Corrective Action Plans

Finding 392585 (2021-003)

Material Weakness 2021

The Jackson County Health Care Authority

AL

Questioned Costs Allowable Costs / Cost Principles Eligibility

Finding 2021-003- Material Weakness and Material Noncompliance over Allowable Cost and Reporting Contact Person: Andrew Wenning Managements Response: During a review of expenses related to the COVID pandemic, the audit identified payroll and non-payroll expenses that management first thought eligibl...

Finding 2021-003- Material Weakness and Material Noncompliance over Allowable Cost and Reporting Contact Person: Andrew Wenning Managements Response: During a review of expenses related to the COVID pandemic, the audit identified payroll and non-payroll expenses that management first thought eligible but on further review, (and subsequent to the submission to the portal) determined were unallowable per the Provider Relief Fund grant and Coronavirus Relief Fund grant terms and conditions. Management has put into place a policy for an individual in the accounting department to review all COVID expenses on a monthly basis going forward. In addition, management will further investigate the total likely questioned cost in order to determine the complete known questioned cost in the period 1 payroll and non-payroll expenditure population by June 30, 2024. For payroll expenses, the policy includes that a review and approval of the expenditures will be performed by an individual in accounting to ensure that the hours and wages calculated meet the terms and conditions of the PRF. If any non-eligible payroll expenses are identified during the review process, they will be removed. For all other expenses, we will obtain and retain approved copies of all invoices or other documentation to support expenses and review for eligibility. If any non-eligible expenses are identified during the review process, they will be removed. Completion Date: April 5, 2024

View Audit 302859 Questioned Costs: $1

Finding 392584 (2021-002)

Material Weakness 2021

The Jackson County Health Care Authority

AL

Reporting Allowable Costs / Cost Principles Material Weakness

Finding 2021-002- Material Weakness and Material Noncompliance over Reporting Contact Person: Andrew Wenning Managements Response: We have determined that certain expenses reported through the Department of Health and Human Services PRF reporting portal for period 1 did not reconcile to the underlyi...

Finding 2021-002- Material Weakness and Material Noncompliance over Reporting Contact Person: Andrew Wenning Managements Response: We have determined that certain expenses reported through the Department of Health and Human Services PRF reporting portal for period 1 did not reconcile to the underlying expense details by nature and/or function, and therefore did not comply with PRF reporting requirements. We have implemented a monitoring control over PRF reporting to ensure that expenses submitted through the PRF portal are properly classified by nature and/or function, and that such amounts reconcile to the underlying details and accounting records. Completion Date: April 5, 2024

View Audit 302859

Finding 392367 (2021-002)

Material Weakness 2021

Scott County Hospital

KS

Questioned Costs Allowable Costs / Cost Principles Cash Management

Allowable costs related to the program are expenses or losses that were not reimbursed from other sources or that other sources were not obligated to reimburse. The Hospital did not reduce COVID-19 related costs claimed under the PRF program for cost-based reimbursements received from the Medicare p...

Allowable costs related to the program are expenses or losses that were not reimbursed from other sources or that other sources were not obligated to reimburse. The Hospital did not reduce COVID-19 related costs claimed under the PRF program for cost-based reimbursements received from the Medicare program for the COVID-19 related expense. The Hospital will ensure the costs included in all subsequent Provider Relief Fund reporting is reduced for amounts reimbursed by other sources.

View Audit 302715 Questioned Costs: $1

Finding 392313 (2021-005)

Material Weakness 2021

Klamath Health Partners, Inc. Dba: Klamath Open Door Family Practice

OR

Internal Control / Segregation of Duties Material Weakness Period of Performance

2021–005 Period of Performance Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Program Cluster Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H8ECS37958 Award Period: May 1, 2020 through May 31, 2021 Type...

