Corrective Action Plans

REFERENCE: 2022-007 ? Allowable Costs/Cost PrinciplesHIV Emergency Relief Project Grants (Assistance listing No. 93.914)Federal Grantor: Health Resources and Services AdministrationFacility: St. Mary?s Medical Center ? San FranciscoVirginia MasonFinding: At St. Mary?s Medical Center ? San Francisco and Virginia Mason, controls over the requiredallowability criteria with regard to payroll expense were not performed and/or documented throughout the year.Corrective Action Plan: This finding has been corrected. At St. Mary?s Medical Center ? San Francisco, as of July2021 invoices were prepared using actual payroll as opposed to budget. At Virginia Mason, beginning in April 2022,managers receive notification from the payroll department of unapproved time cards that are waiting for approval.A reminder email is sent to managers and employees to approve and submit their time cards on time. Trainingsessions were implemented to instruct all employees and the managers of this requirement. Once the training hasbeen completed and employees or managers miss approving the timecard then disciplinary actions will be taken.Payroll sends out messages of outstanding timecards awaiting approval.Person Responsible: Doug Amarelo ? St. Mary?s Medical Center, San FranciscoRebecca Kiser ? Virginia MasonCompletion: April 2022

REFERENCE: 2022-015 ? Allowable Costs/Cost PrinciplesMedical Assistance Program (Medicaid Cluster) (93.778)Federal Grantor: U.S. Department of Health and Human ServicesFacility: Dignity Health Connected LivingFinding: At Dignity Health Connected Living, internal controls over the required allowability criteria with regard to payroll expense were not performed for 1 of 25 employees selected for testing.Corrective Action Plan: In addition to timecard approval by supervisors, Dignity Health Connected Living finance will review a TEAMs salary report to review that time charged to the grant is accurate and appropriate. Review will be completed on a payperiod basis.Person Responsible: Marcela Ashinhurst, Senior Financial AnalystExpected Completion: April 2023

REFERENCE: 2022-013 ? Allowable Costs/Cost PrinciplesCOVID-19 ? HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund (93.461)Federal Grantor: U.S. Department of Health and Human ServicesFinding Part 1: CommonSpirit Health did not have controls in place to limit the claims being submitted for Testing-Related Items and Services to include items and services related to furnishing or administering the COVID-19 test or for the evaluation of such individuals to determine the need for a COVID-19 test.Corrective Action Plan: Management believes that CommonSpirit Health has the necessary controls in place to support accurate and compliant billing. In addition, Management believes CommonSpirit followed the HRSA uninsured patient reimbursement program guidelines and frequently asked questions (FAQs) related to diagnostic testing and testing-related visits eligible for reimbursement, which were published from time to time after the introduction of this program.Although CommonSpirit Health continues to dispute the findings (REFERENCE 2021-014), CommonSpirit Health is refunding the Questioned Cost of $10,998 related to the findings for 2021 in order to resolve this finding. The refunds will be completed by April 30, 2023. In addition, the Program stopped accepting claims for testing and treatment on March 22, 2022, and claims for vaccine administration on April 5, 2022, due to lack of sufficient funds. CommonSpirit Health has not submitted claims to the Program since the Program was discontinued. In the event that CommonSpirit Health, through its proactive compliance efforts, identifies any additional claims submitted to the Program where reimbursement may not have been appropriate, CommonSpirit Health will refund such claims.Person Responsible: Danielle Weber, System SVP Revenue CycleExpected Completion: Management believes the item is resolved.Finding Part 2: CommonSpirit Health did not have controls in place to ensure that claims were not submitted for reimbursement when COVID-19 was not the primary diagnosis.Corrective Action Plan: Management believes that CommonSpirit Health has the necessary controls in place to support accurate and compliant billing. With respect to this one claim where COVID-19 was incorrectly listed in the primary diagnosis position, CommonSpirit Health will refund the claim amount of $547 by April 30, 2023Person Responsible: Danielle Weber, System SVP Revenue CycleExpected Completion: April 30, 2023

