Corrective Action Plans

Finding 1160270 (2025-001)

Material Weakness 2025

The Episcopal Theological Seminary of the Southwest

TX

Questioned Costs Student Financial Aid Eligibility

Corrective Action Plan (CAP for Finding 2025-001) Date: 2 October 2025 Responsible official: Frederick L. Clement, Executive Vice President Management has corrected the finding by taking the following action: First, the institution entered into a professional services agreement with Higher Education...

Corrective Action Plan (CAP for Finding 2025-001) Date: 2 October 2025 Responsible official: Frederick L. Clement, Executive Vice President Management has corrected the finding by taking the following action: First, the institution entered into a professional services agreement with Higher Education Assistance Group to provide a comprehensive business process review of its financial aid operations. The objective of this review is to improve upon the functionality of processes, internal controls, and systems to ensure regulatory compliance and the effectiveness of service deliverables to students receiving financial aid. This review will include updates to policies, procedures, and internal controls for the import and export of electronic records, document tracking and file review, packaging and awarding, satisfactory academic progress, disbursement and reconciliation, withdrawal and Return to Title IV. Workflow and gap analysis will be performed to ensure intraoffice Title IV program compliance and best practices. Second, the institution has entered into a professional services agreement with Higher Education Assistance Group to provide interim staffing and third-party federal student aid processing including, but not limited to, counseling students and families on financial aid options, assisting with the management of Federal Direct Loan and Federal Graduate PLUS Loan programs to include student eligibility, file review, awarding, and origination and disbursement authorization using Populi, COD and other Department of Education software. In addition, Higher Education Assistance Group will provide additional Title IV training for personnel involved in federal student aid processing. With more than 35 years of experience, Higher Education Assistance Group and its team of seasoned consultants, all of whom have worked in federal student aid administration, whether in public/private colleges and universities or for the Department of Education itself, specializes in the compliant administration of Title IV student financial aid programs. The institution will adopt a supplemental internal control to cross-check student eligibility for Direct PLUS loans to ensure that an over-award is not originated and disbursed. Anticipated completion date: November 15, 2025

View Audit 370654 Questioned Costs: $1

Finding 1160151 (2025-001)

Material Weakness 2025

Burkesville Manor, Inc.

KY

Eligibility HUD Housing Programs

Management agrees with the finding. As of September 26, 2025, the Project has implemented a revised tenant intake checklist at the main office that includes mandatory verification of age eligibility. All tenant files are being reviewed for compliance, and staff have been retrained on eligibility req...

Management agrees with the finding. As of September 26, 2025, the Project has implemented a revised tenant intake checklist at the main office that includes mandatory verification of age eligibility. All tenant files are being reviewed for compliance, and staff have been retrained on eligibility requirements.

View Audit 370535

Finding 1159684 (2025-001)

Material Weakness 2025

Virginia Garcia Medical Health Center

OR

Internal Control / Segregation of Duties Special Tests & Provisions Subrecipient Monitoring

Summary of finding: Five out of 40 charts reviewed by the auditors’ showed exceptions to the Sliding Fee Discount Schedule (SFDS) that are not supported by policy or documentation. Findings were identified in three primary categories: inconsistent collection and scanning of documents at registration...

