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U.S. Department of Health and Human Services Pass-through Entity: North Carolina Department of Health and Human Services Program Name: Medical Assistance Federal A...
U.S. Department of Health and Human Services Pass-through Entity: North Carolina Department of Health and Human Services Program Name: Medical Assistance Federal Assistance Listing Number: 93.778 Material Weakness and Non-Material Non-Compliance - Eligibility Finding 2022-002 Corrective Action Plan: I. Training a. The Quality and Training unit within the Economic Services Division (ESD) will review the findings and create and deliver training to staff that determine Medicaid eligibility and their supervisors and managers to address the specific errors identified during this audit, including but not limited to completing exparte determinations for eligibility when SSA terminates SSI eligibility, sending the 5097 to verify self-attest wages, properly documenting and reacting to IV-D non-cooperation, correct verification and documentation, and performing the required electronic verifications to complete an application or review. This training will be delivered by the end of the third quarter of fiscal year 2023. b. NC FAST Certification for Core Functions and Level One Medicaid policy is required by NC DHHS and completed in the NC FAST Learning Gateway for all staff that determine Medicaid eligibility. This is a staggered process initiated by NC DHHS. Mecklenburg County began this process in September 2021 with all new hires obtaining NC FAST Certification within 90 days of their hire. Existing staff that determine Medicaid eligibility were enrolled in January 2022 and will complete this training within 18 months to meet all state requirements. II. Process Improvement Strategies a. The division is continuing to hire Eligibility Specialist positions that will manage Medicaid cases. These added resources will help alleviate current workload challenges faced by existing staff and allow for a more thorough review of work being completed. b. In December 2022 Sr. Quality & Training Specialists were realigned to provide direct policy support to assigned teams. The assignment of specific Sr. Quality and Training Specialists to work directly with certain teams will enhance the relationship between Q&T, Eligibility staff and their Supervisors, with the goal of improving quality and timeliness of work. This realignment will more easily enable Sr. Quality & Training staff to correct errors identified through the second party review process and share those findings with the worker and their supervisor for learning and accountability purposes. c. A new Quality Assurance team will be created to validate the second party review process across all DSS divisions. This process will involve sampling records that have gone through the second party review process at the divisional level to ensure the review was accurate and that any errors were corrected. This team will also align second party review findings to audit findings to determine if training or process improvement strategies may improve quality. The team should be hired and standard operating procedures drafted by the 4th quarter of FY23. Ill. Quality Sampling and Accountability a. The Quality and Training Unit will complete monthly quality sampling for Medicaid. Error trends will be shared with the managers and their supervisors, who will work collaboratively with Quality & Training staff to coordinate appropriate strategies to train and coach staff to mitigate errors moving forward. b. Supervisors will review specific quality sampling results with their staff. The supervisor will, when necessary and appropriate, address continued errors using an individual Corrective Action Plan with the worker to include refresher training, additional second party review and/or initiating the formal documentation process. c. Managers will review quality sampling results with supervisors quarterly to follow up on errors addressed, trainings completed and progress with individual Corrective Action Plans. Person responsible: Jim Wright, Sr. Social Services Manager Ellese Massey, Social Services Manager Estimated date of completion: June 30, 2023
View Audit 21439 Questioned Costs: $1
Finding 21281 (2022-003)
Significant Deficiency 2022
U.S. Department of Health and Human Services Pass-through Entity: North Carolina Department of Health and Human Services Program Name: Temporary Assistance for Needy Families Federal Assistance Listing Number: 93.558 ...
