Corrective Action Plans

Finding 530226 (2024-003)

Material Weakness 2024

IN

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

FINDING 2024-003 - Child Nutrition Cluster - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Context: During testing we noted the following issues in a sample of forty child nutrition cluster payroll claims: ● 6 of 40 payroll transactions where a timecard was not completed by the ...

FINDING 2024-003 - Child Nutrition Cluster - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Context: During testing we noted the following issues in a sample of forty child nutrition cluster payroll claims: ● 6 of 40 payroll transactions where a timecard was not completed by the employee to validate their hours worked and the time charged to food service. ● 19 of 40 payroll transactions where the School Corporation was unable to provide supporting documentation for approval of the hourly rate paid to employee. The noncompliance was isolated to the payroll periods through August 4, 2023. The School Corporation corrected the issues starting with the next payroll period. Contact Person Responsible for Corrective Action: Michelle L. Keene Contact Phone Number: (812) 384-4386 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: In FY24, the issue was corrected to ensure all employees were only paid for time supported by a time a card and a board approved rate schedule. Anticipated Completion Date: August 19, 2023

View Audit 348324 Questioned Costs: $1

Finding 530223 (2024-003)

Material Weakness 2024

City of Framingham

MA

Eligibility Material Weakness Internal Control / Segregation of Duties

2024-003 Adult Education - Assistance Listing Number 84.002 Recommendation: We recommend procedures to maintain records related to eligibility determinations be implemented/strengthened. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken ...

2024-003 Adult Education - Assistance Listing Number 84.002 Recommendation: We recommend procedures to maintain records related to eligibility determinations be implemented/strengthened. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Adult Education department will now scan in the physical intake form that Adult ESL students self-report their eligibility status for MA DESE ACLS as well as have the student sign that form. This form will be stored electronically in addition to the information from the form being entered into the Adult ESL Access database and LACES . Name(s) of the contact person(s) responsible for corrective action: Dr. Kevin O’Connor, Claudia Castro Alves and Kate Fiore Planned completion date for corrective action plan: Effective as of 08/01/2024

View Audit 348312

Finding 530207 (2024-003)

Material Weakness 2024

Northeast Dubois County School Corporation

IN

School Nutrition Programs Internal Control / Segregation of Duties Eligibility § 200.303

FINDING 2024-003 Information on the federal program: Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (or...

FINDING 2024-003 Information on the federal program: Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (or Other Identifying Numbers): FY2023, FY2024 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Eligibility Audit Finding: Material Weakness Context: During sample testing of 60 students for eligibility, we noted 14 instances where there was no documented review by someone other than the individual making the eligibility determination. The lack of review was isolated to paper applications. Contact Person Responsible for Corrective Action: Joyce Hulsman Contact Phone Number: 812-678-2781 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: A procedure has been established to ensure dual validation and paper copies are in compliance. Anticipated Completion Date: Already completed.

View Audit 348308

Finding 530181 (2024-032)

Significant Deficiency 2024

State of Arkansas

AR

Allowable Costs / Cost Principles Eligibility Special Tests & Provisions

Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. For Sample Item 17, the screening activities associated with the revalidation were completed prior to the revalidation date through the Provider Enrollment, Chain, and Ownership System (PECOS). The provider ...

Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. For Sample Item 17, the screening activities associated with the revalidation were completed prior to the revalidation date through the Provider Enrollment, Chain, and Ownership System (PECOS). The provider submitted their revalidation application timely, but during the revalidation process the agency requested corrections and clarifications of administrative and tax information. This delayed the final component of the screening, the site visit, until July 15, 2024. For Sample Item 22, DMS confirms there was no W-9 dated prior to February 7, 2024. The primary function of the W-9 form is to confirm the providers name, address, and tax information. This information was already listed in MMIS during the date in question. The W-9 submitted by the provider on April 4, 2024, confirmed the accuracy of the information in MMIS that the provider has used since its initial enrollment on July 20, 1981. DMS is developing a mechanism to obtain information provided on W-9’s by utilizing an electronic process through the provider portal during enrollment. Anticipated Completion Date: June 30, 2025 Contact Person: Elizabeth Pitman Director, Division of Medical Services Department of Human Services 700 Main Street Little Rock, AR 72201 (501) 244-3944 Elizabeth.Pitman@dhs.arkansas.gov

View Audit 348267

Finding 530180 (2024-031)

Significant Deficiency 2024

State of Arkansas

AR

Questioned Costs Eligibility Special Tests & Provisions

Views of Responsible Officials and Planned Corrective Action: DMS concurs with this finding. For Sample Item 15, DMS has implemented an automated process to notify providers of pending revalidations and to terminate them when revalidation is not completed within five years. For Sample Item 21, DMS ...

