Corrective Action Plans

Finding 395509 (2023-005)

Material Weakness 2023

AR

Student Financial Aid Matching / Level of Effort / Earmarking Subrecipient Monitoring

Management concurs with this finding. The College will set policies, procedures and practices in place and adhere to ensure that changes in students’ enrollment are reported accurately and timely as defined in the Federal guidelines. Responsible Administrators: Director of Financial Aid & Regist...

Management concurs with this finding. The College will set policies, procedures and practices in place and adhere to ensure that changes in students’ enrollment are reported accurately and timely as defined in the Federal guidelines. Responsible Administrators: Director of Financial Aid & Registrar Effective: Immediately and ongoing

View Audit 305169

Finding 395507 (2023-004)

Material Weakness 2023

Arkansas Baptist College

AR

Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking

Management concurs with this finding. The College will review and adhere to its practices, policies, and procedures along with federal regulations as it relates to resolving credit balances. The College will resolve credit balances timely and within the 14-day period as defined in the Federal guid...

Management concurs with this finding. The College will review and adhere to its practices, policies, and procedures along with federal regulations as it relates to resolving credit balances. The College will resolve credit balances timely and within the 14-day period as defined in the Federal guidelines. Responsible Administrators: Director of Financial Aid & Chief Financial Officer Effective: Immediately and ongoing

View Audit 305169

Finding 395505 (2023-003)

Material Weakness 2023

Arkansas Baptist College

AR

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Management concurs with this finding. The College will ensure the accuracy of the data that is input into the COD system and the College will work to apply funds appropriately to students' accounts. The College will review and adhere to its practices, policies, and procedures along with federal gu...

Management concurs with this finding. The College will ensure the accuracy of the data that is input into the COD system and the College will work to apply funds appropriately to students' accounts. The College will review and adhere to its practices, policies, and procedures along with federal guidelines as it relates to managing the COD system. Responsible Administrators: Director of Financial Aid & Chief Financial Officer Effective: Immediately and ongoing

View Audit 305169

Finding 395503 (2023-002)

Material Weakness 2023

Arkansas Baptist College

AR

Questioned Costs Student Financial Aid Eligibility

Management concurs with this finding. The College will keep accurate attendance and participation records. The College will calculate R2T4s accurately and will return the funds in a timely manner. The College will review and adhere to its practices, policies, and procedures along with federal gui...

Management concurs with this finding. The College will keep accurate attendance and participation records. The College will calculate R2T4s accurately and will return the funds in a timely manner. The College will review and adhere to its practices, policies, and procedures along with federal guidelines as it relates to R2T4 regulations. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid & Chief Financial Officer Effective: Immediately and ongoing

View Audit 305169 Questioned Costs: $1

Finding 395502 (2023-018)

Material Weakness 2023

Lafayette City_parish Consolidated Government

LA

Reporting

U.S. DEPARTMENT OF COMMERCE: Economic Adjustment Assistance (11.307) 2023-018 Compliance with Reporting See Compliance Finding 2023-017. 2023-017 Compliance with Reporting Recommendation: The Government should establish and maintain effective internal controls to ensure accurate financial infor...

U.S. DEPARTMENT OF COMMERCE: Economic Adjustment Assistance (11.307) 2023-018 Compliance with Reporting See Compliance Finding 2023-017. 2023-017 Compliance with Reporting Recommendation: The Government should establish and maintain effective internal controls to ensure accurate financial information is reported in accordance with the federal guidelines. Corrective Action Plan: The Government agrees with this finding. LUS Fiber and the Accounting Division will work together to review the forms prepared by the Acadiana Planning Commission prior to submission to ensure all information balances to our general ledger. This project is expected to be completed within two to four months and will be overseen by the Interim Fiber Director Jeffery Stewart.

