Corrective Action Plans

Finding 384906 (2023-029)

Material Weakness 2023

State of Vermont

VT

Questioned Costs Special Tests & Provisions Material Weakness § 200.303

Vermont Agency of Digital Services (ADS) meets the biennial ADP system security review requirement on behalf of Vermont Agency of Human Services (AHS) via an IRS Security Audit (cadency of every three years) and by contracting with 3rd party security risk assessment firms like JANUS Associates. Bot...

Vermont Agency of Digital Services (ADS) meets the biennial ADP system security review requirement on behalf of Vermont Agency of Human Services (AHS) via an IRS Security Audit (cadency of every three years) and by contracting with 3rd party security risk assessment firms like JANUS Associates. Both audits use the same standard IRS Publication 1075 which is built on the NIST standard 800-53 revision 5. Over the last year the DCF IT Maintenance & Operations (M&O) Team has provided the IRS two CAP updates for the finding related to the last IRS audit. There is expected to be an overlap between the findings of the last IRS Audit and those identified by JANUS and ADS will complete a cross reference analysis between these two audits by the end of this calendar year. If there are any findings that are unique to JANUS (i.e., not identified in the IRS audit), a CAP will be documented for the finding by the end of this calendar year. An experienced IT Specialist on the DCF IT M&O Team has been assigned to lead this compliance project. Scheduled Completion Date of Corrective Action Plan: December 31, 2023: CAP to be documented. TBD: Documented CAP to be completed. Contacts for Corrective Action Plan: Michael Blanchard, ADS IT Manager michael.blanchard@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 297960

Finding 384905 (2023-028)

Significant Deficiency 2023

State of Vermont

VT

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

With the 2022-36 Corrective Action Plan, Letters of Good Tax Standing have been obtained. A standard operating practice is in place documenting the process. The process of validating tax standing in writing from the Tax Department has been in effect since April 2022. Providers who had their tax stan...

With the 2022-36 Corrective Action Plan, Letters of Good Tax Standing have been obtained. A standard operating practice is in place documenting the process. The process of validating tax standing in writing from the Tax Department has been in effect since April 2022. Providers who had their tax standing validated prior to April 2022 via phone or email were not solicited to obtain a written notification from the Tax Commissioner. The State has determined that it is not necessary to obtain a retroactive written notification from the Tax Commissioner for tax standing prior to April 2022. As of April 2022, all tax standing reviews are validated with a letter from the Tax Department and documented in the PMM. Scheduled Completion Date of Corrective Action Plan: Completed Contacts for Corrective Action Plan: Deidra Jarvis, DVHA Supervisor of Member and Provider Services deidra.jarvis@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 297960

Finding 384904 (2023-027)

Significant Deficiency 2023

State of Vermont

VT

Questioned Costs Procurement, Suspension & Debarment Eligibility § 200.303

The case was mistakenly closed on 6/30/23 based on non-response to an income verification request. A verification notice was sent 6/12/2023. The member did not respond to this notice. The member should then have received notice of termination effective 7/31/2023. The case was not processed for clos...

The case was mistakenly closed on 6/30/23 based on non-response to an income verification request. A verification notice was sent 6/12/2023. The member did not respond to this notice. The member should then have received notice of termination effective 7/31/2023. The case was not processed for closure and appropriate notice was not sent because a system error caused this member to be classified as a new applicant instead of enrollee. This was likely due to case-specific circumstances of timing and household eligibility (other members were no longer eligible for Medicaid). Further, because they were classified as a new applicant, they received an additional verification notice (even though coverage was already terminated) and were ultimately “denied” for non-response in late July. As corrective action, we reinstated CHIP back to 7/1/2023 through 10/31/2023 after sending proper closure notice for failure to respond. Based on our internal QA process, Medicaid Recon and HCQC unit’s internal case reviews, no other incidents of this condition were found as of 10/2/2023. Scheduled Completion Date of Corrective Action Plan: Completed Contacts for Corrective Action Plan: Nicole McAllister, DVHA-HAEEU HCAA II nicole.mcallister@vermont.gov Sarah York, DVHA-HAEEU HCAA I sarah.york@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 297960

Finding 384903 (2023-026)

Significant Deficiency 2023

State of Vermont

VT

Eligibility Questioned Costs Student Financial Aid § 200.303

DCF has updated the eligibility determination procedure document and referenced checklists to ensure that there are additional reviews of the manual data entry and its processing in the data system (SSMIS). There is a process in place by which any cases where manual data entry causes erroneous IV-E ...

