Corrective Action Plans

Finding 972 (2023-001)

Significant Deficiency 2023

KS

Special Tests & Provisions Eligibility

During the 2023 audit of PrairieStar Health Center, FORVIS found two issues with the sliding fee set up. The first issue was that CPT code 73610 was attached to the wrong slide level due to a change in price. The CPT code was attached to the Radiology 2 group which is for CPTs between $100.00 and ...

During the 2023 audit of PrairieStar Health Center, FORVIS found two issues with the sliding fee set up. The first issue was that CPT code 73610 was attached to the wrong slide level due to a change in price. The CPT code was attached to the Radiology 2 group which is for CPTs between $100.00 and $114.99. The price of the CPT had been changed from $102.00 to $120.00 and should have been moved to the Radiology 3 group which is for CPTs between $115.00 and $169.99. The second issue was that CPT code 90620 was not set up to slide. In the six and one-half years that I have been at PrairieStar, we have made great strides in identifying CPT codes that were not attached to a sliding fee group and correcting them. I feel that this is a rare CPT code that has been missed in our review. Plan to Correct Finding Multiple steps have or will be taken to correct this finding. • Both of the errors above have been corrected in our EMR. • We are getting ready to update pricing. As part of this update, I will review the slide group attached to each CPT code to make sure that the correct slide is attached. • We will continue to randomly review sliding fee calculations each month to help identify any errors in sliding fee calculations or setup. Date of Completion Both of the errors described above have been corrected. There is no completion date for the monthly review. This is a part of our monthly routine. Responsible Party Shandi Stallman, Chief Financial Officer, is the party that has overall responsibility for this corrective action.

View Audit 1839

Finding 954 (2023-003)

Significant Deficiency 2023

Bullock Creek School District

MI

School Nutrition Programs Cash Management Eligibility

October 24, 2023 Finding Number: 2023-003 – Significant Deficiency in Internal Control – Eligibility Condition: Of the 22 applications for reduced meals that were selected for testing, 3 did not document evidence of review by staff. Responsible Person: Kim Gagne – Director of Food Service Imple...

October 24, 2023 Finding Number: 2023-003 – Significant Deficiency in Internal Control – Eligibility Condition: Of the 22 applications for reduced meals that were selected for testing, 3 did not document evidence of review by staff. Responsible Person: Kim Gagne – Director of Food Service Implementation Date: 10-24-2023 This year we have a 2-person checking system, Kim Gagne initially completes the applications with a signature and Jody King double checks every application for errors and oversites and adds her signature also. Both have been through the MDE training on the applications and the required information they need. Sincerely, Stephen Grubaugh Director of Business Services

View Audit 1794

Finding 779 (2023-003)

Material Weakness 2023

Pennington County Housing and Redevelopment Commission

SD

Eligibility HUD Housing Programs Material Weakness

Public and Indian Housing AL #14.850 Material Weakness Internal Control Over Compliance Eligibility Checklists 2023-003 Condition: The Commission uses internal control checklists to demonstrate compliance with the various eligibility requirements. During audit fieldwork, we identified two instances...

Public and Indian Housing AL #14.850 Material Weakness Internal Control Over Compliance Eligibility Checklists 2023-003 Condition: The Commission uses internal control checklists to demonstrate compliance with the various eligibility requirements. During audit fieldwork, we identified two instances in which the checklists were used, but steps related to background checks were not complete. In addition, there was no documentation maintained to prove these checks were performed. Criteria: All eligibility requirements must be verified prior to determining tenant eligibility. Repeat of Prior Year Finding: No Auditor’s Recommendation: We recommend the Commission provide further training for program staff and implement periodic reviews of tenant files to ensure internal control processes are followed and eligibility documentation is maintained. Management’s Response: The Commission has provided training for program staff and performs periodic reviews of tenant files to ensure internal control processes are followed and eligibility documentation is maintained. Anticipated Completion Date: Periodic reviews began January 2023. Staff training and periodic reviews are ongoing.

