Corrective Action Plans

Finding 529281 (2024-003)

Material Weakness 2024

IN

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.208 § 200.303 § 200.403

FINDING 2024-003 Finding Subject: Special Education Cluster (IDEA) - Earmarking Contact Person Responsible for Corrective Action: Andrea Phillips, Director of Finance Contact Phone Number and Email Address: (812) 663-4774 aphillips@greensburg.k12.in.us Views of Responsible Officials: We concur with ...

FINDING 2024-003 Finding Subject: Special Education Cluster (IDEA) - Earmarking Contact Person Responsible for Corrective Action: Andrea Phillips, Director of Finance Contact Phone Number and Email Address: (812) 663-4774 aphillips@greensburg.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: At the end of each nine week grading period employees will turn in actual hours worked with non-pub students to the Director of Special Education. The Director of Special Education will verify the actual hours worked with non-pub students, sign off, and then submit the information to the Director of Finance. The Director of Finance will then reconcile actual hours worked to budgeted hours estimated and make any adjustments necessary in the accounting software. Anticipated Completion Date: By April 30, 2025, the Director of Finance should be able to reconcile the 2024-2025 IDEA grants for the 2024-2025 school year thus far.

View Audit 347322

Finding 529270 (2024-001)

Material Weakness 2024

Blue River Valley Schools

IN

Questioned Costs School Nutrition Programs Internal Control / Segregation of Duties § 200.303

Information on the federal program: Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (or Other Identifying ...

Information on the federal program: Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (or Other Identifying Numbers): FY2023, FY2024 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Eligibility Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the eligibility compliance requirement. Context: During the testing of internal controls over eligibility determinations for free and reduced meals, we noted there was no formal review control in place for 26 of the 60 applications selected for testing. Additionally, for one of the 60 selections, the student was improperly classified as free when the annual income per the student's application exceeded the corresponding threshold for that determination. Corrective Action Plan: The School Corporation will implement a system of internal controls to ensure that the applications are being formally reviewed by the Food Services Director and the Corporation Treasurer. Person responsible for implementation and projected implementation date: The Food Services Director and the Corporation Treasurer will be responsible for implementing the corrective action, which will begin with applications for the 2025-2026 school year.

View Audit 347315 Questioned Costs: $1

Finding 529265 (2024-001)

Material Weakness 2024

Centerville-Abington Community Schools

IN

School Nutrition Programs Internal Control / Segregation of Duties Eligibility § 200.303

Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (or Other Identifying Numbers): FY2023, FY2024 Pass-Throug...

Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (or Other Identifying Numbers): FY2023, FY2024 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Eligibility Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the eligibility compliance requirement. Context: During testing over controls for eligibility, for 16 of the 60 applications selected, we noted there was no formal evidence that the applications had been reviewed and further, the application did not specify if the student was eligible for free or reduced lunch. We also noted for 2 of the 60 selections, management was unable to provide support for the student that was selected. Corrective Action Plan: The Food Services Director and the Treasurer will both sign off on the applications once they have completed their review to determine if the application was accurately denied or approved for free or reduced meals. The completed and reviewed applications will be maintained in a safe and secure location, so they are easily accessible in an instance where they would need to be referenced. Person responsible for implementation and projected implementation date: The Food Services Director and the Corporation Treasurer will implement the corrective action plan starting with applications received for the 2025-2026 school year.

View Audit 347308

Finding 529230 (2024-004)

Material Weakness 2024

Daleville Community Schools

IN

Internal Control / Segregation of Duties Material Weakness Reporting § 200.302 § 200.303 § 200.328

Information on the federal program: Subject: Education Stabilization Fund (ESSER) – Internal Controls Federal Agency: Department of Education Federal Program: COVID-19 – Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U Federal Award Numbers and Years (or Other Identifying Nu...

