Corrective Action Plans

Finding 316199 (2022-052)

Material Weakness 2022

State of Colorado

CO

Internal Control / Segregation of Duties Reporting Eligibility

(A) The Department agrees with the audit recommendation to develop and implement formal written policies and procedures. Prior to this audit, the Department began creating formal written policies and procedures for site case reviews, maintenance of supporting documentation, timely training for faile...

(A) The Department agrees with the audit recommendation to develop and implement formal written policies and procedures. Prior to this audit, the Department began creating formal written policies and procedures for site case reviews, maintenance of supporting documentation, timely training for failed workers, and performance of timely re-certification of presumptive eligibility sites (PE site). This finding had no known questionable cost associated with it. (B) The Department agrees with the audit recommendation to develop an effective tracking mechanism to identify and monitor PE sites that are due for re-certification every two years and ensuring that the recertifications are performed. Prior to this audit, the Department began developing a tracking mechanism for PE site re-certifications. This finding had no known questionable cost associated with it. (C) The Department fixed enrollment information for Fiscal Year 2020 and 2021 in CBMS for beneficiaries who were no longer eligible for presumptive eligibility and have either had their benefits terminated or were moved to the regular Medicaid and Children?s Basic Health Plan programs. The Department is currently performing regular reviews to appropriately terminate applicants? presumptive eligibility in CBMS when appropriate. However, the Department has not addressed the programming and system issues in CBMS. The Department plans to fully implement this recommendation by December 2022.

View Audit 282464

Finding 316198 (2022-051)

Material Weakness 2022

State of Colorado

CO

Reporting

(A) The training materials have been created, and the training will take place on June 23, 2022. (B) The policies and procedures have been updated and were effective on July 1, 2022. (C) The Department implemented procedures and coding sufficient to allow proper reporting of overpayments returned ...

(A) The training materials have been created, and the training will take place on June 23, 2022. (B) The policies and procedures have been updated and were effective on July 1, 2022. (C) The Department implemented procedures and coding sufficient to allow proper reporting of overpayments returned greater than one year from the date of discovery for the CMS quarterly reports. (D) The Program Integrity Division has created a supervisory review process that is included in the updated policies and procedures. This process was effective July 1, 2022.

View Audit 282464

Finding 316194 (2022-046)

Material Weakness 2022

State of Colorado

CO

Subrecipient Monitoring Material Weakness Reporting § 200.303

The Department did not have strong enough controls for the initial checks on the financial data reporting templates. This process has been updated and will be rectified in coming cycles. The Department has modified its templates in order to address the concerns provided by the auditors including sig...

The Department did not have strong enough controls for the initial checks on the financial data reporting templates. This process has been updated and will be rectified in coming cycles. The Department has modified its templates in order to address the concerns provided by the auditors including signatures and supplemental reporting. Written policies and procedures for the validation and audit of the templates are being developed currently and will be in place and effective in December 2022. The Department will be correcting this error by posting the audit results along with other quality and audit reports on the following site: https:hcpf.colorado.gov/quality-and-healthimprovement-reports.

View Audit 282464

Finding 316193 (2022-045)

Material Weakness 2022

State of Colorado

CO

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness

(A) The MLR report template has been updated and will now be reviewed at least yearly by the Department. In addition, new written policies and procedures are being developed and will be implemented before the submission of the next MLR for review. (B) The Department will add contract language and e...

(A) The MLR report template has been updated and will now be reviewed at least yearly by the Department. In addition, new written policies and procedures are being developed and will be implemented before the submission of the next MLR for review. (B) The Department will add contract language and enforcement mechanisms in order to receive accurate information in a timely manner. This includes specific timelines for correcting incomplete or inaccurate information in order to submit the MLR report timely to the Centers for Medicare & Medicaid Services.

View Audit 282464

Finding 308694 (2022-067)

Material Weakness 2022

State of Colorado

CO

Subrecipient Monitoring Matching / Level of Effort / Earmarking Reporting § 200.1

(A) CDHS agrees that it needs to it needs to correct the automated reporting process from the eClearance system used to gather data needed for our FFATA reporting. The department thought that the reports obtained from eClearance were complete and relied on them as the basis of our reporting. Upon in...

