Corrective Action Plans

Finding 38619 (2022-002)

Significant Deficiency 2022

IL

Equipment & Real Property Management Matching / Level of Effort / Earmarking § 200.303 § 200.313

AL Numbers: Various Program: Research and Development Cluster Corrective Action: All departments of the University will be reminded by the Central Accounting department that tagging is an integral part of the internal control process for capital assets. The Central Accounting team will send a memo t...

AL Numbers: Various Program: Research and Development Cluster Corrective Action: All departments of the University will be reminded by the Central Accounting department that tagging is an integral part of the internal control process for capital assets. The Central Accounting team will send a memo to all equipment coordinators and Finance Managers at the campus units. The memo will be emailed by April 30, 2023. In addition, the Central Accounting team will schedule a virtual training to go over asset tagging procedures. All equipment coordinators will be invited to the training and it will be scheduled prior to June 30, 2023. Contact: Kathy Conrad and Maru Mendoza Expected Implementation: June 30, 2023

View Audit 48521

Finding 38610 (2022-002)

Significant Deficiency 2022

Alamosa County

CO

Special Tests & Provisions Subrecipient Monitoring Significant Deficiency

Finding 2022-002: Airport Improvement Program, CFDA No. 20.106 U.S. Department of Transportation Compliance Requirement: Special Tests and Provisions Grant No.: Not Applicable Type of Finding: Internal Control (significant deficiency) and Compliance (noncompliance) Recommendation: The County should ...

Finding 2022-002: Airport Improvement Program, CFDA No. 20.106 U.S. Department of Transportation Compliance Requirement: Special Tests and Provisions Grant No.: Not Applicable Type of Finding: Internal Control (significant deficiency) and Compliance (noncompliance) Recommendation: The County should develop policies and procedures to implement monitoring controls over the federal program wage rate requirements. Action Taken: Management will develop a quarterly process to implement monitoring controls needed to ensure proper federal program wage requirements on or before year end close of December 31, 2024.

View Audit 34681

Finding 38605 (2022-006)

Significant Deficiency 2022

Narragansett Indian Tribe

RI

Matching / Level of Effort / Earmarking

2022-006 Matching, Level of Effort, Earmarking NIT reply: NIT is in the process of reviewing the award with the funding agency for a better understanding of the necessary requirements of the award. Speedi Burrell, Director of Finance, Narragansett Indian Tribe

View Audit 34680

Finding 38601 (2022-004)

Material Weakness 2022

Narragansett Indian Tribe

RI

Matching / Level of Effort / Earmarking Procurement, Suspension & Debarment Allowable Costs / Cost Principles

Finding 2022-004 internal Controls and Compliance over Allowable Cost and Allowable Activity - Expenditures NIT reply: NIT will add another signatory/ reviewer to ensure NIT is compliant with our existing policy. Speedi Burrell, Director of Finance, Narragansett Indian Tribe

View Audit 34680

Finding 38581 (2022-004)

None 2022

Simpson University

CO

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles

ARP Earmarking Planned Corrective Action: The Office of Financial Aid called students and conducted in-person interviews as outreach to communicate the opportunity for an income adjustment professional judgement. However, we admittedly did not document the outreach in a manner that we can readily p...

ARP Earmarking Planned Corrective Action: The Office of Financial Aid called students and conducted in-person interviews as outreach to communicate the opportunity for an income adjustment professional judgement. However, we admittedly did not document the outreach in a manner that we can readily produce for audit purposes. Students were notated on a case-by-case basis. The employee leading these efforts is no longer employed by the University. The Office of Financial Aid will send out a new mass communication to all students to ensure students are still aware of the opportunity to submit a professional judgment based on COVID related income adjustments for FY23. Person Responsible for Corrective Action Plan: Shondra Dickson, Ryan Opfer Anticipated Date of Completion: 4/30/2023

View Audit 35847

Finding 38578 (2022-002)

Material Weakness 2022

Homeboy Industries

CA

Reporting Matching / Level of Effort / Earmarking

Management will hold monthly meetings with Government Director and Grants Manager to discuss any new grants received, status changes of existing grants, and review agreements to ensure all federal granted dollars are recognized and included in the SEFA.

View Audit 34305

Finding 38553 (2022-039)

Significant Deficiency 2022

State of Vermont

VT

Special Tests & Provisions Reporting Significant Deficiency § 200.303

Corrective Action Plan: The Agency has submitted the Medical Loss Ratio report for the year ending 12/31/2021 no later than 12/31/2022. The report was delivered on 12/29/2022. Department of Vermont Health Access (DVHA) and the Agency of Human Services (AHS) have worked together over the past year t...

