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Corrective Action Plans

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Finding 1177004 (2025-003)
Material Weakness 2025
Linton-Stockton School Corporation
IN
School Nutrition Programs Internal Control / Segregation of Duties Eligibility § 200.303
FINDING 2025-003 Finding Subject: Child Nutrition Cluster - Eligibility Contact Person Responsible for Corrective Action: Katie Elliott Contact Phone Number and Email Address: 812-847-6020 ext. 1007 katieelliott@lssc.k12.in.us Views of Responsible Officials: We concur with the finding. Description o...
FINDING 2025-003 Finding Subject: Child Nutrition Cluster - Eligibility Contact Person Responsible for Corrective Action: Katie Elliott Contact Phone Number and Email Address: 812-847-6020 ext. 1007 katieelliott@lssc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Eligibility - Income guidelines will be entered by the Director of Food Services and reviewed by the Director of School Finance to ensure accuracy. Review by the Director of School Finance will be noted on the July monthly checklist completed by the Director of School Finance. Direct certification - The direct certification process will be completed on a weekly basis by the Director of Food Services and will be reviewed and signed off via email by the Director of School Finance. Review of Applications - The Food Service Management provider reviews and approves or denies online applications. The applications are printed monthly and maintained in the office of the Director of Food Service. The Director of Food Service will review a sample of applications each month to verify proper approvals and denials. The Director of Food Service will provide verified applications to the Director of School Finance for review. Anticipated Completion Date: This Corrective Action Plan will be put in effect February 2026.
View Audit 390850
Finding 1176993 (2025-001)
Material Weakness 2025
Plumas Corporation
CA
Procurement, Suspension & Debarment Eligibility
The Organization will develop a policy and procedures to ensure that it complies with the requirements of 2 CFR Part 180, Subpart C.
The Organization will develop a policy and procedures to ensure that it complies with the requirements of 2 CFR Part 180, Subpart C.
View Audit 390830
Finding 1176837 (2025-001)
Material Weakness 2025
San Joaquin Delta Community College District
CA
Student Financial Aid Subrecipient Monitoring Eligibility
Views of Responsible Officials and Corrective Action Plan We concur. The Financial Aid Office and IT have Implemented a “Just-In-Time” eligibility verification in MyDelta. Additional manual reconciliation before disbursement has also been implemented.
Views of Responsible Officials and Corrective Action Plan We concur. The Financial Aid Office and IT have Implemented a “Just-In-Time” eligibility verification in MyDelta. Additional manual reconciliation before disbursement has also been implemented.
View Audit 390685
Finding 1176825 (2025-002)
Material Weakness 2025
Silver Creek School Corporation
IN
School Nutrition Programs Internal Control / Segregation of Duties Eligibility § 200.303
FINDING 2025-002 Finding Subject: Subject: Child Nutrition Cluster - Eligibility Contact Person Responsible for Corrective Action: Josh Sinclair, Food Service Director and Allison Vanover, Corporation Treasurer. Contact Phone Number 812-246-3375 Email Address: jsinclair@scsc.school avanover@scsc.sch...
FINDING 2025-002 Finding Subject: Subject: Child Nutrition Cluster - Eligibility Contact Person Responsible for Corrective Action: Josh Sinclair, Food Service Director and Allison Vanover, Corporation Treasurer. Contact Phone Number 812-246-3375 Email Address: jsinclair@scsc.school avanover@scsc.school Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Food Service Director will collaborate with the IT Department to verify the accuracy of income parameters and Direct Certification eligibility data within Infinite Campus. A representative sample of student records will be tested to confirm that the uploaded information was processed correctly and aligns with supporting documentation. Any discrepancies identified will be corrected promptly, and procedures will be reinforced to ensure ongoing accuracy and compliance. Anticipated Completion Date: January 2026
View Audit 390679
Finding 1176718 (2025-002)
Material Weakness 2025
Pensdale Housing, Inc.
CA
Subrecipient Monitoring Eligibility HUD Housing Programs
Comments on the Finding and Each Recommendation The Property received a NSPIRE inspection dated August 1, 2024. The inspection resulted in a score of 59 (out of a possible 100). Scores below 60 are referred to the Departmental Enforcement Center. Management must maintain the Property in decent, safe...
