Corrective Action Plans

Finding 537367 (2024-012)

Significant Deficiency 2024

State of Vermont

VT

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

Reference Number: 2024-012 Prior Year Finding: No Federal Agency: U.S. Department of Transportation State Agency: Agency of Transportation Federal Program: Highway Planning and Construction Assistance Listing Number: 20.205 Award Number and Year: FFY2023 – FFY2024 Compliance Requirement: Special Tes...

Reference Number: 2024-012 Prior Year Finding: No Federal Agency: U.S. Department of Transportation State Agency: Agency of Transportation Federal Program: Highway Planning and Construction Assistance Listing Number: 20.205 Award Number and Year: FFY2023 – FFY2024 Compliance Requirement: Special Tests and Provisions – Wage Rate Requirements Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Recommendation: VTrans should review and enhance procedures and internal controls to ensure that it obtains weekly certified payrolls from all contractors. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: The Daily Work Reports (DWRs) submitted by the contractor concluded the outstanding punchlist items in June 2023, and in September 2023 a subcontractor submitted a DWR to AOT. The project went through Completion and Acceptance (C&A) in December 2023. The C&A process required confirmation that payrolls were received but did not include a final complete-verification step before project closeout. As a result, missing payroll certifications went unnoticed. Additionally, the Civil Rights team was unaware of the subcontractor’s work report since their review is triggered by certified payroll submissions, not DWRs. VTrans is updating the C&A checklist to require final confirmation that all certified payrolls have been received before project closeout, with coordination from the Civil Rights team if any are missing. This checklist is to be verified by both the Resident Engineer and the Regional Engineer. To further strengthen compliance, VTrans Construction will focus on education, and revise pre-construction meeting templates to emphasize that federal wage reporting requirements apply to all work on a project. Additionally, VTrans Civil Rights will reinforce these requirements in annual contractor training to ensure Prime and Subcontractors fully understand their payroll reporting responsibilities. VTrans will also remain cognizant of projects and DWRs submitted by new subcontractors and actively work to educate contractors at this point to prevent future payroll omissions. Scheduled Completion Date of Corrective Action Plan: All corrective actions will be implemented as of April 1, 2025. Contacts for Corrective Action Plan: Douglas Bonneau, VTrans Construction Engineer douglas.bonneau@vermont.gov

View Audit 348596

Finding 537362 (2024-010)

Significant Deficiency 2024

State of Vermont

VT

Questioned Costs Allowable Costs / Cost Principles Period of Performance § 200.303 § 200.308 § 200.309 § 200.403

Reference Number: 2024-010 Prior Year Finding: 2023-008; 2022-017 Federal Agency: U.S. Department of Labor State Agency: Vermont Department of Labor Federal Program: Unemployment Insurance Assistance Listing Number: 17.225 Award Number and Period: Admin 24A55UI000063 (10/1/2023-12/31/2026), DUA 23A6...

Reference Number: 2024-010 Prior Year Finding: 2023-008; 2022-017 Federal Agency: U.S. Department of Labor State Agency: Vermont Department of Labor Federal Program: Unemployment Insurance Assistance Listing Number: 17.225 Award Number and Period: Admin 24A55UI000063 (10/1/2023-12/31/2026), DUA 23A60UD000013 (7/14/2023 - 7/14/2026) Compliance Requirement: Period of Performance Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Recommendation: We recommend the Department review and enhance its procedures and controls to ensure that prior to charging costs to the program, they are incurred within an award’s allowable period of performance. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: The Department will review its procedures and internal controls and update as necessary to ensure that expenditures are incurred within the allowable period of performance for respective awards. It should be noted that during the period of performance for which this audit was conducted there were a large number of personnel changes and shifts. The position that was responsible for the majority of these duties retired in January 2024. We proactively hired for her replacement a year before she retired. Over the course of the year our replacement took over more and more duties. In the process of this replacement, we have completed a tremendous amount of evaluation of our assigned duties, processes, workflow, training, and documentation. Not only in this role, but we are also undergoing a division and business unit wide analysis of our internal controls and workflow. It should also be noted that the UI admin funds are considered ‘formula funds’ from the US DOL. We are expected to run this program year-round with no gaps in service or performance. The funding that we receive from US DOL is based on an antiquated formula that breaks down the amount that is budgeted by Congress between 52 state and territories. We generally do not receive enough funding for the entire year. Also, with the recent trend of Congress to utilize the tool of the Continuing Resolution our funding is often ambiguous until most of the program year is over. We have at times seen our funding cut once a budget had been passed by Congress even though there was only about 3 months left in the program year. We are still expected to run this program and ‘find other sources of funding’. This does make the adherence to the period of performance challenging. However, as we evaluate our internal controls and procedures over the coming months, we will make note of every opportunity to strengthen this function to ensure that all charges applied to program funds are relevant, within the period of performance of the award, and are correctly reviewed and signed. Scheduled Completion Date of Corrective Action Plan: April 1, 2025 Contacts for Corrective Action Plan: Chad Wawrzyniak, Financial Director II chad.wawrzyniak@vermont.gov

