Corrective Action Plans

Finding 51195 (2022-008)

Significant Deficiency 2022

State of Delaware

DE

Questioned Costs Reporting Significant Deficiency § 200.303

Reference Number: 2022-008 Prior Year Finding: No Federal Agency: U.S. Department of Labor State Department Name: Department of Labor ` Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 ? Unemployment Insurance Assistance Listing Number: 17.225 Award Number and Yea...

Reference Number: 2022-008 Prior Year Finding: No Federal Agency: U.S. Department of Labor State Department Name: Department of Labor ` Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 ? Unemployment Insurance Assistance Listing Number: 17.225 Award Number and Year: UI340502055A10 (10/1/2019 ? 12/31/2022), UI347072055A10 (4/1/2020 ? 6/30/2023), UI372152255A10 (10/1/2021 ? 12/31/2024) Compliance Requirement: Reporting ? ETA 9130, Financial Status Report, UI Programs Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend the Division review and enhance procedures and internal controls to ensure that ETA 9130 reports are submitted accurately and that they tie to supporting documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Fiscal department has added to our Policy and Procedures the terms of the reporting period being 45 days after then end of the quarter. It was also posted on a group calendar to begin work on the reports at 30 days after quarter end. Name(s) of the contact person(s) responsible for corrective action: Laurie Wexler Planned completion date for corrective action plan: 01/03/2023

View Audit 43524 Questioned Costs: $1

Finding 51184 (2022-007)

Significant Deficiency 2022

State of Delaware

DE

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

Reference Number: 2022-007 Prior Year Finding: No Federal Agency: U.S. Department of Labor State Department Name: Department of Labor State Division Name: Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 ? Unemployment Insurance Assistance Listing Number: 17.225 A...

Reference Number: 2022-007 Prior Year Finding: No Federal Agency: U.S. Department of Labor State Department Name: Department of Labor State Division Name: Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 ? Unemployment Insurance Assistance Listing Number: 17.225 Award Number and Year: UI340502055A10 (10/1/2019 ? 12/31/2022), UI347072055A10 (4/1/2020 ? 6/30/2023), UI372152255A10 (10/1/2021 ? 12/31/2024) Compliance Requirement: Reporting ? ETA 9050 - Time Lapse of All First Payments except Workshare Report Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: The Division should review and enhance procedures and internal controls to ensure that ETA 9050 reports are submitted timely, by the 20th of the month following the month to which the data relates. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: DE has put a process in place to monitor and track the progress and timeliness of all ETA reporting. Auto-reminders will be created to notify all units responsible for ETA reports two weeks before the due date. Name(s) of the contact person(s) responsible for corrective action: Marie Cameron Planned completion date for corrective action plan: Timeliness Issue corrected. The ETA 9050 has been submitted timely for the months following 12/31/2021, except for the report period 07/31/2022. Auto reminders will be completed by 4/15/2023

View Audit 43524

Finding 51183 (2022-006)

Significant Deficiency 2022

State of Delaware

DE

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

Reference Number: 2022-006 Prior Year Finding: 2021-003 Federal Agency: U.S. Department of Labor State Department Name: Department of Labor State Division Name: Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 ? Unemployment Insurance Assistance Listing Number: 17...

Reference Number: 2022-006 Prior Year Finding: 2021-003 Federal Agency: U.S. Department of Labor State Department Name: Department of Labor State Division Name: Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 ? Unemployment Insurance Assistance Listing Number: 17.225 Award Number and Year: UI340502055A10 (10/1/2019 ? 12/31/2022), UI347072055A10 (4/1/2020 ? 6/30/2023), UI372152255A10 (10/1/2021 ? 12/31/2024) Compliance Requirement: Reporting ? ETA 2208A, Quarterly UI Above-Base Report Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Recommendation: The Division should review and update its reporting procedures and controls to ensure that ETA 2208A ? Quarterly UI Above-Base Reports are submitted no later than 30 days after the end of each quarter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Fiscal department has added to our Policy and Procedures the terms of the reporting period being 30 days after then end of the quarter. It was also posted on a group calendar to begin work on the reports at 20 days after quarter end. Name(s) of the contact person(s) responsible for corrective action: Laurie Wexler Planned completion date for corrective action plan: 01/03/2023

View Audit 43524

Finding 51182 (2022-005)

Material Weakness 2022

State of Delaware

DE

Special Tests & Provisions Material Weakness Matching / Level of Effort / Earmarking § 200.303

Reference Number: 2022-005 Prior Year Finding: 2021-005 Federal Agency: U.S. Department of Labor State Department Name: Department of Labor State Division Name: Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 ? Unemployment Insurance Assistance Listing Number: 17...

