Corrective Action Plans

Finding 1210889 (2024-001)

Material Weakness 2024

MA

Reporting

Audit Finding Reference: 2024-001 Planned Corrective Action: Management acknowledges the finding regarding the untimely submission of the School’s annual filing with the Federal Audit Clearinghouse (FAC) for the fiscal year ended June 30, 2024. The delay was primarily due to the timing of the comple...

Audit Finding Reference: 2024-001 Planned Corrective Action: Management acknowledges the finding regarding the untimely submission of the School’s annual filing with the Federal Audit Clearinghouse (FAC) for the fiscal year ended June 30, 2024. The delay was primarily due to the timing of the completion of prior audits, which impacted the School’s ability to meet the March 31, 2025 deadline. To address this issue and improve the timeliness of future filings, the School and School Committee will implement the following corrective actions: 1. Establishment of a Formal Timeline: Management will develop and adopt a detailed annual audit and reporting calendar that includes key milestones for audit completion and FAC submission to ensure adequate time for timely filing. 2. Monitoring and Verification: The School will establish a structured monitoring system that includes regularly scheduled status meetings (at least monthly, and more frequently as deadlines approach) involving key personnel and, when necessary, external auditors. These meetings will be used to review audit progress against established timelines, identify potential delays early, and implement corrective steps in real time. 3. Improved Coordination with Auditors: Management will work closely with external auditors to establish clear expectations for audit completion, including target dates for each major step of the audit. Name of Contact Person: Melissa Martel, Director of Finance Planned Completion Date: June 30, 2026

View Audit 400233

Finding 1210887 (2024-002)

Material Weakness 2024

Block Island Ecnmc Dev Fndtn Hsng CORP Dba E. Searles Ball Memorial

CT

Reporting

Management acknowledges the finding regarding the replacement reserve account not being funded at the minimum level required by the USDA‑RD approved budget. To address this issue, the Project will work to make a deposit to fully restore the replacement reserve to the required threshold in accordance...

Management acknowledges the finding regarding the replacement reserve account not being funded at the minimum level required by the USDA‑RD approved budget. To address this issue, the Project will work to make a deposit to fully restore the replacement reserve to the required threshold in accordance with USDA‑RD guidelines. In addition, we will continue to monitor reserve balances throughout the year and communicate with USDA‑RD if significant variances arise.

View Audit 400231

Finding 1210885 (2024-001)

Material Weakness 2024

Block Island Ecnmc Dev Fndtn Hsng CORP Dba E. Searles Ball Memorial

CT

Reporting

Management acknowledges the finding regarding the late filing of the single audits. Management will work with the Board of Directors and auditor to develop a plan to ensure future audits are completed on a more timely basis in accordance with the filing requirements.

View Audit 400231

Finding 1210861 (2024-003)

Material Weakness 2024

Berkeley County Public Service District

WV

Reporting Allowable Costs / Cost Principles

The District uses an outside party to oversee grant management. District management will review work performed by outside parties to ensure completeness and accuracy.

View Audit 400206

Finding 1210853 (2024-003)

Material Weakness 2024

Johnson County, Illinois

IL

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting

Corrective Action Plan Management will prepare the schedule of expenditures of federal awards as part of the year end closing process each year to determine their audit requirements under the Uniform Guidance and provide the schedule to the audit firm during the financial audit process.

View Audit 400143

Finding 1210842 (2024-001)

Material Weakness 2024

Connecticut Center of Arts & Technology Inc.

CT

Reporting

The Connecticut Center for Arts and Technology will implement corrective actions to ensure timely compliance with all Federal Single Audit requirements. A formal compliance calendar with key deadlines and automated reminders will be maintained. The Chief Financial Officer will be assigned primary re...

The Connecticut Center for Arts and Technology will implement corrective actions to ensure timely compliance with all Federal Single Audit requirements. A formal compliance calendar with key deadlines and automated reminders will be maintained. The Chief Financial Officer will be assigned primary responsibility for audit compliance, with the Controller serving as a secondary reviewer. Management will conduct quarterly reviews of all Federal grant expenditures to assess whether audit thresholds are met, with results formally documented and approved. The organization will develop a written Single Audit Compliance Policy outlining reporting requirements, roles, responsibilities, and documentation standards, which will be reviewed annually by senior management. Finance staff will receive annual training focused on compliance with timelines, reporting obligations, and internal controls. Finally, a formal pre-submission checklist and review process will ensure the completeness and timely submission of all required reports

View Audit 400130

Finding 1210816 (2024-005)

Material Weakness 2024

Town of Hollywood

SC

Reporting Matching / Level of Effort / Earmarking

The Town will implement new grant management controls to ensure all transactions charged to federal awards are properly documented and retained. Anticipated Completion Date: -----3/31/2026

View Audit 400096

Finding 1210737 (2024-002)

Material Weakness 2024

Shenandoah Area Agency on Aging, INC

VA

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

Management agrees with the finding. Management plans to implement a process to ensure that the AMR report will be submitted accurately. If the Federal Audit Clearinghouse has questions regarding this plan, please call Cindy Donaldson, Director of Finance at 540-635-7141.

