Corrective Action Plans

Finding 546911 (2024-003)

Material Weakness 2024

IL

Questioned Costs Matching / Level of Effort / Earmarking Student Financial Aid § 200.303

Finding No. 2024-003 Failure to Determine Eligibility in Accordance with SFA Regulations ALNs: 84.007, 84.033, 84.063, 84.268 Program: Student Financial Assistance Cluster Corrective Action: Additional training will be provided to staff. Implementation Date: June 30, 2025 Contact Person: Amanda Fija...

Finding No. 2024-003 Failure to Determine Eligibility in Accordance with SFA Regulations ALNs: 84.007, 84.033, 84.063, 84.268 Program: Student Financial Assistance Cluster Corrective Action: Additional training will be provided to staff. Implementation Date: June 30, 2025 Contact Person: Amanda Fijal

View Audit 351271 Questioned Costs: $1

Finding 544724 (2024-004)

Material Weakness 2024

Liberty-Perry Community School Corporation

IN

School Nutrition Programs Eligibility Cash Management § 200.303

Finding 2024-004 Contact Person Responsible for Corrective Action: Brenda Layne, Food Service Director Contact Phone Number: 765-289-7323 We concur with the finding. Corrective Action plan: As of SY 24/25 when the High School Treasurer checks the 10% of the paper applications, she will make a...

Finding 2024-004 Contact Person Responsible for Corrective Action: Brenda Layne, Food Service Director Contact Phone Number: 765-289-7323 We concur with the finding. Corrective Action plan: As of SY 24/25 when the High School Treasurer checks the 10% of the paper applications, she will make a list of the ones she checked and it will be located in the application binder. As of March 1st, 2025 The Food Service Director will run a copy of Direct Certs that Titan has in their file, she will then cross check it with the list that is send from IDOE. She will keep both list together in a file after initialing it. Anticipated completion Date: March 2025

View Audit 351229

Finding 544702 (2024-004)

Significant Deficiency 2024

Camden County

NC

Eligibility

Name of contact Person: Stephanie Wyche, Director of Social Services Corrective Action: [1] Agency has completed training with Adult Medicaid caseworkers regarding correct case documentation as it related to vehicles/personal property. Training was completed on September 5, 2024 and included targete...

Name of contact Person: Stephanie Wyche, Director of Social Services Corrective Action: [1] Agency has completed training with Adult Medicaid caseworkers regarding correct case documentation as it related to vehicles/personal property. Training was completed on September 5, 2024 and included targeted training for vehicles/personal property. MAABD policy sections 2230 V.B1 . (2); MAABD 2230 VIII A 3; MAABD 2230 VII C; MAABD 2230 VII D; and MAABD 2230 VII E were reviewed during this training. Also reviewed was usage of the DMA-5039 Right to Rebut Value of Vehicles. [3] Agency will complete training with all Medicaid caseworkers regarding correct data input into NCFAST, correct base period usage, and the importance of ensuring that accurate calculations are completed when determining Medicaid eligibility. Training has been scheduled for Monday November 25, 2024. [4] Agency will complete training with all Medicaid caseworkers regarding correct data input into NCFAST, correct computation of household composition, correct use of the manual MAGI household composition tool, and the importance of ensuring that data entered into NCFAST is generating the correct household size determination. Training has been scheduled for Monday November 25, 2024. [5] System issues where NCFAST us unable to complete a request of information from the Work Number are much less common than they used to be. Agency will complete training with staff to ensure that data matches are completed outside of NCFAST and documented in the event that OVS or the Work Number is unable to be completed in NCFAST. Staff has been informed that if there is any instance where data matches are unable to be completed in NCFAST, a help desk ticket needs to be submitted and any communications from the state about known issues should be included with documentation on any impacted cases. Training has been scheduled for Monday November 25, 2024. [6] Clear, accurate, and thorough case documentation is critical to the agency's success in ensuring that correct benefits are issued to all clients. Agency will complete training with all Medicaid staff to stress the importance of documenting any action taken on a case. Training has been scheduled for Monday November 25, 2024. Proposed Completion Date: Training for Error Category 1 was completed on September 5, 2024. Training will be completed for Error Categories 2-5 on Monday November 25, 2024.

View Audit 351208

Finding 544699 (2024-002)

Significant Deficiency 2024

The Education Alliance-Business and Community for Public Schools, Inc.

WV

Allowable Costs / Cost Principles Procurement, Suspension & Debarment Cash Management § 200.403 § 200.476

Management recognizes the importanceof maintaining complete and accurate documenation for all expenditures, including credti card charges. While supporting documentation is collected and reviewed, we acknowldge the need to strengthen the review process for complete documenation, cost classification ...