Comments on the Finding and Each Recommendation The Property received a NSPIRE inspection dated August 1, 2024. The inspection resulted in a score of 59 (out of a possible 100). Scores below 60 are referred to the Departmental Enforcement Center. Management must maintain the Property in decent, safe, and sanitary condition and good repair. Management must respond to HUD in three days of receiving the inspection report and confirm all lifethreatening deficiencies have been corrected. Action(s) taken or planned on the finding Management and the Board of Directors concur with the finding and the auditor's recommendations. Management has responded to HUD in regard to this inspection report and on July 8, 2025 another inspection was conducted that resulted in a final score of 95 (out of a possible 100).
View Audit 390616
Finding 1176680 (2025-001)
Material Weakness 2025
La Casa De Felicidad Housing Development Fund Corporation
NY
HUD Housing Programs Eligibility
Management has addressed the issue by recertifying the tenant and does not expect late recertifications or income verification to occur again.
Management has addressed the issue by recertifying the tenant and does not expect late recertifications or income verification to occur again.
View Audit 390549
Finding 1176634 (2025-001)
Material Weakness 2025
University of Kentucky
KY
Eligibility HUD Housing Programs
On November 4, 2025, UK HealthCare (UKHC) Information Technology implemented a system configuration change within Epic related to the NFV Sliding Scale settings. This change restricts the application of Federal Poverty Level (FPL) discounts to accounts with a status of “Approved for Financial Assist...
On November 4, 2025, UK HealthCare (UKHC) Information Technology implemented a system configuration change within Epic related to the NFV Sliding Scale settings. This change restricts the application of Federal Poverty Level (FPL) discounts to accounts with a status of “Approved for Financial Assistance,” thereby preventing discounts from being applied to accounts that have not been formally approved. In addition, on December 8, 2025, a new status option— “Did Not Apply for FA”—was added to the status field within the FPL table in Epic. This option is to be selected when patients do not apply for financial assistance, ensuring that status fields are never left incomplete or blank. NFVCHC staff were notified of this update and instructed to consistently complete this step. Planned Process Improvements:NFVCH leadership will conduct a comprehensive review of the NFV and JB clinic policies and procedures related to Financial Assistance Program (FAP) eligibility determination and reevaluation. This review will ensure that: FAP documentation does not include overlapping coverage periods Effective and termination dates are properly validated Internal processes align with system requirements and safeguard against data inconsistencies Ongoing Monitoring / Sustainability Plan: To strengthen oversight and ensure longterm control effectiveness, UKHC Enterprise Revenue Cycle will incorporate into its monthly audit procedures the following reviews: A report identifying accounts with blank or incomplete status entries on the Federal Poverty Level table A review of overlapping FPL coverage dates Monitoring for patients who have both UK and NFV Charity Care, ensuring the correct NFV FPL table is applied for NFVCH accounts This continuous monitoring will ensure system controls operate as designed and that corrective actions remain effective over time. Responsible Party: Larry Quillen – Executive Director, NFVCH Anne Wray - ERC Revenue Assurance Director/UKHC Target Completion Date: Completed on November 4, 2025, with additional enhancements on December 9, 2025
View Audit 390491
Finding 1176600 (2025-001)
Material Weakness 2025
Triton Regional School District
MA
Eligibility School Nutrition Programs Significant Deficiency § 200.437
Corrective Action Plan Finding 2025-001 Condition: A journal entry was tested during the compliance audit that reclassified $50,000 of employee health costs to the school lunch fund that did not include any documentation of the costs charged to the school lunch fund and how they were allocated. Corr...
