Corrective Action Plans

Finding 515470 (2023-132)

Material Weakness 2023

State of Arizona

AZ

Questioned Costs Special Tests & Provisions Material Weakness

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

Assistance listing number and program name: 93.778 Medicaid Assistance Program (part of the Medicaid Cluster 93.778 COVID-19 Medicaid Assistance Program Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS Division of Budget and Finance Anticipated completion date: December 31, 2024 Agency’s Response: Concur AHCCCS concurs with the finding and would like to note this matter was discovered through internal review of OIG recoupment documentation and filings with 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. Efforts to eliminate this from occurring in the future include recently filling the related following positions that experienced turnover: Accounting Supervisor, Reporting Administrator, and 2 Accounting Specialists. In addition, AHCCCS has increased collaboration across the respective departments and divisions to ensure the federal share of all case recoupments is timely returned to CMS. Further, we have revised our standard work processes to include monthly reconciliations of case recoupments among the various departments and divisions. AHCCCS anticipates to have returned the federal share to CMS for all case recoupments identified by December 31, 2024.

View Audit 333243 Questioned Costs: $1

Finding 515469 (2023-131)

Material Weakness 2023

State of Arizona

AZ

Questioned Costs Special Tests & Provisions Material Weakness

Assistance listing number and program name: 93.778 Medicaid Assistance Program (part of the Medicaid Cluster 93.778 COVID-19 Medicaid Assistance Program Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact persons and titles: Vanessa Templeman, Inspector General, AHCCCS Offic...

Assistance listing number and program name: 93.778 Medicaid Assistance Program (part of the Medicaid Cluster 93.778 COVID-19 Medicaid Assistance Program 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 Budget and Finance Anticipated completion date: December 31, 2024 Agency’s Response: Concur AHCCCS OIG agrees with the finding as stated above. AHCCCS OIG commits to a review of the current Deferred Process and will determine areas of improvement to include; timelines for deferred case review completion, quarterly completed deferred case review reports, and required documentation for all deferred case processes.

View Audit 333243 Questioned Costs: $1

Finding 515468 (2023-130)

Material Weakness 2023

State of Arizona

AZ

Questioned Costs Special Tests & Provisions Procurement, Suspension & Debarment

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

Assistance listing number and program name: 93.778 Medicaid Assistance Program (part of the Medicaid Cluster 93.778 COVID-19 Medicaid Assistance Program Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS Division of Budget and Finance Anticipated completion date: December 31, 2024 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 initiates to combat fraud, waste, and abuse in the Medicaid program. As the extent of the fraud was revealed, AHCCCS recognized the need for holistic and systemwide changes. AHCCCS partnered with the Attorney General and Governor’s Office to develop a comprehensive plan to address the loopholes fraudulent providers were exploiting. Stop gap strategies implemented include, but may not limited to the following: · 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 (“CAF”) 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. · Behavioral Health 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 Behavioral Health 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 (“NCCI”) standards and confirmed no edits had been turned off. · Streamlined AHCCCS reporting of bad actors to the appropriate professional oversight boards. Stop gap strategies in process include, but may not be limited to, the following: · Implementing eligibility integrity requirements for AIHP enrollment. · Linking BHP to BH companies they work for. · Link BH Providers to BH facilities they work at. · 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. · Mandatory transition to Electronic Fund Transfer (direct deposit) for all AHCCCS provider reimbursements. AHCCCS continues to investigate and identify areas of concern and implement necessary system improvements until it is determined that the integrity of the AHCCCS provider network is restored.

View Audit 333243 Questioned Costs: $1

Finding 515447 (2023-112)

Material Weakness 2023

State of Arizona

AZ

Subrecipient Monitoring Matching / Level of Effort / Earmarking Reporting

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 ...

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: Arizona Department of Economic Security (DES) Name of contact person and title: Martha Franquemont, DES Business Administrator Anticipated completion date: June 30, 2025 Agency’s Response: Concur The Department of Economic Security will address the audit recommendations as follows: The Department will immediately report the required missing information for its subawards on the FFATA Subaward Reporting System for this cluster. The Department will also 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. In addition, the Department will redirect and train existing resources to ensure FFATA reports are compiled, reviewed, and submitted timely.

