Corrective Action Plans

Finding 522334 (2024-002)

Significant Deficiency 2024

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

Finding 522245 (2024-002)

Significant Deficiency 2024

Nash County

NC

Eligibility Significant Deficiency 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 For the Year Ended June 30, 2024 Corrective Action Plan 01/10/2025 and...

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 For the Year Ended June 30, 2024 Corrective Action Plan 01/10/2025 and 01/24/2025 Angel Carpenter –Family and Children's Medicaid Supervisor; Goldie Davis - Adult Medicaid Supervisor Medicaid caseworkers will receive additional and/or refresher training to include but not limited to running online data (OVS) when required, reviewing case determinations to ensure correct income and household size are being counted for each household member actively receiving on case(s), and accuracy of data entered onto dashboard. Second Party reviews will continue to be conducted to monitor continued progress and to ensure policies and procedures are correctly followed by caseworkers. Documentation templates have also been created and put into place to assist in ensuring cases are thoroughly documented. Case errors will be included on the Agenda for upcoming Staff Meetings and discussion will include review of accuracy/double checking determination decisions to ensure they are correct prior to authorizing or releasing determinations from hold on cases in NC FAST and ensuring correct income and household compositions are correct on determinations prior to authorizing or releasing cases from hold on cases in NC FAST and ensuring correct income and household compositions are correct on determinations prior to authorizing or releasing cases from hold. Training scheduled by 01/10/2025 for “Income & Deduction Wizard and by 01/24/2025 for “Mastering Medicaid Policy”, “Recertification & NC Fast 20020 (July 2023) “ and “ Recertification & CCU Training. Target checks on correct income, household composition and completed documentation will be completed monthly. Section II - Financial Statement Findings Dec 31, 2024. Mary Hogan, Finance Director The County agrees with the finding and will appropriately budget and make budget anendments for all leases in the future per GASB 87. Claude Mayo Jr. Administration Building • 120 West Washington Street, Suite 3072 • Nashville, NC 27856 Phone (252) 459-9800 • Fax (252) 459-9817 189

View Audit 341498

Finding 522229 (2024-001)

Material Weakness 2024

The Halifax - Warren Smart Start Partnership for Children, Inc.

NC

Questioned Costs Eligibility Subrecipient Monitoring

Going forward, all initial rosters submitted to HWSS will be reviewed by at least two different HWSS staff and compared to eligibility results to verify eligibility prior to entering rosters into NCPK KIDS. Any changes to a roster during the year will also be verified by at least two HWSS staff.

View Audit 341479 Questioned Costs: $1

Finding 522218 (2024-006)

Significant Deficiency 2024

Lee County

NC

Cash Management Eligibility Reporting

Corrective Action Plan For the Year Ended June 30, 2024 Finding 2024-004 Inaccurate Resources Entry Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Proposed completion date: 10/17/2024 Finding 2024-005 Inadequate Request for Information Name of contact person: S...

Corrective Action Plan For the Year Ended June 30, 2024 Finding 2024-004 Inaccurate Resources Entry Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Proposed completion date: 10/17/2024 Finding 2024-005 Inadequate Request for Information Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Proposed completion date: 10/09/2024 and 10/17/2024 Finding 2024-006 Untimely Review of SSI Terminations Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Proposed completion date: 10/17/2024 Section III - Federal Award Findings and Questioned Costs (continued) Training has been conducted on the Inaccurate Resource topic with staff specifically concerning the finding areas and ensuring all verified resources are appropriately updated in the NC FAST evidence. Second party reviews will be enhanced to ensure those conducting the review ensure that proper procedures are being followed with regard to these policies. Training has been conducted on the Inadequate Request for Information topic with staff specifically concerning the finding areas and ensuring all required requests for information are sent via 5097/20020 where applicable. Second party reviews will be enhanced to ensure those conducting the review ensure that proper procedures are being followed with regard to these policies. Training has been conducted on the Untimely Review of SSI Terminations topic with staff specifically concerning the finding areas and ensuring all timeframes are adhered to when processing actions. Second party reviews will be enhanced to ensure those conducting the review ensure that proper procedures are being followed with regard to these policies. 170

View Audit 341449

Finding 522217 (2024-005)

Significant Deficiency 2024

Lee County

NC

Eligibility Reporting Significant Deficiency

Corrective Action Plan For the Year Ended June 30, 2024 Finding 2024-004 Inaccurate Resources Entry Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Proposed completion date: 10/17/2024 Finding 2024-005 Inadequate Request for Information Name of contact person: S...

