Corrective Action Plans

Finding 565451 (2024-019)

Material Weakness 2024

MA

Subrecipient Monitoring Material Weakness Reporting § 200.303

DEPARTMENT OF PUBLIC HEALTH 2024-019 Immunization Cooperative Agreements, COVID-19 - Immunization Cooperative Agreements - Assistance Listing No. 93.268 Recommendation: We recommend the Department complete implementation of its corrective action plan from the prior audit. It should establish procedu...

DEPARTMENT OF PUBLIC HEALTH 2024-019 Immunization Cooperative Agreements, COVID-19 - Immunization Cooperative Agreements - Assistance Listing No. 93.268 Recommendation: We recommend the Department complete implementation of its corrective action plan from the prior audit. It should establish procedures and internal controls to ensure that all required subawards are reported timely and accurately to the FSRS no later than the end of the month following the month of issuance of each subaward. Action taken in response to finding: The Bureau of Infectious Disease and Laboratory Sciences (BIDLS) will put in place starting August 1, 2025 a process to review obligations for subawards under Immunization, Assistance Listing No. 93.268 to identify subawards that fall under the rules set forth by Federal Funding Accountability and Transparency Act (FFATA) and report the appropriate obligations to FSRS according to the above-mentioned recommendations. Name(s) of the contact person(s) responsible for corrective action: Cheryl Bernard-Dort, Director of Administration and Finance, BIDLS Planned completion date for corrective action plan: 9/30/25

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Finding 565448 (2024-018)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring § 200.303 § 200.332

EXECUTIVE OFFICE OF ELDER AFFAIRS 2024-018 Aging Cluster - Assistance Listing No. 93.044, 93.045, 93.053 Recommendation: The Department should review and enhance internal controls and procedures to ensure that it obtains subrecipients’ unique entity identifiers and that all required information is i...

EXECUTIVE OFFICE OF ELDER AFFAIRS 2024-018 Aging Cluster - Assistance Listing No. 93.044, 93.045, 93.053 Recommendation: The Department should review and enhance internal controls and procedures to ensure that it obtains subrecipients’ unique entity identifiers and that all required information is included in all subaward agreements. Action taken in response to finding: AGE establishes contracts in accordance with MA Comptroller guidelines, which do not require the specified unique entity identifiers. However, in accordance with Federal Guidance, AGE will update all entries related to subrecipients to capture this information going forward. This requirement will be added to AGE’s internal control plan, specifically the section on federal grants management and compliance. Name(s) of the contact person(s) responsible for corrective action: Sheila Tunney, CFO Planned completion date for corrective action plan: 9/30/2025

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Finding 565445 (2024-017)

Significant Deficiency 2024

Commonwealth of Massachusetts

MA

Matching / Level of Effort / Earmarking § 200.303

EXECUTIVE OFFICE OF ELDER AFFAIRS 2024-017 Aging Cluster - Assistance Listing No. 93.044, 93.045, 93.053 Recommendation: The Department should review and enhance internal controls and procedures to ensure that the earmark calculation is reviewed and approved by program management. Action taken in ...

EXECUTIVE OFFICE OF ELDER AFFAIRS 2024-017 Aging Cluster - Assistance Listing No. 93.044, 93.045, 93.053 Recommendation: The Department should review and enhance internal controls and procedures to ensure that the earmark calculation is reviewed and approved by program management. Action taken in response to finding: AGE will implement a review and sign off form for the earmark calculation when it is developed annually. This requirement will be added to AGE’s internal control plan, specifically the section on federal grants management and compliance. Name(s) of the contact person(s) responsible for corrective action: Sheila Tunney, CFO Planned completion date for corrective action plan: 9/30/2025

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Finding 565442 (2024-016)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Material Weakness Reporting § 200.303

EXECUTIVE OFFICE OF ELDER AFFAIRS 2024-016 Aging Cluster - Assistance Listing No. 93.044, 93.045, 93.053 Recommendation: We recommend the Department develop procedures and internal controls to ensure that all required subawards are reported timely and accurately to FSRS no later than the end of the...

