Corrective Action Plans

Finding 64471 (2022-001)

Material Weakness 2022

PA

Questioned Costs Student Financial Aid Material Weakness

Lack of Administrative Capability Planned Corrective Action: We have re-reviewed the COVID waivers and made the necessary notes and documentation in our records. Our office is actively recruiting an additional aid counselor to assist with the increased workload due to our significant jump in enrollm...

Lack of Administrative Capability Planned Corrective Action: We have re-reviewed the COVID waivers and made the necessary notes and documentation in our records. Our office is actively recruiting an additional aid counselor to assist with the increased workload due to our significant jump in enrollment (up 52% in the last two years). We are working with our Registrar, Assistant Provost, Brightspace Administrator, and IT to ensure our system is reporting the right information at the right time to the right departments. We have sought guidance from our Department of Education representative in Philadelphia to make sure we are interpreting regulations and guidelines appropriately. We have changed our policies for this upcoming 2023-2024 school year to not disburse any aid until after all of our terms for a given semester have passed their add/drop periods so we can ensure that each student has actively started their program, is continuing to be an active participant, and if not, that we take the necessary steps to adjust or cancel their aid appropriately. This is not something that we take lightly and are determined to correct these issues and take additional preventative measures so that they do not happen again. Person Responsible for Corrective Action Plan: Andrea L Ruth, Director of Financial Aid Anticipated Date of Completion: 4/1/2023

View Audit 73872

Finding 64082 (2022-003)

Material Weakness 2022

Morrison Institute of Technology

IL

Questioned Costs Special Tests & Provisions

2022-003 Student Aid Grants Condition - During fiscal year 2022, the Institute incurred expenses for student aid grant payments that contained academic, performance or attendance provisions: ? $17,000 of student aid grants established a minimum GPA ? $12,000 of student aid grants included perfo...

2022-003 Student Aid Grants Condition - During fiscal year 2022, the Institute incurred expenses for student aid grant payments that contained academic, performance or attendance provisions: ? $17,000 of student aid grants established a minimum GPA ? $12,000 of student aid grants included performance measures ? $16,000 of student aid grants were paid to students that had been nominated by high school counselors for attendance at the Institute ? $6,759 of student aid grants were for students with parents who graduated from the institution Corrective Action Plan - As the finding was the result of interpretation of guidance, the college has implemented increased coordination of any HEERF action. All actions and procedures are reviewed with the fund administrator, fiscal operations, and financial aid on a biweekly basis, and no actions are taken without group review. Contact Person, Title and Phone Number - Scott Connelly, Vice President of Academics, Director of Career and Student Services, (815)-772-7218, Ext. 215 Anticipated Completion Date - August 1, 2022

View Audit 70019 Questioned Costs: $1

Finding 64081 (2022-001)

Significant Deficiency 2022

Housing Authority for the City of Freeport

IL

Questioned Costs HUD Housing Programs

Finding 2022-001 Finding Summary: Tenant files were not in compliance with HUD regulations. Responsible Individuals: Babette Jamison-Varner, Chief Executive Director Corrective Action Plan: HACF will continue to conduct its scheduled annual audit. Additionally, the organization will be consistent i...

Finding 2022-001 Finding Summary: Tenant files were not in compliance with HUD regulations. Responsible Individuals: Babette Jamison-Varner, Chief Executive Director Corrective Action Plan: HACF will continue to conduct its scheduled annual audit. Additionally, the organization will be consistent in its conduct of bi-annual file reviews. These reviews will sample of up to 20 files. Both annual and bi-annual audits will result in documentation of file errors and needed corrections. All audit files will be signed off by the operations manager and the staff. Property management staff will receive ongoing training on reviewing income, assets and rent calculations, tenant record keeping and recertification requirements. Anticipated Completion Date: Annual and bi-annual audit months: December 2022, April 2023, August 2023 & December 2023.

