Corrective Action Plans

Finding 395925 (2023-002)

Material Weakness 2023

NE

Internal Control / Segregation of Duties Material Weakness

March 28, 2024 Nance County, Nebraska, respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Romans, Wiemer & Associates, Certified Public Accountants, P.C., 1910 N Lincoln Ave, York, NE 68467 Audit Pe...

March 28, 2024 Nance County, Nebraska, respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Romans, Wiemer & Associates, Certified Public Accountants, P.C., 1910 N Lincoln Ave, York, NE 68467 Audit Period: July 1, 2022 through June 30, 2023 The findings from the March 28, 2024 schedule of findings and questioned cost are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS – FINANCIAL STATEMENT AUDIT MATERIAL WEAKNESS 2023-001 Internal Control Structure Design Recommendation: While considering the cost of any benefits derived, activities should be segregated and handled by different employees. Action Taken: The cost of implementing a complete set of controls far outweighs the benefits derived by such. It is not financially feasible to have a complete set of controls. FINDINGS – FEDERAL AWARD PROGRAM AUDIT U.S. Department of the Treasury 2023-002 Internal Control Structure Design Recommendation: While considering the cost of any benefits derived, activities should be segregated and handled by different employees. Action Taken: The cost of implementing a complete set of controls far outweighs the benefits derived by such. It is not financially feasible to have a complete set of controls. If the U.S. Department of the Treasury has questions regarding this plan, please call Adrian Chlopek at (308) 536-2331.

View Audit 305578

Finding 395913 (2023-003)

Material Weakness 2023

Louisville Metro Housing Authority

KY

Special Tests & Provisions HUD Housing Programs Material Weakness

Finding Reference Number: 2023-003 Statement of Concurrence or Nonconcurrence: Louisville Metro Housing Authority agrees with Cherry Bekaert in reference to audit finding 2023-003. Corrective Action: To ensure supporting documents are maintained to support all HUD-52722 forms, all privately managed ...

Finding Reference Number: 2023-003 Statement of Concurrence or Nonconcurrence: Louisville Metro Housing Authority agrees with Cherry Bekaert in reference to audit finding 2023-003. Corrective Action: To ensure supporting documents are maintained to support all HUD-52722 forms, all privately managed Mixed-Finance developments will submit utility cost and consumption data to include copies of invoices to LMHA monthly. Utility cost and consumption data to include copies of invoices are already collected by LMHA managed sites. Name of Contact Person: Jeff Ralph, Director of Finance, 502-569-4372, ralph@lmha1.org Projected Completion Date: Louisville Metro Housing Authority is actively working with third party managers to ensure that LMHA receives, on a monthly basis, the utility invoices that support the HUD-52722 forms and maintaining the documentation on LMHA network servers along with a secondary review of all HUD-52723 and HUD 52722 forms prior to annual submission to HUD /Secure Systems/Public Housing Portal (PIH Operating Fund). QUESTIONED COSTS Undeterminable per Cherry Bekaert If the (Office of Policy and Management and/ or Oversight Agency) has questions regarding this Plan, please call Jeff Ralph at 502-569-4372.

View Audit 305538

Finding 395912 (2023-002)

Material Weakness 2023

Louisville Metro Housing Authority

KY

Questioned Costs Special Tests & Provisions HUD Housing Programs

Finding Reference Number: 2023-002 Statement of Concurrence or N onconcurrence: Louisville Metro Housing Authority agrees with Cherry Bekaert in reference to audit finding 2023-002. Corrective Action: To verify that the hours charged by maintenance staff are reasonable, Central Maintenance superviso...

Finding Reference Number: 2023-002 Statement of Concurrence or N onconcurrence: Louisville Metro Housing Authority agrees with Cherry Bekaert in reference to audit finding 2023-002. Corrective Action: To verify that the hours charged by maintenance staff are reasonable, Central Maintenance supervisors/coordinators will verify the accuracy of the hours recorded to work orders completed. Questionable hours will be reviewed and corrected when appropriate. The report will then be submitted to Finance to be charged to Public Housing development. The Finance Department will perform an additional review for reasonableness prior to posting. Name of Contact Person: Greg Crum, Director of Property Management, 502-569-3416, crum@lmhal.org Projected Completion Date: Louisville Metro Housing Authority implemented the corrective action measure in April 2024. LMHA will monitor the issue on a monthly basis in conjunction with its month end accounting close process to ensure compliance with the special fees charged in related party transactions. QUESTIONED COSTS All costs were corrected and fees were reversed. If the (Office of Policy and Management and/ or Oversight Agency) has questions regarding this Plan, please call Jeff Ralph at 502-569-4372.

