Corrective Action Plans

Finding 19840 (2022-002)

Material Weakness 2022

FL

Questioned Costs HUD Housing Programs Material Weakness

2022-002 ? HQS Enforcements Housing Choice Voucher Cluster ? Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend management should designate one person to oversee the inspection process to ensure that all inspections are being performed in a timely manner. Furthermore, management s...

2022-002 ? HQS Enforcements Housing Choice Voucher Cluster ? Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend management should designate one person to oversee the inspection process to ensure that all inspections are being performed in a timely manner. Furthermore, management should ensure no HAP payments are issued for units that have not passed HQS housing inspections. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The PBCHA acknowledges the continuing issues associated with this finding. The COVID-19 pandemic has placed unprecedented stress on companies across the country. The PBCHA was no exception. This stress negatively impacted the PBCHA?s management, workforce and operations which resulted in sudden changes in working arrangements, shortages due to workforce sickness, staffing vacancies and turnover all while dealing with increased housing demand due rising rental costs, and decreased housing supply and housing instability. Despite these challenges, the PBCHA remains strongly focused on continued and improved operations, increased compliance, and accountability. The PBCHA continues to utilize its third-party vendor to complete all HQS inspections. The PBCHA will also utilize the technology available to make its HQS inspections and enforcement process as efficient as possible. This includes improved functionality within its new software system, new guidelines, and handheld technology and RVI methods as appropriate. The PBCHA make decisions, develop strategies, implement policies/procedures, and utilize all available resources during this period of prevailing uncertainty and volatility. Any action taken to address the noted deficiency will be based on careful analysis, innovative thinking, restructuring, flexibility and/or revised strategies to adapt to everchanging business circumstances. Name(s) of the contact person(s) responsible for corrective action: Tyler Rasmussen, Carol Jones- Gilbert

View Audit 23451 Questioned Costs: $1

Finding 19718 (2022-062)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.1 § 200.410

Finding: The Health Care Authority did not have adequate internal controls over and did not comply with requirements to report recoveries of fraudulent overpayments on the CMS-64 report. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID-19 93.778 93.778 Amount $977,612 Stat...

Finding: The Health Care Authority did not have adequate internal controls over and did not comply with requirements to report recoveries of fraudulent overpayments on the CMS-64 report. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID-19 93.778 93.778 Amount $977,612 Status: Corrective action in progress Corrective Action: The Authority partially concurs with the finding. The Authority has established a process to ensure information concerning the status of Medicaid Fraud Control Unit (MFCU) cases is communicated timely to the Authority from the Attorney General?s Office. The Authority has documented the process to ensure recoveries of fraudulent overpayments are reported on the CMS-64 report appropriately and any federal share is returned timely to the Centers for Medicaid & Medicare Services (CMS). The Authority agrees that $1,032 needs to be repaid to CMS and will initiate return of those funds. The Authority does not concur that the remaining $976,580 needs to be returned to CMS. The state pursued assets through its available means and the court. The provider in question has been out of business since 2017 and a final court ruling was made in June 2022. In April 2023, the Attorney General?s Office certified the defaulted corporation had no identifiable assets. In accordance with 42 CFR 433.318(d), the provider is out of business and the Authority is not required to return the overpayment to CMS. The Authority will provide the court documentation and Attorney General?s certification to CMS Audit Resolution. The conditions noted in this finding were previously reported in findings 2021-052 and 2020-050. Completion Date: Estimated September 2023 Agency Contact: Kari Summerour, CPA External Audit Compliance Manager PO Box 45502 Olympia, WA 98504-5502 (360) 725-9586 Kari.Summerour@hca.wa.gov

View Audit 23129 Questioned Costs: $1

Finding 19712 (2022-056)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Finding: The Department of Social and Health Services, Developmental Disabilities Administration, did not have adequate internal controls over and did not comply with requirements to ensure Medicaid payments to supported living providers were allowable and adequately supported. Questioned Costs:...