Corrective Action Plan: The Agency has submitted the Medical Loss Ratio report for the year ending 12/31/2021 no later than 12/31/2022. The report was delivered on 12/29/2022. Department of Vermont Health Access (DVHA) and the Agency of Human Services (AHS) have worked together over the past year to define the roles and responsibilities needed to deliver the Medical Loss Ratio (MLR) to AHS by the due date. AHS has agreed to provide Medicaid summaries, and once December enrollment is available, provide capitation rates multiplied by final enrollment for total calendar year expenditures. Additional to AHS deliverables, DVHA has updated its Standard Operating Procedures (SOP) to reflect the deliverables from AHS, additional detail to support each step in the process, and validation steps for AHS upon completion of the report by DVHA. The steps that have been added to the process allow for a more comprehensive review of the deliverable by both departments which will allow for an on-time delivery in its entirety by the due date of December 31. Scheduled Completion Date of Corrective Action Plan: December 29, 2022 Contacts for Corrective Action Plan: Patrick Rooney, DVHA Financial Director patrick.rooney@vermont.gov Allison Nowak, DVHA Financial Director allison.jensen@vermont.gov Tracy O?Connell, AHS-CO Financial Director tracy.oconnell@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 30446

Finding 38552 (2022-038)

Material Weakness 2022

State of Vermont

VT

Subrecipient Monitoring Material Weakness Reporting § 200.303

Corrective Action Plan: Agency of Human Services Internal Audit Group (AHS-IAG) is a designated centralized reporter of subawards for a Medicaid cluster (AL No. 93.775, 93.777, 93.778) that is shared between all AHS departments. To address omissions and timeliness of subawards and subaward modificat...

Corrective Action Plan: Agency of Human Services Internal Audit Group (AHS-IAG) is a designated centralized reporter of subawards for a Medicaid cluster (AL No. 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 will conduct additional training tailored to each AHS Department to examine the results of FFATA testing conducted internally, and reemphasize the FFATA compliance regulations. This will ensure the Internal Audit Group (IAG) is provided with complete, accurate and timely subaward information for reporting in FSRS going forward. Further, on at least an annual basis, IAG will conduct 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: Annual review of FFATA rules and regulations including subawards sample testing December 31, 2022 Individualized training for each AHS Department January 31, 2023 Contact for Corrective Action Plan: Peter Moino AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 30446

Finding 38551 (2022-037)

Material Weakness 2022

State of Vermont

VT

Eligibility Special Tests & Provisions Material Weakness § 200.303

Corrective Action Plan 1. The corrective measures pertaining to DVHA?s enhanced oversight of Gainwell?s contractual obligation to DVHA to provide licensure validation service and documentation of active licensure will include established benchmarks for the overall improvement of the service, expans...

Corrective Action Plan 1. The corrective measures pertaining to DVHA?s enhanced oversight of Gainwell?s contractual obligation to DVHA to provide licensure validation service and documentation of active licensure will include established benchmarks for the overall improvement of the service, expansion of automated search services, progress reports and overall reduction of manual processes. By 5/1/2023 Gainwell will provide the DVHA Oversight & Monitoring Unit with Progress Reports that will be shared at the Fiscal Agent meeting and with DVHA Leadership to track progress and/or report roadblocks and escalate issues of any actual or potential failures to timely perform provider revalidations. Gainwell will use the Provider Management Module (PMM) and other services available to validate license of a provider. For those providers that cannot be validated through PMM or other services, Gainwell will send a letter notice to those providers. Letter notice must be sent no later than 30 days prior to a license expiration date. Gainwell shall submit to DVHA on a weekly basis a list of providers who have been notified that they are due for re-validation and have not responded within 14 days of license expiration date. Gainwell will use PMM and other services available to validate license of a provider. For those providers that cannot be validated through PMM or other services, Gainwell will send a letter notice to those providers. Letter notice must be sent no later than 30 days prior to a license expiring. The written detailed procedure for license updates will be finalized by 04/01/23 between the State and Gainwell and will include the following: a. Update the look forward period in the license screening service to 45 days. As a result, PMM will be updated automatically when the license screening service is available to locate an updated license. This configuration update will be in place by 04/01/23. For those licenses that the screening service is not able to locate an updated license, Gainwell will review and manually check for an updated license. If a new license is found, Gainwell will update accordingly. Gainwell will explore using Lexis Nexis as an additional service for manual review of license information and provide an update of potential solution by 03/17/23. If determined the Lexis Nexis solution is not viable, Gainwell will propose additional solution options by 05/01/23. b. Any provider whose license was not automatically updated as part of the screening service and could not be manually updated through the review process, an expiring license notification will be sent to the Mail-To contact information on file 30 days prior to their license expiration date. The expiring license notifications will be activated in PMM as of 04/01/23. Providers will be notified of this change in process as of 03/01/23 via banner. c. Gainwell will provide a weekly report of any providers whose license is set to expire in 14 days. This report will be delivered weekly beginning 04/17/23, two weeks after start date of license notifications. DVHA will work with Gainwell to finalize a process to address those providers listed. d. Gainwell will activate the termination job within the PMM that will automatically end a provider?s contract with VT Medicaid when no license was obtained through the process listed above by the license end date. This termination job will be activated on 06/05/23, two months after starting license notification. Notification to providers of this change in process will be sent no later than 05/01/23, via banner. Prior to the termination job being activated, Gainwell will continue to manually terminate when no updated license information is obtained, unless written exception is received from DVHA. All exception requests will be stored as part of the provider?s electronic record within PMM. By March 1st, 2023, Gainwell will provide the following information to DVHA: The databases, services, and available in state and out of state agencies Gainwell currently uses and plans to use in order to monitor and verify provider licenses and certifications; and 2. As of December 31, 2023, all revalidations will electronically reside in PMM. By December 31, 2023, All paper files, maintained prior to the implementation of the PMM, will be cataloged and sent to secure storage. To ensure all records are available for review, all application data is now being processed through PMM and available on demand. This includes paper application sent in by providers, Gainwell inputs the paper application into PMM. 3. The Letters of Good Tax Standing have been obtained. A standard operating practice is in place documenting the process. The process of validating tax standing in writing from the Tax Department has been in effect since April 2022. Providers who had their tax standing validated prior to April 2022 via phone or email were not solicited to obtain a written notification from the Tax Commissioner. At this time, the State has determined that it is not necessary to obtain a retroactive written notification from the Tax Commissioner for tax standing prior to April 2022. As of April 2022, all tax standing reviews are validated with a letter from the Tax Department and documented in the PMM. Scheduled Completion Date of Corrective Action Plan: 1. January 1, 2024 2. December 31, 2023 3. Completed Contacts for Corrective Action Plan: Suellen Bottiggi, DVHA Director of Member and Provider Services suellen.bottiggi@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 30446

