Corrective Action Plans

Finding 565843 (2024-003)

Significant Deficiency 2024

CA

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.328

To address the finding, ARC will strengthen internal controls related to federal reporting by taking the following actions: 1. Enhance Reporting Oversight: The Finance Manager and Grants and Compliance Officer will assume primary responsibility for monitoring and verifying all federal reporting dead...

To address the finding, ARC will strengthen internal controls related to federal reporting by taking the following actions: 1. Enhance Reporting Oversight: The Finance Manager and Grants and Compliance Officer will assume primary responsibility for monitoring and verifying all federal reporting deadlines and submission requirements. 2. Document Retention Procedure: Additional double checks of record retention will take place in monthly reporting meetings, ensuring that centralized record keeping is complete. 3. Compliance Calendar Audit: A quarterly internal audit of the compliance calendar and reporting checklist will be conducted to verify deadlines are met.

View Audit 359567

Finding 565728 (2024-001)

Significant Deficiency 2024

Community Action Agency of Jackson, Lenawee, and Hillsdale

MI

Allowable Costs / Cost Principles Eligibility § 200.303

2024-001 - Missing evidence of review and approval Auditor Description of Condition and Effect: During our testing of Allowable Costs, we noted 4 disbursements tested did not have signed and approved purchase orders. During our testing of Reporting, we noted two quarterly reports that had no evidenc...

2024-001 - Missing evidence of review and approval Auditor Description of Condition and Effect: During our testing of Allowable Costs, we noted 4 disbursements tested did not have signed and approved purchase orders. During our testing of Reporting, we noted two quarterly reports that had no evidence of review and approval. During our Eligibility testing, we noted one applicant whose certification form was not signed by the supervisor. As a result of this condition, there is an increased risk of unallowable expenses being charged to the grant, inaccurate financial reporting, allowing ineligible participants to receive grant benefits and other potential noncompliance with federal regulations. Auditor Recommendation: We recommend the Agency adheres to their internal control process of an independent review and approval of transactions and reporting related to federal grant programs. Corrective Action: The Agency will review the accounts payable/purchase order approval process with the finance department, all of whom were new (or the position vacant) during much of the period being examined, to ensure they understand the various requirements. The Agency will verify the review of the semi-annual and annual federal financial reporting by signing off on the reports after various staff have reviewed them. Responsible Person: Anthony J Samon, CFO Anticipated Completion Date: June 15, 2025

View Audit 359441

Finding 565687 (2024-006)

Significant Deficiency 2024

Washington County

OR

Eligibility HUD Housing Programs Matching / Level of Effort / Earmarking

Auditor recommendation: The County should develop and implement policies and procedures to ensure that all reports are reviewed by someone other than the preparer. Management response: Agree Target date to complete implementation activities: July 2026 Name of specific point of contact for impleme...

Auditor recommendation: The County should develop and implement policies and procedures to ensure that all reports are reviewed by someone other than the preparer. Management response: Agree Target date to complete implementation activities: July 2026 Name of specific point of contact for implementation: Ryan Bansbach, Deputy CFO, Housing, 503.846.8811 Response: The Housing Authority of Washington County (HAWC) is addressing these findings by implementing systems and policies that require secondary review of reports and determinations prior to upward reporting, voucher issuance, or tenant move‐in. HAWC implemented systems in 2025 where the staff preparing and submittng the HUD 52681‐B form will send to the form to the Program Manager or Designee for review and approval stamp before the form is submitted to HUD in the VMS or eVMS system. A checklist has been created and a system updated on routing files after review for eligibility to have a secondary review and final approval prior to issuance of voucher by the program supervisor, program manager or designee. Additional training and internal quality control checks will be implemented to ensure that metric is met. HAWC has also established checklists and procedures to ensure Rent Reasonableness is reviewed and approved prior to tenant move‐in, using a third‐party system to conduct the rent reasonableness determinations. This metric will also be added to the internal quality control procedures to monitor compliance.

View Audit 359401

Finding 565681 (2024-004)

Significant Deficiency 2024

City of Bloomington, Minnesota

MN

HUD Housing Programs Subrecipient Monitoring Eligibility

Corrective Action Plan Actions Planned – The HRA will create monitoring controls to ensure its policies relating to tenant eligibility are being followed. Official Responsible – Sarah Abe, HRA Administrator Planned Completion Date – December 31, 2025 Disagreement With or Explanation of Finding – The...

Corrective Action Plan Actions Planned – The HRA will create monitoring controls to ensure its policies relating to tenant eligibility are being followed. Official Responsible – Sarah Abe, HRA Administrator Planned Completion Date – December 31, 2025 Disagreement With or Explanation of Finding – The HRA agrees with this finding. Plan to Monitor – Sarah Abe, HRA Administrator, will oversee the process to ensure a tenant checklists for eligibility are completed and a separate program specialist is assigned to review and sign off on the checklists.

