Corrective Action Plans

Finding 537540 (2024-002)

Significant Deficiency 2024

Jefferson County Industrial Development Agency

NY

Subrecipient Monitoring Significant Deficiency

Views of Responsible Officials and Planned Corrective Actions: We acknowledge the validity of this finding and offer the following explanation. While we recognized the Agency’s role as a subrecipient, we did not fully understand the guidelines for distinguishing between a “contractor” and a “subreci...

Views of Responsible Officials and Planned Corrective Actions: We acknowledge the validity of this finding and offer the following explanation. While we recognized the Agency’s role as a subrecipient, we did not fully understand the guidelines for distinguishing between a “contractor” and a “subrecipient” when making a subaward to another organization. However, through a thorough discussion and assessment of the guidelines with the auditors, along with a joint review of the GSA-CX-1.8: Subrecipient and Contractor Determination Form, we have gained clarity on the proper process for making accurate determinations in future subawards. Corrective Action: For future grant awards, Agency staff will review the use of funds in accordance with federal guidelines to determine whether the recipient qualifies as a subrecipient or a contractor. Additionally, the Agency has taken steps to notify the organization of their subrecipient status and their obligation to conduct a Single Audit in compliance with Government Accounting Standards and Uniform Guidance requirements.

View Audit 348822

Finding 537537 (2024-001)

Significant Deficiency 2024

Town of Boylston

MA

Subrecipient Monitoring Allowable Costs / Cost Principles Procurement, Suspension & Debarment

Condition: The Town has not documented in writing its policies regarding federal awards. Corrective Action Planned: A financial policy for managing receipt of federal awards is in the process of being created by the Financial Policies Committee Anticipated Completion Date: December 31, 2025 ...

Condition: The Town has not documented in writing its policies regarding federal awards. Corrective Action Planned: A financial policy for managing receipt of federal awards is in the process of being created by the Financial Policies Committee Anticipated Completion Date: December 31, 2025 Contact: April Steward, Town Administrator

View Audit 348815

Finding 537528 (2024-003)

Significant Deficiency 2024

Housing Authority of Prince George's County

MD

HUD Housing Programs Significant Deficiency Special Tests & Provisions

2024-003 Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority review their process and internal controls for rent reasonableness to ensure compliance with HUD requirements and their administrative plan. Explanation of disagreement with audit finding: T...

2024-003 Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority review their process and internal controls for rent reasonableness to ensure compliance with HUD requirements and their administrative plan. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: HAPGC has implemented a new Rent Reasonableness software that provides a user-friendly method for ensuring Rent Reasonableness compliance. HAPGC has hired a new Voucher Program Director. The new Director will strictly enforce current program policy which requires Recertification and Intake Specialists to attach all required documentation within 3 business days of receipt to the program participant’s electronic file. Additionally, Program Managers, as well as Recertification and Intake Specialists, will be held accountable through disciplinary action when corrective actions noted through the quality control review process are not corrected within 15 business days. Finally, all HCV staff persons will be required to take the Housing Choice Voucher Certification class annually to ensure proper training and adequate understanding of the voucher program rules. Name(s) of the contact person(s) responsible for corrective action: Carolyn Floyd, Housing Choice Voucher Program, Director cefloyd@co.pg.md.us. Planned completion date for corrective action plan: December 31, 2025.

View Audit 348795

Finding 537527 (2024-002)

Significant Deficiency 2024

Housing Authority of Prince George's County

MD

HUD Housing Programs Eligibility Significant Deficiency

2024-002 Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority review their process and internal controls for new tenants to ensure compliance with HUD requirements and their administrative plan. Explanation of disagreement with audit finding: There is...

2024-002 Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority review their process and internal controls for new tenants to ensure compliance with HUD requirements and their administrative plan. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: HAPGC has hired a new Voucher Program Director. The new Director will strictly enforce current program policy which requires Recertification and Intake Specialists to attach all required documentation within 3 business days of receipt to the program participant’s electronic file. Additionally, Program Managers, as well as Recertification and Intake Specialists, will be held accountable through disciplinary action when corrective actions noted through the quality control review process are not corrected within 15 business days. Finally, all HCV staff persons will be required to take the Housing Choice Voucher Certification class annually to ensure proper training and adequate understanding of the voucher program rules. Name(s) of the contact person(s) responsible for corrective action: Carolyn Floyd, Housing Choice Voucher Program, Director cefloyd@co.pg.md.us. Planned completion date for corrective action plan: December 31, 2025.

View Audit 348795

Finding 537526 (2024-001)

Significant Deficiency 2024

Housing Authority of Prince George's County

MD

HUD Housing Programs Eligibility Significant Deficiency

2024-001 Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority review their process and internal controls over eligibility to ensure compliance with HUD requirements and their administrative plan. Explanation of disagreement with audit finding: There i...