Summary of finding: Five out of 40 charts reviewed by the auditors’ showed exceptions to the Sliding Fee Discount Schedule (SFDS) that are not supported by policy or documentation. Findings were identified in three primary categories: inconsistent collection and scanning of documents at registration, Electronic Health Records (EHR) not operating as expected for one line of the SFDS and error not caught and corrected, and a significant process change from percentage to fixed fee SFDS causing inconsistent application during transition and training period. Planned corrective action: System Configuration:  Leaders for all service lines and Billing Department will work with EHR Support Team and vendor to review and test all possible SFDS options to verify rules are functioning as expected and as outlined in the SFDS policy.  Annual review and testing of EHR rules governing SFDS to validate ongoing compliance. Contact person: Jennifer Velez, Revenue Cycle Director Completion date for action: 10/31/2025 Staff Training and Documentation:  All staff responsible for registration and income verification in all service lines, programs, and sites will receive a review of income eligibility assessment, documentation, and application.  Registration Program Manager and EHR Trainers will work with Learning and Development Department to develop competency standard for income eligibility assessment, documentation, and application for all staff responsible for registration and income verification in all service lines, programs, and sites. All identified staff will be required to demonstrate competence annually using the Learning Management System (LMS).  The Center will audit 5 patient records for FPL (Federal Poverty Level) documentation per site or program two times annually during C-Qual (the Center’s internal audit process). This will result in 180 charts each year.  Site Managers or Department Administrators will review front office dashboard in monthly management meetings and develop site specific action plans if exceptions are identified. This was added to the standing agenda for the Primary Care Clinic Managers (PCCM) meeting in September 2025. Contact person: Angela Hurley, Director of Operations Completion date for action: 12/31/2025 Implementation Controls:  Update SFDS policy to include review and verification of EHR alignment with fee schedule following any update or change approved by the Board of Directors.  Develop checklist for roll-out of changes in SFDS that prompts change management and training team to review readiness and validation procedures before going live with changes. Contact person: Angela Hurley, Director of Operations Completion date for action: 9/30/2025

View Audit 370272

Finding 1159455 (2025-001)

Material Weakness 2025

Great Falls Housing Authority

MT

HUD Housing Programs Eligibility Significant Deficiency

Finding 2025-001- Public Housing Internal Control over Waiting List - Eligibility Noncompliance and Significant Deficiency Low Rent Public Housing - Subsidy ALN 14.850 Corrective Action Plan: The Great Falls Housing Authority printed out waiting lists on the date of the audit finding. We will keep n...

Finding 2025-001- Public Housing Internal Control over Waiting List - Eligibility Noncompliance and Significant Deficiency Low Rent Public Housing - Subsidy ALN 14.850 Corrective Action Plan: The Great Falls Housing Authority printed out waiting lists on the date of the audit finding. We will keep notes on the list and at periodic times when adding or deleting applicants we will maintain all lists in a binder for historical review. Person Responsible: Donna Halbleib, Program Supervisor Anticipated Completion Date: Already implemented and will be continuously kept - March 31, 2026

View Audit 370192

Finding 1157136 (2025-001)

Material Weakness 2025

Community Health Centers of Burlington, Inc.

VT

Special Tests & Provisions Eligibility Internal Control / Segregation of Duties

Response to FY2025 Audit Finding: Impact: "Lack of policy enforcement may have resulted in the Organization providing discounted services greater to or less than the appropriate amounts to beneficiaries" Why: 1. Were staff not consistently collecting the required income and family size documentation...

Response to FY2025 Audit Finding: Impact: "Lack of policy enforcement may have resulted in the Organization providing discounted services greater to or less than the appropriate amounts to beneficiaries" Why: 1. Were staff not consistently collecting the required income and family size documentation? 2. Was training not comprehensive enough or did staff turnover lead to a knowledge gap? 3. Is the Organizations policy or process for documenting income unclear or not consistently enforced? 4. Was there a system in place to audit patient files internally to catch documentation errors? 5. Is the culture of compliance not strong enough to prioritize consistent documentation? Action: 1. Update/Revise sliding fee policy and procedure to clearly define acceptable documentation process for income verification and annual re-evaluation 2. Create and deliver comprehensive training to all relevant staff (front desk, enrollment specialist, and billing) 3. Implement ongoing monitoring – • Establish a new scheduled internal audit process to regularly review a sample of patient documentation for sliding fee documentation compliance. • Establish metrics to track progress, such as percentage of patient files with complete sliding fee documentation, for new and annual sliding fee applications. 4. Once all actions are complete and the issue is resolved, document these improvements to continue the cycle of compliance 5. Continue to audit files at random to ensure documentation compliance continues

View Audit 369470

Finding 1155821 (2025-001)

Material Weakness 2025

Gooding Senior Housing Association INC

ID

Reporting Matching / Level of Effort / Earmarking Procurement, Suspension & Debarment § 200.512

Finding 2025-001 Federal assistance listing number and name: 10.415 Rural Rent Housing Loans Awards numbers and years: 2025 Federal agency: United States Department of Agriculture Compliance Requirement: Activities allowed or unallowed, allowable costs/ cash management, eligibility, equipment, perio...

