Corrective Action Plans

Finding 36819 (2022-002)

Material Weakness 2022

OH

Allowable Costs / Cost Principles Period of Performance Matching / Level of Effort / Earmarking § 200.303 § 200.430

The Darke County Educational Service Center?s management will continue to review payroll calculations and believes this was an isolated error.

View Audit 26899

Finding 36812 (2022-002)

Significant Deficiency 2022

National Trust for Historic Preservation in the United States

DC

Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303 § 200.430

2022-002 INTERNAL CONTROL OVER COMPLIANCE WITH ACTIVITIES ALLOWED OR UNALLOWED, ALLOWABLE COST/COST PRINCIPLES ? PAYROLL ACTIVITIES The National Trust has implemented new procedures in fiscal year 2023 requiring supervisors to review and approve time charged to federal awards through the ADP timekee...

2022-002 INTERNAL CONTROL OVER COMPLIANCE WITH ACTIVITIES ALLOWED OR UNALLOWED, ALLOWABLE COST/COST PRINCIPLES ? PAYROLL ACTIVITIES The National Trust has implemented new procedures in fiscal year 2023 requiring supervisors to review and approve time charged to federal awards through the ADP timekeeping system in addition to the reviews performed by finance staff as part of ongoing monitoring of federal awards, including approval of time incurred during the fiscal year prior to implementation of new procedures. Individual(s) Responsible for Corrective Action Plan: Laura Bracis Chief Financial Officer 202-588-6153 Anticipated Completion Date: June 30 , 2023

View Audit 32413

Finding 36769 (2022-001)

Significant Deficiency 2022

Community Action Pioneer Valley, Inc. and Subsidiaries

MA

Allowable Costs / Cost Principles Subrecipient Monitoring

Recommendation: The Organization should consistently allocate the indirect cost rate to all CoC grants. View of Responsible Officials: Responsible officials agree with the recommendation and will implement controls to allocate the indirect cost rate consistently.

View Audit 30708

Finding 36768 (2022-004)

Material Weakness 2022

Housing Authority of the City of Imperial, Nebraska

NE

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

Finding 2022-004 The Authority agrees with the finding and responds stating that our project is relatively small with only one administrative staff. The board has reviewed this issue and determined there are no additional procedures which can reasonably be done to eliminate these deficiencies and a...

Finding 2022-004 The Authority agrees with the finding and responds stating that our project is relatively small with only one administrative staff. The board has reviewed this issue and determined there are no additional procedures which can reasonably be done to eliminate these deficiencies and accepts them.

View Audit 30476

Finding 36765 (2022-002)

Material Weakness 2022

Gering Elderly Housing Corporation

NE

Allowable Costs / Cost Principles HUD Housing Programs Material Weakness

Finding 2022-002: Allowable Costs Section 202 Capital Advance, 14.157 Material Weakness I agree with the finding. The previous management did not submit budget for the year 2021-2022. Although I submitted a budget for the year, HUD only renewed the previous budget on file as they needed to compl...

Finding 2022-002: Allowable Costs Section 202 Capital Advance, 14.157 Material Weakness I agree with the finding. The previous management did not submit budget for the year 2021-2022. Although I submitted a budget for the year, HUD only renewed the previous budget on file as they needed to complete approval by 5-1-2022 of the New Management Agent. HUD approval effectively locked in the budget for the period 7/1/2022 -6/30/23. A revised budget has been submitted and approved by the Board of Directors for the period 7/1/2022 ? 6/30/2023. A budget will be prepared and submitted to both the Board and HUD for the period 7/1/2023 ? 6/30/2024.

View Audit 36057

Finding 36762 (2022-001)

Significant Deficiency 2022

Communities in Schools of the Dallas Region, Inc.

TX

Allowable Costs / Cost Principles Reporting Significant Deficiency

Finding No. 2022-001: Allowable costs ? Significant deficiency in internal control over compliance. The 21st Century grant director was provided a PEX card (prepaid credit card) to make purchases for the program. The purchases were approved per the budgeted line items by the grantor. The CFO met wit...

