Corrective Action Plans

Finding 515469 (2023-131)

Material Weakness 2023

State of Arizona

AZ

Questioned Costs Special Tests & Provisions Material Weakness

Assistance listing number and program name: 93.778 Medicaid Assistance Program (part of the Medicaid Cluster 93.778 COVID-19 Medicaid Assistance Program Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact persons and titles: Vanessa Templeman, Inspector General, AHCCCS Offic...

Assistance listing number and program name: 93.778 Medicaid Assistance Program (part of the Medicaid Cluster 93.778 COVID-19 Medicaid Assistance Program Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact persons and titles: Vanessa Templeman, Inspector General, AHCCCS Office of Inspector General; Jeff Tegen, Assistant Director, AHCCCS Division of Budget and Finance Anticipated completion date: December 31, 2024 Agency’s Response: Concur AHCCCS OIG agrees with the finding as stated above. AHCCCS OIG commits to a review of the current Deferred Process and will determine areas of improvement to include; timelines for deferred case review completion, quarterly completed deferred case review reports, and required documentation for all deferred case processes.

View Audit 333243 Questioned Costs: $1

Finding 515468 (2023-130)

Material Weakness 2023

State of Arizona

AZ

Questioned Costs Special Tests & Provisions Procurement, Suspension & Debarment

Assistance listing number and program name: 93.778 Medicaid Assistance Program (part of the Medicaid Cluster 93.778 COVID-19 Medicaid Assistance Program Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS Division of B...

Assistance listing number and program name: 93.778 Medicaid Assistance Program (part of the Medicaid Cluster 93.778 COVID-19 Medicaid Assistance Program Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS Division of Budget and Finance Anticipated completion date: December 31, 2024 Agency’s Response: Concur In May 2023, AHCCCS announced its initial findings of credible and willful fraud by sober-living providers across the state. Since then, AHCCCS has suspended more than 300 providers, assisted over 10,000 individuals with the humanitarian response, and implemented more than 20 new initiates to combat fraud, waste, and abuse in the Medicaid program. As the extent of the fraud was revealed, AHCCCS recognized the need for holistic and systemwide changes. AHCCCS partnered with the Attorney General and Governor’s Office to develop a comprehensive plan to address the loopholes fraudulent providers were exploiting. Stop gap strategies implemented include, but may not limited to the following: · Increased scrutiny of claims based on claims volume. · Issued a moratorium on new provider registrations for impacted provider types · Prevented Reimbursement of Claims for Impossibly Rendered Services · Claims for Substance Abuse Services for Children under the age of 12 to Require Clinical Review Prior to Payment · Set thresholds for services to initiate a prepayment review. · Required claims to be billed for specific dates of service rather than ranges. · Flagged claims for services of the same style/overlapping codes. · Created a prepayment review process for providers utilizing suspicious billing practices. · Eliminated retroactive billing. · Credible Allegation of Fraud (“CAF”) suspensions include both provider entities and owners/ behavioral health (“BH”) practitioners. · Implemented ID.Me identity verification for AHCCCS Online. · Required providers to disclose any third-party billing relationships. · Behavioral Health Providers are now considered high-risk provider types for provider enrollment. · Per Diem codes have been set to only be able to be billed once per day. · Practitioners, including Behavioral Health Technicians, can no longer be patients at the same provider. · Worked with the Arizona Corporation Commission to flag suspicious registrations. · Ensured AHCCCS coding adhered to National Correct Coding Initiative (“NCCI”) standards and confirmed no edits had been turned off. · Streamlined AHCCCS reporting of bad actors to the appropriate professional oversight boards. Stop gap strategies in process include, but may not be limited to, the following: · Implementing eligibility integrity requirements for AIHP enrollment. · Linking BHP to BH companies they work for. · Link BH Providers to BH facilities they work at. · Conduct onsite quality of care reviews for patients in treatment longer than 90 days. · Require medical records to define specialized services. · Implement a new pre/post pay claims system. · Mandatory transition to Electronic Fund Transfer (direct deposit) for all AHCCCS provider reimbursements. AHCCCS continues to investigate and identify areas of concern and implement necessary system improvements until it is determined that the integrity of the AHCCCS provider network is restored.

View Audit 333243 Questioned Costs: $1

Finding 515347 (2023-125)

Material Weakness 2023

State of Arizona

AZ

Questioned Costs Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303 § 200.332 § 200.513 § 200.521

Assistance listing numbers and program names: 84.010 Title I Grants to Local Educational Agencies 84.367 Supporting Effective Instruction State Grants (formerly Improving Teacher Quality State Grants) Agency: Arizona Department of Education (ADE) Name of contact person and title: Dr. Sarka White, AD...

