Corrective Action Plans

Finding 558286 (2024-056)

Material Weakness 2024

RI

Eligibility Questioned Costs Cash Management

2024-056a: During SFY 2024, several system fixes were deployed to address the findings noted in 2024-056. Specifically, in September 2024, a system fix was put in place to ensure children with verified SSNs were appropriately evaluated for Medicaid/CHIP coverage and excluded from Cover All Kids. R...

2024-056a: During SFY 2024, several system fixes were deployed to address the findings noted in 2024-056. Specifically, in September 2024, a system fix was put in place to ensure children with verified SSNs were appropriately evaluated for Medicaid/CHIP coverage and excluded from Cover All Kids. RI Bridges appropriately determines eligibility for CHIP when TPL data is not present. Once TPL information is known to the system, existing eligibility rules will only evaluate for Medicaid, not CHIP. The TPL exceptions noted by the OAG show a discrepancy between TPL data in the MMIS and the information sent to RI Bridges via the TPL loopback file. EOHHS will work with their vendor to determine the root cause of the discrepancy and establish a corrective action plan if appropriate. Rhode Island did not participate in the February 2024 PARIS interstate match due to a file issue that has since been addressed in April 2024. The May and August 2024 PARIS matches were suspended at the Federal level for all States due to an outstanding computer matching agreement between the DoD and HHS/ACF. Enhancements to existing PARIS Interstate match logic are scheduled to run as planned for fall/winter 2025. Income/Wage Validation: EOHHS completed implementation of an interface on 3/5/24 between The Work Number (TWN) and RI Bridges. Contract and budget actions for TWN services were not completed until fall 2024. The system requirements that Equifax initially communicated to the State and our Integrated Eligibility System implementation partner were incomplete and the original integration configured in fall 2024 did not successfully pass testing. A system modification to correct the original specifications was originally scheduled for February 2025 but was delayed due to the 12/13/24 RI Bridges cyber event. Target date for TWN implementation is July 2025. Anticipated Completion Date: July 1, 2025 for income/wage validation. Contact Person: Anthony Salvo, Implementation Director of Policy and Programs, Executive Office of Health and Human Services anthony.salvo@ohhs.ri.gov 2024-056b: The Center for Staff Development and Learning (CSDL) the lead for training at the Rhode Island Department of Human Services (RIDHS) will work towards correction by using a blended approach to learning using formal (classroom or virtual learning sessions) and on the job learning activities. will conduct the following: a. The CSDL Team will continue to include in its Ex Parte Learning Series review of where the system performs an Ex Parte review to determine Medicaid eligibility for age outs ages 19, 26, and 65. In addition, included in the Medicaid Refresher, currently in development, a review will be done of updating income and verification procedures that includes end date and employment segments when household members lost employment. b. The Operations staff supervisors will schedule processing labs that will require the participants to process live cases with guidance from a supervisor. Anticipated Completion Date: The trainings and refresher learnings are ongoing. Processing labs are scheduled as need for this specific topic, we anticipate that processing labs will be scheduled and completed between July – September of 2025. The Medicaid Refresher Learning Series will be released in July. This training will also be ongoing. Contact Person: Zulma Valenzuela, Assistant Director of Administrative Services, Center for Staff Development and Learning, Department of Human Services zulma.valenzuela@dhs.ri.gov 2024-056c: As noted in prior year responses, CMS will not pursue recoveries associated with questioned costs given that recoveries based on eligibility errors can only be pursued when identified by programs operating under CMS’ Payment Error Rate Measurement program per section 1903(u) of the Social Security Act and regulations at 42 CFR Part 431, Subpart Q. This limits CMS’s ability to recover on most of the SSA eligibility findings. While CMS will pursue the internal control deficiencies noted by the SSA, CMS will not pursue recoveries associated with the questioned costs. Anticipated Completion Date: Not Applicable Contact Person: Anthony Salvo, Implementation Director of Policy and Programs, Executive Office of Health and Human Services anthony.salvo@ohhs.ri.gov

View Audit 355126 Questioned Costs: $1

Finding 558283 (2024-055)

Material Weakness 2024

State of Rhode Island

RI

Special Tests & Provisions Questioned Costs Subrecipient Monitoring

Management agrees with the findings, with some concerns noted in the corrective actions below. These corrective action steps are separated by specific health and safety finding. Background Checks: DHS will prioritize an emergency reopening of the regulations for both family and child care center r...

