Corrective Action Plans

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Corrective Action Plan: The District has implemented financial policies and procedures to ensure a timely independent audit process and subsequent timely filing of the audit with the Federal Audit Clearinghouse.
Corrective Action Plan: The District has implemented financial policies and procedures to ensure a timely independent audit process and subsequent timely filing of the audit with the Federal Audit Clearinghouse.
Corrective action plan includes more thorough monitoring on the part of executive director and program director to periodically and regularly monitor and assess that the required two-thirds of recipients meet the requirements for being first generation college attendees and come from low income fami...
Corrective action plan includes more thorough monitoring on the part of executive director and program director to periodically and regularly monitor and assess that the required two-thirds of recipients meet the requirements for being first generation college attendees and come from low income families.
FINDING 2023-010 Finding Subject: ESSER (Education Stabilization Fund) – Allowable Activities, Allowable Costs/Cost Principles Federal Programs: Education Stabilization Fund Summary of Finding: An effective internal control system, which would include segregation of duties, was not in place at the S...
FINDING 2023-010 Finding Subject: ESSER (Education Stabilization Fund) – Allowable Activities, Allowable Costs/Cost Principles Federal Programs: Education Stabilization Fund Summary of Finding: An effective internal control system, which would include segregation of duties, was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Activities Allowed and Allowable Costs/Cost Principles compliance requirement. The School Corporation did not have internal controls in place over payroll disbursements. A detailed report of payroll disbursements paid without evidence of review and approval by a knowledgeable person. Contact Person Responsible for Corrective Action: Amy K. Sivley Contact Phone Number and Email Address: 260-563-2151; sivleya@apaches.k12.in.us Views of Responsible Officials: We concur with the finding. Explanation and Reasons for Disagreement: n/a Description of Corrective Action Plan: Develop process and procedures for verifying payroll disbursements from grant funds. On a monthly basis, Payroll coordinator will print payroll disbursements from federal grant funds to be reviewed, verified and signed off by Superintendent/CFO. Anticipated Completion Date: To begin immediately, March 2024
FINDING 2023-007 Finding Subject: Special Education Cluster - Equipment and Real Property Management Summary of Finding: The School Corporation had not properly designed or implemented a system of internal controls, which would include appropriate segregation of duties, that would likely be effectiv...
FINDING 2023-007 Finding Subject: Special Education Cluster - Equipment and Real Property Management Summary of Finding: The School Corporation had not properly designed or implemented a system of internal controls, which would include appropriate segregation of duties, that would likely be effective in preventing, or detecting and correcting, noncompliance. A property record or capital asset listing which would include a description of the property, a serial number or other identification number, the source of funding for the property (including the federal award identification number (FAIN)), who holds title, the acquisition date, cost of the property, percentage of federal participation in the project costs for the federal award under which the property was acquired, the location, and use and condition of the property is to be maintained for assets purchased that exceed the School Corporation's capitalization threshold. The School Corporation purchased on piece of equipment in the amount of $75,387 with Special Education Funds. The listing did not include all the required elements for the one piece of equipment purchased. The required elements are the description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. The lack of internal controls and noncompliance were systemic issues throughout the audit period. Contact Person Responsible for Corrective Action: Amy K. Sivley Contact Phone Number and Email Address: 260-563-2151; sivleya@apaches.k12.in.us Views of Responsible Officials: We concur with the finding. Explanation and Reasons for Disagreement: n/a Description of Corrective Action Plan: Develop processes and procedures to ensure that purchases made with federal dollars are correctly recorded on capital asset ledger. Anticipated Completion Date: To begin immediately, March 2024
FINDING 2023-006 Finding Subject: Special Education Cluster - Activities Allowed, Allowable Costs/Cost Principles, Period of Performance Summary of Finding: An effective internal control system, which would include segregation of duties, was not in place at the School Corporation in order to ensure ...