Finding: The Department of Social and Health Services, Developmental Disabilities Administration, did not have adequate internal controls over and did not comply with requirements to ensure Medicaid payments to supported living providers were allowable and adequately supported. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID-19 93.778 93.778 COVID-19 Amount $237,404,150 Status: Corrective action not taken Corrective Action: The Department does not concur with the finding. The Department performed payment reconciliations, cost report reviews, and settlement assessments for all 140 cost reports received during the first half of fiscal year 2022 (July 1, 2021, through December 31, 2021). Of the cost reports received, 66 providers (47 percent) were subject to the Developmental Disabilities Administration (DDA) payroll verification review. The State Auditor?s Office (SAO) did not question any of the costs that were associated with the 66 providers. However, SAO is questioning all payments made to the 74 providers who did not receive a payroll verification review in the first half of the fiscal year. For the second half of the fiscal year (January 1, 2022, through June 30, 2022), even though the Department had the same internal controls in place, SAO asserted that every payment during this time frame was a questioned cost because the cost reports for calendar year 2022 had not yet been submitted for department review. The Department strongly disagrees that all these costs should be questioned. The Department reconciles payments on a calendar year basis, while SAO audits on a fiscal year basis and does not consider activities that fall outside of the audit period. The Developmental Disabilities Administration has numerous internal controls in place which provide sufficient assurance that the services paid for were provided. These include: ? Medicaid service verifications, ? Allowable costs payment reconciliations, ? Payroll verification processes, ? Review of rate payments and increases, ? Quality assurance reviews, ? Duplicate payment reports, ? Residential Care Services certification processes, ? Contract monitoring, ? Reconciliation processes for rates, cost reports, and settlements, ? Segregation of duties and other verification and approval processes. The Department strongly believes that its current oversight and monitoring procedures adequately confirm that services received by clients meet the certification standards for supported living providers. The Department continues its efforts to bring quality services to clients who receive habilitative residential support while following all program requirements, including reconciling the settlement amounts that were issued to providers in the cost report settlement process. Based on the information provided above, the Department maintains that the questioned costs for this audit finding are not substantiated. Unfortunately, SAO did not choose a more collaborative approach aimed at supporting the Department in its continuing quality improvement efforts. The Department continues to adjust its processes openly and appropriately as needed and remains open to partnering with SAO to resolve disagreements in this audit area and find common ground. The Department intends to send a request to the Centers for Medicare & Medicaid Services, through the audit resolution process, requesting the questioned costs reported by the SAO be rescinded. The conditions noted in this finding were previously reported in findings 2021-049, 2020-051, 2019-054, 2018-058, 2017-044, 2016-041, 2016-045, 2015-049, 2015-052, 2014-041, 2014-042, 2013-036, 2013-038 and 2012-039. The auditors determined findings 2016-041, 2015-052, 2014-041 and 2013-038 were resolved in fiscal year 2018. Completion Date: Not applicable Agency Contact: Richard Meyer External Audit Compliance Manager PO Box 45804 Olympia, WA 98504-5804 (360) 664-6027 Richard.Meyer@dshs.wa.gov

View Audit 23129 Questioned Costs: $1

Finding 19652 (2022-045)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with health and safety requirements for the Child Care and Development Fund program. Questioned Costs: Assistance Listing # 93.575 93.575 COVID-19 93.596 Amount $412 Sta...