REFERENCE: 2022-014 ? Allowable Costs/Cost PrinciplesCoronavirus Relief Fund (21.019)Federal Grantor: U.S. Department of TreasuryFacility: CHI MemorialFinding: At CHI Memorial, controls over the required allowability criteria and period of performance with regard to payroll expense were not performed and/or documented.Corrective Action Plan: Hospital staff will be provided training to refresh the requirement to approve timecards for supervisees. Accounting/finance will review payroll reports to ensure only time properly approved is charged to grant for reimbursement.Person Responsible: Craig Nielsen, Market Director Operational FinanceExpected Completion: April 2023

REFERENCE: 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Research and Development Cluster (Multiple)Federal Grantor: U.S. Department of DefenseU.S. Department of Health and Human ServicesFacility: St. Joseph?s Hospital and Medical CenterFinding: St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Corrective Action Plan: On a quarterly basis, program managers and grant managers meet with the principal investigator on all of their federal grants. During the meeting, the actual hours for all individuals are reviewed. Additionally, a reconciliation of actual to budget is performed. Documentation of the quarterly reviews is maintained on a google shared drive. Quarterly meetings include evaluation of salary charged to grant in comparison to NIH salary cap.Person Responsible: Research Ops Managers; Tomas Cortez, Grant Accounting ManagerCompletion: September 2022

REFERENCE: 2022-008 ? Activities Allowed or UnallowedResearch and Development Cluster (Multiple)Federal Grantor: U.S. Department of DefenseU.S. Department of Health and Human ServicesFacility: St. Joseph?s Hospital and Medical CenterFinding: St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Corrective Action Plan: On a quarterly basis, program managers and grant managers meet with the principal investigator on all of their federal grants. During the meeting, the actual hours for all individuals are reviewed. Additionally, a reconciliation of actual to budget is performed. Documentation of the quarterly reviews is maintained on a google shared drive. Clinical time for federal grants will be supported by a completed timesheet signed by a supervisor or PI. Timesheets will be completed monthly.Person Responsible: Research Ops Managers; Tomas Cortez, Grant Accounting ManagerExpected Completion: September 2022

REFERENCE: 2022-009 ? Activities Allowed or UnallowedResearch and Development Cluster (Multiple)Federal Grantor: U.S. Department of DefenseU.S. Department of Health and Human ServicesFacility: St. Joseph?s Hospital and Medical CenterFinding: At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Corrective Action Plan: Indirect expense calculation is reviewed and compared to grant agreement by Grant Accounting Manager prior to month end close.Person Responsible: Tomas Cortez, Grant Accounting ManagerCompletion: January 2022

Finding Number 2022-208: State Opioid Response program performance progress reports did not have documentation to support completion of a review for accuracy and compliance prior to submission.Federal Program: 93.788 - Opioid STRRelated to Prior Finding: N/AAgency?s view: The Department agrees with this finding.The contract manager attests that she did, in fact, review, edit, re-review and ultimately approve the 5 program performance reports to the grantor. The reports were either emailed to the Program Manager or uploaded in Teams for her review/approval. The auditor was provided documentation of these reviewed documents, including editing notes by that manager. Additionally, one-on-one supervision notes between the person submitting the reports and the contract manager validate that these reports were, in fact, reviewed and approved prior to submission to the grantor. The federal funder does not require this type of documentation of review/approval and the program was not aware of this CFR requirement. The program does, however, agree, that review and approval of these reports was not documented and that a corrective action plan is warranted.Corrective Action: Beginning April 1, 2023, all required federal reports will include thefollowing statement, which will be signed and dated electronically by the approving reviewerbefore the report is submitted:? I, _______________________, have reviewed and approved this report prior tosubmission.Name, titleA copy of the approved and signed report will be retained in DBH?s electronic grant fundingrecords.Anticipated Corrective Action Date: April 1, 2023Responsible for Corrective Action: Kelly Combs, Bureau Chief, Compliancekelly.combs@dhw.idaho.gov 208-334-5814

