Corrective Action Plans

Finding 402820 (2021-001)

Significant Deficiency 2021

NM

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency § 200.303 § 200.403 § 200.430

Recommendation: The Auditor recommends that the Entity implement controls for documenting and retaining information on expenditures charged to federal awards to follow the requirements over 2 CFR Section 200.430(g)(i) and in addition the Entity is properly paying employees at the approved pay rate. ...

Recommendation: The Auditor recommends that the Entity implement controls for documenting and retaining information on expenditures charged to federal awards to follow the requirements over 2 CFR Section 200.430(g)(i) and in addition the Entity is properly paying employees at the approved pay rate. Action Taken: 1. Policy Revision and Development: o Develop or revise existing policies to clearly define the processes for documenting and retaining expenditure information related to federal awards. These policies should explicitly follow the requirements over 2 CFR Section 200.430(g)(i), ensuring that all expenditures are properly documented and justified as per federal award conditions. Specifically, approval of differential rates will be added to those policies. o Ensure that the policy includes guidelines for regularly reviewing employee pay rates against approved rates for compliance with federal award conditions. 2. Training and Awareness Programs: o Implement comprehensive training programs for all staff involved in charging costs to federal awards. This training should cover the importance of compliance with federal regulations, specifically focusing on the documentation and retention of expenditure information and adherence to approved pay rates. o Schedule regular refresher training sessions to ensure ongoing compliance and awareness. 3. Enhanced Monitoring and Audit Trails: o Introduce monitoring mechanisms to regularly review expenditures charged to federal awards for compliance with documented policies and federal requirements. o Develop an audit trail system that allows for the easy retrieval of documentation supporting expenditures and payroll compliance. This system should enable auditors to trace the documentation back to the federal award and the approved budget items. 4. Internal Control Improvements: o Review and strengthen internal controls related to the processing of expenditures and payroll to ensure that all transactions are authorized, recorded accurately, and in compliance with federal award requirements. o Implement segregation of duties where possible, to reduce the risk of errors or fraud in the charging of costs to federal awards. 5. Regular Compliance Reviews and Updates: o Conduct periodic internal reviews to assess compliance with federal award requirements and the effectiveness of the implemented corrective actions. o Ensure that any changes in federal regulations or award-specific requirements are promptly incorporated into the hospital's policies and training programs. 6. Documentation and Communication: o Maintain comprehensive records of all actions taken to address the audit findings, including policy revisions, training sessions, and internal review outcomes. Specifically, records for those these expenditures will remain onsite and not sent to long-term storage if the employee or vendor no longer has a relationship with the facilities. o Communicate regularly with federal awarding agencies to update them on the corrective actions taken and to seek guidance on compliance matters as needed. Implementation Timeline and Responsibility Assignment: • Management positions including the CEO, CFO and CNO for the 2021 fiscal year are no longer employed by Terry Memorial Hospital District. Administration employed in 2023 acknowledges these deficiencies and accepts responsibility for developing, applying and maintaining this corrective action plan going forward. • Assign specific responsibilities to designated staff members or departments for each component of the corrective action plan. • Set clear deadlines for the completion of each action item, with an initial goal to address all significant deficiencies within one to three months from the date of the audit report. Monitoring and Reporting: • Establish a mechanism for ongoing monitoring of the effectiveness of the corrective action plan, with periodic reports to senior management and the board of directors. Feedback Loop: • Create a feedback loop with employees and management to continuously improve internal controls and compliance processes based on practical experiences and challenges encountered during implementation. Responsible Person: Whitney Wilson, CFO

View Audit 310010 Questioned Costs: $1

Finding 402384 (2021-016)

Material Weakness 2021

State of California

CA

Questioned Costs Eligibility Matching / Level of Effort / Earmarking § 200.303

Of the 20 claimants the auditor determined to be ineligible for Lost Wages Assistance (LWA) benefits, 17 were Pandemic Unemployment Assistance (PUA) claimants disqualified due to identity issues discovered through the EDD’s new fraud enhancements outlined in the response to the finding for Reference...