Views of Responsible Officials and Planned Corrective Action: DMS concurs with this finding. For Sample Item 15, DMS has implemented an automated process to notify providers of pending revalidations and to terminate them when revalidation is not completed within five years. For Sample Item 21, DMS has implemented automated processes utilizing data transfers from licensing boards that will now terminate providers when their license lapses. In addition, DMS is developing a mechanism to obtain information provided on W-9’s by utilizing an electronic process through the provider portal during enrollment. This provider was terminated on 10/2/23. For Sample Item 40, DMS has coordinated with Division of Provider Services and Quality Assurance (DPSQA) to interface with their certification tracking system and to provide additional notifications to providers when their certification period is nearing expiration. Notifications are being sent 30 days prior to the lapse of certification. DMS confirmed with DPSQA that there were no adverse events that lead to the termination of the provider’s certification. Anticipated Completion Date: June 30, 2025 Contact Person: Elizabeth Pitman Director, Division of Medical Services Department of Human Services 700 Main Street Little Rock, AR 72201 (501) 244-3944 Elizabeth.Pitman@dhs.arkansas.gov

View Audit 348267 Questioned Costs: $1

Finding 530177 (2024-028)

Significant Deficiency 2024

State of Arkansas

AR

Questioned Costs Subrecipient Monitoring Eligibility

Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. The first two deficiencies occurred prior to implementation of the agency’s current integrated eligibility system (ARIES). The date of death for the beneficiary did not cross over from the prior eligibility ...

Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. The first two deficiencies occurred prior to implementation of the agency’s current integrated eligibility system (ARIES). The date of death for the beneficiary did not cross over from the prior eligibility system to MMIS. The agency has implemented a process to monitor and address when eligibility updates do not cross over successfully from the ARIES system to MMIS. For the second case, the missing documentation was likely the result of a failure to scan or appropriately index the document in the prior eligibility system. The agency will continue its practice of reviewing a sample of eligibility cases for accuracy. For the third case, the coverage did not close properly at the end of the month due to a system defect. The correction for this defect was deployed in ARIES on 3/31/24. Anticipated Completion Date: Complete Contact Person: Mary Franklin Director, Division of County Operations Department of Human Services 700 Main Street Little Rock, AR 72201 (501) 681-8377 Mary.Franklin@dhs.arkansas.gov

View Audit 348267 Questioned Costs: $1

Finding 530176 (2024-027)

Material Weakness 2024

State of Arkansas

AR

Questioned Costs Subrecipient Monitoring Matching / Level of Effort / Earmarking

Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. Since June 2023, DYS has made multiple changes to improve monitoring of suspension and reinstatement of Medicaid eligibility for incarcerated juveniles. For juveniles with SSI Medicaid, the Social Security A...

Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. Since June 2023, DYS has made multiple changes to improve monitoring of suspension and reinstatement of Medicaid eligibility for incarcerated juveniles. For juveniles with SSI Medicaid, the Social Security Administration (SSA) is responsible for suspending Medicaid coverage. All incarcerations for cases noted in the findings involving SSI Medicaid were reported timely to SSA by the agency. DYS closely monitors these cases and continues to send closure requests to SSA until the cases are closed out. SSI cases account for 76% of the total questioned costs noted in the finding. The Division of Medical Services (DMS) implemented an MMIS change in September 2024 that automatically updates member profiles to accurately reflect incarceration dates. This change will resolve the remaining deficiencies noted in the finding. All payments noted as questioned costs were capitated payments made for the PASSE, Dental Managed Care, and NET programs. The agency currently has a reconciliation process for all three programs that identifies payments made after the member’s incarceration date that should be recouped. Any uncollected overpayments noted in the findings will be recouped as part of the next reconciliation process. Anticipated Completion Date: Complete Contact Person: Elizabeth Pitman Director, Division of Medical Services Department of Human Services 700 Main Street Little Rock, AR 72201 (501) 244-3944 Elizabeth.Pitman@dhs.arkansas.gov

View Audit 348267 Questioned Costs: $1

Finding 530174 (2024-025)

Material Weakness 2024

State of Arkansas

AR

Questioned Costs Subrecipient Monitoring Eligibility

Views of Responsible Officials and Planned Corrective Action: DHS concurs with the finding. For Sample Item 32, the agency’s revalidation date was set for March 27, 2024, and the provider submitted their application for revalidation prior to that date. System updates and monitoring controls have bee...

