Corrective Action Plans

Finding 522274 (2023-004)

Material Weakness 2023

Children's Hospital of Chicago Medical Center and Affiliated Corporati

IL

Reporting Internal Control / Segregation of Duties § 200.502 § 200.510

Finding 2023-004- Lack of Effective Controls Over Preparation of Schedule of Expenditures of Federal Awards Grantor: U.S. Department of the Treasury Assisstance Listing#: 21.027 Title: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Award Year: Fiscal year 2023 9/1/22-8/31/23 Award Number...

Finding 2023-004- Lack of Effective Controls Over Preparation of Schedule of Expenditures of Federal Awards Grantor: U.S. Department of the Treasury Assisstance Listing#: 21.027 Title: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Award Year: Fiscal year 2023 9/1/22-8/31/23 Award Number: Not Listed Management understands the importance of effective internal controls over the preparation of the Schedule of Expenditures of Federal Awards (SEFA). At the time of preparing the 2023 SEFA, $2 Million was improperly excluded causing the reported to be restated. Corrective Action Plan and Anticipated Completion Date: The total expenditures reported in error for the 2023 SEFA will be restated and the consolidated Financial and Compliance Report in Accordance with the Uniform Guidance will be re-sibmitted to the appropriate federal and state agencies. On a go forward basis, management's review will include a reconciliation of all grant expenses reported on the current SEFA to the grant awards listed on the State of Illinois Department of Public Health (IDPH) grant portal (EGrMS) to ensure all federal awards are reported.

View Audit 341545

Finding 522249 (2023-001)

Material Weakness 2023

Detroit Police Athletic League, Inc.

MI

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

Finding: The Organization did not have adequate and effective controls over compliance in place as it relates to activities allowed or unallowed and allowable costs. We noted instances where payroll and non-payroll related expenditures did not have documentation of review. Corrective Response: Manag...

Finding: The Organization did not have adequate and effective controls over compliance in place as it relates to activities allowed or unallowed and allowable costs. We noted instances where payroll and non-payroll related expenditures did not have documentation of review. Corrective Response: Management represents that there was not sufficient documentation of controls. Operational and reporting improvements will be pursued to better document expenditure review on a go-forward basis.

View Audit 341505

Finding 522220 (2023-002)

Material Weakness 2023

Boys & Girls Club of Paterson and Passaic, Inc.

NJ

Questioned Costs Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.302 § 200.403

Recommendation 1: Comment: We appreciate the recommendation and fully agree with the importance of having a clear documentation process for all deliveries. To address this, we will implement a policy that ensures all deliveries to the Organization and Units are properly documented. A designated empl...

Recommendation 1: Comment: We appreciate the recommendation and fully agree with the importance of having a clear documentation process for all deliveries. To address this, we will implement a policy that ensures all deliveries to the Organization and Units are properly documented. A designated employee responsible for receiving deliveries will be tasked with ensuring that all receipts and receiving reports are accurately matched with the corresponding invoices. This process will enhance our internal controls and improve the tracking and accountability of all deliveries. Recommendation 2: Comment: We will implement a policy requiring Unit Directors to submit daily "End of Day Reports" using a standardized template. This template will capture essential information, including activities conducted, materials distributed, and deliveries received. We will also establish a policy for maintaining and utilizing sign-in sheets at each Unit, outlining the required information such as the activity or event description, number of children involved, materials distributed, and the names of the Unit Director and Assistant Director. These sign-in sheets will be submitted to the appropriate parties promptly and saved in an online repository, organized by Unit and grant year. Additionally, supporting documentation will be collected and stored as part of the overall documentation process. We are committed to enforcing these policies to ensure timely submission and proper maintenance of all required documentation, further reinforcing our dedication to transparency, accountability, and effective use of grant funds.

