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Corrective Action Plans

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Finding 383503 (2023-003)
Significant Deficiency 2023
Cornish College of the Arts and Cornish Foundation
WA
Questioned Costs Student Financial Aid Significant Deficiency
Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend that the College review its procedures related to outstanding student refund checks to ensure they are being returned to the Department of Education after 240 days. Explanation of disagreement with au...
Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend that the College review its procedures related to outstanding student refund checks to ensure they are being returned to the Department of Education after 240 days. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Existing Unclaimed Property procedures have been reviewed and training will be given to ensure timely review of outstanding student refund checks to ensure compliance. Name(s) of the contact person(s) responsible for corrective action: Debbie Treen, VP Finance and CFO, pending hiring of open Controller position Planned completion date for corrective action plan: July 31, 2024
View Audit 296558 Questioned Costs: $1
Finding 383477 (2023-010)
Significant Deficiency 2023
State of Utah
UT
Internal Control / Segregation of Duties Significant Deficiency Matching / Level of Effort / Earmarking § 200.303
2023-010. Pharmacy Rebate Invoices Not Checked for Accuracy and Timeliness State Agency: Department of Health and Human Services Federal Agency: Department of Health and Human Services We will immediately reinstate the controls and provide training to the responsible employee and the backup to monit...
2023-010. Pharmacy Rebate Invoices Not Checked for Accuracy and Timeliness State Agency: Department of Health and Human Services Federal Agency: Department of Health and Human Services We will immediately reinstate the controls and provide training to the responsible employee and the backup to monitor the accuracy and timeliness of the rebates. We will ensure that this training includes a standard operating procedure detailing how these reviews will be conducted. Contact Person: Jamie Sorenson, Office Director, Office of Financial Services, 385-290-5380 Anticipated Correction Date: March 31, 2024
View Audit 296545
Finding 383473 (2023-009)
Significant Deficiency 2023
State of Utah
UT
Eligibility Subrecipient Monitoring Reporting
2023-009. Untimely Implementation of Provider Eligibility Requirement Changes State Agency: Department of Health and Human Services Federal Agency: Department of Health and Human Services The Division of Integrated Healthcare has a standard operating procedure to ensure timely compliance for new Med...
2023-009. Untimely Implementation of Provider Eligibility Requirement Changes State Agency: Department of Health and Human Services Federal Agency: Department of Health and Human Services The Division of Integrated Healthcare has a standard operating procedure to ensure timely compliance for new Medicaid rules, regulations, policy changes and other operational requirements. As additional system requirements are identified, that information is entered into the Division’s tracking system called “SPOT”. SPOT is an effective “ticket” system that manages future enhancements, change requests, defects, and other system needs. Prioritization and escalation of the “ticket” ensures that complex or high priority items receive the necessary attention promptly. During the time of the audit finding, DIH was involved in the final stages of PRISM testing and go-live activities and could not make any system changes or it would have potentially impacted the release of the PRISM system. The effective date of the SPOT standard operating procedure was April 3, 2023. Utah Medicaid is in compliance with the audit recommendation. Contact Person: Shandi Adamson, Office Director, Office of Medicaid Operations, 801-793-7261 Anticipated Correction Date: April 3, 2023
View Audit 296545
Finding 383469 (2023-008)
Significant Deficiency 2023
State of Utah
UT
Subrecipient Monitoring Significant Deficiency
2023-008. Noncompliance with Timing of Health and Safety Surveys State Agency: Department of Health and Human Services Federal Agency: Department of Health and Human Services DLBC/OL is taking the following steps to achieve compliance with required survey timeframes: 1. Increase Health Facility Lice...
