Corrective Action Plans

Finding 385221 (2023-001)

Significant Deficiency 2023

IN

Questioned Costs Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.303

Finding 2023-001 – Title I Grants to Local Education Agencies – Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Amy Phillips Contact Phone Number: (765) 662-2546 ext 8070 Views of Responsible Official: We concur with the finding. Des...

Finding 2023-001 – Title I Grants to Local Education Agencies – Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Amy Phillips Contact Phone Number: (765) 662-2546 ext 8070 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Marion Community Schools will establish an internal control system that will require review of all timesheets and payroll registers by the Chief Financial Officer (CFO) or the Assistant Chief Financial Officer (Asst CFO). Timesheets/payroll registers will be reviewed for any new or updated wage amounts and provide a second sign off documenting that these were reviewed and approved. The payroll employee should bring these forward for initial review, however, the CFO/Asst CFO will still review registers as a double check and to prevent errors. Payroll changes should be kept together for easy reference, as well as with the payroll file for the period in which the change was made. Anticipated Completion Date: Immediately

View Audit 298224 Questioned Costs: $1

Finding 385085 (2023-002)

Significant Deficiency 2023

American Samoa Community College

AS

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

Finding Number 2023-002 – Enrollment Reporting, Significant Deficiency in Internal Control over Compliance. Contact Person(s): Shanell Tilo, Financial Aid Officer Dr. Emilia Le’i, Dean of Student Services Dr. Letupu Moananu, Vice President of Academics, Community, and Student Affairs Explanation ...

Finding Number 2023-002 – Enrollment Reporting, Significant Deficiency in Internal Control over Compliance. Contact Person(s): Shanell Tilo, Financial Aid Officer Dr. Emilia Le’i, Dean of Student Services Dr. Letupu Moananu, Vice President of Academics, Community, and Student Affairs Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreement. Corrective actions taken/planned: The Financial Aid Coordinator (control #1, with FA Officer as alternate) has been assigned to transmit the bi-monthly Enrollment Report roster. The control #1 reviews the roster and performs data entry, status updates, and submission by the 15th of the reporting month. On the 1st of every nonreporting month, control #1 will review and report any enrollment status changes before the 15th. Financial Aid Manager (control #2) will review the status updates on NSLDS before and after every submission. Identified errors will be documented and returned to control #1 for correction and resubmission. The policy will ensure all student changes in status are identified, updated, and submitted timely and accurately. ASCC FAO participates in Federal Student Aid (FSA) training and conferences regarding NSLDS updates, changes, and functionality. FAO also subscribes to the Weekly Knowledge Center Updates from FSA Partner Connect. ASCC is a member of the National Association of Student Financial Aid Administrators (NASFAA). All of these resources provide access and education in the process of enrollment reporting and compliance, as well as the responsibilities and consequences of inaccurate reporting. Graduates: Students who graduate will be updated into NSLDS within one week after graduation. Official / Unofficial Withdrawal: All Withdrawals must then be reported to NSLDS within 45 days. On the 1st of every nonreporting month, control #1 will review and report any enrollment status changes before the 15th. Financial Aid Manager (control #2) will review the status updates on NSLDS before and after every submission. Identified errors will be documented and returned to control #1 for correction and resubmission. The policy will ensure all student changes in status are identified, updated, and submitted timely and accurately. ASCC FAO participates in Federal Student Aid (FSA) training and conferences regarding NSLDS updates, changes, and functionality. FAO also subscribes to the Weekly Knowledge Center Updates from FSA Partner Connect. ASCC is a member of the National Association of Student Financial Aid Administrators (NASFAA). All of these resources provide access and education in the process of enrollment reporting and compliance, as well as the responsibilities and consequences of inaccurate reporting. Graduates: Students who graduate will be updated into NSLDS within one week after graduation. Official / Unofficial Withdrawal: All Withdrawals must then be reported to NSLDS within 45 days.

View Audit 298200

Finding 385071 (2023-001)

Significant Deficiency 2023

Snowflake Unified School District No. 5

AZ

School Nutrition Programs Cash Management Eligibility

Findings and Questioned Costs Related to Federal Awards Finding Number: 2023‐001 Program Name/Assistance Listing Title: Child Nutrition Cluster Assistance Listing Numbers: 10.553, 10.555, 10.559 Contact Person: Mark Ollerton, Business Manager Anticipated Completion Date: Because this has been addres...

