Corrective Action Plans

Finding 57901 (2022-003)

Material Weakness 2022

Jefferson County

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

FINDING 2022-003 Contact Person Responsible for Corrective Action:Heather Huff Contact Phone Number:812-265-8907 Views of Responsible Official: We Concur Description of Corrective Action Plan: Jefferson County will now as of (8-15-23) collect a contract when disbursing Federal funds that will includ...

FINDING 2022-003 Contact Person Responsible for Corrective Action:Heather Huff Contact Phone Number:812-265-8907 Views of Responsible Official: We Concur Description of Corrective Action Plan: Jefferson County will now as of (8-15-23) collect a contract when disbursing Federal funds that will include information that by agreeing to receive the funds you will use funds for the intended purposes, and your organization is not disbarred. Anticipated Completion Date: To be completed April 15th 2024.

View Audit 55047

Finding 57900 (2022-001)

Significant Deficiency 2022

Northern Essex Community College

MA

Questioned Costs Cash Management

Finding number: 2022-001 Federal agency: U.S. Department of Education Programs: Higher Education Emergency Relief Fund Assistance Listing #: 84.425F Award year: 2022 Corrective Action Plan: We agree with the audit finding. We did not realize that under the HEERF III Issued...

Finding number: 2022-001 Federal agency: U.S. Department of Education Programs: Higher Education Emergency Relief Fund Assistance Listing #: 84.425F Award year: 2022 Corrective Action Plan: We agree with the audit finding. We did not realize that under the HEERF III Issued Guidelines/(FAQs) that as a grantee we were under an obligation to minimize the time between drawing down funds from G5 and paying obligations incurred by the college/grantee. We had thought that the related guidelines were similar to CARES/HEERF I and we wanted to ensure that we had drawn down the funds timely once they were awarded to the college. HEERF III institutional funds spent as of June 30, 2022 were $783,442 and total HEERF III institutional grant funds spent as of January 2023 total $3,214,528. The college management?s plan is to spend all HERRF III funds for plan identified activities by June 30, 2023. Going forward, the college will ensure full compliance with the issued drawn down of awarded funds guidelines. Timeline for Implementation of Corrective Action Plan: The corrective action plane was implemented December 7, 2022. Contact Person Anthony DeGregorio, Comptroller and Director of Fiscal Services

View Audit 54842 Questioned Costs: $1

Finding 57899 (2022-001)

Significant Deficiency 2022

Saint Mary's University of Minnesota

MN

Student Financial Aid Matching / Level of Effort / Earmarking Reporting

Corrective Action: The two students whose information was not reported within 60 days was due to an internal failure to report the status change by the Financial Aid and Registrar's Office. The one student whose effective date varied between program and campus level stems from system limitations, as...

Corrective Action: The two students whose information was not reported within 60 days was due to an internal failure to report the status change by the Financial Aid and Registrar's Office. The one student whose effective date varied between program and campus level stems from system limitations, as the process to report this status change on the program level but not the enrollment level, as required by NSLDS, is a manual process. The University continues to refine the manual process required for reporting this type of status change. For the four students who never had their graduation status reported to the NSLDS, Management noted one actual failure to report and three instances where the status change was reported to the Clearinghouse, but not reflected on NSLDS. The University is working with the Clearinghouse to understand what went wrong and how to prevent it in the future. The University is in the middle of implementation of a new student information system which is expected to improve this and other processes. Implementation is anticipated to be complete by July 2023.

View Audit 54321

Finding 57898 (2022-002)

Significant Deficiency 2022

New Haven Legal Assistance Association, Inc.

CT

Allowable Costs / Cost Principles Significant Deficiency Internal Control / Segregation of Duties

Coronavirus State and Local Fiscal Recovery Funds ? Assistance Listing No. 21.027 Recommendation: We recommend that the Organization retain records to satisfy the time and effort documentation as required by Uniform Guidance (2 CFR Part 200). Explanation of disagreement with audit finding: There is ...

Coronavirus State and Local Fiscal Recovery Funds ? Assistance Listing No. 21.027 Recommendation: We recommend that the Organization retain records to satisfy the time and effort documentation as required by Uniform Guidance (2 CFR Part 200). Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Laura Clark, the Director of Finance, has met with the management team and LAA has revised its procedure for supervisors keeping time under the Right To Counsel program. Now, supervisors of the program are required to maintain separate time entries in our case management system for Right To Counsel cases. Before billing under the program, Laura Clark will run a Crystal Report, which captures time entered into the case management system, to ensure the percentage billed is correct. This has been discussed and implemented. Name of the contact person responsible for corrective action: Laura Clark, Director of Finance Planned completion date for corrective action plan: June 2023

View Audit 54852

Finding 57897 (2022-001)

Significant Deficiency 2022

New Haven Legal Assistance Association, Inc.

