Corrective Action Plans

Finding 479059 (2023-002)

Significant Deficiency 2023

NM

Procurement, Suspension & Debarment § 200.214 § 200.320

Responsible Official and Corrective Action Plan: NMHC management is in agreement with this finding. Management has reviewed the existing federal procurement policies and procedures found in 2 CFR 200 and will enforce the policies and procedures to ensure existing suspension and debarment policies an...

Responsible Official and Corrective Action Plan: NMHC management is in agreement with this finding. Management has reviewed the existing federal procurement policies and procedures found in 2 CFR 200 and will enforce the policies and procedures to ensure existing suspension and debarment policies and procedures are followed. NMHC’s Executive Director or Deputy Director will review all potential purchases and contracts for compliance with the policies. The Executive Director or Deputy Director will also provide an additional check by reviewing all vendors paid $25,000 or more against the SAM website. Proof of the SAM website review and approval will be maintained in each vendor file. All future contracts of any size will also include a clause or condition to the covered transaction with the contractor/vendor that must be signed by that person. The Executive Director will update the existing NMHC policies and procedures manual by adding the new thresholds for micro-purchases and small purchases. The Executive Director will also add explicit reference to the $25,000 threshold for vendors under procurement regulations regarding debarment and suspension. Corrective Action Plan Timeline: Management anticipates the above corrective action plan to be fully implemented by July 31, 2024. Designation Of Employee Position Responsible For Meeting Deadline: Personnel responsible for ensuring implementation include the Executive Director and Deputy Director.

View Audit 315582

Finding 479057 (2023-001)

Material Weakness 2023

North Fork Special Service District

UT

Procurement, Suspension & Debarment § 200.317 § 200.318 § 200.326

1) Management will review procurement policies with staff 2) Timely action will be taken to solicit bids for contracts that exceed District thresholds. 3) To ensure full and open competition takes place, management will routinely review current contracts and spending reports to identify expenditures...

1) Management will review procurement policies with staff 2) Timely action will be taken to solicit bids for contracts that exceed District thresholds. 3) To ensure full and open competition takes place, management will routinely review current contracts and spending reports to identify expenditures that exceed the dollar amount threshold to individual vendors. Anticipated completion date: June 30, 2024 Responsible contact person: Emily Johnson

View Audit 315577

Finding 479056 (2023-003)

Material Weakness 2023

Evergreen Youth & Family Services, Inc.

MN

Subrecipient Monitoring Material Weakness Reporting

Transitional Living for homeless Youth – Assistance Listing No. 93.550 Recommendation: It is recommended that the Organization implement controls to monitor program income and ensure that the funds are being properly used before requesting additional federal funds. This could include regular reporti...

Transitional Living for homeless Youth – Assistance Listing No. 93.550 Recommendation: It is recommended that the Organization implement controls to monitor program income and ensure that the funds are being properly used before requesting additional federal funds. This could include regular reporting on the use of program income and conducting periodic reviews to ensure compliance with program requirements. Additionally, the Organization should review its policies and procedures to ensure they are in compliance with program requirements and make any necessary updates. Finally, the Organization should ensure that all staff members responsible for monitoring program income are properly trained and have a clear understanding of program requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: During each Payment Management System Draw process, the Finance Director will verify the draw amounts and run a program income and expense report to verify that the amount of miscellaneous expenses for the Transitional Living Program are more than the program income received. A copy of the income and expense statement will be saved in each draw file with the other verification documents. A column for verification initials of this process was added to the ACF Grant Balances Spreadsheet used for recording the draw amounts and dates of the draws. Name(s) of the contact person(s) responsible for corrective action: Julia Montebello, Finance Director Planned completion date for corrective action plan: 4/26/2024

View Audit 315565

Finding 479055 (2023-002)

Material Weakness 2023

Evergreen Youth & Family Services, Inc.

MN

Eligibility Material Weakness Internal Control / Segregation of Duties

Transitional Living for Homeless Youth – Assistance Listing No. 93.550 Recommendation: It is recommended that the Organization implement controls to ensure that proper documentation and support for eligibility is obtained and reviewed by a qualified individual. Explanation of disagreement with audit...

