Corrective Action Plans

Finding 12175 (2022-002)

Significant Deficiency 2022

NE

Questioned Costs Allowable Costs / Cost Principles Cash Management

Corrective Action Plan: The organization is implementing new software for tracking client expense, which has functionality to import copies of credit card receipts and check requests into each client?s record. We have emphasized to case managers the importance of keeping receipts. Reasonable complet...

Corrective Action Plan: The organization is implementing new software for tracking client expense, which has functionality to import copies of credit card receipts and check requests into each client?s record. We have emphasized to case managers the importance of keeping receipts. Reasonable completion date: June 1, 2023 Responsible Party: Tanya DeWolf, Director of Refugee Services

View Audit 16282

Finding 12174 (2022-001)

Material Weakness 2022

Refugee Empowerment Center

NE

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.431

Corrective Action Plan: The organization has implemented a new payroll system, which includes time tracking. It has also changed its policy to pay overtime rather than accruing comp-time, as well as an implementing an unlimited PTO policy. These changes will eliminate charging grants for undocumente...

Corrective Action Plan: The organization has implemented a new payroll system, which includes time tracking. It has also changed its policy to pay overtime rather than accruing comp-time, as well as an implementing an unlimited PTO policy. These changes will eliminate charging grants for undocumented accrued time. Reasonable completion date: October 1, 2022 Responsible Party: Rick Rummel, Director of Finance & Administration

View Audit 16282 Questioned Costs: $1

Finding 12169 (2022-001)

None 2022

Frankenmuth School District

MI

Cash Management School Nutrition Programs Questioned Costs

Certain matters were brought to our attention as a result of the audit process. These are described more fully in the Schedule of Findings and Questioned Costs. We evaluated the matters noted below, and have described our planned actions as a result. 2022-001 - Program Income - Food Se...

Certain matters were brought to our attention as a result of the audit process. These are described more fully in the Schedule of Findings and Questioned Costs. We evaluated the matters noted below, and have described our planned actions as a result. 2022-001 - Program Income - Food Service Fund Balance Management Assessment - We concur with the audit assessment regarding this matter. Planned Corrective Action - The District is aware of the USDA fund balance requirements. The District operated under the Seamless Summer Option during fiscal year 2021-22 which allowed all of our students to eat both breakfast and lunch for free. The District received a large amount of federal funding which in turn resulted in more fund balance than allowed by USDA at 6/30/2022 ($5,466). The Food Service Director and Business Manager are in the process of creating a spenddown plan to be submitted to MDE which will move fund balance within an allowable range. Responsible Party - Business Manager Date of Planned Corrective Action - June 2023

View Audit 16273

Finding 12166 (2022-001)

Significant Deficiency 2022

Marana Health Center, INC

AZ

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties

Marana Health Center, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit Period: July 1, 2021 - June 30, 2022 Category: GENERAL MARANA HEALTH CENTER, INC. AD-2-010 Procedure: Sliding Fee Schedule Patient Demographic Changes Page 1 of 2 I. ...

