Corrective Action Plans

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Section Ill- Federal Award Findings and Questioned Costs Health Center Program Cluster, Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), COVID - 19 Health Center Program (Community Health Centers, Migrant Health...
Section Ill- Federal Award Findings and Questioned Costs Health Center Program Cluster, Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), COVID - 19 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), Grants for New and Expanded Services under the Health Center Program and COVID-19 Grants for New and Expanded Services under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 Item 2023-001- Special Tests Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Repeat Finding Yes Action Taken As of May 1, 2023, the Director of Revenue and/or designee runs a slide fee report daily the reflects everyone that applied the day before. Billing personnel separate the report and audit the files to ensure the correct slide has been applied. The paper application is forwarded to the billing department for a third audit if the application is in order and has been uploaded into the patients' files and then it is manually filed. The CFO will perform random audits and will present to the Board and CEO a quarterly report with the results. In addition, As of July 1, 2023, the Access Coordinators who normally collect and process the slide fee discount program applications are now reporting to the finance department with the Director of Revenue supervising and training staff. In addition, there will now be a Lead Access Coordinator in very clinic that will audit and perform additional training where necessary.
The District will review the CNIPS report going forward and maintain the necessary supporting documentation of approvals.
The District will review the CNIPS report going forward and maintain the necessary supporting documentation of approvals.
The district will ensure that all federally paid employees have a supporting and accurate Federal Time Certification record.
The district will ensure that all federally paid employees have a supporting and accurate Federal Time Certification record.
View Audit 316649 Questioned Costs: $1
HSEM concurs with the finding. As a result of the audit, the practice of using individual emails to submit correspondence to FEMA was immediately addressed with staff and future correspondence will only be sent using the general shared email inbox. Regularly during staff meetings employees are remin...
HSEM concurs with the finding. As a result of the audit, the practice of using individual emails to submit correspondence to FEMA was immediately addressed with staff and future correspondence will only be sent using the general shared email inbox. Regularly during staff meetings employees are reminded to copy communications to the general shared inbox. Additionally, HSEM is currently working with the State’s Department of Information and Technology to gain access to prior staff’s emails. To note, the final paragraph in the Conditions section makes an incorrect statement regarding the submittal timeline requirements for Project Completion and Certification reports. PCCs are due within 90 days of project completion, not project obligation.
(SSA 4513) The department concurs with this finding and plans to work on the following areas to make reviewing and understanding of the reports an easier process: NHDDS will make sure that line 7 on the 4513 report is checked appropriately on all future reporting. NH DDS will update all process d...
(SSA 4513) The department concurs with this finding and plans to work on the following areas to make reviewing and understanding of the reports an easier process: NHDDS will make sure that line 7 on the 4513 report is checked appropriately on all future reporting. NH DDS will update all process directions for all fiscal reporting. For these directions, NH DDS will update all spreadsheets used for reporting purposes, add labels to column headers and link to cells when able for better understanding of our business processes and where amounts are pulled from. NH DDS will keep all backup documentation needed for these directions, to review all current open grant years. NHDDS will create “Mock” documents of each reporting process to help in any further reviews. (SSA 4514) Administrator runs a leave report for a 1-month time frame. Put in alpha order and date order. In an excel spreadsheet, staff are in alpha order. Leave time is added to each individual staff member for a time frame of 3 months (quarterly report). The total for each individual staff member is then populated to a second spread sheet which is broken out by position categories and each position total is then populated to the 4514 report. • On Duty Hours (column A) are the number of days worked in a quarter, times 7.50 hours per day. • Holiday/Leave Hours (column B) are the number of Holidays (7.50 hours per day) during that quarter plus the amount of leave (hours and minutes) per individual staff member during that quarter. • Total Hours (column C) is the amount of column A, plus column B, equals column C. • Total Part-Time Personnel-Is the number of hours the physician worked during that quarter. A report is run in Virtual Time Clock for the quarterly time frame and hours are entered into Part-Time, Medical Consultants (h.) Prior to completing the quarterly report, the excel spread sheet, sheet 2, will be reviewed to ensure cell equations are correct to eliminate formula errors used to calculate quarterly hours. When emailing the Administrator, the quarterly report for signature, the following statement will be in the body of the email to certify cell equations were reviewed prior, to eliminate formula errors: “I certify that I reviewed the SSA-4514 prior to completion, to ensure that cell equations were correct to eliminate formula errors.” Sent to the Administrator for signature then sent off to Region. Sent emails will be saved in an outlook folder for future reference and proofs that reports were sent.
