Corrective Action Plans

Finding 514055 (2024-001)

Material Weakness 2024

FL

HUD Housing Programs Eligibility Material Weakness

2024-001 Eligibility – Tenant Files Section 8 Housing Choice Vouchers Program – CFDA Number 14.871 Mainstream – Vouchers CFDA Number 14.879 Material Weakness in Internal Control and Material Noncompliance This is a repeat finding (the prior year finding was a significant deficiency) of 2023-002 from...

2024-001 Eligibility – Tenant Files Section 8 Housing Choice Vouchers Program – CFDA Number 14.871 Mainstream – Vouchers CFDA Number 14.879 Material Weakness in Internal Control and Material Noncompliance This is a repeat finding (the prior year finding was a significant deficiency) of 2023-002 from March 31, 2023 (initially occurred as Finding 2021-003, Significant Deficiency) Condition: Out of a total tenant population of approximately 1,775 tenants, 25 files were selected for testing. Exceptions were noted as follows: • 1 tenant file had the following errors: o Miscalculation of social security income reported on the form 50058 (used a prior year SSI instead of the current year). Correcting this error would decrease the HAP rent from $1,610 to $1,567. o One missing 214-affidavit form for a member of the household. However, based on the birth certificate, the member of the household is a U.S. citizen. • 1 tenant file had the following errors: o Two members of the household did not check the checkbox on the 214-affidavit form indicating their immigration status. However, based on the birth certificates, the two household members are U.S. citizens. o The 9886 form was not dated. Thus, we do not know if the 9886 form was signed within 15 month required timeframe. • 1 tenant file had the following errors: o Missing 214-affidavit form for a member of the household. However, based on the birth certificate, the member of the household is a U.S. citizen. o The tenant did not sign and date the Form 9886. • 1 tenant file had the following errors and correcting the errors would increase the HAP rent from $1,130 to $1,159: o Miscalculation of social security income reported on the 50058. o Miscalculation of medical expense reported on the 50058. • 1 tenant file error where a member of the household over the age of 18 did not sign the Form 9886. • 1 tenant file error where social security income was calculated incorrectly. Correcting the income would decrease the HAP rent from $1,155 to $1,153. • 1 tenant file error where a member of the household over the age of 18 did not sign the 9886. • 1 tenant file error where the tenant dated the year on the 9886 form 2013 when it should be 2023. • 1 tenant file error where a member of the household over 18 years old did not sign Form 9886. • 1 tenant file error where the tenant’s wage income was miscalculated. However, correcting the error would have no effect on the HAP rent amount. • 1 tenant file error where there was no EIV form for the recertification period. • 1 tenant file error where tenant wage income was calculated incorrectly. Correcting these income issues would decrease the HAP rent from $1,207 to $896. • 1 tenant file had the following errors and correcting the errors would decrease the HAP rent from $1,378 to $1,030: o An incorrect utility allowance was reported on the Form 50058. o Income support was not reported correctly on the Form 50058. • 1 tenant file had the following errors: o A member of the household did not check the checkbox on the 214-affidavit form indicating their immigration status. However, based on the birth certificate, the household member is a U.S. citizen. o Support for tenant’s pension income was over 12 months old. • 1 tenant file error where child support income was calculated incorrectly. However, correcting the error would have no effect on the HAP rent amount. Recommendation: The Authority should correct the deficiencies noted in the tested files and utilize an ongoing quality control review process on the entire tenant population to ensure proper compliance with the requirements related to tenant eligibility. Ongoing staff training and timely management reviews should be utilized to ensure staff is aware of acceptable procedures. In addition, the Authority should review staffing levels, skill sets and case load. Action Taken: We concur with the recommendation. Due to the COVID-19 pandemic and related staff absences and turnover, we were unable to provide an ongoing quality control review processes and provide ongoing staff training and timely management reviews. We are focused on implementing such procedures and will review staffing levels, skill sets, and case load for each employee.1 tenant file error where the Form 50058 reported an incorrect utility allowance, but correcting the allowance would not change the HAP rent amount.

View Audit 332251

Finding 514042 (2024-002)

Significant Deficiency 2024

City of Greenville

SC

HUD Housing Programs Reporting Internal Control / Segregation of Duties

CONTACT PERSON: James Kennedy, Comptroller, jkennedy@greenvillesc.gov CORRECTIVE ACTION: The Office of Management and Budget has established regular meetings with Community Development departments to ensure collaboration and provide quick resolution of any reporting issues. Office of Management and...

CONTACT PERSON: James Kennedy, Comptroller, jkennedy@greenvillesc.gov CORRECTIVE ACTION: The Office of Management and Budget has established regular meetings with Community Development departments to ensure collaboration and provide quick resolution of any reporting issues. Office of Management and Budget will increase oversight by instituting a mandatory review and approval process for each financial report. This process will ensure that all financial reports are reconciled to supporting documentation and prior submissions before being finalized. PROPOSED COMPLETION DATE: Prior to December 31, 2024.