U.S. Department of Health and Human Services Pass-through Entity: North Carolina Department of Health and Human Services Program Name: Temporary Assistance for Needy Families Federal Assistance Listing Number: 93.558 Significant Deficiency - Eligibility Finding 2022-003 Corrective Action Plan: I. Quality Sampling and Accountability a. In December 2022 Sr. Quality & Training Specialists were realigned to provide direct policy support to assigned teams. The assignment of specific Sr. Quality and Training Specialists to work directly with certain teams will enhance the relationship between Q&T, Eligibility staff and their Supervisors, with the goal of improving quality and timeliness of work. This realignment will more easily enable Sr. Quality & Training staff to correct errors identified through the second party review process and share those findings with the worker and their Supervisor for learning and accountability purposes. b. The Quality and Training Unit will complete monthly quality sampling for TANF. Error trends will be shared with the managers and their supervisors, who will work collaboratively with Quality & Training staff to coordinate appropriate strategies to train and coach staff to mitigate errors moving forward. c. Supervisors will review specific quality sampling results with their staff. The supervisor will, when necessary and appropriate, address continued errors using an individual Corrective Action Plan with the worker to include refresher training, additional second party review and/or initiating the formal documentation process. d. Managers will review quality sampling results with supervisors quarterly to follow up on errors addressed, trainings completed and progress with individual Corrective Action Plans II. Process Improvement - A new Quality Assurance team will be created to validate the second party review process across all DSS divisions. This process will involve sampling records that have gone through the second party review process at the divisional level to ensure the review was accurate and that any errors were corrected. This team will also align second party review findings to audit findings to determine if training or process improvement strategies may improve quality. The team should be hired and standard operating procedures drafted by 4th quarter of FY23. Person responsible: Jim Wright, Sr. Social Services Manager Ellese Massey, Social Services Manager Estimated date of completion: June 30, 2023
TOCC RESPONSE TO 2022-002 Submission of Single Audit Reports (Material Weakness). We agree with the finding. To improve TOCC?s financial reporting process and ensure timely completion of our annual single report, the TOCC will take the following steps: 1. The Dean of Finance, Controller, and an add...
TOCC RESPONSE TO 2022-002 Submission of Single Audit Reports (Material Weakness). We agree with the finding. To improve TOCC?s financial reporting process and ensure timely completion of our annual single report, the TOCC will take the following steps: 1. The Dean of Finance, Controller, and an additional contracted expert are developing and implementing a project plan that outlines all necessary tasks and timelines for completion. That information will be used by the President and Administrative Council in a report to the Board of Trustees semi-annually; 2. The group will arrange regular check-ins and progress reviews to ensure that all tasks are on track. 3. TOCC will make more use of the Data Management System?s technology and automation tools to streamline the process of financial reporting, reduce the workload, and decrease potential for human error resulting from manual processes; 4. To ensure compliance with the latest financial regulations and requirements, administration will provide finance and accounting staff with needed training and professional development. 5. Additional accounting support has been and will be employed to review procedures and to assist with tasks as the need indicates. 6. TOCC?s adherence to this corrective action plan will ensure that the audit will be completed by the single audit deadline of March 31, 2024.
2022-001 Higher Education Emergency Relief Fund ? CFDA No. 84.425E; 84.425F Recommendation: We recommend that the College implement controls related to cash management that designates a different reviewer and signer of drawdowns that occur within a given year. Explanation of disagreement with audi...
2022-001 Higher Education Emergency Relief Fund ? CFDA No. 84.425E; 84.425F Recommendation: We recommend that the College implement controls related to cash management that designates a different reviewer and signer of drawdowns that occur within a given year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: As a result of audit finding and 2022-001, the College implemented a process that includes formalized review and approval of drawdowns of federal awards. Name(s) of the contact person(s) responsible for corrective action: Jacob Wheeler Planned completion date for corrective action plan: 6/30/23
2022-003 Federal Agency: Department of Education Federal Program: COVID-19 Education Stabilization Fund Assistance Listing Number: 84.425F Condition The University did not properly design or implement an effective internal control system to ensure HEERF reports were properly completed and posted....
2022-003 Federal Agency: Department of Education Federal Program: COVID-19 Education Stabilization Fund Assistance Listing Number: 84.425F Condition The University did not properly design or implement an effective internal control system to ensure HEERF reports were properly completed and posted. Views of Responsible Officials and Planned Corrective Actions PFW Contact Person Responsible for Corrective Action: Ron Herrell, Director of Financial Aid Contact Phone Number: 260-481-6242 The PFW Office of Financial Aid Director will complete the quarterly reports and a dual review process will be implemented to ensure accuracy. The quarterly report will be updated on the HEERF site and sent to the Assistant Director of Enrollment and Institutional Scholarships to post. The information posted will be compared to the reports submitted quarterly. Anticipated Completion Date: February 2023 Once the Corrective Action Plan is completed, Purdue Internal Audit will conduct a follow-up review to ensure the corrective action plan is fully implemented and being followed consistently. PNW Contact Person Responsible for Corrective Action: Michael Biel, Executive Director of Financial Aid Contact Phone Number: 219-989-2510 PNW acknowledges that, while it had the appropriate Institutional HERF reporting completed, they missed updating the required student portion questions and answers that get posted to the reporting webpage. Once that was discovered, it was corrected in April 2022. PNW has ensured that the process now identifies looking at both the combined (updated) reporting PDF and the questions and answers that are required to be posted to the reporting webpage. PNW has spent all of its HEERF funding and no further reporting except the final annual report should be required. Completion Date: April 2022 Once the Corrective Action Plan is completed, Purdue Internal Audit will conduct a follow-up review to ensure the corrective action plan is fully implemented and being followed consistently.
