Corrective Action Plans

Finding 391324 (2023-006)

Material Weakness 2023

ND

Material Weakness Reporting Internal Control / Segregation of Duties § 200.303

Reporting Federal Agency Name: Department of Hea lth and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center claimed lost revenues that were incorrectly calculated or not supp...

Reporting Federal Agency Name: Department of Hea lth and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center claimed lost revenues that were incorrectly calculated or not supported. These were improperly included within the HHS Report Period 4 and caused the Report to be inaccurate. Responsible Individuals: Corey Ulmer, CFO Corrective Action Plan: We will implement internal control policies to ensure that the required reports are properly reviewed prior to submission to ensure all key line items are necessary, correct, meet the requirements of the federal program, and are properly recorded in the reports required to be submitted to the federal agency. Anticipated Completion Date: 6/30/2024

View Audit 301891

Finding 391323 (2023-005)

Material Weakness 2023

Ashley Medical Center

ND

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

Activities Allowed or Unallowed, Allowable Costs/Costs Principles Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center selected lo...

Activities Allowed or Unallowed, Allowable Costs/Costs Principles Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center selected lost revenue ca lculation option i which is actual to actual methodology of calculating lost revenues attributable to coronavirus. The Medical Center did not incorporate the financial audit adjustments into the actual revenue amounts reported within the HHS special report for the fiscal years 2019, 2020, and 2021. Responsible Individuals: Corey Ulmer, CFO Corrective Action Plan: We will implement internal control policies to ensure the lost revenue calculation is supported by internal financia ls. We will also implement control policies to ensure a secondary review and approval over the final lost revenue calculation. Anticipated Completion Date: 6/30/2024

View Audit 301891

Finding 391321 (2023-003)

Material Weakness 2023

Ashley Medical Center

ND

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

Activities Allowed or Unallowed, Allowable Costs/Costs Principles Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center does not ha...

Activities Allowed or Unallowed, Allowable Costs/Costs Principles Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center does not have an adequate internal control policy in place to ensure review and approval of cash disbursements claimed under the federal programs were documented and to ensure that expenses claimed in the Report were complete, accurate, and reduced by other funding sources. Responsible Individuals: Corey Ulmer, CFO Corrective Action Plan: We will implement internal control policies to ensure all amounts reimbursed by other funding sources are adequately documented and reduced from the eligible expenditure listing and are properly recorded in the Report required to be submitted to the federal agency. We will also implement internal control policies to ensure that the required Report are properly reviewed prior to submission to ensure all key line items are necessary, correct, meet the requirements of the federal program, and are properly recorded in the Report required to be submitted to the federal agency. Anticipated Completion Date: 6/30/2024

View Audit 301891

Finding 391307 (2023-008)

Significant Deficiency 2023

Chestnut Hill College

PA

Student Financial Aid Subrecipient Monitoring Significant Deficiency

Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.038, 84.063, 84.268, 84.379 Recommendation: The College should develop and implement an approved written information security program and verify there is a risk management section that describes how the College is identifying,...

Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.038, 84.063, 84.268, 84.379 Recommendation: The College should develop and implement an approved written information security program and verify there is a risk management section that describes how the College is identifying, assessing and communicating risks. In addition, there should be a description on the evaluation of safeguard sufficiency in mitigating risks. The information security program should also include the following: • IT Security Policy • Acceptable Use Policy • Incident Response Policy • Data Classification Policies • Vendor Management Policy • Patch Management Policy • Data Disposal Policy • Risk Assessment Policy • Logical Access and User Access Review Policies • Evidence of Review by CIO/CISO and responsibility of program Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The college will develop and implement an information security program to verify our risk management efforts. This plan will identify how we are identifying, assessing and communicating risks. Name(s) of the contact person(s) responsible for corrective action: Jossie Johnson - Director of Financial Aid and Scott Seidman – Director of IT Planned completion date for corrective action plan: September 30, 2024

View Audit 301881

Finding 391303 (2023-007)

Significant Deficiency 2023

Chestnut Hill College

PA

Student Financial Aid Reporting Significant Deficiency

Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.063, 84.268, 84.379 Recommendation: We recommend the College evaluate its procedures and policies around reporting to the COD to ensure that student information is reported timely. Explanation of disagreement with audit finding: There...

Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.063, 84.268, 84.379 Recommendation: We recommend the College evaluate its procedures and policies around reporting to the COD to ensure that student information is reported timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The college will evaluate our procedures and review regulations to ensure the appropriate enrollment information is reported, timely. In the summer of 2023, the financial aid office implemented weekly COD mismatch updates and real time R2T4 adjustments. In doing so, we are ensuring that COD has the most accurate information and adjustments are reported in a timely manner. Name(s) of the contact person(s) responsible for corrective action: Jossie Johnson – Director of Financial Aid and Michael Reig – Registrar. Planned completion date for corrective action plan: June 30, 2024

View Audit 301881

Finding 391301 (2023-006)

Significant Deficiency 2023

Chestnut Hill College

PA

Reporting Student Financial Aid Significant Deficiency

Student Financial Aid Cluster – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College evaluate its procedures and review regulations set by the Department of Education around NSLDS to ensure the College understands the definitions for each enrollment information that gets re...

Student Financial Aid Cluster – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College evaluate its procedures and review regulations set by the Department of Education around NSLDS to ensure the College understands the definitions for each enrollment information that gets reported. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The college will evaluate our procedures and review regulations to ensure the appropriate enrollment information is reported, timely. Name(s) of the contact person(s) responsible for corrective action: Jossie Johnson – Director of Financial Aid and Michael Reig – Registrar. Planned completion date for corrective action plan: June 30, 2024

View Audit 301881

Finding 391297 (2023-005)

Significant Deficiency 2023

Chestnut Hill College

PA

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

Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.063, 84.268, 84.379 Recommendation: We recommend reviewing the report that is run to identify withdrawn students to understand why these students were not included, as well as implement a compensating control to ensure future students...

Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.063, 84.268, 84.379 Recommendation: We recommend reviewing the report that is run to identify withdrawn students to understand why these students were not included, as well as implement a compensating control to ensure future students are not missed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Office fully understands federal requirements surrounding the completion of R2T4s and strive to remain up to date with R2T4 best practice. We are fully committed to identifying the root cause, implementing corrective actions, and improving the system to prevent similar issues in the future. Name(s) of the contact person(s) responsible for corrective action: Jossie Johnson – Director of Financial Aid and Michael Reig – Registrar. Planned completion date for corrective action plan: April 30, 2024

View Audit 301881

Finding 391296 (2023-004)

Significant Deficiency 2023

Chestnut Hill College

PA

Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Student Financial Aid Cluster – Assistance Listing No. 84.268 Recommendation: We recommend the College review its policies and procedures around sending exit counseling information to students to ensure students are receiving proper counseling. Explanation of disagreement with audit finding: There i...

Student Financial Aid Cluster – Assistance Listing No. 84.268 Recommendation: We recommend the College review its policies and procedures around sending exit counseling information to students to ensure students are receiving proper counseling. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Action taken in response to finding: We have conducted a thorough review of our exit counseling procedures and have identified areas of opportunity. Our team is committed to making the necessary corrections to ensure compliance with regulatory requirements. Our goal is to enhance our exit counseling program to better support students in understanding their rights and responsibilities regarding their federal student loans. We will execute this plan by including exit notices in our biweekly notifications, emailing students once an R2T4 is completed and notifying students that are less than halftime students the day after add/ period of each semester. For graduating students, we will host an event leading up to graduation where students can learn about the repayment process and an opportunity for students to complete their exit counseling. . Name(s) of the contact person(s) responsible for corrective action: Jossie Johnson – Director of Financial Aid Planned completion date for corrective action plan: April 30, 2024

View Audit 301881

Finding 391294 (2023-003)

Significant Deficiency 2023

Chestnut Hill College

PA

Student Financial Aid Reporting Significant Deficiency

Student Financial Aid Cluster – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College evaluate its procedures and policies around reporting to the COD to ensure that student information is reported timely. Explanation of disagreement with audit finding: There is no disagreem...

