Corrective Action Plans

Finding 521055 (2024-001)

Significant Deficiency 2024

The Russell Child Development Center, Inc.

KS

Cash Management Eligibility Significant Deficiency

2024-001 Eligibility Condition Six providers received an improper amount for their meal reimbursement for the month tested. Recommendation Controls should be reviewed and updated to ensure that reimbursements are only requested for complete and accurate meal counts at the correct rate of reimburse...

2024-001 Eligibility Condition Six providers received an improper amount for their meal reimbursement for the month tested. Recommendation Controls should be reviewed and updated to ensure that reimbursements are only requested for complete and accurate meal counts at the correct rate of reimbursement, and that only eligible participants are submitted to the State for reimbursement. Comments on the Finding Recommendation The CACFP at The Russell Child Development Center, Inc. is aware of the oversight and will continue to strive to improve its review process. Action Taken: As of the date of this notice, CACFP staff will continue to verify that the tally marks from the paper claims match the total provided. Those tally marks are then entered into My Food Program, and the total is again verified to match the paper claim. The Director of the CACFP program is now a third check for the tally marks matching what’s entered into My Food Program, as well as the totals claimed by the provider. Manual claim adjustments will continue to be saved and filed with supporting documentation, if applicable.

View Audit 340951

Finding 521044 (2024-001)

Significant Deficiency 2024

Chase Brexton Health Services, Inc.

MD

Eligibility Internal Control / Segregation of Duties

The Operations and Social Work and Outreach teams, under the leadership of Alice Sliwka, Chief Operating and Quality Officer, will review and revise our current practices to ensure education and accompanying audits address compliance for all Chase Brexton patients qualifying for a sliding fee discou...

The Operations and Social Work and Outreach teams, under the leadership of Alice Sliwka, Chief Operating and Quality Officer, will review and revise our current practices to ensure education and accompanying audits address compliance for all Chase Brexton patients qualifying for a sliding fee discount. This will ensure that all persons, regardless of need, will be evaluated annually to ensure all required documentation is obtained, retained, and properly evaluated as to level of sliding fee scale. Chase Brexton will begin the process of evaluating and developing these protocols immediately with completion expected by March 31, 2025.

View Audit 340926

Finding 520954 (2024-002)

Significant Deficiency 2024

Orion Area Not-for Profit Housing Corporation

MI

HUD Housing Programs Allowable Costs / Cost Principles Eligibility

Corrective Action Plan Orion Area Non-Profit Housing Corporation Project No. 044-11113 Year Ended June 30, 2024 January 31, 2025 FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2024-002 – Eligibility - Tenant Income Threshold Finding Type. Immaterial noncompliance, Significant deficiency in internal...

Corrective Action Plan Orion Area Non-Profit Housing Corporation Project No. 044-11113 Year Ended June 30, 2024 January 31, 2025 FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2024-002 – Eligibility - Tenant Income Threshold Finding Type. Immaterial noncompliance, Significant deficiency in internal controls over compliance (Eligibility) Federal programs U.S. Department of Housing and Urban Development  Section 8 Housing Assistance Payments (ALN# 14.195) Condition. Less than 40% of tenants who moved into the property during the year met the extremely low-income threshold and management did not maintain records of marketing efforts targeted to extremely low-income families, demonstrating that reasonable efforts were made to fill available units accordingly and that such efforts are ongoing. Effect. As a result of this condition, the Project failed to meet the prescribed income targeting requirements and documentation of marketing efforts to reach the target population. Plan. Management agrees with finding 2024-002. Management agrees to target extremely low-income individuals for residence, and to retain marketing records that support this effort. Contact Person Responsible for This Corrective Action: Laura Maisevich, Senior Housing Manager Anticipated completion date: June 30, 2025

View Audit 340845

Finding 520950 (2024-001)

Significant Deficiency 2024

East Detroit Area Non-Profit Housing Corporation

MI

Allowable Costs / Cost Principles Eligibility HUD Housing Programs

Corrective Action Plan East Detroit Area Non-Profit Housing Corporation Project No. 044-EH221 Year Ended June 30, 2024 January 31, 2025 FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2024-001 – Eligibility - Tenant File Documentation Finding Type. Immaterial noncompliance, Significant deficiency in...

