Corrective Action Plans

Finding 395690 (2023-001)

Significant Deficiency 2023

OH

HUD Housing Programs Reporting Significant Deficiency

Management acknowledges noncompliance in the current fiscal year and has addressed all of the health and safety issues as of May 19. 2023.

View Audit 305310

Finding 395640 (2023-001)

None 2023

Housing Authority City of Kennewick

WA

Questioned Costs HUD Housing Programs Reporting

Condition and Context: The Housing Authority City of Kennewick's (KHA) audit was performed when the agency was going through a major software accounting conversion. The trial balance conversion had an unexpected delay which caused a delay in submitting financial reports and records to the auditors. ...

Condition and Context: The Housing Authority City of Kennewick's (KHA) audit was performed when the agency was going through a major software accounting conversion. The trial balance conversion had an unexpected delay which caused a delay in submitting financial reports and records to the auditors. The Housing Authority submitted documents requested between the sixth and seventh month after the fiscal year end. Auditors reviewed records submitted on the eighth month after the fiscal year end. This did not allow KHA enough time to upload additional information requested. The audit was not able to be completed by the due date and the report was not submitted to the Federal Clearinghouse which was due nine months after the fiscal year end. Recommendation: The Auditors recommended that the Authority develop a process or a procedure to ensure the preparation year-end financial records and draft financial statements is completed timely to allow sufficient time for the audit of such information to occur prior to all deadlines for audit submission. Plan for Corrective Action: Management addressed the internal control accounting deficiencies by establishing a year-end check list procedure to ensure that the financial statements and records are ready during audit timing. Additionally, now that the software conversion has been completed, management is acquiring a third-party consultant to assist with the accounting reporting settings and clearing up any pending software conversion issues. Actions Taken: KHA is now submitting the audit report to the Federal Clearinghouse as of the date of this report. Management has reached out to a third-party consultant to help clear out pending software issues and to ensure that accounting reports are correct for future audits.

View Audit 305251

Finding 395635 (2023-001)

Significant Deficiency 2023

Community Health Services, Inc.

CT

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Community Health Services, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: December 31, 2023 The findings from the December 31, 2023 schedule of findings and questioned costs are...

Community Health Services, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: December 31, 2023 The findings from the December 31, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS Section Ill- Federal Award Findings and Questioned Costs Health Center Program Cluster, Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), COVID - 19 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), Grants for New and Expanded Services under the Health Center Program and COVID-19 Grants for New and Expanded Services under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 Item 2023-00.1 - Special Tests Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated based on family size and income. Repeat Finding Yes Action Taken The Center implemented internal controls to mitigate the risk of missing sliding fee discount documentation. The creation of this control consisted of designing a report that would identify all sliding fee discount applicants for the specified timeframe, as well as identify whether supporting documentation had been scanned into the patient's electronic health record. The Director of Development, Grants and Outreach or the Director of Finance and Grants Administration reviews all slide applications before they are scanned and entered into the electronic health record and applied to the patient's account. The Center will continue monthly internal auditing procedures where an Eligibility Specialist haphazardly selects slide applications from the previous month to ensure compliance. As a result of the repeated finding, the Center created an excel template that will accurately calculate and feed the slide result in effort to minimize manual calculation errors. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Dianna Kulmacz, CFO at (860) 808-8765.

View Audit 305248

Finding 395631 (2023-001)

Significant Deficiency 2023

Indiana Health Centers, Inc.

IN

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Section Ill- Federal Award Findings and Questioned Costs Health Center Program Cluster, Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), COVID - 19 Health Center Program (Community Health Centers, Migrant Health...

