Corrective Action Plans

Finding 391673 (2023-013)

Material Weakness 2023

HI

Subrecipient Monitoring Material Weakness Reporting

Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: Subawards will be entered into the FSRS within the appropriate timeframe following the execution of the contract. Expected Completion Date: Not applica...

Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: Subawards will be entered into the FSRS within the appropriate timeframe following the execution of the contract. Expected Completion Date: Not applicable as reporting of federal subawards is an ongoing requirement. Responding Officials: Catherine Scardino, Temporary Assistance for Needy Families Program Administrator

View Audit 302108

Finding 391671 (2023-012)

Material Weakness 2023

Department of Human Services

HI

Questioned Costs Special Tests & Provisions Student Financial Aid

Views of Responding Officials: The Department agrees with the finding and will implement corrective action, however, notes the following: The referrals to the Child Support Enforcement Agency (“CSEA”) are done through an interface between the HAWI eligibility and CSEA’s KEIKI systems. When a recip...

Views of Responding Officials: The Department agrees with the finding and will implement corrective action, however, notes the following: The referrals to the Child Support Enforcement Agency (“CSEA”) are done through an interface between the HAWI eligibility and CSEA’s KEIKI systems. When a recipient is determined noncompliant by CSEA, the information is sent via the interface from KEIKI to HAWI in the form of a system-generated alert. This process worked well when application processing and maintenance of recipient cases were done in a case management method (e.g., each eligibility worker assigned to process applications and/or maintain a caseload of active cases). Using this method, eligibility workers managed their caseloads and checked for incoming alerts for cases assigned to them; these alerts included the CSEA noncompliant alerts coming from the KEIKI system. Workers were able to take appropriate and timely action in response to the alerts received. However, necessary changes were made to how applications and active cases are managed. The division stopped the case management method and converted to “task-oriented” processing statewide. Workers are no longer assigned to caseloads but are assigned to “tasks” such as processing applications, incoming documents/verifications, reported changes, six month review and annual recertifications, etc. A case is not reviewed and worked in HAWI until a worker is prompted to do so, e.g., six-month review, annual recertification or a change was reported by the household. It is until such action occurs when an eligibility worker, who picks up the task, will check for alerts for the case. Aside from that, recipient cases will not be reviewed during their certification period. So how the “alerts” were developed in HAWI no longer works for the way we currently process applications and maintain recipient cases. We are unable to modify the HAWI system because we are currently developing a new eligibility system that will replace HAWI. The new eligibility system is scheduled to go into production in late 2024. Corrective Action Taken or Planned: As an interim solution until the new eligibility system rolls out into production, a shared folder is being created where CSEA will place the monthly reports of non cooperating TANF cases so designated TANF staff members, who are granted access to the shared folder, will be able to retrieve the reports. TANFPO will review the identified TANF cases. Individual lists will be forwarded to the Section Administrators to instruct the affected Processing Centers to take appropriate action (i.e., TANF case closure due to noncompliance with CSEA). Expected Completion Date: July 1, 2024 Responding Officials: Catherine Scardino, Temporary Assistance for Needy Families Program Administrator

View Audit 302108 Questioned Costs: $1

Finding 391669 (2023-011)

Material Weakness 2023

Department of Human Services

HI

Questioned Costs Eligibility Special Tests & Provisions

Views of Responding Officials: The Department does not agree with this finding. According to 45 CFR section 205.55, it states, “…the State agency will request through the IEVS…”. However, the policy does not specify the State agency must “properly use IEVS information to evaluate benefit amounts…...

Views of Responding Officials: The Department does not agree with this finding. According to 45 CFR section 205.55, it states, “…the State agency will request through the IEVS…”. However, the policy does not specify the State agency must “properly use IEVS information to evaluate benefit amounts…” as notated in this finding under “Effect.” Unless IEVS provides the necessary information for the applicable benefit month(s) used to determine a TANF applicant’s or recipient’s (“client”) eligibility, information obtained will only validate whether a household received an income source, after the fact, but will not verify the dollar amount. Hard-copy verification is obtained from the client to verify income source and dollar amount, for the applicable benefit months, to determine eligibility in accordance with §17 676 51, Hawaii Administrative Rules. For example, if a client applied for TANF on January 31, 2024, and the Department processes the application on February 29, 2024 (current month), verification of the household’s income received in January 2024 and received thus far in February 2024, must be obtained to determine eligibility for the month of application (January 2024) and subsequent months (based on projected income). Data obtained from IEVS are not current. For example, wage information through SWICA becomes available on a quarterly basis. The most current SWICA information available would have been for quarter ending December 31, 2023, for an application that was processed on February 29, 2024. Eligibility determination would have been improperly made if SWICA information was applied. Corrective Action Taken or Planned: The Department will continue to conduct IEVS check and utilize information obtained to determine eligibility if the information is applicable, otherwise, IEVS information will continue to be used to validate any source of income. Expected Completion Date: Ongoing Responding Officials: Catherine Scardino, Temporary Assistance for Needy Families Program Administrator

View Audit 302108 Questioned Costs: $1

Finding 391665 (2023-009)

Material Weakness 2023

Department of Human Services

HI

Questioned Costs Allowable Costs / Cost Principles Eligibility

Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: 1. Child Welfare Service (“CWS”) staff will be informed of the audit findings, the importance of diligent compliance of policies and procedures, records m...

Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: 1. Child Welfare Service (“CWS”) staff will be informed of the audit findings, the importance of diligent compliance of policies and procedures, records maintenance and this corrective action plan. 2. Unit staff (Licensing, CWS, and FPPEU) who manage cases identified with errors in this audit will be retrained, ensuring familiarity with grant requirements and related policies and procedures. • Staff will be given coaching/supervisory support to correctly complete documentation. 3. Case specific audit findings and corrective action taken will be noted in each record where there was a finding. • Secure a copy of the missing modified guardianship/permanency assistance agreement, demonstrating support for the monthly assistance paid. • Document the qualifying need for Difficulty of Care (“DOC”) determination for the records, showing how DOC was calculated. • Investigate whether the child who attained the age of 14 was consulted regarding the kinship guardianship agreement. Discuss this with the youth and document. • Locate missing clearances or re run them if not located, placing note in record about audit re run. Note: Not all clearances are secured prior to placement; FBI clearances come later and are NOT required prior to placement in a “provisionally licensed” home. • Secure documentation for case regarding continuation of monthly subsidy payments after the child’s 18th birthday. 4. The identified errors and the related corrective action steps proposed above will be reviewed by CWS Administrators, staff supervisors, and the Management Information Compliance Unit (“MICU”) within 90 days to ensure missing documentation has been secured and/or properly noted in record. 5. MICU staff will audit records with findings to ensure errors have been documented and corrected. • MICU will work with Branch Administrators, Social Services Assistants (“SSA”), and program personnel to ensure file updates with completion of missing information. 6. As CWS implements this corrective action plan and monitors the results, the action steps proposed in 1 – 5 may be modified, based on input from CWS Administrators or exploration groups with line staff who complete this documentation. Expected Completion Date: May 31, 2024 and on-going Responding Officials: Kisha C. Raby, Social Services Division, Child Welfare Services Program Development Office, Administrator

View Audit 302108 Questioned Costs: $1

Finding 391663 (2023-008)

Material Weakness 2023

Department of Human Services

HI

Questioned Costs Student Financial Aid Allowable Costs / Cost Principles

Views of Responding Officials: The Department agrees with the finding and will implement corrective action; however, notes the following: Adoption Assistance is an incentive program with payment beginning prior to the finalization of an adoption. The adoption decree is not required for payment as ...

Views of Responding Officials: The Department agrees with the finding and will implement corrective action; however, notes the following: Adoption Assistance is an incentive program with payment beginning prior to the finalization of an adoption. The adoption decree is not required for payment as the Adoption Assistance Agreement must be entered into prior to the finalization of an adoption. Corrective Action Taken or Planned: 1. Child Welfare Service (“CWS”) staff will be informed of the audit findings, the importance of diligent compliance of policies and procedures, records maintenance and this corrective action plan. 2. Unit staff (Licensing, CWS, and FPPEU) who manage cases identified with errors in this audit will be retrained, ensuring familiarity with grant requirements and related policies and procedures. • Staff will be given coaching/supervisory support to correctly complete documentation. 3. Case specific audit findings and corrective action taken will be noted in each record where there was a finding. • Research/review and document why licensing approval was granted to a household with an individual who was convicted of spousal abuse. i. If review determines that Adoption Assistance Agreement (“AAA”) was inappropriately authorized, provide family with an adverse action notice discontinuing the AAA and explaining the appeals process. • Investigate whether supporting documentation regarding whether the State determined that the child cannot or should not be returned to the home of his or her parents can be located and added to the record. • Secure a copy of the missing adoption decree, although adoption assistance is an incentive program with payment beginning prior to the finalization of an adoption. • Document the qualifying need for Difficulty of Care (“DOC”) determination for the records, showing how DOC was calculated. • Document how income eligibility was verified. • Secure missing modified adoption agreements. • Locate missing clearances or re run them if not located. Note: Not all clearances are secured prior to placement; FBI clearances come later and are NOT required prior to placement in a “provisionally licensed” home. 4. The identified errors and the related corrective action steps proposed above will be reviewed by CWS Administrators, staff supervisors, and the Management Information Compliance Unit (“MICU”) within 90 days to ensure missing documentation has been secured and/or properly noted in record. 5. MICU staff will audit records with findings to ensure errors have been documented and corrected. • MICU will work with Branch Administrators, Social Services Assistants (“SSA”), and program personnel to ensure file updates with completion of missing information. 6. As CWS implements this corrective action plan and monitors the results, the action steps proposed in 1 – 5 may be modified, based on input from CWS Administrators or exploration groups with line staff who complete this documentation. Expected Completion Date: May 31, 2024 and on going Responding Officials: Kisha C. Raby, Social Services Division, Child Welfare Services Program Development Office, Administrator, and Tonia Mahi, Social Services Division, Child Welfare Services Program Development Office, Assistant Branch Administrator

View Audit 302108 Questioned Costs: $1

Finding 391661 (2023-010)

Material Weakness 2023

Department of Human Services

HI

Questioned Costs Student Financial Aid Allowable Costs / Cost Principles

Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: 1. Child Welfare Service (“CWS”) staff will be informed of the audit findings, the importance of diligent compliance of policies and procedures, records m...

Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: 1. Child Welfare Service (“CWS”) staff will be informed of the audit findings, the importance of diligent compliance of policies and procedures, records maintenance and this corrective action plan. 2. Unit staff (Licensing, CWS, and FPPEU) who manage cases identified with errors in this audit will be retrained, ensuring familiarity with grant requirements and related policies and procedures. • Staff will be given coaching/supervisory support to correctly complete documentation. 3. Case specific audit findings and corrective action taken will be noted in each record where there was a finding. • Locate Police Protective Custody form, Voluntary Foster Custody Agreement, or other documentation which clarifies whether the child was removed as part of a voluntary placement agreement or judicial determination. • Locate missing clearances or re-run them if not located, placing note in record about audit re run. Note: Not all clearances are secured prior to placement; FBI clearances come later and are not required prior to placement in a “provisionally licensed” home. • Document the qualifying need for Difficulty of Care (“DOC”) determination for the records, showing how DOC was calculated. • Review resource caregiver licensing status and locate missing license or reissue license. • Investigate the case where the Judicial Determination was missing and therefore did not support the removal of the child was contrary to the welfare of the child, if the Department made reasonable efforts to prevent removal and finalize the permanency plan, and if the determination was within 60 days from removal. i. Locate court order documenting “contrary to welfare” language, verifying timelines, place in record and document findings. • Locate missing Imua Kakou minutes or secure additional documentation validating monthly meeting requirement was met. 4. The identified errors and the related corrective action steps proposed above will be reviewed by CWS Administrators, staff supervisors, and the Management Information Compliance Unit (“MICU”) within 90 days to ensure missing documentation has been secured and/or properly noted in record. 5. MICU staff will audit records with findings to ensure errors have been documented and corrected. • MICU will work with Branch Administrators, Social Services Assistants (“SSA”) and program personnel to ensure file updates with completion of missing information. 6. As CWS implements this corrective action plan and monitors the results, the action steps proposed in 1 – 5 may be modified, based on input from CWS Administrators or exploration groups with line staff who complete this documentation. Expected Completion Date: May 31, 2024 and on-going Responding Officials: Kisha C. Raby, Social Services Division, Child Welfare Services Program Development Office, Administrator

View Audit 302108 Questioned Costs: $1

Finding 391617 (2023-006)

Significant Deficiency 2023

County of Maui

HI

Allowable Costs / Cost Principles Subrecipient Monitoring Cash Management § 200.400 § 200.430

Ref. No. Compliance and Internal Control over Compliance Findings 2023-006 Allowable Costs – Significant Deficiency Recommendation We recommend the County follow their internal control process to ensure that adequate documentation supports the accumulation of costs charged to the Program as requ...

Ref. No. Compliance and Internal Control over Compliance Findings 2023-006 Allowable Costs – Significant Deficiency Recommendation We recommend the County follow their internal control process to ensure that adequate documentation supports the accumulation of costs charged to the Program as required by 2 CFR §200 Subpart E. View of Responsible Officials and Planned Corrective Action Management agrees with this finding. The Department of the Prosecuting Attorney’s office has reviewed and agreed a detailed line item report and Payment Request/Approval form did not accompany the respective RFF. The Department has already corrected these deficiencies to ensure each expense has an Expense Approval form with justification and that each RFF is accompanied with a detailed line item report and backup documentation for each expense being requested for reimbursement. Each payroll and non-payroll monthly invoices submitted clearly shows the breakdown. With each invoice submitted, it will state, as an example, “VOCA-SNAP 21-V2-01 Report & Attachments MM/YY”. A sample of this was submitted on March 25, 2024 with response. In short, the necessary back-up requested going forward is and will be available to submit for future audits or reviews. Anticipated Completion Date: 3/27/2024 Responding Person(s): Robert Nadal Grant Management Specialist Phone No. 808-270-7608

View Audit 302070

Finding 391599 (2023-006)

Material Weakness 2023

St. Francis School District

WI

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Subrecipient Monitoring

St. Francis School District has taken steps to ensure all transactions expensed to district funds including federal and state funds are properly reviewed by appropriate parties with knowledge of allowable costs and the specific expense incurred. Prior to Items being purchased with grant funds all re...

St. Francis School District has taken steps to ensure all transactions expensed to district funds including federal and state funds are properly reviewed by appropriate parties with knowledge of allowable costs and the specific expense incurred. Prior to Items being purchased with grant funds all requests are to be approved by the budget manager who oversees the specific funds. Orders may only be placed once approval is received from the budget manager and the Director of Finance. Payment of an invoice is not to be made until service has been rendered complete or item has been received in full. Budget managers approve all invoices prior to Director of Finance reviewing for final approval of payment.

View Audit 302062

Finding 391588 (2023-001)

Material Weakness 2023

Mono County Office of Education

CA

Questioned Costs Special Tests & Provisions Eligibility

April 1, 2024 Finding Number 50000 (2023-001) Noncompliance and Internal Control over Federal Compliance Federal Program – Child Care and Development Fund Cluster – Assistance Listing 93.575 and 93.576, Federal Alternative Payment Corrective Action Plan: Anticipated Completion Date April 30, 2024...

