Corrective Action Plans

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CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Education The City of Haverhill, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Powers & Sullivan, LLC 100...
CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Education The City of Haverhill, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Powers & Sullivan, LLC 100 Quannapowitt Parkway, Suite 101 Wakefield, MA 01880 Audit period: July 1, 2021 through June 30, 2022 The finding from the June 30, 2022, schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS?FEDERAL AWARD PROGRAMS AUDITS U.S. DEPARTMENT OF EDUCATION Passed through the Massachusetts Department of Elementary and Secondary Education Title I Grants to Local Educational Agencies Title I Grants to Local Educational Agencies Federal Assistance Listing No. 84.010 2022-004: Affirmation of Consultation Forms to Private Schools Compliance Requirement: Special Tests and Provisions Type of Finding: Compliance and Internal Control Over Compliance ? Other Matter Criteria or Specific Requirement: Grantees must provide equitable services to eligible private school children, their teachers, and their families. Grantees must conduct timely and documented consultation with private school officials to determine the kind of educational services to provide to eligible private school children. Grantees must also ensure the planned services were provided, and ensure the required amount was used for private school children. Condition: The City was required to ensure a portion of this grant was available for the equitable participation of students, families, and educators in non-profit, non-public (private) schools in existence. Public school officials were required to initiate contact and make good faith efforts to have timely and meaningful consultation with private school officials regarding the participation of private school students, families, and educators in these programs and services. The City was required to document these consultations via signed Affirmation of Consultation forms. The City was unable to provide this form for one of the private schools in which federal funds were allocated. Questioned Costs: None Reported. Context: The City has not complied with grant requirements to complete the appropriate forms regarding private school consultations. Effect: The City has not complied with the grant requirements. Cause: Lack of controls over maintaining adequate support for the consultations with private school officials for Title I allocations to all private schools to determine the kind of educational services to provide to eligible private school children. Recommendation: Management should implement procedures to ensure compliance with all grant requirements including the completion and retention of all required forms. These should be filed in an organized manner to allow for timely review upon request. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and will implement internal controls procedures to ensure that all Affirmation of Consultation forms are completed, retained, and adequately maintained in an organized manner to ensure that grant requirements can be supported upon request. Management plans to implement these procedures in 2023. If the Oversight Agency has questions regarding this plan, please call Michael Pfifferling, Assistant Superintendent of Finance and Operations at 978-374-3400. Sincerely yours, Michael Pfifferling Assistant Superintendent of Finance and Operations City of Haverhill
The Organization agrees with the recommendation. An internal review is currently in process to review and update policies as needed to address the use of federal funds.
The Organization agrees with the recommendation. An internal review is currently in process to review and update policies as needed to address the use of federal funds.
Corrective Action Plan and Status of Prior Year Findings Management?s Corrective Action Plan: Individual(s) Responsible for Corrective Action Plan Tysha Dixon Director, Financial Reporting (215) 496-8168 Anticipated Completion Date Completed March 2023 Management?s Corrective Action Plan Manage...
Corrective Action Plan and Status of Prior Year Findings Management?s Corrective Action Plan: Individual(s) Responsible for Corrective Action Plan Tysha Dixon Director, Financial Reporting (215) 496-8168 Anticipated Completion Date Completed March 2023 Management?s Corrective Action Plan Management will continue to rely on its existing controls in place; however, noting that Management will closely monitor loans and loan disbursements where the funding source has changed closely to ensure that disbursements are in accordance with funding terms and approval limits. Management will continue to rely on its existing controls that are in place, including the ongoing communication with the City for any changes in transactions that require their approval. In the circumstances where management is pending a contract amendment from the City for loans requiring additional funding, management will determine if there are unrestricted funding sources to support the change in the approved amount of the loan until the amended contract is finalized. Questioned Program: CFDA #14.218 Community Development Block Grants (CDBG)
View Audit 52296 Questioned Costs: $1
The organization moved offices and storage facilities, and in the process, evidence of pay rate in personnel file of was misplaced. Managers will be retrained regarding the required paperwork necessary to retain for all employees. In addition, moving forward, our payroll company has agreed to advis...
The organization moved offices and storage facilities, and in the process, evidence of pay rate in personnel file of was misplaced. Managers will be retrained regarding the required paperwork necessary to retain for all employees. In addition, moving forward, our payroll company has agreed to advise us on the privacy and records retention landscape as well as provide us with a solution for federal, state, and local HR compliance.
View Audit 50468 Questioned Costs: $1
The organization knows and understands what are the allowable and unallowable cost and the SVOG, as well as the for documentation under 2CFR Part 200. It took tremendous effort to maintain internal controls during the pandemic closure, but with all departments informed and aligned, board of directo...
The organization knows and understands what are the allowable and unallowable cost and the SVOG, as well as the for documentation under 2CFR Part 200. It took tremendous effort to maintain internal controls during the pandemic closure, but with all departments informed and aligned, board of directors and leadership have re-examined organizational practices to see if there is a way to improve internal controls. The organization has designated individuals that are responsible for the compliance with all requirements under the grants, as well as the requirements for each Assistance Listing Number. In addition, the organization has engaged an external professional firm with knowledge and experience in federal awards for accounting services.
View Audit 50468 Questioned Costs: $1
Views of Responsible Officials and Planned Corrective Actions: Prior to the FYE 2021 audits, MECCA had identified issues regarding the proper maintenance and review of payroll records and corrective action was taken in November 2021 by the Operations and Administration Coordinator. In November 2021,...
