Corrective Action Plans

Finding 24718 (2022-054)

Material Weakness 2022

State of Michigan

MI

Questioned Costs Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.516

Finding 2022-054 Temporary Assistance for Needy Families, ALN 93.558 - Non-Financial Eligibility Documentation Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS?s ESA will continue to emphasize the importance of maintaining eligibility documentation through ongoing st...

Finding 2022-054 Temporary Assistance for Needy Families, ALN 93.558 - Non-Financial Eligibility Documentation Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS?s ESA will continue to emphasize the importance of maintaining eligibility documentation through ongoing staff training and a memorandum sent out to the local offices. ESA leadership will reach out to the managers of the individual specialists regarding the issues identified and provide additional guidance. Anticipated Completion Date Training will be ongoing. ESA will issue the memorandum and address the specific issues with local office management and specialists by August 31, 2023. Responsible Individual(s) Kenton Schulze, MDHHS Lana Karadsheh, MDHHS Brian Sanborn, MDHHS

View Audit 20093 Questioned Costs: $1

Finding 24715 (2022-002)

Material Weakness 2022

Alfred Saliba Family Services Center, Inc.

AL

Matching / Level of Effort / Earmarking Reporting Equipment & Real Property Management § 200.303

Item 2022-002 (Repeat 2021-001) Reporting ? Management?s Response ? Management concurs with the finding. The Agency encountered technical difficulties when attempting to submit the report and is currently seeking the assistance of their representative at Region Four to assist with completing the fil...

Item 2022-002 (Repeat 2021-001) Reporting ? Management?s Response ? Management concurs with the finding. The Agency encountered technical difficulties when attempting to submit the report and is currently seeking the assistance of their representative at Region Four to assist with completing the filing requirement. The grants manager has become aware of the due date for the SF429 and where it is to be submitted and will take full responsibility for the completion and the uploading of this report. Anticipated Completion: September 30, 2023 Responsible Party: Belinda Mitchell, Executive Director

View Audit 21276

Finding 24674 (2022-026)

Significant Deficiency 2022

State of Michigan

MI

Cash Management Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Finding 2022-026 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC), ALN 93.323 and Disaster Grants - Public Assistance (Presidentially Declared Disasters), ALN 97.036 - Long-Term Care (LTC) Facility COVID-19 Testing Reimbursements Management Views MDHHS agrees with the finding. ...

Finding 2022-026 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC), ALN 93.323 and Disaster Grants - Public Assistance (Presidentially Declared Disasters), ALN 97.036 - Long-Term Care (LTC) Facility COVID-19 Testing Reimbursements Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS will enhance written procedures to reflect the process in place to ensure that LTC facility COVID-19 testing reimbursement requests are reasonable and appropriate. MDHHS will also improve documentation of the procedures performed as part of the current process. Anticipated Completion Date MDHHS expects completion of the written procedures and improved documentation going forward by June 15, 2023. MDHHS expects to process all remaining payments for costs incurred during the PHE by September 30, 2023. Responsible Individual(s) Shannah Havens, MDHHS

View Audit 20093

Finding 24634 (2022-015)

Material Weakness 2022

The City of New York

NY

Questioned Costs Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Finding No. 2022-015 Department(s) New York City Administration for Children?s Services New York City Human Resources Administration Program(s) Assistance Listing Number 93.575, Child Care and Development Block Grant Corrective Action(s) HRA HRA will convene a small workgroup to meet bi-weekly to r...

Finding No. 2022-015 Department(s) New York City Administration for Children?s Services New York City Human Resources Administration Program(s) Assistance Listing Number 93.575, Child Care and Development Block Grant Corrective Action(s) HRA HRA will convene a small workgroup to meet bi-weekly to review the details and history of the cases identified to try to isolate the cause of the errors, and once we determine the cause, will work with the necessary parties/stakeholders to develop an approach to avoid the situation from repeating itself. First meeting will be 2nd week of April to identify the appropriate parties to include and come up with meeting goal and agenda. ACS Case No. 1 The audit reviewed a child care case relating to an older Fair Hearing which had not been closed timely per the original State Fair Hearing decision, which had been issued prior to FY22. ACS' Child and Family Well-Being (CFWB) division had previously instituted a new Quality Assurance review of pending Fair Hearing cases and through this QA review had already identified and closed the case. However, the auditors reviewed an earlier State FY22 claim prior to ACS' identification of the case. Per the new QA protocol, CFWB will be reviewing HRA/DSS systems reports on a monthly basis, identify any questioned cases and take appropriate follow-up action. CFWB is also preparing new written guidelines. Case No. 2 In one child care case, ACS was not able to provide eligibility documentation. Further ACS research determined a systems coding inconsistency. ACS procedure is to run reports to identify inconsistencies with programmatic codes and review any flagged cases prior to submission of claims to the State. However, in this instance, the case was not identified in the report. ACS will propose creation of a new exception report with a more refined level of detail to identify any case coding inconsistencies and allow follow up to ensure complete case eligibility support for any flagged cases. ACS will work with HRA/DSS on report development. Anticipated Completion Date HRA Beginning Q2 2023 ? Convene workgroup Beginning Q3 2023 ? Completion date ACS Initiated in FY 2022 ? New quality assurance (QA) review To be completed in FY 2023 ? New written guidelines and refined reporting Person(s) Responsible for Implementation HRA Ramon E. Flores Assistant Deputy Commissioner, Family Independence Administration (FIA) FloresRa@hra.nyc.gov ACS For new QA and guidelines Isabel Villegas Executive Director, Policy & Compliance Division of Child and Family Well-Being (212) 393-5325 For refined reporting Pauline Young Assistant Commissioner for Claiming and Revenue Division of Finance (212) 676-8803