Finding 38549 (2022-036)

Material Weakness 2022

State of Vermont

VT

Eligibility Special Tests & Provisions Material Weakness § 200.303

Corrective Action Plan: 1. The corrective measures pertaining to DVHA?s enhanced oversight of Gainwell?s contractual obligation to DVHA to provide licensure validation service and documentation of active licensure will include established benchmarks for the overall improvement of the service, expans...

Corrective Action Plan: 1. The corrective measures pertaining to DVHA?s enhanced oversight of Gainwell?s contractual obligation to DVHA to provide licensure validation service and documentation of active licensure will include established benchmarks for the overall improvement of the service, expansion of automated search services, progress reports and overall reduction of manual processes. By 5/1/2023 Gainwell will provide the DVHA Oversight & Monitoring Unit with Progress Reports that will be shared at the Fiscal Agent meeting and with DVHA Leadership to track progress and/or report roadblocks and escalate issues of any actual or potential failures to timely perform provider revalidations. Gainwell will use the Provider Management Module (PMM) and other services available to validate license of a provider. For those providers that cannot be validated through PMM or other services, Gainwell will send a letter notice to those providers. Letter notice must be sent no later than 30 days prior to a license expiration date. Gainwell shall submit to DVHA on a weekly basis a list of providers who have been notified that they are due for re-validation and have not responded within 14 days of license expiration date. The written detailed procedure for license updates will be finalized by 04/01/23 between the State and Gainwell and will include the following: a. Update the look forward period in the license screening service to 45 days. As a result, PMM will be updated automatically when the license screening service is available to locate an updated license. This configuration update will be in place by 04/01/23. For those licenses that the screening service is not able to locate an updated license, Gainwell will review and manually check for an updated license. If a new license is found, Gainwell will update accordingly. Gainwell will explore using Lexis Nexis as an additional service for manual review of license information and provide an update of potential solution by 03/17/23. If determined the Lexis Nexis solution is not viable, Gainwell will propose additional solution options by 05/01/23. b. Any provider whose license was not automatically updated as part of the screening service and could not be manually updated through the review process, an expiring license notification will be sent to the Mail-To contact information on file 30 days prior to their license expiration date. The expiring license notifications will be activated in PMM as of 04/01/23. Providers will be notified of this change in process as of 03/01/23 via banner. c. Gainwell will provide a weekly report of any providers whose license is set to expire in 14 days. This report will be delivered weekly beginning 04/17/23, two weeks after start date of license notifications. DVHA will work with Gainwell to finalize a process to address those providers listed. d. Gainwell will activate the termination job within PMM that will automatically end a provider?s contract with VT Medicaid when no license was obtained through the process listed above by the license end date. This termination job will be activated on 06/05/23, two months after starting license notification. Notification to providers of this change in process will be sent no later than 05/01/23, via banner. Prior to the termination job being activated, Gainwell will continue to manually terminate when no updated license information is obtained, unless written exception is received from the DVHA. All exception requests will be stored as part of the provider?s electronic record within PMM. By March 1st, 2023, Gainwell will provide the following information to DVHA: The databases, services, and available in state and out of state agencies Gainwell currently uses and plans to use in order to monitor and verify provider licenses and certifications; and 2. To ensure all providers revalidate a minimum of every 5 years, PMM is automatically assigning the revalidation due date. Providers are notified 90 days prior to the due date and again at 45 days, if the provider does not revalidate by the due date, their contract is automatically terminated. At this time, all active providers are assigned a revalidation due date and every provider converted from the old system to PMM has a schedule that will result in revalidation of all legacy providers by December 31, 2023. Exception: If a provider?s revalidation application is returned to them, the provider has until their revalidation due date, or 30 days, whichever is greater, to correct and resubmit their revalidation. Example: Provider?s revalidation due date is 12/30/23 and their revalidation application is returned on 12/29/23. The provider will have until 01/29/24 to correct and resubmit. 3. The Letters of Good Tax Standing have been obtained. A standard operating practice is in place documenting the process. The process of validating tax standing in writing from the Tax Department has been in effect since April 2022. Providers who had their tax standing validated prior to April 2022 via phone or email were not solicited to obtain a written notification from the Tax Commissioner. At this time, the State has determined that it is not necessary to obtain a retroactive written notification from the Tax Commissioner for tax standing prior to April 2022. As of April 2022, all tax standing reviews are validated with a letter from the Tax Department and documented in the PMM. Scheduled Completion Date of Corrective Action Plan: 1. January 1, 2024 2. December 31, 2023 3. Completed Contacts for Corrective Action Plan: Suellen Bottiggi, DVHA Director of Member and Provider Services suellen.bottiggi@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 30446

