Corrective Action Plans

Finding 389655 (2023-001)

Significant Deficiency 2023

Norfolk Redevelopment and Housing Authority

VA

Questioned Costs HUD Housing Programs Eligibility

Corrective action plan: • On the first Friday of each month, the Housing Choice Voucher Program staff meets to discuss program policies and procedures for training purposes. At each meeting, specific aspects of administering the program are reviewed, along with the related HUD policies. Staff member...

Corrective action plan: • On the first Friday of each month, the Housing Choice Voucher Program staff meets to discuss program policies and procedures for training purposes. At each meeting, specific aspects of administering the program are reviewed, along with the related HUD policies. Staff members are given the opportunity to ask any questions on any procedures or policies they may not understand. Activities from the Nan McKay Rent Calculation training are passed out to staff to complete individually. After staff completes the activity, the answers are reviewed as a group. Other activities take place which involve the staff answering questions regarding various case studies of situations that may occur in the daily activities of administering the HCV Program. • January 9th – 11th, all HCV and PBV Specialist received Combo HCV/LIPH Rent Calculation training with HOTMA updates from Nan McKay and Associates. • Review and update Administrative Plan/SOP with Policies and Procedures to ensure all staff is familiar with policies and procedures. • Staff restructuring • In-service meetings with Compliance Specialist as staff challenges some write ups of deficiencies to ensure that there are mutual understandings of policies. • HCV/Occupancy Specialists have been instructed to triple check all certifications for accuracy to mitigate the possibility for careless errors PERSONS INVOLVED HCV Case Management Staff Asset Manager RAD Project Based Voucher Community Manager Compliance Specialist Compliance Supervisor HCV Program Director Occupancy Specialist MONITORING The Compliance Supervisor and Specialist will continue to monitor files. The Compliance Supervisor and Specialist will begin adding the CFR Regulation and or Administrative Plan Policy and page number to each deficiency write-up to assist staff in understanding the error so that staff will not make consistent errors. The Compliance Supervisor will provide to staff recommendations for improvement. It is hopeful that a greater number of participant files will be audited throughout the year for both the HCV Program and for the PBV communities. On the first Friday of each month, the Housing Choice Voucher Program staff meets to discuss program policies and procedures for training purposes. During these meetings specific aspects of administering the program are reviewed, along with the related HUD policies. Staff members are given the opportunity to ask any questions on procedures or policies they may not understand. During many meetings, activities from the Nan McKay Rent Calculation training are passed out to staff to complete individually. After staff completes the activity, the answers are reviewed as a group. Staff also answers questions regarding various case studies that may occur in the daily activities of administering the HCV Program. We also have NRHA’s Compliance staff provide training to review common errors and to discuss any areas staff may have that are gray with audited files. Staff has also gone through an intensive training on the common errors per NRHA’s Compliance Department. Quarterly Quality Control trainings are held with caseworkers lead by the NRHA Compliance Department to address concerns and common errors. The Admission and Continued Occupancy Policies (ACOP) and Administrative Plan policies and procedures are reviewed to ensure that all staff has a clear understanding of the proper ways of calculating income, applying allowances, using proper payment standards, and approvals of lease ups and completion of certifications. A departmental quality control team was established to ensure there is consistency of policies and procedures and that when new procedures are implemented the processes are properly documented and disseminated to all staff. A departmental quality control sub-team was formed after the audit to include the actual custodians of program participant files comprised of:  1 Tax Credit PBV Property Manager  1 LIPH Property Manager  1 Compliance Specialist  1 Occupancy Specialist  1 Senior HCV Specialist  1 Tax Credit Administrative Assistant NRHA Caseworkers and Administrative Staff have been instructed to triple check all certifications for accuracy to mitigate the possibility for careless errors. The NRHA Compliance Department continues to audit files for the HCV Program to ensure that files are being processed properly; income calculated correctly, verifications are in the file, HAP payments issued are correct, and that units are inspected timely. Findings are noted and must be corrected by the Case Worker or Administrative Staff and the file is reevaluated by the Compliance Department to ensure findings were corrected. NRHA Caseworkers and Administrative Staff have been instructed to triple check all certifications for accuracy to mitigate the possibility for careless errors. The NRHA Compliance Department continues to audit files for the HCV Program to ensure that files are being processed properly; income calculated correctly, verifications are in the file, HAP payments issued are correct, and that units are inspected timely. Findings are noted and must be corrected by the Case Worker or Administrative Staff and the file is reevaluated by the Compliance Department to ensure findings were corrected. NRHA will continue to investigate the possibility of increasing the number of program participant files reviewed by the Compliance Department. NRHA has begun contract negotiations with a new software vendor. It is the feeling of the agency that with a different software platform the errors being made will lessen as the information gathered to perform rent calculations will be in a more automated form. It is anticipated that this will lessen staff time needed to enter the information and thus allow for more time to be spent verifying accuracy of information. The timeline for implementation is for the software to be live at the beginning of the 2026 fiscal year. This over-riding strategy is to be done in conjunction with the steps outlined below to mitigate this situation.