View Audit 348596 Questioned Costs: $1

Finding 537359 (2024-007)

Significant Deficiency 2024

State of Vermont

VT

Allowable Costs / Cost Principles Subrecipient Monitoring Period of Performance § 200.303 § 200.308 § 200.309 § 200.403

Reference Number: 2024-007 Prior Year Finding: No Federal Agency: U.S. Department of Defense State Agency: Vermont State Military Department Federal Program: National Guard Military Operations and Maintenance (O&M) Projects Assistance Listing Number: 12.401 Award Number and Period: W912LN2421001 (10...

Reference Number: 2024-007 Prior Year Finding: No Federal Agency: U.S. Department of Defense State Agency: Vermont State Military Department Federal Program: National Guard Military Operations and Maintenance (O&M) Projects Assistance Listing Number: 12.401 Award Number and Period: W912LN2421001 (10/1/2023 – 9/20/2024) Compliance Requirement: Period of Performance Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Recommendation: The Department should review and enhance its procedures and internal controls to ensure that it charges expenditures to the program that are incurred within an award’s allowable period of performance. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: The Department agrees with this finding and will implement the following: • Update Accounts Payable Standard Operating Procedures to include instructions for determining the appropriate Federal Fiscal year for coding and paying vendor invoices. • Distribute updated procedures and train staff to ensure understanding of Period of Performance reporting requirements. • Update Vision query to include the Invoice Date field. Current reports used for preparing the SF-270 only include the Vision transaction date, therefore the preparer and reviewer are not able to determine the performance dates of individual transactions based on this report alone and rely on proper coding of the Class field during voucher entry. Adding the Invoice Date to the report will improve the department’s ability to QC the SF-270 for period of performance discrepancies prior to submission for reimbursement. • The Financial Director will perform quarterly audits of this Vision report to identify any improper reporting. Any errors identified will be corrected with a journal voucher and subsequently corrected on the next SF-270. Scheduled Completion Date of Corrective Action Plan: April 15, 2025 Contacts for Corrective Action Plan: Kim Fedele, Financial Director kimberly.fedele@vermont.gov

View Audit 348596

Finding 537342 (2024-026)

Significant Deficiency 2024

State of Vermont

VT

Questioned Costs Cash Management Reporting § 200.303 § 200.514

Reference Number: 2024-026 Prior Year Finding: 2023-023 Federal Agency: U.S. Department of Agriculture U.S. Department of Health and Human Services State Agency: Department of Finance and Management Federal Program: SNAP Cluster Temporary Assistance for Needy Families CCDF Cluster Assistance Listing...

Reference Number: 2024-026 Prior Year Finding: 2023-023 Federal Agency: U.S. Department of Agriculture U.S. Department of Health and Human Services State Agency: Department of Finance and Management Federal Program: SNAP Cluster Temporary Assistance for Needy Families CCDF Cluster Assistance Listing Number: 10.551, 10.561, 93.558, 93.575, 93.596 Award Number and Year: 4VT400406 (10/1/2022 – 9/30/2023) 4VT402513 (10/1/2023 – 9/30/2024) 2301VTTANF (10/1/2022 – 9/30/2023) 2401VTTANF (10/1/2023 – 9/30/2024) 2301VTCCDD (10/1/2022 – 9/30/2025) 2401VTCCDD (10/1/2023 – 9/30/2026) Compliance Requirement: Cash Management Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend that Finance review and enhance its internal controls and procedures over the CMIA Annual Report to ensure that it verifies the correct interest rate is applied and that State and Federal interest liabilities are properly calculated in accordance with 2 CFR section 200.514. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: The current available rate at the time of calculation, review, entry, and moving to draft were all accurate to what U.S. Treasury had available at the time. The rate was updated on December 3rd, after our submissions had already been locked via the draft process in the CMIAS portal done on November, 26th. The process was not fully submitted due to issues with the CMIAS portal not allowing us to submit which has been extensively documented via multiple email chains with U.S. Treasury CMIA over the past two years. Finance and Management will take a screenshot of the CMIA interest rate page dated on the review date of the CMIA Annual Report submissions from departments to ensure that we maintain the historical rate posted to the U.S. Treasury CMIA page at the time of review. Additionally, AHS will take their own screenshots of the CMIA Interest Rate page from U.S. Treasury website on the date of their Annual Report Summary submissions for record and to show that the rate from this time was checked and applied to the current year’s program. If during the review, there is any discrepancy between the review screen of the rates and the calculations screenshot of the rates; the calculation spreadsheets will be kicked back to AHS to be updated. Scheduled Completion Date of Corrective Action Plan: November 30, 2025 Contacts for Corrective Action Plan: Jordan Black-Deegan, Statewide Grants Administrator jordan.black-deegan@vermont.gov Sarena Boland, Financial Manager III sarena.boland@vermont.gov