Student Financial Aid Cluster – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College evaluate its procedures and policies around reporting to the COD to ensure that student information is reported timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Financial Aid policies and procedures will be reviewed and amended as necessary. In conjunction with the Registrar’s Office all student changes and information will be reported and reconciled timely. Name(s) of the contact person(s) responsible for corrective action: Jossie Johnson – Director of Financial Aid Planned completion date for corrective action plan: September 30, 2024

View Audit 301881

Finding 391289 (2023-002)

Significant Deficiency 2023

Chestnut Hill College

PA

Questioned Costs Student Financial Aid Significant Deficiency

Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268, 84.379 Recommendation: We recommend the College review its policies and procedures related to Title IV outstanding checks to ensure they are being returned to the Department of Education after 240 days. Explanatio...

Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268, 84.379 Recommendation: We recommend the College review its policies and procedures related to Title IV outstanding checks to ensure they are being returned to the Department of Education after 240 days. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The office of Financial Aid and Accounting will review outstanding checks on a monthly basis. In addition, any checks related to financial aid returns or refunds will be sent to the Department of Education within the required time frame. Name(s) of the contact person(s) responsible for corrective action: Larz Jeter – Controller and Jossie Johnson – Financial Aid Director Planned completion date for corrective action plan: September 30, 2024.

View Audit 301881 Questioned Costs: $1

Finding 391288 (2023-004)

Material Weakness 2023

Des Moines Area Metropolitan Planning Organization

IA

Reporting Internal Control / Segregation of Duties

The corrective action plan was documented in our response to the auditor’s comment. See the Schedule of Findings and Questioned Costs.

View Audit 301879

Finding 391286 (2023-003)

Material Weakness 2023

Des Moines Area Metropolitan Planning Organization

IA

Internal Control / Segregation of Duties

The corrective action plan was documented in our response to the auditor’s comment. See the Schedule of Findings and Questioned Costs.

View Audit 301879

Finding 391264 (2023-001)

Significant Deficiency 2023

The Children's Home Society of Florida

FL

Allowable Costs / Cost Principles Cash Management Significant Deficiency § 200.403 § 200.430

Identifying Number: 2023-001 – Activities Allowed or Unallowed; Allowable Costs/Costs Principles Finding: The Code of Federal Regulations (CFR) Section 200.403(g) states that for costs to be allowable under federal awards, they must be adequately documented and there must be sufficient documentation...

Identifying Number: 2023-001 – Activities Allowed or Unallowed; Allowable Costs/Costs Principles Finding: The Code of Federal Regulations (CFR) Section 200.403(g) states that for costs to be allowable under federal awards, they must be adequately documented and there must be sufficient documentation. Additionally, CFR Section 200.430 states that charges to federal awards for salaries and wages must be based on records that accurately reflect the work performed and are supported by a system of internal control which provides reasonable assurance that the charges are accurate and allowable. The Florida’s Division of Accounting and Auditing Reference Guide for State Expenditures states that supporting documentation shall be maintained in support of expenditure payment requests for cost reimbursement contracts including that approved timesheets support the hours worked on the project or activity must be kept. During our testing of payroll disbursements, we noted that seven of the 120 payroll expenditures selected for testing did not have a properly approved timecard for the pay period selected. Corrective Actions Taken or Planned: All of the timecards noted in the finding above have been reviewed for accuracy and retroactively approved by the Chief Talent Officer. The following corrective actions are in the process of being implemented: • CHS’s Payroll and Talent teams will conduct a review of timecards completed after July 1, 2023. The accuracy of any unapproved timecards identified will be verified and retroactively approved by the designated supervisor, or the Chief Talent Officer if the designated supervisor is no longer available. • After each payroll period, a list of unapproved timecards will be provided to the Talent Team so the respective Talent Business Partner may follow up with corrective action with those supervisors who have two or more repeat occurrences. Such corrective action will include: o A thorough review with the supervisor of the CHS policies and practices relative to supervisory duties regarding the management and approval of employee timecards. o Mandatory refresher education and training on the supervisory timecard review and approval process in the CHS HRIS, Paylocity. In addition, CHS is formally implementing a new HRIS, UKG PRO, in July 2024. This system has advanced notification and tracking features that will assist supervisors in proper management and approval of timecards. Person(s) Responsible for Corrective Actions: Barbara McDonald, Chief Financial Officer and Chief Administrative Officer and Heather Vogel, Chief Talent Officer Anticipated Completion Date for Corrective Actions: Implementation of the Corrective Actions outlined above will begin immediately to be completed by June 30, 2024.