View Audit 300553 Questioned Costs: $1

Finding 389651 (2023-007)

Significant Deficiency 2023

Felician University

NJ

Questioned Costs Allowable Costs / Cost Principles § 200.405

Higher Education Institutional Aid – Fostering Inclusive Excellence for STEM Achievement – Assistance Listing No. 84.031C Recommendation: We recommend the University calculate the indirect costs when the direct cost is incurred instead of claiming the amount per the budget to ensure indirect costs ...

Higher Education Institutional Aid – Fostering Inclusive Excellence for STEM Achievement – Assistance Listing No. 84.031C Recommendation: We recommend the University calculate the indirect costs when the direct cost is incurred instead of claiming the amount per the budget to ensure indirect costs are consistently calculated and allocated throughout the grant term. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the finding: The Finance department implemented a quarterly process aimed at accurately calculating indirect costs, ensuring their recognition period when expenses are incurred. Name(s) of the contact person(s) responsible for corrective action: Shalini Patel, Controller Planned completion date for a corrective action plan: April 1, 2024

View Audit 300547 Questioned Costs: $1

Finding 389649 (2023-006)

Significant Deficiency 2023

Felician University

NJ

Matching / Level of Effort / Earmarking Questioned Costs Reporting

Education Stabilization Fund – Higher Education Emergency Relief Fund –Student Portion, and Minority Serving Institutions – Assistance Listing No. 84.425E, 84.425L Recommendation: We recommend the University implement a process to ensure all grant agreements are reviewed and there is a clear unders...

Education Stabilization Fund – Higher Education Emergency Relief Fund –Student Portion, and Minority Serving Institutions – Assistance Listing No. 84.425E, 84.425L Recommendation: We recommend the University implement a process to ensure all grant agreements are reviewed and there is a clear understanding of any reporting and/or earmarking requirements to limit the risk of noncompliance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: While the requirement to notify financial aid applicants of their right to a recalculation of financial aid through professional judgment was satisfied and documented, we acknowledge the oversight in not reporting associated expenses. To address this, Finance and Financial Aid collaborated to enhance our process for reviewing all grant agreements meticulously. This includes ensuring a clear understanding of reporting and earmarking requirements to maintain compliance and transparency moving forward. Name(s) of the contact person(s) responsible for corrective action: Shalini Patel, Controller and Cynthia Montalvo, Assistant Director of Enrollment Management. Planned completion date for corrective action plan: June 30th 2024.

View Audit 300547

Finding 389645 (2023-005)

Significant Deficiency 2023

Felician University

NJ

Questioned Costs Student Financial Aid Significant Deficiency

Federal Supplemental Educational Opportunity Grant; Federal Work Study Program; Federal Pell Grant Program; Federal Direct Student Loans – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the University review its policies and procedures related to Title IV outstan...

Federal Supplemental Educational Opportunity Grant; Federal Work Study Program; Federal Pell Grant Program; Federal Direct Student Loans – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the University review its policies and procedures related to Title IV outstanding checks to ensure they are being returned to the Department of Education after 240 days. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Student Accounts initiated a thorough review with Finance and Financial Aid to ensure timely return of Title V funds to the Department of Education of uncashed refund checks exceeding 240 days. This includes documenting new procedures in our Policies and Procedures manual and providing staff training. Planned Completion Date for Corrective Action Plan: June 30th, 2024 Name(s) of the contact person(s) responsible for corrective action: Mariela Henriques, Director of Student Accounts

View Audit 300547 Questioned Costs: $1

Finding 389643 (2023-004)

Significant Deficiency 2023

Felician University

NJ

Questioned Costs Student Financial Aid Reporting

Federal Pell Grant Program; Federal Direct Student Loans – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the University evaluate its procedures and policies around reporting to the COD to ensure that student information is reported accurately and timely. Explanation of disagre...

Federal Pell Grant Program; Federal Direct Student Loans – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the University evaluate its procedures and policies around reporting to the COD to ensure that student information is reported accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Financial Aid will update reporting procedures for COD system accuracy and timeliness, followed by comprehensive staff training on requirements and deadlines. We'll implement monitoring for closer disbursement date tracking and enhance communication channels between departments for smoother coordination. Name(s) of the contact person(s) responsible for corrective action: Kathy Prieto, Director of Financial Aid. Planned completion date for corrective action plan: June 30th, 2024

View Audit 300547

Finding 389585 (2023-004)

Material Weakness 2023

Morning Calm Apt

WA

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring

FINDING NO. 2022-004 Statement of Condition: Management had developed activity level controls over compliance that included compliance review of all tenant certifications of income used in determining the amount of rent amounts due from eligible PRAC 202 participants (tenants) by the Coast complianc...

