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Finding 558271 (2024-053)
Significant Deficiency 2024
2024-053a: The State (EOHHS) receives quarterly user access reports from the MMIS fiscal agent. Anyone identified on the reports that have not logged in for a period of 60 days will have their access terminated. Terminating the users access locks them out and prevents access the system without fir...
2024-053a: The State (EOHHS) receives quarterly user access reports from the MMIS fiscal agent. Anyone identified on the reports that have not logged in for a period of 60 days will have their access terminated. Terminating the users access locks them out and prevents access the system without first requesting a password reset, which is reviewed and approved/denied by EOHHS systems group. In addition, when a user leaves state service or moves to another agency, their access is terminated immediately. An SOP will be implemented with offboarding procedures to assist in timely removal of access. Access is maintained and controlled within the GainwellNow system. Email notifications of pending requests for access are sent to Hector Rivera and Kim Tebow (both EOHHS), who must then review the request and attached form and either grant or deny access. An FTE will be added to the EOHHS/Medicaid Systems team to standardize all user access policies and procedures. Oversight of all IT security activities performed by the MMIS contractor is the responsibility of the EOHHS/Medicaid Project/Contract Manager assigned to the vendor. This individual is supported by the ETSS AIM assigned to support EOHHS/Medicaid. A SOC audit is completed yearly and provides documentation for penetration and vulnerability testing. Anticipated Completion Date: Current and Ongoing Contact Persons: Brian Tichenor, Medicaid Systems Manager, Executive Office of Health and Human Services brian.tichenor@ohhs.ri.gov Hector Rivera, Interdepartmental Project Manager, Executive Office of Health and Human Services hector.l.rivera@ohhs.ri.gov Kimberly Tebow, Senior Medical Care Specialist, Executive Office of Health and Human Services kimberly.tebow@ohhs.ri.gov 2024-053b: The 2025 MARS-E Assessment is underway and will be completed by 4/30/2025. The results will be reviewed to assure the items in the previous MARS-E assessment have been addressed as expected by the state. Documentation lacking to evaluate security controls; Complete pending MARS-E Assessment Continued use of unsupported applications in need of update or patching; major upgrade of the end of life frameworks is planned for SFY2026 start. This expensive upgrade structurally supports most of the modernization platforms that the state is considering. Start SFY 2026; Completion SFY 2027 Lack of contractor tracking of exceptions and risk assessments; Exceptions for vulnerabilities are tracked in JIRA. Risk assessments are performed in all security tests and periodically on security controls. CISO approves all vulnerability exceptions. Complete pending MARS-E Assessment Contractor only sharing partial vulnerability scanning results; Raw report results are provided in Sharepoint in support of the risk assessment process. Complete pending MARS-E Assessment Lack of a robust triage process for security vulnerabilities; Complete pending MARS-E Assessment Inadequate consideration of IT security vulnerabilities with industry best practices. Security vulnerability assessments are performed using the CMS method of impact X probability. The method has been reviewed by state and MARS-E assessor. Complete pending MARS-E Assessment Anticipated Completion Dates: See above Contact Person: Deb Merrill, Security Officer, Enterprise Technology System Services, Department of Administration deb.merrill@doit.ri.gov 2024-053c: The State (EOHHS) collaborates with system vendors (MMIS/Gainwell and Deloitte/RI Bridges) Maintenance & Operations (M&O) and Security teams to ensure annual risk assessment/vulnerability best practices and lessons learned are integrated into annual planning and scope of work for future FYs. Anticipated Completion Date: Current and Ongoing Contact Persons: Brian Tichenor, Medicaid Systems Manager, Executive Office of Health and Human Services brian.tichenor@ohhs.ri.gov Hector Rivera, Interdepartmental Project Manager, Executive Office of Health and Human Services hector.l.rivera@ohhs.ri.gov 2024-053d: Our controls for User Access are in place. Depending on the access requested by the type of user and the program being administered, access are provided accordingly. Anticipated Completion Date: Current and Ongoing Contact Persons: Saurabh Gosai, Director – Technology, Strategy and Innovation, Department Human Services saurabh.u.gosai@dhs.ri.gov Sherri Kennedy, Chief - Human Services Policy and Systems Specialist, Department of Human Services sherri.kennedy@dhs.ri.gov
System changes to modify the time schedule that RIBridges interfaces with SWICA for processing tasks has already been submitted (RIB-141767). Currently, the interface occurs twice yearly. This will increase the frequency to quarterly. Anticipated Completion Date: October 31, 2025 Contact Person:...
