Corrective Action Plans

Finding 398543 (2023-002)

None 2023

City of Haverhill

MA

Reporting Internal Control / Segregation of Duties

CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Elementary and Secondary Education The City of Haverhill, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: ...

CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Elementary and Secondary Education The City of Haverhill, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Powers & Sullivan, LLC 100 Quannapowitt Parkway, Suite 101 Wakefield, MA 01880 Audit period: July 1, 2022 through June 30, 2023 The finding from the June 30, 2023, schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS U.S. DEPARTMENT OF TREASURY COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Federal Assistance Listing Number 21.027 2023-002: Reporting to the Federal Government Compliance Requirement: Reporting Type of Finding: Compliance and Internal Control over Compliance – Other Matter Criteria or Specific Requirement: Grantees must comply with reporting requirements established by the U.S. Treasury that includes reporting the total grant expenditures incurred for the reporting period. Since the City is a Metropolitan City with a population below 250,000 residents that was allocated more than $10.0 million in funding, the City is required to submit, to the U.S. Department of Treasury, a project and expenditure report 30 days after the end of each quarter. Condition: The City submitted the appropriate quarterly report timely, however the report submitted through June 30, 2023, did not reconcile into the City’s accounting ledgers by approximately $787,000. Questioned Costs: None Reported. Context: The City filed the required project and expenditure report in a timely manner, however the report submitted to the U.S. Treasury’s Portal was $787,000 less than the expenditures reported to the City’s accounting ledgers. A large majority of the missing expenditures related to year end warrants processed. In compiling the information for reporting purposes, the City did not extract the expenditure information correctly from the general ledger and omitted some of the City’s year end warrants. Effect: The expenditures reported on the City’s project and expenditure report did not match the accounting records. Cause: The City did not set the report parameters in the City’s accounting software to generate all 2023 expenditures incurred. Recommendation: Management should correct the report in the next reporting submission. Views of Responsible Officials and Planned Corrective Actions: Management made a good faith effort to correctly report its expenditures to the U.S. Treasury Department on an accurate and timely basis. The accounting ledgers require specific parameters to be set when the underlying data to compile the reports is generated. There was a clerical error in running these reports, and Management expects to correct this on the subsequent period’s reporting in fiscal 2024. If the Oversight Agency has questions regarding this plan, please call Angel Perkins, Chief Financial Officer & City Auditor at (978)-374-2306.

View Audit 307261

Finding 398496 (2023-001)

Material Weakness 2023

Pomona Valley Hospital Medical Center

CA

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Period of Performance

Finding 2023-001 – Internal Control Deficiency Over Activities Allowed or Unallowed and Activities Allowed/Allowable Costs Federal Grantor: Department of Homeland Security; Federal Emergency Management Agency (FEMA) Assistance Listing No.: 97.036, Disaster Grants – Public Assistance (Presidentia...

Finding 2023-001 – Internal Control Deficiency Over Activities Allowed or Unallowed and Activities Allowed/Allowable Costs Federal Grantor: Department of Homeland Security; Federal Emergency Management Agency (FEMA) Assistance Listing No.: 97.036, Disaster Grants – Public Assistance (Presidentially Declared Disasters) Award Period of Performance: January 20, 2020 – May 11, 2023 Finding: Management did not consistently retain documentation evidencing the performance of controls to ensure allowable COVID-19 expenses were charged to the program. Corrective Action Plan: All of these deficiencies were related to the selections being more than 36 months old, which is past the current documentation retention policy of PVHMC for non-controlled substances and non-patient records. In order to ensure that documentation is retained for future audits, all FEMA related documentation that is still retained will be kept indefinitely to ensure compliance in future years. Person Responsible: Juli Hester, Chief Financial Officer Estimated Completion Date: May 31, 2024

View Audit 307226

Finding 398483 (2023-002)

Significant Deficiency 2023

Crazy Horse School

SD

Internal Control / Segregation of Duties HUD Housing Programs Reporting

2023-002 FINDING: Internal Controls over Financial Reporting Question Cost: None noted. Not considered a material weakness Response: Crazy Horse School Business Office staff will follow auditor’s recommendation. The Business Manager will determine the financial statements, schedule of expenditures o...

