Corrective Action Plans

Finding 537575 (2024-001)

Material Weakness 2024

FL

Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303

Finding: 2024-001 Suspension and Debarment Condition: The University was not able to provide an audit trail to support the verification that a vendor was not suspended and debarred before entering into a contract. Anticipated Completion Date: Implemented in October 2024. Person Responsible: Carol Bu...

Finding: 2024-001 Suspension and Debarment Condition: The University was not able to provide an audit trail to support the verification that a vendor was not suspended and debarred before entering into a contract. Anticipated Completion Date: Implemented in October 2024. Person Responsible: Carol Buckels, Director of Grants, Sponsored Research & Strategic Initiatives Corrective Actions Taken or Planned: The Sponsored Research Administration Office (SRA) ensures all purchases, reimbursements, and any other expenditure submitted for payment are first approved by the Principal Investigator (PI). SRA will review the approved budget to ensure funding is available. If the payment request is for purchases that require payment to specific vendors, the SRA verifies that the entity being used for these purchases is not suspended or debarred, or otherwise excluded from participating in the transaction. This verification is accomplished by checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration (GSA). SRA submits the verification along with the purchasing request or check request to accounts payable or purchasing for processing. If the expenditure amount is above the SRA approval level, the request is then escalated for additional approval (Director of Academic Administration, Provost, etc.) before sending to accounts payable or purchasing for processing.

View Audit 348854

Finding 537525 (2024-001)

Significant Deficiency 2024

John F. Kennedy Center for Performing Arts

DC

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.308 § 200.403

2024-001 – Internal Control over Compliance and Compliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Contacts: Regina Frazier Title: Payroll Manager Anticipated Completion Date: September 2025 Corrective Action: The Center is dedicated to maintaining compliance wi...

2024-001 – Internal Control over Compliance and Compliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Contacts: Regina Frazier Title: Payroll Manager Anticipated Completion Date: September 2025 Corrective Action: The Center is dedicated to maintaining compliance with federal regulations concerning allowable and unallowable activities and costs. In response to the recent audit finding, the Center’s payroll department will proactively engage with key stakeholders in high-risk areas prior to the start of the fiscal year. This engagement will involve reviewing payroll submission templates and ensuring that the rates align with the most current employment agreements. Status as of March 2025: All affected employees have been reimbursed, and key stakeholders in high-risk areas have been informed of the corrective action plan.

View Audit 348794

Finding 537520 (2024-001)

Significant Deficiency 2024

City of Glendale

CA

Matching / Level of Effort / Earmarking

In October 2024, the City hired a new staff member to conduct monitoring operations, and inspections resumed in late October 2024.

View Audit 348749

Finding 537519 (2024-001)

None 2024

William Marsh Rice University

TX

Student Financial Aid Matching / Level of Effort / Earmarking Subrecipient Monitoring

William Marsh Rice University Response The following is William Marsh Rice University’s Response to the audit of Federal programs in accordance with the Uniform Guidance for the year ended June 30, 2024. Finding 2024-001 – Loan Disbursement Notification Cluster: Student Financial Assistance Cluster ...

William Marsh Rice University Response The following is William Marsh Rice University’s Response to the audit of Federal programs in accordance with the Uniform Guidance for the year ended June 30, 2024. Finding 2024-001 – Loan Disbursement Notification Cluster: Student Financial Assistance Cluster Awarding Agency: Department of Education Award Name: Federal Direct Student Loans Award Year: July 1, 2023 – June 30, 2024 Assistance Listing Number: 84.268 Pass-through Entity: Not applicable We acknowledge the audit finding regarding the missing documentation of the loan disbursement notification for the 2023-2024 academic year. The issue began when an automated rule was disabled by a system update. This prevented the loan disbursement notices from being sent to students. Upon recognizing the underlying reason, the loan disbursement notice, which is sent one day after a loan disbursement posts to a student’s account, had its system rules reengaged. This was achieved through a collaborative effort involving the Office of Financial Aid, the Bursar's Office, and Administrative Systems. Notices resumed on September 26, 2024, and we have since conducted spot checks to confirm that the notices are being sent as required. To prevent a recurrence of this issue, we have implemented the following measures: 1. Annual Review: We have updated our staff calendar with an annual reminder to review and request updates to the text and rules of the loan disbursement notice. 2. Documentation: We have ensured that the scheduled disbursement dates and the right to cancel are disclosed in multiple areas, including the all-freshmen notice, other loan/aid award notices, the loan section of our website, and the financial aid section of General Announcements for both undergraduate and graduate students. Prior to and including the 2023-2024 academic year, this information has been updated and made available on an annual basis in these areas. This practice will continue. Effective Date: September 26, 2024 Person(s) responsible for implementation: Paul Negrete, Executive Director for University Financial Aid Services, 713-348-5905 We believe these actions address the audit finding and will help maintain compliance with notification requirements moving forward. Sincerely, Paul Negrete Executive Director University Financial Aid Services