Of the 20 claimants the auditor determined to be ineligible for Lost Wages Assistance (LWA) benefits, 17 were Pandemic Unemployment Assistance (PUA) claimants disqualified due to identity issues discovered through the EDD’s new fraud enhancements outlined in the response to the finding for Reference Number 2021-003. The other three claimants were receiving regular Unemployment Insurance (UI) benefits (one claimant) and Pandemic Emergency Unemployment Compensation (PEUC) benefits (two claimants). Those three claimants were paid pending the adjudication of potential eligibility issues, which were later found to be disqualifying. EDD has corrected both issues that resulted in the LWA payments being made to ineligible claimants. Regarding the issue of PUA claimants paid prior to the discovery of the potential identity issues, as outlined in the response to the finding for Reference Number 2021-003, during the years 2020 and 2021, the EDD implemented multiple new fraud prevention measures. Regarding the issue of the regular UI and PEUC claimants being paid prior to the adjudication of the potential eligibility issues, the EDD resumed adjudicating all potential eligibility issues as of January 2021 and will complete the remaining retroactive workload by April 30, 2023. Estimated Implementation Date: September 2020 (Fraud Enhancements) and January 2021 (Resumption of Adjudications) Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California Employment Development Department

View Audit 309913 Questioned Costs: $1

Finding 402380 (2021-015)

Significant Deficiency 2021

State of California

CA

Questioned Costs Reporting Special Tests & Provisions § 200.303

Health Care Services agrees with the recommendation. Effective September 1, 2021, System Development Notice (SDN) 20039 made updates to the Claims Processing Accounts Receivable System, requiring the Fiscal Intermediary (FI) to record the FFP rate including the Budget Program (i.e., Medicaid Assista...

Health Care Services agrees with the recommendation. Effective September 1, 2021, System Development Notice (SDN) 20039 made updates to the Claims Processing Accounts Receivable System, requiring the Fiscal Intermediary (FI) to record the FFP rate including the Budget Program (i.e., Medicaid Assistance Program vs. Children’s Health Insurance Program) for each overpayment account receivable set up after the effective date. The FFP rate and Budget Program information for each overpayment is provided on the Action Notices to the FI. The SDN also made updates to the California Omnibus Budget Reconciliation Act of 1985 (COBRA) system to enable the system to receive the FFP rate and Budget Program information for each overpayment set up by the FI and updated COBRA reports, thereby allowing Health Care Services to report the correct FFP rate for overpayments on the CMS-64 and CMS-21. Estimated Implementation Date: September 30, 2021 Contact: Wendy Griffe, Chief Internal Audits California Department of Health Care Services

View Audit 309913 Questioned Costs: $1

Finding 402371 (2021-011)

Material Weakness 2021

State of California

CA

Eligibility Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.303

The Office of AIDS (OA) agrees with the finding and recommendation. OA developed and implemented additional, internal quality assurance (QA) processes in April of 2022 to ensure that secondary reviews of AIDS Drug Assistance Program (ADAP) applications are consistently enforcing the existing guideli...

The Office of AIDS (OA) agrees with the finding and recommendation. OA developed and implemented additional, internal quality assurance (QA) processes in April of 2022 to ensure that secondary reviews of AIDS Drug Assistance Program (ADAP) applications are consistently enforcing the existing guidelines, including acceptable supporting documentation and accurate eligibility requirements. During this audit period, and through December 2021, ADAP had issued multiple policy memos to respond to the COVID-19 pandemic, which enabled staff and enrollment workers to defer documentation collection, when necessary, to remain flexible and ensure clients impacted by the pandemic, and associated site closures, did not lose eligibility and access to life saving medications and comprehensive healthcare. These flexibilities in our guidelines were implemented based on guidance received from our federal funder, Health Resources and Services Administration (HRSA), which encouraged ADAPs to reassess their organization's eligibility and recertification policies and procedures, and remove any barriers that may impede social distancing, or other public health strategies, necessary to minimize COVID-19 transmission. This documentation deferral was terminated on December 31, 2021, and since January 1, 2022, full documentation and eligibility requirements have been enforced. This, combined with ongoing QA efforts, will help to mitigate future findings in ADAP applications dated January 1, 2022 onward. Estimated Implementation Date: Already implemented as of April 2022 Contact: Sharisse Kemp, Branch Chief AIDS Drug Assistance Program Branch California Department of Public Health

