Corrective Action Plans

Finding 390901 (2023-004)

None 2023

LA

Allowable Costs / Cost Principles Questioned Costs HUD Housing Programs

Dear Mr. Waguespack: The Department of Children and Family Services (DCFS) has reviewed the finding “Improper Employee Activity in Federal Program”. The Department concurs with the finding and continues to prioritize prevention and detection of improper activity associated with programs it administ...

Dear Mr. Waguespack: The Department of Children and Family Services (DCFS) has reviewed the finding “Improper Employee Activity in Federal Program”. The Department concurs with the finding and continues to prioritize prevention and detection of improper activity associated with programs it administers. The Fraud and Recovery Unit (FRU) investigated two employees for suspected payroll fraud. The FRU determined that one employee received wages from DCFS and a secondary employer for the same hours worked. DCFS is pursuing recoupment of wages paid for the duplicative hours and will seek recoupment of funds in the amount $875.00 from this employee. DCFS is conducting additional inquiries related to the other employee’s suspected activities to determine the actual loss to the agency and will proceed accordingly. Both employees are no longer employed with the Department. DCFS will continue to investigate improper employee activities and emphasize the consequences of illegal acts. If you have any questions, please contact Rhonda Brown, Fraud and Recovery Unit Director, at Rhonda.Brown.DCFS@LA.GOV.

View Audit 301612 Questioned Costs: $1

Finding 390844 (2023-003)

None 2023

Rockton School District No. 140

IL

Questioned Costs

The District will review all grant documentation prior to allocating expenses to grants.

View Audit 301558 Questioned Costs: $1

Finding 390832 (2023-005)

Material Weakness 2023

County of Solano

CA

Internal Control / Segregation of Duties Questioned Costs Material Weakness § 200.303

Federal Agency: U.S. Department of Health and Human Services Program/Cluster: Epidemiology and Laboratory Capacity for Infectious Diseases Federal Assistance Listing Number: 93.323 Pass‐through: California Department of Public Health Award No. and Year: COVID-19ELC48, COVID-19ELC106, 2021/2022 Compl...

Federal Agency: U.S. Department of Health and Human Services Program/Cluster: Epidemiology and Laboratory Capacity for Infectious Diseases Federal Assistance Listing Number: 93.323 Pass‐through: California Department of Public Health Award No. and Year: COVID-19ELC48, COVID-19ELC106, 2021/2022 Compliance Requirement: Reporting Type of Finding: Material Weakness in Internal Control over Compliance Views of Responsible Officials and Corrective Action Plan: Management agrees with the finding. Corrective action was implemented in April 2023. Responsible Individual(s): Nina Delmendo, Director of Administrative Services Anticipated Completion Date: April 2023

View Audit 301557

Finding 390824 (2023-001)

Material Weakness 2023

Beaver County Career & Technology Center

PA

Questioned Costs Procurement, Suspension & Debarment § 200.318 § 200.320

MANAGEMENT’S CORRECTIVE ACTION PLAN: Management will review and update as necessary, it’s current procurement policies and procedures to ensure compliance with all applicable sections of the Uniform Guidance, in specific, Sections 2 CFR 200.318(i) and 200.320(a)(2)(i) of the Uniform Guidance, as we...

MANAGEMENT’S CORRECTIVE ACTION PLAN: Management will review and update as necessary, it’s current procurement policies and procedures to ensure compliance with all applicable sections of the Uniform Guidance, in specific, Sections 2 CFR 200.318(i) and 200.320(a)(2)(i) of the Uniform Guidance, as well as 24 PS 8.807.1. In specific, these procedures will include 1) obtaining all relevant information pertaining to procurements involving federal assistance from any cooperative purchasing group and 2) obtaining quotations from three qualified providers where applicable and documenting those results. These two (2) updated procedures will be implemented during the remaining months of the 2023-2024 fiscal year, and all subsequent years, for future purchases where applicable.

