Corrective Action Plans

Finding 516482 (2023-001)

Material Weakness 2023

Wahkiakum County

WA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Wahkiakum County January 1, 2023 through December 31, 2023 This schedule presents the corrective action the County is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations...

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Wahkiakum County January 1, 2023 through December 31, 2023 This schedule presents the corrective action the County is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2023-001 Finding caption: The County did not have adequate controls for ensuring compliance with federal requirements for allowable activities and costs. Name, address, and telephone of County contact person: Tammy Peterson, PO Box 85, 360-795-8005 Corrective action the auditee plans to take in response to the finding: (If the auditee does not concur with the finding, the auditee must list the reasons for disagreement). A request was made to the payroll department for a report for the Sheriff’s office for the August payroll. I meant the July time issued on August 5th. The report I received was for August time with a September 5th pay date. This was a misunderstanding and not an intentional oversight. In the future, we will ensure that the report dates match the payroll we are requesting. Anticipated date to complete the corrective action: September 13, 2024

View Audit 334391 Questioned Costs: $1

Finding 516472 (2023-009)

Material Weakness 2023

Academy of America

MI

Subrecipient Monitoring Material Weakness Reporting § 200.303

View of Responsible Officials and Corrective Action Plan – Management will monitor the review and approval procedures for reporting to ensure that reports are signed off to indicated and document that review and approval has been made.

View Audit 334382

Finding 516365 (2023-001)

Significant Deficiency 2023

Urban Community School

OH

Internal Control / Segregation of Duties

Corrective Actions: We have re-assigned responsibility for submitting receipts for credit card charges to the Manager of the Food Service Program, who has been running our program for 18 years. We sent our policy on receipt requirements for all credit card receipts to all relevant staff. The CFO and...

Corrective Actions: We have re-assigned responsibility for submitting receipts for credit card charges to the Manager of the Food Service Program, who has been running our program for 18 years. We sent our policy on receipt requirements for all credit card receipts to all relevant staff. The CFO and Business Manager will both review the monthly credit card charges for appropriate supporting documentation for credit card charges.

View Audit 334301

Finding 516325 (2023-002)

Material Weakness 2023

All Nations Health Center, Inc.

MT

Subrecipient Monitoring Eligibility Material Weakness

All Nations Health Center has switched EHR systems that allows for intake coordinators to suspend/pause eligibility status until all proper documentation has been obtain from the client, scanned into the system, and filed appropriately.

View Audit 334164

Finding 516271 (2023-002)

Significant Deficiency 2023

Blackbelt Unincorporated Wastewater Program

AL

Reporting Internal Control / Segregation of Duties

The Program engaged a qualified CPA firm for the Single Audit as soon as possible and the report was submitted as soon as possible. Individual(s) Responsible Sherry Bradley Completion Date Plan has been implemented as soon as possible.

View Audit 334090

Finding 516134 (2023-002)

Material Weakness 2023

Kalama School District

WA

Subrecipient Monitoring Internal Control / Segregation of Duties Special Tests & Provisions

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Kalama School District No. 402 September 1, 2022 through August 31, 2023 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Fed...

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Kalama School District No. 402 September 1, 2022 through August 31, 2023 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2023-002 Finding caption: The District did not have adequate internal controls for ensuring compliance with federal wage rate requirements. Name, address, and telephone of District contact person: James Capen Director of Business Services 360-673-5282 Corrective action the auditee plans to take in response to the finding: The Kalama School District has taken the following steps to ensure that we are currently in compliance, and will continue to stay in compliance, with the Davis-Bacon Act; 1. All new contractors and existing contractors covered by the Davis-Bacon Act will submit certification attesting to compliance of prevailing wage requirements. 2. District staff will review the State Labor and Industries prevailing wage and certification website on a weekly basis when work is performed or collect a certified payroll record from the contractor on a weekly basis. 3. All new staff that have purchasing or financial oversight will be trained on these procedures when hired and on an ongoing basis. Anticipated date to complete the corrective action: 7-26-24

View Audit 333974

Finding 516123 (2023-001)

None 2023

National Association of Police Athletic/activities Leagues, Inc.