Marana Health Center, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit Period: July 1, 2021 - June 30, 2022 Category: GENERAL MARANA HEALTH CENTER, INC. AD-2-010 Procedure: Sliding Fee Schedule Patient Demographic Changes Page 1 of 2 I. PURPOSE: The Sliding Fee Schedule (SFS) Patient Demographic Changes process was created to ensure any patient who is certified on MHC Healthcare's (MHC) SFS and has changes on their Patient Profile (Profile) to their Family Size and/or Income are referred to the Outreach Department (OR) and that these changes are only made by an OR employee or the OR Manager. II. PROCESSES: A. Front Office (FO) staff print Profiles from the Electronic Health Record (EHR) for all patient appointments, which allows patients to make required changes to their demographics on file. This includes Family Size and/or Income. When a patient on MHC's SFS notifies FO of changes to the aforementioned demographics, the patient must be referred to the MHC OR Department for further review. Only OR staff may make these demographic changes in the EHR for SFS Patients. Ill. PROCEDURES: A. FO staff will print a Profile for all patient appointments. 1. FO will ensure all patients review the Profile for required changes to their demographics in the EHR system. a. If the patient is on the SFS and notates any changes required on the Profile to be made to their Family Size and/or Income, the FO will: 1) Immediately notify the health center's assigned OR employee that a patient in the office for an appointment has required changes to these demographics. a) Notification can be made via telephone or a Teams message. b) If the site does not have an assigned OR employee, notification will be made to the OR Manager. 2) The OR employee will respond to FO: a) The patient is placed on the OR schedule for an immediate appointment while the patient is in the health center and available, either prior to or after the clinical visit, depending on allowable time. b) An appointment will be scheduled while the patient is in the health center for a later date to review changes and the possible affect these changes may have on the patient's SFS certification and/or SFS tier. c) The patient is contacted via telephone by the OR employee to schedule an appointment to review the possible changes to the patient's SFS certification and/or SFS tier. d) When scheduling the appointment, the patient may schedule it at the Health Center or choose to have this appointment via telehealth. 3) Only OR employees may change the Family Size and/or Income demographics in the EHR for SFS patients. a) FO will make all necessary demographic changes in the EHR, excluding Family Size and/or Income. b. FO will scan the Profile into the EHR and forward a copy to the appropriate OR employee. 2. The OR Manager will ensure that FO staff have a current list of OR employees, along with appropriate contact information and location. Category: GENERAL MARANA HEALTH CENTER, INC. AD-2-010 Procedure: Sliding Fee Schedule Patient Demographic Changes Page 2 of 2 3. The OR Manager will immediately communicate any deviations to this policy and procedure to the assigned Associate Director of Integrated Operations (ADIO) when noted. IV. REFERENCES: Sliding Fee Schedule V. ATTACHMENTS: None Approved: Original Approval: 09/2022 9/28/2022 Date 9/28/2022 Date Reviewed/Revised: Responsible Party: Director, Integrated Operations If the Department of Health and Human Services has questions regarding this plan, please call Tamie Olson, CFO at (520) 784-8655.

View Audit 16269

Finding 12150 (2022-001)

Significant Deficiency 2022

Richland Medical Center, Inc. D/b/a Central Ozarks Medical Center

MO

Questioned Costs Subrecipient Monitoring Eligibility

CORRECTIVE ACTION PLAN May 30, 2023 United States Department of Health and Human Services Richland Medical Center, Inc. d/b/a Central Ozarks Medical Center respectfully submits the following corrective action plan for the year ended November 30, 2022. CohnReznick LLP 350 Church Street Hartford, CT 0...

CORRECTIVE ACTION PLAN May 30, 2023 United States Department of Health and Human Services Richland Medical Center, Inc. d/b/a Central Ozarks Medical Center respectfully submits the following corrective action plan for the year ended November 30, 2022. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: November 30,2022 The findings from the November 30, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS SIGNIFICANT DEFICIENCIES Health Center Program Cluster, Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), COVID - 19 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), and Grants for New and Expanded Services under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 2022-001 Recommendation The Center should ensure that internal controls are in place to effectively ensure that patients receive the correct sliding fee discount. Action Taken In May 2022 COMC hired a Sliding Fee Coordinator. This position reviews all new slide fee applications to ensure all required documentation is present and that the correct slide scale has been applied. This position also reviews current slide applications for patients that are sacheduled for upcoming appointments to ensure paperwork is current or if paperwork is outdated a new application is received. This position also monitors and trains staff on the slide fee process. The finding from this year was prior to the position being filled in 2022. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Sabrina McAfee, CFO at (573) 836-7079. Sincerely yours, Sabrina McAfee Chief Financial Officer

View Audit 16226

Finding 12149 (2022-001)

Significant Deficiency 2022

Nutrition, INC

IN

Internal Control / Segregation of Duties Questioned Costs

Finding 2022-001 ? Financial Statement and Federal Awards Statement of Condition: Nutrition was not segregating duties of accounting and administrative responsibilities for internal control purposes. Status: Coming out of the pandemic impacted the ability to complete the segregation of duties proces...

