Corrective Action Plans

Finding 551105 (2024-013)

Significant Deficiency 2024

NC

Student Financial Aid Significant Deficiency Matching / Level of Effort / Earmarking

Student Financial Assistance Cluster - Assistance Listing No. 84.268 Recommendation: The University should ensure all necessary employees receive proper training, support, and time to follow the University’s policies and federal requirements related to monthly reconciliations. There should be a proc...

Student Financial Assistance Cluster - Assistance Listing No. 84.268 Recommendation: The University should ensure all necessary employees receive proper training, support, and time to follow the University’s policies and federal requirements related to monthly reconciliations. There should be a process to maintain all reconciliations as support of performance monthly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Business Office will complete monthly reconciliations in addition to the reconciliation at the time of draw of federal funds to comply with federal requirements. Name(s) of the contact person(s) responsible for corrective action: Belinda Burke, VP for Finance and Administration, CFO Planned completion date for corrective action plan: April 2025

View Audit 352022

Finding 551103 (2024-012)

Significant Deficiency 2024

William Peace Universirty

NC

Student Financial Aid Reporting Significant Deficiency

Student Financial Assistance Cluster - Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the University evaluate its procedures and policies around reporting to the COD to ensure that student information is reported timely. Explanation of disagreement with audit finding: There is no...

Student Financial Assistance Cluster - Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the University evaluate its procedures and policies around reporting to the COD to ensure that student information is reported timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Department will evaluate its policies and procedures around reporting to the COD to ensure that student information is reported timely. Name(s) of the contact person(s) responsible for corrective action: Damon Wade, VP for Enrollment Management and Marketing Planned completion date for corrective action plan: April 2025

View Audit 352022

Finding 551099 (2024-011)

Significant Deficiency 2024

William Peace Universirty

NC

Significant Deficiency Internal Control / Segregation of Duties

Student Financial Assistance Cluster - Assistance Listing No. 84.063, 84.268, 84.007,84.033 Recommendation: The University should review the procedures surrounding the verification process to ensure all necessary support and documentation is obtained as well as maintained in student files. Explanati...

Student Financial Assistance Cluster - Assistance Listing No. 84.063, 84.268, 84.007,84.033 Recommendation: The University should review the procedures surrounding the verification process to ensure all necessary support and documentation is obtained as well as maintained in student files. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Office has added personnel and implemented an electronic document management system. All verification documentation is now scanned and maintained within each student’s electronic file to ensure accuracy, completeness, and audit readiness. Staff continue to receive regular training on verification protocols. Name(s) of the contact person(s) responsible for corrective action: Damon Wade, VP for Enrollment Management and Marketing Planned completion date for corrective action plan: April 2025

View Audit 352022

Finding 551097 (2024-009)

Significant Deficiency 2024

William Peace Universirty

NC

Student Financial Aid Significant Deficiency Internal Control / Segregation of Duties

Student Financial Assistance Cluster - Assistance Listing No. No. 84.063 Recommendation: We recommend the University implement a review process to ensure calculations of Pell awards are using the correct information. Explanation of disagreement with audit finding: There is no disagreement with the a...

Student Financial Assistance Cluster - Assistance Listing No. No. 84.063 Recommendation: We recommend the University implement a review process to ensure calculations of Pell awards are using the correct information. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To reduce calculation errors in Pell Grant awards, the Financial Aid Office has hired additional staff, increased training, and implemented an automated packaging system. This system ensures Pell award amounts are calculated using accurate and verified student information. Name(s) of the contact person(s) responsible for corrective action: Damon Wade, VP for Enrollment Management and Marketing Planned completion date for corrective action plan: August 2025

View Audit 352022

Finding 551094 (2024-008)

Significant Deficiency 2024

William Peace Universirty

NC

Subrecipient Monitoring Student Financial Aid Significant Deficiency

Student Financial Assistance Cluster - Assistance Listing No. No. 84.063, 84.268, 84.007, 84.033 Recommendation: We recommend the University ensure its written information security program addresses the required minimum elements as outlined in 16 CFR 314.4. Explanation of disagreement with audit fin...

