Corrective Action Plans

Finding 39690 (2022-006)

Significant Deficiency 2022

IL

Reporting Questioned Costs Cash Management

Finding #2022-006: regarding CCH did not comply with the reporting requirements as outlined in the agreement. Cause: The grant agreement received from the City of Chicago was...

Finding #2022-006: regarding CCH did not comply with the reporting requirements as outlined in the agreement. Cause: The grant agreement received from the City of Chicago was executed late and insufficient internal controls were in place to ensure the grant was assigned to the Department?s Grant vouchering tracking schedule to determine when the grant monthly voucher reports are due to the City of Chicago. Corrective Action: The CCH Director of Grant Accounting will establish internal control(s) to ensure all Grant agreements are included in the Department?s Grant vouchering tracking schedule. Anticipated completion of the corrective action will be December 31, 2023.

View Audit 37825

Finding 39689 (2022-005)

Significant Deficiency 2022

Cook County, Illinios

IL

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.403

Finding #2022-005: regarding CCDPH not adequately complying with federal regulations over allowable costs. Cause: The cause of this finding resulted from not following the estab...

Finding #2022-005: regarding CCDPH not adequately complying with federal regulations over allowable costs. Cause: The cause of this finding resulted from not following the established controls that ensure proper support documentation is included with the journal entry chargeback entries prepared by Finance staff to justify the charges incurred to the Grant. Additionally, the Program Lead (key personnel) assigned to the program left the organization prior to the Grant ending which affected the periodic review for allowable costs/charges. Corrective Action: The CCH Director of Grant Accounting will reinforce current internal controls so that the reviewer/approver (staff who prepares the chargeback) includes proper supporting documents and attaches to the entries in the EBS Oracle System. Additionally, the CCH Director of Grant Accounting will continue to reinforce current CCH procedures and ensure Grant expenditures are periodically reviewed and checked for allowability and reasonableness (based on activities) by both the Finance and Programmatic areas. Anticipated completion of the corrective action will be December 31, 2023.

View Audit 37825 Questioned Costs: $1

Finding 39688 (2022-010)

Significant Deficiency 2022

Cook County, Illinios

IL

Cash Management Reporting Questioned Costs § 200.303

Subject: Corrective Action Plan For: Finding 2022-010 Cook County Health would like to respond to the finding related to the Provider Relief Fund {PRF) Phase 2 Reporting. The FY'22 SEFA amount (including both lost revenues and expenditures) for the HRSA PRF Phase 2 Reporting period was $31,163,323...

Subject: Corrective Action Plan For: Finding 2022-010 Cook County Health would like to respond to the finding related to the Provider Relief Fund {PRF) Phase 2 Reporting. The FY'22 SEFA amount (including both lost revenues and expenditures) for the HRSA PRF Phase 2 Reporting period was $31,163,323.35. Cause: The cause of this finding resulted from a misunderstanding of the expense data that was rolling/ inputted in the HRSA portal. The Unreimbursed Expenses line should have been inputted as Other PRF Expenses. CCH Management has instituted the following Corrective Action Plan (CAP) to prevent future occurrence. Corrective Action Plan: To ensure accurate data is reported, CCH has implemented the following corrective action plan: ? Any future HRSA- PRF Audit Portal data submission will require multiple reviews. The review will be led by CCH Finance's Associate Chief Financial Officer to ensure the report is accurate and complete prior to submission. Status - Phase 4 PRF Reporting was reviewed on March 28th, 2023, by the CFO and ACFO prior to submission. ? To buttress this CAP, CCH has created a dedicated GL account code to track all PRF activities - lost revenue, cash disbursed, and expenses incurred. Fully Implemented since - (August 30th, 2022) ? A recurring monthly reconciliation meeting has been instituted to track lost revenues, and expenses that were paid with PRF and not through any other type of assistance. Recurring Monthly Reconciliation Leader- Scott Spencer, Associate Chief Financial Officer. Please note that CCH has not received any PRF funding since January 2022.

View Audit 37825

Finding 39683 (2022-003)

Significant Deficiency 2022

Cook County, Illinios

IL

Eligibility Questioned Costs

Findings 2022 ? 003 Emergency Rental Assistance (ERA) Program Federal Assistance Listing # (21.023) ? Allowable Costs/Eligibility Corrective Action Plan: ...