April 1, 2024 Finding Number 50000 (2023-001) Noncompliance and Internal Control over Federal Compliance Federal Program – Child Care and Development Fund Cluster – Assistance Listing 93.575 and 93.576, Federal Alternative Payment Corrective Action Plan: Anticipated Completion Date April 30, 2024 Prior to Mono County Office of Education (MCOE) taking over this program, another agency was responsible for the original eligibility determinations and special tests and provisions, including the files selected for this audit. After discussion about the audit findings, MCOE investigated further, and it was noted that the staff at the time were not following the procedures and forms that were in place. Items were either not completed or filled out correctly in many instances. Since this discovery, MCOE has developed a corrective action plan as follows to adhere to the program’s requirements: • MCOE will ensure that existing and new staff are trained to adhere to the policies and procedures for the program. • MCOE will be conducting annual reviews of all service providers and children served to ensure MCOE is maintaining the required documents on file. • MCOE has developed a double-check procedure to ensure that staff is keeping the required documentation on file for both providers and children served moving forward. I, Jennifer Weston, CBO, will be responsible for the implementation and monitoring of the corrective action plan. Sincerely, Jennifer Weston Chief Business Officer Mono County Office of Education

View Audit 302045 Questioned Costs: $1

Finding 391582 (2023-013)

Material Weakness 2023

The City of New York

NY

Questioned Costs Internal Control / Segregation of Duties Eligibility § 200.303

Finding No. 2023-013 Department(s): New York City Administration for Children’s Services and New York City Human Resources Administration Program(s): Assistance Listing Number 93.575, Child Care and Development Block Grant Corrective Action(s): ACS: ACS will work with other agencies to promote co...

Finding No. 2023-013 Department(s): New York City Administration for Children’s Services and New York City Human Resources Administration Program(s): Assistance Listing Number 93.575, Child Care and Development Block Grant Corrective Action(s): ACS: ACS will work with other agencies to promote compliance and internal controls going forward. HRA: In response to the findings, HRA made the following training requests to address the specific findings identified in this audit: 1. Training ID 2344 - Childcare liaisons and Childcare Review Team (CCRT) require training for the appropriate documentation necessary for the approval and provision of childcare. Audit findings confirmed that the staff charged with approval and authorizing childcare will take refresher training about the appropriate documentation requirements (i.e., CS-274w, LDSS 4699, LDSS 4700, etc.). The training will emphasize the requirement that any approved childcare must have support underlying employment/education documentation to justify the provision of the childcare. Childcare is a supportive service, so any childcare must have employment/engagement/education as a condition precedent. 2. Training ID 2343 - The training will include information about the client's employment, rate of pay, frequency of pay, and getting the appropriate documentation into the case records. Audits confirmed that 1) when the agency budgeted income and approved supportive services (i.e., childcare), the record did not have supporting income and employment related documents; 2) training will include the process for budgeting the earned income and applied any earned income disregards. Anticipated Completion Date: April 2024 and ongoing Person(s) Responsible for Implementation: ACS: Rahel Getachew, Associate Commissioner (212)-676-8818. HRA: Ramon E. Flores, Deputy Commissioner, Family Independence Administration (FIA) floresra@hra.nyc.gov

View Audit 302042 Questioned Costs: $1

Finding 391568 (2023-016)

Material Weakness 2023

The City of New York

NY

HUD Housing Programs Eligibility Material Weakness § 200.303

Finding No. 2023-016 Department(s): New York City Housing Preservation & Development Program(s): Assistance Listing Number 14.871, Housing Voucher Cluster: Section 8 Housing Choice Vouchers Corrective Action(s): During the pandemic, HPD adopted HUD CARES Act waivers, intended to minimize health ...

Finding No. 2023-016 Department(s): New York City Housing Preservation & Development Program(s): Assistance Listing Number 14.871, Housing Voucher Cluster: Section 8 Housing Choice Vouchers Corrective Action(s): During the pandemic, HPD adopted HUD CARES Act waivers, intended to minimize health and safety risks to applicants, participants, owners and staff, and which included the temporary suspension of adverse actions. Although HPD continued to request recertification packages during the period of the waivers until today, from February 2020 through December 2021, HPD did not penalize families who did not submit complete recertification packages. Additionally, HPD is among the City agencies that experienced a staff retention crisis, with attrition rates among its Rental Subsidy Program administrative teams swelling from 12 percent in 2020 to 27 percent in 2022. During the audit period, HPD was experiencing its highest vacancy rate. This meant standard recertifications were delayed because participants did not respond to recertification packages they were asked to complete, HPD did not have the capacity to revoke subsidies for those who did not comply, and the agency had significant backlog as a result of staff vacancies. Though HPD’s vacancy rate improved, it takes significant time to train and prepare staff to do the work. Finally, even though HPD’s COVID-era policies involving adverse action have ceased and normal processes are now in effect, due process requires intensive tracking and follow up to ideally have participants comply with requirements but if necessary to terminate assistance for those who do not comply. Therefore, there will be a significant lag between the re-implementation of HPD’s policy to take enforcement actions when recertification packages are not completed or missing and HPD’s actually terminating assistance. Corrective Action(s): 1. Build on existing systems to more closely track recertifications that are mailed and not returned. 2. Develop more robust digital operations that were started during the pandemic leading to reporting capabilities that will help with tracking overdue recertifications. 3. Work more closely with Community Based Organizations that can assist participants complete and return recertification package. 4. Continue close coordination to implement the Housing Access and Stability staffing plan and identify priority hires to onboard critically needed staff timely. 5. Invest in a training team to meet the training needs of new staff. Anticipated Completion Date: April 2025 Person(s) Responsible for Implementation: Dinsiri Fikru, Assistant Commissioner, Division of Program Policy and Innovation, Office of Housing Access and Stability FIKRUD@hpd.nyc.gov

