Corrective Action Plans

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Views of Responsible Officials: The college agrees with this finding with explanation. These occurrences were anomalies related to a rare misalignment of the academic calendar for summer session for the 2023/2024 academic year. The calculation findings for five of the seven students were related to ...
Views of Responsible Officials: The college agrees with this finding with explanation. These occurrences were anomalies related to a rare misalignment of the academic calendar for summer session for the 2023/2024 academic year. The calculation findings for five of the seven students were related to a schedule misalignment for the summer semester. The academic calendar for the 2023/2024 award year had 106 days of enrollment during the summer semester. There was a gap of six days between the Summer 2 and Summer 3 terms skewed the calculations. The College has not identified a similar alignment gap for any previous award year. The Financial Aid Office will actively monitor the development of the academic calendar. Additionally, the Financial Office will review and revise existing procedures to identify areas for improvement to ensure that all withdrawn students who began attendance will have their Return to Title IV calculations accurately completed. The Financial Aid Office has taken steps to retrain relevant financial aid personnel and developed internal checks for accuracy in the calculation process.
Views of Responsible Officials: The College has noted that this finding may not align with the unique nature of our summer session, which has three terms included. There are four non-standard summer terms that do not follow the same reporting structure as the Fall and Spring Terms. The College inter...
Views of Responsible Officials: The College has noted that this finding may not align with the unique nature of our summer session, which has three terms included. There are four non-standard summer terms that do not follow the same reporting structure as the Fall and Spring Terms. The College interprets the 60-day reporting requirement to apply to the standard terms for Fall and Spring only. Historically, the college has reported summer enrollments in August, which has been treated as compliant by the Clearinghouse. However, after further review, the College will adjust its reporting schedule to align with recommendations from this finding. This adjustment will ensure that summer reporting aligns with the 60-day timeframe that is consistent with the Fall and Spring terms.
UPS-AIDS has always used the budget allocations for wages and salaries in the past until this year that it becomes an issue. The finding was not corrected because management did not have sufficient time to prepare for the subsequent year after the previous year was submitted in a very short period o...
UPS-AIDS has always used the budget allocations for wages and salaries in the past until this year that it becomes an issue. The finding was not corrected because management did not have sufficient time to prepare for the subsequent year after the previous year was submitted in a very short period of time. Nevertheless, we have agreed to comply as they have requested. However, we have agreed to comply with 2 CFR 200.430. Ive Pierre, Chief Financial Officer, will implement a time study by June 30, 2025.
View Audit 352063 Questioned Costs: $1
Federal Agency: U.S. Department of Health and Human Services Program/Cluster: Foster Care Federal Assistance Listing Number: 93.658 Pass‐through: California Department of Social Services Award No. and Year: 1946001347 A7, 2023/2024 Compliance Requirement: Allowable Activities and Allowed Costs Type ...
Federal Agency: U.S. Department of Health and Human Services Program/Cluster: Foster Care Federal Assistance Listing Number: 93.658 Pass‐through: California Department of Social Services Award No. and Year: 1946001347 A7, 2023/2024 Compliance Requirement: Allowable Activities and Allowed Costs Type of Finding: Material Weakness in Internal Control over Compliance, Instance of Noncompliance Views of Responsible Officials and Corrective Action Plan: Solano County has policies and procedures as well as systematic processes and oversight set up to ensure accurate assessments and determinations are made regarding the Federal or Non-Federal Eligibility of youth in the Foster Care system. It is Solano County’s policy to conduct these assessments at the onset of the case and ensure quality documentation. In addition, the Foster Care unit has a Lead worker and Supervisor who conduct periodic reviews of open cases to ensure accuracy of documentation and adherence to timelines are met. The specific corrective actions identified in this audit found errors related to the migration of data to the CalSAWS program in 2023, where an identified payment was incorrectly identified (Non-Federal to Federal) due to errors or information which existed in CalWin and were transferred improperly to CalSAWS. These conversion errors occurred automatically. As a result, the Foster Care Eligibility Unit has implemented the following changes. • Correction to identified payment: o The identified case was corrected immediately, and all payments adjusted as appropriate. • Changes to workflow to ensure accuracy: o The entire caseload of open Foster Care Eligibility cases will be reviewed to ensure that the original determination or as found in the FC3 or FC3A and granting comments, is correctly input in CalSAWS, and any payment errors corrected as needed. o The case aid code (noting eligibility type) will be included next to the youth’s name to ensure that it shows in the workload report in CalSAWS to ensure the information is easily accessible and any future errors can be identified. o Cases will be reviewed to ensure the above changes are completed through the unit supervisor’s ongoing qualitative review of cases. • The Foster Care Eligibility Supervisor will discuss the findings and requirement with subordinate staff in the following ways: o Unit meeting communication regarding Corrective Action findings and Agency steps to remediate. o Issue a reminder to all staff regarding the above remediation plan. Responsible Individual(s): Kim McDowell, Social Services Manager Neely McElroy, Deputy Director, Child Welfare Services Anticipated Completion Date: May 31, 2025
View Audit 352056 Questioned Costs: $1
Federal Agency: U.S. Department of Health and Human Services Program/Cluster: Foster Care Federal Assistance Listing Number: 93.658 Pass‐through: California Department of Social Services Award No. and Year: 1946001347 A7, 2023/24 Compliance Requirement: Eligibility Type of Finding: Material Weakness...
