Corrective Action Plans

Finding 34673 (2022-004)

Significant Deficiency 2022

West Virginia Public Transit Association

WV

Questioned Costs Reporting Internal Control / Segregation of Duties

CONTROLS OVER GRANT REPORTING Department of Health and Human Services 93.788 Management within West Virginia Public Transit Association appreciates and shares the auditors? concern with integrity as it relates to controls over grant reporting. The State Opioid Response Transportation Project Manager...

CONTROLS OVER GRANT REPORTING Department of Health and Human Services 93.788 Management within West Virginia Public Transit Association appreciates and shares the auditors? concern with integrity as it relates to controls over grant reporting. The State Opioid Response Transportation Project Manager will submit all future grant reports to the West Virginia Public Transit Association Treasurer for review prior to submission to grantor. The Treasurer will document approval in writing. This will begin with the quarter ending September 29, 2023.

View Audit 31088

Finding 34667 (2022-002)

Significant Deficiency 2022

Boys & Girls Clubs in Tennessee

TN

Subrecipient Monitoring Questioned Costs Cash Management

Individual Responsible for Corrective Action Plan: Whitney Holliday, Director of Club Financial Services Corrective Action: Previous Process: The previous process was created prior to the current admin becoming the dedicated Financial Services leader on the Boys & Girls Clubs in TN/TN Alliance admi...

Individual Responsible for Corrective Action Plan: Whitney Holliday, Director of Club Financial Services Corrective Action: Previous Process: The previous process was created prior to the current admin becoming the dedicated Financial Services leader on the Boys & Girls Clubs in TN/TN Alliance admin team. All changes took place over the 2022/2023 grant cycles. Current Process: The previous process was overhauled to our current process in Q1 of 2022. Training and updates to the process were performed with 20 organizations throughout the year. We also implemented better direct communication with admin/staff 1:1s and a quarterly financial update call to continue training and best practice sharing. Process Update: A process update will be implemented beginning with July 2023 reimbursement requests/submissions to funders. These updates will be shared with individual Clubs with an expectation of full implementation by the end of Q3 2023. The admin will enhance its policies and procedures over sub-recipient monitoring to ensure accurate invoicing. -All reimbursement requests due from the Clubs by the 15th of each month o Previous Process: ? Requests were either loaded in the shared drive or emailed directly to the admin. Requests were consistently late and admin would communicate with each Club to see if they submitted something but it was missed. o Current Process: ? Calendar reminders are disbursed to all financial contacts with the deadlines clearly defined ? All submissions must be made in the shared drive. No email reimbursement requests are allowed. ? Admin no longer reached out to Clubs if nothing is loaded in the shared drive to process by the deadline ? Direct communication opened and established between Club financial leaders and admin financial leader to ensure all deadlines are met o Process Update: ? No update is needed ? Reimbursement Request/Cover Sheet o Previous Process: ? Submissions were processed based on a spreadsheet that the Clubs tracked in the shared drive. ? Manual verification of lines requested o Current Process: ? A cover sheet detailing the calculations of each line in the reimbursement request is required with each submission. Acknowledgment by Clubs that they have included/not included (timesheets signed in 3 places, receipts with no sales tax or other unallowable expenses, request submitted by the 15th of each month) via check boxes prior to authorized signature and date. ? All salary and benefit calculations must be completely detailed in the supporting documentation. This has remained difficult with all 20 organizations having different pay structures, paycheck layouts, benefit providers, etc. ? All supporting documentation must be present at the time of processing or line item requests are removed from overall submission. ? All submissions are compiled and sent to funders by their deadline on a monthly basis o Process Update: ? Additional calculation details will now be required for all submissions. We will add a separate box for the percentage breakdown to be charged to each grant to match supporting documentation exactly. ? All communication of errors will be in writing and detailed notes will be kept. No more phone conversations about corrections unless also documented in writing. ? If there are any unclear calculations in the request, it will be sent back to the Club to submit the following month. This will take the liability for the error off the admin and place it back with the Club. ? We will no longer allow miscellaneous benefits (other than payroll taxes) as an allowable expense for reimbursement as they are difficult to verify. ? 1:1 training will be conducted with each Club prior to their first reimbursement request for new grant cycles. With turnover and task sharing in our organization, this will ensure direct training and increase compliance. ? Quarterly financial update calls will be longer/more specific. ? We will no longer allow Clubs to combine requests over multiple months. This inconsistency tends to lead to errors. ? Additional admin support has been added to decrease the number of requests being processed by one individual per month. We have hired an additional staff member. ? Status of Funds o Previous Process: ? Clubs kept up with their budgets/available balances themselves o Current Process: ? Admin updates a running spreadsheet in the shared drive after each month's submission to ensure Clubs are aware of their available balances for each grant o Process Update: No update is needed Anticipated Completion Date: September 30, 2023

