Corrective Action Plans

Finding 500117 (2023-003)

Material Weakness 2023

MI

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness § 200.302

Condition: The Township's March 31, 2024 report overstated expenses incurred for the reporting period by approximately $600,000. Planned Corrective Action: Molly Phillips and Katelyn Massey are working together to ensure that the expenses will be reported within the year they are incurring, and allo...

Condition: The Township's March 31, 2024 report overstated expenses incurred for the reporting period by approximately $600,000. Planned Corrective Action: Molly Phillips and Katelyn Massey are working together to ensure that the expenses will be reported within the year they are incurring, and allocated into the correct funds as approved by the Township Board. Contact person responsible for corrective action: Molly Phillips and Katelyn Massey Anticipated Completion Date: 12/31/2024

View Audit 322964

Finding 500103 (2023-001)

Significant Deficiency 2023

Cassia

MN

Internal Control / Segregation of Duties Reporting Significant Deficiency

COVID-19 Provider Relief Funding – Assistance Listing No. 93.489 Recommendation: Management of Cassia and Support Corporations should review the lost revenues included on the reporting submissions to ensure the lost revenues agree with the internal financial statements. Explanation of disagreement...

COVID-19 Provider Relief Funding – Assistance Listing No. 93.489 Recommendation: Management of Cassia and Support Corporations should review the lost revenues included on the reporting submissions to ensure the lost revenues agree with the internal financial statements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will implement a review process of the lost revenues that are being reported in the Provider Relief Fund reporting portal to ensure the lost reviews being reported tie to the internal financial statements. Name(s) of the contact person(s) responsible for corrective action: Kathy Youngquist, CFO Planned completion date for corrective action plan: September 2024

View Audit 322937

Finding 500100 (2023-003)

Material Weakness 2023

City of Wausau

WI

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness

Federal Funding Accountability and Transparency Act- CDBG Community Development Block Grants/Entitlement Grants – Assistance Listing No. 14.218 Recommendation: We recommend the City review the various grant requirements and laws surrounding the CDBG grant program and ensure that any written internal...

Federal Funding Accountability and Transparency Act- CDBG Community Development Block Grants/Entitlement Grants – Assistance Listing No. 14.218 Recommendation: We recommend the City review the various grant requirements and laws surrounding the CDBG grant program and ensure that any written internal control or procedure manuals include all of the required compliance requirements. We also recommend that the City ensure multiple individuals are trained on the administration of the grant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: This process will be added to the CDBG Policy and Procedure Manual to address the audit findings and improve reporting oversight. Name(s) of the contact person(s) responsible for corrective action: Tammy Stratz Planned completion date for corrective action plan: 10/14/2024

View Audit 322932

Finding 499998 (2023-003)

Material Weakness 2023

Wayne Township

IN

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

FINDING 2023-003 (Medicaid Cluster – Activities Allowed or Unallowed, Allowable Costs/Cost Principles) Contact Person Responsible for Corrective Action: Jeb Bardon Contact Phone Number: 317-418-7855 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The...

FINDING 2023-003 (Medicaid Cluster – Activities Allowed or Unallowed, Allowable Costs/Cost Principles) Contact Person Responsible for Corrective Action: Jeb Bardon Contact Phone Number: 317-418-7855 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Federal Cost report beginning 2022 will be done by a new firm. The firm is Blue & Co. They are a wellestablished CPA. The information that is supplied to the CPA firm will be maintained by Wayne Township and will be put the finished cost report. This is for the financial and other metrics that are needed for the report. The cost report will be reviewed for accuracy by the Township Office. The Ambulance payment adjustment is received about two- and one-half years in arrears. This comment would be repeated until we receive the funds for ambulance activity completed in 2023, which will occur in 2026. The payments received by the Medicaid program will be reviewed by the Township Accounting Specialist. After the person agrees it is then inputted into the accounting software and coded to the proper account. Before the Cost report is signed and submitted it will be reviewed by the Township and will ask questions as needed. Anticipated Completion Date: 12/31/24

View Audit 322923

Finding 499980 (2023-002)

Significant Deficiency 2023

Acupuncture and Integrative Medicine College, Berkeley

CA

Student Financial Aid Reporting Significant Deficiency

The NSLDS Enrollment Reporting has been reporting to NSLDS by the third-party servicer RGM. According to NSLDS Enrollment Reporting Guide, “At a minimum, schools are required to certify enrollment every 60 days, and respond within 15 days of the date that NSLDS sends a Roster file to the school or i...