2021–005 Period of Performance Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Program Cluster Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H8ECS37958 Award Period: May 1, 2020 through May 31, 2021 Type of Finding: • Material Weakness in Internal Control over Compliance • Other Matters (Modified Opinion) Criteria or specific requirement: According to § 75.302 Financial management and standards for financial management systems of 45 CFR Part 75, the non-federal entity’s financial management systems, including records documenting compliance with federal statutes, regulations, and the terms and conditions of the federal award, must be sufficient to permit the preparation of reports required by general and program-specific terms and conditions. Further, the financial management system of each non-federal entity must provide accurate, current, and complete disclosure of the financial results of each federal award or program in accordance with the reporting requirements. According to § 75.303 Internal controls of 45 CFR Part 75, the non-federal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Condition: CLA was unable to verify if the Family Practice is in compliance with period of performance. Questioned costs: Unknown Context: During our review expenditures for period of performance we noted expenditures were not supported by adequate records and documentation to facilitate testing. Recommendation: We recommend the Family Practice design controls and procedures to ensure the documentation and records required to identify expenses and the date incurred are properly maintained in the files of the Family Practice. Cause: Management oversight. The Family Practice lacked established internal controls and procedures over financial grant management to ensure supporting records and documentation are properly maintained in the files of the Family Practice. Effect: Inability to support compliance with the grant and a potential loss of federal funding. Recommendation: We recommend the Family Practice design controls and procedures to ensure documentation is properly maintained in the files of Family Practice. Views of responsible officials: There is no disagreement with the audit finding.

View Audit 302660

Finding 392307 (2021-003)

Material Weakness 2021

Klamath Health Partners, Inc. Dba: Klamath Open Door Family Practice

OR

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Cash Management

2021-003 Material Weakness - Allowable and Unallowable Activities and Allowable Costs Recommendation: We recommend the Family Practice design controls and procedures to ensure submitted reports and the documentation used to prepare the reports are properly maintained in the files of the Family Pract...

2021-003 Material Weakness - Allowable and Unallowable Activities and Allowable Costs Recommendation: We recommend the Family Practice design controls and procedures to ensure submitted reports and the documentation used to prepare the reports are properly maintained in the files of the Family Practice. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Family Practice designed controls and procedures to ensure submitted reports and the documentation used to prepare the reports are properly maintained in the files of the Family Practice. The CEO and CFO roles have been separated into two distinct positions. Separating the roles has significantly strengthened internal controls. Furthermore, a controller has been hired to prepare the reports and maintain appropriate and complete supporting documentation, which will then be reviewed by the CFO and CEO before submission. Name(s) of the contact person(s) responsible for corrective action: Amanda Blodgett, CEO Planned completion date for corrective action plan: December 31, 2024

View Audit 302660

Finding 392306 (2021-001)

Material Weakness 2021

St. John's Lutheran Home of Albert Lea

MN

Material Weakness Reporting Internal Control / Segregation of Duties

Management will continue to allow the audit firm to create the draft financial statements and related footnote disclosures, and will review and approve these prior to the issuance of the annual financial statements.

View Audit 302650

Finding 392164 (2021-005)

Material Weakness 2021

Neighborhood Legal Services Michigan

MI

Questioned Costs Period of Performance Subrecipient Monitoring

We agree with the auditors' comments, and the following action will be taken to improve the situation. We have adjusted the Organization’s Accounting Policies & Procedure Manual to include a detailed review of the General Ledger detail supporting each draw request. Accounting personnel will ensure t...

We agree with the auditors' comments, and the following action will be taken to improve the situation. We have adjusted the Organization’s Accounting Policies & Procedure Manual to include a detailed review of the General Ledger detail supporting each draw request. Accounting personnel will ensure the Organization’s General Ledger specifically details the month of rent and utility allowance being provided so eligible costs are clearly delineated. Someone other than the preparer will perform a review of each drawdown request to ensure that costs are not being drawn down prior to the operating start date of each individual grant. This issue was discussed with HUD in March 2024 at which time procedural changes were implemented. Effective March 2024 the preparer is required to include the month of rent and utility allowance being provided in the General Ledger detail. A review of the General Ledger detail supporting each draw request will be performed by someone other than the preparer to ensure that costs are not being drawn down prior to the operating start date of each individual grant.

