Corrective Action Plans

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Views of Responsible Officials and Planned Corrective Action: Management agrees with this finding. As noted, a turnover in staff happened right at the time when the verification for FY22 was due and the new staff member did not realize the required verification had not occurred. The School followed ...
Views of Responsible Officials and Planned Corrective Action: Management agrees with this finding. As noted, a turnover in staff happened right at the time when the verification for FY22 was due and the new staff member did not realize the required verification had not occurred. The School followed proper procedures each year prior to FY22. The School identified the FY22 error at the beginning of the 2022-2023 school year prior to the audit. Immediate action was taken to ensure this error would not reoccur in the future when the School experienced a staffing change. In so doing, the School implemented a step-by-step tutorial of procedures, including reporting dates and deadlines. Necessary staff members have attended, and will continue to attend, training for items related to the application of Educational Benefits. The verification process was checked by a supervisor to ensure proper processes were followed for the 2022-2023 school year and they were.
FINDING 2022-004 Name of Responsible Individual For Finding(s): Bryan Soady, Former Alliance Executive Director Name of Responsible Individual For Correction(s): Awisi Bustos, Current Alliance Executive Director Corrective Action: The Alliance will enhance its procedures and internal controls over r...
FINDING 2022-004 Name of Responsible Individual For Finding(s): Bryan Soady, Former Alliance Executive Director Name of Responsible Individual For Correction(s): Awisi Bustos, Current Alliance Executive Director Corrective Action: The Alliance will enhance its procedures and internal controls over record retention to ensure complete and accurate financial reporting. Anticipated Completion Date: September 30, 2023
View Audit 37905 Questioned Costs: $1
CORRECTIVE ACTION PLAN To Whom It May Concern: This letter includes the corrective action plan in response to the audit finding from the Single Audit for the 2021-22 Award Year. Audit Finding 2022-001: Student received an incorrect amount of Pell award and was over awarded by $200. The amount was re...
CORRECTIVE ACTION PLAN To Whom It May Concern: This letter includes the corrective action plan in response to the audit finding from the Single Audit for the 2021-22 Award Year. Audit Finding 2022-001: Student received an incorrect amount of Pell award and was over awarded by $200. The amount was returned to the U.S. Department of Education in July 2022. Corrective Action Plan: This was an unusual case where a third disbursement was added manually late in the year due to a Professional Judgement appeal. In order to avoid an over-award in the future, the Financial Aid Office will implement the following: - The Financial Aid Office will request training from our Ellucian consultant on how best to add unusual disbursements. - Otherwise, staff should consistently use the Pell auto-package functionality within the Colleague system. - If a disbursement must be added manually due to a functionality error, the award change must be reviewed by a senior staff member. - The grant amounts will be audited at the end of the year. The contact person responsible for the corrective action is Cheryl Gillies, Executive Director, Financial Aid. The corrective action has been implemented as of July 31, 2022. Please let me know if you have any additional questions. Sincerely, Cheryl Gillies Executive Director, Financial Aid ArtCenter 1700 Lida St. Pasadena, CA 91103 626.396.2204
View Audit 38006 Questioned Costs: $1
2022-01 Covid-19 Provider Relief Funds - 93.498 Document Retention Policy Criteria: Federal award guidelines state that financial records, supporting documents, statistical records and all non-federal entity records related to a federal award must be retained for a period of three years from the da...
2022-01 Covid-19 Provider Relief Funds - 93.498 Document Retention Policy Criteria: Federal award guidelines state that financial records, supporting documents, statistical records and all non-federal entity records related to a federal award must be retained for a period of three years from the date of submission of the final expenditure report. Condition: As a result of our audit procedures, we noted there were significant delays in locating supporting documentation for our selections. In our sample of 25 cash receipts, there were two instances where supporting documentation provided was incomplete. Cause: The Organization did not have a centralized filing system or documentation retention policy. Effect: Audit procedures were delayed. Recommendation: We recommend that the Organization develop a formal record retention policy (a minimum of three years) sufficient to meet audit requirements. In addition, we recommend that management develop a record retention schedule to ensure that staff are aware of where electronic records are stored in the event of turnover within key functions. Management Response: The Organization will continue to strengthen our internal controls by developing a written document retention policy and central filing system for financial records.