View Audit 332240

Finding 514041 (2024-001)

Significant Deficiency 2024

Alabama Hospital Association

AL

Reporting Internal Control / Segregation of Duties § 200.302 § 200.303

Corrective Action Plan: AlaHA will accomplish the following: 1) Send guidance to hospital systems with multiple facilities reported on their 941s that they should retain general ledger detail reconciliations to support the funds received. 2) Request the hospital involved in the exception cited fo...

Corrective Action Plan: AlaHA will accomplish the following: 1) Send guidance to hospital systems with multiple facilities reported on their 941s that they should retain general ledger detail reconciliations to support the funds received. 2) Request the hospital involved in the exception cited for not having submitted general ledger evidence submit additional support for the reconciliation they submitted. 3) Should a similar tranche of funds become available in the future, AlaHA will ensure disbursements are not made before receipt of general ledger evidence to support the amount reported by the hospital. Target Date: For items 1 & 2 in the corrective action plan, November 6, 2023.

View Audit 332229

Finding 514040 (2024-001)

Significant Deficiency 2024

Alabama Housing Finance Authority

AL

Eligibility Matching / Level of Effort / Earmarking

Finding 2024-001 Eligibility Management agrees with the summarized findings. Management has reviewed the current policies and procedures to ensure that the steps to be performed are clearly stated for the underwriting and disbursement staff. Management has discussed the findings with staff members a...

Finding 2024-001 Eligibility Management agrees with the summarized findings. Management has reviewed the current policies and procedures to ensure that the steps to be performed are clearly stated for the underwriting and disbursement staff. Management has discussed the findings with staff members and will provide additional training as deemed necessary.

View Audit 332226

Finding 514014 (2024-001)

Significant Deficiency 2024

City of Sault Ste. Marie

MI

Procurement, Suspension & Debarment § 200.214

M anagements Response/Corrective Action Plan: The City of Sault Ste. Marie has instituted the following measures to remedy this deficiency to be implemented immediately. 1. Management learned of this deficiency in response to a request for documentation of a check for debarment in connection with th...

M anagements Response/Corrective Action Plan: The City of Sault Ste. Marie has instituted the following measures to remedy this deficiency to be implemented immediately. 1. Management learned of this deficiency in response to a request for documentation of a check for debarment in connection with the single audit field work in October 2024. Upon further i nquiry, City staff didn't have documentation of this kind. This task slipped through the cracks because a process was not in place to ensure it was completed. 2. In reference to the City's Uniform Guidance Policies, most recently approved by the City Commission on February 5, 2024, page 43, the City will include a suspension/debarment clause in all written contracts in which the vendor will certify that it is not suspended or debarred. Alternatively, the city may request vendor/contractor sign a certification regarding suspension or debarment. Executed certificates and procurement files will be retained by the City Clerk's office. This language was in the policy but was not implemented. 3. A sample certificate is provided on page 51 of the unform guidance policy. This sample certificate, if completed, would have provided evidence but was not implemented. For future contracts, this certificate will be completed prior to the bid award and documentation that it has been completed will be required for future City contracts that are part of a federal grant award. 4. If for any reason this signed certificate is not available prior to the award bid recommendation, City staff will check the vendor's status on Sam.gov and will document the results in the narrative of the memo. This will be required for all contracts related to federal grants. City staff will be provided instructions about how to check the status as by the State of Michigan in the following link... https://www.michigan.gov/msp/-/media/Proiect/Websites/msp/EM HSD/gra nts2/instructions for checking for excluded debarred contractors revised 72020.pdf?rev=0a928fb6b4b54253b2a627f1eb70dcd8&hash=31DC61AC1AB1E38D5A84952C43D27 F82 5. Going forward, City staff will add a note to the narrative of the agenda memo in BoardDocs to state whether the City has a certificate or found that the vendor was not suspended or debarred and provide documentation to be attached to the memo for all bid award recommendations. For example, we might indicate that the vendor/contractor was checked on Sam.gov and the contractor was not suspended or debarred and then follow up with a signed certificate when the contract is signed. Alternatively, a copy of the certificate, if separate from the contract, can be attached to the requisition in the P0 module. 6. This updated process will be shared with all project managers and grant administrators, along with staff in Finance and Clerks offices, so that we can ensure it is completed with each contract and project managers are supported during the busy construction season. 7. When bid award agenda memos route through Finance, they'll be reviewed to ensure this task has been completed and documentation is provided. This corrective action is being implemented as of this date and is expected to fully resolve the deficiency. Thank you for this opportunity for improvement. Sincerely, Kristin M. Collins Finance Director/Treasurer

View Audit 332219

Finding 514001 (2024-003)

Significant Deficiency 2024

Clearfield County Career and Technology Center

PA

Reporting

Management agrees and is working to realign staff responsibilities to provide a dedicated business office staff member to oversee, track, report and manage all of the Center's grant awards. See corrective action plan.