Finding Number 2022-202: The Commission did not complete required reports for the Federal Funding Accountability and Transparency Act (FFATA).Federal Programs: 93.044, 93.045, 93.053 ? Aging ClusterRelated to Prior Finding: N/AAgency?s view: The Commission agrees with this finding.Corrective Action: Federal Funding Accountability and Transparency Act (FFATA) reporting for federal fiscal years 2021, and 2022 have been completed as of March 27, 2023. The agency will complete FFATA reporting as awards are administered to sub-awardees going forward.Anticipated Corrective Action Date: March 27, 2023Responsible for Corrective Action: Joe Zaher, Senior Financial SpecialistJoe.zaher@aging.idaho.gov 208-577-2864

Finding Number 2022-201: The Commission did not complete the required Federal Financial SF-425 Report for the Aging Cluster Grant program in a timely manner.Federal Programs: 93.044, 93.045, 93.053 ? Aging ClusterRelated to Prior Finding: N/AAgency?s view: The Commission agrees with this finding.Corrective Action: Actions have been taken to complete SF-425 reports as they come due for each grant. A reporting workbook has been created to track awards and reporting dates. Reporting period end dates and due dates will be added to fiscal staff calendars. We will continue to keep our federal partners appraised of our progress through completion.Anticipated Corrective Action Date: 'A soft target date for completion of all past due reports is set for September 30, 2023, and a hard target date of December 31, 2023.Responsible for Corrective Action: Joe Zaher, Senior Financial SpecialistJoe.zaher@aging.idaho.gov 208-577-2864

Finding Number 2022-205: An expenditure was made by the Department for unallowable activities from the Elementary and Secondary School Emergency Relief (ESSER) program.Federal Program: 84.425U - Education Stabilization Fund - ARPA ESSER IIIRelated to Prior Finding: N/AAgency?s view: The Department agrees with this finding.Corrective Action: When the Elementary and Secondary School Emergency Relief Funds {ESSER) were first awarded, it was not required that districts attach any documentation to their Grant Reimbursement Application {GRA) requests. Federal Programs will start requiring that all requests coming in through the GRA system have supporting documentation attached as of July 1, 2023, which is the beginning of our next fiscal cycle.Anticipated Corrective Action Date: We will announce this new procedure through emails and during our state-wide Consolidated Federal and State Grant Application training in April and May2023.Responsible for Corrective Action: Gideon Tolman, Chief Financial Officergtolman@sde.idaho.gov 208-332-6874

Finding Number 2022-206: The Department did not complete required subrecipient monitoring of the Elementary and Secondary School Emergency Relief (ESSER) Fund of the Education Stabilization Fund.Federal Programs:84.425U - Education Stabilization Fund ? ARPA ESSER III84.425D - Education Stabilization Fund - Elementary and Secondary School Emergency Relief Fund84.425W - Education Stabilization Fund - ARPA ESSER - Homeless Children and Youth84.425R - Education Stabilization Fund - Emergency Assistance for Non-Public SchoolsRelated to Prior Finding: 2021-204Agency?s view: The Department agrees with this finding.Corrective Action: It was not until the end of the 2022 legislative session that spending authority was given to the State Department of Education to use ARP ESSER Sincerely, administrative funds to hire additional staff to meet the robust requirements identified by the U.S. Department of Education. Up to that point, only one full-time person was handling all of the needs associated with ESSER funds. Since then, two positions have been hired. The ESSER Data and Reporting Coordinator began in April 2022, and the ESSER Monitoring Coordinator began in June 2022. While developing the monitoring procedures began in July 2022, it was after the audit timeframe. The Department now has in place all ESSER monitoring policies and procedures and will complete year one monitoring before May 5, 2023.Anticipated Corrective Action Date: May 2023Responsible for Corrective Action: Gideon Tolman, Chief Financial Officergtolman@sde.idaho.gov 208-332-6874