View Audit 302371 Questioned Costs: $1

Finding 392163 (2021-004)

Material Weakness 2021

Neighborhood Legal Services Michigan

MI

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

We agree with the auditors' comments, and the following action will be taken to improve the situation. As of the date of this report, we are adjusting the Organization’s Accounting Policies & Procedure Manual to include a detailed review of the General Ledger detail supporting each draw request. The...

We agree with the auditors' comments, and the following action will be taken to improve the situation. As of the date of this report, we are adjusting the Organization’s Accounting Policies & Procedure Manual to include a detailed review of the General Ledger detail supporting each draw request. The purpose of this change is to request drawdowns that agree with actual expenses incurred during the draw period requested. Due to late completion of the 2020 audit, recommendations cited in the audit report were not implemented in 2021. During 2022, the practice of tracking grant utilization on a monthly basis was instituted for all grant awards. Documentation of allocation methodologies for shared expenses (i.e., office rent, general office supplies, telephone/internet costs, copiers, payroll processing) had begun. After the 2020 audit report date, all grant draws were supported by the expense detail reflected in the general ledger as prepared by a Sr. Accountant and reviewed and approved by the Chief Financial Officer. Further, monthly reconciliations of grant draw requests and posted revenues, receivables, and expenses will be performed for each grant. The services of an external consultant were utilized to assess the finance department’s staffing levels. This resulted in the onboarding of three (3) new Sr. Accountants and a Chief Financial Officer by early 2022. This provides adequate staffing to perform a review of the federal grant expenditures on a timely basis.

View Audit 302371 Questioned Costs: $1

Finding 392100 (2021-005)

Material Weakness 2021

Avita Health System

OH

Subrecipient Monitoring Material Weakness Reporting § 200.303

Finding Number: 2021-005 Condition: - The System received targeted distributions for Bucyrus Community Hospital. A period one portal submission was completed, but no allowable expenses or lost revenues were reported within the Bucyrus Community Hospital report. All allowable expenses and lost reve...

Finding Number: 2021-005 Condition: - The System received targeted distributions for Bucyrus Community Hospital. A period one portal submission was completed, but no allowable expenses or lost revenues were reported within the Bucyrus Community Hospital report. All allowable expenses and lost revenues were reported on the first period portal submission for Galion Community Hospital, another hospital of the Avita Health System. Planned Corrective Action: The portal submission could not be modified by the time we identified the reporting issue. As such, no corrective report was completed, however management will implement procedures to ensure reporting requirements are adequately reviewed for all federal funding. Contact person responsible for corrective action: Eric Draime, Vice President/CFO Anticipated Completion Date: June 30, 2024

View Audit 302244

Finding 392099 (2021-004)

Material Weakness 2021

Avita Health System

OH

Reporting Subrecipient Monitoring Material Weakness

Finding Number: 2021-004 Condition: The information entered into the period one HHS portal submission for Galion Community Hospital was not adequately supported or reviewed in accordance with the terms and conditions of the PRF funding and the Notice. Planned Corrective Action: The System utilized l...

Finding Number: 2021-004 Condition: The information entered into the period one HHS portal submission for Galion Community Hospital was not adequately supported or reviewed in accordance with the terms and conditions of the PRF funding and the Notice. Planned Corrective Action: The System utilized lost revenue to support expenditures recognized on the Schedule. For future grant funds received, management will adequately review terms and conditions of the funding received and ensure allowable expense are properly supported before completing the required reports. Contact person responsible for corrective action: Eric Draime, Vice President/CFO Anticipated Completion Date: June 30, 2024

View Audit 302244

Finding 392079 (2021-004)

Material Weakness 2021

Lss Housing Jamestown, Inc.

