Corrective Action Plans

Finding 51521 (2022-304)

Significant Deficiency 2022

WI

Internal Control / Segregation of Duties Subrecipient Monitoring Cash Management § 200.303

CAP for Finding: 2022-304 DATE: March 23, 2023 TO: Carolyn Stittleburg, Deputy State Auditor Legislative Audit Bureau FROM: Barry Kasten, Director Bureau of Fiscal Services Department of Health Services SUBJECT: Corrective Action Plan ? Coronavirus State and Local Fiscal Recovery Funds ? Monitoring ...

CAP for Finding: 2022-304 DATE: March 23, 2023 TO: Carolyn Stittleburg, Deputy State Auditor Legislative Audit Bureau FROM: Barry Kasten, Director Bureau of Fiscal Services Department of Health Services SUBJECT: Corrective Action Plan ? Coronavirus State and Local Fiscal Recovery Funds ? Monitoring of Local and Tribal Health Department Response and Recovery Support Program Expenditures Department staff has reviewed the Legislative Audit Bureau?s (LAB) interim audit memo for Finding 2022-304: Coronavirus State and Local Fiscal Recovery Funds ? Monitoring of Local and Tribal Health Department Response and Recovery Support Program Expenditures. This is the department?s Corrective Action Plan. ? Recommendation (2022-304): Coronavirus State and Local Fiscal Recovery Funds ? Monitoring of Local and Tribal Health Department Response and Recovery Support Program Expenditures We recommend the Wisconsin Department of Health Services: ? Develop and implement written policies and procedures for the review and tracking of the quarterly reports used to monitor expenditures under the Local and Tribal Health Department Response and Recovery Support program. Wisconsin Department of Health Services Planned Corrective Action: As beneficiaries, the Treasury Guidance indicates that Local and Tribal Health Departments are not subject to subrecipient monitoring and reporting requirements. The designation of beneficiary is unique to the CSLFRF and thus is not as familiar to DHS as the subrecipient designation and subsequent reporting requirements. The uncertainty surrounding this designation resulted in DPH not following the best practices described in the DPH Contract Management Manual. DPH?s Contract Management Manual outlines requirements and best practices for contract management. This Manual describes how to best review and track expenditures to monitor expenditures. The Manual encourages the best practice of requesting enhanced expenditure reporting from agencies, in addition to the reporting required for CARS payments. The Manual describes the role of the contract administrator in reviewing the expenditure information against the approved budget to ensure expenses are reasonable and allowable. The Manual also suggests maintaining copies of submitted reports and verifying the amounts in the submitted reports correspond to CARS reports. Examples of expenditure tracking are provided as is a description of how this tracking and other fiscal monitoring supports bureaus within DPH and DHS. DHS will review the existing policies and procedures in the Contract Management Manual to ensure that the level of detail is sufficient to prevent further non-compliance. We recommend the Wisconsin Department of Health Services: ? Maintain the quarterly reports, document its review of the quarterly reports, and document its correspondence with the public health departments regarding resolution of reporting variances. Wisconsin Department of Health Services Planned Corrective Action: DPH hired a position in June 2022 to manage and track expenditures and reporting for its Coronavirus State and Local Fiscal Recovery Funds granted to locals and tribal public health departments. DPH will continue to review, track, and maintain quarterly reports, and document correspondence with the local and tribal public health departments per best practices in the DPH Contract Management Manual. We recommend the Wisconsin Department of Health Services: ? Review the contracts with the public health departments and determine whether any revisions are needed to clarify expectations for documentation and timeliness of filing the quarterlyreports; and Wisconsin Department of Health Services Planned Corrective Action: DPH will review its contracts with the local and tribal public health departments and ensure timely filing of quarterly reports. Specific areas of non-compliance have been identified and division staff will review and draft updated scope of work language to mitigate delays in reporting from our local partners. We recommend the Wisconsin Department of Health Services: ? Ensure it obtains quarterly reports to support the payments it made to the City of Milwaukee Public Health Department. Wisconsin Department of Health Services Planned Corrective Action: DPH has now obtained quarterly reports from the City of Milwaukee Public Health Department and is in the process of reviewing them. Division staff will work with the City of Milwaukee Health Department to ensure future compliance. Anticipated Completion Date: June 30, 2023 Person responsible for corrective action: Karen Drogsvold, Budget Section Manager Division of Public Health, Bureau of Operations karen.drogsvold@dhs.wisconsin.gov

View Audit 44861

Finding 51518 (2022-100)

Significant Deficiency 2022

State of Wisconsin

WI

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

CAP for Finding: 2022-100 Auditor Recommendation: Develop and implement controls to identify when an applicant applies for funding under multiple programs and to assess the appropriateness of whether it would be making payments to an applicant that applies under multiple programs. Planned Corrective...