Finding Number 2022-212: The Department did not maintain consistent operation of controls and compliance with Electronic Benefit Transfer (EBT) Card Security procedures for the Supplemental Nutrition Assistance Program (SNAP).Federal Programs:10.551 - Supplemental Nutrition Assistance Program (SNAP)10.561 - State Administrative Matching Grants for the Supplemental Nutrition Assistance ProgramRelated to Prior Finding: 2021-210Agency?s view: The Department agrees with this finding.Corrective Action: Immediately upon receiving the audit finding in March 2022, staffreviewed and revised procedures and fully implemented a corrective action plan by June 30, 2022. The entire EBT team was trained on the bulk card ordering and issuing process and modified security procedures to mitigate the risk of non-compliance in the future. The bulk card managers in the field offices review and reconcile card issuances monthly. Also, the EBT Supervisor documents the review of the previous quarter?s electronic card audits for accuracy and completeness.Anticipated Corrective Action Date: See corrective action above.Responsible for Corrective Action: Kelly Combs, Bureau Chief, Compliancekelly.combs@dhw.idaho.gov 208-334-5814

LockHaven: Recommendation: The University should review its policies and procedures around grant reporting to ensure all reporting requirements are met timely and accurately.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: The University will review its policies and procedures around grant reporting to ensure all reporting requirements are met timely and accurately. The University will put necessary controls in place to ensure reports are posted within ten days of the end of the quarter. Documentation of report review and approval will be in writing and saved to ensure documentation is available to support review and approval of report submissions.Name(s) of the contact person(s) responsible for corrective action: Michael Hall, Director of Financial Aid.Planned completion date for corrective action plan: April 30, 2023Clarion: Recommendation: The University should review its policies and procedures around grant reporting to ensure all reporting requirements are met timely and accurately.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: This finding resulted from a combination of staff turnover and the complexity of integration. All grant-related reporting requirements will be reviewed to ensure that they are properly documented and scheduled for completion and review when required by the granting authority.Name(s) of the contact person(s) responsible for corrective action: Sean Bliley, Controller, 814-732-1304Planned completion date for corrective action plan: June 30, 2023Bloomsburg: Recommendation: The University should review its policies and procedures around grant reporting to ensure all reporting requirements are met timely and accurately.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: We have reviewed the reporting requirements published by the federal government to ensure compliance with all procedures. In addition, we have established review procedures so that each document is reviewed prior to publishing on our website.Name(s) of the contact person(s) responsible for corrective action: : Amanda Kishbaugh at (570) 389-4497.Planned completion date for corrective action plan: April 30, 2023Edinboro: Recommendation: The University should review its policies and procedures around grant reporting to ensure all reporting requirements are met timely and accurately.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: All grant-related reporting requirements will be reviewed to ensure that they are properly documented and scheduled for completion and review when required by the granting authority.Name(s) of the contact person(s) responsible for corrective action: Sean Bliley, Controller, 814-732-1304. Planned completion date for corrective action plan: 06/30/2023California: Recommendation: The University should review its policies and procedures around grant reporting to ensure all reporting requirements are met timely and accurately. Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: This finding resulted from a combination of staff turnover and the complexity of integration. All grant-related reporting requirements will be reviewed to ensure that they are properly documented and scheduled for completion and review when required by the granting authority.Name(s) of the contact person(s) responsible for corrective action: Sean Bliley, Controller, 814-732-1304Planned completion date for corrective action plan: June 30, 2023 Mansfield: Recommendation: The University should review its policies and procedures around grant reporting to ensure all reporting requirements are met timely and accurately.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: The University will review its policies and procedures around grant reporting to ensure all reporting requirements are met timely and accurately. Documentation of report review and approval will be in writing and saved to ensure documentation is available to support review and approval of report submissions.Name(s) of the contact person(s) responsible for corrective action: Colleen Jackson, Assistant Controller, Pam Kathcart, Director of Financial AidPlanned completion date for corrective action plan: April 30, 2023 Millersville: Recommendation: The University should review its policies and procedures around grant reporting to ensure all reporting requirements are met timely and accurately.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: The finding related to the institutional report not being displayed on the website refers to reporting of December 31st, 2021 (due to be posted on website by January 10th, 2022). The university was alerted to the issue of approval requirements during the last single audit process, which was after the December 31st report was posted. All reports posted to the website after the finding in last year?s audit were completed with Finance and Administration Vice President or Associate Vice President approvals prior to posting.Name(s) of the contact person(s) responsible for corrective action: Tammy Aument-Martin, Director of Accounting & Budget at 717-871-4091 and Emi Alvarez, Director of Financial Aid at 717-871-5100.Planned completion date for corrective action plan: 06/30/2022 (all HEERF funds were drawn down and recorded) Cheyney: Recommendation: The University should review its policies and procedures around grant reporting to ensure all reporting requirements are met timely and accurately.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: Additional policies and procedures were implemented to mitigate errors in the future.Planned completion date for corrective action plan: 9/30/2023Name(s) of the contact person(s) responsible for corrective action: Victoria Atkins at (610) 399-2097.