View Audit 341463 Questioned Costs: $1

Finding 522214 (2023-005)

Material Weakness 2023

City of Clinton

MN

Material Weakness Reporting Internal Control / Segregation of Duties

Recommendation: We recommend the City adopt procedures to ensure applicable reports are submitted timely and accurately. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action Taken in Response to the Finding: The City will adopt procedures and work w...

Recommendation: We recommend the City adopt procedures to ensure applicable reports are submitted timely and accurately. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action Taken in Response to the Finding: The City will adopt procedures and work with federal agencies to ensure accurate and timely reporting. Official Responsible for Corrective Action: Kristi Lillehaug, City Clerk/Treasurer. Planned Completion Date for Corrective Action Plan: December 31, 2024.

View Audit 341444

Finding 522193 (2023-002)

None 2023

Hannas House

CA

Allowable Costs / Cost Principles Eligibility Reporting § 200.508 § 200.509 § 200.512

The Organization’s Accounting Department, under the direction of the Chief Executive Officer, Connie Franks, will ensure that there’s proactive communication, dedicated resource allocation, and regular status checks on the deadline. He should ensure everyone involved understands the deadlines and re...

The Organization’s Accounting Department, under the direction of the Chief Executive Officer, Connie Franks, will ensure that there’s proactive communication, dedicated resource allocation, and regular status checks on the deadline. He should ensure everyone involved understands the deadlines and responsibilities to avoid any delays. Completion of the referenced corrective action will be implemented by January 2025.

View Audit 341401

Finding 522152 (2023-001)

Significant Deficiency 2023

Housing Authority of the County of Monroe

WI

Internal Control / Segregation of Duties Reporting

Corrective Action Planned: Due to the Authority’s size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size.

View Audit 341370

Finding 521708 (2023-003)

Material Weakness 2023

Beth Israel Lahey Health, Inc.

MA

Reporting Internal Control / Segregation of Duties

Management Response and Corrective Action Plan Finding 2023-003 – Reporting Program: Provider Relief Fund and American Rescue Plan Federal Agency: Health Resources and Services Administration Assistance Listing Number: 93.498 Responsible Individual: Katherine Bacher, VP of System Services Account...

Management Response and Corrective Action Plan Finding 2023-003 – Reporting Program: Provider Relief Fund and American Rescue Plan Federal Agency: Health Resources and Services Administration Assistance Listing Number: 93.498 Responsible Individual: Katherine Bacher, VP of System Services Accounting and Finance Contact Information: Katherine.bacher@bilh.org; 617-278-7059 Management agrees with the recommendation and moving forward, BILH will centralize the compilation of the SEFA, along with conducting periodic reconciliations of the schedule, the general ledger and supporting documentation. Management will also utilize its new accounting system to track all federal funding by requiring the appropriate worktags be utilized when recording such transactions, allowing for accurate reporting. Lastly, management will require at least two reviews of the SEFA. Corrective Action Plan: • Management will have training sessions with the Finance staff on the use of worktags when recording federal funding. • A new position has been created, Director of Technical Accounting, who will be responsible for compiling the SEFA and ensuring accuracy of the filing, with sign off by department managers who are submitting information • Director of Research Finance will review initial draft of SEFA for completeness and accuracy • VP of Revenue and Reimbursement will review the initial draft of SEFA for completeness and accuracy • VP of System Services Accounting and Finance will final review for completeness and accuracy Expected Completion Date: June 30, 2025 Status of Completion: In Process

View Audit 341213

Finding 521247 (2023-001)

Material Weakness 2023

The Island Water Association, Inc.

FL

Material Weakness Reporting Internal Control / Segregation of Duties

Management will continue to rely on the audit firm to draft the financial statements and the related notes to the financial statements, and will review, approve, and accept responsibility for the annual financial statements prior to their issuance. Management will continue to increase internal abili...

Management will continue to rely on the audit firm to draft the financial statements and the related notes to the financial statements, and will review, approve, and accept responsibility for the annual financial statements prior to their issuance. Management will continue to increase internal abilities and advancement in order to monimize reliance on audit firm for financial statements.