Views of Responsible Officials and Planned Corrective Action: DHS concurs with the finding. For Sample Item 32, the agency’s revalidation date was set for March 27, 2024, and the provider submitted their application for revalidation prior to that date. System updates and monitoring controls have been implemented to ensure correct revalidation dates are entered in MMIS. For Sample Item 15, the provider submitted a revalidation application prior to their scheduled termination date. Since there was an active application in the system, the provider was not terminated. The revalidation was successfully completed. For Sample Item 21, the provider submitted their revalidation application on October 16, 2023, which was prior to the November 11, 2023 deadlines. Multiple follow-ups and requests for additional information from the provider resulted in completion of the revalidation after the deadline date. Anticipated Completion Date: Complete Contact Person: Elizabeth Pitman Director, Division of Medical Services Department of Human Services 700 Main Street Little Rock, AR 72201 (501) 244-3944 Elizabeth.Pitman@dhs.arkansas.gov

View Audit 348267 Questioned Costs: $1

Finding 530170 (2024-022)

Significant Deficiency 2024

State of Arkansas

AR

Questioned Costs Subrecipient Monitoring Eligibility

Views of Responsible Officials and Planned Corrective Action: DHS concurs with the finding. The agency updated its documented controls in March 2024 to require confirmation that agreements are signed by all parties before processing adoption subsidy packets and that all adoption files contain comple...

Views of Responsible Officials and Planned Corrective Action: DHS concurs with the finding. The agency updated its documented controls in March 2024 to require confirmation that agreements are signed by all parties before processing adoption subsidy packets and that all adoption files contain complete documentation. All findings occurred prior to the agency updating its documented controls. Anticipated Completion Date: Complete Contact Person: Tiffany Wright Director, Division of Children and Family Services Department of Human Services 700 Main Street Little Rock, AR 72201 (501) 396-6477 Tiffany.wright@dhs.arkansas.gov

View Audit 348267 Questioned Costs: $1

Finding 530169 (2024-021)

Significant Deficiency 2024

State of Arkansas

AR

Questioned Costs Allowable Costs / Cost Principles Eligibility

Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. The DHS Accounts Receivables Unit is developing documented procedures and controls addressing the process for entering adoption subsidy overpayments into the agency’s accounts receivable system (AROPTS) and ...

Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. The DHS Accounts Receivables Unit is developing documented procedures and controls addressing the process for entering adoption subsidy overpayments into the agency’s accounts receivable system (AROPTS) and DCFS is updating documented procedures and training on reporting of collected overpayments to the Accounts Receivable Unit. System changes are also in process for AROPTS that will pull the adjusted balance for overpayments when a notice is being created. Anticipated Completion Date: April 30, 2025 Contact Person: Renee Ikard Chief Financial Officer Department of Human Services 700 Main Street Little Rock, AR 72201 (501) 682-8985 Renee.Ikard@dhs.arkansas.gov

View Audit 348267 Questioned Costs: $1

Finding 530161 (2024-013)

Significant Deficiency 2024

State of Arkansas

AR

Subrecipient Monitoring Eligibility Reporting § 200.303

Views of Responsible Officials and Planned Corrective Action: ARS Discussion The Agency acknowledges the lack of adequate internal controls necessary to ensure accurate maintenance of supporting documentation during our migration to our new case management system (CMS). ARS Action Taken The Agency h...

Views of Responsible Officials and Planned Corrective Action: ARS Discussion The Agency acknowledges the lack of adequate internal controls necessary to ensure accurate maintenance of supporting documentation during our migration to our new case management system (CMS). ARS Action Taken The Agency has taken the below steps to mitigate the lack of internal controls regarding supporting documentation, mainly attachments, located in our CMS in the future. • As the transfer of data to our new CMS platform concludes, that impediment has significantly diminished. The Agency has an appropriate method of control in place to detect any case file errors that may occur because of an incomplete retrieval or an insufficient data element input. In both instances, data analyst personnel from Program, Planning, Development and Evaluation (PPD&E) employ RSA’s edit check process that identifies specific errors prior to submission of the RSA 911 report. Those errors are then methodically corrected in our CMS ensuring the RSA 911 report is error free. • In instances where information is miscoded in the client case file, or is missing, the division’s Quality Assurance (QA) team identifies those errors and employes best practice training methods to ensure the case file complies with federal regulations. • Finally, our new CMS data hosted on an AR DIS platform is regularly backed up on a separate server to ensure that if anything were to happen to the primary CMS, we have a back up of all case data, including supporting documentation, and attachments. This data would be able to be accessed as a backup if data in the CMS was compromised in any way. Anticipated Completion Date: Complete Contact Person: Robert Trevino Associate Commissioner of PPD&E Arkansas Rehabilitation Services 1 Commerce Way Little Rock, AR 72202 (501) 296-1604 Robert.Trevino@Arkansas.gov

View Audit 348267

Finding 530152 (2024-004)

Significant Deficiency 2024

State of Arkansas

AR

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

Views of Responsible Officials and Planned Corrective Action: The Arkansas Department of Education (ADE), Division of Elementary and Secondary Education (DESE), Health and Nutrition Unit (HNU), concur with the finding. The HNU implemented a new application and payment system that began in 2024. Du...