View Audit 400030

Finding 1210663 (2024-002)

Material Weakness 2024

Gascosage Electric Cooperative

MO

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.303

Gascosage Electric Cooperative Responsible Party: Luther Riddle, General Manager LRiddle@gascosage.coop Audit Period Ending: December 31, 2024 Finding #2024-002 Statement of Condition - Effective internal controls to maintain evidence of review and approval of reports with appropriate segregation of...

Gascosage Electric Cooperative Responsible Party: Luther Riddle, General Manager LRiddle@gascosage.coop Audit Period Ending: December 31, 2024 Finding #2024-002 Statement of Condition - Effective internal controls to maintain evidence of review and approval of reports with appropriate segregation of duties were not in place. The Organization concurs with the finding and management will implement procedures to ensure appropriate internal control procedures are in place for reporting. Management will implement additional internal controls to ensure appropriate segregation of duties between report preparation and review.

View Audit 399958

Finding 1210649 (2024-014)

Material Weakness 2024

Philander Smith College

AR

Student Financial Aid Reporting

Federal Program/ Assistance Listing Number (ALN) 84.268, 84.063, 84.007, 84.033 Finding Reference Number 2024-014 1. Finding Summary The auditor determined that the institution did not accurately report recipient counts on the FISAP in accordance with federal reporting requirements. As a result, the...

Federal Program/ Assistance Listing Number (ALN) 84.268, 84.063, 84.007, 84.033 Finding Reference Number 2024-014 1. Finding Summary The auditor determined that the institution did not accurately report recipient counts on the FISAP in accordance with federal reporting requirements. As a result, the institution could not demonstrate compliance with Title IV reporting obligations under its Program Participation Agreement, increasing the risk of inaccurate federal reporting and potential compliance findings. 2. Management's Position Management agrees with the finding. Management Explanation Management agrees with the finding and acknowledges that recipient counts reported on the FISAP were not consistently accurate in accordance with federal reporting requirements. 3. Root Cause Analysis The root cause of this finding resulted from failure to reconcile ISIR income data to the summary totals reported on the FI SAP, use of incorrect or incomplete datasets when preparing recipient counts, and insufficient supervisory review of the FISAP reporting process. 4. Corrective Action(s) Management has added secondary review, implemented periodic internal monitoring, and added system configuration limitations. Description of Corrective Actions The institution has implemented a supervisory or secondary review to validate FISAP data and recipient counts prior to submission, and established periodic internal monitoring and quality assurance reviews to ensure accuracy and completeness of reported information. Additionally, system configuration limitations impacting data extraction and reconciliation have been identified and addressed through revised reporting procedures and compensating manual controls. 5. Risk Mitigation (Required - Even if Disagreeing) These corrective actions mitigate the risk of inaccurate FISAP reporting by strengthening oversight, improving data validation, and establishing compensating controls to address system limitations. Ongoing monitoring and quality assurance reviews further reduce compliance risk and support accurate and reliable federal reporting. 6. Responsible Party • Office/Department: Office of Financial Aid • Title of Responsible Official: Director of Financial Aid • Name (optional): ____________ 7. Implementation Timeline • Corrective action implemented: Yes (No) • If not fully implemented, expected completion date: December 31, 2026 8. Status of Corrective Action (For Prior-Year or Repeat Findings) Fully implemented Partially implemented (Not yet implemented) Evidence of Implementation In progress, evidence is not yet available. 9. Monitoring and Sustainability Supervisory review and periodic internal monitoring will be conducted each reporting cycle to ensure FISAP recipient counts are accurate, complete, and supported by reconciled data. Continued use of quality assurance reviews, documented procedures, and compensating controls for system limitations will support long-term compliance and timely identification and correction of reporting discrepancies.

View Audit 399950

Finding 1210629 (2024-009)

Material Weakness 2024

Philander Smith College

AR

Student Financial Aid Reporting Subrecipient Monitoring

Federal Program/ Assistance Listing Number (ALN) 84.268, 84.063, 84.007, 84.033 Finding Reference Number 2024-009 1. Finding Summary The auditor identified that some students lacked required documentation ofhigh school completion or an allowable alternative in their files yet were awarded Title IV f...