FINDING NO. 2022-004 Statement of Condition: Management had developed activity level controls over compliance that included compliance review of all tenant certifications of income used in determining the amount of rent amounts due from eligible PRAC 202 participants (tenants) by the Coast compliance department. However, during our testing, management had no documentation evidencing such reviews had occurred; further, during our interview process of site staff (community managers), staff asserted that no such reviews had occurred, and that no feedback on tenant certifications was provided by the compliance department. Auditor Recommendation: Management should have a process to review and approve all tenant certifications being prepared by site staff (community managers). The approval process should include an approval stamp or some other evidence that each file has been reviewed by the compliance department and is approved for processing. Further, senior management should have an ongoing monitoring process to ensure that the compliance department is carrying out the review process. Action Taken: Management agrees with the recommendation of the auditor, and will ensure that evidence of certification review and approval is documented with a approval stamp or some other documentary evidence.

View Audit 300512

Finding 389584 (2023-003)

None 2023

Morning Calm Apt

WA

HUD Housing Programs Questioned Costs Cash Management

FINDING NO. 2022-003 Statement of Condition: Management made an unauthorized withdrawal of $4,400 from the residual receipts account during the fiscal year ended June 30, 2022; the funds have not been returned to the residual receipts account. Auditor Recommendation: Management should deposit $4,400...

FINDING NO. 2022-003 Statement of Condition: Management made an unauthorized withdrawal of $4,400 from the residual receipts account during the fiscal year ended June 30, 2022; the funds have not been returned to the residual receipts account. Auditor Recommendation: Management should deposit $4,400 into the residual receipts account to refund the unapproved withdrawal. S3800-150: Action Taken: Management agrees with the finding, and has taken corrective actions which include communication with the Project Accountant and Regional Manager and will transfer $4,400 from the operating account to the residual receipts account.

View Audit 300512

Finding 389583 (2023-002)

Significant Deficiency 2023

Morning Calm Apt

WA

Questioned Costs Subrecipient Monitoring HUD Housing Programs

FINDING NO. 2023-002 Statement of Condition: Management only made nine (9) of the twelve (12) monthly required reserve deposits, leaving the account underfunded by $4,053 at June 30, 2022; for the year ended june 30, 2023, only $2,702 of the required $16,212 in deposits were made, leaving the accoun...

FINDING NO. 2023-002 Statement of Condition: Management only made nine (9) of the twelve (12) monthly required reserve deposits, leaving the account underfunded by $4,053 at June 30, 2022; for the year ended june 30, 2023, only $2,702 of the required $16,212 in deposits were made, leaving the account behind schedule by another $13,510, for a total deficiency of $17,563. Auditor Recommendation: Management agrees with the finding, and has taken corrective actions which include communication with the Project Accountant and Regional Manager. All future deposits the replacement reserve will be made as required in the regulatory agreement. Action Taken: Senior management has discussed the deficiency with the Project Accountant and Regional Manager. All future deposits the replacement reserve will be made as required in the regulatory agreement assuming there is sufficient cash in the operating account to make the deposit. -

View Audit 300512 Questioned Costs: $1

Finding 389579 (2023-303)

Significant Deficiency 2023

State of Wisconsin

WI

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2023-303: Medical Assistance – IRIS Financial Integrity and Accountability Oversight Activities. This is the department’s response.  Recommendation (2023-303): Medical Assistance – IRIS Financial Inte...

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2023-303: Medical Assistance – IRIS Financial Integrity and Accountability Oversight Activities. This is the department’s response.  Recommendation (2023-303): Medical Assistance – IRIS Financial Integrity and Accountability Oversight Activities We recommend the Wisconsin Department of Health Services: • Implement the financial integrity and accountability oversight activities in its approved waiver; or • Determine if alternative oversight activities that meet the objective to provide financial integrity and accountability oversight can be performed; and • Work with the federal government to determine whether an amendment to its current waiver is needed. Wisconsin Department of Health Services Planned Corrective Action: DHS agrees with the finding to complete an audit of 20 percent of the claims exceeding $2,500 or more. DHS will conduct this audit for such claims from July 1, 2023, onward. DHS agrees with the finding to complete a data integrity audit of the IRIS participant data submitted by the fiscal employer agents (FEAs) through the Information Exchange System. For CY 2022, DHS completed an aggregated comparison by FEA of submitted encounter and funding data to evaluate the completeness of submissions. As encounter data submissions for CY 2023 are finalized, DHS will conduct an aggregated comparison as well as a detailed data integrity audit of encounter records using random sampling to comply with waiver requirements. Anticipated Completion Date: September 30, 2024 Person responsible for corrective action: Daniel Bush, Section Manager Division of Medicaid Services, Bureau of Rate Setting, IRIS Fiscal Management Section danielp.bush@dhs.wisconsin.gov

View Audit 300490

Finding 389577 (2023-300)

Material Weakness 2023

State of Wisconsin

WI

Allowable Costs / Cost Principles Eligibility Questioned Costs

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2023-300: Eligibility for the Children’s Health Insurance Program. This is the department’s Corrective Action Plan. Recommendation (2023-300): Eligibility for the Children’s Health Insurance Program We...