View Audit 69234

Finding 63664 (2022-001)

Significant Deficiency 2022

Foothill - De Anza Community College District

CA

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

2022-001 Student Financial Aid Cluster ? Enrollment Reporting ? Various Recommendation: We recommend that each College review their existing procedures and controls and identify necessary changes needed to ensure timely reporting of student status changes to NSLDS as required by regulations. Foothil...

2022-001 Student Financial Aid Cluster ? Enrollment Reporting ? Various Recommendation: We recommend that each College review their existing procedures and controls and identify necessary changes needed to ensure timely reporting of student status changes to NSLDS as required by regulations. Foothill College Response Explanation of disagreement with finding: There is no disagreement with the finding and the Foothill College will resolve it. Action taken in response to finding: Using the samples from the findings as an example, the Dean of Enrollment Services will contact with National Student Clearinghouse Audit support and request a review of the data received from the College by 3/1/2023. If the issue is with our data, the College with work our technical support team and request a specialist from Ellucian ? Banner that supports the enrollment reporting process. If the issue is merely additional training needed on how to handle the error report file, then additional training will be requested for appropriate Admissions & Records staff for one-on-one training with the National Student Clearinghouse. Name of the contact person responsible for corrective action: Anthony Cervantes, Dean of Enrollment Services Planned completion date for corrective action plan: April 1, 2023. De Anza College Response Explanation of disagreement with finding: De Anza College has reported all five students in question within 30 days of their status change to the National Clearing House. However, the NCH failed to report to the NSLDS the change of status within 30 days after we correctly reported the change in enrollment. The College has provided proof of our reporting to the NCH, but because the students were not reported by the NCH in a timely manner, we are responsible to take actions to correct this process and make sure that the NCH is reporting on time and with right reports. Action taken in response to finding: The College can see some improvement in numbers of unreported or misreported student records from the NCH to the NSLDS. The Dean of Enrollment Services will continue working with the National Clearing House on the reporting process to avoid discrepancies and delays in the future. Name of the contact person responsible for corrective action: Nazy Galoyan, Dean of Enrollment Services Planned completion date for corrective action plan: June 2023.

View Audit 68659

Finding 63291 (2022-001)

None 2022

City of Carson

CA

Questioned Costs Reporting

The City has received access to the Reporting site and the accountant assigned to the ARPA fund has reported the required Quarterly reports prior due dates. The required ARPA quarterly report will be filed timely by its due date as staff now has authorized access to the ARPA portal. Corrective Actio...

The City has received access to the Reporting site and the accountant assigned to the ARPA fund has reported the required Quarterly reports prior due dates. The required ARPA quarterly report will be filed timely by its due date as staff now has authorized access to the ARPA portal. Corrective Action Plan has been implemented as of June 30, 2022, and the city personnel responsible for the correction were Deputy City Manager, Tarik Rahmani, and the accounting team.

View Audit 70879

Finding 63277 (2022-004)

Significant Deficiency 2022

City of Gardena

CA

Questioned Costs Subrecipient Monitoring HUD Housing Programs

2022-004 Reporting ? Internal Control and Compliance over Reporting City?s Corrective Action Plan: City will follow its grant management policies to ensure the reporting requirements are met in a timely manner. Responsible Person: Ray Beeman, Director of Administrative Services Expected Implementati...

2022-004 Reporting ? Internal Control and Compliance over Reporting City?s Corrective Action Plan: City will follow its grant management policies to ensure the reporting requirements are met in a timely manner. Responsible Person: Ray Beeman, Director of Administrative Services Expected Implementation Date: July 1, 2023

View Audit 69837

Finding 63263 (2022-005)

Significant Deficiency 2022

Lennox School District

CA

Subrecipient Monitoring Questioned Costs

To avoid the potential costs and risks associated with the loss of records, a retention schedule would be created. All financial records must be stored securely in a safe location and accessible only by authorized personnel. A guide will be created for employees on how to manage their desk documents...

To avoid the potential costs and risks associated with the loss of records, a retention schedule would be created. All financial records must be stored securely in a safe location and accessible only by authorized personnel. A guide will be created for employees on how to manage their desk documents and how to identify their storage location. The Assistant Superintendent of Business Services and Director of Fiscal Services will be responsible for implementing and supervising the records management system.