Finding 2022-001 ? Financial Statement and Federal Awards Statement of Condition: Nutrition was not segregating duties of accounting and administrative responsibilities for internal control purposes. Status: Coming out of the pandemic impacted the ability to complete the segregation of duties process, due to the lack of staff. As a result, Nutrition is working to develop the processes that will help to implement the procedures that will segregate duties and will continue working with team members to implement processes to segregate duties moving forward. At this time, the development is on-going and will take place when the business growth warrants and supports such an action. Presently, adding additional staff to provide another layer of preparation, review, and monitoring would outweigh the costs.

View Audit 16224

Finding 12131 (2022-001)

Significant Deficiency 2022

Midwest Food Bank Nfp

IL

Questioned Costs Procurement, Suspension & Debarment § 200.318 § 200.327

2022-001: Procurement Requirements Criteria: The Organization is required to establish a procurement policy in accordance with Uniform Guidance requirements, as specified in the compliance supplement. Condition: The Organization did not establish a procurement policy in accordance with Uniform Guida...

2022-001: Procurement Requirements Criteria: The Organization is required to establish a procurement policy in accordance with Uniform Guidance requirements, as specified in the compliance supplement. Condition: The Organization did not establish a procurement policy in accordance with Uniform Guidance 2 CFR 200.318 ? 200.327, as required for the major program. The Organization developed and implemented a policy during 2022 but it was not in effect for the whole organization for the entire year. Questioned costs: None Cause and Effect: By not having an updated procurement policy the Organization could expense funds that are not in accordance with the procurement policies established by Uniform Guidance. Corrective Plan: Midwest Food Bank NFP established a procurement policy in accordance with Uniform Guidance in 2022 to be fully implemented across the Organization with an effective date of January 1, 2023, led by Lisa Martin, CFO.

View Audit 16212

Finding 12125 (2022-001)

Significant Deficiency 2022

Regent at Apple Valley, LLC Dba: the Seasons at Apple Valley

MN

Questioned Costs HUD Housing Programs

Management is required to retain the HUD approved management agreement to ensure payments made are in accordance with HUD requirements. The Project does not have a HUD approved management agreement. Recommendation: Recommend that management work with HUD to have the current management agreement appr...

Management is required to retain the HUD approved management agreement to ensure payments made are in accordance with HUD requirements. The Project does not have a HUD approved management agreement. Recommendation: Recommend that management work with HUD to have the current management agreement approved. There is no disagreement with the audit finding. Action taken in response to finding: We have contacted HUD to obtain an approved management agreement. Name of the contact person responsible for corrective action: Lisa Gindt Planned completion date for corrective action plan: May 2023 If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Lisa Gindt at 651-766-4368.

View Audit 16186

Finding 12124 (2022-002)

Significant Deficiency 2022

St. Francis County Housing Authority

AR

Questioned Costs HUD Housing Programs Cash Management

2022-002 Ineligible Expenditures Federal Program: Housing Choice Voucher Program, CFDA No. 14.871 Criteria: All payments must be eligible items under federal guidelines. Condition: During the fiscal year ending June 30, 2022 CARES Act funds were used to provide funds to the board members. E...

