Corrective Action Plans

Finding 366756 (2022-007)

Material Weakness 2022

IN

Internal Control / Segregation of Duties Subrecipient Monitoring Cash Management § 200.302 § 200.303 § 200.328 § 200.329 § 200.334

FINDING 2022-007 Finding Subject: COVID-19 - Education Stabilization Fund - Reporting Summary of Finding: Finding: No oversight of reports and supporting documentation did not agrees to report submitted Recommendation: Provide oversight of reports submitted and retain supporting documentation that a...

FINDING 2022-007 Finding Subject: COVID-19 - Education Stabilization Fund - Reporting Summary of Finding: Finding: No oversight of reports and supporting documentation did not agrees to report submitted Recommendation: Provide oversight of reports submitted and retain supporting documentation that agrees to reports submitted Contact Person Responsible for Corrective Action: Kareemah Fowler, Assistant Superintendent of Business and Finance Deb Martin, Director of Student Learning & Title I Contact Phone Number and Email Address: Kareemah Fowler (574) 393-6088; kfowler@sbcsc.k12.in.us Deb Martin (574) 393-6053; dmartin@sbcsc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: All reports and supporting documentation, which supports each report submitted, will be reviewed/approved by the program director. All supporting documentation will be retained for future audits. Anticipated Completion Date: December 8, 2024

View Audit 289747

Finding 366754 (2022-005)

Material Weakness 2022

South Bend Community School Corporation

IN

Special Tests & Provisions Subrecipient Monitoring Material Weakness § 200.303

FINDING 2022-005 Finding Subject: Title I Grants to Local Educational Agencies - Special Tests and Provisions - Annual Report Card/High School Graduation Rate Summary of Finding: Finding: Exit documentation was missing or incorrectly matched with student mobility codes for students in the testing sa...

FINDING 2022-005 Finding Subject: Title I Grants to Local Educational Agencies - Special Tests and Provisions - Annual Report Card/High School Graduation Rate Summary of Finding: Finding: Exit documentation was missing or incorrectly matched with student mobility codes for students in the testing sample of the 2022 cohort. Contact Person Responsible for Corrective Action: Rafi Nolan-Abrahamian, Assistant Superintendent of Accountability and Innovation Contact Phone Number and Email Address: 574-393-6179; rnolan-abrahamian@sbcsc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: SBCSC will conduct re-training of all High School principals and data technicians to review SBCSC withdrawal policies (outlined below), along with required documentation for each exit/mobility code. This training will be conducted in January 2024. District staff will confirm with each high school that procedures below are in place by reviewing cohort binders with the principal and data technician. Meetings will be scheduled in the Spring of 2024. Procedure for Withdrawing Students from all SBCSC High Schools Anytime a parent requests that a student withdraw from a high school, the following steps must be followed. If a parent is not requesting a transfer, the principal will complete an exit interview. All transfers will follow this procedure. (Please also see the procedure for processing no shows.) 1. Only the principal is allowed to sign the withdrawal form. If the principal is not available, an assistant principal may sign the withdrawal form and immediately email it to the principal. 2. Prior to signing the withdrawal form, the principal will speak with the parents and student to gather any information that may help the school understand why a withdrawal is necessary. Once this conversation has happened, the principal will advise the parent and student. 43 INDIANA STATE BOARD OF ACCOUNTS South􀀃Bend􀀃Community􀀃School􀀃Corporation􀀃 215􀀃South􀀃Dr.􀀃Martin􀀃Luther􀀃King􀀃Jr.􀀃Boulevard􀀃􀀃 􀀃South􀀃Bend,􀀃Indiana􀀃46601􀀃􀀃 574􀇦393􀇦6100􀀃􀀃 􀀃 􀀃 􀀃 􀀃 INTEGRITY􀀃•􀀃ACCOUNTABILITY􀀃•􀀃EMPOWERMENT􀀃 􀀃 ACADEMIC􀀃QUALITY􀀃|􀀃EQUITY,􀀃INCLUSION􀀃&􀀃JUSTICE􀀃|􀀃FINANCIAL􀀃 SUSTAINABILITY􀀃|􀀃COMMUNITY􀀃PARTNERSHIPS􀀃 􀀃 3. If it is determined that the student will transfer, the signed withdrawal form will be filed in a binder based on class cohort. For example, all students scheduled to graduate in the spring of 2022 will be filed with the 2022 cohort. The principal must determine the name and contact information for the receiving school. 4. It is the responsibility of the data technician to manage these cohorts by checking Learning Connection weekly. If discrepancies are visible in Learning Connection, a data technician will contact the SBCSC Department of Research and Evaluation and the IDOE. 5. The secretary of student management will forward any requests for records to the data technician to file with the student’s withdrawal paperwork. (We must have a request for records for every student withdrawing from SBCSC.) 6. The data technician will follow up regarding any student with whom we did not receive a request for records for within one week of the withdrawal. The data technician will contact the receiving school and parent to locate the records request. 7. The data technician will continue to locate a request for records weekly until the request is received by SBCSC. 8. Documentation will be maintained of all efforts made to collect the information. Anticipated Completion Date: Spring 2024