CT

Procurement, Suspension & Debarment Significant Deficiency § 200.318 § 200.326

Coronavirus State and Local Fiscal Recovery Funds ? Assistance Listing No. 21.027 Recommendation: We recommend that the Organization review its procurement policy and conflict of interest policy and make necessary changes to comply with the criteria as set out in 2 CFR sections 200.318 and 200.326. ...

Coronavirus State and Local Fiscal Recovery Funds ? Assistance Listing No. 21.027 Recommendation: We recommend that the Organization review its procurement policy and conflict of interest policy and make necessary changes to comply with the criteria as set out in 2 CFR sections 200.318 and 200.326. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Laura Clark, the Director of Finance, is currently developing a procurement and related conflict of interest policy. These policies will be presented to the Board of Directors for approval at the July 2023 board meeting. Name of the contact person responsible for corrective action: Laura Clark, Director of Finance Planned completion date for corrective action plan: July 2023

View Audit 54852

Finding 57896 (2022-002)

None 2022

Yorkville Joint #2 School District

WI

Management Response - The District Administrator and Business Manager review and approve the financial statements. Upon completion of the full audit, the school board reviews, comments on and approves the audited financial statements.

View Audit 54521

Finding 57895 (2022-001)

None 2022

Yorkville Joint #2 School District

WI

Internal Control / Segregation of Duties

Management Response ? Because of the size of the office and the district, we are precluded from maintaining a proper staff size to ensure a proper segregation of duties. We are aware of this condition and we realize that the concentration of duties and responsibilities in a limited number of indivi...

Management Response ? Because of the size of the office and the district, we are precluded from maintaining a proper staff size to ensure a proper segregation of duties. We are aware of this condition and we realize that the concentration of duties and responsibilities in a limited number of individuals in not desirable for an effective system of internal control. To mitigate the issue of lack of segregation of duties, we have cross trained virtually each of the business office employees. While we do have a dedicated payroll person, another individual will perform cross checks & verifications independently. The same goes for issuing checks, accounts receivable, accounts payable, and activity funds. These functions are overseen by the business manager.

View Audit 54521

Finding 57892 (2022-004)

Material Weakness 2022

Eastern Connecticut Regional Educational Service Center

CT

Questioned Costs Allowable Costs / Cost Principles

SINGLE AUDIT CORRECTIVE ACTION PLAN For the Fiscal Year Ended June 30, 2022 To Government Officials: SINGLE AUDIT FINDINGS: Finding 2022-004 Activities Allowed or Unallowed Description of Finding One transaction charged to the grant was not authorized per the employee agreement. Statement o...

SINGLE AUDIT CORRECTIVE ACTION PLAN For the Fiscal Year Ended June 30, 2022 To Government Officials: SINGLE AUDIT FINDINGS: Finding 2022-004 Activities Allowed or Unallowed Description of Finding One transaction charged to the grant was not authorized per the employee agreement. Statement of Concurrence or Nonconcurrence Management agrees with the finding. Corrective Action EASTCONN Chief Financial Officer will review procedures and strengthen controls to ensure that only allowed expenditures are charged to the grant. Name of Contact Person Eric S. Protulis, Executive Director Projected Completion Date September 2023

View Audit 54356 Questioned Costs: $1

Finding 57888 (2022-003)

Significant Deficiency 2022

Eastern Connecticut Regional Educational Service Center

CT

Procurement, Suspension & Debarment § 200.318 § 200.326

SINGLE AUDIT CORRECTIVE ACTION PLAN For the Fiscal Year Ended June 30, 2022 To Government Officials: SINGLE AUDIT FINDINGS: Finding 2022-003 Description of Finding Procurement and Suspension and Debarment 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirem...

SINGLE AUDIT CORRECTIVE ACTION PLAN For the Fiscal Year Ended June 30, 2022 To Government Officials: SINGLE AUDIT FINDINGS: Finding 2022-003 Description of Finding Procurement and Suspension and Debarment 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Award requires compliance with the provisions of procurement, suspension, and debarment. EASTCONN should have internal controls designed to ensure compliance with those provisions. EASTCONN?s procurement standards do not include the required elements as outlined in 2 CFR sections 200.318 through 200.326. Statement of Concurrence or Nonconcurrence Management agrees with the finding. Corrective Action EASTCONN?s Executive Director and the Board of Directors will review, revise, and approve an updated procurement policy to incorporate required elements of the Uniform Guidance related to expenditures funded with Federal Grants. Name of Contact Person Eric S. Protulis, Executive Director Projected Completion Date November 2023

View Audit 54356

Finding 57887 (2022-001)

Material Weakness 2022

Northshore University Healthsystem

IL

Cash Management Eligibility Period of Performance

Corrective Action Plan Finding 2022-001 Assistance Listing #93.461 Internal Control over Compliance? Activities Allowed or Unallowed and Eligibility, Due to the evolving nature of the COVID-19 pandemic, and the rapid pace in which programs were implemented, documentation of controls related to the r...

