Corrective Action Plans

Finding 1211000 (2024-023)

Material Weakness 2024

MS

Eligibility Special Tests & Provisions Allowable Costs / Cost Principles

93.767 Children's Health Insurance Program (CHIP) 93.778 Medical Assistance Program (Medicaid; Title XIX) 2024-023 Strengthen Controls to Ensure Compliance with Provider Eligibility Requirements of CHIP and the Medical Assistance Program DOM Response: Two instances of no documentation that required ...

93.767 Children's Health Insurance Program (CHIP) 93.778 Medical Assistance Program (Medicaid; Title XIX) 2024-023 Strengthen Controls to Ensure Compliance with Provider Eligibility Requirements of CHIP and the Medical Assistance Program DOM Response: Two instances of no documentation that required fee were collected. DOM Partially Concurs. After a review of the 2 files, DOM has found in one instance an application fee was collected and sent to DOM for processing; however, the receipt of the application fee was not indicated by comments in the system. DOM will work with Gainwell to ensure remedial training is conducted to reduce errors in the future. One (1) instance correlates to an application received before DOM began requiring the fee on October I, 2022. Thirty-eight instances of no documentation that provider's medical license was current and free of limitations. DOM Partially Concurs. After a review of the 38 files, DOM has found in thirty-one (31) instances the license from the board was attached and the checklist completed after the license was not verified by LexisNexis . Two (2) instances were applications approved prior to the Gainwell implementation; however, the licenses remain valid in SFY 2024 and reflect correct effective dates in the system. One (1) instance is a group and does not require license. Four (4) instances the license from the board was manually verified and attached after the license was not verified by LexisNexis; however, there were typographical errors or omissions in the license fields in the system. DOM will ensure Gainwell conducts remedial training to mitigate these errors in the future. Thirty-one instances of no documentation of review prior to approval of provider's application. DOM Does Not Concur. After a review of the 31 files, DOM has verified all applications identified within this finding as being approved by DOM without review have documented comments in the system of record to show a review of each application was conducted prior to approval. This would include Fifteen (15) instances with review notes, requests for missing information (if applicable), etc. entered by reviewers since the Gainwell Go-Live. Sixteen (16) instances with review notes, requests for missing information (if applicable), etc. entered by reviewers prior to the Gainwell Go-Live. Ten instances of no documentation of verified identity and exclusion status of providers using required federal databases prior to application approval. DOM Partially Concurs. After a review of the 10 files, DOM has found in five (5) instances the LexisNexis report indicated the NPI was verified. One (I) instance of the NPI not verified by LexisNexis, but the Gainwell Analyst performed a manual search in NPPES and attached the verification results on 11/14/24. Four (4) instances before Gainwell began processing applications. The provider was sent to Digital Harbor for screening. DOM's contractual relationship with Digital Harbor ended in 2016 and the data is no longer available. Agency began revalidation in 2017 by stratifying all providers; however, due to PHE all revalidations were paused. As a result, not all revalidations have been completed. At this time, revalidation dates have been assigned in alignment with CMS guidance and will be completed within CMS required timelines, i.e. 44 months from end of the PHE. One (I) instance has a note indicating revalidation occurred in 2017, but no documentation can be located in the system, which potentially could be attributed to data conversion from the legacy system to the new system. Four instances of no documentation of OIG exclusion checks prior to application approval. DOM Concurs. After a review of the 4 files, DOM has found in three (3) instances contain a comment within