Corrective Action Plans

Finding 58382 (2022-001)

Significant Deficiency 2022

CA

Cash Management Significant Deficiency Internal Control / Segregation of Duties § 200.512

2022-001 - INTERNAL CONTROL OVER COMPLIANCE - SIGNIFICANT DEFICIENCY CONDITION: DLS submitted the 2021 data collection package to the Audit Clearinghouse after the required due date. CAUSE: The Judicial Council of California did not process the reimbursement requests timely. DLS was unable to dete...

2022-001 - INTERNAL CONTROL OVER COMPLIANCE - SIGNIFICANT DEFICIENCY CONDITION: DLS submitted the 2021 data collection package to the Audit Clearinghouse after the required due date. CAUSE: The Judicial Council of California did not process the reimbursement requests timely. DLS was unable to determine actual revenue and contract receivable until resolution. CRITERIA: Uniform Guidance 2 CFR 200.512(a) requires that the audit package and the data collection form shall be submitted 30 days after receipt of the auditor's report(s), or 9 months after the end of the fiscal year. EFFECT: DLS was not in compliance with Uniform Guidance 2 CFR 200.512(a). QUESTIONED COSTS: n/a RECOMMENDATION: DLS should ensure timely compliance as part of year end audit process. Management Response: DLS will schedule its annual audit to occur in August, at the latest. This will ensure that the annual audit is completed in time to meet the Sept. 30th filing deadline with the Audit Clearinghouse. In the event that the Judicial Council is unable to process reimbursements timely, DLS' management will estimate revenue and receivable balances based on reasonable and probable amounts so that the audit will still be completed on time. Date: 9.13.23 __________________________________ John P. Passalacqua, Executive Director

View Audit 54163

Finding 58380 (2022-003)

Significant Deficiency 2022

Midland Univeristy

NE

Subrecipient Monitoring Reporting Significant Deficiency

To Whom It May Concern: Midland University Single Audit Report: Corrective Action Plan - Year ended May 31, 2022 Finding 2022-003 ? Reporting - Higher Education Emergency Relief Fund Condition/Context: The quarterly and annual reporting contained some information that did not agree to support prov...

To Whom It May Concern: Midland University Single Audit Report: Corrective Action Plan - Year ended May 31, 2022 Finding 2022-003 ? Reporting - Higher Education Emergency Relief Fund Condition/Context: The quarterly and annual reporting contained some information that did not agree to support provided, and some of the quarterly reports were posted to the University?s website late. The University?s student portion quarterly reports June 30, 2021 and March 30, 2022 were selected for testing: ? Both reports included the number of students eligible for emergency student grants and the University was not able to provide support for as the counts were estimated. ? The June 30, 2021 report the amount of emergency grants disbursed to students and the number of students that received the grants both did not agree to the support provided. ? The June 30, 2021 report was posted to the University's website after the deadline of 10 days after calendar quarter end, it was posted October 27, 2021. ? The March 30, 2022 report, the amount of emergency grants disbursed to students and the number of students who received the grants were cumulative numbers and not just for the quarter as required. The University?s institutional portion quarterly report for June 30, 2021 selected for testing reported the total for lost revenue from academic sources and the total for other uses that did not agree to support provided. Additionally, the report was posted to the University's website after the deadline of 10 days after calendar quarter end, it was posted November 18, 2021. The 2021 annual report had some information that did not agree to the underlying support provided by the University. Specifically, the total for lost revenue and the total for other uses, and the required two new uses (direct outreach and monitoring and suppressing) were not reported although the support file provided did include costs for those items. Additionally, the number of students who received emergency grants did not agree to the support provided, and the institutional portion emergency grants to student accounts to cover outstanding amounts was reported incorrectly and should have been lost revenue for room & board refunds. Corrective Action Plan The University is currently gathering data for the 2022 HEERF annual performance report to be completed between March 6 to March 24, 2023. During this time, corrections can and will be made to the 2021 annual performance report. Proper support will be maintained for both reports. There will be no reporting past calendar 2022 as all awarded HEERF funds have been expended.

View Audit 54189

Finding 58378 (2022-002)

Significant Deficiency 2022

Midland Univeristy

NE

Student Financial Aid Matching / Level of Effort / Earmarking Subrecipient Monitoring

To Whom It May Concern: Midland University Single Audit Report: Corrective Action Plan - Year ended May 31, 2022 Finding 2022-002 ? NSLDS Enrollment Reporting Condition/Context: For 6 of 25 students tested, the status effective date or program was reported incorrectly or the student was not reporte...

