Corrective Action Plans

Finding 10600 (2022-019)

Material Weakness 2022

OK

Procurement, Suspension & Debarment Eligibility Material Weakness § 200.303

COVID-19 Educational Stabilization Fund: HEERF Institutional Portion – Assistance Listing No. 84.425F Recommendation: We recommend the University review internal control reports and implement review controls for work performed by third party servicers. Action taken in response to finding: The Univer...

COVID-19 Educational Stabilization Fund: HEERF Institutional Portion – Assistance Listing No. 84.425F Recommendation: We recommend the University review internal control reports and implement review controls for work performed by third party servicers. Action taken in response to finding: The University agrees with the finding and has developed the following corrective action plan. The University is utilizing Visual Compliance to assess all vendors for suspension and debarment but will obtain and document the review of the SOC 2 report for Visual Compliance annually. Name(s) of the contact person(s) responsible for corrective action: Scott Schlotthauer, Chief Procurement Officer at Oklahoma State University. Planned completion date for corrective action plan: December 2023

View Audit 14277

Finding 10563 (2022-018)

Material Weakness 2022

Langston University

OK

Student Financial Aid Eligibility Material Weakness § 200.303

Student Financial Aid Cluster: Federal Supplemental Educational Opportunity Grant – Assistance Listing No. 84.007 Federal Work Study Program – Assistance Listing No. 84.033 Federal Pell Grant Program – Assistance Listing No. 84.063 Federal Direct Student Loans – Assistance Listing No. 84.268 Recomme...

Student Financial Aid Cluster: Federal Supplemental Educational Opportunity Grant – Assistance Listing No. 84.007 Federal Work Study Program – Assistance Listing No. 84.033 Federal Pell Grant Program – Assistance Listing No. 84.063 Federal Direct Student Loans – Assistance Listing No. 84.268 Recommendation: We recommend the University review internal control reports and implement review controls for work performed by third party servicers. Action taken in response to finding: The University agrees with the finding and has developed the following corrective action plan. The University is already utilizing Visual Compliance to assess all vendors for suspension and debarment but will obtain and document the review of the SOC 2 report for Visual Compliance annually. Name(s) of the contact person(s) responsible for corrective action: Scott Schlotthauer, Chief Procurement Officer at Oklahoma State University. Planned completion date for corrective action plan: December 2023

View Audit 14277

Finding 10558 (2022-013)

Material Weakness 2022

Langston University

OK

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

Student Financial Aid Cluster: Federal Supplemental Educational Opportunity Grant – Assistance Listing No. 84.007 Federal Work Study Program – Assistance Listing No. 84.033 Federal Pell Grant Program – Assistance Listing No. 84.063 Federal Direct Student Loans – Assistance Listing No. 84.268 Recomme...

Student Financial Aid Cluster: Federal Supplemental Educational Opportunity Grant – Assistance Listing No. 84.007 Federal Work Study Program – Assistance Listing No. 84.033 Federal Pell Grant Program – Assistance Listing No. 84.063 Federal Direct Student Loans – Assistance Listing No. 84.268 Recommendation: We recommend the University evaluate its procedures around disbursements of loans and ensure that notifications of disbursements are sent and contain all of the required elements outlined in the FSA handbook. Action taken in response to finding: The University agrees with the finding and has developed the following corrective action plan. Loan disbursement procedures and processes are being updated to ensure notifications are sent as outlined in the FSA Handbook. The University will develop policies and procedures to ensure compliance with the FSA Handbook. Name(s) of the contact person(s) responsible for corrective action: Sheila McGill Executive Director, Financial Aid & Scholarships, Langston University. Planned completion date for corrective action plan: January 2024

View Audit 14277

Finding 9908 (2022-001)

Significant Deficiency 2022

Peoples Advantage Federal Credit Union

VA

Eligibility Reporting Matching / Level of Effort / Earmarking

Recommendation: Established procedures to either identify and track eligible loans deployed during the RRP grant performance period or establish a method in which to validate the analysis and data provided by Inclusiv. Views of Responsible Officials and Planned Corrective Actions: Management agre...