System changes to modify the time schedule that RIBridges interfaces with SWICA for processing tasks has already been submitted (RIB-141767). Currently, the interface occurs twice yearly. This will increase the frequency to quarterly. Anticipated Completion Date: October 31, 2025 Contact Person: Donna Rook, Administrator, Family and Adult Services, Department of Human Services donna.m.rook@dhs.ri.gov
View Audit 355126 Questioned Costs: $1
DHS continues its prior actions of training addressing eligibility, standing agenda on meetings, and quarterly meetings. At this time, DHS has completed the solicitation to hire a contractor to identify problematic processes, through the Business Processing Excellence Reengineering project. (BPER). ...
DHS continues its prior actions of training addressing eligibility, standing agenda on meetings, and quarterly meetings. At this time, DHS has completed the solicitation to hire a contractor to identify problematic processes, through the Business Processing Excellence Reengineering project. (BPER). The scope of work includes evaluating the eligibility to determine the deficiencies and to propose solutions. Anticipated Completion Date: Ongoing Contact Person: Donna Rook, Administrator, Family and Adult Services, Department of Human Servicesdonna.m.rook@dhs.ri.gov
View Audit 355126 Questioned Costs: $1
Finding: 1 of 60 individuals had a return-to-work date submitted by the employer, however, the claimant received three payments after that date. DLT did not investigate any potential overpayment. (Questioned costs - $2,139) We do not concur with this finding. Per ETA guidance, specifically UIPL ...
Finding: 1 of 60 individuals had a return-to-work date submitted by the employer, however, the claimant received three payments after that date. DLT did not investigate any potential overpayment. (Questioned costs - $2,139) We do not concur with this finding. Per ETA guidance, specifically UIPL 01-16, because this claim was in payment status, we have to continue to make timely weekly payments (after proper certification), and an overpayment cannot be deemed recoverable until an official ineligibility determination is rendered. Unemployment Insurance Program Letter 01-16 states “in order to be eligible to receive administrative grants, a state must do the following in context of identifying and establishing improper payments…continue to make timely UC payments (if due) and wait to commence recovery of overpayments until an official determination of ineligibility is made…” In addition to the above requirement, data that State Workforce Agencies gather from crossmatch sources such as IB4, wage record /benefit, SDNH and NDNH wage/benefit have to be verified prior to initiating a decision disqualifying benefits. The actual cross match itself simply produces possible cases to investigate. The investigation is then initiated when the department sends out a request for wages form (720). When the form is returned by the employer the department can then use the verified information to render a disqualifying decision. A crossmatch itself is not enough to render a working and collecting determination based on wage record data as the claimant may have had actual earning within the quarter. The date identified on a NDNH crossmatch also is not enough to render a disqualification. This information needs to be verified. From: Unemployment Insurance 401 Handbook ETA 227 – OVERPAYMENT DETECTION AND RECOVERY ACTIVITIES E. Definitions 4. Cases Investigated. The number of cases emanating from a state-initiated overpayment detection process for which an investigation regarding a potential overpayment has been concluded. Example: during a wage/benefit crossmatch process, a state agency produces a printout identifying all benefit payments matched against wages in the same quarter. After the printout is screened, requests are sent to employers to identify which weeks in the quarter were worked. When an employer reply indicates overlap with weeks for which benefits were paid, claims are investigated to determine if they were overpaid. This was a continued claim that was effective 8/13/23 and the claimant certified weekly through 2/17/24. The RTW date listen on the ledger was autogenerated on 2/27/24. At this time the claimant had exhausted their balance of credits, all benefits had been paid. The date listed as the return-to-work date from the NDNH crossmatch stated 1/30/24. Since this date had the potential to affect benefits the department initiated it’s investigation and did send a 720 form to the employer to obtain the proper wage information. Since the requested information was not returned by the employer, the department lacked the proper information necessary to render a disqualification based on ETA guidelines. Finding: 1 of 60 was not registered within EmployRI and staff were unable to locate any records of the claimant. (Questioned costs - $10,829) The agency concurs with the above finding that includes state UC questioned costs of $10,829. This exception was caused by a programming (IT system) error. A nightly job is run that is sent to Workforce Development (Geosol) which then registers claimant’s with EmployRI. An issue was discovered on claims where the effective date of the claim was 56 days prior to the first payment being issued. These claimants were not populated on the nightly transfer to Workforce. ETSS has confirmed that this programming error has been fixed. We acknowledge the Auditor’s recommendations and offer the following response. We feel the findings, while relevant, are de minimis in scope, when compared to the workload volumes processed. Our current unemployment systems (Tax and Benefits) are aged and distressed. Due to their age and technology constraints, any changes or modifications needed, cannot be easily or quickly implemented. As such a larger burden is placed on staff to handle manually. DLT ‘s limited technology resources combined with having limited staffing resources also hinder our efficiency. We have limited staff resources