Views of Responsible Officials and Planned Corrective Action: The Arkansas Department of Education (ADE), Division of Elementary and Secondary Education (DESE), Health and Nutrition Unit (HNU), concur with the finding. The HNU implemented a new application and payment system that began in 2024. During implementation and subsequent operations, several issues with data transfers between the old and new system were identified and now corrected. The HNU Application and Finance staff will receive training to ensure that all criteria are met prior to the retroactive payment of claims. Anticipated Completion Date: April 1, 2025 Contact Person: Sheila Chastain Associate Director Arkansas Department of Education, DESE, Nutrition Services #4 Capitol Mall, Box #12 Little Rock, AR 72201 (501) 324-9502 Sheila.Chastain@ade.arkansas.gov Pamela Burton Director Arkansas Department of Education, DESE, Nutrition Services #4 Capitol Mall, Box #19 Little Rock, AR 72201 (501) 320-8978 Pamela.Burton@ade.arkansas.gov

View Audit 348267 Questioned Costs: $1

Finding 530093 (2024-001)

Significant Deficiency 2024

Midland School District

AR

School Nutrition Programs Eligibility

The Midland School District will ensure all criteria and specific requirements are met for the District in processing free and reduced price meals for the District’s child nutrition program and classify them in accordance with federal guidelines established by the U.S. Department of Agriculture. Ap...

The Midland School District will ensure all criteria and specific requirements are met for the District in processing free and reduced price meals for the District’s child nutrition program and classify them in accordance with federal guidelines established by the U.S. Department of Agriculture. Applications will include the required information to be considered for free and reduced price meals.

View Audit 348148

Finding 530093 (2024-001)

Significant Deficiency 2024

Midland School District

AR

School Nutrition Programs Eligibility

A. The District will establish controls to ensure free and reduced price meal applications are properly completed by the applicant before processing.

View Audit 348148

Finding 530093 (2024-001)

Significant Deficiency 2024

Midland School District

AR

School Nutrition Programs Eligibility

B. The District will ensure that a complete application includes the names of children for whom the application is made.

View Audit 348148

Finding 530093 (2024-001)

Significant Deficiency 2024

Midland School District

AR

School Nutrition Programs Eligibility

C. A SNAP case number of the household for whom the application is made if person has SNAP.

View Audit 348148

Finding 530093 (2024-001)

Significant Deficiency 2024

Midland School District

AR

School Nutrition Programs Eligibility

D. The signature of an adult household member has been submitted on the paperwork. (this may be a foster parent or an official of a court or other agency with responsibility for the child.

View Audit 348148

Finding 530093 (2024-001)

Significant Deficiency 2024

Midland School District

AR

School Nutrition Programs Eligibility

E. The names of all household members.

View Audit 348148

Finding 530093 (2024-001)

Significant Deficiency 2024

Midland School District

AR

School Nutrition Programs Eligibility

F. The amount of current income by each member and the source of the income.

View Audit 348148

Finding 530093 (2024-001)

Significant Deficiency 2024

Midland School District

AR

School Nutrition Programs Eligibility

G. The last four of the social security number of the adult household member who signs the application or an indication that the household member does not have a social security number (box checked for “no social security number”) Indication that the child is a foster child

View Audit 348148

Finding 530065 (2024-067)

Material Weakness 2024

State of Nebraska

NE

Questioned Costs Eligibility Allowable Costs / Cost Principles § 200.303

Program: AL 21.023 – COVID-19 Emergency Rental Assistance – Allowability & Eligibility Corrective Action Plan: • Additional guidance will be provided to Nelnet reviewers, specifically regarding households with no income that need to be verified every 90 days and households with more than one ad...