EXECUTIVE OFFICE OF ELDER AFFAIRS 2024-016 Aging Cluster - Assistance Listing No. 93.044, 93.045, 93.053 Recommendation: We recommend the Department develop procedures and internal controls to ensure that all required subawards are reported timely and accurately to FSRS no later than the end of the month following the month of issuance of each subaward. Action taken in response to finding: AGE has developed a form to attach to all relevant contracts to capture required reporting requirements and will implement a calendar of reporting deadlines to the AGE internal control plan, specifically the section regarding federal grants management. Name(s) of the contact person(s) responsible for corrective action: Sheila Tunney, CFO Planned completion date for corrective action plan: 9/30/2025

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Finding 565439 (2024-015)

Significant Deficiency 2024

Commonwealth of Massachusetts

MA

Matching / Level of Effort / Earmarking § 200.303

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-015 WIOA Cluster - Assistance Listing No. 17.258, 17.259, 17.278 Recommendation: We recommend the Department review and enhance its controls over reporting earmarking requirements to ensure that reports are accurate and compliant, and that doc...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-015 WIOA Cluster - Assistance Listing No. 17.258, 17.259, 17.278 Recommendation: We recommend the Department review and enhance its controls over reporting earmarking requirements to ensure that reports are accurate and compliant, and that documentation is maintained and readily available for audit. Action taken in response to finding: Beginning in FY26, phase codes associated with federal grant activity will be further disaggregated and mapped in MMARS screen BQ87 (Federal Grant Phase Budget Status). This enhancement will improve the accuracy and clarity of budget-to-actual comparisons by providing a clearer breakout of expenditures by phase. It will also strengthen internal controls and facilitate better alignment between MMARS, Finance Data Mart, and federal reporting requirements. Finance and DCS will continue to conduct joint reviews of the earmarks each quarter to ensure accuracy and allowability. Name(s) of the contact person(s) responsible for corrective action: Sarah Shannon, Ken Luke, Dave Manning Planned completion date for corrective action plan: 12/31/2025

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Finding 565436 (2024-014)

Significant Deficiency 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring § 200.303 § 200.332

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-014 WIOA Cluster - Assistance Listing No. 17.258, 17.259, 17.278 Recommendation: We recommend the Department review and enhance internal controls and procedures to ensure that required information is included in its subawards. Action taken in ...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-014 WIOA Cluster - Assistance Listing No. 17.258, 17.259, 17.278 Recommendation: We recommend the Department review and enhance internal controls and procedures to ensure that required information is included in its subawards. Action taken in response to finding: The MassHire Department of Career Services (MHDCS) has reviewed, enhanced, and revised its documented internal controls and procedures to ensure that required award information is included and provided to its sub awardees through its formal submitted documentation. Name(s) of the contact person(s) responsible for corrective action: Michael Williams- Director of MHDCS Field Management & Oversight Planned completion date for corrective action plan: MHDCS partially implemented the above referenced internal control procedures on 12/30/22, prior to the end of Fiscal Year 2023. This procedure was fully implemented on 7/1/23 (the beginning of Fiscal Year ’24). MHDCS continues the process currently in FY 2025. MHDCS has revised all Financial/Fiscal related documentation (i.e., Budget Sheets, Contracts) for sub awardees to include the Federal Award Identification Number (FAIN) identifier, Federal award date as well as the Unique Entity Identifier (UEI) and the documented internal procedures as recommended through this audit finding. The FAIN and UEI numbers are consistently included on all budget sheets, contracts and contract modifications submitted to the EOLWD Budget and Finance department for processing and submission to each local entity or sub awardee.

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Finding 565433 (2024-013)

Significant Deficiency 2024

Commonwealth of Massachusetts

MA

Allowable Costs / Cost Principles § 200.303 § 200.430

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-013 WIOA Cluster - Assistance Listing No. 17.258, 17.259, 17.278 Recommendation: The Department should update its procedures and controls and perform additional training over time and effort reporting to ensure that payroll costs charged to th...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-013 WIOA Cluster - Assistance Listing No. 17.258, 17.259, 17.278 Recommendation: The Department should update its procedures and controls and perform additional training over time and effort reporting to ensure that payroll costs charged to the program are based on actual time and effort and a combination code that is allowable under the program. The Department should not seek federal reimbursement unless it can substantiate that the time and effort was dedicated to the federal program. Action taken in response to finding: EOLWD Finance continues to address time and effort reporting compliance through targeted training and system enhancements. Ongoing training is provided for new staff to ensure they correctly enter combo codes that align with the activities performed. To strengthen oversight, a custom report has been developed to identify employees missing combo codes each week, allowing Finance staff to proactively follow up and ensure proper time charging weekly. Looking ahead, Finance will collaborate with departments in the upcoming fiscal year to update labor distribution profiles, ensuring that employees are defaulted to the correct combo codes for accurate and efficient time reporting. Name(s) of the contact person(s) responsible for corrective action: Sarah Shannon, Ken Luke, Anna Yong, Vina Yung Planned completion date for corrective action plan: 12/31/2025

