Corrective Action Plans

Finding 523271 (2024-002)

None 2024

AL

Student Financial Aid Eligibility Reporting

Management’s Response: Management understands the importance of ensuring information is reported accurately and timely and the requirement to report to the NSLDS the enrollment status of students who receive federal funds. The College will review its controls and procedures to ensure that not only a...

Management’s Response: Management understands the importance of ensuring information is reported accurately and timely and the requirement to report to the NSLDS the enrollment status of students who receive federal funds. The College will review its controls and procedures to ensure that not only are status changes reported to the Clearinghouse, but also that the enrollment changes are reported appropriately from the National Student Clearinghouse to NSLDS. Views of Responsible Officials and Corrective Action: We will reassess controls, review these processes and implement controls, including multiple layers of review, to ensure that timely and accurate enrollment reporting is made. Furthermore, the reporting data was appropriately updated subsequent to the required timeframe. Name of Responsible Person: Melissa Creasy, Director of Student Financial Aid Implementation Date: Immediately

View Audit 342533

Finding 523090 (2024-003)

Significant Deficiency 2024

St. Louis Area Food Bank, Inc.

MO

Internal Control / Segregation of Duties Eligibility Significant Deficiency

Finding 2024-003: Lack Internal Control Over Compliance for Timely Execution of Required Agreements Corrective Action Plan: Single Audit partner agreements for fiscal year 2024 (July 1, 2023 - June 30, 2024) with five (5) partner agencies were signed in June 2024 and November 2024. Management notes...

Finding 2024-003: Lack Internal Control Over Compliance for Timely Execution of Required Agreements Corrective Action Plan: Single Audit partner agreements for fiscal year 2024 (July 1, 2023 - June 30, 2024) with five (5) partner agencies were signed in June 2024 and November 2024. Management notes that as of year-end and final fieldwork, personnel are now in place who understand the importance of maintaining and completing required documentation, including annual and bi-annual agreements. Management will implement additional measures, such as improved tracking systems and staff training, to prevent future delays in the execution of required annual and bi-annual agreements. Management currently reconciles Al33 documents to agency partners. In addition, the management team is ensuring documents are signed and stored in an electronic document signature platfonn i.e DocuSign. Access to this platform will be available to all key staff for utilization and verification. Tracking is also documented within a separate excel spreadsheet and reconciled back to the electronic signature database. A Standard Operating Procedure has been created and implemented. Name of Responsible Person: Meredith Knopp, Chief Executive Officer Anticipated Completion Date: December 31 , 2024

View Audit 342402

Finding 522995 (2024-002)

None 2024

Community Action Partnership of Cambria County

PA

Special Tests & Provisions Subrecipient Monitoring Eligibility

Name of Contact Person – Tracy Helsel, Head Start Program Director Recommendation: It was recommended that program management provide training and education to the governing body on the Head Start Program including eligibility requirements, policies, and practices, and ensure documentation of such ...

Name of Contact Person – Tracy Helsel, Head Start Program Director Recommendation: It was recommended that program management provide training and education to the governing body on the Head Start Program including eligibility requirements, policies, and practices, and ensure documentation of such training. Action Taken: As this compliance issue was recently addressed in the Organization’s ACF monitoring review, the Organization implemented corrective action that included in-person, virtual, and recorded training to board members, as well as providing binders to the governing body members that contained hard copies of protocols and training materials. Completion Date: September 30, 2024

View Audit 342242

Finding 522751 (2024-001)

Significant Deficiency 2024

The Housing Authority of the City of Auburn, Alabama

AL

Questioned Costs HUD Housing Programs Eligibility

A. Finding Finding 2024-001: Moving to Work Resident Files - Eligibility- Rent Calculations & HAP Disbursements Noncompliance & Significant Deficiency -ALN #14.881 B. Condition & Cause Twenty (20) HCV tenant-based resident files and twenty (20) HCV project-based resident files were reviewed for a t...

