Corrective Action Plans

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

Finding 558328 (2024-066)

Significant Deficiency 2024

State of Rhode Island

RI

Allowable Costs / Cost Principles Cash Management Eligibility

This audit finding refers to retroactive Medicaid billing from BHDDH for dates of service in 2022 and 2023 once the IMD status was removed from ESH. That provider type currently does not require the Medicare information to be submitted to EOHHS for processing. They bill with a type of bill and if ...

This audit finding refers to retroactive Medicaid billing from BHDDH for dates of service in 2022 and 2023 once the IMD status was removed from ESH. That provider type currently does not require the Medicare information to be submitted to EOHHS for processing. They bill with a type of bill and if there is eligibility on file for Eleanor Slater, the claim is paid. EOHHS will pursue a project to correct this finding. Project PH0630 - OI Edit for ESH was created and is being worked on by Gainwell and the State. The Project Charter states that the state must have controls in place to ensure that claims from the State Hospital, including Eleanor Slater Hospital (ESH) are reimbursed by Medicaid as the payer of last resort. Meetings, requirements gathering, and business designs are ongoing. The Business Design is anticipated to be completed by end of April 2025. Anticipated Completion Date: To Be Determined Contact Person: Hector Rivera, Interdepartmental Project Manager, Executive Office of Health and Human Services hector.l.rivera@ohhs.ri.gov

View Audit 355126

Finding 558323 (2024-065)

Material Weakness 2024

State of Rhode Island

RI

Questioned Costs Eligibility Allowable Costs / Cost Principles

2024-065a: Rhode Island did not participate in the February 2024 PARIS interstate match due to a file issue that has since been addressed in April 2024. The May and August 2024 PARIS matches were suspended at the Federal level for all States due to an outstanding computer matching agreement between...

2024-065a: Rhode Island did not participate in the February 2024 PARIS interstate match due to a file issue that has since been addressed in April 2024. The May and August 2024 PARIS matches were suspended at the Federal level for all States due to an outstanding computer matching agreement between the DoD and HHS/ACF. Enhancements to existing PARIS Interstate match logic are scheduled to run as planned for fall/winter 2025. EOHHS completed implementation of an interface on 3/5/24 between The Work Number (TWN) and RI Bridges. Contract and budget actions for TWN services were not completed until fall 2024. The system requirements that Equifax initially communicated to the State and our Integrated Eligibility System implementation partner were incomplete and the original integration configured in fall 2024 did not successfully pass testing. A system modification to correct the original specifications was originally scheduled for February 2025 but was delayed due to the 12/13/24 RI Bridges cyber event. Target date for TWN implementation is July 2025. The Death Match process resumed in Spring 2025. Long-term modifications are scheduled for December 2025. These modifications include connecting RI Bridges to the SSA Death Master File (DMF) and utilizing the data from DMF as the primary source for monthly death verifications. During SFY 2024, several system fixes were deployed to address the findings noted in 2024-065. Specifically, in September 2024, a system fix was put in place to ensure children with verified SSNs were appropriately evaluated for Medicaid/CHIP coverage and excluded from Cover All Kids. The system automatically identifies individuals aging out of Medicaid Expansion prior to their 65th birth month and redetermines eligibility. EOHHS will improve controls of this process and ensure that if the system is unable to accurately remove the member from the Medicaid expansion category, a manual workaround will be implemented. Anticipated Completion Date: January 1, 2026 Contact Person: Anthony Salvo, Implementation Director of Policy and Programs, Executive Office of Health and Human Services anthony.salvo@ohhs.ri.gov 2024-065b: EOHHS will proactively work with the system vendor and other State agencies to implement controls over eligibility system and process deficiencies. Corrective actions will include, but are not limited to, manual processes, code fixes, and new system enhancements. Anticipated Completion Date: Ongoing Contact Person: Anthony Salvo, Implementation Director of Policy and Programs, Executive Office of Health and Human Services anthony.salvo@ohhs.ri.gov 2024-065c: EOHHS will identify and return any potential ineligible costs by end of the current Federal Fiscal Year (FFY). Anticipated Completion Date: September 30, 2025 Contact Person: Allison Shartrand, Assistant Director, Financial & Contract Management, Executive Office of Health and Human Services allison.shartrand@ohhs.ri.gov

View Audit 355126 Questioned Costs: $1

Finding 558319 (2024-064)

Significant Deficiency 2024

State of Rhode Island

RI

Eligibility Internal Control / Segregation of Duties

EOHHS currently maintains full staffing within the Medicaid Eligibility Quality Control (MEQC) Unit, consisting of two (2) dedicated analysts and one (1) unit supervisor at EOHHS. Oversight of the unit is provided by a Deputy Medicaid Program Director who operates independently from the Medicaid op...

EOHHS currently maintains full staffing within the Medicaid Eligibility Quality Control (MEQC) Unit, consisting of two (2) dedicated analysts and one (1) unit supervisor at EOHHS. Oversight of the unit is provided by a Deputy Medicaid Program Director who operates independently from the Medicaid operations and policy divisions, in accordance with 42 CFR §431.812, ensuring the unit’s objectivity and compliance with federal separation-of-function requirements. All future MEQC reviews will be conducted exclusively by this independent unit. Should any staffing limitations arise that may impact the timely completion of reviews, EOHHS is committed to proactively communicate with both EOHHS Leadership and CMS to request additional time or support, as appropriate. This structure supports consistent quality assurance, audit readiness, and adherence to MEQC program integrity standards. Anticipated Completion Date: Completed Contact Person: Mark Kraics, Deputy Medicaid Director, Executive Office of Health and Human Services mark.kraics@ohhs.ri.gov

View Audit 355126

Finding 558315 (2024-063)

Significant Deficiency 2024

State of Rhode Island

RI

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

EOHHS amended and updated its guidelines and standard operating procedures leveraging the CMS ‘Delivering Service in School-Based Settings: A Comprehensive Guide to Medicaid Services and Administrative Claiming’ as a source document. In addition to ensuring alignment with CMS requirements, the upda...