Views of Responsible Officials and Planned Corrective Actions: Prior to the FYE 2021 audits, MECCA had identified issues regarding the proper maintenance and review of payroll records and corrective action was taken in November 2021 by the Operations and Administration Coordinator. In November 2021, a full-service payroll and HR company was brought on to support MECCA in meeting all regulatory requirements, which began processing MECCA?s payroll in February 2022 and began working with the Operations and Administration Coordinator to do an internal HR audit in March and April of 2022. As of February 2022, all new employees were on boarded in compliance with all relevant regulatory requirements. And as of January 2023, all active employee files were complete with necessary documentation. In addition to the above corrective action, in April 2022, MECCA?s then Finance Manager implemented a Time and Effort policy and conducted a Time Survey to capture the staff time spent on programs. From May 2022 to September 2022, MECCA required staff to recertify time allocations quarterly. Starting October 2022, MECCA staff certify their time and effort allocations monthly. MECCA conducts the Time Survey annually, and the current Finance and Operations Director is responsible for ensuring staff Time and Effort is properly captured. The then Executive Director and the then Director of Operations and Program Administration were responsible for ensuring the corrective actions were implemented. In 2023, MECCA's Current Executive Director will be responsible for ensuring compliance to all relevant regulatory requirements. The Executive Director serves as the organizational HR supervisor and is responsible for working with and overseeing the payroll and HR company to ensure that onboarding, proper documentation, timekeeping, payroll, and any HR updates or pay rate changes are done for compliance. Name of Contact Person Responsible for Corrective Action Plan: Yesenia Ochoa, Executive Director Anticipated Completion Date: January 31, 2023
During the 2022 audit of Community Health Center of Central Missouri, our auditors found two instances of the PRF calculation being calculated incorrectly. The two instances were: 1) Lost revenue was calculated on a quarterly basis using post-date instead of date of service which resulted in a ne...
During the 2022 audit of Community Health Center of Central Missouri, our auditors found two instances of the PRF calculation being calculated incorrectly. The two instances were: 1) Lost revenue was calculated on a quarterly basis using post-date instead of date of service which resulted in a negative patient service revenue balance in self pay during 2020 Quarter 1-Quarter 3 2) Lost revenue was calculated without consideration of Medicaid cost report settlement and incentive revenue. This has resulted in a finding in the current year financial statements audit. Management has evaluated the finding and reviewed whether any funds need to be repaid and evaluated its controls around future provider relief reporting cycles. It has been determined that even with the two errors identified lost revenues would have been sufficient to obligate the entire award. Therefore, we have determined no repayment is necessary. If allowed in future provider relief reporting periods, Community Health Center of Central Missouri will correct the misreporting. Toby Barnett, Chief Financial Officer, is the party that has overall responsibility for this corrective action. The anticipated completion date is unknown at this time due to reporting portal for period 1 being closed. It is unknown if HHS will allow corrections to period 1 reports.
View Audit 41964 Questioned Costs: $1
2022-056 Department of Human Services/Oregon Health Authority Return questioned costs related to 2019-014 audit finding Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.777 and 93.778 Medicaid Cluster Federal Award Numbers and Years: 18...
2022-056 Department of Human Services/Oregon Health Authority Return questioned costs related to 2019-014 audit finding Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.777 and 93.778 Medicaid Cluster Federal Award Numbers and Years: 1805OR5MAP, 2018; 1805OR5ADM, 2018; 1905OR5MAP, 2019; 1905OR5ADM, 2019 Compliance Requirement: Activities Allowed or Unallowed; Allowable Costs/Cost Principles Type of Finding: Noncompliance Prior Year Finding: 2019-014 Questioned Costs: $348,080 (known) Criteria: 42 CFR 433.32(a); 42 CFR 433.312(a); 42 CFR 447.45(f)(1)(iv) During our testing for the fiscal year 2019 we noted that the MMIS data tables did not agree to the rates established by CMS for 2 procedures codes. Using incorrect rates resulted in an overpayment of $348,080 to providers. This overpayment was first reported in the fiscal year-end June 30, 2019, Secretary of State audit report number 2020-14, finding number 2019-014. As of January 1, 2020, management updated the MMIS data tables to ensure all future provider payments were made at the correct rate. Additionally, management updated control procedures to ensure MMIS data tables are updated timely and accurately. However, as of May 1, 2023, the overpayment to providers has not been collected, federal funds have not been returned, and the planned repayment method has not been approved by CMS. Per authority management they plan to let these overpayments run through their cost settlement process which would be an unusual method to return federal funds. We recommend authority management reimburse the federal agency for unallowable costs. MANAGEMENT RESPONSE: We agree with this recommendation. As indicated in the report and as of January 1, 2020, authority management updated the MMIS data tables to ensure all future provider payments were made at the correct rate. Additionally, authority management updated control procedures to ensure MMIS data tables are updated timely and accurately. The recoupment of funds paid for incorrect rates will be completed through the FFS cost settlement process. We expect to have this completed on or before June 30, 2024. We will evaluate the use of alternate recoupment processes in the event of future corrections. Anticipated Completion Date: June 30, 2024 Contact: Mick Mitchell, Business Operations Manager
View Audit 45093 Questioned Costs: $1
Finding 47823 (2022-055)
Significant Deficiency 2022
2022-055 Department of Human Services/Oregon Health Authority Strengthen review over direct costs charged to the program Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.777 and 93.778 Medicaid Cluster Federal Award Numbers and Years: 2...