View Audit 22749 Questioned Costs: $1

Finding 24633 (2022-006)

None 2022

The City of New York

NY

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Subrecipient Monitoring § 200.514

Finding No. 2022-006 Department(s) New York City Department of Health and Mental Hygiene Program(s) Assistance Listing Number 93.069, Public Health Emergency Preparedness Corrective Action(s) DOHMH?s Office of Emergency Preparedness and Response (OEPR) and Division of Finance are in agreement with t...

Finding No. 2022-006 Department(s) New York City Department of Health and Mental Hygiene Program(s) Assistance Listing Number 93.069, Public Health Emergency Preparedness Corrective Action(s) DOHMH?s Office of Emergency Preparedness and Response (OEPR) and Division of Finance are in agreement with the recommendations. Non-compliance with the level of effort requirement occurred because the agency received additional federal funds as part of the American Rescue Plan and utilized those funds to cover city tax levy costs in FY22. This was a one-time offset. In addition to strengthening and maintaining internal controls, DOHMH plans to revisit how maintenance of effort is calculated for the PHEP award, as it is currently calculated using a 15-year-old formula that has not been tweaked to ensure it accurately captures health care preparedness and public health security spending. DOHMH will close out a 5-year project period on the PHEP award in 2024 and plans to revisit the current maintenance of effort formula in advance of applying for the new project period. Anticipated Completion Date June 2024 Person(s) Responsible for Implementation Monica Marquez Assistant Commissioner, OEPR (347) 396-2730 Wai ting Yu Assistant Commissioner, Central Finance (347) 396-6214

View Audit 22749

Finding 24617 (2022-012)

Material Weakness 2022

The City of New York

NY

Questioned Costs Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Finding No. 2022-012 Department(s) New York City Human Resources Administration Program(s) Assistance Listing Number 14.239, HOME Investment Partnerships Program Corrective Action(s) Response: ? HRA agrees that the Agency had challenges in retaining some recertification documentation during the COVI...

Finding No. 2022-012 Department(s) New York City Human Resources Administration Program(s) Assistance Listing Number 14.239, HOME Investment Partnerships Program Corrective Action(s) Response: ? HRA agrees that the Agency had challenges in retaining some recertification documentation during the COVID Public Health crisis when staff were working from home and then ultimately leaving the Agency prior to the return to office. ? The identified HOME TBRA tenants had been originally found eligible over five years ago and have been recertified annually every year following. ? This FY22 audit was conducted on the heels of the FY21 audit where the finding was the same and the recommended Corrective Action was the development of a Quality Assurance Checklist due by November 2022 and ongoing. ? HRA agrees to strengthen internal controls and have created and implemented a Quality Assurance Tool that ensure eligibility is accurately assessed, allowable cost is correctly calculated and appropriate evidence (i.e. Recertification Information Form, Proof of Income, Rent Reasonableness Information, Passed Inspection, Landlord Packet, Client Packet, RAC, Tenant Breakdown) that support annual approval is maintained. Also, the payment system already fully requires supervisor approval before annual payments can be set up. Absolutely no payment can go out without supervisor approval. Corrective Actions: ? Strengthen internal governance and future compliance. ? Hire an Executive Director for the TBRA ? Create and implement a Quality Assurance tool that includes information that supports eligibility. ? Provide refresher training for staff involved with TBRA. Anticipated Completion Date May 2023 and ongoing Person(s) Responsible for Implementation Dori Hopkins-Figeroux Director, TBRA (929) 252-6089 Dwana Abraham Assistant Deputy Commissioner (929) 221-6726

View Audit 22749 Questioned Costs: $1

Finding 24615 (2022-008)

None 2022

The City of New York

NY

Special Tests & Provisions Subrecipient Monitoring Matching / Level of Effort / Earmarking

Finding No. 2022-008 Department(s) New York City Department of Housing Preservation and Development Program(s) Assistance Listing Number 14.239, HOME Investment Partnerships Program Corrective Action(s) The Department of Housing Preservation and Development (HPD) continues to maintain processes and...