2023-008. Noncompliance with Timing of Health and Safety Surveys State Agency: Department of Health and Human Services Federal Agency: Department of Health and Human Services DLBC/OL is taking the following steps to achieve compliance with required survey timeframes: 1. Increase Health Facility Licensing fees by 43% to facilitate the hiring of 4 additional staff. 2. Dedicate one-time funds for contracting with a third-party surveyor to help address Health and Safety survey backlog. 3. Work with the DHHS, Office of Innovation to review the health facility team’s processes to improve efficiencies. 4. Organize a separate complaint investigation unit to help expedite complaint and survey completion. Contact Person: Simon Bolivar, Office Director, Office of Licensing, 801-803-4618 Anticipated Correction Date: July 1, 2024
View Audit 296545
Finding 383465 (2023-007)
Significant Deficiency 2023
State of Utah
UT
Subrecipient Monitoring Significant Deficiency Matching / Level of Effort / Earmarking § 200.303
2023-007. Noncompliance with Required Audit of MCO Encounter and Financial Data State Agency: Department of Health and Human Services Federal Agency: Department of Health and Human Services The department started encounter data validation audits August 22, 2023. These audits are being conducted by t...
2023-007. Noncompliance with Required Audit of MCO Encounter and Financial Data State Agency: Department of Health and Human Services Federal Agency: Department of Health and Human Services The department started encounter data validation audits August 22, 2023. These audits are being conducted by the department’s contracted auditor. The department is currently having discussions with CMS about the types of audits that satisfy the financial audit part of the regulatory requirement. When the results from the encounter data and financial audits are completed by the department’s contracted auditor, they will be posted to the department’s website. Contact Person: Greg Trollan, Office Director, Office of Managed Healthcare, 801-538-6088 Anticipated Correction Date: December 31, 2024
View Audit 296545
Finding 383431 (2023-004)
Significant Deficiency 2023
State of Utah
UT
Subrecipient Monitoring Significant Deficiency Internal Control / Segregation of Duties § 200.303
2023-004. Higher Education Emergency Relief Fund Quarterly Reports Not Reviewed for Accuracy State Agency: Utah Tech University Federal Agency: Department of Education Although HEERF funds have been fully expended by the University as of 6/30/23, any future reporting of federal funds of a similar na...
2023-004. Higher Education Emergency Relief Fund Quarterly Reports Not Reviewed for Accuracy State Agency: Utah Tech University Federal Agency: Department of Education Although HEERF funds have been fully expended by the University as of 6/30/23, any future reporting of federal funds of a similar nature will include a secondary review process. The secondary review will be jointly coordinated by Scott Jensen, Assistant Vice President of Business and Auxiliary Services (435-879-4603) and Bryant Flake, Executive Director of Planning and Budget (435-879-4602). This corrective action will be implemented immediately.
View Audit 296545
Finding 383413 (2023-019)
Significant Deficiency 2023
State of Utah
UT
Subrecipient Monitoring Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.214 § 200.303
2023-019. Suspension and Debarment Not Verified Before Awarding Contracts State Agency: Governor’s Office of Planning and Budget Federal Agency: Department of the Treasury GOPB will review its June 2023 training on requirements for SLFRF agreements and retrain all state entities receiving ARPA funds...
2023-019. Suspension and Debarment Not Verified Before Awarding Contracts State Agency: Governor’s Office of Planning and Budget Federal Agency: Department of the Treasury GOPB will review its June 2023 training on requirements for SLFRF agreements and retrain all state entities receiving ARPA funds during April 2024. Part of this training will focus on the requirement to perform timely suspension and debarment checks. GOPB will also reissue the guidance documents requiring suspension and debarment clauses in contract agreements. GOPB will include the reference guide to agencies that contains the standardized language about suspension and debarment checks to use in new agreements. GOPB will collaborate with the Division of Finance to examine FAQ 13.15 and summarize which requirements do and do not apply to revenue replacement projects in order to guide agency compliance activities. GOPB will review processes in place to perform suspension and debarment checks, when required, as part of the ongoing monitoring activities and sample contract agreements to verify inclusion of the appropriate contractual provisions. Contact Person: Darcy Jaimez, Fiscal Grant Manager, 385-377-3373 Anticipated Correction Date: April 30, 2024
View Audit 296545
Finding 383395 (2023-018)
Significant Deficiency 2023
State of Utah
UT
Subrecipient Monitoring Reporting Significant Deficiency
2023-018. Underlying Accounting Data Does Not Support Coronavirus SLFRF Quarterly Reports State Agency: Governor’s Office of Planning and Budget Federal Agency: Department of the Treasury GOPB will document its reporting process, policies, and procedures. As part of the reporting process, GOPB will ...