Reference Number: 2022-005 Prior Year Finding: 2021-005 Federal Agency: U.S. Department of Labor State Department Name: Department of Labor State Division Name: Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 ? Unemployment Insurance Assistance Listing Number: 17.225 Award Number and Year: UI340502055A10 (10/1/2019 ? 12/31/2022), UI347072055A10 (4/1/2020 ? 6/30/2023), UI372152255A10 (10/1/2021 ? 12/31/2024) Compliance Requirement: Special Tests and Provisions ? Employer Experience Rating Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Recommendation: The Division should review and enhance procedures and controls to ensure that employer experience rates are properly calculated and applied. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: MERIT rating was completed on a Emergency Rule due to COVID 19 pandemic. Mainframe system required manual intervention to complete this special law. DOL does not consider the rate the employer places on the UC8 tax form only the rate assessed. The accounts that were incorrect were a result of the special rule and needed constant manual intervention. Should an overpayment occur DOL notifies employer of credit and allows them to utilize that on future quarterly payments. If the credit cannot be used we issue a check for the refund. DOL Staff created Emergency Rule 21 changing the tax table to correct the mainframe issue. Name(s) of the contact person(s) responsible for corrective action: Laura Henderson Planned completion date for corrective action plan: Resolved

View Audit 43524

Finding 51181 (2022-004)

Material Weakness 2022

State of Delaware

DE

Special Tests & Provisions Procurement, Suspension & Debarment Material Weakness § 200.303

Reference Number: 2022-004 Prior Year Finding: No Federal Agency: U.S. Department of Labor State Department Name: Department of Labor State Division Name: Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 ? Unemployment Insurance Assistance Listing Number: 17.225 A...

Reference Number: 2022-004 Prior Year Finding: No Federal Agency: U.S. Department of Labor State Department Name: Department of Labor State Division Name: Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 ? Unemployment Insurance Assistance Listing Number: 17.225 Award Number and Year: UI340502055A10 (10/1/2019 ? 12/31/2022), UI347072055A10 (4/1/2020 ? 6/30/2023), UI372152255A10 (10/1/2021 ? 12/31/2024) Compliance Requirement: Special Tests and Provisions ? UI Benefit Payments Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance Recommendation We recommend the Division review and enhance procedures and controls to ensure that BAM case investigations are completed timely in accordance with the time limits established in the ET Handbook No. 395. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. The BAM Unit experienced high turnover volumes during the pandemic, creating a backlog of UI Benefit investigations. The pandemic also changed the workforce dynamic, creating a culture of fully remote jobs in many job markets, which left most State agencies struggling to fill positions; because of this, State Government lost its competitive edge as an employer, resulting in low applicant response to job postings. It took the BAM unit several job reposting?s to get vacancies filled. However, we have filled most of the vacancies and will conduct interviews on Friday, 03/24/23, to fill the remaining two vacancies in the unit. We also recently made a change to our training strategy. There will be consecutive weeks of training in a classroom setting, along with OTJT. The BAM unit also assigns all available NASWA training to new hires during their first weeks of employment. We chose this training strategy to provide all new hires with consistent training to ensure understanding of the BAM investigative process. In addition, we will be hiring a Sr. accountant who will focus on all backlog items only. We are also in the process of converting all paper-driven methods to fully electronic ones. All BAM employees will receive the necessary tools, training, and work-from-home equipment for working successfully from home, allowing us to maintain production in case of another catastrophic event. Name(s) of the contact person(s) responsible for corrective action: Edward Gregware, Ann Marie Vanderhout, and Marie Cameron Planned completion date for corrective action plan: The management team is working on a plan to resolve all case investigation backlogs. We will be hiring a Sr. Accountant who will focus solely on backlogged cases. We now have three QC BAM auditors and will be hiring a fourth. Once fully trained, all BAM auditors will be assigned 7 cases weekly to complete within 45 days to ensure we meet the time frames established in the ETA Handbook No. 395. An auditor takes approximately 3 to 6 months to train and operate independently. At a minimum, it will take around 12 to 18 months to get new hires properly trained and backlogs resolved.

