Corrective Action Plans

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

Finding 392584 (2021-002)

Material Weakness 2021

The Jackson County Health Care Authority

AL

Reporting Allowable Costs / Cost Principles Material Weakness

Finding 2021-002- Material Weakness and Material Noncompliance over Reporting Contact Person: Andrew Wenning Managements Response: We have determined that certain expenses reported through the Department of Health and Human Services PRF reporting portal for period 1 did not reconcile to the underlyi...

Finding 2021-002- Material Weakness and Material Noncompliance over Reporting Contact Person: Andrew Wenning Managements Response: We have determined that certain expenses reported through the Department of Health and Human Services PRF reporting portal for period 1 did not reconcile to the underlying expense details by nature and/or function, and therefore did not comply with PRF reporting requirements. We have implemented a monitoring control over PRF reporting to ensure that expenses submitted through the PRF portal are properly classified by nature and/or function, and that such amounts reconcile to the underlying details and accounting records. Completion Date: April 5, 2024

View Audit 302859

Finding 392367 (2021-002)

Material Weakness 2021

Scott County Hospital

KS

Questioned Costs Allowable Costs / Cost Principles Cash Management

Allowable costs related to the program are expenses or losses that were not reimbursed from other sources or that other sources were not obligated to reimburse. The Hospital did not reduce COVID-19 related costs claimed under the PRF program for cost-based reimbursements received from the Medicare p...

Allowable costs related to the program are expenses or losses that were not reimbursed from other sources or that other sources were not obligated to reimburse. The Hospital did not reduce COVID-19 related costs claimed under the PRF program for cost-based reimbursements received from the Medicare program for the COVID-19 related expense. The Hospital will ensure the costs included in all subsequent Provider Relief Fund reporting is reduced for amounts reimbursed by other sources.

View Audit 302715 Questioned Costs: $1

Finding 392314 (2021-006)

Significant Deficiency 2021

Klamath Health Partners, Inc. Dba: Klamath Open Door Family Practice

OR

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

2021–006 Allowable Costs Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Program Cluster Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H80CS00233 – 20 Award Period: January 1, 2021 through December 31, 20...

2021–006 Allowable Costs Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Program Cluster Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H80CS00233 – 20 Award Period: January 1, 2021 through December 31, 2021 Type of Finding: • Significant Deficiency in Internal Control over Compliance • Other Matters Criteria or specific requirement: According to § 75.302 Financial management and standards for financial management systems of 45 CFR Part 75, the 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. Further, the financial management system of each non-federal entity must provide accurate, current, and complete disclosure of the financial results of each federal award or program in accordance with the reporting requirements. According to § 75.303 Internal controls of 45 CFR Part 75, 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: Documentation supporting allowable costs was not maintained by the Family Practice. Questioned costs: Unknown Context: During our testing of expenditures we noted two instances where payroll expenditures charged to the grant were not supported the by the employee’s approved wage rate. Recommendation: We recommend the Family Practice design controls and procedures to ensure the documentation and records required to support wage calculations are properly maintained in the files of the Family Practice. Cause: Management oversight. The Family Practice lacked established internal controls and procedures over financial grant management to ensure supporting records and documentation are properly maintained in the files of the Family Practice. Effect: Inability to support compliance with the grant and a potential loss of federal funding. Recommendation: We recommend the Family Practice design controls and procedures to ensure documentation is properly maintained in the files of the Family Practice. Views of responsible officials: There is no disagreement with the audit finding.

View Audit 302660

Finding 392307 (2021-003)

Material Weakness 2021

Klamath Health Partners, Inc. Dba: Klamath Open Door Family Practice

OR

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Cash Management

2021-003 Material Weakness - Allowable and Unallowable Activities and Allowable Costs Recommendation: We recommend the Family Practice design controls and procedures to ensure submitted reports and the documentation used to prepare the reports are properly maintained in the files of the Family Pract...

2021-003 Material Weakness - Allowable and Unallowable Activities and Allowable Costs Recommendation: We recommend the Family Practice design controls and procedures to ensure submitted reports and the documentation used to prepare the reports are properly maintained in the files of the Family Practice. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Family Practice designed controls and procedures to ensure submitted reports and the documentation used to prepare the reports are properly maintained in the files of the Family Practice. The CEO and CFO roles have been separated into two distinct positions. Separating the roles has significantly strengthened internal controls. Furthermore, a controller has been hired to prepare the reports and maintain appropriate and complete supporting documentation, which will then be reviewed by the CFO and CEO before submission. Name(s) of the contact person(s) responsible for corrective action: Amanda Blodgett, CEO Planned completion date for corrective action plan: December 31, 2024

View Audit 302660

Finding 392164 (2021-005)

Material Weakness 2021

Neighborhood Legal Services Michigan

MI

Questioned Costs Period of Performance Subrecipient Monitoring

We agree with the auditors' comments, and the following action will be taken to improve the situation. We have adjusted the Organization’s Accounting Policies & Procedure Manual to include a detailed review of the General Ledger detail supporting each draw request. Accounting personnel will ensure t...