Federal Agency: U.S. Department of Health and Human Services Program/Cluster: Foster Care Federal Assistance Listing Number: 93.658 Pass‐through: California Department of Social Services Award No. and Year: 1946001347 A7, 2023/24 Compliance Requirement: Eligibility Type of Finding: Material Weakness in Internal Control over Compliance, Instance of Noncompliance Views of Responsible Officials and Corrective Action Plan: Solano County has policies and procedures as well as systematic processes and oversight set up to ensure accurate assessments and determinations are made regarding the Federal or Non-Federal Eligibility of youth in the Foster Care system. It is Solano County’s policy to conduct these assessments at the onset of the case and ensure quality documentation. In addition, the Foster Care unit has a Lead worker and Supervisor who conduct periodic reviews of open cases to ensure accuracy of documentation and adherence to timelines are met. The specific corrective actions identified in this audit found errors related to the migration of data to the CalSAWS program in 2023, where two cases were inadvertently converted from Non-Federal to Federal cases due to errors or information which existed in CalWin and were transferred improperly to CalSAWS. These conversion errors occurred automatically. As a result, the Foster Care Eligibility Unit has implemented the following changes. • Corrections to identified cases: o The two identified cases were corrected immediately, and all payments adjusted as appropriate. • Changes to workflow to ensure accuracy: o The entire caseload of open Foster Care Eligibility cases will be reviewed to ensure that the original determination or as found in the FC3 or FC3A and granting comments, is correctly input in CalSAWS, and any payment errors corrected as needed. o The case aid code (noting eligibility type) will be included next to the youth’s name to ensure that it shows in the workload report in CalSAWS to ensure the information is easily accessible and any future errors can be identified. o Cases will be reviewed to ensure the above changes are completed through the unit supervisor’s ongoing qualitative review of cases. • The Foster Care Eligibility Supervisor will discuss the findings and requirement with subordinate staff in the following ways: o Unit meeting communication regarding Corrective Action findings and Agency steps to remediate. o Issue a reminder to all staff regarding the above remediation plan. Responsible Individual(s): Kim McDowell, Social Services Manager Neely McElroy, Deputy Director, Child Welfare Services Anticipated Completion Date: May 31, 2025
View Audit 352056 Questioned Costs: $1
Finding 2024-002 – Significant Deficiency Award No.: 97.036, Disaster Grants-Public Assistance (Presidentially Declared Disasters) Federal Grantor: U.S. Department of Homeland Security, Federal Emergency Management Agency, Passed-through California Governor’s Office of Emergency Services, FEMA-...
