Corrective Action Plans

Finding 537612 (2024-001)

Material Weakness 2024

The Center: Resources for Teaching and Learning

IL

Procurement, Suspension & Debarment Subrecipient Monitoring Internal Control / Segregation of Duties § 200.14

The Organization will review its procurement procedures to ensure they include performing and documenting the appropriate searches. The Organization accepts the recommendations.

View Audit 348881

Finding 537591 (2024-001)

Significant Deficiency 2024

University System of New Hampshire

NH

Student Financial Aid Significant Deficiency Internal Control / Segregation of Duties

Student Financial Assistance Cluster – Assistance Listing Numbers 84.007, 84.033, 84.038, 84.063, 84.268 Recommendation: We recommend that the College put a process in place to refund student credit balances that arose from federal funds within 14 days. Explanation of disagreement with audit find...

Student Financial Assistance Cluster – Assistance Listing Numbers 84.007, 84.033, 84.038, 84.063, 84.268 Recommendation: We recommend that the College put a process in place to refund student credit balances that arose from federal funds within 14 days. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College will update credit balance reporting and monitoring procedures and provide training to staff to ensure refunds are done in a timely manner. Name(s) of the contact person(s) responsible for corrective action: Cathy Mullins, Director of Financial Aid and Scholarships. Keene State College Planned completion date for corrective action plan: April 30, 2025

View Audit 348873

Finding 537590 (2024-005)

Material Weakness 2024

Metropolitan School District of Shakamak

IN

Special Tests & Provisions Subrecipient Monitoring Material Weakness § 200.303

FINDING 2022-005 Contact Person Responsible for Corrective Action: Jeff Gambill, Superintendent; Brian Rehmel, Maintenance Supervisor Contact Phone Number: 812-665-3550 Views of Responsible Official: We concur with the finding, Description of Corrective Action Plan: The Superintendent and Ma...

FINDING 2022-005 Contact Person Responsible for Corrective Action: Jeff Gambill, Superintendent; Brian Rehmel, Maintenance Supervisor Contact Phone Number: 812-665-3550 Views of Responsible Official: We concur with the finding, Description of Corrective Action Plan: The Superintendent and Maintenance Supervisor will begin ensuring all vendor contracts with labor installation in excess of $2,000 which are funded by federal grants including Davis Bacon Wage Rate Requirement clauses and implement a formal review process to ensure the required weekly payroll reports certifications are collected and reviewed to ensure compliance with federal regulations Anticipated Completion Date: Immediate review will begin of all vendor contracts funded by federal grants.

View Audit 348863

Finding 537589 (2024-003)

Material Weakness 2024

Metropolitan School District of Shakamak

IN

Equipment & Real Property Management Internal Control / Segregation of Duties § 200.313

FINDING 2022-003 Contact Person Responsible for Corrective Action: Jeff Gambill, Superintendent; Brian Rehmel, Maintenance Supervisor Contact Phone Number: 812-665-3550 Views of Responsible Official: We concur with the finding, Description of Corrective Action Plan: The Superintendent and Ma...

FINDING 2022-003 Contact Person Responsible for Corrective Action: Jeff Gambill, Superintendent; Brian Rehmel, Maintenance Supervisor Contact Phone Number: 812-665-3550 Views of Responsible Official: We concur with the finding, Description of Corrective Action Plan: The Superintendent and Maintenance Supervisor will begin reviewing all capital asset inventories. These inventories are completed every two years, by an independent company. The Superintendent and Maintenance Supervisor will also maintain a corporation capital asset listing, updating any additions between inventories, to verify that the assets are properly accounted for on the capital asset inventory. The Superintendent and Maintenance Supervisor will add to the corporation capital asset listing, the assets that were omitted from the most recent capital asset inventory, and ensure that those assets are listed in the next capital asset inventory. Anticipated Completion Date: The Superintendent and Maintenance Supervisor will immediately begin maintaining a capital asset listing, updating any additions between inventories, as well as adding the assets that were omitted on the previous capital asset inventory.

View Audit 348863

Finding 537587 (2024-004)

Material Weakness 2024

Metropolitan School District of Shakamak

IN

Internal Control / Segregation of Duties Material Weakness Reporting § 200.302 § 200.303 § 200.328

FINDING 2022-004 Contact Person Responsible for Corrective Action: Jeff Gambill, Superintendent; Jennifer Barcus, Corporation Treasurer; Jeri Morin, Data Coordinator Contact Phone Number: 812-665-3550 Views of Responsible Official: We concur with the finding. Description of Corrective Action P...