Finding 2025-001 Federal assistance listing number and name: 10.415 Rural Rent Housing Loans Awards numbers and years: 2025 Federal agency: United States Department of Agriculture Compliance Requirement: Activities allowed or unallowed, allowable costs/ cash management, eligibility, equipment, period of performance, procurement, program income, reporting, special tests Questioned Costs: None Name of contact person and title: Pat Bishop, President Condition and Context: The auditee did not submit the required audit reports to the Federal Audit Clearinghouse (FAC) and Rural Development (RD) in a timely manner. Specifically:  The 2023 Audit Report was not submitted to the FAC as required under 2 CFR Part 200, Subpart F.  The 2024 Audit Report was submitted past the regulatory deadline to both the FAC and RD. Management Response: Management plans to develop and implement an internal audit compliance calendar with clearly defined submission deadlines for all audit-related deliverables, including due dates for the FAC and RD and Create an internal checklist and sign-off process to confirm that each audit deliverable has been submitted to all required agencies and portals. Status: In progress Anticipated Completion Date: Estimated 2025

View Audit 368214

Finding 1154962 (2025-004)

Material Weakness 2025

Miami-Cass County Rural Electric Membership Corporation

IN

Questioned Costs Eligibility

Management of Miami-Cass REMC and Subsidiary will implement procedures to prevent unallowable costs. In addition, the State of Indiana Office of Community and Rural Affairs will be alerted of the questioned costs. Management agrees with this finding.

View Audit 367301 Questioned Costs: $1

Finding 1153310 (2025-002)

Material Weakness 2025

Mountain Famly Health Centers

CO

Questioned Costs Subrecipient Monitoring Eligibility

Condition –The Organization determines the sliding fee discount charged to the patients based on their annual gross income and household size. During our testing of sliding fee discounts, we found two encounters where the patients were charged incorrect copays. Recommendation – The Organization shou...

Condition –The Organization determines the sliding fee discount charged to the patients based on their annual gross income and household size. During our testing of sliding fee discounts, we found two encounters where the patients were charged incorrect copays. Recommendation – The Organization should strengthen processes surrounding the monitoring of the program to ensure the Organization’s policies are consistently and properly applied. Views of Responsible Officials and Planned Corrective Actions – Management agrees with the finding. The Organization has developed a plan for addressing this issue that includes updated procedures, training, and auditing. All teams engaged in the patient collection, enrollment, and eligibility process will be retrained on the process with emphasis on proper documentation and provide feedback and retraining as necessary to staff as needed. Anticipated Date of Completion – By October 31, 2025. Action Taken – Management has scheduled time at front desk/billing meetings to retrain staff on processes that ensure appropriate sliding fee rates are utilized for each sliding fee encounter. Specifically, training will focus on encounters with both an office visit and lab are properly identified so that the lab co-pay is adjusted appropriately. Person Responsible for Corrective Action Plan – Steven Leazer, Chief Financial Officer.

View Audit 366550 Questioned Costs: $1

Finding 575330 (2025-001)

Significant Deficiency 2025

United Methodist Western Kansas Mexican American Ministries Inc. D/b/a Genesis Family Health

KS

Special Tests & Provisions Subrecipient Monitoring Eligibility

Corrective Action Plan Year Ended April 30, 2025 To Health Resources and Services Administration United Methodist Western Kansas Mexican-American Ministries, Inc. d/b/a Genesis Family Health respectfully submits the following corrective action plan for the year ended April 30, 2025. CohnReznick LLP ...