Federal Program/ Assistance Listing Number (ALN) 84.268, 84.063, 84.007, 84.033 Finding Reference Number 2024-009 1. Finding Summary The auditor identified that some students lacked required documentation ofhigh school completion or an allowable alternative in their files yet were awarded Title IV federal student aid. As a result, the institution could not demonstrate compliance with Title IV student eligibility requirements, creating a risk of disbursement to ineligible students. 2. Management's Position Management agrees with the finding. Management Explanation Management agrees with the finding and acknowledges that required documentation of high school completion or an allowable alternative was not consistently maintained in student files prior to the disbursement of Title IV federal student aid. 3. Root Cause Analysis The root cause of this finding was insufficient supervisory review of student eligibility documentation and decentralized documentation practices that resulted in inconsistent collection and retention of required records. 4. Corrective Action(s) Management has implemented standardized checklists and workflows, added secondary review, enhanced system controls, and implemented periodic internal monitoring. Description of Corrective Actions The institution has taken corrective action to strengthen compliance with Title IV student eligibility requirements related to documentation of high school completion. Management has implemented standardized eligibility checklists and documented workflows to ensure required documentation is collected and verified prior to awarding or disbursing federal student aid. A mandatory supervisory or secondary review has been added to confirm eligibility and documentation completeness before processing or disbursement occurs. In addition, system controls within the Student Information System (SIS), financial aid software, and document management systems have been enhanced to require receipt and retention of acceptable high school completion documentation before Title IV funds can be awarded. Targeted staff training has been conducted to reinforce federal eligibility requirements, institutional procedures, and documentation standards. To ensure ongoing compliance, the institution has established periodic internal monitoring and quality assurance reviews of student files to verify documentation accuracy and consistency. These measures are designed to prevent recurrence of the finding and support sustained compliance with federal regulations. 5. Risk Mitigation (Required - Even if Disagreeing) The implemented corrective actions mitigate the risk of awarding or disbursing Title IV funds to ineligible students by ensuring that high school completion documentation is collected, verified, and retained prior to aid processing. Standardized workflows, enhanced system controls, supervisory review, targeted staff training, and ongoing internal monitoring collectively strengthen compliance oversight, reduce documentation errors, and promote consistent adherence to federal student eligibility requirements. 6. Responsible Party • Office/Department: Office of Admissions • Title of Responsible Official: Director of Admissions • Name (optional): _ 7. Implementation Timeline a. Corrective action implemented: Yes (No) b. If not fully implemented, expected completion date: June 30, 2026 8. Status of Corrective Action (For Prior-Year or Repeat Findings) Fully implemented Partially implemented (Not yet implemented) Evidence of Implementation In progress, evidence is not yet available. 9. Monitoring and Sustainability Management will conduct periodic internal reviews and quality assurance checks of student eligibility files to confirm that required high school completion documentation is consistently obtained and maintained prior to Title IV disbursement. Supervisory reviews, ongoing staff training, and continued use of standardized workflows and system controls will be sustained to reinforce compliance, identify issues timely, and ensure long-term adherence to federal Title IV eligibility requirements.

View Audit 399950

Finding 1210625 (2024-008)

Material Weakness 2024

Philander Smith College

AR

Student Financial Aid Subrecipient Monitoring Material Weakness

Federal Program/ Assistance Listing Number (ALN) 84.268, 84.063, 84.007, 84.033 Finding Reference Number 2024-008 1. Finding Summary The auditor identified that seven (7) out of sixty (60) sampled students had Title IV-created credit balances that remained on their accounts for more than 14 days wit...

Federal Program/ Assistance Listing Number (ALN) 84.268, 84.063, 84.007, 84.033 Finding Reference Number 2024-008 1. Finding Summary The auditor identified that seven (7) out of sixty (60) sampled students had Title IV-created credit balances that remained on their accounts for more than 14 days without being released to the student or parent. 2. Management's Position Management agrees with the finding. Management Explanation Management agrees with the finding and acknowledges that the identified condition resulted from the system not pulling credit balances per semester. 3. Root Cause Analysis The root cause was the absence of the system not pulling credit balances per semester. Therefore, it is a manual process to verify if the current semester aid creates a refund for current semester charges when a balance from a prior semester is rolling forward. 4. Corrective Action(s) Management has enhanced system controls and implemented periodic internal monitoring. Description of Corrective Actions To address this finding and prevent recurrence, the University is performing weekly reviews of all student accounts that had aid processed during that week. This review is important because all statements are reviewed even if a credit balance is not showing to identify if the aid for the period creates a credit for the semester despite a beginning balance. Further, the University is transitioning to a new accounting system which will identify credit by term. The new system, Colleague, which will automate the process, will be implemented in approximately 18 months. 5. Risk Mitigation (Required - Even if Disagreeing) The institution recognizes the importance of mitigating compliance risk in this area. According!y, the corrective actions described above are designed to timely identify student accounts with a refundable credit balance and future audit findings. 6. Responsible Party a. Office/Department: Business Office b. Title of Responsible Official: Senior Accountant c. Name (optional): 7. Implementation Timeline Manual corrective actions have been implemented and are ongoing as part of standard operating procedures. The automated process is anticipated to be fully in place within 18 months once the University transitions to the Colleague system. • Corrective action implemented: Yes (No) • If not fully implemented, expected completion date: Action is fully implemented, but will transition to a new automated process at a later date. 8.Status of Corrective Action (For Prior-Year or Repeat Findings) (Fully implemented) Partially implemented Not yet implemented Evidence of Implementation An example can be provided for a student with a balance who received a refund for the current semester despite not showing a credit balance. 9. Monitoring and Sustainability The University will continue its manual review process until it can be automated.

View Audit 399950

Finding 1210609 (2024-004)

Material Weakness 2024

Philander Smith College

AR

Student Financial Aid Reporting

Federal Program / Assistance Listing Number (ALN) 84.268, 84.063, 84.007, 84.033 Finding Reference Number 2024-004 1. Finding Summary The auditor found that the University did not complete or document required monthly or year-end reconciliations for several Title IV programs, resulting in unreconcil...