COVID-19 EDUCATION STABILIZATION FUND ? ASSISTANCE LISTING 84.425U PASSED THROUGH THE PENNSYLVANIA DEPARTMENT OF EDUCATION; GRANT PERIOD ? YEAR ENDED JUNE 30, 2022. Management Response: An invoice was accidently allocated to both federal programs but was corrected before ARP final reporting was done...
COVID-19 EDUCATION STABILIZATION FUND ? ASSISTANCE LISTING 84.425U PASSED THROUGH THE PENNSYLVANIA DEPARTMENT OF EDUCATION; GRANT PERIOD ? YEAR ENDED JUNE 30, 2022. Management Response: An invoice was accidently allocated to both federal programs but was corrected before ARP final reporting was done. Corrective Action Plan: All final reporting will be reviewed, and any duplicate dollar figures will be reviewed to ensure expenditures are not duly list. Person Responsible: Christina Bason, Superintendent Anticipated Completion Date: Immediately
COVID-19 EDUCATION STABILIZATION FUND ? ASSISTANCE LISTING 84.425D AND 84.425U PASSED THROUGH THE PENNSYLVANIA DEPARTMENT OF EDUCATION; GRANT PERIOD ? YEAR ENDED JUNE 30, 2022. Management Response: The system the District is using is the library book borrowing system to manage the technology equipme...
COVID-19 EDUCATION STABILIZATION FUND ? ASSISTANCE LISTING 84.425D AND 84.425U PASSED THROUGH THE PENNSYLVANIA DEPARTMENT OF EDUCATION; GRANT PERIOD ? YEAR ENDED JUNE 30, 2022. Management Response: The system the District is using is the library book borrowing system to manage the technology equipment. Corrective Action Plan: A system for tracking technology equipment is being purchased for the 2023-2024 school year. Person Responsible: Sebastian Peipher, Director of Technology Anticipated Completion Date: Immediately
COVID-19 EDUCATION STABILIZATION FUND ? ASSISTANCE LISTING 84.425D AND 84.425U PASSED THROUGH THE PENNSYLVANIA DEPARTMENT OF EDUCATION; GRANT PERIOD ? YEAR ENDED JUNE 30, 2022. Management Response: Quarterly funding request reports require electronic signature with verification responsibilities of t...
COVID-19 EDUCATION STABILIZATION FUND ? ASSISTANCE LISTING 84.425D AND 84.425U PASSED THROUGH THE PENNSYLVANIA DEPARTMENT OF EDUCATION; GRANT PERIOD ? YEAR ENDED JUNE 30, 2022. Management Response: Quarterly funding request reports require electronic signature with verification responsibilities of the employee completing the funding request. Quarterly reports do not include any documentation of expenditures but are simply statements of additional funds being requested. Corrective Action Plan: Quarterly report summaries will be emailed to the business manager and accountant to review. Person Responsible: Christina Bason, Superintendent Anticipated Completion Date: Immediately
Finding 35997 (2022-002)
Significant Deficiency 2022
Contact person(s) responsible for corrective action - Amy Cavelier and Robert Wagstaff, Registrar?s Office Anticipated completion date ? August 31, 2023 Corrective Action The Registrar?s office will ensure proper controls and processes are in place to ensure program-level effective date information...
Contact person(s) responsible for corrective action - Amy Cavelier and Robert Wagstaff, Registrar?s Office Anticipated completion date ? August 31, 2023 Corrective Action The Registrar?s office will ensure proper controls and processes are in place to ensure program-level effective date information is properly and timely submitted to the NSLDS. Timeframe: June through August 2023 Responsible Parties: Amy Cavelier and Robert Wagstaff Goal: Registrar management and staff are working with the College?s Student Information Systems and IT departments to verify when and how the conflicting program-level effective dates were entered. At this point, we believe that the data originating from Jenzabar is correct. Discrepancies were created during the NSC error cleaning process, and data including those discrepancies were reported to the NSC and subsequently the NSLDS. Registrar?s Office management and staff are working with the NSLDS to obtain final student data reports which will be compared to the monthly student data files originally submitted to the NSC, prior to error correction, to identify the discrepancies and the cause of the data errors. The College is transitioning the enrollment reporting responsibility to another member of the Registrar?s Office. This transition will include formal training on the Jenzabar student information system, with a particular focus on NSLDS data reporting, as well as the NSC and NSLDS data submission processes. Our first Jenzabar training sessions have been scheduled for June 30 and July 7, 2023.