A. Finding Finding 2024-001: Moving to Work Resident Files - Eligibility- Rent Calculations & HAP Disbursements Noncompliance & Significant Deficiency -ALN #14.881 B. Condition & Cause Twenty (20) HCV tenant-based resident files and twenty (20) HCV project-based resident files were reviewed for a total of forty (40) Moving to Work resident files reviewed. In the TBV file review, one (1) instance of a resident's income being miscalculated on HUD form 50058 was noted. The Authority understated the resident's income which resulted in a lower rent charge amount than expected. Also in the TBV file review, one (I) instance of the Authority issuing a double payment of HAP funding to a landlord was noted. The total amount of the overpayment was $2,006 which has since been requested back from the property owner. C. Background Information Due to organizational restructuring, the HCV Manager moved to the Multi-family Housing department and the new HCV Manager was an internal promotion from within the HCV Department leaving a vacancy in the PBV Caseworker position. In addition, the TBV Caseworker resigned in November 2023 and was replaced by a new staff member in December 2023. The HCV application/in-take position also had turnover during the fiscal year, resulting in a relatively inexperienced HCV staff for a significant portion of the fiscal year. Due to the new staff, HCV has devoted significant resources to train new staff and implement internal control measures to minimize non-compliance and reduce errors; however, the process is still ongoing and will be continually evaluated and adjusted to ensure compliance with HUD's regulatory requirements. D. Controls to Correct the Deficiency In an effort to correct the finding noted above, the Auburn Housing Authority (AHA) has implemented and/or will implement the following by FYE2025: a. HCV Manager will perform a comprehensive audit of tenant files for existing tenants to identify any additional deficiencies and assess the need for staff training. b. HCV Manager will perform monthly file reviews on all recertifications completed during FYE2025 to identify rent calculation errors and compliance issues and assess the need for staff training. c. During FYE2025, the Chief Operating Officer (COO) will perform quality controls by randomly selecting departmental files for review. d. To eliminate HAP Disbursement Errors, monthly HAP Requests will be prepared by the Caseworker and reviewed by the IICV Manager and COO prior to submission to the Chief Executive Officer (CEO) for final review and approval. e. Other internal control measures to eliminate future audit findings. E. Person Responsible: Sharon N. Tolbert, CEO F. Anticipated Completion Date: June 30, 2025

View Audit 342124 Questioned Costs: $1

Finding 522706 (2024-001)

None 2024

Senior Citizens Housing Dev CORP of Chicago Dba Senate Apartments

FL

HUD Housing Programs Eligibility Reporting

Oversight Agency for Audit, Senior Citizens Housing Development Corporation of Chicago respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Co...

Oversight Agency for Audit, Senior Citizens Housing Development Corporation of Chicago respectfully submits the following corrective action plan for the year ended June 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: July 1, 2023 through June 30, 2024 The findings for the June 30, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. SECTION III – FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING No. 2024-001: Section 8 Project Based Rental Assistance, ALN 14.195 Recommendation: The Project should implement procedures to ensure that proper initial eligibility procedures are conducted for potential tenants and that tenant files are accurately maintained. Action Taken: Monthly reminders are being sent to all managers to run their EIV reports for the month. In addition, random files are being reviewed by compliance to ensure EIV reports are pulled, unit inspections performed, and required documentation is complete and accurate.

View Audit 342089

Finding 522695 (2024-001)

Significant Deficiency 2024

South Carolina Regional Housing Authority No. 3

SC

HUD Housing Programs Eligibility Significant Deficiency

Finding 2024-001 – Moving to Work Demonstration ALN 14.881 - Income Verification Requirements, Eligibility- Noncompliance & Significant Deficiency Corrective Action Plan: We are using the recommendations provided by the auditor's and are changing our file check list so that the EIV report will be i...

Finding 2024-001 – Moving to Work Demonstration ALN 14.881 - Income Verification Requirements, Eligibility- Noncompliance & Significant Deficiency Corrective Action Plan: We are using the recommendations provided by the auditor's and are changing our file check list so that the EIV report will be included in all the necessary check list. Also, the HA staff will use hierarchy for documentation in order of priority for participants for the HCV program. • Up-front income verification (UIV) using HUD EJV system • Up-front income verification (UIV) using a non-HUD system • Written third-party verification provided by applicant or participant • Written third-party verification form • Oral third-party verification • Self-certification Person Responsible: Doris Jamison and Janie Robinson Anticipated Completion Date: June 30, 2025

View Audit 342050

Finding 522670 (2024-001)

Significant Deficiency 2024

Berkeley Housing Authority

CA

HUD Housing Programs Internal Control / Segregation of Duties Eligibility

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Moving to Work Demonstration Program to ensure that established internal control policies are being followed on a timely basis. James Wi...

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Moving to Work Demonstration Program to ensure that established internal control policies are being followed on a timely basis. James Williams, Executive Director, will be responsible to implement this corrective action by June 30, 2025.

View Audit 341981

Finding 522641 (2024-004)

Material Weakness 2024

Oak Park Elementary School District 97

IL

Questioned Costs Subrecipient Monitoring Eligibility § 200.516

Corrective Action Plan Finding No.: 2024 - 004 Condition: The District did not meet its maintenance of effort on either the aggregate or the per capita basis for fiscal year 2024. The shortfall in maintenance of effort was $401,982. Plan: The District will implement procedures and internal con...