View Audit 309913

Finding 402368 (2021-009)

Significant Deficiency 2021

State of California

CA

Cash Management Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303 § 200.305

Office of AIDS (OA) agrees with the finding and has implemented solutions to meet the auditor's recommendation. OA has already taken steps to remedy the issue by using its Support Branch to realign staff and responsibilities to allow for a greater focus on fiscal reporting and invoice processing. T...

Office of AIDS (OA) agrees with the finding and has implemented solutions to meet the auditor's recommendation. OA has already taken steps to remedy the issue by using its Support Branch to realign staff and responsibilities to allow for a greater focus on fiscal reporting and invoice processing. The Care Branch has also put an increased emphasis on tracking and reviewing invoices for payment to prevent similar delays. Subsequently, the Ryan White Grant closeouts had all invoices processed and paid prior to the Federal Financial Report closeout deadlines to ensure that drawn cash for invoices was not held for extended timeframes. Estimated Implementation Date: July 1, 2021 Contact: Joseph Gonzales, Branch Chief Office of AIDS Support Branch California Department of Public Health

View Audit 309913

Finding 402364 (2021-008)

Material Weakness 2021

State of California

CA

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

Health Care Services agrees with the recommendation and implemented corrective action by October 31, 2022. Health Care Services, or DHCS, published Behavioral Health Information Notice (BHIN) 22-045 which outlines Health Care Services sanctions policy. The BHIN states “Under state and federal law D...

Health Care Services agrees with the recommendation and implemented corrective action by October 31, 2022. Health Care Services, or DHCS, published Behavioral Health Information Notice (BHIN) 22-045 which outlines Health Care Services sanctions policy. The BHIN states “Under state and federal law DHCS must enforce compliance with the terms of the DHCS’ contracts with Mental Health Plans and Drug Medi-Cal Organized Delivery System counties, as well as ensure compliance with applicable state and federal laws and regulations, in accordance with its authority and obligations under state and federal requirements.” Lastly, under the section titled ‘Exhibit A - Attachment 3’ of the County Mental Health Plan Contract counties are required to submit cost reports timely which would allow Health Care Services to impose sanctions on counties who do not submit cost reports in a timely manner. This BHIN resolves the finding. Additionally, Health Care Services will not be collecting cost reports for dates of service after State Fiscal Year 2022-23. Under the California Advancing and Innovating Medi-Cal (CalAIM) initiative, and pursuant to Welfare and Institutions Code, Section 14184.403(b), Health Care Services will replace the current Certified Public Expenditures (CPE) reimbursement methodology with an intergovernmental transfer (IGT) reimbursement methodology. The IGT reimbursement methodology will make a single and final payment for services provided to the county, which includes the non-federal portion of the claims. This change will eliminate the requirement for the county submission of cost reports. Estimated Implementation Date: October 31, 2022 Contact: Wendy Griffe, Chief Internal Audits California Department of Health Care Services

View Audit 309913

Finding 402359 (2021-005)

Material Weakness 2021

State of California

CA

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

Given the unprecedented volume of unemployment insurance claims during the federal disaster -approximately 20 million claims compared to 3.8 million during the Great Recession - EDD took action to speed payments to eligible claimants whenever possible. For example, EDD launched in July 2021 a Condit...

