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MAINTENANCE OF EFFORT Department of Education (DOE) Assistance Listing Number 84.425C/84.425D/84.425R/84.425U DOE submitted a waiver request in June 2022 and is currently working with the U.S. Education Department to obtain a waiver for Maintenance of Effort for FY22. DOE is also working with the ...
MAINTENANCE OF EFFORT Department of Education (DOE) Assistance Listing Number 84.425C/84.425D/84.425R/84.425U DOE submitted a waiver request in June 2022 and is currently working with the U.S. Education Department to obtain a waiver for Maintenance of Effort for FY22. DOE is also working with the Office of the Governor and Legislative Leaders to review compliance for the 2023 fiscal year.
Finding 46234 (2022-017)
Significant Deficiency 2022
SPECIAL TESTS AND PROVISIONS ? GRAMM-LEACH-BLILEY ACT ? STUDENT INFORMATION SECURITY Fairmont State University and Pierpont Community and Technical College Assistance Listing Number 84.007, 84.033, 84.038, 84.063, 84.268, 84.379, 84.408, 93.264, 93.342, 93.364, 93.925 Fairmont State University (FSU...
SPECIAL TESTS AND PROVISIONS ? GRAMM-LEACH-BLILEY ACT ? STUDENT INFORMATION SECURITY Fairmont State University and Pierpont Community and Technical College Assistance Listing Number 84.007, 84.033, 84.038, 84.063, 84.268, 84.379, 84.408, 93.264, 93.342, 93.364, 93.925 Fairmont State University (FSU) response FSU entered into a contract with Wolf & Company to perform an external risk assessment for our systems in 2021 but was not completed due to staffing changes until 2022. The external risk assessment was received from Wolf in June 2022. The report and its suggestions were immediately reviewed and approved. This action will be implemented in January 2023 for fiscal year 2023 and will be implemented each July, starting with July 2023, hereafter. It was not understood that annual reviews needed to occur at the beginning of each fiscal year until this finding was received. Pierpont Community and Technical College (PCTC) response In December 2022 and January 2023, PTCT developed the following policies and procedures, which also detail internal controls, relative to the Gramm-Leach-Bliley Act and student information security. ? Access to Security Controlled Spaces Policy ? Anti-Virus Policy ? Backup and Recovery Policy ? Change Management Policy ? Computer Disposal Policy ? Computer Security Policy ? Data Security Policy ? IT Firewall Policy ? IT Incident Response Policy ? System Update Policy ? Mobile Device Use Policy ? Remote Access Policy ? Risk Assessment Policy ? Banner Document Procedure ? Banner Security Procedure ? Argos Access Procedure ? Active Directory Security and User Creation ? National Student Loan Clearinghouse Enrollment Submission Procedure ? National Student Loan Clearinghouse Graduate Only Submission Procedure ? Nelnet Refunds Procedure ? Risk Assessment Procedure Risk assessments will now be performed two times a year and will follow the Risk Assessment Procedure. This procedure also incorporates all policies, procedures, and internal controls as the framework for the ensuring of student information security.
SPECIAL TESTS AND PROVISIONS - VERIFICATION Bluefield State University, Fairmont State University, and Pierpont Community and Technical College Assistance Listing Number 84.007, 84.033, 84.038, 84.063, 84.268, 84.379, 84.408, 93.264, 93.342, 93.364, 93.925 Bluefield State University (BSU) response...
SPECIAL TESTS AND PROVISIONS - VERIFICATION Bluefield State University, Fairmont State University, and Pierpont Community and Technical College Assistance Listing Number 84.007, 84.033, 84.038, 84.063, 84.268, 84.379, 84.408, 93.264, 93.342, 93.364, 93.925 Bluefield State University (BSU) response Effective January 2023, after all calculations are made and checklists are completed the files will be reviewed by another counselor for accuracy. This reviewer will sign off on the file and checklist that it has been reviewed and no errors were found or recalculation needed. Both the preparer and the reviewer will sign off and date the checklist. Fairmont State University (FSU) response Controls were put into place in 2020-2021 to address the additional review of the verification process once the initial review was completed. FSU found that through some reporting and timing that the additional review did not occur for all students. FSU will implement a weekly review with a comprehensive review monthly to ensure no students are missed through the additional review process in February 2023. Pierpont Community and Technical College (PCTC) response Staff members have been, and will continue to be, prompted to print, scan and keep all documentation pertaining to verifications. In these two cases, the counselor did not print the Confirmation page that displays upon completing V4 & V5 verifications in Central Processing System (CPS) and did not follow the flow of placing the verification packet in the appropriate location for second review. PCTC has reviewed policies and procedures and made a slight modification. Beginning with the 22/23 aid year, the Financial Aid Administrator (FAA) brings the completed verification packet to the Director of Financial Aid. The Director then determines who will complete the second review. The second review can be completed by either the Director of Financial Aid, the Assistant Director of Financial Aid or another qualified FAA. Once completed and signed off, the verification packet is place into the permanent individual student?s file.
