Corrective Action Plans

Finding 537566 (2024-002)

Significant Deficiency 2024

Seniorsplus

ME

Questioned Costs Subrecipient Monitoring Significant Deficiency § 200.303

Management is committed to compliance in accordance with all grant agreements and will work to formally document the Agency’s internal controls over Federal and State awards. Additional training will be provided as needed to prevent future findings.

View Audit 348846

Finding 537556 (2024-001)

Material Weakness 2024

Northern Cambria School District

PA

Questioned Costs Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.439

CONDITION: The Northern Cambria School District contracted Eber HVAC, Inc. for the School District’s RTU Replacement Project which constitutes a construction-related purchase respectively which requires prior approval from the Pennsylvania Department of Education (PDE). The School District did not o...

CONDITION: The Northern Cambria School District contracted Eber HVAC, Inc. for the School District’s RTU Replacement Project which constitutes a construction-related purchase respectively which requires prior approval from the Pennsylvania Department of Education (PDE). The School District did not obtain the required prior approval from PDE for this expenditure. This is a repeat finding (2023-001) for the prior fiscal year. CRITERIA: PDE and Section 2 CFR 200.439(b) of the Uniform Guidance require prior written approval by the federal or pass-through awarding agency for capital purchases including equipment, buildings, and land. Capital expenditures for special purpose equipment with a unit cost of $5,000 or more must also have prior approval. MANAGEMENT’S CORRECTIVE ACTION PLAN: Management will complete the Prior Approval Form for the Pennsylvania Department of Education (PDE) and obtain approval from PDE in advance of incurring any future federally funded expenditures, that meet PDE’s criteria as a capital purchase, to ensure compliance with PDE and Section 2 CFR 200.439(b) of the Uniform Guidance. This procedure will be implemented effective immediately for all future applicable capital purchases.

View Audit 348842 Questioned Costs: $1

Finding 537554 (2024-001)

Significant Deficiency 2024

Town of East Greenwich Housing Authority

RI

HUD Housing Programs Questioned Costs Special Tests & Provisions

2024-001 General Depository Agreements a. Corrective Action-It was found that the Depository Agreement on file with EGHA and Citizens Bank going back to 2010 was never fully executed. A new HUD 51999 was completed and signed by the EGHA Executive Director and forwarded to Citizens for signatures. On...

2024-001 General Depository Agreements a. Corrective Action-It was found that the Depository Agreement on file with EGHA and Citizens Bank going back to 2010 was never fully executed. A new HUD 51999 was completed and signed by the EGHA Executive Director and forwarded to Citizens for signatures. Once completed, it will be forwarded to HUD for their signature.

View Audit 348840

Finding 537546 (2024-001)

Significant Deficiency 2024

Integral Care

TX

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management § 200.1 § 200.414

Corrective Action Plan Finding 2024-001 Finding Summary: The Center did not exclude charges for patient care when calculating modified total direct costs (MTDC) in accordance with Uniform Guidance and TxGMS and thus the indirect rate used in calculating the indirect amount charged to the grant was n...

Corrective Action Plan Finding 2024-001 Finding Summary: The Center did not exclude charges for patient care when calculating modified total direct costs (MTDC) in accordance with Uniform Guidance and TxGMS and thus the indirect rate used in calculating the indirect amount charged to the grant was not consistently accurate. Corrective Action Plan: The Center has historically calculated the indirect amount using the same methodology over time. Given the small volume of patient receipts, the impact on the total indirect amount is minor. We believe that had we modified our calculations, we would have had enough modified total direct costs to cover the change in the calculation. The Center will modify all future calculations to ensure alignment. We will also review the fiscal year covered under this audit to understand what the impact of the change would have been on the split between cost types. Note that since we are midway through our next fiscal year, and we consider the differences minor, we have determined that we will correct for any future reimbursement requests, but will not modify prior reimbursement requests. Similarly, we will conduct a review of that fiscal year to determine the impact of the change and verify it is not significant. Responsible Individuals: Rusty Taylor, CFO Joe Carrington, Director of Financial Planning and Analysis Anticipated Completion Date: August 2025

View Audit 348829 Questioned Costs: $1

Finding 537530 (2024-005)

Material Weakness 2024

Housing Authority of Prince George's County

MD

Questioned Costs Special Tests & Provisions HUD Housing Programs

2024-005 Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority implements controls to ensure that HQS inspections are performed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in r...