FINDING 2022-004 Contact Person Responsible for Corrective Action: Jeff Gambill, Superintendent; Jennifer Barcus, Corporation Treasurer; Jeri Morin, Data Coordinator Contact Phone Number: 812-665-3550 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Superintendent will prepare all annual data reports and have a documented formal review from the Corporation Treasurer and the Data Coordinator, prior to submission, to validate the accuracy and completeness of the data submitted. Anticipated Completion Date: Immediate review will begin of all annual data reports.

View Audit 348863

Finding 537583 (2024-002)

Significant Deficiency 2024

Weston County School District No. One

WY

Internal Control / Segregation of Duties

The District has separated duties to the extent possible and has implemented compensating controls to monitor the accounting activities.

View Audit 348857

Finding 537566 (2024-002)

Significant Deficiency 2024

Seniorsplus

ME

Subrecipient Monitoring Significant Deficiency Internal Control / Segregation of Duties § 200.303

Management is committed to compliance in accordance with all grant agreements and will work to formally document the Agency’s internal controls over Federal and State awards. Additional training will be provided as needed to prevent future findings.

View Audit 348846

Finding 537530 (2024-005)

Material Weakness 2024

Housing Authority of Prince George's County

MD

Special Tests & Provisions HUD Housing Programs Material Weakness

2024-005 Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority implements controls to ensure that HQS inspections are performed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in r...

2024-005 Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority implements controls to ensure that HQS inspections are performed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: HAPGC has hired a new Voucher Program Director. The new Director will strictly enforce current program policy which requires strict enforcement of HQS inspection rules. Additionally, HAPGC will review processes associated with scheduling HQS Inspections and work with the HQS Inspection contractor to ensure compliance. Finally, all HCV staff persons will be required to take the Housing Choice Voucher Certification class annually to ensure proper training and adequate understanding of the voucher program rules. Name(s) of the contact person(s) responsible for corrective action: Carolyn Floyd, Housing Choice Voucher Program, Director cefloyd@co.pg.md.us. Planned completion date for corrective action plan: December 31, 2025. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Jessica Anderson-Preston, Executive Director at 301-883-5552 or email jgandersonpreston@co.pg.md.us.

View Audit 348795

Finding 537529 (2024-004)

Material Weakness 2024

Housing Authority of Prince George's County

MD

Questioned Costs Special Tests & Provisions Material Weakness

2024-004 Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority implements controls to ensure that the Authority requires HQS deficiencies to be corrected within the timeframe set forth by 2 CFR section 982.404(a). We recommend the Authority implements co...

2024-004 Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority implements controls to ensure that the Authority requires HQS deficiencies to be corrected within the timeframe set forth by 2 CFR section 982.404(a). We recommend the Authority implements controls to ensure abatement is timely for units that do not correct the cited HQS deficiencies within the required timeframe. Explanation of disagreement with audit finding: HAPGC has hired a new Voucher Program Director. The new Director will strictly enforce current program policy which requires strict enforcement of abatement rules. Additionally, Program Managers, as well as Recertification and Intake Specialists, will be held accountable through disciplinary action when corrective actions noted through the quality control review process are not corrected within 15 business days. Finally, all HCV staff persons will be required to take the Housing Choice Voucher Certification class annually to ensure proper training and adequate understanding of the voucher program rules. Name(s) of the contact person(s) responsible for corrective action: Carolyn Floyd, Housing Choice Voucher Program, Director cefloyd@co.pg.md.us. Planned completion date for corrective action plan: December 31, 2025.

View Audit 348795 Questioned Costs: $1

Finding 537528 (2024-003)

Significant Deficiency 2024

Housing Authority of Prince George's County

MD

HUD Housing Programs Significant Deficiency Special Tests & Provisions

2024-003 Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority review their process and internal controls for rent reasonableness to ensure compliance with HUD requirements and their administrative plan. Explanation of disagreement with audit finding: T...

