Corrective Action Plans

Finding 498752 (2023-001)

Material Weakness 2023

Thurston County

WA

Subrecipient Monitoring Internal Control / Segregation of Duties Allowable Costs / Cost Principles

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Thurston County January 1, 2023 through December 31, 2023 This schedule presents the corrective action planned by the County for findings reported in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part...

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Thurston County January 1, 2023 through December 31, 2023 This schedule presents the corrective action planned by the County for findings reported in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2023-001 Finding caption: The County had inadequate internal controls for ensuring compliance with federal reporting requirements. Name, address, and telephone of County contact person: Darren Bennett, Financial Services Manager, (360) 867-2253 2000 Lakeridge Dr. SW Olympia, WA 98502-6090 Corrective action the auditee plans to take in response to the finding: The County values the opportunity to collaborate with the State Auditor’s Office in enhancing our financial reporting processes. In 2022, we faced notable turnover in the positions responsible for FFATA reporting due to the Public Health Emergency. Furthermore, as we transitioned out of this emergency in 2023, ongoing staffing challenges contributed to a loss of historical knowledge and established practices. In response to the recommendation, the County has taken and plans to take the following actions: • Update procedures for FFATA reporting, including staff responsibilities and timelines (implemented 8/2/2024). • Ensure management oversight to ensure timely and accurate reporting. • Provide training to all staff involved in the FFATA reporting process on their responsibilities (occurred 8/1/2024) We appreciate the opportunity to work with the State Auditor’s Office staff to improve the accuracy of our FFATA reporting requirements. Anticipated date to complete the corrective action: August 2, 2024

View Audit 321441

Finding 498750 (2023-001)

Material Weakness 2023

San Antonio Community Hospital

CA

Allowable Costs / Cost Principles Period of Performance Matching / Level of Effort / Earmarking

Finding 2023-001 Internal Control Deficiency over Allowable Costs Federal Grantor: United States Department of Homeland Security Assistance Listing No.: 97.036 Award Period of Performance: January 1, 2020 – July 1, 2022 Summary of Finding: Management did not consistently retain documentation evid...

Finding 2023-001 Internal Control Deficiency over Allowable Costs Federal Grantor: United States Department of Homeland Security Assistance Listing No.: 97.036 Award Period of Performance: January 1, 2020 – July 1, 2022 Summary of Finding: Management did not consistently retain documentation evidencing the performance of internal controls in place to review and approve FEMA expenditures submitted to the FEMA Portal. Corrective Action Plan: Management will ensure documentation is retained to evidence the controls were performed. Responsible Party: Wah-chung Hsu, Chief Financial Officer Anticipated Completion Date: December 31, 2024

View Audit 321440

Finding 498736 (2023-001)

Significant Deficiency 2023

Converge, Inc.

MS

Questioned Costs Procurement, Suspension & Debarment Allowable Costs / Cost Principles

Management agrees with the finding and has already implemented approval processes prior to purchasing. We have also implemented itemized receipts required for all purchase in our expense management software.

View Audit 321411 Questioned Costs: $1

Finding 498706 (2023-002)

Material Weakness 2023

Maine Afl-Cio

ME

Allowable Costs / Cost Principles

All invoices and expenditures follow procedures outlined in the ME AFL-CIO Financial Management Policies and receive approval prior to payment being issued. All amounts charged to the award reflect amounts in budgets approved in the contract. The Organization is now requesting stipend recipients t...

All invoices and expenditures follow procedures outlined in the ME AFL-CIO Financial Management Policies and receive approval prior to payment being issued. All amounts charged to the award reflect amounts in budgets approved in the contract. The Organization is now requesting stipend recipients to sign receipts. Regarding the six out of 20 disbursements lacking adequate support for expenses charged to the Registered Apprenticeship contract, five of these six were individual pre-apprentice participants who were prohibited from completing our financial need pre-screening form and signing it. As an alternative process we interviewed these five individuals and interviewed their pre-release supervisors and confirmed financial need in all five cases. Management will research compliance with CFDA numbers at the beginning of the grant. All grant related expenses match approved expenses in accordance with the contracts and grant guidance. Moving forward, we will implement tracking by class in Quickbooks, more aggressively track time charged to awards, and again review the OMB Compliance Supplements for each award.