View Audit 40967 Questioned Costs: $1
Finding 46230 (2022-013)
Significant Deficiency 2022
FISCAL OPERATIONS REPORT AND APPLICATION TO PARTICIPATE Fairmont State University, West Virginia State University, and West Virginia School of Osteopathic Medicine Assistance Listing Number 84.007, 84.033, 84.038, 84.063, 84.268, 84.379, 93.264, 93.342, 93.364, 93.925 Fairmont State University (FS...
FISCAL OPERATIONS REPORT AND APPLICATION TO PARTICIPATE Fairmont State University, West Virginia State University, and West Virginia School of Osteopathic Medicine Assistance Listing Number 84.007, 84.033, 84.038, 84.063, 84.268, 84.379, 93.264, 93.342, 93.364, 93.925 Fairmont State University (FSU) response As of January 2023, the Financial Reporting Manager will complete Part II of the Fiscal Operations Report and Application to Participate (FISAP) submission. The Controller will review and compare with audited financial statements to ensure the correct amounts are recorded prior to approval and submission by the institution. West Virginia State University (WVSU) response This finding was a result of inaccurate reporting. The dollar amounts used for tuition and fees in the original calculation were incorrect. The supporting documentation was updated after submission of the FISAP to include correct numbers. To prevent this from occurring in the future, a dual review will be required for all reporting data. The Office of Financial Aid and Scholarships will verify the Federal Work-Study (FWS) and Supplemental Education Opportunity Grant (SEOG) fund allocations are identified correctly on the FISAP, in regard to transfer of funds, to accurately reflect the allotted fund amounts and amounts paid to student accounts in Banner. These changes were made effective March 2022 and reflected in the FY22 FISAP. West Virginia School of Osteopathic Medicine (WVSOM) response Internally generated reports used to prepare the FISAP from WVSOM?s management system have been modified to ensure accuracy and clarity of the data. Procedures are in place for a secondary review of the report prior to submission.
Finding 46227 (2022-010)
Significant Deficiency 2022
REPORTING State of West Virginia (WV) Assistance Listing Number 21.027 Going forward, WV will ensure that all data requested for calculations related to the revenue replacement calculation or any other aspect of reporting to the Department of Treasury is independently reviewed to ensure the data u...
REPORTING State of West Virginia (WV) Assistance Listing Number 21.027 Going forward, WV will ensure that all data requested for calculations related to the revenue replacement calculation or any other aspect of reporting to the Department of Treasury is independently reviewed to ensure the data used is aligned with the parameters needed for reporting (e.g. all transactions fall within the proper dates, appropriate accounts and cost categories are included, etc.) prior to use for such calculations. Analytical procedures will be used to compare data used to other financial reports to ensure reasonableness.
SPECIAL TESTS AND PROVISION ? UI PROGRAM INTEGRITY - OVERPAYMENTS Workforce West Virginia (WWV) Assistance Listing Number 17.225, COVID-19 17.225 WWV will provide training to all Unemployment Insurance claim staff by March 2023 and review procedures related to the establishment of overpayments.
SPECIAL TESTS AND PROVISION ? UI PROGRAM INTEGRITY - OVERPAYMENTS Workforce West Virginia (WWV) Assistance Listing Number 17.225, COVID-19 17.225 WWV will provide training to all Unemployment Insurance claim staff by March 2023 and review procedures related to the establishment of overpayments.
View Audit 40967 Questioned Costs: $1
INTERNAL CONTROLS OVER INFORMATION TECHNOLOGY Workforce West Virginia (WWV) Assistance Listing Number 17.225, COVID-19 17.225 As of November 2022, WWV began and will continue to develop the processes for periodic review of user accounts for ABPS, UC Tax, and wvOASIS. Processes will include documen...
INTERNAL CONTROLS OVER INFORMATION TECHNOLOGY Workforce West Virginia (WWV) Assistance Listing Number 17.225, COVID-19 17.225 As of November 2022, WWV began and will continue to develop the processes for periodic review of user accounts for ABPS, UC Tax, and wvOASIS. Processes will include documenting termination of employees timely to the West Virginia Office of Technology (WVOT) to remove network access or within the organization to remove access to IT systems at the time of exit. WVOT will be adding features to Ivanti (WVOT service portal) so that WWV may download account management activity for validation, tracking, and review. WWV participates in Disaster Recovery operations when the WVOT holds them. Since WWV is covered by WVOT, WWV cannot reasonably procure a separate process for disaster recovery testing without the assistance and involvement of WVOT.
