Corrective Action Plans

Finding 558468 (2024-013)

Material Weakness 2024

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Special Tests & Provisions Procurement, Suspension & Debarment

Finding: The Washington State Department of Transportation did not have adequate internal controls over and did not comply with requirements to collect certified payrolls from contractors on projects funded by the Highway Planning and Construction program. Questioned Costs: Assistance Listing # ...

Finding: The Washington State Department of Transportation did not have adequate internal controls over and did not comply with requirements to collect certified payrolls from contractors on projects funded by the Highway Planning and Construction program. Questioned Costs: Assistance Listing # 20.205 Amount $0 Status: Corrective action in progress Corrective Action: In July 2020 and November 2024, the Department received management decision letters from the Federal Highway Administration (FHWA) in response to similar findings for the fiscal years 2018, 2019, and 2023, respectively, which stated: • FHWA approved the Department’s Construction Manual and Standard Specifications and confirmed that documented procedures contain the necessary controls to ensure reasonable compliance with 29 CFR 5.5 and the Davis-Bacon and Related Acts. • FHWA agreed that current processes in place are reasonable and satisfy the intent of the Department of Labor’s certified payroll requirements. • Ensuring all certified payrolls are collected, and considering sanctions or other appropriate actions for missing payrolls using the methods outlined in WSDOT’s procedures provide sufficient internal control and reasonable compliance, notwithstanding the collection of the payrolls within a seven-day period. • FHWA considers this finding to be resolved. The Department continues to strive for improvements in this area. To further address the prior year’s audit recommendations, the Department took actions to update the Construction Manual, which was approved by FHWA and released in February 2025. This includes: • Updated language for certified payroll collection requirements when no work is performed on federal projects. • Clarified the authority to withhold payments regarding federal wage administration. • Standardized the required frequency of checking for certified payroll collection and the methods to document tracking. • Defined “timely,” given the circumstances surrounding weekly collection of certified payrolls and sanctions on a monthly pay estimate, including: o The timeline when the Department must communicate overdue certified payroll to the contractor and the allowable methods of that communication. o The timeline for determining when the Department must consider imposing sanctions on the contractor after a certified payroll is overdue. o The minimum required documentation that sanctions (e.g., partial deferral of payment) were considered against the contractor regarding an overdue certified payroll. The Department discussed the updates to the Construction Manual and the audit findings at the statewide Documentation Engineering meeting, which was held in February 2025. Additionally, the Department will: • Release the Construction Bulletin to include highlights on the updates in the Construction Manual. • Share the details of the audit testing and exceptions with the Regional Documentation Engineers. The conditions noted in this finding were previously reported in finding 2023-013. Estimated June 2025 Jesse Daniels External Audit Liaison PO Box 47320 Olympia, WA 98504-7320 (360) 705-7035 danielje@wsdot.wa.gov

View Audit 355165

Finding 558467 (2024-012)

Material Weakness 2024

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring

Finding: The Washington State Department of Transportation did not have adequate internal controls over and did not comply with requirements to perform risk assessments for subrecipients of the Highway Planning and Construction program. Questioned Costs: Assistance Listing # 20.205 Amount $0 ...

Finding: The Washington State Department of Transportation did not have adequate internal controls over and did not comply with requirements to perform risk assessments for subrecipients of the Highway Planning and Construction program. Questioned Costs: Assistance Listing # 20.205 Amount $0 Status: Corrective action in progress Corrective Action: The Washington State Department of Transportation (WSDOT) is committed to ensuring our grant programs comply with federal regulations regarding required risk assessments. Risk assessments for subrecipients under the Federal Highway Administration grant programs are the responsibility of WSDOT’s Regional Local Programs Engineers, located in the six WSDOT regions. The Department has attempted to complete a risk assessment at each phase of a project, however, staff turnover contributed to the lack of consistency and timeliness in completing these assessments. To help ensure consistency, the Department has updated position descriptions for Local Programs Engineers to reflect this requirement. The Department will: • Ensure audit findings and exceptions are shared with responsible staff and regional management. • Communicate with Regional Local Programs Engineers to ensure risk assessments are performed and properly documented in accordance with the risk assessment program guidelines. • Communicate with regional management to ensure required monitoring activities by staff are tracked, and the status of these activities are reported as part of annual performance evaluations. Communication with Regional Local Programs Engineers and regional management will continue to be on-going. The conditions noted in this finding were previously reported in finding 2023-012. Completion Date: Estimated June 2025 Agency Contact: Jesse Daniels External Audit Liaison PO Box 47320 Olympia, WA 98504-7320 (360) 705-7035 danielje@wsdot.wa.gov