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Finding 565430 (2024-012)

Significant Deficiency 2024

Commonwealth of Massachusetts

MA

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.403

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-012 WIOA Cluster - Assistance Listing No. 17.258, 17.259, 17.278 Recommendation: We recommend the Agency review and enhance procedures and controls to ensure that costs charged to the program are allowable, approved, and accounted for properly...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-012 WIOA Cluster - Assistance Listing No. 17.258, 17.259, 17.278 Recommendation: We recommend the Agency review and enhance procedures and controls to ensure that costs charged to the program are allowable, approved, and accounted for properly in the Commonwealth’s accounting system. Action taken in response to finding: During the review, supporting documentation for certain expenditure adjustments (EX) could not be located. Since then, the department has taken steps to strengthen internal controls and improve documentation practices. Under new management, enhanced oversight procedures have been implemented, requiring all expenditure adjustments to undergo review and approval by multiple levels of management and staff. To ensure transparency and audit readiness, all supporting documentation is now stored in a centralized and accessible SharePoint repository. Additionally, revised procedures are being integrated into the department's standard operating protocols to support ongoing monitoring. These updates are designed to ensure that all future adjustments are properly documented, allowable under applicable federal regulations, and readily available for review. Name(s) of the contact person(s) responsible for corrective action: Ken Luke Planned completion date for corrective action plan: 9/30/2025

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Finding 565427 (2024-011)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Material Weakness Reporting Matching / Level of Effort / Earmarking § 200.303

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-011 WIOA Cluster - Assistance Listing No. 17.258, 17.259, 17.278 Recommendation: The Department should review its procedures to ensure that ETA 9130 reports are accurate and agree with supporting documentation. We further recommend that intern...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-011 WIOA Cluster - Assistance Listing No. 17.258, 17.259, 17.278 Recommendation: The Department should review its procedures to ensure that ETA 9130 reports are accurate and agree with supporting documentation. We further recommend that internal controls are enhanced to ensure that reports are reviewed for accuracy prior to submission. Action taken in response to finding: This issue occurred during a period when the preparation and submission of the ETA 9130 reports were handled by a single staff member without peer review. The lack of internal checks and collaborative review contributed to the inaccuracies. With new management and restructured team now in place, we have implemented and strengthened review processes. Moving forward, ETA 9130 reports will be jointly reviewed by Finance and program staff before submission and certification. Supporting documentation will be cross-checked for accuracy and completeness, and all relevant files will be maintained in a centralized, shared folder to ensure transparency and accountability. This multi-layered review and documentation process will be incorporated into standard quarterly reporting procedures to prevent future discrepancies and ensure federal reporting integrity. Name(s) of the contact person(s) responsible for corrective action: Sarah Shannon, Ken Luke, Vina Yung Planned completion date for corrective action plan: 8/30/2025

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Finding 565424 (2024-010)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Material Weakness Reporting § 200.303

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-010 WIOA Cluster - Assistance Listing No. 17.258, 17.259, 17.278 Recommendation: The Department should implement procedures and internal controls to ensure that all required subawards are reviewed, approved and subsequently reported timely to ...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-010 WIOA Cluster - Assistance Listing No. 17.258, 17.259, 17.278 Recommendation: The Department should implement procedures and internal controls to ensure that all required subawards are reviewed, approved and subsequently reported timely to FSRS no later than the end of the month following the month of issuance. Documentation of implemented controls should be readily available for auditors. Action taken in response to finding: EOLWD Finance has finalized a Standard Operating Procedure (SOP) to ensure compliance with the Federal Funding Accountability and Transparency Act (FFATA) reporting requirements. FFATA reporting as of FY 2025 has been transitioned to SAM.gov, providing a more streamlined and user-friendly platform for managing and tracking subaward reporting. To support timely submissions, a calendar reminder has been implemented to prompt monthly checks of reporting activity. The next phase of implementation will focus on expanding staff training to ensure more team members are equipped to complete FFATA reporting tasks accurately and efficiently. Ongoing monitoring will continue to ensure reporting remains timely and accurate, with periodic reviews conducted to assess performance and identify any needed updates to the SOP. Name(s) of the contact person(s) responsible for corrective action: Sarah Shannon, Ken Luke Planned completion date for corrective action plan: 9/30/2025

