Corrective Action Plans

Finding 35390 (2022-003)

Significant Deficiency 2022

Heartland Community Health Clinic D/b/a Heartland Health Services

IL

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

2022-003 Health Centers Cluster ? Assistance Listing No. 93.224 and 93.527 Recommendation: Management should consider increasing the frequency of its self-reviews of patient encounters or expanding its sample sizes in addition to providing additional training for front desk staff regarding the col...

2022-003 Health Centers Cluster ? Assistance Listing No. 93.224 and 93.527 Recommendation: Management should consider increasing the frequency of its self-reviews of patient encounters or expanding its sample sizes in addition to providing additional training for front desk staff regarding the collection and verification of patient information for each patient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: 1) Expired sliding fee application Design, implement, and review a monthly report to ensure that the appropriate employees are making the Financial Assistance (FA) and Sliding Fee Discount Program adjustments. Every 2 months ? internal audits of FA and Self Pay patient accounts will be completed and documented. Additional training will be completed and documented for all Revenue Cycle Team members. We will review Discount Program along with Financial Assistance policies and procedures and discuss our financial policy related to ? Sliding Fee Scale. 2) Incorrectly assigned discount due to brief variation in sliding fee tables to expand the number of patients eligible to receive discounts. Heartland?s policies and procedures clearly reflect that the sliding fee scale discount program will only be extended to eligible patients up to 200% of the federal poverty guidelines. The Revenue Cycle Manager and CFO will ensure on a every 2-month basis that no slides will be given to ineligible patients based on income and family size. This monthly review will be documented, approved, and filed by fiscal year. Name(s) of the contact person(s) responsible for corrective action: Michael Cohlman, CFO and Katie Saucedo, Revenue Cycle Manager Planned completion date for corrective action plan: 4/1/23

View Audit 33693

Finding 35383 (2022-001)

Material Weakness 2022

Newport Consolidated Joint School District No. 56-415

WA

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

The District?s finding for not having adequate internal controls for ensuring compliance with wage rate requirements was solely because the district did not know about the federal requirement to monitor all certified payrolls paid by the contractors who provided the portable to the vendor the Distri...

The District?s finding for not having adequate internal controls for ensuring compliance with wage rate requirements was solely because the district did not know about the federal requirement to monitor all certified payrolls paid by the contractors who provided the portable to the vendor the District purchased from. Upon learning that the District is required to monitor certified payrolls paid by contractors and subcontractors who provide products to our vendors, the District will request certified payrolls from our vendors ensuring prevailing wages are paid from any corresponding contractor and subcontractor prior to final payment.

View Audit 31715

Finding 35380 (2022-001)

Significant Deficiency 2022

United Home for Aged Hebrews D/b/a United Hebrew Geriatric Center

NY

Reporting Internal Control / Segregation of Duties

We plan to hire a new individual in the Finance Department who is a level below myself and give the responsibility of the preparation of the PRF, so that I can be the reviewer of the PRF report to ensure that it is accurate.

View Audit 27701

Finding 35377 (2022-005)

Significant Deficiency 2022

Meeker County

MN

Eligibility Significant Deficiency Internal Control / Segregation of Duties

ELIGIBILITY Recommendation: The County should implement additional procedures to provide reasonable assurance that necessary documentation is properly input in MAXIS. Case file reviews should be performed. Explanation of disagreement with audit finding: There is no disagreement with the audit findin...

ELIGIBILITY Recommendation: The County should implement additional procedures to provide reasonable assurance that necessary documentation is properly input in MAXIS. Case file reviews should be performed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Supervisor will sample and perform a quality review on a quarterly basis to ensure case workers are accurately assessing eligibility. Review will be documented. Supervisor will review at least 1 casefile for each caseworker per quarter and randomly pull additional cases from new caseworkers. Name of the contact person responsible for corrective action: LoAnn Shepard, Eligibility Supervisor Planned completion date for corrective action plan: December 31, 2023

View Audit 26710

Finding 35369 (2022-004)

Significant Deficiency 2022

Edna Martin Christian Center, Inc.