View Audit 348596 Questioned Costs: $1

Finding 537340 (2024-005)

Significant Deficiency 2024

State of Vermont

VT

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

Reference Number: 2024-005 Prior Year Finding: No Federal Agency: U.S. Department of Agriculture State Agency: Agency of Human Services Federal Program: SNAP Cluster Assistance Listing Number: 10.551, 10.561 Award Number and Year: 4VT400406 (10/1/2022 – 9/30/2023) 4VT402513 (10/1/2023 – 9/30/2024) C...

Reference Number: 2024-005 Prior Year Finding: No Federal Agency: U.S. Department of Agriculture State Agency: Agency of Human Services Federal Program: SNAP Cluster Assistance Listing Number: 10.551, 10.561 Award Number and Year: 4VT400406 (10/1/2022 – 9/30/2023) 4VT402513 (10/1/2023 – 9/30/2024) Compliance Requirement: Special Tests and Provisions – EBT Card Security Type of Finding: Significant Deficiency in Internal Control Over Compliance Recommendation: We recommend that the Agency review and enhance internal controls to ensure that it maintains documentation of the daily/weekly reconciliation of destroyed EBT cards. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: Cards were automatically printing at 1:00 AM which presented many opportunities for errors. The printers can only hold 100 cards in their hoppers and only print on one printer at a time. If there were more than 100 cards to be printed the printer(s) would error out and subsequently drop cards from the print file and/or print duplicates when the errors were corrected once someone was in the office. We have now updated the print jobs to print at 9:00 AM when a trained EBT staff member is there to monitor the printing. Additionally, we have a system in place to rotate printing on the 3 printers monthly to spread the wear and tear evenly. Increases to opened card inventory, decreases in the opened card inventory due to printing, and decreases in the opened card inventory due to shredded cards are included on the daily “Card Count” Excel that is then converted to a PDF for signatures through DocuSign. This daily “Card Count” Excel is updated and verified by EBT personnel to ensure that the remaining opened card inventory is reflective of what was added to the opened card inventory, what was printed, and what was shredded. Printed card counts on this “Card Count” Excel and PDF will be reflective of the daily “EBT Printing Reports” that are auto generated and e-mailed to the EBT staff. When there are excessive shredded cards (more than 5) EBT personnel will create a detailed e-mail to verify the day’s events with IT personnel. Once verified by the IT personnel, the e-mail will be a part of the DocuSign packet for the “Card Count” PDF to explain and backup the events from that particular day. The “Card Count” Excel and PDF is produced by the EBT staff person in the office to physically oversee that day’s printing. EBT staff rotate days that they are in the office; meaning that the EBT Financial Manager and the Financial Director of Operations verify that the rolling count is correct each week on Thursday’s and Wednesday’s (respectively) as they are in the office to process the printed cards. Scheduled Completion Date of Corrective Action Plan: EBT personnel have implemented the above e-mail attachment to the “Card Count” PDF solution as of November 2024. Contacts for Corrective Action Plan: Katherine Lettieri, Financial Manager III katherine.lettieri@vermont.gov Kristina Roy, Admin Services Coordinator I kristina.roy@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 348596

Finding 537307 (2024-002)

Significant Deficiency 2024

Municipality of Moca

PR

Subrecipient Monitoring Reporting Significant Deficiency § 200.328

Finding 2024-002: Compliance requirement: Reporting-Coronavirus State and Local Fiscal Recovery Reportable Condition: See Condition 2024-002 Recommendation ...

