Corrective Action Plans

Finding 46160 (2022-004)

Significant Deficiency 2022

Waushara County

WI

Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking § 200.214

U.S. Department of the Treasury and Wisconsin Department of Health Services (DHS) 2022-004 Suspension and Debarment Coronavirus State and Local Fiscal Recovery Funds ? Assistance Listing No. 21.027 Recommendation: We recommend the County use sam.gov or the ELPS listing to review clients prior to e...

U.S. Department of the Treasury and Wisconsin Department of Health Services (DHS) 2022-004 Suspension and Debarment Coronavirus State and Local Fiscal Recovery Funds ? Assistance Listing No. 21.027 Recommendation: We recommend the County use sam.gov or the ELPS listing to review clients prior to entering into procurement transactions in excess of the covered transaction threshold in accordance with the Uniform Guidance. We also recommend that there is a review of this documentation prior to approval of use of the vendor and that documentation of the search and approval is maintained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Departments have been given instructions on how to use the sam.gov website, some have worked with CLA to make sure necessary proof is documented and we continue to remind departments at department head meetings as well as in emails when departments are making purchases. Name(s) of the contact person(s) responsible for corrective action: Sarah Luchini Planned completion date for corrective action plan: 2023

View Audit 40814

Finding 46138 (2022-002)

Material Weakness 2022

Oglesby Esd No. 125

IL

Questioned Costs Matching / Level of Effort / Earmarking § 200.302

The District will create general ledger accounts to better segregate and track expenditures specific to grant programs. The District will also have grant expenditures reports reviewed by someone other than the preparer before submission.

View Audit 40647 Questioned Costs: $1

Finding 46134 (2022-004)

Significant Deficiency 2022

Freeborn County

MN

Internal Control / Segregation of Duties Special Tests & Provisions Reporting § 200.303

2022-004 SPECIAL PROVISIONS Medical Assistance Program ? Assistance Listing No. 93.778 Recommendation: We recommend that the County enact policies to ensure that Collaborative reports are reviewed prior to submission in a timely manner. Explanation of disagreement with audit finding: There is no dis...

2022-004 SPECIAL PROVISIONS Medical Assistance Program ? Assistance Listing No. 93.778 Recommendation: We recommend that the County enact policies to ensure that Collaborative reports are reviewed prior to submission in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement procedures to ensure that all reports are reviewed prior to submission. Name of the contact person responsible for corrective action: Pat Paquin, Finance Manager Planned completion date for corrective action plan: December 31, 2023

View Audit 40299

Finding 46133 (2022-003)

Significant Deficiency 2022

Freeborn County

MN

Internal Control / Segregation of Duties Reporting Significant Deficiency § 200.303

2022-003 REPORTING Medical Assistance Program ? Assistance Listing No. 93.778 Recommendation: We recommend that the County enact policies to ensure that reports are reviewed prior to submission in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audi...

2022-003 REPORTING Medical Assistance Program ? Assistance Listing No. 93.778 Recommendation: We recommend that the County enact policies to ensure that reports are reviewed prior to submission in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement procedures to ensure that all reports are reviewed prior to submission. Names of the contact person responsible for corrective action: Pat Paquin, Finance Manager Planned completion date for corrective action plan: December 31, 2023

View Audit 40299

Finding 46118 (2022-001)

Material Weakness 2022

Lubbock Christian University

TX

Student Financial Aid Matching / Level of Effort / Earmarking Subrecipient Monitoring

Finding 2022-001 Enrollment Reporting Views of Responsible Officials The University agrees with the auditor?s findings and recommendations. Corrective Action Plan The University has implemented additional training for this compliance requirement to ensure that changes in enrollment status are record...

Finding 2022-001 Enrollment Reporting Views of Responsible Officials The University agrees with the auditor?s findings and recommendations. Corrective Action Plan The University has implemented additional training for this compliance requirement to ensure that changes in enrollment status are recorded correctly in the system and reported accurately. Additionally, the University will resolve status change discrepancies and review status change reporting output monthly to ensure that changes are reported accurately. Implementation Date Immediate Individual(s) Responsible Yvonne Harwood, Vice President of Institutional Effectiveness and Becky Wilson, Assistance Vice President of Financial Assistance

View Audit 41496

Finding 46115 (2022-001)

Material Weakness 2022

Global Community Charter School

NY

Matching / Level of Effort / Earmarking Special Tests & Provisions Procurement, Suspension & Debarment § 200.303 § 200.320

Re: Finding 2022-001: GCCS management will retain documentation to support proper operation of internal controls and compliance with applicable Federal statutes, regulations, and terms and conditions of the awards received.