View Audit 348737

Finding 537488 (2024-003)

Significant Deficiency 2024

City and Borough of Juneau, Alaska

AK

Reporting Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303 § 200.306

FEDERAL AWARD FINDING Finding: 2024-003 Significant Deficiency in Internal Controls over Compliance and Compliance – Setup and Monitoring of Reporting and Match Name of Contact Person: Angie Flick, Director of Finance Corrective Action: The accountants will be going through additional training on se...

FEDERAL AWARD FINDING Finding: 2024-003 Significant Deficiency in Internal Controls over Compliance and Compliance – Setup and Monitoring of Reporting and Match Name of Contact Person: Angie Flick, Director of Finance Corrective Action: The accountants will be going through additional training on setting up grants in the system and how to reconcile them. CBJ will also be completing a grant reconciliation process quarterly instead of annually. This will act both as a control as well as an opportunity to make timely corrections in the case of error. Proposed Completion Date: September 30, 2025

View Audit 348728

Finding 537480 (2024-001)

Significant Deficiency 2024

Imperial Valley Regional Occupational Program

CA

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

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

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

View Audit 348697

Finding 537474 (2024-003)

Material Weakness 2024

Southwestern Adventist University

TX

Student Financial Aid Material Weakness Reporting

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

View Audit 348681

Finding 537470 (2024-001)

None 2024

Southwestern Adventist University

TX

Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking

Corrective Action: Here are the immediate corrective actions taken: • There are now appropriate staffing levels in the Records office. Training is up-to-date as well. • A thorough review of the reporting requirements and a step-by-step guide was made by ITS and the Registrar to ensure NSC reports ...

Corrective Action: Here are the immediate corrective actions taken: • There are now appropriate staffing levels in the Records office. Training is up-to-date as well. • A thorough review of the reporting requirements and a step-by-step guide was made by ITS and the Registrar to ensure NSC reports are correct and meet the NSC requirements. • The missing NSLDS reports for the 2022-2023 academic year have been prepared and submitted. 2023-24 academic year were prepared and submitted as of 2/11/2025. The 2024-2025 academic year will be prepared and submitted by the end of the Spring 2025 semester. • Coordination with the NSC representatives to ensure the validity and accuracy of the reports in compliance with submission requirements and verification of report acceptance. To prevent future occurrences of missed NSLDS reporting, the following steps have been implemented: • Responsibility: The registrar is the primary reporting coordinator to the National Student Clearinghouse, with support from both Student Financial Services and ITS. • Automated Reminders: Calendar alerts and task management reminders are sent monthly to notify responsible staff well in advance of reporting deadlines this includes the Registrar, Student Financial Services and ITS. • Training and Documentation: A standard operating procedure (SOP) has been documented to guide future reporting efforts. However, ITS must make it a priority when there are changes to NSC reporting requirements. This was lacking during the 2022-2024 periods the university failed to report. • Management Oversight: The Vice President for Academic Administration must also ensure that all these processes and departments are working to ensure the student data is being reported correctly and on-time. We are confident that these measures will address the issue of failure to report to the NSC and ensure full compliance with NSLDS reporting requirements in the future. Contact Persons: Duane Valencia, Assistant Financial Vice President – Student Finance Jason Kowarsch, Registrar Completion Date: February 11, 2025

View Audit 348681

Finding 537469 (2024-002)

None 2024

Southwestern Adventist University

TX

Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking

Corrective Action: Financial aid will be processed on or after census day (12th day of enrollment period) for all students identified by the Registrar and financially cleared as enrolled as of that date. The Registrar will ensure students listed as enrolled as of census date, are registered and att...