DCF has updated the eligibility determination procedure document and referenced checklists to ensure that there are additional reviews of the manual data entry and its processing in the data system (SSMIS). There is a process in place by which any cases where manual data entry causes erroneous IV-E draws, the Department will make changes in the data system and return IV-E funds erroneously claimed within one quarter of the mistake being identified. Scheduled Completion Date of Corrective Action Plan: January 1, 2024 Contact for Corrective Action Plan: Gillie Hopkins, DCF-FSD Permanency Planning Program Manager gillie.hopkins@vermont.gov Barbara Joyal, DCF-FSD System of Care Unit Director barbara.joyal@vermont.gov Beth Sausville, DCF-FSD System of Care Unit Director beth.sausville@vermont.gov Ed Dwinell, DCF Business Office, Financial Director ed.dwinell@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 297960 Questioned Costs: $1

Finding 384901 (2023-024)

Material Weakness 2023

State of Vermont

VT

Questioned Costs Subrecipient Monitoring Material Weakness § 200.303

The Financial Administrator will ensure that subrecipient grants containing federal funding that meet the FFATA reporting threshold are marked as “required for entry into the FSRS system” upon grant execution. The Financial Administrator and Manager will then confirm that all executed agreements tha...

The Financial Administrator will ensure that subrecipient grants containing federal funding that meet the FFATA reporting threshold are marked as “required for entry into the FSRS system” upon grant execution. The Financial Administrator and Manager will then confirm that all executed agreements that meet the FFATA reporting requirement have been entered and submitted into the FSRS system by the last business day of each month. Please note that the scheduled completion date is 2/1/23 as the same FFATA reporting finding was identified for a different program during the SFY22 Single Audit, and the corrective action plan was applied across the Department as a whole. The FFATA issues identified in the SFY23 Single Audit pre-dated the implementation of our corrective action plan. Scheduled Completion Date of Corrective Action Plan: 2/1/2023 Contacts for Corrective Action Plan: Lillian Smith, VDH Financial Administrator lillian.smith@vermont.gov Jessica Brown, VDH Financial Manager jessica.p.brown@vermont.gov Megan Hoke, VDH Financial Director megan.hoke@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 297960

Finding 384895 (2023-021)

Significant Deficiency 2023

State of Vermont

VT

Questioned Costs Subrecipient Monitoring Reporting § 200.303

Due to staff vacancies and turnover that arose in the DCF Quality Assurance & Reporting (QA&R) team during the summer of 2022, there was insufficient intra-team communication and training regarding FFATA reporting requirements. As of January 1, 2024, then, formal procedures and training will be put...

Due to staff vacancies and turnover that arose in the DCF Quality Assurance & Reporting (QA&R) team during the summer of 2022, there was insufficient intra-team communication and training regarding FFATA reporting requirements. As of January 1, 2024, then, formal procedures and training will be put in place to ensure all QA&R staff are prepared to execute their responsibilities pertaining to FFATA reporting requirements. Further, in order to monitor FFATA reporting compliance going forward, AHS Internal Audit Group (IAG) will include LIHEAP subawards in its annual review. Scheduled Completion Date of the Corrective Action Plan: January 1, 2024: FFATA reporting procedures and training in place and operating. December 31, 2024: Annual review of FFATA rules and regulations including subawards review. Contacts for Corrective Action Plan: Melanie Rutledge, DCF Financial Director I melanie.rutledge@vermont.gov Megan Smeaton, DCF Financial Director IV megan.smeaton@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 297960

Finding 384883 (2023-019)

Material Weakness 2023

State of Vermont

VT

Questioned Costs Special Tests & Provisions Material Weakness § 200.303

The Agency has started implementing this process July 1, 2023 as a component of last year’s corrective action plan. The Agency will identify if a new ESEA Federal grant (or a grant based on an ESEA program) includes an Equitable Service requirement during the program completion of the “New Grant ...