Section Ill- Federal Award Findings and Questioned Costs Health Center Program Cluster, Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), COVID - 19 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), Grants for New and Expanded Services under the Health Center Program and COVID-19 Grants for New and Expanded Services under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 Item 2023-001 - Special Tests Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated based on family size and income. Repeat Finding Yes Action Taken In 2023, IHC implemented each IHC site auditing five accounts per front office staff twice per month that will be reviewed by the Office Manager, Practice Manager, and Director of Operations, with any sliding issues being addressed with the respective front office staff with re education. As this has not resolved all the sliding fee issues, IHC will be implementing two-person verification for sliding fees provided for any eligible IHC patient. The following process will be followed for EVERY patient that presents with Proof of Income (POI). A. When a patient presents to the clinic and provides POI upon checking in or completing an Intake appointment, the Front Office Staff (FOS) will make a copy of the documents provided. B. The FOS will then calculate the income based on the POI provided, showing the work on the copy. C. The FOS will initial the document where the calculations were completed. D. They will then get a second person to verify the calculations were completed correctly and initial the document. E. The initial FOS employee will enter the information into the SFS section of the pt's chart. F. There will be a FOS SFS Two-Person Verification Log to track who verified each patients POI. G. The FOS SFS Two-Person Verification Log will be kept in the LMT Teams file for each site. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Mr. Tracy Nagel, CFO at (317) 576-1335. Sincerely yours, Mr. Tracy Nagel, Chief Financial Officer

View Audit 305245

Finding 395596 (2023-001)

Material Weakness 2023

Southwest Organizing Project

IL

Allowable Costs / Cost Principles Reporting Questioned Costs § 200.100 § 200.510

Finding No. 2023-001 Schedule of Expenditures of Federal Awards Personnel Responsible for Corrective Action: Name: Edith Robles Department: Finance Title: Director of Finance Anticipated Completion Date: June 30, 2024 Corrective Action Plan: An adequate system of internal controls will be put in pla...

Finding No. 2023-001 Schedule of Expenditures of Federal Awards Personnel Responsible for Corrective Action: Name: Edith Robles Department: Finance Title: Director of Finance Anticipated Completion Date: June 30, 2024 Corrective Action Plan: An adequate system of internal controls will be put in place by the end of fiscal year 2024. To ensure SEFA will include accurate assisting listing numbers and accurate inclusion of all federal programs. Allowable and unallowable costs will be reviewed to ensure accurate federal expenditure reporting. Edith Robles will perform an exhaustive review of all grants to close out the fiscal year in preparation for the audit process. In addition to these, SWOP will work with a consultant to provide necessary training of finance personnel.

View Audit 305207

Finding 395578 (2023-002)

Significant Deficiency 2023

The Guthrie Clinic

PA

Internal Control / Segregation of Duties Questioned Costs Reporting § 200.303

Finding 2023-002 Condition/Context The Corporation used the Lost Revenues Reporting Method: Alternative Reasonable Methodology (Option 3) for measuring lost revenues. In the Corporation's Period 4 submission for Robert Packer Hospital, TIN 24-0795463, total lost revenues were incorrectly reported as...

Finding 2023-002 Condition/Context The Corporation used the Lost Revenues Reporting Method: Alternative Reasonable Methodology (Option 3) for measuring lost revenues. In the Corporation's Period 4 submission for Robert Packer Hospital, TIN 24-0795463, total lost revenues were incorrectly reported as $13,011,879, rather than $12,930,176. Total lost revenues available to be used in this reporting period based on the adjusted amount was $7,142,168 on payments in the period of $7,142,168. This is not a statistically valid sample. Corrective Action Plan Corrective Action Planned: The Corporation agrees with the finding. Management increased the level of review over the lost revenue calculations for future reporting periods. Management did not believe that further corrections to the Period 4 report were necessary as the remaining available lost revenues after adjusting for the error were equal to the payments received in the period and there was no further submissions necessary for Robert Parker Hospital. Name(s) of Contact Person(s) Responsible for Corrective Action: Sean Monahan, Corporate Financial Controller and Fran Macafee, VP, CFO – Guthrie Lourdes Hospital. Anticipated Completion Date: September 30, 2023

View Audit 305185

Finding 395577 (2023-001)

Significant Deficiency 2023

The Guthrie Clinic

PA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Cash Management § 200.303

Finding 2023-001 Condition/Context The Corporation’s review process failed to detect errors in the calculation of amounts related to the pay for event program that were applied to the Federal award. Errors were discovered in 8 of the 44 items tested for the pay for event program which would have inc...