Management recognizes the importanceof maintaining complete and accurate documenation for all expenditures, including credti card charges. While supporting documentation is collected and reviewed, we acknowldge the need to strengthen the review process for complete documenation, cost classification and recording. To address this, all relevant staff received additional training in January and February 2025 regarding identifying allowable and unallowable costs and properly documenting expenses in accirdance with federal cost principles. In addition, the new program director has scheduled quarerly meetings with the external accountant to implenet a revised system for classifying direct and indirect costs and to develop any additional staff training. These steps will help ensure that all costs are allowable, appropriately allocated, and accurately recorded in the general ledger.

View Audit 351204

Finding 544464 (2024-001)

Significant Deficiency 2024

Housing Authority of the City of Greensboro

NC

HUD Housing Programs Subrecipient Monitoring Eligibility

2024-001 ALN 14.850 – Public Housing Operating Fund - Eligibility The Executive Director agrees with the finding as listed in the Schedule of Findings and Responses and will follow the Auditor's recommendations. Person Responsible for Correction of Finding: Ms. Khristian Allen, Executive Director Pr...

2024-001 ALN 14.850 – Public Housing Operating Fund - Eligibility The Executive Director agrees with the finding as listed in the Schedule of Findings and Responses and will follow the Auditor's recommendations. Person Responsible for Correction of Finding: Ms. Khristian Allen, Executive Director Projected Completion Date: June 30, 2025

View Audit 351142

Finding 544459 (2024-002)

Significant Deficiency 2024

Community Clinic of Maui, Inc.

HI

Special Tests & Provisions Subrecipient Monitoring Eligibility

Federal Award Findings and Questioned Costs: Finding 2024.002 - Sliding Fee Scale Documentation Recommendation 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. Action Taken Mana...

Federal Award Findings and Questioned Costs: Finding 2024.002 - Sliding Fee Scale Documentation Recommendation 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. Action Taken Management recently migrated their electronic health records from AthenaPractice and Dentrix to EPIC. EPIC is programmed to calculate the sliding fee discount based upon the Family Size and Income that is entered into the system, unlike Dentrix which did not have this capability. In addition, monthly audits are conducted by the Billing Department to ensure that the supporting documentation matches the information entered into EPIC. If there are any question regarding this plan, please e-mail Monique van der Aa at monique@ccmaui.org. Sincerely, Monique van der Aa Chief Financial Officer

View Audit 351137

Finding 544452 (2024-003)

Material Weakness 2024

Ivy Tech Community College of Indiana

IN

Subrecipient Monitoring Eligibility Material Weakness § 200.303 § 200.329

FINDING 2024-003 (Auditor Assigned Reference Number) Finding Subject: TRIO - Reporting Contact Person Responsible for Corrective Action: Nichole Stitt, AVP Sponsored Programs Contact Phone Number and Email Address: 317-921-4800 ext. 084987 and nstitt@ivytech.edu Views of Responsible Officials: We co...

FINDING 2024-003 (Auditor Assigned Reference Number) Finding Subject: TRIO - Reporting Contact Person Responsible for Corrective Action: Nichole Stitt, AVP Sponsored Programs Contact Phone Number and Email Address: 317-921-4800 ext. 084987 and nstitt@ivytech.edu Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The college will develop an internal control system to ensure compliance with the requirement related to the TRIO reporting compliance requirement. Anticipated Completion Date: The projected date of completion for the CAP mentioned above is June 30, 2025. The Student Support Services APR process was corrected in April 2024, a query interfacing with Banner to identify errors in the APRs submitted by each campus, was created.

View Audit 351125

Finding 544449 (2024-002)

Significant Deficiency 2024

Ivy Tech Community College of Indiana

IN

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

FINDING 2024-002 (Auditor Assigned Reference Number) Finding Subject: TRIO - Eligibility Contact Person Responsible for Corrective Action: Nichole Stitt, AVP Sponsored Programs Contact Phone Number and Email Address: 317-921-4800 ext. 084987 and nstitt@ivytech.edu Views of Responsible Officials: We ...

FINDING 2024-002 (Auditor Assigned Reference Number) Finding Subject: TRIO - Eligibility Contact Person Responsible for Corrective Action: Nichole Stitt, AVP Sponsored Programs Contact Phone Number and Email Address: 317-921-4800 ext. 084987 and nstitt@ivytech.edu Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The college will develop an internal control system to ensure compliance with TRIO – Eligibility requirements. Anticipated Completion Date: The projected date of completion for the CAP mentioned above is June 30, 2025.

View Audit 351125

Finding 544423 (2024-004)

None 2024

City of Oxnard

CA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Eligibility § 200.430

The Department will conduct a formal review of its processes and policies to identify potential weaknesses in the payroll timekeeping and approval process, and will update its policies and procedures to align with the roles and responsibilities of those involved in rostering and timekeeping. The dep...

