Corrective Action Plans

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Finding 554744 (2024-010)
Significant Deficiency 2024
2024-010 Oregon Health Authority Submit required Federal Funding Accountability and Transparency Act reports Management Response: The agency agrees with the finding. The FFATA Reporting Coordinator position within the Office of Contracts & Procurement (OC&P) has been vacant for eight months but sho...
2024-010 Oregon Health Authority Submit required Federal Funding Accountability and Transparency Act reports Management Response: The agency agrees with the finding. The FFATA Reporting Coordinator position within the Office of Contracts & Procurement (OC&P) has been vacant for eight months but should be filled by April 15, 2025. On March 8, 2025, FSRS.gov was retired, and all subaward reporting data and functionality are now on SAM.gov. The new SAM.gov reporting system will allow for multiple Data Entry roles, allowing each program or division of ODHS/OHA to submit their own reporting, and allowing OC&P to conduct Quality Assurance/Quality Control. Once the FFATA Reporting Coordinator is onboard and trained, we anticipate the FFATA reporting will resume and any missing reports will be submitted by April 15, 2026. Anticipated Completion Date: April 15, 2026 Contact person: Noemi Schlegel, Compliance & Audits Program Manager
Finding 554739 (2024-025)
Significant Deficiency 2024
2024-025 Oregon Department of Human Services Ensure work participation rate calculation uses verified and accurate data Management Response: We agree with this recommendation. Office of Program Integrity’s leadership priorities are to update the risk assessment and to continue to meet weekly with th...
2024-025 Oregon Department of Human Services Ensure work participation rate calculation uses verified and accurate data Management Response: We agree with this recommendation. Office of Program Integrity’s leadership priorities are to update the risk assessment and to continue to meet weekly with the Chief Operating Officer to highlight the risks associated with inadequate staffing levels. Risk mitigation efforts to ensure JOBS reviews are performed in accordance with established procedures include cross training JOBS second level Quality Control beginning in March 2025 and time studies planned to determine adequate staffing levels for additional position requests. ODHS has a current workgroup led by the Project Management Office (PMO) that is tasked with conducting a training and coaching gap analysis for family coaches and making recommendations regarding Oregon’s Work Participation Rate. The workgroup consists of TANF policy analysts and the self- sufficiency training unit. In addition to the gap analysis, the workgroup is currently producing communications regarding documentation of work participation hours. ODHS will implement additional recommendations once they are identified. Anticipated Completion Date: 12/31/2025 Contact Person: Eva Ruiz, TANF program manager
Finding 554736 (2024-022)
Significant Deficiency 2024
2024-022 Oregon Department of Human Services Improve controls to ensure eligibility criteria are met Management Response: We agree with this recommendation. Beginning in April 2025 the Quality Control (QC) manager will have oversight of the process and be included in the emails between the QC lead a...
2024-022 Oregon Department of Human Services Improve controls to ensure eligibility criteria are met Management Response: We agree with this recommendation. Beginning in April 2025 the Quality Control (QC) manager will have oversight of the process and be included in the emails between the QC lead and administration concerning the error packets being sent to the branch for corrective action by the 15th of each month. The QC manager will check on the 16th of each month to ensure the task was completed. Department management acknowledges the finding and has already initiated actions to address the concerns. The State of Oregon has implemented a structured approach to address this concern. Since January 2025, the Oregon Eligibility Partnership (OEP) has updated and developed six eligibility guides aimed at improving, understanding, and execution of processes related to TANF enrollment, including asset pursuit and IEVS checks. These guides are now available as part of the training curriculum for eligibility workers. Additionally, the "Verification Take Time for Training" (TT4T) module, which was last presented in October 2022, will be reviewed by the OEP to assess potential gaps or outdated information. Any necessary updates will be incorporated by July 2025 to ensure comprehensive training is available to all eligibility workers. Finally, OEP will continue to monitor the effectiveness of the updated training materials and guides through ongoing reviews, feedback collection from eligibility workers, and periodic review and refreshing of the materials. Anticipated Completion Date: December 31, 2025 Contact Person: Eva Ruiz, TANF program manager
View Audit 353343 Questioned Costs: $1
Finding 554735 (2024-021)
Significant Deficiency 2024
2024-021 Oregon Department of Human Services Obtain accurate information from the ONE application Management Response: We agree with this recommendation. ODHS will continue to monitor and review the ACF-199 and ACF-209 prior to submission. The review will include a sample of JOBS eligible individual...