Finding 2023-001 Condition/Context The Corporation’s review process failed to detect errors in the calculation of amounts related to the pay for event program that were applied to the Federal award. Errors were discovered in 8 of the 44 items tested for the pay for event program which would have increased the allowable costs eligible for reimbursement under the Federal award by $671. This is not a statistically valid sample. Corrective Action Plan Corrective Action Planned: The Corporation agrees with the finding. Management implemented an enhanced review process to validate all amounts reported on the PRF Reporting Portal Submission, and to ensure compliance with existing policies and terms and conditions of the Provider Relief Funds. Further action was not considered necessary as the errors would result in increased costs eligible for reimbursement under the Federal award and no further funding is available. Name(s) of Contact Person(s) Responsible for Corrective Action: Kristen Maffei, Manager – Nursing Administration, Sean Monahan, Corporate Financial Controller and Fran Macafee, VP, CFO – Guthrie Lourdes Hospital. Kristen Maffei, Manager – Nursing Administration, Sean Monahan, Corporate Financial Controller and Fran Macafee, VP, CFO – Guthrie Lourdes Hospital. Anticipated Completion Date: This was corrected as of June 30, 2023, and the pay for event program was phased-out after the final Provider Relief Funds were released.

View Audit 305185

Finding 395527 (2023-003)

Material Weakness 2023

Denver City Independent School District

TX

Internal Control / Segregation of Duties Subrecipient Monitoring

The person responsible for corrective action is Rick Martinez, Superintendent. Procedures have been implemented to assure the District has no significant deficiencies in internal controls or noncompliance in the future. The District has hired new personnel in key areas and have sought outside help f...

The person responsible for corrective action is Rick Martinez, Superintendent. Procedures have been implemented to assure the District has no significant deficiencies in internal controls or noncompliance in the future. The District has hired new personnel in key areas and have sought outside help from the Region Service Center. 79

View Audit 305182

Finding 395526 (2023-002)

Material Weakness 2023

Denver City Independent School District

TX

Internal Control / Segregation of Duties

The person responsible for corrective action is Rick Martinez, Superintendent. Procedures have been implemented to assure the District has no significant deficiencies in internal controls or noncompliance in the future. The District has hired new personnel in key areas and have sought outside help f...

The person responsible for corrective action is Rick Martinez, Superintendent. Procedures have been implemented to assure the District has no significant deficiencies in internal controls or noncompliance in the future. The District has hired new personnel in key areas and have sought outside help from the Region Service Center. 79

View Audit 305182

Finding 395525 (2023-002)

Significant Deficiency 2023

Universidad Teologica Del Caribe, Inc.

PR

Student Financial Aid Special Tests & Provisions Eligibility

Institutional Comments on Findings and Recommendations: The institution agrees with the auditor on this finding in that there were (3) three cases where the enrollment status was not reported correctly. Although as was observed by the auditor, the enrollment status for the three students in questio...

Institutional Comments on Findings and Recommendations: The institution agrees with the auditor on this finding in that there were (3) three cases where the enrollment status was not reported correctly. Although as was observed by the auditor, the enrollment status for the three students in question were corrected in the next enrollment report that was submitted. During the audit period, the institution was unable to update, submit or complete in a timely manner Enrollment reports for the period of July through December 2022. This was mainly due to problems with the implementation of a new format for enrollment reporting through the NSLDS Modernized Website. The institution has on file, multiple inquiries to the NSLDS Customer Support Center in relation to this issue. The Department of Education also posted various Electronic Announcements updating and giving continued guidance to institutions on this issue. The auditors were provided with copies of all of ED’s posting and updates as related to this issue. Nevertheless, during the subsequent months from January 2023 to June 2023 covered in this audit period, the institution was able to complete and report the current enrollment status of students to the NSLDS platform. Actions Taken or Planned: The matter as related to this finding has already been discussed with the Registrar who is responsible for the completion and submission of the Enrollment Reports to the Department of Education To continue to improve on the reporting to student’s enrollment status, the institution would continue to submit its Enrollment Reports monthly instead of every two months as schedule. Status of Corrective Actions on Prior Findings: The issue as related to this finding occurred in the past audit.

View Audit 305178

Finding 395524 (2023-001)

Significant Deficiency 2023

Universidad Teologica Del Caribe, Inc.

PR

Questioned Costs Student Financial Aid Procurement, Suspension & Debarment

Institutional Comments on Findings and Recommendations: Compliance Requirements – Applicable After a Student Begins Attendance: The institution agrees with the auditors on this finding in which there were two (2) cases where the auditors noted that the institution failed to determine that the stud...