The Department will conduct a formal review of its processes and policies to identify potential weaknesses in the payroll timekeeping and approval process, and will update its policies and procedures to align with the roles and responsibilities of those involved in rostering and timekeeping. The department has already taken corrective action to ensure that duty chiefs are finalizing the rosters before the end of their shift and making it the responsibility of the timekeeper to initiate action when finalization by the Duty Chiefs has not occurred so the timekeepers review process can be completed.

View Audit 351106

Finding 544397 (2024-001)

Significant Deficiency 2024

Michigan State University

MI

Student Financial Aid Matching / Level of Effort / Earmarking Eligibility

Condition: The notifications related to the direct loan borrowers did not include information on the right to cancel or instructions on how to cancel the loans. Planned Corrective Action: Missing notifications to students was a result of a coding error in the automated process that was resolved on S...

Condition: The notifications related to the direct loan borrowers did not include information on the right to cancel or instructions on how to cancel the loans. Planned Corrective Action: Missing notifications to students was a result of a coding error in the automated process that was resolved on September 5, 2023. Notifications to parents didn’t begin until the Summer 2023, with an automated procedure being implemented in the Fall 2023 semester. A coding issue was identified and resolved in the automated procedure to notify parents in early January 2024. Contact person responsible for corrective action: Kent McGowan, Assistant Director, Office of Financial Aid Anticipated Completion Date: This finding was corrected as of January 2024.

View Audit 351055

Finding 544345 (2024-001)

Significant Deficiency 2024

Jellico Housing Authority

TN

HUD Housing Programs Eligibility

Jellico Housing Authority respectfully submits the following corrective action plan for the year ended June 30, 2024. Responsible Official: Crystal Creekmore, Executive Director Name and address of independent public accounting firm: Miller & Rose, PA 1309 East Race Searcy, AR 72143 Audit per...

Jellico Housing Authority respectfully submits the following corrective action plan for the year ended June 30, 2024. Responsible Official: Crystal Creekmore, Executive Director Name and address of independent public accounting firm: Miller & Rose, PA 1309 East Race Searcy, AR 72143 Audit period: Year ended June 30, 2024 Oversight Agency: U.S. Department of Housing and Urban Development The findings from the June 30, 2024, audit are discussed below. The findings are numbered to correspond to the auditing findings disclosed in the Schedule of Findings and Questioned Costs. Significant Deficiency 2024-001 Eligibility Federal Program: Public and Indian Housing, Federal Assistance Listing Number 14.850 Condition and Criteria: The Authority’s purpose for existence is to provide decent, safe, and affordable housing for low-income families. As such, the Authority prepares a file for each admitted family, which contains information necessary to determine eligibility for assistance and calculations of rent to be paid by the family. HUD regulations prescribe the content of these family files. These requirements consist of the following: a. As a condition of admission or continued occupancy, the tenant and other family members are required to provide necessary information, documentation, and releases for the PHA to verify income eligibility. b. For both family income examinations and reexaminations, obtain and document in the family file third party verification of: (1) reported family annual income; (2) the value of assets; (3) expenses related to deductions from annual income; and (4) other factors that affect the determination of adjusted income or income-based rent. c. Determine income eligibility and calculate the tenant’s rent payment in accordance with HUD regulations. d. Select tenants from the public housing waiting list in accordance with the PHA’s tenant selection policies. e. Re-examine family income and composition at least once every 12 months and adjust the tenant rent and housing assistance payment as necessary. Population and Items Tested: We selected thirteen public housing tenant files for testing. One file did not contain an annual re-examination. The tenant did not provide the information required to complete the re-examination and was ultimately evicted. One file did not contain tenant signatures on the annual re-examination documents including the required authorizations for the release of information. Auditor’s Recommendation: All re-examinations should be completed on an annual basis and the required documents should be signed by the tenant. Planned corrective actions: We will comply with the auditor’s recommendation. Estimated Date of Completion: June 30, 2024

View Audit 350961

Finding 544139 (2024-003)

Significant Deficiency 2024

Washington Adventist University

MD

Questioned Costs Eligibility Student Financial Aid § 200.303

Action taken in response to finding: The University has SAP policies and procedures in place to determine student’s eligibility for Financial Aid that complies with Federal regulations, including qualitative (GPA), quantitative (pace of completion) and maximum timeframe standards. The SAP finding m...

Action taken in response to finding: The University has SAP policies and procedures in place to determine student’s eligibility for Financial Aid that complies with Federal regulations, including qualitative (GPA), quantitative (pace of completion) and maximum timeframe standards. The SAP finding may be due to system error with the Colleague ERP when the SAP report was run. The University will evaluate our SAP procedures and perform internal audits to identify gaps or inconsistencies and implement corrective actions as needed. Training will be provided to financial aid staff on SAP requirements and procedures to ensure consistent application and understanding. Name(s) of the contact person(s) responsible for corrective action: Alfred Taylor Planned completion date for corrective action plan: June 30, 2025

View Audit 350924 Questioned Costs: $1

Finding 544078 (2024-001)

Material Weakness 2024

Gaudenzia Inc.