View Audit 333243

Finding 515369 (2023-127)

Material Weakness 2023

State of Arizona

AZ

Allowable Costs / Cost Principles Cash Management Reporting § 200.301 § 200.302 § 200.303

Assistance listing numbers and program names: 84.425D COVID-19 - Education Stabilization Fund—Elementary and Secondary School Emergency Relief (ESSER) Fund 84.425R COVID-19 - Coronavirus Response and Relief Supplemental Appropriations Act, 2021 – Emergency Assistance to Non-Public Schools (CRSSA EAN...

Assistance listing numbers and program names: 84.425D COVID-19 - Education Stabilization Fund—Elementary and Secondary School Emergency Relief (ESSER) Fund 84.425R COVID-19 - Coronavirus Response and Relief Supplemental Appropriations Act, 2021 – Emergency Assistance to Non-Public Schools (CRSSA EANS) Agency: Arizona Department of Education (ADE) Name of contact persons and titles: Michelle Udall, ADE Associate Superintendent Dr. Sarka White, ADE Deputy Associate Superintendent Anticipated completion date: November 30, 2024 Agency’s response: Concur ESSER Reporting will be validated by at least 2 people before submitting to U.S. Department of Education. This validation will include the reconciliation of data from the LEA to ADE's report. ADE is finalizing policies and procedures for validating the data prior to submission. ADE has already begun implementing a reconciliation system to ensure accurate reporting in the EANS annual performance report. This system tracks obligations by category, expenses, and appropriate earmarking of nonpublic schools (e.g., DUNS/UEI, grades served). ADE is finalizing general policies and procedures for how this data is compiled, interpreted, and reported based on the initial implementation and corrections of the EANS program.

View Audit 333243

Finding 515367 (2023-104)

Significant Deficiency 2023

State of Arizona

AZ

Subrecipient Monitoring Reporting § 200.303

Assistance listing number and program name: 84.425C COVID-19 - Education Stabilization Fund –Governor’s Emergency Education Relief (GEER) Fund Agency: Arizona Governor’s Office of Strategic Planning and Budgeting (Office) Name of contact person and title: Sarah Brown, Director Anticipated completion...

Assistance listing number and program name: 84.425C COVID-19 - Education Stabilization Fund –Governor’s Emergency Education Relief (GEER) Fund Agency: Arizona Governor’s Office of Strategic Planning and Budgeting (Office) Name of contact person and title: Sarah Brown, Director Anticipated completion date: May 1, 2025 Agency’s response: Concur Corrective Action Plan: The Office agrees with this finding and will begin to take corrective action to bring the program fully into compliance with FFATA reporting requirements under federal and state guidelines. The Office previously reported staff turnover for key personnel directly responsible for preparing, submitting, and reviewing FFATA reporting (i.e., 100 percent turnover). After reviewing supporting documentation and consulting with the U.S. Department of Education, the Office has determined that staff misinterpreted the reporting guidance. The Office understood the reporting did not require submissions on subawards made by another state agency. The Office did report the awards made to that respective state agency but did not include the agency subawards. The Office is working with the state agency to collect subaward data required for accurate reporting. During fiscal year 2025, the Office took significant corrective action to improve FFATA reporting. This corrective action plan includes the following: • FFATA Reporting Reconciliation—The Office will review, correct, and/or resubmit any inaccurately reported information, including subawards. • Annual Performance Reporting (APR) Reconciliation—The Office is unable to amend and resubmit the fiscal year 2022 APR per guidance from the U.S. Department of Education - Education Stabilization Fund Reporting Helpdesk. The reporting portal is unable to accept any revisions for fiscal year 2022. The Office will review any current reporting and ensure subaward data is included. • Update Written Procedures—The Office will update its written procedures to incorporate a process for reviewing federal guidance on a schedule aligned with federal reporting windows as applicable. • 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. As of this date, the Office has allocated sufficient resources to comply with the award terms and program requirements by establishing a Grants Compliance and Reporting Team dedicated to performing necessary FFATA reporting procedures. The Office is committed to ongoing staff training, improved internal reporting processes, and ensuring the State’s stakeholders and the public have access to transparent and timely information about all federal award spending decisions on the USAspending.gov website as federal laws and regulations require.