The NSLDS Enrollment Reporting has been reporting to NSLDS by the third-party servicer RGM. According to NSLDS Enrollment Reporting Guide, “At a minimum, schools are required to certify enrollment every 60 days, and respond within 15 days of the date that NSLDS sends a Roster file to the school or it’s third-party servicer.” And “Rosters will be sent to schools no less frequently than every two months.” It seems RGM did not receive the rosters from NSLDS thus the Enrollment Reporting was not filed in a timely manner. The school will work closely with the third-party servicer and monitor the NSLDS Enrollment Reporting from now on, effective September 23, 2024.

View Audit 322916

Finding 499979 (2023-001)

Significant Deficiency 2023

Acupuncture and Integrative Medicine College, Berkeley

CA

Student Financial Aid Significant Deficiency Matching / Level of Effort / Earmarking

The NSLDS Enrollment Reporting has been reporting to NSLDS by the third-party servicer RGM. A reminder will be posted in RGM and the school will review the monthly roster. The school will work closely with the third-party servicer to make sure correct student status information is reported to the N...

The NSLDS Enrollment Reporting has been reporting to NSLDS by the third-party servicer RGM. A reminder will be posted in RGM and the school will review the monthly roster. The school will work closely with the third-party servicer to make sure correct student status information is reported to the NSLDS from now on. Effective completion September 24, 2024

View Audit 322916

Finding 499960 (2023-009)

Significant Deficiency 2023

Kandiyohi County

MN

Student Financial Aid Allowable Costs / Cost Principles Significant Deficiency § 200.303

SSIS ACTIVITIES ALLOWED/ALLOWABLE COSTS Recommendation: It is recommended that the County implement procedures to document review of disbursements when not able to show an electronic approval in the SSIS system. Explanation of disagreement with audit finding: There is no disagreement with the audit ...

SSIS ACTIVITIES ALLOWED/ALLOWABLE COSTS Recommendation: It is recommended that the County implement procedures to document review of disbursements when not able to show an electronic approval in the SSIS system. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement procedures to document review for all SSIS disbursements. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2024

View Audit 322900

Finding 499959 (2023-008)

Significant Deficiency 2023

Kandiyohi County

MN

Student Financial Aid Reporting Significant Deficiency § 200.303

FOSTER CARE REPORTING Recommendation: It is recommended that the County implement procedures to review the foster care report and retain evidence of the review on file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to findin...

FOSTER CARE REPORTING Recommendation: It is recommended that the County implement procedures to review the foster care report and retain evidence of the review on file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will start printing a coversheet for the Fiscal Supervisor to sign and retain physical evidence of the review being done. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2024

View Audit 322900

Finding 499956 (2023-006)

Significant Deficiency 2023

Kandiyohi County

MN

Student Financial Aid Allowable Costs / Cost Principles Eligibility

TIME STUDY – ACTIVITIES ALLOWED/ALLOWABLE COSTS Recommendation: It is recommended that the county streamline the payroll change process between the payroll department and human services department. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Acti...

TIME STUDY – ACTIVITIES ALLOWED/ALLOWABLE COSTS Recommendation: It is recommended that the county streamline the payroll change process between the payroll department and human services department. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will continue to work at this area and internal controls to achieve the overall goal. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2024

View Audit 322900

Finding 499955 (2023-005)

Significant Deficiency 2023

Kandiyohi County

MN

Student Financial Aid Eligibility Reporting § 200.303

CASEFILE REVIEW (2022-005) Recommendation: It is recommended the County review case files on a periodic basis throughout the year and document the reviews. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Count...

CASEFILE REVIEW (2022-005) Recommendation: It is recommended the County review case files on a periodic basis throughout the year and document the reviews. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will continue to work at this area and internal controls to achieve the overall goal. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2024

View Audit 322900

Finding 499953 (2023-007)

Significant Deficiency 2023

Kandiyohi County

MN

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.303

SLFRF REPORTING Recommendation: It is recommended that the County sign off to indicate review of SLFRF Report. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will continue to work at this area and inter...