2022-002 Ineligible Expenditures Federal Program: Housing Choice Voucher Program, CFDA No. 14.871 Criteria: All payments must be eligible items under federal guidelines. Condition: During the fiscal year ending June 30, 2022 CARES Act funds were used to provide funds to the board members. Each board member was provided a check in the amount of $2,500. Two of the board members returned their check prior to cashing them once they found out it was not allowed. Questioned costs: $5,000. Effect: Payments were made that are not allowable under HUD of federal guidelines. Cause: PHA was not aware of the limitations in place for payments made to board members. Repeat Finding: This finding was reported in the prior audit as item 2021-002. Recommendation: Reimbursement for the payments should be made to the Housing Authority. Views of responsible officials and planned corrective actions: We have begun the process of reimbursing the amounts paid to the board members and will refrain from making these payments in the future.

View Audit 16182 Questioned Costs: $1

Finding 12122 (2022-002)

Significant Deficiency 2022

Quincy Area Network Against Domestic Abuse

IL

Subrecipient Monitoring Reporting Questioned Costs § 200.329

Finding 2022-002 Reporting ? The Executive Advocate (Tony Metz) will review newly signed con tracts for programmatic report requirements and enter the due dates into the tracking spreadsheet. ? Each staff member with responsi bility for completing reports will have access to the tracking spreadsheet...

Finding 2022-002 Reporting ? The Executive Advocate (Tony Metz) will review newly signed con tracts for programmatic report requirements and enter the due dates into the tracking spreadsheet. ? Each staff member with responsi bility for completing reports will have access to the tracking spreadsheet document. ? The Executive Advocate will remind the team member responsible for completing the report two weeks before the due date. ? The assigned staff member will complete the report, submit the report, and mark the submission date in the tracking spreadsheet. ? The Execu tive Advocate will be responsible for monitoring th e submission of reports and alerting the Chief Executive Officer prior to any missed deadlin es. This process will be reviewed by the Finance Committee and approved by the Quanada Board of Trustees as part of our Fiscal Policy document.

View Audit 16172

Finding 12119 (2022-001)

Significant Deficiency 2022

Cartwright Elementary School District No. 83

AZ

Questioned Costs Special Tests & Provisions Procurement, Suspension & Debarment

Finding Number: 2022-001 Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U Contact Person: Dr. Derek Etheridge Anticipated Completion Date: December 15, 2022 Planned Corrective Action: Recommendation: The District should review Fed...

Finding Number: 2022-001 Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U Contact Person: Dr. Derek Etheridge Anticipated Completion Date: December 15, 2022 Planned Corrective Action: Recommendation: The District should review Federal requirements over Davis Bacon. Planned Corrective Action: Members of the Cartwright School District Federal Programs Department and members of the Cartwright School District Business Services Department will attend training on the Education Department General Administrative Regulations (EDGAR), specifically as it relates to the use of Federal funds for the purpose of construction, including Davis Bacon. This training will be conducted by Brustein & Manasevit, Arizona Department of Education, or another expert in EDGAR policies and procedures. Recommendation: The District should develop policies and procedures [around Davis Bacon] and ensure those developed policies and procedures are implemented. Planned Corrective Action: In general, Federal funds will not be used for construction projects in the district, as construction is generally not allowed using Federal funding sources. However, in the rare event that Federal funds are used for construction projects, the following policies/procedures will be implemented: ? Before the school district enters into a contract for a construction project, the Director of Federal Programs will ensure the project is allowable under the appropriate Federal grant and will submit required documentation to request prior approval from the Arizona Department of Education. The District will not proceed with the planned construction project until the Arizona Department of Education provides approval. ? All construction contracts in which Federal funds will be used will contain language requiring prevailing wages. ? All construction contracts in which Federal funds will be used will contain language requiring the contractor and/or subcontractor to submit certified payroll records weekly to the Cartwright School District Director of Business Services. ? The Cartwright School District Director of Business Services will review the certified payroll records weekly to ensure prevailing wages are being paid by the contractor and/or subcontractor. Recommendation: The District should review the chart of accounts and ensure grant budget and expenditure amounts are recorded as prescribed in the chart of accounts. Planned Corrective Action: Members of the Cartwright School District Business Services Department will attend training on the Uniform System of Financial Records (USFR), specifically the section regarding the chart of accounts. This training will be conducted by Heinfeld & Meech, Arizona Association of School Business Officials, or another expert in the Uniform System of Financial Records? chart of accounts. The Director of Business Services will then present the information to all District administrators, including those in the Federal Programs Department. All requisitions will follow multiple approvals to provide the opportunity to review the account codes for accuracy. At a minimum, when utilizing Federal funds, approvals will include an administrator in Cartwright School District?s Federal Programs Department, the Cartwright School District Purchasing Department, and an administrator in Cartwright School District?s Business Services Department.