Findings and Questioned Costs Related to Federal Awards Finding Number: 2023‐001 Program Name/Assistance Listing Title: Child Nutrition Cluster Assistance Listing Numbers: 10.553, 10.555, 10.559 Contact Person: Mark Ollerton, Business Manager Anticipated Completion Date: Because this has been addressed the completion date is immediate as to the corrective action plan, March 25, 2024. Planned Corrective Action: The process in the District is that two individuals reconcile the number prior to submission of claims. After evaluating what caused the error, the staff did follow best practices in that two separate individuals reconciled the numbers for the claim. After this was completed, the claim was created and submitted to be processed by the Arizona Department of Education Child Nutrition Program. In developing the claim, a number was entered incorrectly on the claim. The corrective action is already in place. The District will continue with the dual review of the numbers. The error has been discussed with staff and they will be more diligent in their part of entering the claim information.

View Audit 298163

Finding 385031 (2023-001)

Significant Deficiency 2023

Autonomous Municipality of Caguas

PR

HUD Housing Programs Subrecipient Monitoring Eligibility

The Municipality of Caguas PHA will implement internal controls which ensure that the families files conform to the program requirements for the annual recertifications. Each month the Program Manager or the persona assigned by the Director, will select a sample of files of each zone and verify the ...

The Municipality of Caguas PHA will implement internal controls which ensure that the families files conform to the program requirements for the annual recertifications. Each month the Program Manager or the persona assigned by the Director, will select a sample of files of each zone and verify the following: Voucher Size, Family Composition, income., Inspection Documents, Payment Standards, Utilities, and the rent calculation in the Form HUD-50058, Family Report and other required documents. Files without all the required documentation will be assigned to the respective Housing Office (HO). The HO must contact the family and request the necessary documentation in order to complete the tenant file. The HO will be required to complete all corrective actions within 15 days upon assignment. If additional time is needed, the Director or the person assigned will evaluate the case and may provide an additional 15 days for a maximum of 30 days.

View Audit 298127

Finding 384991 (2023-004)

Significant Deficiency 2023

Emmaus Bible College

IA

Subrecipient Monitoring Significant Deficiency

Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: The College concurs with the audit finding of partial compliance and recognizes the need to fully comply with GLBA regulations. The College has implemented annual cybersecurity training for employees. The College is in process on u...

Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: The College concurs with the audit finding of partial compliance and recognizes the need to fully comply with GLBA regulations. The College has implemented annual cybersecurity training for employees. The College is in process on updating its risk assessment, improving safeguards, updating and improving policies and procedures, improving continuous monitoring, and updating incident response plan. The Director of Technology Services will present written status report to the board at the next relevant meeting after March 2024 and this will be done on an annual basis going forward. Person Responsible for Corrective Action Plan: Steven Jabini, Director of Technology Services Anticipated Date of Completion: May 31, 2024

View Audit 298054

Finding 384989 (2023-001)

Significant Deficiency 2023

Newberry County Memorial Hospital

NC

Questioned Costs Reporting Significant Deficiency

Department of Health and Human Services Newberry County Memorial Hospital respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 through June 30, 2023 The finding from the schedule of findings and questioned costs is discussed below....

Department of Health and Human Services Newberry County Memorial Hospital respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 through June 30, 2023 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS Department of Health and Human Services 2023-001 Provider Relief Funding – Assistance Listing No. 93.498 Recommendation: We recommend the Organization perform a detailed review of the supporting documentation to ensure accurate expenses are inputted in the internal tracking spreadsheets that is ultimately used by the Management to input into the HRSA reporting portal. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The hospital attempted to track COVID supplies to each nursing unit cost center. This required the Materials Management department to track detailed items in a spreadsheet format. Human error resulted in two of the items being charged with an incorrect amount. The hospital is implementing a new procedure that will improve tracking each expense from the storeroom. An additional step will be for the ACFO to check each month's COVID expense allocation to the spreadsheet to identify potential errors and improve accuracy of the reporting the claimed expenses. Name(s) of the contact person(s) responsible for corrective action: John L. Doyle, Chief Financial Officer Planned completion date for corrective action plan: September 30, 2024 If the Department of Health and Human Services has questions regarding this plan, please call John L. Doyle, CFO, at 803-405-7137