View Audit 289747

Finding 366753 (2022-004)

Material Weakness 2022

South Bend Community School Corporation

IN

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

FINDING 2022-004 Finding Subject: Title I Grants to Local Educational Agencies - Reporting Summary of Finding: Finding: Detail data on the Form 9 and Reimbursement Request was not provided to knowledgeable individuals for review. Recommendation: Design control that provides sufficient data to knowle...

FINDING 2022-004 Finding Subject: Title I Grants to Local Educational Agencies - Reporting Summary of Finding: Finding: Detail data on the Form 9 and Reimbursement Request was not provided to knowledgeable individuals for review. Recommendation: Design control that provides sufficient data to knowledgeable individuals for review. Contact Person Responsible for Corrective Action: Kareemah Fowler, Assistant Superintendent of Business and Finance Contact Phone Number and Email Address: (574) 393-6088; kfowler@sbcsc.k12.in.us Views of Responsible Officials: We concur with the findings. Description of Corrective Action Plan: Form 9 Data The Human Resources Department has added a second review to verify all employee distribution codes are correct when recording/updating employee requisitions. Additionally, detailed expense reports and payroll distribution reports that support each reimbursement request are being provided to knowledgeable employees to review. Anticipated Completion Date: Completed December 8, 2023, and May 2023 Reimbursement Requests Summary level payroll data is no longer being used to support reimbursement requests. Detailed expense reports and payroll distribution reports that support each reimbursement request are being provided to knowledgeable employees to review. Anticipated Completion Date: Completed May 2023.

View Audit 289747

Finding 366751 (2022-002)

Material Weakness 2022

South Bend Community School Corporation

IN

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

FINDING 2022-002 Finding Subject: Title I Grants to Local Educational Agencies -Internal Controls Summary of Finding: Finding: Ineffective internal controls over Eligibility, Level of Efforts and Earmarking Recommendation: That the School Corporation design and implement a proper system of internal ...

FINDING 2022-002 Finding Subject: Title I Grants to Local Educational Agencies -Internal Controls Summary of Finding: Finding: Ineffective internal controls over Eligibility, Level of Efforts and Earmarking Recommendation: That the School Corporation design and implement a proper system of internal control, including policies and procedures that would provide segregation of duties to ensure appropriate reviews, approvals and oversight are taking place. Contact Person Responsible for Corrective Action: Rafi Nolan-Abrahamian, Assistant Superintendent of Accountability and Innovation Kareemah Fowler, Assistant Superintendent of Business and Finance Debra Martin, Director of Student Learning and of Title I Contact Phone Number and Email Address: Rafi Nolan-Abrahamian (574) 393-6179; rnolan-abrahamian@sbcsc.k12.in.us Kareemah Fowler (574) 393-6088; kfowler@sbcsc.k12.in.us Deb Martin (574) 393-6053; dmartin@sbcsc.k12.in.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: Eligibility The district has followed the procedures below to ensure the publishing of accurate eligibility information. The district has now clearly documented the procedures for future audit cycles. Titan (lunch status data) is imported into PowerSchool every week by the Student Information System administrator in the lead up to October reporting deadlines. Prior to certification, the Data Content Manager republishes all of the student demographic/identification records to update the certified values. Pupil Enrollment rosters from Data Exchange are compared to files from Titan to verify alignment of all individual student lunch status values. Anticipated Completion Date: Completed October 2023 39 INDIANA STATE BOARD OF ACCOUNTS South􀀃Bend􀀃Community􀀃School􀀃Corporation􀀃 215􀀃South􀀃Dr.􀀃Martin􀀃Luther􀀃King􀀃Jr.􀀃Boulevard􀀃􀀃 􀀃South􀀃Bend,􀀃Indiana􀀃46601􀀃􀀃 574􀇦393􀇦6100􀀃􀀃 􀀃 􀀃 􀀃 􀀃 INTEGRITY􀀃•􀀃ACCOUNTABILITY􀀃•􀀃EMPOWERMENT􀀃 􀀃 ACADEMIC􀀃QUALITY􀀃|􀀃EQUITY,􀀃INCLUSION􀀃&􀀃JUSTICE􀀃|􀀃FINANCIAL􀀃 SUSTAINABILITY􀀃|􀀃COMMUNITY􀀃PARTNERSHIPS􀀃 􀀃 Level of Effort The Human Resources Department has added a second review to verify all employee distribution codes are correct when recording/updating employee requisitions. Additionally, detailed expense reports and payroll distribution reports that support each reimbursement request are being provided to knowledgeable employees to review. Anticipated Completion Date: Completed December 8, 2023, and May 2023 Earmarking Summary level payroll data is no longer being used to support reimbursement requests. Detailed expense reports and payroll distribution reports that support each reimbursement request are being provided to knowledgeable employees to review. Anticipated Completion Date: Completed May 2023