Corrective Action Plan Finding 2022-001 Assistance Listing #93.461 Internal Control over Compliance? Activities Allowed or Unallowed and Eligibility, Due to the evolving nature of the COVID-19 pandemic, and the rapid pace in which programs were implemented, documentation of controls related to the reporting of COVID-19 uninsured patients was not maintained. However, controls were in place and proper submission of claims was accurate. As part of the prior year audit finding, NorthShore implemented a process as of January 2022 to document internal controls related to the quality review of claims to ensure patients meet the eligibility requirements. HRSA reviewed the documentation and determined that the finding had been satisfactorily resolved. Although the program has now ended, NorthShore will ensure the internal controls are documented should the HRSA program be reinstated. Responsible Official: John Skeans, Senior Vice President, Patient Financial Services.

View Audit 54355

Finding 57884 (2022-001)

Significant Deficiency 2022

Heartland Medical Clinic, Inc., D/b/a Heartland Community Health Center

KS

HUD Housing Programs Internal Control / Segregation of Duties

Corrective Action Plan Year Ended April 30, 2022 To United States Department of Health and Human Services Heartland Community Health Center respectfully submits the following corrective action plan for the year ended April 30, 2022. CohnReznick, LLP 350 Church Street Hartford, CT 06103 Audit P...

Corrective Action Plan Year Ended April 30, 2022 To United States Department of Health and Human Services Heartland Community Health Center respectfully submits the following corrective action plan for the year ended April 30, 2022. CohnReznick, LLP 350 Church Street Hartford, CT 06103 Audit Period: April 30, 2022 The findings from the April 30, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Federal Awards Findings: Finding 2022.001 - Sliding Fee Scale Discount Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated. Action Taken ? Monthly Audits o The immediate supervisor of front office operations will routinely audit sliding fee verification on a monthly basis to verify that information has been captured and recorded correctly. These monthly audits will be adopted as standard protocol and procedure for front office operations, effective January 2023. Any findings through the audit process will be reported to the COO. At least five patient charts will be audited monthly. o In addition, the billing manager will also review audit findings or summaries to ensure adequate adjustment to patient accounts to correlate with the patient?s eligibility status. ? Staff Training o Although Heartland has offered periodic sliding fee scale procedure training, administration will be scheduling additional trainings with a focus on required documentation and proper set up sliding fee. o Supervisor of front office operations will review and implement and update standard operating procedure for sliding fee scale verification. o Employees will receive a copy of the sliding fee scale policy and sign that they have read the material. o Front office employees at all locations will complete a sliding fee schedule competency check-off sheet that will be reviewed by the immediate supervisor and billing manager. If there are any question regarding this plan, please e-mail Scott Burcher at sburcher@heartlandhealth.org. Sincerely, Scott Burcher Chief Financial Officer

View Audit 52958

Finding 57873 (2022-004)

Significant Deficiency 2022

Indigenous Peoples Task Force

MN

Allowable Costs / Cost Principles

Name of Contact Person ? Sharon Day, Executive Director Corrective action ? IPTF has hired a new contract accountant, who will be responsible for ensuring proper payroll allocation calculation and recording. Completion date ? Management and the Board of Directors implemented the above as of December...

Name of Contact Person ? Sharon Day, Executive Director Corrective action ? IPTF has hired a new contract accountant, who will be responsible for ensuring proper payroll allocation calculation and recording. Completion date ? Management and the Board of Directors implemented the above as of December 2022.

View Audit 54316

Finding 57872 (2022-003)

Significant Deficiency 2022

Indigenous Peoples Task Force

MN

Reporting

Name of Contact Person ? Sharon Day, Executive Director Corrective action ? IPTF has hired a new contract accountant, who will be responsible for ensuring that the accounting records are prepared accurately and timely to ensure that these required reports can be submitted on time. Completion date ? ...

Name of Contact Person ? Sharon Day, Executive Director Corrective action ? IPTF has hired a new contract accountant, who will be responsible for ensuring that the accounting records are prepared accurately and timely to ensure that these required reports can be submitted on time. Completion date ? Management and the Board of Directors implemented the above as of December 2022.

View Audit 54316

Finding 57859 (2022-002)

Material Weakness 2022

Indigenous Peoples Task Force

MN

Internal Control / Segregation of Duties Material Weakness Reporting

Name of Contact Person ? Sharon Day, Executive Director Corrective action ? IPTF has hired a new contract accountant and will ensure they establish procedures to review internal books and records on a monthly basis and make all required adjustments as needed, to ensure that the information taken fro...