SLFRF REPORTING Recommendation: It is recommended that the County sign off to indicate review of SLFRF Report. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will continue to work at this area and internal controls to achieve the overall goal. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2024

View Audit 322900

Finding 499948 (2023-003)

Material Weakness 2023

Town of Whitestown

IN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness § 200.1 § 200.303

FINDING 2023-003 (Auditor Assigned Reference Number) Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The Town submitted one P&E report during the audit period timely; however, a single employee prepared and submitted the P&E report withou...

FINDING 2023-003 (Auditor Assigned Reference Number) Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The Town submitted one P&E report during the audit period timely; however, a single employee prepared and submitted the P&E report without a review or oversight process in place to prevent or detect and correct errors. Only one annual report was required to be submitted by the Town. For the report tested, all activity for the reporting period was not included, information submitted was not supported by the Town's records, and the reports were not fairly presented. Contact Person Responsible for Corrective Action: Matt Sumner Contact Phone Number and Email Address: 317-732-4532, msumner@whitestown.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: For applicable reports that are to be submitted for federal grants, we will implement a control/review and ensure the information being reported is correct prior to submission. Anticipated Completion Date: November 1, 2024

View Audit 322895

Finding 499944 (2023-002)

Significant Deficiency 2023

Community Development Corporation of Oregon

OR

Questioned Costs Reporting Cash Management

We now have a dedicated grants reviewer in finance to support project management's reporting since January 2024 with cross training in the finance team. We will update our practices guide to include the documentation process for compliance by October 2024. Lynn Ketch, Executive Director, is the pers...

We now have a dedicated grants reviewer in finance to support project management's reporting since January 2024 with cross training in the finance team. We will update our practices guide to include the documentation process for compliance by October 2024. Lynn Ketch, Executive Director, is the person responsible for the plan.

View Audit 322891 Questioned Costs: $1

Finding 499935 (2023-002)

Significant Deficiency 2023

Episcopal Homes of Minnesota and Affiliates

MN

Allowable Costs / Cost Principles Reporting Significant Deficiency

View of Responsible Officials: Management agrees with the finding and recommendation and will review procedures to ensure future reporting submissions are detail reviewed. Responsible Party Sherri Friedrich Estimated Completion December 31, 2024

View Audit 322883

Finding 499934 (2023-004)

Significant Deficiency 2023

Countryside Public Health

MN

Internal Control / Segregation of Duties Eligibility Significant Deficiency

Federal Agency: U.S. Department of Agriculture Federal Program Name: WIC Special Supplemental Nutrition Program for Women, Infants, and Children Assistance Listing Number: 10.557 Federal Award Identification Number and Year: 22MN004W1003, 2023 Pass-Through Agency: Minnesota Department of Health Pass...

Federal Agency: U.S. Department of Agriculture Federal Program Name: WIC Special Supplemental Nutrition Program for Women, Infants, and Children Assistance Listing Number: 10.557 Federal Award Identification Number and Year: 22MN004W1003, 2023 Pass-Through Agency: Minnesota Department of Health Pass-Through Number: 22MN004W1003 Award Period: Year Ended December 31, 2023 Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: It is recommended Countryside Public Health Service implement procedures to ensure there are always two individuals involved in the determination. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Countryside Public Health Service will implement procedures to ensure there are always two individuals involved in the determination. Name of the contact person responsible for corrective action plan: Liz Auch, Administrator Planned completion date for corrective action plan: December 31, 2024

View Audit 322879

Finding 499929 (2023-004)

Material Weakness 2023

Chris Properties Graham Circle, Inc.

GA

Questioned Costs Cash Management Internal Control / Segregation of Duties

The Organization secured Attain Partners, a professional services firm, to assist with grants management and reporting. Attain Partners reviewed the SEFA report, as well as the grantbudget, general ledger information, documentation, and drawdowns for the grant from the U.S. Department of Health and ...