Corrective Action Plan For the Year Ended June 30, 2024 Finding 2024-004 Inaccurate Resources Entry Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Proposed completion date: 10/17/2024 Finding 2024-005 Inadequate Request for Information Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Proposed completion date: 10/09/2024 and 10/17/2024 Finding 2024-006 Untimely Review of SSI Terminations Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Proposed completion date: 10/17/2024 Section III - Federal Award Findings and Questioned Costs (continued) Training has been conducted on the Inaccurate Resource topic with staff specifically concerning the finding areas and ensuring all verified resources are appropriately updated in the NC FAST evidence. Second party reviews will be enhanced to ensure those conducting the review ensure that proper procedures are being followed with regard to these policies. Training has been conducted on the Inadequate Request for Information topic with staff specifically concerning the finding areas and ensuring all required requests for information are sent via 5097/20020 where applicable. Second party reviews will be enhanced to ensure those conducting the review ensure that proper procedures are being followed with regard to these policies. Training has been conducted on the Untimely Review of SSI Terminations topic with staff specifically concerning the finding areas and ensuring all timeframes are adhered to when processing actions. Second party reviews will be enhanced to ensure those conducting the review ensure that proper procedures are being followed with regard to these policies. 170

View Audit 341449

Finding 522216 (2024-004)

Significant Deficiency 2024

Lee County

NC

Eligibility Significant Deficiency

Corrective Action Plan For the Year Ended June 30, 2024 Finding 2024-004 Inaccurate Resources Entry Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Proposed completion date: 10/17/2024 Finding 2024-005 Inadequate Request for Information Name of contact person: S...

Corrective Action Plan For the Year Ended June 30, 2024 Finding 2024-004 Inaccurate Resources Entry Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Proposed completion date: 10/17/2024 Finding 2024-005 Inadequate Request for Information Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Proposed completion date: 10/09/2024 and 10/17/2024 Finding 2024-006 Untimely Review of SSI Terminations Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Proposed completion date: 10/17/2024 Section III - Federal Award Findings and Questioned Costs (continued) Training has been conducted on the Inaccurate Resource topic with staff specifically concerning the finding areas and ensuring all verified resources are appropriately updated in the NC FAST evidence. Second party reviews will be enhanced to ensure those conducting the review ensure that proper procedures are being followed with regard to these policies. Training has been conducted on the Inadequate Request for Information topic with staff specifically concerning the finding areas and ensuring all required requests for information are sent via 5097/20020 where applicable. Second party reviews will be enhanced to ensure those conducting the review ensure that proper procedures are being followed with regard to these policies. Training has been conducted on the Untimely Review of SSI Terminations topic with staff specifically concerning the finding areas and ensuring all timeframes are adhered to when processing actions. Second party reviews will be enhanced to ensure those conducting the review ensure that proper procedures are being followed with regard to these policies. 170

View Audit 341449

Finding 522215 (2024-003)

Significant Deficiency 2024

Lee County

NC

Subrecipient Monitoring 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: Finding 2024-003 Inaccurate Information Entry Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Acti...

Finding 2024-001 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-002 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-003 Inaccurate Information Entry Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Proposed completion date: 10/9/2024 6/30/2025 Section III - Federal Award Findings and Questioned Costs Training has been conducted on the Inaccurate Information Entry topic with staff specifically concerning the finding areas and ensuring all verified information is appropriately updated in the NC FAST evidence. Second party reviews will be enhanced to ensure those conducting the review verify that proper procedures are being followed with regard to these policies. Corrective Action Plan For the Year Ended June 30, 2024 Section II - Financial Statement Findings 6/30/2025 Candace Iceman, Finance Director Budget amendments will be prepared to properly account for lease and subscription principal payments and required reporting. In addition, the budget will be closely monitored going forward to ensure budget availability. Candace Iceman, Finance Director A full review of the existing lease and subscription agreements will be done to ensure accurate data is being tracked and terminations are being removed from all reporting schedules in a timely manner. Additionally, any existing agreements that have a change of terms will be terminated instead of modified to provide accurate and transparent information. Reviews of these documents will be conducted quarterly to make timely adjustments and corrections. 169

View Audit 341449

Finding 522176 (2024-005)

None 2024

Sitting Bull College

ND

Questioned Costs Eligibility Significant Deficiency

Contract Person Dr. Koreen Ressler Corrective Action The College is outsourcing federal financial aid to Campus Ivy. The company will assist with proper controls and procedures to ensure students are disbursed the correct amount of PELL funds. Completion Date Fiscal year 2025

View Audit 341393 Questioned Costs: $1

Finding 522006 (2024-001)

Material Weakness 2024

University of Kansas School of Medicine - Wichita Mpa

KS

Internal Control / Segregation of Duties Eligibility Reporting

In response to Finding 2024-001 Segregation of Duties/ Review Procedures identified in the fiscal year 2024 audit, the University of Kansas School of Medicine-Wichita Medical Practice Association has modified the HOPW A, housing opportunities for persons with AIDS, procedures for verifying the parti...