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with health and safety requirements for the Child Care and Development Fund program. Questioned Costs: Assistance Listing # 93.575 93.575 COVID-19 93.596 Amount $412 Status: Corrective action in progress Corrective Action: The Department is strongly committed to ensuring the health, safety, and well-being of all children in care. The Department concurs with the finding and has taken the following actions: ? In September 2020, in response to the COVID-19 pandemic, the Department obtained grantor?s approval to revise the Child Care and Development Fund (CCDF) State Plan to waive the annual unannounced monitoring requirement and allowing for virtual monitoring, through September 30, 2021, but some providers were unable to participate in the virtual process resulting in monitoring visits not being conducted during state fiscal year 2022. ? In the fall of 2022, to address staff turnover issues, the Department began recruiting new staff and providing training on child care licensing rules and regulations. This included adding a new position in November 2022 to assist supervisors with onboarding and training new staff hired during the audit period. ? The Department implemented a data driven, phased in approach, to return staff to in-person field work after the COVID-19 pandemic: o In July 2022, began authorizing staff, subject to pandemic related restrictions, to visit providers on-site to provide assistance with meeting health and safety requirements. o In the spring of 2023, prioritized monitoring visits to return to compliance with CCDF health and safety requirements. ? Established an overpayment for the questioned costs and referred to the Office of Financial Recovery for collection. ? For license-exempt family, friend, and neighbor (FFN) providers, the Department: o Requested approval from the Office of Child Care for a hybrid monitoring approach (in-person and virtual visits). o Dedicated staff resources to update WA Compass to include all health and safety requirements for FFNs and address data format issues. The Department will continue to strengthen internal controls as follows: For licensed providers: ? Continue to implement return to in-person field work by reducing pandemic level requirements. ? Prioritize new staff training to first focus on monitoring visits and health and safety requirements. ? Continue to track and monitor health and safety requirements with available tools until all WA Compass system development is completed. ? Create an in-training licensing position to assist staff recruitment efforts and add additional lead worker positions to assist supervisors with training and caseload management. ? Conduct a root cause analysis to determine other underlying causes for missed monitoring visits and untimely follow-ups, and how to address them. ? Examine ways to secure resources to add additional full-time staff to support caseload needs. For FFN providers: ? Continue to track and monitor FFN health and safety requirements with available tools until all WA Compass system development is completed. The conditions noted in this finding were previously reported in findings 2021-039, 2020-042, 2019-039, 2018-035, 2017-025, 2016-022 and 2015-024. Completion Date: Estimated July 2024 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

View Audit 23129 Questioned Costs: $1

Finding 19648 (2022-041)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

Questioned Costs Matching / Level of Effort / Earmarking Subrecipient Monitoring

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with requirements to ensure payments to child care providers for the Child Care and Development Fund Cluster programs were allowable and properly supported. Questioned Costs: A...

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with requirements to ensure payments to child care providers for the Child Care and Development Fund Cluster programs were allowable and properly supported. Questioned Costs: Assistance Listing # 93.575 93.575 COVID-19 93.596 Amount $260,552,979 Status: Corrective action in progress Corrective Action: The Child Care and Development Fund (CCDF) program was previously managed by the Department of Social and Health Services and the Department of Early Learning. Since the program transitioned in 2019, the Department has been making efforts to strengthen internal controls over payments to child care providers and other CCDF grant requirements. The Department implemented grant-level management of all federal funds, including the CCDF grant. The Department allocated the CCDF grant to eligible clients and allowable activities in compliance with 45 CFR 98.67. For the fiscal year 2021 program audit, the State Auditor?s Office (SAO) issued a finding with $32 questioned costs for non-compliance with the CCDF eligibility requirement. No other findings, management letters, or exit items were reported in this compliance area or the cost allocation of funds based on eligibility. Given that eligibility or cost allocation has not been an area of concern, and transfers were processed between CCDF source of funds with the same eligibility criteria, the Department is assured that CCDF funding was spent appropriately within federal regulations. The Department is committed to improving internal controls. The Department does not currently have the resources to develop and maintain the business process redesign, as well as the information technology initiatives necessary to meet the level of assurance recommended by SAO. In response to prior year?s audit recommendations, the Department has submitted a budget request to the Legislature in the 2023-2025 biennial budget for additional resources to process adjustments to include transaction-level data. As part of the audit resolution process, the Department of Health and Human Services (HHS), which oversees the CCDF program at the federal level, reviews all SAO findings and issues management decision letters. The letters will reflect the grantor?s determination of whether an audit finding is sustained, the reasons for the decision, and the required actions by the auditee. When a management decision is issued for the fiscal year 2021 finding, the Department will work with HHS and follow the audit resolution process. The conditions noted in this finding were previously reported in findings 2021-033, 2020-038, 2019-035, 2018-034, 2017-024, 2016-021, 2015-023, 2014-023, 2013-016, 12-28, 11-23, 10-31, 9-12 and 8-13. Completion Date: Estimated December 2024 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

View Audit 23129 Questioned Costs: $1

Finding 19633 (2022-025)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

Finding: The Office of Superintendent of Public Instruction did not have adequate controls over and did not comply with requirements to ensure it met the earmarking requirements for the Special Education program. Questioned Costs: Assistance Listing # 84.027 84.027 COVID-19 84.173 Amount $18...

