Office of the State Auditor

CONDITION The Department of Human Services made payments under the Vocational Rehabilitation program outside of the 2021 and 2022 grant award periods of performance which was 10/1/20 - 9/30/21, and 10/1/21-9/30/22 with an allowable liquidation period, to pay for obligations, through 12/31/2022 and 12/31/2023, respectively. Payments made after the liquidation period totaled $1,495.35 for the 2021 grant. Payments obligated after the obligation period totaled $23,340 for the 2021 grant and $7,156 for the 2022 grant. CRITERIA The following criteria requires federal funds to be obligated by the end of the two-year period of performance window and those obligations must be liquidated within 90 days after the end date of period of performance. 2 CFR 200.343 requires: " Unless the Federal awarding agency or pass-through entity authorizes an extension, a non-Federal entity must liquidate all obligations incurred under the Federal award not later than 90 calendar days after the end date of the period of performance as specified in the terms and conditions of the Federal award. 34 CFR 361.64 requires: " (a) Except as provided in paragraph (b) of this section, any Federal funds, including reallotted funds, that are appropriated for a fiscal year to carry out a program under this part that are not obligated by the State by the beginning of the succeeding fiscal year and any program income received during a fiscal year that is not obligated by the State by the beginning of the succeeding fiscal year remain available for obligation by the State during that succeeding fiscal year. (b) Federal funds appropriated for a fiscal year remain available for obligation in the succeeding fiscal year only to the extent that the State met the matching requirement for those Federal funds by obligating, in accordance with 34 CFR 76.707, the non-Federal share in the fiscal year for which the funds were appropriated." The following criteria pertains to the establishment and maintenance of effective internal control to ensure payments are made within the correct period of performance. 45 CFR 75.303 states the non-Federal entity must, "establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." CAUSE The Department of Health and Human Services (DHHS), Vocational Rehabilitation Program, allowed payments to universities for tuition to be charged during the federal grant prior to the period when the service was provided. This issue was noted in three of five errors found in sampling and affected both the FFY 2021 and FFY 2022 grants. The remaining two errors were a result of expenditures being assigned improper coding which was not identified during the regular period of performance reviews performed by DHHS. The first occurred prior to the implementation of the period of performance reviews and the second was an expenditure to another state agency that was evaluated by the agency's review using the date of the check rather than the dates on the invoice. EFFECT Known unallowable costs totaling $30,496. were charged to the grants due to being obligated or liquidated after the period of performance. When projected to the population, an additional $50,372 in errors are likely. CONTEXT The Department of Health and Human Services had 395 payments totaling $514,546 after the period of performance for the FFY2021 and FY2022 federal grants. Of this amount, $26,367 were tuition fee payments determined to be the total population of known questioned costs related to tuition fees. $36,969 of the remaining population were sampled and $4,128 were errors. These errors projected to $54,401. Where sampling was performed, the audit used a non-statistical sampling method. IDENTIFICATION AS A REPEAT FINDING Finding 2022-021 was reported in the immediate prior year. Findings 2020-019, 2018-031, and 2016-053 were reported in previous years. The prior audit finding was reported as implemented on the summary schedule of prior audit findings. This materially misrepresents the status of the finding. RECOMMENDATION We recommend the Department of Health and Human Services improve procedures to review transactions for period of performance corrections to prevent and detect payments from being charged to the Vocational Rehabilitation program outside the period of performance. DEPARTMENT OF HEALTH AND HUMAN SERVICES RESPONSE The Department of Health and Human Services agrees with the recommendation. See “Management’s Response and Corrective Action” section of this report.

Department of Health and Human Services Response/Corrective Action Plan The Department of Health and Human Services agrees with the recommendation. To address this, the department will run quarterly reports from AWARE to identify any payments charged to the incorrect period of performance. Grant guidance has been updated to ensure items with unique service dates are properly reviewed. Additionally, during the three-month liquidation period, a monthly review of all expenditures will be conducted to verify they are applied to the correct period of performance. These actions will strengthen oversight and ensure compliance with grant requirements. Contact Person: Eric Haas, Assistant CFO Anticipated Completion Date: December 2024

2022-021

CONDITION The Medicaid program integrity unit within DHHS is not independent from other Medicaid operations. The program integrity unit has system access that allows the unit to process and adjudicate Medicaid claims within the Medicaid Management Information System (MMIS). The audit compared claims by User IDs creating and last editing the claims to the employees by name within the program integrity unit. A review of access of MMIS identified 3 members of the program integrity unit with access within MMIS to process (submit, validate, edit, and override) claims during the audit period of July 1, 2022, through June 30, 2024. The audit did not identify any transactions where the 3 employees either created or last edited claims. CRITERIA The GAO Greenbook Principle 11.14 states "Management designs control activities to limit user access to information technology through authorization control activities such as providing a unique user identification or token to authorized users. These control activities may restrict authorized users to the applications or functions commensurate with their assigned responsibilities, supporting an appropriate segregation of duties." The GAO Greenbook Principle 10.03 states “Management divides or segregates key duties and responsibilities among different people to reduce the risk of error, misuse, or fraud. This includes separating the responsibilities for authorizing transactions, processing and recording them, reviewing the transactions, and handling any related assets so that no one individual controls all key aspects of a transaction or event.” Per DHHS' security plan for MMIS "The organization employs the concept of least privilege, allowing only authorized accesses for users (and processes acting on behalf of users) which are necessary to accomplish assigned tasks in accordance with missions and business functions." 45 CFR 75.303 states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. CAUSE Members of the program integrity unit are given access within MMIS that allows them to adjudicate and process claims. EFFECT There is a risk of self-review that the program integrity employee may review providers related to or actual claims that the same employee previously processed or adjudicated. CONTEXT 42 CFR 456.2 requires "The Medicaid agency must implement a statewide surveillance and utilization control program that safeguards against unnecessary or inappropriate use of Medicaid services and against excess payments." The program integrity unit is the team responsible for performing utilization reviews and other audits of claims and providers within the Medicaid program. During this period there were 12,228,253 claims and over $2 billion Medicaid expenditures reported on the 2023 and 2024 SEFAs. Where sampling was performed, the audit used a non-statistical sampling method. IDENTIFICATION AS A REPEAT FINDING Not a repeat finding. RECOMMENDATION We recommend that DHHS restrict access of the program integrity unit employees within MMIS from processing and adjudicating claims. DEPARTMENT OF HEALTH AND HUMAN SERVICES RESPONSE The Department of Health and Human Services disagrees with the finding. The federal regulations do not explicitly mandate the separation of duties between employees conducting audits and those processing claims. While 42 CFR 456.2 requires Medicaid agencies to implement a surveillance and utilization control program, it does not specifically require the segregation of these roles. The regulation promotes control measures but does not mandate a distinct separation of duties. Based on this, we do not support this recommendation, as it exceeds the requirements outlined in the applicable federal rules. HHS remains committed to maintaining strong internal controls and believe our current structure aligns with regulatory expectations. See “Management’s Response and Corrective Action” section of this report. AUDITOR’S CONCLUDING COMMENTS While the audit did not identify noncompliance due to the lack of segregation of duties, this doesn’t remove the requirement of 45 CFR 75.303 to have proper internal controls and the guidance of the GAO Greenbook. This includes separating the responsibilities for authorizing, processing and recording, and reviewing the transactions.

Department of Health and Human Services Response/Corrective Action Plan The Department of Health and Human Services disagrees with the finding. The federal regulations do not explicitly mandate the separation of duties between employees conducting audits and those processing claims. While 42 CFR 456.2 requires Medicaid agencies to implement a surveillance and utilization control program, it does not specifically require the segregation of these roles. The regulation promotes control measures but does not mandate a distinct separation of duties. Based on this, we do not support this recommendation, as it exceeds the requirements outlined in the applicable federal rules. HHS remains committed to maintaining strong internal controls and believe our current structure aligns with regulatory expectations. Contact Person: Sarah Aker, Medicaid Executive Director Krista Fremming, Assistant Director Anticipated Completion Date: N/A

CONDITION The Department of Health and Human Services, Homeowner's Assistance Fund (HAF) program, made assistance payments in excess of the supported payment amounts. More specifically, 2 of the 60 eligibility payments reviewed resulted in actual overpayments of $14,993 and additional likely questioned costs of $317,445 when projected to the entire population. One of these errors was identified from a population of applications that had two separate reviewers during application and funding amount processing while the other error was derived from the population that had the same reviewer for the application and funding amount decision processing. CRITERIA • 2 CFR 200.303 states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. • 2 CFR 200.302(a) Each state must expend and account for the Federal award in accordance with state laws and procedures for expending and accounting for the state's own funds. In addition, the state's and the other non-Federal entity's financial management systems, including records documenting compliance with Federal statutes, regulations, and the terms and conditions of the Federal award, must be sufficient to permit the preparation of reports required by general and program-specific terms and conditions; and the tracing of funds to a level of expenditures adequate to establish that such funds have been used according to the Federal statutes, regulations, and the terms and conditions of the Federal award. • DHHS's HAF Policies & Procedures outlines its Tier 1 and Tier 2 reviews for its HAF application eligibility process. CAUSE The Department of Health and Human Services, Homeowner's Assistance Fund (HAF) program, did not have procedures in place to ensure assistance payments did not exceed the amounts on supporting documentation provided by the recipient. EFFECT The Department issued assistance payments for amounts greater than the underlying support for two unique households. CONTEXT During the audit period, the program paid over $32 million of Federal HAF assistance to citizens of North Dakota. Approximately $1.75 million of these payments did not go through the program's two tier eligibility review process. This translates to 1,323 out of the 34,432 payments during the audit period having the same reviewer for both tier 1 and tier 2 review. The State Auditor's Office performed eligibility testing of 60 applications with 20 of the 60 being from the applications that had the same reviewer for both tier 1 and tier 2 review and 40 being from applications with different reviewers for tier 1 and tier 2 review. From the 20 applications and associated payments with the same reviewer, one overpayment of $2,993.82 was identified which projected to $11,953.30. From the 40 applications with different reviewers, one overpayment of $12,000 was noted which projected to $320,485.56. In aggregate, these errors totaled $14,993.82 with an additional likely questioned cost of $317,445. Where sampling was performed, the audit used a non-statistical sampling method. IDENTIFICATION AS A REPEAT FINDING Not a repeat finding. RECOMMENDATION We recommend the Department of Health and Human Services implement procedures and ensure the funding decision and payment amounts are supported by the applicant provided documentation. Additionally, we recommend the Department ensure the improper payments are recouped through the HAF program's refunding process. DEPARTMENT OF HEALTH AND HUMAN SERVICES RESPONSE The Department of Health and Human Services agrees with the recommendation. See “Management’s Response and Corrective Action” section of this report.

