Corrective Action Plans

Finding 390901 (2023-004)

None 2023

LA

Questioned Costs Allowable Costs / Cost Principles HUD Housing Programs

Dear Mr. Waguespack: The Department of Children and Family Services (DCFS) has reviewed the finding “Improper Employee Activity in Federal Program”. The Department concurs with the finding and continues to prioritize prevention and detection of improper activity associated with programs it administ...

Dear Mr. Waguespack: The Department of Children and Family Services (DCFS) has reviewed the finding “Improper Employee Activity in Federal Program”. The Department concurs with the finding and continues to prioritize prevention and detection of improper activity associated with programs it administers. The Fraud and Recovery Unit (FRU) investigated two employees for suspected payroll fraud. The FRU determined that one employee received wages from DCFS and a secondary employer for the same hours worked. DCFS is pursuing recoupment of wages paid for the duplicative hours and will seek recoupment of funds in the amount $875.00 from this employee. DCFS is conducting additional inquiries related to the other employee’s suspected activities to determine the actual loss to the agency and will proceed accordingly. Both employees are no longer employed with the Department. DCFS will continue to investigate improper employee activities and emphasize the consequences of illegal acts. If you have any questions, please contact Rhonda Brown, Fraud and Recovery Unit Director, at Rhonda.Brown.DCFS@LA.GOV.

View Audit 301612 Questioned Costs: $1

Finding 390876 (2023-001)

Significant Deficiency 2023

Spring Hill College

AL

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

(Repeat) Federal Direct Student Loans, ALN 84.268; Grant period—Year ended June 30, 2023 Condition: There was lack of documentation related to disbursement notices and exit counseling for eight out of thirty-four students tested. Criteria: According to §668.165, before an institution disburses tit...

(Repeat) Federal Direct Student Loans, ALN 84.268; Grant period—Year ended June 30, 2023 Condition: There was lack of documentation related to disbursement notices and exit counseling for eight out of thirty-four students tested. Criteria: According to §668.165, before an institution disburses title IV, HEA program funds for any award year, the institution must notify a student of the amount of funds that the student or his or her parent can expect to receive under each title IV, HEA program, and how and when those funds will be disbursed. Additionally, according to §682.604, a school must ensure that exit counseling is conducted with each loan borrower and graduate either in person, by audiovisual presentation, or by interactive electronic means. Cause: The College was unable to locate the documents for the students as a result of transitioning softwares. Effect: Certain documentation for disbursement notices and exit counseling was lost during the transition of the College's software. Context: During the compliance audit testing of ALN 84.268, it was determined that documentation to confirm delivery of disbursement notices and performance of exit counseling could not be provided for certain students selected for testing. Recommendation: We recommend all required documentation be backed up to support compliance with certain requirements. View of Responsible Officials and Planned Corrective Action: The College is currently working with their IT department to make sure that all types of communication includes copying the financial aid department email to make sure the College has support for all communications to prevent this in the future.

View Audit 301577

Finding 390812 (2023-001)

Material Weakness 2023

City of Fitchburg, Massachusetts

MA

Questioned Costs Internal Control / Segregation of Duties Allowable Costs / Cost Principles

Planned Correction Action: Moving forward grants will not be set up with account #s for use until the funds are received and award letter is issued with actual start date. This will stop any expenses being posted prior to the start date. Name of Contact Person and Completion Date: Jeremy Roche, As...

Planned Correction Action: Moving forward grants will not be set up with account #s for use until the funds are received and award letter is issued with actual start date. This will stop any expenses being posted prior to the start date. Name of Contact Person and Completion Date: Jeremy Roche, Assistant Superintendent of Finance and Operations. This plan will go into effect immediately.

View Audit 301533 Questioned Costs: $1

Finding 390808 (2023-004)

Material Weakness 2023

City of Portland Maine

ME

Allowable Costs / Cost Principles Significant Deficiency

Corrective Action Plan Finding 2023-004 Improve Time and Effort Documentation Planned Corrective Action: The Housing and Economic Development Department will amend the current process used to document time and effort certifications for salaried employees, by adding the signature of the supervisor to...

