Corrective Action Plans

Finding 521061 (2024-002)

Significant Deficiency 2024

SD

Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking

Finding 2024-002 Federal Agency Name: Department of Education Assistance Listing Number: #84.268 Program Name: Federal Direct Student Loans Finding Summary: 1 of the 60 students selected for testing the reporting of student status changes were reported with the incorrect enrollment status based on N...

Finding 2024-002 Federal Agency Name: Department of Education Assistance Listing Number: #84.268 Program Name: Federal Direct Student Loans Finding Summary: 1 of the 60 students selected for testing the reporting of student status changes were reported with the incorrect enrollment status based on NSLDS Enrollment Reporting guidance. 3 of the 60 students selected for testing the reporting of student status changes were reported to NSLDS with incorrect program begin dates based on NSLDS Enrollment Reporting guidance. 1 of the 60 students selected for testing the reporting of student status changes were reported to NSLDS with an incorrect status effective date based on NSLDS Enrollment Reporting guidance. Corrective Action Plan: LATC currently runs a SQL database script against the enrollment file before sending it to NSC. This script checks for missing and erroneous data (race/ethnicity, nondegree seeking majors, anticipated grad dates, etc.) in the file and updates it to correct values. The Director of Enrollment will work with the Database Administrator to regularly update these tables and review to ensure accurate information is being imported. The Registrar’s office will manually investigate these records and (if necessary) updated before sending the file to NSC. Every 30 days, representatives from the Financial Aid and the Registrar’s departments will pull 10 randomly selected student files to compare information in National Student Clearinghouse, PowerFaids, and NSLDS. The Director of Enrollment will work the error reports that the National Student Clearinghouse sends to LATC after every enrollment file upload with the assistance of the Database Administrator to ensure data submitted is compliant with DOE regulations. The Director of Financial Aid will review NSLDS to ensure corrections submitted by the Director of Enrollment are being properly recorded. Responsible Individual(s): Eric Schultz, Director of Enrollment and Kayla Bossly, Director of Financial Aid Anticipated Completion Date: Corrections complete by December 31, 2024. New process is ongoing.

View Audit 340969

Finding 521058 (2024-004)

Significant Deficiency 2024

Wagner Community Memorial Hospital

SD

Special Tests & Provisions Questioned Costs Subrecipient Monitoring § 200.303

Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants Federal Financial Assistance Listing #10.766 Compliance Requirement: Special Test and Provisions Finding Summary: The Hospital’s reserve account is fully funded per the requirements in the loan resol...

Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants Federal Financial Assistance Listing #10.766 Compliance Requirement: Special Test and Provisions Finding Summary: The Hospital’s reserve account is fully funded per the requirements in the loan resolution security agreement. However, there is no documented secondary monitoring of the reserve balance as compared to the required minimum reserve balance. Responsible Individuals: Joshua Christensen, CFO Corrective Action Plan: The reserve account balance is monitored at each of the bi-monthly board of directors’ meetings. This review will include the current reserve account balance, the required minimum reserve account balance and a calculation to show the current balance is within compliance. The review and approval by the board of directors will be documented within the board minutes. Anticipated Completion Date: December 2024

View Audit 340965

Finding 521055 (2024-001)

Significant Deficiency 2024

The Russell Child Development Center, Inc.

KS

Cash Management Eligibility Significant Deficiency

2024-001 Eligibility Condition Six providers received an improper amount for their meal reimbursement for the month tested. Recommendation Controls should be reviewed and updated to ensure that reimbursements are only requested for complete and accurate meal counts at the correct rate of reimburse...

2024-001 Eligibility Condition Six providers received an improper amount for their meal reimbursement for the month tested. Recommendation Controls should be reviewed and updated to ensure that reimbursements are only requested for complete and accurate meal counts at the correct rate of reimbursement, and that only eligible participants are submitted to the State for reimbursement. Comments on the Finding Recommendation The CACFP at The Russell Child Development Center, Inc. is aware of the oversight and will continue to strive to improve its review process. Action Taken: As of the date of this notice, CACFP staff will continue to verify that the tally marks from the paper claims match the total provided. Those tally marks are then entered into My Food Program, and the total is again verified to match the paper claim. The Director of the CACFP program is now a third check for the tally marks matching what’s entered into My Food Program, as well as the totals claimed by the provider. Manual claim adjustments will continue to be saved and filed with supporting documentation, if applicable.

