Corrective Action Plans

Finding 397056 (2021-005)

Material Weakness 2021

Open Cities Health Center, Inc. and Affiliate

MN

Questioned Costs Allowable Costs / Cost Principles Eligibility

Finding 2021-005 Compliance Requirement: Allowable Cost/Cost Principles Material Weakness Assistance Living Number 93.224 Health Center Programs Grant Award Number H80CS00112 U.S. Department of Human Services Condition: A walkthrough of fourteen individuals was performed to agree personnel files a...

Finding 2021-005 Compliance Requirement: Allowable Cost/Cost Principles Material Weakness Assistance Living Number 93.224 Health Center Programs Grant Award Number H80CS00112 U.S. Department of Human Services Condition: A walkthrough of fourteen individuals was performed to agree personnel files and to payroll. Of the fourteen files reviewed, seven had no approved current pay rate documented, and the salary or hourly rate paid was not the rate contained in the file. Action Planned in Response to the Finding: Effective immediately, the human resources team will begin using of a checklist within each file as an additional procedure to ensure that each file contains all necessary documents and that the file has been updated for current rates of pay. Official Responsible for Ensuring the CAP: Becky Howard Planned Completion Date: June 30th, 2024

View Audit 306434 Questioned Costs: $1

Finding 396650 (2021-001)

Material Weakness 2021

Three Rivers Health System, Inc. and Subsidiaries

MI

Questioned Costs Allowable Costs / Cost Principles Material Weakness

Finding Number: 2021-001 Condition: The Organization's controls in place for reporting submission did not identify that guidelines were not followed related to the reporting of expenses. Planned Corrective Action: The Organization accepts the finding and has implemented additional layers of review r...

Finding Number: 2021-001 Condition: The Organization's controls in place for reporting submission did not identify that guidelines were not followed related to the reporting of expenses. Planned Corrective Action: The Organization accepts the finding and has implemented additional layers of review regarding expense submission to ensure the reports are submitted within the established guidelines. The submission was prepared by prior management that is no longer at the organization during a period of transition from the acquisition by Beacon. Subsequent reporting was performed for TRH by Beacon management after this initial submission and subsequent audits were performed with all findings resolved. As stated above, the Organization had sufficient additional expenditures and lost revenue from the COVID-19 pandemic and there are no resulting PRF recognition issues. Contact person responsible for corrective action: Harley McCoige, Controller Anticipated Completion Date: N/A - Completed

View Audit 306248 Questioned Costs: $1

Finding 396548 (2021-002)

Material Weakness 2021

Bioscience and Technology Business Center, Inc. D/b/a Ku Innovation Park

KS

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

The Organization will designate a knowledgeable person separate from the preparer of the reports to review all expenditures that go into the reports prior to submission.

View Audit 306121

Finding 396242 (2021-005)

Significant Deficiency 2021

California Fire Safe Council, Inc.

CA

Questioned Costs Allowable Costs / Cost Principles § 200.403

Finding 2021-005 Management agrees with the finding and is implementing the accompanying corrective action plan. Views of Responsible Officials: Jessica Martinez, Program Director Jacy Hyde, Executive Director Joel Rusco, Chief Financial and Administrative Officer Contact Person: Joel Rusco, Chief F...

Finding 2021-005 Management agrees with the finding and is implementing the accompanying corrective action plan. Views of Responsible Officials: Jessica Martinez, Program Director Jacy Hyde, Executive Director Joel Rusco, Chief Financial and Administrative Officer Contact Person: Joel Rusco, Chief Financial and Administrative Officer Jessica Martinez, Program Director Corrective Action Plan: • CFSC has reviewed the payroll procedures and has retained Clark Nuber to implement an additional review of grant-related charges as well as the procedure to ensure charges are accurately recorded. • Clark Nuber has done a review of the current time and effort policy and procedures and proposed updates and revisions. Clark Nuber’s recommendations will be reviewed and approved cy CFSC management and thereafter implemented by CFSC staff. • Any changes to timecards or reporting allocations for payroll be substantiated by supporting documentation. Journal entry and cost transfer policies and procedures will be enhanced to require sufficient documentation, attestations, and approvals before the charges are recorded or reported to funders. • A full review of costing policies and procedures, IDC rate calculations, and cost allocation plan is anticipated to begin mid-2024. Anticipated Completion Date: The Payroll and Time and Effort policies and procedures review is to be completed by the end of Quarter 2 of FY 2024.