EDMS that verifies the providers were sent to Digital Harbor for screening. DOM's contractual relationship with Digital Harbor ended in 2016 and the data is no longer available. Please note: Agency began revalidation in 2017 by stratifying all providers, however due to PHE all revalidations were paused. As a result, not all revalidations have been completed. At this time, revalidation dates have been assigned in alignment with CMS guidance and will be completed within CMS required timelines, i.e., 44 months from end of the PHE. One (1) instance has a note indicating revalidation occurred in 2017, but no documentation can be located in the system, which potentially could be attributed to data conversion from the legacy system to the new system. Two instances of no documentation of collection of the provider's NPI. DOM Concurs. After a review of the 2 files, DOM has found all instances contain a comment within the system which verifies the provider was sent to Digital Harbor for screening. DOM's contractual relationship with Digital Harbor ended in 2016 and the data is no longer available. Eight instances of missing or incomplete documentation of required disclosure details. DOM Partially Concurs. After a review of the 8 files, DOM has found in two (2) instances where the individual provider's date of birth is in the system. Two (2) instances where the individual provider's date of birth is not available as it was not a required element at the time of application. DOM will ensure the date of birth is obtained from the provider and added to the system. Three (3) instances where the organizational provider has all required elements. One (1) instance where the organizational provider's address is not available as it was not a required element at the time of application. The missing data is now required and will be collected at the next revalidation. Four instances of no documentation required screening procedures in accordance with provider's designated risk level. DOM Partially Concurs. After a review of the 4 files, DOM has found in three (3) instances where the individual provider's file contains a comment within EDMS verifies provider was sent to Digital Harbor for screening. DOM's contractual relationship with Digital Harbor ended in 2016 and the data is no longer available. Please note: Agency began revalidation in 2017 by stratifying all providers, however due to PHE all revalidations were paused. As a result, not all revalidations have been completed. At this time, revalidation dates have been assigned in alignment with CMS guidance and will be completed within CMS required timelines, i.e., 44 months from end of the PHE. One ( l) instance the individual provider was screened, and a site visit was conducted (as this provider type was deemed moderate risk at that time) and the documentation is available in the system. DOM Corrective Action Plan: a. In response to the audit findings, the Division of Medicaid (DOM) will collaborate with its Fiscal Agent, Gainwell Technologies, to review all identified issues and implement corrective measures. As part of this effort, mandatory refresher and remedial training will be conducted for Gainwell Provider Enrollment staff. This training will emphasize the requirement for comprehensive and accurate documentation within provider files, including clear, detailed, and supportive comments that fully reflect all actions taken during the enrollment and maintenance processes. Additionally, DOM will implement enhanced oversight and quality assurance monitoring to ensure sustained compliance with documentation standards. DOM notes that certain discrepancies identified in the audit may predate the implementation of the MESA system and the transition to Gainwell Technologies as the Fiscal Agent. Due to system conversion constraints, data limitations, and the absence of complete historical documentation within the current system, DOM's ability to retrospectively validate or remediate these pre-implementation discrepancies is limited. As such, corrective actions will be applied prospectively, with a focus on ensuring accuracy, completeness, and compliance within the current MESA environment moving forward. b. Bill Hardin c. March 31, 2026

