Corrective Action Plans

Finding 38552 (2022-038)

Material Weakness 2022

State of Vermont

VT

Questioned Costs Subrecipient Monitoring Material Weakness § 200.303

Corrective Action Plan: Agency of Human Services Internal Audit Group (AHS-IAG) is a designated centralized reporter of subawards for a Medicaid cluster (AL No. 93.775, 93.777, 93.778) that is shared between all AHS departments. To address omissions and timeliness of subawards and subaward modificat...

Corrective Action Plan: Agency of Human Services Internal Audit Group (AHS-IAG) is a designated centralized reporter of subawards for a Medicaid cluster (AL No. 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 will conduct additional training tailored to each AHS Department to examine the results of FFATA testing conducted internally, and reemphasize the FFATA compliance regulations. This will ensure the Internal Audit Group (IAG) is provided with complete, accurate and timely subaward information for reporting in FSRS going forward. Further, on at least an annual basis, IAG will conduct 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: Annual review of FFATA rules and regulations including subawards sample testing December 31, 2022 Individualized training for each AHS Department January 31, 2023 Contact for Corrective Action Plan: Peter Moino AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 30446

Finding 38551 (2022-037)

Material Weakness 2022

State of Vermont

VT

Eligibility Questioned Costs Special Tests & Provisions § 200.303

Corrective Action Plan 1. The corrective measures pertaining to DVHA?s enhanced oversight of Gainwell?s contractual obligation to DVHA to provide licensure validation service and documentation of active licensure will include established benchmarks for the overall improvement of the service, expans...

Corrective Action Plan 1. The corrective measures pertaining to DVHA?s enhanced oversight of Gainwell?s contractual obligation to DVHA to provide licensure validation service and documentation of active licensure will include established benchmarks for the overall improvement of the service, expansion of automated search services, progress reports and overall reduction of manual processes. By 5/1/2023 Gainwell will provide the DVHA Oversight & Monitoring Unit with Progress Reports that will be shared at the Fiscal Agent meeting and with DVHA Leadership to track progress and/or report roadblocks and escalate issues of any actual or potential failures to timely perform provider revalidations. Gainwell will use the Provider Management Module (PMM) and other services available to validate license of a provider. For those providers that cannot be validated through PMM or other services, Gainwell will send a letter notice to those providers. Letter notice must be sent no later than 30 days prior to a license expiration date. Gainwell shall submit to DVHA on a weekly basis a list of providers who have been notified that they are due for re-validation and have not responded within 14 days of license expiration date. Gainwell will use PMM and other services available to validate license of a provider. For those providers that cannot be validated through PMM or other services, Gainwell will send a letter notice to those providers. Letter notice must be sent no later than 30 days prior to a license expiring. The written detailed procedure for license updates will be finalized by 04/01/23 between the State and Gainwell and will include the following: a. Update the look forward period in the license screening service to 45 days. As a result, PMM will be updated automatically when the license screening service is available to locate an updated license. This configuration update will be in place by 04/01/23. For those licenses that the screening service is not able to locate an updated license, Gainwell will review and manually check for an updated license. If a new license is found, Gainwell will update accordingly. Gainwell will explore using Lexis Nexis as an additional service for manual review of license information and provide an update of potential solution by 03/17/23. If determined the Lexis Nexis solution is not viable, Gainwell will propose additional solution options by 05/01/23. b. Any provider whose license was not automatically updated as part of the screening service and could not be manually updated through the review process, an expiring license notification will be sent to the Mail-To contact information on file 30 days prior to their license expiration date. The expiring license notifications will be activated in PMM as of 04/01/23. Providers will be notified of this change in process as of 03/01/23 via banner. c. Gainwell will provide a weekly report of any providers whose license is set to expire in 14 days. This report will be delivered weekly beginning 04/17/23, two weeks after start date of license notifications. DVHA will work with Gainwell to finalize a process to address those providers listed. d. Gainwell will activate the termination job within the PMM that will automatically end a provider?s contract with VT Medicaid when no license was obtained through the process listed above by the license end date. This termination job will be activated on 06/05/23, two months after starting license notification. Notification to providers of this change in process will be sent no later than 05/01/23, via banner. Prior to the termination job being activated, Gainwell will continue to manually terminate when no updated license information is obtained, unless written exception is received from DVHA. All exception requests will be stored as part of the provider?s electronic record within PMM. By March 1st, 2023, Gainwell will provide the following information to DVHA: The databases, services, and available in state and out of state agencies Gainwell currently uses and plans to use in order to monitor and verify provider licenses and certifications; and 2. As of December 31, 2023, all revalidations will electronically reside in PMM. By December 31, 2023, All paper files, maintained prior to the implementation of the PMM, will be cataloged and sent to secure storage. To ensure all records are available for review, all application data is now being processed through PMM and available on demand. This includes paper application sent in by providers, Gainwell inputs the paper application into PMM. 3. The Letters of Good Tax Standing have been obtained. A standard operating practice is in place documenting the process. The process of validating tax standing in writing from the Tax Department has been in effect since April 2022. Providers who had their tax standing validated prior to April 2022 via phone or email were not solicited to obtain a written notification from the Tax Commissioner. At this time, the State has determined that it is not necessary to obtain a retroactive written notification from the Tax Commissioner for tax standing prior to April 2022. As of April 2022, all tax standing reviews are validated with a letter from the Tax Department and documented in the PMM. Scheduled Completion Date of Corrective Action Plan: 1. January 1, 2024 2. December 31, 2023 3. Completed Contacts for Corrective Action Plan: Suellen Bottiggi, DVHA Director of Member and Provider Services suellen.bottiggi@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 30446

