Corrective Action Plans

Finding 20392 (2022-004)

Material Weakness 2022

AZ

Allowable Costs / Cost Principles Material Weakness Reporting § 200.303

Finding 2022-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Compliance Requirement: Reporting Finding Summary: The Hospital did not properly include 340B reve...

Finding 2022-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Compliance Requirement: Reporting Finding Summary: The Hospital did not properly include 340B revenues and final audit adjustments in net patient service revenue. In addition, the Hospital did not properly report payor categories for quarters in which the net patient service revenues were negative. Responsible Individuals: Patti Clavette, Chief Financial Officer; Jackie Lundblad, Chief Executive Officer Corrective Action Plan: Management will modify the lost revenue reported on future reports, if any, to reflect an accurate total lost revenue amount. In addition, a formal review and approval process will be implemented to ensure calculations are in accordance with applicable requirements and a member of management will be identified to review all reporting requirements for federal grants and awards to ensure the Hospital is in compliance with the requirements. Anticipated Completion Date: September 30, 2023

View Audit 21564

Finding 20391 (2022-006)

Significant Deficiency 2022

Wickenburg Community Hospital

AZ

Questioned Costs Allowable Costs / Cost Principles Cash Management

Finding 2022-006 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Assistance Listing #10.766 Compliance Requirement: Allowable Costs Finding Summary: Management calculated the applicant?s contribution as 25% of the funds requested ...

Finding 2022-006 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Assistance Listing #10.766 Compliance Requirement: Allowable Costs Finding Summary: Management calculated the applicant?s contribution as 25% of the funds requested for reimbursements instead of first applying the full contribution to the requested reimbursement. Responsible Individuals: Patti Clavette, Chief Financial Officer; Jackie Lundblad, Chief Executive Officer Corrective Action Plan: Management will properly adjust subsequent requests for reimbursement under the grant agreement for the remaining portion of the applicant?s contribution. In addition, management will evaluate controls in place to ensure conditions of future grants are met in order to prevent further noncompliance or question costs. Anticipated Completion Date: September 30, 2023

View Audit 21564 Questioned Costs: $1

Finding 20384 (2022-004)

Material Weakness 2022

Morris Area Public School 2769

MN

Allowable Costs / Cost Principles Material Weakness School Nutrition Programs

Finding Summary: During the course of our engagement, we noted instances where documentation was not retained supporting payroll expenditures and invoices were paid in an incorrect amount that was charged to the federal Child Nutrition Cluster program. Responsible Individuals: Shane Monson, Superint...

Finding Summary: During the course of our engagement, we noted instances where documentation was not retained supporting payroll expenditures and invoices were paid in an incorrect amount that was charged to the federal Child Nutrition Cluster program. Responsible Individuals: Shane Monson, Superintendent. Corrective Action Plan: The District will review and strengthen the controls surrounding the review and approval of allowable costs to ensure they are supported, approved of, and calculations are accurate. Anticipated Completion Date: June 30, 2023

View Audit 20655

Finding 20379 (2022-001)

Significant Deficiency 2022

Junior Achievement of Arizona, Inc.

AZ

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

Management has implemented procedures to verify that the expenditures that are requested for reimbursement are not duplicated and are allowable under the Uniform Guidance. Review procedures have been added to help ensure that only allowable salaries expenses are included in reimbursement requests an...

Management has implemented procedures to verify that the expenditures that are requested for reimbursement are not duplicated and are allowable under the Uniform Guidance. Review procedures have been added to help ensure that only allowable salaries expenses are included in reimbursement requests and that all voided checks are omitted.

View Audit 19855 Questioned Costs: $1

Finding 20378 (2022-002)

Significant Deficiency 2022

Housing Authority of the Township of Neptune

NJ

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.423 § 200.438 § 200.473

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program to ensure that established internal control policies are being followed on a timely basis. Bart Cook,...

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program to ensure that established internal control policies are being followed on a timely basis. Bart Cook, Executive Director, is responsible for implementing this corrective action by September 30, 2023.

View Audit 19315 Questioned Costs: $1

Finding 20377 (2022-001)

Significant Deficiency 2022

Peacehealth Networks

WA

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

As noted within the portal filing summary for the general reporting Period 1, the Corporation?s consolidated lost revenue totaled $141,363,926. Payments from the PRF for Period 1 totaled $53,982,121 for the consolidated parent and $14,810,675 for St. John?s Medical Center Period 2 targeted report. A...