View Audit 355165

Finding 558466 (2024-011)

Material Weakness 2024

State of Washington C/o Office of Financial Management

WA

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

Finding: The Washington State Department of Transportation did not have adequate internal controls over and did not comply with federal requirements for suspension and debarment and wage rate notification. Questioned Costs: Assistance Listing # 20.205 Amount $0 Status: Corrective action co...

Finding: The Washington State Department of Transportation did not have adequate internal controls over and did not comply with federal requirements for suspension and debarment and wage rate notification. Questioned Costs: Assistance Listing # 20.205 Amount $0 Status: Corrective action complete Corrective Action: The Department is committed to ensuring our programs comply with federal regulations related to procurement, suspension, and debarment. The Department has policies and procedures in place, approved by the Federal Highway Administration (FHWA), to ensure all federally funded construction contracts have the necessary elements to meet both state and federal requirements. The Department provided clear guidance to teams to ensure Form FHWA-1273 Required Contract Provisions Federal-Aid Construction Contracts is included in all contracts. It was simply a mistake that Form 1273 was left out of the contract in question. In this case, the contract documents were some 1,200 pages and the inclusion of this form in an appendix was overlooked by the project team. As a result of various other checks and balances in place, the Department subsequently discovered the oversight and a change order was executed on July 18, 2024, to include the form. This was completed before any contract work commenced and prior to audit work beginning for the program. For added assurance, all contracts include language that requires the contractor to meet the various requirements associated with Form FHWA-1273, whether the form is included in the contract or not. The Department had follow-up conversations with appropriate staff to ensure all contracts awarded contain the required elements. Completion Date: February 2025 Agency Contact: Jesse Daniels External Audit Liaison PO Box 47320 Olympia, WA 98504-7320 (360) 705-7035 danielje@wsdot.wa.gov

View Audit 355165

Finding 558462 (2024-009)

Material Weakness 2024

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Internal Control / Segregation of Duties Special Tests & Provisions

Finding: The Employment Security Department did not have adequate internal controls over and did not comply with requirements to ensure it profiled all claimants under the Unemployment Insurance program to identify people likely to need reemployment services and ensure staff providing those service...

Finding: The Employment Security Department did not have adequate internal controls over and did not comply with requirements to ensure it profiled all claimants under the Unemployment Insurance program to identify people likely to need reemployment services and ensure staff providing those services received required training. Questioned Costs: Assistance Listing # 17.225 17.225 COVID-19 Amount $0 Status: Corrective action in progress Corrective Action: The Department concurs with the audit recommendation to review the Worker Profiling and Reemployment Services calculation of the profile score within the Unemployment Tax and Benefit (UTAB) system. In response to the prior year’s finding, the Department began investigating the process of the score calculation in October 2024. The Department is also examining resource allocation to more effectively validate the profile score and ensure that coefficient values are correctly determined and assigned by the UTAB system. The Department partially concurs with the recommendation to reconcile the UTAB and Reemployment Appointment Scheduler (RAS) interface. There is currently a process in place to notify the RAS team if a record fails at the time of data transmission between UTAB and RAS. The Department will review its processes to verify the complete UTAB exit file was successfully received by RAS. The Department partially concurs with the recommendation to ensure staff have completed the required training before providing services to claimants. The Department currently monitors local offices to ensure staff have taken the required training to be able to provide reemployment screening services to claimants. The exception cited in the finding was due to one staff out of 277 who missed the refresher training during fiscal year 2024. The Department will continue to monitor local staff training to ensure compliance. The conditions noted in this finding were previously reported in finding 2023-010. Completion Date: Estimated May 2025 Agency Contact: Jay Summers  External Audit Manager   PO Box 9046   Olympia, WA 98507-9046  (360) 529-6718  Joshua.Summers@esd.wa.gov