Finding: 2022-082 - During the testing of the University of Alaska Fairbanks (UAF) Minority Serving Institution (MSI) expenditures there was an observed instance, among the forty that were tested, of an interdepartmental transaction being claimed as a reimbursable expenditure. Students from the MacClean House dorm, which is operated by the UAF Residence Life unit, were required to quarantine in the MacLean House dorm, which is operated by the College of Rural and Community Development (CRCD) unit. This resulted in the UAF Residence Life unit paying the CRCD unit for the students' housing costs. This transaction was included as areimbursable expenditure, despite having a net $0 impact on the income statement.Questioned Costs: $2,100.97 - ALN 84.425F - Grant Award P425L200248Assistance Listing Number: 84.425FAssistance Listing Title: HEERF MSI PortionViews of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): There is no disagreement with the audit finding.Corrective Action (corrective action planned): The University of Alaska Fairbanks has removed the interdepartmental transactions from the award. Management will ensure interdepartmental transaction is not included in the expenditures in the future.Completion Date (list anticipated completion date): CompletedAgency Contact (name of person responsible for corrective action): Amanda Wall, Associate Vice Chancellor for Financial Services, 907-474-7552

Finding: 2022-056 - Certain behavioral health providers were not screened and enrolled in accordance with federal eligibility requirements.Questioned Costs: Assistance Listing 93.767: $1,669; Assistance Listing 93.778: $425,224Assistance Listing Number: 93.767; 93.775, 93.777, 93 .778Assistance Listing Title: CHIP; Medicaid ClusterViews of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH agrees with the finding.Corrective Action (corrective action planned): The department is assessing the issues identified in the fmdmg and collaborating internally on the necessary corrective action. It is anticipated multiple courses of action may be necessary and include, among others, strengthening the provider enrollment grid and policies.Completion Date (list anticipated completion date): DOH anticipates the finding will be resolved in FY2025.Agency Contact (name of person responsible for corrective action): Josephine Stern, Assistant Commissioner

Finding: 2022-051 - DHSS staff claimed inaccurate federal reimbursement for behavioral health costs.Questioned Costs: Assistance Listing 93.767: Indeterminate; Assistance Listing 93.778: IndeterminateAssistance Listing Number: 93.767; 93.775, 93.777, 93 .778Assistance Listing Title: CHIP; Medicaid ClusterViews of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH agrees with the finding.Corrective Action (corrective action planned): The Division of Behavioral Health (DBH) is working with the ASO to ensure accurate member eligibility file load and claims processing issues under a corrective action plan to resolve issues that led to inaccurate federal reimbursement.Completion Date (list anticipated completion date): DOH anticipates an interim resolution will be in place during FY2023 followed with a full system resolution in FY2024.Agency Contact (name of person responsible for corrective action): Josephine Stern, Assistant Commissioner