View Audit 1490

Finding 708 (2023-001)

None 2023

Georgia Association for Primary Healthcare

SC

Eligibility Matching / Level of Effort / Earmarking Special Tests & Provisions

In Finding 2023-001, it was noted that the Organization had found 1 of the 15 patients tested were not in the proper slide category based on the income backup received for the patient. We also found 1 of the 15 patients tested did not have backup for income on file for the sliding fee scale but was ...

In Finding 2023-001, it was noted that the Organization had found 1 of the 15 patients tested were not in the proper slide category based on the income backup received for the patient. We also found 1 of the 15 patients tested did not have backup for income on file for the sliding fee scale but was on the scale and had visits that were applied to the scale. Management recognizes the importance of complying with grant guidelines. In response to Finding 2023-001, Management has taken the necessary steps to ensure full compliance with the provisions of the program, identified specifically as Sliding Fee Discount Program (SFDP) within our organization. These steps include: a. Implementing a new process for adding the sliding fee discount to patient accounts. Each patient that applies for the slide will be scheduled under “eligibility” with an appointment. After the patient has completed the application, the information will be entered into Athena, and then the plan will be calculated. The paperwork will then be uploaded as an attachment to the Sliding Fee Discount Policy. Each week, a report will be generated in Athena and sent to the Clinical Services Manager. This report will list all patients that had an appointment with eligibility for the prior week. The Clinical Services Manager will then use that report and verify that all information is uploaded and entered correctly. b. Training on the new process will occur. All support staff responsible for entering and uploading the Sliding Fee Discount will go through thorough training of the new process. Additionally, the Clinical Services Manager will complete peer-to-peer training on the verification process.

View Audit 1359

Finding 695 (2023-001)

Significant Deficiency 2023

Parkland Community College, Community College District #505

IL

Student Financial Aid Questioned Costs Special Tests & Provisions

Action Plan for Enrollment Reporting Audit Finding 2023-001 Issue - It was discovered that there was a Colleague system update that occurred that caused the Standard Reporting Flag to change from Yes to No, which resulted in inaccurate reporting to NSC. For all terms that a student can attend, the...

Action Plan for Enrollment Reporting Audit Finding 2023-001 Issue - It was discovered that there was a Colleague system update that occurred that caused the Standard Reporting Flag to change from Yes to No, which resulted in inaccurate reporting to NSC. For all terms that a student can attend, the flag must be set to Yes for the reporting to be accurate. The following action plans will be put into place, to ensure that reporting is accurate: Action Plan 1 - A self-audit will be completed monthly when National Student Clearinghouse enrollment reporting is completed. This self-audit is to verify the students' enrollment status is accurate. To verify the accuracy, a sample of students will be pulled from the self-audit who have withdrawn, graduated, or had enrollment changes. Action Plan 2 - Admissions and Records and Financial Aid will work closely with the IT department any time there is a Colleague system update to fully comprehend the implications of the system update and how that could impact reporting and documented procedures.

View Audit 1326

Finding 636 (2023-005)

Significant Deficiency 2023

Moraine Valley Community College District Number 524

IL

Student Financial Aid Matching / Level of Effort / Earmarking Questioned Costs § 200.303

Identifying Number: 2023-005 Finding: The College did not apply the appropriate clock to credit hour conversion formula for certain applicable financial aid eligible programs. The College also did not have sufficient evidence of controls being in place to ensure compliance with this requirement. ...

Identifying Number: 2023-005 Finding: The College did not apply the appropriate clock to credit hour conversion formula for certain applicable financial aid eligible programs. The College also did not have sufficient evidence of controls being in place to ensure compliance with this requirement. Corrective Action Planned: Moraine Valley Community College will evaluate all certificates that are standalone programs. Financial Aid will receive a list of these programs and work with IT to identify students enrolled in those programs. Financial Aid will also update our policies and procedures to ensure that all clock to credit hour conversion formulas are being applied and documented per Uniform Grant Guidance (34 CFR 688.8). Anticipated Completion Date: June 30, 2024 Responsible Person: Tasha Campbell, Director of Financial Aid campbellt68@morainevalley.edu

View Audit 1222

Finding 590 (2023-001)

Significant Deficiency 2023

Community Health Centers of Western Kentucky, Inc.