View Audit 400294

Finding 1210999 (2024-021)

Material Weakness 2024

State of Mississippi

MS

Eligibility Material Weakness Reporting § 200.09

93.767 Children's Health Insurance Program (CHIP) 93.778 Medical Assistance Program (Medicaid; Title XIX) Eligibility 2024-021 Strengthen Controls to Ensure Compliance with Eligibility Requirements of the Children's Health Insurance Program (CHIP) and the Medical Assistance Program DOM Response: Use...

93.767 Children's Health Insurance Program (CHIP) 93.778 Medical Assistance Program (Medicaid; Title XIX) Eligibility 2024-021 Strengthen Controls to Ensure Compliance with Eligibility Requirements of the Children's Health Insurance Program (CHIP) and the Medical Assistance Program DOM Response: Use of Tax Return Resources Three MAGI beneficiaries - DOM did not verify self-employment income reported on tax return One of the 180 MAGI beneficiaries - reported self-employment income, DOM did not request a tax return DOM Does Not Concur. OSA compared eligibility data to state income tax returns. DOM is prohibited from accessing state income tax records per Mississippi Code Annotated 27-3-73 and currently, is not allowed to have access to federal income tax records. For eligibility, DOM asserts compliance with the CMS-approved state plan. During the audit period, the state used the CMS MAGI Based Verification plan to confirm income reports using all available electronic data sources according to CMS's reasonable compatibility standard. DOM must accept applicant information and use CMS-approved verification methods to check its accuracy. If self-employment income is not reported and DOM's tools do not detect it, DOM has met eligibility and compliance standards set by CMS. In addition, tax returns are considered outdated and not relevant to DOM. Six of the 180 MAGI beneficiaries - income was not verified through Mississippi Department of Employment Security DOM Partially Concurs. Four beneficiaries' income was not verified through Mississippi Department of Employment Security (MDES). DOM requested MDES on the identified beneficiaries and found no new information that would have affected the eligibility decision. DOM does not concur with two of the findings as MDES was requested on those beneficiaries. Each finding will be reviewed with the individual team members and additional communication has been provided to all Eligibility Team Members. Twelve of the 300 beneficiaries - the beneficiary's case file did not contain a completed application. DOM Concurs. DOM was unable to locate and provide the auditors the original application for the twelve beneficiaries. These documents do not impact the redetermination of eligibility. All redetermination decisions have been verified as accurate. Six of the 300 beneficiaries - DOM could not provide a case file. DOM Concurs. DOM was unable to locate and provide the auditors the case files for six beneficiaries. These documents do not impact the redetermination of eligibility. All redetermination decisions have been verified as accurate. One ABD beneficiary - resources were not verified through AVS at the time of redetermination. DOM Concurs. DOM has since requested AVS records for the beneficiary in question. No bank accounts were found, which indicates there was no impact to eligibility. The Eligibility Team Member will be coached to ensure appropriate processes are followed for all future cases. One hundred thirty-five beneficiaries were not included on all of the required quarterly Public Assistance Reporting Information System (PARIS) file transmissions for fiscal year 2024. DOM Partially Concurs. DOM does not concur with a number of these findings as they were appropriately absent from the PARIS request file because they were in a denied status, had retroactive coverage, or was absent due to the timing of the case approval. DOM concurs with some of the findings. Findings related to COE 29 - Family Planning were addressed in late 2023, which was after the approval of these cases. This issue was resolved in late 2023. There were findings that occurred due to the timing of the PARIS file. DOM has submitted a change request to submit the PARIS file based on the run date not based on the end of the previous month. All previously missed members were added to the 11/1/2025 PARIS outgoing data file, and this report was provided to the auditors. No eligibility decisions were affected by the 11/1/2025 returned PARIS file. DOM Corrective Action Plan: a. DOM submitted a change request to submit the PARIS file based on the eligibility end date of the previous quarter rather than the actual run date. This has been completed. All individual issues identified will be reviewed with the appropriate team member. b. Brian Whitmire c. March 31, 2026

View Audit 400294

Finding 1210988 (2024-013)

Material Weakness 2024

State of Mississippi

MS

Reporting Student Financial Aid Subrecipient Monitoring

Finding 2024- 013: Terminated User Access Not Removed Timely Significant Deficiency In Internal Control Over Financial Reporting Criteria: Per 45 CFR 75.303(a), non-Federal entitles expendingHHS awards must establish and maintain effective internal controls over compliance with Federal states, regul...