Corrective Action Planned: The identified payments relate to postage expenditures recorded in the Child Support Enforcement Grant. Postage expenditures are controlled in the State's mailing system through mail codes. Agencies send approved postage budgets to the Department of Administrative Service...
Corrective Action Planned: The identified payments relate to postage expenditures recorded in the Child Support Enforcement Grant. Postage expenditures are controlled in the State's mailing system through mail codes. Agencies send approved postage budgets to the Department of Administrative Services (DAS), who then creates a new mail code or adds additional funding to existing codes in the system. All mail processed through the mailing system is charged to these individual mail codes. A monthly expenditure report from the mailing system is interfaced with NH First, and the DAS uploads a journal entry to the general ledger to record these expenditures. The review and approvals for these postage transactions occur upfront at the agency level, not through a NH First approval workflow. DHHS and DAS will work together to document adequate evidence of this upfront review and approval.
View Audit 316627 Questioned Costs: $1
The Department continues to work with its federal partners to ensure timely access to required reports.
The Department continues to work with its federal partners to ensure timely access to required reports.
Corrective Action Planned: The Bureau of Employment Supports has undergone significant programmatic changes over the past 3 years. As part of those changes, our Work Verification Plan was updated and submitted for approval on July 8, 2022. It was approved by the Administration of Children and Famil...
Corrective Action Planned: The Bureau of Employment Supports has undergone significant programmatic changes over the past 3 years. As part of those changes, our Work Verification Plan was updated and submitted for approval on July 8, 2022. It was approved by the Administration of Children and Families on February 9, 2024, making the updates to the NH work verification plan in effect back to July 9, 2022. The audit period in question is from July 1, 2022 to June 30, 2023. Trainings, supports and guidance have taken place throughout that time to correct hour errors such as those identified through this audit. Uploading documents into the e-folder was found to be error prone, therefore, on March 1, 2023, NHEP leadership provided guidance and training on a specific process of indexing and scanning documents to ensure that moving forward the Career Counselors are checking their e-folder’s to ensure that documents are properly uploaded and visible. In addition, a statewide training took place on May 5, 2023, to look in depth at past audit findings, during which, strategies were identified to help alleviate these errors from re-occurring. An additional statewide training also took place on December 15, 2023, which involved discussion around the audit, which was about to begin, including what the general focus of the audit has historically been. As of April 2023, an additional Quality Assurance Specialist was hired to help monitor and support newly hired career counselors in their first year of employment. This additional Specialist has allowed for guidance to be available not only to newly hired staff, but also to seasoned staff throughout the state. The need for an extra layer of training throughout the year for newly hired Career Counselors was identified in the summer of 2023 and the NHEP Leadership Team developed a weekly Quality Assurance meeting. These weekly meetings started August 30, 2023. These meetings provide real time training to review best practices and further career counselors understanding of federal and state policies. The meetings have been successful and are now bi-weekly. As of February 28, 2024, the meetings have been opened to all career counselors throughout the state, not just those under 9 months of employment. The meetings ensure that there is consistent messaging across the state and also provide an opportunity for statewide collaboration between career counselors. Through cursory investigations, we believe that these new supports and processes, have already shown to be effective in improving the accuracy of supporting and recording hours. The last audit yielded 15% discrepancies in hour errors. This audit period had a decrease of 12%, indicating 3% discrepancies in hour errors. NHEP leadership has also been working with the NEW HEIGHTS system to streamline the process of uploading documents to further decrease the potential for errors. A change request form was submitted approximately two years ago. In order to address the audit findings, within the next 90 days, NHEP leadership is holding a statewide mandatory staff training to review the audit process and findings that were identified. During the meeting, in regards to the over reporting hours error, the Leadership Team will reiterate and discuss the importance of uploading documents prior to inputting hours. In regards to the under reporting hours error, the meeting will also include further training about the importance of justification for any differences in hours than what is reported on the activity tracker. Further, that any differences need to be documented in either a sticky note or a RID note. In addition, the Quality Assurance meetings will continue to be held bi-weekly to address issues or trends in the moment. Our continuous transparency will further ensure buy-in from the staff to put systems in place for themselves as well as to increase self-monitoring practices and in turn, decrease errors in the future.