2023-018. Underlying Accounting Data Does Not Support Coronavirus SLFRF Quarterly Reports State Agency: Governor’s Office of Planning and Budget Federal Agency: Department of the Treasury GOPB will document its reporting process, policies, and procedures. As part of the reporting process, GOPB will continue to review and update its master SLFRF expenditure file and accounting code crosswalk to reconcile all reported SLFRF expenditures to FINET transactions. Any adjustments or deviations from the standard coding will be documented, so they can be tracked by GOPB, the Division of Finance, agencies managing SLFRF projects, and other entities reviewing reporting data. Additionally, GOPB will have one additional staff member review quarterly report data, updates made to the accounting code crosswalk, and documentation for adjustments to verify that they are accurately accounted for in future reports and FINET transactions. Contact Person: Duncan Evans, Senior Managing Director of Budget and Operations, 801-538-1592 Anticipated Correction Date: April 30, 2024
View Audit 296545
Finding 383371 (2023-014)
Significant Deficiency 2023
State of Utah
UT
Questioned Costs Eligibility Subrecipient Monitoring
2023-014. Missing Documentation for Emergency Rental Assistance Payments State Agency: Department of Workforce Services Federal Agency: Department of the Treasury As of March 2023, the Department of Workforce Services Housing and Community Development Division (HCD) stopped processing applications d...
2023-014. Missing Documentation for Emergency Rental Assistance Payments State Agency: Department of Workforce Services Federal Agency: Department of the Treasury As of March 2023, the Department of Workforce Services Housing and Community Development Division (HCD) stopped processing applications due to program funding exhaustion. In the event that the Federal Government reinstates the ERA Program, HCD will adopt additional training procedures to ensure that all program workers understand and adhere to ERA policy and procedures, including reviewing applications for completeness and accuracy prior to payment disbursement. Contact Person: Jennifer Edwards, Assistant Division Director, 385-222-6271 Anticipated Correction Date: April 2023
View Audit 296545 Questioned Costs: $1
Finding 383366 (2023-016)
Significant Deficiency 2023
State of Utah
UT
Reporting Subrecipient Monitoring Cash Management
2023-016. Underlying Accounting Data Does Not Support CRF Quarterly Reports State Agency: Governor’s Office of Planning and Budget Federal Agency: Department of the Treasury GOPB has reviewed its master CRF expenditure file and reconciled all reported CRF expenditures to FINET transactions. The reco...
2023-016. Underlying Accounting Data Does Not Support CRF Quarterly Reports State Agency: Governor’s Office of Planning and Budget Federal Agency: Department of the Treasury GOPB has reviewed its master CRF expenditure file and reconciled all reported CRF expenditures to FINET transactions. The reconciliation accounted for original expenditure transactions, CRF expenditures that were booked when agencies are reimbursed for eligible transactions, and FEMA reimbursements for expenditures charged to the CRF. GOPB made final updates to the September 31, 2023, CRF quarterly report that was submitted on October 10, 2023. Contact Person: Duncan Evans, Senior Managing Director of Budget and Operations, 801-538-1592 Anticipated Correction Date: Completed October 10, 2023
View Audit 296545
Finding 383361 (2023-015)
Significant Deficiency 2023
State of Utah
UT
Subrecipient Monitoring Matching / Level of Effort / Earmarking Cash Management § 200.1
2023-015. Obligation of CRF Funds Not Completed Within Proper Timeframe State Agency: Governor’s Office of Planning and Budget Federal Agency: Department of the Treasury GOPB will save copies of the Treasury Department guidance documents and the September 2022 email from the Treasury Office of the I...
2023-015. Obligation of CRF Funds Not Completed Within Proper Timeframe State Agency: Governor’s Office of Planning and Budget Federal Agency: Department of the Treasury GOPB will save copies of the Treasury Department guidance documents and the September 2022 email from the Treasury Office of the Inspector General that it used to determine that it could update the December 31, 2022 quarterly CRF report to include additional benefit payments from the Unemployment Compensation Fund made between March 1, 2020 and December 31, 2021. GOPB will also save copies of financial reports and other documentation that demonstrates the total costs incurred from the Unemployment Compensation Fund during that time frame did not exceed total deposits into the fund from the CRF, SLFRF, or other sources. Contact Person: Duncan Evans, Senior Managing Director of Budget and Operations, 801-538-1592 Anticipated Correction Date: March 31, 2024
View Audit 296545
Finding 383354 (2023-003)
Significant Deficiency 2023
State of Utah
UT
Subrecipient Monitoring Matching / Level of Effort / Earmarking Reporting
2023-003. USBE Did Not Properly Report All Required Subawards in the Federal Reporting System State Agency: Utah State Board of Education Federal Agency: Department of Agriculture Employees have been trained, and we will continue to ensure they are trained in the reconciliation processes to mitigate...
