Corrective Action Plans

Finding 480519 (2021-003)

Material Weakness 2021

Virginia Commonwealth University Health System

VA

Questioned Costs Reporting Matching / Level of Effort / Earmarking

Corrective action plan over control environment over lost revenue COVID – 19 – Provider Relief Funding (Assistance Listing #93.498) Recommendation: The Authority’s procedures for calculating lost revenues for the purposes of PRF reporting should be designed to ensure that audited year end numbers ar...

Corrective action plan over control environment over lost revenue COVID – 19 – Provider Relief Funding (Assistance Listing #93.498) Recommendation: The Authority’s procedures for calculating lost revenues for the purposes of PRF reporting should be designed to ensure that audited year end numbers are reported and/or tied back to amounts that are reported. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: As of July 2024, there is no further lost revenue reporting that is required to be reported. Management will implement more robust internal controls in preparation for similar future grant reporting. For lost revenues that have been submitted for PRF that do not tie back to an audited financial statement, a reconciliation will be completed and documented. Name(s) of the contact person(s) responsible for corrective action: Min Cummings, VP of Finance and Accounting, 703-629-8155 Planned completion date for corrective action plan: July 31, 2024 and going forward.

View Audit 316713

Finding 480517 (2021-001)

Material Weakness 2021

Virginia Commonwealth University Health System

VA

Reporting Questioned Costs Subrecipient Monitoring

Timely Preparation of Schedule of Expenditures of Federal Awards (SEFA) COVID – 19 – Coronavirus Relief Fund (Assistance Listing # 21.019); COVID – 19 – Provider Relief Fund (Assistance Listing #93.498) Recommendation: The Authority’s policy and procedure should be designed to ensure timely reportin...

Timely Preparation of Schedule of Expenditures of Federal Awards (SEFA) COVID – 19 – Coronavirus Relief Fund (Assistance Listing # 21.019); COVID – 19 – Provider Relief Fund (Assistance Listing #93.498) Recommendation: The Authority’s policy and procedure should be designed to ensure timely reporting as required by the Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Management will enhance its procedures around the preparation of the SEFA to include a timely year-end reconciliation between the general ledger and all source documentation to ensure that all Federal expenditures are complete and accurately reported in the SEFA in fiscal 2024. Name(s) of the contact person(s) responsible for corrective action: Min Cummings, VP of Finance and Accounting, 703-629-8155. Planned completion date for corrective action plan: For the creation of the Schedule for FY2023.

View Audit 316713

Finding 480062 (2021-005)

Material Weakness 2021

Cornerstones Inc, Cornerstones Housing Corporation & Rihc Partners, Lp

VA

Questioned Costs Eligibility Material Weakness

Cornerstones acknowledges that our files were incomplete. It is our position that the COVID-19 pandemic created immense need to which Cornerstones responded by expanding rapidly and mobilizing funding and program requests that did not receive the benefit of comprehensive planning; the focus was on h...

Cornerstones acknowledges that our files were incomplete. It is our position that the COVID-19 pandemic created immense need to which Cornerstones responded by expanding rapidly and mobilizing funding and program requests that did not receive the benefit of comprehensive planning; the focus was on health prevention, isolation and quarantine activities and temporary shelter for homeless and other low-income, vulnerable seniors and disabled persons. We served those in need and our intake processes and record keeping did not keep pace. Additionally, given the time that has passed since the services in question, it is possible that records that did exist were misplaced. Staff turnover, resulting from the pandemic burden, made it challenging to go back to the work that had been done. In the time since these events Cornerstones has further emphasized the compliance and documentation needs of the case management process, and we have filled turned-over positions with experienced staff that also understand intake and documentation requirements. We have also hired a Senior Director, Finance with over 20 years of federal contracts experience that is an integral part of increased program compliance and operational oversight responsibilities within the Finance/Operations function.

View Audit 316340

Finding 479733 (2021-008)

Material Weakness 2021

Cambria Heights School District

PA

Questioned Costs Procurement, Suspension & Debarment § 200.318 § 200.320

CONDITION: The Cambria Heights School District contracted with a third-party vendor (Trafera) for the purchase of technology equipment. The contract with Trafera was procured through a cooperative purchasing group (COSTARS). The District did not obtain an adequate number of price or rate quotations ...