Assistance listing numbers and program names: 84.010 Title I Grants to Local Educational Agencies 84.367 Supporting Effective Instruction State Grants (formerly Improving Teacher Quality State Grants) Agency: Arizona Department of Education (ADE) Name of contact person and title: Dr. Sarka White, ADE Deputy Associate Superintendent Anticipated completion date: December 15, 2024 Agency’s response: Concur The Arizona Department of Education (ADE) has already begun implementing a program to ensure accurate and quality programmatic monitoring for all ESEA programs which specifically requires LEAs to meet 100% of the requirements of all statutorily required items to be monitored regardless of CMO affiliation. This development of programmatic monitoring will design a system of integrity to allow each LEA to have unique monitoring findings and ensure they are treated as all other LEAs regardless of management status. The Arizona Department of Education (ADE) is finalizing all program policies and procedures along with field training and staff training on how this program is implemented. ADE began providing an assurance document to charters in May 2024 which asks the charters to assure that if they do business with a CMO, the CMO does not have fiscal or operational authority for the LEA. The charter is asked to submit to ADE a copy of their organizational chart, along with the assurances document. Grants Management has created a new user role in the Grants Management Enterprise (GME) system, called the LEA Contracted Update role. This role allows a CMO person the access to perform fiscal tasks for which they have been contracted but does not hold the final submit or approve capacity, that must be reserved for authorized employees of the LEA. Grants Management has provided the placeholder for the assurance and organizational chart in the LEA Document Library, along with the communication to eligible entities (charters in this case). Individual program areas within ADE who review and approve funding applications will be responsible for verifying the assurances have been signed and uploaded and only authorized people at the LEA are actioning funding applications in GME prior to the program area giving director approval to the application.

View Audit 333243 Questioned Costs: $1

Finding 515345 (2023-123)

Material Weakness 2023

State of Arizona

AZ

Questioned Costs Subrecipient Monitoring § 200.303 § 200.513 § 200.521

Assistance listing numbers and program names: 84.010 Title I Grants to Local Educational Agencies 84.367 Supporting Effective Instruction State Grants (formerly Improving Teacher Quality State Grants) Agency: Arizona Department of Education (ADE) Name of contact person and title: Nicole Von Prisk, A...

Assistance listing numbers and program names: 84.010 Title I Grants to Local Educational Agencies 84.367 Supporting Effective Instruction State Grants (formerly Improving Teacher Quality State Grants) Agency: Arizona Department of Education (ADE) Name of contact person and title: Nicole Von Prisk, ADE Deputy Associate Superintendent of Grants Management Matt McClary, ADE Compliance Officer Anticipated completion date: April 2025 Agency’s response: Concur • Tech team supervisor will have someone from that team put eyes on the initial generated report to compare results to prior year, looking at total number of LEAs, then greenlighting the initial report for the Tech Director and the Fiscal Director to review. • Once the Fiscal and Tech Directors receive the report, they will be responsible for sampling the data that populated into the report, by looking at overall numbers who Pass, Pass with Exception, or Fail and doing a comparison for analysis to prior year summary results. They will conduct a random sampling, comparing totals to latest AFR totals, to ensure amounts populated correctly. Once random sampling has been completed, it will be sent to Deputy Associate Superintendent for final checks. • Deputy Associate Superintendent will give final approval to move to public display of data, after confirmation of completeness and accuracy of data populated.

View Audit 333243 Questioned Costs: $1

Finding 515344 (2023-122)

Material Weakness 2023

State of Arizona

AZ

Questioned Costs Allowable Costs / Cost Principles Eligibility § 200.303 § 200.513 § 200.521

Assistance listing numbers and program names: 84.010 Title I Grants to Local Educational Agencies 84.367 Supporting Effective Instruction State Grants (formerly Improving Teacher Quality State Grants) Agency: Arizona Department of Education (ADE) Name of contact person and title: Dr. Sarka White, AD...

Assistance listing numbers and program names: 84.010 Title I Grants to Local Educational Agencies 84.367 Supporting Effective Instruction State Grants (formerly Improving Teacher Quality State Grants) Agency: Arizona Department of Education (ADE) Name of contact person and title: Dr. Sarka White, ADE Deputy Associate Superintendent Chris Brown, Business Officer of Education Programs Anticipated completion date: February 2025 Agency’s response: Concur • The Arizona Department of Education (ADE) has already begun to document and execute practices addressing the recommendations issued by the auditor's office. • ADE has already drafted a comprehensive policies and procedures document outlining eligibility, duties, and responsibilities with individuals who oversee and double-check the work. This document was created and refined by reviewing other states’ procedures, federal technical assistance groups, communications with the Title federal program office at the United States Department of Education, and internal procedures in other units. • The Title I unit has been restructured to have an operations team with multiple staff members overseeing data quality and internal controls for allocations. This updated structure ensures that multiple individuals are involved in the allocation process. Staffing for this should be completed by February 2025. • The updated processes include entity management to determine when charter LEAs open and operate each year. Now, other systems validate this information instead of copying the information from the prior year. As such, this item has already been completed. • Finally, the department will follow up with the United States Department of Education (USED) regarding recalculating the fiscal year 2023 and the six ineligible LEAs for Title II funds to determine feasible processes and resolutions to each audit recommendation.

View Audit 333243 Questioned Costs: $1

Finding 515227 (2023-106)

Material Weakness 2023

State of Arizona

AZ

Questioned Costs Subrecipient Monitoring Reporting § 200.303 § 200.331 § 200.332

Assistance listing number and program name: 21.027 COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Agency: Arizona Department of Economic Security (DES) Name of contact person and title: Jim Whallon, DES Deputy CFO Anticipated completion date: June 30, 2026 Agency’s response: Concur Th...