View Audit 341192

Finding 521245 (2023-004)

Significant Deficiency 2023

Centers for New Horizons, Inc.

IL

Internal Control / Segregation of Duties

The program tested requires a manual entry directly into the grantors system. Going forward the Organization will document the review and approval of the amounts submitted monthly to this system.

View Audit 341185

Finding 521127 (2023-003)

Material Weakness 2023

Lake County, Colorado

CO

Internal Control / Segregation of Duties Reporting

Problem: Lake County Government did not file quarterly or annual reports as required by Coronavirus State and Local Fiscal Recovery Funds as per Department of Treasury. Actions Steps: All Coronavirus State and Local Fiscal Recovery Funds must be managed going forward as per the standardized grant fu...

Problem: Lake County Government did not file quarterly or annual reports as required by Coronavirus State and Local Fiscal Recovery Funds as per Department of Treasury. Actions Steps: All Coronavirus State and Local Fiscal Recovery Funds must be managed going forward as per the standardized grant funding policy in both process and procedure. Status: Granted funds awarded to Lake County Government are managed and controlled via the BOCC voted and approved Lake County Grant Policy. Dates: July 2024 to present Goal: To accurately and reliably manage and report on all funds granted awarded to Lake County Government.

View Audit 341067

Finding 521118 (2023-002)

Significant Deficiency 2023

City of Lake Worth Beach

FL

Internal Control / Segregation of Duties

Management accepts the finding and recommendation. During fiscal year 2023, the finance department hired additional personnel to assist with the completion of the year-end closing processes and procedures. We have discussed with employees the importance of timely submission of the City’s annual audi...

Management accepts the finding and recommendation. During fiscal year 2023, the finance department hired additional personnel to assist with the completion of the year-end closing processes and procedures. We have discussed with employees the importance of timely submission of the City’s annual audit package and data collection form to the federal audit clearinghouse on an ongoing basis.

View Audit 341066

Finding 521096 (2023-009)

Significant Deficiency 2023

City of Medford

MA

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Subrecipient Monitoring § 200.214

Condition: Suspension and debarment compliance was not verified for two covered transactions. Corrective Action Planned: All Purchase Order requests that are associated with a federal government grant will all have an attached list showing the company is not on the debarment list. We will also u...

Condition: Suspension and debarment compliance was not verified for two covered transactions. Corrective Action Planned: All Purchase Order requests that are associated with a federal government grant will all have an attached list showing the company is not on the debarment list. We will also update our School Contract language to include specific wording where the Vendor acknowledges the law and forfeits the contract if they are on the debarment list after the contract has been signed. A statement will be added to the contracts that states the following: ‘The Contractor (or use the term in the contract that identifies the vendor instead of Contractor) certifies under the pains and penalties of perjury, that the Contractor is not currently debarred or suspended by the Federal government, or any of its agencies, entities or subdivisions, nor is the Contractor currently debarred or suspended by the Commonwealth Massachusetts or any of its agencies, entities or subdivisions.’ If there is a section in the contract where the vendor certifies to other conditions (i.e. state taxes paid), then this language could be included under that section as another certification requirement. A Google Drive has been created to upload all supporting documents on a yearly basis. Anticipated Completion Date: 2/17/2025 Contact: Noel Velez, Director of Finance and Fiona Maxwell, Procurement Director

View Audit 341024

Finding 521094 (2023-010)

Material Weakness 2023

City of Medford

MA

Material Weakness Internal Control / Segregation of Duties

Condition: The City did not reconcile its 2021 and 2022 revenue loss calculations with the final adjusted general ledger. Calendar year 2021 revenue was understated by $5,040,960 and calendar year 2022 revenue was understated by $1,455,486 in the 2021 and 2022 revenue loss calculations, respective...