Recommendation: Established procedures to either identify and track eligible loans deployed during the RRP grant performance period or establish a method in which to validate the analysis and data provided by Inclusiv. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and will ensure we are able to identify eligible loans deployed in the TM in the future.

View Audit 13531

Finding 9840 (2022-027)

Material Weakness 2022

State of Illinois

IL

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

The third-party service provider has provided SOC1 reports that appear to have resolved the internal controls. The service provider will continue to provide SOC 1 reports through Fiscal Year 2024. The IDES will review to ensure that appropriate controls remain in place.

View Audit 13503

Finding 9820 (2022-019)

Material Weakness 2022

State of Illinois

IL

Questioned Costs Allowable Costs / Cost Principles Eligibility § 200.303

The DCFS is currently working with USDHHS’ Childrens’ Bureau (CB) on a Program Improvement Plan (PIP) related to Adoption Assistance subsidy payments. The PIP requires significant changes to DCFS’ policy that are still being vetted by CB and DCFS management, which will have a significant impact on ...

The DCFS is currently working with USDHHS’ Childrens’ Bureau (CB) on a Program Improvement Plan (PIP) related to Adoption Assistance subsidy payments. The PIP requires significant changes to DCFS’ policy that are still being vetted by CB and DCFS management, which will have a significant impact on how this program is carried out. As soon as the policy changes are completed, the DCFS will finalize procedures consistent with policy, the Social Security Act, and Title IV-E. These procedures will include controls to ensure payments made are appropriate per the subsidy agreements with the adoptive parents and federal requirements. In the meantime, the DCFS will be implementing the following: 1. The DCFS is revising the communication with adoptive parents reminding them of their responsibility to inform the DCFS of situational changes that could affect the subsidy agreement. 2. The DCFS is amending its adoption agreement template to more clearly define how and when an adoption subsidy can be suspended or terminated by the DCFS. 3. The DCFS’ Policy, Legal, Quality Assurance, Finance and Adoptions Administration divisions are currently reviewing all forms and policy documents to ensure they are consistent in communicating the preceding steps. The DCFS will include definitions of legal responsibly and financial support to establish the parameters of suspension or termination of subsidy payments. There has been significant progress in this area that has resulted in significant policy changes that are being finalized with assistance and input from the CB. 4. The DCFS will amend its Title IV-E plan related to adoption subsidy payments to include definitions consistent with item 3 above. 5. The DCFS will review its processes, including its information systems, to determine if information captured by permanency case workers can be data mined for review to support continued adoption subsidy payments. 6. The DCFS is creating communication procedures related to appeal decisions of termination and suspension of subsidy payments to adoptive parents to ensure they are aware of their rights to appeal and how the appeal process works.

View Audit 13503 Questioned Costs: $1

Finding 9806 (2022-016)

Material Weakness 2022

State of Illinois

IL

Questioned Costs Allowable Costs / Cost Principles Eligibility § 200.303

Adhering to the Federal Centers for Medicare and Medicaid Services (CMS) directive, effective April 1, 2023, the State resumed normal operations, including restarting full Medicaid and CHIP eligibility renewals and terminations of coverage for individuals who are no longer eligible. States can term...

Adhering to the Federal Centers for Medicare and Medicaid Services (CMS) directive, effective April 1, 2023, the State resumed normal operations, including restarting full Medicaid and CHIP eligibility renewals and terminations of coverage for individuals who are no longer eligible. States can terminate Medicaid enrollment for individuals no longer eligible. States will have up to 14 months to return to normal eligibility and enrollment operations. As of April 30, 2023, there were 5,678 medical applications 45 days or older, (2% higher than previously reported in June 2022), but still a significant reduction (96%) from a high of 147,038 at the end of January 2019. As of the same date, there were 6,789 total medical renewals on hand, a significant decrease since the last reporting (9,412 were reported for June 30, 2022.) In addition, the DHFS has established June 30, 2024, as the completion date for - (1) updating the system to force processing of a redetermination when a form is received, and a worker attempts another type of action (currently at 70% completion), and (2) developing reports for the DHFS and the Illinois Department of Human Services to identify redeterminations that have been received but not yet processed (currently at 80% completion).

