to finding: MDUA’s legacy system had a known issue with maintaining documents. In some instances, the legacy system did not keep a copy of correspondence. In May 2025, MDUA implemented a new, modernized UI administrative system known as EMT. During the integration process, memorializing documents the system generated was a priority. Now with a fully implemented system, all documents will be saved. In addition, the RESEA program has a required reporting standard administered through the federal SUN system. Although MDUA has an established process for completing this work, MDUA does not have an audit trail to show it was completed. Moving forward, MDUA will enhance this procedure to ensure MDUA has documentation to maintain compliance. Name(s) of the contact person(s) responsible for corrective action: John Saulnier, Director of Benefit Performance Planned completion date for corrective action plan: 9/30/2025

View Audit 359283

Finding 565411 (2024-003)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Special Tests & Provisions Procurement, Suspension & Debarment Eligibility § 200.303

DEPARTMENT OF TRANSITIONAL ASSISTANCE 2024-003 SNAP Cluster - Assistance Listing No. 10.551, 10.561 Recommendation: We recommend the Department review and enhance procedures and controls to ensure that documentation for EBT reconciliations is maintained in accordance with the federal program require...

DEPARTMENT OF TRANSITIONAL ASSISTANCE 2024-003 SNAP Cluster - Assistance Listing No. 10.551, 10.561 Recommendation: We recommend the Department review and enhance procedures and controls to ensure that documentation for EBT reconciliations is maintained in accordance with the federal program requirements. Action taken in response to finding: Starting July 2025, the Accounting Director (or Deputy Accounting Director when hired) will sign and date the reconciliation documentation (and retain) when reviews are performed. The standard operating procedures will be clarified that preparer and reviewer typing their names and date within the reconciliation documentation is an acceptable form of sign-off upon completion of the reconciliations and reviews. Name(s) of the contact person(s) responsible for corrective action: Keivon Spencer, Director of Accounting | DTA Finance Planned completion date for corrective action plan: June 30, 2025 and forward – Sign and date reconciliation reviews October 30, 2025 – Standard operating procedures

View Audit 359283

Finding 565372 (2024-002)

Significant Deficiency 2024

Summit County Colorado

CO

Eligibility Subrecipient Monitoring

Finding 2024-002 Federal Agency Name: U.S. Department of Health and Human Services Passed-through Colorado Department of Health Care Policy and Financing Program Name: Medical Assistance Program CFDA # 93.778 Initial Fiscal Year Finding Occurred: 2024 Finding Summary: Our auditors, Eide Bailly, test...

Finding 2024-002 Federal Agency Name: U.S. Department of Health and Human Services Passed-through Colorado Department of Health Care Policy and Financing Program Name: Medical Assistance Program CFDA # 93.778 Initial Fiscal Year Finding Occurred: 2024 Finding Summary: Our auditors, Eide Bailly, tested eligibility determination and controls over this process for sixty case files. They noted the following in our testing: • One instance of non-compliance in which the County did not complete the eligibility determination and approve/deny the case within 45 days and no notice of action was sent to the client within the required timeframe. • Two instances of non-compliance in which the County did not ensure removal from the Medicaid program due to cases being ineligible because of over income or being undocumented. Responsible Individuals: Joanne Sprouse, Human Services Director Corrective Action Plan: Summit County Human Services has successfully retrained all case managers on application processing protocols, utilizing state-approved training modules administered through the Staff Development Department. Summit County Human Services strictly follows state-mandated guidelines for processing Medical Assistance applications and ensures that all cases are approved or denied within the 45-day timeframe established by state regulations. To enhance the accuracy of eligibility determinations for all household members, case managers will also complete the "Case Wrap-Up Training" through CoLearn, an online training platform developed by the State's Staff Development Department. Completion of this training ensures that eligibility determinations are accurate, and that appropriate client correspondence is issued. In instances where eligibility errors are identified in Medicaid applications submitted via Connect for Health Colorado, a third-party agency operating independently from the county, Summit County will notify the agency within 24 hours. While such errors fall outside the county's control, the county is committed to promptly communicating corrections to ensure accurate application outcomes. Anticipated Completion Date: Ongoing

View Audit 359213

Finding 565343 (2024-002)

Material Weakness 2024

Housing Authority of the County of Dauphin

PA

Questioned Costs HUD Housing Programs Eligibility

Finding Number: 2024-002 Planned Corrective Action: Applicable staff will be briefed on the finding and training will be provided on both written policy and procedure. The Housing Authority has a quality assurance program to monitor and ensure all clients complete an annual family income reeaxaminat...