2024-021 Oregon Department of Human Services Obtain accurate information from the ONE application Management Response: We agree with this recommendation. ODHS will continue to monitor and review the ACF-199 and ACF-209 prior to submission. The review will include a sample of JOBS eligible individuals who do not have countable work activities in the ACF reports, to confirm that their TRACS personal development plan (PDP) accurately reflects engagement and activities in which the individual is engaged. Additionally, ODHS will implement a tracking system to ensure the review of reports is clearly documented. ODHS will continue to work with our vendor to secure a SOC 2 Type II audit of our processes and oversight of the ONE system in 2025. Additionally, ODHS will work on amending the ONE Maintenance & Operations agreement with Deloitte for them to obtain a scoped SOC 2 Type II audit related to their work within the ONE system. ODHS would expect to negotiate this additional audit requirement in 2025 with the first audit then happening in 2026. Anticipated Completion Date: December 31, 2025 Contact Person: Eva Ruiz, TANF program manager
Finding 554733 (2024-029)
Significant Deficiency 2024
2024-029 Oregon Commission for the Blind Strengthen internal controls to ensure performance data reports are accurate Management Response: We agree with the recommendation. The agency is committed to ensuring the RSA-911 client case information report is accurate, and to ensuring the agency’s case m...
2024-029 Oregon Commission for the Blind Strengthen internal controls to ensure performance data reports are accurate Management Response: We agree with the recommendation. The agency is committed to ensuring the RSA-911 client case information report is accurate, and to ensuring the agency’s case management system is well-documented and current. This issue was initially identified during the statewide single audit for the period ended June 30, 2023. In response to the prior year’s finding, the agency created a new case-note category for documenting client employment start date and wages at exit. Compliance with this new control is then verified as part of our pre-closure case file review process. The agency will continue to provide training to staff on the use of this case note category to ensure we are consistently documenting the start date of employment in the primary occupation and the hourly wage at exit. Anticipated Completion Date: July 1, 2025 Contact person: Angel Hale, Director of Vocational Rehabilitation Services
Finding 554732 (2024-028)
Significant Deficiency 2024
2024-028 Oregon Department of Human Services Strengthen internal controls to ensure performance data reports are accurate Management Response: We agree with this recommendation. We agree with the recommendation and will ensure adequate supporting documentation is maintained and readily available to ...
2024-028 Oregon Department of Human Services Strengthen internal controls to ensure performance data reports are accurate Management Response: We agree with this recommendation. We agree with the recommendation and will ensure adequate supporting documentation is maintained and readily available to support information reported in the RSA-911. We will update internal controls related to this matter. Anticipated Completion Date: September 30, 2024 Contact Person: Bryan Campbell, Vocational Rehabilitation Operations Manager
Finding 554731 (2024-043)
Significant Deficiency 2024
2024-043 Department of Veterans' Affairs Encourage accuracy of per diem recalculations Management Response: ODVA agrees with this recommendation Reconciliation/recalculation procedures have been updated to fully align with regulations as established by 38 CFR 51.40. These procedures will include cal...
2024-043 Department of Veterans' Affairs Encourage accuracy of per diem recalculations Management Response: ODVA agrees with this recommendation Reconciliation/recalculation procedures have been updated to fully align with regulations as established by 38 CFR 51.40. These procedures will include calculation of days when a veteran may be absent for purposes other than receiving hospital care. In addition to strengthening procedures, the controller will review the reconciliation each month. Anticipated Completion Date: June 30, 2025 Contact person: Nicole Dolan, Budget and Fiscal Manager
Finding 554730 (2024-038)
Significant Deficiency 2024
2024-038 Oregon Business Development Department Implement controls over reporting Management Response: We agree with this recommendation. The submission of the quarterly financial reports by Business Oregon to DAS CFRT is on-going and within the submission deadline of DAS CFRT staff. When preparing ...