2022-055 Department of Human Services/Oregon Health Authority Strengthen review over direct costs charged to the program Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.777 and 93.778 Medicaid Cluster Federal Award Numbers and Years: 2105OR5MAP, 2021; 2105OR5ADM, 2021; 2205OR5MAP, 2022; 2205OR5ADM, 2022 Compliance Requirement: Activities Allowed or Unallowed; Allowable Costs/Cost Principles Type of Finding: Significant Deficiency; Noncompliance Prior Year Finding: N/A Questioned Costs: $47,942 (known) Criteria: 2 CFR 200.1(1); 2 CFR 200.400(a); 2 CFR 200.404; 42 CFR ? 433.32(a) Federal regulations only allow the Medicaid program to charge allowable program expenditures at the federal financial participation rate for various program costs at the time of payment for services provided. The Department of Human Services (department) and the Oregon Health Authority (authority) make payments to vendors other than providers through the state?s accounting system. We judgmentally selected payments to 28 vendors for our review. We identified the following 2 errors, which were not identified during their review process, that resulted in improper payment of Medicaid expenditures: Payments to one vendor charged expenditures related to a specific project unrelated to the Medicaid program, resulting in known federally funded questioned costs of $1,361. For one payment management was unable to provide a contract or support for bids collected for the project charged to the Medicaid program, resulting in known federally funded questioned costs of $46,581. The above issues occurred due to human error and inadequate record maintenance which could lead to unallowed activities/costs being charged to the Medicaid program. We recommend department and authority management strengthen controls over review to ensure transactions are adequately supported and reviewed. Additionally, we recommend the authority reimburse the federal agency for unallowable costs. MANAGEMENT RESPONSE: We agree with this recommendation. ODHS Facilities Management Response for Finding #1: The Office of Facilities Management (OFM) is committed to providing accurate coding for payments. Communications have been made with staff responsible for coding invoices and the need to conduct thorough reviews to ensure coding is accurate and charged to the appropriate funding source for the goods or services the agency is being invoiced for. OFM will be communicating with the programs that provide coding to confirm that the information provided appropriately aligns with the intended use of the funds. The department will review current processes and forms to ensure there is sufficient detail to verify accuracy. Questioned costs of $1,361 in Federal Funds (and $2,722 in Total Funds) paid with invoice number VP815455, was corrected on 4/26/2023 with document BTCL1412. ODHS, Aging and People with Disabilities (APD) Response for Finding #2: The department is committed to storing and retaining supporting documentation for all authorized payments. The processes and procedures on contract bidding and approval associated with payment authorization for 1915k services and support are being reviewed and improvements such as central repositories are being explored. Once analysis and improvements are complete, they will be documented and communicated to staff within the department and to the Office of Financial Services for awareness. Additionally, as part of succession plan development, the department will create intentional opportunities for knowledge transfer, shared document storage, and increased transparency amongst work teams, which will assist with document location in the context of unexpected personnel changes. The department will reimburse the federal agency for any unallowable costs. Anticipated Completion Date: June 30, 2024 Contact: Jennifer Stallsworth, Chief of Staff or David Hawkins, Construction and Facility Maintenance Manager
View Audit 45093 Questioned Costs: $1
Finding 47822 (2022-054)
Significant Deficiency 2022
2022-054 Department of Human Services/Oregon Health Authority Improve controls over payments for Medicaid clients Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.777 and 93.778 Medicaid Cluster Federal Award Numbers and Years: 2105OR5M...
2022-054 Department of Human Services/Oregon Health Authority Improve controls over payments for Medicaid clients Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.777 and 93.778 Medicaid Cluster Federal Award Numbers and Years: 2105OR5MAP, 2021; 2105OR5ADM, 2021; 2205OR5MAP, 2022; 2205OR5ADM, 2022 Compliance Requirement: Activities Allowed or Unallowed; Allowable Costs/Cost Principles Type of Finding: Significant Deficiency; Noncompliance Prior Year Finding: N/A Questioned Costs: N/A Criteria: 2 CFR 200.1(1); 2 CFR 200.400(a); 2 CFR 200.404; 42 CFR ? 433.32(a) Federal regulations only allow the Medicaid program to charge allowable program expenditures at the federal financial participation rate for various program costs at the time of payment for services provided. The Department of Human Services (department) and the Oregon Health Authority (authority) make payments to service providers through the Jsystems system. We randomly sampled 61 clients and one Medicaid service payment associated with each client using a statistically valid sample. We reviewed agency documentation to test compliance with the Activities Allowed or Unallowed & Allowable Cost requirements. For 1 client, we found the issues described below. The claim selected as our sample item did not have mileage accurately calculated, which resulted in an overpayment. Further review of payments for this client identified additional inaccurate payments during the fiscal year for mileage to this provider. Questioned costs identified for our sample item resulted in an overpayment of $6.00 and other identified questioned costs resulted in an underpayment of ($5.27). The above issues occurred due to human error when entering mileage into the state payment system from the home care worker mileage tracking software (OR-PTC), which lead to improper payments. Phase 1 of the OR-PTC system was implemented in September of 2021. During this phase of the implementation branches must run a report of mileage claims and enter these claims manually into the payment system. Due to the exceptions noted above, we reviewed all clients within our sample for the fiscal year which had mileage entered into the OR-PTC system and identified multiple additional underpayments and overpayments that resulted in an overall underpayment of ($49.07). Due to the systemic nature of this issue, we are unable to reasonably estimate or quantify remaining potential questioned costs outside of our sample population. We recommend department and authority management strengthen controls over the OR-PTC system to ensure transactions are adequately supported and reviewed. MANAGEMENT RESPONSE: We agree with this recommendation. The department is engaged in ongoing efforts to mitigate this risk through continued communications with local offices and their leadership around the importance of correct data entry and reviewing changes to our KPI?s that we report quarterly to CMS. Regional Readiness Coordinators (RRCs) provide training, reinforce best practices, review business processes, and provide feedback on issues we are seeing to reduce incidences of human error. The department will also continue to review and research authorizations for Mileage and Time entries that do not align with existing claims to determine where additional RRC support is needed. Several system enhancements and changes slated for June 2023 are intended to help providers claim time accurately and reduce local office workload associated with reviewing pending entries. This will not fully resolve the issues noted by SOS, however, implementation of phase 2A of the Provider Time Capture System, which is scheduled to go into production July 12, 2024, will eliminate the need for local offices to manually enter mileage or hours into the mainframe payment systems and will automatically flag discrepancies between OR PTC DCI and the Mainframe. The department has corrected all identified issues discovered through the audit process. Anticipated Completion Date: July 31, 2024 Contact: Jennifer Stallsworth, Chief of Staff
2022-041 Oregon Health Authority Ensure expenditures of federal funds are recorded to the appropriate program Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.958 Block Grants for Community Mental Health Services (COVID-19) 93.959 Bloc...