2024-003 Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority review their process and internal controls for rent reasonableness to ensure compliance with HUD requirements and their administrative plan. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: HAPGC has implemented a new Rent Reasonableness software that provides a user-friendly method for ensuring Rent Reasonableness compliance. HAPGC has hired a new Voucher Program Director. The new Director will strictly enforce current program policy which requires Recertification and Intake Specialists to attach all required documentation within 3 business days of receipt to the program participant’s electronic file. Additionally, Program Managers, as well as Recertification and Intake Specialists, will be held accountable through disciplinary action when corrective actions noted through the quality control review process are not corrected within 15 business days. Finally, all HCV staff persons will be required to take the Housing Choice Voucher Certification class annually to ensure proper training and adequate understanding of the voucher program rules. Name(s) of the contact person(s) responsible for corrective action: Carolyn Floyd, Housing Choice Voucher Program, Director cefloyd@co.pg.md.us. Planned completion date for corrective action plan: December 31, 2025.

View Audit 348795

Finding 537527 (2024-002)

Significant Deficiency 2024

Housing Authority of Prince George's County

MD

HUD Housing Programs Eligibility Significant Deficiency

2024-002 Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority review their process and internal controls for new tenants to ensure compliance with HUD requirements and their administrative plan. Explanation of disagreement with audit finding: There is...

2024-002 Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority review their process and internal controls for new tenants to ensure compliance with HUD requirements and their administrative plan. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: HAPGC has hired a new Voucher Program Director. The new Director will strictly enforce current program policy which requires Recertification and Intake Specialists to attach all required documentation within 3 business days of receipt to the program participant’s electronic file. Additionally, Program Managers, as well as Recertification and Intake Specialists, will be held accountable through disciplinary action when corrective actions noted through the quality control review process are not corrected within 15 business days. Finally, all HCV staff persons will be required to take the Housing Choice Voucher Certification class annually to ensure proper training and adequate understanding of the voucher program rules. Name(s) of the contact person(s) responsible for corrective action: Carolyn Floyd, Housing Choice Voucher Program, Director cefloyd@co.pg.md.us. Planned completion date for corrective action plan: December 31, 2025.

View Audit 348795

Finding 537526 (2024-001)

Significant Deficiency 2024

Housing Authority of Prince George's County

MD

HUD Housing Programs Eligibility Significant Deficiency

2024-001 Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority review their process and internal controls over eligibility to ensure compliance with HUD requirements and their administrative plan. Explanation of disagreement with audit finding: There i...

2024-001 Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority review their process and internal controls over eligibility to ensure compliance with HUD requirements and their administrative plan. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: HAPGC has hired a new Voucher Program Director. The new Director will strictly enforce current program policy which requires Recertification and Intake Specialists to attach all required documentation within 3 business days of receipt to the program participant’s electronic file. Additionally, Program Managers, as well as Recertification and Intake Specialists, will be held accountable through disciplinary action when corrective actions noted through the quality control review process are not corrected within 15 business days. Finally, all HCV staff persons will be required to take the Housing Choice Voucher Certification class annually to ensure proper training and adequate understanding of the voucher program rules. Name(s) of the contact person(s) responsible for corrective action: Carolyn Floyd, Housing Choice Voucher Program, Director cefloyd@co.pg.md.us. Planned completion date for corrective action plan: December 31, 2025.

View Audit 348795

Finding 537480 (2024-001)

Significant Deficiency 2024

Imperial Valley Regional Occupational Program

CA

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.430

The plan will be to do several things in order to correct the issue. Hold training for management and clerical staff on updates to timesheet and time accounting protocols to ensure understanding of the processes. Have staff and management update timesheets to include the source of funding, the na...

The plan will be to do several things in order to correct the issue. Hold training for management and clerical staff on updates to timesheet and time accounting protocols to ensure understanding of the processes. Have staff and management update timesheets to include the source of funding, the name of the project and resource code applicable to the project. Have management and clerical staff verify information on timesheets and sign and date the timesheets once verified.

View Audit 348697

Finding 537477 (2024-001)

Significant Deficiency 2024

New Hampton Community School District

IA

Internal Control / Segregation of Duties

Management is cognizant of this limitation and will implement additional procedures where possible.

