Corrective Action Plans

Finding 48240 (2022-001)

Significant Deficiency 2022

NJ

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

Finding No. 2022-001 Compliance Requirement ? Reporting ? Significant Deficiency and Noncompliance Planned Corrective Action The University will ensure that each report submission that is required to support spending under each of the Higher Education Emergency Relief Funds and other related fundi...

Finding No. 2022-001 Compliance Requirement ? Reporting ? Significant Deficiency and Noncompliance Planned Corrective Action The University will ensure that each report submission that is required to support spending under each of the Higher Education Emergency Relief Funds and other related funding programs has formal supporting documentation to evidence appropriate review of the report. This issue of how eligible students were determined and how the amounts distributed were determined was identified on the Q4 2021 Report due to the timing of the test work in the prior year Single Audit. This issue was corrected in the Q1 2022 Report and all available funding has been spent. The Assistant Vice President for Financial Aid has ensured that the total number of students eligible to receive a grant and the total number of students who receive grants is properly reviewed and documented. The Manager of Financial Planning, Budgeting and Analysis will ensure that all submitted Institutional Aid Reports are properly reconciled to actual expenditures rather than anticipated expenditures. The Q4 2021 Report was revised and reposted to reflect that expenditures were related to other costs rather than lost revenue. Each Student Aid Report and Institutional Aid Report will be reviewed and approved by the Associate Vice President for Finance. This review and approval will be documented in the file. The submitted Reports will also be provided to the CFO, Vice President for Finance and Treasurer. Timing of Completion This corrective action was implemented in FY22 and FY23.

View Audit 42638

Finding 48234 (2022-002)

Significant Deficiency 2022

Monument Health, Inc.

SD

Allowable Costs / Cost Principles Cash Management Significant Deficiency § 200.303

Finding: 2022-002 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 HRSA Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund Federal Financial Assistance Listing #: #93.461 Finding Summary: Audit testing identified one instance ...

Finding: 2022-002 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 HRSA Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund Federal Financial Assistance Listing #: #93.461 Finding Summary: Audit testing identified one instance in which health services provided to a patient were reimbursed under the federal program, and the health services provided did not meet the terms and conditions of the federal program. Through the coding process, an incorrect diagnosis code was included in the system, and therefore, the patient?s health services flowed into Monument Health?s Uninsured Program workflow which resulted in $3,563 of health services being reimbursed under the federal program. As part of the audit, a sample of 60 patients were selected for testing, accounting for $1,659,497 of $4,344,728 of monies received from the federal agency. Responsible Individuals: Austin Willuweit, Vice President of Finance Jen Schmaltz, Corporate Controller Corrective Action Plan: Monument Health will develop a review process to identify claims that could have a diagnosis coding issue. A return of any excess reimbursement will be completed. Anticipated Completion Date: June 30, 2023

View Audit 40813

Finding 48210 (2022-007)

Significant Deficiency 2022

Winner Regional Healthcare Center

SD

Student Financial Aid Reporting Significant Deficiency § 200.303

Finding 2022-007 Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants FFAL #10.766 Finding Summary: The fiscal year 2021 audit report was requited to be submitted to the federal agency by September 30th, 2022. We did not provide the 2021 audit report wi...

Finding 2022-007 Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants FFAL #10.766 Finding Summary: The fiscal year 2021 audit report was requited to be submitted to the federal agency by September 30th, 2022. We did not provide the 2021 audit report within the timeframe requested by the federal agency representative. Responsible Individuals: Amanda Soesbe, Chief Finance Officer Corrective Action Plan: The CFO will send the audited financial statements to USDA by the deadline. Anticipated Completion Date: 9-30-2023

View Audit 46933

Finding 48203 (2022-005)

Significant Deficiency 2022

Catholic Charities West Michigan

MI

Special Tests & Provisions Eligibility Significant Deficiency

The Program Coordinator will complete the Volunteer File Master Checklist for each new volunteer including the income verification and background checks as well as other required steps. The Program Coordinator will sign and date the form. The Program Supervisor will review the checklist for comple...

The Program Coordinator will complete the Volunteer File Master Checklist for each new volunteer including the income verification and background checks as well as other required steps. The Program Coordinator will sign and date the form. The Program Supervisor will review the checklist for completeness and sign and date the form. The completed form will be filed in the volunteer?s file. This practice is being implemented currently.