Name of Contact Person ? Sharon Day, Executive Director Corrective action ? IPTF has hired a new contract accountant and will ensure they establish procedures to review internal books and records on a monthly basis and make all required adjustments as needed, to ensure that the information taken from the accounting records is complete and accurate. They will also ensure that all documents related to pledges are obtained and reviews to ensure all transactions are recorded correctly. Completion date ? Management and the Board of Directors implemented the above as of December 2022.

View Audit 54316

Finding 57858 (2022-001)

Material Weakness 2022

Indigenous Peoples Task Force

MN

Internal Control / Segregation of Duties Material Weakness Reporting

Name of Contact Person ? Sharon Day, Executive Director Corrective action ? IPTF has hired a new contract accountant and will ensure they prepare internal financial statements on a monthly basis as required by their written financial policies and sent to management for review. Also, the board will p...

Name of Contact Person ? Sharon Day, Executive Director Corrective action ? IPTF has hired a new contract accountant and will ensure they prepare internal financial statements on a monthly basis as required by their written financial policies and sent to management for review. Also, the board will plan to meet quarterly and document meeting minutes. Completion date ? Management and the Board of Directors implemented the above as of December 2022.

View Audit 54316

Finding 57814 (2022-004)

Significant Deficiency 2022

Hemingford Public Schools, District No 10

NE

Reporting § 200.510

Finding 2022-004: Preparation of the Schedule of Expenditures of Federal Awards. District staff are aware of this responsibility and will plan to prepare the SEFA annually in future years.

View Audit 44873

Finding 53082 (2022-007)

Significant Deficiency 2022

State of Wisconsin

WI

Procurement, Suspension & Debarment Subrecipient Monitoring Internal Control / Segregation of Duties

CAP for Finding: 2022-007 Planned Corrective Action: The UW System has adequate processes in place for reviewing access to ShopUW+ but agrees to better document these processes. UW System Administration (UWSA) has revised the disbursement internal control template, which all UW universities use in d...

CAP for Finding: 2022-007 Planned Corrective Action: The UW System has adequate processes in place for reviewing access to ShopUW+ but agrees to better document these processes. UW System Administration (UWSA) has revised the disbursement internal control template, which all UW universities use in developing their internal control plans, to document the UW System?s security reviews. UWSA will also update the language surrounding its weekly access reports, to explain their purpose and importance. To monitor this control, the UW System will add a statement to this effect in the universities? annual delegation agreement and certifications. UWSA is actively taking steps to mature its third-party risk management practices, including the development of guidance and best practices for UW universities. Current efforts are focused on optimizing available resources to provide the highest return on value. UWSA currently performs periodic reviews of cloud-based third-party internal controls during precontract evaluations and at the time of contract renewals. This includes obtaining and reviewing service organization audit reports, if available. UWSA will evaluate the efficacy of increasing the periodicity of these reviews to an annual basis. UWSA will also evaluate means for communicating identified expectations systemwide, up to and including the creation of a new policy. Anticipated Completion Date: June 30, 2023 Person responsible for corrective action: Julie Gordon, Senior Associate Vice President Finance, UW System Administration jgordon@uwsa.edu

View Audit 44861

Finding 53081 (2022-704)

None 2022

State of Wisconsin

WI

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.405 § 200.516

CAP for Finding: 2022-704 Finding 2022-704: Research and Development Cluster?Unallowable Costs Planned Corrective Action: We agree with the condition that expenditures noted by the auditors were posted to federal awards in error. Our institution has robust policies and procedures in place along with...

CAP for Finding: 2022-704 Finding 2022-704: Research and Development Cluster?Unallowable Costs Planned Corrective Action: We agree with the condition that expenditures noted by the auditors were posted to federal awards in error. Our institution has robust policies and procedures in place along with multiple levels of review for transactions that post to awards. However, there may be rare instances where a transaction posts to an award for which it is not allowable or allocable. As noted by the auditors, they sampled from a population of $86.9 million from certain expenditure codes and only questioned $650 in costs. These expenditures have now been transferred off the awards to non-sponsored funding. To help Research Administrators manage Research and Development Awards, RSP (Research and Sponsored Programs) offers a variety of tools. RSP maintains a website that houses policies and procedures related to all relevant Research Administration topics. In addition to this, the RSP website has FAQ (Frequently Asked Questions) pages on a variety of Research Administration topics. RSP also offers a comprehensive training program called RED (Research Education Development). We offer courses that include topics such as a basic introduction to research administration, closeout of awards, cost-share, cost-transfers, and many others. We will remind administrators and their staff of all the relevant information our website houses and that they should take any pertinent RED. Lastly, we will remind staff that they can retake courses if they haven?t taken them recently and want to refresh their knowledge. Anticipated Completion Date: 5/31/23 Person responsible for corrective action: Kyle Everard, Manager of NSF-DOE Team Research and Sponsored Programs Kyle.Everard@rsp.wisc.edu

View Audit 44861 Questioned Costs: $1

Finding 53080 (2022-700)

Significant Deficiency 2022

State of Wisconsin

WI

Equipment & Real Property Management § 200.313

CAP for Finding: 2022-700 Finding 2022-700: Research and Development Cluster?Physical Inventory Requirements for Federal Equipment Planned Corrective Action: The University agrees with the condition that we did not perform a physical inventory of all federal equipment during the period from July 1, ...