Finding 2024-002 – Significant Deficiency Award No.: 97.036, Disaster Grants-Public Assistance (Presidentially Declared Disasters) Federal Grantor: U.S. Department of Homeland Security, Federal Emergency Management Agency, Passed-through California Governor’s Office of Emergency Services, FEMA-4683-DR-CA Compliance Requirement: Other compliance requirements. Condition: The schedule of Expenditures of Federal Awards (SEFA) was not complete, and expenditures reported on the SEFA were revised during the single audit. Criteria: 2 CFR Part 200, Subpart F (Uniform Guidance) Section 200.502 states, “The auditee should prepare a Schedule of Expenditures of Federal Awards for the period covered by the auditee’s financial statements.” Internal controls over the SEFA should be in place ensure accrual basis expenses incurred under the federal program are properly reported as expenses on the SEFA and are properly reported as revenue in the financial statements prior to the start of the single audit. Cause: SEFA was not fully reconciled and finalized until after the single audit began. Effect: The expenses included on the SEFA for program 97.036, Disaster Grants-Public Assistance (Presidentially Declared Disasters), program FEMA-4683-DR-CA, were revised during the single audit and questioned costs in the amount of $131,195 were identified, which could have resulted in the auditor not selecting the correct major program or expenses for testing and could have resulted in the single audit not satisfying the requirements of the Uniform Guidance. Context: The District provided cost estimates to the California Governor’s Office of Emergency Services (CalOES) for the amount of flood damage expenses incurred for FEMA Project 725590 and 710830 that were used by CalOES to reimburse the District. The District did not adequately reconcile the expenses incurred at year-end to expense reports available in the accounting system and did not revise the expense estimates provided to CalOES to the actual amounts incurred during the year, resulting in CalOES overpaying the District and the District using the estimated costs on the SEFA for the single audit. Recommendation: We recommend additional review procedures be implemented to ensure the SEFA is complete and accurate when the single audit begins, which includes reconciling all expenses incurred under each federal award down to the invoice, payroll check and lowest level of other costs claimed, cutting-off each expense at year-end and claiming the reconciled qualifying expenses within 45 days after each quarter end. At year-end, programs should be reviewed for cost adjustments, extensions, and other changes that should be reflected on the SEFA when reconciling expenses for the SEFA. Separate program codes should be used for each grant on the SEFA that summarizes expenses down to the individual invoice level that should be provided to the auditor for the single audit. If overclaimed amounts are identified, the grantor and/or pass-though agency should be contacted to determine whether to return the funds or apply the overclaimed amounts to future claims. Views of Responsible Officials and Planned Corrective Actions: The District will implement a formal reconciliation process to ensure all expenditures incurred under each federal award are accurately recorded before the start of the single audit. A quarterly reconciliation process will be conducted after each quarter-end to review and adjust expenses as necessary. The District will contact FEMA to determine whether the questioned costs may be applied to a future claim or whether the amount needs to be returned to FEMA. Estimated Completion Date of Corrective Action: October 1, 2025
Trinity College of Florida will develop, implement and maintain a written information security program in accordance with GLBA compliance
Trinity College of Florida will develop, implement and maintain a written information security program in accordance with GLBA compliance
Finding Number: 2024-002 Planned Corrective Action: The sliding fee adjustment errors resulted from manual errors. Going forward, we will implement a process to periodically review sliding fee adjustments throughout the year for accuracy. Further, we will correct the EHR system error which resulted...
Finding Number: 2024-002 Planned Corrective Action: The sliding fee adjustment errors resulted from manual errors. Going forward, we will implement a process to periodically review sliding fee adjustments throughout the year for accuracy. Further, we will correct the EHR system error which resulted in write-off adjustments being incorrectly coded to sliding fee adjustments. Anticipated Completion Date: 6/30/2025 Responsible Contact Person: Jared Close, Controller
Student Financial Assistance Cluster - Assistance Listing No. 84.268 Recommendation: The University should ensure all necessary employees receive proper training, support, and time to follow the University’s policies and federal requirements related to monthly reconciliations. There should be a proc...
Student Financial Assistance Cluster - Assistance Listing No. 84.268 Recommendation: The University should ensure all necessary employees receive proper training, support, and time to follow the University’s policies and federal requirements related to monthly reconciliations. There should be a process to maintain all reconciliations as support of performance monthly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Business Office will complete monthly reconciliations in addition to the reconciliation at the time of draw of federal funds to comply with federal requirements. Name(s) of the contact person(s) responsible for corrective action: Belinda Burke, VP for Finance and Administration, CFO Planned completion date for corrective action plan: April 2025
Student Financial Assistance Cluster - Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the University evaluate its procedures and policies around reporting to the COD to ensure that student information is reported timely. Explanation of disagreement with audit finding: There is no...
Student Financial Assistance Cluster - Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the University evaluate its procedures and policies around reporting to the COD to ensure that student information is reported timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Department will evaluate its policies and procedures around reporting to the COD to ensure that student information is reported timely. Name(s) of the contact person(s) responsible for corrective action: Damon Wade, VP for Enrollment Management and Marketing Planned completion date for corrective action plan: April 2025
Student Financial Assistance Cluster - Assistance Listing No. 84.063, 84.268, 84.007,84.033 Recommendation: The University should review the procedures surrounding the verification process to ensure all necessary support and documentation is obtained as well as maintained in student files. Explanati...