Corrective Action Plan East Detroit Area Non-Profit Housing Corporation Project No. 044-EH221 Year Ended June 30, 2024 January 31, 2025 FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2024-001 – Eligibility - Tenant File Documentation Finding Type. Immaterial noncompliance, Significant deficiency in internal controls over compliance (Eligibility) Federal programs U.S. Department of Housing and Urban Development  Supportive Housing for the Elderly (ALN# 14.157) Condition. Out of a sample of 6 tenant files, it was noted: 1. One out of six instances where an EIV was not run for a tenant file within 90 days of move in; 2. One out of six instances where a refund was not disbursed to a tenant within 60 days of move-out; 3. Two out of six instances where the incorrect checking account balance was used in the verification of tenant assets; Effect. As a result of this condition, employees did not follow HUD guideline procedures, and/or did not properly calculate the tenant subsidy in HUD Form 50059. While there were no significant differences in the amount of subsidies allowed compared to subsidies received, the lack of effective internal controls could lead to future significant noncompliance. Plan. Management agrees with finding 2024-001. All files are to be inspected in the current fiscal year to ensure compliance with HUD regulations. File maintenance will be competed following each move in and annual recertification. In addition to one-on-one training, the housing administrator has signed up for additional training including a WebEx on annual recertification and a basic EIV course. Additional training sessions are forthcoming. Contact Person Responsible for This Corrective Action: Laura Maisevich, Senior Housing Manager Anticipated completion date: 1/31/2025

View Audit 340843

Finding 520948 (2024-002)

Significant Deficiency 2024

Highland Area Non-Profit Housing Corporation

MI

HUD Housing Programs Allowable Costs / Cost Principles Eligibility

Corrective Action Plan Highland Area Non-Profit Housing Corporation Project No. 044-11111 Year Ended June 30, 2024 January 31, 2025 FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2024-002 – Eligibility - Tenant Income Threshold Finding Type. Immaterial noncompliance, Significant deficiency in inter...

Corrective Action Plan Highland Area Non-Profit Housing Corporation Project No. 044-11111 Year Ended June 30, 2024 January 31, 2025 FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2024-002 – Eligibility - Tenant Income Threshold Finding Type. Immaterial noncompliance, Significant deficiency in internal controls over compliance (Eligibility) Federal programs U.S. Department of Housing and Urban Development  Section 8 Housing Assistance Payments (ALN# 14.195) Condition. Less than 40% of tenants who moved into the property during the year met the extremely low-income threshold and management did not maintain records of marketing efforts targeted to extremely low-income families, demonstrating that reasonable efforts were made to fill available units accordingly and that such efforts are ongoing. Effect. As a result of this condition, the Project failed to meet the prescribed income targeting requirements and documentation of marketing efforts to reach the target population. Plan. Management agrees with finding 2024-002. Management agrees to target extremely low-income individuals for residence, and to retain marketing records that support this effort. Contact Person Responsible for This Corrective Action: Laura Maisevich, Senior Housing Manager Anticipated completion date: June 30, 2025

View Audit 340840

Finding 520888 (2024-001)

Significant Deficiency 2024

Rainbow Fleet, Inc.

OK

Eligibility Reporting Matching / Level of Effort / Earmarking § 200.512

Recommendation: We recommend that management implement processes to ensure timely completion and submission of the Single Audit report in future years. This could include setting internal deadlines, increasing oversight, and coordinating with the audit firm to identify and address potential delays e...