View Audit 289747

Finding 366672 (2022-003)

None 2022

Boys & Girls Club of North Alabama, INC

AL

Cash Management Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Finding 2022-003 Finding: CACFP requires that non-Federal entities receiving Federal Awards establish and maintain internal control designed to reasonably ensure compliance with Federal Statutes, regulations, and the terms and conditions of the Federal award. As part of our review of the Child and...

Finding 2022-003 Finding: CACFP requires that non-Federal entities receiving Federal Awards establish and maintain internal control designed to reasonably ensure compliance with Federal Statutes, regulations, and the terms and conditions of the Federal award. As part of our review of the Child and Adult Care Food Program (CACFP) it was noted the Club was not adhering to accrual accounting as it pertains to reporting of expenses. Response: Adjustments have been made to the process of monthly adjustments. Additional procedures will be put in place to ensure financial reporting is done correctly.

View Audit 289590

Finding 366671 (2022-002)

None 2022

Boys & Girls Club of North Alabama, INC

AL

Cash Management Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Finding 2022-002 Finding: CACFP requires that non-Federal entities receiving Federal Awards establish and maintain internal control designed to reasonably ensure compliance with Federal Statutes, regulations, and the terms and conditions of the Federal award. As part of our review of the Child and...

Finding 2022-002 Finding: CACFP requires that non-Federal entities receiving Federal Awards establish and maintain internal control designed to reasonably ensure compliance with Federal Statutes, regulations, and the terms and conditions of the Federal award. As part of our review of the Child and Adult Care Food Program (CACFP) it was noted some of the Club’s daily food invoices were missing the site supervisor’s signature for having received the meals specified. Response: The monitor and director will review each month’s daily food invoices from all sites to ensure they are complete. Additional procedures will be put in place to ensure all daily food invoices have the appropriate receiving signatures.

View Audit 289590

Finding 366670 (2022-001)

None 2022

Boys & Girls Club of North Alabama, INC

AL

Cash Management Reporting Matching / Level of Effort / Earmarking § 200.303

Finding 2022-001 Finding: CACFP requires that non-Federal entities receiving Federal Awards establish and maintain internal control designed to reasonably ensure compliance with Federal Statutes, regulations, and the terms and conditions of the Federal award. The Club was unable to replicate exact...

Finding 2022-001 Finding: CACFP requires that non-Federal entities receiving Federal Awards establish and maintain internal control designed to reasonably ensure compliance with Federal Statutes, regulations, and the terms and conditions of the Federal award. The Club was unable to replicate exact payroll expenses that were reported to the state monthly for the program. This is due to a lack of payroll documentation retained monthly. This documentation took time to replicate during the audit. No fraud is suspected related to payroll reporting issues for the program. Response: Adjustments were made to the payroll process to retain all supporting documentation and to replicate any prior period paperwork. The Club switched to a new payroll processor which has enabled improved payroll reporting.