2024-001 Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority review their process and internal controls over eligibility to ensure compliance with HUD requirements and their administrative plan. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: HAPGC has hired a new Voucher Program Director. The new Director will strictly enforce current program policy which requires Recertification and Intake Specialists to attach all required documentation within 3 business days of receipt to the program participant’s electronic file. Additionally, Program Managers, as well as Recertification and Intake Specialists, will be held accountable through disciplinary action when corrective actions noted through the quality control review process are not corrected within 15 business days. Finally, all HCV staff persons will be required to take the Housing Choice Voucher Certification class annually to ensure proper training and adequate understanding of the voucher program rules. Name(s) of the contact person(s) responsible for corrective action: Carolyn Floyd, Housing Choice Voucher Program, Director cefloyd@co.pg.md.us. Planned completion date for corrective action plan: December 31, 2025.

View Audit 348795

Finding 537488 (2024-003)

Significant Deficiency 2024

City and Borough of Juneau, Alaska

AK

Reporting Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303 § 200.306

FEDERAL AWARD FINDING Finding: 2024-003 Significant Deficiency in Internal Controls over Compliance and Compliance – Setup and Monitoring of Reporting and Match Name of Contact Person: Angie Flick, Director of Finance Corrective Action: The accountants will be going through additional training on se...

FEDERAL AWARD FINDING Finding: 2024-003 Significant Deficiency in Internal Controls over Compliance and Compliance – Setup and Monitoring of Reporting and Match Name of Contact Person: Angie Flick, Director of Finance Corrective Action: The accountants will be going through additional training on setting up grants in the system and how to reconcile them. CBJ will also be completing a grant reconciliation process quarterly instead of annually. This will act both as a control as well as an opportunity to make timely corrections in the case of error. Proposed Completion Date: September 30, 2025

View Audit 348728

Finding 537486 (2024-003)

Significant Deficiency 2024

Town of Manchester

MD

Procurement, Suspension & Debarment Subrecipient Monitoring Eligibility § 200.214 § 200.303

DEPARTMENT OF TREASURY 2024-003 Coronavirus State and Local Fiscal Recovery Funds -Assistance Listing No. 21.027 Recommendation: We recommend management ensure policies and procedures include the three options for determining suspension and debarment status listed in 2 CFR 180.300 and that controls ...

DEPARTMENT OF TREASURY 2024-003 Coronavirus State and Local Fiscal Recovery Funds -Assistance Listing No. 21.027 Recommendation: We recommend management ensure policies and procedures include the three options for determining suspension and debarment status listed in 2 CFR 180.300 and that controls are sufficient to ensure that the suspension and debarment status is verified for all vendors prior to issuance of the contract. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Town will ensure all new vendors will sign a suspension and debarment agreement prior to any payments being made. Name of the contact person responsible for corrective action: Kelly Baldwin, Director of Finance Planned completion date for corrective action plan: March 31, 2025 If the Cognizant or Oversight Agency has questions regarding this plan, please call Kelly Baldwin, Director of Finance at 410-239-3200.

View Audit 348723

Finding 537483 (2024-001)

Significant Deficiency 2024

Kyrene Elementary School District No. 28

AZ

Questioned Costs Allowable Costs / Cost Principles School Nutrition Programs

Findings and Questioned Costs Related to Federal Awards Finding Number: 2024‐001 Program Name/Assistance Listing Title: Child Nutrition Cluster Assistance Listing Numbers: 10.553, 10.555, 10.559 Contact Person: Brian Lockery, Director of Finance Anticipated Completion Date: The finding was corrected...

Findings and Questioned Costs Related to Federal Awards Finding Number: 2024‐001 Program Name/Assistance Listing Title: Child Nutrition Cluster Assistance Listing Numbers: 10.553, 10.555, 10.559 Contact Person: Brian Lockery, Director of Finance Anticipated Completion Date: The finding was corrected as of February 18, 2025. Planned Corrective Action: District staff took the following steps to immediately remedy this finding:  Entered and approved a journal entry in the FY24 general ledger to correct the indirect cost transfer out of Fund 510 and into Fund 570 as authorized under the program.  Submitted to ADE a request to open a 15‐915 data correction to submit a revised FY24 Annual Financial Report (AFR), Food Service AFR and School by School (AFR).  ADE opened the 15‐915 window, and Kyrene submitted all three revised AFRs.  ADE processed and approved all three AFRs.  Kyrene submitted all three revised AFRs to its governing board for approval on March 25, 2025.  FY25 opening fund balances were additionally corrected to reflect the changes approved in the revised AFRs. Kyrene remedied this finding as of February 18, 2025. Kyrene now employs a new, revised calculator tool which limits the amount of the food service contract expenses to $25,000 maximum annually. This worksheet will be used to calculate the maximum allowable indirect cost rate transfer from Fund 510 Food Services to Fund 570 Indirect Costs.