Finding No. 2022-001: Allowable costs ? Significant deficiency in internal control over compliance. The 21st Century grant director was provided a PEX card (prepaid credit card) to make purchases for the program. The purchases were approved per the budgeted line items by the grantor. The CFO met with the program director on a bi-weekly basis and the program director outlined all anticipated expenses for the program. They were discussed and approved during the meeting but were not physically documented. The purchases were made and receipts were uploaded into the PEX system, however there was no signature on the receipts to document the approval. These expenses were later reviewed and summarized by the CFO in an Excel spreadsheet prior to billing the grantor. We have incorporated and communicated changes to our policy and standard procedure to ensure the documentation of manager?s approval of invoices are kept on file. Employees under the 21st Century program have been trained and approval of purchases are now physically documented electronically as of January of 2023. Given CISDR's expanded workload and doubling the number of schools from two years prior, the Finance team was functioning with one full time CFO and one part time accountant. In March 2023 we hired a full-time senior accountant to manage the internal controls compliance over expenditures. The plan has already been implemented.

View Audit 35133

Finding 36759 (2022-003)

Significant Deficiency 2022

Portland Va Research Foundation

OR

Questioned Costs Internal Control / Segregation of Duties Subrecipient Monitoring

Allowable Costs Recommendation: We recommend that the organization implement procedures to ensure that indirect costs are charged in accordance with its approved indirect cost rate proposal. Explanation of disagreement with audit findings: There is no disagreement with the audit findings. Action tak...

Allowable Costs Recommendation: We recommend that the organization implement procedures to ensure that indirect costs are charged in accordance with its approved indirect cost rate proposal. Explanation of disagreement with audit findings: There is no disagreement with the audit findings. Action taken in response to finding: Once the issue was identified as a result of the audit, PVARF staff worked diligently to return the excess funds to the funding source, as well as determining an effective resolution to ensure there is no reoccurrence of inappropriate billing of the foundation?s indirect cost rate. Action Plan: In addition to implementing a project management platform that accurately identify the correct indirect cost rate to be charged, PVARF is also working to ensure cross training is occurring between administrative positions, improving information sharing, and standardizing training. Name(s) of the contact people responsible for correction action: J. Rowland, H. Tyre, S. Dolan Plan completion date for corrective action plan: July 31, 2023

View Audit 35130 Questioned Costs: $1

Finding 36758 (2022-002)

Significant Deficiency 2022

Portland Va Research Foundation

OR

Questioned Costs Allowable Costs / Cost Principles Cash Management

Memorandum of Understanding Billing Recommendation: We recommend that the organization implement procedures to ensure that reimbursement requests are based on actual invoices. Explanation of disagreement with audit findings: there is no disagreement with the audit findings. Action taken in response...

Memorandum of Understanding Billing Recommendation: We recommend that the organization implement procedures to ensure that reimbursement requests are based on actual invoices. Explanation of disagreement with audit findings: there is no disagreement with the audit findings. Action taken in response to finding: Once this deficiency was identified, PVARF immediately contacted VA Portland Health Care System to determine if invoicing would the forthcoming. When it was made clear that there was no forthcoming invoicing, the sponsor was contacted to determine refund steps. Ultimately, the funds were returned to the agency that was inappropriately billed. Action Plan: In addition to ensuring effective communication between the stakeholders, PVARF implemented standard follow-up protocols to make certain VAPORHCS is invoicing PVARF timely, PVARF is in the process of implementing a project management platform that will effectively and efficiently manage major milestones such as invoicing for grants, contracts, and clinical trials. It was also made clear to PVARF administrative staff that there will be no billing ahead of receipt of invoices on any agreements, and that doing so is a breach of the executed contract. Name(s) of the contact people responsible for correction action: Admin Staff Team Plan completion date for corrective action plan: July 31, 2023

View Audit 35130 Questioned Costs: $1

Finding 36744 (2022-002)

Significant Deficiency 2022

Northland Pines School District

WI

Internal Control / Segregation of Duties Allowable Costs / Cost Principles HUD Housing Programs

2022-002 Journal Entry Approval Recommendation: We recommend the District review its written procedures to ensure there are adequate controls over journal entry reviews. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action Taken in Response to Fi...

2022-002 Journal Entry Approval Recommendation: We recommend the District review its written procedures to ensure there are adequate controls over journal entry reviews. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action Taken in Response to Finding: The Business Manager will review and approve all journal entries submitted via Skyward by the Accounting Coordinator and ensure proper supporting documentation is attached to each entry. In turn, the Accounting Coordinator will do the same for all journal entries submitted by the Business Manager. Name of Responsible Official: Tera Fritz, Business Manager Expected Completion Date: July 1, 2022

View Audit 25955

Finding 36742 (2022-022)

Material Weakness 2022

Government of the District of Columbia

DC

Allowable Costs / Cost Principles § 200.303 § 200.430

The District Department of Health (DC Health) concurs with the finding, causes and recommendations cited in the fiscal year 2022 single audit for the HIV Emergency Relief Project Grants (HIVER) program. Corrective action plan objectives are to have the following completed in fiscal year 2023: (1) a...