View Audit 298040 Questioned Costs: $1

Finding 384985 (2023-001)

Significant Deficiency 2023

Madison Area Technical College District

WI

Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Student Financial Aid Cluster – Assistance Listing No. 84.063 & 84.268 Recommendation: We recommend that the College design and implement controls to ensure reporting to NSLDS are designed to capture all enrolled students and programs offered by the District. Explanation of disagreement with audit...

Student Financial Aid Cluster – Assistance Listing No. 84.063 & 84.268 Recommendation: We recommend that the College design and implement controls to ensure reporting to NSLDS are designed to capture all enrolled students and programs offered by the District. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District worked with NSC to resolve the errors surrounding mismatched CIP codes, resulting in the enrollment report being finalized in late 2022. The College will work with their Records Department to explore accommodations surrounding future term requirements. Name(s) of the contact person(s) responsible for corrective action: Laurie Grigg, Chief Financial Officer Planned completion date for corrective action plan: June 30, 2024

View Audit 298033

Finding 384974 (2023-001)

Significant Deficiency 2023

Community Service Society of New York

NY

Subrecipient Monitoring Reporting Significant Deficiency

Community Service Society (the Society) requires its subrecipients to submit their financial and progress program reports five days after the end of the reporting period. This is done so that the Society can review the underlying documentation in those reports to ensure that proper payments are made...

Community Service Society (the Society) requires its subrecipients to submit their financial and progress program reports five days after the end of the reporting period. This is done so that the Society can review the underlying documentation in those reports to ensure that proper payments are made to the subrecipients and, in turn, proper and timely reports are filed by the Society with the State of New York. There are instances when, because of delays in receipt of information from the subrecipients, or information from the subrecipients needs to be revised, reports are submitted late to the State of New York. The Society notifies the State of New York when reports will be submitted late. In addition, the Society is working with its subrecipients to improve their reporting procedures, as well as the timeliness and accuracy of their reports. This will result in the Society improving the timeliness of its reporting to the State of New York.

View Audit 298015

Finding 384944 (2023-003)

Significant Deficiency 2023

Central College

IA

Reporting Student Financial Aid Significant Deficiency

FISAP Reporting Recommendation: We recommend the College evaluate its procedures for reviewing the FISAP and implement changes to validate the information on the FISAP. Views of Responsible Officials and Planned Corrective Actions: This number comes directly from an eligible aid applicant’s report...

FISAP Reporting Recommendation: We recommend the College evaluate its procedures for reviewing the FISAP and implement changes to validate the information on the FISAP. Views of Responsible Officials and Planned Corrective Actions: This number comes directly from an eligible aid applicant’s report. The College has implemented additional oversight procedures for the control to double check figures in future FISAP filings prior to submission. Anticipated Completion Date: September 30, 2023

View Audit 297984

Finding 384943 (2023-002)

Significant Deficiency 2023

Central College

IA

Student Financial Aid Eligibility Reporting

Pell and SEOG Awarding Errors Recommendation: We recommend the College evaluate its procedures for reviewing financial assistance and implement changes to validate the awarding of financial assistance. Views of Responsible Officials and Planned Corrective Actions: When the Department of Education c...

Pell and SEOG Awarding Errors Recommendation: We recommend the College evaluate its procedures for reviewing financial assistance and implement changes to validate the awarding of financial assistance. Views of Responsible Officials and Planned Corrective Actions: When the Department of Education changes Pell Grant eligibility parameters, there is a process that is run to update Pella Grant eligibility in the Datatel processing system. However, when new eligibility parameters increase the number of eligible students due to increasing the estimated family contribution (EFC) eligibility cut-off, there is a separate process that must be run to catch these newly eligible students. This was the scenario in 2022-2023. Six students that were not originally eligible for Pell Grant became eligible. Similar circumstances also occurred in 23-24 and the process was run ensuring all eligible students are being awarded. The additional process has been added to the financial aid calendar to ensure this will not happen in the future. Anticipated Completion Date: September 30, 2023

View Audit 297984

Finding 384942 (2023-001)

Significant Deficiency 2023

Central College

IA

Student Financial Aid Reporting Significant Deficiency

Return of Title IV Funds (R2T4) Calculation Errors Recommendation: We recommend the College evaluate its procedures for reviewing R2T4 calculations and implement changes to validate the inputs to the calculation. Views of Responsible Officials and Planned Corrective Actions: The finding is due to C...