Finding No. 2022-008 Department(s) New York City Department of Housing Preservation and Development Program(s) Assistance Listing Number 14.239, HOME Investment Partnerships Program Corrective Action(s) The Department of Housing Preservation and Development (HPD) continues to maintain processes and procedures supporting compliance with Housing Quality (HQ) inspection standards. HPD routinely conducts HQ inspections of HOME Investment Partnership Program assisted rental units and continues to maintain systems to facilitate and promote compliance with HOME inspection requirements; HPD inspects HOME units periodically and follows up on failed inspections routinely. Further, HPD continues to review program requirements and operations to enhance program oversight and ensure the timeliness of repairs. As part of HPD?s ongoing effort to accomplish complete and timely repairs of all HOME units, building owners are notified of failed inspections, and regularly provided with detailed reports identifying non-compliant conditions. HPD also continues to impress upon owners the critical importance of completing timely repairs of all HOME units. Building owners are notified of failed inspections and provided detailed reports regularly, identifying non-compliant conditions. With respect to the finding, HPD recognizes that in six (6) instances, the Certification of Repair was not submitted within the 90-day timeframe. HPD will continue to follow-up with the owner(s) until all required repairs are certified as complete. In addition, HPD will consider, on a case-by-case basis, documenting its rationale for not exercising extreme remedies (such as withdrawal of future funding) for failure to complete repairs within the 90-day cure period. Anticipated Completion Date March 2022 and ongoing Person(s) Responsible for Implementation Arabia Brown Deputy Director, Tax Credit and HOME Compliance (212) 863-8204

View Audit 22749

Finding 24613 (2022-003)

Significant Deficiency 2022

Greene Acres Nursing Home Association, Inc.

AR

Matching / Level of Effort / Earmarking § 200.302 § 200.305

Views of responsible officials and planned corrective actions: Management agrees with this finding and will write policies and procedures for Federal awards.

View Audit 21261

Finding 24611 (2022-001)

Material Weakness 2022

Greene Acres Nursing Home Association, Inc.

AR

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303

Views of responsible officials and planned corrective actions: Management agrees with this finding and will ensure proper review is performed and evidenced.

View Audit 21261 Questioned Costs: $1

Finding 24575 (2022-050)

Significant Deficiency 2022

State of Michigan

MI

Questioned Costs Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles

Finding 2022-050 Medicaid Cluster, ALN 93.775, 93.777 and 93.778 - Practitioner Reimbursement Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has determined the primary remaining source of overlaps between fee-for-service and capitation payments is retroactive remov...

Finding 2022-050 Medicaid Cluster, ALN 93.775, 93.777 and 93.778 - Practitioner Reimbursement Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has determined the primary remaining source of overlaps between fee-for-service and capitation payments is retroactive removal of Medicaid eligibility within Bridges. In November 2019, MDHHS formed a multi-disciplinary work group within the Medical Services Administration to address the problems created when eligibility is removed retroactively. An interface fix is being implemented in December 2023 that will address several existing issues. This upgraded interface will remove existing limitations to mitigate the occurrence of retroactive disenrollment. In addition, the work group continues to evaluate whether any additional process and system changes are needed to further mitigate the occurrence of overlapping payments. Anticipated Completion Date The interface fix will be implemented by December 31, 2023, and evaluation of whether additional process and system changes are needed to further mitigate the occurrence of overlapping payments is ongoing. Responsible Individual(s) Alexis Bond, MDHHS Latina McCausey, MDHHS

View Audit 20093 Questioned Costs: $1

Finding 24574 (2022-049)

Significant Deficiency 2022

State of Michigan

MI

Questioned Costs Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.516

Finding 2022-049 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Home Help Payment Oversight Management Views MDHHS agrees with the finding. Planned Corrective Action Beginning in April 2022, MDHHS automated the payment methodology for ESV to ensure that payments to individual providers using E...

Finding 2022-049 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Home Help Payment Oversight Management Views MDHHS agrees with the finding. Planned Corrective Action Beginning in April 2022, MDHHS automated the payment methodology for ESV to ensure that payments to individual providers using ESV are based on tasks authorized and completed, and compared to approved authorizations before payment is issued. Also, individual caregiver verifications currently in ESV and Paper Service Verification (PSV) will be replaced with Electronic Visit Verification (EVV), which will help ensure payments are reflective of the services provided. MDHHS will continue to manually review PSVs until EVV is implemented. Anticipated Completion Date December 2024 Responsible Individual(s) Elaina Brown-Mingo, MDHHS Michelle Martin, MDHHS

View Audit 20093 Questioned Costs: $1

Finding 24573 (2022-048)

Significant Deficiency 2022

State of Michigan

MI

Questioned Costs Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.516

Finding 2022-048 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Ineligible HHP Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS made improvements to the monthly hospitalization reports to help capture all facility stays for Home Help Clients. MDHHS is no...