View Audit 305166

Finding 395501 (2023-017)

None 2023

Lafayette City_parish Consolidated Government

LA

Reporting

U.S. DEPARTMENT OF COMMERCE: Economic Adjustment Assistance (11.307) 2023-017 Compliance with Reporting Recommendation: The Government should establish and maintain effective internal controls to ensure accurate financial information is reported in accordance with the federal guidelines. Corre...

U.S. DEPARTMENT OF COMMERCE: Economic Adjustment Assistance (11.307) 2023-017 Compliance with Reporting Recommendation: The Government should establish and maintain effective internal controls to ensure accurate financial information is reported in accordance with the federal guidelines. Corrective Action Plan: The Government agrees with this finding. LUS Fiber and the Accounting Division will work together to review the forms prepared by the Acadiana Planning Commission prior to submission to ensure all information balances to our general ledger. This project is expected to be completed within two to four months and will be overseen by the Interim Fiber Director Jeffery Stewart.

View Audit 305166

Finding 395434 (2023-003)

Significant Deficiency 2023

The Literacy Lab

DC

Allowable Costs / Cost Principles § 200.430 § 200.431

Person Responsible: Chief Operating Officer, Deirdre Bagley, will coordinate with the finance team Implementation Date: By August 30, 2024 Management’s response: In response to the recommendation that the Organization apply salaries on each of its Federal awards, based on actual time spent on each a...

Person Responsible: Chief Operating Officer, Deirdre Bagley, will coordinate with the finance team Implementation Date: By August 30, 2024 Management’s response: In response to the recommendation that the Organization apply salaries on each of its Federal awards, based on actual time spent on each award per employee, as supported by timesheets and other records, we concur with the recommendation and are in the process of creating a single, succinct schedule so that the auditors can easily test and reconcile the salary amounts to the supporting payroll and other records.

View Audit 305163

Finding 395409 (2023-002)

Significant Deficiency 2023

The Literacy Lab

DC

Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking § 200.302

Person Responsible: Chief Operating Officer, Deirdre Bagley, will coordinate with the finance team Implementation Date: By August 30, 2024 Management’s response: In response to the recommendation that the Organization properly apply allowed indirect cost rates across its Federal awards, we concur wi...

Person Responsible: Chief Operating Officer, Deirdre Bagley, will coordinate with the finance team Implementation Date: By August 30, 2024 Management’s response: In response to the recommendation that the Organization properly apply allowed indirect cost rates across its Federal awards, we concur with the recommendation and are in the process of creating a single, succinct schedule and the supporting documentation on indirect cost rates and rationale to allow the auditors to easily verify that the costs have been charged appropriately.

View Audit 305163

Finding 395408 (2023-001)

Significant Deficiency 2023

The Literacy Lab

DC

Allowable Costs / Cost Principles § 200.302 § 200.430 § 200.431

Person Responsible: Chief Operating Officer, Deirdre Bagley, will coordinate with the finance team Implementation Date: By August 30, 2024 Management’s response: In response to the recommendation that the Organization apply salaries on each of its Federal awards, based on actual time spent on each a...

Person Responsible: Chief Operating Officer, Deirdre Bagley, will coordinate with the finance team Implementation Date: By August 30, 2024 Management’s response: In response to the recommendation that the Organization apply salaries on each of its Federal awards, based on actual time spent on each award per employee, as supported by timesheets and other records, we concur with the recommendation and are in the process of creating a single, succinct schedule so that the auditors can easily test and reconcile the salary amounts to the supporting details.

View Audit 305163

Finding 395402 (2023-003)

Material Weakness 2023

Western Heights Independent School District No. I-41

OK

Subrecipient Monitoring

Views of Responsible Officials and Planned Corrective Action: May 2023 was when FY22 audit was completed and the food service provider had already been selected and utilized by the District. FY24 the District has received food service management company contract. The contract has been board approve...

Views of Responsible Officials and Planned Corrective Action: May 2023 was when FY22 audit was completed and the food service provider had already been selected and utilized by the District. FY24 the District has received food service management company contract. The contract has been board approved.