Given the unprecedented volume of unemployment insurance claims during the federal disaster -approximately 20 million claims compared to 3.8 million during the Great Recession - EDD took action to speed payments to eligible claimants whenever possible. For example, EDD launched in July 2021 a Conditional Payment Program to speed payments to claimants who certified for benefits and already received at least one week of benefits in the past but whose payments were later pending for more than two weeks. EDD also boosted its capacity to process workloads, prioritized timely payments, and employed automation among other measures. As reported in Reference Number 2020-006 in fiscal year 2019-2020, EDD began automatically cross-matching EDD wage records and Franchise Tax Board (FTB) records in November 2020 to assist in verifying the income of PUA claimants. Claimants who could not be automatically verified through the FTB wage record match were required to submit additional documentation to EDD for a manual review. Regarding the manual processing of the income documents to substantiate the PUA weekly benefit amounts that have been increased above the minimum California weekly benefit amount (WBA) of $167, in June 2022, the EDD submitted a blanket waiver application to the U.S. Department of Labor (DOL), pursuant to the DOL Unemployment Insurance Program Letter 20-21, Change 1. EDD’s application is pending the DOL’s determination. If approved, our blanket waiver application would cover any overpayments for claimants who, through no fault of their own, failed to provide proof of income substantiation to support the increase or whose WBA will be decreased because the proof they provided was insufficient. Regarding the verification of employment or self-employment substantiation (known in California as “Self-employment/Employment Substantiation” or “SEES”), this verification process is being implemented in two phases. Phase 1 of the SEES effort was implemented on November 10, 2021, and involved notifying claimants registered in California’s UI Online (UIO) system by email and text of their requirement to provide SEES documentation. Phase 2 will involve notifying claimants who did not respond to the UIO request for SEES documentation, and those who are not registered in UIO, via a paper notice mailed through the United States Postal Service (USPS). EDD submitted a blanket overpayment waiver application in June 2022 to DOL regarding this issue. EDD will assess further implementation based on the DOL’s decision. If approved, our blanket waiver application would cover any overpayments for claimants who, through no fault of their own, provided insufficient documentation or did not provide any documentation. Estimated Implementation Date: To be determined once the DOL provides a decision on the waiver application. Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California Employment Development Department

View Audit 309913 Questioned Costs: $1

Finding 402357 (2021-004)

Material Weakness 2021

State of California

CA

Questioned Costs Eligibility Matching / Level of Effort / Earmarking § 200.303

Since fiscal year 2020-21, EDD has implemented dozens of strict anti-fraud measures to continue to evaluate and enhance its fraud detection. These measures, described in last year’s response to finding Reference Number 2020-005, included, but were not limited to, cross matching claimant information ...

Since fiscal year 2020-21, EDD has implemented dozens of strict anti-fraud measures to continue to evaluate and enhance its fraud detection. These measures, described in last year’s response to finding Reference Number 2020-005, included, but were not limited to, cross matching claimant information against law enforcement and government databases and implementing rigorous new identity verification procedures. As a result, EDD caught and stopped multiple fraud attempts starting in September 2020. As previously described, EDD implemented the following measures to address the nationwide fraud attempts perpetrated against the new emergency federal benefit programs in 2020-21: • Implemented additional cross-matches in September 2020 to detect multiple claims per address. • Ceased automatically backdating Pandemic Unemployment Assistance (PUA) claims under federal rules in September 2020. • Strengthened identity verification procedures in October 2020 by implementing ID.me. • Implemented additional cross-matches in November 2020 against state inmate information. • Vetted applications against law enforcement databases and other tools provided by Thomson Reuters in December 2020 to further curb identity and non-identity fraud. • Established a 1099-G call center to help victims of identity theft deal with any tax-related questions. • Ceased printing Social Security numbers on mailed documents to reduce identity theft risk. • Enhanced benefit card security with Bank of America. • Partnered with state, local and federal law enforcement agencies to support thousands of criminal investigations, arrests, prosecutions and convictions. The EDD will continue to evaluate and enhance the fraud detection/prevention tools that have been put in place. Estimated Implementation Date: September 2020 Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California Employment Development Department

View Audit 309913 Questioned Costs: $1

Finding 401850 (2021-001)

Material Weakness 2021

McIntosh County

OK

Internal Control / Segregation of Duties

During 2023, the county implemented internal controls over the control environment, risk assessment, informaion, communication and monitoring over federal grants through meetings when a grant is received. We will ensure employees have the current compliance supplement and adequate documentation wil...