View Audit 301878

Finding 391257 (2023-001)

Significant Deficiency 2023

Commonwealth of Puerto Rico Municipality of Sabana Grande

PR

Reporting Significant Deficiency Internal Control / Segregation of Duties

The Municipality will be implementing the internal controls and procedures to assure that the required reports are completed and be submitted as per program regulations on the 15th day of the following month; the expenses were incurred.

View Audit 301875

Finding 391253 (2023-005)

None 2023

Saint Elizabeth University

NJ

Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Federal Direct Loans Reconciliations Planned Corrective Action: The University’s Financial Aid Office will review the reconciliations to ensure that the Direct Loan Program is reconciled. We will also refer the ED announcement DL-22-07 to maintain consistent and accurate reconciliations. Person ...

Federal Direct Loans Reconciliations Planned Corrective Action: The University’s Financial Aid Office will review the reconciliations to ensure that the Direct Loan Program is reconciled. We will also refer the ED announcement DL-22-07 to maintain consistent and accurate reconciliations. Person Responsible for Corrective Action Plan: Nicholas Capodice, Director of Financial Aid Anticipated Date of Completion: April 30, 2024

View Audit 301872

Finding 391250 (2023-004)

Significant Deficiency 2023

Saint Elizabeth University

NJ

Questioned Costs Student Financial Aid Significant Deficiency

Unofficial Withdrawals Planned Corrective Action: The University will run zero credit reports at the end of each semester to ensure all potential unofficial withdrawals are followed up on so that R2T4’s are completed timely when required. Person Responsible for Corrective Action Plan: Nicholas Cap...

Unofficial Withdrawals Planned Corrective Action: The University will run zero credit reports at the end of each semester to ensure all potential unofficial withdrawals are followed up on so that R2T4’s are completed timely when required. Person Responsible for Corrective Action Plan: Nicholas Capodice, Director of Financial Aid Anticipated Date of Completion: June 30th, 2024

View Audit 301872 Questioned Costs: $1

Finding 391208 (2023-001)

Material Weakness 2023

Higher Horizons Day Care Center, Inc.

VA

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

Based on FY2022 findings, Higher Horizons implemented internal control policies and procedures, effective May 1, 2023. The procedures address all the segregation of duties from journal entries to posting, reconciliation to reporting, and access to the accounting software. The implementation of the i...