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2023-300: Eligibility for the Children’s Health Insurance Program. This is the department’s Corrective Action Plan. Recommendation (2023-300): Eligibility for the Children’s Health Insurance Program We recommend the Wisconsin Department of Health Services work with the federal government to resolve these improper payments, including the determination of the total amount of improper payments, and return these amounts to the federal government, as appropriate. Wisconsin Department of Health Services Planned Corrective Action: The Division of Medicaid Services (DMS) acknowledges that we maintained eligibility under the Children’s Health Insurance Program (CHIP) for individuals who had turned age 19, including SCHIP participants. It was our overarching policy to not terminate health care coverage upon certain changes in circumstances for Medicaid participants during the federal public health emergency (PHE). To comply with this policy, DHS made system changes at the beginning of the pandemic to maintain eligibility for all participants. After CMS provided additional information specific to SCHIP, DHS considered whether to make the necessary system changes to terminate SCHIP participants who turned 19 during the public health emergency. Because of the system limitation and DHS’s overarching goals to maintain continuous coverage, amongst other reasons, DHS decided to temporarily keep all CHIP participants enrolled until the public health emergency ended. DMS leaders met with CMS leaders on May 11, 2022, to discuss this compliance issue and related systems limitations. During that meeting, CMS indicated that they understood the system and communication challenges of having a single program that combines Medicaid and CHIP. CMS also acknowledged that the federal public health emergency was likely to end at any time, so making the required system changes would not be prudent. CMS said they would follow up with Wisconsin if they determined that further state action was needed, but they did not communicate to us after the meeting that they felt the compliance issue needed to be addressed. This confirmed the Medicaid Director’s decision to not pursue costly systems changes to support a change that might only be needed for a short period of time. After the PHE ended, DHS took proactive steps to identify aged-out CHIP participants and ensure that their eligibility was redetermined in the first two months of unwinding. In contrast to the rest of the CHIP and Medicaid population, whose renewals were distributed over a 12-month period from June 2023 through May 2024, these members’ renewals were accelerated to June and July 2023, so that their CHIP coverage would end as soon as possible after the end of the PHE. While we agree conceptually with the finding, the questioned costs identified do not consider that many (if not most) of the ineligible members would have been eligible for Medicaid as childless adults upon aging out of the CHIP program. We will discuss this likelihood with CMS and if necessary, use data available in our CARES eligibility system to assess how many of these members did retain eligibility as childless adults or in other categories of Medicaid after completing renewals in June and July. Anticipated Completion Date: March 31, 2024 Person responsible for corrective action: Jori Mundy, Director Bureau of Eligibility and Enrollment Policy, Division of Medicaid Services jori.mundy@dhs.wisconsin.gov. Rebuttal from the Wisconsin Legislative Audit Bureau - As stated in the finding, and as acknoledged by DHS, DHS maintained continous eligibility for SCHIP participants who were over age 19. This eligibility requirement continue through the public health emergency. Since CHIP and MEDICAID are separate programs, consideration of whether these participants could have been eligible for the Medicaid program would not have been part of our audit. Payments to providers for these participants were funded by SCHIP and not the medicaid program.

View Audit 300490 Questioned Costs: $1

Finding 389544 (2023-500)

None 2023

State of Wisconsin

WI

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

I am writing to you in response to the finding 2023-500: Coronavirus State and Local Fiscal Recovery Funds. I agree with the finding and recommendation that was identified during the audit. Please see our below action plan that was conducted as soon as we were made aware of the issue: Corrective ...

