Corrective Action Plans

Finding 10227 (2023-005)

Significant Deficiency 2023

IA

Allowable Costs / Cost Principles Eligibility Reporting § 200.303

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year - Period 4 TIN#421030129 Federal Financial Assistance Listing #93.498 Compliance Requirement: Acti...

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year - Period 4 TIN#421030129 Federal Financial Assistance Listing #93.498 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles and Reporting Finding Summary: The Hospital did not retain evidence of the review and approval of the expenditure listing and lost revenue calculation by a separate individual outside of the preparer. In addition, the Hospital's special report submitted to the Department of Health and Human Services for Period 4 TIN #421030129 did not have evidence that it was reviewed and approved by a separate individual outside of the preparer. Responsible Individuals: Michael Coyle, CEO Corrective Action Plan: Management agrees with the finding. Controls will be put into place to ensure review and approval by a separate individual outside of the preparer is retained. Anticipated Completion Date: November 30, 2023

View Audit 13879

Finding 10143 (2023-005)

Significant Deficiency 2023

Mater Academy of Nevada

NV

Allowable Costs / Cost Principles School Nutrition Programs Significant Deficiency § 200.303

Finding Number: 2023-005 Approval Of Expense Transactions Corrective Action Plan: A process was put in place in May 2023 to ensure that all principal approvals are documented in writing or electronic approval in the system which can be date stamped by the system. Payroll will not be run, nor grant...

Finding Number: 2023-005 Approval Of Expense Transactions Corrective Action Plan: A process was put in place in May 2023 to ensure that all principal approvals are documented in writing or electronic approval in the system which can be date stamped by the system. Payroll will not be run, nor grants submitted, until proper approval is received. Personnel Responsible for Corrective Action: Nachum Golodner, Academica Director of Accounting Anticipated Completion Date: June 30, 2024

View Audit 13766

Finding 10114 (2023-004)

Significant Deficiency 2023

Mater Academy of Nevada

NV

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Finding Number: 2023-004 and 2022-005 – Review and Approval of the Schedule of Expenditures of Federal Awards (SEFA) Corrective Action Plan: While there was a review of the SEFA, the documentation of said review did not occur properly. Management has put in place a process to document preparation/r...

Finding Number: 2023-004 and 2022-005 – Review and Approval of the Schedule of Expenditures of Federal Awards (SEFA) Corrective Action Plan: While there was a review of the SEFA, the documentation of said review did not occur properly. Management has put in place a process to document preparation/review of the SEFA evidenced by signature and date. Personnel Responsible for Corrective Action: Nachum Golodner, Academica Director of Accounting Anticipated Completion Date: June 30, 2024

View Audit 13766

Finding 10095 (2023-002)

Significant Deficiency 2023

Glen Oaks Community College

MI

Subrecipient Monitoring Eligibility Significant Deficiency

2023-02 – Gramm Leach Bliley Missing Elements. Auditor Description of Conditional and Effect. The most recent written security policy fails to address how the College will evaluate and adjust its information security program for any changes in the College's operations or the results of risk assessme...

2023-02 – Gramm Leach Bliley Missing Elements. Auditor Description of Conditional and Effect. The most recent written security policy fails to address how the College will evaluate and adjust its information security program for any changes in the College's operations or the results of risk assessments. Auditor Recommendation. We recommend that the College implement procedures to ensure that all Gramm Leach Bliley policies are met and confirmed by a second individual. Corrective Action. GOCC will require all procedures and policies are updated and reviewed on an annual basis to make sure we are incompliance with the requirements. Responsible Party. Chief Financial Officer/Controller and IT Director. Anticipated Completion Date. June 30, 2024.

View Audit 13719

Finding 10091 (2023-001)

Significant Deficiency 2023

Glen Oaks Community College

MI

Eligibility Significant Deficiency Internal Control / Segregation of Duties

2023-001 – Satisfactory Academic Progress. Auditor Description of Conditional and Effect. One student out of the 40 tested received federal aid, but did not meet the criteria for satisfactory academic progress, but did not receive a warning. The College's SAP policy published on its website is not b...