Information on the federal program: Subject: Education Stabilization Fund (ESSER) – Internal Controls Federal Agency: Department of Education Federal Program: COVID-19 – Education Stabilization Fund Assistance Listing Number: 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 Finding: Material Weakness Context: The School Corporation was required to submit two Annual Data Reports to the Indiana Department of Education (IDOE) during the audit period to meet federal reporting requirements for ESSER grant awards. We noted that the ESSER I and ESSER III amounts reported for the reports covering the FY22 time period ($22,163 and $409,347, respectively) did not agree to the underlying expenditure records ($3,796 and $404,347 respectively) for the period of July 1, 2021 through June 30, 2022. Additionally, we noted that the ESSER II amount reported for the reports covering the FY23 time period ($131,439) did not agree to the underlying expenditure records ($153,216) for the period of July 1, 2022 through June 30, 2023). We also noted there was no documented, secondary review of the information in the FY23 annual data reports by someone other than the preparer. Contact Person Responsible for Corrective Action: Dr. David Stashevsky Contact Phone Number: 765-378-3329 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The assistant superintendent will manage the grant with the superintendent providing oversight. The assistant superintendent will coordinate the receipts and expenditures of funds with the corporation treasurer. The superintendent will review all financial reports and approve in writing with notification sent to the assistant superintendent and treasurer. Anticipated Completion Date: The correction will be on the next annual report when it is due.

View Audit 347248

Finding 529223 (2024-002)

Material Weakness 2024

National Governors Association Center for Best Practices

DC

Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking § 200.213 § 200.318

NGA had previously developed and socialized our procurement process and procedure with our staff members. In response to this finding, NGA will continue to train program staff on the documentation requirements regarding procurement decisions required to comply with our established policy. We will co...

NGA had previously developed and socialized our procurement process and procedure with our staff members. In response to this finding, NGA will continue to train program staff on the documentation requirements regarding procurement decisions required to comply with our established policy. We will continue to review new contract requests carefully to ensure that all the necessary compliance documentation is captured and easily accessible to auditors in the future. Also, in cases where circumstances require that NGA work with a specific entity, we work with program leaders to produce a memo to file highlighting the particular requirements of the work and decision criteria that lead to our selection of individual vendors. The CFO will also work with management to inform supervisors when procedures are not followed. They may follow up with individuals who have not completed the compliance requirements or steps.

View Audit 347217

Finding 529221 (2024-002)

Material Weakness 2024

Elwood Community School Corporation

IN

Subrecipient Monitoring Material Weakness Reporting § 200.303

Information on the federal program: Subject: Education Stabilization Fund (ESSER) - Internal Controls Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U Federal Award Numbers and Years (or Other Identifying Num...

Information on the federal program: Subject: Education Stabilization Fund (ESSER) - Internal Controls Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listing Number: 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 Finding: Material Weakness Condition: An effective internal control system was not in place at the School Corporation to ensure compliance with requirements related to the grant agreement and the reporting compliance requirements. The School Corporation was not formally reviewing the ESSER reports being submitted by comparing the underlying expenditure detail to the amounts reported for each grant for the reporting period. Context: The School Corporation was required to submit six Annual Data Reports to the Indiana Department of Education (IDOE) during the audit period to meet federal reporting requirements for ESSER grant awards. Crowe noted the following reporting errors for the Year 3 reports (July 1, 2021 through June 30, 2022). The ESSER If amount reported on the Year 3 report ($585,040) did not agree to the underlying expenditure records ($581,468). This is the exact amount reported as the SEA reserve amount on the Annual Data Report. Crowe noted the ESSER Ill amount reported on the Year 3 report ($0) did not agree to the underlying expenditure records ($351,831). Crowe noted the following reporting error for the Year 4 reports (July 1, 2022 through June 30, 2023). The ESSER Ill amount reported on the Year 4 report ($1,062,765) did not agree to the underlying expenditure records ($1,054,618). This is the exact amount reported as the SEA reserve amount on the Annual Data Report. Corrective Action Plan: The School Corporation will implement internal control procedures to ensure the amounts reported in the annual data reports agree to the underlying support and detail from the internal records. A formal review process will be implemented. Person responsible for implementation and projected implementation date: The Corporation's Treasurer and Superintendent will be responsible for implementing the corrective action, which will be implemented immediately.

View Audit 347212

Finding 529199 (2024-002)

Significant Deficiency 2024

Humboldt County Resource Conservation District

CA

Subrecipient Monitoring Matching / Level of Effort / Earmarking Procurement, Suspension & Debarment § 200.318 § 200.327

The District will update the procurement policy to reflect all the required files as noted in the procurement standards set out at 2 CFR sections 200.318 through 200.327. The District Board of Directors will review and approve all updates through Board action at a Regular Meeting of the Board of Dir...