View Audit 348687

Finding 537474 (2024-003)

Material Weakness 2024

Southwestern Adventist University

TX

Student Financial Aid Material Weakness Reporting

Corrective Action: See above corrective action plans for 2024-001 and 2024-002. Contact Persons: Duane Valencia, Assistant Financial Vice President – Student Finance Jason Kowarsch, Registrar

View Audit 348681

Finding 537461 (2024-002)

Significant Deficiency 2024

Fontbonne University

MO

Student Financial Aid Special Tests & Provisions Internal Control / Segregation of Duties

Corrective Action Plan 2024-002: The University concurs with the finding. The University has corrected the two Spring 2024 RT24 calculations and initiated additional Pell grant disbursements to the noted students. The University has updated its calculations of the scheduled breaks for the 2024-2025 ...

Corrective Action Plan 2024-002: The University concurs with the finding. The University has corrected the two Spring 2024 RT24 calculations and initiated additional Pell grant disbursements to the noted students. The University has updated its calculations of the scheduled breaks for the 2024-2025 academic year. Completion Date: August 2024 Contact Person: Megan Morton, Director of Financial Services

View Audit 348677

Finding 537456 (2024-001)

Significant Deficiency 2024

State System of Higher Education, Commonwealth of Pennsylvania

PA

Student Financial Aid Reporting Significant Deficiency § 200.303

ESU: The University acknowledges this is a repeat finding. In response, updated policies and procedures were implemented in May 2024. The audit sample included students from Fall 2023 and Spring 2024—periods that predated the implementation of the corrective measures. To improve compliance, the Univ...

ESU: The University acknowledges this is a repeat finding. In response, updated policies and procedures were implemented in May 2024. The audit sample included students from Fall 2023 and Spring 2024—periods that predated the implementation of the corrective measures. To improve compliance, the University has introduced enhanced reporting mechanisms to identify when a student is no longer participating in any enrolled courses during a given semester. Once a determination is made that a student has withdrawn, University Registrar staff manually update the student’s status in the National Student Clearinghouse. This process reduces the delay between a student’s actual withdrawal and the status update reported to NSLDS. These steps are intended to ensure timely and accurate reporting moving forward. IUP: IUP will set guidelines that all degree clearing must be done with the 45 day time line so the students are reported within the 60 days limit. Cheyney:Cheyney University of Pennsylvania utilizes the National Student Clearinghouse as a third-party service provider for enrollment reporting and provides all enrollment data to NSC, believing that enrollment would be reported to NSLDS in compliance with federal regulations; unfortunately, the enrollment data from the NSC roster which is provided to National Student Loan Data Systems (NSLDS), is only matched to students who currently have existing enrollment records in NSLDS. Student enrollment information is provided to NSLDS from Common Originations and Disbursements (COD). Cheyney University is a Heightened Cash Monitoring 2 (HCM2) institution, and students' Title IV aid/ disbursements are reported differently than advance pay institutions. The student records from COD are only provided to NSLDS upon approval of disbursement from Ed after the University HCM2 submissions are approved. As of Fall 2024, Cheyney University has continued to directly report and upload enrollment for all Title IV recipients to NSLDS from the monthly NSC enrollment rosters. Kutztown: We will target shortening our status change reporting process to 2-3 days to compensate from the (up to) 30 day lag between NSC reporting and NSLDS reporting. We will connect with another PASSHE school that was on the findings report for the last period - but not this period - to ascertain how they avoided the repeat, and to learn additional best practices. We will renew our cooperative efforts with financial aid to ensure both sides of the equation – NSC and NSLDS – are communicating and that both offices are involved in double checking Commonwealth: The issues with enrollment reporting were one-time issues related to the integration of the three schools and the implementation of and data migration to a new student information system. Issues have been resolved and Commonwealth University is currently reporting on the prescribed schedule. Millersville: The Registrar’s Office will review its reporting procedures to ensure that students’ statuses are timely reported to NSLDS as required by Federal regulations. Primarily, the frequency of submissions to the NSC.

View Audit 348667

Finding 537447 (2024-002)

Significant Deficiency 2024

Saint Peter's University and Affiliates

NJ

Questioned Costs Student Financial Aid Significant Deficiency

Student Financial Aid Cluster – Federal Assistance Listing Numbers 84.007, 84.033, 84.063 and 84.268 Recommendation: We recommend the University review its policies and procedures related to outstanding student refund checks to ensure they are being returned to the Department of Education after 240 ...