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Finding 565422 (2024-006)

Significant Deficiency 2024

Commonwealth of Massachusetts

MA

Special Tests & Provisions Eligibility Reporting § 200.303

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT Unemployment Insurance, COVID-19 – Unemployment Insurance - Assistance Listing No. 17.225 Recommendation: We recommend the Department review and enhance procedures and controls to ensure that RESEA program requirements are met. We further recommend...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT Unemployment Insurance, COVID-19 – Unemployment Insurance - Assistance Listing No. 17.225 Recommendation: We recommend the Department review and enhance procedures and controls to ensure that RESEA program requirements are met. We further recommend the Department develop a formal process to review quarterly performance reports for accuracy prior to submission. Action taken in response to finding: MDUA’s legacy system had a known issue with maintaining documents. In some instances, the legacy system did not keep a copy of correspondence. In May 2025, MDUA implemented a new, modernized UI administrative system known as EMT. During the integration process, memorializing documents the system generated was a priority. Now with a fully implemented system, all documents will be saved. In addition, the RESEA program has a required reporting standard administered through the federal SUN system. Although MDUA has an established process for completing this work, MDUA does not have an audit trail to show it was completed. Moving forward, MDUA will enhance this procedure to ensure MDUA has documentation to maintain compliance. Name(s) of the contact person(s) responsible for corrective action: John Saulnier, Director of Benefit Performance Planned completion date for corrective action plan: 9/30/2025

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Finding 565420 (2024-005)

Significant Deficiency 2024

Commonwealth of Massachusetts

MA

Special Tests & Provisions Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-005 Unemployment Insurance, COVID-19 – Unemployment Insurance - Assistance Listing No. 17.225 Recommendation: We recommend the Department review and enhance procedures and controls to ensure that BAM case investigations are completed timely in...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-005 Unemployment Insurance, COVID-19 – Unemployment Insurance - Assistance Listing No. 17.225 Recommendation: We recommend the Department review and enhance procedures and controls to ensure that BAM case investigations are completed timely in accordance with the time limits established in the ET Handbook No. 395. Action taken in response to finding: Analysis showed that BAM Investigators spend a minimum of 20% of work hours devoted to clerical tasks necessary to develop an investigatory file. As part of MDUA’s modernized UI system, the new system features an electronic BAM casefile which should reduce clerical work 5% or below, and, in turn, allow additional time to investigate and complete case work. BAM has always relied on postal mail as a primary methodology to contact interested persons. By integrating the BAM casefile into the UI system, investigators can send questionnaires and notifications to interested persons through the system. In turn, interested persons may complete questionnaires and upload information into the system thereby reducing time between issuance of documents and response. Name(s) of the contact person(s) responsible for corrective action: Susan Saulnier, Director of UI Performs Planned completion date for corrective action plan: June 2026 This statistic is compiled for a year of data. Because BAM was not an on-line program, all cases prior to May 18, 2025 remain in the old format, and, therefore were not placed in the new system. As of May 19, 2025 and moving forward, all BAM cases will be held in the electronic case file. By June 2026, MDUA will have a year of data with improvements to BAM investigative methodology.

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Finding 565418 (2024-009)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Reporting § 200.303

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-009 Employment Service Cluster - Assistance Listing No. 17.207, 17.801 Recommendation: We recommend the Department implement its corrective action plan from the prior year. Procedures and internal controls over reporting should be sufficient t...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-009 Employment Service Cluster - Assistance Listing No. 17.207, 17.801 Recommendation: We recommend the Department implement its corrective action plan from the prior year. Procedures and internal controls over reporting should be sufficient to ensure that reports are accurate and supported by documentation. Action taken in response to finding: Finance has developed a new Expenditure Detail Report (EDR) with their internal Finance Data Mart. This new report is designed to mirror the structure of federal quarter filings and improve the traceability between reported expenditures and source documentation. Beginning in FY26, phase codes associated with federal grant activity will be further disaggregated and mapped in MMARS screen BQ87 (Federal Grant Phase Budget Status). This enhancement will improve the accuracy and clarity of budget-to-actual comparisons by providing a clearer breakout of expenditures by phase. It will also strengthen internal controls and facilitate better alignment between MMARS, Finance Data Mart, and federal reporting requirements. Finance and DCS will continue to conduct joint reviews of the EDR each quarter to ensure data consistency across systems and compliance with federal reporting standards. Name(s) of the contact person(s) responsible for corrective action: Sarah Shannon, Ken Luke, Vina Yung, Sacha Stadhard Planned completion date for corrective action plan: 12/31/2025