2023-001 – Satisfactory Academic Progress. Auditor Description of Conditional and Effect. One student out of the 40 tested received federal aid, but did not meet the criteria for satisfactory academic progress, but did not receive a warning. The College's SAP policy published on its website is not based on how the College determines whether students meet the College's SAP requirements. Auditor Recommendation. We recommend the College implement stronger procedures around awarding federal aid to ensure that students receive a warning letter from the College when they didn't meet SAP. We recommend that the College correct its SAP policy to match how they are currently evaluating whether students meet the requirements to continue receiving financial aid. Corrective Action. The school has edited the SAP policy on the College's website. The school will implement additional controls to address the failure to notify a student after they fail to meet the College's SAP policy. Responsible Party. Director of Financial Aid. Anticipated Completion Date. August 8, 2023

View Audit 13719

Finding 10062 (2023-001)

Significant Deficiency 2023

Luzerne County Transportation Authority

PA

Reporting Eligibility Significant Deficiency

The Authority did not file the first three quarterly Medical Assistance reports before the due date however funding was not affected. The Authority is aware of the requirements associated with Medical Assistance Program reporting and the required deadlines. Adjustments in the process have been made ...

The Authority did not file the first three quarterly Medical Assistance reports before the due date however funding was not affected. The Authority is aware of the requirements associated with Medical Assistance Program reporting and the required deadlines. Adjustments in the process have been made and emphasis will be placed on timely reporting. Management believes that the current process in place for reporting is appropriate and is actively monitoring approaching deadlines.

View Audit 13692

Finding 10059 (2023-001)

Significant Deficiency 2023

Lifespring, Inc.

IN

Special Tests & Provisions Significant Deficiency Internal Control / Segregation of Duties

Management concurs with audit finding. The Center is developing procedures and policies surrounding review of sliding fee discounts are reviewed and revised in order to strengthen internal controls to help ensure calculations and applications are done correctly.

View Audit 13682

Finding 9996 (2023-002)

Significant Deficiency 2023

Cumberland County Board of Education

NC

Subrecipient Monitoring Cash Management Reporting

Name of Contact Person: Jay Toland, Associate Superintendent of Business Operations The finding resulted from significant turnover within the Finance Department. Management has established procedures to ensure that all bank account and other required reconciliations are prepared on a timely basis go...

Name of Contact Person: Jay Toland, Associate Superintendent of Business Operations The finding resulted from significant turnover within the Finance Department. Management has established procedures to ensure that all bank account and other required reconciliations are prepared on a timely basis going forward. The Finance department will also strive to keep key positions filled at all times and ensure that staff receives appropriate training regarding reconciliations. Proposed Completion Date: Immediately

View Audit 13648

Finding 9987 (2023-002)

Significant Deficiency 2023

Rannie Webster Foundation

NH

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

Silverstone Living (SL) recognized several operational opportunities for the sustainability of the Foundation, which is the reason why the affiliation occurred. These opportunities were three-fold: increasing census to fill beds which have been unoccupied for some time, maximizing the reimbursemen...

Silverstone Living (SL) recognized several operational opportunities for the sustainability of the Foundation, which is the reason why the affiliation occurred. These opportunities were three-fold: increasing census to fill beds which have been unoccupied for some time, maximizing the reimbursement for services already being provided, and the control and reduction of expenses. In the short amount of time since the affiliation with SL, the average daily census has increased over the prior 3-year period by nearly 7% for Assisted Living services, and nearly 9% for skilled and nursing services. This equates to over $1,000,000 in additional annual revenues because of the census increase alone. SL believes that there is potential to further increase census as we continue to stabilize and onboard additional clinical staffing. SL recently brought on an individual skilled in coding maximization to ensure the Foundation receives the appropriate reimbursement for the services being provided which was previously lacking. On the expense side, SL renegotiated rates with staffing agencies for clinical positions as well as the contracted rehabilitation services to reduce the amounts being charged which has resulted in nearly $40,000 per month in savings from the earlier part of the calendar year. SL also brought the Foundation under its umbrella in the areas of employee benefits and facility insurance, negating any premium increases and a reduction of over $50,000 in Workers Compensation insurance premiums in the coming year. Through attrition, SL also worked to restructure and eliminate several non-clinical positions for operational efficiency and will continue to review staffing needs as turnover occurs. SL is continuing to transition administrative functions such as payroll and accounting onto its systems, further reducing outside contracted services and systems over the coming months. Through this multi-pronged approach, we are seeing dramatic improvements in the financial outlook of the Foundation. During the 3-month fiscal period beginning 2024 compared to the same period in 2023, there has been a $670,000 improvement in income from operations, which we believe will trend throughout the remainder of the new fiscal year, and into the future.

