Corrective Action Plans

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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
Finding 548695 (2024-012)
Significant Deficiency 2024
2024-012. Inadequate SLFRF Subrecipient Monitoring State Agency: Governor’s Office of Planning and Budget Federal Agency: Department of the Treasury To help staff at DEQ, DNR, and other agencies managing SLFRF funding improve their understanding of the subrecipient requirements and improve internal ...
2024-012. Inadequate SLFRF Subrecipient Monitoring State Agency: Governor’s Office of Planning and Budget Federal Agency: Department of the Treasury To help staff at DEQ, DNR, and other agencies managing SLFRF funding improve their understanding of the subrecipient requirements and improve internal controls to ensure compliance with these requirements, GOPB will review its ARPA Reference Guide and other ARPA SLFRF training materials to make sure these materials provide adequate guidance, policies, and procedures to agencies managing ARPA SLFRF funding. GOPB will specifically review guidance on the following: • Establishing and following agency policies and procedures to ensure compliance with subrecipient monitoring requirements. • Communicating required federal award information to sub-recipients • Evaluating each subrecipients risk of noncompliance with federal statutes, regulations, and the terms and conditions of the subaward. • Monitor subrecipients according to their assessed risk and as required by 2 CFR 200.332. As part of the process of reviewing these materials, GOPB will work with DEQ and DNR to understand specific areas of guidance, training, or compliance that need to be strengthened. After reviewing and updating the ARPA Reference Guide and other ARPA SLFRF training materials, GOPB will distribute the updated guide to all agencies managing ARPA SLFRF funding. Additionally, GOPB will hold a dedicated training session with both DEQ and DNR, focusing on key areas such as subrecipient compliance requirements, internal controls, risk-based monitoring, Single Audit requirements, and federal compliance standards. GOPB will also maintain a schedule of regular training, site visits, and reviews to ensure ongoing adherence to monitoring protocols and to reinforce internal controls across all agencies. Contact Person: Duncan Evans, Senior Managing Director of Budget and Operations, 801-538-1592 Anticipated Correction Date: November 30, 2024 State Agency: Department of Natural Resources The Department of Natural Resources will review the ARPA Reference Guide and other GOPB ARPA SLFRF training materials provided by Governor’s Office of Planning and Budget to ensure our agency is compliant with managing all SLFRF subrecipient requirements and improve internal controls. DNR will work with GOPB to ensure that key personnel in our agency are doing the following: • Gaining a better understanding of subrecipient requirements and associated internal controls. Water Resources will review the ARPA Reference Guide and GOPB ARPA SLRF training materials to identify internal control weaknesses so they can be addressed. The Finance Manager, Contract/Grants Analyst and Project Funding Section Manager at the Division of Water Resources will also meet directly with GOPB by December 16, 2024 to ensure we understand all subrecipient monitoring requirements. • Establishing and following written policies and procedures to ensure compliance with subrecipient monitoring requirements. The Finance Manager will establish written policies and procedures by December 16, 2024 to ensure compliance with subrecipient monitoring requirements. • Communicating required federal award information to sub-recipients. Federal award information is included in all ARP A contracts executed by the Division of Water Resources and has been since June 2023. Federal award information associated with ARPA contracts executed before June 2023 were subsequently distributed to those grant applicants so that all grantees have the required federal award information. We will continue to review and ensure we are compliant with this requirement. • Evaluating each subrecipient's risk of noncompliance with federal statutes, regulations, and the terms and conditions of the subaward. Since May 2024 Water Resources has been requiring each ARPA grant applicant to fill out a risk assessment questionnaire. We will continue to assess responses to our grant recipients. The Finance Manager and the Project Funding manager will distribute a risk assessment questionnaire to all other grant recipients who have not filled one out yet so we have this information on file for all of our ARPA grantees. This will be completed by December 16, 2024. • Monitoring subrecipients according to their assessed risk and as required by 2 CFR 200.332. The Finance Manager and the Project Funding Manager will meet prior to December 16, 2024 to determine if additional monitoring tools are necessary for any of our subrecipients, which could include site visits, technical assistance, or additional monitoring based upon potential risk. As part of the process of reviewing these requirements, DNR will work with GOPB to understand specific areas of guidance, training, or compliance that need to be strengthened. DNR will work closely with GOPB to ensure specific personnel are trained, focusing on key areas such as subrecipient compliance requirements, internal controls, risk-based monitoring, Single Audit requirements, and federal compliance standards. DNR will ensure that this corrective action plan is implemented and adhered to. State Agency: Department of Environmental Quality DEQ is in the process of hiring a new FTE, one of whose responsibilities will be to review and monitor DEQ’s compliance with sub-recipient monitoring requirements for ARPA and other federal funds. This will ensure that risk assessments, Single Audit report reviews, and other monitoring activities are completed timely, properly documented, and in compliance with federal requirements. Responsible Person: Craig Silotti, Finance Director, 801 536-4460 Anticipated Completion Date: January 31, 2024
Finding 548694 (2024-009)
Significant Deficiency 2024
2024-009. Unallowable Cash Medical Assistance Benefit Issuances State Agency: Department of Workforce Services Federal Agency: Department of the Treasury All cases cited in error have been reviewed, and all corrective actions have been completed. One-on-one meetings with individual staff who took ap...