View Audit 340951

Finding 520954 (2024-002)

Significant Deficiency 2024

Orion Area Not-for Profit Housing Corporation

MI

HUD Housing Programs Allowable Costs / Cost Principles Eligibility

Corrective Action Plan Orion Area Non-Profit Housing Corporation Project No. 044-11113 Year Ended June 30, 2024 January 31, 2025 FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2024-002 – Eligibility - Tenant Income Threshold Finding Type. Immaterial noncompliance, Significant deficiency in internal...

Corrective Action Plan Orion Area Non-Profit Housing Corporation Project No. 044-11113 Year Ended June 30, 2024 January 31, 2025 FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2024-002 – Eligibility - Tenant Income Threshold Finding Type. Immaterial noncompliance, Significant deficiency in internal controls over compliance (Eligibility) Federal programs U.S. Department of Housing and Urban Development  Section 8 Housing Assistance Payments (ALN# 14.195) Condition. Less than 40% of tenants who moved into the property during the year met the extremely low-income threshold and management did not maintain records of marketing efforts targeted to extremely low-income families, demonstrating that reasonable efforts were made to fill available units accordingly and that such efforts are ongoing. Effect. As a result of this condition, the Project failed to meet the prescribed income targeting requirements and documentation of marketing efforts to reach the target population. Plan. Management agrees with finding 2024-002. Management agrees to target extremely low-income individuals for residence, and to retain marketing records that support this effort. Contact Person Responsible for This Corrective Action: Laura Maisevich, Senior Housing Manager Anticipated completion date: June 30, 2025

View Audit 340845

Finding 520950 (2024-001)

Significant Deficiency 2024

East Detroit Area Non-Profit Housing Corporation

MI

Questioned Costs Allowable Costs / Cost Principles Eligibility

Corrective Action Plan East Detroit Area Non-Profit Housing Corporation Project No. 044-EH221 Year Ended June 30, 2024 January 31, 2025 FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2024-001 – Eligibility - Tenant File Documentation Finding Type. Immaterial noncompliance, Significant deficiency in...

Corrective Action Plan East Detroit Area Non-Profit Housing Corporation Project No. 044-EH221 Year Ended June 30, 2024 January 31, 2025 FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2024-001 – Eligibility - Tenant File Documentation Finding Type. Immaterial noncompliance, Significant deficiency in internal controls over compliance (Eligibility) Federal programs U.S. Department of Housing and Urban Development  Supportive Housing for the Elderly (ALN# 14.157) Condition. Out of a sample of 6 tenant files, it was noted: 1. One out of six instances where an EIV was not run for a tenant file within 90 days of move in; 2. One out of six instances where a refund was not disbursed to a tenant within 60 days of move-out; 3. Two out of six instances where the incorrect checking account balance was used in the verification of tenant assets; Effect. As a result of this condition, employees did not follow HUD guideline procedures, and/or did not properly calculate the tenant subsidy in HUD Form 50059. While there were no significant differences in the amount of subsidies allowed compared to subsidies received, the lack of effective internal controls could lead to future significant noncompliance. Plan. Management agrees with finding 2024-001. All files are to be inspected in the current fiscal year to ensure compliance with HUD regulations. File maintenance will be competed following each move in and annual recertification. In addition to one-on-one training, the housing administrator has signed up for additional training including a WebEx on annual recertification and a basic EIV course. Additional training sessions are forthcoming. Contact Person Responsible for This Corrective Action: Laura Maisevich, Senior Housing Manager Anticipated completion date: 1/31/2025

View Audit 340843

Finding 520948 (2024-002)

Significant Deficiency 2024

Highland Area Non-Profit Housing Corporation

MI

HUD Housing Programs Allowable Costs / Cost Principles Eligibility

Corrective Action Plan Highland Area Non-Profit Housing Corporation Project No. 044-11111 Year Ended June 30, 2024 January 31, 2025 FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2024-002 – Eligibility - Tenant Income Threshold Finding Type. Immaterial noncompliance, Significant deficiency in inter...