View Audit 348721 Questioned Costs: $1

Finding 537462 (2024-003)

Significant Deficiency 2024

Fontbonne University

MO

Student Financial Aid Matching / Level of Effort / Earmarking Cash Management

Corrective Action Plan 2024-003: The University concurs with the finding and has made the required corrections to the COD disbursement dates. The University process when posting Aid has remained consistent each year, this appears to be an isolated incident where CAMS did not pick up the date listed ...

Corrective Action Plan 2024-003: The University concurs with the finding and has made the required corrections to the COD disbursement dates. The University process when posting Aid has remained consistent each year, this appears to be an isolated incident where CAMS did not pick up the date listed on the disbursement screen for these students and pass that to COD. The University has implemented a control to complete the disbursements each time and then verify the date reflects correctly in COD afterwards. While this should be an automatic process, and has been in previous years, it will be something the University verifies now with each aid posting. Completion Date: August 2024 Contact Person: Megan Morton, Director of Financial Services

View Audit 348677

Finding 537461 (2024-002)

Significant Deficiency 2024

Fontbonne University

MO

Student Financial Aid Special Tests & Provisions Internal Control / Segregation of Duties

Corrective Action Plan 2024-002: The University concurs with the finding. The University has corrected the two Spring 2024 RT24 calculations and initiated additional Pell grant disbursements to the noted students. The University has updated its calculations of the scheduled breaks for the 2024-2025 ...

Corrective Action Plan 2024-002: The University concurs with the finding. The University has corrected the two Spring 2024 RT24 calculations and initiated additional Pell grant disbursements to the noted students. The University has updated its calculations of the scheduled breaks for the 2024-2025 academic year. Completion Date: August 2024 Contact Person: Megan Morton, Director of Financial Services

View Audit 348677

Finding 537460 (2024-003)

Significant Deficiency 2024

State System of Higher Education, Commonwealth of Pennsylvania

PA

Matching / Level of Effort / Earmarking Student Financial Aid Significant Deficiency § 200.303

Commonwealth: Direct Loan processor will submit monthly reconciliations to Executive Director of Financial Aid or designated campus director for review and approval

View Audit 348667

Finding 537458 (2024-002)

Significant Deficiency 2024

State System of Higher Education, Commonwealth of Pennsylvania

PA

Student Financial Aid Matching / Level of Effort / Earmarking Reporting § 200.303

ESU: The University acknowledges this is a repeat finding. While a corrective action plan was implemented in May 2024, the audit sample consisted of students from Fall 2023 and Spring 2024, before the updated procedures were in effect. Since then, the University has enhanced its process for identify...

ESU: The University acknowledges this is a repeat finding. While a corrective action plan was implemented in May 2024, the audit sample consisted of students from Fall 2023 and Spring 2024, before the updated procedures were in effect. Since then, the University has enhanced its process for identifying when a student ceases participation in a course. Faculty are now required to indicate when a student stops attending. If a faculty member and student agree on issuing an incomplete grade, both must sign a document attesting that the incomplete is a valid final grade. This ensures clarity for the Registrar's Office. Registrar staff now update the National Student Clearinghouse promptly once a student’s last date of activity is confirmed, particularly when a student withdraws from all courses. This process supports timely compliance with the 60-day federal reporting requirement. Additionally, the University is reviewing its procedures for reporting program enrollment effective dates to ensure consistency with NSLDS standards. All updates are submitted through the National Student Clearinghouse. IUP: IUP will set guidelines that all degree clearing must be done with the 45 day time line so the students are reported within the 60 days limit Cheyney: Cheyney University of Pennsylvania extracts current enrollment information, including any enrollment status changes for all students from the University system of record based on the schedule timeline provided to NSC. As of Fall 2024, The Registrar’s Office continues to review NSC information following transmission, particularly for effective dates of completely withdrawn students. The NSC reports enrollments to NSLDS for the University. Cheyney University had previously learned that NSLDS did not receive students' enrollment status changes from NSC in a timely manner due the University HCM2 status and timing of students being reported to NSLDS from COD based on Ed’s approval of the University HCM2 submissions Kutztown: We will shorten our process to 2-3 days to compensate from the (up to) 30 day lag between NSC reporting and NSLDS reporting. We will connect with another PASSHE school (not on the findings report) to ascertain how they keep their submissions timely, and learn best practices. We will renew our cooperative efforts with financial aid to ensure both sides of the equation – NSC and NSLDS – are communicating and that both offices are involved in double checking. Commonwealth: The issues with enrollment reporting were one-time issues related to the integration of the three schools and the implementation of and data migration to a new student information system. Issues have been resolved and Commonwealth University is currently reporting on the prescribed schedule Millersville: The Registrar’s Office will evaluate their procedures and review policies surrounding reporting status changes to NSLDS to ensure the enrollment effective date reported to NSLDS is aligning with the University’s last date of attendance. Primarily, the frequency of submissions to the NSC.