CAP for Finding: 2022-700 Finding 2022-700: Research and Development Cluster?Physical Inventory Requirements for Federal Equipment Planned Corrective Action: The University agrees with the condition that we did not perform a physical inventory of all federal equipment during the period from July 1, 2020, through June 30, 2022, because of staffing issues and backlog in the FY 2020-21 physical inventories. Much of the staffing issues were related to Covid-19 both physical availability and turnover. As operations have since normalized, we do not believe a corrective action plan to our procedures is needed. However, we do recognize that we need to catch up on the backlog of inventory. Since June 30, 2022, Property Control has hired three new employees and is now fully staffed. We are in the middle of conducting the FY 2022-23 physical inventories. We selected 45 departments and a total of 6089 assets. Of the total asset count 5295 were federal equipment, which is 62% of all federal equipment for FY 2022-23. We have received 19 departments? inventory submissions and have completed 4 of them. The Property Control team along with campus staff are working diligently to get these inventories completed by year-end June 30, 2023. We have every confidence that rest of the 38% of federal equipment will be inventoried as required under 2 CFR s. 200.313 (d) (2) by fiscal year end 2024. Anticipated Completion Date: 6/30/2024 Person responsible for corrective action: Cha Ying Lor, Finance Associate Director Division of Business Services Accounting Services ? Financial Information Management chaying.lor@wisc.edu

View Audit 44861

Finding 53079 (2022-300)

None 2022

State of Wisconsin

WI

Questioned Costs Allowable Costs / Cost Principles § 200.402 § 200.403

CAP for Finding: 2022-300 DATE: March 20, 2023 TO: Erin Scharlau, Financial Audit Director Legislative Audit Bureau FROM: Barry Kasten, Director Bureau of Fiscal Services Department of Health Services SUBJECT: Corrective Action Plan ? Disaster Grants ? Public Assistance (Presidentially Declared Disa...

CAP for Finding: 2022-300 DATE: March 20, 2023 TO: Erin Scharlau, Financial Audit Director Legislative Audit Bureau FROM: Barry Kasten, Director Bureau of Fiscal Services Department of Health Services SUBJECT: Corrective Action Plan ? Disaster Grants ? Public Assistance (Presidentially Declared Disasters) ? Unallowable Costs Department staff has reviewed the Legislative Audit Bureau?s (LAB) interim audit memo for Finding 2022-300: Disaster Grants ? Public Assistance (Presidentially Declared Disasters) ? Unallowable Costs. This is the department?s Corrective Action Plan. ? Recommendation (2022-300): Disaster Grants ? Public Assistance (Presidentially Declared Disasters) ? Unallowable Costs We recommend the Wisconsin Department of Health Services: ? Work with the federal government to resolve the $855,368 in unallowable costs we identified. Wisconsin Department of Health Services Planned Corrective Action: DHS will reach out to the federal government as suggested to resolve this issue. Anticipated Completion Date: June 30, 2023 Person responsible for corrective action: Barry Kasten, Director Bureau of Financial Services, Division of Enterprise Services barry.kasten@dhs.wisconsin.gov

View Audit 44861 Questioned Costs: $1

Finding 53058 (2022-001)

Significant Deficiency 2022

State of Wisconsin

WI

Questioned Costs Significant Deficiency

CAP for Finding: 2022-001 DATE: November 16, 2022 TO: Lisa Kasel, Assistant Financial Audit Director Legislative Audit Bureau FROM: Barry Kasten, Director Bureau of Fiscal Services Department of Health Services SUBJECT: Corrective Action Plan ? Medical Assistance Program Third-Party Liability Depart...