View Audit 289590

Finding 366662 (2022-006)

Material Weakness 2022

Housing Authority of the City of Camden

NJ

Questioned Costs Internal Control / Segregation of Duties Eligibility

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program to ensure that established internal control policies are being followed on a timely basis. Melody Joh...

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program to ensure that established internal control policies are being followed on a timely basis. Melody Johnson-Williams, Executive Director, is responsible for implementing this corrective action by December 31, 2023.

View Audit 289566 Questioned Costs: $1

Finding 366661 (2022-005)

Significant Deficiency 2022

Housing Authority of the City of Camden

NJ

Questioned Costs HUD Housing Programs Significant Deficiency

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers Program to ensure that established internal control policies are being followed on a timely basis. M...

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers Program to ensure that established internal control policies are being followed on a timely basis. Melody Johnson-Williams, Executive Director, is responsible for implementing this corrective action by December 31, 2023.

View Audit 289566 Questioned Costs: $1

Finding 366660 (2022-004)

Significant Deficiency 2022

Housing Authority of the City of Camden

NJ

Questioned Costs HUD Housing Programs Eligibility

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight on the maintenance of the waiting list and process of housing applicants to better monitor adequacy with compliance requirements. Melody Johns...

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight on the maintenance of the waiting list and process of housing applicants to better monitor adequacy with compliance requirements. Melody Johnson-Williams, Executive Director, is responsible for implementing this corrective action by December 31, 2023.

View Audit 289566 Questioned Costs: $1

Finding 366659 (2022-003)

Material Weakness 2022

Housing Authority of the City of Camden

NJ

Questioned Costs HUD Housing Programs Eligibility

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers Program to ensure that established internal control policies are being followed on a timely basis. Me...

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers Program to ensure that established internal control policies are being followed on a timely basis. Melody Johnson-Williams, Executive Director, is responsible for implementing this corrective action by December 31, 2023.

View Audit 289566 Questioned Costs: $1

Finding 366596 (2022-003)

Material Weakness 2022

East Union Community School District

IA

Internal Control / Segregation of Duties

The District continues to review its control procedures to obtain the maximum internal control possible under the circumstances.

View Audit 289451

Finding 366549 (2022-003)

Significant Deficiency 2022

City of Warwick, Rhode Island

RI

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

Warwick Public Schools is in the process of hiring an assistant controller responsible for grants finance. This individual will reconcile expenses monthly, record revenues, receivables and reimbursements on a monthly basis. This will prevent the amount of year-end cleanup going forward.

View Audit 289401

Finding 366494 (2022-001)

Significant Deficiency 2022

Habcore, Inc.

NJ

Internal Control / Segregation of Duties

HABcore will follow-up with NJ HMFA to determine if the $150 quarterly deposits are still necessary, and if so, will catch up and comply.

View Audit 16123

Finding 322674 (2022-006)

Significant Deficiency 2022

Heartland Care Center Inc.

IA

Internal Control / Segregation of Duties Subrecipient Monitoring Matching / Level of Effort / Earmarking

GSA_MIGRATION

View Audit 282473

Finding 322673 (2022-005)

Significant Deficiency 2022

Heartland Care Center Inc.

IA

Internal Control / Segregation of Duties Reporting Matching / Level of Effort / Earmarking

GSA_MIGRATION

View Audit 282473

Finding 322672 (2022-004)

None 2022

Heartland Care Center Inc.

IA

Internal Control / Segregation of Duties Subrecipient Monitoring Matching / Level of Effort / Earmarking

INSURANCE POLICY CO-OBLIGEE Criteria: The Organization is responsible for having the USDA Rural Development listed as a co-obligee on fidelity bonds or mortgagee (loss payee) on the property insurance policy....

INSURANCE POLICY CO-OBLIGEE Criteria: The Organization is responsible for having the USDA Rural Development listed as a co-obligee on fidelity bonds or mortgagee (loss payee) on the property insurance policy. Condition: During our review of internal control procedures for the Community Facilities Loans & Grants Cluster, we identified the USDA Rural Development was not listed as a co-obligee on the fidelity bonds or mortgagee (loss payee) on the property insurance policy. Cause: The requirement was not met due to managements? oversight of the requirement to update the property insurance policy. Potential Effect: As a result, the Agency reserves the right to withdraw Agency funding. Recommendation: The Organization should review current procedures to ensure that they are complying with all requirements of the USDA Rural Development loan. Client Response: The Organization will review their monitoring procedures to ensure that they follow loan requirements and also update the insurance policy to include USDA Rural Development as the mortgagee (loss payee).

