Corrective Action Plans

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Corrective Action Plan The University acknowledges this finding and is committed to implementing immediate measures to ensure compliance with federal enrollment reporting requirements. The following steps will be undertaken: 1. Establish an Internal Audit Function: The University is actively seeki...
Corrective Action Plan The University acknowledges this finding and is committed to implementing immediate measures to ensure compliance with federal enrollment reporting requirements. The following steps will be undertaken: 1. Establish an Internal Audit Function: The University is actively seeking to fill a newly approved internal auditor position, with a dedicated budget line item to support this function. This role will provide leadership on all corrective action plans and serve as the primary contact for audit-related matters, ensuring onsite management for compliance issues within the University and its affiliated agencies. 2. Engage External Expertise: The Office of the Registrar will engage with the internal auditor and the National Student Loan Clearinghouse to review critical processes. This ongoing collaboration aims to assess the department’s strengths, weaknesses, opportunities, and threats, facilitating continuous improvement and compliance. 3. Enhance Staffing and Technological Resources: The University has made necessary staffing changes and will continue to evaluate the efficiency of the enrollment reporting process. This includes hiring additional staff as needed and incorporating advanced technology solutions to address this recurring issue. The implementation of enhanced technology will assist the Registrar in receiving alerts and status reports, ensuring timely and accurate processing. 4. Implement Robust Monitoring Systems: The University aims to generate necessary information and update systems to improve its capability to monitor student enrollment statuses, thereby enhancing compliance. This initiative will address challenges associated with certifying these enrollment status changes in a timely manner. 5. Strengthen Reporting Processes: Given the recurrence of this finding, the University will implement an enhanced reporting process, requiring the filing of transfer student status reports on a semester basis until the issue is resolved. The internal audit team will lead this reporting cycle, ensuring accountability and compliance. The internal audit unit will oversee and manage these corrective actions until the matter is fully resolved. The University is dedicated to enhancing its procedures and internal controls to ensure full compliance with enrollment reporting requirements. By implementing these measures, the University aims to rectify the identified deficiencies and prevent similar occurrences in the future, thereby upholding the integrity of its financial aid programs and maintaining compliance with federal regulations. Anticipated Completion Date: September 1, 2025
We acknowledge BDO’s recommendation to ensure consistent approval and retention of timesheets by both employees and supervisors for each pay period requested for reimbursement. However, VOAWW asserts that we have established controls in place to obtain and retain timesheet approvals, and the two ins...
We acknowledge BDO’s recommendation to ensure consistent approval and retention of timesheets by both employees and supervisors for each pay period requested for reimbursement. However, VOAWW asserts that we have established controls in place to obtain and retain timesheet approvals, and the two instances of missing approvals identified in the audit were due to human error rather than a lack of controls. To prevent such occurrences in the future and reinforce our existing procedures, we will continue implementing and strengthening the following controls: • Proactive Timesheet Approval Monitoring – Reports are regularly run to identify missing timesheet approvals before payroll is processed. Employees and supervisors with outstanding approvals receive reminders to ensure further action as needed, including notifying program directors about missing timesheet submissions or approvals resulting in out-of-compliance with federal awards and Uniform Guidance. • Real-Time Payroll Processing Checks – During payroll processing, additional reminders are sent to employees and supervisors who have not yet approved their timesheets, further reducing the likelihood of omissions. • Additional Approval Outside the System – In response to BDO’s recommendation, we will require managers to email Payroll at the end of every pay period affirming that they have reviewed and approved all timecards. This additional layer of approval ensures that even if a manager forgets to approve a timesheet in the system, there is still documented confirmation of their review. • Post-Payroll Compensating Control Implemented in FY24 – To mitigate any risk of over/undercharging grants due to miscoded time from unapproved timesheets, a compensating control was introduced in FY24. This process requires Program Management to review and approve a post-payroll report identifying any discrepancies in time allocations, ensuring that all time charged to grants is accurate and properly approved. • Documentation and Continuous Improvement – VOAWW provided attestations to BDO where available and acknowledges that the compensating control was not fully implemented during FY23 but was in place for most of FY24. Moving forward, we will ensure that this control is consistently applied across all programs. By maintaining and strengthening these controls, including the additional email approval process, we are confident in our ability to ensure proper timesheet approvals while mitigating any risk of inaccurate grant charging. Responsible Individual: Claire Danielson, Controller Estimated time of completion: June 2025
We acknowledge the auditors’ recommendation regarding the need for a more arm’s-length approach in determining rent charges between entities. To address this finding, we are making adjustments to our rent allocation methodology to enhance transparency and ensure compliance with best practices. As ...