Finding: The Office of Superintendent of Public Instruction did not have adequate controls over and did not comply with requirements to ensure it met the earmarking requirements for the Special Education program. Questioned Costs: Assistance Listing # 84.027 84.027 COVID-19 84.173 Amount $188,873 Status: Corrective action complete Corrective Action: When the Special Education program underwent a fiscal leadership transition in 2021, the incoming director identified necessary changes in agency procedures for closing out the fiscal year for the program. Since that time, the Office has fully implemented internal controls to ensure spending plans do not exceed the maximum allowable amounts earmarked for administration and other state-level activities. The updated procedures require the director of Operations and the budget analyst to perform the following: ? Review criteria for spending plans at the beginning of the fiscal year. ? Review the Grant Award Notice and Grants to States Summary Table and Preschool Grants to States Summary Table. ? Review spending plans and update the maximum allowable amounts earmarked for administration and other state-level activities in the spending plan throughout the fiscal year. ? Meet weekly to review spending plans and update plans as requests are received. ? Review monthly expenditure reports during weekly meetings. These updated procedures have contributed to increased communication and partnership between the director of Operations and the budget analyst. These internal controls provide assurance that maximum allowable amounts earmarked for administration and other state-level activities will be in compliance with federal rules. The Office will consult with the federal grantor to discuss whether the questioned costs identified in the audit should be repaid. Completion Date: March 2023 Agency Contact: Tania May Assistant Superintendent, Special Education PO Box 47200 Olympia, WA 98504-7200 (360) 725-6075 tania.may@k12.wa.us

View Audit 23129 Questioned Costs: $1

Finding 19554 (2022-022)

None 2022

State of Washington C/o Office of Financial Management

WA

Student Financial Aid Allowable Costs / Cost Principles Questioned Costs § 200.1 § 200.410 § 200.516

Finding: Washington State University did not ensure that returns of Title IV funds were accurate for the Student Financial Assistance programs. Questioned Costs: Assistance Listing # 84.007 84.033 84.038 84.063 84.268 84.379 Amount $2,582 Status: Corrective action complete Corrective Act...

Finding: Washington State University did not ensure that returns of Title IV funds were accurate for the Student Financial Assistance programs. Questioned Costs: Assistance Listing # 84.007 84.033 84.038 84.063 84.268 84.379 Amount $2,582 Status: Corrective action complete Corrective Action: The University has improved processes for the return of Title IV funds. The University: ? Included a standard calculation in workbooks to quickly identify whether amounts to be returned for withdrawn students will exceed the amounts disbursed. ? Implemented a quality check to review these exceptions, and to investigate and correct as necessary. The University has returned all questioned costs to the sponsors. Completion Date: May 2023 Agency Contact: Heather Lopez Chief Audit Executive PO Box 641221 Pullman, WA 99164-1221 (509) 335-2001 hlopez@wsu.edu

View Audit 23129 Questioned Costs: $1

Finding 16702 (2022-004)

Significant Deficiency 2022

Grand Forks County

ND

Reporting Questioned Costs Significant Deficiency

2022-004 - Finding Condition We sampled 2 of 4 quarterly reports submitted that contained 2022 federal expenditures and tested for accuracy and to ensure the reports are submitted by their respective due dale. We noted one report had expenses listed not in the correct project when compared to the su...

2022-004 - Finding Condition We sampled 2 of 4 quarterly reports submitted that contained 2022 federal expenditures and tested for accuracy and to ensure the reports are submitted by their respective due dale. We noted one report had expenses listed not in the correct project when compared to the supporting documentation. These expenses were corrected in the next quarters' report, but we also noted another project had expenses overstated in the same report. We also noted that the County had corrected this overstatement by year end. Corrective Action Plan per Debbie Nelson, Auditor We agree. We will review the reporting requirements of the Coronavirus State and Local Fiscal Recovery Funds to ensure all costs and obligations for various projects, contracts, and expenditures are included in the appropriate sections of the report. Anticipated Completion Date Fiscal Year 2023

View Audit 21335

Finding 16700 (2022-001)

Significant Deficiency 2022

Beacon Senior Housing Corporation

CA

Questioned Costs Subrecipient Monitoring HUD Housing Programs

Name of auditee: Beacon Senior Housing Corporation HUD auditee identification number: 122-EE137 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended September 30, 2022 CAP prepared by Name: Mary Grace Crisostomo Position: Asset Manager Telephone number: (818) 247...