EOHHS amended and updated its guidelines and standard operating procedures leveraging the CMS ‘Delivering Service in School-Based Settings: A Comprehensive Guide to Medicaid Services and Administrative Claiming’ as a source document. In addition to ensuring alignment with CMS requirements, the updated guidelines include a uniform schedule of quarterly submission dates and details the billing responsibilities of participating LEAs. These responsibilities include meeting all Medicaid documentation requirements; submitting the Certification of Local Funds on a quarterly basis; and signing provider agreements and maintaining all other records used to support claims submitted for Medicaid reimbursement. Upon receipt of these submissions a new audit tool will be utilized to ensure each submissions contains the required documentation. Beginning June 2025, EOHHS will initiate on-site reviews of twenty (20) LEAs using a tiered, randomized sample of claims from State Fiscal Year 2023 (SFY23). The sample will include claims with at least 20 claims per LEA, selected to ensure wide geographic representation. If documentation is missing, incomplete, or found to be in error, the LEA and their billing contractor will be notified and corrective action will be implemented. Lastly, EOHHS is also working in partnership with the CMS School-Based Services Technical Assistance Center to ensure continued alignment with federal expectations and the implementation of national best practices in school-based Medicaid claiming and update guidance. Anticipated Completion Date: Administrative Claiming Materials – June 1, 2024; On-site Audit – June 30, 2025 Contact Persons: Tyler McFeeters, Health Program Administrator, Executive Office of Health and Human Services tyler.mcfeeters@ohhs.ri.gov Mark Kraics, Deputy Medicaid Director, Executive Office of Health and Human Services mark.kraics@ohhs.ri.gov

View Audit 355126

Finding 558311 (2024-062)

Significant Deficiency 2024

State of Rhode Island

RI

Allowable Costs / Cost Principles Subrecipient Monitoring Eligibility

Each health plan reports TPL recoveries to EOHHS in its quarterly financial report (FDCR). These recoveries are used as a direct offset to medical expenses. As such, claims paid by the plans on behalf of a member with TPL will remain in the EOHHS encounter data warehouse. Health plans do not void...

Each health plan reports TPL recoveries to EOHHS in its quarterly financial report (FDCR). These recoveries are used as a direct offset to medical expenses. As such, claims paid by the plans on behalf of a member with TPL will remain in the EOHHS encounter data warehouse. Health plans do not void claims that have previously been paid to account for any TPL liability. Rather, they seek to recover from the third party any amount owed and report that amount to the state. In each of the last two fiscal years, this reduced medical expenditures by just under $8 million. 2025 Update: Following the process from 2023 and 2024, we are requesting a new TPL files from Gainwell that will be shared to each MCO. Anticipated Completion Date: Ongoing Contact Person: Jeffrey Schmeltz, Chief, Family Health Systems, Executive Office of Health and Human Services jeffrey.schmeltz@ohhs.ri.gov

View Audit 355126

Finding 558307 (2024-061)

Significant Deficiency 2024

State of Rhode Island

RI

Reporting

2024-061a: In order to determine CHIP eligibility appropriately, the IES would need to know of all TPL coverages at the time of the eligibility determination. This is not always the case as data is not always self-reported or available. The solution implemented on 5/19/2022 improved the eligibilit...

2024-061a: In order to determine CHIP eligibility appropriately, the IES would need to know of all TPL coverages at the time of the eligibility determination. This is not always the case as data is not always self-reported or available. The solution implemented on 5/19/2022 improved the eligibility determination process by looping TPL data from the states’ MMIS to the IES on a regular basis. Anticipated Completion Date: Monitoring Contact Person: Jeffrey Schmeltz, Chief, Family Health Systems, Executive Office of Health and Human Services jeffrey.schmeltz@ohhs.ri.gov 2024-061b / 2024-061c: The EOHHS Finance team created a Medicaid Administrative Claiming Reporting training presentation and trained all sister agencies with expectations for administrative claiming. The training included the following topics: administrative claiming background; completing required CMS-64 quarterly reporting for EOHHS which include timelines and supporting documentation; and frequently asked questions. The team also created a draft manual and shared this manual with the Medicaid admin claiming agencies. Additionally, EOHHS hired an additional FTE in the Medicaid Finance team during Autumn 2024 to support Medicaid Administrative Claiming of all agencies; however, this FTE was unable to commence work due to being placed in a three-day rule as acting Medicaid CFO. The FTE will resume full-time work in the new position in Mid-May 2025. The goal of this position will be to work with the EOHHS Medicaid and Central Management teams to develop processes to address the audit findings. The Medicaid Finance team also has worked closely with the Medicaid program’s Division of Executive Administrative and Support Services to develop cross-training and draft SOPs which building supervisory reviews of reporting. EOHHS agrees that the CHIP with TPL population requires attention. We believe almost all the instances reported by OAG are from “timing” issues between the MMIS’ collection of verified TPL and the sync with RIBridges. EOHHS has created a new project for the RIBridges system to automate triggers on CHIP cases when TPL is added so that eligibility is timely. This will hopefully result in a reduced number of months when a CHIP aid category and TPL segment overlap for members. Anticipated Completion Date: Ongoing Contact Person: Dezeree Hodish, Associate Director (Financial Management), Executive Office of Health and Human Services dezeree.hodish@ohhs.ri.gov

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