Corrective Action Plans

Finding 24571 (2022-025)

Material Weakness 2022

State of Michigan

MI

Questioned Costs Material Weakness

Finding 2022-025 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Managed Care Periodic Audits Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS formally added the Encounter Data Validation (EDV) protocol to its Ex...

Finding 2022-025 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Managed Care Periodic Audits Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS formally added the Encounter Data Validation (EDV) protocol to its External Quality Review Organization contracts as of October 1, 2022. EDV activities are currently underway and a final report outlining the results of the review will be posted to the website once available. Anticipated Completion Date MDHHS anticipates the first review will be completed and posted to the website by September 30, 2023. Responsible Individual(s) Brad Barron, MDHHS Jackie Sproat, MDHHS Matthew Seager, MDHHS

View Audit 20093

Finding 24570 (2022-024)

Significant Deficiency 2022

State of Michigan

MI

Questioned Costs

Finding 2022-024 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Medical Loss Ratio Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS will instruct the contracted actuary to include a comparison of the amounts rep...

Finding 2022-024 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Medical Loss Ratio Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS will instruct the contracted actuary to include a comparison of the amounts reported in the medical loss ratio calculation with audited financial reports. Anticipated Completion Date September 30, 2023 Responsible Individual(s) Keith White, MDHHS

View Audit 20093

Finding 24569 (2022-023)

Significant Deficiency 2022

State of Michigan

MI

Questioned Costs Reporting

Finding 2022-023 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Refunding of Federal Share of Overpayments Management Views MDHHS agrees with the finding. Planned Corrective Action For parts a., b., d., and e., CHAMPS enhancements were imp...

Finding 2022-023 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Refunding of Federal Share of Overpayments Management Views MDHHS agrees with the finding. Planned Corrective Action For parts a., b., d., and e., CHAMPS enhancements were implemented into production during fiscal year 2023 to correct the reporting of quarterly expenditures. MDHHS is currently finalizing updates to rules within CHAMPS. MDHHS is currently working with the Adult Services Authorized Payments (ASAP) system vendor to correct the reports used for the preparation of the quarterly statement of expenditures report (CMS-64) report. For part c., MDHHS will explore system enhancements to identify overpayments returned late and to calculate the corresponding interest due to the Centers for Medicare and Medicaid Services. Anticipated Completion Date a., b., d., and e. MDHHS expects CHAMPS updates to be finalized by June 30, 2023, and ASAP reports to be corrected by July 31, 2023. c. MDHHS does not yet have an estimated completion date for the system enhancements related to the calculation of interest. Responsible Individual(s) Gina Fleury, MDHHS Carol O?Callaghan, MDHHS Darryl Walker, MDHHS

View Audit 20093 Questioned Costs: $1

Finding 24568 (2022-022)

Significant Deficiency 2022

State of Michigan

MI

Eligibility Questioned Costs HUD Housing Programs

Finding 2022-022 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Provider Eligibility Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS will amend the managed care contracts to require that signatures are obtained...

Finding 2022-022 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Provider Eligibility Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS will amend the managed care contracts to require that signatures are obtained on the Provider Screening Information Collection Tool (PSICT) forms when contracts and waivers are renewed and extended. Annually, MDHHS will send a reminder to the managed care entities to report any change in ownership to MDHHS within 35 days. In addition, MDHHS has incorporated a review of provider agreements as part of their monitoring process conducted for all MI Choice Waiver Program (MI Choice) entities. Anticipated Completion Date MDHHS will send the annual reminder to managed care entities beginning August 2023. MDHHS anticipates that signatures will be obtained on the PSICTs effective October 2023 for the fiscal year 2024 contract cycle. MDHHS expects to complete its current review of provider agreements for MI Choice entities by July 2023 and reviews will be ongoing. Responsible Individual(s) Elizabeth Gallagher, MDHHS Latina McCausey, MDHHS

View Audit 20093

Finding 24567 (2022-021)

Significant Deficiency 2022

State of Michigan

MI

Questioned Costs Eligibility Internal Control / Segregation of Duties

Finding 2022-021 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Eligibility Interface Errors Management Views MDHHS agrees with the finding. Planned Corrective Action Bridges is the system of record for eligibility and produces reports with p...