The District will update the procurement policy to reflect all the required files as noted in the procurement standards set out at 2 CFR sections 200.318 through 200.327. The District Board of Directors will review and approve all updates through Board action at a Regular Meeting of the Board of Directors

View Audit 347185

Finding 529193 (2024-004)

Significant Deficiency 2024

Chicago State University

IL

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Student Financial Aid § 200.303

The staff ember responsible for running the process has started to send notification manually instead of through the Banner System until a resolution to the glitch has been identified Task Activity Expected Start Date Expected End Date Completion Date Manual emails sent January 2025 Ongoing Depends...

The staff ember responsible for running the process has started to send notification manually instead of through the Banner System until a resolution to the glitch has been identified Task Activity Expected Start Date Expected End Date Completion Date Manual emails sent January 2025 Ongoing Depends upon resolution from Ellucian

View Audit 347176

Finding 529177 (2024-002)

Significant Deficiency 2024

Thomas Edison State University and Its Affiliate the New Jersey State

NJ

Student Financial Aid Special Tests & Provisions Reporting

2024-002 Special Tests (Enrollment Reporting) Federal Agency: Student Financial Assistance Cluster - U.S. Department of Education Program Titles and ALN: Federal Pell Grant Program (ALN 84.063) and Federal Direct Student Loans (ALN 84.268) Federal Grant Numbers: E-P063P243920 (7/1/2024 – 6/30/2025...

2024-002 Special Tests (Enrollment Reporting) Federal Agency: Student Financial Assistance Cluster - U.S. Department of Education Program Titles and ALN: Federal Pell Grant Program (ALN 84.063) and Federal Direct Student Loans (ALN 84.268) Federal Grant Numbers: E-P063P243920 (7/1/2024 – 6/30/2025), P268K253920 (7/1/2024 – 6/30/2025) Contact Person: Catharine A. Punchello, Vice Provost and University Registrar, 609-984-1180, x3135 Corrective Action: National Student Loan Data System (NSLDS) has resolved the issue causing the Error Code 75 (EC75) errors. Our last large batch of 75 errors was received in response to our Student Status Confirmation Report (SSCR) on July 8, 2024. We received one EC75 on September 13, 2024 and two EC75 on November 8, 2024 and none since then. The University continues to monitor NSLDS’ error reports on our SSCRs to ensure we are aware if they return. The University will continue to submit the SSCR responses to the Clearinghouse and ensure we report individual graduations or enrollment if there are error codes that cannot be resolved timely through the Clearinghouse process. Anticipated Completion Date: Completed

View Audit 347163

Finding 529175 (2024-001)

Significant Deficiency 2024

Thomas Edison State University and Its Affiliate the New Jersey State

NJ

Special Tests & Provisions Student Financial Aid Significant Deficiency

2024-001 Special Tests and Provisions (Verification) Federal Agency: Student Financial Assistance Cluster - U.S. Department of Education Program Titles and Assistance Listing Numbers (ALN): Federal Pell Grant Program (ALN 84.063) and Federal Direct Student Loans (ALN 84.268) Federal Grant Numbers:...

2024-001 Special Tests and Provisions (Verification) Federal Agency: Student Financial Assistance Cluster - U.S. Department of Education Program Titles and Assistance Listing Numbers (ALN): Federal Pell Grant Program (ALN 84.063) and Federal Direct Student Loans (ALN 84.268) Federal Grant Numbers: E-P063P243920 (7/1/2024 – 6/30/2025), P268K253920 (7/1/2024 – 6/30/2025) Contact Person: James Owens, Director of Financial Aid, (609) 633-9658 x 3400 Corrective Action: The University has enhanced its report for required verification documentation to highlight those selected with V4 or V5 status to ensure all proper documentation is requested and provided by the students as required for the verification status. The review will be done on a monthly basis throughout the fiscal year. Anticipated Completion Date: April 2025

View Audit 347163

Finding 529134 (2024-001)

Significant Deficiency 2024

Timothy L. Johnson Academy

IN

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.329

March 13, 2025 Donovan CPAs 9292 N. Meridian Street, Suite 150 Indianapolis, IN 46260 Timothy L Johnson Academy Elementary school has already taken the following actions to address the FY2024 finding of noncompliance with Federal grant awards: 1. We transitioned to a new business services provid...

