Corrective Action Plans

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Benjie Read CFO and Felecia Read Staff Accountant, will update written policies and procedures to implement the requirements of 2 CFR 200.305 to include a review and documentation of the cash draw requests prior to submission. This will be completed within 90 days of audit completion. In addition, w...
Benjie Read CFO and Felecia Read Staff Accountant, will update written policies and procedures to implement the requirements of 2 CFR 200.305 to include a review and documentation of the cash draw requests prior to submission. This will be completed within 90 days of audit completion. In addition, we no longer operate the only Federal program where cash draws were allowed.
With the support of a new leadership team, Jefferson Parish is committed to strengthening oversight and monitoring federal grants financial and compliance activities. To enhance reliability, the Parish has engaged Deloitte & Touche LLP as a consultant to assist with improving documentation procedure...
With the support of a new leadership team, Jefferson Parish is committed to strengthening oversight and monitoring federal grants financial and compliance activities. To enhance reliability, the Parish has engaged Deloitte & Touche LLP as a consultant to assist with improving documentation procedures and strengthen internal controls supporting financial and compliance activities going forward. As part of this effort Jefferson Parish and Deloitte are working across Finance, Accounting, and programmatic departments to establish improved federal grants governance and policy. This includes quarterly oversight and review processes and procedures to monitor the use of federal funds and confirm that compliance activities are occurring. This also includes improved preventative controls to require the performance of due diligence activities for each federal fund sub-recipient or individuals receiving federal assistance prior to the awarding or disbursement of federal funds. The Parish will also develop a policy and communicate annually to all departments the requirements to report to the appropriate authorities, including the Louisiana Legislative Auditor's Office and the Jefferson Parish District Attorney's Office. Community Development Director Stephanie Brumfield, Interim Finance Director Victor LaRocca and Risk Management Director Maria Leon will develop and communicate the policy for reporting fraud which should be enacted by January of 2026.
View Audit 370431 Questioned Costs: $1
Finding 2023-001 - Special Tests and Provisions: Wage Rate Requirements Responsible Individual: Arlene Dickens, Chief School Financial Officer Corrective Action: Wage rate clauses will be included in all federally funded construction contracts. Contractors and subcontractors will be notified in writ...
Finding 2023-001 - Special Tests and Provisions: Wage Rate Requirements Responsible Individual: Arlene Dickens, Chief School Financial Officer Corrective Action: Wage rate clauses will be included in all federally funded construction contracts. Contractors and subcontractors will be notified in writing of prevailing wage requirements, and certified payrolls will be required and reviewed for all weeks for which construction work is performed. Anticipated Completion Date: October 1, 2025
View Audit 370343 Questioned Costs: $1
PAX implemented a dedicated cost center in the books and records specifically for tracking cost shared expenses midyear during FY23 rather than the previous practice of recognition of cost share at year end closing. Full implementation of contemporaneous tracking of cost share was implemented in FY2...
PAX implemented a dedicated cost center in the books and records specifically for tracking cost shared expenses midyear during FY23 rather than the previous practice of recognition of cost share at year end closing. Full implementation of contemporaneous tracking of cost share was implemented in FY24. Additionally, PAX now reconciles against this cost center to ensure that the expenses reported to the grantor and budgetary allocations align with the actual expenditures.
Management’s Response and Corrective Action: The City recently went through implementation of a new financial software, which has allowed for development of some documentation and assignment of roles and responsibilities with the new system. Staff will make efforts to enhance and update this documen...
Management’s Response and Corrective Action: The City recently went through implementation of a new financial software, which has allowed for development of some documentation and assignment of roles and responsibilities with the new system. Staff will make efforts to enhance and update this documentation to provide specific details about the annual financial reporting. The City has also struggled with vacancies in key positions, as well as challenges in completing successful recruitments to fill the positions; staff exploring options for third party assistance with financial reporting functions.
Niagara Area Management Corporation is recruiting a new Chief Financial Officer and has a new Director of Finance. NAMC has also engaged a new public accounting firm. It is NAMC policy to submit the annual audited financial statements and the data collection form to the Federal Audit Clearinghouse w...