FINDING 2023-006 Finding Subject: Special Education Cluster - Activities Allowed, Allowable Costs/Cost Principles, Period of Performance Summary of Finding: An effective internal control system, which would include segregation of duties, was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Activities Allowed, Allowable Costs/Cost Principles, and Period of Performance compliance requirements. The School Corporation did not have internal controls in place over payroll disbursements. A detailed report of payroll disbursements was paid without evidence of review and approval by a knowledgeable person. Contact Person Responsible for Corrective Action: Amy K. Sivley Contact Phone Number and Email Address: 260-563-2151; sivleya@apaches.k12.in.us Views of Responsible Officials: We concur with the finding. Explanation and Reasons for Disagreement: n/a Description of Corrective Action Plan: Develop process and procedures for verifying disbursements from grant funds. On a monthly basis, Corporation Treasure will print expenditure report from federal grant funds to be reviewed, verified and signed off by Superintendent/CFO. Anticipated Completion Date: To begin immediately, March 2024
FINDING 2023-005 Finding Subject: Child Nutrition Cluster - Special Tests & Provisions: School Food Service Accounts Summary of Finding: The School Corporation had not properly designed or implemented a system of internal controls, which would include appropriate segregation of duties, that would li...
FINDING 2023-005 Finding Subject: Child Nutrition Cluster - Special Tests & Provisions: School Food Service Accounts Summary of Finding: The School Corporation had not properly designed or implemented a system of internal controls, which would include appropriate segregation of duties, that would likely be effective in preventing, or detecting and correcting, noncompliance for Special Tests & Provisions: School Food Service Accounts. Contact Person Responsible for Corrective Action: Amy K. Sivley Contact Phone Number and Email Address: 260-563-2151; sivleya@apaches.k12.in.us Views of Responsible Officials: We concur with the finding. Explanation and Reasons for Disagreement: n/a Description of Corrective Action Plan: On a monthly basis, Corporation Treasure will print receipt postings to be reviewed, verified and signed off by Superintendent/CFO. Anticipated Completion Date: To begin immediately, March 2024
CONTACT PERSON RESPONSIBLE FOR CORRECTIVE ACTION: Gabrielle Krol, Business Manager CORRECTIVE ACTION PLAN (concerning finding 2023-001: Special Tests and Provisions-Wage Rate Requirements) CORRECTIVE ACTION: Maine School Administrative District 52 has already begun implementing the corrective ac...
CONTACT PERSON RESPONSIBLE FOR CORRECTIVE ACTION: Gabrielle Krol, Business Manager CORRECTIVE ACTION PLAN (concerning finding 2023-001: Special Tests and Provisions-Wage Rate Requirements) CORRECTIVE ACTION: Maine School Administrative District 52 has already begun implementing the corrective action plan for the finding related to the Education Stabilization Fund. Our FY 2022 Audit was not completed until April 2023, which was after this current finding had already taken place. During the FY 2022 Audit process, it was brought to our attention that MSAD 52 was in need of ensuring compliance with the prevailing wage requirements when Federal Funds were being used, also known as the Davis Bacon Act. When this was brought to our attention, we began providing all contractors who were bidding on work at the district with the current prevailing wage information for Androscoggin County. In addition, we had each contractor sign the certification that they would pay all employees working on any project at MSAD 52 the prevailing wage. In addition, we are now requiring all contractors provide certified timesheets prior to releasing payment for the work. ANTICIPATED COMPLETION DATE: This has begun effective March 2024.
Finding Number 2023-226: The Department did not develop and execute a Value Engineering work plan in compliance with the regulations for the federal Highway Planning and Construction grant. Federal Programs: 20.205 – Highway Planning and Construction Grant Related to Prior Finding: N/A Agency’s ...
Finding Number 2023-226: The Department did not develop and execute a Value Engineering work plan in compliance with the regulations for the federal Highway Planning and Construction grant. Federal Programs: 20.205 – Highway Planning and Construction Grant Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: ITD will develop a new standard operating procedure (SOP) to follow to ensure that the Districts develop an Annual Value Engineering Work Plan and that the Statewide Work Plan is compiled annually by the Headquarters Value Engineering Coordinator. This SOP will be developed in collaboration with FHWA staff to ensure 2 CFR 200.303 and 23 CFR Part 627 compliance. The SOP will include details as to who, what, where and when the specific tasks will occur so to provide clarity and control with regard to developing the work plan as well as monitoring, assessing and reporting on the Departments Value Engineering Program. Anticipated Corrective Action Date: The new SOP will be developed prior to FFY 2025, and statewide outreach and education will follow shortly thereafter. Responsible for Corrective Action: Monica Crider, PE, State Design Engineer Monica.Crider@itd.idaho.gov 208-334-8502
Finding Number 2023-224: The required audited financial reports were not collected as required to ensure compliance with the Managed Care Organization contracts. Federal Programs: 93.777 - State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare; 93.778 Medical A...