FINDING 2022-2 - WE AGREE. WE HAVE EFFECTIVELY MANAGED OUR PROJECT AND ALL PROJECT IMPLEMENTATION HAS BEEN PERFORMED TIMELY. ALL FUNDS DISBURSED BY DEQ HAVE BEEN PAID TIMELY, BUT WE WERE NOT AWARE OF THE 3-BANKING DAY RULE. WE ARE NOW AWARE OF THE 3-DAY RULE AND WILL PUT PROCEDURES IN PLACE SO TH...
FINDING 2022-2 - WE AGREE. WE HAVE EFFECTIVELY MANAGED OUR PROJECT AND ALL PROJECT IMPLEMENTATION HAS BEEN PERFORMED TIMELY. ALL FUNDS DISBURSED BY DEQ HAVE BEEN PAID TIMELY, BUT WE WERE NOT AWARE OF THE 3-BANKING DAY RULE. WE ARE NOW AWARE OF THE 3-DAY RULE AND WILL PUT PROCEDURES IN PLACE SO THAT APPROPRIATE PERSONNEL IS NOTIFIED OF THE RECEIPT OF FUNDS AND ENSURES FUNDS ARE DISBURSED TIMELY.
Description of Finding: Finding 2022-002 condition relates to noncompliance of regulation 45 CFR Part 75, Subpart F which requires a non-federal entity that spends $750,00 or more in federal awards during their fiscal year to complete and audit under Uniform Guidance and submit related reports...
Description of Finding: Finding 2022-002 condition relates to noncompliance of regulation 45 CFR Part 75, Subpart F which requires a non-federal entity that spends $750,00 or more in federal awards during their fiscal year to complete and audit under Uniform Guidance and submit related reports to the Federal Audit Clearinghouse within the earlier of 30 calendar days after receipt of the auditor?s report or nine months after the end of the audit period. Statement of Concurrence or Nonconcurrence: SCUREF management concurs with this finding. Corrective Action: To resolve audit finding 2022-002, SCUREF management will begin the audit process no later than September 15 of each year subsequent to the end of the audit period. Name of Contact Person: LaDonna Hall, CFO lhall@scuref.org 803-642-4187 Projected Completion Date: SCUREF?s management will begin working with the Hobbs group in September 2023 to complete the audit for FYE23.
Condition: The Organization did not have written policies, procedures and standards of conduct relative to federal awards as required by Uniform Guidance (2 CFR 200), Subparts D (Post Federal Award Requirements) and E (Cost Principles). Criteria: Uniform Guidance required nonfederal entities tha...
Condition: The Organization did not have written policies, procedures and standards of conduct relative to federal awards as required by Uniform Guidance (2 CFR 200), Subparts D (Post Federal Award Requirements) and E (Cost Principles). Criteria: Uniform Guidance required nonfederal entities that receive federal awards establish written policies, procedures and standards of conduct. Cause: The Organization lacks written policies, procedures or standards of conduct required by the current federal regulations. Effect: Failure to establish these policies, procedures or standards of conduct puts the Organization in noncompliance with federal regulations and increases the likelihood of fraud, waste and abuse of federal funds. It also may increase the likelihood of findings in subsequent single audits due to lack of adequate internal controls. Auditor?s Recommendation: We recommend that the Organization adopts written policies, procedures and standards of conduct relative to federal awards as required by Uniform Guidance. We have provided sample policies to review and consider. Management Response: The Organization will work with their auditor to develop and adopt written grant procedures that are in accordance with the Uniform Guidance. Contact Person: Debra Behrens Anticipated Completion: Ongoing
January 5, 2023 RE: Finding 2022-004: Internal Control over Compliance The following is the Corrective Action Plan (CAP) related to the noted finding. Corrective Action Plan Agency: U.S. Department of Health and Human Services Audit Period: June 2022 Audit Finding number: 2022-004 Audit Finding ...