We acknowledge the auditors’ recommendation regarding the need for a more arm’s-length approach in determining rent charges between entities. To address this finding, we are making adjustments to our rent allocation methodology to enhance transparency and ensure compliance with best practices. As part of our corrective action plan, we will implement the following measures: • Transition to an Actual Expense Allocation Methodology – VOAWW will modify the rent allocation process to allocate actual expenses incurred, ensuring that charges between entities reflect true costs. This approach eliminates the need for a year-end true-up process while maintaining fairness and accuracy. • Implementation of a True-Up Process for FY25 – While transitioning to the new methodology, we will conduct a true-up process for FY25 to reconcile any discrepancies and ensure that rent allocations align with actual expenses. These actions will help strengthen our internal controls and ensure that inter-entity rent allocations are handled in a compliant and equitable manner. Responsible Individual: Claire Danielson, Controller Estimated time of completion: June 2025
We acknowledge the repeated finding regarding the lack of documentation around the review, approval, and submission of required performance reports. To address this issue, we remain committed to the continued implementation and strengthening of the controls we began putting in place last year.   ...
We acknowledge the repeated finding regarding the lack of documentation around the review, approval, and submission of required performance reports. To address this issue, we remain committed to the continued implementation and strengthening of the controls we began putting in place last year.   As part of our ongoing efforts, we are enhancing our processes through the following actions: • Strengthened Implementation of CC-001 – We will reinforce the policies and procedures established in CC-001 to ensure consistent adherence across all reporting functions. This includes analyzing resources allocated to perform this control, enhancing internal review protocols and ensuring clear documentation of approvals. • Implementation of ContractSafe Reporting Management – VOAWW is in the process of implementing ContractSafe, a Contract database with a reporting management system designed to send automated reporting reminders and track report submissions. This system will improve compliance by ensuring reports are submitted accurately and on time while maintaining a clear audit trail of approvals. • Improved Monitoring and Accountability – We will regularly assess the effectiveness of these controls, making necessary adjustments to further strengthen oversight and prevent future occurrences of this finding. By taking these steps, we aim to fully resolve this issue and establish a more robust and transparent process for managing required reports. Responsible Individual: Claire Danielson, Controller Estimated time of completion: June 2025
The Board has developed procedures to ensure that all purchase orders are approved before orders are placed, all expenditures are properly authorized by the respective program director and supporting documentation is adequately maintained. The Board is using a requisition form in Droplet to achieve ...
The Board has developed procedures to ensure that all purchase orders are approved before orders are placed, all expenditures are properly authorized by the respective program director and supporting documentation is adequately maintained. The Board is using a requisition form in Droplet to achieve this goal. All employees authorized to make or approve purchases have been trained on purchasing procedures outlined in the Purchasing Policies and Procedures Manual for Local Educational Agencies in the State of West Virginia by the WVDE Office of School Finance on 2/23/2024.
View Audit 352084 Questioned Costs: $1
The Board will establish procedures that will ensure compliance with guidance set forth in Title 2 U.S. Code of Federal Regulations (CFR) Part 200 for Special Education.
The Board will establish procedures that will ensure compliance with guidance set forth in Title 2 U.S. Code of Federal Regulations (CFR) Part 200 for Special Education.
View Audit 352084 Questioned Costs: $1
Agency Response: Currently, Young at Heart follows policies and procedures for holidays, week hours, etc. CEO and CFO are aware we must follow our policies. We have changed the work week policy and the holiday listings in our policies. Creating new policies was part of the corrective action plan wit...
Agency Response: Currently, Young at Heart follows policies and procedures for holidays, week hours, etc. CEO and CFO are aware we must follow our policies. We have changed the work week policy and the holiday listings in our policies. Creating new policies was part of the corrective action plan with the DHSS. The policies were created and approved by Young at Heart Board in July 2024. Employees work a 36 hour week and receive 13 paid holidays. The credit card procedure now is being followed as it should. This was also on the Correctve Action Plan with DHSS. Both the previous CEO (Michael Stopka) and CFO (Shari Harris) are no longer employed with the agency. When I started as CFO, the current interim CEO Freda Miller and I called the board chair regarding the personal charges by Michael Stopka on the corporate credit card. The board chair was unaware of this and would address the issue and make sure he not only didn’t use the card for personal charges but would not pay it online and bypass the internal control function of accounts payable and cash disbursements. The current procedure of all purchases must be approved by the CEO and CFO prior to purchase. Once the item is purchased, the receipt and the requisition is sent to the fiscal assistant who matches the receipts to the credit card bill. Once all items are accounted for, the fiscal assistant will cut a check. The check will then be signed by CEO and a board member. The credit card bill is no longer being paid on-line. I believe the internal control problems have been addressed both on the corrective action plan with MO DHSS and by current management. These items were corrected in July 2024 after M. Stopka & S. Harris had left the agency.