Assistance listing number and program name: 21.027 COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Agency: Arizona Department of Economic Security (DES) Name of contact person and title: Jim Whallon, DES Deputy CFO Anticipated completion date: June 30, 2026 Agency’s response: Concur The Department of Economic Security will address the audit recommendations as follows: 1. Perform required monitoring of its subrecipients and their compliance with the award terms and program requirements. The Department will revise its agency-wide policies and procedures related to single audit requirements for pass-through entities to include guidance regarding how to establish effective subrecipient monitoring procedures. The Department will also offer additional subrecipient monitoring guidance for programs administered by divisions with existing subrecipient monitoring findings. 2. Properly classify and report subrecipient expenditures on the State’s SEFA. The Department will revise its procedures related to single audit requirements to include steps detailing the instructions for classifying and reporting subrecipient expenditures on the State’s SEFA. The updated procedures will include actions needed to be taken to ensure each pass-through relationship is appropriately determined and that every subrecipient relationship is communicated to the staff responsible for compiling the State’s SEFA. 3. Develop, implement, and train all divisions on entity-wide written subrecipient-monitoring policies and procedures requiring all divisions to: a. Assess the risk of each subrecipient’s noncompliance and carry out monitoring activities based on those risk assessments such as reviewing financial and performance reports, providing training or technical assistance on program-related matters, and performing on-site reviews, selective audits, and/or other monitoring procedures. b. Verify subrecipients receive timely single audits, if required; follow up on and ensure that corrective action is taken on any audit findings that could potentially affect the program; and issue management decisions for any audit findings pertaining to the federal award. c. Maintain documentation of monitoring procedures demonstrating they were performed, including the monitoring procedures’ results and any Department actions taken, if appropriate. In addition to the revisions in policy and procedures outlined in Recommendation #1 above, the Department will train staff responsible for administering compliance requirements for pass-through entities. This training will include instructions to formulate a risk assessment, review controls related to compliance requirements, review timely single audit submittal, follow up on audit findings, issue management decisions for findings, and maintain adequate documentation of monitoring procedures. The training will be provided to all staff responsible for administering programs with pass-through entities. 4. Allocate sufficient resources, such as staffing, to comply with the award terms and program requirements, and designate individuals within each division to perform necessary subrecipient-monitoring procedures. The Department will conduct analyses to determine resources needed, including staffing, to ensure compliance with applicable requirements. For example, the Department will assess the efficiency of its subrecipient-monitoring procedures, estimate future workloads, determine staffing needed to meet those workloads, and assign sufficient staff the responsibility for ensuring compliance with each requirement outlined in the federal award. The Department will also ensure the staff responsible for administering the compliance requirements prioritize this responsibility and communicate anticipated compliance deficiencies to management. 5. Update the form it uses to determine whether other parties receiving program monies have the role of a subrecipient or contractor to include guidance for how to determine each characteristic of a subrecipient and contractor relationship and require a conclusion to be documented. In addition, train staff to properly complete the form and perform supervisory reviews of it. The Department will revise its Contractor/Subrecipient Determination form to clearly identify the final determination of a pass-through entity. The Department will also provide guidance to accompany the form that shows how to determine each characteristic of a subrecipient and contractor as well as how to make the final determination regarding the contractor versus subrecipient relationship. The Department will then provide training to staff responsible for using this form as part of the training outlined in Recommendation #3 above.

View Audit 333243 Questioned Costs: $1

Finding 515224 (2023-102)

Material Weakness 2023

State of Arizona

AZ

Questioned Costs Subrecipient Monitoring § 200.303 § 200.332 § 200.513 § 200.521

Assistance listing numbers and program names: 21.027 COVID-19 - Coronavirus State and Local Fiscal Recovery Funds 84.425C COVID-19 Education Stabilization Fund –Governor’s Emergency Education Relief (GEER) Fund Agency: Arizona Governor’s Office of Strategic Planning and Budgeting (Office) Name of c...