March 13, 2025 Donovan CPAs 9292 N. Meridian Street, Suite 150 Indianapolis, IN 46260 Timothy L Johnson Academy Elementary school has already taken the following actions to address the FY2024 finding of noncompliance with Federal grant awards: 1. We transitioned to a new business services provider in FY2025, and part of that transition included a complete overhaul of our grants management. 2. As part of this transition, we created procedures that better integrated our grants management processes with our financial accounting processes. This already allows us to better track the differences in our reimbursement-based grants, cash-basis state reporting, and GAAP-based accounting principles. 3. We also now have a more transparent school-level view of all our grants, which adds a level of control while working with an outsourced business and grants service provider. 4. Dawn Starks and Brad Yoder were responsible on the school side for these procedure changes. Brian Anderson and Kim Tarin from the Center for Innovative Education Solutions were responsible for this as the new business and grants services provider.

View Audit 347076

Finding 529130 (2024-001)

Material Weakness 2024

Barnesville Exempted Village School District

OH

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

The school district will implement a formal policy requiring detailed review and approval of all food service management invoices to ensure compliance with federal regulations. Staff will be trained on allowable costs and a standardized checklist will be used for invoice reviews. Monthly reviews, pe...

The school district will implement a formal policy requiring detailed review and approval of all food service management invoices to ensure compliance with federal regulations. Staff will be trained on allowable costs and a standardized checklist will be used for invoice reviews. Monthly reviews, periodic audits, and updated procedures for handling unallowable costs will be established to ensure ongoing compliance and proper documentation.

View Audit 347067

Finding 529128 (2024-002)

Significant Deficiency 2024

Department of Housing of the Commonwealth of Puerto Rico

PR

Reporting Subrecipient Monitoring Significant Deficiency

VIEWS OF RESPONSIBLE OFFICIALS The designated officer of the CDBG-DR/MIT Program to perform this task resigned suddenly. We recruited and trained a new officer, but during the transition process some First-Tier Sub awardee contracts were not reported in the Subaward Reporting System (FSRS) in a time...

VIEWS OF RESPONSIBLE OFFICIALS The designated officer of the CDBG-DR/MIT Program to perform this task resigned suddenly. We recruited and trained a new officer, but during the transition process some First-Tier Sub awardee contracts were not reported in the Subaward Reporting System (FSRS) in a timely manner. To prevent this condition in the future, we have trained more than one officer for this task, and have placed a level of supervision to fully comply with this obligation. IMPLEMENTATION DATE Already implemented RESPONSIBLE PERSON Félix Hernández Cabán Director of Disaster Recovery CDBG-DR Program Finance & Monitoring Division

View Audit 347065

Finding 529125 (2024-001)

Material Weakness 2024

Knox Community School Corporation

IN

Subrecipient Monitoring Material Weakness Reporting § 200.302 § 200.303 § 200.328

FINDING 2024-001 Information on the federal program: Subject: Education Stabilization Fund (ESSER) – Internal Controls Federal Agency: Department of Education Federal Program: COVID-19 – Education Stabilization Fund Assistance Listing Number: 84.425U Federal Award Numbers and Years (or Other Identif...

FINDING 2024-001 Information on the federal program: Subject: Education Stabilization Fund (ESSER) – Internal Controls Federal Agency: Department of Education Federal Program: COVID-19 – Education Stabilization Fund Assistance Listing Number: 84.425U Federal Award Numbers and Years (or Other Identifying Numbers): S425U210013 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Material Weakness Context: The School Corporation was required to submit two Annual Data Reports to the Indiana Department of Education (IDOE) to meet federal reporting requirements for ESSER grant awards. The Annual Data Reports were prepared by School Corporation management and reviewed by someone other than the preparer, however, the review process in place did not prevent, or detect and correct, errors. During testing of the accuracy of the annual data reports, the following errors were noted: • The Year 2 Annual Data Report for the ESSER III (84.425U) grant award reported total disbursements of $2,219,321 for the period of July 1, 2021 through June 30, 2022 compared to underlying disbursement detail of $2,715,940. • The Year 3 Annual Data Report for the ESSER III (84.425U) grant award reported total disbursements of $224,309 for the period of July 1, 2022 through June 30, 2023 compared to underlying disbursement detail of $306,194. Contact Person Responsible for Corrective Action: Kasey Clark Contact Phone Number: 574-772-1604 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: There will be two people who look over the ESSER reports before submitting to the state to make sure they agree with the reports. Anticipated Completion Date: When next report is due.