Management agrees with the findings, with some concerns noted in the corrective actions below. These corrective action steps are separated by specific health and safety finding. Background Checks: DHS will prioritize an emergency reopening of the regulations for both family and child care center regulations to require all providers and staff who work with children to enroll in the workforce registry no later than one month after promulgation. This will allow DHS staff to access employee files in real time to ensure that all staff have appropriate and current comprehensive background checks in their digital files. Until this regulation goes into effect, DHS will implement an immediate policy that all staff who work with children have their staff files audited as part of on-site monitoring visits. Previously, DHS looked only at those staff who were new since this last visit. However, this led to expired background checks being found during the audit. These expired checks also counted as not being able to demonstrate completion of the background check. DHS does want to acknowledge that during this audit, all staff were required to show evidence of a comprehensive background check. This included staff who did not have access to children and/or were not in the building when children were present. This does not align with regulation 218-RICR-70-00-1.12.A.1 which states, “All individuals working or engaging directly with children who are employed or act as a volunteer in the program, must complete all requirements of a comprehensive background check as outlined here: https://dhs.ri.gov/programs-and-services/child-care/child-care-providers/background-checks.” While the auditing team was informed of this, those staff not working with children who were on a payroll sheet were included as a finding against the Department. DHS will send out communication to the field alerting them that the lack of background checks is not tolerated. Staff who do not have these checks on file will be sent home until a background check is received (a practice that already exists, but typically the licensor is not looking at all files for every visit). For center providers, any staff or provider who is found to not have this information will be told to leave the program until this evidence is found. This may result in programs needing to temporarily close due to staff ratio issues. For family child care providers, this will involve a file audit of all received background checks, as well as a visit to ensure that there are no additional or new household members who have not completed this check. Any provider who has not submitted or completed an updated background check will be required to close until received. Any provider who is found to have household members who have not been listed and/or completed appropriate background checks will be closed due to failure to adhere to regulations. Immunizations: DHS recognizes and supports the importance of ensuring children are receiving timely vaccinations. However, DHS also recognizes that providers are only able to gather this data directly from families. Families who do not provide updated immunizations may be excluded from care if they do not provide these records. DHS will communicate with providers that no child should be enrolled without this documentation and that failure to provide updates to this documentation can result in dismissal from the program. DHS does not know if any of the children identified in this finding had medical or religious exemptions for their immunizations but would challenge that this finding could be skewed if this additional information was not ascertained by the auditing team. DHS will continue to partner with the Rhode Island Department of Health to ensure that programs are actively monitored and surveyed regarding immunization documentation. Emergency Preparedness Plan: DHS has been working with providers to ensure they have documented the required components of an emergency preparedness plan as required by federal funding agencies. DHS is requiring providers to include the DHS emergency plan form as part of renewal (for already existing providers) or as part of initial licensure. Absence of this form does not mean that the criteria is not being met. DHS did not train the auditors on what these required areas were and cannot speak to how this was monitored. However, DHS will continue to work with our providers to ensure that these criteria are met as part of the requirements in RISES. DHS has also created a training with The Center for Early Learning Professionals that reviews how to complete this plan and implement through practice. Unallowable Items In Cribs: This audit found that 30% of providers were found to have unallowable items in cribs. For the purposes of this audit, this finding included cribs that did not have children sleeping in them. Per the regulations for both Family and Child Care Centers, “No items are placed in the crib with an Infant except for a pacifier.” (218-RICR-70-00-2.3.3.C.1.k and 218-RICR-70-00-1.10.C.i respectively) DHS requests that only those providers who were found to have children in cribs with items be included in the finding. DHS has worked with The Center for Early Learning Professionals to develop individual trainings related to safe sleep. Providers who are found to be noncompliant regarding safe sleep practices are referred to those trainings with additional monitoring visits occurring to ensure changes have been made. As a result of this audit, DHS will inform providers that any safe sleep violations may result in a probationary status with additional licensing action possible if the continued noncompliance with safe sleep is observed. Toxic Substances unlabeled and accessible: DHS continues to monitor for this in both Family Child Care and Center-based programs. Typically, these are addressed and corrected onsite. Repeated noncompliance in this area can lead to probationary status. DHS will be reviewing the probationary process and use Technical Assistance with our federal funders to evaluate how other states address probation and other licensing actions. The goal is to solidify the current processes to ensure that there is an appropriate escalation review for repeated noncompliance that starts with probation and possibly lead to suspension of license. This will be communicated regularly to all providers. Developmental history: Per regulations, developmental histories are required only for programs serving infants and toddlers. Per Family Child Care regulation (218-RICR-70-00-2.3.6.F.7.a) and Child Care Center regulation (218-RICR-70-00-1.13.F.8.a), only files for infants and toddlers must contain developmental histories. DHS is unable to confirm whether or not this finding is related to this age group or if this finding occurred because age groups beyond that were assessed for compliance. Without this clarification, DHS would contest that this finding is accurate. DHS continues to support the provider community - both Family Child Care and Center providers - ensuring that they have gathered as much information as possible on the children they are enrolling in care. DHS will continue to audit files while on site to ensure that infants and toddlers have these documents completed. In the new RISES system, new providers who identify the desire to be licensed for either age group are required to submit examples of these forms as part of the initial application. For current providers, those serving these age groups will not be able to submit their first renewal in the system without uploading examples of these completed forms. Anticipated Completion Date: Background Checks: DHS will meet with policy staff immediately to discuss the emergency promulgation of new regulations. DHS will also immediately send out an email to the provider community regarding the outcomes of this audit and the responses that DHS intends to implement. Monitoring of programs, including for compliance of this regulation, will be ongoing. All other findings will be addressed in an ongoing fashion. Contact Person: Nicole Chiello, Assistant Director, Office of Child Care, Department of Human Services nicole.chiello@dhs.ri.gov

View Audit 355126

Finding 558280 (2024-054)

Material Weakness 2024

State of Rhode Island

RI

Questioned Costs Eligibility Matching / Level of Effort / Earmarking

Management agrees with the finding regarding inaccurate calculations. Management disagrees with the finding regarding information about DCYF children in the system. The Office of Child Care (OCC) is continually reviewing available training materials related to CCAP eligibility and case processing ...