CAP for Finding: 2022-100 Auditor Recommendation: Develop and implement controls to identify when an applicant applies for funding under multiple programs and to assess the appropriateness of whether it would be making payments to an applicant that applies under multiple programs. Planned Corrective Action: The Wisconsin Department of Administration (DOA or Department) will develop and implement controls to identify when an applicant applies for funding under multiple programs and to assess the appropriateness of whether it would be making payments to an applicant that applies under multiple programs. The controls will be documented in the Department?s Grants Management Guide and will consider, among other things, the purpose of the assistance being awarded and the criteria for the award. As the auditors noted specific to this finding and recommendation, DOA implemented controls for certain programs where it was anticipated an applicant might apply under more than one program. For programs where the controls were not implemented prior to award, the Department has subsequently reviewed to verify that an applicant was not paid for the same losses under more than one program, and none aside from that which was the condition for this finding were identified. Anticipated Completion Date: June 30, 2023 Auditor Recommendation: Review the specific payments made to the organization we identified and seek repayment of the amount that was made inappropriately. Planned Corrective Action: DOA has reviewed the specific payments made to the organization identified by the auditors and sought repayment of the amount that was not properly paid. Anticipated Completion Date: March 31, 2023 Person responsible for corrective action: Colleen Holtan, Director Bureau of Financial Management Division of Enterprise Operations colleen.holtan@wisconsin.gov

View Audit 44861 Questioned Costs: $1

Finding 51507 (2022-600)

Significant Deficiency 2022

State of Wisconsin

WI

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.303

CAP for Finding: 2022-600 Finding 2022-600: Unemployment Insurance Program?Reporting 1. RECOMMENDATION: Continue to make progress in developing and implementing adequate procedures for the preparation and review of the Unemployment Insurance program's performance reports to ensure the accuracy of th...

CAP for Finding: 2022-600 Finding 2022-600: Unemployment Insurance Program?Reporting 1. RECOMMENDATION: Continue to make progress in developing and implementing adequate procedures for the preparation and review of the Unemployment Insurance program's performance reports to ensure the accuracy of the amounts reported to the federal government. Planned Corrective Action: DWD developed and implemented adequate procedures for the preparation and review of the UI performance and special reports to ensure the accuracy of amounts reported to the federal government; and retains documentation to support the amounts included in each report it submits to the federal government. Anticipated Completion Date: Completed before September 30, 2022 Name, Title: Jim Chiolino, Administrator Division or Unit (If applicable): Unemployment Insurance Division Email address: jim.chiolino@dwd.wisconsin.gov CC: Pamela McGillivray Lynda Jarstad Jason Schunk

View Audit 44861

Finding 51362 (2022-002)

Significant Deficiency 2022

College of Biblical Studies

TX

Procurement, Suspension & Debarment § 200.303

2022-002 Internal Controls over Suspension and Debarment (Significant Deficiency) U.S. Department of Education COVID -19: Education Stabilization Fund: Higher Education Emergency Relief Fund 84.425F ? COVID-19 Institutional Portion Recommendation: The College should establish proc...

2022-002 Internal Controls over Suspension and Debarment (Significant Deficiency) U.S. Department of Education COVID -19: Education Stabilization Fund: Higher Education Emergency Relief Fund 84.425F ? COVID-19 Institutional Portion Recommendation: The College should establish procedures to ensure that controls related to suspension and debarment are devised, are consistently implemented and that all written records are maintained to support that the compliance requirement is met. Corrective Action: The College subsequently collected a certification from the respective companies affirming that the companies are not suspended/debarred. Purchasing policies and procedures will be updated to include a control to verify that a company?s status is not suspended or debarred from receiving federal funding as required by 2 CFR Section 180, Subpart C. Responsible Parties: A. Benjamin Chelladurai, VP/CFO and Paul Keith, VP/COO Date Corrected: This recommendation was implemented with immediate effect.

View Audit 49051

Finding 51361 (2022-001)

Significant Deficiency 2022

College of Biblical Studies

TX

Cash Management Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

2022-001 Compliance and Internal Controls over Cash Management (Significant Deficiency) U.S. Department of Education COVID -19: Education Stabilization Fund: Higher Education Emergency Relief Fund 84.425E ? COVID-19 Student Portion Recommendation: While not applicable for HEERF fun...