Transitional Living for Homeless Youth – Assistance Listing No. 93.550 Recommendation: It is recommended that the Organization implement controls to ensure that proper documentation and support for eligibility is obtained and reviewed by a qualified individual. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Program Director will conduct Weekly Document Reviews for new and ongoing clients and will also verify eligibility as staff submit weekly request forms for clients to receive services. Weekly Review Schedule: • The Program Director will conduct a review of all documentation once a week. Verification Process: • During the review, the Program Director will verify that all required documents for eligibility is being completed accurately, processed, and documented. Documentation of Review: • The results of this review will be documented on each client’s initial intake form and in Apricot. • The Program Director will sign the intake form to indicate verification and completion of the review and will also document this in Apricot. • By adhering to this procedure, we ensure that all documentation is thoroughly checked and validated on a consistent basis, maintaining the integrity and accuracy of our eligibility process. Name(s) of the contact person(s) responsible for corrective action: Elena Guerra, EYS Program Director. Planned completion date for corrective action plan: ongoing

View Audit 315565

Finding 479054 (2023-001)

Significant Deficiency 2023

Evergreen Youth & Family Services, Inc.

MN

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Transitional Living for Homeless Youth – Assistance Listing No. 93.550 Recommendation: It is recommended that the Organization implement controls to ensure that clients meet eligibility requirements before being enrolled in the program. This could include verifying age at the time of enrollment and ...

Transitional Living for Homeless Youth – Assistance Listing No. 93.550 Recommendation: It is recommended that the Organization implement controls to ensure that clients meet eligibility requirements before being enrolled in the program. This could include verifying age at the time of enrollment and periodically re-verifying eligibility for on-going clients. Additionally, the Organization should review its policies and procedures to ensure that they are in compliance with program requirements and make any necessary updates. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Clearly define eligibility requirements for staff conducting intakes, along with the intake process. Staff and Program Director will reverify eligibility when doing check requests. Two opportunities will be provided for staff each year to revisit eligibility requirements and to provide staff with refresher training. Intake Process: At the time of intake into the program, client’s will be asked for their driver’s license, state ID, permit, tribal ID, or birth certificate. If the client doesn't have any Identification, staff will calculate the client's age using the client's reported date of birth. Staff will then attempt to help the client secure personal vital documents and add copies to the client file for verification. The Program Director will also verify eligibility. Training: Staff to be trained in the spring and fall of each year to revisit eligibility requirements, intake processes, along with agency core values, mission and vision. Name(s) of the contact person(s) responsible for corrective action: Elena Guerra, EYS Program Director Planned completion date for corrective action plan: • Clearly define eligibility requirements for staff by July 1, 2024. • Host trainings by September 30, 2024, and March 31, 2025. • Verify eligibility for new clients and current clients on an ongoing basis.

View Audit 315565

Finding 479035 (2023-002)

None 2023

603 Legal Aid

NH

Subrecipient Monitoring Internal Control / Segregation of Duties

2023-002 Planned Corrective Action: We agree with the need for updated policies and/or procedures to be codified in the Organization’s Accounting Manual to ensure compliance with the new 2023 LSC Financial Guide requirements. In 2022, 603 Legal Aid drafted a set of accounting policies based on the p...

2023-002 Planned Corrective Action: We agree with the need for updated policies and/or procedures to be codified in the Organization’s Accounting Manual to ensure compliance with the new 2023 LSC Financial Guide requirements. In 2022, 603 Legal Aid drafted a set of accounting policies based on the previous Financial Guide and operations at the time (which included different staffing positions to those in place at present). The Organization currently has a temporary consultant filling in for the Senior Accountant position while a permanent hire is found. Working with the Board Treasurer, he is in the process of updating the 603 Legal Aid 2022 draft of policies to reflect changes in the new LSC Financial Guide as well as operational changes at 603 Legal Aid. This work is expected to be handed off to the permanent Senior Accountant when hired, who will be responsible for ongoing oversight of the Organization’s Accounting Manual to ensure compliance. Responsible Person: Temporary Consultant, Senior Accountant Date of Completion: December 31, 2024

View Audit 315557

Finding 479034 (2023-001)

None 2023

603 Legal Aid

NH

Internal Control / Segregation of Duties

2023-001 Planned Corrective Action: The Organization has already taken the necessary corrective action steps to be in compliance with this regulation. In January 2024, 603 Legal Aid communicated with our LSC Program Officer to review the Board of Directors composition requirements and discuss the pl...