To Whom It May Concern: Midland University Single Audit Report: Corrective Action Plan - Year ended May 31, 2022 Finding 2022-002 ? NSLDS Enrollment Reporting Condition/Context: For 6 of 25 students tested, the status effective date or program was reported incorrectly or the student was not reported to NSLDS. ? Two students' withdrawn dates reported to NSLDS did not agree to the support provided from the University's system. Additionally, one of these student's enrollment status was reported incorrectly as full time not 3/4 time. The University subsequently corrected these students? records in NSLDS and the auditor viewed the screen prints with the corrections. ? One student's graduated date reported to NSLDS did not agree to the support provided from the University's system, however the University believes the date reported to NSLDS was correct and the system's date was incorrect. ? One student's full time status effective date was reported incorrectly as January 10, 2022 not August 30, 2021. The University subsequently corrected the student?s record in NSLDS and the auditor viewed the screen print with the corrections. ? One student was incorrectly not reported to NSLDS when they attended and had Title IV loans during 2021-22. The University subsequently corrected the student?s record in NSLDS and the auditor viewed the screen prints with the corrections. ? One student's status dates reported to NSLDS for campus level January 10, 2022 did not agree to the support provided by the University's system of April 4, 2022. The University subsequently corrected the student?s record in NSLDS and the auditor viewed the screen print with the corrections. The sample was not a statistically valid sample. Corrective Action Plan The University has made all corrections to the identified records. The University is reviewing its current processes and evaluating if additional review controls need to be put in place to ensure timely and accurate NSLDS data.

View Audit 54189

Finding 58377 (2022-001)

Significant Deficiency 2022

Midland Univeristy

NE

Questioned Costs Student Financial Aid Matching / Level of Effort / Earmarking

To Whom It May Concern: Midland University Single Audit Report: Corrective Action Plan - Year ended May 31, 2022 Finding 2022-001 ? Title IV Credit Balances Condition/Context: For 4 of 25 students tested, the credit balance was not resolved in compliance with the regulations, the student?s Title I...

To Whom It May Concern: Midland University Single Audit Report: Corrective Action Plan - Year ended May 31, 2022 Finding 2022-001 ? Title IV Credit Balances Condition/Context: For 4 of 25 students tested, the credit balance was not resolved in compliance with the regulations, the student?s Title IV credit balances on their accounts were held and applied to future charges without student or parent authorization. The first student?s Title IV credit balance was $759 of Direct Loan funds, the second student?s was $3,702 of Direct Loan funds, the third student?s was $390 of Direct Loan funds and the fourth student?s was $2,850 of Direct Loan funds and $943 of Teach Grant funds. The sample was not a statistically valid sample. Corrective Action Plan The University agrees with the finding. The occurrence of Title IV credit balances occurs primarily with graduate program students. A review is being conducted of current internal control processes and evaluating what additional reporting is capable within the student information system to assist in identifying these Title IV credit balances in a more timely manner. Title IV credit balances are being monitored during the Spring 2023 terms and new procedures will be put in place for the Fall 2024 term.

View Audit 54189 Questioned Costs: $1

Finding 58303 (2022-003)

Significant Deficiency 2022

College Dreams, INC

OR

Eligibility Significant Deficiency

Finding # 2022-003 Immaterial Noncompliance U.S. Department of Labor 17.249 WIOA Youth Activities Finding: One case file out of fifteen tested did not meet eligibility criteria Recommendation: Procedures should be in place to ensure eligibility is properly documented and exceptions are obtained. ...

Finding # 2022-003 Immaterial Noncompliance U.S. Department of Labor 17.249 WIOA Youth Activities Finding: One case file out of fifteen tested did not meet eligibility criteria Recommendation: Procedures should be in place to ensure eligibility is properly documented and exceptions are obtained. Corrective Action: Management understands exceptions are allowed with explicit approval and that document is maintained Anticipated Completion Date: June 30, 2023

View Audit 54075

Finding 58302 (2022-002)

Significant Deficiency 2022

College Dreams, INC

OR

Period of Performance Significant Deficiency

Finding # 2022-002 Immaterial Noncompliance U.S. Department of Labor 17.249 WIOA Youth Activities Finding: Expenses were charged for services outside of the contract period Recommendation: Procedures should be in place to ensure invoices are accrued and charged to the proper period when services/...

