Corrective Action Plans

Finding 521192 (2024-003)

Significant Deficiency 2024

Western Piedmont Regional Transit Authority

NC

Questioned Costs Procurement, Suspension & Debarment Significant Deficiency

Finding: 2024-003 Name of Contact Person: Scott Cook Corrective Action/Management’s Response: WPRTA will better ensure that proper procurement documentation is maintained. Proposed Completion Date: Immediately and ongoing

View Audit 341148 Questioned Costs: $1

Finding 521186 (2024-002)

Significant Deficiency 2024

Western Piedmont Regional Transit Authority

NC

Reporting Subrecipient Monitoring Significant Deficiency

Name of Contact Person: Scott Cook Corrective Action/Management’s Response: WPRTA will timely submit the Transportation Asset Management (TAM) inventory report. Proposed Completion Date: Immediately and ongoing

View Audit 341148

Finding 521162 (2024-003)

Significant Deficiency 2024

Eastern Wyoming College

WY

Student Financial Aid Allowable Costs / Cost Principles Reporting

Corrective actions: The Financial Aid Office has historically received a copy of the Fund 10 and Fund 13 ledgers from the Business Office and then calculated the tuition and fees, making sure to remove the concurrently enrolled students and inapplicable fees. This calculation was completed without k...

Corrective actions: The Financial Aid Office has historically received a copy of the Fund 10 and Fund 13 ledgers from the Business Office and then calculated the tuition and fees, making sure to remove the concurrently enrolled students and inapplicable fees. This calculation was completed without knowledge that some of the Fund 13 Fees pass through and are already included the Fund 10 details. This resulted in a number of Fund 13 Fees being counted twice. This process has been corrected starting with the 24-25 FISAP. The CFO and Financial Aid Director worked together and the CFO calculated the tuition and fees for Part II Section E of the FISAP. This ensured the correct calculation and eliminated the inclusion of fees that were flowing through the two different GL fund accounts. Anticipated completion date: September 30,2024 Contact person: Rebecca McAllister/Kwin Wilkes

View Audit 341116

Finding 521160 (2024-002)

Significant Deficiency 2024

Eastern Wyoming College

WY

Student Financial Aid Reporting Significant Deficiency

Corrective actions: Eastern Wyoming College currently has a service arrangement with National Student Clearinghouse (NSC) to provide enrollment reporting to the National Student Loan Data System (NSLDS) per the requirements outlined in CFR 690.83 (b)(2), 685.309(b), and per the NSLDS Enrollment Repo...

Corrective actions: Eastern Wyoming College currently has a service arrangement with National Student Clearinghouse (NSC) to provide enrollment reporting to the National Student Loan Data System (NSLDS) per the requirements outlined in CFR 690.83 (b)(2), 685.309(b), and per the NSLDS Enrollment Reporting Guide. These regulations require institutions to report changes in enrollment within a 60-day period. In fulfilling these requirements, EWC's Data Analyst utilizes reports in Colleague to complete the enrollment reporting requirements and submit these reports to NSC. This occurs every thirty days, which exceeding meets the 60-day requirement. EWC's Office of Institutional Research, through the Data Analyst, works with the Registrar and the Financial Aid Office to review and resolve any reporting errors with NSC. Historically, this process worked with minimal errors, but the HCM2 processes posed some unforeseen challenges in the reporting process. To meet these challenges, the Data Analyst sends the student rosters to the NSC. If the students on the SSCR roster are not part of the NSLDS database as a current borrower or recipient of federal student aid, then the Data Analyst must manually upload the information to the NSLDS instead of relying on NSC to initiate the reporting. The Student Financial Aid and Registrar Offices have implemented controls to ensure the proper and timely reporting of student status changes. Upon the implementation of an effective reporting control process, EWC will directly review the student status changes at the NSLDS rather than rely solely on its third-party service provider. For instances where students program length was not reporting correctly, this was resolved at the end of 2022-2023 award year, and the Financial Aid office updated all the Colleague screens used to pull the reports utilized by Institutional Research in submitting the report. EWC has developed and distributed Standard Operating Procedures to ensure the withdrawal dates reported in each office are using the same information. Anticipated completion date: October 2024 Contact person: Rebecca McAllister/Xi Feng

View Audit 341116

Finding 521153 (2024-002)

Significant Deficiency 2024

Isd # 13 Columbia Heights

MN

Procurement, Suspension & Debarment Internal Control / Segregation of Duties School Nutrition Programs

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF AGRICULTURE – PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, CHILD NUTRITION CLUSTER (FEDERAL ALN 10.553, 10.555, AND 10.559) 2024-002 Internal Control Over Compliance With Federal Suspension and Debarment Requireme...

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF AGRICULTURE – PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, CHILD NUTRITION CLUSTER (FEDERAL ALN 10.553, 10.555, AND 10.559) 2024-002 Internal Control Over Compliance With Federal Suspension and Debarment Requirements Finding Summary 2 CFR § 180 requires the District to establish and maintain effective internal control over compliance with requirements applicable to federal program expenditures, including suspension and debarment requirements applicable to the child nutrition cluster. The District did not have sufficient controls in place within its child nutrition cluster to assure that it was not contracting for goods or services with parties that are suspended or debarred, or whose principals are suspended or debarred from participating in contracts involving the expenditures of federal program funds. Actions Planned – The District will review policies and procedures relating to suspension and debarment for its federal programs and will ensure that all parties with which it contracts for goods or services are eligible to participate in contracts involving the expenditures of federal program funding. Official Responsible – Bryan Hennekens, Director of Finance and Operations. Planned Completion Date – June 30, 2025. Disagreement With or Explanation of Finding – The District is in agreement with this finding. Plan to Monitor – Bryan Hennekens, Director of Finance and Operations, will work with the financial auditors to review specific weaknesses identified during the annual audit and actions needed to eliminate or mitigate this internal control weakness.

View Audit 341108

Finding 521061 (2024-002)

Significant Deficiency 2024

Watertown School District No. 14-4

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 Subrecipient Monitoring Significant Deficiency § 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

Allowable Costs / Cost Principles Eligibility HUD Housing Programs

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

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

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

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

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

Eligibility Significant Deficiency Internal Control / Segregation of Duties

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

Questioned Costs Allowable Costs / Cost Principles School Nutrition Programs

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

Corrective Action Plans

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