2024-005 Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority implements controls to ensure that HQS inspections are performed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: HAPGC has hired a new Voucher Program Director. The new Director will strictly enforce current program policy which requires strict enforcement of HQS inspection rules. Additionally, HAPGC will review processes associated with scheduling HQS Inspections and work with the HQS Inspection contractor to ensure compliance. Finally, all HCV staff persons will be required to take the Housing Choice Voucher Certification class annually to ensure proper training and adequate understanding of the voucher program rules. Name(s) of the contact person(s) responsible for corrective action: Carolyn Floyd, Housing Choice Voucher Program, Director cefloyd@co.pg.md.us. Planned completion date for corrective action plan: December 31, 2025. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Jessica Anderson-Preston, Executive Director at 301-883-5552 or email jgandersonpreston@co.pg.md.us.

View Audit 348795

Finding 537529 (2024-004)

Material Weakness 2024

Housing Authority of Prince George's County

MD

Questioned Costs Special Tests & Provisions Material Weakness

2024-004 Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority implements controls to ensure that the Authority requires HQS deficiencies to be corrected within the timeframe set forth by 2 CFR section 982.404(a). We recommend the Authority implements co...

2024-004 Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority implements controls to ensure that the Authority requires HQS deficiencies to be corrected within the timeframe set forth by 2 CFR section 982.404(a). We recommend the Authority implements controls to ensure abatement is timely for units that do not correct the cited HQS deficiencies within the required timeframe. Explanation of disagreement with audit finding: HAPGC has hired a new Voucher Program Director. The new Director will strictly enforce current program policy which requires strict enforcement of abatement rules. Additionally, Program Managers, as well as Recertification and Intake Specialists, will be held accountable through disciplinary action when corrective actions noted through the quality control review process are not corrected within 15 business days. Finally, all HCV staff persons will be required to take the Housing Choice Voucher Certification class annually to ensure proper training and adequate understanding of the voucher program rules. Name(s) of the contact person(s) responsible for corrective action: Carolyn Floyd, Housing Choice Voucher Program, Director cefloyd@co.pg.md.us. Planned completion date for corrective action plan: December 31, 2025.

View Audit 348795 Questioned Costs: $1

Finding 537519 (2024-001)

None 2024

William Marsh Rice University

TX

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

William Marsh Rice University Response The following is William Marsh Rice University’s Response to the audit of Federal programs in accordance with the Uniform Guidance for the year ended June 30, 2024. Finding 2024-001 – Loan Disbursement Notification Cluster: Student Financial Assistance Cluster ...

William Marsh Rice University Response The following is William Marsh Rice University’s Response to the audit of Federal programs in accordance with the Uniform Guidance for the year ended June 30, 2024. Finding 2024-001 – Loan Disbursement Notification Cluster: Student Financial Assistance Cluster Awarding Agency: Department of Education Award Name: Federal Direct Student Loans Award Year: July 1, 2023 – June 30, 2024 Assistance Listing Number: 84.268 Pass-through Entity: Not applicable We acknowledge the audit finding regarding the missing documentation of the loan disbursement notification for the 2023-2024 academic year. The issue began when an automated rule was disabled by a system update. This prevented the loan disbursement notices from being sent to students. Upon recognizing the underlying reason, the loan disbursement notice, which is sent one day after a loan disbursement posts to a student’s account, had its system rules reengaged. This was achieved through a collaborative effort involving the Office of Financial Aid, the Bursar's Office, and Administrative Systems. Notices resumed on September 26, 2024, and we have since conducted spot checks to confirm that the notices are being sent as required. To prevent a recurrence of this issue, we have implemented the following measures: 1. Annual Review: We have updated our staff calendar with an annual reminder to review and request updates to the text and rules of the loan disbursement notice. 2. Documentation: We have ensured that the scheduled disbursement dates and the right to cancel are disclosed in multiple areas, including the all-freshmen notice, other loan/aid award notices, the loan section of our website, and the financial aid section of General Announcements for both undergraduate and graduate students. Prior to and including the 2023-2024 academic year, this information has been updated and made available on an annual basis in these areas. This practice will continue. Effective Date: September 26, 2024 Person(s) responsible for implementation: Paul Negrete, Executive Director for University Financial Aid Services, 713-348-5905 We believe these actions address the audit finding and will help maintain compliance with notification requirements moving forward. Sincerely, Paul Negrete Executive Director University Financial Aid Services

View Audit 348737

Finding 537483 (2024-001)

Significant Deficiency 2024

Kyrene Elementary School District No. 28

AZ

Allowable Costs / Cost Principles School Nutrition Programs Questioned Costs

Findings and Questioned Costs Related to Federal Awards Finding Number: 2024‐001 Program Name/Assistance Listing Title: Child Nutrition Cluster Assistance Listing Numbers: 10.553, 10.555, 10.559 Contact Person: Brian Lockery, Director of Finance Anticipated Completion Date: The finding was corrected...

