Corrective Action Plans

Finding 481531 (2023-006)

Material Weakness 2023

State of Montana

MT

HUD Housing Programs Internal Control / Segregation of Duties Eligibility § 200.303

ALN: 14.195, 14.856, 14.871, 14.879, Corrective Action Plan: Inadequate Baseline Security Controls - Housing Assistance Payment System - DOC - The Montana Department of Commerce has updated password requirements to comply with statewide policies. The passwords are now sent through encrypted emails...

ALN: 14.195, 14.856, 14.871, 14.879, Corrective Action Plan: Inadequate Baseline Security Controls - Housing Assistance Payment System - DOC - The Montana Department of Commerce has updated password requirements to comply with statewide policies. The passwords are now sent through encrypted emails and users are required to change their passwords upon initial login. The department has also developed a process to conduct and document access reviews. Additionally, the department has developed a change control policy to address roles, responsibilities, and configuration management processes as well as procedures to adequately document the department’s understanding of change impact to the system. The department has provided training and support to the backup user access manager. Person(s) Responsible for Corrective Measures: Ingrid Mallo, Chief Financial Officer, Montana Department of Commerce, Target Date: 06/24/2024

View Audit 317490

Finding 481473 (2023-064)

Material Weakness 2023

State of Montana

MT

Questioned Costs Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303

ALN: 93.575, 93.596, Corrective Action Plan: Inadequate Documentation of Recipient Eligibility - CCDF - DPHHS - The Montana Department of Public Health and Human Services, Child Care and Development Fund programs are continuing to review questioned costs per the guidance received from Office of Ch...

ALN: 93.575, 93.596, Corrective Action Plan: Inadequate Documentation of Recipient Eligibility - CCDF - DPHHS - The Montana Department of Public Health and Human Services, Child Care and Development Fund programs are continuing to review questioned costs per the guidance received from Office of Child Care (OCC). The department documents the extent to which families receiving the 2021 Coronavirus Response and Relief Supplemental Appropriations Act (CRRSA) funded subsidies were eligible, including income-eligible or essential workers. The department additionally documents the extent to which providers who served families met applicable health and safety requirements. Program staff will enhance controls and training and will work with federal partners to ensure funding is in alignment with applicable terms and conditions. Person(s) Responsible for Corrective Measures: Tracy Moseman, Administrator, Montana Department of Public Health and Human Services, Target Date: 12/31/2024

View Audit 317490 Questioned Costs: $1

Finding 481472 (2023-060)

Material Weakness 2023

State of Montana

MT

Subrecipient Monitoring Matching / Level of Effort / Earmarking Eligibility § 200.303 § 200.334

ALN: 93.575, 93.596, Corrective Action Plan: Inadequate Subrecipient Monitoring - CCDF - DPHHS - The Montana Department of Public Health and Human Services, Child Care and Development Fund programs will develop monitoring procedures to coordinate state plan requirements with contract requirements ...

ALN: 93.575, 93.596, Corrective Action Plan: Inadequate Subrecipient Monitoring - CCDF - DPHHS - The Montana Department of Public Health and Human Services, Child Care and Development Fund programs will develop monitoring procedures to coordinate state plan requirements with contract requirements and make amendments to contracts when State Plan changes. Person(s) Responsible for Corrective Measures: Tracy Moseman, Administrator, Montana Department of Public Health and Human Services, Target Date: 12/31/2024

View Audit 317490

Finding 481436 (2023-001)

None 2023

Ncsc/usa Housing Development Corporation Three, INC

FL

HUD Housing Programs Eligibility Reporting

Oversight Agency for Audit, NCSC/USA Housing Development Corporation Three, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral...

Oversight Agency for Audit, NCSC/USA Housing Development Corporation Three, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067. Audit period: January 1, 2023 through December 31, 2023 The findings from the December 31, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers in the schedule. SECTION III - FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING No. 2023-001: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should implement procedures to ensure that required documentation is obtained prior to acceptance and maintained in the tenant files. Action Taken: Further staff training has been completed and processes put in place to prevent moving forward.

