Corrective Action Plans

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U.S. Department of Housing and Urban Development – CFDA #14.872 Capital Fund Program – 2021 Procurement, Suspension and Debarment Significant Deficiency in Internal Control over Compliance Finding Summary: Testing indicated that the Authority had not retained documentation that they had performed a ...
U.S. Department of Housing and Urban Development – CFDA #14.872 Capital Fund Program – 2021 Procurement, Suspension and Debarment Significant Deficiency in Internal Control over Compliance Finding Summary: Testing indicated that the Authority had not retained documentation that they had performed a search for suspension or disbarment prior to entering into contracts with certain vendors. Responsible Individual: Steven Trujillo, Executive Director Corrective Action Plan: We have implemented a procedure, and a routing form, that now requires our Procurement Officer to indicate that they have performed a search for suspension or debarment prior to implementing a contract and they provide a document from Sam.Gov to verify their search. Anticipated Completion Date: January 2023
U.S. Department of Housing and Urban Development – CFDA #14.850 Public and Indian Housing – 2021 Special Tests and Provisions: Project-Based Budgeting and Accounting Material Weakness in Internal Control over Compliance Finding Summary: During testing, we identified several errors in how expenses we...
U.S. Department of Housing and Urban Development – CFDA #14.850 Public and Indian Housing – 2021 Special Tests and Provisions: Project-Based Budgeting and Accounting Material Weakness in Internal Control over Compliance Finding Summary: During testing, we identified several errors in how expenses were being charged and or allocated to the projects. In addition, there was insufficient documentation supporting how allocation methods were determined and there were no reviews of the allocation calculations by another individual. Responsible Individual: Steven Trujillo, Executive Director Corrective Action Plan: We agree that in 2021 expenses were not consistently allocated to our Public Housing Projects. However, we have now implemented consistent allocation methods so that expenses charged to our Public Housing projects will be reasonable and proper. We also review those allocation methods an a regular basis and change them as necessary. Anticipated Completion Date: January 2023
U.S. Department of Housing and Urban Development – CFDA #14.850 Public and Indian Housing – 2021 Eligibility Material Weakness in Internal Control over Compliance Finding Summary: Testing indicated that there was an error in a tenant’s rent calculation that was not detected by the Authority’s intern...
U.S. Department of Housing and Urban Development – CFDA #14.850 Public and Indian Housing – 2021 Eligibility Material Weakness in Internal Control over Compliance Finding Summary: Testing indicated that there was an error in a tenant’s rent calculation that was not detected by the Authority’s internal controls. In addition, there was no review of the rent calculation by another individual. Responsible Individual: Steven Trujillo, Executive Director Corrective Action Plan: We have implemented a process to ensure eligibility requirements are being followed and that another person reviews the rent calculations once they are determined. Anticipated Completion Date: January 2023
U.S. Department of Housing and Urban Development – CFDA #14.182/14.856 Section 8 Project-based Cluster– 2021 Eligibility Significant Deficiency in Internal Control over Compliance Finding Summary: The Authority could not find a tenant file from 2021. In addition, there was 1 participant file that di...
U.S. Department of Housing and Urban Development – CFDA #14.182/14.856 Section 8 Project-based Cluster– 2021 Eligibility Significant Deficiency in Internal Control over Compliance Finding Summary: The Authority could not find a tenant file from 2021. In addition, there was 1 participant file that did not have a signed HUD-50059 form that was signed by the participant or the Authority. Responsible Individual: Steven Trujillo, Executive Director Corrective Action Plan: We have established procedures to ensure that all files are maintained and that all forms are signed by both the tenant and the Authority. Anticipated Completion Date: January 2023
U.S. Department of Housing and Urban Development – CFDA #14.871 Section 8 Housing Choice Vouchers Special Test and Provisions – HQS Enforcement Material Weakness in Internal Control over Compliance and Material Instance of Non-Compliance Finding Summary: There was no documentation of a life-threaten...