(A) CDHS agrees that it needs to it needs to correct the automated reporting process from the eClearance system used to gather data needed for our FFATA reporting. The department thought that the reports obtained from eClearance were complete and relied on them as the basis of our reporting. Upon investigation we found that an internal process change enacted during the implementation of another system at the start of the pandemic was the cause of the data discrepancy. This occurred because the new system made the routing in eClearance after a certain point unnecessary for internal processing so this stopped. It was unknown that this further routing to archive files in eClearance was the trigger for eClearance to push out FFATA report data. Since the department has been able to identify the cause we are able to immediately remedy the problem and ensure that all processes are in sync to ensure accurate and complete FFATA data is contained in automated reporting processes. The department will catch up on FFATA reporting that was missed during this time frame. (B) The department agrees that it needs to implement procedures to validate that data derived from automated processes used as a basis for FFATA reporting should be periodically validated against another data source. To do this the department will create and implement procedures to use CORE reports of encumbrance data referencing subrecipient object codes and tie this to information received from the automated eClearance report. Doing this will validate that the data provided from eClearance is a complete listing of all FFATA reportable subrecipient awards, and thus is a valid source to base FFATA reporting on. This will also help us monitor the process in case any future inadvertent changes are made to processes that could cause data validity issues. (C) CDHS agrees that a supervisory review is needed over the FFATA reporting process in order to ensure more consistency, accuracy and timeliness in reporting processes and standards. The department is currently developing procedures that will allow for more oversight of the FFATA reporting through supervisory reviews and cross training staff on FFATA reporting duties. Supervisory reviews will help ensure that reporting is completed in line with reporting procedures and timeframes and can be a second set of eyes to ensure that information appears accurate and adds analytical judgement value (example - a supervisor might see that July typically has high volume, but this July volume is low, why). In addition, the department is taking this opportunity to cross train other staff on the process so that more individuals can be involved which leads to more transparency over processes allowing various individuals to notice if something isn't working as designed. These new procedures are being developed and implemented as the department catches up on reporting subrecipient awards that were missed since the automated process stopped working.

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Finding 308689 (2022-069)

Material Weakness 2022

State of Colorado

CO

Equipment & Real Property Management Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.303

(B) The Department agrees to develop and implement policies and procedures requiring Department staff to perform reconciliations of recipient agencies? and Regional Food Banks? physical inventories to the Web-based Supply Chain Management system to ensure inventory records are complete and accurate....

(B) The Department agrees to develop and implement policies and procedures requiring Department staff to perform reconciliations of recipient agencies? and Regional Food Banks? physical inventories to the Web-based Supply Chain Management system to ensure inventory records are complete and accurate. Starting in January 2021 the Department began developing a position description for an Inventory Specialist with the focus of ensuring accurate and thorough accounting of all year-end inventory and reconciliations. The position was hired in April 2021. Due to the implementation of the inventory database and the timing of beginning and ending inventories, the Department anticipates being able to do a full reconciliation of inventories by December 2022. (C) The Department agrees to develop and implement a tracking system for food inventory at recipient agencies and Regional Food Banks using the Web Supply Chain Management system receipts as the basis of food received, including the maintenance of supporting documents. The Department is undertaking an inventory overhaul which includes implementing a new inventory database and creating and hiring an Inventory Specialist. The Department recognized the need for inventory software and started the process of obtaining it in June 2020. In May 2021, the Department received a signed licensing agreement for a new database which is expected to be implemented in six months per an OIT timeline. In addition to the database, the Department recently hired a new Inventory Specialist position. This position will lead the development of policies, procedures, inventory reconciliations, and monthly report management. Once the Inventory Specialist has a comprehensive understanding of federal and state policy and the new database software, the Department will develop policies and procedures, training for partner agencies, and roll out new requirements for the tracking and reconciliation of program inventories.

View Audit 282464

Finding 308688 (2022-068)

Material Weakness 2022

State of Colorado

CO

Reporting Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.1 § 200.38 § 200.510

(A) CDHS agrees to enhance internal controls over monthly P-EBT reporting to better ensure accuracy. P-EBT is a new program derived from pandemic funding. Being a new program with a lack of federal guidance at implementation, and urgency to get the funds disbursed program staff had to learn about th...