View Audit 317461

Finding 481400 (2024-001)

Significant Deficiency 2023

Flathead Valley Community College

MT

Student Financial Aid Eligibility Significant Deficiency

Finding: 2024-01 Federal Agency Name: Department of Education Assistance Listing Number: 84.063 Program Name: Student Financial Aid Cluster - Pell Finding Summary: During testing of students that were disbursed Pell Grants, three students out of a total of 40 that were tested did not receive th...

Finding: 2024-01 Federal Agency Name: Department of Education Assistance Listing Number: 84.063 Program Name: Student Financial Aid Cluster - Pell Finding Summary: During testing of students that were disbursed Pell Grants, three students out of a total of 40 that were tested did not receive the appropriate amount of Pell Grant. Corrective Action: The Pell amounts were reviewed when the error was found during the audit. Students with incorrect amounts were then awarded additional funding based on Title IV guideline. Going forward the following steps will be taken to ensure the error does not occur in the future: • Financial aid staff will review the Financial Aid awarding system prior to awarding and make sure the correct fields have been updated to show the correct Pell cost of attendance. • A second review will be conducted again at census prior to disbursing funds • A final review will be conducted at the end of the semester.Responsible Individual: Crystal Morris, Director, Financial Aid Anticipated Completion Date: March 2024

View Audit 317429

Finding 481318 (2023-008)

Material Weakness 2023

Mesa County, Colorado

CO

Subrecipient Monitoring Eligibility

The County concurs with this finding and will be working to improve the timeliness of Medicaid eligibility determinations by using the COGNOS reports to determine which cases are approaching the due date.

View Audit 317385

Finding 481317 (2023-007)

Material Weakness 2023

Mesa County, Colorado

CO

Eligibility Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

The County concurs with this finding and will be working to enhance documentation of the review of the Adoption Assistance eligibility determinations.

View Audit 317385

Finding 481316 (2023-006)

Material Weakness 2023

Mesa County, Colorado

CO

Eligibility Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

The County concurs with this finding and will be working to enhance documentation of the review of the IV-E eligibility determinations.

View Audit 317385

Finding 481254 (2023-006)

Material Weakness 2023

District of Columbia Housing Authority

MD

Eligibility HUD Housing Programs Material Weakness

Housing Voucher Cluster – Assistance Listing Nos. 14.871/14.879 Recommendation: We recommend the Authority implements controls to ensure that documentation is maintained for new tenants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken ...

Housing Voucher Cluster – Assistance Listing Nos. 14.871/14.879 Recommendation: We recommend the Authority implements controls to ensure that documentation is maintained for new tenants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken or planned in response to finding: The HCVP is implementing a monthly quality control protocol to review new applicant files for completeness. A new Program Director was assigned to oversee this quality control process. The Program Director will also monitor the new tenant checklist which will be created to ensure that all new tenant documentation is accurately maintained. The OAC shall monitor and collaborate with the HCVP to ensure that the checklist is accurate and available for auditing. Name of the contact person responsible for corrective action: Starr Lane. Planned completion date for corrective action plan: 7/31/24.

View Audit 317348

Finding 481251 (2023-003)

Material Weakness 2023

District of Columbia Housing Authority

MD

HUD Housing Programs Eligibility Material Weakness

Housing Voucher Cluster – Assistance Listing Nos. 14.871/14.879 Recommendation: We recommend that DCHA staff review the controls in place to ensure that required eligibility determination documentation is complete, accurate, and available for audit. Explanation of disagreement with audit finding: ...