View Audit 302042

Finding 391565 (2023-015)

Material Weakness 2023

The City of New York

NY

HUD Housing Programs Internal Control / Segregation of Duties Special Tests & Provisions § 200.303

Finding No. 2023-015 Department(s): New York City Housing Preservation & Development Program(s): Assistance Listing Numbers: 14.249, Section 8 Project-Based Cluster: Section 8 Moderate Rehabilitation Single Room Occupancy 14.856, Section 8 Project-Based Cluster: Lower Income Housing Assistance P...

Finding No. 2023-015 Department(s): New York City Housing Preservation & Development Program(s): Assistance Listing Numbers: 14.249, Section 8 Project-Based Cluster: Section 8 Moderate Rehabilitation Single Room Occupancy 14.856, Section 8 Project-Based Cluster: Lower Income Housing Assistance Program – Section 8 Moderate Rehabilitation Corrective Action(s): These deficiencies result from HPD adopting HUD CARES Act waivers, intended to minimize health and safety risks to applicants, participants, owners and staff, and which included the temporary suspension of inspections and adverse actions. HPD conducted limited inspections and did not take enforcement action during the waiver period of 2/1/2020 through 12/31/2021. These waivers ended in 2022 in the midst of a significant HPD staffing shortage. HPD is among the City agencies that experienced a staff retention crisis, with attrition rates among its Housing Maintenance Code inspection team that mirrored the 27 percent experienced in HPD’s rental subsidy program administration team. Although HPD’s COVID-era policies have ceased, and normal processes are now in effect, it will take a significant period of time for full standard operations to resume. Corrective Action(s): 1. Develop a detailed tracking process for routine inspection scheduling. 2. Prioritize inspections for units that are upcoming or those that have gone the longest without an inspection. 3. Develop a detailed tracking and follow up process for enforcing failed inspections. 4. Make every effort to ensure staff vacancy rates are addressed through in house recruitment or other means as needed. Anticipated Completion Date: April 2025 Person(s) Responsible for Implementation: Dinsiri Fikru, Assistant Commissioner, Division of Program Policy and Innovation, Office of Housing Access and Stability FIKRUD@hpd.nyc.gov

View Audit 302042

Finding 391564 (2023-014)

Material Weakness 2023

The City of New York

NY

HUD Housing Programs Eligibility Material Weakness § 200.303

Finding No. 2023-014 Department(s): New York City Housing Preservation & Development Program(s): Assistance Listing Numbers: 14.249, Section 8 Project-Based Cluster: Section 8 Moderate Rehabilitation Single Room Occupancy 14.856, Section 8 Project-Based Cluster: Lower Income Housing Assistance P...

Finding No. 2023-014 Department(s): New York City Housing Preservation & Development Program(s): Assistance Listing Numbers: 14.249, Section 8 Project-Based Cluster: Section 8 Moderate Rehabilitation Single Room Occupancy 14.856, Section 8 Project-Based Cluster: Lower Income Housing Assistance Program – Section 8 Moderate Rehabilitation Corrective Action(s): During the pandemic, HPD adopted HUD CARES Act waivers, intended to minimize health and safety risks to applicants, participants, owners and staff, and which included the temporary suspension of adverse actions. Although HPD continued to request recertification packages during the period the waivers, February 2020 through December 2021, HPD did not penalize families who did not submit complete recertification packages at that time until more recently. Additionally, HPD is among the City agencies that experienced a staff retention crisis, with attrition rates among its Rental Subsidy Program administrative teams swelling from 12 percent in 2020 to 27 percent in 2022. During the audit period, HPD was experiencing its highest vacancy rate. This meant standard recertifications were delayed because participants did not respond to recertification packages they were asked to complete, HPD did not have the capacity to revoke subsidies for those who did not comply, and the agency had significant backlog as a result of staff vacancies. Though HPD’s vacancy rate improved, it takes significant time to train and prepare staff to do the work. Finally, even though HPD’s COVID-era policies involving adverse action have ceased and normal processes are now in effect, due process requires intensive tracking and follow-up to ideally have participants comply with requirements (but if necessary to terminate assistance for those who do not comply). Therefore, there will be a significant lag between the re-implementation of HPD’s policy to take enforcement actions when recertification packages are not completed or missing and HPD’s actually terminating assistance. Corrective Action(s): 1. Build on existing systems to more closely track recertifications that are mailed and not returned. 2. Develop more robust digital operations that were started during the pandemic leading to reporting capabilities that will help with tracking overdue recertifications. 3. Work more closely with Community Based Organizations that can assist participants complete and return recertification package. 4. Continue close coordination to implement the Housing Access and Stability staffing plan and identify priority hires to onboard critically needed staff timely. 5. Invest in a training team to meet the training needs of new staff. Anticipated Completion Date: April 2025 Person(s) Responsible for Implementation: Dinsiri Fikru, Assistant Commissioner, Division of Program Policy and Innovation, Office of Housing Access and Stability FIKRUD@hpd.nyc.gov

View Audit 302042

Finding 391558 (2023-002)

Material Weakness 2023

The City of New York

NY

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

Finding No. 2023-002 Department(s): New York City Human Resources Administration Program(s): Assistance Listing Number 14.239, HOME Investment Partnerships Program Corrective Action(s): This FY23 audit was conducted on the heels of the FY22 audit where the questioned cost finding is a similar er...