Recommendation: We recommend that management implement processes to ensure timely completion and submission of the Single Audit report in future years. This could include setting internal deadlines, increasing oversight, and coordinating with the audit firm to identify and address potential delays earlier in the audit process. Action Taken: Management agrees with the finding and will take steps to improve the timeliness of the audit process. Specifically, management has hired a new Chief Operating Officer and Chief Executive Officer who have been notified of the reporting requirements of the federal awards. Anticipated completion date: January 31, 2025 Name of contact person and title: Quisha Beardsley, Chief Executive Officer

View Audit 340750

Finding 520857 (2024-002)

None 2024

Williams College

MA

Student Financial Aid Reporting Eligibility

Management agrees with the finding and in concurrence with the recommendations the Registrar’s Office processes and documentation will be updated as follows: Major change process: If a request is submitted to drop a major while a student is on leave, the effective date will be recorded as the date...

Management agrees with the finding and in concurrence with the recommendations the Registrar’s Office processes and documentation will be updated as follows: Major change process: If a request is submitted to drop a major while a student is on leave, the effective date will be recorded as the date of the leave rather than the date the change was initiated. Leave of absence process: All withdrawals will be reported to the National Student Clearinghouse (NSC) manually within 2 weeks of being processed to avoid any delays or issues with the regularly scheduled Peoplesoft delivered report. If due to the schedule, a W status is reported via the delivered report instead of by hand, the person responsible for enrollment reporting will verify the status with the NSC, including program-level data. Ongoing training will be provided and a senior member of our staff will audit the major change and leave of absence processes moving forward. This corrective action plan has been implemented as of January 2025.

View Audit 340686

Finding 520845 (2024-002)

None 2024

Simpson University

CO

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Incorrect Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: Our records indicate that the student's account at Simpson University was reported to the National Student Clearinghouse (NSC) on several occasions while the student was enrolled. It is the duty o...

Incorrect Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: Our records indicate that the student's account at Simpson University was reported to the National Student Clearinghouse (NSC) on several occasions while the student was enrolled. It is the duty of the NSC program to ensure the accurate transmission of information to the National Student Loan Data System (NSLDS). Once the data leaves Simpson University, the university does not track its progress to other entities. It is recommended that any necessary adjustments be discussed directly with the NSC, particularly if issues arise from their data transfer to third parties. To ensure accuracy, various methods can be implemented, such as conducting random data audits to verify that the information sent to NSC matches that in the NSLDS. This process can be quite exhaustive. Alternatively, a sample audit might involve reviewing a certain error threshold; for instance, if 300 records are submitted, a check of 15-30 records could be performed, reflecting an error tolerance of approximately 5-10%. Another option is for the reporting body to collaborate with NSC in identifying any errors or complications that may affect the correct data transmission. Simpson University maintains evidence that all data submissions to the NSC have been properly reported, accepted, and timely without any discrepancies. Person Responsible for Corrective Action Plan: Adrienne Currington, Registrar Anticipated Date of Completion: Next NSC reporting cycle

View Audit 340662

Finding 520819 (2024-003)

Material Weakness 2024

Alamance County, North Carolina

NC

Eligibility Material Weakness Internal Control / Segregation of Duties

Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: Management acknowledges this finding, recognizing that the reviewed sample includes casework from an earlier period when record-keeping practices were not as rigorous as they are today. Actions have alread...

Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: Management acknowledges this finding, recognizing that the reviewed sample includes casework from an earlier period when record-keeping practices were not as rigorous as they are today. Actions have already been taken to enhance record-keeping among current staff and cases. Caseworkers will be reminded to ensure that all documents are properly filed and to double-check the accuracy of the information entered to minimize human error. Training sessions will emphasize the expectations for document retention and the importance of reviewing inputted information for accuracy. Additionally, supervisors and Quality Assurance staff will conduct targeted second-party reviews related to these findings. Proposed Completion Date: Immediate and ongoing.

