Corrective Action Plans

Finding 386493 (2023-029)

Material Weakness 2023

State of Arkansas

AR

Questioned Costs Subrecipient Monitoring Eligibility

Views of Responsible Officials and Planned Corrective Action: DHS concurs with the finding. The agency is in the process of developing an MMIS change that will automatically update member profiles to accurately reflect incarceration dates. This will ensure capitated payments are paused and reinstat...

Views of Responsible Officials and Planned Corrective Action: DHS concurs with the finding. The agency is in the process of developing an MMIS change that will automatically update member profiles to accurately reflect incarceration dates. This will ensure capitated payments are paused and reinstated in a timely manner and that recoupments and repayments are subsequently processed. The agency is conducting an ARIES system review to determine the root cause of the incorrect eligibility determinations and will identify and implement any needed updates to the automatic renewal process. Anticipated Completion Date: 6/30/2024 Contact Person: Name: Mary Franklin Title: Director, Division of County Operations Agency: Department of Human Services Address: 700 Main Street City, State, Zip: Little Rock, AR 72201 Phone Number: 501-681-8377 Email Address: Mary.Franklin@dhs.arkansas.gov

View Audit 298801 Questioned Costs: $1

Finding 386492 (2023-028)

Material Weakness 2023

State of Arkansas

AR

Questioned Costs Subrecipient Monitoring Eligibility

Views of Responsible Officials and Planned Corrective Action: DHS concurs with the finding. Since June 2023, DYS has made multiple changes to improve monitoring of suspension and reinstatement of Medicaid eligibility for incarcerated juveniles. For juveniles with SSI Medicaid, the Social Security A...

Views of Responsible Officials and Planned Corrective Action: DHS concurs with the finding. Since June 2023, DYS has made multiple changes to improve monitoring of suspension and reinstatement of Medicaid eligibility for incarcerated juveniles. For juveniles with SSI Medicaid, the Social Security Administration (SSA) is responsible for suspending Medicaid coverage. All incarcerations for cases noted in the findings involving SSI Medicaid were reported timely to SSA by the agency. DYS closely monitors these cases and continues to send closure requests to SSA until the cases are closed out. DYS has also updated its communication processes with DCO to ensure cases are suspended and reinstated in a timely manner. All payments noted as occurring during the incarceration period were capitated payments made for the PASSE, Dental Managed Care, NET, and PCCM programs. Some audit findings highlighted payments made for members during their month of incarceration, which is acceptable for all programs. The full monthly rate is paid for Dental Managed Care, NET, and PCCM even if the member is only eligible for part of the month. The PASSE program operates on a per-diem basis and any payments made for days when the member is ineligible are recouped as part of a monthly reconciliation. The agency currently has a reconciliation process for all four programs that identifies payments made after a member’s incarceration date that should be recouped. Some payments noted in the findings will be recouped as part of a reconciliation process that has yet to run. In addition to the current reconciliation process, the agency is in the process of developing an MMIS change that will automatically update member profiles to accurately reflect incarceration dates. This will ensure capitated payments are paused and reinstated in a timely manner and that recoupments and repayments are subsequently processed. Anticipated Completion Date: 6/30/2024 Contact Person: Name: Elizabeth Pitman Title: Director, Division of Medical Services Agency: Department of Human Services Address: 700 Main Street City, State, Zip: Little Rock, AR 72201 Phone Number: 501-244-3944 Email Address: Elizabeth.Pitman@dhs.arkansas.gov

View Audit 298801 Questioned Costs: $1

Finding 386490 (2023-026)

Material Weakness 2023

State of Arkansas

AR

Questioned Costs Eligibility Special Tests & Provisions

Views of Responsible Officials and Planned Corrective Action: DHS disputes the finding. The revalidation date for the provider noted in sample item 28 was 7/20/2022. Per CMS guidance, revalidations, site visits, and fingerprint background checks were paused during the COVID Public Health Emergency ...