Community Development Block Grant Program (CDBG) Assistance Listing Number 14.228, COVID-19 14.228 Since the COVID pandemic occurred, the West Virginia Community Advance and Development office (CAD) experienced a high personnel turnover rate. As a result, CAD experienced a delay in implementing th...
Community Development Block Grant Program (CDBG) Assistance Listing Number 14.228, COVID-19 14.228 Since the COVID pandemic occurred, the West Virginia Community Advance and Development office (CAD) experienced a high personnel turnover rate. As a result, CAD experienced a delay in implementing the corrective action plan related to this finding. During the last 30 days, CAD has completed Federal Funding Accountability and Transparency Act (FFATA) training and has designated the personnel to the FFATA reporting process. Additionally, CAD has developed a checklist related to these grant awards which includes the FFATA system entry submission. These policies and procedures were implemented February 1, 2023.
Department of Education (DOE) Assistance Listing Number 10.553, 10.555, 10.556, 10.559, 10.582 Program Management will implement policies and procedures to ensure Transparency Act reporting is conducted with proper reviews and timely submissions. In order to comply with the Federal Funding Account...
Department of Education (DOE) Assistance Listing Number 10.553, 10.555, 10.556, 10.559, 10.582 Program Management will implement policies and procedures to ensure Transparency Act reporting is conducted with proper reviews and timely submissions. In order to comply with the Federal Funding Accountability and Transparency Act (Pub. L. No. 109-282) (Transparency Act), as amended by Section 6202(a) of the Government Funding Transparency Act of 2008 (Pub. L. No. 111-252), that relate to sub-award reporting, DOE is working with the Child Nutrition Claiming Software vendor to create a report that will be run on the first of each month. Staff from the Office of Internal Operations and Office of Child Nutrition will be assigned to generate, enter, and submit data as required by the Transparency Act. To meet the timelines for reporting as established by the Transparency Act, the report will pull all activity for the prior month including all original reimbursement claims, as well as amendments that occur in that month to reimbursement claims that were previously reported. Prior to submission of the data, a report of its contents will be reviewed and approved by either the Child Nutrition Program Director or the Director of Internal Operations. Once the data is approved, it will be submitted. The timeline for development and initiation of this reporting process (barring any unforeseen system limitations) is tentatively set for July 1, 2023.
Department of Health and Human Resources (DHHR) Assistance Listing Number 10.551, 10.561, COVID-19 10.561 The DHHR Bureau for Family Assistance (the Bureau) analyzed the condition that led to this finding. The emergency supplement in question was paid on the initial month of SNAP issuance. However...
Department of Health and Human Resources (DHHR) Assistance Listing Number 10.551, 10.561, COVID-19 10.561 The DHHR Bureau for Family Assistance (the Bureau) analyzed the condition that led to this finding. The emergency supplement in question was paid on the initial month of SNAP issuance. However, these supplements were not to be based on the initial or prorated months of SNAP benefits. Per the U.S. Department of Agriculture, Food and Nutrition Service (FNS), emergency supplements were not to be initiated until the second month of SNAP issuance (i.e., the month following active SNAP approval). The emergency supplement allotments will end February 28, 2023. If the FNS instructs the Bureau to issue emergency supplement allotments for the SNAP Program beyond February 28, 2023, the Bureau will develop a blackboard course with video to ensure that all workers are trained on the procedures and policy. The blackboard platform has the capability to track who has completed the training which will ensure supervisors can determine who has or has not completed the required training.
Finding 46205 (2022-044)
Significant Deficiency 2022
INTERNAL CONTROL ? PAYROLL Department of Health and Human Resources (DHHR) Assistance Listing Number 93.558, 93.658, 10.557 For the condition whereby a timecard for the WIC program was not approved by a manager in the automated payroll system, the DHHR Office of Human Resources Management (OHRM) r...