View Audit 16170

Finding 12118 (2022-001)

Material Weakness 2022

Vanderbilt University Medical Center

TN

Eligibility Questioned Costs Cash Management

Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.461, COVID 19 HRSA COVID 19 Claims Reimbursement for the Uninsured Program and the COVID 19 Coverage Assistance Fund Management agrees with this find...

Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.461, COVID 19 HRSA COVID 19 Claims Reimbursement for the Uninsured Program and the COVID 19 Coverage Assistance Fund Management agrees with this finding and performed a review of claims submitted to the HRSA COVID 19 Uninsured Program identifying payments for ineligible services and refunded the entire overpayment amount. In March 2022, HRSA announced the discontinuance of the HRSA COVID 19 Uninsured Program, and therefore, remediation of internal controls is no longer applicable. Paula Yarbrough, VUMC Director ? Grants and Contracts, will be responsible for implementation by fiscal year-end 2023.

View Audit 16159 Questioned Costs: $1

Finding 12117 (2022-003)

Material Weakness 2022

Vanderbilt University Medical Center

TN

Questioned Costs Reporting Matching / Level of Effort / Earmarking § 200.303

Federal Grantor: U.S. Department of Health and Human Services (HHS) Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498, COVID 19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution All expenditures included by VUMC Management (Management) in its sub...

Federal Grantor: U.S. Department of Health and Human Services (HHS) Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498, COVID 19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution All expenditures included by VUMC Management (Management) in its submissions in the Department of Health and Human Services (HHS) portal were verified against HHS guidance to ensure allowability. Management understands that additional audit evidence must be retained at a detailed enough level to allow the auditor to meet their reperformance standard. Management believes that our control risk is mitigated by the fact that our lost revenues far exceed any provider relief funding received. However, should management need to report any future eligible expenses in the HHS portal, we will retain additional audit evidence to enable auditor reperformance of the controls regarding allowability of expenditures. Management also established appropriate review and approval controls surrounding the performance and review of the lost revenue analytic and the subsequent reporting of lost revenue in the HHS portal. Management retained documentation to support execution of this control; however, Management understands that additional audit evidence supporting the reviews was not available to the auditor to evidence execution of this control. Management will retain additional audit evidence to allow the auditor to reperform execution of this control for future HHS portal submissions. Paula Yarbrough, VUMC Director ? Grants and Contracts, will be responsible for implementation by fiscal year-end 2023.

View Audit 16159

Finding 12114 (2022-001)

None 2022

Swedishamerican Health System Corporation

IL

Questioned Costs Reporting Internal Control / Segregation of Duties § 200.303

Corrective Action Plan For: SwedishAmerican Health System Finding number: 2022-001 Description of the finding: Amounts reported as eligible expenses in Reporting Period 2 were overstated by approximately $1,059,100. Corrective actions taken or planned: Lab expenses were erroneously duplicated d...

