Corrective Action Plans

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Finding 554770 (2024-039)
Significant Deficiency 2024
2024-039 Oregon Department of Emergency Management Continue FFATA reporting improvements and make inquiries on FSRS functionality Management Response: The Oregon Department of Emergency Management (OEM) concurs with the finding and the recommendations as outlined in the letter and above. OEM has und...
2024-039 Oregon Department of Emergency Management Continue FFATA reporting improvements and make inquiries on FSRS functionality Management Response: The Oregon Department of Emergency Management (OEM) concurs with the finding and the recommendations as outlined in the letter and above. OEM has undertaken and continues the following corrective actions to address the recommendations made by the Secretary of State’s Audits Division: • OEM has developed procedures for capturing necessary information and ensuring FFATA reports are filed in compliance with federal criteria. • OEM has identified all awards since July 1st 2023 and is working to ensure 100% compliance from that date forward. • OEM will conduct timely follow up on all submissions that fail to successfully load into the system, and clearly document that follow up for inclusion in our files. • OEM will continue to review older awards to determine what actions should be taken. Anticipated completion date: June 30, 2025. Contact person: Amy Mettler, Chief Financial Officer.
Finding 554759 (2024-019)
Significant Deficiency 2024
2024-019 Oregon Department of Human Services Improve controls and compliance over long-term care facility auditsManagement Response: We agree with this recommendation and will make these changes on the July 1, 2025 cost report template. We will be adding a line item to distinguish between Total Admi...
2024-019 Oregon Department of Human Services Improve controls and compliance over long-term care facility auditsManagement Response: We agree with this recommendation and will make these changes on the July 1, 2025 cost report template. We will be adding a line item to distinguish between Total Administration overtime and Administrator only overtime. .Anticipated Completion Date: July 1, 2025 Contact person: Jennifer Stallsworth, Chief of Staff, ODHS APD, April Gillette, OHA Medicaid Division, Strategic Operations & Improvement Director
Finding 554757 (2024-017)
Significant Deficiency 2024
2024-017 Oregon Department of Human Services/Oregon Health Authority Strengthen internal controls over the ONE system Management Response: We agree with this recommendation. ODHS will continue to work with our vendor to secure a SOC 2 Type II audit of our processes and oversight of the ONE system in...
2024-017 Oregon Department of Human Services/Oregon Health Authority Strengthen internal controls over the ONE system Management Response: We agree with this recommendation. ODHS will continue to work with our vendor to secure a SOC 2 Type II audit of our processes and oversight of the ONE system in 2025. Additionally, ODHS will work on amending the ONE M&O agreement with Deloitte for them to obtain a scoped SOC 2 Type II audit related to their work within the ONE system. ODHS would expect to negotiate this additional audit requirement in 2025 with the first audit then happening in 2026. In addition, the agency will request reports that will allow reconciliation of transactions between ONE and the mainframe system. Anticipated Completion Date: December 31, 2026 Contact person: Jennifer Stallsworth, Chief of Staff, ODHS APD, April Gillette, OHA Medicaid Division, Strategic Operations & Improvement Director
Finding 554751 (2024-011)
Significant Deficiency 2024
2024-011 Oregon Health Authority Strengthen existing controls to ensure only those costs incurred during the period of performance are charged to the grant Management Response: The agency agrees with the finding. While the appropriate internal controls are in place to review the period of performan...
2024-011 Oregon Health Authority Strengthen existing controls to ensure only those costs incurred during the period of performance are charged to the grant Management Response: The agency agrees with the finding. While the appropriate internal controls are in place to review the period of performance, a mistake was made while following the procedures. Secondary reviews will be performed going forward to ensure all expenditures are appropriately captured. The expenditures in question were moved to the correct phase 22 on Jan. 23, 2025 with document BTCG3186. Anticipated Completion Date: January 23, 2025 Contact Person: Travis Labrum, Accounting Manager
View Audit 353343 Questioned Costs: $1
Finding 554744 (2024-010)
Significant Deficiency 2024
2024-010 Oregon Health Authority Submit required Federal Funding Accountability and Transparency Act reports Management Response: The agency agrees with the finding. The FFATA Reporting Coordinator position within the Office of Contracts & Procurement (OC&P) has been vacant for eight months but sho...