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Finding 565416 (2024-008)

None 2024

Commonwealth of Massachusetts

MA

Matching / Level of Effort / Earmarking § 200.303

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-008 Employment Service Cluster - Assistance Listing No. 17.207, 17.801 Recommendation: We recommend the Department develop and document internal controls over reporting earmarking requirements to ensure that reports are accurate and that earma...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-008 Employment Service Cluster - Assistance Listing No. 17.207, 17.801 Recommendation: We recommend the Department develop and document internal controls over reporting earmarking requirements to ensure that reports are accurate and that earmarking requirements are met. Action taken in response to finding: EOLWD Finance has developed a new Expenditure Detail Report (EDR) within their internal Finance Data Mart. This new report is designed to mirror the structure of federal quarter filings and improve the traceability between reported expenditures and source documentation. Beginning in FY26, phase codes associated with federal grant activity will be further disaggregated and mapped in MMARS screen BQ87 (Federal Grant Phase Budget Status). This enhancement will improve the accuracy and clarity of budget-to-actual comparisons by providing a clearer breakout of expenditures by phase. It will also strengthen internal controls and facilitate better alignment between MMARS, Finance Data Mart, and federal reporting requirements. Finance and DCS will continue to conduct joint reviews of the EDR each quarter to ensure data consistency across systems and compliance with federal reporting standards. Name(s) of the contact person(s) responsible for corrective action: Dave Manning and Ken Luke Planned completion date for corrective action plan: 12/31/2025

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Finding 565414 (2024-007)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Material Weakness Reporting § 200.303

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-007 Employment Service Cluster - Assistance Listing No. 17.207, 17.801 Recommendation: The Department should implement procedures and internal controls to ensure that all required subawards are reviewed, approved, and subsequently timely submi...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-007 Employment Service Cluster - Assistance Listing No. 17.207, 17.801 Recommendation: The Department should implement procedures and internal controls to ensure that all required subawards are reviewed, approved, and subsequently timely submitted to FSRS no later than the end of the month following the month of issuance. Documentation of implemented controls should be readily available for auditors. Action taken in response to finding: EOLWD Finance needs to update the Standard Operating Procedure (SOP) to ensure compliance with the Federal Funding Accountability and Transparency Act (FFATA) reporting requirements. FFATA reporting as of FY 2025 has been transitioned to SAM.gov, providing a more streamlined and user-friendly platform for managing and tracking subaward reporting. To support timely submissions, a calendar reminder has been implemented to prompt monthly checks of reporting activity. The next phase of implementation will focus on expanding staff training to ensure more team members are equipped to complete FFATA reporting tasks accurately and by establishing a more accurate subaward report. Ongoing monitoring will continue to ensure reporting remains timely and accurate, with periodic reviews conducted to assess performance and identify any needed updates to the SOP. Name(s) of the contact person(s) responsible for corrective action: Sarah Shannon, Ken Luke Planned completion date for corrective action plan: 9/30/2025

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Finding 565412 (2024-004)

Significant Deficiency 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring § 200.303 § 200.332

DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION 2024-004 Child and Adult Care Food Program - Assistance Listing No. 10.558 Recommendation: The Department should review and enhance internal controls and procedures to ensure that required information is obtained prior to entering into a subrecipient ...

DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION 2024-004 Child and Adult Care Food Program - Assistance Listing No. 10.558 Recommendation: The Department should review and enhance internal controls and procedures to ensure that required information is obtained prior to entering into a subrecipient agreement. Action taken in response to finding: The Office for Food and Nutrition Programs (FNP) has confirmed the 19 CACFP subrecipients (out of 327) that either do not have a UEI or have one but has not registered it in SAM.gov. FNP will notify the subrecipients that their federal reimbursements will be put on hold until they take action and provide DESE with sufficient documentation that they have completed the tasks. Name(s) of the contact person(s) responsible for corrective action: Rob Leshin, Director, Food and Nutrition Programs Planned completion date for corrective action plan: July 15, 2025

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Finding 565411 (2024-003)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Special Tests & Provisions Procurement, Suspension & Debarment Eligibility § 200.303

DEPARTMENT OF TRANSITIONAL ASSISTANCE 2024-003 SNAP Cluster - Assistance Listing No. 10.551, 10.561 Recommendation: We recommend the Department review and enhance procedures and controls to ensure that documentation for EBT reconciliations is maintained in accordance with the federal program require...

DEPARTMENT OF TRANSITIONAL ASSISTANCE 2024-003 SNAP Cluster - Assistance Listing No. 10.551, 10.561 Recommendation: We recommend the Department review and enhance procedures and controls to ensure that documentation for EBT reconciliations is maintained in accordance with the federal program requirements. Action taken in response to finding: Starting July 2025, the Accounting Director (or Deputy Accounting Director when hired) will sign and date the reconciliation documentation (and retain) when reviews are performed. The standard operating procedures will be clarified that preparer and reviewer typing their names and date within the reconciliation documentation is an acceptable form of sign-off upon completion of the reconciliations and reviews. Name(s) of the contact person(s) responsible for corrective action: Keivon Spencer, Director of Accounting | DTA Finance Planned completion date for corrective action plan: June 30, 2025 and forward – Sign and date reconciliation reviews October 30, 2025 – Standard operating procedures

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Finding 565408 (2024-001)

Significant Deficiency 2024

Thomas Wilbur Homestead, INC

RI

Reporting § 200.512

DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2024-001: Significant Deficiency - Late Audit Reporting Recommendation: Implement procedures and controls to ensure that future audits are completed and submitted in a timely manner. Action Taken: Management agrees with the auditor's finding and re...

DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2024-001: Significant Deficiency - Late Audit Reporting Recommendation: Implement procedures and controls to ensure that future audits are completed and submitted in a timely manner. Action Taken: Management agrees with the auditor's finding and recommendation. The new Deputy Director of Finance will play a key role in ensuring adherence to audit timelines and enhancing overall reporting efficiency.

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Finding 565406 (2024-008)

Significant Deficiency 2024

Kearsarge Elderly Housing, Inc.

NH

HUD Housing Programs Internal Control / Segregation of Duties

The Director of Affordable Housing did not notice that on the withdrawal approval letter the amount had been changed. The request was sent to the bank with the original amount on it, and the transfer was done at the higher amount. The money was returned to the RFR account on 5-20-2025. Completion...

The Director of Affordable Housing did not notice that on the withdrawal approval letter the amount had been changed. The request was sent to the bank with the original amount on it, and the transfer was done at the higher amount. The money was returned to the RFR account on 5-20-2025. Completion Date: 5/20/2025 Contact: Jill Lesmerises, CFO

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Finding 565404 (2024-007)

Material Weakness 2024

Kearsarge Elderly Housing, Inc.

NH

Please see below the new process regarding filling vacancies and completing management duties in a timely manner: 1. Immediate Focus on Vacancies: We are prioritizing the filling of vacant units by having two staff members complete move ins at the same time. 2. Streamlined Recertification Process...

Please see below the new process regarding filling vacancies and completing management duties in a timely manner: 1. Immediate Focus on Vacancies: We are prioritizing the filling of vacant units by having two staff members complete move ins at the same time. 2. Streamlined Recertification Process: We have updated our process to ensure all tenants are recertified in a timely manner. There has been a new system in place to monitor deadlines and improve efficiency. 3. Staffing and Training: We are actively recruiting and training additional staff to ensure these tasks are handled promptly, preventing future delays. These steps will address the backlog of management duties and ensure that all tasks, such as filling vacancies and completing tenant recertifications, are handled in a timely and efficient manner. Completion Date: 2/1/2025 Contact: Jackie Oliveira-Director of Affordable Housing

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Finding 565402 (2024-006)

Significant Deficiency 2024

Kearsarge Elderly Housing, Inc.

NH

Internal Control / Segregation of Duties Allowable Costs / Cost Principles

The Director of Affordable Housing will ensure that her staff submit allocation sheets each pay period. The Director will review the allocation sheets for accuracy, and the Director will approve the allocation sheets before submitting to Payroll for processing. The Chief Operating Officer will ensu...