Finding Number: 2024-002 Planned Corrective Action: Applicable staff will be briefed on the finding and training will be provided on both written policy and procedure. The Housing Authority has a quality assurance program to monitor and ensure all clients complete an annual family income reeaxamination in accordance with Eligibility, Reporting and Housing Assistance Payment Requirements. Anticipated Completion Date: 6/30/2025 Responsible Contact Person: Kristen Runion, HCV Supervisor

View Audit 359165 Questioned Costs: $1

Finding 565324 (2024-001)

Significant Deficiency 2024

Bath Housing Development Corporation

ME

Eligibility HUD Housing Programs Significant Deficiency

Finfing Number: 2024-001: Eligibility Planned Corrective Action: 1. All 2024 reexamination files will be reviewed to confirm a corresponding file is present and social security income is accruately reflected. File findings will be noted accordingly. 2. Moving forward, a Quality Control audit will ...

Finfing Number: 2024-001: Eligibility Planned Corrective Action: 1. All 2024 reexamination files will be reviewed to confirm a corresponding file is present and social security income is accruately reflected. File findings will be noted accordingly. 2. Moving forward, a Quality Control audit will occur monthly to include: - Confirmation of corresponding file for every annual reexamination completed. - 50% of all reexamination files will be audited to confirm the following: > Verification of income and assets. > Gross income is accurately reflected. > An EIV report is present; social security income reported is accurate. > A signed 50059 is present in the file. The audit will be conducted by a staff member that did not complete the reexam. Anticipated Completion Date: 1. July 31, 2025; 2. Ongoing Responsible Contact Person: Jessica Irish

View Audit 359147

Finding 565020 (2024-001)

Significant Deficiency 2024

Commonwealth Institute of Funeral Service

TX

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

Finding #2024-001 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Education, Student Financial Assistance Programs Cluster, Assistance Listing #84.063, Federal Pell Grant Program, Assistance Listing #84.268, Federal Direct Student Loans, Contracts #...

Finding #2024-001 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Education, Student Financial Assistance Programs Cluster, Assistance Listing #84.063, Federal Pell Grant Program, Assistance Listing #84.268, Federal Direct Student Loans, Contracts #003556 and G03556, Contract years: 05/05/21 – 12/31/26. Recommendation: Emphasize the importance of accurately reporting enrollment status. Planned corrective action: Management agrees with audit finding #2024-001. The Financial Aid Coordinator is responsible for reporting enrollment status changes, certifying enrollment every 60 days, and responding to NSLDS Roster files within 15 days, all through the NSLDSFAP website. To enhance the accuracy of these enrollment reports, the Institute is implementing a new double-check process. Henceforth, the Financial Aid Coordinator will print all enrollment status changes or enrollment report rosters prior to making any online updates or certifications. These printed reports will then be given to the Director of Operations for verification. Only after this verification will the Financial Aid Coordinator proceed with the necessary changes or certifications on the NSLDSFAP website. All printed reports will be retained by the Financial Aid Coordinator for documentation. Responsible officer: Cody Lopasky, President. Estimated completion date: June 1, 2025.

View Audit 358905

Finding 565014 (2024-001)

None 2024

Hillsboro-Deering Cooperative School District

NH

School Nutrition Programs Eligibility Internal Control / Segregation of Duties

For the purpose of future audits, we will utilize a coding system for the applications we receive (i.e., the first application we receive will be coded “1”). The auditors can request a random sample based on the coding system and we will redact information on the application to protect household and...

For the purpose of future audits, we will utilize a coding system for the applications we receive (i.e., the first application we receive will be coded “1”). The auditors can request a random sample based on the coding system and we will redact information on the application to protect household and student information.

