Corrective Action Plans

Finding 20676 (2022-004)

Significant Deficiency 2022

Lebanon Community Unit School District 9

IL

Questioned Costs

LEBANON COMMUNITY UNIT SCHOOL DISTRICT NO. 9 LEBANON, ILLINOIS CORRECTIVE ACTION PLAN FOR CURRENT YEAR AUDIT FINDINGS YEAR ENDING JUNE 30, 2022 Corrective Action Plan Finding No: 2022-004 Condition: The District failed to accurately record revenues and expenditures for a federal program (Eme...

LEBANON COMMUNITY UNIT SCHOOL DISTRICT NO. 9 LEBANON, ILLINOIS CORRECTIVE ACTION PLAN FOR CURRENT YEAR AUDIT FINDINGS YEAR ENDING JUNE 30, 2022 Corrective Action Plan Finding No: 2022-004 Condition: The District failed to accurately record revenues and expenditures for a federal program (Emergency Connectivity Fund) on its general ledger. Plan: See Management?s Response below. Anticipated Date of Completion: Fiscal Year 2023 Name of Contact Person: Patrick Keeney, Superintendent Management Response: The District will implement proper controls to ensure all federal grant revenues and expenditures are recorded on its general ledger.

View Audit 23924

Finding 20675 (2022-004)

Significant Deficiency 2022

Butler Health System and Subsidiaries

PA

Questioned Costs Reporting Internal Control / Segregation of Duties

Views of Responsible Officials and Planned Corrective Actions ? Management acknowledges errors were made regarding the submission of lost revenue amounts within the provider reporting submission and that these errors were administrative in nature. Management?s correction action plan includes implem...

Views of Responsible Officials and Planned Corrective Actions ? Management acknowledges errors were made regarding the submission of lost revenue amounts within the provider reporting submission and that these errors were administrative in nature. Management?s correction action plan includes implementing an additional level of review and scrutiny prior to finalizing submission. This level of review will include reviewing supporting documents and calculation to validate amounts entered are appropriate.

View Audit 23696

Finding 20674 (2022-003)

Material Weakness 2022

Butler Health System and Subsidiaries

PA

Allowable Costs / Cost Principles Questioned Costs Reporting

Views of Responsible Officials and Planned Corrective Actions ? Management acknowledges errors were made by contracted vendor for a subsidiary provider reporting submission. Management?s corrective action plan includes establishing appropriate review and approval process whereby the parent organiza...

Views of Responsible Officials and Planned Corrective Actions ? Management acknowledges errors were made by contracted vendor for a subsidiary provider reporting submission. Management?s corrective action plan includes establishing appropriate review and approval process whereby the parent organization is reviewing reporting submission of subsidiary organizations including those prepared by third-party vendors. In addition, future reporting submissions will be prepared with oversight by the parent organization to ensure corrections are made retroactive to the covered period of this audit.

View Audit 23696 Questioned Costs: $1

Finding 20660 (2022-003)

Significant Deficiency 2022

Sharon Joint #11 School District

WI

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties

Reference Number: 2022-003 Description: Federal #85.425 ? Education Stabilization Fund Corrective Action Plan: The District will ensure compliance with Federal Fund requirements by applying the requirements to contracts for which the District plans to use Federal Funds as well as contracts that mig...

Reference Number: 2022-003 Description: Federal #85.425 ? Education Stabilization Fund Corrective Action Plan: The District will ensure compliance with Federal Fund requirements by applying the requirements to contracts for which the District plans to use Federal Funds as well as contracts that might be used to claim Federal Funds. Anticipated Corrective Action Plan Completion Date: Ongoing. Contact Information: For additional information regarding this finding please contact Sara Andrus, District Administrator, at 262-736-4477.

View Audit 20590

Finding 20659 (2022-003)

Material Weakness 2022

Southern Mono Healthcare District Dba Mammoth Hospital

CA

Questioned Costs Material Weakness Reporting § 200.303

Finding 2022-003 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year ? Period 2 TIN #953154530 Federal Financial Assistance Listing #: #93.498 Finding Summa...