View Audit 69237

Finding 62816 (2022-006)

None 2022

Chawanakee Unified School District

CA

Questioned Costs Reporting Equipment & Real Property Management

Federal Award Findings and Questioned Costs Finding Identification: 2022 ? 006 Federal ? Elementary and Secondary School Emergency II Relief Fund Program #50000 Name of contact person: Dr. John Quinto, CBO Corrective Action: Chief Business Official to create a process to track all grants that...

Federal Award Findings and Questioned Costs Finding Identification: 2022 ? 006 Federal ? Elementary and Secondary School Emergency II Relief Fund Program #50000 Name of contact person: Dr. John Quinto, CBO Corrective Action: Chief Business Official to create a process to track all grants that also allows for oversight of expenditure plans, budgeting, and expensing per grants expenditures, and submissions of expenditure reports. Proposed Completion Date: January 6, 2023

View Audit 59340

Finding 62792 (2022-001)

Significant Deficiency 2022

The Pines Housing, Inc.

OR

Questioned Costs HUD Housing Programs Reporting

Condition: The security deposit liabilities of $20.052 exceeded the balance in the security deposit bank account of $18,496. There is a security deposit funding deficit of $1,556, resulting in an instance of noncompliance. Comments on the finding and the recommendation: The Organization concurs with...

Condition: The security deposit liabilities of $20.052 exceeded the balance in the security deposit bank account of $18,496. There is a security deposit funding deficit of $1,556, resulting in an instance of noncompliance. Comments on the finding and the recommendation: The Organization concurs with the finding and the recommendation. Action(s) taken or planned on the finding: The management agent, Quantum, is responsible for reconciling the security liability account with the security deposit funding. The Asset Management Director, Holly Vander Schaaf is responsible for reviewing the security deposit handling and accounting on a monthly basis.

View Audit 54429 Questioned Costs: $1

Finding 62683 (2022-001)

Material Weakness 2022

Maine School Administrative District No. 32

ME

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring

Recommendations We recommend the District implement a federal procurement policy to follow. We also recommend they work with the Contractor to determine if prevailing wages were paid and pay any additional amount necessary to adhere to the prevailing wage amounts. District?s Response The District...

Recommendations We recommend the District implement a federal procurement policy to follow. We also recommend they work with the Contractor to determine if prevailing wages were paid and pay any additional amount necessary to adhere to the prevailing wage amounts. District?s Response The District is committed to remedying the findings. A federal procurement policy is being drafted and is expected to be implemented by the Board of Directors soon. The District will determine how much (if any) additional wages are to be paid to meet the prevailing wages requirement and pay them as soon as they have been identified.

View Audit 54477 Questioned Costs: $1

Finding 62644 (2022-002)

Material Weakness 2022

Nationwide Children's Hospital

OH

Questioned Costs Allowable Costs / Cost Principles Reporting § 200.303

Finding 2022-002 Grantor: Department of Health and Human Services Federal Program: Teenage Pregnancy Prevention Program Allergy And Infectious Diseases Research Assistance Listing #: 93.267 93.855 Pass-through Grantor Pass-Through Award Number Pass-through Award Period None None Various ...

Finding 2022-002 Grantor: Department of Health and Human Services Federal Program: Teenage Pregnancy Prevention Program Allergy And Infectious Diseases Research Assistance Listing #: 93.267 93.855 Pass-through Grantor Pass-Through Award Number Pass-through Award Period None None Various Award Year: Fiscal year 2022 1/1/2022 ? 12/31/2022 Award Number: 5 TP1AH000212-02 5R01AI126890-05 5U01AI131386-05 5R01AI146581-02 Management agrees with the recommendation. Management will implement the following changes to Time and Effort practices. Corrective Action Plan and Anticipated Completion Date Management?s corrective action plan includes: ? Review and revise Time and Effort internal policy to include more robust internal controls. ? Develop escalation procedures for delayed certification. ? Outstanding time and efforts to be certified. Responsible person: Aaron Ufferman, Director, Sponsored Projects Completion Date: December 31, 2023.