View Audit 13626

Finding 9986 (2023-001)

Significant Deficiency 2023

Rannie Webster Foundation

NH

Internal Control / Segregation of Duties Cash Management HUD Housing Programs

Action taken in response to finding: A clerical support position was recently hired at the end of November, 2023 who will be responsible for handling all receipts and processing of deposits via remote deposit, which was also recently implemented so deposits can be done daily. This will segregate th...

Action taken in response to finding: A clerical support position was recently hired at the end of November, 2023 who will be responsible for handling all receipts and processing of deposits via remote deposit, which was also recently implemented so deposits can be done daily. This will segregate the cash handling from the recording of receipts once he is fully trained on the system. Bank reconciliation reviews will be completed monthly.

View Audit 13626

Finding 9981 (2023-001)

Significant Deficiency 2023

Harford Community College

MD

Student Financial Aid Matching / Level of Effort / Earmarking Reporting § 200.303

U.S. Department of Education 2023-001: Special Tests and Provisions - National Student Loan Data System (NSLDS) Reporting Condition: Student’s change in enrollment status was not properly reported to National Student Loan Data System (NSLDS). Recommendation: We recommend the College review its repor...

U.S. Department of Education 2023-001: Special Tests and Provisions - National Student Loan Data System (NSLDS) Reporting Condition: Student’s change in enrollment status was not properly reported to National Student Loan Data System (NSLDS). Recommendation: We recommend the College review its reporting procedures to ensure that students’ statuses and enrollment information are correctly and timely reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College worked with the National Student Clearinghouse (NSC) to correct and update the students’ statuses to graduation. Per the recommendation of the NSC Audit Resource Division, the College will now add an additional graduate only file to the enrollment verify file and submit the degree verify file after the enrollment graduate file had been submitted. After these reports are run any students who are still being put on the graduate not applied list will be manually updated by the Registrar Office. Name of the contact person responsible for corrective action: Courtney Mitchell, Registrar Planned completion date for corrective action plan: November 30, 2023

View Audit 13614

Finding 9921 (2023-002)

Significant Deficiency 2023

Florida Southern College

FL

Student Financial Aid Reporting Significant Deficiency

Enrollment Reporting Recommendation: We recommend that the College review and implement procedures to ensure the correct date and status is reported to the NSLDS in all cases. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response...

Enrollment Reporting Recommendation: We recommend that the College review and implement procedures to ensure the correct date and status is reported to the NSLDS in all cases. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: For the two students who were dual degree, manual entry errors were the cause and were corrected. The College will implement a process in September 2023 where a second reviewer from Institutional Research will review the manual entry for student status changes to ensure that the correct dates are reported to NSDLS. For the third student, the timing of the notification of withdrawal, which had to be processed retroactively, and when the certification file was sent to NSDLS caused the student to be left out of the certification file. The College has added additional College officials (in Institutional Research) to the daily and monthly withdrawal lists so students who are processed retroactively will not be missed. Name(s) of the contact person(s) responsible for corrective action: Lindsay Thibodaux Planned completion date for corrective action plan: September 2023

View Audit 13554

Finding 9919 (2023-001)

Significant Deficiency 2023

Florida Southern College

FL

Questioned Costs Student Financial Aid Significant Deficiency

2023-001 Return to Title IV Recommendation: We recommend that the College review and implement procedures to ensure that withdrawals are properly communicated to all departments and processed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. ...

2023-001 Return to Title IV Recommendation: We recommend that the College review and implement procedures to ensure that withdrawals are properly communicated to all departments and processed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College will implement a plan to require faculty to update the last date of attendance at the end of the term in the portal for students attending distance learning classes. This date will be used by the Registrar’s Office and Financial Aid Office for reporting. Name(s) of the contact person(s) responsible for corrective action: Dr. Tracy Tedder Planned completion date for corrective action plan: August 2023

View Audit 13554 Questioned Costs: $1

Finding 9914 (2023-008)

Significant Deficiency 2023

Edgecombe County

NC

Eligibility Reporting Significant Deficiency

Finding: 2023-008 Untimely Review of SSI Termination Section III - Federal Award Findings and Question Costs (continued) Corrective Action: MA-1000 SSI Medicaid Automated Process Section VII - SSI Terminations training will be conducted with all workers. SSI termination reports will be monitored to ...