View Audit 333243

Finding 515348 (2023-126)

Material Weakness 2023

State of Arizona

AZ

Reporting Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303

Assistance listing number and program name: 84.010 Title I Grants to Local Educational Agencies 84.367 Supporting Effective Instruction State Grants (formerly Improving Teacher Quality State Grants) 84.425D COVID-19 - Education Stabilization Fund-Elementary and Secondary School Emergency Relief (ESS...

Assistance listing number and program name: 84.010 Title I Grants to Local Educational Agencies 84.367 Supporting Effective Instruction State Grants (formerly Improving Teacher Quality State Grants) 84.425D COVID-19 - Education Stabilization Fund-Elementary and Secondary School Emergency Relief (ESSER) Fund 84.425U COVID-19 - Education Stabilization Fund - American Rescue Plan - Elementary and Secondary Schools Emergency Relief (ARP ESSER) Fund Agency: Arizona Department of Education (ADE) Name of contact persons and titles: Nicole Von Prisk, ADE Deputy Associate Superintendent of Grants Management Matt McClary, ADE Compliance Officer Anticipated completion date: October 30, 2024 Agency’s response: Concur Arizona Department of Education has worked in cooperation with our vendor to correct outdated SQL queries that were identified and returning only approved grant award amounts rather than all awarded amounts, regardless of approval status. We will ensure that the original award amounts are being queried and, in return, reported within the FFATA Subaward Reporting System (FSRS). Additionally, through the reconciliation process each month, correct award amounts will align with corresponding Federal Award Identification Number (FAIN). 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 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 of 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 correcting award information for all federal grants moving forward from this point. Our Compliance Officer reconciles the current FSRS award information monthly with our Lead Grants Coordinator or our Deputy Associate Superintendent. Any missing or duplicate information is corrected prior to the FSRS upload.

View Audit 333243

Finding 515227 (2023-106)

Material Weakness 2023

State of Arizona

AZ

Questioned Costs Subrecipient Monitoring Reporting § 200.303 § 200.331 § 200.332

Assistance listing number and program name: 21.027 COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Agency: Arizona Department of Economic Security (DES) Name of contact person and title: Jim Whallon, DES Deputy CFO Anticipated completion date: June 30, 2026 Agency’s response: Concur Th...

Assistance listing number and program name: 21.027 COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Agency: Arizona Department of Economic Security (DES) Name of contact person and title: Jim Whallon, DES Deputy CFO Anticipated completion date: June 30, 2026 Agency’s response: Concur The Department of Economic Security will address the audit recommendations as follows: 1. Perform required monitoring of its subrecipients and their compliance with the award terms and program requirements. The Department will revise its agency-wide policies and procedures related to single audit requirements for pass-through entities to include guidance regarding how to establish effective subrecipient monitoring procedures. The Department will also offer additional subrecipient monitoring guidance for programs administered by divisions with existing subrecipient monitoring findings. 2. Properly classify and report subrecipient expenditures on the State’s SEFA. The Department will revise its procedures related to single audit requirements to include steps detailing the instructions for classifying and reporting subrecipient expenditures on the State’s SEFA. The updated procedures will include actions needed to be taken to ensure each pass-through relationship is appropriately determined and that every subrecipient relationship is communicated to the staff responsible for compiling the State’s SEFA. 3. Develop, implement, and train all divisions on entity-wide written subrecipient-monitoring policies and procedures requiring all divisions to: a. Assess the risk of each subrecipient’s noncompliance and carry out monitoring activities based on those risk assessments such as reviewing financial and performance reports, providing training or technical assistance on program-related matters, and performing on-site reviews, selective audits, and/or other monitoring procedures. b. Verify subrecipients receive timely single audits, if required; follow up on and ensure that corrective action is taken on any audit findings that could potentially affect the program; and issue management decisions for any audit findings pertaining to the federal award. c. Maintain documentation of monitoring procedures demonstrating they were performed, including the monitoring procedures’ results and any Department actions taken, if appropriate. In addition to the revisions in policy and procedures outlined in Recommendation #1 above, the Department will train staff responsible for administering compliance requirements for pass-through entities. This training will include instructions to formulate a risk assessment, review controls related to compliance requirements, review timely single audit submittal, follow up on audit findings, issue management decisions for findings, and maintain adequate documentation of monitoring procedures. The training will be provided to all staff responsible for administering programs with pass-through entities. 4. Allocate sufficient resources, such as staffing, to comply with the award terms and program requirements, and designate individuals within each division to perform necessary subrecipient-monitoring procedures. The Department will conduct analyses to determine resources needed, including staffing, to ensure compliance with applicable requirements. For example, the Department will assess the efficiency of its subrecipient-monitoring procedures, estimate future workloads, determine staffing needed to meet those workloads, and assign sufficient staff the responsibility for ensuring compliance with each requirement outlined in the federal award. The Department will also ensure the staff responsible for administering the compliance requirements prioritize this responsibility and communicate anticipated compliance deficiencies to management. 5. Update the form it uses to determine whether other parties receiving program monies have the role of a subrecipient or contractor to include guidance for how to determine each characteristic of a subrecipient and contractor relationship and require a conclusion to be documented. In addition, train staff to properly complete the form and perform supervisory reviews of it. The Department will revise its Contractor/Subrecipient Determination form to clearly identify the final determination of a pass-through entity. The Department will also provide guidance to accompany the form that shows how to determine each characteristic of a subrecipient and contractor as well as how to make the final determination regarding the contractor versus subrecipient relationship. The Department will then provide training to staff responsible for using this form as part of the training outlined in Recommendation #3 above.

