Corrective Action Plans

Finding 366751 (2022-002)

Material Weakness 2022

IN

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

FINDING 2022-002 Finding Subject: Title I Grants to Local Educational Agencies -Internal Controls Summary of Finding: Finding: Ineffective internal controls over Eligibility, Level of Efforts and Earmarking Recommendation: That the School Corporation design and implement a proper system of internal ...

FINDING 2022-002 Finding Subject: Title I Grants to Local Educational Agencies -Internal Controls Summary of Finding: Finding: Ineffective internal controls over Eligibility, Level of Efforts and Earmarking Recommendation: That the School Corporation design and implement a proper system of internal control, including policies and procedures that would provide segregation of duties to ensure appropriate reviews, approvals and oversight are taking place. Contact Person Responsible for Corrective Action: Rafi Nolan-Abrahamian, Assistant Superintendent of Accountability and Innovation Kareemah Fowler, Assistant Superintendent of Business and Finance Debra Martin, Director of Student Learning and of Title I Contact Phone Number and Email Address: Rafi Nolan-Abrahamian (574) 393-6179; rnolan-abrahamian@sbcsc.k12.in.us Kareemah Fowler (574) 393-6088; kfowler@sbcsc.k12.in.us Deb Martin (574) 393-6053; dmartin@sbcsc.k12.in.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: Eligibility The district has followed the procedures below to ensure the publishing of accurate eligibility information. The district has now clearly documented the procedures for future audit cycles. Titan (lunch status data) is imported into PowerSchool every week by the Student Information System administrator in the lead up to October reporting deadlines. Prior to certification, the Data Content Manager republishes all of the student demographic/identification records to update the certified values. Pupil Enrollment rosters from Data Exchange are compared to files from Titan to verify alignment of all individual student lunch status values. Anticipated Completion Date: Completed October 2023 39 INDIANA STATE BOARD OF ACCOUNTS South􀀃Bend􀀃Community􀀃School􀀃Corporation􀀃 215􀀃South􀀃Dr.􀀃Martin􀀃Luther􀀃King􀀃Jr.􀀃Boulevard􀀃􀀃 􀀃South􀀃Bend,􀀃Indiana􀀃46601􀀃􀀃 574􀇦393􀇦6100􀀃􀀃 􀀃 􀀃 􀀃 􀀃 INTEGRITY􀀃•􀀃ACCOUNTABILITY􀀃•􀀃EMPOWERMENT􀀃 􀀃 ACADEMIC􀀃QUALITY􀀃|􀀃EQUITY,􀀃INCLUSION􀀃&􀀃JUSTICE􀀃|􀀃FINANCIAL􀀃 SUSTAINABILITY􀀃|􀀃COMMUNITY􀀃PARTNERSHIPS􀀃 􀀃 Level of Effort The Human Resources Department has added a second review to verify all employee distribution codes are correct when recording/updating employee requisitions. Additionally, detailed expense reports and payroll distribution reports that support each reimbursement request are being provided to knowledgeable employees to review. Anticipated Completion Date: Completed December 8, 2023, and May 2023 Earmarking Summary level payroll data is no longer being used to support reimbursement requests. Detailed expense reports and payroll distribution reports that support each reimbursement request are being provided to knowledgeable employees to review. Anticipated Completion Date: Completed May 2023

View Audit 289747

Finding 366636 (2022-004)

Significant Deficiency 2022

City of Clarksville

TX

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting

City of Clarksville, TX accounting department and Mayor will develop a process in which the audit will be completed in a timely manner to submit it to the FAC by hiring an auditor earlier in the year and submitting to the Clearing house within 30 days of the audit report or nine months after the Org...

City of Clarksville, TX accounting department and Mayor will develop a process in which the audit will be completed in a timely manner to submit it to the FAC by hiring an auditor earlier in the year and submitting to the Clearing house within 30 days of the audit report or nine months after the Organization’s year end.

View Audit 289546

Finding 366532 (2022-005)

Significant Deficiency 2022

Dalewood Estates Senior Housing, Inc.

SC

Questioned Costs Subrecipient Monitoring

Finding 2022-005: Comments on the Finding and Each Recommendation The Form SF-SAC Single Audit Data Collection Form for the year ended December 31, 2022 was not submitted to the federal audit clearinghouse in the required timeframe. Action(s) taken or planned on the finding The Corporation shou...