The District Department of Health (DC Health) concurs with the finding, causes and recommendations cited in the fiscal year 2022 single audit for the HIV Emergency Relief Project Grants (HIVER) program. Corrective action plan objectives are to have the following completed in fiscal year 2023: (1) a regular schedule of payroll data runs and reports of budget-to-actual time migrated to a certification platform managed by the Office of Grants Management, (2) full utilization of a uniform navigable tool and one-stop document for supervisors to certify time and effort and to request next actions if actual costs do not align with personnel budgets, (3) to create an IT solution or mechanism to route and track submissions between supervisors, the Office of Grants Management and the Office of the Chief Financial Officer (OCFO), and (4) the SOP will also be updated to integrate any procedural changes resulting from full implementation. See Corrective Action Plan for chart/table

View Audit 31369

Finding 36722 (2022-019)

Significant Deficiency 2022

Government of the District of Columbia

DC

Allowable Costs / Cost Principles § 200.303 § 200.430

DHS agrees with the finding. DHS will institute a policy and procedure to support payroll expenditures. This will include pulling a sample on a quarterly basis to perform a reconciliation of employees? pay per the Personnel Action Form to the payroll amount posted in the PeopleSoft payroll system. ...

DHS agrees with the finding. DHS will institute a policy and procedure to support payroll expenditures. This will include pulling a sample on a quarterly basis to perform a reconciliation of employees? pay per the Personnel Action Form to the payroll amount posted in the PeopleSoft payroll system. See Corrective Action Plan for chart/table

View Audit 31369

Finding 36718 (2022-016)

Significant Deficiency 2022

Government of the District of Columbia

DC

Allowable Costs / Cost Principles Student Financial Aid Matching / Level of Effort / Earmarking § 200.303

CFSA concurs with the finding as stated. In the three (3) instances of overtime payments in the sample, the employees in question were designated ?on-call? staff during non-business hours. In the event of emergency situations involving child protection or child placement, the ?on-call? staff are r...

CFSA concurs with the finding as stated. In the three (3) instances of overtime payments in the sample, the employees in question were designated ?on-call? staff during non-business hours. In the event of emergency situations involving child protection or child placement, the ?on-call? staff are required to report to work to assist with resolution to the child-based emergency. Their overtime is essentially pre-approved by their management team. CFSA will orient staff to a uniform process to record and account for staff-specific, day-specific, and duration-specific instances of overtime. CFSA will train and monitor usage, and full implementation will occur by September 30, 2023. See Corrective Action Plan for chart/table

View Audit 31369

Finding 36708 (2022-012)

Material Weakness 2022

Government of the District of Columbia

DC

Special Tests & Provisions Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

The Department of Human Services (DHS) agrees with the findings and will work with the DCAS and the Division of Innovation and Change Management (DICM) teams to mitigate the causes of the findings. This corrective action plan has multiple layers in which ESA will collaborate efforts between multipl...

The Department of Human Services (DHS) agrees with the findings and will work with the DCAS and the Division of Innovation and Change Management (DICM) teams to mitigate the causes of the findings. This corrective action plan has multiple layers in which ESA will collaborate efforts between multiple units within DHS/ ESA that includes the Division of Customer Workforce, Employment and Training (DCWET), the Division of Program Operations (DPO), and DICM. The Office of Performance Monitoring (OPM) has a process in place to monitor and confirm the hours reported from CATCH. OPM Monitors will continue to randomly generate 60 sample cases from Q5i monthly, review them and if they find any discrepancies would refer them to either OWO, DPO, or TEP Providers for resolution. When OPM conducts their review of DCAS hours, and identifies income and hour differences, the Department of Program Operations (DPO) is informed and/or the Office of Work Opportunity (OWO) requesting their assistance with resolving the discrepancy. While this would be a short-term solution it will go a long way to resolving some of the discrepancies in reported work hours that are being transmitted to Q5i. The Office of Work Opportunity (OWO) conducts outreach to customers come in for assessment and assignment to a TEP Providers. This process would eliminate instances where hours found in the DCAS system is unknown to the CATCH system. ESA will work with DCAS to enhance the system to tie the income evidence in the income support case to the employment evidence in the person record to allow the employment hours to end date once the income evidence is end dated. This will automate the process by connecting the 2-step process into one task. This automation process would be a permanent solution to curbing stale of unsubstantiated hours from migrating to Q5i.Once the system enhancement is in place, training will be conducted for all DPO Social Service Representatives on the DCAS screens which require action to confirm employment. See Corrective Action Plan for chart/table