(A) CDHS agrees to enhance internal controls over monthly P-EBT reporting to better ensure accuracy. P-EBT is a new program derived from pandemic funding. Being a new program with a lack of federal guidance at implementation, and urgency to get the funds disbursed program staff had to learn about the nuances of the program and the reporting requirements as it was being implemented. During implementation we recognized that there are some inherent differences with P-EBT from other benefit programs which caused processes to have to be adjusted slightly. Additionally, timing of federal report filing for the P-EBT program is not in synch with our other processes and associated federal reporting requirements and deadlines. This makes it impossible to ensure reconciliation procedures are performed before filing occurs, which is one of our typical internal controls. As a compensating internal control CDHS will ensure that supervisory review processes are performed over P-EBT reporting, and that P-EBT reporting is reconciled to other sources (CBMS and CFMS) as soon as possible after reporting is available. If changes are discovered CDHS will make adjustments to filed P-EBT reports as needed based on reconciliation findings, and communicate changes to necessary parties. (B) CDHS will work to ensure better coordination between program activities and the accounting section relating to federal reporting changes. Accounting will iterate the importance of timely informing the accounting staff when changes are made to program filed federal reports. This message will be delivered in periodic fiscal meetings and identified on the closing calendar. The P-EBT program will ensure that corrections are communicated to accounting on any updates completed on the FNS-292-B report upon discovery, and no later than 30 days after the reporting period. (C) CDHS will ensure that review and approval processes are occurring as designed at various points in the process leading up to entry into CORE. As part of the Requisition (RQS) approval process program and accounting staff independently approve that the correct direct or subrecipient object code is used. These approved RQS transactions are then transitioned into encumbrance documents that drive which object code future expenditures will be booked to. For CCDF transactions related to this finding, both the OEC and Accounting teams inadvertently approved an incorrect object code in 4 RQS's. Staffing shortages coupled with a large increase in workload related to pandemic funding contributed to this oversight. To correct OEC and Accounting will train new staff, periodically familiarize themselves with the appropriate object codes, and perform quality assurance review over object codes before applying approval in CORE. The K1 is compiled from balances derived from expenditure data recorded in CORE. The compilation of the K1 relies on the fact that expenditure balances are accurate, and that prior reviews and approvals of individual transactions have occurred as designed. The K1 currently goes through various levels of review focusing on balance level validation coupled with analytical procedures. To enhance the review process, CDHS will ensure analytical procedures include line level expenditure comparison at the direct and subrecipient levels.

View Audit 282464

Finding 301049 (2022-042)

Significant Deficiency 2022

State of Colorado

CO

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking § 200.1 § 200.303

(A) We agree with this recommendation. In recent years, the Federal Government had multiple continuing resolutions in their budget process, resulting in CDE?s Title I allocations coming in multiple iterations. For the last several years, CDE has received revised allocations from the US Department of...

(A) We agree with this recommendation. In recent years, the Federal Government had multiple continuing resolutions in their budget process, resulting in CDE?s Title I allocations coming in multiple iterations. For the last several years, CDE has received revised allocations from the US Department of Education for the fiscal year as late as early summer; in one example, we received six revisions. With staffing shortages and the administrative burden to continuously revise, research issues and update FFATA for each allocation change, CDE took the step to report only the final allocation to FFATA, which was reported as of the month the awardee was awarded. However, the report was submitted later in the fiscal year. CDE will take a two-fold approach to rectify the issue related to the required FFATA reporting for Title I. First, we will report to FSRS the initial awards within 30 days following the date the awardee was provided final approval on their award. This is consistent with CDE?s approach to all other federal awards. Second, we will monitor the continuing resolutions and changes in allocations, and report only the net changes to each awardee, in the month those changes occur from the US Department of Education. Thereby, FSRS will represent the total revised award. In addition to this approach, all Title I awards will continue to be a part of our regular FFATA reconciliation process. (B) We agree with this recommendation. CDE identified its own failure to report two ESSER subawards to FFATA within 30 days as part of the successful development and implementation of a FFATA-specific reconciliation process in Summer 2022. CDE will continue to refine and improve its FFATA reconciliation process.

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Finding 291593 (2022-073)

Significant Deficiency 2022

State of Colorado

CO

Reporting Internal Control / Segregation of Duties Cash Management § 200.303

CDLE will continue to develop, formally document, and implement policies for completing its federal reports for the Unemployment Insurance program. These policies will require the workbooks used to prepare the reports to be protected, for the data to be substantiated, and will require supervisory re...