Finding 21227 (2022-001)
Significant Deficiency 2022
2022-001 Federal Agency: Department of Education Federal Programs: Federal Supplemental Educational Opportunity Grants (FSEOG), Federal Pell Grant Program, Federal Direct Student Loans Assistance Listing Numbers: 84.007, 84.063, 84.268 Condition Special Tests and Provisions - Return of Title IV Fu...
2022-001 Federal Agency: Department of Education Federal Programs: Federal Supplemental Educational Opportunity Grants (FSEOG), Federal Pell Grant Program, Federal Direct Student Loans Assistance Listing Numbers: 84.007, 84.063, 84.268 Condition Special Tests and Provisions - Return of Title IV Funds The Purdue Fort Wayne campus did not properly design or implement an effective internal control system to ensure compliance with the requirement for timely return of funds related to the Special Tests and Provisions - Return of Title IV Funds. Specifically, there was a lack of timeliness in initiating a return of Title IV funds, causing a return to be issued more than 45 days after the date the University became aware of student's withdrawal date. Views of Responsible Officials and Corrective Action Plan Contact Person Responsible for Corrective Action: Ron Herrell, Director of Financial Aid Contact Phone Number: 260-481-6242 The PFW Office of Financial Aid has an established Return of Title Four Aid (R2T4) policy and underlying control structure in place to ensure compliance with the R2T4 requirements. The PFW Office of Financial Aid will enhance its current R2T4 policy and procedure to include a step-by-step process to completing an R2T4. This will ensure that in the absence of the Assistant Director of Loans (who is currently responsible for R2T4 calculation completion) a succession list determining who is next in line to complete R2T4 calculations will be established to ensure these are completed in the 45-day window. Anticipated Completion Date: December 2022 Once the Corrective Action Plan is completed, Purdue Internal Audit will conduct a follow-up review to ensure the corrective action plan is fully implemented and being followed consistently.
FINDING 2022-003 Subject: Special Education Cluster - Earmarking Audit Finding: Significant Deficiency Condition: The School Corporation is a member of the Northeast Indiana Special Education Cooperative (Cooperative). The School Corporation did not have adequate internal controls in place to e...
FINDING 2022-003 Subject: Special Education Cluster - Earmarking Audit Finding: Significant Deficiency Condition: The School Corporation is a member of the Northeast Indiana Special Education Cooperative (Cooperative). The School Corporation did not have adequate internal controls in place to ensure that the Cooperative complied with the earmarking requirements. Context: The School Corporation is a member of the Northeast Indiana Special Education Cooperative (Cooperative). During fiscal year 2021-2022, the Cooperative operated the special education programs and spent the federal money on behalf of all its members. 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. However, 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 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. The Non-Public Proportionate Share expenditures for 19611-042-PN01 and 20611-042-PN01 grant awards could not be verified for the individual schools to verify the minimum amount per the grant awards was expended and properly reported to IDOE as required. The School Corporation?s minimum earmarking requirements for the 19611-042-PN01 and 20611-042-PN01 grant awards were $1,095 and $1,791, respectively. The lack of internal controls and noncompliance were isolated to the 19611-042-PN01 and 20611-042-PN01 grant awards. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Hamilton Community Schools will work with the Northeast Indiana Special Education Cooperative to ensure proper oversight and internal controls are maintained of awarded monies. Responsible Party and Timeline for Completion: Brittany Taylor, Business Manager Completion Date: 6/30/2023
2022-003 Compliance and Internal Controls over Allowable Costs and Earmarking (Significant Deficiency) Assistance Listing Number 64.033 VA Supportive Services for Veteran Families, A Supportive Services for Veteran Families ? Shallow Subsidy, and COVID ? 19 VA Supportive Services for Veteran Famili...