Findings 2022 ? 003 Emergency Rental Assistance (ERA) Program Federal Assistance Listing # (21.023) ? Allowable Costs/Eligibility Corrective Action Plan: Key considerations are: Treasury added flexibility between the ERA 1 and 2 programs relaxed the burden of proof necessary for applicants to qualify for funding. 1. The reduction of burden and qualifications allowed for self-attestation, third party income verification or certification, and internal policies to reduce burden as supported by the Treasury. 2. Rental payments calculations and assumptions on timing may not have taken into consideration the FAQ guidance covering overall ceilings on payments in ERA I funding once ERA II was in place, which allowed for an 18-month cap on both funding sources. DPD will continue to work towards recovering over-allocations to awardees and initiate collection efforts directed towards owners and landlords. As we finalize the ERA II program by September 2024, DPD will reconcile the payment status of the ERA II awardees and notify awardees of overpayment and repayment requirements. Please reference the following: ERA-FAQ and ERA Questions. https:www.google.com/url?sa=t&source=web&rct=j&url=https:home.treasury.gov/system/files/136/ERA-FAQ-8-25-2021.pdf&ved=2ahUKEwjZ05HLjOL_AhVEkmoFHaXiAMwQFnoECCIQAQ&usg=AOvVaw1SKQl-IN3zig70bkVCxj9C

View Audit 37825 Questioned Costs: $1

Finding 39682 (2022-002)

Significant Deficiency 2022

Cook County, Illinios

IL

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Findings 2022 ? 002 Emergency Solutions Grant (ESG) Program, Federal Assistance Listing #14.231 Corrective Action Plan: Last year, the ESG program was monitored by the U.S. Departm...

Findings 2022 ? 002 Emergency Solutions Grant (ESG) Program, Federal Assistance Listing #14.231 Corrective Action Plan: Last year, the ESG program was monitored by the U.S. Department of Housing and Urban Development (HUD) local Office. This year, the ESG-Coronavirus (CV) program will be monitored by HUD. The local HUD office is currently working with DPD staff in various technical assistance workshop to prep for an upcoming session. These meetings have occurred since April 2023. At HUD?s request, DPD rewrote various policies and procedures. We are still awaiting HUD?s final approval on the recommended policies and procedures revisions. DPD will be using the revised policies and procedures to monitoring concerns going forward. ESG has a complicated billing structure which includes five (5) different spending areas from which a subrecipient can choose for payment. Unfortunately, the ESG and ESG-CV program includes one (1) dedicated staff person and support from the Deputy. This complicated billing structure forces DPD, to provide an extensive amount of technical assistance to various subrecipients due to incorrect invoice submissions. Many of the subrecipients are understaffed and lack the capacity to bill properly. On various occasions, DPD staff has spent a considerable amount of time assisting subrecipients with preparing request for reimbursements. The amount of technical assistance dedicated towards these efforts will be reduced as a result of ESG ending in December 2023 and a new grant cycle beginning in January 2024. ESG-CV will close permanently in September 2023. Recommendation/corrective action planning will be taken on future grant awards that may have similar compliance requirements. DPD plans to hire new staff to expedite the payment process as well as to provide technical assistance to our subrecipients. With ESG-CV ending in September 2023 and new staff on board, this should reduce the amount of time for processing payment to DPD subrecipients.

View Audit 37825

Finding 39672 (2022-004)

Material Weakness 2022

Westwood Community School District

MI

Questioned Costs Allowable Costs / Cost Principles Cash Management

The District concurs with the finding. The District will implement procedures to ensure compliance with the allowability requirements.

View Audit 37977 Questioned Costs: $1

Finding 39668 (2022-001)

Significant Deficiency 2022

World Vision International and World Vision Inc.

WA

Subrecipient Monitoring Reporting Questioned Costs

Finding 2022-001 ? Reporting - Late filing of FFATA required reports World Vision implemented an improved control process for collecting required information and trained relevant staff on the strengthened review procedures and the importance of submitting FFATA reports prior to the due date. Contact...