View Audit 41361

Finding 46102 (2022-002)

None 2022

Crf Xii, Inc. Dba Prov. Place of Bloomington Apartments

IN

Reporting Matching / Level of Effort / Earmarking

Findings - Federal Award Programs Audit: U.S. Department of Housing and Urban Development Finding 2022-002: Section 223(f) Loan Program, CFDA 14.157 Recommendation: The management agent should ensure the Project is properly maintained. Action Taken: Management is in the process of addressing the ...

Findings - Federal Award Programs Audit: U.S. Department of Housing and Urban Development Finding 2022-002: Section 223(f) Loan Program, CFDA 14.157 Recommendation: The management agent should ensure the Project is properly maintained. Action Taken: Management is in the process of addressing the various items noted in the REAC inspection report.

View Audit 41495

Finding 46101 (2022-001)

None 2022

Crf Xii, Inc. Dba Prov. Place of Bloomington Apartments

IN

Cash Management HUD Housing Programs Reporting

Findings - Federal Award Programs Audit: U.S. Department of Housing and Urban Development Finding 2022-001: Section 223(f) Loan Program, CFDA 14.157 Recommendation: Make the deposit to the residual receipts account as required and ensure that all future residual receipts amounts are deposited with...

Findings - Federal Award Programs Audit: U.S. Department of Housing and Urban Development Finding 2022-001: Section 223(f) Loan Program, CFDA 14.157 Recommendation: Make the deposit to the residual receipts account as required and ensure that all future residual receipts amounts are deposited within 90 days after year end. Action Taken: Management will make the required residual receipts deposit as soon as possible and will ensure compliance in the future.

View Audit 41495

Finding 46091 (2022-002)

Significant Deficiency 2022

Eastern New Mexico University

NM

Matching / Level of Effort / Earmarking Student Financial Aid Reporting

Corrective Action: Management agrees that students were not properly reported to the Clearinghouse or NSLDS again and that all of the proposed corrective action in FY 21 did not occur. The registrar did not utilize NSLDS access until October 2022 and was not able to verify the submissions. Timeli...

Corrective Action: Management agrees that students were not properly reported to the Clearinghouse or NSLDS again and that all of the proposed corrective action in FY 21 did not occur. The registrar did not utilize NSLDS access until October 2022 and was not able to verify the submissions. Timeline of Corrective Action: Immediate. The registrar now has access to NSLDS as well as the Clearinghouse and has established procedures to verify the submission after every upload. The Financial Aid and Registrar Offices have agreed to meet quarterly to review submissions and to include Roswell offices in the meetings too. Responsible Party(ies): Registrar; Portales Campus

View Audit 41471

Finding 46073 (2022-002)

Significant Deficiency 2022

Lincoln County, Nebraska

NE

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

Finding 2022-002: Coronavirus State and Local Fiscal Recovery Funds Reporting Corrective Action Planned: The Lincoln County Board of Commissioners will discuss establishing a policy for reporting requirements. They will also discuss who will file reports for the county going forward and perhaps ...

Finding 2022-002: Coronavirus State and Local Fiscal Recovery Funds Reporting Corrective Action Planned: The Lincoln County Board of Commissioners will discuss establishing a policy for reporting requirements. They will also discuss who will file reports for the county going forward and perhaps someone to review the document before submission who is not involved in the preparation of the report. Anticipated Completion Date: Ongoing ? preferably by the next reporting date in April 2023 Responsible Party: Christopher D. Bruns, Lincoln County Board Chairman

View Audit 40615

Finding 46064 (2022-001)

Significant Deficiency 2022

Charles R. Drew University of Medicine and Science

CA

Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking

Management?s Corrective Action Plan: The University acknowledges the finding and the recommendation from Moss Adams regarding improving procedures. Finding-2022-001 Special Tests and Provisions-Enrollment Reporting-Significant Deficiency in Internal Controls Over Compliance Improved Process of Proto...

