Corrective Action Plans

Finding 367114 (2022-037)

Significant Deficiency 2022

State of Nevada

NV

Matching / Level of Effort / Earmarking § 200.303

Finding #2022-037 – Title I Grants to Local Education Agencies, CFDA 84.010 Matching, Level of Effort, and Earmarking – Significant Deficiency in Internal Control over Compliance resulted in the following Eide Bailly, LLP recommendation: Eide Bailly recommended NDE enhance internal controls to ensur...

Finding #2022-037 – Title I Grants to Local Education Agencies, CFDA 84.010 Matching, Level of Effort, and Earmarking – Significant Deficiency in Internal Control over Compliance resulted in the following Eide Bailly, LLP recommendation: Eide Bailly recommended NDE enhance internal controls to ensure information included in the maintenance of effort monitoring document agrees to underlying documentation. NDE Response Due to rapid turnover, changes in assigned personnel, and inconsistent file architecture, NDE has struggled to ensure that source documentation is labeled and retained appropriately. Efforts to ensure consistent business practices within the Student Investment Division are underway. Corrective Action NDE shall develop a comprehensive Policy and Procedure (1.9 Title I ESEA MOE) documenting the process for the development, review, and finalization of the MOE report. Supplemental to the Policy and Procedure, NDE shall develop a Business Rule which clearly crosswalks source data to reporting outcomes. This business rule shall integrate principles from NDE’s Records Management Program, to include clear file architecture for supporting documentation. A checklist detailing the chain of review shall also be implemented to track the review and approval process of federal reports prior to submission. Finally, NDE shall implement internal control monitoring specific to this report upon completion of an internal monitoring assessment. NDE will further review existing internal controls to determine if further support is necessary. The Office of Division Compliance will collaborate with the Office of District Support Services to develop and finalize these documents. Responsible Parties and Anticipated Completion Date Student Investment Division, Offices of District Support Services and Division Compliance; May 1, 2024. Please reach out to Amelia Thibault at sidcompliance@doe.nv.gov with any questions.

View Audit 290300

Finding 367107 (2022-030)

Significant Deficiency 2022

State of Nevada

NV

Reporting Allowable Costs / Cost Principles Significant Deficiency § 200.303

Audit Finding: 2022-030 Homeowner Assistance Fund: 21.026 Reporting Significant Deficiency in Internal Control over Compliance Summary: There was no evidence that the one-time interim report was reviewed by an individual separate from the preparer. Recommendation: Implement internal controls to ens...

Audit Finding: 2022-030 Homeowner Assistance Fund: 21.026 Reporting Significant Deficiency in Internal Control over Compliance Summary: There was no evidence that the one-time interim report was reviewed by an individual separate from the preparer. Recommendation: Implement internal controls to ensure compliance with subrecipient monitoring requirements. Agency Response: The Division agrees with the finding. The Division would like to note, and be given consideration for, the substantive fact of the context of the time period in a pandemic, a once in a lifetime crisis that was impacting daily work and personal lives of all Nevadans, including Division staff. Corrective Action: The Division will establish an internal audit and compliance committee to enhance oversight of existing policies for assessing risk, monitoring, and sharing best practices across its business. The internal audit and compliance committee will be responsible for reviewing internal controls and policies on an annual basis, following up on any audit findings and ensuring follow-through of corrective action plans. This will include ensuring policies and procedures are followed in which reports submitted to federal funders are reviewed by an individual independent of the preparation of the reports. Adoption of Corrective Action: January 2024 Division Contact and Corrective Action Plan Lead: Christine Hess, Chief Financial Officer Nevada Housing Division 775-687-2249 chess@housing.nv.gov

View Audit 290300

Finding 367104 (2022-026)

Significant Deficiency 2022

State of Nevada

NV

Reporting Internal Control / Segregation of Duties § 200.303

Audit Finding: 2022-026 Emergency Rental Assistance Program: 21.023 Reporting Significant Deficiency in Internal Control over Compliance Summary: There was no review of the SF-425 reports or Quarterly Reports by an individual independent of the preparation of the reports. Recommendation: Implement i...