View Audit 332198

Finding 514000 (2024-006)

Significant Deficiency 2024

Mecklenburg County

NC

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303 § 200.334

U.S. Department of Health and Human Services Program Name: Maternal and Child Health Services Block Grant Federal Assistance Listing Number: 93.994 Significant Deficiency, Nonmaterial Noncompliance - Reporting Finding 2024-006 Criteria or Specific Requirement: Per Section 200.303 of the Uniform Gran...

U.S. Department of Health and Human Services Program Name: Maternal and Child Health Services Block Grant Federal Assistance Listing Number: 93.994 Significant Deficiency, Nonmaterial Noncompliance - Reporting Finding 2024-006 Criteria or Specific Requirement: Per Section 200.303 of the Uniform Grant Guidance, a nonfederal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Per 2 CFR 200.334 the recipient must retain all Federal award records for three years from the date of submission of their final financial report. Condition: During the audit we tested 13 reports and noted the following: a) There were four (4) instances out of 13 reports tested where the submitted reports were unable to be provided, including the date of submission for the reports. b) There were 10 instances out of 13 reports tested where the County was unable to provide evidence the report was reviewed prior to submission. Questioned Costs: None. Effect: By not having the required documentation and underlying support, the County is not able to demonstrate compliance with the applicable requirements. Cause: The County did not have a formal policy to ensure documentation was retained to evidence review and submission of all reports. Recommendation: The County should consider creating a formalized policy to require all submitted reports and underlying data are retained in accordance with the Uniform Grant Guidance requirements. Views of Responsible Officials: Management agrees with the finding and is implementing procedures to correct this which is further discussed in the Corrective Action Plan. Corrective Action Plan: See Corrective Action Plan prepared by the County. The Health Department will create and adopt a policy to ensure that federal award reports and data are retained in accordance with Uniform Guidance. The Health Department will also collaborate with NCDHHS to develop a procedure to address circumstances when the required report consists of answering a NCDHHS survey or form that does not have “save” or “download” capability, making it difficult to retain the required documentation. In addition, the Health Department will develop a standard operating procedure whereby program managers document that they have reviewed federal award reports prior to submission. While review of grant reports is common, the Health Department did not have adequate documentation to demonstrate completion of this step. Completion Date: April 30, 2025 Responsible Person(s): Jana Harrison, Business Operations Director

View Audit 332196

Finding 513997 (2024-005)

Significant Deficiency 2024

Mecklenburg County

NC

Procurement, Suspension & Debarment Significant Deficiency

U.S. Department of Treasury Program Name: Coronavirus State and Local Fiscal Recovery Funds Federal Assistance Listing Number: 21.027 Significant Deficiency, Nonmaterial Noncompliance - Procurement Finding 2024-005 – Repeat Finding Criteria or Specific Requirement: Per Section 200.318 of the Uniform...

U.S. Department of Treasury Program Name: Coronavirus State and Local Fiscal Recovery Funds Federal Assistance Listing Number: 21.027 Significant Deficiency, Nonmaterial Noncompliance - Procurement Finding 2024-005 – Repeat Finding Criteria or Specific Requirement: Per Section 200.318 of the Uniform Grant Guidance, a nonfederal entity must use documented procurement procedures for the acquisition of services required under a federal or State award. Condition: During the audit we tested 10 contracts and noted the following: a) There was one (1) instance out of 10 contracts tested where the County did not properly verify the vendor was not suspended or debarred prior to contract execution. b) There were three (3) instances out of 10 contracts tested where the County did not properly follow the Uniform Grant Guidance procurement standards for contracted services. Questioned Costs: None. Effect: By not having the required documentation and rationalization in the files, the County could have improperly contracted with a vendor that was not considered eligible to be paid with grant proceeds. Cause: The County did not ensure all contracts utilized for the grant were contracted and properly documented using the required procurement requirements in accordance with the Uniform Grant Guidance procurement standards. Recommendation: The County should consider utilizing the Uniform Grant Guidance procurement standards for all County contracts or ensure new contracts are executed when Federal or State grant funds are identified to be utilized for the contracts. Views of Responsible Officials: Management agrees with the finding and is implementing procedures to correct this which is further discussed in the Corrective Action Plan. Corrective Action Plan: In order to better follow UG requirements, Procurement will incorporate enhanced training on UG requirements for the division and create oversight mechanisms to ensure approval processes include senior level oversight on federally funded spending where the Simplified Acquisition Threshold has been exceeded. Completion Date: February 28, 2025 Responsible Person(s): Teresa Rausch, Procurement Director & David Boyd, Chief Financial Officer

View Audit 332196

Finding 513996 (2024-003)

Material Weakness 2024

Mecklenburg County

NC

Subrecipient Monitoring Eligibility Material Weakness

U.S. Department of Agriculture Pass-through Entity: North Carolina Department of Health and Human Services Program Name: Special Supplemental Nutrition Program for Women, Infants, and Children Federal Assistance Listing Number 10.557 Material Weakness – Eligibility Finding 2024-003 Criteria: Per Sec...