View Audit 305153

Finding 395394 (2023-005)

Significant Deficiency 2023

Lancaster County Career and Technology Center

PA

Questioned Costs Subrecipient Monitoring Cash Management

The Center did not retain the eligibility documentation for one student and there was an incorrect computation for one student. Response and Planned Corrective Action: The Center acknowledges this finding, and will take the steps necessary to ensure that the information in the system is updated regu...

The Center did not retain the eligibility documentation for one student and there was an incorrect computation for one student. Response and Planned Corrective Action: The Center acknowledges this finding, and will take the steps necessary to ensure that the information in the system is updated regularly. Planned Corrective Action: to be implemented immediately. o The Director of Food Service will review the controls currently in place and revise accordingly to ensure that accuracy and completeness of data is maintained. o Proper documentation will be maintained by school staff and will be reviewed regularly by the Director of Food Services and or the Business Manager/Asst. Business Manager.

View Audit 305132 Questioned Costs: $1

Finding 395392 (2023-003)

Significant Deficiency 2023

Lancaster County Career and Technology Center

PA

Subrecipient Monitoring Equipment & Real Property Management Procurement, Suspension & Debarment

Condition: The Center did not receive proper approval for the purchase of capital equipment purchased with grant funds in the current year. Response and Planned Corrective Action: The Center acknowledges this finding, and has since revised its permission process to include the requisite steps as re...

Condition: The Center did not receive proper approval for the purchase of capital equipment purchased with grant funds in the current year. Response and Planned Corrective Action: The Center acknowledges this finding, and has since revised its permission process to include the requisite steps as required by the US DoE (ED) Uniform Grant Guidance (UGG) in its subsequent purchases with Federal Funds. It is also noted that most if not all of these purchases were made after the receipt of delayed guidance from PA Department of Education’s Federal Programs Office. When alerted to the guidance, the Center implemented the proper procedures. Planned Corrective Action: to be implemented immediately. o The Business Manager/Asst. Business Manager will review all federally funded capital requests to ensure that the proper processes are followed in the procurement of bids and quotes.

View Audit 305132

Finding 395388 (2023-004)

Significant Deficiency 2023

Lancaster County Career and Technology Center

PA

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.318 § 200.320

The Center did not follow the appropriate procedures to comply with Uniform Grant Guidance. During testing, it was noted that the Center made procurements through noncompetitive procurement arrangements. Consistent with 2 CFR § 200.320(c)(3), an LEA may determine that its response to the COVID-19 p...

The Center did not follow the appropriate procedures to comply with Uniform Grant Guidance. During testing, it was noted that the Center made procurements through noncompetitive procurement arrangements. Consistent with 2 CFR § 200.320(c)(3), an LEA may determine that its response to the COVID-19 pandemic qualifies as a public exigency or emergency that does not permit the delay that would result from competitive bidding. Under these circumstances, and to the degree doing so is consistent with its own policies and procedures, the Center could use noncompetitive procurement. The Center should consult with the Pennsylvania Department of Education before using this authority. Subsequently, the Center paid for this purchase utilizing the Education Stabilization Fund and Career and Technical Education monies. In using federal funds to pay for these items, the Center inadvertently did not follow its procurement policy. Response and Planned Corrective Action: The Center acknowledges this finding, and has since revised its procurement process to include the requisite items as required by the US DoE (ED) Uniform Grant Guidance (UGG) in its subsequent purchases with Federal Funds. It is also noted that most if not all of these purchases were made in response to the COVID-19 Pandemic, and with delayed guidance from PA Department of Education’s Federal Programs Office. When alerted to the guidance, the Center implemented the proper procedures. Planned Corrective Action: • When using federal funds, the Business Manager/Asst. Business Manager will ensure that cooperative purchasing programs or noncompetitive purchasing arrangements comply with the UGG procurement policy. • The Business Manager/Asst. Business Manager will document the process and how it complied with the procurement standards and keep such documentation with Federal Award budget/procurement documents.