This function (FFATA reporting) has now been designated to our Federal Reporting Group, which will allow for redundancy in personnel. A new policy and procedure, which will include internal controls, will be developed and implemented.
This function (FFATA reporting) has now been designated to our Federal Reporting Group, which will allow for redundancy in personnel. A new policy and procedure, which will include internal controls, will be developed and implemented.
NHED concurs with the finding identified with the expenditures of $3605. The NHED will have the LEA’s submitting for indirect costs after September 30th upload an invoice and back up documentation into GMS. The NHED concurs with the findings identified with expenditures of $5,172. There were i...
NHED concurs with the finding identified with the expenditures of $3605. The NHED will have the LEA’s submitting for indirect costs after September 30th upload an invoice and back up documentation into GMS. The NHED concurs with the findings identified with expenditures of $5,172. There were in fact some items that were charged outside the period of performance. This happened prior to us receiving the FY22 audit finding and putting in place new controls to prevent. We have since put into place DOE-OBM-33 to ensure payments are being reviewed closely to the period of performance at multiple times. We have also corrected any items charged to the wrong CAN. The NHED concurs with the findings identified with expenditures of $816. We will look into the district returning these funds or other enforcement actions. In addition to the DOE-OBM-033 process, the Division of Learner Support has created and implemented a transfer of funds procedure.
View Audit 316627 Questioned Costs: $1
The Office of ESEA Title programs and Covid-19 education programs have established an internal process to sample and test reports compiled to ensure operations are executed as intended. These internal controls include a monthly reporting sign off Excel sheet, certification on each FFATA submission a...
The Office of ESEA Title programs and Covid-19 education programs have established an internal process to sample and test reports compiled to ensure operations are executed as intended. These internal controls include a monthly reporting sign off Excel sheet, certification on each FFATA submission and a secondary certification for accuracy verification, and a division wide process for FFATA filing and verification. Division wide training occurred on October 26, 2023. Due to grant award notification (GAN) changes and development within our grants management system (GMS), the FFATA process has also been developing and shifting; therefore the FFATA process will be revisited annually and updated as needed. A revised procedure for FFATA reporting will be completed prior to additional training being offered. To ensure that processes are being followed, newly hired staff is trained appropriately, and updates to the GAN process are considered within the FFATA process we will hold another training this spring, March 14th, 2024, prior to new subawards being issued.
Corrective Action Planned: The Office of ESEA Title Programs’ accountant identified when the miscalculation first took place in 2021-2022 and made changes to the workbook formula to correctly calculate the LEA allocations. The office administrator and the bureau administrator both thoroughly review...
Corrective Action Planned: The Office of ESEA Title Programs’ accountant identified when the miscalculation first took place in 2021-2022 and made changes to the workbook formula to correctly calculate the LEA allocations. The office administrator and the bureau administrator both thoroughly reviewed the Title I, Part A allocation workbooks and relayed questions, comments and concerns to the accountant, to ensure compliance with federal statutes, regulations, and the terms and conditions of the federal award. This three-step review ensures that formulas are executed as required under Title I, Part A legislation. As a part of the corrective action plan, the Office intends to establish internal controls that ensure the three-step review will take place annually prior to awarding allocations to LEAs. Each level of review will be passed forward via email documenting that the allocation review has taken place and allocations are approved, in order of; 1. Accountant, 2. Office Administrator, 3. Bureau Administrator. Once all three reviews are completed and approved via the same email chain, the email will be saved on the department’s common drive for auditing purposes.
BEA will evaluate existing internal controls in place to ensure that the precision level of the control is such that it would detect an error in the expenditures reported in comparison to the expenditures incurred within the general ledger, account for precision level control when changing guidance ...
BEA will evaluate existing internal controls in place to ensure that the precision level of the control is such that it would detect an error in the expenditures reported in comparison to the expenditures incurred within the general ledger, account for precision level control when changing guidance exists, and that all documentation used to support the amounts reported on the federal report are properly maintained. Condition A has been completed. In January 2024, BEA evaluated internal controls related to the review and approval of expenditures. The following additional reconciliation step was added to the processes of preparation of expenditure draws and reporting preparation: • Broadband program Accountant II performs a data extract from NHFirst and reconciles the drawdown calculation totals as well as “dashboard” reporting totals to the NHFirst data extract to confirm accuracy of all data points. This second data validation step has been added to ensure all expenditures recorded in NHFirst are evaluated against program guidelines, submitted for reimbursement and included on required reports. Condition B & C to be completed no later than 12/31/2024.