2023-003. USBE Did Not Properly Report All Required Subawards in the Federal Reporting System State Agency: Utah State Board of Education Federal Agency: Department of Agriculture Employees have been trained, and we will continue to ensure they are trained in the reconciliation processes to mitigate the risk of this occurring again. Contact Person: Scott Jones, Deputy Superintendent of Operations, Scott.jones@schools.utah.gov Anticipated Completion Date: Completed, no further action necessary.
View Audit 296545
Finding 383352 (2023-013)
Significant Deficiency 2023
State of Utah
UT
Questioned Costs Subrecipient Monitoring Cash Management
2023-013. Improper Reimbursement of Utility Expenditures Due to Lack of Effective Internal Controls State Agency: Department of Transportation Federal Agency: Department of Transportation UDOT will train employees to verify utility agreements are drafted and effective before UDOT works on projects w...
2023-013. Improper Reimbursement of Utility Expenditures Due to Lack of Effective Internal Controls State Agency: Department of Transportation Federal Agency: Department of Transportation UDOT will train employees to verify utility agreements are drafted and effective before UDOT works on projects with utility partners. UDOT will continue to coordinate with utility partners to align reimbursement practices with the applicable federal requirements. Responsible Party: Carmen Swanwick, Project Development Director, (801) 232-7802 Completion Date: June 2025
View Audit 296545 Questioned Costs: $1
Finding 383350 (2023-012)
Significant Deficiency 2023
State of Utah
UT
Subrecipient Monitoring Internal Control / Segregation of Duties Reporting
2023-012. Noncompliance Resulting from the Failure to Implement Effective Internal Controls Over Value Engineering Program State Agency: Department of Transportation Federal Agency: Department of Transportation UDOT will train the responsible employees to comply with VE requirements for applicable f...
2023-012. Noncompliance Resulting from the Failure to Implement Effective Internal Controls Over Value Engineering Program State Agency: Department of Transportation Federal Agency: Department of Transportation UDOT will train the responsible employees to comply with VE requirements for applicable federal projects. UDOT will take this opportunity to update the UDOT VE Program and determine which controls will help project managers better understand and comply with VE requirements. Responsible Party: Carmen Swanwick, Project Development Director, (801) 232-7802 Completion Date: June 2025
View Audit 296545
Finding 383348 (2023-011)
Significant Deficiency 2023
State of Utah
UT
Subrecipient Monitoring Significant Deficiency Internal Control / Segregation of Duties
2023-011. Improper Acceptance of Materials Due to Lack of Effective Internal Controls Over the Quality Assurance Program State Agency: Department of Transportation Federal Agency: Department of Transportation UDOT will train employees to test materials within the quality assurance program (QAP) requ...
2023-011. Improper Acceptance of Materials Due to Lack of Effective Internal Controls Over the Quality Assurance Program State Agency: Department of Transportation Federal Agency: Department of Transportation UDOT will train employees to test materials within the quality assurance program (QAP) requirements. Furthermore, the materials division will ensure testers are fully certified before they proceed with testing of materials. Responsible Party: Carmen Swanwick, Project Development Director, (801) 232-7802 Anticipated Completion Date: June 2025
View Audit 296545
Finding 383304 (2023-009)
Significant Deficiency 2023
Eastern Regional Housing Authority
NM
HUD Housing Programs Reporting Significant Deficiency
2023-009: Application Access Control – Significant Deficiency in internal controls over compliance over Recommendation: We recommend that the Housing Authority should review each employee’s access permissions within the “Housi...