Views of Responsible Officials and Planned Corrective Action: DHS disputes the finding. The revalidation date for the provider noted in sample item 28 was 7/20/2022. Per CMS guidance, revalidations, site visits, and fingerprint background checks were paused during the COVID Public Health Emergency (PHE) (3/1/2020-5/11/2023) and states were given until 11/11/2023 to complete revalidations due during the PHE. As this provider’s revalidation and site visit were completed on 10/12/2023, the agency is in compliance with all provider revalidation requirements. Based on research conducted by DMS, the provider noted in sample item 36 was not enrolled until 9/16/2018. Therefore, the revalidation date for this provider is 9/16/2023 as opposed to 6/12/2023 and there would be no questioned cost for the audit period. Anticipated Completion Date: Complete Contact Person: Name: Elizabeth Pitman Title: Director, Division of Medical Services Agency: Department of Human Services Address: 700 Main Street City, State, Zip: Little Rock, AR 72201 Phone Number: 501-244-3944 Email Address: Elizabeth.Pitman@dhs.arkansas.gov

View Audit 298801 Questioned Costs: $1

Finding 386489 (2023-025)

Material Weakness 2023

State of Arkansas

AR

Questioned Costs Eligibility Subrecipient Monitoring

Views of Responsible Officials and Planned Corrective Action: DHS concurs with the finding. The agency is conducting an ARIES system review to determine the root cause of the incorrect eligibility determinations and will identify and implement any needed updates to the automatic renewal process. ...

Views of Responsible Officials and Planned Corrective Action: DHS concurs with the finding. The agency is conducting an ARIES system review to determine the root cause of the incorrect eligibility determinations and will identify and implement any needed updates to the automatic renewal process. Anticipated Completion Date: 4/30/2024 Contact Person: Name: Mary Franklin Title: Director, Division of County Operations Agency: Department of Human Services Address: 700 Main Street City, State, Zip: Little Rock, AR 72201 Phone Number: 501-681-8377 Email Address: Mary.Franklin@dhs.arkansas.gov

View Audit 298801 Questioned Costs: $1

Finding 386488 (2023-024)

Material Weakness 2023

State of Arkansas

AR

Questioned Costs Subrecipient Monitoring Eligibility

Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. As the Public Health Emergency has concluded, the agency has returned to normal operations which requires disenrollment of any PASSE member that has not received an independent assessment within the last 12...

Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. As the Public Health Emergency has concluded, the agency has returned to normal operations which requires disenrollment of any PASSE member that has not received an independent assessment within the last 12 months. Anticipated Completion Date: Complete Contact Person: Name: Elizabeth Pitman Title: Director, Division of Medical Services Agency: Department of Human Services Address: 700 Main Street City, State, Zip: Little Rock, AR 72201 Phone Number: 501-244-3944 Email Address: Elizabeth.Pitman@dhs.arkansas.gov

View Audit 298801 Questioned Costs: $1

Finding 386486 (2023-023)

Material Weakness 2023

State of Arkansas

AR

Subrecipient Monitoring Special Tests & Provisions Matching / Level of Effort / Earmarking

Views of Responsible Officials and Planned Corrective Action: DHS concurs, in part, and disputes, in part, the finding. DHS has submitted and received approval from CMS for changes to the Dental Managed Care contract that requires the completion of annual audited financial reports. The agency disa...

Views of Responsible Officials and Planned Corrective Action: DHS concurs, in part, and disputes, in part, the finding. DHS has submitted and received approval from CMS for changes to the Dental Managed Care contract that requires the completion of annual audited financial reports. The agency disagrees that the audited financial reports submitted by the PASSE and Dental Managed Care Organizations (DMO) do not comply with 42 CFR 438.3(M). CMS guidance pertaining to that regulation provides that states have the flexibility to specify the applicable generally accepted accounting and auditing principles for the audited financial reports in the managed care plan contracts. The Arkansas Insurance Department also requires insurers to submit annual audited financial statements. Ark. Code Ann. 23-61-108 requires PASSE’s and DMO’s to follow the National Association of Insurance Commissioners Accounting Practices and Procedures Manual. DHS interprets 42 CFR 438.3(M) and its related guidance to permit the State Medicaid Agency flexibility to adopt the same accounting principles as the State Insurance Agency. As a practical matter, DHS reviewed the use of the audited financial statements and the information necessary to be contained within those statements. DMS discussed the use of the audited financial statements with the External Quality Review Organization (EQRO) that performs our External Quality Review. The EQRO confirmed that audited financial statements that complied with the Arkansas statutory basis would be satisfactory for review purposes. Anticipated Completion Date: Complete Contact Person: Name: Elizabeth Pitman Title: Director, Division of Medical Services Agency: Department of Human Services Address: 700 Main Street City, State, Zip: Little Rock, AR 72201 Phone Number: 501-244-3944 Email Address: Elizabeth.Pitman@dhs.arkansas.gov

