Corrective Action Plans

Finding 12265 (2022-004)

Material Weakness 2022

MD

Questioned Costs Allowable Costs / Cost Principles Material Weakness

Finding 2022-004: Material Weakness over Allowable Costs - Review of Non-Payroll Expenditures Information on the Federal Program: Department of Human and Health - Center for Disease Control: Improving Epilepsy Programs, Services and Outcomes Through Partnerships. Finding: The Uniform Guidance req...

Finding 2022-004: Material Weakness over Allowable Costs - Review of Non-Payroll Expenditures Information on the Federal Program: Department of Human and Health - Center for Disease Control: Improving Epilepsy Programs, Services and Outcomes Through Partnerships. Finding: The Uniform Guidance requires organizations to establish internal controls to detect potential noncompliance. Management has an established control in place, in that all expenditures paid through the Concur system were reviewed and approved by an appropriate project manager, but did not retain evidence of this approval occurring during the year for 9 non-payroll expenditures chosen for testing. Planned Corrective Action: We had a number of technical issues with Concur which resulted in a cessation of use in January 2022 and a transition to PN3 which was being used for payables. We transitioned to PN3 in January 2022 and are no longer using Concur. PN3 maintains all audit trails. Name and Person Responsible: Caro Marie Brown (Senior Director of Finance), June Nolan (Accounts Payable Accountant), and Lindey Camerata (Controller). Anticipated Completion Date: January 2022.

View Audit 16547

Finding 12262 (2022-004)

Significant Deficiency 2022

Village of Armada

MI

Reporting Internal Control / Segregation of Duties

THE VILLAGE OF ARMADA WILL CREATE A FEDERAL AWARD ADMINISTRATION POLICY. DUE TO THE VERY MINIMAL TIMES THAT A SINGLE AUDIT IS REQUIRED, THE VILLAGE WILL LOCATE A SIMPLIFIED VERSION TO SUIT OUR REQUIREMENTS.

View Audit 16522

Finding 12251 (2022-001)

None 2022

Hartford Healthcare Corporation

CT

Questioned Costs Subrecipient Monitoring Reporting § 200.303

Management believes additional expenditures are available to offset the duplication of expenses as well as lost revenue which would remediate the duplication.

View Audit 16503 Questioned Costs: $1

Finding 12249 (2022-003)

Material Weakness 2022

Alamance County, North Carolina

NC

Questioned Costs Material Weakness Internal Control / Segregation of Duties

Finding: 2022-003 Name of Contact Person: Nicole Alston Corrective Action/Management?s Response: The WIC Director or Clerical Supervisor will provide training to the clerical team members regarding incoming transfers/certification periods. The training will include corrective action/work arou...

Finding: 2022-003 Name of Contact Person: Nicole Alston Corrective Action/Management?s Response: The WIC Director or Clerical Supervisor will provide training to the clerical team members regarding incoming transfers/certification periods. The training will include corrective action/work around in the event that the Crossroads system will not accept the correct certification dates indicated on the Verification of Certification from the previous WIC site. WIC will complete this training by 12/31/22 as evidenced by the meeting minutes and staff signatures. For quality assurance, the Clerical Supervisor will keep VOCs on file and will indicate if there were any issues with certification dates along with a follow-up date for auditing the client record. Proposed Completion Date: Immediately and Ongoing

View Audit 16498 Questioned Costs: $1

Finding 12248 (2022-002)

Material Weakness 2022

Alamance County, North Carolina

NC

Eligibility Material Weakness Internal Control / Segregation of Duties

Finding: 2022-002 Name of Contact Person: Nicole Alston Corrective Action/Management?s Response: The WIC Director, Clerical Supervisor or designee will randomly audit a minimum of 10 Crossroads records at least quarterly for quality assurance. WIC has revised the audit tool to include additio...