Management agrees with the finding regarding inaccurate calculations. Management disagrees with the finding regarding information about DCYF children in the system. The Office of Child Care (OCC) is continually reviewing available training materials related to CCAP eligibility and case processing and has identified certain gaps where additional training/clarification, and more frequent communication to processing staff is needed – specifically in income calculation/input of paystubs, confirming asset declarations, and confirming need hours. OCC is working with the DHS training department to create a CCAP-specific training to provide in-depth coverage of program requirements. OCC continues to present at quarterly meetings to highlight error findings and the critical importance of accurate documentation. In addition, the CCAP administrator works continuously with field staff and Deloitte through weekly theme meetings to identify areas where system changes can improve accuracy of eligibility determinations. OCC is currently reviewing the grace period/short-term approval policy, how it is applied to specific cases, and how it is implemented in RIBridges. The finding has been escalated from the CCAP administrator to the assistant director of the Office of Child Care to ensure continued collaboration from all facets of the eligibility work to continue to improve errors in determination. Anticipated Completion Date: Ongoing – will continue to see a decline in errors in eligibility approval. Contact Person: Nicole Chiello, Assistant Director, Office of Child Care, Department of Human Services nicole.chiello@dhs.ri.gov

View Audit 355126 Questioned Costs: $1

Finding 558266 (2024-052)

Significant Deficiency 2024

State of Rhode Island

RI

Questioned Costs Allowable Costs / Cost Principles § 200.403

DHS has a policy for subrecipient monitoring, which includes documentation required to be submitted by a subrecipient. The documentation is based on assessing the risk of each subrecipient. There is no requirement in the Uniform Grant Guidance in regard to supporting documentation requirements. T...

DHS has a policy for subrecipient monitoring, which includes documentation required to be submitted by a subrecipient. The documentation is based on assessing the risk of each subrecipient. There is no requirement in the Uniform Grant Guidance in regard to supporting documentation requirements. The invoice needs to be certified by an authorized agent and the expense needs to have been reasonably incurred. DHS ensures compliance in numerous ways, including monthly programmatic meetings, site visits, review of single audits and past performance. Additionally, DHS contracts include a budget narrative and allows for DHS to require additional documentation for audit purposes. If requested, DHS would have been able to produce more documentation to satisfy the allowability of costs. Anticipated Completion Date: Not Applicable Contact Person: Ben Quattrucci, Associate Director Financial Contract Management, Department of Human Services benjamin.a.quattrucci@dhs.ri.gov

View Audit 355126 Questioned Costs: $1

Finding 558259 (2024-050)

Material Weakness 2024

State of Rhode Island

RI

Questioned Costs Special Tests & Provisions Subrecipient Monitoring § 200.303

System changes to modify the time schedule that RIBridges interfaces with SWICA for processing tasks has already been submitted (RIB-141767). Currently, the interface occurs twice yearly. This will increase the frequency to quarterly. Anticipated Completion Date: October 31, 2025 Contact Person:...

System changes to modify the time schedule that RIBridges interfaces with SWICA for processing tasks has already been submitted (RIB-141767). Currently, the interface occurs twice yearly. This will increase the frequency to quarterly. Anticipated Completion Date: October 31, 2025 Contact Person: Donna Rook, Administrator, Family and Adult Services, Department of Human Services donna.m.rook@dhs.ri.gov

View Audit 355126 Questioned Costs: $1

Finding 558257 (2024-049)

Material Weakness 2024

State of Rhode Island

RI

Eligibility Internal Control / Segregation of Duties Questioned Costs

DHS continues its prior actions of training addressing eligibility, standing agenda on meetings, and quarterly meetings. At this time, DHS has completed the solicitation to hire a contractor to identify problematic processes, through the Business Processing Excellence Reengineering project. (BPER). ...

DHS continues its prior actions of training addressing eligibility, standing agenda on meetings, and quarterly meetings. At this time, DHS has completed the solicitation to hire a contractor to identify problematic processes, through the Business Processing Excellence Reengineering project. (BPER). The scope of work includes evaluating the eligibility to determine the deficiencies and to propose solutions. Anticipated Completion Date: Ongoing Contact Person: Donna Rook, Administrator, Family and Adult Services, Department of Human Servicesdonna.m.rook@dhs.ri.gov

View Audit 355126 Questioned Costs: $1

Finding 558248 (2024-046)

Significant Deficiency 2024

State of Rhode Island

RI

Questioned Costs Allowable Costs / Cost Principles § 200.430

RIDOH agrees with the finding and recommendation. Corrective action plan: • In gathering time sheets for the requested audit samples, RIDOH found that some Master Time Sheet Coordinators (staff responsible for receiving signed time sheets, populating the Master Time Sheet spreadsheets sent weekly f...