2024-010 Oregon Health Authority Submit required Federal Funding Accountability and Transparency Act reports Management Response: The agency agrees with the finding. The FFATA Reporting Coordinator position within the Office of Contracts & Procurement (OC&P) has been vacant for eight months but should be filled by April 15, 2025. On March 8, 2025, FSRS.gov was retired, and all subaward reporting data and functionality are now on SAM.gov. The new SAM.gov reporting system will allow for multiple Data Entry roles, allowing each program or division of ODHS/OHA to submit their own reporting, and allowing OC&P to conduct Quality Assurance/Quality Control. Once the FFATA Reporting Coordinator is onboard and trained, we anticipate the FFATA reporting will resume and any missing reports will be submitted by April 15, 2026. Anticipated Completion Date: April 15, 2026 Contact person: Noemi Schlegel, Compliance & Audits Program Manager
Finding 554742 (2024-033)
Significant Deficiency 2024
2024-033 Oregon Housing and Community Services Department Federal reports should contain accurate information Management Response: The agency agrees with this finding. A dedicated staff resource has been trained and has brought grant reconciliations and reporting current. Additional training has bee...
2024-033 Oregon Housing and Community Services Department Federal reports should contain accurate information Management Response: The agency agrees with this finding. A dedicated staff resource has been trained and has brought grant reconciliations and reporting current. Additional training has been provided for awareness of the obligation requirements as well. Anticipated Completion Date: June 30, 2025 Contact person: Beth Brown, Controller
Finding 554737 (2024-023)
Significant Deficiency 2024
2024-023 Oregon Department of Human Services Strengthen controls over program expenditures Management Response: We agree with this recommendation. Department management acknowledges the finding and has already initiated actions to address the concerns. Quarterly collaboration meetings including TANF...
2024-023 Oregon Department of Human Services Strengthen controls over program expenditures Management Response: We agree with this recommendation. Department management acknowledges the finding and has already initiated actions to address the concerns. Quarterly collaboration meetings including TANF and TADVS policy, business security unit, business operations, and office of financial services began in July 2024. Issues and resolutions are discussed during these quarterly meetings; as a result, guidance for staff has been developed, and regular internal audits take place throughout the year. Business operations team in partnership with TANF policy will send out communication reminding staff of the process when a check is reported as lost, and the steps that must happen prior to a replacement check being issued. In addition, policy and business operations will attend meetings with those who have a leadership role in the system to approve payments and share the transmittal along with a discussion on ways to mitigate duplicate payments in the future. Child Welfare reviewed and corrected the transaction identified in this audit. Although the SPOTS card was reimbursed on July 21, 2023, the request in OR-Kids was not canceled on that day causing the transaction to hit the SFMA. During the audit, the error was discovered and Federal Policy and Resources worked with Office of Financial Services (OFS) to correct the reimbursement on February 26, 2025. The transaction was canceled in the OR-Kids system through financial cycle on February 26, 2025. OFS entered the correction in SFMA to reflect the reduction to TANF funding, which processed through OR-Kids on February 27, 2025, and interfaced to SFMA on the evening of February 27, 2025. Anticipated Completion Date: 12/31/2025 Contact Person: Eva Ruiz, TANF program manager
View Audit 353343 Questioned Costs: $1
Finding 554736 (2024-022)
Significant Deficiency 2024
2024-022 Oregon Department of Human Services Improve controls to ensure eligibility criteria are met Management Response: We agree with this recommendation. Beginning in April 2025 the Quality Control (QC) manager will have oversight of the process and be included in the emails between the QC lead a...