Student Financial Aid Cluster – Federal Assistance Listing Numbers 84.007, 84.033, 84.063 and 84.268 Recommendation: We recommend the University review its policies and procedures related to outstanding student refund checks to ensure they are being returned to the Department of Education after 240 days. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has developed a policy to identify uncashed Title IV refund checks prior to the 240-day expiration date. The policy includes steps to contact students whose checks did not clear and to return the refunds to the Department within 240 days after the issue date of the check. The procedures will ensure that reviews are completed and returned timely according to applicable regulations. Name(s) of the contact person(s) responsible for corrective action: Lillian Perreira-Talty, Director of Student Accounts (201) 761-6080 Planned completion date for corrective action plan: Completed

View Audit 348651 Questioned Costs: $1

Finding 537443 (2024-001)

Significant Deficiency 2024

Saint Peter's University and Affiliates

NJ

Reporting Student Financial Aid Significant Deficiency

Student Financial Aid Cluster – Federal Assistance Listing Numbers 84.063 and 84.268 Recommendation: We recommend the University evaluate its procedures and review policies in overseeing submissions to the NSLDS completed by the third-party servicer. Additionally, we recommend the University review ...

Student Financial Aid Cluster – Federal Assistance Listing Numbers 84.063 and 84.268 Recommendation: We recommend the University evaluate its procedures and review policies in overseeing submissions to the NSLDS completed by the third-party servicer. Additionally, we recommend the University review its policies and procedures on reporting enrollment information to the NSLDS to ensure that all relevant information is being captured and reported timely in accordance with applicable regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has updated its policies and procedures for NSLDS submissions via their third-party servicer to ensure relavant information is being captured and reported timely in accordance with applicable regulations. Name(s) of the contact person(s) responsible for corrective action: Kamla Singh-Ramoutar, University Registrar, (201) 761-6051 Planned completion date for corrective action plan: Completed

View Audit 348651

Finding 537424 (2024-006)

Material Weakness 2024

Blackford County Schools

IN

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.302 § 200.303 § 200.328 § 200.329 § 200.334

FINDING 2024-006 Subject: COVID‐19 ‐ Education Stabilization Fund ‐ Reporting Federal Agency: Department of Education Federal Program: COVID‐19 ‐ Education Stabilization Fund Assistance Listing Numbers: 84.425D, 84.425U Federal Award Numbers and Years (or Other Identifying Numbers): S425D210013, S42...

FINDING 2024-006 Subject: COVID‐19 ‐ Education Stabilization Fund ‐ Reporting Federal Agency: Department of Education Federal Program: COVID‐19 ‐ Education Stabilization Fund Assistance Listing Numbers: 84.425D, 84.425U Federal Award Numbers and Years (or Other Identifying Numbers): S425D210013, S425U210013 Pass‐Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Findings: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Chad Yencer, Superintendent Contact Phone Number: 765-348-7550 Views of Responsible Official: We concur with this finding Description of Corrective Action Plan: Internal Control 1. For state reporting related to ESSER grants, the Grants/Data Specialist will compile all required information and maintain thorough supporting documentation. The Corporation Treasurer will then review the compiled financial data for the reporting period, verifying its accuracy before presenting it to the Superintendent. Finally, the Superintendent will review the information and supporting documentation, confirming its accuracy prior to submission to the Indiana Department of Education (IDOE). All workpapers and calculations will be recorded and kept for verification Anticipated Completion Date: August 2025

View Audit 348618

Finding 537413 (2024-028)

Significant Deficiency 2024

State of Vermont

VT

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Reference Number: 2024-028 Prior Year Finding: 2023-034 Federal Agency: U.S. Department of Homeland Security State Agency: Department of Public Safety Federal Program: Disaster Grants - Public Assistance (Presidentially Declared Disasters) Assistance Listing Number: 97.036 Award Number and Year: FEM...