Finding 2022-001 ? Reporting - Late filing of FFATA required reports World Vision implemented an improved control process for collecting required information and trained relevant staff on the strengthened review procedures and the importance of submitting FFATA reports prior to the due date. Contact Person Responsible for Correct Action: Kenneth E. Botka Completion Date: March 11, 2022

View Audit 37786

Finding 39658 (2022-001)

Significant Deficiency 2022

Odd Fellows South Oak Building CORP

NE

Questioned Costs HUD Housing Programs Cash Management

Comments on the Finding and Each Recommendation: The required deposit of $66,982, per the December 31, 2021 Computation of Surplus Cash, Distributions and Residual Receipts, was not deposited into the Residual Receipts Fund within 90 days of fiscal year end. The Regulatory Agreement requires Surpl...

Comments on the Finding and Each Recommendation: The required deposit of $66,982, per the December 31, 2021 Computation of Surplus Cash, Distributions and Residual Receipts, was not deposited into the Residual Receipts Fund within 90 days of fiscal year end. The Regulatory Agreement requires Surplus Cash, as defined by HUD, to be deposited into a separate Residual Receipts Fund within 90 days of fiscal year end. As a result, the Corporation was not in compliance with the Regulatory Agreement. Management should monitor the Surplus Cash position and make required deposits to the Residual Receipts Fund within 90 days of fiscal year end. Action(s) taken or planned on the finding: Management deposited the $66,982 to the Residual Receipts Fund on May 13, 2022. No further action is required.

View Audit 37823 Questioned Costs: $1

Finding 39656 (2022-101)

Significant Deficiency 2022

Benjamin Franklin Charter School - Queen Creek

AZ

Questioned Costs Reporting Significant Deficiency § 200.61

CORRECTIVE ACTION PLAN JUNE 30, 2022 REFERENCE: 2022-101 CFDA NUMBER: 84.027A ? SPECIAL EDUCATION GRANTS TO STATES CFDA NUMBER: 84.027X ? COVID 19 - SPECIAL EDUCATION GRANTS TO STATES U.S. DEPARTMENT OF EDUCATION ? 2022 PASSED THROUGH ARIZONA STATE DEPARTMENT OF EDUCATION GRANT NUMBERS: H027A21000...

CORRECTIVE ACTION PLAN JUNE 30, 2022 REFERENCE: 2022-101 CFDA NUMBER: 84.027A ? SPECIAL EDUCATION GRANTS TO STATES CFDA NUMBER: 84.027X ? COVID 19 - SPECIAL EDUCATION GRANTS TO STATES U.S. DEPARTMENT OF EDUCATION ? 2022 PASSED THROUGH ARIZONA STATE DEPARTMENT OF EDUCATION GRANT NUMBERS: H027A210007, H027X210007 CLIENT RESPONSE AND CORRECTIVE ACTION PLAN We concur with the condition. 1. Name of the contact person responsible for corrective action: Joanne Poirier 2. Corrective action planned: Developed and implemented a `File Verification Form? demonstrating documentation of internal control processes and procedures to ensure students? files include required documentation. 3. Anticipated completion date: July 15, 2022

View Audit 37246

Finding 39655 (2022-001)

Significant Deficiency 2022

Housing Authority of Douglas County

GA

Special Tests & Provisions Questioned Costs Allowable Costs / Cost Principles

Finding 2022-001 - Special Tests and Provisions, RAD Replacement Reserve - Significant Deficiency, CFDA #14.182 Corrective Action Plan: Will full fund the R4R account in 2023 and going forward as indicated by HUD. Person Responsible: Jennifer Fr...

Finding 2022-001 - Special Tests and Provisions, RAD Replacement Reserve - Significant Deficiency, CFDA #14.182 Corrective Action Plan: Will full fund the R4R account in 2023 and going forward as indicated by HUD. Person Responsible: Jennifer Fralish Anticipated Completion Date: YE 2023 and beyond

View Audit 37897

Finding 39654 (2022-002)

Significant Deficiency 2022

Keystone Place Housing Corporation

MO

Questioned Costs HUD Housing Programs Reporting

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED DECEMBER 31, 2022 Name of Audit: Keystone Place Housing Corporation HUD Project Number: 084-HD063 Name of Audit Firm: Welch & Associates, LLC Period Covered by Audit: Year Ending December 31, 2022 Corrective Action Plan Prepared by: Name: Rodney Potter Posit...