In order to meet the segregation of duties, the Department will explore the need to create a position to ensure requisite segregation of duties requirements. With regard to the segregation of duties, the SF-270 is required form that DMAVS submits to the National Guard Appendix Program Manager for re...
In order to meet the segregation of duties, the Department will explore the need to create a position to ensure requisite segregation of duties requirements. With regard to the segregation of duties, the SF-270 is required form that DMAVS submits to the National Guard Appendix Program Manager for reimbursement with all back up documentation. The National Guard Appendix Program Manager, National Guard Grants Officer Representative, and National Guard United States Property Fiscal Officer (USPFO)/controller located in Concord, NH review, sign and submit the form to the Department of Defense on behalf of DMAVS to request the cash draw. Prior to the submission of reimbursement of any funds, each billing and invoice is reviewed, entered into a ledger and reconciled by three members of the accounting team. Once reconciled, the SF-270 is prepared and signed by the Financial Administrator. The SF-270 is then submitted to the appendix program manager for concurrence and then to the federal fiscal agent (USPFO) for approval. No funds are drawn down until approved by the USPFO. If this is not a satisfactory level of review, the department will request a new position to ensure that there the business function has the proper level of staffing to meet the requirements for segregation of duties.
For clarity the Department will create a redundant manual ledger that duplicates the functions of the current ledger and Detailed Transaction Register (DTR). DMAVS has existing policies and procedures in place to track all federal funds, state funds and mixed funds, and uses spreadsheets for all tr...
For clarity the Department will create a redundant manual ledger that duplicates the functions of the current ledger and Detailed Transaction Register (DTR). DMAVS has existing policies and procedures in place to track all federal funds, state funds and mixed funds, and uses spreadsheets for all transactions that reconciles every month to NH First Detail Transaction Register (DTR), Federal Fund tracking sheet, and Federal reimbursement tracking sheet with backup documents. The tracking sheet for the federal register is not intended to account for the state share of billing. The state share is accurately accounted for in the DTR, the cumulative accounting in the SF-270 and associated back up documentation. Supporting documentation to substantiate the accuracy of lines a, c, e, and f is in the DTR, the cumulative accounting of each SF-270, the supporting documentation sent with the billing to the Federal Government, and Year-end Agency Report for Federal Awards. This includes reconciliation and analysis of SADB expenditures and revenues to the Statement of Appropriations by each Program Accounting Unit. The SF-270 form is continuous cumulative data that starts Oct 1st and runs through the end of that Federal Fiscal Year. The SF-270 is the required federal form DMAVS submits to the Federal National Guard Appendix Program Manager for reimbursement. Back up documentation is submitted with the SF-270. The National Guard Appendix Program Manager, National Guard Grants Officer Representative, and National Guard United States Property Fiscal Officer (USPFO)/controller located in Concord, NH review, sign and submit the form to the Department of Defense to affect the cash draw. DMAVS does not unilaterally make cash draws to the federal government. The USPFO, who is substantially involved provides an independent review and reconciles any discrepancies prior to approving any requests for reimbursement. One possible explanation for the finding is that the selected test works were not continuous.
Name of contact person: Renae Alston Corrective Action: The County will continue to train employees on a monthly basis and as needed when new and updated policies are received. Supervisors and lead workers will continue to conduct second party reviews and utilizing any findings to aid in training st...
Name of contact person: Renae Alston Corrective Action: The County will continue to train employees on a monthly basis and as needed when new and updated policies are received. Supervisors and lead workers will continue to conduct second party reviews and utilizing any findings to aid in training staff on any necessary policy information. The department will continue to implement changes as necessary to achieve the overall improvement of eligibility determinations. Proposed Completion Date: June 30, 2024
Finding 480347 (2023-001)
Significant Deficiency 2023
Finding 2023.001 - Sliding Fee Scale Documentation Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken CareArc was notified of the 2023 annual audit...