View Audit 355165

Finding 558461 (2024-008)

Significant Deficiency 2024

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Special Tests & Provisions Internal Control / Segregation of Duties

Finding: The Employment Security Department did not have adequate internal controls to ensure compliance with federal requirements to annually certify that employer tax credits reported under the Federal Unemployment Tax Act are matched against employer contributions paid under the Unemployment Ins...

Finding: The Employment Security Department did not have adequate internal controls to ensure compliance with federal requirements to annually certify that employer tax credits reported under the Federal Unemployment Tax Act are matched against employer contributions paid under the Unemployment Insurance program. Questioned Costs: Assistance Listing # 17.225 17.225 COVID-19 Amount $0 Status: Corrective action complete Corrective Action: The Department is committed to ensuring that the required reports for the Federal Unemployment Tax Act are properly reviewed and in compliance with federal requirements. The Department has a process in place for a secondary review of the employer tax credit reports prior to certification. The two exceptions identified in the audit were isolated incidents where both the preparer and reviewer missed one of the 50 lines on the two reports being reviewed. The Department will ensure management adequately reviews employer account reconciliations performed by staff to ensure the required number of accounts are reviewed for all reports prior to submission. Completion Date: February 2025 Agency Contact: Jay Summers External Audit Manager PO Box 9046 Olympia, WA 98507-9046 (360) 529-6718 Joshua.Summers@esd.wa.gov

View Audit 355165

Finding 558460 (2024-007)

Material Weakness 2024

State of Washington C/o Office of Financial Management

WA

Internal Control / Segregation of Duties Subrecipient Monitoring Allowable Costs / Cost Principles

Finding: The Employment Security Department did not have adequate internal controls over and did not comply with federal requirements to conduct case reviews for the Benefit Accuracy Measurement program of the Unemployment Insurance program in a timely manner. Questioned Costs: Assistance Listin...

Finding: The Employment Security Department did not have adequate internal controls over and did not comply with federal requirements to conduct case reviews for the Benefit Accuracy Measurement program of the Unemployment Insurance program in a timely manner. Questioned Costs: Assistance Listing # 17.225 17.225 COVID-19 Amount $0 Status: Corrective action complete Corrective Action: The Department is committed to ensuring our Benefit Accuracy Measurement (BAM) program complies with federal regulations. Historically, the BAM unit has been challenged to maintain full levels of staffing. Staff turnover, lengthy training requirements, and unique skill sets make these positions difficult to maintain. The Department has implemented changes to position descriptions which have resulted in the hiring and retention of qualified staff. As a result, the unit has improved its case sampling timelines by implementing regular case reviews to ensure the 60-day, 90-day, and 120-day timelines are met. Additionally, the Department, in collaboration with the U.S. Department of Labor (USDOL), developed a State Quality Service Plan (SQSP) which includes metrics to improve program outcomes. The team has implemented additional internal communication to follow up on cases which are approaching the 120-day timeline. Although the 120-day timeline is not an improvement measure listed on the SQSP, the Department will continue to work with USDOL to implement guidance and processes to meet the 120-day requirement. The conditions noted in this finding were previously reported in findings 2023-009, 2022-006, 2021-005, and 2020-011. Completion Date: January 2025 Agency Contact: Jay Summers External Audit Manager PO Box 9046 Olympia, WA 98507-9046 (360) 529-6718 Joshua.Summers@esd.wa.gov

View Audit 355165

Finding 558459 (2024-006)

Material Weakness 2024

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness

Finding: The Office of Superintendent of Public Instruction did not have internal controls over and did not comply with requirements to verify single audits were completed for all subrecipients of the Child and Adult Care Program. Questioned Costs: Assistance Listing # 10.558 Amount $0 Sta...