View Audit 31369

Finding 36706 (2022-010)

Significant Deficiency 2022

Government of the District of Columbia

DC

Allowable Costs / Cost Principles § 200.303 § 200.430

The Department of Human Services (DHS) concurs with the finding. Moving forward, DHS will follow the guidance set forth by the District Personnel Manual (DPM) issuance regarding pre-approval documentation for overtime. The plan is as follows: ? An e-mail will be sent to senior leadership quarterly...

The Department of Human Services (DHS) concurs with the finding. Moving forward, DHS will follow the guidance set forth by the District Personnel Manual (DPM) issuance regarding pre-approval documentation for overtime. The plan is as follows: ? An e-mail will be sent to senior leadership quarterly to remind staff of the requirement and to share with the respective division/office overtime approving officials regarding the written pre-approval documentation requirement, to include the link to the DPM issuance. ? On a quarterly basis, select a random sample of staff working overtime. ? E-mail the respective overtime approving officials to obtain copies of all the supporting documentation to confirm that the pre-authorization of overtime that has been worked is being completed. See Corrective Action Plan for chart/table

View Audit 31369

Finding 36699 (2022-001)

Significant Deficiency 2022

City of Hazelwood, Missouri

MO

Subrecipient Monitoring Reporting Allowable Costs / Cost Principles

Title 2 U.S. Code of Federal Regulations Part 200 is being reviewed and training sessions will be initiated by the Finance Director's office. The Finance Director is working towards capturing grant transactions in a manner sufficient to readily report the necessary information required on the Schedu...

Title 2 U.S. Code of Federal Regulations Part 200 is being reviewed and training sessions will be initiated by the Finance Director's office. The Finance Director is working towards capturing grant transactions in a manner sufficient to readily report the necessary information required on the Schedule of Expenditures of Federal Awards by the next audit period. The expected completion date is June 30, 2023. The phone number for the Finance Director's office is (314) 513-5040.

View Audit 30393

Finding 36693 (2022-004)

Material Weakness 2022

Crawford County

IN

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

FINDING 2022-004 Contact Person Responsible for Corrective Action: Wendy Marples, County Auditor Contact Phone Number: 812-338-2142 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: All future reporting of the Coronavirus State and Local Fiscal Recover...

FINDING 2022-004 Contact Person Responsible for Corrective Action: Wendy Marples, County Auditor Contact Phone Number: 812-338-2142 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: All future reporting of the Coronavirus State and Local Fiscal Recovery Funds will be reviewed for accuracy by a second staff member of the Auditor?s office prior to submission. The report will be signed and dated by both the preparer and reviewer. All documentation will be maintained to help prevent any future inconsistencies. Anticipated Completion Date: April 2024

View Audit 34823

Finding 36687 (2022-004)

Significant Deficiency 2022

Housing Authority of the City of Marianna

AR

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

Finding 2022-004 Criteria or Specific Requirement: CFDA 14.850; US Department of Housing and Urban Development; Public and Indian Housing; annual contributions contract number FW-7097; fiscal year ending March 31, 2022.Allowable costs/cost principals in accordance with 24 CFR 200, the PHA Annual Co...

Finding 2022-004 Criteria or Specific Requirement: CFDA 14.850; US Department of Housing and Urban Development; Public and Indian Housing; annual contributions contract number FW-7097; fiscal year ending March 31, 2022.Allowable costs/cost principals in accordance with 24 CFR 200, the PHA Annual Contributions Contract, and PHA Internal Control Policy. Recommendation for Corrective Action: Establish and enforce controls over Board of Commissioners and Managements review and supervision of purchasing procedures. Specific internal control and budgetary procedures should be implemented to ensure all costs are reasonable and necessary for the economical operation of the project for the purpose of serving families of low-income status in accordance with 24 CFR section 200. Views of Responsible Officials: We will review existing policies, implementing control procedures to correct these deficiencies. We will also provide increased supervision and training over this area. Planned Corrective Action/Action Taken: We will review existing policies, implementing control procedures to correct these deficiencies. We will also provide increased supervision and training over this area. We anticipate a complete resolution of this type of error by December 31, 2022. Anticipated Completion Date: We will have this resolved by December 31, 2022 Auditors Evaluation of Auditee Comments: Management?s comments in relation to its corrective action plan appear reasonable, valid, and supported with sufficient, appropriate evidence.