View Audit 340657

Finding 520818 (2024-002)

Material Weakness 2024

Alamance County, North Carolina

NC

Eligibility Material Weakness Internal Control / Segregation of Duties

Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: Management concurs with this audit finding. Caseworkers will receive a refresher training that includes reviewing case evidence and determinations to ensure the MAGI household is accurate. Supervisors and/...

Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: Management concurs with this audit finding. Caseworkers will receive a refresher training that includes reviewing case evidence and determinations to ensure the MAGI household is accurate. Supervisors and/or Quality Assurance staff will continue to perform monthly second party reviews on cases and will strengthen the procedures and tracking around this process. Identified issues will be promptly addressed with the team or individually to improve overall case management. Proposed Completion Date: Immediate and ongoing.

View Audit 340657

Finding 520816 (2024-003)

Significant Deficiency 2024

Paris Junior College

TX

Eligibility Internal Control / Segregation of Duties

Recommendations We recommend the College implement a review process of students' applications to ensure eligibility compliance requirements are met. Action Plan: Paris Junior College management will ensure that a comprehensive procedure is established and implemented to ensure compliance requireme...

Recommendations We recommend the College implement a review process of students' applications to ensure eligibility compliance requirements are met. Action Plan: Paris Junior College management will ensure that a comprehensive procedure is established and implemented to ensure compliance requirements are met. Contact Person: Lisa Elliott, VP Student Services Anticipated Completion Date: February 15, 2025

View Audit 340636

Finding 520757 (2024-001)

None 2024

State Technical College of Missouri

MO

Student Financial Aid Eligibility Internal Control / Segregation of Duties

2024-001 Incorrect Pell Disbursement Amount - Student Financial Aid Cluster Assistance Listing Number 84.007, 84.033, 84.063, 84.268, Grant Period - Year Ended June 30, 2024 Condition Found During our student file testing we noted two students out of forty were not disbursed the correct Pell Grant a...

2024-001 Incorrect Pell Disbursement Amount - Student Financial Aid Cluster Assistance Listing Number 84.007, 84.033, 84.063, 84.268, Grant Period - Year Ended June 30, 2024 Condition Found During our student file testing we noted two students out of forty were not disbursed the correct Pell Grant award. Based on the student’s enrollment status and need, the College under awarded the students by $716. We consider this to be an instance of noncompliance relating to the Eligibility Compliance Requirement. Corrective Action Plan The Financial Aid Office will implement a more comprehensive process to review schedule and FAFSA change reports to identify any impact on Pell awards for affected students. Responsible Person for Corrective Action Plan Heather Kleekamp, Director of Financial Aid Implementation Date of Corrective Action Plan January 2, 2025

View Audit 340518

Finding 520699 (2024-004)

Significant Deficiency 2024

Community Action of Southern Indiana

IN

Allowable Costs / Cost Principles Eligibility

Response: The Agency acknowledges this error and agrees with the recommendations. The Agency provides the additional context that the purge of records was carried out by a previous program staff member who was terminated from the Agency. The Agency has adopted a new Document Retention and Destructio...

Response: The Agency acknowledges this error and agrees with the recommendations. The Agency provides the additional context that the purge of records was carried out by a previous program staff member who was terminated from the Agency. The Agency has adopted a new Document Retention and Destruction Policy, and all program and administrative staff leadership has received training on the new policy

View Audit 340424

Finding 520661 (2024-002)

Significant Deficiency 2024

Martin County

NC

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

2024-002 Inadequate Documentation Maintained. Name of Contact Person - Angela Ellis, DSS Director. The DSS department will offer additional training to all case workers to ensure proper documentation requirements and proper review procedures are being followed to ensure files are properly maintai...