View Audit 321405

Finding 498678 (2023-002)

Material Weakness 2023

Topeka Housing Authority

KS

Questioned Costs Allowable Costs / Cost Principles HUD Housing Programs § 200.403 § 200.405

The Authority will limit advancing funds from the Section 8 Housing Choice Voucher and Emergency Housing Voucher Programs, to allowable Fees only. The Authority’s Executive Director, Trey George, has assumed the responsibility of executing this corrective action as of November 1, 2024.

View Audit 321393 Questioned Costs: $1

Finding 498668 (2023-002)

Material Weakness 2023

Mahnomen County

MN

Questioned Costs Allowable Costs / Cost Principles HUD Housing Programs

Contact Person – Bruce Starkey, County Administrator Corrective Action Plan – The County will review procedures to ensure expenditures charged to federal programs are supported with actual expenditures. Reports will undergo a review prior to submission. Completion Date – 9/30/2024

View Audit 321383 Questioned Costs: $1

Finding 498608 (2023-003)

Material Weakness 2023

City of Olympia

WA

Subrecipient Monitoring Special Tests & Provisions Allowable Costs / Cost Principles

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE City of Olympia January 1, 2023 through December 31, 2023 This schedule presents the corrective action planned by the City for findings reported in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 2...

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE City of Olympia January 1, 2023 through December 31, 2023 This schedule presents the corrective action planned by the City for findings reported in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). ref number: 2023-003 Finding caption: The City did not have adequate internal controls in place for ensuring compliance with federal special reporting and rehabilitation requirements. Name, address, and telephone of City contact person: Darian Lightfoot, Director of Housing and Homeless Response 601 4th Ave E, Olympia, WA 98501 (360)753-8033 Corrective action the auditee plans to take in response to the finding: The City takes seriously the use of federal funds, and the compliance requirements associated with them. The Housing and Homelessness Response team is committed to ensuring there are no further instances of noncompliance by updating our processes to meet these requirements. The inspections of rehabilitation projects were being performed remotely by reviewing contractor invoices and payments as evidence of work completion. Though each individual project site was not visited, the team did perform on-site monitoring visits at subrecipients’ locations and reviewed subrecipients’ documentation of project files. This process was a holdover from COVID, when we were unable to physically go on site to every project site. As COVID restrictions have lifted, we understand that a physical inspection at each site is now necessary. Moving forward, we have implemented requirements to inspect all sites receiving CDBG rehabilitation funding as a part of project close-out. Staff will also continue to review subrecipient records during monitoring to ensure subrecipients have adequate recordkeeping of completed rehabilitation projects. The department was unaware of the requirements of the FFATA filing and will be scheduling trainings to learn more about grant requirements. We thank the auditors for bringing the requirements to our attention. Anticipated date to complete the corrective action: 12/31/2024

View Audit 321336

Finding 498591 (2023-002)

Material Weakness 2023

Baltimore Corps, INC

DC

Allowable Costs / Cost Principles § 200.430 § 200.514

Schedule of Corrective Action Plan For the Year Ended June 30, 2023 Finding 2023-002: Material Weakness over Activities Allowed or Unallowed and Allowable Cost/Cost Principle (Payroll) Responsible Official’s Response and Corrective Action Plan We concur with the finding related to deficiencies in ou...

Schedule of Corrective Action Plan For the Year Ended June 30, 2023 Finding 2023-002: Material Weakness over Activities Allowed or Unallowed and Allowable Cost/Cost Principle (Payroll) Responsible Official’s Response and Corrective Action Plan We concur with the finding related to deficiencies in our time tracking Process. We have implemented a time tracking system using QuickBooks Time starting in the fourth quarter of fiscal year 2024. This system is designed to accurately capture, and record employees’ hours worked by project/grant. Comprehensive training sessions have been conducted for all affected employees to ensure they are proficient in using the new time tracking system. Supervisors have received additional training on monitoring and verifying time entries. Planned Implementation Date of Corrective Action Plan April 1, 2024 Person Responsible for Corrective Action Plan Caryn York, Executive Director

View Audit 321331

Finding 498543 (2023-003)

Material Weakness 2023

Town of Arcadia

IN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness § 200.1 § 200.303

FINDING 2023-003 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The Project and Expenditure (P&E) report covering April 1, 2022, to March 31, 2023, was submitted without a review or oversight process in place to prevent or detect and cor...

