Corrective Action Plans

Finding 478407 (2022-003)

Material Weakness 2022

MI

Questioned Costs Period of Performance Subrecipient Monitoring

Following the completion of the 2021 Single Audit, we adjusted the Organization's Accounting Policies & Procedure Manual to include detailed information outlined in HUD's electronic Line of Credit Control System (eLOCCS) inclusive of the roles and responsibilities of the system's Users and Approving...

Following the completion of the 2021 Single Audit, we adjusted the Organization's Accounting Policies & Procedure Manual to include detailed information outlined in HUD's electronic Line of Credit Control System (eLOCCS) inclusive of the roles and responsibilities of the system's Users and Approving Official. Specifically, Accounting Department Leadership (i.e., the Chief Financial Officer), designated accounting personnel (i.e., Accountants), and/or agency Executive Leadership (i.e., CEO/Executive Director), must be cognizant of a grant's period of performance.

View Audit 315097 Questioned Costs: $1

Finding 478189 (2022-003)

Material Weakness 2022

Crow Creek Tribal Schools

SD

Allowable Costs / Cost Principles Material Weakness § 200.303

Individual(s) Responsible: Rob Coverdale, Superintendent; Anthony Barker, Business Manager Action: Review Policies and Procedures to ensure that management has implemented control processes to comply with the federal requirements and can provide documentation to support the transactions. Anticipated...

Individual(s) Responsible: Rob Coverdale, Superintendent; Anthony Barker, Business Manager Action: Review Policies and Procedures to ensure that management has implemented control processes to comply with the federal requirements and can provide documentation to support the transactions. Anticipated Completion Date: September 30, 2024

View Audit 314870

Finding 478000 (2022-002)

Material Weakness 2022

Human Response Network

CA

Reporting Internal Control / Segregation of Duties Material Weakness

Explanation and Corrective Action Taken: The audit for the Year Ended June 30, 2021 was completed in June 2023 which has caused a rippling effect for subsequent audits to be late. The Fiscal Officer that was responsible for the June 30, 2021 audit did not prepare or provide the necessary financial i...

Explanation and Corrective Action Taken: The audit for the Year Ended June 30, 2021 was completed in June 2023 which has caused a rippling effect for subsequent audits to be late. The Fiscal Officer that was responsible for the June 30, 2021 audit did not prepare or provide the necessary financial information to the Auditors. That Fiscal Officer resigned in March 2022 and the position remained vacant until August 1st, 2022. In August 2022, the preceding Fiscal Officer was rehired. During their prior employment from February 2013 until March 2021 there were no audit findings. In addition to the Fiscal Officer position being vacant for five months, there was a new fiscal coordinator position created and the fiscal assistant position had gone through 3 staff members in less than three years. There are no staff at Human Response Network with accounting experience except for the Fiscal Officer and fiscal department of three. The rehired Fiscal Officer determined that many balance sheet accounts were not reconciled monthly. It was discovered that closing entries had not been done and the financial statements provided to the auditors were inaccurate. The accounts not reconciled included the following accounts: • Cash • Contracts Receivable to the General Ledger • Prepaid Expenses to Accrue Expenses • Depreciation / Property & Equipment Schedule • Accounts Payable Aging to the General Ledger • Deferred Revenue to the General Ledger The Fiscal Officer performed a thorough review of the allocation methodology, journal entries, and other accounting transactions to ensure that the transactions were recorded properly and pooled expenses were correctly allocated. There were a number of transactions that were not coded correctly. Pooled expenses were allocated correctly. The trial balance discrepancies from Fiscal Year 2021/22 were researched and reconciled and all the balance sheet accounts were reconciled. Transactions were re-coded to their correct account. The Fiscal Officer continues training staff on the proper procedures and use of the financial software. An audit engagement letter for 2021/22 was executed on September 15, 2023. The majority of information was provided to the Auditors between November 2023 and early February 2024. Scheduling conflicts prevented continued work on the audit until late-May 2024. Human Response Network agrees that monthly reconciliations of all general ledger and balance sheet accounts should be performed timely and accurately. As of August 2022, Human Response Network staff began reconciling accounts and projects on a regular basis as a part of the monthly closing process. Staff continue to receive ongoing training and mentoring by the experienced staff members.