U.S. Department of Housing and Urban Development – CFDA #14.871 Section 8 Housing Choice Vouchers Special Test and Provisions – HQS Enforcement Material Weakness in Internal Control over Compliance and Material Instance of Non-Compliance Finding Summary: There was no documentation of a life-threatening issue being resolved within 24 hours. There were 60 failed inspection reports tested and 13 instances where a life-threatening issue was identified and HACP did not have documentation that the issue was resolved within 24 hours as required. Responsible Individual: Steven Trujillo, Executive Director Corrective Action Plan: We have procedures in place that require follow up inspections and believe these issues were corrected, but the documentation was not obtained. The Housing Authority has implemented a process that requires proper documentation to be completed, after a failed inspection, to show that proper action was taken to correct the issue within the prescribed timeframe. Anticipate Completion Date: January 2023
Management Response: This finding has been corrected, management concur that in the past, we have been late in filing both our form 990 with the IRS and our Audit report with the Federal Audit Clearinghouse (FAC). For filing our 990 taxes return our tax year ends September 30, and with the submissio...
Management Response: This finding has been corrected, management concur that in the past, we have been late in filing both our form 990 with the IRS and our Audit report with the Federal Audit Clearinghouse (FAC). For filing our 990 taxes return our tax year ends September 30, and with the submission of this Audit we are current. Management has put in place procedures and processes to ensure that the return is filed in a timely manner. Gateway’s Board is regularly updated regarding the Audits and the 990 this is an effective business practice monthly documented meeting with the Board of Directors. Gateway Board of Directors are involved with the engagement of all Auditors, this has always been an active procedure and remains ongoing.
Management Response: The current policy will be reviewed for changes necessary to ensure compliance with Section 330(k)(3)(E), (F), and (G) of the PHS Act; and 42 CFR 51c.303(e), (f), and (g) and 42 CFR 56.303(e), (f), and (g). We concur that we did not write off the receivables from the subsidiary ...
Management Response: The current policy will be reviewed for changes necessary to ensure compliance with Section 330(k)(3)(E), (F), and (G) of the PHS Act; and 42 CFR 51c.303(e), (f), and (g) and 42 CFR 56.303(e), (f), and (g). We concur that we did not write off the receivables from the subsidiary ledger monthly, which will be reviewed as to the efficiency of monthly write-off, with any necessary changes. We did make a bad debt allowance for those write-offs in a timely manner, thus meeting the essence of our policy #PS-06 entitled Billing, Collection and Debt Write-off.
Management Response: Gateway Community Health Centers, Inc. has implemented all necessary new processes and procedures to ensure cash disbursements are properly authorized and approved, supported by appropriate documentation. Specifically, regarding the hiring of an onsite staff, the new Certified P...
Management Response: Gateway Community Health Centers, Inc. has implemented all necessary new processes and procedures to ensure cash disbursements are properly authorized and approved, supported by appropriate documentation. Specifically, regarding the hiring of an onsite staff, the new Certified Public Accountant (CPA) who was most recently hired is not an onsite staff, however he is skilled and has the expertise to provide oversight of the accounting processes and procedures. Gateway has hired adequate onsite staff to perform the accounting clerk tasks which are not performed by a Finance Officer. The health center determines its size and composition of staffing. The total number of staff to perform the duties is in place and adequate for a small\medium size health center. The CPA is onsite quarterly or more to do reviews and necessary departmental oversight. Staffing changes have been implemented to correct authorization and approvals of cash disbursements.
National Park Service Conservation, Protection, outreach, and Education – Assistance Listing No. 15.954 Recommendation: We recommend management review its current processes and procedures to ensure reports are submitted timely, reviewed, and ensure evidence is retained to support the compilation, r...
National Park Service Conservation, Protection, outreach, and Education – Assistance Listing No. 15.954 Recommendation: We recommend management review its current processes and procedures to ensure reports are submitted timely, reviewed, and ensure evidence is retained to support the compilation, review, and submission of the reports and ensure compliance with UG. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: As of the fall of fiscal year 2023, all Federal Reporting has been brought up to date. TAS now tracks all reporting due dates and requirements in a spreadsheet that is managed by our Program point person in conjunction with the finance staff to ensure both Project Performance Reports and Financial Reports are submitted by the federal due dates. Name(s) of the contact person(s) responsible for corrective action: Kim Lopez, Director of Finance & Operations, Erin Zylstra, Quantitative Ecologist Planned completion date for corrective action plan: COMPLETED
Finding # 2021-008 Utility Allowance Calculation Corrective Action Plan: When the new director, Robert Weismore, was hired on September 7, 2022, he replaced the former director and 3 staff members. In October he hired the current staff of Ms. Schaefer, Ms. Lynn. Ms. Filipski was hired as a part tim...