Reference Number: 2024-028 Prior Year Finding: 2023-034 Federal Agency: U.S. Department of Homeland Security State Agency: Department of Public Safety Federal Program: Disaster Grants - Public Assistance (Presidentially Declared Disasters) Assistance Listing Number: 97.036 Award Number and Year: FEMA-4474-DR-VT (2020), FEMA-4532-DR-VT (2020), FEMA-4621-DR-VT (2021), FEMA-4695-DR-VT (2023), FEMA-4720-DR-VT (2023) Compliance Requirement: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend the Department complete implementation of its corrective action plan from the prior year. The Department should continue to improve its procedures and internal controls to ensure that all required subawards and subaward modifications are reported accurately and timely to FSRS no later than the end of the month following the month of issuance in accordance with FFATA reporting requirements. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: Public Safety will continue implementation of its corrective action plan from the prior year. A new procedure will be developed for a periodic review of FFATA entries to add a control step ensuring that all FFATA entries are timely and accurate. A training will also be delivered to Public Assistance staff to ensure that the FFATA entry process is understood in both FSRS and SAM.gov. These corrective actions will be completed by April 4th, 2025 Scheduled Completion Date of Corrective Action Plan: April 4, 2025 Contacts for Corrective Action Plan: Richard Hallenbeck, Director of Administration/Finance richard.hallenbeck@vermont.gov

View Audit 348596

Finding 537402 (2024-025)

Significant Deficiency 2024

State of Vermont

VT

Special Tests & Provisions Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Reference Number: 2024-025 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services (Agency) Federal Program: Medicaid Cluster Assistance Listing Number: 93.775, 93.777, 93.778 Award Number and Year: 2305VT5MAP (10/1/2022 – 9/30/2023)...

Reference Number: 2024-025 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services (Agency) Federal Program: Medicaid Cluster Assistance Listing Number: 93.775, 93.777, 93.778 Award Number and Year: 2305VT5MAP (10/1/2022 – 9/30/2023) 2405VT5MAP (10/1/2023 – 9/30/2024) Compliance Requirement: Special Tests and Provisions – Utilization Control Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend that the Agency review and enhance procedures and controls for Medicaid utilization control to ensure that cases are closed timely and that documentation of the results of reviews are maintained and communicated. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: The Special investigations Unit (SIU) only refers two types of cases to the Medicaid Fraud Residential Abuse Unit (MFRAU), these cases are: Personal Care Attendant (PCA) and provider fraud and abuse. Prior to 2021 most of those cases were kept in paper format. Since then, the SIU has fully transitioned to electronic files only. All PCA cases referred to MFRAU are assigned to the Duty Auditor (DA) of the Special Investigations Unit (SIU). The DA must send the case referral via a form that MFRAU must return with notification of acceptance or declination to investigate the allegation. If the case is accepted, then it remains under “open referred to MFRAU” status in our database and updates must be provided and documented by the DA during our MFRAU/SIU quarterly meetings until SIU receives a closure memo from MFRAU that documents the completion of their review. Additionally, all provider cases remain open with the auditor who investigated and referred the matter until a closing memo is received by the SIU. All documented follow ups are recorded in the case log. Scheduled Completion Date of Corrective Action Plan: This process has been implemented since 2021 for cases generated from that year forward. SIU Procedure Manual has been updated accordingly as of December 31, 2024. Contacts for Corrective Action Plan: Nadeth Fitzgerald, Director – SIU nadeth.fitzgerald@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 348596

Finding 537400 (2024-023)

Significant Deficiency 2024

State of Vermont

VT

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Reference Number: 2024-023 Prior Year Finding: 2023-030; 2022-038; 2021-026 Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: Medicaid Cluster Assistance Listing Number: 93.775, 93.777, 93.778 Award Number and Year: 2305VT5MAP (10/1/...

Reference Number: 2024-023 Prior Year Finding: 2023-030; 2022-038; 2021-026 Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: Medicaid Cluster Assistance Listing Number: 93.775, 93.777, 93.778 Award Number and Year: 2305VT5MAP (10/1/2022 – 9/30/2023) 2405VT5MAP (10/1/2023 – 9/30/2024) Compliance Requirement: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend that the Agency complete implementation of its prior year CAP to ensure that all required subawards and subaward modifications are reported timely to FSRS in accordance with FFATA requirements. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: Agency of Human Services Internal Audit Group (AHS-IAG) is a designated centralized reporter of subawards for a Medicaid cluster (ALN 93.775, 93.777, 93.778) that is shared between all AHS departments. To address omissions and timeliness of subawards and subaward modifications reporting to FSRS, IAG conducted additional training tailored to each AHS Department to examine the results of FFATA testing conducted internally and reemphasized the FFATA compliance regulations. This ensured the Internal Audit Group (IAG) is provided with complete, accurate and timely subaward information for reporting in FSRS going forward. The context of the 2024 finding indicates that the departments understood the training materials and complied with the requirements to report. On at least an annual basis, IAG conducts a review of current federal rules and regulations pertaining to FFATA reporting for FSRS to assure the Agency’s procedures are up to-date. Coincidentally, IAG will also select a random sample of subawards and subawards modifications that meet the required threshold for FFATA reporting to ensure they are reported in FSRS system on a complete, accurate and timely basis. Scheduled Completion Date of Corrective Action Plan: March 31, 2025: Annual review of FFATA rules and regulations including subawards review. Contacts for Corrective Action Plan: Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 348596

