Corrective Action Plans

Finding 32586 (2022-002)

None 2022

CA

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.430

Radiant Health Centers has recently transitioned to a new Human Resources Information System, PayCom, that will better help the organization track timesheets, including a more accurate reflection of time staff worked and electronic documentation of review and approval by supervisors of their staff.

View Audit 27115

Finding 32478 (2022-009)

Significant Deficiency 2022

Commonwealth of Pennsylvania

PA

Special Tests & Provisions Questioned Costs Significant Deficiency

Office of Medical Assistance Programs? Bureau of Data and Claims Management (BDCM) is currently negotiating an amendment to the PROMISe contract with Gainwell Technologies which will bolster the NCCI performance requirement to explicitly include the elements identified in the finding. Anticipated C...

Office of Medical Assistance Programs? Bureau of Data and Claims Management (BDCM) is currently negotiating an amendment to the PROMISe contract with Gainwell Technologies which will bolster the NCCI performance requirement to explicitly include the elements identified in the finding. Anticipated Completion Date: 05/01/2023 Contact Person and Title: Toni Hoffecker, Dir., Div. of Systems, Monitoring and Oversight, BDCM

View Audit 27724

Finding 32455 (2022-007)

Significant Deficiency 2022

Commonwealth of Pennsylvania

PA

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking § 200.303

Similar to other DHS programs, DHS has implemented an after-action review of information submitted, using a contracted vendor. DHS faced challenges implementing a program with 67 counties and no central eligibility determination system. DHS has learned that implementing the supportive services and m...

Similar to other DHS programs, DHS has implemented an after-action review of information submitted, using a contracted vendor. DHS faced challenges implementing a program with 67 counties and no central eligibility determination system. DHS has learned that implementing the supportive services and multi-sector partnerships was challenging in the context of the global pandemic and workforce shortages. This made DHS dependent on local county reports to maintain program oversight and compile statewide data for submission to US Treasury. DHS plans to strengthen this control as we plan for future emergency or pandemic programs related to rental assistance. Anticipated Completion Date: 06/30/2023 Contact Person and Title: Joel O?Donnell, Director, Bureau of Program Support, OIM

View Audit 27724 Questioned Costs: $1

Finding 32426 (2022-006)

Material Weakness 2022

Commonwealth of Pennsylvania

PA

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Bureau of Operations (BOO): BOO will take the following actions to address the finding: 1. All CAOs and district offices will be reminded of the EBT Coordinators?, alternates?, pinners?, and card makers? responsibilities. The BOO will ensure users in the EBT Card Tracking Database know their respo...

Bureau of Operations (BOO): BOO will take the following actions to address the finding: 1. All CAOs and district offices will be reminded of the EBT Coordinators?, alternates?, pinners?, and card makers? responsibilities. The BOO will ensure users in the EBT Card Tracking Database know their responsibilities and segregation of duties and will ensure there is coverage for card pinning until 5:00 pm each business day. Also, reminders to be sent to review the OIM EBT Procedural Manual periodically and when updates occur. This has already taken place on October 7, 2022. 2. All CAOs and district offices will be reminded to maintain adequate security of the EBT cards, card inventory, pinning devices, and ribbons. The EBT office will ensure all offices have two pinning devices and that they are in working order. This has already taken place on October 7, 2022. 3. OIM mandates annual training for EBT personnel to be completed at the beginning of each year. The training includes reviewing the procedures that safeguard access to the EBT systems. Also included are the following: a. Review of roles and responsibilities and who may hold a role b. Card maker and pinner coverage for all business hours c. Proper security for EBT cards and associated items d. Timeframes for submitting changes e. Retention timeframes Training was completed in January 2023. Area managers and staff assistants monitor completion of the training. Bureau of Program Support (BPS)/EBT Project Office: BPS will take the following actions to address the finding: 1. The EBT Project Office will make updates to the EBT Procedures Manual (Manual) and OIM EPPIC EBT Systems Application form (application) as needed. Notification of updates will be sent to CAO staff via email. This is expected to occur by April 30, 2023. 2. The EBT Program office will provide guidelines for the CAOs to follow when reviewing/updating their written internal procedures for EBT security of card mailings. This is expected to occur by April 30, 2023. 3. The EBT Project Officer will start retraining parties that are responsible for the completion of the EBT Headquarters Card Destruction log. This is expected to occur by May 1, 2023. Bureau of Program Evaluation (BPE), Division of Corrective Action (DCA) will take the following actions to address the finding: BPE, DCA conducts EBT Card Security reviews at every CAO and District Office that issues EBT cards. These reviews are completed on a consistent basis, and in the future will be completed annually on a 3-year rotation basis, to ensure the improvement of the execution of documented policies and procedures. BPE/DCA will adjust the review criteria to incorporate any procedural changes implemented in the Electronic Benefit Transfer Handbook. Current rotation schedule spans FFY 2022- FFY 2024. The annual reviews for this cycle started October 2022. Anticipated Completion Date: BOO 1,2, 3- Completed; BPS 1, 2- 04/30/2023; BPS 3- 05/01/2023; BPE- Completed Contact Person and Title: BOO- Jeanette Coulston, Staff Assistant to Director of Bureau of Operations; BPS- Tonya Holloway, Division Director; BPE- Amira S. Milikin, Division Director