View Audit 54476 Questioned Costs: $1

Finding 62571 (2022-001)

Significant Deficiency 2022

Boise State University

ID

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

Federal Program Title: Student Financial Assistance Cluster ALN: 84.007, 84.038, 84.063, 84.268, 84.379 Recommendation: We recommend the University update their R2T4 calculation process to eliminate the students that completed 49% of the payment period days in their modular classes. We also recomm...

Federal Program Title: Student Financial Assistance Cluster ALN: 84.007, 84.038, 84.063, 84.268, 84.379 Recommendation: We recommend the University update their R2T4 calculation process to eliminate the students that completed 49% of the payment period days in their modular classes. We also recommend the University review the calculation for automatic last date of attendance overrides. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Financial Aid and Scholarships office has created the following workflow queries to systematically review R2T4 calculations for accuracy: 1) BFA_R2T4_MOD_ONLY_AUDIT_1 -- module-only students who have earned more that 49% and have an R2T4 calculation. 2) BFA_R2T4_MOD_ONLY_AUDIT_2 -- the percent earned on the Return TIV Session does not match the Pct. TIV Aid Earned on the Worksheet. 3) BFA_R2T4_MOD_ONLY_AUDIT_3 -- if there are two withdrawal dates, the latest is used in the worksheet. These queries will become part of the monthly workflows and alert management for additional review. Name(s) of the contact person(s) responsible for corrective action: Kelley Christianson, Director of Financial Aid and Scholarships: kelleychristianson@boisestate.edu Planned completion date for corrective action plan: March 31, 2023

View Audit 54662

Finding 62569 (2022-003)

Material Weakness 2022

Brookshire Municipal Water District

TX

Cash Management Reporting Internal Control / Segregation of Duties

Finding 2022-003: Cash Management Contact Information of Responsible Party: Tonya Pierre, General Manager Corrective Action Plans: The District will review and monitor debt compliance requirements throughout the year to ensure that timely decisions can be made to ensure compliance. the District will...

Finding 2022-003: Cash Management Contact Information of Responsible Party: Tonya Pierre, General Manager Corrective Action Plans: The District will review and monitor debt compliance requirements throughout the year to ensure that timely decisions can be made to ensure compliance. the District will discuss increase the water and wastewater rates again to insure they are producing sufficient revenue to pay the district expenses. Start Date: April 2023 Target End Date: July 2024 Status: 50% Completed

View Audit 54120

Finding 62417 (2022-005)

Significant Deficiency 2022

Morgan County Hospital Authority

GA

Questioned Costs Reporting Matching / Level of Effort / Earmarking

Significant Deficiency (2022-005) Recommendation: The Authority should continue to improve its understanding of the reporting requirements as specified in the applicable loan document and create a process to ensure reports are submitted in a timely manner. Planned Corrective Action: The Authority wi...

Significant Deficiency (2022-005) Recommendation: The Authority should continue to improve its understanding of the reporting requirements as specified in the applicable loan document and create a process to ensure reports are submitted in a timely manner. Planned Corrective Action: The Authority will create a process to send the Annual Budget, Projected Cashflow and quarterly Internal Financial Statements to the USDA. This will be included as a part of our month end close process and reports will be sent to the USDA by our Finance Department and confirmed by the CFO.

View Audit 54105

Finding 62342 (2022-001)

None 2022

Bulter County Community College

KS

Questioned Costs Reporting

Finding Reference Number ? 2022-001 Criteria or Specific Requirement ? Under the CARES Act 18004(e) and the CRRSAA 314(e), there are three components to reporting HEERF, public reporting on student aid portion, public reporting on the institutional portion, and annual reporting. The public reporti...

