Corrective Action Plans

Finding 46205 (2022-044)

Significant Deficiency 2022

WV

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

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.

View Audit 40967

Finding 46204 (2022-001)

Material Weakness 2022

State of West Virginia

WV

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

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.

View Audit 40967

Finding 46195 (2022-001)

Material Weakness 2022

Chehalis School District No. 302

WA

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

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

View Audit 40903

Finding 46194 (2022-002)

Material Weakness 2022

Chehalis School District No. 302

WA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

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

Finding 46193 (2022-001)

Material Weakness 2022

Louisiana Human Resources Dev. Institute

LA

Internal Control / Segregation of Duties

Management has noted this condition and has determined that the cost necessary to establish adequate segregation of duties is not justifiable at this time.

View Audit 40865

Finding 46191 (2022-001)

Significant Deficiency 2022

Town of Westport, Conencticut

CT

Internal Control / Segregation of Duties Reporting Significant Deficiency

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.

View Audit 40828

Finding 46184 (2022-001)

Material Weakness 2022

Caromont Health, Inc.

NC

Allowable Costs / Cost Principles Material Weakness Reporting

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.

View Audit 41344

Finding 46182 (2022-002)

Significant Deficiency 2022

Cle Elum-Roslyn School District No. 404

WA

Questioned Costs Subrecipient Monitoring Internal Control / Segregation of Duties

The District concurs and will review current year?s indirect rates for ESSER reimbursements.

View Audit 41236 Questioned Costs: $1

Finding 46168 (2022-001)

Significant Deficiency 2022

Community Medical Centers, Inc.

CA

Subrecipient Monitoring Internal Control / Segregation of Duties

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

View Audit 41173

Finding 46163 (2022-002)

Significant Deficiency 2022

Shepherd Public School District

MI

Cash Management Reporting School Nutrition Programs

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.

View Audit 41016

Finding 46162 (2022-001)

Material Weakness 2022

Shepherd Public School District

MI

Cash Management School Nutrition Programs Material Weakness

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.

View Audit 41016

Finding 46161 (2022-006)

Significant Deficiency 2022

Waushara County

WI

Reporting Significant Deficiency Internal Control / Segregation of Duties

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.

View Audit 40814

Finding 46137 (2022-001)

Material Weakness 2022

Oglesby Esd No. 125

IL

Internal Control / Segregation of Duties Reporting

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.

View Audit 40647

Finding 46135 (2022-001)

Significant Deficiency 2022

Villagereach

WA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

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

View Audit 40696

Finding 46134 (2022-004)

Significant Deficiency 2022

Freeborn County

MN

Internal Control / Segregation of Duties Special Tests & Provisions Reporting § 200.303

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

View Audit 40299

Finding 46133 (2022-003)

Significant Deficiency 2022

Freeborn County

MN

Internal Control / Segregation of Duties Reporting Significant Deficiency § 200.303

2022-003 REPORTING Medical Assistance Program ? Assistance Listing No. 93.778 Recommendation: We recommend that the County enact policies to ensure that reports are reviewed prior to submission in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audi...

2022-003 REPORTING Medical Assistance Program ? Assistance Listing No. 93.778 Recommendation: We recommend that the County enact policies to ensure that 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. Names of the contact person responsible for corrective action: Pat Paquin, Finance Manager Planned completion date for corrective action plan: December 31, 2023

View Audit 40299

Finding 46124 (2022-002)

Material Weakness 2022

Otto-Eldred School District

PA

Internal Control / Segregation of Duties Cash Management

Adjusting Journal Entries, Required Disclosures and Draft Financial Statements Auditor?s Recommendation: Although auditors may continue to provide such assistance both now and, in the future, under the pronouncement, the District should continue to review and accept both proposed adjusting journal ...

Adjusting Journal Entries, Required Disclosures and Draft Financial Statements Auditor?s Recommendation: Although auditors may continue to provide such assistance both now and, in the future, under the pronouncement, the District should continue to review and accept both proposed adjusting journal entries and footnote disclosures, along with the draft financial statements. School District?s Response: Jodi Flexman, Business Manager, has received, reviewed and accepted all journal entries, footnote disclosures and draft financial statements proposed for the current year audit and will continue to review similar information for the year ending June 30, 2023 and in future years. Further, the District believes it has a thorough understanding of these financial statements and the ability to make informed judgments based on these financial statements.