FINDING 2023-003 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The Project and Expenditure (P&E) report covering April 1, 2022, to March 31, 2023, was submitted without a review or oversight process in place to prevent or detect and correct errors. As a result, errors in reporting were identified. Contact Person Responsible for Corrective Action: Jennifer Pickett Contact Person Phone Number: 317-984-3512 jennifer.pickett@arcadia.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: When the Clerk-Treasurer goes to do the Project and Expenditure report next, she will have the Grant Administrator set with her to complete the form. After the form is completed and has no errors the Clerk Treasurer will print the report off and allow her Deputy Clerk Treasurer to review it. Anticipated Completion Date: This will be corrected in 2025 when the report must be submitted again.

View Audit 321300

Finding 498531 (2023-001)

Material Weakness 2023

Howard County

IN

Allowable Costs / Cost Principles Material Weakness Period of Performance § 200.1 § 200.303

FINDING 2023-001 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Summary of Finding: The Deputy Auditor prepared the quarterly reports and the Auditor reviewed the reports; however, the control was not effective and did not detect and allow correction of mat...

FINDING 2023-001 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Summary of Finding: The Deputy Auditor prepared the quarterly reports and the Auditor reviewed the reports; however, the control was not effective and did not detect and allow correction of material misstatements prior to submission. Two of the four quarterly reports submitted during the audit period were selected for testing. For the two reports tested, all activity for the reporting period was not included, information submitted was not supported by the County's records, and the reports were not fairly presented Contact Person Responsible for Corrective Action: Jessica Secrease Contact Phone Number and Email Address: 765-456-2804 Jessica.secrease@howardcountyin.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The County will follow the internal controls established, including policies and procedures to ensure that the County provides the Treasury with complete and accurate information for the P&E Report in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. The Chief Deputy will continue to work with the Projects Manager to ensure the reporting is accurate and all obligations and expenditures are reported correctly before sending the information to a third-party vendor. The Auditor will review and approve any reporting prior to submission. Initialed reports will be kept within the grant file. Anticipated Completion Date: September 2024

View Audit 321268

Finding 498509 (2023-004)

Material Weakness 2023

Traverse County

MN

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

Finding Number: 2023-004 Finding Title: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Shelly Staebler Corrective Action Planned: Traverse County Social Services Fiscal departmen...

Finding Number: 2023-004 Finding Title: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Shelly Staebler Corrective Action Planned: Traverse County Social Services Fiscal department will work on identifying allowable and unallowable expenditures that are submitted on these reports, so only allowable expenditures are submitted going forward. Anticipated Completion Date: Completed, September 7, 2024

View Audit 321238

Finding 498502 (2023-002)

Significant Deficiency 2023

Metropolitan Public Defender Services, Inc.

OR

Allowable Costs / Cost Principles

Finding no.: 2023-002 Contact person(s) responsible: Sally Alworth Corrective action planned: As of April 1, 2023, MPD has adopted a new written policy for administrative cost allocation. Costs that are not allowable for federal grants are flagged both on timecards and on purchasing transactio...

Finding no.: 2023-002 Contact person(s) responsible: Sally Alworth Corrective action planned: As of April 1, 2023, MPD has adopted a new written policy for administrative cost allocation. Costs that are not allowable for federal grants are flagged both on timecards and on purchasing transactions with a subaccount code that segregates them from overhead allocations. Costs related to facilities – rent, equipment leases, office insurance, shared supplies, depreciation, etc. – are now allocated to departments based on the square footage occupancy of each department, calculated using the guidance referenced in 2 CFR 200. Administrative costs that serve the entire organization such as Human Resources, Accounting, outsourced IT support, etc., are allocated to each department based on headcount, as we consider the number of personnel per department to be the best estimate of supporting services required by each team. The Payroll Specialist generates a current employee roster by department at the end of each month, which is used to update the administrative allocation. Once all costs have been allocated to the department level, both facilities and administrative costs are allocated down to individual grants based on the proportion of total wage costs assigned to each grant within the department for that month. Anticipated completion date: April 1, 2023

View Audit 321233

Finding 498501 (2023-001)

Material Weakness 2023

Metropolitan Public Defender Services, Inc.