View Audit 359386

Finding 565660 (2024-002)

Significant Deficiency 2024

Housing Authority of the City of Greenville

NC

HUD Housing Programs Subrecipient Monitoring Eligibility

Finding 2024-002 – Continuum of Care Tenant Files – Eligibility – Internal Control over Tenant Files – Noncompliance and Significant Deficiency Corrective Action Plan: The Housing Authority of the City of Greenville (HACG) has implemented and/or will implement the following by our fiscal year-end ...

Finding 2024-002 – Continuum of Care Tenant Files – Eligibility – Internal Control over Tenant Files – Noncompliance and Significant Deficiency Corrective Action Plan: The Housing Authority of the City of Greenville (HACG) has implemented and/or will implement the following by our fiscal year-end September 30, 2025: a. Program Coordinators will maintain all Continuum of Care Tenant files in individual file folders designated by special purpose voucher programs. All loose documents will be anchored in tenant files. b. An action plan has been developed for the Continuum of Care programs to ensure that all program files are HUD, State, and HACG compliant starting with October 1, 2024, files through the current. c. Continuum of Care fiscal year 2024 (October 2023-September 2024) re- exams and interims will be caught up and completed as they become effective. All tenant files will be reviewed and compliant by FYE2024. d. All late/overdue re-exams will be compliant by FYE2024. e. During FYE2024, the Housing Choice Voucher Director will perform quality controls on all Continuum of Care tenant files processed each month prior to initialization (25th-30th of each month). f. File checklist sheets will be placed in each file upon quality control review to be signed off by the Housing Choice Voucher Director. g. Additional training will be required and ongoing for Program Coordinators. h. Other internal control measures will be implemented as deemed necessary by the Deputy Executive Director/COO, to eliminate future audit findings. Person Responsible: Shanetta Moye, Deputy Executive Director/COO Anticipated Completion Date: September 30, 2025

View Audit 359338

Finding 565659 (2024-001)

Significant Deficiency 2024

Housing Authority of the City of Greenville

NC

HUD Housing Programs Subrecipient Monitoring Eligibility

Finding 2024-001 – Housing Choice Voucher Tenant Files – Eligibility – Internal Control over Tenant Files – Noncompliance and Significant Deficiency Corrective Action Plan: The Housing Authority of the City of Greenville (HACG) has implemented and/or will implement the following by our fiscal year...

Finding 2024-001 – Housing Choice Voucher Tenant Files – Eligibility – Internal Control over Tenant Files – Noncompliance and Significant Deficiency Corrective Action Plan: The Housing Authority of the City of Greenville (HACG) has implemented and/or will implement the following by our fiscal year-end September 30, 2025: a. Housing Choice Voucher tenant files will be reviewed and quality controlled each month prior to initialization (25th-30th of each month) by the Housing Choice Voucher Director. b. An action plan has been developed for the Housing Choice Voucher department to ensure that all Housing Choice Voucher files are HUD and GHA compliant starting with October 1, 2024 files through the current. c. Housing Choice Voucher calendar-year 2024 (October 2023-September 2024) re-exams are substantially complete, as they become effective. All tenant files will be reviewed and HUD-compliant by FYE2024. d. During FYE2024, the Housing Choice Voucher Director will perform 40% quality controls of the monthly re-exams processed by the Housing Specialists. e. File checklist sheets will be placed in each file upon quality control review to be signed off by the Housing Choice Voucher Director. f. Additional training has been and will be made available as necessary. g. Other internal control measures will be implemented as deemed necessary by the Deputy Executive Director/COO, to eliminate future audit findings. Person Responsible: Shanetta Moye, Deputy Executive Director/COO Anticipated Completion Date: September 30, 2025

View Audit 359338

Finding 565479 (2024-035)

Significant Deficiency 2024

Commonwealth of Massachusetts

MA

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

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES 2024-035 Medicaid Cluster, COVID-19 – Medicaid Cluster - Assistance Listing No. 93.775, 93.777, 93.778 Recommendation: The Department should enhance its procedures and internal controls to ensure it promptly follows up with participants whose eligibility...

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES 2024-035 Medicaid Cluster, COVID-19 – Medicaid Cluster - Assistance Listing No. 93.775, 93.777, 93.778 Recommendation: The Department should enhance its procedures and internal controls to ensure it promptly follows up with participants whose eligibility review identifies errors and that ineligible participants are terminated from the program. Action taken in response to finding: The State will implement the following corrective actions to enhance the oversight within the Eligibility Quality Assurance (EQA) program: • Annual refresher training for supervisory staff The State will perform an annual refresher training for all Team Leaders and Supervisors who are responsible for reviewing and correcting tasks identified by the Eligibility Quality Assurance unit. • Comprehensive training for new supervisory workers The State will ensure that all newly appointed Team Leaders and Supervisors receive a comprehensive training that will include a detailed overview of the eligibility review and correction process established by the Eligibility Quality Assurance unit. • Review of corrections The State will establish a process to assist and remind managers and supervisors that they are expected to review and approve all corrections made by the eligibility workers in response to the Eligibility Quality Assurance Unit findings. Documentations of such corrections will be maintained for audit and monitoring purposes. • Standardized member outreach process for incomplete Employee Sponsored Insurance forms (ESI). The State will develop and implement a standardized process for timely outreach to members whose ESI form is identified as incomplete. Name(s) of the contact person(s) responsible for corrective action: Tosin Adebiyi, Assistant Director of Special Eligibility Programs and Audits Marco Gonzalez, Eligibility Quality Assurance Team Leader Planned completion date for corrective action plan: All corrective actions are targeted for full implementation by December 31st, 2026.