Based on FY2022 findings, Higher Horizons implemented internal control policies and procedures, effective May 1, 2023. The procedures address all the segregation of duties from journal entries to posting, reconciliation to reporting, and access to the accounting software. The implementation of the internal control policies and procedures were initiated in May and June of 2023 (the last two months of FY 2023). During FY2024, these procedures were enforced to mitigate risks due to lack of sound internal control. To further strengthen the internal control system, Higher Horizons changed the requisition and accounts payable paper-based to paperless (electronic) process effective July 1, 2023. The electronic requisition system (Microix) is integrated with the accounting software (Abila), which has noticeably enhanced the internal control system.The Microix electronic requisition system eliminates the need to monitor the flow of paper documents, eliminates the risk of losing documents, and disallows purchases without approval. Microix features also require allowability of requisitions to be determined, all changes & communications to be captured, eliminates re-keying the information into Abila, minimizes manual interventions in entering & posting transactions, and much more. Higher Horizons will continue assessing & monitoring the effectiveness of our internal control, review the outcomes, and as needed, will further strengthen the process. Higher Horizons will monitor individual access to general ledger, subsidiary ledger, assets of the organization, accounting software, and Paycom. Access control procedures will be developed and implemented before the end of May 2024. As indicated in FY2023 audit findings, one of the causes for inadequate segregation of duties is the small number of staff in the Finance Department. Higher Horizons will contract with a finance consultant to review the current finance department staffing structure. The consultant will provide feedback and recommendation for adequately staffing the finance department to ensure segregation of duties. The finance management staff will conduct a comprehensive study of accounting and financial tasks, policies and procedures, and standard operating procedures by contracting the financial consultant before the end of June 2024. The study will be presented to the Board for approval, and OFC and OHS for funding.

View Audit 301845

Finding 391207 (2023-001)

Material Weakness 2023

St. Claire Regional Medical Center, Inc.

KY

Cash Management Material Weakness Reporting

April 1, 2024 U.S. Department of Health and Human Services St. Claire Regional Medical Center, Inc. respectively submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Blue & Co., LLC 2650 Eastpoint Parkway, Suite 300 ...

April 1, 2024 U.S. Department of Health and Human Services St. Claire Regional Medical Center, Inc. respectively submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Blue & Co., LLC 2650 Eastpoint Parkway, Suite 300 Louisville, Kentucky 40223 Audit Period: Year ended June 30, 2023 The findings from the Schedule of Findings and Questioned Costs for the year ended June 30, 2023, are discussed below. The findings are numbered consistently with the numbers assigned in the Schedule. FINDINGS – FEDRAL AWARD PROGRAM AUDITS 2023-001 Condition: Untimely disbursement of federal grant funds received: When receiving federal grants funds for the HHS Rural Health Care Services Outreach, Rural Health Network Development, and Small Health Care Provider Quality Improvement Plan Program, the Hospital did not disburse federal grant funds received within 3 working days. Action: Management implemented internal control procedures by December 31, 2023 to ensure proper and timely disbursements of federal grant funds to ensure proper cash management of future HHS Rural Health Care Services Outreach, Rural Health Network Development, and Small Health Care Provider Quality Improvement Plan Program funds.

View Audit 301841

Finding 391197 (2023-004)

Significant Deficiency 2023

Puerto Rico Highways and Transportation Authority

PR

Internal Control / Segregation of Duties Reporting Significant Deficiency

The Authority will perform an internal review of the toll credits usage Excel spreadsheet and will reconcile all credits used by the projects with a starting date in FY 2023 and later with the last version of the Federal-Aid Project Agreement approved by FHWA. Also, the credits summary will be deliv...

The Authority will perform an internal review of the toll credits usage Excel spreadsheet and will reconcile all credits used by the projects with a starting date in FY 2023 and later with the last version of the Federal-Aid Project Agreement approved by FHWA. Also, the credits summary will be delivered on a quarterly basis to the Executive Staff for the approval process. For the fiscal year 2024, the manual process of reconciling toll credits balance of the new projects with a starting date of January 2024 and later will be changed to an automated process with the PMIS Program, as agreed in Section II of the Memorandum of Understanding (MOU) signed in February 2016 between FHWA and the Authority. In addition, current toll credits tracking, reconciliation, and approval processes are reviewed by FHWA PR Division for compliance. Responsible: Mr. Enrique J. Rosa Torres, Budget Office Auxiliary Director Status: In process. Expected to be completed on or before June 30, 2025.