Assistance listing numbers and program names: 21.027 COVID-19 - Coronavirus State and Local Fiscal Recovery Funds 84.425C COVID-19 Education Stabilization Fund –Governor’s Emergency Education Relief (GEER) Fund Agency: Arizona Governor’s Office of Strategic Planning and Budgeting (Office) Name of contact person and title: Sarah Brown, Director Anticipated completion date: July 31, 2025 Agency’s response: Concur During fiscal year 2024, the Office took significant corrective action to improve subrecipient monitoring by developing and implementing a comprehensive subrecipient monitoring plan. This plan includes the following: • Financial Report-Reimbursement Requests—The Office reviews the grantee's financial reports to ensure costs align with the approved budget, program objectives, and federal cost principles. • Performance Reports—The Office reviews the submission of programmatic reports. The timelines for submission and frequency of the programmatic activity reports are defined in the terms and conditions of each award. The program activity reports document that all program requirements are being satisfactorily fulfilled. Grantee outreach is conducted when performance activity is lagging. Grantee check-ins and/or additional milestones are set to ensure goals are met. The Office may amend or terminate the grant award if sufficient progress is lacking. • Single Audit Reports—The Office confirms any required Single Audits and reviews a copy of the most recent report. • A Single Audit Questionnaire is distributed to grantees annually to confirm if the entity is subject to this federal audit requirement. • The Office also reviews total payments issued to an entity by the Office in the prior year to confirm if disbursements met the audit threshold. • The Office requests grantees submit their Single Audit Reporting Package (SARP) with any findings and the required Corrective Action Plan. In addition, the Office collects SARPs from the federal clearinghouse. • The Office reviews SARPs for any findings and conducts follow-up monitoring of CAPs that impact any grant funding managed by the Office. Management decisions are issued to grantees as required for specific grant findings. • Risk Assessment (RA)—The Office conducts a Risk Assessment (RA) of grantees when applying for grants to inform the grant award decision and possible grantee oversight or restrictions. Additionally, the Office conducts an annual RA of any grantee currently awarded funding. • The RA contains a self-assessment for the grantee to complete and an internal review conducted by the Office. Scores from both are weighted and used to calculate the overall risk score for each grantee as high, medium, and low risk. • The Office utilizes the RA results to prioritize high-risk grantees, which are reviewed through a desk or on-site monitoring. Medium-risk grantees will receive additional support and be referred to our Compliance and Reporting team for further review if additional concerns arise. Office staff now attend ongoing internal and external training to improve their understanding of compliance requirements, identify noncompliance, and actively reduce the risks of waste, fraud, and abuse of federal dollars through our subrecipient monitoring process. The Office has developed and implemented processes for requirements such as single audit review and corrective action follow-up, risk assessment, and subrecipient monitoring to address the specific findings. During the time frame corresponding to this audit finding, the pace and volume of grants management administrative duties required to be executed exceeded staffing capacity, contributing to the findings noted. As of this date, the Office has achieved stability in both manager and staff positions. In addition, the Office has allocated sufficient resources to comply with the award terms and program requirements by establishing a Grants Compliance and Reporting Team dedicated to performing necessary subrecipient monitoring procedures. Furthermore, the Office has implemented all recommendations and would like to specifically highlight efforts to work with subrecipients to resolve the potential disallowed costs of $1,903,858 of program monies that may have been spent in violation of its federal award terms by conducting on-site monitoring visits, desk reviews, and facilitating subrecipient technical assistance. OSPB is committed to continuing these efforts.

View Audit 333243 Questioned Costs: $1

Finding 515212 (2023-105)

Material Weakness 2023

State of Arizona

AZ

Questioned Costs Allowable Costs / Cost Principles Eligibility § 200.303 § 200.403 § 200.404 § 200.513 § 200.521

Assistance listing numbers and program names: 21.023 COVID-19 - Emergency Rental Assistance Program 21.027 COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Agency: Arizona Department of Economic Security (DES) Name of contact person and title: Molly Bright, DES CCSD Assistant Director An...

Assistance listing numbers and program names: 21.023 COVID-19 - Emergency Rental Assistance Program 21.027 COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Agency: Arizona Department of Economic Security (DES) Name of contact person and title: Molly Bright, DES CCSD Assistant Director Anticipated completion date: June 30, 2026 Agency’s Response: Concur The Department of Economic Security will address the audit recommendations as follows: 1. Ensure benefit payments are for allowable costs paid to or on behalf of eligible program applicants. The Department will review and confirm that benefits payments paid to or on the behalf of eligible program applicants are allowable expenditures of the federal funding being disbursed. 2. Follow existing policies and procedures to obtain required documentation to support requirements related to where the applicant lives and their income to ensure program applicants are eligible to receive benefit payments. The Department will abide by the existing adjudication policies and procedures that require the submission of substantiating documentation supporting the claims made by applicants regarding where they live and their household income to confirm that applicants are eligible to receive benefit payments under the program and to verify the amount of benefits they shall receive. 3. Allocate sufficient staffing resources to perform a thorough evaluation of program benefits applications and provide training on eligibility requirements and allowable benefit payments. The Department will attempt to obtain or allocate additional resources to staffing to support the program benefits application evaluation process and will provide additional training to staff on eligibility requirements and allowable benefit payment regulations. 4. Update the checklist Division personnel use to perform a post-review of eligibility determinations to include detailed guidance for verifying the determinations aligned with the Division’s written policies and procedures and supported by adequate documentation. The Department will update the checklist being used by staff to perform post-review of eligibility determinations to include detailed guidance on verifying the applicant benefits determinations in alignment with the divisional policies and procedures and evidenced by adequate substantiating documentation.

View Audit 333243 Questioned Costs: $1

Finding 515176 (2023-113)

Significant Deficiency 2023

State of Arizona

AZ

Questioned Costs Subrecipient Monitoring § 200.303

Assistance listing numbers and program names: 17.258 WIOA Adult Program 17.259 WIOA Youth Activities 17.278 WIOA Dislocated Worker Formula Grants Agency: Arizona Department of Economic Security (DES) Name of contact persons and titles: Aaron Johnson, DES Fiscal Compliance Manager Tarry Haynie, DES ...