Finding 2022-003 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year ? Period 2 TIN #953154530 Federal Financial Assistance Listing #: #93.498 Finding Summary: The District incorrectly selected Option i as the reporting method when they submitted their report as the client had calculated the amount reported based on Option iii. Responsible Individuals: Melanie Van Winkle, CFO Corrective Action Plan: As mentioned above in Finding 2022-002 a policy was developed on October 14, 2022, and has been followed since that date. For the Provider Relief Fund reporting #4 Option iii was chosen in March 2023. Unfortunately, this finding and policy were after the Provider Relief Fund reporting #2 was submitted in March 2022. Anticipated Completion Date: The new policy was created in October 2022 and the correct selection of Option iii for PRF reporting #4 was completed in March 2023.

View Audit 20512

Finding 20645 (2022-003)

Significant Deficiency 2022

Rowan County, North Carolina

NC

Questioned Costs Reporting Significant Deficiency

Name of Contact Person: Toshia Kelly, Economic Services Quality Assurance Supervisor, 704-216-8374 Corrective Action/Management Response: The Department concurs with the finding of two quarterly reports being submitted after the due date. The responsibility for submitting quarterly reports will be t...

Name of Contact Person: Toshia Kelly, Economic Services Quality Assurance Supervisor, 704-216-8374 Corrective Action/Management Response: The Department concurs with the finding of two quarterly reports being submitted after the due date. The responsibility for submitting quarterly reports will be transferred to the Quality Assurance Supervisor and oversight will be provided by Deputy Director. Proposed Completion Date: Effective this date, 11-18-22

View Audit 28584

Finding 20636 (2022-002)

Material Weakness 2022

Rowan County, North Carolina

NC

Questioned Costs Special Tests & Provisions Material Weakness

Name of Contact Person: Billie Culp, Economic Services Program Manager, 704-216-8350 Corrective Action/Management Response: The Department concurs that no verification is available to support two applicants were denied assistance and received notice of denial and right to a hearing. All staff respon...

Name of Contact Person: Billie Culp, Economic Services Program Manager, 704-216-8350 Corrective Action/Management Response: The Department concurs that no verification is available to support two applicants were denied assistance and received notice of denial and right to a hearing. All staff responsible for working LIEAP applications will receive training that covers program specific information, income calculations, dictation requirements, notices and NCFAST procedures. Proposed Completion Date: November 28, 2022

View Audit 28584

Finding 20635 (2022-001)

Material Weakness 2022

Rowan County, North Carolina

NC

Questioned Costs Eligibility Material Weakness

Name of Contact Person: Billie Culp, Economic Services Program Manager, 704-216-8350 Corrective Action/Management Response: The Department concurs with the following finding: 1) Failure to properly determine income for five (5) applicants. 2) Failing to ensure the client?s signature was provided aut...

Name of Contact Person: Billie Culp, Economic Services Program Manager, 704-216-8350 Corrective Action/Management Response: The Department concurs with the following finding: 1) Failure to properly determine income for five (5) applicants. 2) Failing to ensure the client?s signature was provided authorizing the application. All staff responsible for working LIEAP applications will receive training that covers program specific information, income calculations, dictation requirements, notices and NCFAST procedures. Proposed Completion Date: November 28, 2022

View Audit 28584

Finding 20634 (2022-004)

Material Weakness 2022

Rowan County, North Carolina

NC

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

Name of Contact Person: Anna Bumgarner, Finance Director Corrective Action/Management Response: The County interpretation of the interim rule for premium pay was incorrect. The interpretation was not realized until the auditor?s preliminary work was completed for the FY22 audit. When this error in i...

Name of Contact Person: Anna Bumgarner, Finance Director Corrective Action/Management Response: The County interpretation of the interim rule for premium pay was incorrect. The interpretation was not realized until the auditor?s preliminary work was completed for the FY22 audit. When this error in interpretation was pointed out to the County the former Finance Director provided the needed response on the ARPA quarterly report. The response on the quarterly report has corrected the item and no additional action is needed. Proposed Completion Date: April 2022

View Audit 28584

Finding 20629 (2022-005)

Significant Deficiency 2022

Municipality of Coamo

PR

Questioned Costs Reporting Significant Deficiency

COMMONWEALTH OF PUERTO RICO MUNICIPALITY OF COAMO Corrective Action Plan For the Fiscal Year Ended June 30, 2022 _____________________________________________________________________________________________________________________ Audit Report: Reports on Compliance and Internal Control in Acc...