Audit Finding: 2022-026 Emergency Rental Assistance Program: 21.023 Reporting Significant Deficiency in Internal Control over Compliance Summary: There was no review of the SF-425 reports or Quarterly Reports by an individual independent of the preparation of the reports. Recommendation: Implement internal controls to ensure reports are reviewed prior to submission. Agency Response: The Nevada Housing Division (“Division”) agrees with the finding. The Division would like to note, and be given consideration for, the substantive fact of the context of the time period in a pandemic, a once in a lifetime crisis that was impacting daily work and personal lives of all Nevadans, including Division staff. Corrective Action: The Division will establish an internal audit and compliance committee to enhance oversight of existing policies for assessing risk, monitoring, and sharing best practices across its business. The internal audit and compliance committee will be responsible for reviewing internal controls and policies on an annual basis, following up on any audit findings and ensuring follow-through of corrective action plans. This will include ensuring policies and procedures are followed in which reports submitted to federal funders are reviewed by an individual independent of the preparation of the reports. Adoption of Corrective Action: January 2024 Division Contact and Corrective Action Plan Lead: Christine Hess, Chief Financial Officer Nevada Housing Division 775-687-2249 chess@housing.nv.gov

View Audit 290300

Finding 367099 (2022-021)

Material Weakness 2022

State of Nevada

NV

Internal Control / Segregation of Duties Special Tests & Provisions Allowable Costs / Cost Principles § 200.303

Finding 2022-021 Investigations performed by the UI BAM supervisor or senior investigator are not reviewed by someone other than the investigator. In addition, completion of cases and timely data entry requirements were not met. A nonstatistical sample of 60 completed BAM cases out of a population ...

Finding 2022-021 Investigations performed by the UI BAM supervisor or senior investigator are not reviewed by someone other than the investigator. In addition, completion of cases and timely data entry requirements were not met. A nonstatistical sample of 60 completed BAM cases out of a population of 734 was selected for testing. The investigator and reviewer were the same person for 17 of the cases tested. In addition, a time lapse report of case completion was examined for paid claims accuracy. Of these investigations, 85.19% of the cases were completed within 90 days, rather than the 95% required. In addition, the total completion was 92.12% complete, rather than the 98% completion required. Recommendation We recommend the Department implement internal controls to ensure appropriate segregation of duties on all BAM investigations and to ensure timeliness requirements are met. Nevada DETR’s Response The Employment Security Division’s Unemployment Insurance Support Services (UISS) recognizes the importance of internal controls for a system of checks and balances to ensure no one person has control over all parts of BAM investigations, and to ensure investigation timeliness. Background: BAM timeliness has been impacted since 2020 due to many factors that include but are not limited to significant staff turnover (i.e., retirement, promotions, and recruitment/retainment of qualified staff). Historically, the BAM supervisor PCN 5089 has been tasked with training and reviewing new staff work and activities, which resulted in experienced investigators’ work not being reviewed in attempts to meet timeliness on other BAM cases. Nevada DETR ESD UISS’ Corrective Action Plan: Attached (ATTACHMENT A) is DETR’s Benefit Accuracy Measurement (BAM) Segregation of Duties Internal Control. Estimated Date of Completion: COMPLETED Contact Person: Kristine K. Nelson, ESD Administrator, DETR/ESD (775)684-3828, kknelson@detr.nv.gov

View Audit 290300

Finding 366881 (2022-003)

Significant Deficiency 2022

Comunidades Latinas Unidas En Servicio INC

MN

Procurement, Suspension & Debarment § 200.303

Significant Deficiency 2023-003 Control over Compliance – Suspension & Debarment Documentation Assistance Listing No. 93.829– Substance Abuse and Mental Health Services Administration (SAMHSA)– Health Clinic(CCBHC) Expansion Recommendation: We recommend management adopt a policy to ensure evidence o...