PA

Allowable Costs / Cost Principles Eligibility Matching / Level of Effort / Earmarking

2024-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: HOME Investment Partnership Program Assistance Listing Number: 14.239 Pass-Through Agencies: City of Philadelphia, Redevelopment Authority: Venango – Loan Thompson Street – Loan County of S...

2024-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: HOME Investment Partnership Program Assistance Listing Number: 14.239 Pass-Through Agencies: City of Philadelphia, Redevelopment Authority: Venango – Loan Thompson Street – Loan County of Schuylkill - Home Investment Partnerships and Housing Trust Funds Programs: Fountain Springs - Loan Mayor and City of Baltimore: Baltimore Housing - Park Heights Women and Children - Loan Condition: As part of the eligibility requirement for the HOME Investment Partnership program, we are required to review files of client residents who were provided residential drug and alcohol treatment services at the Organization’s locations in Venango (Re-Entry), Fountain Springs, Thompson Street, and Park Heights Women and Children. We sampled a total of 40 resident clients at these four locations covered by HOME loans and requested documentation within client resident files, including proof of residency, proof of income (low income or homeless), and lease or housing agreement (depending on program requirements). Of the 40 resident client files reviewed, management was unable to provide any proof of income or determination of homelessness or residency for 24 files. Recommendation: We recommend that management adopt policies and procedures including both the communication of compliance requirements between staff and locations and the development of documentation and processes to assist in how income eligibility is determined. This includes management developing certain income verification documents that can be used as part of the intake process for determining the eligibility of the residential client. In addition, process will need to be developed for the redetermination of income if a residential client has lived over a year at a particular location. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Gaudenzia, Inc believes that had the requisite documentation been completed, it would have been in compliance with the low-income compliance requirement as the referral sources that were used to place the clients in the program are all coming from CBH as well as other MCO funded partners. These referral sources are typically Medicaid clients and are typically well below the low-income requirement thresholds. Action taken in response to finding: Gaudenzia, Inc has incorporated existing low-income eligibility procedures to the Project Home Loans program sites to be in full compliance of the eligibility requirements. These procedures will be reinforced within our programs to ensure the requisite documentation is in place. Name of the contact person responsible for corrective action: Nikant Ohri, Chief Financial Officer, nikant.ohri@guadenzia.org (610) 860-2061 Planned completion date for corrective action plan: June 30, 2025

View Audit 350881

Finding 544074 (2024-001)

Significant Deficiency 2024

Housing Authority of the City of Reno

NV

HUD Housing Programs Eligibility Significant Deficiency

Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend that the Authority reviews the controls in place to ensure that income reported within the HUD-50058 is supported through 3rd party verification. Explanation of disagreement with audit finding: There is...

Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend that the Authority reviews the controls in place to ensure that income reported within the HUD-50058 is supported through 3rd party verification. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Since the audit findings were noted, the RHA immediately implemented a 3rd party approval process for all 50058 transactions. For 60 days, the Senior Property Manager and the Compliance Specialist will review all completed recertifications performed by Property Managers to ensure compliance with all HUD regulations prior to approving the 50058 in our software system. Upon approval, the Senior Property Manager or the Compliance Specialist will sign off on the recertification packet prior to it being scanned to the tenant’s file. If errors are found, the Property Manager will be advised to make the necessary corrections/changes. Once the corrections are made it will be resubmitted to the Senior Property Manager or Compliance Specialist for approval. After 60 days, an assessment of all errors noted will be completed to determine if there are consistent errors occurring which warrant additional training or if specific Property Managers require additional support with continued review of all recertifications. If a Property Manager’s work was free of errors after the initial 60 days, then a random selection of 25% of their work product will be reviewed monthly and signed off on the recertification packet prior to being scanned to the tenant’s file. The Asset Management Administrator or Director of Asset Management will pull a random selection of 10% of the approved recertifications that the Senior Property Manager and Compliance Specialist approved to also verify their accuracy in approving files. RHA is also sending all Property Managers through the Nan McKay HCV and Public Housing Rent Calculation training which will take place in person from February 18, 2025, through February 20, 2025. This will be at least the second time each Property Manager will complete this training since their hire date. Name(s) of the contact person(s) responsible for corrective action: Kristin Scott Planned completion date for corrective action plan: May 1, 2025 (ongoing for regular quality control efforts).