Management?s Corrective Action Plan: The University acknowledges the finding and the recommendation from Moss Adams regarding improving procedures. Finding-2022-001 Special Tests and Provisions-Enrollment Reporting-Significant Deficiency in Internal Controls Over Compliance Improved Process of Protocol: The University will implement corrective action during November 2022 related to the filing of the NSLDS report. This will include updating monthly reporting to National Student Clearinghouse when responding to NSLDS roster files rather than every other month. Additionally, the department has revised paperwork for graduating students to ensure status are processed in a timely manner by the Registrar. Contact Person Responsible for Corrective Action: Raquel Munoz. Registrar Anticipated Completion Date: November 2022

View Audit 40248

Finding 46060 (2022-002)

None 2022

Johnstown-Cambria County Airport Authority

PA

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

Airport Improvement Program (AIP) Award 3-42-0045-055-2020 ? CFDA No. 20.106 Name of contact person ? Heather Tomasko, Assistant Manager Recommendation: We recommend that management develop a process of tracking operating expenses used for reimbursement requests and implement an internal contr...

Airport Improvement Program (AIP) Award 3-42-0045-055-2020 ? CFDA No. 20.106 Name of contact person ? Heather Tomasko, Assistant Manager Recommendation: We recommend that management develop a process of tracking operating expenses used for reimbursement requests and implement an internal control procedure to avoid duplicating expenses from previous reimbursement requests. Based on our analysis of the Authority?s 2022 operating expenses, the Authority has over $100,000 in unsubmitted/unreimbursed operating expenses that appear eligible for AIP 55 to cover the questioned costs. Therefore, we also recommend the Authority contact the Federal Aviation Administration and inquire about the procedure to revise the reimbursement requests that included duplicate expenses. Further, we recommend that management review subsequent reimbursement requests to ensure accuracy and revise, if necessary. Action Taken: Management agrees with the recommendations. Management will contact the Federal Aviation Administration to determine the process to revise the reimbursement requests using other eligible expenses. Further, we will develop an internal control procedure to prevent future errors. Proposed Completion Date: June 15, 2023.

View Audit 40645 Questioned Costs: $1

Finding 46058 (2022-003)

Significant Deficiency 2022

Colona Grade School District No. 190

IL

Subrecipient Monitoring Cash Management Significant Deficiency § 200.305

Finding No.: 2022- 003 Condition: The District's expenditure report filed for June 30, 2022 included expenditures paid in July and August 2022. These amounts were not reported as committed or obligated. Plan: Grant expenditure reports will be prepared on the cash basis and obligations reported. ...

Finding No.: 2022- 003 Condition: The District's expenditure report filed for June 30, 2022 included expenditures paid in July and August 2022. These amounts were not reported as committed or obligated. Plan: Grant expenditure reports will be prepared on the cash basis and obligations reported. The liquidation of the obligations will be reported on subsequent liquidation reports. Anticipated Date of Completion: August 31, 2022 Name of Contact Person: Dr. Mike Ruff, Superintendent Management Response: There is no disagreement with this finding and management will monitor all future federal reimbursement requests. Committed and obligated expenditures will be reported appropriately, and will be paid within 90 days after project completion.

View Audit 40633

Finding 46055 (2022-004)

Material Weakness 2022

Housing Authority of the City of Oakland, California

CA

HUD Housing Programs Eligibility Subrecipient Monitoring § 200.303

Reference Number 2022-004: The Office of Property Operations has reviewed the audit finding report and recommendations. The department will implement steps to monitor compliance with Public Housing program policies to ensure staff perform timely annual re-certifications, following established guidel...

Reference Number 2022-004: The Office of Property Operations has reviewed the audit finding report and recommendations. The department will implement steps to monitor compliance with Public Housing program policies to ensure staff perform timely annual re-certifications, following established guidelines and retaining acceptable documentation to support resident eligibility determinations and subsequent re-certifications. These items include: ? Ensuring all initial eligibility information is received at the time of unit leasing ? Updating protocols for documenting the re-certification process, including file checklists to ensure all documents are in the resident file ? Re-establishing a file audit protocol to be performed on a quarterly basis ? Closely monitoring delayed re-certifications, including written documentation regarding any delays ? Creating a standard operating procedure to document any delays in re-certifications that may impact the timeliness and accuracy of data reported to the HUD system ? Scheduling recertification training for all staff involved in the re-certification process before June 30, 2023 Contact Information: Michelle Hasan, Director of Leased Housing

View Audit 52339

Finding 46051 (2022-002)

Significant Deficiency 2022

Compton Community College District

CA

Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Views of Responsible Officials and Corrective Action Plan We concur. Admissions and Records is aware of this issue and the impact that is has on the NSLDS reporting and will implement a business practice that includes a collaboration with Financial Aid and Academic Affairs to address this matter. Ad...