KY

Special Tests & Provisions Eligibility Matching / Level of Effort / Earmarking

The accounting department, under direction of the CFO, will conduct monthly audits of random patients' accounts for whom the sliding fee schedule has been applied, as well as training for receptionist to minimize errors. Receptionists have been mandated, along with assistance from internal billing s...

The accounting department, under direction of the CFO, will conduct monthly audits of random patients' accounts for whom the sliding fee schedule has been applied, as well as training for receptionist to minimize errors. Receptionists have been mandated, along with assistance from internal billing staff, to review all patients' accounts (including income verification) at least annually.

View Audit 1185

Finding 549 (2023-001)

None 2023

Rural Housing for the Elderly, Inc.

NH

Eligibility HUD Housing Programs Internal Control / Segregation of Duties

Completed corrective action: Manager completed correction and new HUD 50059A recertification's corrected for July 31, 2023. Ongoing Corrective Action: Additional file review after recertifications and move-ins. Additional trainings for Income VS Assets for all managers.

View Audit 1082

Finding 547 (2023-001)

None 2023

Snhs Elderly Housing V, Inc.

NH

Eligibility HUD Housing Programs Internal Control / Segregation of Duties

Completed corrective action: Manager completed correction and new HUD 50059A recertification's corrected for June 30, 2023. Ongoing Corrective Action: Additional file review after recertifications and move-ins. Additional trainings for Income VS Assets for all managers.

View Audit 1072

Finding 545 (2023-001)

None 2023

Rural Housing for the Elderly Ii, Inc.

NH

Eligibility HUD Housing Programs Internal Control / Segregation of Duties

Completed corrective action: Manager completed correction and new HUD 50059A recertification's corrected for June 30, 2023. Ongoing Corrective Action: Additional file review after recertifications and move-ins. Additional trainings for Income VS Assets for all managers.

View Audit 1071

Finding 439 (2023-003)

Material Weakness 2023

Housing Authority of the City of Imperial, Nebraska

NE

Internal Control / Segregation of Duties Special Tests & Provisions Eligibility

Finding 2023-003 The Authority agrees with the finding and responds by stating that our project is relatively small with only one administrative staff. The Board has reviewed this issue and determined there are no additional procedures which can reasonably be done to eliminate these deficiencies a...

Finding 2023-003 The Authority agrees with the finding and responds by stating that our project is relatively small with only one administrative staff. The Board has reviewed this issue and determined there are no additional procedures which can reasonably be done to eliminate these deficiencies and accepts them.

View Audit 966

Finding 436 (2023-001)

None 2023

Howard Payne University

TX

Reporting Questioned Costs Student Financial Aid

Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: A review is being completed by the Registrar’s Office to determine if something is in the student record that may prevent a student from being reported correctly. If a common factor can be determined, then ...

Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: A review is being completed by the Registrar’s Office to determine if something is in the student record that may prevent a student from being reported correctly. If a common factor can be determined, then it will be corrected. Until then, Enrollment reporting to NSC will be reviewed twice. Follow up will be done regarding last date of attendance reporting for those students who do fail to complete the semester. Person Responsible for Corrective Action Plan: Karen LaQuey, Director, Student Financial Aid Director; Wendy McNeeley, previous Registrar; Kristina Penland, Registrar Anticipated Date of Completion: 12/12/2023

View Audit 959

Finding 425 (2023-001)

Significant Deficiency 2023

Shands Jacksonville Medical Center, INC

FL

Allowable Costs / Cost Principles Cash Management Eligibility

Views of responsible officials and planned corrective actions: The Financial and Data Analytics Director conducts spot testing of each bi-weekly payroll expenditure report received from Human Resources for eligible PRF reporting. Evidence of testing is retained. Responsible Officials: Dean C. Cocchi...

Views of responsible officials and planned corrective actions: The Financial and Data Analytics Director conducts spot testing of each bi-weekly payroll expenditure report received from Human Resources for eligible PRF reporting. Evidence of testing is retained. Responsible Officials: Dean C. Cocchi, Vice President and CFO Completion Date: March 31, 2022

View Audit 896

Finding 373 (2023-002)

Material Weakness 2023

Kearney Housing Agency

NE

Eligibility HUD Housing Programs Material Weakness

The Director has added to her monthly checklist to review quality control logs and follow up on any QC reviews that are not being conducted in a timely fashion.