View Audit 27724 Questioned Costs: $1

Finding 32425 (2022-001)

Significant Deficiency 2022

Area Xv Multi-County Housing Agency

IA

HUD Housing Programs Special Tests & Provisions Subrecipient Monitoring

The Authority recognizes that the utility schedule was not updated in the most recent fiscal year. There has been staff turnover in the Authority in the roles that have oversight over these policies and in the transition, numerous things were not communicated as to whose responsibility it now is. Th...

The Authority recognizes that the utility schedule was not updated in the most recent fiscal year. There has been staff turnover in the Authority in the roles that have oversight over these policies and in the transition, numerous things were not communicated as to whose responsibility it now is. The Executive Director will be contacting HUD to determine the next course of action as the utility allowance schedule has been updated for 2023.

View Audit 27901

Finding 32418 (2022-003)

Significant Deficiency 2022

Crawford County Community School Corporation

IN

Subrecipient Monitoring Reporting Significant Deficiency § 200.302 § 200.303 § 200.328

Finding 2022-003 Information on the federal program: Subject: Education Stabilization Fund ? Internal Controls Federal Agency: Department of Education Federal Program: COVID-19 ? Education Stabilization Fund Assistance Listing Number: 84.425C, 84.425D, 84.425U Pass-Through Entity: Indiana Departmen...

Finding 2022-003 Information on the federal program: Subject: Education Stabilization Fund ? Internal Controls Federal Agency: Department of Education Federal Program: COVID-19 ? Education Stabilization Fund Assistance Listing Number: 84.425C, 84.425D, 84.425U Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Significant Deficiency Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Reporting compliance requirements. Context: The School Corporation was required to submit two Annual Data Reports to the Indiana Department of Education (IDOE) to meet federal reporting requirements for ESSER grant awards and the GEER grant award. The first report was for the period of March 13, 2020 to September 30, 2020 and was due by January 21, 2021. The second report was for the period of October 1, 2020 to June 30, 2021 and was due by May 13, 2022. We noted for both reports that were submitted, there was no documented review by someone other than the preparer of the report to ensure the information submitted was complete and accurate. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding. Crawford County Community School Corporation will continue submission of required data to the IDOE on federal spending with at least two people completing the curation. However, final drafts will be reviewed and then final reports will be signed by the at least two people who reviewed the final draft. This signed copy, if not required to be submitting to the IDOE, will be kept locally. Responsible party and timeline for completion: 1) Amy Belcher, Program Administrator, will ensure all final reports have been reviewed and signed by at least two people before submission to the IDOE immediately.

View Audit 27913

Finding 32412 (2022-001)

Material Weakness 2022

Board of Education of Collierville Schools

TN

Questioned Costs Material Weakness Matching / Level of Effort / Earmarking § 200.303 § 200.326

2022-001: Material Weakness-Davis-Bacon Wage Rate Requirements Corrective Action: Corrective action has been taken. Management has started requiring weekly collection of payrolls from contractors for projects. These are reviewed on a weekly basis for compliance with Davis-Bacon requirements. Wage re...