2022-041 Oregon Health Authority Ensure expenditures of federal funds are recorded to the appropriate program Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.958 Block Grants for Community Mental Health Services (COVID-19) 93.959 Block Grants for Prevention and Treatment of Substance Abuse (COVID-19) Federal Award Numbers and Years: 93.958 ? 1B09SM083994, 1B09SM085378 (COVID-19); 93.959 ? 1B08TI083513, 1B08TI083963 (COVID-19) Compliance Requirement: Activities Allowed or Unallowed Type of Finding: Material Weakness; Material Noncompliance Prior Year Finding: N/A Questioned Costs: 93.958 - $2,268,421 (known COVID-19) Criteria: 2 CFR 200.303; 42 USC 300x-1 The department was required to submit a spending plan documenting the intended use of the awarded COVID-19 funding allocations under the Mental Health Block Grant (MHBG) and Substance Abuse Block Grant (SABG). The expenditure of COVID-19 funding should align with each block grant?s approved spending plan. Federal regulations also require recipients of federal awards establish and maintain internal controls designed to reasonably ensure compliance with federal statutes, regulations, and terms and conditions of the Federal award. Our testing of state fiscal year 2022 MHBG COVID-19 expenditures identified $10.4 million in workforce development incentive payments inappropriately recorded under the MHBG. Further inquiry into the payments revealed the department determined during state fiscal year 2023 these expenditures were not included in the MHBG COVID-19 spending plans and were not allowable activities under the MHBG. The department determined incentive payments totaling $8.1 million in COVID-19 expenditures should have been recorded under the SABG in accordance with the SABG COVID-19 spending plans. The department subsequently moved the $8.1 million of the combined $10.4 million total COVID-19 incentive payment expenditures to the SABG; however, the remaining $2.3 million in incentive payment expenditures were left in the MHBG as a funding source had yet to be determined. An adjustment to the Schedule of Expenditures of Federal Awards (SEFA) was required to move the $8.1 million in COVID-19 spending from the MHBG to SABG. The remaining $2.3 million is considered questioned costs under the MHBG. We recommend department management ensure controls are properly designed and implemented to record only allowable expenditures to the appropriate federal programs. MANAGEMENT RESPONSE: We agree with this recommendation. The identified expenditures were initially charged to the MHBG in error, and when the error was found by OHA staff, the funding source was corrected to SAPT for the authorized $8.1 million prior to the SOS audit beginning. There was still $2.3 million remaining coded to MHBG which after extensive review and leadership decision, has now been re-coded appropriately. OHA?s existing internal controls identified this issue initially, no additional corrective action is needed. Anticipated Completion Date: July 5, 2023 Contact: Sarah Adelhart, Interim Manager
2022-035 Department of Human Services Improve controls over benefit time tracking and discontinuance of federal funding Federal Awarding Agency: U.S. Department of the Treasury Assistance Listing Number and Name: 93.558 Temporary Assistance for Needy Families Federal Award Numbers and Years: 202...
2022-035 Department of Human Services Improve controls over benefit time tracking and discontinuance of federal funding Federal Awarding Agency: U.S. Department of the Treasury Assistance Listing Number and Name: 93.558 Temporary Assistance for Needy Families Federal Award Numbers and Years: 2021G996115, 2021; 2022G996115, 2022 Compliance Requirement: Allowable Costs/Cost Principles Type of Finding: Material Weakness; Noncompliance Prior Year Finding: N/A Questioned Costs: $1,866 known Criteria: 45 CFR 264.1 Federal regulations prohibit federal funding to families that include an adult head-of-household who has received federal assistance for a cumulative of 60 months, and who do not have an allowed exception. The Oregon Department of Human Services? (department) case management system, Oregon Eligibility (ONE), tracks months counting towards the federal limit. When 60 months is reached, ONE sends an indicator to the financial subsystem containing funding coding. If Temporary Assistance for Needy Families (TANF) benefits continue, they are to be funded with state funds. The population of cases identified in ONE as having reached 60 cumulative federal months is obtained from the quarterly performance data reports compiled by a service provider. As stated in a separate finding, titled `Ensure performance data reports are complete and accurate,? we determined the data reports are not complete or accurate, therefore, the population of cases over 60 federal months is also incomplete. However, we tested some cases in the reports to verify ONE was accurately counting federal months and to determine if federal funding was appropriately discontinued. We randomly selected ten cases from an incomplete population of 3,193 and found one case where federal funding inappropriately continued after reaching 60 months due to a coding issue within the financial subsystem, resulting in federal overpayments of $1,944 for recurring monthly cash assistance benefits, and $1,866 for expenses related to seeking employment (JOBS) in fiscal year 2022. The department was aware of the cash assistance coding issue and the JOBS coding issue as early as October 2021. A $5.6 million correction for regular cash assistance was made in accounting records in September 30, 2022, which corrected the cash assistance benefits portion of the error noted above. The JOBS coding issue has yet to be corrected in accounting records and the department did not have an adjustment total readily available. As the regular cash assistance correction surpassed $5 million, we have reasonable assurance that the uncorrected federal JOBS payments also exceed $25,000 in likely questioned costs. We recommend department management make timely corrections to federal/state coding splits in the financial subsystem and also make timely corrections in state accounting records. We also recommend the department reimburse the federal agency for unallowable costs. MANAGEMENT RESPONSE: We agree with this recommendation. The Department will analyze and identify the missing indicators sent from ONE to the financial subsystems to determine the correct funding stream. The Strategic Systems Unit will put together a TANF funding matrix to be approved by program. Indicators will be corrected through a system defect, a Work Item, or Change Request, depending on the Level of effort to resolve. Financial adjustments will be made by Office of Financial Services to credit the TANF federal grant rather than reimbursing, per instructions outlined in TANF-ACF-PI-2006-03. Anticipated Completion Date: December 31, 2023 Contact: Annette Palmer, TANF Program Manager
View Audit 45093 Questioned Costs: $1
Finding 47790 (2022-052)
Significant Deficiency 2022
2022-052 Oregon Health Authority Improve review of expenditure transactions Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (COVID-19) Federal Award Numbers and Years: 6 NU...