2023-002 FINDING: Internal Controls over Financial Reporting Question Cost: None noted. Not considered a material weakness Response: Crazy Horse School Business Office staff will follow auditor’s recommendation. The Business Manager will determine the financial statements, schedule of expenditures of federal awards and related footnotes are free of material misstatement and the audit package is filed timely. The most effective controls lie in the management and the Board of Education’s knowledge of the School’s financial operations. Supervision and review functions will be done continually during all phases of the accounting cycle. Cross training with the Business Office staff will continue to be done. The Business Manager will continue to assist with disclosure information and approve any adjusting entries to the trial balance. She reviews and approves all draft and final copies of the financial statements including disclosures. In light of the guidance of SAS 115, the Business Manager will continue additional and continuing training for herself as well as the designated staff. The goal is still to provide training in government financial reporting and current reporting standards to enable management to continue to take the responsibility for the statements and disclosures. The school will continue their implantation of their new financial policies and take steps to ensure they are being followed. All expenditures will continue be reviewed to ensure they are properly documented, coded, and the expenditures are allowable for grant. Review of paychecks will continue to include recalculation of hours on timesheets and leave accrual calculation. With the continue Covid, Flu Seasons, Weather closures, Funeral closures, and my illness this past year has made it very difficult at times to get things done in a timely manner. We will continue to improve and hope to have a better year. This School’s financial stability is better than it has been for years with a clean opinion and no question costs. We will continue to improve, with our outstanding Business Office Staff, and we will continue to make sure we are on top of the internal controls daily. We are not perfect and there is always room to get better and better! ANTICIPATED COMPLETION DATE: June 30, 2025 PERSON(S) RESPONSIBLE: Leslie Cuny, Business Manager

View Audit 307206

Finding 398482 (2023-001)

Material Weakness 2023

Crazy Horse School

SD

Subrecipient Monitoring Cash Management Matching / Level of Effort / Earmarking

2023-001 FINDING: Deficit Fund Balances Questioned Costs: None noted. Recommendation: We recommend the School continue to implement their plan to liquidate all remaining debt from the general fund. We also recommend they continue a vigilant oversight of all budgets of the School. Response: The curre...

2023-001 FINDING: Deficit Fund Balances Questioned Costs: None noted. Recommendation: We recommend the School continue to implement their plan to liquidate all remaining debt from the general fund. We also recommend they continue a vigilant oversight of all budgets of the School. Response: The current Business Manager is enforcing the CHS Policies that do not permit expenditures in excess of the approved budget without Board approval. In addition, the current Business Manager does not include any carryover from prior budgets in the existing budget until the audit is completed and the financial statements are reconciled. The Business Manager has restricted use of General Fund revenues to remedy the deficit, including income received by the School that is non-program income, and the School Board is responsible for monitoring expenditures monthly. ANTICIPATED COMPLETION DATE: June 30, 2025 PERSON(S) RESPONSIBLE: Leslie Cuny, Business Manager

View Audit 307206

Finding 398460 (2023-001)

Material Weakness 2023

Mount Vernon School District No. 320

WA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Finding ref number: 2023-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with allowable activities and costs, equipment and restricted purpose requirements. Name, address, and telephone of District contact person: Tim Papendorf, Information Services ...