Finding 2022-005: Comments on the Finding and Each Recommendation The Form SF-SAC Single Audit Data Collection Form for the year ended December 31, 2022 was not submitted to the federal audit clearinghouse in the required timeframe. Action(s) taken or planned on the finding The Corporation should submit the Form SF-SAC Single Audit Data Collection Forms for the year ended December 31, 2022 as soon as practical. Management and the Board of Directors concur with the finding and the auditor's recommendations. Form SF-SAC Single Audit Data Collection Form for the year ended December 31, 2022 will be submitted to the federal audit clearinghouse upon completion of the audit.

View Audit 289369

Finding 366531 (2022-004)

Significant Deficiency 2022

Dalewood Estates Senior Housing, Inc.

SC

Questioned Costs Subrecipient Monitoring HUD Housing Programs

Finding 2022-004: Comments on the Finding and Each Recommendation The Corporation did not furnish HUD with complete financial statements by the due date of September 30, 2023. Action(s) taken or planned on the finding The Corporation should file the December 31, 2022 financial statements as so...

Finding 2022-004: Comments on the Finding and Each Recommendation The Corporation did not furnish HUD with complete financial statements by the due date of September 30, 2023. Action(s) taken or planned on the finding The Corporation should file the December 31, 2022 financial statements as soon as practical and should ensure the annual financial report is filed by the HUD deadline in future periods. Management and the Board of Directors concur with the finding and the auditor's recommendations. The Corporation intends to submit the financial statements to HUD by January 26, 2024.

View Audit 289369

Finding 366530 (2022-003)

Significant Deficiency 2022

Dalewood Estates Senior Housing, Inc.

SC

Questioned Costs Subrecipient Monitoring HUD Housing Programs

Finding 2022-003: Comments on the Finding and Each Recommendation During prior years, the Board of Directors disbursed funds from the replacement reserve to fund development of other housing developments. Action(s) taken or planned on the finding The Board of Directors should replace the funds ...

Finding 2022-003: Comments on the Finding and Each Recommendation During prior years, the Board of Directors disbursed funds from the replacement reserve to fund development of other housing developments. Action(s) taken or planned on the finding The Board of Directors should replace the funds that were disbursed from the reserve for replacements without HUD approval. Management and the Board of Directors concur with the finding and the auditor's recommendation. The Board of Directors entered into a repayment agreement with HUD beginning in 2023 to repay the unapproved disbursements from the reserve for replacements reserve to the Property.

View Audit 289369

Finding 366529 (2022-002)

Significant Deficiency 2022

Dalewood Estates Senior Housing, Inc.

SC

Questioned Costs Subrecipient Monitoring

Finding 2022-002: Comments on the Finding and Each Recommendation The Form SF-SAC Single Audit Data Collection Form for the years ended December 31, 2018, 2019, 2020 and 2021 were not submitted to the federal audit clearinghouse in the required timeframe. Action(s) taken or planned on the findin...

Finding 2022-002: Comments on the Finding and Each Recommendation The Form SF-SAC Single Audit Data Collection Form for the years ended December 31, 2018, 2019, 2020 and 2021 were not submitted to the federal audit clearinghouse in the required timeframe. Action(s) taken or planned on the finding The Corporation should submit the Form SF-SAC Single Audit Data Collection Forms for the years ended December 31, 2018, 2019, 2020 and 2021 as soon as practical. Management and the Board of Directors concur with the finding and the auditor's recommendation. Form SF-SAC Single Audit Data Collection Form for the year ended December 31, 2018 was submitted to the federal audit clearinghouse on March 8, 2023, the Form SF-SAC Single Audit Data Collection Form for the year ended December 31, 2019 was submitted on March 8, 2023, the Form SF-SAC Single Audit Data Collection Form for the year ended December 31, 2020 was submitted on April 3, 2023, and the Form SF-SAC Single Audit Data Collection Form for the year ended December 31, 2021 was submitted on February 15, 2023. No further action is required.

View Audit 289369

Finding 366528 (2022-001)

Significant Deficiency 2022

Dalewood Estates Senior Housing, Inc.

SC

Questioned Costs Subrecipient Monitoring HUD Housing Programs

Finding 2022-001: Comments on the Finding and Each Recommendation The owners have not filed the 2017, 2018, 2019, 2020, 2021 or 2022 federal income tax returns. Action(s) taken or planned on the finding Tax returns should be filed on a timely basis. Management and the Board of Directors concur ...