Corrective Action Plan Highland Area Non-Profit Housing Corporation Project No. 044-11111 Year Ended June 30, 2024 January 31, 2025 FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2024-002 – Eligibility - Tenant Income Threshold Finding Type. Immaterial noncompliance, Significant deficiency in internal controls over compliance (Eligibility) Federal programs U.S. Department of Housing and Urban Development  Section 8 Housing Assistance Payments (ALN# 14.195) Condition. Less than 40% of tenants who moved into the property during the year met the extremely low-income threshold and management did not maintain records of marketing efforts targeted to extremely low-income families, demonstrating that reasonable efforts were made to fill available units accordingly and that such efforts are ongoing. Effect. As a result of this condition, the Project failed to meet the prescribed income targeting requirements and documentation of marketing efforts to reach the target population. Plan. Management agrees with finding 2024-002. Management agrees to target extremely low-income individuals for residence, and to retain marketing records that support this effort. Contact Person Responsible for This Corrective Action: Laura Maisevich, Senior Housing Manager Anticipated completion date: June 30, 2025

View Audit 340840

Finding 520885 (2024-004)

Significant Deficiency 2024

Good Shepherd Real Estate Holding, LLC D/b/a the Good Shepherd

OH

HUD Housing Programs Reporting Significant Deficiency

Finding Number: 2024-004 Condition: The Corporation failed to make the required reserve for replacements deposits in the current fiscal year. Planned Corrective Action: Corrected Contact person responsible for corrective action: Fikru Nigusse, CFO Anticipated Completion Date: N/A

View Audit 340743

Finding 520834 (2024-007)

Significant Deficiency 2024

Alamance County, North Carolina

NC

Questioned Costs Cash Management Significant Deficiency

Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: Correction for the questioned costs were completed when reporting September 2024’s 1571. Supervisor has reviewed with accounts payable staff the importance of reviewing all aspects of the payable and makin...

Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: Correction for the questioned costs were completed when reporting September 2024’s 1571. Supervisor has reviewed with accounts payable staff the importance of reviewing all aspects of the payable and making sure that information is accurate. Going forward supervisor will send out notification when IRS mileage reimbursement rates change and accounts payable staff will ensure the payable has the correct IRS mileage reimbursement rate listed. Proposed Completion Date: Immediate and ongoing.

View Audit 340657 Questioned Costs: $1

Finding 520786 (2024-002)

Significant Deficiency 2024

Davidson County, North Carolina

NC

Questioned Costs Significant Deficiency

Finding: 2024-002 The County did not perform Strengths + Needs Assessments on four participants for the Work First Family Assistance (TANF) program. All participants were eligible for benefits. Name of Contact Person: Patricia Baker Policy The County is responsible for completing the DSS-5298, Work ...

Finding: 2024-002 The County did not perform Strengths + Needs Assessments on four participants for the Work First Family Assistance (TANF) program. All participants were eligible for benefits. Name of Contact Person: Patricia Baker Policy The County is responsible for completing the DSS-5298, Work First Family Assessment of Strengths and Needs, within six weeks from the date of application, and no less often than once every twelve weeks of the case being open for Employment Services. The DSS-5298 should be reviewed and updated at least every twelve weeks in coordination with the quarterly update to the Mutual Responsibility Agreement/Outcome Plan. Cause Due to inexperienced staff, the Strengths and Needs (DSS-5298) form was not completed accurately and timely for (4) Work First Family Assistance cases. Corrective Action Plan All Work First Family Assistance staff have reviewed the pending and active Work First Family Assistance cases to ensure the Strengths and Needs assessment has been completed. If it was not completed, staff will follow up at the next review/appointment time with the households to ensure compliance. All Work First Family Assistance staff completed classroom training related to Work First Family Assistance policy, including required forms necessary to determine and continue eligibility for assistance. This training was completed between July and October 2024. There is currently (1) full time staff working the Work First Family Assistance caseload. There is (1) vacancy, and (1) additional staff who assists on a limited basis with reviews and child-only cases. Leadership has reviewed the DSS-5298 requirement with applicable staff to ensure their knowledge and understanding of this required form to be present and reviewed with active case participants. Timeframe Policy + remedial training was completed upon discovery of this information being missing in June 2024. Training occurred in person, by the Family Support Services Supervisor, between July and October 2024. Follow Up Training and Quality Assurance staff will continue to monitor Work First Family Assessment cases by completing second party reviews for 25% of case actions completed. This includes applications, reviews, and changes for Work First Family Assistance cases. Second Party Audit scores will be shared directly with staff and Leadership to determine additional training needs, as applicable. Second Party Audit data will be stored in a Shared Folder, and reviewed by Leadership monthly. Proposed Completion Date: With continuous monitoring and implementation of policy and procedural training that was completed in July-October 2024, Davidson County will be in compliance with the Strengths and Needs Assessment requirement for Work First Family Assistance.