Return of Title IV Funds (R2T4) Calculation Errors Recommendation: We recommend the College evaluate its procedures for reviewing R2T4 calculations and implement changes to validate the inputs to the calculation. Views of Responsible Officials and Planned Corrective Actions: The finding is due to Central College incorrectly inputting the number of break days in the school calendar profile in the R2T4 section of the common origination and disbursement website. When doing annual set-up, the financial aid office will now be confirming correct dates with Central’s controller. The school calendar profiles have already been issued to Forge Financial & Management Consulting for the 23-24 academic year. Anticipated Completion Date: September 30, 2023

View Audit 297984

Finding 384937 (2023-003)

Significant Deficiency 2023

Palmdale Aerospace Academy

CA

Reporting Significant Deficiency Internal Control / Segregation of Duties

Fiscal year ended June 30, 2023, represents a transition year for the Academy as it is the first fiscal year in which Academy staff has been in charge of processing all accounting and business transactions in‐house. Previously the Academy utilized a back‐office provider. In making the transition to ...

Fiscal year ended June 30, 2023, represents a transition year for the Academy as it is the first fiscal year in which Academy staff has been in charge of processing all accounting and business transactions in‐house. Previously the Academy utilized a back‐office provider. In making the transition to in‐house processing, the Academy has sought to build up the capabilities of its business department, including the full implementation of a new financial software system as well as augmenting the capabilities of staff both in number and in capabilities. In addition, the Academy has made extensive use of expert outside consultants to strengthen its system of internal controls and accounting procedures to ensure that a robust system for processing accounting and business transactions is in place. The Academy will continue to both procure the services of outside experts and augment the capabilities of the business department as deemed necessary. In addition, the departments in charge of maintaining files and records pertinent to financial transactions will strengthen their procedures to ensure that all such files and records are properly maintained, and the business department will audit such on a quarterly basis. The business department will continue to ensure that all accounts receivable, accounts payable, and refundable advances will be reconciled quarterly. As well, at the end of each fiscal year, all areas will be reconciled and adjusted as needed. At the beginning of each fiscal year, all areas will be verified for accuracy and any necessary corrections will be made accordingly.

View Audit 297979

Finding 384934 (2023-002)

Significant Deficiency 2023

Palmdale Aerospace Academy

CA

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Significant Deficiency

Fiscal year ended June 30, 2023, represents a transition year for the Academy as it is the first fiscal year in which Academy staff has been in charge of processing all accounting and business transactions in‐house. Previously the Academy utilized a back‐office provider. In making the transition to ...

Fiscal year ended June 30, 2023, represents a transition year for the Academy as it is the first fiscal year in which Academy staff has been in charge of processing all accounting and business transactions in‐house. Previously the Academy utilized a back‐office provider. In making the transition to in‐house processing, the Academy has sought to build up the capabilities of its business department, including the full implementation of a new financial software system as well as augmenting the capabilities of staff both in number and in capabilities. In addition, the Academy has made extensive use of expert outside consultants to strengthen its system of internal controls and accounting procedures to ensure that a robust system for processing accounting and business transactions is in place. The Academy will continue to both procure the services of outside experts and augment the capabilities of the business department as deemed necessary. In addition, the departments in charge of maintaining files and records pertinent to financial transactions will strengthen their procedures to ensure that all such files and records are properly maintained, and the business department will audit such on a quarterly basis. The business department will continue to ensure that all accounts receivable, accounts payable, and refundable advances will be reconciled quarterly. As well, at the end of each fiscal year, all areas will be reconciled and adjusted as needed. At the beginning of each fiscal year, all areas will be verified for accuracy and any necessary corrections will be made accordingly.