DC

Reporting Internal Control / Segregation of Duties § 200.512

Management’s Response: Management acknowledges the delay in submission and is taking corrective action to address the issue. Steps include improving internal controls, implementing a detailed timeline for the audit process, etc. Management is committed to ensuring future compliance with reporting de...

Management’s Response: Management acknowledges the delay in submission and is taking corrective action to address the issue. Steps include improving internal controls, implementing a detailed timeline for the audit process, etc. Management is committed to ensuring future compliance with reporting deadlines.

View Audit 333940

Finding 516078 (2023-001)

Significant Deficiency 2023

Chesapeake Hospital Authority

VA

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.512

2023-001 – Reporting – Submission of the Data Collection Form Individuals Responsible for Corrective Action Plan: J. Neal Bolton, Director of Revenue Management & Budget Shemaine Rose, Controller Anticipated Completion Date: December 2024 Management acknowledges that the reporting package and dat...

2023-001 – Reporting – Submission of the Data Collection Form Individuals Responsible for Corrective Action Plan: J. Neal Bolton, Director of Revenue Management & Budget Shemaine Rose, Controller Anticipated Completion Date: December 2024 Management acknowledges that the reporting package and data collection form for the year ended June 30, 2023, was not filed with the Federal Audit Clearinghouse on or before the deadline of March 31, 2024. Management maintains that appropriate schedules and notes thereto were prepared accurately and timely, and that the delay was due primarily to the unique nature of Provider Relief Funds being reported, which resulted in evolving compliance requirements over the funding and reporting periods. Management will file the reporting package and data collection form immediately upon completion and will continue to monitor and adhere to future Federal compliance updates to prevent such delays in the future.

View Audit 333892

Finding 516060 (2023-002)

Material Weakness 2023

Red Oak Community School District

IA

Internal Control / Segregation of Duties Reporting

The District now has one less office employee and are initiating additional separation of duties such as mail opening, check and deposit handling, and additional cross handling on outgoing checks.

View Audit 333830

Finding 515976 (2023-005)

Significant Deficiency 2023

The National Judicial College

NV

Reporting Internal Control / Segregation of Duties

Shifts in operational priorities during the Spring and Summer of 2024, led to resource conflicts that hindered the audit process during critical periods. These changes, driven by direction from the Board of Trustees created unforeseen challenges that affected the timely completion of certain audit-r...

Shifts in operational priorities during the Spring and Summer of 2024, led to resource conflicts that hindered the audit process during critical periods. These changes, driven by direction from the Board of Trustees created unforeseen challenges that affected the timely completion of certain audit-related tasks. The College is committed to accelerating the fieldwork of future audits to ensure it is better prepared to handle unscheduled resource demands that may lead to delays in the audit process. In addition, the College, the auditors and the Audit Chair will meet to establish a timeline and dates for the audit planning and preparation, completion of the audit field work and the submission of the audited report. Patrick Grimes is the individual responsible for oversight of this corrective action plan.

View Audit 333783

Finding 515835 (2023-008)

Material Weakness 2023

Isanti County

MN

Allowable Costs / Cost Principles Cash Management Material Weakness

Federal Agency: US Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2205MN5ADM, 2023 Award Period: January 1, 2023 through December 31, 2023 Type of Finding: • Significant Deficiency in ...

Federal Agency: US Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2205MN5ADM, 2023 Award Period: January 1, 2023 through December 31, 2023 Type of Finding: • Significant Deficiency in Internal Control over Compliance Recommendation: We recommend the County puts in place the proper procedures to ensure it has proper controls in place to properly document the review of all the LCTS reports submitted by each collaborative member each quarter for accuracy. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will ensure there are proper financial procedures and controls in place to properly document the review of all required reports for the program. Name(s) of the contact person(s) responsible for corrective action: Angie Larson, Auditor-Treasurer / Chief Financial Officer Planned completion date for corrective action plan: December, 31 2024

View Audit 333691

Finding 515833 (2023-007)

Material Weakness 2023

Isanti County

MN

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

Federal Agency: US Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2205MN5ADM, 2023 Award Period: January 1, 2023 through December 31, 2023 Type of Finding: • Material Weakness in Inter...

