Corrective Action Plans

Finding 537566 (2024-002)

Significant Deficiency 2024

Seniorsplus

ME

Subrecipient Monitoring Significant Deficiency Internal Control / Segregation of Duties § 200.303

Management is committed to compliance in accordance with all grant agreements and will work to formally document the Agency’s internal controls over Federal and State awards. Additional training will be provided as needed to prevent future findings.

View Audit 348846

Finding 537542 (2024-002)

Material Weakness 2024

Warrick County School Corporation

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.1 § 200.303 § 200.317 § 200.318 § 200.319

Finding 2024‐002 Finding Subject: Special Education Cluster (IDEA) ‐ Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Todd A. Armstrong, Assistant Superintendent Contact Phone Number and Email Address: (812) 897‐6036 tarmstrong@warrick.k12.in.us Views of the...

Finding 2024‐002 Finding Subject: Special Education Cluster (IDEA) ‐ Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Todd A. Armstrong, Assistant Superintendent Contact Phone Number and Email Address: (812) 897‐6036 tarmstrong@warrick.k12.in.us Views of the Responsible Official: We concur with the finding. Additional Explanation: Although the vendors selected provided specific services outlined in the federal grant, proper documentation of how those vendors were selected was not maintained. Moreover, the department believed by following the spending allotted in the grant, they were meeting necessary purchasing guidelines. Internal controls did not identify this misstep and allowed the services to be purchased. To avoid this in the future, guidelines will be prepared for all departments submitting purchase requests, and an additional control will be put in place to verify that procedures are followed. Description of Corrective Action Plan: 1) Create and write an administrative guideline that outlines expected purchasing procedures. 2) Distribute and make available the administrative guideline to employees. 3) Create an additional internal control in the business office to verify that those procedures were met with each requisition or request for purchase. 4) Provide necessary corrections to any request that does not follow guidelines. Mr. Armstrong will oversee, direct, and coordinate this process. He will work with the Corporation administrative team to develop and write the guidelines. The Business department will distribute the guidelines to all interested parties and have guidelines available upon request. Mr. Armstrong will outline expectations and determine when they have been met satisfactorily. Anticipated Completion Date: The remedy for this finding will be in place prior to June 30, 2025.

View Audit 348824

Finding 537525 (2024-001)

Significant Deficiency 2024

John F. Kennedy Center for Performing Arts

DC

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.308 § 200.403

2024-001 – Internal Control over Compliance and Compliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Contacts: Regina Frazier Title: Payroll Manager Anticipated Completion Date: September 2025 Corrective Action: The Center is dedicated to maintaining compliance wi...

2024-001 – Internal Control over Compliance and Compliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Contacts: Regina Frazier Title: Payroll Manager Anticipated Completion Date: September 2025 Corrective Action: The Center is dedicated to maintaining compliance with federal regulations concerning allowable and unallowable activities and costs. In response to the recent audit finding, the Center’s payroll department will proactively engage with key stakeholders in high-risk areas prior to the start of the fiscal year. This engagement will involve reviewing payroll submission templates and ensuring that the rates align with the most current employment agreements. Status as of March 2025: All affected employees have been reimbursed, and key stakeholders in high-risk areas have been informed of the corrective action plan.

View Audit 348794

Finding 537488 (2024-003)

Significant Deficiency 2024

City and Borough of Juneau, Alaska

AK

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

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

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

View Audit 348728

Finding 537486 (2024-003)

Significant Deficiency 2024

Town of Manchester

MD

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

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

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

View Audit 348723

Finding 537460 (2024-003)

Significant Deficiency 2024

State System of Higher Education, Commonwealth of Pennsylvania

PA

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

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

View Audit 348667

Finding 537458 (2024-002)

Significant Deficiency 2024

State System of Higher Education, Commonwealth of Pennsylvania

PA

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

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

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

View Audit 348667

Finding 537456 (2024-001)