View Audit 358891

Finding 564934 (2024-002)

Significant Deficiency 2024

Sunshine Community Health Center, Inc.

AK

Special Tests & Provisions Eligibility Significant Deficiency

Federal Award Finding: 2024-002 Significant Deficiency in Internal Control and Noncompliance with Special Tests and Provisions in Application of Organization's Sliding Fee Discounts Policy Name and Contact Person: Gina McCullough, Chief Financial Officer (907) 733-2273 gmccullough@sunshineclinic.org...

Federal Award Finding: 2024-002 Significant Deficiency in Internal Control and Noncompliance with Special Tests and Provisions in Application of Organization's Sliding Fee Discounts Policy Name and Contact Person: Gina McCullough, Chief Financial Officer (907) 733-2273 gmccullough@sunshineclinic.org Corrective Action: The Organization will take steps to ensure that staff are proficient in the completion of the application of the slide adjustments within the EHR system and are working to improve the review process of those adjustments being applied to ensure compliance. Proposed Completion Date: June 30, 2025

View Audit 358850

Finding 564598 (2024-002)

Significant Deficiency 2024

National Indian Youth Council, Inc.

NM

Eligibility Significant Deficiency § 200.303 § 200.430

Recommendation Implement a centralized, access-controlled digital system for participant file storage. Additionally, management should require the use of a standardized eligibility checklist and conduct periodic file audits to ensure documentation completeness and compliance with WIOA requirements. ...

Recommendation Implement a centralized, access-controlled digital system for participant file storage. Additionally, management should require the use of a standardized eligibility checklist and conduct periodic file audits to ensure documentation completeness and compliance with WIOA requirements. Management Response Corrective Action: In response to this incident, we have reinstated the Eligibility Determination and Intake (EDIR) Form. This form clearly states the participant identification information, the characteristics tracked by our program data management tool (GPMS), and states what has been provided by the participant to determine their eligibility for the program. Provided in a check list format, the form clearly demonstrates what makes the participant eligible for our program services. The form also lists the documentation included in the application that has been provided by the participant. This form added to the program application and maintained in the participant's official record will ensure that all WIOA eligibility documentation has been received, reviewed, and approved at the time of intake. Due Date of Completion: Completed as of May 31, 2025 Responsible Person(s):Director of Programs and Development is responsible for re-instating the use of the form and the Field Office Managers and Job Developers are responsible for filling out the form and including it in the participant's official record.

View Audit 358729

Finding 564496 (2024-001)

Significant Deficiency 2024

Prairie State College - Community College District No. 515

IL

Eligibility

To ensure alignment with these procedures, we will reinforce the following corrective steps within our TRIO Student Support Services processes. Application Completion: Program staff will verify that both student and parent/guardian signatures are present on all applications before they are processed...

To ensure alignment with these procedures, we will reinforce the following corrective steps within our TRIO Student Support Services processes. Application Completion: Program staff will verify that both student and parent/guardian signatures are present on all applications before they are processed. Any incomplete applications will be returned for completion prior to review. Eligibility Review: We will continue to review applications thoroughly to confirm students meet the required eligibility criteria, documenting the review process to maintain clear records of eligibility determinations. Additionally, we will implement periodic file audits to ensure ongoing compliance with these controls and address any discrepancies promptly. As for the TRIO Upward Bound corrective measure, we will implement the following steps to address this issue and prevent it moving forward. 1. Application review checklist:program staff will utilize a standardized checklist to verify that all required fields, including student and parent/guardian signatures, are completed before accpeting applications. 2. Staff training: conduct a brief refresher training course with the team to reinforce the importance of thoroughly reviewing applications for completeness and required signatures during intake. 3. Periodic file audits: perform periodic file audits prior to submission deadlines to ensure application compliance and identify any missing information. Contact person(s) responsible for corrective action: Desiree Anderson, Associate Vice President, Student Affairs Anticipated completion date: August 15, 2025

View Audit 358618

Finding 564424 (2024-101)

Significant Deficiency 2024

B J Enterprises, Inc.