Federal Agency: US Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2205MN5ADM, 2023 Award Period: January 1, 2023 through December 31, 2023 Type of Finding: • Material Weakness in Internal Control over Compliance Recommendation: We recommend the County puts in place the proper procedures to ensure it has proper controls in place to properly document the review of all required reports for the program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will ensure there are proper financial procedures and controls in place to properly document the review of all required reports for the program. Name(s) of the contact person(s) responsible for corrective action: Angie Larson, Auditor-Treasurer / Chief Financial Officer Planned completion date for corrective action plan: December, 31 2024

View Audit 333691

Finding 515831 (2023-006)

Material Weakness 2023

Isanti County

MN

Allowable Costs / Cost Principles HUD Housing Programs Material Weakness

Federal Agency: US Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2205MN5ADM, 2023 Award Period: January 1, 2023 through December 31, 2023 Type of Finding: • Material Weakness in Inter...

Federal Agency: US Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2205MN5ADM, 2023 Award Period: January 1, 2023 through December 31, 2023 Type of Finding: • Material Weakness in Internal Control over Compliance Recommendation: We recommend the County puts in place the proper procedures to ensure it has proper controls in place to properly document the review of the state time study listings each quarter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will ensure there are proper financial procedures and controls in place to properly document the review of the state time study listings each quarter. Name(s) of the contact person(s) responsible for corrective action: Angie Larson, Auditor-Treasurer / Chief Financial Officer Planned completion date for corrective action plan: December, 31 2024

View Audit 333691

Finding 515681 (2023-001)

Significant Deficiency 2023

Word of Hope Ministries, Inc.

WI

Internal Control / Segregation of Duties Reporting

The Company does not have the resources and/or staff to prepare the financial statements and notes but will continue to oversee the auditor’s services and review and approve the financial statements and notes.

View Audit 333495

Finding 515609 (2023-001)

Significant Deficiency 2023

Kansas Association of Conservation Districts

KS

Procurement, Suspension & Debarment Significant Deficiency Internal Control / Segregation of Duties § 200.319

Management agrees with the findings and recommendation. The District will update its policies and procedures to ensure they meet the Uniform Guidance Requirements. .

View Audit 333385

Finding 515608 (2023-001)

Material Weakness 2023

City of Clarion

IA

Internal Control / Segregation of Duties

The City should review its control activities to obtain the maximum internal control possible under the circumstances utilizing currently available staff, including elected officials, to provide additional controls through review of financial transactions, reconciliations and financial report. The r...

The City should review its control activities to obtain the maximum internal control possible under the circumstances utilizing currently available staff, including elected officials, to provide additional controls through review of financial transactions, reconciliations and financial report. The reviews should be documented by the signature or initials of the reviewer and the date of the review.

View Audit 333381

Finding 515573 (2023-008)

Significant Deficiency 2023

Unity Health Care, Inc.

MD

Eligibility Internal Control / Segregation of Duties Subrecipient Monitoring

Management Response #2023-008: Due to staff turnover, the Corporation did not consistently enforce segregation of duties between the individual responsible for determining income eligibility and the one completing the medical risk assessment. The Corporation also failed to provide sufficient support...

Management Response #2023-008: Due to staff turnover, the Corporation did not consistently enforce segregation of duties between the individual responsible for determining income eligibility and the one completing the medical risk assessment. The Corporation also failed to provide sufficient support to verify that the applicant signed the Rights and Obligations statement. Corrective Action Plan: • All eligibility verification data, including screenshots and signed Rights and Obligations statements, will be stored in a centralized, secure shared drive maintained and managed by the WIC Director to ensure it is protected with limited access and password protection. The drive will be organized using a de-identified naming convention to ensure privacy while maintaining ease of access for authorized staff. • To maintain a robust system of checks and balances, tasks related to eligibility verification and documentation will be divided among different team members. This separation will prevent any one individual from having full control over the process, reducing the risk of oversight or potential errors. • The WIC Department’s policy and procedure manuals will be revised and updated to include the new eligibility verification process. • To ensure adherence to the new protocols, periodic audits and review sessions will be conducted by the WIC Director or designated compliance staff to verify that documentation is being properly maintained and that all procedures are followed. Staff will be required to undergo refresher training sessions as needed to reinforce the updated protocols and best practices. Responsible Party: Tracy Harrison, COO

View Audit 333283

Finding 515490 (2023-129)

Significant Deficiency 2023

State of Arizona

AZ

Student Financial Aid Eligibility Matching / Level of Effort / Earmarking § 200.303

Cluster Name: Student Financial Assistance Cluster Assistance listing numbers and names: Northern Arizona University 84.007 Federal Supplemental Educational Opportunity Grants 84.033 Federal Work-Study 84.038 Federal Perkins Loan Program—Federal Capital Contributions 84.063 Federal Pell Grant Progra...

