Corrective Action Plans

Finding 48049 (2022-002)

Significant Deficiency 2022

NM

Procurement, Suspension & Debarment Material Weakness Significant Deficiency

2022-002 - Policies and Procedures for Federal Awards Corrective action planned: The Medical Center is in the process of developing policies and procedures as relates to federal awards, and anticipates having written federal procurement policies and procedures in place within 60 days of issuance of...

2022-002 - Policies and Procedures for Federal Awards Corrective action planned: The Medical Center is in the process of developing policies and procedures as relates to federal awards, and anticipates having written federal procurement policies and procedures in place within 60 days of issuance of this report. Anticipated completion date: March 31, 2023 Contact person responsible for corrective action: Patrick Banks, CFO

View Audit 41047

Finding 48047 (2022-001)

Significant Deficiency 2022

Alabama Statewide 911 Board

AL

Significant Deficiency Internal Control / Segregation of Duties § 200.302

Finding 2022-001: The Alabama Statewide 9-1-1 Board (the Board) will develop a grants manual or additional written policies to incorporate all the requirements of 2 CFR 200 and ensure compliance with grant requirements.

View Audit 41046

Finding 47865 (2022-001)

Significant Deficiency 2022

Mission Consolidated Independent School District

TX

Matching / Level of Effort / Earmarking Subrecipient Monitoring HUD Housing Programs § 200.303

The District is currently compliant with ESSA LEA MOE. The Texas Education Agency (TEA) will issue FY 2022 ESSA LEA MOE compliance determinations in Spring 2023. If it is determined that the District will not meet ESSA LEA MOE compliance, then the District understands that it has two potential av...

The District is currently compliant with ESSA LEA MOE. The Texas Education Agency (TEA) will issue FY 2022 ESSA LEA MOE compliance determinations in Spring 2023. If it is determined that the District will not meet ESSA LEA MOE compliance, then the District understands that it has two potential avenues of relief: 1. 5-year flexibility: If a District is non-compliant with FY 2022 ESSA LEA MOE (determinations that FFCR will issue in Spring 2023) but was compliant in FYs 2017, 2018, 2019, 2020, and 2021 then the District would not have its FY 2024 (the school year 2023?2024) ESSA allocations reduced. However, the District would still be considered non-compliant, and FY 2023 expenditures would be compared to FY 2021. 2. USDE waiver: A non-compliant District can submit a waiver request to the U.S. Department of Education (USDE), as TEA does not have the authority to waive ESSA LEA MOE. USDE considers each request on a case-by-case basis and has not shared the criteria they use to evaluate requests. If a District is non-compliant, even if they are eligible for the 5-year flexibility, FFCR staff contact the impacted Districts to advise them on the steps to submit a waiver request to USDE. The District met ESSA LEA MOE in fiscal years 2017, 2018, 2019, 2020, and 2021. Therefore, the District will utilize the allowable 5-year flexibility and submit the USDE waiver. The District will continue to run the state aid template every six weeks to monitor student enrollment and attendance to project revenue. The District will facilitate meetings with the program directors, Human Resources, and Payroll department. In addition, the District will monitor actual expenditures compared to the budget every six weeks to ensure that MOE tests are met by year-end. Contact person: Joel Garcia, Assistant Superintendent for Finance Proposed Completion Date: November 15. 2022 "See full CAP in report"

View Audit 51195

Finding 47847 (2022-002)

None 2022

Glendale Arts

CA

Questioned Costs Allowable Costs / Cost Principles Material Weakness

The organization moved offices and storage facilities, and in the process, evidence of pay rate in personnel file of was misplaced. Managers will be retrained regarding the required paperwork necessary to retain for all employees. In addition, moving forward, our payroll company has agreed to advis...

The organization moved offices and storage facilities, and in the process, evidence of pay rate in personnel file of was misplaced. Managers will be retrained regarding the required paperwork necessary to retain for all employees. In addition, moving forward, our payroll company has agreed to advise us on the privacy and records retention landscape as well as provide us with a solution for federal, state, and local HR compliance.

View Audit 50468 Questioned Costs: $1

Finding 47845 (2022-003)

Significant Deficiency 2022

Multi-Ethnic Collaborative of Community Agencies

CA

Significant Deficiency

Views of Responsible Officials and Planned Corrective Actions: Prior to the FYE 2021 audits, MECCA had identified issues regarding the proper maintenance and review of payroll records and corrective action was taken in November 2021 by the Operations and Administration Coordinator. In November 2021,...

Views of Responsible Officials and Planned Corrective Actions: Prior to the FYE 2021 audits, MECCA had identified issues regarding the proper maintenance and review of payroll records and corrective action was taken in November 2021 by the Operations and Administration Coordinator. In November 2021, a full-service payroll and HR company was brought on to support MECCA in meeting all regulatory requirements, which began processing MECCA?s payroll in February 2022 and began working with the Operations and Administration Coordinator to do an internal HR audit in March and April of 2022. As of February 2022, all new employees were on boarded in compliance with all relevant regulatory requirements. And as of January 2023, all active employee files were complete with necessary documentation. In addition to the above corrective action, in April 2022, MECCA?s then Finance Manager implemented a Time and Effort policy and conducted a Time Survey to capture the staff time spent on programs. From May 2022 to September 2022, MECCA required staff to recertify time allocations quarterly. Starting October 2022, MECCA staff certify their time and effort allocations monthly. MECCA conducts the Time Survey annually, and the current Finance and Operations Director is responsible for ensuring staff Time and Effort is properly captured. The then Executive Director and the then Director of Operations and Program Administration were responsible for ensuring the corrective actions were implemented. In 2023, MECCA's Current Executive Director will be responsible for ensuring compliance to all relevant regulatory requirements. The Executive Director serves as the organizational HR supervisor and is responsible for working with and overseeing the payroll and HR company to ensure that onboarding, proper documentation, timekeeping, payroll, and any HR updates or pay rate changes are done for compliance. Name of Contact Person Responsible for Corrective Action Plan: Yesenia Ochoa, Executive Director Anticipated Completion Date: January 31, 2023

View Audit 49291

Finding 47843 (2022-002)

Significant Deficiency 2022

Multi-Ethnic Collaborative of Community Agencies

CA

Significant Deficiency

Views of Responsible Officials and Planned Corrective Actions: Prior to the FYE 2021 audits, MECCA had identified issues regarding the proper maintenance and review of payroll records and corrective action was taken in November 2021 by the Operations and Administration Coordinator. In November 2021,...