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED DECEMBER 31, 2022 Name of Audit: Keystone Place Housing Corporation HUD Project Number: 084-HD063 Name of Audit Firm: Welch & Associates, LLC Period Covered by Audit: Year Ending December 31, 2022 Corrective Action Plan Prepared by: Name: Rodney Potter Position: Assistant Executive Director Telephone Number: (816) 364-3827 Findings-Financial Statement Audit None Findings-Federal Award Programs Audit Federal Agency: U.S. Department of Housing and Urban Development Federal Program: Supportive Housing for Persons with Disabilities ? Section 811 Assistance Listing Number: 14.181 Finding 2022-002 Comments on Findings and Each Recommendation Keystone Place Housing Corporation agrees with the auditors? finding and recommendation. Action(s) Taken or Planned on the Finding We will ensure a current and approved HUD Form 9839-B is on file. The form has been submitted to HUD for approval on March 22, 2023.

View Audit 36917 Questioned Costs: $1

Finding 39649 (2022-001)

Material Weakness 2022

Little Rock School District

AR

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.439

Finding 2022-001 Allowable Costs/Cost Principles Criteria or Specific requirement: Purchases of equipment and other capital expenditures require the written approval of the Federal awarding agency or pass-through entity, as specified in Office of Management and Budget (OMB) 2 CFR section 200.439. ...

Finding 2022-001 Allowable Costs/Cost Principles Criteria or Specific requirement: Purchases of equipment and other capital expenditures require the written approval of the Federal awarding agency or pass-through entity, as specified in Office of Management and Budget (OMB) 2 CFR section 200.439. Condition: In our test of equipment purchases from the COVID-19 Education Stabilization Fund, we identified the purchase of 447 pieces of equipment with the unit costs greater than the $5,000 threshold for which the District did not obtain prior written approval from the Arkansas Division of Elementary and Secondary Education (DESE). Retroactive approval was subsequently obtained from DESE during the audit fieldwork. LRSD Response: The District will continue to monitor internal controls in regards to use of ESSER funds and ensure all prior approvals are granted by DESE before purchasing of capital assets with a unit value equal to or greater than $5,000. Responsible LRSD Staff: Kelsey Bailey, CDFO, will be responsible for ensuring compliance. Completion Date: Kelsey Bailey has made contact with Jayne Greene at DESE for guidance and retroactive approval was granted from DESE on March 9, 2023. Please let me know if additional information is needed. Respectfully, Kelsey Bailey Chief Deputy Finance & Operations Officer

View Audit 37215 Questioned Costs: $1

Finding 39622 (2022-003)

None 2022

Central Dewitt Community School District

IA

Subrecipient Monitoring Equipment & Real Property Management Questioned Costs § 200.313

The District will review current processes for purchasing equipment within Iowa Department of Education approval amounts or seek amendments when approval cost limits cannot be met. June 30, 2023 Cyndie Johnson

View Audit 46139 Questioned Costs: $1

Finding 39619 (2022-001)

Significant Deficiency 2022

Pueblo Community Health Center, Inc.

CO

Questioned Costs

Consolidated Health Centers Grant? Assistance Listing No. 93.224 and 93.527 Recommendation: Our auditors recommended the Organization take measures to ensure that appropriate sliding fee rates/categories are used for each sliding fee encounter. Explanation of disagreement with audit finding: There i...

Consolidated Health Centers Grant? Assistance Listing No. 93.224 and 93.527 Recommendation: Our auditors recommended the Organization take measures to ensure that appropriate sliding fee rates/categories are used for each sliding fee encounter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization agrees with the finding of one visit receiving an incorrect sliding fee discount. The application process for determining the correct sliding fee discount is layered in human interventions resulting in multiple areas an error could occur. The Outreach and Enrollment Department, who handles the sliding fee application process, will continue to receive training on the processes and the reason why for correctly completing and entering the sliding fee application within the Electronic Health Record. An internal audit will continue to monitor the discount received matches the sliding fee application. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Phillip Davis, CFO at 719-543-8718 ext. 295.