INTERNAL CONTROL ? PAYROLL Department of Health and Human Resources (DHHR) Assistance Listing Number 93.558, 93.658, 10.557 For the condition whereby a timecard for the WIC program was not approved by a manager in the automated payroll system, the DHHR Office of Human Resources Management (OHRM) received confirmation from the manager that the timecard was accurate. However, the confirmation was not obtained until after the state?s independent auditors inquired about the timecard. To enhance the controls and improve the documentation surrounding timecard approvals in general, the OHRM has instructed their payroll processors to use a log to note any issues with timecards prior to signing off on the timecards within the automated payroll system. The log will be shared with timekeepers and managers in the field (i.e., the various DHHR bureaus and offices throughout the state). The timekeepers and managers in the field will be required to note resolution of the issues directly on the log. If there are any unresolved issues remaining after signing off on the timecard in the system, the issues will be documented along with the manager?s actions. The ultimate goal is to obtain management approval for every timecard, whether such approval is documented directly within the automated payroll system prior to sign-off or documented outside of the system after sign-off. As is always the case, if adjustments to a timecard are necessary after the sign-off process, the OHRM will utilize their ?OHRM-36 Kronos Time & Leave Correction" form. When deemed necessary, the log and any related documentation will be shared with the state?s independent auditors during fieldwork for the West Virginia Single Audit. The anticipated date for completion of the log and the procedures related thereto is February 10, 2023. For the condition whereby the payroll system was unavailable due to a ransomware attack, the OHRM switched to a manual timekeeping system immediately after the attack and developed processes and controls related thereto. However, as the state?s independent auditors indicated, the OHRM did not maintain adequate documentation related to the controls and the precision of the controls in all instances. Accordingly, the OHRM is working on a contingency plan to document the steps to take in the event of another ransomware attack or any other incident that causes the automated payroll system to be unavailable. The anticipated date for completion is March 31, 2023.
DHHR INFORMATION SYSTEM AND RELATED BUSINESS PROCESS CONTROLS Department of Health and Human Resources (DHHR) Assistance Listing Number 10.551, 10.561, COVID-19 10.561, 10.542, 93.558, COVID-19 93.558, 93.568, COVID-19 93.568, 93.575, 93.596, COVID-19 93.575, 93.658, 93.659, 93.767, 93.775, 93.777, ...
DHHR INFORMATION SYSTEM AND RELATED BUSINESS PROCESS CONTROLS Department of Health and Human Resources (DHHR) Assistance Listing Number 10.551, 10.561, COVID-19 10.561, 10.542, 93.558, COVID-19 93.558, 93.568, COVID-19 93.568, 93.575, 93.596, COVID-19 93.575, 93.658, 93.659, 93.767, 93.775, 93.777, COVID-19 93.777, 93.778, COVID-19 93.778, ARRA 93.778 Enhancing the Quality Control process (by adding other programs to the overall scope and expanding the populations for sampling to include payments that have case data that is initiated and approved by the same person as well as case data that is entered by one person without another level of approval) would prove costly for the DHHR due to the additional staff throughout the DHHR that would be required to accomplish such a task. Although enhancing the Quality Control process is still a possibility, upon further discussions within the DHHR, it was determined that prior to considering such an enhancement, the Bureau for Social Services, Bureau for Family Assistance, and other DHHR units should work together to perform the following: outline the existing internal controls over payments by payment type or program, determine the number of payments per month whereby one employee initiates and approves a payment (in relation to the population of all payments) and conclude on the risk of those payments being improper. Management can then identify areas of focus to conclude on the adequacy of the internal controls and make revisions to policies and procedures, if necessary. In short, although there are existing controls in place, the controls have not been documented and communicated to the State?s independent auditors in an effective manner.
Finding ref number: 2022-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with wage rate requirements. Name, address, and telephone of School District contact person: Heather C. Pinkerton 310 SW 16th St Chehalis, WA 98532 360-807-7207 Corrective actio...
Finding ref number: 2022-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with wage rate requirements. Name, address, and telephone of School District contact person: Heather C. Pinkerton 310 SW 16th St Chehalis, WA 98532 360-807-7207 Corrective action the auditee plans to take in response to the finding: It is highly unusual for the district to utilize federal funds for construction projects; the Covid-19 Education Stabilization Funds were an anomaly. The District?s Director of Business and Operations was unaware that prevailing wage clauses are required to be included in all public works contracts over $2,000 that are paid with federal funds. She was aware that prevailing wages need to be paid. The audit finding does not dispute that prevailing wages were paid appropriately, just that the clauses were not included in the contracts. To be very clear, this finding is for not having required language in contracts. The District is now aware that inclusion of the clauses is a compliance requirement. Going forward, it is unlikely that federal funds will be used for construction projects; however, when federal funds are utilized for construction projects, the District will either include the required prevailing wage rate clauses in its contracts or will obtain a separate signed clause with the required prevailing wage rate information. Anticipated date to complete the corrective action: Immediately
Finding ref number: 2022-002 Finding caption: The District did not have adequate internal controls for ensuring compliance with allowable activities and costs and restricted purpose requirements. Name, address, and telephone of School District contact person: Heather C. Pinkerton 310 SW 16th St Cheh...