2023-001 Planned Corrective Action: The Organization has already taken the necessary corrective action steps to be in compliance with this regulation. In January 2024, 603 Legal Aid communicated with our LSC Program Officer to review the Board of Directors composition requirements and discuss the plan for bringing the Organization into compliance. A new McCollum attorney joined the Board in January 2024, bringing 603 Legal Aid into compliance. Additionally, the Chair of the Board Development Committee has agreed to create and maintain a running list of Board members for ongoing oversight throughout the year to ensure continued compliance. Responsible Person: Ariel Clemmer Date of Completion: Compliant as of January 2024

View Audit 315557

Finding 479033 (2023-001)

None 2023

City of Aurora, Colorado

CO

Questioned Costs Allowable Costs / Cost Principles

CITY OF AURORA PLANNED ACTION: The City agrees with the finding and City staff will implement additional internal controls, including sending payroll reports to grant managers each pay period for review and signoff for the audit file. In addition, staff will increase the frequency of time and effort...

CITY OF AURORA PLANNED ACTION: The City agrees with the finding and City staff will implement additional internal controls, including sending payroll reports to grant managers each pay period for review and signoff for the audit file. In addition, staff will increase the frequency of time and effort certifications to quarterly to identify changes in employee job duties and cost allocations on a timely basis. CITY OF AURORA RESPONSIBLE PARTY: Nancy Wishmeyer, Controller COMPLETION DATE: Q3 2024

View Audit 315556 Questioned Costs: $1

Finding 479032 (2023-001)

Significant Deficiency 2023

Georgia-Alabama Land Trust, Inc.

AL

Procurement, Suspension & Debarment

Organization will ensure all covered transactions are properly reviewed and documentation maintained in the procurement files, prior to entering into future agreements.

View Audit 315552

Finding 479031 (2023-001)

Significant Deficiency 2023

Nutrition, INC

IN

Internal Control / Segregation of Duties

Corrective Action Plan Name of Auditee: Nutrition, Inc. Name of audit firm: Donovan CPAs Period covered by the audit: October 01, 2022 - September 30, 2023 Corrective action prepared by: Name: Sudie Shaw-Price, Nutrition, Inc. Position: Executive director Telephone number: (317)543-9452 Email addres...

Corrective Action Plan Name of Auditee: Nutrition, Inc. Name of audit firm: Donovan CPAs Period covered by the audit: October 01, 2022 - September 30, 2023 Corrective action prepared by: Name: Sudie Shaw-Price, Nutrition, Inc. Position: Executive director Telephone number: (317)543-9452 Email address: sprice@nutritionincindy.org Current Finding on Schedule of Findings, Questioned Costs, and Recommendations Finding 2023-001 – Financial Statement and Federal Awards Statement of Condition: Nutrition was not segregating duties of accounting and administrative responsibilities for internal control purposes. Status: Coming out of the pandemic impacted the ability to complete the segregation of duties process, due to the lack of staff. As a result, Nutrition is working to develop the processes that will help to implement the procedures that will segregate duties and will continue working with team members to implement processes to segregate duties moving forward. At this time, the development is on-going and will take place when the business growth warrants and supports such an action. Presently, adding additional staff to provide another layer of preparation, review, and monitoring would outweigh the costs.

View Audit 315550

Finding 479030 (2023-003)

Material Weakness 2023

West Central Nebraska Joint Housing Authority

NE

Internal Control / Segregation of Duties Special Tests & Provisions Eligibility

Finding 2023-003: We agree with the finding. The Authority is relatively small with limited administrative staff. Further, the Board of Commissioners is a volunteer oversight board and not a managing board and does not have the time or expertise to provide the necessary services to correct the inte...

Finding 2023-003: We agree with the finding. The Authority is relatively small with limited administrative staff. Further, the Board of Commissioners is a volunteer oversight board and not a managing board and does not have the time or expertise to provide the necessary services to correct the internal control deficiencies noted. The Board had reviewed the issue and determined that there are no additional procedures which can be reasonably done to eliminate the deficiencies and accepts them.