Corrective Action: Financial aid will be processed on or after census day (12th day of enrollment period) for all students identified by the Registrar and financially cleared as enrolled as of that date. The Registrar will ensure students listed as enrolled as of census date, are registered and attending classes. Student Finance has learned to identify anomalies within the Ellucian system that caused the system to not auto-adjust to account for student eligibility. More staff training will be done in Student Finance to review awarding, to prevent this as an ongoing issue. Contact Persons: Duane Valencia, Assistant Financial Vice President – Student Finance Jason Kowarsch, Registrar Completion Date: To be completed by June 1, 2025

View Audit 348681

Finding 537467 (2024-002)

Significant Deficiency 2024

Delaware Valley University

PA

Student Financial Aid Matching / Level of Effort / Earmarking Reporting

Finding 2024-002 Name of Responsible Individual: James Slizewski, Registrar Corrective Action: The University has implemented several corrective actions to address this finding. We have created a comprehensive process document to ensure accurate reporting of student enrollment changes. This document...

Finding 2024-002 Name of Responsible Individual: James Slizewski, Registrar Corrective Action: The University has implemented several corrective actions to address this finding. We have created a comprehensive process document to ensure accurate reporting of student enrollment changes. This document outlines each step of the reporting process in detail, providing clear guidelines and procedures for staff to follow for each type of enrollment report that is required. This document will also outline a procedure for conducting reviews of student status changes to ensure they align with our reported data. These reviews will involve cross-checking the information in our reporting system with data generated by our student information system’s delivered enrollment reporting process to identify discrepancies prior to submitting the report. Additionally, we are seeking training and outside consultation on how to better utilize our student information system more effectively. We will engage with consultants to improve our student information system’s delivered student withdrawal and enrollment reporting processes. By utilizing our student information system’s delivered processes more effectively, we will reduce future enrollment reporting errors. Anticipated Completion Date: February 2025

View Audit 348680

Finding 537462 (2024-003)

Significant Deficiency 2024

Fontbonne University

MO

Student Financial Aid Matching / Level of Effort / Earmarking Cash Management

Corrective Action Plan 2024-003: The University concurs with the finding and has made the required corrections to the COD disbursement dates. The University process when posting Aid has remained consistent each year, this appears to be an isolated incident where CAMS did not pick up the date listed ...

Corrective Action Plan 2024-003: The University concurs with the finding and has made the required corrections to the COD disbursement dates. The University process when posting Aid has remained consistent each year, this appears to be an isolated incident where CAMS did not pick up the date listed on the disbursement screen for these students and pass that to COD. The University has implemented a control to complete the disbursements each time and then verify the date reflects correctly in COD afterwards. While this should be an automatic process, and has been in previous years, it will be something the University verifies now with each aid posting. Completion Date: August 2024 Contact Person: Megan Morton, Director of Financial Services

View Audit 348677

Finding 537460 (2024-003)

Significant Deficiency 2024

State System of Higher Education, Commonwealth of Pennsylvania

PA

Matching / Level of Effort / Earmarking Student Financial Aid Significant Deficiency § 200.303

Commonwealth: Direct Loan processor will submit monthly reconciliations to Executive Director of Financial Aid or designated campus director for review and approval

View Audit 348667

Finding 537458 (2024-002)

Significant Deficiency 2024

State System of Higher Education, Commonwealth of Pennsylvania

PA

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

ESU: The University acknowledges this is a repeat finding. While a corrective action plan was implemented in May 2024, the audit sample consisted of students from Fall 2023 and Spring 2024, before the updated procedures were in effect. Since then, the University has enhanced its process for identify...