View Audit 34598

Finding 34663 (2022-002)

Significant Deficiency 2022

Fort Bragg Schools Cafeteria Fund

NC

Internal Control / Segregation of Duties Questioned Costs Significant Deficiency

Finding: 2022-002 Segregation of Duties Name of Contact Person: Mike Riles and John McKnight Corrective Action: Duties will be divided equally within the Central Office. Proposed Completion Date: August 21, 2023

View Audit 34592

Finding 34662 (2022-001)

Significant Deficiency 2022

Fort Bragg Schools Cafeteria Fund

NC

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties

Finding: 2022-001 Financial Statement Preparation Name of Contact Person: Ms. Robin Norwood Corrective Action: The Financial administration portion of the office will be turned over to NAF (Non appropriated Funds) at the start of school. Proposed Completion Date: August 21, 2023

View Audit 34592

Finding 34661 (2022-001)

None 2022

Ideo.org

CA

Reporting Questioned Costs

Corrective Action Plan For the Year Ended December 31, 2022 Finding: 2022-001 Preparation of the Schedule of Expenditures of Federal Awards Criteria and Condition Pursuant to the requirement set forth in the compliance requirements of Title 2 Subtitle A Chapter II Part 200 Subpart F ?200.510, the ...

Corrective Action Plan For the Year Ended December 31, 2022 Finding: 2022-001 Preparation of the Schedule of Expenditures of Federal Awards Criteria and Condition Pursuant to the requirement set forth in the compliance requirements of Title 2 Subtitle A Chapter II Part 200 Subpart F ?200.510, the Schedule of Expenditures of Federal Awards must include the total federal awards expended. The Organization did not include all federal expenditures on its Schedule of Expenditures of Federal Awards. Questioned Cost There were no questioned costs associated with this finding. Cause/Effect The Organization did not have complete procedures documented to prepare the Schedule of Expenditures of Federal Awards. Repeat Finding This finding is not a repeat finding. Recommendation We recommend that the Organization improve its tracking of federal awards to ensure that all amounts are properly included in the Schedule of Expenditure of Federal Awards. View of responsible officials Management agrees with the recommendation. Planned Corrective Action IDEO.org will implement a system where the Partnerships team will inquire all incoming partners around whether or not the source of funding is a federal award. Depending on that reply, the Finance team will be alerted via a tracking field in our opportunities database. Implementation Date of Plan January 1, 2023 Responsible Official Stephanie Wei Contact Information for Responsible Official stephanie@ideo.org

View Audit 33166

Finding 34644 (2022-002)

None 2022

Morris County Usd 417

KS

Allowable Costs / Cost Principles Questioned Costs Procurement, Suspension & Debarment § 200.403

The Board will require approval for such expenditures made in short succession and for the bid process to be followed as required by law when the ultimate result of the transaction is a purchase of goods or services of an amount exceeding $20,000.

View Audit 29881 Questioned Costs: $1

Finding 34642 (2022-001)

Significant Deficiency 2022

Marjaree Mason Center, Inc.

CA

Questioned Costs Procurement, Suspension & Debarment § 200.320

To Whom It May Concern, As required by the standards applicable to financial audits contained in Government Auditing Standards, issued by the Comptroller General of the United States and Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, a...