Findings and Questioned Costs Related to Federal Awards Finding Number: 2024‐001 Program Name/Assistance Listing Title: Child Nutrition Cluster Assistance Listing Numbers: 10.553, 10.555, 10.559 Contact Person: Brian Lockery, Director of Finance Anticipated Completion Date: The finding was corrected as of February 18, 2025. Planned Corrective Action: District staff took the following steps to immediately remedy this finding:  Entered and approved a journal entry in the FY24 general ledger to correct the indirect cost transfer out of Fund 510 and into Fund 570 as authorized under the program.  Submitted to ADE a request to open a 15‐915 data correction to submit a revised FY24 Annual Financial Report (AFR), Food Service AFR and School by School (AFR).  ADE opened the 15‐915 window, and Kyrene submitted all three revised AFRs.  ADE processed and approved all three AFRs.  Kyrene submitted all three revised AFRs to its governing board for approval on March 25, 2025.  FY25 opening fund balances were additionally corrected to reflect the changes approved in the revised AFRs. Kyrene remedied this finding as of February 18, 2025. Kyrene now employs a new, revised calculator tool which limits the amount of the food service contract expenses to $25,000 maximum annually. This worksheet will be used to calculate the maximum allowable indirect cost rate transfer from Fund 510 Food Services to Fund 570 Indirect Costs.

View Audit 348721 Questioned Costs: $1

Finding 537460 (2024-003)

Significant Deficiency 2024

State System of Higher Education, Commonwealth of Pennsylvania

PA

Matching / Level of Effort / Earmarking Questioned Costs Student Financial Aid § 200.303

Commonwealth: Direct Loan processor will submit monthly reconciliations to Executive Director of Financial Aid or designated campus director for review and approval

View Audit 348667

Finding 537456 (2024-001)

Significant Deficiency 2024

State System of Higher Education, Commonwealth of Pennsylvania

PA

Questioned Costs Student Financial Aid Reporting § 200.303

ESU: The University acknowledges this is a repeat finding. In response, updated policies and procedures were implemented in May 2024. The audit sample included students from Fall 2023 and Spring 2024—periods that predated the implementation of the corrective measures. To improve compliance, the Univ...

ESU: The University acknowledges this is a repeat finding. In response, updated policies and procedures were implemented in May 2024. The audit sample included students from Fall 2023 and Spring 2024—periods that predated the implementation of the corrective measures. To improve compliance, the University has introduced enhanced reporting mechanisms to identify when a student is no longer participating in any enrolled courses during a given semester. Once a determination is made that a student has withdrawn, University Registrar staff manually update the student’s status in the National Student Clearinghouse. This process reduces the delay between a student’s actual withdrawal and the status update reported to NSLDS. These steps are intended to ensure timely and accurate reporting moving forward. IUP: IUP will set guidelines that all degree clearing must be done with the 45 day time line so the students are reported within the 60 days limit. Cheyney:Cheyney University of Pennsylvania utilizes the National Student Clearinghouse as a third-party service provider for enrollment reporting and provides all enrollment data to NSC, believing that enrollment would be reported to NSLDS in compliance with federal regulations; unfortunately, the enrollment data from the NSC roster which is provided to National Student Loan Data Systems (NSLDS), is only matched to students who currently have existing enrollment records in NSLDS. Student enrollment information is provided to NSLDS from Common Originations and Disbursements (COD). Cheyney University is a Heightened Cash Monitoring 2 (HCM2) institution, and students' Title IV aid/ disbursements are reported differently than advance pay institutions. The student records from COD are only provided to NSLDS upon approval of disbursement from Ed after the University HCM2 submissions are approved. As of Fall 2024, Cheyney University has continued to directly report and upload enrollment for all Title IV recipients to NSLDS from the monthly NSC enrollment rosters. Kutztown: We will target shortening our status change reporting process to 2-3 days to compensate from the (up to) 30 day lag between NSC reporting and NSLDS reporting. We will connect with another PASSHE school that was on the findings report for the last period - but not this period - to ascertain how they avoided the repeat, and to learn additional best practices. We will renew our cooperative efforts with financial aid to ensure both sides of the equation – NSC and NSLDS – are communicating and that both offices are involved in double checking Commonwealth: The issues with enrollment reporting were one-time issues related to the integration of the three schools and the implementation of and data migration to a new student information system. Issues have been resolved and Commonwealth University is currently reporting on the prescribed schedule. Millersville: The Registrar’s Office will review its reporting procedures to ensure that students’ statuses are timely reported to NSLDS as required by Federal regulations. Primarily, the frequency of submissions to the NSC.

View Audit 348667

Finding 537455 (2024-001)

Significant Deficiency 2024

Brac Usa, Inc.