View Audit 13503 Questioned Costs: $1

Finding 9760 (2022-009)

Material Weakness 2022

State of Illinois

IL

Questioned Costs Eligibility Matching / Level of Effort / Earmarking § 200.303

For future consideration of funding, the IDHS will ensure that, in addition to meeting health and safety requirements, the providers will also complete certification and attestation that verifies that they meet the requirements and eligibility of the program.

View Audit 13503 Questioned Costs: $1

Finding 9742 (2022-005)

Material Weakness 2022

State of Illinois

IL

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303

• The IDHS has logged Integrated Eligibility System (IES) enhancement request ILIES-279032 to implement Telephonic Signature for the Responsible Service Payee (RSP) signature. Since COVID, much of the IDHS’ interactions are done via telephone. As such, the RSP Signature page is mailed to customers ...

• The IDHS has logged Integrated Eligibility System (IES) enhancement request ILIES-279032 to implement Telephonic Signature for the Responsible Service Payee (RSP) signature. Since COVID, much of the IDHS’ interactions are done via telephone. As such, the RSP Signature page is mailed to customers when the updates are completed by phone. By implementing Telephonic Signature for the RSP, the IDHS will no longer have to generate correspondence to customers and have them return the signature page. • The IDHS is in the process of adding Family and Resource Center (FCRC) TANF Queues to its call center. When a customer with active TANF calls in, the caller will be routed to the local office TANF Queue. TANF workers within each FCRC will answer the calls and manage the TANF. This will improve the IDHS’ tracking and follow-up with TANF customers. • Communication will be made with regional administrators regarding the 04/25/2023 Action Memo “Uploading the Responsibility and Service Plan Signature Page into the Electronic Case Record.”

View Audit 13503 Questioned Costs: $1

Finding 9518 (2022-002)

Significant Deficiency 2022

Jefferson County Housing Authority

AL

HUD Housing Programs Eligibility Significant Deficiency

FINDINGS—FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Housing and Urban Development 2022-002-Eligibility Public Housing - Assistance Listing No. 14.850 Recommendation: We recommend management should designate one person to review a sample of the files that have been recertified each month, to de...

FINDINGS—FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Housing and Urban Development 2022-002-Eligibility Public Housing - Assistance Listing No. 14.850 Recommendation: We recommend management should designate one person to review a sample of the files that have been recertified each month, to determine if the tenant files were prepared in accordance with internal policies and until the compliance deficiencies have been corrected. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Public Housing Property Managers will sample a percentage of monthly recertifications to ensure that tenant files contain the necessary updated HUD forms. Name(s) of the contact person(s) responsible for corrective action: Hannah Gore, ED and Public Housing Property Managers Planned completion date for corrective action plan: December 31, 2023 If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call the Executive Director at (205) 244-1348

View Audit 13164

Finding 9211 (2022-001)

Significant Deficiency 2022

Metro Community Health Centers, Inc.

NY

Eligibility

The desired outcome of this corrective action plan is to retrain all staff working with the MCHC sliding fee discount scale and to have consistent and reliable application of the MCHC sliding fee discount scale to all eligible patients. Corrective Actions MCHC will implement a sliding fee discount ...