Corrective Action Plan Finding 2023-004 Improve Time and Effort Documentation Planned Corrective Action: The Housing and Economic Development Department will amend the current process used to document time and effort certifications for salaried employees, by adding the signature of the supervisor to each weekly time tracker. The supervisor for HCD staff is the HCD Division Director. The supervisor for the HCD Division Director and the Senior Accountant is the Housing and Economic Development Department Director Anticipated Completion Date: April 1, 2024 Contact Person: Mary Davis, Division Director, Housing and Community Development

View Audit 301530

Finding 390807 (2023-003)

Material Weakness 2023

City of Portland Maine

ME

Questioned Costs Allowable Costs / Cost Principles Material Weakness

Audit Finding Reference: 2023-003 Improve Controls and Documentation over Payroll Process Planned Corrective Action: Beginning with the first payroll of the calendar year 2024, the Portland Public School District went to the ADP payroll system. This change in payroll ERP system allowed for the overh...

Audit Finding Reference: 2023-003 Improve Controls and Documentation over Payroll Process Planned Corrective Action: Beginning with the first payroll of the calendar year 2024, the Portland Public School District went to the ADP payroll system. This change in payroll ERP system allowed for the overhaul of the payroll process that was currently in place. The Executive Director of Finance worked with ADP to ensure that permissions for both the Human Resources and the Payroll teams were specifically set up so that they did not have access to each other’s processes. The HR generalists have been trained to process the information that once was processed by payroll personnel. Furthermore, access is not managed by staff but by a department head to ensure that proper access for individuals is maintained. Proper documentation of time and attendance is maintained in payroll and electronically filed with each payroll period in an organized manner. The Executive Director of Finance is always looking for continuous improvements for proper documentation in payroll. Name of Contact Person: Helene DiBartolomeo, CPA Executive Director of Finance Anticipated Completion Date: Internal controls - 1/1/2024 Documentation - 2/23/24 353

View Audit 301530 Questioned Costs: $1

Finding 390786 (2023-004)

Significant Deficiency 2023

Allenstown School District

NH

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303 § 200.430

Audit Finding Reference: 2023-004 Lack of Documentation to Support Distribution of Wages Management’s View and Planned Corrective Action: After review we have also determined that this documentation was lacking due to the employee longer working in the district. The grant manager did verify that the...

Audit Finding Reference: 2023-004 Lack of Documentation to Support Distribution of Wages Management’s View and Planned Corrective Action: After review we have also determined that this documentation was lacking due to the employee longer working in the district. The grant manager did verify that the employee worked the hours noted, but lacks the employees’ signature. This is not a typical occurrence Time and Effort is used and submitted. A Time and Effort policy and procedure has been established, documented and implemented. Federally funded stipends are no longer processed until the Time and Effort Log of hours have been received. Once we have received the form(s), which we now attach to the position in our accounting system we then process in payroll. This procedure is also located in our Federal Funds Handbook. A communication will be sent to Grant Manager’s reminding them of the Time & Effort policy and procedures. Name of Contact Person and Completion Date: Name 1 Amber Wheeler Name 2 Danielle Rossetti Anticipated Completion Date – Procedure has changed a reminder will be communicated by March 30th.

View Audit 301524 Questioned Costs: $1

Finding 390781 (2023-001)

Significant Deficiency 2023

Au Health System, Inc.

GA

Allowable Costs / Cost Principles § 200.303 § 200.430

Item 2023‐001 – Allowable Costs/Activities Contact person: Wendy Stephens, Senior Accounting Manager Management’s Response – Management’s controls over approval of time sheets operated effectively 97.5% of the time prior to processing of payroll. The payroll expenditures allocated to the COVID-19...

Item 2023‐001 – Allowable Costs/Activities Contact person: Wendy Stephens, Senior Accounting Manager Management’s Response – Management’s controls over approval of time sheets operated effectively 97.5% of the time prior to processing of payroll. The payroll expenditures allocated to the COVID-19 Provider Relief Fund – Assistance Listing 93.498 were allocated to the Provider Relief Funding and including in reporting of expenditures based on management review of guidance provided by HRSA in determination of the portion of the payroll costs allocated as qualifying and allowable expenditures under the program. The guidance on allowable costs was determined by HRSA subsequent to disbursement of the funds by HRSA and after incurrence of the expenditures given the immediacy of the COVID-19 pandemic providing of funds and incurrence of costs. Management will perform an annual review of expenditures allocated to a grant to confirm the allowability of the costs under the respective program. Management’s controls over approval of time sheets operated effectively 97% of the time prior to processing payroll. The payroll expenditures related to the 1 time sheet not approved prior to payment of payroll are for an employee assigned to work specifically on the program funded by Assistance Listing #93.778. Management will perform an annual review of expenditures allocated to a grant to confirm the allowability of the costs under the respective program. Management expects the corrective actions described above to be complete no later than June 30, 2024.