Finding 38549 (2022-036)

Material Weakness 2022

State of Vermont

VT

Eligibility Questioned Costs Special Tests & Provisions § 200.303

Corrective Action Plan: 1. The corrective measures pertaining to DVHA?s enhanced oversight of Gainwell?s contractual obligation to DVHA to provide licensure validation service and documentation of active licensure will include established benchmarks for the overall improvement of the service, expans...

Corrective Action Plan: 1. The corrective measures pertaining to DVHA?s enhanced oversight of Gainwell?s contractual obligation to DVHA to provide licensure validation service and documentation of active licensure will include established benchmarks for the overall improvement of the service, expansion of automated search services, progress reports and overall reduction of manual processes. By 5/1/2023 Gainwell will provide the DVHA Oversight & Monitoring Unit with Progress Reports that will be shared at the Fiscal Agent meeting and with DVHA Leadership to track progress and/or report roadblocks and escalate issues of any actual or potential failures to timely perform provider revalidations. Gainwell will use the Provider Management Module (PMM) and other services available to validate license of a provider. For those providers that cannot be validated through PMM or other services, Gainwell will send a letter notice to those providers. Letter notice must be sent no later than 30 days prior to a license expiration date. Gainwell shall submit to DVHA on a weekly basis a list of providers who have been notified that they are due for re-validation and have not responded within 14 days of license expiration date. The written detailed procedure for license updates will be finalized by 04/01/23 between the State and Gainwell and will include the following: a. Update the look forward period in the license screening service to 45 days. As a result, PMM will be updated automatically when the license screening service is available to locate an updated license. This configuration update will be in place by 04/01/23. For those licenses that the screening service is not able to locate an updated license, Gainwell will review and manually check for an updated license. If a new license is found, Gainwell will update accordingly. Gainwell will explore using Lexis Nexis as an additional service for manual review of license information and provide an update of potential solution by 03/17/23. If determined the Lexis Nexis solution is not viable, Gainwell will propose additional solution options by 05/01/23. b. Any provider whose license was not automatically updated as part of the screening service and could not be manually updated through the review process, an expiring license notification will be sent to the Mail-To contact information on file 30 days prior to their license expiration date. The expiring license notifications will be activated in PMM as of 04/01/23. Providers will be notified of this change in process as of 03/01/23 via banner. c. Gainwell will provide a weekly report of any providers whose license is set to expire in 14 days. This report will be delivered weekly beginning 04/17/23, two weeks after start date of license notifications. DVHA will work with Gainwell to finalize a process to address those providers listed. d. Gainwell will activate the termination job within PMM that will automatically end a provider?s contract with VT Medicaid when no license was obtained through the process listed above by the license end date. This termination job will be activated on 06/05/23, two months after starting license notification. Notification to providers of this change in process will be sent no later than 05/01/23, via banner. Prior to the termination job being activated, Gainwell will continue to manually terminate when no updated license information is obtained, unless written exception is received from the DVHA. All exception requests will be stored as part of the provider?s electronic record within PMM. By March 1st, 2023, Gainwell will provide the following information to DVHA: The databases, services, and available in state and out of state agencies Gainwell currently uses and plans to use in order to monitor and verify provider licenses and certifications; and 2. To ensure all providers revalidate a minimum of every 5 years, PMM is automatically assigning the revalidation due date. Providers are notified 90 days prior to the due date and again at 45 days, if the provider does not revalidate by the due date, their contract is automatically terminated. At this time, all active providers are assigned a revalidation due date and every provider converted from the old system to PMM has a schedule that will result in revalidation of all legacy providers by December 31, 2023. Exception: If a provider?s revalidation application is returned to them, the provider has until their revalidation due date, or 30 days, whichever is greater, to correct and resubmit their revalidation. Example: Provider?s revalidation due date is 12/30/23 and their revalidation application is returned on 12/29/23. The provider will have until 01/29/24 to correct and resubmit. 3. The Letters of Good Tax Standing have been obtained. A standard operating practice is in place documenting the process. The process of validating tax standing in writing from the Tax Department has been in effect since April 2022. Providers who had their tax standing validated prior to April 2022 via phone or email were not solicited to obtain a written notification from the Tax Commissioner. At this time, the State has determined that it is not necessary to obtain a retroactive written notification from the Tax Commissioner for tax standing prior to April 2022. As of April 2022, all tax standing reviews are validated with a letter from the Tax Department and documented in the PMM. Scheduled Completion Date of Corrective Action Plan: 1. January 1, 2024 2. December 31, 2023 3. Completed Contacts for Corrective Action Plan: Suellen Bottiggi, DVHA Director of Member and Provider Services suellen.bottiggi@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 30446