ESU: The University acknowledges this is a repeat finding. While a corrective action plan was implemented in May 2024, the audit sample consisted of students from Fall 2023 and Spring 2024, before the updated procedures were in effect. Since then, the University has enhanced its process for identifying when a student ceases participation in a course. Faculty are now required to indicate when a student stops attending. If a faculty member and student agree on issuing an incomplete grade, both must sign a document attesting that the incomplete is a valid final grade. This ensures clarity for the Registrar's Office. Registrar staff now update the National Student Clearinghouse promptly once a student’s last date of activity is confirmed, particularly when a student withdraws from all courses. This process supports timely compliance with the 60-day federal reporting requirement. Additionally, the University is reviewing its procedures for reporting program enrollment effective dates to ensure consistency with NSLDS standards. All updates are submitted through the National Student Clearinghouse. IUP: IUP will set guidelines that all degree clearing must be done with the 45 day time line so the students are reported within the 60 days limit Cheyney: Cheyney University of Pennsylvania extracts current enrollment information, including any enrollment status changes for all students from the University system of record based on the schedule timeline provided to NSC. As of Fall 2024, The Registrar’s Office continues to review NSC information following transmission, particularly for effective dates of completely withdrawn students. The NSC reports enrollments to NSLDS for the University. Cheyney University had previously learned that NSLDS did not receive students' enrollment status changes from NSC in a timely manner due the University HCM2 status and timing of students being reported to NSLDS from COD based on Ed’s approval of the University HCM2 submissions Kutztown: We will shorten our process to 2-3 days to compensate from the (up to) 30 day lag between NSC reporting and NSLDS reporting. We will connect with another PASSHE school (not on the findings report) to ascertain how they keep their submissions timely, and learn best practices. We will renew our cooperative efforts with financial aid to ensure both sides of the equation – NSC and NSLDS – are communicating and that both offices are involved in double checking. Commonwealth: The issues with enrollment reporting were one-time issues related to the integration of the three schools and the implementation of and data migration to a new student information system. Issues have been resolved and Commonwealth University is currently reporting on the prescribed schedule Millersville: The Registrar’s Office will evaluate their procedures and review policies surrounding reporting status changes to NSLDS to ensure the enrollment effective date reported to NSLDS is aligning with the University’s last date of attendance. Primarily, the frequency of submissions to the NSC.

View Audit 348667

Finding 537424 (2024-006)

Material Weakness 2024

Blackford County Schools

IN

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

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

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

View Audit 348618

Finding 537413 (2024-028)

Significant Deficiency 2024

State of Vermont

VT

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

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

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

View Audit 348596

Finding 537402 (2024-025)

Significant Deficiency 2024

State of Vermont

VT

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

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

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

View Audit 348596

Finding 537401 (2024-024)

Significant Deficiency 2024

State of Vermont

VT

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

Reference Number: 2024-024 Prior Year Finding: 2023-031; 2022-037; 2021-025; 2020-014; 2019-010 Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: Medicaid Cluster Assistance Listing Number: 93.775, 93.777, 93.778 Award Number and Yea...

Reference Number: 2024-024 Prior Year Finding: 2023-031; 2022-037; 2021-025; 2020-014; 2019-010 Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: Medicaid Cluster Assistance Listing Number: 93.775, 93.777, 93.778 Award Number and Year: 2305VT5MAP (10/1/2022 – 9/30/2023) 2405VT5MAP (10/1/2023 – 9/30/2025) Compliance Requirement: Special Tests and Provisions - Provider Health and Safety Standards Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend the Agency fully implement its CAP to ensure that documentation is maintained in accordance with program requirements and that all providers are compliant with required health and safety standards. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: All Letters of Good Standing as well as a Standard Operating Procedure to ensure continuation were implemented in April of 2022. Prior to April the process was manual and via telephone or email with the Tax Department. All Providers who had their tax standing validated prior to April 2022 via phone or email were not solicited to get a written notification from the Tax Commissioner. As of April 2022 all tax standing reviews are validated with a letter from the Vermont Tax department and documented in the Provider Management Module. Verification with the VT Tax Department of a provider’s tax standing has always occurred; However, the good standing verification was documented in the PMM system and the confirmation of the verification from the VT Tax Department was not consistently maintained in the PMM. Although the Agency has implemented its corrective action plan from a prior year audit, cases will still be identified under this CAP until the provider is due for their 5-year revalidation and successfully revalidates with VT Medicaid. Scheduled Completion Date of Corrective Action Plan: Completed Contacts for Corrective Action Plan: Deidra Jarvis, Member and Provider Services Supervisor deidra.Jarvis@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 348596

Finding 537400 (2024-023)

Significant Deficiency 2024

State of Vermont

VT

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

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

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

View Audit 348596

Finding 537399 (2024-022)

Significant Deficiency 2024

State of Vermont

VT

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

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

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

View Audit 348596

Finding 537387 (2024-021)

Significant Deficiency 2024

State of Vermont

VT

Eligibility Student Financial Aid Subrecipient Monitoring § 200.303

Reference Number: 2024-021 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: CCDF Cluster Assistance Listing Number: 93.575, 93.596 Award Number and Year: 2301VTCCDD (10/1/2022 – 9/30/2025) 2401VTCCDD (10/1/202...