Corrective Action Plan Finding No.: 2024 - 004 Condition: The District did not meet its maintenance of effort on either the aggregate or the per capita basis for fiscal year 2024. The shortfall in maintenance of effort was $401,982. Plan: The District will implement procedures and internal controls in FY 2025 to monitor maintenance of effort compliance. Furthermore the District will perform a comprehensive review of fiscal year 2024 expenditures to identify the cause of the decrease in special education expenditures from the FY 2023 amounts to determine if allowable exceptions can be identified in accordance with federal guidelines. Anticipated Date of Completion: 6/30/2025 Name of Contact Person: Sheila Johnson, Assistant Superintendent of Finance and Operations

View Audit 341891 Questioned Costs: $1

Finding 522637 (2024-001)

Material Weakness 2024

North Central Parke Community School Corporation

IN

School Nutrition Programs Eligibility Material Weakness § 200.303

FINDING 2024-001 Finding Subject: Child Nutrition Cluster-Eligibility Summary of Finding: An effective internal control system, which would include segregation of duties, was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the...

FINDING 2024-001 Finding Subject: Child Nutrition Cluster-Eligibility Summary of Finding: An effective internal control system, which would include segregation of duties, was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the following compliance requirements for Eligibility related to income guidelines and Direct Certifications. No controls were in place to ensure the Food Service Director was inputting the income guidelines into the Harmony software correctly and that direct certification reports were run at the start of the school year and monthly thereafter, and that the student statuses were updated, accordingly. No one verified that the year-to-date direct certification reports were run to catch any students that were missing. Contact Person Responsible for Corrective Action: Vonessia Harmon, Business Manager Contact Phone Number and Email Address: 765-569-4195 harmonv@ncp.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Food Service Director is responsible for ensuring the annual Free & Reduced income guidelines are entered into the student software system prior to Online Registration each school year. The Food Service Director will provide a copy of the income guidelines to the Business Manager for review. The Business Manager will review the income guidelines for accuracy and keep the documentation on file. The Food Service Director is responsible for running the Direct Certification reports. Direct Certification Reports shall be completed at the start of each school year and on a monthly basis thereafter. The Food Service Director is responsible for ensuring that student records are updated to the proper eligibility status in the student software system. The Business Manager is responsible for reviewing the Direct Certification Reports on a monthly basis and confirming that the student records have been updated. Audit Evidence: Copies of annual income guidelines and all Direct Certification Reports signed by both the Food Service Director and the Business Manager will be kept on file along with proof of the updated student record(s). Anticipated Completion Date: Effective immediately

View Audit 341884

Finding 522594 (2024-001)

Significant Deficiency 2024

Cny Works, Inc.

NY

Subrecipient Monitoring Allowable Costs / Cost Principles Eligibility

Corrective Action Plan for FYE June 30, 2024 Finding 2024-001 Corrective Action Plan: The Youth Department had a leadership void for the first half of program year 2023 which resulted in having a vacuum on direct leadership in the department which unfortunately led to this finding. I am pleased to r...

Corrective Action Plan for FYE June 30, 2024 Finding 2024-001 Corrective Action Plan: The Youth Department had a leadership void for the first half of program year 2023 which resulted in having a vacuum on direct leadership in the department which unfortunately led to this finding. I am pleased to report that in January 2024 CNY Works welcomed a new Director of Youth Services which has led the department to transform and flourish in the last year. Under the new leadership, the Youth Department has implemented new internal controls, processes and has staff focused and running programs under the Workforce Innovation and Opportunity Act (WIOA). Nonetheless, CNY Work youth staff along with the Executive Director and the Director of Youth Services will review current policies and procedures to ensure these are operating effectively reflecting allowable activities and allowable costs (including hours worked by youth in the program) are allocated and charged accurately to the federal program. Emphasizing the importance of internal controls to ensure documents are signed by designated individuals to comply with requirements. The Director of Youth Services will continue to review timesheets, eligibility forms, and signatures, along with other requirements of the program to ensure internal control procedures are adequate and operating as intended. Finally, management will continue to analyze methods for monitoring the operational effectiveness of the applied internal controls on compliance and document any mitigating controls that are developed and implemented. Contact Person Responsible for Corrective Action Plan: Rosemary Avila-Ticio Executive Director, CNY Works Phone Number: 315-477-6901 Email: ravila@cnyworks.com Anticipated Completion Date of Corrective Action Plan: March 30, 2025

View Audit 341825

Finding 522593 (2024-001)

Significant Deficiency 2024

University of Mobile, Inc.

AL

Eligibility Matching / Level of Effort / Earmarking

2024-001 Federal Direct Student Loans, ALN 84.268 Condition: There were incorrect cost of attendance amounts used to calculate subsidized loans for 5 out 40 students tested. Criteria: According to the U.S. Department of Education, an institution must use cost of attendance minus expected family co...