View Audit 46136

Finding 39615 (2022-001)

Material Weakness 2022

Bickford Street Elderly Housing Corporation

MA

Questioned Costs HUD Housing Programs

Department of Housing and Urban Development Finding No. 2022-001 Unauthorized Distributions; Assistance Listing Number 14.157 Supportive Housing for the Elderly Recommendation: The Sponsor should immediately reimburse the amount due to the Project and establish procedures to ensure payments of this ...

Department of Housing and Urban Development Finding No. 2022-001 Unauthorized Distributions; Assistance Listing Number 14.157 Supportive Housing for the Elderly Recommendation: The Sponsor should immediately reimburse the amount due to the Project and establish procedures to ensure payments of this nature are not made in the future. Corrective Action: The Sponsor has repaid the fees to the Project as requested by HUD.

View Audit 44829 Questioned Costs: $1

Finding 39608 (2022-003)

Material Weakness 2022

Friendly House, Inc.

AZ

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring

2022-003 Cash Management Material Noncompliance Cash Management Material Weakness in Internal Control over Compliance U.S. Department of Health and Human Services Passed-through the Arizona Department of Economic Security Refugee and Entrant Assistance State Administered Federal Financial Assistance...

2022-003 Cash Management Material Noncompliance Cash Management Material Weakness in Internal Control over Compliance U.S. Department of Health and Human Services Passed-through the Arizona Department of Economic Security Refugee and Entrant Assistance State Administered Federal Financial Assistance Listing/CFDA #93.566; ADES18-191650; October 1, 2020 to September 30, 2021 and October 1, 2021 to September 30, 2022 Condition: Eide Bailly LLP (EB) noted that four out of four draw requests did not have adequate support for the class hours included. Management?s Response and Corrective Action Plan: ? Monthly Attendance Report are completed by data specialist using individual teachers? daily rosters. ? The Monthly Attendance Reports are verified by the program manager and corrected if any mistakes are identified. ? Monthly invoices are reviewed, prior to submission, with the Department Manager for additional verification and approval. ? After the student attendance has been reviewed by Program Manager and verified by the Department Manager, a review log is signed off by both the Program Manager and the Department Manager. ? Any changes to either the attendance logs or monthly student attendance will only be made with the authorization of the department manager after data has been verified, with an explanation of why that was needed. ? After the appropriate verifications have taken place, the Program Manager creates the monthly invoice, they will maintain and verify documentation for the student attendance hours reflected on the invoice. ? Management will continue to discuss and explore ways to strengthen our current internal controls, including, purchasing tracking software and/or the creation of a google form/document. ? Management will routinely review and consider any needed modifications to or implementation of new policies and procedures that would strengthen internal controls surrounding the invoicing process, record-keeping, and the management thereof. Contact Person: Jose J. Vaquera, VP of Client Services Anticipated Completion Date: May 15, 2023

View Audit 37105

Finding 39607 (2022-002)

Significant Deficiency 2022

Friendly House, Inc.

AZ

Questioned Costs Reporting Significant Deficiency

2022-002 Reporting Noncompliance Reporting Significant Deficiency in Internal Control over Compliance U.S. Department of Health and Human Services Passed-through the Arizona Department of Economic Security Refugee and Entrant Assistance State Administered Federal Financial Assistance Listing/CFDA #9...