Finding: The Office of Superintendent of Public Instruction did not have internal controls over and did not comply with requirements to verify single audits were completed for all subrecipients of the Child and Adult Care Program. Questioned Costs: Assistance Listing # 10.558 Amount $0 Status: Corrective action in progress Corrective Action: The Office has implemented internal controls to ensure all subrecipients requiring a single audit are identified and to follow up on any program-related findings that require a management decision. Procedures are also updated to maintain the subrecipient audit tracking log. The Office will implement a training plan for the Child Nutrition Services fiscal team, which includes cross training and completing the State Auditor’s Office subrecipient monitoring training. The Office will follow up with the subrecipient identified in the audit to ensure it obtains its required single audit. The conditions noted in this finding were previously reported in finding 2023-004. Completion Date: Estimated June 2025 Agency Contact: Debbie Libra Fiscal & Claims Supervisor PO Box 47200 Olympia, WA 98504-7200 (564) 233-8620 Debbie.libra@k12.wa.us

View Audit 355165

Finding 558458 (2024-005)

Material Weakness 2024

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring

Finding: The Office of Superintendent of Public Instruction did not have adequate internal controls over and did not comply with the required monitoring of subrecipients of the Child and Adult Care Food Program. Questioned Costs: Assistance Listing # 10.558 Amount $0 Status: Corrective act...

Finding: The Office of Superintendent of Public Instruction did not have adequate internal controls over and did not comply with the required monitoring of subrecipients of the Child and Adult Care Food Program. Questioned Costs: Assistance Listing # 10.558 Amount $0 Status: Corrective action in progress Corrective Action: The Office has established and implemented a procedure for tracking subrecipient monitoring activities assigned to staff. The procedure includes expectations of program specialists to complete a minimum number of administrative reviews each month. Progress is regularly reviewed to address workload issues. The Office also identified the need for additional staff resources to provide coverage during absences. However, we were not able to secure funding to move forward with recruitment until fiscal year 2025. The Office is planning on hiring new staff by April 30, 2025. Meanwhile, a temporary position was filled to assist with completing the 23 administrative reviews that were not completed for fiscal year 2024. The Office expects these reviews will be completed by September 1, 2025. The conditions noted in this finding were previously reported in finding 2023-002. Completion Date: Estimated September 2025 Agency Contact: Chaundi Barbosa CACFP Director PO Box 47200 Olympia, WA 98504-7200 (360) 764-0411 Chaundra.Barboza@k12.wa.us

View Audit 355165

Finding 558457 (2024-004)

Material Weakness 2024

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Internal Control / Segregation of Duties

Finding: The Office of Superintendent of Public Instruction did not have adequate internal controls over and did not comply with requirements to ensure it communicated federal award identification elements to subrecipients of the Child and Adult Care Food Program. Questioned Costs: Assistance Li...

Finding: The Office of Superintendent of Public Instruction did not have adequate internal controls over and did not comply with requirements to ensure it communicated federal award identification elements to subrecipients of the Child and Adult Care Food Program. Questioned Costs: Assistance Listing # 10.558 Amount $0 Status: Corrective action complete Corrective Action: During fiscal year 2025, the Office amended its procedure of sending grant requirements to all subrecipients bi-annually. The current procedures require the program specialist to distribute federal award information and requirements to all subrecipients upon approval of the renewal application. The updated procedure will go into effect for all subrecipients during the fiscal year 2026 renewal cycle. The conditions noted in this finding were previously reported in finding 2023-003. Completion Date: March 2025 Agency Contact: Chaundi Barbosa Director, CACFP PO Box 47200 Olympia, WA 98504-7200 (360) 725-0411 Chaundra.Barbza@k12.wa.us

View Audit 355165

Finding 558456 (2024-002)

Material Weakness 2024

Denham Springs Housing Authority

LA

Reporting

Finding 2024-002-Late Filing of Report Condition State law requires the annual audit report be filed no later than six months after fiscal year end with the Louisiana Legislative Auditor. Corrective Action Planned: We will comply with the auditor’s recommendation. Person Responsible for Correcti...