Finding: 2022-002 Name of Contact Person: Nicole Alston Corrective Action/Management?s Response: The WIC Director, Clerical Supervisor or designee will randomly audit a minimum of 10 Crossroads records at least quarterly for quality assurance. WIC has revised the audit tool to include additional eligibility criteria (attached for review). Proposed Completion Date: Immediately and Ongoing

View Audit 16498

Finding 12244 (2022-002)

Significant Deficiency 2022

Housing Authority of the City of Washington

GA

HUD Housing Programs Eligibility Internal Control / Segregation of Duties

2022-2 Condition: Deficiencies Noted in Examination of New Construction Section 8 Tenant Files Steps to resolve: We will review the internal control procedures over tenant file re-certifications and documents. Management has implemented procedures in order t...

2022-2 Condition: Deficiencies Noted in Examination of New Construction Section 8 Tenant Files Steps to resolve: We will review the internal control procedures over tenant file re-certifications and documents. Management has implemented procedures in order to clear this finding in FY 2023. Timeframe: By FYE December 31, 2023 Individual responsible for correction: Ms. Zena Zahran, Executive Director

View Audit 16463

Finding 12243 (2022-001)

Significant Deficiency 2022

Housing Authority of the City of Washington

GA

Questioned Costs HUD Housing Programs Internal Control / Segregation of Duties

2022-1 Condition: Deficiencies Noted in Cash Disbursements Steps to resolve: We will review the cash disbursement documentation process in order to ensure that each disbursement is fully documented. We will update internal control policies to ensure complete compliance with HUD regulations. Manag...

2022-1 Condition: Deficiencies Noted in Cash Disbursements Steps to resolve: We will review the cash disbursement documentation process in order to ensure that each disbursement is fully documented. We will update internal control policies to ensure complete compliance with HUD regulations. Management has implemented procedures to clear this finding in FY 2023. Timeframe: By FYE December 31, 2023 Individual responsible for correction: Ms. Zena Zahran, Executive Director

View Audit 16463

Finding 12242 (2022-004)

Significant Deficiency 2022

Pioneer Housing Development Inc. Dba John Paul Apartments 092-11212

MN

Special Tests & Provisions Questioned Costs Significant Deficiency

Finding 2022-004 Special Tests and Provisions Noncompliance and Significant Deficiency in Internal Control over Compliance U.S. Department of Housing and Urban Development CFA #14.134 Section 207 Insured Loan Balance Finding Summary: Upon termination of lease, Minnesota statutes require that th...

Finding 2022-004 Special Tests and Provisions Noncompliance and Significant Deficiency in Internal Control over Compliance U.S. Department of Housing and Urban Development CFA #14.134 Section 207 Insured Loan Balance Finding Summary: Upon termination of lease, Minnesota statutes require that the Project refund tenant security deposits within 21 days of termination of tenancy. The Project did not pay out one deposit within the 21 day requirement for termination of tenancy. Responsible Individuals: Brenda Weller, Director of Finance Corrective Action Plan: Management agrees with the finding and will work to refund tenant security deposits within 21 days of termination of tenancy. Anticipated Completion Date: December 31, 2023

View Audit 16461

Finding 12229 (2022-004)

Significant Deficiency 2022

Minnesota Prairie County Alliance

MN

Questioned Costs Eligibility Significant Deficiency

Finding Number: 2022-004 Finding Title: Child Support Non-Cooperation Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: Jeremy Allen Corrective Action Planned: Agency will correct the cases that were cited for errors. Supervisor will re...

Finding Number: 2022-004 Finding Title: Child Support Non-Cooperation Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: Jeremy Allen Corrective Action Planned: Agency will correct the cases that were cited for errors. Supervisor will review relevant policies for assets and child support non-coop with Eligibility workers on the Family Team to provide additional support and guidance for processing of these cases. Anticipated Completion Date: 8/31/2023

View Audit 16416

Finding 12228 (2022-003)

Significant Deficiency 2022

Minnesota Prairie County Alliance

MN

Questioned Costs Eligibility Significant Deficiency

Finding Number: 2022-003 Finding Title: Eligibility Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: Jeremy Allen Corrective Action Planned: Agency will correct the cases that were cited for errors. Supervisor will review relevant poli...