Assistance listing numbers and program names: 17.258 WIOA Adult Program 17.259 WIOA Youth Activities 17.278 WIOA Dislocated Worker Formula Grants Agency: Arizona Department of Economic Security (DES) Name of contact persons and titles: Aaron Johnson, DES Fiscal Compliance Manager Tarry Haynie, DES Senior Fiscal Analyst Anticipated completion date: June 30, 2025 Agency’s Response: Concur To ensure the Department’s Division of Employment and Rehabilitation Services (DERS) Finance and Business Operations Administration (FBOA) performs the required monitoring of its sub-recipients and complies with the award terms and program requirements, it has added additional internal controls by updating the monitoring schedule to include backup fiscal monitors. The FBOA will also update its procedures to include the process for backup monitors to take on primary monitoring duties in the event an assigned staff member is unable to perform the onsite monitoring review as scheduled. During fiscal year 2023, the fiscal compliance team within the FBOA consisted of only three staff members. They have since onboarded two additional staff, bringing the total number of fiscal compliance monitors to five. One of these additional staff members completed training and was assigned a full caseload in December 2023. The second new staff member is currently undergoing training and is expected to finish training and absorb a full caseload beginning March 2025. The Department is on track to complete all required onsite sub-recipient fiscal monitoring for fiscal year 2025.

View Audit 333243 Questioned Costs: $1

Finding 515170 (2023-118)

Material Weakness 2023

State of Arizona

AZ

Questioned Costs Procurement, Suspension & Debarment § 200.303 § 200.317 § 200.321 § 200.322 § 200.323

Assistance listing number and program name: 14.267 Continuum of Care Program Agency: Arizona Department of Housing (DOH) Name of contact person and title: Lori Moreno, DOH Human Resources and Procurement Administrator Anticipated completion date: March 31, 2025 Agency’s Response: Concur The Depart...

Assistance listing number and program name: 14.267 Continuum of Care Program Agency: Arizona Department of Housing (DOH) Name of contact person and title: Lori Moreno, DOH Human Resources and Procurement Administrator Anticipated completion date: March 31, 2025 Agency’s Response: Concur The Department will update written policies and procedures related to procurement to incorporate applicable aspects of Federal Regulations 2 CFR §§200.321, 200.322, 200.323, and 200.327. The updated policy will address competition through competitive bids, sole source selections, and retention of procurement documents. In addition, the policy will state the Federal requirements that are to be included in purchase orders and contracts.

View Audit 333243 Questioned Costs: $1

Finding 515169 (2023-117)

Material Weakness 2023

State of Arizona

AZ

Questioned Costs Subrecipient Monitoring § 200.303 § 200.331 § 200.332 § 200.513 § 200.521

Assistance listing number and program name: 14.267 Continuum of Care Program Agency: Arizona Department of Housing (DOH) Name of contact person and title: Keon Montgomery, DOH Assistant Deputy Director of Programs Anticipated completion date: January 30, 2025 Agency’s Response: Concur The Departme...

Assistance listing number and program name: 14.267 Continuum of Care Program Agency: Arizona Department of Housing (DOH) Name of contact person and title: Keon Montgomery, DOH Assistant Deputy Director of Programs Anticipated completion date: January 30, 2025 Agency’s Response: Concur The Department resumed monitoring duties and developed a monitoring schedule to ensure subrecipients maintain program compliance. The Department also established a risk assessment tool that assess risk associated with each subrecipient. Records of subrecipient monitoring will be kept for a period of time to demonstrate monitoring activities were performed.

View Audit 333243 Questioned Costs: $1

Finding 515168 (2023-116)

Material Weakness 2023

State of Arizona

AZ

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.112 § 200.303 § 200.332 § 200.513 § 200.521

Assistance listing number and program name: 14.267 Continuum of Care Program Agency: Arizona Department of Housing (DOH) Name of contact person and title: Keon Montgomery, DOH Assistant Deputy Director of Programs Anticipated completion date: January 30, 2025 Agency’s Response: Concur The Departmen...

Assistance listing number and program name: 14.267 Continuum of Care Program Agency: Arizona Department of Housing (DOH) Name of contact person and title: Keon Montgomery, DOH Assistant Deputy Director of Programs Anticipated completion date: January 30, 2025 Agency’s Response: Concur The Department is no longer reimbursing the subrecipient for unsupported or ineligible costs and is pursuing repayment of funds from the subrecipient. Written policies for reviewing and approving subrecipient reimbursements, as well as, risk assessment were reviewed, updated and amended to ensure ongoing compliance. Staff has been trained and new policies were implemented in FY 2024 subsequent to the period reviewed in this audit. Contract Specialists in the Special Needs Division have received additional training through HUD TA support on CoC standards to ensure all request for reimbursement from subrecipients are eligible, reasonable and appropriately documented, including any allocations and purchasing requirements.