Finding # 2021-008 Utility Allowance Calculation Corrective Action Plan: When the new director, Robert Weismore, was hired on September 7, 2022, he replaced the former director and 3 staff members. In October he hired the current staff of Ms. Schaefer, Ms. Lynn. Ms. Filipski was hired as a part time employee in the middle of September 2022. For the next 2 months the staff reviewed each file and recalculated the figures using the correct payment standards for the necessary period and also used the September 1, 2022 approved utility schedule installed by the current staff. The recalculations caused the North Syracuse Housing Authority to reimburse $25,463 to previously miscalculated tenants. Also, had to repay HUD $23,000. The current payment standards are up to date and the current utility schedule was updated effective 7/1/2023 and will be updated effective 7/1/24 and each July thereafter.
Finding # 2021-004 Voucher Re-Examination Corrective Action Plan: Effective 11/1/2022 all recommendations are completed with up to 90 days notice to prospective tenant, with notification as the proper verification needed to complete the recert to completion. Notification is also sent to the owner o...
Finding # 2021-004 Voucher Re-Examination Corrective Action Plan: Effective 11/1/2022 all recommendations are completed with up to 90 days notice to prospective tenant, with notification as the proper verification needed to complete the recert to completion. Notification is also sent to the owner of the recertification. Once the proper verification is completed calculations are completed the tenant and owner are mailed an addendum stating new rental breakdown. The new current staff has between 10 and 15 years' experience completing recertifications. Please see item 2020-008 regarding utilities and payment standards.
Federal Award Finding: 2021-008 Material Weakness in Internal Control over Compliance and Nompliance - Reporting Requirements. Name and Contact Person: Pete Kelly, Chief Executive Officer. Corrective Action: The Fairbanks Rescue Mission's Board of Directors created a Finance Committee with extensiv...
Federal Award Finding: 2021-008 Material Weakness in Internal Control over Compliance and Nompliance - Reporting Requirements. Name and Contact Person: Pete Kelly, Chief Executive Officer. Corrective Action: The Fairbanks Rescue Mission's Board of Directors created a Finance Committee with extensive banking and accounting experience to create a higher level of scrutiny and oversite of the Missions finances. We contracted a professional accounting/bookkeeping firm {Midnight Sun Bookkeeping Services) and empowered them to establish procedures and practices consistent with GAAP {Generally Accepted Accounting Principles) as well as track and participate in day to day activities of Accounting; thereby, assuring accuracy of financial data and assuring compliance. We have formalized check writing, money handling, and credit card control procedures. Switched to an online time tracking system for employees and digitized all employee documents. Created an online filing system for all grant expenses Proposed Completion Date: January 01, 2024
View Audit 302911 Questioned Costs: $1
Federal Award Finding: 2021-007 Material Weakness in Internal Control over Compliance and Noncompliance - Eligibility Requirement. Name and Contact Person: Pete Kelly, Chief Executive Officer. Corrective Action: The Fairbanks Rescue Mission's Board of Directors created a Finance Committee with exte...
Federal Award Finding: 2021-007 Material Weakness in Internal Control over Compliance and Noncompliance - Eligibility Requirement. Name and Contact Person: Pete Kelly, Chief Executive Officer. Corrective Action: The Fairbanks Rescue Mission's Board of Directors created a Finance Committee with extensive banking and accounting experience to create a higher level of scrutiny and oversite of the Missions finances. We contracted a professional accounting/bookkeeping firm {Midnight Sun Bookkeeping Services) and empowered them to establish procedures and practices consistent with GAAP {Generally Accepted Accounting Principles) as well as track and participate in day to day activities of Accounting; thereby, assuring accuracy of financial data and assuring compliance. We have formalized check writing, money handling, and credit card control procedures. Switched to an online time tracking system for employees and digitized all employee documents. Created an online filing system for all grant expenses Proposed Completion Date: January 01, 2024
View Audit 302911 Questioned Costs: $1
Financial Statement and Federal Award Finding: 2021-005 Material Weakness in Internal Control over Financial Reporting and Compliance and Noncompliance -Allowable Costs/Cost Principles. Name and Contact Person: Pete Kelly, Chief Executive Officer. Corrective Action: The Fairbanks Rescue Mission's...