Finding Number: 2022-003 Finding Title: Eligibility Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: Jeremy Allen Corrective Action Planned: Agency will correct the cases that were cited for errors. Supervisor will review relevant policies for assets and child support non-coop with Eligibility workers on the Family Team to provide additional support and guidance for processing of these cases. Anticipated Completion Date: 8/31/2023

View Audit 16416

Finding 12222 (2022-001)

Significant Deficiency 2022

Benevolent Corporation Cedar Community

WI

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

Finding #2022-001: Internal Controls Over Compliance Related to Payroll; Federal Program: Provider Relief Fund (93.498); Response: We will review department documentation of hours allocated to grants; Responsible party: Kevin Sander, Controller; Estimated Completion: The very next payroll submission...

Finding #2022-001: Internal Controls Over Compliance Related to Payroll; Federal Program: Provider Relief Fund (93.498); Response: We will review department documentation of hours allocated to grants; Responsible party: Kevin Sander, Controller; Estimated Completion: The very next payroll submission.

View Audit 16382

Finding 12221 (2022-001)

Significant Deficiency 2022

The Housing Authority of the City of Decatur, Alabama

AL

Questioned Costs Special Tests & Provisions Reporting

February 10, 2023 Rubino & Company 6903 Rockledge Drive, Suite 1200 Bethesda, MD 20817-1818 Re: Corrective Action Plan to Finding 2022-001 Housing Authority of the City Decatur received the draft audit report for Fiscal Year Ended June 30, 2022. As per your request, this is the Corrective Action Pla...

February 10, 2023 Rubino & Company 6903 Rockledge Drive, Suite 1200 Bethesda, MD 20817-1818 Re: Corrective Action Plan to Finding 2022-001 Housing Authority of the City Decatur received the draft audit report for Fiscal Year Ended June 30, 2022. As per your request, this is the Corrective Action Plan for the finding in Section III ? Federal Award Findings and Questioned Costs. Finding 2022-001 Public and Indian Housing ? Special Test and Provisions ? Wage Rate Requirements Significant Deficiency in Internal Controls Cause: The Authority failed to obtain payroll reports for one of the contracts that required Davis-Bacon wage requirements. Auditor?s Recommendation: We recommend that DHA obtain and review the missing payroll reports from the contractor, and if necessary, follow up on any non-compliance. DHA should also establish procedures to ensure that required payroll reports are obtained for all contracts subject to Davis-Bacon wage requirements. DHA Corrective Action Plan: DHA failed to obtain payroll reports from said contractor. Moving forward Taura L. Denmon, Executive Director or Mechelle Dowdy, Director of Housing will be responsible for receiving and checking Davis-Bacon wage reporting requirements. Staff Contact: Taura L. Denmon, Executive Director Target Completion Date: October 31, 2022 Sincerely, Taura L. Denmon Executive Director

View Audit 16376

Finding 12220 (2022-001)

Material Weakness 2022

Hsg Authority of the City of Lakewood Dba Metro West Housing Solutions

CO

HUD Housing Programs Material Weakness Special Tests & Provisions

Department of Housing and Urban Development Federal Financial Assistance Listing #14.871 Section 8 Housing Choice Vouchers Program Special Tests and Provisions: Housing Quality Standards Failed Inspections Material Weakness Finding Summary: Metro West Housing Solutions did not perform re-inspection...