Significant Deficiency 2024

State System of Higher Education, Commonwealth of Pennsylvania

PA

Student Financial Aid Reporting Significant Deficiency § 200.303

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

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

View Audit 348667

Finding 537424 (2024-006)

Material Weakness 2024

Blackford County Schools

IN

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.302 § 200.303 § 200.328 § 200.329 § 200.334

FINDING 2024-006 Subject: COVID‐19 ‐ Education Stabilization Fund ‐ Reporting Federal Agency: Department of Education Federal Program: COVID‐19 ‐ Education Stabilization Fund Assistance Listing Numbers: 84.425D, 84.425U Federal Award Numbers and Years (or Other Identifying Numbers): S425D210013, S42...

FINDING 2024-006 Subject: COVID‐19 ‐ Education Stabilization Fund ‐ Reporting Federal Agency: Department of Education Federal Program: COVID‐19 ‐ Education Stabilization Fund Assistance Listing Numbers: 84.425D, 84.425U Federal Award Numbers and Years (or Other Identifying Numbers): S425D210013, S425U210013 Pass‐Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Findings: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Chad Yencer, Superintendent Contact Phone Number: 765-348-7550 Views of Responsible Official: We concur with this finding Description of Corrective Action Plan: Internal Control 1. For state reporting related to ESSER grants, the Grants/Data Specialist will compile all required information and maintain thorough supporting documentation. The Corporation Treasurer will then review the compiled financial data for the reporting period, verifying its accuracy before presenting it to the Superintendent. Finally, the Superintendent will review the information and supporting documentation, confirming its accuracy prior to submission to the Indiana Department of Education (IDOE). All workpapers and calculations will be recorded and kept for verification Anticipated Completion Date: August 2025

View Audit 348618

Finding 537423 (2024-005)

Material Weakness 2024

Blackford County Schools

IN

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303 § 200.334 § 200.403

FINDING 2024-005 Subject: COVID-19 - Education Stabilization Fund - Allowable Costs/Cost Principles and Allowable Activities Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425C, 84.425U Federal Award Numbers and...

FINDING 2024-005 Subject: COVID-19 - Education Stabilization Fund - Allowable Costs/Cost Principles and Allowable Activities Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425C, 84.425U Federal Award Numbers and Year (or Other Identifying Numbers): S425D210013, S425U210013 Pass-Through Entity: Indiana Department of Education Compliance Requirements: Allowable Costs/Cost Principles Audit Findings: Material Weakness, Modified Opinion Person Responsible for Corrective Action: Chad Yencer - Superintendent Contact Phone Number: 765-348-7550 Views of Responsible Official: Agree Description of Corrective Action Plan: This was a singular occurrence where the rate for a remedial program was not approved by the BCS school board, and where the payments did not tie back to an allowable cost. This program and fund are no longer active. Anticipated Completion Date: Completed

View Audit 348618 Questioned Costs: $1

Finding 537415 (2024-004)

Material Weakness 2024

Blackford County Schools

IN

Procurement, Suspension & Debarment School Nutrition Programs § 200.303

FINDING 2024-004 Subject: Child Nutrition Cluster - Procurement and Suspension and Debarment Federal Agency: Department of Agriculture Federal Programs: School Breakfast Program, National School Lunch Program, Summer Food Service Program ALN Numbers: 10.553, 10.555, 10.559 Federal Award Numbers and ...

