Corrective Action Plans

Finding 516372 (2024-002)

Significant Deficiency 2024

OR

Student Financial Aid Matching / Level of Effort / Earmarking Eligibility § 200.303

Recommendation: We recommend the College evaluate its procedures and policies around reporting disbursements to COD to ensure that student information is reported accurately and timely. In addition, the College should revise their procedures to include documentation of the key control. Explanation...

Recommendation: We recommend the College evaluate its procedures and policies around reporting disbursements to COD to ensure that student information is reported accurately and timely. In addition, the College should revise their procedures to include documentation of the key control. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We have updated our procedure to reconcile Pell and Loans twice monthly to be able to catch any reporting errors within the 15-day reporting window. Name(s) of the contact person(s) responsible for corrective action: Sarah Geleynse Planned completion date for corrective action plan: Implemented September 2024

View Audit 334325

Finding 516371 (2024-001)

Significant Deficiency 2024

Clatsop Community College

OR

Student Financial Aid Eligibility Matching / Level of Effort / Earmarking § 200.303

Student Financial Aid Cluster – Assistance Listing No. 84.063 Recommendation: The College changed systems since the end of this fiscal year, and we recommend the College review the auto-packaging rounding rules of its new system to ensure that the Pell award is calculated in accordance with federal...

Student Financial Aid Cluster – Assistance Listing No. 84.063 Recommendation: The College changed systems since the end of this fiscal year, and we recommend the College review the auto-packaging rounding rules of its new system to ensure that the Pell award is calculated in accordance with federal regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We have implemented the auditor’s recommendation and thoroughly tested award rounding in the new SIS. Name(s) of the contact person(s) responsible for corrective action: Sarah Geleynse Planned completion date for corrective action plan: Implemented September 2024

View Audit 334325

Finding 516356 (2024-001)

Material Weakness 2024

Liberty County District School Board

FL

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Planned Corrective Action - The District has established procedures for ensuring and documenting that Title I program resources are properly allocated to schools. The District, under a new Director of Finance, has set up spreadsheets to assist in calculating a percentage to be allocated to each sch...

Planned Corrective Action - The District has established procedures for ensuring and documenting that Title I program resources are properly allocated to schools. The District, under a new Director of Finance, has set up spreadsheets to assist in calculating a percentage to be allocated to each school based on a rank system, which will comply with the FDOE guidelines for allocating funds to schools based on the percentage of students from low-income families. These formula-based spreadsheets are used when preparing the budget when applying for the grant each year. Throughout the fiscal year expenditures are checked to make sure the monies spent are still in rank order for each school. Anticipated Completion Date - December 30, 2024. We will provide documentation to the FDOE supporting the allowability of the questioned costs totaling $247,075 or allocate that amount to the applicable underfunded Title I schools. Responsible Contact Person - Mandie Fowler, Director of Curriculum & Instruction

View Audit 334181 Questioned Costs: $1

Finding 516286 (2024-004)

Significant Deficiency 2024

Western Oregon University

OR

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

Finding: 2024-004 Federal Agency Name: U.S. Department of EducationAssistance Listing Number(s): 84.007, 84.033, 84.038, 84.063, and 84.268. Program Name: Student Financial Assistance Cluster Finding Summary: Awards must be coordinated among the various programs and with other federal and nonfede...

Finding: 2024-004 Federal Agency Name: U.S. Department of EducationAssistance Listing Number(s): 84.007, 84.033, 84.038, 84.063, and 84.268. Program Name: Student Financial Assistance Cluster Finding Summary: Awards must be coordinated among the various programs and with other federal and nonfederal aid (need and non-need-based aid) to ensure that total aid is not awarded in excess of the student’s financial need or cost of attendance (34 CFR 668.42, FWS, and FSEOG, 34 CFR 673.5 and 673.6; Direct Loan, 34 CFR 685.301). Financial need is defined as the student’s COA minus the student’s EFC (as computed by the central processor and included on the student’s SAR/ISIR). During the testing of compliance for Eligibility, it was noted students who worked as Resident Advisors for the University, did not have their Title IV aid adjusted for amounts they received via direct payments to cover the cost of their housing. As a result, the University compensated the students for the cost of their housing outside the normal processing and packaging of Title IV aid, resulting in $26,572 of Direct Loans being disbursed to student’s in excess of their financial need. Responsible Individuals: Kella Helyer, Director of Financial Aid Corrective Action Plan: The current year (2024-25) Resident Assistant benefits have been taken into consideration for all applicable students. Anticipated Completion Date: 9/10/2024

View Audit 334105 Questioned Costs: $1

Finding 516219 (2024-004)

Significant Deficiency 2024

Yadkin County

NC

Cash Management Eligibility Reporting

Finding: 2024-003 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-004 Name of contact person: Corrective Action: Proposed Completion Date: Corrective actions for Finding 2024-001, 2024-002, 2024-003, and 2024-004 also apply to State award findings. Finding: 2024-00...