Condition: The City did not reconcile its 2021 and 2022 revenue loss calculations with the final adjusted general ledger. Calendar year 2021 revenue was understated by $5,040,960 and calendar year 2022 revenue was understated by $1,455,486 in the 2021 and 2022 revenue loss calculations, respectively. Corrective Action Planned: Revenue reports for Calendar years 2020 - 2023 have been re-run and revenue loss calculations have been re-run by ARPA consultant for those years with results given to Auditors. Anticipated Completion Date: Complete Contact: Robert Dickinson, City Auditor

View Audit 341024

Finding 521085 (2023-007)

Significant Deficiency 2023

City of Medford

MA

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Subrecipient Monitoring § 200.214

Condition: Suspension and debarment compliance was not verified for five covered transactions. Corrective Action Planned: All Purchase Order requests that are associated with a federal government grant will all have an attached list showing the company is not on the debarment list. We will also ...

Condition: Suspension and debarment compliance was not verified for five covered transactions. Corrective Action Planned: All Purchase Order requests that are associated with a federal government grant will all have an attached list showing the company is not on the debarment list. We will also update our School Contract language to include specific wording where the Vendor acknowledges the law and forfeits the contract if they are on the debarment list after the contract has been signed. A statement will be added to the contracts that states the following: ‘The Contractor (or use the term in the contract that identifies the vendor instead of Contractor) certifies under the pains and penalties of perjury, that the Contractor is not currently debarred or suspended by the Federal government, or any of its agencies, entities or subdivisions, nor is the Contractor currently debarred or suspended by the Commonwealth Massachusetts or any of its agencies, entities or subdivisions.’ If there is a section in the contract where the vendor certifies to other conditions (i.e. state taxes paid), then this language could be included under that section as another certification requirement. A Google Drive has been created to upload all supporting documents on a yearly basis. Anticipated Completion Date: 2/17/2025 Contact: Noel Velez, Director of Finance and Fiona Maxwell, Procurement Director

View Audit 341024

Finding 521084 (2023-006)

Material Weakness 2023

City of Medford

MA

School Nutrition Programs Eligibility Material Weakness

Condition: The Food Service Department did not perform its verification process by the date required by the state pass-through agency. Corrective Action Planned: No applications were submitted to be verified. The school district prompted caregivers on numerous occasions to return the forms witho...

Condition: The Food Service Department did not perform its verification process by the date required by the state pass-through agency. Corrective Action Planned: No applications were submitted to be verified. The school district prompted caregivers on numerous occasions to return the forms without receiving any. Anticipated Completion Date: 2/17/2025 Contact: Peter Cushing, Assistant Superintendent

View Audit 341024

Finding 521083 (2023-005)

Material Weakness 2023

City of Medford

MA

School Nutrition Programs Eligibility Material Weakness

Condition: Free or reduced meals applications could not be provided. The Food Service Department did not process free or reduced priced meals applications for the 2022-2023 school year. Corrective Action Planned: The School District has hired a qualified leader for the School Nutrition Program i...

Condition: Free or reduced meals applications could not be provided. The Food Service Department did not process free or reduced priced meals applications for the 2022-2023 school year. Corrective Action Planned: The School District has hired a qualified leader for the School Nutrition Program in order to comply with the requirements of this program. Additionally, the school district has enrolled all but the Brooks Elementary School as Community Eligibility Provision (CEP) sites and we are no longer required to collect these forms. At the Brooks School, these forms were sent to families from the Brooks School during the FY24 school year. Despite the efforts of the school and Food Services Director, no forms were returned to the school. Presently the forms are not required for the Brooks as the CEP eligibility requirements were reduced from 40% to 25% for determination. Anticipated Completion Date: 2/15/2025 Contact: Peter Cushing, Assistant Superintendent

View Audit 341024

Finding 521082 (2023-004)

Material Weakness 2023

City of Medford

MA

Questioned Costs School Nutrition Programs Allowable Costs / Cost Principles

Condition: Claims support could only be provided by the School for two months. For one month, support was in the form of spreadsheets with tray counts in lieu of a point-of-sale system. For the other month, the tray count spreadsheets were accompanied by reports from the point-of-sale system. Th...