Cluster Name: Student Financial Assistance Cluster Assistance listing numbers and names: Northern Arizona University 84.007 Federal Supplemental Educational Opportunity Grants 84.033 Federal Work-Study 84.038 Federal Perkins Loan Program—Federal Capital Contributions 84.063 Federal Pell Grant Programs 84.268 Federal Direct Student Loans 84.379 Teacher Education Assistance for College and Higher Education Grants (TEACH Grants) 93.364 Nursing Student Loans 93.925 Scholarships for Health Professions Students from Disadvantaged Backgrounds—Scholarships for Disadvantaged Students (SDS) Agency: Northern Arizona University (NAU) Name of contract person and title: Bradley Miner, NAU Associate Vice President and Comptroller Anticipated Completion Date June 30, 2024 Agency’s Response: Concur The University agrees with this finding and although it relies on the Federal agencies for valid identity verification, the University has already taken significant corrective action to proactively monitor and detect fraudulent student identities. The University has various internal controls, system fraud controls, and integrity measures in place as required or identified as industry best-practice to mitigate and prevent the increasing sophistication of fraudulent activity. In academic year 2023 the University had 282 online students selected for Verification by the Department of Education (ED). The 8 isolated fraud instances were the only identified fraud cases. The University receives valid identity verification checks from the Department of Education (ED) as an input for creating student profiles. Additionally, the University works with administrative agencies and leverages FAFSA checks conducted by Social Security Administration (SSA), Department of Veteran Affairs (VA), Department of Homeland Security (DHS), National Student Loan Data System (NSLDS), Department of Defense (DOD), Department of Justice (DOJ). Financial Aid does not disburse until enrollment verification is complete. 1. The University has reviewed prior fiscal years to determine if additional fraudulently enrolled students received student financial assistance, and if fraudulent loans and awards were awarded. The University conducted an in-depth analysis of multiple qualitative attributes of students receiving financial assistance. This analysis identified high risk students receiving loans and awards. Students in this population were required to complete V4 verification. 2. The University implemented anti-fraud measures as an alternative to automated student Internet Protocol (IP) verification. During the analysis to identify fraudulently enrolled students, the University identified programs at high-risk for fraudulent activity. As a proactive fraudulent activity identification measure, the University will require all students in high-risk programs, with active FAFSAs to submit and complete V4 identity verification. This anti-fraud measure will identify fraudulently enrolled students prior to the disbursement of student financial assistance including loans and awards. 3. The University has put in to place a number of additional verification measures and detective controls to validate online student identities and check for repetitive information and trends. The University is conducting feasibility studies to determine if the suggested guidance for Internet Protocol student verification abides by certain security and privacy standards and policies. Additionally, the University has concern with fraudsters ability to mask Internet Protocols by deploying Virtual Private Networks (VPNs). This renders the advanced protocols ineffective. As a compensating control, the University will begin selecting 5% of online students for V4 verification. Random sampling of online students for identity verification provides enhanced detective measures to combat the risk of identity theft for use in financial aid fraud. Additionally, the University put in place several upfront measures to detect repetitive information and trends to identify potentially fraudulent activity. Detective monitoring reporting identifies duplicate deposit information, redundant student email information, and duplicate student address information. The Department will continue to utilize these successful anti-fraud measures to proactively identify fraudulent student identities. 4. The University will continue its efforts working with law enforcement agencies to recover improper payments for fraudulent claims it paid due to identity theft, to the extent practicable. The University worked with law enforcement agencies to investigate the fraud. At the conclusion of the investigation $138,135 has been repaid. The University will continue to partner with federal, state, and local law enforcement agencies and financial institutions across the country to recover losses and aggressively pursue legal action against perpetrators of fraud.