View Audit 43524

Finding 51125 (2022-002)

Significant Deficiency 2022

Kennesaw State University Research and Service Foundation, Inc.

GA

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking

Audit Finding Number: 2022-002 Auditee?s Response: The Foundation concurs with Finding 2022-002 Corrective Action Plan: Sponsored Programs is in the process of implementing a new software system (Maximus) allowing for systematic Time and Effort (TE) tracking rather than manual. Time and Effort repor...

Audit Finding Number: 2022-002 Auditee?s Response: The Foundation concurs with Finding 2022-002 Corrective Action Plan: Sponsored Programs is in the process of implementing a new software system (Maximus) allowing for systematic Time and Effort (TE) tracking rather than manual. Time and Effort reports will be generated in the Maximus system which will allow for completion tracking and reminder alerts to all parties. Implementation related to the corrective action plan in the prior year had been delayed due to the company?s schedule but is currently on track for completion by the anticipated completion date. Concurrently, Grants Accounting will serve in a support role verifying all TE certification forms have been received based off the list generated by Sponsored Programs/Maximus. SponProg and Grants Accounting have already met to generate an ongoing schedule for future TE cycles to ensure timely processing and collection. Grants Accounting management will meet with Kennesaw State University?s payroll department and the auditors to review available reporting options for TE charges based on pay periods. One of the missing certifications were for an award noted as a prize. Three were for a program where the TE form was provided, but the responsible person did not sign. While the services recorded to the grant were appropriate, management will refund the amounts associated with missing certifications to the respective grants. Anticipated Completion Date: Maximus Go Live is scheduled for July 2023 pending any further implementation delays. KSU is currently in the data testing phase with the Maximus implementation team. Schedule for future cycles has already been developed and implemented as of March 2023. The review of payroll reports will work in conjunction with the implementation of Maximus. Responsible Person, Title: Renita Wiley, Director of Sponsored Programs / Rob Bridges, Director of Grants Accounting Approved: Rob Bridges Date: 3/31/2023

View Audit 41338 Questioned Costs: $1

Finding 51118 (2022-001)

Material Weakness 2022

City of Headland

AL

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.302 § 200.305

The City is in agreement with the finding noted and will consider formally documenting policies and procedures. Heather Shippey, City Clerk will be responsible for the corrective action and anticipated completion of corrective action will be taken before September 30, 2023.

View Audit 48078

Finding 51112 (2022-001)

Significant Deficiency 2022

Olivet Nazarene University

IL

Student Financial Aid Matching / Level of Effort / Earmarking Eligibility § 200.303

The University understands the importance of accurate verification. It was missed by the verification specialist, and not a matter of process. The specialist simply missed the line on the tax document that listed the education credits. This caused the student to receive $200 less Pell funding than t...

The University understands the importance of accurate verification. It was missed by the verification specialist, and not a matter of process. The specialist simply missed the line on the tax document that listed the education credits. This caused the student to receive $200 less Pell funding than the eligibility. The student should have received $200 in additional Pell Grant funds, so the school contacted the student and applied $200 in university funding to offset that loss. On November 21st, Tim Schultz (verification specialist) was instructed about this important process. The Executive Director of Student Finance, Tiffany McCann, will help monitor those verification materials and process, which should reduce the chances of a repeat mistake and ensure compliance.

View Audit 42623

Finding 51107 (2022-002)

Significant Deficiency 2022

Henry J. Austin Health Center, Inc.