OR

Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.420 § 200.476

Finding no.: 2023-001 Contact person(s) responsible: Sally Alworth Corrective action planned: As of April 15, 2023, a new timecard system was implemented and charges to grants are supported by actual timecard entries. Timecards are approved by the employee and reviewed by a supervisor prior to...

Finding no.: 2023-001 Contact person(s) responsible: Sally Alworth Corrective action planned: As of April 15, 2023, a new timecard system was implemented and charges to grants are supported by actual timecard entries. Timecards are approved by the employee and reviewed by a supervisor prior to payroll processing. Anticipated completion date: April 15, 2023

View Audit 321233

Finding 498487 (2023-002)

Significant Deficiency 2023

Enterprisekc

KS

Procurement, Suspension & Debarment Allowable Costs / Cost Principles

Corrective Action Plan 2023-002: EnterpriseKC has conducted the suspension and debarment checks and has included those checks in the contract files for all covered transactions and has also updated its procedures to ensure those checks are conducted and added to the contract file at or before the co...

Corrective Action Plan 2023-002: EnterpriseKC has conducted the suspension and debarment checks and has included those checks in the contract files for all covered transactions and has also updated its procedures to ensure those checks are conducted and added to the contract file at or before the contract effective date. Completion Date: August 2024 Contact Person: Jay Konomos, Pillar Leader

View Audit 321192

Finding 498486 (2023-001)

Significant Deficiency 2023

Enterprisekc

KS

Questioned Costs Allowable Costs / Cost Principles § 200.413 § 200.430

Corrective Action Plan 2023-001: Management will implement a comprehensive time tracking review process that also extends to reviewing time for employees that choose to work remotely and will ensure that time not allocated to the grant is not included in the costs allocated to the grant. Management ...

Corrective Action Plan 2023-001: Management will implement a comprehensive time tracking review process that also extends to reviewing time for employees that choose to work remotely and will ensure that time not allocated to the grant is not included in the costs allocated to the grant. Management will revise the fringe benefit rate that gets charged to the hourly rates to ensure that none of the costs included in the fringe benefits are also direct expenses billed to the grant. The unallowable costs will be redirected to other allowable grant costs in 2024. Anticipated Completion Date: September 2024 Contact Person: Jay Konomos, Pillar Leader

View Audit 321192 Questioned Costs: $1

Finding 498466 (2023-001)

None 2023

Medical Debt Resolution, Inc.

NY

Questioned Costs Allowable Costs / Cost Principles

Finding Number: 2023-001 Compliance Requirement: Activities Allowed or Unallowed; Allowable Costs/Cost Principles Programs: United States Department of the Treasury ALN Number: 21.019 ALN Name: Coronavirus Relief Fund Contract Periods: August 9, 2022 – December 31, 2024 (County of Cook, Illinois); J...

Finding Number: 2023-001 Compliance Requirement: Activities Allowed or Unallowed; Allowable Costs/Cost Principles Programs: United States Department of the Treasury ALN Number: 21.019 ALN Name: Coronavirus Relief Fund Contract Periods: August 9, 2022 – December 31, 2024 (County of Cook, Illinois); June 16, 2023 – June 16, 2024 (City of New Orleans, Louisiana) Planned Corrective Action: In order to ensure that retroactive personnel costs are allocated to grants appropriately, the following measures are being implemented: 1. Effective October 1, 2024, Medical Debt Resolution, Inc. (the Organization) is transitioning to a common-date annual review including a common annual salary adjustment date for all personnel. This will ensure a timely administration of personnel compensation adjustments, thus eliminating the need for retroactive pay. 2. In the unlikely event of a retrospective pay need in the future, the Organization will develop and implement a new standard operating procedure for Allocation of Retrospective Pay which will provide guidelines for how to appropriately allocate the cost across funds if multiple periods are involved. 3. The Organization is thoroughly reviewing all retrospective payments made in 2023 and 2024 YTD and will be issuing an adjustment to all grants, as applicable, by October 31, 2024. Person Responsible: Vice President, Finance & Administration Expected Completion Date: October 31, 2024