IN

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

2022-004 Innovative Approaches to Literacy; Full-Service Community Schools; and Promise Neighborhoods ? Assistance Listing No. 84.215J Recommendation: We recommend that the organization review their policies and procedures surrounding federal grants administration and ensure a review process is in p...

2022-004 Innovative Approaches to Literacy; Full-Service Community Schools; and Promise Neighborhoods ? Assistance Listing No. 84.215J Recommendation: We recommend that the organization review their policies and procedures surrounding federal grants administration and ensure a review process is in place to ensure that all necessary compliance requirements are met and the organization?s records are complete to support all reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Grant Manager utilizes fluxx grant management system which documents all submission of grant reports and maintains documentation support. Finance as well has organized a filing system organized by department and then list accounting function as well as report assistance for grants. Name of the contact person responsible for corrective action: Anthony Conley Grant Manager / Compliance Specialist Planned completion date for corrective action plan: 12/31/2023

View Audit 24189

Finding 35367 (2022-002)

Significant Deficiency 2022

Edna Martin Christian Center, Inc.

IN

Internal Control / Segregation of Duties Reporting Significant Deficiency

2022-002 Segregation of Duties Recommendation: The organization should evaluate their financial reporting processes and controls, including the segregation of duties among its internal staff (including the number of internal staff), to determine whether additional controls over the financial reporti...

2022-002 Segregation of Duties Recommendation: The organization should evaluate their financial reporting processes and controls, including the segregation of duties among its internal staff (including the number of internal staff), to determine whether additional controls over the financial reporting function can be implemented to provide reasonable assurance that financial statements are prepared in accordance with U.S. GAAP. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Assemble a finance team and identify finance function roles for staffing and personnel. Name of the contact person responsible for corrective action: Sam Jones, Outsourced CFO Planned completion date for corrective action plan: 12/31/2023

View Audit 24189

Finding 35366 (2022-001)

Significant Deficiency 2022

Edna Martin Christian Center, Inc.

IN

Reporting Significant Deficiency Internal Control / Segregation of Duties

2022-001 Financial Statement Preparation and Adjusting Journal Entries Recommendation: The organization should evaluate their financial reporting processes and controls, including the expertise of its internal staff, to determine whether additional controls over the preparation of annual financial s...

2022-001 Financial Statement Preparation and Adjusting Journal Entries Recommendation: The organization should evaluate their financial reporting processes and controls, including the expertise of its internal staff, to determine whether additional controls over the preparation of annual financial statements can be implemented to provide reasonable assurance that financial statements are prepared in accordance with U.S. GAAP. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Assemble an accounting team with designated roles including expert experience and perform policy written period ending procedures on time to assure accuracy in the financial. Name of the contact person responsible for corrective action: Sam Jones, Outsourced CFO Planned completion date for corrective action plan: 12/31/2023

View Audit 24189

Finding 35365 (2022-001)

Material Weakness 2022

Black Hills Community Economic Development, Inc.

SD

Reporting Internal Control / Segregation of Duties

Finding No. 2022-001: Financial Statement and Schedule of Expenditures of Federal Awards (SEFA) Preparation Responsible Individuals: Fran White, Executive Director Corrective Action Plan: The Organization has accepted the risk associated with the finding regarding the preparation of the financial st...

Finding No. 2022-001: Financial Statement and Schedule of Expenditures of Federal Awards (SEFA) Preparation Responsible Individuals: Fran White, Executive Director Corrective Action Plan: The Organization has accepted the risk associated with the finding regarding the preparation of the financial statements, and will continue to have the independent auditor prepare the annual financial statements. Anticipated Completion Date: Ongoing

View Audit 23946

Finding 35364 (2022-006)

None 2022

United Way of Acadiana, INC

LA

Reporting Internal Control / Segregation of Duties

2022-006 Controls Over Reporting See Internal Control finding 2022-004.