As noted within the portal filing summary for the general reporting Period 1, the Corporation?s consolidated lost revenue totaled $141,363,926. Payments from the PRF for Period 1 totaled $53,982,121 for the consolidated parent and $14,810,675 for St. John?s Medical Center Period 2 targeted report. As a result, there were sufficient qualifying lost revenues to receive and earn all PRF funds received, regardless of the reporting error identified and described in the ?condition found? section above. Therefore, management believes no repayment of PRF funds received would be required. Management is implementing a process to add additional review steps prior to finalizing future reporting submissions.

View Audit 19419

Finding 20375 (2022-003)

Material Weakness 2022

The Be Kind People Project Foundation

AZ

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

2022-003 Material Weakness in Internal Control over Compliance with Activities Allowed or Unallowed and Allowable Costs/ Cost Principles Condition: The Organization did not retain the required documentation to support the review of expenditures. Cause: The Organization had turnover and limited st...

2022-003 Material Weakness in Internal Control over Compliance with Activities Allowed or Unallowed and Allowable Costs/ Cost Principles Condition: The Organization did not retain the required documentation to support the review of expenditures. Cause: The Organization had turnover and limited staffing available. Management?s Response and Corrective Action Plan: Changing the personnel involved has solved much of the problem, also the full awareness of what needs to be retained has also been explained to management. If/ when funds from federal sources are used, those expenditures will be reviewed monthly. Specifically, this will mean: ? Maintain EIDL-sourced funds in separate bank/ account. ? Have single authorization for any movement/ usage of funds in EIDL account. ? If/when funds from EIDL are used, have a written statement for purpose and documentation produced for use at the time of request. Responsible Individuals: ? Maintain separate account ? Marcia Meyer, CEO, in conjunction with Board Finance Committee ? Authorization for use of funds ? Marcia Meyer ? Maintenance of records for use ? JC Thompson ? Confirmation with use of funds per allowable uses per national guidelines ? Jennie Myers ? Reporting on monthly finance report ? Jennie Myers Anticipated Completion Date: This process is underway and will be visible at the fiscal year-end audit in June 2023.

View Audit 19100

Finding 20360 (2022-004)

Significant Deficiency 2022

Joseph's House and Shelter, Inc.

NY

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Finding 2022-004 ? Allowable Costs/Cost Principles--Significant Deficiency Recommendation: The Organization should put in place policies and procedures necessary to maintain detailed contemporaneous documentation supporting the allocation of payroll and related expenses to individual programs in a...

Finding 2022-004 ? Allowable Costs/Cost Principles--Significant Deficiency Recommendation: The Organization should put in place policies and procedures necessary to maintain detailed contemporaneous documentation supporting the allocation of payroll and related expenses to individual programs in a manner that accurately reflects the work performed. Views of Responsible Officials and Planned Corrective Actions: The Executive Director worked with the Director of Grants and Finance to review and revise the agency?s accounting policies and procures. To ensure proper oversight, all procedures and reports will be reviewed by the Board?s Finance Committee, followed by a final review and approval of the Full Board of Directors of Joseph?s House & Shelter. One project of note was a collaborative effort undertaken by the Executive Director, a new Director of HR and Administration, the Human Resources Manager, and the Director of Grants and Finance to roll out a more detailed time keeping system that is used to track employee time spent per program. This data is then subsequently directly coded and uploaded into the accounting software. This process ensures on an ongoing basis that the allocation of payroll and related expenses will accurately reflect the work being performed and has significantly improved timely and precise grant claims. This was implemented in Q2 2023.

View Audit 18957

Finding 20359 (2022-003)

Material Weakness 2022

Joseph's House and Shelter, Inc.

NY

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness

Finding 2022-003 ? General Oversite ? Material Weakness Recommendation: We recommend that the Organization create policies and procedures to ensure proper oversight of the financial reporting function. In addition, we would recommend the Organization to consider the costs and benefits of restruct...