Views of Responsible Officials and Planned Corrective Actions: Prior to the FYE 2021 audits, MECCA had identified issues regarding the proper maintenance and review of payroll records and corrective action was taken in November 2021 by the Operations and Administration Coordinator. In November 2021, a full-service payroll and HR company was brought on to support MECCA in meeting all regulatory requirements, which began processing MECCA?s payroll in February 2022 and began working with the Operations and Administration Coordinator to do an internal HR audit in March and April of 2022. As of February 2022, all new employees were on boarded in compliance with all relevant regulatory requirements. And as of January 2023, all active employee files were complete with necessary documentation. In addition to the above corrective action, in April 2022, MECCA?s then Finance Manager implemented a Time and Effort policy and conducted a Time Survey to capture the staff time spent on programs. From May 2022 to September 2022, MECCA required staff to recertify time allocations quarterly. Starting October 2022, MECCA staff certify their time and effort allocations monthly. MECCA conducts the Time Survey annually, and the current Finance and Operations Director is responsible for ensuring staff Time and Effort is properly captured. The then Executive Director and the then Director of Operations and Program Administration were responsible for ensuring the corrective actions were implemented. In 2023, MECCA's Current Executive Director will be responsible for ensuring compliance to all relevant regulatory requirements. The Executive Director serves as the organizational HR supervisor and is responsible for working with and overseeing the payroll and HR company to ensure that onboarding, proper documentation, timekeeping, payroll, and any HR updates or pay rate changes are done for compliance. Name of Contact Person Responsible for Corrective Action Plan: Yesenia Ochoa, Executive Director Anticipated Completion Date: January 31, 2023

View Audit 49291

Finding 47842 (2022-001)

Significant Deficiency 2022

Multi-Ethnic Collaborative of Community Agencies

CA

Allowable Costs / Cost Principles Significant Deficiency

Views of Responsible Officials and Planned Corrective Actions: Prior to the FYE 2021 audits, MECCA had identified issues regarding the proper maintenance and review of payroll records and corrective action was taken in November 2021 by the Operations and Administration Coordinator. In November 2021,...

Views of Responsible Officials and Planned Corrective Actions: Prior to the FYE 2021 audits, MECCA had identified issues regarding the proper maintenance and review of payroll records and corrective action was taken in November 2021 by the Operations and Administration Coordinator. In November 2021, a full-service payroll and HR company was brought on to support MECCA in meeting all regulatory requirements, which began processing MECCA?s payroll in February 2022 and began working with the Operations and Administration Coordinator to do an internal HR audit in March and April of 2022. As of February 2022, all new employees were on boarded in compliance with all relevant regulatory requirements. And as of January 2023, all active employee files were complete with necessary documentation. In addition to the above corrective action, in April 2022, MECCA?s then Finance Manager implemented a Time and Effort policy and conducted a Time Survey to capture the staff time spent on programs. From May 2022 to September 2022, MECCA required staff to recertify time allocations quarterly. Starting October 2022, MECCA staff certify their time and effort allocations monthly. MECCA conducts the Time Survey annually, and the current Finance and Operations Director is responsible for ensuring staff Time and Effort is properly captured. The then Executive Director and the then Director of Operations and Program Administration were responsible for ensuring the corrective actions were implemented. In 2023, MECCA's Current Executive Director will be responsible for ensuring compliance to all relevant regulatory requirements. The Executive Director serves as the organizational HR supervisor and is responsible for working with and overseeing the payroll and HR company to ensure that onboarding, proper documentation, timekeeping, payroll, and any HR updates or pay rate changes are done for compliance. Name of Contact Person Responsible for Corrective Action Plan: Yesenia Ochoa, Executive Director Anticipated Completion Date: January 31, 2023

View Audit 49291

Finding 47827 (2022-057)

Significant Deficiency 2022

State of Oregon

OR

Eligibility Special Tests & Provisions Significant Deficiency

2022-057 Department of Human Services/Oregon Health Authority Improve documentation for provider eligibility determinations and revalidations Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.777 and 93.778 Medicaid Cluster Federal Award ...