View Audit 41510

Finding 48199 (2022-003)

Significant Deficiency 2022

Catholic Charities West Michigan

MI

Reporting Significant Deficiency

Catholic Charities West Michigan agrees that a separate review of both semi-annual reports and the quarterly Payment Management Services reports for Foster Grandparents/Senior Companion Cluster needs to occur and we have made those changes June 2022 as noted in the recommendations for this item.

View Audit 41510

Finding 48198 (2022-002)

Significant Deficiency 2022

Catholic Charities West Michigan

MI

Subrecipient Monitoring Cash Management Reporting

An Administrative Financial Management Policy is being written to address proper identification, grant relationship, and allowable costs of federal grants. This policy should be in place by June 2023. Catholic Charities West Michigan adopted a cash management policy in February 2023 supporting pro...

An Administrative Financial Management Policy is being written to address proper identification, grant relationship, and allowable costs of federal grants. This policy should be in place by June 2023. Catholic Charities West Michigan adopted a cash management policy in February 2023 supporting procedures to follow to assure timely draw and expenditures of federal dollars.

View Audit 41510

Finding 48190 (2022-002)

Significant Deficiency 2022

Watertown School District No. 14-4

SD

Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking

Finding 2022-002 Federal Agency Name: Department of Education Program Name: Student Financial Aid Cluster CFDA # 84.268 - Federal Direct Student Loans Special Tests and Provisions ? Return of Title IV Funds Finding Summary: 1 of 30 students tested for return of Title IV had a withdrawal determina...

Finding 2022-002 Federal Agency Name: Department of Education Program Name: Student Financial Aid Cluster CFDA # 84.268 - Federal Direct Student Loans Special Tests and Provisions ? Return of Title IV Funds Finding Summary: 1 of 30 students tested for return of Title IV had a withdrawal determination date outside of the 30-day requirement. For a student who withdraws without providing notification from a school that is not required to take attendance, the school much determine the withdrawal date no later than 30 days after the end of the earlier of 1) the payment period or the period of enrollment, 2) the academic year, or 3) the student?s educational program. Responsible Individuals: Eric Schultz, Director of Enrollment and Marlene Seeklander, Director of Financial Aid Corrective Action Plan: The Registrar?s Office will take the following action: For all programs that have SOE/Internship/Clinical experiences, a roster will be generated, and the instructors will be required to verify that the student has been placed and is actively participating in the SOE/Internship/Clinical. Moving forward, this will be a reminder that is emphasized on a regular basis. At the instructor in-service sessions in August, the Director or Enrollment and Director of Financial Aid present a session which is a series of reminders and other important information that instructors need to know. While we already address the need to notify the Registration Office that a student is no longer attending, we plan to expand on that topic. We will include a slide with the audit finding as outlined so they can see the audit ramifications it has on LATC. We will also explain that this is an institutional responsibility, which includes all staff, all program instructors and all adjuncts. Anticipated Completion Date: Ongoing

View Audit 53320

Finding 48181 (2022-004)

Significant Deficiency 2022

Summit Academy Oic

MN

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

2021-004 COVID-19 HEERF Student Aid Portion and COVID-19 HEERF Institutional Portion Recommendation: We recommend the Organization establish a system to track due dates of reports to ensure timely submission and retain documents to support the submission and accuracy of the reports. Explanation of d...

2021-004 COVID-19 HEERF Student Aid Portion and COVID-19 HEERF Institutional Portion Recommendation: We recommend the Organization establish a system to track due dates of reports to ensure timely submission and retain documents to support the submission and accuracy of the reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: I do not disagree with this finding, however it is important to clarify that this is not a repeat finding from 2021, but rather, this is the exact same incident of the 2021 finding. The 2021 audit was not conducted until February 2022 which happens to also fall into our FY2022. As a result, this finding was corrected immediately following the FY21 discovery and the corrective action was put into place at that time and remains in place and effective. That corrective action was and is as follows: Summit did and continues to have the due dates for the various reporting deadlines, and we did meet those deadlines, however the issue remains that once our reports were updated to the website as required, there exists no audit log of the dates of the changes. As a solution to this issue, we have created a due date log that will be updated with the change date and the log will be signed by the originator of the report as well as the overseer of the website. This signed log will be preserved for review. Names of the contact persons responsible for corrective action: Reports will continue to be filed by the CFO (Marc Carrier) and the Digital Marketing Specialist (Rachel Prost) will be responsible for the website update. This was implemented March 31,2022 and remains in place.