U.S. Department of Agriculture Pass-through Entity: North Carolina Department of Health and Human Services Program Name: Special Supplemental Nutrition Program for Women, Infants, and Children Federal Assistance Listing Number 10.557 Material Weakness – Eligibility Finding 2024-003 Criteria: Per Section 200.303 of the Uniform Grant Guidance, a non-federal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Condition: For the WIC program, we were unable to obtain evidence to corroborate the review of the Senior Quality Training Specialist eligibility determinations. Questioned Costs: None Effect: By not having the required documentation to support the review by the Senior Quality Training Specialist, the County is unable to support their assertion the cases are properly reviewed by an individual other than the preparer. Cause: County does not have a formal policy for documenting evidence of the review by the Senior Quality Training Specialist. Recommendation: We recommend the County implement a policy to ensure the review by the Senior Quality Training Specialist is properly documented and retained. Views of Responsible Officials: Management agrees with the finding and is implementing procedures to correct this which is further discussed in the Corrective Action Plan. Corrective Action Plan: See below Corrective Action Plan prepared by the County. Program leadership will collaborate The Total Quality Team i.e. Compliance Coordinator and Quality Assurance Coordinator to revise current internal monitoring policies and procedures. Internal monitoring tools will be created to align with state and federal guidelines. Following review with Total Quality, staff will be trained on revised monitoring processes, policy, and procedures. WIC Policy A-19 mandates the use of the State Agency's WIC program monitoring tool for conducting record audits. To ensure proper implementation, this policy will be reviewed with the Senior Quality and Training Specialist. The WIC Senior Quality Training Specialist and WIC leadership will maintain audit documentation in accordance with Policy A-13, Retention of Administrative Documents, established by Mecklenburg County Health Department. The following the phases of the corrective action plan will be completed by March 31st, 2025. Phase1: Review of Federal Guidelines Phase 2: Review Of State Guidelines Phase 3: Internal Policy Review Phase 4: Creation and Implementation of new internal monitoring processes. Phase 5: Staff Training Completion Date: March 31, 2025 Responsible Person(s): WIC Director, Ali Raza and Senior Quality and Training Specialist, Tamika Moore

View Audit 332196

Finding 513985 (2024-002)

Significant Deficiency 2024

Mecklenburg County

NC

Questioned Costs Cash Management Period of Performance § 200.1

Department of Housing and Urban Development Program Name: Continuum of Care Program Federal Assistance Listing Number: 14.267 Significant Deficiency, Nonmaterial Noncompliance – Period of Performance Finding 2024-002 Criteria: Period of performance is defined in 2 CFR 200.1 as “the time interval bet...

Department of Housing and Urban Development Program Name: Continuum of Care Program Federal Assistance Listing Number: 14.267 Significant Deficiency, Nonmaterial Noncompliance – Period of Performance Finding 2024-002 Criteria: Period of performance is defined in 2 CFR 200.1 as “the time interval between the start and end date of a federal award, which may include one or more budget periods.” Condition: For one award, the 2023 grant award project was not closed timely in the general ledger system and the County erroneously recorded fiscal year 2024 grant costs of $1,059 to the project, which was beyond the approved period of performance of the award. Additionally, for one award, the County recorded grant costs of $28,685 to the project, which was beyond the approved period of performance of the award. Effect: By not having the grant project codes properly closed at the end of the period of performance, the County could potentially request reimbursement for costs incurred and recorded beyond the grants approved period of performance from the Federal government. Questioned Costs: $29,744 Cause: The County did not have a formal policy to ensure grant project codes were properly closed and expenditures were not being recorded beyond the grant award’s stated period of performance. Recommendation: We recommend the County should implement a formal policy to ensure all grants are properly closed and no costs are incurred on grants after their period of performance. Views of Responsible Officials: Management agrees with the finding and is implementing procedures to correct this which is further discussed in the Corrective Action Plan. Corrective Action Plan: See below Corrective Action Plan prepared by the County. Following the end of grant term, June 30th, Shelter Plus Care (SPC) program will ensure all final payments are made out of the grant by mid-August to ensure timely reconciliation. • Grant Management /Revenue Reimbursement Team will send final draw for review and approval by SPC Supervisor and upon confirmation, email communication will be made with Accountant III (within the Budget Team) for final review. • Accountant III will provide Purchase Order by Unit report (PD615) report to SPC program to ensure all POs are closed out. • Accountant III will review PD615 report to ensure deactivation. Ongoing review will take place at least 2 months following the 90-day close-out period. •The SPC/Finance Team will work with staff, supervisors and payroll to ensure all applicable payroll is allocated to proper (active) grant unit and respective entries are processed timely. • When new grant is established, the SPC team will ensure that time posted and approved for SPC admin costs in PeopleSoft are for the correct grant unit/ grant fiscal period as well as ensure that funds are encumbered and paid from correct grant/grant fiscal period. In addition to these steps, ongoing review and monitoring of grant will occur monthly during SPC’s Finance Meeting on the 4th Thursdays of the month and during the CSS Grants Meeting on the 4th Tuesdays of the month. Completion Date: June 30, 2025 Responsible Person(s): Adia Robinson, Clinical Supervisor

View Audit 332196 Questioned Costs: $1

Finding 513979 (2024-001)

Material Weakness 2024

Mecklenburg County

NC

Internal Control / Segregation of Duties Subrecipient Monitoring Eligibility

U.S. Department of Health and Human Services Pass-through Entity: North Carolina Department of Health and Human Services Program Name: Medical Assistance Federal Assistance Listing Number: 93.778 Material Weakness and Nonmaterial Noncompliance – Eligibility ...