Finding 2023.001 - Sliding Fee Scale Documentation Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken CareArc was notified of the 2023 annual audit finding related to Sliding Fee Discounts being applied incorrectly according to the Health Center Program Compliance Manual and out of compliance with our sliding fee policy. CareArc's CFO was aware of the incorrect slide adjustments during the sampling process of the audit. The two patients on Slide B that should have received 50% discount, only received 49% ($3.00 miscalculation) as our electronic medical records did not identify an internal lab as being all inclusive of the same-day office visit. The corrective action plan was to have the Electronic Medical Records system recognize internal labs as being all inclusive of the same-day office visit. This issue was identified by CareArc through an internal audit in September 2023 and we began working with Health Choice Network (HCN). HCN is our vendor that helps program our electronic medical records system. HCN has helped CareArc correct the system going forward. CareArc is working with HCN on creating a report on historical slide applications to correct accounts earlier in 2023. CareArc was able to manually correct the two identified patient accounts. The corrective action plan is still in process of being implemented by CareArc with the assistance of HCN/EPIC with an estimated completion in September 2024. If there are any question regarding this plan, please e-mail Seresa Howe at showe@carearc.org.
DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT ASI-Reno, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Baker Meinz & Associates, Ltd. 1000 Shelard Parkway, Suite 110 Minneapolis, MN 55426 Audi...
DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT ASI-Reno, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Baker Meinz & Associates, Ltd. 1000 Shelard Parkway, Suite 110 Minneapolis, MN 55426 Audit Period: December 31, 2023 The findings from the December 31, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDINGS - FINANCIAL STATEMENT AUDIT - NONE; FINDINGS - FEDERAL AWARD PROGRAMS AUDIT - DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT; FINDING 2023-001: SECTION 811, ASSISTANCE LISTING NUMBER 14.181 The Project withdrew funds from the replacement reserve account that were subsequently reimbursed by the insurance company. Recommendation: The Project should deposit $5,500 into the replacement reserve account. Action Taken: The Project agrees with the finding. Management will deposit $5,500 into the replacement reserve account. If the Department of Housing and Urban Development has questions regarding this plan, please call Chuck Reuter at 651-645-7271.
View Audit 316599 Questioned Costs: $1
ASI Billings, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Baker Meinz & Associates, Ltd. 1000 Shelard Parkway, Suite 110 Minneapolis, MN 55426 Audit Period: December 31, 2023; The finding...
ASI Billings, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Baker Meinz & Associates, Ltd. 1000 Shelard Parkway, Suite 110 Minneapolis, MN 55426 Audit Period: December 31, 2023; The findings from the December 31, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDINGS - FINANCIAL STATEMENT AUDIT - None, FINDINGS - FEDERAL AWARD PROGRAMS AUDIT - None; DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2023-001: SECTION 811, ASSISTANCE LISTING NUMBER 14.181 In 2 of 25 cash disbursements tested, the Project paid the expense of another project under common management. Recommendation: The Project should carefully review invoices before payment to make sure it only pays the proper amount. Action Taken: The Project agrees with the finding. The accounts payable staff will be reminded to be careful when entering invoices for payment. The finding was corrected in January 2024. If the Department of Housing and Urban Development has questions regarding this plan, please call Chuck Reuter at 651-645-7271.
View Audit 316598 Questioned Costs: $1
FINDING 2023-001: SECTION 811, FEDERAL ASSISTANCE LISTING NUMBER 14.181 Condition: One of the tenant files tested contained a mathematical error in computing household income in the process of computing the tenant share of monthly rent. Recommendation: The Project should recompute the HUD subsidy a...
FINDING 2023-001: SECTION 811, FEDERAL ASSISTANCE LISTING NUMBER 14.181 Condition: One of the tenant files tested contained a mathematical error in computing household income in the process of computing the tenant share of monthly rent. Recommendation: The Project should recompute the HUD subsidy and tenant rent for this tenant and adjust a future monthly billing. Project managers should be aware of the importance of computing the tenant's household income correctly. Action taken: The Project agrees with the finding. Tenant rent was recomputed in January 2024 and management adjusted the April 2024 HUD billing. If the Department of Housing and Urban Development has questions regarding this plan, please call Chuck Reuter at 651-645-7271.
View Audit 316587 Questioned Costs: $1
Condition: In 1 of 25 cash disbursements tested, the Project paid the expense of another project under common management. Recommendation: The Project should carefully review invoices before payment to make sure it only pays the proper amount. Action Taken: The Project agrees with the finding. The ac...