Student Financial Assistance Cluster - Assistance Listing No. No. 84.063, 84.268, 84.007, 84.033 Recommendation: We recommend the University ensure its written information security program addresses the required minimum elements as outlined in 16 CFR 314.4. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Information Technology Department will ensure its written information security program addresses the required minimum elements outlined in 16 CFR 314.4. Name(s) of the contact person(s) responsible for corrective action: Belinda Burke, VP for Finance and Administration, CFO Planned completion date for corrective action plan: April 2025

View Audit 352022

Finding 551093 (2024-007)

Significant Deficiency 2024

William Peace Universirty

NC

Questioned Costs Student Financial Aid Significant Deficiency

Student Financial Assistance Cluster - Assistance Listing No. 84.268 Recommendation: We recommend the University establish additional policies to ensure all students meet the financial need criteria before awarding Title IV funds. Explanation of disagreement with audit finding: There is no disagree...

Student Financial Assistance Cluster - Assistance Listing No. 84.268 Recommendation: We recommend the University establish additional policies to ensure all students meet the financial need criteria before awarding Title IV funds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Office has hired additional personnel to enhance oversight and processing capacity. Staff will continue to receive training and will review all late and supplemental awards to verify that students meet financial need criteria before Title IV funds are disbursed. Name(s) of the contact person(s) responsible for corrective action: Damon Wade, VP for Enrollment Management and Marketing Planned completion date for corrective action plan: June 2025

View Audit 352022 Questioned Costs: $1

Finding 551091 (2024-006)

Significant Deficiency 2024

William Peace Universirty

NC

Reporting Student Financial Aid Significant Deficiency

Student Financial Assistance Cluster - Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the University evaluate its procedures and review regulations to ensure the University understands the definitions for enrollment information required to be reported to the NSLDS. Explanation of...

Student Financial Assistance Cluster - Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the University evaluate its procedures and review regulations to ensure the University understands the definitions for enrollment information required to be reported to the NSLDS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Given the findings related to enrollment reporting, the University will review policies and procedures to ensure information is reported in a timely and accurate manner. The University will review the NSLDS regulations and ensure understanding and compliance of the NSLDS definitions related to required reporting of enrollment changes. The University will verify program lengths for all active programs reported to NSLDS. The Registrar is the responsible party for enrollment reporting via NSC to NSLDS. Name(s) of the contact person(s) responsible for corrective action: Lynda Szymanski, VP for Academic Affairs Planned completion date for corrective action plan: April 2025

View Audit 352022

Finding 551087 (2024-005)

Significant Deficiency 2024

William Peace Universirty

NC

Student Financial Aid Significant Deficiency Matching / Level of Effort / Earmarking

Student Financial Assistance Cluster - Assistance Listing No. 84.063, 84.268, 84.007, 84.033 Recommendation: We recommend the University review the R2T4 requirements and ensure their process incorporates a review of students to ensure no calculations are missed that should be performed. Explanation ...

Student Financial Assistance Cluster - Assistance Listing No. 84.063, 84.268, 84.007, 84.033 Recommendation: We recommend the University review the R2T4 requirements and ensure their process incorporates a review of students to ensure no calculations are missed that should be performed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: At the conclusion of each academic term, the Director of Financial Aid will review enrollment data with the Registrar’s Office to identify students who may require Return of Title IV (R2T4) calculations. Completion of all required R2T4 calculations will be documented and verified by the Director to ensure full compliance with federal guidelines. Name(s) of the contact person(s) responsible for corrective action: Damon Wade, VP for Enrollment Management and Marketing Planned completion date for corrective action plan: May 2025

View Audit 352022

Finding 549905 (2024-018)

Significant Deficiency 2024

State of Utah

UT

Subrecipient Monitoring Allowable Costs / Cost Principles Significant Deficiency § 200.302 § 200.430

2024-018. USU Extension Extra Services Compensation Program Non-Compliance with Uniform Guidance State Agency: Utah State University Research & Development Federal Agency: Various 1) Potential Financial Impact USU retained Huron Higher Education Consulting to conduct a Uniform Guidance compliance r...