2024-022 Oregon Department of Human Services Improve controls to ensure eligibility criteria are met Management Response: We agree with this recommendation. Beginning in April 2025 the Quality Control (QC) manager will have oversight of the process and be included in the emails between the QC lead and administration concerning the error packets being sent to the branch for corrective action by the 15th of each month. The QC manager will check on the 16th of each month to ensure the task was completed. Department management acknowledges the finding and has already initiated actions to address the concerns. The State of Oregon has implemented a structured approach to address this concern. Since January 2025, the Oregon Eligibility Partnership (OEP) has updated and developed six eligibility guides aimed at improving, understanding, and execution of processes related to TANF enrollment, including asset pursuit and IEVS checks. These guides are now available as part of the training curriculum for eligibility workers. Additionally, the "Verification Take Time for Training" (TT4T) module, which was last presented in October 2022, will be reviewed by the OEP to assess potential gaps or outdated information. Any necessary updates will be incorporated by July 2025 to ensure comprehensive training is available to all eligibility workers. Finally, OEP will continue to monitor the effectiveness of the updated training materials and guides through ongoing reviews, feedback collection from eligibility workers, and periodic review and refreshing of the materials. Anticipated Completion Date: December 31, 2025 Contact Person: Eva Ruiz, TANF program manager
View Audit 353343 Questioned Costs: $1
Finding 554731 (2024-043)
Significant Deficiency 2024
2024-043 Department of Veterans' Affairs Encourage accuracy of per diem recalculations Management Response: ODVA agrees with this recommendation Reconciliation/recalculation procedures have been updated to fully align with regulations as established by 38 CFR 51.40. These procedures will include cal...
2024-043 Department of Veterans' Affairs Encourage accuracy of per diem recalculations Management Response: ODVA agrees with this recommendation Reconciliation/recalculation procedures have been updated to fully align with regulations as established by 38 CFR 51.40. These procedures will include calculation of days when a veteran may be absent for purposes other than receiving hospital care. In addition to strengthening procedures, the controller will review the reconciliation each month. Anticipated Completion Date: June 30, 2025 Contact person: Nicole Dolan, Budget and Fiscal Manager
Finding 554730 (2024-038)
Significant Deficiency 2024
2024-038 Oregon Business Development Department Implement controls over reporting Management Response: We agree with this recommendation. The submission of the quarterly financial reports by Business Oregon to DAS CFRT is on-going and within the submission deadline of DAS CFRT staff. When preparing ...
2024-038 Oregon Business Development Department Implement controls over reporting Management Response: We agree with this recommendation. The submission of the quarterly financial reports by Business Oregon to DAS CFRT is on-going and within the submission deadline of DAS CFRT staff. When preparing for the quarterly financial report, the accounting/financial data has been prepared by our accountant and reviewed by Business Oregon’s accounting manager. The data is then submitted to program staff to complete the programmatic narrative and other performance-related information to further explain or describe the transactions for the reporting period, and then program staff submits the quarterly report to DAS CFRT. Going forward, to ensure reports submitted to DAS CFRT match with accounting records, management will make procedure changes by routing the report back to the accounting team for final review of financial data after program has entered their part of the report before sending to DAS CFRT. We will implement this process change effective immediately for the quarterly report ending March 2025. For the cumulative variance of $1.6 million, Business Oregon will conduct research to determine the cause of the variance. The under-reporting of expenses on the quarterly report ending June 2024 could be the result of data provided to DAS in mid-July 2024, to meet DAS CFRT reporting deadline, when the fiscal month of June 2024 was not officially closed until early August 2024. While the fiscal year-end process was still on-going through August 2024, the month of June is still open for accrual entries or adjustments, resulting to more expenditures in accounting records than what was reported to DAS in July. Business Oregon will perform reconciliation of data from 2020 to March 2025 to true up the expenditures reported in the accounting records and the reports submitted to DAS CFRT. Anticipated Completion Date: March 31, 2025 Contact person: Imee Anderson, Chief Financial Officer, Mia Seo, Deputy-Chief Financial Officer, Rory Spencer, Accounting Manager
Finding 554721 (2024-031)
Significant Deficiency 2024
2024-031 Department of Education Implement controls to ensure FFATA reporting is completed for all required subawards Management Response: ODE agrees with this finding. To strengthen controls and ensure FFATA reporting is completed for all required subawards, ODE plans to implement the following pro...