AZ

Procurement, Suspension & Debarment Cash Management Eligibility § 200.303

REFERENCE: 2024-101 REPEAT FINDING REFERENCE: 2023-001 CFDA NUMBER: 10.558 – CHILD AND ADULT CARE FOOD PROGRAM U.S. DEPARTMENT OF AGRICULTURE - FOOD AND NUTRITION - 2024 PASSED THROUGH ARIZONA STATE DEPARTMENT OF EDUCATION GRANT NUMBER 6AZ300003 CLIENT RESPONSE AND CORRECTIVE ACTION PLAN We concur ...

REFERENCE: 2024-101 REPEAT FINDING REFERENCE: 2023-001 CFDA NUMBER: 10.558 – CHILD AND ADULT CARE FOOD PROGRAM U.S. DEPARTMENT OF AGRICULTURE - FOOD AND NUTRITION - 2024 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, MPH, RD 2. Corrective action planned: The menu reader (Area Coordinator) will double check the meal counts to the menus to ensure all meal counts: * are clerically accurate; * are claimed for providers own, only when day care children are present; * are claimed only when children are present to eat those meals and; * are claimed only when 2 snacks and 1 meal or 2 meals and 1 snack are claimed for each child. The menu reader will double check the list of Income Eligible providers each month to make sure providers’ own are claimed only when we have the Income Affidavits. The Director will re-train the menu readers in these specific areas at the next staff meeting and through virtual training. 3. Anticipated completion date: June 2025 through October 2025

View Audit 358561

Finding 564420 (2024-001)

Significant Deficiency 2024

Senior Citizens Housing Development Corporation of Montgomery County

FL

HUD Housing Programs Eligibility Reporting

Oversight Agency for Audit, Senior Citizens Housing Development Corporation of Montgomery County, operating as Council House, respectfully submits the following corrective action plan for the year ended September 30, 2024. Name and address of independent public accounting firm: Bellows Associates, P...

Oversight Agency for Audit, Senior Citizens Housing Development Corporation of Montgomery County, operating as Council House, respectfully submits the following corrective action plan for the year ended September 30, 2024. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067 Audit period: October 1, 2023 through September 30, 2024 The finding from the September 30, 2024 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number in the schedule. SECTION III – FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING No. 2024-001: Project Based Rental Assistance Program, ALN 14.195 Recommendation: The manager should verify eligibility by obtaining and maintaining all required documents for all tenants, maintain support for tenant income verification through the EIV system in a timely manner, and perform appropriate unit inspections. Furthermore, annual recertifications should be performed prior to expirations and transmitted to HUD through TRACS. Action Taken: Staff training has been provided with additional HUD training inclusive of EIV reporting and tenant file maintenance and included in monthly reporting procedures If the audit Oversight Agency has questions regarding these plans, please call Irene Phillips at 954-835-9200. Sincerely yours, Irene Phillips CFO

View Audit 358536

Finding 564274 (2024-003)

Significant Deficiency 2024

East River Legal Services Corporation

SD

Internal Control / Segregation of Duties Cash Management Eligibility

Federal Agency Name: Legal Services Corporation Program Name: Legal Services Corporation – Basic Field Grant FFAL#: 09-542026 Finding Summary: Testing identified one case in which the U.S. Citizen Attestation was not obtained and one case in which documentation was not obtained and retained within ...

Federal Agency Name: Legal Services Corporation Program Name: Legal Services Corporation – Basic Field Grant FFAL#: 09-542026 Finding Summary: Testing identified one case in which the U.S. Citizen Attestation was not obtained and one case in which documentation was not obtained and retained within the case file detailing immigration documents being received and reviewed. Responsible Individuals: Lea Wroblewski, Executive Director. Corrective Action Plan: The Organization will communicate to staff the importance of ensuring all required case file documentation is obtained and retained as required by the federal program. The compliance officer will review case file documentation for compliance after the case is closed and will provide staff training as needed to improve compliance. Completion Date: May 2025

View Audit 358389

Finding 564243 (2024-015)

Material Weakness 2024

Charter County of Wayne, Michigan

MI

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

Condition: The County’s controls over meal participants did not ensure a review was in place to check the intake forms for Halal Home Delivered meal participants or that updated assessments were obtained for home delivered meals. Lastly there was not a control in place to ensure liquid meal particip...