View Audit 297979

Finding 384925 (2023-001)

Significant Deficiency 2023

Community Health Project, INC Dba Michael Callen-Audre Lorde Chc

NY

Special Tests & Provisions Significant Deficiency Internal Control / Segregation of Duties

March 15, 2024 Health Resources and Services Administration Patrick McGovern, Community Health Project, Inc.’s (d/b/a Michael Callen-Audre Lorde Community Health Center’s) CEO respectfully submits the following corrective action plan for the year ended June 30, 2023: CohnReznick LLP 1301 Avenue of t...

March 15, 2024 Health Resources and Services Administration Patrick McGovern, Community Health Project, Inc.’s (d/b/a Michael Callen-Audre Lorde Community Health Center’s) CEO respectfully submits the following corrective action plan for the year ended June 30, 2023: CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: June 30, 2023 The findings from the June 30, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS FEDERAL AWARD PROGRAM AUDITS Material Weakness 2023-002 - Accuracy of Reporting to the PRF Portal: U.S. Department of Health and Human Services, COVID-19: Provider Relief Fund and American Rescue Plan ("ARP") Rural Distribution: Assistance Listing Number 93.498 – Reporting Recommendation We recommend that the Organization strengthen its system of internal controls to ensure that all reporting that is done and submitted is consistent with requirements and instructions as provided by regulatory agencies. Action Taken The Organization has implemented policies and procedure to ensure controls are implemented to review against underlying documentation prior to submission to ensure compliance with regulatory agencies. Significant Deficiency 2023-001 - Implementation of Sliding Fee Scale Policy: U.S. Department of Health and Human Services, Health Center Program Cluster: Assistance Listing Number 93.224/93.527 - Special Tests and Provisions Chelsea 356 West 18th Street New York, NY 10011 212.271.7200 Thea Spyer Center 230 West 17th St New York, NY 10011 212.271.7200 Bronx 3144 3rd Ave Bronx, NY 10451 718.215.1800 Recommendation We recommend that management implement their policy that requires board review of the sliding fee scale in a consistent manner. The approval of the sliding fee scale should be added to the agenda items as a recurring annual matter to help ensure that it is completed. We recommend further that the employee/s in charge of inputting the sliding fee scale into the electronic medical record (EMR) system obtain evidence of board approval of the sliding fee scale before it is coded into the EMR. Action Taken The organization has implemented an annual approval process for the sliding fee scale to be added as an agenda item for our board approval within the first quarter of every calendar year. For the 2023 sliding fee scale, the board subsequently performed its review and did not find any errors with it thus they retroactively approved and authorized its application We have implemented a procedure whereby the billing department in charge shall seek to obtain this approval annually. Sincerely yours, Signature: Name: Patrick McGovern Title: Chief Executive Officer Organization’s Name: Callen-Lorde Community Health Center Date: 3/15/2024

View Audit 297971

Finding 384922 (2023-033)

Significant Deficiency 2023

State of Vermont

VT

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

The Financial Administrator will ensure that subrecipient grants containing federal funding that meet the FFATA reporting threshold are marked as “required for entry into the FSRS system” upon grant execution. The Financial Administrator and Manager will then confirm that all executed agreements tha...

The Financial Administrator will ensure that subrecipient grants containing federal funding that meet the FFATA reporting threshold are marked as “required for entry into the FSRS system” upon grant execution. The Financial Administrator and Manager will then confirm that all executed agreements that meet the FFATA reporting requirement have been entered and submitted into the FSRS system by the last business day of each month. Please note that the scheduled completion date is 2/1/23 as the same FFATA reporting finding was identified for a different program during the SFY22 Single Audit, and the corrective action plan was applied across the Department as a whole. The FFATA issues identified in the SFY23 Single Audit pre-dated the implementation of our corrective action plan. Scheduled Completion Date of Corrective Action Plan: Completed Contacts for Corrective Action Plan: Lillian Smith, VDH Financial Administrator lillian.smith@vermont.gov Jessica Brown, VDH Financial Manager jessica.p.brown@vermont.gov Megan Hoke, VDH Financial Director megan.hoke@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 297960

Finding 384918 (2023-032)

Significant Deficiency 2023

State of Vermont

VT

Questioned Costs Cash Management Significant Deficiency § 200.303 § 200.514

The Agency of Human Services receives funding under ALNs 93.775, 93.777, and 93.778 and is responsible for reporting the federal interest liability for these programs to the Department of Finance and Management. The Agency of Human Services previously relied on the Department of Finance and Manageme...