View Audit 282473

Finding 322671 (2022-003)

None 2022

Heartland Care Center Inc.

IA

Internal Control / Segregation of Duties Reporting Matching / Level of Effort / Earmarking

REPORTING Criteria: The Organization is responsible for maintaining proper controls over programs to submit complete and accurate quarterly financial statements within 20 days of the quarte...

REPORTING Criteria: The Organization is responsible for maintaining proper controls over programs to submit complete and accurate quarterly financial statements within 20 days of the quarter end, and the annual budget must be submitted to the Agency 30 days prior to the beginning of the borrower?s fiscal year. Condition: During our review of internal control procedures for the Community Facilities Loans & Grants Cluster, we identified the quarterly financial statements were not submitted timely for the third quarter of 2021 and fourth quarter of 2021, the annual budget was not submitted timely, and the first quarter of 2022 financial statement was not submitted accurately. Cause: The submission of timely and complete reports was not met due to managements? oversight of the requirement to submit quarterly financials. Potential Effect: As a result, the Agency reserves the right to withdraw Agency funding. Recommendation: The Organization should review current processes and ensure the financial reports are reviewed for accuracy and submitted timely by someone who did not prepare the reports. Client Response: The Organization will modify the process to include review by another individual and monitor due dates to submit future reports accurately and on time.

View Audit 282473

Finding 316358 (2022-078)

Significant Deficiency 2022

State of Colorado

CO

Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303 § 200.332 § 200.521

(A) CDOT will work with various divisions to devise a plan that will comply with this finding and the recommendations noted within. This plan shall include identifying a centralized location for all policies and procedures related to subrecipient monitoring. We will look at all policies and procedur...

(A) CDOT will work with various divisions to devise a plan that will comply with this finding and the recommendations noted within. This plan shall include identifying a centralized location for all policies and procedures related to subrecipient monitoring. We will look at all policies and procedures to ensure they clearly identify responsibilities and requirements for non-compliance. (B) CDOT will work with various divisions to devise a plan that will comply with this finding and the recommendations noted within. This plan shall include establishing a process by which an analysis of contracted entities will be performed to identify and properly record entities as a vendor or subrecipient.

View Audit 282464

Finding 316224 (2022-050)

Material Weakness 2022

State of Colorado

CO

Eligibility Internal Control / Segregation of Duties Subrecipient Monitoring

(B) The Department revised its training model which is on track and will be fully rolled out to all eligibility sites by July 2022. (D) The Department disagrees with the auditor?s findings and questioned costs related to capitation payments under the Eligibility Issues Identified through Data Analy...

(B) The Department revised its training model which is on track and will be fully rolled out to all eligibility sites by July 2022. (D) The Department disagrees with the auditor?s findings and questioned costs related to capitation payments under the Eligibility Issues Identified through Data Analyses section. These costs are related to cases that were ?not eligible? in CBMS but were showing as ?eligible? in Colorado interChange that were already identified by the Department. The Department was actively working to resolve these cases with CMS prior to the Public Health Emergency (PHE). The Department developed and implemented a reconciliation report that is used to research and resolve CBMS and Colorado interChange interface mismatches. Members identified on the reconciliation reports were being manually updated until March 2020. CMS instructed the Department to cease work on these cases when the PHE was implemented. During the PHE the Department was not allowed to terminate benefits for anyone receiving benefits prior to March 2020, even if eligibility was determined incorrectly prior to the PHE. During this unprecedented time, the authority and operations regarding these cases was not immediately available. The auditors? retrospective review fails to address the uncertainty that occurred during this period of the PHE. The Department agrees to resume work on the manual reconciliation process when authorized by CMS.

View Audit 282464

Finding 316199 (2022-052)

Material Weakness 2022

State of Colorado

CO

Internal Control / Segregation of Duties Reporting Eligibility

(A) The Department agrees with the audit recommendation to develop and implement formal written policies and procedures. Prior to this audit, the Department began creating formal written policies and procedures for site case reviews, maintenance of supporting documentation, timely training for faile...