Federal Program / Assistance Listing Number (ALN) 84.268, 84.063, 84.007, 84.033 Finding Reference Number 2024-004 1. Finding Summary The auditor found that the University did not complete or document required monthly or year-end reconciliations for several Title IV programs, resulting in unreconciled financial aid records between the Office of Financial Aid, the general ledger, and federal systems. Federal regulations require these reconciliations to ensure the accuracy of disbursements and compliance with Title IV requirements. 2. Management's Position Management agrees with the finding. Management Explanation Management agrees with the finding and acknowledges the failure to perform timely and documented reconciliations of Title IV programs during the audit period. Management concurs with the auditor's assessment that reconciliation is a critical internal control and recognizes the need to strengthen coordination, documentation, and timeliness between the Office of Financial Aid and the Business Office. 3. Root Cause Analysis The root cause was insufficient staff training on Title IV reconciliation and reporting requirements, resulting in inconsistent understanding of regulatory timelines, documentation standards, and cross-department coordination responsibilities. These training gaps limited the effective implementation of required reconciliation and monitoring processes. 4. Corrective Action(s) Management is working to implement standardized workflows and periodic internal monitoring between the Office of Financial Aid and the Business Office. Description of Corrective Actions To address this finding and prevent recurrence, the University has implemented standardized reconciliation procedures aligned with federal requirements. Reconciliation responsibilities have been formally assigned to a designated Financial Aid Counselor, with monthly reconciliations scheduled throughout each month for all Title IV programs. The Office of Financial Aid now utilizes standardized reconciliation checklists and templates, requires documented coordination and data matching with the Business Office and federal systems (COD and GS), and retains all monthly and year-end reconciliation records in accordance with federal record-keeping requirements. In addition, a mandatory year-end reconciliation review is completed prior to FISAP submission to ensure consistency across internal records, the general ledger, and federal reporting systems. 5. Risk Mitigation (Required - Even if Disagreeing) The University acknowledges the need to proactively manage regulatory exposure in this area. The corrective measures implemented are intended to strengthen oversight, promote consistent application of federal requirements, improve the accuracy and timeliness of reconciliation activities, and minimize the likelihood of future reporting issues or audit observations. 6. Responsible Party • Office/Department: Office of Financial Aid • Title of Responsible Official: Financial Aid Director • Name (optional): _ 7. Implementation Timeline • Corrective action implemented: (Yes) No • If not fully implemented, expected completion date: June 30, 2026 8. Status of Corrective Action (For Prior-Year or Repeat Findings) Fully implemented Partially implemented (Not yet implemented) Evidence of Implementation In progress, evidence is not yet available. 9. Monitoring and Sustainability The University will maintain ongoing oversight of reconciliation activities through routine internal reviews and supervisory verification to ensure procedures are consistently followed. Reconciliation processes and documentation practices will be periodically evaluated and updated as needed to support sustained compliance with Title IV requirements and long-term operational effectiveness.

View Audit 399950

Finding 1210410 (2024-118)

Material Weakness 2024

State of Arizona

AZ

Allowable Costs / Cost Principles Reporting § 200.303 § 200.430

See the University response section at the end of this report for the corrective action plan for finding 2024-118.

View Audit 399861

Finding 1209148 (2024-117)

Material Weakness 2024

State of Arizona

AZ

Subrecipient Monitoring Reporting Cash Management § 200.303 § 200.305 § 200.328 § 200.334 § 200.513

Assistance listing numbers and program names 97.024 Emergency Management Performance Grants Agency: Department of Emergency and Military Affairs (DEMA) Name of contact person and title: Keith Tagaban, Audit Supervisor Anticipated completion date: September 18, 2026 Agency’s Response: Concur The Depa...

Assistance listing numbers and program names 97.024 Emergency Management Performance Grants Agency: Department of Emergency and Military Affairs (DEMA) Name of contact person and title: Keith Tagaban, Audit Supervisor Anticipated completion date: September 18, 2026 Agency’s Response: Concur The Department of Emergency and Military Affairs (DEMA) will maintain complete, accurate, and auditable documentation to support all federal award expenditures, matching contributions, and financial reporting in accordance with 2 CFR Part 200 and applicable award terms and conditions, with records retained for a minimum of three years following submission of the final Federal Financial Report (FFR). DEMA will ensure all FFRs are reviewed for accuracy, completeness, and compliance prior to submission and will promptly correct any identified discrepancies in coordination with the federal awarding agency. The Department will implement and enforce written policies and procedures governing reimbursement requests, financial reporting, matching requirements, and record retention, including management review to ensure costs reported are allowable, allocable, reasonable, and adequately supported, and will maintain sufficient staffing and oversight to sustain ongoing compliance.

View Audit 399861

Finding 1209144 (2024-122)

Material Weakness 2024

State of Arizona

AZ

Special Tests & Provisions Material Weakness Reporting

Assistance listing numbers and program names: 93.778 Medicaid Assistance Program (Medicaid; Title XIX) 93.778 COVID-19 Medicaid Assistance Program (Medicaid; Title XIX) 93.767 Children’s Health Insurance Program (CHIP) Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact pers...

Assistance listing numbers and program names: 93.778 Medicaid Assistance Program (Medicaid; Title XIX) 93.778 COVID-19 Medicaid Assistance Program (Medicaid; Title XIX) 93.767 Children’s Health Insurance Program (CHIP) Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS Division of Business and Finance Completion date: June 30, 2025 Agency’s Response: Concur AHCCCS would like to note this matter was discovered through internal review of Office of the Inspector General (OIG) recoupment documentation and filings with Centers for Medicare & Medicaid Services (CMS). This matter was reviewed in detail by our financial management team and AHCCCS determined this was caused by a few factors: (1) staffing issues and employee turnover in all units involved in the process to return OIG recoupments to CMS. (2) A breakdown of inter and intra-departmental communication and collaboration. Actions Taken: ● Filling the related following positions that experienced turnover: Accounting Supervisor, Reporting Administrator, and 2 Accounting Specialists. ● Increased collaboration across the respective departments and divisions to ensure the federal share of all case recoupments is timely returned to CMS. ● Revised our standard work processes to include quarterly reconciliations of case recoupments among the various departments and divisions. Actions Remaining: ● AHCCCS anticipates having reported and returned the federal share to CMS for all case recoupments identified by June 30, 2025.