Student Financial Assistance Cluster - Assistance Listing No. 84.063, 84.268, 84.007,84.033 Recommendation: The University should review the procedures surrounding the verification process to ensure all necessary support and documentation is obtained as well as maintained in student files. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Office has added personnel and implemented an electronic document management system. All verification documentation is now scanned and maintained within each student’s electronic file to ensure accuracy, completeness, and audit readiness. Staff continue to receive regular training on verification protocols. Name(s) of the contact person(s) responsible for corrective action: Damon Wade, VP for Enrollment Management and Marketing Planned completion date for corrective action plan: April 2025
Student Financial Assistance Cluster - Assistance Listing No. No. 84.268 Recommendation: We recommend the University review its process around sending exit counseling information to students to ensure this information is received and the University is performing required procedures. Explanation of d...
Student Financial Assistance Cluster - Assistance Listing No. No. 84.268 Recommendation: We recommend the University review its process around sending exit counseling information to students to ensure this information is received and the University is performing required procedures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Office has hired additional staff, enhanced training efforts, and established a standard procedure to send loan exit counseling notifications to students at the end of each term, ensuring regulatory compliance. Name(s) of the contact person(s) responsible for corrective action: Damon Wade, VP for Enrollment Management and Marketing Planned completion date for corrective action plan: June 2025
Student Financial Assistance Cluster - Assistance Listing No. No. 84.063 Recommendation: We recommend the University implement a review process to ensure calculations of Pell awards are using the correct information. Explanation of disagreement with audit finding: There is no disagreement with the a...
Student Financial Assistance Cluster - Assistance Listing No. No. 84.063 Recommendation: We recommend the University implement a review process to ensure calculations of Pell awards are using the correct information. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To reduce calculation errors in Pell Grant awards, the Financial Aid Office has hired additional staff, increased training, and implemented an automated packaging system. This system ensures Pell award amounts are calculated using accurate and verified student information. Name(s) of the contact person(s) responsible for corrective action: Damon Wade, VP for Enrollment Management and Marketing Planned completion date for corrective action plan: August 2025
Student Financial Assistance Cluster - Assistance Listing No. 84.268 Recommendation: We recommend the University establish additional policies to ensure all students meet the financial need criteria before awarding Title IV funds. Explanation of disagreement with audit finding: There is no disagree...
Student Financial Assistance Cluster - Assistance Listing No. 84.268 Recommendation: We recommend the University establish additional policies to ensure all students meet the financial need criteria before awarding Title IV funds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Office has hired additional personnel to enhance oversight and processing capacity. Staff will continue to receive training and will review all late and supplemental awards to verify that students meet financial need criteria before Title IV funds are disbursed. Name(s) of the contact person(s) responsible for corrective action: Damon Wade, VP for Enrollment Management and Marketing Planned completion date for corrective action plan: June 2025
View Audit 352022 Questioned Costs: $1
Student Financial Assistance Cluster - Assistance Listing No. 84.063, 84.268, 84.007, 84.033 Recommendation: We recommend the University review the R2T4 requirements and ensure their process incorporates a review of students to ensure no calculations are missed that should be performed. Explanation ...
Student Financial Assistance Cluster - Assistance Listing No. 84.063, 84.268, 84.007, 84.033 Recommendation: We recommend the University review the R2T4 requirements and ensure their process incorporates a review of students to ensure no calculations are missed that should be performed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: At the conclusion of each academic term, the Director of Financial Aid will review enrollment data with the Registrar’s Office to identify students who may require Return of Title IV (R2T4) calculations. Completion of all required R2T4 calculations will be documented and verified by the Director to ensure full compliance with federal guidelines. Name(s) of the contact person(s) responsible for corrective action: Damon Wade, VP for Enrollment Management and Marketing Planned completion date for corrective action plan: May 2025
Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing and Section 8 Housing Choice Vouchers Programs to ensure that established internal control policies are bein...
Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing and Section 8 Housing Choice Vouchers Programs to ensure that established internal control policies are being followed on a timely basis. Julio Marenco, Interim Executive Director, will be responsible to implement this corrective action by June 30, 2025.