View Audit 315549

Finding 479029 (2023-001)

Significant Deficiency 2023

Ellis County, Kansas

KS

Reporting Internal Control / Segregation of Duties

Federal Program Coronavirus State and Local Fiscal Recovery Funds – 21.027 Compliance Requirements Reporting Condition During review of the annual program reporting, it was noted that project expenditures incurred and current period project obligations were not properly noted. Recommendation We reco...

Federal Program Coronavirus State and Local Fiscal Recovery Funds – 21.027 Compliance Requirements Reporting Condition During review of the annual program reporting, it was noted that project expenditures incurred and current period project obligations were not properly noted. Recommendation We recommend the County review its grant reporting procedures and implement controls to ensure that grant reports are completed accurately. Comments on the Finding Recommendation Ellis County staff concur, and we will improve our quality control processes to ensure that reported amounts are accurate. It proves a great point to have these reports checked and double checked by another individual for quality control processes. Actions Taken Prior to completing the next annual reporting period, staff involved with the reporting process will review information provided by the Treasury about the items to be reported upon. We will also have a second person review the numerical values to ensure they are correct per Ellis County reports. Before final submittals to the U.S. Treasury, staff will also meet with the auditor to ensure that all definitions are understood. At that time, any questions that arise will be addressed with an appropriate source before completing the submission.

View Audit 315532

Finding 479025 (2023-003)

Significant Deficiency 2023

Catholic Social Services

NE

Reporting Internal Control / Segregation of Duties Significant Deficiency

CSS management will improve its system of internal controls in order to actively track and adhere to reporting requirements outlined in its award agreements.

View Audit 315529

Finding 479024 (2023-002)

Significant Deficiency 2023

Catholic Social Services

NE

Reporting Internal Control / Segregation of Duties Significant Deficiency § 200.512

CSS management will improve staffing and internal controls to ensure compliance with the timely reporting requirements stated in 2 CFR §200.512.

View Audit 315529

Finding 479023 (2023-001)

Material Weakness 2023

Catholic Social Services

NE

Internal Control / Segregation of Duties Material Weakness Reporting

Catholic Social Services' management will improve its system of internal controls to correctly identify and present a complete and accurate schedule of expenditures of federal awards.

View Audit 315529

Finding 479014 (2023-002)

Significant Deficiency 2023

Arapahoe County, Colorado

CO

Special Tests & Provisions HUD Housing Programs Significant Deficiency

HOME Investment Partnerships Program and COVID-19 HOME Investment Partnerships Program - Significant Deficiency Condition: The County did not conduct the required inspections of the HOMEassisted rental housing units during the year ended December 31, 2023. Recommendation: We recommend the County con...

HOME Investment Partnerships Program and COVID-19 HOME Investment Partnerships Program - Significant Deficiency Condition: The County did not conduct the required inspections of the HOMEassisted rental housing units during the year ended December 31, 2023. Recommendation: We recommend the County continue to train personnel so that the inspections are completed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: In 2023, performance issues with the administration of the HOME program were discovered, to include the absence of required inspections. With significant turnover of tenured leadership and employees within the Community Resources Department, Arapahoe County Community Resources took proactive measures in 2023 for review of the Community Development Housing and Homeless Services (CDHHS) programs by recognized consultants within the field. Community Resources has contracted with two consultants, to assist in a full review and re-development of policies and procedures (Civitas) for the CDBG and HOME programs as well as a full review of all case files (Affordable Housing Consultants). Included with this response are the contracts with both Civitas and Affordable Housing Consultants for verification purposes. The County anticipates their work to be completed and an implementation of updated policies and procedures for these programs by fall of 2024. The role of Program Administrator over the HOME program was not filled until April of 2024. This role will be responsible for all future HOME program inspections. Community Resources CDHHS employees will be taking part in a two-day training in June 2024 (June 11th and 12th, 2024) for the following:  Davis Bacon & Related Acts (Applicability, wage determinations, payroll review, interviews, common errors and how to correct)  Section 3 (Applicability, Safe Harbor benchmarks, documenting compliance, qualitative efforts)  TBRA Inspections (National Standards for the Physical Inspection of Real Estate (NSPIRE) administrative procedures)  HOME Program - Implementation and Best Practices - Arapahoe County, CO - June 12, 2024  This HOME training is an introductory course focusing on underwriting and subsidy layering requirements.  Eligible Activities (Homeowner rehab programs, Homebuyer programs, Rental housing)  Underwriting (Subsidy layering and underwriting requirements and best practices)  Community Housing Development Organization (CHDO) (Requirements, best practices, management, etc)  Long-term Compliance (HOME Match, eligible beneficiaries, income limits, subsidy layering & limits, affordability, written agreements, etc)  IDIS and Reporting Arapahoe County staff will be conducting monitoring of the two Tenant Based Rental Assistance (TBRA) programs and projects within in the affordability period (20-year span) between mid-June to mid-August of 2024. The remaining HOME program projects, within the affordability period (20-year span) will have audits completed by the end of our 2023 grant cycle, September 30th, 2024. Name of the contact person responsible for corrective action: Katherine Smith Planned completion date for corrective action plan: September 30, 2024