Condition: The County’s controls over meal participants did not ensure a review was in place to check the intake forms for Halal Home Delivered meal participants or that updated assessments were obtained for home delivered meals. Lastly there was not a control in place to ensure liquid meal participants maintained a physician order, renewed every six months, stating the need for the continued supplement service. Planned Corrective Action: Wayne County’s Department of Senior Services will implement processes to ensure only eligible individuals receive meals. A quarterly report will be run to verify all home delivered meal clients have updated assessments and reassessments and will be reviewed by the Department Director and or Division Director quarterly. Halal home delivered meal clients assessments will be reviewed by a second staff member to ensure eligibility and verified by the Department Director and or Division Director monthly. Contact person responsible for corrective action: Joan Siavrakas, Division Director Anticipated Completion Date: 04/25/2025

View Audit 358351

Finding 564124 (2024-002)

Significant Deficiency 2024

The Benjamin Rose Institute on Aging

OH

Eligibility

Comments on the Finding and Each Recommendation – We acknowledge the finding to review our procedures around appropriate documentation for eligibility of recipients for the program. We plan to verify eligibility for all clients through income verification and include enhanced audit processes in our ...

Comments on the Finding and Each Recommendation – We acknowledge the finding to review our procedures around appropriate documentation for eligibility of recipients for the program. We plan to verify eligibility for all clients through income verification and include enhanced audit processes in our supervisory review prior to signing off of files for submission to accounts payable for processing going forward. This enhanced process includes a signoff on the check request cover sheet, implemented in April 2025, as verification of the review of the income verification being completed at the time of file review. All files in support of income verification get scanned into our Salesforce software as documentation with client files. We further plan to increase our internal audits of files to 10 a month, selecting a sample across counselors each month. This process will include a review of income verification completed within each file. Finally, we will be including an internal quality improvement monitor in our QI committee to track progress on these efforts. Actions Taken on the Finding – By taking these steps we aim to fully resolve this issue and establish a more robust and transparent process to ensure proper documentation of eligibility for the remainder of this grant.

View Audit 358229

Finding 564106 (2024-001)

Significant Deficiency 2024

Mental Health America of Dutchess County, Inc.

NY

Eligibility Significant Deficiency Matching / Level of Effort / Earmarking

The person responsible for the correcting the finding and timeline are as follows: The Director of Veterans Programs, Alyssa Carion, Due Date: May 1, 2025. Regarding finding #2024-001, all items identified have been addressed and the due date has been met. All missing program agreements noted in the...

The person responsible for the correcting the finding and timeline are as follows: The Director of Veterans Programs, Alyssa Carion, Due Date: May 1, 2025. Regarding finding #2024-001, all items identified have been addressed and the due date has been met. All missing program agreements noted in the SSG Fox audit have been loaded to participant files. Policy and procedures have been updated to state that the patient health questionnaire must be completed by a staff member and a policy for releasing program participants has been added. Tracking participants outside of the online portal is in place and includes enrollment date, disenrollment date for all clients form program inception. In addition, a monthly control is in place to review the spreadsheet o ensure all documents are included.

View Audit 358209

Finding 563860 (2024-001)

None 2024

Independent Housing I, Inc. - Independence House 023-Eh-020

MA

HUD Housing Programs Eligibility

FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT Department of Housing and Urban Development Finding 2024-001: Major Program: Section 8 Housing Assistance Payments Program, Federal Assistance Listing Number 14.195 RECOMMENDATION The auditor recommends the Project organize the archived tenant informa...

FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT Department of Housing and Urban Development Finding 2024-001: Major Program: Section 8 Housing Assistance Payments Program, Federal Assistance Listing Number 14.195 RECOMMENDATION The auditor recommends the Project organize the archived tenant information and include original information in the active tenant files. ACTION TAKEN The Project will be organizing the archived tenant information and including the original information in the active tenant files. The Project will continue to train staff on the HUD Handbook requirements for tenant files.