Finding # 2022-002 Immaterial Noncompliance U.S. Department of Labor 17.249 WIOA Youth Activities Finding: Expenses were charged for services outside of the contract period Recommendation: Procedures should be in place to ensure invoices are accrued and charged to the proper period when services/goods were performed or received. Corrective Action: Expenses will be reviewed during month end close to ensure proper recording. Management will provide training to program personnel. Anticipated Completion Date: June 30, 2023

View Audit 54075

Finding 58301 (2022-001)

Significant Deficiency 2022

College Dreams, INC

OR

Allowable Costs / Cost Principles Significant Deficiency

Finding # 2022-001 Significant Deficiency U.S. Department of Labor 17.249 WIOA Youth Activities Finding: Control processes in place are not consistently followed and documented for review and approvals of timesheets for accuracy. Recommendation: Procedures should be in place to ensure reviews are...

Finding # 2022-001 Significant Deficiency U.S. Department of Labor 17.249 WIOA Youth Activities Finding: Control processes in place are not consistently followed and documented for review and approvals of timesheets for accuracy. Recommendation: Procedures should be in place to ensure reviews are being done by supervisory personnel with documentation included. Corrective Action: Management will implement procedures to ensure that all staff timesheets, if not signed by a supervisor, are accompanied by some other form of approval such as an e-mail. Anticipated Completion Date: December 31, 2022

View Audit 54075

Finding 58295 (2022-001)

Significant Deficiency 2022

Saint Leo University, INC

FL

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.303

2022-001 HEERF Reporting Recommendation: We recommend that the University review their reporting policies and procedures to ensure accurate reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Immediate act...

2022-001 HEERF Reporting Recommendation: We recommend that the University review their reporting policies and procedures to ensure accurate reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Immediate action was taken to update the quarterly report and post the updated report to our university?s website. Error was made due to data file showing category under other uses in previous quarterly reports. When new quarterly report was prepared the amount was reported on proper lost revenue line but was not deducted from the other uses total. This resulted in an overstatement of expenditures. An additional step was implemented to confirm total balance with data spreadsheet balance of expenditures. Name(s) of the contact person(s) responsible for corrective action: Jennifer Martell, Controller Planned completion date for corrective action plan: This was immediately corrected when brought to our attention on 5/26/22 for the quarterly report ending 3/31/22 which was originally posted to our website on 4/10/22.

View Audit 60987

Finding 58138 (2022-001)

Significant Deficiency 2022

Amesbury Housing Authority

MA

Special Tests & Provisions Eligibility HUD Housing Programs

Finding #2022-001 ? Special Tests and Provisions: Selection from the Waiting List The Authority acknowledges that waiting list documentation could not be located for two (2) new admissions during the audit period. The Authority experienced significant staff turnover in recent years that resulted in ...

Finding #2022-001 ? Special Tests and Provisions: Selection from the Waiting List The Authority acknowledges that waiting list documentation could not be located for two (2) new admissions during the audit period. The Authority experienced significant staff turnover in recent years that resulted in lacking internal controls. The Authority has effectively corrected this deficiency by contracting with the Chelsea Housing Authority for administration of the Authority?s Section 8 Housing Choice Voucher Program. The Chelsea Housing Authority has staff capacity, experience, and certifications to effectively administer all aspects of this program including selections from the waiting list. Implementation Date of Corrective Action: February 7, 2022 Person Responsible for Correction Action: Adam Garvey, Executive Director

View Audit 54100

Finding 58137 (2022-001)

Significant Deficiency 2022

Lewisburg Housing Authority

TN

HUD Housing Programs Significant Deficiency Special Tests & Provisions

The Authority receives federal funding from the U.S. Department of Housing and Urban Development (HUD} under two programs. A portion of the Authority's federal funding is received under the Capital Fund Program (CFP}. The CFP provides financial assistance to public housing authorities to make impr...

The Authority receives federal funding from the U.S. Department of Housing and Urban Development (HUD} under two programs. A portion of the Authority's federal funding is received under the Capital Fund Program (CFP}. The CFP provides financial assistance to public housing authorities to make improvements to existing public housing units. Compliance with regard to this finding can be found at 24CFR905.104. Per 24CFR905.104, all HUD approvals required in this part must be in writing and from an official designated to grant such approval. Prior to receiving HU D's written approval of the Authorities budget change request. The Authority requested and received a disbursement of 1480 "General Capital Activity" funds and treated these funds as if they were 1406 "Operation" funds. The cause of this noncompliance is due to the lack of understanding when funds can be disbursed to the Authority. The effect of this noncompliance is the potential for HUD to impose sanctions on the PHA, which can be found at 24CFR905.804. Response: This Finding happen because a revision was made and sent to HUD. The drawn down happen before HUD approved the revision. HUD has been contacted and the revision has been made and approved. All the CFP Funds are in order.There will not be any other drawn downs made until the funds have been approved by HUD. All line items will be reviewed and assured that there is enough allotted to that line to draw down. Ronald Robinson, PHM,CEO Lewisburg Housing Authority