to manually address our workload volumes, as well as the sheer number of forms involved in making proper determinations. In addition to this, the law requires benefit payments to be made timely based on available information until verifiable evidence is found that justifies a disqualification. Therefore, until we can implement a more modernized tax and benefits system, we acknowledge that similar findings such as these may persist. We will continue to utilize the resources we currently have and strive to be more efficient. We hope that by providing additional staff training and by strengthening our relationship with Workforce Development, this improved efficiency will be realized. We are in the process of evaluating whether or not an amendment to our work search requirement, is needed. In doing so, we will evaluate whether any changes are necessary to either; our internal policy, the guidance provided on the claimant’s benefit rights, the guidance displayed on DLT’s website and to regulation 1.18 Filing of Claims for Unemployment Insurance Benefits. Any necessary modifications will be made. Anticipated Completion Date: December 31, 2025 Contact Person: Philip D’Ambra, Director of Income Support, Department of Labor and Training philip.l.dambra@dlt.ri.gov
View Audit 355126 Questioned Costs: $1
Finding 558180 (2024-001)
Significant Deficiency 2024
Department of Homeland Security Hazard Mitigation Grant-Assistance Listing No. 97.039 Recommendation: It was noted that improvements were observed compared to the previous year, however, we advise the County to maintain a review process to ensure quarterly reports are thoroughly examined before su...
Department of Homeland Security Hazard Mitigation Grant-Assistance Listing No. 97.039 Recommendation: It was noted that improvements were observed compared to the previous year, however, we advise the County to maintain a review process to ensure quarterly reports are thoroughly examined before submission to FDEM. Additionally, monitoring procedures should be established to guarantee the proper submission of close-out reports. Implementing a technology solution could aid the grant manager in gathering the necessary reports for the grantor, facilitating easier oversight and monitoring of grant compliance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will further strengthen oversight of programmatic reporting by developing and implementing a system of monitoring procedures to guarantee that periodic reports contain the appropriate data, have an adequate review performed by the relative Division Director, and are submitted within the timeframe required by the funder. The proper submission of close-out reports will also be accomplished through the developed monitoring procedures. A grant management software will be purchased and implemented and become a foundational component of the County's grant management infrastructure, allowing for more effective oversight by the County grant manager and ensuring greater compliance with all applicable regulations. Additionally, the County will implement mandatory trainings focusing on 2 CFR Part 200, to ensure fiscal and project managers involved with grant projects are fully educated on uniform administrative requirements, including proper reporting and close-out procedures, cost principles, and audit requirements related to federal and pass-through awards. Name(s) of the contact person(s) responsible for corrective action: Terri Saltzman, Grants and Community Investment Manager. Planned completion date for corrective action plan: September 30, 2025. If the Department of Homeland Security has questions regarding this plan, please call Terri Saltzman at 863-519-2049.
General Background During the 2023-2024 award year, Hult International Business School, Inc.’s (“Hult”) financial aid department faced a convergence of challenges that led to the findings noted in this audit. These included the transition to the Regent Education system, unexpected staff turnover - ...
General Background During the 2023-2024 award year, Hult International Business School, Inc.’s (“Hult”) financial aid department faced a convergence of challenges that led to the findings noted in this audit. These included the transition to the Regent Education system, unexpected staff turnover - including the departure of the Director and subsequently, remaining team - complications stemming from the Department of Education’s FAFSA simplification rollout, and a transition to a new third-party servicer. While these disruptions created a challenging environment in AY23–24, they do not reflect Hult’s current or ongoing ability to effectively manage Title IV funds. Each of the former mitigating issues have since been addressed and resolved, and Hult took steps to significantly limit how students were impacted during this transitional period. Following the departure of key personnel in Spring 2024, we identified gaps in oversight and internal controls that warranted further attention. In response, we immediately removed the individual who had been responsible for oversight of the Financial Aid team and launched a cross-functional committee to conduct an internal audit and process overhaul. Our goal was not only to correct past mistakes but to build a stronger, more resilient foundation moving forward. Key corrective actions include: • Contracting Financial Aid Solutions (FAS) to manage core Title IV functions, including awarding, disbursement, and cash management activities for immediate compliance support, while we rebuilt our internal capacity • Conducting a full review and overhaul of our processes, procedures, and Regent system configuration to align with business needs and Title IV compliance • Hiring and training a qualified, in-house financial aid team, with a focus on cross-training and succession planning, to ensure continuity and operational stability • Revising our existing internal controls managed by the financial aid team, and implementing new internal controls, independently managed by our central finance team, to