Significant Deficiency 2023-003 Control over Compliance – Suspension & Debarment Documentation Assistance Listing No. 93.829– Substance Abuse and Mental Health Services Administration (SAMHSA)– Health Clinic(CCBHC) Expansion Recommendation: We recommend management adopt a policy to ensure evidence of compliance to suspension and debarment regulations are maintained. This can include maintaining evidence that management reviewed the GSA website, maintaining a certification from the vendor, or including a clause in a contract with vendors that they are not suspended or debarred. Management Response: Management requested and received pre-approval from the federal granting agency to use the two specified vendors identified in the audit finding. The two vendors are a reputable research nonprofit (and sole source for this work in Minnesota) and a reputable company used before to maintain our Electronic Health Records system. We could not show documentation of verifying the vendor’s suspension and debarment credentials prior to entering into the contract, so the auditors determined that they must report this matter since the control over reviewing the vendors’ suspension and debarment qualifications was not documented prior to signing a contract with them. We have met internally to ensure our procurement procedures account retain such documentation going forward, but Management reiterates that the federal granting agency approved the use of these vendors prior to entering into contract. Action taken in response to finding: Management received notification of this matter in June 2023 and conducted suspension and debarred verification. Upon notification of this matter, the VP of Finance and Administration and the Controller initiated improved processes and guidelines with the leads of our Procurement and Accounting teams to ensure documentation of suspension & debarment qualifications of current and future vendors/consultants for our programs and clinical services. In addition, our template contract for external services has been updated to require this verification prior to entering into a contract with external consultants/vendors so we can ensure compliance with this federal requirement. Name of the contact person responsible for corrective action: Ryan Robinson (VPFA) Planned completion date for corrective action plan: June 2023

View Audit 290024

Finding 366772 (2022-004)

Material Weakness 2022

Center for Disease Dynamics Economics & Policy Inc.

MD

Internal Control / Segregation of Duties Cash Management Material Weakness § 200.302 § 200.303

Agree with the finding. We will implement the segregation of duties matrix as part of SOPs. We will ensure that authorization and review of cash draws of fedral funds are done by some one other than the individual who initiates and records the transaction . We have implemented the same and Dr EIli (...

Agree with the finding. We will implement the segregation of duties matrix as part of SOPs. We will ensure that authorization and review of cash draws of fedral funds are done by some one other than the individual who initiates and records the transaction . We have implemented the same and Dr EIli (pi) is reviewing and approving the report before each withdrawal. The Finance Head ( Nafih) is withdrawing the fund .Anticipated Completion Date : 12/31/2022 Actual date of implementation :01/24/2023

View Audit 289832

Finding 366756 (2022-007)

Material Weakness 2022

South Bend Community School Corporation

IN

Internal Control / Segregation of Duties Subrecipient Monitoring Cash Management § 200.302 § 200.303 § 200.328 § 200.329 § 200.334

FINDING 2022-007 Finding Subject: COVID-19 - Education Stabilization Fund - Reporting Summary of Finding: Finding: No oversight of reports and supporting documentation did not agrees to report submitted Recommendation: Provide oversight of reports submitted and retain supporting documentation that a...

FINDING 2022-007 Finding Subject: COVID-19 - Education Stabilization Fund - Reporting Summary of Finding: Finding: No oversight of reports and supporting documentation did not agrees to report submitted Recommendation: Provide oversight of reports submitted and retain supporting documentation that agrees to reports submitted Contact Person Responsible for Corrective Action: Kareemah Fowler, Assistant Superintendent of Business and Finance Deb Martin, Director of Student Learning & Title I Contact Phone Number and Email Address: Kareemah Fowler (574) 393-6088; kfowler@sbcsc.k12.in.us Deb Martin (574) 393-6053; dmartin@sbcsc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: All reports and supporting documentation, which supports each report submitted, will be reviewed/approved by the program director. All supporting documentation will be retained for future audits. Anticipated Completion Date: December 8, 2024

View Audit 289747

Finding 366755 (2022-006)

Material Weakness 2022

South Bend Community School Corporation

IN

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.334 § 200.403 § 200.430

FINDING 2022-006 Finding Subject: COVID-19 - Education Stabilization Fund - Allowable Costs/Cost Principles Summary of Finding: Finding: Documentation for 3 employees was not available to verify the contract amounts. Recommendation: Documents be retained to support amounts paid. Contact Person Respo...

FINDING 2022-006 Finding Subject: COVID-19 - Education Stabilization Fund - Allowable Costs/Cost Principles Summary of Finding: Finding: Documentation for 3 employees was not available to verify the contract amounts. Recommendation: Documents be retained to support amounts paid. Contact Person Responsible for Corrective Action: Kareemah Fowler, Assistant Superintendent of Business and Finance Contact Phone Number and Email Address: (574) 393-6088; kfowler@sbcsc.k12.in.us Views of Responsible Officials: We disagree with the finding. Explanation and Reasons for Disagreement: While we agree that the single source document used by the State to validate a teacher’s contract was not available for 3 employees. We provided sufficient alternate documents that would allow the State to validate the contract amount being paid, and whether the proper employees were paid from or should have been paid from the Education Stabilization Funds. The documents provided sufficient data to support the questioned cost of $26,207 outlined in the finding. We will be working with our software vendor to rectify the glitch that prevented us from providing the documentation requested by the State for future audit. Description of Corrective Action Plan: We will be working with our software vendor to rectify the glitch that prevented us from providing the documentation requested by the State. Anticipated Completion Date: January 2024