2022-057 Department of Human Services/Oregon Health Authority Improve documentation for provider eligibility determinations and revalidations Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.777 and 93.778 Medicaid Cluster Federal Award Numbers and Years: 2105OR5MAP, 2021; 2105OR5ADM, 2021; 2205OR5MAP, 2022; 2205OR5ADM, 2022 Compliance Requirement: Special Tests and Provisions Type of Finding: Significant Deficiency Prior Year Finding: 2021-020 Questioned Costs: N/A Criteria: 42 CFR 455.436; 42 CFR 455.102 to 455.107; 42 CFR 455.414 Provider eligibility requirements for the Medicaid program differ depending upon the type of services provided; however, all providers are subject to specified database checks and are required to sign an adherence to federal regulations agreement (agreement). Typically, the agreement includes disclosures specifically required by federal regulations. Additionally, the federal regulations require that the Oregon Health Authority (authority) and Department of Human Services (department) determine eligibility for Medicaid providers and revalidate providers at least every five years by performing database checks to ensure providers are still eligible to participate in the Medicaid program. We selected a random sample of 62 providers in the Medicaid program with 32 providers enrolled by the authority and 30 enrolled by the department. For 4 providers we found the issues described below. I-9 form for 1 department provider could not be located. This provider is not currently a provider with the State and an updated I-9 will not be obtained. Based on our review of other available support we were able to determine this to be an eligible provider during the fiscal year. I-9 form for 1 department provider could not be located. The department has since obtained a completed I-9 form. I-9 forms for 2 department providers did not include a review of minimum acceptable documents to verify identity and employment authorization. The department is actively working to obtain missing documentation and based on our review of other available support we were able to determine these to be eligible providers during the fiscal year. The above issues occurred due to human error and inadequate record maintenance which could lead to ineligible providers receiving Medicaid funding. We recommend department management strengthen controls to ensure documentation supporting a provider?s eligibility determination and revalidation is complete. MANAGEMENT RESPONSE: We agree with this recommendation. ODDS Response: The department is committed to having completed I-9 forms on file for all Personal Support Workers through our Fiscal Intermediary. The Provider Enrollment Unit now has a quality assurance staff who will conduct spot checks of the FI work. This is in process now and reviews will continue. APD Response: The department is committed to having completed I-9 forms on file for all employees and homecare workers. This expectation, as it relates to homecare workers, was reinforced by the department at the Client Employment Program Annual Summit held on 3/28/23 and 3/29/23. This Summit was attended by approximately 160 local office staff. Local office staff were instructed on how to properly fill out the I-9 form and retention requirements. Staff were also reminded of resources available to answer questions, including central office points of contact. The department is also exploring short- and long-term solutions to mitigate this risk, including creating a peer review process on business procedures across the state intended to assist in not only accuracy, but knowledge transfer, developmental growth and mentoring opportunities. The department may also explore system changes that would automatically validate the completion of tasks related to provider enrollment and renewals, including the presence of required documentation. Anticipated Completion Date: June 1, 2023 Contact: Vanessa Richkind, ODDS Provider Administration Manager or Diana Nott, APD Provider Relations Unit Manager

View Audit 45093

Finding 47807 (2022-048)

Significant Deficiency 2022

State of Oregon

OR

Subrecipient Monitoring Reporting Significant Deficiency

2022-048 Oregon Health Authority Improve review of federal performance progress reports Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.788 Opioid STR (Non-major program) Federal Award Numbers and Years: H79TI081716, 2020; H79TI083316, 2...

2022-048 Oregon Health Authority Improve review of federal performance progress reports Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.788 Opioid STR (Non-major program) Federal Award Numbers and Years: H79TI081716, 2020; H79TI083316, 2021 Compliance Requirement: Reporting Type of Finding: Significant Deficiency Prior Year Finding: 2019-020 Questioned Costs: N/A Criteria: 45 CFR 75.303(a); 45 CFR 75.342(b); Opioid STR Notice of Awards Federal regulations require performance progress reports (reports) be submitted semi-annually and include an overview of the goals and objectives accomplished during the funding period as stated in the grants? funding opportunity announcements. In addition, federal regulations require award grantees to establish and maintain effective internal control that provides reasonable assurance the award is managed in compliance with regulations and terms and conditions of the award. Effective controls may include review and approval of reports for completeness and accuracy. The Health Systems Division of the Oregon Health Authority (department) developed a tool to document post award monitoring in March of 2020, and for three years, the department has pointed to this tool as an action taken to ensure reports are complete and accurate. Although the department has yet to implement this tool, we found evidence of other internal controls that were partially implemented. Program now utilizes collaborative online software called Smartsheet which allows a contracted evaluator to compile subrecipient performance data the department can monitor and edit in real time. The department uses the Smartsheet as support for progress report data. We found some key data elements in the SOR2 year 2 progress report did not agree to support in Smartsheet. Program stated they reviewed a different spreadsheet supplied by the evaluator, not Smartsheet, which had totals agreeing to the submitted report. However, the department did not retain this additional spreadsheet. Without retaining the underlying support used for review, we are unable to assess the effectiveness of the department?s review of the report prior to submission. Program now requires manager review of reports prior to submission. We found evidence of manager review of the SOR2 year 2 progress report, however it was dated two days after the report was submitted. Ineffective controls could result in a misrepresentation of the grant?s performance. We recommend department management implement internal controls to ensure performance progress reports are complete and accurate prior to report submission. MANAGEMENT RESPONSE: We agree with this recommendation. To ensure performance progress reports are complete and accurate prior to report submission, the department will review current internal controls and plans to implement revised or new controls. The current process steps we are reviewing include: ? Sending the completed report via email to the program manager requesting they review the report for completeness and accuracy. ? Documenting approval via email confirmation that the report is complete and accurate prior to submission to federal funders. There is a need to revisit the internal control of having only managers designated to review the federal performance progress reports; we plan to discuss having the following individuals designated to conduct this review: principal investigator, grant coordinator, active partner, or manager. Anticipated Completion Date: December 31, 2023 Contact: Kelsey Smith-Payne, Opioid SOR Grants Project Director and Sarah Adelhart, Interim Manager

View Audit 45093

Finding 47805 (2022-058)

Significant Deficiency 2022

State of Oregon

OR

Questioned Costs Eligibility Period of Performance

2022-058 Department of Human Services Perform timely reconciliations of refinanced OR-Kids transactions Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.667 Social Services Block Grant Federal Award Numbers and Years: 2101ORSOSR, 2021; 22...