To Whom It May Concern, As required by the standards applicable to financial audits contained in Government Auditing Standards, issued by the Comptroller General of the United States and Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), we have provided below our response and corrective action plan addressing the finding in the Report of Independent Auditors on Compliance for the Major Federal Program and Report on Internal Control Over Compliance Required by the Uniform Guidance for the year ended September 30, 2022. Response and Corrective Action Plan Finding 2022-001: Department of Housing and Urban Development - Continuum of Care Program - Assistance Listing No. 14.267; Grant period: Year Ended December 31, 2022. Cause: Management obtained rate quotations from an adequate number of vendors, but did not retain sufficient documentation and did not perform a formal assessment to proceed with the purchase. Contact Person: Marcus Martin, Director of Finance Management Response: The Marjaree Mason Center (MMC) did not correctly document the purchase of a new vehicle including having justification on the selection of the vendor. When researching the purchase of the vehicle, MMC researched different options for the vehicle, but did not keep the documentation of the research. Effective immediately, MMC has implemented new procedures when it comes to procedures for any contracts/invoices over $10,000. The Manager submitting the request much attach at least three quotes and written justification approved by the Director of Finance and/or Executive Director before the contract is signed or payments are released. Sincerely, Marcus Martin Director of Finance Marjaree Mason Center marcus@mmcenter.org

View Audit 24657 Questioned Costs: $1

Finding 34641 (2022-002)

Significant Deficiency 2022

Legal Aid Services of Oklahoma, Inc.

OK

Eligibility Questioned Costs

Finding 2022-002 ? Eligibility and documentation of Emergency Rental Assistance Program (ERAP) 21.023 Finding 2022-001 Corrective Action Plan Condition: Case files relating to housing stability service applicants under ERAP 1 lacked sufficient documentation or self-attestation in LASO?s case manag...

Finding 2022-002 ? Eligibility and documentation of Emergency Rental Assistance Program (ERAP) 21.023 Finding 2022-001 Corrective Action Plan Condition: Case files relating to housing stability service applicants under ERAP 1 lacked sufficient documentation or self-attestation in LASO?s case management system for providing evidence of how COVID-19 resulted in the applicant?s financial hardship. Additionally, case files which were noted by LASO as not COVID-19 related but still assigned to ERAP 1, and documented financial hardship linked to no illness, health, or related COVID-19 impacts resulting in ineligible cases for ERAP 1. In conjunction with our FY2022 annual audit, please see the LASO?s corrective action plan below: The ERAP 1 grant with its unique requirements has expired. Under ERAP 2, requirements no longer require direct COVID impact but rather a showing of financial hardship. LASO has assigned two full time grant managers for the ERAP 2 activities in OKC and Tulsa to ensure future compliance. Expected completion date: 07/01/2023 Party Responsible: Michael Figgins, Executive Director Contact Information: 405-488-6768 or michael.figgins@laok.org

View Audit 24458

Finding 34639 (2022-001)

Significant Deficiency 2022

Pierce Mortuary Colleges, Inc.

IL

Questioned Costs Student Financial Aid HUD Housing Programs

A. Comments on Findings and Recommendations: Finding 2022-001 Exit Counseling Condition: The Institution did not timely perform the required FDL exit counseling for 10 of 20 students in the sample requiring exit counseling. PMC agrees with the condition outlined in Finding 2022-001 Exit Counseling. ...