Finding 2022-001: Comments on the Finding and Each Recommendation The owners have not filed the 2017, 2018, 2019, 2020, 2021 or 2022 federal income tax returns. Action(s) taken or planned on the finding Tax returns should be filed on a timely basis. Management and the Board of Directors concur with the finding and the auditor's recommendation. Management and the Board of Directors are taking steps to file the previous tax returns and have the Corporation's not-for-profit designation reinstated.

View Audit 289369

Finding 366517 (2022-001)

Significant Deficiency 2022

Community Action of Laramie County, Inc.

WY

Subrecipient Monitoring Eligibility Significant Deficiency

Documentation is now in place to ensure the eligibility for current and future clients. A system is in place to track the documentation. During FY2022, the agency had turnovers in the Case Manager department in which procedures were missed and/or not documented. Files are reviewed quarterly to ensur...

Documentation is now in place to ensure the eligibility for current and future clients. A system is in place to track the documentation. During FY2022, the agency had turnovers in the Case Manager department in which procedures were missed and/or not documented. Files are reviewed quarterly to ensure proper due diligence by the Program Director and/or their designee.

View Audit 289308

Finding 322674 (2022-006)

Significant Deficiency 2022

Heartland Care Center Inc.

IA

Internal Control / Segregation of Duties Subrecipient Monitoring Matching / Level of Effort / Earmarking

GSA_MIGRATION

View Audit 282473

Finding 322672 (2022-004)

None 2022

Heartland Care Center Inc.

IA

Internal Control / Segregation of Duties Subrecipient Monitoring Matching / Level of Effort / Earmarking

INSURANCE POLICY CO-OBLIGEE Criteria: The Organization is responsible for having the USDA Rural Development listed as a co-obligee on fidelity bonds or mortgagee (loss payee) on the property insurance policy....

INSURANCE POLICY CO-OBLIGEE Criteria: The Organization is responsible for having the USDA Rural Development listed as a co-obligee on fidelity bonds or mortgagee (loss payee) on the property insurance policy. Condition: During our review of internal control procedures for the Community Facilities Loans & Grants Cluster, we identified the USDA Rural Development was not listed as a co-obligee on the fidelity bonds or mortgagee (loss payee) on the property insurance policy. Cause: The requirement was not met due to managements? oversight of the requirement to update the property insurance policy. Potential Effect: As a result, the Agency reserves the right to withdraw Agency funding. Recommendation: The Organization should review current procedures to ensure that they are complying with all requirements of the USDA Rural Development loan. Client Response: The Organization will review their monitoring procedures to ensure that they follow loan requirements and also update the insurance policy to include USDA Rural Development as the mortgagee (loss payee).

View Audit 282473

Finding 316358 (2022-078)

Significant Deficiency 2022

State of Colorado

CO

Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303 § 200.332 § 200.521

(A) CDOT will work with various divisions to devise a plan that will comply with this finding and the recommendations noted within. This plan shall include identifying a centralized location for all policies and procedures related to subrecipient monitoring. We will look at all policies and procedur...

(A) CDOT will work with various divisions to devise a plan that will comply with this finding and the recommendations noted within. This plan shall include identifying a centralized location for all policies and procedures related to subrecipient monitoring. We will look at all policies and procedures to ensure they clearly identify responsibilities and requirements for non-compliance. (B) CDOT will work with various divisions to devise a plan that will comply with this finding and the recommendations noted within. This plan shall include establishing a process by which an analysis of contracted entities will be performed to identify and properly record entities as a vendor or subrecipient.

View Audit 282464

Finding 316224 (2022-050)

Material Weakness 2022

State of Colorado

CO

Eligibility Internal Control / Segregation of Duties Subrecipient Monitoring

(B) The Department revised its training model which is on track and will be fully rolled out to all eligibility sites by July 2022. (D) The Department disagrees with the auditor?s findings and questioned costs related to capitation payments under the Eligibility Issues Identified through Data Analy...