Views of Responsible Officials and Corrective Action Plan We concur. Admissions and Records is aware of this issue and the impact that is has on the NSLDS reporting and will implement a business practice that includes a collaboration with Financial Aid and Academic Affairs to address this matter. Additionally, Admissions and Records will work with Academic Affairs to implement a district policy to enforce faculty drops by the established deadlines. Lastly, a recent update was applied to our Banner ERP system on November 13, 2022, to address a known defect that prevented faculty from dropping students by the class census date and W deadline.

View Audit 52256

Finding 46043 (2022-001)

Significant Deficiency 2022

Hopewell Redevelopment and Housing Authority

VA

HUD Housing Programs Matching / Level of Effort / Earmarking Cash Management

December 29, 2022 RE: Corrective Action Plan for Finding No.2022-001 Finding No. 2022-001 Housing Choice Voucher, CFDA #14.871 Low Rent Public Housing, CFDA #14.850 Compliance Requirement: Activities Allowed or Unallowed Type of Finding: Noncompliance, Significant Deficiency The Business Activities ...

December 29, 2022 RE: Corrective Action Plan for Finding No.2022-001 Finding No. 2022-001 Housing Choice Voucher, CFDA #14.871 Low Rent Public Housing, CFDA #14.850 Compliance Requirement: Activities Allowed or Unallowed Type of Finding: Noncompliance, Significant Deficiency The Business Activities and State and Local programs had not generated sufficient cash required to reimburse the revolving fund for expenses incurred on its behalf before the end of the operating cycle. Corrective Action: The Housing Authority will reconcile and settle interfund balances on a monthly basis and implement greater oversight with review and sign off; confirming the reconciliation is complete no later than the 10th calendar day of the following month. In addition, the Authority will establish controls to restrict interfund transactions for which there is no certainty of reimbursement before the accounting period cut-off by documenting that reimbursement will occur no later than 30 calendar days after obligation/disbursement. If unable to confirm reimbursement within 30 calendar days, no disbursement will be made for business activities until reimbursement is certain to occur within the established 30-day timeframe. Please contact Lisa Wilson at Lisa.Wilson@hopewellrha.org for this corrective action.

View Audit 50618

Finding 46037 (2022-002)

Significant Deficiency 2022

Northern Wells Community Schools

IN

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.208 § 200.303 § 200.403

FINDING 2022-002 Information on the federal program: Subject: Special Education Cluster (IDEA) - Earmarking Federal Agency: Department of Education Federal Program: Special Education Grants to States Assistance Listing Number: 84.027 Federal Award Number: 20611-001-PN01 Pass-Through Entity: Indian...

FINDING 2022-002 Information on the federal program: Subject: Special Education Cluster (IDEA) - Earmarking Federal Agency: Department of Education Federal Program: Special Education Grants to States Assistance Listing Number: 84.027 Federal Award Number: 20611-001-PN01 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Matching, Level of Effort, Earmarking Audit Findings: Significant Deficiency Condition: The School Corporation is a member of the Adams Wells Special Services Cooperative (Cooperative). During fiscal year 2021-2022, the Cooperative operated the special education programs and spent the federal money on behalf of all its member schools. As the grant agreements were between the Indiana Department of Education (IDOE) and each member school, the school corporation was responsible for ensuring and providing oversight of the Cooperative. There was inadequate oversight performed by the School Corporation in order to ensure compliance with the Matching, Level of Effort, Earmarking compliance requirement. The School Corporation did not have internal controls in place to ensure that the Cooperative complied with the earmarking requirements. The Cooperative did not have adequate procedures in place to ensure that the required level of expenditures for non-public school students with disabilities was met for each member school. The Cooperative did not have effective internal controls to ensure non-public school expenditures were appropriately identified and reported. Context: The Non-Public Proportionate Share expenditures for the 20611-001-PN01 grant award could not be verified for the individual member schools. Total non-public expenditures were posted as expended. The member school proportionate share expenditures were then determined by applying a budgeted percentage to the total non-public expenditures. These were the amounts reported to IDOE. As such, we were unable to identify if the minimum amount per member school was expended and properly reported to IDOE as required. The School Corporation?s Non-Public Proportionate Share for the 20611-001-PN01 grant application was $9,319. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Our corrective action plan is following the AWSSC plan of: Co-ops cannot combine proportionate share funds. Funds must be spent within each LEA?s geographic boundary. We will not receive a repeat finding for FY21. We will correct for FY22 and forward. Time and Effort Logs are being completed to show how many hours personnel are servicing Non-Pub students with a service plan. If Materials and Equipment are purchased for a specific student?s need, per the service plan, then those expenditures are 100% school specific. Per the DOE, Materials used by our Speech Language Pathologist for Speech Therapy for all six school corporations, those expenditures are split evenly across all school corporations with a non-pub proportionate share allocation. Responsible Party and Timeline for Completion: The Superintendent and Corporation Treasurer will work with the Adams Wells Special Services Cooperative to monitor and verify those expenditures are allocated appropriately across all school corporations with a non-pub proportionate share allocation.