Finding 2022-048 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Ineligible HHP Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS made improvements to the monthly hospitalization reports to help capture all facility stays for Home Help Clients. MDHHS is now pulling reports by billing date instead of hospitalization dates to capture inpatient stays that are billed late. MDHHS also implemented a new policy on February 1, 2023, that allows payment for Home Help Program (HHP) services on the day an individual is admitted to the hospital. MDHHS changed the HHP payment process to an automated process during April 2022, tying payments to services on the Electronic Service Verification (ESV) prior to payment being made. In addition, MDHHS modified policy to begin recoupment by task instead of by daily rate for services provided on overlapping days. MDHHS provided a recoupment calculator and training for HHP staff to ensure the correct amount is recouped using the revised policy and procedure. Anticipated Completion Date Completed Responsible Individual(s) Elaina Brown-Mingo, MDHHS Michelle Martin, MDHHS

View Audit 20093 Questioned Costs: $1

Finding 24572 (2022-047)

Significant Deficiency 2022

State of Michigan

MI

Questioned Costs Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.516

Finding 2022-047 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Payments on Behalf of Ineligible Beneficiaries Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS implemented a system solution to identify out of sync records between CHAMPS and Bridges and retrigger ...

Finding 2022-047 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Payments on Behalf of Ineligible Beneficiaries Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS implemented a system solution to identify out of sync records between CHAMPS and Bridges and retrigger updates to CHAMPS. MDHHS is also developing a prior report review process to ensure impacted records that do not get corrected with the CHAMPS retrigger are addressed. Anticipated Completion Date The system solution was implemented as of August 31, 2022. The prior report review process will be implemented by September 30, 2023, and reviews will be ongoing. Responsible Individual(s) Jamy Hengesbach, MDHHS

View Audit 20093 Questioned Costs: $1

Finding 24565 (2022-019)

Material Weakness 2022

State of Michigan

MI

Questioned Costs Eligibility Material Weakness § 200.516

Finding 2022-019 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Beneficiary Eligibility Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS continues to pursue other data sources for income verification and other s...

Finding 2022-019 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Beneficiary Eligibility Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS continues to pursue other data sources for income verification and other system enhancements so that all case data is available to all reviewers. MDHHS conducts mandated training for local office caseworkers. In addition, MDHHS will continue to determine where additional training or enhancements to training are needed to ensure eligibility is accurately determined and documentation is properly maintained and loaded to the electronic case file. Lastly, MDHHS has been working since 2018 to ensure correct eligibility classifications in Bridges at the time of payment and a system change was implemented in April 2021 to correct the issue. All new cases are being correctly routed. MDHHS expects that all existing cases will be updated during the 14-month period following the May 11, 2023 end of the PHE, as allowed by the Centers for Medicare and Medicaid Services. Anticipated Completion Date MDHHS continues to pursue other data sources for income verification and other system enhancements, in addition to determining where training is needed, on an ongoing basis. MDHHS expects to have all existing cases updated by June 2024. Responsible Individual(s) Logan Dreasky, MDHHS Brant Cole, MDHHS Mariah Schaefer, MDHHS

View Audit 20093 Questioned Costs: $1

Finding 24510 (2022-046)

Significant Deficiency 2022

State of Michigan

MI

Questioned Costs Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.516

Finding 2022-046 CCDF Cluster, ALN 93.575 and 93.596 - Provider Health and Safety Requirements Management Views MDE and the Department of Licensing and Regulatory Affairs (LARA) agree with the finding. Planned Corrective Action For part a., the Child Care Licensing Bureau (CCLB) within LARA has ...

Finding 2022-046 CCDF Cluster, ALN 93.575 and 93.596 - Provider Health and Safety Requirements Management Views MDE and the Department of Licensing and Regulatory Affairs (LARA) agree with the finding. Planned Corrective Action For part a., the Child Care Licensing Bureau (CCLB) within LARA has updated its internal policies to clarify how it manages workflow operations, while ensuring CCLB meets federal compliance requirements. In June 2022, the Child Care Organizations Act was amended and the language in Michigan Compiled Law 722.113h was changed to allow for inspections to be conducted in accordance with the State plan. The State plan specifies the annual licensing inspection requirement, at 45 CFR 98.42(b)(2)(i)(B) for unannounced inspections, must be performed ?not less than annually.? According to guidance from the Federal Office of Child Care Region V, this does not mean that inspections must be performed at exact 12-month intervals; therefore, the lead agency has flexibility to schedule the inspections within each calendar year. CCLB has subsequently completed the annually required renewal and/or interim inspections for the licenses identified in the audit sample. The applicable health and safety requirements were reviewed during the inspections conducted. For part b., CCLB is currently creating a new licensing system that will automate letters being sent to licensed child care providers. The new system will generate and store inspection reports directly in the system instead of creating the report in a separate location and then manually moving it to other locations (network drive, SharePoint). This allows the inspection reports to be maintained digitally and be accessible at a later date, while ensuring proper documentation to support renewal inspections is maintained. For part c., in June 2022, CCLB implemented a new process to save all extension letters mailed in PDF format and stored in the current system to be accessed and available upon request. In addition, CCLB will incorporate refresher trainings regarding documentation and storage of inspection reports at its biannual all-staff trainings. The current process of documentation creation and storage will be phased out after the new licensing system is implemented and processes are no longer manually done by CCLB staff. Anticipated Completion Date a. Completed b. October 1, 2023 c. October 1, 2023 Responsible Individual(s) Emily Laidlaw, LARA Lisa Brewer-Walraven, MDE