View Audit 348667

Finding 537456 (2024-001)

Significant Deficiency 2024

State System of Higher Education, Commonwealth of Pennsylvania

PA

Student Financial Aid Reporting Significant Deficiency § 200.303

ESU: The University acknowledges this is a repeat finding. In response, updated policies and procedures were implemented in May 2024. The audit sample included students from Fall 2023 and Spring 2024—periods that predated the implementation of the corrective measures. To improve compliance, the Univ...

ESU: The University acknowledges this is a repeat finding. In response, updated policies and procedures were implemented in May 2024. The audit sample included students from Fall 2023 and Spring 2024—periods that predated the implementation of the corrective measures. To improve compliance, the University has introduced enhanced reporting mechanisms to identify when a student is no longer participating in any enrolled courses during a given semester. Once a determination is made that a student has withdrawn, University Registrar staff manually update the student’s status in the National Student Clearinghouse. This process reduces the delay between a student’s actual withdrawal and the status update reported to NSLDS. These steps are intended to ensure timely and accurate reporting moving forward. IUP: IUP will set guidelines that all degree clearing must be done with the 45 day time line so the students are reported within the 60 days limit. Cheyney:Cheyney University of Pennsylvania utilizes the National Student Clearinghouse as a third-party service provider for enrollment reporting and provides all enrollment data to NSC, believing that enrollment would be reported to NSLDS in compliance with federal regulations; unfortunately, the enrollment data from the NSC roster which is provided to National Student Loan Data Systems (NSLDS), is only matched to students who currently have existing enrollment records in NSLDS. Student enrollment information is provided to NSLDS from Common Originations and Disbursements (COD). Cheyney University is a Heightened Cash Monitoring 2 (HCM2) institution, and students' Title IV aid/ disbursements are reported differently than advance pay institutions. The student records from COD are only provided to NSLDS upon approval of disbursement from Ed after the University HCM2 submissions are approved. As of Fall 2024, Cheyney University has continued to directly report and upload enrollment for all Title IV recipients to NSLDS from the monthly NSC enrollment rosters. Kutztown: We will target shortening our status change reporting process to 2-3 days to compensate from the (up to) 30 day lag between NSC reporting and NSLDS reporting. We will connect with another PASSHE school that was on the findings report for the last period - but not this period - to ascertain how they avoided the repeat, and to learn additional best practices. We will renew our cooperative efforts with financial aid to ensure both sides of the equation – NSC and NSLDS – are communicating and that both offices are involved in double checking Commonwealth: The issues with enrollment reporting were one-time issues related to the integration of the three schools and the implementation of and data migration to a new student information system. Issues have been resolved and Commonwealth University is currently reporting on the prescribed schedule. Millersville: The Registrar’s Office will review its reporting procedures to ensure that students’ statuses are timely reported to NSLDS as required by Federal regulations. Primarily, the frequency of submissions to the NSC.

View Audit 348667

Finding 537453 (2024-003)

Significant Deficiency 2024

Saint Peter's University and Affiliates

NJ

Procurement, Suspension & Debarment Subrecipient Monitoring Significant Deficiency

STEM - PODER – Federal Assistance Listing Number 84.031C Recommendation: We recommend the University document and implement policies and procedures that are aligned with Uniform Grant Guidance for suspension and debarment to ensure the University is following requirements. Explanation of disagreemen...

STEM - PODER – Federal Assistance Listing Number 84.031C Recommendation: We recommend the University document and implement policies and procedures that are aligned with Uniform Grant Guidance for suspension and debarment to ensure the University is following requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University is in the process of developing and implementing a formal policy and procedure to verify that a vendor is not debarred or suspended in the System for Award Management (SAM) database. The procedure, which will be in place by the end of FY 2025, will outline roles, responsibilities, and documentation requirements to ensure consistent compliance. Name(s) of the contact person(s) responsible for corrective action: Diane DiStaulo, Director of Accounting Operations, (201) 761-7415 Planned completion date for corrective action plan: by the end of FY2025

View Audit 348651

Finding 537447 (2024-002)

Significant Deficiency 2024

Saint Peter's University and Affiliates

NJ

Questioned Costs Student Financial Aid Significant Deficiency

Student Financial Aid Cluster – Federal Assistance Listing Numbers 84.007, 84.033, 84.063 and 84.268 Recommendation: We recommend the University review its policies and procedures related to outstanding student refund checks to ensure they are being returned to the Department of Education after 240 ...