View Audit 333243

Finding 515487 (2023-120)

Significant Deficiency 2023

State of Arizona

AZ

Subrecipient Monitoring Internal Control / Segregation of Duties Student Financial Aid

Assistance listing number and program name: 93.658 Foster Care—Title IV-E 93.658 COVID-19 - Foster Care—Title IV-E Agency: Arizona Department of Child Safety (DCS) Name of contact person and title: Emilio Gonzales, DCS Audit Administrator Anticipated completion date: Fiscal Year 2025 Agency’s Respo...

Assistance listing number and program name: 93.658 Foster Care—Title IV-E 93.658 COVID-19 - Foster Care—Title IV-E Agency: Arizona Department of Child Safety (DCS) Name of contact person and title: Emilio Gonzales, DCS Audit Administrator Anticipated completion date: Fiscal Year 2025 Agency’s Response: Concur The Department will comply with the Federal Funding Accountability and Transparency Act (FFATA) and Federal Uniform Guidance regulations in accordance with the Department’s Grant policies and procedures. As of November 2024, the Department worked with the federal agency to resolve the inability to submit outstanding subaward information prior to January 2024. The FFATA reporting was completed for fiscal years 2024, 2023, 2022 and 2021. The Department will also continue to follow its policies and procedures for reporting subaward actions, as required.

View Audit 333243

Finding 515471 (2023-133)

Significant Deficiency 2023

State of Arizona

AZ

Internal Control / Segregation of Duties Eligibility Reporting

Assistance listing number and program name: 93.778 Medicaid Assistance Program (part of the Medicaid Cluster 93.778 COVID-19 Medicaid Assistance Program Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS Division of B...

Assistance listing number and program name: 93.778 Medicaid Assistance Program (part of the Medicaid Cluster 93.778 COVID-19 Medicaid Assistance Program Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS Division of Budget and Finance Anticipated completion date: December 31, 2024 Agency’s Response: Concur AHCCCS concurs with the finding in this audit and would like to note this finding is related to no notice of disenrollment being mailed to a deceased member, and not related to enrollment ineligibility. AHCCCS Division of Member and Provider Services (“DMPS”) will identify the standard process for notification that should have been followed for this case. Once the root cause of the issue has been established, AHCCCS will assess current processes and procedures, as appropriate, to address this issue.

View Audit 333243

Finding 515470 (2023-132)

Material Weakness 2023

State of Arizona

AZ

Questioned Costs Special Tests & Provisions Material Weakness

Assistance listing number and program name: 93.778 Medicaid Assistance Program (part of the Medicaid Cluster 93.778 COVID-19 Medicaid Assistance Program Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS Division of B...

Assistance listing number and program name: 93.778 Medicaid Assistance Program (part of the Medicaid Cluster 93.778 COVID-19 Medicaid Assistance Program Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS Division of Budget and Finance Anticipated completion date: December 31, 2024 Agency’s Response: Concur AHCCCS concurs with the finding and would like to note this matter was discovered through internal review of OIG recoupment documentation and filings with CMS. This matter was reviewed in detail by our financial management team and AHCCCS determined this was caused by a few factors: (1) staffing issues and employee turnover in all units involved in the process to return OIG recoupments to CMS. (2) A breakdown of inter and intra-departmental communication and collaboration. Efforts to eliminate this from occurring in the future include recently filling the related following positions that experienced turnover: Accounting Supervisor, Reporting Administrator, and 2 Accounting Specialists. In addition, AHCCCS has increased collaboration across the respective departments and divisions to ensure the federal share of all case recoupments is timely returned to CMS. Further, we have revised our standard work processes to include monthly reconciliations of case recoupments among the various departments and divisions. AHCCCS anticipates to have returned the federal share to CMS for all case recoupments identified by December 31, 2024.

View Audit 333243 Questioned Costs: $1

Finding 515469 (2023-131)

Material Weakness 2023

State of Arizona

AZ

Questioned Costs Special Tests & Provisions Material Weakness

Assistance listing number and program name: 93.778 Medicaid Assistance Program (part of the Medicaid Cluster 93.778 COVID-19 Medicaid Assistance Program Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact persons and titles: Vanessa Templeman, Inspector General, AHCCCS Offic...