Institutional Comments on Findings and Recommendations: Compliance Requirements – Applicable After a Student Begins Attendance: The institution agrees with the auditors on this finding in which there were two (2) cases where the auditors noted that the institution failed to determine that the students withdrew within fourteen (14) days after the student’s last day of attendance. In one (1) of the two (2) cases the Date of Determination was twenty-two (22) days after the Last Day of Attendance and in the second case, the Date of Determination was Three (3) days after the Last Day of Attendance. All funds due to the Department, (for the first case $682.00 of Unsub. Direct Loan funds and in the second case $974.22 of Federal Pell Grant funds), were returned within the forty-five (45) days required timeframe as of the Date of Determination of each case. This process was evidenced to the auditors for their records. Actions Taken or Planned: The institution is fully aware of the Return of Title IV funds (R2T4) reporting requirements and deadlines. The issue related to this finding was identified as a lack in some Faculty notifying student absences within the fourteen (14) day timeframe to process an R2T4 in a timely manner as required. Although this issue was already discussed with them by the Dean of Academic Affairs, an additional follow up meeting would be held to remind them of the importance in monitoring student attendance and notifying student absences to the Registrar office within the required timeframes to fully comply with the R2T4 reporting requirements. Status of Corrective Actions on Prior Findings: The issue as related to this finding occurred in the past audit.

View Audit 305178 Questioned Costs: $1

Finding 395377 (2023-022)

Significant Deficiency 2023

State of Oregon

OR

Special Tests & Provisions Questioned Costs Significant Deficiency

2023-022 Oregon Department of Human Services/Oregon Health Authority Ensure compliance with federal Medicaid hospital audit requirements MANAGEMENT RESPONSE: We agree with this recommendation. The authority agrees with this finding and has completed the work to reconstitute the required tools neces...

2023-022 Oregon Department of Human Services/Oregon Health Authority Ensure compliance with federal Medicaid hospital audit requirements MANAGEMENT RESPONSE: We agree with this recommendation. The authority agrees with this finding and has completed the work to reconstitute the required tools necessary to perform these audits. As of January 2024, the authority has sent cost statements to the hospitals for review and response and is working to collect other reports required for completing the audits from actuaries and intermediaries. The authority will begin processing full audits starting April 2024 for outstanding Fiscal Year 2016 forward. The authority anticipates that the audits through Fiscal year 2020 will be completed by Dec. 31, 2024. The authority also affirms that the corrective action for finding 2021-17 has been implemented and resolved. This can be validated as completed audits become available in 2024. Anticipated Completion Date: December 31, 2024 Contact person: April Gillette, Strategic Operations and Improvement Director

View Audit 305129

Finding 395356 (2023-019)

Significant Deficiency 2023

State of Oregon

OR

Questioned Costs Reporting Significant Deficiency § 200.303

2023-019 Oregon Housing and Community Services Ensure documentation is retained to support amounts reported MANAGEMENT RESPONSE: We agree with this recommendation. Staff have received training and documentation is now retained consistently to support reported figures. Anticipated Completion Date:...

2023-019 Oregon Housing and Community Services Ensure documentation is retained to support amounts reported MANAGEMENT RESPONSE: We agree with this recommendation. Staff have received training and documentation is now retained consistently to support reported figures. Anticipated Completion Date: June 30, 2024 Contact person: Dean Criscola, Controller

View Audit 305129

Finding 395341 (2023-042)

Significant Deficiency 2023

State of Oregon

OR

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303 § 200.439

2023-042 Oregon Department of Education Retain support for pre-approval of equipment purchases MANAGEMENT RESPONSE: We agree with this recommendation. ODE has already developed and implemented updates to the capital expenditure request review and approval process to ensure equipment approvals are...