Finding: 2023-008 Untimely Review of SSI Termination Section III - Federal Award Findings and Question Costs (continued) Corrective Action: MA-1000 SSI Medicaid Automated Process Section VII - SSI Terminations training will be conducted with all workers. SSI termination reports will be monitored to ensure that there is not an untimely review of terminated SSI recipients. Documentation templete will be used to ensure that all online verifications have been completed and the evidence matches the information in NCFAST. Medicaid Supervisors and Quality Control workers will review files internally to ensure that OVS is ran and AB is evaluated for all Medicaid programs when SSI is terminated. Name of contact person: Veronica Lyons, Tina Radford, Virginia Ewuell, & Angel Joyner - Medicaid Supervisors Corrective actions for finding 2023-004, 2023-005, 2023-006, 2023-007, 2023-008 also apply to the State Award findings. Edgecombe County, NC Section IV - State Award Findings and Question Costs Corrective Action: MA-2261 1/3 Reduction, MA-2280 CAP, and MA-2230 Financial Resources training completed with all workers. Caseworkers will be instructed to end date evidence and start a new evidence for the new receritification period to show the updated information. Caseworkers will be instructed to run OVS/AVS prior to working any evidence in the case. Documentation template will serve as a reminder to ensure online verifications are ran on each case. Medicaid Supervisors and Quality Control workers will review files internally to ensure policy is applied to all cases and online verifications are completed and documented. Proposed Completion Date: Training and implementation of additional reviews and procedures will be implemented by February 15, 2024. Proposed Completion Date: Training and implementation of additional reviews and procedures will be implemented by February 15, 2024.

View Audit 13548

Finding 9913 (2023-007)

Significant Deficiency 2023

Edgecombe County

NC

Eligibility Significant Deficiency

Finding: 2023-007 Inadequate Request for Information Finding: 2023-008 Untimely Review of SSI Termination Section III - Federal Award Findings and Question Costs (continued) Corrective Action: MA-1000 SSI Medicaid Automated Process Section VII - SSI Terminations training will be conducted with all w...

Finding: 2023-007 Inadequate Request for Information Finding: 2023-008 Untimely Review of SSI Termination Section III - Federal Award Findings and Question Costs (continued) Corrective Action: MA-1000 SSI Medicaid Automated Process Section VII - SSI Terminations training will be conducted with all workers. SSI termination reports will be monitored to ensure that there is not an untimely review of terminated SSI recipients. Documentation templete will be used to ensure that all online verifications have been completed and the evidence matches the information in NCFAST. Medicaid Supervisors and Quality Control workers will review files internally to ensure that OVS is ran and AB is evaluated for all Medicaid programs when SSI is terminated. Name of contact person: Veronica Lyons, Tina Radford, Virginia Ewuell, & Angel Joyner - Medicaid Supervisors Corrective actions for finding 2023-004, 2023-005, 2023-006, 2023-007, 2023-008 also apply to the State Award findings. Edgecombe County, NC Section IV - State Award Findings and Question Costs Corrective Action: MA-2261 1/3 Reduction, MA-2280 CAP, and MA-2230 Financial Resources training completed with all workers. Caseworkers will be instructed to end date evidence and start a new evidence for the new receritification period to show the updated information. Caseworkers will be instructed to run OVS/AVS prior to working any evidence in the case. Documentation template will serve as a reminder to ensure online verifications are ran on each case. Medicaid Supervisors and Quality Control workers will review files internally to ensure policy is applied to all cases and online verifications are completed and documented. Proposed Completion Date: Training and implementation of additional reviews and procedures will be implemented by February 15, 2024.

View Audit 13548

Finding 9912 (2023-006)

Significant Deficiency 2023

Edgecombe County

NC

Eligibility Significant Deficiency

Finding: 2023-006 Inaccurate Resource Calculation Edgecombe County, NC Section III - Federal Award Findings and Question Costs Name of contact person: Veronica Lyons, Tina Radford, Virginia Ewuell, & Angel Joyner/Medicaid Supervisors Corrective Action: The errors that were found were under the polic...