Finding 2022-021 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Eligibility Interface Errors Management Views MDHHS agrees with the finding. Planned Corrective Action Bridges is the system of record for eligibility and produces reports with potential duplicate records for local office staff to review. In addition, CHAMPS is currently designed to reject potential duplicate records to prevent duplicate payments for the same individuals that already exist in CHAMPS and places these records on a CHAMPS report for review. These two reports could potentially contain the same duplicate records identified by both CHAMPS and Bridges. MDHHS central office will develop a process to reconcile the rejected records identified on the CHAMPS and Bridges reports and ensure that MDHHS is appropriately reviewing those records and making any necessary corrections. Anticipated Completion Date December 2023 Responsible Individual(s) Jamy Hengesbach, MDHHS Mariah Schaefer, MDHHS

View Audit 20093

Finding 24565 (2022-019)

Material Weakness 2022

State of Michigan

MI

Eligibility Questioned Costs Material Weakness § 200.516

Finding 2022-019 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Beneficiary Eligibility Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS continues to pursue other data sources for income verification and other s...

Finding 2022-019 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Beneficiary Eligibility Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS continues to pursue other data sources for income verification and other system enhancements so that all case data is available to all reviewers. MDHHS conducts mandated training for local office caseworkers. In addition, MDHHS will continue to determine where additional training or enhancements to training are needed to ensure eligibility is accurately determined and documentation is properly maintained and loaded to the electronic case file. Lastly, MDHHS has been working since 2018 to ensure correct eligibility classifications in Bridges at the time of payment and a system change was implemented in April 2021 to correct the issue. All new cases are being correctly routed. MDHHS expects that all existing cases will be updated during the 14-month period following the May 11, 2023 end of the PHE, as allowed by the Centers for Medicare and Medicaid Services. Anticipated Completion Date MDHHS continues to pursue other data sources for income verification and other system enhancements, in addition to determining where training is needed, on an ongoing basis. MDHHS expects to have all existing cases updated by June 2024. Responsible Individual(s) Logan Dreasky, MDHHS Brant Cole, MDHHS Mariah Schaefer, MDHHS

View Audit 20093 Questioned Costs: $1

Finding 24564 (2022-017)

Material Weakness 2022

State of Michigan

MI

Reporting Questioned Costs Subrecipient Monitoring

Finding 2022-017 MDHHS - FFATA Reporting Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has submitted all outstanding FFATA reports. MDHHS provided additional instruction to the individuals responsible for providing account code and funding source information relat...

Finding 2022-017 MDHHS - FFATA Reporting Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has submitted all outstanding FFATA reports. MDHHS provided additional instruction to the individuals responsible for providing account code and funding source information related to FFATA submissions. Anticipated Completion Date Completed Responsible Individual(s) Jeanette Hensler, MDHHS Chad Dzingleski, MDHHS

View Audit 20093

Finding 24562 (2022-009)

Significant Deficiency 2022

State of Michigan

MI

Questioned Costs Eligibility Internal Control / Segregation of Duties

Finding 2022-009 CHAMPS General Controls Management Views Although MDHHS and DTMB had not fully documented all database specific configuration standards until after the audit period, DTMB disagrees that during the audit period the system contained potentially vulnerable database configurations a...

Finding 2022-009 CHAMPS General Controls Management Views Although MDHHS and DTMB had not fully documented all database specific configuration standards until after the audit period, DTMB disagrees that during the audit period the system contained potentially vulnerable database configurations and disagrees that DTMB cannot ensure the security of the data. DTMB has been and continues to implement the manufacturer?s recommendations regarding security configurations. In addition, the databases reside in restricted trusted internal security zones, protected by firewalls, which are specific to each application and database, in conjunction with intrusion protection, antivirus software, and SOM standard security safeguards. Planned Corrective Action DTMB developed an organization-wide framework for database security configuration management. Anticipated Completion Date DTMB anticipates having compliance documentation by September 30, 2023. Responsible Individual(s) Nathan Buckwalter, DTMB

View Audit 20093

Finding 24539 (2022-003)

Significant Deficiency 2022

Okeechobee County, Fl

FL

Questioned Costs Subrecipient Monitoring Cash Management § 200.303

Airport Improvement Program ? Assistance Listing No. 20.106 Recommendation: We recommend all reports submitted to grantors be reviewed by knowledgeable personnel before submittal. A copy of the review, approval, approval date, and submittal date should be maintained as evidence. Explanation of disag...