View Audit 301555 Questioned Costs: $1

Finding 390816 (2023-001)

Material Weakness 2023

Western Beaver County School District

PA

Questioned Costs Procurement, Suspension & Debarment § 200.318 § 200.320

MANAGEMENT’S CORRECTIVE ACTION PLAN: Management will review and update as necessary, it’s current procurement policies and procedures to ensure compliance with all applicable sections of the Uniform Guidance, in specific, Sections 2 CFR 200.318(i) and 200.320(a)(2)(i) of the Uniform Guidance, as we...

MANAGEMENT’S CORRECTIVE ACTION PLAN: Management will review and update as necessary, it’s current procurement policies and procedures to ensure compliance with all applicable sections of the Uniform Guidance, in specific, Sections 2 CFR 200.318(i) and 200.320(a)(2)(i) of the Uniform Guidance, as well as 24 PS 8.807.1. In specific, these procedures will include 1) obtaining all relevant information pertaining to procurements involving federal assistance from any cooperative purchasing group and 2) obtaining quotations from three qualified providers where applicable and documenting those results. These two (2) updated procedures will be implemented during the remaining months of the 2023-2024 fiscal year, and all subsequent years, for future purchases where applicable.

View Audit 301534 Questioned Costs: $1

Finding 390812 (2023-001)

Material Weakness 2023

City of Fitchburg, Massachusetts

MA

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

Planned Correction Action: Moving forward grants will not be set up with account #s for use until the funds are received and award letter is issued with actual start date. This will stop any expenses being posted prior to the start date. Name of Contact Person and Completion Date: Jeremy Roche, As...

Planned Correction Action: Moving forward grants will not be set up with account #s for use until the funds are received and award letter is issued with actual start date. This will stop any expenses being posted prior to the start date. Name of Contact Person and Completion Date: Jeremy Roche, Assistant Superintendent of Finance and Operations. This plan will go into effect immediately.

View Audit 301533 Questioned Costs: $1

Finding 390809 (2023-005)

Significant Deficiency 2023

City of Portland Maine

ME

Reporting Significant Deficiency Internal Control / Segregation of Duties

Corrective Action Plan Finding 2023-005 Improve Compliance with American Rescue Plan Reporting Planned Corrective Action: In future reporting periods the City will ensure all activity is included within our U.S. Treasury Reporting Portal quarterly submissions, including activity from the formula app...

Corrective Action Plan Finding 2023-005 Improve Compliance with American Rescue Plan Reporting Planned Corrective Action: In future reporting periods the City will ensure all activity is included within our U.S. Treasury Reporting Portal quarterly submissions, including activity from the formula approach to our revenue replacement category. Anticipated Completion Date: June 30, 2024 Contact Person: Brendan O’Connell, Director of Finance

View Audit 301530

Finding 390807 (2023-003)

Material Weakness 2023

City of Portland Maine

ME

Allowable Costs / Cost Principles Questioned Costs Material Weakness

Audit Finding Reference: 2023-003 Improve Controls and Documentation over Payroll Process Planned Corrective Action: Beginning with the first payroll of the calendar year 2024, the Portland Public School District went to the ADP payroll system. This change in payroll ERP system allowed for the overh...

Audit Finding Reference: 2023-003 Improve Controls and Documentation over Payroll Process Planned Corrective Action: Beginning with the first payroll of the calendar year 2024, the Portland Public School District went to the ADP payroll system. This change in payroll ERP system allowed for the overhaul of the payroll process that was currently in place. The Executive Director of Finance worked with ADP to ensure that permissions for both the Human Resources and the Payroll teams were specifically set up so that they did not have access to each other’s processes. The HR generalists have been trained to process the information that once was processed by payroll personnel. Furthermore, access is not managed by staff but by a department head to ensure that proper access for individuals is maintained. Proper documentation of time and attendance is maintained in payroll and electronically filed with each payroll period in an organized manner. The Executive Director of Finance is always looking for continuous improvements for proper documentation in payroll. Name of Contact Person: Helene DiBartolomeo, CPA Executive Director of Finance Anticipated Completion Date: Internal controls - 1/1/2024 Documentation - 2/23/24 353

View Audit 301530 Questioned Costs: $1

Finding 390786 (2023-004)

Significant Deficiency 2023

Allenstown School District

NH

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303 § 200.430

Audit Finding Reference: 2023-004 Lack of Documentation to Support Distribution of Wages Management’s View and Planned Corrective Action: After review we have also determined that this documentation was lacking due to the employee longer working in the district. The grant manager did verify that the...