View Audit 54533

Finding 58081 (2022-012)

Significant Deficiency 2022

County of San Joaquin

CA

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Program: COVID-19 ? Emergency Rental Assistance Program, (ERAP) CFDA No.: 21.023 Federal Agency: U.S. Department of the Treasury Pass-through: N/A Award Year: 2021-2022 Compliance Requirement: Reporting Grant Award Number: Applies to all awards with findings and no specific grant award Type of Findi...

Program: COVID-19 ? Emergency Rental Assistance Program, (ERAP) CFDA No.: 21.023 Federal Agency: U.S. Department of the Treasury Pass-through: N/A Award Year: 2021-2022 Compliance Requirement: Reporting Grant Award Number: Applies to all awards with findings and no specific grant award Type of Finding: Instance of Noncompliance, Significant Deficiency in Internal Control over Compliance Repeat Finding from Prior Year: No Management?s or Department?s Response: Concurred. Views of Responsible Officials and Corrective Action: During the fiscal year, the County had routed the second tranche of funding to the State as the County did not have the capacity to continue the program. Name of Responsible Person: Connie Hart, Deputy County Administrator Name of Department Contact: Connie Hart, Deputy County Administrator Projected Implementation Date: June 30, 2023

View Audit 53495

Finding 58077 (2022-001)

Significant Deficiency 2022

Housing Authority of the City of Miami Beach

FL

Questioned Costs HUD Housing Programs Subrecipient Monitoring

2022-001 Housing Voucher Cluster-Assistance Listing No. 14.871/14.879 Recommendation: The Authority should review their process for monitoring failed inspections and ensuring that proper abatement occurs on a timely basis. Explanation of disagreement with audit finding: There is no disagreement with...

2022-001 Housing Voucher Cluster-Assistance Listing No. 14.871/14.879 Recommendation: The Authority should review their process for monitoring failed inspections and ensuring that proper abatement occurs on a timely basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority has reviewed its updated HOS policies, including its HOS enforcement policies. The PHA will utilize the feature of our current Software (Emphasys Elite) that will automatically place the unit into abatement upon the unit resulting in two consecutive failed inspections. The Section 8- Special Projects Supervisor will review the report biweekly to ensure that all failed units have been placed on abatement. The Section 8- Special Projects Supervisor will notify all HCV staff of the appropriate action to take regarding abated units. Name(s) of the contact person(s) responsible for corrective action: Suzie Millien, Section 8-HCV Supervisor. Planned completion date for corrective action plan: 3/31/2023.

View Audit 53252 Questioned Costs: $1

Finding 58076 (2022-001)

Significant Deficiency 2022

Village Cooperative of Mason City

IA

Internal Control / Segregation of Duties Significant Deficiency

The Board of Directors is and will remain involved in the financial affairs of the Cooperative.

View Audit 54469

Finding 58013 (2022-002)

Significant Deficiency 2022

Klamath-Trinity Joint Unified School District

CA

Questioned Costs Equipment & Real Property Management Subrecipient Monitoring

Corrective Action Plan and Views of Responsible Officials The District?s Budget and Purchasing Technician will ensure that each department manager submits the requirements with the needs to the State prior to purchasing.

View Audit 52187 Questioned Costs: $1

Finding 58012 (2022-003)

Significant Deficiency 2022

Klamath-Trinity Joint Unified School District

CA

Matching / Level of Effort / Earmarking Special Tests & Provisions Subrecipient Monitoring

Corrective Action Plan and Views of Responsible Officials The District?s Maintenance and Transportation Director will establish a procedure guide for future projects to meet the requirements of prevailing wages as well as all other State compliances for facility projects.

View Audit 52187

Finding 57953 (2022-001)

Significant Deficiency 2022

Goodwill Industries of Hawaii, Inc.

HI

Subrecipient Monitoring Reporting Significant Deficiency § 200.329

Corrective Action Plan in Response to Single Audit Finding Year Ended December 31, 2022 Type of Finding: Internal Control - significant finding; Compliance ? significant finding Recommendation: The Organization should improve processes and procedures to ensure that quarterly reports required by...