Airport Improvement Program ? Assistance Listing No. 20.106 Recommendation: We recommend all reports submitted to grantors be reviewed by knowledgeable personnel before submittal. A copy of the review, approval, approval date, and submittal date should be maintained as evidence. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Staff will ensure that all reports submitted to grantors be reviewed by knowledgeable personnel before submitting. A copy of the review, approval, approval date, and submittal date will be maintained as evidence. Name(s) of the contact person(s) responsible for corrective action: Budget and Grants Director Johnathan Blanco. Planned completion date for corrective action plan: September 30, 2023.

View Audit 21248

Finding 24510 (2022-046)

Significant Deficiency 2022

State of Michigan

MI

Questioned Costs Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.516

Finding 2022-046 CCDF Cluster, ALN 93.575 and 93.596 - Provider Health and Safety Requirements Management Views MDE and the Department of Licensing and Regulatory Affairs (LARA) agree with the finding. Planned Corrective Action For part a., the Child Care Licensing Bureau (CCLB) within LARA has ...

Finding 2022-046 CCDF Cluster, ALN 93.575 and 93.596 - Provider Health and Safety Requirements Management Views MDE and the Department of Licensing and Regulatory Affairs (LARA) agree with the finding. Planned Corrective Action For part a., the Child Care Licensing Bureau (CCLB) within LARA has updated its internal policies to clarify how it manages workflow operations, while ensuring CCLB meets federal compliance requirements. In June 2022, the Child Care Organizations Act was amended and the language in Michigan Compiled Law 722.113h was changed to allow for inspections to be conducted in accordance with the State plan. The State plan specifies the annual licensing inspection requirement, at 45 CFR 98.42(b)(2)(i)(B) for unannounced inspections, must be performed ?not less than annually.? According to guidance from the Federal Office of Child Care Region V, this does not mean that inspections must be performed at exact 12-month intervals; therefore, the lead agency has flexibility to schedule the inspections within each calendar year. CCLB has subsequently completed the annually required renewal and/or interim inspections for the licenses identified in the audit sample. The applicable health and safety requirements were reviewed during the inspections conducted. For part b., CCLB is currently creating a new licensing system that will automate letters being sent to licensed child care providers. The new system will generate and store inspection reports directly in the system instead of creating the report in a separate location and then manually moving it to other locations (network drive, SharePoint). This allows the inspection reports to be maintained digitally and be accessible at a later date, while ensuring proper documentation to support renewal inspections is maintained. For part c., in June 2022, CCLB implemented a new process to save all extension letters mailed in PDF format and stored in the current system to be accessed and available upon request. In addition, CCLB will incorporate refresher trainings regarding documentation and storage of inspection reports at its biannual all-staff trainings. The current process of documentation creation and storage will be phased out after the new licensing system is implemented and processes are no longer manually done by CCLB staff. Anticipated Completion Date a. Completed b. October 1, 2023 c. October 1, 2023 Responsible Individual(s) Emily Laidlaw, LARA Lisa Brewer-Walraven, MDE

View Audit 20093 Questioned Costs: $1

Finding 24509 (2022-045)

Significant Deficiency 2022

State of Michigan

MI

Allowable Costs / Cost Principles Questioned Costs Eligibility

Finding 2022-045 CCDF Cluster, ALN 93.575 and 93.596 - Child Care Stabilization Grants Management Views MDE agrees with the finding. MDE?s written procedures for the fall 2021 grant round required manual verification of the number of subsidy eligible children, increasing the risk for human error in...

Finding 2022-045 CCDF Cluster, ALN 93.575 and 93.596 - Child Care Stabilization Grants Management Views MDE agrees with the finding. MDE?s written procedures for the fall 2021 grant round required manual verification of the number of subsidy eligible children, increasing the risk for human error in documenting the appropriate number of subsidy eligible children on the provider?s application. The exceptions noted by the auditors were found in the fall 2021 grant round before procedures were modified in the spring of 2022. Planned Corrective Action MDE revised procedures in March 2022 for the spring 2022 grant round to prepopulate applications based on the number of subsidy eligible children directly from Bridges for specified pay periods, also allowing the providers to dispute the number of subsidy eligible children included in the prepopulated application. Anticipated Completion Date Completed Responsible Individual(s) Lisa Brewer-Walraven, MDE

View Audit 20093

Finding 24508 (2022-044)

Material Weakness 2022

State of Michigan

MI

Questioned Costs Matching / Level of Effort / Earmarking § 200.516

Finding 2022-044 CCDF Cluster, ALN 93.575 and 93.596 - Client Eligibility Management Views MDHHS and MDE agree with the finding. Planned Corrective Action MDHHS Public Assistance Operations (PAO), within the ESA, will continue assisting the local office and BSC staff by providing guidance on MDE ...