I am writing to you in response to the finding 2023-500: Coronavirus State and Local Fiscal Recovery Funds. I agree with the finding and recommendation that was identified during the audit. Please see our below action plan that was conducted as soon as we were made aware of the issue: Corrective Action Plan Finding 2023-500: Coronavirus State and Local Fiscal Recovery Funds—Unallowable Costs Planned Corrective Action: Communication was sent out on October 2nd, 2023, to the Division of State Patrol on what classifications were deemed allowable for reimbursement to prevent future unallowable costs. On October 9th, 2023, a journal was completed for $2,173.12 to remove the unallowable costs from the grant. Lastly, on October 10th, the process of reviewing and approving the expenditures being submitted for reimbursement are now completed in three different organizational areas in the Department to ensure compliance with the MOA. Anticipated Completion Date: Completed on October 10th, 2023 Person responsible for corrective action: Cody Castillo, WisDOT Controller Division of Business Management, Bureau of Financial Management Cody.Castillo@dot.wi.gov

View Audit 300490 Questioned Costs: $1

Finding 389543 (2023-309)

None 2023

State of Wisconsin

WI

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

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2023-309: Coronavirus State and Local Fiscal Recovery Funds – Unallowable Costs. This is the department’s Corrective Action Plan.  Recommendation (2023-309): Coronavirus State and Local Fiscal Recover...

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2023-309: Coronavirus State and Local Fiscal Recovery Funds – Unallowable Costs. This is the department’s Corrective Action Plan.  Recommendation (2023-309): Coronavirus State and Local Fiscal Recovery Funds – Unallowable Costs We recommend the Wisconsin Department of Health Services ensure it retains documentation to support the costs charged to the Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) program, and work with the Department of Administration and the U.S. Department of the Treasury to resolve the questioned costs we identified. Wisconsin Department of Health Services Planned Corrective Action: As CSLFRF programs have matured, DHS has continued to review and revise our processes. DHS will take this opportunity to ensure that procedures surrounding approving of invoices, storing of documentation, and comprehension of the period of performance are updated and understood by our grant administrators. DHS will work with DOA and US Treasury to resolve the questioned costs. Anticipated Completion Date: June 30, 2024 Person responsible for corrective action: Natalie Easterday, Director Office of Preparedness and Emergency Health Care, Division of Public Health natalie.easterday@dhs.wisconsin.gov

View Audit 300490 Questioned Costs: $1

Finding 389542 (2023-307)

Significant Deficiency 2023

State of Wisconsin

WI

Questioned Costs Allowable Costs / Cost Principles Period of Performance § 200.303

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2023-307: Coronavirus State and Local Fiscal Recovery Funds – Unallowable Costs. This is the department’s response.  Recommendation (2023-307): Coronavirus State and Local Fiscal Recovery Funds – Unal...

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2023-307: Coronavirus State and Local Fiscal Recovery Funds – Unallowable Costs. This is the department’s response.  Recommendation (2023-307): Coronavirus State and Local Fiscal Recovery Funds – Unallowable Costs We recommend the Wisconsin Department of Health Services: • Review its current procedures for approving invoices related to the Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) program to ensure the steps required for approving invoices are appropriate and documented, and that documentation is maintained either in STAR or in a central location accessible in the event of employee turnover; • Take additional steps to ensure that expenditures charged to the CSLFRF program are within the period of performance; • Provide training to staff responsible for approving invoices to ensure staff understand what documentation is required to support approvals and the required period of performance for the CSLFRF; and • Work with the Wisconsin Department of Administration and the U.S. Department of the Treasury to resolve the questioned costs related to the CSLFRF program. Wisconsin Department of Health Services Planned Corrective Action: As CSLFRF programs have matured, DHS has continually reviewed and revised our processes. We will take this opportunity to ensure that procedures surrounding approving of invoices, storing of documentation, and comprehension of the period of performance are updated and understood by our grant administrators, including providing training as necessary. DHS will work with DOA and US Treasury to resolve the questioned costs. Anticipated Completion Date: September 30, 2024 Person responsible for corrective action: Christina Isenring, Director Bureau of Operations, Division of Public Health christinam.isenring@dhs.wisconsin.gov

View Audit 300490 Questioned Costs: $1

Finding 389541 (2023-105)

None 2023

State of Wisconsin

WI

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

Finding 2023-105: Coronavirus State and Local Fiscal Recovery Funds—Unallowable Costs Auditor Recommendation: We recommend the Wisconsin Department of Administration ensure only allowable costs are charged to federal grant programs, and work with the U.S. Department of the Treasury to resolve th...

Finding 2023-105: Coronavirus State and Local Fiscal Recovery Funds—Unallowable Costs Auditor Recommendation: We recommend the Wisconsin Department of Administration ensure only allowable costs are charged to federal grant programs, and work with the U.S. Department of the Treasury to resolve the questioned costs we identified related to the Coronavirus State and Local Fiscal Recovery Funds program. Planned Corrective Action: The Wisconsin Department of Administration (Department) resolved the Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) costs questioned by the auditors by recouping from the school district the amount of the overpayment and obtaining from the local law enforcement agencies documentation of additional eligible expenses in amounts not less than the overpayments. The Department will continue to ensure only allowable costs are charged to federal grant programs. Anticipated Completion Date: December 18, 2023 Person responsible for corrective action: Colleen Holtan, Director Bureau of Financial Management Division of Enterprise Operations colleen.holtan@wisconsin.gov

View Audit 300490 Questioned Costs: $1

Finding 389540 (2023-104)

Significant Deficiency 2023

State of Wisconsin

WI

Questioned Costs Eligibility Significant Deficiency

Finding 2023-104: Homeowner Assistance Fund—Documentation to Support Applicant Eligibility and Benefit Payments Auditor Recommendation: Revise its procedures to ensure the Department of Administration completes a sufficient review to ensure adequate supporting documentation is included in the Ho...