2022-003 Compliance and Internal Controls over Allowable Costs and Earmarking (Significant Deficiency) Assistance Listing Number 64.033 VA Supportive Services for Veteran Families, A Supportive Services for Veteran Families ? Shallow Subsidy, and COVID ? 19 VA Supportive Services for Veteran Families 2020-2021 and 2021-2022 Funding U.S. Department of Veteran Affairs Recommendation: The Agency should establish and follow an allowable indirect allocation policy based on identifiable measures. The indirect costs charged to the grant can be substantiated by actual costs incurred. Corrective Action: Management will ensure the indirect allocation policy is correct, and actual and allowable costs will substantiate the indirect charge to grants. Responsible Party: Controller and Chief Operating Officer Date Expected to be Corrected: Immediately
View Audit 23531 Questioned Costs: $1
Finding 21196 (2022-002)
Significant Deficiency 2022
Finding 2022-002: Education Stabilization Fund, COVID-19 ? Higher Education Emergency Relief Fund Institutional Portion ? Earmarking Name of Contact Person: Richard Rosen, Vice President for Financial and Institutional Services Corrective Action Plan: The Academy will review the earmarking requ...
Finding 2022-002: Education Stabilization Fund, COVID-19 ? Higher Education Emergency Relief Fund Institutional Portion ? Earmarking Name of Contact Person: Richard Rosen, Vice President for Financial and Institutional Services Corrective Action Plan: The Academy will review the earmarking requirements, document the Academy?s reasoning for allocation of the funds, and follow-up with the U.S. Department of Education to ensure that the Academy is complying with the applicable provisions of the award. Planned Completion Date: September 2023
Finding 21139 (2022-002)
Significant Deficiency 2022
Finding ref number: 2022-002 Finding caption: The County did not have adequate internal controls for ensuring compliance with federal match requirements. Name, address, and telephone of Pierce County?s contact person: Thomas Taylor 950 Fawcett Ave., Suite 100 Tacoma, WA 98402 253-798-7577 Corrective...
Finding ref number: 2022-002 Finding caption: The County did not have adequate internal controls for ensuring compliance with federal match requirements. Name, address, and telephone of Pierce County?s contact person: Thomas Taylor 950 Fawcett Ave., Suite 100 Tacoma, WA 98402 253-798-7577 Corrective action the auditee plans to take in response to the finding: County staff have already worked with the U.S. Department of Housing and Urban Development to bring contracts with match requirements into compliance and to implement internal controls so that adequate information will be reviewed and retained. Anticipated date to complete the corrective action: September 1, 2023
View Audit 21681 Questioned Costs: $1
Finding Reference Number: 2022-001 Title and CFDA Number of Federal Program: 14.219 - Flexible Subsidy Program Supportive Housing for the Elderly (Section 202) Federal Award Agency: U.S. Department of Housing and Urban Development Name of Contact Person: Greg Franks, President of Manor Managem...
Finding Reference Number: 2022-001 Title and CFDA Number of Federal Program: 14.219 - Flexible Subsidy Program Supportive Housing for the Elderly (Section 202) Federal Award Agency: U.S. Department of Housing and Urban Development Name of Contact Person: Greg Franks, President of Manor Management Corrective Action: Effective immediately, all incoming, potential residents will be required to verify their income / assets regardless of their request to pay market rent and not qualify for US Department and Housing Urban Development, Project Based, Section 8 rent subsidies. Date of Planned Corrective Action: February 27, 2023
Issue: During the Auditor?s testing of Economic Development Cluster Loans, they noted an instance where a loan-required Life Insurance policy lapsed and the District did not thoroughly document their follow up in the lapse in coverage. Loans are required to be covered by life insurance. Without life...
Issue: During the Auditor?s testing of Economic Development Cluster Loans, they noted an instance where a loan-required Life Insurance policy lapsed and the District did not thoroughly document their follow up in the lapse in coverage. Loans are required to be covered by life insurance. Without life insurance the loan may not be covered. Recommendation: The Auditor recommends that the District thoroughly documents their process of follow up to lapse coverage. Action Taken: Management agrees that all follow ups on life insurance policy lapses that are made by telephone will include information about the purpose of the call, the phone number called, the date and time of the call, and whether a voicemail was able to be left.
(#2022-002) Reporting? BOCES did not prepare or upload to its website required Quarterly Reporting Forms or Student Aid Portion information timely. Corrective Action Plan At the outset of grant implementation, tasks associated with grant reporting including preparation, review, and submission wi...