Finding Reference Number ? 2022-001 Criteria or Specific Requirement ? Under the CARES Act 18004(e) and the CRRSAA 314(e), there are three components to reporting HEERF, public reporting on student aid portion, public reporting on the institutional portion, and annual reporting. The public reporting on student aid requires institutions to publicly post certain information, including four items defined by the U.S. Department of Education (ED) as key items, on their website as soon as possible but no later than 30 days after the publication of the notice or 30 days after the ED first obligated funds. The report must be updated no later than 10 days after the end of each calendar quarter. The public reporting on institutional aid requires institutions to publicly post the HEERF institutional reporting form on the institution's primary website no later than 10 days after the end of each calendar quarter with the exception of the first report, which was due October 30, 2020, and the report covering the first quarter of 2021, which was due July 10, 2021. Recommendation ? We recommend that management review this area and establish procedures to ensure required reports are completed timely. Views of Responsible Officials and Corrective Action Plan ? Management concurs with the findings and recommendation. Responsible personnel will review current guidance available from the Department of Education website and develop internal procedures to ensure timely compliance. This plan will include personnel (responsibility) redundancy to account for employee absences or turnover, and a monthly review of available guidance to ensure the College stays current with any changes to this guidance. Individuals Responsible ? _______ Anticipated Completion Date ? _________

View Audit 52273

Finding 62268 (2022-003)

Material Weakness 2022

Bethany Lutheran Home for the Aged, Inc.

SD

Special Tests & Provisions Questioned Costs Subrecipient Monitoring § 200.303

2022-003 Department of Agriculture Federal Financial Assistance Listing/CFDA #10.766 Communities Facilities and Loans Grants Cluster Special Tests & Provisions Material Weakness in Internal Control over Compliance Condition: Management did not have access to the relevant documents and was unaware...

2022-003 Department of Agriculture Federal Financial Assistance Listing/CFDA #10.766 Communities Facilities and Loans Grants Cluster Special Tests & Provisions Material Weakness in Internal Control over Compliance Condition: Management did not have access to the relevant documents and was unaware of the USDA reserve requirement until further discussion with USDA. The Organization had cash balances on hand exceeding the required reserve amount; however, the funds were not segregated in a separate bookkeeping account or bank account. Responsible Party: Dalton Huber, CFO Corrective Action Plan: Management is presently working with First Interstate Bank to set up an FDIC insured savings account for this reserve requirement. This account will be maintained going forward. The required balance will be presented to the board monthly in comparison to the actual balance in the account. Anticipated Completion Date: January 31, 2023.

View Audit 54088

Finding 62145 (2022-001)

Significant Deficiency 2022

Columbus House, Inc. and Subsidiaries

CT

Questioned Costs Procurement, Suspension & Debarment Significant Deficiency § 200.318 § 200.326

U.S Department of Housing and Urban Development Columbus House, Inc. and Subsidiaries (the Organization) respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 2021 ? June 30, 2022 The findings from the schedule of findings and questioned c...

U.S Department of Housing and Urban Development Columbus House, Inc. and Subsidiaries (the Organization) respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 2021 ? June 30, 2022 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS?FEDERAL AWARD PROGRAMS AUDITS U.S DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT 2022-001 Emergency Solutions Grant Program ? Assistance Listing No. 14.231 Recommendation: We recommend that the Organization review its formal procurement policies and make necessary changes to comply with the terminology requirements as set out in 2 CFR sections 200.318 and 200.326. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management is in the process of updating its procurement policies to ensure that all necessary language is included so that it will comply with all of the requirements listed in sections 200.315 through 200.326 of the Uniform Guidance. Name of the contact person responsible for corrective action: Margaret Middleton, CEO Planned completion date for corrective action plan: February 2023 If the U.S Department of Housing and Urban Development has questions regarding this plan, please call Margaret Middleton at 203-401-4400.

View Audit 57170

Finding 62131 (2022-001)

Significant Deficiency 2022

Owensboro Health, Inc.