View Audit 20093 Questioned Costs: $1

Finding 24508 (2022-044)

Material Weakness 2022

State of Michigan

MI

Questioned Costs Matching / Level of Effort / Earmarking § 200.516

Finding 2022-044 CCDF Cluster, ALN 93.575 and 93.596 - Client Eligibility Management Views MDHHS and MDE agree with the finding. Planned Corrective Action MDHHS Public Assistance Operations (PAO), within the ESA, will continue assisting the local office and BSC staff by providing guidance on MDE ...

Finding 2022-044 CCDF Cluster, ALN 93.575 and 93.596 - Client Eligibility Management Views MDHHS and MDE agree with the finding. Planned Corrective Action MDHHS Public Assistance Operations (PAO), within the ESA, will continue assisting the local office and BSC staff by providing guidance on MDE policies and processes. ESA will inform the local office and BSC staff of policy changes or noted trends during PAO?s Bridges Bits and Bytes communications sessions. ESA?s Payment Accuracy Unit completed case reads in December 2022 and, as a result, ESA and MDE finalized a checklist on May 9, 2023, for use by local office staff to help ensure required documentation that supports eligibility is obtained. Also, MDE launched a Child Development and Care case review SharePoint site on May 1, 2023, to share information with MDE and MDHHS staff, reduce errors and promote integrity efforts for the program. Anticipated Completion Date MDHHS assistance and guidance for local office and BSC staff is ongoing. Responsible Individual(s) Mariah Schaefer, MDHHS Gayle Vail, MDHHS Lisa Brewer-Walraven, MDE

View Audit 20093 Questioned Costs: $1

Finding 24488 (2022-043)

Significant Deficiency 2022

State of Michigan

MI

Matching / Level of Effort / Earmarking Subrecipient Monitoring Allowable Costs / Cost Principles

Finding 2022-043 Aging Cluster, ALN 93.044, 93.045, and 93.053 - AIS FIRST User Access Management Views Although MDHHS thoroughly reviewed the access forms, MDHHS agrees that the final approval was not documented. Planned Corrective Action MDHHS has instructed staff that all forms must either cont...

Finding 2022-043 Aging Cluster, ALN 93.044, 93.045, and 93.053 - AIS FIRST User Access Management Views Although MDHHS thoroughly reviewed the access forms, MDHHS agrees that the final approval was not documented. Planned Corrective Action MDHHS has instructed staff that all forms must either contain a handwritten or electronic signature. MDHHS will also develop and implement an internal process for staff to ensure all future security forms contain the required approvals. Anticipated Completion Date July 1, 2023 Responsible Individual(s) Jen Hunt, MDHHS Cindy Masterson, MDHHS

View Audit 20093

Finding 24467 (2022-001)

Significant Deficiency 2022

University of the Pacific

CA

Student Financial Aid Matching / Level of Effort / Earmarking Reporting

Finding #2022-001: Pacific understands finding #2022-001 and we agree that the University will modify internal controls to ensure accurate and timely reporting of student status changes to the National Student Loan Data System (NSLDS). The University has adjusted the completion/graduation process an...

Finding #2022-001: Pacific understands finding #2022-001 and we agree that the University will modify internal controls to ensure accurate and timely reporting of student status changes to the National Student Loan Data System (NSLDS). The University has adjusted the completion/graduation process and procedure to capture students (within the 60 days required to transmit status change to NSLDS) whose degree have been awarded. The university will correct error reports within the 10-day period to ensure the student status is updated within the 60-day requirement to transmit status change to NSLDS. Finding #2022-001 Action: The Office of the Registrar concurs with the audit test work of enrollment reporting which noted while there is a process in place to correctly submit information to NSLDS, during the audit test work the engagement team noted that three student's information was inaccurately reported to NSLDS. The University's control failed in detecting that inaccurate information was reported to NSLDS. It was discovered in December 2022 that the Registrar staff did not review the error report from the clearinghouse to ensure students? final status to NSLDS during the required reporting period. Per the 2022 Enrollment Reporting Guide, ?After the institution submits the Enrollment Reporting roster to NSLDS, NSLDS evaluates the enrollment Reporting roster and provides the institution an Error/Acknowledgement file. If errors are identified, institutions have 10 days to correct the errors and resubmit to NSLDS.? While the University acknowledges the critical nature of taking corrective action on this finding, it also notes incorrect reporting of ?G ? for ?W? statuses results in no harm to individual students in their loan repayment start dates nor financial loss to the U.S. Department of Education?s federal loan program. The University agrees with this statement and, as of July 2022, has adjusted the completion/graduation process and procedure to capture students (within the 60 days required to transmit status change to NSLDS) who have been awarded their degree but files appear in the clearinghouse error report. The University will correct error report and resubmit within 10-days and ensure in NSLDS that the update is complete. Person(s) responsible: Karen Johnson University Registrar