2022-052 Oregon Health Authority Improve review of expenditure transactions Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (COVID-19) Federal Award Numbers and Years: 6 NU50CK000541, 2021 (COVID-19) Compliance Requirements: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Type of Finding: Significant Deficiency, Noncompliance Prior Year Finding: N/A Questioned Costs: $35,416 (known) (COVID-19) Criteria: 2 CFR 200.303 As part of our testing, we reviewed expenditures charged to the program to ensure they were properly approved and an appropriate use of program resources. We randomly selected 25 of 2,355 non-payroll transactions as the basis for our testing. For one of the transactions, there was no evidence the expenditures had been reviewed and approved as appropriate expenditures for the program. The specific transaction was for cell phones and data plans on wireless devices and consisted of 584 separate devices. Only 24 (2.5%) of those devices had been approved by a manager. The department will pay the vendor for the full amount of the invoice. Managers are expected to review the charges for their unit and verify they are directed to the proper cost center. The $35,416 in questioned costs represents the charges for the devices without approval. Also, during fiscal year 2022, payroll for the department was processed through the Oregon State Payroll Application (OSPA). As part of each monthly payroll cycle, managers are expected to review and approve employee?s reported hours to ensure expenditures are accurate and are billed to the correct program(s). Although state policy requires managers to review the timesheets, the automated controls in the system will process the payroll without a review, effectively making the managerial review optional. The OSPA was retired as of November 30, 2022; however, the replacement payroll system operates in a similar manner for managerial review. As part of our testing of payroll expenditures, we found one of 25 randomly selected timesheets were not reviewed by a manager prior to release into the payroll system. We were able to perform alternative procedures to verify the amounts charged to the program were appropriate and there are no questioned costs. The lack of review increases the risk that inappropriate costs may be charged to federal programs. We recommend management ensure wireless device charges are properly reviewed, and expenditures are charged to the correct cost center or program. We also recommend management implement procedures to ensure all employee payroll submissions are reviewed and approved by program management. MANAGEMENT RESPONSE: We agree with this recommendation. The questioned costs related to cell phone charges appear to have resulted from a lack of formal process in the Coronavirus Response and Recovery Unit. This unit has closed and departments have returned to standardized formal processes. Corrective action plan: ? Prior to ?COVID-19? processes and procedures will be followed ? Administrative staff will parse cell phone charges and code invoices according to employee payroll ? Approving manager will review coding for accuracy prior to approval Anticipated Completion Date: January 1, 2023 Contact: Merry Carlson, ELC Contracts Manager
View Audit 45093 Questioned Costs: $1
Finding 47786 (2022-050)
Significant Deficiency 2022
2022-050 Oregon Health Authority Improve review of expenditure transactions Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.268 Immunization Cooperative Agreements (COVID-19) Federal Award Numbers and Years: 5 NH23IP922626, 2022 (COVID-1...
2022-050 Oregon Health Authority Improve review of expenditure transactions Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.268 Immunization Cooperative Agreements (COVID-19) Federal Award Numbers and Years: 5 NH23IP922626, 2022 (COVID-19) 6 NH23IP922626, 2022 (COVID-19) Compliance Requirements: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Type of Finding: Significant Deficiency Prior Year Finding: N/A Questioned Costs: N/A Criteria: 2 CFR 200.303 During fiscal year 2022, payroll for the Oregon Health Authority was processed through the Oregon State Payroll Application (OSPA). As part of each monthly payroll cycle, managers are expected to review and approve employee?s reported hours to ensure expenditures are accurate and are billed to the correct program(s). Although state policy requires managers to review the timesheets, the automated controls in the system will process the payroll without a review, effectively making the managerial review optional. The OSPA was retired as of November 30, 2022. However, the new Workday application that went into effect to replace the OSPA has the same weakness where payroll will process without regard for the managerial review. As part of our testing of program expenditures, we found that 3 of 134 timesheets were not reviewed by a manager prior to release into the payroll system. For each of these items, we were able to perform alternative procedures to verify that the amounts charged to the program were appropriate and there are no questioned costs. However, the lack of review increases the risk that inappropriate payroll costs may be charged to the program. We recommend management implement procedures to ensure that all employee payroll submissions are properly reviewed, and payroll is appropriately charged to the correct cost center or program. MANAGEMENT RESPONSE: We agree with this recommendation. The Oregon Immunization Program (OIP) section manager immediately notified all supervisory managers and administrative support staff of the finding on June 5th. Finding: ?As part of our testing of program expenditures, we found that 3 of 134 timesheets were not reviewed by a manager prior to release into the payroll system.? Supervisory managers were reminded that it is an expectation of their position to ensure that payroll time entries are thoroughly reviewed, and discrepancies resolved, and final entries approve according to agency requirements ? on time, every month. On June 5th, program administrative staff and the section manager began development of an internal standard operating procedure (SOP) that will thoroughly document the steps the program requires of supervisory managers to assure that all employee payroll submissions are properly reviewed and payroll is appropriately charged to the correct cost center or program. The final SOP will be signed by each supervisory manager in the program, and included in a quarterly Performance, Accountability and Feedback (PAF) session between each supervisory manager and the section manager. The final SOP will be delivered to the offices of the Secretary of State Audit Division, and DAS once approved by the Division management, and signed by each OIP supervisory manager. This finding and the resolution will be shared as well with our funder, the Centers for Disease Control and Prevention, as required by our cooperative agreement. Anticipated Completion Date: July 5, 2023 Contact: Mimi Luther, OIP Section Manager (interim)
Finding 47785 (2022-049)
Significant Deficiency 2022
2022-049 Oregon Health Authority Return overdraw of reclassified FEMA expenditures Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.268 Immunization Cooperative Agreements (COVID-19); 93.323 Epidemiology and Laboratory Capacity for Infe...