Finding: 2024-003 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-004 Name of contact person: Corrective Action: Proposed Completion Date: Corrective actions for Finding 2024-001, 2024-002, 2024-003, and 2024-004 also apply to State award findings. Finding: 2024-005 Name of contact person: Lindsey Cearlock Corrective Action: Proposed Completion Date: Immediately. To review all grant documentation carefully and ensure the County is compliant with all requirements. Section IV - State Award Findings and Questioned Costs Jessica Wall, Director YCHSA will continue second party at least 76 Medicaid cases per quarter and will do a targeted second party review of an additional 50 cases to verify that appropriate requests for informaiton are made. YCHSA will implement a checklist to be used prior to eligibility decision for applications and recertifications that would ensure that appropriate information requests have been made and evaluated. YCHSA will develop a shared training platform that will include powerpoint presentations and handouts around the areas of information requests. Checklist will be developed and implemented by 11/18/24. YCHSA will complete an additional targeted review of at least 50 cases per quarter beginning with Quarter 2 of Fiscal Year 2025. YCHSA will develop shared training platform with the expectation that staff will have completed at least one module by 11/30/24. Supervisors will provide staff with a report at least once per month that includes terminated SSI cases that require a full eligibility evaluation. Staff will return this report each month with their initials to indicate that they have initiated full evaluations. Training will be provided by 11/30/24. Training will be provided by 11/30/24 and staff will received SSI Termination Report by 11/30/24. Jessica Wall, Director

View Audit 334031

Finding 516218 (2024-003)

Significant Deficiency 2024

Yadkin County

NC

Eligibility Reporting

Finding: 2024-003 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-004 Name of contact person: Corrective Action: Proposed Completion Date: Corrective actions for Finding 2024-001, 2024-002, 2024-003, and 2024-004 also apply to State award findings. Finding: 2024-00...

Finding: 2024-003 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-004 Name of contact person: Corrective Action: Proposed Completion Date: Corrective actions for Finding 2024-001, 2024-002, 2024-003, and 2024-004 also apply to State award findings. Finding: 2024-005 Name of contact person: Lindsey Cearlock Corrective Action: Proposed Completion Date: Immediately. To review all grant documentation carefully and ensure the County is compliant with all requirements. Section IV - State Award Findings and Questioned Costs Jessica Wall, Director YCHSA will continue second party at least 76 Medicaid cases per quarter and will do a targeted second party review of an additional 50 cases to verify that appropriate requests for informaiton are made. YCHSA will implement a checklist to be used prior to eligibility decision for applications and recertifications that would ensure that appropriate information requests have been made and evaluated. YCHSA will develop a shared training platform that will include powerpoint presentations and handouts around the areas of information requests. Checklist will be developed and implemented by 11/18/24. YCHSA will complete an additional targeted review of at least 50 cases per quarter beginning with Quarter 2 of Fiscal Year 2025. YCHSA will develop shared training platform with the expectation that staff will have completed at least one module by 11/30/24. Supervisors will provide staff with a report at least once per month that includes terminated SSI cases that require a full eligibility evaluation. Staff will return this report each month with their initials to indicate that they have initiated full evaluations. Training will be provided by 11/30/24. Training will be provided by 11/30/24 and staff will received SSI Termination Report by 11/30/24. Jessica Wall, Director

View Audit 334031

Finding 516217 (2024-002)

Significant Deficiency 2024

Yadkin 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: Corrective Action Plan For the Year Ended June 30, 2024 Section II - Financial Statement Findings Section III - Federal Award ...

Finding: 2024-001 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-002 Name of contact person: Corrective Action: Proposed Completion Date: Corrective Action Plan For the Year Ended June 30, 2024 Section II - Financial Statement Findings Section III - Federal Award Findings and Questioned Costs Jessica Wall, Director YCHSA will inititate income calculation quizzes for staff following training to ensure understanding of training around this finding. YCHSA will continue second party at least 76 Medicaid cases per quarter and will do a targeted second party review of an additional 50 cases to verify appropriate income calculations and household members. YCHSA will implement a checklist to be used prior to eligibility decision for applications and recerts that would ensure that determinations in the case and correct outcomes. YCHSA will develop a shared training platform that will include powerpoint presentations and handouts around the areas of accurate information entry. Calculation quizzes will be in use by November 30, 2024. Checklist will be developed and implemented by 11/18/24. YCHSA will complete an additional targeted review of at least 50 cases per quarter beginning with Quarter 2 of Fiscal Year 2025. YCHSA will develop shared training platform with the expectation that staff will have completed at least one module by 11/30/24. Jessica Wall, Director YCHSA will continue second party at least 76 Medicaid cases per quarter and will do a targeted second party review of an additional 15 cases to verify appropriate resource entry. YCHSA will implement a checklist to be used prior to eligibility decision for applications and recertifications that would ensure that appropriate resources have been entered and evaluated. YCHSA will develop a shared training platform that will include powerpoint presentations and handouts around the areas of accurate resource entry. Checklist will be developed and implemented by 11/18/24. YCHSA will complete an additional targeted review of at least 15 cases per quarter beginning with Quarter 2 of Fiscal Year 2025. YCHSA will develop shared training platform with the expectation that staff will have completed at least one module by 11/30/24.