2022-058 Department of Human Services Perform timely reconciliations of refinanced OR-Kids transactions Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.667 Social Services Block Grant Federal Award Numbers and Years: 2101ORSOSR, 2021; 2201ORSOSR, 2022 Compliance Requirement: Period of Performance Type of Finding: Significant Deficiency; Noncompliance Prior Year Finding: N/A Questioned Costs: $1,308,457 (likely) Criteria: 42 USC 1397a(c); 45 CFR 75.386a(2); 45 CFR 96.30b(2) According to federal requirements, to be eligible for federal funding, expenditures must be expended in the fiscal year allotted or in the succeeding fiscal year (period of performance). Additionally, federal post-closeout requirements stipulate the return of any funds due because of later refunds, corrections, or other transactions. As part of the grant closeout process, block grants also require the grantees to report the total funds expended and the date of the last expenditure. Grant closeout is the process by which the federal awarding agency determines that all applicable administrative actions and all required work have been completed. Social Services Block Grant (SSBG) has expenditures originating from the child welfare system, OR-Kids. OR-Kids is used to manage placements, eligibility, payments, and other case information. When various corrections are initiated, OR-Kids can re-process transactions as far back as January 1, 2008. For some placement corrections, OR-Kids processed the recovery of the funds in a state grant (Miscellaneous Other Fund grant), instead of the federal grant. To date, the department has not completed permanent fixes to the OR-Kids system to prevent these re-processing errors from occurring. During fiscal year 2022, the department was reconciling the Miscellaneous Other Fund grant and identified refunds related to SSBG. The refinanced expenditures reduced the amount of SSBG expenditures originally reported in closed grant awards. Instead of submitting a refund, the department identified expenditures recorded in subsequent grants that could have been used to backfill the reduction of expenditures. Allowable expenditures, that met the period of performance, were subsequently moved. To illustrate, a total of $1.3 million of expenditures were moved in the accounting system from grant award 21 (federal fiscal year 2021) to grant award 20. The department then moved expenditures totaling $1.2 million from grant award 20 to grant award 19. This process continued for all grant awards going back to grant award 11 (federal fiscal year 2011). The table below illustrates the movement of expenditures between grant awards. ?See Corrective Action Plan for Table? Although the department only moved expenditures that qualified for each respective period of performance, we question whether the federal awarding agency would allow the department to backfill the $1.3 million of expenditures in question after grant closeout had been completed. We recommend department management conduct more timely reconciliations of OR-Kids refinancing adjustments to ensure adjustments are made during the related periods of performance. We further recommend management work with its federal awarding agency to determine if it is appropriate to backfill program expenditures between grants to account for the reduction in expenditures created by the reconciliation process. If not appropriate, the questioned costs should be repaid to the federal awarding agency. MANAGEMENT RESPONSE: The agency disagrees with this finding. SFMA grant phase is an internal tracking mechanism only and is not mandated by ACF. None of the expenditures observed were moved into or out of the period of performance for which they originally qualified for. SSBG awards have a two-year period of performance for claiming. As a result, there is an overlap between internal phases where expenditures qualify for two at any given time. Assignment of phase in SFMA is based on internal balancing needs to ensure claiming is not over or under the award for that period. Prior period adjustments occur periodically and are debited or credited to the phase they were originally recorded under. Should those adjustments cause a phase to become under or over reported, the assigned phase in SFMA is adjusted to maintain consistency between SFMA expenditures and the SF-425 report provided to ACF. If a prior period increasing expenditure is outside the period of performance, it is moved to non-reportable and state only funding. Anticipated Completion Date: N/A Contact: Fariborz Pakseresht, Oregon Department of Human Services Director

View Audit 45093 Questioned Costs: $1

Finding 47798 (2022-040)

Significant Deficiency 2022

State of Oregon

OR

Questioned Costs Eligibility Significant Deficiency

2022-040 Department of Human Services Improve controls to ensure eligibility criteria are met Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.558 Temporary Assistance for Needy Families Federal Award Numbers and Years: 2021G996115, ...

2022-040 Department of Human Services Improve controls to ensure eligibility criteria are met Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.558 Temporary Assistance for Needy Families Federal Award Numbers and Years: 2021G996115, 2021; 2022G996115, 2022 Compliance Requirement: Eligibility Type of Finding: Significant Deficiency, Noncompliance Prior Year Finding: N/A Questioned Costs: $9,569 (known); $931,750 (likely) Criteria: 45 CFR 264.1; Oregon TANF State Plan The State of Oregon Temporary Assistance for Needy Families (TANF) State Plan (Plan) defines financial neediness criteria with its adjusted income limit tables. Federal regulations establish 60 cumulative months as the length of time a client may receive federal TANF assistance. The department uses its case management system, Oregon Eligibility (ONE), to count federal-eligible benefit months, and when 60 months is reached, an indicator is sent to the financial subsystem to change federal funding to state funding. From a population of 105,267 TANF benefit payments recorded in ONE, we randomly selected a sample of 40 and two additional individually significant payments for testing. We found: One sample?s financial eligibility information included a disaster relief benefit without details showing the date of payment and the covered time period. As a result, auditors and the department are unable to determine if this case met financial eligibility criteria, resulting in questioned costs of $1,311. One individually significant case?s child support and spousal support were entered incorrectly into ONE. The countable income at time of certification did not meet the adjusted income limit, making the client ineligible for TANF benefits. Questioned costs for this case total $8,258. We recommend department management ensure federally-funded client benefits are paid on behalf of eligible individuals, and documentation is retained to support eligibility decisions. We also recommend department management correct the identified error cases and reimburse the federal agency for questioned costs. MANAGEMENT RESPONSE: We agree with this recommendation. The Department will communicate to eligibility staff the importance of reviewing information reported by the applicant compared to information received from a third-party and direct staff to case note in the ONE system how the discrepancy was reconciled. The Department will also communicate the requirement to maintain eligibility records in both case notes and electronic file when applicable. The Department will review the cases cited and make an appropriate referral to the Overpayment Recovery Unit. Overpayments recouped can then be adjusted by Office of Financial Services to credit the TANF federal grant rather than reimbursing, per instructions outlined in TANF-ACF-PI-2006-03. Anticipated Completion Date: October 31, 2023 Contact: Annette Palmer, TANF Program Manager

View Audit 45093 Questioned Costs: $1

Finding 47791 (2022-053)

Significant Deficiency 2022

State of Oregon

OR

Reporting Material Weakness Significant Deficiency § 200.328

2022-053 Oregon Health Authority Improve financial reporting accuracy Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (COVID-19) Federal Award Numbers and Years: 6 NU50CK00...