View Audit 305132

Finding 395387 (2023-002)

Significant Deficiency 2023

Lancaster County Career and Technology Center

PA

Subrecipient Monitoring

The Center did not file the required quarterly reports for June 2023 and had a late filing for September 2022 report for grant #224-21-1161. Also, the Center did not file quarterly reports for June 2023 and September 2022 for grant #380-23-0039 and #381-23-0014. Response and Planned Corrective Actio...

The Center did not file the required quarterly reports for June 2023 and had a late filing for September 2022 report for grant #224-21-1161. Also, the Center did not file quarterly reports for June 2023 and September 2022 for grant #380-23-0039 and #381-23-0014. Response and Planned Corrective Action: The Center has implemented a series of reminders in the email and calendar system for the Business Manager, the Assistant Business Manager, and the Administrative Director to ensure that timely submission of the quarterly reporting is completed. Planned Corrective Action: To be implemented immediately. · The Business Manager/Asst. Business Manager will establish additional procedures to ensure that the Center files all quarterly cash on hand within 10 days of quarter ending and final expenditure reports within 30 days after the funds are expended, but no later than 30 days after the ending date of the project. · This included calendar reminders and follow up and accountability to supervisors at the Center.

View Audit 305132

Finding 395384 (2023-034)

Significant Deficiency 2023

State of Oregon

OR

Subrecipient Monitoring § 200.332

2023-034 Oregon Department of Emergency Management Fully implement subrecipient risk assessments MANAGEMENT RESPONSE: We agree with this recommendation. ODEM will undertake the following corrective actions to address the recommendations made by the Secretary of State’s Audits Division: a. ODEM wi...

2023-034 Oregon Department of Emergency Management Fully implement subrecipient risk assessments MANAGEMENT RESPONSE: We agree with this recommendation. ODEM will undertake the following corrective actions to address the recommendations made by the Secretary of State’s Audits Division: a. ODEM will continue to develop the risk assessment policy and procedures, including monitoring controls to identify and follow-up with subrecipients that have not completed a risk assessment. b. ODEM will develop an agency wide subrecipient monitoring policy in accordance with 2 CFR 200. This policy will include discussion on how ODEM prioritizes subrecipient monitoring based on the results of the risk assessment. Anticipated Completion Date: December 31, 2024 Contact person: Jeff Flowers, Chief Financial Officer

View Audit 305129

Finding 395383 (2023-033)

Material Weakness 2023

State of Oregon

OR

Subrecipient Monitoring Material Weakness Reporting § 200.303

2023-033 Oregon Department of Emergency Management Implement controls over FFATA reporting MANAGEMENT RESPONSE: We agree with this recommendation. ODEM has undertaken the following corrective actions to address the recommendations made by the Secretary of State’s Audits Division: a. ODEM has dev...

2023-033 Oregon Department of Emergency Management Implement controls over FFATA reporting MANAGEMENT RESPONSE: We agree with this recommendation. ODEM has undertaken the following corrective actions to address the recommendations made by the Secretary of State’s Audits Division: a. ODEM has developed procedures for capturing necessary information and ensuring FFATA reports are filed in compliance with federal criteria. b. ODEM has identified all awards since July 1st 2023 and is working to ensure 100% compliance from that date forward. c. ODEM will continue to review older awards to determine what actions should be taken. Anticipated Completion Date: December 30, 2024. Contact person: Jeff Flowers, Chief Financial Officer

View Audit 305129

Finding 395379 (2023-024)

Significant Deficiency 2023

State of Oregon

OR

Questioned Costs Allowable Costs / Cost Principles § 200.1 § 200.400

2023-024 Oregon Department of Human Services/Oregon Health Authority Strengthen review over direct costs charged to the program MANAGEMENT RESPONSE: We agree with this recommendation. The ODHS Office of Facilities Management coordinates care of a 168-building portfolio. Part of this work is coord...