2023-009: Application Access Control – Significant Deficiency in internal controls over compliance over Recommendation: We recommend that the Housing Authority should review each employee’s access permissions within the “Housing Pro” software and modify their access according to their job responsibilities. Action Taken: All employee access was reviewed and corrected so that only the two Deputy Directors have administrative access. Due Date of Completion: November 30, 2023 Responsible Official: Irene Murillo, Deputy Director
View Audit 296494
Finding 383303 (2023-001)
Significant Deficiency 2023
Eastern Regional Housing Authority
NM
HUD Housing Programs Reporting Significant Deficiency
2023-001: Internal Controls over Federal Award – Reporting (VMS) - Significant Deficiency in Internal controls over compliance over reporting Recommendation: The Authority should establish a clearly documented review process wherein someone other than the preparer reviews the VMS report prior to sub...
2023-001: Internal Controls over Federal Award – Reporting (VMS) - Significant Deficiency in Internal controls over compliance over reporting Recommendation: The Authority should establish a clearly documented review process wherein someone other than the preparer reviews the VMS report prior to submission. Action Taken: The Authority will have a member of management review VMS submissions prior to submission. Due Date of Completion: February 2024 Responsible Official: Chris Herbert, Executive Director, Irene Murillo, Deputy Director, Carol Hensley, Assistant Deputy Director
View Audit 296494
Finding 383283 (2023-017)
Significant Deficiency 2023
State of Texas C/o Comptroller of Public Accounts
TX
Internal Control / Segregation of Duties Special Tests & Provisions Subrecipient Monitoring § 200.303
Corrective action plan: To ensure compliance is being met with Risk Assessments, the Chief Information Security Officer (CISO) will implement regular compliance reviews, at the beginning of each quarter with Program Director level leadership. Any non-compliance will be addressed with the Program are...
Corrective action plan: To ensure compliance is being met with Risk Assessments, the Chief Information Security Officer (CISO) will implement regular compliance reviews, at the beginning of each quarter with Program Director level leadership. Any non-compliance will be addressed with the Program area by regularly sharing email reminders for reporting, training, and assistance from security. The reports will begin to be shared on July 31, 2024. Application Services, in collaboration with the CISO and the Information Technology (IT) Business Operations’ Policy, Planning, and Performance team, will establish and publish a process for the successful completion of Risk Assessments, including roles and responsibilities, processes, and procedures to ensure timely completion and ongoing compliance. The target implementation date for this document is January 15, 2025. Implementation date: January 15, 2025 Responsible persons: Leatha Marr, Director, IT Applications Services, and Vikram Muralidharan, Chief Information Security Officer
View Audit 296491
Finding 383223 (2023-110)
Significant Deficiency 2023
State of Texas C/o Comptroller of Public Accounts
TX
Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking
Corrective Action Plan: The Office of Financial Aid has revised the award and disbursement notifications to TEACH Grant recipients to include all required elements. The award notification now describes how and when funds will be disbursed. The TEACH disbursement notification now includes the date of...
Corrective Action Plan: The Office of Financial Aid has revised the award and disbursement notifications to TEACH Grant recipients to include all required elements. The award notification now describes how and when funds will be disbursed. The TEACH disbursement notification now includes the date of disbursement, student's right to cancel all or part of the award, and guidance for procedures and time for canceling the award. The policy and procedure will be revised to include these updated procedures. Implementation Date: March 2024 Responsible Persons: Amanda Petrosian, Director of Financial Aid Josiah Mendoza, Assistant Director of Operations
View Audit 296491
Finding 383206 (2023-149)
Significant Deficiency 2023
State of Texas C/o Comptroller of Public Accounts
TX
Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking
Corrective Action Plan: The University reviewed and corrected the queries used to ensure that students receive the appropriate notifications for disbursements made for TEACH grants and any Federal Direct Loans. Implementation Date: 05/2023 Responsible Person: Scott Lapinski, Assistant Vice President...
Corrective Action Plan: The University reviewed and corrected the queries used to ensure that students receive the appropriate notifications for disbursements made for TEACH grants and any Federal Direct Loans. Implementation Date: 05/2023 Responsible Person: Scott Lapinski, Assistant Vice President for Enrollment Management/Director of Financial Aid
View Audit 296491
Finding 383189 (2023-127)
Significant Deficiency 2023
State of Texas C/o Comptroller of Public Accounts
TX
Questioned Costs Special Tests & Provisions Student Financial Aid
Corrective Action Plan: • The University has already implemented significant process enhancements in this area. • The University immediately updated the ECAR to add the School of Veterinary Medicine at Amarillo. • The University has implemented updated procedures requiring both the Primary and Secon...