Finding 2022-044 CCDF Cluster, ALN 93.575 and 93.596 - Client Eligibility Management Views MDHHS and MDE agree with the finding. Planned Corrective Action MDHHS Public Assistance Operations (PAO), within the ESA, will continue assisting the local office and BSC staff by providing guidance on MDE policies and processes. ESA will inform the local office and BSC staff of policy changes or noted trends during PAO?s Bridges Bits and Bytes communications sessions. ESA?s Payment Accuracy Unit completed case reads in December 2022 and, as a result, ESA and MDE finalized a checklist on May 9, 2023, for use by local office staff to help ensure required documentation that supports eligibility is obtained. Also, MDE launched a Child Development and Care case review SharePoint site on May 1, 2023, to share information with MDE and MDHHS staff, reduce errors and promote integrity efforts for the program. Anticipated Completion Date MDHHS assistance and guidance for local office and BSC staff is ongoing. Responsible Individual(s) Mariah Schaefer, MDHHS Gayle Vail, MDHHS Lisa Brewer-Walraven, MDE

View Audit 20093 Questioned Costs: $1

Finding 24447 (2022-016)

Significant Deficiency 2022

State of Michigan

MI

Questioned Costs Subrecipient Monitoring Reporting

Finding 2022-016 MDE - FFATA Reporting Management Views MDE agrees with the finding. Planned Corrective Action With current capacity, MDE is unable to devote additional resources to submitting a new report each month. MDE is coordinating with the program offices to improve the Federal Funding Ac...

Finding 2022-016 MDE - FFATA Reporting Management Views MDE agrees with the finding. Planned Corrective Action With current capacity, MDE is unable to devote additional resources to submitting a new report each month. MDE is coordinating with the program offices to improve the Federal Funding Accountability and Transparency Act (FFATA) reporting process in order to submit subaward information in accordance with FFATA and federal guidance either by the program office staff or by securing additional resources. Anticipated Completion Date The enhanced process is anticipated to begin with October 1, 2024 grants. Responsible Individual(s) Spencer Simmons, MDE

View Audit 20093

Finding 24432 (2022-041)

Significant Deficiency 2022

State of Michigan

MI

Allowable Costs / Cost Principles Eligibility Questioned Costs § 200.516

Finding 2022-041 Homeowner Assistance Fund, ALN 21.026 - Eligibility Determinations Management Views MSHDA agrees with the finding. Planned Corrective Action For parts a. and b., MSHDA will implement further training of both Case Managers and Case Manager Assistants to address the cited items. Thi...

Finding 2022-041 Homeowner Assistance Fund, ALN 21.026 - Eligibility Determinations Management Views MSHDA agrees with the finding. Planned Corrective Action For parts a. and b., MSHDA will implement further training of both Case Managers and Case Manager Assistants to address the cited items. This will include additional training on documentation of the homeowner?s hardship and detailing calculations in the case notes. For part c., MSHDA will provide additional training to staff making sure that all fields on the checklist are answered correctly. The checklist now has a system failsafe that all fields must have an answer prior to allowing the file to be conditionally approved in the online application portal. Anticipated Completion Date Completed Responsible Individual(s) Dawn Hengesbach, MSHDA Glenn Ross, MSHDA Raul Escobedo, MSHDA Krysta Smith, MSHDA

View Audit 20093 Questioned Costs: $1

Finding 24429 (2022-012)

Significant Deficiency 2022

State of Michigan

MI

Questioned Costs Internal Control / Segregation of Duties § 200.303

Finding 2022-012 MATT 2.0 Change Management Process Management Views MSHDA agrees with the finding. Corrective Action MSHDA completed the improvement of the existing change management process for the MSHDA Activity Tracking Tool (MATT) 2.0 in November of 2021, which includes requiring electronical...