Finding 2024-002-Late Filing of Report Condition State law requires the annual audit report be filed no later than six months after fiscal year end with the Louisiana Legislative Auditor. Corrective Action Planned: We will comply with the auditor’s recommendation. Person Responsible for Corrective Action: Fred Banks, Executive Director Telephone: (225) 664-3301 Housing Authority of Denham Springs Fax: (225) 664-3309 600 Eugene Street Denham Springs, LA 70726 Anticipated Completion Date- March 31, 2026

View Audit 355161

Finding 558455 (2024-001)

Material Weakness 2024

Denham Springs Housing Authority

LA

HUD Housing Programs Reporting Internal Control / Segregation of Duties

DENHAM SPRINGS HOUSING AUTHORITY 600 Eugene Street Denham Springs, LA 70726 Phone No. (225) 664-3301 Fax No. (225) 664-3309 HOUSING AUTHORITY OF DENHAM SPRINGS, LOUISIANA CORRECTIVE ACTION PLAN YEAR ENDED SEPTEMBER 30, 2024 Finding 2024-001-Utility Allowances Need Updating Condition Feder...

DENHAM SPRINGS HOUSING AUTHORITY 600 Eugene Street Denham Springs, LA 70726 Phone No. (225) 664-3301 Fax No. (225) 664-3309 HOUSING AUTHORITY OF DENHAM SPRINGS, LOUISIANA CORRECTIVE ACTION PLAN YEAR ENDED SEPTEMBER 30, 2024 Finding 2024-001-Utility Allowances Need Updating Condition Federal regulations require that utility allowances be reviewed annually. If any category increases more than 10% since the last rate change, the allowances should be revised. Corrective Action Planned: We will comply with the auditor’s recommendation. Person Responsible for Corrective Action: Fred Banks, Executive Director Telephone: (225) 664-3301 Housing Authority of Denham Springs Fax: (225) 664-3309 600 Eugene Street Denham Springs, LA 70726 Anticipated Completion Date- September 20, 2025

View Audit 355161

Finding 558453 (2024-003)

None 2024

Sistema Universitario Ana G. Mendez, Incorporado

PR

Reporting

The Registrar will prepare a notification for the academic deans regarding the processes that may impact the degree certification process to the Federal Department of Education, in compliance with the 60-day regulatory period. The Enrollment Reporting Manual will be reviewed. This guide states that...

The Registrar will prepare a notification for the academic deans regarding the processes that may impact the degree certification process to the Federal Department of Education, in compliance with the 60-day regulatory period. The Enrollment Reporting Manual will be reviewed. This guide states that the assistant registrar will draw a sample of the population to review the data submitted to NSLDS. A retraining session will be coordinated to review the NSLDS certification process. This activity will be aligned with the recent updates of the electronic platform.

View Audit 355152

Finding 558451 (2024-002)

None 2024

Sistema Universitario Ana G. Mendez, Incorporado

PR

Student Financial Aid

A user guide will be reviewed by the Registrar describing the steps to assemble the academic year in Banner system. This document will outline all the validation tables managed at the registrar’s office that have an impact on financial aid office procedures. In a coordinated effort with the financi...

A user guide will be reviewed by the Registrar describing the steps to assemble the academic year in Banner system. This document will outline all the validation tables managed at the registrar’s office that have an impact on financial aid office procedures. In a coordinated effort with the financial aid office, a review process will be conducted for cases involving total withdrawal transactions. A report will be created to ensure the accuracy of the information and to identify any discrepancies. To provide a comprehensive analysis, the report will help identify the cases that impact the return of Title IV funds.

View Audit 355152

Finding 558448 (2024-001)

None 2024

Sistema Universitario Ana G. Mendez, Incorporado

PR

Reporting

The reconciliation process and procedure of returned funds were reviewed by the accounting, bursar, and financial aid areas. The returned check process was reviewed and updated accordingly.