Federal Agency: U.S. Department of Housing and Urban Development Program/Cluster: Housing Voucher Cluster Federal Assistance Listing Number: 14.871, 14.879 Pass‐through: n/a – direct award Award No. and Year: CA131, 2023/2024 Compliance Requirement: Reporting Type of Finding: Material Weakness in In...
Federal Agency: U.S. Department of Housing and Urban Development Program/Cluster: Housing Voucher Cluster Federal Assistance Listing Number: 14.871, 14.879 Pass‐through: n/a – direct award Award No. and Year: CA131, 2023/2024 Compliance Requirement: Reporting Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Views of Responsible Officials and Corrective Action Plan: Since May 2022, the County has contacted multiple agencies trying to report through the FSRS system on the multiple Housing Voucher awards, with no success. The County’s assigned Housing and Urban Development (HUD) office is the San Francisco regional office. Per their director, “These are systems that we don’t work with in HUD PIH so I won’t be able to be of assistance relative to this.” The County is unable to complete FFATA reporting for reasons outside of the County’s control. Responsible Individual(s): James Bezek, Director of Resources Management Anticipated Completion Date: Because the corrective action is outside of the County’s control, we cannot determine an anticipated completion date.
Federal Agency: U.S. Department of Housing and Urban Development Program/Cluster: Housing Voucher Cluster Federal Assistance Listing Number: 14.871, 14.879 Pass‐through: n/a – direct award Award No. and Year: CA131, 2023/2024 Compliance Requirement: Subrecipient Monitoring Type of Finding: Material ...
Federal Agency: U.S. Department of Housing and Urban Development Program/Cluster: Housing Voucher Cluster Federal Assistance Listing Number: 14.871, 14.879 Pass‐through: n/a – direct award Award No. and Year: CA131, 2023/2024 Compliance Requirement: Subrecipient Monitoring Type of Finding: Material Weakness in Internal Control over Compliance, Instance of Noncompliance Views of Responsible Officials and Corrective Action Plan: Due to the subrecipient’s low-risk status, another site visit is not due until FY2025/26. When that visit takes place, the County will formally document and communicate the results of the site visit. The department has created a subrecipient monitoring checklist to be completed quarterly which includes review of quarterly reports and will serve as documentation. Additionally, the department has a standing quarterly meeting with the subrecipient and will add an agenda item for quarterly report review discussion. The department will begin taking meeting minutes for documentation. Responsible Individual(s): James Bezek, Director of Resources Management Anticipated Completion Date: June 30, 2025
Trinity College of Florida will develop, implement and maintain a written information security program in accordance with GLBA compliance
Trinity College of Florida will develop, implement and maintain a written information security program in accordance with GLBA compliance
Views of Responsible Officials and Planned Corrective Actions – Management acknowledges the audit finding related to procurement and suspension and debarment compliance under Federal Programs: Technical and Non-Financial Assistance to Health Centers, Grants for New and Expanded Services under the He...
Views of Responsible Officials and Planned Corrective Actions – Management acknowledges the audit finding related to procurement and suspension and debarment compliance under Federal Programs: Technical and Non-Financial Assistance to Health Centers, Grants for New and Expanded Services under the Health Center Program (Federal Assistance Listing Numbers 93.129, 93.527; Federal Award Year 2023-2024). We are committed to implementing corrective measures to address the identified deficiencies and ensure full compliance with 2 CFR 200.318 and 2 CFR 180 regulations. Corrective Actions Taken: 1. Established & Implemented Detailed Record-Keeping for Procurement Transactions: - A new accounting system with a centralized procurement tracking system has been implemented and is currently being used. Bill.com is used to record vendor invoices and procurement transactions in real time and syncs with Sage Intacct, the new accounting software implemented in January 2024. - Detailed records of all federal grant expenditures are maintained in Bill.com and monthly reconciliations are conducted in the general ledger to ensure all procurement transactions are properly classified to their specific grant by their grant ID. 2. Established & Implemented Suspension & Debarment Verification Procedures: - A new accounting system with a centralized procurement tracking system has been implemented and is currently being used. Bill.com is used to record vendor information including Sam.gov vendor eligibility documentation. - All vendors are verified using Sam.gov. and documentation is kept in the electronic vendor file in Bill.com. This process was implemented in March 2024 and is ongoing. 3. Monitoring - The Finance team conducts annual self-assessments to ensure vendor eligibility documentation is current and up to date. Any vendors that are suspended, debarred, or otherwise excluded from federal assistance programs are reported to the Executive team to ensure compliance. We believe that these actions will significantly mitigate the risks associated with the identified conditions and strengthen our internal control environment and align our procurement practices with federal regulations.
Management is implementing enhanced controls and formal procedures to ensure that all funding sources, particularly those received through intermediary or passthroughentities, are correctly identified and appropriately classified for reporting. These measures include: - Expanding documentation reque...