2023-042 Oregon Department of Education Retain support for pre-approval of equipment purchases MANAGEMENT RESPONSE: We agree with this recommendation. ODE has already developed and implemented updates to the capital expenditure request review and approval process to ensure equipment approvals are retained. Early ESSER capital project tag requests were split between a committee for large projects and the individual grant finance manager. Approvals were primarily sent via email from the grant finance manager. Some of those messages are archived in the ESSER.ODE inbox, however some went out directly from staff email. Records are available for the committee decisions. When the smaller approvals moved from the finance manager to an ESSER team, many of those decisions were made in conjunction with other meetings. Some records are available; however, the Capital Expenditure Tracker was the primary location of decisions. In October 2022, staffing changes allowed the committee and team structure to become more formalized. Committee meeting decisions shifted from a “minute”- style agenda to being more systematized in an online log. Team meeting decisions followed a similar process update in April 2023. The online agenda/log allows for consistent tracking of projects that are up for discussion and which approval are put on hold for elevation approval, correction, or clarification from the district. Committee and team meetings have been established weekly. When all information is received from a district, the project is placed on the appropriate agenda for that week. Approvals are sent out within 2 business days. A column was added to the Capital Expenditure Tracker, which remains the primary location of records, to track when the approval emails were sent. Corrections have already been developed and implemented as of April 2024. Anticipated Completion Date: April 30, 2024 Contact person: Cynthia Stinson, Senior Manager of Federal Investments and Pandemic Renewal Effort

View Audit 305129

Finding 395340 (2023-041)

Significant Deficiency 2023

State of Oregon

OR

Questioned Costs Subrecipient Monitoring Reporting § 200.303

2023-041 Oregon Department of Education Improve FFATA reporting controls MANAGEMENT RESPONSE: We agree with this recommendation. ODE will implement the following corrective action to ensure monthly FFATA reports are independently reviewed to ensure accurate and complete reporting. 1. Review and u...

2023-041 Oregon Department of Education Improve FFATA reporting controls MANAGEMENT RESPONSE: We agree with this recommendation. ODE will implement the following corrective action to ensure monthly FFATA reports are independently reviewed to ensure accurate and complete reporting. 1. Review and update list of all FFATA eligible federal awards monthly. 2. Implement a new query tool that will reduce manual processes. 3. Collaborate with ODE partners to access agency-collected unique entity identifier (UEI) information for sub awardees. 4. Monthly review of FFATA reporting by a second accountant. Anticipated Completion Date: June 30, 2024 Contact person: Kristie Miller, Accounting Director

View Audit 305129

Finding 395338 (2023-031)

Significant Deficiency 2023

State of Oregon

OR

Questioned Costs Eligibility Period of Performance

2023-031 Oregon Commission for the Blind Improve controls over compliance reporting MANAGEMENT RESPONSE: We agree with this recommendation. The agency is committed to ensuring the RSA-911 client case information report is accurate and well supported. The agency’s practice is to maintain documenta...

2023-031 Oregon Commission for the Blind Improve controls over compliance reporting MANAGEMENT RESPONSE: We agree with this recommendation. The agency is committed to ensuring the RSA-911 client case information report is accurate and well supported. The agency’s practice is to maintain documentation that supports information contained in the case management system. This practice includes requesting information from clients regarding the start date of employment in the primary occupation and the hourly wage at exit. This information can be difficult to locate due to the numerous case notes in the case management system. Due to the difficulty locating this documentation in the tight timelines of the audit, the agency spent some additional time attempting to locate it after the audit testing period had closed. The agency did find the supporting documentation for one of the two clients that was not located during the audit. For the other client, the agency identified documentation showing that we had requested this information from the client through multiple methods, but it was never received. The agency has created a new case-note category for documenting client employment start date and wages at exit. The agency will provide training to staff on the use of this case note category to ensure this documentation is able to be located more easily and to reinforce the importance of maintaining documentation to support information contained in the case management system. Anticipated Completion Date: August 1, 2024 Contact person: Angel Hale, Director of Vocational Rehabilitation Services

View Audit 305129

Finding 395335 (2023-028)

Material Weakness 2023

State of Oregon

OR

Questioned Costs Eligibility Material Weakness § 200.303

2023-028 Department of Human Services Strengthen controls to ensure adequate supporting documentation and accuracy over reporting MANAGEMENT RESPONSE: We agree with the first recommendation. We disagree with the second recommendation. We agree with the first recommendation and will ensure adequa...