View Audit 321164 Questioned Costs: $1

Finding 498463 (2023-010)

Significant Deficiency 2023

City of Baton Rouge - Parish of East Baton Rouge

LA

Allowable Costs / Cost Principles

Management’s response and corrective action is as follows: To improve the accuracy of ITA tracking, a revised ITA tracking system will be implemented. This will include data entry fields to capture all necessary information for each ITA payment, minimizing errors and omissions. Reconciliation wi...

Management’s response and corrective action is as follows: To improve the accuracy of ITA tracking, a revised ITA tracking system will be implemented. This will include data entry fields to capture all necessary information for each ITA payment, minimizing errors and omissions. Reconciliation with MUNIS on a monthly basis to identify any discrepancies. Additionally, mandatory training on the revised ITA Tracking system will be conducted for relevant staff members to ensure continuity. Expected Implementation Date: July 202 Contact person: Amanda Stanley, Chief WIOA Administrator, EmployBR

View Audit 321162

Finding 498460 (2023-009)

Significant Deficiency 2023

City of Baton Rouge - Parish of East Baton Rouge

LA

Allowable Costs / Cost Principles § 200.430

Management’s response and corrective action is as follows: To improve the accuracy and timeliness of payroll processing, a revised payroll procedures manual will be developed and disseminated to all staff responsible for time approval. Additionally, mandatory training on the ExecuTime system will ...

Management’s response and corrective action is as follows: To improve the accuracy and timeliness of payroll processing, a revised payroll procedures manual will be developed and disseminated to all staff responsible for time approval. Additionally, mandatory training on the ExecuTime system will be conducted for these staff members to ensure they have the necessary skills for proper and timely time sheet approvals. Expected Implementation Date: June 2024 Contact person: Amanda Stanley, Chief WIOA Administrator, EmployBR

View Audit 321162

Finding 498457 (2023-006)

Significant Deficiency 2023

City of Baton Rouge - Parish of East Baton Rouge

LA

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management

Management’s response and corrective action is as follows: Architect certification is not required by the Department of Housing and Urban Development nor our policies and procedures. It is listed in our contracts as one of the many different types of reimbursement documentation our office will acc...

Management’s response and corrective action is as follows: Architect certification is not required by the Department of Housing and Urban Development nor our policies and procedures. It is listed in our contracts as one of the many different types of reimbursement documentation our office will accept. For many projects, an architect certification for each draw would be financially prohibitive and would likely reduce the financial viability of affordable housing developments. Our office does conduct intermittent on-site or desktop monitoring throughout the course of the project to ensure evidence activities. Additionally, all construction projects must complete permit requirements to ensure housing quality. Evidence of monitoring or activity was provided to the auditors. Expected Implementation Date: October 2024 Contact person: Marlee Pittman Miller, Director, Mayor-President’s Office of Community Development

View Audit 321162

Finding 498455 (2023-004)

Significant Deficiency 2023

City of Baton Rouge - Parish of East Baton Rouge

LA

Questioned Costs Subrecipient Monitoring Internal Control / Segregation of Duties § 200.522

Management’s response and corrective action is as follows: After reviewing the condition, cause, and effect of the presented Finding, the City-Parish finds it important to clarify that the duplicative charges were initially identified and documented as a self-reported finding. This discrepancy was...