Finding 2024-002: Compliance requirement: Reporting-Coronavirus State and Local Fiscal Recovery Reportable Condition: See Condition 2024-002 Recommendation The Municipality should maintain the schedule of the due dates or the reuired rports of each federal program to comply with the required submissions to the federal awarding agencies. Also, they had to submi the quaterly report to comply with the requiremnts. Action Taken Due to the shift from annual to quaterly reporting, the Municipality initially missed a quaterly report deadline because of unfamiliarity with the new schedule. however, since then , we have consistently met all the subsequent quaterly deadlines. we will continue to carefully monitor and verifiy all reporting deadlines to guarantee accurate and timely submissions moving foward.

View Audit 348562

Finding 537266 (2024-002)

Significant Deficiency 2024

Phoenix Indian Center

AZ

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.510

Corrective Action Plan: Several steps have been taken to address the need for timely and accurate reporting. The steps taken and listed below will allow management to properly administer grants and file audit and data collection timely in the future. Turnover of finance staff occurred. Management ac...

Corrective Action Plan: Several steps have been taken to address the need for timely and accurate reporting. The steps taken and listed below will allow management to properly administer grants and file audit and data collection timely in the future. Turnover of finance staff occurred. Management acquired the services of an outside firm to address the deficiencies in the records and to correct and establish a system in order to prevent further occurrences of late reconciliations and untimely reporting. Management has restructuring the finance department with two positions, hiring a Director of Finance and Grants & Contracts Analyst. Additional steps implemented and processes improved in order to establish a system of recording and reporting all financial events: • Payroll entry is streamlined including contemporaneous entry. • Credit cards – Reporting and recording is established in a file so that purchases are logged at the initialization of each purchase. • Reconciliation of all balance sheet accounts are maintained on a current month basis. • A checklist is established for monthly steps. This checklist is maintained by Finance and forwarded to the CEO along with the monthly financial reports. • A thorough review of separation of duties for internal controls was conducted. Implementation is an ongoing process as is analyzing improvements. Persons Responsible: Jolyana Begay-Kroupa, CEO Katherine Gray, Finance Director Estimated Completion Date: June 30, 2025

View Audit 348497

Finding 537263 (2024-003)

Significant Deficiency 2024

Project Quest

OR

Reporting Significant Deficiency

Finding # 2024-003 Type: Significant deficiency over reporting A.L. Number: 21.027 Department of U.S. Treasury Significant Deficiency Reports submitted to funding agencies did not have documented review and approval. Corrective Action: The Organization agrees with the auditor’s recommendation. A...

Finding # 2024-003 Type: Significant deficiency over reporting A.L. Number: 21.027 Department of U.S. Treasury Significant Deficiency Reports submitted to funding agencies did not have documented review and approval. Corrective Action: The Organization agrees with the auditor’s recommendation. At the time of this audit’s publishing, the Organization has implemented additional procedures and controls to document review and approval of reports. Anticipated Completion Date March 2025

View Audit 348495

Finding 537253 (2024-002)

Significant Deficiency 2024

Youth Shelters and Family Services, Inc.

NM

Reporting Subrecipient Monitoring Significant Deficiency § 200.510

Views Of Responsible Officials and Corrective Action Plan Response: Youth Shelters and Family Services, Inc. (YSFS) acknowledges the finding and agrees that improvements are needed in preparing the Schedule of Expenditures of Federal Awards (SEFA). YSFS is committed to ensuring compliance with 2 C...

Views Of Responsible Officials and Corrective Action Plan Response: Youth Shelters and Family Services, Inc. (YSFS) acknowledges the finding and agrees that improvements are needed in preparing the Schedule of Expenditures of Federal Awards (SEFA). YSFS is committed to ensuring compliance with 2 CFR 200.510(b) and will take the necessary steps to enhance the accuracy and timeliness of SEFA preparation. Corrective Action Plan: To address the identified deficiencies, YSFS will develop processes to aid in the implementation of the following corrective actions: 1. Establish a Formal SEFA Preparation Process: • Develop and implement a standardized SEFA preparation procedure, including all required elements (a federal portion of expenditures, grant name, grantor name, Assistance Listing number, and pass-through entity information). • Assign clear responsibilities for SEFA preparation and review to designated finance personnel. • SEFA will be prepared quarterly, rather than waiting until year-end, to allow for ongoing review and corrections. 2. Improve Internal Controls Over SEFA Preparation: • Implement a reconciliation process to compare SEFA expenditures with the federal revenues and expenditures. • Review and update QuickBooks job categories regularly to ensure proper coding of federal expenditures. • Establish a dual-review process where a second finance team member or external consultant reviews SEFA for accuracy before submission. 3. Training and Capacity Building: • Provide training to finance staff on Uniform Guidance requirements for SEFA preparation. • Ensure staff are familiar with federal grant compliance requirements and reporting obligations. 4. Enhance Monitoring and Accountability: • Set internal deadlines for SEFA preparation to prevent delays. • Conduct periodic internal reviews of federal grant expenditures to ensure compliance and accuracy. • Management oversight of SEFA preparation is required to ensure completeness and correctness. Finding resolved timeline: YSFS aims to develop a process to implement these corrective actions and have an accurate, timely SEFA process by June 30, 2025, to ensure compliance with federal regulations in the upcoming fiscal year. Designation of employee position responsible for meeting this deadline: Heather Hoffman, Julie Weigand, and an external consultant will oversee and ensure this corrective action plan's development and successful implementation.