2024-002 Inadequate Documentation Maintained. Name of Contact Person - Angela Ellis, DSS Director. The DSS department will offer additional training to all case workers to ensure proper documentation requirements and proper review procedures are being followed to ensure files are properly maintained going forward. Employees will be retrained on what files should contain and the importance of complete and accurate record keeping. In addition, additional training will be provdied on online verifications, documented resources of income and those amounts agree to information in NC FAST. Proposed Completion Date: March 31, 2025

View Audit 340373

Finding 520646 (2024-003)

Significant Deficiency 2024

North Country Food Bank, Inc.

MN

Internal Control / Segregation of Duties Eligibility

Contact Person: Susie Novak Boelter, Executive Director Corrective Action Plan: The Food Bank will review their procedures to ensure all applications are maintained and the file checklist is completed for all TEFAP Agency files. Completion Date: Immediately

View Audit 340321

Finding 520635 (2024-004)

Significant Deficiency 2024

Hyde County

NC

Eligibility Significant Deficiency

Inaccurate Information Entry Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor C...

Inaccurate Information Entry Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: New process changes made 11/2022. Addition of Internal Quality Assurance employee by 1/6/25. Section IV - State Award Findings and Questioned Costs Finding: 2024-002 Inaccurate Resource Calculation In the past (prior to employment of the curent Medicaid Supervisor), staff were improperly trained on using replacement value of property vs. tax value. This is not current practice and values have been changed to tax value on all cases worked/supervised by Medicaid Supervisor. Current Recipient Eligibility Audits show the correct value is being used as there have been no findings. New process changes made 11/2022. Addition of Internal Quality Assurance employee by 1/6/25. Corrective actions for findings 2024-001, 2024-002, 2024-003, 2024-004 also apply to the State Awards findings. Finding: 2024-003 Inadequate Request for information The agency has experienced changes in staffing since the period that the error occured. New procedures have been put in place and training is ongoing. Additional Quality Assurance efforts will continue to ensure staff are sending the correct forms and accurately addressing employment results found in the system. New process changes made 11/2022. Addition of Internal Quality Assurance employee by 1/6/25. No corrective action will be implemented going forward as this policy is no longer required as of August 2023. The error for untimely IV-D (child support) referral was made under old policy. New policy effective August 2023 under Admin Letter 13-23 no longer requires post eligibility referrals to Child Support. Finding: 2024-004 Non-Cooperation With Child Support Procedures Finding: 2024-001 Workers will actively check eligibility for household size and income. An active Second Party process is in place that involves reviewing the eligibility check for accuracy. Since November 2022, the new Medicaid Supervisor has provided training and put quality control in place to help eliminate these type of errors. Further, the Agency is currently reorganizing by placing another employee in place to perform Quality Assurance/Internal Audit duties. The work of that employee will be to mirror all audits and randomly review cases checking for any recurrence of specific previous findings.

View Audit 340308

Finding 520634 (2024-003)

Significant Deficiency 2024

Hyde County

NC

Eligibility Significant Deficiency

Inaccurate Information Entry Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor C...

Inaccurate Information Entry Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: New process changes made 11/2022. Addition of Internal Quality Assurance employee by 1/6/25. Section IV - State Award Findings and Questioned Costs Finding: 2024-002 Inaccurate Resource Calculation In the past (prior to employment of the curent Medicaid Supervisor), staff were improperly trained on using replacement value of property vs. tax value. This is not current practice and values have been changed to tax value on all cases worked/supervised by Medicaid Supervisor. Current Recipient Eligibility Audits show the correct value is being used as there have been no findings. New process changes made 11/2022. Addition of Internal Quality Assurance employee by 1/6/25. Corrective actions for findings 2024-001, 2024-002, 2024-003, 2024-004 also apply to the State Awards findings. Finding: 2024-003 Inadequate Request for information The agency has experienced changes in staffing since the period that the error occured. New procedures have been put in place and training is ongoing. Additional Quality Assurance efforts will continue to ensure staff are sending the correct forms and accurately addressing employment results found in the system. New process changes made 11/2022. Addition of Internal Quality Assurance employee by 1/6/25. No corrective action will be implemented going forward as this policy is no longer required as of August 2023. The error for untimely IV-D (child support) referral was made under old policy. New policy effective August 2023 under Admin Letter 13-23 no longer requires post eligibility referrals to Child Support. Finding: 2024-004 Non-Cooperation With Child Support Procedures Finding: 2024-001 Workers will actively check eligibility for household size and income. An active Second Party process is in place that involves reviewing the eligibility check for accuracy. Since November 2022, the new Medicaid Supervisor has provided training and put quality control in place to help eliminate these type of errors. Further, the Agency is currently reorganizing by placing another employee in place to perform Quality Assurance/Internal Audit duties. The work of that employee will be to mirror all audits and randomly review cases checking for any recurrence of specific previous findings.