2022-001: Material Weakness-Davis-Bacon Wage Rate Requirements Corrective Action: Corrective action has been taken. Management has started requiring weekly collection of payrolls from contractors for projects. These are reviewed on a weekly basis for compliance with Davis-Bacon requirements. Wage requirement clauses will be included in all contract agreements going forward. The responsibility for monitoring and reviewing certified payrolls and contracts has been assigned to the Chief of Operations or his designee. Contact Person: Anita Floyd Completion Date: December 2022

View Audit 28398

Finding 32402 (2022-001)

Material Weakness 2022

Enumclaw School District No. 216

WA

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

SUMMARY SCHEDULE OF PRIOR AUDIT FINDINGS Enumclaw School District No. 216 September 1, 2021 through August 31, 2022 This schedule presents the status of findings reported in prior audit periods. Audit Period: September 1, 2020 ? August 31, 2021 Report Ref. No.: 1030921 Finding Ref. No.: 2021-001 Ass...

SUMMARY SCHEDULE OF PRIOR AUDIT FINDINGS Enumclaw School District No. 216 September 1, 2021 through August 31, 2022 This schedule presents the status of findings reported in prior audit periods. Audit Period: September 1, 2020 ? August 31, 2021 Report Ref. No.: 1030921 Finding Ref. No.: 2021-001 Assistance Listing Number(s): 84.425 Federal Program Name and Granting Agency: COVID-19 Education Stabilization Fund, U.S. Department of Education Pass-Through Agency Name: Office of Superintendent of Public Instruction Finding Caption: The District did not have adequate internal controls for ensuring compliance with Davis-Bacon Act (prevailing wage rate) requirements. Background: During the 2020-2021 school year, the District paid $658,502 from its ESSER II award to 11 contractors to repair and replace the roof at two schools, update HVAC controls in seven schools, and replace wet and rotting insulation to improve air quality and circulation to prevent the spread of COVID-19. Additionally, the District used its ESSER II award to replace faulty and broken bathroom sinks to allow for safe and consistent use of sinks for hand washing. Our audit found the District did not have adequate internal controls for ensuring compliance with federal prevailing wage rate requirements. Specifically, the District did not collect weekly certified payroll reports from the contractors to confirm they paid laborers proper prevailing wages. We consider this deficiency in internal controls to be a material weakness, which led to material noncompliance. The issue was not reported as a finding in the prior audit.

View Audit 27599

Finding 32396 (2022-001)

Material Weakness 2022

Leap Charities, Inc.

ID

Questioned Costs Reporting Internal Control / Segregation of Duties § 200.512

The Organization started its remediation of its accounting closing processes during 2021. As a part of the Organization?s remediation they hired an external consultant to provide chief financial officer/controller level services over the Organization?s accounting and financial processes. Timely and ...

The Organization started its remediation of its accounting closing processes during 2021. As a part of the Organization?s remediation they hired an external consultant to provide chief financial officer/controller level services over the Organization?s accounting and financial processes. Timely and accurate accounting records will ensure the timely completion of future reporting requirements for the Organization.

View Audit 27380

Finding 32395 (2022-004)

Significant Deficiency 2022

Village of Clearwater, Nebraska

NE

Procurement, Suspension & Debarment Internal Control / Segregation of Duties § 200.317 § 200.327

Corrective Action Planned: The Village of Clearwater, Nebraska's management and Village Board will work on developing formal written procedures for procurement, suspension and debarment transactions. Additionally, the Village will adopt written standards of conduct covering conflicts of interest.. A...

Corrective Action Planned: The Village of Clearwater, Nebraska's management and Village Board will work on developing formal written procedures for procurement, suspension and debarment transactions. Additionally, the Village will adopt written standards of conduct covering conflicts of interest.. Anticipated Completion Date: Continuous. Responsible: Management and Village Board.

View Audit 28078

Finding 32393 (2022-003)

Significant Deficiency 2022

Cabrini University

PA

Questioned Costs Student Financial Aid Significant Deficiency

2022-003 Student Financial Assistance Cluster ? Assistance Listing No. 84.038 Recommendation: We recommend the University evaluate its procedures around the retention of Perkins loans r...