COMMONWEALTH OF PUERTO RICO MUNICIPALITY OF COAMO Corrective Action Plan For the Fiscal Year Ended June 30, 2022 _____________________________________________________________________________________________________________________ Audit Report: Reports on Compliance and Internal Control in Accordance with Government Auditing Standards and OMB Super Circular Uniform Guidance Audit Period: July 1, 2021 ? June 30, 2022 Fiscal Year: 2021-2022 Principal Executive: Hon. Juan C. Garcia Padilla, Mayor Contact Person: Mrs. Miraisa David Esparra, Finance and Budget Director Phone: (787) 825-1150 Original Finding Number: 2022-005 Statement of Concurrence or Non concurrence: We concur with the finding. Corrective Action: The fiscal year 2021-2022 Single Audit Report for Municipality of Coamo will be submitted through the Federal Audit Clearinghouse (FAC) no later than April 30, 2023. About the subsequent year Single Audit, we engaged the audit services on March 31, 2023, and we are going to engage the financial statements preparation consulting services on July 2023, in order to comply with fiscal year 2022-2023 Single Audit submission dateline. Implementation Date: April 30, 2023 Responsible Person: Mrs. Miraisa David Esparra Finance Department Director See Corrective Action Plan for chart/table

View Audit 27451

Finding 20627 (2022-003)

Significant Deficiency 2022

Municipality of Coamo

PR

Equipment & Real Property Management Questioned Costs Significant Deficiency

COMMONWEALTH OF PUERTO RICO MUNICIPALITY OF COAMO Corrective Action Plan For the Fiscal Year Ended June 30, 2022 _____________________________________________________________________________________________________________________ Audit Report: Reports on Compliance and Internal Control in Acc...

COMMONWEALTH OF PUERTO RICO MUNICIPALITY OF COAMO Corrective Action Plan For the Fiscal Year Ended June 30, 2022 _____________________________________________________________________________________________________________________ Audit Report: Reports on Compliance and Internal Control in Accordance with Government Auditing Standards and OMB Super Circular Uniform Guidance Audit Period: July 1, 2021 ? June 30, 2022 Fiscal Year: 2021-2022 Principal Executive: Hon. Juan C. Garcia Padilla, Mayor Contact Person: Mrs. Miraisa David Esparra, Finance and Budget Director Phone: (787) 825-1150 Original Finding Number: 2022-003 Corrective Action Statement of Concurrence or Non concurrence: We concur with the finding. Corrective Action: During the fiscal year 2021-2022 the Community Development Block Grants/State?s Program administered by the Municipality of Coamo expended $360,628. Of such total expended, $132,062 were related to capital expenditures; $21,749 for the installation of an elevator in a building whose construction is in progress, and $110,313 for municipal streets paving as specified in the approved proposal. But, as expressed in the corrective action related to Finding 2022-002, we are going to identify budgetary resources to engage another staff to work with the capital assets subsidiary ledger completeness. Implementation Date: During the Fiscal Year 2023-2024 Responsible Person: Mrs. Miraisa David Esparra Finance Department Director See Corrective Action Plan for chart/table

View Audit 27451

Finding 20622 (2022-001)

Material Weakness 2022

Butler County Community College

PA

Questioned Costs Reporting

The College concurs with Finding 2022-001 by our audit firm. In response to that finding the College has reviewed and accepted the recommendation by our audit firm as of December 1, 2022. As of September 2022, Butler County Community College has completed necessary programming changes to compile req...

The College concurs with Finding 2022-001 by our audit firm. In response to that finding the College has reviewed and accepted the recommendation by our audit firm as of December 1, 2022. As of September 2022, Butler County Community College has completed necessary programming changes to compile required reporting data for required reports. The most recent quarterly report as required by 2 CFR Part 200 was completed and it is posted prominently on our website. The College also has plans to complete spending of funds from the Education Stabilization fund prior to December 31, 2022 and will submit the final Annual report on time and close out this grant. The Controller for the College, Wm. Jake Friel, will be responsible for the compliance and along with Finance Office staff will complete the required reports and submit the reports to the website manager to post on the agreed website page.