View Audit 340308

Finding 520633 (2024-002)

Significant Deficiency 2024

Hyde County

NC

Eligibility Significant Deficiency

Inaccurate Information Entry Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor C...

Inaccurate Information Entry Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: New process changes made 11/2022. Addition of Internal Quality Assurance employee by 1/6/25. Section IV - State Award Findings and Questioned Costs Finding: 2024-002 Inaccurate Resource Calculation In the past (prior to employment of the curent Medicaid Supervisor), staff were improperly trained on using replacement value of property vs. tax value. This is not current practice and values have been changed to tax value on all cases worked/supervised by Medicaid Supervisor. Current Recipient Eligibility Audits show the correct value is being used as there have been no findings. New process changes made 11/2022. Addition of Internal Quality Assurance employee by 1/6/25. Corrective actions for findings 2024-001, 2024-002, 2024-003, 2024-004 also apply to the State Awards findings. Finding: 2024-003 Inadequate Request for information The agency has experienced changes in staffing since the period that the error occured. New procedures have been put in place and training is ongoing. Additional Quality Assurance efforts will continue to ensure staff are sending the correct forms and accurately addressing employment results found in the system. New process changes made 11/2022. Addition of Internal Quality Assurance employee by 1/6/25. No corrective action will be implemented going forward as this policy is no longer required as of August 2023. The error for untimely IV-D (child support) referral was made under old policy. New policy effective August 2023 under Admin Letter 13-23 no longer requires post eligibility referrals to Child Support. Finding: 2024-004 Non-Cooperation With Child Support Procedures Finding: 2024-001 Workers will actively check eligibility for household size and income. An active Second Party process is in place that involves reviewing the eligibility check for accuracy. Since November 2022, the new Medicaid Supervisor has provided training and put quality control in place to help eliminate these type of errors. Further, the Agency is currently reorganizing by placing another employee in place to perform Quality Assurance/Internal Audit duties. The work of that employee will be to mirror all audits and randomly review cases checking for any recurrence of specific previous findings.

View Audit 340308

Finding 520632 (2024-001)

Significant Deficiency 2024

Hyde County

NC

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Inaccurate Information Entry Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor C...

Inaccurate Information Entry Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: New process changes made 11/2022. Addition of Internal Quality Assurance employee by 1/6/25. Section IV - State Award Findings and Questioned Costs Finding: 2024-002 Inaccurate Resource Calculation In the past (prior to employment of the curent Medicaid Supervisor), staff were improperly trained on using replacement value of property vs. tax value. This is not current practice and values have been changed to tax value on all cases worked/supervised by Medicaid Supervisor. Current Recipient Eligibility Audits show the correct value is being used as there have been no findings. New process changes made 11/2022. Addition of Internal Quality Assurance employee by 1/6/25. Corrective actions for findings 2024-001, 2024-002, 2024-003, 2024-004 also apply to the State Awards findings. Finding: 2024-003 Inadequate Request for information The agency has experienced changes in staffing since the period that the error occured. New procedures have been put in place and training is ongoing. Additional Quality Assurance efforts will continue to ensure staff are sending the correct forms and accurately addressing employment results found in the system. New process changes made 11/2022. Addition of Internal Quality Assurance employee by 1/6/25. No corrective action will be implemented going forward as this policy is no longer required as of August 2023. The error for untimely IV-D (child support) referral was made under old policy. New policy effective August 2023 under Admin Letter 13-23 no longer requires post eligibility referrals to Child Support. Finding: 2024-004 Non-Cooperation With Child Support Procedures Finding: 2024-001 Workers will actively check eligibility for household size and income. An active Second Party process is in place that involves reviewing the eligibility check for accuracy. Since November 2022, the new Medicaid Supervisor has provided training and put quality control in place to help eliminate these type of errors. Further, the Agency is currently reorganizing by placing another employee in place to perform Quality Assurance/Internal Audit duties. The work of that employee will be to mirror all audits and randomly review cases checking for any recurrence of specific previous findings.