KY

Questioned Costs Reporting Matching / Level of Effort / Earmarking

Finding Name: 2022-001-Reporting Federal Program: COVID-19 Provider Relief Fund ALN: 93.498 Owensboro Health, Inc. (OHI)?s System CFO and VP of Accounting has reviewed the COVID-19 Provider Relief Fund findings from KPMG relating to the Uniform Guidance. We understand the recommendation set forth ...

Finding Name: 2022-001-Reporting Federal Program: COVID-19 Provider Relief Fund ALN: 93.498 Owensboro Health, Inc. (OHI)?s System CFO and VP of Accounting has reviewed the COVID-19 Provider Relief Fund findings from KPMG relating to the Uniform Guidance. We understand the recommendation set forth by KPMG and will revamp our controls and processes to include additional review of the quarterly grant reports entered in the US Department of Health Human Services portal before and after submission. OHI?s corrective action plan: 1. Going forward, OHI will have a formal agenda to discuss and approve the grant reports prior to the submission to the US Department of Health and Human Services portal. 2. The quarterly Cares Act (PRF) reporting will be reviewed, approved and attested by the System CFO, VP of Accounting, Manager of Revenue and Regulatory Analysis and Manager of Decision Support. Contact person/s responsible for the correction action: Ruby Jacildo and Jeremy Stewart Anticipated Date: March 31, 2023

View Audit 56996

Finding 62124 (2022-005)

Significant Deficiency 2022

Southern Illinois University

IL

Internal Control / Segregation of Duties Questioned Costs Eligibility § 200.303

2022-005. Finding: Inadequate Procedures for Ensuring Retention of Eligibility Documentation for the Upward Bound Program ? Edwardsville Campus Response: We agree we did not have adequate procedures to ensure the required documents were retained for all students who received stipends during the per...

2022-005. Finding: Inadequate Procedures for Ensuring Retention of Eligibility Documentation for the Upward Bound Program ? Edwardsville Campus Response: We agree we did not have adequate procedures to ensure the required documents were retained for all students who received stipends during the period tested. Corrective Action Plan: We will implement adequate controls to ensure document retention, including in instances where responsible staff have departed the University. Contact Person: Timothy Staples (Director of University Services to East St Louis) Anticipated completion date: June 30, 2023

View Audit 56947

Finding 62118 (2022-001)

Significant Deficiency 2022

The Boys & Girls Clubs of Boston, Inc.

MA

School Nutrition Programs Questioned Costs Cash Management

Finding: During a review by the external auditors of the tally sheets utilized by the clubs for meals served and submitted to the finance department for input into the billing system used by the Department of Education (DOE) for reimbursement, it was discovered that an incorrect number of meals was ...

Finding: During a review by the external auditors of the tally sheets utilized by the clubs for meals served and submitted to the finance department for input into the billing system used by the Department of Education (DOE) for reimbursement, it was discovered that an incorrect number of meals was keyed into the system for one club. The number of meals submitted was higher than what the club had originally reported and resulted in an overpayment received from DOE. Corrective Actions Taken or Planned: The organization, with oversight from Kay Ridgard, Controller, immediately contacted DOE and let them know of the error. DOE made the corrective adjustment in their system and recovered the overpayment by reducing the upcoming September 2022 payment due to the organization by the amount of the overpayment received. There was a complete review of the internal process used in the billing of DOE for meals for each location. The process for submission for reimbursement is outlined below with changes highlighted: 1. Tally sheets sent from the clubs are reviewed by the Accounts Payable Associate (Procurement Coordinator when hired) to ensure that there are no addition errors. 2. Numbers from the tally sheets are entered into an Excel file to give summary totals for the organization and this is used by the Accounts Payable Associate to input data into the DOE system. 3. The Controller (or Manager) reviews the excel file before the data is input into the DOE system to ensure it accurately reflects the tally sheets. 4. Data is input in the DOE system and reports are generated showing the accepted submission that will be reimbursed. 5. The Controller (or Manager) performs a second review to ensure the submitted data match the previously reviewed Excel file.