View Audit 314739

Finding 477990 (2022-003)

Material Weakness 2022

American Academy of Child and Adolescent Psychiatry

DC

Material Weakness Reporting Internal Control / Segregation of Duties

Identifying number: 2022-003: Finding: The Academy’s 2022 data collection form was not submitted within nine months after the end of the audit period. Corrective Actions Taken or Planned: 1. Beginning in fall of 2022, the Academy has contracted with an outsourced accounting and consulting fir...

Identifying number: 2022-003: Finding: The Academy’s 2022 data collection form was not submitted within nine months after the end of the audit period. Corrective Actions Taken or Planned: 1. Beginning in fall of 2022, the Academy has contracted with an outsourced accounting and consulting firm to manage the financial reporting surrounding its federal funding. The firm is working in consultation with organization leadership and a federal grant consultant to provide the necessary support to produce the federal report package prior to the reporting deadline. Name of Responsible Person: Heidi Fordi, Executive Director/CEO Projected Date of Completion: July 2024

View Audit 314720

Finding 477890 (2022-001)

Material Weakness 2022

Minnesota Indian Women's Sexual Assault Coalition

MN

Material Weakness Reporting Internal Control / Segregation of Duties

In 2022 two grant awards from private foundations were incorrectly classified as “without donor restrictions” in the accounting system. Our Financial Policies and Procedures specify in Part I, Section 6 that MIWSAC will recognize contributions based on any donor imposed purpose or time restrictions ...

In 2022 two grant awards from private foundations were incorrectly classified as “without donor restrictions” in the accounting system. Our Financial Policies and Procedures specify in Part I, Section 6 that MIWSAC will recognize contributions based on any donor imposed purpose or time restrictions identified in the award notice or grant document. Further, our Financial Policies and Procedures specify in Part IV, Section 1 the following procedures be applied for all gifts, contributions and grants: 1. Finance Manager and AIOA Controller will review award documents, grant documents or other correspondence received from donor/funder to determine the type of donor restriction(s). 2. Finance Manager and Executive Director will establish any required tracking of donor restricted revenues and how/when restrictions will be satisfied and released. 3. The AIOA Controller will add new donor restricted revenues to the Net Assets workpaper and subtract donor restricted funds that have been released from restriction. 4. The Finance Manager or AIOA Controller will prepare a journal entry as part of the month-end procedures to reclass any new donor restricted revenue from Unrestricted Net Assets to Net Assets with Donor Restriction and to record satisfaction of restrictions by reclassing from Net Assets with Donor Restriction to Unrestricted Net Assets. In the case of the two grants identified by the auditors as mis-classified, the policies were followed but the conclusions reached were incorrect. In one case the error was a clear oversight of the AIOA Controller. In the second case, the language the donor used in the grant document for a general operations award was ambiguous and open to more than one interpretation. Our AIOA Controller determined the award to have no restrictions but in a discussion with auditors we have agreed the “2 year” language in the grant document, though not clearly defined, would necessitate placing a time restriction on 50% of the award. The corrections were made as part of the audit engagement by the AIOA Controller posting a reclassing entry to revenue and net assets with donor restrictions. This audit adjustment was reviewed and agreed upon by management. Further corrective action will be for the AIOA Controller to consult with and collaborate with the AIOA CFO on the determination of the revenue treatment of grants and contributions received from private foundations to ascertain the existence of conditions and/or donor imposed restrictions. This corrective action has been implemented as of 8/25/2023. Corrective Action contact/responsible party: Jerry Frick, Fractional CFO – All In One Accounting Jerry.frick@allinoneaccounting.com 651-347-4471 Corrective Action Contact: Nicole Matthews, Executive Director nmatthews@miwsac.org 651-646-4800

View Audit 314524

Finding 457880 (2022-002)

Material Weakness 2022

Central Midlands Council of Governments

SC

Material Weakness Reporting

Finding 2022-002 Report Submission to the Federal Audit Clearinghouse (Other Matter Required to be Reported Under the Uniform Guidance) (Material Weakness)Name of Contact Person Responsible for the Corrective Action Plan:Melissa Labbe, Director of FinanceCorrective Action Plan:Central Midlands Counc...

Finding 2022-002 Report Submission to the Federal Audit Clearinghouse (Other Matter Required to be Reported Under the Uniform Guidance) (Material Weakness)Name of Contact Person Responsible for the Corrective Action Plan:Melissa Labbe, Director of FinanceCorrective Action Plan:Central Midlands Council of Governments has filled key positions needed to address staffing needs necessary to achieve timely reporting and reconciliations. During FY2023, CMCOG has also undertaken to train its Finance staff to further enhance our ability to provide timely and accurate reports.Anticipated Completion Date: June 30, 2023

View Audit 314371

Finding 455009 (2022-001)

Material Weakness 2022

Italian Home for Children, INC

MA

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness

Views of Responsible Officials and Planned Corrective Actions:We agree with the auditor?s recommendation. It should be noted Italian Home for Children (IHC) has the recommended internal controls in place and are functioning well. However, with the impact of the novel coronavirus (COVID-19) as well a...