View Audit 333243 Questioned Costs: $1

Finding 515225 (2023-103)

Material Weakness 2023

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: Arizona Governor’s Office of Strategic Planning and Budgeting (Office) Name of contact person and title: Sarah Brown, Director Anticipated completion date: February 28, 2025 Agency...

Assistance listing number and program name: 21.027 COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Agency: Arizona Governor’s Office of Strategic Planning and Budgeting (Office) Name of contact person and title: Sarah Brown, Director Anticipated completion date: February 28, 2025 Agency’s response: Concur The Office agrees with this finding and will begin to take corrective action to bring the program fully into compliance with SLFRF Federal grant reporting requirements. The Office recognizes the importance of transparency in utilizing 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, the Office is taking corrective action to improve SLFRF reporting, including the following: • Award Reconciliation—The Office has conducted a comprehensive review and extensive reconciliation of all awards to identify reporting inaccuracies. • 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 made for the program. • 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. • Update Written Procedures—Based on the comprehensive review noted in the response above, the Office is working to develop improved reporting procedures to ensure accurate submission of grant expenditure data. This may include 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. The Office will continue to strengthen internal controls to prevent similar issues from occurring in the future. This will involve 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 a new Grants Technology and Data team dedicated to the oversight of performing necessary SLFRF program reporting procedures.

View Audit 333243

Finding 515214 (2023-108)

Significant Deficiency 2023

State of Arizona

AZ

Period of Performance Reporting Internal Control / Segregation of Duties § 200.303 § 200.344

Assistance listing number and program name: 21.023 COVID-19 - Emergency Rental Assistance Program Agency: Arizona Department of Economic Security (DES) Name of contact person and title: Leanna DeKing, DES Policy Planning Project Manager Anticipated completion date: June 30, 2025 Agency’s Response: ...

Assistance listing number and program name: 21.023 COVID-19 - Emergency Rental Assistance Program Agency: Arizona Department of Economic Security (DES) Name of contact person and title: Leanna DeKing, DES Policy Planning Project Manager Anticipated completion date: June 30, 2025 Agency’s Response: Concur The Department of Economic Security will address the audit recommendations as follows: The Department will ensure program costs are properly recorded in the financial system during the period of performance and only obligated costs are spent during the liquidation period. Closeout activities, such as direct administrative costs, will be obligated prior to the end of the award period and spent within the liquidation period, or 120 calendar days after the period of performance ends. The Department will allocate sufficient resources to perform essential grant closeout functions to help prevent inappropriate charges. The Department will also update existing grant closeout procedures to require a review and approval of grant expenditures during the liquidation period to ensure they are allowable and properly obligated prior to the period of performance end date.

View Audit 333243

Finding 515213 (2023-107)

Material Weakness 2023

State of Arizona

AZ

Reporting Period of Performance Internal Control / Segregation of Duties § 200.303 § 200.334

Assistance listing number and program name: 21.023 COVID-19 - Emergency Rental Assistance Program Agency: Arizona Department of Economic Security (DES) Name of contact person and title: Molly Bright, DES CCSD Assistant Director Anticipated completion date: June 30, 2025 Agency’s response: Concur The...