The Agency has started implementing this process July 1, 2023 as a component of last year’s corrective action plan. The Agency will identify if a new ESEA Federal grant (or a grant based on an ESEA program) includes an Equitable Service requirement during the program completion of the “New Grant Checklist”. If a new grant includes an Equitable Service requirement, the ESEA Equitable Service’s Ombudsman will be notified and will work with the grant program manager to ensure the build of the GMS application includes the correct level of detail and controls to meet the SEA requirements for oversight. When appropriate, the Agency will use its process for handling of Equitable Services associated with the Consolidated Federal Programs as models for determining the correct calculation method. The Agency will utilize built in business rules and internal controls within the Grants Management System (GMS) to gather the following information in the grant application for AOE review and approval prior to issuing a grant award agreement: 1. Calculation of the total proportionate share dollars an LEA must set aside for Equitable Services 2. Identification of Independent Schools participating in Equitable Services applicable to each LEA 3. Calculation of the dollars available for Equitable Services for each participating Independent School For each Federal grant that requires an equitable services component, the Agency will document the review and approval of the Equitable Services information through one of two processes prior to the grant award agreement: 1. A dedicated review assignment specific to equitable services, or 2. Verification statements on the review checklist for a general application reviewer Position Responsible for Implementation of Corrective Action Name: Deborah Bloom, Assistant Director, Federal and Education Support Programs Position: Assistant Director Email: deborah.bloom@vermont.gov Phone Number: 802-828-1390 Date of Implementation of Corrective Action: July 1, 2023

View Audit 297960

Finding 384877 (2023-018)

Material Weakness 2023

State of Vermont

VT

Questioned Costs Subrecipient Monitoring Material Weakness § 200.303

To address the accuracy and timeliness of our entries into the FFATA system, we will use the USASPENDING.GOV website to assist us in reconciling what has been entered into the FFATA system. This will allow us to ensure that our grant ledgers agree with what is entered into FFATA. In March 2023 we s...

To address the accuracy and timeliness of our entries into the FFATA system, we will use the USASPENDING.GOV website to assist us in reconciling what has been entered into the FFATA system. This will allow us to ensure that our grant ledgers agree with what is entered into FFATA. In March 2023 we started reconciliations and plan to continue reconciling a couple times each year. The work will be done by the Deputy CFO or position assigned by the Deputy CFO. We will also implement a process that will have all the steps necessary for a grant award or an amendment to ensure it is posted properly within our internal files and the external systems. This will ensure that new awards and amendments get routed and entered in the FFATA system timely. We will look into the Batch upload process to allow for data to be entered into the system easier. Position Responsible for Implementation of Corrective Action Name: Sean Cousino Position: Deputy CFO Email: sean.couisno@vermont.gov Phone Number: 802 595-3693 Date of Implementation of Corrective Action: 5/01/2024

View Audit 297960

Finding 384875 (2023-016)

Significant Deficiency 2023

State of Vermont

VT

Questioned Costs Subrecipient Monitoring Reporting § 200.303

To address the accuracy and timeliness of our entries into the FFATA system, we will use the USASPENDING.GOV website to assist us in reconciling what has been entered into the FFATA system. This will allow us to ensure that our grant ledgers agree with what is entered into FFATA. In March 2023 we s...