Condition: Claims support could only be provided by the School for two months. For one month, support was in the form of spreadsheets with tray counts in lieu of a point-of-sale system. For the other month, the tray count spreadsheets were accompanied by reports from the point-of-sale system. The point-of-sale system reports provided did not agree to the amounts claimed for reimbursement. The tray counts did not indicate whether the meal provided was paid, free or reduced. The claims for reimbursement submitted by the School used allocation percentages derived from prior year claims when estimating amounts to be claimed as paid, free and reduced. The tray count spreadsheets for the other months could not be located by the School. Corrective Action Planned: In January 2023 DESE sent an auditor to review the Medford School Nutrition Program. Before this review, there was significantly limited oversight by the central office finance team. Almost no documents were prepared before the review as required by DESE. As a result of this audit a 58-item, 19-page Corrective Action Plan was issued to the district. A new district leader was assigned for departmental oversight. The district then had weekly meetings with DESE to address the corrective action plan, for this was the single largest CAP DESE has issued to any district of our size. Nearly $1.3 million in reimbursements were withheld from the district from approximately November 2022 through the end of the Fiscal Year. DESE issued the reimbursements with a nominal penalty during the summer of 2023. At the end of FY23, the district terminated the director of the program. We are now training several individuals in the MCPPO program for enhanced oversight. DESE forced an immediate return audit for FY24. This was an exceptional action as DESE has only rarely done this. The same reviewer attended and noted significant improvements as a result of district actions undertaken. As relates to this particular finding, the School Department has purchased and is consistently using a point of sale system for students to purchase their meals. The system is used to track all transactions. Anticipated Completion Date: 2/17/2025 Contact: Peter Cushing, Assistant Superintendent

View Audit 341024 Questioned Costs: $1

Finding 521048 (2023-001)

Significant Deficiency 2023

Meadows Mental Health Policy Institute for Texas

TX

Reporting Significant Deficiency Internal Control / Segregation of Duties

The Meadows Mental Health Policy Institute for Texas (the Institute) respectfully submits the following corrective action plan for the year ended December 31, 2023. Audit period: 01/01/2023 – 12/31/2023 The findings from the Schedule of Findings and Questioned Costs identified in the December 05, 20...

The Meadows Mental Health Policy Institute for Texas (the Institute) respectfully submits the following corrective action plan for the year ended December 31, 2023. Audit period: 01/01/2023 – 12/31/2023 The findings from the Schedule of Findings and Questioned Costs identified in the December 05, 2024, audit report are discussed below. Findings are numbered consistently with the numbers assigned in the schedule. Findings – Federal Awards Audit Significant Deficiency Federal Awards Program Audit Findings and Recommendations Finding 2023-001: Reporting – significant deficiency in internal control over compliance and compliance finding. All federal grants. Criteria: Grantees who are subject to single audit requirements are required to submit their Data Collection form to the Federal Audit Clearinghouse within the earlier of 30 calendar days after receipt of the auditors’ report or 9 months after the audit period. Condition: The Institute’s Data Collection form was late for the years ended December 31, 2022, and 2023. Cause: Delays in completing the audits resulted in the Data Collection forms being submitted after 9 months from the end of the audit report. Effect: The Institute was not in compliance with single audit reporting requirements. Recommendation: Internal controls and processes should be implemented to ensure audits are completed in a timely manner to meet federal reporting deadlines. Institute Action Plan: • Hire new finance and accounting senior management [completed November 2024]. o Hired new CFO (October 2024; started January 02, 2025) o Hired new Controller (November 2024; starts February 17, 2025) Establish timeline for review and acceptance of 2024 audit [initiated December 2024]. o By May 01, 2025: Institute submits 2024 General Ledger and Trial Balance to auditor o May 01, 2025 – May 11, 2025: Auditor sends sample and other requests for information o May 12, 2025 – May 23, 2025: Audit fieldwork o Week of July 07, 2025: Auditor sends draft audit report to Institute management for review. o Week of July 21, 2025: Institute management reviews draft audit report and notes areas needing clarification and/or corrections. o By Week of August 11, 2025: Auditor provides a final revised audit report to Institute management. o Week of August 18, 2025: Institute management sends audit report to the Institute Board’s Audit and Finance Committee for review. o By week of September 1, 2025: The Audit and Finance Committee meets to review and accept final audit report on behalf of the Board. o By September 15, 2025: Data Collection Form is submitted to the Federal Audit Clearinghouse (i.e., well in advance of the September 30, 2025, submission due date for the Data Collection Form). o October 29, 2025: The Institute Board ratifies the Audit and Finance Committee’s acceptance of final audit report. • Q1-Q2 2025: Perform gap analysis evaluation of existing Accounting staff and address any gaps in coverage and provide access to and training on financial systems and historical data archives [initiated and ongoing]. Corrective Action Contact Person(s): Maryana Geller, Chief Financial and Administrative Officer Planned Completion Date for Corrective Action Plan: September 15, 2025