Finding 38548 (2022-035)

Significant Deficiency 2022

State of Vermont

VT

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

Corrective Action Plan: ? One of sixty participants selected for testing turned 19 during the fiscal year. Due to the COVID-19 Public Health Emergency, states did not get authority to move customers from one MEC coverage group to another MEC coverage group until January 2021. The SoV began transitio...

Corrective Action Plan: ? One of sixty participants selected for testing turned 19 during the fiscal year. Due to the COVID-19 Public Health Emergency, states did not get authority to move customers from one MEC coverage group to another MEC coverage group until January 2021. The SoV began transitioning eligible age-off?s in March 2021. A report was created to capture anyone who had aged off since the start of the PHE. HC eligibility staff worked through the report to determine if customers were eligible to transition to another MEC coverage group. This individual was not captured on the report. They did not get transitioned until April 20, 2022 when the customer called and asked to be screened for Medicaid new adult. This case appears to be an isolated case and has since been corrected. ? For one of sixty participants, eligibility determination exceeded 45 days. Due to the COVID-19 Public Health Emergency, the SoV was accepting self-attestation for all income and resource verifications until November 1, 2021. In this case, the customer applied via the self-service portal and their MAGI-income verification line item (VLI) was pending. The SoV had reports in place at the time to pull all self-service applications with pending VLI?s to manually change them to verified. The SoV ran a report in October 2021 prior to the state resuming verifications for new applications to ensure all pending verification line items were verified and customers were enrolled timely. This appears to be an isolated case. Scheduled Completion Date of Corrective Action Plan: ? Age-off correction: April 20, 2022 ? Eligibility determination timeliness: September 15, 2021 Contacts for Corrective Action Plan: Nicole McAllister, DVHA-HAEEU HCAA II nicole.mcallister@vermont.gov Sarah York, DVHA-HAEEU HCAA I sarah.york@vermont.gov

View Audit 30446

Finding 38547 (2022-034)

Significant Deficiency 2022

State of Vermont

VT

Student Financial Aid Eligibility Significant Deficiency § 200.303

Corrective Action Plan: The Child Development Division (CDD) has recently switched to a new IT system, Child Development Division Information System (CDDIS), that will check for the child?s IV-E eligibility and check to make sure that the child is in an eligible placement. With these checks it will...

Corrective Action Plan: The Child Development Division (CDD) has recently switched to a new IT system, Child Development Division Information System (CDDIS), that will check for the child?s IV-E eligibility and check to make sure that the child is in an eligible placement. With these checks it will allow the child to be marked as IV-E eligible or not and draw down the appropriate funding to match the eligibility. Scheduled Completion Date of Corrective Action Plan: July 31, 2023 Contacts for Corrective Action Plan: Karolyn Long ? Karolyn.Long@vermont.gov Emily Hazard ? Emily.Hazard@vermont.gov

View Audit 30446

Finding 38544 (2022-033)

Significant Deficiency 2022

State of Vermont

VT

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

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 al...

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. Scheduled Completion Date: 2/1/2023 Contacts for Corrective Action Plan: Jessica Brown, Financial Administrator, Vermont Department of Health Karen Clark, Financial Manager, Vermont Department of Health Megan Hoke, Financial Director, Vermont Department of Health Peter Moino, Director of Internal Audit, Vermont Agency of Human Services

View Audit 30446

Finding 38543 (2022-032)

Significant Deficiency 2022

State of Vermont

VT

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

Corrective Action Plan ? Program Reporting: The Administrative Services Manager and the Public Health Preparedness Coordinator will create a central location for all supporting documentation to be stored and will ensure that the appropriate backup documentation is available for each progress report...