Corrective Action Plan Finding 2025-001 Condition: A journal entry was tested during the compliance audit that reclassified $50,000 of employee health costs to the school lunch fund that did not include any documentation of the costs charged to the school lunch fund and how they were allocated. Corrective Action Planned: Effective July 1, 2025, the District began to implement a structured and documented cost allocation process for employee healthcare expenses attributable to the Food Services Department. Beginning in FY26: • Charges will be processed monthly to ensure transparency, consistency, and proper budget tracking. Anticipated Completion Date: Ongoing Contact: Richard Poor, Director of Finance & Operations
View Audit 390416
Finding 1176593 (2025-002)
Material Weakness 2025
Sabin Group 1 Hud Project No. 101-Hh003-Np-Cmi-L8
CO
HUD Housing Programs Subrecipient Monitoring Eligibility
February 25, 2026 CORRECTIVE ACTION PLAN FISCAL YEAR OF FINDING: June 30, 2025 AUDITOR FINDING: 2025-002 – AL# 14.157 Supportive Housing for the Elderly (Section 202) Area: Eligibility In accordance with 24 CFR section 891.410, section 5.230, and OMB No. 2502-0204, owner shall re-examine tenant elig...
February 25, 2026 CORRECTIVE ACTION PLAN FISCAL YEAR OF FINDING: June 30, 2025 AUDITOR FINDING: 2025-002 – AL# 14.157 Supportive Housing for the Elderly (Section 202) Area: Eligibility In accordance with 24 CFR section 891.410, section 5.230, and OMB No. 2502-0204, owner shall re-examine tenant eligibility at least every 12 months with respect to family income, composition and is required to obtain signed consent forms from assistance applicants. In accordance with HUD Multifamily Occupancy Handbook, Chapter 7, annual certification should be completed and submitted through TRACS within 15 months from previous year’s anniversary date. Based on testing performed recertifications did not occur within the required time period. It is recommended to add monitoring controls to help ensure recertifications are completed in accordance with 24 CFR section 891-410, section 5.230, and OMB No. 2502-0204. CLIENT PLANNED ACTION: (1) Annual recertification report will be reviewed monthly with ComCap Management to ensure timely completion of all recertifications. Demands will be given to tenants if recertifications are not completed within 60 days of initial notification. (2) Monthly dashboards will continue to be produced and reviewed with ComCap Management. The monthly dashboards include annual recertifications, occupancy/vacancy, and move-in/move-outs. CLIENT RESPONSIBLE PARTY: Darla Goddard, Director of Real Estate COMPLETION DATE: 01/01/2026
View Audit 390410
Finding 1176580 (2025-004)
Material Weakness 2025
McDowell County
NC
Eligibility Internal Control / Segregation of Duties Reporting
McDowell County Corrective Action Plan For the Year Ended June 30, 2025 Finding 2025-003 Late Submission of Data Collection Form Name of contact person: Corrective Action: Proposed Completion Date: Finding 2025-004 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed Comp...
McDowell County Corrective Action Plan For the Year Ended June 30, 2025 Finding 2025-003 Late Submission of Data Collection Form Name of contact person: Corrective Action: Proposed Completion Date: Finding 2025-004 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed Completion Date: Corrective Actions for Findings 2025-004 also apply to State requirements and State Awards. Lynn Freeman, Medicaid Program Manager We will provide refresher trainings on household composition, electronic income/resource matches, Request for information requirements, and timely recertifications, with weekly sessions on new policy changes. Medicaid management will collaborate with upper management on solutions to enhance quality control capacity and address staffing constraints. This will include the backlog from the Hurricane Helene-related statewide recertification pause by prioritizing workload distribution. Monthly reviews will continue to be conducted to meet state-mandated requirements, with continued focus on strengthening controls. All required trainings will be completed by November 30, 2025. Section IV - State Award Findings and Question Costs Alison Bell, Finance Officer The 2024 audit report was delayed due to the County's audit firm experiencing a significant cybersecurity incident between October 2024 and February 2025; fieldwork had been completed in October however the financials could not be finished timely and subsequently the data collection was filed late. The audit firm has accepted full responsibility for the delay and informed the County that they would not longer provided audit services to counties. McDowell County issued requests for proposals to all firms qualified to perform county audits for fiscal year 2025 and intends to submit their data collection timely moving forward. June 30, 2026 Section III - Federal Award Findings and Question Costs 161
View Audit 390382
Finding 1176533 (2025-015)
Material Weakness 2025
State of West Virginia
WV
Allowable Costs / Cost Principles Eligibility § 200.303 § 200.403
2025-015 ALLOWABLE COSTS/COST PRINCIPLES, ELIGIBILITY DEPARTMENT OF HEALTH & HUMAN SERVICES (DOHHS) Assistance Listing Number: 93.658 DOHHS’s corrective action plan from the prior audit indicated that a system change was made during FY 2025 to prevent future payments to psychiatric facilities from b...