View Audit 348481

Finding 537244 (2024-003)

Significant Deficiency 2024

Rider University

NJ

Questioned Costs Student Financial Aid Eligibility

Federal Direct Student Loans – Assistance Listing No. 84.268 Recommendation: We recommend the University evaluate its procedures around packaging and awarding students to ensure loan eligibility is reassessed prior to disbursement. Explanation of disagreement with audit finding: There is no disagr...

Federal Direct Student Loans – Assistance Listing No. 84.268 Recommendation: We recommend the University evaluate its procedures around packaging and awarding students to ensure loan eligibility is reassessed prior to disbursement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has strengthened its procedures to ensure student loan eligibility is reconciled after awarding. The Direct Loan project manager will conduct additional reviews to verify continued eligibility. Name(s) of the contact person(s) responsible for corrective action: Fatima Sulaman Planned completion date for corrective action plan: 3/17/25

View Audit 348448 Questioned Costs: $1

Finding 537243 (2024-002)

Significant Deficiency 2024

Rider University

NJ

Questioned Costs Student Financial Aid Significant Deficiency

Federal Pell Grant Program – Assistance Listing No. 84.063 Recommendation: We recommend that a review is implemented to ensure calculations of Pell awards are using the correct EFC. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in respo...

Federal Pell Grant Program – Assistance Listing No. 84.063 Recommendation: We recommend that a review is implemented to ensure calculations of Pell awards are using the correct EFC. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has implemented a review process to ensure Pell Grant awards are calculated using the correct EFC/SAI. Financial Aid staff will conduct periodic quality control checks to verify that EFC/SAI values are accurately applied in award determinations. Name(s) of the contact person(s) responsible for corrective action: Fatima Sulaman Planned completion date for corrective action plan: 3/17/25

View Audit 348448 Questioned Costs: $1

Finding 537241 (2024-001)

Significant Deficiency 2024

Rider University

NJ

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

Federal Pell Grant Program & Federal Supplemental Education Opportunity Grants – Assistance Listing No. 84.063 & 84.007 Recommendation: We recommend the University implement policies to review all student award packages at the start of the academic year to ensure no over awards exist. In addition, ...

Federal Pell Grant Program & Federal Supplemental Education Opportunity Grants – Assistance Listing No. 84.063 & 84.007 Recommendation: We recommend the University implement policies to review all student award packages at the start of the academic year to ensure no over awards exist. In addition, we recommend the University implement procedures for adjusting aid when an outside scholarship is received by the student. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has implemented enhanced procedures to review all student award packages at the start of the academic year to ensure compliacne with federal overaward regulations. Additionally, the new staff member that is responsible for adding outside scholarships to student accounts has received training to ensure they review for potential over awards. Name(s) of the contact person(s) responsible for correcitve action: Marivic Delacruz and Renato Aguilar Planned completion date for corrective action plan: 3/17/25

View Audit 348448 Questioned Costs: $1

Finding 535541 (2024-105)

Significant Deficiency 2024

State of Texas C/o Comptroller of Public Accounts

TX

Equipment & Real Property Management Significant Deficiency § 200.313

Corrective Action Plan: UTMB will conduct a review of asset property records to ensure the serial numbers and locations are correct. UTMB Finance will coordinate with UTMB Supply Chain to evaluate and strengthen controls related to assets in Surplus warehouse. Implementation Date: November 1, 20...

Corrective Action Plan: UTMB will conduct a review of asset property records to ensure the serial numbers and locations are correct. UTMB Finance will coordinate with UTMB Supply Chain to evaluate and strengthen controls related to assets in Surplus warehouse. Implementation Date: November 1, 2025 Responsible Person: Mike Linton, Sr. Finance Manager

View Audit 348386

Finding 531534 (2024-103)

Significant Deficiency 2024

State of Texas C/o Comptroller of Public Accounts

TX

Equipment & Real Property Management Significant Deficiency § 200.313

Corrective Action Plan: UT Health-San Antonio’s Property Control group will continue to stress the importance of updating equipment locations in a timely manner. The University’s Property Control practices will be enhanced to emphasized compliance with our property policies. The Property Control ...