2022-049 Oregon Health Authority Return overdraw of reclassified FEMA expenditures Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.268 Immunization Cooperative Agreements (COVID-19); 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (COVID-19) Federal Award Numbers and Years: 93.268: 5 NH23IP922626 (COVID-19); 93.268: 6 NH23IP922626 (COVID-19); 93.323: 6 NU50CK000541 (COVID-19) Compliance Requirement: Activities Allowed or Unallowed Type of Finding: Significant Deficiency, Noncompliance Prior Year Finding: N/A Questioned Costs: 93.268 - $36,783 (known) (COVID-19) 93.323 - $73,333 (known) (COVID-19) Criteria: 2 CFR 200.403 During the COVID-19 pandemic, the Oregon Health Authority (department) spent money from Federal Emergency Management Agency (FEMA) awards to address needs in addressing the pandemic. Due to delays in receiving federal reimbursement for the expenditures, the department reclassified the expenditures to other programs where reimbursements would occur timelier. In our testing of Activities Allowed or Unallowed, we reviewed two individually significant items in the accounting system reclassifying 398 and 914 individual expenditures from the FEMA grants to the Immunization Cooperative Agreements program and Epidemiology and Laboratory Capacity program, respectively. Based upon the account coding of the original transactions, all of the reclassifications were allowable and consistent with program requirements. However, we found several transactions were reclassified twice, resulting in an excess of $36,783 charged to the Immunization program and $73,333 charged to the Epidemiology program. The reclassifications were completed in two batches and the managerial review of the reclassifying transactions failed to detect some transactions were included in both batches. We recommend department management correct the entries and reimburse excess cash drawn to the federal agency for unallowable costs. We also recommend department management revise the review procedures to verify that the same expenditure transactions are not duplicated in multiple batches. MANAGEMENT RESPONSE: We agree with this recommendation. Corrective action plan: ? The agency has reviewed the questioned costs and has corrected the entries with BTCL7084 and reimbursed the federal programs. ? The department has regular processes to review for duplicate adjusting entries. However, this process was missed for this entry. ? Department management will work with department staff to reinforce their understanding of the need to follow these processes to ensure transactions are not adjusted more than once. Anticipated Completion Date: June 1, 2023 Contact: Nichole Petersen, Division Liaison ? PH/ HP&A/ OEBB/ PEBB
View Audit 45093 Questioned Costs: $1
FA 2022-001 Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Period of Performance Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Department of ...
FA 2022-001 Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Period of Performance Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: COVID-19 - 84.425D - Elementary and Secondary School Emergency Relief Fund COVID-19 - 84.425U - American Rescue Plan Elementary and Secondary School Emergency Relief Fund COVID-19 - 84.425W - American Rescue Plan Elementary and Secondary School Emergency Relief Fund - Homeless Children and Youth Federal Award Number: S425D210012 (Year: 2021), S425U2120012 (Year: 2021) S425W210011 (Year: 2021) Questioned Costs: $108,220 Description: A review of expenditures charged to the Elementary and Secondary School Emergency Relief Fund program revealed that the School District's internal control procedures were not operating appropriately to ensure that expenditures were allowable for the program. Corrective Action Plans: We concur with this finding. A new Federal Programs Director began work during the period of the audit. The change in personnel coupled with the influx of new grants, large awards of grant dollars and new regulations and requirements contributed to the finding. To correct, staff meet and attend training on all federal grant funds received to ensure compliance on all reporting requirements. The federal programs director enters and monitors all grant budgets into the consolidated application and supplies all prior approval forms for those items for which it is required. The federal programs director also approves all purchase requisitions using federal funds before items can be purchased; she also reviews and approves request for reimbursement of federal funds before those funds are drawn down. (Superintendent approves as well.) Estimated Completion Date: June 30, 2023 Contact Person: Debbie Driggers Powell Telephone: (912) 557-3327 Email: dpowell@tattnall.k12.ga.us
View Audit 40842 Questioned Costs: $1
Finding 47746 (2022-003)
Material Weakness 2022
COMPLIANCE 2022-003 Controls Over Activities Allowed Recommendation: The City should review their established policies and procedures for effectiveness and ensure all employees adhere to all established procedures. Corrective Action Plan: The City of Scott will review financial policies and procedur...
COMPLIANCE 2022-003 Controls Over Activities Allowed Recommendation: The City should review their established policies and procedures for effectiveness and ensure all employees adhere to all established procedures. Corrective Action Plan: The City of Scott will review financial policies and procedures and make any necessary changes to ensure an effective control environment.
View Audit 53113 Questioned Costs: $1
Finding 47745 (2022-002)
Material Weakness 2022
INTERNAL CONTROL 2022-002 Controls Over Activities Allowed Recommendation: The City should review their established policies and procedures for effectiveness and ensure all employees adhere to all established procedures. Corrective Action Plan: The City of Scott will review financial policies and pr...
INTERNAL CONTROL 2022-002 Controls Over Activities Allowed Recommendation: The City should review their established policies and procedures for effectiveness and ensure all employees adhere to all established procedures. Corrective Action Plan: The City of Scott will review financial policies and procedures and make any necessary changes to ensure an effective control environment.
View Audit 53113 Questioned Costs: $1
Finding Number: 2022-003 Condition: During payroll expenditure testing of salaried employees, it was identified that, for employees who spend time in multiple cost objectives, appropriate controls were not in place to perform a timely reconciliation between the time charged to Title I based on budge...