View Audit 305892 Questioned Costs: $1

Finding 396189 (2021-004)

Significant Deficiency 2021

City of Manteca

CA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Finding #SA2021-004: Allowable Subrecipient and Contract Costs Assistance Listing Number: 14.218 Assistance Listing Title: COVID-19 - Community Development Block Grants/Entitlement Grants Name of Federal Agency: Department of Housing and Urban Development Pass Through Entity: San Joaquin County Comm...

Finding #SA2021-004: Allowable Subrecipient and Contract Costs Assistance Listing Number: 14.218 Assistance Listing Title: COVID-19 - Community Development Block Grants/Entitlement Grants Name of Federal Agency: Department of Housing and Urban Development Pass Through Entity: San Joaquin County Community Development Department Federal Award Identification Number: A-93-916 • Name(s) of the contact person: Shay Narayan, Director of Finance; Carmen Gusman, Deputy Director of Finance • Corrective Action Plan: The City will develop procedures for grant management, accounting and reporting to ensure that only allowable subrecipient costs are claimed and are supported by contract. • Anticipated Completion Date: 06/30/24

View Audit 305817 Questioned Costs: $1

Finding 396188 (2021-003)

Material Weakness 2021

City of Manteca

CA

Questioned Costs Allowable Costs / Cost Principles Eligibility § 200.430

Finding Reference Number #SA2021-003: Pro-Rating Annual Payroll Costs Charged to Grant Assistance Listing Number: 21.019 Assistance Listing Title: COVID-19 - Coronavirus Relief Fund Name of Federal Agency: Department of Treasury Pass Through Entity: California Department of Finance Federal Award Ide...

Finding Reference Number #SA2021-003: Pro-Rating Annual Payroll Costs Charged to Grant Assistance Listing Number: 21.019 Assistance Listing Title: COVID-19 - Coronavirus Relief Fund Name of Federal Agency: Department of Treasury Pass Through Entity: California Department of Finance Federal Award Identification Number: 390 • Name(s) of the contact person: Shay Narayan, Director of Finance; Carmen Gusman, Deputy Director of Finance • Corrective Action Plan: Now that payroll services and the budget unit are both fully staffed, the City will be able to develop procedures that will ensure personnel budgets and costs are accurately pro-rated to the appropriate funding source. Additionally, the City expects to have sufficient staffing to work more closely with grantors make certain the all eligible costs are accounted for. • Anticipated Completion Date: 06/30/24

View Audit 305817 Questioned Costs: $1

Finding 396187 (2021-002)

Significant Deficiency 2021

City of Manteca

CA

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.430

Finding Reference Number #SA2021-002: Support for Payroll Costs Charged to Grant CFDA number: 20.507 CFDA Title: Federal Transit – Formula Grants (Urbanized Area Formula Program) Name of Federal Agency: Department of Transportation - Federal Transportation Administration Federal Award Identification...