Student Financial Aid Cluster – Federal Assistance Listing Numbers 84.007, 84.033, 84.063 and 84.268 Recommendation: We recommend the University review its policies and procedures related to outstanding student refund checks to ensure they are being returned to the Department of Education after 240 days. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has developed a policy to identify uncashed Title IV refund checks prior to the 240-day expiration date. The policy includes steps to contact students whose checks did not clear and to return the refunds to the Department within 240 days after the issue date of the check. The procedures will ensure that reviews are completed and returned timely according to applicable regulations. Name(s) of the contact person(s) responsible for corrective action: Lillian Perreira-Talty, Director of Student Accounts (201) 761-6080 Planned completion date for corrective action plan: Completed

View Audit 348651 Questioned Costs: $1

Finding 537443 (2024-001)

Significant Deficiency 2024

Saint Peter's University and Affiliates

NJ

Reporting Student Financial Aid Significant Deficiency

Student Financial Aid Cluster – Federal Assistance Listing Numbers 84.063 and 84.268 Recommendation: We recommend the University evaluate its procedures and review policies in overseeing submissions to the NSLDS completed by the third-party servicer. Additionally, we recommend the University review ...

Student Financial Aid Cluster – Federal Assistance Listing Numbers 84.063 and 84.268 Recommendation: We recommend the University evaluate its procedures and review policies in overseeing submissions to the NSLDS completed by the third-party servicer. Additionally, we recommend the University review its policies and procedures on reporting enrollment information to the NSLDS to ensure that all relevant information is being captured and reported timely in accordance with applicable regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has updated its policies and procedures for NSLDS submissions via their third-party servicer to ensure relavant information is being captured and reported timely in accordance with applicable regulations. Name(s) of the contact person(s) responsible for corrective action: Kamla Singh-Ramoutar, University Registrar, (201) 761-6051 Planned completion date for corrective action plan: Completed

View Audit 348651

Finding 537413 (2024-028)

Significant Deficiency 2024

State of Vermont

VT

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Reference Number: 2024-028 Prior Year Finding: 2023-034 Federal Agency: U.S. Department of Homeland Security State Agency: Department of Public Safety Federal Program: Disaster Grants - Public Assistance (Presidentially Declared Disasters) Assistance Listing Number: 97.036 Award Number and Year: FEM...

Reference Number: 2024-028 Prior Year Finding: 2023-034 Federal Agency: U.S. Department of Homeland Security State Agency: Department of Public Safety Federal Program: Disaster Grants - Public Assistance (Presidentially Declared Disasters) Assistance Listing Number: 97.036 Award Number and Year: FEMA-4474-DR-VT (2020), FEMA-4532-DR-VT (2020), FEMA-4621-DR-VT (2021), FEMA-4695-DR-VT (2023), FEMA-4720-DR-VT (2023) Compliance Requirement: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend the Department complete implementation of its corrective action plan from the prior year. The Department should continue to improve its procedures and internal controls to ensure that all required subawards and subaward modifications are reported accurately and timely to FSRS no later than the end of the month following the month of issuance in accordance with FFATA reporting requirements. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: Public Safety will continue implementation of its corrective action plan from the prior year. A new procedure will be developed for a periodic review of FFATA entries to add a control step ensuring that all FFATA entries are timely and accurate. A training will also be delivered to Public Assistance staff to ensure that the FFATA entry process is understood in both FSRS and SAM.gov. These corrective actions will be completed by April 4th, 2025 Scheduled Completion Date of Corrective Action Plan: April 4, 2025 Contacts for Corrective Action Plan: Richard Hallenbeck, Director of Administration/Finance richard.hallenbeck@vermont.gov

View Audit 348596

Finding 537402 (2024-025)

Significant Deficiency 2024

State of Vermont

VT

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

Reference Number: 2024-025 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services (Agency) Federal Program: Medicaid Cluster Assistance Listing Number: 93.775, 93.777, 93.778 Award Number and Year: 2305VT5MAP (10/1/2022 – 9/30/2023)...

Reference Number: 2024-025 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services (Agency) Federal Program: Medicaid Cluster Assistance Listing Number: 93.775, 93.777, 93.778 Award Number and Year: 2305VT5MAP (10/1/2022 – 9/30/2023) 2405VT5MAP (10/1/2023 – 9/30/2024) Compliance Requirement: Special Tests and Provisions – Utilization Control Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend that the Agency review and enhance procedures and controls for Medicaid utilization control to ensure that cases are closed timely and that documentation of the results of reviews are maintained and communicated. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: The Special investigations Unit (SIU) only refers two types of cases to the Medicaid Fraud Residential Abuse Unit (MFRAU), these cases are: Personal Care Attendant (PCA) and provider fraud and abuse. Prior to 2021 most of those cases were kept in paper format. Since then, the SIU has fully transitioned to electronic files only. All PCA cases referred to MFRAU are assigned to the Duty Auditor (DA) of the Special Investigations Unit (SIU). The DA must send the case referral via a form that MFRAU must return with notification of acceptance or declination to investigate the allegation. If the case is accepted, then it remains under “open referred to MFRAU” status in our database and updates must be provided and documented by the DA during our MFRAU/SIU quarterly meetings until SIU receives a closure memo from MFRAU that documents the completion of their review. Additionally, all provider cases remain open with the auditor who investigated and referred the matter until a closing memo is received by the SIU. All documented follow ups are recorded in the case log. Scheduled Completion Date of Corrective Action Plan: This process has been implemented since 2021 for cases generated from that year forward. SIU Procedure Manual has been updated accordingly as of December 31, 2024. Contacts for Corrective Action Plan: Nadeth Fitzgerald, Director – SIU nadeth.fitzgerald@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 348596

Finding 537401 (2024-024)

Significant Deficiency 2024

State of Vermont

VT

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

Reference Number: 2024-024 Prior Year Finding: 2023-031; 2022-037; 2021-025; 2020-014; 2019-010 Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: Medicaid Cluster Assistance Listing Number: 93.775, 93.777, 93.778 Award Number and Yea...