Corrective Action Plan Year Ended April 30, 2025 To Health Resources and Services Administration United Methodist Western Kansas Mexican-American Ministries, Inc. d/b/a Genesis Family Health respectfully submits the following corrective action plan for the year ended April 30, 2025. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: April 30, 2025 The findings from the April 30, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Financial Statement Findings: Finding 2025.001 - Sliding Fee Scale Documentation Recommendation The Organization 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. Action Taken GFH implemented an O&E Department (Onboarding and Enrollment) July 2023. This has been a timely process, but it has been implemented across all clinic sites. The purpose of this department is to ensure all required documentation is current, accurate, scanned in chart and applied to patients EMR. This process includes current registration, slide application, POIs, IDs and insurance verification for coverage. All patients are required to complete an onboarding and enrollment appointment to ensure required information is added to the patient’s account and the sliding fee discount is accurately applied. The slide application with the incorrect discount was completed on 06/27/2023 and the patient returned to the clinic for a follow-up appointment on 6/17/2024 (10 days prior to the annual O&E update appointment). All other accounts audited were after the O&E implementation in July 2023 and no errors or deficiencies were identified. Additionally, Genesis Family Health has implemented a mandatory annual review process for all staff with electronic acknowledgement of the staff member's understanding of the Sliding Fee Discount Policy. If there are any questions regarding this plan, please contact Amanda Vaughan at: Amanda.Vaughan@genesisfh.org Sincerely, Amanda Vaughan (electronically signed 7/31/2025) Amanda Vaughan - Chief Financial Officer

View Audit 365383

Finding 572002 (2025-002)

Material Weakness 2025

Homes for Laurel Ii, INC

MD

Eligibility HUD Housing Programs

Recommendation Management should enhance and strengthen procedures to ensure tenant income certifications are completed within 90 days of the tenant being entered into the HUD TRACS system. Finding Resolution Status: Resolved Views of Responsible Officials Management agrees with the finding and reco...

Recommendation Management should enhance and strengthen procedures to ensure tenant income certifications are completed within 90 days of the tenant being entered into the HUD TRACS system. Finding Resolution Status: Resolved Views of Responsible Officials Management agrees with the finding and recommendation and will ensure timely income verifications going forward.

View Audit 363099

Finding 569930 (2025-001)

Material Weakness 2025

Maplewood Housing for the Elderly Corporation

DE

Eligibility HUD Housing Programs

Management concurs with the findings and had already commenced corrective actions prior to the issuance of this report. These actions were initiated to address deficiencies resulting from the inadequate performance of the former property manager, who resigned from the position. Additionally, a new p...

Management concurs with the findings and had already commenced corrective actions prior to the issuance of this report. These actions were initiated to address deficiencies resulting from the inadequate performance of the former property manager, who resigned from the position. Additionally, a new property manager has been hired to ensure compliance with established procedures and to oversee the continued implementation of corrective measures.

View Audit 361171

Finding 565965 (2025-002)

Significant Deficiency 2025

The Young Men's Christian Association of the Capital District

NY

Procurement, Suspension & Debarment Eligibility § 200.214

The Capital District YMCA reviewed the vendor used for our project when the auditors brought this to our attention and we did not find any suspension or disbarment information. We will incorporate this vendor review into our process for all programs or activities related to Federal contracts. This w...

The Capital District YMCA reviewed the vendor used for our project when the auditors brought this to our attention and we did not find any suspension or disbarment information. We will incorporate this vendor review into our process for all programs or activities related to Federal contracts. This will be done in conjunction with the procurement policy and be in place by July 31, 2025. The SVP/CFO Mary Maziejka will be responsible for development and implementation of the policy.

View Audit 359622

Finding 1225260 (2024-005)

Material Weakness 2024

Compañia de Turismo de Puerto Rico

PR

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Eligibility

Responsibility for Suspension and Debarment compliance has been formally assigned to the Legal Affairs Division. The Legal Affairs Division is responsible for performing and documenting reviews of contractor eligibility, including verification through SAM and other applicable federal sources, prior ...

Responsibility for Suspension and Debarment compliance has been formally assigned to the Legal Affairs Division. The Legal Affairs Division is responsible for performing and documenting reviews of contractor eligibility, including verification through SAM and other applicable federal sources, prior to contract execution and when otherwise required by federal regulations.

View Audit 408295

Finding 1224757 (2024-004)

Material Weakness 2024

Scott County School District 2

IN

School Nutrition Programs Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303

FINDING 2024-004 Finding Subject: Child Nutrition Cluster – Internal Controls Contact Person Responsible for Corrective Action: Superintendent and Food Service Director Contact Phone Number and Email Address: Kyle Neukam; 812-752-8921; kneukam@scsd2.k12.in.us Tammy Mosier; 812-752-8921; tmosier@scsd...