View Audit 350875

Finding 542030 (2024-002)

Significant Deficiency 2024

University of Pikeville

KY

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

Federal Program: U.S. Department of Education Federal Direct Loan Program, Federal Assistance Listing 84.268 Criteria: The University is required to comply with 36 CFR Section 685.309(b). Condition: During our testing of 40 students for eligibility, we noted three students in which the students' ...

Federal Program: U.S. Department of Education Federal Direct Loan Program, Federal Assistance Listing 84.268 Criteria: The University is required to comply with 36 CFR Section 685.309(b). Condition: During our testing of 40 students for eligibility, we noted three students in which the students' status change was not timely reported to the National Student Loan Database System (NSLDS). Corrective Actions Taken or Planned: For the year ended June 30, 2024, three students were reported late to NSLDS. Each student, after being identified, were then reported to NSLDS with the correct status and date. The Office of Institutional Research will work with the Registrar’s Office to ensure that students are reported in a timely manner. The Director of Institutional Research has provided the following steps that will be taken when a student is reported as withdrawn: 1. View the student's transcript in Ellucian to see if he/she withdrew or is back-dated as never enrolling. 2. Update Excel file for the term enrollment accordingly. 3. Update National Student Clearinghouse (NSC) file that will be submitted on the next due date. 4. Manually update the student's enrollment in National Student Clearinghouse 5. Manually update the student's enrollment in NSLDS Name of Responsible Person: Daniel Donner, Director of Financial Aid Completion Date: August 13, 2024

View Audit 350857

Finding 542029 (2024-001)

Significant Deficiency 2024

University of Pikeville

KY

Questioned Costs Student Financial Aid Eligibility

Finding 2024-001 Federal Program: U.S. Department of Education Federal Pell Grant Program, Federal Assistance Listing 84.063 Criteria: The University must comply with 34 CFR 690.61(a)(1). Condition: During our testing of 40 students for eligibility, we noted one student who was eligible for a Pel...

Finding 2024-001 Federal Program: U.S. Department of Education Federal Pell Grant Program, Federal Assistance Listing 84.063 Criteria: The University must comply with 34 CFR 690.61(a)(1). Condition: During our testing of 40 students for eligibility, we noted one student who was eligible for a Pell grant, but was not awarded nor disbursed a Pell grant. Upon further analysis, there were four additional students that were eligible for a Pell grant and were not awarded nor disbursed a Pell grant. Corrective Actions Taken or Planned: For the year ended June 30, 2024, it was found that some students were not awarded eligible Pell grants. After the initial students were discovered, the University reviewed all students that were active for the 2023-2024 award year and reviewed their most current Institutional Student Information Record (ISIR) to determine which students may not have been awarded Pell grants correctly. Affected students were then awarded as needed and funds applied to their account. Going forward, the University will review subsequent student ISIRs and run additional reports to ensure students are awarded the correct amount of Pell grants. This additional review will capture those who would have previously been missed. Name of Responsible Person: Daniel Donner, Director of Financial Aid Completion Date: August 13, 2024

View Audit 350857 Questioned Costs: $1

Finding 541988 (2024-002)

Significant Deficiency 2024

College Unbound

RI

Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Finding number: 2024-002 Federal agency: U.S. Department of Education Programs: Federal Direct Student Loans Assistance listing #: 84.268 Award year: 2024 Corrective Action Plan: These findings are from Fall 2023. College Unbound has corrected this as of Spring 2024. The new practice, start...

Finding number: 2024-002 Federal agency: U.S. Department of Education Programs: Federal Direct Student Loans Assistance listing #: 84.268 Award year: 2024 Corrective Action Plan: These findings are from Fall 2023. College Unbound has corrected this as of Spring 2024. The new practice, started February 2024, is to run a weekly report every Friday of disbursements made during that week. Every student on that disbursement list receives and email that a disbursement has been made and instructions how to review their account in their online student portal. We have been replicating this process for over 12 months now and will continue to do so in the future. Timeline for Implementation of Corrective Action Plan: Completed Contact Person: Mark Hartonchik, CFO

View Audit 350797

Finding 541987 (2024-003)

Significant Deficiency 2024

College Unbound

RI

Questioned Costs Matching / Level of Effort / Earmarking Student Financial Aid

Finding number: 2024-003 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance listing #: 84.063 and 84.268 Award year: 2024 Corrective Action Plan: This finding was the result of failure to fully...

Finding number: 2024-003 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance listing #: 84.063 and 84.268 Award year: 2024 Corrective Action Plan: This finding was the result of failure to fully execute a professional judgment (PJ) calculation. We processed a PJ on the now-closed FAA access but failed to import the updated EFC into our system. As FAA is now closed, we cannot show the updated EFC. College Unbound does regular monthly checks to ensure that no student exceeds cost of attendance or need. This one was a PJ done sloppily. Timeline for Implementation of Corrective Action Plan: Completed Contact Person: Mark Hartonchik, CFO

View Audit 350797 Questioned Costs: $1

Finding 541970 (2024-001)

Significant Deficiency 2024

Housing Authority of the City of Galveston, Texas

TX

Eligibility HUD Housing Programs Significant Deficiency

2024-001 Eligibility Housing Voucher Cluster Significant deficiency in internal control Other Matter to be Reported Under the Uniform Guidance Condition: Out of a population of approximately 1,700 for Housing Voucher Cluster, 41 tenant files were tested and 4 files had the following deficiencies: ...