2022-002 Reporting Noncompliance Reporting Significant Deficiency in Internal Control over Compliance U.S. Department of Health and Human Services Passed-through the Arizona Department of Economic Security Refugee and Entrant Assistance State Administered Federal Financial Assistance Listing/CFDA #93.566; ADES18-191650; October 1, 2020 to September 30, 2021 and October 1, 2021 to September 30, 2022 Condition: Eide Bailly LLP (EB) noted the following internal control issues. ? Although the reports were reviewed in accordance with the internal controls, two out of three reports tested lacked the required documentation to support the reports. Management?s Response and Corrective Action Plan: ? Trimester reports are submitted on February 15, June 15, and October 15 each calendar year. ? Starting with the Trimester Report due on February 15, 2022, the Program Manager will continue the review process of the Trimester Report and maintain the required documentation which supports the report?s data. ? The Department Manager will review the Trimester Report before submission. Documentation showing this review will be maintained. ? During the review process, Management will continue to discuss ways to strengthen our current internal controls. Management will routinely review and consider any needed modifications to or implementation of new policies and procedures that would strengthen internal controls surrounding the reporting process, record-keeping, and the management thereof. ? The trimester report due on October 15, 2021 was prepared and submitted before the auditor?s noted this original finding in our prior year?s audit and before we designed a corrective action plan. ? The Arizona Department of Economic Security (DES) has determined that trimester reports are no longer a requirement for the new grant year effective October 1, 2023. The data referenced in this finding is no longer a requirement of our new grant with DES. Contact Person: Jose J. Vaquera, VP of Client Services Anticipated Completion Date: Effective on October 1, 2023, a new DES grant year, the above-mentioned trimester report is no longer required by funder.

View Audit 37105

Finding 39604 (2022-001)

Significant Deficiency 2022

Shanti Project

CA

Questioned Costs Eligibility

CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2022 COGNIZANT OR OVERSIGHT AGENCY U.S. Department of Health and Human Services INDEPENDENT PUBLIC ACCOUNTING FIRM Karlsson & Lane, An Accountancy Corporation 4725 First Street, Suite 226 Pleasanton, California 94566 AUDIT PERIOD - For the year ended June 3...

CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2022 COGNIZANT OR OVERSIGHT AGENCY U.S. Department of Health and Human Services INDEPENDENT PUBLIC ACCOUNTING FIRM Karlsson & Lane, An Accountancy Corporation 4725 First Street, Suite 226 Pleasanton, California 94566 AUDIT PERIOD - For the year ended June 30, 2022 The findings from the June 30, 2022 Schedule of Findings and Questioned Costs are discussed below. FINDINGS - FEDERAL AWARD PROGRAMS AUDIT 2022-001 The Organization should implement a procedure and control to determine program participant eligibility on at least an annual or six month schedule as required by the program. Action: The Organization agrees with the finding, and will implement procedures to implement the recommendation. Conclusion: If the U.S. Department of Health and Human Services has questions regarding this plan, please contact Charlie Meade at: 3170 23rd Street San Francisco, CA 94110 (415) 625 5220 cmeade@shanti.org CORRECTIVE ACTION: Following this audit finding, Shanti?s HIV Programs performed an internal review of all clients served during FY 2021-present to identify active clients out of compliance with Ryan White eligibility. Shanti?s HIV Programs will rectify the auditor?s findings in the following ways: All clients with outstanding eligibility documents will be reached out to regarding their compliance status and HIV Programs staff will attempt to obtain proper documentation. If a client is unable to provide Ryan White eligibility documents, they may sign an attestation stating that they are a San Francisco resident and their income is at or below 500% of the Federal Poverty Level. When eligibility documentation is received, HIV Programs will update the ARIES database, the client?s chart and Shanti?s internal tracking document. Shanti will communicate status updates regarding client eligibility and will inform the appropriate parties if any clients served during the FY 22-23 contract period were not able to prove Ryan White eligibility. Previously reported UOS and UDC that remain undocumented will be restated with February 2023 reporting. POLICY & PROCEDURE CHANGES: HIV Programs? Policies and Procedures will be updated to reflect that clients who are not in compliance with Ryan White eligibility should not receive services or be billed for until documentation is provided. o The Director of HIV Programs will review a listing of all clients out of compliance monthly. o HIV Care Navigators and/or the HIV Program Coordinator will follow-up with clients out of compliance to obtain documentation. o The Director of HIV Programs will review the clients reported monthly into ARIES and sign off that all clients are eligible and documented to have received services during the month. o The Director of HIV Programs will sign off on all UOS and UDC reported monthly to finance for inclusion on the monthly invoices to the City. PROJECTED COMPLETION DATE: Shanti?s HIV Programs Department is working diligently to update Ryan White eligibility documents for all clients served during the FY 21-22 and FY 22-23 contract periods. The corrective action plan is anticipated to take until the end of the FY 22-23 contract period (2/28/23).

View Audit 34026

Finding 39596 (2022-001)

Significant Deficiency 2022

Community Health & Social Services Center, Inc.