View Audit 334031

Finding 516216 (2024-001)

Significant Deficiency 2024

Yadkin 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: Corrective Action Plan For the Year Ended June 30, 2024 Section II - Financial Statement Findings Section III - Federal Award ...

Finding: 2024-001 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-002 Name of contact person: Corrective Action: Proposed Completion Date: Corrective Action Plan For the Year Ended June 30, 2024 Section II - Financial Statement Findings Section III - Federal Award Findings and Questioned Costs Jessica Wall, Director YCHSA will inititate income calculation quizzes for staff following training to ensure understanding of training around this finding. YCHSA will continue second party at least 76 Medicaid cases per quarter and will do a targeted second party review of an additional 50 cases to verify appropriate income calculations and household members. YCHSA will implement a checklist to be used prior to eligibility decision for applications and recerts that would ensure that determinations in the case and correct outcomes. YCHSA will develop a shared training platform that will include powerpoint presentations and handouts around the areas of accurate information entry. Calculation quizzes will be in use by November 30, 2024. Checklist will be developed and implemented by 11/18/24. YCHSA will complete an additional targeted review of at least 50 cases per quarter beginning with Quarter 2 of Fiscal Year 2025. YCHSA will develop shared training platform with the expectation that staff will have completed at least one module by 11/30/24. Jessica Wall, Director YCHSA will continue second party at least 76 Medicaid cases per quarter and will do a targeted second party review of an additional 15 cases to verify appropriate resource entry. YCHSA will implement a checklist to be used prior to eligibility decision for applications and recertifications that would ensure that appropriate resources have been entered and evaluated. YCHSA will develop a shared training platform that will include powerpoint presentations and handouts around the areas of accurate resource entry. Checklist will be developed and implemented by 11/18/24. YCHSA will complete an additional targeted review of at least 15 cases per quarter beginning with Quarter 2 of Fiscal Year 2025. YCHSA will develop shared training platform with the expectation that staff will have completed at least one module by 11/30/24.

View Audit 334031

Finding 516212 (2024-007)

Material Weakness 2024

School District of Bonduel

WI

School Nutrition Programs Eligibility

2024-007 – Child Nutrition Cluster – Eligibility - The District is aware of the missing eligibility documents for the Child Nutrition program and will implement new procedures and a plan to reduce the missing documentation. Responsible Officials – Joe Dawidziak, Superintendent Anticipated Completion...

2024-007 – Child Nutrition Cluster – Eligibility - The District is aware of the missing eligibility documents for the Child Nutrition program and will implement new procedures and a plan to reduce the missing documentation. Responsible Officials – Joe Dawidziak, Superintendent Anticipated Completion Date – The District will correct this in the subsequent fiscal year.

View Audit 334029

Finding 516138 (2024-001)

Significant Deficiency 2024

Riverside Community College District

CA

Student Financial Aid Eligibility Significant Deficiency

Views of Responsible Officials and Corrective Action Plan The College, with support from the District, will implement an annual review of compliance requirements and training for all staff associated with eligibility requirements for calculated disbursements amounts to ensure accuracy. Norco College...

Views of Responsible Officials and Corrective Action Plan The College, with support from the District, will implement an annual review of compliance requirements and training for all staff associated with eligibility requirements for calculated disbursements amounts to ensure accuracy. Norco College Student Financial Services reviewed the workflow and processing procedures of flagging student files in a timely manner for those that qualify for the additional Pell indicator. The intention of these efforts is to meet regulatory compliance requirements as they are related to student Pell eligibility when awarding and packaging students for additional Pell. There was staff turnover during the 2023-24 award year resulting in procedures misunderstood and not followed consistently which caused the student to not be flagged at the appropriate time in the awarding and disbursement process. An Assistant Director position was approved and filled as of May 2024. The Assistant Director is responsible for Pell grant payment oversight during the authorization and approval of the institution’s monthly disbursement process to ensure federal guidelines are adhered to. The Assistant Director has completed thorough training regarding the disbursement process and Pell eligibility. Additionally, training is conducted on a regular basis to review student Pell disbursement eligibility for accuracy.