Finding ref number: 2023-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with allowable activities and costs, equipment and restricted purpose requirements. Name, address, and telephone of District contact person: Tim Papendorf, Information Services Supervisor 124 E. Lawrence Street, Mount Vernon, WA 98273 360-428-6110 Corrective action the auditee plans to take in response to the finding: Concern: The district failed to maintain sufficient documentation proving that the equipment provided to students matched their actual unmet needs. Reimbursement was sought based on estimated unmet needs rather than documented, actual unmet needs. Response: The Mount Vernon School District mandates that students use districtassigned devices for remote learning. According to grant training provided to the district, if students are required to use district-owned devices for remote learning, Chromebooks could be distributed to any student who did not have a district-assigned device that meets hardware standards. The standards used to assess the hardware included Chromebooks that were older than four years, unable to support the necessary software and digital learning tools, and devices at their end-of-life stage, meaning they no longer received automatic updates from Google. We assessed our inventory and supplied new Chromebooks to students based on our understanding of their needs. Chromebooks were only provided to students who lacked a device that met our hardware standards. Resolution: During this audit, the district learned that its understanding was inaccurate. However, we are confident our need exceeded our request. In May 2020, Page 71Office of the Washington State Auditor sao.wa.gov as directed by OSPI, the district conducted a survey which revealed that only 38% of our families had access to a device at home suitable for online learning. Given our students in poverty population was 4,365 during the 2022-23 school year, the 1,869 devices for which funding was requested only partially met our overall device needs. This audit has improved our understanding of the requirements related to verifying unmet needs. Moving forward, we will directly contact families and collect signatures to confirm their needs. These records will be attached to student profiles within our asset management system (Destiny) before ECF funded Chromebooks are assigned to them. Concern: Inventory records were incomplete, missing the names of 273 students assigned laptops funded by the ECF, thus failing to fully meet FCC documentation requirements. Response: The district acknowledges challenges related to student device assignment. Staff reductions and changes in our inventory and check-out processes necessitate updates and training, which is ongoing. We are committed to ensuring accurate and timely updates to our records. Resolution: A list of inventory discrepancies has been distributed, and action is being taken to update our records. To strengthen our existing systems, we will implement additional biannual training sessions with our inventory managers. These trainings will cover best practices for record keeping and emphasize the importance of maintaining accurate inventory records. We will conduct monthly audits of our records, and correction requests will be sent to individual sites to promptly address any information inaccuracies. Concern: MVSD lacked documentation to show that it only provided one device per student or location, leading to possible over-issuance of equipment. Response: While the district acknowledges the need to improve its student assignment inventory within Destiny, we have confirmed that only one device is assigned per student through the use of our additional inventory system (Google Workspace). Resolution: The district will enhance its inventory practices and explore additional redundancies to ensure effective contingencies if future data issues arise. Anticipated date to complete the corrective action: ● Unmet Needs Documentation: May 31, 2024 ● Inventory Update: June 20th, 2024 ● Staff Training: June 20th, 2024 (Ongoing)

View Audit 307176 Questioned Costs: $1

Finding 398457 (2023-006)

Material Weakness 2023

Pana Community Unit School District 8

IL

Reporting Internal Control / Segregation of Duties

03-011-0080-26 CORRECTIVE ACTION PLAN FOR CURRENT YEAR AUDIT FINDINGS Year Ending June 30, 2023 Corrective Action Plan Finding No.: 2023-_ 006_ Condition: Expenditure functions and objects used to record grant expenditures in the general ledger are not consistent with the expenditure function...

03-011-0080-26 CORRECTIVE ACTION PLAN FOR CURRENT YEAR AUDIT FINDINGS Year Ending June 30, 2023 Corrective Action Plan Finding No.: 2023-_ 006_ Condition: Expenditure functions and objects used to record grant expenditures in the general ledger are not consistent with the expenditure functions and objects used for grant reporting. In addition, general ledger support for each expenditure report submitted is not complete and readily available. Plan: Grant expenditures will be recorded in the same general ledger expenditure functions as are used for grant reporting and supporting general ledger reports will be maintained in District files for all expenditure reports filed. The employees assigned to code grant expenditures and prepare grant expenditure reports will work together to accomplish this. Anticipated Date of Completion: 06/30/2024 Name of Contact Person: Jason Bauer Management Response: Management will implement the auditor's recommendation for the year ended June 30, 2024.

View Audit 307162

Finding 398452 (2023-001)

Significant Deficiency 2023

Northeast Texas Public Health District

TX

Questioned Costs Internal Control / Segregation of Duties Subrecipient Monitoring

The Northeast Texas Public Health District (NET Health) will take steps to ensure overall effective grant monitoring and to increase communications between NET Health Grant Managers and the Chief Financial Officer and Chief Executive Officer. The NET Health Leadership Team will discuss any issues du...

The Northeast Texas Public Health District (NET Health) will take steps to ensure overall effective grant monitoring and to increase communications between NET Health Grant Managers and the Chief Financial Officer and Chief Executive Officer. The NET Health Leadership Team will discuss any issues during our weekly Leadership Team meetings to ensure compliance. These weekly meetings will address costs expended within the grant parameters and ensure grant funds will be more evenly expended during the year as appropriate. NET Heatlh will continue to develop effective methods of grant oversight as it finds weaknesses in its processes. To ensure compliance with the period of performance requirements, NET Health will change its processes effectively immediately. Going forward checks will only be prepared, dated, signed, and mailed to vendors after work is completed or items are received. There will be enhanced internal controls by establishing procedures to monitor and ensure timely payment of accrued expenditures, such as regularly accounting for any outstanding checks and actively communicating with vendors on performance requirements. In addition, we will enhance communication and coordination among relevant departments to expedite the payment process while maintaining compliance with grant regulations. George T. Roberts, CEO, and Lawanda Owens, CFO, are the persons responsible for this action plan going forward. NET Health is expected to have this action plan implemented by May 1, 2024.

