Corrective Action Plans

Finding 390795 (2021-003)

Material Weakness 2021

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

Finding 377355 (2022-003)

Material Weakness 2021

Red Wind Consulting INC

CO

Allowable Costs / Cost Principles Cash Management Material Weakness § 200.43

Responsible Official’s Response: Management agrees with the recommendation to establish and follow a documented internal control process over the review of allowable costs. Staff will work to develop an appropriate internal control process and once the process has been developed staff will document ...

Responsible Official’s Response: Management agrees with the recommendation to establish and follow a documented internal control process over the review of allowable costs. Staff will work to develop an appropriate internal control process and once the process has been developed staff will document in writing, the process and review it with department leaders. Additionally, staff members working in areas concerning this process will be trained to ensure process adherence.

View Audit 295151

Finding 377354 (2022-002)

Material Weakness 2021

Red Wind Consulting INC

CO

Subrecipient Monitoring Material Weakness Reporting

Responsible Official’s Response: Management agrees with the recommendation to establish and follow a documented internal control process over the review of reporting. Staff will work to develop an appropriate internal control process and once the process has been developed staff will document in wri...

Responsible Official’s Response: Management agrees with the recommendation to establish and follow a documented internal control process over the review of reporting. Staff will work to develop an appropriate internal control process and once the process has been developed staff will document in writing, the process and review it with department leaders. Additionally, staff members working in areas concerning this process will be trained to ensure process adherence.

View Audit 295151

Finding 375950 (2021-005)

Material Weakness 2021

Hogar Fortaleza Del Caido, Inc.

PR

Reporting Material Weakness § 200.512

See the Corrective Action Plan for chart/table.

View Audit 295003

Finding 375949 (2021-004)

Material Weakness 2021

Hogar Fortaleza Del Caido, Inc.

PR

Equipment & Real Property Management Material Weakness

See the Corrective Action Plan for chart/table.

View Audit 295003

Finding 375833 (2021-003)

Material Weakness 2021

California Asian Pacific Chamber of Commerce

CA

Questioned Costs Allowable Costs / Cost Principles Material Weakness § 200.400

Description of Finding: Expenditure detail does not support the amounts billed Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: CalAsian acknowledges the serious nature of this finding and the pote...

Description of Finding: Expenditure detail does not support the amounts billed Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: CalAsian acknowledges the serious nature of this finding and the potential for damage to relationships with the grantors and Federal entities. The Interim Controller and Director of Finance are working to secure an ERP system which will allow for better cost collection, reporting and reviews of the grant-related expenses for accuracy, reliability, and reconciliation. Subcontractor invoices will be required to provide specific information related to the grant, scope of work and any other pertinent details for proper charging in the accounting system. Detailed paper timesheets will be provided in the interim for all employees to ensure compliance with the requirements and provide proper support for all grant costs. Monthly reviews by the Project Directors/Managers plus Accounting will be performed to identify any potential cost charging issues and corrective action(s) required. Name of Contact Person: Ryan Fong, Director of Finance, 916-446-7883, rfong@calasiancc.org Pat Fong Kushida, President & CEO, 916-446-7883, patfongkushida@calasiancc.org Projected Completion Date: March 2024 for detailed paper timesheets, December 2024 for ERP system

View Audit 294918 Questioned Costs: $1

Finding 375831 (2021-001)

Material Weakness 2021

California Asian Pacific Chamber of Commerce

CA

Reporting Subrecipient Monitoring Material Weakness

Description of Finding: Untimely audit submission in accordance with OMB Uniform Guidance Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: CalAsian understands the seriousness of this deficiency an...