January 5, 2023 RE: Finding 2022-004: Internal Control over Compliance The following is the Corrective Action Plan (CAP) related to the noted finding. Corrective Action Plan Agency: U.S. Department of Health and Human Services Audit Period: June 2022 Audit Finding number: 2022-004 Audit Finding Title: Internal Control over Compliance Specific Steps to be Taken: The YWCA Pueblo?s financial management policies and procedures for cash disbursements will be followed diligently. Electronic systems will be put into place to ensure that cash disbursements are approved, and all supporting documents are available at time of approval. Anticipated Completion Date: February 2023 Name and title of contact person responsible for Corrective Action Plan: Name: Maureen White Title: Executive Director
Higher Education Emergency Relief Funds ? Assistance Listing No. 84.425 Recommendation: We recommend the universities review their reporting procedures to ensure all required steps are included as well as the supporting documentation to prepare the report is retained. University of Maine at Fort Ken...
Higher Education Emergency Relief Funds ? Assistance Listing No. 84.425 Recommendation: We recommend the universities review their reporting procedures to ensure all required steps are included as well as the supporting documentation to prepare the report is retained. University of Maine at Fort Kent (UMFK) Condition: Two quarterly student reports tested were missing a required disclosure item. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: UMFK has amended all quarterly reports (9/30/2021, 12/31/2021, and 3/31/2022) to include the missing required disclosure item related to eligible students. Supporting worksheets have been updated to include all relevant disclosure items and reported data is verified using queries from both the financial and student information systems to ensure report accuracy and completeness. A review process has been implemented whereby the Financial Analyst signs off on preparation and the Chief Business Officer performs a final review and approval prior to submission. Name(s) of the contact person(s) responsible for corrective action: Megan Desjardins, Financial Analyst for the University of Maine at Fort Kent Pamela Ashby, Chief Business Officer for the University of Maine at Fort Kent Planned completion date for corrective action plan: Completed March 3, 2023 University of Maine at Farmington (UMF) Condition: One annual report tested where the supporting documentation did not agree to what was included in the report. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We realized the error during the next quarterly report cycle and corrected our internal data sheets, but the federal reporting portal was not open for corrections. Now that the federal reporting portal has reopened, we are in the process of correcting the 2021 annual report. In response to this finding, we have incorporated a verification of data in the spreadsheets used to prepare the annual report and now require a final review by the Chief Business Officer or his or her designee prior to submission. Name(s) of the contact person(s) responsible for corrective action: Christine Wilson, Vice President for Student Affairs and Enrollment Management at the University of Maine at Farmington Planned completion date for corrective action plan: March 31, 2023 University of Maine at Presque Isle (UMPI) Condition: One quarterly institutional report was not published timely. Two quarterly student reports tested where the supporting documentation did not agree to what was included in the report. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: As a result of a retirement in June 2022, we implemented additional internal controls for the timely compiling and review of required HEERF quarterly reports. The quarterly reports are now compiled by two staff members, and then reviewed and signed off by the Director of Financial Aid and the Controller?s Office the week prior to each deadline for the posting of the report to the institution?s website. As of July 1, 2022, with the updated quarterly report template and requirements from the Department of Education, we implemented a new, standardized process for gathering the appropriate student data for the reports, and new processes for documenting and retaining the data used in the reports. The reports in question were completed prior to this new process and amendments correcting the report information were made on September 6, 2022, and subsequently posted to the institution?s website. Name(s) of the contact person(s) responsible for corrective action: Connie Smith, Director of Financial Aid for the University of Maine at Presque Isle Planned completion date for corrective action plan: Completed September 6, 2022 University of Maine (UM) Condition: Two quarterly student reports tested where the supporting documentation did not agree to what was included in the report. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: As of July 1, 2022, with the updated quarterly report template and requirements from the Department of Education, we implemented a new, standardized process for gathering the appropriate student data for the reports, and new processes for documenting and retaining the data used in the reports. The reports in question were completed prior to this new process and amendments correcting the report information were made on January 27, 2023 and subsequently posted to the institution?s website. Name(s) of the contact person(s) responsible for corrective action: Connie Smith, Director of Financial Aid for the University of Maine Planned completion date for corrective action plan: Completed January 27, 2023
Student Financial Assistance Cluster ? Assistance Listing No. Various Recommendation: We recommend the University evaluate its procedures and policies around reporting disbursements to COD to ensure that student information is reported accurately and timely. University of Maine at Presque Isle (UMPI...