2022-001 Compliance and Internal Controls over Cash Management (Significant Deficiency) U.S. Department of Education COVID -19: Education Stabilization Fund: Higher Education Emergency Relief Fund 84.425E ? COVID-19 Student Portion Recommendation: While not applicable for HEERF funding since this has been fully utilized, for all related federal awards to students, we recommend that in order to minimize the time between funds drawn and eventual disbursement to students, the Business Office should only make draws after communication from the Student Financial Aid department that all student reviews have been completed and these are ready to be paid. Evidence of this communication should also be maintained to allow for proper audit trail. Corrective Action: The College will implement procedures related to federal awards to students that includes the authorization for draws only after formal written communication from the Student Financial Department that all student reviews have been completed with written authorization that they are final and ready for payment. Responsible Parties: A. Benjamin Chelladurai, VP/CFO and Dr. Lisa Stewart, VP/Director of Financial Aid Date Corrected: This recommendation was implemented with immediate effect.

View Audit 49051

Finding 51334 (2022-002)

Significant Deficiency 2022

North Mississippi Health Services, Inc.

MS

Allowable Costs / Cost Principles Cash Management Reporting § 200.303

See Corrective Action Plan for chart/table

View Audit 53146

Finding 51333 (2022-001)

Material Weakness 2022

North Mississippi Health Services, Inc.

MS

Reporting § 200.303 § 200.502 § 200.510

See Corrective Action Plan for chart/table

View Audit 53146

Finding 51323 (2022-001)

Material Weakness 2022

City of Lebanon

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

FINDING 2022-001 Contact Person Responsible for Corrective Action: Tonya Thayer Contact Phone Number: 1-765-482-1218 Views of Responsible Official: We concur with the finding the City did not have the correct system in place to prevent errors. Description of Corrective Action Plan: From this day for...

FINDING 2022-001 Contact Person Responsible for Corrective Action: Tonya Thayer Contact Phone Number: 1-765-482-1218 Views of Responsible Official: We concur with the finding the City did not have the correct system in place to prevent errors. Description of Corrective Action Plan: From this day forward any Federal contracts the City signs that are $25,000 and over will need to be verified by Deputy Clerk Treasurer by looking at the SAM (System for Award Management) to make sure the contractor is not suspended or debarred. Anticipated Completion Date: June 28, 2023

View Audit 51086

Finding 51264 (2022-003)

Significant Deficiency 2022

Longwood Central School District

NY

Allowable Costs / Cost Principles § 200.303 § 200.430

2022-003. Allowable Costs/Costs Principles United States Department of Education, passed-through New York State Department of Education: Special Education Cluster Special Education Grants to States ALN: 84.027A Special Education Grants to States: IDEA 611 ARP Allocations ALN: 84.027X Special Educati...

2022-003. Allowable Costs/Costs Principles United States Department of Education, passed-through New York State Department of Education: Special Education Cluster Special Education Grants to States ALN: 84.027A Special Education Grants to States: IDEA 611 ARP Allocations ALN: 84.027X Special Education Preschool Grants ALN: 84.173A Special Education Preschool Grants: IDEA 619 ARP Allocations ALN: 84.173X Education Stabilization Fund (ESF) COVID-19: Governor?s Emergency Education Relief (GEER) Fund ALN: 84.425C COVID-19: Elementary and Secondary School Emergency Relief (ESSER) Fund ALN: 84.425D COVID-19: American Rescue Plan ? Elementary and Secondary School Emergency Relief (ARP ESSER) Fund ALN: 84.425U Condition: Subpart E, 2 CFR ?200.430 of the Uniform Guidance requires that charges to ?federal awards for salaries and wages must be based on records that accurately reflect the work performed.? The documentation should support the distribution of the employee?s compensation among specific activities if the employee works on more than one federal award, or a federal award and non-federal award. The preparation of personnel activity reports (PARs) or periodic certifications or the equivalent is the most effective way to comply with this requirement. During the current year, the District failed to prepare periodic certification equivalents correctly, to comply with Subpart E, 2 CFR ?200.430. - 13 - Planned Corrective Action: The Deputy Treasurer, Treasurer, and Payroll Supervisor will develop procedures to ensure that the Payroll Office obtains the necessary documentation to certify that salaries and wages were charged to the appropriate grants. Responsible Contact Person: Dr. Rodney Asse - Assistant Superintendent for Business Riverhead Central School District 814 Harrison Avenue - Riverhead, New York, 11901 Anticipated Completion Date: June 30, 2023

View Audit 44022

Finding 51263 (2022-001)

Significant Deficiency 2022

Longwood Central School District

NY

Cash Management Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.303

2022-001. Internal Control Over Compliance United States Department of Education, passed-through New York State Department of Education: Special Education Cluster Special Education Grants to States ALN: 84.027A Special Education Grants to States: IDEA 611 ARP Allocations ALN: 84.027X Special Educati...