2025-015 ALLOWABLE COSTS/COST PRINCIPLES, ELIGIBILITY DEPARTMENT OF HEALTH & HUMAN SERVICES (DOHHS) Assistance Listing Number: 93.658 DOHHS’s corrective action plan from the prior audit indicated that a system change was made during FY 2025 to prevent future payments to psychiatric facilities from being charged to the Foster Care program. This change did go into effect on September 19, 2024. However, this provider was an anomaly. The facility was a Residential Treatment Facility which was Title IV-E eligible until they received Psychiatric Residential Treatment Facility (PRTF) status in August of 2024, however, they did not provide DOHHS documentation until February 2025. Immediate action was taken by a call ticket to the Technical Call Center to ensure that the PRTF was not continuing to show as IV-E eligible. The staff from the Division of Regulatory Management will continue, as part of their annual licensing review will ensure wvPATH provider records are updated to reflect timely licensing status as well as ensuring that child specific agreements do not lapse. The previously stated Corrective Action Plan remains in place and will continue.
View Audit 390319
Finding 1176531 (2025-014)
Material Weakness 2025
State of West Virginia
WV
Special Tests & Provisions Subrecipient Monitoring Eligibility
2024-014 SPECIAL TESTS AND PROVISIONS - HEALTH AND SAFETY REQUIREMENTS DEPARTMENT OF HUMAN SERVICES (DOHS) Assistance Listing Number: 93.575/93.596 The Quality Assurance specialists have established a plan of action for each Regulation Unit (Child Care Licensing Unit and Family Child Care Unit) to m...
2024-014 SPECIAL TESTS AND PROVISIONS - HEALTH AND SAFETY REQUIREMENTS DEPARTMENT OF HUMAN SERVICES (DOHS) Assistance Listing Number: 93.575/93.596 The Quality Assurance specialists have established a plan of action for each Regulation Unit (Child Care Licensing Unit and Family Child Care Unit) to maintain continual monitoring of conducted Annual Unannounced Monitoring Visits required under 45 CFR §98.42(b)(2)(i)(B). Within the tracking spreadsheet, detailed information is input from our documentation system PATH COGNOS Report PCC-PLI 1080. Information includes Provider Name, Provider Number, Provider Type, Specialist Name, and columns for visits conducted and visits not yet conducted. To provide an overall year-to-date calculation of monthly totals/percentages, a Yearly Summary tab is included in the spreadsheet for a quick reference analysis to provide an additional method of tracking visits. As the monthly totals and percentages change, the data updates on the monthly tabs and the Yearly Summary tab. Program Managers have implemented individual efforts to track visits conducted by specialists. The PCC-PLI 1080 report is distributed twice per month by PM II to each Program Manager for review. Specialists have been instructed to include completed annual unannounced monitoring visits on monthly report data, which can then be compared with the PCC-PLI-1080 reports. Additionally, a tracking system has been implemented that requires specialists to pre-plan annual unannounced visits for the 2026 calendar year to ensure visits are completed.
View Audit 390319
Finding 1176526 (2025-022)
Material Weakness 2025
State of West Virginia
WV
Eligibility Special Tests & Provisions Material Weakness § 200.303
2025-022 SPECIAL TESTS AND PROVISIONS – INCOME ELIGIBILITY AND VERIFICATION SYSTEM DEPARTMENT OF HUMAN SERVICES (DOHS) Assistance Listing Number: 93.558 Effective April 1, 2026, the Department of Human Services’ Bureau for Family Assistance will implement a series of mandatory training and policy en...