Corrective Action Plan: • The University has already implemented significant process enhancements in this area. • The University immediately updated the ECAR to add the School of Veterinary Medicine at Amarillo. • The University has implemented updated procedures requiring both the Primary and Secondary designee to review the ECAR quarterly for any required changes. Implementation Date: August 2023 Responsible Persons: Jamie Hansard and Kyle Phillips
View Audit 296491 Questioned Costs: $1
Finding 383165 (2023-161)
Significant Deficiency 2023
State of Texas C/o Comptroller of Public Accounts
TX
Student Financial Aid Special Tests & Provisions Reporting
Corrective Action Plan: The University has implemented a correction to the reporting logic that caused the inaccurate reporting of program begin date for some students. This implementation was effective for enrollment reporting beginning with the Fall 2023 semester. In addition, the University is ut...
Corrective Action Plan: The University has implemented a correction to the reporting logic that caused the inaccurate reporting of program begin date for some students. This implementation was effective for enrollment reporting beginning with the Fall 2023 semester. In addition, the University is utilizing available error reports via the National Student Clearinghouse to ensure program begin dates and other program-level data reported is accurate. Implementation Date: August 2023 Responsible Persons: Ashley Wheelis, Deputy Registrar Molly Collins, Associate Registrar Zach Yeager, Assistant Director
View Audit 296491
Finding 383163 (2023-159)
Significant Deficiency 2023
State of Texas C/o Comptroller of Public Accounts
TX
Student Financial Aid Subrecipient Monitoring Allowable Costs / Cost Principles
Corrective Action Plan: The University is updating procedures to ensure unallowable charges are not paid using Title IV funds without proper authorization from the student or parent. The University will review and improve, as necessary, existing controls to ensure that Title IV aid in excess of the ...
Corrective Action Plan: The University is updating procedures to ensure unallowable charges are not paid using Title IV funds without proper authorization from the student or parent. The University will review and improve, as necessary, existing controls to ensure that Title IV aid in excess of the student’s institutional charges will not be held without written authorization from the student or parent. Implementation Date: May 2024 Responsible Persons: Beth Tolan, Associate Vice President of Financial Aid & Scholarships Christopher Foster, Associate Vice President of Student Accounting
View Audit 296491
Finding 383162 (2023-158)
Significant Deficiency 2023
State of Texas C/o Comptroller of Public Accounts
TX
Student Financial Aid Matching / Level of Effort / Earmarking Reporting
Corrective Action Plan: The University will implement additional controls to check internal disbursement dates against disbursement dates reported in COD in instances where manual reporting is required. Implementation Date: May 2024 Responsible Persons: Kimberley Wells, Director of Financial Aid & S...
Corrective Action Plan: The University will implement additional controls to check internal disbursement dates against disbursement dates reported in COD in instances where manual reporting is required. Implementation Date: May 2024 Responsible Persons: Kimberley Wells, Director of Financial Aid & Scholarships John Robert, Associate Director of Financial Aid & Scholarships Beth Tolan, Associate Vice President of Financial Aid & Scholarships
View Audit 296491
Finding 383160 (2023-156)
Significant Deficiency 2023
State of Texas C/o Comptroller of Public Accounts
TX
Student Financial Aid Special Tests & Provisions Reporting
Corrective Action Plan: The Office of the Registrar and the Office of Scholarships and Financial Aid will collaborate to identify the root cause of why some student data is not being reported in a timely manner. The Office of the Registrar will also institute monthly validation into their business p...
Corrective Action Plan: The Office of the Registrar and the Office of Scholarships and Financial Aid will collaborate to identify the root cause of why some student data is not being reported in a timely manner. The Office of the Registrar will also institute monthly validation into their business processes in alignment with the NSC and NSLDS submission schedule. Implementation Date: February 2025 Responsible Persons: Rachel Honora, Senior Associate Registrar Reggie Brazzle, Director of Operations, SFA
View Audit 296491
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