Finding ref number: 2022-002 Finding caption: The District did not have adequate internal controls for ensuring compliance with allowable activities and costs and restricted purpose requirements. Name, address, and telephone of School District contact person: Heather C. Pinkerton 310 SW 16th St Chehalis, WA 98532 360-807-7207 Corrective action the auditee plans to take in response to the finding: The Chehalis School District does not concur with the finding or the questioned costs. The State Auditor?s Office (SAO) reviewed various types of documentation and did not accept documentation presented by the District to reduce or eliminate questioned costs. The standard of documentation required by SAO to satisfy ?unmet need? would have been hard to meet even if the District hadn?t been in the midst of a pandemic. The District has internal controls over asset inventory and provided equipment only to students and staff with unmet needs, and all costs were allowable, reasonable and necessary. We continue to communicate with other agencies with the ultimate goal of helping the Federal Communications Commission (FCC) understand that they should not seek any recovery of funds resulting from ?documentation? issues considering the massive public health response, deployment logistics, vague federal guidance, and the effective return to in-person learning. Along with countless other districts across the State of Washington, we look forward to working with the FCC to resolve this finding. We appreciate the guidance that was provided by the FCC, as noted below. Guidance from the FCC Devices for remote learning could also be used at school. During the pandemic in Washington State we experienced times when classrooms, schools and or districts were closed by health department and state regulations because of outbreaks. Districts had to be prepared to support remote learning each day with constantly changing guidance on who was allowed to be in person. The following guidance from the Federal Communications Commission, titled ?Emergency Connectivity Fund Common Misconceptions?, ?Misconception #2: If schools have returned to in-class instruction for the upcoming school year, they are not eligible to participate. Answer: This is false. Equipment and services provided to students or school staff who would otherwise lack sufficient access to connected devices, and/or broadband internet access connection while off campus are eligible for Emergency Connectivity Fund Support.? From the Federal Communications Commission Order FCC-CIRC21-93-043021, question 77: ?We think schools are in the best position to determine whether their students and staff have devices and broadband services sufficient to meet their remote learning needs, and we recognize that they are making such decisions in the midst of a pandemic. We, therefore, will not impose any specific metrics or process requirements on those determinations.? And from question 53: ??we are sensitive to the need to provide some flexibility during this uncertain time. If those connected devices were purchased for the purpose of providing students?with devices for off-campus use consistent with the rules we adopt today, we will not prohibit such on-campus use.? Corrective action the auditee plans to take in response to the finding: The Chehalis School District does not concur with the finding or the questioned costs. The State Auditor?s Office (SAO) reviewed various types of documentation and did not accept documentation presented by the District to reduce or eliminate questioned costs. The standard of documentation required by SAO to satisfy ?unmet need? would have been hard to meet even if the District hadn?t been in the midst of a pandemic. The District has internal controls over asset inventory and provided equipment only to students and staff with unmet needs, and all costs were allowable, reasonable and necessary. We continue to communicate with other agencies with the ultimate goal of helping the Federal Communications Commission (FCC) understand that they should not seek any recovery of funds resulting from ?documentation? issues considering the massive public health response, deployment logistics, vague federal guidance, and the effective return to in-person learning. Along with countless other districts across the State of Washington, we look forward to working with the FCC to resolve this finding. We appreciate the guidance that was provided by the FCC, as noted below. Guidance from the FCC Devices for remote learning could also be used at school. During the pandemic in Washington State we experienced times when classrooms, schools and or districts were closed by health department and state regulations because of outbreaks. Districts had to be prepared to support remote learning each day with constantly changing guidance on who was allowed to be in person. The following guidance from the Federal Communications Commission, titled ?Emergency Connectivity Fund Common Misconceptions?, ?Misconception #2: If schools have returned to in-class instruction for the upcoming school year, they are not eligible to participate. Answer: This is false. Equipment and services provided to students or school staff who would otherwise lack sufficient access to connected devices, and/or broadband internet access connection while off campus are eligible for Emergency Connectivity Fund Support.? From the Federal Communications Commission Order FCC-CIRC21-93-043021, question 77: ?We think schools are in the best position to determine whether their students and staff have devices and broadband services sufficient to meet their remote learning needs, and we recognize that they are making such decisions in the midst of a pandemic. We, therefore, will not impose any specific metrics or process requirements on those determinations.? And from question 53: ??we are sensitive to the need to provide some flexibility during this uncertain time. If those connected devices were purchased for the purpose of providing students?with devices for off-campus use consistent with the rules we adopt today, we will not prohibit such on-campus use.? Anticipated date to complete the corrective action: We will work with the FCC to resolve this issue according to their timeline.
View Audit 40903 Questioned Costs: $1
Management has noted this condition and has determined that the cost necessary to establish adequate segregation of duties is not justifiable at this time.
Management has noted this condition and has determined that the cost necessary to establish adequate segregation of duties is not justifiable at this time.