NY

Subrecipient Monitoring Allowable Costs / Cost Principles Questioned Costs § 200.332 § 200.501

Views of Responsible Officials and Planned Corrective Actions: We are committed to strengthening our internal controls and procedures to ensure full compliance with Uniform Guidance requirements. We also acknowledge that the audit waiver BRAC Bangladesh received from the USAID Mission in Bangladesh ...

Views of Responsible Officials and Planned Corrective Actions: We are committed to strengthening our internal controls and procedures to ensure full compliance with Uniform Guidance requirements. We also acknowledge that the audit waiver BRAC Bangladesh received from the USAID Mission in Bangladesh was not sufficient to exempt them from conducting a program-specific audit of the Department of State (BPRM) funded project, SPRMCO23CA0152. In response to the finding, BRAC Bangladesh has already conducted an audit of the project, which demonstrated that the financial statements and schedule of expenditures were free from material misstatements. Moving forward, we will amend our subagreement templates to include specific language around USG audit requirements, and the submission of audit reports will be included in the reporting section of the agreements. We will also update our Fiscal Policies and Procedures Manual to formalize the process for receiving and reviewing audit reports, and establishing follow-up procedures to resolve potential audit findings. We will also maintain clear documentation of the submission, review, and follow up of audits.

View Audit 348663

Finding 537447 (2024-002)

Significant Deficiency 2024

Saint Peter's University and Affiliates

NJ

Questioned Costs Student Financial Aid Significant Deficiency

Student Financial Aid Cluster – Federal Assistance Listing Numbers 84.007, 84.033, 84.063 and 84.268 Recommendation: We recommend the University review its policies and procedures related to outstanding student refund checks to ensure they are being returned to the Department of Education after 240 ...

Student Financial Aid Cluster – Federal Assistance Listing Numbers 84.007, 84.033, 84.063 and 84.268 Recommendation: We recommend the University review its policies and procedures related to outstanding student refund checks to ensure they are being returned to the Department of Education after 240 days. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has developed a policy to identify uncashed Title IV refund checks prior to the 240-day expiration date. The policy includes steps to contact students whose checks did not clear and to return the refunds to the Department within 240 days after the issue date of the check. The procedures will ensure that reviews are completed and returned timely according to applicable regulations. Name(s) of the contact person(s) responsible for corrective action: Lillian Perreira-Talty, Director of Student Accounts (201) 761-6080 Planned completion date for corrective action plan: Completed

View Audit 348651 Questioned Costs: $1

Finding 537435 (2024-002)

Material Weakness 2024

Housing Authority of the City of Brownwood, Texas

TX

Questioned Costs Procurement, Suspension & Debarment

HOUSING AUTHORITY OF THE CITY OF BROWNWOOD, TEXAS CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2024 The Housing Authority of the City of Brownwood, Texas respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and Address of Independent Audit Firm: Urlaub & Co....

HOUSING AUTHORITY OF THE CITY OF BROWNWOOD, TEXAS CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2024 The Housing Authority of the City of Brownwood, Texas respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and Address of Independent Audit Firm: Urlaub & Co., PLLC P.O. Box 2663 Ada, OK 74821 Audit Period: June 30, 2024 The finding from the June 30, 2024 schedule of findings and questioned costs are discussed below: SECTION II – Financial Statement Findings 2024-001 Procurement Response: The Authority will review our procurement policy as well as the guidance obtained when we attended the procurement training conference. We will specifically review the appropriate times that tasks must be consolidated into a single procurement action. We will include in the bid proposals the conditions, material types, and specifications for the bid. We will document all procurement transactions. We will maintain a formal bid tabulation form for all contracts procured. We will request assistance from our Board of Commissioners to review bids and to prepare the bid tabulation for formal bids over $50,000. Contact Person: David Long, Executive Director Anticipated Date of Completion: June, 2025 SECTION III – Federal Award Findings and Questioned Costs U.S. Department of Housing and Urban Development 14.872 – Public Housing Capital Fund 2024-002 Procurement Response: See the response in Finding 2024-001.

View Audit 348623 Questioned Costs: $1

Finding 537433 (2024-005)

Significant Deficiency 2024

Little Eagle Grant School

SD

Questioned Costs Allowable Costs / Cost Principles Procurement, Suspension & Debarment

Contact Person – Pedro Rosa, Business Manager Corrective Action Plan –Management recommends all school personnel follow the purchase order process when making any purchases with school funding, as established by the School Board. Management has also started the practice of scanning all purchase docu...