View Audit 289747 Questioned Costs: $1

Finding 366754 (2022-005)

Material Weakness 2022

South Bend Community School Corporation

IN

Special Tests & Provisions Subrecipient Monitoring Material Weakness § 200.303

FINDING 2022-005 Finding Subject: Title I Grants to Local Educational Agencies - Special Tests and Provisions - Annual Report Card/High School Graduation Rate Summary of Finding: Finding: Exit documentation was missing or incorrectly matched with student mobility codes for students in the testing sa...

FINDING 2022-005 Finding Subject: Title I Grants to Local Educational Agencies - Special Tests and Provisions - Annual Report Card/High School Graduation Rate Summary of Finding: Finding: Exit documentation was missing or incorrectly matched with student mobility codes for students in the testing sample of the 2022 cohort. Contact Person Responsible for Corrective Action: Rafi Nolan-Abrahamian, Assistant Superintendent of Accountability and Innovation Contact Phone Number and Email Address: 574-393-6179; rnolan-abrahamian@sbcsc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: SBCSC will conduct re-training of all High School principals and data technicians to review SBCSC withdrawal policies (outlined below), along with required documentation for each exit/mobility code. This training will be conducted in January 2024. District staff will confirm with each high school that procedures below are in place by reviewing cohort binders with the principal and data technician. Meetings will be scheduled in the Spring of 2024. Procedure for Withdrawing Students from all SBCSC High Schools Anytime a parent requests that a student withdraw from a high school, the following steps must be followed. If a parent is not requesting a transfer, the principal will complete an exit interview. All transfers will follow this procedure. (Please also see the procedure for processing no shows.) 1. Only the principal is allowed to sign the withdrawal form. If the principal is not available, an assistant principal may sign the withdrawal form and immediately email it to the principal. 2. Prior to signing the withdrawal form, the principal will speak with the parents and student to gather any information that may help the school understand why a withdrawal is necessary. Once this conversation has happened, the principal will advise the parent and student. 43 INDIANA STATE BOARD OF ACCOUNTS South􀀃Bend􀀃Community􀀃School􀀃Corporation􀀃 215􀀃South􀀃Dr.􀀃Martin􀀃Luther􀀃King􀀃Jr.􀀃Boulevard􀀃􀀃 􀀃South􀀃Bend,􀀃Indiana􀀃46601􀀃􀀃 574􀇦393􀇦6100􀀃􀀃 􀀃 􀀃 􀀃 􀀃 INTEGRITY􀀃•􀀃ACCOUNTABILITY􀀃•􀀃EMPOWERMENT􀀃 􀀃 ACADEMIC􀀃QUALITY􀀃|􀀃EQUITY,􀀃INCLUSION􀀃&􀀃JUSTICE􀀃|􀀃FINANCIAL􀀃 SUSTAINABILITY􀀃|􀀃COMMUNITY􀀃PARTNERSHIPS􀀃 􀀃 3. If it is determined that the student will transfer, the signed withdrawal form will be filed in a binder based on class cohort. For example, all students scheduled to graduate in the spring of 2022 will be filed with the 2022 cohort. The principal must determine the name and contact information for the receiving school. 4. It is the responsibility of the data technician to manage these cohorts by checking Learning Connection weekly. If discrepancies are visible in Learning Connection, a data technician will contact the SBCSC Department of Research and Evaluation and the IDOE. 5. The secretary of student management will forward any requests for records to the data technician to file with the student’s withdrawal paperwork. (We must have a request for records for every student withdrawing from SBCSC.) 6. The data technician will follow up regarding any student with whom we did not receive a request for records for within one week of the withdrawal. The data technician will contact the receiving school and parent to locate the records request. 7. The data technician will continue to locate a request for records weekly until the request is received by SBCSC. 8. Documentation will be maintained of all efforts made to collect the information. Anticipated Completion Date: Spring 2024

View Audit 289747

Finding 366753 (2022-004)

Material Weakness 2022

South Bend Community School Corporation

IN

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

FINDING 2022-004 Finding Subject: Title I Grants to Local Educational Agencies - Reporting Summary of Finding: Finding: Detail data on the Form 9 and Reimbursement Request was not provided to knowledgeable individuals for review. Recommendation: Design control that provides sufficient data to knowle...