2022-003 Student Financial Assistance Cluster ? Assistance Listing No. 84.038 Recommendation: We recommend the University evaluate its procedures around the retention of Perkins loans records to ensure that all records for open loans are being properly maintained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University will continue to identify open loan records with missing master promissory notes. As such loan records are identified, the University will take necessary measures to request permission to assign these loans to the Department of Education. As this work is ongoing, all current loan records will continue to be stored securely in the Bursar?s area. Name(s) of the contact person(s) responsible for corrective action: Rita Lambert, Bursar Planned completion date for corrective action plan: August 31, 2023

View Audit 27062

Finding 32392 (2022-004)

Significant Deficiency 2022

Cabrini University

PA

Questioned Costs Student Financial Aid Significant Deficiency

2022-004 Student Financial Assistance Cluster ? Assistance Listing No. 84.268 Recommendation: We recommend the University review all R2T4 calculations to ensure the correct net disbur...

2022-004 Student Financial Assistance Cluster ? Assistance Listing No. 84.268 Recommendation: We recommend the University review all R2T4 calculations to ensure the correct net disbursed amounts are entered for all Title IV aid. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Office of Financial Aid will recalculate the R2T4 with the correct net disbursement amount and request the additional funding directly through COD. Going forward, the Office of Financial Aid will perform a secondary review of all R2T4 calculations prior to processing for accuracy. Name(s) of the contact person(s) responsible for corrective action: Robert Forest, Director of Financial Aid Planned completion date for corrective action plan: March 30, 2023

View Audit 27062 Questioned Costs: $1

Finding 32391 (2022-002)

Significant Deficiency 2022

Cabrini University

PA

Reporting Student Financial Aid Significant Deficiency

2022-002 Student Financial Assistance Cluster ? Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the University review its policies and procedures to ensure accurate e...

2022-002 Student Financial Assistance Cluster ? Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the University review its policies and procedures to ensure accurate effective dates are reported in both the campus and program level records submitted to the NSLDS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Registrar?s Office will review National Student Clearinghouse (NSC) information following transmission, particularly for effective dates of completely withdrawn students. The NSC reports enrollments to NSLDS for the University. Name(s) of the contact person(s) responsible for corrective action: Gerard J. Donahue, Registrar Planned completion date for corrective action plan: June 30, 2023

View Audit 27062

Finding 32390 (2022-002)

Material Weakness 2022

Christian Housing of St. Joseph, INC Chilton Place Apts.

MO

HUD Housing Programs Internal Control / Segregation of Duties Subrecipient Monitoring

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED MARCH 31, 2022 Name of Audit: Christian Housing of St. Joseph, Inc. HUD Project Number: 084-11148 Name of Audit Firm: Welch & Associates, LLC Period Covered by Audit: Year Ended March 31, 2022 Corrective Action Plan Prepared by: Name: Tamara Wallace Position...

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED MARCH 31, 2022 Name of Audit: Christian Housing of St. Joseph, Inc. HUD Project Number: 084-11148 Name of Audit Firm: Welch & Associates, LLC Period Covered by Audit: Year Ended March 31, 2022 Corrective Action Plan Prepared by: Name: Tamara Wallace Position: Executive Director ? Management Agent Telephone Number: 816-233-4250 Finding 2022-002 Comments on Findings and Each Recommendation: The Organization agrees with the auditors? finding. Action(s) Taken or Planned on the Finding: The Organization is in the process of selling its assets pending HUD approval and expects to dissolve within the next 12 months (see Note 11).

View Audit 27889

Finding 32389 (2022-001)

Material Weakness 2022

Christian Housing of St. Joseph, INC Chilton Place Apts.

MO

HUD Housing Programs Procurement, Suspension & Debarment Reporting

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED MARCH 31, 2022 Name of Audit: Christian Housing of St. Joseph, Inc. HUD Project Number: 084-11148 Name of Audit Firm: Welch & Associates, LLC Period Covered by Audit: Year Ended March 31, 2022 Corrective Action Plan Prepared by: Name: Tamara Wallace Position...

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED MARCH 31, 2022 Name of Audit: Christian Housing of St. Joseph, Inc. HUD Project Number: 084-11148 Name of Audit Firm: Welch & Associates, LLC Period Covered by Audit: Year Ended March 31, 2022 Corrective Action Plan Prepared by: Name: Tamara Wallace Position: Executive Director ? Management Agent Telephone Number: 816-233-4250 Findings-Financial Statement Audit None Findings-Federal Award Program Audit Federal Agency: Department of Housing and Urban Development Major Program: Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects Section 207/223f Assistance Listing Number: 14.155 Finding 2022-001 Comments on Findings and Each Recommendation: The Organization agrees with the auditors? finding. Action(s) Taken or Planned on the Finding: Management will ensure that the accounts reconcile to source documents, including report from the software used to process tenant rental activities. Management expects to establish the process by September 30, 2022.