CAP for Finding: 2022-001 DATE: November 16, 2022 TO: Lisa Kasel, Assistant Financial Audit Director Legislative Audit Bureau FROM: Barry Kasten, Director Bureau of Fiscal Services Department of Health Services SUBJECT: Corrective Action Plan ? Medical Assistance Program Third-Party Liability Department staff has reviewed the Legislative Audit Bureau?s (LAB) interim audit memo for Finding 2022-001: Medical Assistance Program Third-Party Liability. This is the department?s Corrective Action Plan. ? Recommendation (2022-001): Medical Assistance Program Third-Party Liability We recommend the Wisconsin Department of Health Services: ? Review and update the Medicaid Management Information System cost avoidance rules to properly identify and deny payment for claims that may be covered by third-party insurers. Wisconsin Department of Health Services Planned Corrective Action: DHS has completed an assessment of Medicaid Management Information System (MMIS) cost avoidance rules and will implement changes by December 31, 2022, necessary to properly identify and deny outpatient services when a participant is enrolled in Medicare or other third-party insurance at the time the service was provided. We recommend the Wisconsin Department of Health Services: ? Identify payments made during FY 2021-22 that may have been improper due to inaccurate cost avoidance rules and seek to recover these amounts; ? Return to the federal government recovered payment that may have been improper; and Wisconsin Department of Health Services Planned Corrective Action: DHS will attempt to recover $1,956 in improper payments for outpatient services not properly identified and denied under cost avoidance rules in MMIS by December 31, 2022, and return to the federal government the estimated federal share of $1,293. DHS will complete an assessment and identify paid claims by March 31, 2023, where cost avoidance rules were not appropriately applied for outpatient services when a participant was enrolled in Medicare or other third-party insurance with a date of service after July 1, 2021, and return to the federal government recovered payments that were improper. We recommend the Wisconsin Department of Health Services: ? Perform an assessment and implement additional procedures to review changes to cost avoidance rules in the future. Wisconsin Department of Health Services Planned Corrective Action: DHS will implement processes and procedures by December 31, 2022, for conducting production validation on any configuration changes impacting cost avoidance rules. Anticipated Completion Date: March 31, 2023 Person responsible for corrective action: Nick Havens, Director Bureau of System Management, Division of Medicaid Services Nicholas.Havens@dhs.wisconsin.gov

View Audit 44861 Questioned Costs: $1

Finding 53056 (2022-301)

None 2022

State of Wisconsin

WI

Questioned Costs Allowable Costs / Cost Principles § 200.516

CAP for Finding: 2022-301 DATE: March 21, 2023 TO: Lisa Kasel, Assistant Financial Audit Director Legislative Audit Bureau FROM: Barry Kasten, Director Bureau of Fiscal Services Department of Health Services SUBJECT: Corrective Action Plan ? Medical Assistance Program ? Home and Community-Based Serv...

CAP for Finding: 2022-301 DATE: March 21, 2023 TO: Lisa Kasel, Assistant Financial Audit Director Legislative Audit Bureau FROM: Barry Kasten, Director Bureau of Fiscal Services Department of Health Services SUBJECT: Corrective Action Plan ? Medical Assistance Program ? Home and Community-Based Services Unallowable Costs Department staff has reviewed the Legislative Audit Bureau?s (LAB) interim audit memo for Finding 2022-301: Medical Assistance Program ? Home and Community-Based Services Unallowable Costs. This is the department?s Corrective Action Plan. ? Recommendation (2022-301): Medical Assistance Program ? Home and Community-Based Services Unallowable Costs We recommend the Wisconsin Department of Health Services: ? work with the fiscal employer agency that improperly approved the payment we identified to determine how this payment was made, assess whether changes to current processes are needed, document its assessment, and implement corrective actions, as appropriate. Wisconsin Department of Health Services Planned Corrective Action: Based on the LAB findings, the DMS Bureau of Quality and Oversight (BQO) will implement a Corrective Action Plan (CAP) with the IRIS Fiscal Employer Agent (FEA), iLIFE. A review of the LAB findings indicates that iLIFE inadvertently issued a payment to an IRIS participant-hired worker (PHW) based on a service authorization associated with a participant that the PHW did not support. The IRIS provider agreement indicates that FEA?s are responsible for verifying invoices, timesheets, and other claims for payment for services and periods of time authorized by participants? service plans. iLIFE indicated their system?s optical character recognition (OCR) misread a PHW?s employee identification number causing the payment to be sent to the wrong PHW resulting in an overpayment. iLIFE will be required to fix their OCR and review process to complete the CAP. BQO will issue a CAP notification to iLIFE by March 27, 2023. BQO will work with iLIFE to ensure the system errors are corrected to prevent further occurrences and anticipates the CAP will remain open for approximately 6 months. Anticipated Completion Date: September 2023 Person responsible for corrective action: Ann Lamberg, Deputy Director Bureau of Quality and Oversight, Division of Medicaid Services ann.lamberg@dhs.wisconsin.gov

View Audit 44861 Questioned Costs: $1

Finding 53055 (2022-104)

Significant Deficiency 2022

State of Wisconsin

WI

Subrecipient Monitoring Reporting Significant Deficiency

CAP for Finding: 2022-104 Auditor Recommendation: Improve Federal Funding Accountability and Transparency Act reporting procedures to ensure accurate award information, including the federal award identification number, is being used. Planned Corrective Action: The Wisconsin Department of Administra...