View Audit 355152

Finding 558349 (2024-001)

Significant Deficiency 2024

Town of Thompson, Connecticut

CT

Procurement, Suspension & Debarment Subrecipient Monitoring

DEBARMENT- INTERNAL CONTROL OVER VERIFICATION AGAINST THE SYSTEM FOR AWARD MANAGEMENT (“SAM”) Description of Finding: 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, (Uniform Guidance) requires compliance with provisions of procurement,...

DEBARMENT- INTERNAL CONTROL OVER VERIFICATION AGAINST THE SYSTEM FOR AWARD MANAGEMENT (“SAM”) Description of Finding: 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, (Uniform Guidance) requires compliance with provisions of procurement, suspension, and debarment. Non-federal entities are required to ensure that they do not award contracts or make subawards to any parties that are suspended or debarred from receiving federal funds. This verification may be accomplished by checking the System for Award Management (SAM). The Town does not have a process in place to check that vendors are not suspended or debarred by checking the System for Award Management (SAM). Statement of Concurrence or Nonconcurrence: The Town agrees with the audit finding. Corrective Action: The Town will establish policies and procedures to ensure vendors are not suspended or debarred by checking the System for Award Management (SAM) and maintain documentation showing that verification. Name of Contact Person: William J. Steglitz, Finance Director, (860) 923-3593. Projected Completion Date: June 30, 2025.

View Audit 355150

Finding 558343 (2024-001)

Significant Deficiency 2024

Colorado Youth for A Change

CO

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Finding 2024-001: Special Tests and Provisions – CFDA# 94.006 (AmeriCorps State and National): Living Allowance Maximum Threshold Exceeded Audit Finding: Colorado Youth For A Change can only pay AmeriCorps member a living allowance that does not exceed the maximum living allowance threshold per the ...

Finding 2024-001: Special Tests and Provisions – CFDA# 94.006 (AmeriCorps State and National): Living Allowance Maximum Threshold Exceeded Audit Finding: Colorado Youth For A Change can only pay AmeriCorps member a living allowance that does not exceed the maximum living allowance threshold per the Uniform Guidance and grant guidelines. In our audit, we found that twenty AmeriCorps members were paid a living allowance that exceeded the maximum threshold by $1,255 individually, and $25,100 in aggregate. This constitutes a violation of federal grant guidelines and is considered an unallowable cost, requiring corrective action and potential reimbursement to the funding agency. Audit Recommendation: We recommend Colorado Youth For A Change to compare their living allowance calculations to the annual maximum threshold amount to ensure no AmeriCorps members are paid a living allowance in excess of the annual maximum threshold amount. Management’s Response and Corrective Action Plan: Colorado Youth For A Change acknowledges the finding and recommendation. Living allowances for the 25-26 program year have been double-checked against the current NOFA and have been confirmed to be under maximum requirements. An annual process for this action will be instituted. Contact and Completion Date: Mary Zanotti (maryz@youthforachange.org) is the primary contact, and the Executive Director at Colorado Youth For A Change. The correction action is expected to be resolved before the end of the next fiscal year-end of December 31, 2025.

View Audit 355136 Questioned Costs: $1

Finding 558342 (2024-003)

Material Weakness 2024

Fayette County Commission

WV

Questioned Costs Allowable Costs / Cost Principles

See the PDF.

View Audit 355134 Questioned Costs: $1

Finding 558341 (2024-003)

Material Weakness 2024

Box Butte General Hospital

NE

Reporting Matching / Level of Effort / Earmarking

Effect and recommendation The Hospital implemented a new accounting and electronic health record (EHR) system in May of 2023 and experienced significant delays in being able to bill and process claims. In addition, there was a cyberattack on the Hospital’s claims processing clearinghouse in Februar...