Views of Responsible Officials and Planned Corrective Actions:We agree with the auditor?s recommendation. It should be noted Italian Home for Children (IHC) has the recommended internal controls in place and are functioning well. However, with the impact of the novel coronavirus (COVID-19) as well as turnover in the IHC?s Finance team, official sign off was not always being done. IHC?s Accounts Payable team will obtain approvals of individual invoices either physically or electronically from the appropriate individuals. Approved invoices will be forwarded to a different individual on the Finance team to review and authorize payment. The check/ACH remitted for payment will be signed by someone other than the individual who authorized payment of the invoices. In addition, IHC will ensure there is either electronic or paper audit trail of reviews and approvals. This will ensure all expenditures are appropriately reviewed and approved prior to payment. Finally, all items referred to in the finding were for allowable costs and no items of noncompliance were identified.

View Audit 313970

Finding 452425 (2022-020)

Material Weakness 2022

State of New Jersey

NJ

Subrecipient Monitoring Material Weakness Reporting § 200.303

FINDING # 2022-020No finding in prior yearThe DHS Division of Family Development (DFD) agrees with the audit finding regarding the submission of subawards to the FFFATA Subaward Reporting System (FSRS).In accordance with the finding recommendation, the DFD will develop internal controls and procedur...

FINDING # 2022-020No finding in prior yearThe DHS Division of Family Development (DFD) agrees with the audit finding regarding the submission of subawards to the FFFATA Subaward Reporting System (FSRS).In accordance with the finding recommendation, the DFD will develop internal controls and procedures to ensure the timely reporting of all required subawards to FSRS. An initial review of the FSRS by DFD fiscal staff appeared to indicate that some federal grant data that should be prepopulated on the website was missing (e.g. Child Care M&M available; discretionary not found). DFD will work with the necessary federal agencies to ensure that the Division can input the required information for all awards.Assessment and development of policy and procedures related to this task will take approximately three months. Staff assignment, training, and submission of federal grant information to the federal website will occur over the next State fiscal year 2024.Projected policy and procedures development completion: July 1, 2023.Assignment and submission of federal reports: June 30, 2024.COMPLETION DATE/CONTACT PERSON Fiscal Year 2024Thomas Mattaliano, CFO-DFD(609) 588-3370Thomas.Mattaliano@dhs.nj.gov

View Audit 313443

Finding 452419 (2022-017)

Material Weakness 2022

State of New Jersey

NJ

Subrecipient Monitoring Material Weakness Reporting § 200.303

FINDING # 2022-017No finding in prior yearThe Department of Community Affairs (DCA) now has a staff member in place with assigned responsibility for the FFATA reporting in the Federal Subaward Reporting System (FSRS) and other required federal reporting. To ensure that all required reporting in FSRS...

FINDING # 2022-017No finding in prior yearThe Department of Community Affairs (DCA) now has a staff member in place with assigned responsibility for the FFATA reporting in the Federal Subaward Reporting System (FSRS) and other required federal reporting. To ensure that all required reporting in FSRS is completed timely, the process and procedures will be fully documented and the LIHEAP program manager will verify completion each month. DCA will also hire additional staff or cross-train current staff to further support the federal reporting function.COMPLETION DATE/CONTACT PERSON June 30, 2023Fidel Ekhelar(609) 815-3905Fidel.Ekhelar@dca.nj.gov

View Audit 313443

Finding 452414 (2022-015)

Material Weakness 2022

State of New Jersey

NJ

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

FINDING # 2022-0152021-017With the Corrective Action Plan (CAP) previously developed as a result of the prior year 2021 audit finding, the Department?s Grants Unit with coordination from ELC program fiscal staff added a new function to the SAGE system that pulls all subaward data for all of ELC usin...