Corrective Action Plan For: SwedishAmerican Health System Finding number: 2022-001 Description of the finding: Amounts reported as eligible expenses in Reporting Period 2 were overstated by approximately $1,059,100. Corrective actions taken or planned: Lab expenses were erroneously duplicated due to using two sources for COVD-19 lab expenses ? 1) lab expenses internally charged to certain departments, and 2) a summary of lab expenses for all departments. This was discovered in April 2022, after Reporting Period 2 had closed on March 31, 2022. The reporting portal does not allow edits to a prior closed period; therefore, we assessed all received PRF funds against all uses of funds. Reporting Period 1 and 2 we only used expenses; however, we had lost revenue of approximately ($26,783,301) when comparing actual net revenues from April 1, 2020 to June, 30 2020, to the same period April 1, 2019 to June 30, 2019. When subtracting overstated lab expenses of $1,059,100 from Reporting Period 2, this leaves lost revenues of approximately ($25,724,223) to use in in future reporting periods. Reporting Period 3 and Reporting Period 4 we received funds of approximately $17,354,104 which is less than the remaining lost revenue of approximately ($25,724,223). Reporting Period 3 and Reporting Period 4 will only use lost revenues to justify the funds received. If we could correct reporting period 2 we would claim $1,059,100 against lost revenue and reduce the duplicated expense. However, if we receive funds for reporting periods after Reporting Period 4, we will deduct the excess expenses reported from lost revenues remaining to be claimed. Anticipated completion date: 4/18/2022 Person responsible for Corrective Action Plan: Patricia DeWane, CFO and Treasurer, (779) 696-4009 pdewane@uwhealth.org SwedishAmerican Health System, SwedishAmerican Hospital, DBA UW Health

View Audit 16158

Finding 11998 (2022-001)

Significant Deficiency 2022

Caap Housing, Inc. Dba Emma O. Johnson Homes 073-11685

IN

Questioned Costs HUD Housing Programs

Finding No. 2022-001- Federal Award Finding Statement of Condition: Security deposit liability account is underfunded at December 31, 2022. Criteria: HUD requires the security deposit cash account to be maintained in an amount equal to or greater than the security deposit liability on hand. The secu...

Finding No. 2022-001- Federal Award Finding Statement of Condition: Security deposit liability account is underfunded at December 31, 2022. Criteria: HUD requires the security deposit cash account to be maintained in an amount equal to or greater than the security deposit liability on hand. The security deposit account was underfunded by $9,505 during the year ended December 31, 2022. Effect: Security deposit liability account is underfunded. Cause: Funds from the security deposit cash account were transferred to the operating account to assist project cash flow throughout the year. Recommendation: Management should transfer funds back to the security deposit cash account to cover the shortfall. Management Response: Management agrees with the finding and will transfer the required funds back to the security deposit cash account.

View Audit 16083 Questioned Costs: $1

Finding 11965 (2022-001)

Material Weakness 2022

Mohawk Valley Community Action Agency, Inc.

NY

HUD Housing Programs Reporting Questioned Costs

Name of auditee: Village of New Hartford Section 8 Housing Assistance Payments Program (NY552) TIN: 16-0918009 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: January 1, 2022 - December 31, 2022 CAP prepared by: Amy Turner aturner@mvcaa.com Finding 2022-001 Village of New Hartfor...

Name of auditee: Village of New Hartford Section 8 Housing Assistance Payments Program (NY552) TIN: 16-0918009 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: January 1, 2022 - December 31, 2022 CAP prepared by: Amy Turner aturner@mvcaa.com Finding 2022-001 Village of New Hartford Section 8 Housing Assistance Payments Program (NY552)’s administering agency Mohawk Valley Community Action Agency, Inc., has implemented accounting procedures to ensure proper identification of federal expenditures and timely submission of the data collection form to the Federal Audit Clearinghouse.

View Audit 15948

Finding 11958 (2022-001)

Significant Deficiency 2022

Kent School District No. 415

WA

Subrecipient Monitoring Internal Control / Segregation of Duties Questioned Costs

Finding ref number: 2022-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with requirements for time-and-effort documentation. Name, address, and telephone of District contact person: Benjamin Rarick, Associate Superintendent of Finance 12033 SE 256th...