View Audit 340308

Finding 520596 (2024-001)

Significant Deficiency 2024

Nebraska Aids Project, Inc.

NE

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

U.S. Department of Health and Human Services, Pass-through Programs from: Nebraska Department of Health and Human Services and the Iowa Department of Health and Human Services HIV Care Formula Grants, AL #93.917 Award No. 24X07HA00042, 24X07HA00041, 5884HC14 Award Periods: April 1, 2023 to March 31,...

U.S. Department of Health and Human Services, Pass-through Programs from: Nebraska Department of Health and Human Services and the Iowa Department of Health and Human Services HIV Care Formula Grants, AL #93.917 Award No. 24X07HA00042, 24X07HA00041, 5884HC14 Award Periods: April 1, 2023 to March 31, 2024 and April 1, 2024 to March 31, 2025 Eligibility: Significant Deficiency in Internal Control over Compliance Finding Summary: For 1 of 25 program participants selected for testing from the State of Nebraska, the participant file was missing documentation of HIV status. For 1 of 13 program participants selected for testing from the State of Iowa, the participant file was missing documentation for the annual recertification. Responsible Individuals: Brent Koster, Executive Director Corrective Action Plan: Procedures will be developed to ensure proper eligibility determinations are maintained in the file. Additionally, recertifications will be completed timely and documentation maintained in the file. Anticipated Completion Date: June 2025

View Audit 340211

Finding 520581 (2024-002)

Significant Deficiency 2024

Community Teamwork, Inc.

MA

Questioned Costs Eligibility HUD Housing Programs

1) Community Teamwork, Inc. has enhanced the verification process by introducing mandatory second-level reviews for all income and asset calculations for new employees. An extensive staff training program has been initiated that focuses on HUD and EOHLC requirements, with specific attention to the v...

1) Community Teamwork, Inc. has enhanced the verification process by introducing mandatory second-level reviews for all income and asset calculations for new employees. An extensive staff training program has been initiated that focuses on HUD and EOHLC requirements, with specific attention to the verification and documentation procedures. New employees will undergo a tiered review process where the new employees’ work will be audited by experienced staff until they have met the error compliance threshold. In addition, Community Teamwork, Inc. has updated their internal training protocols to focus on acceptable verification methods, accurate income reporting, and the correct completion of Form HUD-50058 MTW. As part of new protocols, program representatives are required to review the utility breakdown located in the tenant files to confirm that the utility allowance given to the tenant during the annual certification matches with the utility allowance in the tenant file. 2) Director of Intake and Leasing will ensure that the 120-day report is being run in a timely manner.

View Audit 340186 Questioned Costs: $1

Finding 520579 (2024-001)

Significant Deficiency 2024

Community Teamwork, Inc.

MA

HUD Housing Programs Internal Control / Segregation of Duties Eligibility

Community Teamwork, Inc. has enhanced the verification process by introducing mandatory second-level reviews for all income and asset calculations for new employees. An extensive staff training program has been initiated that focuses on HUD and EOHLC requirements, with specific attention to the veri...