PA

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

Views of Responsible Officials: The Center has implemented new Grant and Payment Management System (PMS) reconciliation workbooks to track grant expenditures. The Center also engages with consultants to assist with proper reporting and timely filing to avoid audit adjustments. In addition, the Stand...

Views of Responsible Officials: The Center has implemented new Grant and Payment Management System (PMS) reconciliation workbooks to track grant expenditures. The Center also engages with consultants to assist with proper reporting and timely filing to avoid audit adjustments. In addition, the Standard Operation Procedures will be updated to ensure that an appropriate protocol and controls for reviewing and approval of documentation prior to submission are in place. The Center will implement a plan that will include revision and approval from the Chief Financial Officer or designee prior to submission, required in the Payment Management System.

View Audit 51067

Finding 51069 (2022-003)

Significant Deficiency 2022

Blue Earth County

MN

Questioned Costs Matching / Level of Effort / Earmarking Procurement, Suspension & Debarment § 200.303 § 200.318 § 200.326

Recommendation: We recommend the County management establish internal controls to ensure compliance with federal procurement requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The finance department has...

Recommendation: We recommend the County management establish internal controls to ensure compliance with federal procurement requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The finance department has met with the IT department to discuss federal procurement requirements and possible checklists. Name of the contact person responsible for corrective action: Lisa Malinski, Finance Director

View Audit 49837 Questioned Costs: $1

Finding 51065 (2022-002)

Significant Deficiency 2022

Blue Earth County

MN

Eligibility Significant Deficiency Matching / Level of Effort / Earmarking

Recommendation: We recommend the County management establish internal controls over eligibility. Case files should be reviewed to ensure proper documentation exists to support the eligibility determination. Explanation of disagreement with audit finding: There is no disagreement with the audit find...

Recommendation: We recommend the County management establish internal controls over eligibility. Case files should be reviewed to ensure proper documentation exists to support the eligibility determination. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement additional review procedures. Name of the contact person responsible for corrective action: Lisa Malinski, Finance Director

View Audit 49837

Finding 50981 (2022-003)

Significant Deficiency 2022

Union County

NC

Questioned Costs Allowable Costs / Cost Principles Cash Management

Responsible Parties: Michelle Lancaster, Deputy County Manager / Human Services Director Beverly Liles, Finance Director ...

Responsible Parties: Michelle Lancaster, Deputy County Manager / Human Services Director Beverly Liles, Finance Director Finding 2022-003, Significant Deficiency and Nonmaterial Noncompliance - Special Test and Provisions See Corrective Action Plan for chart / table.

View Audit 45126 Questioned Costs: $1

Finding 50976 (2022-001)

Material Weakness 2022

Ou Medicine, Inc.

OK

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

Corrective Action Plan Finding 2022-001 Internal Control Deficiency Allowed/Allowable Costs At the beginning of the pandemic, OU Health created working groups to evaluate the requirements for COVID-19 funding received and ensure the funds were only used for allowable purposes. The working groups w...

Corrective Action Plan Finding 2022-001 Internal Control Deficiency Allowed/Allowable Costs At the beginning of the pandemic, OU Health created working groups to evaluate the requirements for COVID-19 funding received and ensure the funds were only used for allowable purposes. The working groups were assisted by outside consultants to stay updated on the reporting requirements as the continued to evolve. As part of the Uniform Guidance audit, OU Health provided documentation of the FEMA review process that explained how eligible costs were identified and submitted. To ensure internal controls are documented to the level necessary under current audit standards, OU Health will develop a checklist to document the review and approval of supporting documentation of personnel costs as reported as FEMA federal expenditures. The supporting documentation will be reviewed by management to ensure expenses charged to the federal program are allowable and have not been reimbursed under another federal program. The checklist will be retained with the existing report. Responsible Official: Michael Milligan, Vice President of Accounting Anticipated Completion Date: March 31, 2023

View Audit 40950 Questioned Costs: $1

Finding 50966 (2022-001)

Significant Deficiency 2022

Carver County

MN

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Significant Deficiency

Carver County ? Corrective Action Plan Year Ended December 31,2022 U.S. Department of Health and Human Services Carver County respectfully submits the following corrective action plan for the year ended December 31, 2022. Audit period: 1/1/2022 to 12/31/2022 The findings from the schedule of finding...