ND

Allowable Costs / Cost Principles Eligibility Special Tests & Provisions § 200.334

US Department of Housing and Urban Development Federal Financial Assistance Listing #14.157 Supportive Housing for the Elderly (Section 202) Finding Summary: As a result of management transition, supporting documentation for expense transactions and tenant eligibility were destroyed and were unable ...

US Department of Housing and Urban Development Federal Financial Assistance Listing #14.157 Supportive Housing for the Elderly (Section 202) Finding Summary: As a result of management transition, supporting documentation for expense transactions and tenant eligibility were destroyed and were unable to be recreated. The organization was lacking appropriate internal controls to ensure records were retained for the required period of time. Responsible Individual: Dawn Helmowski, Finance Director Corrective Action Plan: Subsequent to the audit period under review, the affiliated entity of Luther Social Services of North Dakota has been replaced with Beyond Shelter, Inc. Upon this change, the new LSS Jamestown Housing, Inc. Board of Directors, implemented a Document Retention and Destruction Policy that includes retention or required documents for the required time periods that will ensure documents are retained. This policy was put into place on April 19, 2023. Anticipated Completion Date: April 2023

View Audit 302211

Finding 390821 (2021-001)

Significant Deficiency 2021

Brush Hill Development Corporation

MA

HUD Housing Programs Material Weakness Reporting

The audited financial statements have been filed with HUD via its REAC system. If thereare any questions regarding this plan, please call Yulia Garcia, Controller, at 508-778-5040.

View Audit 301537

Finding 390796 (2021-004)

Material Weakness 2021

Helping Hand House

WA

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.400

1. All related administrative and program operational costs have been appropriately classified and documented in QuickBooks beginning in 2022. 2. Monthly review of administrative and program operational costs is performed by management and grant awarders.

View Audit 301528 Questioned Costs: $1

Finding 390795 (2021-003)

Material Weakness 2021

Helping Hand House

WA

Subrecipient Monitoring Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303

1. Processes related to the program stating roles of each individual involved in the process were documented and implemented in September 2022. 2. Regular risk assessment and monitoring functions are performed by management and grant awarders.

View Audit 301528

Finding 389451 (2021-002)

Material Weakness 2021

Maryland Network Against Domestic Violence, INC

MD

Subrecipient Monitoring Material Weakness Reporting

2021-002 Summary of Finding (optional) Late submission of required financial, programmatic, and performance reports: All of the grants under these programs require that financial, programmatic, and performance reports be submitted on a monthly, quarterly basis and/or annual basis. Monthly and quarte...

2021-002 Summary of Finding (optional) Late submission of required financial, programmatic, and performance reports: All of the grants under these programs require that financial, programmatic, and performance reports be submitted on a monthly, quarterly basis and/or annual basis. Monthly and quarterly financial and performance reports are due within thirty calendar days from the end of each quarter. Annual financial and performance reports are due within 90 calendar days from the end of each grant year. During our testing, we noted nine reports that were submitted after the deadline. We consider this to be an instance of noncompliance and a material weakness in internal control over compliance for the reporting requirement. Statement of Concurrence or Nonconcurrence The Maryland Network Against Domestic Violence concurs with this finding. Corrective Action MNADV continued to experience significant transitions during FY21. FY21 was the first full fiscal year for the new Executive Director and a new finance manager was hired at the beginning of FY21. These senior leadership transitions were marked by a learning curve for both the Executive Director and Finance Manager who had to learn the reporting processes and online systems for each of the different grants which included federal, state and private reporting systems. Also of note was a lack of completed audits for FY19 and FY20, which meant that substantial work had to be completed to ensure that what was reported for each grant was indeed accurate. All of these factors contributed to reports being late and none of these factors are still at play. The current Executive Director and Finance Manager are now familiar with all reporting systems. All login and secondary authentication methods have been properly set up and are functioning as desired. Internal processes for collecting grant data and reporting out this data have been established.