Corrective Action Plan in Response to Single Audit Finding Year Ended December 31, 2022 Type of Finding: Internal Control - significant finding; Compliance ? significant finding Recommendation: The Organization should improve processes and procedures to ensure that quarterly reports required by the pass-through entity are completed and submitted on a timely basis. Reference Number: 2022-001 View of Responsible Officials: Management agrees with the finding and recommendation. Corrective Action Plan: Management will review reporting requirements on the contracts and develop a timetable to ensure that the reports are prepared and submitted to the funder in compliance with the deadlines in the contract. Contact Person: Brent Arakaki, Chief Financial Officer, Telephone number: (808)792-8585, Email: barakaki@higoodwill.org Anticipated Completion Date: August 31, 2023.

View Audit 56118

Finding 57931 (2022-003)

Significant Deficiency 2022

The City of Oklahoma City

OK

Allowable Costs / Cost Principles Significant Deficiency § 200.403

Corrective Action Plan Year Ended June 30, 2022 Finding 2022-003: (Significant Deficiency) AL# 97.036: Disaster Grants - Public Assistance (Presidentially Declared Disasters), Passed Thru the Oklahoma Department of Emergency Management, U.S. Department of Homeland Security, Award# PA-06-OK-PW-00187,...

Corrective Action Plan Year Ended June 30, 2022 Finding 2022-003: (Significant Deficiency) AL# 97.036: Disaster Grants - Public Assistance (Presidentially Declared Disasters), Passed Thru the Oklahoma Department of Emergency Management, U.S. Department of Homeland Security, Award# PA-06-OK-PW-00187, 2022 Condition: There were three instances in which an employee's pay rate used in calculating payroll expense was the current pay rate and not the pay rate in effective at the time the work was performed. Criteria or Specific Requirement: 2 CFR 200.403(g) states that costs must be adequately documented. Cause: Employees received pay increases between the time the service was performed and when costs were identified as being covered by the disaster grant. The pay rate used was the pay rate for those employees at the time the expenditures were identified. Effect: Not properly identifying the appropriate pay rates used in determining payroll expenses may cause the federal program to be overcharged. Corrective Action Plan: The City will implement the following steps: 1. The Parks and Recreation Department will immediately implement a process where the Parks & Grounds Superintendent (or designee) will review employee pay information that administrative staff prepares for entry into the federal grant website ensuring that it is properly formatted and accurately reflects the pay at the time the work was performed. 2. A procedure will be added to the FEMA section of the City's Grants Manual to include a second review to verify that the pay rates being used to determine payroll expenses are the rates that were in effect at the time the service was provided. This verification will be documented in the Grants database maintained by the Accounting Services Division.

View Audit 54638

Finding 57903 (2022-001)

Significant Deficiency 2022

Girard Lutheran Housing Corporation

PA

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

2022-001 Federal agency: U.S. Department of Housing and Urban Development Federal program title: Supportive Housing for the Elderly Section 202 CFDA Number: 14.157 Criteria or specific requirement: Expired Project Rental Assistance Contract (PRAC). Condition: The Corporation did not renew the PRAC t...

2022-001 Federal agency: U.S. Department of Housing and Urban Development Federal program title: Supportive Housing for the Elderly Section 202 CFDA Number: 14.157 Criteria or specific requirement: Expired Project Rental Assistance Contract (PRAC). Condition: The Corporation did not renew the PRAC timely. Context: The PRAC expired January 31, 2022, and was not renewed until November 7, 2022. Recommendation: The Corporation should ensure the PRAC is renewed on a timely basis annually. Action taken in response to finding: Managements acknowledges this finding and is taking steps to correct. Management has counseled HUD building management on the need for timely submissions of proposed budgets and contract completion. A master schedule has been set up and all budget submissions will now be reviewed by the Finance Department prior to submission. Name of contact person responsible for corrective action: Jeffrey Carraway

View Audit 55722

Finding 57899 (2022-001)

Significant Deficiency 2022

Saint Mary's University of Minnesota

MN

Student Financial Aid Matching / Level of Effort / Earmarking Reporting

Corrective Action: The two students whose information was not reported within 60 days was due to an internal failure to report the status change by the Financial Aid and Registrar's Office. The one student whose effective date varied between program and campus level stems from system limitations, as...

Corrective Action: The two students whose information was not reported within 60 days was due to an internal failure to report the status change by the Financial Aid and Registrar's Office. The one student whose effective date varied between program and campus level stems from system limitations, as the process to report this status change on the program level but not the enrollment level, as required by NSLDS, is a manual process. The University continues to refine the manual process required for reporting this type of status change. For the four students who never had their graduation status reported to the NSLDS, Management noted one actual failure to report and three instances where the status change was reported to the Clearinghouse, but not reflected on NSLDS. The University is working with the Clearinghouse to understand what went wrong and how to prevent it in the future. The University is in the middle of implementation of a new student information system which is expected to improve this and other processes. Implementation is anticipated to be complete by July 2023.