2023-024 Oregon Department of Human Services/Oregon Health Authority Strengthen review over direct costs charged to the program MANAGEMENT RESPONSE: We agree with this recommendation. The ODHS Office of Facilities Management coordinates care of a 168-building portfolio. Part of this work is coordination of furniture reconfiguration, minor and major remodels of office spaces and other building maintenance work. For these projects we rely on program staff with understanding of their funding sources to provide us with accurate coding to support the project related costs. Our office does not work directly with funding source management only coding and billing. To better track who is providing us the coding and maintain a record of payment approval we have revised our workorder form to include who from the program is providing the coding and what authority they have to provide the coding. This will allow us to assure that important details are captured regarding funding application and coding for billing and protect from funds being drawn from sources that do not support and/or are not appropriate for a given project. The questioned costs of $3,849 were corrected and refunded to CMS using document BTCL1485 with a April 17, 2024 effective date. The refund will be reported on the Q3 FFY 2024 CMS 64 which will be submitted by June 30, 2024. Anticipated Completion Date: June 30, 2024 Contact person: Karuna Thompson, Construction and Facilities Maintenance Manager; Travis Labrum, Grant Accounting Manager

View Audit 305129 Questioned Costs: $1

Finding 395378 (2023-023)

Material Weakness 2023

State of Oregon

OR

Questioned Costs Eligibility Special Tests & Provisions

2023-023 Oregon Department of Human Services/Oregon Health Authority Improve documentation for provider eligibility determinations and revalidations MANAGEMENT RESPONSE: We agree with this recommendation. The authority will provide two separate training modules to enrollment staff and staff respo...

2023-023 Oregon Department of Human Services/Oregon Health Authority Improve documentation for provider eligibility determinations and revalidations MANAGEMENT RESPONSE: We agree with this recommendation. The authority will provide two separate training modules to enrollment staff and staff responsible for the CCO enrollment and validation regarding complete ownership and disclosure documents. We will perform the trainings on April 18, 2024, during our monthly staff meeting and a separate ownership form only training on May 30, 2024. The Office of Developmental Disability Services has implemented new contractual language for our fiscal intermediary to review I-9 for providers with stricter criteria. This was added earlier this year and is already in place in the contract and implemented. Further, upon enrollment, state staff are validating older I-9s for providers who have submitted their I-9 historically. The Office of Aging and People with Disabilities is committed to ensuring Provider Enrollment Agreements and accurate I-9 forms are on file and ensuring records are stored and retained properly for all Home Care Workers. The department will reinforce the requirements concerning the collection and storage of agreements at both the Quarterly Home Care Coordinators meeting on May 30, 2024, and at the AAA/APD Local Line Leadership meeting on May 16, 2024. The department will also create a reference guide in the new ODHS Field Business Procedure Manual implemented in February 2024. The department will make provider enrollment agreements and I-9 forms available statewide via DocuSign as an optional tool for state staff that guides them through accurately completing information on the form and capturing electronic signatures. This will ensure that all required fields in forms are filled out correctly including ensuring the presence of required documentation to mitigate human error. Additionally, we will continue to explore developing a training module for front office staff and office managers as well as a peer review process on business procedures and exploring ways that we can leverage technology such as the replacement Electronic Data Management System (EDMS) "Laserfiche" implemented by Imaging and Records Management Services (IRMS) to store provider records electronically. The questioned costs of $1,786 will be refunded to CMS and reported on the CMS 64 by 6/30/2024. Of note, the prior year finding with questioned costs of $1,843 has since been found as the provider being eligible. No corrective action is needed. Anticipated Completion Date: August 30, 2024 Contact person: Todd Howard, Business Operations Supervisor; Vanessa Richkind, Provider Administration Manager; Jennifer Stallsworth, Chief of Staff; Travis Labrum, Grant Accounting Manager

View Audit 305129 Questioned Costs: $1

Finding 395377 (2023-022)

Significant Deficiency 2023

State of Oregon

OR

Special Tests & Provisions Significant Deficiency Internal Control / Segregation of Duties

2023-022 Oregon Department of Human Services/Oregon Health Authority Ensure compliance with federal Medicaid hospital audit requirements MANAGEMENT RESPONSE: We agree with this recommendation. The authority agrees with this finding and has completed the work to reconstitute the required tools neces...