CDLE will continue to develop, formally document, and implement policies for completing its federal reports for the Unemployment Insurance program. These policies will require the workbooks used to prepare the reports to be protected, for the data to be substantiated, and will require supervisory review on a monthly basis prior to submitting the reports to the federal government.

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Finding 291592 (2022-070)

Material Weakness 2022

State of Colorado

CO

Internal Control / Segregation of Duties Subrecipient Monitoring Eligibility

(A) The Department agrees with this finding. The Department is moving all adjudication and investigation of program integrity holds into the MyUI+ system, so there will be one system of record. The Department will ensure that all program integrity holds have all documentation through adjudication an...

(A) The Department agrees with this finding. The Department is moving all adjudication and investigation of program integrity holds into the MyUI+ system, so there will be one system of record. The Department will ensure that all program integrity holds have all documentation through adjudication and investigation, including log notes. The Department anticipates this to be fully implemented by July 2024. (B) The Department agrees with this finding. The department has modified processes to ensure all holds are only routed to the appropriate team to be adjudicated. In addition the Department is working to have all claims identified as fraud delivered in a workflow process in MyUI+ rather than the various processes in place now. Further the department is working with our MyUI+ system experts to implement new technology to strengthen and streamline the fraud indicator escalation process and systems within MyUI+. In working with our MyUI+ system experts, the Department anticipates this to be fully implemented by July 2024. (C) The Department agrees with this finding. The Department will continue strengthening security in this area and internal procedures to periodically monitor the potential for internal fraud activities. Additionally, the Department will periodically monitor and review My UI+ access levels for appropriateness. In consultation with our MyUI+ systems experts, the Department anticipates this finding to be fully implemented by July 2024. (D) The Department agrees with this finding. The Department will reinforce and strengthen the ethics policies in yearly communication to staff and tighten escalation policies to ensure pressures and inappropriate requests are handled in accordance with guidelines. The Department anticipates this will be completed by July 2023. (E) When a PI hold is identified as being highly suspicious for criminally fraudulent activity, it is routed to a specialized unit for review, thereby leaving the standard adjudication process. This is handled by passing the review to the UI Investigations and/or Criminal Enforcement (ICE) unit. The investigator performs their investigation and if no actual fraudulent activity is found they will release the hold. The UI Division also performs several quality control reviews of claims and claim decisions via Benefits Payment Control (BPC), Benefits Accuracy Measurements (BAM), Benefits Timeliness and Quality (BTQ), and internal Quality Assurance (QA) reviews. Claims are reviewed for such criteria as adequate support documentation, benefit payment accuracy, timely processing, and correct claim decision determination on all program integrity holds. The Green Book states in Section 10.14, ? If segregation of duties is not practical within an operational process because of limited personnel or other factors, management designs alternative control activities to address the risk of fraud, waste, or abuse in the operational process.? CDLE believes the reviews represent adequate and sufficient compensating controls for the need for segregation of duties on fraud holds. Changing the current process would hinder our ability to deliver UI benefit services timely to our customers and would put us in jeopardy of fulfilling our federal and state payment timeliness requirements.

View Audit 282464

Finding 291585 (2022-071)

Material Weakness 2022

State of Colorado

CO

Subrecipient Monitoring Reporting § 200.1

By the implementation date, the Department of Labor and Employment (CDLE) will complete a review of grant agreements for reporting requirements, including the Federal Funding Accountability and Transparency Act of 2006. By the implementation date, the CDLE will develop and implement appropriate cont...

By the implementation date, the Department of Labor and Employment (CDLE) will complete a review of grant agreements for reporting requirements, including the Federal Funding Accountability and Transparency Act of 2006. By the implementation date, the CDLE will develop and implement appropriate controls and processes to come into compliance with the reporting requirements and submit FFATA reports for the 10 entities identified in the audit.

View Audit 282464

Finding 291584 (2022-072)

Significant Deficiency 2022

State of Colorado

CO

Internal Control / Segregation of Duties Eligibility Reporting

(A) The Department will formalize IT security policies and procedures to comply with the Business Owner requirements contained within the Governor's Office of Information Technology's (OIT) March 2022, Colorado Information Security Policies. The Department will further formalize a procedure for prod...