(B) The Department revised its training model which is on track and will be fully rolled out to all eligibility sites by July 2022. (D) The Department disagrees with the auditor?s findings and questioned costs related to capitation payments under the Eligibility Issues Identified through Data Analyses section. These costs are related to cases that were ?not eligible? in CBMS but were showing as ?eligible? in Colorado interChange that were already identified by the Department. The Department was actively working to resolve these cases with CMS prior to the Public Health Emergency (PHE). The Department developed and implemented a reconciliation report that is used to research and resolve CBMS and Colorado interChange interface mismatches. Members identified on the reconciliation reports were being manually updated until March 2020. CMS instructed the Department to cease work on these cases when the PHE was implemented. During the PHE the Department was not allowed to terminate benefits for anyone receiving benefits prior to March 2020, even if eligibility was determined incorrectly prior to the PHE. During this unprecedented time, the authority and operations regarding these cases was not immediately available. The auditors? retrospective review fails to address the uncertainty that occurred during this period of the PHE. The Department agrees to resume work on the manual reconciliation process when authorized by CMS.

View Audit 282464

Finding 316202 (2022-048)

Material Weakness 2022

State of Colorado

CO

Subrecipient Monitoring Eligibility Allowable Costs / Cost Principles

(A) Caseworker errors can be caused by an array of issues, including, training material retention; a lack of adequate funding to balance caseload inventory versus available work hours and staffing levels; a lack of quality review and performance reinforcement; and an assortment of local issues that ...

(A) Caseworker errors can be caused by an array of issues, including, training material retention; a lack of adequate funding to balance caseload inventory versus available work hours and staffing levels; a lack of quality review and performance reinforcement; and an assortment of local issues that lead to employee turnover. The Department will continue to work with eligibility sites regarding caseworker errors identified through this audit. The Department?s caseworker training resources, or Staff Development Center (SDC), is in the process of revamping all of their foundational training materials into a "Process-Based Training" model to be more effective and efficient based on training industry best practice. In addition, the SDC is converting all training materials into several different training modalities (instructor led courses, eLearning courses, desk aids, process manuals, infographics, workbooks, etc.) to be more engaging, effective, and accessible to adult learners with varying needs and preferences across large geographical areas. The revised training model is on track to be completed by July 31, 2021 and fully rolled out to all counties by Fiscal year end 2022. (C) The Department has thoroughly researched the issues identified in this audit and has made changes to CBMS to ensure that it is using the correct income information, income thresholds in determining eligibility, and buy-in premiums are assessed. These issues were fixed May 2019, February 2020, and March 2020, and in June 2021 the income information system issue will be corrected. The Department disagrees with the auditor?s questioned costs and projection of those questions costs. The Department disagrees with the auditor?s sampling, stratification, and costs used to generate the projected questioned costs. The costs incorrectly include members who remain eligible once the identified error had been resolved, payments that will be recovered by the Department through an existing process to recover capitation payments from deceased members, a Social Security Administration (SSA) interface error outside the control of the Department, and costs related to an already identified issue regarding reconciling eligibility between CBMS and Colorado interChange. Some of these costs are related to cases that were ?not eligible? in CBMS but were showing as ?eligible? in Colorado interChange that were already identified by the Department and should have been excluded from the questioned costs and the resulting projections. The Department will resume the reconciliation process between CBMS and Colorado interChange when authorized by CMS. Regarding the SSA interfaces, SSA posted results that are valid conditions for Medicaid eligibility, so those costs should have been excluded from the resulting projections. The Department agrees to bring interface issues to the attention of SSA. The Department has heard that other individuals have been notified on an SSA incarceration status which was incorrect. We have reached out to SSA concerning interface issues and will reach out again. In the meantime we will work with our eligibility workers to attempt to update these cases when they occur.

View Audit 282464

Finding 316201 (2022-054)

Material Weakness 2022

State of Colorado

CO

Eligibility Questioned Costs Subrecipient Monitoring § 200.303

(A) The state implemented the first phase of the monitoring dashboard in June 2020 with Project 13889 that identifies members that are active with no SSN without exemptions. The second phase of the monitoring dashboard implementation was pushed back to July 2023 due to competing legislative mandates...

(A) The state implemented the first phase of the monitoring dashboard in June 2020 with Project 13889 that identifies members that are active with no SSN without exemptions. The second phase of the monitoring dashboard implementation was pushed back to July 2023 due to competing legislative mandates.