Department of Health and Human Services Response/Corrective Action Plan The Department of Health and Human Services agrees with the recommendation. During review of audit found two overpayment errors as a result of outdated supporting documents. Refunds have been requested. HHS provides ongoing training with eligibility and supervisory staff regarding document and eligibility requirements with staff. HHS actively monitors application quality and provides ongoing quality control reviews ensuring consistent adherence to best practices. Contact Person: Jessica Thomasson, Executive Policy Director Anticipated Completion Date: October 2024

CONDITION The Department of Public Instruction incorrectly included neglected or delinquent facilities as part of their Title IIA allocation to Local Educational Agencies (LEA). We selected a sample of 17 in 2022-2023 and 17 in 2023-2024. Of the 17 samples in 2022-2023, we identified a 100% error rate. The total known allocation error identified was $60,026. This amount was the total allocated to negligent and delinquent districts. By allocating this amount to the noneligible districts, the eligible school districts were under allocated by the same amount. This was issue was fixed by the department for the 2023-2024 year and no error were found during the testing of 2023-2024. CRITERIA The Elementary and Secondary Education Act of 1965 (ESEA Section 2012(a)(1)) states, the State, acting through the State Educational Agency (DPI), shall award subgrants to eligible local educational agencies (LEA). 2 CFR 200.303(a) states that non-Federal entities must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulation, and the terms and conditions of the federal award. The Elementary and Secondary Education Act of 1965 (ESEA Section 8101(30) states "the term local educational agency means a public board of education or other public authority legally constituted within a state for either administrative control or direction of, or to perform a service function for, public elementary schools or secondary schools in a city, county, township, school district, or other political subdivision of a state, or for a combination of school districts or counties that is recognized in a state administrative agency for its public elementary school or secondary schools." The Elementary and Secondary Education Act of 1965 (ESEA Section 1432) defines Institutions for Neglected or Delinquent Children and Youth as "a public or private residential facility, other than a foster home, that is operated for the care of children who have been committed to the institution or voluntarily placed in the institution under applicable State law, due to abandonment, neglect, or death of their parents or guardian; or a public or private residential facility for the care of children who have deemed adjudicated to be delinquent or in need of supervision." As Neglected and Delinquent Facilities are operated only for the care of old children who have been committed or placed in their institution due to abandonment, neglect, death of their parents or guardians, or in need of supervision, these facilities are not recognized as Local Educational Agency. CAUSE The Department of Public Instruction was unaware that neglected and delinquent facilities could not be included in their Title IIA allocation calculation and on subrecipient's grant awards. EFFECT The Department of Public Instruction did not comply with the allocation requirements to LEAs for Title IIA grants. The LEAs eligible to receive funding were allocated less than they should have. CONTEXT The Department of Public Instruction allocated $9,834,095 in Federal funds to 169 school districts during the 2022-2023 school year and $9,939,938 in Federal funds to 169 school districts during the 2023-2024 school year. Where sampling was performed, the audit used a non-statistical sampling method. IDENTIFICATION AS A REPEAT FINDING Finding 2022-032 was reported in the immediate prior year. The prior audit finding was reported as implemented on the summary schedule of prior audit findings. This materially misrepresents the status of the finding. RECOMMENDATION We recommend the Department of Public Instruction ensure the Title IIA allocations are calculated based on the Federal requirements. DEPARTMENT OF PUBLIC INSTRUCTION RESPONSE The Department of Public Instruction agrees with the finding. See “Management’s Response and Corrective Action” section of this report.

Department of Public Instruction Response/Corrective Action Plan: We agree with the finding. The issue has already been corrected as stated in the finding. Contact Person: Jamie Mertz, CFO Anticipated Completion Date: The issue has already been corrected.

2022-032

CONDITION The University of North Dakota has federally funded equipment that is not being properly identified with the corresponding major equipment asset tags on the asset. We tested a total of 21 capital assets and 10 of those were at the University of North Dakota where we found 5 assets without any major equipment identification tags on them for an error rate of 50%. CRITERIA 2 CFR section 200.313(d)(3) states in part that a control system must be in place to ensure safeguards for preventing property loss, damage, or theft. 2 CFR section 200.313(b) states in part that a State must use, manage and dispose of equipment acquired under a Federal award in accordance with State laws and procedures. The University of North Dakota Capital Asset policy states in part that the campus department is responsible for using correct chart field when acquiring all assets, tagging and tracking their major equipment, and completing annual inventory of all major equipment. CAUSE The departments and/or principal investigator (PI) purchasing the equipment did not correctly attach the major equipment tags to the asset as required by the University of North Dakota's Capital Asset policy. EFFECT There is noncompliance with federal rules and regulations as well as the University of North Dakota's Capital Asset policy, thus increasing the risk that federally funded equipment is not properly identified. CONTEXT For the audit period, the Research and Development Cluster had 207 equipment asset additions ($9,958,360). All the issues noted originated from one single department at the University of North Dakota. The insufficient tagging of capital asset deviations seems to be an isolated incident contained to this department, which in total for our audit period had 16 new additions totaling $419,060. Where sampling was performed, the audit used a non-statistical sampling method. IDENTIFICATION AS A REPEAT FINDING Not a repeat finding. RECOMMENDATION We recommend that the University of North Dakota ensure federally funded equipment is properly tagged. UNIVERSITY SYSTEM RESPONSE The University of North Dakota agrees with the finding. See “Management’s Response and Corrective Action” section of this report.

University System Response/Corrective Action Plan Agree. UND Asset Management adequately informs UND departments that the department is required to secure the tag to the asset. The requirement is also clearly listed in UND’s Capital Asset policy. UND Asset Management will work closely with departments to stress that they are required to secure tags to all major equipment assets. Contact Person: Sharon Loiland, Controller Anticipated Completion Date: March 31, 2025

?See Schedule of Findings and Questioned Costs for chart/table? CONDITION The Department of Human Services has not completed a risk analysis and security review of the Medicaid Management Information System (MMIS) since 2019. CRITERIA 45 CFR 95.621(f)(3) states that state agencies shall review the Automatic Data Processing (ADP) system security of installations involved in the administration of Health and Human Services (HHS) programs on a biennial basis. 45 CFR 95.621(f)(6) states that the state agency shall maintain reports of their biennial ADP system security reviews, together with pertinent supporting documentation, for HHS on-site review. 45 CFR 75.303 states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. CAUSE A risk analysis and security review was not completed in 2020 and 2021 due to resources being dedicated to the developing of new software. This new software will automate many of the processes surrounding the risk analysis and security review as well as user access reviews and will save personnel time. EFFECT The risk analysis has not been completed regularly and there is the possibility the security over different areas of the system can become compromised bringing into question the validity of the data contained within the system. CONTEXT There were $2,496,097,225 of Medicaid payments that were processed in the MMIS and eligibility systems during our audit period of July 1, 2020, through June 30, 2022. Where sampling was performed, the audit used a non-statistical sampling method. IDENTIFICATION AS A REPEAT FINDING Not a repeat finding. RECOMMENDATION We recommend the Department of Human Services complete a risk analysis and security review of MMIS biennially. DEPARTMENT OF HUMAN SERVICES RESPONSE The Department agrees with the recommendation. See ?Management?s Response and Corrective Action? section of this report.

Finding: 2022-009 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. The department will work with NDIT to ensure they restart and maintain the risk analysis and security review for MMIS. Contact Person: Tory Brabandt, Medicaid Enterprise Director Anticipated Completion Date: December 31, 2023

?See Schedule of Findings and Questioned Costs for chart/table? CONDITION The medical loss ratio report for reporting calendar year 2020 did not contain the minimum Federal regulation required elements. DHS did not maintain the required attestation statement to address accuracy for reporting year 2020. As of March 2, 2023, the medical loss ratio report for reporting year 2021, which was due in November 2022, has not been finalized as outlined in the Sanford Health Plan contract. The contract required completion prior to 11 months following the applicable MLR reporting year or a mutually agreed upon alternative date. CRITERIA Effective January 1, 2020, Sanford Health Plan Contract states, prior to 11 months following the applicable MLR reporting year or a mutually agreed upon alternative date, STATE shall finalize the MLR (Medical Loss Ratio) reporting year with any balance due to STATE as required in paragraph (G) of this section within 60 days. 42 CFR 438.8 (n) MCOs, PIHPs, and PAHPs must attest to the accuracy of the calculation of the MLR in accordance with requirements of this section when submitting the report required under paragraph (k) of this section. 45 CFR 75.303 states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. CAUSE The attestation statement to address accuracy was not provided to the auditor. The Department indicated the statement was obtained by an employee no longer with the Department and it was not shared with other team members. The Medical Loss Ratio report for reporting year 2021 was not finalized as outlined in the Sanford Health Plan Contract, "Prior to 11 months following the applicable MLR reporting year or a mutually agreed upon alternative date, STATE shall finalize the MLR reporting year with any balance due to STATE as required in paragraph (G) of this section within 60 days". This was due to a large reconciliation taking longer than normal to complete. A mutually agreed upon alternative date was not determined due to research needing to be done on both sides, sometimes not knowing how long it would take. EFFECT Absent the inclusion of all required medical loss ratio information, the Department cannot demonstrate compliance with Federal regulations. CONTEXT During our audit period of July 1, 2020, through June 30, 2022, the Department of Human Services contracted with one MCO health plan that was subject to MLR Federal reporting requirements. Where sampling was performed, the audit used a non-statistical sampling method. IDENTIFICATION AS A REPEAT FINDING Not a repeat finding. RECOMMENDATION We recommend the Department of Human Services ensures the medical loss ratio report is finalized as outlined in the contract and all required documentation is properly maintained. DEPARTMENT OF HUMAN SERVICES RESPONSE The Department agrees with the finding. See ?Management?s Response and Corrective Action? section of this report.

Finding: 2022-010 Department of Human Services Response/Corrective Action Plan: The Department agrees with the finding. When the Department had to re-procure the Medicaid Expansion MCO contract for a January 1, 2022, start date, the contract was overhauled and made much more specific in terms of the MLR requirements, so we do not anticipate the same issues happening again. Below is contract language that addresses this finding. Appendix E, Article 1 10. Reporting requirements 1. MCO shall submit two reports to STATE that includes at least the following information for each MLR Reporting Year, one of which excludes the adjustments identified in (I) and (C)(3)(d) above: 1. Total incurred claims. 2. Expenditures on quality improving activities. 3. Expenditures related to activities compliant with program integrity requirements (42 C.F.R. ?438.608(a)(1) through (5), (7), (8) and (b)). 4. Non-claims costs. 5. Premium revenue. 6. Taxes, licensing, and regulatory fees. 7. Methodology(ies) for allocation of expenditures. 8. Any credibility adjustment applied. 9. The calculated MLR. 10. Any remittance owed to STATE, if applicable. 11. A comparison of the information reported in this paragraph with the audited financial report required under 42 C.F.R. ?438.3(m). 12. A description of the aggregation method used under paragraph (F) of this article. 13. The number of Member Months. 2. MCO must require any third-party vendor providing claims adjudication activities to provide all underlying data associated with MLR reporting to that MCO within 180 days of the end of the MLR Reporting Year or within 30 days of being requested by MCO whichever comes sooner, regardless of current contractual limitations, to calculate and validate the accuracy of MLR reporting. 3. Prior to ten (10) months following the applicable MLR Reporting Year, MCO must submit the report required in paragraph (I)(1) of this article based on data including eight (8) months of claims run out. 4. MCO shall attest to the accuracy of the calculation of the MLR in accordance with requirements of this article when submitting the report required under this paragraph. 2. Prior to eleven (11) months following the applicable MLR Reporting Year or a mutually agreed upon alternative date, STATE shall finalize the MLR Reporting Year with any balance due to STATE as required in paragraph (H) of this article within sixty (60) days. Contact Person: Jared Ferguson, Medicaid Expansion Administrator Anticipated Completion Date: Already Completed

?See Schedule of Findings and Questioned Costs for chart/table? CONDITION The Department of Human Services is not properly monitoring corrective orders issued to child care providers and performing re-inspections of identified deficiencies within specified time frames. 5 of 586 corrective orders issued during our audit period did not identify a date the orders were corrected. 187 of 586 (32%) corrective orders were not re-inspected within the 24-hour, 20-day, or 60-day time frame allowed for correction. 8 of 586 (1%) correction orders indicated correction before the violation date which potentially could mean inaccurate dates were being tracked. CRITERIA North Dakota Century Code (NDCC) section 50-11.1-07.2 requires that the Department or the Department's authorized agency issue a correction order whenever it is determined upon inspection that a program or premises is not in compliance with this chapter or rules adopted under this chapter. NDCC section 50-11.1-07.3 requires the Department or the Department's authorized agency shall re-inspect an early childhood program issued a correction order under NDCC section 50-11.1-07.2, at the end of the period allowed for correction. 45 CFR 98.41 requires that lead agencies must certify that procedures are in effect to ensure that providers serving children who receive subsidies comply with all applicable health and safety requirements. 45 CFR 75.303 states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. CAUSE The Department's procedures for monitoring the resolution of corrective orders is ineffective. Due to employee turnover and the lack of guidance, corrective orders and dates are not consistently documented on the tracking sheet. EFFECT Child care providers are operating without proper follow-up of corrective orders potentially jeopardizing the health and safety of children. CONTEXT During fiscal years 2021 and 2022, there were 1,170 licensed providers in North Dakota receiving payments from the Child Care Assistance program. The following list is the number of corrective orders issued by calendar year: 2022 - 152 (through July) 2021 - 291 2020 - 143 (July through December) Where sampling was performed, the audit used a non-statistical sampling method. IDENTIFICATION AS A REPEAT FINDING Finding 2020-011 was reported in the immediate prior year. Findings 2018-013 and 2016-026 were made in previous years. RECOMMENDATION We recommend the Department of Human Service improve procedures to ensure child care correction orders are resolved before the end of each allowed correction period with accurate tracking of dates. DEPARTMENT OF HUMAN SERVICES RESPONSE The Department of Health and Human Service agrees with this recommendation. See ?Management?s Response and Corrective Action? section of this report.