The desired outcome of this corrective action plan is to retrain all staff working with the MCHC sliding fee discount scale and to have consistent and reliable application of the MCHC sliding fee discount scale to all eligible patients. Corrective Actions MCHC will implement a sliding fee discount schedule retraining program and engage all front desk staff, health center directors, and billing staff. Training will encompass all aspects of the sliding fee discount scale including but not limited to how individuals register, attest and apply the MCHC sliding fee discount scale. Retraining will be provided on a semiannual basis and include mock tests. This training program will be under the direct supervision of the Chief Operating Officer. All MCHC staff will be refamiliarized with the MCHC policy and procedures that relate to the Sliding Fee Discount Scale as part of the retraining process and will continue to review the Sliding fee discount program policy and procedure on an annual basis. The MCHC Sliding Fee Discount Scale and associated policy and procedure will be updated annually in accordance with policy, and we will ensure that the slide is provided to staff annually. A dedicated staff will be identified and assigned to do spot check reviews of the application of the sliding fee discount scale monthly and this will be implemented immediately. MCHC will provide an annual presentation on the Sliding Fee Discount Scale program to the MCHC Board of Directors that included annual updates to the program. The MCHC policies and procedures related to the Sliding Fee Discount Scale program will be revised to ensure inclusion of the above changes. Goal - Metro Community Health Center is committed to ensuring that we are compliant with all regulations as they relate to the Sliding Fee Discount Program. MCHC’s commitment moving forward is to perform more regular trainings as it relates to the sliding fee discount program as well as more regular review and testing of the program to ensure that the policies that are written are being appropriately applied and administered.

View Audit 12576

Finding 8718 (2022-005)

Material Weakness 2022

Cardiovascular Center Corporation of Puerto Rico and the Caribbean

PR

Questioned Costs Eligibility Subrecipient Monitoring

Finding No. 2022-005 - Activities Allowed or Unallowed, Eligible Uses - Premium Pay Condition During our examination, we noted three (3) instances, which based on the regulation previously indicated, the premium pay was paid to employees whose wages are higher than 150 percent of the Puerto Rico ...

Finding No. 2022-005 - Activities Allowed or Unallowed, Eligible Uses - Premium Pay Condition During our examination, we noted three (3) instances, which based on the regulation previously indicated, the premium pay was paid to employees whose wages are higher than 150 percent of the Puerto Rico median annual wage of $30,750. Corporation response The Corporation agrees with the finding. Corrective Action Plan Upon receipt of the audit findings, we initiated an immediate review of our premium pay practices and expendih1re related to the American Rescue Plan Act, Public 117-2 ("ARP") We are implementing quick corrective actions to address the identified deficiencies and ensure compliance with allowable uses for future activities as outlined in the ARP Act. The Corporation will establish a communication with the Health Department of Puerto Rico to obtain instructions for the correction of this non-compliance event and questioned cost appointed by external auditors. Names of the contact persons responsible for corrective action plan Jesus A. Rodriguez Aviles - Financial Planning and Analysis Associate Director Cecilia Robles Kakiuchi - Financial Planning and Analysis Director Anticipated Completion Date Fiscal Year 2024

View Audit 11856 Questioned Costs: $1

Finding 8705 (2022-003)

Material Weakness 2022

Dakota County

MN

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

2022-003 – TEMPORARY ASSISTANCE FOR NEEDY FAMILIES – ELIGIBILITY U.S. Department of Health and Human Services Temporary Assistance for Needy Families Assistance Listing Number: 93.558 Passed Through Minnesota Department of Human Services Pass Through Number: H55214077 Award Period: 2022 Recommen...

2022-003 – TEMPORARY ASSISTANCE FOR NEEDY FAMILIES – ELIGIBILITY U.S. Department of Health and Human Services Temporary Assistance for Needy Families Assistance Listing Number: 93.558 Passed Through Minnesota Department of Human Services Pass Through Number: H55214077 Award Period: 2022 Recommendation: We recommend the County implement process and procedures to provide reasonable assurance that all necessary documentation to support eligibility determination exists and is properly input or updated in MAXIS and issues are followed up in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The County will ensure processes and procedures are in place to properly document and support eligibility determination, properly input and update MAXIS, and properly resolve issues promptly. Periodic review of case files will be included in the annual internal audit work plan. Name of the contact person responsible for corrective action: Tiffinie Miller-Sammons, Deputy Director Planned completion date for corrective action plan: December 31, 2023

View Audit 11849

Finding 8698 (2022-004)

Material Weakness 2022

Dakota County

MN

Eligibility Material Weakness Reporting § 200.303

2022-004 – SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM CLUSTER – SPECIAL PROVISIONS U.S. Department of Agriculture Supplemental Nutrition Assistance Program Cluster Assistance Listing Number: 10.561 Passed Through Minnesota Department of Human Services Pass Through Number: H55210010 Award Period: 20...