View Audit 347048

Finding 529115 (2024-001)

None 2024

Miami Dade County District School Board

FL

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Special Test — 84.063 — Federal Pell Grant Program ...

Special Test — 84.063 — Federal Pell Grant Program Views of responsible officials and planned corrective actions: District management and the technical college director are responsible for providing supervisory oversight for each Technical College’s Registration Office and Financial Aid Office as it relates to the timely and accurate reporting of NSLDS data. NSLDS data will be reviewed by the Financial Aid Officer monthly and will continue to be updated programmatically every 60 days to ensure compliance with the 60-day reporting requirement. The Financial Aid Officer will continue to complete an internal NSLDS Status Change Form and enter updates into the NSLDS reporting platform within 15 business days. Effective immediately, the Financial Aid Officer will enter a new program enrollment line with the updated enrollment status so that information is reflected in the historical action taken for each student. District management and the technical college director will direct the Financial Aid Officer to print the updated NSLDS Enrollment History, confirming the date that the enrollment status was reported. The NSLDS Enrollment History and the NSLDS Status Change form will be maintained in the student’s Financial Aid folder for future reference.

View Audit 347039

Finding 529081 (2024-020)

Material Weakness 2024

State of North Dakota

ND

Questioned Costs Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking § 200.303 § 200.317

University System Response/Corrective Action Plan Bismarck State College: Agree. On the published RFQ, Bismarck State College identified a selection committee composed of nine members with the registered engineer and registered architect listed as TBD, as these members had not yet been identified. T...

University System Response/Corrective Action Plan Bismarck State College: Agree. On the published RFQ, Bismarck State College identified a selection committee composed of nine members with the registered engineer and registered architect listed as TBD, as these members had not yet been identified. The selection committee later downsized to seven members. Bismarck State College understands that an amendment to the RFQ should have been released. Four selection committee members evaluated the RFQ submittals, three from Bismarck State College and a licensed contractor. Bismarck State College understands that all seven members must be present during the initial review. Bismarck State College did have all seven members present, including a registered engineer and registered architect during the interviews and final decision when selecting the CMAR. Bismarck State College has reviewed the selection process and will adhere to ensure compliance for construction projects. Minot State University: Minot State agrees with the audit recommendation in that not all the proper steps were completed in the procurement of architect and Construction Management at Risk (CMaR) services and will ensure proper procedures are followed going forward. Upon review, Minot State is confident that all Hartnett Hall remodel project expenses are appropriate, allowable, and allocable to the project. University of North Dakota: Agree. The University of North Dakota's solicitation templates for A/E and CMAR have been moved to an electronic system effective 2023, and our templates were updated with the correct proposal criteria at that time. Contact Person: Bismarck State College: Sonya Koble – Chief Financial Officer Minot State University: Krista Lambrecht, VP for Administration & Finance University of North Dakota: Tom Scrivener, CPO Anticipated Completion Date: Bismarck State College: September 2024 Minot State University: Immediately University of North Dakota: Completed.

View Audit 346994 Questioned Costs: $1

Finding 529071 (2024-001)

Material Weakness 2024

State of North Dakota

ND

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

Adjutant General Response/Corrective Action Plan: The agency agrees with the finding. In March 2024, the agency self-identified the reporting change and adjusted internal procedures to report new subawards based on obligation amount vs reporting on payments over $30,000 at the end of every month...