During 2023, the county implemented internal controls over the control environment, risk assessment, informaion, communication and monitoring over federal grants through meetings when a grant is received. We will ensure employees have the current compliance supplement and adequate documentation will be kept.

View Audit 309759

Finding 401837 (2021-001)

Material Weakness 2021

Aging Projects, Inc.

KS

Internal Control / Segregation of Duties

The size of the Organization prohibits hiring additional personnel. Duties have always been segregated where possible and currently another staff person is being trained in recording and summarizing transactions to further break out duties. The Board of Directors is involved where possible.

View Audit 309748

Finding 401704 (2021-004)

Significant Deficiency 2021

Northwest Indian College

WA

Equipment & Real Property Management Procurement, Suspension & Debarment Internal Control / Segregation of Duties § 200.303 § 200.313

Recommendation: We recommend the College implement policies and procedures to ensure all property and equipment purchased with federal funds includes such information in the property records to comply with the requirement. Explanation of disagreement with audit finding: There is no disagreement with...

Recommendation: We recommend the College implement policies and procedures to ensure all property and equipment purchased with federal funds includes such information in the property records to comply with the requirement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College has begun to explore the Asset Module in the Jenzabar platform, with the goal that Procurement is the first stage of our property tracking. Work continues to be a challenge in this area as we are short staffed. The Business Office Staff will continue to work with the Purchasing staff to identify how best to proceed with this requirement. The College currently has Policies that speak to Assets and the recording of such. The College will strengthen the specifics of what an Asset listing is to include. Name of the contact person responsible for corrective action: Raquel Vigil, Chief Financial Officer, Clarissa Salhus, Finance Manager, Charles Roberts, Purchasing Manager, and Paul Roberts, Fiscal Technician/Receiving Planned completion date for corrective action plan: March 31, 2025

View Audit 309644

Finding 401250 (2021-001)

Significant Deficiency 2021

Presbyterian Homes of Tennessee, Inc.

TN

Reporting Significant Deficiency Internal Control / Segregation of Duties

Department of Health and Human Services Presbyterian Homes of Tennessee, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2021. Audit period: January 1, 2021 through December 31, 2021 The finding from the schedule of findings and questioned costs is disc...

Department of Health and Human Services Presbyterian Homes of Tennessee, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2021. Audit period: January 1, 2021 through December 31, 2021 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS Department of Health and Human Services 2021-001 Provider Relief Funding – Assistance Listing No. 93.498 Recommendation: The organization updated the submission related to its Period 1 reporting, which included an updated lost revenue calculation to support all provider relief fund payments received. The organization should ensure the proper review procedures are in place for any future submissions to ensure accurate reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: An amended Period 1 submission report, using the lost revenues, was submitted. Appropriate review procedures will be put in place to ensure accurate reporting on any future submissions. Name of the contact person responsible for corrective action: Erik Hockman, CFO Planned completion date for corrective action plan: May 2, 2023 If the Department of Health and Human Services has questions regarding this plan, please call Erik Hockman at 865-243-3613.

View Audit 309260

Finding 400966 (2021-004)

Material Weakness 2021

Gloversville Housing Authority

RI

HUD Housing Programs Internal Control / Segregation of Duties Subrecipient Monitoring

Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority will ensure annual audits are conducted and timely electronic submissions of GAAP-based unaudited and audited financial information to HUD through the F...

Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority will ensure annual audits are conducted and timely electronic submissions of GAAP-based unaudited and audited financial information to HUD through the FASS-PH system. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director

View Audit 309030

Finding 400958 (2021-002)

Material Weakness 2021

Gloversville Housing Authority

RI

Internal Control / Segregation of Duties Procurement, Suspension & Debarment Subrecipient Monitoring § 200.302

Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority will maintain proper monitoring, communication and control activities to ensure adherence to the Authority’s key administrative policies including procu...

Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority will maintain proper monitoring, communication and control activities to ensure adherence to the Authority’s key administrative policies including procurement, occupancy and the HCV administrative plan. Additionally, management will have the Board approve all policies and procedures adopted and communicate them with the third party company that manages the Authority’s Housing Choice Voucher and Mainstream Voucher programs. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director

View Audit 309030

Finding 400853 (2021-004)

Material Weakness 2021

Camden County Board of Social Services

NJ

Reporting Internal Control / Segregation of Duties

Corrective Action Plan: All Bank Reconciliations will be reviewed for the Assistance and Clearing Fund. All unidentified adjustments will be researched, and adjustments will be made on the corresponding reports submitted to the Division of Family Development. Responsible Party: Accountant Anticip...

Corrective Action Plan: All Bank Reconciliations will be reviewed for the Assistance and Clearing Fund. All unidentified adjustments will be researched, and adjustments will be made on the corresponding reports submitted to the Division of Family Development. Responsible Party: Accountant Anticipated Completion Date: Immediately

View Audit 308868

Finding 400852 (2021-005)

Material Weakness 2021

Camden County Board of Social Services

NJ

Cash Management Reporting Internal Control / Segregation of Duties

Corrective Action Plan: All Bank Reconciliations will be reviewed for the Assistance and Clearing Fund. All unidentified adjustments will be researched, and adjustments will be made on the corresponding reports submitted to the Division of Family Development. Responsible Party: Accountant Anticip...

Corrective Action Plan: All Bank Reconciliations will be reviewed for the Assistance and Clearing Fund. All unidentified adjustments will be researched, and adjustments will be made on the corresponding reports submitted to the Division of Family Development. Responsible Party: Accountant Anticipated Completion Date: Immediately

View Audit 308868

Finding 400851 (2021-003)

Material Weakness 2021

Camden County Board of Social Services

NJ

Reporting Internal Control / Segregation of Duties

Corrective Action Plan: All Bank Reconciliations will be reviewed for the Assistance and Clearing Fund. All unidentified adjustments will be researched, and adjustments will be made on the corresponding reports submitted to the Division of Family Development. Responsible Party: Accountant Anticip...

Corrective Action Plan: All Bank Reconciliations will be reviewed for the Assistance and Clearing Fund. All unidentified adjustments will be researched, and adjustments will be made on the corresponding reports submitted to the Division of Family Development. Responsible Party: Accountant Anticipated Completion Date: Immediately

View Audit 308868

Finding 400188 (2021-008)

Material Weakness 2021

Hodgeman County Health Center

KS

Reporting Internal Control / Segregation of Duties

Condition The Health Center’s financial statement and compliance audits for the December 31, 2021 reporting period were not filed within the required timeline. Views of responsible officials and planned corrective actions Management will continue to monitor and enhance our internal controls to as...

Condition The Health Center’s financial statement and compliance audits for the December 31, 2021 reporting period were not filed within the required timeline. Views of responsible officials and planned corrective actions Management will continue to monitor and enhance our internal controls to assure all future reporting timelines are met. Anticipated completion date Ongoing

View Audit 308322

Finding 400187 (2021-007)

Material Weakness 2021

Hodgeman County Health Center

KS

Reporting Internal Control / Segregation of Duties

Condition Management should have a process in place to ensure the internal completion of the schedule of federal expenditures (SEFA) including all required disclosures. Views of responsible officials and planned corrective actions We will continue to monitor and, although we have limited personnel...