2022-004 – SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM CLUSTER – SPECIAL PROVISIONS U.S. Department of Agriculture Supplemental Nutrition Assistance Program Cluster Assistance Listing Number: 10.561 Passed Through Minnesota Department of Human Services Pass Through Number: H55210010 Award Period: 2022 Recommendation: We recommend the County implement process and procedures to provide reasonable assurance that all necessary documentation to support eligibility determination exists and is properly input or updated in MAXIS and issues are followed up in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The County will ensure processes and procedures are in place to properly document and support eligibility determination, properly input and update MAXIS, and properly resolve issues promptly. Periodic review of case files will be included in the annual internal audit work plan. Name of the contact person responsible for corrective action: Daren Nyquist, Administration Manager Planned completion date for corrective action plan: December 31, 2023

View Audit 11849

Finding 8641 (2022-005)

Significant Deficiency 2022

Kandiyohi County

MN

Eligibility Reporting Significant Deficiency

2022.005 CASEFILE REVIEW Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Recommendation: It is recommended the County perform internal casefile reviews of Medical Assistance Casefiles. Action taken in response to finding: The County will continue to w...

2022.005 CASEFILE REVIEW Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Recommendation: It is recommended the County perform internal casefile reviews of Medical Assistance Casefiles. Action taken in response to finding: The County will continue to work at this area and internal controls to achieve the overall goal. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2023

View Audit 11795

Finding 8366 (2022-002)

None 2022

Ferry County

WA

Questioned Costs Allowable Costs / Cost Principles Eligibility

The County will establish procedures to verify eligibility of program costs by requiring proof of eligibility be attached to grant fund expense vouchers when submitted to the auditor’s office for processing.

View Audit 11191 Questioned Costs: $1

Finding 7971 (2022-002)

Significant Deficiency 2022

Clay County

MN

Eligibility Significant Deficiency Internal Control / Segregation of Duties § 200.303

Finding Number: 2022-002 Finding Title: Eligibility Program: Temporary Assistance for Needy Families (AL No. 93.558) Name of Contact Person Responsible for Corrective Action: Rhonda Porter, Director and Karen Syverson, Supervisor Corrective Action Planned: All five cases found to have errors are bei...

Finding Number: 2022-002 Finding Title: Eligibility Program: Temporary Assistance for Needy Families (AL No. 93.558) Name of Contact Person Responsible for Corrective Action: Rhonda Porter, Director and Karen Syverson, Supervisor Corrective Action Planned: All five cases found to have errors are being reviewed and will be corrected as appropriate. All case errors will be reviewed with staff who are involved in administering this program. Case file reviews will continue to occur, and any errors found will continue to be reviewed with staff and training provided. Anticipated Completion Date: The five cases found in error will be corrected by December 31, 2023. Family Team will review these errors on Dec. 14, 2023. Case file reviews will continue monthly.

View Audit 10394

Finding 7857 (2022-002)

Significant Deficiency 2022

Care Housing Inc.

CO

Eligibility Significant Deficiency Internal Control / Segregation of Duties

U.S. Department of Housing and Urban Development CFDA # 14.239 HOME Investment Partnerships Program Applicable Federal Award Number and Year – 2022 Eligibility Significant Deficiency in Internal Control over Compliance Finding Summary: The Organization does not retain documentation that supports the...

U.S. Department of Housing and Urban Development CFDA # 14.239 HOME Investment Partnerships Program Applicable Federal Award Number and Year – 2022 Eligibility Significant Deficiency in Internal Control over Compliance Finding Summary: The Organization does not retain documentation that supports the internal controls in place over the review of the annual certifications for the HOME units. Responsible Individuals: Steve Kuehneman, Executive Director and Jacki Kurchinski, Director of Property Management and Operations Corrective Action Plan: Management agrees with the finding. The Organization added steps to the annual certification process to document the approval of the annual certifications of HOME units. Anticipated Completion Date: 2024

View Audit 10232

Finding 7790 (2022-001)

Significant Deficiency 2022

Golden Harvest Food Bank, Inc.