FINDING - FEDERAL AWARD PROGRAMS AUDIT United States Department of the Treasury 2022-001 COVID-19 American Rescue Plan Act Local Fiscal Recovery ? AL No. 21.027 Recommendation: We recommend that the Town implement a control for the Project and Expenditure Report to be reviewed by an individual ind...
FINDING - FEDERAL AWARD PROGRAMS AUDIT United States Department of the Treasury 2022-001 COVID-19 American Rescue Plan Act Local Fiscal Recovery ? AL No. 21.027 Recommendation: We recommend that the Town implement a control for the Project and Expenditure Report to be reviewed by an individual independent of the preparation process prior to submission to the Treasury. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management agrees with this finding. Management further notes that a two-step review process has been implemented where the Controller will review the documents sign-off before the Finance Directors submits them through the State portal. The of the contact person responsible for corrective action: Sheila Carey Planned completion date for corrective action plan: March 30, 2023.
Finding 2022-001 Contact Person: Shari Reese Completion Date: March 13, 2023 Managements Response: Reporting Period 1: During Reporting Period 1, several subsidiaries of CaroMont Health, Inc. (?Parent?) received general distributions from the CARES Act Provider Relief Fund (?PRF?). Management ...
Finding 2022-001 Contact Person: Shari Reese Completion Date: March 13, 2023 Managements Response: Reporting Period 1: During Reporting Period 1, several subsidiaries of CaroMont Health, Inc. (?Parent?) received general distributions from the CARES Act Provider Relief Fund (?PRF?). Management reported all the general distributions received by the subsidiaries under the Parent entity in the portal, including the general distributions received by CaroMont Regional Medical Center (?Hospital?). Management listed the TINS of the subsidiaries, including the Hospital, in the Subsidiary Data section in the Parent?s portal. Management reported lost revenues utilizing option i, 2019 Actual Revenues, for the subsidiaries in the Parent?s portal. Reporting Period 2: During Reporting Period 2, the Hospital received both general and a targeted distributions (High Impact Area) from the CARES Act PRF. Management was unsure how to report so it contacted the HRSA Provider Support Line. HRSA opened case #00025470 and on January 18, 2022, Management had a phone conference with a representative of HRSA to discuss Period 2 reporting. HRSA advised management to report as follows: ? Hospital ? report the targeted distribution. Only report revenue, expenses, and data for the Hospital. ? Parent ? report general distributions. Don?t change any numbers from Period 1. Report revenue, expenses, and data for all subsidiary TINS listed in the portal. Management specifically remembers explaining to the HRSA representative that this approach would result in double counting of Total Unused Lost Revenues because Hospital revenues would be reported in both portals. The HRSA representative said that would be okay because Management answered YES to ?Is the parent entity reporting on your General Distribution payments?? in the Hospital portal, because the Hospital?s TIN is listed in the Subsidiary Information section in the Parent?s portal, and because the Parent?s TIN is listed in the Subsidiary Questionnaire section in the Hospital?s portal. Management documented these instructions in their notes made during the call. Management also specifically remembers asking the HRSA representative if the Hospital revenue should be removed from the prior quarters in the Parent portal when reporting Period 2 to which the representative replied, ?don?t change any numbers?. Management documented these instructions in their notes made during the call. Management filed the Period 2 reports for the Parent and the Hospital in accordance with HRSA?s instructions received during this phone conference. Management reported lost revenues under option i, 2019 Actual Revenues, for the listed subsidiaries in the Parent portal and for the Hospital in the Hospital portal. However, since Management was concerned this approach would result in double counting of unused lost revenues, they created a reconciliation spreadsheet on February 1, 2022. This spreadsheet documented unused lost revenues from the PRF Financial Reporting Summary Reporting pages in the Parent and Hospital portals for Period 1 and Period 2 and calculated the correct total unused lost revenues when the reports were combined and the double counting was eliminated. Management?s intent was to update this reconciliation during Period 4 reporting to ensure the remaining unused lost revenues in both the Parent and Hospital portals exceeded the combined reconciled lost revenue ? thereby ensuring there would be no double counting of lost revenues after all PRF reporting was completed. Reporting Period 4: During Report Period 4, several subsidiaries of the Parent received general distributions from the CARES Act PRF and targeted distributions from the American Rescue Plan (?ARP?). By the time the Portal Reporting opened for Period 4, CaroMont?s auditors were conducting the Single Audit for the year ended June 30, 2022, and reached out to Management to discuss their concerns about potential double counting of lost revenues in the Period 2 portal reporting. Management explained their process for reporting Period 2 and shared with the auditors their reconciliation spreadsheet that was created on February 1, 2022. The auditors had also performed a reconciliation that resulted in the same outcome. The auditors and management subsequently had several discussions on the different alternatives available to correct the Period 2 overstatement. Management evaluated the alternatives and ultimately decided to change its calculation of Lost Revenues in the Parent portal for Period 4 from option i, 2019 Actual Revenue, to option iii, Alternative Method of Calculating Lost Revenues Attributable to COVID-19. However, management continued to report lost revenues in the Hospital portal for Period 4 utilizing option i, 2019 Actual Revenue, as it had in Period 2. Management created another reconciliation spreadsheet on February 23, 2023 that demonstrated the Hospital revenue was excluded from the Parent?s lost revenue calculations in Period 4. This spreadsheet was uploaded as supporting documentation for option iii in the Parent?s portal. By changing from option i to option iii for lost revenues in the Parent portal for Period 4, management corrected the overstatement of lost revenues identified in the Audit of Federal Awards Performed in Accordance with U.S. Office of Management and Budget Uniform Guidance for the year ended June 30, 2022.