View Audit 333243 Questioned Costs: $1

Finding 515166 (2023-115)

Significant Deficiency 2023

State of Arizona

AZ

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.112 § 200.303 § 200.332 § 200.513 § 200.521

Assistance listing numbers and program names: 14.231 Emergency Solutions Grant Program 14.231 COVID-19 - Emergency Solutions Grant Program 93.558 Temporary Assistance for Needy Families 93.558 COVID-19-Temporary Assistance for Needy Families Agency: Arizona Department of Economic Security (DES) Name...

Assistance listing numbers and program names: 14.231 Emergency Solutions Grant Program 14.231 COVID-19 - Emergency Solutions Grant Program 93.558 Temporary Assistance for Needy Families 93.558 COVID-19-Temporary Assistance for Needy Families Agency: Arizona Department of Economic Security (DES) Name of contact person and title: Molly Bright, DES CCSD Assistant Director Anticipated completion date: June 30, 2025 Agency’s Response: Concur The Department will stop the reimbursement of costs to all nonprofit and contracted subrecipients for items that are disallowed and/or restricted by the regulations of the federal Emergency Solutions Grant (ESG) program and Temporary Assistance for Needy Families (TANF) grant, including payments to personnel that violate the conflict-of-interest disclosure requirements. The Department will revise its expenditure review procedures to ensure compliance with these regulations prior to disbursing any ESG and/or TANF funding to any subrecipient for any purpose. These revisions will include review and approval by applicable management personnel prior to disbursement of federal funding. The Department is also in the process of establishing a divisional Monitoring and Compliance Policy and Procedure Manual which will establish procedures specific to subrecipient monitoring. The Department will continue to assess the risk of noncompliance violations for each subrecipient and establish a plan of action to address noncompliance. The plan of action will include an array of training and educational processes to ensure applicable personnel are knowledgeable of programmatic compliance requirements and Department contracts. The Department will also monitor subrecipients per its updated policies and procedures and will ensure proper oversight of federal expenditures as required by federal regulations. The Department has amended its contracts with the applicable subrecipients to more clearly outline the regulatory requirements and expectations for expenditures under the ESG and TANF grants. The Department will also continue to resolve the unallowable costs reimbursed to subrecipients as deemed appropriate by the applicable federal agencies.

View Audit 333243 Questioned Costs: $1

Finding 514695 (2023-007)

Material Weakness 2023

Career Academy of South Bend, INC

IN

Questioned Costs Allowable Costs / Cost Principles

2023-007 Allowable Costs Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and has contracted with an outside firm that specializes in SBOA compliance, as well as Federal Award Compliance in line with Uniform Guidance. The firm will assist in the devel...

2023-007 Allowable Costs Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and has contracted with an outside firm that specializes in SBOA compliance, as well as Federal Award Compliance in line with Uniform Guidance. The firm will assist in the development of the required manuals, policies, procedures and review processes. The current estimated completion date is February 28, 2025.

View Audit 333072 Questioned Costs: $1

Finding 514494 (2023-005)

Material Weakness 2023

Michael Fields Agricultural Institute, Inc.

WI

Questioned Costs Procurement, Suspension & Debarment § 200.317 § 200.318 § 200.327

Auditor’s Recommendation: The Organization should develop and document procurement procedures that meet state, local, and Uniform Guidance requirements. Internal controls should be designed, implemented, and documented within the procurement procedures to ensure compliance with 2 CFR sections 200.31...

Auditor’s Recommendation: The Organization should develop and document procurement procedures that meet state, local, and Uniform Guidance requirements. Internal controls should be designed, implemented, and documented within the procurement procedures to ensure compliance with 2 CFR sections 200.317 through 200.327. At a minimum, the procurement history including rationale for the method, procurement method support, contract selections and rejections, suspension and debarment, and bases for contract prices should be documented. Corrective Action: Implement Policy A10 – “Grant Management Protocols.” Utilize Donor Database for managing subawards. Responsible for Corrective Action: Finance Team (Outsourced accounting firm, Operations Manager, Executive Director) Anticipated Completion Date: December 31 2024

View Audit 332826 Questioned Costs: $1

Finding 514361 (2023-001)

Significant Deficiency 2023

The Hearth Foundation INC

TX

Questioned Costs HUD Housing Programs Cash Management

Management will continue to attempt to contact the Project's HUD Project Coordinator in order to obtain the required approval for the withdrawal from the reserve for replacements account

View Audit 332653 Questioned Costs: $1

Finding 514295 (2023-010)

Material Weakness 2023

US Water Alliance

WA

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.430

Finding: 2023-010 Environmental Finance Center Grants – Assistance Listing No. 66.203 U.S. Environmental Protection Agency Gra...