Name of auditee: Beacon Senior Housing Corporation HUD auditee identification number: 122-EE137 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended September 30, 2022 CAP prepared by Name: Mary Grace Crisostomo Position: Asset Manager Telephone number: (818) 247-0420 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Finding 2022-001: Comments on the Finding and Each Recommendation During the year ended September 30, 2022, management made duplicate withdrawals from the reserve for replacements account totaling $6,717. The reserve for replacements account was not reimbursed for these duplicate withdrawals. Management should transfer funds of $6,717 from the operating cash account to the reserve for replacements account. Action(s) taken or planned on the finding Management concurs with the finding and the auditor's recommendation. Management intends to transfer $6,717 from the operating cash account to the reserve for replacements account.

View Audit 21334 Questioned Costs: $1

Finding 16699 (2022-004)

Significant Deficiency 2022

Independent School District 480

MN

Questioned Costs Eligibility Reporting

Contact Person - Jason Vold, Superintendent Corrective Action Plan - The District will establish a policy and procedure over the submission and retention of all source documents used in filling out Impact Aid applications. Completion Date - Immediately

View Audit 21326

Finding 16626 (2022-001)

Significant Deficiency 2022

Wake Forest University

NC

Questioned Costs Cash Management Eligibility § 200.303

Finding No. 2022-001: Allowability Corrective Action Planned The Uninsured Testing and Treatment Program ended as of March 31, 2022. As a result, Wake Forest has not implemented additional controls beyond the increased frequency at which we review accounts that are HRSA eligible and the increased ed...

Finding No. 2022-001: Allowability Corrective Action Planned The Uninsured Testing and Treatment Program ended as of March 31, 2022. As a result, Wake Forest has not implemented additional controls beyond the increased frequency at which we review accounts that are HRSA eligible and the increased education for our Financial Counseling Unit and Cash Control staff and leadership. In order to ensure compliance with future programs of this nature, Wake Forest will establish the controls necessary to review and monitor each account and ensure compliance is met with the program requirements. Each control will then be tested to ensure operating effectiveness.

View Audit 22102 Questioned Costs: $1

Finding 16624 (2022-001)

None 2022

13west 103rd Street CORP

NY

Questioned Costs Cash Management HUD Housing Programs

13 West 103rd Street Corporation 290 Lenox, 3rd Floor New York, NY 10027 AUDITEE?S CORRECTIVE ACTION PLAN Name and Number of Project 13 West 103rd Street Corporation, FHA Project Number 012-HD006 Auditor/Audit Firm PKF O?Connor Davies LLP Audit Period June 30, 2022 Finding 2022-001 ? Timely De...

13 West 103rd Street Corporation 290 Lenox, 3rd Floor New York, NY 10027 AUDITEE?S CORRECTIVE ACTION PLAN Name and Number of Project 13 West 103rd Street Corporation, FHA Project Number 012-HD006 Auditor/Audit Firm PKF O?Connor Davies LLP Audit Period June 30, 2022 Finding 2022-001 ? Timely Deposit of Surplus Cash A. Comments on Finding and Recommendations Recommendation ? We recommend that management ensures the surplus cash deposit is done timely in the future. B. Actions Taken or Planned Auditee agrees with this finding. Our policy has been to make surplus cash deposits after the final audit has been issued. Going forward our focus will be to work with the auditor and owner to get the audits finalized earlier so adequate time is left for the deposits to be made. In instances where the final is not going to be issued and allow enough time, the deposit will be made based on the reviewed draft. C. Status of Corrective Action on Prior Findings No prior findings. Ezra Miller, CFO

View Audit 21282

Finding 16609 (2022-002)

None 2022

Highmark Health

PA

Questioned Costs Reporting

Management?s Views and Corrective Action Plan 2022-002: Incorrect lost revenue option selected for the HHS Portal submissions Department of Health and Human Resources ? Health Resources and Services Administration (?HRSA?) Program Name: COVID-19 Provider Relief Fund (?PRF?) Assistance Listing...