View Audit 26584

Finding 20611 (2022-002)

Material Weakness 2022

Mahalo Homes, Inc.

MD

HUD Housing Programs Questioned Costs Cash Management

Recommendation: Training of staff should be performed to bring staff up to date with the implementation of all residual receipts compliance requirements. Action Taken: The Organization will pay down the residual receipts note in the amount previously approved by HUD. Otherwise it will appear that th...

Recommendation: Training of staff should be performed to bring staff up to date with the implementation of all residual receipts compliance requirements. Action Taken: The Organization will pay down the residual receipts note in the amount previously approved by HUD. Otherwise it will appear that they are holding excess residual receipts, which is not the case.

View Audit 20879 Questioned Costs: $1

Finding 20610 (2022-001)

Material Weakness 2022

Mahalo Homes, Inc.

MD

Questioned Costs HUD Housing Programs Reporting

Recommendation: In conjunction with Mahalo Homes, Inc. and their local HUD field office, it was determined that the related party should invoice the Organization for project expenses on a monthly basis. In turn, Mahalo Homes, Inc. should pay the invoice amount on a monthly basis. Action Taken: The a...

Recommendation: In conjunction with Mahalo Homes, Inc. and their local HUD field office, it was determined that the related party should invoice the Organization for project expenses on a monthly basis. In turn, Mahalo Homes, Inc. should pay the invoice amount on a monthly basis. Action Taken: The auditors have worked with the auditee to determine a course of action. All parties agreed with the recommendation to avoid unauthorized distributions.

View Audit 20879 Questioned Costs: $1

Finding 20609 (2022-002)

None 2022

Robeson County Housing Authority

NC

Questioned Costs HUD Housing Programs

2022-002: The files in question will be adjusted during the tenant?s annual recertification. The housing managers (along with internal audit team members) will attend yearly rent recalculation refresher courses and check for errors when recalculating rent. The internal audit team will conduct intern...

2022-002: The files in question will be adjusted during the tenant?s annual recertification. The housing managers (along with internal audit team members) will attend yearly rent recalculation refresher courses and check for errors when recalculating rent. The internal audit team will conduct internal tenant file reviews monthly. The Housing Director will discuss file management during monthly staff meetings. The Authority plans to implement these procedures effective January 1, 2023.

View Audit 19320 Questioned Costs: $1

Finding 20598 (2022-002)

Significant Deficiency 2022

Alliance for Community Empowerment, Inc.

CT

Questioned Costs Allowable Costs / Cost Principles

Head Start ? Assistance Listing No. 93.600 Recommendation: Alliance for Community Empowerment, Inc. should formalize review over employee coding and allocations to ensure that allocations are based on actual time and effort. Explanation of disagreement with audit finding: There is no disagreement wi...

Head Start ? Assistance Listing No. 93.600 Recommendation: Alliance for Community Empowerment, Inc. should formalize review over employee coding and allocations to ensure that allocations are based on actual time and effort. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The entry of all department coding will be reviewed by the Payment Coordinator by running a new hire report to ensure all new and returning employees are allocated to the proper department code. Name of the contact person responsible for corrective action: Indi Hayes Planned completion date for corrective action plan: 04/24/2023 If the Department of Health and Human Services has questions regarding this plan, please call Indi Hayes at 475.476.7440.

View Audit 20358 Questioned Costs: $1

Finding 20597 (2022-001)

Significant Deficiency 2022

Alliance for Community Empowerment, Inc.

CT

Questioned Costs Allowable Costs / Cost Principles Period of Performance

Head Start ? Assistance Listing No. 93.600 Community Services Block Grant ? Assistance Listing No. 93.569 Recommendation: We recommend Alliance for Community Empowerment, Inc. design controls to ensure an adequate review process is in place to review the period of costs incurred to ensure costs are ...