View Audit 42070

Finding 46123 (2022-001)

None 2022

Milestone Recovery and Subsidiaries

ME

Reporting Internal Control / Segregation of Duties

Views of responsible officials and planned corrective action: We are in agreement with the finding. We are taking steps to create an updated process to ensure compliance with this requirement moving forward.

View Audit 40960

Finding 46104 (2022-003)

Material Weakness 2022

Southwestern Wisconsin Community School District

WI

Material Weakness Reporting Internal Control / Segregation of Duties

Finding #2022-003- Material Adjustments Condition: Johnson Block and Company, Inc. proposed numerous adjusting journal entries. We deem these entries to be significant in relation to the financial statements. Since the District did not make these adjustments in its accounting system prior to the au...

Finding #2022-003- Material Adjustments Condition: Johnson Block and Company, Inc. proposed numerous adjusting journal entries. We deem these entries to be significant in relation to the financial statements. Since the District did not make these adjustments in its accounting system prior to the audit, a material weakness exists in the District?s internal controls. Effect: This means that the proper recording and reporting of financial information may not occur within a timely manner. Cause: Financial information was not recorded in a timely manner and material adjustments were needed in order to correct various transactions. Criteria: Material adjusting journal entries not prepared by the District before the audit are considered an internal control weakness. Recommendation: Policies and procedures should be implemented to ensure account balances are properly recorded in a timely manner. Response: The District will work to establish policies and procedures to reduce the number of adjusting journal entries proposed by the auditor. Contact Person: John Costello Anticipated Completion: June 30, 2023

View Audit 40958

Finding 46103 (2022-001)

Material Weakness 2022

Southwestern Wisconsin Community School District

WI

Internal Control / Segregation of Duties

Finding #2022-001 - Segregation of Duties Condition: The limited size of the District?s office staff prevents the ideal separation of functions. The bookkeeper prints accounts payable checks, has access to the password to print electronic signatures and performs bank reconciliations. The bookkee...

Finding #2022-001 - Segregation of Duties Condition: The limited size of the District?s office staff prevents the ideal separation of functions. The bookkeeper prints accounts payable checks, has access to the password to print electronic signatures and performs bank reconciliations. The bookkeeper also performed all payroll functions during 2021/22. Effect: Because of the lack of segregation of duties, errors or irregularities could occur and not be detected on a timely basis. Cause: Limited number of personnel. Criteria: Checks and balances should be in place to allow management or employees, in the normal course of performing their assigned functions, to prevent, or detect and correct any misstatements on a timely basis. Recommendation: Procedures should be implemented segregating duties among different employees. Management should continue to maintain a working knowledge of matters relating to the district?s operations. Response: We agree with this finding but do not believe it is cost effective to increase the office staff in an attempt to bring about a more effective segregation of duties. The Board reviews and approves all expenditures on a monthly basis prior to mailing accounts payable checks. Contact Person: John Costello Anticipated Completion: Ongoing.

View Audit 40958

Finding 46100 (2022-004)

Significant Deficiency 2022

Eastern New Mexico University

NM

Eligibility Significant Deficiency Internal Control / Segregation of Duties § 200.62

Corrective Action: A review of related GEAR UP grant processes and eligibility requirements for students currently involved in the programs will be conducted by June 30, 2023. Additionally, records and reviews of student participation in GEAR UP activities will be performed on a monthly basis. Tim...

Corrective Action: A review of related GEAR UP grant processes and eligibility requirements for students currently involved in the programs will be conducted by June 30, 2023. Additionally, records and reviews of student participation in GEAR UP activities will be performed on a monthly basis. Timeline of Corrective Action: The review of student participation will begin by November 30, 2022. Responsible Party(ies): GEAR UP Program Director; Roswell Campus

View Audit 41471

Finding 46088 (2022-001)

Significant Deficiency 2022

Village Cooperative of Greeley

CO

Internal Control / Segregation of Duties Significant Deficiency

Department of Housing and Urban Development HUD project FHA #101-23103 Village Cooperative of Greeley Federal ID# 81-5277495 The FASS system generated the following findings from its review of the August 31, 2022 financial statements. The results of the assessment are summarized below. The project o...