View Audit 22556

Finding 24397 (2022-002)

Material Weakness 2022

Ocala Housing Authority

FL

HUD Housing Programs Eligibility Material Weakness

2022-002 Tenant Files: Eligibility Program: U.S. Department of HUD: Section 8 Housing Choice Vouchers (CFDA 14.871) Type of Finding: Material Weakness in Internal Control and Material Noncompliance This is a repeat finding of 2021-001 from September 30, 2021 (Other Matter and Significant Deficiency ...

2022-002 Tenant Files: Eligibility Program: U.S. Department of HUD: Section 8 Housing Choice Vouchers (CFDA 14.871) Type of Finding: Material Weakness in Internal Control and Material Noncompliance This is a repeat finding of 2021-001 from September 30, 2021 (Other Matter and Significant Deficiency in Internal Control over Compliance). Originally reported as finding 2019-001 from September 30, 2019 (Material Weakness in Internal Control and Material Noncompliance) Statement of Condition: Out of a total tenant population of approximately 1,114 vouchers, 25 files were selected for testing. Exceptions were noted as follows: ? 1 tenant file had the following errors: o The tenant?s annual recertification application is missing. o The tenant?s signed 9886 form is missing. o The wrong utility allowance schedule was used to calculate the tenants? utility allowance. Correcting this error would cause the HAP rent to increase by $9. o The tenant?s signed HAP contract is missing. ? 1 tenant file had the following errors: o The name and social security number for one of the tenant?s dependents was reported incorrectly on the 50058 form. o The tenant?s utility allowance was calculated correctly but was reported incorrectly on the 50058 form. Correcting this error would cause the HAP rent to increase by $56. ? 1 tenant file had the following errors: o The lease agreement was not signed by the tenant. o The tenant?s assets was reported in error. Correcting this error would cause the rent to increase by $8. ? 2 tenant files where the tenants? income was miscalculated. Correcting the errors would cause the HAP rent for one of tenant files to decrease by $12 and the other to increase by $181. ? 2 tenant files where the wrong utility allowance schedule was used to calculate the tenants? utility allowance. Correcting these errors would cause the HAP rent for one of the tenant files to decrease by $13 and the other to increase by $14. ? 1 tenant file where the family?s assets was reported in error. Correcting the errors had no effect on the HAP rent. ? 1 tenant file where a member of the household moved but was reported on the 50058 form. ? 1 tenant file where the tenant?s signed HAP contract is missing. ? 1 tenant file where the EIV report was never generated or was misplaced. In addition to the above, we noted the following during our new admissions testing (out of a total of 118 new admission, 18 files were selected for testing.): ? 1 tenant file where the member of the household did not checkmark the checkbox on the 214-affidavit form indicating that they are a U.S. Citizen or permanent resident. However, the member?s birth certificate confirms that the member is a U.S. Citizen. ? 1 tenant file where the tenant?s signed 214-affidavit is missing. However, the member?s birth certificate confirms that the member is a U.S. Citizen. Recommendation: The Authority should correct the deficiencies noted in the tested files and utilize an ongoing quality control review process on the entire tenant population to ensure proper compliance with the requirements related to tenant eligibility. Ongoing staff training and timely management reviews should be utilized to ensure staff is aware of acceptable procedures. In addition, the Authority should review staffing levels, skill sets and case load. Action Taken: The Authority concurs with this finding. The Authority has an established review, oversight and training process and will continue to improve its review, oversight, and training process to ensure proper procedures are being followed. All audit findings of the files tested will have been corrected. The Authority has implemented a quality control system so that every file receives a quality review for appropriate third-party verification and upfront income and assistance is determined. The agency has created a Family Worksheet and an HCV Computation Worksheet to help staff identify errors in calculations and to check for accuracy prior to completing Annual Reexaminations and Interim Recertifications. The agency has changed its filing system to enable staff to thoroughly review all forms prior to admission and during regular recertification and interim adjustment processing. The agency created an Other Adult packet to ensure 214 forms and other pertinent are completed for all adult household members. The HCV Counselor caseloads have been distributed equitably amongst Counselors to promote efficiency and accuracy while working on each HCV participant?s file. The Counselor?s caseload is divided alphabetically and assigned by multifamily developments to track and monitor counselors? strength and weaknesses, and to determine if additional training and/or monitoring is needed. Internal file reviews are being completed and management will continue to conduct a 10% review for each Counselor?s processing of annual recertifications. This percentage may increase if work product indicates a need for more stringent review. To further ensure compliance and accuracy, the HCV Program Manager will review at least 1 out of every 5 intake files. The Authority has had a significant turnover in the HCV department over the past 24 months. All HCV staff will attend Voucher Specialist training and Nan McKay HCV Rental Calculation Certification training. Effective Date: June 20, 2023 Contact Information Gwendolyn B. Dawson, CEO Ocala Housing Authority 1629 NW 4th Street Ocala, Florida 34475 (352) 369-2636

View Audit 22927

Finding 24396 (2022-001)

Significant Deficiency 2022

The Reed Institute

OR

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

The following corrective measures have been implemented: The Director of Financial Aid requests the amounts and number of students who received HEERF funding from the Business Office at the end of each quarter and reviews, confirms, and documents the date of request and review. A log of the website ...