View Audit 30837 Questioned Costs: $1

Finding 36662 (2022-002)

Material Weakness 2022

Rockbridge Area Social Services Board

VA

Questioned Costs Allowable Costs / Cost Principles Cash Management

Corrective Action Plan The City of Buena Vista, Virginia respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Robinson, Farmer, Cox Associates 10 Hedgerow Drive Staunton, VA 24401 Audit Period: July 1, 202...

Corrective Action Plan The City of Buena Vista, Virginia respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Robinson, Farmer, Cox Associates 10 Hedgerow Drive Staunton, VA 24401 Audit Period: July 1, 2021 to June 30, 2022 The findings from the June 30, 2022 schedule of findings and questioned costs is discussed below. The findings are numbered consistently with the number assigned in the schedule. Financial Statement Findings 2022-001 Material Weakness Responsible Person, Title: Jason Tyree, City Manager; Charles Clemmer, Finance Director Audit Finding: The City's financial statements required several material adjusting entries by the Auditor to ensure such statements complied with Generally Accepted Accounting Principles. Auditor Recommendation: Management should review the current year adjusting entries and consider whether or not they apply during the next fiscal year. Anticipated Completion Date: 02-15-2023 City's Response: Concur Corrective Action Planned: Management will review current year adjusting entries and determine whether or not they apply during the next fiscal year. In addition, management will closely review financial statements so material adjusting entries by Auditor will not be necessary. Federal Award Findings and Questioned Costs 2022-002 Material Weakness and Compliance Finding Responsible Person, Title: Dr. Francis, Superintendent; Denise Fitzgerald, Grant Coordinator; Sandra Mohler, Finance Audit Finding: During a test of disbursements, we observed that an invoice was submitted for reimbursement to Virginia Department of Education under the Education Stabilization Fund (ESSER) as well as under the Coronavirus Tate and Local Fiscal Recovery Funds to Support HVAC Replacement. Under the terms of the Coronavirus State and Local Fiscal Recovery Funds to Support HVAC Replacement, there is a 100% local match required, which could be funded with ESSER funding. The School Board's total HVAC project was $224,856 and the School Board received reimbursement in the amount of $424,856 ($224,856 under ESSER and $200,000 under ARPA HVAC). Auditor Recommendation: The School Board should thoroughly review the terms and conditions of federal awards before submitting reimbursement to ensure compliance with federal programs. Anticipated Completion Date: 02-15-2023 City's Response: Concur Corrective Action Planned: Amendments were completed in a timely manner with the advice and guidance from VDOE Directors- Lynn Sodat and Susan Dandridge. These amendments reflect the necessary changes for the BVCPS to be in compliance with both grants. Both have received final approval from VDOE. Moving Forward BVCPS will continue to review on an ongoing basis of all approved expenditures by Denise Fitzgerald and Sandra Mohler in order to maintain proper financial records for future audits and accountability to the VDOE guidelines. This information will be shared monthly with our Core Committee, which consists of the following SBO personnel: Dr. Miller, Dr. Francis, Denise Fitzgerald, Juli Gibson, Robin Williams, Sherrie Wheeler and Sandra Mohler. Any questions regarding this corrective action plan can be addressed by Charles Clemmer, City Finance Director at 540-261-8602.

View Audit 34865 Questioned Costs: $1

Finding 36660 (2022-101)

Significant Deficiency 2022

Ethos Academy: A Challenge Foundation Academy, Inc.

AZ

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

We have prepared the following corrective action plan as required by the standards applicable to financial audits contained in Government Auditing Standards and by the audit requirements of Title 2 U.S Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Au...