View Audit 358077

Finding 563814 (2024-004)

Material Weakness 2024

Waimanalo Health Center

HI

Special Tests & Provisions Eligibility Material Weakness

Health Resources and Services Administration Mary Frances Oneha, Waimanalo Health Center’s CEO respectfully submits the following corrective action plan for the year ended June 30, 2024: CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: June 30, 2024Item 2024-004 - Speci...

Health Resources and Services Administration Mary Frances Oneha, Waimanalo Health Center’s CEO respectfully submits the following corrective action plan for the year ended June 30, 2024: CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: June 30, 2024Item 2024-004 - Special Tests and Provisions (Material Weakness) During our audit, we noted that the Center did not properly determine the sliding fee discount of certain eligible patients based on information provided during the patient registration process. Recommendation We recommend that the Center conduct training of all of its personnel who are involved in determining the sliding fee scale of patients. We also recommend that an internal audit of a sample of patient charts be conducted periodically to ensure that patients' sliding fee scale discounts or category is properly and accurately determined based on information provided by patients. Finally, we recommend that such internal audit be documented. Action Taken Management agrees with the finding and will be establishing policies and procedures and conducting training for all personnel involved in determining patients' sliding fee scale to help ensure the accuracy of the process. Management will also implement an internal audit of a sample of patient charts and will ensure that such audits are properly documented. Effectivity Date: June 30, 2025

View Audit 358045

Finding 563809 (2024-003)

Significant Deficiency 2024

The Housing & Redevelopment Commission of the City of Watertown, Sd

SD

HUD Housing Programs Eligibility Reporting

Federal Agency Name: US Department of Housing and Urban Development Program Name: Section 8 Housing Choice Vouchers Federal Financial Assistance Listing Number: 14.871 Finding Summary: The commission is required to calculate the tenant's rent payment using documentation from third party verification...

Federal Agency Name: US Department of Housing and Urban Development Program Name: Section 8 Housing Choice Vouchers Federal Financial Assistance Listing Number: 14.871 Finding Summary: The commission is required to calculate the tenant's rent payment using documentation from third party verification used to calculate payment of assistance; in one of the 40 tenant files tested, the tenant's payment amounts were calculated incorrectly. Responsible Individuals: Mary Goldade, Executive Director Corrective Action Plan: Continued training and additional review of calculations by an individual not performing the original calculation will be done to ensure accurate calculations going forward. Anticipated Completion Date: June 30, 2025

View Audit 358024

Finding 563792 (2024-002)

Significant Deficiency 2024

Herzing University, Ltd.

WI

Student Financial Aid Subrecipient Monitoring Eligibility § 200.303

Audit Firm: RSM US LLP 30 S Wacker Drive, Suite 3300 Chicago, IL 60606 Audit Period: 1/1/2024 – 12/31/2024 Comments on Findings and Recommendations: Finding 2024-002 – Eligibility - Pell Finding: Herzing University did not properly award Pell funding to an eligible student in the Spring 2024 semeste...

Audit Firm: RSM US LLP 30 S Wacker Drive, Suite 3300 Chicago, IL 60606 Audit Period: 1/1/2024 – 12/31/2024 Comments on Findings and Recommendations: Finding 2024-002 – Eligibility - Pell Finding: Herzing University did not properly award Pell funding to an eligible student in the Spring 2024 semester. Condition: A student was eligible to receive Pell funding but did not receive Pell funds due to an employee error. For one out of 40 students tested for eligibility, we noted 1 student (2.5%) who was eligible to receive Pell funding but did not receive Pell funds due to an employee error. Action Taken: The identified student withdrew from the University on May 8, 2023. The student’s 2023-24 Pell award was cancelled during the required R2T4 process that was completed on May 23, 2023. The 2023-24 Pell award for the Spring 2024 semester was not manually reinstated upon the student’s return to an Active status on June 28, 2023. The employee who was responsible for updating the student’s financial aid package upon the student’s return to an Active status erroneously neglected to reinstate the 2023-24 Pell award for the Spring 2024 semester. This finding is attributed to human error. In April 2025, Herzing University created an internal compliance checkpoint for Pell awarding. This checkpoint will identify any students with a Pell eligible SAI for the Federal Award year that do not have Pell packaged for the semester. This checkpoint was completed for the Spring 2025 semester on April 7, 2025, and will be completed each semester going forward. Any affected students identified during the completion of this semester-based checkpoint will have their financial aid package revised to include Pell funding for the applicable semester, prior to the end of the semester. Herzing University’s Policy Manual was updated in April 2025 to reflect the addition of the Pell Awarding compliance checkpoint. For the identified student, Herzing University has provided a tuition waiver for the amount of the Pell funds that the student was eligible for and should have received for the Spring 2024 semester. The required corrective action for Finding 2024-002 listed in the SFA audit for the period 1/1/2024 – 12/31/2024 was completed on 5/7/2025. The person responsible for completion of the corrective action was Kevin McShane, Vice President of Financial Aid & Compliance. ____________________________________ _______________________ Kevin McShane Date Vice President of Financial Aid & Compliance Herzing University 275 W. Wisconsin Ave., Ste. 210, Milwaukee, WI 53203 Email Address: kmcshane@herzing.edu