2024-038 Oregon Business Development Department Implement controls over reporting Management Response: We agree with this recommendation. The submission of the quarterly financial reports by Business Oregon to DAS CFRT is on-going and within the submission deadline of DAS CFRT staff. When preparing for the quarterly financial report, the accounting/financial data has been prepared by our accountant and reviewed by Business Oregon’s accounting manager. The data is then submitted to program staff to complete the programmatic narrative and other performance-related information to further explain or describe the transactions for the reporting period, and then program staff submits the quarterly report to DAS CFRT. Going forward, to ensure reports submitted to DAS CFRT match with accounting records, management will make procedure changes by routing the report back to the accounting team for final review of financial data after program has entered their part of the report before sending to DAS CFRT. We will implement this process change effective immediately for the quarterly report ending March 2025. For the cumulative variance of $1.6 million, Business Oregon will conduct research to determine the cause of the variance. The under-reporting of expenses on the quarterly report ending June 2024 could be the result of data provided to DAS in mid-July 2024, to meet DAS CFRT reporting deadline, when the fiscal month of June 2024 was not officially closed until early August 2024. While the fiscal year-end process was still on-going through August 2024, the month of June is still open for accrual entries or adjustments, resulting to more expenditures in accounting records than what was reported to DAS in July. Business Oregon will perform reconciliation of data from 2020 to March 2025 to true up the expenditures reported in the accounting records and the reports submitted to DAS CFRT. Anticipated Completion Date: March 31, 2025 Contact person: Imee Anderson, Chief Financial Officer, Mia Seo, Deputy-Chief Financial Officer, Rory Spencer, Accounting Manager
Finding 554722 (2024-041)
Significant Deficiency 2024
2024-041 Oregon Military Department Ensure undisbursed obligation extension support is retained Management Response: We agree with this recommendation. The Oregon Military Department (OMD) acknowledges the finding related to the retention of support for undisbursed obligation extensions. We recogniz...
2024-041 Oregon Military Department Ensure undisbursed obligation extension support is retained Management Response: We agree with this recommendation. The Oregon Military Department (OMD) acknowledges the finding related to the retention of support for undisbursed obligation extensions. We recognize the importance of maintaining documentation to support the extensions of General Terms and Conditions (GTC) Cooperative Agreement (CA) Awards to ensure compliance with federal regulations and avoid potential funding risks. OMD will implement following corrective actions to address the recommendation made in the Audit Report. • Standardized Documentation Process: We will develop and implement a standardized process for tracking and retaining all submitted GTA CA Award extensions, including detailed listings of un-cleared obligations and projected liquidation timelines. • Internal Review and Monitoring: A designated team within the finance division will conduct quarterly reviews of undisbursed obligations to ensure compliance with extension requirements. • Training and Accountability: Training will be provided to relevant personnel on the importance of documentation retention, compliance requirements, and the consequences of noncompliance. Management will also assign accountability measures to track adherence to the new procedures. Anticipated completion date: June 30, 2025. Contact person: Adam Giblin, Chief Financial Officer.
Finding 554721 (2024-031)
Significant Deficiency 2024
2024-031 Department of Education Implement controls to ensure FFATA reporting is completed for all required subawards Management Response: ODE agrees with this finding. To strengthen controls and ensure FFATA reporting is completed for all required subawards, ODE plans to implement the following pro...
2024-031 Department of Education Implement controls to ensure FFATA reporting is completed for all required subawards Management Response: ODE agrees with this finding. To strengthen controls and ensure FFATA reporting is completed for all required subawards, ODE plans to implement the following process improvements: • Collaborate with the Child Nutrition program management and Fiscal Grants team to provide full documentation of grant awards including terms, conditions and attachments. • Update ODE’s grant profile request Smartsheet tool to: o Identify FFATA eligibility prior to setting up a new grant award in the accounting system. o Automatically notify the FFATA team of new grant awards that require reporting. Anticipated Completion Date: June 30, 2025 Contact person: Kristie Miller, Accounting Director
Finding 2024-003: Lower Income Housing Assistance Program - Section 8 New Construction and Substantial Rehabilitation Assistance Listing Number: 14.182 U.S. Department of Housing and Urban Development Compliance Require...