Contact Person – Pedro Rosa, Business Manager Corrective Action Plan –Management recommends all school personnel follow the purchase order process when making any purchases with school funding, as established by the School Board. Management has also started the practice of scanning all purchase documents onto every purchase transaction in order to eliminate the possibility of lost or misplaced documents. Completion Date – 06/30/2025

View Audit 348621

Finding 537431 (2024-004)

Significant Deficiency 2024

Little Eagle Grant School

SD

Questioned Costs Allowable Costs / Cost Principles Procurement, Suspension & Debarment

Contact Person – Pedro Rosa, Business Manager Corrective Action Plan – Management recommends the school purchasers and purchasing supervisors use IRS De Minimus standards for all gifts, including door prizes. Management also recommends school personnel get proper approval before making any purchases...

Contact Person – Pedro Rosa, Business Manager Corrective Action Plan – Management recommends the school purchasers and purchasing supervisors use IRS De Minimus standards for all gifts, including door prizes. Management also recommends school personnel get proper approval before making any purchases with school funding. Completion Date – 06/30/2025

View Audit 348621 Questioned Costs: $1

Finding 537423 (2024-005)

Material Weakness 2024

Blackford County Schools

IN

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303 § 200.334 § 200.403

FINDING 2024-005 Subject: COVID-19 - Education Stabilization Fund - Allowable Costs/Cost Principles and Allowable Activities Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425C, 84.425U Federal Award Numbers and...

FINDING 2024-005 Subject: COVID-19 - Education Stabilization Fund - Allowable Costs/Cost Principles and Allowable Activities Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425C, 84.425U Federal Award Numbers and Year (or Other Identifying Numbers): S425D210013, S425U210013 Pass-Through Entity: Indiana Department of Education Compliance Requirements: Allowable Costs/Cost Principles Audit Findings: Material Weakness, Modified Opinion Person Responsible for Corrective Action: Chad Yencer - Superintendent Contact Phone Number: 765-348-7550 Views of Responsible Official: Agree Description of Corrective Action Plan: This was a singular occurrence where the rate for a remedial program was not approved by the BCS school board, and where the payments did not tie back to an allowable cost. This program and fund are no longer active. Anticipated Completion Date: Completed

View Audit 348618 Questioned Costs: $1

Finding 537414 (2024-003)

Material Weakness 2024

Blackford County Schools

IN

Questioned Costs Allowable Costs / Cost Principles School Nutrition Programs § 200.303 § 200.403

Finding 2024‐003 Subject: Child Nutrition Cluster – Allowable Costs/ Cost Principles Federal Agency: Department of Agriculture Federal Programs: School Breakfast Program, National School Lunch Program, Summer Food Service Program for Children Assistance Listings Numbers: 10.553, 10.555, 10.559 Compl...

Finding 2024‐003 Subject: Child Nutrition Cluster – Allowable Costs/ Cost Principles Federal Agency: Department of Agriculture Federal Programs: School Breakfast Program, National School Lunch Program, Summer Food Service Program for Children Assistance Listings Numbers: 10.553, 10.555, 10.559 Compliance Requirement: Allowable Costs/ Cost Principles Audit Findings: Material Weakness, Other Matters Contact Person Responsible for Corrective Action: Julie Dodd, Treasurer Contact Phone Number: 765-348-7550 Views of Responsible Official: We concur with the finding of the auditor Description of Corrective Action Plan: This was a singular occurrence in which indirect costs were applied in the wrong year. Moving forward, no indirect costs will be charged or paid outside of the correct time period for the fiscal year. Anticipated Completion Date: Completed

View Audit 348618 Questioned Costs: $1

Finding 537413 (2024-028)

Significant Deficiency 2024

State of Vermont

VT

Questioned Costs Subrecipient Monitoring Reporting § 200.303

Reference Number: 2024-028 Prior Year Finding: 2023-034 Federal Agency: U.S. Department of Homeland Security State Agency: Department of Public Safety Federal Program: Disaster Grants - Public Assistance (Presidentially Declared Disasters) Assistance Listing Number: 97.036 Award Number and Year: FEM...

Reference Number: 2024-028 Prior Year Finding: 2023-034 Federal Agency: U.S. Department of Homeland Security State Agency: Department of Public Safety Federal Program: Disaster Grants - Public Assistance (Presidentially Declared Disasters) Assistance Listing Number: 97.036 Award Number and Year: FEMA-4474-DR-VT (2020), FEMA-4532-DR-VT (2020), FEMA-4621-DR-VT (2021), FEMA-4695-DR-VT (2023), FEMA-4720-DR-VT (2023) Compliance Requirement: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend the Department complete implementation of its corrective action plan from the prior year. The Department should continue to improve its procedures and internal controls to ensure that all required subawards and subaward modifications are reported accurately and timely to FSRS no later than the end of the month following the month of issuance in accordance with FFATA reporting requirements. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: Public Safety will continue implementation of its corrective action plan from the prior year. A new procedure will be developed for a periodic review of FFATA entries to add a control step ensuring that all FFATA entries are timely and accurate. A training will also be delivered to Public Assistance staff to ensure that the FFATA entry process is understood in both FSRS and SAM.gov. These corrective actions will be completed by April 4th, 2025 Scheduled Completion Date of Corrective Action Plan: April 4, 2025 Contacts for Corrective Action Plan: Richard Hallenbeck, Director of Administration/Finance richard.hallenbeck@vermont.gov