View Audit 298801

Finding 386484 (2023-022)

Material Weakness 2023

State of Arkansas

AR

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Views of Responsible Officials and Planned Corrective Action: DHS concurs with the finding. The agency will update its written reporting instructions for Medicaid and CHIP to cover all items in the report workbooks. After the conclusion of the audit testing, the agency confirmed that the noted vari...

Views of Responsible Officials and Planned Corrective Action: DHS concurs with the finding. The agency will update its written reporting instructions for Medicaid and CHIP to cover all items in the report workbooks. After the conclusion of the audit testing, the agency confirmed that the noted variance between the agency’s accounting system and reported expenditures for the quarter ended September 30, 2022, was below the 5% threshold which requires an explanation to be provided to CMS financial analysts. The agency has reassigned resources to the Medicaid reporting section which will allow for additional time to spend researching variances identified in quarterly reconciliations. The agency also confirmed that the understatement of the federal portion of the September 30, 2022, CMS-64 report was $10,582, and the overstatement of the federal portion of the of the March 31, 2023, CMS-64 report was $30,664. The agency will correct these errors through an adjustment on an upcoming submission of the CMS-64 report. Anticipated Completion Date: 7/31/2024 Contact Person: Name: Jason Callan Title: Medicaid Chief Financial Officer Agency: Department of Human Services Address: 700 Main Street City, State, Zip: Little Rock, AR 72201 Phone Number: 501-320-6540 Email Address: Jason.Callan@dhs.arkansas.gov

View Audit 298801 Questioned Costs: $1

Finding 386478 (2023-019)

Material Weakness 2023

State of Arkansas

AR

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

Views of Responsible Officials and Planned Corrective Action: DHS concurs, in part, and disputes, in part, this finding. The noted MLR remittance was submitted for collection on December 12, 2023. The agency has developed and implemented a process to collect all MLR rebates through monthly capitati...

Views of Responsible Officials and Planned Corrective Action: DHS concurs, in part, and disputes, in part, this finding. The noted MLR remittance was submitted for collection on December 12, 2023. The agency has developed and implemented a process to collect all MLR rebates through monthly capitation payments. The agency will amend its Dental Managed Care contract to address this recoupment process. The agency has provided its actuary with the audited financial statements for all Dental Managed Care and PASSE entities dating back to the beginning of these programs and will update its internal control to clarify the process for calculating the three years of reports that must be submitted to the actuary. The agency disagrees that approved contracted rates were not being used for calendar year 2022. 42 CFR § 438.4(b) only requires that capitation rates be set at an actuarially sound rate for a specified time period. The requirement to receive approval for capitated rates does not mean that states are required to use previously approved rates from a prior year until a new one is approved. Actuarial best practices dictate that it is not appropriate to pay actuarial rates developed for a prior time period because there may be material differences in trend rates, covered benefits, provider reimbursement, and covered populations. Instead, it is optimal to use rates specifically developed for the applicable time limit even if CMS has not approved the rates. By using this approach, the agency ensures that it is paying MCO’s and PASSE’s capitation rates developed to be consistent with their financial responsibilities. Continued adherence to this practice is necessary as CMS consistently approves rates well after the beginning of the contract year. While CMS approval is beyond the agency’s control, agency controls and contracts have been updated to ensure rates and contracts are submitted 90 days prior to the start of the contract year. Anticipated Completion Date: Complete Contact Person: Name: Elizabeth Pitman Title: Director, Division of Medical Services Agency: Department of Human Services Address: 700 Main Street City, State, Zip: Little Rock, AR 72201 Phone Number: 501-244-3944 Email Address: Elizabeth.Pitman@dhs.arkansas.gov

View Audit 298801 Questioned Costs: $1

Finding 386475 (2023-016)

Material Weakness 2023

State of Arkansas

AR

Questioned Costs Subrecipient Monitoring Eligibility

Views of Responsible Officials and Planned Corrective Action: DHS concurs with the finding. The agency has updated its internal controls procedures to require enhanced review of payments made after the death of a provider or a client and enhanced monitoring of when a client is removed from an adopt...