Carver County ? Corrective Action Plan Year Ended December 31,2022 U.S. Department of Health and Human Services Carver County respectfully submits the following corrective action plan for the year ended December 31, 2022. Audit period: 1/1/2022 to 12/31/2022 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS?FINANCIAL STATEMENT AUDIT None FINDINGS?FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Health and Human Services 2022-001 Medical Assistance ? Assistance Listing No. 93.778 Recommendation: We recommend the County reviews its procedures for giving timely notice of an individual?s termination to other departments. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will incorporate procedures and controls to ensure timely notice is given to other departments of an individual?s termination. Name of the contact person responsible for corrective action: Mary Kaye Wahl (Assistant Financial Services Director) Planned completion date for corrective action plan: December 31, 2023. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Mary Kaye Wahl at 962-361-1938.

View Audit 43619

Finding 50952 (2022-001)

Significant Deficiency 2022

St John's Health Care Corporation

NY

HUD Housing Programs Matching / Level of Effort / Earmarking

Recommendation: Adhere to the HUD regulatory agreement in relation to obtaining prior written approval from HUD before encumbering the Project. Action Taken: During 2022, the Home received approval for the entirety of the loan balance and recognized the proceeds of the Small Business Administratio...

Recommendation: Adhere to the HUD regulatory agreement in relation to obtaining prior written approval from HUD before encumbering the Project. Action Taken: During 2022, the Home received approval for the entirety of the loan balance and recognized the proceeds of the Small Business Administration loan as of December 31, 2022. The Home obtained the Small Business Administration loan as a prudent business decision to meet operating expenses. The Home will obtain prior written approval from HUD before encumbering the Project in the future.

View Audit 53719

Finding 50951 (2022-004)

Significant Deficiency 2022

Southwest Healthcare Services

ND

Special Tests & Provisions Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Finding Summary: Southwest completed the Provider Relief Fund reporting requirement without factoring in the amounts of expenses that were reimbursed by other sources. This specifically relates to the amount that Southwest was reimbursed by Medicare as a result of being a critical access hospital th...

Finding Summary: Southwest completed the Provider Relief Fund reporting requirement without factoring in the amounts of expenses that were reimbursed by other sources. This specifically relates to the amount that Southwest was reimbursed by Medicare as a result of being a critical access hospital that get reimbursed based on cost. Responsible Individuals: Dennis Goebel, Chief Executive Officer; Amanda Loughman, Chief Financial Officer. Corrective Action Plan: Management will ensure to factor in a portion of the Provider Relief Fund expenses that are being reimbursed by other sources when completing the reporting requirements. Anticipated Completion Date: 12/31/2023

View Audit 52761

Finding 50949 (2022-001)

Significant Deficiency 2022

Multnomah Education Service District

OR

HUD Housing Programs Significant Deficiency Matching / Level of Effort / Earmarking § 200.326

November 15, 2022 Oregon Secretary of state, Audits Division 255 Capito! St. NE, Suite #500 Salem, OR 97310 Plan of Action for Multnomah Education Service District The Multnomah Education Service District respectfully submits the following corrective action plan in response to deficiencies reported ...