U.S. Department of Health and Human Services Pass-through Entity: North Carolina Department of Health and Human Services Program Name: Medical Assistance Federal Assistance Listing Number: 93.778 Material Weakness and Nonmaterial Noncompliance – Eligibility Finding 2024-001 – Repeat Finding Criteria or Specific Requirement: Per Section 200.303 of the Uniform Grant Guidance, a nonfederal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. The County should have adequate documentation for each participant that supports each eligibility determination and the information entered into NCFAST. We noted several errors related to the following compliance criteria: a) Self-attestation wages should be compared to information in NC FAST. b) All countable resources should be confirmed and recalculated and ensure they are computed accurately in NC FAST. c) An OVS inquiry must be completed and agreed to information reported in NC FAST. d) An ex parte review is required every six (6) to twelve (12) months. e) Forced eligibility cases should maintain the proper documentation within NC FAST to support the determination for the required forced eligibility. f) For Aged, Blind, or Disabled cases or MQB programs the Register of Deeds is required to be verified and documented in the case file g) The caseworker should prepare and submit a DMA-5097 form in the case of incompatible income verification and self-attestation income as described in the Eligibility Review Document. h) For countable earned and unearned income, income conversion and computation was done in accordance with policy manuals, and have to agree to amounts in NC FAST. Condition: The following are the results of nonmaterial noncompliance noted for each criteria listed above out of the 122 program participants selected for testing: a) There were four instances where the participants self-attest wages did not agree to the wages entered into NC FAST. b) There were three instances where the countable resources were inaccurate within NC FAST. c) There was one instance where the OVS query was not run at the time of the determination. d) There were two instances where the ex parte review was not completed timely. e)There were two instances where the support for the forced eligibility was not properly maintained in NC FAST. f) There was one instance where the Register of Deeds support was not maintained in NC FAST. g) There were five instances where the income was incompatible between the income verification and self-attestation income but no DMA-5097 was sent. h) There were two instances where countable income was not properly included in NC FAST. Lastly, there were 6 instances out of 60 program participants tested for control testing where the County did not remediate the errors identified within their internal review timely. Context: There were 14 out of 124 unique participants tested with the errors noted above. Questioned Costs: None noted. Effect: By not having the required documentation in the files or information being incorrectly documented, eligibility cannot be readily substantiated and there is a risk the County could provide funding to individuals who are not eligible. Cause: County oversight when performing reviews over applications. Additionally, the County does not have a formal process in place to ensure issues identified during the review process are appropriately corrected on a consistent and timely basis. Recommendation: Although these issues will occur from time to time considering the volume of case files, the County should review their processes to ensure proper supporting documentation of eligibility is maintained within each case file. Additionally, Mecklenburg County should consider implementing a formal policy for the requirements of having documentation corrected within a specific timeframe once identified. Views of Responsible Officials: Management agrees with the finding and is implementing procedures to correct this which is further discussed in the Corrective Action Plan. Corrective Action Plan: The County will take a multi-faceted approach to mitigating such errors in the future. Training: The Staff Development Unit within the Economic Services Division (ESD) will review the findings and create and deliver training to staff that determine Medicaid eligibility and their supervisors and managers to address the specific errors identified. This training will be delivered by the end of January 2025. Responsible Individual(s): Staphon Snelling, Training and Development Manager Anticipated Completion Date: January 31, 2025 Process Improvement: The Economic Services Division (ESD) has trained new hires in one function of the Medicaid program, for example, processing applications or recertifications/changes. This has built a stronger foundation before they learn the second function of their assigned program. Our Supervisors and Quality and Training Specialists are working even more closely together to follow up on errors and help ensure identified challenges in training and mentoring are addressed before they are released from mentoring. Ex parte reviews are directly assigned for Family and Children’s Medicaid and for Adult Medicaid, renewals are placed into Current for workers to get next and work as soon as possible. Family and Children’s Medicaid will provide second-function training for current employees on recertifications. Adult Medicaid has 10 currently in mentoring for recertifications. Kim Konior is responsible for monitoring ex-parte review reports and MAGI cases are being assigned out by Supervisor Collin Smith and Jannicia Austin for Adult Medicaid. Each month the Medicaid managers Kim Konior and Lynn Martin review the progress and update the Assistant Division Director on the current status and plans to continually improve in this area. Supervisors will ensure that second party reviews are reviewed and corrected for any internal control and eligibility errors within 5 business days of receipt. Supervisors ensure that updates to the quality sampling tracking log are completed by the 20th day of the following month. Responsible Individual(s): Kim Konior and Lynn Martin Medicaid Program Managers and Staphon Snelling, Training and Development Manager Anticipated Completion Date: Will begin Family and Children’s Medicaid recertification training in third Quarter of FY25 (Jan 2025) and end by the end of 2nd quarter of FY 2025 (December 2025). Quality Sampling and Accountability: The Quality and Training Unit complete monthly quality sampling for Medicaid. Error trends are shared with the managers and their supervisors, who work collaboratively with Quality and Training staff to coordinate appropriate strategies to train and coach staff to mitigate errors moving forward. Supervisors review specific quality sampling results with their staff. The supervisor when necessary and appropriate, address continued errors using an individual Corrective Action Plan with the worker to include refresher training, additional second party review and/or initiating the formal documentation process. Managers review quality sampling results with supervisors quarterly to follow up on errors addressed, trainings completed and progress with individual Corrective Action Plans. Supervisors, front line, and Managers have quality measure on their workplan to ensure timely response and accountability is held. All levels are to achieve an average quality score of 80% quarterly. Note that this error was found at a much higher rate last year. We are continuing to reinforce this importance and expect the improvement that we have achieved within one year will continue to grow as we keep reinforcing quality into our everyday work culture. Protocol for second party reviews provided 08/2024 in place for ESD. Cases will be checked by Quality and Training by the last day of each business month. Quality and Training will check and provide feedback to workers within 2 business days of the case being checked. Corrections of errors and rebuttals for QS errors should be submitted within 5 business days of feedback being provided and a response will be received within 3 business days of receipt. The Quality Assurance team in OSI/CFAS conduct an independent evaluation and review the second party review process at the divisional level to ensure review was accurate and errors were corrected timely. This team reports out to ESD Leadership quarterly on findings. Responsible Individual(s): Kim Konior and Lynn Martin, Medicaid Program Managers & Julio Rosales, Quality Assurance Supervisor, Staphon Snelling Training and Development Manager Anticipated Completion Date: Currently Ongoing