View Audit 315527

Finding 478998 (2023-001)

Material Weakness 2023

Arapahoe County, Colorado

CO

Reporting Subrecipient Monitoring Material Weakness § 200.303

Community Development Block Grant and COVID-19 Community Development Block Grant – Material Weakness Condition: During testing of the Federal Funding Accountability and Transparency Act (FFATA) reports, it was noted that no FFATA reporting had been completed during the year ended December 31, 2023. ...

Community Development Block Grant and COVID-19 Community Development Block Grant – Material Weakness Condition: During testing of the Federal Funding Accountability and Transparency Act (FFATA) reports, it was noted that no FFATA reporting had been completed during the year ended December 31, 2023. Recommendation: We recommend that the County continue with the process being implemented during the fiscal year 2024, which includes completing submission of the reports and tracking the timely submission of the FFATA reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: With significant turnover of tenured leadership and employees within the Community Resources Department, Arapahoe County Community Resources took proactive measures in 2023 for review of the Community Development Housing and Homeless Services (CDHHS) programs (CDBG and HOME Investment) by recognized consultants within the field. Community Resources has contracted with two consultants, to assist in a full review and re-development of policies and procedures (Civitas) for the CDBG and HOME programs as well as a full review of all case files (Affordable Housing Consultants). Included with this response are the contracts with both Civitas and Affordable Housing Consultants for verification purposes. The County anticipates their work to be completed and an implementation of updated policies and procedures for these programs by fall of 2024. In response to the direct finding of no FFATA reporting during the year ending December 31st, 2023, Arapahoe County has ensured the entry of all sampled contracts. Demonstration of the report submissions have been submitted for verification purposes. It is important to note that all sub-agreements included the necessary FFATA information for the review period, but Community Resources failed to ensure that this information was entered into the FFATA Subaward Reporting System (FSRS). To ensure internal controls are in place for the FFATA’s timely and accurate submissions for all future subawards, Arapahoe County’s Community Resources Department has created the following internal controls and governance: 1. Creation of the FFATA Reporting Form which will be completed and submitted along with all future subaward agreements and includes all necessary information for complete and accurate submittal into FSRS. 2. Creation of the FFATA Subrecipient Reporting Work Instructions which detail the process, to include roles and responsibilities, for the completion and entry of the FFATA. 3. Update to our Grant Administration Policy which includes the requirement to complete and enter the FFATA in our grant administration oversight and track timely submission of the reports. Name of the contact persons responsible for corrective action: Katherine Smith Planned completion date for corrective action plan: September 30, 2024

View Audit 315527

Finding 478996 (2023-037)

Material Weakness 2023

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Material Weakness Reporting § 200.303

DEPARTMENT OF PUBLIC HEALTH 2023-037 Block Grants for Prevention and Treatment of Substance Abuse, COVID-19 - Block Grants for Prevention and Treatment of Substance Abuse - Assistance Listing No. 93.959 Action taken in response to the finding: All subrecipient FFATA information will be batch upload...