Corrective Action Plan: UT Health-San Antonio’s Property Control group will continue to stress the importance of updating equipment locations in a timely manner. The University’s Property Control practices will be enhanced to emphasized compliance with our property policies. The Property Control Office will continue to perform more rigorous spot audit reviews subsequent to the annual inventory process for respective departments with federally funded assets. Implementation Date: February 2025 Responsible Person: Yvette Martinez, Senior Director of Financial Affairs

View Audit 348386

Finding 530406 (2024-101)

Significant Deficiency 2024

State of Texas C/o Comptroller of Public Accounts

TX

Equipment & Real Property Management Significant Deficiency § 200.313

Corrective Action Plan: TEES Property Management will continue working with departments to increase their awareness regarding the updating of location information in a timely manner. Departments will also be reminded regularly to notify property management of missing and/or stolen property when d...

Corrective Action Plan: TEES Property Management will continue working with departments to increase their awareness regarding the updating of location information in a timely manner. Departments will also be reminded regularly to notify property management of missing and/or stolen property when discovered and to submit the appropriate forms. Property Management will increase communication to departments regarding the replacement of asset tags that have been damaged and/or are missing. A listserv has been established by TEES to effectively and efficiently communicate this information to the departments. Implementation Date: February 2025 Responsible Person: Jennifer Caddel, Inventory & Property Control Coordinator

View Audit 348386

Finding 530389 (2024-020)

Significant Deficiency 2024

State of Texas C/o Comptroller of Public Accounts

TX

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

Corrective action plan: TxDOT AVN will implement procedures to ensure FFATA reports are reviewed and approved by a separate individual and submitted in a timely manner. Implementation dates: The procedure has been partially implemented, including the addition of the screen shots. A full implementa...

Corrective action plan: TxDOT AVN will implement procedures to ensure FFATA reports are reviewed and approved by a separate individual and submitted in a timely manner. Implementation dates: The procedure has been partially implemented, including the addition of the screen shots. A full implementation will be completed by March 1, 2025. Responsible persons: Michelle Burcham, AVN Grant & Admin Section Director, Allison Martin, Grant Manager Lead, Cassandra Moore, Grant Manager

View Audit 348386

Finding 530379 (2024-017)

Significant Deficiency 2024

State of Texas C/o Comptroller of Public Accounts

TX

Internal Control / Segregation of Duties Special Tests & Provisions Subrecipient Monitoring § 200.303

Corrective action plan: CMS is in the process of training the Manager of Physical Inspection to review and assign properties for timely inspections to ensure multiple staff members have oversight of the process. In addition, CMS is utilizing a new process using Excel to ensure all HOME-rental prop...

Corrective action plan: CMS is in the process of training the Manager of Physical Inspection to review and assign properties for timely inspections to ensure multiple staff members have oversight of the process. In addition, CMS is utilizing a new process using Excel to ensure all HOME-rental properties are inspected within required federal timeframes and this process is completed by two staff members independently. Implementation dates: On February 6, 2025, the new process of reconciling travel using Excel tools by independent staff was implemented to ensure no HOME-rental properties are inspected late. Responsible persons: Wendy Quackenbush, Director of Multifamily Compliance, Manual Pena, Manager of Physical Inspections and Carolyn Metzger, Team Leader.

View Audit 348386

Finding 530372 (2024-015)

Significant Deficiency 2024

State of Texas C/o Comptroller of Public Accounts

TX

Special Tests & Provisions Allowable Costs / Cost Principles Reporting § 200.303

Corrective action plan: Based on the recommendation above, HHSC Medicaid & CHIP Services (MCS) Financial Reporting and Audit Coordination (FRAC) has incorporated the suggested enhanced controls around the review of MLR report submissions to ensure they are complete and accurate. In order to enhan...