FINDING 2022-004 Finding Subject: Title I Grants to Local Educational Agencies - Reporting Summary of Finding: Finding: Detail data on the Form 9 and Reimbursement Request was not provided to knowledgeable individuals for review. Recommendation: Design control that provides sufficient data to knowledgeable individuals for review. Contact Person Responsible for Corrective Action: Kareemah Fowler, Assistant Superintendent of Business and Finance Contact Phone Number and Email Address: (574) 393-6088; kfowler@sbcsc.k12.in.us Views of Responsible Officials: We concur with the findings. Description of Corrective Action Plan: Form 9 Data The Human Resources Department has added a second review to verify all employee distribution codes are correct when recording/updating employee requisitions. Additionally, detailed expense reports and payroll distribution reports that support each reimbursement request are being provided to knowledgeable employees to review. Anticipated Completion Date: Completed December 8, 2023, and May 2023 Reimbursement Requests Summary level payroll data is no longer being used to support reimbursement requests. Detailed expense reports and payroll distribution reports that support each reimbursement request are being provided to knowledgeable employees to review. Anticipated Completion Date: Completed May 2023.

View Audit 289747

Finding 366752 (2022-003)

Material Weakness 2022

South Bend Community School Corporation

IN

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.334 § 200.403 § 200.430

FINDING 2022-003 Finding Subject: Title I Grants to Local Educational Agencies - Allowable Costs/Cost Principles Summary of Finding: Finding: Documentation for 10 employees was not available to verify the contract amounts. Recommendation: Documents be retained to support amounts paid. Contact Person...

FINDING 2022-003 Finding Subject: Title I Grants to Local Educational Agencies - Allowable Costs/Cost Principles Summary of Finding: Finding: Documentation for 10 employees was not available to verify the contract amounts. Recommendation: Documents be retained to support amounts paid. Contact Person Responsible for Corrective Action: Kareemah Fowler, Assistant Superintendent of Business and Finance Contact Phone Number and Email Address: (574) 393-6088; kfowler@sbcsc.k12.in.us Views of Responsible Officials: We disagree with the finding. Explanation and Reasons for Disagreement: While we agree that the single source document used by the State to validate a teacher’s contract was not available for 10 employees. We provided sufficient alternate documents that would allow the State to validate the contract's amount being paid, and whether the proper employees were paid from or should have been paid from the Title I funds. The documents provided sufficient data to support the questioned cost of $203,488 outlined in the finding. We will be working with our software vendor to rectify the glitch that prevented us from providing the documentation requested by the State for future audit. Description of Corrective Action Plan: We will be working with our software vendor to rectify the glitch that prevented us from providing the documentation requested by the State. Anticipated Completion Date: January 2024

View Audit 289747 Questioned Costs: $1

Finding 366751 (2022-002)

Material Weakness 2022

South Bend Community School Corporation

IN

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

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

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

View Audit 289747

Finding 366672 (2022-003)

None 2022

Boys & Girls Club of North Alabama, INC

AL

Cash Management Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Finding 2022-003 Finding: CACFP requires that non-Federal entities receiving Federal Awards establish and maintain internal control designed to reasonably ensure compliance with Federal Statutes, regulations, and the terms and conditions of the Federal award. As part of our review of the Child and...

Finding 2022-003 Finding: CACFP requires that non-Federal entities receiving Federal Awards establish and maintain internal control designed to reasonably ensure compliance with Federal Statutes, regulations, and the terms and conditions of the Federal award. As part of our review of the Child and Adult Care Food Program (CACFP) it was noted the Club was not adhering to accrual accounting as it pertains to reporting of expenses. Response: Adjustments have been made to the process of monthly adjustments. Additional procedures will be put in place to ensure financial reporting is done correctly.