ensure data accuracy, monitor for discrepancies, and enable prompt resolution of any identified issues • Committing dedicated project management resources to identify process gaps, streamline operations, and optimize our use of system tools These measures represent a deep and sustained investment in the integrity, compliance, and effectiveness of our Title IV operations. We take full responsibility for the instances raised and addressed in this report and are fully committed to preventing their recurrence. With these systems now in place, we are confident in our ability to maintain high-quality, compliant financial aid administration moving forward. Corrective Action Plan - Finding 2024-002 The twenty impacted students noted in Finding 2024-002 were tied to just two disbursement batches - dated September 28, 2023, and February 28, 2024 — not twenty separate events. In both cases, disbursements were accurately recorded in COD, funds were available to students on time, and G-5 draws were eventually completed (during year-end reconciliation) in September 2024. Since the majority of the funds in these disbursement batches were FSEOG, there was not a significant impact on ED Title IV accounting due to FSEOG budgets being predetermined and capped. Additionally, the amounts of these disbursements were credited to students’ accounts, so they were not disadvantaged by this administrative delay. As with the instances in Finding 1 these delays resulted from administrative oversight and human error. While disbursements were initiated in Regent, the full-step process not properly completed, and the managing staff failed to conduct a timely review that would have identified that funds were requested but never received. These issues occurred during periods of major administrative transitions—first, during the initial implementation of Regent in the fall, and then in the spring, during the departure of the former Financial Aid Director and the handoff between third-party servicers. These were isolated incidents caused by temporary disruptions to our internal controls, not indicators of systemic risk. All underlying conditions have since been fully resolved. In response, as outlined in our response to Finding 1, we conducted a full review and overhaul of our Title IV processes. As of Spring 2024, Financial Aid Solutions (FAS) has assumed direct management of awarding, disbursement, and cash management for the 2024–25 academic year. This support has enabled us to fully leverage Regent’s compliance features, enforce strict reconciliation protocols through FAS, and add real-time oversight by Hult’s central finance team. Specifically, to ensure timely and accurate G-5 draws: • FAS manages Title IV disbursements, including the G5 draw downs and reconciliations with COD • All disbursement process steps are actioned within the same business day to reduce errors • Hult has implemented internal controls to reconcile Title IV cash transactions against student ledgers within 1-2 business days • Hult’s revised the monthly bank reconciliation of the federal account to specifically capture unfunded disbursements These measures have established strong safeguards for the Title IV cash management operations. With these protocols in place, we are confident that delayed G-5 draws will not recur in the 2024-2025 award year or beyond.
General Background During the 2023-2024 award year, Hult International Business School, Inc.’s (“Hult”) financial aid department faced a convergence of challenges that led to the findings noted in this audit. These included the transition to the Regent Education system, unexpected staff turnover - ...
General Background During the 2023-2024 award year, Hult International Business School, Inc.’s (“Hult”) financial aid department faced a convergence of challenges that led to the findings noted in this audit. These included the transition to the Regent Education system, unexpected staff turnover - including the departure of the Director and subsequently, remaining team - complications stemming from the Department of Education’s FAFSA simplification rollout, and a transition to a new third-party servicer. While these disruptions created a challenging environment in AY23–24, they do not reflect Hult’s current or ongoing ability to effectively manage Title IV funds. Each of the former mitigating issues have since been addressed and resolved, and Hult took steps to significantly limit how students were impacted during this transitional period. Following the departure of key personnel in Spring 2024, we identified gaps in oversight and internal controls that warranted further attention. In response, we immediately removed the individual who had been responsible for oversight of the Financial Aid team and launched a cross-functional committee to conduct an internal audit and process overhaul. Our goal was not only to correct past mistakes but to build a stronger, more resilient foundation moving forward. Key corrective actions include: • Contracting Financial Aid Solutions (FAS) to manage core Title IV functions, including awarding, disbursement, and cash management activities for immediate compliance support, while we rebuilt our internal capacity • Conducting a full review and overhaul of our processes, procedures, and Regent system configuration to align with business needs and Title IV compliance • Hiring and training a qualified, in-house financial aid team, with a focus on cross-training and succession planning, to ensure continuity and operational stability • Revising our existing internal controls managed by the financial aid team, and implementing new internal controls, independently managed by our central finance team, to ensure data accuracy, monitor for discrepancies, and enable prompt resolution of any identified issues • Committing dedicated project management resources to identify process gaps, streamline operations, and optimize our use of system tools These measures represent a deep and sustained investment in the integrity, compliance, and effectiveness of our Title