The District concurs and will review current year?s indirect rates for ESSER reimbursements.
The District concurs and will review current year?s indirect rates for ESSER reimbursements.
View Audit 41236 Questioned Costs: $1
Name of Contact Person(s) Responsible for Corrective Action: Jaime Allen, Chief Financial Officer Training: Retrain staff on sliding fee policy procedures to ensure (1) income is properly verified, adequately documented and retained and (2) the sliding fee discount is properly determined and applied...
Name of Contact Person(s) Responsible for Corrective Action: Jaime Allen, Chief Financial Officer Training: Retrain staff on sliding fee policy procedures to ensure (1) income is properly verified, adequately documented and retained and (2) the sliding fee discount is properly determined and applied. All new Front Office staff will receive sliding fee program training as part of their 4-day front office training during onboarding. By Feb 28, 2022, the Front Office Trainer will review documentation requirements around sliding fee scale for patients, including checking applications for completion and making sure the sliding fee applied is being correctly calculated by all Front Office Leads, Supervisors and Center Managers. By Mar 2, 2022, the Front Office Trainer will help create a front office compliance checklist to review front office procedures around documentation, insurance, sliding fees and other programs. Sliding Fee Annual Update: The Revenue Cycle Director will notify the Applications Team and Front Office trainer each year when the sliding fee scale has been updated. The Applications Team will update the UDS table and map to the calculator in the EHR. The Front Officer trainer will review sliding fee updates on an annual basis update trainings with front office staff and within thirty days of notification of any sliding fee policy revisions. Internal Audit: An additional level of review will be added to the process to ensure program compliance. The Revenue Cycle Director will create and document a sliding fee scale internal audit process that will be performed monthly. When the audit is performed, findings will be reported to the following: General Counsel & Compliance Officer, Chief Financial Officer, Chief Operating Officer, Front Officer Trainer, Center Manager, and lead/supervisors. Front Office Trainers will work closely with Center Managers, Leads and Supervisors to ensure that ongoing compliance on sliding fees are met based on internal audit findings. Refresher trainings to staff will be provided based on patterns determined by internal audit findings. This process was implemented on March 2, 2022. Anticipated Completion Date: March 2, 2022
Finding 2022-002 ? REPORTING Type: Significant Deficiency in Internal Control! Noncompliance ? Reporting Program: Child Nutrition Cluster (ALN 10.553, 10.555 and 10.559) Condition: Meals claimed were not supported by count sheets for lunch for one of the two months meals were tested. Criteria: The D...
Finding 2022-002 ? REPORTING Type: Significant Deficiency in Internal Control! Noncompliance ? Reporting Program: Child Nutrition Cluster (ALN 10.553, 10.555 and 10.559) Condition: Meals claimed were not supported by count sheets for lunch for one of the two months meals were tested. Criteria: The District is required to claim meals served, by category, based on reports provided from individual meal serve counts. Cause: This condition was caused by an insufficient internal control process for comparison of supporting documentation of meal counts to meal claims. Effect: Based on a comparison of meals claimed to reports provided from individual meal serve counts, the District has underclaimed reimbursement for the year by an immaterial amount. Questioned Costs: None. Recommendation: We recommend that the District review their process of meal claims and make necessary changes to ensure that all meals claimed, by category, agree to supporting documentation. Corrective Action Plan: Shepherd Public Schools Food Service Department will implement internal control review process to ensure that individual meal serve counts match identically the meals claimed by reviewing original count sheets at the time of certification of meal claims. Either the food service director or assigned designee will verify counts at the end of each month. This internal control review process will begin effective with the October 2022 claims report.