To address the accuracy and timeliness of our entries into the FFATA system, we will use the USASPENDING.GOV website to assist us in reconciling what has been entered into the FFATA system. This will allow us to ensure that our grant ledgers agree with what is entered into FFATA. In March 2023 we started reconciliations and plan to continue reconciling a couple times each year. The work will be done by the Deputy CFO or position assigned by the Deputy CFO. We will also implement a process that will have all the steps necessary for a grant award or an amendment to ensure it is posted properly within our internal files and the external systems. This will ensure that new awards and amendments get routed and entered in the FFATA system timely. We will look into the Batch upload process to allow for data to be entered into the system easier. Position Responsible for Implementation of Corrective Action Name: Sean Cousino Position: Deputy CFO Email: sean.couisno@vermont.gov Phone Number: 802 595-3693 Date of Implementation of Corrective Action: 5/01/2024

View Audit 297960

Finding 384858 (2023-009)

Material Weakness 2023

State of Vermont

VT

Matching / Level of Effort / Earmarking Questioned Costs Subrecipient Monitoring § 200.303

The reporting portal of the U.S. Treasury changes on an almost quarterly basis. These changes include new data requirements, added/changed functionality, and new data verification mechanisms. The incredibly small group of dedicated reporters for the Agency does their best to ensure that every new c...

The reporting portal of the U.S. Treasury changes on an almost quarterly basis. These changes include new data requirements, added/changed functionality, and new data verification mechanisms. The incredibly small group of dedicated reporters for the Agency does their best to ensure that every new change in the portal process is recognized and incorporated into our processes and that the data in the portal matches what we have on file. Regarding the reporting period in question, current period obligations were inadvertently not reported at the individual project level due to an error in an internal data query used to generate the project upload templates used to enter data into the portal. The error went unnoticed by Agency staff partially because verification of cumulative obligations and total current period obligations, which is automatically verified in the portal and double checked by Agency staff, was successful which suggested there were no issues with the uploaded data. After researching the issue, Agency staff discovered that the data provided at the project level is not used in any auto calculations in the portal and there are no verification mechanisms in place within the portal to ensure it is accurate. Moving forward, the Agency will initiate a new process. A primary review of the templates will be conducted by an individual other than the individual that has prepared the templates before uploading. Additionally, a review of the portal data by a multi-person team will be completed before the portal data is certified. Scheduled Completion Date of Corrective Action Plan: Expected: April, 2024: New processes integrated into FY24 Q3 Reporting Cycle Contacts for Corrective Action Plan: Douglas Farnham Chief Recovery Officer, Vermont State Recovery Office Douglas.Farnham@vermont.gov (802) 585-8119 Ethan Hurley Director of Finance & Operations, Vermont State Recovery Office Ethan.Hurley@vermont.gov (802) 461-5317

View Audit 297960

Finding 384856 (2023-008)

Significant Deficiency 2023

State of Vermont

VT

Allowable Costs / Cost Principles Period of Performance Questioned Costs § 200.303 § 200.308 § 200.309 § 200.403

The Department will review its procedures and internal controls and update as necessary to ensure that expenditures are incurred within the allowable period of performance for respective awards. It should be noted that during the period of performance for which this audit was conducted there were a...

The Department will review its procedures and internal controls and update as necessary to ensure that expenditures are incurred within the allowable period of performance for respective awards. It should be noted that during the period of performance for which this audit was conducted there were a large number of personnel changes and shifts. The position that was responsible for the majority of these duties retired in January 2024. We proactively hired for her replacement a year before she retired. Over the course of the year our replacement took over more and more duties. In the process of this replacement, we have completed a tremendous amount of evaluation of our assigned duties, processes, workflow, training, and documentation. Not only in this role, but we are also undergoing a division and business unit wide analysis of our internal controls and workflow. It should also be noted that the UI admin funds are considered ‘formula funds’ from the US DOL. We are expected to run this program year-round with no gaps in service or performance. The funding that we receive from US DOL is based on an antiquated formula that breaks down the amount that is budgeted by Congress between 52 state and territories. We generally do not receive enough funding for the entire year. Also, with the recent trend of Congress to utilize the tool of the Continuing Resolution our funding is often ambiguous until most of the program year is over. We have at times seen our funding cut once a budget had been passed by Congress even though there was only about 3 months left in the program year. We are still expected to run this program and ‘find other sources of funding’. This does make the adherence to the period of performance challenging. However, as we evaluate our internal controls and procedures over the coming months, we will make note of every opportunity to strengthen this function to ensure that all charges applied to program funds are relevant, within the period of performance of the award, and are correctly reviewed and signed. Cameron Wood, UI Director, Cameron.Wood@vermont.gov Scheduled Completion Date of Corrective Action Plan: August 31, 2024