Finding Number 2023-224: The required audited financial reports were not collected as required to ensure compliance with the Managed Care Organization contracts. Federal Programs: 93.777 - State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare; 93.778 Medical Assistance Program Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: The Division will amend all current managed care contracts to include the requirement to submit an audited financial report annually. This contract language will also be incorporated into all future Medicaid managed care procurements. The Division will also review and confirm all required contract elements outlined in 42 CFR 438.3 are clearly outlined in Medicaid managed care contracts. Lastly, the Division intends to coordinate with the Department of Insurance to learn more about their review process of audited financial statements and determine if there is an opportunity to coordinate oversight efforts for Medicaid managed care contracts going forward. Anticipated Corrective Action Date: September 2024 Responsible for Corrective Action: Juliet Charron, Division Administrator Juliet.Charron@dhw.idaho.gov 208-364-1831 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814
Finding 390644 (2023-223)
Significant Deficiency 2023
Finding Number 2023-223: Managed Care providers lacked documentation to support continued eligibility within the Medicaid Program. Federal Programs: 93.777 - State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare; 93.778 Medical Assistance Program Related to P...
Finding Number 2023-223: Managed Care providers lacked documentation to support continued eligibility within the Medicaid Program. Federal Programs: 93.777 - State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare; 93.778 Medical Assistance Program Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: The 21st Century Cures Act requires all states to enroll both fee-for-service and managed care providers. Idaho Medicaid is currently out of compliance with this requirement for most of the providers within managed care contractor networks. The state is also working to come into compliance with a requirement in the Affordable Care Act to revalidate all enrolled providers at least every 5 years. The Division has begun the systems work necessary to come into compliance with both of these requirements and anticipates working through enrollment and revalidation activities into CY2025. Once completed, the Division will have an accurate and complete provider file that will be shared with contracted managed care plans to support their contracting efforts. Any providers who contract with the managed care plans will be required to be fully enrolled and credentialed with Idaho Medicaid before rendering services and billing. Pursuant to the Consolidated Appropriations Act of 2023, states are required by July 2025 to have a searchable and regularly updated provider directory for both managed care plans and fee-for-service programs. Idaho Medicaid is working to develop processes to validate directories and ensure that providers are providing updates to their information as necessary. Through this effort, Idaho Medicaid will further bolster internal processes and controls to ensure accurate provider network information is shared with Medicaid participants and maintained within our systems. Anticipated Corrective Action Date: July 2025 Responsible for Corrective Action: Juliet Charron, Division Administrator Juliet.Charron@dhw.idaho.gov 208-364-1831 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814
Finding 390642 (2023-221)
Significant Deficiency 2023
Finding Number 2023-221: The Department did not review subrecipient application information for the Coronavirus State and Local Fiscal Recovery Funds at a sufficient level to identify missing information. Federal Programs: 21.027 – Coronavirus State and Local Fiscal Recovery Fund Related to Prior ...
Finding Number 2023-221: The Department did not review subrecipient application information for the Coronavirus State and Local Fiscal Recovery Funds at a sufficient level to identify missing information. Federal Programs: 21.027 – Coronavirus State and Local Fiscal Recovery Fund Related to Prior Finding: 2022-210 Agency’s view: The Department agrees with this finding. Corrective Action: The Division of Public Health and Idaho Council on Domestic Violence and Victim Assistance (ICDVVA) will take steps to ensure new staff receive training related to awarding grants, to include components on appropriate internal controls, identifying required grant elements, detailing the grant process, and outlining record retention requirements. All current employees have been trained as of March 2024. All newly hired employees will be trained beginning April 2024. Anticipated Corrective Action Date: April 2024 Responsible for Corrective Action: Elke Shaw-Tulloch, Division Administrator Division of Public Health Elke.Shaw-Tulloch@dhw.idaho.gov 208-354-5950 Dana Wiemiller, Executive Director ICDVVA Dana.Wiemiller@icdv.idaho.gov 208-332-1545 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814
Finding Number 2023-217: The Department does not have documented internal controls for adjustments processed to the Foster Care -Title IV—E program. Federal Programs: 93.658 – Foster Care Title IV-E Related to Prior Finding: N/A Agency’s view: The Office agrees with this finding. Corrective Act...