Corrective Action Plan ? Program Reporting: The Administrative Services Manager and the Public Health Preparedness Coordinator will create a central location for all supporting documentation to be stored and will ensure that the appropriate backup documentation is available for each progress report submitted to the CDC. The State Epidemiologist and PH Preparedness Coordinator will be responsible for ensuring that subject matter experts responsible for providing the information contained in progress reports are aware of the need to save supporting documentation. This supporting documentation will include ?point in time? reports from various electronic reporting systems as needed to ensure that data included in progress reports can be validated in the future. To ensure that progress reports are submitted timely the Public Health Preparedness Coordinator will verify that final copies of all program reports submitted are saved in a central location. The PH Preparedness Coordinator will also ensure that this supporting documentation includes a way to verify the date of report submission to the CDC. Corrective Action Plan ? Financial Reporting: The VDH Business Office will ensure that all financial reports are reviewed for accuracy prior to submission. The VDH business office will also continue to ensure that supporting documentation is available for all financial reports submitted, including date/time stamps recording timely submission. Scheduled Completion Date: 2/1/2023 Contacts for Corrective Action Plan: Patsy Kelso, State Epidemiologist, Vermont Department of Health Catherine Markesich, PH Preparedness Coordinator, Vermont Department of Health Megan Hoke, Financial Director, Vermont Department of Health Peter Moino, Director of Internal Audit, Vermont Agency of Human Services

View Audit 30446

Finding 38540 (2022-031)

Significant Deficiency 2022

State of Vermont

VT

Reporting Subrecipient Monitoring Significant Deficiency § 200.303

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 al...

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. Scheduled Completion Date: 2/1/2023 Contacts for Corrective Action Plan: Jessica Brown, Financial Administrator, Vermont Department of Health Karen Clark, Financial Manager, Vermont Department of Health Megan Hoke, Financial Director, Vermont Department of Health Peter Moino, Director of Internal Audit, Vermont Agency of Human Services

View Audit 30446

Finding 38530 (2022-026)

Material Weakness 2022

State of Vermont

VT

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

Corrective Action Plan: The Agency will identify if a new ESEA Federal grant (or a grant based on an ESEA program) includes an Equitable Service requirement during the program completion of the ?New Grant Checklist?. If a new grant includes an Equitable Service requirement, the ESEA Equitable Servic...

Corrective Action Plan: The Agency will identify if a new ESEA Federal grant (or a grant based on an ESEA program) includes an Equitable Service requirement during the program completion of the ?New Grant Checklist?. If a new grant includes an Equitable Service requirement, the ESEA Equitable Service?s Ombudsman will be notified and will work with the grant program manager to ensure the build of the GMS application includes the correct level of detail and controls to meet the SEA requirements for oversight. When appropriate, the Agency will use its process for handling of Equitable Services associated with the Consolidated Federal Programs as models for determining the correct calculation method. The Agency will utilize built in business rules and internal controls within the Grants Management System (GMS) to gather the following information in the grant application for AOE review and approval prior to issuing a grant award agreement: 1. Calculation of the total proportionate share dollars an LEA must set aside for Equitable Services 2. Identification of Independent Schools participating in Equitable Services applicable to each LEA 3. Calculation of the dollars available for Equitable Services for each participating Independent School For each Federal grant that requires an equitable services component, the Agency will document the review and approval of the Equitable Services information through one of two processes prior to the grant award agreement: 1. A dedicated review assignment specific to equitable services, or 2. Verification statements on the review checklist for a general application reviewer Position Responsible for Implementation of Corrective Action: Anne Bordonaro, Division Director, Federal & Education Support Programs anne.bordonaro@vermont.gov 802-828-1388 Date of Implementation of Corrective Action: July 1, 2023

View Audit 30446

Finding 38529 (2022-029)

Significant Deficiency 2022

State of Vermont

VT

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Corrective Action Plan: To address the accuracy and timeliness of our entries into the FFATA system, we will use the USASPENDING.GOV website to assist us in reconciling what has been entered into the FFATA system. This will allow us to ensure that our grant ledgers agree with what is entered into ...

Corrective Action Plan: To address the accuracy and timeliness of our entries into the FFATA system, we will use the USASPENDING.GOV website to assist us in reconciling what has been entered into the FFATA system. This will allow us to ensure that our grant ledgers agree with what is entered into FFATA. This will be a reconciliation completed at least quarterly (following SOV fiscal year quarters) and will be completed by the Deputy CFO or position assigned by the Deputy CFO. We will also implement a process that will have all the steps necessary for a grant award or an amendment to ensure it is posted properly within our internal files and the external systems. This will ensure that new awards and amendments get routed and entered in the FFATA system timely. Our finance team also attended a FFATA training on February 3, 2023 for additional training on the FFATA system. We will look into the Batch upload process which was described in that training. Position Responsible for Implementation of Corrective Action Name: Sean Cousino Position: Deputy Chief Financial Officer Email: sean.cousino@vermont.gov Phone Number: 802 595-3693 Date of Implementation of Corrective Action: First Reconciliation to be completed March/April 2023 Full Implementation June 1,2023

View Audit 30446

Finding 38528 (2022-027)

Significant Deficiency 2022

State of Vermont

VT

Reporting Cash Management Significant Deficiency § 200.302 § 200.303

Corrective Action Plan: We will be implementing a new process that is more automated to ensure accuracy and timeliness of our CMIA draws. We have created a new draw sheet that will be more easily loaded and will be reconciled a couple times a year. The Deputy CFO or person assigned by the Deput...