Finding 2022-003 ? General Oversite ? Material Weakness Recommendation: We recommend that the Organization create policies and procedures to ensure proper oversight of the financial reporting function. In addition, we would recommend the Organization to consider the costs and benefits of restructuring the finance department. This could include allocating additional resources to hire additional employees, reallocation of responsibilities within the organization and less reliance on the contracted accounting services. View of Responsible Officials and Planned Corrective Actions: The Executive Director has worked with the Director of Grants and Finance to review and revise the agency?s accounting policies and procures. To ensure proper oversight, all procedures and reports will be reviewed by the Board?s Finance Committee, followed by a final review and approval of the Full Board of Directors of Joseph?s House & Shelter. Beginning in Q1 2022, agency leadership took necessary action to begin restructuring the Finance Department following a change in staffing with the contracted accounting service. In Q2 2022, the agency promoted a long-tenured staff member to the newly-created Director of Grants and Finance position, which separated and removed all finance duties from the Director of Administration. To support the Director of Grants and Finance, a full time Grants and Finance Specialist staff position was created in Q3 of 2022. The organization has scaled back reliance on the contracted accounting service and has ensured that all claims, with the implementation of personnel time tracking systems, are submitted through our Finance Department. We continue to use a contracted accounting service for higher-level accounting duties and for on-going advisement that supplements, instead of replaces, the work of internal staff. We are confident these changes have improved the agency?s ability to provide adequate management oversight in the financial reporting process. This was completed in Q2 of 2023.

View Audit 18957

Finding 20322 (2022-002)

None 2022

City of Birmingham

AL

Special Tests & Provisions Subrecipient Monitoring Allowable Costs / Cost Principles

Corrective Action Plan: Management has arranged for grants training for relevant employees. Directors over the City's ESG federal program will develop procedures with the City's Finance Department in order to ensure that the City meets the award requirements for both ESG and ESG- CV funds. Perso...

Corrective Action Plan: Management has arranged for grants training for relevant employees. Directors over the City's ESG federal program will develop procedures with the City's Finance Department in order to ensure that the City meets the award requirements for both ESG and ESG- CV funds. Person Responsible: Dr. Meghan V. Thomas, Director of Community Development Aaron L. Saxton, Acting Director of Finance

View Audit 28073

Finding 20318 (2022-001)

Material Weakness 2022

Advance Community Health

NC

Allowable Costs / Cost Principles HUD Housing Programs Reporting

Advance Community Health was inundated with HRSA reporting due to the multiple funding we received in response to the Covid-19 Pandemic. In an effort to help health centers deal expeditiously with the Covid crisis some of the funding was given in advance with reporting requirements to follow. The ...

Advance Community Health was inundated with HRSA reporting due to the multiple funding we received in response to the Covid-19 Pandemic. In an effort to help health centers deal expeditiously with the Covid crisis some of the funding was given in advance with reporting requirements to follow. The rush to get funding out to address the Covid-19 pandemic crisis resulted in reporting requirements that were developed and implemented very quickly, and the reporting requirements were confusing to many health centers. The Provider Relief Funding was one of the instances in which funding was given in advance with reporting requirements to follow. As a result of the confusion surrounding these last-minute reporting requirements, we believe that the former CFO inadvertently omitted certain revenue that perhaps should have been included in the Provider Relief Funding (PRF) report and there was no clear explanation in the narrative section as to why these revenues were omitted. We attempted to recall and amend the PRF report but were told by the PRF reporting team that we are unable to amend the report at this time. However, should the opportunity to amend the PRF Report occur, we will make the appropriate amendment to the PRF report with a reconciliation and narrative that will support the earning of the PRF funding. To prevent future occurrences of where it is not clear why revenue items are being omitted or included on a federal provider relief report, a reconciliation will be prepared that ties the revenue section of the PRF report with the revenue section of the internal financial statements. The reconciliation will clearly outline what is included in and what is omitted from the report and establish clear documentation to strongly support the amounts on the PRF report. A narrative documenting why certain revenue is omitted should be attached, which will clearly and concisely explain how the revenue amounts on the PRF report were derived. The reconciliation will be prepared by our senior accountant and reviewed by the CFO. Tiffany Robertson, the interim CFO and Rhonda Payne, our Chief Compliance Officer will be responsible for and will continue to assess our internal reporting processes. We will continue to conduct staff training as deemed necessary to ensure compliance with federal reporting requirements for PRF funding. The training and procedure should be implemented by December 2022.

View Audit 26499

Finding 20313 (2022-002)

Material Weakness 2022

Erie Elementary Charter School

IL

Allowable Costs / Cost Principles Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking § 200.302 § 200.303 § 200.305 § 200.318 § 200.319

FINDING NUMBER: 2022-002 Condition: The Organization is either lacking or has non-conforming written policies and procedures for the following administrative functions, required by the Uniform Guidance: 1. Financial Management - 2 CFR 200.302(b)(6) 2. Allowable Costs - 2 CFR 200.302(b)(7) 3. Federal...