Program: AL 21.023 – COVID-19 Emergency Rental Assistance – Allowability & Eligibility Corrective Action Plan: • Additional guidance will be provided to Nelnet reviewers, specifically regarding households with no income that need to be verified every 90 days and households with more than one adult in the home. • Additional guidance will be provided to Nelnet reviewers regarding applicant communication such as move outs, relocations, payment concerns, etc. • NEMA will work with NIFA and will continue to pursue any payments that should be returned due to tenant vacating rental unit. • NEMA will advise NIFA and will implement any recommended changes to late fee policy. Contact: Erv Portis, Impala Carey, NEMA Anticipated Completion Date: 28 March, 2025

View Audit 348113 Questioned Costs: $1

Finding 530062 (2024-065)

Significant Deficiency 2024

State of Nebraska

NE

Reporting Eligibility HUD Housing Programs

Program: AL 17.225 – Unemployment Insurance (UI) – State – Special Tests Corrective Action Plan: We continue to refine our processes to ensure that overpayments are established promptly and in accordance with all applicable regulations. We will continue to monitor the implemented procedures and ...

Program: AL 17.225 – Unemployment Insurance (UI) – State – Special Tests Corrective Action Plan: We continue to refine our processes to ensure that overpayments are established promptly and in accordance with all applicable regulations. We will continue to monitor the implemented procedures and make improvements as necessary to ensure that overpayments are established and processed accurately and timely. We are working with our vendor to correct the system issues related to charging. Contact: Andi Bridgmon Anticipated Completion Date: December 2025

View Audit 348113

Finding 530059 (2024-061)

Material Weakness 2024

State of Nebraska

NE

Questioned Costs Eligibility

Program: AL 17.225 – Unemployment Insurance (UI) – State – Allowability & Eligibility Corrective Action Plan: For wage crossmatches, we are providing additional training to more staff so they can effectively handle these tasks. We are also optimizing the crossmatch system to better detect potent...

Program: AL 17.225 – Unemployment Insurance (UI) – State – Allowability & Eligibility Corrective Action Plan: For wage crossmatches, we are providing additional training to more staff so they can effectively handle these tasks. We are also optimizing the crossmatch system to better detect potential fraud. NDOL has emphasized the importance of thoroughly reviewing separation information requests during the adjudication process. If we identify any issues, they are addressed on an individual basis. Additionally, we review separation information as part of our internal quality control process to ensure consistent and thorough evaluation. Additional BIU staff were trained on quarterly wage crossmatches by 12/31/2024. Contact: Andi Bridgmon Anticipated Completion Date: September 2025

View Audit 348113 Questioned Costs: $1

Finding 530047 (2024-053)

Significant Deficiency 2024

State of Nebraska

NE

Questioned Costs Allowable Costs / Cost Principles Eligibility

Program: AL 93.778 – Medical Assistance Program; AL 93.778 – COVID-19 Medical Assistance Program – Allowability Corrective Action Plan: The Department has been actively working with program, technology, and the EVV vendor to implement system controls to address the deficiencies identified in this...

Program: AL 93.778 – Medical Assistance Program; AL 93.778 – COVID-19 Medical Assistance Program – Allowability Corrective Action Plan: The Department has been actively working with program, technology, and the EVV vendor to implement system controls to address the deficiencies identified in this and prior year’s findings. The Department has two system change releases scheduled, the first in February 2025 and the second in late June 2025 to implement additional system improvements. Contact: Jeremy Brunssen Anticipated Completion Date: 7/1/2025

View Audit 348113 Questioned Costs: $1

Finding 530042 (2024-058)

Significant Deficiency 2024

State of Nebraska

NE

Questioned Costs Eligibility

Program: AL 93.778 – Medical Assistance Program; AL 93.767 – Children’s Health Insurance Program (CHIP) – Allowability & Eligibility Corrective Action Plan: The Department will ensure established, standard protocol are followed and ensure rate approvals are obtained from CMS prior to updating cap...

Program: AL 93.778 – Medical Assistance Program; AL 93.767 – Children’s Health Insurance Program (CHIP) – Allowability & Eligibility Corrective Action Plan: The Department will ensure established, standard protocol are followed and ensure rate approvals are obtained from CMS prior to updating capitation rates for rating periods. Additionally, the MLTC Eligibility Policy Unit will review user guides that contain business processes where the noted errors occurred. The intent is to review the user guides from the lens of the findings and update them for clarity if deemed necessary. User guides are reviewed and updated as needed as requirements change from changes in program, state, or federal law. Eligibility Operations supervisory chain for the caseworker assigned to the case noted in the finding will follow up with the individual staff members who made the errors to ensure they understand the policies going forward. Eligibility Policy will coordinate with eligibility operations supervisor on these follow-ups. Contact: Jeremy Brunssen Anticipated Completion Date: 6/30/2025

View Audit 348113 Questioned Costs: $1

Corrective Action Plans

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