2024-018. USU Extension Extra Services Compensation Program Non-Compliance with Uniform Guidance State Agency: Utah State University Research & Development Federal Agency: Various 1) Potential Financial Impact USU retained Huron Higher Education Consulting to conduct a Uniform Guidance compliance review of compensation costs charged to federal sponsors. Huron Consulting routinely works with Carnegie R1 institutions to review research compliance issues. Huron conducted a detailed review of an extensive data set for ESC payments made to USU employees, focusing on employees who had salary charged to federal grants or designated as a grant cost share. This review identified limited instances (1) when salaries directly charged to sponsored projects included extra service compensation in the institutional base salary and (2) when extra service compensation was charged to federal sponsors. Overall, the review found that the vast majority of USU ESC payments (referred to as secondary payments in the internal audit) were not charged to federal sponsored awards. Out of a total population of $5.8 million ESC payments reviewed, the unallowed compensation costs related to ESC is approximately $140,000. USU is in the process of addressing the unallowable compensation costs by removing unallowable charges on open awards and refunding unallowable charges on closed awards. 2) Policies and required documentation for ESC. ESC Policies: USU is reviewing its policies associated with ESC and institutional base salary (IBS) (both currently defined in USU Policy 376: Extra Service Compensation). A working group has been established that includes the Provost’s Office, the President’s Office, the Office of Research and Human Resources to develop updated procedures for requesting ESC. Once in place, a new Extra Service Compensation website will be rolled out that will provide guidance on the policy, acceptable uses of extra-service Compensation, and training materials. In conjunction with the website development, a communication plan to inform stakeholders, especially approving department heads and administrators, will be developed. Institutional Base Salary Policy and Procedures: USU will create and implement an Institutional Base Salary policy that aligns with federal requirements and industry best practices and specifically defines salary components and the associated pay codes that are included and excluded from an employee’s institutional base salary. USU will also update its time and effort certification system with correct institutional base salary mapping. 3) Internal controls for sponsored program compensation USU will implement the following improvements in its internal controls: Revised ESC Form. USU has revised its ESC Form to include documentation / calculation demonstrating payment is commensurate with institutional base salary. Revised ESC Application and Approval Process: USU has already updated the internal ESC review process to include appropriate controls to ensure that all ESC requests are reviewed for Uniform Guidance and USU policy requirements. In this regard, all ESC requests at USU are now reviewed by the Office of Sponsored Programs in the context of all funding sources associated with the applicant (including cost share indexes). This change directly addresses prior routing based on the source of funding which resulted in the Office of Research/Sponsored Programs being bypassed for state-funded ESC requests. Certification language has been inserted at appropriate approval levels to ensure that employees are not receiving ESC related to their primary position/workload. Improved Definitions of Primary Work Statement: USU has initiated a collaborative effort between Human Resources, the Provost’s Office, and the Office of Research to clearly define the primary work assignment for faculty via the role statement or annual work plans to clarify the full workload associated with the IBS. Increased Compliance Monitoring: After-the-fact monthly review of ESC payments is being collaboratively performed between the Office of Research and Provost’s Office. Additionally, USU has reorganized its operations to house post-award research administrators within the Office of Research and added an additional supervisory position to manage post award compliance and management. USU will charge central-post award research administrators with monitoring salary charges to sponsored awards and cost share accounts as a secondary internal control. Research Incentive Programs: The Office of Research will establish permissible conditions and components for research incentive programs and any and all proposed programs will be reviewed and approved by the Office of Research before implementation. 4) Adequate training to university personnel regarding sponsored programs compensation compliance. Uniform Guidance training for faculty and staff: USU is building and incorporating new training modules for those managing federal awards which will include guidance on allowable compensation costs and determining institutional base salary. ESC Training: USU has developed a new required annual training for anyone requesting or approving ESC from all types of funding sources at USU (delivered via USU’s Learn Blue system). This training addresses requirements for ESC and employees’ role and responsibilities for compliance requirements. Additional training regarding time and effort certification will be developed. Pay Code Training: USU will provide additional training and education for departmental and payroll staff responsible for coding and processing salary across the institution. Responsible Person: Lisa M. Berreau Vice President for Research Utah State University 435-797-3509 Anticipated completion date of corrective action plan: Actively in progress and full completion by Jan. 1, 2026.