Finding 2022-001 ? EXCESS FUND BALANCE IN FOOD SERVICE FUND Type: Material Weakness in Internal Control / Noncompliance ? Special Tests and Provisions Program: Child Nutrition Cluster (ALN 10.553, 10.555 and 10.559) Condition: As of year-end the District had a fund balance in the non-profit food ser...
Finding 2022-001 ? EXCESS FUND BALANCE IN FOOD SERVICE FUND Type: Material Weakness in Internal Control / Noncompliance ? Special Tests and Provisions Program: Child Nutrition Cluster (ALN 10.553, 10.555 and 10.559) Condition: As of year-end the District had a fund balance in the non-profit food service fund in excess of three months' operating expenses by approximately $165,196. Criteria: The USDA requires that the District limit its net cash resources to an amount that does not exceed 3 months average expenditures of the nan-profit food service fund per requirements in 7 CFR Part 210. 14(b). Cause: This condition was caused by the meal claims increasing and having more reimbursements come in than anticipated. Effect: The District will be required to develop a spending plan for reducing the balance to an acceptable level during the following school year. The plan must be submitted to MDE, Office of School Support Services, for prior approval. Recommendation: We recommend that the District develop a spending plan as required by MDE, and submit the plan at their earliest convenience. Corrective Action Plan: Shepherd Public Schools will work with MDE to create a spenddown plan to address the excess fund balance in the food service fund. This plan will include allowable equipment upgrades and replacements to be crafted in collaboration with the food service director, district business manager and superintendent, as well as any other members deemed appropriate by superintendent. The process of creating the plan is expected to begin immediately, with compliance of 7CFR Part 210.14(b) to be met no later than June 30, 2023.
Finding 46161 (2022-006)
Significant Deficiency 2022
U.S. Department of Health and Human Services and Wisconsin Department of Health Services (DHS) 2022-006 WIMCR Reporting Medical Assistance Program ? Assistance Listing No. 93.778 Recommendation: CLA recommends the County develop and implement a process to require review and approval of the WIMCR re...
U.S. Department of Health and Human Services and Wisconsin Department of Health Services (DHS) 2022-006 WIMCR Reporting Medical Assistance Program ? Assistance Listing No. 93.778 Recommendation: CLA recommends the County develop and implement a process to require review and approval of the WIMCR reports prior to the submission of the report to the state to help ensure that the data reported are accurate, complete and supporting documentation is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Annual WIMCR reporting to be completed by Waushara County DHS Finance team; Financial Manager and/or Financial Assistant. If both positions are fully employed both positions need to review and sign off on data prior to submission. If one of the positions is vacant a second review of data and sign-off needs to be done by someone else within DHS ? likely the DHS Director. Name(s) of the contact person(s) responsible for corrective action: Peder Culver, Finance Manager, Clara Voigtlander, DHS Director Planned completion date for corrective action plan: 2022 WIMCR has been submitted. Action plan will be in place for 2023 reporting or sooner, if 2022 WIMCR is re-opened.
Familiarize staff with financial reporting requirements and segregate duties to the extent possible. The cost of training or adding personnel will be considered, if cost effective.
Familiarize staff with financial reporting requirements and segregate duties to the extent possible. The cost of training or adding personnel will be considered, if cost effective.
Finding 46135 (2022-001)
Significant Deficiency 2022
Management Response: We acknowledge the finding and provide the following corrective action plan. Corrective Action Plan: VillageReach has reallocated questioned costs and these are correctly reflected in FY22 audited financials. VillageReach will update and implement internal audit procedures. Vil...
Management Response: We acknowledge the finding and provide the following corrective action plan. Corrective Action Plan: VillageReach has reallocated questioned costs and these are correctly reflected in FY22 audited financials. VillageReach will update and implement internal audit procedures. VillageReach will continue to monitor compliance with data entry processes. In addition, VillageReach has retained external consultants for assistance with process improvements. Anticipated completion date: 1/23/23 Name(s) of the contact person(s) responsible for corrective action: Arin Ricchiuti, Controller and Ann Holmes, VP Global Operations
Finding 46134 (2022-004)
Significant Deficiency 2022
2022-004 SPECIAL PROVISIONS Medical Assistance Program ? Assistance Listing No. 93.778 Recommendation: We recommend that the County enact policies to ensure that Collaborative reports are reviewed prior to submission in a timely manner. Explanation of disagreement with audit finding: There is no dis...
2022-004 SPECIAL PROVISIONS Medical Assistance Program ? Assistance Listing No. 93.778 Recommendation: We recommend that the County enact policies to ensure that Collaborative reports are reviewed prior to submission in a timely manner. 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 ensure that all reports are reviewed prior to submission. Name of the contact person responsible for corrective action: Pat Paquin, Finance Manager Planned completion date for corrective action plan: December 31, 2023
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