View Audit 24188

Finding 35360 (2022-005)

None 2022

United Way of Acadiana, INC

LA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

2022-005 Controls Over Activities Allowed/Allowable Costs See Internal Control finding 2022-003.

View Audit 24188

Finding 35359 (2022-003)

Material Weakness 2022

United Way of Acadiana, INC

LA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

2022-003 Controls Over Activities Allowed/Allowable Costs Recommendation: The Organization should review their established policies and procedures for effectiveness and ensure all employees adhere to all established procedures. Additionally, management should ensure all costs charged to the progr...

2022-003 Controls Over Activities Allowed/Allowable Costs Recommendation: The Organization should review their established policies and procedures for effectiveness and ensure all employees adhere to all established procedures. Additionally, management should ensure all costs charged to the program are allowable under the grant guidelines. Corrective Action Plan: United Way of Acadiana has welcomed a new Finance Director with experience in establishing internal controls. We are committed to implementing comprehensive internal controls that encompass enhancing financial reporting processes to ensure accuracy, transparency, and compliance with regulatory standards; budget oversight, risk management and expenditure and cash flow management.

View Audit 24188

Finding 35356 (2022-003)

Significant Deficiency 2022

Boys & Girls Clubs of Central Florida, Inc.

FL

Internal Control / Segregation of Duties § 200.403 § 200.430

Management is in agreement with this finding and was aware of the Organization?s manual process to approve and store physical copies of pay rate approval, which could potentially create risk of losing physical copies. In September 2022, the Organization has modified this process to allow managers to...

Management is in agreement with this finding and was aware of the Organization?s manual process to approve and store physical copies of pay rate approval, which could potentially create risk of losing physical copies. In September 2022, the Organization has modified this process to allow managers to virtually approve and store digital copies of pay rate documentation.

View Audit 23844

Finding 35355 (2022-002)

Material Weakness 2022

Agency for Substance Abuse Prevention, Inc.

AL

Reporting Internal Control / Segregation of Duties

Material Adjustments Description of Finding: The auditor found that The Entity relied on auditors to propose entries after audit procedures and had not recorded entries needed at the time of the audit. Statement of Concurrence or Nonconcurrence: Management concurs with this finding. Corrective ...

Material Adjustments Description of Finding: The auditor found that The Entity relied on auditors to propose entries after audit procedures and had not recorded entries needed at the time of the audit. Statement of Concurrence or Nonconcurrence: Management concurs with this finding. Corrective Action: During the fiscal year ending September 30, 2022, the Entity employed the services of an experienced contract accountant. Performance was evaluated regularly and the decision was made to terminate her services for inadequate performance and a new accountant was hired internally. Management has provided training to the new accountant and has coordinate processes with external auditor to insure accurate interim reporting in the future. The Entity will continue to incorporate financial reporting internal controls to detect material adjustments, prevent materially misstated financial statements, and increase the accuracy of interim financial reports used by management.

View Audit 29962

Finding 35354 (2022-001)

Material Weakness 2022

Agency for Substance Abuse Prevention, Inc.

AL

Internal Control / Segregation of Duties Reporting Subrecipient Monitoring

Segregation of Duties: Description of Finding: The auditor found that duties were not segregated in a number of areas where small adjustments to the policies of the Entity could help to further facilitate this important control. Statement of Concurrence or Nonconcurrence: Management concurs with...

Segregation of Duties: Description of Finding: The auditor found that duties were not segregated in a number of areas where small adjustments to the policies of the Entity could help to further facilitate this important control. Statement of Concurrence or Nonconcurrence: Management concurs with this finding. Corrective Action: Management has issued written policies and required training of all employees that handle financial transactions and will continually evaluate processes to find ways to segregate duties where possible. Management and the board of directors will continue to oversee operations closely requiring approvals for all transactions.

View Audit 29962

Finding 35342 (2022-002)

Significant Deficiency 2022

Marshfield Clinic Health System, Inc.