Department of Housing and Urban Development Federal Financial Assistance Listing #14.871 Section 8 Housing Choice Vouchers Program Special Tests and Provisions: Housing Quality Standards Failed Inspections Material Weakness Finding Summary: Metro West Housing Solutions did not perform re-inspections of 6 failed inspections within the prescribed 30-day HAP requirement during 2022. Responsible Individuals: Tillie Wright, HCV Administrator Corrective Action Plan: It was decided that adding back the position of in-house full-time inspector and an additional Section 8 Housing Specialist was the step needed to better keep on top of inspections. The inspector was hired on 6/22/2023 and started work on 07/10/2023. He has passed his HQS training test. In addition, he, and HCV Administrator both did a short training on the Inspection Module through Yardi. He is currently shadowing the former in-house inspector who is employed at MWHS in a different position. Once the new inspector is fully trained, the HCV Administrator plans to shift some responsibilities over to him, including scheduling and coordination of inspections both in house and 3rd party, insuring all the PIC submissions are entered, and monitoring all failed inspections. The Section 8 team was short staffed most of 2022. They will be fully staffed including the additional team member on 8/13/2023 when two new hires start. Anticipated Completion Date: We anticipate the inspector will be fully trained by mid-August 2023 and after training will slowly start taking over duties from the HCV Administrator over the next 30 days. The two new Specialists should be trained by the end of September and staff case loads will be redistributed in the next few months following that.

View Audit 16367

Finding 12216 (2022-001)

Significant Deficiency 2022

Duncanville Independent School District

TX

Questioned Costs Special Tests & Provisions Significant Deficiency

Corrective Action Plan Finding 2022-001 Assistance Listing # 84.010A Title I, Part A Department of Education passed through Texas Education Agency Compliance Requirements: Special Tests and Provisions - Annual Report Card, High School Graduation Rate Significant Deficiency in Controls over Complianc...

Corrective Action Plan Finding 2022-001 Assistance Listing # 84.010A Title I, Part A Department of Education passed through Texas Education Agency Compliance Requirements: Special Tests and Provisions - Annual Report Card, High School Graduation Rate Significant Deficiency in Controls over Compliance Views of Responsible Officials and Planned Corrective Actions: While Duncanville High School works diligently to make sure that all students leaving the district are correctly documented, we will take the following measures to insure that 100% of leaver records are complete and accurate: 1. DHS will immediately begin cross training office personnel so that multiple personnel will be able to correctly withdraw all students, 2. DHS will put into place a fail-safe system where all withdrawal documents are double checked and signed off by an administrator, and 3. The PEIMS department will check all records for accuracy and completion for all students withdrawing. These steps will insure that Duncanville High School will be 100% complaint with all withdrawal of students. Person responsible: Duncanville High School: Executive Principal PEIMS: Director of Informational lSystems

View Audit 16362

Finding 12207 (2022-001)

Significant Deficiency 2022

Independent School District No. 696

MN

Internal Control / Segregation of Duties

Finding Number: 2022-001 Finding Title: SEGREGATION OF DUTIES Name of Contact Person Responsible for Corrective Action Spencer Aune, Business Manager Corrective Action Planned Management will attempt to monitor transactions. and structure the duties of office personnel to help ensure as much segrega...

Finding Number: 2022-001 Finding Title: SEGREGATION OF DUTIES Name of Contact Person Responsible for Corrective Action Spencer Aune, Business Manager Corrective Action Planned Management will attempt to monitor transactions. and structure the duties of office personnel to help ensure as much segregation of duties as possible within the District's staffing limitations and funding constraints. Anticipated Completion Date Ongoing.

View Audit 16347

Finding 12203 (2022-001)

None 2022

School of Excellence in Education

TX

Questioned Costs Internal Control / Segregation of Duties Special Tests & Provisions

Summary Description: During the summer the Campus Testing Coordinator (Instructional Coach) for the campus resigned. Although the testing coordinators received testing security training that included the required storage of documentation, there was not a set of internal controls to ensure that the d...