Finding 2024- 013: Terminated User Access Not Removed Timely Significant Deficiency In Internal Control Over Financial Reporting Criteria: Per 45 CFR 75.303(a), non-Federal entitles expendingHHS awards must establish and maintain effective internal controls over compliance with Federal states, regulati ons, and the terms and conditions of the Federal award. Management must mainta in effective user access controls over financia l reporting systems. This Includes promptly removing or disabling access for terminated users and periodically reviewing user access to confirm it aligns with current employment status and job responsibilities. Condition: Testing of IT general controls identifiedinstances where terminated employees' user accounts or financial application access remained active beyond the termination date. MDCPS did not disable terminated user access or remove related application rights in a timely manner. Perspective: During our review of general IT controls, the auditor received a list of terminated employees. Of the 11 employees presented, 6 maintainedaccess to MACWIS after termination.Further, during the performance of a process walkthrough,it was noted that the former chief financial officer was still active in CapPlus and SPHARS. Personnel Responsiblefor Corrective Action: Nome: Shannon Rushton (Employee Seporotlon SOP) Title : Deputy Commissionerof Human Capitol Email: Shannon.Rushton@mdcps.ms.gov Phone Number: 601-359-2696 Name: Christopher Ray (CapPlus User Termination) Title: Deputy Director to the CFO Email: Christopher.Roy@mdcps.ms.gov Phone Number: 601-359-4043 Corrective Action Plan: MDCPS has reinforcedthe EmployeeSeparation St andard Operating Procedure(2.19.2.2) to ensure all system access is removed promptly upon employee separation. Human Resources will notify system administrators immedai tely upon employeetermination, and system administrators will disable all associated application access no later than th e employee's final day of employment. Human Resources will conduct periodic user access reviews to ensure procedures are properly Imp lemented. The Finance Division will ensure the cap Plus software's access and penn1ss1ons are monitored and maintained by the agency with assistance from Interactive Voice Application (IVA). Upon a Cap Plus user's termination , they will be removed from the Cap Plu s software upon their last day of employment or the removal of th eir dutie.s by the agency. These permissions do not require IT or Human Resource control as Cap Plus i s independent of all accounting, payroll, and HR software. Antldpated Completion Date: Empl oyee Separation SOP effectiveas of July 22, 2025. CapP lus user's termination procedures effective as of March 31, 2026.

View Audit 400294

Finding 1210980 (2024-037)

Material Weakness 2024

State of Mississippi

MS

Reporting Internal Control / Segregation of Duties Procurement, Suspension & Debarment

ALN Number 2024 -037 93.558 Temporary Assistance for Needy Families (TANF) 93.568 Low-Income Home Energy Assistance Program (LIHEAP) Strengthen Controls to Ensure Compliance with Federal Funding Accountability and Transparency Act (FFATA) Reporting Requirements. Federal Award No. All Current Active ...

ALN Number 2024 -037 93.558 Temporary Assistance for Needy Families (TANF) 93.568 Low-Income Home Energy Assistance Program (LIHEAP) Strengthen Controls to Ensure Compliance with Federal Funding Accountability and Transparency Act (FFATA) Reporting Requirements. Federal Award No. All Current Active Grants Response: MOHS does not concur with this finding. MOHS has implemented and adhered to standardized operating procedures (SOPs) over the past year to ensure timely and periodic reporting under the Federal Funding Accountability and Transparency Act (FFATA). In March 2025. the federal government retired the Federal Subaward Reporting System (FSRS), which MDHS used to submit new and modified awards. The successor platform, SAM.gov. launched with migrated award data that reflects only the most recent award amount. Historical submission details-including the timestamps that demonstrated timely filings-were not retained in the migrated records. Because the majority of MDHS's FFATA submissions typically occur in November and January. the migrated data does not display the original submission dates associated with those reports. Following the retirement of FSRS, MDHS no longer has access to the legacy system and therefore cannot produce the historical report previously used to verify timely submission. Additionally, the compliance supplement does not address the FFATA reporting processes within SAM.gov. Notwithstanding these system changes, MOHS continues to prepare and submit FFATA reports in accordance with its established SOPs and within the required timeframes. Corrective Action Plan: MOHS will make efforts to create practical. auditable processes to ensure timely and accurate FFATA reporting and solid proof of timeliness and completeness, in the new system.

View Audit 400294

Finding 1210973 (2024-034)

Material Weakness 2024

State of Mississippi

MS

Procurement, Suspension & Debarment Reporting Internal Control / Segregation of Duties § 200.303

The Department should review and enhance controls and procedures to ensure that financial and programmatic/progress reports are reviewed and approved prior to submission. Copies of all reports should be retained and be readily available for audit. Response: The Department concurs with the finding an...