Views of Responsible Officials and Planned Corrective Action: DHS concurs with the finding. The agency has updated its internal controls procedures to require enhanced review of payments made after the death of a provider or a client and enhanced monitoring of when a client is removed from an adoptive parent’s home. The Accounts Receivable Unit in the Office of Finance has implemented systems changes that ensures all claims will generate a collections notice with the correct claims data. The noted outstanding collection notices have been sent and data entry errors have been corrected. Anticipated Completion Date: Complete Contact Person: Name: Tiffany Wright Title: Director, Division of Children and Family Services Agency: Department of Human Services Address: 700 Main Street City, State, Zip: Little Rock, AR 72201 Phone Number: 501-396-6477 Email Address: Tiffany.Wright@dhs.arkansas.gov

View Audit 298801 Questioned Costs: $1

Finding 386474 (2023-015)

Material Weakness 2023

State of Arkansas

AR

Questioned Costs Subrecipient Monitoring Eligibility

Views of Responsible Officials and Planned Corrective Action: DHS concurs with the finding. The agency has updated its documented controls to require confirmation that agreements are signed by all parties before processing adoption subsidy packets. Adoption staff will be trained on the updated cont...

Views of Responsible Officials and Planned Corrective Action: DHS concurs with the finding. The agency has updated its documented controls to require confirmation that agreements are signed by all parties before processing adoption subsidy packets. Adoption staff will be trained on the updated controls. Anticipated Completion Date: 3/31/2024 Contact Person: Name: Tiffany Wright Title: Director, Division of Children and Family Services Agency: Department of Human Services Address: 700 Main Street City, State, Zip: Little Rock, AR 72201 Phone Number: 501-396-6477 Email Address: Tiffany.Wright@dhs.arkansas.gov

View Audit 298801 Questioned Costs: $1

Finding 386470 (2023-013)

Material Weakness 2023

State of Arkansas

AR

Matching / Level of Effort / Earmarking Subrecipient Monitoring Material Weakness § 200.302 § 200.303

Views of Responsible Officials and Planned Corrective Action: Arkansas Department of Education recognizes this finding. ADE Finance understands the importance of supporting documentation for non-LEAs and has implemented a plan for FY23 communications. Furthermore, ADE Finance conducted follow-up com...

Views of Responsible Officials and Planned Corrective Action: Arkansas Department of Education recognizes this finding. ADE Finance understands the importance of supporting documentation for non-LEAs and has implemented a plan for FY23 communications. Furthermore, ADE Finance conducted follow-up communication with the U.S. Department of Education (ED) on March 1, 2024. It was concluded that FTE position data for non-LEAs were optional for Years 1 and 2 Annual Performance Reports per the ESSER Form Review Webinar Guidance. ADE was further instructed to omit non-LEA information from the template should it be unreasonable to provide for the FY22 reporting year in question. ADE will ensure non-LEA entities provide the requested 5.a – Full-Time Equivalent (FTE) Compliance Supplement information for supporting documentation with FY23 and subsequent Reporting Periods. Anticipated Completion Date: May 2024. ADE Finance is coordinating communication with non-Local Educational Agencies (non-LEAs) in effort to revise the data for FY22, however will omit the related data per U.S. Department of Education (ED) guidance provided on March 1, 2024, should non-LEAs be unable to provide quality data. Contact Person: Name: Amy Thomas Title: Accounting Operations Manager Agency: Arkansas Department of Education Address: Four Capitol Mall, Room 204 City, State, Zip: Little Rock, AR, 72201 Phone Number: 501-682-3636 Email Address: Amy.Thomas@ade.arkansas.gov

View Audit 298801

Finding 386469 (2023-012)

Material Weakness 2023

State of Arkansas

AR

Questioned Costs Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.302

Views of Responsible Officials and Planned Corrective Action: Arkansas Department of Education recognizes this finding. The ADE Finance unit utilized data extracted from the statewide Local Educational Agencies (LEAs) system, APSCN, for the majority of parameters reported. However, APSCN does not h...