Effect and recommendation The Hospital implemented a new accounting and electronic health record (EHR) system in May of 2023 and experienced significant delays in being able to bill and process claims. In addition, there was a cyberattack on the Hospital’s claims processing clearinghouse in February 2024 that took the hospital offline from processing claims. These two events resulted in the financial statement audit requiring significantly more time to complete resulting in the Hospital’s financial statements and compliance audits for June 30, 2024 reporting period not being filed within the required timeline. Views of responsible officials and planned corrective actions The financial statement and compliance audit will be filed with the Federal Audit Clearinghouse shortly after issuance. Anticipated completion date Ongoing

View Audit 355131

Finding 558340 (2024-002)

Material Weakness 2024

Box Butte General Hospital

NE

Cash Management Material Weakness Matching / Level of Effort / Earmarking

Effect and recommendation The Hospital implemented a new accounting and electronic health record (EHR) system in May of 2023 and experienced significant delays in being able to bill and process claims. In addition, there was a cyberattack on the Hospital’s claims processing clearinghouse in Februar...

Effect and recommendation The Hospital implemented a new accounting and electronic health record (EHR) system in May of 2023 and experienced significant delays in being able to bill and process claims. In addition, there was a cyberattack on the Hospital’s claims processing clearinghouse in February 2024 that took the hospital offline from processing claims. These two events had a negative and material impact on overall operating results as additional accounts receivable allowances for both contractual adjustments and bad debts were necessary at June 30, 2024. The negative impact on overall operations resulted in the Hospital not meeting the required 1.5 debt service coverage ratio and having less than 90 days of cash on hand at June 30, 2024. The Hospital did receive a waiver for from the USDA regarding not meeting these loan covenants for fiscal year 2024. Views of responsible officials and planned corrective actions The implementation of the new electronic health records created a delay in operational workflow processes which required vendor modifications and corrections to the system. This delayed submitting insurance claims for reimbursement continued throughout fiscal year 2024. Operations have now stabilized and the debt service coverage ratio is expected to be in compliance in fiscal year 2025. Hospital management notified its USDA representatives and received a waiver from the required 1.5 debt service coverage ratio and required 90 days of cash on hand for the period ended June 30, 2024. Anticipated completion date Ongoing

View Audit 355131

Finding 558339 (2024-004)

Significant Deficiency 2024

Sunshine Connections, Inc.

KS

Subrecipient Monitoring

2024-004 – 10.558 – Child and Adult Care Food Program –Subrecipient Monitoring Condition Two providers who began Program operations during the period did not undergo a site visit during each new facility’s four weeks of operations. Recommendation Controls should be reviewed and updated to ensure tha...

2024-004 – 10.558 – Child and Adult Care Food Program –Subrecipient Monitoring Condition Two providers who began Program operations during the period did not undergo a site visit during each new facility’s four weeks of operations. Recommendation Controls should be reviewed and updated to ensure that all new providers undergo a site visit within the first four weeks of operations. Comments on the Finding The Organization is aware of the oversight and will strive to improve the process. Action Taken The Director has added a column to her spreadsheet that tracks site visits. For any new participants to the program, this column will note the first date that they began participating, to better track when their first follow up visit must occur.

View Audit 355130

Finding 558338 (2024-003)

Significant Deficiency 2024

Sunshine Connections, Inc.

KS

Cash Management Eligibility Internal Control / Segregation of Duties

2024-003 – 10.558 – Child and Adult Care Food Program –Eligibility Condition Two providers received an improper amount for their meal reimbursement for the month tested. Recommendation Controls should be reviewed and updated to ensure that complete and accurate meal counts are submitted to the State...

2024-003 – 10.558 – Child and Adult Care Food Program –Eligibility Condition Two providers received an improper amount for their meal reimbursement for the month tested. Recommendation Controls should be reviewed and updated to ensure that complete and accurate meal counts are submitted to the State for reimbursement. Comments on the Finding Given the Organization’s limited size, it is not always feasible to fully segregate the duties surrounding the meal claims processes. However, in order to mitigate errors, steps have been taken to implement checks within those processes. Action Taken Whenever possible, an employee other than the Director will prepare the claims. The Director of the Organization will later review the claims for accuracy and compare the claim numbers in both the excel spreadsheet and the Little Organizer program to ensure their correctness.

View Audit 355130

Finding 558336 (2024-070)

Material Weakness 2024

State of Rhode Island

RI

Subrecipient Monitoring

RIEMA acknowledges the audit finding regarding incomplete reporting of certain subawards to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) for fiscal year 2024. The reporting gap occurred due to the departure of the staff member previously responsible for F...