(A) The Department will formalize IT security policies and procedures to comply with the Business Owner requirements contained within the Governor's Office of Information Technology's (OIT) March 2022, Colorado Information Security Policies. The Department will further formalize a procedure for product owners to annually review the OIT Colorado Information Security Policies and ensure alignment with the formalized Department IT policies and update any affected formalized IT procedures. The Department will communicate the formalized policies and procedures to Department staff and IT Service Providers, and then any future changes, as deemed necessary. (B) The Department will formalize IT security policies and procedures to comply with the Business Owner requirements contained within the Governor's Office of Information Technology's (OIT) March 2022, Colorado Information Security Policies. The Department will further formalize a procedure for product owners to annually review the OIT Colorado Information Security Policies and ensure alignment with the formalized Department IT policies and update any affected formalized IT procedures. The Department will communicate the formalized policies and procedures to Department staff and IT Service Providers, and then any future changes, as deemed necessary. (C) CDLE agrees with the recommendation and as part of A and B recommendations of this document, the Department will include a requirement from vendors to affirm they have reviewed and will comply with OIT security policies for all new contracts. Furthermore, as the Department becomes aware of changes to OIT Security Policies through its annual review process, these will be communicated to the vendors, and they will be required to reaffirm their compliance with any applicable changes. We will work with our current vendors for MyUI+ and Connecting Colorado to address the compliance issues noted in the audit and ensure they are compliant with OIT Security Policies and IT policies developed in part A and B of this recommendation. If non-compliance is determined to be unavoidable, the Department will file for a security exception with OIT. (D) CDLE agrees with the recommendation and will implement recommendation Part D as noted in the confidential finding. (E) CDLE agrees with the recommendation and will implement recommendation Part E as noted in the confidential finding.

View Audit 282464

Finding 286713 (2022-079)

Material Weakness 2022

State of Colorado

CO

Subrecipient Monitoring Reporting § 200.303 § 200.332 § 200.501

The Department of the Treasury (Treasury) strengthened its internal controls with DOLA?s agreement to disseminate the necessary information to the subrecipients in compliance with federal requirements for subrecipient monitoring and reporting for the Minerals Leasing Act program (Program) at the ear...

The Department of the Treasury (Treasury) strengthened its internal controls with DOLA?s agreement to disseminate the necessary information to the subrecipients in compliance with federal requirements for subrecipient monitoring and reporting for the Minerals Leasing Act program (Program) at the earliest possible opportunity following receipt of the recommendation in the previous FYE?s report as the monitoring and reporting for the Program could only be performed following the annual distribution of such funds which took place subsequent to FYE 2022. The Department will formalize an Interagency Agreement with DOLA and any other relevant parties, incorporating additional corrective action before the stated date above (June 30, 2023).

View Audit 282464

Finding 286697 (2022-059)

Significant Deficiency 2022

State of Colorado

CO

Reporting Internal Control / Segregation of Duties § 200.303

Front Range: Moving forward the Director of Financial Aid will engage the Restricted Funds Accountants in a quality assurance review of both dollars spent, type of fund, and student counts before it is submitted for final review and publishing by the Director of Resource Development and Senior Grant...

Front Range: Moving forward the Director of Financial Aid will engage the Restricted Funds Accountants in a quality assurance review of both dollars spent, type of fund, and student counts before it is submitted for final review and publishing by the Director of Resource Development and Senior Grant Administrator. The most recently submitted information for the quarterly report of September 30, 2022 will be sent to the Restricted Funds Accountants to validate that FRCC has been and will continue to be in compliance for quarterly HEERF reporting. Lamar: The Financial Aid Director and the Controller will compile their reporting support on the shared drive they utilize for other routine purposes as well, to ensure clear documentation of the numbers reported. The original report containing errors was corrected, validated, and reposted. All past year?s reporting data was made available on the shared drive as of July 2022. Pueblo: Each quarter Financial aid will obtain and compare Cognos and Banner disbursement reports for accuracy. Once the unduplicated student count is determined it will be sent to the Vice President of Student Success to validate and approve going forward. Financial aid will ensure staff maintain supporting documentation for any institutional expenditures information that was obtained from the fiscal office. Disbursement and expenditure data will be compiled for the Department of Education?s Quarterly Report by the submission deadline and will be submitted as PDF to webmaster for posting on PCC?s website and a copy emailed to a contact at the Department of Education and will archive the submission for future reference.