MI

Questioned Costs

Community Health and Social Services Center, Inc. respectfully submits the following corrective action plan for the year ended September 30, 2022. The findings from the September 30, 2022, schedule of findings and questioned costs are discussed below. The findings are numbered consistently as assign...

Community Health and Social Services Center, Inc. respectfully submits the following corrective action plan for the year ended September 30, 2022. The findings from the September 30, 2022, schedule of findings and questioned costs are discussed below. The findings are numbered consistently as assigned in the schedule. Government Auditing Standards Findings: Finding Number: 2022-001, 2021-001, Significant Deficiency and Noncompliance - Sliding Fee. Recommendation: We recommend that sliding fee applications be completed for each sliding fee patient. Procedures should be implemented to verify applications are completed before the encounter is billed. In addition, the Center could consider increasing its internal sampling throughout the year to verify sliding fee applications are obtained, completed and agree to the discount applied. Action Taken: CHASS management concurs with the audit finding. Every week, a member of the Billing Staff will review self-pay claims to locate an internal sample of 5 claims that have a sliding fee discount applied. Once the 5 claims are selected, they will check to make sure supporting documentation is in the patient?s record and that the patient-provided income is entered correctly into the billing system. The claim will also be reviewed to make sure the appropriate discount was applied. Any errors will be reported to the CSR supervisor for follow-up and corrections with the Customer Service Representatives responsible for the original entry. In addition, Henry Ford Community Connect (which administers the billing software) has been contacted to resolve issues with EPIC not applying the correct discount despite correct patient information being entered. Responsible parties: Angela Salgado, Chief Operating Officer, Mariana Gutierrez, Billing Manager. Anticipated completion date: These actions were implemented starting in April 2022, however turnover in management resulted in inadequate follow-up. This will be addressed more thoroughly beginning in June 2023.

View Audit 37381

Finding 39593 (2022-001)

None 2022

Rutgers, the State University of New Jersey

NJ

Allowable Costs / Cost Principles Questioned Costs Reporting § 200.430

Management agrees with the finding. The noted PI circumvented existing internal controls, all of which performed as designed to ensure financial compliance and grants stewardship. Management recognizes the opportunity to ensure that PIs are aware of the University?s grant accounting policies and pra...

Management agrees with the finding. The noted PI circumvented existing internal controls, all of which performed as designed to ensure financial compliance and grants stewardship. Management recognizes the opportunity to ensure that PIs are aware of the University?s grant accounting policies and practices as well as federal policies through formal trainings. Research Financial Services, and the Office for Research will work closely with the Chancellor led units to create and enforce trainings for our university faculty and researchers. Management will also investigate opportunities to reduce opportunities to circumvent controls.

View Audit 37104 Questioned Costs: $1

Finding 39590 (2022-003)

Significant Deficiency 2022

Rutgers, the State University of New Jersey

NJ

Questioned Costs Reporting Significant Deficiency

Rutgers University-Newark made the decision to use some of their institutional HEERF funds as direct payments to student accounts in order to both reduce the burden on students and as a reimbursement to the University for outstanding student receivables. The University?s understanding was that fund...

Rutgers University-Newark made the decision to use some of their institutional HEERF funds as direct payments to student accounts in order to both reduce the burden on students and as a reimbursement to the University for outstanding student receivables. The University?s understanding was that funds used in this manner from the institutional portion of HEERF funds did not require student consent. The finding has pointed out that information did exist in an FAQ, which clarifies that when using institutional HEERF funds in this manner student consent is required. Going forward we will change our policy so when applying any HEERF funds to student receivables as a direct grant to the student, a consent process will be in place that allows students to authorize the University to reduce their outstanding charges. Moving forward, the consent and distribution process for any direct student grants, including institutional HEERF funds, will be moved under University Enrollment Services which will ensure that the proper distribution of funds occurs and that internal controls are in place so that the awarding criteria are adhered to across all student recipients.

View Audit 37104 Questioned Costs: $1

Finding 39588 (2022-002)

Significant Deficiency 2022

Rutgers, the State University of New Jersey

NJ

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

Concerning the HEERF Student Aid quarterly report, the reporting responsibility for the quarter closing December 31, 2021 was assigned to two individuals who have since separated from university employment. The reporting requirements were understood and while there is no reason to believe that the ...