RIDOH agrees with the finding and recommendation. Corrective action plan: • In gathering time sheets for the requested audit samples, RIDOH found that some Master Time Sheet Coordinators (staff responsible for receiving signed time sheets, populating the Master Time Sheet spreadsheets sent weekly from/to HR/Payroll, and saving time sheets to the Time Sheet Repository in Teams) were saving documents locally instead of in the central Teams site. RIDOH is providing training and increased oversight of the non-compliant Time Sheet Coordinators and is conducting ongoing checks of the time sheets uploaded to Teams weekly to assure the time sheets are saved properly. • Instructions have been provided and will be reiterated Department-wide that all time sheets must be signed and dated by both the employee and supervisors, and signatures without dates are not acceptable. • RIDOH will adjust the questioned costs for ELC and DWSRF to appropriate non-federal funds. • RIDOH has been working to move staff that use the general category codes (i.e., EH Management & Leadership) to non-federal funding sources as much as possible and will begin requiring staff on federal funds to record their hours for each federal grant separately. This is a complicated process and will be fully implemented once Time and Effort reporting is transferred to Workday (the ERP). Anticipated Completion Date: The first three bullets above will be completed by June 30, 2025. Transition of Time and Effort reporting to Workday has been delayed, and the new target implementation date has not been announced. Contact Persons: Alisha Colella, Chief Financial Officer, Department of Health alisha.colella@health.ri.gov Carla Lundquist, Deputy CFO / Federal Grants Manager, Department of Health carla.lundquist@health.ri.gov

View Audit 355126 Questioned Costs: $1

Finding 558245 (2024-045)

Material Weakness 2024

State of Rhode Island

RI

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303

RIDOH agrees with the finding and recommendations and will develop and implement enhanced internal controls over Uniform Grant Spreadsheets (UGSs) to assure that all indirect cost billings and drawdowns of federal funds are appropriate and accurate. The UGS internal controls will include (but are n...

RIDOH agrees with the finding and recommendations and will develop and implement enhanced internal controls over Uniform Grant Spreadsheets (UGSs) to assure that all indirect cost billings and drawdowns of federal funds are appropriate and accurate. The UGS internal controls will include (but are not limited to): • Mandatory refresher training for all staff that complete and/or review UGSs, with focus on areas of potential errors and correct entry of UGS data in the Monthly Federal Grants Tracking spreadsheet used for drawdowns and indirect billing. • Providing a crosswalk of expenditure categories and natural accounts to grants management staff to assure appropriate and consistent assignment of transactions to categories subject to/not subject to indirect costs. • A rotating schedule of monthly in-depth reviews of UGSs to assure that data entry aligns with RIFANS transaction reports, transactions are recorded so natural accounts align with correct expenditure categories, the appropriate indirect cost rate is entered, and formulas for computation of indirect costs are not corrupted. Reviews will be conducted by supervisors of staff completing UGSs, and results will be reported to the Deputy CFO/Federal Grants Manager. • Review of the Monthly Federal Grants Tracking spreadsheets each month before indirect cost billing and federal drawdowns are completed, to assure that expenditures reported align with RIFANS reports and indirect billings and drawdown requests are appropriate. RIDOH credited the ELC Enhancing Detection federal award for the unallowable indirect costs on 3/14/2025 (J25075GMC530). The credit was calculated using RIFANS transaction data from 7/1/2020 through 3/13/2025, not from the UGSs. The UGSs for this award and others are being re-built from the start of the award using RIFANS data in new, less complicated templates to assure correct charging and reporting going forward. Anticipated Completion Date: July 31, 2025 Contact Persons: Alisha Colella, Chief Financial Officer, Department of Health alisha.colella@health.ri.gov Carla Lundquist, Deputy CFO / Federal Grants Manager, Department of Health carla.lundquist@health.ri.gov

View Audit 355126 Questioned Costs: $1

Finding 558244 (2024-044)

Material Weakness 2024

State of Rhode Island

RI

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.332 § 200.403

2024-044a: Management agrees with this finding and will communicate the requirements for subrecipient monitoring and specifically the review of single audit reports to our agency partners for implementation. 2024-044b: Management agrees with this finding and will communicate the requirements for su...

2024-044a: Management agrees with this finding and will communicate the requirements for subrecipient monitoring and specifically the review of single audit reports to our agency partners for implementation. 2024-044b: Management agrees with this finding and will communicate the requirements for subrecipient monitoring and specifically the review of single audit reports to our agency partners for implementation. 2024-044c: Management agrees with this finding and will communicate the requirements for subrecipient monitoring; specifically, the documentation of expenses, and meeting notes. Anticipated Completion Date: Completed April 23, 2025 Contact Persons: Paul L. Dion, Director, Pandemic Recovery Office, Department of Administration paul.l.dion@doa.ri.gov Brianna Ruggiero, Chief of Staff, Pandemic Recovery Office, Department of Administration brianna.ruggiero@doa.ri.gov

View Audit 355126 Questioned Costs: $1

Finding 558234 (2024-039)

Material Weakness 2024

State of Rhode Island

RI

Questioned Costs Special Tests & Provisions Reporting

UI Administrative staff meet with ETSS staff on a weekly basis to review and prioritize pending projects. The project related to the programming changes that are necessary to incorporate the 15% penalty, on fraud overpayments, is on the list, however, due to the complexity of the programming requir...