Assistance listing number and program name: 21.023 COVID-19 - Emergency Rental Assistance Program Agency: Arizona Department of Economic Security (DES) Name of contact person and title: Molly Bright, DES CCSD Assistant Director Anticipated completion date: June 30, 2025 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 supporting the program information being reported to the federal agency for each Emergency Rental Assistance Program (ERAP) award. DES will also abide by its policies and procedures to retain all records relating to federal awards for a period of 5 years after all the federal funds are expended. For future related programs with this requirement, the Department will develop and implement internal control policies and procedures that ensure systems properly display complete and accurate data on the federal reporting dashboard as instructed by the federal agency’s reporting guidelines. Additionally, these policies and provisions will ensure that any future ERAP award funding received by the Department will be separately reported to avoid commingling. Finally, the Department will require that ERAP personnel verify the reported program information to ensure all report element sections are complete and accurate, and that it matches the underlying benefits and financial systems data. The Department sunset the ERAP program on October 13th, 2023, due to an exhaustion of ERA 1 and ERA 2 funding.

View Audit 333243

Finding 515207 (2023-110)

Significant Deficiency 2023

State of Arizona

AZ

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

Assistance listing number and program name: 17.225 Unemployment Insurance Agency: Arizona Department of Economic Security (DES) Name of contact person and title: Tracy Raymer, DES Business Analyst Manager Anticipated completion date: June 30, 2025 Agency’s Response: Concur The Department of Economi...

Assistance listing number and program name: 17.225 Unemployment Insurance Agency: Arizona Department of Economic Security (DES) Name of contact person and title: Tracy Raymer, DES Business Analyst Manager Anticipated completion date: June 30, 2025 Agency’s Response: Concur The Department of Economic Security will address the audit recommendations as follows: Develop and implement written policies and procedures to ensure it prepares and retains detailed documentation, such as system reports, queries, or screenshots, to support the program information it reports to the federal agency for the UI program for a period of at least three (3) years. Beginning July 2024, the Department has assembled and retained all detailed supporting source documentation that supports the data provided in the 9050 - Time Lapse of All First Payments except Workshare report and will retain it for a period of no less than three (3) years.

View Audit 333243

Finding 515206 (2023-109)

Significant Deficiency 2023

State of Arizona

AZ

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

Assistance listing number and program name: 17.225 Unemployment Insurance Agency: Arizona Department of Economic Security (DES) Name of contact persons and titles: Jacqueline Butera, DES Administrator Jean Ahumada, DES BAM Manager Anticipated completion date: March 18, 2024 Agency’s Response: Concu...

Assistance listing number and program name: 17.225 Unemployment Insurance Agency: Arizona Department of Economic Security (DES) Name of contact persons and titles: Jacqueline Butera, DES Administrator Jean Ahumada, DES BAM Manager Anticipated completion date: March 18, 2024 Agency’s Response: Concur The Department of Economic Security will address the audit recommendations as follows: The controls the Department put in place to address the federal regulation requirements, are multi-year remediation plans. The controls include recruiting and retaining a workforce with a strong knowledge and understanding of Unemployment Insurance Laws, Policies, and Procedures, as well as proper case management skills. From December 2022 through March 2024, the Benefit Accuracy and Measurement (BAM) unit experienced an 18 percent attrition rate. Given the fact that the BAM unit is made up of nine (9) auditors, one of which is a lead who does not receive a full caseload, an 18 percent attrition rate results in a significant impact on the distribution of workloads amongst experienced and new staff, respectively. As of December 2023, the BAM unit was 90 percent staffed with only 67 percent of auditors working a full caseload. This is because new hires with prior program knowledge do not receive a full caseload until three (3) months from their new hire date. During SFY 2023, the Department carefully balanced meaningful recruitments, staff training, and case assignments in order to support staff retention while addressing the federal timeliness requirements. As of March 18, 2024, the Department fully implemented the multi-year remediation plan, and has shown sustainable performance improvement in both the paid and denied claims accuracy measures since September 2023, due to these controls. As of SFY 2024, the Department has met all Paid Case Accuracy and Denied Case Accuracy timeliness performance measures.