Finding: 2022-012 Department of Human Services Response/Corrective Action Plan: The Department of Health and Human Service agrees with this recommendation. The Department has been working with a developer to create a Child Care Licensing Data System to replace a paper process and multiple spreadsheets. The system allows each licensing specialist to see their workflow when they log into the system. It also notifies when a reinspection is needed and will escalate the notice if the reinspection is not done timely. Contact Person: Carmen Traeholt, Child Care Licensing Administrator Anticipated Completion Date: The data system launched in December 2022.

2020-011

?See Schedule of Findings and Questioned Costs for chart/table? CONDITION The Department of Human Services is not performing annual unannounced inspections of child care providers in operation. An annual unannounced inspection was not completed on 9 of 71 providers that were tested. CRITERIA 45 CFR 98.42(b)(2)(B) requires that not less than annually, an unannounced inspection for compliance with all child care licensing standards, which shall include an inspection for compliance with health and safety and fire standards, shall be completed. Department policy 620-01-116 states, the authorized agent is required to perform an unannounced review at least annually for each licensed or self-declared child care provider. 45 CFR 75.303 states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. CAUSE The Department's procedures for ensuring unannounced visits are performed annually is ineffective. EFFECT Child care providers are operating child care facilities without proper monitoring of whether health and safety conditions have been met. CONTEXT During fiscal years 2021 and 2022 there were 1,871 providers from the Child Care Assistance program. The 12.7% error rate applied to the population would result in an estimated 237 providers not receiving unannounced visits. Errors were found within group, center, and self-declared providers. Where sampling was performed, the audit used a non-statistical sampling method. IDENTIFICATION AS A REPEAT FINDING Finding 2020-015 was reported in the immediate prior year. Findings 2018-017 and 2016-027 were made in previous years. RECOMMENDATION We recommend the Department of Human Services develop corrective action and perform annual unannounced inspections of child care providers in operation in accordance with 45 CFR 98.42(b)(2)(B) and Department policy. DEPARTMENT OF HUMAN SERVICES RESPONSE The Department agrees with the recommendation. See ?Management?s Response and Corrective Action? section of this report.

Finding: 2022-013 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. The Child Care Licensing System (CCL) went live Dec. 2022, CCL will add upcoming unannounced visits to Licensing Specialist?s work que. Licensing Supervisors and the Licensing Administrator will run a monthly report to assure unannounced visits are being completed by the Licensing Specialists. Contact Person: Carmen Traeholt, Child Care Licensing Administrator Anticipated Completion Date: Completed January 2023

2020-015

?See Schedule of Findings and Questioned Costs for chart/table? CONDITION We identified an individual receiving LIHEAP benefits when they were living at one of their parents' houses rent-free. There was no rental contract on file or adequate documentation to allow this individual to receive LIHEAP benefits. We identified a known error of $749.37. When projected against the population, the remaining likely projected error is $302,293.17. CRITERIA 45 CFR 75.303 states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. DHS LIHEAP policy 415-20-10-35, "Households that receive rent-free housing including fuel as a required condition of part of an employment agreement, or as a gift, or through legal action (separation/divorce), are NOT vulnerable to the rising cost of heat and are therefore not eligible for heating assistance from LIHEAP." CAUSE County eligibility workers did not obtain enough documentation to confirm that the case was in compliance with DHS LIHEAP policy 415-20-10-35. EFFECT Improper overpayment of LIHEAP benefits. CONTEXT During state fiscal years, approximately 189,548 payments, totaling $34 million, were processed through the Department of Human Services' Legacy and SPACES eligibility systems. From the SPACES system there were 88,917 payments totaling $15.5 million and from the LEGACY system there were 100,631 payments totaling $18.4 million. The State Auditor's office performed a test of 80 payments, 40 from LEGACY and 40 from SPACES. The SPACES sample of payments was stratified with 66,548 payments under $200 (13 tested); 21,606 payments from $200-$999 (tested 24); and 763 payments with amount over $1,000 (tested 3). The error was identified in eligibility testing of payment records from the SPACES system which were approximately $15.5 million, and projected within stratified payments individually less than $200 ($5.28 million, 66,548 payments). Where sampling was performed, the audit used a non-statistical sampling method. IDENTIFICATION AS A REPEAT FINDING Not a repeat finding. RECOMMENDATION We recommend the Department of Human Services ensure adequate rental documentation is on file and proper eligibility determinations of the Low-Income Home Energy Assistance Program (LIHEAP) are made. DEPARTMENT OF HUMAN SERVICES RESPONSE The Department agrees with the recommendation. See ?Management?s Response and Corrective Action? section of this report.

Finding: 2022-015 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. The Department will ensure eligibility workers are properly trained to determine and verify eligibility for households that are NOT vulnerable as they are receiving rent-free housing that includes the cost of fuel (for heating). Contact Person: Rachel Iverson Schafer Director of Program Administration Anticipated Completion Date: Update policy for FY2024 heating season and include in the FY2024 training. Updated policy by October 1, 2023. Training to be completed by October 29, 2023.

?See Schedule of Findings and Questioned Costs for chart/table? CONDITION We found that, of the 40 cases tested from the Department of Human Services' (DHS) Legacy system for proper eligibility, 17 cases were processed as eligible without a worker verifying eligibility information through the State NDVerify system. Under the LIHEAP FFY 2021 and FFY 2022 Detailed Model Plan (SF-424) of the State Plan, Monitoring section, NDVerify is identified as the monitoring schedule and protocol under section 10.6. This section in the State Plan is the response for covering 45 CFR ? 75.342, Monitoring and Reporting Program Performance. The Department implemented a new SPACES eligibility system for LIHEAP which was used for the 2022 heating season. NDVerify is integrated into the SPACES system and there were no errors in testing that NDVerify in SPACES was searched for the 2022 heating season eligibility. CRITERIA 45 CFR 75.342(a), Monitoring by the Non-Federal Entity, states the non-Federal entity is responsible for oversight of the operations of the Federal award supported activities. The non-Federal entity must monitor its activities under Federal awards to assure compliance with applicable Federal requirements and performance expectations are being achieved. Monitoring by the non-Federal entity must cover each program, function or activity. Within the Detailed Model Plan (SF-424), section 10.6 (Monitoring), of the FFY 2021 and FFY 2022 State Plans, DHS submitted monitoring schedule and protocol using NDVerify. "The North Dakota Department of Human Services has built a web-based verification system called NDVerify that streamlines the search of different interfaces/sources to obtain verification electronically. NDVerify allows eligibility workers to search multiple interfaces/sources for all household members included in a LIHEAP case at the same time. NDVerify also stores the search based on the date completed for historical purposes." 45 CFR 75.303 states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. CAUSE NDVerify was not integrated with the Legacy System. The DHS does not have a policy specifically requiring workers to perform NDVerify checks for all applications. While the Detailed Model Plan (SF-424) of the State Plan identifies several eligibility checks to integrated information through NDVerify, the DHS considers the use of NDVerify as optional and an available resource rather than a requirement. EFFECT Without verifying information with available state interfaces, there is no way to tell if the applicant is providing all the necessary information and this could impact eligibility determinations. The following sources/interfaces are included with NDVerify: Birth/Death Records (ND Vital Records) Health Insurance (DEERS) ND Child Support ND Department of Corrections ND Motor Vehicle/Watercraft (Motor Vehicle/Game & Fish) ND State Directory of New Hire ND State Hospital Admission/Discharge ND Unemployment Insurance Benefits (Job Service) ND Wages (Job Service) Other Benefit Information (SSA) SNAP Intentional Program Violations WSI Medical Claims Status Request UPA Request 40 Quarters Systematic Alien Verification for Entitlements (SAVE) CONTEXT The Department utilized the Legacy system for the 2021 heating season. Per the FFY 2021 Household report, there were 14,282 applications and $18,407,731.73 in payments for the LIHEAP Program. DHS implemented the SPACES system for the 2022 heating season. NDVerify is integrated with SPACES and there were no errors in testing that NDVerify was used within SPACES. Where sampling was performed, the audit used a non-statistical sampling method. IDENTIFICATION AS A REPEAT FINDING Not a repeat finding. RECOMMENDATION We recommend the Department of Human Services ensure eligibility is verified through the State NDVerify system prior to approval of all LIHEAP applications or revise the State Plan to identify the use of NDVerify as optional for approval by the Federal awarding agency. DEPARTMENT OF HUMAN SERVICES RESPONSE The Department disagrees with this finding. See ?Management?s Response and Corrective Action? section of this report. AUDITOR?S CONCLUDING COMMENTS DHS informed the Federal agency of their procedures for Program Integrity in Section 17 of the state plan, ?All sources and types of income that exceed $500 per year must be verified.? DHS also, outlines under their monitoring procedures in the State plan that the eligibility workers have access to the NDVerify system to verify identification and income. NDVerify allows DHS to obtain identification and income records such as birth/death records, health insurance, child support, new hire information, unemployment insurance benefits, social security administration, supplemental nutrition assistance program benefits, etc. Relying solely on hard copies from the applicant to determine eligibility and not cross-checking the information for accuracy is not verifying all sources nor following procedures that were identified to the Federal agency in the state plan.

Finding: 2022-017 Department of Human Services Response/Corrective Action Plan: The Department disagrees with the recommendation. NDVerify allows eligibility workers to search multiple interfaces/sources for all household members included in a LIHEAP case at the same time, however, the Department does allow for other means, such as hard copy verification from the applicant or a third-party, to support eligibility determinations. It is important to note, since fully transitioning to SPACES, no errors have been noted. Contact Person: Rachel Iverson Schafer Director of Program Administration Anticipated Completion Date ND Verify will continue to be a source for workers to utilize. FY2024 LIHEAP training will continue to train on the value of using this interface.