View Audit 352015 Questioned Costs: $1
View of Responsible Officials and Corrective Actions: The Authority has recognized the deficiencies related to payroll and will implement internal control procedures that will ensure compliance with the Authority's internal control policies and personnel policy. Julio Marenco, Interim Executive Dire...
View of Responsible Officials and Corrective Actions: The Authority has recognized the deficiencies related to payroll and will implement internal control procedures that will ensure compliance with the Authority's internal control policies and personnel policy. Julio Marenco, Interim Executive Director, will be responsible to implement this corrective action by June 30, 2025.
View Audit 352015 Questioned Costs: $1
Identifying Number: SA 2024-003 Description of Finding: During the audit of payroll expense testing, it was noted that five samples have Personnel Action Forms (PAF) without the signature of the General Manager. In addition, one of those five samples has a variance between the pay rate per PAF and p...
Identifying Number: SA 2024-003 Description of Finding: During the audit of payroll expense testing, it was noted that five samples have Personnel Action Forms (PAF) without the signature of the General Manager. In addition, one of those five samples has a variance between the pay rate per PAF and pay rate per payroll register. Per current policies and procedures, for pay rate changes, a PAF should be created by the HR Manager and signed by the General Manager. Additionally, MARTA was unable to provide PAF for four samples. Corrective Actions Taken or Planned: 1. We will review our procedures on processing PAF, communicate more effectively to close loop on paperwork process, and confirm authorized signatures. 2. We will review all files for completed PAF forms and practice better diligence going forward in maintaining all documentation in personnel files. Personnel responsible for implementation: Jacob Phillips, HR Manager Anticipated completion date: Effective immediately
Finding 549905 (2024-018)
Significant Deficiency 2024
2024-018. USU Extension Extra Services Compensation Program Non-Compliance with Uniform Guidance State Agency: Utah State University Research & Development Federal Agency: Various 1) Potential Financial Impact USU retained Huron Higher Education Consulting to conduct a Uniform Guidance compliance r...
2024-018. USU Extension Extra Services Compensation Program Non-Compliance with Uniform Guidance State Agency: Utah State University Research & Development Federal Agency: Various 1) Potential Financial Impact USU retained Huron Higher Education Consulting to conduct a Uniform Guidance compliance review of compensation costs charged to federal sponsors. Huron Consulting routinely works with Carnegie R1 institutions to review research compliance issues. Huron conducted a detailed review of an extensive data set for ESC payments made to USU employees, focusing on employees who had salary charged to federal grants or designated as a grant cost share. This review identified limited instances (1) when salaries directly charged to sponsored projects included extra service compensation in the institutional base salary and (2) when extra service compensation was charged to federal sponsors. Overall, the review found that the vast majority of USU ESC payments (referred to as secondary payments in the internal audit) were not charged to federal sponsored awards. Out of a total population of $5.8 million ESC payments reviewed, the unallowed compensation costs related to ESC is approximately $140,000. USU is in the process of addressing the unallowable compensation costs by removing unallowable charges on open awards and refunding unallowable charges on closed awards. 2) Policies and required documentation for ESC. ESC Policies: USU is reviewing its policies associated with ESC and institutional base salary (IBS) (both currently defined in USU Policy 376: Extra Service Compensation). A working group has been established that includes the Provost’s Office, the President’s Office, the Office of Research and Human Resources to develop updated procedures for requesting ESC. Once in place, a new Extra Service Compensation website will be rolled out that will provide guidance on the policy, acceptable uses of extra-service Compensation, and training materials. In conjunction with the website development, a communication plan to inform stakeholders, especially approving department heads and administrators, will be developed. Institutional Base Salary Policy and Procedures: USU will create and implement an Institutional Base Salary policy that aligns with federal requirements and industry best practices and specifically defines salary components and the associated pay codes that are included and excluded from an employee’s institutional base salary. USU will also update its time and effort certification system with correct institutional base salary mapping. 