View Audit 301517

Finding 390773 (2023-001)

Significant Deficiency 2023

Lima Urban Minority Alcoholism & Drug Outreach Program, Inc.

OH

Questioned Costs Allowable Costs / Cost Principles Reporting § 200.1 § 200.303

Audit Period: Fiscal Year July 1, 2022 - June 30,2023 Re: Lima UMADAOP respectively submits the following corrective action plan for the year ended June 30, 2023. 2023-001 Reporting (Significant Deficiency) Recommendation: We suggest that Management engage in quarterly monitoring of their feder...

Audit Period: Fiscal Year July 1, 2022 - June 30,2023 Re: Lima UMADAOP respectively submits the following corrective action plan for the year ended June 30, 2023. 2023-001 Reporting (Significant Deficiency) Recommendation: We suggest that Management engage in quarterly monitoring of their federal expenditures. This proactive strategy will aid management in preparing the Schedule of Expenditures of Federal Awards (SEFA) at year-end, as the amounts will have undergone partial scrutiny for completeness and accuracy throughout the year. Corrective Action Plan: The Agency will review and strengthen all controls and make any necessary changes moving forward. The Accountant will provide any necessary training to the Bookkeeper as well as monitor and review all expenditures on monthly basis. The Accountant and the CEO will review the Schedule of Expenditures of Federal Awards (SEFA) on a quarterly basis to confirm the completeness and accuracy for all future audits. Responsible Party: CEO, Accountant, Bookkeeper Date Expected to be Corrected: Immediately

View Audit 301491 Questioned Costs: $1

Finding 390756 (2023-005)

Material Weakness 2023

Washington Community Schools, Inc.

IN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness § 200.302 § 200.303 § 200.328 § 200.329

FINDING 2023-005 Finding Subject: COVID‐19 Education Stabilization Fund ‐ Reporting Summary of Finding: Reports were not supported by underlying accounting records. Contact Person Responsible for Corrective Action: Carrie Alford Contact Phone Number and Email Address: (812)254-5536 calford@wcs.k12.i...

FINDING 2023-005 Finding Subject: COVID‐19 Education Stabilization Fund ‐ Reporting Summary of Finding: Reports were not supported by underlying accounting records. Contact Person Responsible for Corrective Action: Carrie Alford Contact Phone Number and Email Address: (812)254-5536 calford@wcs.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Washington Community Schools like all other school corps across the state, got the requests for these reports with very little to no instruction of how to complete them. We weren’t told they would be part of the audit and therefore didn’t retain reports used to complete some of the reports. Going forward we will ensure reports proving numbers reported are available to SBOA. Anticipated Completion Date: 06/30/2024

View Audit 301486

Finding 390751 (2023-003)

Material Weakness 2023

Washington Community Schools, Inc.

IN

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.208 § 200.303 § 200.403

FINDING 2023-003 Finding Subject: Special Education Cluster (IDEA) ‐ Earmarking Summary of Finding: Proportionate Share Reporting could not be verified Contact Person Responsible for Corrective Action: Kevin Frank Contact Phone Number and Email Address: 812-254-5536 kfrank@wcs.k12.in.us Views of Res...

FINDING 2023-003 Finding Subject: Special Education Cluster (IDEA) ‐ Earmarking Summary of Finding: Proportionate Share Reporting could not be verified Contact Person Responsible for Corrective Action: Kevin Frank Contact Phone Number and Email Address: 812-254-5536 kfrank@wcs.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Washington Community Schools will require the Director of the Daviess Martin Special Ed Cooperative to provide Proportionate Share expenditure data and emphasize the importance of having this information available for SBOA. Unfortunately, due to our configuration, WCS doesn’t have access to this data and it is up to the Coop to complete the requirements. Mr. Frank will offer training to DMSEC staff to ensure compliance. Anticipated Completion Date: 02/01/2024

View Audit 301486

Finding 390731 (2023-001)

Significant Deficiency 2023

Boston Public Health Commission

MA

Period of Performance Subrecipient Monitoring Allowable Costs / Cost Principles § 200.308 § 200.309 § 200.403

2023-001 Block Grants for Prevention and Treatment of Substance Abuse – Assistance Listing No. 93.959 Recommendation: We recommend procedures be implemented to ensure that all costs charged to the grant are incurred within the grant period of performance. Explanation of disagreement with audit fin...