2022-053 Oregon Health Authority Improve financial reporting accuracy Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (COVID-19) Federal Award Numbers and Years: 6 NU50CK000541, 2020 (COVID-19); 6 NU50CK000541, 2021 (COVID-19) Compliance Requirements: Reporting Type of Finding: Significant Deficiency, Noncompliance Prior Year Finding: 2021-022 Questioned Costs: N/A Criteria: 2 CFR 200.328 In response to the COVID-19 pandemic, the Centers for Disease Control (CDC) awarded states substantial funds for the purpose of addressing the pandemic at the state level. Among other requirements, states are required to submit monthly financial reports to the CDC providing totals spent on travel, payroll, equipment, and other categories. During the fiscal year 2021 audit, we reported a material weakness relating to the accuracy of the amounts reported to the CDC. The same issue persisted throughout fiscal year 2022. As of June 30, 2022, the department had not taken the necessary actions to implement the prior recommendations and had not fully corrected the reports submitted in fiscal years 2021 and 2022. However, as of March 2023, the department had implemented the appropriate corrective actions and the previously inaccurate reports have been updated, including the reports for fiscal year 2022. Audit standards require that we report on the status as of June 30, 2022. We recommend department management maintain the necessary internal controls to ensure the monthly financial reports are accurate and agree to the accounting records. MANAGEMENT RESPONSE: We agree with this recommendation. As you note in your audit letter, our financial reporting accuracy had been remedied for all historical and current reports by March 2023. Unfortunately, these improvements were not in place by June 30, 2022 and, for that reason, a finding was noted. Corrective action plan: ? All monthly financial reporting has been assigned to our Fiscal Analyst ? The Fiscal Analyst submits monthly financial reports and the query used to generate the reports to the Office of Financial Services (OFS) for review and approval ? The Fiscal Analyst revises monthly financial reports based on OFS feedback ? Following OFS approval, monthly financial reports are entered into CAMP by an ELC administrative staff member and verified by a second team member Anticipated Completion Date: March 31, 2023 Contact: Merry Carlson, ELC Contracts Manager

View Audit 45093

Finding 47790 (2022-052)

Significant Deficiency 2022

State of Oregon

OR

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency § 200.303

2022-052 Oregon Health Authority Improve review of expenditure transactions Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (COVID-19) Federal Award Numbers and Years: 6 NU...

2022-052 Oregon Health Authority Improve review of expenditure transactions Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (COVID-19) Federal Award Numbers and Years: 6 NU50CK000541, 2021 (COVID-19) Compliance Requirements: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Type of Finding: Significant Deficiency, Noncompliance Prior Year Finding: N/A Questioned Costs: $35,416 (known) (COVID-19) Criteria: 2 CFR 200.303 As part of our testing, we reviewed expenditures charged to the program to ensure they were properly approved and an appropriate use of program resources. We randomly selected 25 of 2,355 non-payroll transactions as the basis for our testing. For one of the transactions, there was no evidence the expenditures had been reviewed and approved as appropriate expenditures for the program. The specific transaction was for cell phones and data plans on wireless devices and consisted of 584 separate devices. Only 24 (2.5%) of those devices had been approved by a manager. The department will pay the vendor for the full amount of the invoice. Managers are expected to review the charges for their unit and verify they are directed to the proper cost center. The $35,416 in questioned costs represents the charges for the devices without approval. Also, during fiscal year 2022, payroll for the department was processed through the Oregon State Payroll Application (OSPA). As part of each monthly payroll cycle, managers are expected to review and approve employee?s reported hours to ensure expenditures are accurate and are billed to the correct program(s). Although state policy requires managers to review the timesheets, the automated controls in the system will process the payroll without a review, effectively making the managerial review optional. The OSPA was retired as of November 30, 2022; however, the replacement payroll system operates in a similar manner for managerial review. As part of our testing of payroll expenditures, we found one of 25 randomly selected timesheets were not reviewed by a manager prior to release into the payroll system. We were able to perform alternative procedures to verify the amounts charged to the program were appropriate and there are no questioned costs. The lack of review increases the risk that inappropriate costs may be charged to federal programs. We recommend management ensure wireless device charges are properly reviewed, and expenditures are charged to the correct cost center or program. We also recommend management implement procedures to ensure all employee payroll submissions are reviewed and approved by program management. MANAGEMENT RESPONSE: We agree with this recommendation. The questioned costs related to cell phone charges appear to have resulted from a lack of formal process in the Coronavirus Response and Recovery Unit. This unit has closed and departments have returned to standardized formal processes. Corrective action plan: ? Prior to ?COVID-19? processes and procedures will be followed ? Administrative staff will parse cell phone charges and code invoices according to employee payroll ? Approving manager will review coding for accuracy prior to approval Anticipated Completion Date: January 1, 2023 Contact: Merry Carlson, ELC Contracts Manager

View Audit 45093 Questioned Costs: $1

Finding 47789 (2022-051)

Significant Deficiency 2022

State of Oregon

OR

Questioned Costs Cash Management Significant Deficiency § 200.302

2022-051 Oregon Health Authority Correct expenditures charged to the incorrect program Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (COVID-19) Federal Award Numbers and ...