View Audit 352012

Finding 548761 (2024-008)

Significant Deficiency 2024

State of Utah

UT

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

2024-008. Non-Payroll Expenditures Did Not Receive Adequate Reviews State Agency: University of Utah Research & Development Federal Agency: Department of Health and Human Services The Controller’s Office will work directly with the identified PI’s to provide additional training and understanding of ...

2024-008. Non-Payroll Expenditures Did Not Receive Adequate Reviews State Agency: University of Utah Research & Development Federal Agency: Department of Health and Human Services The Controller’s Office will work directly with the identified PI’s to provide additional training and understanding of the importance of appropriate and timely approvals. In addition, the Controller will work with the Office of Sponsored Projects and the Financial Reporting & Accounting office to review current training processes, as well as the process for notification and follow up with those AE’s/PI’s who do not meet the standard set forth in policy. Contact Person: Steven Phillips Anticipated Correction Date: 6/30/2025

View Audit 352012

Finding 548758 (2024-005)

Significant Deficiency 2024

State of Utah

UT

Subrecipient Monitoring Significant Deficiency

2024-005. Required Health and Safety Surveys Not Performed Within Statutory Timeline State Agency: Department of Health and Human Services Federal Agency: Department of Health and Human Services To address this finding (and prior year finding number 2023-008), the Division of Licensing and Backgroun...

2024-005. Required Health and Safety Surveys Not Performed Within Statutory Timeline State Agency: Department of Health and Human Services Federal Agency: Department of Health and Human Services To address this finding (and prior year finding number 2023-008), the Division of Licensing and Background Checks (DLBC), Office of Licensing (OL) took the following corrective action to achieve compliance with required survey time frames: • Increased Health Facility Licensing fees by 43% to facilitate the hiring of 4 additional staff for the 2025 state fiscal year. • Dedicated one-time funds for contracting with a third-party surveyor and hired two, time- limited positions to help address the Health and Safety survey backlog in fiscal year 2024 and 2025. • Continued to work with the DHHS Office of Innovation to review the health facility team’s processes to improve efficiencies. • Organized a separate complaint investigation unit in August 2024 to help expedite complaint and survey completion. The DBLC, OL will continue to follow through with these additional resources in order to achieve compliance with the required survey timelines. In addition, the OL plans to streamline the writing and reporting procedures while ensuring compliance with CMS guidance. The goal is to shorten the time required to write reports and therefore increase the number of surveys completed. Implementation Date: July 1, 2026 Contact: Courtney Webb, Financial Manager, Division of Finance & Administration, courtneywebb@utah.gov

View Audit 352012

Finding 548755 (2024-004)

Significant Deficiency 2024

State of Utah

UT

Eligibility Subrecipient Monitoring Cash Management

2024-004. Inadequate Procedures to Identify Healthcare Providers with Expired Licenses State Agency: Department of Health and Human Services Federal Agency: Department of Health and Human Services Out-of-state providers and the provider whose license expired during the PHE. During the PHE an expire...