Audit Finding Reference: 2023-004 Lack of Documentation to Support Distribution of Wages Management’s View and Planned Corrective Action: After review we have also determined that this documentation was lacking due to the employee longer working in the district. The grant manager did verify that the employee worked the hours noted, but lacks the employees’ signature. This is not a typical occurrence Time and Effort is used and submitted. A Time and Effort policy and procedure has been established, documented and implemented. Federally funded stipends are no longer processed until the Time and Effort Log of hours have been received. Once we have received the form(s), which we now attach to the position in our accounting system we then process in payroll. This procedure is also located in our Federal Funds Handbook. A communication will be sent to Grant Manager’s reminding them of the Time & Effort policy and procedures. Name of Contact Person and Completion Date: Name 1 Amber Wheeler Name 2 Danielle Rossetti Anticipated Completion Date – Procedure has changed a reminder will be communicated by March 30th.

View Audit 301524 Questioned Costs: $1

Finding 390781 (2023-001)

Significant Deficiency 2023

Au Health System, Inc.

GA

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.430

Item 2023‐001 – Allowable Costs/Activities Contact person: Wendy Stephens, Senior Accounting Manager Management’s Response – Management’s controls over approval of time sheets operated effectively 97.5% of the time prior to processing of payroll. The payroll expenditures allocated to the COVID-19...

Item 2023‐001 – Allowable Costs/Activities Contact person: Wendy Stephens, Senior Accounting Manager Management’s Response – Management’s controls over approval of time sheets operated effectively 97.5% of the time prior to processing of payroll. The payroll expenditures allocated to the COVID-19 Provider Relief Fund – Assistance Listing 93.498 were allocated to the Provider Relief Funding and including in reporting of expenditures based on management review of guidance provided by HRSA in determination of the portion of the payroll costs allocated as qualifying and allowable expenditures under the program. The guidance on allowable costs was determined by HRSA subsequent to disbursement of the funds by HRSA and after incurrence of the expenditures given the immediacy of the COVID-19 pandemic providing of funds and incurrence of costs. Management will perform an annual review of expenditures allocated to a grant to confirm the allowability of the costs under the respective program. Management’s controls over approval of time sheets operated effectively 97% of the time prior to processing payroll. The payroll expenditures related to the 1 time sheet not approved prior to payment of payroll are for an employee assigned to work specifically on the program funded by Assistance Listing #93.778. Management will perform an annual review of expenditures allocated to a grant to confirm the allowability of the costs under the respective program. Management expects the corrective actions described above to be complete no later than June 30, 2024.

View Audit 301517

Finding 390780 (2023-001)

Material Weakness 2023

Merritt Independent School District #2

OK

Questioned Costs Subrecipient Monitoring Material Weakness

The district has developed and implemented internal controls to ensure that if federal awards are expended on construction all requirements of the Davis-Bacon Act will be met.

View Audit 301513

Finding 390775 (2023-001)

Significant Deficiency 2023

Town of York

ME

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring

Management’s response/corrective action plan: Procedures have been recirculated to all responsible for purchases and bids that involve federal funds and acknowledgement of the oversight has been addressed with those responsible for checking SAM.gov for suspended and debarred vendors. An after the f...