Views of Responsible Officials and Planned Corrective Action: Arkansas Department of Education recognizes this finding. The ADE Finance unit utilized data extracted from the statewide Local Educational Agencies (LEAs) system, APSCN, for the majority of parameters reported. However, APSCN does not have the ability to cross-reference financial expenses with Local Educational Agency’s (LEAs) personnel data, which led to the creation of the survey. LEAs were expected to report data during a subsequent school year post COVID-19 Pandemic. ADE gathered state total expenses for requested categories from the system compiled with the requested breakdowns by position type obtained in the manual survey. The two data sets did not align, thus seen in Questioned Costs which reflects the difference between the two datasets. LEA actual expenses, associated drawdowns, and disbursements were not affected by the amounts reported in the annual ESSER data. ADE Finance is currently working with APSCN personnel to explore options for assembling data without manual input from LEAs. When implemented, discrepancies in the state data reported to federal systems and LEAs data should not exist. ADE has the goal of utilizing this method for FY23 reporting in May 2024. Anticipated Completion Date: ADE Finance will revise its uploaded FY22 ESSER data template during the allowable period of July 29, 2024, through August 15, 2024. Contact Person: Name: Amy Thomas Title: Accounting Operations Manager Agency: Arkansas Department of Education Address: Four Capitol Mall, Room 204 City, State, Zip: Little Rock, AR, 72201 Phone Number: 501-682-3636 Email Address: Amy.Thomas@ade.arkansas.gov

View Audit 298801 Questioned Costs: $1

Finding 386468 (2023-011)

Material Weakness 2023

State of Arkansas

AR

Questioned Costs Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.302

Views of Responsible Officials and Planned Corrective Action: Arkansas Department of Education recognizes this finding. ADE Finance completed the named report which contained a subtotal error that overstated the totals when provided to Legislative Auditors. However, logic verifications built into t...

Views of Responsible Officials and Planned Corrective Action: Arkansas Department of Education recognizes this finding. ADE Finance completed the named report which contained a subtotal error that overstated the totals when provided to Legislative Auditors. However, logic verifications built into the Federal System disallowed the items mentioned to be submitted. Therefore, the data reflected in Federal reporting for Arkansas was not overstated nor actual expenses and associated drawdowns completed erroneously. This information was confirmed with the U.S. Department of Education (ED) on February 21, 2024. ADE Finance assures that revisions to the FY23 ESSER data template will be made and uploaded to the Federal Reporting System during the allowable period of July 29, 2024, and August 15, 2024. Anticipated Completion Date: Data was effectively corrected at the time of reporting within the Federal System. ADE Finance will revise its uploaded FY23 ESSER data template during the allowable period of July 29, 2024, through August 15, 2024. Contact Person: Name: Amy Thomas Title: Accounting Operations Manager Agency: Arkansas Department of Education Address: Four Capitol Mall, Room 204 City, State, Zip: Little Rock, AR, 72201 Phone Number: 501-682-3636 Email Address: Amy.Thomas@ade.arkansas.gov

View Audit 298801 Questioned Costs: $1

Finding 386450 (2023-001)

Material Weakness 2023

Kimball School District No. 7-2

SD

Internal Control / Segregation of Duties Material Weakness

Dr. Chris Noid is the contract person responsible for the corrective action plan for this finding. This finding is due to the limited number (one) of employees in the district's business office. Staffing the office at an efficient and financially feasible level precludes the hiring of enough perso...

Dr. Chris Noid is the contract person responsible for the corrective action plan for this finding. This finding is due to the limited number (one) of employees in the district's business office. Staffing the office at an efficient and financially feasible level precludes the hiring of enough personnel to provide an ideal environment for the internal controls. Kimball School District adopted an Internal Controls and Procedures policy in December 2017 and was updated in June 2021. We are aware of the weakness in internal controls and will adhere to policies and procedures we have in place while providing compensating controls to reduce the risk. This will be an ongoing process.