View Audit 301808

Finding 391196 (2023-003)

Significant Deficiency 2023

Puerto Rico Highways and Transportation Authority

PR

Internal Control / Segregation of Duties Reporting Significant Deficiency

Corrective Action Plan: The Authority assigned an Analyst and a Supervisor the responsibility to monitor compliance with all related Federal requirements for the reporting process of these funds. Also, an adequate training was provided to the personnel involved in the administration of this program....

Corrective Action Plan: The Authority assigned an Analyst and a Supervisor the responsibility to monitor compliance with all related Federal requirements for the reporting process of these funds. Also, an adequate training was provided to the personnel involved in the administration of this program. Responsible: Mr. Ramon L. Rivera Rivera, Analyst Mr. Enrique J. Rosa Torres, Budget Office Auxiliary Director Status: Completed on June 30, 2023.

View Audit 301808

Finding 391189 (2023-003)

Significant Deficiency 2023

City and Borough of Juneau, Alaska

AK

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

Finding: 2023-003 Significant Deficiency in Internal Controls over Compliance and Compliance – Reporting (Bartlett Regional Hospital enterprise fund) Name of Contact Person: Joe Wanner, Chief Financial Officer Corrective Action: For any unusual or new grant reporting, management will implement add...

Finding: 2023-003 Significant Deficiency in Internal Controls over Compliance and Compliance – Reporting (Bartlett Regional Hospital enterprise fund) Name of Contact Person: Joe Wanner, Chief Financial Officer Corrective Action: For any unusual or new grant reporting, management will implement additional review procedures to ensure information is captured as expected. The unallowable expense, which had previously been reported and was mistakenly included in the report again, will be “replaced” by unreimbursed lost revenues, which was the intended use of the funds from the beginning. Proposed Completion Date: March 26, 2024

View Audit 301806 Questioned Costs: $1

Finding 391171 (2023-004)

Significant Deficiency 2023

Mercy Health

MO

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Finding 2023-004 Reporting Identification of the federal program: Federal Grantor: United States Department of Homeland Security Pass-Through Grantor: State of Missouri, State Emergency Management Agency Assistance Listing No.: 97.036, COVID-19 Disaster Grants – Public Assistance (Presidentially D...

Finding 2023-004 Reporting Identification of the federal program: Federal Grantor: United States Department of Homeland Security Pass-Through Grantor: State of Missouri, State Emergency Management Agency Assistance Listing No.: 97.036, COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) (“FEMA”) Pass-Through Award Numbers: Project# 699963 P/W# 624; Project# 185883 P/W# 529; and Project# 150136 P/W# 171 Condition: Timeliness and submission of the quarterly reports required by the State of Missouri could not be verified. Views of Responsible Officials and Planned Corrective Actions: The state of Missouri requires all quarterly reports be mailed. While we did send in our quarterly reports to the state of Missouri as required, we do not have proof of submissions as we did not send by certified mail. All future quarterly reporting will be documented with an email to our State SEMA representative when we send out quarterly reports so there is documentation for our records. Responsible Party: Emily Bruening, Director – Finance Date of Completion: This will be implemented for our next round of quarterly reporting, due in April 2024.

View Audit 301777

Finding 391169 (2023-002)

Significant Deficiency 2023

Mercy Health

MO

Internal Control / Segregation of Duties Reporting Matching / Level of Effort / Earmarking § 200.303

Finding 2023-002 Reporting Information on the federal program: Federal Grantor: United States Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498, COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distrib...

Finding 2023-002 Reporting Information on the federal program: Federal Grantor: United States Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498, COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (“PRF”) Payment Received Period: 01/01/2020–12/31/2022 (Period 4) and 01/01/2020–06/30/2023 (Period 5) Condition: For one of the sampled PRF reports (Mercy Hospital South Period 5 PRF Report), the amount reported for net patient service revenue (NPSR) for calendar year 2023 quarter 2 (CY2023 Q2) was incorrect for one reporting tax identification number (TIN). Views of Responsible Officials and Planned Corrective Actions: One cost report adjustment for the current year was inaccurately labeled as a prior year adjustment. This was an isolated oversight by our revenue analysis team. We will perform additional review of cost report adjustments used for PRF funding to ensure the amounts reported are accurate and in compliance with the terms of the agreement. Responsible Party: Kathryn Stecich, Executive Director, Revenue Cycle Date of Completion: By 6/30/24

View Audit 301777

Finding 391168 (2023-001)

Material Weakness 2023

Mercy Health

MO

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

Finding 2023-001 Activities Allowed or Unallowed Information on the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498, COVID-19 Provider Relief Fund and American Rescue Plan (AR...