Assistance listing number and program name: 93.778 Medicaid Assistance Program (part of the Medicaid Cluster 93.778 COVID-19 Medicaid Assistance Program Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact persons and titles: Vanessa Templeman, Inspector General, AHCCCS Office of Inspector General; Jeff Tegen, Assistant Director, AHCCCS Division of Budget and Finance Anticipated completion date: December 31, 2024 Agency’s Response: Concur AHCCCS OIG agrees with the finding as stated above. AHCCCS OIG commits to a review of the current Deferred Process and will determine areas of improvement to include; timelines for deferred case review completion, quarterly completed deferred case review reports, and required documentation for all deferred case processes.

View Audit 333243 Questioned Costs: $1

Finding 515468 (2023-130)

Material Weakness 2023

State of Arizona

AZ

Questioned Costs Special Tests & Provisions Procurement, Suspension & Debarment

Assistance listing number and program name: 93.778 Medicaid Assistance Program (part of the Medicaid Cluster 93.778 COVID-19 Medicaid Assistance Program Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS Division of B...

Assistance listing number and program name: 93.778 Medicaid Assistance Program (part of the Medicaid Cluster 93.778 COVID-19 Medicaid Assistance Program Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS Division of Budget and Finance Anticipated completion date: December 31, 2024 Agency’s Response: Concur In May 2023, AHCCCS announced its initial findings of credible and willful fraud by sober-living providers across the state. Since then, AHCCCS has suspended more than 300 providers, assisted over 10,000 individuals with the humanitarian response, and implemented more than 20 new initiates to combat fraud, waste, and abuse in the Medicaid program. As the extent of the fraud was revealed, AHCCCS recognized the need for holistic and systemwide changes. AHCCCS partnered with the Attorney General and Governor’s Office to develop a comprehensive plan to address the loopholes fraudulent providers were exploiting. Stop gap strategies implemented include, but may not limited to the following: · Increased scrutiny of claims based on claims volume. · Issued a moratorium on new provider registrations for impacted provider types · Prevented Reimbursement of Claims for Impossibly Rendered Services · Claims for Substance Abuse Services for Children under the age of 12 to Require Clinical Review Prior to Payment · Set thresholds for services to initiate a prepayment review. · Required claims to be billed for specific dates of service rather than ranges. · Flagged claims for services of the same style/overlapping codes. · Created a prepayment review process for providers utilizing suspicious billing practices. · Eliminated retroactive billing. · Credible Allegation of Fraud (“CAF”) suspensions include both provider entities and owners/ behavioral health (“BH”) practitioners. · Implemented ID.Me identity verification for AHCCCS Online. · Required providers to disclose any third-party billing relationships. · Behavioral Health Providers are now considered high-risk provider types for provider enrollment. · Per Diem codes have been set to only be able to be billed once per day. · Practitioners, including Behavioral Health Technicians, can no longer be patients at the same provider. · Worked with the Arizona Corporation Commission to flag suspicious registrations. · Ensured AHCCCS coding adhered to National Correct Coding Initiative (“NCCI”) standards and confirmed no edits had been turned off. · Streamlined AHCCCS reporting of bad actors to the appropriate professional oversight boards. Stop gap strategies in process include, but may not be limited to, the following: · Implementing eligibility integrity requirements for AIHP enrollment. · Linking BHP to BH companies they work for. · Link BH Providers to BH facilities they work at. · Conduct onsite quality of care reviews for patients in treatment longer than 90 days. · Require medical records to define specialized services. · Implement a new pre/post pay claims system. · Mandatory transition to Electronic Fund Transfer (direct deposit) for all AHCCCS provider reimbursements. AHCCCS continues to investigate and identify areas of concern and implement necessary system improvements until it is determined that the integrity of the AHCCCS provider network is restored.