In response to Finding 2024-001 Segregation of Duties/ Review Procedures identified in the fiscal year 2024 audit, the University of Kansas School of Medicine-Wichita Medical Practice Association has modified the HOPW A, housing opportunities for persons with AIDS, procedures for verifying the participant's eligibility, rent and utility assistance calculations for accuracy assurance. Immediately, the program has modified the KCTH checklist for housing assistance/support services to include a verification line for both the "intake" and the "verified" for each participant file. To manage the increasing workload of the growing program, a new housing coordinator position is in the recruitment stage. This position will ensure there is an available FTE to complete the verification process timely and assist the Ryan White case managers with client housing needs. Sheila Norris, Director of Finance, will serve as the contact person for this corrective action plan. We hope these changes will sufficiently address Finding 2024-001 Segregation of Duties/ Review Procedures.

View Audit 341251

Finding 522004 (2024-001)

None 2024

Baptist Bible College

MO

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

Program Name: Federal Direct Student Loan Program ALN and Program Expenditures: 84.268($1,647,759)Award Number: P268K243629 Federal Award Year: July 1, 2023 to June 30, 2024 Questioned Costs:$1,000 Condition Found: The amount of unsubsidized Federal Direct Loans awarded was incorrect for one of thir...

Program Name: Federal Direct Student Loan Program ALN and Program Expenditures: 84.268($1,647,759)Award Number: P268K243629 Federal Award Year: July 1, 2023 to June 30, 2024 Questioned Costs:$1,000 Condition Found: The amount of unsubsidized Federal Direct Loans awarded was incorrect for one of thirty-two students in our sample that received Federal Direct Loans. Corrective Action Plan: Management agrees with the auditors’ finding. The Financial Aid Director returned $1,000 of unsubsidized Federal Direct Loan funds to the Department of Education on October 24, 2024. The financial aid office and registrar’s office will work together to ensure that both parties are aware of the student’s credit hours passed and their eligibility for federal aid. Anticipated Completion Date: The corrective action was completed on October 24, 2024 Contact Person Brian Rains, Director of Financial Aid 17-268-6045

View Audit 341250 Questioned Costs: $1

Finding 521531 (2024-002)

None 2024

Southern Wesleyan University

SC

Questioned Costs Student Financial Aid Eligibility

Need Analysis Planned Corrective Action: A process to periodically review over and under awarding of federal need-based aid will be implemented. This will require IT assistance to create and run lists of students in this situation on a weekly basis. Person Responsible for Corrective Action Plan: T...

Need Analysis Planned Corrective Action: A process to periodically review over and under awarding of federal need-based aid will be implemented. This will require IT assistance to create and run lists of students in this situation on a weekly basis. Person Responsible for Corrective Action Plan: Thomas Valles, Director of Financial Aid Anticipated Date of Completion: April 30, 2025

View Audit 341204 Questioned Costs: $1

Finding 521435 (2024-003)

Significant Deficiency 2024

Langston University

OK

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

Recommendation: We recommend the University evaluate its procedures around disbursements of loans and ensure that notifications of disbursements are sent and contain all the required elements outlined in the FSA handbook. Explanation of disagreement with audit finding: There is no disagreement with ...

Recommendation: We recommend the University evaluate its procedures around disbursements of loans and ensure that notifications of disbursements are sent and contain all the required elements outlined in the FSA handbook. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Questioned Costs: N/A Action taken in response to finding: This is a repeat finding that was first presented to the University in conjunction with the release of the 2022 audit report in November 2023. Loan disbursement procedures and processes have been updated to ensure notifications are sent as outlined in the FSA Handbook. Name(s) of the contact person(s) responsible for the corrective action: Mr. Heath Burge, Assistant Vice President for Strategic Enrollment and Advising Services and Ms. Nacasaw Coppage, Interim Director, Office of Financial Aid. Planned completion date for corrective action plan: December 2024

View Audit 341200

Finding 521239 (2024-001)

Significant Deficiency 2024

School City of Whiting

IN

School Nutrition Programs Internal Control / Segregation of Duties Eligibility § 200.303

FINDING 2024-001 Child Nutrition Cluster - Eligibility School Breakfast program, National School Lunch Program, Eligibility, Significant Deficiency Contact Person Responsible for Corrective Action: Contact Phone Number: Kim Pusateri 219-659-0656 ext. 157 Views of Responsible Official: We concur with...