Finding 38548 (2022-035)

Significant Deficiency 2022

State of Vermont

VT

Eligibility Questioned Costs Significant Deficiency § 200.303

Corrective Action Plan: ? One of sixty participants selected for testing turned 19 during the fiscal year. Due to the COVID-19 Public Health Emergency, states did not get authority to move customers from one MEC coverage group to another MEC coverage group until January 2021. The SoV began transitio...

Corrective Action Plan: ? One of sixty participants selected for testing turned 19 during the fiscal year. Due to the COVID-19 Public Health Emergency, states did not get authority to move customers from one MEC coverage group to another MEC coverage group until January 2021. The SoV began transitioning eligible age-off?s in March 2021. A report was created to capture anyone who had aged off since the start of the PHE. HC eligibility staff worked through the report to determine if customers were eligible to transition to another MEC coverage group. This individual was not captured on the report. They did not get transitioned until April 20, 2022 when the customer called and asked to be screened for Medicaid new adult. This case appears to be an isolated case and has since been corrected. ? For one of sixty participants, eligibility determination exceeded 45 days. Due to the COVID-19 Public Health Emergency, the SoV was accepting self-attestation for all income and resource verifications until November 1, 2021. In this case, the customer applied via the self-service portal and their MAGI-income verification line item (VLI) was pending. The SoV had reports in place at the time to pull all self-service applications with pending VLI?s to manually change them to verified. The SoV ran a report in October 2021 prior to the state resuming verifications for new applications to ensure all pending verification line items were verified and customers were enrolled timely. This appears to be an isolated case. Scheduled Completion Date of Corrective Action Plan: ? Age-off correction: April 20, 2022 ? Eligibility determination timeliness: September 15, 2021 Contacts for Corrective Action Plan: Nicole McAllister, DVHA-HAEEU HCAA II nicole.mcallister@vermont.gov Sarah York, DVHA-HAEEU HCAA I sarah.york@vermont.gov

View Audit 30446

Finding 38547 (2022-034)

Significant Deficiency 2022

State of Vermont

VT

Questioned Costs Student Financial Aid Eligibility § 200.303

Corrective Action Plan: The Child Development Division (CDD) has recently switched to a new IT system, Child Development Division Information System (CDDIS), that will check for the child?s IV-E eligibility and check to make sure that the child is in an eligible placement. With these checks it will...

Corrective Action Plan: The Child Development Division (CDD) has recently switched to a new IT system, Child Development Division Information System (CDDIS), that will check for the child?s IV-E eligibility and check to make sure that the child is in an eligible placement. With these checks it will allow the child to be marked as IV-E eligible or not and draw down the appropriate funding to match the eligibility. Scheduled Completion Date of Corrective Action Plan: July 31, 2023 Contacts for Corrective Action Plan: Karolyn Long ? Karolyn.Long@vermont.gov Emily Hazard ? Emily.Hazard@vermont.gov

View Audit 30446

Finding 38544 (2022-033)

Significant Deficiency 2022

State of Vermont

VT

Questioned Costs Subrecipient Monitoring Reporting § 200.303

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 al...