View Audit 305538 Questioned Costs: $1

Finding 395911 (2023-001)

Material Weakness 2023

Louisville Metro Housing Authority

KY

HUD Housing Programs Eligibility Material Weakness

Finding Reference Number: 2023-001 Statement of Concurrence or N onconcurrence: Louisville Metro Housing Authority agrees with Cherry Bekaert in reference to audit finding 2023-001. Corrective Action: LMHA has implemented a comprehensive plan to resolve the backlog of recertifications that necessita...

Finding Reference Number: 2023-001 Statement of Concurrence or N onconcurrence: Louisville Metro Housing Authority agrees with Cherry Bekaert in reference to audit finding 2023-001. Corrective Action: LMHA has implemented a comprehensive plan to resolve the backlog of recertifications that necessitated the roll forward of tenant's prior year form HUD-50058 family report without updating family income and composition. First and foremost, representing the rolling forward of the tenant's HUD-50058 as a biennial recertification has been discontinued. Compliance staff has implemented training of Housing Specialists and other staff to assure biennial recertification and use of HUD-50058 Type 2 ("Annual Recertification") will now be compliant. LMHA has contracted with a vendor to assist with the recertification process. LMHA has also restructured workflows to provide efficiencies and accountability that will promote compliance. LMHA is also working with various HUD departments and personnel to assess noncompliance and how to move forward. In addition to resolving these issues with HUD, LMHA has engaged its Financial Auditor, Cherry Bekaert, to review the Housing Choice Voucher Program for process, compliance, and internal control. Name of Contact Person: Sarah Galloway, Special Assistant to the Executive Director, 502-569-3422, galloway@lmhal.org Projected Completion Date: Louisville Metro Housing Authority implemented the corrective action measure in March 2024. LMHA will monitor the issue on a monthly basis to ensure compliance with the HCV program. QUESTIONED COSTS Undeterminable per Cherry Bekaert If the (Office of Policy and Management and/or Oversight Agency) has questions regarding this Plan, please call Jeff Ralph at 502-569-4372.

View Audit 305538

Finding 395903 (2023-006)

Material Weakness 2023

Mass Transportation Authority

MI

Cash Management Material Weakness § 200.303

Finding Number: 2023-006 Condition: Currently one person prepares the reimbursement requests and no one reviews them for accuracy prior to submitting the requests to the State through the Operating Assistance Report (OAR) for reimbursement. Planned Corrective Action: Management will identify a new p...

Finding Number: 2023-006 Condition: Currently one person prepares the reimbursement requests and no one reviews them for accuracy prior to submitting the requests to the State through the Operating Assistance Report (OAR) for reimbursement. Planned Corrective Action: Management will identify a new process for OAR assignment and submission. Currently the OARs are prepared and submitted by the CFO due to staffing limitations. Nevertheless, the CFO will work to identify an individual within the Finance Department that has the skillset and capacity to prepare the OARs for CFO review prior to submission. Contact person responsible for corrective action: Colette Champine, CFO Anticipated Completion Date: July 10, 2024

View Audit 305528

Finding 395816 (2023-103)

Material Weakness 2023

Greater Phoenix Urban League INC

AZ

Allowable Costs / Cost Principles Cash Management Material Weakness

Finding 2023-103 Allowable Costs/Cost Principles/Reporting (Material Weakness, Compliance Finding) Repeat Finding. Responsible Individuals: William Bridgeman, Chief Fiscal Officer Natalie Alvarez, Chief Operating Officer- Head Start Director Corrective Action Plan: Greater Phoenix Urban League (Dele...

Finding 2023-103 Allowable Costs/Cost Principles/Reporting (Material Weakness, Compliance Finding) Repeat Finding. Responsible Individuals: William Bridgeman, Chief Fiscal Officer Natalie Alvarez, Chief Operating Officer- Head Start Director Corrective Action Plan: Greater Phoenix Urban League (Delegate Agency) will continue its on- going collaborate with the City of Phoenix (Grantee) in evaluating the process and effectiveness of inserting and updating the “quarterly administrative reporting package”, relatively to its use and the accuracy of the content that flows within the excel workbooks. Anticipated Completion Date: On going throughout the contract period on an annualized basis. July 1, 2024

View Audit 305459

Finding 395815 (2023-102)

Material Weakness 2023

Greater Phoenix Urban League INC

AZ

Questioned Costs Allowable Costs / Cost Principles Reporting

Finding 2023-102 – Allowable Costs/Cost Principle (Material Weakness, Compliance Finding) Responsible Individual: William Bridgeman-Chief Fiscal Officer Corrective Action Plan: The organization tracks all revenue and expenses specifically and directly related to the Head Start Program CFDA 93.600 by...