FINDING 2024-004 Finding Subject: Child Nutrition Cluster – Internal Controls Contact Person Responsible for Corrective Action: Superintendent and Food Service Director Contact Phone Number and Email Address: Kyle Neukam; 812-752-8921; kneukam@scsd2.k12.in.us Tammy Mosier; 812-752-8921; tmosier@scsd2.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: A new Food Service Director has been appointed and the District partnered with OPAA! Food Management to provide oversight and compliance support. Invoice review procedures ensure pricing accuracy and compliance with contracts. Risk assessment and monitoring procedures have been implemented to ensure ongoing compliance. Scott County School District 2 now participates in the Community Eligibility Provision (CEP) for its school nutrition programs. Under CEP, individual household applications for free and reduced-price meal eligibility are no longer collected or processed. As a result, the eligibility determination procedures that were the subject of finding are no longer applicable. Therefore, no further action is warranted regarding this compliance requirement. The School Corporation has implemented procedures designed to strengthen the control environment, improve risk assessment and information and communication processes, enhance control activities, and provide ongoing monitoring to ensure compliance with Child Nutrition Program requirements and timely identification and correction of deficiencies. Anticipated Completion Date: August 2026

View Audit 407972

Finding 1224529 (2024-004)

Material Weakness 2024

Harvest Homes Corporation 094-Hd005-Np-Cmi

ND

Internal Control / Segregation of Duties Subrecipient Monitoring Eligibility

Contact Person – Terry Hanson, Executive Director Corrective Action Plan – The Project will review its policies and procedures over documentation of periodic review of tenant files. Completion Date – 12/31/26

View Audit 407778

Finding 1224332 (2024-005)

Material Weakness 2024

Juel Fairbanks Chemical Dependency Services

MN

Eligibility

Finance policy and procedure manual was updated with recommendations. See attached.

View Audit 407643

Finding 1223787 (2024-007)

Material Weakness 2024

Wilkin County

MN

Eligibility Material Weakness Internal Control / Segregation of Duties § 200.303

Finding Number: 2024-007 Finding Title: Eligibility – MAXIS Program: 93.778 Grants to States for Medicaid Name of Contact Person Responsible for Corrective Action: Cindy Noetzelman Corrective Action Planned: Cases have been corrected and there was a discussion with staff on the process and the need ...

Finding Number: 2024-007 Finding Title: Eligibility – MAXIS Program: 93.778 Grants to States for Medicaid Name of Contact Person Responsible for Corrective Action: Cindy Noetzelman Corrective Action Planned: Cases have been corrected and there was a discussion with staff on the process and the need for correct entries. We will continue to review at monthly staffing meetings to ensure correct procedures continue to be followed. Anticipated Completion Date: Cases have been corrected as of Dec 31, 2025

View Audit 407264

Finding 1223694 (2024-002)

Material Weakness 2024

145 SO. 3RD STREET HOUSING DEVELOPMENT FUND CORPORATION

NY

HUD Housing Programs Eligibility

Management has implemented the following corrective actions to address the deficiencies noted in tenant file maintenance and eligibility determinations: A. Strengthening Recertification Compliance 1. Implementation of a Recertification Tracking System: a. A digital tracking log will be used to monit...