IV operations. We take full responsibility for the instances raised and addressed in this report and are fully committed to preventing their recurrence. With these systems now in place, we are confident in our ability to maintain high-quality, compliant financial aid administration moving forward. Corrective Action Plan - Finding 2024-001 Hult acknowledges that Title IV funds were returned outside the 45-day window in three instances, two of which were identified during the course of this audit preparation. These delays, caused by human errors from former staff who failed to follow timely reconciliation procedures and follow through on system-initiated returns, have since been corrected and all ineligible funds have been returned in full. At this time, Hult was transitioning to a new Regent Education platform under two successive, financial aid directors. The second, despite claiming expertise with Regent, lacked the operational understanding needed for effective implementation and ongoing oversight of this system. While the individuals responsible for these occurrences are no longer with Hult, we accept full accountability for the errors and are committed to ensuring consistent, Title IV compliance moving forward. Following the departure of our most recent director in late Spring 2024, we undertook a thorough review of our financial aid operations. This assessment identified key areas for administrative improvement, which we addressed immediately by engaging Financial Aid Solutions (FAS) to reinforce our compliance functions and provide us with interim, expert support. Throughout Summer 2024, Hult implemented a comprehensive set of corrective actions to strengthen our internal controls and safeguard against future errors. These include: • Extensively redeveloped and tested our Regent infrastructure – in close collaboration with Regent and FAS – to ensure the system operates effectively with Hult’s academic structure, ensures the accuracy of data outputs, and maintains compliance with Title IV regulations • Hired a qualified, experienced, in-house financial aid team of three. We have and continue to prioritize cross-training and succession planning to ensure operational continuity • Implemented a dual-review process for all Title IV awards, with FAS processing calculations in Regent and Hult staff independently verifying them before disbursing funds • Introduced independent, recurring reconciliations of Title IV transactions by Hult’s central finance team, to ensure record accuracy and promptly resolve any issues identified These ongoing efforts have established a more resilient and accountable operational framework. We are confident that with these controls in place, Hult will remain fully compliant with Title IV regulations, and there will be no repeat instances of late returns in the 2024–25 award year.
2024-002: Annual Reporting to VDARS, ALN 93.044 Special Programs for the Aging – Title III, Part B- Grants for Supporting Services and Senior Centers, ALN 93.045 Special Programs for the Aging - Title III, Part C1 – Nutrition Services, ALN 93.053 Nutrition Services Incentive Program, Reporting (Sign...
2024-002: Annual Reporting to VDARS, ALN 93.044 Special Programs for the Aging – Title III, Part B- Grants for Supporting Services and Senior Centers, ALN 93.045 Special Programs for the Aging - Title III, Part C1 – Nutrition Services, ALN 93.053 Nutrition Services Incentive Program, Reporting (Significant Deficiency) Condition The 13th Aging Monthly Report required by the pass-through agency, Virginia Department of Aging and Rehabilitative Services (VDARS) contained inaccurate revenue and expenditure data which did not agree to the general ledger. Criteria VDARS requires the annual 13th Month Aging Monthly Report to be submitted by November 15th. The report must contain complete and accurate information as a restating of the monthly reporting for the fiscal year. Cause The 13th Aging Monthly Report was not reconciled to underlying financial records, resulting in unexplained differences between the report and trial balance provided as part of the audit. Inaccurate reporting of such revenues and expenditures did not impact the outcome of requirements of the Agency to meet level of effort metrics as required under the grant awards. Effect The submission of the 13th AMR included data that did not agree to underlying financial records. This should have been caught during the course of a review process before submission. Therefore, it is considered a significant deficiency of internal controls over compliance. Repeat Finding 2013-01 Recommendation Ensure reporting is submitted accurately by the deadline stated by VDARS. Implement a review process for each monthly submission, including documentation of the review. Reconcile the federal, state and local totals reported in the Aging Monthly Report to the underlying financial records as stated in the financial system to ensure accuracy before submission to VDARS. Planned Corrective Action Management agrees with the finding. Management plans to implement a process to ensure that the AMR report will be submitted accurately.
Audit Finding Reference: 2024-002 Comments on the Finding and Each Recommendation: Management agrees with the finding. Corrective Action Planned or Taken: Management will formalize the approval process of HAP voucher requests with documentation and approval occurring via email to ensure evidence ...
Audit Finding Reference: 2024-002 Comments on the Finding and Each Recommendation: Management agrees with the finding. Corrective Action Planned or Taken: Management will formalize the approval process of HAP voucher requests with documentation and approval occurring via email to ensure evidence of the approval.
Audit Finding Reference: 2024-001 Comments on the Finding and Each Recommendation: Management agrees with the finding. Corrective Action Planned or Taken: Management will formalize the approval process of disbursements with documentation and approval occurring via email to ensure evidence of the ...