Finding Reference Number #SA2021-002: Support for Payroll Costs Charged to Grant CFDA number: 20.507 CFDA Title: Federal Transit – Formula Grants (Urbanized Area Formula Program) Name of Federal Agency: Department of Transportation - Federal Transportation Administration Federal Award Identification Number: CA-2021-009-01, CA-2020-005-01, CA-2020-005-02 • Fiscal Year of Initial Finding: 2019 • Name(s) of the contact person: Shay Narayan, Director of Finance; Carmen Gusman, Deputy Director of Finance • Corrective Action Plan: The City is conducting a cost allocation study which includes a federal cost allocation plan. We anticipate incorporating the new allocations into the FY 2024-25 Annual Budget. • Anticipated Completion Date: 07/01/2024

View Audit 305817 Questioned Costs: $1

Finding 396035 (2021-011)

Material Weakness 2021

Cherokee County

OK

Questioned Costs Allowable Costs / Cost Principles

Cherokee County will implement a system of internal controls to ensure compliance with grant requirements in the future

View Audit 305648 Questioned Costs: $1

Finding 395770 (2021-003)

Material Weakness 2021

United Keetoowah Band of Cherokee Indians in Oklahoma

OK

Questioned Costs Allowable Costs / Cost Principles Cash Management

2021-003 Costs must be adequately documented Management Response: The Tribe recently went through administrative changes and we now have a Finance Department that will ensure we address this concern and correct it in a timely manner. We will revisit our current controls and use updated technology to...

2021-003 Costs must be adequately documented Management Response: The Tribe recently went through administrative changes and we now have a Finance Department that will ensure we address this concern and correct it in a timely manner. We will revisit our current controls and use updated technology to improve our processes. Anticipated Completion Date: 12/31/2024 Responsible Party: Treasurer, Comptroller, Accounting Manager and Federal Programs Accounting Manager

View Audit 305423 Questioned Costs: $1

Finding 395328 (2022-001)

Material Weakness 2021

West Hawaii Community Health Center, Inc.

HI

Questioned Costs Allowable Costs / Cost Principles Reporting

West Hawaii Community Health Center, Inc. d/b/a Hawai’i Island Community Health Center Schedule of Findings and Questioned Costs Year Ended December 31, 2021- Section III – Federal Award Findings and Questioned Costs Reference Number Finding 2021-001 Provider Relief Fund and American Rescue Plan (A...

West Hawaii Community Health Center, Inc. d/b/a Hawai’i Island Community Health Center Schedule of Findings and Questioned Costs Year Ended December 31, 2021- Section III – Federal Award Findings and Questioned Costs Reference Number Finding 2021-001 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing Number 93.498 U.S. Department of Health and Human Services Criteria or Specific Requirement – Reporting (45 CFR 75.342) and Activities Allowed/Unallowed and Cost Principles (Pub. L. No. 116-136, 134 Stat. 563 and Pub. L. No. 116-139, 134 Stat. 622 and 623) Condition – The Organization is required to prepare and submit period-one Provider Relief Fund (PRF) reporting. This report is to be prepared using accurate financial information and submitted by the deadline established. Questioned Costs – Unknown Context – The period one PRF report was tested. The Organization selected option two to report lost revenues based on a comparison of quarterly budgeted patient revenues to actual. For this approach, budgeted revenues may only be used if the budget(s) covering the period of availability that ended June 30, 2021, were approved prior to March 27, 2020. The 2021 budget which covered budgeted revenues from January 1, 2021 through June 30, 2022, was approved after the required date. In addition, certain patient service revenue accounts were improperly excluded from quarterly revenues related to patient care. Effect – Errors were made in lost revenues. Cause – The Organization did not qualify to use option two to report lost revenues and should have used one of the two other options in reporting lost revenues. The Organization also improperly excluded certain patient service revenue components in their calculation. Identification as a Repeat Finding – Not a repeat finding. Recommendation – Policies and procedures over federal grant reporting should be monitored to ensure reports are prepared using complete and accurate information. Views of Responsible Officials: The budget period for January through December 2021 was approved prior to year-end 2020. Our budgets would most likely not be accurate if we prepared the FY (CY) 2021 budget by March 2020, especially considering COVID unknowns, as we have been growing rapidly as a Federally Qualified Health Center(FQHC). There were frequent changes in the PRF payment reporting portal at the time after funds were received. We did confer with our outside audit team before reporting but possibly due the changes, we may have misunderstood, or checked the wrong box in reporting portal, as we did include our budgets showing approval dates and explanation of our process. Our FQHC did show how we fully obligated the funds. The lost revenue mentioned was related to ‘contract with payer for Per Member Per Month’, which we did not realize had to be included in reporting. It is recorded in General Ledger, but not the billing software per patient account, nor included in the submitted reports retrieved directly from our billing software at the time. The auditor did confirm our reported revenue was sufficient to cover funding received. We are very careful about accurate reporting and review our policies. All of our policies were also reviewed during our HRSA OS Visit Sept 2021, along with our HRSA reporting for these PRF awards, with no findings, so we did not realize we had a problem until a higher level audit review as we finalized our 2021 audit this week. We had many delays in closing this 2021 audit year and this surfacing took us by surprise. Planned Corrective Action: We will work with HRSA on resolution of the finding. Anticipated Completion Date: Will work to resolve as soon as possible pending HRSA’s review Contact Person Responsible for Corrective Action: Diane Pautz, CFO West Hawaii Community Health Center, Inc. 75-5751 Kuakini Hwy, Ste 203 Kailua Kona, HI 96740 dpautz@westhawaiichc.org