2023-028 Department of Human Services Strengthen controls to ensure adequate supporting documentation and accuracy over reporting MANAGEMENT RESPONSE: We agree with the first recommendation. We disagree with the second recommendation. We agree with the first recommendation and will ensure adequate supporting documentation is maintained and readily available to support information reported in the RSA-911. We disagree with the second recommendation. The RSA-17 is currently reviewed by both Program Leadership as well as the ODHS Grant Accounting Manager. Certification is evidenced by the signed RSA-17. This level of review meets federal requirements. Additional review and discussion may be had as a form of best practice but should not be considered a control mechanism. The Grant Accounting Unit will highlight the certification process in the RSA-17 desk manual to delineate between control functions and best practices. Anticipated Completion Date: June 30, 2024 Contact person: Keith Ozols, Vocational Rehabilitation Services Director; Travis Labrum, Grant Accounting Manager

View Audit 305129

Finding 395334 (2023-043)

Significant Deficiency 2023

State of Oregon

OR

Questioned Costs Reporting Significant Deficiency § 200.303

2023-043 Oregon Business Development Department Management should implement accounting review of quarterly reports before submitting to DAS MANAGEMENT RESPONSE: We agree with this recommendation. We agree with this finding. Business Oregon has gone through significant personnel change during the ...

2023-043 Oregon Business Development Department Management should implement accounting review of quarterly reports before submitting to DAS MANAGEMENT RESPONSE: We agree with this recommendation. We agree with this finding. Business Oregon has gone through significant personnel change during the period of American Rescue Plan Act (ARPA) grant disbursements, from January 2022 to June 2023. The Chief Financial Officer, Accounting Manager, and Accountants had moved on to other state agencies. The accounting positions were left vacant for months due to challenges in timely filling these positions with the right skill sets. Although there were only a few accounting staff left when majority of the grant disbursements were made, the remaining accounting processed the disbursements with very tight deadlines. The accounting staff processed grant disbursements through appropriate internal control procedures, reviewed supporting documents for appropriate signature approval on the requests, and made accounting entries for these grant activity transactions. Below is a list of staff hire dates to illustrate the turnover we faced during this time period: • Federal Grant Accountant – November 2023 • Chief Financial Officer – October 2023 • Deputy CFO/Accounting Manager – May 2023 • Program Accountant 2 – April 2023 • Accounting Technician – April 2023 • Debt Accountant 3 – March 2023 • Program Accountant 3 – January 2023 • Program Accountant 3 – August 2022 Due to the accounting team not having enough personnel at the time to prepare reports for the DAS ARPA Grant Program Coordinator, Business Oregon program staff (not accounting staff) took the initiative to complete the reports and submitted the periodic/quarterly reports to DAS. As the Business Oregon program staff did not have access to the SFMA (state accounting system), the program staff used data from another system (Salesforce, not an accounting system) to fill the needed information for the reports. The initial reports submitted to DAS were not reviewed by accounting staff. The program staff continued to complete the reports for DAS until first quarter of 2023, until accountant positions were filled in 2023. While preparing for the FY 2023 Year-End Closing process (June 2023 to July 2023), the newly hired accountants and Deputy CFO/Accounting Manager reviewed as many FY23 financial transactions as they could and made necessary adjustments and accounting entry corrections. Reporting discrepancies were identified between department accounting records and the reports submitted by program staff to DAS/US Dept of Treasury. Business Oregon accountants worked with DAS on revising the SEFA reports and identified ARPA grant-related items that needs to be corrected. The research continued even after the fiscal year 2023 reporting has closed. A reconciliation of records between department accounting and the reports submitted to the DAS Grant program coordinator was completed in January 2024, and the Business Oregon accounting team submitted a revised FY 2023 SEFA report corrections to the DAS SARS team. Going forward, management will ensure that the completion of quarterly financial reports for grant reporting is performed and submitted by the agency’s accounting team and not program staff to ensure data comes from the accounting system with the review by an accountant or accounting manager. Anticipated Completion Date: June 30, 2024 Contact person: Imee Anderson, Chief Financial Officer; Karl Mielke, Deputy Chief Financial Officer

View Audit 305129

Finding 395309 (2023-004)

Significant Deficiency 2023

School District of Thorp

WI

Internal Control / Segregation of Duties Questioned Costs Reporting

The Bookkeeper will look at and sign off on all final food service claims before being submitted.