Finding: 2023-006 Inaccurate Resource Calculation Edgecombe County, NC Section III - Federal Award Findings and Question Costs Name of contact person: Veronica Lyons, Tina Radford, Virginia Ewuell, & Angel Joyner/Medicaid Supervisors Corrective Action: The errors that were found were under the policy of having to comply with Child Support. As of August 18, 2023, this policy is no longer in effect while we are under the CCU (Continuous Coverage Unwinding). Medicaid Supervisors will continue to abide by the policy changes as they come into effect to reconvene the compliance with Child Support. Proposed Completion Date: Not applicable. Name of contact person: Virginia Ewuell & Angel Joyner - Medicaid Supervisors Name of contact person: Veronica Lyons, Tina Radford, Virginia Ewuell, & Angel Joyner - Medicaid Supervisors Proposed Completion Date: Training and implementation of additional reviews and procedures will be implemented by February 15, 2024. Corrective Action: MA-2230 Financials Resources training will be conducted with all workers. Documentation template will be updated to cover all of the possible resources for workers to check for when completing applications and reviews. Caseworkers will be instructed to end date evidence and start a new evidence for the new review period to show the updated information. Medicaid Supervisors and the Quality Control workers will review files internally to ensure verifications received from AB matches information in NCFAST and changes are applied. Proposed Completion Date: Training and implementation of additional reviews and procedures will be implemented by February 15, 2024.

View Audit 13548

Finding 9911 (2023-005)

Significant Deficiency 2023

Edgecombe County

NC

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Finding: 2023-005 Inaccurate Information Entry Finding: 2023-006 Inaccurate Resource Calculation Edgecombe County, NC Section III - Federal Award Findings and Question Costs Name of contact person: Veronica Lyons, Tina Radford, Virginia Ewuell, & Angel Joyner/Medicaid Supervisors Corrective Action: ...

Finding: 2023-005 Inaccurate Information Entry Finding: 2023-006 Inaccurate Resource Calculation Edgecombe County, NC Section III - Federal Award Findings and Question Costs Name of contact person: Veronica Lyons, Tina Radford, Virginia Ewuell, & Angel Joyner/Medicaid Supervisors Corrective Action: The errors that were found were under the policy of having to comply with Child Support. As of August 18, 2023, this policy is no longer in effect while we are under the CCU (Continuous Coverage Unwinding). Medicaid Supervisors will continue to abide by the policy changes as they come into effect to reconvene the compliance with Child Support. Proposed Completion Date: Not applicable. Name of contact person: Virginia Ewuell & Angel Joyner - Medicaid Supervisors Name of contact person: Veronica Lyons, Tina Radford, Virginia Ewuell, & Angel Joyner - Medicaid Supervisors Proposed Completion Date: Training and implementation of additional reviews and procedures will be implemented by February 15, 2024. Corrective Action: MA-2230 Financials Resources training will be conducted with all workers. Documentation template will be updated to cover all of the possible resources for workers to check for when completing applications and reviews. Caseworkers will be instructed to end date evidence and start a new evidence for the new review period to show the updated information. Medicaid Supervisors and the Quality Control workers will review files internally to ensure verifications received from AB matches information in NCFAST and changes are applied. Proposed Completion Date: Training and implementation of additional reviews and procedures will be implemented by February 15, 2024. Corrective Action: MA-3300 Income training will be conducted with all workers. Documentation template updated to include running TWN, OVS, AVS and double checking to ensure that all household members are included. Them template will also ensure that evidence is updated and changes are applied. Workers will also use the automated budget to ensure that information matches the determination in NCFAST. Medicaid Supervisors and Quality Control workers will review files internally to ensure verifications match the evidence put in NCFAST and changes are applied to the cases and case evidence includes all household members.

View Audit 13548

Finding 9910 (2023-004)

Significant Deficiency 2023

Edgecombe County

NC

Eligibility Significant Deficiency

Finding: 2023-004 IV-D Non-Cooperation Finding: 2023-005 Inaccurate Information Entry Finding: 2023-006 Inaccurate Resource Calculation Edgecombe County, NC Section III - Federal Award Findings and Question Costs Name of contact person: Veronica Lyons, Tina Radford, Virginia Ewuell, & Angel Joyner/M...

Finding: 2023-004 IV-D Non-Cooperation Finding: 2023-005 Inaccurate Information Entry Finding: 2023-006 Inaccurate Resource Calculation Edgecombe County, NC Section III - Federal Award Findings and Question Costs Name of contact person: Veronica Lyons, Tina Radford, Virginia Ewuell, & Angel Joyner/Medicaid Supervisors Corrective Action: The errors that were found were under the policy of having to comply with Child Support. As of August 18, 2023, this policy is no longer in effect while we are under the CCU (Continuous Coverage Unwinding). Medicaid Supervisors will continue to abide by the policy changes as they come into effect to reconvene the compliance with Child Support. Proposed Completion Date: Not applicable.