View Audit 50517 Questioned Costs: $1

Finding 62117 (2022-002)

Significant Deficiency 2022

Waupun Area School District

WI

Questioned Costs Cash Management Reporting

Finding 2022-002 ? Federal and State Findings and Questioned Costs Corrective Action Plan: Edit check reports from the district?s student information syste, Infinite Campus, will be provided on a monthly basis, no later than the 5th of the month for the preceding month. Any errors listed on the repo...

Finding 2022-002 ? Federal and State Findings and Questioned Costs Corrective Action Plan: Edit check reports from the district?s student information syste, Infinite Campus, will be provided on a monthly basis, no later than the 5th of the month for the preceding month. Any errors listed on the reports will be researched and corrected by the Food Service Director or Assisitant Food Service Director. After all meal sales errors are corrected the final reports will be provided to the Director of Business Services no later than the 10th of the month. These reports will be used to make the monthly federal (USDA) food service claims and retained as documentation for the claims. Person(s) Responsible: Director of Business Services and Food Service Director. Timing for Implementation: August 2022.

View Audit 50512

Finding 62077 (2022-003)

Significant Deficiency 2022

Southern Illinois University

IL

Questioned Costs

2022-003. Finding: Sliding Fee Discount Not Applied to All Eligible Patients ? School of Medicine Response: We agree. We did not provide the sliding fee discount to eligible patients after a Medicare claim posting. Now that we are aware of the weakness, we are committed and have developed a correcti...

2022-003. Finding: Sliding Fee Discount Not Applied to All Eligible Patients ? School of Medicine Response: We agree. We did not provide the sliding fee discount to eligible patients after a Medicare claim posting. Now that we are aware of the weakness, we are committed and have developed a corrective action plan to address the matter. Corrective Action Plan: The following corrective actions are in process: ? In conjunction with SIU Patient Business Services (PBS): Review and revise/update all billing policies/procedures that relate to the Sliding Fee Discount Program (SFDP). o Status: Currently in process of review o Anticipated completion date: 2-3 months (April-May 2023) ? Educate staff on updated SFDP; including all applicable PBS staff members, all FQHC financial counselors, and any FQHC administration staff. Re-education will be performed semi-annually to all staff mentioned above o Status: Pending o Anticipated completion date: 3-6 months (June-Sept 2023) ? Develop and implement a self-audit procedure to be performed internally on a quarterly basis o Status: Pending o Anticipated completion date: 6-9 months (By end of year 2023) Contact Person: Agnes Arnold (Asst Professor of Family and Community Medicine) Anticipated completion date: As noted above.

View Audit 56947

Finding 61900 (2022-003)

Significant Deficiency 2022

Housing Opportunities Commission of Montgomery County, MD

MD

HUD Housing Programs Questioned Costs Significant Deficiency

2022-003 Housing Voucher Cluster-HCVP Housing Quality Standards and Enforcement ? Assistance Listing No. 14.871 / 14.879 Context: Testing of 40 HCVP tenant files for failed inspection standards revealed the following: ? Three files where abatement ought to have been implemented, but records could no...

2022-003 Housing Voucher Cluster-HCVP Housing Quality Standards and Enforcement ? Assistance Listing No. 14.871 / 14.879 Context: Testing of 40 HCVP tenant files for failed inspection standards revealed the following: ? Three files where abatement ought to have been implemented, but records could not be located. Context: Testing of 40 HCVP tenant files for annual inspection standards revealed the following: ? Three files where the inspection was not completed annually or within HUD?s granted extension for COVID 19. Recommendation: The Commission should implement processes to ensure that all proper documentation is being maintained for inspections of tenant residences. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: ? HOC procured Inspection Experts Inc. (?IEI?) on July 1, 2022, to conduct all initial, annual, special and quality control inspections ? HOC meets with IEI monthly to provide the report of annual inspections, and discuss progress and the alignment of expectations. ? HOC staff receives a report of units requiring abatement daily from IEI & immediately place the units in abatement. ? An HOC Senior Manager reviews the abatement report weekly to conduct quality control reviews of all records, ensuring that all units are placed in abatement ? The HOC Compliance Team will conduct quality control reviews of completed files. Staff from the Housing Resources Management Team will meet with the HOC Compliance Team following each review period to discuss systemic findings and schedule staff trainings in areas requiring improvement. Name(s) of the contact person(s) responsible for corrective action: Lynn Hayes, Director of Housing Resources/Darcel Cox, Chief Compliance Officer Planned completion date for corrective action plan: June 30, 2023