The Organization secured Attain Partners, a professional services firm, to assist with grants management and reporting. Attain Partners reviewed the SEFA report, as well as the grantbudget, general ledger information, documentation, and drawdowns for the grant from the U.S. Department of Health and Human Services (CFDA 93.958) internally known as theSAMHSA R&R grant. They discovered that the budgets were submitted incorrectly, without requesting any indirect costs (IDC), which led to the grant being awarded without IDC. The FY23 draws totaled $2,094,362.95, while the FY23 expenditures recorded in the general ledger amounted to $1,754,696.48, excluding IDC, resulting in $339,667 in questioned costs. As the grant closed on 9/30/2023, the organization is unable to request reimbursement for the IDC. The Grants Management team will undertake a comprehensive revision of the existing policies and procedures and will develop new ones as needed. These policies and procedures will encompass the following processes to ensure proper levels of review and compliance with authorized drawdowns: • The Grants Management team will ensure grant budgets are submitted with the correct IDC and the award includes the IDC in the total amount. • The Grants Management team will ensure the IDC is calculated correctly and included in the drawdown amount. • The Grants Administrator and the Sr. Grants and Budget Analyst will reconcile the grant expenditures monthly to ensure the expenditures allocated to grants are documented, allowable and the drawdowns are equal to actual expenditures.

View Audit 322863 Questioned Costs: $1

Finding 499928 (2023-003)

Material Weakness 2023

Chris Properties Graham Circle, Inc.

GA

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

To address the deficiencies identified in the audit regarding allowable costs, the Organization has implemented the following procedures: 1. Procurement • A Procurement Manager was hired to lead the process for sourcing, negotiating terms and conditions, and purchasing items for the organization. • ...

To address the deficiencies identified in the audit regarding allowable costs, the Organization has implemented the following procedures: 1. Procurement • A Procurement Manager was hired to lead the process for sourcing, negotiating terms and conditions, and purchasing items for the organization. • The Procurement Manager is responsible for inspecting goods as necessary and keeping records of all steps in the process. 2. Accounts Payable • Manual check request forms have been implemented; however, the Finance Department is exploring an electronic approval process through a third-party system that interfaces with Sage Intacct. • Invoices are approved by the appropriate program or administrative leader prior to submitting to Accounts Payable. • The appropriate program or administrative leader is responsible for ensuring the correct department, project, and general ledger codes are included on the check request. • The Sr. Accounts Payable Analyst is responsible for ensuring the check requests are completed with the pertinent information, entering invoices that have been approved and uploading the invoices and any additional supporting documentation into the Sage Intacct accounting system as an attachment.

View Audit 322863 Questioned Costs: $1

Finding 499927 (2023-002)

Material Weakness 2023

Chris Properties Graham Circle, Inc.

GA

Questioned Costs Reporting Matching / Level of Effort / Earmarking

To address the deficiencies identified in the audit regarding payroll allocations, the Organization will utilize the services of Attain Partners, a professional services firm specializing in grants management. Attain Partners will assist the Organization with implementing procedures including the fo...

To address the deficiencies identified in the audit regarding payroll allocations, the Organization will utilize the services of Attain Partners, a professional services firm specializing in grants management. Attain Partners will assist the Organization with implementing procedures including the following Time and Effort Recording • Work with the CFO, COO, and CCO to revise the current T&E policies and procedures. • Work with Finance and HR to revise the current payroll allocation form to include all information needed to correctly record the T&E information in the HRIS and accounting system. • Work with Finance and HR to ensure the payroll allocation journal entries in the accounting system are correctly labeled, easily identifiable, and allocated correctly. • Work with HR to determine the correct reports needed to track employee allocations are designed correctly in the HRIS. 2. Effort Reports/Certifications • Work with the program leadership on the Time and Effort Certification process including individual and project certifications. • Assist the program leadership in reviewing the time charged to the grants per pay period and certifying that actual time and effort was charged and not budgeted time and effort. • Work with Finance and HR in comparing labor reports to any journal entry with the retro reference, to ensure there was a change and an allocation form completed. This manual process is needed as the current HRIS does not record retro changes.

View Audit 322863 Questioned Costs: $1

Finding 499915 (2023-001)

Significant Deficiency 2023

Boys & Girls Clubs, Northwest Georgia, Inc.

GA

Internal Control / Segregation of Duties Cash Management Reporting

2022-01: Segregation of Duties Name of contact person: J.R. Davis, Chief Executive Officer Corrective Action: Duties and functions will be reviewed to determine where segregation needs to occur. The duties will be separated as much as possible and alternative controls will be implemented to co...