Corrective action plan: Based on the recommendation above, HHSC Medicaid & CHIP Services (MCS) Financial Reporting and Audit Coordination (FRAC) has incorporated the suggested enhanced controls around the review of MLR report submissions to ensure they are complete and accurate. In order to enhance existing controls, MCS FRAC has included a section for MLR reviewers to ensure Methodology(ies) for allocation of expenditures tab questions are complete. Likewise, specific instructions have been added to the review document to ensure the recommendations are met. These enhanced controls will be included in Fiscal Year (FY) 2025 and ongoing review of MLR report submissions. Implementation dates: November 2025 Responsible persons: Jason Mendl, Deputy Associate Commissioner, FRAC

View Audit 348386

Finding 530367 (2024-014)

Significant Deficiency 2024

State of Texas C/o Comptroller of Public Accounts

TX

Special Tests & Provisions Subrecipient Monitoring Eligibility § 200.303

Corrective action plan: HHSC's OIG has taken action to ensure timely reviews of the Centers for Medicare/Medicaid Services (CMS) Data Exchange Portal (DEX) reports. HHSC's OIG has multiple employees that have access to the systems necessary to retrieve the reports and has trained those employees o...

Corrective action plan: HHSC's OIG has taken action to ensure timely reviews of the Centers for Medicare/Medicaid Services (CMS) Data Exchange Portal (DEX) reports. HHSC's OIG has multiple employees that have access to the systems necessary to retrieve the reports and has trained those employees on the review process. Implementation dates: July 10, 2024 (Implemented) Responsible persons: Robin Bernard, Director, Financial Analysis and Case Management

View Audit 348386

Finding 530362 (2024-013)

Significant Deficiency 2024

State of Texas C/o Comptroller of Public Accounts

TX

Eligibility Special Tests & Provisions Procurement, Suspension & Debarment § 200.303

Corrective action plan: In December 2021, the Texas Health and Human Services Commission (HHSC) implemented the Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment Management System (PEMS), an automated system that is the single tool for provider enrollment, re-enrollment, revalidat...

Corrective action plan: In December 2021, the Texas Health and Human Services Commission (HHSC) implemented the Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment Management System (PEMS), an automated system that is the single tool for provider enrollment, re-enrollment, revalidation, and maintenance requests (maintaining and updating provider enrollment record information). Medicaid provider enrollment, revalidation, and re-enrollment documentation, including risk-based screenings, are tracked in PEMS. Additionally, the relevant federal databases are checked at least monthly for all providers currently enrolled in Medicaid. HHSC continues efforts to enroll Medicaid providers, including LTC providers, through the PEMS. HHSC continued to operate under the public health emergency (PHE) waiver through May 11, 2023. As a result of the PHE end date and provider revalidation requirements, the projected end date for required revalidation of Medicaid providers is January 11, 2027. Of the Medicaid providers requested during the fiscal year 2024 Statewide Single Audit, the listed exceptions only apply to two LTC providers. The PEMS automated disenrollment process for providers who did not complete their revalidation was disabled during the PHE and had not yet been reenabled at the time these providers were due for revalidation. Manual disenrollment batches occurred through July 2024 with approved disenrollment exclusions based on a providers in-flight application, receipt of paid claims, and missing revalidation reminder notifications. The PEMS automatic disenrollment process was re-enabled in August 2024. Implementation dates: December 2021, PEMS implementation (Implemented) January 2027, provider enrollment and revalidation completed Responsible persons: Jordan Nichols, Deputy Associate Commissioner, Medicaid and CHIP Services Operations Management

View Audit 348386

Finding 530357 (2024-012)

Significant Deficiency 2024

State of Texas C/o Comptroller of Public Accounts

TX

Internal Control / Segregation of Duties Special Tests & Provisions Subrecipient Monitoring § 200.303

Corrective action plan: For awareness, effective February 1, 2025, Anil Koindala was hired as the Health and Human Services (HHS) Chief Information Security Officer (CISO). At HHSC, the Deputy Executive Commissioner for each HHS organizational area is responsible for assigning an information owne...

Corrective action plan: For awareness, effective February 1, 2025, Anil Koindala was hired as the Health and Human Services (HHS) Chief Information Security Officer (CISO). At HHSC, the Deputy Executive Commissioner for each HHS organizational area is responsible for assigning an information owner (IO) for each of their area’s HHS information systems which also includes performing Risk Assessments for the systems they are responsible for. To ensure Risk Assessment compliance is met, the CISO will send out quarterly reminders to the IO for the completion of risk assessments. The reminders have started to be sent on July 31, 2024. While the risk assessment will be completed by the IO, the CISO will assist any non-compliant area with training that will be provided by their Information Security Portfolio Manager (ISPM). Additionally, the CISO office ensures that a risk assessment and System Security Plan (SSP) are in place before granting an Authority to Operate (ATO). The CISO is currently developing policies and procedures to establish and publish a process for the successful completion of Risk Assessments, including roles and responsibilities, processes, and procedures to ensure timely completion and ongoing compliance. Implementation date: August 31, 2025 Responsible persons: Anil Koindala, Chief Information Security Officer, Information Technology Jeremy Sadler, Director, Information Security Risk Cristina Denz, Manager, Policy and Compliance

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Finding 530352 (2024-011)

Significant Deficiency 2024

State of Texas C/o Comptroller of Public Accounts

TX

Eligibility Significant Deficiency Internal Control / Segregation of Duties § 200.303

Corrective action plan: Since fiscal year 2022, Access and Eligibility Services (AES) has focused on hiring initiatives, strategic workload strategies, system improvements, and training to improve workload capacity to enable AES to reallocate workforce resources to applications waiting the longest...