2024-009. Unallowable Cash Medical Assistance Benefit Issuances State Agency: Department of Workforce Services Federal Agency: Department of the Treasury All cases cited in error have been reviewed, and all corrective actions have been completed. One-on-one meetings with individual staff who took approval actions on these cases will be scheduled to discuss what led to the incorrect decision and review the policy and procedure for learning. In addition, all eligibility workers who manage refugee programs will receive training on common error elements. All one-on-one meetings and team training will be completed by April 30, 2025. Anticipated correction date: April 30, 2025 Responsible person: Muris Prses, Division Director, Eligibility Services Division, 801-889-9712
View Audit 352012 Questioned Costs: $1
Finding 548693 (2024-007)
Significant Deficiency 2024
2024-007. Refugee Grant Expenditures Charged Outside Award Period State Agency: Department of Workforce Services Federal Agency: Department of Health and Human Services The department will implement a more detailed and thorough review of transactions to ensure that costs are attributed to the applic...
2024-007. Refugee Grant Expenditures Charged Outside Award Period State Agency: Department of Workforce Services Federal Agency: Department of Health and Human Services The department will implement a more detailed and thorough review of transactions to ensure that costs are attributed to the applicable period of performance in which the work was performed, and expenses were incurred and will ensure that costs are subsequently charged to the corresponding grant award. Anticipated correction date: January 31, 2025 Responsible person: Nathan Harrison, Executive Finance Director, 801-808-0676
View Audit 352012 Questioned Costs: $1
Finding 548692 (2024-006)
Significant Deficiency 2024
2024-006. TANF ACF-204 Report Does Not Match Supporting Documentation State Agency: Department of Workforce Services Federal Agency: Department of Health and Human Services The report processes will be updated to add internal controls. The program manager will coordinate with finance staff to review...
2024-006. TANF ACF-204 Report Does Not Match Supporting Documentation State Agency: Department of Workforce Services Federal Agency: Department of Health and Human Services The report processes will be updated to add internal controls. The program manager will coordinate with finance staff to review all finance documentation utilized for the report. Prior to submission of the report, it will be reviewed by division and finance leadership to ensure the report aligns with documentation and is correct. Anticipated correction date: December 31, 2024 Responsible person: Liz Carver, Division Director, 801-514-1017
We concur with the auditor’s finding. The University has engaged a third party to review our reconciliation procedures and to make recommendations on improvements to our current policy. The recommendations will also include any additional documentation showing proof that the reconciliation has been ...
We concur with the auditor’s finding. The University has engaged a third party to review our reconciliation procedures and to make recommendations on improvements to our current policy. The recommendations will also include any additional documentation showing proof that the reconciliation has been completed as timely as required. The Vice President of Business & Finance and the Director of Student Financial Aid will review the reconciliations. Monitoring reports will be completed and shared with senior management and relevant department leaders. Implementation date: Immediately. Persons Responsible: Vice President for Business and Finance, Controller, and Director of Student Financial Aid.
Subrecipient Agreements Significant Deficiency and Non-Material Noncompliance Recommendation: We recommend the City review 2CFR200 to ensure information required in subrecipient agreements is properly included. Corrective Action: The Housing and Homelessness Division is aware of the deficiency ident...
Subrecipient Agreements Significant Deficiency and Non-Material Noncompliance Recommendation: We recommend the City review 2CFR200 to ensure information required in subrecipient agreements is properly included. Corrective Action: The Housing and Homelessness Division is aware of the deficiency identified and is actively coordinating with the City’s legal department to incorporate the required information into the City’s subrecipient agreement templates. Staff will review the 2CFR200 and ensure the required information is incorporated into the City’s sub-recipient agreement templates. Person Responsible for Corrective Action: The Housing and Division Managers, Senior Management Analyst, City’s Legal Department. Anticipated Completion Date for Corrective Action: 8 Weeks from approval of this corrective action plan 2024-03 – Subaward Reporting Requirements for Federal Funding Accountability and Transparency Act (FFATA) Significant Deficiency and Non-Material Noncompliance Recommendation: We recommend the City implement a tracking system to remind staff of the various reports due and respective deadlines. Corrective Action: Develop and implement an agreement routing cover page or other tracking system for all agreements, including sub-recipient agreements. This system will consist of required action items, including various Federal, State, and Local reports due and respective deadlines necessary to comply with sub-award reporting requirements consistent with the Federal Funding Accountability and Transparency Act (FFATA) and other applicable reporting requirements. Person Responsible for Corrective Action: The Housing and Homelessness Division’s Senior Management Analyst Anticipated Completion Date for Corrective Action: 4 Weeks from approval of this corrective action plan.