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. Scheduled Completion Date: 2/1/2023 Contacts for Corrective Action Plan: Jessica Brown, Financial Administrator, Vermont Department of Health Karen Clark, Financial Manager, Vermont Department of Health Megan Hoke, Financial Director, Vermont Department of Health Peter Moino, Director of Internal Audit, Vermont Agency of Human Services

View Audit 30446

Finding 38543 (2022-032)

Significant Deficiency 2022

State of Vermont

VT

Reporting Questioned Costs Significant Deficiency § 200.303

Corrective Action Plan ? Program Reporting: The Administrative Services Manager and the Public Health Preparedness Coordinator will create a central location for all supporting documentation to be stored and will ensure that the appropriate backup documentation is available for each progress report...

Corrective Action Plan ? Program Reporting: The Administrative Services Manager and the Public Health Preparedness Coordinator will create a central location for all supporting documentation to be stored and will ensure that the appropriate backup documentation is available for each progress report submitted to the CDC. The State Epidemiologist and PH Preparedness Coordinator will be responsible for ensuring that subject matter experts responsible for providing the information contained in progress reports are aware of the need to save supporting documentation. This supporting documentation will include ?point in time? reports from various electronic reporting systems as needed to ensure that data included in progress reports can be validated in the future. To ensure that progress reports are submitted timely the Public Health Preparedness Coordinator will verify that final copies of all program reports submitted are saved in a central location. The PH Preparedness Coordinator will also ensure that this supporting documentation includes a way to verify the date of report submission to the CDC. Corrective Action Plan ? Financial Reporting: The VDH Business Office will ensure that all financial reports are reviewed for accuracy prior to submission. The VDH business office will also continue to ensure that supporting documentation is available for all financial reports submitted, including date/time stamps recording timely submission. Scheduled Completion Date: 2/1/2023 Contacts for Corrective Action Plan: Patsy Kelso, State Epidemiologist, Vermont Department of Health Catherine Markesich, PH Preparedness Coordinator, Vermont Department of Health Megan Hoke, Financial Director, Vermont Department of Health Peter Moino, Director of Internal Audit, Vermont Agency of Human Services

View Audit 30446

Finding 38540 (2022-031)

Significant Deficiency 2022

State of Vermont

VT

Reporting Subrecipient Monitoring Significant Deficiency § 200.303

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 al...

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. Scheduled Completion Date: 2/1/2023 Contacts for Corrective Action Plan: Jessica Brown, Financial Administrator, Vermont Department of Health Karen Clark, Financial Manager, Vermont Department of Health Megan Hoke, Financial Director, Vermont Department of Health Peter Moino, Director of Internal Audit, Vermont Agency of Human Services

View Audit 30446

Finding 38539 (2022-030)

Significant Deficiency 2022

State of Vermont

VT

Allowable Costs / Cost Principles Questioned Costs § 200.303 § 200.403 § 200.405

Corrective Action Plan: VDH has updated its accounting structure and cost allocation plan to ensure that costs not otherwise eligible under federal grant awards are not attributed to the VDH administrative cost pool and allocated to federal grant programs. Scheduled Completion Date: 10/1/2022 ...

Corrective Action Plan: VDH has updated its accounting structure and cost allocation plan to ensure that costs not otherwise eligible under federal grant awards are not attributed to the VDH administrative cost pool and allocated to federal grant programs. Scheduled Completion Date: 10/1/2022 Contacts for Corrective Action Plan: Megan Hoke, Financial Director, Vermont Department of Health Peter Moino, Director of Internal Audit, Vermont Agency of Human Services

View Audit 30446

Finding 38534 (2022-028)

Significant Deficiency 2022

State of Vermont

VT

Equipment & Real Property Management § 200.303 § 200.313

Corrective Action Plan: The AOE will require each participating independent school complete an inventory webform every two years for each piece of equipment that has been reimbursed or purchased by VTAOE for use by the independent school under CRRSAA. The Equipment will be tagged as property of the ...

Corrective Action Plan: The AOE will require each participating independent school complete an inventory webform every two years for each piece of equipment that has been reimbursed or purchased by VTAOE for use by the independent school under CRRSAA. The Equipment will be tagged as property of the State of Vermont, and we will require a picture of the item for our records to ensure the item is in a good condition. We will maintain a list of equipment items including all that is required in 2 CFR section 200.313(d) (1). Our Administrative Services Director will add equipment and maintain our equipment list. Updates will be provided to this position by the EANS program team following the process below. The AOE EANS Program team will review each Equipment inventory submission for completeness including: the current condition and if the item is still being used for its intended purpose. Once the inventory is complete, the Program team will provide the inventory updates to the AOE Finance Team. As long as an independent school continues to use the equipment for an approved purpose, they will be asked to complete the inventory every two years. The Administrative Services Director will work with the State of Vermont?s Department of Buildings and General Services when equipment items need to be disposed of. We will provide them a list of the items and they will instruct us how to proceed. Position Responsible for Implementation of Corrective Action Name: Sean Cousino Position: Deputy Chief Financial Officer Email: sean.cousino@vermont.gov Phone Number: 802 595-3693 Date of Implementation of Corrective Action: 7/1/2023

View Audit 30446

Finding 38530 (2022-026)

Material Weakness 2022

State of Vermont

VT

Questioned Costs Special Tests & Provisions Material Weakness § 200.303

Corrective Action Plan: The Agency will identify if a new ESEA Federal grant (or a grant based on an ESEA program) includes an Equitable Service requirement during the program completion of the ?New Grant Checklist?. If a new grant includes an Equitable Service requirement, the ESEA Equitable Servic...