The Department should review and enhance controls and procedures to ensure that financial and programmatic/progress reports are reviewed and approved prior to submission. Copies of all reports should be retained and be readily available for audit. Response: The Department concurs with the finding and the need to enhance and strengthen controls and procedures to ensure programmatic/progress reports are reviewed and approved prior to submission and retain copies for audit. Prior to the conclusion of the audit, the Department formed a Grants Management Division and initiated the development of an internal grants management module for the agency. Corrective Action: The Department formed a Grants Management Division within the agency in 2025 responsible for the financial reporting of its federal grants. The Division prepares, submits, and retains copies of the financial reports and supporting documentation. Prior to submission, the prepared financial reports are approved by the responsible program. Programmatic/progress reports are the responsibility program. The program will track programmatic/progress reports to ensure all are reviewed and approved prior to submission and retained for audit purposes. Name of contact person responsible for the corrective action: Lucreta Tribune (Grants Management Division) and Theresa Kittle (Program-Epidemiology) Anticipated date for completion of corrective action: December 31, 2026

View Audit 400294

Finding 1210964 (2024-009)

Material Weakness 2024

State of Mississippi

MS

Reporting Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

Assistance Listing No. 17.258, 17.259, 17.278 and Workforce Innovation and Opportunity Act Cluster Type of Compliance Requirement: Reporting - FFATA Response: There is no disagreement with the audit finding. Corrective Action Plan: MDES agrees that the FSRS system generated reports provided to CLA d...

Assistance Listing No. 17.258, 17.259, 17.278 and Workforce Innovation and Opportunity Act Cluster Type of Compliance Requirement: Reporting - FFATA Response: There is no disagreement with the audit finding. Corrective Action Plan: MDES agrees that the FSRS system generated reports provided to CLA did not indicate the date of submission and therefore CLA was unable to determine if the reports were submitted timely. MDES will strengthen controls to ensure that future system generated reports have a confirmed submission date documented. Name(s) of the contact person(s) responsible for corrective actions: Contact person(s) responsible: Tyler Berch Contact Phone number: 601-321-6214

View Audit 400294

Finding 1210958 (2024-008)

Material Weakness 2024

State of Mississippi

MS

Reporting Matching / Level of Effort / Earmarking Procurement, Suspension & Debarment § 200.303

Compliance Finding on FFATAReporting Reference No. 2024-008 Dear Auditor White: Pursuant to the policies and procedures governing audits of state agencies, I am hereby submitting our response to a finding made during the recent audit of the Mississippi Development Authority ("MDA") concerning the re...

Compliance Finding on FFATAReporting Reference No. 2024-008 Dear Auditor White: Pursuant to the policies and procedures governing audits of state agencies, I am hereby submitting our response to a finding made during the recent audit of the Mississippi Development Authority ("MDA") concerning the reporting requirements under the "Federal Funding Accountability and Transparency Act" ("FFATA"). Specifically, the following determination was made: AUDIT FINDING: FFATA reporting During Fiscal year 2024, subawards were obligated on February 20, 2024, should have been reported to FSRS by April 30, 2024. MDA could not provide support that required FFATA reporting was completed by April 30, 2024 per SAM.gov, ten of the ten subawards selected for testing were not reported to FSRS until 7/31/2024. 2024-008: We recommend that MDA develop internal controls and procedures to ensure that all required subawards are reported to SAM.gov in accordance with FFATA reporting requirements. Response: During the period in question, the General Services Administration ("GSA") began the process of converting the Federal Subaward Reporting System ("FSRS") into the System for Award Management ("SAM.gov"). As of March 8, 2025, FSRS was formally retired by GSA; POST OFFICE BOX 849 • JACKSON, MISSISSIPPI 39205-0849 TELEPHONE (601) 359-3449 • FAX (601) 359-2832 • www.mississippi.org therefore, it was no longer available to determine the status of any information which once resided within it. It should be noted that, per GSA, all "data entered and saved into FSRS.gov by the deadline will be moved to SAM.gov and will be available beginning March 8, 2025." The auditors first brought the deficiency to MDA's attention on May 25, 2025. By this time, FSRS was inaccessible to detennine what reporting had been made prior to the conversion. MDA produced a printout showing that the required information was entered into the FSRS system for the grants, complying with FFATA. Furthermore, MDA presented a note published by GSA on April 25, 2025, which stated under the heading "Subaward and Subcontract Search" that it had " resolved an issue where there were missing reports from the Subaward and Subcontract search results." This note clearly establishes that there were data/reports lost in the conversion process. Upon lea rning of the deficie ncy, MDA reported the same to GSA; however, no response addressing the issue has been received. Con-ective Action Plan: Because no specific policy or procedure exists addressing FFATA repo rting, MDA is developing a specific policy and procedure to ensure all requirements of the law are met. This policy will adopt the deadline for filing the required information in SAM.gov by the end of the month following the month in which MDA makes a subgra nt greater than or equal to $30,000. Furthe rmore, MDA will screen capture all reports, with proper documentation of the date of submitta l, and place this documentation into the grant file and the electronic file system, as well as maintain a separate FFATA reporting file for each fiscal year. This policy and procedure will be finalized within the next thirty (30) days. Charles L. Bea rman, the director of the Community Incentives Division of MDA, is responsible for this con-ective action. If you should have any question s conce rning this matter, please contact me. I want to thank you and your team for your service to our state and for your cooperation in this regard