Department of Housing and Urban Development HUD project FHA #101-23103 Village Cooperative of Greeley Federal ID# 81-5277495 The FASS system generated the following findings from its review of the August 31, 2022 financial statements. The results of the assessment are summarized below. The project owner should provide their assigned HUD Project Manager a written response addressing each of the findings, and appropriate documentation (e.g. copies of cancelled checks, bank statements, etc.) to prove the finding has been resolved. Project Auditor Findings: The auditor reported the following findings: Compliance Oriented Findings. The Schedule of Findings and Questioned Costs by the auditor contained findings related to the following Auditor Indicator Codes: Finding Reference No. / Code - Finding Condition 2022-001 / S - Internal Control Deficiencies Corrective Action(s). For all audit findings that were unresolved as of the date of the audit report, the owner must provide their HUD Project Manager a written response and supporting documentation indicating the finding has been resolved. Corrective Action Plan: The

View Audit 40957

Finding 46085 (2022-004)

Significant Deficiency 2022

Wayne Public Schools

NE

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

Finding: 2022-004 Name of Contact Person: Dr. Mark Lenihan, Superintendent Corrective Action: The District relies on the auditor to propose adjustments necessary to prepare the schedule of expenditures of federal awards including the related note disclosures. The District reviews the schedule o...

Finding: 2022-004 Name of Contact Person: Dr. Mark Lenihan, Superintendent Corrective Action: The District relies on the auditor to propose adjustments necessary to prepare the schedule of expenditures of federal awards including the related note disclosures. The District reviews the schedule of expenditures of federal awards and approves all adjustments. Proposed Completion Date: Immediately

View Audit 41359

Finding 46080 (2022-001)

Material Weakness 2022

Hilltop Health Services Corporation

CO

Material Weakness Reporting Internal Control / Segregation of Duties § 200.303

Finding 2022-01 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Financial Assistance Listing #: 93.498 Finding Summary: We reported expenses reimbursed from other sources as Unreimb...

Finding 2022-01 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Financial Assistance Listing #: 93.498 Finding Summary: We reported expenses reimbursed from other sources as Unreimbursed Expenses Attributable to Coronavirus in the Period 2 Department of Health and Human Services (HHS) report. Additionally, due to a formula error, we omitted certain patient revenues in Q2 ? Q4 of 2021 - actual in the HHS Period 2 Report. These errors in reporting did not result in any questioned costs because we reported lost revenues attributable to the impact of the coronavirus well in excess of the funding received when using the corrected calculation. As a result, there were no questioned costs. Responsible Individuals: Carter Bair, CFO Corrective Action Plan: Management agrees that the reporting was in error for the Provider Relief Fund and American Rescue Plan. The issue arose due to some confusion in the instructions over Reimbursed and Un-Reimbursed funds. Though the reporting error did not affect the allowability of our expenses that were applied to these funds, it did affect the reporting. We have agreed that in the future we will have more than one individual reviewing the reimbursement rules and calculations used for reporting. Anticipated Completion Date: December 1, 2022

View Audit 40854

Finding 46078 (2022-003)

Material Weakness 2022

East River Legal Services Corporation

SD

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

Finding 2022-003 Federal Agency Name: Legal Services Corporation Program Name: LSC Basic Field Grant; LSC Technology Improvement Grant. CFDA#: 09-542026 Finding Summary: Total hours and LSC hours worked used to drive monthly allocation of indirect expenses by grant did not agree to total hours and ...

Finding 2022-003 Federal Agency Name: Legal Services Corporation Program Name: LSC Basic Field Grant; LSC Technology Improvement Grant. CFDA#: 09-542026 Finding Summary: Total hours and LSC hours worked used to drive monthly allocation of indirect expenses by grant did not agree to total hours and LSC hours worked in the Organization?s timekeeping software for eight of the twelve months. Additionally, one instance identified in which the rate of pay paid to an employee did not agree to the approved rate of pay. Responsible Individuals: Kathy Schroeder, 3rd party accountant, and Lea Wroblewski, Executive Director. Corrective Action Plan: Additional procedures are being followed to ensure that the timekeeping software is completed on a timely basis and locked down by the Executive Director or Technology Consultant when all entries have been made and reviewed. The time report used for the indirect expense allocations is not processed until the software is locked down. All changes to employees pay calculation are made after the submission of an approved Personnel Action Form is provided to the staff accountant. Each payroll is then reviewed by the Executive Director and a board member before processing. Completion Date: 06/30/2023

View Audit 40917

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