View Audit 52878

Finding 61899 (2022-002)

Significant Deficiency 2022

Housing Opportunities Commission of Montgomery County, MD

MD

HUD Housing Programs Questioned Costs Significant Deficiency

2022-002 Housing Voucher Cluster-HCVP Rent Reasonableness Test ? Assistance Listing No. 14.871 / 14.879 Context: Testing of 40 HCVP tenant files for rent reasonableness standards revealed the following: ? One file that was missing the rent reasonableness comparison report to substantiate the contrac...

2022-002 Housing Voucher Cluster-HCVP Rent Reasonableness Test ? Assistance Listing No. 14.871 / 14.879 Context: Testing of 40 HCVP tenant files for rent reasonableness standards revealed the following: ? One file that was missing the rent reasonableness comparison report to substantiate the contract rent. ? One file that was missing the lease amendment letter effective for the sampled contract rent change. Recommendation: The Commission should implement processes to ensure that all proper documentation is being maintained during the rent approval process for every tenant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: ? HOC will continue to work with the software developer to identify and resolve software glitches. ? The HOC Compliance Team will conduct quality control reviews of completed files. Staff from the Housing Resources Management Team will meet with the HOC Compliance Team following each review period to discuss systemic findings and schedule staff trainings in areas requiring improvement. ? HOC implemented Rent Cafe, Yardi?s software module to process electronic recertifications. The Lease Amendment Letter is automatically uploaded into Yardi when a customer completes the recertification online. Name(s) of the contact person(s) responsible for corrective action: Lynn Hayes, Director of Housing Resources/Darcel Cox, Chief Compliance Officer Planned completion date for corrective action plan: June 30, 2023

View Audit 52878

Finding 61898 (2022-001)

Significant Deficiency 2022

Housing Opportunities Commission of Montgomery County, MD

MD

HUD Housing Programs Questioned Costs Eligibility

2022-001 Housing Voucher Cluster-HCVP Eligibility ? Assistance Listing No. 14.871 / 14.879 Context: Testing of 40 HCVP tenant files for eligibility standards revealed the following: ? One file where the tenant received an allowance without proper verification or support. Recommendation: The Commissi...

2022-001 Housing Voucher Cluster-HCVP Eligibility ? Assistance Listing No. 14.871 / 14.879 Context: Testing of 40 HCVP tenant files for eligibility standards revealed the following: ? One file where the tenant received an allowance without proper verification or support. Recommendation: The Commission should implement processes to ensure that all proper documentation is being maintained during the recertification process for every tenant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: ? The Housing Resources Division(HRD) will hire an internal trainer to address systemic errors, reinforce program rules and introduce new regulatory requirements. The trainer will meet with staff monthly to reinforce program requirements and provide individual coaching as needed. Moreover, HOC will continue to archive recorded trainings in a resource library so the materials are accessible to staff at all times ? The HOC Compliance Team will conduct quality control reviews of completed files. Staff from the Housing Resources Management Team will meet with the HOC Compliance Team following each review period to discuss systemic findings and schedule staff trainings in areas requiring improvement. ? HOC will procure a professional consulting company to provide a comprehensive refresher training on the Housing Choice Voucher (HCV) eligibility requirements. ? The Housing Resources Management Team will continue to meet with staff regularly to provide staff development trainings, including reiteration of the Quality Control Checklist, the HUD verification hierarchy and uploading all documents into AO Docs, HOCs electronic filing system. Name(s) of the contact person(s) responsible for corrective action: Lynn Hayes, Director of Housing Resources/Darcel Cox, Chief Compliance Officer Planned completion date for corrective action plan: June 30,, 2023

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