View Audit 305106

Finding 395267 (2023-060)

Material Weakness 2023

State of Rhode Island

RI

Questioned Costs Special Tests & Provisions Eligibility

Finding 2023-060 – Corrective Action Plan Rhode Island Medicaid’s Provider Enrollment project went live on 2/01/2024. Any provider that isn’t screened and enrolled with the State Medicaid Agency will have claims deny. Additionally, MCOs have terminated providers in their network who are not scree...

Finding 2023-060 – Corrective Action Plan Rhode Island Medicaid’s Provider Enrollment project went live on 2/01/2024. Any provider that isn’t screened and enrolled with the State Medicaid Agency will have claims deny. Additionally, MCOs have terminated providers in their network who are not screened and redirected members to fully screened and enrolled providers. Rhode Island Medicaid continues to work with its fiscal agent and MMIS contractor, Gainwell Technologies, to ensure all edits are systematic. Anticipated Completion Date: Implemented February 1, 2024 Contact Persons: Kimberly Tebow, Senior Medical Care Specialist, Executive Office of Health & Human Services kimberly.tebow@ohhs.ri.gov Chantele Rotolo, Assistant Administrator for Family & Children Services, Executive Office of Health & Human Services chantele.rotolo@ohhs.ri.gov

View Audit 305097 Questioned Costs: $1

Finding 395256 (2023-056)

Material Weakness 2023

State of Rhode Island

RI

Questioned Costs Subrecipient Monitoring Eligibility

Finding 2023-056 – Corrective Action Plan Management agrees with the finding. Regulation 4.5.1, RIW approved families are categorically eligible for CCAP services when they have an acceptable need for services related to fulfilling RIW program requirements. The determination of employment plan com...

Finding 2023-056 – Corrective Action Plan Management agrees with the finding. Regulation 4.5.1, RIW approved families are categorically eligible for CCAP services when they have an acceptable need for services related to fulfilling RIW program requirements. The determination of employment plan components including any combination of education and work-related activities in the approved plan are determined by RIW Regulations, section 2.11. The need for services in an RIW CCAP case is based on the employment plan. In situations where an applicant parent does not comply with the RIW employment plan, CCAP services would not be approved. Once CCAP services are approved based on an employment plan for an RIW recipient, the approval is for a 12-month certification period and would not be terminated, per ACF federal requirements, for a subsequent change in employment plan participation or change in income (unless in excess of 85% SMI). It should be noted that in all cases, the decortications were documented in Bridges. CCAP training has also been enhanced in many ways. CCAP training is delivered along with RIW training on a bi-monthly basis for new hires and/or existing ETs The CCAP training module was revised to include topics specific to improper payments. Office of Child Care also holds monthly CCAP office hours for operations staff to connect with program admins, policy and training specialist to answer/troubleshoot questions from the field. Monthly analysis by error type now includes location and worker ID for analysis of more targeted training. DHS also continues to look at system and process improvements. Weekly CCAP theme meetings are ongoing to identify and solution Bridges related incidents. The CCAP Regulations have been reviewed and were opened Q1 2024 for policy updates to streamline and simplify verification processes where possible. Anticipated Completion Date: July 1, 2024 Contact Person: Nicole Chiello, Assistant Director – Office of Child Care, Department of Human Services nicole.chiello@dhs.ri.gov

View Audit 305097 Questioned Costs: $1

Finding 395247 (2023-054)

Significant Deficiency 2023

State of Rhode Island

RI

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

Finding 2023-054 – Corrective Action Plan 2023-054a – The State (EOHHS) receives quarterly user access reports from the MMIS fiscal agent. Anyone identified on the reports that have not logged in for a period of 60 days will have their access deleted. Currently, they are locked out and cannot acc...

Finding 2023-054 – Corrective Action Plan 2023-054a – The State (EOHHS) receives quarterly user access reports from the MMIS fiscal agent. Anyone identified on the reports that have not logged in for a period of 60 days will have their access deleted. Currently, they are locked out and cannot access the system without first requesting a password reset, which is reviewed and approved/denied by EOHHS systems group. In addition, when a user leaves state service or moves to another agency, their access is deleted. 2023-054b – The State (EOHHS) collaborates with system vendors (MMIS/Gainwell and Deloitte/RI Bridges) Maintenance & Operations (M&O) and Security teams and to ensure annual risk assessment/vulnerability best practices and lessons learned are integrated into annual planning and scope of work for future FYs. Anticipated Completion Date: Current and Ongoing Contact Persons: Brian Tichenor, RIBridges Medicaid Administrator, Executive Office of Health & Human Services brian.tichenor@ohhs.ri.gov Hector Rivera, Interdepartmental Project Manager, Executive Office of Health & Human Services hector.l.rivera@ohhs.ri.gov