A. Comments on Findings and Recommendations: Finding 2022-001 Exit Counseling Condition: The Institution did not timely perform the required FDL exit counseling for 10 of 20 students in the sample requiring exit counseling. PMC agrees with the condition outlined in Finding 2022-001 Exit Counseling. B. Prior Audit Findings There were no findings in the prior audit. C. Corrective Action Taken on Findings Finding 2022-001 Exit Counseling Current processes for exit counseling are to ensure graduating students receive exit counseling during the final quarter of enrollment as well as receive an e-mail with directions on how to complete exit counseling at www.studentloans.gov from the financial aid department. Students that are enrolled in less-than-halftime credits are also provided exit counseling when the quarter starts or known when the student drops down to that enrollment status through reduction of courses. When students withdraw they will be notified that they are to confirm whether or not a student has received direct loans or not; if yes, they are to perform their exit counseling duties. There has been a lack of quality assurance that has led to exit counseling being completed after 30 days for a variety of reasons. To correct this issue, PMC Registrar will run an enrollment status change report on a bi-weekly basis to catch any student that has changed to an out-of-school status and/or a less-than-half-time status to ensure the financial aid department completes their exit counseling phone call or in-person meeting, as well as their exit counseling e-mail with information regarding completing exit counseling via www.studentloans.gov. Within seven (7) days of the report being run, each student file will be checked to ensure exit counseling was completed and notes are placed within the file to verify exit counseling was completed within the 30 day period of the enrollment status change as required.

View Audit 24183

Finding 34632 (2022-020)

Significant Deficiency 2022

Commonwealth of Massachusetts

MA

Questioned Costs Special Tests & Provisions Eligibility § 200.303

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES 2022-020 Medicaid Cluster, COVID-19 ? Medicaid Cluster, Children?s Health Insurance Program ? Assistance Listing No. 93.775, 93.777, 93.778, 93.767 ...

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES 2022-020 Medicaid Cluster, COVID-19 ? Medicaid Cluster, Children?s Health Insurance Program ? Assistance Listing No. 93.775, 93.777, 93.778, 93.767 Action taken in response to the finding: MassHealth agrees with the recommendation and notes that all the identified findings relate to MassHealth?s Dental Third-Party Administrator DentaQuest. To address the findings and recommendation, MassHealth will require DentaQuest to implement a corrective action plan to review and improve internal controls for the retention of provider enrollment documentation. As part of this corrective action plan, MassHealth will require DentaQuest to ensure that all required documents are obtained and retained during validation and revalidation processes for both individual and group practices. To support this, DentaQuest will also be required to provide additional training to its provider enrollment staff on document retention. Name of the contact person responsible for corrective action: Tuyen Vu, Dental Program Manager Planned completion date for corrective action plan: EHS plans the completion date for the corrective action plan in July 2024.

View Audit 31118

Finding 34629 (2022-019)

Significant Deficiency 2022

Commonwealth of Massachusetts

MA

Questioned Costs Allowable Costs / Cost Principles Reporting § 200.303

DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT 2022-019 Low-Income Home Energy Assistance, COVID-19 ? Low-Income ...

DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT 2022-019 Low-Income Home Energy Assistance, COVID-19 ? Low-Income Home Energy Assistance ? Assistance Listing No. 93.568 Action taken in response to the finding: The Department of Housing and Community Development (DHCD) implemented new policies and procedures for LIHEAP reporting requirements necessary to ensure the reports are submitted timely and with accurate data to US HHS reporting systems. The DHCD Community Service Unit Manager, or their delegee, will coordinate with the LIHEAP Coordinator and/or other staff as needed to track deadline dates for all LIHEAP reports. Additionally, prior to submission all reports will be reviewed and verified against data sources by a Community Service staff member not involved in the creation of the reports. Name of the contact person responsible for corrective action: Ed Kiely, Community Service Unit Manager Planned completion date for corrective action plan: June 1, 2023

View Audit 31118

Finding 34624 (2022-016)

Significant Deficiency 2022

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Reporting Questioned Costs § 200.303

DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION 2022-016 COVID-19 ? Elementary and Secondary School Emergency Relief Fund (ESSER), COVID-19 ? American Rescue Plan ? Elementary and Secondary S...

DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION 2022-016 COVID-19 ? Elementary and Secondary School Emergency Relief Fund (ESSER), COVID-19 ? American Rescue Plan ? Elementary and Secondary School Emergency Relief (ARP ESSER) ? Assistance Listing No. 84.425D, 84.425U Action taken in response to the finding: DESE has enhanced policies and procedures to ensure the Annual Report has amounts reported are verified with supporting documentation. In addition, DESE corrected all 1st year reporting errors for both the Year 2 and Year 3 Annual Reports submitted to the U.S. Department of Education and all amounts were verified with supporting documentation for accuracy. Name of the contact person responsible for corrective action: Julia Jou, Director of Budget, Jeffrey Benbenek, Director of Audit & Compliance Planned completion date for corrective action plan: July 1, 2023

View Audit 31118

Finding 34623 (2022-015)

Significant Deficiency 2022

Commonwealth of Massachusetts

MA

Questioned Costs Reporting Significant Deficiency § 200.303

DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT 2022-015 COVID-19 ? Emergency Rental Assistance ? Assistance Listing No. 21.023 ...

DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT 2022-015 COVID-19 ? Emergency Rental Assistance ? Assistance Listing No. 21.023 Action taken in response to the finding: As of June 2022, monthly reports are no longer required for ERA. All reports will be uploaded to treasury before the deadline. Name of the contact person responsible for corrective action: Molly Butman Planned completion date for corrective action plan: April 10, 2023

View Audit 31118

Finding 34609 (2022-011)

Material Weakness 2022

Commonwealth of Massachusetts

MA

Questioned Costs Subrecipient Monitoring Material Weakness § 200.303

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2022-011 WIOA Cluster ? Assistance Listing No. 17.258, 17.259, 17.278 ...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2022-011 WIOA Cluster ? Assistance Listing No. 17.258, 17.259, 17.278 Action taken in response to the finding: Reporting has been built to notify responsible parties of the award periods of performance and highlight any issues for corrective action in accordance to previously filed FFATA reporting. In addition, FFATA reporting has been created in EOLWD?s DataMart application. Actions taken are as follows: ? Performed FFATA training ? Created accounts for employee access to FFATA ? Filed existing outstanding and new grant FFATA reports ? Used new reporting to notify responsible parties that a new grant/modification has arrived and requires a FFATA Subaward report filed ? Training for existing staff complete and new staff will be trained accordingly as part of their onboarding. Name of the contact person responsible for corrective action: Malachy Rice, Director of Federal Grants, EOLWD Planned completion date for corrective action plan: June 30, 2023

View Audit 31118

Finding 34608 (2022-010)

Material Weakness 2022

Commonwealth of Massachusetts

MA

Internal Control / Segregation of Duties Questioned Costs Material Weakness § 200.303

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2022-010 WIOA Cluster ? Assistance Listing No. 17.258, 17....

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2022-010 WIOA Cluster ? Assistance Listing No. 17.258, 17.259, 17.278 Action taken in response to the finding: Staffing: Two new Budget Analysts will begin working for EOLWD at the end of June in 2023. These analysts will provide additional capacity for filing 9130s for WIOA. Training: In March and April 2023, EOLWD provided training to new staff on the preparation, certification, and submission of 9130 reports. Staff beginning in June 2023 will be trained during the next 9130 reporting period. Automating Business Practices: EOLWD refined its automated 9130 reporting for the March 31, 2023, reporting period and is finalizing further refinements that will be implemented prior to the next quarterly reporting period. Standard Operating Procedures: EOLWD developed job aides for the preparation of 9130 reports with its new automated processes and is in the process of drafting new Standard Operating Procedures (SOP). These SOPs will be finalized and submitted to DOL by October 1, 2023, as outlined in the corrective action plan schedule provided to DOL. An updated version of this schedule is provided below. Name of the contact person responsible for corrective action: Malachy Rice, Director of Federal Grants, EOLWD Planned completion date for corrective action plan: October 1, 2023

View Audit 31118

Finding 34607 (2022-001)

Significant Deficiency 2022

Legal Aid of North Carolina, Inc.

NC

Questioned Costs Subrecipient Monitoring HUD Housing Programs

CORRECTIVE ACTION PLAN April 28, 2023 Legal Services Corporation Legal Aid of North Carolina, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Romeo, Wiggins & Company, LLP, 8210 Creedmoor...