Management has implemented the following corrective actions to address the deficiencies noted in tenant file maintenance and eligibility determinations: A. Strengthening Recertification Compliance 1. Implementation of a Recertification Tracking System: a. A digital tracking log will be used to monitor upcoming recertifications with alerts at 90, 60, and 30 days before due dates. b. The Senior Housing Specialist will oversee timely completion and issue weekly progress reports to the Director of Asset Management. c. Non-compliant files will be flagged for immediate follow-up with tenants. d. PMCS, a third-party group, will assist with recertifications. 2. Enforcing Timely Recertifications: a. Recertifications must be completed no later than 30 days before expiration. b. Staff will receive monthly reminders, and escalation measures will be implemented for delays. 3. Quarterly Internal Audits: a. PMCS and internal staff will conduct random file audits every three months to ensure adherence. b. Deficiencies will be addressed in real-time, and corrective steps will be logged. B. Ensuring EIV System Compliance 1. Standardizing EIV Compliance Procedures: a. A formal checklist will be created for EIV report reviews, ensuring all required reports are generated before lease renewals. b. EIV data will be cross-referenced with tenant files every quarter to ensure completeness. 2. Internal Monthly EIV Reviews: a. The Senior Housing Specialist will generate and review EIV reports on the 1st of each month. b. The Director of Asset Management, Third-Party Compliance Officer (PMCS), and Senior Housing Specialist will verify compliance before reports are finalized. 3. Quarterly Compliance Reports: a. The Compliance Officer will submit a quarterly compliance report documenting completion rates and deficiencies. C. Enhancing Staff Training and Accountability 1. Mandatory Quarterly Training: a. Staff will undergo quarterly compliance training covering HUD Handbook 4350.3, recertifications, and EIV compliance. b. Training sessions will be documented, and staff performance assessed. 2. Clarification of Responsibilities: a. Staff roles will be clearly outlined in a Standard Operating Procedure (SOP) document. b. Staff will be required to acknowledge their roles in compliance processes. 3. PMCS Involvement for Training Support: a. PMCS will offer supplementary training sessions as needed. D. Documentation and Oversight Enhancements 1. Maintaining Complete and Auditable Files: a. All lease and EIV documentation will be stored both physically and digitally. b. A real-time compliance dashboard will track completion rates. 2. Routine Management Reviews: a. The Senior Housing Specialist and Director of Asset Management will conduct monthly spot checks to verify document accuracy and completion. b. Non-compliance will result in formal corrective actions.

View Audit 407198

Finding 1223448 (2024-100)

Material Weakness 2024

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Special Tests & Provisions Subrecipient Monitoring Eligibility § 200.303

To address these challenges and strengthen program integrity, DHS implemented the Provider Enrollment Application (PEA) Portal on March 2, 2026. The PEA Portal modernizes provider enrollment and revalidation by electronically collecting, storing, and maintaining required documentation in a centraliz...

To address these challenges and strengthen program integrity, DHS implemented the Provider Enrollment Application (PEA) Portal on March 2, 2026. The PEA Portal modernizes provider enrollment and revalidation by electronically collecting, storing, and maintaining required documentation in a centralized system. The portal supports retention of Medicaid Provider Agreements, screening documentation, ownership disclosures, licensure information, and other enrollment records within a single electronic repository. The PEA Portal improves document retention and accessibility, creates an electronic audit trail, and enables staff to retrieve enrollment and screening records more efficiently. It also strengthens oversight by standardizing enrollment workflows, reducing reliance on paper files, and improving documentation consistency. These enhancements better position DHS to demonstrate compliance during future audits and monitoring reviews. DHS recognizes the importance of maintaining complete, accurate, and accessible provider enrollment records. In addition to implementing the PEA Portal, DHS is strengthening policies and procedures related to provider file maintenance, document retention, and quality assurance reviews. Staff training and periodic monitoring will help ensure required enrollment documents and exclusion screening records are consistently maintained and available for inspection. DHS is committed to maintaining compliance with federal Medicaid and CHIP provider enrollment requirements and believes the corrective actions implemented, including deployment of the PEA Portal, will improve documentation controls, strengthen program integrity, and reduce the risk of similar findings in the future.

View Audit 406809

Finding 1223447 (2024-099)

Material Weakness 2024

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Special Tests & Provisions Subrecipient Monitoring Eligibility § 200.303

During the audit period, the Department did not complete the required ADP Risk Analysis and System Security Review for systems supporting the Medicaid Program, and certain monitoring controls were not operating at a sufficient level of precision to ensure compliance with federal requirements. To add...