View Audit 297960

Finding 384852 (2023-006)

Material Weakness 2023

State of Vermont

VT

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

In 2015, the Department lost access to certain federal IRS information, including the ability to store electronic federal tax information on the Department’s internal information technology servers. Subsequent to 2015, the Department has maintained a physical copy of the annual IRS 940 FUTA match f...

In 2015, the Department lost access to certain federal IRS information, including the ability to store electronic federal tax information on the Department’s internal information technology servers. Subsequent to 2015, the Department has maintained a physical copy of the annual IRS 940 FUTA match file for auditing purposes. This year, the Department did not maintain that file. The Department will review current procedures and internal controls with the Agency of Digital Services and update as necessary to ensure that a copy of the IRS 940 FUTA match file is maintained for auditing purposes. Cameron Wood, UI Director, Cameron.Wood@vermont.gov Scheduled Completion Date of Corrective Action Plan: August 31, 2024

View Audit 297960

Finding 384850 (2023-005)

Material Weakness 2023

State of Vermont

VT

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

The Department is currently undergoing a division and business unit wide analysis of our internal controls and procedures. As part of that effort, the Department will review internal controls and update as necessary to ensure that all required reports are filed timely and accurately and that report...

The Department is currently undergoing a division and business unit wide analysis of our internal controls and procedures. As part of that effort, the Department will review internal controls and update as necessary to ensure that all required reports are filed timely and accurately and that reports are reviewed and approved by authorized State officials prior to submission. Cameron Wood, UI Director, Cameron.Wood@vermont.gov Scheduled Completion Date of Corrective Action Plan: August 31, 2024

View Audit 297960

Finding 384843 (2023-004)

Significant Deficiency 2023

State of Vermont

VT

Questioned Costs Cash Management § 200.303 § 200.514

In March 2023, AOE implemented a new process that is more automated to ensure accuracy and timeliness of our CMIA draws. We have created a new draw sheet that will be more easily loaded and will be reconciled a couple times a year. The Deputy CFO or person assigned by the Deputy CFO will perform a...

In March 2023, AOE implemented a new process that is more automated to ensure accuracy and timeliness of our CMIA draws. We have created a new draw sheet that will be more easily loaded and will be reconciled a couple times a year. The Deputy CFO or person assigned by the Deputy CFO will perform a reconciliation at least two times a year. Name: Sean Cousino Position: Deputy CFO Email: sean.couisno@vermont.gov Phone Number: 802 595-3693 Date of Implementation of Corrective Action: March 15, 2023

View Audit 297960 Questioned Costs: $1

Finding 384836 (2023-003)

Significant Deficiency 2023

State of Vermont

VT

Questioned Costs Subrecipient Monitoring Reporting § 200.303

To address the accuracy and timeliness of our entries into the FFATA system, we will use the USASPENDING.GOV website to assist us in reconciling what has been entered into the FFATA system. This will allow us to ensure that our grant ledgers agree with what is entered into FFATA. In March 2023 we s...