2023-022 Oregon Department of Human Services/Oregon Health Authority Ensure compliance with federal Medicaid hospital audit requirements MANAGEMENT RESPONSE: We agree with this recommendation. The authority agrees with this finding and has completed the work to reconstitute the required tools necessary to perform these audits. As of January 2024, the authority has sent cost statements to the hospitals for review and response and is working to collect other reports required for completing the audits from actuaries and intermediaries. The authority will begin processing full audits starting April 2024 for outstanding Fiscal Year 2016 forward. The authority anticipates that the audits through Fiscal year 2020 will be completed by Dec. 31, 2024. The authority also affirms that the corrective action for finding 2021-17 has been implemented and resolved. This can be validated as completed audits become available in 2024. Anticipated Completion Date: December 31, 2024 Contact person: April Gillette, Strategic Operations and Improvement Director

View Audit 305129

Finding 395368 (2023-038)

Significant Deficiency 2023

State of Oregon

OR

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

2023-038 Department of Early Learning and Care Retain support and improve controls over reporting MANAGEMENT RESPONSE: We agree with this recommendation. DELC will work with the Department of Revenue to substantiate the amount of tax credits used in prior years to meet federal matching and mainte...

2023-038 Department of Early Learning and Care Retain support and improve controls over reporting MANAGEMENT RESPONSE: We agree with this recommendation. DELC will work with the Department of Revenue to substantiate the amount of tax credits used in prior years to meet federal matching and maintenance of effort requirements for FY 20 to FY 22 and ensure this information is retained appropriately outside beyond just email records. In addition, DELC will update processes and procedures to ensure that tax credit amounts used in future reports are properly documented and substantiated by the Department of Revenue. Anticipated Completion Date: October 31, 2024 Contact person: Ali Webb, Operations and Policy Analyst; Connie Range, Fiscal Analyst

View Audit 305129

Finding 395367 (2023-037)

Significant Deficiency 2023

State of Oregon

OR

Questioned Costs Allowable Costs / Cost Principles

2023-037 Department of Early Learning and Care Improve controls over payroll MANAGEMENT RESPONSE: We agree with this recommendation. DELC concurs with the findings with the following clarification: position descriptions are typically retained for employees even after they leave employment. Howev...

2023-037 Department of Early Learning and Care Improve controls over payroll MANAGEMENT RESPONSE: We agree with this recommendation. DELC concurs with the findings with the following clarification: position descriptions are typically retained for employees even after they leave employment. However, for the two employees referenced, we were unable to locate their position descriptions. DELC agrees with the stated recommendations and will take the following corrective action steps: • Human Resources will audit all DELC employee records to ensure that positions descriptions are signed, and in the employee’s Workday personnel file. • Human Resources will reiterate expectations to managers to ensure that timesheets are reviewed and approved by managers before the deadline each month. • Budget will monitor payroll charges to identify when time has been incorrectly charged. • DELC will reimburse the federal agency for the known unallowable costs. The anticipated completion date for having signed position descriptions for all DELC employees is December 31, 2024. The agency has already messaged to managers the expectations and importance of reviewing and approving employees time before the deadline each month and will continue to do so monthly prior to each deadline. Anticipated Completion Date: December 31, 2024 Contact person: Heather Thomas, Human Resources Manager; Connie Range, Fiscal Analyst

View Audit 305129 Questioned Costs: $1

Finding 395366 (2023-036)

Significant Deficiency 2023

State of Oregon

OR

Questioned Costs Allowable Costs / Cost Principles

2023-036 Department of Early Learning and Care Improve controls over family copay and child care hour calculations MANAGEMENT RESPONSE: We partially agree with this recommendation. DELC does not concur with the finding regarding a case with the copay amount not reflected in reimbursement between ...