FINDING 2024-004 Subject: Child Nutrition Cluster - Procurement and Suspension and Debarment Federal Agency: Department of Agriculture Federal Programs: School Breakfast Program, National School Lunch Program, Summer Food Service Program ALN Numbers: 10.553, 10.555, 10.559 Federal Award Numbers and Years (or Other Identifying Numbers): FY23, FY24 Pass-Through Entity: Indiana Department of Education Compliance Requirements: Procurement and Suspension and Debarment Audit Findings: Material Weakness, Non-Compliance Contact Person Responsible for Corrective Action: Chad Yencer - Superintendent Contact Phone Number: 765-348-7550 Views of Responsible Official: We concur with this finding Description of Corrective Action Plan: BCS has established the following internal controls to ensure compliance: 1. Internal Control: When a purchase is made at $10,000 or more using Federal Funds, the superintendent will require that any vendors selected are in compliance with the Procurement and Suspension and Debarment compliance requirement by completing one of the following quality checks with each vendor prior to purchase: a. Checking the federal System for Award Management (SAM) database at https://sam.gov/content/exclusions and maintain a screenshot of the search results. b. Collect a certification from the vendor directly c. Add a clause or condition to the covered transaction with the vendor In this audit, the Deputy Treasurer conducted the check but misspelled the vendors name while checking so no actual check was completed. Anticipated Completion Date: This corrective action will be implemented and completed immediately with any purchase made that meets the above threshold.

View Audit 348618

Finding 537414 (2024-003)

Material Weakness 2024

Blackford County Schools

IN

Questioned Costs Allowable Costs / Cost Principles School Nutrition Programs § 200.303 § 200.403

Finding 2024‐003 Subject: Child Nutrition Cluster – Allowable Costs/ Cost Principles Federal Agency: Department of Agriculture Federal Programs: School Breakfast Program, National School Lunch Program, Summer Food Service Program for Children Assistance Listings Numbers: 10.553, 10.555, 10.559 Compl...

Finding 2024‐003 Subject: Child Nutrition Cluster – Allowable Costs/ Cost Principles Federal Agency: Department of Agriculture Federal Programs: School Breakfast Program, National School Lunch Program, Summer Food Service Program for Children Assistance Listings Numbers: 10.553, 10.555, 10.559 Compliance Requirement: Allowable Costs/ Cost Principles Audit Findings: Material Weakness, Other Matters Contact Person Responsible for Corrective Action: Julie Dodd, Treasurer Contact Phone Number: 765-348-7550 Views of Responsible Official: We concur with the finding of the auditor Description of Corrective Action Plan: This was a singular occurrence in which indirect costs were applied in the wrong year. Moving forward, no indirect costs will be charged or paid outside of the correct time period for the fiscal year. Anticipated Completion Date: Completed

View Audit 348618 Questioned Costs: $1

Finding 537413 (2024-028)

Significant Deficiency 2024

State of Vermont

VT

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

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

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

View Audit 348596

Finding 537402 (2024-025)

Significant Deficiency 2024

State of Vermont

VT

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

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

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

View Audit 348596

Finding 537401 (2024-024)

Significant Deficiency 2024

State of Vermont

VT

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

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

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

View Audit 348596

Finding 537400 (2024-023)

Significant Deficiency 2024

State of Vermont

VT

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

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

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

View Audit 348596

Finding 537399 (2024-022)

Significant Deficiency 2024

State of Vermont

VT

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

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

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

View Audit 348596

Finding 537387 (2024-021)

Significant Deficiency 2024

State of Vermont

VT

Eligibility Student Financial Aid Subrecipient Monitoring § 200.303

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

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

View Audit 348596

Finding 537386 (2024-020)

Material Weakness 2024

State of Vermont

VT

Special Tests & Provisions Subrecipient Monitoring Material Weakness § 200.303

Reference Number: 2024-020 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: CCDF Cluster Assistance Listing Number: 93.575, 93.596 Award Number and Year: 2301VTCCDD (10/1/2022 – 9/30/2025) 2401VTCCDD (10/1/202...