The Director of Affordable Housing will ensure that her staff submit allocation sheets each pay period. The Director will review the allocation sheets for accuracy, and the Director will approve the allocation sheets before submitting to Payroll for processing. The Chief Operating Officer will ensure that the Director of Affordable Housing submits an allocation sheet each pay period. The COO will check the allocation sheet for accuracy before approving the allocation sheet and submitting to Payroll for processing. The allocation sheet submitted will include detailed information on the job duties performed during that pay period by the staff member submitting the allocation sheet. Completion Date: 3/28/25 Contact: Jackie Oliveira-Director of Affordable Housing

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Finding 565400 (2024-005)

Significant Deficiency 2024

Kearsarge Elderly Housing, Inc.

NH

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

The Director of Affordable Housing will document job duties for each position in the department. The Director will be sure that staff are recording duties performed on their timesheet. Anticipated Completion Date: 3/28/25 Contact: Jackie Oliveira-Director of Affordable Housing

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Finding 565398 (2024-004)

None 2024

Kearsarge Elderly Housing, Inc.

NH

Please see below the new process regarding hiring additional staff and turnover at Community Action Program Belknap-Merrimack Counties Inc. Due to lack of management, it is understood the importance of having staff training on a regular basis to ensure management and compliance duties can be perf...

Please see below the new process regarding hiring additional staff and turnover at Community Action Program Belknap-Merrimack Counties Inc. Due to lack of management, it is understood the importance of having staff training on a regular basis to ensure management and compliance duties can be performed adequately. Community Action Program Belknap-Merrimack Counties Inc. plans to improve the standards of employee training and will be hosting quarterly trainings on employee responsibilities, performance, and areas for improvement. This includes HUD trainings and keeping up to date on any new HUD policies and procedures. We understand the importance of a well-trained staff. We are committed to our performance and adhering to HUD standards while implementing policies to follow for continuous improvement. Anticipated completion Date: 9/30/2025 Contact: Jackie Oliveira-Director of Affordable Housing

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Finding 565395 (2024-003)

None 2024

Kearsarge Elderly Housing, Inc.

NH

HUD Housing Programs Internal Control / Segregation of Duties

We have reviewed the finding regarding the need for a system ensuring that more than one individual holds an EIV (Enterprise Income Verification) license and that the license does not lapse. We understand the importance of maintaining access to the EIV system and ensuring uninterrupted compliance wi...

We have reviewed the finding regarding the need for a system ensuring that more than one individual holds an EIV (Enterprise Income Verification) license and that the license does not lapse. We understand the importance of maintaining access to the EIV system and ensuring uninterrupted compliance with HUD requirements. In response to this finding, we have taken the following corrective actions: Designating Multiple EIV Users: We have implemented a policy that ensures at least two staff members are trained and hold active EIV access. This provides continuity in the event that one staff member is unavailable or the license needs to be renewed. Tracking License Expiration: We have established a system to track EIV license expiration dates and will proactively initiate renewal processes well in advance of any license lapsing. A reminder system has been set up to notify both the employee holding the license and the supervisor, ensuring that renewals are completed on time. Backup Procedures: In addition, we have documented backup procedures to ensure that another individual with the appropriate access is available to perform EIV-related tasks in case of staff turnover or other absences. Completion Date: 7/1/2024 Contact: Jackie Oliveira-Director of Affordable Housing

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Finding 565394 (2024-002)

Significant Deficiency 2024

Kearsarge Elderly Housing, Inc.

NH

HUD Housing Programs Internal Control / Segregation of Duties

Please see below the new process ensuring that all HUD forms are certified by an authorized user: Tracking System: A system has been implemented to monitor certifier assignments and send reminders for updates. Training & Oversight: Staff training will be enhanced, and management will increase over...

Please see below the new process ensuring that all HUD forms are certified by an authorized user: Tracking System: A system has been implemented to monitor certifier assignments and send reminders for updates. Training & Oversight: Staff training will be enhanced, and management will increase oversight to ensure compliance. Monitoring and Accountability: Management will regularly review the certification process to ensure all forms are signed by the appropriate certifiers and to verify that all necessary updates are made promptly. Completion Date: 7/1/2024 Contact: Jackie Oliveira-Director of Affordable Housing

View Audit 359276

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