View Audit 399861

Finding 1209141 (2024-121)

Material Weakness 2024

State of Arizona

AZ

Special Tests & Provisions Material Weakness Reporting

Assistance listing numbers and program names: 93.778 Medicaid Assistance Program (Medicaid; Title XIX) 93.778 COVID-19 Medicaid Assistance Program (Medicaid; Title XIX) 93.767 Children’s Health Insurance Program (CHIP) Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact pers...

Assistance listing numbers and program names: 93.778 Medicaid Assistance Program (Medicaid; Title XIX) 93.778 COVID-19 Medicaid Assistance Program (Medicaid; Title XIX) 93.767 Children’s Health Insurance Program (CHIP) Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact persons and titles: Vanessa Templeman, Inspector General, AHCCCS Office of Inspector General Jeff Tegen, Assistant Director, AHCCCS Division of Business and Finance Completion date: December 31, 2025 Agency’s Response: Concur In fiscal year 2023, the process of holding quarterly reviews of deferred cases did not occur due to resources being diverted to focus on Strike Force activities involved in addressing the behavioral health crisis. Additionally, Office of the Inspector General (OIG) announced a re-organization in December 2023 that resulted in permanent transitions to other teams for several staff. Teams were given time to finalize cases and move items to other investigators in order to limit disruption to cases. By April 2024, after the Strike Force initiative had been unwound and the member team structure changes for personnel were finalized, the member team restarted its process of quarterly deferred case reviews. At the first review in April 2024, cases in the deferred backlog that were not completed in the timeframe set for the reviews were postponed to the next quarterly review in July. AHCCCS OIG commits to a review of the current Deferred Process and will determine areas of improvement to include timeliness for deferred case review completion, quarterly completed deferred case review reports, and required documentation for all deferred case processes.

View Audit 399861

Finding 1209138 (2024-115)

Material Weakness 2024

State of Arizona

AZ

Subrecipient Monitoring Reporting Procurement, Suspension & Debarment

Assistance listing numbers and program names 93.268 Immunization Cooperative Agreements 93.268 COVID-19- Immunization Cooperative Agreements 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) 93.323 COVID-19 - Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) ...

Assistance listing numbers and program names 93.268 Immunization Cooperative Agreements 93.268 COVID-19- Immunization Cooperative Agreements 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) 93.323 COVID-19 - Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Agency: Department of Health Services (DHS) Name of contact person and title: Lora Andrikopoulos , Grants Administrator Anticipated completion date: June 30, 2026 Agency’s Response: Concur ADHS will continue to work with the CQI Team, Financial Services - Assurance Team, Procurement, Program Managers, Finance Managers, Grants, and other internal partners to update the FFATA process. The process moving forward will include a communication plan, updates to the current standard work, the creation of a new standard work if necessary for the subaward communication process, and additional training.

View Audit 399861

Finding 1209130 (2024-120)

Material Weakness 2024

State of Arizona

AZ

Special Tests & Provisions Procurement, Suspension & Debarment Cash Management

Assistance listing number and program name: 93.778 Medicaid Assistance Program (Medicaid; Title XIX) 93.778 COVID-19 Medicaid Assistance Program (Medicaid; Title XIX) Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS...