Management is implementing enhanced controls and formal procedures to ensure that all funding sources, particularly those received through intermediary or passthroughentities, are correctly identified and appropriately classified for reporting. These measures include: - Expanding documentation requests to verify funding sources. - Maintaining ongoing dialogue with pass-through entities to confirm federal assistance classifications.
Student Financial Assistance Cluster - Assistance Listing No. No. 84.063, 84.268, 84.007, 84.033 Recommendation: We recommend the University ensure its written information security program addresses the required minimum elements as outlined in 16 CFR 314.4. Explanation of disagreement with audit fin...
Student Financial Assistance Cluster - Assistance Listing No. No. 84.063, 84.268, 84.007, 84.033 Recommendation: We recommend the University ensure its written information security program addresses the required minimum elements as outlined in 16 CFR 314.4. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Information Technology Department will ensure its written information security program addresses the required minimum elements outlined in 16 CFR 314.4. Name(s) of the contact person(s) responsible for corrective action: Belinda Burke, VP for Finance and Administration, CFO Planned completion date for corrective action plan: April 2025
Finding 549905 (2024-018)
Significant Deficiency 2024
2024-018. USU Extension Extra Services Compensation Program Non-Compliance with Uniform Guidance State Agency: Utah State University Research & Development Federal Agency: Various 1) Potential Financial Impact USU retained Huron Higher Education Consulting to conduct a Uniform Guidance compliance r...
2024-018. USU Extension Extra Services Compensation Program Non-Compliance with Uniform Guidance State Agency: Utah State University Research & Development Federal Agency: Various 1) Potential Financial Impact USU retained Huron Higher Education Consulting to conduct a Uniform Guidance compliance review of compensation costs charged to federal sponsors. Huron Consulting routinely works with Carnegie R1 institutions to review research compliance issues. Huron conducted a detailed review of an extensive data set for ESC payments made to USU employees, focusing on employees who had salary charged to federal grants or designated as a grant cost share. This review identified limited instances (1) when salaries directly charged to sponsored projects included extra service compensation in the institutional base salary and (2) when extra service compensation was charged to federal sponsors. Overall, the review found that the vast majority of USU ESC payments (referred to as secondary payments in the internal audit) were not charged to federal sponsored awards. Out of a total population of $5.8 million ESC payments reviewed, the unallowed compensation costs related to ESC is approximately $140,000. USU is in the process of addressing the unallowable compensation costs by removing unallowable charges on open awards and refunding unallowable charges on closed awards. 2) Policies and required documentation for ESC. ESC Policies: USU is reviewing its policies associated with ESC and institutional base salary (IBS) (both currently defined in USU Policy 376: Extra Service Compensation). A working group has been established that includes the Provost’s Office, the President’s Office, the Office of Research and Human Resources to develop updated procedures for requesting ESC. Once in place, a new Extra Service Compensation website will be rolled out that will provide guidance on the policy, acceptable uses of extra-service Compensation, and training materials. In conjunction with the website development, a communication plan to inform stakeholders, especially approving department heads and administrators, will be developed. Institutional Base Salary Policy and Procedures: USU will create and implement an Institutional Base Salary policy that aligns with federal requirements and industry best practices and specifically defines salary components and the associated pay codes that are included and excluded from an employee’s institutional base salary. USU will also update its time and effort certification system with correct institutional base salary mapping. 3) Internal controls for sponsored program compensation USU will implement the following improvements in its internal controls: Revised ESC Form. USU has revised its ESC Form to include documentation / calculation demonstrating payment is commensurate with institutional base salary. Revised ESC Application and Approval Process: USU has already updated the internal ESC review process to include appropriate controls to ensure that all ESC requests are reviewed for Uniform Guidance and USU policy requirements. In this regard, all ESC requests at USU are now reviewed by the Office of Sponsored Programs in the context of all funding sources associated with the applicant (including cost share indexes). This change directly addresses prior routing based on the source of funding which resulted in the Office of Research/Sponsored Programs being bypassed for state-funded ESC requests. Certification language has been inserted at appropriate approval levels to ensure that employees are not receiving ESC related to their primary position/workload. Improved Definitions of Primary Work Statement: USU has initiated a collaborative effort between Human Resources, the Provost’s Office, and the Office of Research to clearly define the primary work assignment for faculty via the role statement or annual work plans to clarify the full workload associated with the IBS. Increased Compliance Monitoring: After-the-fact monthly review of ESC payments is being collaboratively performed between the Office of Research and Provost’s Office. Additionally, USU has reorganized its operations to house post-award research administrators within the Office of Research and added an additional supervisory position to manage post award compliance and management. USU will charge central-post award research administrators with monitoring salary charges to sponsored awards and cost share accounts as a secondary internal control. Research Incentive Programs: The Office of Research will establish permissible conditions and components for research incentive programs and any and all proposed programs will be reviewed and approved by the Office of Research before implementation. 4) Adequate training to university personnel regarding sponsored programs compensation compliance. Uniform Guidance training for faculty and staff: USU is building and incorporating new training modules for those managing federal awards which will include guidance on allowable compensation costs and determining institutional base salary. ESC Training: USU has developed a new required annual training for anyone requesting or approving ESC from all types of funding sources at USU (delivered via USU’s Learn Blue system). This training addresses requirements for ESC and employees’ role and responsibilities for compliance requirements. Additional training regarding time and effort certification will be developed. Pay Code Training: USU will provide additional training and education for departmental and payroll staff responsible for coding and processing salary across the institution. Responsible Person: Lisa M. Berreau Vice President for Research Utah State University 435-797-3509 Anticipated completion date of corrective action plan: Actively in progress and full completion by Jan. 1, 2026.