Finding Number 2023-217: The Department does not have documented internal controls for adjustments processed to the Foster Care -Title IV—E program. Federal Programs: 93.658 – Foster Care Title IV-E Related to Prior Finding: N/A Agency’s view: The Office agrees with this finding. Corrective Action: The Department will continue to record adjustment activity through Help Desk tickets, SharePoint documentation, and ESPI. The Department will ensure improved visibility to the adjustment and approval process and documentation by ensuring all roles who need access (including auditors), have access to all relevant systems and storage locations such as access to SharePoint and Help Desk tickets. This step will be completed by April 30, 2024. Anticipated Corrective Action Date: April 30, 2024 Responsible for Corrective Action: Cameron Gilliland, Division Administrator Cameron.Gilliland@dhw.idaho.gov 208-334-0641 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814
Finding Number 2023-216: The Department did not have appropriate documentation to support allowability of transactions for the Foster Care Title IV-E program. Federal Programs: 93.658 – Foster Care Title IV-E Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. ...
Finding Number 2023-216: The Department did not have appropriate documentation to support allowability of transactions for the Foster Care Title IV-E program. Federal Programs: 93.658 – Foster Care Title IV-E Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: A new feature was added to ESPI on 1/9/24 to record the reason (purpose) for certain service types, including transportation. The system is programmed to disallow Title IV-E if the reason listed does not meet IV-E eligibility criteria (see image below). An additional control will be added to the system to have the same control procedure used for a medical service type and education service type. Further development is underway for additional control procedures and should be completed by April of 2025. P-card transactions do not process through ESPI. Quarterly reports will be obtained to review any P-card transactions that utilized Title IV-E to confirm appropriate documentation is on record. This will be completed by April 30, 2024. Anticipated Corrective Action Date: April 30, 2024 Responsible for Corrective Action: Cameron Gilliland, Division Administrator Cameron.Gilliland@dhw.idaho.gov 208-334-0641 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814
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Finding Number 2023-215: The Department’s review of child care providers health and safety inspections for the Child Care and Development Fund (CCDF) were not completed timely. Federal Programs: 93.575 – Child Care and Development Block Grant; 93.596 – Child Care Mandatory and Matching Funds of the...
Finding Number 2023-215: The Department’s review of child care providers health and safety inspections for the Child Care and Development Fund (CCDF) were not completed timely. Federal Programs: 93.575 – Child Care and Development Block Grant; 93.596 – Child Care Mandatory and Matching Funds of the Child Care and Development Fund Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: The division will complete reviews of the health and safety inspections in a timely manner. The division will review and update the existing process document to support this corrective action plan defining timeframes for completion of these reviews so that there is appropriate time to remediate issues raised during the inspections and ensure compliance. The updated process document will be in place and appropriate staff will implement by 9/30/2024. Anticipated Corrective Action Date: December 2024 Responsible for Corrective Action: Shane Leach, Division Administrator Shane.Leach@dhw.idaho.gov 208-859-1033 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814
Finding Number 2023-214: The Department did not maintain sufficient documentation to support eligibility award decisions for the Community Partners Grants within the Child Care and Development Fund (CCDF) program. Federal Programs: 93.575 – Child Care and Development Block Grant; 93.596 – Child Car...
Finding Number 2023-214: The Department did not maintain sufficient documentation to support eligibility award decisions for the Community Partners Grants within the Child Care and Development Fund (CCDF) program. Federal Programs: 93.575 – Child Care and Development Block Grant; 93.596 – Child Care Mandatory and Matching Funds of the Child Care and Development Fund Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: The division will: • All employees who administer grants will be required to complete training related to awarding grants, to include components on appropriate internal controls, identifying required grant elements, detailing the grant process, and outlining record retention requirements. All current employees have been trained as of March 2024. • The Division will work closely with the Division of Management Services to support the development and implementation of updated record retention policies and processes which will result in relevant documents being centrally retained. Estimated completion date December 31, 2024. Between now and when that central repository is available, individual rubrics and their supporting documents related to grant awards will be retained. • All employees will complete an annual employee conflict-of-interest disclosure and recertification process. Current completion of the new employee conflict of interest from will be completed by April 2024. Anticipated Corrective Action Date: December 2024 Responsible for Corrective Action: Shane Leach, Division Administrator Shane.Leach@dhw.idaho.gov 208-859-1033 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814
Finding Number 2023-212: The review of the Low-Income Home Energy Assistance Program (LIHEAP) earmarking compliance requirements was not documented. Federal Programs: 93.568 – Low-Income Home Energy Assistance Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. ...