CAP for Finding: 2022-104 Auditor Recommendation: Improve Federal Funding Accountability and Transparency Act reporting procedures to ensure accurate award information, including the federal award identification number, is being used. Planned Corrective Action: The Wisconsin Department of Administration?s (Department or DOA) Bureau of Financial Management (BFM) and Division of Energy, Housing and Community Resources (DEHCR) will work together to implement procedures to ensure the accuracy of the award information that is transmitted to the Division of Executive Budget and Finance (DEBF), Systems, Operations and Federal Funds Team (Federal Funds Team) for Federal Funding Accountability and Transparency Act (FFATA) reporting. The procedures may include, among other things, DEHCR?s provision of the federal award document containing the federal award identification number (FAIN) to BFM concurrent with the request to establish the award for reporting. Anticipated Completion Date: June 30, 2023 Auditor Recommendation: Improve Federal Funding Accountability and Transparency Act reporting procedures to ensure rejected subaward information is reviewed and communicated to the appropriate program staff for investigation and resolution. Planned Corrective Action: The Department will improve FFATA reporting procedures to ensure rejected subaward information is reviewed and communicated to the appropriate program staff for investigation and resolution. DEBF?s Federal Funds Team will communicate error messages it receives for rejected reports in a timely manner to agency and program staff originating the reports, and the error log received from the FFATA Subaward Reporting System (FSRS) will be made available electronically for agency program staff as well as maintained for documentation purposes. Anticipated Completion Date: June 30, 2023 Auditor Recommendation: Improve Federal Funding Accountability and Transparency Act reporting procedures to ensure documentation of rejected subaward information is maintained to demonstrate that the Department of Administration attempted to enter the subaward information; and Planned Corrective Action: The Department will improve FFATA reporting procedures to ensure documentation of rejected subaward information is maintained to demonstrate that the Department attempted to enter the subaward information in FSRS. As previously noted, the Federal Funds Team will communicate to agency and program staff the error messages received for rejected reports and make available and maintain for archival purposes error logs received from FSRS. Additionally, the Federal Funds Team will record in the Wisconsin FFATA reporting system if an upload of the subaward information cannot be completed during the intended reporting period due to reasons that are beyond its control, such as delays in the federal government?s assignment of federal award identification numbers (FAINs) for new grant awards. Anticipated Completion Date: June 30, 2023 Auditor Recommendation: Improve Federal Funding Accountability and Transparency Act reporting procedures to ensure all required subawards of $30,000 or more, including any amendments or modifications to a subaward, are identified and submitted to the Federal Funding Accountability and Transparency Act Subaward Reporting System in a timely manner. Planned Corrective Action: The Department takes seriously its responsibility to ensure all required subawards of $30,000 or more, including any amendments or modifications to a subaward, are identified and submitted to FSRS in a timely manner. The Federal Funds Team in fulfilling its enterprise role related to FSRS reporting, delivered agency and program staff training on the requirements of 2 CFR s. 170, in February 2023, concurrent with the introduction of its new Wisconsin FFATA reporting system, and will highlight FFATA reporting requirements in its monthly reporting timeline communications. As previously noted, BFM and DEHCR will work together to implement improved procedures to ensure the accuracy of the award information that is transmitted to DEBF. They will also implement procedures to verify the completeness of the data that is uploaded to FSRS, including confirming the availability of the data in USAspending.gov. Anticipated Completion Date: June 30, 2023 Persons responsible for corrective action: Susan Brown, Administrator Division of Energy, Housing and Community Resources susan.brown@wisconsin.gov Colleen Holtan, Director Bureau of Financial Management Division of Enterprise Operations colleen.holtan@wisconsin.gov Dustin Trickle, Executive Policy and Budget Manager Division of Executive Budget and Finance dustin.trickle1@wisconsin.gov

View Audit 44861

Finding 53053 (2022-101)

Significant Deficiency 2022

State of Wisconsin

WI

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

CAP for Finding: 2022-101 Auditor Recommendation: Establish and implement written procedures for making updates to the benefit calculation parameters in the Home Energy (HE) Plus application. Planned Corrective Action: The Wisconsin Department of Administration (Department or DOA) will establish and...