CORRECTIVE ACTION PLAN April 28, 2023 Legal Services Corporation Legal Aid of North Carolina, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Romeo, Wiggins & Company, LLP, 8210 Creedmoor Road, Suite 202, Raleigh, NC 27613 Audit Period: Year Ended December 31, 2022 The findings from the December 31, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FEDERAL AWARD FINDINGS AND QUESTIONED COSTS SIGNIFICANT DEFICIENCY 2022-001: Case File Documentation/CFDA 09.634032 Recommendation: We recommend that management re-emphasize the importance of maintaining adequate documentation of retainer determination for all LSC eligible cases. Periodic reviews of case files should be performed to ensure compliance. Action Taken: The largest number of errors were discovered in one office, which office has a relatively new managing attorney. Legal Aid of North Carolina, Inc.?s Compliance Officer will provide compliance training targeted to this manager and her staff, emphasize compliance in new hire onboarding training, and train managers and supervisors promoted to new leadership roles. Additionally, all advocacy staff (attorneys and paralegals) will have mandatory annual refresher training on when and how to execute retainers. The training will also include a review of LSC Regulation 1611.9, Retainer Agreements. To strengthen the compliance process and assure requirements are met, Legal Aid of North Carolina, Inc. will perform semi-annual internal self-inspections to include retainer monitoring. We also plan to perform retainer monitoring of field offices that this audit and future self-inspections identify as missing required case documentation, including retainer agreements. Finally, our case management system will be evaluated for opportunities to more systematic alert case closing approvers or report on potential missing required documents. Legal Services Corporation Page Two If Legal Services Corporation has questions regarding this plan, please call Jim Strand, LANC CFO at 984-263-9609. Sincerely yours, Ashley Campbell Chief Executive Officer

View Audit 36954

Finding 34600 (2022-001)

Significant Deficiency 2022

University of Tulsa

OK

Student Financial Aid Questioned Costs Special Tests & Provisions

Corrective Action Plan The University of Tulsa Student Financial Services External Audit: Academic Year 21/22 During the spring 2022 semester, The University of Tulsa closed for a 5-day period due to inclement weather. The Return of Title IV (R2T4) calculations that were conducted adjusted total...

Corrective Action Plan The University of Tulsa Student Financial Services External Audit: Academic Year 21/22 During the spring 2022 semester, The University of Tulsa closed for a 5-day period due to inclement weather. The Return of Title IV (R2T4) calculations that were conducted adjusted total number of days in the semester; but did not adjust total days attended on the R2T4 calculations. The University of Tulsa reviewed all R2T4 calculations for spring 2022 with a withdraw date of February 2 or after. 11 recalculations were required, funds are being returned to the Department of Education. For future semesters, the formula for breaks will be hard coded into the COD R2T4 formula for all new breaks in the event of school closure during a semester to avoid missing either a reduction in the numerator or denominator. Name of the contact person responsible for corrective action: Vicki Hendrickson, Director, Student Financial Services

View Audit 35438 Questioned Costs: $1

Finding 34595 (2022-002)

Material Weakness 2022

Dawson County School District No. 20

NE

Questioned Costs

The entity's Board and management were not aware of the Davis-Bacon wage requirements relating to construction contracts paid with ESF Funds. An individual at the district will be in charge of ensuring Davis-Bacon requirements are met in the future for any projects that must comply.

View Audit 35996 Questioned Costs: $1

Finding 34590 (2022-002)

Significant Deficiency 2022

City of Kotzebue, Alaska

AK

Questioned Costs Procurement, Suspension & Debarment

Finding 2022-002 Finance Department will require a minimum of three quotes for any purchase above $10,000. Additionally, any purchase made above $50,000 will require a signed and approved Resolution from the City Council. The Finance Department will create and formally adopt a procurement process fo...

Finding 2022-002 Finance Department will require a minimum of three quotes for any purchase above $10,000. Additionally, any purchase made above $50,000 will require a signed and approved Resolution from the City Council. The Finance Department will create and formally adopt a procurement process for the City of Kotzebue to be approved by the City Council. Estimated completion date: September 30, 2023

View Audit 32429 Questioned Costs: $1

Finding 34589 (2022-002)

Significant Deficiency 2022

Wilkes County, North Carolina

NC

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Policy training is being completed with Medicaid staff to ensure all income and resources are correctly documented and applied in NC FAST. Second Party Reviews continue to be utilized in order to identify any eligibility determination deficiencies. Supervisors will give additional attention to AVS i...