View Audit 282464

Finding 286696 (2022-063)

Significant Deficiency 2022

State of Colorado

CO

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.303 § 200.334

In December 2022, the Office of Financial Aid strengthened its internal control over the reporting requirements for the Higher Education Emergency Relief Fund (HEERF), by adding the report due dates to the internal operational calendar. Additional level reviews were also added to the submission proc...

In December 2022, the Office of Financial Aid strengthened its internal control over the reporting requirements for the Higher Education Emergency Relief Fund (HEERF), by adding the report due dates to the internal operational calendar. Additional level reviews were also added to the submission process before the required reports will be sent to the Department of Education and posted on the financial aid website.

View Audit 282464

Finding 286694 (2022-064)

Significant Deficiency 2022

State of Colorado

CO

Matching / Level of Effort / Earmarking Student Financial Aid Reporting § 200.303

Management agrees. After the notification of the missing HEERF report in December 2021, the UCCS Controller proposed a ?cross-check? process to ensure all future reporting is in compliance and reported in a timely manner. This process is used for both the quarterly and annual reporting process. In ...

Management agrees. After the notification of the missing HEERF report in December 2021, the UCCS Controller proposed a ?cross-check? process to ensure all future reporting is in compliance and reported in a timely manner. This process is used for both the quarterly and annual reporting process. In the quarterly reporting process, the UCCS Controller completes the institutional report and emails the report to the UCCS Financial Aid office Senior Executive Director for verification of the amounts and the data submitted. The Senior Executive Director then enters the student aid portion?s information and provides this to the UCCS Controller for verification of the data. Once verified, the report is uploaded to the UCCS website and a confirmation email is sent to the UCCS Controller as well as the heerfreporting@ed.gov for verification of completion of the website posting.

View Audit 282464

Finding 286570 (2022-060)

Significant Deficiency 2022

State of Colorado

CO

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Mines was delayed in processing NSLDS files due to staffing changes and employee leave. Mines has constructed a process to ensure timely future reporting along with an agreed upon trained back-up for the primary person if they are out for an extended time. Additionally, we have changed how often we ...

Mines was delayed in processing NSLDS files due to staffing changes and employee leave. Mines has constructed a process to ensure timely future reporting along with an agreed upon trained back-up for the primary person if they are out for an extended time. Additionally, we have changed how often we report enrollment files to the Clearinghouse (NSC). We are now reporting every two weeks. The error reports generated after the files are submitted are reviewed as soon as they?re posted, a copy downloaded from NSC and reviewed for corrections which are then completed as soon as possible. Mines is working on an updating the documentation for the full process, including all of the cleanup reports that are run in COGNOS and the Banner jobs before the enrollment file is even processed.

View Audit 282464

Finding 280731 (2022-001)

Significant Deficiency 2022

Asian Task Force Against Domestic Violence, Inc.

MA

Reporting Significant Deficiency

Management is planning on submitting its FY22 data collection form on time.

View Audit 264725

Finding 279140 (2022-003)

Material Weakness 2022

Central Oklahoma Community Action Agency

OK

Reporting

2022-003: NON-COMPLIANCE WITH AUDITEE RESPONSIBILITIES RELATED TO REPORTING REQUIREMENTS UNDER UNIFORM GUIDANCE Responsible Person: Tracy Izell Corrective Action Planned: COCAA has shifted more of the day to day input responsibilities to the Finance Office Manager. In addition, COCAA will retain...

2022-003: NON-COMPLIANCE WITH AUDITEE RESPONSIBILITIES RELATED TO REPORTING REQUIREMENTS UNDER UNIFORM GUIDANCE Responsible Person: Tracy Izell Corrective Action Planned: COCAA has shifted more of the day to day input responsibilities to the Finance Office Manager. In addition, COCAA will retain the services of an MIP Expert recommended to us by other CAA?s. Anticipated Completion Date: Started but will be ongoing. The MIP Expert will be dependent upon schedules, but we are looking within the next 6 months. COCAA?s overall response to the audit experience can be summed up in disappointment. The lack of clear communication which we believe could have been prevented. In all the other audits I have been through, the field auditor would meet with us to explain what they found, why they found it and asked us for our input. Many times, this is simply a communication error and can be cleared up in that meeting. However, that meeting never happened. In fact, there was no communication and we were told by Saunders twice, there were no findings, only to get this report. COCAA has acknowledged the timeliness issue and have made adjustments in order to remedy this particular finding. I would also like to add that I have requested clarification for the journal entries made and still have not received a response. COCAA also acknowledges the auditors have had turmoil in their personal lives. We, at COCAA, are truly saddened by these events as we believe and wish everyone good fortune which, as well all know, doesn?t come all the time. We totally understand that Saunders has not been engaged since they are dealing with other issues. However, we do feel the audit events were not reflective of COCAA?s Management or Board or the way the COCAA handles their business. This audit experience has been abysmal at best.