Finding 537399 (2024-022)

Significant Deficiency 2024

State of Vermont

VT

Eligibility Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Reference Number: 2024-022 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services (Agency) Federal Program: Medicaid Cluster Assistance Listing Number: 93.775, 93.777, 93.778 Award Number and Year: 2305VT5MAP (10/1/2022 – 9/30/2023)...

Reference Number: 2024-022 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services (Agency) Federal Program: Medicaid Cluster Assistance Listing Number: 93.775, 93.777, 93.778 Award Number and Year: 2305VT5MAP (10/1/2022 – 9/30/2023) Compliance Requirement: Eligibility Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend that the Agency review and enhance procedures and controls for Medicaid eligibility renewals to ensure that benefits for eligible participants are not discontinued. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: The error was caused by a caseworker not following the steps within the job aid when processing eligibility for a late renewal form. Coverage closed on 9/30/24 for non-review. The renewal form was received on 10/17/2023 yet, coverage was reinstated for 11/1/2024 instead of 10/1/24. The gap in coverage was corrected on 9/16/2024 and coverage was backdated to 10/1/24. The eligibility unit notified the worker’s supervisor who reviewed the case error with the caseworker. In addition, eligibility staff receive refresher training yearly to review our business processes. The Eligibility Unit will continue to monitor cases through our internal QA process unit and through our off-year reviews conducted by the QC unit. Scheduled Completion Date of Corrective Action Plan: Coverage was corrected on September 16, 2024. Contacts for Corrective Action Plan: Nicole McAllister, Healthcare Assistant Administrator II nicole.mcallister@vermont.gov Sarah York, Healthcare Assistant Administrator I sarah.york@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 348596

Finding 537386 (2024-020)

Material Weakness 2024

State of Vermont

VT

Special Tests & Provisions Subrecipient Monitoring Material Weakness § 200.303

Reference Number: 2024-020 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: CCDF Cluster Assistance Listing Number: 93.575, 93.596 Award Number and Year: 2301VTCCDD (10/1/2022 – 9/30/2025) 2401VTCCDD (10/1/202...

Reference Number: 2024-020 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: CCDF Cluster Assistance Listing Number: 93.575, 93.596 Award Number and Year: 2301VTCCDD (10/1/2022 – 9/30/2025) 2401VTCCDD (10/1/2023 – 9/30/2026) Compliance Requirement: Special Tests and Provisions – Health and Safety Requirements Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance Recommendation: We recommend that the Agency review and enhance training monitoring procedures and controls to ensure that all child care providers complete required health and safety training. We further recommend that the Agency update its training content to ensure that it includes all required elements. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: Department for Children and Families-Child Development Division (DCF-CDD) licensing unit is in the process of rule revisions which will include all the required health and safety topics that must be covered within the first three months of employment. DCF-CDD licensing unit will be updating our monitoring checklists to ensure we are regulating to the federal standard. DCF-CDD licensing unit will conduct staff training that review the results of the SFY 2024 Single Audit and establish clear procedures for licensing staff to follow when monitoring licensed providers and their staff for ongoing professional development requirements. Scheduled Completion Date of Corrective Action Plan: DCF-CDD is currently in the rule revision process and have a goal to shepherd the rules through promulgation by December 31, 2025. DCF-CDD will update our monitoring checklists to align with the rule revision which will include a complete pre-service orientation training list that aligns with the federal standard. This will be completed by December 31, 2025. DCF-CDD will review the results of the SFY 2024 Single Audit with the licensing team on January 21, 2025. Licensing supervisors will begin reviewing annual site visit reports for the licensors they supervise to ensure CDD is monitoring for the required ongoing professional development trainings required beginning immediately. Contacts for Corrective Action Plan: Beth Maurer, Director of Child Care Licensing elizabeth.maurer@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

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