View Audit 40998

Finding 46032 (2022-001)

Material Weakness 2022

Northern Wells Community Schools

IN

Questioned Costs School Nutrition Programs Cash Management § 200.303

FINDING 2022-001 Information on the federal program: Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program, After School Snacks, Summer Food Service Program for Children Assistance Lis...

FINDING 2022-001 Information on the federal program: Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program, After School Snacks, Summer Food Service Program for Children Assistance Listing Number: 10.553, 10.555, 10.559 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Material Weakness 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 requirement. Context: We noted that for four claims in a sample of four, the meal counts were over/under claimed for the month. We noted that in October 2020, the School Corporation had underclaimed lunches by 212 meals and overclaimed breakfast by 42 meals. In April 2021, the School Corporation had overclaimed breakfast by 397 meals. In October 2021, the School Corporation had underclaimed lunches by 48 meals and snacks by 36 meals. In April 2022, the School Corporation had overclaimed lunches by two meals, snacks by 45 meals, and underclaimed breakfast by 2 meals. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Going forward, we will have multiple people verifying the data before submission to reimbursement for claims to make sure all meals submitted are accurate and meet the criteria and eligibility of the Child Nutrition Cluster. Responsible Party and Timeline for Completion: The Food Service Director and the Corporation Treasurer are the responsible parties for this corrective action. This will be implemented 4/1/2023.

View Audit 40998 Questioned Costs: $1

Finding 46020 (2022-003)

None 2022

Department of Education, State of Hawaii

HI

Eligibility Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.403

2022-003 Student Eligibility View of Responsible Officials Management agrees with the finding and recommendation. Corrective Action Plan The Community Education Specialist will create written AEFLA participant eligibility procedures for AEFLA-funded adult schools based on USC ?3272 and ?3102....

2022-003 Student Eligibility View of Responsible Officials Management agrees with the finding and recommendation. Corrective Action Plan The Community Education Specialist will create written AEFLA participant eligibility procedures for AEFLA-funded adult schools based on USC ?3272 and ?3102. The procedures will inform the adult school staff of the following: ? The Workforce Innovation and Opportunity Act ? The Adult Education and Family Literacy Act ? The relevant US Code and Code of Federal Regulations ? A definition of AEFLA-eligible individuals ? Categories of funding and their purpose ? The role of the US DOE Office of Career Technical and Adult Education ? The role of Hawaii state director (Community Education Specialist) for adult education ? The role of the AEFLA-funded local service providers The procedures will be disseminated to all AEFLA-funded adult school staff, and training will be provided. Contact Person: Dan Miyamoto, TA Community Education Specialist Curriculum Innovation Branch Office of Curriculum and Instructional Design Anticipated Completion Date: August 31, 2023

View Audit 44330

Finding 46000 (2022-005)

Significant Deficiency 2022

County of Nevada

CA

Period of Performance Reporting Internal Control / Segregation of Duties § 200.302 § 200.303

DEPARTMENT OF TREASURY 2022-005 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) ? Assistance Listing No. 21.027 Recommendation: We recommend the County design controls to ensure review and approval of reports are maintained in the County's grant files. Also, we recommend the County design...