Finding 548761 (2024-008)
Significant Deficiency 2024
2024-008. Non-Payroll Expenditures Did Not Receive Adequate Reviews State Agency: University of Utah Research & Development Federal Agency: Department of Health and Human Services The Controller’s Office will work directly with the identified PI’s to provide additional training and understanding of ...
2024-008. Non-Payroll Expenditures Did Not Receive Adequate Reviews State Agency: University of Utah Research & Development Federal Agency: Department of Health and Human Services The Controller’s Office will work directly with the identified PI’s to provide additional training and understanding of the importance of appropriate and timely approvals. In addition, the Controller will work with the Office of Sponsored Projects and the Financial Reporting & Accounting office to review current training processes, as well as the process for notification and follow up with those AE’s/PI’s who do not meet the standard set forth in policy. Contact Person: Steven Phillips Anticipated Correction Date: 6/30/2025
Finding 548758 (2024-005)
Significant Deficiency 2024
2024-005. Required Health and Safety Surveys Not Performed Within Statutory Timeline State Agency: Department of Health and Human Services Federal Agency: Department of Health and Human Services To address this finding (and prior year finding number 2023-008), the Division of Licensing and Backgroun...
2024-005. Required Health and Safety Surveys Not Performed Within Statutory Timeline State Agency: Department of Health and Human Services Federal Agency: Department of Health and Human Services To address this finding (and prior year finding number 2023-008), the Division of Licensing and Background Checks (DLBC), Office of Licensing (OL) took the following corrective action to achieve compliance with required survey time frames: • Increased Health Facility Licensing fees by 43% to facilitate the hiring of 4 additional staff for the 2025 state fiscal year. • Dedicated one-time funds for contracting with a third-party surveyor and hired two, time- limited positions to help address the Health and Safety survey backlog in fiscal year 2024 and 2025. • Continued to work with the DHHS Office of Innovation to review the health facility team’s processes to improve efficiencies. • Organized a separate complaint investigation unit in August 2024 to help expedite complaint and survey completion. The DBLC, OL will continue to follow through with these additional resources in order to achieve compliance with the required survey timelines. In addition, the OL plans to streamline the writing and reporting procedures while ensuring compliance with CMS guidance. The goal is to shorten the time required to write reports and therefore increase the number of surveys completed. Implementation Date: July 1, 2026 Contact: Courtney Webb, Financial Manager, Division of Finance & Administration, courtneywebb@utah.gov
Finding 548755 (2024-004)
Significant Deficiency 2024
2024-004. Inadequate Procedures to Identify Healthcare Providers with Expired Licenses State Agency: Department of Health and Human Services Federal Agency: Department of Health and Human Services Out-of-state providers and the provider whose license expired during the PHE. During the PHE an expire...
2024-004. Inadequate Procedures to Identify Healthcare Providers with Expired Licenses State Agency: Department of Health and Human Services Federal Agency: Department of Health and Human Services Out-of-state providers and the provider whose license expired during the PHE. During the PHE an expired license report was not properly monitored. Prospectively, DHHS will ensure license expiration notifications are reviewed on a monthly basis. Additionally, DHHS will work with the PRISM contractor to explore pathways to identify all providers (out-of-state and in-state) whose licenses may have already expired. DHHS will follow the current license expiration process and close those providers as appropriate. Provider initially granted eligibility in the legacy system. In any future event involving data conversion, DHHS will ensure that all relevant data from the existing system is thoroughly collected and reviewed prior to the conversion process. This will help guarantee data integrity and minimize the risk of issues arising during the transition. Implementation Date: July 31, 2025 Contact: Shandi Adamson, Director, Office of Medicaid Operations, shandiadamson@utah.gov
Finding 548753 (2024-003)
Significant Deficiency 2024
2024-003. Incomplete Pharmacy Rebate Reporting and Invoicing State Agency: Department of Health and Human Services Federal Agency: Department of Health and Human Services Following the launch of the Medicaid Provider Reimbursement Information System for Medicaid (PRISM) in April 2023, not all pharma...