View Audit 289590

Finding 366671 (2022-002)

None 2022

Boys & Girls Club of North Alabama, INC

AL

Cash Management Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Finding 2022-002 Finding: CACFP requires that non-Federal entities receiving Federal Awards establish and maintain internal control designed to reasonably ensure compliance with Federal Statutes, regulations, and the terms and conditions of the Federal award. As part of our review of the Child and...

Finding 2022-002 Finding: CACFP requires that non-Federal entities receiving Federal Awards establish and maintain internal control designed to reasonably ensure compliance with Federal Statutes, regulations, and the terms and conditions of the Federal award. As part of our review of the Child and Adult Care Food Program (CACFP) it was noted some of the Club’s daily food invoices were missing the site supervisor’s signature for having received the meals specified. Response: The monitor and director will review each month’s daily food invoices from all sites to ensure they are complete. Additional procedures will be put in place to ensure all daily food invoices have the appropriate receiving signatures.

View Audit 289590

Finding 366670 (2022-001)

None 2022

Boys & Girls Club of North Alabama, INC

AL

Cash Management Reporting Matching / Level of Effort / Earmarking § 200.303

Finding 2022-001 Finding: CACFP requires that non-Federal entities receiving Federal Awards establish and maintain internal control designed to reasonably ensure compliance with Federal Statutes, regulations, and the terms and conditions of the Federal award. The Club was unable to replicate exact...

Finding 2022-001 Finding: CACFP requires that non-Federal entities receiving Federal Awards establish and maintain internal control designed to reasonably ensure compliance with Federal Statutes, regulations, and the terms and conditions of the Federal award. The Club was unable to replicate exact payroll expenses that were reported to the state monthly for the program. This is due to a lack of payroll documentation retained monthly. This documentation took time to replicate during the audit. No fraud is suspected related to payroll reporting issues for the program. Response: Adjustments were made to the payroll process to retain all supporting documentation and to replicate any prior period paperwork. The Club switched to a new payroll processor which has enabled improved payroll reporting.

View Audit 289590

Finding 366553 (2022-004)

Significant Deficiency 2022

City of Warwick, Rhode Island

RI

Allowable Costs / Cost Principles § 200.303 § 200.430

We will be performing a reconciliation between HR and Payroll to ensure that individuals being paid by a grant are documented correctly and paid according to that documentation.

View Audit 289401

Finding 366549 (2022-003)

Significant Deficiency 2022

City of Warwick, Rhode Island

RI

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

Warwick Public Schools is in the process of hiring an assistant controller responsible for grants finance. This individual will reconcile expenses monthly, record revenues, receivables and reimbursements on a monthly basis. This will prevent the amount of year-end cleanup going forward.

View Audit 289401

Finding 366543 (2022-002)

Significant Deficiency 2022

St. Barnabas Health System, Inc.

PA

Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.303

Management will work to make all necessary corrections on the period 6 report, if available. If period 6 is not available then we will work with HRSA to correct reporting errors outlined above through a revision to past reporting, providing additional documentation directly to the agency, or updates...

Management will work to make all necessary corrections on the period 6 report, if available. If period 6 is not available then we will work with HRSA to correct reporting errors outlined above through a revision to past reporting, providing additional documentation directly to the agency, or updates via future reporting, as applicable and deemed appropriate by the federal agency official.

View Audit 289380

Finding 366541 (2022-001)

Significant Deficiency 2022

St. Barnabas Health System, Inc.

PA

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

Management will work with the HRSA to correct reporting errors outlined above through a revision to past reporting, providing additional documentation directly to the agency, or updates via future reporting, as applicable and deemed appropriate by the federal agency official.

View Audit 289380

Finding 316358 (2022-078)

Significant Deficiency 2022

State of Colorado

CO

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

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

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

View Audit 282464

Finding 316201 (2022-054)

Material Weakness 2022

State of Colorado

CO

Eligibility Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

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

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

View Audit 282464

Finding 316196 (2022-055)

Material Weakness 2022

State of Colorado

CO

Eligibility Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

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

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

View Audit 282464

Finding 316195 (2022-047)

Material Weakness 2022

State of Colorado

CO

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

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

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

View Audit 282464

Finding 316194 (2022-046)

Material Weakness 2022

State of Colorado

CO

Subrecipient Monitoring Material Weakness Reporting § 200.303

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

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

View Audit 282464

Finding 316191 (2022-043)

Material Weakness 2022

State of Colorado

CO

Eligibility Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

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

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

View Audit 282464

Corrective Action Plans

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