View Audit 333243

Finding 515177 (2023-114)

Significant Deficiency 2023

State of Arizona

AZ

Subrecipient Monitoring Reporting § 200.303

Assistance listing numbers and program names: 17.258 WIOA Adult Program 17.259 WIOA Youth Activities 17.278 WIOA Dislocated Worker Formula Grants Agency: Arizona Department of Economic Security (DES) Name of contact persons and titles: Aaron Johnson, DES Fiscal Compliance Manager Jacy Wilmes, DES D...

Assistance listing numbers and program names: 17.258 WIOA Adult Program 17.259 WIOA Youth Activities 17.278 WIOA Dislocated Worker Formula Grants Agency: Arizona Department of Economic Security (DES) Name of contact persons and titles: Aaron Johnson, DES Fiscal Compliance Manager Jacy Wilmes, DES Deputy Business Administrator Anticipated completion date: June 30, 2025 Agency’s Response: Concur The Department of Economic Security will address the audit recommendations as follows: The Department will immediately report the required missing information for its subawards on the FFATA Subaward Reporting System for the WIOA cluster. The Department will also follow the State’s accounting manual for reporting subaward actions equaling or exceeding $30,000 no later than the month-end of the month following the sub-award action. In addition, the Department will implement procedures requiring independent reviews to ensure the sub-award data is reviewed for accuracy prior to and after uploading to the federal government’s reporting system.

View Audit 333243

Finding 515148 (2023-004)

Material Weakness 2023

Knotts Family Agency

CA

Allowable Costs / Cost Principles Reporting

1. Engaging CDSS for Clarification: KFA will formally engage the California Department of Social Services (CDSS) to clarify the applicability of federal guidelines for fee-for-service foster care providers. This includes obtaining specific guidance on financial reporting structure and reconciliation...

1. Engaging CDSS for Clarification: KFA will formally engage the California Department of Social Services (CDSS) to clarify the applicability of federal guidelines for fee-for-service foster care providers. This includes obtaining specific guidance on financial reporting structure and reconciliation requirements. 2. Enhancing Financial Management Systems: KFA is implementing a financial management system capable of tracking costs by funding source, program, and passthrough entity. This system will facilitate accurate allocation of both direct and indirect costs and ensure compliance with federal guidelines. 3. Developing Comprehensive Cost Allocation Methodology: A consistent and documented cost allocation methodology is being developed, which includes time certifications for staff whose work spans multiple programs. This methodology will be reviewed annually to ensure continued compliance with applicable regulations. 4. Strengthening FC32 Reporting: Processes are being established to reconcile FC32 reports with functional expense statements. Allocations for executive salaries to the federal program will adhere to the federal executive level 2 salary limitation as required. 5. Training and Documentation: Financial and administrative staff are receiving training on cost allocation principles, federal salary limitations, and FC32 reporting requirements. Comprehensive documentation of all methodologies and calculations will be maintained for transparency and audit readiness. 6. Monthly Reconciliations: A monthly reconciliation process is being implemented to ensure expenditures and revenues align with the terms and conditions of the foster care program.

View Audit 333188

Finding 515096 (2023-002)

Significant Deficiency 2023

Caldwell County, Missouri

MO

Subrecipient Monitoring Reporting HUD Housing Programs § 200.510

I was a newly elected official in 2023 with no prior training in the County Clerk’s office. After this finding was brought to my attention, I created a process where all grants received are tracked as are the expenditures for each grant so they can accurately be reported.

View Audit 333148

Finding 515086 (2023-003)

Significant Deficiency 2023

Shalom Health Care Center, Inc.

IN

Reporting

The following steps have been taken or will be taken to address Finding 2023-003: Shalom Health Care Center, inc. has been working with the auditor and reviewing the guidance for the preparation of the SEFA. Shalom will ensure that all program clusters are properly listed. (Management did challenge...

The following steps have been taken or will be taken to address Finding 2023-003: Shalom Health Care Center, inc. has been working with the auditor and reviewing the guidance for the preparation of the SEFA. Shalom will ensure that all program clusters are properly listed. (Management did challenge this as being a Significant Deficiency and believes that it should be listed as a note). Contact Person: Michael A. Nio, Chief Financial Shalom Health Care Center, Inc. anino@shalomhealthcenter.org 317-269-7198

View Audit 333141

Finding 515081 (2023-001)

Material Weakness 2023

Shalom Health Care Center, Inc.