View Audit 282464

Finding 316200 (2022-053)

Significant Deficiency 2022

State of Colorado

CO

Eligibility Procurement, Suspension & Debarment Subrecipient Monitoring

(A) The Department completed the system enhancement, allowing on-going data feeds from DORA into the interChange. The enhancement included implementation of a front-end claim edit, to prevent claim payments to providers with an expired license. The edit will be functional once the impact to provider...

(A) The Department completed the system enhancement, allowing on-going data feeds from DORA into the interChange. The enhancement included implementation of a front-end claim edit, to prevent claim payments to providers with an expired license. The edit will be functional once the impact to providers has been determined. The project was completed mid July 2022 with courtesy notices to our provider network, to update license information as applicable. Policies and procedures were updated to address this finding on May 17, 2022. The policy and procedure is effective July 1, 2022. (B) The Department has updated its policies and procedure for reviewing license actions, effective July 1, 2022. (C) Licensure continues to be a quality monitoring criterion for the Department and the Fiscal Agent. The Department completed the system enhancement, allowing on-going data feeds from DORA into the interChange. The enhancement included implementation of a front-end claim edit, to prevent claim payments to providers with an expired license. The edit will be functional once the impact to providers has been determined. The project was completed mid July 2022 with courtesy notices to our provider network, to update license information as applicable.

View Audit 282464

Finding 316199 (2022-052)

Material Weakness 2022

State of Colorado

CO

Internal Control / Segregation of Duties Reporting Eligibility

(A) The Department agrees with the audit recommendation to develop and implement formal written policies and procedures. Prior to this audit, the Department began creating formal written policies and procedures for site case reviews, maintenance of supporting documentation, timely training for faile...

(A) The Department agrees with the audit recommendation to develop and implement formal written policies and procedures. Prior to this audit, the Department began creating formal written policies and procedures for site case reviews, maintenance of supporting documentation, timely training for failed workers, and performance of timely re-certification of presumptive eligibility sites (PE site). This finding had no known questionable cost associated with it. (B) The Department agrees with the audit recommendation to develop an effective tracking mechanism to identify and monitor PE sites that are due for re-certification every two years and ensuring that the recertifications are performed. Prior to this audit, the Department began developing a tracking mechanism for PE site re-certifications. This finding had no known questionable cost associated with it. (C) The Department fixed enrollment information for Fiscal Year 2020 and 2021 in CBMS for beneficiaries who were no longer eligible for presumptive eligibility and have either had their benefits terminated or were moved to the regular Medicaid and Children?s Basic Health Plan programs. The Department is currently performing regular reviews to appropriately terminate applicants? presumptive eligibility in CBMS when appropriate. However, the Department has not addressed the programming and system issues in CBMS. The Department plans to fully implement this recommendation by December 2022.

View Audit 282464

Finding 316197 (2022-049)

Material Weakness 2022

State of Colorado

CO

Eligibility Questioned Costs Subrecipient Monitoring

(A) The Department will create written procedures documenting system and monitoring processes used to prevent claims from paying after a beneficiary?s date-of-death is verified. In addition, the procedures will document the processes used to recover payments made between a beneficiary?s verified dat...

(A) The Department will create written procedures documenting system and monitoring processes used to prevent claims from paying after a beneficiary?s date-of-death is verified. In addition, the procedures will document the processes used to recover payments made between a beneficiary?s verified date-of-death and the date the Colorado interChange system is updated with the date-of-death. (B) The system issues described in this audit were resolved as of April 2020 for fee-for-service claims and November 2020 for capitation payments. Once a beneficiary's date-of-death is verified, payments that were made after to the date-of-death will be recovered through the Department's existing processes. As noted in the Department?s response to Recommendation (A), the Department will create written procedures documenting system and monitoring processes used to prevent claims from paying after a beneficiary?s date-of-death is verified. In addition, the procedures will document the processes used to recover payments made between a beneficiary?s verified date-of-death and the date the Colorado interChange system is updated with the date-of-death. (C) The review for FFS claims is complete and all Notices of Adverse Action have been sent to providers. At this time we are waiting on any requests for informal reconsiderations, appeals, and/or payments to process.

View Audit 282464

Finding 316196 (2022-055)

Material Weakness 2022

State of Colorado

CO

Eligibility Questioned Costs Procurement, Suspension & Debarment § 200.303

(A) The Department continues to work with the Fiscal Agent to ensure that the required database matches occur and the interChange properly displays the results of Social Security Number and Federal Employer Identification Number verifications for all providers. The project was completed mid July 202...