View Audit 348596

Finding 537402 (2024-025)

Significant Deficiency 2024

State of Vermont

VT

Questioned Costs Special Tests & Provisions Significant Deficiency § 200.303

Reference Number: 2024-025 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services (Agency) Federal Program: Medicaid Cluster Assistance Listing Number: 93.775, 93.777, 93.778 Award Number and Year: 2305VT5MAP (10/1/2022 – 9/30/2023)...

Reference Number: 2024-025 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services (Agency) Federal Program: Medicaid Cluster Assistance Listing Number: 93.775, 93.777, 93.778 Award Number and Year: 2305VT5MAP (10/1/2022 – 9/30/2023) 2405VT5MAP (10/1/2023 – 9/30/2024) Compliance Requirement: Special Tests and Provisions – Utilization Control Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend that the Agency review and enhance procedures and controls for Medicaid utilization control to ensure that cases are closed timely and that documentation of the results of reviews are maintained and communicated. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: The Special investigations Unit (SIU) only refers two types of cases to the Medicaid Fraud Residential Abuse Unit (MFRAU), these cases are: Personal Care Attendant (PCA) and provider fraud and abuse. Prior to 2021 most of those cases were kept in paper format. Since then, the SIU has fully transitioned to electronic files only. All PCA cases referred to MFRAU are assigned to the Duty Auditor (DA) of the Special Investigations Unit (SIU). The DA must send the case referral via a form that MFRAU must return with notification of acceptance or declination to investigate the allegation. If the case is accepted, then it remains under “open referred to MFRAU” status in our database and updates must be provided and documented by the DA during our MFRAU/SIU quarterly meetings until SIU receives a closure memo from MFRAU that documents the completion of their review. Additionally, all provider cases remain open with the auditor who investigated and referred the matter until a closing memo is received by the SIU. All documented follow ups are recorded in the case log. Scheduled Completion Date of Corrective Action Plan: This process has been implemented since 2021 for cases generated from that year forward. SIU Procedure Manual has been updated accordingly as of December 31, 2024. Contacts for Corrective Action Plan: Nadeth Fitzgerald, Director – SIU nadeth.fitzgerald@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 348596

Finding 537401 (2024-024)

Significant Deficiency 2024

State of Vermont

VT

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

Reference Number: 2024-024 Prior Year Finding: 2023-031; 2022-037; 2021-025; 2020-014; 2019-010 Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: Medicaid Cluster Assistance Listing Number: 93.775, 93.777, 93.778 Award Number and Yea...

Reference Number: 2024-024 Prior Year Finding: 2023-031; 2022-037; 2021-025; 2020-014; 2019-010 Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: Medicaid Cluster Assistance Listing Number: 93.775, 93.777, 93.778 Award Number and Year: 2305VT5MAP (10/1/2022 – 9/30/2023) 2405VT5MAP (10/1/2023 – 9/30/2025) Compliance Requirement: Special Tests and Provisions - Provider Health and Safety Standards Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend the Agency fully implement its CAP to ensure that documentation is maintained in accordance with program requirements and that all providers are compliant with required health and safety standards. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: All Letters of Good Standing as well as a Standard Operating Procedure to ensure continuation were implemented in April of 2022. Prior to April the process was manual and via telephone or email with the Tax Department. All Providers who had their tax standing validated prior to April 2022 via phone or email were not solicited to get a written notification from the Tax Commissioner. As of April 2022 all tax standing reviews are validated with a letter from the Vermont Tax department and documented in the Provider Management Module. Verification with the VT Tax Department of a provider’s tax standing has always occurred; However, the good standing verification was documented in the PMM system and the confirmation of the verification from the VT Tax Department was not consistently maintained in the PMM. Although the Agency has implemented its corrective action plan from a prior year audit, cases will still be identified under this CAP until the provider is due for their 5-year revalidation and successfully revalidates with VT Medicaid. Scheduled Completion Date of Corrective Action Plan: Completed Contacts for Corrective Action Plan: Deidra Jarvis, Member and Provider Services Supervisor deidra.Jarvis@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 348596

Finding 537400 (2024-023)

Significant Deficiency 2024

State of Vermont

VT

Questioned Costs Subrecipient Monitoring Reporting § 200.303

Reference Number: 2024-023 Prior Year Finding: 2023-030; 2022-038; 2021-026 Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: Medicaid Cluster Assistance Listing Number: 93.775, 93.777, 93.778 Award Number and Year: 2305VT5MAP (10/1/...