View Audit 305127 Questioned Costs: $1

Finding 395061 (2021-005)

Material Weakness 2021

Housing Authority of Cass County

ND

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

Contact Person Derek Johnson, Executive Director Corrective Action Plan The Authority will review its policies and procedures over program compliance requirements and monitoring of program activity. Planned Completion Date for CAP December 31, 2022.

View Audit 304992 Questioned Costs: $1

Finding 394531 (2021-108)

Significant Deficiency 2021

Pancare of Florida, INC

FL

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303 § 200.328

Lack of Documentation Related to Reporting Condition: The Organization did not maintain proper documentation in support of reporting requirements. Corrective Action Planned: The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within th...

Lack of Documentation Related to Reporting Condition: The Organization did not maintain proper documentation in support of reporting requirements. Corrective Action Planned: The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization. Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: Implement

View Audit 304417

Finding 394530 (2021-107)

Material Weakness 2021

Pancare of Florida, INC

FL

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.303

Lack of Documentation for Expenses Submitted for Reimbursement Condition: The Organization submitted costs for reimbursement of medical supplies which could not be supported with related invoices. Corrective Action Planned: The Organization has hired a new Chief Financial Officer, as of March 2022...

Lack of Documentation for Expenses Submitted for Reimbursement Condition: The Organization submitted costs for reimbursement of medical supplies which could not be supported with related invoices. Corrective Action Planned: The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization. Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: Implemented

View Audit 304417 Questioned Costs: $1

Finding 394528 (2021-105)

Material Weakness 2021

Pancare of Florida, INC

FL

Cash Management Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

Use of Budgeted Versus Actual Costs for Reimbursements Condition: The Organization made drawdowns after month-end based on budgeted period expenses rather than actual salary expenses to support the amounts being requested for reimbursement. Corrective Action Planned: The Organization has hired a n...

Use of Budgeted Versus Actual Costs for Reimbursements Condition: The Organization made drawdowns after month-end based on budgeted period expenses rather than actual salary expenses to support the amounts being requested for reimbursement. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization. Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: Implemented

View Audit 304417

Finding 394021 (2021-004)

Material Weakness 2021

Abilities Network, Inc.

MD

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.407

Recommendation: The auditors recommend the Organization design, implement, and monitor internal controls over allocations as well as maintain source documentation to support amounts charged to the grant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding...