2023-001 Block Grants for Prevention and Treatment of Substance Abuse – Assistance Listing No. 93.959 Recommendation: We recommend procedures be implemented to ensure that all costs charged to the grant are incurred within the grant period of performance. Explanation of disagreement with audit finding: There is no disagreement with the finding. Action taken in response to finding: We have controls in place to ensure that costs charged to a grant are incurred within the grant period of performance. This finding exposed a vulnerability that circumvented our controls. We will use this finding to pinpoint the cause(s) and make the necessary corrective adjustments. Name(s) of the contact person(s) responsible for corrective action: Deborah Grupp-Patrutz and Steve Simmons Planned completion date for corrective action plan: Prior to June 30, 2024

View Audit 301437

Finding 390729 (2023-003)

None 2023

Clay County Board of Education

WV

Allowable Costs / Cost Principles HUD Housing Programs Reporting

#2303-003 Reporting of Time and Effort US Department of Education Title I Grants to Local Educational Agencies AL#84.010 ...

#2303-003 Reporting of Time and Effort US Department of Education Title I Grants to Local Educational Agencies AL#84.010 Recommendation: We recommend that the Clay County Board of Education's Title I Department implement procedures to accurately document and maintain the "Time and Effort" Documentation of all employees funded with federal funding, as required. Action Taken: The Title I Department of the Clay County Board of Education will implement procedures to ensure that "Time and Effort" Documentation and records are adequately maintained, as required for all applicable employees. Jennifer R. Paxton, CPA/Treasurer, and the Title I Director are responsible for implementing these procedures immediately.

View Audit 301414

Finding 390713 (2023-003)

Significant Deficiency 2023

Housing Authority of the City of Hope

AR

Procurement, Suspension & Debarment Allowable Costs / Cost Principles

Condition and Criteria: Expenses charged to the program should be specific to the operating expenses of the program. Allocation of payroll and related benefits were cited as a concern in the CMR. As a result, costs may not be properly allocated across all programs correctly.Auditor’s Recommendati...

Condition and Criteria: Expenses charged to the program should be specific to the operating expenses of the program. Allocation of payroll and related benefits were cited as a concern in the CMR. As a result, costs may not be properly allocated across all programs correctly.Auditor’s Recommendation: Documentation of expenses and the related procurement should be maintained and accessible for review. In addition, the cost allocation of expenses across programs should be reviewed. Grantee Response: After the end of the fiscal year, we reviewed the allocation of salaries and benefits among programs and provided a journal entry to be recorded as part of the audit adjustments. Anticipated Completion Date: June 30, 2024

View Audit 301395

Finding 390693 (2023-010)

Material Weakness 2023

Wabash City Schools

IN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness § 200.303

FINDING 2023-010 Finding Subject: ESSER (Education Stabilization Fund) – Allowable Activities, Allowable Costs/Cost Principles Federal Programs: Education Stabilization Fund Summary of Finding: An effective internal control system, which would include segregation of duties, was not in place at the S...

FINDING 2023-010 Finding Subject: ESSER (Education Stabilization Fund) – Allowable Activities, Allowable Costs/Cost Principles Federal Programs: Education Stabilization Fund Summary of Finding: An effective internal control system, which would include segregation of duties, was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Activities Allowed and Allowable Costs/Cost Principles compliance requirement. The School Corporation did not have internal controls in place over payroll disbursements. A detailed report of payroll disbursements paid without evidence of review and approval by a knowledgeable person. Contact Person Responsible for Corrective Action: Amy K. Sivley Contact Phone Number and Email Address: 260-563-2151; sivleya@apaches.k12.in.us Views of Responsible Officials: We concur with the finding. Explanation and Reasons for Disagreement: n/a Description of Corrective Action Plan: Develop process and procedures for verifying payroll disbursements from grant funds. On a monthly basis, Payroll coordinator will print payroll disbursements from federal grant funds to be reviewed, verified and signed off by Superintendent/CFO. Anticipated Completion Date: To begin immediately, March 2024

View Audit 301362

Finding 390690 (2023-009)

Material Weakness 2023

Wabash City Schools

IN

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.303 § 200.403

FINDING 2023-009 Finding Subject: Special Education Cluster - Earmarking Summary of Finding: The School Corporation is a member of the Wabash Miami Area Programs for Exceptional Children (Cooperative). During fiscal year 2021-2022 and 2022-2023, the Cooperative operated the special education program...