View Audit 333977

Finding 516067 (2024-007)

Significant Deficiency 2024

Edgecombe County

NC

Eligibility

Corrective Action: Application checklist updated to include a line items to ask if the client owns their home; does the client have to pay rent or any other living expenses; and was the case evaluated for 1/3 reduction if applicable. These additions to the checklist will serve as a reminder to the w...

Corrective Action: Application checklist updated to include a line items to ask if the client owns their home; does the client have to pay rent or any other living expenses; and was the case evaluated for 1/3 reduction if applicable. These additions to the checklist will serve as a reminder to the worker that all of these areas are covered when working the case. Training will be conducted with all workers on MA-2261 1/3 Reduction, and MA-2230 Financial Resources. Medicaid Supervisors and Quality Control workers will review files internally to ensure policy is applied to all cases and that the evidence entered into NCFAST matches the information in determinations. Proposed Completion Date: Training and implementation of additional reviews and procedures will be implemented by January 15, 2025. Proposed Completion Date: Training and implementation of additional reviews and procedures will be implemented by January 15, 2025. Name of contact person: Virginia Ewuell and Angel Joyner, Medicaid Supervisors. Denise McKnight, Social Services Program Administrator Corrective Action: SSI termination reports are being worked and monitored to ensure that SSI terminated recepients are reviewed and acted on timely. Application checklist has been updated with the line item to check to see if SSI has been terminated. Medicaid Supervisors and Quality Control workers will review files internally to ensure policy is applied to all cases and that the evidence entered into NCFAST matches the information in determinations.

View Audit 333850

Finding 516066 (2024-006)

Significant Deficiency 2024

Edgecombe County

NC

Eligibility Significant Deficiency

Corrective Action: Application checklist updated to include a line items to ask if the client owns their home; does the client have to pay rent or any other living expenses; and was the case evaluated for 1/3 reduction if applicable. These additions to the checklist will serve as a reminder to the w...

Corrective Action: Application checklist updated to include a line items to ask if the client owns their home; does the client have to pay rent or any other living expenses; and was the case evaluated for 1/3 reduction if applicable. These additions to the checklist will serve as a reminder to the worker that all of these areas are covered when working the case. Training will be conducted with all workers on MA-2261 1/3 Reduction, and MA-2230 Financial Resources. Medicaid Supervisors and Quality Control workers will review files internally to ensure policy is applied to all cases and that the evidence entered into NCFAST matches the information in determinations. Proposed Completion Date: Training and implementation of additional reviews and procedures will be implemented by January 15, 2025. Proposed Completion Date: Training and implementation of additional reviews and procedures will be implemented by January 15, 2025. Name of contact person: Virginia Ewuell and Angel Joyner, Medicaid Supervisors. Denise McKnight, Social Services Program Administrator Corrective Action: SSI termination reports are being worked and monitored to ensure that SSI terminated recepients are reviewed and acted on timely. Application checklist has been updated with the line item to check to see if SSI has been terminated. Medicaid Supervisors and Quality Control workers will review files internally to ensure policy is applied to all cases and that the evidence entered into NCFAST matches the information in determinations.

View Audit 333850

Finding 516065 (2024-005)

Significant Deficiency 2024

Edgecombe County

NC

Eligibility Significant Deficiency

Finding: 2024-004 Inaccurate Information Entry Finding: 2024-005 Inaccurate Resource Calculation Finding: 2024-006 Inadequate Request for Information Corrective Action: Application checklist updated to include a list of persons in the household, a line item also added to ask if changes have been app...

Finding: 2024-004 Inaccurate Information Entry Finding: 2024-005 Inaccurate Resource Calculation Finding: 2024-006 Inadequate Request for Information Corrective Action: Application checklist updated to include a list of persons in the household, a line item also added to ask if changes have been applied in NCFAST. A line item was also added to list the children in the home and request for IV-D referral if applicable. Medicaid Supervisors and Quality Control workers will review files internally prior to approval or denial of a case to ensure that verifications match the evidence in NCFAST and changes have been applied to the cases. This will serve as a second check to catch things prior to the case being completed. MA-3300 Income training will be conducted with all workers. Corrective Action: Application checklist updated to include a line item to check to see if the bank account information in evidence matches what shows in determinations. Caseworkers will be trained to enddate old evidence and start a new evidence for a new period to show when the information has been updated. Medicaid Supervisors and Quality Control workers will review files internally to ensure verifications received and put into evidence matches information in determinations once an eligibility check has been ran. They will also ensure that changes have been applied. Proposed Completion Date: Training and implementation of additional reviews and procedures will be implemented by January 15, 2025.