IN

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Cash Management

The following steps have been taken or will be taken to address Finding 2023-001: Shalom Health Care Center, Inc. has made some changes in how the draws are done with each payroll versus previously per month. Shalom has also hired new staff to help keep up with the grants and payrolls and entering d...

The following steps have been taken or will be taken to address Finding 2023-001: Shalom Health Care Center, Inc. has made some changes in how the draws are done with each payroll versus previously per month. Shalom has also hired new staff to help keep up with the grants and payrolls and entering data into the accounting system, as we had previously had turnover and were using temp services for some of the prior year. Contact Person: Michael A. Nino, Chief Financial Shalom Health Care Center, Inc. anino@shalomhealthcenter.org 317-269-7198

View Audit 333141

Finding 514703 (2023-008)

Material Weakness 2023

Career Academy of South Bend, INC

IN

Reporting School Nutrition Programs § 200.512

2023-008 Reporting Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding. The necessary reports will be filed as soon as they are available.

View Audit 333072

Finding 514671 (2023-004)

Material Weakness 2023

Career Academy of South Bend, INC

IN

Reporting Material Weakness

2023-004 PREPARATION OF SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and has created and filled the position of Manager of Grants Management. This staff member will be responsible for the oversight and m...

2023-004 PREPARATION OF SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and has created and filled the position of Manager of Grants Management. This staff member will be responsible for the oversight and management of all grants. Additionally, the School has contracted with an outside firm that specializes in State Board of Accounts compliance, as well as Federal Award Compliance in line with Uniform Guidance. The firm will assist in the development of the required manuals, policies, procedures and review processes. The current estimated completion date is February 28, 2025.

View Audit 333072

Finding 514656 (2023-002)

Material Weakness 2023

International Registration Plan, Inc.

VA

Reporting

We have alerted the Federal Motor Carrier Safety Administration (“FMCSA”) as to the error and will work with them to correct the reporting of these expenditures upon submission to the Federal Audit Clearinghouse of the data collection form and single audit reporting package for the year ended Septem...

We have alerted the Federal Motor Carrier Safety Administration (“FMCSA”) as to the error and will work with them to correct the reporting of these expenditures upon submission to the Federal Audit Clearinghouse of the data collection form and single audit reporting package for the year ended September 30, 2023.

View Audit 333064

Finding 514639 (2023-002)

Material Weakness 2023

Children's Place Association

IL

Subrecipient Monitoring Reporting

Reporting – The Association agrees that certain monthly reports were not submitted in accordance with due dates. The Association has hired a Grant Administrator whose responsibility is to ensure timely submission of monthly reports. Anticipated Completion Date - December 31, 2024; Responsible ...

Reporting – The Association agrees that certain monthly reports were not submitted in accordance with due dates. The Association has hired a Grant Administrator whose responsibility is to ensure timely submission of monthly reports. Anticipated Completion Date - December 31, 2024; Responsible Contact Person for Planned Corrective Action - LaToyia Neal, CFO

View Audit 333009

Finding 514627 (2023-002)

Material Weakness 2023

Hartley-Melvin-Sanborn Community School District

IA

Internal Control / Segregation of Duties Reporting

The District will review its control procedures to obtain the maximum internal control possible.

View Audit 332999

Finding 514624 (2023-001)

Significant Deficiency 2023

Rape Crisis Center of Collin County

TX

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

Finding Number: 2023-001: Allowable Costs – 4 out of the 25 samples tested did not have documented approval from management of the charges on the credit card statement prior to payment. Planned Corrective Action: The Turning Point has an established credit card policy which outlines the appropriate ...

Finding Number: 2023-001: Allowable Costs – 4 out of the 25 samples tested did not have documented approval from management of the charges on the credit card statement prior to payment. Planned Corrective Action: The Turning Point has an established credit card policy which outlines the appropriate approval processes. We have addressed the previous Finance Director’s non-compliance of this policy by providing training on this process to the new Finance Director, have begun implementing regular audits, and ensuring senior leadership has access to all documents needed for approval. Future adherence will be monitored through quarterly reviews and disciplinary action for noncompliance. Anticipated Completion Date: October 1, 2024 Responsible Contact Person: Tana Rice, Director of Finance

View Audit 332994

Finding 514439 (2023-003)

Material Weakness 2023

Eastern Carolina Human Services Agency, Inc.