(A) The Department agrees with the audit recommendation to develop and implement formal written policies and procedures. Prior to this audit, the Department began creating formal written policies and procedures for site case reviews, maintenance of supporting documentation, timely training for failed workers, and performance of timely re-certification of presumptive eligibility sites (PE site). This finding had no known questionable cost associated with it. (B) The Department agrees with the audit recommendation to develop an effective tracking mechanism to identify and monitor PE sites that are due for re-certification every two years and ensuring that the recertifications are performed. Prior to this audit, the Department began developing a tracking mechanism for PE site re-certifications. This finding had no known questionable cost associated with it. (C) The Department fixed enrollment information for Fiscal Year 2020 and 2021 in CBMS for beneficiaries who were no longer eligible for presumptive eligibility and have either had their benefits terminated or were moved to the regular Medicaid and Children?s Basic Health Plan programs. The Department is currently performing regular reviews to appropriately terminate applicants? presumptive eligibility in CBMS when appropriate. However, the Department has not addressed the programming and system issues in CBMS. The Department plans to fully implement this recommendation by December 2022.

View Audit 282464

Finding 316195 (2022-047)

Material Weakness 2022

State of Colorado

CO

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303 § 200.516 § 200.84

(B) The Department will review and revise, as necessary, its taxi claim billing requirements and rates to ensure that they are consistent. In addition, the Department will devise controls to ensure that taxi claims are paid in accordance with established requirements and rates and explore controls t...

(B) The Department will review and revise, as necessary, its taxi claim billing requirements and rates to ensure that they are consistent. In addition, the Department will devise controls to ensure that taxi claims are paid in accordance with established requirements and rates and explore controls to ensure that only permitted providers bill as a taxi. The Department is working on reductions in the max fee and unit limits for taxi claim billing codes, which it will have completed by the end of October 2021. In addition, the Department is considering systematically pricing the code at each taxi provider?s specific Public Utilities Commission (PUC) rate. This change, if pursued, will require a system change request, which will take a year or more, which is why the Department has selected an implementation date of December 2022. If this proves infeasible, alternate controls will be implemented. HCPF has met with DORA PUC. The Department is trying to establish a process to decide if the PUC taxi rate still applies or an internal rate can be created. Because of these discussions and needed system changes the implementation date has been moved to December 2023. (D) The Department intends to define in rule the types of documentation that NEMT providers must keep on hand and make clear that they must furnish records to the Department upon request. The July 2022 date will allow for the completion of formal rulemaking. The Department further intends to develop and implement a process to perform regular risk-based provider file reviews with a focus on noncompliant providers. These reviews will ensure, at a minimum, that the providers? paid claims are supported with appropriate documentation and represent the least costly option appropriate to meet each recipient?s needs. The Department met with the RAC team on February 22, 2023 to come up with a process to perform small audits for claims from providers that are outside the Intelliride service area. New systems will be implemented which has pushed the anticipated completion date to December 2023. (E) The Department will amend its contract with its NEMT broker by adding a mandatory annual audit so that it can reconcile trip scheduling data with paid claims data. This will help ensure that the Department pays accurately, pays for NEMT services, and pays for the least costly transportation option appropriate for each recipient. The Department chose July 2022 to add the audit through its annual contract amendment and renewal processes. The contract amendment was completed and signed June 30, 2022 that included a clause for an annual audit of claims. (F) The Department will develop a data review process to reconcile interChange data on NEMT trip claims to interChange data on Medicaid medical claims. This process will entail periodic reviews of NEMT claims to see if members have corresponding medical claims on those dates. If they do not, the Department will follow up with the appropriate NEMT provider to investigate. The July 2022 implementation date reflects the potential need for system changes. This is implemented, the Department has been pulling claims data and where corresponding medical claims are not found HCPF is investigating on a case by case basis to find the cause. (G) Department staff will work with the Department?s Program Integrity (PI) staff on processes to investigate and recover, as appropriate, the overpayments and inappropriate payments that the audit identified as known or likely questioned costs, and repay the federal portion, as appropriate. The December 2022 implementation date reflects the time needed to investigate and when appropriate, recover any overpayments. This has been implemented and the federal portion has been returned to CMS. (H) The Department will develop a process to track staff time and productivity to ensure that it has sufficient staff assigned to oversee and administer NEMT. This process will include documenting time spent each week on various tasks to get a sense of where help is needed, and which tasks take up the most staff resources. Based on its findings, the Department will explore staffing options, as needed. The Department selected the July 2022 implementation date to allow for data collection through the end of State Fiscal Year 2021-22. This has been implemented. New NEMT staff was hired November 1, 2022 to act as the liaison to the counties and clients in the 55 counties outside of the Intelliride service area.