The Agency of Human Services receives funding under ALNs 93.775, 93.777, and 93.778 and is responsible for reporting the federal interest liability for these programs to the Department of Finance and Management. The Agency of Human Services previously relied on the Department of Finance and Management for notification of the annual interest rate. Going forward, the Agency of Human Services will obtain the annual interest rate directly from the CMIA website: Cash Management Improvement Act - Annual Interest Rates (treasury.gov). The Department of Finance and Management will also verify the Agency of Human Services’ submission prior to submitting the CMIA Annual Report to the US Department of the Treasury. Position Responsible for Implementation of Corrective Action Candace Elmquist Financial Director Candace.Elmquist@vermont.gov Peter Moino Director of Internal Audit Peter.Moino@vermont.gov Date of Implementation of Corrective Action: Completed: 2/6/2024

View Audit 297960 Questioned Costs: $1

Finding 384914 (2023-031)

Significant Deficiency 2023

State of Vermont

VT

Eligibility Matching / Level of Effort / Earmarking Special Tests & Provisions § 200.303

1. With the 2022-37 Corrective Action Plan, Gainwell activated the termination job within the PMM that automatically ends a provider’s contract with VT Medicaid when no license was obtained by the license end date. This termination job was activated on 06/05/23. 2. With the 2022-37 Corrective Acti...

1. With the 2022-37 Corrective Action Plan, Gainwell activated the termination job within the PMM that automatically ends a provider’s contract with VT Medicaid when no license was obtained by the license end date. This termination job was activated on 06/05/23. 2. With the 2022-37 Corrective Action Plan, Letters of Good Tax Standing have been obtained. A standard operating practice is in place documenting the process. The process of validating tax standing in writing from the Tax Department has been in effect since April 2022. Providers who had their tax standing validated prior to April 2022 via phone or email were not solicited to obtain a written notification from the Tax Commissioner. The State has determined that it is not necessary to obtain a retroactive written notification from the Tax Commissioner for tax standing prior to April 2022. As of April 2022, all tax standing reviews are validated with a letter from the Tax Department and documented in the PMM. Scheduled Completion Date of Corrective Action Plan: 1. Completed 2. Completed Contacts for Corrective Action Plan: Deidra Jarvis, DVHA Member and Provider Services deidra.jarvis@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 297960

Finding 384910 (2023-030)

Significant Deficiency 2023

State of Vermont

VT

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Agency of Human Services Internal Audit Group (AHS-IAG) is a designated centralized reporter of subawards for a Medicaid cluster (ALN 93.775, 93.777, 93.778) that is shared between all AHS departments. To address omissions and timeliness of subawards and subaward modifications reporting to FSRS, IAG...

Agency of Human Services Internal Audit Group (AHS-IAG) is a designated centralized reporter of subawards for a Medicaid cluster (ALN 93.775, 93.777, 93.778) that is shared between all AHS departments. To address omissions and timeliness of subawards and subaward modifications reporting to FSRS, IAG conducted additional training tailored to each AHS Department to examine the results of FFATA testing conducted internally and reemphasized the FFATA compliance regulations. This ensured the Internal Audit Group (IAG) is provided with complete, accurate and timely subaward information for reporting in FSRS going forward. The results of the 2023 finding show that the departments understood the training materials and complied with the requirements to report. Although not timely, regarding the reporting in FY2023, the FY2024 should yield timeliness because of the prior year corrective action completion that was closed on 04/11/2023. On at least an annual basis, IAG conducts a review of current federal rules and regulations pertaining to FFATA reporting for FSRS to assure the Agency’s procedures are up to-date. Coincidentally, IAG will also select a random sample of subawards and subawards modifications that meet the required threshold for FFATA reporting to ensure they are reported in FSRS system on a complete, accurate and timely basis. Scheduled Completion Date of Corrective Action Plan: December 31, 2023: Annual review of FFATA rules and regulations including subawards review. Contacts for Corrective Action Plan: Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 297960

Finding 384905 (2023-028)

Significant Deficiency 2023

State of Vermont

VT

Eligibility Matching / Level of Effort / Earmarking Special Tests & Provisions § 200.303

With the 2022-36 Corrective Action Plan, Letters of Good Tax Standing have been obtained. A standard operating practice is in place documenting the process. The process of validating tax standing in writing from the Tax Department has been in effect since April 2022. Providers who had their tax stan...