View Audit 340576

Finding 520751 (2024-002)

Significant Deficiency 2024

Loogootee Community School Corporation

IN

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.302 § 200.303 § 200.328

The Corporation will have a secondary review process in place to assure the information and timeline are correct before submission.

View Audit 340471

Finding 520729 (2024-003)

Significant Deficiency 2024

Unified School District No. 489

KS

Significant Deficiency Internal Control / Segregation of Duties

2024-003 Federal Award Special Education (IDEA) Cluster – 84.027 and 84.173 Compliance Requirement Maintenance of Effort Condition Certain expenditure amounts reported to the State Department of Education for the Maintenance of Effort calculation were not accurate or could not be corroborated. Recom...

2024-003 Federal Award Special Education (IDEA) Cluster – 84.027 and 84.173 Compliance Requirement Maintenance of Effort Condition Certain expenditure amounts reported to the State Department of Education for the Maintenance of Effort calculation were not accurate or could not be corroborated. Recommendation Procedures should be established and implemented to ensure that all supporting documentation used in the preparation of the Maintenance of Effort submission be saved and that all expenditures reported are accurate. Comments on the Finding Recommendation The district agrees with the finding and noted the difference between records used and the final records for the school year in question. The district is aware of the oversight and will continue to improve the maintenance of effort submission process. Action Taken For the maintenance of effort submission to be completed in January 2025, all amounts will be tied to data within the District’s accounting records updated after end of year adjustments. Any data or information used in the preparation will be marked and saved in a file for documentation purposes.

View Audit 340450

Finding 520657 (2024-001)

Significant Deficiency 2024

Luzerne County Transportation Authority

PA

Significant Deficiency

Since discussed with the Auditors in the previous year, LCTA has taken the necessary steps to ensure Medical Assistant Reports are filed timely as confirmed by the remaining three quarters of FY 23-24 being filed on or before the deadlikne date. LCTA will continue to monitor the requirements assocai...

Since discussed with the Auditors in the previous year, LCTA has taken the necessary steps to ensure Medical Assistant Reports are filed timely as confirmed by the remaining three quarters of FY 23-24 being filed on or before the deadlikne date. LCTA will continue to monitor the requirements assocaited with the Medical Assistance Program and be vigilant in meeting the deadlines.

View Audit 340361

Finding 520635 (2024-004)

Significant Deficiency 2024

Hyde County

NC

Questioned Costs Eligibility Significant Deficiency

Inaccurate Information Entry Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor C...