Management?s Views and Corrective Action Plan 2022-002: Incorrect lost revenue option selected for the HHS Portal submissions Department of Health and Human Resources ? Health Resources and Services Administration (?HRSA?) Program Name: COVID-19 Provider Relief Fund (?PRF?) Assistance Listing Number: 93.498 Federal Award Year: Reporting Period 4 Management?s Response Management agrees with the finding as it relates to the selection of the incorrect option (Option (i)) for the calculation of lost revenues for one Taxpayer Identification Number (TIN) entity within the Reporting Period 4 submission, as well as the incorrect response to the following question within the reporting portal: ?Did you acquire or divest subsidiaries that are ?eligible health care providers? during the period of availability of funds?? In 2021, the applicable TIN entity had less than a full year of operations. Although operations of the TIN ceased within 2021, management considered the actual revenues earned in 2021 within the Reporting Period 4?s period of availability to be appropriate for the lost revenue calculation per review and understanding of the reporting guidance, and therefore Option (i) was selected. The incorrect responses to the above noted reporting portal question was due to human error, and was not identified during the overall review prior to submission. To ensure accuracy and compliance with the reporting requirements, an additional level of detailed review of the portal submission will be added and required to be completed prior to final submissions. This review will include a comparison of the lost revenue option selected with the nature of the applicable TIN entity?s operations during the period of availability to ensure appropriateness of the selection with the guidance, as well as a detailed review of all responses to required questions within the reporting portal for accuracy. Anticipated Completion Date Reporting Period 5 is currently open, with a submission deadline of September 30, 2023. Management is currently in the process of completing this submission, with implementation of the additional review procedures discussed above included within the current submission process. Responsible Parties Matthew Bazzani, Chief Accounting Officer, Highmark Health

View Audit 22499

Finding 16550 (2022-002)

Material Weakness 2022

American Seed Trade Association

VA

Reporting Questioned Costs

Views of Responsible Officials and Planned Corrective Action Management is implementing new policies and procedures to ensure all federal program expenses are captured in the correct accounting period and is exploring how to modify its accounting software to better track federal program expenses. Wi...

Views of Responsible Officials and Planned Corrective Action Management is implementing new policies and procedures to ensure all federal program expenses are captured in the correct accounting period and is exploring how to modify its accounting software to better track federal program expenses. Will also coordinate with key employees to identify any payments not submitted at fiscal yearend. Responsible Party and Implementation Date: Ann Jorss, Chief Operation Officer, is the responsible party for implementing the corrective action and has implemented the recommendations herein as of November 15, 2022.

View Audit 21356

Finding 16549 (2022-004)

Material Weakness 2022

Madison Metropolitan School District

WI

Questioned Costs Procurement, Suspension & Debarment Cash Management

Views of Responsible Officials and Planned Corrective Actions: Upon reviewing our inventory records, schools had 98 devices in students' hands but not documented properly. The students had possession of the device, but the device was not checked out in inventory to the students. This has been resolv...

Views of Responsible Officials and Planned Corrective Actions: Upon reviewing our inventory records, schools had 98 devices in students' hands but not documented properly. The students had possession of the device, but the device was not checked out in inventory to the students. This has been resolved. Each Kindergarten classroom had 3 to 4 devices as spares across the 52 buildings. These were put in place to cover the enrollment of new students. When new students enrolled, they would have a device to use the same day. As we have discovered in ECF guidance, we cannot keep spares when using ECF funds for devices; we will immediately relocate the spares to students in other grade levels in need of a device so that each device is in a student?s hands for full use per ECF guidance.

View Audit 21329 Questioned Costs: $1

Finding 16546 (2022-001)

Significant Deficiency 2022

Swan Memorial Housing Association

WA

HUD Housing Programs Questioned Costs Procurement, Suspension & Debarment

Finding Reference Number #2022-001 Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and is in the process of funding the deficiency. Contact Person Responsible: Tom Anderson Anticipated Completion Date: December 31, 2022

View Audit 20458

Finding 16545 (2022-001)

None 2022

Green Mountain Support Services, Inc.