GA

Eligibility Subrecipient Monitoring Significant Deficiency

Finding 2022-001 ...

Finding 2022-001 Mercy Church was a new agency in 2022 and signed all agreements July 20, 2022. The annual mandatory Recertification training for all agencies occurs at the end of July and the first of August each year. Therefore, there is an approximate six-week period before the new fiscal year begins October 1. Following recertification, all agencies are activated in CERES for the new year and as a result, Mercy Church was also activated and placed their first order in September shortly before the new fiscal year began. They have been compliant ever since, it was just a matter of timing. Our Community Impact team will ensure that new agencies that are brought on prior to the fiscal year are not activated in our systems until the new fiscal year begins to prevent this in the future. All agencies are trained and monitored for federal compliance on a regular basis. Person responsible: Amy Breitmann...10/1/23 completion date

View Audit 10130

Finding 7604 (2022-004)

Significant Deficiency 2022

Jefferson Parish

LA

HUD Housing Programs Procurement, Suspension & Debarment Subrecipient Monitoring

The Housing Services Development District (HSDD) had previously been attempting to reconstruct, where feasible, the client files received from the previous management contractor. We have continued on this effort in an attempt to eliminate the audit finding moving forward. It should be noted, that fi...

The Housing Services Development District (HSDD) had previously been attempting to reconstruct, where feasible, the client files received from the previous management contractor. We have continued on this effort in an attempt to eliminate the audit finding moving forward. It should be noted, that files effected under the HSDD Management did not contain this deficiency. As such, audit files selected for the 2023 audit year will contain all relevant monitoring documentation.

View Audit 9942

Finding 7380 (2022-005)

Significant Deficiency 2022

Change, Inc.

MN

Eligibility Significant Deficiency

We have developed an internal auditing process that includes a staff member external to the participant files reviews to ensure all participant eligibility forms are signed.

View Audit 9524

Finding 6966 (2022-005)

Significant Deficiency 2022

Fredericksburg Area Health and Support Services, Inc.

VA

Eligibility Subrecipient Monitoring

Finding: The Organization had contradicting support for the income eligibility documentation for two clients. All documentation supported the conclusion that the client was eligible based on their income, however the lack of consistent evidence results in the conclusion that proper review and appro...

Finding: The Organization had contradicting support for the income eligibility documentation for two clients. All documentation supported the conclusion that the client was eligible based on their income, however the lack of consistent evidence results in the conclusion that proper review and approval of this documentation is not occurring. Corrective Action Taken or Planned: An Eligibility and Retention Specialist was hired March 10, 2023, whose sole responsibilities pertain to eligibility. Name of Contact Person: Jacob Ducey, Grants Manager Phone Number of Contact Person: (540) 907-4555 Projected Completion Date: October 31, 2023

View Audit 9001

Finding 6842 (2022-003)

Material Weakness 2022

Community Health and Emergency Services, Inc.

IL

Internal Control / Segregation of Duties Special Tests & Provisions Eligibility

FINDING NO. 2022-003: Ineffective Internal Controls over Sliding Fee Revenues Condition: During the compliance testing of the Uniform Guidance “Special Tests and Provisions – Sliding Fee Applications” requirements, we noted the following exceptions: • Three (3) out of thirty-four (34) were miss...