Reference Number: 2024-021 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: CCDF Cluster Assistance Listing Number: 93.575, 93.596 Award Number and Year: 2301VTCCDD (10/1/2022 – 9/30/2025) 2401VTCCDD (10/1/2023 – 9/30/2026) Compliance Requirement: Eligibility Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend that the Agency review and enhance procedures and controls to ensure that it verifies U.S. citizenship for all participants and confirm that only eligible participants receive benefits under the program. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: This finding has been corrected as of January 2024 dating back to October 2023. The State is no longer pooling funding sources which means that we can identify cases by their true funding source. This means that only true CCDF cases will be audited going forward and family service cases (protective service) no longer follow CCDF rules including citizenship and identity. Scheduled Completion Date of Corrective Action Plan: December 31, 2024 Contacts for Corrective Action Plan: Karolyn Long, Operations Director karolyn.long@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 348596

Finding 537386 (2024-020)

Material Weakness 2024

State of Vermont

VT

Special Tests & Provisions Subrecipient Monitoring Material Weakness § 200.303

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

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

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Finding 537379 (2024-019)

Significant Deficiency 2024

State of Vermont

VT

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

Reference Number: 2024-019 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: Temporary Assistance for Needy Families Assistance Listing Number: 93.558 Award Number and Year: 2301VTTANF (10/1/2022 – 9/30/2023) 2...

Reference Number: 2024-019 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: Temporary Assistance for Needy Families Assistance Listing Number: 93.558 Award Number and Year: 2301VTTANF (10/1/2022 – 9/30/2023) 2401VTTANF (10/1/2023 – 9/30/2024) Compliance Requirement: Reporting – ACF-199 Special Tests and Provisions – Penalty for Failure to Comply with Work Verification Plan Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend that the Agency review and enhance procedures and controls to ensure that it maintains adequate documentation, verification, and internal control procedures to ensure the accuracy of work participation rates reported in the ACF-199 reports. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: For the data system programming error finding, the Department removed the hard coding in the programming that limited participant hours to 40. This was completed as soon as the error was identified and our regional team approved the proposed corrective action. For the individual instances where the reported work participation rates reported on the ACF-199 report did not agree with supporting documentation and that supporting documentation contained errors or was incomplete, the Department will do the following: • Highlight each of the individual types of errors in our weekly newsletter that goes out to all staff and describe the correct action that should have been taken in documentation. • Have members of Reach Up Central Office (RUCO) team attend the Senior Benefits Program Specialist Sr. BPS) meeting to review the individual types of errors and describe the correct action that should have been taken. Sr. BPS are responsible for the direct training of district Benefits Program Specialists (BPS) that process eligibility. Following their meeting they will return to their district offices and provide an overview to the district eligibility staff. • RUCO will hold a virtual office hours session for eligibility staff to attend focused on the individual types of errors and the correct action that should have been taken. Scheduled Completion Date of Corrective Action Plan: • Data system programming error was corrected in October 2024. • Newsletter highlights will be shared with staff by January 31, 2025. • Sr BPS meeting will be attended by February 28, 2025. • Virtual office hours will be held by March 31, 2025. Contacts for Corrective Action Plan: Chris Dorer, Reach Up Assistant Administrator christine.dorer@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

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Finding 537378 (2024-018)

Material Weakness 2024

State of Vermont

VT

Subrecipient Monitoring Material Weakness Reporting § 200.303

Reference Number: 2024-018 Prior Year Finding: 2023-024 Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: COVID-19 - Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Hea...

Reference Number: 2024-018 Prior Year Finding: 2023-024 Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: COVID-19 - Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crises Assistance Listing Number: 93.391 Award Number and Year: NH75OT000034 (6/1/2021 – 5/31/2026) Compliance Requirement: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance Recommendation: We recommend the Agency complete implementation of its prior year CAP to ensure that all required subawards and subaward modifications are reported timely to FSRS in accordance with FFATA requirements and that all previously issued subawards are reported. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: The Financial Administrator will ensure that subrecipient grants containing federal funding that meet the FFATA reporting threshold are marked as “required for entry into the FSRS system” upon grant execution. The Financial Administrator and Manager will then confirm that all executed agreements that meet the FFATA reporting requirement have been entered and submitted into the FSRS system by the last business day of each month. Please note that the scheduled completion date is 2/1/23 as the same FFATA reporting finding was identified for a different program during the SFY22 Single Audit, and the corrective action plan was applied across the Department as a whole. The FFATA issues identified in the SFY24 Single Audit pre-dated the implementation of the Health Department’s original corrective action plan. Scheduled Completion Date of Corrective Action Plan: February 1, 2023 Contacts for Corrective Action Plan: Lillian Smith, Financial Administrator lillian.smith@vermont.gov Jessica Brown, Financial Manager jessica.brown@vermont.gov Megan Hoke, Financial Director megan.hoke@vermont.gov Peter Moino, Director of Internal Audit peter.moino@vermont.gov