View Audit 358003

Finding 563791 (2024-001)

Significant Deficiency 2024

Herzing University, Ltd.

WI

Student Financial Aid Subrecipient Monitoring Eligibility § 200.303

Audit Firm: RSM US LLP 30 S Wacker Drive, Suite 3300 Chicago, IL 60606 Audit Period: 1/1/2024 – 12/31/2024 Comments on Findings and Recommendations: Finding 2024-001 – Eligibility - SEOG Finding: Herzing University did not properly award SEOG funding to an eligible student in the Fall 2024 semester....

Audit Firm: RSM US LLP 30 S Wacker Drive, Suite 3300 Chicago, IL 60606 Audit Period: 1/1/2024 – 12/31/2024 Comments on Findings and Recommendations: Finding 2024-001 – Eligibility - SEOG Finding: Herzing University did not properly award SEOG funding to an eligible student in the Fall 2024 semester. Condition: A student was eligible to receive SEOG funding but did not receive SEOG funds due to an employee error. For one out of 40 students tested for eligibility, we noted 1 student (2.5%) who was eligible to receive SEOG funding but did not receive SEOG funds due to an employee error. Action Taken: On May 1, 2024, a Financial Aid Advisor manually cancelled the identified student’s 2024-25 SEOG award in Regent (Herzing University’s Financial Aid Management Software), with a notation that the student had an ineligible Student Aid Index (SAI). The student had an SAI of -117 on their 2024-25 ISIR, and in accordance with Herzing University’s FSEOG policy were eligible for 2024-25 SEOG in the Fall 2024 semester. The award was incorrectly manually canceled by the advisor because of human error. In April 2025, Herzing University created an internal compliance checkpoint for FSEOG awarding. This checkpoint will serve as a safety net to identify any students who have a Pell award for the Federal Award year, have an SAI that is FSEOG eligible according to Herzing University’s FSEOG policy, and do not correctly have FSEOG packaged for the semester. Any affected students identified during the completion of this semester-based checkpoint will have their financial aid package reviewed and if necessary revised to include FSEOG funding for the applicable semester, prior to the end of the semester. This checkpoint was completed for the Spring 2025 semester on April 4, 2025, and will be completed each semester going forward. Herzing University’s Policy Manual was updated in April 2025 to reflect the addition of the FSEOG Awarding compliance checkpoint. For the identified student, Herzing University has provided a tuition waiver for the amount of the FSEOG funds that the student was eligible for and should have received for the Fall 2024 semester. The required corrective action for Finding 2024-001 listed in the SFA audit for the period 1/1/2024 – 12/31/2024 was completed on 5/7/2025. The person responsible for completion of the corrective action was Kevin McShane, Vice President of Financial Aid & Compliance. ____________________________________ _______________________ Kevin McShane Date Vice President of Financial Aid & Compliance Herzing University 275 W. Wisconsin Ave., Ste. 210, Milwaukee, WI 53203 Email Address: kmcshane@herzing.edu

View Audit 358003

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