(#2022-002) Reporting? BOCES did not prepare or upload to its website required Quarterly Reporting Forms or Student Aid Portion information timely. Corrective Action Plan At the outset of grant implementation, tasks associated with grant reporting including preparation, review, and submission will be clearly identified and assigned to appropriate personnel. A shared calendar of deadlines will be created and maintained. Responsible Party Ms. Amy Windus, Executive Director of Finance Anticipated Completion Date June 30, 2023
Corrective Action Plan Contact Person: Randy Cates rcates@yesomaha.org 402.345-6704 FINDING 2022-003: Schedule of Expenditures of Federal Awards Regarding Schedule of Expenditures of Federal Awards?we have a system in place to timely and accurately track and record all expense submis...
Corrective Action Plan Contact Person: Randy Cates rcates@yesomaha.org 402.345-6704 FINDING 2022-003: Schedule of Expenditures of Federal Awards Regarding Schedule of Expenditures of Federal Awards?we have a system in place to timely and accurately track and record all expense submissions and related fund receipts. Our Director of Development will forward all grant related information to our Grant?s Manager, Director of Operations, CFO, and our CPA Firm. Process steps include: ? All parties mentioned above will meet to review the Grant. ? The Grant Manager will provide oversite of the grant and will: o Create a document that details the type of expenses (and % thereof) that are grant eligible. This document is shared with all parties mentioned above. o Review with Director of Operations and CFO all invoicing and payroll information relating to illegibility. o CFO will code all eligible expenses and share that information with CPA firm for tracking purposes. o CPA firm will compile expense submission reports per the grant schedule. o Grant Manager will review, approve, and submit grant reports to the granting agency. o Fund receipts will be processed by Development Team and the information will be shared with all parties mentioned above. o Development Team will deposit funds received. o CPA firm will track and record all fund receipts. o Grant?s Manager will maintain a file with all relevant information for each grant. Reasonable completion date: Process is place as of July 7, 2023 Responsible Party: Randy Cates, CFO
Finding 2022-002 Identification of the Federal Program: Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Pass-Through Gr...
Finding 2022-002 Identification of the Federal Program: Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Pass-Through Grantor: Not applicable Pass-Through Award Number: Not applicable Pass-Through Award Period: 1/1/2020-12/31/2022 (Periods 3 and 4) Summary of finding: Management?s internal controls over the review and interpretation of instructions related to the input of lost revenue into the HRSA PRF portal were not sufficient to ensure the lost revenue recorded in the General Distribution portal ?Total Lost Revenues for the Period of Availability (January 1, 2020 to December 31, 2022)? line did not include the lost revenues that had been transferred from the Parent to subsidiaries and recorded in the portal for the subsidiaries Targeted Distributions. Corrective Action Plan: When populating the Period 4 HRSA PRF portal for Spectrum Health System, Corewell Health West management was aware that the inputs were not considering the System lost revenue attributed to the affiliates appropriately. In order to communicate to the users of the portal and other auditors, Management included an excel tracking worksheet which was uploaded on the HRSA PRF portal showing the total lost revenue used as an organization and the remaining balance left to be used. When populating the Period 5 filing, due September 30, 2023, Corewell Health West Management will correctly input the lost revenue in the Parent submission in order to reflect the lost revenue used by the individual subsidiaries. Individual responsible for the corrective action: Cindy Brink, Director, System Accounting & Reporting Timing of the Corrective Action Period 5 HRSA PRF portal filing, due September 30, 2023.
FINDING 2022-003 (Medical Assistance Program) Contact Person Responsible for Corrective Action: Jeb Bardon Contact Phone Number: 317-418-7855 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Internal controls are being updated and will be adopted by t...
FINDING 2022-003 (Medical Assistance Program) Contact Person Responsible for Corrective Action: Jeb Bardon Contact Phone Number: 317-418-7855 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Internal controls are being updated and will be adopted by the Board. The Township and Fire Department have worked on division of duties. Now the Fire Department will process a payment and will be approved by someone else in Fire Department. Then, the bill will be reviewed by the Township Accounting Specialist and will be paid by the outside accounting service. After the check is written, the Trustee will sign. If an invoice is over $5000 the Trustee will sign off prior to the payment. The payments received by the Medicaid program will be reviewed by the Township Accounting Specialist. After the person agrees it is then inputted in the accounting software and coded to the proper account. The accounting software is reconciled on a monthly basis to ensure all transactions are accounted for properly and accurately. Anticipated Completion Date: 9/30/23
FINDING 2022-002 (Medicaid Cluster ? Activities Allowed or Unallowed) Contact Person Responsible for Corrective Action: Jeb Bardon Contact Phone Number 317-418-7855 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Federal Cost report beginning 202...