2025-022 SPECIAL TESTS AND PROVISIONS – INCOME ELIGIBILITY AND VERIFICATION SYSTEM DEPARTMENT OF HUMAN SERVICES (DOHS) Assistance Listing Number: 93.558 Effective April 1, 2026, the Department of Human Services’ Bureau for Family Assistance will implement a series of mandatory training and policy enhancements designed to bolster compliance and documentation standards for all WV WORKS workers. The primary focus of these updates is the rigorous handling of data matches; specifically, workers must complete a Blackboard course on Single Agency Audits that emphasizes the necessity of documenting all Income and Eligibility Verification System (IEVS) matches. To support this at the foundational level, an IEVS case comments exercise has been integrated into the third week of the standard training curriculum. Monitoring and quality control will also enhance Rushmore Review protocols. Supervisors are now required to perform three Rushmore Reviews per month, while the WV WORKS policy team will continue their own reviews to track systemic trends. Furthermore, the Division of Performance and Quality Improvement (DPQI) will now include specific compliance checks for data match completion within their monthly review of 18 cases. To ensure staff are well-equipped for these changes, the Division of Professional Development has released a suite of resources, including procedural Desk Guides and supplementary YouTube training videos. Supervisors are required to present them during monthly unit meetings. To finalize the process, every worker must provide a formal sign-off to confirm they have received and understood the updated procedures regarding data exchanges. 85
View Audit 390319
Finding 1176502 (2025-019)
Material Weakness 2025
State of West Virginia
WV
Procurement, Suspension & Debarment Subrecipient Monitoring Eligibility § 200.214 § 200.303
2025-019 SUSPENSION AND DEBARMENT HIGHER EDUCATION POLICY COMMISSION Assistance Listing Number: 47.076 This finding was previously identified during the FY 2024 audit. Since the original finding, HEPC has addressed and resolved this issue by strengthening its internal controls and procedures. On Mar...
2025-019 SUSPENSION AND DEBARMENT HIGHER EDUCATION POLICY COMMISSION Assistance Listing Number: 47.076 This finding was previously identified during the FY 2024 audit. Since the original finding, HEPC has addressed and resolved this issue by strengthening its internal controls and procedures. On March 31, 2025, HEPC updated policies and procedures that established and maintain effective control over federal awards. The update established a threshold for identifying covered transactions and provides clear guidance on conducting suspension and debarment searches in SAM.gov for those transactions. The update also provided additional steps for documentation required to assess whether a vendor is excluded or disqualified if not in SAM.gov. The instances noted in this finding happened before the corrective action plan was implemented. Management believes the updated processes and procedures are effective.
View Audit 390319
Finding 1176485 (2025-003)
Material Weakness 2025
Claflin University
SC
Student Financial Aid Eligibility
The University acknowledges the Pell Grant under award identified during the audit. University officials have developed the following corrective actions to ensure correct calculation of Pell Grant awards in accordance with 34 CFR §690.75. To correct the underlying problem, Financial Aid staff will w...
The University acknowledges the Pell Grant under award identified during the audit. University officials have developed the following corrective actions to ensure correct calculation of Pell Grant awards in accordance with 34 CFR §690.75. To correct the underlying problem, Financial Aid staff will work directly with Power FAIDS support to identify the specific cause(s) of the miscalculation of Pell Grant awarding. The University will also enhance staff competency through targeted training on the Pell Grant calculation methodology. All training activities will be documented and maintained in office records as part of the University’s compliance documentation. Additionally, the University will develop and revise internal policies and procedures related to Pell Grants to ensure consistency, accuracy, and adherence to federal regulations. These updated procedures will guide staff in the correct application of Pell rules and system processes. Further, to ensure ongoing compliance, the University will implement monitoring and quality‑assurance measures. These measures will include the conduct of monthly internal audits by an internal reviewer within Financial Aid to ensure Pell award accuracy. Monitoring results will be reviewed by the Director of Financial Aid and reported to the Vice President for Enrollment Management for oversight and accountability. Finally, these officials will ensure that the financial aid software used by the University is properly configured and maintained to address and prevent future awarding issues.