?See Schedule of Findings and Questioned Costs for chart/table? CONDITION The Department of Human Services, Emergency Rental Assistance (ERA) program, incorrectly calculated monthly rental assistance amounts by using the incorrect monthly rent amount and transition percentage for the applicable month of assistance. More specifically, 1 out of the 60 households sampled received monthly assistance in excess of the proper calculated payment amounts resulting in total overpayments of $977 and total likely projected questioned costs of $155,267. CRITERIA 2 CFR 200.303 states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. ND ERA Policies & Procedures states that, "North Dakota will implement a payment coverage structure that provides applicants with rental assistance required while supporting their transition from relying on rental assistance. Availability of assistance will be structured as follows: Months one (1) through six (6): 100% of rent will be eligible, Months seven (7) through ten (10): 85% of rent will be eligible, Months (11) through eighteen (18): 70% of rent will be eligible". The outlined policy allows for an individual to receive up to twelve months of total rental assistance including 100% of their monthly rent for the first 6 months, 85% of their monthly rent for the next four months, and 70% of their monthly rent for the final two months. CAUSE The Department of Human Services, Emergency Rental Assistance (ERA) program, review did not identify correct monthly rent amounts and applied incorrect assistance percentages used to calculate the monthly ERA payments. EFFECT The Department issued payments that were not allowable under the Emergency Rental Assistance program. CONTEXT During state fiscal years, approximately 11,178 applications, totaling $46 million were processed by the Department. The State Auditor's office performed a test of sixty applications with one error that resulted in an overpayment of $977 and projected to additional likely questioned costs of $155,267. Where sampling was performed, the audit used a non-statistical sampling method. IDENTIFICATION AS A REPEAT FINDING Not a repeat finding. RECOMMENDATION We recommend the Department of Human Services (ERA Program) ensure monthly payment amounts are calculated correctly and reviewed for accuracy. Additionally, we recommend the Department ensure the improper payments are recouped through the ERA program's refunding process. DEPARTMENT OF HUMAN SERVICES RESPONSE The Department of Human Services agrees with the recommendation. See ?Management?s Response and Corrective Action? section of this report.

Finding: 2022-018 Department of Human Services Response/Corrective Action Plan: The Department of Human Services agrees with the recommendation. The Department will ensure rent changes are accurately reflected in Service Now and therefore the monthly amount is calculated accurately. If a payment is issued in excess of what the household is eligible to receive, it is standard practice for DHS to request refunds or apply payments to future months of the renter?s direct rental obligation or direct utility assistance (as per the state?s program/policy manual). Contact Person: Nikki Aden, Director Housing Stability Anticipated Completion Date: Complete.

?See Schedule of Findings and Questioned Costs for chart/table? CONDITION During our testing of eligibility, we noted that eligibility was not properly determined by the Department of Human Services (DHS) for 1 of 60 CHIP cases that were tested. For this case, the income exceeded the Federal Poverty Line (FPL) threshold for CHIP. This resulted in a known Federal error for this case of $498 with a likely additional federal questioned cost of $52,643. CRITERIA 42 CFR 457.965 states the State must include in each applicant's record facts to support the State's determination of the applicant's eligibility for Children's Health Insurance Program (CHIP). 45 CFR 75.303 states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. 42 CFR 431.804 ?Eligibility error? is an error resulting from the States' improper application of Federal rules and the State's documented policies and procedures that causes a beneficiary to be determined eligible when he or she is ineligible for Medicaid or CHIP, causes a beneficiary to be determined eligible for the incorrect type of assistance, causes applications for Medicaid or CHIP to be improperly denied by the State, or causes existing cases to be improperly terminated from Medicaid or CHIP by the State. An eligibility error may also be caused when a redetermination did not occur timely or a required element of the eligibility determination process (for example income) cannot be verified as being performed/completed by the state. 42 CFR 431.960(b)(1) A data processing error is an error resulting in an overpayment or underpayment that is determined from a review of the claim and other information available in the State's Medicaid Management Information System, related systems, or outside sources of provider verification resulting in Federal and/or State improper payments.) CAUSE Since the income was over the FPL for CHIP, the Department stated that state's system, SPACES, should have sustained benefits under the existing coverage which, in this one case was Medicaid (Affordable Care Act Child). The Department stated the SPACES system failed to sustain the benefits under Medicaid. Both Medicaid and CHIP are fee-for-service programs and the total payment amount was not impacted.) EFFECT The Department incorrectly claimed the FMAP rate for CHIP rather than Medicaid based on the child's category of eligibility. CONTEXT There were 18,177 payments totaling $26.2 million made during the audit period from CHIP. The individual case was from a stratified population of $17,965,913 for individual payment amounts between $1,000 to $49,999. The payment of $4,134 was projected to this stratified population of CHIP payments. The FMAP rates were then applied to the payment and the projection amount to determine the Federal amount in error which were calculated as the difference between the CHIP FMAP rate (71.85%) and Medicaid FMAP rate (59.79%). Where sampling was performed, the audit used a non-statistical sampling method. IDENTIFICATION AS A REPEAT FINDING Finding 2020-002 was reported in the immediate prior year. Findings 2018-002 and 2016-004 were reported in previous years. The prior audit finding was reported as implemented on the summary schedule of prior audit findings. This materially misrepresents the status of the finding for CHIP. RECOMMENDATION We recommend the Department of Human Services review the SPACES system edit checks and ensure eligibility determinations made for the CHIP programs are proper. We also recommend corrections to payments and Federal reimbursement of CHIP. DEPARTMENT OF HUMAN SERVICES RESPONSE The Department agrees with this recommendation. See ?Management?s Response and Corrective Action? section of this report.

Finding: 2022-019 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. Due to Medicaid continuous enrollment requirements ending on March 30, 2023, the SPACES system will be converted back to its normal rules and this issue should not happen again. The Department will do a review of CHIP eligibility to ensure incorrect claims are identified and corrected. Claims paid in error will be adjusted to reflect the proper category of eligibility, so the applicable fund code is applied, which will apply the correct FMAP. Contact Person: Erik Elkins, Assistant Director, Medical Services Anticipated Completion Date: April 30, 2023

2020-002

?See Schedule of Findings and Questioned Costs for chart/table? CONDITION The Department of Human Services did not meet the level of effort requirement for pregnant women and women with dependent children as they were unable to provide tracking information on the expenditures for the related services provided during the audit for the 2019 and 2020 grant awards. At a minimum, the Department was required to maintain a level of effort of the 1994 base amount which was $254,665. Since the Department was unable to identify expenditures for the 2019 and 2020 grant awards, the known error is $509,330. CRITERIA 45 CFR 75.303 states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Per 45 CFR 96.124(c): (1) The State for fiscal year 1993 shall expend not less than five percent of the grant to increase (relative to fiscal year 1992) the availability of treatment services designed for pregnant women and women with dependent children (either by establishing new programs or expanding the capacity of existing programs). The base for fiscal year 1993 shall be an amount equal to the fiscal year 1992 alcohol and drug services Block Grant expenditures and State expenditures for pregnant women and women with dependent children as described in paragraph (e) of this section, and to this base shall be added at least 5 percent of the 1993 Block Grant allotment. The base shall be calculated using Generally Accepted Accounting Principles and the composition of the base shall be applied consistently from year to year. States shall report the methods used to calculate their base for fiscal year 1992 expenditures on treatment for pregnant women and women with dependent children. (2) For fiscal year 1994, the State shall, consistent with paragraph (c)(1) of this section, expend not less than five percent of the grant to increase (relative to fiscal year 1993) the availability of such services to pregnant women and women with dependent children. (3) For grants beyond fiscal year 1994, the States shall expend no less than an amount equal to the amount expended by the State for fiscal year 1994. CAUSE The Department indicated there are no providers offering these specialized treatment services for pregnant women and women with dependent children. EFFECT Noncompliance with 45 CFR 96.124(c) to provide treatment services designed for pregnant women and women with dependent children at no less than an amount equal to the amount expended by the State for fiscal year 1994. Pregnant women addicted to drugs or alcohol face significant risks. The drug rehab programs for pregnant women and women with children provide specific services and support. CONTEXT The 2019 and 2020 grant years were the only grants to close during the audit period. The 1994 base amount is $254,655 per grant year. The substance abuse program expenditures for SFY 2021 were $10,447,419 and SFY 2022 were $6,310,633 as reported on the SFY 2021, 2022 Schedule of Expenditures of Federal Awards for CFDA 93.959. Where sampling was performed, the audit used a non-statistical sampling method. IDENTIFICATION AS A REPEAT FINDING Not a repeat finding. RECOMMENDATION We recommend the Department of Human Services develop corrective action and expend, at a minimum, the amount expended by the State for fiscal year 1994, for the availability of treatment services designed for pregnant women and women with dependent children either by establishing new programs or expanding the capacity of existing programs DEPARTMENT OF HUMAN SERVICES RESPONSE The Department agrees with the recommendation. See ?Management?s Response and Corrective Action? section of this report.

Finding: 2022-020 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. These services were provided by a contracted vendor in two separate sites in different cities for over ten years. In October 2018, due to staffing performance concerns and licensing investigations, the state ended the contract with this vendor in one city. In April 2019 the vendor ended the contract in the second city. Three Requests for Proposals have been issued since that date and no proposals were received. Market research was conducted with several potential providers and due to lack of interest, capacity concerns, workforce issues as well as the effects of the COVID-19 pandemic, the department has been unable to meet the expenditure requirements. The Department has met several times with the Federal Substance Abuse and Mental Health Services Administration regarding this issue. Currently the Department is requesting funding from the North Dakota Legislative Assembly to develop of a Pregnant and Parenting Women?s Residential Treatment Program within the Department. If approved, the Department will work to secure locations and renovate spaces that is not allowable with the Federal Funds. Contact Person: Lacresha Graham, Manager Addiction Treatment and Recovery Program and Policy Anticipated Completion Date: September 2023

?See Schedule of Findings and Questioned Costs for chart/table? CONDITION The Department of Human Services made payments under the Vocational Rehabilitation program outside of the period of performance for the 2019 grant award which had a period of performance of 10/1/18 - 9/30/19 with an allowable liquidation period through 1/31/2021. More specifically, the program charged $2,454 to the 2019 grant award when the underlying obligations actually occurred during the 2020 grant award period of performance. CRITERIA The following criteria note that Federal funds must be obligated by the end of the two-year period of performance window and those obligations must be liquidated within 120 days after the end date of period of performance. 2 CFR 200.344 requires: " Unless the Federal awarding agency or pass-through entity authorizes an extension, a non-Federal entity must liquidate all obligations incurred under the Federal award not later than 120 calendar days after the end date of the period of performance as specified in the terms and conditions of the Federal award.? 34 CFR 361.64 requires: " (a) Except as provided in paragraph (b) of this section, any Federal funds, including reallotted funds, that are appropriated for a fiscal year to carry out a program under this part that are not obligated by the State by the beginning of the succeeding fiscal year and any program income received during a fiscal year that is not obligated by the State by the beginning of the succeeding fiscal year remain available for obligation by the State during that succeeding fiscal year. (b) Federal funds appropriated for a fiscal year remain available for obligation in the succeeding fiscal year only to the extent that the State met the matching requirement for those Federal funds by obligating, in accordance with 34 CFR 76.707, the non-Federal share in the fiscal year for which the funds were appropriated." The following criteria pertains to the establishment and maintenance of effective internal control to ensure payments are made within the correct period of performance. 2 CFR 200.303 states the non-Federal entity must, "establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." CAUSE The Department of Human Services, Vocational Rehabilitation Program, review of the expenditure period of performance, as outlined in its period of performance procedures, were not followed. Therefore, the grant award monitoring procedures were unable to detect payments made outside of the period of performance. EFFECT Unallowable costs totaling $2,454 were charged to the 2019 grant award with a total projected questioned cost amount of $41,717. CONTEXT The Department of Human Services, Vocational Rehabilitation program, had expenditures of $412,720 after the obligation period for the 2019 and 2020 awards. Of this amount, one payment totaling $2,454 was identified by sampling as an error. Where sampling was performed, the audit used a non-statistical sampling method. IDENTIFICATION AS A REPEAT FINDING Finding 2020-019 was reported in the immediate prior year. Findings 2018-031 and 2016-053 were reported in previous years. The prior audit finding was reported as implemented on the summary schedule of prior audit findings. This materially misrepresents the status of the finding. RECOMMENDATION We recommend the Department of Human Services follow its procedures to prevent and detect Vocational Rehabilitation payments from occurring outside the period of performance. DEPARTMENT OF HUMAN SERVICES RESPONSE The Department of Health and Human Services agrees with the recommendation. See ?Management?s Response and Corrective Action? section of this report.