2024-001 Eligibility Housing Voucher Cluster Significant deficiency in internal control Other Matter to be Reported Under the Uniform Guidance Condition: Out of a population of approximately 1,700 for Housing Voucher Cluster, 41 tenant files were tested and 4 files had the following deficiencies: • Two files had incorrect payment standard; • One file had incorrect income calculation standard; and • One file was missing an EIV report for the annual recertification. Auditor Recommendations: The Authority should reevaluate their established procedures and controls in place to ensure full compliance in regards to eligibility and the timeliness of recertifications. The Authority needs to correct the deficiencies noted in the tested files and consider the impact to the rest of the population of tenant files that were not selected as part of the auditor's sample. Action Taken; GHA is currently updating its Standards Operating Procedures and will continue to provide training and guidance to all staff to ensure that all transactions are implemented correctly, including payment standards, income calculations and to ensure all necessary documentation including EIV is placed in the participant's files. Name(s) of the contact person(s) responsible for corrective action: Maria Godwin Planned completion date for corrective action plan: GHA staff has been reminded to double check their work to avoid human errors. Additionally all training will be completed by August 2025.

View Audit 350765

Finding 541969 (2024-002)

Significant Deficiency 2024

Housing Authority of the City of Galveston, Texas

TX

HUD Housing Programs Subrecipient Monitoring Eligibility

2024-002 Eligibility Public and Indian Housing Significant deficiency in internal control Other Matter to be Reported Under the Uniform Guidance Condition: Out of a total tenant population of approximately 430 for Public and Indian Housing, 44 tenant files were tested and 8 files had the following d...

2024-002 Eligibility Public and Indian Housing Significant deficiency in internal control Other Matter to be Reported Under the Uniform Guidance Condition: Out of a total tenant population of approximately 430 for Public and Indian Housing, 44 tenant files were tested and 8 files had the following deficiencies: • Six files had incorrect or missing flat rent option sheets ; • One file was missing a custody information; and • One file had incorrect income calculation. Auditor Recommendations: The Authority should correct the deficiencies noted in the tested files and perform reviews of the remaining universe, for consideration of similar errors. In addition, the Authority should establish quality control review procedures to ensure proper monitoring of compliance with the requirements related to tenant eligibility. Action Taken: Updates were made to the flat rent option sheet and they have been placed in all files. The missing custody information has been obtained and placed in the folder. GHA will continue to provide training and guidance to all staff to ensure that all transactions are implemented correctly, including income calculation standard, and to ensure that all necessary documentation is placed in the participant's files. Name(s} of the contact person(s) responsible for corrective action: Odelia Williams, Director of Public Housing Planned completion date for corrective action plan: GHA staff completed the corrections and has been reminded to double check their work to avoid human error. Additionally, all training will be completed by August 2025.

View Audit 350765

Finding 541888 (2024-027)

Significant Deficiency 2024

State of Louisiana

LA

Questioned Costs Eligibility Internal Control / Segregation of Duties

Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated January 16, 2025 regarding a reportable audit finding related to Noncompliance with and Inadequate Controls over Maternity Kick Payments. LDH appre...

Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated January 16, 2025 regarding a reportable audit finding related to Noncompliance with and Inadequate Controls over Maternity Kick Payments. LDH appreciates the opportunity to provide this response to your office’s findings. Finding: Noncompliance with and Inadequate Controls over Maternity Kick Payments Recommendation: LDH should strengthen existing policies and procedures to ensure all maternity kick payments are supported with an eligible triggering event before payment is made to the MCOs. LDH Response: LDH does not concur with the finding of noncompliance with or inadequate controls over maternity kick payments. Maternity kick payments are triggered by a monthly automated procedure that reviews delivery encounters against specific criteria and makes payments to the MCOs when qualifying deliveries are identified. Each quarter, LDH/Gainwell performs a kick payment review procedure to recover payments from the MCOs when the original delivery encounter is voided without a qualifying replacement encounter or without another qualifying encounter in the same delivery event/episode of care. The kick payments identified in LLA’s finding had already been identified by our internal review procedures and flagged for recovery during the September 2024 kick payment review. Specifically, our review determined that these 24 kick payments were inappropriately triggered due to a coding change that was intended to limit the lookback period for qualifying encounters to January 1, 2023 (to align with the current MCO contract period), but was also unintentionally bypassing the 6/1/15 DOS (Date of Service) restriction for global maternity codes on professional/physician encounters. This coding error was discovered by Gainwell after LDH staff noted that the majority of kick payments flagged for recovery had a July 16, 2024 payment date and questioned that anomaly. Since LDH’s normal review and control procedures led to the identification the logic error and the appropriate recovery of the erroneous kick payments, we do not agree that controls are inadequate or that LDH is non-compliant with its policies and procedures for maternity kick payments. Additionally, LLA’s identification of many of these kick payments is simply due to the timing of its analysis as compared to the timing of LDH’s final SFY24 quarterly review in early June 2024. Had LDH/Gainwell performed its review at the end of June 2024 instead of the beginning of the month, 16 kicks with payment dates in June 2024 would not have been identified in LLA’s review. Corrective Action: Corrective action is not necessary, as recoveries were identified and processed as part of the regularly scheduled review process; however, LDH will modify the timing of its final quarterly reviews to ensure that payment/voids in June do not result in a finding. You may contact Kimberly Sullivan, Medicaid Director at (225) 219-7810 or via e-mail at Kimberly.Sullivan@la.gov or Marisa Naquin, Medicaid Program Manager 2 at (504) 408-1828 or via email at Marisa.Naquin@la.gov with any questions about this matter.

View Audit 350759 Questioned Costs: $1

Finding 541887 (2024-026)

Significant Deficiency 2024

State of Louisiana

LA

Questioned Costs Allowable Costs / Cost Principles Eligibility

Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated February 6, 2025 regarding a reportable audit finding related to Inadequate Internal Controls over Eligibility Determinations. LDH appreciates the ...

Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated February 6, 2025 regarding a reportable audit finding related to Inadequate Internal Controls over Eligibility Determinations. LDH appreciates the opportunity to provide this response to your office’s findings. Finding: Inadequate Internal Controls over Eligibility Determinations. Recommendation: LDH should ensure its employees follow procedure relating to eligibility determinations and redeterminations in the Medicaid and CHIP programs to ensure the case records support the eligibility decisions. LDH Response: LDH concurs in part with LLA’s finding of inadequate controls over eligibility determinations. For one Medicaid and five CHIP findings noted as the renewal not properly documented, LDH does not concur. LLA noted an error for a “SNAP” or “ELE” renewal documented as a “Streamlined” renewal. “SNAP”, “ELE”, and “Streamlined” renewals are all forms of an ex parte renewal per federal regulations at 42 CFR §435.916(b)(1) which requires the Medicaid agency to complete a renewal on the basis of information available to the agency without requiring information from the beneficiary. LDH uses these labels internally to identify what information or process used to complete the ex parte renewal. LDH presented documentation from system logs, which showed a system bug misidentified the ex parte process used but there was no error in the determination made. For one CHIP finding noted as inadequate documentation regarding income to support the renewal determination, LDH does not concur. The auditor cited a separate case in which a Medicaid analyst requested a written affidavit for the ending of self-employment income but not requested in this case. There is nothing in LDH policy or procedure that requires a written affidavit to verify ending of self-employment income. Corrective Actions: LDH already has a continual process of reviewing findings from internal case reviews, system bugs, appeal cases, external audits, or other sources then incorporating into policy/procedure updates, refresher trainings, reminder memos, and/or staff meetings. The findings from this audit will be added to this process. In addition, by April 1, 2025 Eligibility Program Operations will issue a summary of these findings to eligibility staff statewide reiterating the need to follow procedures and regulations relating to eligibility determinations to ensure the case records support the eligibility decisions. You may contact Kimberly Sullivan, Interim Medicaid Director at (225) 219-7810 or via e-mail at Kimberly.Sullivan@la.gov or Rhett Decoteau, Medicaid Section Chief at (225) 342-9044 or via email at Rhett.Decoteau@la.gov with any questions about this matter.

View Audit 350759 Questioned Costs: $1

Finding 541872 (2024-015)

Significant Deficiency 2024

State of Louisiana

LA

Reporting Student Financial Aid Special Tests & Provisions

We have reviewed the audit findings from your letter dated January 24, 2025, and appreciate the time and effort of your staff in assisting us in improving our operations. Please find our response to the finding below. Finding: Inaccurate Reporting of Student Enrollment Status Management concurs wi...