View Audit 54321

Finding 57898 (2022-002)

Significant Deficiency 2022

New Haven Legal Assistance Association, Inc.

CT

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

Coronavirus State and Local Fiscal Recovery Funds ? Assistance Listing No. 21.027 Recommendation: We recommend that the Organization retain records to satisfy the time and effort documentation as required by Uniform Guidance (2 CFR Part 200). Explanation of disagreement with audit finding: There is ...

Coronavirus State and Local Fiscal Recovery Funds ? Assistance Listing No. 21.027 Recommendation: We recommend that the Organization retain records to satisfy the time and effort documentation as required by Uniform Guidance (2 CFR Part 200). Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Laura Clark, the Director of Finance, has met with the management team and LAA has revised its procedure for supervisors keeping time under the Right To Counsel program. Now, supervisors of the program are required to maintain separate time entries in our case management system for Right To Counsel cases. Before billing under the program, Laura Clark will run a Crystal Report, which captures time entered into the case management system, to ensure the percentage billed is correct. This has been discussed and implemented. Name of the contact person responsible for corrective action: Laura Clark, Director of Finance Planned completion date for corrective action plan: June 2023

View Audit 54852

Finding 57897 (2022-001)

Significant Deficiency 2022

New Haven Legal Assistance Association, Inc.

CT

Procurement, Suspension & Debarment Significant Deficiency § 200.318 § 200.326

Coronavirus State and Local Fiscal Recovery Funds ? Assistance Listing No. 21.027 Recommendation: We recommend that the Organization review its procurement policy and conflict of interest policy and make necessary changes to comply with the criteria as set out in 2 CFR sections 200.318 and 200.326. ...

Coronavirus State and Local Fiscal Recovery Funds ? Assistance Listing No. 21.027 Recommendation: We recommend that the Organization review its procurement policy and conflict of interest policy and make necessary changes to comply with the criteria as set out in 2 CFR sections 200.318 and 200.326. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Laura Clark, the Director of Finance, is currently developing a procurement and related conflict of interest policy. These policies will be presented to the Board of Directors for approval at the July 2023 board meeting. Name of the contact person responsible for corrective action: Laura Clark, Director of Finance Planned completion date for corrective action plan: July 2023

View Audit 54852

Finding 53082 (2022-007)

Significant Deficiency 2022

State of Wisconsin

WI

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

CAP for Finding: 2022-007 Planned Corrective Action: The UW System has adequate processes in place for reviewing access to ShopUW+ but agrees to better document these processes. UW System Administration (UWSA) has revised the disbursement internal control template, which all UW universities use in d...

CAP for Finding: 2022-007 Planned Corrective Action: The UW System has adequate processes in place for reviewing access to ShopUW+ but agrees to better document these processes. UW System Administration (UWSA) has revised the disbursement internal control template, which all UW universities use in developing their internal control plans, to document the UW System?s security reviews. UWSA will also update the language surrounding its weekly access reports, to explain their purpose and importance. To monitor this control, the UW System will add a statement to this effect in the universities? annual delegation agreement and certifications. UWSA is actively taking steps to mature its third-party risk management practices, including the development of guidance and best practices for UW universities. Current efforts are focused on optimizing available resources to provide the highest return on value. UWSA currently performs periodic reviews of cloud-based third-party internal controls during precontract evaluations and at the time of contract renewals. This includes obtaining and reviewing service organization audit reports, if available. UWSA will evaluate the efficacy of increasing the periodicity of these reviews to an annual basis. UWSA will also evaluate means for communicating identified expectations systemwide, up to and including the creation of a new policy. Anticipated Completion Date: June 30, 2023 Person responsible for corrective action: Julie Gordon, Senior Associate Vice President Finance, UW System Administration jgordon@uwsa.edu

View Audit 44861

Finding 53058 (2022-001)

Significant Deficiency 2022

State of Wisconsin

WI

Questioned Costs Significant Deficiency

CAP for Finding: 2022-001 DATE: November 16, 2022 TO: Lisa Kasel, Assistant Financial Audit Director Legislative Audit Bureau FROM: Barry Kasten, Director Bureau of Fiscal Services Department of Health Services SUBJECT: Corrective Action Plan ? Medical Assistance Program Third-Party Liability Depart...