Management’s response and corrective action is as follows: After reviewing the condition, cause, and effect of the presented Finding, the City-Parish finds it important to clarify that the duplicative charges were initially identified and documented as a self-reported finding. This discrepancy was discovered during the subrecipient monitoring component of this award and was promptly reported and reconciled prior to being presented as an audit finding. Upon identification of the duplicative charges, totaling approximately $22,000, immediate corrective action was taken to address the non-compliance. Dated January 5, 2024, a memorandum was filed disclosing the duplicative reimbursements, documenting the actions taken to rectify these charges, and recommending further steps to enhance the internal controls of the non-profit organization. The following information summarizes the East Baton Rouge City-Parish American Rescue Plan Act (ARPA): Duplication of Benefits - Findings and Corrective Action Memorandum: This memorandum documents the incidental reimbursement of multiple duplicative items associated with the subrecipient’s grant agreement and the corrective actions undertaken to resolve these findings, ensuring compliance with the terms of this award. During the routine subrecipient monitoring reviews, it was discovered that duplicate reimbursements occurred for 12 items between separate federal awards (American Rescue Plan Act SLFRF and CARES Act). In accordance with 2 CFR 200.522(c), a corrective action plan was provided to resolve the non-compliance. To address this, the following actions were taken: 1) Reconciliation of Duplicate Reimbursements: The non-profit entity has since reconciled the total value of $22,222.98 in duplicate reimbursements with an equivalent value of eligible expenses, including all necessary backup documentation to satisfy existing procurement and reimbursement requirements. 2) Development of a Duplication of Benefits Policy: It was recommended that the non-profit entity develop a comprehensive duplication of benefits policy to strengthen their internal controls further. These additional safeguards are considered best practices and are intended to minimize the risk of future non-compliance. Additionally, a comprehensive, grant specific, financial management policy template was provided to support the non-profits action to adopt and implement an appropriate standard of internal controls. The City-Parish is committed to maintaining robust internal controls and ensuring compliance with federal regulations. Immediate corrective measures were proactively taken to address these duplicative charges. Additionally, the City-Parish's third-party grants manager has established recurring weekly monitoring meetings with the non-profit entity to support the development and implementation of an adequate system of internal controls. Continuous efforts are being made to improve these processes to prevent such issues in the future. Expected Implementation Date: January 2024 Contact person: Courtney Scott, Assistant Chief Administrative Officer, Mayor-President’s Office

View Audit 321162 Questioned Costs: $1

Finding 498454 (2023-003)

None 2023

City of Baton Rouge - Parish of East Baton Rouge

LA

Questioned Costs Allowable Costs / Cost Principles

Management’s response and corrective action is as follows: The volume, complexity, and rapid pace needed to provide benefits inherently results in higher risk of fraud. The City-Parish's policies and procedures detected the fraud as required by program guidance. Additional restrictions were impleme...

Management’s response and corrective action is as follows: The volume, complexity, and rapid pace needed to provide benefits inherently results in higher risk of fraud. The City-Parish's policies and procedures detected the fraud as required by program guidance. Additional restrictions were implemented to further protect the program from fraud including no longer allowing any exceptions to homestead, not allowing any single-room rentals, and requiring a landlord provide documentation of 3 months of rental payments/deposits—no handwritten receipts accepted. The City-Parish also sent an email blast out to applicants to ensure they understood the additional documentation requirements. Consultants for the City-Parish provided a fraud detection tip sheet to case managers, consolidating previously given guidance, to assist them in determining potential incidents of fraud. There have been no instances of suspected fraud since July 2023 due to these measures. Expected Implementation Date: June 2024 Contact person: Dante Bidwell, Chief Administrative Officer, Office of the Mayor-President

View Audit 321162 Questioned Costs: $1

Finding 498429 (2023-006)