View Audit 300405

Finding 387479 (2021-006)

Material Weakness 2021

Atoka County Healthcare Authority

OK

Allowable Costs / Cost Principles Cash Management Material Weakness § 200.303

Tracking of Eligible Expenditures and Lost Revenues Finding 2021‐006 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVDI‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Finding Summary: The Authority did not hav...

Tracking of Eligible Expenditures and Lost Revenues Finding 2021‐006 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVDI‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Finding Summary: The Authority did not have internal controls established over the federal award to ensure the federal award has been managed in compliance with federal states, regulations and conditions of the federal award. Corrective Action Plan: The Authority’s management company is reviewing compliance with all laws and regulations and ensuring conditions are met. Responsible Individual: Priacilla Leatherman, VP of Finance Anticipated Completion Date: August 2022

View Audit 299648

Finding 387478 (2021-005)

Material Weakness 2021

Atoka County Healthcare Authority

OK

Reporting Material Weakness

Preparation of Schedule of Expenditures of Federal Awards Finding 2021‐005 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVDI‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Finding Summary: Eide Bailly LLP pre...

Preparation of Schedule of Expenditures of Federal Awards Finding 2021‐005 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVDI‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Finding Summary: Eide Bailly LLP prepared the schedule of expenditures of federal awards (schedule) and accompanying notes to the schedule. Corrective Action Plan: Due to cost considerations, we will continue to have our auditor prepare our schedule and accompanying notes to the schedule. Responsible Individual: Priacilla Leatherman, VP of Finance Anticipated Completion Date: Ongoing.

View Audit 299648

Finding 386979 (2021-005)

Material Weakness 2021

Healthsource Saginaw, Inc.

MI

Material Weakness Matching / Level of Effort / Earmarking § 200.403

Condition: HealthSource did not have controls in place to ensure the inputs in their Covid related expense spreadsheet that was used to input the amount of 'Other PRF Expenses' reported in the portal submissions agreed to source documentation. Planned Corrective Action: All future submissions will b...

Condition: HealthSource did not have controls in place to ensure the inputs in their Covid related expense spreadsheet that was used to input the amount of 'Other PRF Expenses' reported in the portal submissions agreed to source documentation. Planned Corrective Action: All future submissions will be reviewed with the CEO and President for accuracy and thoroughness prior to submission upload. Contact person responsible for corrective action: Sonja Martinez, Chief Financial Officer Anticipated Completion Date: 12/31/2024

View Audit 299334

Finding 386978 (2021-004)

Material Weakness 2021

Healthsource Saginaw, Inc.

MI

Material Weakness Reporting Matching / Level of Effort / Earmarking

Condition: HealthSource's controls in place for reporting submissions did not identify that guidelines were not followed related to expense reporting and the lost revenue calculations. Planned Corrective Action: All future submissions will be reviewed with CEO and President for accuracy and thorough...

Condition: HealthSource's controls in place for reporting submissions did not identify that guidelines were not followed related to expense reporting and the lost revenue calculations. Planned Corrective Action: All future submissions will be reviewed with CEO and President for accuracy and thoroughness prior to submission upload. Contact person responsible for corrective action: Sonja Martinez, Chief Financial Officer Anticipated Completion Date: 12/31/2024

View Audit 299334

Finding 386977 (2021-003)

Material Weakness 2021

Healthsource Saginaw, Inc.

MI

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

Condition: HealthSource does not have a review process in place related to the Covid expense spreadsheet used to input expenses into the required reporting submissions to the U.S. Department of Health and Human Services for the Provider Relief Fund program and not having a review process in place ov...

Condition: HealthSource does not have a review process in place related to the Covid expense spreadsheet used to input expenses into the required reporting submissions to the U.S. Department of Health and Human Services for the Provider Relief Fund program and not having a review process in place over the forementioned required submissions. Planned Corrective Action: A review of all updates to Covid revenue and expenses will be performed with the CEO and President as indicated by new activity, and before any submissions are uploaded. Contact person responsible for corrective action: Sonja Martinez, Chief Financial Officer Anticipated Completion Date: 12/31/2024

View Audit 299334

Finding 380908 (2021-009)

Material Weakness 2021

Love County Health Center D/b/a Mercy Health Love County

OK

Reporting Material Weakness

Finding 2021-009 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital does not have an internal control system designed to provide for a complete and accurate sche...