3) Internal controls for sponsored program compensation USU will implement the following improvements in its internal controls: Revised ESC Form. USU has revised its ESC Form to include documentation / calculation demonstrating payment is commensurate with institutional base salary. Revised ESC Application and Approval Process: USU has already updated the internal ESC review process to include appropriate controls to ensure that all ESC requests are reviewed for Uniform Guidance and USU policy requirements. In this regard, all ESC requests at USU are now reviewed by the Office of Sponsored Programs in the context of all funding sources associated with the applicant (including cost share indexes). This change directly addresses prior routing based on the source of funding which resulted in the Office of Research/Sponsored Programs being bypassed for state-funded ESC requests. Certification language has been inserted at appropriate approval levels to ensure that employees are not receiving ESC related to their primary position/workload. Improved Definitions of Primary Work Statement: USU has initiated a collaborative effort between Human Resources, the Provost’s Office, and the Office of Research to clearly define the primary work assignment for faculty via the role statement or annual work plans to clarify the full workload associated with the IBS. Increased Compliance Monitoring: After-the-fact monthly review of ESC payments is being collaboratively performed between the Office of Research and Provost’s Office. Additionally, USU has reorganized its operations to house post-award research administrators within the Office of Research and added an additional supervisory position to manage post award compliance and management. USU will charge central-post award research administrators with monitoring salary charges to sponsored awards and cost share accounts as a secondary internal control. Research Incentive Programs: The Office of Research will establish permissible conditions and components for research incentive programs and any and all proposed programs will be reviewed and approved by the Office of Research before implementation. 4) Adequate training to university personnel regarding sponsored programs compensation compliance. Uniform Guidance training for faculty and staff: USU is building and incorporating new training modules for those managing federal awards which will include guidance on allowable compensation costs and determining institutional base salary. ESC Training: USU has developed a new required annual training for anyone requesting or approving ESC from all types of funding sources at USU (delivered via USU’s Learn Blue system). This training addresses requirements for ESC and employees’ role and responsibilities for compliance requirements. Additional training regarding time and effort certification will be developed. Pay Code Training: USU will provide additional training and education for departmental and payroll staff responsible for coding and processing salary across the institution. Responsible Person: Lisa M. Berreau Vice President for Research Utah State University 435-797-3509 Anticipated completion date of corrective action plan: Actively in progress and full completion by Jan. 1, 2026.
Finding 548761 (2024-008)
Significant Deficiency 2024
2024-008. Non-Payroll Expenditures Did Not Receive Adequate Reviews State Agency: University of Utah Research & Development Federal Agency: Department of Health and Human Services The Controller’s Office will work directly with the identified PI’s to provide additional training and understanding of ...
2024-008. Non-Payroll Expenditures Did Not Receive Adequate Reviews State Agency: University of Utah Research & Development Federal Agency: Department of Health and Human Services The Controller’s Office will work directly with the identified PI’s to provide additional training and understanding of the importance of appropriate and timely approvals. In addition, the Controller will work with the Office of Sponsored Projects and the Financial Reporting & Accounting office to review current training processes, as well as the process for notification and follow up with those AE’s/PI’s who do not meet the standard set forth in policy. Contact Person: Steven Phillips Anticipated Correction Date: 6/30/2025
Finding 548758 (2024-005)
Significant Deficiency 2024
2024-005. Required Health and Safety Surveys Not Performed Within Statutory Timeline State Agency: Department of Health and Human Services Federal Agency: Department of Health and Human Services To address this finding (and prior year finding number 2023-008), the Division of Licensing and Backgroun...
2024-005. Required Health and Safety Surveys Not Performed Within Statutory Timeline State Agency: Department of Health and Human Services Federal Agency: Department of Health and Human Services To address this finding (and prior year finding number 2023-008), the Division of Licensing and Background Checks (DLBC), Office of Licensing (OL) took the following corrective action to achieve compliance with required survey time frames: • Increased Health Facility Licensing fees by 43% to facilitate the hiring of 4 additional staff for the 2025 state fiscal year. • Dedicated one-time funds for contracting with a third-party surveyor and hired two, time- limited positions to help address the Health and Safety survey backlog in fiscal year 2024 and 2025. • Continued to work with the DHHS Office of Innovation to review the health facility team’s processes to improve efficiencies. • Organized a separate complaint investigation unit in August 2024 to help expedite complaint and survey completion. The DBLC, OL will continue to follow through with these additional resources in order to achieve compliance with the required survey timelines. In addition, the OL plans to streamline the writing and reporting procedures while ensuring compliance with CMS guidance. The goal is to shorten the time required to write reports and therefore increase the number of surveys completed. Implementation Date: July 1, 2026 Contact: Courtney Webb, Financial Manager, Division of Finance & Administration, courtneywebb@utah.gov
Finding 548753 (2024-003)
Significant Deficiency 2024
2024-003. Incomplete Pharmacy Rebate Reporting and Invoicing State Agency: Department of Health and Human Services Federal Agency: Department of Health and Human Services Following the launch of the Medicaid Provider Reimbursement Information System for Medicaid (PRISM) in April 2023, not all pharma...