View Audit 51844

Finding 48176 (2022-003)

Significant Deficiency 2022

Summit Academy Oic

MN

Reporting Significant Deficiency Internal Control / Segregation of Duties

2022-003 COD Reporting Recommendation: We recommend the Academy evaluate its procedures and policies around reporting disbursements to COD to ensure that student information is reported accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit fin...

2022-003 COD Reporting Recommendation: We recommend the Academy evaluate its procedures and policies around reporting disbursements to COD to ensure that student information is reported accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: FA staff will research and receive more training on how to audit dates between our internal records system (CNS) and COD, and if adjustments are needed, how to correctly apply adjustments to disbursement dates. When disbursing Pell, FA staff will check through the expected dates (disbursement dates) in our system before exporting the Pell request to COD. In the event dates need adjusting after Pell has be received, the dates will be updated in CNS (Summit?s records system) prior to applying. The dates will also be checked, and if necessary, updated on COD to ensure they match, and both systems reflect the accurate disbursement date. Note: Due to late notification of 2020-2021 Audit Findings, we were unaware of deficiencies in our process, therefore; did not begin corrective action until near the end of 2021-2022 AY. Name of the contact person responsible for corrective action: Jennifer Haavisto Planned completion date for corrective action plan: 3/15/2023

View Audit 51844

Finding 48175 (2022-002)

Significant Deficiency 2022

Summit Academy Oic

MN

Student Financial Aid Reporting Significant Deficiency

2022-002 NSLDS Reporting Recommendation: We recommend the Organization reevaluate its procedure and review polies surrounding reporting status changes to NSLDS to ensure timely reporting as well as put a process in place to ensure the enrollment effective date reported to NSLDS is aligning with the ...

2022-002 NSLDS Reporting Recommendation: We recommend the Organization reevaluate its procedure and review polies surrounding reporting status changes to NSLDS to ensure timely reporting as well as put a process in place to ensure the enrollment effective date reported to NSLDS is aligning with the organizations last date of attendance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Financial Aid staff will utilize the most recent NSLDS Enrollment Reporting Guide, and the corresponding NSLDS Enrollment Reporting Guide Appendices in order to evaluate current procedures and improve upon where necessary in order to be in compliance. The guide and appendices will also be shared with the Registrar?s office for review. The Registrar?s Office and Financial Aid Office will work together to ensure both departments? tasks and processing concerning NSLDS enrollment reporting are done so in a timely manner. The data provided to Financial Aid staff will be reviewed uploaded to NSLDS within one week of receiving it from the Registrar to make certain the reporting is accurate and falling within the required timeframes. The Financial Aid staff and Registrar will revamp current reporting process to reduce risk on incorrect data being reported as well as to ensure all the correct data is being compiled and reviewed prior to reporting. Note: Due to late notification of 2020-2021 Audit Findings, we were unaware of deficiencies in our process, therefore; did not begin corrective action until near the end of 2021-2022 AY. Name of the contact person responsible for corrective action: Jennifer Haavisto Planned completion date for corrective action plan: 3/15/2023

View Audit 51844

Finding 48173 (2022-001)

Significant Deficiency 2022

Oklahoma Public School Resource Center INC

OK

Subrecipient Monitoring Reporting Significant Deficiency

OPSRC is now registered on the FSRS reporting system and staff are working with the federal Education Program Specialist to schedule report training and to clarify how to file reports. A policy and procedure will be approved by the OPSRC board of directors and adopted that ensures timely review of ...

OPSRC is now registered on the FSRS reporting system and staff are working with the federal Education Program Specialist to schedule report training and to clarify how to file reports. A policy and procedure will be approved by the OPSRC board of directors and adopted that ensures timely review of subrecipient reporting under the Federal Funding Accountability and Transparency Act. We anticipate the corrective action to be accomplished by May 2023. Eric Doss, Director, Quality Charter Schools and Pat McKinstry, Deputy Director will be responsible for ensuring compliance.