2022-001. Internal Control Over Compliance United States Department of Education, passed-through New York State Department of Education: Special Education Cluster Special Education Grants to States ALN: 84.027A Special Education Grants to States: IDEA 611 ARP Allocations ALN: 84.027X Special Education Preschool Grants ALN: 84.173A Special Education Preschool Grants: IDEA 619 ARP Allocations ALN: 84.173X Education Stabilization Fund (ESF) COVID-19: Governor?s Emergency Education Relief (GEER) Fund ALN: 84.425C COVID-19: Elementary and Secondary School Emergency Relief (ESSER) Fund ALN: 84.425D COVID-19: American Rescue Plan ? Elementary and Secondary School Emergency Relief (ARP ESSER) Fund ALN: 84.425U Condition: The District has not updated its existing policies and written procedures to conform to Uniform Guidance requirements. Planned Corrective Action: The District will update its existing policies and written procedures to conform to Uniform Guidance requirements. Responsible Contact Person: Dr. Rodney Asse - Assistant Superintendent for Business Riverhead Central School District 814 Harrison Avenue - Riverhead, New York, 11901 Anticipated Completion Date: The District adopted a Federal Funds Procedural Manual on January 24, 2023.

View Audit 44022

Finding 51255 (2022-001)

Material Weakness 2022

Brown County Schools

IN

Internal Control / Segregation of Duties Special Tests & Provisions Material Weakness § 200.303

FINDING 2022-001 Contact Person Responsible for Corrective Action: Dawn Ray Contact Phone Number: 812-988-6601 Views of Responsible Official: Brown County Schools viewed this Internal Controls requirement as being fulfilled by Performance Services, Inc. (PSI) as part of their responsibilities as...

FINDING 2022-001 Contact Person Responsible for Corrective Action: Dawn Ray Contact Phone Number: 812-988-6601 Views of Responsible Official: Brown County Schools viewed this Internal Controls requirement as being fulfilled by Performance Services, Inc. (PSI) as part of their responsibilities as contractor for their sub-contractor?s certified payroll as it is addressed in PSI?s sub-contractor contract. The sub-contractor sends their certified payroll to PSI who verifies all information including Wage Rate requirements before rendering payment. Brown County Schools did not know that we were to complete this extra step. Description of Corrective Action Plan: Brown County Schools will require notification of certified payroll reviews be sent to us with the monthly work updates after the contractor has reviewed them for accuracy and compliance with prevailing wage requirements. Anticipated Completion Date: Effective immediately at conclusion of the 2020-2022 audit.

View Audit 43527

Finding 51253 (2022-033)

Material Weakness 2022

State of Delaware

DE

Student Financial Aid Material Weakness Reporting § 200.303

Reference Number: 2022-033 Prior Year Finding: 2021-008 Federal Agency: U.S. Department of Education State Department Name: Delaware Technical Community College Federal Program: COVID-19 ? HEERF Student Aid Portion, COVID-19 ? HEERF Institutional Portion Assistance Listing Number: 84.425E, F Award N...

Reference Number: 2022-033 Prior Year Finding: 2021-008 Federal Agency: U.S. Department of Education State Department Name: Delaware Technical Community College Federal Program: COVID-19 ? HEERF Student Aid Portion, COVID-19 ? HEERF Institutional Portion Assistance Listing Number: 84.425E, F Award Number and Year: P425E204740 (5/24/2020 ? 6/30/2023) P425F204690 (8/18/2020 ? 6/30/2023) Compliance Requirement: Reporting ? Special Reporting Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance Recommendation: The College should review and enhance internal controls and procedures to ensure that it maintains documentation supporting the Annual Report and the quarterly student aid portion reports and that this documentation is available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College?s 2021 Year 2 Annual HEERF-Student Aid report table (Page 3 Table 8a Row 2) was corrected March 24, 2023 and in agreement with Delaware Tech?s student ledger detail (Banner student accounting system extract) when the federal reporting system was open for limited system data entry time. The Year 2 report was corrected and resubmitted as 2022 Year 3 Annual HEERF report filed. Filing is saved for audit review per federal system acceptance communicated. Additional Fiscal Accounting staff have trained to assist the Financial Aid Office with Quarterly HEERF Student Aid Reporting, report posting within 10 days post quarter end, and grant records management for immediate availability. The college continues to review and enhance our HEERF reporting internal controls with reports compiled and confirmed by a team ensuring multiple layers of reconciliation and final system report filing confirmation. Improved data summaries from system extracts with use of website tracking and snapshots at a single point-in-time are in place to support timely reporting and audit verification with the College?s quarterly and cumulative student award disbursement ledger detail. All website update requests will occur via use of the College?s Web Request ticketing system ending with a copy of the site update each quarter. Name(s) of the contact person(s) responsible for corrective action: Carol Rhodes, Assistant Vice President for Finance Planned completion date for corrective action plan: March 2023

View Audit 43524

Finding 51250 (2022-029)

Material Weakness 2022

State of Delaware

DE

Subrecipient Monitoring Reporting § 200.1 § 200.303 § 200.332 § 200.501 § 200.521

Reference Number: 2022-029 Prior Year Finding: 2021-027 Federal Agency: U.S. Department Homeland Security State Department Name: Department of Safety and Homeland Security, Federal Emergency Management Agency (FEMA) State Division Name: Delaware Emergency Management Agency (DEMA) Federal Program: Di...