WI

Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.303

Finding 2022-002 Name of Contact Person: Debra Hansen, Accounting Manager ? Grants and Gifts Corrective Action Plan: Effective May 2023, MMC ? Dickinson converted to the MCHS, Inc accounting systems and its accounting staff fully joined the MCHS, Inc centralized accounting team by August 2023, su...

Finding 2022-002 Name of Contact Person: Debra Hansen, Accounting Manager ? Grants and Gifts Corrective Action Plan: Effective May 2023, MMC ? Dickinson converted to the MCHS, Inc accounting systems and its accounting staff fully joined the MCHS, Inc centralized accounting team by August 2023, such that the MCHS system of controls now extend to MMC-Dickinson. Specifically with these changes, grant accounting duties are also transitioning to the MCHS grant accounting team which extends MCHS system of controls over grant accounting to MMC-Dickinson to ensure accurate and timely completion of the Schedule. Proposed Completion Date: December 31, 2023

View Audit 24187

Finding 35341 (2022-003)

Significant Deficiency 2022

Marshfield Clinic Health System, Inc.

WI

Subrecipient Monitoring Significant Deficiency Matching / Level of Effort / Earmarking

Finding 2022-003 Name of Contact Person: Debra Hansen, Accounting Manager ? Grants and Gifts Corrective Action Plan: Effective May 2023, MMC ? Dickinson converted to the MCHS, Inc accounting systems and its accounting staff fully joined the MCHS, Inc centralized accounting team by August 2023, such...

Finding 2022-003 Name of Contact Person: Debra Hansen, Accounting Manager ? Grants and Gifts Corrective Action Plan: Effective May 2023, MMC ? Dickinson converted to the MCHS, Inc accounting systems and its accounting staff fully joined the MCHS, Inc centralized accounting team by August 2023, such that the MCHS system of controls now extend to MMC-Dickinson. With these changes, the MCHS Treasury department will include MMC-Dickinson and this debt in their system of controls and processes which includes monitoring the debt and related reserve accounts for compliance with debt service reserve requirements. Proposed Completion Date: December 31, 2023

View Audit 24187

Finding 35340 (2022-004)

Significant Deficiency 2022

Marshfield Clinic Health System, Inc.

WI

Questioned Costs Allowable Costs / Cost Principles Eligibility § 200.303

Finding 2022-004 Name of Contact Person: Dan Fischer, Internal Consultant (former Controller) Corrective Action Plan: In early 2022, the team calculating physician compensation costs eligible for reporting in the HRSA portal experienced turnover of staff and thorough review of new staff?s work wa...

Finding 2022-004 Name of Contact Person: Dan Fischer, Internal Consultant (former Controller) Corrective Action Plan: In early 2022, the team calculating physician compensation costs eligible for reporting in the HRSA portal experienced turnover of staff and thorough review of new staff?s work was not completed for several months. Although expenses were overstated in the portal, the grant was not overcharged as lower expenses reported for physician compensation costs would have been replaced by increasing the amount related to additional eligible lost revenues. Management will implement review procedures for eligible physician compensation costs to ensure expenditures to the portal are accurate. Proposed Completion Date: December 31, 2023

View Audit 24187 Questioned Costs: $1

Finding 35327 (2022-003)

Significant Deficiency 2022

Pennsauken Lutheran Housing, INC

NJ

Subrecipient Monitoring Eligibility HUD Housing Programs

Planned Corrective Actions: We will re-enforce the use of the mov in/recertification file checklist as a tool for project managers to utilize. We will also conduct at a minimum, semiannual in-house refresher sessions. In addition, we will conduct file reviews for move ins and perform random file aud...

Planned Corrective Actions: We will re-enforce the use of the mov in/recertification file checklist as a tool for project managers to utilize. We will also conduct at a minimum, semiannual in-house refresher sessions. In addition, we will conduct file reviews for move ins and perform random file audits on annual recertifications.