View Audit 51839

Finding 48112 (2022-005)

Significant Deficiency 2022

Town of Enfield, Connecticut

CT

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Significant Deficiency § 200.318 § 200.326

Finding 2022-005 Reporting Significant Deficiency ? Internal Control over Compliance Other Matters (Noncompliance) Description of Finding The Town's Program Status Reports were not reviewed separate from preparer prior to submission. Statement of Concurrence or NonConcurrence Management agrees wi...

Finding 2022-005 Reporting Significant Deficiency ? Internal Control over Compliance Other Matters (Noncompliance) Description of Finding The Town's Program Status Reports were not reviewed separate from preparer prior to submission. Statement of Concurrence or NonConcurrence Management agrees with this finding. Corrective Action The Town is in process of developing a formal policy. Name of Contact Person John Wilcox Projected Completion Date June 30, 2023

View Audit 53687

Finding 48111 (2022-003)

Significant Deficiency 2022

Graham County

NC

Eligibility Significant Deficiency

Finding: 2022-003 Name of contact person: Amy Seay - Director of Social Services Corrective Action: The Department will continue to provide more in-depth training to ensure cases requiring IV-D Cooperation are meeting policy guidelines. Proposed Completion Date: As soon as possible

View Audit 54380

Finding 48071 (2022-001)

Significant Deficiency 2022

Village Cooperative of Sioux 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 53107

Finding 48068 (2022-001)

Significant Deficiency 2022

The Housing Authority of the City of Auburn, Alabama

AL

Eligibility HUD Housing Programs Significant Deficiency

Finding 2022-001 ? Moving to Work Tenant Files ? Eligibility ? Annual Recertifications ? Noncompliance & Significant Deficiency ? CFDA #14.881 Corrective Action Plan: The Auburn Housing Authority (AHA) has implemented and/or will implement the following by FYE 2023: a. PBV case management is now ...

Finding 2022-001 ? Moving to Work Tenant Files ? Eligibility ? Annual Recertifications ? Noncompliance & Significant Deficiency ? CFDA #14.881 Corrective Action Plan: The Auburn Housing Authority (AHA) has implemented and/or will implement the following by FYE 2023: a. PBV case management is now administered in-house b. HCV has developed an action plan to ensure that all PBV files are HUD-compliant c. PBV calendar-year 2022 (January 2022-December 2022) re-exams are substantially complete. All files will be HUD-compliance by FYE2023. d. During FYE2023, the HCV Manager will perform quality controls by randomly selecting departmental files. e. Other internal control measures will be implemented to eliminate future audit findings. Person Responsible: Sharon Tolbert, CEO Anticipated Completion Date: June 30, 2023

View Audit 51285

Finding 48061 (2022-001)

Significant Deficiency 2022

Minneapolis College of Art and Design

MN

Subrecipient Monitoring Reporting Significant Deficiency § 200.328 § 200.329

Finding 2022-01: COVID1-19 Education Stabilization Fund, Higher Education Emergency Relief Funds ? Reporting Program: COVID-19 Education Stabilization Fund Federal Agency: U.S. Department of Education Pass Through Entity: Not Applicable Assistance Listing Number: 84.425E, 84.425F Federal Award Numb...

Finding 2022-01: COVID1-19 Education Stabilization Fund, Higher Education Emergency Relief Funds ? Reporting Program: COVID-19 Education Stabilization Fund Federal Agency: U.S. Department of Education Pass Through Entity: Not Applicable Assistance Listing Number: 84.425E, 84.425F Federal Award Number: P425E200445 Federal Award Year: June 30, 2022 Condition: The College did not post the required quarterly reports for the Student Portion. Additionally, during the audit, it was noted that the College was unable to provide a copy of the annual report and supporting documentation for the year ended December 31, 2021. Corrective Action Plan Management agrees with the finding, and is committed to strengthening its procedures to avoid similar issues in the future. Quarterly reports for the Student Portion have now been posted on the College website. Turnover in finance department staff resulted in difficulty locating copies of reports submitted by former staff. New staff will be trained on the Department?s HEERF requirements to ensure accurate and timely future reporting.

View Audit 51558

Finding 48049 (2022-002)

Significant Deficiency 2022

Gila Regional Medical Center

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

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