FINDING 2022-002 (Medicaid Cluster ? Activities Allowed or Unallowed) Contact Person Responsible for Corrective Action: Jeb Bardon Contact Phone Number 317-418-7855 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Federal Cost report beginning 2022 will be done by a new firm. The firm is Blue & Co. They are a wellestablished CPA. The information that is supplied to the CPA firm will be maintained by Wayne Township and will be put the finished cost report. This is for the financial and other metrics that are needed for the report. The cost report will be reviewed for accuracy by the Township Office. Since the audit is just completed for 2019, this comment be repeated until we receive the funds for 2023 which will probably occur in 2026. Anticipated Completion Date: 9/30/23
FINDING 2022-003 Contact Person Responsible for Corrective Action: Chad Shireman Contact Phone Number: 812-738-8241 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The county will ensure that internal controls that are currently in place will be modi...
FINDING 2022-003 Contact Person Responsible for Corrective Action: Chad Shireman Contact Phone Number: 812-738-8241 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The county will ensure that internal controls that are currently in place will be modified in order to be effective in preventing, detecting and correcting errors. This will include making sure the county auditor and designated county commissioner are aware of all reporting deadlines and reporting periods covered. Once the county auditor enters expenditure and obligation information, the designated county commissioner will review the data and submit the necessary report(s). Anticipated Completion Date: This will be completed by September 30, 2023, allowing the county auditor to update the designated county commissioner in the Department of the Treasury?s system and inform him of all upcoming report deadlines. This will ensure the effectiveness of existing internal controls.
Finding 2022-006 Identification of the Federal Program: Federal Agency: U.S. Department of Health and Human Services, United States Department of Defense Assistance Listing: Various ? Research & Development (R&D) Cluster Pass-Through Grantor: Various Pass-Through Award Number: Various Pass-Through ...
Finding 2022-006 Identification of the Federal Program: Federal Agency: U.S. Department of Health and Human Services, United States Department of Defense Assistance Listing: Various ? Research & Development (R&D) Cluster Pass-Through Grantor: Various Pass-Through Award Number: Various Pass-Through Award Period: 1/1/2022-12/31/2022 Summary of the finding: Management did not retain evidence to support their review over the patient data submitted to Sponsor for the per diem billings from February 1, 2022 to December 31, 2022 was complete and accurate. Corrective action plan: The current attestation memo control will be replaced as follows: There are two categories of study activity that required review and approval by the appropriate individual (i.e., Principal Investigator, Clinical Research Manager (CRM) or a delegate): (1) at the time of enrollment to assure that the study participant met sponsor-defined eligibility requirements and (2) subsequent study activities that may include but are not limited to a study visit, data collection, follow-up phone call, questionnaire completion, laboratory testing, biospecimen collection, or some combination of these. Verification of eligibility at the time of enrollment will continue to be reviewed and approved by the study PI, CRM, or appropriate delegate per sponsor requirements. Documentation is maintained in study-specific binders, per FDA audit standards and internationally-accepted Good Clinical Practice principles to assure that only patients meeting the sponsor?s defined eligibility criteria are enrolled into the study. Review of study activities subsequent to the study participant enrollment will be conducted monthly by the CRM or their delegate. Sponsored Programs Administration (SPA) will prepare and send each CRM a Transaction Report downloaded from the institutional clinical trial management system for each federally funded study, at least quarterly, that includes a listing of study visits associated with enrolled study participants that occurred within the defined period of time. The CRM/delegate will review the report detail provided and, upon approval, sign, and date the report. To assure that the information in the report is consistent with what was submitted to third parties which generates reimbursement, the CRM/delegate will conduct an audit of a sample of patients from a random selection of studies included in the Transaction Report. Each sample will be verified against documentation maintained in the study binder. Audit results affirming document review will be recorded in an audit tracking log which will be retained with the study activity report in their Clinical Trial Office (CTO) file as evidence of their review of study activity for federally funded fixed fee/per patient studies. For those federally funded fixed fee/per patient studies that do not utilize the standard institutional clinical trial management system, a similar study activity report downloaded from the clinical trial management system utilized for the study will be used for review, signed and dated upon approval and kept in the CTO files as evidence of review. Individuals responsible for corrective action: Giacomo DeChellis, Sr. Director, Research Operations, Corewell Health East Timing of corrective action: September 1, 2023 and going forward.