VT

Questioned Costs

2022 Corrective Action Plan Finding 2022-001 ? PRF Reporting Plan: We will review any future Provider Relief ...

2022 Corrective Action Plan Finding 2022-001 ? PRF Reporting Plan: We will review any future Provider Relief Funding reporting before submitting the report, to ensure all expenses have been properly included. The review will be completed by someone other than the person completing the report. Expected Implementation Date: January 1, 2023 Contact: (ARIS is a Contracted Business Service for GMSS) Shannon Burbela ARIS Solutions PO Box 4409 White River Junction, VT 05001 (802) 281-7830

View Audit 20456

Finding 16544 (2022-001)

Material Weakness 2022

Bonner General Hospital, Inc.

ID

Questioned Costs Material Weakness Reporting § 200.303

Finding 2022-001 Finding Summary: The Hospital excluded certain amounts from the amounts reported as "2021 actuals (Calendar Year)" patient care revenue within the Period 4 Department of Health and Human Services report submission process. Responsible Individuals: John Hennessy, CFO Corrective Acti...

Finding 2022-001 Finding Summary: The Hospital excluded certain amounts from the amounts reported as "2021 actuals (Calendar Year)" patient care revenue within the Period 4 Department of Health and Human Services report submission process. Responsible Individuals: John Hennessy, CFO Corrective Action Plan: The cause of the finding was due to management's review of the schedule did not identify that there was an adjustment to net patient revenue that was not incorporated within the 2021 actuals. Going forward, management will reconcile the internal generated financials used for quarterly reporting with the audited financials to ensure the schedule used includes all adjustments to net patient revenue. Anticipated Completion Date: September 28, 2023 Federal Agency Name: Department of Health and Human Services Program Name: COVJD-19 Provider Relief Funds and American Rescue Plan (ARP) Rural Distribution CFDA #93.498

View Audit 20452

Finding 16535 (2022-001)

Material Weakness 2022

City of Midland, Texas

TX

Questioned Costs Subrecipient Monitoring Reporting

Corrective Action Plan for Finding 2022-001 The City did not have adequate controls or procedures in place to identify the applicable reporting requirement and ensure the information was filed accurately and timely. Views of Responsible Officials and Planned Corrective Actions: Management agrees...

Corrective Action Plan for Finding 2022-001 The City did not have adequate controls or procedures in place to identify the applicable reporting requirement and ensure the information was filed accurately and timely. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding. Finance Department has implemented a new process that requires reports to be completed by the 15th of the following month. Reports from Community Development Manager are to be submitted to Comptroller for review and sign off to be reported timely by the report due date. Responsible Party: The Comptroller is responsible to follow-up and ensure report is completed. Implementation Date: March 15, 2023

View Audit 20427

Finding 16529 (2022-001)

Material Weakness 2022

Sea Mar Community Health Center and Subsidiaries

WA

Questioned Costs Special Tests & Provisions Material Weakness

Finding 2022-001 Sea Mar will retrain medical, dental and behavioral health department staff at all sites who conduct and/or oversee the patient registration and income verification process. This includes Health Center Administrators, Front Desk Supervisors, Dental Supervisors, Financial Specialist...

Finding 2022-001 Sea Mar will retrain medical, dental and behavioral health department staff at all sites who conduct and/or oversee the patient registration and income verification process. This includes Health Center Administrators, Front Desk Supervisors, Dental Supervisors, Financial Specialists and Receptionists. This training will be conducted via Relias (web-based training and testing). This training will be required for all staff including new hires to ensure compliance and consistency. A competency test will be administered after the training, which requires a score of I 00% to pass. If an employee does not pass the competency test, they will be retrained and will retake the test. We will track and run reports for all staff that are required to complete these tasks to ensure compliance. This log will demonstrate that staff at the sites were trained and have passed the competency test. Sea Mar will conduct an audit to determine the accuracy of income verifications. The audit will select a random sample of patients to test and verify accuracy and completeness. Sea Mar has set a goal to achieve accuracy percentage of 95%-100% and will conduct monthly audits to monitor accuracy and improvement. Sea Mar will also implement a process that will require supervisors to review and sign off on employee's income verifications to ensure they are accurate. Supervisors will be expected to ensure this process is being conducted accurately at their sites and to retrain staff who are not accurately verifying income. This review and sign off process will be verified during the quarterly audit. The quarterly audit will also identify sites and staff who need additional training. The contact person for the corrective action plan is Sea Mar's Chief Compliance Officer, Kristina Hoeschen, Kristina Hoeschen@seamarchc.org ,and the anticipated completion date of November 30, 2022.