Corrective Action Plan: The Agency will identify if a new ESEA Federal grant (or a grant based on an ESEA program) includes an Equitable Service requirement during the program completion of the ?New Grant Checklist?. If a new grant includes an Equitable Service requirement, the ESEA Equitable Service?s Ombudsman will be notified and will work with the grant program manager to ensure the build of the GMS application includes the correct level of detail and controls to meet the SEA requirements for oversight. When appropriate, the Agency will use its process for handling of Equitable Services associated with the Consolidated Federal Programs as models for determining the correct calculation method. The Agency will utilize built in business rules and internal controls within the Grants Management System (GMS) to gather the following information in the grant application for AOE review and approval prior to issuing a grant award agreement: 1. Calculation of the total proportionate share dollars an LEA must set aside for Equitable Services 2. Identification of Independent Schools participating in Equitable Services applicable to each LEA 3. Calculation of the dollars available for Equitable Services for each participating Independent School For each Federal grant that requires an equitable services component, the Agency will document the review and approval of the Equitable Services information through one of two processes prior to the grant award agreement: 1. A dedicated review assignment specific to equitable services, or 2. Verification statements on the review checklist for a general application reviewer Position Responsible for Implementation of Corrective Action: Anne Bordonaro, Division Director, Federal & Education Support Programs anne.bordonaro@vermont.gov 802-828-1388 Date of Implementation of Corrective Action: July 1, 2023

View Audit 30446

Finding 38529 (2022-029)

Significant Deficiency 2022

State of Vermont

VT

Questioned Costs Subrecipient Monitoring Reporting § 200.303

Corrective Action Plan: To address the accuracy and timeliness of our entries into the FFATA system, we will use the USASPENDING.GOV website to assist us in reconciling what has been entered into the FFATA system. This will allow us to ensure that our grant ledgers agree with what is entered into ...

Corrective Action Plan: To address the accuracy and timeliness of our entries into the FFATA system, we will use the USASPENDING.GOV website to assist us in reconciling what has been entered into the FFATA system. This will allow us to ensure that our grant ledgers agree with what is entered into FFATA. This will be a reconciliation completed at least quarterly (following SOV fiscal year quarters) and will be completed by the Deputy CFO or position assigned by the Deputy CFO. We will also implement a process that will have all the steps necessary for a grant award or an amendment to ensure it is posted properly within our internal files and the external systems. This will ensure that new awards and amendments get routed and entered in the FFATA system timely. Our finance team also attended a FFATA training on February 3, 2023 for additional training on the FFATA system. We will look into the Batch upload process which was described in that training. Position Responsible for Implementation of Corrective Action Name: Sean Cousino Position: Deputy Chief Financial Officer Email: sean.cousino@vermont.gov Phone Number: 802 595-3693 Date of Implementation of Corrective Action: First Reconciliation to be completed March/April 2023 Full Implementation June 1,2023

View Audit 30446

Finding 38528 (2022-027)

Significant Deficiency 2022

State of Vermont

VT

Reporting Questioned Costs Cash Management § 200.302 § 200.303

Corrective Action Plan: We will be implementing a new process that is more automated to ensure accuracy and timeliness of our CMIA draws. We have created a new draw sheet that will be more easily loaded and will be reconciled a couple times a year. The Deputy CFO or person assigned by the Deput...

Corrective Action Plan: We will be implementing a new process that is more automated to ensure accuracy and timeliness of our CMIA draws. We have created a new draw sheet that will be more easily loaded and will be reconciled a couple times a year. The Deputy CFO or person assigned by the Deputy CFO will perform a reconciliation at least two times a year, with the first reconciliation being done before the end of FY 2023. We are currently using the new form and plan to be doing our draws in compliance with CMIA by 4/1/2023. We are also keeping all the backup for the draw electronically to allow for the review to be done more easily. Position Responsible for Implementation of Corrective Action Name: Sean Cousino Position: Deputy CFO Email: sean.cousino@vermont.gov Phone Number: 802 595-3693 Date of Implementation of Corrective Action: April 1st, 2023

View Audit 30446

Finding 38475 (2022-003)

Significant Deficiency 2022

McKendree University

IL

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.303

2022-003 Education Stabilization Fund: Higher Education Emergency Relief Fund Student Portion and Institutional Portion? Assistance Listing No. 84.425E, 84.425F Recommendation: We recommend the University design controls to ensure an adequate review and approval process is in place and documented. E...