Finding Number: 2022-003 Condition: During payroll expenditure testing of salaried employees, it was identified that, for employees who spend time in multiple cost objectives, appropriate controls were not in place to perform a timely reconciliation between the time charged to Title I based on budget estimates and the actual time expended on Title I activities. Ultimately a reconciliation was performed and approximately $ 99,000 was overcharged to Title I and subsequently reclassified as a non- grant expenditure. However, the School District requested and received reimbursement for this amount during the year- end June 30,2022. Planned Corrective Action: The School District will implement procedures to complete a review and reconciliation process to support the amount charged to Title I based on budget estimates is reasonable when compared to actual time expended on federal and state grants, specifically Title I Reconciliation will occur more than once a year to be able to align grant budgets, as needed. Contact person responsible for corrective action: Jennifer Graber, Director of Curriculum and Instruction and Blair Brindley, Director of Business Operations Anticipated Completion Date: 6/30/2023
Finding 2022-0003 Identification of federal program: US Department of Education 84.425C, 84.425D and 84.425U Education Stabilization Fund Criteria: Nonfederal entities shall include in their construction contracts subject to the Wage Rate Requirements (which still may be referenced as the Davis-Ba...
Finding 2022-0003 Identification of federal program: US Department of Education 84.425C, 84.425D and 84.425U Education Stabilization Fund Criteria: Nonfederal entities shall include in their construction contracts subject to the Wage Rate Requirements (which still may be referenced as the Davis-Bacon Act) a provision that the contractor or subcontractor comply with those requirements and the DOL regulations (29 CFR Part 5, Labor Standards Provisions Applicable to Contracts Governing Federally Financed and Assisted Construction) (2CFR section 200.327; Appendix II D to 2 CFR Part 200). This includes a requirement for the contractor or subcontractor to submit to the nonfederal entity weekly, for each week in which any contract work is performed, a copy of the payroll and a statement of compliance (certified payroll) (29 CFR section 5.5 and 5.6; the A-102 Common Rule(section 36(i)(S)): 0MB Circular A-110 (2 CFR Part 215, Appendix A, Contract Provisions); 2 CFR Part 176, Subpart C; and 2 CFR section 200.327). Condition: A LEA must use ESF funds for minor remodeling, renovation or construction contracts that are over $2,000 and use laborers and mechanics that must meet Davis-Bacon prevailing wage requirements. Cause: The School failed to timely notify a certain contractor about the Davis-Bacon Act contract clause requirements related to the prevailing wage rate for contractors and subcontractors. As a result, the contractor did not provide the certified payrolls or statement of compliance. Potential Effect: The contractor may not have complied with the wage requirements. Questioned costs: $214,716.62. Context: A total sample of one (1) item related to a certain contractors HVAC project was selected as part of allowable cost testing for the Education Stabilization Fund. Recommendation: We recommend that the School provide timely communication related to the prevailing wage rate requirements for contracts with future contractors and subcontractors. The School should also ensure that the proper prevailing wage rate clauses are included in future contracts. We further recommend that the School ensure the contractors and subcontractors compliance with the required federal compliance requirements. Action: We concur with the recommendation and will implement the appropriate language identifying the prevailing wage rate requirements in future contracts with both contractors and subcontractors. Furthermore, certified payrolls and statements of compliance with be required and tracked for each project.
View Audit 53695 Questioned Costs: $1
Finding ref number: 2022-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with allowable activities and costs and restricted purpose requirements Name, address, and telephone of District contact person: Amy Karcher, Finance Manager PO Box 8937 Vanco...
Finding ref number: 2022-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with allowable activities and costs and restricted purpose requirements Name, address, and telephone of District contact person: Amy Karcher, Finance Manager PO Box 8937 Vancouver, WA 98668-8937 (360) 313-1348 Corrective action the auditee plans to take in response to the finding: (If the auditee does not concur with the finding, the auditee must list the reasons for disagreement). This audit finding related to unique rules associated with one-time, pandemic-necessitated funding, so VPS is extremely unlikely to have to navigate these compliance expectations ever again. However, VPS will aspire to slow down the procurement and deployment of grant-funded resources as long as possible in the future in order to learn more of what the final audit expectations may be. Anticipated date to complete the corrective action: Undeterminable based on rarity of event
View Audit 52811 Questioned Costs: $1
Finding 47715 (2022-001)
Material Weakness 2022
FINDING 2022-001 Contact Person Responsible for Corrective Action: Linda Pruitt Contact Phone number: 765-342-1001 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Morgan County Commissioners adopted Ordinance No. 2023-10 which establishes interna...
FINDING 2022-001 Contact Person Responsible for Corrective Action: Linda Pruitt Contact Phone number: 765-342-1001 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Morgan County Commissioners adopted Ordinance No. 2023-10 which establishes internal control procedures related to the expenditure of ARPA funds. This ordinance also requires reports to be reviewed by the Auditor?s office prior to submission and a printed copy with the County Administrator?s signature and the County Auditor or Deputy Auditor?s signature shall be retained. This ordinance took effect upon passage on April 17, 2023. Anticipated Completion Date: Has already been corrected.
Planned Corrective Actions: In its Provider Relief reporting submission for the year ended September 30, 2022, the District initially selected option 2 based on quarterly actuals to budget quarterly lost revenue. However, the District, including the nursing homes for which they operate, did not have...