UI Administrative staff meet with ETSS staff on a weekly basis to review and prioritize pending projects. The project related to the programming changes that are necessary to incorporate the 15% penalty, on fraud overpayments, is on the list, however, due to the complexity of the programming required as well as other competing obligations previously prioritized, this work has not yet started. Therefore, we anticipate this project will be implemented by next fall. Discussions regarding the non-relief of charges will begin when programming for the 15% project is complete. Anticipated Completion Date: September 30, 2026 Contact Person: Philip D’Ambra, Director of Income Support, Department of Labor and Training philip.l.dambra@dlt.ri.gov

View Audit 355126 Questioned Costs: $1

Finding 558232 (2024-038)

Material Weakness 2024

State of Rhode Island

RI

Eligibility Internal Control / Segregation of Duties Questioned Costs

Finding: 1 of 60 individuals had a return-to-work date submitted by the employer, however, the claimant received three payments after that date. DLT did not investigate any potential overpayment. (Questioned costs - $2,139) We do not concur with this finding. Per ETA guidance, specifically UIPL ...

Finding: 1 of 60 individuals had a return-to-work date submitted by the employer, however, the claimant received three payments after that date. DLT did not investigate any potential overpayment. (Questioned costs - $2,139) We do not concur with this finding. Per ETA guidance, specifically UIPL 01-16, because this claim was in payment status, we have to continue to make timely weekly payments (after proper certification), and an overpayment cannot be deemed recoverable until an official ineligibility determination is rendered. Unemployment Insurance Program Letter 01-16 states “in order to be eligible to receive administrative grants, a state must do the following in context of identifying and establishing improper payments…continue to make timely UC payments (if due) and wait to commence recovery of overpayments until an official determination of ineligibility is made…” In addition to the above requirement, data that State Workforce Agencies gather from crossmatch sources such as IB4, wage record /benefit, SDNH and NDNH wage/benefit have to be verified prior to initiating a decision disqualifying benefits. The actual cross match itself simply produces possible cases to investigate. The investigation is then initiated when the department sends out a request for wages form (720). When the form is returned by the employer the department can then use the verified information to render a disqualifying decision. A crossmatch itself is not enough to render a working and collecting determination based on wage record data as the claimant may have had actual earning within the quarter. The date identified on a NDNH crossmatch also is not enough to render a disqualification. This information needs to be verified. From: Unemployment Insurance 401 Handbook ETA 227 – OVERPAYMENT DETECTION AND RECOVERY ACTIVITIES E. Definitions 4. Cases Investigated. The number of cases emanating from a state-initiated overpayment detection process for which an investigation regarding a potential overpayment has been concluded. Example: during a wage/benefit crossmatch process, a state agency produces a printout identifying all benefit payments matched against wages in the same quarter. After the printout is screened, requests are sent to employers to identify which weeks in the quarter were worked. When an employer reply indicates overlap with weeks for which benefits were paid, claims are investigated to determine if they were overpaid. This was a continued claim that was effective 8/13/23 and the claimant certified weekly through 2/17/24. The RTW date listen on the ledger was autogenerated on 2/27/24. At this time the claimant had exhausted their balance of credits, all benefits had been paid. The date listed as the return-to-work date from the NDNH crossmatch stated 1/30/24. Since this date had the potential to affect benefits the department initiated it’s investigation and did send a 720 form to the employer to obtain the proper wage information. Since the requested information was not returned by the employer, the department lacked the proper information necessary to render a disqualification based on ETA guidelines. Finding: 1 of 60 was not registered within EmployRI and staff were unable to locate any records of the claimant. (Questioned costs - $10,829) The agency concurs with the above finding that includes state UC questioned costs of $10,829. This exception was caused by a programming (IT system) error. A nightly job is run that is sent to Workforce Development (Geosol) which then registers claimant’s with EmployRI. An issue was discovered on claims where the effective date of the claim was 56 days prior to the first payment being issued. These claimants were not populated on the nightly transfer to Workforce. ETSS has confirmed that this programming error has been fixed. We acknowledge the Auditor’s recommendations and offer the following response. We feel the findings, while relevant, are de minimis in scope, when compared to the workload volumes processed. Our current unemployment systems (Tax and Benefits) are aged and distressed. Due to their age and technology constraints, any changes or modifications needed, cannot be easily or quickly implemented. As such a larger burden is placed on staff to handle manually. DLT ‘s limited technology resources combined with having limited staffing resources also hinder our efficiency. We have limited staff resources to manually address our workload volumes, as well as the sheer number of forms involved in making proper determinations. In addition to this, the law requires benefit payments to be made timely based on available information until verifiable evidence is found that justifies a disqualification. Therefore, until we can implement a more modernized tax and benefits system, we acknowledge that similar findings such as these may persist. We will continue to utilize the resources we currently have and strive to be more efficient. We hope that by providing additional staff training and by strengthening our relationship with Workforce Development, this improved efficiency will be realized. We are in the process of evaluating whether or not an amendment to our work search requirement, is needed. In doing so, we will evaluate whether any changes are necessary to either; our internal policy, the guidance provided on the claimant’s benefit rights, the guidance displayed on DLT’s website and to regulation 1.18 Filing of Claims for Unemployment Insurance Benefits. Any necessary modifications will be made. Anticipated Completion Date: December 31, 2025 Contact Person: Philip D’Ambra, Director of Income Support, Department of Labor and Training philip.l.dambra@dlt.ri.gov

View Audit 355126 Questioned Costs: $1

Finding 558218 (2024-036)

Significant Deficiency 2024

State of Rhode Island

RI

Matching / Level of Effort / Earmarking Special Tests & Provisions Questioned Costs

RIDE’s Office of School Health & Wellness will develop a guidance document for LEAs regarding Paid Lunch Equity calculations and send communication at least annually to ensure LEAs have complied with 7 CFR Sec. 210.14(e). Anticipated Completion Date: June 30, 2026 Contact Persons: Brandon Bohl, Fi...