2024-001 Federal Direct Student Loans, ALN 84.268 Condition: There were incorrect cost of attendance amounts used to calculate subsidized loans for 5 out 40 students tested. Criteria: According to the U.S. Department of Education, an institution must use cost of attendance minus expected family contribution and other financial aid to calculate the amount of subsidized loans that students are eligible to receive. Cause: The University’s student information system (SIS) uses rules to determine which budget components should be assigned to students' cost of attendance based on housing choice, program of student, and classification. It was determined early in the packaging process that some of those budget components were being assigned incorrectly. A support ticket was opened with SIS helpdesk and the issue was corrected within 48 hours. Once the SIS was corrected to assign budget components according to the rules for each budget, all students were reassigned budgets to reflect the correct amounts. Effect: Subsidized loans could have been improperly calculated at the time of packaging, but prior to applying these funds to student charges, there are student eligibility criteria (SEC) rules in place that prevents aid from transmitting if the student is not entitled. In addition, staff weekly run reports to review cost of attendance and subsidized/unsubsidized eligibility. Context: During the compliance audit testing of federal direct student loans, it was determined that the incorrect cost of attendance total was used on the student loan worksheet to calculate eligibility for 5 out of 40 students tested, but SIS reflected the updated correct cost of attendance. Recommendation: We recommend the University continue to monitor the system for future issues and consider updating the supporting documentation as appropriate in the future. View of Responsible Officials and Planned Corrective Action: Management has corrected the SIS. In reviewing the students affected, it was determined the calculated subsidized loan amounts were still appropriate even though the student loan worksheet did not match the cost of attendance reflected in the SIS.

View Audit 341821

Finding 522542 (2024-002)

Significant Deficiency 2024

Capital Area Food Bank, Inc.,

DC

Questioned Costs Eligibility Subrecipient Monitoring

Finding 2024-002: Eligibility – Significant Deficiency in Internal Control over Compliance, Other Matter Compliance Finding Condition: During eligibility testing, we found instances of non-compliance, as follows: TEFAP – We noted that for one out of 20 participants sampled for TEFAP, an ineligible c...

Finding 2024-002: Eligibility – Significant Deficiency in Internal Control over Compliance, Other Matter Compliance Finding Condition: During eligibility testing, we found instances of non-compliance, as follows: TEFAP – We noted that for one out of 20 participants sampled for TEFAP, an ineligible community partner organization was able to order approximately 100 pounds of TEFAP food from CAFB’s website. CSFP – We noted that for one out of 40 individual participants sampled for CSFP, one participant’s original enrollment documents supporting eligibility was missing. The organization did have the participant’s re-enrollment documents for the subsequent fiscal year. This is related to a person being eligible to receive food. Views of Responsible Officials and Planned Corrective Actions: The Organization's investigation into the root causes of the two incidents revealed clerical errors. For the TEFAP incident, a mistake in the partner organization's profile allowed access to USDA food via our online ordering portal. Regarding the CSFP participant, the initial eligibility documents were misplaced, but subsequent reauthorization documents were available. The Organization’s planned corrective actions with respect to the two instances include the following: TEFAP partner eligibility:  Review and enhance existing procedures for establishing partner organization profiles; and  Establish a periodic reconciliation of partner organization’s authorized to access TEFAP commodities in the online ordering portal with a listing of authorized TEFAP partners CSFP eligibility:  Review and enhance existing procedures for filing individual eligibility documents; and  Continued internal reviews by the Organization’s compliance department covering the filing of individual eligibility documents Anticipated Completion Date: March 2025

View Audit 341804 Questioned Costs: $1

Finding 522488 (2024-002)

Material Weakness 2024

Westmoreland County Community College

PA

Questioned Costs Student Financial Aid Allowable Costs / Cost Principles

Finding 2024-002: Student Financial Aid Cluster Allowable Costs and Allowable Activities and Eligibility View of Responsible Officials and Planned Corrective Action: The College has documented procedures in place - Auto packaging and Repackaging within the new SIS calculates Pell awards based on the...

Finding 2024-002: Student Financial Aid Cluster Allowable Costs and Allowable Activities and Eligibility View of Responsible Officials and Planned Corrective Action: The College has documented procedures in place - Auto packaging and Repackaging within the new SIS calculates Pell awards based on the SAI and the Enrollment Intensity of the student (based on new Regulations starting with the 2024-2025 Academic Year). If the Cost of Attendance needs to be manually adjusted, the Financial Aid Staff member will document the breakdown of the COA. System Reports will be reviewed to allow for a secondary review of awards.