FINDING 2024-001 Child Nutrition Cluster - Eligibility School Breakfast program, National School Lunch Program, Eligibility, Significant Deficiency Contact Person Responsible for Corrective Action: Contact Phone Number: Kim Pusateri 219-659-0656 ext. 157 Views of Responsible Official: We concur with the finding. Internal Controls and procedures will be implemented to ensure accurate eligibility determinations for free and reduced-price meals by implementing internal controls, segregation of duties, and documented reviews. Description of Corrective Action Plan: Applications (eligibility): • Maintain records of all reviews for audit purposes. o Take a picture of the eligibility grid for review and date it. o Require two staff members (Director of Food Services and designee) to sign off on the review. Direct Certifications • The direct certification report will be run monthly and uploaded into the school point-of-sale system. A copy of the report will be saved, printed and checked that it was uploaded properly. A copy of the student's application and history will be printed and stapled to the direct cert report to verify that the change was made. It will be dated and initialed and saved in a folder. Anticipated Completion Date: Immediately

View Audit 341181

Finding 521130 (2024-005)

Material Weakness 2024

Sheridan Community Schools

IN

School Nutrition Programs Internal Control / Segregation of Duties Eligibility § 200.303

FINDING 2024-005 Finding Subject: Child Nutrition Cluster (School Lunch) – Eligibility Summary of Finding: Café Director uploaded the Direct Certification reports from the state into the software system without following a documented oversight or review process to ensure that direct certified studen...

FINDING 2024-005 Finding Subject: Child Nutrition Cluster (School Lunch) – Eligibility Summary of Finding: Café Director uploaded the Direct Certification reports from the state into the software system without following a documented oversight or review process to ensure that direct certified students were accurately processed. This highlights a lack of documented controls for directly certified students. Contact Person Responsible for Corrective Action: Robin Popejoy Contact Phone Number and Email Address: 317.758.4172 – rpopejoy@sheridan.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Data Department will collaborate with the Café Department to input and ensure the accuracy of the information. Anticipated Completion Date: Already started in August of 2024.

View Audit 341082

Finding 521128 (2024-001)

None 2024

Calvary Towers, INC

VA

Eligibility

Management will ensure that tenant files will retain all necessary documentation and required forms to substantiate eligibility and compliance with rent procedures. Files will not be purged of any documentation that supports tenant's eligibility. Anticipated completion date: January 22, 2025. Respon...

Management will ensure that tenant files will retain all necessary documentation and required forms to substantiate eligibility and compliance with rent procedures. Files will not be purged of any documentation that supports tenant's eligibility. Anticipated completion date: January 22, 2025. Responsible Contact Person: Michelle N. Thomas, Property Manager

View Audit 341077

Finding 521062 (2024-001)

None 2024

Galapagos Rockford Charter School Nfp, Inc.

IL

Eligibility Reporting

Corrective Action Plan June 30, 2024 Galapagos Rockford Charter School NFP, Inc. respectfully submits the following corrective action plan for the year ended June 20, 2024. Name and address of public accounting firm: Grieco & Adelman LLC 2340 S River Road, Suite 311 Des Plaines, IL 60018 Audi...

Corrective Action Plan June 30, 2024 Galapagos Rockford Charter School NFP, Inc. respectfully submits the following corrective action plan for the year ended June 20, 2024. Name and address of public accounting firm: Grieco & Adelman LLC 2340 S River Road, Suite 311 Des Plaines, IL 60018 Audit Period: June 30, 2024 The findings from the June 30, 2024 Schedule of Findings and Questioned Costs are discussed below: Finding No.2023-001: Noncompliance with Federal Filing Requirements Action Taken: Timely filing will be made for the fiscal year ended June 30, 2024 Sincerely yours, 􀀁f-Luu Michael Lane ChiefExecutive Officer

View Audit 340975

Corrective Action Plans

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