To address the accuracy and timeliness of our entries into the FFATA system, we will use the USASPENDING.GOV website to assist us in reconciling what has been entered into the FFATA system. This will allow us to ensure that our grant ledgers agree with what is entered into FFATA. In March 2023 we started reconciliations and plan to continue reconciling a couple times each year. The work will be done by the Deputy CFO or position assigned by the Deputy CFO. We will also implement a process that will have all the steps necessary for a grant award or an amendment to ensure it is posted properly within our internal files and the external systems. This will ensure that new awards and amendments get routed and entered in the FFATA system timely. We will look into the Batch upload process to allow for data to be entered into the system easier. Name: Sean Cousino Position: Deputy CFO Email: sean.couisno@vermont.gov Phone Number: 802 595-3693 Date of Implementation of Corrective Action: 5/01/2024

View Audit 297960

Finding 384789 (2023-005)

Material Weakness 2023

Newport News Redevelopment and Housing Authority

VA

HUD Housing Programs Questioned Costs Material Weakness

2023-005 Housing Voucher Cluster – Assistance Listing No. 14.871/14.879/14.EHV Recommendation: We recommend the Authority review their reasonable rent determination process to ensure that it is performed before the rent is set to go into effect. Explanation of disagreement with audit finding: There ...

2023-005 Housing Voucher Cluster – Assistance Listing No. 14.871/14.879/14.EHV Recommendation: We recommend the Authority review their reasonable rent determination process to ensure that it is performed before the rent is set to go into effect. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Director of Housing will ensure staff perform the rent reasonableness determination prior to the effective date. Name(s) of the contact person(s) responsible for corrective action: Director of Housing Planned completion date for corrective action plan: June 30, 2024

View Audit 297906 Questioned Costs: $1

Finding 384788 (2023-004)

Material Weakness 2023

Newport News Redevelopment and Housing Authority

VA

HUD Housing Programs Questioned Costs Material Weakness

2023-004 Housing Voucher Cluster – Assistance Listing No. 14.871/14.879/14.EHV Recommendation: We recommend the Authority review their inspection process to ensure that they are performed timely and that all documentation is maintained within Yardi. We recommend the Authority review their process fo...

2023-004 Housing Voucher Cluster – Assistance Listing No. 14.871/14.879/14.EHV Recommendation: We recommend the Authority review their inspection process to ensure that they are performed timely and that all documentation is maintained within Yardi. We recommend the Authority review their process for abatement/enforcing family obligations to ensure timely correction and enforcement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Director of Housing will ensure the inspection process in performed timely and the documentation is maintained within the Yardi software program. Processes will be reviewed and updated to ensure timely correction and enforcement. Name(s) of the contact person(s) responsible for corrective action: Director of Housing Planned completion date for corrective action plan: June 30, 2024

View Audit 297906 Questioned Costs: $1

Finding 384787 (2023-003)

Material Weakness 2023

Newport News Redevelopment and Housing Authority

VA

Questioned Costs HUD Housing Programs Eligibility

2023-003 Housing Voucher Cluster – Assistance Listing No. 14.871/14.879/14.EHV Recommendation: We recommend the Authority review their recertification process to ensure that all Eligibility requirements are met and all necessary documentation is maintained. We recommend the Authority review their pr...

2023-003 Housing Voucher Cluster – Assistance Listing No. 14.871/14.879/14.EHV Recommendation: We recommend the Authority review their recertification process to ensure that all Eligibility requirements are met and all necessary documentation is maintained. We recommend the Authority review their processes to ensure that the HAP calculated on the HUD-50058 is the amount paid to the landlords. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Director of Housing will ensure staff is properly trained to ensure the recertification process is completed correctly. Name(s) of the contact person(s) responsible for corrective action: Director of Housing Planned completion date for corrective action plan: June 30, 2024

View Audit 297906 Questioned Costs: $1

Finding 384785 (2023-001)

Significant Deficiency 2023

Central Community College

NE

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

The College identified what took place during contact with the Clearinghouse. Student records have been updated and procedures have been implemented to ensure accuracy of enrollment reporting in addition to implementing review procedures between college records and NSLDS enrollment reports.

View Audit 297900

Finding 384774 (2023-004)

Significant Deficiency 2023

Legacy Medical Care Inc.

IL

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.308 § 200.309 § 200.403

Action taken in response to finding: • Staff will verify that costs were incurred within the grant period. • Staff will verify that payroll costs are charged according to the period end date and not the pay date.

View Audit 297887 Questioned Costs: $1

Finding 384773 (2023-003)

Significant Deficiency 2023

Legacy Medical Care Inc.