Finding 2023-102 – Allowable Costs/Cost Principle (Material Weakness, Compliance Finding) Responsible Individual: William Bridgeman-Chief Fiscal Officer Corrective Action Plan: The organization tracks all revenue and expenses specifically and directly related to the Head Start Program CFDA 93.600 by individual general ledger. Each revenue and expenses account are supported with documentation. Classes within QuickBooks are available within the platform. However, using classes is optional and with the purchase of the more advance version of QuickBooks “QuickBooks Enterprise Platinum” it’s the intent of the organization to move to enhanced detail general ledger accounts (which will provide detail data relating to each individual transaction). As it relates to Assistance Listing No 93.185 National Urban League Vaccine Equity 2021-22 in the amount of $40,000 and Assistance Listing no. 10-551 in the amount of $52,129 is not affiliated with Head Start from a program perspective. No staff time or expenses of the two grants are related to the Head Start Program. Each of the reference programs are stand-alone funded through a third-party pass through grantee and not a direct grant from a federal agency. However, the organization will establish separate classes within QuickBooks Enterprise Platinum for each federal and state contract. The implementation of the vertical classes within the QuickBooks Enterprise Platinum platform will consist of the reconciliation of cost reimbursements with a separate and dedicated “in kind” calculation of 25% within the class where applicable as per grantee requirement. Implementation Date: July 1, 2024

View Audit 305459 Questioned Costs: $1

Finding 395814 (2023-101)

Material Weakness 2023

Greater Phoenix Urban League INC

AZ

Questioned Costs Allowable Costs / Cost Principles Cash Management

Finding 2023-101 Allowable Costs/Cost Principle and Reporting (Material Weakness Compliance Finding) Repeat Finding Responsible Individuals: William Bridgeman Chief Fiscal Officer Natalie Alvarez- Chief Operating Officer Head Start Director Corrective Action Plan: Greater Phoenix Urban League has r...

Finding 2023-101 Allowable Costs/Cost Principle and Reporting (Material Weakness Compliance Finding) Repeat Finding Responsible Individuals: William Bridgeman Chief Fiscal Officer Natalie Alvarez- Chief Operating Officer Head Start Director Corrective Action Plan: Greater Phoenix Urban League has received great support from our community partners by providing in-kind space in 4 school districts and the abundance of parent volunteer support for our Head Start program, however, the program struggles to identify the in-kind match during the turn to full on campus instruction. COVID19 has had a considerable impact on the programs ’s ability to meet the non-federal share obligation as families and community volunteers are not allowed fully back onto Head Start Campuses and enrollment has declined. The program was unable to open several classrooms due to lack of qualified staff and low enrollment. In the past, Greater Phoenix Urban League Head Start has relied heavily on in-kind Space as the main source of program match and with the closing of classrooms in-kind was very difficult to collect. We believe we have worked towards meeting the challenge of program in-kind match. We have used ARPA funds to develop “A grow your own program.” Greater Phoenix Urban League Head Start has recruited parents and the community to participant in a workforce development program to train and hire new Head Start staff as classroom aides and teacher assistances. We also have contracted with an organization to provided contracted instructional support to open up temporarily closed classrooms. The program will continue to identify non-federal share to meet the obligations of the grant award. COVID will continue to have an impact on the programs ’s ability to meet non-federal share but it certainly opens new channels of identifying non-federal share. The following steps are in progress of being implemented in fiscal year 23-24 within the grantee: • An internal control process has been developed to review the current system to document the resources for non-federal share. A Data Assistant will review and analyze at our process in collecting in kind. • Revised Policies and procedures will be developed to assisted instructional staff to collect parent volunteer hours. • Parent Policy Committee will be trained on the non-federal share in-kind as it relates to their important role within the Head Start Program. • Greater Phoenix Urban League Head Start will continue to review the internal control process annually to ensure compliance with the Head Start Program Performance Standards, federal regulations, and City of Phoenix Grantee regulations. • Greater Phoenix Urban League Chief Fiscal Officer, fiscal staff, Program Director and Grantee Fiscal and Program staff will meet monthly to review fiscal reporting and requirements, to ensure grant obligations are on track. • Greater Phoenix Urban League will continue their efforts to identify citywide partners that can provide non-federal share to the Head Start Program. • Greater Phoenix Urban League Chief Fiscal Officer, fiscal staff, Program Director and Grantee Fiscal and Program staff will meet monthly to review fiscal reporting and requirements, to ensure grant obligations are on track. • All third-party appraisals will be conducted in May 2024 to reflect the current market value of space and real property. • The activities mentioned above will assist the Greater Phoenix Urban League-Head Start Program in meeting its obligations in the coming years. Anticipated Completion Date: Ongoing throughout the contract period on an annualized basis. May 1, 2024