View Audit 782

Finding 361 (2023-003)

Significant Deficiency 2023

Sebeka Public Schools

MN

Allowable Costs / Cost Principles Cash Management Eligibility

Contact Person – Superintendent; Corrective Action Plan – The District has established a procedure for review of journal entries; Completion Date – Completed

View Audit 736

Finding 249 (2023-001)

Significant Deficiency 2023

Morrison Institute of Technology

IL

Eligibility Reporting

Condition - The institution had the following changes that were required to be updated on their ECAR: • The V.P. of Finance (equivalent to a chief financial officer) was no longer active at the institution as of April 2022. • A Board Member was no longer serving the institution as of May 2021. •...

Condition - The institution had the following changes that were required to be updated on their ECAR: • The V.P. of Finance (equivalent to a chief financial officer) was no longer active at the institution as of April 2022. • A Board Member was no longer serving the institution as of May 2021. • A Board Member was added to the Board in October 2021. These changes to the institution’s ECAR information were not submitted until June 2023, subsequent to inquiry by auditors. Corrective Action Plan - The College will review current procedures and adjust accordingly to ensure timely ECAR updates. Contact Person, Title and Phone Number - Chris Scott, President, (815)-772-7218, Ext. 212 Anticipated Completion Date - August 1, 2023

View Audit 493

Finding 222 (2023-003)

Material Weakness 2023

Mary Lee Charles Place

TX

Questioned Costs HUD Housing Programs Eligibility

Management agrees with the finding and will begin an independent review of each tenant file to include examination of proof of disability paperwork to determine if there are any discrepancies and take corrective measures. Leasing office staff will undergo additional HUD 811 training regarding the in...

Management agrees with the finding and will begin an independent review of each tenant file to include examination of proof of disability paperwork to determine if there are any discrepancies and take corrective measures. Leasing office staff will undergo additional HUD 811 training regarding the initial and recertification process. Additionally, management is staffing the property with a dedicated property manager that will be responsible for reviewing tenant files for compliance with HUD procedures including eligibility requirements and ensure supporting documentation is maintained in each tenant’s file prior to signing new or amended leases. Management has requested proof of disability from the tenant that satisfies HUD guidelines and will not renew lease if it is not received. The training and file review will be completed by November 30, 2023. If the tenant does not produce proof of disability their lease will not be renewed on May 11, 2024.

View Audit 460 Questioned Costs: $1

Finding 165 (2023-002)

Material Weakness 2023

Low Rent Housing Agency of Grinnell, Iowa

IA

Internal Control / Segregation of Duties Special Tests & Provisions Eligibility

Finding 2023-002 Internal Control Structure Material Weakness – Eligibility, Reporting and Special Tests and provisions Repeat Finding 2022-02 I agree with finding The Authority is relatively small with limited administrative staff. Further, the Board of Commissioners is a volunteer oversight boar...

Finding 2023-002 Internal Control Structure Material Weakness – Eligibility, Reporting and Special Tests and provisions Repeat Finding 2022-02 I agree with finding The Authority is relatively small with limited administrative staff. Further, the Board of Commissioners is a volunteer oversight board and not a managing board and does not have the time or expertise to provide the necessary services to correct the internal control deficiencies noted. The Board has reviewed the issue and determined that there are no additional procedures which can be reasonably done to eliminate the deficiencies and accepts them.

View Audit 243

Finding 156 (2023-008)

Material Weakness 2023

Virginia Union University

VA

Questioned Costs Eligibility Internal Control / Segregation of Duties

Criteria: Recipients of HEERF funding must acknowledge that it may not condition the receipt of an emergency financial aid grant on continued or future enrollment with the Recipient. Recipients also acknowledge that it may not require a student to consent to the application of the emergency financia...