2024-004. Inadequate Procedures to Identify Healthcare Providers with Expired Licenses State Agency: Department of Health and Human Services Federal Agency: Department of Health and Human Services Out-of-state providers and the provider whose license expired during the PHE. During the PHE an expired license report was not properly monitored. Prospectively, DHHS will ensure license expiration notifications are reviewed on a monthly basis. Additionally, DHHS will work with the PRISM contractor to explore pathways to identify all providers (out-of-state and in-state) whose licenses may have already expired. DHHS will follow the current license expiration process and close those providers as appropriate. Provider initially granted eligibility in the legacy system. In any future event involving data conversion, DHHS will ensure that all relevant data from the existing system is thoroughly collected and reviewed prior to the conversion process. This will help guarantee data integrity and minimize the risk of issues arising during the transition. Implementation Date: July 31, 2025 Contact: Shandi Adamson, Director, Office of Medicaid Operations, shandiadamson@utah.gov

View Audit 352012

Finding 548753 (2024-003)

Significant Deficiency 2024

State of Utah

UT

Subrecipient Monitoring HUD Housing Programs Reporting

2024-003. Incomplete Pharmacy Rebate Reporting and Invoicing State Agency: Department of Health and Human Services Federal Agency: Department of Health and Human Services Following the launch of the Medicaid Provider Reimbursement Information System for Medicaid (PRISM) in April 2023, not all pharma...

2024-003. Incomplete Pharmacy Rebate Reporting and Invoicing State Agency: Department of Health and Human Services Federal Agency: Department of Health and Human Services Following the launch of the Medicaid Provider Reimbursement Information System for Medicaid (PRISM) in April 2023, not all pharmacy files from managed care entities and JCODE drugs properly transmitted to the third-party organization’s system. The key pharmacy claims files that needed to interface with the third-party organization’s system have now been rebuilt and are undergoing interface testing. After testing, the historic and more current files will be put into production and be transmitted to the third-party organization. Following receipt, the third-party organization will invoice and collect the unbilled rebates. Once this interface issue is resolved, all future required drug utilization data as well as rebate invoices will be sent to manufacturers within the required time frame. All claims received will be invoiced 60 days after the end of the current quarter they are received in, per CMS's rule. DHHS informed CMS of this issue in August 2024. At that time, CMS said the state was out of compliance and inquired on timelines to come into compliance. The state will provide updates to CMS when the backlogged files have been successfully transmitted and manufacturers have been invoiced. According to the third-party pharmacy organization, manufacturers were notified about this issue when it was discovered in May 2023 and advised that when the issues with invoicing these rebates is resolved they will be expected to pay the balance due. Implementation Date: May 30, 2025 Contact: Sepideh Daeery, Pharmacy Director, Division of Integrated Healthcare, sepidehdaeery@utah.gov Anticipated Correction Date: June 30, 2024

View Audit 352012

Finding 548751 (2024-011)

Significant Deficiency 2024

State of Utah

UT

Subrecipient Monitoring Reporting Significant Deficiency

2024-011. DWS-Adopted Guidelines Not Followed When Evaluating an Applicant Housing Project State Agency: Department of Workforce Services Federal Agency: Department of Housing and Urban Development The Housing and Community Development Division is in the process of completing a full HTF policy and p...

2024-011. DWS-Adopted Guidelines Not Followed When Evaluating an Applicant Housing Project State Agency: Department of Workforce Services Federal Agency: Department of Housing and Urban Development The Housing and Community Development Division is in the process of completing a full HTF policy and procedures rewrite with a robust internal controls process. This will include an updated HTF monitoring checklist and a quality control check of said monitoring checklist by the Program Manager. Anticipated correction date: March 31, 2025 Responsible person: Daniel Murphy, HCD Program Manager, 385-630-8368

View Audit 352012

Finding 548749 (2024-010)

Significant Deficiency 2024

State of Utah

UT

Eligibility Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303

2024-010. HTF Project Does Not Meet Eligible Income Requirements State Agency: Department of Workforce Services Federal Agency: Department of Housing and Urban Development The Housing and Community Development Division is in the process of completing a full HTF policy and procedures rewrite with a r...