Assistance listing number and program name: 93.778 Medicaid Assistance Program (Medicaid; Title XIX) 93.778 COVID-19 Medicaid Assistance Program (Medicaid; Title XIX) Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS Division of Business and Finance Anticipated completion date: December 31, 2027 Agency’s Response: Concur In May 2023, AHCCCS announced its initial findings of credible and willful fraud by sober-living providers across the state. Since then, AHCCCS has suspended more than 300 providers, assisted over 10,000 individuals with the humanitarian response, and implemented more than 20 new initiatives to combat fraud, waste, and abuse in the Medicaid program. As the extent of the fraud was revealed, AHCCCS recognized the need for comprehensive, system-wide strategies. AHCCCS partnered with the Attorney General and Governor’s Office to develop a comprehensive plan to address the loopholes fraudulent providers were exploiting. Actions Taken: ● Increased scrutiny of claims based on claims volume. ● Issued a moratorium on new provider registrations for impacted provider types. ● Prevented Reimbursement of Claims for Impossibly Rendered Services. ● Claims for Substance Abuse Services for Children under the age of 12 to Require Clinical Review Prior to Payment. ● Set thresholds for services to initiate a prepayment review. ● Required claims to be billed for specific dates of service rather than ranges. ● Flagged claims for services of the same style/overlapping codes. ● Created a prepayment review process for providers utilizing suspicious billing practices. ● Eliminated retroactive billing. ● Credible Allegation of Fraud suspensions include both provider entities and owners/ behavioral health (BH) practitioners. ● Implemented ID.Me identity verification for AHCCCS Online. ● Required providers to disclose any third-party billing relationships. ● BH Providers are now considered high-risk provider types for provider enrollment. ● Per Diem codes have been set to only be able to be billed once per day. ● Practitioners, including BH Technicians, can no longer be patients at the same provider. ● Worked with the Arizona Corporation Commission to flag suspicious registrations. ● Ensured AHCCCS coding adhered to National Correct Coding Initiative standards and confirmed no edits had been turned off. ● Streamlined AHCCCS reporting of bad actors to the appropriate professional oversight boards. ● Creation and publication of the Covered Behavioral Health Services Guide to connect all relevant AHCCCS policies and explain how they interact in the Behavioral Health System of Care. ● Robust changes to our AHCCCS Provider Enrollment System to address fraud, waste and abuse (FWA) issues. ● Update to the Behavioral Health Residential Facilities policy (to be published shortly) to provide greater detail and clarity for providers and members about what should and should not be included in services rendered by this provider type. ● Creation of the prepayment review process for fee for service claims and inclusion of data measurement to allow for agile modification going forward to respond to over utilization or abuse of codes. ● Creation of the Community Partner Assistor Organization Reviews to prevent abuse of access to the Health-e-Arizona Plus system. ● Designated pathways of partnering on large scale quality of care investigations between the Division of Fee for Service and managed care organizations to prevent unnecessary member impact. ● Social media campaign to encourage the public to report FWA/abuse & neglect. ● Requirement of all providers to transition to Electronic Funds Transfer. ● Removed the phone attestation option for American Indian Health Program (AIHP) enrollment, and are in the process of implementing the AIHP verification process with tribal partners and Indian Health Services based on utilization. ● Memorandums of Understanding with AZ Board of BH Examiners and Board of Nursing to promote interagency information sharing and referrals, as well as the close referral relationship with the Arizona Department of Health Services. ● Regular Public BH System Cross-Agency Collaboration meetings including all agencies, boards, commissions and the GO in the public health space ● Updates to the provider enrollment policy in AMPM 610, explicitly requiring many more disclosures of providers, and making it clear without full and transparent registration information, providers will be terminated or denied enrollment with AHCCCS. ● Implemented policies which required BH Professionals, required to oversee the clinical services provided at Behavioral Health Residential Facilities and Outpatient Behavioral Health Clinics, to be reported upon registration and be listed on claims submissions ● Mandatory transition to Electronic Fund Transfer (direct deposit) for all AHCCCS provider reimbursements ● Linking BHP to BH companies and facilities they work for Actions Remaining (but not limited to): Implementing eligibility integrity requirements for AIHP enrollment. ● Implementation of Alivia – a new AI powered data analytics platform for pre-pay and post-pay claims analysis, currently in the development and planning stage ● Conduct onsite quality of care reviews for patients in treatment longer than 90 days. ● Require medical records to define specialized services. ● Implement a new pre/post pay claims system. AHCCCS continuously monitors our systems and investigates instances of fraud, waste or abuse. Any areas of concern which are identified are then addressed and system improvements are made. Furthermore, AHCCCS utilizes data analysis to confirm that these system improvements are having the intended impacts and that provider networks remain robust.

View Audit 399861

Finding 1209115 (2024-108)

Material Weakness 2024

State of Arizona

AZ

Procurement, Suspension & Debarment Subrecipient Monitoring Matching / Level of Effort / Earmarking

Assistance listing numbers and program names: 93.575 Child Care and Development Block Grant 93.575 COVID-19 Child Care and Development Block Grant 93.596 Child Care Mandatory and Matching Funds of the Child Care and Development Fund 93.596 COVID-19 Child Care Mandatory and Matching Funds of the Chil...

Assistance listing numbers and program names: 93.575 Child Care and Development Block Grant 93.575 COVID-19 Child Care and Development Block Grant 93.596 Child Care Mandatory and Matching Funds of the Child Care and Development Fund 93.596 COVID-19 Child Care Mandatory and Matching Funds of the Child Care and Development Fund Agency: Department of Economic Security (DES) Name of contact person and title: Molly Bright, Community Services Division Assistant Director Anticipated completion date: June 30, 2026 Agency’s Response: Concur The Department of Economic Security will address the audit recommendations as follows: The Department will review, correct, and /or complete any incomplete or inaccurate information for its subawards on the Federal Funding Accountability and Transparency Act Subaward Reporting System. The Department will follow the State’s accounting manual for reporting subaward actions equaling or exceeding $30,000 no later than month-end of the month following the subaward action. The Department has implemented procedures that ensure that the contracts team communicates all new contracts and contract amendments in the APP.

View Audit 399861

Finding 1209098 (2024-112)

Material Weakness 2024

State of Arizona

AZ

Subrecipient Monitoring Procurement, Suspension & Debarment Reporting § 200.303

Assistance listing numbers and program names 84.010 Title I Grants to Local Education Agencies 84.367 Supporting Effective Instruction state Grants, Title II (formerly Improving Teacher Quality State Grants) 84.425D COVID-19 – Education Stabilization Fund –Elementary and Secondary School Emergency R...