Adjutant General Response/Corrective Action Plan: The agency agrees with the finding. In March 2024, the agency self-identified the reporting change and adjusted internal procedures to report new subawards based on obligation amount vs reporting on payments over $30,000 at the end of every month. Any obligations that have been identified as missed in the transition have since been reported, and the new method of reporting on obligations will be followed moving forward. The agency will ensure per Federal regulation 2 CFR 170, Appendix A that each subaward that equals or exceeds $30,000 no later than the end of the month following the month in which the obligation was made will be reported. Contact Person: Jennifer Scheet, Division Chief – Fiscal & Admin Services, 701-333-2079, jenniferscheet@nd.gov Anticipated Completion Date: The audit period covered July 1, 2022 – June 30, 2024 and the agency corrected the reporting in March 2024 after self-identifying the reporting criteria.

View Audit 346994

Finding 529065 (2024-011)

Significant Deficiency 2024

State of North Dakota

ND

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

Department of Health and Human Services Response/Corrective Action Plan The Department of Health and Human Services agrees with the recommendation. The department will develop and implement a process whereby any provider who fails to respond to a request for records as part of an audit or program ...

Department of Health and Human Services Response/Corrective Action Plan The Department of Health and Human Services agrees with the recommendation. The department will develop and implement a process whereby any provider who fails to respond to a request for records as part of an audit or program integrity review by the established deadline will be subject to a corrective sanction process. This process will include a pre-payment review of claims for a designated period. Additionally, the department will continue to recover payments made on unsupported claims. Contact Person: Sarah Aker, Medicaid Executive Director Anticipated Completion Date: 12/31/2025

View Audit 346994 Questioned Costs: $1

Finding 529060 (2024-008)

Significant Deficiency 2024

State of North Dakota

ND

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

Department of Health and Human Services Response/Corrective Action Plan The Department of Health and Human Services disagrees with the finding. The federal regulations do not explicitly mandate the separation of duties between employees conducting audits and those processing claims. While 42 CFR 456...

Department of Health and Human Services Response/Corrective Action Plan The Department of Health and Human Services disagrees with the finding. The federal regulations do not explicitly mandate the separation of duties between employees conducting audits and those processing claims. While 42 CFR 456.2 requires Medicaid agencies to implement a surveillance and utilization control program, it does not specifically require the segregation of these roles. The regulation promotes control measures but does not mandate a distinct separation of duties. Based on this, we do not support this recommendation, as it exceeds the requirements outlined in the applicable federal rules. HHS remains committed to maintaining strong internal controls and believe our current structure aligns with regulatory expectations. Contact Person: Sarah Aker, Medicaid Executive Director Krista Fremming, Assistant Director Anticipated Completion Date: N/A

View Audit 346994

Finding 529058 (2024-007)

Significant Deficiency 2024

State of North Dakota

ND

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

Department of Health and Human Services Response/Corrective Action Plan The Department of Health and Human Services agrees with the recommendation. The department has controls in place to prevent errors. The target for this year’s Payment Error Rate Measurement (PERM) audit is 3.02%. Currently, ...

Department of Health and Human Services Response/Corrective Action Plan The Department of Health and Human Services agrees with the recommendation. The department has controls in place to prevent errors. The target for this year’s Payment Error Rate Measurement (PERM) audit is 3.02%. Currently, our error rate stands at 2.1%, which is below the CMS PERM target. The department will continue to recover the payments made on unsupported claims. Contact Person: Sarah Aker, Medicaid Executive Director Krista Fremming, Assistant Director Anticipated Completion Date: 06/30/2025

View Audit 346994 Questioned Costs: $1

Finding 529057 (2024-010)

Significant Deficiency 2024

State of North Dakota

ND

Questioned Costs Student Financial Aid Matching / Level of Effort / Earmarking

Department of Health and Human Services Response/Corrective Action Plan The Department of Health and Human Services agrees with the recommendation. HHS has begun the process of recoupment and will work to receive full repayment, to date the balance remaining was $5,000 and a payment plan has been...