Finding 2023-104: Homeowner Assistance Fund—Documentation to Support Applicant Eligibility and Benefit Payments Auditor Recommendation: Revise its procedures to ensure the Department of Administration completes a sufficient review to ensure adequate supporting documentation is included in the Homeowner Assistance Fund program’s computer system prior to an approval of the benefit payment. Planned Corrective Action: The Wisconsin Department of Administration (Department) will revise its procedures to ensure it completes a sufficient review to ensure adequate supporting documentation is included in the Homeowner Assistance Fund program’s computer system prior to an approval of the benefit payment. Auditor Recommendation: Provide training or other technical assistance to the community action agencies on the adequacy of supporting documentation agencies are to obtain, evaluate, and enter into the Homeowner Assistance Fund program’s computer system. Planned Corrective Action: The Department will provide additional training and technical assistance to the community action agencies on the adequacy of supporting documentation agencies are to obtain, evaluate, and enter into the Homeowner Assistance Fund program’s computer system, the requirements for which are as contained in its Wisconsin Help for Homeowners (WHH) Program Manual. Training and technical assistance will be provided through communications with program administrators and during program monitoring. The Department further notes that, after providing nearly $70 million in assistance to help prevent foreclosure through mortgage, tax, and utility payments to more than 8,600 Wisconsin households facing pandemic-related financial hardship, the WHH Program closed to new applications on March 8, 2024.Anticipated Completion Date: June 30, 2024. Persons responsible for corrective action: David Pawlisch, Administrator Division of Energy, Housing and Community Resources david.pawlisch@wisconsin.gov

View Audit 300490 Questioned Costs: $1

Finding 389539 (2023-101)

Material Weakness 2023

State of Wisconsin

WI

Questioned Costs Eligibility Material Weakness § 200.303

Finding 2023-101: Homeowner Assistance Fund – Service Organization Controls Auditor Recommendation: Obtain the service organization audit report for the computer system used to administer the Homeowner Assistance Fund. Planned Corrective Action: The Wisconsin Department of Administration (Depar...

Finding 2023-101: Homeowner Assistance Fund – Service Organization Controls Auditor Recommendation: Obtain the service organization audit report for the computer system used to administer the Homeowner Assistance Fund. Planned Corrective Action: The Wisconsin Department of Administration (Department) has requested and will obtain the service organization audit report for the computer system used to administer the Homeowner Assistance Fund. Anticipated Completion Date: Immediately following the issuance of the service organization audit report for the period ended May 31, 2024, which is anticipated to be received not later than September 30, 2024. Auditor Recommendation: Complete a review of the service organization audit report, assess the effectiveness of the internal controls on the computer system maintained by the service organization, and document its review. Planned Corrective Action: The Department will develop the means to inform and document its review of the service organization audit report and its assessment of the effectiveness of the internal controls on the computer system maintained by the service organization. The Department will utilize those means to evidence reviews and assessments it completed but did not document as reported to and by the auditors, and for future received service organization audit reports, including the report that will be obtained for the period ended May 31, 2024. Anticipated Completion Date: June 30, 2024, as related to the development and use of the means to evidence prior completed but undocumented reviews and assessments, and within thirty days of receipt of the service organization audit report for the period ended May 31, 2024, which is anticipated to be received not later than September 30, 2024. Auditor Recommendation: Complete a review of the complementary user entity controls at the Department of Administration that are required to be in place for it to rely on the service organization audit report, document its review, and implement user entity controls, if needed. Planned Corrective Action: The Department will develop the means to inform and document its review of the complementary user entity controls at the Department that are required to be in place for it to rely on the service organization audit report, and will implement user entity controls, if needed. The Department will utilize those means to evidence the review of complementary user entity controls it completed but did not document as reported to and by the auditors, and for complementary user entity controls contained in future service organization audit reports, including the report that will be obtained for the period ended May 31, 2024. Anticipated Completion Date: June 30, 2024, as related to the development and use of the means to document the prior completed but undocumented review, and within thirty days of receipt of the service organization audit report for the period ended May 31, 2024, which is anticipated to be received not later than September 30, 2024. Persons responsible for corrective action: David Pawlisch, Administrator Division of Energy, Housing and Community Resources david.pawlisch@wisconsin.gov

View Audit 300490

Finding 389537 (2023-102)

Material Weakness 2023

State of Wisconsin

WI

Allowable Costs / Cost Principles Eligibility Questioned Costs

Finding 2023-102: Emergency Rental Assistance Program—Documentation to Support Applicant Eligibility and Benefit Payments Auditor Recommendation: Obtain required documentation for the four applicants we identified or seek to recoup improper benefit payments it made to these applicants. Planned ...