FINDING 2023-009 Finding Subject: Special Education Cluster - Earmarking Summary of Finding: The School Corporation is a member of the Wabash Miami Area Programs for Exceptional Children (Cooperative). During fiscal year 2021-2022 and 2022-2023, the Cooperative operated the special education programs and spent the federal money on behalf of all its members. As the grant agreements were between the Indiana Department of Education (IDOE) and each member school, the School Corporation was responsible for ensuring and providing oversight of the Cooperative. However, there was inadequate oversight performed by the School Corporation in order to ensure compliance with the Matching Level of Effort, Earmarking compliance requirement. The School Corporation did not have internal controls in place to ensure that the Cooperative complied with the earmarking requirements. The Cooperative did not have adequate procedures in place to ensure that the required level of expenditures for non-public school students with disabilities was met for each member school. The Cooperative did not have effective internal controls to ensure non-public school expenditures were appropriately identified and reported. The Non-Public Proportionate Share expenditures for the 20611-054-PN01, 20619-054-PN01, 21611- 054-PN01 and 21619-054-PN01 grant awards could not be verified for the individual member schools. The non-public school share funds for all member schools were comingled and the aggregate amount of expenditures was then allocated to the member schools on a percentage basis. These allocations were the amounts reported to IDOE. As such, we were unable to identify which expenditures were for each school in order to verify the minimum amount per the grant award was expended and properly reported to IDOE as required. The lack of internal controls and noncompliance were isolated to the 20611-054-PN01, 20619-054- PN01, 21611-054-PN01 and 21619-054-PN01 grant awards. Contact Person Responsible for Corrective Action: Amy K. Sivley Contact Phone Number and Email Address: 260-563-2151; sivleya@apaches.k12.in.us Views of Responsible Officials: We concur with the finding. Explanation and Reasons for Disagreement: n/a Description of Corrective Action Plan: The district will collaborate with the SPED co-op to implement controls to ensure compliance with earmarking requirements. Anticipated Completion Date: To be completed by July 2024

View Audit 301362

Finding 390682 (2023-006)

Material Weakness 2023

Wabash City Schools

IN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness § 200.303

FINDING 2023-006 Finding Subject: Special Education Cluster - Activities Allowed, Allowable Costs/Cost Principles, Period of Performance Summary of Finding: An effective internal control system, which would include segregation of duties, was not in place at the School Corporation in order to ensure ...

FINDING 2023-006 Finding Subject: Special Education Cluster - Activities Allowed, Allowable Costs/Cost Principles, Period of Performance Summary of Finding: An effective internal control system, which would include segregation of duties, was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Activities Allowed, Allowable Costs/Cost Principles, and Period of Performance compliance requirements. The School Corporation did not have internal controls in place over payroll disbursements. A detailed report of payroll disbursements was paid without evidence of review and approval by a knowledgeable person. Contact Person Responsible for Corrective Action: Amy K. Sivley Contact Phone Number and Email Address: 260-563-2151; sivleya@apaches.k12.in.us Views of Responsible Officials: We concur with the finding. Explanation and Reasons for Disagreement: n/a Description of Corrective Action Plan: Develop process and procedures for verifying disbursements from grant funds. On a monthly basis, Corporation Treasure will print expenditure report from federal grant funds to be reviewed, verified and signed off by Superintendent/CFO. Anticipated Completion Date: To begin immediately, March 2024

View Audit 301362

Finding 390676 (2023-005)

Material Weakness 2023

Wabash City Schools

IN

School Nutrition Programs Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.303

FINDING 2023-005 Finding Subject: Child Nutrition Cluster - Special Tests & Provisions: School Food Service Accounts Summary of Finding: The School Corporation had not properly designed or implemented a system of internal controls, which would include appropriate segregation of duties, that would li...