Significant Deficiency 2023

State of Missouri

MO

Questioned Costs Allowable Costs / Cost Principles Eligibility

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Social Services (DSS) – MO HealthNet Division (MHD) and Family Support Division (FSD) Audit Finding Number: 2023-006 Medicaid and CHIP Participant Eligibility Terminations Name of...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Social Services (DSS) – MO HealthNet Division (MHD) and Family Support Division (FSD) Audit Finding Number: 2023-006 Medicaid and CHIP Participant Eligibility Terminations Name of the contact person responsible for corrective action: Heather Atkins Anticipated completion date for corrective action: June 30, 2024 Recommendations: The DSS through the MHD and the FSD review, strengthen, and enforce internal controls to ensure ineligible participant cases are closed when necessary and resume the DHSS vital records death match in the MEDES. DSS Response: The DSS partially agrees with this finding. Although, at this time, a death match with Department of Health and Senior Services (DHSS) vital records is not functional in MEDES, the death match is functional in the Family Assistance Management Information System (FAMIS) eligibility system currently used for SNAP, TANF, and MO HealthNet for Aged, Blind, and Disabled individuals. When the match is received into FAMIS from DHSS, that information is included on the eligibility file submitted to MMIS to ensure that the death date is captured in MMIS to prohibit any payments after the death of the individual. This control ensures that no improper payments are made on a beneficiary’s behalf after the date of death. DSS has processes in place to close eligibility when death information is received from family members and providers during the certification period. Additionally, DSS administers an electronic verification match with the federal hub during the annual review process to inquire about death. DSS also intends to resume use of the DHSS vital statistics match in MEDES in the future, but does not have an expected resumption date at this time. During the audit period, the FSD Call Center had processes in place to accept calls for applications, renewals, change in circumstance, and inquiries. However, contracted staff are unable to authorize any action that results in a case closing and that authorization must be completed by a DSS employee. There were procedures in place to transfer a call that will result in a case closing to a DSS employee. However, the participant cited in the finding failed to remain on the line during the transfer process, resulting in DSS staff not receiving the request to voluntarily close the case. Although call center staff noted in the electronic case file the purpose of the call, there are not systematic controls in place to take action or create tasks for DSS employees from the case notes. The DSS is strengthening internal controls by developing technology to receive changes from participants using technology that will populate the changes reported into MEDES and will create a task for DSS staff to review and authorize the change in the case. Additionally, participants can also report changes, including voluntary case closure on the FSD Portal at https://mydss.mo.gov/. Changes reported through the FSD Portal are uploaded and tasks are generated for DSS staff to review and complete the determination. Corrective action planned is as follows: Technology updates to receive changes from participants will be implemented in June 2024.

View Audit 321142 Questioned Costs: $1

Finding 498428 (2023-005)

Significant Deficiency 2023

State of Missouri

MO

Allowable Costs / Cost Principles Eligibility Significant Deficiency

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Social Services (DSS) – MO HealthNet Division (MHD) and Family Support Division (FSD) Audit Finding Number: 2023-005 Medicaid and CHIP MAGI-Based Participant Eligibility Redeterminations...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Social Services (DSS) – MO HealthNet Division (MHD) and Family Support Division (FSD) Audit Finding Number: 2023-005 Medicaid and CHIP MAGI-Based Participant Eligibility Redeterminations Name of the contact person responsible for corrective action: Heather Atkins Anticipated completion date for corrective action: N/A Recommendations: The DSS through the MHD and the FSD review and correct cases for participants with manual overrides in the MEDES, ensure redeterminations are completed for these participants as required, and close the cases of any ineligible participants. In addition, the DSS should ensure system controls are functioning as designed for these participants. DSS Response: The DSS disagrees with this finding. The DSS disagrees there is a significant deficiency in internal controls. As noted in the finding, from the 60 participants selected, the SAO did not identify any participants with previously-established overrides; therefore, no incorrect payments were cited. Section 6008 of the Families First Coronavirus Response Act (FFCRA) required states to provide continuous coverage, through the end of the month in which the PHE period ends, to all Medicaid beneficiaries who were enrolled in Medicaid on or after March 18, 2020, regardless of any changes in eligibility unless the individual voluntarily terminated eligibility, is deceased, or moved out of state. As required by the Centers for Medicaid and Medicare Services (CMS) during the PHE, the DSS had processes in place to terminate eligibility for individuals who were deceased, voluntarily requested closure, or reported they have moved out of state when a current change was reported. The Consolidated Appropriations Act, 2023, signed on December 29, 2022, amended section 6008 of the FFCRA such that the continuous enrollment condition ended on March 31, 2023. During the PHE, the DSS did not conduct reviews of cases that did not report current changes. The DSS developed a report identifying all individuals with manual overrides and their certification dates to complete annual reviews on them. The DSS is actively working the report and have initiated annual reviews on all individuals that have had MO HealthNet eligibility for at least twelve consecutive months. The DSS anticipates completing the review of all individuals by August 31, 2024, to account for the required 90 day reconsideration period as required in 42 CFR 435.916.