2022-051 Oregon Health Authority Correct expenditures charged to the incorrect program Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (COVID-19) Federal Award Numbers and Years: 6 NU50CK000541 (COVID-19) Compliance Requirements: Activities Allowed or Unallowed Type of Finding: Significant Deficiency, Noncompliance Prior Year Finding: N/A Questioned Costs: $356,050 (COVID-19) Criteria: 2 CFR 200.302 To address the COVID-19 pandemic, the Center for Disease Control (CDC) awarded the Oregon Health Authority (department) over $495 million in additional funding beyond the normal funding levels for the Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) program. The funding was awarded for specific purposes such as enhancing detection, reopening schools, and enhancing detection expansion. The purposes of these awards generally do not allow for expenditures directly related to operating the COVID-19 vaccine clinics. In our testing, we identified two payments totaling $356,050 relating to emergency medical technicians attending vaccine clinics to assist if those receiving the vaccine had adverse reactions and required medical attention. Per department management, the transactions should have been charged to a different grant provided by the Federal Emergency Management Agency (FEMA). The error was caused by incorrect account coding when the invoice was processed. Other transactions under this contract were properly charged to the FEMA grant. We recommend management correct the accounting error and ensure the expenditures are charged to the correct programs. We also recommend the department determine if there are additional questioned costs relating to the advanced cash draw as the federal programs have different timing for federal reimbursements. MANAGEMENT RESPONSE: We agree with this recommendation. Corrective action plan: ? Adjust the two identified payments charged to the grant in error ? Adjust the erroneous charges to the Federal Emergency Management Agency (FEMA) grant ? Complete internal audit of expenditures and adjust any non-grant compliant expenditures out of this grant prior to federal financial reporting and close-out. Anticipated Completion Date: June 30, 2023 Contact: Kim Riddell, Program Support Coordinator and Jeff Cartwright, ACDP Lead Fiscal Analyst

View Audit 45093 Questioned Costs: $1

Finding 47787 (2022-045)

Significant Deficiency 2022

State of Oregon

OR

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

2022-045 Oregon Health Authority Submit required FFATA reports Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.268 Immunization Cooperative Agreements; 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases; 93.958 Bloc...

2022-045 Oregon Health Authority Submit required FFATA reports Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.268 Immunization Cooperative Agreements; 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases; 93.958 Block Grants for Community Mental Health Services; 93.959 Block Grants for Prevention and Treatment of Substance Abuse Federal Award Numbers and Years: 93.268: 5 NH23IP922626; 6 NH23IP922626; 93.323: 6 NU50CK000541; 93.958: 1B09SM083823, 2021; 93.959: 6B08TI083472, 2021; 6B08TI084667, 2022 Compliance Requirement: Reporting Type of Finding: Significant Deficiency; Noncompliance Prior Year Finding: N/A Questioned Costs: N/A Criteria: 2 CFR 170 Appendix A; 2 CFR 200.303 Federal regulations require recipients of federal awards to report certain subaward information in the FFATA Subaward Reporting System (FSRS) for subawards meeting the criteria for reporting. Reports must be submitted no later than the end of the month following the month in which the subawards were made. Federal regulations also require recipients of federal awards establish and maintain internal controls designed to reasonably ensure compliance with federal laws, regulations, and program compliance requirements. We identified and reviewed the reporting status of all the department?s subawards subject to FFATA reporting during the audit period. We determined: Five of 30 Mental Health Block Grant (MHBG) subawards were not reported, totaling $4.2 million in obligations. 12 of 65 Substance Abuse Block Grant (SABG) subawards were not reported, totaling $6.2 million in obligations. Four of 37 Epidemiology and Laboratory Capacity (ELC) subawards were not reported, totaling almost $55.5 million in obligations. Five of 39 Immunization Cooperative Agreements subawards were not reported, totaling $6.3 million in obligations. Of the total not reported, one SABG, one ELC, and two Immunization subawards were not reported in the FSRS due to oversights in the department?s reporting process. The remaining unreported subawards resulted from the department?s suspension of FFATA reporting stemming from the federal replacement of the DUNS number with the Unique Entity Identifier (UEI) in May 2022. The department did not have UEI numbers for all subrecipients at the time of the replacement which prevented the department from submitting accurate reports. FFATA reporting was suspended through the end of state fiscal year 2022 and into the following state fiscal year. Although the department suspended FFATA reporting in the FSRS, a tracking spreadsheet was maintained that included all subaward award information needed for reporting once reporting is resumed. We recommend department management resume FFATA reporting as soon as feasible and ensure all necessary subawards are reported. We further recommend department management implement controls to ensure all subawards are appropriately tracked and reported. MANAGEMENT RESPONSE: We agree with this recommendation. On April 4, 2022, the federal government made a switch in the identifying information required for a subrecipient, changing from the previously used DUNS to a newly assigned Unique Entity Identifier (UEI). ODHS/OHA was not made aware of the upcoming federal switch until late March 2022. OHA?s Office of Contracts & Procurement (OC&P) is working directly with Program Contract Administrator?s to request the missing UEIs. As the data comes in from Program it is being validated for accuracy and updated in the appropriate systems, so when all missing UEIs from a given FAIN?s report month are collected, all NTE changes can be made immediately. OC&P is confident all FFATA reporting related to this audit will be submitted by July 31, 2023. Anticipated Completion Date: July 31, 2023 Contact: Brenda Brown, Procurement Manager

View Audit 45093

Finding 47786 (2022-050)

Significant Deficiency 2022

State of Oregon

OR

Allowable Costs / Cost Principles Significant Deficiency § 200.303

2022-050 Oregon Health Authority Improve review of expenditure transactions Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.268 Immunization Cooperative Agreements (COVID-19) Federal Award Numbers and Years: 5 NH23IP922626, 2022 (COVID-1...