Finding: 2022-050 - Testing of 40 behavioral health claims paid during FY 22 identified 27 (68 percent) with errors:? Three providers were not enrolled in the Medicaid program at the time medical services were rendered.? Three providers that billed for and received payment for the claims were not associated with the individual medical provider that rendered the medical services.? Three claims were paid even though the claims were submitted with an incorrect National Provider Identifier. The providers were validly enrolled.? Thirteen claims did not identify the provider who rendered medical services. State regulations specifically outline requirements for providers who are qualified to render the services.? Five claims identified the provider who rendered the medical service, but the provider had not met qualification requirements.Questioned Costs: Assistance Listing 93.767: None; Assistance Listing 93.778: $1,406Assistance Listing Number: 93.767; 93.775, 93.777, 93.778Assistance Listing Title: Children?s Health Insurance Program (CHIP); Medicaid ClusterViews of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH agrees with the finding.Corrective Action (corrective action planned): The Division of Behavioral Health (DBH) is working with the ASO to ensure accurate load of provider information into the Facets Medicaid Management Information System (MMIS) and implement routine monitoring procedures, including quarterly sampling, of paid claims.Completion Date (list anticipated completion date): DOH anticipates the finding will be resolved in FY2023. Agency Contact (name of person responsible for corrective action): Josephine Stern, Assistant Commissioner

Finding: 2022-048 - Auditors could not obtain sufficient and appropriate evidence to verify compliance with LIHEAP? s period of performance requirements.Questioned Costs: NoneAssistance Listing Number: 93.568Assistance Listing Title: LIHEAPViews of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH agrees with the finding.Corrective Action (corrective action planned): The Division of Public Assistance plans to review all current LIHEAP compliance procedures to identify areas for improvement. Potential modification of accounting structures will be examined as well. Staff training will take place to ensure any new procedures are fully understood prior to official implementation of updated processes.Completion Date (list anticipated completion date): DOH anticipates the finding will be resolved in FY2024.Agency Contact (name of person responsible for corrective action): Josephine Stern, Assistant Commissioner

Finding: 2022-045 - DHSS?s information technology staff did not properly limit user access to DPA?s EIS during FY22.Questioned Costs: NoneAssistance Listing Number: 93.558; 93.775, 93.777, 93.778Assistance Listing Title: TANF; Medicaid ClusterViews of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH agrees with the finding.Corrective Action (corrective action planned): The Division is implementing protocols to reconcile users in every eligibility system at a minimum of twice yearly. These protocols will be used to identify and deactivate user accounts that are no longer needed but have not been reported via the established formal process.Completion Date (list anticipated completion date): DOH anticipates the finding will be resolved in FY2024.Agency Contact (name of person responsible for corrective action): Josephine Stern, Assistant Commissioner

Finding: 2022-041 - Five of the eight child support noncooperation alerts tested (63 percent) were not assessed a penalty to reduce TANF benefits when determined necessary.Questioned Costs: $4,542Assistance Listing Number: 93.55 8Assistance Listing Title: TANFViews of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH agrees with the finding.Corrective Action (corrective action planned): The agency continues to work through priorities and mandates implemented due to the ending of the public health emergency, which has increased the workload beyond what the division had experienced in the prior year. This has impacted the ability to meaningfully execute the corrective action plan. The Division is currently implementing strategies, which includes increasing staffing, to address the increased workload and upcoming PHE unwinding efforts. The agency will continue moving forward with corrective actions.Completion Date (list anticipated completion date): DOH anticipates the finding will be resolved in FY2024.Agency Contact (name of person responsible for corrective action): Josephine Stern, Assistant Commissioner