Housing Voucher Cluster – Assistance Listing Nos. 14.871/14.879 Recommendation: We recommend that DCHA staff review the controls in place to ensure that required eligibility determination documentation is complete, accurate, and available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken or planned in response to finding: The HCVP has a program eligibility team that processes applications. Once completed, the file will be reviewed monthly by an HCVP quality control staff and quarterly by the OAC to ensure that documentation is complete, accurate, and available for audit. Name of the contact person responsible for corrective action: Khaliah Payne. Planned completion date for corrective action plan: 9/30/24

View Audit 317348

Finding 481239 (2023-002)

Material Weakness 2023

District of Columbia Housing Authority

MD

Eligibility HUD Housing Programs Material Weakness

Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend that DCHA staff review the controls in place to ensure that required eligibility determination documentation is complete, accurate, and available for audit. Explanation of disagreement with audit find...

Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend that DCHA staff review the controls in place to ensure that required eligibility determination documentation is complete, accurate, and available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken or planned in response to finding: The HCVP has a program eligibility team that processes applications, and once complete, the file is reviewed by a quality control and compliance officer for compliance. The Office of Audit and Compliance (OAC) shall periodically monitor this process to ensure that eligibility determination documentation is complete, accurate, and available for audit. Name of the contact person responsible for corrective action: Khaliah Payne. Planned completion date for corrective action plan: 9/30/24

View Audit 317348

Finding 481183 (2023-005)

Material Weakness 2023

Alexander Local School District

OH

Eligibility School Nutrition Programs

All paper application will be organized, filed, and stored in the Food Service office/storage for review and auditing needs.

View Audit 317284

Finding 481178 (2023-004)

Material Weakness 2023

Alexander Local School District

OH

School Nutrition Programs Eligibility

Our current DFN will attend both the Food Service Management Company (FSMC) annual training and ODEW’s provided state training on school meal applications. All paper application will be organized, filed, and stored in the Food Service office/storage for review and auditing needs. Online/electronica...

Our current DFN will attend both the Food Service Management Company (FSMC) annual training and ODEW’s provided state training on school meal applications. All paper application will be organized, filed, and stored in the Food Service office/storage for review and auditing needs. Online/electronical applications will be held on the SFA server and detailed reports will be printed, organized, and stored with manual versions.

View Audit 317284

Finding 481042 (2023-003)

Material Weakness 2023

Mower County

MN

Eligibility Material Weakness Internal Control / Segregation of Duties

Recommendation: We recommend that a supervisor or team lead perform regular internal reviews on MAXIS and METS casefiles to determine that proper policies and procedures are being followed in determining eligibility. Explanation of disagreement with audit finding: There is no disagreement with the ...

Recommendation: We recommend that a supervisor or team lead perform regular internal reviews on MAXIS and METS casefiles to determine that proper policies and procedures are being followed in determining eligibility. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement policies to complete casefile reviews over all Medical Assistance casefiles. Name of the contact person responsible for corrective action: Loni Swenson, Finance Manager Planned completion date for corrective action plan: December 31, 2024

View Audit 317177

Finding 480999 (2023-002)

Significant Deficiency 2023

Town of Sutton

MA

School Nutrition Programs Eligibility Significant Deficiency

Audit Reference: 23-002 Non-Compliance Issue: lack of confirming signature on free/reduced applications. Applications must be confirmed by the confirming official listed on the Free & Reduced Price Meals Policy submitted to ESE. Root Cause Analysis: All applications were not printed and signed by co...