View Audit 332196

Finding 513977 (2024-001)

Significant Deficiency 2024

City of Altoona

IA

Reporting Internal Control / Segregation of Duties

We have reviewed procedures and have made recommendations to ensure reports are accurate in the future.

View Audit 332188

Finding 513976 (2024-005)

Significant Deficiency 2024

Community Unit School District 100

IL

Reporting Subrecipient Monitoring Allowable Costs / Cost Principles

Condition: Quarterly expenditure reports for the projects expenditures were not timely filed for ESSER III D3 (2 of 4 quarters required). Plan: To avoid this reporting and internal control issue, the District should schedule the due dates of all expenditure reports in order to avoid late filings. ...

Condition: Quarterly expenditure reports for the projects expenditures were not timely filed for ESSER III D3 (2 of 4 quarters required). Plan: To avoid this reporting and internal control issue, the District should schedule the due dates of all expenditure reports in order to avoid late filings. Anticipated Date of Completion: June 30, 2025 Name of Contact Person: Jason Brunaugh, Assistant Superintendent of Finance and Human Resources Management Response: This District is aware of the issue and has determined that the majority of the problem occurs when a grant is first approved, and the first reporting period is missed or if a grant continues into subsequent project years. Management has found a dashboard within IWAS that has a listing of all grants by project year and dates that the grants and budgets are approved that will help determine when the first expenditure reports are due. Additionally, management will work on a process to ensure that expenditure reports are no longer missed or filed late.

View Audit 332183

Finding 513974 (2024-006)

Significant Deficiency 2024

Community Unit School District 100

IL

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Condition: Expenditures claimed on the projects’ quarterly reports were not included in the detailed budget approved by ISBE resulting in questioned costs for the projects. Plan: To avoid this reporting issue, the District should compare expenditure reports to the program budget that has been submi...

Condition: Expenditures claimed on the projects’ quarterly reports were not included in the detailed budget approved by ISBE resulting in questioned costs for the projects. Plan: To avoid this reporting issue, the District should compare expenditure reports to the program budget that has been submitted. Budget policies per the State and Federal Grant Administration Policy should be reviewed and followed accordingly. Anticipated Date of Completion: June 30, 2025 Name of Contact Person: Jason Brunaugh, Assistant Superintendent of Finance and Human Resources Management Response: The District will work to properly report transactions in the future and follow the guidelines set forth in the policy manual.

View Audit 332183 Questioned Costs: $1

Finding 513973 (2024-007)

Significant Deficiency 2024

Community Unit School District 100

IL

Questioned Costs Subrecipient Monitoring Cash Management

Condition: The expenditure reports filed with the Illinois State Board of Education do not match the general ledger detail. Plan: To avoid this reporting issue, the District should review expenditure reports prior to using them to prepare the projects’ quarterly reports. Anticipated Date of Comple...

Condition: The expenditure reports filed with the Illinois State Board of Education do not match the general ledger detail. Plan: To avoid this reporting issue, the District should review expenditure reports prior to using them to prepare the projects’ quarterly reports. Anticipated Date of Completion: June 30, 2025 Name of Contact Person: Jason Brunaugh, Assistant Superintendent of Finance and Human Resources Management Response: The District will work to properly report transactions in the future.