November 15, 2022 Oregon Secretary of state, Audits Division 255 Capito! St. NE, Suite #500 Salem, OR 97310 Plan of Action for Multnomah Education Service District The Multnomah Education Service District respectfully submits the following corrective action plan in response to deficiencies reported In our audit of fiscal year ended June 30, 2022. The audit was completed by the independent auditing firm Talbot, Korvola and Warwick, and reported the deficiency listed below. The plan of action was adopted by the governing body at their meeting on November 15, 2022, as indicated by signatures below. Finding 2022.001: Significant deficiency Condition: The provisions for the prevailing wage rates requirements were not included in the construction contracts in excess of $2,000 financed by ESF funds and that the required certified payrolls were not obtained. The related deficiency in internal controls over compliance is considered to be a significant deficiency. As the District does not typically fund construction projects with federal fund, the District's staff were unaware of the $2,000 threshold for construction contacts financed by ESF funds to include prevailing wage rates requirements and used a threshold of $50,000, the Oregon Bureau of Labor & Industries' threshold for prevailing wage rate requirements for public works projects in Oregon. Cause: Effect or potential effect: Without adequate internal controls over wage rate requirements and Including the required provisions in construrtion contracts in excess of $2,000 financed by ESF funds, the District cannot demonstrate compliance with the wage rate requirements of the Davis-Bacon Act requirements. Questioned Costs: Questioned costs, if any, are indeterminable. Out of nine capital projects totaling $123,558, a sample of three capital projects was haphazardly selected. The capital projects were between $9,405 and $14,360 and totaled $26,024. Context; Recommendation: The District should obtain an understanding of all compliance requirements and implement controls to ensure compliance with federal wage rate requirements. Superintendent Dr. Faul Coakley Board of Directors Jessica Ariate ? Mary Botkin ? Kristin Corniielle < Katrina Doughty ? Dr. Samuel Henry ? Deny.se Peterson ? Helen Ying I !611 NE ??ns\?orth Circle ? Portland. Oregon 97220 ? (502) 255-18^1 ? MultnofiialiESD.org p!an ?? action: The Director oi Business & Operations is responsible for implementing the plan of action. All construction projects are managed by the MESD Facilities office. The Director instructed the MESD Contract and Risk Manager, meet with the Facilities office to inform staff of the Davis-Bacon prevailing wage requirements for construction contracts in excess of $ ? 2,00 . Facilities will include the consideration of Davis-Bacon requirements when reviewing a project request that is or has the potential of being federally funded. Facilities will implement the requirements of the Davis-Bacon Act as needed. Timeframe: The meeting took place on November 2, 2022. Facilities has updated their internal procedures. ? ' Multnora ESD Board Chair, Denyse Peterson Superintendent, Dr. Paul Coakley

View Audit 53728

Finding 50948 (2022-004)

Material Weakness 2022

McIntosh Senior Living

MN

Special Tests & Provisions Material Weakness Matching / Level of Effort / Earmarking § 200.303

Finding 2022-004 Federal Agency Name Department of Agriculture Program Name Community Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary The reserve account was not separately identified and there was no formal review separate from the preparer over t...

Finding 2022-004 Federal Agency Name Department of Agriculture Program Name Community Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary The reserve account was not separately identified and there was no formal review separate from the preparer over the reserve fund reconciliation. Responsible Individuals Sharlene Knutson, Administrator Corrective Action Plan We have adopted a policy to enhance internal control to ensure the reserve fund reconciliation has a secondary review and approval that is documents. Anticipated Completion Date September 30, 2023

View Audit 52757

Finding 50947 (2022-003)

Material Weakness 2022

McIntosh Senior Living

MN

Reporting Material Weakness Matching / Level of Effort / Earmarking

Finding 2022-003 Federal Agency Name Department of Agriculture Program Name Community Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary Eide Bailly LLP prepared our schedule of expenditures of federal awards (Schedule) and accompanying notes to the S...

Finding 2022-003 Federal Agency Name Department of Agriculture Program Name Community Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary Eide Bailly LLP prepared our schedule of expenditures of federal awards (Schedule) and accompanying notes to the Schedule. Responsible Individuals Sharlene Knutson, Administrator Corrective Action Plan Having auditors assist with preparing the schedule of expenditures of federal awards (SEFA) is not unusual. We will continue to be aware of the financial reporting requirements relating to the Organization?s schedules of expenditures of federal awards and internal control that impact reporting. Anticipated Completion Date Ongoing

View Audit 52757

Finding 50946 (2022-001)

Significant Deficiency 2022

Piedmont Healthcare, Inc.