Student Financial Assistance Cluster ? Assistance Listing No. Various Recommendation: We recommend the University evaluate its procedures and policies around reporting disbursements to COD to ensure that student information is reported accurately and timely. University of Maine at Presque Isle (UMPI) Condition: During our testing at the University of Maine at Presque Isle, we noted one Pell disbursement that was not reported within the required 15 days and two Pell disbursements where the disbursement date per COD did not match the disbursement date per the student?s account. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Following the May 2022 retirement of the staff member responsible for this task, we implemented a weekly process to ensure timely reporting to COD, as well as timely resolutions to any issues encountered in sending these files. We also trained additional personnel to send these files and identify/resolve issues in the files and to have a documented internal control process to track the sending, receipt and error resolution process of COD files. Name(s) of the contact person(s) responsible for corrective action: Connie Smith, Director of Financial Aid for the University of Maine at Presque Isle Planned completion date for corrective action plan: July 1, 2022 - We implemented the new weekly process as described above to ensure files are sent and issues are resolved in a timely manner. March 1, 2023 - All staff responsible for this new process have been trained to send and review these files.
FINDING 2022-003 Subject: COVID-19 ? Education Stabilization Fund - Reporting Person Responsible for Corrective Action: Tammy Whisenant ? 219-962-1159 Views of Responsible Official: We concur with the finding. I have viewed and acknowledge the discrepancies listed. However, as I am new to my positio...
FINDING 2022-003 Subject: COVID-19 ? Education Stabilization Fund - Reporting Person Responsible for Corrective Action: Tammy Whisenant ? 219-962-1159 Views of Responsible Official: We concur with the finding. I have viewed and acknowledge the discrepancies listed. However, as I am new to my position, I am unable to determine the cause of the discrepancies. Personnel responsible for these areas assumed responsibilities just prior to and/or after this audit period commenced. Description of Corrective Action Plan: The corrective action will include: 1) Assess current assignments and identify opportunities to implement multiple level of review and verification. 2) Continue improved training, education and professional development of personnel responsible for financial transactions and reporting relating to federal programs. 3) Improved use of technology-based financial systems to ensure effectiveness and accuracy of financial transactions and reporting for federal programs. Anticipated Completion Date: An assessment of actions, needs and a plan will be completed by April 30, 2023; with an implementation to occurring by June 30, 2023. ________________________________ Tammy Whisenant, Director of Finance/Treasurer Lake Station Community Schools February 28, 2023
Upon discovery of the over award, funds were returned for the student immediately. Moving forward, the Financial Aid team will implement a review process at the beginning of each term that will identify students nearing aggregate loan limits to ensure students are not over awarded.
Upon discovery of the over award, funds were returned for the student immediately. Moving forward, the Financial Aid team will implement a review process at the beginning of each term that will identify students nearing aggregate loan limits to ensure students are not over awarded.
Both the Financial Aid team and Student Accounts team have developed a weekly disbursement and posting schedule. A cut off time for processing will be implemented to ensure both dates are aligned and to accommodate any file response import delays.
Both the Financial Aid team and Student Accounts team have developed a weekly disbursement and posting schedule. A cut off time for processing will be implemented to ensure both dates are aligned and to accommodate any file response import delays.
We recommend the University review its reporting procedures to ensure that roster file submissions are reported timely to NSLDS as required by regulations.
We recommend the University review its reporting procedures to ensure that roster file submissions are reported timely to NSLDS as required by regulations.
The University contracted with National Student Clearinghouse (NSC). In the prior year, we identified a data exchange issue between our institution and NSC. We have now resolved that issue.
The University contracted with National Student Clearinghouse (NSC). In the prior year, we identified a data exchange issue between our institution and NSC. We have now resolved that issue.
Finding 35920 (2022-001)
Significant Deficiency 2022
Condition: There was lack of documentation related to disbursement notices and exit counseling for nine out of thirty-four students tested. Criteria: According to ?668.165, before an institution disburses title IV, HEA program funds for any award year, the institution must notify a student of the a...