Audit Reference: 23-002 Non-Compliance Issue: lack of confirming signature on free/reduced applications. Applications must be confirmed by the confirming official listed on the Free & Reduced Price Meals Policy submitted to ESE. Root Cause Analysis: All applications were not printed and signed by confirming official. Corrective Action(s): Printing and signing all applications as they come in including online applications. 2. Action Item: o Description: Setting plans in place to make sure all applications are signed as printed or passed in and making sure that all signed applications are passed in to auditor not electronic copies. o Responsible Person/Department: Christina Poquette o Expected Completion Date: On going Name: Christina Poquette Title: Director of Food and Nutrition Signature: Date: 5/20/2024 Acknowledgement by Responsible Parties: Name: Title: Signature: Date: 5/20/2024

View Audit 317107

Finding 480998 (2023-001)

Material Weakness 2023

Town of Sutton

MA

School Nutrition Programs Eligibility Internal Control / Segregation of Duties

Organization Name: Sutton Public Schools Address: 16 Putnam Hill Rd Sutton MA 01590 Issue Date: 05/20/2024 Audit Reference: 23-001 Non-Compliance Issue: verification process not completed during school year 22-23 Root Cause Analysis: This was caused by lack of knowledge due to manager change over wi...

Organization Name: Sutton Public Schools Address: 16 Putnam Hill Rd Sutton MA 01590 Issue Date: 05/20/2024 Audit Reference: 23-001 Non-Compliance Issue: verification process not completed during school year 22-23 Root Cause Analysis: This was caused by lack of knowledge due to manager change over with no overlap and managers starting date after verification completion deadline. Corrective Action(s): In planning for next school year, it has been set as a calendar reminder for October 1st to start the verification process with weekly goals set as to what needs to be done each week. As well as a reminder set for November 15th to make sure verification paperwork is submitted prior to the due date of November 17th. 1. Action Item: o Description: Set plans and calendar reminders in place to ensure the verification process is start prior to the end of September and that all is completed to be completed accurately before due date o Responsible Person/Department: Christina Poquette o Expected Completion Date:10/17/2024 Name: Christina Poquette Title: Director of Food and Nutrition Signature: Date: 5/20/2024 Acknowledgement by Responsible Parties: Name: Title: Signature: Date:5/20/2024 Organization Name: Sutton Public Schools Address: 16 Putnam Hill Rd Sutton MA 01590 Issue Date: 05/20/2024

View Audit 317107

Finding 480996 (2023-001)

None 2023

Indiana University Health, Inc. and Subsidiaries

IN

Subrecipient Monitoring Eligibility Reporting

Finding 2023-01 Scope Limitation – Eligibility (ALN 10.557) Indiana University Health utilizes a paperless system in accordance with U.S. Department of Agriculture and State of Indiana guidelines. As such, no corrective action will be taken. Contact Person(s) Responsible for Corrective Action: Chri...

Finding 2023-01 Scope Limitation – Eligibility (ALN 10.557) Indiana University Health utilizes a paperless system in accordance with U.S. Department of Agriculture and State of Indiana guidelines. As such, no corrective action will be taken. Contact Person(s) Responsible for Corrective Action: Christine Smith Anticipated Completion Date: N/A

View Audit 317105

Finding 480945 (2023-001)

None 2023

Town of Wilbraham, Ma

MA

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management

Audit Finding Reference: 2023-001 – Document Policies and Procedures over Federal Awards Planned Corrective Action: The Town is in the process of reviewing Policies and Procedures as they relate to Federal Awards. Name of Contact Person and Completion Date: Derek Geser, Wilbraham Town Accounta...

Audit Finding Reference: 2023-001 – Document Policies and Procedures over Federal Awards Planned Corrective Action: The Town is in the process of reviewing Policies and Procedures as they relate to Federal Awards. Name of Contact Person and Completion Date: Derek Geser, Wilbraham Town Accountant & Nick Breault, Wilbraham Town Administrator - No estimated completion date as of now.

View Audit 317055

Finding 480840 (2023-002)

Significant Deficiency 2023

Springfield Housing Authority

IL

HUD Housing Programs Internal Control / Segregation of Duties Subrecipient Monitoring

FINDING 2023-002 "Housing Choice Voucher Tenant Files - Eligibility - Internal Control over Tenant Files - Noncompliance & Significant Deficiency " SHA RESPONSE The Springfield Housing Authority acknowledges the seven (7) errors as delineated in the full 2023 FYE audit report. In 2023, the Spri...