Reference Number: 2022-029 Prior Year Finding: 2021-027 Federal Agency: U.S. Department Homeland Security State Department Name: Department of Safety and Homeland Security, Federal Emergency Management Agency (FEMA) State Division Name: Delaware Emergency Management Agency (DEMA) Federal Program: Disaster Grants - Public Assistance (Presidentially Declared Disasters), COVID-19 ? Disaster Grants ? Public Assistance (Presidentially Declared Disasters) Assistance Listing Number: 97.036 Award Number and Year: 4526-DR-DE (2022), 4566-DR-DE (2022), 4627-DR-DE (2022) Compliance Requirement: Subrecipient Monitoring Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance Recommendation: DEMA should review and enhance internal controls and procedures to ensure that all required information is included in all subawards, that subrecipients are properly monitored, and that evaluation of independent audits is performed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A contractor has been assigned to develop and implement internal controls to ensure all required information is included in all subawards, that subrecipients are properly monitored, and that evaluation of independent audits is performed. Subaward letters were updated in September 2022 and a monitoring protocol implemented to begin monitoring all subrecipients to date to include an evaluation of independent audits that is documented as part of the monitoring visit. Name(s) of the contact person(s) responsible for corrective action: Tramaine Childs Disaster Recovery Specialist Innovative Emergency Management Inc. 318.278.2813 (Mobile) Tramaine.Childs@iem.com Planned completion date for corrective action plan: September 26, 2022

View Audit 43524

Finding 51249 (2022-028)

Material Weakness 2022

State of Delaware

DE

Matching / Level of Effort / Earmarking Subrecipient Monitoring Material Weakness § 200.303

Reference Number: 2022-028 Prior Year Finding: No Federal Agency: U.S. Department Homeland Security State Agency: Department of Safety and Homeland Security, Federal Emergency Management Agency (FEMA) State Division: Delaware Emergency Management Agency (DEMA) Federal Program: Disaster Grants - Publ...

Reference Number: 2022-028 Prior Year Finding: No Federal Agency: U.S. Department Homeland Security State Agency: Department of Safety and Homeland Security, Federal Emergency Management Agency (FEMA) State Division: Delaware Emergency Management Agency (DEMA) Federal Program: Disaster Grants - Public Assistance (Presidentially Declared Disasters), COVID-19 ? Disaster Grants ? Public Assistance (Presidentially Declared Disasters) Assistance Listing Number: 97.036 Award Number and Year: 4526-DR-DE (2022), 4566-DR-DE (2022), 4627-DR-DE (2022) 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 that DEMA enhance internal controls and procedures to ensure that FFATA reporting requirements are met and supporting documentation for submission is maintained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: DEMA finance section has created a group account for FFATA reporting using the group email DEMAFiscal@delaware.gov to enable anyone in that section to access, edit, and submit reports as needed. This will ensure that everyone in the finance section has access to information regardless of turnover. This will also share the workload and assist with timely reporting. Name(s) of the contact person(s) responsible for corrective action: Frances Cordell Manager, Support Services (302) 659-2244 (office) (302) 222-6565 (mobile) Planned completion date for corrective action plan: March 20, 2023

View Audit 43524

Finding 51244 (2022-027)

Significant Deficiency 2022

State of Delaware

DE

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.430

Reference Number: 2022-027 Prior Year Finding: 2021-025 Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Substance Abuse and Mental Health Federal Program: Block Grants for Prevention and Tre...