FINDING 2023-005 Finding Subject: Child Nutrition Cluster - Special Tests & Provisions: School Food Service Accounts Summary of Finding: The School Corporation had not properly designed or implemented a system of internal controls, which would include appropriate segregation of duties, that would likely be effective in preventing, or detecting and correcting, noncompliance for Special Tests & Provisions: School Food Service Accounts. Contact Person Responsible for Corrective Action: Amy K. Sivley Contact Phone Number and Email Address: 260-563-2151; sivleya@apaches.k12.in.us Views of Responsible Officials: We concur with the finding. Explanation and Reasons for Disagreement: n/a Description of Corrective Action Plan: On a monthly basis, Corporation Treasure will print receipt postings to be reviewed, verified and signed off by Superintendent/CFO. Anticipated Completion Date: To begin immediately, March 2024

View Audit 301362

Finding 390664 (2023-003)

Material Weakness 2023

Wabash City Schools

IN

Questioned Costs Allowable Costs / Cost Principles School Nutrition Programs § 200.302 § 200.303 § 200.439

FINDING 2023-003 Finding Subject: Child Nutrition Cluster - Allowable Activities and Allowable Costs Summary of Finding: The School Corporation had not properly designed or implemented a system of internal control, which would include appropriate segregation of duties, that would likely be effective...

FINDING 2023-003 Finding Subject: Child Nutrition Cluster - Allowable Activities and Allowable Costs Summary of Finding: The School Corporation had not properly designed or implemented a system of internal control, which would include appropriate segregation of duties, that would likely be effective in preventing, or detecting and correcting noncompliance related to allowable activities and allowable costs. The School Corporation purchased two pieces of equipment that were over $5,000 each in Fiscal Year 2023 without approval from the Federal awarding agency or pass-through entity. The first piece of equipment was a liftgate in the amount of $6,906, and the second piece of equipment was a vehicle in the amount of $7,500 for a combined total of $14,406. The financial management system of each non-federal entity must provide written procedures for determining allowability of costs in accordance with the federal regulations and the terms and conditions of the Federal Award. The policy should provide clear guidance as to what costs constitute appropriate direct and indirect charges to federal awards as well as provide for consistency in charging practices across the School Corporation. The School Corporation did not have an allowable costs policy outlining the School Corporation's processes and policies with regards to costs charged to federal grants. Contact Person Responsible for Corrective Action: Amy K. Sivley Contact Phone Number and Email Address: 260-563-2151; sivleya@apaches.k12.in.us Views of Responsible Officials: We concur with the finding. Explanation and Reasons for Disagreement: n/a Description of Corrective Action Plan: Retrain Food Service Director and Assistant Food Service Director on the process for purchasing equipment. The district will also develop and pass an Allowable Costs Policy. Anticipated Completion Date: To be completed by July 1, 2024

View Audit 301362 Questioned Costs: $1

Finding 390648 (2023-224)

Material Weakness 2023

State of Idaho

ID

Internal Control / Segregation of Duties Special Tests & Provisions Allowable Costs / Cost Principles § 200.303

Finding Number 2023-224: The required audited financial reports were not collected as required to ensure compliance with the Managed Care Organization contracts. Federal Programs: 93.777 - State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare; 93.778 Medical A...

Finding Number 2023-224: The required audited financial reports were not collected as required to ensure compliance with the Managed Care Organization contracts. Federal Programs: 93.777 - State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare; 93.778 Medical Assistance Program Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: The Division will amend all current managed care contracts to include the requirement to submit an audited financial report annually. This contract language will also be incorporated into all future Medicaid managed care procurements. The Division will also review and confirm all required contract elements outlined in 42 CFR 438.3 are clearly outlined in Medicaid managed care contracts. Lastly, the Division intends to coordinate with the Department of Insurance to learn more about their review process of audited financial statements and determine if there is an opportunity to coordinate oversight efforts for Medicaid managed care contracts going forward. Anticipated Corrective Action Date: September 2024 Responsible for Corrective Action: Juliet Charron, Division Administrator Juliet.Charron@dhw.idaho.gov 208-364-1831 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

View Audit 301345

Finding 390644 (2023-223)

Significant Deficiency 2023

State of Idaho

ID

Internal Control / Segregation of Duties Special Tests & Provisions Allowable Costs / Cost Principles § 200.303

Finding Number 2023-223: Managed Care providers lacked documentation to support continued eligibility within the Medicaid Program. Federal Programs: 93.777 - State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare; 93.778 Medical Assistance Program Related to P...