Summary Description: During the summer the Campus Testing Coordinator (Instructional Coach) for the campus resigned. Although the testing coordinators received testing security training that included the required storage of documentation, there was not a set of internal controls to ensure that the documentation would be secured for the district. Points of Contact: ? Superintendent, Dr. Mechiel Rozas, mechiel.rozas@legacytraditional.org ? District STAAR Testing Coordinator, Valarie Walker, valarie.walker@legacytraditional.org ? Campus STAAR Campus Coordinator 2002-2023: Kehinde Stevenson, Evonne Murillo, Kim Wood, Molly Stumpo Resources Requirements: ? Campus Testing Coordinators have trained each semester using slides prepared by TEA with an overview of documentations requirements and storage. ? Testing Security training for Campus Testing Coordinators using the Learning Management System (LMS) in the Testing Information Distribution Engine (T.I.D.E.) Planned Milestones: ? Fall Campus Testing Coordinator Training (October 27, 2022) ? Training and signed documentation to verify understanding of the security requirements for the year and the steps to ensure securing protocols are followed if there is an early departure from duties. ? Campus Testing Coordinators meet with the District Testing Coordinator monthly to review expectations and confirm compliance. This information is shared with the district Superintendent on the first Monday in each month. ? Spring Campus Testing Coordinator Training (January 11, 2023) ? Training and signed documentation to verify understanding of the security requirements for the year and the steps to ensure securing protocols are followed if there is an early departure from duties. ? Original copies of documents submitted to the District Testing Coordinator at the end of each testing session and copies filed for the campus and maintained at the campus level (December 16, 2022 EOC; April 3, 2023 TELPAS; May 15, 2023 Spring STAAR and EOC; June 30, 2023 Summer EOC). Scheduled Completion Date: The campus Testing Coordinator will secure the Campus Principal signage page completed with final submission to the District Testing Coordinator along with Principal oaths by May 15, 2023 for elementary campuses and June 30,2023 for the high school campus. Change in Procedure: The District Testing Coordinator has enhanced the training for testing procedures and systems of accountability have been created. Campus Testing Coordinator training now includes testing security responsibilities if there is a departure from the position or the district. The district will continue to train Campus Testing Coordinators twice a year, but the internal controls now include the collection of original documents on specific dates at the end of each testing session, rather than at the end of the school year, along with monthly checks for compliance. The Principal of each campus must review the testing binder and secure storage of materials after completing the signage document in the testing binder and ensure submission of the testing binder to the District Testing Coordinator by the scheduled completion dates.

View Audit 16336

Finding 12197 (2022-001)

Material Weakness 2022

Forrest City School District

AR

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

Contact Person(s) Responsible for Corrective Action: Dr. Tiffany Hardrick, Superintendent and Sharon Wilson, Federal Coordinator Corrective Action Planned: All services prepaid for professional development were rendered and properly documented, i.e participant sign in sheets and agendas which i...

Contact Person(s) Responsible for Corrective Action: Dr. Tiffany Hardrick, Superintendent and Sharon Wilson, Federal Coordinator Corrective Action Planned: All services prepaid for professional development were rendered and properly documented, i.e participant sign in sheets and agendas which is required as part of the districts control procedures to ensure that services paid for are in fact received . It should be noted that the district prepaid for services based on verbal and email guidance of the Public-School Program Manager from DESE public school accountability department. The purpose of prepayment was to avoid returning funds as advised. (Email Documentation can be provided). In addition, Solution Tree, a state approved partner, sent an email as recently as April 3, 2023 encouraging districts to "Pre-pay years of PD with federal funds". (Documentation can be provided). However, the district will implement procedures to review payments to vendors in the future to ensure that services have been rendered prior to payment. Anticipated Completion Date: The corrective actions are anticipated to be complete and in place immediately after the completion date of this audit.

View Audit 16316 Questioned Costs: $1

Finding 12195 (2022-002)

Significant Deficiency 2022

Ensign College

UT

Student Financial Aid Significant Deficiency Matching / Level of Effort / Earmarking

Management Views and Corrective Action Plan Year Ending December 31, 2022 Finding 2022-002 ? Pell Grant Notification Letters Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing #: 84.063 Title: Federal Pell Grant Program Award Years: 7/2021 ? 6/2023...