View Audit 305459 Questioned Costs: $1

Finding 395729 (2023-004)

Material Weakness 2023

Central Montana Medical Center

MT

Material Weakness Reporting Internal Control / Segregation of Duties § 200.303

2023‐004 – Year Ended June 30, 2023 Department of Health and Human Services Federal Assistance Listing/# 93.498 Reporting Material Weakness in Internal Control Over Compliance and Material Noncompliance Finding Summary: 2 CFR 200.303(a) establishes that the auditee must establish and maintain eff...

2023‐004 – Year Ended June 30, 2023 Department of Health and Human Services Federal Assistance Listing/# 93.498 Reporting Material Weakness in Internal Control Over Compliance and Material Noncompliance Finding Summary: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. The Facilities did not consider the impact of the year-end audit adjustments on the quarters applicable to Period 4 when reporting lost revenue. Key line items for reporting related to lost revenue were materially misstated. No lost revenue was claimed during the current period. Responsible Individual: Perry Howell, CFO Corrective Action Plan: The Facilities will enhance internal control policies to ensure all amounts are adequately documented and properly recorded in the reports required to be submitted to the federal agency. The Hospital will enhance internal control policies to ensure that the required reports are properly reviewed prior to submission to ensure all key line items are necessary, correct, meet the requirements of the federal program, and are properly recorded in the reports required to be submitted to the federal agency. Anticipated Completion Date: June 2024

View Audit 305361

Finding 395698 (2023-003)

Material Weakness 2023

Irvington Community Schools, Inc.

IN

School Nutrition Programs Internal Control / Segregation of Duties Subrecipient Monitoring

3. Finding 2023-003. Fund Balance Management Corrective Action: Previous audit year expenses were classified as “General” funds when they should have classified as “Food Service”. This, in aggregate, has led to an excess fund balance. Management, will work with the state on how to transfer the large...

3. Finding 2023-003. Fund Balance Management Corrective Action: Previous audit year expenses were classified as “General” funds when they should have classified as “Food Service”. This, in aggregate, has led to an excess fund balance. Management, will work with the state on how to transfer the large arrear fund balances between accounts. Management will also endeavor to assure that all ongoing expenses are allocated to the correct fund. Responsible Person/Position: Rod Iberg/COO and Linda Heidrich/Staff Accountant

View Audit 305326

Finding 395383 (2023-033)

Material Weakness 2023

State of Oregon

OR

Subrecipient Monitoring Material Weakness Reporting § 200.303

2023-033 Oregon Department of Emergency Management Implement controls over FFATA reporting MANAGEMENT RESPONSE: We agree with this recommendation. ODEM has undertaken the following corrective actions to address the recommendations made by the Secretary of State’s Audits Division: a. ODEM has dev...

2023-033 Oregon Department of Emergency Management Implement controls over FFATA reporting MANAGEMENT RESPONSE: We agree with this recommendation. ODEM has undertaken the following corrective actions to address the recommendations made by the Secretary of State’s Audits Division: a. ODEM has developed procedures for capturing necessary information and ensuring FFATA reports are filed in compliance with federal criteria. b. ODEM has identified all awards since July 1st 2023 and is working to ensure 100% compliance from that date forward. c. ODEM will continue to review older awards to determine what actions should be taken. Anticipated Completion Date: December 30, 2024. Contact person: Jeff Flowers, Chief Financial Officer

View Audit 305129

Finding 395378 (2023-023)

Material Weakness 2023

State of Oregon

OR

Questioned Costs Eligibility Special Tests & Provisions

2023-023 Oregon Department of Human Services/Oregon Health Authority Improve documentation for provider eligibility determinations and revalidations MANAGEMENT RESPONSE: We agree with this recommendation. The authority will provide two separate training modules to enrollment staff and staff respo...