2022-050 Oregon Health Authority Improve review of expenditure transactions Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.268 Immunization Cooperative Agreements (COVID-19) Federal Award Numbers and Years: 5 NH23IP922626, 2022 (COVID-19) 6 NH23IP922626, 2022 (COVID-19) Compliance Requirements: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Type of Finding: Significant Deficiency Prior Year Finding: N/A Questioned Costs: N/A Criteria: 2 CFR 200.303 During fiscal year 2022, payroll for the Oregon Health Authority was processed through the Oregon State Payroll Application (OSPA). As part of each monthly payroll cycle, managers are expected to review and approve employee?s reported hours to ensure expenditures are accurate and are billed to the correct program(s). Although state policy requires managers to review the timesheets, the automated controls in the system will process the payroll without a review, effectively making the managerial review optional. The OSPA was retired as of November 30, 2022. However, the new Workday application that went into effect to replace the OSPA has the same weakness where payroll will process without regard for the managerial review. As part of our testing of program expenditures, we found that 3 of 134 timesheets were not reviewed by a manager prior to release into the payroll system. For each of these items, we were able to perform alternative procedures to verify that the amounts charged to the program were appropriate and there are no questioned costs. However, the lack of review increases the risk that inappropriate payroll costs may be charged to the program. We recommend management implement procedures to ensure that all employee payroll submissions are properly reviewed, and payroll is appropriately charged to the correct cost center or program. MANAGEMENT RESPONSE: We agree with this recommendation. The Oregon Immunization Program (OIP) section manager immediately notified all supervisory managers and administrative support staff of the finding on June 5th. Finding: ?As part of our testing of program expenditures, we found that 3 of 134 timesheets were not reviewed by a manager prior to release into the payroll system.? Supervisory managers were reminded that it is an expectation of their position to ensure that payroll time entries are thoroughly reviewed, and discrepancies resolved, and final entries approve according to agency requirements ? on time, every month. On June 5th, program administrative staff and the section manager began development of an internal standard operating procedure (SOP) that will thoroughly document the steps the program requires of supervisory managers to assure that all employee payroll submissions are properly reviewed and payroll is appropriately charged to the correct cost center or program. The final SOP will be signed by each supervisory manager in the program, and included in a quarterly Performance, Accountability and Feedback (PAF) session between each supervisory manager and the section manager. The final SOP will be delivered to the offices of the Secretary of State Audit Division, and DAS once approved by the Division management, and signed by each OIP supervisory manager. This finding and the resolution will be shared as well with our funder, the Centers for Disease Control and Prevention, as required by our cooperative agreement. Anticipated Completion Date: July 5, 2023 Contact: Mimi Luther, OIP Section Manager (interim)

View Audit 45093

Finding 47771 (2022-102)

Significant Deficiency 2022

Labors Community Service Agency

AZ

Reporting Special Tests & Provisions Significant Deficiency

Finding 2022 - 102 ? Improve the Timeliness of Filing the Annual Audit (Significant Deficiency) FAL Number: 14.239 Program Title: HOME Investment Partnership Program Condition and Context: LCSA?s single audit reporting package for the fiscal year ended June 30, 2022, was not submitted to the Fe...

Finding 2022 - 102 ? Improve the Timeliness of Filing the Annual Audit (Significant Deficiency) FAL Number: 14.239 Program Title: HOME Investment Partnership Program Condition and Context: LCSA?s single audit reporting package for the fiscal year ended June 30, 2022, was not submitted to the Federal Audit Clearinghouse by the required deadline of March 31, 2023. Recommendation: The auditors recommend that LCSA devote the necessary resources to the accounting function to meet its reporting obligations. Doing so will improve the timeliness of LCSA?s submittal to the Federal Audit Clearinghouse. Contact Name: Rebekah Friend, Executive Director Corrective Action Planned: Management is contracting with an outside accounting company to reconcile all accounting records on a monthly basis to allow the audits to be on time. Anticipated Completion Date: Immediately

View Audit 41448

Finding 47770 (2022-101)

Significant Deficiency 2022

Labors Community Service Agency

AZ

Special Tests & Provisions Subrecipient Monitoring Significant Deficiency

Finding 2022 - 101 ? Improve Home Inspection Process (Significant Deficiency) FAL Number: 14.239 Program Title: HOME Investment Partnership Program Condition and Context: LCSA did not properly document the procedures taken to inspect the homes maintained through their HOME program. Recommendati...

Finding 2022 - 101 ? Improve Home Inspection Process (Significant Deficiency) FAL Number: 14.239 Program Title: HOME Investment Partnership Program Condition and Context: LCSA did not properly document the procedures taken to inspect the homes maintained through their HOME program. Recommendation: The auditors recommend maintaining a list or memoranda including the items inspected at each home during routine inspections for documentation purposes. Contact Name: Rebekah Friend, Executive Director Corrective Action Planned: Management is creating a procedure and form to document the tracking of homes maintained. Anticipated Completion Date: Immediately

View Audit 41448

Finding 47741 (2022-002)

Significant Deficiency 2022

Ave Maria University, Inc. and Subsidiaries

FL

Eligibility Reporting Significant Deficiency § 200.328 § 200.329

Finding Number: 2022-002 Planned Corrective Action: The Business office has endeavored to keep pace with the shifting and changing guidance that is promulgated by the Department of Education. This ...

Finding Number: 2022-002 Planned Corrective Action: The Business office has endeavored to keep pace with the shifting and changing guidance that is promulgated by the Department of Education. This has been a challenge. The Chief Financial Officer continues to monitor any guidance updates and make the appropriate changes to the reports to ensure their accuracy. There was only one report posted that contained one typographical error, but it is the University?s responsibility to ensure the accuracy of the reports and these reports will be monitored more closely going forward. Anticipated Completion Date: Continuing Responsible Contact Person: Eugene L. Munin

View Audit 52869

Finding 47729 (2022-002)

Significant Deficiency 2022

Western States Information Network, Inc.

CA

Cash Management Reporting Significant Deficiency

WSIN concurs on finding 2022-002. To prevent further incidences, WSIN plans to revise its written accounting procedures to strengthen internal control policies on reporting program income. Greater emphasis will be taken to ensure the general ledger is updated in a timely manner, so program income is...

WSIN concurs on finding 2022-002. To prevent further incidences, WSIN plans to revise its written accounting procedures to strengthen internal control policies on reporting program income. Greater emphasis will be taken to ensure the general ledger is updated in a timely manner, so program income is reported on the federal financial quarterly reports based off the WSIN general ledger rather than a secondary tracking spreadsheet. WSIN management will ensure financial reporting has been through a secondary review prior to submission to US DOJ/OJP/BJA.