View Audit 333243 Questioned Costs: $1

Finding 515369 (2023-127)

Material Weakness 2023

State of Arizona

AZ

Allowable Costs / Cost Principles Cash Management Reporting § 200.301 § 200.302 § 200.303

Assistance listing numbers and program names: 84.425D COVID-19 - Education Stabilization Fund—Elementary and Secondary School Emergency Relief (ESSER) Fund 84.425R COVID-19 - Coronavirus Response and Relief Supplemental Appropriations Act, 2021 – Emergency Assistance to Non-Public Schools (CRSSA EAN...

Assistance listing numbers and program names: 84.425D COVID-19 - Education Stabilization Fund—Elementary and Secondary School Emergency Relief (ESSER) Fund 84.425R COVID-19 - Coronavirus Response and Relief Supplemental Appropriations Act, 2021 – Emergency Assistance to Non-Public Schools (CRSSA EANS) Agency: Arizona Department of Education (ADE) Name of contact persons and titles: Michelle Udall, ADE Associate Superintendent Dr. Sarka White, ADE Deputy Associate Superintendent Anticipated completion date: November 30, 2024 Agency’s response: Concur ESSER Reporting will be validated by at least 2 people before submitting to U.S. Department of Education. This validation will include the reconciliation of data from the LEA to ADE's report. ADE is finalizing policies and procedures for validating the data prior to submission. ADE has already begun implementing a reconciliation system to ensure accurate reporting in the EANS annual performance report. This system tracks obligations by category, expenses, and appropriate earmarking of nonpublic schools (e.g., DUNS/UEI, grades served). ADE is finalizing general policies and procedures for how this data is compiled, interpreted, and reported based on the initial implementation and corrections of the EANS program.

View Audit 333243

Finding 515348 (2023-126)

Material Weakness 2023

State of Arizona

AZ

Reporting Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303

Assistance listing number and program name: 84.010 Title I Grants to Local Educational Agencies 84.367 Supporting Effective Instruction State Grants (formerly Improving Teacher Quality State Grants) 84.425D COVID-19 - Education Stabilization Fund-Elementary and Secondary School Emergency Relief (ESS...

Assistance listing number and program name: 84.010 Title I Grants to Local Educational Agencies 84.367 Supporting Effective Instruction State Grants (formerly Improving Teacher Quality State Grants) 84.425D COVID-19 - Education Stabilization Fund-Elementary and Secondary School Emergency Relief (ESSER) Fund 84.425U COVID-19 - Education Stabilization Fund - American Rescue Plan - Elementary and Secondary Schools Emergency Relief (ARP ESSER) Fund Agency: Arizona Department of Education (ADE) Name of contact persons and titles: Nicole Von Prisk, ADE Deputy Associate Superintendent of Grants Management Matt McClary, ADE Compliance Officer Anticipated completion date: October 30, 2024 Agency’s response: Concur Arizona Department of Education has worked in cooperation with our vendor to correct outdated SQL queries that were identified and returning only approved grant award amounts rather than all awarded amounts, regardless of approval status. We will ensure that the original award amounts are being queried and, in return, reported within the FFATA Subaward Reporting System (FSRS). Additionally, through the reconciliation process each month, correct award amounts will align with corresponding Federal Award Identification Number (FAIN). We have implemented an automated monthly reporting workflow/schedule which will help ensure required FFATA reporting is submitted timely. This process automation helps prompt monthly FFATA reporting uploads by leveraging office tools that are readily available and ensures monthly upload deadlines are met by automatically scheduling the task and requiring follow-up by the assignee. In January of 2024 the staff assigned to FFATA uploads changed again (for the fourth time in a year) and at that point a new staff member assumed responsibility for FFATA uploads. As numerous corrections needed were discovered through the reconciliation process, new reports were uploaded. Some of these were original uploads for entities that were missing FSRS information altogether and some were corrections to previously uploaded yet incorrect information. With each monthly upload, a new date was being captured and while some of the information was new entity award information, not all of the information being updated was untimely. This has been a long and arduous process, and we look forward to not having continued FFATA findings, as we are making progress to correcting award information for all federal grants moving forward from this point. Our Compliance Officer reconciles the current FSRS award information monthly with our Lead Grants Coordinator or our Deputy Associate Superintendent. Any missing or duplicate information is corrected prior to the FSRS upload.

View Audit 333243

Corrective Action Plans

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