2022-01: Segregation of Duties Name of contact person: J.R. Davis, Chief Executive Officer Corrective Action: Duties and functions will be reviewed to determine where segregation needs to occur. The duties will be separated as much as possible and alternative controls will be implemented to compensate for lack of segregation. However, the risk of not segregated certain duties are not worth the additional costs. Nonfinancial employees will be trained and provide some assistance. Proposed completion date: The Board will implement the above procedure immediately.

View Audit 322856

Finding 499912 (2023-001)

Significant Deficiency 2023

Alabama Nursing Home Association Education Foundation

AL

Period of Performance Significant Deficiency Matching / Level of Effort / Earmarking § 200.203 § 200.303

Planned Corrective Action: The Foundation followed the express instructions of the State of Alabama, Department of Finance (the “Grantor”) to The Alabama Nursing Home Association Education Foundation (the “Foundation”), which permitted the Foundation to rely upon the certifications of nursing home a...

Planned Corrective Action: The Foundation followed the express instructions of the State of Alabama, Department of Finance (the “Grantor”) to The Alabama Nursing Home Association Education Foundation (the “Foundation”), which permitted the Foundation to rely upon the certifications of nursing home applicants that the applicant had or will have sufficient unmet needs related to qualifying purposes due to the COVID‐19 pandemic to support the receipt of the various allocations of the herein described COVID‐19 Funds. Under the terms of the certification, each applying nursing home further certified that for ten (10) years it would maintain auditable records supporting the unmet need and use of the COVID‐19 Funds. This manner of requiring only a certification for the distribution to health care providers is consistent with the requirements the federal government used when distributing an array of emergency funding (e.g., provider relief funds, rural funds, and infection control funds) to health care providers to meet the unmet needs caused by the COVID‐19 pandemic. The term “COVID‐19 Funds” means those funds the Foundation received from the Grantor with respect to (i) The CARES Act Corona Virus Relief Funds for the period from January 31, 2020, through December 31, 2021, and (ii) America Rescue Plan Act (ARPA) funds for unmet needs for qualifying purposes incurred or to be incurred during the period March 11, 2021, through December 31, 2024. To provide further assurance that the COVID‐19 Funds were properly applied by the nursing home beneficiaries receiving COVID‐19 Funds through the Foundation, the Foundation is working with its outside accountants and legal counsel to develop a look‐back review plan. The framework of the lookback review plan will be for each nursing home beneficiary that received COVID‐19 Funds to submit during the calendar year 2024, a worksheet similar to the period reporting worksheets that are required by the federal Health Resources & Services Administration (HRSA) to justify the COVID‐19 provider relief funds, rural funds, and infection control funds received by health care providers. In addition to these HRSA type worksheets, a more in‐depth examination of a sample of nursing homes will be made by randomly selecting 10 nursing homes from a pool of the 30 nursing homes that received the most COVID‐19 Funds through the Foundation, plus another 10 nursing homes from the remainder of the pool of beneficiary nursing homes. These randomly selected nursing homes will be required to supply actual documentation supporting the COVID‐19 Funds received. This documentation will include invoices, payroll records, revenue journals, and cost reports. Among the provisions of the certifications submitted by each applying nursing home, is an acknowledgement that (i) the nursing home is subject to audit by the applicable State and federal agencies, and the Foundation, (ii) any COVID‐19 Funds received through the Foundation and not properly applied must be refunded, and the nursing home will comply with the requirement that it must maintain for ten (10) years auditable records supporting its use of the COVID‐19 Funds it received through the Foundation. In the event that it is determined that one or more nursing homes were unable to properly apply the COVID‐19 Funds to an unmet need for a qualifying purpose, those COVID‐19 Funds will be recouped and either redistributed to any nursing homes that are able show an unmet need continues to exist using a distribution formula consistent with past distributions of refunded COVID‐19 Funds, or returned to the Grantor. This redistribution or return to the Grantor will occur no later than December 31, 2024. Person(s) Responsible: John Matson, Executive Director

View Audit 322841

Finding 499909 (2023-001)

Significant Deficiency 2023

Centra Health, Inc.

VA

Student Financial Aid Subrecipient Monitoring Internal Control / Segregation of Duties

Name of Contact Person Responsible for Corrective Action: John Hunt Centra Health Corporate Director, Information Security and Disaster Recovery 561-613-7342 john.hunt@centrahealth.com Anticipated Completion date: December 31, 2024 Corrective Action: 2023-001 – Special tests and provisions:...