IL

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.403

Action taken in response to finding: • All costs charged to grants will be reviewed and verified. • Indirect costs will be checked and verified for all grants

View Audit 297887 Questioned Costs: $1

Finding 384770 (2023-002)

Significant Deficiency 2023

Legacy Medical Care Inc.

IL

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties

Action taken in response to finding: • LMC staff will institute a monthly review of ten self-pay encounters and will provide training to staff as needed.

View Audit 297887

Finding 384766 (2023-003)

Material Weakness 2023

Housing Authority of the City of Martinsburg

WV

Eligibility Questioned Costs Procurement, Suspension & Debarment

Finding 2023-003 - Documentation of Costs and Vendor Invoices - Financial Reporting and Internal Controls ALN 14.850 & 14.871- Noncompliance & Material Weakness Corrective Action Plan: Vendor invoice backup supplied to HUD for questionable expense s. Executive Director must approve all expenses goi...

Finding 2023-003 - Documentation of Costs and Vendor Invoices - Financial Reporting and Internal Controls ALN 14.850 & 14.871- Noncompliance & Material Weakness Corrective Action Plan: Vendor invoice backup supplied to HUD for questionable expense s. Executive Director must approve all expenses going forward and keep sufficient backup for audit. Person Responsible: John Sales, Interim Executive Director Anticipated Completion Date: January 31, 2024

View Audit 297881 Questioned Costs: $1

Finding 384754 (2023-014)

Significant Deficiency 2023

State of Kansas

KS

Matching / Level of Effort / Earmarking Questioned Costs § 200.303

Condition: From a sample of sixty providers, nine of the providers did not have a recertification survey completed within the required timeframe which is used to meet the provider health and safety standards. Recommendation: We recommend the State train all staff members to properly verify provide...