Reference Number: 2022-027 Prior Year Finding: 2021-025 Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Substance Abuse and Mental Health Federal Program: Block Grants for Prevention and Treatment of Substance Abuse, COVID-19 - Block Grants for Prevention and Treatment of Substance Abuse Assistance Listing Number: 93.959 Award Number and Year: B08TI083060 (10/1/2019 ? 9/30/2021), B08TI083488 (10/1/2020 ? 9/30/2022) Compliance Requirement: Allowable Cost/Cost Principles ? Time and Effort Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: The Division should reevaluate its current process, implement proper controls, and perform additional training over time and effort reporting. The Division should not seek federal reimbursement unless it can substantiate that the time and effort was dedicated to the federal program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Division will reevaluate its current process, implement proper controls, and perform additional training over time and effort reporting. The Division will not seek federal reimbursement unless it can substantiate that the time and effort was dedicated to the federal program. Name(s) of the contact person(s) responsible for corrective action: Mequoria Bowden, Chief of Administration, Office of the Secretary Administration Planned completion date for corrective action plan: October 31, 2023

View Audit 43524 Questioned Costs: $1

Finding 51243 (2022-026)

Material Weakness 2022

State of Delaware

DE

Matching / Level of Effort / Earmarking Material Weakness § 200.303

Reference Number: 2022-026 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Substance Abuse and Mental Health Federal Program: Block Grants for Prevention and Treatment...

Reference Number: 2022-026 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Substance Abuse and Mental Health Federal Program: Block Grants for Prevention and Treatment of Substance Abuse, COVID-19 - Block Grants for Prevention and Treatment of Substance Abuse Assistance Listing Number: 93.959 Award Number and Year: B08TI083060 (10/1/2019 ? 9/30/2021), B08TI083488 (10/1/2020 ? 9/30/2022) Compliance Requirement: Level of Effort Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance Recommendation: The Division should review and enhance procedures and internal controls to ensure that it expends State funds in accordance with level of effort requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Division will review and enhance its procedures and internal controls to ensure that is expends State funds in accordance with level of effort requirements. This review is to include a more detailed procedure for gathering and organizing data from the state?s accounting system. Division program staff believe that this requirement was in fact met; however, the current process documentation is not clear enough to provide the level of support needed for the audit. Name(s) of the contact person(s) responsible for corrective action: Vivek Maharaj, DSAMH Grants Planned completion date for corrective action plan: June 30, 2023

View Audit 43524

Finding 51242 (2022-025)

Material Weakness 2022

State of Delaware

DE

Subrecipient Monitoring Material Weakness Reporting § 200.303

Reference Number: 2022-025 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Department of Health and Social Services State Division: Division of Substance Abuse and Mental Health Federal Program: Block Grants for Prevention and Treatment of Substance ...

Reference Number: 2022-025 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Department of Health and Social Services State Division: Division of Substance Abuse and Mental Health Federal Program: Block Grants for Prevention and Treatment of Substance Abuse, COVID-19 - Block Grants for Prevention and Treatment of Substance Abuse Assistance Listing Number: 93.959 Award Number and Year: B08TI083060 (10/1/2019 ? 9/30/2021), B08TI083488 (10/1/2020 ? 9/30/2022) 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 that the Division develop internal controls and procedures to ensure that FFATA reporting requirements are met. We further recommend the Division develop controls and procedures to ensure that all required subawards are reported accurately and timely to FSRS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Division will reevaluate its current process, implement proper controls for FFATA reporting standards, and ensure subawards are reviewed timely. In addition, staff will be assigned to verify information prior to being keyed into FSRS. Name(s) of the contact person(s) responsible for corrective action: Mequoria Bowden, Chief of Administration, Office of the Secretary Planned completion date for corrective action plan: October 31, 2023

View Audit 43524

Finding 51241 (2022-024)

Material Weakness 2022

State of Delaware

DE

Subrecipient Monitoring Reporting § 200.303 § 200.332 § 200.425 § 200.501 § 200.521

Reference Number: 2022-024 Prior Year Finding: 2021-024 Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Substance Abuse and Mental Health Federal Program: Block Grants for Prevention and Tre...

Reference Number: 2022-024 Prior Year Finding: 2021-024 Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Substance Abuse and Mental Health Federal Program: Block Grants for Prevention and Treatment of Substance Abuse, COVID-10 - Block Grants for Prevention and Treatment of Substance Abuse Assistance Listing Number: 93.959 Award Number and Year: B08TI083060 (10/1/2019 ? 9/30/2021), B08TI083488 (10/1/2020 ? 9/30/2022) Compliance Requirement: Subrecipient Monitoring Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance Recommendation: The Division should review and enhance internal controls and procedures to ensure that all required information is included in all subawards and provided to the subrecipients, that proper subrecipient monitoring is conducted, and that evaluation of independent audits is performed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Division has been working to implement corrective action. DSAMH continues to update and enhance policies and procedures to ensure that proper subrecipient monitoring is conducted in accordance with Federal regulations. Name(s) of the contact person(s) responsible for corrective action: Mequoria Bowden, Chief of Administration Office of the Secretary Administration Planned completion date for corrective action plan: October 31, 2023

View Audit 43524

Finding 51240 (2022-023)

Significant Deficiency 2022

State of Delaware

DE

Subrecipient Monitoring § 200.303 § 200.332 § 200.425 § 200.521

Reference Number: 2022-023 Prior Year Finding: 2021-018 Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Substance Abuse and Mental Health Federal Program: Opioid STR Assistance Listing Numbe...