View Audit 298800

Finding 386447 (2023-002)

Material Weakness 2023

Franklin County Medical Center, A Component Unit of Franklin Countyid

ID

Questioned Costs Allowable Costs / Cost Principles Material Weakness

Corrective action planned: Utilize a CPA experienced with federal award to review and ensure compliance with grant proposals and activities. Anticipated completion date: April 30, 2024 Contact person responsible for corrective action: Jalen Tollefson, Grant Director

View Audit 298791 Questioned Costs: $1

Finding 386321 (2023-001)

Material Weakness 2023

Grand Valley State University

MI

Allowable Costs / Cost Principles Material Weakness Reporting § 200.430

The University implemented a new grant management software that will provide greater functionality to complete the effort certification process within the time requirements as identified in the University's Time and Effort Reporting policy.

View Audit 298711

Finding 386320 (2023-002)

Material Weakness 2023

Grand Valley State University

MI

Subrecipient Monitoring Material Weakness Reporting

When the University is unable to access the FFATA system, University staff will capture a screen snip of the error message and save it to the secure shared drive and follow-up with an email to the system’s help desk prior to the 30-day reporting requirement.

View Audit 298711

Finding 386244 (2023-004)

Material Weakness 2023

Lansing Housing Commission

MI

Subrecipient Monitoring HUD Housing Programs Material Weakness § 200.334

Condition: The Commission did have required written policies in place during the year under audit or retained copies of grant agreements once they became the direct recipient of the grants. Planned Corrective Action: Management agrees with the finding as reported. To correct this finding, the Commis...

Condition: The Commission did have required written policies in place during the year under audit or retained copies of grant agreements once they became the direct recipient of the grants. Planned Corrective Action: Management agrees with the finding as reported. To correct this finding, the Commission reviewed its policies and procedures and revised as needed to comply with federal regulations. The policies were presented and approved at the August 2023 board meeting. The Commission has sent revised policies to HUD for their review and approval. Contact person responsible for corrective action: Steve Raiche Anticipated Completion Date: 6/30/2024

View Audit 298666

Finding 386243 (2023-003)

Material Weakness 2023

Lansing Housing Commission

MI

Questioned Costs Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.306

Condition: The Commission was unable to provide adequate source documentation to support that the match requirement was met. Planned Corrective Action: Management agrees that match requirements for Continuum of Care awards have not been maintained as required by the Uniform Guidance. In July 2023, m...

Condition: The Commission was unable to provide adequate source documentation to support that the match requirement was met. Planned Corrective Action: Management agrees that match requirements for Continuum of Care awards have not been maintained as required by the Uniform Guidance. In July 2023, management was notified by HUD after completion of an on-site monitoring visit that the Commission's claimed matching expenses that were not adequately supported by source documentation. In response, management has placed in service additional controls to ensure the compliance requirements are being monitored and in place for the new program. Contact person responsible for corrective action: Steve Raiche Anticipated Completion Date: 6/30/2024

View Audit 298666 Questioned Costs: $1

Finding 386209 (2023-003)

Material Weakness 2023

Valley County Hospital D/b/a Valley County Health System

NE

Allowable Costs / Cost Principles Eligibility Material Weakness § 200.303

Criteria: 2CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Conditio...

Criteria: 2CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition: The Health System’s final expenditure listing identified as eligible and claimed under the Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution program were not reviewed and approved by a separate individual outside of the preparer. In addition, the Health System’s special report submitted to the Department of Health and Human Services for Period 4 was not reviewed and approved by a separate individual outside of the preparer. Responsible Individual: Ashley Woodward, Chief Financial Officer Corrective Action Plan: Management is aware of this control deficiency. Management is reviewing its system of internal control over compliance and plans to implement a control process which includes a secondary review and approval of the summarized final expenditure listing used to claim the allowable costs under the federal program and a secondary review and approval of required reports to be submitted to the federal agency. Anticipated Completion Date: June 30, 2024

View Audit 298633

Finding 386160 (2023-001)

Material Weakness 2023

Morris Heights Health Center, Inc. and Subsidiaries

NY

Material Weakness Reporting Internal Control / Segregation of Duties

2023-001 - Accuracy of Reporting to the PRF Portal: U.S. Department of Health and Human Services, COVID-19: Provider Relief Fund and American Rescue Plan ("ARP") Rural Distribution: Assistance Listing Number 93.498 - Reporting Recommendation We recommend that the Organization strengthen its system...