Financial Statement and Federal Award Finding: 2021-005 Material Weakness in Internal Control over Financial Reporting and Compliance and Noncompliance -Allowable Costs/Cost Principles. Name and Contact Person: Pete Kelly, Chief Executive Officer. Corrective Action: The Fairbanks Rescue Mission's Board of Directors created a Finance Committee with extensive banking and accounting experience to create a higher level of scrutiny and oversite of the Missions finances. We contracted a professional accounting/bookkeeping firm (Midnight Sun Bookkeeping Services) and empowered them to establish procedures and practices consistent with GAAP (Generally Accepted Accounting Principles) as well as track and participate in day to day activities of Accounting; thereby, assuring accuracy of financial data and assuring compliance. We have formalized check writing, money handling, and credit card control procedures. Switched to an online time tracking system for employees and digitized all employee documents. Created an online filing system for all grant expenses Proposed Completion Date: January 01, 2024
View Audit 302911 Questioned Costs: $1
Significant Deficiency in Internal Control over Compliance, Noncompliance – Reporting Name of Contact Person: Anita Andrews, Tribal Administrator Corrective Action Plan: As we continue to recover from the many set-backs over the past few years related to COVID-19 we will strive to ensure that ...
Significant Deficiency in Internal Control over Compliance, Noncompliance – Reporting Name of Contact Person: Anita Andrews, Tribal Administrator Corrective Action Plan: As we continue to recover from the many set-backs over the past few years related to COVID-19 we will strive to ensure that our future audits are completed in time to file the form SF-SAC within the required nine months of our fiscal year end (9/30). Our corrective action plan includes: - Closing the fiscal year books within 90 days after our fiscal year end (excluding any required adjusting journal entries that may be necessary). - Scheduling our audit to occur within 100 days after our fiscal year end. - Obtaining a final audit report prior to the end of June following our fiscal year end. Proposed Completion Date: We are anticipating that the completion date of the above corrective action plan will be for Fiscal Year 2023.
Contact Person: Timothy Evans Managements Response: Management had claimed pharmacy costs for drugs that were reimbursed by insurance plans. We incorrectly made an assumption that all drug related expenditures for treating the coronavirus virus were allowable expenditures. We have changed o...
Contact Person: Timothy Evans Managements Response: Management had claimed pharmacy costs for drugs that were reimbursed by insurance plans. We incorrectly made an assumption that all drug related expenditures for treating the coronavirus virus were allowable expenditures. We have changed our processes for inclusion of only expenditures that have not been reimbursed. Similarly we included costs of COVID testing expenditures however, some of those costs were either billed to patients or reimbursed from other sources. We have corrected that process also. Completion Date: January 2024.
View Audit 302889 Questioned Costs: $1
2021–006 Allowable Costs Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Program Cluster Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H80CS00233 – 20 Award Period: January 1, 2021 through December 31, 20...
2021–006 Allowable Costs Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Program Cluster Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H80CS00233 – 20 Award Period: January 1, 2021 through December 31, 2021 Type of Finding: • Significant Deficiency in Internal Control over Compliance • Other Matters Criteria or specific requirement: According to § 75.302 Financial management and standards for financial management systems of 45 CFR Part 75, the non-federal entity’s financial management systems, including records documenting compliance with federal statutes, regulations, and the terms and conditions of the federal award, must be sufficient to permit the preparation of reports required by general and program-specific terms and conditions. Further, the financial management system of each non-federal entity must provide accurate, current, and complete disclosure of the financial results of each federal award or program in accordance with the reporting requirements. According to § 75.303 Internal controls of 45 CFR Part 75, the non-federal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Condition: Documentation supporting allowable costs was not maintained by the Family Practice. Questioned costs: Unknown Context: During our testing of expenditures we noted two instances where payroll expenditures charged to the grant were not supported the by the employee’s approved wage rate. Recommendation: We recommend the Family Practice design controls and procedures to ensure the documentation and records required to support wage calculations are properly maintained in the files of the Family Practice. Cause: Management oversight. The Family Practice lacked established internal controls and procedures over financial grant management to ensure supporting records and documentation are properly maintained in the files of the Family Practice. Effect: Inability to support compliance with the grant and a potential loss of federal funding. Recommendation: We recommend the Family Practice design controls and procedures to ensure documentation is properly maintained in the files of the Family Practice. Views of responsible officials: There is no disagreement with the audit finding.