Name of Contact Person Responsible for Corrective Action: John Hunt Centra Health Corporate Director, Information Security and Disaster Recovery 561-613-7342 john.hunt@centrahealth.com Anticipated Completion date: December 31, 2024 Corrective Action: 2023-001 – Special tests and provisions: To assure compliance with GLBA requirements, Centra is partnering with a third-party vendor to conduct a full GLBA risk assessment in FY2024 and will document safeguards for any identified risks. Additionally, Centra has hired dedicated staff for coordinating future risk assessments and will conduct an annual risk assessment that addresses the three required areas noted in 16 CFR 314.4 (b), will document safeguards for any identified risks, and will regularly test, monitor, and adjust safeguards, as needed.

View Audit 322835

Finding 499906 (2023-001)

Significant Deficiency 2023

San Joaquin County Child Abuse Prevention Council

CA

Reporting Internal Control / Segregation of Duties § 200.512

Recommendation: We recommend that management evaluate all aspects of the financial close and reporting processes and establish effective internal controls and procedures to ensure timely submission of the financial statements and supporting schedules. Management should complete the year end closing ...

Recommendation: We recommend that management evaluate all aspects of the financial close and reporting processes and establish effective internal controls and procedures to ensure timely submission of the financial statements and supporting schedules. Management should complete the year end closing process in an adequate timeframe so the audit fieldwork can commence earlier therefore completing the report submission by the deadline. Management's Response: Leadership recognizes the federal award finding and questioned costs and is already moving forward with a systems change in the finance department to ensure timeliness of completing the necessary processes with the annual audit.

View Audit 322832

Finding 499904 (2023-001)

Significant Deficiency 2023

Whitman-Walker Clinic, Inc. Dba Whitman-Walker Health

DC

Reporting Internal Control / Segregation of Duties § 200.502 § 200.510

2023-001 – Preparation of the Schedule of Expenditures of Federal Awards Individual Responsible for Corrective Action Plan Jennifer Maher, CFO Londilia McCoy-Scott, Director of Contract and Grant Accounting Anticipated Completion Date: December 31, 2024 Corrective Action Plan: In reconciling t...

2023-001 – Preparation of the Schedule of Expenditures of Federal Awards Individual Responsible for Corrective Action Plan Jennifer Maher, CFO Londilia McCoy-Scott, Director of Contract and Grant Accounting Anticipated Completion Date: December 31, 2024 Corrective Action Plan: In reconciling the 2023 grant expenditure activity, management identified that some grant expenditures from 2022 were not included in the 2022 Schedule and self-disclosed this anomaly to the auditor. These expenditures were then incorporated in the 2023 Schedule to ensure that they were reported as timely as possible. Grants management staff from Finance and Program departments are meeting monthly to ensure that the expenditures are recorded in the appropriate year.

View Audit 322830

Finding 499893 (2023-003)

Significant Deficiency 2023

Lutheran Metropolitan Ministry

OH

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

LMM agrees that 4 out of 40 tested non-payroll costs did not have evidence of approval for payment. While the payments were for contracted services that were received by LMM the written approval for payment was not able to be located. LMM has recently adopted Concur for expense management. With this...

LMM agrees that 4 out of 40 tested non-payroll costs did not have evidence of approval for payment. While the payments were for contracted services that were received by LMM the written approval for payment was not able to be located. LMM has recently adopted Concur for expense management. With this platform all approvals are required electronically and evidence of approval will be able to be submitted.

View Audit 322823

Finding 499885 (2023-002)

Significant Deficiency 2023

Special Health Resources for Texas, Inc.

TX

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties

To ensure that the Sliding Fee Discount Form is being completed for all patients, the Revenue Cycle Manager will conduct new onsite trainings at all locations. The Revenue Cycle Manager will work closely with front line support staff, Clinic Managers, Director of Operations and the Director of Quali...

To ensure that the Sliding Fee Discount Form is being completed for all patients, the Revenue Cycle Manager will conduct new onsite trainings at all locations. The Revenue Cycle Manager will work closely with front line support staff, Clinic Managers, Director of Operations and the Director of Quality. They will conduct weekly audits to 5% of patient charts to ensure that the trainings are being successful.

View Audit 322795 Questioned Costs: $1

Corrective Action Plans

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