Criteria: Recipients of HEERF funding must acknowledge that it may not condition the receipt of an emergency financial aid grant on continued or future enrollment with the Recipient. Recipients also acknowledge that it may not require a student to consent to the application of the emergency financial aid grant to the student's oustanding account balance as a condition of receipt of or eligibility for an emergency financial aid grant funding. The recipient also acknowledges that adding preconditions to receiving a financial aid grant that thwart this requirement may be subjected to oversight and corrective action. In consideration for this award, Recipients agree that they hold these grant funds in trust for students and act in the nature of a fiduciary for students. The University concurs with this finding and will adhere to the corrective action plan. Corrective Action: The audit for FY22 was not finalized until June 27, 2023. Now that the FY23 audit is finalized, any such compliance issues with students will be taken care of during actual registration process. In the future, any such forms that will need student authorization will be handled during the registration process. Responsbile Person(s): Robin Jefferson, Director of Student Accounts rljefferson@vuu.edu 804 342-3976. Robert Merino, Executive Director of Financial Aid jrmerino@vuu.edu 281 795-6190. Planned Date of Completion of Corrective Action: December 31, 2023.

View Audit 218

Finding 119 (2023-002)

Significant Deficiency 2023

Health Services, Inc.

AL

Special Tests & Provisions Eligibility Significant Deficiency

The area of compliance evaluated relates to the area of organizational workflow that includes patient intake. Due to the severity of this issue, management has implemented the following as a corrective action: Contact granting organization for technical assistance with implementing and maintaining ...

The area of compliance evaluated relates to the area of organizational workflow that includes patient intake. Due to the severity of this issue, management has implemented the following as a corrective action: Contact granting organization for technical assistance with implementing and maintaining compliance during a period of increased staffing shortages and turnovers  Redesigned current workflow and office procedures to include the following changes: o Entry Level intake will only involve information gathering and collection of copays o 1st Level Supervision will review data and determine eligibility of sliding fee and application o 2nd Level Supervision will perform random chart audits Monthly o 3rd Level Supervisor will perform random chart audits Quarterly  All patient intake staff will receive one-on-one training on Sliding Fee and the importance of documentation.

View Audit 152

Finding 69 (2023-001)

Significant Deficiency 2023

Freestore Foodbank, Inc. and Affiliates

OH

Eligibility Internal Control / Segregation of Duties

Criteria: Under the requirements of the Office of Management and Budget, only a financially needy family that consists of, at a minimum, a minor child living with a parent or other caretaker relative, or a pregnant woman may receive TANF “assistance” or most maintenance-of-effort funded benefits, se...

Criteria: Under the requirements of the Office of Management and Budget, only a financially needy family that consists of, at a minimum, a minor child living with a parent or other caretaker relative, or a pregnant woman may receive TANF “assistance” or most maintenance-of-effort funded benefits, services or “assistance”. The child must be less than 18 years old, or, if a full-time student in a secondary school (or the equivalent level of vocational or technical training), less than 19 years old. Freestore Foodbank Inc. and Affiliates require all individuals receiving food to complete an eligibility form prior to receiving food. Condition: We noted one instance (in a sample of 40 clients) in which an eligibility form was not obtained prior to client receiving food. Planned Corrective Action: Management will perform periodic audits of eligibility forms starting 10/15/2023 to ensure compliance. Management will retrain staff to ensure completeness of the intake process. Furthermore, by 9/30/2023, management will work with the developers of the database to see if controls can be implemented in the software, so food cannot be distributed before the signing of the required form.

View Audit 63

Finding 1228668 (2022-003)

Material Weakness 2022

Housing Authority of the City of Tulsa

OK

HUD Housing Programs Eligibility Significant Deficiency

Public and Indian Housing – ALN #14.850 Recommendation: We recommend that management review their procedures to ensure that all required documentation is maintained in the file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. procedures for tenant inc...

Public and Indian Housing – ALN #14.850 Recommendation: We recommend that management review their procedures to ensure that all required documentation is maintained in the file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. procedures for tenant income and asset verification to ensure that all required third-party documentation is obtained, retained, and reviewed before certifications are finalized. Supervisory review procedures were enhanced to include verification of income documentation, asset calculations, and tenant file completeness. Staff received refresher training on HUD documentation requirements, income and asset verification procedures, and file quality control standards. In addition, ongoing file audits and management review procedures have been implemented to identify and correct documentation deficiencies promptly. Name(s) of the contact person(s) responsible for corrective action: Jason Epperson, Assistant Vice President Planned completion date for corrective action plan: December 31, 2026

View Audit 410330

Finding 1227167 (2022-002)

Material Weakness 2022

County of Rockingham

NH

Allowable Costs / Cost Principles Eligibility Significant Deficiency § 200.303 § 200.334

Audit Finding Reference: 2022-002 Corrective Action Taken or Planned: 1. Formalized Record Retention Policies: A formal record retention policy specific to federal grant programs will be implemented to ensure full compliance with 2 CFR 200.334. This policy will apply regardless of whether documentat...