GA

Allowable Costs / Cost Principles Reporting Matching / Level of Effort / Earmarking § 200.303

Finding No. 2022-001 ? Activities Allowed and Unallowable/Allowable Costs Program: COVID -19 Provider Relief Fund Award Year: January 1, 2020 through June 30, 2022 (a) Criteria or Requirement Per 2 CFR 200.303, the non-Federal entity must establish and maintain effective internal control over th...

Finding No. 2022-001 ? Activities Allowed and Unallowable/Allowable Costs Program: COVID -19 Provider Relief Fund Award Year: January 1, 2020 through June 30, 2022 (a) Criteria or Requirement Per 2 CFR 200.303, the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. (b) Condition Found, Including Perspective During our test work, we selected a sample of 40 incentive bonus payments made during the fiscal year 2022 reporting period. We noted that PHC was unable to provide evidence of management review and approval for each of the incentive bonus payments sampled. These disbursements were made for allowable costs under the terms and conditions of the program. (c) Possible Cause PHC was unable to provide evidence of certain management reviews and approvals because the control was not designed to require the retention of documentation of management review at the transactional level. (d) Questioned Cost None. (e) Effect Evidence of the effective operation of management review controls was not maintained in accordance with Federal requirements. (f) Statistical Validity The sample was not intended to be, and was not, a statistically valid sample. (g) Repeat Finding in the Prior Year Repeat of prior year Finding No. 2021-001. (h) Recommendation We recommend that PHC strengthen controls over the management review process to enhance the retention of evidence of management review and approval. (i) View of Responsible Officials Management concurs with the finding. While we believe appropriate controls exist relating to the management review and approval of allowable costs at the transactional level, we concur that procedures relating to obtaining and maintaining documentation of such reviews need to be strengthened. (j) Corrective Action Plan Management will ensure communication of the finding to the reviewers and submitters of allowable costs and revise procedures to ensure documentation of reviews and approvals is obtained and maintained. Prior to submitting allowable costs to Health Resources and Services Administration (?HRSA?), we will obtain documentation of the approval of these costs and maintain this documentation in the same manner as the documentation of the submission of the costs to HRSA. (k) Anticipated Completion Date Correction of corrective action anticipated by August 31, 2023. (l) Name of Person for Corrective Action Marie Gaffney, Vice President Corporate Finance: (470) 271-6007.

View Audit 53715

Finding 50945 (2022-001)

Material Weakness 2022

Garrett Regional Medical Center

MD

Questioned Costs Allowable Costs / Cost Principles Special Tests & Provisions § 200.303

Finding 2022-001- Allowable Costs, Activities Allowed and Special Tests and Provisions Contact Person: Lori Dixon Management?s Response: GRMC management will implement the following processes/procedures as a result of the finding of the 2022 Single Audit. During the audit review, FEMA hours we...

Finding 2022-001- Allowable Costs, Activities Allowed and Special Tests and Provisions Contact Person: Lori Dixon Management?s Response: GRMC management will implement the following processes/procedures as a result of the finding of the 2022 Single Audit. During the audit review, FEMA hours were found to be unallowable on sample patients treated for COVID. Management reviewed the findings and identified additional patients/hours not covered by other funding sources to replace the unallowed data totaling $8,550. Completion Date: The steps above will be completed by October 31, 2023.

View Audit 52431 Questioned Costs: $1

Finding 50941 (2022-002)

Significant Deficiency 2022

Westward Heights

WY

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.327

Effective immediately, the Chief Financial Analyst has created a schedule for all Westward Heights Care Center monthly financial statements be completed and sent to the Administrator by approximately the 20th of each month. This will allow time to get the quarterly reports completed and sent to the ...

Effective immediately, the Chief Financial Analyst has created a schedule for all Westward Heights Care Center monthly financial statements be completed and sent to the Administrator by approximately the 20th of each month. This will allow time to get the quarterly reports completed and sent to the USDA. The annual budget was not completed on time as there was a new administrator. The administrator now has the experience and education to get the budget completed by November 30th and sent to the USDA.

View Audit 50043

Finding 50934 (2022-001)

Material Weakness 2022

Jennings American Legion Hospital, Inc.