Finding 2022-012 MATT 2.0 Change Management Process Management Views MSHDA agrees with the finding. Corrective Action MSHDA completed the improvement of the existing change management process for the MSHDA Activity Tracking Tool (MATT) 2.0 in November of 2021, which includes requiring electronically documented approval before any production changes can be made. The remaining record that did not have documented support was a training issue that has already been addressed. Anticipated Completion Date Completed Responsible Individual(s) Mark Whitaker, MSHDA SaVille Hill, MSHDA

View Audit 20093

Finding 24428 (2022-011)

Significant Deficiency 2022

State of Michigan

MI

Questioned Costs Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303

Finding 2022-011 MATT 2.0 Security Management and Access Controls Management Views The Michigan State Housing Development Authority (MSHDA) agrees with the finding. Planned Corrective Action For parts, a., b., and c., as of November 30, 2022, MSHDA implemented system security processes and procedu...

Finding 2022-011 MATT 2.0 Security Management and Access Controls Management Views The Michigan State Housing Development Authority (MSHDA) agrees with the finding. Planned Corrective Action For parts, a., b., and c., as of November 30, 2022, MSHDA implemented system security processes and procedures to review active generic and test accounts and to review and disable user accounts inactive for 60 days. In addition, MSHDA implemented a monitoring process that includes semiannual review of privileged accounts and annual review of all other accounts. For part d., MSHDA provided additional training to the user who did not properly approve and document a system access form. Anticipated Completion Date Completed Responsible Individual(s) Mark Whitaker, MSHDA SaVille Hill, MSHDA

View Audit 20093

Finding 24422 (2022-039)

Significant Deficiency 2022

State of Michigan

MI

Subrecipient Monitoring Allowable Costs / Cost Principles Equipment & Real Property Management § 200.303

Finding 2022-039 Formula Grants for Rural Areas and Tribal Transit Program, ALN 20.509 - PTMS Security Management and Access Controls Management Views MDOT agrees with the finding. Planned Corrective Action MDOT?s Office of Enterprise Information Management (EIM) and Office of Passenger Transporta...

Finding 2022-039 Formula Grants for Rural Areas and Tribal Transit Program, ALN 20.509 - PTMS Security Management and Access Controls Management Views MDOT agrees with the finding. Planned Corrective Action MDOT?s Office of Enterprise Information Management (EIM) and Office of Passenger Transportation (OPT) will collaborate and provide oversight to ensure there is properly approved access for Public Transportation Management System (PTMS) users and that PTMS user access is reviewed semiannually for privileged accounts and/or annually for all other accounts. MDOT EIM and OPT will do this by reviewing security management and access control procedures and making any necessary updates, providing training on the process and documentation requirements, and designating a PTMS system security administrator(s) and back-up(s) as needed. Anticipated Completion Date August 1, 2023 Responsible Individual(s) Kyle Nelson, MDOT Andy Esch, MDOT OPT Business area system administrator(s)

View Audit 20093

Finding 24412 (2022-064)

None 2022

State of Michigan

MI

Special Tests & Provisions Questioned Costs Allowable Costs / Cost Principles

Finding 2022-064 Unemployment Insurance, ALN 17.225 See Department of Labor and Economic Opportunity, Unemployment Insurance Agency, Unemployment Compensation Fund, Report on Expenditure of Federal Awards, Year Ended September 30, 2022, Corrective Action Plan, Finding 2022-003.

View Audit 20093

Finding 24411 (2022-063)

None 2022

State of Michigan

MI

Special Tests & Provisions Questioned Costs

Finding 2022-063 Unemployment Insurance, ALN 17.225 See Department of Labor and Economic Opportunity, Unemployment Insurance Agency, Unemployment Compensation Fund, Report on Expenditure of Federal Awards, Year Ended September 30, 2022, Corrective Action Plan, Finding 2022-002.

View Audit 20093

Finding 24410 (2022-062)

Material Weakness 2022

State of Michigan

MI

Allowable Costs / Cost Principles Eligibility Questioned Costs

Finding 2022-062 Unemployment Insurance, ALN 17.225 See Department of Labor and Economic Opportunity, Unemployment Insurance Agency, Unemployment Compensation Fund, Report on Expenditure of Federal Awards, Year Ended September 30, 2022, Corrective Action Plan, Finding 2022-001.

View Audit 20093 Questioned Costs: $1

Finding 24396 (2022-001)

Significant Deficiency 2022

The Reed Institute

OR

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

The following corrective measures have been implemented: The Director of Financial Aid requests the amounts and number of students who received HEERF funding from the Business Office at the end of each quarter and reviews, confirms, and documents the date of request and review. A log of the website ...