NC

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.512

Eastern Carolina Human Services Agency, Inc. Corrective Action Plan For FY Ending June 30, 2023 ...

Eastern Carolina Human Services Agency, Inc. Corrective Action Plan For FY Ending June 30, 2023 Section II. Financial Statement Findings. 1. Finding 2023-001 - U.S. Department of Health and Human Services, Community Services Block Grant, Assistance Listing #93.569; U.S. Department of Housing and Urban Development, Housing Voucher Cluster, Assistance Listing #14.871/14.879. Statement of Condition: Internal control processes over financial accounting did not ensure that all transactions were properly recorded. Internal control processes over financial accounting did not ensure that key accounts were reconciled or received on a periodic basis. Contact Person: Ashlee Graziano, Finance Officer, or Trudy Murray, Executive Director. Action Plan: After review/monitoring of the previous Finance Officers duties and responsibilities, it was determined that the internal control processes of the finance department were not carried out properly to meet the requirements of 2 CFR Part 200 Section 200.302. Therefore, the agency terminated the Finance Officer. The agency immediately began the search for a new Finance Officer via Indeed and other employment hiring agencies. This process took much longer than expected which left an unexperienced Accounting Technician to operate the Finance Department along with limited finance knowledge of the Executive Director. After several advertisements for the vacant position the agency interviewed numerous applicants and was finally able to hire the current Finance Officer. The Finance Officer has worked continuously to insure that the internal control process of the department is implemented by making sure all accounts are reconciled and reviewed with supporting evidence of each review. With this process back in place, management and the Board of Directors will review and sign off on each account's financial statements. Additionally, the agency has approved and scheduled HUD training for the Finance Officer through Nan McCay. Further, financial and accounting training for the Finance Officer/ Finance Department has already been requested through the agency's local HUD Field Office analysis in Greensboro, NC. Finding 2023-002 - U. S. Department of Housing and Urban Development Voucher Cluster, Assistance Listing #14.871/14.879 Statement of Condition: For the year ended June 30, 2022, the Organization did not submit their audited financial statements to HUD by the required deadline. For the year ended June 30, 2023, the Origination did not submit their unaudited or audited financial statements to HUD by the required deadline. Contact Person: Ashlee Graziano, Finance Officer, or Trudy Murray, Executive Director Action Plan: The submittal of the GAAP-based unaudited and audited report for FY ending June 30, 2022, was a management oversight due to the lack of a Finance Officer in place. The agency currently has a Finance Officer in place who will submit timely GAAP-based unaudited and audited financial information electronically to HUD via the Financial Assessment Sub-System (FASS-PH). Additionally, the agency has approved and scheduled HUD training for the Finance Officer through Nan McCay. Further, financial and accounting training for the Finance Officer/ Finance Department has already been requested through the agency's local HUD Field Office analysis in Greensboro, NC. Finding 2023-03 - U.S. Department of Health and Human Services Community Services Block Grant, Assistance Listing #93.569; U.S. Department of Housing and Urban Development, Housing Voucher Cluster, Assistance Listing #14.871/14.879. Statement of Condition: The origination did not submit the data collection form and required reporting package to the Federal Audit Clearinghouse (FAC) for the year ended June 30, 2023, by the required due date. Contact Person: Ashlee Graziano, Finance Officer, or Trudy Murray, Executive Director Action Plan: Management will ensure that the audit and data collection forms are completed timely and the data collection form and required reporting package are submitted electronically to the FAC each fiscal year going forward. To further ensure this finding is resolved, training for the Finance Officer/Finance Department has already been requested through the agency's local HUD Field Office analysis in Greensboro, NC. Section II - Findings relating to the financial statements which are required to be reported in accordance with generally accepted government auditing standards. 1. Finding 2022-001 Statement of Condition: Controls over the vendor payment process were not properly followed. Action Plan: Submitted previously with Financial Statements and Independent Auditor's Report FY Ended June 30, 2022. Current Status: Corrected The Management Department (Finance Officer and Executive Director), with the supervision of the Board of Directors Finance Officer, will continue to make every effort necessary to meet all HUD submission as required, in order to be in compliance with all HUD rules and regulations. Respectfully submitted, Trudy Murray Executive Director

View Audit 332768

Corrective Action Plans

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