With the 2022-36 Corrective Action Plan, Letters of Good Tax Standing have been obtained. A standard operating practice is in place documenting the process. The process of validating tax standing in writing from the Tax Department has been in effect since April 2022. Providers who had their tax standing validated prior to April 2022 via phone or email were not solicited to obtain a written notification from the Tax Commissioner. The State has determined that it is not necessary to obtain a retroactive written notification from the Tax Commissioner for tax standing prior to April 2022. As of April 2022, all tax standing reviews are validated with a letter from the Tax Department and documented in the PMM. Scheduled Completion Date of Corrective Action Plan: Completed Contacts for Corrective Action Plan: Deidra Jarvis, DVHA Supervisor of Member and Provider Services deidra.jarvis@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 297960

Finding 384904 (2023-027)

Significant Deficiency 2023

State of Vermont

VT

Procurement, Suspension & Debarment Eligibility Significant Deficiency § 200.303

The case was mistakenly closed on 6/30/23 based on non-response to an income verification request. A verification notice was sent 6/12/2023. The member did not respond to this notice. The member should then have received notice of termination effective 7/31/2023. The case was not processed for clos...

The case was mistakenly closed on 6/30/23 based on non-response to an income verification request. A verification notice was sent 6/12/2023. The member did not respond to this notice. The member should then have received notice of termination effective 7/31/2023. The case was not processed for closure and appropriate notice was not sent because a system error caused this member to be classified as a new applicant instead of enrollee. This was likely due to case-specific circumstances of timing and household eligibility (other members were no longer eligible for Medicaid). Further, because they were classified as a new applicant, they received an additional verification notice (even though coverage was already terminated) and were ultimately “denied” for non-response in late July. As corrective action, we reinstated CHIP back to 7/1/2023 through 10/31/2023 after sending proper closure notice for failure to respond. Based on our internal QA process, Medicaid Recon and HCQC unit’s internal case reviews, no other incidents of this condition were found as of 10/2/2023. Scheduled Completion Date of Corrective Action Plan: Completed Contacts for Corrective Action Plan: Nicole McAllister, DVHA-HAEEU HCAA II nicole.mcallister@vermont.gov Sarah York, DVHA-HAEEU HCAA I sarah.york@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 297960

Finding 384903 (2023-026)

Significant Deficiency 2023

State of Vermont

VT

Questioned Costs Eligibility Student Financial Aid § 200.303

DCF has updated the eligibility determination procedure document and referenced checklists to ensure that there are additional reviews of the manual data entry and its processing in the data system (SSMIS). There is a process in place by which any cases where manual data entry causes erroneous IV-E ...

DCF has updated the eligibility determination procedure document and referenced checklists to ensure that there are additional reviews of the manual data entry and its processing in the data system (SSMIS). There is a process in place by which any cases where manual data entry causes erroneous IV-E draws, the Department will make changes in the data system and return IV-E funds erroneously claimed within one quarter of the mistake being identified. Scheduled Completion Date of Corrective Action Plan: January 1, 2024 Contact for Corrective Action Plan: Gillie Hopkins, DCF-FSD Permanency Planning Program Manager gillie.hopkins@vermont.gov Barbara Joyal, DCF-FSD System of Care Unit Director barbara.joyal@vermont.gov Beth Sausville, DCF-FSD System of Care Unit Director beth.sausville@vermont.gov Ed Dwinell, DCF Business Office, Financial Director ed.dwinell@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 297960 Questioned Costs: $1

Finding 384902 (2023-025)

Significant Deficiency 2023

State of Vermont

VT

Procurement, Suspension & Debarment Significant Deficiency § 200.303 § 200.324

The Division Administrator and the Division Director will create a central location for all supporting procurement documentation related to the division. This documentation will include but is not limited to the original RFP, bids, award selection criteria and bid review. Procurement documentation w...