Head Start ? Assistance Listing No. 93.600 Community Services Block Grant ? Assistance Listing No. 93.569 Recommendation: We recommend Alliance for Community Empowerment, Inc. design controls to ensure an adequate review process is in place to review the period of costs incurred to ensure costs are charged to grants in the proper period. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All expenditures will be reviewed and recorded in the proper period of performance. The correction was put into place during the audit and all expenditures have been reviewed during entry and at the point of signature from the Finance Director. Name of the contact person responsible for corrective action: Indi Hayes Planned completion date for corrective action plan: 4/24/2023

View Audit 20358 Questioned Costs: $1

Finding 20583 (2022-002)

None 2022

Tuskegee University

AL

Questioned Costs Allowable Costs / Cost Principles § 200.430

Finding 2022-002 ? Allowable Cost/ Cost Principles Planned Corrective Action: In November 2022, the University removed all unallowable salary and related fringe benefits costs off the affected grants, returned funds to USDA through the ASAP drawdown process, and corrected the SEFA. Additionally, the...

Finding 2022-002 ? Allowable Cost/ Cost Principles Planned Corrective Action: In November 2022, the University removed all unallowable salary and related fringe benefits costs off the affected grants, returned funds to USDA through the ASAP drawdown process, and corrected the SEFA. Additionally, the Office of Human Resources (HR) and Office of Grants and Contracts (OGCA) have implemented and strengthen monthly review procedures for Personnel Action Forms. In January 2023, Human Resources granted the OGCA query and view access to the Person?s Pay Distribution Module for employees working on grants and contracts. This will allow the OGCA staff to compare the PAFs to HR and Payroll data and identify errors, if any, for correction. Upon receipt of PAFs in the OGCA, the following steps will occur: A. (1) Verify that the faculty and or staff can be specifically identified with the sponsored project; (2) Verified the position in the budget and/or have the prior written approval of the funding agency; (3) Compare the grant period to the personnel action form (PAF) start and end date; and (4) ensure that required approved signatures (Principal Investigator, Department Head and/or Dean) are present. C. Once the above conditions have been met, the Financial Analyst signs the PAF, forward to the Budget Officer and the VP for Business Affairs/CFO, for approval. The approved document is then submitted to the Office of the President and finally, Human Resources for review, approval, and compliance with university employment guidelines and policies. Once approved, HR enters the PAF into the Colleague System. An employment contract is generated as applicable. D. Monthly Review of the Grants General Ledger Summary Report (GLSA) and the General Ledger Trial Balance (GLTB) and or General Ledger Budget Status (GLBS) are completed by the Grants Financial Analysts. This monthly review is to verify that amounts charged are allowable and accurately posted to the correct departmental account and object codes. Payroll charges are compared to the PAFs. E. The OGCA, HR, and Payroll Offices collaborate on any discrepancies or errors and resolve immediately. Anticipated Date of Completion: Corrective action completed as of the date of this report. Person Responsible for Corrective Action Plan: Mr. Dexter Odom, Chief Financial Officer

View Audit 20254 Questioned Costs: $1

Finding 20569 (2022-001)

Material Weakness 2022

Icahn School of Medicine at Mount Sinai

NY

Matching / Level of Effort / Earmarking Special Tests & Provisions Questioned Costs § 200.303

Finding 2022-001 Special Tests and Provisions Information on the federal program: Grantor: Department of Education Program Name: Federal Direct Student Loans Assistance Listing No.: 84.268 Views of responsible officials and planned corrective actions: Management agrees with the finding described ab...

Finding 2022-001 Special Tests and Provisions Information on the federal program: Grantor: Department of Education Program Name: Federal Direct Student Loans Assistance Listing No.: 84.268 Views of responsible officials and planned corrective actions: Management agrees with the finding described above. The ISMMS Office of Student Financial Services has implemented a combined monthly reconciliation and drawdown process that identifies and resolves discrepancies, as required by the U.S. Department of Education?s Direct Loan reconciliation guidelines under 34 CFR 685.300(b)(5). The process will be detailed in the School?s procedure manual and staff will be trained accordingly. With this new process in place, we will be compliant with the U.S. Department of Education regulations. Name of responsible official: LaVerne Walker Director of Student Financial Services laverne.walker@mssm.edu Projected completion date: ? September 26, 2023: Completed implementation of combined monthly reconciliation and drawdown process ? December 31, 2023: Completed staff training sessions and revision to procedure manual

View Audit 28674

Finding 20566 (2022-001)

Significant Deficiency 2022

Johnnie B. Moore Towers, Inc.