View Audit 307138 Questioned Costs: $1

Finding 398450 (2023-005)

Significant Deficiency 2023

Nassau Community College

NY

Student Financial Aid Cash Management Reporting

NCC conducted staff training to reinforce requirements for the return of funds within 240 days for all federal award checks returned uncashed. Effective November 2023, we implemented an automated process to assist with identifying federal funds that need to be returned.

View Audit 307129

Finding 398448 (2023-004)

Significant Deficiency 2023

Nassau Community College

NY

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

The HEERF reports are being updated, approved and uploaded to our website.

View Audit 307129

Finding 398446 (2023-003)

Significant Deficiency 2023

Nassau Community College

NY

Student Financial Aid Reporting Significant Deficiency

The attendance process has been moved to the Registrar’s Office and registration status codes for unofficial withdrawals have been created in order for the system to find those students when submitting monthly enrollment reporting to clearinghouse, which is then sent to NSLDS.

View Audit 307129

Finding 398435 (2023-002)

Significant Deficiency 2023

Grameen Foundation

DC

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

Views of Responsible Officials: Finance management recognizes the importance of regular account analysis and account reconciliations. In view of the finance department’s staffing constraints, some account reconciliations were performed less frequently. As staffing issues (e.g., learning curve of new...

Views of Responsible Officials: Finance management recognizes the importance of regular account analysis and account reconciliations. In view of the finance department’s staffing constraints, some account reconciliations were performed less frequently. As staffing issues (e.g., learning curve of new hire and return of staff from extended leave) are addressed, the finance team now performs regular account reconciliations as part of the month-end financial reporting close. Specific accounts are flagged for monthly reconciliations, i.e. bank and investment accounts, intercompany accounts, prepaids, advances, receivables and payables. Other accounts with only periodic activity, will be reconciled on a quarterly, mid-year, or yearly basis, as determined.

View Audit 307128

Finding 398433 (2023-006)

Significant Deficiency 2023

Women's Foundation for the State of Arizona

AZ

Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.430

At this time, the Foundation can confirm all employees have rate of pay documentation in their employee files. The Foundation is working to adopt stronger policies around contractors engaged with the organization with oversight to contractors’ pay provided by the staffed CEO.

View Audit 307125

Finding 398432 (2023-005)

Significant Deficiency 2023

Women's Foundation for the State of Arizona

AZ

Reporting Internal Control / Segregation of Duties

The Foundation will work to have the staffed CEO review and sign off on all reports and payroll registers in general with a specific focus on those tied to government grants.

View Audit 307125

Finding 398419 (2023-001)

Material Weakness 2023

Metro Towers, Inc. St. James Place

MO

HUD Housing Programs Special Tests & Provisions Procurement, Suspension & Debarment

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED DECEMBER 31, 2023 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee t...

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED DECEMBER 31, 2023 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee to prepare a corrective action plan to address each audit finding included in the current year auditor’s reports. The Corrective Action Plan for Current Year Findings present our corrective action plan for the Financial Statement and/or Federal Award Findings described in the accompanying Schedule of Findings and Questioned Costs for the period ended December 31, 2023. Finding 2023-001 Responsible Party Name: Fred Gibbs Position: President – Management Agent Telephone Number: 913-709-1811 Federal Agency U.S. Department of Housing and Urban Development Federal Program Mortgage Insurance for Purchase or Refinancing of Existing Multifamily Rental Housing (Section 207/223(F)) Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Auditee’s Comment on Finding We agree with the auditor’s finding. Corrective Action We will follow our policies and procedures to ensure that accounting records are kept accurate and complete, and a responsible official will review and sign off on the monthly financial statements. Anticipated Completion Date June 30, 2024

View Audit 307115

Finding 398413 (2023-001)

Significant Deficiency 2023

Wahkiakum School District No. 200

WA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Wahkiakum School District No. 200 September 1, 2022 through August 31, 2023 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code o...