2024-010. HTF Project Does Not Meet Eligible Income Requirements State Agency: Department of Workforce Services Federal Agency: Department of Housing and Urban Development The Housing and Community Development Division is in the process of completing a full HTF policy and procedures rewrite with a robust internal controls process. This will include an updated HTF monitoring checklist and a quality control check of said monitoring checklist by the Program Manager. Anticipated correction date: March 31, 2025 Responsible person: Daniel Murphy, HCD Program Manager, 385-630-8368

View Audit 352012

Finding 548698 (2024-015)

Significant Deficiency 2024

State of Utah

UT

Subrecipient Monitoring Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

2024-015. Reported Number of Homeowners Overstated State Agency: Department of Workforce Services Federal Agency: Department of the Treasury The Housing and Community Development Division will adopt a quality review process to address this finding. Fortunately, the Quarterly Reports are cumulative s...

2024-015. Reported Number of Homeowners Overstated State Agency: Department of Workforce Services Federal Agency: Department of the Treasury The Housing and Community Development Division will adopt a quality review process to address this finding. Fortunately, the Quarterly Reports are cumulative so we have updated the current report to reflect the accurate household counts with an AMI under 100%. Anticipated correction date: March 31, 2025 Responsible person: Ambra Peterson, HCD Program Manager, 385-312-6551

View Audit 352012

Finding 548697 (2024-014)

Significant Deficiency 2024

State of Utah

UT

Subrecipient Monitoring Reporting Significant Deficiency

2024-014. Errors in Coronavirus SLFRF Quarterly Reports State Agency: Governor’s Office of Planning and Budget Federal Agency: Department of the Treasury GOPB has not received a response from the Treasury Office of Recovery Programs regarding the application of the $10 million capital expenditure re...

2024-014. Errors in Coronavirus SLFRF Quarterly Reports State Agency: Governor’s Office of Planning and Budget Federal Agency: Department of the Treasury GOPB has not received a response from the Treasury Office of Recovery Programs regarding the application of the $10 million capital expenditure reporting threshold. GOPB is working with the National Association of State Budget Officers to see if they can receive a response. GOPB will add a new capital expenditure section to each ARPA SLFRF Appropriation Tracking and Documentation Form to document the applicability of capital expense requirements for the project. If a project requires additional justification, based on clarification provided by the Treasury, GOPB and the agency will record the justification and documentation on the form and submit that information in the next quarterly ARPA SLFRF P&E Report-Quarter 4 2024. While preparing the October 2024 ARPA SLFRF P&E Report-Quarter 3 2024, GOPB will reconcile all reported obligations with backup documents. This reconciliation will be completed for future reports. Contact Person: Darcy Jaimez, Fiscal Grant Manager, 385-377-3373 Anticipated Correction Date: October 31, 2024

View Audit 352012

Finding 548696 (2024-013)

Significant Deficiency 2024

State of Utah

UT

Questioned Costs Subrecipient Monitoring Internal Control / Segregation of Duties

2024-013. Misunderstanding Caused Improper Spending of Coronavirus State and Local Fiscal Recovery Funds (SLFRF) State Agency: Governor’s Office of Planning and Budget Federal Agency: Department of the Treasury GOPB agrees with the finding. We acknowledge that GOEO mistakenly recorded $559,900 of e...