Recommendation: The auditors recommend the Organization design, implement, and monitor internal controls over allocations as well as maintain source documentation to support amounts charged to the grant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review the current internal controls over allocations and source documentation to identify any gaps or weaknesses and develop a plan to address any identified gaps or weaknesses, including updating policies and procedures as necessary. Management will also communicate the updated policies and procedures to all relevant employees and provide training as needed. Monitoring and testing procedures will be implemented to ensure that the updated policies and procedures are being followed. There will also be regular reviews and updates to the policies and procedures as needed to ensure ongoing effectiveness. Management will assign responsibility for maintaining source documentation to a specific individual or team and develop a system for organizing and storing source documentation, such as a centralized electronic database. Monitoring and testing procedures will be implemented to ensure that source documentation is being maintained and is readily accessible. Lastly, there will be regular reviews and updates to the system for organizing and storing source documentation as needed to ensure ongoing effectiveness. Name of the contact person responsible for corrective action: Lyn Elliot, CEO Planned completion date for corrective action plan: 4/1/2024

View Audit 304152 Questioned Costs: $1

Finding 393829 (2021-003)

Material Weakness 2021

Okeene Municipal Hospital and Schallmo Authority

OK

Questioned Costs Internal Control / Segregation of Duties Allowable Costs / Cost Principles

Given the complexity of the reporting requirements, including changing FAQ's, reporting deadline extensions, and the inability to update reporting to reflect expenses incurred within the guidelines such as lost revenue the Authority will apply such expenses as offsets to its provider relief fund dis...

Given the complexity of the reporting requirements, including changing FAQ's, reporting deadline extensions, and the inability to update reporting to reflect expenses incurred within the guidelines such as lost revenue the Authority will apply such expenses as offsets to its provider relief fund distributions. The Authority will continue to monitor the Health and Human Resources Provider Relief Fund General and Targeted Distribution Post-Payment Notice of Reporting Requirements and the most recently distributed Provide Relief Fund frequently asked questions which provide details on requirements related to the program.

View Audit 304032 Questioned Costs: $1

Finding 393828 (2021-002)

Material Weakness 2021

Okeene Municipal Hospital and Schallmo Authority

OK

Questioned Costs Internal Control / Segregation of Duties Allowable Costs / Cost Principles

Given the complexity of the reporting requirements, including changing FAQ's, reporting deadline extensions, and the inability to update reporting to reflect expenses incurred within the guidelines such as lost revenue the Authority will apply such expenses as offsets to its provider relief fund dis...

Given the complexity of the reporting requirements, including changing FAQ's, reporting deadline extensions, and the inability to update reporting to reflect expenses incurred within the guidelines such as lost revenue the Authority will apply such expenses as offsets to its provider relief fund distributions. The Authority will continue to monitor the Health and Human Resources Provider Relief Fund General and Targeted Distribution Post-Payment Notice of Reporting Requirements and the most recently distributed Provide Relief Fund frequently asked questions which provide details on requirements related to the program.

View Audit 304032 Questioned Costs: $1

Finding 393788 (2021-005)

Material Weakness 2021

Housing Authority of the City of Pueblo

CO

Special Tests & Provisions Allowable Costs / Cost Principles HUD Housing Programs

U.S. Department of Housing and Urban Development – CFDA #14.850 Public and Indian Housing – 2021 Special Tests and Provisions: Project-Based Budgeting and Accounting Material Weakness in Internal Control over Compliance Finding Summary: During testing, we identified several errors in how expenses we...

U.S. Department of Housing and Urban Development – CFDA #14.850 Public and Indian Housing – 2021 Special Tests and Provisions: Project-Based Budgeting and Accounting Material Weakness in Internal Control over Compliance Finding Summary: During testing, we identified several errors in how expenses were being charged and or allocated to the projects. In addition, there was insufficient documentation supporting how allocation methods were determined and there were no reviews of the allocation calculations by another individual. Responsible Individual: Steven Trujillo, Executive Director Corrective Action Plan: We agree that in 2021 expenses were not consistently allocated to our Public Housing Projects. However, we have now implemented consistent allocation methods so that expenses charged to our Public Housing projects will be reasonable and proper. We also review those allocation methods an a regular basis and change them as necessary. Anticipated Completion Date: January 2023

View Audit 303983

Finding 393709 (2021-003)

Material Weakness 2021

Community Development Partnership

MA

Allowable Costs / Cost Principles § 200.302

We are working with our Net Suite consultants to correct the historical transactions and on-going system procedures and processes to ensure that the accounting software provides that all financial transactions are properly allocated to programs and properties funded with federal funds.Anticipated Co...