Finding Number 2023-223: Managed Care providers lacked documentation to support continued eligibility within the Medicaid Program. Federal Programs: 93.777 - State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare; 93.778 Medical Assistance Program Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: The 21st Century Cures Act requires all states to enroll both fee-for-service and managed care providers. Idaho Medicaid is currently out of compliance with this requirement for most of the providers within managed care contractor networks. The state is also working to come into compliance with a requirement in the Affordable Care Act to revalidate all enrolled providers at least every 5 years. The Division has begun the systems work necessary to come into compliance with both of these requirements and anticipates working through enrollment and revalidation activities into CY2025. Once completed, the Division will have an accurate and complete provider file that will be shared with contracted managed care plans to support their contracting efforts. Any providers who contract with the managed care plans will be required to be fully enrolled and credentialed with Idaho Medicaid before rendering services and billing. Pursuant to the Consolidated Appropriations Act of 2023, states are required by July 2025 to have a searchable and regularly updated provider directory for both managed care plans and fee-for-service programs. Idaho Medicaid is working to develop processes to validate directories and ensure that providers are providing updates to their information as necessary. Through this effort, Idaho Medicaid will further bolster internal processes and controls to ensure accurate provider network information is shared with Medicaid participants and maintained within our systems. Anticipated Corrective Action Date: July 2025 Responsible for Corrective Action: Juliet Charron, Division Administrator Juliet.Charron@dhw.idaho.gov 208-364-1831 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

View Audit 301345

Finding 390638 (2023-217)

Material Weakness 2023

State of Idaho

ID

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Student Financial Aid § 200.303

Finding Number 2023-217: The Department does not have documented internal controls for adjustments processed to the Foster Care -Title IV—E program. Federal Programs: 93.658 – Foster Care Title IV-E Related to Prior Finding: N/A Agency’s view: The Office agrees with this finding. Corrective Act...

Finding Number 2023-217: The Department does not have documented internal controls for adjustments processed to the Foster Care -Title IV—E program. Federal Programs: 93.658 – Foster Care Title IV-E Related to Prior Finding: N/A Agency’s view: The Office agrees with this finding. Corrective Action: The Department will continue to record adjustment activity through Help Desk tickets, SharePoint documentation, and ESPI. The Department will ensure improved visibility to the adjustment and approval process and documentation by ensuring all roles who need access (including auditors), have access to all relevant systems and storage locations such as access to SharePoint and Help Desk tickets. This step will be completed by April 30, 2024. Anticipated Corrective Action Date: April 30, 2024 Responsible for Corrective Action: Cameron Gilliland, Division Administrator Cameron.Gilliland@dhw.idaho.gov 208-334-0641 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

View Audit 301345

Finding 390637 (2023-216)

Material Weakness 2023

State of Idaho

ID

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303

Finding Number 2023-216: The Department did not have appropriate documentation to support allowability of transactions for the Foster Care Title IV-E program. Federal Programs: 93.658 – Foster Care Title IV-E Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. ...

Finding Number 2023-216: The Department did not have appropriate documentation to support allowability of transactions for the Foster Care Title IV-E program. Federal Programs: 93.658 – Foster Care Title IV-E Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: A new feature was added to ESPI on 1/9/24 to record the reason (purpose) for certain service types, including transportation. The system is programmed to disallow Title IV-E if the reason listed does not meet IV-E eligibility criteria (see image below). An additional control will be added to the system to have the same control procedure used for a medical service type and education service type. Further development is underway for additional control procedures and should be completed by April of 2025. P-card transactions do not process through ESPI. Quarterly reports will be obtained to review any P-card transactions that utilized Title IV-E to confirm appropriate documentation is on record. This will be completed by April 30, 2024. Anticipated Corrective Action Date: April 30, 2024 Responsible for Corrective Action: Cameron Gilliland, Division Administrator Cameron.Gilliland@dhw.idaho.gov 208-334-0641 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

View Audit 301345 Questioned Costs: $1

Finding 390630 (2023-213)

Material Weakness 2023

State of Idaho

ID

Subrecipient Monitoring Allowable Costs / Cost Principles § 200.1 § 200.303 § 200.331 § 200.332 § 200.414

Finding Number 2023-213: The Department erroneously determined that two recipients of Temporary Assistance for Needy Families (TANF) funding were contractors instead of subrecipients resulting in noncompliance with the subrecipient monitoring requirements. Federal Programs: 93.558 – Temporary Ass...