Condition: There was lack of documentation related to disbursement notices and exit counseling for nine out of thirty-four students tested. Criteria: According to ?668.165, before an institution disburses title IV, HEA program funds for any award year, the institution must notify a student of the amount of funds that the student or his or her parent can expect to receive under each title IV, HEA program, and how and when those funds will be disbursed. Additionally, according to ?682.604, a school must ensure that exit counseling is conducted with each loan borrower and graduate either in person, by audiovisual presentation, or by interactive electronic means. Cause: The College was unable to locate the documents for the students as a result of transitioning softwares. Effect: Certain documentation for disbursement notices and exit counseling was lost during the transition of the College's software. Context: During the compliance audit testing of ALN 84.268 and ALN 84.379, it was determined that documenation to confirm delivery of disbursement notices and performance of exit counseling could not be provided for certain students selected for testing. Recommendation: We recommend all required documentation be backed up to support compliance with certain requirements. View of Responsible Officials and Planned Corrective Action: The College is currently working with their IT department to make sure that all types of communication includes copying the financial aid department email to make sure the College has support for all communications to prevent this in the future.
Finding 35903 (2022-003)
Significant Deficiency 2022
Finding 2022-003: Policies and Procedures Related to Packaging Student Financial Aid ? SFA Cluster (significant deficiency) Corrective Action: Lyon College has two employees in the Financial Aid office. We do have a process in place to review the packaging of new student aid (FTFT and TXFR), tho...
Finding 2022-003: Policies and Procedures Related to Packaging Student Financial Aid ? SFA Cluster (significant deficiency) Corrective Action: Lyon College has two employees in the Financial Aid office. We do have a process in place to review the packaging of new student aid (FTFT and TXFR), though it is very manual, and requires both FA employees to be involved (in order to separate duties). It is still not foolproof. Our current software will not prevent us from overpackaging subsidized loans in our manual packaging process, but we can run a report to check and see if the field marked `Awards to Report as Need-Based? is greater than the field marked `Original Need?. If any are found, we can make the necessary adjustment. In the packaging of returning students ? the larger group of students - we do not have a review process in place. We will review to see if we can find a practical way, with our current limited personnel, to implement a review process for returning student award packages. The overpackaged student was simply a human keystroke error. Sub (remaining need) was calculated to be $4,484 and we input $4,884, a transposition. This was a returning student who likely did not get reviewed, and we also failed to pick it up in the process described below, comparing original need to awards marked as need. Our current software will not prevent us from overpackaging subsidized loans in our manual packaging process, but we can run a report to check and see if the field marked `Awards to Report as Need-Based? is greater than the field marked `Original Need?. If any are found, we can make the necessary adjustment. The other student was underpackaged with subsidized loans. In this case, the student was packaged on 7/15 based off of the only FAFSA we had available at that time, received on 6/29. On that FAFSA, the student had an EFC of $28,180, and no need. Therefore, all loans ($7,500) were packaged as unsubsidized. A PLUS loan denial came in the next day and the additional $5,000 was also packaged as unsubsidized. On 8/4, a revised FAFSA came in showing an EFC of $5,119. No adjustment was made to reclassify part of the loans as subsidized based on the `need? shown on the revised FAFSA. The Financial Aid Office believes that running the comparison report mentioned above on a regular basis will help us to find over-packaged need-based loans that we either made a mistake on during our initial packaging process, or due to a revised FAFSA that created additional need. Proposed Completion Date: The FAO will begin running the `Original Need vs. Aid Packaged As Need? Report on a monthly basis, and most importantly, in August immediately before aid is originated and disbursed.
Finding 35901 (2022-002)
Significant Deficiency 2022
Finding 2022-002: Allowability (COVID-19 ? Provider Relief Fund) Name of Contact Person: David Thomas, Group Vice President & Controller Corrective Action Plan: Atrium Health management believes that, while the Provider Relief Funds reporting was completed on a periodic basis throughout the pand...