CAP for Finding: 2022-101 Auditor Recommendation: Establish and implement written procedures for making updates to the benefit calculation parameters in the Home Energy (HE) Plus application. Planned Corrective Action: The Wisconsin Department of Administration (Department or DOA) will establish and implement written procedures for entering and updating the benefit calculation parameters related to the Wisconsin Home Energy Assistance Program (WHEAP) in the HE Plus (HE+) System. The Department?s procedures will reflect that it incorporated a module for determining the LIHEAP heating maximum benefit in the HE+ System and eliminated the use of an external Microsoft Access database for that purpose subsequent to the period under audit (i.e., in state fiscal year [SFY] 2022-23). Anticipated Completion Date: May 1, 2023 Auditor Recommendation: Reassess its existing procedures for performing a review of the benefit calculation parameters entered into the Home Energy (HE) Plus application, make adjustments to its existing procedures as necessary, and document the performance of each review. Planned Corrective Action: The Department necessarily reassessed its procedures for reviewing the entry of benefit calculation parameters into the HE+ System when it incorporated a module for determining the LIHEAP heating maximum benefit in the HE+ System and eliminated the use of an external Microsoft Access database for that purpose subsequent to the period under audit (i.e., in state fiscal year [SFY] 2022-23). The development and implementation of the new system functionality, which was used for the determining the federal fiscal year (FFY) 2023 WHEAP program benefits, improved program integrity through the elimination of manual data entry of end result benefit factors and proxy values. Program integrity will be further strengthened through the creation of a form to document the review of the benefit calculation parameters entered into HE+. The form will be created by May 1, 2023, and implemented with the FFY24 benefit formula calculation scheduled to be completed in July 2023. Anticipated Completion Date: May 1, 2023 Auditor Recommendation: Complete its review of the 605 households that were underpaid heating benefits due to the error and issue supplemental heating benefit payments. Planned Corrective Action: DOA completed its review of the households that were underpaid heating benefits and will issue the supplemental heating benefit payments as soon as practical. Anticipated Completion Date: June 30, 2023 Person responsible for corrective action: Susan Brown, Administrator Division of Energy, Housing and Community Resources susan.brown@wisconsin.gov

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Finding 53042 (2022-303)

Significant Deficiency 2022

State of Wisconsin

WI

Subrecipient Monitoring Procurement, Suspension & Debarment Reporting

CAP for Finding: 2022-303 DATE: March 21, 2023 TO: Lisa Kasel, Assistant Financial Audit Director Legislative Audit Bureau FROM: Barry Kasten, Director Bureau of Fiscal Services Department of Health Services SUBJECT: Corrective Action Plan ? Federal Funding Accountability and Transparency Act Report...

CAP for Finding: 2022-303 DATE: March 21, 2023 TO: Lisa Kasel, Assistant Financial Audit Director Legislative Audit Bureau FROM: Barry Kasten, Director Bureau of Fiscal Services Department of Health Services SUBJECT: Corrective Action Plan ? Federal Funding Accountability and Transparency Act Reporting ? Immunization Cooperative Agreements Department staff has reviewed the Legislative Audit Bureau?s (LAB) interim audit memo for Finding 2022-303: Federal Funding Accountability and Transparency Act Reporting ? Immunization Cooperative Agreements. This is the department?s Corrective Action Plan. ? Recommendation (2022-303): Federal Funding Accountability and Transparency Act Reporting? Immunization Cooperative Agreements We recommend the Wisconsin Department of Health Services: ? Update the queries used to identify subawards in the State?s accounting system, STAR, that are subject to Federal Funding Accountability and Transparency Act reporting to ensure all required subawards are identified; and ? Ensure all required subwards of $30,000 or more, including any amendments or modifications to a subaward, are identified and submitted to the Federal Fund Accountability and Transparency Act Subaward Reporting System in a timely manner. Wisconsin Department of Health Services Planned Corrective Action: BFS agrees that the circumstances shaped by the COVID emergency required BFS to prioritize tasks critical to essential functions over those with little to no financial impact. Furthermore, during this same period, there was turnover in this position. Lack of priority and new staffing led to late reporting. Additionally, procedural misunderstandings contributed to continued reporting delays of the correcting items identified in the first finding. The summer and early Fall of 2022 allowed for additional research, clarification, and catching up. Since November of 2022 there have been timely monthly uploads of collected data and it has continued to be reported monthly. BFS also agrees that LAB identified several contracts not yet reported. Upon discovery, BFS made it a priority to take steps necessary to immediately report the missing contracts on the FSRS site. Investigations into the missing contracts revealed that there was an issue with the query being used to pull the STAR data. Investigations into the CARS query led to discovery of the incorrect usage of the date parameters. DHS will correct the query errors and modify the FFATA procedures for accurate, complete, and timely reporting. Anticipated Completion Date: May 2023 Person responsible for corrective action: Vanessa Salata, Section Chief Expenditure Accounting Section Chief, Bureau of Fiscal Services, Division of Enterprise Services vanessaa.salata@dhs.wisconsin.gov

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Corrective Action Plans

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