View Audit 27889

Finding 32372 (2022-001)

Material Weakness 2022

School District of Haveford Township

PA

School Nutrition Programs Internal Control / Segregation of Duties Subrecipient Monitoring

Management?s Response: Management will implement safeguards to ensure responsible business office employees are held accountable for following procedures to ensure timely and complete monthly and annual financial reporting.

View Audit 28232

Finding 32371 (2022-002)

Material Weakness 2022

Inova Health System

VA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Recommendation: Inova Juniper Program?s (IJP) existing policies and procedures are in line with the requirements of the pass-through agreement with the Department; however, IJP should continue to evaluate whether appropriate oversight is performed to ensure that these policies and procedures are bei...

Recommendation: Inova Juniper Program?s (IJP) existing policies and procedures are in line with the requirements of the pass-through agreement with the Department; however, IJP should continue to evaluate whether appropriate oversight is performed to ensure that these policies and procedures are being followed with regard to eligibility verification for all clients. View of Responsible Officials: Management concurs with the finding and has implemented, during 2021 and 2022, procedures to ensure the appropriate oversight is performed regarding eligibility. inova.org Inova Health Care Services Name(s) of the Contact Person(s) Responsible for Corrective Action: Christopher T. Smith, Vice President of Finance and Corporate Controller, 571-472-8122. Christopher Trump, Senior Director of Financial Reporting, 571-373-2868. Michael H. Lowen, Director, Grant Accounting, 571-472-8108. Mara Carter, Senior Director Community Health, Inova Juniper Program, 703-321-2687 Planned Completion Date for Corrective Action Planned: Corrective action plan has been implemented.

View Audit 27876 Questioned Costs: $1

Finding 32369 (2022-001)

Significant Deficiency 2022

Inova Health System

VA

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Recommendation: Management should design internal controls related to the documentation of the review of the expenditures for the HRSA portal submission to ensure that the reported amounts are accurate. View of Responsible Officials: Management concurs with the finding and will implement procedures ...

Recommendation: Management should design internal controls related to the documentation of the review of the expenditures for the HRSA portal submission to ensure that the reported amounts are accurate. View of Responsible Officials: Management concurs with the finding and will implement procedures to ensure that HRSA reporting reports are prepared by individuals with HRSA reporting experience and reviewed by management prior to submission. Name(s) of the Contact Person(s) Responsible for Corrective Action: Christopher T. Smith, Vice President of Finance and Corporate Controller, 571-472-8122. Christopher Trump, Senior Director of Financial Reporting, 571-373-2868. Michael H. Lowen, Director, Grant Accounting, 571-472-8108. Planned Completion Date for Corrective Action Planned: Ongoing with a completion date of December 31, 2023.

View Audit 27876

Finding 32363 (2022-001)

Significant Deficiency 2022

Beaufort County

NC

Questioned Costs Eligibility Internal Control / Segregation of Duties

Finding 2022-001 Name of contact person: Amy Alligood, Income Maintenance Administrator Corrective Action: "Supervisors will be second partying records internally to ensure accuracy of cases. Applications will be reviewed and recertifications will be monitored ...

Finding 2022-001 Name of contact person: Amy Alligood, Income Maintenance Administrator Corrective Action: "Supervisors will be second partying records internally to ensure accuracy of cases. Applications will be reviewed and recertifications will be monitored on a rotation basis. Findings from second party reviews will be reviewed with the worker to monitor a pattern for errors and will review policy guidelines to ensure the worker is knowledgeable of policy requirements. Training will be provided to ensure all files have accurate information entry to include correct household composition and correct income calculations. Supervisors will provide training to ensure workers are aware of proper documentation required to support eligibility decisions. Checklists have been established to include errors cited during audit. Checklists are to be completed at applications and recertifications. " Proposed completion date: Training will be provided the week of November 7, 2022, to review findings and corrective action items. Trainings will continue every week to review policy changes, NCF AST updates as well as common errors that may be found during second party reviews. There were six ( 6) technical errors cited with a review date from a prior fiscal year.

View Audit 27610

Finding 32355 (2022-001)

Significant Deficiency 2022

Thomas Health System, Inc.