RIDE’s Office of School Health & Wellness will develop a guidance document for LEAs regarding Paid Lunch Equity calculations and send communication at least annually to ensure LEAs have complied with 7 CFR Sec. 210.14(e). Anticipated Completion Date: June 30, 2026 Contact Persons: Brandon Bohl, Finance Director, Department of Elementary and Secondary Education brandon.bohl@ride.ri.gov Rosemary Reilly-Chammat, Director – Office of School Health & Wellness, Department of Elementary and Secondary Education rosemary.reilly-chammat@ride.ri.gov Jennifer Goodwin, School Health Specialist, Department of Elementary and Secondary Education jennifer.goodwin@ride.ri.gov

View Audit 355126

Finding 558195 (2024-031)

None 2024

State of Rhode Island

RI

Allowable Costs / Cost Principles Questioned Costs § 200.516

Pursuant to federal SNAP regulations at 7 CFR 272.4(g) and corresponding state regulations, the Department is required to establish and operate a fraud detection unit, which is responsible for the detection and investigation of SNAP fraud. The Office of Internal Audit (OIA) at the Department of Adm...

Pursuant to federal SNAP regulations at 7 CFR 272.4(g) and corresponding state regulations, the Department is required to establish and operate a fraud detection unit, which is responsible for the detection and investigation of SNAP fraud. The Office of Internal Audit (OIA) at the Department of Administration, Office of Management and Budget, through a Memorandum of Understanding (MOU), provides DHS with fraud detection, investigation and prevention services across DHS’s public assistance programs, including SNAP. DHS staff refer to OIA SNAP cases in which staff suspect fraud. OIA, in turn, investigates the allegation. If OIA determines that the household has committed an intentional program violation of SNAP, they pursue disqualification of the individual(s) from the program, either through an administrative disqualification hearing (ADH), a waiver of ADH, or refer the case to the state police for criminal prosecution. If the individual is found to have committed the IPV, and received SNAP benefits they were not entitled to, DHS establishes an overpayment claim against the household’s liable individuals. The liable individuals are required to make payment agreements to return to DHS, the benefits they received, but were not entitled to. If the fraud is referred for criminal prosecution, the amount of overpaid benefits is determined by the Court through an Order for Restitution. DHS followed the established and required protocols in the case cited in this finding. DHS referred a case to OIA in which identity fraud was suspected. OIA, with DHS assistance, and collaboration from the USDA Office of Inspector General (OIG), conducted the investigation, which revealed, not only fraudulent actions, but also criminal behavior and a significant estimate of overpaid SNAP benefits. The case was referred to the U.S. Attorney’s Office for prosecution. The criminal case is currently pending. Once a disposition is issued, DHS will take the appropriate sanction actions(s), including any disqualification from the SNAP, as well establishing an overpayment claim for any restitution ordered. Pursuant to federal regulations, any collection by DHS of any overpaid SNAP benefits will be returned to the Food and Nutrition Service (FNS), with DHS retaining 30% as provided for in the regulations. Should the liable individual not pay the ordered restitution in a timely manner and the claim becomes delinquent, DHS will pursue all other available collection actions to recoup the overpaid benefits. OIA and DHS also engage in fraud prevention activities, mainly by utilizing data analytics and identifying case issues that are indicative of fraudulent activities. Once an issue is identified, OIA, in conjunction with DHS, review the impacted case population and determine actions that should be taken to mitigate the issue as well as educate customers on actions they can take to safeguard their benefits, including changing EBT card PINs, freezing cards or limiting access to out-of-state or internet transactions. Other prevention actions that may be taken include changes to the card security through vendor options, as well as widespread communication to customers and the public on new fraud trends, etc. OIA and DHS also provide training to DHS staff to spot fraud in cases, including identifying fraudulent/altered documents, use of invalid identification cards, and identity fraud trends, etc. Approximately 60% of DHS staff have completed or are in the process of completing the fraud training. Anticipated Completion Date: The criminal case is ongoing. Contact Person: Iwona Ramian, Deputy Chief Legal Counsel, Department of Human Services iwona.ramian@dhs.ri.gov

View Audit 355126 Questioned Costs: $1

Finding 558194 (2024-030)

Significant Deficiency 2024

State of Rhode Island

RI

Questioned Costs Allowable Costs / Cost Principles

Management will submit the cost allocation methodology for grants management services allocated to federal programs as part of the billed costs going forward. Anticipated Completion Date: Completed Contact Person: Kayla Marques, Supervisor Financial Management and Reporting, Department of Administ...