RIEMA acknowledges the audit finding regarding incomplete reporting of certain subawards to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) for fiscal year 2024. The reporting gap occurred due to the departure of the staff member previously responsible for FFATA reporting. Unfortunately, this position remained vacant until February of the current year, which contributed to delays and omissions in subaward reporting during that period. To prevent recurrence, RIEMA has filled the vacated position and will ensure the new staff member receives comprehensive training on FFATA requirements and FSRS procedures. Moving forward, we are also reviewing our internal processes to ensure continuity and compliance, even during periods of staffing transitions. RIEMA remains committed to full compliance with federal reporting requirements and transparency in the use of grant funds. Anticipated Completion Date: September 2025 Contact Person: Brian Riggs, Chief Financial Officer, Rhode Island Emergency Management Agency brian.j.riggs@ema.ri.gov

View Audit 355126

Finding 558334 (2024-069)

Significant Deficiency 2024

State of Rhode Island

RI

Reporting

The Agency acknowledges that an inaccurate SF-425 was submitted for March 2024 and the cause was a formula error that was not detected prior to submission. This was a one-off issue that had already been corrected prior to the submission of future SF-425s as acknowledged by the auditor’s statement “...

The Agency acknowledges that an inaccurate SF-425 was submitted for March 2024 and the cause was a formula error that was not detected prior to submission. This was a one-off issue that had already been corrected prior to the submission of future SF-425s as acknowledged by the auditor’s statement “Cumulative amounts reported at State fiscal year end were accurate and complete.” Anticipated Completion Date: RIEMA submission of the revised March 2024 SF-425 and acknowledgement of receipt from FEMA of said revised March 2024 SF-425 has an anticipated completion date of May 2, 2025. Contact Person: Brian Riggs, Chief Financial Officer, Rhode Island Emergency Management Agency brian.j.riggs@ema.ri.gov

View Audit 355126

Finding 558332 (2024-068)

Material Weakness 2024

State of Rhode Island

RI

Subrecipient Monitoring § 200.332

The RIEMA Recovery staff will revise the Federal Audit Clearinghouse tracking form to include the recommended items. We will not only include findings directly related to our program, FEMA 97.036, but all FEMA findings. We will also add any findings that were noted on any program on the tracking f...

The RIEMA Recovery staff will revise the Federal Audit Clearinghouse tracking form to include the recommended items. We will not only include findings directly related to our program, FEMA 97.036, but all FEMA findings. We will also add any findings that were noted on any program on the tracking form. We are also creating an additional form, Verification of Compliance – FAC.Gov, which will be submitted to the RIEMA fiscal department. This form identifies any findings and requests their recommendation on proceeding with reimbursement to the sub-recipient in our payment package. Also, we will be incorporating our review of the Single Audit Report in both the tracking form and the verification form. Anticipated Completion Date: RIEMA is implementing this for all project reviews. Contact Person: Lawrence Macedo, Recovery Branch Chief, Rhode Island Emergency Management Agency lawrence.macedo@ema.ri.gov

View Audit 355126

Finding 558330 (2024-067)

Significant Deficiency 2024

State of Rhode Island

RI

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.403

The RIEMA Recovery staff will conduct an additional review of all projects prior to obligation including both small and large projects. This review will include not only that the state required documentation is included but will also review the FEMA final validation report submitted with the projec...

The RIEMA Recovery staff will conduct an additional review of all projects prior to obligation including both small and large projects. This review will include not only that the state required documentation is included but will also review the FEMA final validation report submitted with the project. We acknowledge the errors which were reported by the State audit review of project number 694201 for federal disaster declaration DR-4505-RI. The agency will contact the Office of Housing and Community Development of the finding and they will be required to reimburse FEMA the unallowable costs. Anticipated Completion Date: RIEMA is implementing this immediately for all project reviews. Contact Person: Lawrence Macedo, Recovery Branch Chief, Rhode Island Emergency Management Agency lawrence.macedo@ema.ri.gov

View Audit 355126 Questioned Costs: $1

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