2023-036 Department of Early Learning and Care Improve controls over family copay and child care hour calculations MANAGEMENT RESPONSE: We partially agree with this recommendation. DELC does not concur with the finding regarding a case with the copay amount not reflected in reimbursement between multiple providers. DELC sends out billing forms in advance of the month and providers are allowed to bill for anticipated hours of attendance. We do not require that the primary provider bill, nor can we retroactively reduce the secondary providers payment amount by the copay amount if the primary provider does not bill. DELC has the following language in our ruleset (5b) reflected below, which allows the copay to be zero if the provider to whom the copay is designated does not submit a billing for the month. 414-175-0051 Requirement to Make Copay or Satisfactory Arrangements 1) The Need Group must use a child care provider who meets the requirements in OAR 414-175-0080 and 414-175-0085. 2) The caretaker is responsible for paying the copayment to the primary provider of child care unless the Child Care Billing form was sent to the provider showing no copayment. 3) If the caretaker has only one provider during a month, that provider is the primary provider. If the caretaker uses more than one provider, the caretaker must designate one as the primary provider. Notwithstanding any designation by the caretaker, the Department considers a provider having the copayment amount (not to exceed the caretaker's established copayment amount) deducted from its valid billing statement the primary provider for that period. 4) If the copayment exceeds the amount billed by the primary provider, the Department may treat a different provider as the primary provider or split the copayment among the providers who bill for care. 5) The copayment amount due from the caretaker to the provider is the lesser of: a. The copayment amount determined by the Department based on family size and income. b. The total amount allowed by the Department on a provider claim. DELC does not concur with the finding regarding the overpayment for the months of January, February, and March when the parent changed providers. An overpayment referral was made to the Overpayment Writing Unit in the Oregon Department of Human Services when the new provider was set up. The provider in question did submit billing forms for payment for January, February, and March 2024. When the parent called in late March to end the previous provider, she gave the end date of 1/16/23. The provider was allowed to bill for absent days for the rest of January and the full month of February as absent days. The provider was unable to bill for March since it doesn’t not fall within OAR 414-175-0075 and is considered abandonment of care. DPU made an overpayment referral to the Overpayment Writing Unit when the new provider was set up. The provider was written up for an overpayment for March in the amount of $1,395.00. DELC concurs will all other findings in this area. DELC agrees with stated recommendations and will take the following corrective action steps: • The Child Care Assistance Program team will develop a training partially focused on error trends found in this report to educate staff on findings and preventative measures. • The Child Care Assistance Program team will provide case finding information to OPAR for recoupment purposes. • DELC will reimburse the federal agency for unallowable costs. Anticipated Completion Date: December 31, 2024 Contact person: Regina Siefert, Childcare Policy Analyst

View Audit 305129 Questioned Costs: $1

Finding 395365 (2023-035)

Significant Deficiency 2023

State of Oregon

OR

Questioned Costs Allowable Costs / Cost Principles

2023-035 Department of Early Learning and Care Use restricted indirect cost rate when required MANAGEMENT RESPONSE: We agree with this recommendation. DELC concurs with these findings; however, the findings are related to the indirect rate charged while the Early Learning Division was part of the...

2023-035 Department of Early Learning and Care Use restricted indirect cost rate when required MANAGEMENT RESPONSE: We agree with this recommendation. DELC concurs with these findings; however, the findings are related to the indirect rate charged while the Early Learning Division was part of the Oregon Department of Education. DELC will continue to work with the Oregon Department of Education to determine if any other indirect costs were incorrectly charged and will help make appropriate corrections to ensure federal grants were not overcharged. We will create processes and procedures to ensure expenditures are allowable before a federal draw is completed and that the correct indirect rate is charged. Anticipated Completion Date: December 31, 2024 Contact person: Natalie Day, Accounting Manager; Connie Range, Fiscal Analyst

View Audit 305129 Questioned Costs: $1

Finding 395362 (2023-021)

Significant Deficiency 2023

State of Oregon

OR

Matching / Level of Effort / Earmarking § 200.303

2023-021 Oregon Health Authority Implement controls to ensure earmarked expenditures are tracked and compliance achieved MANAGEMENT RESPONSE: We agree with this recommendation. As noted in the audit report, OHA has already taken corrective actions to ensure controls are in place for tracking app...