Reference Number: 2024-024 Prior Year Finding: 2023-031; 2022-037; 2021-025; 2020-014; 2019-010 Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: Medicaid Cluster Assistance Listing Number: 93.775, 93.777, 93.778 Award Number and Year: 2305VT5MAP (10/1/2022 – 9/30/2023) 2405VT5MAP (10/1/2023 – 9/30/2025) Compliance Requirement: Special Tests and Provisions - Provider Health and Safety Standards Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend the Agency fully implement its CAP to ensure that documentation is maintained in accordance with program requirements and that all providers are compliant with required health and safety standards. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: All Letters of Good Standing as well as a Standard Operating Procedure to ensure continuation were implemented in April of 2022. Prior to April the process was manual and via telephone or email with the Tax Department. All Providers who had their tax standing validated prior to April 2022 via phone or email were not solicited to get a written notification from the Tax Commissioner. As of April 2022 all tax standing reviews are validated with a letter from the Vermont Tax department and documented in the Provider Management Module. Verification with the VT Tax Department of a provider’s tax standing has always occurred; However, the good standing verification was documented in the PMM system and the confirmation of the verification from the VT Tax Department was not consistently maintained in the PMM. Although the Agency has implemented its corrective action plan from a prior year audit, cases will still be identified under this CAP until the provider is due for their 5-year revalidation and successfully revalidates with VT Medicaid. Scheduled Completion Date of Corrective Action Plan: Completed Contacts for Corrective Action Plan: Deidra Jarvis, Member and Provider Services Supervisor deidra.Jarvis@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 348596

Finding 537400 (2024-023)

Significant Deficiency 2024

State of Vermont

VT

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Reference Number: 2024-023 Prior Year Finding: 2023-030; 2022-038; 2021-026 Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: Medicaid Cluster Assistance Listing Number: 93.775, 93.777, 93.778 Award Number and Year: 2305VT5MAP (10/1/...

Reference Number: 2024-023 Prior Year Finding: 2023-030; 2022-038; 2021-026 Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: Medicaid Cluster Assistance Listing Number: 93.775, 93.777, 93.778 Award Number and Year: 2305VT5MAP (10/1/2022 – 9/30/2023) 2405VT5MAP (10/1/2023 – 9/30/2024) Compliance Requirement: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend that the Agency complete implementation of its prior year CAP to ensure that all required subawards and subaward modifications are reported timely to FSRS in accordance with FFATA requirements. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: Agency of Human Services Internal Audit Group (AHS-IAG) is a designated centralized reporter of subawards for a Medicaid cluster (ALN 93.775, 93.777, 93.778) that is shared between all AHS departments. To address omissions and timeliness of subawards and subaward modifications reporting to FSRS, IAG conducted additional training tailored to each AHS Department to examine the results of FFATA testing conducted internally and reemphasized the FFATA compliance regulations. This ensured the Internal Audit Group (IAG) is provided with complete, accurate and timely subaward information for reporting in FSRS going forward. The context of the 2024 finding indicates that the departments understood the training materials and complied with the requirements to report. On at least an annual basis, IAG conducts a review of current federal rules and regulations pertaining to FFATA reporting for FSRS to assure the Agency’s procedures are up to-date. Coincidentally, IAG will also select a random sample of subawards and subawards modifications that meet the required threshold for FFATA reporting to ensure they are reported in FSRS system on a complete, accurate and timely basis. Scheduled Completion Date of Corrective Action Plan: March 31, 2025: Annual review of FFATA rules and regulations including subawards review. Contacts for Corrective Action Plan: Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 348596

Finding 537399 (2024-022)

Significant Deficiency 2024

State of Vermont

VT

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

Reference Number: 2024-022 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services (Agency) Federal Program: Medicaid Cluster Assistance Listing Number: 93.775, 93.777, 93.778 Award Number and Year: 2305VT5MAP (10/1/2022 – 9/30/2023)...