Management Views and Corrective Action Plan Year Ending December 31, 2022 Finding 2022-002 ? Pell Grant Notification Letters Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing #: 84.063 Title: Federal Pell Grant Program Award Years: 7/2021 ? 6/2023 Management agrees with the finding and proposes the following Corrective Action Plan: Corrective Action Plan This issue is a result of no manual or system controls in place to prevent disbursement of financial aid to a student?s account if a student?s federal financial aid award notification was not yet communicated. This issue was corrected as soon as it was identified by changing our procedures to require Pell notification letters be sent as soon as funds are awarded and before funds are disbursed to a student?s account. As an additional precaution, Pell notification letters will be added to the nightly batch process in PeopleSoft to ensure letters are sent timely. Financial aid staff will also receive additional training in this area. Timing Procedures will be changed in May 2023 by Riley Niemand, Manager of Financial Aid, to require Pell notification letters be sent as soon as funds are awarded and prior to funds being disbursed to a student?s account. During May 2023, Riley Niemand will also provide additional training to financial aid staff in this area. Additionally, Riley Niemand started working with a consultant to add Pell notification letters to the daily batch process. This work is expected to be complete by June 2023. Sincerely, S.Christopher Reitz Director of Financial Services and Controller creitz@ensign.edu 801-524-8109

View Audit 16301

Finding 12175 (2022-002)

Significant Deficiency 2022

Refugee Empowerment Center

NE

Questioned Costs Allowable Costs / Cost Principles Cash Management

Corrective Action Plan: The organization is implementing new software for tracking client expense, which has functionality to import copies of credit card receipts and check requests into each client?s record. We have emphasized to case managers the importance of keeping receipts. Reasonable complet...

Corrective Action Plan: The organization is implementing new software for tracking client expense, which has functionality to import copies of credit card receipts and check requests into each client?s record. We have emphasized to case managers the importance of keeping receipts. Reasonable completion date: June 1, 2023 Responsible Party: Tanya DeWolf, Director of Refugee Services

View Audit 16282

Finding 12174 (2022-001)

Material Weakness 2022

Refugee Empowerment Center

NE

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.431

Corrective Action Plan: The organization has implemented a new payroll system, which includes time tracking. It has also changed its policy to pay overtime rather than accruing comp-time, as well as an implementing an unlimited PTO policy. These changes will eliminate charging grants for undocumente...

Corrective Action Plan: The organization has implemented a new payroll system, which includes time tracking. It has also changed its policy to pay overtime rather than accruing comp-time, as well as an implementing an unlimited PTO policy. These changes will eliminate charging grants for undocumented accrued time. Reasonable completion date: October 1, 2022 Responsible Party: Rick Rummel, Director of Finance & Administration

View Audit 16282 Questioned Costs: $1

Finding 12169 (2022-001)

None 2022

Frankenmuth School District

MI

Cash Management School Nutrition Programs Questioned Costs

Certain matters were brought to our attention as a result of the audit process. These are described more fully in the Schedule of Findings and Questioned Costs. We evaluated the matters noted below, and have described our planned actions as a result. 2022-001 - Program Income - Food Se...