Assistance listing numbers and program names 84.010 Title I Grants to Local Education Agencies 84.367 Supporting Effective Instruction state Grants, Title II (formerly Improving Teacher Quality State Grants) 84.425D COVID-19 – Education Stabilization Fund –Elementary and Secondary School Emergency Relief (ESSER) 84.425U COVID-19 – Education Stabilization Fund – American Rescue Plan – Elementary and Secondary School Emergency Relief (ARP-ESSER) Agency: Arizona Department of Education (ADE) Name of contact person and title: Matthew McClary, Grants Management Compliance Officer Nicole von Prisk, Deputy Associate Superintendent Anticipated completion date: October 2027 Agency’s Response: Concur The Arizona Department of Education has worked in cooperation with our vendor to correct outdated SQL queries that were identified and return only approved grant award amounts rather than all awarded amounts, regardless of approval status. This issue was causing several subaward amounts to incorrectly update. Moving forward, we are ensuring that the original award amounts are being queried and, in return, reported within SAM.gov (System for Award Management). Additionally, through the reconciliation process each month, correct award amounts will align with the corresponding Federal Award Identification Number (FAIN). Reports being submitted late: We have implemented an automated monthly reporting workflow/schedule which will help ensure required FFATA reporting is submitted timely. This process automation helps prompt monthly FFATA reporting uploads by leveraging office tools that are readily available and ensures monthly upload deadlines are met by automatically scheduling the task and requiring follow-up by the assignee. In January of 2024, the staff assigned to FFATA uploads changed again (for the fourth time in a year) and at that point a new staff member assumed responsibility for FFATA uploads. As numerous corrections needed were discovered through the reconciliation process, new reports were uploaded. Some of these were original uploads for entities that were missing SAM.gov (formerly FSRS) information altogether, and some were corrections to previously uploaded yet incorrect information. With each monthly upload, a new date was being captured and while some of the information was new entity award information, not all the information being updated was untimely. This has been a long and arduous process, and we look forward to not having continued FFATA findings, as we are making progress to correct award information for all federal grants moving forward from this point. Inaccurate and/or Incomplete Data: Our Compliance Officer conducts a monthly reconciliation of current SAM.gov award information in coordination with either the Lead Grants Coordinator or the Deputy Associate Superintendent. During this review, any missing, inconsistent, or duplicate data is identified and corrected prior to the upload into SAM.gov. Once the subawards have been uploaded, the reconciliation process is repeated to verify the accuracy of the information recorded within SAM.gov. Note: On October 30, 2025, we became aware that USASpending.gov was no longer updating subawards to correspond with the data we have submitted in SAM.gov. We raised a service desk ticket to USA Spending (Case 00089604), but the issue is ongoing. USA Spending has stated that they “are aware of an issue with the outbound API in SAM to USA Spending, but due to the lapse in funding, the SAM team working on this specific issue has been furloughed until funding is restored.” The reconciliation process where subawards uploaded to SAM.gov are compared to the data in USASpending.gov continues to be heavily impacted until this service is restored. To ensure accurate documentation and timely resolution of system related challenges encountered when submitting subawards in SAM.gov, the Compliance Officer has implemented a formal Incident Tracking process. All technical issues are logged at the time they occur, and each incident is subsequently submitted to the Federal Service Desk (FSD.gov). Upon submission, the incident is assigned an official Incident Request ID along with a corresponding date and time stamp, enabling effective monitoring and follow‑up. Grants Management will establish, implement, and enforce internal and external controls to ensure that risk is minimized and can be appropriately evaluated during any monitoring conducted by the agency. The internal and external controls that will be implemented will establish guidelines addressing conflicts of interest, related-party transactions, and insufficient segregation of duties. Implementation will be based on reference materials provided by the U.S. Department of Education Office of Inspector General, as well as technical assistance from organizations with legal and governmental expertise. ADE’s software will be updated appropriately.

View Audit 399861

Finding 1209083 (2024-103)

Material Weakness 2024

State of Arizona

AZ

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

Assistance listing number and program name: 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds Agency: Governor’s Office of Strategic Planning and Budgeting (Office) Name of contact person and title: Ben Henderson, Director Governor’s Office of Strategic Planning & Budgeting Anticipat...