Finding 2022-001 Identification of the Federal Program: Federal Agency: U.S. Department of Health and Human Services, United States Department of Defense Assistance Listing: Various ? Research & Development (R&D) Cluster Pass-Through Grantor: Various Pass-Through Award Number: Various Pass-Through A...
Finding 2022-001 Identification of the Federal Program: Federal Agency: U.S. Department of Health and Human Services, United States Department of Defense Assistance Listing: Various ? Research & Development (R&D) Cluster Pass-Through Grantor: Various Pass-Through Award Number: Various Pass-Through Award Period: Various Federal Agency: Department of Homeland Security Assistance Listing: 97.036 ? COVID-19 Disaster Grants ? Public Assistance (Presidentially Declared Disasters) (FEMA) Pass-Through Grantor: Michigan State Police Emergency Management and Homeland Security Division Pass-Through Award Number: 4494-DR-MI Pass-Through Award Period: 1/20/2020-7/1/2022 Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Pass-Through Award Period: 1/1/2020-12/31/2022 (Periods 3 and 4) Summary of finding: The draft Schedule of Expenditures of Federal Awards (the Schedule) prepared by Corewell Health and Subsidiaries (the System) was misstated. Total federal expenses included on the Schedule were $102,235,937 for the year ended December 31, 2022. Total expenses included on the final Schedule were $101,562,371 for the year ended December 31, 2022. The federal expenditures were misstated as follows: See Corrective Action Plan for chart/table. Corrective Action Plan: The enhanced Schedule process and controls implemented by Corewell Health East in 2023 will be reviewed. The misstated amounts of the R&D Cluster occurred as a result of the timing of posted expenses during the first month of the merger of Spectrum Health and Beaumont Health in February 2022. This was a one-time occurrence and we do not anticipate that this will be an issue in future years. In addition, the successful implementation and transition to Workday, a new Corporate financial management system, has improved award setup functionality that enables improved differentiation of awards, identifying which need to be included on the annual Schedule of Expenditures of Federal Awards and those that should be excluded. The understatement related to FEMA was a one-time occurrence related to the clarification of guidelines on the inclusion of a new Category Z FEMA obligation in 2022 on the SEFA. This has been corrected in 2023. The overstatement related to PRF was due to an initial inclusion of Corewell Health East funding on the Schedule as well as an adjustment related to the submitted amount of Corewell Health West funding on the Schedule. On the 2023 SEFA, a management review and sign-off of the inputs prior to submission will be implemented. Individuals responsible for corrective action: Giacomo DeChellis, Sr. Director, Research Operations, Corewell Health East and Cindy Brink, Director, System Accounting and Reporting Timing of corrective action: July 1, 2023 and going forward.
Finding 2022-004 Identification of the Federal Program: Federal Agency: U.S. Department of Health and Human Services, United States Department of Defense Assistance Listing: Various, Research & Development (R&D) Cluster Pass-Through Grantor: Various Pass-Through Award Number: Various Pass-Through A...
Finding 2022-004 Identification of the Federal Program: Federal Agency: U.S. Department of Health and Human Services, United States Department of Defense Assistance Listing: Various, Research & Development (R&D) Cluster Pass-Through Grantor: Various Pass-Through Award Number: Various Pass-Through Award Period: 1/1/2022-12/31/2022 Summary of finding: Corewell Health West did not have an internal control over the review and approval of the fringe rate application control from January 1 to October 31, 2022. Corrective action plan: Management will continue to perform the internal control over the fringe rate implemented in November 2022. Individuals responsible for corrective action: Joseph Fugitt, Sr. Director, Research Finance & Operations, Corewell Health West, Emily Guzman, Director, Research Finance, Corewell Health West Timing of corrective action: For calendar year 2023 and going forward.
Finding 2022-003 Information on the Federal Program: Federal Agency: U.S. Department of Health and Human Services, United States Department of Defense Assistance Listing: Various, Research & Development (R&D) Cluster Pass-Through Grantor: Various Pass-Through Award Number: Various Pass-Through Awar...