FINDING NO. 2022-003: Ineffective Internal Controls over Sliding Fee Revenues Condition: During the compliance testing of the Uniform Guidance “Special Tests and Provisions – Sliding Fee Applications” requirements, we noted the following exceptions: • Three (3) out of thirty-four (34) were missing applications. • Fourteen (14) out of thirty-four (34) sliding fee adjustments were calculated incorrectly based on the sliding fee schedule. • One (1) out of thirty-four (34) sliding fee adjustments were not properly applied to the patient’s account. Plan: CHESI has implemented a new workflow process to ensure compliance with the program requirements of the sliding fee program. CHESI has developed a new sliding fee procedure and trained all staff to ensure the applications are complete and signed by the patient, income is verified, the proper discount is calculated based on the sliding fee schedule, the proper amount of discount is applied to the patient’s account, and the application is approved and signed by the Billing Manager. All sliding fee applications will also be scanned into the patient’s chart once completed and approved. Anticipated Date of Completion: December 31, 2023 Name of Contact Person: Kanci Houston, CEO

View Audit 8765

Finding 5959 (2022-117)

Material Weakness 2022

State of Arizona

AZ

Student Financial Aid Eligibility Internal Control / Segregation of Duties

Assistance listing number and program name: 93.658 Foster Care – Title IV-E Agency: Department of Child Safety Name of contact person and title: Tanya Abdellatif, Assistant Director Anticipated completion date: June 30, 2025 Agency’s Response: Concur Department will ensure background checks for ch...

Assistance listing number and program name: 93.658 Foster Care – Title IV-E Agency: Department of Child Safety Name of contact person and title: Tanya Abdellatif, Assistant Director Anticipated completion date: June 30, 2025 Agency’s Response: Concur Department will ensure background checks for childcare institutions’ employees are completed prior to their hire date by: • Reviewing and amending DCS 15-32 Background Checks – Child Welfare Agency Staff policy and procedures to clarify that Child Welfare Agencies shall request and receive results for DCS Central Registry background checks prior to employment/date of hire. • Revising the Personnel File Monitoring Tool for licensing to include language that background checks need to be completed prior to hire and ensure all Child Welfare Licensing staff are utilizing the updated checklist. • Implementing, as part of the Quarterly Site Visit Process for childcare institutions, a process to review backgrounds checks to identify opportunities for improvement, trends and establish actions (countermeasures) to resolve any areas of concern. Hiring processes for each agency will also be reviewed during the quarterly site visits. • Providing updates related to policies and procedures during Quarterly Provider Meetings for childcare institutions, implementing monthly provider calls/meetings and conducting monthly unit/team meetings for Department. • Presenting the safety requirement expectations related to background checks for employees to childcare institutions and how the safety requirements are necessary for foster care maintenance payments at a quarterly meeting. • Conducting monthly monitoring of childcare institutions’ compliance with safety requirement expectations (background checks) for new and existing employees for fiscal year 2023.

View Audit 7884

Finding 5930 (2022-126)

Significant Deficiency 2022

State of Arizona

AZ

Questioned Costs Student Financial Aid Eligibility § 200.303

Assistance listing number and program name: 84.425E COVID-19 Education Stabilization Fund—Higher Education Emergency Relief Fund (HEERF)—Student Portion Student Financial Assistance Cluster 84.007 Federal Supplemental Educational Opportunity Grants 84.033 Federal Work-Study 84.038 Federal Perkins L...

Assistance listing number and program name: 84.425E COVID-19 Education Stabilization Fund—Higher Education Emergency Relief Fund (HEERF)—Student Portion Student Financial Assistance Cluster 84.007 Federal Supplemental Educational Opportunity Grants 84.033 Federal Work-Study 84.038 Federal Perkins Loan Program—Federal Capital Contributions 84.063 Federal Pell Grant Programs 84.268 Federal Direct Student Loans 84.379 Teacher Education Assistance for College and Higher Education Grants (TEACH Grants) 93.364 Nursing Student Loans 93.925 Scholarships for Health Professions Students from Disadvantaged Backgrounds—Scholarships for Disadvantaged Students (SDS) Agency: Northern Arizona University (NAA) Name of contact person and title: Bradley Miner, Interim Associate Vice President and Comptroller Anticipated completion date: November 30, 2023 Agency’s Response: Concur See University response section at the end of this report for the corrective action response for finding 2022-126.

View Audit 7884 Questioned Costs: $1

Corrective Action Plans

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