Community Teamwork, Inc. has enhanced the verification process by introducing mandatory second-level reviews for all income and asset calculations for new employees. An extensive staff training program has been initiated that focuses on HUD and EOHLC requirements, with specific attention to the verification and documentation procedures. New employees will undergo a tiered review process where the new employees’ work will be audited by experienced staff until they have met the error compliance threshold. In addition, Community Teamwork, Inc. has updated their internal training protocols to focus on acceptable verification methods, accurate income reporting, and the correct completion of form HUD-50058.

View Audit 340186

Finding 520570 (2024-003)

Material Weakness 2024

Buncombe County, Nc

NC

Procurement, Suspension & Debarment Eligibility Material Weakness

2024-003 Material Weakness – Eligibility Second Party Reviews The auditor recommends that the County abide by the State policies in terms of the frequency and amount of case reviews each month. They also recommend that policies and procedures are documented surrounding second party reviews and rei...

2024-003 Material Weakness – Eligibility Second Party Reviews The auditor recommends that the County abide by the State policies in terms of the frequency and amount of case reviews each month. They also recommend that policies and procedures are documented surrounding second party reviews and reinforced to ensure that reviews are completed and followed up on as necessary. There is no disagreement with this audit finding. The County’s Quality Assurance (QA) team will review 100% of all TANF re-certifications. Monthly, a report from NC FAST will be published to identify the audits needed to complete the required 25% expectation and assigned to members of the QA team. A contingency plan will be created so that enough staff will be able to backfill the QA team if members are temporarily re-assigned or are unable to complete audits. New reports will be created to confirm compliance by tracking audit completion rates and identify shortfalls immediately. Person responsible for correction action: Leigh Anderson, HHS Business Administrator Completion date: Immediate – Creation of new audit workflow 2/10/2025 – Establish audit contingency plan 2/28/2025 – Creation of monthly compliance reporting

View Audit 340126

Finding 520374 (2024-001)

Material Weakness 2024

Erie County Metropolitan Housing Authority

OH

Eligibility Subrecipient Monitoring HUD Housing Programs § 200.303

Case Managers will ensure all documents are scanned and retained for the Authority’s files prior to destroying them.

View Audit 340087

Finding 520270 (2024-004)

Significant Deficiency 2024

The University of Akron

OH

Eligibility

FINDING 2O24-OO4 - TRIO Eligibitity Federal Program Information: TRIO Cluster: TRIO Talent Search, ALN #84.044 TRIO Upward Bound, ALN #84.047 Criteria: Determination of student eligibility associated with TRIO programs should be documented with all documentation retained. Condition: Student TRIO eli...

FINDING 2O24-OO4 - TRIO Eligibitity Federal Program Information: TRIO Cluster: TRIO Talent Search, ALN #84.044 TRIO Upward Bound, ALN #84.047 Criteria: Determination of student eligibility associated with TRIO programs should be documented with all documentation retained. Condition: Student TRIO eligibility was not properly documented. Context: The following errors were identified during the testing of Student TRIO eligibility: . For the TRIO Upward Bound program, 4 of 15 selections were found to have incomplete documentation of the determination associated with the University Eligibility Determination Certificate intake forms. o For the TRIO Talent Search program, 3 of 45 selections were found to be students allocated to a waitlist for the program and eventually admitted, but no final documented determination of eligibility into the program was made. Questioned Cost: None Effect: Ineligible students could receive TRIO funding if eligibility is not properly documented and retained. Cause: Documentation was not updated when subsequent documentation or changes were made to participants. Repeat Finding: Yes Recommendation: We recommend implementing a formalized process for ensuring that appropriate determination of student eligibility for TRIO programs occurs. Response: The Office of Academic Achievement Programs will update their procedures to ensure that all appropriate documentation is maintained when making eligibility determinations for each student. Douglas Bru baugh, Controller Brett Riebau, Director, Financial Reporting

View Audit 339919

Corrective Action Plans

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