Reference Number: 2024-022 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services (Agency) Federal Program: Medicaid Cluster Assistance Listing Number: 93.775, 93.777, 93.778 Award Number and Year: 2305VT5MAP (10/1/2022 – 9/30/2023) Compliance Requirement: Eligibility Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend that the Agency review and enhance procedures and controls for Medicaid eligibility renewals to ensure that benefits for eligible participants are not discontinued. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: The error was caused by a caseworker not following the steps within the job aid when processing eligibility for a late renewal form. Coverage closed on 9/30/24 for non-review. The renewal form was received on 10/17/2023 yet, coverage was reinstated for 11/1/2024 instead of 10/1/24. The gap in coverage was corrected on 9/16/2024 and coverage was backdated to 10/1/24. The eligibility unit notified the worker’s supervisor who reviewed the case error with the caseworker. In addition, eligibility staff receive refresher training yearly to review our business processes. The Eligibility Unit will continue to monitor cases through our internal QA process unit and through our off-year reviews conducted by the QC unit. Scheduled Completion Date of Corrective Action Plan: Coverage was corrected on September 16, 2024. Contacts for Corrective Action Plan: Nicole McAllister, Healthcare Assistant Administrator II nicole.mcallister@vermont.gov Sarah York, Healthcare Assistant Administrator I sarah.york@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 348596

Finding 537387 (2024-021)

Significant Deficiency 2024

State of Vermont

VT

Eligibility Student Financial Aid Subrecipient Monitoring § 200.303

Reference Number: 2024-021 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: CCDF Cluster Assistance Listing Number: 93.575, 93.596 Award Number and Year: 2301VTCCDD (10/1/2022 – 9/30/2025) 2401VTCCDD (10/1/202...

Reference Number: 2024-021 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: CCDF Cluster Assistance Listing Number: 93.575, 93.596 Award Number and Year: 2301VTCCDD (10/1/2022 – 9/30/2025) 2401VTCCDD (10/1/2023 – 9/30/2026) Compliance Requirement: Eligibility Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend that the Agency review and enhance procedures and controls to ensure that it verifies U.S. citizenship for all participants and confirm that only eligible participants receive benefits under the program. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: This finding has been corrected as of January 2024 dating back to October 2023. The State is no longer pooling funding sources which means that we can identify cases by their true funding source. This means that only true CCDF cases will be audited going forward and family service cases (protective service) no longer follow CCDF rules including citizenship and identity. Scheduled Completion Date of Corrective Action Plan: December 31, 2024 Contacts for Corrective Action Plan: Karolyn Long, Operations Director karolyn.long@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 348596

Finding 537379 (2024-019)

Significant Deficiency 2024

State of Vermont

VT

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

Reference Number: 2024-019 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: Temporary Assistance for Needy Families Assistance Listing Number: 93.558 Award Number and Year: 2301VTTANF (10/1/2022 – 9/30/2023) 2...

Reference Number: 2024-019 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: Temporary Assistance for Needy Families Assistance Listing Number: 93.558 Award Number and Year: 2301VTTANF (10/1/2022 – 9/30/2023) 2401VTTANF (10/1/2023 – 9/30/2024) Compliance Requirement: Reporting – ACF-199 Special Tests and Provisions – Penalty for Failure to Comply with Work Verification Plan Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend that the Agency review and enhance procedures and controls to ensure that it maintains adequate documentation, verification, and internal control procedures to ensure the accuracy of work participation rates reported in the ACF-199 reports. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: For the data system programming error finding, the Department removed the hard coding in the programming that limited participant hours to 40. This was completed as soon as the error was identified and our regional team approved the proposed corrective action. For the individual instances where the reported work participation rates reported on the ACF-199 report did not agree with supporting documentation and that supporting documentation contained errors or was incomplete, the Department will do the following: • Highlight each of the individual types of errors in our weekly newsletter that goes out to all staff and describe the correct action that should have been taken in documentation. • Have members of Reach Up Central Office (RUCO) team attend the Senior Benefits Program Specialist Sr. BPS) meeting to review the individual types of errors and describe the correct action that should have been taken. Sr. BPS are responsible for the direct training of district Benefits Program Specialists (BPS) that process eligibility. Following their meeting they will return to their district offices and provide an overview to the district eligibility staff. • RUCO will hold a virtual office hours session for eligibility staff to attend focused on the individual types of errors and the correct action that should have been taken. Scheduled Completion Date of Corrective Action Plan: • Data system programming error was corrected in October 2024. • Newsletter highlights will be shared with staff by January 31, 2025. • Sr BPS meeting will be attended by February 28, 2025. • Virtual office hours will be held by March 31, 2025. Contacts for Corrective Action Plan: Chris Dorer, Reach Up Assistant Administrator christine.dorer@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 348596

Finding 537373 (2024-016)

Significant Deficiency 2024

State of Vermont

VT

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Reference Number: 2024-016 Prior Year Finding: 2023-018; 2022-029; 2021-018 Federal Agency: U.S. Department of Education State Agency: Agency of Education Federal Program: COVID-19 – Governor’s Emergency Education Relief Fund COVID-19 – Elementary and Secondary School Emergency Relief Fund (ESSER) C...