Finding Number 2023-212: The review of the Low-Income Home Energy Assistance Program (LIHEAP) earmarking compliance requirements was not documented. Federal Programs: 93.568 – Low-Income Home Energy Assistance Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: The Program will document the current process regarding the preparation, review, and approval of the Low-Income Home Energy Assistance Program (LIHEAP) budget that includes maintaining the documentation of the earmarking reviews that are being completed. The program will prepare the Low-Income Home Energy Assistance Program (LIHEAP) budget. This budget will be submitted to the Bureau Chief, as a second review of accuracy and compliance, to include review of earmarking limits, prior to routing the Annual State Plan for review and submittal or the allocation of any funding. Documentation will be maintained to support the review and approval. Anticipated Corrective Action Date: The Program will write a process document to support this corrective action and will implement this process prior to the start of the new LIHEAP season beginning 10/1/2024. Program will have a process document in place by 9/30/24. Responsible for Corrective Action: Shane Leach, Division Administrator Shane.Leach@dhw.idaho.gov 208-859-1033 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814
Finding 390628 (2023-211)
Significant Deficiency 2023
Finding Number 2023-211: The review and approval of the annual updates to the Low-Income Home Energy Assistance Program (LIHEAP) benefits matrix were not documented. Federal Programs: 93.568 – Low-Income Home Energy Assistance Related to Prior Finding: N/A Agency’s view: The Department agrees wit...
Finding Number 2023-211: The review and approval of the annual updates to the Low-Income Home Energy Assistance Program (LIHEAP) benefits matrix were not documented. Federal Programs: 93.568 – Low-Income Home Energy Assistance Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: Testing of the updated benefits matrix will be completed by the Program annually, and the results will be documented using an established scenario testing script. Results of the testing will be documented and submitted to the Bureau Chief, as a second review of accuracy and compliance, prior to moving the updated matrix into the production environment. Documentation will be maintained to support the review and approval. Anticipated Corrective Action Date: The Program will write a process document to support this corrective action and will implement this process prior to the start of the new LIHEAP season beginning 10/1/2024. Program will have a process document in place by 9/30/24. Responsible for Corrective Action: Shane Leach, Division Administrator Shane.Leach@dhw.idaho.gov 208-859-1033 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814
Finding Number 2023-210: Low-Income Home Energy Assistance Program (LIHEAP) performance and special reports did not include a review for accuracy and compliance prior to submission. Federal Programs: 93.568 – Low-Income Home Energy Assistance Related to Prior Finding: N/A Agency’s view: The Depar...
Finding Number 2023-210: Low-Income Home Energy Assistance Program (LIHEAP) performance and special reports did not include a review for accuracy and compliance prior to submission. Federal Programs: 93.568 – Low-Income Home Energy Assistance Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: The Program will develop a process to work with the Information Management and Analysis Team (IMAT) within the division to compile the data for the Low-Income Home Energy Assistance Program (LIHEAP) reports. Program will review the completed reports for accuracy. All reports will then be submitted to the Bureau Chief, as a second review of accuracy, prior to submission to Federal Partners. Documentation will be maintained to support the preparation, review, and approval steps. The process outlines a timeline to have reports prepared and reviewed ahead of the established deadline. Program will communicate with our Federal Partner if circumstances arise that would prevent a report from being submitted by an established deadline to receive an extension. Anticipated Corrective Action Date: The Program has already implemented the involvement of IMAT and secondary review and approval processes. Program will write a process document to support the corrective action. The documented process will be in place by April 15th, 2024. Responsible for Corrective Action: Shane Leach, Division Administrator Shane.Leach@dhw.idaho.gov 208-859-1033 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814
Finding 390612 (2023-209)
Significant Deficiency 2023
Finding Number 2023-209: Monthly cost allocation statistics, used to allocate indirect costs to federal grants, were not reviewed and approved by the Department. Federal Programs: 10.551 - Supplemental Nutrition Assistance Program (SNAP) 10.561 - State Administrative Matching Grants for the Suppl...