DEPARTMENT OF PUBLIC HEALTH 2023-037 Block Grants for Prevention and Treatment of Substance Abuse, COVID-19 - Block Grants for Prevention and Treatment of Substance Abuse - Assistance Listing No. 93.959 Action taken in response to the finding: All subrecipient FFATA information will be batch uploaded to FSRS within 30 days of execution of subcontracts. The majority of BSAS subrecipient contracts are executed as of July 1. A batch upload of data will be completed each year in that period. All outlying contracts not executed on June 30 will have their FFATA data uploaded to FSRS within 30 days of contract execution throughout the year. These uploads will be conducted by the BSAS Grants coordinator. Once successfully uploaded the Grants coordinator will receive a FFATA submission receipt from FSRS for each FFATA submission. They will share this with their supervisor and the Fiscal Director for confirmation. These records will be kept on file in the BSAS Grant Teams file for future reference. Our internal Fiscal Compliance Auditor will review batches of these submission quarterly to ensure compliance. Name of the contact person responsible for corrective action: Shannon McEneaney-Farron, BSAS Fiscal Director Planned completion date for corrective action plan: July 31, 2024 If the Department of Health and Human Services has questions regarding this plan, please call David Godin at 617-721-6200.

View Audit 315520

Finding 478995 (2023-036)

Significant Deficiency 2023

Commonwealth of Massachusetts

MA

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

DEPARTMENT OF PUBLIC HEALTH 2023-036 Opioid – STR - Assistance Listing No. 93.788 Action taken in response to the finding: This particular finding was in relation to an Interdepartmental Service Agreement ISA (815 CMR 6.00) with The Hampden County Sheriff’s Office (Department) for which we do not h...

DEPARTMENT OF PUBLIC HEALTH 2023-036 Opioid – STR - Assistance Listing No. 93.788 Action taken in response to the finding: This particular finding was in relation to an Interdepartmental Service Agreement ISA (815 CMR 6.00) with The Hampden County Sheriff’s Office (Department) for which we do not have direct access to their contracts. We will be including in future ISA agreements, language that states that monthly detailed SAMS reports associated with ISA funded agreements must be submitted to the BSAS ISA office for review monthly to verify that no vendors utilized have been documented in SAMS as being barred from receiving federal funding. These records will be reviewed by the BSAS ISA manager, and any questions or concerns will be relayed to the ISA child agency by the BSAS ISA manager via email for documentation. If any child agency is repeatedly non-compliant, we will work with them on a corrective action plan for their site. If the issues are not resolved we will review the status of their agreement, and our continued relationship with them. All related records will be kept in the BSAS ISA offices Teams files for the child agency. The SAMS reports for internal contracts already have a set process in place where they run, verified, and included with procurement packages by the BSAS Procurement manager before any vendor contracting packages are moved forward for execution. These are part of the contracting package documentation that is stored in PTS Procurement Tracking System. As a note, the SAMS report review process is in addition to the sanctioning process managed by the Commonwealth’s Comptroller’s office, which reviews vendors’ status as to ensure they are compliant in line with the Commonwealth’s vendor requirements. Debarment in these cases is relayed to BSAS via the DPH POS Purchase of Service Office. The DPH POS office is responsible for putting debarred vendors in pending status in EIM so no payments are made until the vendor’s compliance issues are resolved. Name of the contact person responsible for corrective action: Shannon McEneaney-Farron, BSAS Fiscal Director Planned completion date for corrective action plan: Ongoing. This process will commence as of July 1, 2024.

View Audit 315520

Finding 478994 (2023-035)

Significant Deficiency 2023

Commonwealth of Massachusetts

MA

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

DEPARTMENT OF PUBLIC HEALTH 2023-035 Opioid – STR - Assistance Listing No. 93.788 Action taken in response to the finding: Reporting - GRPA Submission evidence: Per recommendations of the auditing team the Project PI will review all data provided to them by the project staff before submitting to SP...