FINDING # 2022-0152021-017With the Corrective Action Plan (CAP) previously developed as a result of the prior year 2021 audit finding, the Department?s Grants Unit with coordination from ELC program fiscal staff added a new function to the SAGE system that pulls all subaward data for all of ELC using its assigned ALN number 93.323. This system change was implemented in September 2022 that allows SAGE to pull data by CFDA number and enables the ELC fiscal staff to access all ELC subawards. ELC fiscal staff also has a reminder set to report at the end of each month, to enter FFATA information into FSRS, and to upload each report to SharePoint ELC Document Library at the end of each month.As per the prior year CAP created in September 2022, FFATA information for ELC subawards began being entered into FSRS on September 1, 2022.COMPLETION DATE/CONTACT PERSON September 2022Secil Onat(609) 913-5308Secil.Onat@doh.nj.gov

View Audit 313443

Finding 452410 (2022-013)

Material Weakness 2022

State of New Jersey

NJ

Subrecipient Monitoring Material Weakness Reporting § 200.303

FINDING # 2022-013No finding in prior yearThe Department of Health, Division of Epidemiology, Environmental and Occupational Health?s (DEEOH), Vaccine Preventable Disease Program (VPDP) will attain full compliance with Federal Funding Accountability and Transparency Act (FFATA) requirements. The VPD...

FINDING # 2022-013No finding in prior yearThe Department of Health, Division of Epidemiology, Environmental and Occupational Health?s (DEEOH), Vaccine Preventable Disease Program (VPDP) will attain full compliance with Federal Funding Accountability and Transparency Act (FFATA) requirements. The VPDP on boarded a full-time lead fiscal/grants officer in August 2022 to oversee the Immunization Cooperative Agreements, including COVID-19 supplemental funding. VPDP fiscal/grants leadership will implement FFATA procedures for the Immunization Cooperative Agreement. These procedures shall include creating a list of all active first-tier subawards of federal funds DEEOH has issued at $30,000 or more under this Cooperative Agreement. The list will include all the data fields required for FFATA reporting. DEEOH fiscal/grants leadership will ensure each of the identified sub-awards is entered on the FFATA Subaward Reporting System (FSRS) website within 30 days of award issuance or award amendment.COMPLETION DATE/CONTACT PERSON March 24, 2023Susan Barcarola(609) 913-5302Susan.Barcarola1@doh.nj.gov

View Audit 313443

Finding 452405 (2022-012)

Material Weakness 2022

State of New Jersey

NJ

Subrecipient Monitoring Material Weakness Reporting § 200.303

FINDING # 2022-0122021-015The Department of Human Services, Division of Aging Services (DoAS) continues to work towards attaining full compliance with Federal Funding Accountability and Transparency Act (FFATA) requirements. The DoAS continues to consult with the Department and/or other DHS Divisio...

FINDING # 2022-0122021-015The Department of Human Services, Division of Aging Services (DoAS) continues to work towards attaining full compliance with Federal Funding Accountability and Transparency Act (FFATA) requirements. The DoAS continues to consult with the Department and/or other DHS Division fiscal leadership to finalize the FFATA procedures. These procedures shall include creating a list of all active first-tier subawards of federal funds DoAS has issued at $30,000 or more. The list will include all the data fields required for FFATA reporting. DoAS grants management members will ensure each of the identified subawards is entered on the Federal Subaward Reporting System (FSRS) website. DoAS will also revise internal procedures to ensure all future subawards of $30,000 or more are entered on FSRS within 30 days of award.COMPLETION DATE/CONTACT PERSON April 30, 2023Hetal Bhatt609-438-4586Hetal.Bhatt@dhs.nj.govDennis McGowan609-438-4739Dennis.McGowan@dhs.nj.gov

View Audit 313443

Finding 452399 (2022-009)

Material Weakness 2022

State of New Jersey

NJ

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness § 200.303

FINDING # 2022-009No finding in prior yearThe Department of Community Affairs (DCA) has internal controls and procedures in place to ensure that required subawards are reported timely to FSRS in accordance with FFATA reporting requirements. The Homeowner Assistance Fund award received by DCA was uni...