View Audit 340943

Finding 520958 (2023-001)

Material Weakness 2023

Hui No Ke Ola Pono, Inc.

HI

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

Internal control over payroll and disbursements In January 2023 changes to any pay rates were submitted on a Personnel Action Form (PAF) by the Operations Manager. The PAF included the old pay rate and the new pay rate and was submitted to the Executive Director for review and approval. After app...

Internal control over payroll and disbursements In January 2023 changes to any pay rates were submitted on a Personnel Action Form (PAF) by the Operations Manager. The PAF included the old pay rate and the new pay rate and was submitted to the Executive Director for review and approval. After approval, the form was filed in the employees paper file, as well as uploaded to their electronic record on the ProService platform. In May 2024, we hired a Human Resources Specialist who is responsible for updating and maintaining all personnel files and processing of payroll records. In October 2023, we hired an Accounting Specialist (AS) who is responsible for the processing of all vendor disbursements. Prior to ordering items or services, a Purchase Requisiton (PR) is submitted by the program manager to the Executive Director or Programs Director for review and approval. Upon approval the PR is submitted to the Controller for expense and grant coding. PR is then submitted to the AS to assign a PR number and enter the expenses on the PR tracking log. When the PR has been assigned a PR number it is sent to the Operations Manager for purchasing. When the invoice is received the PR is matched to the invoice indicating proper approvals. If the purchase is over $5,000, a Procurement form is completed to solicit 3 bids and reviewed and approved by the Executive Director. If the purchase is over $20,000, the Procurement form is submitted to the Board of Directors for approval. All Procurement forms are attached to invoices for payment processing. Internal control over account balances During the fiscal year, it was noted that there were credit card entries that were duplicated, and have been corrected as of the date of this report. Due to miscommunication with the previous fiscal staff, payments made by credit card were entered as an invoice and as an adjusting journal entry.

View Audit 340855

Finding 520848 (2023-006)

Material Weakness 2023

Municipality of Ceiba

PR

HUD Housing Programs Eligibility Internal Control / Segregation of Duties

We concur with the finding. During the fiscal year 2024-2025, all participant files will be revised to include all missing documents referred to in the finding.

View Audit 340664

Finding 520776 (2023-001)

Material Weakness 2023

The Learning Tree, Inc.

AL

Questioned Costs Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

2023-001 – Special Test and Provision – Wage Rate Requirement – Material Weakness in Internal Controls over Compliance/Material Noncompliance Recommendation: The auditor recommends the Organization strengthen the controls in place to provide assurance that contract agreements entered into with subco...