View Audit 282464

Finding 316194 (2022-046)

Material Weakness 2022

State of Colorado

CO

Subrecipient Monitoring Material Weakness Reporting § 200.303

The Department did not have strong enough controls for the initial checks on the financial data reporting templates. This process has been updated and will be rectified in coming cycles. The Department has modified its templates in order to address the concerns provided by the auditors including sig...

The Department did not have strong enough controls for the initial checks on the financial data reporting templates. This process has been updated and will be rectified in coming cycles. The Department has modified its templates in order to address the concerns provided by the auditors including signatures and supplemental reporting. Written policies and procedures for the validation and audit of the templates are being developed currently and will be in place and effective in December 2022. The Department will be correcting this error by posting the audit results along with other quality and audit reports on the following site: https:hcpf.colorado.gov/quality-and-healthimprovement-reports.

View Audit 282464

Finding 316193 (2022-045)

Material Weakness 2022

State of Colorado

CO

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness

(A) The MLR report template has been updated and will now be reviewed at least yearly by the Department. In addition, new written policies and procedures are being developed and will be implemented before the submission of the next MLR for review. (B) The Department will add contract language and e...

(A) The MLR report template has been updated and will now be reviewed at least yearly by the Department. In addition, new written policies and procedures are being developed and will be implemented before the submission of the next MLR for review. (B) The Department will add contract language and enforcement mechanisms in order to receive accurate information in a timely manner. This includes specific timelines for correcting incomplete or inaccurate information in order to submit the MLR report timely to the Centers for Medicare & Medicaid Services.

View Audit 282464

Finding 308694 (2022-067)

Material Weakness 2022

State of Colorado

CO

Subrecipient Monitoring Matching / Level of Effort / Earmarking Reporting § 200.1

(A) CDHS agrees that it needs to it needs to correct the automated reporting process from the eClearance system used to gather data needed for our FFATA reporting. The department thought that the reports obtained from eClearance were complete and relied on them as the basis of our reporting. Upon in...

(A) CDHS agrees that it needs to it needs to correct the automated reporting process from the eClearance system used to gather data needed for our FFATA reporting. The department thought that the reports obtained from eClearance were complete and relied on them as the basis of our reporting. Upon investigation we found that an internal process change enacted during the implementation of another system at the start of the pandemic was the cause of the data discrepancy. This occurred because the new system made the routing in eClearance after a certain point unnecessary for internal processing so this stopped. It was unknown that this further routing to archive files in eClearance was the trigger for eClearance to push out FFATA report data. Since the department has been able to identify the cause we are able to immediately remedy the problem and ensure that all processes are in sync to ensure accurate and complete FFATA data is contained in automated reporting processes. The department will catch up on FFATA reporting that was missed during this time frame. (B) The department agrees that it needs to implement procedures to validate that data derived from automated processes used as a basis for FFATA reporting should be periodically validated against another data source. To do this the department will create and implement procedures to use CORE reports of encumbrance data referencing subrecipient object codes and tie this to information received from the automated eClearance report. Doing this will validate that the data provided from eClearance is a complete listing of all FFATA reportable subrecipient awards, and thus is a valid source to base FFATA reporting on. This will also help us monitor the process in case any future inadvertent changes are made to processes that could cause data validity issues. (C) CDHS agrees that a supervisory review is needed over the FFATA reporting process in order to ensure more consistency, accuracy and timeliness in reporting processes and standards. The department is currently developing procedures that will allow for more oversight of the FFATA reporting through supervisory reviews and cross training staff on FFATA reporting duties. Supervisory reviews will help ensure that reporting is completed in line with reporting procedures and timeframes and can be a second set of eyes to ensure that information appears accurate and adds analytical judgement value (example - a supervisor might see that July typically has high volume, but this July volume is low, why). In addition, the department is taking this opportunity to cross train other staff on the process so that more individuals can be involved which leads to more transparency over processes allowing various individuals to notice if something isn't working as designed. These new procedures are being developed and implemented as the department catches up on reporting subrecipient awards that were missed since the automated process stopped working.

View Audit 282464

Corrective Action Plans

Filters