The following corrective measures have been implemented: The Director of Financial Aid requests the amounts and number of students who received HEERF funding from the Business Office at the end of each quarter and reviews, confirms, and documents the date of request and review. A log of the website updates is maintained to document timely submission of data. The website was revamped to include all necessary reporting requirements including the number of eligible students for CRSSA HEERF II and ARP HEERF III. This updated process was implemented upon identification of the prior year finding, which occurred after the first quarterly report for fiscal year 2022 was posted.

View Audit 22802

Finding 24324 (2022-001)

Material Weakness 2022

Columbia Local School District

OH

Matching / Level of Effort / Earmarking Subrecipient Monitoring

The District is aware of the requirement in Federal Program legislation to ensure the inclusion of the prevailing wage rate provision in agreements, as well as to obtain certified payroll reports to verify prevailing wages were paid. At the time the District entered into the agreement with West Roo...

The District is aware of the requirement in Federal Program legislation to ensure the inclusion of the prevailing wage rate provision in agreements, as well as to obtain certified payroll reports to verify prevailing wages were paid. At the time the District entered into the agreement with West Roofing to install and renovate the HVAC system at Columbia High School, which was January 7, 2021, ESSER funds were not awarded to the District planned on using Permanent Improvement funds (a non-federal program sourced fund) to pay West Roofing. The District initially paid West Roofing from the Permanent Improvement fund for the installation/renovation of the HVAC at Columbia High School as per the initial contract. Once the ESSER funds were awarded, they allowed for previous expenses related to improving air quality to be included as part of reimbursement through ESSER funds. The prevailing wage was not met under the existing contract. The District has implemented the following Action Plan for Correction: 1. The Treasurer will ensure all agreements intended to be sourced through Federal Funds will contain prevailing wage rate provisions prior to signing such agreements. 2. The Treasurer will ensure that invoices from contractors contain the necessary prevailing wage certified payroll reports prior to approving such invoices for payment from Federal Funds. 3. The Treasurer will educate all responsible parties in the District regarding prevailing wage documentation to ensure appropriate documentation is obtained prior to payment to the contractors and prior to requesting Federal Funds.

View Audit 19658

Finding 24310 (2022-004)

Material Weakness 2022

West Noble School Corporation

IN

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.208 § 200.303 § 200.403

FINDING 2022-004 Contact Person Responsible for Corrective Action: Barbara Fought Contact Phone Number: 260-260-3191 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: West Noble School Corporation will work with the Northeast Indiana Special Education ...

FINDING 2022-004 Contact Person Responsible for Corrective Action: Barbara Fought Contact Phone Number: 260-260-3191 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: West Noble School Corporation will work with the Northeast Indiana Special Education Cooperative to implement the procedures detailed below. The Northeast Indiana Special Education Cooperative (NEISEC) Treasurer will reach out to member schools during the writing process of the IDEA 611 and 619 grants in order for each member school to submit their plans for their allocation of proportionate share money. NEISEC will provide the allocation amounts to each cooperative school. These submissions will include a proportionate share budget and include proportionate share staff names and any necessary information for the budget categories. The NEISEC Treasurer will then compile the proportionate share information and include on the grant submission. The LEA Treasurer will be given a copy of the grant application and budget upon approval of the grant. Any NEISEC employee being paid out of proportionate share grant funds for salary and benefits will be paid from the fiscal agent?s financial software. The LEA Treasurer will keep a spreadsheet of employee proportionate share expenses and this spreadsheet will be updated monthly based on time and effort logs that are submitted by all cooperative schools to the LEA and NEISEC. Any employee utilizing proportionate share funds that is not an employee of NEISEC, but rather a direct employee of a member school, will be paid directly by that member school. Time and effort logs will still be submitted to the LEA and NEISEC Treasurers for these employees in order to generate a direct reimbursement from the grant fund to the member school. For any expenses for a category outside of salary and benefits, a member school will need to submit an invoice and proof of purchase for equipment, supplies, etc. to NEISEC and the LEA in order to be directly reimbursed for those proportionate share expenses. If the request was not in the initial grant budget, the member school must submit all relevant information to NEISEC in order for a grant modification to be completed. Per IDOE the grant modification must be approved first prior to purchasing the items. Time and effort logs as well as invoice and proof of payment must be sent to the LEA Treasurer and NEISEC in order to complete the grant reimbursement requests. INDIANA STATE BOARD OF ACCOUNTS 29 TELEPHONE (260) 894-3191 - 5050 N US HIGHWAY 33 - LIGONIER, IN 46767-9606 - FAX (260) 894-3260 - 1-800-488-3191 - WNSC@WESTNOBLE.K12.IN.US At the end of the grant period, any school with remaining proportionate share money will be required to complete a waiver. As of this date (2/10/2023) DeKalb County Eastern CSD and NEISEC are still in communication with SBOA and IDOE to review the proportionate share plan and ensure all necessary requirements will be satisfied. Anticipated Completion Date: Changes discussed above will be implemented for the remainder of the FY23 grant period starting 07/01/2023.