View Audit 24060

Finding 35322 (2022-002)

Material Weakness 2022

Sweeny Hospital District

TX

Allowable Costs / Cost Principles Reporting Internal Control / Segregation of Duties

We are in receipt of the findings required to be reported by the single audit for Period 2 and Period 3 reporting for payments received from the Provider Relief Fund (PRF), specifically, regarding discrepancies in the reporting requirements and auditing for the above period for the PRF. Management d...

We are in receipt of the findings required to be reported by the single audit for Period 2 and Period 3 reporting for payments received from the Provider Relief Fund (PRF), specifically, regarding discrepancies in the reporting requirements and auditing for the above period for the PRF. Management does not dispute the finding. Subsequent to the completion of the FY 2021 single audit and the completion of reporting for periods 2 and 3, the district has prioritized the development of policies over financial reporting processes for all future periods of PRF reporting and auditing. The district will perform detailed analysis of the reporting requirements in accordance with the guidelines set forth by HRSA. The hospital CEO, Kelly Park, will oversee this to ensure that this is accomplished. The district will also provide its? consultants and information to be submitted to HRSA for accuracy. The district has already implemented these new procedures for period 4 reporting, and is confident that all future submissions will be correct. The Corrective Action Plan will be implemented by September 30, 2023.

View Audit 24008

Finding 35285 (2022-001)

Significant Deficiency 2022

City of Kearney, Nebraska

NE

Internal Control / Segregation of Duties Reporting Significant Deficiency

Planned Corrective Action: It is cost prohibitive for the City of Kearney to hire sufficient personnel in order to assign responsibilities in such a way that different employees handle different portions of a transaction. However, the City of Kearney will evaluate the distribution of duties to cur...

Planned Corrective Action: It is cost prohibitive for the City of Kearney to hire sufficient personnel in order to assign responsibilities in such a way that different employees handle different portions of a transaction. However, the City of Kearney will evaluate the distribution of duties to current employees and closely monitor all accounting functions.

View Audit 24775

Finding 35284 (2022-001)

Significant Deficiency 2022

Aspirus, Inc.

WI

Internal Control / Segregation of Duties Cash Management Eligibility

Response: At the time of sending the claim to HRSA the patient did not have other insurance coverage. Subsequently we received information that the patient had other coverage. This information was received by the Financial Clearance department but there was a lack of communication to the Credit Ba...

Response: At the time of sending the claim to HRSA the patient did not have other insurance coverage. Subsequently we received information that the patient had other coverage. This information was received by the Financial Clearance department but there was a lack of communication to the Credit Balance Manager as provided for in our process. Although the Credit Balance team would have found and refunded the money to HRSA after the other insurance paid through their normal credit review process, this was not yet completed at the time of the audit. There is an opportunity to increase the timeliness of the refunding process as addressed in our action plan. Corrective Action Plan: ? Refund HRSA for overpayments found during audit ? Completed on 3/13/2023 and 3/15/2023, respectively. ? Reeducation to Financial Clearance team to notify Credit Balance Manager of change of coverage for HRSA accounts as soon as receive information. ? Education and process change with Initial Claims Team, who also reviews coverage changes, to notify Credit Balance Manager of change of coverage for HRSA accounts as soon as they receive. ? Explore Epic build to route accounts with HRSA coverage change to a Credit Balance WQ to be promptly worked.

View Audit 24698

Finding 35246 (2022-001)

Significant Deficiency 2022

Durand Community Unit School District No. 322

IL

Internal Control / Segregation of Duties

The district will continue to have a second individual review all monthly bank statements, reconciliations, and treasurer's reports. The district will designate someone besides the Treasurer to review accounts payable checks prior to mailing them and stamp them with the Superintendent's signature so...

The district will continue to have a second individual review all monthly bank statements, reconciliations, and treasurer's reports. The district will designate someone besides the Treasurer to review accounts payable checks prior to mailing them and stamp them with the Superintendent's signature so there will be two signatures required on all accounts payable checks. See full Corrective Action Plan on district letterhead.