WV

Questioned Costs Reporting Significant Deficiency

Finding 2022-001 Program: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing Number: 93.498 Criteria: All recipients of Provider Relief Funds (PRF) payments must comply with the reporting requirements described in the PRF terms and conditions an...

Finding 2022-001 Program: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing Number: 93.498 Criteria: All recipients of Provider Relief Funds (PRF) payments must comply with the reporting requirements described in the PRF terms and conditions and specified in directions issued by the U.S. Department of Health and Human Services. Condition and Context: The System did not complete the PRF reporting for Period 2 in accordance with the U.S. Department of Health and Human Services guidance due to errors in the underlying data that lead to errors in the Period 2 report that was submitted. In the period 2 Submission, the System reported $2,283,650 of COVID-19 expenses, but failed to reduce the expenses by amounts reimbursed by other sources. Management updated their policies and procedures prior to Reporting Period 3 to address this issue. The System had $42,620,438 of lost revenue through Period 2 reporting, and has received $17,690,624 in PRF payments. Corrective Action Plan Corrective Action Planned: Thomas Health System, Inc. and its subsidiaries agrees with the finding, and policy and procedures were updated before reporting Period 3. Period 3 and 4 reporting were completed in accordance with the U.S. Department of Health and Human Services most guidance. The System received a notice from the Department of Health & Human Services dated December 29, 2022 that HRSA's Division of Financial Integrity has determined that the findings cited in the Single Audit Report for fiscal year October 1, 2020 through September 30, 2021 has been satisfactorily resolved. Name of Contact Person Responsible for Corrective Action: Timothy Skeldon, Chief Financial Officer, 4605 MacCorkle Ave SW, South Charleston, WV 25309 Anticipated Completion Date: Completed September 30, 2022

View Audit 28447

Finding 32353 (2022-002)

Material Weakness 2022

Spooner Health System

WI

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

FINDINGS?FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Health and Human Services 2022-002 Provider Relief Fund ? Assistance Listing No. 93.498 Recommendation: We recommend that management review the Provider Relief Fund guidelines to make sure amounts requested for reimbursement are in line with...

FINDINGS?FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Health and Human Services 2022-002 Provider Relief Fund ? Assistance Listing No. 93.498 Recommendation: We recommend that management review the Provider Relief Fund guidelines to make sure amounts requested for reimbursement are in line with the guidelines. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: During the onset of the COVID-19 pandemic and the distribution of the PRF dollars, there were many unknowns and many elements changed including criteria and timelines. The System will continue to review the PRF Terms and Conditions and understand these to the best of our knowledge. However, it is noted that there was sufficient lost revenue to support the PRF distributions received. Name(s) of the contact person(s) responsible for corrective action: Rebecca Busch, CFO Planned completion date for corrective action plan: We look to HRSA for guidance on how to correct the Period 1 report or will correct the error in a future reporting period. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Rebecca Busch, CFO at 715-939-1732.

View Audit 27255 Questioned Costs: $1

Finding 32352 (2022-003)

Material Weakness 2022

Spooner Health System

WI

Questioned Costs Material Weakness Reporting

2022-003 Provider Relief Fund ? Assistance Listing No. 93.498 Recommendation: We recommend the System review the Provider Relief Fund reporting guidelines to make sure the amounts claimed are in line with the guidelines. We also recommend a review take place to make sure all amounts claimed are corr...

2022-003 Provider Relief Fund ? Assistance Listing No. 93.498 Recommendation: We recommend the System review the Provider Relief Fund reporting guidelines to make sure the amounts claimed are in line with the guidelines. We also recommend a review take place to make sure all amounts claimed are correctly calculated. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: During the onset of the COVID-19 pandemic and the distribution of the PRF dollars, there were many unknowns and many elements changed including criteria and timelines. The System will continue to review the PRF Terms and Conditions and understand these to the best of our knowledge. Based on the updated lost revenue numbers the System?s lost revenue would have increased from what was reported in the Phase 1 PRF report. Name(s) of the contact person(s) responsible for corrective action: Rebecca Busch, CFO Planned completion date for corrective action plan: We look to HRSA for guidance on how to correct the Period 1 report or will correct the error in future reporting periods. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Rebecca Busch, CFO at 715-939-1732.