Finding: 2022-021 Department of Human Services Response/Corrective Action Plan: The Department of Health and Human Services agrees with the recommendation. The Department will run reports from AWARE quarterly to identify any payments made from the system that were charged to the incorrect period of performance. Contact Person: April Haring, Program Accountant for Vocational Rehabilitation Anticipated Completion Date: The Department began running the report in December 2022.

2020-019

?See Schedule of Findings and Questioned Costs for chart/table? CONDITION The Department of Public Instruction did not formally track that letters of intent were received from all non-public schools. CRITERIA 18005(a) CARES Act: Section 18005(a) of the CARES Act requires a Local Educational Agency (LEA) that receives funds under the ESSER Fund to provide equitable services in the same manner as provided under section 1117 of the Elementary and Secondary Education Act of 1965 (ESEA) to students and teachers in non-public schools, as determined in consultation with representatives of non-public schools. 1117(b)(1) of the ESEA: (b)CONSULTATION. ? (1) IN GENERAL.?To ensure timely and meaningful consultation, a local educational agency shall consult with appropriate private school officials during the design and development of such agency?s programs under this part. Such agency and private school officials shall both have the goal of reaching agreement on how to provide equitable and effective programs for eligible private school children, the results of which agreement shall be transmitted to the ombudsman designated under subsection (a)(3)(B). 34 CFR 76.665(b)(1): An LEA must promptly consult with representatives of non-public elementary and secondary schools during the design and development of the LEA's plans to spend funds from a CARES Act program and before the LEA makes any decision affecting the opportunities of students and teachers in non-public schools to benefit from those funds. As provided in section 1117(b)(1) of the ESEA, the LEA and non-public school officials shall both have the goal of reaching timely agreement on how to provide equitable and effective programs for non-public school students and teachers. 2 CFR 200.303(a) states that non-Federal entities must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. CAUSE The Department of Public Instruction stated that they manually tracked the letters of intent but did not retain a record of this process to support that all letters of intent were received. EFFECT The lack of adequate procedures for tracking non-public school letters of intent increase the risk of non-public schools not participating in the program. CONTEXT The Department of Public Instruction (DPI) is responsible for initiating the consulting process by contacting representatives in all non-public schools in the state to notify them of the opportunity for their students and teachers to obtain equitable services. If non-public school officials want equitable services for their students and teachers, DPI must consult with those officials before DPI makes any decision that affects the opportunity of non-public school to participate in the activities funded under the CARES Act programs. If a non-public school declines to participate in the CARES Act programs or does not respond to DPI's good-faith effort to make contact, DPI has no further responsibility to provide equitable services to students or teachers in that school. However, DPI must be able to demonstrate that it made a good faith effort to contact all the nonpublic schools in the state. Where sampling was performed, the audit used a non-statistical sampling method. IDENTIFICATION AS A REPEAT FINDING Not a repeat finding. RECOMMENDATION We recommend the Department of Public Instruction improve procedures for tracking to ensure all Education Stabilization program letters of intent from non-public schools are received in order to verify all of them were contacted. DEPARTMENT OF PUBLIC INSTRUCTION RESPONSE The Department of Public Instruction agrees with this finding. See ?Management?s Response and Corrective Action? section of this report.

Finding: 2022-025 Department of Public Instruction Response/Corrective Action Plan: The Department of Public Instruction agrees with this finding. The Department of Public Instruction is reviewing and rewriting ESSER I Equitable Services internal procedures to ensure that the records are retained in digital format. Contact Person Ann Ellefson, Academic Support Director Anticipated Completion Date This process will be completed by March 31, 2023.

?See Schedule of Findings and Questioned Costs for chart/table? CONDITION The Department of Public Instruction did not meet the maintenance of effort requirement for the 2021-2022 school year for the Supporting Effective Instruction program during the audit period. CRITERIA 34 CFR section 299.5a General. An LEA receiving funds under an applicable program listed in paragraph (b) of this section may receive its full allocation of funds only if the SEA finds that either the combined fiscal effort per student or the aggregate expenditures of State and local funds with respect to the provision of free public education in the LEA for the preceding fiscal year was not less than 90 percent of the combined fiscal effort per student or the aggregate expenditures for the second preceding fiscal year. SEC. 8521 of the Elementary and Secondary Education Act of 1965 (ESEA) (20 U.S.C. 7901) MAINTENANCE OF EFFORT. (a) IN GENERAL.?A local educational agency may receive funds under a covered program for any fiscal year only if the State educational agency finds that either the combined fiscal effort per student or the aggregate expenditures of the agency and the State with respect to the provision of free public education by the agency for the preceding fiscal year was not less than 90 percent of the combined fiscal effort or aggregate expenditures for the second preceding fiscal year, subject to the requirements of subsection (b). 2 CFR 200.303(a) states that non-Federal entities must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. CAUSE The Department of Public Instruction indicated that a waiver for the maintenance of effort requirement for the 2021-2022 school year was received. However, they were unable to locate any documentation supporting the waiver. EFFECT The Department of Public Instruction is not in compliance with the 90% maintenance of effort requirement for the 2021-2022 school year. CONTEXT The Department of Public Instruction distributed $9,575,000 in Federal funds under the Supporting Effective Instruction program to 159 different school districts during the 2021-2022 school year. Where sampling was performed, the audit used a non-statistical sampling method. IDENTIFICATION AS A REPEAT FINDING Not a repeat finding. RECOMMENDATION We recommend the Department of Public Instruction ensure the maintenance of effort requirement is met in accordance with the Supporting Effective Instruction program guidelines. DEPARTMENT OF PUBLIC INSTRUCTION RESPONSE The Department of Public Instruction agrees with the finding. See ?Management?s Response and Corrective Action? section of this report.

Finding: 2022-030 Department of Public Instruction Response/Corrective Action Plan: The Department of Public Instruction agrees with the finding. All pertinent information pertaining to the allocation of Title Program funds will be stored in a single location, both physical and electronic. Contact Person Jamie Mertz, Fiscal Management Director Anticipated Completion Date March 1, 2023

?See Schedule of Findings and Questioned Costs for chart/table? CONDITION The Department of Public Instruction (DPI) incorrectly included neglected or delinquent facilities as part of their Title IIA allocation to Local Educational Agencies (LEA). We selected a sample of 36 and identified a 100% error rate. The total known allocation error identified was $62,546.99. When projected against the population, the total projected error is $115,041.65. CRITERIA The Elementary and Secondary Education Act of 1965 (ESEA Section 2102(a)(1)) states, the State, acting through the State educational agency (DPI), shall award subgrants to eligible local educational agencies. 2 CFR 200.303(a) states that non-Federal entities must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. CAUSE The Department of Public Instruction was unaware that neglected and delinquent facilities could not be included in their Title IIA allocation calculations and on subrecipient's grant awards. EFFECT The Department did not comply with the allocation requirements to LEAs for Title IIA grants. CONTEXT The Department of Public Instruction allocated $9,503,744 in Federal funds to 183 school districts during the 2020-2021 school year and $9,603,024 in Federal funds to 170 school districts during the 2021-2022 school year. Where sampling was performed, the audit used a non-statistical sampling method. IDENTIFICATION AS A REPEAT FINDING Not a repeat finding. RECOMMENDATION We recommend the Department of Public Instruction ensure the Title IIA allocations are calculated based on the Federal requirements. DEPARTMENT OF PUBLIC INSTRUCTION RESPONSE The NDDPI agrees with the recommendation. See ?Management?s Response and Corrective Action? section of this report.

Finding: 2022-032 Department of Public Instruction Response/Corrective Action Plan: The NDDPI Agrees with the recommendation. When calculating 2023-2024 and future allocations, the NDDPI will ensure compliance with ESEA Section 2102(a)(1) and will not include Neglected and Delinquent facilities in the allocation or equitable share processes. Additionally, the NDDPI will communicate the change in practices to impacted public school districts and Neglected and Delinquent facilities during spring/summer 2023. Contact Person Allocations: Jamie Mertz, Fiscal Management Director Correspondence: Ann Ellefson, Academic Support Director Anticipated Completion Date The process will be complete by July 1, 2023.

See Schedule of Findings and Questioned Costs for chart/table CRITERIA 2 CFR 200.510(b)(1-6), states that the grantee is responsible for the accurate preparation of the Schedule of Federal Awards. According to "Standards for Internal Control in the Federal Government" quality information needs to be communicated to enable personnel to perform key roles in achieving the entities objectives. (GAO-14.704G paragraphs 14.02 and 14.03) CONDITION The Department of Commerce does not have proper controls in place to ensure accuracy of the data that is included on the Schedule of Expenditures of Federal Awards (SEFA). The following was noted on the fiscal year 2019 SEFA: ? An independent review was not performed on the Schedule of Expenditures of Federal Awards. ? The total amount of expenditures was overstated by $11.2 million. Of that amount: o The Community Development Block Grant program was overstated by $5.5 million. o The Community Services Block Grant program was overstated by $3.2 million. o The HOME Investment Partnerships Program was overstated by $3.1 million. o The Weatherization Assistance for Low-Income Persons was overstated by $2.5 million CAUSE Due to employee turnover, inexperienced staff prepared the SEFA without supervisory review EFFECT Inaccurate information was initially reported in the Schedule of Expenditures of Federal Awards and detected and corrected through the audit. CONTEXT Incorrect expenditures reported on the fiscal year 2019 SEFA totaled $11.2 million and affected 14 programs. For fiscal year 2019, 100% (2 out of 2) of the Federal programs reviewed as major programs had incorrect expenditure amounts reported on the SEFA. These 2 programs made up 53% ($8.2 million) of the overall total corrected Federal expenditures ($14.7 million) listed on the Department of Commerce's SEFA for fiscal year 2019. RECOMMENDATION We recommend the Department of Commerce accurately prepare and perform an independent review of the Schedule of Expenditures of Federal Awards. DEPARTMENT OF COMMERCE RESPONSE/CORRECTIVE ACTION PLAN See ?Management?s Response and Corrective Action? section of this report.

Finding: 2020-001 Department of Commerce Response/Corrective Action Plan: The Department of Commerce agrees with the recommendation and will ensure accurate preparation of the Schedule of Expenditures of Federal Awards and the schedule will be reviewed by the Lead Fiscal Officer before being submitted. Contact Person: Celeste Engelhard, Lead Fiscal Officer Anticipated Completion Date: We immediately put our corrective action plan into place. The 2020 SEFA was completed and reviewed before being submitted to the Office of Management and Budget.