Audit Finding Reference: 2022-002 Corrective Action Taken or Planned: 1. Formalized Record Retention Policies: A formal record retention policy specific to federal grant programs will be implemented to ensure full compliance with 2 CFR 200.334. This policy will apply regardless of whether documentation is stored internally or by third-party systems. Any documentation downloaded or transferred from third-party systems will be subject to a review process to verify completeness and accuracy before being finalized for County retention. The County shall also take steps to ensure that information downloads and exports from third-party systems represent omplete and accurate records. 2. Audit Timing Advocacy and Preparedness: The County will continue to maintain timely documentation and preparedness for audits and will also advocate for timely initiation and completion of future audits. Significant delays in the audit process, through no fault of the County, as observed during the FY2022 audit, substantially impacted the County's ability to access necessary documentation and demonstrate compliance. Although the County made every effort to retain records in accordance with federal requirements, the timing of the audit fieldwork occurred well after the program had concluded in May 2023. Had the audit been conducted in a timely manner, full access to the third-party platform used for program administration would have been available, along with all supporting documentation. However, by the time the audit took place, the program had been closed for over 18 months, and access to the external software system had lapsed in accordance with the expiration of the service agreement. 3. Internal Audit Readiness Reviews: Beginning with FY2025, the County will conduct internal audit readiness reviews shortly after fiscal year-end to ensure all documentation for closed federal programs is centralized, archived, and accessible for future audit purposes, even if conducted years later. Anticipated Completion Date: October 15, 2025 Contact Person Responsible for Corrective Action: Charles Nickerson, Senior Director of Finance

View Audit 409335

Finding 1227057 (2022-001)

Material Weakness 2022

GREAT NORTHWEST WHOLESALE WATER COMMISSION

MO

Reporting Eligibility § 200.501 § 200.512

Federal Program: Direct - USDA Rural Utilities Service award; ALN 10.760, 'Water and Waste Disposal Systems for Rural Communities' (Single Audit / Uniform Guidance).Condition: The Great Northwest Wholesale Water Commission did not complete and submit its reporting package, including the SEFA and the...

Federal Program: Direct - USDA Rural Utilities Service award; ALN 10.760, 'Water and Waste Disposal Systems for Rural Communities' (Single Audit / Uniform Guidance).Condition: The Great Northwest Wholesale Water Commission did not complete and submit its reporting package, including the SEFA and the single audit report, to the Federal Audit Clearinghouse within nine months of the fiscal year end. Criteria: Under 2 CFR §200.512, the audit must be completed, and the data collection form and reporting package must be submitted within 30 calendar days after receipt of the auditor's report, or nine months after the fiscal year end, whichever is earlier. Corrective Action Plan: Management acknowledges the finding and has implemented procedures to improve the timely completion and submission of the data collection form to the Federal Audit Clearinghouse. Management has engaged an audit firm to complete the December 31, 2022, 2023, and 2024 audits and will submit the reporting package to the Federal Audit Clearinghouse upon completion. Management will coordinate with the auditors throughout the audit process, monitor applicable reporting deadlines, and establish internal timelines to ensure the audit report and data collection form are submitted within the required time frame prescribed by 2 CFR 200.512(a). Personnel responsible for Corrective Action: Jerri Dearmont, Executive Director Anticipated Completion Date: August 18, 2026

View Audit 409232

Finding 1223981 (2022-003)

Material Weakness 2022

NEW YORK MORTGAGE COALITION, INC.

NY

Procurement, Suspension & Debarment Subrecipient Monitoring Eligibility

Management will implement procedures to ensure that documentation of the verification process for suspension and debarment is maintained to support the organization's internal control over compliance.

View Audit 407388

Corrective Action Plans

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