2024-003. Incomplete Pharmacy Rebate Reporting and Invoicing State Agency: Department of Health and Human Services Federal Agency: Department of Health and Human Services Following the launch of the Medicaid Provider Reimbursement Information System for Medicaid (PRISM) in April 2023, not all pharmacy files from managed care entities and JCODE drugs properly transmitted to the third-party organization’s system. The key pharmacy claims files that needed to interface with the third-party organization’s system have now been rebuilt and are undergoing interface testing. After testing, the historic and more current files will be put into production and be transmitted to the third-party organization. Following receipt, the third-party organization will invoice and collect the unbilled rebates. Once this interface issue is resolved, all future required drug utilization data as well as rebate invoices will be sent to manufacturers within the required time frame. All claims received will be invoiced 60 days after the end of the current quarter they are received in, per CMS's rule. DHHS informed CMS of this issue in August 2024. At that time, CMS said the state was out of compliance and inquired on timelines to come into compliance. The state will provide updates to CMS when the backlogged files have been successfully transmitted and manufacturers have been invoiced. According to the third-party pharmacy organization, manufacturers were notified about this issue when it was discovered in May 2023 and advised that when the issues with invoicing these rebates is resolved they will be expected to pay the balance due. Implementation Date: May 30, 2025 Contact: Sepideh Daeery, Pharmacy Director, Division of Integrated Healthcare, sepidehdaeery@utah.gov Anticipated Correction Date: June 30, 2024
Finding 548751 (2024-011)
Significant Deficiency 2024
2024-011. DWS-Adopted Guidelines Not Followed When Evaluating an Applicant Housing Project State Agency: Department of Workforce Services Federal Agency: Department of Housing and Urban Development The Housing and Community Development Division is in the process of completing a full HTF policy and p...
2024-011. DWS-Adopted Guidelines Not Followed When Evaluating an Applicant Housing Project State Agency: Department of Workforce Services Federal Agency: Department of Housing and Urban Development The Housing and Community Development Division is in the process of completing a full HTF policy and procedures rewrite with a robust internal controls process. This will include an updated HTF monitoring checklist and a quality control check of said monitoring checklist by the Program Manager. Anticipated correction date: March 31, 2025 Responsible person: Daniel Murphy, HCD Program Manager, 385-630-8368
Finding 548749 (2024-010)
Significant Deficiency 2024
2024-010. HTF Project Does Not Meet Eligible Income Requirements State Agency: Department of Workforce Services Federal Agency: Department of Housing and Urban Development The Housing and Community Development Division is in the process of completing a full HTF policy and procedures rewrite with a r...
2024-010. HTF Project Does Not Meet Eligible Income Requirements State Agency: Department of Workforce Services Federal Agency: Department of Housing and Urban Development The Housing and Community Development Division is in the process of completing a full HTF policy and procedures rewrite with a robust internal controls process. This will include an updated HTF monitoring checklist and a quality control check of said monitoring checklist by the Program Manager. Anticipated correction date: March 31, 2025 Responsible person: Daniel Murphy, HCD Program Manager, 385-630-8368
2024-017. Working Capital Reserves in Excess of Federal Guidelines State Agency: Public Employee Health Program Federal Agency: Various State Medical Given that the PEHP State Medical Program reserves are just over 60 days, our corrective action plan focuses on continuous monitoring and financial st...
2024-017. Working Capital Reserves in Excess of Federal Guidelines State Agency: Public Employee Health Program Federal Agency: Various State Medical Given that the PEHP State Medical Program reserves are just over 60 days, our corrective action plan focuses on continuous monitoring and financial stewardship to ensure compliance with reserve requirements while maintaining the program's financial health. The program was below 60 days on June 30, 2023. There are inherent variabilities and risks associated with medical claims, and reserve fluctuations are expected due to factors such as claim experience, utilization trends, and cost variations. We do not anticipate issuing a refund unless there is a long-term trend of excess reserves over the next three years. PEHP will continue to track performance and adjust necessary to maintain levels. Long-Term Disability After the measurement date of June 30, 2024, the PEHP Board of Directors approved a refund of excess reserves of $3,468,201.87 to the state of Utah. PEHP issued a check on September 12, 2024, and requested State Finance to calculate the federal portion of the refund and distribute it appropriately to the federal government. Additionally, our corrective action plan focuses on ensuring financial stability while evaluating the impact of recent plan modifications introduced by Senate Bill 21 from the 2025 Utah Legislative Session. The bill introduced specific changes to the LTD program that may impact claims experience and long-term reserve requirements. A thorough actuarial analysis is underway to assess how these modifications will affect future liabilities. While excess reserves still exist, it is prudent to allow for the recent changes to fully materialize before making any further financial adjustments or refunds. PEHP closely monitors how these modifications affect benefit, utilization, and reserve levels. Medicare Supplement While PEHP did acknowledge we would issue a refund last year, the overall trend of the Medicare reserve is moving in the opposite direction. In fact, as of December 31, 2024, the preliminary calculated reserve has experienced a notable decrease compared prior year levels due to PEHP's proactive efforts to manage and optimize reserve levels. These efforts have focused on aligning reserves with claim experience, refining cost management strategies, and ensuring long-term sustainability. One such effort relates to recent Medicare Part D Program changes that eliminated the donut hole, reducing plan options from three to one. PEHP is year one of a three-year transition to a single Part D rate that will continue to draw reserves. We believe allowing these changes to fully materialize before any further financial adjustments or refunds is prudent.