See Schedule of Findings and Questioned Costs for chart/table CRITERIA 42 CFR 431.10 states the State Medicaid Agency or its designee is required to determine client eligibility in accordance with eligibility requirements defined in the approved State plan. 42 CFR 435.603 (a)(2) states that the agency must apply the financial methodologies set forth in this section in determining the financial eligibility of all individuals for Medicaid. 42 CFR 457.965 states the State must include in each applicant's record facts to support the State's determination of the applicant's eligibility for CHIP. 45 CFR 75.303 states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. CONDITION During our testing of eligibility, we noted that eligibility was not properly determined by the Department of Human Services (DHS) in the Children's Health Insurance Program and Medicaid. DHS did not properly determine eligibility in 4 of 60 Children's Health Insurance Program (CHIP) cases reviewed. Each of the cases were missing either income verifications, a narrative to support determinations, or both. The errors resulted in improper payments totaling $4,659. When projected against the entire population, the likely questioned costs total $1,119,228. DHS did not properly determine eligibility in 1 of the 60 Medicaid cases reviewed due to a lack of updated income information on the individual. As a result, auditor was unable to determine if the individual should have been eligible for Medicaid or not. The error resulted in an improper payment totaling $123. When projected against the entire population, the likely questioned costs total $695,468. The Department's Quality Control Unit did their own review and also identified eligibility determination errors as noted below. The eligibility testing required by Center for Medicare and Medicaid Services (CMS) performed by the Department's Quality Control Unit for the calendar year 2019 for the Medicaid program identified 14 of the 200 active cases tested had eligibility determination errors, an error rate of 7%. While 35 out of the 200 negative cases tested had eligibility determination errors, an error rate of 17.5%. The eligibility testing required by Center for Medicare and Medicaid Services (CMS) performed by the Department's Quality Control Unit for the calendar year 2019 for the Children's Health Insurance Program (CHIP) identified 27 of the 200 active cases tested had eligibility determination errors, an error rate of 13.5%. While 28 out of the 200 negative cases tested had eligibility determination errors, an error rate of 14%. Due to the public health emergency (Covid-19) CMS has changed its requirements for the payment review portion of active cases. It is no longer required to determine payment error amounts. As a result, we are unable to identify improper Federal payment amounts for the eligibility errors of the Department's Quality Control Unit testing. CAUSE The Department is not documenting how the amount of income was determined. Also, the Department is relying on applicants to provide updated income when there are changes in employment status. These employment changes are not communicated timely to the Department. The Department verifies income with North Dakota Job Service periodically, but between income verifications the applicant is required to provide updated information when income changes. EFFECT Unallowable payments were made to providers on behalf of individuals whose eligibility for the CHIP and Medicaid was not proper. CONTEXT There were 126,060 CHIP and Medicaid cases that received over $2.6 billion in payments for fiscal years ended June 30, 2019 and 2020. IDENTIFICATION AS A REPEAT FINDING Finding 2018-002 and 2018-006 were reported in the immediate prior year. Finding 2016-004 and 2016-016 were made in previous years. RECOMMENDATION We recommend the Department of Human Services ensure eligibility determinations made for the Medicaid and CHIP programs are proper. DEPARTMENT OF HUMAN SERVICES RESPONSE/CORRECTIVE ACTION PLAN See ?Management?s Response and Corrective Action? section of this report.

Finding: 2020-002 Department of Human Services Response/Corrective Action Plan: The Department of Human Services agrees with the recommendation. The Medicaid Policy Unit has implemented ELearning training that is mandatory for all Medicaid Eligibility Workers. ? The Training Modules are as follows: ? Electronic Data Sources ? Documentation & Narratives ? Common Eligibility Errors: Income ? Common Eligibility Errors: Household Composition ? Non-ACA Reviews ? TPL The system error related to Defect 158460 has since been implemented which fixed the issue in SPACES. The PaSS Unit provides ongoing training for eligibility workers. Contact Person: Joyce Johnson, Medical Policy Director and Juli Johnson, Medicaid Policy Administrator Anticipated Completion Date: Completed

2018-002, 2018-006

See Schedule of Findings and Questioned Costs for chart/table CRITERIA 42 CFR 456.5 The agency must establish and use written criteria for evaluating the appropriateness and quality of Medicaid services. This section does not apply to services in hospitals and mental hospitals. For these facilities, see the following sections: 456.122 and 456.132 of subpart C; and 456.232 of subpart D. The North Dakota Program Integrity Unit Audit Oversight outlines the type and frequency of audits to be performed. CONDITION The Department of Human Services Program Integrity Unit did not fully execute their audit oversight document for the Medicaid Program. Per the audit oversight document the new rehabilitation provider audit and the recipient analysis are to be completed semi-annually. The new rehabilitation provider audit was scheduled to start in the first quarter of calendar year 2019, however, it was never completed and it was determined to discontinue these audits. While the recipient analysis was completed during the second half of calendar year 2018 and all of calendar year 2019, it had not been completed yet for calendar year 2020. Additionally, the ambulance audits are to be conducted on a weekly basis. While the ambulance audits were completed for most of calendar years 2018 and 2019, there were no reviews completed for December 2018 and audits stopped after February 2020. CAUSE The new rehabilitation provider audit was not completed due to the lack of time and resources as well as upper management?s decision to focus on audits that have a bigger fiscal impact. The semi-annual recipient analysis was not completed for 2020 as the compliance technician was new to the position and due to a lack of communication did not realize they needed to complete the analysis. The ambulance reviews have not been completed since February 2020 due to the changing of staff and procedures. EFFECT The audits completed as required by the Audit Oversight document are the primary process to identify improper use of Medicaid funds. If the audits are not being completed timely, individuals could be misusing Medicaid funds. CONTEXT The Recipient Analysis and New Rehabilitation Provider Audits are required, by the Audit Oversight document, to be performed once every six months. Additionally, Ambulance Audits are required by the Audit Oversight document to be performed weekly. The Department did not perform all of these required reviews timely during the audit period. IDENTIFICATION AS A REPEAT FINDING Finding 2018-003 was reported in the immediate prior year. Findings 2016-003, 2014-002, 2012-003 were made in previous years. RECOMMENDATION We recommend the Department of Human Services ensure the Program Integrity Unit fully executes their Audit Oversight policy. DEPARTMENT OF HUMAN SERVICES RESPONSE/CORRECTIVE ACTION PLAN See ?Management?s Response and Corrective Action? section of this report.

Finding: 2020-006 Department of Human Services Response/Corrective Action Plan: The Department of Human Services agrees with the recommendation. The Program Integrity Unit has revised the language in the Audit Overview Oversight document to better reflect the new rehabilitation provider process. It is not a formal audit but rather an educational review process meant to assist the providers in billing correctly. The Program Integrity Unit has reassigned the layperson ambulance reviews to the Utilization Review team due to no longer having a layperson in the PIU. The PIU will pull the applicable claims data for the UR team to conduct the review. Prior to reassigning to the UR team, a temporary enrollment staff helped get the late ambulance claim reviews caught up. Requests for the sample of ambulance claims for 4th quarter 2020 went out and we are currently receiving responses and are current with the reviews. The semi-annual recipient analysis for first half of 2020 was completed in October of 2020. The second half of 2020 will be reviewed this month. Due to the declaration of the Public Health Emergency as of March 2020, State Medicaid Agencies were encouraged to halt auditing to allow healthcare facilities to focus on treating patients associated with the pandemic. Contact Person: Dawn Mock, Medicaid Program Integrity Administrator Anticipated Completion Date: Completed

2018-003

See Schedule of Findings and Questioned Costs fpr chart/table CRITERIA NCCI Medicaid Technical Guidance Manual Section 7.1.2 states at a minimum, the following elements must be included in the confidentiality agreements for any contracted party using the Medicaid NCCI files posted to the Medicaid Integrity Institute: ? Disclosure shall be limited to only those responsible for the implementation of the quarterly state Medicaid NCCI edit files. Disclosure shall not be made prior to the start of the new calendar quarter. ? After the start of the new calendar quarter, a Contracted Party may disclose only non-confidential information contained in the Medicaid NCCI edit files that is also available to the general public found on the Medicaid NCCI webpage. ? The Contracted Party agrees to use any non-public information from the quarterly state Medicaid NCCI edit files only for any business purposes directly related to the implementation of the Medicaid NCCI methodologies in the particular state. ? New, revised, or deleted Medicaid NCCI edits shall not be published or otherwise shared with individuals, medical societies, or any other entities unless it is a Contracted Party prior to the posting of the Medicaid NCCI edits on the Medicaid NCCI webpage. ? Implementation of New, revised, or deleted Medicaid NCCI edits shall not occur prior to the first day of the calendar quarter. ? Only a state Medicaid agency has the discretion to release additional information for selected individual edits or limited ranges of edits from the files posted on the Medicaid Integrity Institute. ? State Medicaid agencies must impose penalties, up to and including loss of contract, for violations of any confidentiality agreement relating to use of the MII edit files. CONDITION The Department of Human Services does not have a confidentiality agreement in place with Cotiviti in regards to the NCCI. Medicaid National Correct Coding Initiative (NCCI) methodologies must be applied to Medicaid fee-for-service claims submitted with, and reimbursed on the basis of, Healthcare Common Procedure Coding System codes and Current Procedural Terminology codes. The NCCI files are to be updated on a quarterly basis as required by the Medicaid Integrity Institute. The Department of Human Services contracts with Cotiviti to implement the correct quarterly files from Medicaid Integrity Institute. The NCCI Medicaid Technical Guidance Manual requires a confidentiality agreement to be in place for any contracted party using the Medicaid NCCI files. CAUSE The Department of Human Services was unaware of the requirement to have a confidentiality agreement EFFECT The lack of a confidentiality agreement with Cotiviti could result in Cotiviti using non-public information from the quarterly state Medicaid NCCI edit files for non-business purposes without any penalties being imposed. Additionally, the lack of a confidentiality agreement with Cotiviti could lead to Cotiviti not updating the quarterly files timely. CONTEXT There were 121,684 individuals that were Medicaid eligible during our audit period of July 1, 2018, through June 30, 2020 that had claims being processed by the Department of Human Services through Cotiviti. RECOMMENDATION We recommend the Department of Human Services ensure a confidentiality agreement is in place with Cotiviti in regards to National Correct Coding Initiative. DEPARTMENT OF HUMAN SERVICES RESPONSE/CORRECTIVE ACTION PLAN See ?Management?s Response and Corrective Action? section of this report.

Finding: 2020-007 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation and will sign an amendment to the Cotiviti contract which will meet the requirements of the confidentiality agreement in Section 7.1.2 of the Medicaid National Correct Coding Initiative Technical Guidance Manual, revised 01/01/2020. Contact Person: Caprice Knapp, Medicaid Director Anticipated Completion Date: March 2021

See Schedule of Findings and Questioned Costs for chart/table CRITERIA 45 CFR 98.41(1)(i)(A) states lead agencies shall assure that children receiving services under the CCDF are age-appropriately immunized. Those health and safety provisions shall incorporate the latest recommendation for childhood immunization of the respective state. Lead agencies may exempt: (1) Children who are cared for by relatives, provided there are no other unrelated children who are cared for in the same setting. (2) Children who receive care in their own homes, provided there are no other unrelated children who are cared for in the home. (3) Children whose parents object to immunization on religious grounds. (4) Children whose medical condition contraindicates immunization. 45 CFR 98.41(iv) requires prevention and response to emergencies due to food and allergic reactions. Allergic reactions are identified on the Statement of Health for each individual child. 45 CFR 98.41 states that lead agencies must certify that procedures are in effect to ensure that child care providers, for which assistance is provided under the Child Care Assistance Program, comply with all applicable health and safety requirements. North Dakota Century Code section 50-11.1-07 requires a licensee to maintain records as the Department prescribes regarding each child, and shall report to the Department or the Department's authorized agent, when requested, upon forms furnished by the Department, facts the Department may require with reference to each child. CONDITION The Department of Human Services does not ensure that child care providers have records for enrolled children as identified by Federal health and safety requirements. Required records include immunization records and a statement of health for each child enrolled with the provider. Of 83 licenses tested, 27 were either missing records or did not have documentation identifying records were reviewed during the licensing process resulting in a 33% error rate. CAUSE Department approval of child care licenses does not include verification that county licensors reviewed required child care records and ensured missing documentation was obtained. EFFECT Children could be at risk due to unidentified health concerns. CONTEXT During fiscal year 2017 and 2018, there were 2,174 licensed providers that received payments totaling $29.4 million. IDENTIFICATION AS A REPEAT FINDING Finding 2018-007 was reported in the immediate prior year. RECOMMENDATION We recommend the Department of Human Services develop procedures to ensure required child care records are maintained by the child care provider. DEPARTMENT OF HUMAN SERVICES RESPONSE/CORRECTIVE ACTION PLAN See ?Management?s Response and Corrective Action? section of this report.