FINDING NUMBER: 2022-002 Condition: The Organization is either lacking or has non-conforming written policies and procedures for the following administrative functions, required by the Uniform Guidance: 1. Financial Management - 2 CFR 200.302(b)(6) 2. Allowable Costs - 2 CFR 200.302(b)(7) 3. Federal payment - 2 CFR 200.305(b)(1) 4. Procurement - 2 CFR 200.318(a) and 2 CFR 200.318(c)(1) 5. Competition - 2 CFR 200.319(d) 5. Competition ? 2 CFR 200.319(d) 6. Methods of procurement to be followed - 2 CFR 200.320 7. Compensation (Personal Services) - 2 CFR 200.430(a)(1) 8. Compensation (Fringe Benefits - Leave) - 2 CFR 200.431(b)(1) 9. Relocation costs of employees - 2 CFR 200.464(a)(2) 10. Travel costs - 2 CFR 200.474 Planned Corrective Action: Management agrees with the finding and plans to review Uniform Guidance, modify and create policies and procedures where necessary to meet administrative Uniform Guidance requirements. The adopted policies and procedures will be reviewed and approved by the School Board of Directors at the organization?s next scheduled Board meeting. School Representative Responsible for Corrective Action: Carlos Perez, Executive Director Anticipated Completion Date: June 14, 2023

View Audit 25279

Finding 20278 (2022-001)

Significant Deficiency 2022

Epic Academy

IL

Allowable Costs / Cost Principles Subrecipient Monitoring Cash Management § 200.410

Identifying Number: 2022-001 Finding: The following discrepancies and inconsistencies were identified: administrative procedures and requirements of the grantor were not followed; there were no proper review or approval of required reporting prior to submission. Contact person responsible for corr...

Identifying Number: 2022-001 Finding: The following discrepancies and inconsistencies were identified: administrative procedures and requirements of the grantor were not followed; there were no proper review or approval of required reporting prior to submission. Contact person responsible for corrective action: Kevyn Harmon, Senior Director of Finance & Administration Corrective Action: All personnel involved with the ESSER III ? MFT Programs undergo training on the all the processes and requirements to administer the programs, and management will perform proper review of all claims for reimbursement. In additional, an annual update on the procedures and the requirements to ensure propriety and accuracy. Proposed Completion Date: EPIC Academy will complete implementation of the above procedures by November 30, 2022.

View Audit 23750

Finding 20277 (2022-002)

None 2022

Epic Academy

IL

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.302 § 200.303 § 200.308 § 200.410 § 200.430

Identifying Number: 2022-002 Finding: The following discrepancies and inconsistencies were identified: administrative procedures and requirements of the grantor were not followed; there were no proper review or approval of required reporting prior to submission. Contact person responsible for corr...

Identifying Number: 2022-002 Finding: The following discrepancies and inconsistencies were identified: administrative procedures and requirements of the grantor were not followed; there were no proper review or approval of required reporting prior to submission. Contact person responsible for corrective action: Kevyn Harmon, Senior Director of Finance & Administration Corrective Action: All personnel involved with the Title programs undergo training on the all the processes and requirements to administer the programs, and management will perform proper review of all claims for reimbursement. In additional, an annual update on the procedures and the requirements to ensure propriety and accuracy. Proposed Completion Date: EPIC Academy will complete implementation of the above procedures by November 30, 2022.

View Audit 23750 Questioned Costs: $1

Finding 20271 (2022-002)

Significant Deficiency 2022

Healthwest

MI

Questioned Costs Allowable Costs / Cost Principles Period of Performance § 200.309

Finding 2022-002 ? Considered a significant deficiency in internal control over compliance/immaterial non-compliance Federal Grant ? ALN 93.958 Condition ? During testing it was noted that FICA costs were overcharged by $14,047. Corrective Action ? HealthWest will review its methods for determini...

Finding 2022-002 ? Considered a significant deficiency in internal control over compliance/immaterial non-compliance Federal Grant ? ALN 93.958 Condition ? During testing it was noted that FICA costs were overcharged by $14,047. Corrective Action ? HealthWest will review its methods for determining allocations of fringe benefits to their grants. Review and, any necessary, updates to daily procedures and processes are occurring. All finance staff and any HealthWest staff assigned to grants will be required to obtain grants specific training annually. Finally, monthly monitoring of all expenses will be reviewed. Contract Person ? Brandy Carlson, Chief Financial Officer Anticipated Completion Date ? June 30, 2023

View Audit 21044 Questioned Costs: $1

Finding 20251 (2022-015)

Material Weakness 2022

Doral Academy of Nevada

NV

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

Finding Number: 2022-015 ? Reporting Corrective Action Plan: A process has been put in place for the school principal to review all RFRs prior to submission to the grantor. Approval is evidenced by email sent by principal to the Director of Grant Management, which is saved with the RFR as support. R...