Policy training is being completed with Medicaid staff to ensure all income and resources are correctly documented and applied in NC FAST. Second Party Reviews continue to be utilized in order to identify any eligibility determination deficiencies. Supervisors will give additional attention to AVS information and how it is documented in NC FAST when conducting reviews.

View Audit 31229 Questioned Costs: $1

Finding 34585 (2022-001)

Significant Deficiency 2022

Wilkes County, North Carolina

NC

Significant Deficiency Internal Control / Segregation of Duties Questioned Costs

Additional training is being provided to DSS staff on importance of securing work areas and how breach may occur with workstations left unattended and unsecured. Computer workstations log out automatically after brief period of idle time, however staff have been instructed to use manual lock of work...

Additional training is being provided to DSS staff on importance of securing work areas and how breach may occur with workstations left unattended and unsecured. Computer workstations log out automatically after brief period of idle time, however staff have been instructed to use manual lock of workstations whenever stepping away from desk. Supervisors have also been instructed to do random visual checks of workstations.

View Audit 31229

Finding 34584 (2022-001)

Significant Deficiency 2022

Corry Memorial Hospital Association D/b/a Lecom Health Corry Memorial

PA

Special Tests & Provisions Questioned Costs Student Financial Aid

Finding 2022-001: Federal Program: Community Facilities Loans and Grants Cluster: Community Facilities Loans and Grants Assistance Listing Number: 10.766 Criteria: Section 4.4 of the Community Facilities Direct Loan agreement stipulates that the borrower must maintain funds in accounts in accord...

Finding 2022-001: Federal Program: Community Facilities Loans and Grants Cluster: Community Facilities Loans and Grants Assistance Listing Number: 10.766 Criteria: Section 4.4 of the Community Facilities Direct Loan agreement stipulates that the borrower must maintain funds in accounts in accordance with Section 4 of the Loan Resolution. The Loan Resolution stipulates that the borrower must establish a General Account and Reserve Account. The Reserve account must be funded to an amount equaling or exceeding $1,167,219. Condition and Context: The Association did not have a specific Reserve Account established in accordance with the Loan Resolution. Corrective Action Plan: Corry Memorial Hospital Association d/b/a LECOM Health Corry Memorial Hospital and Subsidiaries agrees with the finding and will implement controls sufficient to identify and monitor ongoing compliance with requirements. Additionally, Corry Memorial Hospital Association d/b/a LECOM Health Corry Memorial Hospital and Subsidiaries will establish and fund the required reserve account. Contact Person: Tim McGahen, Chief Financial Officer 965 Shamrock Lane, Corry, PA 16407 Expected Date of Resolution: The policies are expected to be updated effective March 30, 2023. The Reserve account is expected to be established and funded by March 1, 2023.

View Audit 31227

Finding 34577 (2022-003)

Material Weakness 2022

Heart of America Medical Center

ND

Reporting Questioned Costs Material Weakness

Finding 2022-03 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution CFDA #93.498 Finding Summary: Eide Bailly assisted in the preparation of our draft consolidated schedule of expenditures and federal ...

Finding 2022-03 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution CFDA #93.498 Finding Summary: Eide Bailly assisted in the preparation of our draft consolidated schedule of expenditures and federal awards and accompanying notes to the consolidated schedule of expenditures and federal awards. Responsible Individuals: Melissa Shepard, CFO and Erik Christenson, CEO Corrective Action Plan: It is not cost effective to have an internal control system designed to provide for a complete and accurate consolidated schedule of expenditures and federal awards. We requested that our auditors, Eide Bailly LLP, assist in the preparation of the consolidated schedule of expenditures. We have designated a member of management to review the drafted consolidated schedule of expenditures. Anticipated Completion Date: Ongoing

View Audit 33781

Finding 34576 (2022-006)

Significant Deficiency 2022

Onslow County, North Carolina

NC

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Re: Single County Audit Finding 2022-006, Significant Deficiency over Eligibility Cause: Caseworkers did not take proper steps ensuring what was used for eligibility determination was complete and accurate per program guidelines. Auditors Recommendation: Caseworkers should review eligibility deter...