Management will submit the cost allocation methodology for grants management services allocated to federal programs as part of the billed costs going forward. Anticipated Completion Date: Completed Contact Person: Kayla Marques, Supervisor Financial Management and Reporting, Department of Administration, Office of Accounts & Control kayla.marques@doa.ri.gov

View Audit 355126 Questioned Costs: $1

Finding 558193 (2024-029)

Significant Deficiency 2024

State of Rhode Island

RI

Reporting Questioned Costs Subrecipient Monitoring

Procedures are in process of being reviewed and will be completed prior to the issuance of this report. Underlying reports will be updated with the ERP implementation and corrected to capture all data for all programs in the TSA. Anticipated Completion Date: December 31, 2025 Contact Person: Xiom...

Procedures are in process of being reviewed and will be completed prior to the issuance of this report. Underlying reports will be updated with the ERP implementation and corrected to capture all data for all programs in the TSA. Anticipated Completion Date: December 31, 2025 Contact Person: Xiomara Soto, Administrator Financial Management & Reporting, Department of Administration, Office of Accounts & Control xiomara.c.soto@doa.ri.gov

View Audit 355126 Questioned Costs: $1

Finding 558173 (2024-001)

Significant Deficiency 2024

North Plainfield School District

NJ

Allowable Costs / Cost Principles Questioned Costs Subrecipient Monitoring

The District will ensure that Additional or Compensatory Special Education or Related Services (ACSERS) funds are not used to fund Substitute Services due to the teacher shortage.

View Audit 355081 Questioned Costs: $1

Finding 558164 (2024-002)

None 2024

Hamdard Health Alliance

IL

Special Tests & Provisions Questioned Costs Eligibility

2024-002: Health Centers Cluster – ALN# 93.224 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), ALN# 93.527 Grants for New and Expanded Services under the Health Center Program, June 30, 2024 - Special Tests and ...

2024-002: Health Centers Cluster – ALN# 93.224 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), ALN# 93.527 Grants for New and Expanded Services under the Health Center Program, June 30, 2024 - Special Tests and Provisions Condition: The Organization did not retain documentation or other evidence that patients were eligible for adjustment (discount) that was received. Corrective Action Plan: Patient Service Representatives are responsible for ensuring sliding fee schedule docuemtns are current. We have implemented another layer of oversight to ensure moving forward, we will be able to identify any patients with expired documentation for the sliding fee scale application. The PSR Lead will run a monthly report in the EMR to capture any information that may have been inadvertently missed and will help us ensure updates are completed accurately and in a timely manner. A report was run initially for the current fiscal year and will be run monthly going forward to identify expired applications so we can update accordingly. Responsible Person for Corrective Action Plan: Director of Operations and PSR Leads Implmentation Date of Corrective Action Plan: April 16, 2025

View Audit 355041

Finding 558163 (2024-002)

Significant Deficiency 2024

Community Living Opportunities Ii, INC

KS

Questioned Costs Cash Management Reporting

Audit Finding Reference: 2024-002 Comments on the Finding and Each Recommendation: Management agrees with the finding. Corrective Action Planned or Taken: Management will formalize the approval process of HAP voucher requests with documentation and approval occurring via email to ensure evidence ...

Audit Finding Reference: 2024-002 Comments on the Finding and Each Recommendation: Management agrees with the finding. Corrective Action Planned or Taken: Management will formalize the approval process of HAP voucher requests with documentation and approval occurring via email to ensure evidence of the approval.

View Audit 355040

Finding 558162 (2024-001)

Significant Deficiency 2024

Community Living Opportunities Ii, INC

KS

Questioned Costs Reporting Internal Control / Segregation of Duties

Audit Finding Reference: 2024-001 Comments on the Finding and Each Recommendation: Management agrees with the finding. Corrective Action Planned or Taken: Management will formalize the approval process of disbursements with documentation and approval occurring via email to ensure evidence of the ...

Audit Finding Reference: 2024-001 Comments on the Finding and Each Recommendation: Management agrees with the finding. Corrective Action Planned or Taken: Management will formalize the approval process of disbursements with documentation and approval occurring via email to ensure evidence of the approval.

View Audit 355040

Finding 558147 (2024-001)

Significant Deficiency 2024

Willow Creek Housing, Inc.

MD

Questioned Costs Subrecipient Monitoring HUD Housing Programs

Finding 2024-001: Comments on the Finding and Each Recommendation: The Corporation did not obtain a HUD approved Project Owner's/Management Agent's Certification (Form HUD-9839-B) and the Property paid unapproved management fees to the Agent. The Agent should submit an updated Project Owner's/Manag...

Finding 2024-001: Comments on the Finding and Each Recommendation: The Corporation did not obtain a HUD approved Project Owner's/Management Agent's Certification (Form HUD-9839-B) and the Property paid unapproved management fees to the Agent. The Agent should submit an updated Project Owner's/Management Agent's Certification for HUD's review and approval. Action(s) taken or planned on the finding: Management concurs with the finding and recommendation, and the Agent will submit an updated Project Owner's/Management Agent's Certification for HUD's review and approval.

View Audit 355030

Finding 558144 (2024-001)

Significant Deficiency 2024

Nassau Community College

NY

Questioned Costs Student Financial Aid Reporting

Student Financial Aid Cluster – Assistance Listing 84.063 and 84.268 Recommendation: The College should review their reporting internal controls and procedures to ensure that they require students' statuses to be reported timely to NSLDS as required by federal regulations. Explanation of disagreem...