Niagara Area Management Corporation is recruiting a new Chief Financial Officer and has a new Director of Finance. NAMC has also engaged a new public accounting firm. It is NAMC policy to submit the annual audited financial statements and the data collection form to the Federal Audit Clearinghouse within 9 months after year-end.
To: FY2023 Uniform Guidance Reporting Package From: Gina Smith, VP, Fiscal Service/Controller RE: 2023 Uniform Guidance Audit Corrective Action Plan Date: 9/27/2024 Finding 2023-001 – Reporting Federal Program: Provider Relief Fund and American Rescue Plan Rural Distribution ALN: 93.498 Grady Memori...
To: FY2023 Uniform Guidance Reporting Package From: Gina Smith, VP, Fiscal Service/Controller RE: 2023 Uniform Guidance Audit Corrective Action Plan Date: 9/27/2024 Finding 2023-001 – Reporting Federal Program: Provider Relief Fund and American Rescue Plan Rural Distribution ALN: 93.498 Grady Memorial Hospital Corporation’s (Grady) CFO and VP of Fiscal Services/Controller have reviewed the reporting from KPMG relating to the Uniform Guidance. We understand the recommendation set forth by KPMG and will revamp our controls and processes to include additional management review of the SEFA to include the prior of any submission and to provide evidence of the related review Grady’s corrective action plan: Grady Memorial Hospital Corporation has implemented a new review policy for the submissions of PRF reports which also includes a new reporting and review procedure that are performed by the Controller and Tax & Technical Accounting Manager. GMHC will implement controls and processes to ensure grant reports are reviewed prior to submission and that evidence of review is maintained within the timeline it was signed. Contact person/s responsible for the correction action: Gina Smith, VP, Fiscal Service/Controller Anticipated Completion Date: Grady Memorial Hospital Corporation has implemented controls and processes to ensure grant reports are reviewed prior to submission and that evidence of review is maintained
(2023-005) Late Submission of Single Audit Reporting Package Criteria Per 2 CFR § 200.512(l), non-federal entities must submit the Single Audit reporting package to the Federal Audit Clearinghouse within the earlier of 30 calendar days after receipt of the auditor’s report or nine months after the f...
(2023-005) Late Submission of Single Audit Reporting Package Criteria Per 2 CFR § 200.512(l), non-federal entities must submit the Single Audit reporting package to the Federal Audit Clearinghouse within the earlier of 30 calendar days after receipt of the auditor’s report or nine months after the fiscal year-end. Condition The District’s reporting package for the fiscal year ended June 30, 2023, was not submitted to the Federal Audit Clearinghouse within the required timeframe. As of the date of this report, the reporting package has not yet been submitted. Cause The District did not have adequate procedures in place to ensure timely completion of the financial audit and preparation of the reporting package. Effect The District did not comply with the Uniform Guidance submission deadline, which may impact the timeliness of federal oversight and potentially affect future federal funding decisions. Questioned Costs No questioned costs were identified as a result of our procedures. Context/Sampling The FY2023 Single audit was performed in 2025 after it was determined that the grant funds were expended on eligible activities, triggering the Single Audit requirement. The delay was due to the District not identifying the requirement timely and lacking procedures to ensure prompt submission. Recommendation We recommend that the District implement processes and internal controls to ensure future Single Audits are completed and submitted within the required timeframe. Management’s Corrective Action Planned Management concurs with the recommendation. IVGID will establish a procedure to review and reconcile grants both federal and state at year-end to determine the need for a single audit and submission to the required agencies.
Views of Responsible Officials: The cause is related to the digital nature of the drawdown process and staff turnover. ICFJ will institute a procedure to capture drawdown information and/or create a documentation at the time of drawdown. Storage of the documentation will be incorporated into ICFJ’s ...
Views of Responsible Officials: The cause is related to the digital nature of the drawdown process and staff turnover. ICFJ will institute a procedure to capture drawdown information and/or create a documentation at the time of drawdown. Storage of the documentation will be incorporated into ICFJ’s digital records storage.