View Audit 268719

Finding 279102 (2022-002)

None 2022

Greater Cleveland Food Bank

OH

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

Finding: 2022-002 Internal Control over Compliance with Reporting Agency: Greater Cleveland Food Bank Name of responsible contact person and title: Jessica Morgan, CPO & Valissa Turner Howard, VP of Talent and Legal Affairs Anticipated completion date: 7/31/2023 Agency's response: Concur Planned Cor...

Finding: 2022-002 Internal Control over Compliance with Reporting Agency: Greater Cleveland Food Bank Name of responsible contact person and title: Jessica Morgan, CPO & Valissa Turner Howard, VP of Talent and Legal Affairs Anticipated completion date: 7/31/2023 Agency's response: Concur Planned Corrective Action(s): ? The Agency Services Analyst will complete the quarterly report within 35 days of the end of the quarter to ensure proper review, approval, and corrections if necessary, in order to be submitted within the 45-day requirement. Prior to the report being submitted, the Director of Agency Services will continue to review and will provide oversight for timely submission. ? Include in our Internal Auditing Program of the OAF/TANF contract, review of all supporting documents to validate timely reporting. ? The VP of Talent and Legal Affairs with the support of the Compliance Manager will review the timelines for all required reporting to the Ohio Association of Food banks on an annual basis with supervisors and those employees responsible for reporting.

View Audit 264352

Finding 279095 (2022-002)

Significant Deficiency 2022

Mahoning-Youngstown Community Action Partnership, Inc.

OH

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

Finding: 2022-002 Agency: U.S. Department of Health and Human Services ? ALN 93.558 ? TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) Name of contact person and title: Shelia Triplett, Executive Director Anticipated completion date: September 2023 MYCAP?s respo...

Finding: 2022-002 Agency: U.S. Department of Health and Human Services ? ALN 93.558 ? TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) Name of contact person and title: Shelia Triplett, Executive Director Anticipated completion date: September 2023 MYCAP?s response: Concur MYCAP agrees with this finding and provided the following response for corrective action: U.S. Department of Health and Human Services ? Significant Deficiency ? Internal Controls over Compliance ? Eligibility Plan of Action: The Support Specialist will gather all required documents for the TANF program, ensuring the application documents and required income are on file. The Chief Operating Officer (COO) will conduct a second review of all TANF files for proper eligibility requirements including recalculations of income, ensuring all files are eligible, marking the file with initial and approval for processing.

View Audit 264349

Finding 279094 (2022-001)

Material Weakness 2022

Mahoning-Youngstown Community Action Partnership, Inc.

OH

Reporting § 200.508 § 200.510

Finding: 2022-001 Agency: U.S. Department of Health and Human Services ? ALN 93.558 ? TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) Name of contact person and title: David Drawl, CFO Anticipated completion date: December 2023 MYCAP?s response: Concur ...

Finding: 2022-001 Agency: U.S. Department of Health and Human Services ? ALN 93.558 ? TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) Name of contact person and title: David Drawl, CFO Anticipated completion date: December 2023 MYCAP?s response: Concur MYCAP agrees with this finding and provided the following response for corrective action: U.S. Department of Health and Human Services ? Material Weakness ? Internal Controls over Compliance ? Reporting Plan of Action: The material weaknesses identified by the auditor is correct as presented. Upon learning of the omission, MYCAP immediately adjusted the SEFA and presented the requested information to the auditor in such time that the program mentioned is included in the audit. MYCAP will accept the recommendations presented by the auditor and incorporate them into their fiscal procedures as well as incur additional training in GAAP conversion and preparation for audit.

View Audit 264349

Finding 270208 (2022-006)

Material Weakness 2022

Overdose Lifeline, Inc.

IN

Reporting Internal Control / Segregation of Duties Material Weakness

Finding 2022-06 Report Preparation and Submission Condition: It was discovered that the Organization demonstrated deficiencies in reporting accuracy and completeness, as well as a failure to comply with state law by not filing a required annual report. Upon review of the Organization?s reporting p...