Finding 2024-003: Lower Income Housing Assistance Program - Section 8 New Construction and Substantial Rehabilitation Assistance Listing Number: 14.182 U.S. Department of Housing and Urban Development Compliance Requirements: Special Tests and Provisions Type of finding: Internal Control (material weakness) and Compliance (material noncompliance) Recommendation: The Organization should strengthen its internal controls with adopted policies and procedures to establish a monitoring process to ensure compliance with Mortgage Restructuring Loan terms and conditions. Action Taken: Director should review monthly statements and provide to bookkeeper for documentation. Annually, the bookkeeper and director should review the terms and determine the amount due for electronic payment of the Mortgage Restructuring Loan to be made by the bookkeeper. If there are any questions regarding this plan, please call the responsible party at (719) 852-5778. Sincerely yours, Monica Wolfe Executive Director Tri-County Senior Citizens and Housing, Inc.
Finding 2024-002: Lower Income Housing Assistance Program - Section 8 New Construction and Substantial Rehabilitation Assistance Listing Number: 14.182 U.S. Department of Housing and Urban Development ...
Finding 2024-002: Lower Income Housing Assistance Program - Section 8 New Construction and Substantial Rehabilitation Assistance Listing Number: 14.182 U.S. Department of Housing and Urban Development (Repeat of Finding 2023-002 and 2022-002) Compliance Requirements: Cash Management, Eligibility, Reporting, Special Tests and Provisions Type of finding: Internal Control Over Compliance (significant deficiency) Recommendation: The Organization should strengthen its internal controls with adopted policies and procedures to ensure a review process is established through adequate segregation of duties. The Organization should consider assessing and realigning the duties and responsibilities of administrative staff allowing the administrator to act in a more supervisory position. Action Taken: At this time, we do not have an administrative assistant/Activities Coordinator. Administrator works closely with the bookkeeper. Administrator and Executive Director will schedule every third recertification for review. Executive Director does review of the financial statements on a monthly basis when they are emailed over just before Policy Board meetings. During audit last year, we understood that reporting and eligibility did not have to happen at each interval but a review by another party in office every few re-certifications, as well as reviewing cash management. If there are any questions regarding this plan, please call the responsible party at (719) 852-5778. Sincerely yours, Monica Wolfe Executive Director Tri-County Senior Citizens and Housing, Inc.
Recommendation: Management should implement a formalized process for reviewing all required reports prior to submission. Management’s Response: Management agrees that all financial data would potentially be more accurate if reviewed by an additional qualified person prior to use. However, limited ...
Recommendation: Management should implement a formalized process for reviewing all required reports prior to submission. Management’s Response: Management agrees that all financial data would potentially be more accurate if reviewed by an additional qualified person prior to use. However, limited staff has prevented this from always being practical. In the future, management will seek ways to add more controls to all of our processes, including reviews, to ensure more accurate and reliable data is submitted. Responsible Parties: Jeff Sabo, Airport Manager Anticipated Completion Date: April 1, 2025
CORRECTIVE ACTION PLAN YEAR END JUNE 30, 2024 Gettysburg Area School District respectfully submits the following corrective action plan in response to the findings listed in Section II of the Schedule of Findings and Questioned Costs for the year end June 30, 2024. Finding 2024-001: Reporting Requ...
CORRECTIVE ACTION PLAN YEAR END JUNE 30, 2024 Gettysburg Area School District respectfully submits the following corrective action plan in response to the findings listed in Section II of the Schedule of Findings and Questioned Costs for the year end June 30, 2024. Finding 2024-001: Reporting Requirements Condition: The District did not file the Title I, Title II, Title III, Title IV, ARP ESSER, ARP ESSER 7%, ARP ESSER Homeless Children and Youth, and ARP ESSER 2.5% Reconciliation of Cash on Hand Quarterly Reports for September 2023 and March 2024 in an timely manner within the 10-day requirement. The District did not file the Title I, Title II, Title III, Title IV, ARP ESSER, ARP ESSER 7%, ARP ESSER Homeless Children and Youth, and ARP ESSER 2.5% Reconciliation of Cash on Hand Quarterly Reports for December 2023 and June 2024. Additionally, the Final Expenditure Report for the ESSER II was not filed by the required due date. The reports noted here were not related to a single audit requirement and thus were reported as a financial statement internal control finding. Corrective Actions Taken or Planned: Corrective Action has been addressed for the Federal filing requirements for the 2024-2025 fiscal year and thereafter.