FINDING 2023-002 "Housing Choice Voucher Tenant Files - Eligibility - Internal Control over Tenant Files - Noncompliance & Significant Deficiency " SHA RESPONSE The Springfield Housing Authority acknowledges the seven (7) errors as delineated in the full 2023 FYE audit report. In 2023, the Springfield Housing Authority Housing Choice Voucher program delineated the following positions to undertake Income and rent calculations: one {l) Special Programs Coordinator, four (4) HCV Specialists and one {1) Program Integrity Specialist. Of those six (6) employees, only onehas a tenure longer than 12 months. Due to continuing post COVID-19 turnover and lack of qualified workers in the local workforce, the SHA expertenced a higher than usual turnover rate in the HCV positions that conduct rent calculations during the majority of FY2023. The Springfield Housing Authority hired third party consultants to assist with annualrecertificationsin the 3rd Quarter of 2023. The primary function of the Program Integrity Specialist position ls to audit and quality control tenant files and rent calculations conducted by HCV Specialists. The HCV Director and/or HCV Manager is responsible for reviewing 3% of recertiflcations audited by the Program Integrity Specialist position as an additional quality control measure. This error rate was directly attributable to the unprecedented turnover rate of HCV Specialists duringthe 2023 fiscal year. The SHA will take the following corrective actions to correct the errors and/or prevent the errors moving forward: • The Program Integrity Speclalist will conduct reviews of 100% of annual and interim recertificatlons for HCV program participants by December 31, 2024. • The Program Integrity Specialist will ensure 100% audited file corrections are completed by the HCV Specialists, monthly. • The HCV Director and/or Manager will review 10% of the recertifications audited by the Program Integrity Speclallst as an additional quality controlmeasure by December 31, 2024. • The HCV Director, HCV Manager, HCV Specialists and Program Integrity Specialist will be provided with additional internal and external training opportunities in Housing Choice Voucher program income andrent calculations andprogram Integrity by December 31, 2024. • The HCV Manager will re-review the flies Identified with errors during the independent audit and resolve the errors in accordance with the SHA Administrative Plan and HUD rules and regulations by September 30, 2024. Person Responsible: Melissa Huffstedtler, Deputy Director Anticipated Completion Date: December 31, 2024

View Audit 316970

Finding 480745 (2023-001)

Significant Deficiency 2023

Dunn Housing Authority

NC

Eligibility HUD Housing Programs Reporting

Dunn Housing Authority Corrective Action Plan For the Year Ended December 31, 2023 Finding 2023-001 Name of Contact Person: Felicia Chester Executive Director Corrective Action: We will implement proper internal control procedures for the Public and Indian Housing program eligibility requirements. ...

Dunn Housing Authority Corrective Action Plan For the Year Ended December 31, 2023 Finding 2023-001 Name of Contact Person: Felicia Chester Executive Director Corrective Action: We will implement proper internal control procedures for the Public and Indian Housing program eligibility requirements. Management has established a checklist for applications and will establish checklists for move-ins and move-outs. Proposed Completion Date: Immediately

View Audit 316948

Finding 480653 (2023-006)

Significant Deficiency 2023

Integrated Community Solutions, Inc.

WI

HUD Housing Programs Subrecipient Monitoring Allowable Costs / Cost Principles

Action taken in response to finding: ICS will provide additional training for staff regarding how to document family size, voucher size, and citizenship. Proper documentation will be reviewed, and files will continue to be reviewed monthly for compliance. Names of the contact persons responsible f...

Action taken in response to finding: ICS will provide additional training for staff regarding how to document family size, voucher size, and citizenship. Proper documentation will be reviewed, and files will continue to be reviewed monthly for compliance. Names of the contact persons responsible for corrective action: Matt Roberts and Megan Walker Planned completion date for corrective action plan: Immediately

View Audit 316843

Finding 480648 (2023-005)

Significant Deficiency 2023

Integrated Community Solutions, Inc.