2023-023 Oregon Department of Human Services/Oregon Health Authority Improve documentation for provider eligibility determinations and revalidations MANAGEMENT RESPONSE: We agree with this recommendation. The authority will provide two separate training modules to enrollment staff and staff responsible for the CCO enrollment and validation regarding complete ownership and disclosure documents. We will perform the trainings on April 18, 2024, during our monthly staff meeting and a separate ownership form only training on May 30, 2024. The Office of Developmental Disability Services has implemented new contractual language for our fiscal intermediary to review I-9 for providers with stricter criteria. This was added earlier this year and is already in place in the contract and implemented. Further, upon enrollment, state staff are validating older I-9s for providers who have submitted their I-9 historically. The Office of Aging and People with Disabilities is committed to ensuring Provider Enrollment Agreements and accurate I-9 forms are on file and ensuring records are stored and retained properly for all Home Care Workers. The department will reinforce the requirements concerning the collection and storage of agreements at both the Quarterly Home Care Coordinators meeting on May 30, 2024, and at the AAA/APD Local Line Leadership meeting on May 16, 2024. The department will also create a reference guide in the new ODHS Field Business Procedure Manual implemented in February 2024. The department will make provider enrollment agreements and I-9 forms available statewide via DocuSign as an optional tool for state staff that guides them through accurately completing information on the form and capturing electronic signatures. This will ensure that all required fields in forms are filled out correctly including ensuring the presence of required documentation to mitigate human error. Additionally, we will continue to explore developing a training module for front office staff and office managers as well as a peer review process on business procedures and exploring ways that we can leverage technology such as the replacement Electronic Data Management System (EDMS) "Laserfiche" implemented by Imaging and Records Management Services (IRMS) to store provider records electronically. The questioned costs of $1,786 will be refunded to CMS and reported on the CMS 64 by 6/30/2024. Of note, the prior year finding with questioned costs of $1,843 has since been found as the provider being eligible. No corrective action is needed. Anticipated Completion Date: August 30, 2024 Contact person: Todd Howard, Business Operations Supervisor; Vanessa Richkind, Provider Administration Manager; Jennifer Stallsworth, Chief of Staff; Travis Labrum, Grant Accounting Manager

View Audit 305129 Questioned Costs: $1

Finding 395336 (2023-029)

Material Weakness 2023

State of Oregon

OR

Questioned Costs Allowable Costs / Cost Principles Material Weakness

2023-029 Department of Human Services Strengthen controls over program expenditures MANAGEMENT RESPONSE: We agree with this recommendation. Questioned costs consist of facility payments totaling $139 and a separate payment which exceeded costs of client services by $10. The agency agrees with th...

2023-029 Department of Human Services Strengthen controls over program expenditures MANAGEMENT RESPONSE: We agree with this recommendation. Questioned costs consist of facility payments totaling $139 and a separate payment which exceeded costs of client services by $10. The agency agrees with the finding and will refund those questioned costs. The agency will review the specific circumstances for each of the invoices paid to ensure staff receive the appropriate training as well as reiterate the need to review invoices carefully according to current policies and practices to avoid coding errors. Anticipated Completion Date: June 30, 2024 Contact person: Keith Ozols, Vocational Rehabilitation Services Director

View Audit 305129 Questioned Costs: $1

Finding 395335 (2023-028)

Material Weakness 2023

State of Oregon

OR

Eligibility Material Weakness Period of Performance § 200.303

2023-028 Department of Human Services Strengthen controls to ensure adequate supporting documentation and accuracy over reporting MANAGEMENT RESPONSE: We agree with the first recommendation. We disagree with the second recommendation. We agree with the first recommendation and will ensure adequa...

2023-028 Department of Human Services Strengthen controls to ensure adequate supporting documentation and accuracy over reporting MANAGEMENT RESPONSE: We agree with the first recommendation. We disagree with the second recommendation. We agree with the first recommendation and will ensure adequate supporting documentation is maintained and readily available to support information reported in the RSA-911. We disagree with the second recommendation. The RSA-17 is currently reviewed by both Program Leadership as well as the ODHS Grant Accounting Manager. Certification is evidenced by the signed RSA-17. This level of review meets federal requirements. Additional review and discussion may be had as a form of best practice but should not be considered a control mechanism. The Grant Accounting Unit will highlight the certification process in the RSA-17 desk manual to delineate between control functions and best practices. Anticipated Completion Date: June 30, 2024 Contact person: Keith Ozols, Vocational Rehabilitation Services Director; Travis Labrum, Grant Accounting Manager

View Audit 305129

Finding 395289 (2023-064)

Material Weakness 2023

State of Rhode Island

RI

Questioned Costs Eligibility Cash Management

Finding 2023-064 – Corrective Action Plan 2023-064a – Death reporting: Permanent system fix will deploy 28 June 2024; enhancement will trigger a 1A code from RI Bridges to send date of death to MMIS when date of death is added on a case with closed eligibility. This fix should remedy audit finding...