Inaccurate Information Entry Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: New process changes made 11/2022. Addition of Internal Quality Assurance employee by 1/6/25. Section IV - State Award Findings and Questioned Costs Finding: 2024-002 Inaccurate Resource Calculation In the past (prior to employment of the curent Medicaid Supervisor), staff were improperly trained on using replacement value of property vs. tax value. This is not current practice and values have been changed to tax value on all cases worked/supervised by Medicaid Supervisor. Current Recipient Eligibility Audits show the correct value is being used as there have been no findings. New process changes made 11/2022. Addition of Internal Quality Assurance employee by 1/6/25. Corrective actions for findings 2024-001, 2024-002, 2024-003, 2024-004 also apply to the State Awards findings. Finding: 2024-003 Inadequate Request for information The agency has experienced changes in staffing since the period that the error occured. New procedures have been put in place and training is ongoing. Additional Quality Assurance efforts will continue to ensure staff are sending the correct forms and accurately addressing employment results found in the system. New process changes made 11/2022. Addition of Internal Quality Assurance employee by 1/6/25. No corrective action will be implemented going forward as this policy is no longer required as of August 2023. The error for untimely IV-D (child support) referral was made under old policy. New policy effective August 2023 under Admin Letter 13-23 no longer requires post eligibility referrals to Child Support. Finding: 2024-004 Non-Cooperation With Child Support Procedures Finding: 2024-001 Workers will actively check eligibility for household size and income. An active Second Party process is in place that involves reviewing the eligibility check for accuracy. Since November 2022, the new Medicaid Supervisor has provided training and put quality control in place to help eliminate these type of errors. Further, the Agency is currently reorganizing by placing another employee in place to perform Quality Assurance/Internal Audit duties. The work of that employee will be to mirror all audits and randomly review cases checking for any recurrence of specific previous findings.

View Audit 340308

Finding 520634 (2024-003)

Significant Deficiency 2024

Hyde County

NC

Questioned Costs Eligibility Significant Deficiency

Inaccurate Information Entry Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor C...

Inaccurate Information Entry Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: New process changes made 11/2022. Addition of Internal Quality Assurance employee by 1/6/25. Section IV - State Award Findings and Questioned Costs Finding: 2024-002 Inaccurate Resource Calculation In the past (prior to employment of the curent Medicaid Supervisor), staff were improperly trained on using replacement value of property vs. tax value. This is not current practice and values have been changed to tax value on all cases worked/supervised by Medicaid Supervisor. Current Recipient Eligibility Audits show the correct value is being used as there have been no findings. New process changes made 11/2022. Addition of Internal Quality Assurance employee by 1/6/25. Corrective actions for findings 2024-001, 2024-002, 2024-003, 2024-004 also apply to the State Awards findings. Finding: 2024-003 Inadequate Request for information The agency has experienced changes in staffing since the period that the error occured. New procedures have been put in place and training is ongoing. Additional Quality Assurance efforts will continue to ensure staff are sending the correct forms and accurately addressing employment results found in the system. New process changes made 11/2022. Addition of Internal Quality Assurance employee by 1/6/25. No corrective action will be implemented going forward as this policy is no longer required as of August 2023. The error for untimely IV-D (child support) referral was made under old policy. New policy effective August 2023 under Admin Letter 13-23 no longer requires post eligibility referrals to Child Support. Finding: 2024-004 Non-Cooperation With Child Support Procedures Finding: 2024-001 Workers will actively check eligibility for household size and income. An active Second Party process is in place that involves reviewing the eligibility check for accuracy. Since November 2022, the new Medicaid Supervisor has provided training and put quality control in place to help eliminate these type of errors. Further, the Agency is currently reorganizing by placing another employee in place to perform Quality Assurance/Internal Audit duties. The work of that employee will be to mirror all audits and randomly review cases checking for any recurrence of specific previous findings.

View Audit 340308

Finding 520633 (2024-002)

Significant Deficiency 2024

Hyde County

NC

Questioned Costs Eligibility Significant Deficiency

Inaccurate Information Entry Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor C...