Finding: 2023-010 Environmental Finance Center Grants – Assistance Listing No. 66.203 U.S. Environmental Protection Agency Grant No. 539001D, Grant period July 1,2022 - September 30, 2023 Grant No. 5127620, Grant period October 1, 2022 – September 30,2023 Grant No. 5126607, Grant period July 1,2022 - September 30, 2023 Description of the Findings: For the period from October 2022 thru May 2023 U.S. Water Alliance did not have a timekeeping system in place. A timekeeping system was implemented in June of 2023, that provides for employees to record hours worked for specific cost objectives, including Federal grants. There are limitations to the timekeeping system’s capabilities. One is no availability to run timesheet reports for closed grants after the grant period ended. Second is the need to manually adjust hours transferred from the timekeeping system to payroll processing system due to semi-monthly payroll processing and the need to have total number of hours equal to 86.67 for salaried employees. For these three awards, budget estimates or relative level of effort by percent of full-time employees and active projects were used throughout the entire grant period, even after the timekeeping system was put in place. No reconciliation between the budget estimates or relative level of effort by percent of full-time employees and active projects and the hours recorded in the timekeeping system was completed even for the period in which the timekeeping system was in place. Views of Responsible Official(s) and Planned Corrective Actions: A new timekeeping system was implemented in June 2023 to allocate work hours specific to cost objectives, including Federal Grants. While there are limitations to the system, the allocations are transferred from the timekeeping system upon supervisor approval to the Prism (HRIS) Portal and used to prepare payment vouchers. From the HRIS system, we can produce labor allocation reports reflecting how the time was originally allocated in the timekeeping system. The US Water Alliance indeed operates on a semi-monthly payroll period. It has allowed the Alliance to have fixed pay dates though they may not fall on the same day of the week each month. If the pay date falls on a weekend or holiday, the pay date is typically the business day prior. Because all months are not the same length, the size of the paycheck could vary in that the first paycheck could cover 13-14 days and the second paycheck could cover 15-16 days. To eliminate the variation in the size of the paycheck, specifically for salaried employees, the total yearly salary is evenly divided between 24 payments resulting in the same paycheck amount each time. This division results in 86.67 hours paid in each paycheck and will at times require our payroll partner to adjust the hours allocated downward or upward to equal 86.67. In the rare case that work hours are adjusted upward, the work hours are allocated to the primary funding source for the position. The process has worked traditionally as the Alliance has no hourly employees. Specifically for the three awards referenced, reconciliation between the budget estimates, relative level of effort by percent of full-time employees and active projects, and the hours recorded in the timekeeping system were completed. Staff opted to continue reporting on relative level of effort by percent of full-time employees as opposed to shifting as the timekeeping system was very new and staff experienced a significant learning curve. Additionally, there were only two months left in the grant period. Relative level of effort was carefully documented internally via calendars, Monday.com project management software, and Excel spreadsheets. Since its implementation, staff have been better trained in the use of the timekeeping system. We are also transitioning to a new timekeeping system in December 2024 with enhanced reporting and ease of use. The Alliance will also shift to a bi-weekly payroll period effectively reducing the need to adjust work hour allocations upward or downward to equal 86.67 hours. Completion Date: June 2023 Responsible Official(s): ShaQuina Davis

View Audit 332559 Questioned Costs: $1

Finding 514112 (2023-003)

Material Weakness 2023

Corvallis Caring Place Project No. 126-22128

OR

Questioned Costs HUD Housing Programs Reporting

The Organization’s management agent is not approved by HUD. Management fees paid to unauthorized management agents are considered unauthorized distributions of project funds. Views of Management and Corrective Action Plan: The Organization has chosen to change management agents to one that will be a...

The Organization’s management agent is not approved by HUD. Management fees paid to unauthorized management agents are considered unauthorized distributions of project funds. Views of Management and Corrective Action Plan: The Organization has chosen to change management agents to one that will be approved by HUD. Contact Person: Mauro Hernandez

View Audit 332280 Questioned Costs: $1

Finding 513905 (2023-003)

Significant Deficiency 2023

Northwest Georgia Housing Authority

GA

Questioned Costs Cash Management HUD Housing Programs

2023-003 – ALN 14.850 – Public & Indian Housing – Activities Allowed or Unallowed Current management acknowledges the finding and is following the auditor’s recommendations. Person Responsible for Correction of Exception: Mr. Justin Jones, Executive Director Projected Completion Date: December 31, 2...

2023-003 – ALN 14.850 – Public & Indian Housing – Activities Allowed or Unallowed Current management acknowledges the finding and is following the auditor’s recommendations. Person Responsible for Correction of Exception: Mr. Justin Jones, Executive Director Projected Completion Date: December 31, 2024

View Audit 332117 Questioned Costs: $1

Finding 513868 (2023-003)

Material Weakness 2023

Ministerial Alliance Retirement Center 042-Eh127

OH

Questioned Costs HUD Housing Programs Internal Control / Segregation of Duties

Comments on Findings and Recommendations: Management concurs with the findings and auditors’ recommendations to enhance internal controls to ensure compliance with the HUD Regulatory Agreement. Action(s) Taken or Planned for amounts due back to the Project: The management company previously advised ...

Comments on Findings and Recommendations: Management concurs with the findings and auditors’ recommendations to enhance internal controls to ensure compliance with the HUD Regulatory Agreement. Action(s) Taken or Planned for amounts due back to the Project: The management company previously advised HUD that it is in the process of marketing and selling its affordable property portfolio. The management company has reached an agreement in principle with a buyer for the sale of a significant portion of its affordable property portfolio. The buyer has significant experience in the affordable housing industry and is well-positioned to own and manage these properties. The parties are in the process of drafting all necessary documents and will work with HUD on all necessary documentation and approvals promptly once the underlying documents are fully negotiated. The management company is confident that there will be sufficient funds at the conclusion of the collective transactions with the buyer for the (re)payment of amounts to address the Findings identified herein. The management company anticipates closings by the end of 2024.