2024-016. Working Capital Reserves in Excess of Federal Guidelines State Agency: Department of Governmental Operations Federal Agency: Various Division of Purchasing and General Services Cooperative Contract Management Fund – State Purchasing continues to decrease the administrative fees on state co...
2024-016. Working Capital Reserves in Excess of Federal Guidelines State Agency: Department of Governmental Operations Federal Agency: Various Division of Purchasing and General Services Cooperative Contract Management Fund – State Purchasing continues to decrease the administrative fees on state cooperative contracts as each contract expires and is rebid. This is a slow process since State Purchasing has nearly 1,300 cooperative contracts with an average 5-year term. With only about 20% of the contracts expiring each year, this is an ongoing and slow process. Although State Purchasing is allowed under law to collect up to a 1.0% administrative fee on each cooperative contract, currently the average administrative fee is 0.35%. The excess reserves are also being reallocated to other programs. These allocations are intended to both reduce the excess reserve balance and to create efficiencies within the division to better serve state agencies. Federal Surplus Property Fund – The excess reserves are to be used in relocating Surplus to the Taylorsville State Office Building in March 2025. Contact Person: Windy Aphayrath (waphayrath@utah.gov, 801-957-7138), Director, Division of Purchasing and General Services Anticipated Correction Date: June 30, 2025 Division of Finance Purchasing Cards Fund (P-Card) – The system implementation was completed at the end of calendar year 2024. State Finance is working to analyze the annual costs of the system, develop a cost allocation strategy between the travel and P-Card programs, and adjust travel rates to cover the travel program's ongoing costs. The P-Card program will then distribute any remaining P-Card rebates to state agencies respective to their spending, if applicable. This effort will eliminate any excess federal reserves in the P-Card fund by the end of fiscal year 2025. Contact Person: Allyson Branch (abranch@utah.gov, 801-597-3523), Assistant Director, Division of Finance Anticipated Correction Date: June 30, 2025 Division of Risk Management Workers’ Compensation Fund – The Division of Risk Management has received approval from the Utah Legislature to reduce rates for workers’ compensation in fiscal year 2026. This will take effect on July 1, 2025. The division will also request at the next Legislative session to reallocate excess reserves from the Workers’ Compensation Fund to the Property Fund. This will be completed by July 1, 2026. Contact Person: Rachel Terry (rachelgterry@utah.gov, 801-702-7445), Director, Division of Risk Management, Anticipated Correction Date: July 1, 2026 Division of Technology Services Communication Services – The Division has worked to reduce the excess reserves and has been successful in decreasing the balance compared to the previous year. In addition, the current year rate was calculated to continue decreasing the excess reserve balance. Next year rates have also been adjusted to further reduce the excess reserve balance. We are working to balance reductions in retained earnings while maintaining services until the products reach the end of their lifecycle. Network Services – The Division is estimating that excess reserves will decrease as a result of anticipated increases in expenses over fiscal years 2025, 2026, and 2027 to support the migration to a cloud-based platform. We will continue to monitor rates and expenses as the technology environment continually changes. Printing Services – The Division has set the current year rate to recover costs in order to reduce the excess reserves. The threshold for this program has a small limit for a product with a very high volume. Print demand this year has been low, and we are forecasting this to be fully corrected by the end of fiscal year 2025. Contact Person: Jake Hennessy (jakehennessy@utah.gov, 385-271-2301), Executive Finance Director, Department of Government Operations Anticipated Correction Date: June 30, 2025 Division of Human Resource Management Human Resources Field Services – A cost allocation plan was developed to better align expenses with the specific service area supported. Field Service rates were lowered for fiscal year 2025. We anticipate continuing to fine tune rates to bring the Field Service reserve balance down. Contact Person: John Barrand (jbarrand@utah.gov, 801-957-9350), Director, Division of Human Resource Management Anticipated Correction Date: June 30, 2025
Finding 548698 (2024-015)
Significant Deficiency 2024
2024-015. Reported Number of Homeowners Overstated State Agency: Department of Workforce Services Federal Agency: Department of the Treasury The Housing and Community Development Division will adopt a quality review process to address this finding. Fortunately, the Quarterly Reports are cumulative s...