Views of Responsible Officials: ICFJ will implement procedures and control processes to track cost share requirements and the progress towards the requirements. Support for the cost share claimed should also be available upon request.
Views of Responsible Officials: ICFJ will implement procedures and control processes to track cost share requirements and the progress towards the requirements. Support for the cost share claimed should also be available upon request.
FINDING 2023-004 Finding Subject: COVID-19-Education Stabilization Fund - Special Tests and Provisions – Wage Rate Requirements Summary of Finding: Construction contracts in excess of $2,000 financed by federal assistance funds must pay wages not less than those established for the locality of the p...
FINDING 2023-004 Finding Subject: COVID-19-Education Stabilization Fund - Special Tests and Provisions – Wage Rate Requirements Summary of Finding: Construction contracts in excess of $2,000 financed by federal assistance funds must pay wages not less than those established for the locality of the project (prevailing wage rates) by the Department of Labor (DOL) to their laborers and mechanics. Nonfederal entities are to include in their construction contracts subject to the Wage Rate Requirements a provision that the contractor or subcontractor comply with these requirements and the DOL regulations. This would include a requirement to submit a copy of the payroll and statement of compliance to the entity for each week in which contract work was performed. The School Corporation had not designed nor implemented a system of internal controls to ensure that construction contracts in excess of $2,000 paid from federal grant funds included a prevailing wage rate clause. One construction contract, totaling$149,995, was paid for with COVID-19 – Education Stabilization Fund grant funds during the audit period. The contract did not include the required prevailing wage rate clause, nor were the certified payrolls submitted by the contractor. Contact Person Responsible for Corrective Action: Leslie Rittenhouse Contact Phone Number and Email Address: 765-395-3341 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The district has no plans nor approved budget for any remaining ESSER funds to be used a manner which would relate to the prevailing wage rate clause. Should the district amend the use of ESSER funding to include such activity the prevailing wage clause requirements will be completed in full. Anticipated Completion Date: Immediately.
FINDING 2023-003 Finding Subject: COVID-19-Education Stabilization Fund - Reporting Summary of Finding: The School Corporation was required to submit an annual data report to the Indiana Department of Education (IDOE) via JotForm, a form/report builder. Data to be submitted included, but was not lim...
FINDING 2023-003 Finding Subject: COVID-19-Education Stabilization Fund - Reporting Summary of Finding: The School Corporation was required to submit an annual data report to the Indiana Department of Education (IDOE) via JotForm, a form/report builder. Data to be submitted included, but was not limited to, current period expenditures, prior period expenditures, and expenditures per activity. During the audit period the School Corporation submitted two ESSER I reports, two ESSER II reports and two ESSER III reports, for a total of six reports. The annual data reports were prepared by the Treasurer. Due to the lack of effective internal controls one of the six annual data reports was not supported by the School Corporation’s records. For the ESSER III, Year 2 report, which covered the period of July 1, 2021 to June 30, 2022, total expenses per the report were $688,778. However, the School Corporation’s ledger had total expenses for the award, for that time period, of $784,638. The lack of controls and noncompliance were isolated to the ESSER III, Year 2 report. Contact Person Responsible for Corrective Action: Leslie Rittenhouse Contact Phone Number and Email Address: 765-395-3341 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: As the finding and error occurred in one entry of one report the district will continue the practice of having a second party review financial system data against report entries. The error in this instance was a misunderstanding of the entry. A secondary review of reporting guidelines and entries will take place prior to submission of any ESSER Data Reporting. Anticipated Completion Date: Upon the next submission of ESSER Data reporting.
The City has developed a Personnel Activity Report (PAR) that has each federal grant program available as a drop-down menu item. Employees will be required to indicate time spent on grant activities daily. This PAR will be reviewed an approved by the employees' supervisor and then submitted to Payro...
The City has developed a Personnel Activity Report (PAR) that has each federal grant program available as a drop-down menu item. Employees will be required to indicate time spent on grant activities daily. This PAR will be reviewed an approved by the employees' supervisor and then submitted to Payroll for allocation to appropriate grant funds. The PAR will be retained by Payroll as backup.