FINDING # 2022-009No finding in prior yearThe Department of Community Affairs (DCA) has internal controls and procedures in place to ensure that required subawards are reported timely to FSRS in accordance with FFATA reporting requirements. The Homeowner Assistance Fund award received by DCA was unique in that it was planned and fully reallocated via Memorandum of Understanding (MOU) agreement to a DCA affiliate organization to administer on the State?s behalf. As a result, the DCA did not initially believe this single reallocation transaction was subject to FFATA reporting requirements. The Accountability Officer at the affiliate organization will be involved should another program and contractual arrangement of this type occur and will ensure that the FSRS reporting is done timely. No further subaward transactions are expected to be processed by DCA as the full allocation was disbursed to our affiliate organization upon receipt of the award and execution of the MOU.COMPLETION DATE/CONTACT PERSON Fiscal Years 2023-2024John Alexy(609) 913.4385John.Alexy@dca.nj.gov

View Audit 313443

Finding 452395 (2022-007)

Material Weakness 2022

State of New Jersey

NJ

Subrecipient Monitoring Material Weakness Reporting § 200.303

FINDING # 2022-007No finding in prior yearIn recent years, the DLWD has transitioned from a manual contract process to a web-based system (i.e., SAGE and IGX systems) and has also experienced changes in personnel responsible for the contracting process. Although progress has been made with getting ...

FINDING # 2022-007No finding in prior yearIn recent years, the DLWD has transitioned from a manual contract process to a web-based system (i.e., SAGE and IGX systems) and has also experienced changes in personnel responsible for the contracting process. Although progress has been made with getting the FFATA Reporting Unit access to these automated systems, the DLWD will continue to enhance the communication between the offices that prepare and approve the contracts/agreements and the FFATA Reporting Unit. DLWD will also develop procedures to ensure that timely and accurate information is provided to the FFATA Reporting Unit and that group will also be included in the grant approval process so the unit is notified timely.COMPLETION DATE/CONTACT PERSON December 31, 2023Ahmanish Robinson(609) 984-4356Ahmanish.Robinson@dol.nj.gov

View Audit 313443

Finding 452387 (2022-003)

Material Weakness 2022

State of New Jersey

NJ

Questioned Costs Eligibility Internal Control / Segregation of Duties § 200.303

FINDING # 2022-0032021-007The Department of Labor and Workforce Development (DLWD) has controls in place to only allow an FPUC payment to be made when an underlying Unemployment Insurance (UI) payment has also been processed. FPUC payments should not be issued to any claim without the underlying UI...

FINDING # 2022-0032021-007The Department of Labor and Workforce Development (DLWD) has controls in place to only allow an FPUC payment to be made when an underlying Unemployment Insurance (UI) payment has also been processed. FPUC payments should not be issued to any claim without the underlying UI payment being made for the same week. The two FPUC payments issued and noted as exceptions during eligibility testing will be reviewed independently by DLWD to determine if the payments issued were to eligible recipients or not.For the PUA exceptions noted during Eligibility testing, overall the DLWD issued PUA payments to over 680,000 claimants during the COVID-19 pandemic. DLWD had controls in place to require a COVID related reason to make the claim PUA eligible and the weekly PUA certification required claimants to choose a COVID related reason for why they were out of work before they could get paid. The PUA payments in question will be reviewed independently by the DLWD to determine if the payments issued under PUA were appropriate or if they should have been paid instead under the regular UI program.COMPLETION DATE/CONTACT PERSON February 2023Ronald Marino - DLWD(609) 292-2810Ronald.Marino@dol.nj.gov

View Audit 313443 Questioned Costs: $1

Finding 452381 (2022-002)

Material Weakness 2022

State of New Jersey

NJ

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

FINDING # 2022-002No finding in prior yearThe Department of Agriculture, Division of Food and Nutrition (DOA) was delinquent in submitting required reporting in the FFFATA Subaward Reporting System (FSRS) due to the inability to make system updates for the UEI change during the pandemic. This preve...

FINDING # 2022-002No finding in prior yearThe Department of Agriculture, Division of Food and Nutrition (DOA) was delinquent in submitting required reporting in the FFFATA Subaward Reporting System (FSRS) due to the inability to make system updates for the UEI change during the pandemic. This prevented the DOA from pulling data to submit the reports to the FSRS. The DOA has two technical staff members assigned to query the data fields required to upload the report. Once the query is complete the data is converted to a CSV file and uploaded to FSRS. As of December 2022, monthly reporting has resumed. Successful monthly upload documentation will now be provided and monitored by the Assistant Division Director and Fiscal Coordinator.COMPLETION DATE/CONTACT PERSON December 2022Melissa Pajak(609) 690-8880Melissa.Pajak@ag.nj.gov

View Audit 313443

Finding 449494 (2022-004)

Material Weakness 2022

Baltimore County, Maryland

MD

Material Weakness Reporting Matching / Level of Effort / Earmarking § 200.303

2022-004 COVID-19-Emergency Rental Assistance ? Assistance Listing No. 21.023Recommendation: We recommend that management review their policies and procedures to ensure that all monthly and quarterly reports showing timely submission and the supporting documentation used to prepare the reports are r...