Reference Number: 2024-023 Prior Year Finding: 2023-030; 2022-038; 2021-026 Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: Medicaid Cluster Assistance Listing Number: 93.775, 93.777, 93.778 Award Number and Year: 2305VT5MAP (10/1/2022 – 9/30/2023) 2405VT5MAP (10/1/2023 – 9/30/2024) Compliance Requirement: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend that the Agency complete implementation of its prior year CAP to ensure that all required subawards and subaward modifications are reported timely to FSRS in accordance with FFATA requirements. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: Agency of Human Services Internal Audit Group (AHS-IAG) is a designated centralized reporter of subawards for a Medicaid cluster (ALN 93.775, 93.777, 93.778) that is shared between all AHS departments. To address omissions and timeliness of subawards and subaward modifications reporting to FSRS, IAG conducted additional training tailored to each AHS Department to examine the results of FFATA testing conducted internally and reemphasized the FFATA compliance regulations. This ensured the Internal Audit Group (IAG) is provided with complete, accurate and timely subaward information for reporting in FSRS going forward. The context of the 2024 finding indicates that the departments understood the training materials and complied with the requirements to report. On at least an annual basis, IAG conducts a review of current federal rules and regulations pertaining to FFATA reporting for FSRS to assure the Agency’s procedures are up to-date. Coincidentally, IAG will also select a random sample of subawards and subawards modifications that meet the required threshold for FFATA reporting to ensure they are reported in FSRS system on a complete, accurate and timely basis. Scheduled Completion Date of Corrective Action Plan: March 31, 2025: Annual review of FFATA rules and regulations including subawards review. Contacts for Corrective Action Plan: Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

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Finding 537399 (2024-022)

Significant Deficiency 2024

State of Vermont

VT

Questioned Costs Eligibility Significant Deficiency § 200.303

Reference Number: 2024-022 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services (Agency) Federal Program: Medicaid Cluster Assistance Listing Number: 93.775, 93.777, 93.778 Award Number and Year: 2305VT5MAP (10/1/2022 – 9/30/2023)...

Reference Number: 2024-022 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services (Agency) Federal Program: Medicaid Cluster Assistance Listing Number: 93.775, 93.777, 93.778 Award Number and Year: 2305VT5MAP (10/1/2022 – 9/30/2023) Compliance Requirement: Eligibility Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend that the Agency review and enhance procedures and controls for Medicaid eligibility renewals to ensure that benefits for eligible participants are not discontinued. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: The error was caused by a caseworker not following the steps within the job aid when processing eligibility for a late renewal form. Coverage closed on 9/30/24 for non-review. The renewal form was received on 10/17/2023 yet, coverage was reinstated for 11/1/2024 instead of 10/1/24. The gap in coverage was corrected on 9/16/2024 and coverage was backdated to 10/1/24. The eligibility unit notified the worker’s supervisor who reviewed the case error with the caseworker. In addition, eligibility staff receive refresher training yearly to review our business processes. The Eligibility Unit will continue to monitor cases through our internal QA process unit and through our off-year reviews conducted by the QC unit. Scheduled Completion Date of Corrective Action Plan: Coverage was corrected on September 16, 2024. Contacts for Corrective Action Plan: Nicole McAllister, Healthcare Assistant Administrator II nicole.mcallister@vermont.gov Sarah York, Healthcare Assistant Administrator I sarah.york@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

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Finding 537387 (2024-021)

Significant Deficiency 2024

State of Vermont

VT

Eligibility Questioned Costs Student Financial Aid § 200.303

Reference Number: 2024-021 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: CCDF Cluster Assistance Listing Number: 93.575, 93.596 Award Number and Year: 2301VTCCDD (10/1/2022 – 9/30/2025) 2401VTCCDD (10/1/202...