Finding No. 2023-002 Department(s): New York City Human Resources Administration Program(s): Assistance Listing Number 14.239, HOME Investment Partnerships Program Corrective Action(s): This FY23 audit was conducted on the heels of the FY22 audit where the questioned cost finding is a similar error type but significantly decreased to $296 from over $18,000. Included in the FY22 recommended Corrective Action was the onboarding of the Executive Director to shepherd the charge with strengthening the teams’ internal governance, appropriate monitoring and future compliance. Adversely, the onboarding of the executive director was lengthy and only recently finalized in the 2nd quarter of FY24. HRA agrees to strengthen internal controls and the new Executive Director is working with the team to ensure they are intentional in appropriately applying the correct formula for calculating allowable cost, particularly the inclusion of “gross” and not “net” income. The Quality Assurance Tool has been updated including specific sub-items to ensure allowable cost is correctly calculated as well as the other deliverables. Corrective Action(s) • Strengthen internal governance and future compliance. • Executive Director for the Home-TBRA now on board. • Update the Quality Assurance tool that includes sub-items information that supports improved review and approval. • Provide refresher training for staff involved with TBRA to improve performance and outcomes. Anticipated Completion Date: June 30, 2024 and ongoing Person(s) Responsible for Implementation: Dori Hopkins-Figeroux, Director - HTBRA hopkinsfigerouxd@hra.nyc.gov 929-252-6089 Jordan Worrell, Executive Director RAP/HTBRA worrellj@hra.nyc.gov 929-252- 5403 Dwana Abraham, Assistant Deputy Commissioner abrahamd@hra.nyc.gov 929-221-6726

View Audit 302042 Questioned Costs: $1

Finding 391471 (2023-002)

Material Weakness 2023

University of Maryland Medical System Corporation

MD

Reporting Subrecipient Monitoring Material Weakness

University of Maryland Medical System Corporation and Subsidiaries Corrective Action Plan Year Ended June 30, 2023 University of Maryland Medical System Corporation and Subsidiaries (the Corporation) respectfully submits the following corrective action plan for the year ended June 30,2023. Audit p...

University of Maryland Medical System Corporation and Subsidiaries Corrective Action Plan Year Ended June 30, 2023 University of Maryland Medical System Corporation and Subsidiaries (the Corporation) respectfully submits the following corrective action plan for the year ended June 30,2023. Audit period: July 1, 2022 to June 30, 2023 MATERIAL WEAKNESS IN INTERNAL CONTROL OVER COMPLIANCE 2023-002 Reporting of Schedule of Expenditures of Federal Awards Assistance Listing Number 97.036 – COVID-19 – Disaster Grants – Public Assistances (Presidentially Declared Disasters) Recommendation: The Corporation’s policy and procedures should be designed to ensure expenditures are reported on the Schedule based on the date on which the expenditures are incurred as required by the Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Management will continue to refine internal procedures and practices. The COVID-19 pandemic grant programs included evolving expectations which did not follow the typical grant process. We will enhance procedures to review related report submissions, obligated worksheets, and incurred expenditures in conjunction with review of the Schedule to verify completeness and accuracy. Planned completion date for corrective action plan: September 30, 2024 Name(s) of the contact person(s) responsible for corrective action: Jeff Chadwick, Financial Reporting Director, jeff.chadwick@umm.edu

View Audit 301956

Finding 391379 (2023-003)

Material Weakness 2023

Ifoster, Inc.

CA

Material Weakness Reporting Internal Control / Segregation of Duties

Finding 2023-003 Finding Summary: Management is responsible for establishing and maintaining an effective system of internal control over financial reporting. Ensuring accruals and expenses are recorded in the appropriate time period and meet the criteria for recognition is a key component of effect...

Finding 2023-003 Finding Summary: Management is responsible for establishing and maintaining an effective system of internal control over financial reporting. Ensuring accruals and expenses are recorded in the appropriate time period and meet the criteria for recognition is a key component of effective internal control over financial reporting. Certain expenses were not recorded in the correct financial reporting period. Responsible Individuals: Mike Maxfield, Controller Corrective Action Plan: Acknowledged. Payroll accruals, which have in the past been immaterial, are being accrued on a monthly basis in fiscal year ending June 30, 2024. Anticipated Completion Date: Ongoing

View Audit 301914

Finding 391378 (2023-002)

Material Weakness 2023

Ifoster, Inc.

CA

Material Weakness Reporting Internal Control / Segregation of Duties

Finding 2023-002 Finding Summary: Internal controls should be in place to provide reasonable assurance that protects iFoster, Inc. from errors or omissions. iFoster, Inc. internal control system did not require consistent approval of grant expenditures as well as properly allocating costs within the...