2021–005 Period of Performance Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Program Cluster Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H8ECS37958 Award Period: May 1, 2020 through May 31, 2021 Type...
2021–005 Period of Performance Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Program Cluster Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H8ECS37958 Award Period: May 1, 2020 through May 31, 2021 Type of Finding: • Material Weakness in Internal Control over Compliance • Other Matters (Modified Opinion) Criteria or specific requirement: According to § 75.302 Financial management and standards for financial management systems of 45 CFR Part 75, the non-federal entity’s financial management systems, including records documenting compliance with federal statutes, regulations, and the terms and conditions of the federal award, must be sufficient to permit the preparation of reports required by general and program-specific terms and conditions. Further, the financial management system of each non-federal entity must provide accurate, current, and complete disclosure of the financial results of each federal award or program in accordance with the reporting requirements. According to § 75.303 Internal controls of 45 CFR Part 75, the non-federal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Condition: CLA was unable to verify if the Family Practice is in compliance with period of performance. Questioned costs: Unknown Context: During our review expenditures for period of performance we noted expenditures were not supported by adequate records and documentation to facilitate testing. Recommendation: We recommend the Family Practice design controls and procedures to ensure the documentation and records required to identify expenses and the date incurred are properly maintained in the files of the Family Practice. Cause: Management oversight. The Family Practice lacked established internal controls and procedures over financial grant management to ensure supporting records and documentation are properly maintained in the files of the Family Practice. Effect: Inability to support compliance with the grant and a potential loss of federal funding. Recommendation: We recommend the Family Practice design controls and procedures to ensure documentation is properly maintained in the files of Family Practice. Views of responsible officials: There is no disagreement with the audit finding.
2021-004 Significant Deficiency - Cash Management Activities Recommendation: We recommend the Family Practice design controls and procedures to ensure the documentation and records are properly maintained in the files of the Family Practice. Explanation of disagreement with audit finding: There is ...
2021-004 Significant Deficiency - Cash Management Activities Recommendation: We recommend the Family Practice design controls and procedures to ensure the documentation and records are properly maintained in the files of the Family Practice. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Family Practice designed controls and procedures to ensure documentation and records are properly maintained in the files of the Family Practice. The CEO and CFO roles have been separated into two distinct positions. Separating the roles has significantly strengthened internal controls.. Furthermore, a controller has been hired to prepare the reports and oversee cash management activities. Name(s) of the contact person(s) responsible for corrective action: Amanda Blodgett, CEO Planned completion date for corrective action plan: March 11, 2024
2021-003 Material Weakness - Allowable and Unallowable Activities and Allowable Costs Recommendation: We recommend the Family Practice design controls and procedures to ensure submitted reports and the documentation used to prepare the reports are properly maintained in the files of the Family Pract...
2021-003 Material Weakness - Allowable and Unallowable Activities and Allowable Costs Recommendation: We recommend the Family Practice design controls and procedures to ensure submitted reports and the documentation used to prepare the reports are properly maintained in the files of the Family Practice. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Family Practice designed controls and procedures to ensure submitted reports and the documentation used to prepare the reports are properly maintained in the files of the Family Practice. The CEO and CFO roles have been separated into two distinct positions. Separating the roles has significantly strengthened internal controls. Furthermore, a controller has been hired to prepare the reports and maintain appropriate and complete supporting documentation, which will then be reviewed by the CFO and CEO before submission. Name(s) of the contact person(s) responsible for corrective action: Amanda Blodgett, CEO Planned completion date for corrective action plan: December 31, 2024
Management will continue to allow the audit firm to create the draft financial statements and related footnote disclosures, and will review and approve these prior to the issuance of the annual financial statements.
Management will continue to allow the audit firm to create the draft financial statements and related footnote disclosures, and will review and approve these prior to the issuance of the annual financial statements.
Finding 2021-002 a. Comments on the Finding and Each Recommendation: We concur with the finding and agree with the recommendations. b. Action(s) Taken or Planned on the Finding In response to this finding regarding non-compliance in Housing Quality Standards (HQS) enforcement, the new management tea...