We have prepared the following corrective action plan as required by the standards applicable to financial audits contained in Government Auditing Standards and by the audit requirements of Title 2 U.S Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Specifically, for each finding we are providing you with the names of the contact people responsible for corrective action, the corrective action planned, and the anticipated completion date. Findings - Financial Statement Audit 2022-001: Significant Deficiency in Internal Controls: Payroll Recommendation: To help ensure that when changes are made to compensation levels employees are accurately paid, the School should implement internal control policies and procedures that require updates being adequately documented in the employee's personnel file. Action Taken: Ethos Academy concurs and has implemented the recommendation. Completion Date: During fiscal year 2023. Contact Person: Tamara Garcia, Director Federal Awards Findings and Questioned Costs 2022-101 Significant Deficiency in Internal Controls Over Compliance: Payroll Recommendation: To help ensure that when changes are made to compensation levels employees are accurately paid, the School should implement internal control policies and procedures that require updates being adequately documented in the employee's personnel file. Action Taken: Ethos Academy concurs and has implemented the recommendation. Completion Date: During fiscal year 2023. Contact Person: Tamara Garcia, Director

View Audit 34862

Finding 36658 (2022-001)

Significant Deficiency 2022

Sugar Valley Rural Charter School

PA

Procurement, Suspension & Debarment Subrecipient Monitoring Internal Control / Segregation of Duties

Corrective Action Plan Finding 2022-001- Significant deficiency in internal controls over compliance: The school recognizes that we have a weakness in our control procedures. The School will strengthen our control procedures for Federal Grants by thoroughly reviewing the grant requirements and trai...

Corrective Action Plan Finding 2022-001- Significant deficiency in internal controls over compliance: The school recognizes that we have a weakness in our control procedures. The School will strengthen our control procedures for Federal Grants by thoroughly reviewing the grant requirements and training staff involved with the grant process. The federal grant coordinator will review the Compliance Supplement and Uniform Guidance and inform staff team members of the requirements. The grant team will review significant transactions to insure proper procedures are followed. The team will also meet on a regular basis to discuss the grants. Responsible Party: Tracie Kennedy, CEO Kristi Courter, Federal Grant Coordinator Completion Date: March 1, 2023

View Audit 34190

Finding 36647 (2022-025)

Material Weakness 2022

State of Georgia/state Accounting Office-Ein Noted

GA

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness § 200.303

2022-025 Improve Controls over Transparency Act Reporting Federal Agency: U.S. Department of Health and Human Services State Entity: Department of Behavioral Health and Developmental Disabilities (DBHDD) Corrective Action Plans: The Department will continue refining the capabilities of the Regulato...

2022-025 Improve Controls over Transparency Act Reporting Federal Agency: U.S. Department of Health and Human Services State Entity: Department of Behavioral Health and Developmental Disabilities (DBHDD) Corrective Action Plans: The Department will continue refining the capabilities of the Regulatory Reporting Database such that it contains all of the necessary reporting data elements required for timely and accurate Federal Funding Accountability and Transparency Act (FFATA) reporting. The Department will develop documentation requirements of each subaward to ensure the appropriate data elements; the reporting guidelines associated with the subawards are properly followed. DBHDD will update the internal controls related to Transparency Act Reporting no later than June 30, 2023. Estimated Completion Date: June 30, 2023 Contact Person: Kenneth Ward, Director of Internal Audit Telephone: 404-884-5486; E-mail: kenneth.ward@dbhdd.ga.gov

View Audit 26105

Finding 36637 (2022-020)

Significant Deficiency 2022

State of Georgia/state Accounting Office-Ein Noted

GA

Questioned Costs Special Tests & Provisions Subrecipient Monitoring § 200.303

2022-020 Improve Controls over the NCCI Medically Unlikely Edits Process Federal Agency: U.S. Department of Health and Human Services State Entity: Department of Community Health (DCH) Corrective Action Plans: DCH has made changes to ensure proper record keeping and approval is maintained. The cha...

2022-020 Improve Controls over the NCCI Medically Unlikely Edits Process Federal Agency: U.S. Department of Health and Human Services State Entity: Department of Community Health (DCH) Corrective Action Plans: DCH has made changes to ensure proper record keeping and approval is maintained. The changes made to Medically Unlikely Edits (MUEs) occurred in 2017, several years prior to the audit in 2022. Moving forward, policy compliance specialists for Durable Medical Equipment (DME) will be required to sign an employee attestation that acknowledges and ensures they understand the Standard Operating Procedure (SOP) as outlined in the Centers for Medicare & Medicaid Services? (CMS) technical guidance manual in section 7.4. This change will be implemented on June 30, 2023. CMS approval of all MUE changes are maintained through the Georgia Medicaid Management Information System (GAMMIS) Georgia Interactive Portal. Upon approval from CMS to deactivate a MUE, the program policy specialist initiates a change order through the Georgia Interactive Portal requesting the current MUE edits to be deactivated and then modified per CMS approval. The approval from CMS is submitted as part of the request. The change order needs to be approved by management before changes can be made in GAMMIS. This process went into effect after the MUE changes made in 2017 in November of 2018. Estimated Completion Date: June 30, 2023 Contact Person: Lynnette Rhodes, MAP Executive Director Telephone: 404-656-7513; E-mail: lrhodes@dch.ga.gov