The City has developed a Personnel Activity Report (PAR) that has each federal grant program available as a drop-down menu item. Employees will be required to indicate time spent on grant activities daily. This PAR will be reviewed an approved by the employees' supervisor and then submitted to Payro...
The City has developed a Personnel Activity Report (PAR) that has each federal grant program available as a drop-down menu item. Employees will be required to indicate time spent on grant activities daily. This PAR will be reviewed an approved by the employees' supervisor and then submitted to Payroll for allocation to appropriate grant funds. The PAR will be retained by Payroll as backup.
Corrective Action Plan: To address this issue and prevent recurrence, the Town has implemented the following measures: 1. Reconciliation Procedures: Finance Department staff will reconcile all expenditures reported on USDA Form E – RD Project Budget/Cost Certification Reporting to the general ledger...
Corrective Action Plan: To address this issue and prevent recurrence, the Town has implemented the following measures: 1. Reconciliation Procedures: Finance Department staff will reconcile all expenditures reported on USDA Form E – RD Project Budget/Cost Certification Reporting to the general ledger, ensuring both the accuracy of amounts and the correct vendor attribution. 2. Vendor Verification: A vendor cross-check process will be added to the review, requiring staff to match each reported expenditure to the appropriate invoice, purchase order, and vendor record before submission. 3. Review & Approval Controls: A supervisory review will be conducted prior to submission of Form E reports to verify vendor accuracy, in addition to ensuring no duplicate or misclassified expenditures are reported. The Town is committed to ensuring compliance with all USDA reporting requirements. By strengthening reconciliation, vendor verification, and review processes, we will reduce the risk of reporting errors and maintain accurate, reliable financial reporting moving forward.
The Board of County Commissioners will work with all elected officials, the new county grant administrator, and federal, state and local partners to develop policies, procedures, and internal controls designed to accurately track grants, including the application process, verification, oversight, an...
The Board of County Commissioners will work with all elected officials, the new county grant administrator, and federal, state and local partners to develop policies, procedures, and internal controls designed to accurately track grants, including the application process, verification, oversight, and reporting of grant requirements. The Board of County Commissioners will work with the new county grant administrator to ensure proper grant administration.
View Audit 367368 Questioned Costs: $1
2024-006 - Reporting - Significant Deficiency/Noncompliance Federal Program: Assistance Listing #21.027, COVID-19 - Coronavirus State and Local Fiscal Recovery Funds, U.S. Department of Treasury, Passed Through Pennsylvania Department of Community and Economic Development, Pass-Through Entity Identi...
2024-006 - Reporting - Significant Deficiency/Noncompliance Federal Program: Assistance Listing #21.027, COVID-19 - Coronavirus State and Local Fiscal Recovery Funds, U.S. Department of Treasury, Passed Through Pennsylvania Department of Community and Economic Development, Pass-Through Entity Identifying Number: not available Condition/Context: The County’s required reports for the quarters ended June 30, 2023, September 30, 2023, and December 31, 2023, were due to be filed by the end of the month after the report end date (July 31, 2023, October 31, 2023, and January 31, 2024, respectively). The County filed its report on August 23, 2023, November 17, 2023, and February 15, 2024 (23, 17, and 15 days, respectively), after the required due date. Views of Responsible Officials and Planned Corrective Actions: Management understands and will seek to implement procedures to ensure future reports are submitted timely. Individual Responsible: Finance Department Timeline for corrective action: By December 31, 2024
Finding Number 2023-071 Subject Heading (Financial) or AL no. and program name (Federal) 93.778 Medicaid Cluster Planned Corrective Action OKDHS Response: The agency will manually load the workflow queues using the monitoring transactions for the G1dx discrepancies, and we will continuously work to ...