Finding 2022-06 Report Preparation and Submission Condition: It was discovered that the Organization demonstrated deficiencies in reporting accuracy and completeness, as well as a failure to comply with state law by not filing a required annual report. Upon review of the Organization?s reporting practices, it was observed that three out of the five reports selected for testing contained discrepancies, inaccuracies, or incomplete reporting metrics. These discrepancies raise concerns about the reliability of the organization's reported data, which can impact decision-making, program effectiveness, and the organization's ability to fulfill its fiduciary responsibilities. Furthermore, the Organization failed to file the mandatory annual report as required by Indiana Code 5-11-1-4, further indicating a deficiency in compliance with local regulations. Corrective Actions Taken or Planned: The Organization?s Board and Executive Team consisting of the CEO and COO acknowledge the finding related to reporting deficiencies. The Organization has adopted internal policies to address this to include a grants management tracking system that records reporting requirements and a checks and balance system. The required annual report process has been initiated and a 2023 report will be filed in the month of October 2023.

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Finding 265183 (2022-003)

Material Weakness 2022

Overdose Lifeline, Inc.

IN

Questioned Costs Period of Performance Subrecipient Monitoring

Finding 2022-03 Expenditure of Funds Outside Contract Period Condition: In the course of testing direct disbursements for adherence to appropriate cutoffs concerning the contract's period of performance, it was discovered that the Organization incurred a substantial amount of expenditures on contr...

Finding 2022-03 Expenditure of Funds Outside Contract Period Condition: In the course of testing direct disbursements for adherence to appropriate cutoffs concerning the contract's period of performance, it was discovered that the Organization incurred a substantial amount of expenditures on contracts prior to the official contract start date. These disbursements took place without acquiring proper authorization for making disbursements prior to the contract's commencement. Despite the unique nature of Naloxone inventory being treated as a prepaid asset due to its delayed usage, the majority, if not all, of the Naloxone units were fully expended before the contract officially commenced. Corrective Actions Taken or Planned: The Organization?s Board and Executive Team consisting of the CEO and the COO acknowledge the finding of expending funds outside the contract period. This finding is connected to the purchase of the emergency medication naloxone. The Organization decided to purchase with no assurance of reimbursement in order to eliminate the lack of emergency medication in an overdose epidemic. The Organization had verbal approval but did not secure approval in writing. Numerous policies will be adopted in 2023 to ensure this does not occur again. Some of these policies include the transition to an experienced nonprofit bookkeeper, training for Finance and Grants Management and tracking mechanisms, monthly grants tracking meetings to ensure inventory and spending, and the adoption of a clear and documented approval process should spending, outside a contract period, be required.

View Audit 261078 Questioned Costs: $1

Finding 265182 (2022-002)

Material Weakness 2022

Overdose Lifeline, Inc.

IN

Reporting

Finding 2022-02 Schedule of Expenditures of Federal Awards Presentation Condition: During the audit, it was identified that the Organization encountered deficiencies in preparing an accurate and complete Schedule of Expenditures of Federal Awards (?SEFA?). The SEFA is a critical component of the or...

Finding 2022-02 Schedule of Expenditures of Federal Awards Presentation Condition: During the audit, it was identified that the Organization encountered deficiencies in preparing an accurate and complete Schedule of Expenditures of Federal Awards (?SEFA?). The SEFA is a critical component of the organization's reporting process, as it provides a summary of federal funds expended and aids in assessing compliance with federal regulations. The organization's failure to ensure the accuracy and completeness of the SEFA indicates shortcomings in its reporting practices. It was observed that the SEFA presented inaccuracies and omissions, compromising the completeness and reliability of reported information. The SEFA did not accurately reflect all federal awards received and expended during the audit period, and relevant details such as award numbers, funding sources, and program titles were either missing or misstated. These deficiencies reflect a lack of adherence to reporting requirements. Corrective Actions Taken or Planned: The Organization?s Board and Executive Team consisting of the CEO and the COO acknowledge the finding related to the preparation of the SEFA. Leadership is confident the addition of a staff person dedicated to grants management will ensure the proper tracking of federal awards and reporting for preparation of the SEFA in future audits. The new Grants Manager will be acquiring training and knowledge to develop an appropriate tracking mechanism.

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Corrective Action Plans

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