View Audit 332183 Questioned Costs: $1

Finding 513972 (2024-004)

Significant Deficiency 2024

Community Unit School District 100

IL

Reporting Subrecipient Monitoring Allowable Costs / Cost Principles

Condition: Quarterly expenditure reports for the projects expenditures were not timely filed for ESSER II CP (1 of 1 quarters required) and ESSER II D2 (1 of 1 quarters required). Plan: To avoid this reporting and internal control issue, the District should schedule the due dates of all expenditure...

Condition: Quarterly expenditure reports for the projects expenditures were not timely filed for ESSER II CP (1 of 1 quarters required) and ESSER II D2 (1 of 1 quarters required). Plan: To avoid this reporting and internal control issue, the District should schedule the due dates of all expenditure reports in order to avoid late filings. Anticipated Date of Completion: June 30, 2025 Name of Contact Person: Jason Brunaugh, Assistant Superintendent of Finance and Human Resources Management Response: This District is aware of the issue and has determined that the majority of the problem occurs when a grant is first approved, and the first reporting period is missed or if a grant continues into subsequent project years. Management has found a dashboard within IWAS that has a listing of all grants by project year and dates that the grants and budgets are approved that will help determine when the first expenditure reports are due. Additionally, management will work on a process to ensure that expenditure reports are no longer missed or filed late.

View Audit 332183

Finding 513971 (2024-008)

Significant Deficiency 2024

Community Unit School District 100

IL

Cash Management Reporting

Condition: The expenditure reports filed with the Illinois State Board of Education do not match the general ledger detail. Plan: To avoid this reporting issue, the District should review expenditure reports prior to using them to prepare the projects’ quarterly reports. Anticipated Date of Comple...

Condition: The expenditure reports filed with the Illinois State Board of Education do not match the general ledger detail. Plan: To avoid this reporting issue, the District should review expenditure reports prior to using them to prepare the projects’ quarterly reports. Anticipated Date of Completion: June 30, 2025 Name of Contact Person: Jason Brunaugh, Assistant Superintendent of Finance and Human Resources Management Response: The District will work to properly report transactions in the future.

View Audit 332183

Finding 513969 (2024-002)

None 2024

Eastern Oklahoma State College

OK

Student Financial Aid Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking

Management Response: The College acknowledges the finding and agrees with the recommendation to proactively obtain the waiver to ensure compliance with federal matching requirements. For the fiscal year 2025, we have already verified and obtained the waiver letter, ensuring that the College qualifie...

Management Response: The College acknowledges the finding and agrees with the recommendation to proactively obtain the waiver to ensure compliance with federal matching requirements. For the fiscal year 2025, we have already verified and obtained the waiver letter, ensuring that the College qualifies for the matching exemption. To prevent future occurrences, we have added the waiver verification process to our compliance tracking spreadsheet. This ensures that the waiver is requested and obtained from the appropriate department each year and documentation is presented to management to verify it has been obtained. We are committed to maintaining accurate oversight of matching requirements and will take all necessary steps to ensure full compliance moving forward.

View Audit 332174

Finding 513968 (2024-001)

Significant Deficiency 2024

Steppingstone, Inc. and Affiliate

MA

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.512

Corrective Action Plan: (unaudited): We agree with the recommendation and have updated the accounting manual. It should also be noted that the Organization has never filed late and has only had this happen once in the history of the Organization which is concurrent with the change in the FAC website...

Corrective Action Plan: (unaudited): We agree with the recommendation and have updated the accounting manual. It should also be noted that the Organization has never filed late and has only had this happen once in the history of the Organization which is concurrent with the change in the FAC website update.

View Audit 332173

Finding 513966 (2024-004)

Significant Deficiency 2024

Greater Washington Educational Telecommunications Association Inc.

VA

Procurement, Suspension & Debarment

To address the deficiency in procurement processes, particularly the lack of suspension and debarment checks, management will update the procurement policies to require a suspension/debarment verification before engaging any vendor for federal award funds. This verification process, conducted throug...

To address the deficiency in procurement processes, particularly the lack of suspension and debarment checks, management will update the procurement policies to require a suspension/debarment verification before engaging any vendor for federal award funds. This verification process, conducted through the System for Award Management (SAM), has been embedded as a mandatory step in the vendor onboarding workflow. Training sessions will be held to educate staff on compliance requirements under the Uniform Guidance, emphasizing the importance of these checks in safeguarding federal funds. Additionally, a compliance tracker will be implemented to document and monitor the completion of suspension and debarment verifications for all federal fund vendors. To ensure ongoing adherence, a quarterly compliance review will be conducted by the procurement and finance teams. Oversight of these corrective actions has been assigned to Dorian Davis, Corporate Controller and Sylvia Gicheru, Assistant Controller with all measures in place by March 31, 2025.