Finding Number: 2022-015 ? Reporting Corrective Action Plan: A process has been put in place for the school principal to review all RFRs prior to submission to the grantor. Approval is evidenced by email sent by principal to the Director of Grant Management, which is saved with the RFR as support. Responsible Individuals: Nachum Golodner, Director of Accounting Anticipated Completion Date: June 30, 2023

View Audit 20771

Finding 20243 (2022-013)

Material Weakness 2022

Doral Academy of Nevada

NV

Allowable Costs / Cost Principles School Nutrition Programs Internal Control / Segregation of Duties § 200.303

Finding Number: 2022-013 ? Activities Allowed or Unallowed and Allowable Costs/Cost Principles Corrective Action Plan: A process has been put in place for the school principal to review all RFRs prior to submission to the grantor. Approval is evidenced by email sent by principal to the Director of G...

Finding Number: 2022-013 ? Activities Allowed or Unallowed and Allowable Costs/Cost Principles Corrective Action Plan: A process has been put in place for the school principal to review all RFRs prior to submission to the grantor. Approval is evidenced by email sent by principal to the Director of Grant Management, which is saved with the RFR as support. Responsible Individuals: Nachum Golodner, Director of Accounting Anticipated Completion Date: June 30, 2023

View Audit 20771

Finding 20242 (2022-016)

Material Weakness 2022

Doral Academy of Nevada

NV

Reporting School Nutrition Programs Internal Control / Segregation of Duties § 200.303

Finding Number: 2022-016 ? SEFA Preparation Corrective Action Plan: In 2022, the office had downsized due to turnover in staff. While a process was in place for reconciling, a secondary review was not performed to verify accuracy of the residual value calculations. To strengthen the oversight of fin...

Finding Number: 2022-016 ? SEFA Preparation Corrective Action Plan: In 2022, the office had downsized due to turnover in staff. While a process was in place for reconciling, a secondary review was not performed to verify accuracy of the residual value calculations. To strengthen the oversight of financial management in the School, Academica Nevada, the School?s management company, has filled all the open positions and realigned staff responsibilities to reduce individual workloads and provide additional oversight and review. The grant manager will reconcile all grants to ensure proper cutoff, with a secondary review performed by a member of management. Responsible Individuals: Nachum Golodner, Director of Accounting Anticipated Completion Date: June 30, 2023

View Audit 20771

Finding 20181 (2022-010)

Material Weakness 2022

Hartford Union High School District

WI

Allowable Costs / Cost Principles School Nutrition Programs

District Response and Corrective Action Plan: The Business Office has implemented new procedures requiring requisitions prior to every purchase. All purchases for the 2022-2023 school will have approval. Timecards are approved in Skyward via the Organizational Chart by each employee?s supervisor.

View Audit 28366

Finding 20138 (2022-001)

Significant Deficiency 2022

Siloam Springs School District

AR

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.439

2022-001 Allowable Costs/Cost Principles The ESSER Coordinator, Shane Patrick, Assistant Superintendent of Operations and the Chief Financial Officer, Terri Raskiewicz, are reviewing all actual expenses that pertain to COVID-19-Education Stabilization Fund. Shane Patrick did reach out to DESE and D...

2022-001 Allowable Costs/Cost Principles The ESSER Coordinator, Shane Patrick, Assistant Superintendent of Operations and the Chief Financial Officer, Terri Raskiewicz, are reviewing all actual expenses that pertain to COVID-19-Education Stabilization Fund. Shane Patrick did reach out to DESE and DESE provided our district with a letter stating these expenses would have been approved had we sent in a justification form. This item was approved by DESE in our overall ESSER plan. We implemented on July 1, 2022

View Audit 19455 Questioned Costs: $1

Finding 20131 (2022-008)

Significant Deficiency 2022

Edgecombe County

NC

Allowable Costs / Cost Principles Eligibility Significant Deficiency

Finding: 2022-008 Significant Deficiency over Eligibility Name of contact person: Lynda Kennedy and Narkeisha Bryant, TANF Supervisors Corrective Action: Files will be reviewed internally by TANF Supervisors and Quality Control Workers to ensure all required e...