2022-003 Education Stabilization Fund: Higher Education Emergency Relief Fund Student Portion and Institutional Portion? Assistance Listing No. 84.425E, 84.425F Recommendation: We recommend the University design controls to ensure an adequate review and approval process is in place and documented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The University will design and implement internal procedures with staff (accountant, interim VP, and president) to ensure adequate review and controls are in place. Name(s) of the contact person(s) responsible for corrective action: John Nisbet, Interim Vice President of Administration & Finance Planned completion date for corrective action plan: April 2023

View Audit 30596

Finding 38406 (2022-101)

Material Weakness 2022

Pima County Community College District

AZ

Questioned Costs Reporting Internal Control / Segregation of Duties § 200.303 § 200.334

Assistance Listings numbers and names 84.425E COVID-19 Education Stabilization Fund?Higher Education Emergency Relief Fund (HEERF) Student Aid Portion 84.425F COVID-19 Education Stabilization Fund?Higher Education Emergency Relief Fund (HEERF) Institutional Portion 84.425L COVID-19 Education Stabili...

Assistance Listings numbers and names 84.425E COVID-19 Education Stabilization Fund?Higher Education Emergency Relief Fund (HEERF) Student Aid Portion 84.425F COVID-19 Education Stabilization Fund?Higher Education Emergency Relief Fund (HEERF) Institutional Portion 84.425L COVID-19 Education Stabilization Fund?Higher Education Emergency Relief Fund (HEERF) Minority Serving Institutions (MSIs) Award Number and Years P425E200055, April 20, 2020, through June 30, 2023 P425F201359, May 6, 2020, through June 30, 2023 P245L200182, June 2, 2020, through June 30, 2023 Federal Agency U.S. Department of Education Compliance Requirement Reporting Questioned costs Not applicable Contact Julie Dall?Aglio, Director for Grant Services Anticipated completion date June 30, 2023 1.The district will follow existing grant services procedures specifically for completing agency federal reporting,so it is accurate and on time. The district will also include a public disclosure notice regarding the timing ofpublic posting and note that the financial reporting is subject to change depending on when the financialbooks close each quarter. 2.To verify the accuracy of the information reported, the following will be performed: ?there will be a cross check using an independent financial analyst from grant services who willprepare the financial information for each grant. ?The grant services director will review the information and enter it into the quarterly reporting forthe 84.25F Institutional and 84.25L MSI reporting. ?The Financial Aid and Scholarships Department will verify 84.425 HEERF Student Aid information thatis compiled by Strategy, Analytics, and Research Department (STAR) and enter it into the samequarterly reporting document. ?The Financial Aid & Scholarships Department will submit the reporting back to Grant Services, andGrant Services will verify the financial information one more time to confirm it is accurate with thegeneral ledger.? The reporting will then be cleared for public posting and submitted through the Financial Aid and Scholarships Department who will contact Web Services for public posting. 3. This reporting process will be coordinated by the grant services director so the reporting can be completed within ten days after each quarter to meet the federal reporting requirements for these three grants. ? Any quarterly reporting will be updated as soon as it is identified there should be corrections. ? All information will be collected in an excel workbook with references to the source of information. ? This will serve as backup for the audit.

View Audit 32632

Finding 38348 (2022-001)

Material Weakness 2022

New York Blood Center, Inc.

NY

Cash Management Material Weakness Matching / Level of Effort / Earmarking § 200.303

Diabetes, Digestive, and Kidney Diseases Extramural Research (ALN 93.847) Mental Health Research Grants (ALN 93.839) Blood Diseases and Resources Research (ALN 93.242) Allergy and Infectious Diseases Research (ALN 93.855) Recommendation: We recommend that the Organization review their approval polic...