2024-015. Reported Number of Homeowners Overstated State Agency: Department of Workforce Services Federal Agency: Department of the Treasury The Housing and Community Development Division will adopt a quality review process to address this finding. Fortunately, the Quarterly Reports are cumulative so we have updated the current report to reflect the accurate household counts with an AMI under 100%. Anticipated correction date: March 31, 2025 Responsible person: Ambra Peterson, HCD Program Manager, 385-312-6551
Finding 548697 (2024-014)
Significant Deficiency 2024
2024-014. Errors in Coronavirus SLFRF Quarterly Reports State Agency: Governor’s Office of Planning and Budget Federal Agency: Department of the Treasury GOPB has not received a response from the Treasury Office of Recovery Programs regarding the application of the $10 million capital expenditure re...
2024-014. Errors in Coronavirus SLFRF Quarterly Reports State Agency: Governor’s Office of Planning and Budget Federal Agency: Department of the Treasury GOPB has not received a response from the Treasury Office of Recovery Programs regarding the application of the $10 million capital expenditure reporting threshold. GOPB is working with the National Association of State Budget Officers to see if they can receive a response. GOPB will add a new capital expenditure section to each ARPA SLFRF Appropriation Tracking and Documentation Form to document the applicability of capital expense requirements for the project. If a project requires additional justification, based on clarification provided by the Treasury, GOPB and the agency will record the justification and documentation on the form and submit that information in the next quarterly ARPA SLFRF P&E Report-Quarter 4 2024. While preparing the October 2024 ARPA SLFRF P&E Report-Quarter 3 2024, GOPB will reconcile all reported obligations with backup documents. This reconciliation will be completed for future reports. Contact Person: Darcy Jaimez, Fiscal Grant Manager, 385-377-3373 Anticipated Correction Date: October 31, 2024
Finding 548696 (2024-013)
Significant Deficiency 2024
2024-013. Misunderstanding Caused Improper Spending of Coronavirus State and Local Fiscal Recovery Funds (SLFRF) State Agency: Governor’s Office of Planning and Budget Federal Agency: Department of the Treasury GOPB agrees with the finding. We acknowledge that GOEO mistakenly recorded $559,900 of e...
2024-013. Misunderstanding Caused Improper Spending of Coronavirus State and Local Fiscal Recovery Funds (SLFRF) State Agency: Governor’s Office of Planning and Budget Federal Agency: Department of the Treasury GOPB agrees with the finding. We acknowledge that GOEO mistakenly recorded $559,900 of expenditures to the SLFRF program and identified the same error during the quarterly expenditure review process. Upon identifying this error, GOPB promptly addressed the issue with GOEO so that expenditures could be corrected in the financial system before the end of the FY 2024 closeout and the July 2024 quarterly ARPA SLFRF report. Corrective Action Plan: To improve oversight and monitoring of expenditures, GOPB will work closely with GOEO to ensure that all expenditures charged to SLFRF projects comply with program requirements. GOPB will also add content to agency SLFRF trainings about regularly reviewing project ARPA SLFRF Appropriation Tracking and Documentation Forms, which outline the budget, scope, eligibility, and coding for ARPA SLFRF projects. The training will specifically emphasize the importance of each agency establishing effective internal controls for recording and reviewing ARPA SLFRF expenditures. In addition to updating its general training materials, GOPB will provide additional training to agency staff managing new projects so they understand policies and procedures. Contact Person: Duncan Evans, Senior Managing Director of Budget and Operations, 801-538-1592 Anticipated Correction Date: Completed October 31, 2024 State Agency: Governor’s Office of Economic Opportunity 1. GOEO will work with GOPB to ensure that all expenditures charged to SLFRF projects comply with program requirements. GOEO will participate in SLFRF trainings about regularly reviewing project ARPA SLFRF Appropriation Tracking and Documentation Forms, which outline the budget, scope, eligibility, and coding for ARPA SLFRF projects. Implementation of this plan has already begun and will be ongoing. 2. GOEO has improved internal controls. This includes improved review procedures by financial analysts and improved approval procedures by financial managers. Implementation of this plan is complete. Contact of Persons Responsible for Corrective Action: Kamron Dalton, Managing Director of Operations Jason Marden, Director of Finance Greg Jeffs, Agency Internal Audit Director (not responsible, but please cc communications)
View Audit 352012 Questioned Costs: $1
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