View Audit 333850

Finding 516064 (2024-004)

Significant Deficiency 2024

Edgecombe County

NC

Eligibility Internal Control / Segregation of Duties

Finding: 2024-004 Inaccurate Information Entry Finding: 2024-005 Inaccurate Resource Calculation Finding: 2024-006 Inadequate Request for Information Corrective Action: Application checklist updated to include a list of persons in the household, a line item also added to ask if changes have been app...

Finding: 2024-004 Inaccurate Information Entry Finding: 2024-005 Inaccurate Resource Calculation Finding: 2024-006 Inadequate Request for Information Corrective Action: Application checklist updated to include a list of persons in the household, a line item also added to ask if changes have been applied in NCFAST. A line item was also added to list the children in the home and request for IV-D referral if applicable. Medicaid Supervisors and Quality Control workers will review files internally prior to approval or denial of a case to ensure that verifications match the evidence in NCFAST and changes have been applied to the cases. This will serve as a second check to catch things prior to the case being completed. MA-3300 Income training will be conducted with all workers. Corrective Action: Application checklist updated to include a line item to check to see if the bank account information in evidence matches what shows in determinations. Caseworkers will be trained to enddate old evidence and start a new evidence for a new period to show when the information has been updated. Medicaid Supervisors and Quality Control workers will review files internally to ensure verifications received and put into evidence matches information in determinations once an eligibility check has been ran. They will also ensure that changes have been applied. Proposed Completion Date: Training and implementation of additional reviews and procedures will be implemented by January 15, 2025.

View Audit 333850

Finding 516063 (2024-003)

Significant Deficiency 2024

Edgecombe County

NC

Eligibility Internal Control / Segregation of Duties

Finding: 2024-003 IV-D Non-Cooperation Edgecombe County County Administration Building 201 St. Andrew St., PO Box 10 Tarboro, NC 27886 252-641-7834 ∙ Fax 252-641-0456 www.edgecombecountync.gov For the Year Ended June 30, 2024 Corrective Action Plan Edgecombe County, NC Proposed Completion Date: June...

Finding: 2024-003 IV-D Non-Cooperation Edgecombe County County Administration Building 201 St. Andrew St., PO Box 10 Tarboro, NC 27886 252-641-7834 ∙ Fax 252-641-0456 www.edgecombecountync.gov For the Year Ended June 30, 2024 Corrective Action Plan Edgecombe County, NC Proposed Completion Date: June 30, 2024 Name of contact person: Linda Barfield, Chief Financial Officer Corrective Action: The budget variance in Debt Service stemmed from the reclassification of lease and subscription expenses originally budgeted at the departmental level. For financial reporting purposes, ease and subscription principal payments were reclassed to debt service to ensure accurate reporting. While the original departmental budgets were within approved limits, the reclassification affected the Debt Service budget after the fiscal year ended. FY24 is the first year of implementation of GASB 96 for subscriptions and the second year of GASB 87 for leases. The impacts of both these GASBs, was not fully known at the time the budget was adopted. The County will make the necessary budget amendments to FY25 budget before the end of the fiscal year to align the budget with anticipated financial reporting. Additionally, the County implemented additional review procedures to monitor such reclassifications closely and will continue to assess our budget tracking processes to prevent similar instances in future periods. Section II. Financial Statement Findings Proposed Completion Date: June 30, 2024 Name of contact person: Linda Barfield, Chief Financial Officer Corrective Action: The County initiated a rate study to assess the adequacy of our current rate structure in supporting both operating expenses and debt service obligations. The rate study analysis is still being finalized, so the impact to the rates is not yet known. The County plans to carefully consider adjustments or operational improvements based on the study’s findings to ensure compliance with bond covenants. Section III - Federal Award Findings and Question Costs Name of contact person: Brandy Dawes and Tina Radford, Medicaid Supervisors. Denise McKnight, Social Services Program Administrator Corrective Action: Application checklist updated to include line items to list all children in the household and absent parents. This list will ensure that the workers include IV-D referrals for all children when a parent is receiving benefits. Medicaid Supervisors and Quality Control workers will review files internally to ensure policy is applied to all cases and that the evidence entered into NCFAST and shows that a IV-D referral have been sent to Child Support.

View Audit 333850

Finding 515855 (2024-001)

Material Weakness 2024

Housing Authority of the City of Raleigh

NC

HUD Housing Programs Eligibility Material Weakness

Finding 2024-001 – Housing Choice Voucher Program Tenant Files – Eligibility – Internal Control over Tenant Files – Noncompliance and Material Weakness - Housing Choice Voucher Program – ALN 14.871 Corrective Action Plan: Timeliness of Annual Recertifications RHA has implemented all strategies ident...