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Finding 537377 (2024-017)

Material Weakness 2024

State of Vermont

VT

Material Weakness Reporting Matching / Level of Effort / Earmarking § 200.303

Reference Number: 2024-017 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: COVID-19 - Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcar...

Reference Number: 2024-017 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: COVID-19 - Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crises Assistance Listing Number: 93.391 Award Number and Year: NH75OT000034 (6/1/2021 – 5/31/2026) Compliance Requirement: Reporting – Performance Reporting Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance Recommendation: We recommend the Agency review and enhance internal controls and procedures to ensure that performance reports are accurate, agree with supporting documentation, and that supporting documentation is maintained and available for audit. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: The Office of Health Equity Integration’s Director and Equity Manager will ensure that all supporting documentation are cross checked with formal submissions in CDC’s REDCap reporting system to verify consistency and accuracy of performance reports. Additionally, the Equity Manager and Program Administrator will confirm all supporting documentation are properly stored in the program’s SharePoint site by the end of each quarterly reporting period. Scheduled Completion Date of Corrective Action Plan: January 31, 2025 Contacts for Corrective Action Plan: Katherine Richardson, Program Administrator katherine.richardson@vermont.gov Ariel Carter, Equity Manager ariel.carter@vermont.gov Song Nguyen, Equity Director song.nguyen@vermont.gov Megan Hoke, Financial Director III megan.hoke@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

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Finding 537373 (2024-016)

Significant Deficiency 2024

State of Vermont

VT

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Reference Number: 2024-016 Prior Year Finding: 2023-018; 2022-029; 2021-018 Federal Agency: U.S. Department of Education State Agency: Agency of Education Federal Program: COVID-19 – Governor’s Emergency Education Relief Fund COVID-19 – Elementary and Secondary School Emergency Relief Fund (ESSER) C...

Reference Number: 2024-016 Prior Year Finding: 2023-018; 2022-029; 2021-018 Federal Agency: U.S. Department of Education State Agency: Agency of Education Federal Program: COVID-19 – Governor’s Emergency Education Relief Fund COVID-19 – Elementary and Secondary School Emergency Relief Fund (ESSER) COVID-19 - Coronavirus Response and Relief Supplemental Appropriations Act, 2021 – Emergency Assistance to Non-Public Schools (CRRSA EANS) COVID-19 – American Rescue Plan – Elementary and Secondary School Emergency Relief (ARP ESSER) COVID-19 - American Rescue Plan – Elementary and Secondary School Emergency Relief –Homeless Children and Youth Assistance Listing Number: 84.425C, 84.425D, 84.425R, 84.425U, 84.425W Award Number and Year: S425C210009 (1/8/2021 – 9/30/2022) S425D210011 (1/5/2021 – 9/30/2022) S425R210033 (2/23/2021 – 9/30/2022) S425U210011 (3/24/2021 – 9/30/2023) S425W210047 (4/23/2021 – 9/30/2023) Compliance Requirement: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend the Agency complete implementation of its corrective action plan from the prior audit. It should review and enhance internal controls and procedures to ensure that all required subawards and subaward amendments are reported timely and accurately to FSRS no later than the end of the month following the month of issuance. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: The Agency implemented a reconciliation process in March of 2023 that allows us to ensure our grant ledgers agree with what is entered into FFATA. The Agency will increase the number of reconciliations per year to quarterly. The Agency continues to work toward our preferred solution to address the accuracy and timeliness of our entries into the FFATA system by creating an upload file of the data from our grants management system. Scheduled Completion Date of Corrective Action Plan: July 1, 2025 Position Responsible for Implementation of Corrective Action Sean Cousino, Interim CFO sean.couisno@vermont.gov

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