View Audit 13548

Finding 9715 (2023-002)

Significant Deficiency 2023

The Corporation of Haverford College

PA

Questioned Costs Student Financial Aid Significant Deficiency

2023-002 – Federal Work Study (FWS) Over Award – Federal Assistance Listing No. 84.033 Recommendation: We recommend the College review its policies and procedures when packaging students for FWS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Actio...

2023-002 – Federal Work Study (FWS) Over Award – Federal Assistance Listing No. 84.033 Recommendation: We recommend the College review its policies and procedures when packaging students for FWS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the finding: The Financial Aid Office acknowledges that three students on the preliminary list of Title IV recipients provided to the auditors reflected an over-award based on the inclusion of FWS funds in their packages. All students are initially packaged through automated packaging, with the College’s software preventing over-awards. However, many awards are adjusted during the course of an academic year, and when this happens, the software’s checks no longer operate. To ensure compliance, the Financial Aid Office conducts ongoing audits throughout the year and a final audit at the end of each year, which also incorporates a final reconciliation of the FWS program. This year, the FWS/final audit was not completed before the preliminary list was submitted to the auditors. Had the audit been completed on time, the three students would not have shown as over-awards, nor would they be counted as FWS recipients. Corrective Action Plan The Financial Aid Office already audits financial aid packages to prevent over-awards. The office will ensure that such audits are completed in a timelier fashion, resulting in a proper final list of Title IV recipients to be submitted for audit review. Name(s) of the contact person(s) responsible for corrective action: Michael Colahan, Student Financial Aid Director Planned completion date for corrective action plan: Effective November 2023

View Audit 13479 Questioned Costs: $1

Finding 9710 (2023-001)

Significant Deficiency 2023

The Corporation of Haverford College

PA

Reporting Student Financial Aid Significant Deficiency

U.S. Department of Education 2023-001 - National Student Loan Data Systems (NSLDS) Enrollment Reporting – Federal Assistance Listing No. 84.007, 84.033, 84.038, 84.063, 84.268 Recommendation: We recommend the College review its policies and procedures on reporting of enrollment status changes to NS...

U.S. Department of Education 2023-001 - National Student Loan Data Systems (NSLDS) Enrollment Reporting – Federal Assistance Listing No. 84.007, 84.033, 84.038, 84.063, 84.268 Recommendation: We recommend the College review its policies and procedures on reporting of enrollment status changes to NSLDS to ensure that all status changes are being reported accurately to be in compliance with regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: These findings result from programming used to pull data files to be submitted to NSLDS via a third-party NSC (National Student Clearinghouse) and issues with the timing of reported data being sent to NSLDS from NSC. In the short term, the Registrar’s Office will review the accuracy of the programming behind the data files generated and submitted to the NSLDS via the NSC and will manually review students with program changes for accuracy. In the longer term, the Registrar’s Office will assess its current method for reporting accurate enrollment and enrollment status changes via a third-party NSC vs. the possibility of submitting to the NSLDS directly. That work may require partnership with external consultants. Name(s) of the contact person(s) responsible for corrective action: James Keane, Registrar Planned completion date for corrective action plan: Effective January 2024.

View Audit 13479

Finding 9669 (2023-002)

Significant Deficiency 2023

Volunteers of America Colorado Branch

CO

Subrecipient Monitoring HUD Housing Programs Significant Deficiency

Finding Number: 2023-002 Condition: In a monitoring visit performed by U.S. Department of Housing and Urban Development (HUD), the grantor found that the supporting documentation submitted does not enable a third-party reviewer to make a clear determination that match requirements were met. Planned ...

Finding Number: 2023-002 Condition: In a monitoring visit performed by U.S. Department of Housing and Urban Development (HUD), the grantor found that the supporting documentation submitted does not enable a third-party reviewer to make a clear determination that match requirements were met. Planned Corrective Action: The Organization established a policy and procedure to calculate the match requirement, compare it with the required total, and proactively identify actions to address any shortages at the end of each month. The Organization also ensured that all matches were supported by documents in a format that third parties could verify. Contact person responsible for corrective action: Chiyoko Yokota, Chief Financial Officer & Angel Hurtado, VP of Programs Anticipated Completion Date: 1/31/2023

View Audit 13410

Finding 9667 (2023-001)

Significant Deficiency 2023

Volunteers of America Colorado Branch

CO

Subrecipient Monitoring Eligibility HUD Housing Programs

Finding Number: 2023-001 Condition: In a monitoring visit performed by HUD, the grantor found that rent reasonableness determination was not completed on five of the six files reviewed. In our testing we found that six of ten participants we tested did not have a rent reasonableness determination da...