Corrective Action Plan: We will be implementing a new process that is more automated to ensure accuracy and timeliness of our CMIA draws. We have created a new draw sheet that will be more easily loaded and will be reconciled a couple times a year. The Deputy CFO or person assigned by the Deputy CFO will perform a reconciliation at least two times a year, with the first reconciliation being done before the end of FY 2023. We are currently using the new form and plan to be doing our draws in compliance with CMIA by 4/1/2023. We are also keeping all the backup for the draw electronically to allow for the review to be done more easily. Position Responsible for Implementation of Corrective Action Name: Sean Cousino Position: Deputy CFO Email: sean.cousino@vermont.gov Phone Number: 802 595-3693 Date of Implementation of Corrective Action: April 1st, 2023

View Audit 30446

Finding 38475 (2022-003)

Significant Deficiency 2022

McKendree University

IL

Allowable Costs / Cost Principles Cash Management Reporting § 200.303

2022-003 Education Stabilization Fund: Higher Education Emergency Relief Fund Student Portion and Institutional Portion? Assistance Listing No. 84.425E, 84.425F Recommendation: We recommend the University design controls to ensure an adequate review and approval process is in place and documented. E...

2022-003 Education Stabilization Fund: Higher Education Emergency Relief Fund Student Portion and Institutional Portion? Assistance Listing No. 84.425E, 84.425F Recommendation: We recommend the University design controls to ensure an adequate review and approval process is in place and documented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The University will design and implement internal procedures with staff (accountant, interim VP, and president) to ensure adequate review and controls are in place. Name(s) of the contact person(s) responsible for corrective action: John Nisbet, Interim Vice President of Administration & Finance Planned completion date for corrective action plan: April 2023

View Audit 30596

Finding 38450 (2022-002)

Significant Deficiency 2022

Washakie County

WY

Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking Eligibility § 200.302 § 200.305 § 200.318 § 200.319 § 200.320

Finding 2022-002 Contact Person: Lily Rakness Parra, County Clerk Corrective Action Planned: Washakie County agrees with the finding of 2022-002. A Sams.gov account has been activated in order to verify that entities that are being utilized for County business are not excluded from or are ineligible...

Finding 2022-002 Contact Person: Lily Rakness Parra, County Clerk Corrective Action Planned: Washakie County agrees with the finding of 2022-002. A Sams.gov account has been activated in order to verify that entities that are being utilized for County business are not excluded from or are ineligible for participation in Federal programs or activities. Also, the County is currently drafting a Procurement Policy for Washakie County to utilize for the use of Federal funding as well as in an everyday manor of purchasing and maintenance of county facilities in order to satisfy above finding.

View Audit 30472

Finding 38422 (2022-001)

Significant Deficiency 2022

Bakerripley

TX

Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking

Finding #2022-001 ? Significant Deficiency and Other Noncompliance Applicable federal programs: Department of Agriculture Assisting Listing: 10.558 ? Child and Adult Care Food Program Direct Federal Funding Contract Number: 02946 Contract Years: 10/01/21 ? 09/30/22 and 10/01/22 ? 09/30/23 Depa...