Diabetes, Digestive, and Kidney Diseases Extramural Research (ALN 93.847) Mental Health Research Grants (ALN 93.839) Blood Diseases and Resources Research (ALN 93.242) Allergy and Infectious Diseases Research (ALN 93.855) Recommendation: We recommend that the Organization review their approval policy around cash management and ensure review is performed before drawdowns and that evidence of this review is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We have implemented the use of a preparer and reviewer for all drawdowns and added a cumulative review to the procedure. Additionally, we have moved from a quarterly to a bimonthly drawdown cycle. Name(s) of the contact person(s) responsible for corrective action: Mahtab Khan Planned completion date for corrective action plan: August 31,2022

View Audit 35886

Finding 38339 (2022-003)

Material Weakness 2022

Howard County

IN

Equipment & Real Property Management § 200.303 § 200.311 § 200.313

FINDING 2022-003 Contact Person Responsible for Corrective Action: Jessica Secrease Contact Phone Number: 765-456-2804 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The County will maintain adequate property records for the State and Local Fiscal R...

FINDING 2022-003 Contact Person Responsible for Corrective Action: Jessica Secrease Contact Phone Number: 765-456-2804 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The County will maintain adequate property records for the State and Local Fiscal Recovery Funds. In the future, the Auditor?s Office will request that the County Commissioners and County Attorney provide all necessary information in order for records to be maintained properly. The County Commissioners will also be reminded that they need to follow the agreements that they approve. Anticipated Completion Date: 06/15/2023

View Audit 32527

Finding 38338 (2022-002)

Significant Deficiency 2022

Howard County

IN

Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking § 200.112 § 200.303 § 200.318

FINDING 2022-002 Contact Person Responsible for Corrective Action: Jessica Secrease Contact Phone Number: 765-456-2804 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The County will establish a federally-compliant conflict of interest policy in addi...

FINDING 2022-002 Contact Person Responsible for Corrective Action: Jessica Secrease Contact Phone Number: 765-456-2804 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The County will establish a federally-compliant conflict of interest policy in addition to the County?s current conflict of interest policy. The County Attorney will be notified again that this policy still needs to be created. Anticipated Completion Date: 10/31/2023

View Audit 32527

Finding 38337 (2022-001)

Material Weakness 2022

Howard County

IN

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

FINDING 2022-001 Contact Person Responsible for Corrective Action: Jessica Secrease Contact Phone Number: 765-456-2804 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The County will establish an effective internal control system that will segregate ...

FINDING 2022-001 Contact Person Responsible for Corrective Action: Jessica Secrease Contact Phone Number: 765-456-2804 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The County will establish an effective internal control system that will segregate duties when it comes to federal compliance reporting. The Chief Deputy will continue to prepare and submit reports. The Auditor will review and approve any reporting prior to submission. Initialed reports will be kept within the grant file. Anticipated Completion Date: 07/31/2023

View Audit 32527

Finding 38219 (2022-001)

Significant Deficiency 2022

Cook County Board of Education

GA

Questioned Costs Cash Management Subrecipient Monitoring § 200.302 § 200.303 § 200.305

Cook County BOE FA 2022-001 Improve Controls over Cash Management Compliance Requirement: Cash Management Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of E...

Cook County BOE FA 2022-001 Improve Controls over Cash Management Compliance Requirement: Cash Management Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: COVID-19 - 84.425D - Elementary and Secondary School Emergency Relief Fund COVID-19 - 84.425U - American Rescue Plan Elementary and Secondary School Emergency Relief Fund Federal Award Number: S425D210012 (Year: 2021) S425U2120012 (Year: 2021) Questioner Costs: $195,559 Description: The School District made cash drawdowns in excess of the immediate cash needs of the Elementary and Secondary School Emergency Relief Fund program. Corrective Action Plans: In order to prevent drawdowns from being mixed up between two federal grants, an additional financial staff member will sign off on the drawdowns. Estimated Completion Date: August 1, 2023 Contact Person: Jackie Sparks, Finance Director Telephone: (229)-896-2294 Email: jsparks@cook.k12.ga.us

View Audit 37553 Questioned Costs: $1

Finding 38193 (2022-001)

Significant Deficiency 2022

Logan County School District

KY

Questioned Costs Allowable Costs / Cost Principles § 200.303

IN REGARDS TO COVID-19 EDUCATION STABILIZATION FUND -- ASSISTANCE LISTING NO. 84.425; GRANT PERIOD -- YEAR ENDED JUNE 30, 2022 THE DISTRICT WILL PUT MEASURES IN PLACE TO ENSURE THAT ALLOWABLE COSTS ARE CHARGED TO THE GRANT. THE ANTICIPATED COMPLETION DATE OF THESE ACTIONS IS NOVEMBER 14, 2022 WITH K...