View Audit 390298
Finding 1176359 (2025-001)
Material Weakness 2025
City of Sterling Heights, Michigan
MI
Subrecipient Monitoring Allowable Costs / Cost Principles Eligibility
2025-001 – Federal Funding Accountability and Transparency Act (FFATA) Reporting Auditor Description of Criteria, Condition, and Effect: Under the requirements of the Federal Funding Accountability and Transparency Act, direct recipients of grants or cooperative agreements are required to report fir...
2025-001 – Federal Funding Accountability and Transparency Act (FFATA) Reporting Auditor Description of Criteria, Condition, and Effect: Under the requirements of the Federal Funding Accountability and Transparency Act, direct recipients of grants or cooperative agreements are required to report first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS). Direct recipients must report key data elements by registering through the FSRS and reporting subaward data through that system. Direct recipients that are awarded a federal grant are required to file a FFATA sub-award report by the end of the month following the month in which the prime awardee awards any sub-grant equal to or greater than $30,000. The City did not submit the required key data elements through the FSRS reporting system as required by the Uniform Guidance and as a result has not completed the appropriate sub-award reporting that is required for direct recipients. Auditor Recommendation: We recommend that the City review its procedures for FFATA reporting through FSRS and ensure that all key data elements are reported timely moving forward. Corrective Action: Upon discovery of the issue in November 2025, City staff corrected the noncompliance by submitting the required report to the appropriate reporting system/entity. To prevent recurrence, management has strengthened internal controls over FFATA reporting and Single Audit preparation by (1) adding review and verification steps, (2) communicating expectations with key personnel, and (3) explicitly assigning submission responsibility to a designated submitter who is independent of the individual(s) responsible for monitoring compliance. These control enhancements are expected to identify and prevent similar deficiencies and, based on implementation to date, appear to be operating effectively. Responsible Person: Jason Denton, Controller Anticipated Completion Date: June 30, 2026
View Audit 390179
Finding 1176226 (2025-003)
Material Weakness 2025
School District of Cadott Community
WI
School Nutrition Programs Allowable Costs / Cost Principles Eligibility
2025-003: Internal Control over Eligibility – Child Nutrition Cluster Corrective Action: Acknowledging the lack of controls within the Child Nutrition program's eligibility process, the District has determined that hiring additional staff to resolve this internal control deficiency is not a cost-eff...
2025-003: Internal Control over Eligibility – Child Nutrition Cluster Corrective Action: Acknowledging the lack of controls within the Child Nutrition program's eligibility process, the District has determined that hiring additional staff to resolve this internal control deficiency is not a cost-effective solution. Consequently, the Food Service Director and the Finance Director share the responsibility of reviewing student eligibility forms. Responsible Person: Danielle Mittermeyer Anticipated Completion Date: Ongoing
View Audit 390107
Finding 1176201 (2025-002)
Material Weakness 2025
Chowan County, North Carolina
NC
Eligibility Significant Deficiency Internal Control / Segregation of Duties
Corrective Action: Trainings, Policy, and Procedures are being developed for all Medicaid caseworkers to follow. Medicaid workers will need to make sure they are working the SSI Termination report to eliminate any future paybacks. Also, a training on SSI Termination / Ex Parte will be conducted with...
Corrective Action: Trainings, Policy, and Procedures are being developed for all Medicaid caseworkers to follow. Medicaid workers will need to make sure they are working the SSI Termination report to eliminate any future paybacks. Also, a training on SSI Termination / Ex Parte will be conducted with all Medicaid workers, including NC Fast Learning Gateway Training “Supplemental Security Income (SSI) Course”. Proposed Completion Date: June 30, 2026. Certain controls are currently being created and reviewed. Management will continue to monitor the progress of this issues and modify the controls as needed.
View Audit 390062
Finding 1176200 (2025-001)
Material Weakness 2025
Chowan County, North Carolina
NC
Eligibility Significant Deficiency
Corrective Action: Trainings, Policy, and Procedures are being developed for all Medicaid caseworkers to follow. Medicaid workers will need to make sure they are working the SSI Termination report to eliminate any future paybacks. Also, a training on SSI Termination / Ex Parte will be conducted with...