GA

Questioned Costs HUD Housing Programs

Reportable Views of Responsible Officials: We agree that the Corporation overpaid the management fees, resulting in a receivable from HRC as of December 31, 2022. Management agrees that the fees were paid in excess of the amount allowed by the HUD approved management certification. Context: Not appl...

Reportable Views of Responsible Officials: We agree that the Corporation overpaid the management fees, resulting in a receivable from HRC as of December 31, 2022. Management agrees that the fees were paid in excess of the amount allowed by the HUD approved management certification. Context: Not applicable Recommendation: Management fee calculations should be consistent with terms agreed upon. Auditors? Summary of the Auditee?s Comments on the Findings and Recommendations: Agree with management's assessment. Response Indicator: Agree Completion Date: 12/31/2023

View Audit 28353 Questioned Costs: $1

Finding 20565 (2022-001)

Material Weakness 2022

Decatur Hospital Authority D/b/a Wise Health System and Affiliates

TX

Allowable Costs / Cost Principles Questioned Costs Reporting

Corrective Action Plan for Finding 2022-001 We are in receipt of the Findings Required to be Reported by Uniform Guidance, regarding questioned costs and material instance of noncompliance with respect to Activities Allowed/Unallowed and Allowable Costs/Cost Principles. Decatur Hospital Authority?s...

Corrective Action Plan for Finding 2022-001 We are in receipt of the Findings Required to be Reported by Uniform Guidance, regarding questioned costs and material instance of noncompliance with respect to Activities Allowed/Unallowed and Allowable Costs/Cost Principles. Decatur Hospital Authority?s Chief Financial Officer, Todd Scroggins, is responsible to oversee and implement the corrective action plan. In its Provider Relief period three and period four reporting submissions for the year ended December 31, 2022, the Authority?s reports included the activity of the Authority and their Nursing Home Facilities (Nursing Homes). The reported activity included other PRF expenses, nursing home infection control expenses and lost revenues. There are four separate nursing home management companies that provide services to the Authority?s seven Nursing Homes. There were approximately $358,571 in nursing home infection control expenses that were unable to be reconciled to eligible expenses for one of the Nursing Homes. The Authority provided the Nursing Homes with templates to use to provide the Authority with the necessary information for the reporting as the reporting was complete on the TIN of the Authority. The Authority relied on the accuracy of the information provided by the Nursing Homes. The Authority was not aware of the findings in the audit of period 1 and period 2 at the time the Authority submitted period 3 reporting. Therefore, the inaccurate reconciliation of eligible infection control expenses from period 2 was also used for reporting in period 3, which caused a recurrence in audit findings due to timing of audits and findings reported to the Authority. The Authority?s CFO will judgmentally perform detailed testing of reported costs and lost revenue from the Nursing homes in future reporting periods. In addition, the Authority?s CFO and management team will perform a detailed analysis of the reporting requirements in accordance with the final guidelines set by HRSA for future reporting periods. As deemed necessary, the Authority will modify the policies and procedures over federal grant reporting. The Authority?s CFO will oversee this to ensure that it is accomplished for future unreported periods as of this date. The corrective action plan will be implemented by December 31, 2023.

View Audit 27070 Questioned Costs: $1

Finding 20564 (2022-002)

Significant Deficiency 2022

Battle Creek Housing Commission

MI

HUD Housing Programs Questioned Costs Reporting

2022-002 Housing Choice Vouchers ? CFDA 14.871 Recommendation: The Commission should implement policies and procedures to ensure all proper reporting is completed per the grant requirements. Action Taken: Management will implement policies and procedures to ensure compliance with all reporting r...