IN REGARDS TO COVID-19 EDUCATION STABILIZATION FUND -- ASSISTANCE LISTING NO. 84.425; GRANT PERIOD -- YEAR ENDED JUNE 30, 2022 THE DISTRICT WILL PUT MEASURES IN PLACE TO ENSURE THAT ALLOWABLE COSTS ARE CHARGED TO THE GRANT. THE ANTICIPATED COMPLETION DATE OF THESE ACTIONS IS NOVEMBER 14, 2022 WITH KARLA PADDOCK THE RESPONSIBILE PERSON FOR IMPLEMENTATION.

View Audit 31205 Questioned Costs: $1

Finding 38070 (2022-008)

Material Weakness 2022

County of Los Angeles

CA

Subrecipient Monitoring Internal Control / Segregation of Duties Reporting § 200.303

DPH agrees with the finding and recommendations. DPH will continue monitoring subawards upon execution and monthly to identify when a subrecipient surpasses the threshold triggering FFATA reporting. DPH will also retain screenshots or printouts when submitting FFATA reports documenting the submissio...

DPH agrees with the finding and recommendations. DPH will continue monitoring subawards upon execution and monthly to identify when a subrecipient surpasses the threshold triggering FFATA reporting. DPH will also retain screenshots or printouts when submitting FFATA reports documenting the submission date.

View Audit 35126

Finding 38067 (2022-010)

Material Weakness 2022

County of Los Angeles

CA

Subrecipient Monitoring Internal Control / Segregation of Duties Reporting § 200.303

DPH agrees with the finding and recommendations. DPH will continue monitoring subawards upon execution and monthly to identify when a subrecipient surpasses the threshold triggering FFATA reporting. DPH will also retain screenshots or printouts when submitting FFATA reports documenting the submissio...

DPH agrees with the finding and recommendations. DPH will continue monitoring subawards upon execution and monthly to identify when a subrecipient surpasses the threshold triggering FFATA reporting. DPH will also retain screenshots or printouts when submitting FFATA reports documenting the submission date.

View Audit 35126

Finding 38065 (2022-002)

Material Weakness 2022

County of Los Angeles

CA

Subrecipient Monitoring Questioned Costs Matching / Level of Effort / Earmarking § 200.303

The Department of Health Services' Emergency Medical Services Agency (EMS) agrees with the finding and recommendation. EMS will strengthen its report submission process to ensure all reports are submitted by the defined due date and retain documentation evidencing submission of the report. The EMS' ...

The Department of Health Services' Emergency Medical Services Agency (EMS) agrees with the finding and recommendation. EMS will strengthen its report submission process to ensure all reports are submitted by the defined due date and retain documentation evidencing submission of the report. The EMS' HPP Coordinator will identify each sub-awardee that meets the $30,000 FFATA threshold and will provide the information to EMS Finance to review and process payment. Before any payment is completed, EMS will obtain and confirm all Unique Entity Identifier (UEI) numbers from the sub-awardees are active prior to issuing any checks. EMS will log all sub-awardees that have reached the threshold into a report and will submit the FFATA report via SAM.gov before the defined due date. To avoid access issues in retrieving submitted documents via the System for Award Management (SAM.gov) website, EMS will retain copies of all reports that include the submission dates.

View Audit 35126

Finding 38061 (2022-002)

Significant Deficiency 2022

Coastal Alabama Community College

AL

Allowable Costs / Cost Principles Questioned Costs Reporting § 200.303

Reference Number: 2022-002 Compliance Requirement: Reporting Type of Finding: Internal Control and Compliance Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Assistance Listing Number(s) and Title: 84.425 ? Higher Education Emergency Relief Fund(HEERF) Fe...

Reference Number: 2022-002 Compliance Requirement: Reporting Type of Finding: Internal Control and Compliance Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Assistance Listing Number(s) and Title: 84.425 ? Higher Education Emergency Relief Fund(HEERF) Federal Awarding Agency: U.S. Department of EducationCorrective Action Plan Coastal Alabama Community College has reviewed and recognizes needed changes be put into place to ensure accurate record keeping for all reported data. Coastal will have the restricted accountant complete the quarterly and annual HEERF reports moving forward and file all data according to the report in an organized and methodical method only after the Director of Accounting has reviewed and signed off on the accuracy of the data being reported. Once the Director of Accounting and/or CFO review the reports and backup data for approval then the approved reports will be filed on-line with the Department of Education via the HEERF site. Expenditures charged against the HEERF funds are reviewed for accuracy and allowable cost through a multi-step purchasing process to ensure allowable cost only and prevent potential for improper spending. The Director of Accounting will make sure that all website required reporting is done in a timely manner moving forward. Anticipated Completion Date: June 15, 2023 Contact Person(s): Jessica Davis, Chief Financial Officer

View Audit 35124

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