(A) The Department continues to work with the Fiscal Agent to ensure that the required database matches occur and the interChange properly displays the results of Social Security Number and Federal Employer Identification Number verifications for all providers. The project was completed mid July 2022.

View Audit 282464

Finding 316195 (2022-047)

Material Weakness 2022

State of Colorado

CO

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Questioned Costs § 200.303 § 200.516 § 200.84

(B) The Department will review and revise, as necessary, its taxi claim billing requirements and rates to ensure that they are consistent. In addition, the Department will devise controls to ensure that taxi claims are paid in accordance with established requirements and rates and explore controls t...

(B) The Department will review and revise, as necessary, its taxi claim billing requirements and rates to ensure that they are consistent. In addition, the Department will devise controls to ensure that taxi claims are paid in accordance with established requirements and rates and explore controls to ensure that only permitted providers bill as a taxi. The Department is working on reductions in the max fee and unit limits for taxi claim billing codes, which it will have completed by the end of October 2021. In addition, the Department is considering systematically pricing the code at each taxi provider?s specific Public Utilities Commission (PUC) rate. This change, if pursued, will require a system change request, which will take a year or more, which is why the Department has selected an implementation date of December 2022. If this proves infeasible, alternate controls will be implemented. HCPF has met with DORA PUC. The Department is trying to establish a process to decide if the PUC taxi rate still applies or an internal rate can be created. Because of these discussions and needed system changes the implementation date has been moved to December 2023. (D) The Department intends to define in rule the types of documentation that NEMT providers must keep on hand and make clear that they must furnish records to the Department upon request. The July 2022 date will allow for the completion of formal rulemaking. The Department further intends to develop and implement a process to perform regular risk-based provider file reviews with a focus on noncompliant providers. These reviews will ensure, at a minimum, that the providers? paid claims are supported with appropriate documentation and represent the least costly option appropriate to meet each recipient?s needs. The Department met with the RAC team on February 22, 2023 to come up with a process to perform small audits for claims from providers that are outside the Intelliride service area. New systems will be implemented which has pushed the anticipated completion date to December 2023. (E) The Department will amend its contract with its NEMT broker by adding a mandatory annual audit so that it can reconcile trip scheduling data with paid claims data. This will help ensure that the Department pays accurately, pays for NEMT services, and pays for the least costly transportation option appropriate for each recipient. The Department chose July 2022 to add the audit through its annual contract amendment and renewal processes. The contract amendment was completed and signed June 30, 2022 that included a clause for an annual audit of claims. (F) The Department will develop a data review process to reconcile interChange data on NEMT trip claims to interChange data on Medicaid medical claims. This process will entail periodic reviews of NEMT claims to see if members have corresponding medical claims on those dates. If they do not, the Department will follow up with the appropriate NEMT provider to investigate. The July 2022 implementation date reflects the potential need for system changes. This is implemented, the Department has been pulling claims data and where corresponding medical claims are not found HCPF is investigating on a case by case basis to find the cause. (G) Department staff will work with the Department?s Program Integrity (PI) staff on processes to investigate and recover, as appropriate, the overpayments and inappropriate payments that the audit identified as known or likely questioned costs, and repay the federal portion, as appropriate. The December 2022 implementation date reflects the time needed to investigate and when appropriate, recover any overpayments. This has been implemented and the federal portion has been returned to CMS. (H) The Department will develop a process to track staff time and productivity to ensure that it has sufficient staff assigned to oversee and administer NEMT. This process will include documenting time spent each week on various tasks to get a sense of where help is needed, and which tasks take up the most staff resources. Based on its findings, the Department will explore staffing options, as needed. The Department selected the July 2022 implementation date to allow for data collection through the end of State Fiscal Year 2021-22. This has been implemented. New NEMT staff was hired November 1, 2022 to act as the liaison to the counties and clients in the 55 counties outside of the Intelliride service area.

View Audit 282464

Finding 316194 (2022-046)

Material Weakness 2022

State of Colorado

CO

Questioned Costs Subrecipient Monitoring Material Weakness § 200.303

The Department did not have strong enough controls for the initial checks on the financial data reporting templates. This process has been updated and will be rectified in coming cycles. The Department has modified its templates in order to address the concerns provided by the auditors including sig...