Reference Number: 2024-016 Prior Year Finding: 2023-018; 2022-029; 2021-018 Federal Agency: U.S. Department of Education State Agency: Agency of Education Federal Program: COVID-19 – Governor’s Emergency Education Relief Fund COVID-19 – Elementary and Secondary School Emergency Relief Fund (ESSER) COVID-19 - Coronavirus Response and Relief Supplemental Appropriations Act, 2021 – Emergency Assistance to Non-Public Schools (CRRSA EANS) COVID-19 – American Rescue Plan – Elementary and Secondary School Emergency Relief (ARP ESSER) COVID-19 - American Rescue Plan – Elementary and Secondary School Emergency Relief –Homeless Children and Youth Assistance Listing Number: 84.425C, 84.425D, 84.425R, 84.425U, 84.425W Award Number and Year: S425C210009 (1/8/2021 – 9/30/2022) S425D210011 (1/5/2021 – 9/30/2022) S425R210033 (2/23/2021 – 9/30/2022) S425U210011 (3/24/2021 – 9/30/2023) S425W210047 (4/23/2021 – 9/30/2023) Compliance Requirement: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend the Agency complete implementation of its corrective action plan from the prior audit. It should review and enhance internal controls and procedures to ensure that all required subawards and subaward amendments are reported timely and accurately to FSRS no later than the end of the month following the month of issuance. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: The Agency implemented a reconciliation process in March of 2023 that allows us to ensure our grant ledgers agree with what is entered into FFATA. The Agency will increase the number of reconciliations per year to quarterly. The Agency continues to work toward our preferred solution to address the accuracy and timeliness of our entries into the FFATA system by creating an upload file of the data from our grants management system. Scheduled Completion Date of Corrective Action Plan: July 1, 2025 Position Responsible for Implementation of Corrective Action Sean Cousino, Interim CFO sean.couisno@vermont.gov

View Audit 348596

Finding 537368 (2024-013)

Significant Deficiency 2024

State of Vermont

VT

Questioned Costs Cash Management Matching / Level of Effort / Earmarking § 200.303 § 200.343

Reference Number: 2024-013 Prior Year Finding: No Federal Agency: U.S. Department of Transportation State Agency: Agency of Transportation Federal Program: Federal Transit Cluster Assistance Listing Number: 20.500, 20.507, 20.526 Award Number and Year: VT-04-0021-01 (3/14/2013 – 6/30/2016) Complianc...

Reference Number: 2024-013 Prior Year Finding: No Federal Agency: U.S. Department of Transportation State Agency: Agency of Transportation Federal Program: Federal Transit Cluster Assistance Listing Number: 20.500, 20.507, 20.526 Award Number and Year: VT-04-0021-01 (3/14/2013 – 6/30/2016) Compliance Requirement: Cash Management, Period of Performance Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend that VTrans review and enhance grant closeout procedures and internal controls to ensure that grants are closed out timely. We further recommend that VTrans review and enhance procedures and internal controls over cash management to ensure that cash draws are performed only against grants for which the period of performance has not expired. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: The following factors contributed to the noncompliance: VTrans experienced staff turnover, at which point close out processes were missed in 2016. This resulted in a grant remaining with an open status in the TrAMS system well beyond the period of performance. During the 2024 review by program staff, a drawdown was inadvertently processed for this grant with the expired period of performance. At the time, VTrans lacked a formal, documented grant closeout process for FTA grants in the TrAMS system. Additionally, there was a breakdown in communication between the Accounts Receivable (AR) team and the Public Transit Program team regarding period of performance eligibility prior to processing the draw. VTrans has taken the following steps to strengthen internal controls and prevent recurrence of this issue: 1. Formalized Closeout Procedures: VTrans has implemented a structured grant closeout process for the AOT Public Transit Program that clearly defines responsibilities, timelines, and verification steps to ensure all federal awards are closed timely and in compliance with FTA requirements. This process assigns specific tasks to designated staff members and ensures that no drawdowns occur after the period of performance has ended. 2. Annual Period of Performance Review: VTrans has established and documented an annual review process for FTA grant periods of performance. This review has been formally integrated into the Agency’s Public Transit cash management procedures, ensuring that grant end dates are proactively monitored, and necessary extensions or closeouts are addressed before expiration. 3. Enhanced Communication and Documentation: VTrans has updated the internal Excel file used to facilitate communication between the Public Transit Program team and the AR team. The file now includes a designated column for period of performance, ensuring that all drawdowns are reviewed for eligibility before processing. This is also addressed in an update to the Agency’s Public Transit cash management procedure memo. VTrans will coordinate with FTA to determine the appropriate resolution for these funds. Any necessary repayment or adjustments will be completed in accordance with FTA guidance. At this time, FTA has not requested the funds be returned. Scheduled Completion Date of Correction Action Plan: All corrective actions will be implemented as of March 1, 2025. Contacts for Corrective Action Plan: Ross MacDonald, Public Transit Director ross.macdonald@vermont.gov

View Audit 348596 Questioned Costs: $1

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