We have reviewed the audit findings from your letter dated January 24, 2025, and appreciate the time and effort of your staff in assisting us in improving our operations. Please find our response to the finding below. Finding: Inaccurate Reporting of Student Enrollment Status Management concurs with the finding noted in the report. Corrective Actions: 1. The Registrar's Office created a new National Student Clearinghouse (NSC) reporting schedule to ensure compliance. Completion Date: August 30, 2024 2. The new NSC reporting schedule will be published on the Registrar's website for accountability and information purposes. Estimated Completion Date: February 15, 2025 3. Programming changes to PeopleSoft will be completed whenever new degree programs are created to ensure that students are reported correctly to the NSC. The Registrar's Office will update its policies and procedures, as well as NSC reporting instructions based on these changes. This will ensure that students are reported correctly to the NSC. Estimated Completion Date: April 1, 2025 4. The Office of Financial Aid granted access to National Student Loan Data System (NSLDS) enrollment corrections to the Registrar’s Office. Completion Date: January 27, 2025 5. The Registrar's Office will create new policy and procedures to manually correct NSLDS enrollment data for any enrollment transactions (retroactive drops or withdrawals) taking place after the final NSC submission for each term that has been sent. Estimated Completion Date: May 16, 2025 Responsible Personnel: University Registrar If you have any additional questions or concerns, please do not hesitate to contact me.

View Audit 350759

Finding 541866 (2024-016)

Significant Deficiency 2024

State of Louisiana

LA

Student Financial Aid Reporting Special Tests & Provisions

Dear Mr. Waguespack: Thank you for the opportunity to offer the University’s response to the referenced finding. FINDING: Control Weaknesses over and noncompliance with Enrollment Reporting RESPONSE: Southern University - Baton Rouge (SUBR) concurs with the above noted finding. Management concur...

Dear Mr. Waguespack: Thank you for the opportunity to offer the University’s response to the referenced finding. FINDING: Control Weaknesses over and noncompliance with Enrollment Reporting RESPONSE: Southern University - Baton Rouge (SUBR) concurs with the above noted finding. Management concurs with this finding. Southern University and A&M College, especially the Office of Financial Aid, and the Office of the Registrar, are committed to ensuring full compliance with federal regulations and improving their reporting processes. Management fixed the file structure with the assistance of an external consultant. Management has also begun a comprehensive review of the current enrollment reporting procedures to identify and address gaps in compliance with federal regulations. New internal controls are being established to verify the accuracy and timeliness of enrollment reporting, including additional data validation checks before submission to NSLDS. The University has engaged an external consultant to assist with assessment and are exploring system upgrades to streamline and automate the submission processes to prevent recurring issues associated with manual operations outside of Banner 9. We acknowledge the auditor's recommendations to strengthen our policies, procedures, and practices for modifying enrollment statuses and tracking these changes promptly. Training sessions will be provided to all enrollment staff, including registrar, to reinforce compliance requirements and reporting deadlines for Federal Pell Grant and Federal Direct Student Loan recipients. Managers will be assigned to monitor and audit enrollment data accuracy and submission timeliness continuously. Regular internal audits will be conducted to ensure ongoing compliance with periodic reports submitted to senior management for review. Management anticipate all corrective actions and implementation to be completed over the next several months, with quarterly progress updates provided to relevant stakeholders. Management is committed to taking the necessary steps to strengthen enrollment reporting procedures and ensure compliance with federal regulations to support students and maintain SUBR's reputation for regulatory compliance. The Vice Chancellor of Enrollment Management Anthony Jackson and Associate Vice Chancellor of Accountability and Accreditation Scott Wicker be responsible for implementing and monitoring corrective actions. If you have any questions or require additional information, please contact Mrs. Desiree Honore Thomas, Associate Vice President at 225-771-3571.

View Audit 350759

Finding 541818 (2024-004)

Significant Deficiency 2024

South Carolina State Housing Finance and Development Authority

SC

Questioned Costs Eligibility HUD Housing Programs

Housing Voucher Cluster – Assistance Listing Numbers 14.871/14.879 Compliance Requirement: Eligibility Recommendation: We recommend the Authority implements controls to ensure that tenant files contain all required documentation. Views of responsible officials: There is no disagreement with the a...

Housing Voucher Cluster – Assistance Listing Numbers 14.871/14.879 Compliance Requirement: Eligibility Recommendation: We recommend the Authority implements controls to ensure that tenant files contain all required documentation. Views of responsible officials: There is no disagreement with the audit finding. Action planned/taken in response to finding: No later than May 2025, SC Housing is restructuring the HCV department. This realignment will reassign the staff member responsible for oversight of the HCV Administrative staff. In addition, all staff will receive additional training for all administrative functions, in order to minimize the number of errors moving forward. Regarding these specific exceptions, staff is working to collect necessary documentation to correct the records, one exception was previously corrected on 11/1/24. Name(s) of the contact person(s) responsible for corrective action: Lisa Wilkerson, Director of Rental Assistance and Compliance Director of HCVP Administration and Services Planned completion date for corrective action plan: Restructure in planned for late April, initial training will begin immediately and continue as needed.

View Audit 350735 Questioned Costs: $1

Corrective Action Plans

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