2024-013. Misunderstanding Caused Improper Spending of Coronavirus State and Local Fiscal Recovery Funds (SLFRF) State Agency: Governor’s Office of Planning and Budget Federal Agency: Department of the Treasury GOPB agrees with the finding. We acknowledge that GOEO mistakenly recorded $559,900 of expenditures to the SLFRF program and identified the same error during the quarterly expenditure review process. Upon identifying this error, GOPB promptly addressed the issue with GOEO so that expenditures could be corrected in the financial system before the end of the FY 2024 closeout and the July 2024 quarterly ARPA SLFRF report. Corrective Action Plan: To improve oversight and monitoring of expenditures, GOPB will work closely with GOEO to ensure that all expenditures charged to SLFRF projects comply with program requirements. GOPB will also add content to agency SLFRF trainings about regularly reviewing project ARPA SLFRF Appropriation Tracking and Documentation Forms, which outline the budget, scope, eligibility, and coding for ARPA SLFRF projects. The training will specifically emphasize the importance of each agency establishing effective internal controls for recording and reviewing ARPA SLFRF expenditures. In addition to updating its general training materials, GOPB will provide additional training to agency staff managing new projects so they understand policies and procedures. Contact Person: Duncan Evans, Senior Managing Director of Budget and Operations, 801-538-1592 Anticipated Correction Date: Completed October 31, 2024 State Agency: Governor’s Office of Economic Opportunity 1. GOEO will work with GOPB to ensure that all expenditures charged to SLFRF projects comply with program requirements. GOEO will participate in SLFRF trainings about regularly reviewing project ARPA SLFRF Appropriation Tracking and Documentation Forms, which outline the budget, scope, eligibility, and coding for ARPA SLFRF projects. Implementation of this plan has already begun and will be ongoing. 2. GOEO has improved internal controls. This includes improved review procedures by financial analysts and improved approval procedures by financial managers. Implementation of this plan is complete. Contact of Persons Responsible for Corrective Action: Kamron Dalton, Managing Director of Operations Jason Marden, Director of Finance Greg Jeffs, Agency Internal Audit Director (not responsible, but please cc communications)

View Audit 352012 Questioned Costs: $1

Finding 548694 (2024-009)

Significant Deficiency 2024

State of Utah

UT

Questioned Costs Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

2024-009. Unallowable Cash Medical Assistance Benefit Issuances State Agency: Department of Workforce Services Federal Agency: Department of the Treasury All cases cited in error have been reviewed, and all corrective actions have been completed. One-on-one meetings with individual staff who took ap...

2024-009. Unallowable Cash Medical Assistance Benefit Issuances State Agency: Department of Workforce Services Federal Agency: Department of the Treasury All cases cited in error have been reviewed, and all corrective actions have been completed. One-on-one meetings with individual staff who took approval actions on these cases will be scheduled to discuss what led to the incorrect decision and review the policy and procedure for learning. In addition, all eligibility workers who manage refugee programs will receive training on common error elements. All one-on-one meetings and team training will be completed by April 30, 2025. Anticipated correction date: April 30, 2025 Responsible person: Muris Prses, Division Director, Eligibility Services Division, 801-889-9712

View Audit 352012 Questioned Costs: $1

Finding 548693 (2024-007)

Significant Deficiency 2024

State of Utah

UT

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

2024-007. Refugee Grant Expenditures Charged Outside Award Period State Agency: Department of Workforce Services Federal Agency: Department of Health and Human Services The department will implement a more detailed and thorough review of transactions to ensure that costs are attributed to the applic...

2024-007. Refugee Grant Expenditures Charged Outside Award Period State Agency: Department of Workforce Services Federal Agency: Department of Health and Human Services The department will implement a more detailed and thorough review of transactions to ensure that costs are attributed to the applicable period of performance in which the work was performed, and expenses were incurred and will ensure that costs are subsequently charged to the corresponding grant award. Anticipated correction date: January 31, 2025 Responsible person: Nathan Harrison, Executive Finance Director, 801-808-0676

View Audit 352012 Questioned Costs: $1

Finding 548692 (2024-006)

Significant Deficiency 2024

State of Utah

UT

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

2024-006. TANF ACF-204 Report Does Not Match Supporting Documentation State Agency: Department of Workforce Services Federal Agency: Department of Health and Human Services The report processes will be updated to add internal controls. The program manager will coordinate with finance staff to review...