2024-003. Incomplete Pharmacy Rebate Reporting and Invoicing State Agency: Department of Health and Human Services Federal Agency: Department of Health and Human Services Following the launch of the Medicaid Provider Reimbursement Information System for Medicaid (PRISM) in April 2023, not all pharmacy files from managed care entities and JCODE drugs properly transmitted to the third-party organization’s system. The key pharmacy claims files that needed to interface with the third-party organization’s system have now been rebuilt and are undergoing interface testing. After testing, the historic and more current files will be put into production and be transmitted to the third-party organization. Following receipt, the third-party organization will invoice and collect the unbilled rebates. Once this interface issue is resolved, all future required drug utilization data as well as rebate invoices will be sent to manufacturers within the required time frame. All claims received will be invoiced 60 days after the end of the current quarter they are received in, per CMS's rule. DHHS informed CMS of this issue in August 2024. At that time, CMS said the state was out of compliance and inquired on timelines to come into compliance. The state will provide updates to CMS when the backlogged files have been successfully transmitted and manufacturers have been invoiced. According to the third-party pharmacy organization, manufacturers were notified about this issue when it was discovered in May 2023 and advised that when the issues with invoicing these rebates is resolved they will be expected to pay the balance due. Implementation Date: May 30, 2025 Contact: Sepideh Daeery, Pharmacy Director, Division of Integrated Healthcare, sepidehdaeery@utah.gov Anticipated Correction Date: June 30, 2024
Finding 548751 (2024-011)
Significant Deficiency 2024
2024-011. DWS-Adopted Guidelines Not Followed When Evaluating an Applicant Housing Project State Agency: Department of Workforce Services Federal Agency: Department of Housing and Urban Development The Housing and Community Development Division is in the process of completing a full HTF policy and p...
2024-011. DWS-Adopted Guidelines Not Followed When Evaluating an Applicant Housing Project State Agency: Department of Workforce Services Federal Agency: Department of Housing and Urban Development The Housing and Community Development Division is in the process of completing a full HTF policy and procedures rewrite with a robust internal controls process. This will include an updated HTF monitoring checklist and a quality control check of said monitoring checklist by the Program Manager. Anticipated correction date: March 31, 2025 Responsible person: Daniel Murphy, HCD Program Manager, 385-630-8368
2024-017. Working Capital Reserves in Excess of Federal Guidelines State Agency: Public Employee Health Program Federal Agency: Various State Medical Given that the PEHP State Medical Program reserves are just over 60 days, our corrective action plan focuses on continuous monitoring and financial st...
2024-017. Working Capital Reserves in Excess of Federal Guidelines State Agency: Public Employee Health Program Federal Agency: Various State Medical Given that the PEHP State Medical Program reserves are just over 60 days, our corrective action plan focuses on continuous monitoring and financial stewardship to ensure compliance with reserve requirements while maintaining the program's financial health. The program was below 60 days on June 30, 2023. There are inherent variabilities and risks associated with medical claims, and reserve fluctuations are expected due to factors such as claim experience, utilization trends, and cost variations. We do not anticipate issuing a refund unless there is a long-term trend of excess reserves over the next three years. PEHP will continue to track performance and adjust necessary to maintain levels. Long-Term Disability After the measurement date of June 30, 2024, the PEHP Board of Directors approved a refund of excess reserves of $3,468,201.87 to the state of Utah. PEHP issued a check on September 12, 2024, and requested State Finance to calculate the federal portion of the refund and distribute it appropriately to the federal government. Additionally, our corrective action plan focuses on ensuring financial stability while evaluating the impact of recent plan modifications introduced by Senate Bill 21 from the 2025 Utah Legislative Session. The bill introduced specific changes to the LTD program that may impact claims experience and long-term reserve requirements. A thorough actuarial analysis is underway to assess how these modifications will affect future liabilities. While excess reserves still exist, it is prudent to allow for the recent changes to fully materialize before making any further financial adjustments or refunds. PEHP closely monitors how these modifications affect benefit, utilization, and reserve levels. Medicare Supplement While PEHP did acknowledge we would issue a refund last year, the overall trend of the Medicare reserve is moving in the opposite direction. In fact, as of December 31, 2024, the preliminary calculated reserve has experienced a notable decrease compared prior year levels due to PEHP's proactive efforts to manage and optimize reserve levels. These efforts have focused on aligning reserves with claim experience, refining cost management strategies, and ensuring long-term sustainability. One such effort relates to recent Medicare Part D Program changes that eliminated the donut hole, reducing plan options from three to one. PEHP is year one of a three-year transition to a single Part D rate that will continue to draw reserves. We believe allowing these changes to fully materialize before any further financial adjustments or refunds is prudent.