The Division Administrator and the Division Director will create a central location for all supporting procurement documentation related to the division. This documentation will include but is not limited to the original RFP, bids, award selection criteria and bid review. Procurement documentation will be stored electronically according to the most current records retention schedule and be made available for review upon request. Scheduled Completion Date of Corrective Action Plan: 3/1/2024 Contacts for Corrective Action Plan: Danielle Tucker, VDH Division Administrator danielle.tucker@vermont.gov William Moran, VDH Division Director william.moran@vermont.gov Megan Hoke, VDH Financial Director megan.hoke@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

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Finding 384899 (2023-023)

Significant Deficiency 2023

State of Vermont

VT

Cash Management Allowable Costs / Cost Principles Significant Deficiency § 200.303 § 200.514

The Agency of Human Services receives funding under ALN 93.568 and is responsible for reporting the federal interest liability for this program to the Department of Finance and Management. The Agency of Human Services previously relied on the Department of Finance and Management for notification of ...

The Agency of Human Services receives funding under ALN 93.568 and is responsible for reporting the federal interest liability for this program to the Department of Finance and Management. The Agency of Human Services previously relied on the Department of Finance and Management for notification of the annual interest rate. Going forward, the Agency of Human Services will obtain the annual interest rate directly from the CMIA website: Cash Management Improvement Act - Annual Interest Rates (treasury.gov). The Department of Finance and Management will also verify the Agency of Human Services’ submission prior to submitting the CMIA Annual Report to the US Department of the Treasury. Position Responsible for Implementation of Corrective Action Candace Elmquist Financial Director Candace.Elmquist@vermont.gov Peter Moino Director of Internal Audit Peter.Moino@vermont.gov Date of Implementation of Corrective Action: Completed: 2/6/2024

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Finding 384895 (2023-021)

Significant Deficiency 2023

State of Vermont

VT

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Due to staff vacancies and turnover that arose in the DCF Quality Assurance & Reporting (QA&R) team during the summer of 2022, there was insufficient intra-team communication and training regarding FFATA reporting requirements. As of January 1, 2024, then, formal procedures and training will be put...

Due to staff vacancies and turnover that arose in the DCF Quality Assurance & Reporting (QA&R) team during the summer of 2022, there was insufficient intra-team communication and training regarding FFATA reporting requirements. As of January 1, 2024, then, formal procedures and training will be put in place to ensure all QA&R staff are prepared to execute their responsibilities pertaining to FFATA reporting requirements. Further, in order to monitor FFATA reporting compliance going forward, AHS Internal Audit Group (IAG) will include LIHEAP subawards in its annual review. Scheduled Completion Date of the Corrective Action Plan: January 1, 2024: FFATA reporting procedures and training in place and operating. December 31, 2024: Annual review of FFATA rules and regulations including subawards review. Contacts for Corrective Action Plan: Melanie Rutledge, DCF Financial Director I melanie.rutledge@vermont.gov Megan Smeaton, DCF Financial Director IV megan.smeaton@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

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Finding 384875 (2023-016)

Significant Deficiency 2023

State of Vermont

VT

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

To address the accuracy and timeliness of our entries into the FFATA system, we will use the USASPENDING.GOV website to assist us in reconciling what has been entered into the FFATA system. This will allow us to ensure that our grant ledgers agree with what is entered into FFATA. In March 2023 we s...

To address the accuracy and timeliness of our entries into the FFATA system, we will use the USASPENDING.GOV website to assist us in reconciling what has been entered into the FFATA system. This will allow us to ensure that our grant ledgers agree with what is entered into FFATA. In March 2023 we started reconciliations and plan to continue reconciling a couple times each year. The work will be done by the Deputy CFO or position assigned by the Deputy CFO. We will also implement a process that will have all the steps necessary for a grant award or an amendment to ensure it is posted properly within our internal files and the external systems. This will ensure that new awards and amendments get routed and entered in the FFATA system timely. We will look into the Batch upload process to allow for data to be entered into the system easier. Position Responsible for Implementation of Corrective Action Name: Sean Cousino Position: Deputy CFO Email: sean.couisno@vermont.gov Phone Number: 802 595-3693 Date of Implementation of Corrective Action: 5/01/2024

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