2024-031 Department of Education Implement controls to ensure FFATA reporting is completed for all required subawards Management Response: ODE agrees with this finding. To strengthen controls and ensure FFATA reporting is completed for all required subawards, ODE plans to implement the following process improvements: • Collaborate with the Child Nutrition program management and Fiscal Grants team to provide full documentation of grant awards including terms, conditions and attachments. • Update ODE’s grant profile request Smartsheet tool to: o Identify FFATA eligibility prior to setting up a new grant award in the accounting system. o Automatically notify the FFATA team of new grant awards that require reporting. Anticipated Completion Date: June 30, 2025 Contact person: Kristie Miller, Accounting Director
Finding 2024-002: Lower Income Housing Assistance Program - Section 8 New Construction and Substantial Rehabilitation Assistance Listing Number: 14.182 U.S. Department of Housing and Urban Development ...
Finding 2024-002: Lower Income Housing Assistance Program - Section 8 New Construction and Substantial Rehabilitation Assistance Listing Number: 14.182 U.S. Department of Housing and Urban Development (Repeat of Finding 2023-002 and 2022-002) Compliance Requirements: Cash Management, Eligibility, Reporting, Special Tests and Provisions Type of finding: Internal Control Over Compliance (significant deficiency) Recommendation: The Organization should strengthen its internal controls with adopted policies and procedures to ensure a review process is established through adequate segregation of duties. The Organization should consider assessing and realigning the duties and responsibilities of administrative staff allowing the administrator to act in a more supervisory position. Action Taken: At this time, we do not have an administrative assistant/Activities Coordinator. Administrator works closely with the bookkeeper. Administrator and Executive Director will schedule every third recertification for review. Executive Director does review of the financial statements on a monthly basis when they are emailed over just before Policy Board meetings. During audit last year, we understood that reporting and eligibility did not have to happen at each interval but a review by another party in office every few re-certifications, as well as reviewing cash management. If there are any questions regarding this plan, please call the responsible party at (719) 852-5778. Sincerely yours, Monica Wolfe Executive Director Tri-County Senior Citizens and Housing, Inc.
Finding 554711 (2024-004)
Significant Deficiency 2024
Recommendation: Management should implement a formalized process for checking all vendors prior to work being started on the project. Management’s Response: In January 2024 a Procurement Manager was hired. Procedures were added to ensure that the City will be in compliance with the 2 CFR 200.303 i...
Recommendation: Management should implement a formalized process for checking all vendors prior to work being started on the project. Management’s Response: In January 2024 a Procurement Manager was hired. Procedures were added to ensure that the City will be in compliance with the 2 CFR 200.303 in the future. Responsible Parties: Jessica Graham, Procurement/Contract Manager Anticipated Completion Date: April 1, 2025
Recommendation: Management should implement a formalized process for reviewing all required reports prior to submission. Management’s Response: Management agrees that all financial data would potentially be more accurate if reviewed by an additional qualified person prior to use. However, limited ...
Recommendation: Management should implement a formalized process for reviewing all required reports prior to submission. Management’s Response: Management agrees that all financial data would potentially be more accurate if reviewed by an additional qualified person prior to use. However, limited staff has prevented this from always being practical. In the future, management will seek ways to add more controls to all of our processes, including reviews, to ensure more accurate and reliable data is submitted. Responsible Parties: Jeff Sabo, Airport Manager Anticipated Completion Date: April 1, 2025
Harris County Public Health management acknowledges the requirements that 2CFR 200.303 establishes that grant recipients should establish, document, and maintain effective internal control over federal awards, including controls over reviews of reports and compliance with reporting requirements. HCP...
Harris County Public Health management acknowledges the requirements that 2CFR 200.303 establishes that grant recipients should establish, document, and maintain effective internal control over federal awards, including controls over reviews of reports and compliance with reporting requirements. HCPH management will establish controls to ensure review, segregation of duties, timely submission, and clear identification of preparers and reviewers of programmatic reports by September 2025.
Corrective action plan - management response: The organization to update policies and procedures, over completing tenant HUD Housing Assistance Payment forms, to include review by a management agent or acting management agent. Name(s) of the contact person(s) responsible for corrective action: Mars...
Corrective action plan - management response: The organization to update policies and procedures, over completing tenant HUD Housing Assistance Payment forms, to include review by a management agent or acting management agent. Name(s) of the contact person(s) responsible for corrective action: Marsha Larkin Marani, Project Manager Planned completion date for corrective action plan: March 2025
Corrective action plan - management response: The organization to update policies and procedures, over completing tenant certification and re-certification, to include review by a management agent or acting management agent. Name(s) of the contact person(s) responsible for corrective action: Marsha...