Condition Management should have a process in place to ensure the internal completion of the schedule of federal expenditures (SEFA) including all required disclosures. Views of responsible officials and planned corrective actions We will continue to monitor and, although we have limited personnel, we will continue to enhance our internal controls over the completion of the SEFA. Anticipated completion date Ongoing

View Audit 308322

Finding 400186 (2021-006)

Material Weakness 2021

Hodgeman County Health Center

KS

Allowable Costs / Cost Principles Material Weakness Reporting

Condition Management provided excel workbooks of costs they determined allowable under the PRF program. Although the workbook totals for some cost reporting categories did match the PRF reporting form, there were several categories that did not. Other reporting errors were also noted on the PRF po...

Condition Management provided excel workbooks of costs they determined allowable under the PRF program. Although the workbook totals for some cost reporting categories did match the PRF reporting form, there were several categories that did not. Other reporting errors were also noted on the PRF portal reporting document. Views of responsible officials and planned corrective actions We will review our current reporting processes and internal controls over PRF reporting to ensure all future reporting requirements are met. Anticipated completion date Ongoing

View Audit 308322

Finding 399406 (2021-008)

Material Weakness 2021

Seminole County

OK

Internal Control / Segregation of Duties

Seminole County strives to gain more understanding and knowledge of requirements and will continue to implement more internal controls to ensure we follow all fedreal grant requirements. This was the first time we had this kind of federal grant program and now we know and understand the grant requi...

Seminole County strives to gain more understanding and knowledge of requirements and will continue to implement more internal controls to ensure we follow all fedreal grant requirements. This was the first time we had this kind of federal grant program and now we know and understand the grant requirements and reporting better.

View Audit 307918

Finding 399397 (2021-007)

Material Weakness 2021

Grant County

OK

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

The County will establish policies and procedures to create better communication between the Emergency Manager and the County Officers.

View Audit 307906

Finding 399392 (2021-002)

Material Weakness 2021

Seiling Municipal Hospital Authority

OK

Questioned Costs Internal Control / Segregation of Duties Procurement, Suspension & Debarment

The criteria for use of the Provider Relief Funds (PRF) changed subsequent to the receipt and expenditure by the Hospital. The Hospital utilized the best information available at the time, during the early days of the public health emergency, in its use of the funds. The Hospital consistently revi...

The criteria for use of the Provider Relief Funds (PRF) changed subsequent to the receipt and expenditure by the Hospital. The Hospital utilized the best information available at the time, during the early days of the public health emergency, in its use of the funds. The Hospital consistently reviews the frequently asked questions for PRF maintained by the Health Resources & Services Administration (HRSA) for guidance on changes and clarification to the rules surrounding the program. In October 2021 — long after most critical access hospitals (CAHs), including Selling, had expended their initial PRF distributions - HRSA added an FAQ addressing cost-based reimbursement, specifically, "How does cost-based reimbursement relate to my Provider Relief Fund payment?" HRSA subsequently has made minor modifications to the language of this FAQ — most recently on October 27, 2022 — but the substantive guidance has remained the same. Unlike E.H.R. capital equipment, where specific cost report guidance was provided, no such guidance was provided for assets purchased to prevent, prepare for, and respond to COVID-19. Neither Prospective Payment System (PPS) nor CAH facilities were required to offset the full amount of funds received because they were considered grants, consistent with the treatment of PRF. We disagree with the audit findings and believe that no corrective action is required.

View Audit 307896 Questioned Costs: $1

Finding 398999 (2021-001)

Material Weakness 2021

Newell-Fonda Community School District

IA

Internal Control / Segregation of Duties

SEE RESPONSE AND CORRECTIVE ACTION PLAN AT II-A-21.

View Audit 307607

Finding 398470 (2021-001)

Significant Deficiency 2021

La Asociacion Nacional Pro Personas Mayores (the National Association for Hispanic Elderly)

CA

Internal Control / Segregation of Duties

Management has submitted final audited financial statements for FY20-21.

View Audit 307200

Corrective Action Plans

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