Finding ref number: 2022-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with requirements for time-and-effort documentation. Name, address, and telephone of District contact person: Benjamin Rarick, Associate Superintendent of Finance 12033 SE 256th Kent, WA 98031 Corrective action the auditee plans to take in response to the finding: The Grants Administrator, under the supervision of the Director of Budget, will do interim and year-end reviews to identify any instances of positions funded by multiple federal funding sources for the purpose of assessing applicability of multi-cost objective T&E requirements and following through as appropriate. The Grants Administrator, under the supervision of the Director of Budget, and in collaboration with the program administrator, will initiate time & effort documentation in every case where there is debatable fact pattern, with the intent of adopting an “abundance of caution” approach to T&E, and will additionally seek written clarification from OSPI and/or the ESD in instances where T&E requirements are not dispositive from the relevant federal compliance supplements and guidance documents. Anticipated date to complete the corrective action: October, 2024

View Audit 15931

Finding 11953 (2022-003)

Material Weakness 2022

Kent School District No. 415

WA

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring

Finding ref number: 2022-003 Finding caption: The District did not have adequate internal controls for ensuring compliance with allowable activities and costs, procurement, and restricted purpose requirements. Name, address, and telephone of District contact person: Benjamin Rarick, Associate Superi...

Finding ref number: 2022-003 Finding caption: The District did not have adequate internal controls for ensuring compliance with allowable activities and costs, procurement, and restricted purpose requirements. Name, address, and telephone of District contact person: Benjamin Rarick, Associate Superintendent of Finance 12033 SE 256th Kent, WA 98031 Corrective action the auditee plans to take in response to the finding: As of the date of this Report, the district has already made its final claims under the Electronic Connectivity Fund (ECF) Program. Accordingly, the district will await further guidance from the FCC and OSPI to understand what additional steps or corrective actions are necessary by KSD to ensure compliance. Anticipated date to complete the corrective action: October, 2024

View Audit 15931 Questioned Costs: $1

Finding 11890 (2022-002)

None 2022

U.s. Foundation of the University of the Valley of Guatemala

NJ

Questioned Costs Subrecipient Monitoring Reporting

Corrective Action Plan: The U.S. Foundation of the University of the Valley of Guatemala (the Organization) filed formal subaward agreements with the U.S. Agency for International Development Foreign Assistance to American Schools and Hospitals Abroad (ASHA) program via email to the Agreement Office...

Corrective Action Plan: The U.S. Foundation of the University of the Valley of Guatemala (the Organization) filed formal subaward agreements with the U.S. Agency for International Development Foreign Assistance to American Schools and Hospitals Abroad (ASHA) program via email to the Agreement Officer's Representative for the Organization, Raymond Jennings (Program and Award Management Team at ASHA) for the AID-ASHA-A-17-00009, 72AHSA19GR00010, and 72ASHA20GR00012 awards. Upon approval of the subaward agreements by ASHA, the Organization reported the subaward in accordance with the requirements of the FFATA by submitting the required information through the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) website. The Foundation acknowledges that this reporting was not done in a timely manner and we have revised our policies to ensure that future subawards are reported in a timely manner. In addition, the amount of the 72ASHA19GR00010 subaward was incorrectly reported as $900,000 when it should be reported as $1,100,000. This error will be corrected by the "Expected Completion Date" as noted. Expected Completion Date: June 30, 2023.

View Audit 15784

Finding 11850 (2022-002)

Significant Deficiency 2022

Grady Memorial Hospital Corporation

GA

Questioned Costs Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Grady’s corrective action plan: Grady Memorial Hospital Corporation will implement the control and process of completing an attestation assuring compliance with the review of the PRF data in the HRSA portal prior to submission. The review was completed online at the time of the submission but was no...