2023-001 – Special Test and Provision – Wage Rate Requirement – Material Weakness in Internal Controls over Compliance/Material Noncompliance Recommendation: The auditor recommends the Organization strengthen the controls in place to provide assurance that contract agreements entered into with subcontractors contain the required clauses set by Davis-Bacon Act and projects that fall under the requirement maintain the weekly certified payrolls. Action Taken: The Director of Operations and management is aware of the noncompliance with the Davis-Bacon Act wage rate requirement. We understand the importance of implementing sound internal controls to ensure the company meets all federal and state compliance requirements. To prevent future noncompliance findings, The Learning Tree, Inc. will implement staff training to fully adhere to all applicable federal and state compliance requirements. In addition, the company will increase oversight over federal grant programs. Responsible Person: Ben Rogers, Director of Operations Anticipated Completion Date: December 31, 2024.

View Audit 340570 Questioned Costs: $1

Finding 520754 (2023-002)

Material Weakness 2023

East Marshall Community School District

IA

Internal Control / Segregation of Duties

The District continues to have segregation of duties as a priority. We accept the auditor’s guidance and continue to keep the task of segregation of duties as a priority.

View Audit 340517

Finding 520700 (2023-004)

Material Weakness 2023

Community Health and Emergency Services, Inc.

IL

Internal Control / Segregation of Duties Special Tests & Provisions Eligibility

2023-004 Ineffective Internal Controls over Sliding Fee Revenues Health Center Program – CFDA #93.527 & 93.224 Condition: During the compliance testing of the Uniform Guidance “Special Tests and Provisions – Sliding Fee Applications” requirements, we noted the following exceptions: • Three (3) out...

2023-004 Ineffective Internal Controls over Sliding Fee Revenues Health Center Program – CFDA #93.527 & 93.224 Condition: During the compliance testing of the Uniform Guidance “Special Tests and Provisions – Sliding Fee Applications” requirements, we noted the following exceptions: • Three (3) out of eighteen (18) sampled did not have the slide fee applied to the lab portion. • Two (2) out of eighteen (18) sampled were calculated incorrectly based on the sliding fee schedule (wrong sliding fee applied based on application). • Two (2) out of eighteen (18) sampled were missing applications. • One (1) out of eighteen (18) sampled were incorrectly in the system with a medical slide A on a dental charge. This patient was also one of the sampled items missing an application so it could not be determined if slide A would have been correct. Action Taken: • CHESI has implemented a new workflow process to ensure compliance with the program requirements of the sliding fee program. CHESI has developed a new sliding fee procedure and trained all staff to ensure the applications are complete and signed by the patient, income is verified, the proper discount is calculated based on the sliding fee schedule, the proper amount of discount is applied to the patient’s account, and the application is approved and signed by the CFO. All sliding fee applications will also be scanned into the patient’s chart once completed and approved. Anticipated Date of Completion and Name of Contact Person: December 31, 2023 – J.P. Champion, Chief Financial Officer

View Audit 340436

Finding 520582 (2023-001)

Material Weakness 2023

Centennial Square

MN

Material Weakness Reporting Internal Control / Segregation of Duties

Management will continue to rely on CliftonLarsonAllen to draft the financial statements and the related notes to the financial statements, and will review, approve, and accept responsibility for the annual financial statements prior to their issuance.

View Audit 340189

Finding 520555 (2023-001)

Significant Deficiency 2023

Housing Authority of Portage County

WI

Internal Control / Segregation of Duties

The Authority’s Board of Commissioners and management will continue to rely on the use of their outside auditors to prepare draft financial statements that were presented in accordance with generally accepted accounting principles. Management will assign a person within the Authority with the skills...

The Authority’s Board of Commissioners and management will continue to rely on the use of their outside auditors to prepare draft financial statements that were presented in accordance with generally accepted accounting principles. Management will assign a person within the Authority with the skills, knowledge and expertise to review and approve the draft financial statements.

View Audit 340118

Corrective Action Plans

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