Concerning the HEERF Student Aid quarterly report, the reporting responsibility for the quarter closing December 31, 2021 was assigned to two individuals who have since separated from university employment. The reporting requirements were understood and while there is no reason to believe that the quarterly report in question was not uploaded, there are no emails or retained backup information for that report. On February 9, 2021, the final Student Aid report was uploaded to the website and that documentation has been provided. The responsibility for quarterly reporting has been moved to the Associate Director for Communications, University Enrollment Services. She has setup an automatic calendar alert to several senior staff members as well as the staff person responsible for the upload so establish multiple points of contact so there is backup immediately in place should we experience additional staff turnover or another unplanned disruption. Regarding the Institutional Aid report, the University acknowledges the deadline was missed by one day. Research Financial Services oversees the institutional aid reporting. The quarterly reporting period through June 30, 2022, had a reporting due date of July 10, 2023. Within those 10 days, four were weekend dates (7/2-7/3) and (7/9-7/10), and 7/4 was observed for a national holiday. We submitted the report for posting Monday morning, in which it landed on our website less than 24 hours after the original due date which fell on a weekend date. In the future we will ensure the public posting of this quarterly report occurs by the deadline.

View Audit 37104

Finding 39587 (2022-002)

Significant Deficiency 2022

Lima Ecumenical Housing Corporation Dba Pilgrim Place Apts 043-11199

OH

Questioned Costs HUD Housing Programs Cash Management

Comments on the Finding and Each Recommendation: The required deposit of $15,276, per the July 31, 2021 Computation of Surplus Cash, Distributions and Residual Receipts, was not deposited into the residual receipts fund within 90 days of fiscal year end. The Regulatory Agreement requires Surplus C...

Comments on the Finding and Each Recommendation: The required deposit of $15,276, per the July 31, 2021 Computation of Surplus Cash, Distributions and Residual Receipts, was not deposited into the residual receipts fund within 90 days of fiscal year end. The Regulatory Agreement requires Surplus Cash, as defined by HUD, to be deposited into a separate residual receipts fund within 90 days of the fiscal year end. The Corporation was not in compliance with the Regulatory Agreement. Management should monitor the Surplus Cash position and make required deposits to the residual receipts fund within 90 days of fiscal year end. Action(s) Taken and Planned on the Finding: Management deposited the $15,276 to the residual receipts fund on May 31, 2022. No further action is required.

View Audit 37873 Questioned Costs: $1

Finding 39531 (2022-002)

Significant Deficiency 2022

Sanford

SD

Allowable Costs / Cost Principles Questioned Costs Reporting § 200.303

Finding 2022-002 ? Activities Allowed or Unallowed and Allowable Costs/Cost Principles Information on 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 ...

Finding 2022-002 ? Activities Allowed or Unallowed and Allowable Costs/Cost Principles Information on 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) Award Year: 2022 Planned corrective actions: Sanford?s preventative and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being used for unallowable contract labor costs. Sanford believes that the risk of any material contract labor costs being incorrectly charged to a federal grant is effectively mitigated through existing preventative and detective internal controls. Sanford will re-educate the senior care facility?s administrators and enhance its procedural documentation regarding retention of evidence related to the approval of contract labor timecards and payment of contract labor invoices for this facility to be consistent with the over 200 other facilities across the system. Responsible official: Dustin Scholz, Executive Director of Operations Anticipated completion date: August 31, 2023

View Audit 34025

Finding 39507 (2022-004)

Significant Deficiency 2022

South Lane School District No 45j3

OR

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring

Prior approval for capital expenditure: We have reviewed our controls over grant expenditures with new staff to ensure that controls over compliance are followed. We have made one modification that includes a review of recorded expenditures recorded in the general ledger prior to year-end to ensure ...

Prior approval for capital expenditure: We have reviewed our controls over grant expenditures with new staff to ensure that controls over compliance are followed. We have made one modification that includes a review of recorded expenditures recorded in the general ledger prior to year-end to ensure that all items recorded have required approval.

View Audit 34125

Corrective Action Plans

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