DEPARTMENT OF PUBLIC HEALTH 2023-035 Opioid – STR - Assistance Listing No. 93.788 Action taken in response to the finding: Reporting - GRPA Submission evidence: Per recommendations of the auditing team the Project PI will review all data provided to them by the project staff before submitting to SPARS. When review is finalized the PI will submit the reports to SPARS. At this time the PI will screenshot an image of each report submission page to SPARS for each GPRA report and save the file as a pdf. (This will need to be done as the reporting system does not return a confirmation report for filings.) Any subsequent updates of data will similarly be reviewed, compared to previous submissions to ensure accuracy, and logged. The same documentation will be recorded and stored with the previous submission data to keep accurate record of any changes. Data to create/compile the report (back up, supporting documentation to match the report) process. These pdf records documenting the time and date of initial report submissions and any edits will be kept on file with both the PI in their Teams program file, and with the BSAS Grant Teams SOR grant file for the corresponding grant year for future reference. Our internal Fiscal Compliance Auditor will review batches of these submission quarterly to ensure compliance. Evidence of Review & Approval process: These records will be reviewed both by the Grant PI and the BSAS Grants specialist to ensure accuracy, in particular where changes are being made. If changes have been made to data that may require future explanation the cause of the variances will be noted by the PI and documentation will be include with the submission records. Reporting – Programmatic Progress Reports Submission evidence: Per recommendations of the auditing team the Project PI will review all data provided to them by the project staff before submitting to eRA Commons. When review is finalized the PI will submit the reports to eRA Commons. At this time the PI will screenshot an image of each report submission page to eRA Commons for each PPR and save the file as a pdf. (This will need to be done as the reporting system does not return a confirmation report for filings.) Any subsequent updates of data will similarly be reviewed, compared to previous submissions to ensure accuracy, and logged. The same documentation will be recorded and stored with the previous submission data to keep accurate record of any changes. Data to create/compile the report (back up, supporting documentation to match the report) process. These pdf records documenting the time and date of initial report submissions and any edits will be kept on file with both the PI in their Teams program file, and with the BSAS Grant Teams SOR grant file for the corresponding grant year for future reference. Our internal Fiscal Compliance Auditor will review batches of these submission quarterly to ensure compliance. Evidence of Review & Approval process: These records will be reviewed both by the Grant PI and the BSAS Grants specialist to ensure accuracy, in particular where changes are being made. If changes have been made to data that may require future explanation the cause of the variances will be noted by the PI and documentation will be included with the submission records. Name of the contact person responsible for corrective action: Shannon McEneaney-Farron, BSAS Fiscal Director, Nicole Schmitt, Director of the Office of Strategy and Innovation (Grant PI) Planned completion date for corrective action plan: Ongoing. This process will commence as of July 1, 2024.

View Audit 315520

Finding 478993 (2023-034)

Significant Deficiency 2023

Commonwealth of Massachusetts

MA

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.430 § 200.430(I)

DEPARTMENT OF PUBLIC HEALTH 2023-034 Opioid – STR - Assistance Listing No. 93.788 Action taken in response to the finding: We are currently working on implementing training during on boarding as well as annual refresher training for these key fiscal requirements including time and effort reporting ...

DEPARTMENT OF PUBLIC HEALTH 2023-034 Opioid – STR - Assistance Listing No. 93.788 Action taken in response to the finding: We are currently working on implementing training during on boarding as well as annual refresher training for these key fiscal requirements including time and effort reporting and plan to have these trainings in place by the end of the 2024 calendar year. In the interim the BSAS grants office will work with Grant PIs to train staff on time and effort reporting, correct any issues with duplicative effort reporting, and ensure staff are allocated to grants in proportion to their actual time worked. This is being corrected by the BSAS grants director and all corrections have been documented through PARS reports. This particular finding was in relation to an Interdepartmental Service Agreement ISA (815 CMR 6.00) with The Dukes County Sheriff’s Office (department) for which we do not have direct access to their payroll. We will be including in future ISA agreements, language that states that monthly detailed payroll reports associated with ISA funds must be submitted to the BSAS ISA office for review. These records will be reviewed by the BSAS ISA manager, and any corrections required will be relayed to the ISA child agency by the BSAS ISA manager via email for documentation. If any child agency is repeatedly non-compliant we will work with them on a corrective action plan for their site. If the issues are not resolved we will review the status of their agreement, and our continued relationship with them. All related records will be kept in the BSAS ISA offices Teams files for the child agency. Name of the contact person responsible for corrective action: Shannon McEneaney-Farron, BSAS Fiscal Director Planned completion date for corrective action plan: Ongoing. This process will commence as of July 1, 2024.

View Audit 315520 Questioned Costs: $1

Finding 478992 (2023-033)

Material Weakness 2023

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Material Weakness Reporting § 200.303

DEPARTMENT OF PUBLIC HEALTH 2023-033 Opioid – STR - Assistance Listing No. 93.788 Action taken in response to the finding: All subrecipient FFATA information will be batch uploaded to FSRS within 30 days of execution of subcontracts. The majority of BSAS subrecipient contracts are executed as of Ju...