Certain matters were brought to our attention as a result of the audit process. These are described more fully in the Schedule of Findings and Questioned Costs. We evaluated the matters noted below, and have described our planned actions as a result. 2022-001 - Program Income - Food Service Fund Balance Management Assessment - We concur with the audit assessment regarding this matter. Planned Corrective Action - The District is aware of the USDA fund balance requirements. The District operated under the Seamless Summer Option during fiscal year 2021-22 which allowed all of our students to eat both breakfast and lunch for free. The District received a large amount of federal funding which in turn resulted in more fund balance than allowed by USDA at 6/30/2022 ($5,466). The Food Service Director and Business Manager are in the process of creating a spenddown plan to be submitted to MDE which will move fund balance within an allowable range. Responsible Party - Business Manager Date of Planned Corrective Action - June 2023

View Audit 16273

Finding 12166 (2022-001)

Significant Deficiency 2022

Marana Health Center, INC

AZ

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties

Marana Health Center, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit Period: July 1, 2021 - June 30, 2022 Category: GENERAL MARANA HEALTH CENTER, INC. AD-2-010 Procedure: Sliding Fee Schedule Patient Demographic Changes Page 1 of 2 I. ...

Marana Health Center, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit Period: July 1, 2021 - June 30, 2022 Category: GENERAL MARANA HEALTH CENTER, INC. AD-2-010 Procedure: Sliding Fee Schedule Patient Demographic Changes Page 1 of 2 I. PURPOSE: The Sliding Fee Schedule (SFS) Patient Demographic Changes process was created to ensure any patient who is certified on MHC Healthcare's (MHC) SFS and has changes on their Patient Profile (Profile) to their Family Size and/or Income are referred to the Outreach Department (OR) and that these changes are only made by an OR employee or the OR Manager. II. PROCESSES: A. Front Office (FO) staff print Profiles from the Electronic Health Record (EHR) for all patient appointments, which allows patients to make required changes to their demographics on file. This includes Family Size and/or Income. When a patient on MHC's SFS notifies FO of changes to the aforementioned demographics, the patient must be referred to the MHC OR Department for further review. Only OR staff may make these demographic changes in the EHR for SFS Patients. Ill. PROCEDURES: A. FO staff will print a Profile for all patient appointments. 1. FO will ensure all patients review the Profile for required changes to their demographics in the EHR system. a. If the patient is on the SFS and notates any changes required on the Profile to be made to their Family Size and/or Income, the FO will: 1) Immediately notify the health center's assigned OR employee that a patient in the office for an appointment has required changes to these demographics. a) Notification can be made via telephone or a Teams message. b) If the site does not have an assigned OR employee, notification will be made to the OR Manager. 2) The OR employee will respond to FO: a) The patient is placed on the OR schedule for an immediate appointment while the patient is in the health center and available, either prior to or after the clinical visit, depending on allowable time. b) An appointment will be scheduled while the patient is in the health center for a later date to review changes and the possible affect these changes may have on the patient's SFS certification and/or SFS tier. c) The patient is contacted via telephone by the OR employee to schedule an appointment to review the possible changes to the patient's SFS certification and/or SFS tier. d) When scheduling the appointment, the patient may schedule it at the Health Center or choose to have this appointment via telehealth. 3) Only OR employees may change the Family Size and/or Income demographics in the EHR for SFS patients. a) FO will make all necessary demographic changes in the EHR, excluding Family Size and/or Income. b. FO will scan the Profile into the EHR and forward a copy to the appropriate OR employee. 2. The OR Manager will ensure that FO staff have a current list of OR employees, along with appropriate contact information and location. Category: GENERAL MARANA HEALTH CENTER, INC. AD-2-010 Procedure: Sliding Fee Schedule Patient Demographic Changes Page 2 of 2 3. The OR Manager will immediately communicate any deviations to this policy and procedure to the assigned Associate Director of Integrated Operations (ADIO) when noted. IV. REFERENCES: Sliding Fee Schedule V. ATTACHMENTS: None Approved: Original Approval: 09/2022 9/28/2022 Date 9/28/2022 Date Reviewed/Revised: Responsible Party: Director, Integrated Operations If the Department of Health and Human Services has questions regarding this plan, please call Tamie Olson, CFO at (520) 784-8655.