Finding Number 2023-209: Monthly cost allocation statistics, used to allocate indirect costs to federal grants, were not reviewed and approved by the Department. Federal Programs: 10.551 - Supplemental Nutrition Assistance Program (SNAP) 10.561 - State Administrative Matching Grants for the Supplemental Nutrition Assistance Program (SNAP) 21.027 - Coronavirus State and Local Fiscal Recovery Funds 93.391 - Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crises 93.558 - Temporary Assistance for Needy Families (TANF) 93.568 - Low-Income Home Energy Assistance 93.569 – Adoption Assistance 93.575 - Child Care and Development Block Grant (CCDF 93.658 - Foster Care Title IV-E 93.777 - State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare 93.778 - Medical Assistance Program Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: With the implementation of Luma and the interfaced cost allocation module, finance has spent a significant amount of time assessing the best practices for cost allocation processing steps. Since going live on 7/1/23, each month, finance has reviewed, revised, and refined process steps. The department’s budget analysts who hold oversight of some cost allocation processes, use a spreadsheet to track processing. Finance has added a step in the process to ensure that finance reviews the cost allocation SharePoint site for review and signature of each supervisor responsible for each statistic. Anticipated Corrective Action Date: March 1, 2024 Responsible for Corrective Action: Staci Phelan, Division Administrator Staci.Phelan@dhw.idaho.gov 208-334-0632 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814
Finding 390599 (2023-208)
Significant Deficiency 2023
Finding Number 2023-208: The Schedule of Expenditures of Federal Awards (SEFA) closing package originally submitted to the Office of the State Controller (Office) included multiple errors. Federal Programs: 10.551 - Supplemental Nutrition Assistance Program (SNAP) 10.561 - State Administrative Mat...
Finding Number 2023-208: The Schedule of Expenditures of Federal Awards (SEFA) closing package originally submitted to the Office of the State Controller (Office) included multiple errors. Federal Programs: 10.551 - Supplemental Nutrition Assistance Program (SNAP) 10.561 - State Administrative Matching Grants for the Supplemental Nutrition Assistance Program (SNAP) 21.027 - Coronavirus State and Local Fiscal Recovery Funds 93.391 - Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crises 93.558 - Temporary Assistance for Needy Families (TANF) 93.568 - Low-Income Home Energy Assistance 93.569 – Adoption Assistance 93.575 - Child Care and Development Block Grant (CCDF 93.658 - Foster Care Title IV-E 93.777 - State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare 93.778 - Medical Assistance Program Related to Prior Finding: 2022-211; 2021-206 Agency’s view: The Department agrees with this finding. Corrective Action: Since the implementation of LUMA, the department has been cognizant of the systematic challenges and risks and is acutely attentive to monitoring and review efforts. For example, due to LUMA, finance now has a new chart of accounts structure, meaning previously used reports for compilation of the SEFA are no longer a concern. The department held a required training on March 12-13, 2024, for all employees involved with grant administration where the determination of contractor vs. subrecipient, as well as proper account coding, were reiterated. Finance has efforts underway to strengthen compliance through report building and monthly monitoring of proper coding. The department will be moving forward with the implementation of Grant Management Software in SFY25, which finance believes will provide further assurances of data accuracy. Finance will confirm all expenditures and adjustments are completed before running reports when preparing the SFY24 and future SEFA’s. This confirmation will be documented via an email to the Financial Manager of the Budget section. The email response will be retained with the SEFA preparation file for audit purposes. Anticipated Corrective Action Date: Partial efforts already completed; full completion by June 30, 2025. Responsible for Corrective Action: Staci Phelan, Division Administrator Staci.Phelan@dhw.idaho.gov 208-334-0632 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814
Finding 390588 (2023-205)
Significant Deficiency 2023
Finding Number 2023-205: The Department understated total federal expenditures on the Schedule of Expenditures of Federal Awards (SEFA) closing package by $24,824,862 and understated amounts passed through to subrecipients by $39,901,202. Federal Programs: 21.027 - Coronavirus State and Local Fisca...