Finding 2022-003 Information on the Federal Program: Federal Agency: U.S. Department of Health and Human Services, United States Department of Defense Assistance Listing: Various, Research & Development (R&D) Cluster Pass-Through Grantor: Various Pass-Through Award Number: Various Pass-Through Award Period: 1/1/2022-12/31/2022 Summary of finding: Management?s policy over effort reporting for Corewell Health West was designed to only require the documented review and approval of the grant effort and not 100% of an employee?s effort, which includes effort spent on non-grant work. Management?s policy related to Corewell Health East over effort for physicians who are not the principal investigator who charge time to the R&D grants does not require their effort report be reviewed and approved by someone who is knowledgeable of the grant. Corrective action plan: Corewell Health West utilizes Workday Grants Management to document the employee self-certification for 100% of each employee?s effort. In addition to the employee self-certification, Management will enable Workday functionality to route the effort certification for approval to a reviewer with knowledge of 100% of the employee?s effort. Corewell Health East will update their Research Time and Effort Reporting policy to reflect that review of the monthly RI Time and Effort Report for Physicians submitted by physicians who are involved as key personnel on federal grants or applicable direct expense reimbursement mechanisms, whether or not compensation is received, will be reviewed by an individual who is familiar with the technical/scientific progress of the award. Individuals responsible for corrective action: For Corewell Health West: Joseph Fugitt, Sr. Director, Research Finance & Operations, Corewell Health West, Emily Guzman, Director, Research Finance, Corewell Health West For Corewell Health East: Giacomo DeChellis, Sr. Director Research Operations, Corewell Health East Timing of corrective action: For Corewell Health West: For calendar year 2023 and going forward. For Corewell Health East: September 1, 2023 and going forward.
Finding #2022-002 Comments on Finding and Recommendation: The Corporation's required deposit into the residual receipts account of $27,293 per the June 30, 2021 Computation of Surplus Cash, Distributions and Residual Receipts was not deposited within 90 days of the fiscal year end. Management should...
Finding #2022-002 Comments on Finding and Recommendation: The Corporation's required deposit into the residual receipts account of $27,293 per the June 30, 2021 Computation of Surplus Cash, Distributions and Residual Receipts was not deposited within 90 days of the fiscal year end. Management should make all required residual receipts deposits per the annual Computation of Surplus Cash, Distributions and Residual Receipts within 90 days after the fiscal year end. Action(s) taken or planned on the finding: Agree. Management deposited $27,293 into the residual receipts fund on February 16, 2022. No further action is required.
View Audit 27624 Questioned Costs: $1
Finding #2022-001 Comments on Finding and Recommendation: The Corporation's Flexible Subsidy Loan was due in full upon maturity of the Corporation's Section 202 mortgage loan, which occurred in March 2017. As of June 30, 2022, the Flexible Subsidy Loan has not been repaid and the Corporation is in t...
Finding #2022-001 Comments on Finding and Recommendation: The Corporation's Flexible Subsidy Loan was due in full upon maturity of the Corporation's Section 202 mortgage loan, which occurred in March 2017. As of June 30, 2022, the Flexible Subsidy Loan has not been repaid and the Corporation is in technical default on the Flexible Subsidy Loan. Management should continue communicating with HUD in order to obtain approval for the deferment request for the Section 201 Flexible Subsidy Loan. Action(s) taken or planned on the finding: Management agrees with the recommendation. Management has submitted a request for deferment of the Flexible Subsidy Loan. Management is awaiting HUD approval of the deferment request.
Return of Title IV Funds (R2T4) Planned Corrective Action: Monthly meetings have been scheduled for the academic year to review completed R2T4?s. The director of financial aid and director of student financial services are also conducting additional training with staff to go over the areas of non...
Return of Title IV Funds (R2T4) Planned Corrective Action: Monthly meetings have been scheduled for the academic year to review completed R2T4?s. The director of financial aid and director of student financial services are also conducting additional training with staff to go over the areas of non-compliance that occurred. We have met with leadership on campus to address the issues with attendance tracking so that timely return of Title IV funds can be completed. Reminders have been sent to professors on attendance policies and procedures. These reminders include updated training materials. We have developed additional reports that will allow the University to monitor if attendance is being tracked by individual professors. Areas of non-compliance will be reported to the vice president for academic affairs and accreditation for follow up. Person Responsible for Corrective Action Plan: Kevin Reed, Director of Financial Aid, and Kylie Pruitt, Director of Student Financial Services Anticipated Date of Completion: October 15, 2022
View Audit 27620 Questioned Costs: $1
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