View Audit 52802

Finding 47712 (2022-003)

Significant Deficiency 2022

Municipality of Naranjito

PR

Reporting Significant Deficiency Internal Control / Segregation of Duties

COMMONWEALTH OF PUERTO RICO MUNICIPALITY OF NARANJITO Corrective Action Plan For the Fiscal Year Ended June 30, 2022 _________________________________________________________________________________________________________________________________ Audit Report: Reports on Compliance and Internal Co...

COMMONWEALTH OF PUERTO RICO MUNICIPALITY OF NARANJITO Corrective Action Plan For the Fiscal Year Ended June 30, 2022 _________________________________________________________________________________________________________________________________ Audit Report: Reports on Compliance and Internal Control in Accordance with Government Auditing Standards and OMB Super Circular Uniform Guidance Audit Period: July 1, 2021 ? June 30, 2022 Fiscal Year: 2021-2022 Principal Executive: Hon. Orlando Ortiz Chevres - Mayor Contact Person: Mrs. Belinda Alvarez, Finance Director Phone: (787) 869 - 2200 Original Finding Number: 2022-003 Statement of Concurrence or Nonconcurrence: We concur with the finding. Corrective Action: The fiscal year 2021-2022 Single Audit submission for Municipality of Naranjito will be submitted through the Federal Audit Clearinghouse (FAC) no later than May 30, 2023. About the subsequent year Single Audit, we engaged the audit services on March 31, 2023, and we are going to engage the financial statements preparation consulting services on July 2023, in order to comply with fiscal year 2022-2023 Single Audit submission dateline. Implementation Date: During Fiscal Year 2023-2024. Responsible Person: Mrs. Belinda Alvarez - Finance Department Director See Corrective Action Plan for chart/table

View Audit 51135

Finding 47704 (2022-003)

Significant Deficiency 2022

Change Happens!

TX

Subrecipient Monitoring Reporting Significant Deficiency

Finding #2022-003 ? Significant Deficiency and Other Noncompliance Applicable federal program: U. S. Department of Health and Human Services Direct Federal Funding Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges Assistance Listing #93.332 Contract #NAVCA210403-01-01,...

Finding #2022-003 ? Significant Deficiency and Other Noncompliance Applicable federal program: U. S. Department of Health and Human Services Direct Federal Funding Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges Assistance Listing #93.332 Contract #NAVCA210403-01-01, Contract year: 08/27/21 ? 08/26/22 Contract #NAVCA210403-02-00, Contract year: 08/27/22 ? 08/26/23 Condition and context: Change Happens did not file the required FFATA reporting for the 7 subawards over $30,000. Recommendation: Develop a process for FFATA reporting to ensure timely reporting for all federal programs, where applicable, and provide training to personnel regarding FFATA reporting requirements. Planned corrective action: A process for FFATA reporting will be finalized to ensure timely reporting of all federal programs. Policies and procedures will be updated to include this required reporting and the associated process. Staff training regarding FFATA reporting requirements will be provided to ensure the process is understood and properly implemented. Responsible officer: Angelica Castillo, CFO Estimated completion date: July 15, 2023

View Audit 47820

Finding 47675 (2022-002)

Significant Deficiency 2022

Network Housing 90, Inc.

OH

HUD Housing Programs Internal Control / Segregation of Duties Reporting

Finding Number: 2022-002 Condition: The Organization failed to make the required reserve for replacements deposits in the current fiscal year. Planned Corrective Action: Management agrees with the finding as reported. Management has instituted procedural changes to ensure that all required deposits ...

Finding Number: 2022-002 Condition: The Organization failed to make the required reserve for replacements deposits in the current fiscal year. Planned Corrective Action: Management agrees with the finding as reported. Management has instituted procedural changes to ensure that all required deposits are made monthly. Additionally, management has taken steps to deposit all delinquent deposits. Contact person responsible for corrective action: Paul Anderson, CFO Anticipated Completion Date: 12/31/2023

View Audit 41635

Finding 47670 (2022-001)

Significant Deficiency 2022

Walter Knox Memorial Hospital Doing Business As Valor Health

ID

Procurement, Suspension & Debarment Material Weakness Significant Deficiency

2022-001 Policies and Procedures for Federal Awards Corrective action planned: Create a written policy and procedure on the tracking and usage of federal awards and have it uploaded into our policy and procedure software. Anticipated completion date: February 28th, 2023 Contact person responsible ...

2022-001 Policies and Procedures for Federal Awards Corrective action planned: Create a written policy and procedure on the tracking and usage of federal awards and have it uploaded into our policy and procedure software. Anticipated completion date: February 28th, 2023 Contact person responsible for corrective action: Corey Furin, CFO

View Audit 52667

Finding 47667 (2022-002)

Significant Deficiency 2022

Housing Authority of Skagit County

WA

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

2022-002 Housing Voucher Cluster ? Assistance Listing No. 14.871 Recommendation: We recommend the Authority implements controls to ensure that a utility allowance review is performed annually. If waivers are requested, we recommend the Authority ensures the requested waivers are approved to ensure c...

2022-002 Housing Voucher Cluster ? Assistance Listing No. 14.871 Recommendation: We recommend the Authority implements controls to ensure that a utility allowance review is performed annually. If waivers are requested, we recommend the Authority ensures the requested waivers are approved to ensure compliance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: If HUD waivers are available and applied for, the Section 8 Program Manager will confirm approval of the waiver before implementing the requested waiver. The waiver approval will be reviewed by the Section 8 Program Manager and co-signed by another manager at HASC. Name(s) of the contact person(s) responsible for corrective action: Cathy Kerr Planned completion date for corrective action plan: July 11, 2023

View Audit 52922

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