View Audit 332165

Finding 513963 (2024-004)

Significant Deficiency 2024

Dakota Prairie Community Action Agency, Inc.

ND

Allowable Costs / Cost Principles § 200.303

Contact Person – Lora Papacheck, CEO Planned Corrective Action – Entity management will retroactively review and approve all journal entries that were charged to federal grants and document in a memo. Completion Date – Fiscal year 2025

View Audit 332161

Finding 513960 (2024-003)

Significant Deficiency 2024

Dakota Prairie Community Action Agency, Inc.

ND

Reporting Internal Control / Segregation of Duties

Contact Person – Lora Papacheck, CEO Planned Corrective Action – The fiscal manager will continue to pull fund income statements by fiscal year to assist in tracking and reconciling grant expenditures. Completion Date – Fiscal year 2025

View Audit 332161

Finding 513951 (2024-002)

Significant Deficiency 2024

Barton County Community College

KS

Special Tests & Provisions Student Financial Aid Reporting

SIGNIFICANT DEFICIENCY 2024-002 Federal Program Student Financial Assistance Cluster Compliance requirements Special Tests and Provisions – Enrollment Reporting Condition During testing, we identified that 6 of the 60 students tested did not have an enrollment status change properly reported. Re...

SIGNIFICANT DEFICIENCY 2024-002 Federal Program Student Financial Assistance Cluster Compliance requirements Special Tests and Provisions – Enrollment Reporting Condition During testing, we identified that 6 of the 60 students tested did not have an enrollment status change properly reported. Recommendation We recommend that the College review its controls to ensure that accurate enrollment information is reported to NSLDS. Comments on the Finding Recommendation Barton County Community College understands the finding. Action Taken Barton County Community College has updated its policies and procedures to reflect emphasis on reporting the unofficial withdrawals to NSLDS within 30 days. Barton’s Financial Aid Office will perform a quality assurance review of NSLDS to ensure that the unofficial withdrawals have been reported. Additionally, Barton’s Registrar will perform a periodic check to see if other enrollment reporting is reflected accurately in the National Student Clearinghouse and the National Student Loan Data System. Date of implementation: This has been implemented for the 2024-2025 award year.

View Audit 332157

Finding 513948 (2024-001)

Material Weakness 2024

Barton County Community College

KS

Student Financial Aid Material Weakness Reporting

MATERIAL WEAKNESS 2024-001 Federal Program Student Financial Assistance Cluster Compliance requirements Special Tests and Provisions – Return to Title IV and Enrollment Reporting Condition The College's official policy is to be an attendance taking institution. However, the date of the institution’...

MATERIAL WEAKNESS 2024-001 Federal Program Student Financial Assistance Cluster Compliance requirements Special Tests and Provisions – Return to Title IV and Enrollment Reporting Condition The College's official policy is to be an attendance taking institution. However, the date of the institution’s determinations for withdrawals does not fall within the required 14 day period, and it instead follows that of institutions that are not attendance taking. Additionally, during testing, it was identified that the College's quality control processes for Return to Title IV calculations were not completed within a timely manner, and that process determined that calculations needed to be adjusted for some of the students. Those corrections were not made within the required 45 day periods, and, as a result of the late corrections, the NSLDS enrollment reporting also had to be updated outside of its typical window. Recommendation We recommend that the College review and update its policies to ensure that all compliance requirements are met within the required timeframes associated with those policies, as well as recommend that the College review its controls to ensure that accurate Return to Title IV calculations are completed in a timely fashion. Comments on the Finding Recommendation Barton County Community College understands the finding. Action Taken Barton’s Director of Financial Aid has informed the following Barton personnel of the finding: • Vice President of Instruction, • Vice President of Student Services, • Dean of Academics, the Dean of Workforce Training and Community Education • Dean of Military Programs, Technical Education, and Outreach Programs • Associate Dean of Instruction The Vice President of Instruction is initiating a project to involve these parties in the implementation of a procedure to report unofficial withdrawals by 14 calendar days to ensure Return of Title IV is completed within the regulatory timeframes and reported to NSLDS within the regulatory timeframe. Date of Implementation: This will be implemented for the spring 2025 term.

View Audit 332157

Finding 513946 (2024-001)

Material Weakness 2024

South Central Cooperative

SD

Internal Control / Segregation of Duties Material Weakness Reporting

The South Central Cooperative Director, Kristi Hilzendeger, is the contact person responsible for the corrective action plan for this finding. This finding is due to the size of the South Central Cooperative, which precludes staffing at a level sufficient to provide an ideal environment for interna...

The South Central Cooperative Director, Kristi Hilzendeger, is the contact person responsible for the corrective action plan for this finding. This finding is due to the size of the South Central Cooperative, which precludes staffing at a level sufficient to provide an ideal environment for internal controls. The Cooperative has developed policies to help monitor the lack of segregation of duties but due to the size of the Cooperative it is not feasible, or fisally responsible to implement anything else at this time. The Cooperative will contrinue to follow the controls currently in place.

View Audit 332156

Corrective Action Plans

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