Management’s response/corrective action plan: Procedures have been recirculated to all responsible for purchases and bids that involve federal funds and acknowledgement of the oversight has been addressed with those responsible for checking SAM.gov for suspended and debarred vendors. An after the fact check was done and determined the vendor used was neither suspended nor debarred. Procedures and policies will be reviewed with heads of departments on a quarterly basis and whenever federal funds are applied for.

View Audit 301499

Finding 390773 (2023-001)

Significant Deficiency 2023

Lima Urban Minority Alcoholism & Drug Outreach Program, Inc.

OH

Questioned Costs Allowable Costs / Cost Principles Reporting § 200.1 § 200.303

Audit Period: Fiscal Year July 1, 2022 - June 30,2023 Re: Lima UMADAOP respectively submits the following corrective action plan for the year ended June 30, 2023. 2023-001 Reporting (Significant Deficiency) Recommendation: We suggest that Management engage in quarterly monitoring of their feder...

Audit Period: Fiscal Year July 1, 2022 - June 30,2023 Re: Lima UMADAOP respectively submits the following corrective action plan for the year ended June 30, 2023. 2023-001 Reporting (Significant Deficiency) Recommendation: We suggest that Management engage in quarterly monitoring of their federal expenditures. This proactive strategy will aid management in preparing the Schedule of Expenditures of Federal Awards (SEFA) at year-end, as the amounts will have undergone partial scrutiny for completeness and accuracy throughout the year. Corrective Action Plan: The Agency will review and strengthen all controls and make any necessary changes moving forward. The Accountant will provide any necessary training to the Bookkeeper as well as monitor and review all expenditures on monthly basis. The Accountant and the CEO will review the Schedule of Expenditures of Federal Awards (SEFA) on a quarterly basis to confirm the completeness and accuracy for all future audits. Responsible Party: CEO, Accountant, Bookkeeper Date Expected to be Corrected: Immediately

View Audit 301491 Questioned Costs: $1

Finding 390741 (2023-001)

None 2023

Board of Education of Somerset County

MD

Questioned Costs Procurement, Suspension & Debarment § 200.318 § 200.326

Somerset County Public Schools respectfully submits the following Corrective Action Plan for the year ended June 30, 2023. Audit Period: July 1, 2022 through June 30, 2023 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the...

Somerset County Public Schools respectfully submits the following Corrective Action Plan for the year ended June 30, 2023. Audit Period: July 1, 2022 through June 30, 2023 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDING- MAJOR FEDERAL AWARD PROGRAM AUDIT U.S Department of Agriculture 2023-001 Paper/Chemical Product Contract Recommendation: The Board should follow its established procedure and policy providing for competitive bids. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Board has entered into a competitively sourced contract with FPC Holding, Inc. as of December 2023 for the purchase of these products. Name of contact person responsible for corrective action: Linda R. Johnson, Director of Finance Planned completion date for corrective action plan: December 1, 2023

View Audit 301442 Questioned Costs: $1

Finding 390729 (2023-003)

None 2023

Clay County Board of Education

WV

Allowable Costs / Cost Principles Questioned Costs HUD Housing Programs

#2303-003 Reporting of Time and Effort US Department of Education Title I Grants to Local Educational Agencies AL#84.010 ...

#2303-003 Reporting of Time and Effort US Department of Education Title I Grants to Local Educational Agencies AL#84.010 Recommendation: We recommend that the Clay County Board of Education's Title I Department implement procedures to accurately document and maintain the "Time and Effort" Documentation of all employees funded with federal funding, as required. Action Taken: The Title I Department of the Clay County Board of Education will implement procedures to ensure that "Time and Effort" Documentation and records are adequately maintained, as required for all applicable employees. Jennifer R. Paxton, CPA/Treasurer, and the Title I Director are responsible for implementing these procedures immediately.

View Audit 301414

Finding 390724 (2023-001)

Significant Deficiency 2023

Tuba City Unified School District No.15

AZ

Procurement, Suspension & Debarment Questioned Costs Special Tests & Provisions

2023-001 Davis-Bacon Act Compliance CFDA Number 84.041 Program Title Impact Aid Federal Agency U.S. Department of Education Compliance Requirement N. Special Tests and Provisions Finding Type Noncompliance, Significant Deficiency Questioned Costs N/A Repeat Finding: Yes, Similar to 2022-001. Conditi...