Finding Number 2023-071 Subject Heading (Financial) or AL no. and program name (Federal) 93.778 Medicaid Cluster Planned Corrective Action OKDHS Response: The agency will manually load the workflow queues using the monitoring transactions for the G1dx discrepancies, and we will continuously work to improve the system failures preventing automatic workload management. This includes bi-weekly updates to ensure all items are properly queued for resolution until the system can fully resume this functionality. OHCA Member Audit Response: Member Audit began receiving Medicaid G1DX files monthly in September of 2023. Files are continuing to be received from DHS each month. Audits are completed monthly and will continue indefinitely. Any discrepancies are discussed with OKDHS to determine the cause and remedy put in place to ensure any failed jobs were resolved. Anticipated Completion Date 9/30/2025 Responsible Contact Person Jennifer McSparrin, OKDHS Programs Administrator of Business Intelligence April Anonsen, Deputy State Medicaid Director Ginger Clayton, Director of Member Audits
Finding Number 2023-037 Subject Heading (Financial) or AL no. and program name (Federal) 93.778 Medicaid Cluster 93.767 Children’s Health Insurance Program Planned Corrective Action OHCA MAGI Response: OHCA implemented system changes to begin income verification requests for all selfattested income ...
Finding Number 2023-037 Subject Heading (Financial) or AL no. and program name (Federal) 93.778 Medicaid Cluster 93.767 Children’s Health Insurance Program Planned Corrective Action OHCA MAGI Response: OHCA implemented system changes to begin income verification requests for all selfattested income from sources unable to be verified through existing data exchange. The system changes went to production on January 13, 2022 but were impacted by Public Health Emergency (PHE) requirements prohibiting termination of eligibility. The system changes became effective at the end of the PHE and have resulted in appropriate verification of income that was previously unverified. Guidance from Centers for Medicare and Medicaid Services (CMS) during the PHE prohibited the agency from requiring verification, renewals, or termination of Medicaid during the PHE. The agency followed the requirements and guidance of CMS throughout the PHE to ensure maintenance of coverage. OHCA is in the process of implementing system changes to ensure only previously verified income is removed and to ensure that applications in a pending status due to incomplete information from the Federal Marketplace continue to receive new data exchange information. OHCA continues to improve zero income self-attestation procedures as the value of the attestations in ensuring accurate eligibility decisions is recognized, and upgrades went to Production on April 17, 2025. Guidance from Centers for Medicare and Medicaid Services (CMS) during the PHE prohibited the agency from requiring verification, renewals, or termination of Medicaid during the PHE. The agency followed the requirements and guidance of CMS throughout the PHE to ensure maintenance of coverage. OHCA concurs with the Soon-to-be-Sooners (STBS) exception. The questioned costs will be reported on the CMS 64.9P line 10A on Cost of Service (COS) line 5 for the quarter ending June 30, 2025. OHCA Member Audit MAGI Response: Member Audit will complete three months of post-corrective action audits to ensure completion. If corrective action results are not sufficient, additional corrective action will be requested, and post- corrective action audit will be repeated. OKDHS Non-MAGI Response: For the non-MAGI deficiencies, OKDHS has addressed case issues through the establishment of a committee responsible for monitoring corrective actions and provided training to all appropriate employees. Additional informational webpages utilized by eligibility staff have been updated. OHCA Member Audit Non-MAGI Response: OHCA Member Audit has been monitoring these issues through monthly case reviews and provides feedback to OKDHS leadership. This process will continue until the issues have been corrected. Additional steps to correct issues are requested as deemed necessary by Member Audit. Anticipated Completion Date 8/31/2025 Responsible Contact Person Chris Dees, Eligibility and Coverage Services Technical Director April Anonsen, Deputy State Medicaid Director Ginger Clayton, OHCA Director of Member Audits Aubrey McDonald , OKDHS Medicaid Program Administrator Ginger Clayton, OHCA Director of Member Audits
View Audit 367158 Questioned Costs: $1
Finding Number 2023-030 Subject Heading (Financial) or AL no. and program name (Federal) 93.778 Medicaid Cluster Planned Corrective Action Internal control processes and procedures to ensure MFCU overpayments are timely reported and refunded to the Center for Medicare and Medicaid Services (CMS) wer...