2023-001 - Accuracy of Reporting to the PRF Portal: U.S. Department of Health and Human Services, COVID-19: Provider Relief Fund and American Rescue Plan ("ARP") Rural Distribution: Assistance Listing Number 93.498 - Reporting Recommendation We recommend that the Organization strengthen its system of internal controls to ensure that all reporting that is done and submitted is consistent with requirements and instructions as provided by regulatory agencies. Action Taken Morris Heights Health Center is in the process of updating its Financial Policy & Procedures to strengthen its system of internal controls by including language that requires adequate review of the requirements and instructions of all regulatory reports. The policy also requires the review & sign-off of all regulatory reports by the Controller/CFO prior to any submission. We expect this to be corrected by April 30th, 2024.

View Audit 298583

Finding 386156 (2023-002)

Material Weakness 2023

Scenic Bluffs Health Center, INC

WI

Questioned Costs Cash Management Material Weakness § 200.430

Action taken in response to finding: A comprehensive spreadsheet including all wages allocated to Federal Grants was created during the course of the Federal Awards program Audits. This spreadsheet allows SBCHC staff to track and verify all wages allocated to Federal Awards on a contemporary basis ...

Action taken in response to finding: A comprehensive spreadsheet including all wages allocated to Federal Grants was created during the course of the Federal Awards program Audits. This spreadsheet allows SBCHC staff to track and verify all wages allocated to Federal Awards on a contemporary basis with internal checks and balances included. These verification processes now happen with every payroll cycle and are documented as such. Any revisions that are required now occur on a regular basis and correspond with the bi-weekly payroll cycle. Name(s) of the contact person(s) responsible for corrective action: Matt Gehri, CFO Planned completion date for corrective action plan: Currently deployed as of February 2024, and has been reviewed back to the beginning of the H80 Federal Grant year of May 1, 2023.

View Audit 298581 Questioned Costs: $1

Finding 386119 (2023-002)

Material Weakness 2023

Northwestern Consolidated School District of Shelby County

IN

School Nutrition Programs Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.303

FINDING 2023-002 Finding Subject: Child Nutrition Cluster – Internal Controls Federal Agency: Department of Agriculture Federal Programs: School Breakfast Program, National School Lunch Program Assistance Listing Numbers: 10.553, 10.555 Federal Award Number: 7350 Pass-Through Entity: Indiana Departm...