Finding Number 2023-205: The Department understated total federal expenditures on the Schedule of Expenditures of Federal Awards (SEFA) closing package by $24,824,862 and understated amounts passed through to subrecipients by $39,901,202. Federal Programs: 21.027 - Coronavirus State and Local Fiscal Recovery Funds; 66.458 - Clean Water State Revolving Fund; 66.468 - Drinking Water State Revolving Fund; 66.419 - Water Pollution Control State, Interstate, and Tribal Program Support; 66.432 - State Public Water System Supervision; 66.460 - Nonpoint Source Implementation Grants; 66.708 - Pollution Prevention Grants; 66.040 - Diesel Emissions Reduction Act State Grants; 81.214 - Environmental Monitoring/Cleanup, Cultural and Resource Management, Emergency Response Research, Outreach, Technical Analysis Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: 1. Identify Root Causes: With the aid of LSO, we identified errors and are acting on a thorough analysis to pinpoint the root causes of the reporting errors on the Schedule of Expenditures of Federal Awards (SEFA) identified during the recent audit. As noted by the auditors, the errors were due to significant turnover-related knowledge gaps, staff being tasked with unfamiliar processes, lack of written desk manuals and other documentation, and issues with maintaining the internal reporting tool. This identification was completed by Rob Sepich, Chief Financial Officer, and Jeri Ann Fogg, Accounting Supervisor, in tandem with the audit. 2. Implement Training and Guidance: DEQ will provide comprehensive training sessions for staff involved in preparing and reviewing SEFA reports, considering the high turnover rate experienced in the department. We are in the process of developing detailed guidelines and documentation outlining SEFA reporting requirements, including specific instructions on categorizing federal awards, allowable expenditures, and reporting formats, to address any knowledge gaps resulting from turnover. As part of the statewide ERP move to LUMA from STARS, staff will utilize new reporting platforms and tools in LUMA to streamline SEFA reporting processes and mitigate potential errors associated with manual data entry or outdated systems. One significant improvement over our legacy reporting will be the use of front-end splits (FES) in LUMA that will automatically split out the state match from the federal component of our expenditures at the time in which they are spent, which was not as clearly defined under STARS. The new accounting system will be clearer to auditors and staff. Rob Sepich, Chief Financial Officer will create reconciliation reports for the SEFA by June 2024, with SEFA reporting compiled and completed in July 2024. 3. Enhance Internal Controls: Moving forward we will significantly strengthen internal controls and review processes to detect and prevent reporting errors in the future, particularly considering the turnover challenges. We anticipate requiring multiple additional review checkpoints and validation procedures within the new reporting platforms to verify the accuracy and completeness of SEFA data that will be reconciled before submission. We will also assign clear responsibilities and designate individuals responsible for overseeing SEFA reporting activities, ensuring continuity and consistency despite turnover and reduce the amount of unfamiliar work given to staff. This will include a review by Doug McRoberts, Grants Manager, Heather Hodges, Principal Budget Analyst, Rob Sepich, Chief Financial Officer, and Jeri Ann Fogg, Accounting Manager. Lastly, we are in the process of developing improved documentation on the new LUMA processes for our day-to-day operations so that we have up to date and accurate desk manuals should we experience additional turnover. These desk manuals are expected to be completed in June 2024. 4. Conduct Comprehensive Review: As part of the audit, we conducted a comprehensive review of the FY 2023 SEFA reports to identify any additional errors or discrepancies that may have been overlooked, considering the turnover-related knowledge gaps. The department was able to resubmit our SEFA closing package, including the list of sub recipients to the State Controller’s Office and LSO Auditors on March 9th, 2024 due to the efforts of Jeri Ann Fogg, Accounting Manager and Rob Sepich, Chief Financial Officer. 5. Continuous Monitoring and Improvement: We will establish a process for ongoing monitoring and periodic review of SEFA reporting activities, leveraging the capabilities of the new reporting platforms in LUMA to streamline processes and enhance accuracy. This will bring us closer to the work processes that other agencies do through the statewide reporting systems and reduce our dependency on reporting tools developed in-house that are unfamiliar to other state agencies. This should reduce the risk of losing key institutional knowledge during turnover and will make it easier for an employee with experience from another agency to be able to quickly pick up our reporting needs. To foster a culture of continuous improvement and knowledge sharing within the department, we will have additional meetings to encourage collaboration and communication to address SEFA reporting and ensure that we are not missing key input from staff. Anticipated Corrective Action Date: See corrective action above for timeline. Responsible for Corrective Action: Rob Sepich, Chief Financial Officer Rob.Sepich@deq.idaho.gov 208-373-0292
Finding 390586 (2023-204)
Significant Deficiency 2023
Finding Number 2023-204: The Schedule of Expenditures of Federal Awards (SEFA) closing package understated the Education Stabilization Fund - Governor’s Emergency Education Relief (GEER II) by $1,039,753 and overstated the Education Stabilization Fund – Emergency Assistance to Non-Public Schools (EA...