Corrective action plan: Since fiscal year 2022, Access and Eligibility Services (AES) has focused on hiring initiatives, strategic workload strategies, system improvements, and training to improve workload capacity to enable AES to reallocate workforce resources to applications waiting the longest to be processed. In addition, AES has reviewed regular monitoring and reporting mechanisms to track application processing times and identify any delays. HHSC conducted a comprehensive review of application processing workflows to identify strategies to increase capacity and/or reduce workload. The review identified more than 40 strategies to improve end-user function, eliminating unnecessary actions and interactions, improving client experience, and promoting timely workflow. As of January 31, 2025, procedural improvements implemented have resulted in most Medicaid applications being processed within three days of receipt, allowing for a greater amount of the full processing timeframe (45 days) being available to establish proper eligibility. AES began implementing identified strategies in September 2024 and ongoing efforts will continue to focus on workforce and workload balance to meet the needs of timeliness of applicable programs. AES will continue to evaluate effectiveness of procedures through feedback loops, ensuring changes made result in sustained improvements and compliance with all relevant regulations. Implementation dates: December 31, 2028 Responsible persons: Molly Regan, Deputy Executive Commissioner, AES Rachel Patton, Associate Commissioner, AES Operations

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Finding 530347 (2024-010)

Significant Deficiency 2024

State of Texas C/o Comptroller of Public Accounts

TX

Allowable Costs / Cost Principles Special Tests & Provisions Eligibility § 200.303

Corrective action plan: HHSC has enacted changes to policies and timelines to ensure SOC 1 Type 2 reports are completed in a timely manner each year. HHSC will evaluate language in new and/or amending contracts to ensure contractual language supports these efforts. Implementation date: September ...

Corrective action plan: HHSC has enacted changes to policies and timelines to ensure SOC 1 Type 2 reports are completed in a timely manner each year. HHSC will evaluate language in new and/or amending contracts to ensure contractual language supports these efforts. Implementation date: September 30, 2025 Responsible persons: Michael Blood, Deputy Associate Commissioner, Contract Administration and Provider Monitoring

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Finding 530344 (2024-009)

Significant Deficiency 2024

State of Texas C/o Comptroller of Public Accounts

TX

Allowable Costs / Cost Principles Significant Deficiency § 200.303

Corrective action plan: The Commission’s current Accounts Payable Policy and Procedures Handbook documents voucher processing requirements including “approval to pay” documentation. The Accounts Payable (AP) management of the CFO Central Accounting division conducts a monthly “AP Talk” to update s...

Corrective action plan: The Commission’s current Accounts Payable Policy and Procedures Handbook documents voucher processing requirements including “approval to pay” documentation. The Accounts Payable (AP) management of the CFO Central Accounting division conducts a monthly “AP Talk” to update staff on changes to policy and procedures and provide refresher trainings, as needed. The program approval requirements for voucher payments and associated documentation will be reviewed in the February “AP Talk” for CFO Central Accounting and submitted to the HHSC peripheral accounting departments by the end of February. Implementation dates: February 28, 2025 Responsible persons: David Schneider, Deputy Director, Expenditure Management

View Audit 348386

Finding 530343 (2024-008)

Significant Deficiency 2024

State of Texas C/o Comptroller of Public Accounts

TX

Reporting Significant Deficiency § 200.303

Corrective action plan: HHSC has already implemented a final review by all agencies who receive SSBG funding and all HHSC staff. In the future, the federal funds office will coordinate efforts with the Federal Reporting personnel to ensure the amounts noted on the ACF-196 report are consistent wit...

Corrective action plan: HHSC has already implemented a final review by all agencies who receive SSBG funding and all HHSC staff. In the future, the federal funds office will coordinate efforts with the Federal Reporting personnel to ensure the amounts noted on the ACF-196 report are consistent with the amount on the Post Expenditure Report. Implementation dates: March 30, 2025 Responsible persons: Racheal Kane, Director, Federal Funds

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