Finding 2021-009 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital does not have an internal control system designed to provide for a complete and accurate schedule of expenditures of federal awards being audited. Responsible Individuals: Scott Callender Corrective Action Plan : Due to the small accounting staff there was little internal review of the schedule of federal expenditures resulting in errors. The Hospital will adopt a policy where the schedule of expenditures will be reviewed by a qualified individual. Anticipated Completion Date: Ongoing

View Audit 295601

Finding 380907 (2021-008)

Material Weakness 2021

Love County Health Center D/b/a Mercy Health Love County

OK

Allowable Costs / Cost Principles Material Weakness Reporting § 200.303

Finding 2021-008 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an adequate internal control policy to ensure reported amounts agreed with under...

Finding 2021-008 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an adequate internal control policy to ensure reported amounts agreed with underlying supporting documentation. In addition the underlying supporting documentation contained errors. Responsible Individuals: Scott Callender Corrective Action Plan: The Hospital will implement a control process to a ensure the report agrees with the under lying supporting documentation. Anticipated Completion Date: Ongoing

View Audit 295601

Finding 380906 (2021-007)

Material Weakness 2021

Love County Health Center D/b/a Mercy Health Love County

OK

Allowable Costs / Cost Principles Cash Management Material Weakness § 200.303

Finding 2021-007 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an adequate internal control policy in place to ensure expenses claimed were bei...

Finding 2021-007 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an adequate internal control policy in place to ensure expenses claimed were being reduced by Medicare's reimbursement or claimed on other grants. The Hospital also did not have a control to ensure the reporting was reviewed and approved by someone other than the preparer. Responsible Individuals: Scott Callender Corrective Action Plan: The Hospital will implement a control process to ensure amounts claimed for this program are reduced by amounts reimbursed or obligated by another source and include a documented secondary review and approval of required reports to be submitted to the federal agency prior to submission Anticipated Completion Date: Ongoing

View Audit 295601

Finding 380905 (2021-006)

Material Weakness 2021

Love County Health Center D/b/a Mercy Health Love County

OK

Allowable Costs / Cost Principles Reporting Procurement, Suspension & Debarment § 200.303

Finding 2021-006 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA# 93.498 Finding Summary: The Hospital did not have an adequate internal control process in place to ensure expenditures claimed were...

Finding 2021-006 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA# 93.498 Finding Summary: The Hospital did not have an adequate internal control process in place to ensure expenditures claimed were being in the proper period. The Hospital also did not have a control to ensure the reporting was reviewed and approved by someone other than the preparer. Responsible Individuals: Scott Callender Corrective Action Plan: The Hospital will implement a control process which includes a documented secondary review and approval of required reports to be submitted to the federal agency prior to submission. Anticipated Completion Date: Ongoing

View Audit 295601

Finding 380904 (2021-005)

Material Weakness 2021

Love County Health Center D/b/a Mercy Health Love County

OK

Allowable Costs / Cost Principles Material Weakness Reporting § 200.303

Finding 2021-005 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an internal control process in place to ensure the calculation of lost revenues ...

Finding 2021-005 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an internal control process in place to ensure the calculation of lost revenues was reviewed and approved. Accordingly, the errors in the lost revenue calculation spreadsheet were not identified by management. In addition, the Hospital did not have an internal control process in place to ensure a review and approval of the Period 1 Report was performed by someone other than the preparer of the report. Responsible Individuals: Scott Callender Corrective Action Plan : The Hospital will implement a control process which includes a documented secondary review and approval of required reports to be submitted to the federal agency prior to submission. Anticipated Completion Date: Ongoing

View Audit 295601

Corrective Action Plans

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