Audit Finding Reference: 2024-001 Comments on the Finding and Each Recommendation: Management agrees with the finding. Corrective Action Planned or Taken: Management will formalize the approval process of disbursements with documentation and approval occurring via email to ensure evidence of the approval.
Student Financial Aid Cluster – Assistance Listing 84.063 and 84.268 Recommendation: The College should review their reporting internal controls and procedures to ensure that they require students' statuses to be reported timely to NSLDS as required by federal regulations. Explanation of disagreem...
Student Financial Aid Cluster – Assistance Listing 84.063 and 84.268 Recommendation: The College should review their reporting internal controls and procedures to ensure that they require students' statuses to be reported timely to NSLDS as required by federal regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We believe that the recent implementation of registration codes for attendance confirmation, along with updates to the eligibility status codes for unofficial and midpoint withdrawals, will effectively reduce delays in reporting enrollment status moving forward. Additionally, we will work closely with the Registrar’s Office and ITS to ensure alignment on their timeline for reporting monthly enrollment status to Clearinghouse. Name(s) of the contact person(s) responsible for corrective action: Patricia Noren Planned completion date for corrective action plan: FY25 If the Department of Education has questions regarding this plan, please call Antoinette Brown 516-572-7743 x24404.
Institutional Comments on Findings and Recommendations: The institution is fully aware of the Enrollment Reporting requirements and deadlines. The institution agrees with the auditor that there were two (2) cases where the enrollment status was reported late and three (3) cases where the auditors we...
Institutional Comments on Findings and Recommendations: The institution is fully aware of the Enrollment Reporting requirements and deadlines. The institution agrees with the auditor that there were two (2) cases where the enrollment status was reported late and three (3) cases where the auditors were unable to verify that changes in student status were reported. The institution informed the auditors that its current policy and procedure is to report all changes to student status monthly instead of every two months as established by the NSLDS reporting schedule to avoid cases on non or late reporting. Since the institution does not maintain copies of the report of enrollment changes that it submits to NSLDS and since the current NSLDS database does not maintain students that are inactive, it was unable to evidence the changes or updates that were made for these students to the auditors. Actions Taken or Planned: The institution has already discussed this issue as observed by the auditors with the officer in charge ofNDSLS Enrollment reporting. The institution would continue with its policy to submit Enrollment Reports monthly to update and notify changes to student's enrollment status more effectively and to avoid cases of late or non-compliance. Status of Corrective Actions on Prior Findings: Some of the issues related to this finding occurred in the past audit.
This finding is related to activities on our VOCA grants. This finding is related to Finding 2024-001. 4 invoices were not approved by management. FRLS’s AP policy that was adopted in September 2024 allowed us to skip separate management approval in cases of recurring invoices such as utilities and ...
This finding is related to activities on our VOCA grants. This finding is related to Finding 2024-001. 4 invoices were not approved by management. FRLS’s AP policy that was adopted in September 2024 allowed us to skip separate management approval in cases of recurring invoices such as utilities and in cases where we have approved contracts such as rent payments, software subscriptions etc. This was our policy before September 2024, but it was not formalized before that date. As in the case of 2024-001. FRLS will modify its AP Policy and Procedures to remove this recurring payment exception and will now require all invoices be approved by management by routing invoices to management for approvals through the Teams automated system. Invoices over $5,000 will also be required to be approved by the Executive Director or their temporary designee. Such designation must be made in writing. This change will be made within the next 60 days.
Finding 2024-005: U.S. Department of Housing and Urban Development – CFDA #14.155 Mortgage Insurance for the Purchase or Refinance of Existing Multifamily Housing Projects Applicable Federal Award Number and Year – HUD loan under section 207/223(f), HUD Project No. 101-11316 Allowable Costs/ Allowab...
Finding 2024-005: U.S. Department of Housing and Urban Development – CFDA #14.155 Mortgage Insurance for the Purchase or Refinance of Existing Multifamily Housing Projects Applicable Federal Award Number and Year – HUD loan under section 207/223(f), HUD Project No. 101-11316 Allowable Costs/ Allowable Activities Name of contact Person: Renee Gallegos, Finance Manager Anticipated completion date: Completed Planned Corrective Action: • Management has updated internal controls to include that all costs charged to the project are for allowable costs.
View Audit 354976 Questioned Costs: $1
Finding 2024-004: U.S. Department of Housing and Urban Development – CFDA #14.871 Housing Choice Vouchers Applicable Federal Award Number and Year- HCV2024 HQS Enforcement Name of contact Person: Jenette Jemison, Director of Housing Operations Anticipated completion date: In Progress Planned Correct...