View Audit 305097

Finding 395244 (2023-051)

Material Weakness 2023

State of Rhode Island

RI

Eligibility Internal Control / Segregation of Duties Questioned Costs

Finding 2023-051 – Corrective Action Plan Management agrees with the finding. DHS completed the scope of work in order to hire an outside contractor to evaluate the work and redefine the workflow distribution to improve timeliness and performance. At this time an outside contractor has not been i...

Finding 2023-051 – Corrective Action Plan Management agrees with the finding. DHS completed the scope of work in order to hire an outside contractor to evaluate the work and redefine the workflow distribution to improve timeliness and performance. At this time an outside contractor has not been identified. An additional staff has been added to the RIW policy unit and assigned as the liaison with CSDL to ensure written instructions are clear and accurate. Another meeting between the RIW policy unit and operations has been added as another avenue to address concerns and make corrections. The system vendor is sampling cases to identify missing components. Anticipated Completion Date: October 1, 2024 Contact Person: Donna M. Rook, Ph.D, MSW, Administrator, Family & Adult Services, Department of Human Services donna.m.rook@dhs.ri.gov

View Audit 305097 Questioned Costs: $1

Finding 395225 (2023-045)

Significant Deficiency 2023

State of Rhode Island

RI

Internal Control / Segregation of Duties Questioned Costs Allowable Costs / Cost Principles

Finding 2023-045 – Corrective Action Plan This error was identified with the USDOE as part of the monitoring in May 2023. All prior years were correct – this was a one-time error in the calculation spreadsheet. As a result, the USDOE did not believe this occurrence rose to the level of a finding ...

Finding 2023-045 – Corrective Action Plan This error was identified with the USDOE as part of the monitoring in May 2023. All prior years were correct – this was a one-time error in the calculation spreadsheet. As a result, the USDOE did not believe this occurrence rose to the level of a finding – but rather a procedural suggestion to have the calculation spreadsheet reviewed as part of an internal control procedure. Although the issue was discovered in May 2023, the USDOE did not feel the corrections was necessary to be implemented prior to June 30, 2023, as suggested by RIDE. The rationale was due to a projection of a large amount of unexpended FY23 funding - prior to redistributing the unexpended funds, the correct allocation calculation would be applied which would correct most of the previous allocations. Anticipated Completion Date: The correct allocation calculation was applied to the FY2023 Perkins Secondary funds on June 6, 2023. Contact Person: Mark Dunham, Chief Financial Officer, Department of Elementary & Secondary Education mark.dunham@ride.ri.gov

View Audit 305097

Finding 395223 (2023-044)

Significant Deficiency 2023

State of Rhode Island

RI

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring

Finding 2023-044 – Corrective Action Plan 2023-044a – RIDE has developed written policies and procedures for the maintenance of AcceleGrants user accounts that will have all inactive users removed after 12 months of inactivity. Anticipated Completion Date: October 31, 2024 2023-044b – RIDE financ...

Finding 2023-044 – Corrective Action Plan 2023-044a – RIDE has developed written policies and procedures for the maintenance of AcceleGrants user accounts that will have all inactive users removed after 12 months of inactivity. Anticipated Completion Date: October 31, 2024 2023-044b – RIDE finance and IT offices will review the user complementary controls noted in the vendors most currently available SOC2 report and implement suggested controls that are deemed appropriate, reasonable, and necessary by the joint RIDE team. RIDE will have this finding resolved by December 31,2024. Anticipated Completion Date: December 31, 2024 2023-044c – Finance and IT at RIDE are working together to determine the correct schedule for regular IT risk assessments. The departments are also in the process of reviewing the disaster recovery plans for the vendor, and a vendor management plan. Anticipated Completion Date: December 31, 2024 Contact Person: Mark Dunham, Chief Financial Officer, Department of Elementary & Secondary Education mark.dunham@ride.ri.gov

View Audit 305097

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