View Audit 321142

Finding 498426 (2023-003)

Material Weakness 2023

State of Missouri

MO

Allowable Costs / Cost Principles Eligibility Matching / Level of Effort / Earmarking

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Social Services (DSS) – MO HealthNet Division (MHD) and Missouri Medicaid Audit and Compliance (MMAC) Audit Finding Number: 2023-003 - Medicaid and CHIP New Provider Eligibility ...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Social Services (DSS) – MO HealthNet Division (MHD) and Missouri Medicaid Audit and Compliance (MMAC) Audit Finding Number: 2023-003 - Medicaid and CHIP New Provider Eligibility Name of the contact person responsible for corrective action: Dale Carr Anticipated completion date for corrective action: June 30, 2024 Recommendation: The DSS through the MHD and the MMAC review, strengthen, and enforce internal controls to ensure complete new provider enrollment application checklists are prepared and retained documenting that new Medicaid and CHIP provider applications were reviewed and screened as required. DSS Response: DSS agrees with the auditor's recommendation. The Corrective Action Plan includes the department’s planned actions to address the finding. Corrective action planned is as follows: 1. The MMAC Provider Enrollment Unit (PEU) will add a new final check box at the bottom of the provider enrollment verification form where the PEU clerk will verify each required step to enroll a new provider was completed. 2. The MMAC PEU will increase the number of quality control reviews of completed provider enrollment verification checklists by supervisors and managers. 3. MMAC PEU will train the staff that are scanning the completed enrollment files into FileNet to look at the verification checklist and make sure it has all required initials and checks. If they determine it does not, it will be returned to the PEU staff member that processed the enrollment. 4. All PEU staff working new enrollments will be retrained on the importance of checking each step on the verification checklist to indicate whether each step was completed or “not applicable”.

View Audit 321142

Finding 498414 (2023-016)

Significant Deficiency 2023

State of Missouri

MO

Questioned Costs Allowable Costs / Cost Principles Eligibility

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Elementary and Secondary Education (DESE) Audit Finding Number: 2023-016 Child Care Payments Name of the contact person responsible for corrective action: Shelley Woods Anti...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Elementary and Secondary Education (DESE) Audit Finding Number: 2023-016 Child Care Payments Name of the contact person responsible for corrective action: Shelley Woods Anticipated completion date for corrective action: 12/31/2024 Corrective action planned is as follows: DESE agrees with the auditor’s finding. It has been challenging to have adequate internal controls over the child care program with two separate state agencies trying to administer different aspects of the program. The Department of Social Services (DSS) has been implementing eligibility and authorizations for families, while DESE has been administering rates, rules, licensure, and provider agreements. Effective July 1, 2024, eligibility and authorizations for families transfers under DESE’s authority to ensure all facets of program implementation are within one state agency for better internal controls. In addition, DESE transitioned to a new Child Care Data System (CCDS) for provider payments in the beginning of January 2024. Access, interfaces, and updates within the older systems has created multiple barriers and payments issues for the program. This single system, CCDS, allows parents to have a streamlined process for eligibility determinations, report changes in address or income, find or change providers, while also giving providers one place to apply for a contract, view authorizations, update contact information, view payment remittances, and make payment adjustments. By December 31, 2024, the CCDS will have combined all functions of FAMIS, FACES, and CCBIS attendance system into CCDS. DESE users can easily and efficiently make family and rate changes as necessary and view all information in the system, which will also strengthen internal controls. DESE also continues to revise and clarify internal procedures to ensure consistent and accurate eligibility determinations and claims processing. CCDF regulations specifically state pursuant to 45 CFR 98.21(a)(1) that because a child meeting eligibility requirements at the most recent eligibility determination or redetermination is considered eligible between redeterminations, any payment for such a child shall not be considered an error or improper payment due to a change in the family's circumstances. Based on this regulation, DESE will work with the Administration for Children and Families to repay any claims considered questioned costs.

View Audit 321142 Questioned Costs: $1

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