The Department did not have strong enough controls for the initial checks on the financial data reporting templates. This process has been updated and will be rectified in coming cycles. The Department has modified its templates in order to address the concerns provided by the auditors including signatures and supplemental reporting. Written policies and procedures for the validation and audit of the templates are being developed currently and will be in place and effective in December 2022. The Department will be correcting this error by posting the audit results along with other quality and audit reports on the following site: https:hcpf.colorado.gov/quality-and-healthimprovement-reports.

View Audit 282464

Finding 316193 (2022-045)

Material Weakness 2022

State of Colorado

CO

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

(A) The MLR report template has been updated and will now be reviewed at least yearly by the Department. In addition, new written policies and procedures are being developed and will be implemented before the submission of the next MLR for review. (B) The Department will add contract language and e...

(A) The MLR report template has been updated and will now be reviewed at least yearly by the Department. In addition, new written policies and procedures are being developed and will be implemented before the submission of the next MLR for review. (B) The Department will add contract language and enforcement mechanisms in order to receive accurate information in a timely manner. This includes specific timelines for correcting incomplete or inaccurate information in order to submit the MLR report timely to the Centers for Medicare & Medicaid Services.

View Audit 282464

Finding 316192 (2022-044)

Material Weakness 2022

State of Colorado

CO

Eligibility Questioned Costs Subrecipient Monitoring

(B) The Department will continue our existing proactive approach to minimize this issue. The resolution of a SSN discrepancy is addressed through manual intervention by county eligibility technicians when identified through the system edit implemented in December 2020. The Department will continue t...

(B) The Department will continue our existing proactive approach to minimize this issue. The resolution of a SSN discrepancy is addressed through manual intervention by county eligibility technicians when identified through the system edit implemented in December 2020. The Department will continue the existing process to address duplicate SSNs. The Department has already made significant progress to monitor CBMS through the use of CBMS monitoring dashboards. These dashboards allow the Department to monitor and perform daily analysis. The Department meets bi-weekly to discuss findings and next steps to resolve any issues identified through the dashboard. These dashboards are being implemented over time as areas of improvements are identified. As part of the Department's continual improvement strategy, SSN discrepancy reports are included in the next implementation phase of the monitoring dashboards scheduled for June 2023. The Department will develop and implement policies and procedures outlining how the report will be used to effectively monitor and correct SSN and State ID discrepancies. Once that work is complete, the Department will send updated written guidance to our county and medical assistance sites on how to use system edits, reports, and dashboards to resolve duplicate SSNs. (C) The Department will continue our existing proactive approach to minimize this issue. The resolution of a SSN discrepancy is addressed through manual intervention by county eligibility technicians when identified through the system edit implemented in December 2020. The Department will continue the existing process to address duplicate SSNs. The Department has already made significant progress to monitor CBMS through the use of CBMS monitoring dashboards. These dashboards allow the Department to monitor and perform daily analysis. The Department meets bi-weekly to discuss findings and next steps to resolve any issues identified through the dashboard. These dashboards are being implemented over time as areas of improvements are identified. As part of the Department's continual improvement strategy, SSN discrepancy reports are included in the next implementation phase of the monitoring dashboards scheduled for June 2023. Once that work is complete, the Department will send updated written guidance to our county and medical assistance sites on how to use system edits, reports, and dashboards to resolve duplicate SSNs appropriately and in a timely manner.

View Audit 282464

Finding 316191 (2022-043)

Material Weakness 2022

State of Colorado

CO

Eligibility Questioned Costs Procurement, Suspension & Debarment § 200.303

(A) The Department and CBMS teams have strengthened their internal controls to ensure payments are only made to providers for eligible members. The Department and CBMS teams will update all member records identified on the Monthly Reconciliation report once the Public Health Emergency ends. TRAILS ...

(A) The Department and CBMS teams have strengthened their internal controls to ensure payments are only made to providers for eligible members. The Department and CBMS teams will update all member records identified on the Monthly Reconciliation report once the Public Health Emergency ends. TRAILS team has provided additional training to the Case Managers to prevent data integrity issues being submitted to CBMS and interChange; however, the TRAILS team does not plan to update the system's internal controls until funding is available. (B) The Department agrees to review the monthly eligibility reconciliation report and is looking forward to resolving the member records once the Public Health Emergency ends to fully resolve the audit finding.