View Audit 26105 Questioned Costs: $1

Finding 36636 (2022-019)

Significant Deficiency 2022

State of Georgia/state Accounting Office-Ein Noted

GA

Special Tests & Provisions Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

2022-019 Strengthen Controls over NCCI Program Requirements Federal Agency: U.S. Department of Health and Human Services State Entity: Department of Community Health (DCH) Corrective Action Plans: On or before September 30, 2023, the Department will revise its contract with the third party to incor...

2022-019 Strengthen Controls over NCCI Program Requirements Federal Agency: U.S. Department of Health and Human Services State Entity: Department of Community Health (DCH) Corrective Action Plans: On or before September 30, 2023, the Department will revise its contract with the third party to incorporate the required changes related to the Medicaid National Correct Coding Initiative (NCCI) edits and confidentiality. Estimated Completion Date: September 30, 2023 Contact Person: Lynnette Rhodes, MAP Executive Director Telephone: 404-656-7513; E-mail: lrhodes@dch.ga.gov

View Audit 26105

Finding 36634 (2022-017)

Significant Deficiency 2022

State of Georgia/state Accounting Office-Ein Noted

GA

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.53

2022-017 Improve Controls over Medicaid Capitation Payment Rates Federal Agency: U.S. Department of Health and Human Services State Entity: Department of Community Health (DCH) Corrective Action Plans: The Department acknowledges that some of the capitation rates in Georgia Medicaid Management Info...

2022-017 Improve Controls over Medicaid Capitation Payment Rates Federal Agency: U.S. Department of Health and Human Services State Entity: Department of Community Health (DCH) Corrective Action Plans: The Department acknowledges that some of the capitation rates in Georgia Medicaid Management Information System (GAMMIS) were inaccurate. The Department will implement the following procedures to ensure capitation rates are accurate: (1) review all capitation rates in GAMMIS from July 1, 2021, to current date, (2) correct all inaccurate capitation rates in GAMMIS, (3) test rates in GAMMIS for accuracy prior to production and (4) re-process Per Member Per Month (PMPM) payments to correct over/under payments. The Department will implement capitation rate adjustments as they are approved by Centers for Medicare & Medicaid Services? (CMS) in conjunction with our Actuaries. The Department will implement this process immediately. Estimated Completion Date: June 30, 2023 Contact Person: Lynnette Rhodes, MAP Executive Director Telephone: 404-656-7513; E-mail: lrhodes@dch.ga.gov

View Audit 26105 Questioned Costs: $1

Finding 36633 (2022-016)

Significant Deficiency 2022

State of Georgia/state Accounting Office-Ein Noted

GA

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.53

2022-016 Improve Controls over Medicaid Capitation Payments for Managed Care Recipients Federal Agency: U.S. Department of Health and Human Services State Entity: Department of Community Health (DCH) Corrective Action Plans: Third party vendor corrected the error that led to the duplicate capitatio...

2022-016 Improve Controls over Medicaid Capitation Payments for Managed Care Recipients Federal Agency: U.S. Department of Health and Human Services State Entity: Department of Community Health (DCH) Corrective Action Plans: Third party vendor corrected the error that led to the duplicate capitation payment issue on a single Georgia Medicaid Management Information System (GAMMIS) ID on 9/16/22. Additional research is required to identify if other instances of duplicate payments to Managed Care Organizations (MCOs) exist and to determine if funds should be recovered. We will also establish a plan to monitor the duplicate member files and address the issue on an ongoing basis. This should be completed by August 2023. Estimated Completion Date: August 31, 2023 Contact Person: Lynnette Rhodes, MAP Executive Director Telephone: 404-656-7513; E-mail: lrhodes@dch.ga.gov

View Audit 26105 Questioned Costs: $1

Corrective Action Plans

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