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Wahkiakum School District No. 200 September 1, 2022 through August 31, 2023 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2023-001 Finding caption: The District did not have adequate controls for ensuring compliance with federal requirements for allowable costs and cost principles Name, address, and telephone of District contact person: Sue Ellyson, Business Manager P.O. Box 398 Cathlamet, WA 98612 (360) 795-3971 Corrective action the auditee plans to take in response to the finding: The District will be more prompt in requesting refunds. Anticipated date to complete the corrective action: The refund was requested 3/1/24 and received 3/15/24.

View Audit 307112 Questioned Costs: $1

Finding 398402 (2023-001)

Material Weakness 2023

South Kitsap School District No. 402

WA

Subrecipient Monitoring Internal Control / Segregation of Duties Special Tests & Provisions

Finding ref number: 2023-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with federal wage rate requirements. Name, address, and telephone of District contact person: Andrea Cooper 2689 Hoover Ave SE Port Orchard, WA 98366 360-874-7015 Corrective...

Finding ref number: 2023-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with federal wage rate requirements. Name, address, and telephone of District contact person: Andrea Cooper 2689 Hoover Ave SE Port Orchard, WA 98366 360-874-7015 Corrective action the auditee plans to take in response to the finding: The District was compliant with federal wage rates and will ensure that all public works projects funded with federal funds have appropriate contract language included in order to comply with all federal wage rate requirements. Anticipated date to complete the corrective action: Immediately.

View Audit 307099

Finding 398348 (2023-001)

Significant Deficiency 2023

Chicago Horticultural Society

IL

Internal Control / Segregation of Duties Cash Management Significant Deficiency § 200.303

Finding Number: 2023-001 Condition: Two reimbursement requests submitted during 2023 did not have documentation available to indicate that the reimbursement request was reviewed by a supervisor for accuracy before submission. Planned Corrective Action: Staff turnover in early 2023 resulted in a temp...

Finding Number: 2023-001 Condition: Two reimbursement requests submitted during 2023 did not have documentation available to indicate that the reimbursement request was reviewed by a supervisor for accuracy before submission. Planned Corrective Action: Staff turnover in early 2023 resulted in a temporary lapse of documentation proving that the internal control process was followed. The Society follows its internal review process and is maintaining documentation that appropriate approvals are in place. Contact person responsible for corrective action: Dharshni Sabapathy, Senior Director of Accounting Anticipated Completion Date: April 25, 2024

View Audit 307016

Finding 398342 (2023-001)

Material Weakness 2023

St Croix Valley Supportive Housing for the Elderly, Inc.

WI

Questioned Costs HUD Housing Programs Material Weakness

Section 202 Capital Advance – Assistance Listing No. 14.157 Recommendation: Accounting staff should reconcile the Replacement Reserve account on a periodic (monthly or quarterly) basis to ensure the monthly transfers are being made. Management should also make the deposit to fully fund the replaceme...

Section 202 Capital Advance – Assistance Listing No. 14.157 Recommendation: Accounting staff should reconcile the Replacement Reserve account on a periodic (monthly or quarterly) basis to ensure the monthly transfers are being made. Management should also make the deposit to fully fund the replacement reserve as soon as possible. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management is in agreement with the finding and has since corrected the issue. Name(s) of the contact person(s) responsible for corrective action: Chuck Armstrong, Director Independent & Affordable Living Planned completion date for corrective action plan: September 30, 2023

View Audit 307011 Questioned Costs: $1

Finding 398335 (2023-002)

Significant Deficiency 2023

Texarkana Arkansas School District

AR

Internal Control / Segregation of Duties Reporting

The District will contact DESE to determine if further steps are needed. The Assistant Superintendent of Student Services will facilitate this action.

View Audit 307003

Finding 398333 (2023-001)

Material Weakness 2023

Texarkana Arkansas School District

AR

Internal Control / Segregation of Duties Special Tests & Provisions Matching / Level of Effort / Earmarking

The District has made several attempts to secure weekly certified payrolls for construction projects on-going since July 2023 once notified of this deficiency for the 2022-2023 audit. We will continue to request certified payrolls for the months prior to April 2024 and will request the payroll info...

The District has made several attempts to secure weekly certified payrolls for construction projects on-going since July 2023 once notified of this deficiency for the 2022-2023 audit. We will continue to request certified payrolls for the months prior to April 2024 and will request the payroll information for current and future construction projects from this point forward. Documentation of attempts to collect the information will be maintained. This will be monitored by the Comptroller and Business Manager for the District.