DEPARTMENT OF TREASURY 2022-005 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) ? Assistance Listing No. 21.027 Recommendation: We recommend the County design controls to ensure review and approval of reports are maintained in the County's grant files. Also, we recommend the County design controls to ensure reports agree to the documentation used to prepare them. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County has revised internal controls to ensure reports are prepared accurately and consistently with the back-up used to prepare them. Within these internal control procedures, an appropriate review and approval process will be utilized and documented to ensure report is accurate with underlying support documentation and clearly documents this review and approval control. As a primary function of this review and approval control process, the reviewer/approver will provide assurance that the federal award is reasonably being managed and complies with all applicable statues, regulations, and terms and conditions. Evidence of review and approval will be maintained within the grant file support documentation for future reference and to be provided in a timely manner. Name(s) of the contact person(s) responsible for corrective action: Barry Anderson Planned completion date for corrective action plan: June 30, 2023

View Audit 41070

Finding 45989 (2022-012)

Material Weakness 2022

Mater Academy of Northern Nevada

NV

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.303

Finding Number: 2022-012 ? Level of Effort ? Maintenance of Effort Corrective Action Plan: A process has been put in place for the school principal to review all Maintenance of Efforts (MOE) prior to submission to the grantor. Approval is evidenced by email sent by principal to the NSLP Grant Manage...

Finding Number: 2022-012 ? Level of Effort ? Maintenance of Effort Corrective Action Plan: A process has been put in place for the school principal to review all Maintenance of Efforts (MOE) prior to submission to the grantor. Approval is evidenced by email sent by principal to the NSLP Grant Manager, which is saved with the MOE as support. Responsible Individuals: Nachum Golodner, Director of Accounting Anticipated Completion Date: June 30, 2023

View Audit 41067

Finding 45982 (2022-002)

Significant Deficiency 2022

Mercy Health

MO

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

Finding 2022-002 Reporting Information on the federal program: Federal Grantor: United States 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 Distribu...

Finding 2022-002 Reporting Information on the federal program: Federal Grantor: United States 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 Provider Relief Fund Reporting Entity: Mercy Hospital Fort Smith, Mercy Hospital Springfield, Mercy Hospital Oklahoma City, Mercy Hospital Joplin Tax Identification Numbers: 710240352, 440552485, 730579285, 270814858 Period of Availability: 01/01/2020?12/31/2021 (Period 2) and 01/01/2020?06/30/2022 (Period 3) Condition: The amounts reported for net patient service revenue (NPSR) by payer for calendar year 2021 Quarter 4 (CY2021 Q4) were incorrect. However, total NPSR was correct. We tested 5 of 14 Period 2 and 3 PRF Reports submitted to HRSA. For 4 of the 5 Period 2 and 3 PRF reports tested, the NPSR amounts reported by payer were incorrect for CY2021 Q4 as follows (increase/(decrease)): See chart/table in the Corrective Action Plan Cause: Management?s review of the allocation of total NPSR to the payer classification required in the PRF report was not sufficiently precise to detect that the incorrect quarter?s payer percentages were used to allocate gross revenue for CY2021 Q4. Views of Responsible Officials and Planned Corrective Actions: While there was no impact on total NPSR reported for Q4 2021, we agree that the percentages used to allocate gross revenue by payer were incorrect. Going forward, we will provide additional review of payer allocation percentages to ensure accuracy. Responsible Parties: Katie Stecich, Executive Director ? Revenue & AR Valuation Date of Completion: The review process was updated immediately after communication with leadership on March 27, 2023.

View Audit 41573

Finding 45981 (2022-001)

Material Weakness 2022

Mercy Health

MO

Eligibility Allowable Costs / Cost Principles Cash Management

Finding 2022-001 Activities Allowed or Unallowed and Eligibility Information on the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.461, COVID-19 HRSA COVID-19 Claims Reimbursement...