View Audit 359283

Finding 565475 (2024-034)

Significant Deficiency 2024

Commonwealth of Massachusetts

MA

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

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

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

View Audit 359283

Finding 565463 (2024-027)

Significant Deficiency 2024

Commonwealth of Massachusetts

MA

Eligibility Special Tests & Provisions Significant Deficiency § 200.303

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

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

View Audit 359283

Finding 565462 (2024-026)

Significant Deficiency 2024

Commonwealth of Massachusetts

MA

Questioned Costs Special Tests & Provisions Student Financial Aid § 200.303

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

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

View Audit 359283 Questioned Costs: $1

Finding 565461 (2024-025)

Significant Deficiency 2024

Commonwealth of Massachusetts

MA

Matching / Level of Effort / Earmarking Eligibility Reporting § 200.303

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

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

View Audit 359283

Finding 565422 (2024-006)

Significant Deficiency 2024

Commonwealth of Massachusetts

MA

Special Tests & Provisions Eligibility Reporting § 200.303

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

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

View Audit 359283

Finding 565411 (2024-003)

Material Weakness 2024

Commonwealth of Massachusetts

MA

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

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

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

View Audit 359283

Finding 565372 (2024-002)

Significant Deficiency 2024

Summit County Colorado

CO

Eligibility Subrecipient Monitoring

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

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

View Audit 359213

Finding 565343 (2024-002)

Material Weakness 2024

Housing Authority of the County of Dauphin

PA

Questioned Costs HUD Housing Programs Eligibility

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

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

View Audit 359165 Questioned Costs: $1

Finding 565324 (2024-001)

Significant Deficiency 2024

Bath Housing Development Corporation

ME

Eligibility HUD Housing Programs Significant Deficiency

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

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

View Audit 359147

Finding 565020 (2024-001)

Significant Deficiency 2024

Commonwealth Institute of Funeral Service

TX

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

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

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

View Audit 358905

Finding 565014 (2024-001)

None 2024

Hillsboro-Deering Cooperative School District

NH

School Nutrition Programs Eligibility Internal Control / Segregation of Duties

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

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

View Audit 358891

Finding 564934 (2024-002)

Significant Deficiency 2024

Sunshine Community Health Center, Inc.

AK

Special Tests & Provisions Eligibility Significant Deficiency

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

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

View Audit 358850

Finding 564598 (2024-002)

Significant Deficiency 2024

National Indian Youth Council, Inc.

NM

Eligibility Significant Deficiency § 200.303 § 200.430

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

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

View Audit 358729

Finding 564496 (2024-001)

Significant Deficiency 2024

Prairie State College - Community College District No. 515

IL

Eligibility

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

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

View Audit 358618

Finding 564424 (2024-101)

Significant Deficiency 2024

B J Enterprises, Inc.

AZ

Procurement, Suspension & Debarment Cash Management Eligibility § 200.303

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

REFERENCE: 2024-101 REPEAT FINDING REFERENCE: 2023-001 CFDA NUMBER: 10.558 – CHILD AND ADULT CARE FOOD PROGRAM U.S. DEPARTMENT OF AGRICULTURE - FOOD AND NUTRITION - 2024 PASSED THROUGH ARIZONA STATE DEPARTMENT OF EDUCATION GRANT NUMBER 6AZ300003 CLIENT RESPONSE AND CORRECTIVE ACTION PLAN We concur with the condition. 1. Name of the contact person responsible for corrective action: Katie O’Neill, MPH, RD 2. Corrective action planned: The menu reader (Area Coordinator) will double check the meal counts to the menus to ensure all meal counts: * are clerically accurate; * are claimed for providers own, only when day care children are present; * are claimed only when children are present to eat those meals and; * are claimed only when 2 snacks and 1 meal or 2 meals and 1 snack are claimed for each child. The menu reader will double check the list of Income Eligible providers each month to make sure providers’ own are claimed only when we have the Income Affidavits. The Director will re-train the menu readers in these specific areas at the next staff meeting and through virtual training. 3. Anticipated completion date: June 2025 through October 2025

View Audit 358561

Finding 564420 (2024-001)

Significant Deficiency 2024

Senior Citizens Housing Development Corporation of Montgomery County

FL

HUD Housing Programs Eligibility Reporting

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

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

View Audit 358536

Finding 564274 (2024-003)

Significant Deficiency 2024

East River Legal Services Corporation

SD

Internal Control / Segregation of Duties Cash Management Eligibility

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

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

View Audit 358389

Finding 564243 (2024-015)

Material Weakness 2024

Charter County of Wayne, Michigan

MI

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

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

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

View Audit 358351

Corrective Action Plans

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