Reference Number: 2022-023 Prior Year Finding: 2021-018 Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Substance Abuse and Mental Health Federal Program: Opioid STR Assistance Listing Number: 93.788 Award Number and Year: H79TI083305 (9/30/2020 ? 9/29/2022) Compliance Requirement: Subrecipient Monitoring Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: The Division should review and enhance internal controls and procedures to ensure that proper subrecipient monitoring is conducted in accordance with Federal regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Division has been working to implement corrective action. DSAMH continues to update and enhance policies and procedures to ensure that proper subrecipient monitoring is conducted in accordance with Federal regulations. Name(s) of the contact person(s) responsible for corrective action: Mequoria Bowden, Chief of Administration, Office of the Secretary Administration Planned completion date for corrective action plan: October 31, 2023

View Audit 43524

Finding 51239 (2022-022)

Material Weakness 2022

State of Delaware

DE

Subrecipient Monitoring Material Weakness Reporting § 200.303

Reference Number: 2022-022 Prior Year Finding: 2021-020 Federal Agency: U.S. Department of Health and Human Services State Agency: Department of Health and Social Services State Division: Division of Substance Abuse and Mental Health Federal Program: Opioid STR Assistance Listing Number: 93.788 Awar...

Reference Number: 2022-022 Prior Year Finding: 2021-020 Federal Agency: U.S. Department of Health and Human Services State Agency: Department of Health and Social Services State Division: Division of Substance Abuse and Mental Health Federal Program: Opioid STR Assistance Listing Number: 93.788 Award Number and Year: H79TI083305 (9/30/2020 ? 9/29/2022) 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 that the Division develop internal controls and procedures to ensure that FFATA reporting requirements are met. We further recommend the Division develop controls and procedures to ensure that all required subawards are reported accurately and timely to FSRS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Division will reevaluate its current process, implement proper controls for FFATA reporting standards, and ensure subawards are reviewed timely. In addition, staff will be assigned to verify information prior to being keyed into FSRS. Name(s) of the contact person(s) responsible for corrective action: Mequoria Bowden, Chief of Administration, Office of the Secretary Administration Planned completion date for corrective action plan: October 31, 2023

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Finding 51229 (2022-021)

Material Weakness 2022

State of Delaware

DE

Internal Control / Segregation of Duties Special Tests & Provisions Subrecipient Monitoring § 200.303

Reference Number: 2022-021 Prior Year Finding: 2021-015 Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Medicaid and Medical Assistance Federal Program: Children?s Health Insurance Program M...

Reference Number: 2022-021 Prior Year Finding: 2021-015 Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Medicaid and Medical Assistance Federal Program: Children?s Health Insurance Program Medicaid Cluster Assistance Listing Number: 93.767, 93.775, 93.777, 93.778 Award Number and Year: 2105DE5021 (10/1/2020 ? 9/30/2022), 2205DE5021 (10/1/2021 ? 9/30/2023) 2105DE5MAP (10/1/2020 ? 9/30/2021), 2205DE5MAP (10/1/2021 ? 9/30/2022) Compliance Requirement: Special Tests ? Provider Eligibility Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Recommendation: The Division should reevaluate its current process and perform additional training for determining and monitoring provider eligibility. More thorough reviews and supervision should be placed around the provider eligibility processes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Division is reevaluating the current process for validating non-Par provider eligibility. This includes developing additional training for determining and monitoring provider eligibility and researching best practices in this area. The Division will also complete more thorough reviews and exercise increased supervisory oversight around the provider eligibility processes. Name(s) of the contact person(s) responsible for corrective action: Kathleen Dougherty Planned completion date for corrective action plan: September 30, 2023

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Finding 51228 (2022-020)

Material Weakness 2022

State of Delaware

DE

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

Reference Number: 2022-020 Prior Year Finding: 2021-016 Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Medicaid and Medical Assistance Federal Program: Children?s Health Insurance Program M...