Finding 2023-102: Emergency Rental Assistance Program—Documentation to Support Applicant Eligibility and Benefit Payments Auditor Recommendation: Obtain required documentation for the four applicants we identified or seek to recoup improper benefit payments it made to these applicants. Planned Corrective Action: The Wisconsin Department of Administration (Department) requested and received from the auditors the four applicants they identified. The Department has reviewed available documentation in its eligibility and benefit determination system and will work with the responsible community action agencies and Energy Services, Inc. (ESI) to obtain required documentation supporting the applicants’ eligibility to receive Wisconsin Emergency Rental Assistance (WERA) Program benefits. Should the Department determine that it provided WERA Program benefits to ineligible recipients, it will seek to recoup the payments made. Auditor Recommendation: Provide additional training and technical assistance to the community action agencies and Energy Services, Inc. (ESI) on the adequacy of supporting documentation that is to be obtained and entered into Home Energy (HE) Plus by the community action agencies and ESI. Planned Corrective Action: The Department will provide additional training and technical assistance to the community action agencies and ESI on the adequacy of supporting documentation obtained and entered into Home Energy (HE) Plus, its eligibility and benefit determination system, based on its monitoring of accepted documentation. Anticipated Completion Date: June 30, 2024. Persons responsible for corrective action: David Pawlisch, Administrator Division of Energy, Housing and Community Resources david.pawlisch@wisconsin.gov

View Audit 300490 Questioned Costs: $1

Finding 389520 (2023-001)

Significant Deficiency 2023

The Tor Project, Inc.

WA

Questioned Costs Subrecipient Monitoring § 200.332

CORRECTIVE ACTION PLAN February 15, 2024 The Tor Project, Inc. (the Organization) respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent accounting firm: CohnReznick LLP 350 Granite Street, Suite 1200 Braintree, MA 02184 Audit peri...

CORRECTIVE ACTION PLAN February 15, 2024 The Tor Project, Inc. (the Organization) respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent accounting firm: CohnReznick LLP 350 Granite Street, Suite 1200 Braintree, MA 02184 Audit period: July 1, 2022 – June 30, 2023 The findings from the June 30, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Federal Award Findings and Questioned Costs Significant Deficiency Item #2023-001 - Subrecipient Monitoring International Programs to Support Democracy Human Rights and Labor – 19.345 Issue: The Organization did not fully monitor the subrecipients to ensure the subaward was used for authorized purposes, in compliance with Federal statutes, regulations, and the terms and conditions of the subaward; and that subaward performance goals are achieved. Recommendation: Management should monitor the activities of the subrecipient as necessary to ensure that the subaward is used for authorized purposes, in compliance with Federal statutes, regulations, and the terms and conditions of the subaward; and that subaward performance goals are achieved per 2 CFR 200.332. Action Taken: Subsequent to fiscal year end, the Agency implemented additional internal controls over subrecipient monitoring and retroactively performed these compliance procedures. The Tor Project, Inc. sampled monthly invoice periods for each active sub-recipient, per grant, in the period of the FY23 annual external audit. The Tor Project reviewed all supporting documentation for the cost reimbursements of the sample to ensure accuracy and completeness of all reimbursed costs. For all sub-recipients, The Tor Project performed the internal audit procedure selecting a sample of monthly invoices at random per sub-recipient, per grant, per year to verify the completeness and accuracy of all reimbursed costs. If there are any questions regarding this plan, please call Susan Abt at 781-307-8651.

View Audit 300483 Questioned Costs: $1

Finding 389519 (2023-003)

Material Weakness 2023

Johnson County, Wyoming

WY

Questioned Costs Subrecipient Monitoring Material Weakness

Corrective Action Plan County staff will continue to increase their knowledge on proper reporting requirement including specific reporting requirement for the different types of grants received by the County and required reporting under each grant. Additionally, the County will implement review pro...

Corrective Action Plan County staff will continue to increase their knowledge on proper reporting requirement including specific reporting requirement for the different types of grants received by the County and required reporting under each grant. Additionally, the County will implement review processes to ensure reports filed are done completely and accurately. Proposed completion date: June 30, 2024.

View Audit 300480

Finding 389517 (2023-001)

Significant Deficiency 2023

Santa Rosa County School Readiness Coalition, Inc.