During the audit period, the Department did not complete the required ADP Risk Analysis and System Security Review for systems supporting the Medicaid Program, and certain monitoring controls were not operating at a sufficient level of precision to ensure compliance with federal requirements. To address this finding, the Department recently issued Requests for Qualifications (RFQs) to seven qualified vendors to perform comprehensive security risk assessments of the Medicaid Enterprise Systems (MES), including the VIBES Eligibility and Enrollment System, Provider Enrollment Application (PEA), Pharmacy Benefit Management (PBM) solution, and related supporting systems. Vendor responses are due within three weeks, after which the Department will evaluate submissions and proceed with the procurement process. The selected vendor will conduct the required risk assessments, identify control deficiencies and security vulnerabilities, and provide recommendations to strengthen the Department's security posture and compliance framework. The Department will work collaboratively with its technology partners, system vendors, and oversight entities to implement corrective actions identified through the assessments and enhance monitoring controls to ensure ongoing compliance with applicable federal requirements.

View Audit 406809

Finding 1223443 (2024-095)

Material Weakness 2024

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Internal Control / Segregation of Duties Eligibility Reporting § 200.303

Conversion from VIMS to VIBES allowed system generated ex parte extensions beyond 12 months without requiring updated member contact or documentation. No process was in place to proactively require updated documentation when extensions exceeded one year, resulting in eligibility continuing without c...

Conversion from VIMS to VIBES allowed system generated ex parte extensions beyond 12 months without requiring updated member contact or documentation. No process was in place to proactively require updated documentation when extensions exceeded one year, resulting in eligibility continuing without current proof in file. DHS will: 1. Implementation of Annual In Person/Active Renewal for Extended Cases 2. If members fail to provide required documentation or complete the renewal process, the case is closed for failure to verify eligibility. Appropriate adverse action notices are issued in accordance with policy and timelines. 3. Staff have been instructed that eligibility determinations must not be maintained solely on a system generated extension; supporting documentation must be present in the electronic case record and/or document management system. A brief standard note template is used in VIBES to reference what documents were received, and the date eligibility was rerun. 4. System Configuration Changes with Vendor (RedMane). Worked with RedMane to adjust system logic so that eligibility cannot be approved or extended if no completed application (or renewal) is on record. 5. Updated written procedure includes, staff must confirm that a completed application (paper, phone, online, or converted electronic record) is present and imaged/recorded before approving eligibility. If the individual fails to submit required information by the due date, staff must proceed with denial/closure and document the action in case notes. 6. Conducted targeted staff training on, requirement for a completed application before approval/extension; proper use of pending status and timeframes; correct closure/denial procedures. Provided written job aids illustrating compliant workflows. 7. Implementation of Review Tracking in SharePoint, as of July 2025, an Excel tracking file housed on SharePoint is used to document: case worker name; member name and address; case number; type of case (new application, renewal, newborn, etc.). Each case is entered when assigned to the worker. 8. The supervisor reviews the case directly in VIBES, confirms eligibility determinations, and applies any needed updates. VIBES records the supervisor’s actions with date, time stamp, and staff ID to show who reviewed and approved the case. The supervisor also applies changes and documents a brief note in the VIBES notes section (e.g., “Supervisor [Name/ID] reviewed and approved eligibility determination; OK to issue Notice of Decision.”). After review, the supervisor updates the SharePoint tracker to reflect that review is complete.

View Audit 406809

Finding 1223427 (2024-090)

Material Weakness 2024

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Eligibility Special Tests & Provisions Subrecipient Monitoring § 200.303

The Government concurs with the auditor’s findings and recommendations. Management will review current procedures to strengthen monitoring and documentation of provider eligibility for ARP Act stabilization funds. DHS is committed to improving internal controls and ensuring compliance with all progr...

The Government concurs with the auditor’s findings and recommendations. Management will review current procedures to strengthen monitoring and documentation of provider eligibility for ARP Act stabilization funds. DHS is committed to improving internal controls and ensuring compliance with all program requirements. An internal programmatic audit process is actively utilized. Subsidy determinations are cross-checked by different workers according to federally and locally established policies. Additionally, DHS is in the process of developing an internal audit and compliance unit. With the requisite staffing, internal audits will be conducted to ensure alignment with the Federal mandates in addition to ensuring overall compliance.

View Audit 406809

Finding 1223425 (2024-088)

Material Weakness 2024

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Special Tests & Provisions Subrecipient Monitoring Eligibility § 200.303

DHS has onboarded additional licensing staff which has built increased capacity to conduct provider visits for the purpose of assessing compliance with health and safety requirements. Efforts to recruit additional staff continue. A visual tracker of provider visits will be utilized to ensure visits ...