Re: Single County Audit Finding 2022-006, Significant Deficiency over Eligibility Cause: Caseworkers did not take proper steps ensuring what was used for eligibility determination was complete and accurate per program guidelines. Auditors Recommendation: Caseworkers should review eligibility determinations and ensure all documentation is included and accurate. Corrective Action Plan: Agency realigned Medicaid to be under one Program Manager to ensure consistency with quality control and review. ? Program Manager, Supervisors, and Lead Workers created a Medicaid Quality Control plan to be followed by all units that includes pulling a random sample from each caseworker every month to include at least 2 approvals and 1 denial. ? The DHB 7078, Second Party Review Worksheet, is completed for each application or case pulled to ensure that policy and procedure is followed. The Explanation of Errors section is completed for any errors discovered and the completed DHB 7078 is then attached to an email and sent to the individual caseworker along with a detailed explanation providing policy and training materials, OST guidance, or emails that reinforce the decision to cite the error. As it relates specifically to the cited error above, the DHB 7078 section B. Documentation is used to review that all required documents are placed in the case record. ? Checklists have been created and are being utilized to prevent errors and all caseworkers have a copy of the DHB 7078 and are required to review prior to authorizing. ? When an error is discovered, the caseworker?s name, case number, and specific error are logged on a Quality Control spreadsheet. This spreadsheet is used to identify training issues and/or repetitive errors. The spreadsheet will be reviewed monthly by Supervisors and Lead Workers for their own unit and reviewed quarterly with all Medicaid Supervisors and Program Manager. ? Along with one-on-one emails that address the individual caseworker errors, group trainings will be held based on repetitive errors and knowledge checks will be utilized at the end of group trainings. ? If an individual caseworker has repeat findings after an error has been addressed there will be a meeting between the caseworker and the supervisor to discuss the issue. During this meeting, training, to include policy sections, training materials, OST guidance, and/or emails will be provided. The caseworker will be asked to sign a training acknowledgement form stating that they have received the training, understand the policy, have no questions, and understand that a full coaching will be implemented if the errors continue. The caseworker will have additional work reviewed for the next 30 days. Proposed Completion Date: Ongoing Name/ Position Contact Person: Kimberli Sholar, Medicaid Program Manager

View Audit 32534

Finding 34574 (2022-005)

Significant Deficiency 2022

Onslow County, North Carolina

NC

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Re: Single County Audit Finding 2022-005, Internal Control Significant Deficiency Cause: Turnover in the department left certain duties unfulfilled during part of the fiscal year. Auditors Recommendation: The County should have procedures in place to cover the second-party review process upon tur...

Re: Single County Audit Finding 2022-005, Internal Control Significant Deficiency Cause: Turnover in the department left certain duties unfulfilled during part of the fiscal year. Auditors Recommendation: The County should have procedures in place to cover the second-party review process upon turnover within the department. Corrective Action Plan: Program Manager, Supervisor and Lead Worker have developed a partnership and will share the responsibility of ensuring second-party reviews are conducted on all required cases. The Program Manager will assume this responsibility in their absence or if a position is vacated. ? The TANF Supervisor and Lead Worker will follow a TANF second-party review formula to ensure 25% of Work First cases will be reviewed for each caseworker, every month, to include applications and recertifications, as outlined in Work First policy. Second-party reviews will be completed weekly by the Lead Worker to ensure program compliance. ? The Lead Worker will log details of each case reviewed on the TANF second-party review log, to include any deficiencies noted. ? The Supervisor and Program Manager will review the log monthly to ensure program compliance, identify any performance issues, and ensure oversight. Errors identified will be addressed with the individual caseworker through emails and individual coaching. Proposed Completion Date: Ongoing Name/ Position Contact Person: Cindi Douglas, Program Manager

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