View Audit 16269

Finding 12150 (2022-001)

Significant Deficiency 2022

Richland Medical Center, Inc. D/b/a Central Ozarks Medical Center

MO

Questioned Costs Subrecipient Monitoring Eligibility

CORRECTIVE ACTION PLAN May 30, 2023 United States Department of Health and Human Services Richland Medical Center, Inc. d/b/a Central Ozarks Medical Center respectfully submits the following corrective action plan for the year ended November 30, 2022. CohnReznick LLP 350 Church Street Hartford, CT 0...

CORRECTIVE ACTION PLAN May 30, 2023 United States Department of Health and Human Services Richland Medical Center, Inc. d/b/a Central Ozarks Medical Center respectfully submits the following corrective action plan for the year ended November 30, 2022. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: November 30,2022 The findings from the November 30, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS SIGNIFICANT DEFICIENCIES Health Center Program Cluster, Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), COVID - 19 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), and Grants for New and Expanded Services under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 2022-001 Recommendation The Center should ensure that internal controls are in place to effectively ensure that patients receive the correct sliding fee discount. Action Taken In May 2022 COMC hired a Sliding Fee Coordinator. This position reviews all new slide fee applications to ensure all required documentation is present and that the correct slide scale has been applied. This position also reviews current slide applications for patients that are sacheduled for upcoming appointments to ensure paperwork is current or if paperwork is outdated a new application is received. This position also monitors and trains staff on the slide fee process. The finding from this year was prior to the position being filled in 2022. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Sabrina McAfee, CFO at (573) 836-7079. Sincerely yours, Sabrina McAfee Chief Financial Officer

View Audit 16226

Finding 12149 (2022-001)

Significant Deficiency 2022

Nutrition, INC

IN

Internal Control / Segregation of Duties Questioned Costs

Finding 2022-001 ? Financial Statement and Federal Awards Statement of Condition: Nutrition was not segregating duties of accounting and administrative responsibilities for internal control purposes. Status: Coming out of the pandemic impacted the ability to complete the segregation of duties proces...

Finding 2022-001 ? Financial Statement and Federal Awards Statement of Condition: Nutrition was not segregating duties of accounting and administrative responsibilities for internal control purposes. Status: Coming out of the pandemic impacted the ability to complete the segregation of duties process, due to the lack of staff. As a result, Nutrition is working to develop the processes that will help to implement the procedures that will segregate duties and will continue working with team members to implement processes to segregate duties moving forward. At this time, the development is on-going and will take place when the business growth warrants and supports such an action. Presently, adding additional staff to provide another layer of preparation, review, and monitoring would outweigh the costs.

View Audit 16224

Finding 12117 (2022-003)

Material Weakness 2022

Vanderbilt University Medical Center

TN

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

Federal Grantor: U.S. Department of Health and Human Services (HHS) Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498, COVID 19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution All expenditures included by VUMC Management (Management) in its sub...

Federal Grantor: U.S. Department of Health and Human Services (HHS) Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498, COVID 19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution All expenditures included by VUMC Management (Management) in its submissions in the Department of Health and Human Services (HHS) portal were verified against HHS guidance to ensure allowability. Management understands that additional audit evidence must be retained at a detailed enough level to allow the auditor to meet their reperformance standard. Management believes that our control risk is mitigated by the fact that our lost revenues far exceed any provider relief funding received. However, should management need to report any future eligible expenses in the HHS portal, we will retain additional audit evidence to enable auditor reperformance of the controls regarding allowability of expenditures. Management also established appropriate review and approval controls surrounding the performance and review of the lost revenue analytic and the subsequent reporting of lost revenue in the HHS portal. Management retained documentation to support execution of this control; however, Management understands that additional audit evidence supporting the reviews was not available to the auditor to evidence execution of this control. Management will retain additional audit evidence to allow the auditor to reperform execution of this control for future HHS portal submissions. Paula Yarbrough, VUMC Director ? Grants and Contracts, will be responsible for implementation by fiscal year-end 2023.

View Audit 16159

Corrective Action Plans

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