2023-021 Oregon Health Authority Implement controls to ensure earmarked expenditures are tracked and compliance achieved MANAGEMENT RESPONSE: We agree with this recommendation. As noted in the audit report, OHA has already taken corrective actions to ensure controls are in place for tracking applicable expenditures in SFMA to ensure compliance with federal Earmarking requirements. The Office of Financial Services, OHA Budget Unit, and block grant planners meet at least once a month to review budgeted earmarked requirements and expenditures to ensure compliance. Block grant planners meet at least once a month with the crisis team and children and family team to review required earmark budgets and expenditures. Anticipated Completion Date: June 30, 2023 Contact person: Annabelle Atalig, Budget and Fiscal Manager; Travis Labrum, Grant Accounting Manager

View Audit 305129

Finding 395360 (2023-020)

Material Weakness 2023

State of Oregon

OR

Subrecipient Monitoring Reporting

2023-020 Oregon Health Authority Implement controls to ensure subrecipients are appropriately identified and monitored MANAGEMENT RESPONSE: We agree with this recommendation. Contracts and program staff have piloted and implemented tools to help administrators determine if the NFP is a contractor...

2023-020 Oregon Health Authority Implement controls to ensure subrecipients are appropriately identified and monitored MANAGEMENT RESPONSE: We agree with this recommendation. Contracts and program staff have piloted and implemented tools to help administrators determine if the NFP is a contractor or sub-recipient using the determination checklist. Department managers have communicated expectations related to the use of this tool and guidance to ensure that contract administrators understand how to determine if an agency is a contractor or sub-recipient. If determination identifies a subrecipient relationship, controls are in place to ensure the Federal Funding Accountability and Transparency Act (FFATA) form, self-assessment, and monitoring plan are completed. Further, mental health block grant planners will assess each new or amended contract for appropriate designation. OHA management plans to establish a single training for all staff to complete before developing a contract. This training will also include necessary messaging to all staff about terminology, location of resources, expectations as an administrator, and compliance/verification processes. OHA will provide this messaging and training through agency-wide emails, newsletters, and all staff meetings. OHA will continue refining its onboarding to incorporate these trainings and messaging. Additionally, the Office of Financial Services reviews each contract to determine the correct coding for each contracted service/deliverable and accurate code, such in State Financial Management Accounting (SFMA) system. Risk assessment survey has been developed that allows for self-assessment and documentation of the process. Administrators are requested to keep a copy of the assessment in their administrative file. Contract administrators create regularly scheduled meetings with the sub-awardee to monitor for compliance, depending on the risk of the sub-awardee. OHA-HSD has created a planning and implementation document to systematically identify the process of self-assessment and monitoring plan. In addition to the 11-module contract administration training required for all administrators. OHA plans to create an accessible folder for download to include the Contract Administration Plan (CAP), RACI Matrix, Monitoring, and closeout activities. Once all of the resources are socialized throughout the Program and Leadership staff, controls are still necessary to get as close to 100% compliance by the administrators. Controls that will be implemented are: • DocuSign CLM- During the automated workflow for approvals, administrators must verify that the determination document and, if applicable, the self-assessment and monitoring plan is attached. If not, the request will be rejected until the proper documentation is provided. • Team audit- The program analyst will perform random audits of grant/contracts administrator folders to confirm documentation is complete for each grant/contract, including monitoring activities, reports, invoices, and grant compliance requirements. Anticipated Completion Date: September 1, 2024 Contact person: Amy Ashton-Williams, Adult Behavioral Health Director

View Audit 305129

Corrective Action Plans

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