Finding 2023-002 Finding Summary: Internal controls should be in place to provide reasonable assurance that protects iFoster, Inc. from errors or omissions. iFoster, Inc. internal control system did not require consistent approval of grant expenditures as well as properly allocating costs within the accounting program. Responsible Individuals: Mike Maxfield, Controller Corrective Action Plan: Acknowledged. Due to the compressed timeframe between initial single audits, corrective action could not be implemented. All grant expenditures now require approval and QuickBooks will be used to allocate costs in fiscal year ending June 30, 2024 rather than using Excel. Anticipated Completion Date: April 20, 2024

View Audit 301914

Finding 391377 (2023-001)

Material Weakness 2023

Ifoster, Inc.

CA

Material Weakness Reporting Internal Control / Segregation of Duties

Finding 2023-001 Finding Summary: Management is responsible for establishing and maintaining an effective system of internal control over financial statement reporting. One of the components of an effective system of internal control over financial reporting is the preparation of full disclosure fin...

Finding 2023-001 Finding Summary: Management is responsible for establishing and maintaining an effective system of internal control over financial statement reporting. One of the components of an effective system of internal control over financial reporting is the preparation of full disclosure financial statements that do not require adjustment as part of the audit process. A second component is that reconciliations and transactions are properly reviewed and approved by the appropriate personnel. As auditors, we were requested to draft the financial statements and accompanying notes to the financial statements. Certain reconciliations and journal entries were not reviewed and approved. Responsible Individuals: Mike Maxfield, Controller Corrective Action Plan: Acknowledged. Due to the compressed timeframe between initial single audits, corrective action could not be implemented. All journal entries are now approved as a part of our month end close process. Although we anticipate the auditor to continue to prepare the financial statements, we believe addressing the internal control noted above will address any material errors noted. Anticipated Completion Date: Ongoing

View Audit 301914

Finding 391324 (2023-006)

Material Weakness 2023

Ashley Medical Center

ND

Material Weakness Reporting Internal Control / Segregation of Duties § 200.303

Reporting Federal Agency Name: Department of Hea lth and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center claimed lost revenues that were incorrectly calculated or not supp...

Reporting Federal Agency Name: Department of Hea lth and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center claimed lost revenues that were incorrectly calculated or not supported. These were improperly included within the HHS Report Period 4 and caused the Report to be inaccurate. Responsible Individuals: Corey Ulmer, CFO Corrective Action Plan: We will implement internal control policies to ensure that the required reports are properly reviewed prior to submission to ensure all key line items are necessary, correct, meet the requirements of the federal program, and are properly recorded in the reports required to be submitted to the federal agency. Anticipated Completion Date: 6/30/2024

View Audit 301891

Finding 391323 (2023-005)

Material Weakness 2023

Ashley Medical Center

ND

Allowable Costs / Cost Principles Material Weakness Internal Control / Segregation of Duties § 200.303

Activities Allowed or Unallowed, Allowable Costs/Costs Principles Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center selected lo...

Activities Allowed or Unallowed, Allowable Costs/Costs Principles Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center selected lost revenue ca lculation option i which is actual to actual methodology of calculating lost revenues attributable to coronavirus. The Medical Center did not incorporate the financial audit adjustments into the actual revenue amounts reported within the HHS special report for the fiscal years 2019, 2020, and 2021. Responsible Individuals: Corey Ulmer, CFO Corrective Action Plan: We will implement internal control policies to ensure the lost revenue calculation is supported by internal financia ls. We will also implement control policies to ensure a secondary review and approval over the final lost revenue calculation. Anticipated Completion Date: 6/30/2024

View Audit 301891

Finding 391321 (2023-003)

Material Weakness 2023

Ashley Medical Center

ND

Allowable Costs / Cost Principles Material Weakness Internal Control / Segregation of Duties § 200.303

Activities Allowed or Unallowed, Allowable Costs/Costs Principles Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center does not ha...

Activities Allowed or Unallowed, Allowable Costs/Costs Principles Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center does not have an adequate internal control policy in place to ensure review and approval of cash disbursements claimed under the federal programs were documented and to ensure that expenses claimed in the Report were complete, accurate, and reduced by other funding sources. Responsible Individuals: Corey Ulmer, CFO Corrective Action Plan: We will implement internal control policies to ensure all amounts reimbursed by other funding sources are adequately documented and reduced from the eligible expenditure listing and are properly recorded in the Report required to be submitted to the federal agency. We will also implement internal control policies to ensure that the required Report are properly reviewed prior to submission to ensure all key line items are necessary, correct, meet the requirements of the federal program, and are properly recorded in the Report required to be submitted to the federal agency. Anticipated Completion Date: 6/30/2024

View Audit 301891

Finding 391208 (2023-001)

Material Weakness 2023

Higher Horizons Day Care Center, Inc.

VA

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness

Based on FY2022 findings, Higher Horizons implemented internal control policies and procedures, effective May 1, 2023. The procedures address all the segregation of duties from journal entries to posting, reconciliation to reporting, and access to the accounting software. The implementation of the i...