2022-004 COVID-19-Emergency Rental Assistance ? Assistance Listing No. 21.023Recommendation: We recommend that management review their policies and procedures to ensure that all monthly and quarterly reports showing timely submission and the supporting documentation used to prepare the reports are retained for audit purposes.Explanation of disagreement with audit finding: DHCD possesses and utilized supporting documentation to prepare the required reports. However, DHCD was provided 24 hours to submit this information while the primary contributing staff was on scheduled leave and unreachable. DHCD disagrees with the statement about monthly and quarterly reports not being submitted timely. All required reports were submitted on-time and in accordance with current Treasury guidance at the time of submission. DHCD cannot ascertain the veracity of this statement about lack of supporting documentation because it was not provided the data points the auditors used to make their determination. Fully reconciled final documentation of ERA1 Participant Household Data Report was given to the Auditors. However, this data would not have matched earlier submissions to Treasury. Treasury requested full revisions because their staff became aware of many structural reporting problems were experienced by recipients while completing the reporting actions. Entries timed out, sometimes disappeared, sometimes double counted, and the database had no ability to allow for corrections once identified. For this reason, Treasury?s final reporting requirements for closeout had the option for jurisdictions to disregard all prior entries and submit a reconciled version of the households assisted and all related expenditures. This final data report was provided in this audit yet it does not match the initial submissions for the reasons stated. Because the Auditors did not afford DHCD the time to review their ?findings?, DHCD cannot ascertain the level of agreement with the statement.Action taken in response to finding: Not applicable, see above.Name(s) of the contact person(s) responsible for corrective action: Colleen MahonyPlanned completion date for corrective action plan: Not applicable, see above.

View Audit 313273

Finding 449481 (2022-002)

Material Weakness 2022

Baltimore County, Maryland

MD

Subrecipient Monitoring HUD Housing Programs Material Weakness

2022-002 CDBG Entitlement Grant Cluster ? Assistance Listing No. 14.218Recommendation: We recommend the County develop internal controls and procedures to ensure that FFATA reporting requirements are met. We further recommend the County develop controls and procedures to ensure that all required sub...

2022-002 CDBG Entitlement Grant Cluster ? Assistance Listing No. 14.218Recommendation: We recommend the County develop internal controls and procedures to ensure that FFATA reporting requirements are met. We further recommend the County develop controls and procedures to ensure that all required subawards are reported accurately and timely to FSRS no later than the end of the month following the month of issuance. We also recommend the County develop internal controls and procedures to ensure the PR29-Cash on Hand reporting requirements are met.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: Due to the volume of the work involved to deploy millions of dollars to mitigate the adverse effect of Covid19 on housing stability we have missed and yet to file the requirement of FFTA reporting. DHCD intend to have these requirements remedied and corrected..Name(s) of the contact person(s) responsible for corrective action: Amir AssadiPlanned completion date for corrective action plan: 6/30/2024

View Audit 313273

Finding 443064 (2022-005)

Material Weakness 2022

Whitko Community School Corporation

IN

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

FINDING 2022-005Contact Person Responsible for Corrective Action: Lynn Leininger, Business ManagerContact Phone Number: (260) 367-3677Whitko Community Schools concurs with the finding and will implement internal controls for all grantrequirements and reporting compliances of the Education Stabilizat...

FINDING 2022-005Contact Person Responsible for Corrective Action: Lynn Leininger, Business ManagerContact Phone Number: (260) 367-3677Whitko Community Schools concurs with the finding and will implement internal controls for all grantrequirements and reporting compliances of the Education Stabilization Funds. All reporting will be a jointeffort between the Business Manager preparing the reports with the assistance of the business officepersonnel. Supporting paperwork and calculations will be maintained to support all report informationsubmitted. Prior to submission of Education Stabilization Funds, all information will be reviewed andsigned by the Deputy Treasurer to insure reporting compliance.The completion date for this corrective action will be May1, 2023.INDIANA STATE

View Audit 312741

Finding 443057 (2022-003)

Material Weakness 2022

Town of Argos

IN

Internal Control / Segregation of Duties Material Weakness Reporting § 200.303

FINDING 2022-003Contact Person Responsible for Corrective Action: Lisa Mullaney Clerk/TreasurerContact Phone Number: 574-892-5717 x222.Views of Responsible Official: I concur with the findings.Description of Corrective Action Plan:The Clerk-Treasurer will review all reports submitted by the 3rd part...