Finding 2023-064 – Corrective Action Plan 2023-064a – Death reporting: Permanent system fix will deploy 28 June 2024; enhancement will trigger a 1A code from RI Bridges to send date of death to MMIS when date of death is added on a case with closed eligibility. This fix should remedy audit finding plus financial impact in the MMIS when members are not closed properly. Anticipated Completion Date: June 28, 2024 2023-064b – Death reporting addressed in response to 2023-064a. Residency/Out of State: State resumed PARIS residency verifications and is pursuing secondary residency checks with Accruint/Lexis Nexis data and automation of manual NCOA database verification process. Additionally, State will benefit from future use of The Work Number Employee Address data to verify residency. Anticipated Completion Date: August 1, 2024 Contact Person: Brian Tichenor, RIBridges Medicaid Administrator, Executive Office of Health & Human Services brian.tichenor@ohhs.ri.gov 2023-064c – EOHHS will identify and return any potential ineligible costs by end of the current Federal Fiscal Year (FFY). Anticipated Completion Date: September 30, 2024 Contact Person: Allison Shartrand, Assistant Director, Financial & Contract Management, Executive Office of Health & Human Services allison.shartrand@ohhs.ri.gov

View Audit 305097 Questioned Costs: $1

Finding 395268 (2023-061)

Material Weakness 2023

State of Rhode Island

RI

Allowable Costs / Cost Principles Cash Management Eligibility

Finding 2023-061 – Corrective Action Plan EOHHS has met expectations on aligning the FSR and FDCR reports, has updated files to Milliman, and continues to monitor compliance. EOHHS is currently in a maintenance phase and will continue monthly oversight going forward. Anticipated Completion Date: ...

Finding 2023-061 – Corrective Action Plan EOHHS has met expectations on aligning the FSR and FDCR reports, has updated files to Milliman, and continues to monitor compliance. EOHHS is currently in a maintenance phase and will continue monthly oversight going forward. Anticipated Completion Date: Current and Ongoing Contact Person: Bill McQuade, Chief of Program Analytics, Executive Office of Health & Human Services bill.mcquade@ohhs.ri.gov

View Audit 305097

Finding 395267 (2023-060)

Material Weakness 2023

State of Rhode Island

RI

Questioned Costs Special Tests & Provisions Eligibility

Finding 2023-060 – Corrective Action Plan Rhode Island Medicaid’s Provider Enrollment project went live on 2/01/2024. Any provider that isn’t screened and enrolled with the State Medicaid Agency will have claims deny. Additionally, MCOs have terminated providers in their network who are not scree...

Finding 2023-060 – Corrective Action Plan Rhode Island Medicaid’s Provider Enrollment project went live on 2/01/2024. Any provider that isn’t screened and enrolled with the State Medicaid Agency will have claims deny. Additionally, MCOs have terminated providers in their network who are not screened and redirected members to fully screened and enrolled providers. Rhode Island Medicaid continues to work with its fiscal agent and MMIS contractor, Gainwell Technologies, to ensure all edits are systematic. Anticipated Completion Date: Implemented February 1, 2024 Contact Persons: Kimberly Tebow, Senior Medical Care Specialist, Executive Office of Health & Human Services kimberly.tebow@ohhs.ri.gov Chantele Rotolo, Assistant Administrator for Family & Children Services, Executive Office of Health & Human Services chantele.rotolo@ohhs.ri.gov

View Audit 305097 Questioned Costs: $1

Finding 395266 (2023-059)

Material Weakness 2023

State of Rhode Island

RI

Special Tests & Provisions Material Weakness

Finding 2023-059 – Corrective Action Plan 2023-059a – EOHHS amended its contracts with the Health Plans (Amendment 11, August 2023), to include the following language in "New Section 2.16.06 Periodic Financial Audit": Effective for the rating year beginning July 1, 2023, and every third year therea...

Finding 2023-059 – Corrective Action Plan 2023-059a – EOHHS amended its contracts with the Health Plans (Amendment 11, August 2023), to include the following language in "New Section 2.16.06 Periodic Financial Audit": Effective for the rating year beginning July 1, 2023, and every third year thereafter, EOHHS will contract with an external firm to conduct an independent audit of plan submitted Financial Data Cost Reporting. The audits will be done in FY 2025, followed by FY 2028, FY 2031, and so forth. The focus of the audit will be to ensure that supporting documentation is available for all Financial Data Cost Report (FDCR) inputs. Anticipated Completion Date: June 30, 2025 2023-059b – All MCOs are monitored weekly to review error reports and resubmissions and monthly for alignment with FSR/FDCR reports. Tufts is working on an active corrective action plan to ensure that Billed Amount and Allowed Amount are included on claims. EOHHS performed and Encounter Data Validation (EDV) Study for dates ranging from Jnuary 1 to December 31, 2021, for encounters submitted to the state between January 1, 2021 and March 31 2022. Anticipated Completion Date: June 1, 2024 Contact Persons: Charles Estabrook, Managed Care Administrator, Executive Office of Health & Human Services charles.estabrook@ohhs.ri.gov Lynn Doherty, Managed Care Compliance Officer, Executive Office of Health & Human Services lynn.doherty@ohhs.ri.gov Chaz Plungis, Chief of Strategic Planning, Monitoring & Evaluation, Executive Office of Health & Human Services charles.plungis@ohhs.ri.gov Bill McQuade, Chief of Program Analytics, Executive Office of Health & Human Services bill.mcquade@ohhs.ri.gov