Inaccurate Information Entry Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: New process changes made 11/2022. Addition of Internal Quality Assurance employee by 1/6/25. Section IV - State Award Findings and Questioned Costs Finding: 2024-002 Inaccurate Resource Calculation In the past (prior to employment of the curent Medicaid Supervisor), staff were improperly trained on using replacement value of property vs. tax value. This is not current practice and values have been changed to tax value on all cases worked/supervised by Medicaid Supervisor. Current Recipient Eligibility Audits show the correct value is being used as there have been no findings. New process changes made 11/2022. Addition of Internal Quality Assurance employee by 1/6/25. Corrective actions for findings 2024-001, 2024-002, 2024-003, 2024-004 also apply to the State Awards findings. Finding: 2024-003 Inadequate Request for information The agency has experienced changes in staffing since the period that the error occured. New procedures have been put in place and training is ongoing. Additional Quality Assurance efforts will continue to ensure staff are sending the correct forms and accurately addressing employment results found in the system. New process changes made 11/2022. Addition of Internal Quality Assurance employee by 1/6/25. No corrective action will be implemented going forward as this policy is no longer required as of August 2023. The error for untimely IV-D (child support) referral was made under old policy. New policy effective August 2023 under Admin Letter 13-23 no longer requires post eligibility referrals to Child Support. Finding: 2024-004 Non-Cooperation With Child Support Procedures Finding: 2024-001 Workers will actively check eligibility for household size and income. An active Second Party process is in place that involves reviewing the eligibility check for accuracy. Since November 2022, the new Medicaid Supervisor has provided training and put quality control in place to help eliminate these type of errors. Further, the Agency is currently reorganizing by placing another employee in place to perform Quality Assurance/Internal Audit duties. The work of that employee will be to mirror all audits and randomly review cases checking for any recurrence of specific previous findings.

View Audit 340308

Finding 520632 (2024-001)

Significant Deficiency 2024

Hyde County

NC

Questioned Costs Eligibility Significant Deficiency

Inaccurate Information Entry Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor C...

Inaccurate Information Entry Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: New process changes made 11/2022. Addition of Internal Quality Assurance employee by 1/6/25. Section IV - State Award Findings and Questioned Costs Finding: 2024-002 Inaccurate Resource Calculation In the past (prior to employment of the curent Medicaid Supervisor), staff were improperly trained on using replacement value of property vs. tax value. This is not current practice and values have been changed to tax value on all cases worked/supervised by Medicaid Supervisor. Current Recipient Eligibility Audits show the correct value is being used as there have been no findings. New process changes made 11/2022. Addition of Internal Quality Assurance employee by 1/6/25. Corrective actions for findings 2024-001, 2024-002, 2024-003, 2024-004 also apply to the State Awards findings. Finding: 2024-003 Inadequate Request for information The agency has experienced changes in staffing since the period that the error occured. New procedures have been put in place and training is ongoing. Additional Quality Assurance efforts will continue to ensure staff are sending the correct forms and accurately addressing employment results found in the system. New process changes made 11/2022. Addition of Internal Quality Assurance employee by 1/6/25. No corrective action will be implemented going forward as this policy is no longer required as of August 2023. The error for untimely IV-D (child support) referral was made under old policy. New policy effective August 2023 under Admin Letter 13-23 no longer requires post eligibility referrals to Child Support. Finding: 2024-004 Non-Cooperation With Child Support Procedures Finding: 2024-001 Workers will actively check eligibility for household size and income. An active Second Party process is in place that involves reviewing the eligibility check for accuracy. Since November 2022, the new Medicaid Supervisor has provided training and put quality control in place to help eliminate these type of errors. Further, the Agency is currently reorganizing by placing another employee in place to perform Quality Assurance/Internal Audit duties. The work of that employee will be to mirror all audits and randomly review cases checking for any recurrence of specific previous findings.

View Audit 340308

Finding 520619 (2024-001)

Significant Deficiency 2024

Tolleson Elementary School District No. 17

AZ

Allowable Costs / Cost Principles School Nutrition Programs Questioned Costs

Findings and Questioned Costs Related to Federal Awards Finding Number: 2024‐001 Program Name/Assistance Listing Title: Child Nutrition Cluster Assistance Listing Numbers: 10.553, 10.555, 10.559 Contact Person: Anita Percell, Executive Director of Business Services Anticipated Completion Date: June ...