Reference Number: 2024-020 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: CCDF Cluster Assistance Listing Number: 93.575, 93.596 Award Number and Year: 2301VTCCDD (10/1/2022 – 9/30/2025) 2401VTCCDD (10/1/2023 – 9/30/2026) Compliance Requirement: Special Tests and Provisions – Health and Safety Requirements Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance Recommendation: We recommend that the Agency review and enhance training monitoring procedures and controls to ensure that all child care providers complete required health and safety training. We further recommend that the Agency update its training content to ensure that it includes all required elements. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: Department for Children and Families-Child Development Division (DCF-CDD) licensing unit is in the process of rule revisions which will include all the required health and safety topics that must be covered within the first three months of employment. DCF-CDD licensing unit will be updating our monitoring checklists to ensure we are regulating to the federal standard. DCF-CDD licensing unit will conduct staff training that review the results of the SFY 2024 Single Audit and establish clear procedures for licensing staff to follow when monitoring licensed providers and their staff for ongoing professional development requirements. Scheduled Completion Date of Corrective Action Plan: DCF-CDD is currently in the rule revision process and have a goal to shepherd the rules through promulgation by December 31, 2025. DCF-CDD will update our monitoring checklists to align with the rule revision which will include a complete pre-service orientation training list that aligns with the federal standard. This will be completed by December 31, 2025. DCF-CDD will review the results of the SFY 2024 Single Audit with the licensing team on January 21, 2025. Licensing supervisors will begin reviewing annual site visit reports for the licensors they supervise to ensure CDD is monitoring for the required ongoing professional development trainings required beginning immediately. Contacts for Corrective Action Plan: Beth Maurer, Director of Child Care Licensing elizabeth.maurer@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

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Finding 537379 (2024-019)

Significant Deficiency 2024

State of Vermont

VT

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

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

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

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Finding 537378 (2024-018)

Material Weakness 2024

State of Vermont

VT

Subrecipient Monitoring Material Weakness Reporting § 200.303

Reference Number: 2024-018 Prior Year Finding: 2023-024 Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: COVID-19 - Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Hea...

Reference Number: 2024-018 Prior Year Finding: 2023-024 Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: COVID-19 - Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crises Assistance Listing Number: 93.391 Award Number and Year: NH75OT000034 (6/1/2021 – 5/31/2026) Compliance Requirement: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance Recommendation: We recommend the Agency complete implementation of its prior year CAP to ensure that all required subawards and subaward modifications are reported timely to FSRS in accordance with FFATA requirements and that all previously issued subawards are reported. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: The Financial Administrator will ensure that subrecipient grants containing federal funding that meet the FFATA reporting threshold are marked as “required for entry into the FSRS system” upon grant execution. The Financial Administrator and Manager will then confirm that all executed agreements that meet the FFATA reporting requirement have been entered and submitted into the FSRS system by the last business day of each month. Please note that the scheduled completion date is 2/1/23 as the same FFATA reporting finding was identified for a different program during the SFY22 Single Audit, and the corrective action plan was applied across the Department as a whole. The FFATA issues identified in the SFY24 Single Audit pre-dated the implementation of the Health Department’s original corrective action plan. Scheduled Completion Date of Corrective Action Plan: February 1, 2023 Contacts for Corrective Action Plan: Lillian Smith, Financial Administrator lillian.smith@vermont.gov Jessica Brown, Financial Manager jessica.brown@vermont.gov Megan Hoke, Financial Director megan.hoke@vermont.gov Peter Moino, Director of Internal Audit peter.moino@vermont.gov

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Finding 537377 (2024-017)

Material Weakness 2024

State of Vermont

VT

Material Weakness Reporting Matching / Level of Effort / Earmarking § 200.303

Reference Number: 2024-017 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: COVID-19 - Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcar...

Reference Number: 2024-017 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: COVID-19 - Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crises Assistance Listing Number: 93.391 Award Number and Year: NH75OT000034 (6/1/2021 – 5/31/2026) Compliance Requirement: Reporting – Performance Reporting Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance Recommendation: We recommend the Agency review and enhance internal controls and procedures to ensure that performance reports are accurate, agree with supporting documentation, and that supporting documentation is maintained and available for audit. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: The Office of Health Equity Integration’s Director and Equity Manager will ensure that all supporting documentation are cross checked with formal submissions in CDC’s REDCap reporting system to verify consistency and accuracy of performance reports. Additionally, the Equity Manager and Program Administrator will confirm all supporting documentation are properly stored in the program’s SharePoint site by the end of each quarterly reporting period. Scheduled Completion Date of Corrective Action Plan: January 31, 2025 Contacts for Corrective Action Plan: Katherine Richardson, Program Administrator katherine.richardson@vermont.gov Ariel Carter, Equity Manager ariel.carter@vermont.gov Song Nguyen, Equity Director song.nguyen@vermont.gov Megan Hoke, Financial Director III megan.hoke@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