Student Financial Aid Cluster – Assistance Listing 84.063 and 84.268 Recommendation: The College should review their reporting internal controls and procedures to ensure that they require students' statuses to be reported timely to NSLDS as required by federal regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We believe that the recent implementation of registration codes for attendance confirmation, along with updates to the eligibility status codes for unofficial and midpoint withdrawals, will effectively reduce delays in reporting enrollment status moving forward. Additionally, we will work closely with the Registrar’s Office and ITS to ensure alignment on their timeline for reporting monthly enrollment status to Clearinghouse. Name(s) of the contact person(s) responsible for corrective action: Patricia Noren Planned completion date for corrective action plan: FY25 If the Department of Education has questions regarding this plan, please call Antoinette Brown 516-572-7743 x24404.

View Audit 355013

Finding 558113 (2024-001)

Significant Deficiency 2024

Metropolitan Development and Housing Agency

TN

Questioned Costs HUD Housing Programs Significant Deficiency

Finding: 2024-001 Program Name: Section 8 Project-Based Cluster (14.195/14.249) Federal Awarding Agency: Department of Housing and Urban Development Compliance Requirement: Housing Quality Standards Type of Finding: Significant Deficiency; Nonmaterial Noncompliance Condition: Of the 40 tenant files ...

Finding: 2024-001 Program Name: Section 8 Project-Based Cluster (14.195/14.249) Federal Awarding Agency: Department of Housing and Urban Development Compliance Requirement: Housing Quality Standards Type of Finding: Significant Deficiency; Nonmaterial Noncompliance Condition: Of the 40 tenant files tested, 7 files did not contain documentation that the annual inspection was performed. Auditor Recommendation: We recommend the Agency uilize a tracking system to ensure inspections are completed annually and documentation is maintained regarding the results of the annual inspections. Management’s Response: The Property Management department will coordinate with the Information Technology team to ensure appropriate documentation and tracking of annual inspections.

View Audit 354991

Finding 558105 (2024-008)

Significant Deficiency 2024

Florida Rural Legal Services, Inc.

AL

Questioned Costs Significant Deficiency

Upon review of the one case file, it appears that the lapse occurred during a turnover in staff assignment. Both the original attorney assigned to this case and the subsequent attorney left the firm and as a result there was a failure to disclose it to LSC. To address this issue and prevent future o...

Upon review of the one case file, it appears that the lapse occurred during a turnover in staff assignment. Both the original attorney assigned to this case and the subsequent attorney left the firm and as a result there was a failure to disclose it to LSC. To address this issue and prevent future occurrences, we are implementing the following corrective actions within the next 60 days:  Case Transfer Protocol: We are creating a case transfer memo form for Legal Server. We will include an assessment of whether the case needs to be reported during the next LSC Case Disclosure Report.  Case Management System Updates: We are also working on a litigation module for Legal Server that will allow us to track when a case moves from pre-litigation to litigation so that we can easily identify cases that should be included in LSC Case Disclosure Report.  Staff Training: Ongoing training is being provided to ensure all attorneys and advocates understand the importance of timely and accurate disclosures, especially during case transfers.

View Audit 354985

Finding 558104 (2024-007)

Significant Deficiency 2024

Florida Rural Legal Services, Inc.

AL

Questioned Costs Allowable Costs / Cost Principles § 200.405

This finding is related to activities on our VOCA grants. This exception was related to a process in place prior to May 2023 for allocating our outside contracted IT services Again, in May 2023 FRLS added an electronic transaction approval process via Teams, that documents approvals for all our AP, ...

This finding is related to activities on our VOCA grants. This exception was related to a process in place prior to May 2023 for allocating our outside contracted IT services Again, in May 2023 FRLS added an electronic transaction approval process via Teams, that documents approvals for all our AP, AR and other transactions initiated by our accounting staff. These are reviewed and approved by the CFO before being posted into the GL. FRLS failed to update its allocation for this prior allocation method for this legacy vendor. The CFO will undertake a review of this process to ensure that we are in compliance with allowable cost documentation requirements. We will also review and update our documentation of allocations and ensure that each month’s allocation is properly approved. This change will be made within the next 60 days.

View Audit 354985 Questioned Costs: $1

Finding 558103 (2024-006)

Significant Deficiency 2024

Florida Rural Legal Services, Inc.

AL

Questioned Costs Subrecipient Monitoring Significant Deficiency

FRLS is in the process of having its PAI program reviewed through the ABA peer review process to assess options for meeting LSC’s PAI requirements. With respect to the waiver carryover, the CFO had conversations with LSC representatives on the proper computation of this and for 2024 LSC approved our...

FRLS is in the process of having its PAI program reviewed through the ABA peer review process to assess options for meeting LSC’s PAI requirements. With respect to the waiver carryover, the CFO had conversations with LSC representatives on the proper computation of this and for 2024 LSC approved our carryover computation. Upon further consultation with LSC It appears that this information was incorrect and FRLS will revise its computation in consultation with LSC. This change will be made by December 31, 2025.

View Audit 354985

Corrective Action Plans

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