Finding 2021-002 a. Comments on the Finding and Each Recommendation: We concur with the finding and agree with the recommendations. b. Action(s) Taken or Planned on the Finding In response to this finding regarding non-compliance in Housing Quality Standards (HQS) enforcement, the new management team at the Authority has developed a focused corrective action plan. This plan includes comprehensive staff training on HUD regulations and HQS compliance, with a completion target of March 2024. Concurrently, our CEO and Director of Programs Administration will oversee the revision and implementation of enhanced HQS monitoring procedures, aiming for completion by March 2024. This involves updating inspection protocols, instituting regular internal audits for compliance, and establishing clear procedures for re-inspections, HAP abatement, and voucher cancellations. Recognizing the oversight of the previous management, the new team is committed to rectifying these issues and ensuring ongoing compliance. We will maintain thorough documentation of all actions taken and provide regular updates on the progress. The HCV Coordinator will be responsible for ongoing compliance monitoring and reporting, ensuring that the program adheres to HUD's Housing Quality Standards and effectively serves its participants. This approach reaffirms our dedication to upholding the integrity and effectiveness of the Housing Voucher Cluster programs.
Condition and Context: The System did not complete the PRF Period 1 reporting in accordance with the U.S. Department of Health and Human Services guidance. The System did not enter the correct amounts from its data supporting lost revenues for all quarters; it also did not enter the correct amounts ...
Condition and Context: The System did not complete the PRF Period 1 reporting in accordance with the U.S. Department of Health and Human Services guidance. The System did not enter the correct amounts from its data supporting lost revenues for all quarters; it also did not enter the correct amounts from its data supporting eligible expenditures. The adjustments needed within the PRF reports to correct the errors decreased year over year lost revenues from $21,664,944 to $11,771,346 and decreased eligible expenditures from $7,527,194 to $4,334,813, on total distributions of PRF funding of $14,972,846. In summary, the data supporting amounts for lost revenues and eligible expenses totals $16,104,159 on total distributions of PRF funding of $14,972,846 in this reporting period. Corrective Action Plan: System management agrees with the finding and has updated its lost revenue calculation. Management attempted to update lost revenue amounts with filing of its Period 4 reports; however, additional data entry errors were made. Management has worked extensively over the past two years to monitor the changing guidelines surrounding the various programs designed to respond to the COVID-19 pandemic. Management has furthered this effort by attending continuing professional education on this topic and reading available guidance to ensure that the final recordkeeping maintained by the System follows the guidance as established by HRSA.
2021-001 – Internal Controls over Allowable Costs Individual Responsible for Corrective Action Plan: J. Neal Bolton, Director of Revenue Management & Budget Shemaine Rose, Controller Anticipated Completion Date: Completed Management notes that all expenses charged to the federal program were revi...
2021-001 – Internal Controls over Allowable Costs Individual Responsible for Corrective Action Plan: J. Neal Bolton, Director of Revenue Management & Budget Shemaine Rose, Controller Anticipated Completion Date: Completed Management notes that all expenses charged to the federal program were reviewed by the Vice President of Human Resources and the Finance Team, with guidance obtained from independent consultants, however, the documentation of the review was not retained. Management also notes that all expenses were deemed to be appropriately charged to the federal program. In order to ensure documentation is retained evidencing approval of costs, the Authority will require physical sign off on all invoices or electronic approval of all costs charged to the federal program.
Finding Number: 2021-005 Condition: - The System received targeted distributions for Bucyrus Community Hospital. A period one portal submission was completed, but no allowable expenses or lost revenues were reported within the Bucyrus Community Hospital report. All allowable expenses and lost reve...
Finding Number: 2021-005 Condition: - The System received targeted distributions for Bucyrus Community Hospital. A period one portal submission was completed, but no allowable expenses or lost revenues were reported within the Bucyrus Community Hospital report. All allowable expenses and lost revenues were reported on the first period portal submission for Galion Community Hospital, another hospital of the Avita Health System. Planned Corrective Action: The portal submission could not be modified by the time we identified the reporting issue. As such, no corrective report was completed, however management will implement procedures to ensure reporting requirements are adequately reviewed for all federal funding. Contact person responsible for corrective action: Eric Draime, Vice President/CFO Anticipated Completion Date: June 30, 2024
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