FINDING 2022-003Contact Person Responsible for Corrective Action: Lisa Mullaney Clerk/TreasurerContact Phone Number: 574-892-5717 x222.Views of Responsible Official: I concur with the findings.Description of Corrective Action Plan:The Clerk-Treasurer will review all reports submitted by the 3rd party grant writer with documentation.Anticipated Completion Date: 09/30/2023

View Audit 312734

Finding 442917 (2022-008)

Material Weakness 2022

Circle of Nations School INC

ND

Internal Control / Segregation of Duties Special Tests & Provisions Material Weakness

2022-008 N. Special Tests and ProvisionsEducation Stabilization Fund CFDA #84.425Material Weakness in Internal Control over Compliance and Material Instance of NoncomplianceFinding Summary: During the course of the engagement, it was identified that the School didnot satisfy the requirements of 2 C...

2022-008 N. Special Tests and ProvisionsEducation Stabilization Fund CFDA #84.425Material Weakness in Internal Control over Compliance and Material Instance of NoncomplianceFinding Summary: During the course of the engagement, it was identified that the School didnot satisfy the requirements of 2 CFR 656.40 through 2 CFR 656.41. The School did not ensure proper inclusion of prevailing wage rate clauses were included in a construction contract and also did not obtain proper support to ensure required certified payrolls were submitted.Corrective Action Plan: The School will review internal controls surrounding required contract language and documentation supporting certified payroll reports are obtained from contractor.Anticipated Completion Date: June 30, 2023

View Audit 312521

Finding 442861 (2022-003)

Material Weakness 2022

Anthem Strong Families

TX

Internal Control / Segregation of Duties Procurement, Suspension & Debarment Allowable Costs / Cost Principles

Management will ensure that accrued expenses are reviewed in detail at grant year end to ensure only costs incurred prior to year end are accrued and reported as grant expenditures.

View Audit 312505

Finding 425828 (2022-006)

Material Weakness 2022

Commonspirit Health

IL

Eligibility Internal Control / Segregation of Duties Material Weakness § 200.303

REFERENCE: 2022-006 ? EligibilityHIV Emergency Relief Project Grants (Assistance listing No. 93.914)Federal Grantor: Health Resources and Services AdministrationFacility: St. Mary?s Medical Center ? San FranciscoSt. Mary Medical Center ? Long BeachFinding: St. Mary Medical Center ? Long Beach and St...

REFERENCE: 2022-006 ? EligibilityHIV Emergency Relief Project Grants (Assistance listing No. 93.914)Federal Grantor: Health Resources and Services AdministrationFacility: St. Mary?s Medical Center ? San FranciscoSt. Mary Medical Center ? Long BeachFinding: St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco did notconsistently retain evidence of their internal controls over the requirement to review eligibility requirements prior toadministering services in accordance with the grant agreements.Corrective Action Plan: This finding has been corrected. The 6 month eligibility check is no longer required. Forthe annual eligibility checks at St. Mary?s Medical Center ? San Francisco, all HIV patients are listed on an Excelspreadsheet that is on a shared drive. Both the Social Worker and Case Manager are responsible for monitoring andupdating patient information contained on the spreadsheet. The spreadsheet is monitored and updated daily. Hardcopies of eligibility documents are kept in a locked file cabinet located in the Social Worker?s office. Along with thehard copies, a face sheet listing eligibility documents, patient name and medical record number and name of personwho received the documents is documented. Electronic copies of eligibility documents are kept on the CaseManager?s password protected computer hard drive. The disposition and status of each patient is documented on thespreadsheet. The date documents were last collected is listed in the first column on the eligibility spreadsheet.Patients not participating on the ADAP program are contacted at least 15 days prior to the expiration of eligibilitydocuments on file. Patient contact attempts are documented in the patient?s medical record. In the event the patientdoes not respond to phone calls the patient is sent a certified letter. Patients may be contacted via secure email withthe address on file. The spreadsheet is reviewed weekly. Outreach attempts are documented in the patient?smedical chart. Corrective action was implemented in July 2022.At St. Mary Medical Center ? Long Beach, In April 2022 management implemented a more robust and electronicfile for each client to make it easy to ensure appropriate tracking of eligibility requirements validation. Files arereviewed monthly to ensure compliance.Person Responsible: Toni Luckett, Manager of Nursing, St. Mary?s San FranciscoSharon McNealy, CFO ? St. Mary Long BeachCompletion: April 30, 2022

View Audit 312373

Finding 425677 (2022-012)

Material Weakness 2022

Commonspirit Health

IL

Eligibility Material Weakness Matching / Level of Effort / Earmarking § 200.303

REFERENCE: 2022-012 ? EligibilityMedicaid Cluster (93.778)Federal Grantor: U.S. Department of Health and Human ServicesFacility: Dignity Health Medical FoundationDignity Health Connected LivingFinding: The Dignity Health Medical Foundation and Dignity Health Connected Living did not retain evidence ...