Planned Corrective Actions: In its Provider Relief reporting submission for the year ended September 30, 2022, the District initially selected option 2 based on quarterly actuals to budget quarterly lost revenue. However, the District, including the nursing homes for which they operate, did not have a budget approved by the respective Board by March 27, 2020 as required under option 2. Technically, the District should have reported under option 3. Management spent significant amount of time and resources evaluating the reporting requirements and considered option 2 with a prorated budget for Q4 2020 and Q1 through Q4 2021 to be a reasonable methodology given the District?s budget cycle is on the fiscal year September 30 and not December 31. Additionally, the calculated budget revenue for the nursing homes were unable to be reconciled to supporting documentation files. During the single audit, it was determined option 3 would have been the more appropriate reporting option to select. Management has performed a detailed analysis of the reporting requirements in accordance with the final guidelines set for by HRSA for future reporting periods. During period 4 reporting, the District elected option 3 to report lost revenues, which was deemed to be a more accurate representation of the lost revenue methodology utilized. As deemed necessary, the District will modify policies and procedures over federal grant reporting. The District?s CFO will oversee this to ensure that this is accomplished.
View Audit 49870 Questioned Costs: $1
Finding #2022-001 ? Material Weakness and Other Noncompliance Applicable federal programs: U. S. Department of Housing and Urban Development Direct Federal Funding Continuum of Care Program Assistance Listing #14.267 Contract #TX0392L6E002006, Contract year: 09/01/21 ? 08/31/22 U. S. Department ...
Finding #2022-001 ? Material Weakness and Other Noncompliance Applicable federal programs: U. S. Department of Housing and Urban Development Direct Federal Funding Continuum of Care Program Assistance Listing #14.267 Contract #TX0392L6E002006, Contract year: 09/01/21 ? 08/31/22 U. S. Department of Health and Human Services Direct Federal Funding Sexual Risk Avoidance Education Assistance Listing #93.060 Contract #90SR0044-03-03, Contract year: 09/30/20 ? 06/30/22 Contract #90SR0120-01-00, Contract year: 09/30/20 ? 09/29/21 Contract #90SR0120-02-00, Contract year: 09/30/21 ? 09/29/22 Contract #90SR0157-01-01, Contract year: 09/30/21 ? 09/29/22 U. S. Department of Health and Human Services Direct Federal Funding Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges Assistance Listing #93.332 Contract #NAVCA210403-01-01, Contract year: 08/27/21 ? 08/26/22 Contract #NAVCA210403-02-00, Contract year: 08/27/22 ? 08/26/23 U. S. Department of Health and Human Services Passed through Texas Health and Human Services Commission Block Grants for Prevention and Treatment of Substance Abuse Assistance Listing #93.959 Contract #HHS000539700204 YPI, Contract year: 09/01/21 ? 08/31/22 Contract #HHS000539700204 YPS, Contract year: 09/01/21 ? 08/31/22 Contract #HHS000539700204 YPU, Contract year: 09/01/21 ? 08/31/22 Condition and context: Time and effort reporting is based on the amount reflected in the budget rather than actual time spent on the program. Additionally, the allocation of certain costs are impacted as they are charged to the program based on the direct salary percentages. Recommendation: Provide training to ensure that salaries and wages charged to federal programs are supported by personnel activity reports based on actual time worked. Planned corrective action: While the salaries and wages charged to federal programs are supported by a system of internal control which provided a historical and reasonable assurance that the charges are accurate, allowable, properly allocated in a manner which supports the distribution of the employee?s salary or wages among specific activities/programs, and reasonably reflect the total activity for which the employee is compensated, revision to the process will be made to ensure that timesheets will be completed based on actual time worked rather than percentages based on assigned work/time distribution. Actual hours worked will be entered onto timesheets and allocated to applicable grants. As is the current policy, all time submitted by employees will require supervisory approval. Salaries and wages charged to the grant will be based on actual work performed determined by hours submitted by employee and approved by the applicable supervisor. Policies and procedures will be updated to include this required process to ensure that the allocation methodology used to allocate costs between programs reflect the actual relative benefit to the grant. Training will be provided to program and accounting staff to ensure that this process is understood and properly implemented. Responsible officer: Angelica Castillo, CFO Estimated completion date: September 1, 2023
Finding ref number: 2022-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with allowable activities and costs and restricted purpose requirements. Name, address, and telephone of District contact person: Sylvia Bazan, Business Manager 212 W. 3rd Str...
Finding ref number: 2022-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with allowable activities and costs and restricted purpose requirements. Name, address, and telephone of District contact person: Sylvia Bazan, Business Manager 212 W. 3rd Street Wapato, WA 98951 (509) 877-4181 Corrective action the auditee plans to take in response to the finding: (If the auditee does not concur with the finding, the auditee must list the reasons for disagreement). During the COVID -19 pandemic, the District applied for ECF funding for hotspots and chrome books for our students. The Wapato School District was not a 1 to 1 District in regards to devices, but we had to pivot quickly to ensure our students had a device and connectivity. This would ensure we could provide instruction during remote learning and school closures during the pandemic. The District provided a survey to all students/parents seeking information regarding connectivity and devices. The survey results showed many of our students did not have adequate connectivity or a device to stream videos, which is needed for remote instruction. Also, the District did not receive responses from all families as they did not have connectivity to do so. The District used its library check out system to issue Chromebook and hot spots to students. The process was for students who needed a device to communicate this to their school building, then they would be directed to the library to obtain a device. The student?s requests were an unmet need. Although the student/parent did not sign a form to document unmet need, the District felt the request for a device was sufficient. As for the per location and per user limitation, the District?s library system was used to provide reports during the audit process, but it was determined the reports were not run at the time of reimbursement. The Wapato School District is a District with over 90% poverty level, the District?s priority was to ensure students were provided devices for instruction and connectivity during the pandemic. The District will strengthen its controls over documenting unmet need for students as well as maintaining reports that show per location/ per user limits at the time ECF funding is requested. Our IT department has started to implement a formal process, which includes a written application for our student/family to submit prior to receiving a device. They are also working on written instructions for the deployment of devices and documentation to be obtained. These instructions will be provided to all school buildings. Anticipated date to complete the corrective action: June 1, 2023
View Audit 49232 Questioned Costs: $1
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