Reference Number: 2022-020 Prior Year Finding: 2021-016 Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Medicaid and Medical Assistance Federal Program: Children?s Health Insurance Program Medicaid Cluster Assistance Listing Number: 93.767, 93.775, 93.777, 93.778 Award Number and Year: 2105DE5021 (10/1/2020 ? 9/30/2022), 2205DE5021 (10/1/2021 ? 9/30/2023) 2105DE5MAP (10/1/2020 ? 9/30/2021), 2205DE5MAP (10/1/2021 ? 9/30/2022) Compliance Requirement: Special Tests ? Managed Care Financial Audit Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance Recommendation: The Division should implement procedures to ensure that it conducts or contracts for independent audits of its managed care providers at least once every three years and posts the results of those audits to their website. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Division will develop a process to ensure the contracted MCO?s have received an independent audit, as required, and that the results of that audit are posted to the website. In addition, the Division will also utilize our independent Actuary CPA to review the financial data of MCO?s as an additional step in the review process. Name(s) of the contact person(s) responsible for corrective action: Kathleen Dougherty Michele Stant Planned completion date for corrective action plan: June 30, 2023

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Finding 51227 (2022-019)

Significant Deficiency 2022

State of Delaware

DE

Special Tests & Provisions Reporting Significant Deficiency § 200.303

Reference Number: 2022-019 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Medicaid and Medical Assistance Federal Program: Children?s Health Insurance Program Medic...

Reference Number: 2022-019 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Medicaid and Medical Assistance Federal Program: Children?s Health Insurance Program Medicaid Cluster Assistance Listing Number: 93.767, 93.775, 93.777, 93.778 Award Number and Year: 2105DE5021 (10/1/2020 ? 9/30/2022), 2205DE5021 (10/1/2021 ? 9/30/2023) 2105DE5MAP (10/1/2020 ? 9/30/2021), 2205DE5MAP (10/1/2021 ? 9/30/2022) Compliance Requirement: Special Tests and Provisions ? Medical Loss Ratio Type of Finding: Significant Deficiency in Internal Control Over Compliance Recommendation: The Division should review and enhance its procedures and controls regarding MLR reporting to ensure that supporting documentation is readily available upon audit request.Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Division will review internal controls and archiving process to ensure all required MLR reporting support documentation is provided in a timely manner during the audit. Name(s) of the contact person(s) responsible for corrective action: Michele Stant Planned completion date for corrective action plan: June 30, 2023

View Audit 43524

Finding 51226 (2022-018)

Material Weakness 2022

State of Delaware

DE

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303 § 200.308 § 200.309 § 200.403

Reference Number: 2022-018 Prior Year Finding: 2021-014 Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Medicaid and Medical Assistance Federal Program: Children?s Health Insurance Program (...

Reference Number: 2022-018 Prior Year Finding: 2021-014 Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Medicaid and Medical Assistance Federal Program: Children?s Health Insurance Program (CHIP) Assistance Listing Number: 93.767 Award Number and Year: 2205DE5021 (10/1/2021 ? 9/30/2023) Compliance Requirement: Period of Performance Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Recommendation: The Division should review and enhance internal controls and procedures to ensure that it charges expenditures to the program that are incurred within an award?s allowable period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: DMMA will review reported expenditures based on the date of the federal draw to ensure that the expenditures occured within the period reported. Name(s) of the contact person(s) responsible for corrective action: Unkyong Goldie Planned completion date for corrective action plan: September 30, 2023

View Audit 43524 Questioned Costs: $1

Finding 51224 (2022-017)

Material Weakness 2022

State of Delaware

DE

Subrecipient Monitoring Material Weakness Reporting § 200.303

Reference Number: 2022-017 Prior Year Finding: 2021-013 Federal Agency: U.S. Department of Health and Human Services State Agency: Department of Health and Social Services State Division: Division of State Service Centers Federal Program: COVID-19 ? Low-Income Home Energy Assistance Assistance Listi...

Reference Number: 2022-017 Prior Year Finding: 2021-013 Federal Agency: U.S. Department of Health and Human Services State Agency: Department of Health and Social Services State Division: Division of State Service Centers Federal Program: COVID-19 ? Low-Income Home Energy Assistance Assistance Listing Number: 93.568 Award Number and Year: 2001DELIEA (10/1/2019 ? 9/30/2021), 2101DELIEA (10/102020 ? 9/30/2022), 2010DEE5C6 (3/11/2021 ? 9/30/2022), 2201DELIEA (10/1/2021 ? 9/30/2023) 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 that the Division develop internal controls and procedures to ensure that FFATA reporting requirements are met. We further recommend the Division develop controls and procedures to ensure that all required subawards are reported accurately and timely to FSRS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Division has developed internal controls and procedures to ensure that FFATA reporting requirments are met and subawards are reported accurately and timely to FSRS. Specifically, the Division and Fiscal staff will work together to collect required information from the contractors and enter the FFATA information into FSRS portal. All contracts will have additional pages (through appendices) to collect information for FFATA reporting. Name(s) of the contact person(s) responsible for corrective action: Christopher Antonio Haly Laasme-McQuilkin Planned completion date for corrective action plan: June 30, 2023

View Audit 43524

Corrective Action Plans

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