View Audit 341751 Questioned Costs: $1

Finding 522479 (2024-004)

Significant Deficiency 2024

Morning Calm Apt

WA

Eligibility Subrecipient Monitoring Reporting

FINDINGS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING NO. 2022-004 Statement of Condition: Management had developed activity level controls over compliance that included compliance review of all tenant certifications including income verifications used in determining the amount of rent amounts d...

FINDINGS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING NO. 2022-004 Statement of Condition: Management had developed activity level controls over compliance that included compliance review of all tenant certifications including income verifications used in determining the amount of rent amounts due from eligible PRAC 202 participants (tenants) by the management firm compliance department. However, during our testing it was discovered that the files were missing documentation of varying importance which if properly reviewed, should have been identified as missing; some files were missing evidence of file review. Auditor Recommendation: Management has a process to review and approve all tenant certifications being prepared by site staff (community managers). The approval process should include an approval stamp or some other evidence that each file has been reviewed by the compliance department and is approved for processing. Further, senior management should have an ongoing monitoring process to ensure that the compliance department is carrying out the review process. S3800-130: Response Indicator: Agree. S3800-140: Completion Date: February 3, 2025 S3800-150: Action Taken: The board had decided to change property management firms because of the history and severity of financial statement findings and major program fundings. The board believes that the new management firm has a properly designed and functioning system of internal controls to prevent tenants from being improperly housed at the property and granted rental assistance for which they are not eligible.

View Audit 341741

Finding 522399 (2024-001)

None 2024

Morehead State University

KY

Eligibility Special Tests & Provisions

Identifying Number: 2024-001 Finding: The provisions of 36 CFR Section 686.31(e) were not followed. Notifications were not sent to TEACH Grant recipients to inform the students of their right to cancel their TEACH Grant and to inform the students of the procedure and time by which the students must ...

Identifying Number: 2024-001 Finding: The provisions of 36 CFR Section 686.31(e) were not followed. Notifications were not sent to TEACH Grant recipients to inform the students of their right to cancel their TEACH Grant and to inform the students of the procedure and time by which the students must notify the institution that he or she wishes to cancel their TEACH Grant or TEACH Grant disbursement. Corrective Actions Taken: We agree with this finding and recommendation. University staff worked with the University's Enterprise System consultants, Ellucian, to develop a procedure to ensure notifications required by 36 CFR Section 686.31(e) are sent to students who receive TEACH Grant funds. Notifications were updated to include language about the right to cancel TEACH Grants and the procedures and time by which the student must notify the institution that he or she wishes to cancel the TEACH Grant or TEACH Grant disbursement. The procedure was implemented to fully comply with 36 CFR Section 686.31(e) on January 30, 2024. Name of Responsible Person: Dr. Heidi Neal, Assistant Vice President of Enrollment Management Completion Date: January 30, 2024

View Audit 341679

Finding 522334 (2024-002)

Significant Deficiency 2024

Region One Education Service Center

TX

Allowable Costs / Cost Principles Eligibility School Nutrition Programs

2024-002 Timely Time and Effort Approvals The Center continues to evaluate its processes related to time and effort. Our Time and Effort electronic system has been evaluated and enhancements are forthcoming to include robust functionalities to include timely supervisor approval notifications. Propos...

2024-002 Timely Time and Effort Approvals The Center continues to evaluate its processes related to time and effort. Our Time and Effort electronic system has been evaluated and enhancements are forthcoming to include robust functionalities to include timely supervisor approval notifications. Proposed Completion Date: May 31, 2025 Name of contact person: Rumalda Ruiz, Deputy Director – Business, Operations, & School Finance Support Contact: (956) 984-6290

View Audit 341604

Finding 522331 (2024-004)

Significant Deficiency 2024

Parkview School District

WI

School Nutrition Programs Eligibility

2024-004 Lack of Retention of Student Applications Condition: In our testing of 40 applications for free and reduced lunch, 1 applications was missing. All other applications properly determined received free or reduced meals as eligibility determined. Criteria: As part of determining student e...

2024-004 Lack of Retention of Student Applications Condition: In our testing of 40 applications for free and reduced lunch, 1 applications was missing. All other applications properly determined received free or reduced meals as eligibility determined. Criteria: As part of determining student eligibility for free or reduced meals, the District receives applications from student families. Federal requirements require the Distict official making the eligibility determination to retain all applications. Cause: Administrative oversight led to one application not being retained. Effect: The District was not in compliance with the requirements of the Child Nutrition Cluster. Recommendation: We recommend the District implement a process that requires immediate filing and retention of all applications after eligibility is determined. View of responsible officials: See attachment for District’s corrective action plan.

View Audit 341597

Finding 522330 (2024-002)

Material Weakness 2024

Rockingham County

NC

Eligibility Reporting

Finding: 2024-001 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-002 Name of contact person: Corrective Action: Proposed Completion Date: Section III Federal Award Findings and Questioned Costs Management will review cases internally to ensure proper documentati...