Finding 2022-001 Activities Allowed or Unallowed and Eligibility Information on the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.461, COVID-19 HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund (HRSA COVID-19 Uninsured Program) Mercy Community: Various Award Number: Various Award Period of Performance: 07/01/2021?March 2022 Condition: Mercy Health did not retain supporting documentation over the HRSA COVID-19 Uninsured Program report query logic (the Report) that was developed to identify patients that meet the allowability and eligibility requirements of the HRSA COVID-19 Uninsured Program. In addition, supporting documentation was not retained to validate who had access to modify and run the script, what changes were made to the script, and how any changes to the script were tested and implemented during the fiscal year based on changes to Health Resources and Services Administration (HRSA) guidance. Further, management did not maintain supporting documentation to demonstrate how it validated the completeness and accuracy of the data extracted by the script. In addition, Mercy Health did not retain supporting documentation over its approval of HRSA COVID-19 Program claims, determination of a patient's uninsured/self-pay status, and review of credit balances. While management had a process to identify and review claims for allowability under the HRSA COVID-19 Uninsured Program, determine a patient's uninsured/self-pay status through third-party insurance discovery, and review of credit balances, sufficient supporting documentation was not retained to support internal controls over the process. Cause: Development of the Report occurred outside of the Information Technology (IT) department that would require a formal process for the development of IT reports, access and program changes; the report resided in the Revenue Cycle department. The Revenue Cycle department did not develop internal control over report writing, program changes and user access. In addition, while management represented that the Report?s logic and subsequent changes to the Report?s logic were reviewed, no audit evidence was retained to support internal controls over that process. Management represented it performed a review of claims charged to the HRSA COVID-19 Uninsured Program for allowability; however, supporting documentation to evidence that the internal controls were sufficiently designed and operating effectively was not maintained. Standard policies, procedures, and internal controls over the review for patient insurance coverage and review of credit balances used in the federal program were not suitability designed to address the unique aspects of the HRSA COVID-19 Uninsured Program. Views of Responsible Officials and Planned Corrective Actions: In March 2022, HRSA announced that the HRSA COVID-19 Uninsured Program was ending. Therefore, remediation of internal controls is no longer applicable. If this program is reinstated, Mercy will take the necessary steps to ensure proper documentation is retained to provide evidence of our internal control processes. Responsible Parties: Mercy?s Revenue Management Department Date of Completion: Not applicable since program has ended.

View Audit 41573

Finding 45947 (2022-005)

Significant Deficiency 2022

Philadelphia Public School District

MS

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.302 § 200.303

District Response: A. What corrective action will be taken: District will limit expenditures to approved budget amounts. B. Who is responsible (name and position): Dr. Stephen Gregory, Federal Program Director C. When will the plan be implemented? Corrective action started May 5, 2023, and will cont...

District Response: A. What corrective action will be taken: District will limit expenditures to approved budget amounts. B. Who is responsible (name and position): Dr. Stephen Gregory, Federal Program Director C. When will the plan be implemented? Corrective action started May 5, 2023, and will continue.

View Audit 41005

Finding 45930 (2022-001)

None 2022

Restart Housing Services, Inc.

MO

HUD Housing Programs Matching / Level of Effort / Earmarking

FINDING 2022-001 ? Replacement Reserve Deposits AL# and Program Expenditures: 14.181 ($1,325,900) 14.181 ($ 50,596) Award Number: N/A Federal Award Year: January 1, 2022 ? December 31, 2022 Questioned Costs: None Condition Found: The reserve for replacement was not funded fully for the ye...

FINDING 2022-001 ? Replacement Reserve Deposits AL# and Program Expenditures: 14.181 ($1,325,900) 14.181 ($ 50,596) Award Number: N/A Federal Award Year: January 1, 2022 ? December 31, 2022 Questioned Costs: None Condition Found: The reserve for replacement was not funded fully for the year ended December 31, 2022. Monthly deposits totaling $5,136 for the year should have been deposited in the account but only $3,434 was deposited. In addition, replacement reserve deposits of $3,852, $5,136 and $3,919 were not made for the years ending December 31, 2020, 2019, and 2018, respectively. Also during 2021, a $4,000 loan was taken from the account by the prior management company. There is no documentation to support HUD approving the withdrawal, and the funds were not paid back to the account by December 31, 2022. In addition, during 2020, HUD approved a $13,357 withdrawal from the account. The funds were transferred to the operating account in March 2020 and again in August 2020. Altogether, a total of $37,112 is due to the replacement reserve account. Corrective Action Plan: The management company is making replacement reserve payments when HUD pays the HAP voucher. The Project was able to make three monthly payments for 2021 and eight for 2022. Management will transfer additional funds from operating to reserve when cash is available. The Project?s goal is be able to pay the current monthly replacement reserve deposit. The amounts due from prior years cannot be funded at this time. Rebecca Hunkins (816-531-8340 ext. 240) is the contact person for this finding. Management anticipates paying all of the 2023 monthly replacement reserve deposits by December 31, 2023.

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