Finding: 2022-038 - Ten of 25 Temporary Assistance for Needy Families (TANF) recipient case files tested lacked documentation supporting the request and use of income and benefit information through the Income Eligibility and Verification System (IEVS) for determining eligibility and benefits. Further, the following eligibility errors were identified:? Eight TANF applicants did not have eligibility redetermined within 12 months and eligibility was automatically extended.? Three TANF applications were not reviewed within 30 days of receipt.? Three applications either did not fill out the felony conviction disclosures or the section was not retained in the case file.? Three applications did not have adequate income verification support.? Three benefit payment amounts were not calculated accurately.? One application did not include child support documentation in the case file.? One renewal application was not reviewed for an eligibility redetermination.Additionally, 24 of the TANF recipient cases received Pandemic Emergency Assistance Fund (PEAF) payments, of which 20 did not have IEVS documentation to support the eligibility determination prior to DHSS making the PEAF payments.Questioned Costs: $138,024Assistance Listing Number: 93.558Assistance Listing Title: TANFViews of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why):DOH agrees with the finding.Corrective Action (corrective action planned): The agency continues to work through priorities and mandates implemented due to the ending of the public health emergency, which has increased the workload beyond what the division had experienced in the prior year. This has impacted the ability to meaningfully execute the corrective action plan. The Division is currently implementing strategies, which includes increasing staffing, to address the increased workload and upcoming PHE unwinding efforts. The agency will continue moving forward with corrective actions.Completion Date (list anticipated completion date): DOH anticipates the finding will be resolved in FY2024.Agency Contact (name of person responsible for corrective action): Josephine Stern, Assistant Commissioner

Finding: 2022-037 - Auditors could not obtain sufficient and appropriate evidence to verify the accuracy of the data reported in the monthly ELC special report for FY22 COVID tests conducted by school districts. In addition, for two ELC grant awards, Enhancing Detection and Reopening Schools, inception to date expenditures were overstated by $4,436,595 and $725,221, respectively, in the June 30, 2022, financial reports.Questioned Costs: NoneAssistance Listing Number: 93.323 Assistance Listing Title: ELCViews of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH agrees with the finding.Corrective Action (corrective action planned): Program Manager will confirm in email that each monthly RedCap upload has been received and reviewed. Copies of monthly reports will be saved. Quarterly reconciliations will be conducted to ensure that adjustments are updated to match monthly reports.Completion Date (list anticipated completion date): DOH anticipates the finding will be resolved in FY2023.Agency Contact (name of person responsible for corrective action): Josephine Stern, Assistant Commissioner

Finding: 2022-035 - Seven of 25 timesheets that charged FY 22 personal services to the Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) program were not supported in compliance with federal requirements.Questioned Costs: $9,778Assistance Listing Number: 93.323Assistance Listing Title: ELCViews of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH agrees with the finding. Corrective Action (corrective action planned): The division will ensure that all long-term, non-perm employees receive the same training as permanent employees on positive time keeping and how to complete a timesheet. Trainings will be completed within one week on hiring. All staff coding time to ELC grants will be required to send timesheets to the Director?s Office Admin staff for review monthly to ensure coding is done correctly.Completion Date (list anticipated completion date): DOH anticipates the finding will be resolved in FY2023.Agency Contact (name of person responsible for corrective action): Josephine Stern, Assistant Commissioner

Finding: 2022-076 ? Four of 12 consultants? indirect cost rates (33 percent) were incorrect in eight professional service agreements reviewed.Questioned Costs: NoneAssistance Listing Number: 20.205, 20.2 19, 20.224Assistance Listing Title: Highway Planning and Construction Cluster (HPCC)Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): AgreeCorrective Action (corrective action planned): DOT&PF?s contracting officers will ensure amendments are completed for the four contracts identified. DOT&PF contract officers will add language to future contracts to state that in the processing of payments the current audited indirect rate will be used. The department anticipates this finding will be resolved by June 30, 2023.Completion Date (list anticipated completion date): June 30, 2023Agency Contact (name of person responsible for corrective action): Hilary Porter, Chief Contracts Officer