Finding Number 2023-030 Subject Heading (Financial) or AL no. and program name (Federal) 93.778 Medicaid Cluster Planned Corrective Action Internal control processes and procedures to ensure MFCU overpayments are timely reported and refunded to the Center for Medicare and Medicaid Services (CMS) were implemented beginning September 2024. These processes include collaborations with the Medicaid Fraud Control Unit at the Oklahoma Attorney General’s office quarterly to track the status of closed cases, obtain sufficient supporting documentation, and timely report and refund identified overpayments on the CMS- 64. Anticipated Completion Date 1/31/2025 Responsible Contact Person Kristine West, Senior Director of Program Integrity and Accountability
Finding Number 2023-024 Subject Heading (Financial) or AL no. and program name (Federal) 93.778 Medicaid Cluster Planned Corrective Action OKDHS Response: OKDHS experienced technical issues at OMES and certificate issues with the IRS. OKDHS upgraded our machine portal for IRS Axway to Windows 10, an...
Finding Number 2023-024 Subject Heading (Financial) or AL no. and program name (Federal) 93.778 Medicaid Cluster Planned Corrective Action OKDHS Response: OKDHS experienced technical issues at OMES and certificate issues with the IRS. OKDHS upgraded our machine portal for IRS Axway to Windows 10, and corrected the certificate issues preventing the job moving to the mainframe. OHCA Member Audit Response: Member Audit began receiving files monthly in September of 2023. Job lists are reviewed and compared against schedules and any discrepancies are discussed with OKDHS to determine the cause and remedy put in place to ensure any failed jobs were resolved. This review will continue indefinitely. Anticipated Completion Date 5/31/2025 Responsible Contact Person Jeff Rosenberry, OKDHS Programs Administrator April Anonsen, Deputy State Medicaid Director Ginger Clayton, OHCA Director of Member Audits
Finding Number 2023-020 Subject Heading (Financial) or AL no. and program name (Federal) 93.778 Medicaid Cluster Planned Corrective Action To improve accuracy and timeliness of expenditure reporting, OHCA plans to schedule internal meetings between Long Term Services and Supports (LTSS) staff, finan...
Finding Number 2023-020 Subject Heading (Financial) or AL no. and program name (Federal) 93.778 Medicaid Cluster Planned Corrective Action To improve accuracy and timeliness of expenditure reporting, OHCA plans to schedule internal meetings between Long Term Services and Supports (LTSS) staff, financial management team, and federal reporting team, at a minimum, quarterly. The team will discuss project progress and review budget to actual expenditures to be reported in the quarterly spending plan. As needed, OHCA will request the Center for Medicare and Medicaid (CMS) Technical Assistance (TA) to ensure OHCA is reporting in the manner CMS requires. Prior to submitting an American Rescue Plan Act of 2021 (ARPA) spending plan, the completed document will be circulated to the internal team for review and approved by the LTSS Senior Director. Because the amount reported is cumulative, the error self-corrects in future spending plans; therefore, OHCA does not plan to re-submit previously reported spending plans. Anticipated Completion Date 10/31/2024 Responsible Contact Person David Ward, Senior Director of Sooner Care Operations
Finding Number 2023-016 Subject Heading (Financial) or AL no. and program name (Federal) 93.778 Medicaid Cluster Planned Corrective Action Program Integrity was actively implementing corrective action to ensure that all overpayments were reported within 12 months from identification when these cases...