Reference Number: 2024-021 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: CCDF Cluster Assistance Listing Number: 93.575, 93.596 Award Number and Year: 2301VTCCDD (10/1/2022 – 9/30/2025) 2401VTCCDD (10/1/2023 – 9/30/2026) Compliance Requirement: Eligibility Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend that the Agency review and enhance procedures and controls to ensure that it verifies U.S. citizenship for all participants and confirm that only eligible participants receive benefits under the program. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: This finding has been corrected as of January 2024 dating back to October 2023. The State is no longer pooling funding sources which means that we can identify cases by their true funding source. This means that only true CCDF cases will be audited going forward and family service cases (protective service) no longer follow CCDF rules including citizenship and identity. Scheduled Completion Date of Corrective Action Plan: December 31, 2024 Contacts for Corrective Action Plan: Karolyn Long, Operations Director karolyn.long@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

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Finding 537386 (2024-020)

Material Weakness 2024

State of Vermont

VT

Special Tests & Provisions Questioned Costs Subrecipient Monitoring § 200.303

Reference Number: 2024-020 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: CCDF Cluster Assistance Listing Number: 93.575, 93.596 Award Number and Year: 2301VTCCDD (10/1/2022 – 9/30/2025) 2401VTCCDD (10/1/202...

Reference Number: 2024-020 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: CCDF Cluster Assistance Listing Number: 93.575, 93.596 Award Number and Year: 2301VTCCDD (10/1/2022 – 9/30/2025) 2401VTCCDD (10/1/2023 – 9/30/2026) Compliance Requirement: Special Tests and Provisions – Health and Safety Requirements Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance Recommendation: We recommend that the Agency review and enhance training monitoring procedures and controls to ensure that all child care providers complete required health and safety training. We further recommend that the Agency update its training content to ensure that it includes all required elements. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: Department for Children and Families-Child Development Division (DCF-CDD) licensing unit is in the process of rule revisions which will include all the required health and safety topics that must be covered within the first three months of employment. DCF-CDD licensing unit will be updating our monitoring checklists to ensure we are regulating to the federal standard. DCF-CDD licensing unit will conduct staff training that review the results of the SFY 2024 Single Audit and establish clear procedures for licensing staff to follow when monitoring licensed providers and their staff for ongoing professional development requirements. Scheduled Completion Date of Corrective Action Plan: DCF-CDD is currently in the rule revision process and have a goal to shepherd the rules through promulgation by December 31, 2025. DCF-CDD will update our monitoring checklists to align with the rule revision which will include a complete pre-service orientation training list that aligns with the federal standard. This will be completed by December 31, 2025. DCF-CDD will review the results of the SFY 2024 Single Audit with the licensing team on January 21, 2025. Licensing supervisors will begin reviewing annual site visit reports for the licensors they supervise to ensure CDD is monitoring for the required ongoing professional development trainings required beginning immediately. Contacts for Corrective Action Plan: Beth Maurer, Director of Child Care Licensing elizabeth.maurer@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

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Finding 537379 (2024-019)

Significant Deficiency 2024

State of Vermont

VT

Matching / Level of Effort / Earmarking Questioned Costs Special Tests & Provisions § 200.303

Reference Number: 2024-019 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: Temporary Assistance for Needy Families Assistance Listing Number: 93.558 Award Number and Year: 2301VTTANF (10/1/2022 – 9/30/2023) 2...

Reference Number: 2024-019 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: Temporary Assistance for Needy Families Assistance Listing Number: 93.558 Award Number and Year: 2301VTTANF (10/1/2022 – 9/30/2023) 2401VTTANF (10/1/2023 – 9/30/2024) Compliance Requirement: Reporting – ACF-199 Special Tests and Provisions – Penalty for Failure to Comply with Work Verification Plan Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend that the Agency review and enhance procedures and controls to ensure that it maintains adequate documentation, verification, and internal control procedures to ensure the accuracy of work participation rates reported in the ACF-199 reports. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: For the data system programming error finding, the Department removed the hard coding in the programming that limited participant hours to 40. This was completed as soon as the error was identified and our regional team approved the proposed corrective action. For the individual instances where the reported work participation rates reported on the ACF-199 report did not agree with supporting documentation and that supporting documentation contained errors or was incomplete, the Department will do the following: • Highlight each of the individual types of errors in our weekly newsletter that goes out to all staff and describe the correct action that should have been taken in documentation. • Have members of Reach Up Central Office (RUCO) team attend the Senior Benefits Program Specialist Sr. BPS) meeting to review the individual types of errors and describe the correct action that should have been taken. Sr. BPS are responsible for the direct training of district Benefits Program Specialists (BPS) that process eligibility. Following their meeting they will return to their district offices and provide an overview to the district eligibility staff. • RUCO will hold a virtual office hours session for eligibility staff to attend focused on the individual types of errors and the correct action that should have been taken. Scheduled Completion Date of Corrective Action Plan: • Data system programming error was corrected in October 2024. • Newsletter highlights will be shared with staff by January 31, 2025. • Sr BPS meeting will be attended by February 28, 2025. • Virtual office hours will be held by March 31, 2025. Contacts for Corrective Action Plan: Chris Dorer, Reach Up Assistant Administrator christine.dorer@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

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