Condition: From a sample of sixty providers, nine of the providers did not have a recertification survey completed within the required timeframe which is used to meet the provider health and safety standards. Recommendation: We recommend the State train all staff members to properly verify providers are meeting the prescribed health and safety standards before making payments to those providers. Views of responsible officials: KDHE/Bureau of Facilities and Licensing (BFL) recognizes the recertification survey deadlines was not met for nine of the sixty non-deemed acute and continuing care providers and supplier types included in this audit consisting of Hospitals, Critical Access Hospitals (CAH), Ambulatory Surgery Centers (ASC), End Stage Renal Disease Facilities (ESRD), Rural Health Clinics (RHC), Hospice and or Home Health Agencies (HHA). The KDHE/BFL would like to clarify that Section 1865(a)(1) of the Social Security Act (the Act) permits providers and suppliers "accredited" or "deemed" by an approved national accreditation organization (AO) to be exempt from routine surveys by State survey agencies to determine compliance with Medicare conditions. Accreditation by an AO is voluntary and is not required for Medicare certification or participation in the Medicare Program.) There is no disagreement with the audit finding but KDHE/BFL does want to identify some of the challenges the State Survey Agency (SSA) faces hindering continued progress with corrective action plans. CMS’s annual appropriation to the SSA has remained unchanged since FY 2015. This has significantly limited the SSA’s capacity to conduct initial, complaint, recertification, and validation surveys. This limitation in funding, coupled with the continuing effects of the COVID-19 Public Health Emergency (PHE), accelerated the loss of SSA surveyor resources and resulted in an ongoing survey backlog. As complaints about provider and supplier quality of care increases, non-statutory recertification surveys and less severe complaint allegations receive a lower priority. Complaint surveys, especially those alleging immediate jeopardy or actual harm to patient health and safety are the primary oversight provided, outside of statutory recertification surveys. These investigations of the most serious allegations also lead to more severe findings, higher numbers of revisits, and additional enforcement workload. Complaint surveys are the primary oversight mechanism for most provider types. CMS has established the following priorities for the SSA’s: 1. Investigation of patient complaints, as these are active quality concerns that must be reviewed to protect the health and safety of the public. 2. Survey and recertification of statutory facilities such as home health agencies (HHAs), and hospices as required by current law; and 3. Survey and recertification of non-statutory facilities, as required by CMS policy with consideration of available funding once priorities one and two have been accomplished. Action taken in response to finding: At the beginning of each federal fiscal year including current FFY24, the BFL utilizes the CMS Mission and Priority Document (MPD) which directs and outlines the work of the SA based on regulatory changes, adjustments in budget allocations, and new initiatives, as well as new requirements based on statutes to prioritize and categorize survey plans. During this current FFY we have begun to restructure the program adding additional program manager positions, health facility surveyors, contracted services, and other support staff. Our goal is always to be able to consistently meet our Tier 1 priority with an emphasis on Tier 2. Recruitment, training, fiscal management & strategies are always a priority and part of action plans to meet these goals. The SSA goals for FFY24: • Complete 100% of the ESRD surveys in Tier 2 provided on the required Outcomes List. Kansas currently has approximately 60 non-deemed ESRD suppliers. • Complete to the extent possible 5% of non-deemed RHCs based on state judgment prioritizing those RHCs most at risk of quality problems for Tier 2. Kansas currently has approximately 135 RHC suppliers. • Complete to the extent possible based on the state’s judgement prioritizing those at risk of quality problems a standard recertification survey with a maximum interval between surveys for any one particular HHA of 36.9 months to meet Tier 1 requirements. Kansas currently has approximately 70 non-deemed, certified HHA’s. • Complete to the extent possible based on the state’s judgement prioritizing those at risk of quality problems a standard recertification survey with a maximum interval between surveys for any one particular Hospice of 36 months to meet Tier 1 requirements. Kansas currently has approximately 50 non-deemed, certified Hospice providers • Complete to the extent possible based on the state’s judgement prioritizing those at risk of quality problems a standard recertification survey at least one, but not less than 5% of the non-deemed hospitals, 5% of the non-deemed psychiatric hospitals, and 5% of non-deemed CAHs. Kansas currently has approximately 74 non-deemed CAHs, 2 Psychiatric/Rehab non-deemed hospitals and 12 non-deemed hospitals. Name(s) of the contact person(s) responsible for corrective action: Jerry Smith, Bureau Director, Bureau of Facilities and Licensing, KDHE, Gerald.Smith@ks.gov Marilyn St Peter, RN, Deputy Director, Bureau of Facilities and Licensing, KDHE, Marilyn.St.Peter@ks.gov Planned completion date for corrective action plan: June 30, 2024

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Finding 384741 (2023-006)

Significant Deficiency 2023

State of Kansas

KS

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

Condition: During our testing of performance reports, we noted five out the five tested reports lacked documentation of review. Recommendation: We recommend the agency implement procedures to ensure reports are properly reviewed as well as increase training efforts on reporting requirements if ther...

Condition: During our testing of performance reports, we noted five out the five tested reports lacked documentation of review. Recommendation: We recommend the agency implement procedures to ensure reports are properly reviewed as well as increase training efforts on reporting requirements if there is future staffing turnover. Views of responsible officials: Management disagrees with the audit finding. There is review and final approval of these quarterly financial reports by the ELC program director prior to submission. The fiscal analyst at KDHE provides these financial reports to the ELC program manager and the ELC program director. The COVID and CORE ELC data from these reports are manually entered into ELC RedCap (for the years that correspond to this audit) and now ELC CAMP. COVID financial reports are then uploaded into GrantSolutions; the core ELC financial reports do not have to be uploaded to GrantSolutions. There is no mechanism to include a signature on these reports, but submission to ELC CAMP and GrantSolutions indicate the reports have been reviewed. Action taken in response to finding: An email advising reports have been reviewed and approved by the program director will be sent to the program manager as proof the reports have been reviewed/approved and are ready to be submitted. The email will be retained for audit reviews. Name(s) of the contact person(s) responsible for corrective action: Sheri Tubach Planned completion date for corrective action plan: Immediately in March 2024.

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Corrective Action Plans

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