2023-001 Davis-Bacon Act Compliance CFDA Number 84.041 Program Title Impact Aid Federal Agency U.S. Department of Education Compliance Requirement N. Special Tests and Provisions Finding Type Noncompliance, Significant Deficiency Questioned Costs N/A Repeat Finding: Yes, Similar to 2022-001. Condition/Context: The District did not retain documentation sufficient to determine the Davis-Bacon compliance clause was included in advertised specifications for one construction project paid with federal Impact Aid funds. Criteria: Department of Labor (DOL) 29 CFR part 5, Labor Standards Provisions Applicable to Contracts Governing Federally Financed and Assisted Construction. Non-federal entities shall include in their federally funded construction contracts in excess of $2,000, that are subject to the Wage Rate Requirements of the Davis-Bacon Act, a provision that the contractor or subcontractor comply with those requirements and the DOL regulations. This includes a requirement for the contractor or subcontractor to submit to the U.S. Department of Labor weekly, for each week in which any contract work is performed, a copy of the payroll and a statement of compliance (certified payrolls). This reporting is often done using Optional Form WH-347, which includes the required statement of compliance. Action planned in response to finding: The District will evaluate its procedures over procuring construction services to ensure all vendors know when the projects will be utilizing federal funds through the purchase order process or other means. The District will also ensure procurement documentation is utilized to properly disclose the adherence to the Davis Bacon Act.

View Audit 301409

Finding 390714 (2023-004)

Material Weakness 2023

Housing Authority of the City of Hope

AR

Questioned Costs Procurement, Suspension & Debarment HUD Housing Programs

Condition and Criteria: PHA and HUD procurement policies require the documentation of the bid process in varying degrees based on the size of the contract or purchase. The PHA is also required to include Davis Bacon requirements in the contracts and monitor its compliance by the contractors. The C...

Condition and Criteria: PHA and HUD procurement policies require the documentation of the bid process in varying degrees based on the size of the contract or purchase. The PHA is also required to include Davis Bacon requirements in the contracts and monitor its compliance by the contractors. The CMR cited disbursements without procurement files totaling $226,057.43. During the audit, we were not provided with copies of the procurement records for these contracts. It also appears that the Davis Bacon standards were not included in the contracts and, as a result, those standards were not monitored.Auditor’s Recommendation: Documentation of expenses and the related procurement should be maintained and accessible for review. In addition, contracts should include Davis Bacon requirements and those requirements should be monitored by the Authority. Grantee Response: We are scheduling training for our staff related to the procurement and contract requirements and will begin better documenting both the procurement and the monitoring. Anticipated Completion Date: June 30, 2024

View Audit 301395 Questioned Costs: $1

Finding 390664 (2023-003)

Material Weakness 2023

Wabash City Schools

IN

Questioned Costs Allowable Costs / Cost Principles School Nutrition Programs § 200.302 § 200.303 § 200.439

FINDING 2023-003 Finding Subject: Child Nutrition Cluster - Allowable Activities and Allowable Costs Summary of Finding: The School Corporation had not properly designed or implemented a system of internal control, which would include appropriate segregation of duties, that would likely be effective...