Findings and Questioned Costs Related to Federal Awards Finding Number: 2024‐001 Program Name/Assistance Listing Title: Child Nutrition Cluster Assistance Listing Numbers: 10.553, 10.555, 10.559 Contact Person: Anita Percell, Executive Director of Business Services Anticipated Completion Date: June 30, 2025 Planned Corrective Action: The District acknowledges the findings regarding the overcharging of indirect costs and is committed to ensuring full compliance with the federal cost principles and guidelines established by USDA and ADE. We will implement strengthened procedures, provide targeted training for relevant staff, and promptly reimburse the questioned costs.

View Audit 340268 Questioned Costs: $1

Finding 520568 (2024-002)

Significant Deficiency 2024

Buncombe County, Nc

NC

Allowable Costs / Cost Principles Reporting Cash Management

2024-002 Significant Deficiency over Activities Allowed and Unallowed and Allowable Costs/Cost Principles The auditors recommend that the County implements a review control over weekly timesheets to ensure the timesheets include all program time coded on the day sheets. NCDHHS policy requires ...

2024-002 Significant Deficiency over Activities Allowed and Unallowed and Allowable Costs/Cost Principles The auditors recommend that the County implements a review control over weekly timesheets to ensure the timesheets include all program time coded on the day sheets. NCDHHS policy requires program salaries to be allocated and supported by payroll and attendance records for individuals. There is no disagreement with this audit finding.The County will develop and deliver day sheet training which will be required for all staff responsible for completing these reports. The County will also conduct random reviews monthly. Any discrepancies identified will be provided to staff leadership for support and correction. The County will implement additional reviews if errors are identified until corrections are made. New reporting will be created to track review findings and will be shared with the Quality and Performance Officer or their designee. Person responsible for correction action: Leigh Anderson, HHS Business Administrator Completion date: 1/31/2025 – Day sheet training 3/1/2025 – Begin review of random of day sheets and timesheets 4/25/2025 – Report tracking of review findings

View Audit 340126

Finding 520312 (2024-003)

Significant Deficiency 2024

Chaffey Community College District

CA

Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

The Financial Aid department will continue to review and update the reporting procedures. The Director of Financial Aid will review the origination and posting of loans with staff and train them to ensure that dates are consistent and in compliance with Title IV regulations.

View Audit 340029

Finding 520305 (2024-002)

Significant Deficiency 2024

Chaffey Community College District

CA

Student Financial Aid Reporting Significant Deficiency

The departments involved in the enrollment reporting process are continuing to review and enhance the workflow in order to report accurately. Monthly submissions by Information Technology Systems (ITS) will be completed in a timely manner to allow for prompt communication of corrections that are req...

The departments involved in the enrollment reporting process are continuing to review and enhance the workflow in order to report accurately. Monthly submissions by Information Technology Systems (ITS) will be completed in a timely manner to allow for prompt communication of corrections that are required, which are communicated to Admissions and Records by the National Student Clearinghouse (NSCH). Admissions and Records will ensure that error reports provided by NSCH are returned to NSCH within 10 business days to allow for a timely submission to the National Student Loan Database (NSLDS). Staff in Admissions and Records has been specifically assigned to complete error reports to contribute to a prompt submission. The Admissions and Records department will collaborate and communicate with the Financial Aid department to identify students with error codes in NSLDS in an effort to correct them. The Admissions and Records and Financial Aid departments will work with the Internal Auditor to perform semiannual reviews of NSLDS data to ensure accuracy of student records.

View Audit 340029

Finding 520298 (2024-001)

Significant Deficiency 2024

Chaffey Community College District

CA

Student Financial Aid Significant Deficiency Internal Control / Segregation of Duties

The District and its Financial Aid department will continue to review and enhance the workflow and procedures of Return to Title IV. The goal of these efforts has been to meet the compliance requirements of Return to Title IV. The District has developed a schedule with specific dates per term for wh...

The District and its Financial Aid department will continue to review and enhance the workflow and procedures of Return to Title IV. The goal of these efforts has been to meet the compliance requirements of Return to Title IV. The District has developed a schedule with specific dates per term for when calculations will be completed, when requests will be made to Accounting to return the District portion of funds within 45 days, and provide ample timelines that can ensure funds get returned within compliance. The District has included the various department areas and staff that are involved in the process to ensure the schedule is consistent and that the funds are returned in the appropriate time frame. The Financial Aid department will continue to meliorate the task of the Return to Title IV calculations. This task is a work function of the Financial Aid Coordinator position. While staff has been trained to perform this function, the District is currently in recruitment to fill the Financial Aid Coordinator position. While the Coordinator will be expected to perform the calculations, they will be submitted to the Director of Financial Aid for review and to ensure accuracy.