Finding 2023-001 Activities Allowed or Unallowed Information on the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498, COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (“PRF”) Award Period of Performance: 01/01/2020–12/31/2022 (Period 4) and 01/01/2020–06/30/2023 (Period 5) Condition: Management performed a duplication of benefits analysis to ensure expenses to be used to substantiate PRF funding received were not reimbursed or obligated to be reimbursed by another source. The methodology included the development of estimated cost reimbursement rates by location that was applied to the PRF expenditures. During our allowable costs testing of expenditures, we noted errors in the duplication of benefits analysis and/or misapplication of the estimated cost reimbursement rates which resulted in a net overstatement of expenses totaling $2,078,408. In addition, we noted instances where employees’ hours reported on the timecards for substantiation of funding for the federal program were not consistently evidenced as reviewed and approved. Views of Responsible Officials and Planned Corrective Actions: While we overstated the expenses submitted totaling $2.1 million, this was an oversight during our review process. There are additional expenditures available in excess of funding received; therefore, we believe we have incurred either lost revenues or expenditures in excess of funding received. We will perform additional review of expenditures including the duplication of benefits analysis and application of the cost reimbursement rates to ensure appropriate amounts are used for PRF funding and ensure compliance with the terms of the agreement. Mercy Health’s Finance team will continue to stress the importance of timecard approval to leadership. Responsible Party: Jill McCart, VP Accounting and Reporting Date of Completion: By 6/30/24

View Audit 301777 Questioned Costs: $1

Finding 391163 (2023-001)

Significant Deficiency 2023

Rsu/msad No. 29

ME

Internal Control / Segregation of Duties

CORRECTIVE ACTION PLAN (Concerning Finding 2023-001) Contact Person Responsible for Corrective Action: Wendy Bradstreet, RSU29 Business Manager Corrective Action: RSU29 will take the following actions to address finding 2023-001 Wage Rate Requirements: Based on conversations with the auditing team t...

CORRECTIVE ACTION PLAN (Concerning Finding 2023-001) Contact Person Responsible for Corrective Action: Wendy Bradstreet, RSU29 Business Manager Corrective Action: RSU29 will take the following actions to address finding 2023-001 Wage Rate Requirements: Based on conversations with the auditing team throughout the FY23 audit process, the district has worked with vendors/contractors to correct the issues in question to comply with CFR(s): 2 CRF Appendix II to Part 200; 29 CFR 5.2; 29 CFR 5.5. For FY23 – vendors have been contacted regarding the Davis Bacon language and applicable corrections have been made on the vendor side to issue back wages to those employees who were below the required wage/benefits amounts. Payroll certifications for those individuals have been received and reviewed by the Business Manager for Davis Bacon compliance. Moving forward to the current fiscal year (FY24), Davis Bacon language will be included for current and future year construction projects paid for with federal and/or state funding. Payroll certifications will be received with each invoice submitted for payment to the district and reviewed by the Business Manager for compliance of Davis Bacon guidelines as applicable. A copy of the OMB Circulars containing the CFR guidelines have been received and reviewed by the Business Manager and applicable grant managers/coordinators to implement a more stringent internal control process and procedure to ensure all requirements are followed. The Business Manager will update the district’s administrative team and central office staff of applicable guidelines to ensure compliance of all projects that is being paid for by federal and/or state funding. Anticipated Completion Date: June 30, 2024

View Audit 301760

Corrective Action Plans

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