FINDING 2023-003 Finding Subject: Child Nutrition Cluster - Allowable Activities and Allowable Costs Summary of Finding: The School Corporation had not properly designed or implemented a system of internal control, which would include appropriate segregation of duties, that would likely be effective in preventing, or detecting and correcting noncompliance related to allowable activities and allowable costs. The School Corporation purchased two pieces of equipment that were over $5,000 each in Fiscal Year 2023 without approval from the Federal awarding agency or pass-through entity. The first piece of equipment was a liftgate in the amount of $6,906, and the second piece of equipment was a vehicle in the amount of $7,500 for a combined total of $14,406. The financial management system of each non-federal entity must provide written procedures for determining allowability of costs in accordance with the federal regulations and the terms and conditions of the Federal Award. The policy should provide clear guidance as to what costs constitute appropriate direct and indirect charges to federal awards as well as provide for consistency in charging practices across the School Corporation. The School Corporation did not have an allowable costs policy outlining the School Corporation's processes and policies with regards to costs charged to federal grants. Contact Person Responsible for Corrective Action: Amy K. Sivley Contact Phone Number and Email Address: 260-563-2151; sivleya@apaches.k12.in.us Views of Responsible Officials: We concur with the finding. Explanation and Reasons for Disagreement: n/a Description of Corrective Action Plan: Retrain Food Service Director and Assistant Food Service Director on the process for purchasing equipment. The district will also develop and pass an Allowable Costs Policy. Anticipated Completion Date: To be completed by July 1, 2024

View Audit 301362 Questioned Costs: $1

Finding 390659 (2023-001)

Material Weakness 2023

Regional School Unit No. 52 D/b/a M.s.a.d No. 52

ME

Special Tests & Provisions Questioned Costs Internal Control / Segregation of Duties

CONTACT PERSON RESPONSIBLE FOR CORRECTIVE ACTION: Gabrielle Krol, Business Manager CORRECTIVE ACTION PLAN (concerning finding 2023-001: Special Tests and Provisions-Wage Rate Requirements) CORRECTIVE ACTION: Maine School Administrative District 52 has already begun implementing the corrective ac...

CONTACT PERSON RESPONSIBLE FOR CORRECTIVE ACTION: Gabrielle Krol, Business Manager CORRECTIVE ACTION PLAN (concerning finding 2023-001: Special Tests and Provisions-Wage Rate Requirements) CORRECTIVE ACTION: Maine School Administrative District 52 has already begun implementing the corrective action plan for the finding related to the Education Stabilization Fund. Our FY 2022 Audit was not completed until April 2023, which was after this current finding had already taken place. During the FY 2022 Audit process, it was brought to our attention that MSAD 52 was in need of ensuring compliance with the prevailing wage requirements when Federal Funds were being used, also known as the Davis Bacon Act. When this was brought to our attention, we began providing all contractors who were bidding on work at the district with the current prevailing wage information for Androscoggin County. In addition, we had each contractor sign the certification that they would pay all employees working on any project at MSAD 52 the prevailing wage. In addition, we are now requiring all contractors provide certified timesheets prior to releasing payment for the work. ANTICIPATED COMPLETION DATE: This has begun effective March 2024.

View Audit 301360

Finding 390653 (2023-226)

Material Weakness 2023

State of Idaho

ID

Special Tests & Provisions Questioned Costs Subrecipient Monitoring § 200.303

Finding Number 2023-226: The Department did not develop and execute a Value Engineering work plan in compliance with the regulations for the federal Highway Planning and Construction grant. Federal Programs: 20.205 – Highway Planning and Construction Grant Related to Prior Finding: N/A Agency’s ...

Finding Number 2023-226: The Department did not develop and execute a Value Engineering work plan in compliance with the regulations for the federal Highway Planning and Construction grant. Federal Programs: 20.205 – Highway Planning and Construction Grant Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: ITD will develop a new standard operating procedure (SOP) to follow to ensure that the Districts develop an Annual Value Engineering Work Plan and that the Statewide Work Plan is compiled annually by the Headquarters Value Engineering Coordinator. This SOP will be developed in collaboration with FHWA staff to ensure 2 CFR 200.303 and 23 CFR Part 627 compliance. The SOP will include details as to who, what, where and when the specific tasks will occur so to provide clarity and control with regard to developing the work plan as well as monitoring, assessing and reporting on the Departments Value Engineering Program. Anticipated Corrective Action Date: The new SOP will be developed prior to FFY 2025, and statewide outreach and education will follow shortly thereafter. Responsible for Corrective Action: Monica Crider, PE, State Design Engineer Monica.Crider@itd.idaho.gov 208-334-8502

View Audit 301345

Finding 390644 (2023-223)

Significant Deficiency 2023

State of Idaho

ID

Internal Control / Segregation of Duties Special Tests & Provisions Questioned Costs § 200.303

Finding Number 2023-223: Managed Care providers lacked documentation to support continued eligibility within the Medicaid Program. Federal Programs: 93.777 - State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare; 93.778 Medical Assistance Program Related to P...