View Audit 20416

Finding 16483 (2022-002)

None 2022

Homewood School District 153

IL

Reporting Questioned Costs § 200.512

Identifying Number: 2022-002 Finding: Late Issuance of the 2022 Single Audit Reporting Package The District?s fiscal year 2022 Single Audit package was not submitted to the Federal Audit Clearinghouse within the required time period. The Single Audit package for the District?s fiscal year ended J...

Identifying Number: 2022-002 Finding: Late Issuance of the 2022 Single Audit Reporting Package The District?s fiscal year 2022 Single Audit package was not submitted to the Federal Audit Clearinghouse within the required time period. The Single Audit package for the District?s fiscal year ended June 30, 2022 should have been submitted to the Federal Audit Clearinghouse by March 31, 2023. Corrective Action Taken or Planned: The District will schedule and complete future external audits in a manner that will allow timely reporting of the Single Audit. Anticipated Completion Date: June 2023 Responsible Person(s): John Gibson, Chief School Business Official

View Audit 20382

Finding 16395 (2022-001)

None 2022

St. George's Senior Housing, Inc.

TX

Questioned Costs HUD Housing Programs

CORRECTIVE ACTION PLAN Name and Number of the Project: St. George?s Senior Housing, Inc. No. 115-EH057 Audit Firm: M Group, LLP Audit Period: The year ended September 30, 2022 Compliance Review A. COMMENTS ON FINDINGS AND RECOMMENDATIONS We concur with the findings and recommendations of our au...

CORRECTIVE ACTION PLAN Name and Number of the Project: St. George?s Senior Housing, Inc. No. 115-EH057 Audit Firm: M Group, LLP Audit Period: The year ended September 30, 2022 Compliance Review A. COMMENTS ON FINDINGS AND RECOMMENDATIONS We concur with the findings and recommendations of our auditors regarding our noncompliance as cited in the accompanying Schedule of Findings and Questioned Costs. ACTIONS TAKEN

View Audit 23155 Questioned Costs: $1

Finding 16388 (2022-001)

None 2022

H.o.l.i.e. of Greenfield Avenue, Inc. - Valentino Square Apartments

WI

Questioned Costs HUD Housing Programs Reporting

Management increased the security deposit bank account by $500 on September 15, 2022 to correct this finding.

View Audit 19955

Finding 16323 (2022-004)

Material Weakness 2022

West Holt Memorial Hospital

NE

Special Tests & Provisions Questioned Costs Cash Management § 200.327 § 200.328

Criteria: The Hospital must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Hospital is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. 2 CFR 200.327 and 2 CF...

Criteria: The Hospital must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Hospital is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. 2 CFR 200.327 and 2 CFR 200.328 require the auditee to collect financial information and monitor its activities under federal awards to assure compliance with applicable federal requirements and performance expectations are being achieved and report these items in accordance with program requirements. Terms and conditions of the federal award require the Hospital to maintain a reserve fund at specified balance levels. Condition: During 2022, the accounts that represented the reserve fund had a balance below that required by the loan resolution agreements and required deposits were not being made to restore the balances to required levels. Planned Corrective Action: Management agrees with the finding and will deposit required amounts into the reserve fund. Planned Completion Date: Ongoing Person Responsible: Jeremy Bauer, CEO

View Audit 22832

Finding 16244 (2022-001)

Significant Deficiency 2022

Northkey Community Care

KY

Questioned Costs Allowable Costs / Cost Principles Reporting

Northern Kentucky Mental Health ? Mental Retardation Regional Board, Inc. agrees with the finding and will complete necessary training with program employees regarding organizations established and required procedures along with the necessity of these procedures and the additional importance due to ...

Northern Kentucky Mental Health ? Mental Retardation Regional Board, Inc. agrees with the finding and will complete necessary training with program employees regarding organizations established and required procedures along with the necessity of these procedures and the additional importance due to federal program requirements.

View Audit 22999

Corrective Action Plans

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