Department of Health and Human Services Response/Corrective Action Plan The Department of Health and Human Services agrees with the recommendation. HHS has begun the process of recoupment and will work to receive full repayment, to date the balance remaining was $5,000 and a payment plan has been sent up to recoup the remaining amount. The Accounts Payable team will collaborate with OMB to implement additional processes within Peoplesoft to verify payment information in the future. Currently, we are working to add display options in the Mass Voucher Approval screen to allow for tallying of the totals of vouchers in range. This addition will enhance the review step to ensure payments are consistent with Program totals for a secondary check before approval of payments are made. Contact Person: Karol Riedman, Assistant CFO Ann Scott, AP Accounting Manager Anticipated Completion Date: 06/30/2025

View Audit 346994 Questioned Costs: $1

Finding 529056 (2024-006)

Significant Deficiency 2024

State of North Dakota

ND

Questioned Costs Period of Performance Subrecipient Monitoring

Department of Health and Human Services Response/Corrective Action Plan The Department of Health and Human Services agrees with the recommendation. The department will monitor expenses within the budget and grant period based on guidance from the federal agency to ensure that the date of expenditu...

Department of Health and Human Services Response/Corrective Action Plan The Department of Health and Human Services agrees with the recommendation. The department will monitor expenses within the budget and grant period based on guidance from the federal agency to ensure that the date of expenditures are not claimed before grant funds are received. Contact Person: Eric Haas, Assistant CFO Anticipated Completion Date: December 2024

View Audit 346994 Questioned Costs: $1

Finding 529055 (2024-005)

Significant Deficiency 2024

State of North Dakota

ND

Questioned Costs Allowable Costs / Cost Principles Period of Performance § 200.343

Department of Health and Human Services Response/Corrective Action Plan The Department of Health and Human Services agrees with the recommendation. To address this, the department will run quarterly reports from AWARE to identify any payments charged to the incorrect period of performance. Grant ...

Department of Health and Human Services Response/Corrective Action Plan The Department of Health and Human Services agrees with the recommendation. To address this, the department will run quarterly reports from AWARE to identify any payments charged to the incorrect period of performance. Grant guidance has been updated to ensure items with unique service dates are properly reviewed. Additionally, during the three-month liquidation period, a monthly review of all expenditures will be conducted to verify they are applied to the correct period of performance. These actions will strengthen oversight and ensure compliance with grant requirements. Contact Person: Eric Haas, Assistant CFO Anticipated Completion Date: December 2024

View Audit 346994 Questioned Costs: $1

Finding 529053 (2024-009)

Significant Deficiency 2024

State of North Dakota

ND

Questioned Costs Eligibility Matching / Level of Effort / Earmarking § 200.302 § 200.303

Department of Health and Human Services Response/Corrective Action Plan The Department of Health and Human Services agrees with the recommendation. During review of audit found two overpayment errors as a result of outdated supporting documents. Refunds have been requested. HHS provides ongoing t...

Department of Health and Human Services Response/Corrective Action Plan The Department of Health and Human Services agrees with the recommendation. During review of audit found two overpayment errors as a result of outdated supporting documents. Refunds have been requested. HHS provides ongoing training with eligibility and supervisory staff regarding document and eligibility requirements with staff. HHS actively monitors application quality and provides ongoing quality control reviews ensuring consistent adherence to best practices. Contact Person: Jessica Thomasson, Executive Policy Director Anticipated Completion Date: October 2024

View Audit 346994 Questioned Costs: $1

Finding 529052 (2024-013)

Significant Deficiency 2024

State of North Dakota

ND

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

Department of Health and Human Services Response/Corrective Action Plan HHS agrees with the recommendation. During a period of high application volume, HHS temporarily bypassed its two-stage review process, assigning supervisors to review cases directly. The audit found no errors in eligibility du...

Department of Health and Human Services Response/Corrective Action Plan HHS agrees with the recommendation. During a period of high application volume, HHS temporarily bypassed its two-stage review process, assigning supervisors to review cases directly. The audit found no errors in eligibility during this time. To address this, HHS updated policies to document exceptions, including thresholds for initiating and ending them, ensuring transparency. Training sessions are being conducted to familiarize staff with these updates, and weekly monitoring of application volumes continues to anticipate surges. Contingency hiring plans and cross-training initiatives are in place to reduce future exceptions. Periodic reviews will ensure compliance, fostering a scalable, accountable process while maintaining high standards during peak periods. These measures ensure consistency and preparedness moving forward. Contact Person: Jessica Thomasson, Executive Policy Director Anticipated Completion Date: August 2024

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