View Audit 331885 Questioned Costs: $1

Finding 513867 (2023-002)

Material Weakness 2023

Ministerial Alliance Retirement Center 042-Eh127

OH

Questioned Costs HUD Housing Programs Internal Control / Segregation of Duties

Comments on Findings and Recommendations: Management concurs with the findings and auditors’ recommendations to enhance internal controls to ensure compliance with the HUD Regulatory Agreement. Action(s) Taken or Planned for amounts due back to the Project: The management company previously advised ...

Comments on Findings and Recommendations: Management concurs with the findings and auditors’ recommendations to enhance internal controls to ensure compliance with the HUD Regulatory Agreement. Action(s) Taken or Planned for amounts due back to the Project: The management company previously advised HUD that it is in the process of marketing and selling its affordable property portfolio. The management company has reached an agreement in principle with a buyer for the sale of a significant portion of its affordable property portfolio. The buyer has significant experience in the affordable housing industry and is well-positioned to own and manage these properties. The parties are in the process of drafting all necessary documents and will work with HUD on all necessary documentation and approvals promptly once the underlying documents are fully negotiated. The management company is confident that there will be sufficient funds at the conclusion of the collective transactions with the buyer for the (re)payment of amounts to address the Findings identified herein. The management company anticipates closings by the end of 2024.

View Audit 331885 Questioned Costs: $1

Finding 513866 (2023-001)

Material Weakness 2023

Ministerial Alliance Retirement Center 042-Eh127

OH

Questioned Costs HUD Housing Programs Internal Control / Segregation of Duties

Comments on Findings and Recommendations: Management concurs with the findings and auditors’ recommendations to enhance internal controls to ensure compliance with the HUD Regulatory Agreement. Action(s) Taken or Planned for amounts due back to the Project: The management company previously advised ...

Comments on Findings and Recommendations: Management concurs with the findings and auditors’ recommendations to enhance internal controls to ensure compliance with the HUD Regulatory Agreement. Action(s) Taken or Planned for amounts due back to the Project: The management company previously advised HUD that it is in the process of marketing and selling its affordable property portfolio. The management company has reached an agreement in principle with a buyer for the sale of a significant portion of its affordable property portfolio. The buyer has significant experience in the affordable housing industry and is well-positioned to own and manage these properties. The parties are in the process of drafting all necessary documents and will work with HUD on all necessary documentation and approvals promptly once the underlying documents are fully negotiated. The management company is confident that there will be sufficient funds at the conclusion of the collective transactions with the buyer for the (re)payment of amounts to address the Findings identified herein. The management company anticipates closings by the end of 2024.

View Audit 331885 Questioned Costs: $1

Finding 513773 (2023-003)

Material Weakness 2023

Black Mesa Community School

AZ

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties

2023-003: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Type of Finding: Noncompliance, Material Weakness Condition: The school lacked adequate internal controls over its accounting disbursements to ensure that a) all financial activities were properly processed and recorded and...

2023-003: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Type of Finding: Noncompliance, Material Weakness Condition: The school lacked adequate internal controls over its accounting disbursements to ensure that a) all financial activities were properly processed and recorded and b) the School remained in compliance with federal requirements. Context: During our review of the school’s accounting records and internal controls, as well as through management inquiry, we noted the following:  For eight of 25 accounts payable transactions tested out of the 15.042 grant, the school did provide adequate documentation to support the allowability of the expenditure.  For twenty-five of 25 accounts payable expenditures tested out of the 15.046 grant, the school paid amounts to and on behalf of illegitimate board members, totaling $82,127.  For twenty-five of 25 payroll disbursements tested out of the 15.046 grant, the school paid board meeting stipends to illegitimate board members, totaling $9,750. Repeat Finding: No. Action planned in response to the finding: Management will evaluate its internal controls over records management to ensure that all accounts payable disbursements are properly supported, and School Board expenditures are only paid out to and on behalf of eligible individuals. Planned completion date for a corrective action plan: June 30, 2024 Name of the contact person responsible for corrective action: Marie Rose, Principal

View Audit 331731 Questioned Costs: $1

Finding 513622 (2023-005)

Material Weakness 2023

Catholic Charities of Central and Northern Missouri

MO

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.302 § 200.403

Catholic Charities of Central and Northern Missouri agrees with this finding and as of July 1, 2024 has altered procedures so that invoices and documentation related to expenditure of federal funds are now scanned and attached to the accounting entry recording the payable.

View Audit 331537 Questioned Costs: $1

Finding 513562 (2023-004)

Material Weakness 2023

Municipality of Ciales

PR

Questioned Costs Allowable Costs / Cost Principles

The Municipality established procedures to verify and reimburse the funds used and to avoid repeating the situation.

View Audit 331400 Questioned Costs: $1

Corrective Action Plans

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