Finding #2022-001 ? Significant Deficiency and Other Noncompliance Applicable federal programs: Department of Agriculture Assisting Listing: 10.558 ? Child and Adult Care Food Program Direct Federal Funding Contract Number: 02946 Contract Years: 10/01/21 ? 09/30/22 and 10/01/22 ? 09/30/23 Department of Housing and Urban Development Assistance Listing #: 14.218 ? COVID-19 Community Development Block Grants/Entitlement Grants ? CDBG ? Entitlement Grants Cluster Passed through Workforce Solutions Capital Area Board of Directors Contract Number: CCS 2019-2024 Contract Years: 10/01/21 ? 09/30/22 and 10/01/22 ? 09/30/23 Passed through the City of Houston Contract Number: 4600016329 Contract Year: 11/15/20 ? 10/31/22 Passed through Harris County Contract Number: B-20UW-48-0002 Contract Year: 03/01/22 ? 09/30/22 Department of Treasury Assistance Listing #: 21.023 ? Emergency Rental Assistance Program Passed through Harris County Contract Number: N/A Contract Year: 06/08/21 ? 12/31/22 Passed through Paso Del Norte Contract Number: N/A Contract Years: 12/01/21 ? 07/31/22 and 04/12/21 ? 12/31/22 Passed through City of Houston Contract Number: 4600016521 Contract Year: 02/12/21 ? 06/30/22 Department of Veterans Affairs Assistance Listing #: 64.033 ? VA Supportive Services for Veteran Families Program Direct Federal Funding Contract Years: 04/01/20 ? 09/30/22; 10/01/21 ? 09/30/23; 10/01/21 ? 09/30/22; 09/01/21 ? 09/30/23 Contract Numbers: 19-TX-290-21; 19-TX-290-22; 19-TX-290-HL; 19-TX-290SS Department of Education Assistance Listing #: 84.425D ? COVID-19 Education Stabilization Fund Passed through the Texas Education Agency Contract Number: 21521001101853 Contract Year: 06/17/21 ? 09/30/22 Assistance Listing #: 84.425U ? Education Stabilization Fund Passed through the Texas Education Agency Contract Number: 21528001101853 and 21528042101853 Contract Years: 06/21/21 ? 09/30/23 and 10/20/21 ? 08/31/24 Department of Health and Human Services Assistance Listing: 93.575 ? Child Care and Development Block Grant ? CCDF Cluster Passed through Houston-Galveston Area Council Contract Numbers: 302-22; 302-23; 302-23; 105-22; 105-23 Contract Years: 10/01/21 ? 09/30/22; 10/01/22 ? 09/30/23; 10/01/22 ? 03/31/23; 10/01/21 ? 09/30/22; 10/01/22 ? 09/30/23 Passed through the Coastal Bend Workforce Development Board Contract Numbers: 2021-22 BakerRipley and 2022-23 BakerRipley Contract Years: 10/01/21 ? 09/30/22 and 10/01/22 ? 09/30/23 Passed through Workforce Solutions Capital Board of Directors Contract Numbers: CCS 2019-2024 and CCS 2019-2024 Contract Years: 10/01/21 ? 09/30/22 and 10/01/22 ? 09/30/23 Passed through the East Texas Workforce Development Board Contract Numbers: BR-CCS-PY21-01 and BR-CCS-PY22-01 Contract Years: 10/01/21 ? 09/30/22 and 10/01/22 ? 09/30/23 Passed through Rural Capital Area Workforce Development Board, Inc. Contract Numbers: NCIWC CCS ? 4-22 and NCIWC CCS ? 5-2023 Contract Years: 10/01/21 ? 09/30/22 and 10/01/21 ? 09/30/23 Assistance Listing #: 93.596 ? Child Care Mandatory and Matching Funds of the Child Care and Development Fund Passed through the Coastal Bend Workforce Development Board Contract Numbers: 2021-22 BakerRipley and 2022-23 BakerRipley Contract Years: 10/01/21 ? 09/30/22 and 10/01/22 ? 09/30/23 Passed through the East Texas Workforce Development Board Contract Numbers: BR-CCS-PY21-01 and BR-CCS-PY22-01 Contract Years: 10/01/21 ? 09/30/22 and 10/01/22 ? 09/30/23 Passed Workforce Solutions Capital Area Board of Directors Contract Numbers: CCS 2019-2024 and CCS 2019-2024 Contract Years: 10/01/21 ? 09/30/22 and 10/01/22 ? 09/30/23 Passed through Houston-Galveston Area Council Contract Numbers: 302-22 and 302-23 Contract Years: 10/01/21 ? 09/30/22 and 10/01/22 ? 09/30/23 Passed through Rural Capital Area Workforce Development Board, Inc. Contract Numbers: NCIWC CCS 4-22 and NCIWC CCS 5-2023 Contract Years: 10/01/21 ? 09/30/22 and 10/01/22 ? 09/30/23 State Programs Texas Education Agency-Foundation School Program 302-22 and 302-23 Workforce Operations and Administrative ? Childcare DFPS 302-22 and 302-23 DFPS Relative/Other Caregiver Kinship 302-22 and 302-23 DFPS General Protective In Home 302-22 and 302-23 DFPS Foster Care ? Title IV-E 302-22 and 302-23 DFPS Foster Care ? Title IV-B 2021-22 BakerRipley and 2022-23 BakerRipley DFPS Relative/Other Caregiver Kinship 2021-22 BakerRipley and 2022-23 BakerRipley DFPS General Protective In Home 2021-22 BakerRipley and 2022-23 BakerRipley DFPS Foster Care ? Title IV-E 2021-22 BakerRipley and 2022-23 BakerRipley DFPS Childcare ? Title IV-B NCIWC CCS 4-22 and NCIWC CCS 5-23 DFPS Relative/Other Caregiver Kinship NCIWC CCS 4-22 and NCIWC CCS 5-23 DFPS General Protective In Home NCIWC CCS 4-22 and NCIWC CCS 5-23 DFPS Foster Care ? Title IV-E NCIWC CCS 4-22 and NCIWC CCS 5-23 DFPS Childcare ? Title IV-B BR-CCS-PY21-01 and BR-CCS-PY22-01 Management and Operations BR-CCS-PY21-01 and BR-CCS-PY22-01 DFPS Relative/Other Caregiver Kinship BR-CCS-PY21-01 and BR-CCS-PY22-01 DFPS General Protective In Home BR-CCS-PY21-01 and BR-CCS-PY22-01 DFPS Foster Care ? Title IV-E BR-CCS-PY21-01 and BR-CCS-PY22-01 DFPS Childcare ? Title IV-B CCS 2019-2024 DFPS Relative/Other Caregiver Kinship CCS 2019-2024 DFPS General Protective In Home CCS 2019-2024 DFPS Foster Care ? Title IV-E CCS 2019-2024 DFPS Childcare ? Title IV-B Recommendation: Re-emphasize to program personnel the procurement process and adherence to BakerRipley?s policies and procedures. Corrective action: BakerRipley will re-emphasize to program personnel the procurement process and adherence to BakerRipley?s policies and procedures. Responsible officer: Kirin Abbasi, Senior Director of Procurement and Contracts Estimated date of completion: December 31, 2023