Finding: 2024-001 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-002 Name of contact person: Corrective Action: Proposed Completion Date: Section III Federal Award Findings and Questioned Costs Management will review cases internally to ensure proper documentation is in place for eligibility. Staff will be provided with refresher training on what information should be included in case files and the importance of this being complete and accurate. Management will review and revise current procedures in place to ensure that all eligibility determination criteria is completed such as online verifications, documented sources of income/resources and amounts are accurately reflected and retained in the case file within the NC FAST Case Management System. Training will be completed by November 1, 2024 Lisa Chaney, Mandy Edwards, Nicole Victory and Debbie McGuire - Medicaid Supervisors Corrective actions for finding 2024-001 and 2024-002 also apply to the State Awards findings. Management will provide refresher training to all staff on what processes to follow when changes are reported to ensure accurate and timely review of all benefits. Management will review and revise current procedures in place to ensure that all eligibility determination criteria and documentation is completed timely and accurately reflected in the case file within the NC Fast Case Management System. Training will be completed by November 1, 2024

View Audit 341596

Finding 522329 (2024-001)

Material Weakness 2024

Rockingham County

NC

Eligibility Reporting Internal Control / Segregation of Duties

Finding: 2024-001 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-002 Name of contact person: Corrective Action: Proposed Completion Date: Section III Federal Award Findings and Questioned Costs Management will review cases internally to ensure proper documentati...

Finding: 2024-001 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-002 Name of contact person: Corrective Action: Proposed Completion Date: Section III Federal Award Findings and Questioned Costs Management will review cases internally to ensure proper documentation is in place for eligibility. Staff will be provided with refresher training on what information should be included in case files and the importance of this being complete and accurate. Management will review and revise current procedures in place to ensure that all eligibility determination criteria is completed such as online verifications, documented sources of income/resources and amounts are accurately reflected and retained in the case file within the NC FAST Case Management System. Training will be completed by November 1, 2024 Lisa Chaney, Mandy Edwards, Nicole Victory and Debbie McGuire - Medicaid Supervisors Corrective actions for finding 2024-001 and 2024-002 also apply to the State Awards findings. Management will provide refresher training to all staff on what processes to follow when changes are reported to ensure accurate and timely review of all benefits. Management will review and revise current procedures in place to ensure that all eligibility determination criteria and documentation is completed timely and accurately reflected in the case file within the NC Fast Case Management System. Training will be completed by November 1, 2024

View Audit 341596

Finding 522295 (2024-005)

Significant Deficiency 2024

Commonspirit Health

IL

Student Financial Aid Special Tests & Provisions Reporting § 200.303

REFERENCE: 2024-005 – Special Tests and Provision – Enrollment Reporting Student Financial Assistance Cluster (Assistance listing No. 84.007, 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science Finding: Good Samaritan College...

REFERENCE: 2024-005 – Special Tests and Provision – Enrollment Reporting Student Financial Assistance Cluster (Assistance listing No. 84.007, 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science Finding: Good Samaritan College of Nursing & Health Science did not have internal controls over enrollment reporting. Student enrollment information, including enrollment status changes and campus level and program level information, was not reported accurately and/or timely to the NSLDS for certain students. Corrective Action Plan: Beginning Spring of 2024, Good Samaritan College changed their reporting cycle to include five submissions per semester. This change was encouraged as a best practice from the American Association of Collegiate Registrars and Admission Officers (AACRAO). Reporting five times within a traditional semester creates an approximate 30-day cycle from first submission to the next, keeping reporting to NSLDS well below the 60-day reporting minimum. Evidence of this will be shared in the College’s monthly Compliance Committee Meetings. To address the issues of reporting “less than half time” for students who were enrolled in zero hours, Good Samaritan College has contacted the Student Information System vendor, Ellucian, to identify a technological solution allowing the reporting of students with zero hours correctly. Until a technological solution can be found, the College Registrar will run a report to cross check against each enrollment transmission for National Student Clearinghouse identifying all students who drop to zero hours and report them as withdrawn to NSC. In turn, NSC will correctly report to NSLDS the status of withdrawn. Reporting is signed off and evidence of this will be shared in the College’s monthly Compliance Committee meetings. Person Responsible: Judy Kronenberger, President Good Samaritan College of Nursing and Health Science Expected Completion: February 2025

View Audit 341568

Finding 522294 (2024-004)

Material Weakness 2024

Commonspirit Health

IL

Eligibility Matching / Level of Effort / Earmarking § 200.303

REFERENCE: 2024-004 – Eligibility HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: U.S. Department of Health and Human Services Facility: Bailey-Boushay House Finding: The Bailey-Boushay House did not retain evidence of eligibility being reviewed prior to patie...