REFERENCE: 2022-012 ? EligibilityMedicaid Cluster (93.778)Federal Grantor: U.S. Department of Health and Human ServicesFacility: Dignity Health Medical FoundationDignity Health Connected LivingFinding: The Dignity Health Medical Foundation and Dignity Health Connected Living did not retain evidence of Medicaid eligibility being reviewed prior to patient services being provided.Corrective Action Plan: For the Medical Assistance Program eligibility is validated through a Medi-Cal system website. Dignity Health Medical Foundation personnel have implemented procedures to ensure documentation of eligibility checks are retained. The Clinic Operations manager has instructed staff and supervisors to save proof of eligibility for all months. The Clinic Operations manager checks for retention of eligibility documentation on a random basis and an internal audit will be performed to check for compliance with the documentation retention.At Connected Living the staff will identify participants who may be ineligible for continued services at the beginning of each service month. The Medi-Cal eligibility report is produced on the first business day of each month. The list includes all eligible and ineligible participants. This report will be saved each month for tracking purposes. The report will be reviewed each month for ineligible participants or factors that may impact eligibility for the coming month. Steps will be taken to obtain proof of eligibility or being termination proceedings.Person Responsible: Nicole Hill, Clinic Operations Manager, Dignity Health Medical Foundation.Kristina Devan, Dignity Health Connected LivingCompletion: July 1, 2022

View Audit 312373

Finding 425672 (2022-013)

Material Weakness 2022

Commonspirit Health

IL

Questioned Costs Allowable Costs / Cost Principles Cash Management

REFERENCE: 2022-013 ? Allowable Costs/Cost PrinciplesCOVID-19 ? HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund (93.461)Federal Grantor: U.S. Department of Health and Human ServicesFinding Part 1: CommonSpirit Health did not have controls in pla...

REFERENCE: 2022-013 ? Allowable Costs/Cost PrinciplesCOVID-19 ? HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund (93.461)Federal Grantor: U.S. Department of Health and Human ServicesFinding Part 1: CommonSpirit Health did not have controls in place to limit the claims being submitted for Testing-Related Items and Services to include items and services related to furnishing or administering the COVID-19 test or for the evaluation of such individuals to determine the need for a COVID-19 test.Corrective Action Plan: Management believes that CommonSpirit Health has the necessary controls in place to support accurate and compliant billing. In addition, Management believes CommonSpirit followed the HRSA uninsured patient reimbursement program guidelines and frequently asked questions (FAQs) related to diagnostic testing and testing-related visits eligible for reimbursement, which were published from time to time after the introduction of this program.Although CommonSpirit Health continues to dispute the findings (REFERENCE 2021-014), CommonSpirit Health is refunding the Questioned Cost of $10,998 related to the findings for 2021 in order to resolve this finding. The refunds will be completed by April 30, 2023. In addition, the Program stopped accepting claims for testing and treatment on March 22, 2022, and claims for vaccine administration on April 5, 2022, due to lack of sufficient funds. CommonSpirit Health has not submitted claims to the Program since the Program was discontinued. In the event that CommonSpirit Health, through its proactive compliance efforts, identifies any additional claims submitted to the Program where reimbursement may not have been appropriate, CommonSpirit Health will refund such claims.Person Responsible: Danielle Weber, System SVP Revenue CycleExpected Completion: Management believes the item is resolved.Finding Part 2: CommonSpirit Health did not have controls in place to ensure that claims were not submitted for reimbursement when COVID-19 was not the primary diagnosis.Corrective Action Plan: Management believes that CommonSpirit Health has the necessary controls in place to support accurate and compliant billing. With respect to this one claim where COVID-19 was incorrectly listed in the primary diagnosis position, CommonSpirit Health will refund the claim amount of $547 by April 30, 2023Person Responsible: Danielle Weber, System SVP Revenue CycleExpected Completion: April 30, 2023

View Audit 312373 Questioned Costs: $1

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