FINDING 2023-002 Finding Subject: Child Nutrition Cluster – Internal Controls Federal Agency: Department of Agriculture Federal Programs: School Breakfast Program, National School Lunch Program Assistance Listing Numbers: 10.553, 10.555 Federal Award Number: 7350 Pass-Through Entity: Indiana Department of Education Compliance Requirements: Activities Allowed and Unallowed, Allowable Costs/Costs Principles, Special Tests and Provisions-Verification of Free and Reduced Price Applications Summary of Finding: Material Weakness Internal Controls were not implemented to prevent noncompliance related to the verification of free and reduced applications and hours and wages. A new internal control procedure will be implemented for the second review of the free and reduced applications and for the hours and wages. Repeat Finding: Prior audit finding number was 2021-002. Contact Person Responsible for Corrective Action: Tammy Achenbach Contact Information: Phone: 317-835-7461 Email: tachenbach@nwshelbyschools.org Views of Responsible Officials: Management agrees with the finding. Management will ensure proper documented review of amounts billed for personnel and for the free and reduce verification 􀀃 INDIANA STATE BOARD OF ACCOUNTS 23 First ~ Best ~ Different! 􀀃 Northwestern􀀃 Consolidated􀀃School􀀃 District􀀃of􀀃Shelby􀀃County􀀃 􀀃 4920􀀃W.􀀃600􀀃N􀀃 Fairland,􀀃IN􀀃46126􀀃 􀀃 Phone:􀀃317􀍲835􀍲7461􀀃 Fax:􀀃317􀍲835􀍲4441􀀃 􀀃 www.nwshelbyschools.org􀀃 Superintendent􀀃 Mr.􀀃Chris􀀃Hoke􀀃 􀀃 Business􀀃Manager􀀃 Mrs.􀀃Tammy􀀃Achenbach􀀃 􀀃 Technology􀀃Director􀀃 Mr.􀀃Josh􀀃Landis􀀃 􀀃 Maintenance􀀃Director􀀃 Mr.􀀃Terry􀀃Coons􀀃 􀀃 Transportation􀀃Director􀀃 Mrs.􀀃Susie􀀃Childress􀀃 􀀃 Special􀀃Education􀀃Director􀀃 Mrs.􀀃Terri􀀃Branson􀀃 􀀃􀀃 School􀀃Board􀀃 Mr.􀀃David􀀃Ploog􀀃 Mrs.􀀃Brooke􀀃Lockett􀀃 Mrs.􀀃Cressa􀀃Rund􀀃 Mr.􀀃Ken􀀃Polston􀀃 Mr.􀀃Terry􀀃Morgan􀀃 Mr.􀀃Travis􀀃Hensler􀀃 Mrs.􀀃Karen􀀃Humphreys􀀃 Cont. page 2 Description of Corrective Action Plan: Review for personnel charges: During the monthly meeting to review the FSMC invoice, along with Operations Ledger, Client P&L, Monthly Reimbursements, Invoices, USDA Reconciliation, Direct Certification, The Hours and Wages will be reviewed and approved. Free and Reduced Verification: Internal Controls for the first round of Free and Reduce Applications will be verified by the Data Controller or the Business Manager and the verification of the random testing of the verifications will be done by the Business Manager or the Deputy Treasurer. Anticipated Completion Date: The district will start the new internal control procedure March 2024 to correct for the 23-24 school year.

View Audit 298525

Finding 386118 (2023-001)

Material Weakness 2023

Hydro-Eakly Independent School District #11

OK

Procurement, Suspension & Debarment Subrecipient Monitoring Material Weakness

The School Superintendent will review all projects funded by Federal funds to determine if any projects are considered construction projects. The Superintendent will require all such contracts to include prevailing wage clauses to ensure that federal wage rates and fringe benefits, are met, as requ...

The School Superintendent will review all projects funded by Federal funds to determine if any projects are considered construction projects. The Superintendent will require all such contracts to include prevailing wage clauses to ensure that federal wage rates and fringe benefits, are met, as required by the Davis-Bacon Act. The Superintendent will review weekly payroll reports provided by the contractor to ensure adherence to the contract clauses. The Superintendent will survey the job site weekly to ensure that required work site notices are posted.

View Audit 298524

Finding 386039 (2023-003)

Material Weakness 2023

Paoli Community School Corporation

IN

Subrecipient Monitoring Internal Control / Segregation of Duties Matching / Level of Effort / Earmarking § 200.302 § 200.303 § 200.328 § 200.329 § 200.334

FINDING 2023-003 Finding Subject: COVID-19 - Education Stabilization Fund - Reporting Summary of Finding: The School Corporation had not designed nor implemented a system of internal control to ensure that the six Elementary and Secondary School Emergency Relief (ESSER) annual data reports required ...

FINDING 2023-003 Finding Subject: COVID-19 - Education Stabilization Fund - Reporting Summary of Finding: The School Corporation had not designed nor implemented a system of internal control to ensure that the six Elementary and Secondary School Emergency Relief (ESSER) annual data reports required to be filed during the audit period were complete and accurate prior to submission. The Reports were prepared by one employee without an oversight or review process in place to prevent, or detect and correct, errors. Contact Person Responsible for Corrective Action: Greg Walker, Superintendent Contact Phone Number and Email Address: 812-723-4717 and walkerg@paoli.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Superintendent will enter information into the annual data report required for ESSER and once completed the Corporation Treasurer will review the information entered for accuracy. The Corporation Treasurer will sign off that the information entered is correct and then the Superintendent will submit the data report. Anticipated Completion Date: Projected date of completion is April 2024.

View Audit 298416

Corrective Action Plans

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