S3800-090 Auditor's Summary of the Auditee's Comments on the Findings and Recommendations: Concur S3800-130 Response Indicator: Agree S3800-140 Completion Date: March 3, 2025 S3800-150 Response: For the year ended December 31, 2024, the Project implemented the rate increase and submitted adjusted HA...
S3800-090 Auditor's Summary of the Auditee's Comments on the Findings and Recommendations: Concur S3800-130 Response Indicator: Agree S3800-140 Completion Date: March 3, 2025 S3800-150 Response: For the year ended December 31, 2024, the Project implemented the rate increase and submitted adjusted HAP billings accordingly with HUD on March 3, 2025. S3800-160 Contact Person - First Name: Dawn S3800-180 Contact Person - Last Name: Kleinschrodt
S3800-090 Auditor's Summary of the Auditee's Comments on the Findings and Recommendations: Concur S3800-130 Response Indicator: Agree S3800-140 Completion Date: November 26, 2024 S3800-150 Response: For the year ended December 31, 2023, the Project filed the FAC data collection form on November 26, ...
S3800-090 Auditor's Summary of the Auditee's Comments on the Findings and Recommendations: Concur S3800-130 Response Indicator: Agree S3800-140 Completion Date: November 26, 2024 S3800-150 Response: For the year ended December 31, 2023, the Project filed the FAC data collection form on November 26, 2024. S3800-160 Contact Person - First Name: Dawn S3800-180 Contact Person - Last Name: Kleinschrodt
S3800-090 Auditor's Summary of the Auditee's Comments on the Findings and Recommendations: Concur S3800-130 Response Indicator: Agree S3800-140 Completion Date: November 22, 2024 S3800-150 Response: For the year ended December 31, 2023, the Project filed the REAC report with HUD on November 22, 2024...
S3800-090 Auditor's Summary of the Auditee's Comments on the Findings and Recommendations: Concur S3800-130 Response Indicator: Agree S3800-140 Completion Date: November 22, 2024 S3800-150 Response: For the year ended December 31, 2023, the Project filed the REAC report with HUD on November 22, 2024. S3800-160 Contact Person - First Name: Dawn S3800-180 Contact Person - Last Name: Kleinschrodt
Harris County Public Health management acknowledges the requirements that each grant has a specified period of performance per the grant agreements of Federal awards. We also agree that failure to ensure expenses are properly reviewed and coded to the correct period or grant could result in noncompl...
Harris County Public Health management acknowledges the requirements that each grant has a specified period of performance per the grant agreements of Federal awards. We also agree that failure to ensure expenses are properly reviewed and coded to the correct period or grant could result in noncompliance with the award contract, which may result in the early termination of the grant award, non-reimbursement of grant funding, or cessation of future funding. HCPH management will ensure that a detailed review of the period of performance is performed by grant staff by instituting staff training and reemphasizing the grant closeout process and procedures by September 2025
Harris County Public Health management acknowledges the requirements that 2CFR 200.303 establishes that grant recipients should establish, document, and maintain effective internal control over federal awards, including controls over reviews of reports and compliance with reporting requirements. HCP...
Harris County Public Health management acknowledges the requirements that 2CFR 200.303 establishes that grant recipients should establish, document, and maintain effective internal control over federal awards, including controls over reviews of reports and compliance with reporting requirements. HCPH management will establish controls to ensure review, segregation of duties, timely submission, and clear identification of preparers and reviewers of programmatic reports by September 2025.