Finding 2024-004: U.S. Department of Housing and Urban Development – CFDA #14.871 Housing Choice Vouchers Applicable Federal Award Number and Year- HCV2024 HQS Enforcement Name of contact Person: Jenette Jemison, Director of Housing Operations Anticipated completion date: In Progress Planned Corrective Action: • SMHO will provide additional staff training and testing of understanding through a thirdparty training platform for inspections and re-inspections procedures. Management will quarterly review each file that requires re-inspection to ensure all documents are present in the file.
Finding 2024-003: U.S. Department of Housing and Urban Development – CFDA #14.871 Housing Choice Vouchers Applicable Federal Award Number and Year- HCV2024 Eligibility Name of contact Person: Jenette Jemison, Director of Housing Operations Anticipated completion date: Completed Planned Corrective Ac...
Finding 2024-003: U.S. Department of Housing and Urban Development – CFDA #14.871 Housing Choice Vouchers Applicable Federal Award Number and Year- HCV2024 Eligibility Name of contact Person: Jenette Jemison, Director of Housing Operations Anticipated completion date: Completed Planned Corrective Action: • SMHO will require managerial file review/approval for income used at new move-ins, port-ins and annual re-exams and the manager/lead will initial the new income line item added to the check sheet for each file to indicate the review/approval has been completed.
Finding 2024-002: U.S. Department of Housing and Urban Development – CFDA #14.871 Housing Choice Vouchers Applicable Federal Award Number and Year- HCV2024 Eligibility Name of contact Person: Jenette Jemison, Director of Housing Operations Anticipated completion date: Completed Planned Corrective Ac...
Finding 2024-002: U.S. Department of Housing and Urban Development – CFDA #14.871 Housing Choice Vouchers Applicable Federal Award Number and Year- HCV2024 Eligibility Name of contact Person: Jenette Jemison, Director of Housing Operations Anticipated completion date: Completed Planned Corrective Action: • SMHO will require managerial file review/approval for all new move-ins, port-ins and annual re-exams and the manager/lead will sign the check sheet for each file to indicate the review/approval has been completed.
Contact Person – Krista Martin, Director of Finance and Administration, and Ryan Riesinger, Executive Director Corrective Action Plan – Review and update procedures over payment requests to ensure allowability accuracy. Completion Date –December 31, 2025
Contact Person – Krista Martin, Director of Finance and Administration, and Ryan Riesinger, Executive Director Corrective Action Plan – Review and update procedures over payment requests to ensure allowability accuracy. Completion Date –December 31, 2025
View Audit 354950 Questioned Costs: $1
Contact Person – Krista Martin, Director of Finance and Administration, and Ryan Riesinger, Executive Director Corrective Action Plan – Review and update procedures to ensure accurate reporting. Completion Date –December 31, 2025
Contact Person – Krista Martin, Director of Finance and Administration, and Ryan Riesinger, Executive Director Corrective Action Plan – Review and update procedures to ensure accurate reporting. Completion Date –December 31, 2025
Ensure full compliance with HUD regulations and internal policies related to eligibility documentation, income verification, utility allowances, and rent reasonableness determinations in the Housing Choice Voucher (HCV) program. 1. Correct the Deficiencies in the Identified Files Issue Missing 214...
Ensure full compliance with HUD regulations and internal policies related to eligibility documentation, income verification, utility allowances, and rent reasonableness determinations in the Housing Choice Voucher (HCV) program. 1. Correct the Deficiencies in the Identified Files Issue Missing 214 Declaration Form Utility Allowance Calculation (2 files) Missing Third-Party Income Verification Missing Rent Reasonableness Determination Action Contact tenant to obtain and file the signed 214 declaration. Recalculate and document the utility allowance using the current approved utility schedule. Request and obtain third-party verification; if unavailable, follow up with tenant and document efforts per HUD guidelines. Conduct and document rent reasonableness review for the current unit. Responsible Party Housing Specialist Housing Specialist Housing Specialist HQS/Rent Reasonableness Officer Timeline Within 10 business days Within 10 business days Within 10 business days Within 10 business days 2. Expand Review to Broader File Population Action Details Responsible Party Timeline Risk-based Review of Additional Files Identify Systemic Issues Report Findings Identify a representative sample of 100-200 files from the broader tenant population to assess the prevalence of the noted deficiencies. Track and categorize findings to identify patterns of noncompliance. Present findings to leadership and recommend procedural changes if systemic issues are found. Quality Assurance (QA) Team QA Manager QA Manager Within 45 days Within 60 days Within 75 days 3. Strengthen Policies, Procedures, and Staff Training Update Procedures Revise Standard Operating Procedures (SOPs) for file documentation, utility allowances, and rent reasonableness. Include clear checklists. Program Manager Within 90 days Staff Training Conduct mandatory refresher training on eligibility documentation,income verification protocols, rent reasonableness, and utility allowance schedules. File Audit Checklist Implement a standardized checklist for file reviews before final approval. 4. Ongoing Monitoring and Compliance Quarterly File Audits Continue random quarterly audits of tenant files to ensure ongoing compliance. Compliance Reporting Include compliance metrics in monthly management reports. Corrective Action Tracking Maintain a tracking system for noted deficiencies and corrective actions taken.