DEPARTMENT OF PUBLIC HEALTH 2023-033 Opioid – STR - Assistance Listing No. 93.788 Action taken in response to the finding: All subrecipient FFATA information will be batch uploaded to FSRS within 30 days of execution of subcontracts. The majority of BSAS subrecipient contracts are executed as of July 1. A batch upload of data will be completed each month over the grant period so that all outlying contracts not executed on June 30 will have their FFATA data uploaded to FSRS within 30 days of contract execution throughout the year. These uploads will be conducted by the BSAS Grants coordinator. Once successfully uploaded the Grants coordinator will receive a FFATA submission receipt from FSRS for each FFATA submission. They will share this with their supervisor and the Fiscal Director for confirmation. These records will be kept on file in the BSAS Grant Teams file for future reference. Our internal Fiscal Compliance Auditor will review batches of these submission quarterly to ensure compliance. Name of the contact person responsible for corrective action: Shannon McEneaney-Farron, BSAS Fiscal Director Planned completion date for corrective action plan: Ongoing. This process will commence as of July 1, 2024.

View Audit 315520

Finding 478987 (2023-032)

Significant Deficiency 2023

Commonwealth of Massachusetts

MA

Questioned Costs Special Tests & Provisions Significant Deficiency § 200.303

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES 2023-032 Medicaid Cluster, COVID-19 – Medicaid Cluster - Assistance Listing No. 93.775, 93.777, 93.778 Action taken in response to the finding: In response to the finding, MassHealth will • Implement corrective measures to ensure workbooks are revamped ...

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES 2023-032 Medicaid Cluster, COVID-19 – Medicaid Cluster - Assistance Listing No. 93.775, 93.777, 93.778 Action taken in response to the finding: In response to the finding, MassHealth will • Implement corrective measures to ensure workbooks are revamped and that processes are implemented to automate and improve the importation of data and to allow more time for quality control review. • Work with staff to develop additional checks to ensure the correct federal share is reported and returned. • Return the identified federal share in the QE 03.2024 CMS 64. Name of the contact person responsible for corrective action: Janet Chin, Director Federal Revenue Claiming, Title XIX & XXI Planned completion date for corrective action plan: Immediate and ongoing

View Audit 315520 Questioned Costs: $1

Finding 478982 (2023-031)

Significant Deficiency 2023

Commonwealth of Massachusetts

MA

Special Tests & Provisions Reporting Significant Deficiency § 200.303

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES 2023-031 Medicaid Cluster, COVID-19 – Medicaid Cluster - Assistance Listing No. 93.775, 93.777, 93.778 Action taken in response to the finding: The Executive Office of Health and Human Services (EOHHS) has reviewed the required elements of reports submi...

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES 2023-031 Medicaid Cluster, COVID-19 – Medicaid Cluster - Assistance Listing No. 93.775, 93.777, 93.778 Action taken in response to the finding: The Executive Office of Health and Human Services (EOHHS) has reviewed the required elements of reports submitted by managed care providers with EOHHS staff and reviewed the steps that EOHHS staff should take when any element of those reports is missing. Name of the contact person responsible for corrective action: Robert Roche, FP&A Analyst Planned completion date for corrective action plan: May 2, 2024

View Audit 315520

Finding 478977 (2023-030)

Material Weakness 2023

Commonwealth of Massachusetts

MA

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

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES 2023-030 Medicaid Cluster, COVID-19 – Medicaid Cluster - Assistance Listing No. 93.775, 93.777, 93.778 Action taken in response to the finding: EOHHS is developing a standardized checklist, using CLA’s guidance as a template, to ensure that SOC reports ...

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES 2023-030 Medicaid Cluster, COVID-19 – Medicaid Cluster - Assistance Listing No. 93.775, 93.777, 93.778 Action taken in response to the finding: EOHHS is developing a standardized checklist, using CLA’s guidance as a template, to ensure that SOC reports are reviewed and that such reviews are documented. Name of the contact person responsible for corrective action: Conduent – Jacob Guggenheim, Director of Healthcare Information and Analysis DentaQuest - Tomaso Calicchio, Director of Specialty Provider Networks Maximus – Janice Wadsworth, Director of Provider Operations Planned completion date for corrective action plan: July 2024

View Audit 315520

Corrective Action Plans

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