We are working with our Net Suite consultants to correct the historical transactions and on-going system procedures and processes to ensure that the accounting software provides that all financial transactions are properly allocated to programs and properties funded with federal funds.Anticipated Completion Date April 30,2024.Responsible Contact Person-Kathleen Boyce, CFAO.

View Audit 303856

Finding 393569 (2021-001)

Significant Deficiency 2021

Roosevelt Fire District

NY

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.512

The Roosevelt Fire District was late in filing their Single Audit for the Fiscal Year Ending 12/31/21 due to limitations caused from COVID. We are a small office with part-time staff and fully volunteer fire & ambulance service.

View Audit 303734

Finding 393497 (2021-004)

Significant Deficiency 2021

Tucson Audubon Society

AZ

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.414

National Park Service Conservation, Protection, outreach, and Education – Assistance Listing No. 15.954 and Research and Development Cluster – Assistance Listing No. 15.608 and 15.945 Recommendation: We recommend management incorporate review control procedures to ensure the 10 percent de minimis r...

National Park Service Conservation, Protection, outreach, and Education – Assistance Listing No. 15.954 and Research and Development Cluster – Assistance Listing No. 15.608 and 15.945 Recommendation: We recommend management incorporate review control procedures to ensure the 10 percent de minimis rate is properly applied in accordance with UG and ensure appropriate costs are charged to the awards consistent with their federally approved budgets. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Upon conducting the FY21 audit TAS was informed that the inclusion of the Biological Expertise line item on federal budgets (approx. 7.5% additional uplift) was not allowable as it was currently being calculated. TAS is allowed a 10% de minimus rate on noted FY21 Federal awards some of which also included a Biological Expertise line item that is budgeted as an hourly rate. TAS had been calculating uplift amounts owed by simply adding the Biological Expertise (7.5%) to the de minimus rate (10%) for a total uplift of 17.5%. This was done at the direction and approval of our federal partners. However, due to Biological Expertise being entered in the federal and approved budgets as an hourly line item and not a percentage TAS was considered out of compliance by using this method of calculation. Moving forward TAS will be billing the de minimus rate (10%) as a percentage and will calculate the Biological Expertise line item as an hourly rate. Name(s) of the contact person(s) responsible for corrective action: Kim Lopez, Director of Finance & Operations Planned completion date for corrective action plan: effective immediately / in progress

View Audit 303685

Finding 392605 (2021-005)

Material Weakness 2021

Fairbanks Rescue Mission, Inc.

AK

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Financial Statement and Federal Award Finding: 2021-005 Material Weakness in Internal Control over Financial Reporting and Compliance and Noncompliance -Allowable Costs/Cost Principles. Name and Contact Person: Pete Kelly, Chief Executive Officer. Corrective Action: The Fairbanks Rescue Mission's...

Financial Statement and Federal Award Finding: 2021-005 Material Weakness in Internal Control over Financial Reporting and Compliance and Noncompliance -Allowable Costs/Cost Principles. Name and Contact Person: Pete Kelly, Chief Executive Officer. Corrective Action: The Fairbanks Rescue Mission's Board of Directors created a Finance Committee with extensive banking and accounting experience to create a higher level of scrutiny and oversite of the Missions finances. We contracted a professional accounting/bookkeeping firm (Midnight Sun Bookkeeping Services) and empowered them to establish procedures and practices consistent with GAAP (Generally Accepted Accounting Principles) as well as track and participate in day to day activities of Accounting; thereby, assuring accuracy of financial data and assuring compliance. We have formalized check writing, money handling, and credit card control procedures. Switched to an online time tracking system for employees and digitized all employee documents. Created an online filing system for all grant expenses Proposed Completion Date: January 01, 2024

View Audit 302911 Questioned Costs: $1

Finding 392596 (2021-002)

Material Weakness 2021

Self Regional Healthcare and Affiliates

SC

Reporting Allowable Costs / Cost Principles Material Weakness

Contact Person: Timothy Evans Managements Response: The issue involved not keeping manual purchase order requests that contained original approvals for a period of greater than two years. At the time of the audit the original manual purchase requisition requests had not been saved or scanned. ...