View Audit 27255

Finding 32351 (2022-004)

Significant Deficiency 2022

Spooner Health System

WI

Questioned Costs Allowable Costs / Cost Principles Cash Management

2022-004 Provider Relief Fund ? Assistance Listing No. 93.498 Recommendation: We recommend that management review the Provider Relief Fund guidelines to make sure amounts requested for reimbursement are in line with the guidelines and tie back to support. Explanation of disagreement with audit findi...

2022-004 Provider Relief Fund ? Assistance Listing No. 93.498 Recommendation: We recommend that management review the Provider Relief Fund guidelines to make sure amounts requested for reimbursement are in line with the guidelines and tie back to support. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: During the onset of the COVID-19 pandemic and the distribution of the PRF dollars, there were many unknowns and many elements changed including criteria and timelines. The System will continue to review the PRF Terms and Conditions and understand these to the best of our knowledge. However, it is noted that there was sufficient lost revenue to support the PRF distributions received. Name(s) of the contact person(s) responsible for corrective action: Rebecca Busch, CFO Planned completion date for corrective action plan: We look to HRSA for guidance on how to correct the Period 1 report or will correct the error in a future reporting period. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Rebecca Busch, CFO at 715-939-1732.

View Audit 27255 Questioned Costs: $1

Finding 32339 (2022-004)

None 2022

Thurston County Chamber of Commerce

WA

Internal Control / Segregation of Duties

CORRECTIVE ACTION PLAN Finding 2022-001 Internal Control over Bank Reconciliation and Vendor Invoice Management Response: Management agrees with this recommendation and have taken steps to implement proper review and documentation for bank reconciliations and vendor invoice approvals. Person Resp...

CORRECTIVE ACTION PLAN Finding 2022-001 Internal Control over Bank Reconciliation and Vendor Invoice Management Response: Management agrees with this recommendation and have taken steps to implement proper review and documentation for bank reconciliations and vendor invoice approvals. Person Responsible: President/CEO, Finance Officer, and Program Managers Finding 2022-02 Debarred and Suspended Vendors Management Response: Management agrees with this recommendation and have taken steps to develop and implement proper internal controls. Person Responsible: Finance Officer and Program Managers Finding 2022-03 Monitoring Subcontractor Performance Management response: Management agrees with the recommendation and have scheduled training for key personnel. Person Responsible: Program Managers Finding 2022-04 Written Approval of Subcontractors Management Response: Management agrees with this recommendation and have scheduled training for key personnel. Person Responsible: President/CEO and Program Managers Finding 2022-005 Indirect Cost Allocation ? Questioned Costs Management Response: Management agrees with the need for additional grant training, especially as it applies to calculating and allocating indirect costs. However, we do have issues with the classification of expenses within the original contract and hope we can reconcile those prior to the finalization of the grant award. Person Responsible: President/CEO Finance Officer

View Audit 27061

Finding 32338 (2022-003)

None 2022

Thurston County Chamber of Commerce

WA

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring

CORRECTIVE ACTION PLAN Finding 2022-001 Internal Control over Bank Reconciliation and Vendor Invoice Management Response: Management agrees with this recommendation and have taken steps to implement proper review and documentation for bank reconciliations and vendor invoice approvals. Person Resp...

CORRECTIVE ACTION PLAN Finding 2022-001 Internal Control over Bank Reconciliation and Vendor Invoice Management Response: Management agrees with this recommendation and have taken steps to implement proper review and documentation for bank reconciliations and vendor invoice approvals. Person Responsible: President/CEO, Finance Officer, and Program Managers Finding 2022-02 Debarred and Suspended Vendors Management Response: Management agrees with this recommendation and have taken steps to develop and implement proper internal controls. Person Responsible: Finance Officer and Program Managers Finding 2022-03 Monitoring Subcontractor Performance Management response: Management agrees with the recommendation and have scheduled training for key personnel. Person Responsible: Program Managers Finding 2022-04 Written Approval of Subcontractors Management Response: Management agrees with this recommendation and have scheduled training for key personnel. Person Responsible: President/CEO and Program Managers Finding 2022-005 Indirect Cost Allocation ? Questioned Costs Management Response: Management agrees with the need for additional grant training, especially as it applies to calculating and allocating indirect costs. However, we do have issues with the classification of expenses within the original contract and hope we can reconcile those prior to the finalization of the grant award. Person Responsible: President/CEO Finance Officer

View Audit 27061

Corrective Action Plans

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