Finding Number: 2023-001 Condition: In a monitoring visit performed by HUD, the grantor found that rent reasonableness determination was not completed on five of the six files reviewed. In our testing we found that six of ten participants we tested did not have a rent reasonableness determination dated prior to the grant funds being expended Planned Corrective Action: The Organization revised the program policy to compare the rent reasonableness of at least three similar units using the Rent Reasonableness Comparison worksheet before any lease-up and document the test with evidence that is reviewed and verified with a supervisor signature prior to execution of the lease. The Organization will repeat this process annually as long as the participant remains in the same unit. The Organization also hired an extra full-time program quality control staff to monitor the compliance with the procedures. Moreover, The Organization will have an internal audit by the finance department at the halfway point of the grant year. Contact person responsible for corrective action: Chiyoko Yokota, Chief Financial Officer & Angel Hurtado, VP of Programs Anticipated Completion Date: 1/31/2023

View Audit 13410

Finding 9636 (2023-003)

Significant Deficiency 2023

Detroit Housing Commission

MI

HUD Housing Programs Eligibility Subrecipient Monitoring

Finding Number: 2023-003 Condition: Participant files selected for testing did not include complete information to support the participant's income to determine the level of benefits provided. Planned Corrective Action: The Housing Choice Voucher Program will work towards and maintain program compli...

Finding Number: 2023-003 Condition: Participant files selected for testing did not include complete information to support the participant's income to determine the level of benefits provided. Planned Corrective Action: The Housing Choice Voucher Program will work towards and maintain program compliance to ensure we are meeting all regulatory requirements. We will do this through staff hiring and restructuring. Ongoing in- house as well as Industry training to stay current and skilled on all program rules and updates as it pertains to the HCV Program with monthly and weekly reporting and monitoring. DHC understands the challenges outlined above and we have implemented measures to improve, redefine, address, and resolve all items according to HUD best practices. We will continue our ongoing efforts and have measurable goals with set dates and timelines. That will show marked improvement over the next 6-12 months in the following areas.  Reduction of Annual recertifications.  Increased utilization.  Increased PBV potential/new RFP.  PIC error corrective actions.  Increased landlord outreach/landlord Fairs.  Customer Service improvement/Call Center Staffing.  Continued industry training for all HCV Housing Specialist.  HCV Department RFP contract proposal. Contact person responsible for corrective action: Felicia Burris, HCV Interim Director. Anticipated Completion Date: 06/30/2024

View Audit 13310

Finding 9632 (2023-002)

Significant Deficiency 2023

Higley Unified School District No. 60

AZ

Special Tests & Provisions Significant Deficiency

Finding Number: 2023‐002 Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U, 84.425W Contact Person: Tyler Moore, Chief Financial Officer Anticipated Completion Date: June 30, 2024 Planned Corrective Action: Higley Unified School District ...

Finding Number: 2023‐002 Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U, 84.425W Contact Person: Tyler Moore, Chief Financial Officer Anticipated Completion Date: June 30, 2024 Planned Corrective Action: Higley Unified School District No. 60 has done the following:  Applicable finance staff have been trained on the additional rules and regulations regarding federal funding related to labor and Davis Bacon prevailing wages.  Purchasing Manager reviews quote/contract specifically looking for the Davis Bacon requirement.  Vendors that provide labor as part of their procurement will not be moved to a federal fund after the start of the project.

View Audit 13309

Finding 9574 (2023-001)

Material Weakness 2023

North Big Horn Hospital District

WY

Material Weakness Reporting Significant Deficiency

Corrective action planned: When HRSA opens the portal again the numbers will be updated to estimates using the Allowance reserve percentages. If the portal does not open again the facility will calculate net patient revenues, using estimates, in a separate file to be sent to HRSA upon request. Ant...

Corrective action planned: When HRSA opens the portal again the numbers will be updated to estimates using the Allowance reserve percentages. If the portal does not open again the facility will calculate net patient revenues, using estimates, in a separate file to be sent to HRSA upon request. Anticipated completion date: Upon request. Contact person responsible for corrective action: Darcy Robertson, CFO

View Audit 13228

Corrective Action Plans

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