WI

HUD Housing Programs Subrecipient Monitoring Eligibility

Action taken in response to finding: ICS will provide additional training to current and new staff regarding the importance of retaining Authorization For Release of Information documentation and the requirement that there are two Authorization forms saved and scanned with each file. ICS will also ...

Action taken in response to finding: ICS will provide additional training to current and new staff regarding the importance of retaining Authorization For Release of Information documentation and the requirement that there are two Authorization forms saved and scanned with each file. ICS will also request that staff review file as they are scanning to assure that documentation is included and scanned properly before saving and shredding the paper file. Names of the contact persons responsible for corrective action: Matt Roberts and Megan Walker Planned completion date for corrective action plan: Immediately

View Audit 316843

Finding 480643 (2023-004)

Significant Deficiency 2023

Integrated Community Solutions, Inc.

WI

HUD Housing Programs Subrecipient Monitoring Eligibility

ICS will provide additional training to current and new staff regarding the importance of retaining asset documentation. ICS will also request that staff review files as they are scanning to assure that documentation is included and scanned properly before saving and shredding the paper file. ICS ...

ICS will provide additional training to current and new staff regarding the importance of retaining asset documentation. ICS will also request that staff review files as they are scanning to assure that documentation is included and scanned properly before saving and shredding the paper file. ICS will also encourage staff provide in writing on the documents how they calculated what was entered. They can either circle the amount they are using or if a calculation is necessary they should write the equation on the verification so all parties know how they came to the amount they are entering into the file. Names of the contact persons responsible for corrective action: Matt Roberts and Megan Walker Planned completion date for corrective action plan: Immediately.

View Audit 316843

Finding 480482 (2023-001)

Significant Deficiency 2023

Richland Medical Center, Inc. D/b/a Central Ozarks Medical Center

MO

Special Tests & Provisions Subrecipient Monitoring Eligibility

Section Ill- Federal Award Findings and Questioned Costs Health Center Program Cluster, Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), COVID - 19 Health Center Program (Community Health Centers, Migrant Health...

Section Ill- Federal Award Findings and Questioned Costs Health Center Program Cluster, Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), COVID - 19 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), Grants for New and Expanded Services under the Health Center Program and COVID-19 Grants for New and Expanded Services under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 Item 2023-001- Special Tests Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Repeat Finding Yes Action Taken As of May 1, 2023, the Director of Revenue and/or designee runs a slide fee report daily the reflects everyone that applied the day before. Billing personnel separate the report and audit the files to ensure the correct slide has been applied. The paper application is forwarded to the billing department for a third audit if the application is in order and has been uploaded into the patients' files and then it is manually filed. The CFO will perform random audits and will present to the Board and CEO a quarterly report with the results. In addition, As of July 1, 2023, the Access Coordinators who normally collect and process the slide fee discount program applications are now reporting to the finance department with the Director of Revenue supervising and training staff. In addition, there will now be a Lead Access Coordinator in very clinic that will audit and perform additional training where necessary.

View Audit 316663

Finding 480387 (2023-003)

Material Weakness 2023

Warren County, North Carolina

NC

Eligibility Material Weakness Equipment & Real Property Management

Name of contact person: Renae Alston Corrective Action: The County will continue to train employees on a monthly basis and as needed when new and updated policies are received. Supervisors and lead workers will continue to conduct second party reviews and utilizing any findings to aid in training st...

Name of contact person: Renae Alston Corrective Action: The County will continue to train employees on a monthly basis and as needed when new and updated policies are received. Supervisors and lead workers will continue to conduct second party reviews and utilizing any findings to aid in training staff on any necessary policy information. The department will continue to implement changes as necessary to achieve the overall improvement of eligibility determinations. Proposed Completion Date: June 30, 2024

View Audit 316617

Corrective Action Plans

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