Based on FY2022 findings, Higher Horizons implemented internal control policies and procedures, effective May 1, 2023. The procedures address all the segregation of duties from journal entries to posting, reconciliation to reporting, and access to the accounting software. The implementation of the internal control policies and procedures were initiated in May and June of 2023 (the last two months of FY 2023). During FY2024, these procedures were enforced to mitigate risks due to lack of sound internal control. To further strengthen the internal control system, Higher Horizons changed the requisition and accounts payable paper-based to paperless (electronic) process effective July 1, 2023. The electronic requisition system (Microix) is integrated with the accounting software (Abila), which has noticeably enhanced the internal control system.The Microix electronic requisition system eliminates the need to monitor the flow of paper documents, eliminates the risk of losing documents, and disallows purchases without approval. Microix features also require allowability of requisitions to be determined, all changes & communications to be captured, eliminates re-keying the information into Abila, minimizes manual interventions in entering & posting transactions, and much more. Higher Horizons will continue assessing & monitoring the effectiveness of our internal control, review the outcomes, and as needed, will further strengthen the process. Higher Horizons will monitor individual access to general ledger, subsidiary ledger, assets of the organization, accounting software, and Paycom. Access control procedures will be developed and implemented before the end of May 2024. As indicated in FY2023 audit findings, one of the causes for inadequate segregation of duties is the small number of staff in the Finance Department. Higher Horizons will contract with a finance consultant to review the current finance department staffing structure. The consultant will provide feedback and recommendation for adequately staffing the finance department to ensure segregation of duties. The finance management staff will conduct a comprehensive study of accounting and financial tasks, policies and procedures, and standard operating procedures by contracting the financial consultant before the end of June 2024. The study will be presented to the Board for approval, and OFC and OHS for funding.

View Audit 301845

Finding 391207 (2023-001)

Material Weakness 2023

St. Claire Regional Medical Center, Inc.

KY

Cash Management Material Weakness Reporting

April 1, 2024 U.S. Department of Health and Human Services St. Claire Regional Medical Center, Inc. respectively submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Blue & Co., LLC 2650 Eastpoint Parkway, Suite 300 ...

April 1, 2024 U.S. Department of Health and Human Services St. Claire Regional Medical Center, Inc. respectively submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Blue & Co., LLC 2650 Eastpoint Parkway, Suite 300 Louisville, Kentucky 40223 Audit Period: Year ended June 30, 2023 The findings from the Schedule of Findings and Questioned Costs for the year ended June 30, 2023, are discussed below. The findings are numbered consistently with the numbers assigned in the Schedule. FINDINGS – FEDRAL AWARD PROGRAM AUDITS 2023-001 Condition: Untimely disbursement of federal grant funds received: When receiving federal grants funds for the HHS Rural Health Care Services Outreach, Rural Health Network Development, and Small Health Care Provider Quality Improvement Plan Program, the Hospital did not disburse federal grant funds received within 3 working days. Action: Management implemented internal control procedures by December 31, 2023 to ensure proper and timely disbursements of federal grant funds to ensure proper cash management of future HHS Rural Health Care Services Outreach, Rural Health Network Development, and Small Health Care Provider Quality Improvement Plan Program funds.

View Audit 301841

Finding 391178 (2023-002)

Material Weakness 2023

Town of Wilton, Connecticut

CT

Reporting Material Weakness

Material Weakness in Internal Control over Compliance Condition: The Town did not submit the required SLFRF Project and Expenditure Report Due April 30, 2023 on time. Recommendation: The Town review grant award documents thoroughly and set up processes and procedures in place to ensure reporting r...

Material Weakness in Internal Control over Compliance Condition: The Town did not submit the required SLFRF Project and Expenditure Report Due April 30, 2023 on time. Recommendation: The Town review grant award documents thoroughly and set up processes and procedures in place to ensure reporting requirements to the awarding agency are completely accurately and timely based on grant requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Town has begun a full review of all grants, especially those received in prior administrations and pre-hire of the current CFO, to assure the compliance of reporting requirements are complete accurate and will be timely reported as stated in the grant requirements. Contact person: Dawn Norton Responsible for corrective action: Dawn Norton, CFO Planned completion date for corrective action plan: March 2024

View Audit 301778

Finding 391146 (2023-004)

Material Weakness 2023

Ohio Institute of Allied Health, Inc.

IL

Questioned Costs Student Financial Aid Subrecipient Monitoring

FINDING 2023-4- Untimely Paid and Unpaid Credit Balances The Institute had Untimely Paid and Unpaid Credit Balances while Participating under the Zone Alternative and the Heightened Cash Monitoring 1 Payment Method A.Comments on Findings and Recommendations: The Institute agrees with the finding and...

FINDING 2023-4- Untimely Paid and Unpaid Credit Balances The Institute had Untimely Paid and Unpaid Credit Balances while Participating under the Zone Alternative and the Heightened Cash Monitoring 1 Payment Method A.Comments on Findings and Recommendations: The Institute agrees with the finding and Auditor's recommendation. B.Actions Taken or Planned We have revised the process of student stipends ofdisbursements. Each student whose account receives a disbursement whom results in a credit balance, will be given stipend prior to any draw down. We shall also make process and procedures with new third-party servicer to ensure stipend is sent prior to drawdown. Signed Betsy Bremke, Administrative Campus Director Date: _3/29/2024__

View Audit 301753 Questioned Costs: $1

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