Finding Number 2023-213: The Department erroneously determined that two recipients of Temporary Assistance for Needy Families (TANF) funding were contractors instead of subrecipients resulting in noncompliance with the subrecipient monitoring requirements. Federal Programs: 93.558 – Temporary Assistance for Needy Families Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: The Department has revised our training of personnel involved in subrecipient and contractor determinations. These contract managers and monitors completed grant training on March 12th-13th, 2024 which included sections about subrecipient and contractor determinations, risk assessment and documentation. All newly hired employees will be trained beginning April 2024 with an on-line module. For the impacted vendor, an updated Risk Assessment was completed and submitted to LSO. Additionally, the Department has started the work to effectively change the designation of the vendor and ensure all required information is provided to this subrecipient. This process will be completed by April 30th, 2024. The Department will develop internal control procedures to ensure all required information is provided to the subrecipients at the time of the subawards. These updated internal control procedures will be completed by June 30th, 2024. Anticipated Corrective Action Date: June 30, 2024 Responsible for Corrective Action: Cameron Gilliland, Division Administrator Cameron.Gilliland@dhw.idaho.gov 208-334-0641 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

View Audit 301345

Finding 390629 (2023-212)

Material Weakness 2023

State of Idaho

ID

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303

Finding Number 2023-212: The review of the Low-Income Home Energy Assistance Program (LIHEAP) earmarking compliance requirements was not documented. Federal Programs: 93.568 – Low-Income Home Energy Assistance Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. ...

Finding Number 2023-212: The review of the Low-Income Home Energy Assistance Program (LIHEAP) earmarking compliance requirements was not documented. Federal Programs: 93.568 – Low-Income Home Energy Assistance Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: The Program will document the current process regarding the preparation, review, and approval of the Low-Income Home Energy Assistance Program (LIHEAP) budget that includes maintaining the documentation of the earmarking reviews that are being completed. The program will prepare the Low-Income Home Energy Assistance Program (LIHEAP) budget. This budget will be submitted to the Bureau Chief, as a second review of accuracy and compliance, to include review of earmarking limits, prior to routing the Annual State Plan for review and submittal or the allocation of any funding. Documentation will be maintained to support the review and approval. Anticipated Corrective Action Date: The Program will write a process document to support this corrective action and will implement this process prior to the start of the new LIHEAP season beginning 10/1/2024. Program will have a process document in place by 9/30/24. Responsible for Corrective Action: Shane Leach, Division Administrator Shane.Leach@dhw.idaho.gov 208-859-1033 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

View Audit 301345

Finding 390628 (2023-211)

Significant Deficiency 2023

State of Idaho

ID

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.303

Finding Number 2023-211: The review and approval of the annual updates to the Low-Income Home Energy Assistance Program (LIHEAP) benefits matrix were not documented. Federal Programs: 93.568 – Low-Income Home Energy Assistance Related to Prior Finding: N/A Agency’s view: The Department agrees wit...

Finding Number 2023-211: The review and approval of the annual updates to the Low-Income Home Energy Assistance Program (LIHEAP) benefits matrix were not documented. Federal Programs: 93.568 – Low-Income Home Energy Assistance Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: Testing of the updated benefits matrix will be completed by the Program annually, and the results will be documented using an established scenario testing script. Results of the testing will be documented and submitted to the Bureau Chief, as a second review of accuracy and compliance, prior to moving the updated matrix into the production environment. Documentation will be maintained to support the review and approval. Anticipated Corrective Action Date: The Program will write a process document to support this corrective action and will implement this process prior to the start of the new LIHEAP season beginning 10/1/2024. Program will have a process document in place by 9/30/24. Responsible for Corrective Action: Shane Leach, Division Administrator Shane.Leach@dhw.idaho.gov 208-859-1033 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

View Audit 301345

Corrective Action Plans

Filters