View Audit 24136

Finding 35227 (2022-003)

Material Weakness 2022

Southeastern Cusd #337

IL

Internal Control / Segregation of Duties Reporting

Condition: The District has one office personnel that is involved in the accounting function. Therefore, the District does not have an adequate segregation of duties over accounting transactions as the employee is responsible for initiating and recording transactions in the general ledger as well...

Condition: The District has one office personnel that is involved in the accounting function. Therefore, the District does not have an adequate segregation of duties over accounting transactions as the employee is responsible for initiating and recording transactions in the general ledger as well as performing reconciliations. There were 2 errors in calculating payroll benefits charged to the grant that were not discovered and corrected by District personnel. Plan: Due to the small size of the District, it is not practical to hire additional personnel solely for the purpose of achieving an ideal segregation of duties over the accounting function. The Superintendent and the Board of Education will review and closely monitor the accounting information on a regular basis. Anticipated Date of Completion: Ongoing Name of Contact Person: D. Todd Fox, Superintendent Management Response: We agree with the finding.

View Audit 30011

Finding 35226 (2022-001)

Significant Deficiency 2022

Be A Champion INC

TX

Significant Deficiency Internal Control / Segregation of Duties

Views of responsible officials and planned corrective action: The Organization agreed with the finding and implemented the recommended procedures.

View Audit 24609

Finding 35215 (2022-002)

Significant Deficiency 2022

Milwaukee Institute of Art and Design, Inc.

WI

Special Tests & Provisions Subrecipient Monitoring Significant Deficiency

Action Plan For the Year Ended May 31, 2022 Finding 2022-002 Section III ? Federal and State Awards Findings and Questioned Costs Assistance listing number(s), federal agency, and program name: 84.063, 84.007, 84.033, and 84.268; United States Department of Education (DOE), Student financial aid clu...

Action Plan For the Year Ended May 31, 2022 Finding 2022-002 Section III ? Federal and State Awards Findings and Questioned Costs Assistance listing number(s), federal agency, and program name: 84.063, 84.007, 84.033, and 84.268; United States Department of Education (DOE), Student financial aid cluster. Finding type: Noncompliance Criteria: The Institute is responsible for safeguarding sensitive data under the Gramm-Leach-Bliley Act, including performing a risk assessment that addresses three required areas noted in 16 CFR 314.4 (b). Statement of condition: A formal risk assessment is not documented which addresses required areas noted in 16 CFR 314.4 (b). Questioned costs: Questioned costs could not be determined. Context: The Institute has safeguards for each area identified within 16 CFR 314.4 (b) in place; however a formal risk assessment and documentation of the relevant safeguards implemented by the Institute to address the risks is not documented. Cause: There is no formal risk assessment documented. Effect: The Institute has no verifiable evidence of the risk assessment performed and the related safeguard for each risk identified. Recommendation: We recommend management review 16 CFR 314.4 (b) to perform a risk assessment that addresses the three required areas, which are (1) employee training and management; (2) information systems, including network and software design, as well as information processing, storage, transmission and disposal; and (3) detecting, preventing and responding to attacks, intrusions, or other systems failures. Management?s Response: Management agrees with the finding. Corrective Action: MIAD will review 16 CFR 314.4 (b) and develop a written Information Security Plan (ISP) that outlines the procedures and practices to protect non-public personal information (NPI) and manage information security risks. MIAD will provide routinely scheduled training to all current and new employees on the importance of protecting NPI and the procedures they must follow, to ensure that employees are up-to-date with the latest information security best practices. MIAD will continue to conduct regular risk assessments to identify potential security vulnerabilities, both internal and external, to evaluate the effectiveness of the ISP. MIAD will develop a plan to investigate and respond to security incidents that may compromise NPI. If an incident occurs MIAD will follow the ISP to remedy the incident, and revise the ISP as needed. Matt Ogden Director of Technology 414.847.3223 mattogden@miad.edu February 14th 2023

View Audit 24280

Corrective Action Plans

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