Finding Number 2023-223: Managed Care providers lacked documentation to support continued eligibility within the Medicaid Program. Federal Programs: 93.777 - State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare; 93.778 Medical Assistance Program Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: The 21st Century Cures Act requires all states to enroll both fee-for-service and managed care providers. Idaho Medicaid is currently out of compliance with this requirement for most of the providers within managed care contractor networks. The state is also working to come into compliance with a requirement in the Affordable Care Act to revalidate all enrolled providers at least every 5 years. The Division has begun the systems work necessary to come into compliance with both of these requirements and anticipates working through enrollment and revalidation activities into CY2025. Once completed, the Division will have an accurate and complete provider file that will be shared with contracted managed care plans to support their contracting efforts. Any providers who contract with the managed care plans will be required to be fully enrolled and credentialed with Idaho Medicaid before rendering services and billing. Pursuant to the Consolidated Appropriations Act of 2023, states are required by July 2025 to have a searchable and regularly updated provider directory for both managed care plans and fee-for-service programs. Idaho Medicaid is working to develop processes to validate directories and ensure that providers are providing updates to their information as necessary. Through this effort, Idaho Medicaid will further bolster internal processes and controls to ensure accurate provider network information is shared with Medicaid participants and maintained within our systems. Anticipated Corrective Action Date: July 2025 Responsible for Corrective Action: Juliet Charron, Division Administrator Juliet.Charron@dhw.idaho.gov 208-364-1831 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

View Audit 301345

Finding 390641 (2023-220)

None 2023

State of Idaho

ID

Questioned Costs Student Financial Aid Eligibility

Finding Number 2023-220: The Department failed to provide necessary supporting documentation for five Adoption Assistance Title IV-E eligibility determinations. Federal Programs: 93.659 – Adoption Assistance Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. ...

Finding Number 2023-220: The Department failed to provide necessary supporting documentation for five Adoption Assistance Title IV-E eligibility determinations. Federal Programs: 93.659 – Adoption Assistance Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: The department agrees with the finding related to the critical importance of obtaining and maintaining documentation for all necessary background checks. Although the department was ultimately able to verify background checks were completed, we agree that we were unable to readily pull the needed documentation on these in a timely manner. The department will assure supporting documentation for Adoption Assistance Title IV-E eligibility determinations are maintained within the electronic filing system by adding an additional verification to the current process. When a supervisor reviews a departmental adoption for finalization, they will verify that a copy of the Enhanced Criminal History Background clearance letter for all adults residing in the home is uploaded to the prospective adoptive parents’ profile in eCabinet (the electronic case management system), and the signed copy of the adoption assistance agreement is uploaded to the child’s profile. The application process for Adoption Assistance Title IV-E eligibility for private adoptions will be updated to include the addition of the Enhanced Criminal History Background clearance letters for all adults residing in the home to the child’s eCabinet file. When a supervisor approves an adoption assistance agreement for a private adoption, they will verify a copy of the signed adoption assistance agreement is uploaded to the adoptive child’s profile. This will be completed by August 2024. Anticipated Corrective Action Date: August 2024 Responsible for Corrective Action: Cameron Gilliland, Division Administrator Cameron.Gilliland@dhw.idaho.gov 208-334-0641 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

View Audit 301345 Questioned Costs: $1

Finding 390639 (2023-218)

None 2023

State of Idaho

ID

Questioned Costs Student Financial Aid Eligibility

Finding Number 2023-218: The Department failed to provide necessary documentation to support the eligibility determination for two foster care providers within the Foster Care -Title IV—E program. Federal Programs: 93.658 – Foster Care Title IV-E Related to Prior Finding: N/A Agency’s view: The D...