View Audit 305097

Finding 395264 (2023-057)

Material Weakness 2023

State of Rhode Island

RI

Questioned Costs Eligibility Cash Management

Finding 2023-057 – Corrective Action Plan 2023-057a – Residency/Out of State: Rhode Island resumed PARIS residency verifications and is pursuing secondary residency checks with Accruint/Lexis Nexis data and automation of manual NCOA database verification process. Additionally, the State will benef...

Finding 2023-057 – Corrective Action Plan 2023-057a – Residency/Out of State: Rhode Island resumed PARIS residency verifications and is pursuing secondary residency checks with Accruint/Lexis Nexis data and automation of manual NCOA database verification process. Additionally, the State will benefit from future use of The Work Number Employee Address data to verify residency. Income/Wage Validation: EOHHS completed implementation of an interface on 23 March 2024 between The Work Number (TWN) and RI Bridges. Contract and budget actions for TWN services are in progress with a goal of initiating TWN wage verifications in July-August 2024. Anticipated Completion Date: September 1, 2024 2023-057b – EOHHS will return any potential ineligible costs by end of the Federal Fiscal Year (FFY). Anticipated Completion Date: September 30, 2024 Contact Person: Brian Tichenor, RIBridges Medicaid Administrator, Executive Office of Health & Human Services brian.tichenor@ohhs.ri.gov

View Audit 305097 Questioned Costs: $1

Finding 395256 (2023-056)

Material Weakness 2023

State of Rhode Island

RI

Questioned Costs Subrecipient Monitoring Eligibility

Finding 2023-056 – Corrective Action Plan Management agrees with the finding. Regulation 4.5.1, RIW approved families are categorically eligible for CCAP services when they have an acceptable need for services related to fulfilling RIW program requirements. The determination of employment plan com...

Finding 2023-056 – Corrective Action Plan Management agrees with the finding. Regulation 4.5.1, RIW approved families are categorically eligible for CCAP services when they have an acceptable need for services related to fulfilling RIW program requirements. The determination of employment plan components including any combination of education and work-related activities in the approved plan are determined by RIW Regulations, section 2.11. The need for services in an RIW CCAP case is based on the employment plan. In situations where an applicant parent does not comply with the RIW employment plan, CCAP services would not be approved. Once CCAP services are approved based on an employment plan for an RIW recipient, the approval is for a 12-month certification period and would not be terminated, per ACF federal requirements, for a subsequent change in employment plan participation or change in income (unless in excess of 85% SMI). It should be noted that in all cases, the decortications were documented in Bridges. CCAP training has also been enhanced in many ways. CCAP training is delivered along with RIW training on a bi-monthly basis for new hires and/or existing ETs The CCAP training module was revised to include topics specific to improper payments. Office of Child Care also holds monthly CCAP office hours for operations staff to connect with program admins, policy and training specialist to answer/troubleshoot questions from the field. Monthly analysis by error type now includes location and worker ID for analysis of more targeted training. DHS also continues to look at system and process improvements. Weekly CCAP theme meetings are ongoing to identify and solution Bridges related incidents. The CCAP Regulations have been reviewed and were opened Q1 2024 for policy updates to streamline and simplify verification processes where possible. Anticipated Completion Date: July 1, 2024 Contact Person: Nicole Chiello, Assistant Director – Office of Child Care, Department of Human Services nicole.chiello@dhs.ri.gov

View Audit 305097 Questioned Costs: $1

Finding 395244 (2023-051)

Material Weakness 2023

State of Rhode Island

RI

Questioned Costs Eligibility Internal Control / Segregation of Duties

Finding 2023-051 – Corrective Action Plan Management agrees with the finding. DHS completed the scope of work in order to hire an outside contractor to evaluate the work and redefine the workflow distribution to improve timeliness and performance. At this time an outside contractor has not been i...