Corrective Action: Trainings, Policy, and Procedures are being developed for all Medicaid caseworkers to follow. Medicaid workers will need to make sure they are working the SSI Termination report to eliminate any future paybacks. Also, a training on SSI Termination / Ex Parte will be conducted with all Medicaid workers, including NC Fast Learning Gateway Training “Supplemental Security Income (SSI) Course”. Proposed Completion Date: June 30, 2026. Certain controls are currently being created and reviewed. Management will continue to monitor the progress of this issues and modify the controls as needed.
View Audit 390062
Finding 1175958 (2025-001)
Material Weakness 2025
Maniilaq Association
AK
Eligibility Significant Deficiency
Finding 2025-001 Eligibility - Noncompliance and Significant Deficiency in Internal Control Over Compliance Planned Corrective Actions: Historical documentation on patient eligibility for IHS beneficiary status residing in paper financial files (in use at the time of roll and scroll registration) wi...
Finding 2025-001 Eligibility - Noncompliance and Significant Deficiency in Internal Control Over Compliance Planned Corrective Actions: Historical documentation on patient eligibility for IHS beneficiary status residing in paper financial files (in use at the time of roll and scroll registration) will be scanned in the BMW registration system making them a permanent part of the patients’ electronic health record. Registration staff is requesting beneficiary identification at the time of registration for all patients that do not have it in their EHR. Project is ongoing. Monthly audits of the elements of registration, including documentation of beneficiary status will be conducted to ensure continual compliance. Individual(s) Responsible for Corrective Action Plan Kandy Barlow VP of Health Services 907-442-7385 Anticipated Completion Date: March 31, 2026
View Audit 389937
Finding 1175824 (2025-002)
Material Weakness 2025
City of Staunton, Virginia
VA
Eligibility
We agree with this comment. Starting with fiscal year 2026, we will ensure that eligibility forms include signature or initials of the preparer, and documentation of review by the supervisor, regardless of whether or not the state form has a second line for the supervisor approval.
We agree with this comment. Starting with fiscal year 2026, we will ensure that eligibility forms include signature or initials of the preparer, and documentation of review by the supervisor, regardless of whether or not the state form has a second line for the supervisor approval.
View Audit 389776
Finding 1175820 (2025-001)
Material Weakness 2025
First Choice Health Centers, Inc.
NY
Special Tests & Provisions Subrecipient Monitoring Eligibility
The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Repeat Finding No Action Taken Management has implemented enhanced internal controls to ensure sliding fee discounts are accuratel...
The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Repeat Finding No Action Taken Management has implemented enhanced internal controls to ensure sliding fee discounts are accurately calculated and fully supported. The Center standardized income verification procedures, reinforced documentation requirements for family size and income, and updated its sliding fee eligibility checklist to ensure consistency. Supervisory review protocols were established to verify proper calculation and supporting documentation prior to approval. Additionally, staff received refresher training on sliding fee policy requirements to promote ongoing compliance. Management will conduct periodic internal audits to monitor adherence and ensure continued effectiveness of these controls. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Sean Murphy, CFO at 860-610-6387.
View Audit 389772
Finding 1175771 (2025-007)
Material Weakness 2025
Big Springs Medical Association D/b/a Missouri Highlands Health Care
MO
Eligibility Internal Control / Segregation of Duties
2025-007: Medication assistance was provided to a patient who was not eligible to receive assistance on the date of service due to active insurance coverage for the prescription. The Organization’s eligibility procedures were not supported by a formal policy or consistently followed as written. Addi...
2025-007: Medication assistance was provided to a patient who was not eligible to receive assistance on the date of service due to active insurance coverage for the prescription. The Organization’s eligibility procedures were not supported by a formal policy or consistently followed as written. Additionally, the Procedure for Medication Financial Assistance provides Community Health Workers and other staff significant discretion in making eligibility determinations. This flexibility and subjective process, while intended to reduce barriers to patients obtaining opioid use disorder treatments, increases the risk for inconsistent and inappropriate eligibility determinations. Responsible Persons: Karen R. White, CPA, Chief Executive Officer and Matthew Derryberry, Chief Financial Officer Completion Date: May 2026 Views of responsible officials and planned corrective actions: Issues identified during the audit were indicative of an overall lack of controls and processes by grant directors and Finance Department staff. The Organization has reviewed the processes and has developed a formalized policy for medication assistance eligibility determinations, clearly identifying grant requirements for eligibility. Additionally, the procedure associated with the policy identifies the need for secondary review of eligibility determinations and clear communication to the Finance Department along with adequate record keeping. The Organization’s CEO, a former CFO of the organization, will continue to provide oversight for the Finance Department to ensure controls and processes are implemented.