2022-002 Housing Choice Vouchers ? CFDA 14.871 Recommendation: The Commission should implement policies and procedures to ensure all proper reporting is completed per the grant requirements. Action Taken: Management will implement policies and procedures to ensure compliance with all reporting requirements of the Housing Choice Voucher Grant. Anticipated Completion Date of Action: September 30, 2023

View Audit 26661

Finding 20562 (2022-001)

Material Weakness 2022

Battle Creek Housing Commission

MI

Questioned Costs Subrecipient Monitoring Material Weakness

Compliance with Laws and Regulations (Material Weakness) 2022-001 Public and Indian Housing ? CFDA 14.850 Recommendation: The Commission should require its financial institutions to provide documentation of collateral at a minimum on a quarterly basis. The Commission should also adopt policies a...

Compliance with Laws and Regulations (Material Weakness) 2022-001 Public and Indian Housing ? CFDA 14.850 Recommendation: The Commission should require its financial institutions to provide documentation of collateral at a minimum on a quarterly basis. The Commission should also adopt policies and procedures to monitor its cash and investments continuously to verify that the collateral provided by the financial institutions is adequate throughout the year. Action Taken: Management will implement a new process that will require the banks to provide proof of insurance coverage on a quarterly basis, at minimum. Anticipated Completion Date of Action: September 30, 2023

View Audit 26661 Questioned Costs: $1

Finding 20560 (2022-001)

Material Weakness 2022

The St. Luke's-Roosevelt Hospital Center and Affiliates

NY

Subrecipient Monitoring Eligibility Questioned Costs § 200.303

Current Year Audit Findings and Corrective Action Plan For the Year Ended December 31, 2022 Finding 2022-001 ? Eligibility Internal control deficiency over the reassessment requirement to determine eligibility Identification of the federal program: Assistance Listing Number 93.914 ? Program ...

Current Year Audit Findings and Corrective Action Plan For the Year Ended December 31, 2022 Finding 2022-001 ? Eligibility Internal control deficiency over the reassessment requirement to determine eligibility Identification of the federal program: Assistance Listing Number 93.914 ? Program Name: HIV Emergency Relief Project Grants ? Grantor: Department of Health and Human Services (HHS) ? Federal award identification number: Not Applicable Views of responsible officials and planned corrective actions: Management agrees with the finding. Management will develop internal controls to implement effective internal controls regarding 1) Review and retention of income and residency verification at program Intakes, and 2) Real time documentation of participants? income and residency eligibility at the required frequency (typically during 6 month Reassessments) with accepted supporting documentation for each participant. 3) This documentation will be entered into our EMR (EPIC) for each patient, outlining our eligibility verifications done at Intakes, Reassessments or Reassessment Attempts, along with screen shots from ePACES and/or other eligibility documents used. This will enable our program team and our funders and auditors to be able to more easily review our documented ongoing program eligibility for each patient. This will also improve our quality controls and will enable program staff to more effectively monitor annual eligibility checks. Contact person: Diane Tider Expected Completion Date: Implementing immediately 10/2/23

View Audit 26659

Finding 20550 (2022-002)

Significant Deficiency 2022

Salud Family Health

CO

Questioned Costs

Recommendation: Out auditors recommended the Corporation 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...

Recommendation: Out auditors recommended the Corporation 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 Corporation utilizes an external billing company. The external billing company has implemented an automated revision using robotics to ensure that sliding fee adjustments are made accurately according to the patients' sliding fee scale. Also, as required by HRSA, the Corporation records household income in our EMR for both sliding fee and non-sliding fee patients. Enrollment specialists process and record household income based on documentation supplied within a sliding fee application. Customer Service Associates record household income based on verbal representations for non-sliding fee patients. The issue involving not having a sliding fee application on file was caused by a Customer Service Associate incorrectly recording a verbal representation as a renewal of a sliding fee application. The Corporation will reinforce to all Customer Service Associates that renewal of sliding fee discounts must be performed by Enrollment Staff so that the income can be verified by documentation. Name(s) of the contact person(s) responsible for corrective action: Dave Madsen, CFO Planned completion date for corrective action plan: Has been implemented.

View Audit 18108

Corrective Action Plans

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