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Finding 537373 (2024-016)

Significant Deficiency 2024

State of Vermont

VT

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

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

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

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Finding 537372 (2024-015)

Significant Deficiency 2024

State of Vermont

VT

Cash Management Internal Control / Segregation of Duties § 200.303

Reference Number: 2024-015 Prior Year Finding: No Federal Agency: U.S. Department of Education State Agency: Agency of Education Federal Program: Student Support and Academic Enrichment Grants Assistance Listing Number: 84.424 Award Number and Year: S424A220047 (7/1/2022 – 9/30/2024) Compliance Requ...

Reference Number: 2024-015 Prior Year Finding: No Federal Agency: U.S. Department of Education State Agency: Agency of Education Federal Program: Student Support and Academic Enrichment Grants Assistance Listing Number: 84.424 Award Number and Year: S424A220047 (7/1/2022 – 9/30/2024) Compliance Requirement: Cash Management Type of Finding: Significant Deficiency in Internal Control Over Compliance Recommendation: We recommend that the Agency review and enhance its internal controls to ensure that drawdowns are reviewed and approved in accordance with the Agency’s policies and procedures. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: The Agency will review its current Federal draw procedures and identify appropriate role assignment to ensure appropriate internal controls exist to allow for a separation of duties and dual control of critical process steps. Scheduled Completion Date of Corrective Action Plan: July 1, 2025 Position Responsible for Implementation of Corrective Action Sean Cousino, Interim CFO sean.couisno@vermont.gov

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Finding 537371 (2024-014)

Significant Deficiency 2024

State of Vermont

VT

Procurement, Suspension & Debarment § 200.219 § 200.303 § 200.324

Reference Number: 2024-014 Prior Year Finding: No Federal Agency: U.S. Department of the Treasury State Agency: Agency of Administration Federal Program: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Award Number and Year: SLFRP4407 (3/3/2021 – 12/31/...

Reference Number: 2024-014 Prior Year Finding: No Federal Agency: U.S. Department of the Treasury State Agency: Agency of Administration Federal Program: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Award Number and Year: SLFRP4407 (3/3/2021 – 12/31/2024) Compliance Requirement: Procurement Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend the Agency review and enhance internal controls and procedures to ensure that it maintains documentation that it competitively procures contracts and that it performs a cost analysis for all procurement actions in accordance with Agency of Administration Bulletin No. 3.5 and federal requirements. Views of responsible officials: Management agrees with the finding. Corrective Action Plan The Agency of Administration has written and published Procurement and Contracting Procedures known as Bulletin 3.5. Section 9.3.14 (Documentation) details the required documentation that should be placed in the contract file. The Department of Buildings and General Services (a department of the Agency of Administration), Office of Purchasing and Contracting, is charged with maintaining procurement documentation on behalf of the Office of the Secretary of Administration. Department of Buildings and General Services, Office of Purchasing and Contracting, will conduct an internal staff re-training on Bulletin 3.5, Section 9.3.14. In addition, the Office of Purchasing and Contracting will perform an internal review for procurements completed by the Secretary’s office to ensure they are in compliance. Scheduled Completion Date of Corrective Action Plan: BGS OPC Staff Training – June 30, 2025 BGS OPC Internal Review – December 31, 2025 Contacts for Corrective Action Plan: Doug Farnham, Chief Recovery Officer douglas.farnham@vermont.gov Deb Damore, Director, Office of Purchasing and Contracting deborah.damore@vermont.gov

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