REFERENCE: 2024-004 – Eligibility HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: U.S. Department of Health and Human Services Facility: Bailey-Boushay House Finding: The Bailey-Boushay House did not retain evidence of eligibility being reviewed prior to patient services being provided. Corrective Action Plan: Bailey-Boushay House Administrative staff will send out upcoming Eligibility expirations occurring in the next 90 days to the Clinical Supervisor and Director of Outpatient Programs. The Clinical Supervisor will forward a list to each care manager/social worker for clients on their caseload. The Clinical Supervisor will discuss the status of these updates during meetings with care manager/social worker. Notes will be made on the caseload list to document the discussion of status. The Clinical Supervisor will send a list to the care management team for clients who are within 30 days of their expiration, in order to identify clients who may be out of contact or less engaged in the program. A note will be provided with these clients' medications to remind them that they need to complete this eligibility update with a care manager or social worker. Quarterly and monthly emails of eligibility expirations will be retained for documentation purposes. Person Responsible: Katie Hara, Director of Outpatient Programs – Bailey Boushay House Expected Completion: February 2025

View Audit 341568

Finding 522263 (2024-003)

Material Weakness 2024

Hall County Housing Authority

NE

Subrecipient Monitoring Eligibility HUD Housing Programs

Corrective Action Plan Contact Person Artena Thompson 1834 W 7th Street Grand Island, NE 68803 (308) 385-5530 Finding 2024-001 Management has recognized the finding and will familiarize themselves with the requirements of these documents to ensure the proper procedures are followed and the proper do...

Corrective Action Plan Contact Person Artena Thompson 1834 W 7th Street Grand Island, NE 68803 (308) 385-5530 Finding 2024-001 Management has recognized the finding and will familiarize themselves with the requirements of these documents to ensure the proper procedures are followed and the proper documents are retained in the tenant files. Finding 2024-002 Management will familiarize themselves with the requirements and guidelines of their ACOP to better ensure that the Authority is operating and maintaining its policies. Finding 2024-003 See Finding 2024-001.

View Audit 341542

Finding 522248 (2024-005)

Significant Deficiency 2024

Nash County

NC

Eligibility Significant Deficiency

For the Year Ended June 30, 2024 Corrective Action Plan Finding 2024-003 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-004 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-005 Name of contact person: Corrective Action: Adult - Trai...

For the Year Ended June 30, 2024 Corrective Action Plan Finding 2024-003 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-004 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-005 Name of contact person: Corrective Action: Adult - Training to be provided to all Adult Medicaid workers to include adequate request for info: Property Checks, Vehicle Rebuttals, Resolution of Vehicles, 1/3 Reduction evaluation, policy section MA-2261and FL2; MA-2270, SA-3200. Targeted second parties will be completed for all workers for error trends. Family and Children's - Training to be provided to all caseworkers to include TWN and OVS learning gateway webinars, along with a review of Magi Budgeting (Household Composition, Income Determination & Introduction to Magi Budgeting). Reminding caseworkers on the importance of documentation and if notes are not documented it didn’t happen, including detailing information out, the documentation template needs to be completed on each case. Target checks on correct income, household composition and completed documentation will be completed monthly. Section III - Federal Award Findings and Questioned Costs (continued) Angel Carpenter –Family and Children's Medicaid Supervisor; Goldie Davis - Adult Medicaid Supervisor Goldie Davis - Adult Medicaid Supervisor Training to be provided to all Adult Medicaid workers to include resource entry/documentation: Policy Section MA-2230, Liquid Resources, Life Insurance CV, Property tax value, and Vehicle tax values. Documentation Long-term care/Private Living Arrangement (PLA) template provided to workers and will be implemented at the county level to be required for all case files. PLA will implement a check list to be attached to all case files as a requirement. Targeted second parties will be completed for all workers for error trends. 12/2/2024 Angel Carpenter –Family and Children's Medicaid Supervisor Medicaid caseworkers will receive refresher training to include how to process an IV-D referral at the request of the Child Support caseworker according to policy. Caseworker will receive the DHB Admin Letter No. 13-23 “Child Support Cooperation and Applying for Other Monetary Benefits Post Eligibility Benefits During the Continuous Coverage Unwinding (CCU) handouts for review. 12/13/2024 Claude Mayo Jr. Administration Building • 120 West Washington Street, Suite 3072 • Nashville, NC 27856 Phone (252) 459-9800 • Fax (252) 459-9817 190

View Audit 341498

Finding 522247 (2024-004)

Significant Deficiency 2024

Nash County

NC

Eligibility Significant Deficiency

For the Year Ended June 30, 2024 Corrective Action Plan Finding 2024-003 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-004 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-005 Name of contact person: Corrective Action: Adult - Trai...