Finding 2022-002: Allowability (COVID-19 ? Provider Relief Fund) Name of Contact Person: David Thomas, Group Vice President & Controller Corrective Action Plan: Atrium Health management believes that, while the Provider Relief Funds reporting was completed on a periodic basis throughout the pandemic, the intent from HRSA was to document the use of those funds for COVID-19 expenses and for lost revenues over the course of the entire pandemic. Because the PRF portal did not allow for previous periods to be restated in response to new information or corrections identified from previous reported periods, the only recourse available for health systems to restate COVID-19 expenses or lost revenues is through future PRF reporting or through the HRSA audit process. Management agrees that the control process in place during the initial reporting process for Wilkes Regional Medical Center did not yield the ultimate cost categorization that was corrected in the PRF reporting noted above; however, management?s interaction with HRSA throughout 2022 and the resulting clarification of COVID-19 expenses, is now incorporated into the overall PRF reporting control process. With respect to the identified questioned costs, management agrees that these costs should not have been included as COVID-19 related expenses for that period. However, management also recognizes that Wilkes Regional Medical Center has unused lost revenues more than this amount and as such, the questioned costs would not be subject to a return of the PRF proceeds. This position is supported by a similar finding in the 2021 Atrium Health Enterprise audit that was resolved with this conclusion and is documented in the Management Decision Letter issued by HRSA dated June 26, 2023. There are no additional PRF reporting periods required to be completed for Wilkes Regional Medical Center and Atrium Health management, when contacted, will provide HRSA auditors similar documentation to support the conclusion reached for these COVID-19 related expenses. Proposed Completion Date: Management will complete the corrective action plan upon request by HRSA.
View Audit 37993 Questioned Costs: $1
Finding 35900 (2022-001)
Significant Deficiency 2022
Finding 2022-001: Allowability (COVID-19 ? HRSA COVID-19 Uninsured Program) Name of Contact Person: David Thomas, Group Vice President & Controller Corrective Action Plan: Atrium Health CMHA currently has an insurance verification process for potentially uninsured patients meeting the criteria p...
Finding 2022-001: Allowability (COVID-19 ? HRSA COVID-19 Uninsured Program) Name of Contact Person: David Thomas, Group Vice President & Controller Corrective Action Plan: Atrium Health CMHA currently has an insurance verification process for potentially uninsured patients meeting the criteria prescribed by HRSA whereby identified accounts are sent nightly to Experian, a multinational consumer credit reporting company, who searches for insurance coverage. Negative confirmation documentation is inserted into the patient record. Management is aware of the importance of this process and has continued education efforts with applicable teammates to ensure this process is followed and documented with each patient. Additionally, the HRSA COVID-19 Uninsured Program ended in April of 2022. Proposed Completion Date: Management completed the 2021 corrective action plan by the end of September 2022. All findings were prior to this date.
Finding 35897 (2022-003)
Significant Deficiency 2022
Finding 2022-003: Allowability of Costs (Research & Development Cluster) Name of Contact Person: David Thomas, Group Vice President & Controller Corrective Action Plan: To address the current year finding, Academic Project Portfolio Management (PPM) Labor team has implemented internal control im...
Finding 2022-003: Allowability of Costs (Research & Development Cluster) Name of Contact Person: David Thomas, Group Vice President & Controller Corrective Action Plan: To address the current year finding, Academic Project Portfolio Management (PPM) Labor team has implemented internal control improvements to ensure all requirements that limit the salary cap allowability of costs are completed and documented appropriately including communication and education of salary cap requirements with the business administrator, plus additional review from the Academic PPM Labor team. Proposed Completion Date: Management will complete the corrective action plan by December 2023.
View Audit 37993 Questioned Costs: $1
Finding 35896 (2022-004)
Significant Deficiency 2022
Finding 2022-004: Allowability of Costs (Research & Development Cluster) Name of Contact Person: David Thomas, Group Vice President & Controller Corrective Action Plan: To address the current year finding, Atrium Health has adopted the Wake Forest University Health Sciences Effort Policy which al...
Finding 2022-004: Allowability of Costs (Research & Development Cluster) Name of Contact Person: David Thomas, Group Vice President & Controller Corrective Action Plan: To address the current year finding, Atrium Health has adopted the Wake Forest University Health Sciences Effort Policy which allows for ?a degree of tolerance? within the effort certification process. Office of Sponsored Programs will review Huron Employee Compensation Compliance (ECC) system for discrepancies over the percentage of tolerance allowed in the policy of plus or minus 5%. Proposed Completion Date: Management completed the corrective action plan by July 2022.
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