View Audit 389688
Finding 1175763 (2025-004)
Material Weakness 2025
Briar Cliff University
IA
Eligibility Student Financial Aid Matching / Level of Effort / Earmarking
Management’s Response: The University has undertaken several initiatives to enhance compliance and accuracy: Management acknowledges the material weakness related to the awarding and disbursement of TEACH Grants and recognizes the importance of ensuring that grant eligibility is verified in accordan...
Management’s Response: The University has undertaken several initiatives to enhance compliance and accuracy: Management acknowledges the material weakness related to the awarding and disbursement of TEACH Grants and recognizes the importance of ensuring that grant eligibility is verified in accordance with federal regulations prior to disbursement. During fiscal year 2025, an eligibility determination error was identified for one student. Subsequent to year-end, the University returned the related TEACH Grant funds to the U.S. Department of Education through the G5 system. Management has taken corrective actions to strengthen eligibility verification and prevent recurrence. Corrective actions implemented include: • Strengthened Leadership and Oversight: A new Financial Aid Director was hired in March 2025 and has prioritized the development and enforcement of appropriate controls over TEACH Grant awarding and disbursement. • Revised Policies and Procedures: TEACH Grant awarding and disbursement procedures were reviewed and updated to ensure alignment with federal eligibility requirements. • Improved Eligibility Documentation: The TEACH Grant application was enhanced to clearly document all required eligibility criteria and support consistent eligibility determinations. • Secondary Review Controls: A secondary review and approval process has been implemented to ensure that TEACH Grant eligibility is independently verified prior to awarding and disbursement. • Enhanced Tracking and Monitoring: Additional tracking mechanisms were implemented to confirm that eligibility requirements are met and documented before funds are applied to student accounts. • Ongoing Compliance Monitoring: The Financial Aid Office continues to monitor TEACH Grant activity to ensure continued compliance with program requirements. Management believes these actions have significantly strengthened internal controls over TEACH Grant awarding and disbursement. Continued application of these procedures is expected to prevent recurrence and support full compliance in future audit periods. These initiatives demonstrate the University’s commitment to maintaining accurate student enrollment records and ensuring compliance with federal regulations, thereby safeguarding the interests of its students and the institution.
View Audit 389674
Finding 1175758 (2025-001)
Material Weakness 2025
Chandler Unified School District No. 80
AZ
School Nutrition Programs Student Financial Aid Allowable Costs / Cost Principles
While the District maintained the requisite supporting documentation, limitations arising from the internal record retention policies in place at the time, coupled with the retirement of key personnel, resulted in certain enrollment records not being readily locatable. The District acknowledges that...
While the District maintained the requisite supporting documentation, limitations arising from the internal record retention policies in place at the time, coupled with the retirement of key personnel, resulted in certain enrollment records not being readily locatable. The District acknowledges that these factors limited the availability of prior-year supporting data. This issue has since been addressed through updated retention practices to ensure that this does not occur going forward. Beginning with the next fiscal year cycle, the District has implemented a documented procedure that specifies the data sources, query parameters, and data pull dates; requires that all supporting extracts and calculations be retained in a centralized, version-controlled folder; and establishes a formal review and approval process to verify that enrollment and low-income counts reconcile to source documentation before submission to ADE. Staff in Federal Programs and Finance have been trained on the new procedure, and an annual internal review has been established to confirm compliance. The Director of Finance and the Director of Federal Programs are responsible for implementing and monitoring this corrective action, which will be completed prior to the next Title I eligibility submission.
View Audit 389666
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