Finding 548660 (2024-002)
Significant Deficiency 2024
Corrective Action: Management will track all grant expenditures using separate project codes for each award to ensure specific identification of the direct costs charged. Additionally, at the end of the reporting period, management will perform a reconciliation between the direct costs charged and t...
Corrective Action: Management will track all grant expenditures using separate project codes for each award to ensure specific identification of the direct costs charged. Additionally, at the end of the reporting period, management will perform a reconciliation between the direct costs charged and the total revenues earned under each award to ensure the amounts are consistent with those reported in the schedule of expenditures of federal awards. Anticipated Completion Date: June 30, 2025
Federal Award Finding: 2024-001 Material Weakness in Compliance and Internal Control over Reporting Name and Contact Person: Adrienne Gaines, Executive Director Corrective Action: WISH has evaluated and revised the processes and procedures regarding monitoring of grant reporting and deadlines, as we...
Federal Award Finding: 2024-001 Material Weakness in Compliance and Internal Control over Reporting Name and Contact Person: Adrienne Gaines, Executive Director Corrective Action: WISH has evaluated and revised the processes and procedures regarding monitoring of grant reporting and deadlines, as well as the processes for maintaining records supporting all grant reports, submission details, and corresponding approvals. Management will appoint an individual to oversee this for each grant. Proposed Completion Date: June 30, 2025
Name of Responsible Individual: Vice President of Enrollment Management (Dr. Stacey Sowell), Director of Financial Aid (Dr. Ojebe Ifegwu), University Registrar (Charee Ellison) Corrective Action: The University concurs with the finding and will monitor internal controls to ensure that the return of...
Name of Responsible Individual: Vice President of Enrollment Management (Dr. Stacey Sowell), Director of Financial Aid (Dr. Ojebe Ifegwu), University Registrar (Charee Ellison) Corrective Action: The University concurs with the finding and will monitor internal controls to ensure that the return of Title IV funds is processed in accordance with federal regulations, specifically within the required 45-day timeframe after determining a student has withdrawn from the university. The university will establish a quarterly audit and monitoring system to review all Title IV fund returns, ensuring compliance with federal guidelines. Anticipated Completion Date: June 30, 2025
Corrective Action Plan: The County (Human Services Agency) acknowledges that, at the time of the FY 2023/24 audit, there was no documented process for completing risk assessments, obtaining copies of single audit reports for each FFA, group home, and STRTP subrecipient, or issuing management decisio...
Corrective Action Plan: The County (Human Services Agency) acknowledges that, at the time of the FY 2023/24 audit, there was no documented process for completing risk assessments, obtaining copies of single audit reports for each FFA, group home, and STRTP subrecipient, or issuing management decision letters as part of a documented monitoring policy and procedure. The County (Human Services Agency) relies on CDSS to perform certain licensing and oversight functions as the single state agency for Title IV-E funds. The County (Human Services Agency) is responsible for and does review these audits and their findings. In response to this finding, the County (Human Services Agency) has established a documented process, implemented in FY 2024/25 documenting risk assessments, obtaining copies of the single audit reports for each FFA, group homes, and STRTPs subrecipient, and issuing management decision letters to ensure compliance. Anticipated completion date June 30, 2025. Contact Information of Responsible Official: Atonya Moore Deputy Director – Fiscal Kings County Human Services Agency 559-852-2214
The District is aware of the importance of maintaining documentation that demonstrates expenditures charged to a program are allocable and allowable. The District will review existing procedures related to the review of temporary workers to ensure that documentation is available to demonstrate charg...
The District is aware of the importance of maintaining documentation that demonstrates expenditures charged to a program are allocable and allowable. The District will review existing procedures related to the review of temporary workers to ensure that documentation is available to demonstrate charges to programs comply with federal guidelines and regulations. The District also recognizes the importance of timely approval of time and effort in compliance with federal regulations. While the District does perform regular reconciliations of expenses to ensure allowability, the District will review and update procedures, as necessary, to continue to improve and document timely supervisory approvals after each bi-weekly payroll is processed in relation to finding 2024-01 in the District’s Report on Internal Controls and Compliance.
View Audit 351965 Questioned Costs: $1
The Finance Department is currently implementing procedures to ensure all frequent and infrequent federal compliance requirements are thoroughly reviewed and adhered with for ongoing federal programs.