View Audit 36769

Finding 38405 (2022-002)

Significant Deficiency 2022

Owensboro-Daviess County Regional Airport Board

KY

Significant Deficiency Matching / Level of Effort / Earmarking § 200.326

FINDINGS ? FEDERAL AWARD PROGRAM AUDIT DEPARTMENT OF TRANSPORTATION 2022-002 Airport Improvement Program ? 20.106 Recommendation: Procedures should be put in place to ensure weekly certified payrolls are received from construction contractors for conformance with Uniform Guidance. Action Taken:...

FINDINGS ? FEDERAL AWARD PROGRAM AUDIT DEPARTMENT OF TRANSPORTATION 2022-002 Airport Improvement Program ? 20.106 Recommendation: Procedures should be put in place to ensure weekly certified payrolls are received from construction contractors for conformance with Uniform Guidance. Action Taken: Airport management will ensure weekly certified payrolls are received during the grant administration process and maintained in grant files.

View Audit 30342

Finding 38402 (2022-004)

Significant Deficiency 2022

Independent School District No. 712

MN

Special Tests & Provisions Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

2022-004 FINDING Contact Person ? Reggie Engebritson, Superintendent Corrective Action Plan ? The District will review and update their policies and procedures. Completion Date ? March 30, 2023

View Audit 37169

Finding 38398 (2022-001)

Significant Deficiency 2022

Local Area of Labor Development Southwest

PR

Matching / Level of Effort / Earmarking

January 27, 2023 Cognizant or Oversight Agency for Audit: Local Area of Labor Development Southwest respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Ortiz, Rivera, Rivera & Co.LLC, Suite 152, PO Box...

January 27, 2023 Cognizant or Oversight Agency for Audit: Local Area of Labor Development Southwest respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Ortiz, Rivera, Rivera & Co.LLC, Suite 152, PO Box 70250, San Juan, Puerto Rico 00936-7250. Audit period: Fiscal year ended June 30, 2022. The findings from the June 30, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS - FEDERAL AWARD PROGRAM AUDITS, DEPARTMENT OF LABOR Finding 2022-001: WIOA Cluster-WIOA Adult Program-CFDA No 17.258, WIOA Youth Activities-CFDA 17.259, Dislocated Worker Formula Grant-CFDA 17.278 Reportable Condition: See Condition 2022-001 Recommendation We recommended the Local Area the monitoring of the earmarking for Youth Program in a quarterly basis to ensure that at the end of the two years meet the requirement. Action Taken The Finance Director and finances personnel will measure in a quarterly basis that the minimum requirements of the 75% and inform and made recommendations to the Executive Director in order to comply with the goal of expenditures required. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call at (787) 892-1000 ext.1010. Cordially Vanessa Ramos

View Audit 34840

Finding 38394 (2022-001)

Significant Deficiency 2022

Roseman University of Health Sciences

NV

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

Corrective Action Plan - Finding: 2022-001: Special Tests and Provisions - Enrollment Reporting - Significant Deficiency in Internal Controls over Compliance. Corrective Action Plan: The University uses Microsoft Forms reporting to notify service units of withdrawals. The Dean (or designee) of each ...

Corrective Action Plan - Finding: 2022-001: Special Tests and Provisions - Enrollment Reporting - Significant Deficiency in Internal Controls over Compliance. Corrective Action Plan: The University uses Microsoft Forms reporting to notify service units of withdrawals. The Dean (or designee) of each program must manually update the Microsoft Office report of a withdrawal ad indicate the effective date, which triggers automated emails to the appropriate units. In the one instance of late reporting, the student was required to withdraw due to a no pass of a class, but he was allowed to complete a clinical/experiential course before being withdrawn. The Dean failed to enter the student's information after the student completed the clinical/experiential course, causing the delay in reporting. The Dean has since begun using reminders on his calendar to withdraw students in this situation. In addition, our Director of Institutional Assessment is in the process of developing and programming logic in the Micrsoft Forms report that allows the Dean to enter a future withdrawal date but delays the reporting of the withdrawal to the service units until that date, allowing the Dean to enter the information into the form immediately after a no pass that requires withdrawal. This will prevent the need to manual reminders to enter the date and prevent late withdrawal notifications. Contact Person Responsible for Corrective Action: Sally Mickelson, Director of Financial Aid. Anticipated Completion Date: December 31, 2022.

View Audit 32450

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