For the Year Ended June 30, 2024 Corrective Action Plan Finding 2024-003 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-004 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-005 Name of contact person: Corrective Action: Adult - Training to be provided to all Adult Medicaid workers to include adequate request for info: Property Checks, Vehicle Rebuttals, Resolution of Vehicles, 1/3 Reduction evaluation, policy section MA-2261and FL2; MA-2270, SA-3200. Targeted second parties will be completed for all workers for error trends. Family and Children's - Training to be provided to all caseworkers to include TWN and OVS learning gateway webinars, along with a review of Magi Budgeting (Household Composition, Income Determination & Introduction to Magi Budgeting). Reminding caseworkers on the importance of documentation and if notes are not documented it didn’t happen, including detailing information out, the documentation template needs to be completed on each case. Target checks on correct income, household composition and completed documentation will be completed monthly. Section III - Federal Award Findings and Questioned Costs (continued) Angel Carpenter –Family and Children's Medicaid Supervisor; Goldie Davis - Adult Medicaid Supervisor Goldie Davis - Adult Medicaid Supervisor Training to be provided to all Adult Medicaid workers to include resource entry/documentation: Policy Section MA-2230, Liquid Resources, Life Insurance CV, Property tax value, and Vehicle tax values. Documentation Long-term care/Private Living Arrangement (PLA) template provided to workers and will be implemented at the county level to be required for all case files. PLA will implement a check list to be attached to all case files as a requirement. Targeted second parties will be completed for all workers for error trends. 12/2/2024 Angel Carpenter –Family and Children's Medicaid Supervisor Medicaid caseworkers will receive refresher training to include how to process an IV-D referral at the request of the Child Support caseworker according to policy. Caseworker will receive the DHB Admin Letter No. 13-23 “Child Support Cooperation and Applying for Other Monetary Benefits Post Eligibility Benefits During the Continuous Coverage Unwinding (CCU) handouts for review. 12/13/2024 Claude Mayo Jr. Administration Building • 120 West Washington Street, Suite 3072 • Nashville, NC 27856 Phone (252) 459-9800 • Fax (252) 459-9817 190

View Audit 341498

Finding 522246 (2024-003)

Significant Deficiency 2024

Nash County

NC

Eligibility Significant Deficiency

For the Year Ended June 30, 2024 Corrective Action Plan Finding 2024-003 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-004 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-005 Name of contact person: Corrective Action: Adult - Trai...

For the Year Ended June 30, 2024 Corrective Action Plan Finding 2024-003 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-004 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-005 Name of contact person: Corrective Action: Adult - Training to be provided to all Adult Medicaid workers to include adequate request for info: Property Checks, Vehicle Rebuttals, Resolution of Vehicles, 1/3 Reduction evaluation, policy section MA-2261and FL2; MA-2270, SA-3200. Targeted second parties will be completed for all workers for error trends. Family and Children's - Training to be provided to all caseworkers to include TWN and OVS learning gateway webinars, along with a review of Magi Budgeting (Household Composition, Income Determination & Introduction to Magi Budgeting). Reminding caseworkers on the importance of documentation and if notes are not documented it didn’t happen, including detailing information out, the documentation template needs to be completed on each case. Target checks on correct income, household composition and completed documentation will be completed monthly. Section III - Federal Award Findings and Questioned Costs (continued) Angel Carpenter –Family and Children's Medicaid Supervisor; Goldie Davis - Adult Medicaid Supervisor Goldie Davis - Adult Medicaid Supervisor Training to be provided to all Adult Medicaid workers to include resource entry/documentation: Policy Section MA-2230, Liquid Resources, Life Insurance CV, Property tax value, and Vehicle tax values. Documentation Long-term care/Private Living Arrangement (PLA) template provided to workers and will be implemented at the county level to be required for all case files. PLA will implement a check list to be attached to all case files as a requirement. Targeted second parties will be completed for all workers for error trends. 12/2/2024 Angel Carpenter –Family and Children's Medicaid Supervisor Medicaid caseworkers will receive refresher training to include how to process an IV-D referral at the request of the Child Support caseworker according to policy. Caseworker will receive the DHB Admin Letter No. 13-23 “Child Support Cooperation and Applying for Other Monetary Benefits Post Eligibility Benefits During the Continuous Coverage Unwinding (CCU) handouts for review. 12/13/2024 Claude Mayo Jr. Administration Building • 120 West Washington Street, Suite 3072 • Nashville, NC 27856 Phone (252) 459-9800 • Fax (252) 459-9817 190

View Audit 341498

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