Finding Number 2023-016 Subject Heading (Financial) or AL no. and program name (Federal) 93.778 Medicaid Cluster Planned Corrective Action Program Integrity was actively implementing corrective action to ensure that all overpayments were reported within 12 months from identification when these cases were closed. The errors associated with this finding were first reported on January 21, 2023 (Finding 2022-039) which resulted in OHCA developing corrective action to evaluate past cases and ensure all cases were reviewed and all overpayments were reported during the initial corrective action cycle. In all three instances related to late reporting of overpayments, all cases were reported on CMS-64.9c1 during implementation of corrective action plan as a result of the previous audit finding. One case was erroneously excluded during the corrective action plan. This finalized case was reported and refunded on the CMS-64.9OFWA, Line 1B for the quarter ending September 30, 2024 utilizing an average FMAP for all impacted programs. Internal procedures have been evaluated to ensure Service Quality Review overpayments are timely reported and refunded to the Center for Medicare and Medicaid Services (CMS). The cost of $4,007 questioned were reported on the CMS 64.9P line 10A on Cost of Service (COS) line 5 for the quarter ending March 31, 2025. Anticipated Completion Date 3/31/2025 Responsible Contact Person Kristine West, Senior Director of Program Integrity and Accountability
View Audit 367158 Questioned Costs: $1
Finding Number 2023-104 Subject Heading (Financial) or AL no. and program name (Federal) 93.575 – CCDF Cluster Planned Corrective Action The Oklahoma Department of Human Services (OKDHS) respectfully does not concur with the finding as written. We believe the State Auditor and Inspector (SAI) has no...
Finding Number 2023-104 Subject Heading (Financial) or AL no. and program name (Federal) 93.575 – CCDF Cluster Planned Corrective Action The Oklahoma Department of Human Services (OKDHS) respectfully does not concur with the finding as written. We believe the State Auditor and Inspector (SAI) has not fully considered the federal flexibility afforded under the American Rescue Plan (ARP) Act, and that some conclusions were drawn from incomplete documentation. The Child Care Desert Grant program was thoughtfully developed in response to urgent needs during the COVID-19 recovery, with the goal of expanding access to child care in underserved communities using the discretion and authority granted to states under federal guidance. While OKDHS acknowledges that improvements could have been made to certain aspects of the program’s implementation—particularly regarding documentation clarity, post-award monitoring, and technical assistance— the SAI findings do not reflect the intent, structure, or compliance framework outlined in federal guidance. 2 CFR § 200.303(a) – Internal Controls DHS has strengthened internal controls consistent with federal expectations. For example, in the instance involving a grantee related to a DHS official, the potential conflict was identified and escalated by OKDHS to SAI as well as the Ethics Commission, and the individual was not directly involved in the reviewing and approving award process. In addition, the employee’s spouse was not included on any documentation included in the facilities application. This demonstrates that internal controls operated effectively. 2 CFR § 200.403 – Allowability of Costs This regulation applies to allowability under the Uniform Guidance, but per 45 CFR § 75.101(d), Subpart E (which ncludes § 200.403) does not apply to CCDF ARP discretionary funds unless explicitly stated. Federal guidance, including ACF-IM-2021-03, affirms that states were given broad flexibility in the design and implementation of such programs. Accordingly, DHS used its discretion to structure payments and allowable uses consistent with that guidance. Many costs questioned by SAI—such as business technology, minor remodeling, and start-up costs—were clearly allowable per the Desert Grant Guidance. 42 U.S. Code § 9858c(c)(2)(I) DHS did not fund sectarian instruction or activities. Expenditures were related to facility compliance and licensing, which is expressly permitted under this section when needed to meet health and safety standards. Providers affirmed compliance in their applications. 42 U.S. Code § 9858k(a) No funding was used for sectarian worship or instruction. All grantees signed affirmations that they would comply with all federal requirements, including those related to religious neutrality. Where expenditures were found that may raise concerns, they are being reviewed for compliance with these requirements. 42 U.S. Code § 9858k(b) DHS did not provide funding for services rendered during the regular school day or for academic credit. In the referenced after-school program, funds were used to expand access to licensed child care outside of regular instructional hours. Documentation of use is being reviewed, and additional guidance will be provided to ensure clarity in future programs. 