Condition: In 1 of 25 cash disbursements tested, the Project paid the expense of another project under common management. Recommendation: The Project should carefully review invoices before payment to make sure it only pays the proper amount. Action Taken: The Project agrees with the finding. The accounts payable staff will be reminded to be careful when entering invoices for payment. The finding was corrected in January 2024. If the Department of Housing and Urban Development has questions regarding these plans, please call Chuck Reuter at 651-645-7271.
View Audit 316560 Questioned Costs: $1
Condition: One of the tenant files tested contained a mathematical error in computing household income in the process of computing the tenant share of monthly rent. Recommendation: The Project should recompute the HUD subsidy and tenant rent for this tenant and adjust a future monthly billing. Proje...
Condition: One of the tenant files tested contained a mathematical error in computing household income in the process of computing the tenant share of monthly rent. Recommendation: The Project should recompute the HUD subsidy and tenant rent for this tenant and adjust a future monthly billing. Project managers should be aware of the importance of computing the tenant's household income correctly. Action taken: The Project agrees with the finding. Tenant rent was recomputed in January 2024. If the Department of Housing and Urban Development has questions regarding these plans, please call Chuck Reuter at 651-645-7271.
View Audit 316560 Questioned Costs: $1
FINDINGS—FEDERAL AWARD PROGRAMS AUDITS USDA Rural Development 2023-005 Community Facilities Loan – Assistance Lising Number: 10.766 Recommendation: We recommend management implement process of transfer and review for reserve fund payments to ensure adequacy of reserve account balance per loan agreem...
FINDINGS—FEDERAL AWARD PROGRAMS AUDITS USDA Rural Development 2023-005 Community Facilities Loan – Assistance Lising Number: 10.766 Recommendation: We recommend management implement process of transfer and review for reserve fund payments to ensure adequacy of reserve account balance per loan agreement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: As of May 2024, management is reviewing with their banks to set up ACH for future transfers. The balance as of December 31, 2023 was $671,066 and deposits will continue until reaching the required amount of $928,800. Name(s) of the contact person(s) responsible for corrective action: Heather Uthoff, CFO Planned completion date for corrective action plan: December 31, 2024 If the USDA Rural Development has questions regarding this plan, please call Heather Uthoff at (515) 733-3030.
View Audit 316554 Questioned Costs: $1
Finding 2023-001 Responsible Individual: Steve Lefever Endeavors obtained verbal approval to include the activities related to utilities and facility services on requests for reimbursement from the official who reviewed and approved billings. Endeavors submits all invoices with attached detailed sup...
Finding 2023-001 Responsible Individual: Steve Lefever Endeavors obtained verbal approval to include the activities related to utilities and facility services on requests for reimbursement from the official who reviewed and approved billings. Endeavors submits all invoices with attached detailed support for each expenditure. All requests for reimbursement to date have been paid for utilities and facility services without exception. Corrective Action Plan (CAP) Endeavors will review each grant at inception and list out requirements related to budget and billings. Grant requirements will also be reviewed with the Grant/Contract Accountant and Program Officials at the start of any subsequent grant years. Endeavors will not submit billings without documented approval from the funder of budget changes from the original award. Anticipated Completion date 8/1/24
View Audit 316543 Questioned Costs: $1
Finding 2023-001 Identification of the federal program: Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (PRF) Pass-Throug...
Finding 2023-001 Identification of the federal program: Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (PRF) Pass-Through Grantor: Not applicable Pass-Through Award Number: Not applicable Pass-Through Award Period: 1/1/2020-12/31/2023 (Periods 5 and 6) Summary of Finding: The “Total Lost Revenues for the Period of Availability (January 1, 2020 to June 30, 2023)” line in the HRSA PRF portal for Spectrum Health System (the Parent), TIN 383382353, General Distribution HRSA PRF report in Reporting Period 5 was $108,697,843. The correct amount of lost revenue reported for Period 5 should have been $107,045,743. The difference represents a $1.6M error in adjusting for targeted funds to determine the Parent lost revenue for period 5. Corrective Action Plan: No further lost revenue reporting is required on the HRSA PRF Portal. Management will implement more robust internal controls in preparation for similar future filings. Individuals responsible for corrective action: Cindy Brink, Director, System Accounting and Reporting Timing of corrective action: July 1, 2024 and going forward.
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