Grady’s corrective action plan: Grady Memorial Hospital Corporation will implement the control and process of completing an attestation assuring compliance with the review of the PRF data in the HRSA portal prior to submission. The review was completed online at the time of the submission but was not formally documented. This will be done and retained by Grady as support going forward

View Audit 15702

Finding 11819 (2022-001)

Significant Deficiency 2022

Neighborhood Healthsource

MN

Questioned Costs Reporting Significant Deficiency

Response: Completing the 2022 audit on a timely basis was compromised by the COVID pandemic and its effect on staffing that delayed the 2021 audit which then impacted the timing of completing the 2022 audit. This will not impact our ability to complete the 2023 audit timely. Responsible Party: Curt...

Response: Completing the 2022 audit on a timely basis was compromised by the COVID pandemic and its effect on staffing that delayed the 2021 audit which then impacted the timing of completing the 2022 audit. This will not impact our ability to complete the 2023 audit timely. Responsible Party: Curt Engels, Finance Director Estimated Completion: On-going

View Audit 15656

Finding 11779 (2022-002)

Material Weakness 2022

Inner City Health Center

CO

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring

2022-002 Federal Program: COVID-19: FY 2020 Health Center Program Look-Alikes: Expanding Capacity for Coronavirus Testing and COVID-19: American Rescue Plan Act Funding for Look-Alikes – Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization review its inter...

2022-002 Federal Program: COVID-19: FY 2020 Health Center Program Look-Alikes: Expanding Capacity for Coronavirus Testing and COVID-19: American Rescue Plan Act Funding for Look-Alikes – Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization review its internal controls in regards to the 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 will review our procedures for ensuring that sliding fee applications are completed accurately and are properly placed in patient files. We will also research and implement safeguards to ensure that the revised procedures are being followed throughout the year, potentially including audits and additional staff training. This will be performed by Andrea Cortez, Chief Operating Officer, Karina Villagrana, Practice Manager, and Andrew Shahidi, Chief Financial Officer in the next 45 days. If during this process we determine that an update, revision, or re-write of the current Sliding Fee Policy is required, we will do so and it will be submitted to the Board of Directors for approval at the March 27, 2024 meeting.

View Audit 15612

Finding 11771 (2022-004)

Significant Deficiency 2022

Family First Health Corporation

PA

Questioned Costs Reporting Significant Deficiency

Audit Finding Reference: 2022-004 Planned Corrective Action: Procedures will be put in place to review accuracy of reporting prior to submission. Completion Date: 3/31/2024 Accounting Name of Contact Person: Jenny Englerth, President/CEO; Brent Doores, CFO

View Audit 15598

Finding 11737 (2022-005)

Material Weakness 2022

Centro De Servicio A La Juventud, Inc.

PR

Questioned Costs Allowable Costs / Cost Principles

Statement of Condition: Cost resulting from non-Federal entity violations of alleged violations of, or failure to comply with, Federal, state, tribal, local or foreign laws and regulations are unallowable. Federal Tax lien provided by section 6321, 6322 and 6323 of the Internal Revenue Code, include...

Statement of Condition: Cost resulting from non-Federal entity violations of alleged violations of, or failure to comply with, Federal, state, tribal, local or foreign laws and regulations are unallowable. Federal Tax lien provided by section 6321, 6322 and 6323 of the Internal Revenue Code, include interest and penalties for Forms 990 and 941. Correction Action Planned for 2022-005 "Administrative Accountant" was hired who will perform the accounting at the Center, review the entries in the mechanized accounting system, and submit a financial statement to the Executive Director that will be discussed with the Board of Directors and any Other component that requires it. With these financial statements, this Accountant will work to submit any tax filing required by the Internal Revenue Service and Department of Treasury of Puerto Rico. Responsable Person: Jean Carlos García Rosa Anticipated Completion Date On or before the end of fiscal year 2022-2023

View Audit 15533 Questioned Costs: $1

Finding 11722 (2022-004)

Significant Deficiency 2022

Harrison County

OH

Eligibility Questioned Costs Reporting

Processes are being implemented.

View Audit 15529

Corrective Action Plans

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