Corrective action plan - management response: The organization to update policies and procedures, over completing tenant certification and re-certification, to include review by a management agent or acting management agent. Name(s) of the contact person(s) responsible for corrective action: Marsha Larkin Marani, Project Manager Planned completion date for corrective action plan: March 2025
Corrective action plan - management response: Management to update income limits in Onesite to reflect HUD income limits applicable as of the tenant’s application date. Name(s) of the contact person(s) responsible for corrective action: Marsha Larkin Marani, Project Manager Planned completion date...
Corrective action plan - management response: Management to update income limits in Onesite to reflect HUD income limits applicable as of the tenant’s application date. Name(s) of the contact person(s) responsible for corrective action: Marsha Larkin Marani, Project Manager Planned completion date for corrective action plan: March 2025 (as Income Thresholds become available annually by HUD)
Finding 554624 (2024-039)
Significant Deficiency 2024
2024-039 Oregon Department of Emergency Management Continue FFATA reporting improvements and make inquiries on FSRS functionality Management Response: The Oregon Department of Emergency Management (OEM) concurs with the finding and the recommendations as outlined in the letter and above. OEM has und...
2024-039 Oregon Department of Emergency Management Continue FFATA reporting improvements and make inquiries on FSRS functionality Management Response: The Oregon Department of Emergency Management (OEM) concurs with the finding and the recommendations as outlined in the letter and above. OEM has undertaken and continues the following corrective actions to address the recommendations made by the Secretary of State’s Audits Division: • OEM has developed procedures for capturing necessary information and ensuring FFATA reports are filed in compliance with federal criteria. • OEM has identified all awards since July 1st 2023 and is working to ensure 100% compliance from that date forward. • OEM will conduct timely follow up on all submissions that fail to successfully load into the system, and clearly document that follow up for inclusion in our files. • OEM will continue to review older awards to determine what actions should be taken. Anticipated completion date: June 30, 2025. Contact person: Amy Mettler, Chief Financial Officer.
Finding 554613 (2024-019)
Significant Deficiency 2024
2024-019 Oregon Department of Human Services Improve controls and compliance over long-term care facility auditsManagement Response: We agree with this recommendation and will make these changes on the July 1, 2025 cost report template. We will be adding a line item to distinguish between Total Admi...
2024-019 Oregon Department of Human Services Improve controls and compliance over long-term care facility auditsManagement Response: We agree with this recommendation and will make these changes on the July 1, 2025 cost report template. We will be adding a line item to distinguish between Total Administration overtime and Administrator only overtime. .Anticipated Completion Date: July 1, 2025 Contact person: Jennifer Stallsworth, Chief of Staff, ODHS APD, April Gillette, OHA Medicaid Division, Strategic Operations & Improvement Director
Finding 554611 (2024-017)
Significant Deficiency 2024
2024-017 Oregon Department of Human Services/Oregon Health Authority Strengthen internal controls over the ONE system Management Response: We agree with this recommendation. ODHS will continue to work with our vendor to secure a SOC 2 Type II audit of our processes and oversight of the ONE system in...
2024-017 Oregon Department of Human Services/Oregon Health Authority Strengthen internal controls over the ONE system Management Response: We agree with this recommendation. ODHS will continue to work with our vendor to secure a SOC 2 Type II audit of our processes and oversight of the ONE system in 2025. Additionally, ODHS will work on amending the ONE M&O agreement with Deloitte for them to obtain a scoped SOC 2 Type II audit related to their work within the ONE system. ODHS would expect to negotiate this additional audit requirement in 2025 with the first audit then happening in 2026. In addition, the agency will request reports that will allow reconciliation of transactions between ONE and the mainframe system. Anticipated Completion Date: December 31, 2026 Contact person: Jennifer Stallsworth, Chief of Staff, ODHS APD, April Gillette, OHA Medicaid Division, Strategic Operations & Improvement Director
Finding 554605 (2024-011)
Significant Deficiency 2024
2024-011 Oregon Health Authority Strengthen existing controls to ensure only those costs incurred during the period of performance are charged to the grant Management Response: The agency agrees with the finding. While the appropriate internal controls are in place to review the period of performan...
