Corrective Action Plans

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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
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.
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.
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
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 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
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
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
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.
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.
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.
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
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.
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.
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.
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
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.
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
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
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
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
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
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
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
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
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.
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.
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