Finding 2023-051 – Corrective Action Plan Management agrees with the finding. DHS completed the scope of work in order to hire an outside contractor to evaluate the work and redefine the workflow distribution to improve timeliness and performance. At this time an outside contractor has not been identified. An additional staff has been added to the RIW policy unit and assigned as the liaison with CSDL to ensure written instructions are clear and accurate. Another meeting between the RIW policy unit and operations has been added as another avenue to address concerns and make corrections. The system vendor is sampling cases to identify missing components. Anticipated Completion Date: October 1, 2024 Contact Person: Donna M. Rook, Ph.D, MSW, Administrator, Family & Adult Services, Department of Human Services donna.m.rook@dhs.ri.gov

View Audit 305097 Questioned Costs: $1

Finding 395228 (2023-048)

Material Weakness 2023

State of Rhode Island

RI

Subrecipient Monitoring Material Weakness Reporting

Finding 2023-048 – Corrective Action Plan RIDE recognizes that CTE Program Monitoring did not reflect US DOE format and therefore developed a monitoring tool that meets USDOE layout and functionality. Using district provided CTE data, RIDE will review written documentation provided by the secondar...

Finding 2023-048 – Corrective Action Plan RIDE recognizes that CTE Program Monitoring did not reflect US DOE format and therefore developed a monitoring tool that meets USDOE layout and functionality. Using district provided CTE data, RIDE will review written documentation provided by the secondary/postsecondary districts being monitored. The monitoring will consist of both a desk audit and an onsite inspection of the subrecipients. After the review process is complete a report for subrecipients will be sent back to the subrecipients that were monitored. This may include next steps and the need (if any) for corrective action. Anticipated Completion Date: On May 1, 2024, and May 3, 2024, RIDE will begin monitoring a secondary and postsecondary Perkins recipient. RIDE will continue with subrecipient monitoring visits in each subsequent fiscal year to satisfy the requirements of the USDOE. Contact Person: Paul McConnell, Career & Technical Education Data Specialist, Department of Elementary & Secondary Education paul.mcconnell@ride.ri.gov

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Finding 395226 (2023-046)

Material Weakness 2023

State of Rhode Island

RI

Allowable Costs / Cost Principles Eligibility Material Weakness

Finding 2023-046 – Corrective Action Plan As a result of the USDOE review, RIDE has made the necessary changes to the redistribution of unspent funds. Anticipated Completion Date: The corrected process for redistributing unspent funds from prior years was communicated to the field during the FY24 ...

Finding 2023-046 – Corrective Action Plan As a result of the USDOE review, RIDE has made the necessary changes to the redistribution of unspent funds. Anticipated Completion Date: The corrected process for redistributing unspent funds from prior years was communicated to the field during the FY24 Perkins Launch Webinar on June 8, 2023. The, corrected calculation redistribution was calculated and implemented on November 27, 2023, when the FY23 funds were redistributed. Contact Person: Mark Dunham, Chief Financial Officer, Department of Elementary & Secondary Education mark.dunham@ride.ri.gov

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Finding 395198 (2023-036)

Material Weakness 2023

State of Rhode Island

RI

Internal Control / Segregation of Duties Special Tests & Provisions Material Weakness

Finding 2023-036 – Corrective Action Plan We feel that compensating controls do currently exist as well as having protocols in place which require evidence of supporting documentation. It should also be noted that tax rates are included as part of our TPS review, handled by USDOL Complete reviews o...

Finding 2023-036 – Corrective Action Plan We feel that compensating controls do currently exist as well as having protocols in place which require evidence of supporting documentation. It should also be noted that tax rates are included as part of our TPS review, handled by USDOL Complete reviews of State internal controls take place every four years unless problems have been discovered or program changes have been made within the last year. To confirm that the State's controls are working effectively and producing accurate outputs, samples of each tax function's outputs are drawn and examined every year. The Tax Performance System (TPS) is intended to assist State administrators in improving their Unemployment Insurance (UI) programs by providing objective information on the quality of existing revenue operations. We have never had a TPS finding relative to Tax Rate computations or experience rating. The auditee will continue to ensure proper documentation is present when any adjustments are made that could have a potential to impact an accounts’ experience rating. Anticipated Completion Date: December 31, 2024 Contact Person: Philip D’Ambra, Director, Income Support, Department of Labor & Training philip.l.dambra@dlt.ri.gov

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Finding 395197 (2023-035)

Material Weakness 2023

State of Rhode Island

RI

Special Tests & Provisions Material Weakness Reporting

Finding 2023-035 – Corrective Action Plan The auditee concurs with this finding. Anticipated Completion Date: December 31, 2024 Contact Person: Philip D’Ambra, Director, Income Support, Department of Labor & Training philip.l.dambra@dlt.ri.gov

View Audit 305097

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