2024-006. TANF ACF-204 Report Does Not Match Supporting Documentation State Agency: Department of Workforce Services Federal Agency: Department of Health and Human Services The report processes will be updated to add internal controls. The program manager will coordinate with finance staff to review all finance documentation utilized for the report. Prior to submission of the report, it will be reviewed by division and finance leadership to ensure the report aligns with documentation and is correct. Anticipated correction date: December 31, 2024 Responsible person: Liz Carver, Division Director, 801-514-1017

View Audit 352012

Finding 548660 (2024-002)

Significant Deficiency 2024

Food Lifeline

WA

Allowable Costs / Cost Principles Subrecipient Monitoring Significant Deficiency § 200.303

Corrective Action: Management will track all grant expenditures using separate project codes for each award to ensure specific identification of the direct costs charged. Additionally, at the end of the reporting period, management will perform a reconciliation between the direct costs charged and t...

Corrective Action: Management will track all grant expenditures using separate project codes for each award to ensure specific identification of the direct costs charged. Additionally, at the end of the reporting period, management will perform a reconciliation between the direct costs charged and the total revenues earned under each award to ensure the amounts are consistent with those reported in the schedule of expenditures of federal awards. Anticipated Completion Date: June 30, 2025

View Audit 351990

Finding 548655 (2024-004)

Significant Deficiency 2024

Ifoster, Inc.

CA

Reporting Significant Deficiency

Federal Agency Name: Corporation for National and Community Service Pass-Through Entity: State of California – California Volunteers Assistance Listing Number: 94.006 Program Name: AmeriCorps State and National Finding Summary: The OMB Compliance Supplement requires that reports submitted to the fed...

Federal Agency Name: Corporation for National and Community Service Pass-Through Entity: State of California – California Volunteers Assistance Listing Number: 94.006 Program Name: AmeriCorps State and National Finding Summary: The OMB Compliance Supplement requires that reports submitted to the federal awarding agency include all activity of the reporting period, are supported by underlying accounting information, and are presented in accordance with program requirements. Amounts reported on the SF-425 were not supported by the underlying accounting information. Responsible Individuals: Reid Cox, CFO Corrective Action Plan: Acknowledged. We have implemented a secondary review process of all SF-425 reports prior to submission. Anticipated Completion Date: Ongoing

View Audit 351989

Finding 548650 (2024-003)

Significant Deficiency 2024

Ifoster, Inc.

CA

Allowable Costs / Cost Principles Significant Deficiency § 200.430

Federal Agency Name: Corporation for National and Community Service Pass-Through Entity: State of Washington – Service Washington, State of California – California Volunteers, State of Kentucky – KY Cabinet of Health and & Family Services Assistance Listing Number: 94.006 Program Name: AmeriCorps St...

Federal Agency Name: Corporation for National and Community Service Pass-Through Entity: State of Washington – Service Washington, State of California – California Volunteers, State of Kentucky – KY Cabinet of Health and & Family Services Assistance Listing Number: 94.006 Program Name: AmeriCorps State and National Finding Summary: Title 2 U.S. Code of Federal Regulations (CFR) Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) section 200.430 provides that records must be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. Amounts for certain personnel costs were not reimbursed at the correct pay rate for certain employees. Responsible Individuals: Reid Cox, CFO Corrective Action Plan: Acknowledged. While current year differences were immaterial and resulted in a slight underbilling, we have implemented a secondary review process of all calculations of hourly payrates to ensure consistency in the payrate calculation. Anticipated Completion Date: Ongoing

View Audit 351989

Finding 548621 (2024-001)

Significant Deficiency 2024

Northwest Arctic Borough, Alaska

AK

Reporting Procurement, Suspension & Debarment Significant Deficiency § 200.328

Name of Contact Person: Dickie Motto, Mayor and Jade Hill Treasurer Corrective Action Plan: NWAB established a policy/procedure to ensure that they are successful and compliant with the program’s reporting requirements and the award(s) are used in accordance with federal statutes, regulations, and ...

Name of Contact Person: Dickie Motto, Mayor and Jade Hill Treasurer Corrective Action Plan: NWAB established a policy/procedure to ensure that they are successful and compliant with the program’s reporting requirements and the award(s) are used in accordance with federal statutes, regulations, and the terms and conditions of the federal and state awards. Proposed Completion Date: Fiscal Year 2024

View Audit 351964

Corrective Action Plans

Filters