Contact Person: Timothy Evans Managements Response: The issue involved not keeping manual purchase order requests that contained original approvals for a period of greater than two years. At the time of the audit the original manual purchase requisition requests had not been saved or scanned. When we recognized this deficiency, we immediately changed our processes so that all original requests for purchase orders that have the authorizing signatures are saved for a period of 5 years. Completion Date: January 2024.

View Audit 302889

Finding 392586 (2021-004)

Material Weakness 2021

The Jackson County Health Care Authority

AL

Questioned Costs Allowable Costs / Cost Principles Eligibility

Finding 2021-004- Material Weakness and Material Noncompliance over Allowable Cost and Reporting Contact Person: Andrew Wenning Managements Response: During a review of expenses related to the COVID pandemic, the audit identified payroll and non-payroll expenses that management first thought eligibl...

Finding 2021-004- Material Weakness and Material Noncompliance over Allowable Cost and Reporting Contact Person: Andrew Wenning Managements Response: During a review of expenses related to the COVID pandemic, the audit identified payroll and non-payroll expenses that management first thought eligible but on further review, (and subsequent to the submission to the portal) determined were unallowable per the Coronavirus Relief Fund grant terms and conditions. Management has put into place a policy for an individual in the accounting department to review all COVID expenses on a monthly basis going forward. In addition, management will further investigate the total likely questioned cost in order to determine the complete known questioned cost in the period 1 payroll and non-payroll expenditure population by June 30, 2024. For payroll expenses, the policy includes that a review and approval of the expenditures will be performed by an individual in accounting to ensure that the hours and wages calculated meet the terms and conditions of the CRF. If any non-eligible payroll expenses are identified during the review process, they will be removed. For all other expenses, we will obtain and retain approved copies of all invoices or other documentation to support expenses and review for eligibility. If any non-eligible expenses are identified during the review process, they will be removed. Completion Date: April 5, 2024

View Audit 302859 Questioned Costs: $1

Finding 392585 (2021-003)

Material Weakness 2021

The Jackson County Health Care Authority

AL

Questioned Costs Allowable Costs / Cost Principles Eligibility

Finding 2021-003- Material Weakness and Material Noncompliance over Allowable Cost and Reporting Contact Person: Andrew Wenning Managements Response: During a review of expenses related to the COVID pandemic, the audit identified payroll and non-payroll expenses that management first thought eligibl...

Finding 2021-003- Material Weakness and Material Noncompliance over Allowable Cost and Reporting Contact Person: Andrew Wenning Managements Response: During a review of expenses related to the COVID pandemic, the audit identified payroll and non-payroll expenses that management first thought eligible but on further review, (and subsequent to the submission to the portal) determined were unallowable per the Provider Relief Fund grant and Coronavirus Relief Fund grant terms and conditions. Management has put into place a policy for an individual in the accounting department to review all COVID expenses on a monthly basis going forward. In addition, management will further investigate the total likely questioned cost in order to determine the complete known questioned cost in the period 1 payroll and non-payroll expenditure population by June 30, 2024. For payroll expenses, the policy includes that a review and approval of the expenditures will be performed by an individual in accounting to ensure that the hours and wages calculated meet the terms and conditions of the PRF. If any non-eligible payroll expenses are identified during the review process, they will be removed. For all other expenses, we will obtain and retain approved copies of all invoices or other documentation to support expenses and review for eligibility. If any non-eligible expenses are identified during the review process, they will be removed. Completion Date: April 5, 2024

View Audit 302859 Questioned Costs: $1

Corrective Action Plans

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