LA

Period of Performance Reporting Matching / Level of Effort / Earmarking

August 26, 2022 Legislative Audit Advisory Council P.O. Box 94397 Baton Rouge, LA 70804-9397 RE: Jennings American Legion Hospital, Inc. FYE 11/30/2021 Financial Statement Audit Management Corrective Action Plan Dear Council Members: Management has taken the following action is response to th...

August 26, 2022 Legislative Audit Advisory Council P.O. Box 94397 Baton Rouge, LA 70804-9397 RE: Jennings American Legion Hospital, Inc. FYE 11/30/2021 Financial Statement Audit Management Corrective Action Plan Dear Council Members: Management has taken the following action is response to the finding of our auditors, Lester, Miller & Wells, CPAs for the fiscal year ended November 30, 2021. Finding 2021-001 ? Medicare and Medicaid Cost Report Receivables Position(s) of Agency Personnel taking correction action: Chief Executive Officer Corrective Action: Management has considered the recommendation and concluded that the implementation cost is greater than the benefit derived from preparing interim cost reports. It is more efficient and cost effective for external cost report preparers to prepare the cost reports at year-end. Finding 2021-002 ? Recognition of Insurance Proceeds Position(s) of Agency Personnel taking correction action: Chief Financial Officer Corrective Action: Management will recognize insurance proceeds as a gain (loss) and ensure assets being replaced or repaired are recorded at cost. If you should require additional information please call (337) 616-7030. Sincerely, Dana D. Williams Chief Executive Officer

View Audit 47564

Finding 50928 (2022-002)

Significant Deficiency 2022

Native American Community Clinic

MN

Cash Management Significant Deficiency Matching / Level of Effort / Earmarking

U.S. Department of Health and Human Services 2022-002 Health Centers Cluster ? Assistance Listing No. 93.224/93.527 Recommendation: We recommend the Organization develop a process to address changes in the approved IDCR midway through grant periods where grant expenditures are reconciled to the new ...

U.S. Department of Health and Human Services 2022-002 Health Centers Cluster ? Assistance Listing No. 93.224/93.527 Recommendation: We recommend the Organization develop a process to address changes in the approved IDCR midway through grant periods where grant expenditures are reconciled to the new IDCR, and additional direct expenditures identified, if needed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will implement processes to review the IDCR used to ensure any changes are incorporated timely and reconciled, as needed. Name(s) of the contact person(s) responsible for corrective action: Jenny Singh, Finance Officer Planned completion date for corrective action plan: December 31, 2023

View Audit 47032

Finding 50924 (2022-002)

Material Weakness 2022

Saint Michael's Clinics, Inc.

NJ

Internal Control / Segregation of Duties Eligibility Subrecipient Monitoring

FINDING 2022-002: Clinic management team acknowledges that from the audit selection made of 65 patients that 15 were not recertified during the six-month period and the supporting documentation was not retained related to income verification for 3 patients. A detail plan of correction has been deve...

FINDING 2022-002: Clinic management team acknowledges that from the audit selection made of 65 patients that 15 were not recertified during the six-month period and the supporting documentation was not retained related to income verification for 3 patients. A detail plan of correction has been developed and is listed below: ? Revamping the job titles and description to encourage better return on recruitment efforts of medical case managers position. ? A position of Certified Case Counselor (CCC) ? Supervisor, was created and filled to provide direct oversight over the medical case managers that perform the bi-annual certifications, and other daily tasks. ? Quality management process, where Clinic clients are called ahead of time to notify them of their recertification requirements. ? Data Analyst(s) will generate a report of patients due for recertification 60 days in advance of the due date. The CCC-Supervisor will be directly accountable to review the progress of the re-certification. This will be further monitored by the Assistant Manager of the clinic. The CCC-Supervisor and Assistant Manager will also monitor retention of income verification supporting documentation for patients. CONTACT PERSON: Raj Mehta, Chief Financial Officer, Peter Ho Memorial Clinic EXPECTED COMPLETION DATE: September 30, 2023

View Audit 43310

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