2024-011 Oregon Health Authority Strengthen existing controls to ensure only those costs incurred during the period of performance are charged to the grant Management Response: The agency agrees with the finding. While the appropriate internal controls are in place to review the period of performance, a mistake was made while following the procedures. Secondary reviews will be performed going forward to ensure all expenditures are appropriately captured. The expenditures in question were moved to the correct phase 22 on Jan. 23, 2025 with document BTCG3186. Anticipated Completion Date: January 23, 2025 Contact Person: Travis Labrum, Accounting Manager
View Audit 353285 Questioned Costs: $1
Finding 554598 (2024-010)
Significant Deficiency 2024
2024-010 Oregon Health Authority Submit required Federal Funding Accountability and Transparency Act reports Management Response: The agency agrees with the finding. The FFATA Reporting Coordinator position within the Office of Contracts & Procurement (OC&P) has been vacant for eight months but sho...
2024-010 Oregon Health Authority Submit required Federal Funding Accountability and Transparency Act reports Management Response: The agency agrees with the finding. The FFATA Reporting Coordinator position within the Office of Contracts & Procurement (OC&P) has been vacant for eight months but should be filled by April 15, 2025. On March 8, 2025, FSRS.gov was retired, and all subaward reporting data and functionality are now on SAM.gov. The new SAM.gov reporting system will allow for multiple Data Entry roles, allowing each program or division of ODHS/OHA to submit their own reporting, and allowing OC&P to conduct Quality Assurance/Quality Control. Once the FFATA Reporting Coordinator is onboard and trained, we anticipate the FFATA reporting will resume and any missing reports will be submitted by April 15, 2026. Anticipated Completion Date: April 15, 2026 Contact person: Noemi Schlegel, Compliance & Audits Program Manager
Finding 554596 (2024-033)
Significant Deficiency 2024
2024-033 Oregon Housing and Community Services Department Federal reports should contain accurate information Management Response: The agency agrees with this finding. A dedicated staff resource has been trained and has brought grant reconciliations and reporting current. Additional training has bee...
2024-033 Oregon Housing and Community Services Department Federal reports should contain accurate information Management Response: The agency agrees with this finding. A dedicated staff resource has been trained and has brought grant reconciliations and reporting current. Additional training has been provided for awareness of the obligation requirements as well. Anticipated Completion Date: June 30, 2025 Contact person: Beth Brown, Controller
Finding 554591 (2024-023)
Significant Deficiency 2024
2024-023 Oregon Department of Human Services Strengthen controls over program expenditures Management Response: We agree with this recommendation. Department management acknowledges the finding and has already initiated actions to address the concerns. Quarterly collaboration meetings including TANF...
2024-023 Oregon Department of Human Services Strengthen controls over program expenditures Management Response: We agree with this recommendation. Department management acknowledges the finding and has already initiated actions to address the concerns. Quarterly collaboration meetings including TANF and TADVS policy, business security unit, business operations, and office of financial services began in July 2024. Issues and resolutions are discussed during these quarterly meetings; as a result, guidance for staff has been developed, and regular internal audits take place throughout the year. Business operations team in partnership with TANF policy will send out communication reminding staff of the process when a check is reported as lost, and the steps that must happen prior to a replacement check being issued. In addition, policy and business operations will attend meetings with those who have a leadership role in the system to approve payments and share the transmittal along with a discussion on ways to mitigate duplicate payments in the future. Child Welfare reviewed and corrected the transaction identified in this audit. Although the SPOTS card was reimbursed on July 21, 2023, the request in OR-Kids was not canceled on that day causing the transaction to hit the SFMA. During the audit, the error was discovered and Federal Policy and Resources worked with Office of Financial Services (OFS) to correct the reimbursement on February 26, 2025. The transaction was canceled in the OR-Kids system through financial cycle on February 26, 2025. OFS entered the correction in SFMA to reflect the reduction to TANF funding, which processed through OR-Kids on February 27, 2025, and interfaced to SFMA on the evening of February 27, 2025. Anticipated Completion Date: 12/31/2025 Contact Person: Eva Ruiz, TANF program manager
View Audit 353285 Questioned Costs: $1
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