Finding Number 2023-218: The Department failed to provide necessary documentation to support the eligibility determination for two foster care providers within the Foster Care -Title IV—E program. Federal Programs: 93.658 – Foster Care Title IV-E Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: The department agrees with the finding related to the critical importance of obtaining and maintaining documentation for all necessary background checks. Although the department was ultimately able to verify background checks were completed, we agree that we were unable to readily pull the needed documentation on these in a timely manner. To correct the issue, the department will add an additional point of verification that the Enhanced Criminal History Background Check clearance letter from the Background Check Unit’s system is uploaded to eCabinet, by having supervisors view the document within eCabinet prior to approving the initial foster care license. Supervisors will also confirm that all ICPC home studies address results of background checks for all adults in the home and any additional potential caregivers. This will be completed April 2024. Anticipated Corrective Action Date: April 2024 Responsible for Corrective Action: Cameron Gilliland, Division Administrator Cameron.Gilliland@dhw.idaho.gov 208-334-0641 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

View Audit 301345 Questioned Costs: $1

Finding 390637 (2023-216)

Material Weakness 2023

State of Idaho

ID

Allowable Costs / Cost Principles Questioned Costs Internal Control / Segregation of Duties § 200.303

Finding Number 2023-216: The Department did not have appropriate documentation to support allowability of transactions for the Foster Care Title IV-E program. Federal Programs: 93.658 – Foster Care Title IV-E Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. ...

Finding Number 2023-216: The Department did not have appropriate documentation to support allowability of transactions for the Foster Care Title IV-E program. Federal Programs: 93.658 – Foster Care Title IV-E Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: A new feature was added to ESPI on 1/9/24 to record the reason (purpose) for certain service types, including transportation. The system is programmed to disallow Title IV-E if the reason listed does not meet IV-E eligibility criteria (see image below). An additional control will be added to the system to have the same control procedure used for a medical service type and education service type. Further development is underway for additional control procedures and should be completed by April of 2025. P-card transactions do not process through ESPI. Quarterly reports will be obtained to review any P-card transactions that utilized Title IV-E to confirm appropriate documentation is on record. This will be completed by April 30, 2024. Anticipated Corrective Action Date: April 30, 2024 Responsible for Corrective Action: Cameron Gilliland, Division Administrator Cameron.Gilliland@dhw.idaho.gov 208-334-0641 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

View Audit 301345 Questioned Costs: $1

Finding 390628 (2023-211)

Significant Deficiency 2023

State of Idaho

ID

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Questioned Costs § 200.303

Finding Number 2023-211: The review and approval of the annual updates to the Low-Income Home Energy Assistance Program (LIHEAP) benefits matrix were not documented. Federal Programs: 93.568 – Low-Income Home Energy Assistance Related to Prior Finding: N/A Agency’s view: The Department agrees wit...

Finding Number 2023-211: The review and approval of the annual updates to the Low-Income Home Energy Assistance Program (LIHEAP) benefits matrix were not documented. Federal Programs: 93.568 – Low-Income Home Energy Assistance Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: Testing of the updated benefits matrix will be completed by the Program annually, and the results will be documented using an established scenario testing script. Results of the testing will be documented and submitted to the Bureau Chief, as a second review of accuracy and compliance, prior to moving the updated matrix into the production environment. Documentation will be maintained to support the review and approval. Anticipated Corrective Action Date: The Program will write a process document to support this corrective action and will implement this process prior to the start of the new LIHEAP season beginning 10/1/2024. Program will have a process document in place by 9/30/24. Responsible for Corrective Action: Shane Leach, Division Administrator Shane.Leach@dhw.idaho.gov 208-859-1033 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

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