The Finance Department is currently implementing procedures to ensure all frequent and infrequent federal compliance requirements are thoroughly reviewed and adhered with for ongoing federal programs.
Finding 548605 (2024-002)
Significant Deficiency 2024
Finding 2024-002 Special Tests and Provision – Internal Control and Compliance over Environmental Reviews (Significant Deficiency) Criteria: Title 24 U.S. Code of Federal Regulations sections 58.1, 58.22, 58.34, 58.35, and 570.604 require projects to have an environmental review unless they meet ...
Finding 2024-002 Special Tests and Provision – Internal Control and Compliance over Environmental Reviews (Significant Deficiency) Criteria: Title 24 U.S. Code of Federal Regulations sections 58.1, 58.22, 58.34, 58.35, and 570.604 require projects to have an environmental review unless they meet criteria specified in the regulations that would exempt or exclude them from environmental certification requirements. For projects where the environmental review was not performed, a written documentation that the review was not required must be prepared. Condition and Context: The City could not provide support that there was pre-award or post-award review of grant projects to determine if a project requires an environmental review or is categorically excluded from the environmental review requirements. The City did not have adequate internal controls to ensure compliance with the special test – environmental review requirements. Testing was performed over each requirement for the City. Out of a total population of twelve (12) projects, we selected a sample of four (4) projects to test for environmental reviews. Four (4) out of the four (4) projects tested did not have an exemption report prepared in a timely manner. The sample was not intended to be, and was not, a statistically valid sample. City’s Corrective Action Plan: The City will reinforce its standard operating procedure concerning Environmental Reviews (ER) and will reinsure that environmental reviews are properly completed for every awarded grant project. Contact person responsible for corrective action: Michael Lima, Finance Director Anticipated completion date: June 30, 2025
Finding 548601 (2024-001)
Significant Deficiency 2024
Finding 2024-001 Reporting – Internal Control and Compliance over Reporting (Significant Deficiency) Criteria: Code of Federal Regulations, Title 2 – Federal Financial Assistance, Subtitle A – Office of Management and Budget Guidance for Federal Financial Assistance, Chapter II – Office of Managem...
Finding 2024-001 Reporting – Internal Control and Compliance over Reporting (Significant Deficiency) Criteria: Code of Federal Regulations, Title 2 – Federal Financial Assistance, Subtitle A – Office of Management and Budget Guidance for Federal Financial Assistance, Chapter II – Office of Management and Budget Guidance, Part 200 – Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, Subpart D – Post Federal Award Requirements: Performance and Financial Monitoring and Reporting Section § 200.328 Financial reporting. (a) The Federal agency must require only OMB-approved government-wide data elements on recipient financial reports. At the time of publication, this consists of the Federal Financial Report (SF-425); however, this also applies to any future OMB-approved government-wide data elements available from the OMB-designated standards lead. (b) The Federal agency or pass-through entity must collect financial reports no less than annually. The Federal agency or pass-through entity may not collect financial reports more frequently than quarterly unless a specific condition has been implemented in accordance with § 200.208. To the extent practicable, the Federal agency or pass-through entity should collect financial reports in coordination with performance reports. (c) The recipient or subrecipient must submit financial reports as required by the Federal award. Reports submitted annually by the recipient or subrecipient must be due no later than 90 calendar days after the reporting period. Reports submitted quarterly or semiannually must be due no later than 30 calendar days after the reporting period. (d) The final financial report submitted by the recipient must be due no later than 120 calendar days after the conclusion of the period of performance. A subrecipient must submit a final financial report to a pass-through entity no later than 90 calendar days after the conclusion of the period of performance. See also § 200.344. The Federal agency or pass-through entity may extend the due date for any financial report with justification from the recipient or subrecipient. Section § 200.303 Internal Controls The recipient and subrecipient must: (a) Establish, document, and maintain effective internal control over the Federal award that provides reasonable assurance that the recipient or subrecipient is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should align with the guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control-Integrated Framework” issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). (b) Comply with the U.S. Constitution, Federal statutes, regulations, and the terms and conditions of the Federal award. Condition and Context: For the Community Development Block Grants/Entitlement Grants Cluster, the City did not submit the reports within the required deadline: Report Type Award Number Period Date Due Date Submitted SF-425 Financial Program-wide reporting 7/1/2023 - 9/30/2023 10/30/2023 1/16/2024 SF-425 Financial Program-wide reporting 1/1/2024 - 3/31/2024 3/30/2024 7/24/2024 Four (4) quarterly financial reports were tested, and two (2) reports were not submitted by the required deadline. City’s Corrective Action Plan: The City has already taken steps to improve its processes/procedures to insure timely submission of all required SF-425 reports. Contact person responsible for corrective action: Michael Lima, Finance Director Anticipated completion date: June 30, 2025
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