Finding 2024-001 – Housing Choice Voucher Program Tenant Files – Eligibility – Internal Control over Tenant Files – Noncompliance and Material Weakness - Housing Choice Voucher Program – ALN 14.871 Corrective Action Plan: Timeliness of Annual Recertifications RHA has implemented all strategies identified in the Corrective Action Plan in response to the previous audit’s finding regarding later annual recertifications, including, but not limited to: • Competitive compensation to attract and retain qualified employees. • Housing Choice Voucher Certification and other training to enhance RHA’s ability to comply with HUD regulations. • Reorganization of the department to implement case management to replace conveyor-belt style approach to annual recertifications to inject greater accountability for outcomes. • Improved supervisor to employee ratios to ensure that managers have reasonable supervisory loads (maximum of 1 TO 6). • Implementation of YARDI software to increase efficiency of our annual recertification processes. In addition to these corrective action strategies, RHA has also implemented state of the art information tools to track recertifications, measure timeliness and completion performance, and motivate staff and teams to perform at the highest level. The results of these efforts are in line with the expectation that was included in the previous corrective action plan: Anticipated Completion Date: These are mainly system changes that will be fully implemented in 2024, for example, new software, with significant improvements that will be evidenced by December 31, 2024. The results so far in December 2024 have exceeded expectations. For example, • As of December 1, 2024, 87% of recertifications with an effective date of January 1, 2025, had been completed. • As of December 16, 2024, 94% had been completed. • As of December 16, 2024, 73% of recertifications with a due date of January 1, 2025, and an effective date of February 1, 2025, have been completed. Our goal is to complete 90 to 95% by the due date, allowing for cases where participants are late in submitting their information. Having completed all corrective action strategies and plans, RHA expects results that will be in full compliance with completing annual recertification by their due date by July 31, 2025. Person Responsible: Priscilla Batts, HCV Director, is principally responsible and accountable for the outcome above.

View Audit 333725

Finding 515841 (2024-006)

Significant Deficiency 2024

Anson County

NC

Eligibility Reporting Significant Deficiency

Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: ...

Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Inaccurate Resources Entry The County met with all Adult Medicaid Staff to discuss inaccurate resource entry and the policy associated with the findings. The County will continue Second Party Reviews and conduct trainings based on findings. Meeting held 10/28 through 10/29/24 Finding: 2024-004 Corrective Actions for findings 2024-002, 2024-003, 2024-004, 2024-005, and 2024-006 also apply to the State Award findings. Finding: 2024-005 Inaccurate Information Entry The County met with All MAGI and Adult Medicaid Staff to discuss inaccurate information entry and the policy associated with the findings. The County will continue Second Party Reviews and conduct trainings based on findings Section IV- State Award Findings and Questioned Costs Finding: 2024-006 Untimely Review of SSI Terminations The County met with all Adult Medicaid Staff to discuss the untimely review of SSI terminations and the policy associated with the findings. The County will continue Second Party Reviews and conduct trainings based on findings. Meeting held 10/28/24

View Audit 333693

Finding 515840 (2024-005)

Significant Deficiency 2024

Anson County

NC

Eligibility Significant Deficiency

Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: ...

Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Inaccurate Resources Entry The County met with all Adult Medicaid Staff to discuss inaccurate resource entry and the policy associated with the findings. The County will continue Second Party Reviews and conduct trainings based on findings. Meeting held 10/28 through 10/29/24 Finding: 2024-004 Corrective Actions for findings 2024-002, 2024-003, 2024-004, 2024-005, and 2024-006 also apply to the State Award findings. Finding: 2024-005 Inaccurate Information Entry The County met with All MAGI and Adult Medicaid Staff to discuss inaccurate information entry and the policy associated with the findings. The County will continue Second Party Reviews and conduct trainings based on findings Section IV- State Award Findings and Questioned Costs Finding: 2024-006 Untimely Review of SSI Terminations The County met with all Adult Medicaid Staff to discuss the untimely review of SSI terminations and the policy associated with the findings. The County will continue Second Party Reviews and conduct trainings based on findings. Meeting held 10/28/24

View Audit 333693

Finding 515839 (2024-004)

Significant Deficiency 2024

Anson County

NC

Eligibility

Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: ...

Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Inaccurate Resources Entry The County met with all Adult Medicaid Staff to discuss inaccurate resource entry and the policy associated with the findings. The County will continue Second Party Reviews and conduct trainings based on findings. Meeting held 10/28 through 10/29/24 Finding: 2024-004 Corrective Actions for findings 2024-002, 2024-003, 2024-004, 2024-005, and 2024-006 also apply to the State Award findings. Finding: 2024-005 Inaccurate Information Entry The County met with All MAGI and Adult Medicaid Staff to discuss inaccurate information entry and the policy associated with the findings. The County will continue Second Party Reviews and conduct trainings based on findings Section IV- State Award Findings and Questioned Costs Finding: 2024-006 Untimely Review of SSI Terminations The County met with all Adult Medicaid Staff to discuss the untimely review of SSI terminations and the policy associated with the findings. The County will continue Second Party Reviews and conduct trainings based on findings. Meeting held 10/28/24

View Audit 333693

Finding 515838 (2024-003)

Significant Deficiency 2024

Anson County

NC

Eligibility Significant Deficiency

Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Finding: 2024-003 IV-D Non-Cooperation The County met with All MAGI Medicaid Staff to discuss the no...

Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Finding: 2024-003 IV-D Non-Cooperation The County met with All MAGI Medicaid Staff to discuss the noncooperation with child support procedures and the policy associated with the findings. The County will continue Second Party Reviews and conduct trainings based on findings. Meeting held 10/29/24 Section III - Federal Award Findings and Questioned Costs Corrective Action Plan Meeting held 10/28/24 Inadequate Request for Information The County met with all Adult Medicaid Staff to discuss inadequate request for information and the policy associated with the findings. The County will continue Second Party Reviews and conduct trainings based on findings. Reconciliation of Records and Reporting Holly Martinez-Borja, Finance Director The County has made great efforts to achieve the timely completion of the annual audit and issuance of the financial statements. The County will ensure the appropriate year-end accounting adjustments to be properly recorded. The County has hired an experienced Finance Officer with 20 years of experience. An Assistant Finance Officer position has been added to the department to assist with the daily operations to increase capacity within the department. Board policies and procedures are implemented to increase oversight and accountability. For the Year Ended June 30, 2024 Section II - Financial Statement Findings Finding: 2024-001 Imminently.

View Audit 333693

Finding 515837 (2024-002)

Significant Deficiency 2024

Anson County

NC

Eligibility Significant Deficiency

Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Finding: 2024-003 IV-D Non-Cooperation The County met with All MAGI Medicaid Staff to discuss the no...

Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Finding: 2024-003 IV-D Non-Cooperation The County met with All MAGI Medicaid Staff to discuss the noncooperation with child support procedures and the policy associated with the findings. The County will continue Second Party Reviews and conduct trainings based on findings. Meeting held 10/29/24 Section III - Federal Award Findings and Questioned Costs Corrective Action Plan Meeting held 10/28/24 Inadequate Request for Information The County met with all Adult Medicaid Staff to discuss inadequate request for information and the policy associated with the findings. The County will continue Second Party Reviews and conduct trainings based on findings. Reconciliation of Records and Reporting Holly Martinez-Borja, Finance Director The County has made great efforts to achieve the timely completion of the annual audit and issuance of the financial statements. The County will ensure the appropriate year-end accounting adjustments to be properly recorded. The County has hired an experienced Finance Officer with 20 years of experience. An Assistant Finance Officer position has been added to the department to assist with the daily operations to increase capacity within the department. Board policies and procedures are implemented to increase oversight and accountability. For the Year Ended June 30, 2024 Section II - Financial Statement Findings Finding: 2024-001 Imminently.

View Audit 333693

Finding 515793 (2024-002)

None 2024

Children's Hospital of Philadelphia

PA

Subrecipient Monitoring Eligibility

Management agrees that 2 of the 25 patient files selected did not have timely recertification of their eligibility for Ryan White services. The 2 patients did meet the criteria for eligibility however documentation of this eligibility is required on an annual basis. The Family Care Center at CHOP is...

Management agrees that 2 of the 25 patient files selected did not have timely recertification of their eligibility for Ryan White services. The 2 patients did meet the criteria for eligibility however documentation of this eligibility is required on an annual basis. The Family Care Center at CHOP is committed to full compliance with reporting requirements for all funders. We have since implemented a monthly report of patients who need updated documentation of their Ryan White eligibility (including financial, residential, and diagnostic assessments) which our medical case managers will complete in EPIC. Once they are complete in EPIC, this will be documented in CAREWare, and we will be able to pull reports to ensure we are meeting this requirement. Any questions about compliance with Ryan White eligibility can be directed to Kathryn Pultman, LCSW, Program Manager at pultmank@chop.edu.

View Audit 333649

Finding 515789 (2024-001)

Significant Deficiency 2024

Peru Community School District 124

IL

Eligibility

The District will ensure personnel receive additional training regarding the verification process for the National School Lunch Program and properly complete the verification process in future years.