Assistance listing number and program name: 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds Agency: Governor’s Office of Strategic Planning and Budgeting (Office) Name of contact person and title: Ben Henderson, Director Governor’s Office of Strategic Planning & Budgeting Anticipated completion date: December 31, 2026 Agency’s Response: Concur The Office agrees with this finding and will continue to take corrective action to bring the program fully into compliance with Coronavirus State and Local Fiscal Recovery Funds (SLFRF) Federal grant reporting requirements. The Office recognizes the importance of transparency in the use of Federal grants and has taken significant corrective action to resolve any inaccuracies in Federal grant reporting. The Office has implemented specific actions to ensure reporting inaccuracies and program expenditure understatements/overstatements do not occur. During fiscal year 2025 and 2026, the Office has taken corrective action to improve SLFRF reporting processes, including conducting weekly reviews and monthly reconciliations as outlined: ● Award Reconciliation — The Office has conducted a comprehensive review and extensive reconciliation of all awards to identify reporting inaccuracies. This reconciliation will continue as an ongoing process through the SLFRF closeout. ● Expenditure Reconciliation — The Office staff responsible for preparing the SLFRF quarterly reports is completing the reconciliation of all expenditures to the State’s accounting records, which are the official expenditures for the program. This will continue as an ongoing process through the SLFRF closeout. ● Enhanced Reporting Mechanisms—The Office will review, correct, and/or resubmit any inaccurately reported information. The staff responsible for preparing the SLFRF quarterly reports is no longer reconciling to the Office’s internal grants-management system. Reports will be compiled from the State’s accounting records, which are the official record of expenditures made for the program. The Office will investigate and resolve any differences prior to submitting the report to the federal agency. This will continue as an ongoing process through the SLFRF closeout. ● Update Procedures—Based on the comprehensive review noted in the response above, the Office is continuing to implement improved reporting procedures to ensure the accurate submission of grant expenditure data. This includes revised standardized templates, improved guidelines, and enhanced communication channels to improve reporting accuracy. ● Ongoing Training — Office staff now attend ongoing internal and external training to improve their understanding of compliance requirements, identify noncompliance, and actively reduce the risks of reporting errors. During fiscal years 2025 and 2026, staff engaged in 18 professional development opportunities, including monthly federal reporting calls, grants management webinars and trainings, internal training sessions, state accounting system training, and participation in a Microsoft data conference. These ongoing efforts reflect our commitment to staying current with compliance requirements and best practices. The Office will continue to strengthen internal controls to prevent similar issues in the future. This involves strengthening oversight, providing additional training to staff members in reporting processes, and implementing regular quality assurance checks. As of this date, the Office has allocated sufficient resources to comply with the award terms and program reporting requirements by establishing the Grants Technology and Data team dedicated to overseeing the necessary SLFRF program reporting procedures. The Office is committed to eliminating any risk through a full reconciliation of expenditures by the end of the program, which occurs during fiscal year 2027.

View Audit 399861

Finding 1208927 (2024-106)

Material Weakness 2024

State of Arizona

AZ

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303 § 200.334

Assistance listing number and program name: 21.023 COVID-19 Emergency Rental Assistance Program Agency: Department of Economic Security (DES) Name of contact person and title: Molly Bright, Community Services Division Assistant Director Anticipated completion date: June 30, 2026 Agency’s Response: C...

Assistance listing number and program name: 21.023 COVID-19 Emergency Rental Assistance Program Agency: Department of Economic Security (DES) Name of contact person and title: Molly Bright, Community Services Division Assistant Director Anticipated completion date: June 30, 2026 Agency’s Response: Concur The Department of Economic Security will address the audit recommendations as follows: The Department will prepare and retain detailed documentation, including system reports, queries, screenshots, and other evidence, to support the program information reported to the federal agency for each Emergency Rental Assistance Program (ERAP) award. DES will also abide by its ERAP policies and procedures to retain all records related to the award for a period of 5 years after all federal funds are expended. The Department sunset the ERAP program on October 13th, 2023, due to an exhaustion of ERA 1 and ERA 2 funding.

View Audit 399861

Finding 1208873 (2024-003)

Material Weakness 2024

County of Columbia, Pennsylvania

PA

Subrecipient Monitoring Reporting Special Tests & Provisions

2024-003 - (Noncompliance) Completion of Single Audit Federal Program: Assistance Listing #14.228 Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii, U.S. Department of Housing and Urban Development, Passed Through Pennsylvania Department of Community and Economi...

2024-003 - (Noncompliance) Completion of Single Audit Federal Program: Assistance Listing #14.228 Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii, U.S. Department of Housing and Urban Development, Passed Through Pennsylvania Department of Community and Economic Development and Pennsylvania Emergency Management Agency, Pass-Through Entity Identifying Numbers: C000073444, C000075689, C000082264, C000086078, and PEMA-2022-007 Condition/Context: The County’s December 31, 2023 Single Audit was not completed and submitted within the required time period. Recommendation: We recommend that as the County gets up and running on the new accounting system, the audit be prioritized in future periods. Views of Responsible Officials and Planned Corrective Actions: Management understands and is working to better anticipate the needs and timing and availability of staff/information to complete the audit. The County has a third party that compiles the information to give to the auditors for auditing. The County is hoping with this that the information being audited will be timelier to get the audit completed.

View Audit 399816

Finding 1208851 (2024-002)

Material Weakness 2024

City of Bloomington

IN

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

Information on the federal program: Federal Agency: Department of the Treasury Pass-Through Entity: N/A – Direct Grant Federal Program: Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Compliance Requirement: Reporting Audit Findings: Significant Deficienc...

Information on the federal program: Federal Agency: Department of the Treasury Pass-Through Entity: N/A – Direct Grant Federal Program: Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Compliance Requirement: Reporting Audit Findings: Significant Deficiency, Noncompliance Condition: City of Bloomington completed quarterly reporting in a timely manner. However, the reports did not have evidence of segregation of duties and the cumulative expenses stated on the report did not agree to the cumulative expenditures reported on previous SEFAs. Context: During our testing procedures over CSLFRF reporting, we noted that segregation of duties is not present in the Federal reporting process. The Deputy Controller prepared and submitted the reports without a secondary review taking place. As a result, the City did not report cumulative expenditures for the grant that were consistent with the expenditures reported on the SEFA. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and has already implemented a policy effective third quarter of 2025 to ensure a documented two-person review process and reconciliation of costs to the report. Responsible party and timeline for completion: The Controller is responsible for overseeing the implementation of the corrective action plan and will ensure the appropriate personnel are involved in the review and reconciliation process. The corrective action plan has already been implemented effective for the third quarter of 2025.

View Audit 399810

Corrective Action Plans

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