Finding 558082 (2024-001)
Significant Deficiency 2024
U.S. Department of Treasury No. 21.027 – Coronavirus State and Local Fiscal Recovery Funds Grant Period Year Ended December 31, 2024 Corrective Action Plan: In order to ensure future submissions are containing segregation of duties, the organization will ensure there are two people a part of the rep...
U.S. Department of Treasury No. 21.027 – Coronavirus State and Local Fiscal Recovery Funds Grant Period Year Ended December 31, 2024 Corrective Action Plan: In order to ensure future submissions are containing segregation of duties, the organization will ensure there are two people a part of the reporting and submission process. One person will fill out the reporting information and another person will sign off and submit the information to ensure two people are part of the process. Responsible for this plan: Ariel Rodriguez, Executive Director Implementation Timeline: Immediately as of April 22nd, 2025
2024-001-Internal Control over Financial, United States Department of Health and Human Services Administration, Native Hawaiian Health Care 93.932 Significant adjusting journal entries Due to the high turnover of fiscal staff in previous years, the Organization fell behind in our audits. Therefor...
2024-001-Internal Control over Financial, United States Department of Health and Human Services Administration, Native Hawaiian Health Care 93.932 Significant adjusting journal entries Due to the high turnover of fiscal staff in previous years, the Organization fell behind in our audits. Therefore, many adjusting entries were required to reconcile accounts, while upkeeping the current financial state of the Organization during fiscal year’s 2024 and 2025, accordingly. In addition to the high turnover, during fiscal year 2024, Maui experienced devastation with the Lahaina wildfires, which led to an increase of funding from donors to support the communities’ needs to recover. Again, our staff were challenged to meet the demands of the requirements of the funding and continue to monitor the previous fiscal year and the current fiscal years financial state. Internal control over disbursements We have made significant improvements from prior years in internal control processes, with regards to disbursements. With the turnover of staff, there was no communication of fiscal internal controls. Since the turnover, we have hired new staff and implemented processes and reviewed the internal controls policies with the new staff to address these issues. We expect these issues to be resolved in fiscal year ending 2025, as these findings have been carryover issues from previous years. Review of cancelled check images During fiscal year 2022, the bank statements no longer included copies of cancelled checks. Due to this change, the cancelled check images are available online. As of January 2025, the Executive Director reviews cancelled check images online monthly. She also reviews the bank statements for awareness of the transactions and balances of accounts monthly.
FINDING NUMBER: 2024-002 Condition: The CMHSP included all contract costs, including amounts over $25,000, in the modified total direct costs. Recommendation: We recommend that the CMHSP review/update policies and procedures to ensure that amounts used to calculate indirect costs charged to the gr...
FINDING NUMBER: 2024-002 Condition: The CMHSP included all contract costs, including amounts over $25,000, in the modified total direct costs. Recommendation: We recommend that the CMHSP review/update policies and procedures to ensure that amounts used to calculate indirect costs charged to the grant properly exclude contract amounts over the allowed limit. Planned Corrective Action: Going forward the Authority will calculate the indirect costs based on up to $25,000 per contract employee. Contact Person: Anthony Shaver, Chief Financial Officer Anticipated Completion Date: 9/30/2025
View Audit 354928 Questioned Costs: $1
Finding 558068 (2024-002)
Significant Deficiency 2024
View of Responsible Officials: Management agrees with recommendation of refund operating cash for the distributions in excess of allowable surplus cash calculations and will refund operating cash. Responsible Party: Sherri Friedrich Estimated Completion: Cash will be refunded by May 31, 2025
View of Responsible Officials: Management agrees with recommendation of refund operating cash for the distributions in excess of allowable surplus cash calculations and will refund operating cash. Responsible Party: Sherri Friedrich Estimated Completion: Cash will be refunded by May 31, 2025
View of Responsible Officials: The Project agrees and will replenish the replacement reserve account. Responsible Party: Sherri Friedrich Estimated Completion: Funds will be replenished by April 30, 2025
View of Responsible Officials: The Project agrees and will replenish the replacement reserve account. Responsible Party: Sherri Friedrich Estimated Completion: Funds will be replenished by April 30, 2025
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