View Audit 282464

Finding 308694 (2022-067)

Material Weakness 2022

State of Colorado

CO

Subrecipient Monitoring Matching / Level of Effort / Earmarking Reporting § 200.1

(A) CDHS agrees that it needs to it needs to correct the automated reporting process from the eClearance system used to gather data needed for our FFATA reporting. The department thought that the reports obtained from eClearance were complete and relied on them as the basis of our reporting. Upon in...

(A) CDHS agrees that it needs to it needs to correct the automated reporting process from the eClearance system used to gather data needed for our FFATA reporting. The department thought that the reports obtained from eClearance were complete and relied on them as the basis of our reporting. Upon investigation we found that an internal process change enacted during the implementation of another system at the start of the pandemic was the cause of the data discrepancy. This occurred because the new system made the routing in eClearance after a certain point unnecessary for internal processing so this stopped. It was unknown that this further routing to archive files in eClearance was the trigger for eClearance to push out FFATA report data. Since the department has been able to identify the cause we are able to immediately remedy the problem and ensure that all processes are in sync to ensure accurate and complete FFATA data is contained in automated reporting processes. The department will catch up on FFATA reporting that was missed during this time frame. (B) The department agrees that it needs to implement procedures to validate that data derived from automated processes used as a basis for FFATA reporting should be periodically validated against another data source. To do this the department will create and implement procedures to use CORE reports of encumbrance data referencing subrecipient object codes and tie this to information received from the automated eClearance report. Doing this will validate that the data provided from eClearance is a complete listing of all FFATA reportable subrecipient awards, and thus is a valid source to base FFATA reporting on. This will also help us monitor the process in case any future inadvertent changes are made to processes that could cause data validity issues. (C) CDHS agrees that a supervisory review is needed over the FFATA reporting process in order to ensure more consistency, accuracy and timeliness in reporting processes and standards. The department is currently developing procedures that will allow for more oversight of the FFATA reporting through supervisory reviews and cross training staff on FFATA reporting duties. Supervisory reviews will help ensure that reporting is completed in line with reporting procedures and timeframes and can be a second set of eyes to ensure that information appears accurate and adds analytical judgement value (example - a supervisor might see that July typically has high volume, but this July volume is low, why). In addition, the department is taking this opportunity to cross train other staff on the process so that more individuals can be involved which leads to more transparency over processes allowing various individuals to notice if something isn't working as designed. These new procedures are being developed and implemented as the department catches up on reporting subrecipient awards that were missed since the automated process stopped working.

View Audit 282464

Finding 308689 (2022-069)

Material Weakness 2022

State of Colorado

CO

Equipment & Real Property Management Internal Control / Segregation of Duties Questioned Costs § 200.303

(B) The Department agrees to develop and implement policies and procedures requiring Department staff to perform reconciliations of recipient agencies? and Regional Food Banks? physical inventories to the Web-based Supply Chain Management system to ensure inventory records are complete and accurate....

(B) The Department agrees to develop and implement policies and procedures requiring Department staff to perform reconciliations of recipient agencies? and Regional Food Banks? physical inventories to the Web-based Supply Chain Management system to ensure inventory records are complete and accurate. Starting in January 2021 the Department began developing a position description for an Inventory Specialist with the focus of ensuring accurate and thorough accounting of all year-end inventory and reconciliations. The position was hired in April 2021. Due to the implementation of the inventory database and the timing of beginning and ending inventories, the Department anticipates being able to do a full reconciliation of inventories by December 2022. (C) The Department agrees to develop and implement a tracking system for food inventory at recipient agencies and Regional Food Banks using the Web Supply Chain Management system receipts as the basis of food received, including the maintenance of supporting documents. The Department is undertaking an inventory overhaul which includes implementing a new inventory database and creating and hiring an Inventory Specialist. The Department recognized the need for inventory software and started the process of obtaining it in June 2020. In May 2021, the Department received a signed licensing agreement for a new database which is expected to be implemented in six months per an OIT timeline. In addition to the database, the Department recently hired a new Inventory Specialist position. This position will lead the development of policies, procedures, inventory reconciliations, and monthly report management. Once the Inventory Specialist has a comprehensive understanding of federal and state policy and the new database software, the Department will develop policies and procedures, training for partner agencies, and roll out new requirements for the tracking and reconciliation of program inventories.

View Audit 282464

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