View Audit 340029

Finding 520293 (2024-003)

Significant Deficiency 2024

T.a. Lawson State Community College

AL

Allowable Costs / Cost Principles Questioned Costs Significant Deficiency

Management's Response: The College will strengthen its policies and procedures surrounding payroll grant disbursements to ensure expenses are properly approved and allowable under the specific grant budget. Management will ensure that budgets are amended when changes in pay rates occur during the ...

Management's Response: The College will strengthen its policies and procedures surrounding payroll grant disbursements to ensure expenses are properly approved and allowable under the specific grant budget. Management will ensure that budgets are amended when changes in pay rates occur during the grant award periods. Anticipated Completion Date: February 28, 2025

View Audit 340025 Questioned Costs: $1

Finding 520291 (2024-002)

Significant Deficiency 2024

T.a. Lawson State Community College

AL

Allowable Costs / Cost Principles Questioned Costs Cash Management

Management's Response: The College will strengthen its policies and procedures surrounding non-payroll grant disbursements to ensure disbursements are approved, allowable, and calculations supported. Management will review budgets on a monthly basis to ensure expenses do not exceed the budget. M...

Management's Response: The College will strengthen its policies and procedures surrounding non-payroll grant disbursements to ensure disbursements are approved, allowable, and calculations supported. Management will review budgets on a monthly basis to ensure expenses do not exceed the budget. Management will review indirect cost calculations to ensure they are calculated at the correct percentages. Management will review invoices three months past year end to ensure the proper accrual of expenses. Anticipated Completion Date: February 28, 2025

View Audit 340025 Questioned Costs: $1

Finding 520287 (2024-001)

Significant Deficiency 2024

Calvin University

MI

Student Financial Aid Significant Deficiency Matching / Level of Effort / Earmarking

Condition: The University does not have controls in place for review of Return of Title IV calculation. Planned Corrective Action: All R2T4 calculations will be reviewed by a second individual within the Calvin Financial Aid Office. Calculations will not become final until both individuals agree wit...

Condition: The University does not have controls in place for review of Return of Title IV calculation. Planned Corrective Action: All R2T4 calculations will be reviewed by a second individual within the Calvin Financial Aid Office. Calculations will not become final until both individuals agree with the specifics of each calculation. Contact person responsible for corrective action: James Koeman, Director of Financial Aid Anticipated Completion Date: Already completed as of the 24FA term.

View Audit 340021

Finding 520252 (2024-001)

Significant Deficiency 2024

Family Health Services of Erie County

OH

Eligibility Significant Deficiency Program Income

Finding Number: 2024-001 Anticipated Completion Date: January 31, 2025 Responsible Contact Person: David Tatro, CEO Planned Corrective Action: The Organization provided approximately 2,300 self-pay encounters to be audited for the year ended May 31, 2024. 40 encounters were identified for compliance...

Finding Number: 2024-001 Anticipated Completion Date: January 31, 2025 Responsible Contact Person: David Tatro, CEO Planned Corrective Action: The Organization provided approximately 2,300 self-pay encounters to be audited for the year ended May 31, 2024. 40 encounters were identified for compliance testing related to the sliding fee. Three self-pay accounts were identified with issues which resulted in this finding. The issues related to patients receiving an improper discount rate. This issue will be resolved as of January 31, 2025 by reviewing all sliding fee scale applications for accuracy. The Organization will continue to monitor the sliding fee scale amounts applied to ensure ongoing compliance with the requirements. The Organization will review five sliding fee scale applications each week to ensure eligibility determination, billing and collection follows the Sliding Fee Discount Program. This will go through May 2025 with a reassessment at that point, based on the results of the internal review.

View Audit 339892

Corrective Action Plans

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