Finding: 2022-008 Significant Deficiency over Eligibility Name of contact person: Lynda Kennedy and Narkeisha Bryant, TANF Supervisors Corrective Action: Files will be reviewed internally by TANF Supervisors and Quality Control Workers to ensure all required evidence is received and documented properly. Workers will be retrained on what files should contain and the importance of complete and accurate record keeping. Workers will be retrained to ensure that all files include verifications, documented sources of income and verify that those amounts will match information in NCFAST. The workers will be retrained to ensure that the results found or documentation in case notes will clearly indicate what actions were performed and the results of those actions. Proposed Completion Date: Training and corrections will be completed by March 1, 2023. Case record reviews are currently being conducted and will be ongoing.

View Audit 22511

Finding 20130 (2022-010)

Significant Deficiency 2022

Edgecombe County

NC

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Procurement, Suspension & Debarment

Finding: 2022-010 Significant Deficiency over Eligibility Name of contact person: Eric Evans, County Manager Corrective Action: The County understands the importance of implementing these policies and will work to have these policies adopted by the Board of Com...

Finding: 2022-010 Significant Deficiency over Eligibility Name of contact person: Eric Evans, County Manager Corrective Action: The County understands the importance of implementing these policies and will work to have these policies adopted by the Board of Commissioners by the end of the fiscal year using the model policies developed by the UNC School of Government. Proposed Completion Date: June 30, 2023

View Audit 22511

Finding 20129 (2022-009)

Significant Deficiency 2022

Edgecombe County

NC

Allowable Costs / Cost Principles Eligibility Significant Deficiency

Finding: 2022-009 Significant Deficiency over Eligibility Name of contact person: Donna Barnes and Linda Jackson, FNS Supervisors Corrective Action: Files will be reviewed internally by FNS Supervisors an Quality Control Workers to ensure that records containt ...

Finding: 2022-009 Significant Deficiency over Eligibility Name of contact person: Donna Barnes and Linda Jackson, FNS Supervisors Corrective Action: Files will be reviewed internally by FNS Supervisors an Quality Control Workers to ensure that records containt all required evidence and is received and documented properly. Workers will be retrained on what files should contain and the importance of complete and accurate record keeping. Workers will be retrained to ensure all files will include verifications, documented sources of income and verify that those amounts will match information in NCFAST. The workers will be retrained to ensure that results found or documentation in case notes will clearly indicate what actions were performed and the results of those actions. Proposed Completion Date: Training and corrections will be completed by March 1, 2023. Case record reviews are currently being conducted and will be ongoing.

View Audit 22511

Finding 20116 (2022-001)

Material Weakness 2022

Albany Area Primary Health Care, Inc.

GA

Allowable Costs / Cost Principles HUD Housing Programs Reporting

Views of Responsible Officials and Planned Corrective Actions ? AAPHC has evaluated the lost revenue calculation used in the period one Provider Relief Fund reporting and has determined that there would still have been sufficient lost revenue incurred to fully obligate the funds received if 340b pha...

Views of Responsible Officials and Planned Corrective Actions ? AAPHC has evaluated the lost revenue calculation used in the period one Provider Relief Fund reporting and has determined that there would still have been sufficient lost revenue incurred to fully obligate the funds received if 340b pharmacy revenue had been included in the calculation. Management intends to correct the lost revenue previously reported when completing the required reporting for the period four funding cycle. Responsible Official: Milton Jordan, Chief Financial Officer Anticipated completion date: March 31, 2023

View Audit 21769

Finding 20109 (2022-001)

Material Weakness 2022

Adventist Health System/west

CA

Questioned Costs Allowable Costs / Cost Principles Reporting

Finding 2022-001 - Internal control deficiency and noncompliance over the allowable activities, allowable costs/cost principles, and reporting compliance requirements Adventist Health had several phone conversations with HRSA over allowable expenses for the ARP program. We explained we had been usi...

Finding 2022-001 - Internal control deficiency and noncompliance over the allowable activities, allowable costs/cost principles, and reporting compliance requirements Adventist Health had several phone conversations with HRSA over allowable expenses for the ARP program. We explained we had been using lost revenue method for prior period reporting. We asked specifically what we can use and not use. We were informed to take the values (in whole) to use as expenses. We were following the guidance we had received by the HRSA employees. The information was confirmed on our methodology for allowable expenses by 2 different employees. Contact Person: Manager, Tax & Audit ? David Dumitru. Expected Completion Date: October 2023

View Audit 20475 Questioned Costs: $1

Corrective Action Plans

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