CAP for Finding: 2022-001 DATE: November 16, 2022 TO: Lisa Kasel, Assistant Financial Audit Director Legislative Audit Bureau FROM: Barry Kasten, Director Bureau of Fiscal Services Department of Health Services SUBJECT: Corrective Action Plan ? Medical Assistance Program Third-Party Liability Department staff has reviewed the Legislative Audit Bureau?s (LAB) interim audit memo for Finding 2022-001: Medical Assistance Program Third-Party Liability. This is the department?s Corrective Action Plan. ? Recommendation (2022-001): Medical Assistance Program Third-Party Liability We recommend the Wisconsin Department of Health Services: ? Review and update the Medicaid Management Information System cost avoidance rules to properly identify and deny payment for claims that may be covered by third-party insurers. Wisconsin Department of Health Services Planned Corrective Action: DHS has completed an assessment of Medicaid Management Information System (MMIS) cost avoidance rules and will implement changes by December 31, 2022, necessary to properly identify and deny outpatient services when a participant is enrolled in Medicare or other third-party insurance at the time the service was provided. We recommend the Wisconsin Department of Health Services: ? Identify payments made during FY 2021-22 that may have been improper due to inaccurate cost avoidance rules and seek to recover these amounts; ? Return to the federal government recovered payment that may have been improper; and Wisconsin Department of Health Services Planned Corrective Action: DHS will attempt to recover $1,956 in improper payments for outpatient services not properly identified and denied under cost avoidance rules in MMIS by December 31, 2022, and return to the federal government the estimated federal share of $1,293. DHS will complete an assessment and identify paid claims by March 31, 2023, where cost avoidance rules were not appropriately applied for outpatient services when a participant was enrolled in Medicare or other third-party insurance with a date of service after July 1, 2021, and return to the federal government recovered payments that were improper. We recommend the Wisconsin Department of Health Services: ? Perform an assessment and implement additional procedures to review changes to cost avoidance rules in the future. Wisconsin Department of Health Services Planned Corrective Action: DHS will implement processes and procedures by December 31, 2022, for conducting production validation on any configuration changes impacting cost avoidance rules. Anticipated Completion Date: March 31, 2023 Person responsible for corrective action: Nick Havens, Director Bureau of System Management, Division of Medicaid Services Nicholas.Havens@dhs.wisconsin.gov

View Audit 44861 Questioned Costs: $1

Finding 53055 (2022-104)

Significant Deficiency 2022

State of Wisconsin

WI

Subrecipient Monitoring Reporting Significant Deficiency

CAP for Finding: 2022-104 Auditor Recommendation: Improve Federal Funding Accountability and Transparency Act reporting procedures to ensure accurate award information, including the federal award identification number, is being used. Planned Corrective Action: The Wisconsin Department of Administra...