View Audit 19951

Finding 24300 (2022-005)

Significant Deficiency 2022

City of Stockton

CA

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

2022-005 Reporting ? Internal Control and Compliance over Reporting City?s Corrective Action Plan: A recent appointment to the Debt and Treasury department has allowed for restructuring of the processes present within the department. Debt and Treasury personnel have been made aware of the previous ...

2022-005 Reporting ? Internal Control and Compliance over Reporting City?s Corrective Action Plan: A recent appointment to the Debt and Treasury department has allowed for restructuring of the processes present within the department. Debt and Treasury personnel have been made aware of the previous insufficiencies and will work with funding sources to identify which requirements are fulfilled by external project managers and which requirements need to be fulfilled by City staff. Responsible Person: Teri Chapa (Program Manager) Expected Implementation Date: March 2023

View Audit 19272

Finding 24243 (2022-001)

Significant Deficiency 2022

South Pike County School District

AR

Equipment & Real Property Management Matching / Level of Effort / Earmarking

The District ensures that starting 2022-2023 school year that all applicable construction contracts will contain the required notifications regarding compliance with the Davis-Bacon Act. Copies of the weekly certified payrolls will be obtained for the applicable projects. EDSD43522-001 The Distr...

The District ensures that starting 2022-2023 school year that all applicable construction contracts will contain the required notifications regarding compliance with the Davis-Bacon Act. Copies of the weekly certified payrolls will be obtained for the applicable projects. EDSD43522-001 The District paid a floor resurfacing company $202,775 to resurface floors throughout the district without obtaining a written contract that included the prevailing wage rate clause. Additionally, weekly certified payrolls were not submitted to the District. The superintendent and/or the district treasurer will ensure that all applicable construction contracts contain the required notification regarding compliance with the Davis-Bacon Act. Copies of the weekly certified payrolls will be obtained for the applicable projects. Met with contractor that is still working on our campus to finish the original project. He has turned in the weekly certified payrolls for the day in August 2022 that was worked and we have written contract on the exact amount that we will still owe to finish out the contract.

View Audit 20967

Finding 24240 (2022-001)

None 2022

Help Housing for the Disabled, Inc.

OH

Special Tests & Provisions Student Financial Aid Cash Management

RE: HELP HOUSING FOR THE DISABLED, INC. 26900 Euclid Avenue Euclid, Ohio 44132 SUBJECT: Corrective Action Plan 042EH430 HELP HOUSING FOR THE DISABLED Reporting Period Ending Date ? June 30, 2022 Finding 2022-001 CFDA: 14.157 Section 202 Direct Loan Criteria: Internal controls over compliance...

RE: HELP HOUSING FOR THE DISABLED, INC. 26900 Euclid Avenue Euclid, Ohio 44132 SUBJECT: Corrective Action Plan 042EH430 HELP HOUSING FOR THE DISABLED Reporting Period Ending Date ? June 30, 2022 Finding 2022-001 CFDA: 14.157 Section 202 Direct Loan Criteria: Internal controls over compliance should be in place to ensure the deposit of surplus cash amounts into the residual receipts account occurs within ninety days after year end. Condition: A deficiency in internal control over compliance existed due to the prior year excess surplus cash amount not being deposited into the residual receipts account within ninety days after the end of the annual fiscal period for which the surplus cash was calculated. Recommendation: The Project should establish procedures to ensure that surplus cash is deposited within ninety days after the end of the annual fiscal period for which the surplus cash is calculated. CORRECTIVE ACTION: Management has agreed to implement the process of depositing surplus cash on the day the audited financial statements are issued. Thorough review of financial statement notes and conversations with audit team during the review process will establish the amount of funds to be deposited. Once this internal review is complete and audited statements are issued the internal management team will routinely make the required deposit and follow up by providing payment confirmation to the outside audit team. This accountability confirmation process will ensure that the deposit is made timely and routinely. Any questions regarding this plan should be directed to: Belinda Glavic Grassi MA, CPA Chief Financial Officer Help Housing for the Disabled, Inc. (216) 432-4810

View Audit 20864

Corrective Action Plans

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