Recommendation: The Commission should implement controls to monitor the Commission’s compliance with HUD requirements. Additionally, the Commission should require its financial institutions to provide documentation of collateral at a minimum on a quarterly basis. The Commission should also adopt p...
Recommendation: The Commission should implement controls to monitor the Commission’s compliance with HUD requirements. Additionally, the Commission should require its financial institutions to provide documentation of collateral at a minimum on a quarterly basis. The Commission should also adopt policies and procedures to monitor its cash and investments continuously to verify that the collateral provided by the financial institutions is adequate throughout the year. Action Taken: Management agrees with the finding. We will contact the financial institution and explained the procedures that need to be in place and will require proof of insurance on a quarterly basis. Anticipated Completion Date of Action: Ongoing
Corrective action plan - management response: The organization to update policies and procedures, over completing tenant HUD Housing Assistance Payment forms, to include review by a management agent or acting management agent. Name(s) of the contact person(s) responsible for corrective action: Mars...
Corrective action plan - management response: The organization to update policies and procedures, over completing tenant HUD Housing Assistance Payment forms, to include review by a management agent or acting management agent. Name(s) of the contact person(s) responsible for corrective action: Marsha Larkin Marani, Project Manager Planned completion date for corrective action plan: March 2025
Corrective action plan - management response: The organization to update policies and procedures, over completing tenant certification and re-certification, to include review by a management agent or acting management agent. Name(s) of the contact person(s) responsible for corrective action: Marsha...
Corrective action plan - management response: The organization to update policies and procedures, over completing tenant certification and re-certification, to include review by a management agent or acting management agent. Name(s) of the contact person(s) responsible for corrective action: Marsha Larkin Marani, Project Manager Planned completion date for corrective action plan: March 2025
Corrective action plan - management response: Management to update income limits in Onesite to reflect HUD income limits applicable as of the tenant’s application date. Name(s) of the contact person(s) responsible for corrective action: Marsha Larkin Marani, Project Manager Planned completion date...
Corrective action plan - management response: Management to update income limits in Onesite to reflect HUD income limits applicable as of the tenant’s application date. Name(s) of the contact person(s) responsible for corrective action: Marsha Larkin Marani, Project Manager Planned completion date for corrective action plan: March 2025 (as Income Thresholds become available annually by HUD)
Finding 554624 (2024-039)
Significant Deficiency 2024
2024-039 Oregon Department of Emergency Management Continue FFATA reporting improvements and make inquiries on FSRS functionality Management Response: The Oregon Department of Emergency Management (OEM) concurs with the finding and the recommendations as outlined in the letter and above. OEM has und...
2024-039 Oregon Department of Emergency Management Continue FFATA reporting improvements and make inquiries on FSRS functionality Management Response: The Oregon Department of Emergency Management (OEM) concurs with the finding and the recommendations as outlined in the letter and above. OEM has undertaken and continues the following corrective actions to address the recommendations made by the Secretary of State’s Audits Division: • OEM has developed procedures for capturing necessary information and ensuring FFATA reports are filed in compliance with federal criteria. • OEM has identified all awards since July 1st 2023 and is working to ensure 100% compliance from that date forward. • OEM will conduct timely follow up on all submissions that fail to successfully load into the system, and clearly document that follow up for inclusion in our files. • OEM will continue to review older awards to determine what actions should be taken. Anticipated completion date: June 30, 2025. Contact person: Amy Mettler, Chief Financial Officer.
Finding 554612 (2024-018)
Significant Deficiency 2024
2024-018 Oregon Department of Human Services Strengthen Medicaid fraud hotline reporting mechanismsManagement Response: We agree with this recommendation and will work to develop a more effective public facing referral process.. Anticipated Completion Date: July 31, 2026 Contact person: Jennifer Sta...
2024-018 Oregon Department of Human Services Strengthen Medicaid fraud hotline reporting mechanismsManagement Response: We agree with this recommendation and will work to develop a more effective public facing referral process.. Anticipated Completion Date: July 31, 2026 Contact person: Jennifer Stallsworth, Chief of Staff, ODHS APD, April Gillette, OHA Medicaid Division, Strategic Operations & Improvement Director
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