The following corrective measures have been implemented: The Director of Financial Aid requests the amounts and number of students who received HEERF funding from the Business Office at the end of each quarter and reviews, confirms, and documents the date of request and review. A log of the website updates is maintained to document timely submission of data. The website was revamped to include all necessary reporting requirements including the number of eligible students for CRSSA HEERF II and ARP HEERF III. This updated process was implemented upon identification of the prior year finding, which occurred after the first quarterly report for fiscal year 2022 was posted.

View Audit 22802

Finding 24395 (2022-002)

Significant Deficiency 2022

Midland County Hospital District

TX

Allowable Costs / Cost Principles Questioned Costs Reporting

Midland County Hospital District Single Audit Report FY2022 Corrective Action Plan Finding 2022-002 - Management agrees with the finding. We have developed policies and procedures over financial reporting to ensure patient service revenue includes Medicaid supplemental payments in all lost revenue t...

Midland County Hospital District Single Audit Report FY2022 Corrective Action Plan Finding 2022-002 - Management agrees with the finding. We have developed policies and procedures over financial reporting to ensure patient service revenue includes Medicaid supplemental payments in all lost revenue that fall under the Federal assistance guidelines and ensure that total revenues are reconciled to the general ledger account balances and supporting information. net revenue was corrected for this issue dure the PRF Reporting Period #3 that was submitted September 29, 2022. Internal controls have been enacted and the Executive Director of Fiscal Services/Controller, Rebbecca Richey will be responsible to ensure all future periods will accurately reflect the lost revenues for the Hospital District. This corrective action plan was implemented on September 29, 2022.

View Audit 20105

Finding 24392 (2022-001)

Significant Deficiency 2022

City of Sierra Vista, Arizona

AZ

Questioned Costs Allowable Costs / Cost Principles Reporting § 200.303

Program Name/Assistance Listing Title: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Contact Person: David Felix, Chief Financial Officer Anticipated Completion Date: May 18, 2023 Planned Corrective Action: When the City received notification of the awa...

Program Name/Assistance Listing Title: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Contact Person: David Felix, Chief Financial Officer Anticipated Completion Date: May 18, 2023 Planned Corrective Action: When the City received notification of the award of CSLFRF funds, the CFO and City Attorney reviewed the law and, based on how it was written, felt that we could apply it to the Fire Department?s salary expenses as over 80% of their calls are for emergency medical services, they are the first responders to a 911 EMS call, and they usually transport the patients to the hospital. Neither in the initial law documentation, nor in the initial application, was there an option to select a $10M de minimus revenue loss option. If this was available, the City would have chosen that up front. We completed the interim report based on data created by inquiries run in our General Ledger on the date we submitted the report. We believed the data was saved on our system, but we can not find the electronic copy of it. As adjustments have been made to the data since then, we are unable to recreate a report that matches the data on the interim report. We can get within $800, but not the exact amount. Going forward, we will ensure the data is saved and put in a place that it is easier to retrieve.

View Audit 19937

Finding 24375 (2022-004)

Significant Deficiency 2022

Midway Public School District No. 128

ND

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

Contact Person Jill Blair Planned Corrective Action June 30, 2023 Planned Completion Date The Superintendent and business manager will work together to ensure all purchases match up with purchase orders and receipts.

View Audit 25109

Finding 24320 (2022-001)

Significant Deficiency 2022

Mountain Famly Health Centers

CO

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring

Consolidated Health Centers Grant ? Assistance Listing No. 93.24 and 93.527 Recommendation: Our auditors recommended the Organization review internal controls in regards to determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories ar...

Consolidated Health Centers Grant ? Assistance Listing No. 93.24 and 93.527 Recommendation: Our auditors recommended the Organization review internal controls in regards to determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized 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 has accepted the recommendations and has scheduled time at bi-weekly front desk/billing meetings to retrain staff on processes that ensure appropriate sliding fee rates are utilized for each sliding fee encounter. Specifically, training will focus on confirming fee schedules are updated on a timely basis per the effective date of the fee change, and encounters with both an office visit and procedures are properly identified so that the procedure co-pay is adjusted off in entirety, leaving only the office visit co-pay as the patient responsibility. Name(s) of the contact person(s) responsible for corrective action: Annette Franta, CFO Planned completion date for corrective action plan: Fiscal year 2023 If the U.S. Department of Health and Human Services has questions regarding this plan, please call Annette Franta, CFO at 970-945-2840.

View Audit 22121

Corrective Action Plans

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