Description of Finding: Untimely audit submission in accordance with OMB Uniform Guidance Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: CalAsian understands the seriousness of this deficiency and the need for strict adherence to timely audit submissions per the OMB Uniform Guidance. Additional staff have been hired to assist in accounting processes; and an Interim Controller has been hired to review all accounting processes and procedures with the Director of Finance, provide best practice recommendations and month-end closing schedule. Monthly reviews of the financial data, including reconciliations of all accounts will be performed and reviewed by the Controller and Director of Finance. Implementation of these recommendations will help to mitigate the risk of untimely submissions in future years. Name of Contact Person: Ryan Fong, Director of Finance, 916-446-7883, rfong@calasiancc.org Pat Fong Kushida, President & CEO, 916-446-7883, patfongkushida@calasiancc.org Projected Completion Date: July 2024

View Audit 294918

Finding 371310 (2021-012)

Material Weakness 2021

City of Bethel, Alaska

AK

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness § 200.303

Finding 2021‐012 Expenditure Approval – Activities Allowed and Unallowed, Allowable Costs – Material Weakness in Internal Control over Compliance Corrective Action Plan Management will implement policies and procedures to ensure expenditures are reviewed timely and approved prior to posting. Expecte...

Finding 2021‐012 Expenditure Approval – Activities Allowed and Unallowed, Allowable Costs – Material Weakness in Internal Control over Compliance Corrective Action Plan Management will implement policies and procedures to ensure expenditures are reviewed timely and approved prior to posting. Expected Completion Date Fiscal Year 2025.

View Audit 292985

Finding 371302 (2021-005)

Material Weakness 2021

City of Bethel, Alaska

AK

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness § 200.512

Finding 2021‐005 Deadline for Federal Single Audit – Reporting – Noncompliance and Material Weakness in Internal Control over Compliance Corrective Action Plan Management will ensure beginning balance reconciliations and year‐end adjustments will be complete by September, and will work with external...

Finding 2021‐005 Deadline for Federal Single Audit – Reporting – Noncompliance and Material Weakness in Internal Control over Compliance Corrective Action Plan Management will ensure beginning balance reconciliations and year‐end adjustments will be complete by September, and will work with external auditors to have a financial statement draft prior to their fieldwork. Expected Completion Date Fiscal year 2025.

View Audit 292985

Finding 370602 (2021-015)

Material Weakness 2021

Kickapoo Tribe in Kansas

KS

Material Weakness Significant Deficiency Matching / Level of Effort / Earmarking

Finding 2021-015 Commingling CRF and ARP Funds Individual(s) Responsible: Grace Ross, Tribal Treasurer, Accounting Director Action: Ensure that funds are separated so that federal funds are spent appropriately. Anticipated Completion Date: Ongoing

View Audit 292271

Finding 370593 (2021-014)

Material Weakness 2021

Kickapoo Tribe in Kansas

KS

Eligibility Material Weakness Significant Deficiency

Finding 2021-014 Eligibility Individual(s) Responsible: Paul Austin, Program Director with supervision from Grace Ross, Tribal Treasurer Action: Will ensure that all patients provide eligibility documentation. Anticipated Completion Date: September 2024

View Audit 292271

Finding 370591 (2021-012)

Material Weakness 2021

Kickapoo Tribe in Kansas

KS

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

Finding 2021-012 Program Income Individual(s) Responsible: Grace Ross, Tribal Treasurer, Accounting Director, Program Directors Action: Ensure that documentation is available for every item purchased or run through payroll. Anticipated Completion Date: September 2023

View Audit 292271

Finding 370586 (2021-009)

Material Weakness 2021

Kickapoo Tribe in Kansas

KS

Reporting Subrecipient Monitoring Allowable Costs / Cost Principles

Finding 2021-009 Reporting Individual(s) Responsible: Grace Ross, Tribal Treasurer, Tribal Administrator Action: Reviewing reporting requirements with department heads and reviewing reports submitted. Anticipated Completion Date: April 2024

View Audit 292271

Finding 370584 (2021-011)

Material Weakness 2021

Kickapoo Tribe in Kansas

KS

Allowable Costs / Cost Principles Material Weakness Significant Deficiency

Finding 2021-011 Allowable Costs and Activities Individual(s) Responsible: Grace Ross, Tribal Treasurer, Accounting Director Action: Current Tribal Council will ensure that all documentation is maintained as backup for all purchases and payroll items. Anticipated Completion Date: September 2023

View Audit 292271

Corrective Action Plans

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