View Audit 307003

Finding 398321 (2023-004)

Material Weakness 2023

Fremont County School District No. 14

WY

Internal Control / Segregation of Duties

CORRECTIVE ACTION - FINDING 2023-004 - SEGREGATION OF DUTIES Anticipated Date of Completion: June 1, 2024 Name of Contact Person: Robin Vail, Business Manager Management Response: Management acknowledges the repeated finding concerning the segregation of duties within the accounting and bookkeeping ...

CORRECTIVE ACTION - FINDING 2023-004 - SEGREGATION OF DUTIES Anticipated Date of Completion: June 1, 2024 Name of Contact Person: Robin Vail, Business Manager Management Response: Management acknowledges the repeated finding concerning the segregation of duties within the accounting and bookkeeping functions at the beginning of the audit period. We recognize the importance of segregating these duties to safeguard assets and ensure the accuracy of financial information. While we faced limitations in resources during that period, we have since hired additional staff to mitigate this risk. Moving forward, we remain committed to maintaining an appropriate segregation of duties to strengthen internal controls and mitigate potential risks.

View Audit 306985

Finding 398271 (2023-001)

Material Weakness 2023

Hope Family Health Services, Inc.

TN

Special Tests & Provisions Internal Control / Segregation of Duties

In Finding 2023-001, it was reported that the Organization did not properly substantiate that proper documentation was obtained and that proper sliding fee discounts were applied for certain patients for the year ended December 31, 2023. Employees will be properly trained to document and apply the...

In Finding 2023-001, it was reported that the Organization did not properly substantiate that proper documentation was obtained and that proper sliding fee discounts were applied for certain patients for the year ended December 31, 2023. Employees will be properly trained to document and apply the sliding fee discounts in accordance with the Organization’s sliding fee policy. Sliding fee discounts will be reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. This review and training will be completed by May 31, 2024.

View Audit 306981

Finding 398267 (2023-001)

Significant Deficiency 2023

Mora Valley Community Health Serivces, Inc.

NM

Internal Control / Segregation of Duties Special Tests & Provisions Significant Deficiency

MVCHS recognizes that in 2023 income for 4 out of 30 patients was incorrectly entered into the system and the slide was improperly applied. 1. MVCHS will also ensure that required income documents are obtained and that the correct income (s) are applied. MVCHS will also ensure that patients who are ...

MVCHS recognizes that in 2023 income for 4 out of 30 patients was incorrectly entered into the system and the slide was improperly applied. 1. MVCHS will also ensure that required income documents are obtained and that the correct income (s) are applied. MVCHS will also ensure that patients who are unable to provide written verification at the time of their first appointment will complete the self-declaration portion of the SFDP application. 2. MVCHS will provide training to Front Office staff to ensure that income and family size are properly entered into the system and the Slide is properly applied. MVCHS will ensure that proper documentation is collected from patients and that accurate information is entered into the system, even during staff turnover. Finance/Billing staff will ensure oversite of documentation. 3. MVCHS reached out to the New Mexico Primary Care Association and was provided training for the Front Office Staff regarding the Sliding Fee Discount Program process in April 2024.

View Audit 306968

Finding 398260 (2023-002)

Significant Deficiency 2023

West Cocalico Township Authority

PA

Internal Control / Segregation of Duties Significant Deficiency

In response to your audit Findings 2023-001 and 2023-002, I would like to offer the following response: Due to the size of the Authority, it is not feasible at this time to hire additional employees to segregate the financial responsibilities. Management will continue to monitor this situation and s...

In response to your audit Findings 2023-001 and 2023-002, I would like to offer the following response: Due to the size of the Authority, it is not feasible at this time to hire additional employees to segregate the financial responsibilities. Management will continue to monitor this situation and segregate duties as is economically feasible.

View Audit 306956

Finding 398259 (2023-001)

Significant Deficiency 2023

West Cocalico Township Authority

PA

Internal Control / Segregation of Duties Significant Deficiency

In response to your audit Findings 2023-001 and 2023-002, I would like to offer the following response: Due to the size of the Authority, it is not feasible at this time to hire additional employees to segregate the financial responsibilities. Management will continue to monitor this situation and s...

In response to your audit Findings 2023-001 and 2023-002, I would like to offer the following response: Due to the size of the Authority, it is not feasible at this time to hire additional employees to segregate the financial responsibilities. Management will continue to monitor this situation and segregate duties as is economically feasible.

View Audit 306956

Corrective Action Plans

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