2024-016. Working Capital Reserves in Excess of Federal Guidelines State Agency: Department of Governmental Operations Federal Agency: Various Division of Purchasing and General Services Cooperative Contract Management Fund – State Purchasing continues to decrease the administrative fees on state co...
2024-016. Working Capital Reserves in Excess of Federal Guidelines State Agency: Department of Governmental Operations Federal Agency: Various Division of Purchasing and General Services Cooperative Contract Management Fund – State Purchasing continues to decrease the administrative fees on state cooperative contracts as each contract expires and is rebid. This is a slow process since State Purchasing has nearly 1,300 cooperative contracts with an average 5-year term. With only about 20% of the contracts expiring each year, this is an ongoing and slow process. Although State Purchasing is allowed under law to collect up to a 1.0% administrative fee on each cooperative contract, currently the average administrative fee is 0.35%. The excess reserves are also being reallocated to other programs. These allocations are intended to both reduce the excess reserve balance and to create efficiencies within the division to better serve state agencies. Federal Surplus Property Fund – The excess reserves are to be used in relocating Surplus to the Taylorsville State Office Building in March 2025. Contact Person: Windy Aphayrath (waphayrath@utah.gov, 801-957-7138), Director, Division of Purchasing and General Services Anticipated Correction Date: June 30, 2025 Division of Finance Purchasing Cards Fund (P-Card) – The system implementation was completed at the end of calendar year 2024. State Finance is working to analyze the annual costs of the system, develop a cost allocation strategy between the travel and P-Card programs, and adjust travel rates to cover the travel program's ongoing costs. The P-Card program will then distribute any remaining P-Card rebates to state agencies respective to their spending, if applicable. This effort will eliminate any excess federal reserves in the P-Card fund by the end of fiscal year 2025. Contact Person: Allyson Branch (abranch@utah.gov, 801-597-3523), Assistant Director, Division of Finance Anticipated Correction Date: June 30, 2025 Division of Risk Management Workers’ Compensation Fund – The Division of Risk Management has received approval from the Utah Legislature to reduce rates for workers’ compensation in fiscal year 2026. This will take effect on July 1, 2025. The division will also request at the next Legislative session to reallocate excess reserves from the Workers’ Compensation Fund to the Property Fund. This will be completed by July 1, 2026. Contact Person: Rachel Terry (rachelgterry@utah.gov, 801-702-7445), Director, Division of Risk Management, Anticipated Correction Date: July 1, 2026 Division of Technology Services Communication Services – The Division has worked to reduce the excess reserves and has been successful in decreasing the balance compared to the previous year. In addition, the current year rate was calculated to continue decreasing the excess reserve balance. Next year rates have also been adjusted to further reduce the excess reserve balance. We are working to balance reductions in retained earnings while maintaining services until the products reach the end of their lifecycle. Network Services – The Division is estimating that excess reserves will decrease as a result of anticipated increases in expenses over fiscal years 2025, 2026, and 2027 to support the migration to a cloud-based platform. We will continue to monitor rates and expenses as the technology environment continually changes. Printing Services – The Division has set the current year rate to recover costs in order to reduce the excess reserves. The threshold for this program has a small limit for a product with a very high volume. Print demand this year has been low, and we are forecasting this to be fully corrected by the end of fiscal year 2025. Contact Person: Jake Hennessy (jakehennessy@utah.gov, 385-271-2301), Executive Finance Director, Department of Government Operations Anticipated Correction Date: June 30, 2025 Division of Human Resource Management Human Resources Field Services – A cost allocation plan was developed to better align expenses with the specific service area supported. Field Service rates were lowered for fiscal year 2025. We anticipate continuing to fine tune rates to bring the Field Service reserve balance down. Contact Person: John Barrand (jbarrand@utah.gov, 801-957-9350), Director, Division of Human Resource Management Anticipated Correction Date: June 30, 2025
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