See Corrective Action Plan for chart/table Finding: 2020-009 Department of Human Services Response/Corrective Action Plan: The Department of Human Services agrees with the recommendation. Early Childhood Services has received Technical Assistance from the regional office (OCC) regarding childcare records. Their recommendations according to CCDF requirements, were to update our compliance checklist (see below) and to eliminate the childcare record (SFN 1426) which is not a required form. All specialists will be using the updated compliance checklist by May of 2021. Contact Person: Carmen Traeholt, Early Childhood Services Statewide Manager Anticipated Completion Date: May 2021

2018-007

See Schedule of Findings and Questioned Costs for chart/table CRITERIA North Dakota Century Code (NDCC) section 50-11.1-07.2 requires that the Department or the Department's authorized agency issue a correction order whenever it is determined upon inspection that a program or premises is not in compliance with this chapter or rules adopted under this chapter. NDCC section 50-11.1-07.3 requires the Department or the Department's authorized agent shall re-inspect an early childhood program issued a correction order under NDCC section 50-11.1-07.2, at the end of the period allowed for correction. 45 CFR 98.41 requires that lead agencies must certify that procedures are in effect to ensure that providers serving children who receive subsidies comply with all applicable health and safety requirements. 45 CFR 75.303 states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. CONDITION The Department of Human Services is not properly monitoring corrective orders issued to child care providers and performing re-inspections of identified deficiencies within specified time frames. Fifty-two of 520 (10%) corrective orders issued during our audit period did not identify a date the orders were determined to be corrected. In addition, 163 of 520 (31%) corrective orders were not re-inspected within the 24 hour, 20 day, or 60 day time frame allowed for correction. CAUSE The Department's procedures for monitoring the resolution of corrective orders is ineffective. EFFECT Child care providers are operating without proper follow up of corrective orders jeopardizing the health and safety of children. In addition, the Department is not ensuring providers are meeting health and safety requirements as required by 45 CFR section 98.41. CONTEXT During fiscal years 2019 and 2020, there were 1,944 licensed providers receiving payments from the Child Care Assistance program. The following list is the number of corrective orders issued by calendar year: 2020 - 70 (through July) 2019 ? 314 2018 ? 136 IDENTIFICATION AS A REPEAT FINDING Finding 2018-013 was reported in the immediate prior year. Finding 2016-026 was made in the previous year. RECOMMENDATION We recommend the Department of Human Services develop procedures to monitor and ensure the resolution of corrective orders including that resolution occurs within specified time frames. DEPARTMENT OF HUMAN SERVICES RESPONSE/CORRECTIVE ACTION PLAN See ?Management?s Response and Corrective Action? section of this report.

Finding: 2020-011 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. During the audit timeframe, County Licensors were inconsistent in how they followed up on corrective orders. As part of Early Childhood Services Redesign (completed by March 2020), all Licensing Specialists are assigned a specific provider case load, which will help Licensing Specialists keep track of any correction orders and follow-up expectations that affect providers they are assigned to work with. Contact Person: Carmen Traeholt, Early Childhood Services Statewide Manager Anticipated Completion Date: March 2021

2018-013

See Schedule of Findings and Questioned Costs for chart/table CRITERIA 45 CFR 98.68(c) states that lead agencies must have procedures in place for documenting and verifying eligibility. 45 CFR 98.45(k) states that lead agencies shall establish a sliding fee scale, based on family size, income, and other appropriate factors, that provides for cost sharing by families that receive CCDF child care services. 45 CFR 98.20(a) states that children must be under age 13, reside with a family whose income does not exceed 85 percent of State/territorial/tribal median income for a family of the same size, and reside with a parent who is working or attending a job training or education program; or are in need of, or are receiving protective services. Lead agencies may choose to provide services during period of job search. CONDITION The Department of Human Services did not properly determine eligibility in 5 of 60 child care assistance cases tested by the auditor. Each of the cases had one or more of the following errors: improperly calculated household income, missing birth records, and missing income verifications. The errors resulted in improper payments totaling $1,698. When projected against the entire population, the projected error is $873,187. CAUSE The Department did not collect or maintain proper documentation to determine eligibility. In addition, data entry and income calculations were not being completed consistently and accurately. EFFECT Unallowable payments were made to providers on behalf of individuals whose eligibility for the Child Care Assistance Program were not proper. CONTEXT There were 5,694 cases that received over $29.3 million in payments for fiscal years ended June 30, 2019 and 2020. IDENTIFICATION AS A REPEAT FINDING Finding 2018-012 was reported in the immediate prior year. Findings 2016-018, 2016-028, 2014-020, 2014-017, 2012-018, 2012-024, 2010-022, 2008-006 were made in previous years. RECOMMENDATION We recommend the Department of Human Services: 1. Develop and implement controls to ensure that all eligibility workers are collecting and maintaining all applicable information for Child Care Assistance eligibility determinations, and 2. Properly determine eligibility for individuals receiving Child Care Assistance and issue payments that comply with requirements set in the Code of Federal Regulations for Child Care Development Funds. DEPARTMENT OF HUMAN SERVICES RESPONSE/CORRECTIVE ACTION PLAN See ?Management?s Response and Corrective Action? section of this report.

Finding: 2020-013 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. DHS provides policy and system trainings, tips and tricks and policy and processing reminders as needed through periodic statewide trainings, monthly newsletters and online help resources. This effort is done in collaboration with the Policy and System Support (PaSS) unit in Economic Assistance. The PaSS unit will begin conducting CCAP New Worker Training annually beginning the winter of 2022. The training will cover all aspects of CCAP eligibility. In March 2019, the department implemented a new eligibility system, SPACES. The implementation of this new system has made processing of cases less error prone as the system calculates all aspects of CCAP eligibility such as countable income amounts, countable households members, allowable child care hours, etc. The department is continually making improvements to the system through change requests. Quality Assurance reviews are completed monthly and the results of those reviews are used to determine training needs, corrective active, etc. to mitigate errors. Contact Person: Emily Hakanson, Child Care Assistance Program Administrator Anticipated Completion Date: CCAP New Worker training will begin annually starting winter 2022. System enhancements and other trainings, reminders, etc. are completed as needed.

2018-012

See Schedule of Findings and Questioned Costs for chart/table CRITERIA 45 CFR 98.41 states that lead agencies must certify that procedures are in effect to ensure that child care providers, for which assistance is provided under the Child Care Assistance Program, comply with all applicable health and safety requirements. 45 CFR 75.303 states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. CONDITION The Department of Human Services is not ensuring child care centers, self-declared, group, preschool, and school-age providers comply with all health and safety standards as defined by North Dakota Administrative Code. The checklists used by county licensors, when conducting annual on-site licensing studies, do not contain all necessary health and safety requirements. The licensing study does not include items related to the following health and safety standard requirements: prevention and control of infectious diseases; prevention of sudden infant death syndrome and use of safe sleeping practices; administration of medication, consistent with standards of parental consent; prevention and responses to emergencies due to food and allergic reaction; building and physical premises safety, including identification and protection from hazards, bodies of water, and vehicular traffic; prevention of shaken baby syndrome, abusive head trauma, and child maltreatment; emergency preparedness and response planning; appropriate precautions if transporting children; pediatric first aid and cardiopulmonary resuscitation; and recognition of child abuse & neglect. CAUSE The Department did not update licensing materials to include verification that all required health and safety standards were met prior to licensing. EFFECT Child care providers may be operating without complying with health and safety requirements, potentially jeopardizing the health and safety of children. CONTEXT Disbursements for the fiscal years ended June 30, 2019 and 2020 totaled $29,366,169 for the CCDF program. The State of North Dakota had 1,944 licensed providers and 230 self declared providers during the audit period. IDENTIFICATION AS A REPEAT FINDING Finding 2018-014 was reported in the immediate prior year. Finding 2016-029 was made in the previous year. RECOMMENDATION We recommend the Department of Human Services: 1. Update the licensing study to include requirements for all necessary health and safety standards for child care centers, self-declared, group, preschool, and school-age providers, and 2. Ensure providers meet all health and safety standards required to be licensed. DEPARTMENT OF HUMAN SERVICES RESPONSE/CORRECTIVE ACTION PLAN See ?Management?s Response and Corrective Action? section of this report.

Finding: 2020-014 Department of Human Services Response/Corrective Action Plan: The Department of Human Services agrees with the recommendation. The State initiated a process redesign for early childhood licensing in August 2019. The redesign was intended to improve consistency of reviews, ongoing monitoring, and corrective action across all 19 Human Service Zones. The bulk of the redesign work took place in advance of the former county-employed early childhood licensors becoming state employees (January 2020). As part of Redesign, DHS piloted the use of a streamlined on-site visit checklist to identify opportunities for efficiencies. Thirteen counties utilized the abbreviated form during pilot (August 2019 ? March 2020); the remaining counties continued to utilize the existing form. It was determined that the abbreviated form would not adequately capture information needed so, in August 2020 all licensors reverted to utilization of the full-length Compliance Checklist to assure all Health and Safety standards are being met. As part of North Dakota?s regular federal review, the current compliance checklist was reviewed by Regional OCS and all recommendations will be implemented in May 2021. Contact Person: Carmen Traeholt, Early Childhood Services Statewide Manager Anticipated Completion Date: May 2021

2018-014

See Schedule of Findings and Questioned Costs for chart/table CRITERIA 45 CFR 98.42 requires that not less than annually, an unannounced inspection for compliance with child care licensing standards, which shall include an inspection for compliance with health and safety and fire standards, shall be completed. Department policy 620-01-116 states, the authorized agent is required to perform an unannounced review at least annually for each licensed or self-declared child care provider. CONDITION The Department of Human Services is not performing annual unannounced inspections of self-declared child care providers in operation. An annual unannounced inspection was not completed on 10 of 23 self-declared providers that were tested. CAUSE The Department's procedures for ensuring unannounced visits are performed annually by county licensors are ineffective. EFFECT Child care providers are operating child care facilities without proper monitoring of whether health and safety conditions have been met. CONTEXT During fiscal years 2019 and 2020, there were 230 self-declared providers from the Child Care Assistance program. IDENTIFICATION AS A REPEAT FINDING Finding 2018-017 was reported in the immediate prior year. Finding 2016-027 was made in the previous year. RECOMMENDATION We recommend the Department of Human Services perform annual unannounced inspections of self-declared child care providers in operation as required by the Code of Federal Regulations and Department policy. DEPARTMENT OF HUMAN SERVICES RESPONSE/CORRECTIVE ACTION PLAN See ?Management?s Response and Corrective Action? section of this report.