FL

Questioned Costs Subrecipient Monitoring Reporting

Finding 2023-001: Internal Control over Compliance and Compliance with Monitoring Responsible Official’s Response and Corrective Action Plan Management has taken corrective action to ensure that monitoring is completed timely in compliance with grant and DEL Program Guidance. Anticipated Completio...

Finding 2023-001: Internal Control over Compliance and Compliance with Monitoring Responsible Official’s Response and Corrective Action Plan Management has taken corrective action to ensure that monitoring is completed timely in compliance with grant and DEL Program Guidance. Anticipated Completion Date: March 2024 Responsible Party: Melissa Stuckey, Chief Executive Officer Date: March 21, 2024

View Audit 300476

Finding 389514 (2023-001)

Material Weakness 2023

American Library Association

IL

Questioned Costs Period of Performance Internal Control / Segregation of Duties

FINDINGS - FEDERAL AWARDS AND QUESTIONED COSTS ...

FINDINGS - FEDERAL AWARDS AND QUESTIONED COSTS MATERIAL WEAKNESS 2023-001 - CONTROLS OVER PERIOD OF PERFORMANCE Recommendation: The auditors recommend the Association implement internal controls and procedures to ensure expenditures are recorded in the proper period. Actions Taken or Planned: During the fiscal year end closing process, invoices will be closely examined to determine proper cut-off procedures are applied and invoices will be matched and recorded in the period that the service is performed and/or the goods are received. In addition, education will be strengthened for Grant Principal Investigators to aid in the determination of recording invoices in the correct fiscal year. Person(s) Responsible: Grant Principal Investigators, Controller, Director of Financial Reporting and Compliance and the Chief Financial Officer. Estimated Date of Completion: The plan will be incorporated into our processes immediately to allow for ample time for education and refinement. The plan will be fully implemented by August 31, 2024.

View Audit 300465

Finding 389500 (2023-003)

Material Weakness 2023

Ojai Unified School District

CA

Subrecipient Monitoring Cash Management Reporting

The Director of Nutrition Services, hired August 2023, has been trained on the verification process and procedures along with timeline compliance requirements.

View Audit 300462

Finding 389482 (2023-002)

Material Weakness 2023

Homeless and Hunger Coalition of Northwest Florida, Inc.

FL

Questioned Costs Material Weakness Internal Control / Segregation of Duties

The Executive Director and one other authorized signer will be required to review all supporting documentation for State or Federal Award program expense paid with any with any type of grant funding using the updated two signature paymont request form which specifies which grant fund is being used. ...

The Executive Director and one other authorized signer will be required to review all supporting documentation for State or Federal Award program expense paid with any with any type of grant funding using the updated two signature paymont request form which specifies which grant fund is being used. Routine indirect general office expenses will require approval by the Executive Director and a second authorized signer. However, the invoice may be reviewed and initialed, omitting the payment request form. However, any funding that is used as a grant administrative cost, will require the two-signature payment request form.

View Audit 300452

Finding 389480 (2023-001)

Significant Deficiency 2023

Endicott College

MA

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

Finding Reference: 2023-001 Finding: During testing of student loan notifications, it was identified that one of forty students selected for test work did not receive a notification for three loan disbursements during the year. The item that was an exception described above did not result in changes...

Finding Reference: 2023-001 Finding: During testing of student loan notifications, it was identified that one of forty students selected for test work did not receive a notification for three loan disbursements during the year. The item that was an exception described above did not result in changes to the amounts awarded or disbursed to students by the College for the current fiscal year. The condition identified was the result of a student that selected to opt-out of College email notifications, which resulted in federal loan notifications to not be delivered. The College did not have adequate processes in place to ensure appropriately notification in accordance with federal regulations when a student selected to opt-out of receiving College communications. Endicott College Responsible Contact: Bryan Cain, Senior VP for Student and External Engagement Corrective Action Plan: This finding was the result of students being allowed to opt out of all notifications from Endicott College, which are initiated thru a notification system called EMMA. EMMA is the system of record used for notifying students of loan disbursements and as a result of students being able to opt out of all EMMA notifications this student was not notified of their loan disbursements. As a result of this finding the college has disabled the ability for students to be able to opt out of all EMMA notifications and thus being unable to opt out of student financial notifications such as loan disbursements. Anticipated Completion Date: February 2024

View Audit 300451

Finding 389467 (2023-001)

Significant Deficiency 2023

Elderly Housing Corporation of Clay County 092-35748-Np-L8

MN

HUD Housing Programs Questioned Costs Special Tests & Provisions

Contact Person Dara Lee, Executive Director of Clay County HRA (Authorized Representative and Agent) Corrective Action Plan Error occurred due to lack of oversight in review of tenant files. Planned Completed Date for CAP Immediately

View Audit 300436

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