View Audit 333640

Finding 515779 (2024-005)

Significant Deficiency 2024

Housing Opportunities Commission of Montgomery County, MD

MD

HUD Housing Programs Eligibility Reporting

Section 8 Project-Based Cluster – Assistance Listing No. 14.195 / 14.856 Recommendation: The Commission should implement processes to ensure that fatal errors occurring during PIC/TRACS submissions are corrected in a timely manner Explanation of disagreement with audit finding: There is no disagre...

Section 8 Project-Based Cluster – Assistance Listing No. 14.195 / 14.856 Recommendation: The Commission should implement processes to ensure that fatal errors occurring during PIC/TRACS submissions are corrected in a timely manner Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Previously,Pratum was responsible for completing the certifications and the HOC team was responsible for transmitting the certifications through TRACS. Effective October 1 2024, Pratum assumed responsibility of ensuring that all certifications are transmitted to TRACS in alignment with the HAP reported date. The Regional Property Manager will conduct monthly reviews of HAP and TRACS submissions to ensure accuracy. HRD staff will provide weekly internal staff training to correct PIC errors and procure additional training from a third party consulting company.. Name(s) of the contact person(s) responsible for corrective action: Carmen McLaurin, Vice President of Operation with Pratum, Darcel Cox, Vice President of Compliance with HOC and Lynn Hayes, Vice President of Housing Resources. Planned completion date for corrective action plan: Pratum immediately implemented the corrective actions as outlined above and will commit to correcting all specific discrepancies by March 31, 2025. The HRD team has corrected the errors and will attempt to secure training from a consultant company no later than March 31, 2024.

View Audit 333618

Finding 515777 (2024-003)

Material Weakness 2024

Housing Opportunities Commission of Montgomery County, MD

MD

HUD Housing Programs Eligibility Material Weakness

Section 8 Project-Based Cluster – Assistance Listing No. 14.195 / 14.856 Recommendation: The Commission should implement processes to ensure that all proper documentation is being maintained during the recertification process for every client. Explanation of disagreement with audit finding: There ...

Section 8 Project-Based Cluster – Assistance Listing No. 14.195 / 14.856 Recommendation: The Commission should implement processes to ensure that all proper documentation is being maintained during the recertification process for every client. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: HOC’s third-party management agent, Pratum Companies, will ensure that all site staff with access to files complete the "Intro to Affordable Housing" training hosted by Pratum Compliance within the next 60 days. Pratum will also mandate that Regional Managers conduct random quarterly reviews of move-in files and annual recertifications. Furthermore, Regional Compliance Managers will perform spot checks and file reviews throughout the year. Currently, every move-in file is reviewed by Pratum’s corporate Compliance team for program compliance, with Community Managers conducting an initial review before submission to the compliance team for final approval. Pratum will ensure that each recertification packet includes a completed application, documentation of income, assets, expenses, and an executed recertification checklist. Additionally, Pratum will generate and send reminder letters at 120, 90, 60, and 30 days to all households to minimize late annual recertifications. The Pratum Regional Managers and the Vice President of Operations will provide oversight and conduct weekly check-ins with the team to assess progress and completion of tasks. Regional Property Managers will review all corrective actions to ensure accuracy. A tracking spreadsheet will be maintained and reviewed during these weekly check-ins. This information will also be shared with the HOC compliance team during the monthly compliance and operations meetings to ensure alignment and transparency. HOC’s Property Management Division now has a Compliance Manager who has updated the internal review process to mandate that all new move-ins and annual recertifications include a completed application, documentation of income, assets, expenses, and an executed recertification checklist. The HOC compliance team will focus on conducting site visits for the Project Based Rental Assisted properties following the same guidelines used for the annual financial audit. The goal is to perform a 100% file review for properties with 25 or less units and a 50% file review for properties with more than 25 units. The Compliance team will continue to conduct bi-monthly quality control reviews for the HOC managed properties, after which relevant parties will convene to discuss corrective actions and training opportunities. This interactive process aims to ensure that discrepancies are addressed and corrected effectively. Name(s) of the contact person(s) responsible for corrective action: Carmen McLaurin, Vice President of Operation with Pratum, Darcel Cox, Vice President of Compliance with HOC and Ali Ozair, Vice President of Property Management with HOC. Planned completion date for corrective action plan: Pratum immediately implemented the corrective actions outlined above and is committed to correcting all specific discrepancies by March 31, 2025. The HOC compliance team will start the site visits in January 2025 and will review files from the start of the fiscal year. The PM Division has begun the updated internal review process outlined in the corrective action and has committed to correcting the discrepancies by November 30, 2024.

View Audit 333618

Corrective Action Plans

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