Finding: 2020-015 Department of Human Services Response/Corrective Action Plan: The Department of Human Services agrees with the recommendation. During the audit timeframe County Licensors were inconsistent in rates of completion for unannounced visits. This was due, in part, to the difference in how each County chose to administer and staff this function; licensors were not consistently required to maintain certain caseloads which contributed to uneven application of this part of the regulation. A major focus of the redesign effort was to ensure that the system was structured to ensure early childhood specialists time was organized to maximize time spent on visits. As part of redesign all Licensing Specialists are assigned a specific case load so they can schedule and follow through with unannounced visits for their assigned providers. This new distribution of work accompanied the transition from county to state employment (Jan 2020) and was being implemented by mid-2020. Early Childhood Services is currently in the process of designing a database to ensure all required documents and licensing visits are complete prior to issuing licenses and certificates to providers. The data base will be complete in April of 2022. Contact Person: Carmen Traeholt, Early Childhood Services Statewide Manager Anticipated Completion Date: April 2022

2018-017

See Schedule of Findings and Questioned Costs for chart/table CRITERIA 45 CFR 75.303 states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. The Department's Early Childhood Services Quality Assurance Policy (620-01-20-20) requires the regional office to perform random provider reviews on an annual basis with the authorized agent. CONDITION The Department of Human Services' monitoring procedures of the county licensors of child care providers is ineffective. The Department's Early Childhood Services supervisors perform procedural reviews of county licensor activities. The selection procedures do not include assurance that activities of all county licensors are reviewed. In addition, errors identified during our testing indicate these reviews are clearly ineffective at identifying material weaknesses and inconsistencies. These errors include nonperformance of unannounced visits, lack of monitoring of corrective orders, and improperly licensed providers. CAUSE The Department has not designed monitoring procedures to carry out the purpose of licensing early childhood service providers to safeguard the health, safety, and development of children. EFFECT Child care providers are operating without complying with licensing requirements and proper monitoring of health and safety conditions which may jeopardize the health and safety of children. CONTEXT The Child Care Assistance program has 5 regional representatives. DHS has created county zone areas throughout the State. This structure has not been fully implemented by assigning zones and responsibilities and, until it is, this finding applies to the regional supervisor responsibilities according to DHS policy. IDENTIFICATION AS A REPEAT FINDING Finding 2018-018 was reported in the immediate prior year. Finding 2016-025 was made in the previous year. RECOMMENDATION We recommend the Department of Human Services perform effective monitoring procedures to ensure all functions of the Child Care Assistance program are properly completed including monitoring correction orders, completing unannounced visits, and properly licensing providers. DEPARTMENT OF HUMAN SERVICES RESPONSE/CORRECTIVE ACTION PLAN See ?Management?s Response and Corrective Action? section of this report.

Finding: 2020-016 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. Early Childhood Services Redesign moved all County Licensors to State employment (Jan 2020) and Early Childhood Services Regional Representatives to a Supervisor status (March 2020). These steps will change how a QA visit is completed. QA visits starting in 2021 will include both standard performance reviews of licensors as well as quality assurance review of outputs and outcomes. This includes review of how licensors conduct visits and complete their core work related to license compliance and health and safety practices of child care programs. Contact Person: Carmen Traeholt, Early Childhood Services Statewide Manager Anticipated Completion Date: June 2021

2018-018

See Schedule of Findings and Questioned Costs for chart/table CRITERIA 45 CFR ?261.60 states: (a) A State must report the actual hours that an individual participates in an activity, subject to the qualifications in paragraphs (b) and (c) of this section and ?261.61(c). It is not sufficient to report the hours an individual is scheduled to participate in an activity. 45 CFR ?261.61 states: (a) A State must support each individual's hours of participation through documentation in the case file. In accordance with ?261.62, a State must describe in its Work Verification Plan the documentation it uses to verify hours of participation in each activity. North Dakota?s Work Verification Plan outlines the use of JOBS Employment Contractors to determine the individual?s hours of participation. The process includes sampling of the JOBS Employment Contractor work to ensure accuracy. 45 CFR ?261.20 states: (c) If the data show that a State met both participation rates in a fiscal year, then the percentage of historic State expenditures that it must expend under TANF, pursuant to ?263.1 of this chapter, decreases from 80 percent to 75 percent for that fiscal year. This is also known as the State's TANF ?maintenance-of-effort? (MOE) requirement.(d) If the data show that a State did not meet a minimum work participation rate for a fiscal year, a State could be subject to a financial penalty. CONDITION The Department of Human Services (DHS) is not in compliance with the Work Verification Plan in regards to monitoring data used to calculate the work participation rate. The work participation rate effects the maintenance-of-effort requirement and could result in sanctions if minimum work participation rates are not met. DHS contracts with Job Opportunities and Basic Skills (JOBS) Employment Contractors to verify work verification documents provided by the client in meeting their work participation hours requirements. This sampling was halted during SPACES implementation. DHS uses this information to report data on their State Work Participation Rates on the ACF-199 report. CAUSE Since SPACES went live, DHS has fallen behind on sending cases to the JOBS work contractors for audit and therefore audits and results thereof are not available. EFFECT DHS's reported Work Participation Rates could be incorrectly calculated which could result in additional maintenance-of-effort requirements and Federal sanctions. CONTEXT No sampling was provided by the Department of Human Services to the JOBS contractors following the March 2019 implementation of the SPACES eligibility system (February 2019 was last monthly sample). RECOMMENDATION We recommend the Department of Human Services ensure compliance with the Work Verification Plan. This includes the JOBS verification of TANF cases and maintenance of results for work participation status accuracy. DEPARTMENT OF HUMAN SERVICES RESPONSE/CORRECTIVE ACTION PLAN See ?Management?s Response and Corrective Action? section of this report.

Finding: 2020-017 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. DHS acknowledges that due to SPACES implementation, the sampling sent to JOBS contractors was put on hold and not provided. Effective February 2021, all future Random Sampling Reports will be sent out monthly. The following monthly Random Sampling Reports have been provided to the Employment Contractors: ? October, November and December 2019 were provided in May 2020 ? April, May and June 2019 were provide in June 2020 ? January, February and March 2020 were provided in June 2020 ? July, August and September 2019 were provided in August 2020 ? April, May and June 2020 were provided in August 2020 ? July, August and September 2020 were provided in December 2020 ? October and November 2020 were provided on January 4, 2021 ? December 2020 will be sent out in February 2021 Contact Person: Joan Schatz, TANF/JOBS Program Administrator Anticipated Completion Date: February 2021

See Schedule of Findings and Questioned Costs for chart/table CRITERIA The following criteria note that Federal funds must be obligated by the end of the two-year period of performance window and those obligations must be liquidated within 90 days after the end date of period of performance. 2 CFR 200.343 requires: " Unless the Federal awarding agency or pass-through entity authorizes an extension, a non-Federal entity must liquidate all obligations incurred under the Federal award not later than 90 calendar days after the end date of the period of performance as specified in the terms and conditions of the Federal award. 34 CFR 361.64 requires: " (a) Except as provided in paragraph (b) of this section, any Federal funds, including reallotted funds, that are appropriated for a fiscal year to carry out a program under this part that are not obligated by the State by the beginning of the succeeding fiscal year and any program income received during a fiscal year that is not obligated by the State by the beginning of the succeeding fiscal year remain available for obligation by the State during that succeeding fiscal year. (b) Federal funds appropriated for a fiscal year remain available for obligation in the succeeding fiscal year only to the extent that the State met the matching requirement for those Federal funds by obligating, in accordance with 34 CFR 76.707, the non-Federal share in the fiscal year for which the funds were appropriated." The following criteria pertains to the establishment and maintenance of effective internal control to ensure payments are made within the correct period of performance. 45 CFR 75.303 states the non-Federal entity must, "establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." CONDITION The Department of Human Services made payments under the Vocational Rehabilitation program outside of the 2018 grant award period of performance which was 10/1/17 - 9/30/19 with an allowable liquidation period, to pay for obligations, through 12/31/19. Payments made after the liquidation period totaled $94,081 for the 2018 grant. CAUSE The Department of Human Services, Vocational Rehabilitation Program, did not properly update speedcharts, which provide for automated coding within the State's accounting system, at its Regional Human Service Centers. This issue was noted in three of the four errors found in sampling and permitted unallowable costs to be charged to the 2018 Federal grant. The final error was due to improper coding when the payment was entered into the system. In addition, review of the program's internal controls regarding period of performance proved inadequate to detect payments made outside of the period of performance as documentation of the review to ensure expenditures are applied to the correct period of performance was not maintained. EFFECT Unallowable costs totaling $94,081 were charged to the grant and are questioned costs. CONTEXT The Department of Human Services, Vocational Rehabilitation program, had expenditures of approximately $7.6 million from the 2018 grant award during the audit period. Of this amount, $94,081 was identified as a known questioned cost from 66 payments. These are all payments after the period of performance. IDENTIFICATION AS A REPEAT FINDING Finding 2018-031 was reported in the immediate prior year. Finding 2016-053 was made in the previous year. RECOMMENDATION We recommend the Department of Human Services implement procedures to prevent and detect Vocational Rehabilitation payments from occurring outside the period of performance. DEPARTMENT OF HUMAN SERVICES RESPONSE/CORRECTIVE ACTION PLAN See ?Management?s Response and Corrective Action? section of this report.

Finding: 2020-019 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. Program Accountant plans on creating a procedure manual for the end of the period of performance, to identify charges that need to be applied to the appropriate grant year. Currently there is not written procedure manual or documentation that outlines the steps needed to ensure proper period of performance. This procedure manual to be created will outline the steps the Program Accountant needs to take in order to check all transactions posting to Peoplesoft from the AWARE case management system, check Peoplesoft speedcharts for both VR central office and the VR regional offices located in the Human Service Centers, and checking the history database for any errors on to ensure a comprehensive review of all transactions between the AWARE system and Peoplesoft. Contact Person: Jacqueline Ressler, Account Manager and Isabel Tischmak, Vocational Rehab Program Accountant Anticipated Completion Date: November 30, 2020

2018-031

See Schedule of Findings and Questioned Costs for chart/table CRITERIA 2 CFR 200.343(b) states unless the Federal awarding agency or pass-through entity authorizes an extension, a non-Federal entity must liquidate all obligations incurred under the Federal award not later than 90 calendar days after the end date of the period of performance as specified in the terms and conditions of the Federal award. 2 CFR 200.309 states a non-Federal entity may charge to the Federal award only allowable costs incurred during the period of performance. CONDITION The Department of Public Instruction made payments after the period of performance. Although the underlying obligations occurred within the period of performance, payments totaling $19,684 did not comply with the Federal period of performance requirements for the Child Nutrition Cluster. These payments were made after the 90 day payment period following the end of the applicable grant awards. There is also a payment of $12,839 which lacked documentation to determine if the underlying obligations occurred within the period of performance and did not comply with the Federal period of performance liquidation period requirements for the Child Nutrition Cluster. The projection on the known questioned costs of $32,523 is an additional $1,153 in payments made after the period of performance. CAUSE For 2 out of 5 items tested, the Department of Public Instruction's system, NDFoods, and PeopleSoft, the state's accounting system, did not properly communicate payment of claims. Two separate payments of the 5 items tested were in error due to untimely identification of an incorrect reimbursement rate being applied to meals which lead to a subsequent correction payment made after the period of performance. Finally, 1 additional payment separate from the errors already identified, was an error due to a lack of documentation of the transaction. EFFECT The Department of Public Instruction charged unallowable costs to the grant. CONTEXT 26 of the 6,636 disbursements that were made by the Department of Public Instruction for the Child Nutrition Cluster for grants that ended during fiscal years 2019 and 2020 were paid outside of the 90 day period of performance. IDENTIFICATION AS A REPEAT FINDING Finding 2018-039 was reported in the immediate prior year. RECOMMENDATION We recommend the Department of Public Instruction ensure Child Nutrition Cluster obligations occur within the period of performance and that payments are not made after the period of performance. DEPARTMENT OF PUBLIC INSTRUCTION RESPONSE/CORRECTIVE ACTION PLAN See ?Management?s Response and Corrective Action? section of this report.

Finding: 2020-023 Department of Public Instruction Response/Corrective Action Plan: The Department of Public Instruction is rewriting internal procedures to ensure that the Child Nutrition Cluster obligations will occur within the period of performance and payment will not be made after the period of performance. Contact Person: Linda Schloer, Director of Child Nutrition and Food Programs Anticipated Completion Date: March 31, 2021

2018-039

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