DHS has onboarded additional licensing staff which has built increased capacity to conduct provider visits for the purpose of assessing compliance with health and safety requirements. Efforts to recruit additional staff continue. A visual tracker of provider visits will be utilized to ensure visits are conducted across all providers.

View Audit 406809

Finding 1223422 (2024-085)

Material Weakness 2024

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Subrecipient Monitoring Eligibility Matching / Level of Effort / Earmarking § 200.303

DHS, has upgraded the child care database to more efficiently produce monthly vouchers without the historical connectivity disruptions that prevented an uninterrupted listing of provider vouchers and the associated subsidy payments. An independent audit will be conducted to verify processes, review ...

DHS, has upgraded the child care database to more efficiently produce monthly vouchers without the historical connectivity disruptions that prevented an uninterrupted listing of provider vouchers and the associated subsidy payments. An independent audit will be conducted to verify processes, review files and make recommendations. Additionally, An Audit and Compliance Unit has been established within the Fiscal Division. Staffing will include a program compliance monitor to work with the Child Care program to ensure compliance to Federal mandates.

View Audit 406809

Finding 1223349 (2024-047)

Material Weakness 2024

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Special Tests & Provisions Eligibility Reporting § 200.303

VIDOL acknowledges the auditor’s finding regarding the failure to submit the required ETA 9129 RESEA Quarterly Reports in a timely manner under the UI-Reemployment Services and Eligibility Assessment (RESEA) program. VIDOL recognizes the importance of maintaining effective internal controls to ensur...

VIDOL acknowledges the auditor’s finding regarding the failure to submit the required ETA 9129 RESEA Quarterly Reports in a timely manner under the UI-Reemployment Services and Eligibility Assessment (RESEA) program. VIDOL recognizes the importance of maintaining effective internal controls to ensure all required Federal reports are accurate, complete, properly reviewed, and submitted within established deadlines in compliance with 2 CFR 200.303. VIDOL concurs with the auditor’s recommendation and is committed to strengthening reporting controls and implementing system improvements to ensure ongoing compliance with Federal reporting requirements. To address the deficiencies identified, VIDOL will implement the following corrective actions: 1. Implementation of RESEA Case Management System: VIDOL is currently in the implementation stage of the core portion of the RESEA case management system that will serve as the official system of record for all RESEA claimant services and reporting activities. The system is expected to go out to production/testing by June 2026 with an identified vendor. The new system will: •Centralize claimant and program data; •Improve tracking of RESEA activities and outcomes; • Generate data necessary for required Federal reporting; •Enhance data accuracy and consistency; and •Support timely submission of ETA 9129 Quarterly Reports. 2. Development of Reporting Policies and Procedures: VIDOL will develop and formalize written policies and procedures governing the preparation, review, approval, and submission of RESEA quarterly reports. These procedures will include: •Clearly defined staff responsibilities; •Reporting timelines and submission deadlines; • Required supervisory review and approval processes; and • Documentation retention requirements supporting reported data. 3. Strengthening Internal Controls Over Reporting: VIDOL will enhance internal controls to ensure: •Required reports are monitored through a reporting calendar and tracking system; •Reports are reviewed for completeness and accuracy prior to submission; •Supporting documentation is maintained and readily accessible; and •Management oversight is performed to ensure compliance with Federal reporting requirements. 4. Periodic Monitoring and Compliance Reviews: Management will conduct periodic reviews of reporting activities to verify reports are submitted timely and supported by accurate documentation. Any reporting deficiencies identified will be addressed promptly through corrective action and additional oversight. 5. Staff Training and Technical Assistance: Staff responsible for RESEA program administration and reporting will receive training on: •Federal reporting requirements for ETA 9129 reports; •Internal control and documentation standards; •Use of the RESEA case management system; and •Procedures for timely report preparation and submission. VIDOL will also seek technical assistance, as needed, to support implementation of the new reporting system and improve compliance processes.

View Audit 406809

Corrective Action Plans

Filters