CAP for Finding: 2022-104 Auditor Recommendation: Improve Federal Funding Accountability and Transparency Act reporting procedures to ensure accurate award information, including the federal award identification number, is being used. Planned Corrective Action: The Wisconsin Department of Administration?s (Department or DOA) Bureau of Financial Management (BFM) and Division of Energy, Housing and Community Resources (DEHCR) will work together to implement procedures to ensure the accuracy of the award information that is transmitted to the Division of Executive Budget and Finance (DEBF), Systems, Operations and Federal Funds Team (Federal Funds Team) for Federal Funding Accountability and Transparency Act (FFATA) reporting. The procedures may include, among other things, DEHCR?s provision of the federal award document containing the federal award identification number (FAIN) to BFM concurrent with the request to establish the award for reporting. Anticipated Completion Date: June 30, 2023 Auditor Recommendation: Improve Federal Funding Accountability and Transparency Act reporting procedures to ensure rejected subaward information is reviewed and communicated to the appropriate program staff for investigation and resolution. Planned Corrective Action: The Department will improve FFATA reporting procedures to ensure rejected subaward information is reviewed and communicated to the appropriate program staff for investigation and resolution. DEBF?s Federal Funds Team will communicate error messages it receives for rejected reports in a timely manner to agency and program staff originating the reports, and the error log received from the FFATA Subaward Reporting System (FSRS) will be made available electronically for agency program staff as well as maintained for documentation purposes. Anticipated Completion Date: June 30, 2023 Auditor Recommendation: Improve Federal Funding Accountability and Transparency Act reporting procedures to ensure documentation of rejected subaward information is maintained to demonstrate that the Department of Administration attempted to enter the subaward information; and Planned Corrective Action: The Department will improve FFATA reporting procedures to ensure documentation of rejected subaward information is maintained to demonstrate that the Department attempted to enter the subaward information in FSRS. As previously noted, the Federal Funds Team will communicate to agency and program staff the error messages received for rejected reports and make available and maintain for archival purposes error logs received from FSRS. Additionally, the Federal Funds Team will record in the Wisconsin FFATA reporting system if an upload of the subaward information cannot be completed during the intended reporting period due to reasons that are beyond its control, such as delays in the federal government?s assignment of federal award identification numbers (FAINs) for new grant awards. Anticipated Completion Date: June 30, 2023 Auditor Recommendation: Improve Federal Funding Accountability and Transparency Act reporting procedures to ensure all required subawards of $30,000 or more, including any amendments or modifications to a subaward, are identified and submitted to the Federal Funding Accountability and Transparency Act Subaward Reporting System in a timely manner. Planned Corrective Action: The Department takes seriously its responsibility to ensure all required subawards of $30,000 or more, including any amendments or modifications to a subaward, are identified and submitted to FSRS in a timely manner. The Federal Funds Team in fulfilling its enterprise role related to FSRS reporting, delivered agency and program staff training on the requirements of 2 CFR s. 170, in February 2023, concurrent with the introduction of its new Wisconsin FFATA reporting system, and will highlight FFATA reporting requirements in its monthly reporting timeline communications. As previously noted, BFM and DEHCR will work together to implement improved procedures to ensure the accuracy of the award information that is transmitted to DEBF. They will also implement procedures to verify the completeness of the data that is uploaded to FSRS, including confirming the availability of the data in USAspending.gov. Anticipated Completion Date: June 30, 2023 Persons responsible for corrective action: Susan Brown, Administrator Division of Energy, Housing and Community Resources susan.brown@wisconsin.gov Colleen Holtan, Director Bureau of Financial Management Division of Enterprise Operations colleen.holtan@wisconsin.gov Dustin Trickle, Executive Policy and Budget Manager Division of Executive Budget and Finance dustin.trickle1@wisconsin.gov

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Finding 53053 (2022-101)

Significant Deficiency 2022

State of Wisconsin

WI

Eligibility Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

CAP for Finding: 2022-101 Auditor Recommendation: Establish and implement written procedures for making updates to the benefit calculation parameters in the Home Energy (HE) Plus application. Planned Corrective Action: The Wisconsin Department of Administration (Department or DOA) will establish and...

CAP for Finding: 2022-101 Auditor Recommendation: Establish and implement written procedures for making updates to the benefit calculation parameters in the Home Energy (HE) Plus application. Planned Corrective Action: The Wisconsin Department of Administration (Department or DOA) will establish and implement written procedures for entering and updating the benefit calculation parameters related to the Wisconsin Home Energy Assistance Program (WHEAP) in the HE Plus (HE+) System. The Department?s procedures will reflect that it incorporated a module for determining the LIHEAP heating maximum benefit in the HE+ System and eliminated the use of an external Microsoft Access database for that purpose subsequent to the period under audit (i.e., in state fiscal year [SFY] 2022-23). Anticipated Completion Date: May 1, 2023 Auditor Recommendation: Reassess its existing procedures for performing a review of the benefit calculation parameters entered into the Home Energy (HE) Plus application, make adjustments to its existing procedures as necessary, and document the performance of each review. Planned Corrective Action: The Department necessarily reassessed its procedures for reviewing the entry of benefit calculation parameters into the HE+ System when it incorporated a module for determining the LIHEAP heating maximum benefit in the HE+ System and eliminated the use of an external Microsoft Access database for that purpose subsequent to the period under audit (i.e., in state fiscal year [SFY] 2022-23). The development and implementation of the new system functionality, which was used for the determining the federal fiscal year (FFY) 2023 WHEAP program benefits, improved program integrity through the elimination of manual data entry of end result benefit factors and proxy values. Program integrity will be further strengthened through the creation of a form to document the review of the benefit calculation parameters entered into HE+. The form will be created by May 1, 2023, and implemented with the FFY24 benefit formula calculation scheduled to be completed in July 2023. Anticipated Completion Date: May 1, 2023 Auditor Recommendation: Complete its review of the 605 households that were underpaid heating benefits due to the error and issue supplemental heating benefit payments. Planned Corrective Action: DOA completed its review of the households that were underpaid heating benefits and will issue the supplemental heating benefit payments as soon as practical. Anticipated Completion Date: June 30, 2023 Person responsible for corrective action: Susan Brown, Administrator Division of Energy, Housing and Community Resources susan.brown@wisconsin.gov

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