View Audit 400294

Finding 1210889 (2024-001)

Material Weakness 2024

Greater Lawrence Technical School

MA

Reporting

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

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

View Audit 400233

Finding 1210887 (2024-002)

Material Weakness 2024

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

CT

Reporting

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

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

View Audit 400231

Finding 1210885 (2024-001)

Material Weakness 2024

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

CT

Reporting

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

View Audit 400231

Finding 1210861 (2024-003)

Material Weakness 2024

Berkeley County Public Service District

WV

Reporting Allowable Costs / Cost Principles

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

View Audit 400206

Finding 1210853 (2024-003)

Material Weakness 2024

Johnson County, Illinois

IL

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting

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

View Audit 400143

Finding 1210842 (2024-001)

Material Weakness 2024

Connecticut Center of Arts & Technology Inc.

CT

Reporting

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

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

View Audit 400130

Finding 1210816 (2024-005)

Material Weakness 2024

Town of Hollywood

SC

Reporting Matching / Level of Effort / Earmarking

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

View Audit 400096

Finding 1210737 (2024-002)

Material Weakness 2024

Shenandoah Area Agency on Aging, INC

VA

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

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

View Audit 400030

Finding 1210663 (2024-002)

Material Weakness 2024

Gascosage Electric Cooperative

MO

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.303

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

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

View Audit 399958

Finding 1210649 (2024-014)

Material Weakness 2024

Philander Smith College

AR

Student Financial Aid Reporting

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

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

View Audit 399950

Finding 1210629 (2024-009)

Material Weakness 2024

Philander Smith College

AR

Student Financial Aid Reporting Subrecipient Monitoring

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

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

View Audit 399950

Finding 1210625 (2024-008)

Material Weakness 2024

Philander Smith College

AR

Student Financial Aid Subrecipient Monitoring Material Weakness

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

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

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Finding 1210609 (2024-004)

Material Weakness 2024

Philander Smith College

AR

Student Financial Aid Reporting

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

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

View Audit 399950

Finding 1210410 (2024-118)

Material Weakness 2024

State of Arizona

AZ

Allowable Costs / Cost Principles Reporting § 200.303 § 200.430

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

View Audit 399861

Finding 1209148 (2024-117)

Material Weakness 2024

State of Arizona

AZ

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

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

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

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Finding 1209144 (2024-122)

Material Weakness 2024

State of Arizona

AZ

Special Tests & Provisions Material Weakness Reporting

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

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

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Finding 1209141 (2024-121)

Material Weakness 2024

State of Arizona

AZ

Special Tests & Provisions Material Weakness Reporting

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

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

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Finding 1209138 (2024-115)

Material Weakness 2024

State of Arizona

AZ

Subrecipient Monitoring Reporting Procurement, Suspension & Debarment

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

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

View Audit 399861

Corrective Action Plans

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