We agree with the auditors' comments, and the following action will be taken to improve the situation. We have adjusted the Organization’s Accounting Policies & Procedure Manual to include a detailed review of the General Ledger detail supporting each draw request. Accounting personnel will ensure the Organization’s General Ledger specifically details the month of rent and utility allowance being provided so eligible costs are clearly delineated. Someone other than the preparer will perform a review of each drawdown request to ensure that costs are not being drawn down prior to the operating start date of each individual grant. This issue was discussed with HUD in March 2024 at which time procedural changes were implemented. Effective March 2024 the preparer is required to include the month of rent and utility allowance being provided in the General Ledger detail. A review of the General Ledger detail supporting each draw request will be performed by someone other than the preparer to ensure that costs are not being drawn down prior to the operating start date of each individual grant.

View Audit 302371 Questioned Costs: $1

Finding 392163 (2021-004)

Material Weakness 2021

Neighborhood Legal Services Michigan

MI

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

We agree with the auditors' comments, and the following action will be taken to improve the situation. As of the date of this report, we are adjusting the Organization’s Accounting Policies & Procedure Manual to include a detailed review of the General Ledger detail supporting each draw request. The...

We agree with the auditors' comments, and the following action will be taken to improve the situation. As of the date of this report, we are adjusting the Organization’s Accounting Policies & Procedure Manual to include a detailed review of the General Ledger detail supporting each draw request. The purpose of this change is to request drawdowns that agree with actual expenses incurred during the draw period requested. Due to late completion of the 2020 audit, recommendations cited in the audit report were not implemented in 2021. During 2022, the practice of tracking grant utilization on a monthly basis was instituted for all grant awards. Documentation of allocation methodologies for shared expenses (i.e., office rent, general office supplies, telephone/internet costs, copiers, payroll processing) had begun. After the 2020 audit report date, all grant draws were supported by the expense detail reflected in the general ledger as prepared by a Sr. Accountant and reviewed and approved by the Chief Financial Officer. Further, monthly reconciliations of grant draw requests and posted revenues, receivables, and expenses will be performed for each grant. The services of an external consultant were utilized to assess the finance department’s staffing levels. This resulted in the onboarding of three (3) new Sr. Accountants and a Chief Financial Officer by early 2022. This provides adequate staffing to perform a review of the federal grant expenditures on a timely basis.

View Audit 302371 Questioned Costs: $1

Finding 392156 (2021-003)

Significant Deficiency 2021

Housing Authority of the City of Renton

WA

HUD Housing Programs Allowable Costs / Cost Principles Eligibility

Finding 2021-003 a. Comments on the Finding and Each Recommendation: Management agrees with both the finding and recommendations. b. Action(s) Taken or Planned on the Finding The management overseeing the process has been completely replaced to ensure a fresh perspective and unwavering dedication to...

Finding 2021-003 a. Comments on the Finding and Each Recommendation: Management agrees with both the finding and recommendations. b. Action(s) Taken or Planned on the Finding The management overseeing the process has been completely replaced to ensure a fresh perspective and unwavering dedication to implementing robust internal controls. To address the shortcomings identified in Finding 2021-003, the Authority commits to a targeted action plan aimed at ensuring timely compliance with reporting requirements. Central to our approach is the engagement of a fee accountant, recognized for expertise in HUD reporting and public housing financial management. This specialist will be tasked with overseeing and streamlining our reporting processes. By leveraging this expertise, we aim to quickly rectify past reporting lapses and ensure future submissions are timely and compliant with HUD requirements. The new fee accountant will conduct a comprehensive review of our current reporting mechanisms, identify bottlenecks, and implement best practices tailored to our operations. This decisive action, centered around the expertise of the newly appointed fee accountant, demonstrates our commitment to enhancing our financial management practices and aligning with HUD's reporting expectations. Through these measures, we anticipate not only meeting HUD's deadlines but also setting a new standard for operational excellence within our Authority.

View Audit 302365

Finding 392112 (2021-001)

Significant Deficiency 2021

Chesapeake Hospital Authority

VA

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

2021-001 – Internal Controls over Allowable Costs Individual Responsible for Corrective Action Plan: J. Neal Bolton, Director of Revenue Management & Budget Shemaine Rose, Controller Anticipated Completion Date: Completed Management notes that all expenses charged to the federal program were revi...

2021-001 – Internal Controls over Allowable Costs Individual Responsible for Corrective Action Plan: J. Neal Bolton, Director of Revenue Management & Budget Shemaine Rose, Controller Anticipated Completion Date: Completed Management notes that all expenses charged to the federal program were reviewed by the Vice President of Human Resources and the Finance Team, with guidance obtained from independent consultants, however, the documentation of the review was not retained. Management also notes that all expenses were deemed to be appropriately charged to the federal program. In order to ensure documentation is retained evidencing approval of costs, the Authority will require physical sign off on all invoices or electronic approval of all costs charged to the federal program.

View Audit 302275

Corrective Action Plans

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