42 U.S. Code § 9858d(b) and 45 CFR § 98.2 – Construction and Renovation DHS recognizes that one provider exceeded the $350,000 minor remodeling limit. This was an isolated case. At the time, DHS did not interpret the project scope as meeting the federal definition of "major renovation." DHS is enhancing its oversight process and guidance to providers to ensure full alignment with federal cost limits moving forward. Additional Clarifications • Expenditures cited as unallowable often fall within the scope of minor remodeling, technology, or business development explicitly allowed in Desert Grant FAQs and ACF guidance. • SAI’s estimate of questioned costs includes speculative assumptions based on documentation gaps—not confirmed misuse. • Many of the questioned costs SAI appears to be extrapolating were supplied directly from OKDHS’ own internal audit team and have either been addressed or are under investigation and should not be included in any additional questioned cost extrapolation. • The program was developed under severe federal timelines (obligation by 9/30/23), and ACF’s memoranda explicitly encouraged innovative approaches, including expansion grants to new and small providers. Corrective Actions (Planned or Completed) to be implemented on future emergency awards 1. Policy & Procedure Enhancements – Revised award language, documentation standards, and milestone disbursement options are being implemented. 2. Conflict of Interest Controls – OKDHS had a conflict of interest control in place to try and capture all potential conflicts based on the structure of the agency. OKDHS is expanding the process to extend to any staff members that have decision making approval. 3. Improved Monitoring – Targeted post-award reviews, site checks, and spending verification measures are being conducted. 4. Provider Training & Technical Assistance – Providers are receiving additional education on fiscal documentation, grant compliance, and reporting expectations. Anticipated Completion Date N/A Responsible Contact Person Kayla Urtz
View Audit 367158 Questioned Costs: $1
Finding Number 2023-103 Subject Heading (Financial) or AL no. and program name (Federal) 93.575 – CCDF Cluster Planned Corrective Action The QRIS incentive payments were designed as a strategic investment to increase participation in Oklahoma’s redesigned Stars Quality Rating and Improvement System ...
Finding Number 2023-103 Subject Heading (Financial) or AL no. and program name (Federal) 93.575 – CCDF Cluster Planned Corrective Action The QRIS incentive payments were designed as a strategic investment to increase participation in Oklahoma’s redesigned Stars Quality Rating and Improvement System (QRIS), which aligns directly with the statutory purposes outlined in 42 USC 9858c(c)(3)(B) — specifically, improving the quality and availability of child care services. The incentive structure was intentionally crafted to encourage engagement among providers who had not previously participated in quality rating efforts. Encouraging this engagement is a nationally recognized strategy to improve the quality of care across the system. 42 USC § 9858c(c)(3)(B) The incentive payments were issued for the express purpose of engaging providers in a new QRIS system designed to improve child care quality, directly aligned with this statute. The law permits “activities that improve the quality or availability of such services” and “any other activity that the State determines to be appropriate.” DHS determined the incentive model was an appropriate and effective method to encourage participation in quality rating, a commonly accepted CCDF quality activity. 45 CFR § 98.67(a) DHS did follow its internal policies and procedures in disbursing incentive payments. Providers submitted applications, were vetted through an internal process, and received payments based on eligibility criteria and Stars level requests. This structure complied with DHS’s established process and satisfied the requirements of §98.67(a). The regulation does not impose a requirement for retrospective receipts or cost documentation for incentive payments. 45 CFR § 98.67(c)(2) QRIS incentive payments were disbursed through traceable, documented transactions—each tied to a provider’s application, Stars level requested, and approved amount. These records are maintained in DHS’s internal systems. There was no requirement in the federal Notice of Award (NOA) to trace QRIS incentive funds to the recipient expenditure level 2 CFR § 200.303(a) DHS established pre-award internal controls, including a structured QRIS application process, eligibility screening, and fixed incentive tiers linked to Stars level requests. The Department maintained auditable records of participation and payment amounts. There was no requirement in the federal Notice of Award to trace these funds to the recipient expenditure level, as the child care providers were not subrecipients under 2 CFR § 200.1. Instead, they received non-reimbursement incentive payments tied to participation in a state-defined quality improvement activity. The internal control standard calls for “reasonable assurance,” which DHS satisfied through documented eligibility reviews, centralized approvals, and audit-ready payment tracking. Anticipated Completion Date N/A Responsible Contact Person Kayla Urtz
View Audit 367158 Questioned Costs: $1
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