Finding Number 2023-204: The Schedule of Expenditures of Federal Awards (SEFA) closing package understated the Education Stabilization Fund - Governor’s Emergency Education Relief (GEER II) by $1,039,753 and overstated the Education Stabilization Fund – Emergency Assistance to Non-Public Schools (EANS) program by the same amount. Federal Programs: 84.425C – Governor's Emergency Education Relief; 84.425R - Emergency Assistance for Non-Public Schools Related to Prior Finding: 2021-202 Agency’s view: The Board agrees with this finding. Corrective Action: The corrective action is to reclass any GEER II Project transactions in FY 2024 to EANS/GEER II Project. That will ensure there are no GEER II transactions in FY 2024 that would need to be adjusted. This was done on March 21, 2024. Anticipated Corrective Action Date: March 21, 2024 Responsible for Corrective Action: Patrick Coulson, Chief Financial Officer Patrick.coulson@OSBE.idaho.gov 208-332-1563
Finding 390585 (2023-203)
Significant Deficiency 2023
Finding Number 2023-203: The Schedule of Expenditures of Federal Awards (SEFA) closing package originally submitted to the Office of the State Controller did not properly report expenditures for the Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) program. Federal Programs: 21.027 – Coron...
Finding Number 2023-203: The Schedule of Expenditures of Federal Awards (SEFA) closing package originally submitted to the Office of the State Controller did not properly report expenditures for the Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) program. Federal Programs: 21.027 – Coronavirus State and Local Fiscal Recovery Fund Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: After management review the department will improve training and process review of preparation of the SEFA closing package to ensure all amounts are correctly reported. This lack of understanding of the SEFA was due to staff turnover and lack of subject matter experts regarding the SEFA for Fiscal Year 2023. The agency will implement the following to fix this issue: a) Financial Manager (or delegate) expenditure detail report shall include grant fund 344 (ARPA grants), 348 fund (grants), and any additional funds designated by the legislature or agency, for the specific purpose of tracking federal grant funding. b) Once prepared by the Financial Manager (or delegate), review of the SEFA by the Financial Officer for completeness, verifying all required grant federal funds appropriated to the agency are included on the SEFA closing package. c) Financial Manager and Financial Officer meet to review the SEFA for agreement of grant expenditure amounts reported on the SEFA. Anticipated Corrective Action Date: Corrective actions will be implemented for fiscal year 2024 reporting. Responsible for Corrective Action: Cindy, McMackin, Financial Manager CMcmacki@idoc.idaho.gov 208-658-2000
Finding 390581 (2023-202)
Significant Deficiency 2023
Finding Number 2023-202: Closing package submissions and revisions completed prior to the draft of the Schedule of Expenditures of Federal Awards (SEFA) being submitted for audit were not included in the schedule resulting in misstatements. Federal Programs: 21.027 – Coronavirus State and Local Fis...
Finding Number 2023-202: Closing package submissions and revisions completed prior to the draft of the Schedule of Expenditures of Federal Awards (SEFA) being submitted for audit were not included in the schedule resulting in misstatements. Federal Programs: 21.027 – Coronavirus State and Local Fiscal Recovery Fund; 93.778 – Medical Assistance Program; 93.767 – Children’s Health Insurance Program Related to Prior Finding: N/A Agency’s view: The Office agrees with this finding. Corrective Action: An agency submitted a revised SEFA template in November 2023. We inadvertently excluded those revisions from the draft of the SEFA provided for audit. To prevent this error from happening again, we will document each agency that submits a revised SEFA template(s) on our SEFA review checklist. This will require the preparer and reviewer(s) to verify and sign off on changes made to the SEFA master file. Anticipated Corrective Action Date: Errors identified were corrected before issuance of the Single Audit report. Corrective actions will be implemented for fiscal year 2024 reporting. Responsible for Corrective Action: Tiffini LeJeune, Reporting and Review Bureau Chief TLeJeune@sco.idaho.gov 208-334-3100
Finding 2023-001 - Reconciliation of General Ledger Accounts Views of Reponsible Officials and Planned Corrective Action - Management will ensure timely reconciliations of GL accounts are completed and reconciliation reports are submitted with the Financials Statements. The internal controls polic...
Finding 2023-001 - Reconciliation of General Ledger Accounts Views of Reponsible Officials and Planned Corrective Action - Management will ensure timely reconciliations of GL accounts are completed and reconciliation reports are submitted with the Financials Statements. The internal controls policies & procedures manual will  be reviewed to strengthen the internal controls system.
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