CONDITION: The Cambria Heights School District contracted with a third-party vendor (Trafera) for the purchase of technology equipment. The contract with Trafera was procured through a cooperative purchasing group (COSTARS). The District did not obtain an adequate number of price or rate quotations for the technology equipment as required by the Uniform Guidance and 24 PS 8.807.1. CRITERIA: As specified in Section 2 CFR 200. 318(i) of the Uniform Guidance, the District must maintain records sufficient to detail the history of procurement. These records will include, but are not necessarily limited to, the following: rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. In addition, small purchase procedures per Section 2 CFR 200.320(a)(2)(i) for acquisitions between the micro-purchase threshold (currently $10,000) and the simplified acquisition threshold (current $250,000), price or rate quotations must be obtained from an adequate number of qualified sources as determined appropriate. Per 24 PS 8.807.1, there should be three quotes that are either written or well documented. The use of COSTARS only constitutes one quotation. RECOMMENDATION: I recommend that the School District update their policies to include those most recent related to ‘federal fiscal compliance’ in accordance with the Uniform Guidance, in particular, procurement policies to address the requirements of Section 2 CFR 200.318(i) and 2 CFR.320(a)(2)(i). In addition, I would recommend that District personnel responsible for expenditures related to federal funding receive updated training related to ‘procurement’ policies and procedures as they relate to federal funding. MANAGEMENT’S PLANNED CORRECTIVE ACTION: Management of the School District will review and update as necessary its ‘federal fiscal compliance policies’ to comply with the requirements of the Uniform Guidance. Particularly as it relates to procurement procedures to address the requirements of Section 2 CFR 200.318(i) and 2 CFR.320(a)(2)(i). In addition, management of the District will obtain training where available and applicable to enhance their internal controls over the management of federal program funds. The District’s timeframe for implementation is effective immediately.

View Audit 316302 Questioned Costs: $1

Finding 479732 (2021-007)

Material Weakness 2021

Cambria Heights School District

PA

Questioned Costs Procurement, Suspension & Debarment § 200.318 § 200.320

CONDITION: During my review of the District’s compliance with the requirements for noncompetitive procurement, I noted the District did not document its rationale for purchases made from ‘CJAWS, Inc.’ totaling $140,389. CRITERIA: In accordance with Section 2 CFR 200.318(i) of the Uniform Guidance, t...

CONDITION: During my review of the District’s compliance with the requirements for noncompetitive procurement, I noted the District did not document its rationale for purchases made from ‘CJAWS, Inc.’ totaling $140,389. CRITERIA: In accordance with Section 2 CFR 200.318(i) of the Uniform Guidance, the District must maintain records sufficient to detail the history of procurement. These records include but are not limited to the rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. Furthermore, Section 2 CFR 200.320(c’) of the Uniform Guidance details five (5) circumstances in which noncompetitive procurement can be used. RECOMMENDATION: I recommend that the School District update their policies to include those most recent related to ‘federal fiscal compliance’ in accordance with the Uniform Guidance, in particular, procurement policies to address the requirements of Section 2 CFR 200.318(i) and 320(c). In addition, I would recommend that District personnel responsible for expenditures related to federal funding receive updated training related to ‘procurement’ policies and procedures as they relate to federal funding. MANAGEMENT’S PLANNED CORRECTIVE ACTION: Management of the School District will review and update as necessary its ‘federal fiscal compliance policies’ to comply with the requirements of the Uniform Guidance. Particularly as it relates to procurement procedures, for acquisitions of property or services in which the aggregate dollar amount is greater than the micro-purchase threshold but does not exceed the simplified acquisition threshold, the District will obtain and document price or rate quotations from at least three qualified sources. In addition, management of the District will obtain training where available and applicable to enhance their internal controls over the management of federal program funds. The District’s timeframe for implementation is effective immediately.

View Audit 316302 Questioned Costs: $1

Finding 479729 (2021-006)

Material Weakness 2021

Cambria Heights School District

PA

Questioned Costs Matching / Level of Effort / Earmarking § 200.302

CONDITION: During my sample review of the District’s completion of its federal grant program ‘Quarterly Cash On Hand Reconciliations’ for the 3rd and 4th fiscal quarters for the GEER grant and the 4th fiscal quarter for the ESSER II grant, that the amounts reported to date for ‘total disbursements’ ...

CONDITION: During my sample review of the District’s completion of its federal grant program ‘Quarterly Cash On Hand Reconciliations’ for the 3rd and 4th fiscal quarters for the GEER grant and the 4th fiscal quarter for the ESSER II grant, that the amounts reported to date for ‘total disbursements’ could not be ascertained from the coding of these expenditures in the District’s general ledger (See Finding 2021-005) and did not reconcile to the separate spreadsheets maintained by the School District. CRITERIA: Section 2 CFR 200.302(a) and 302(b) of the Uniform Guidance requires non-federal organizations such as the School District to maintain financial records which account for federal funds in such a manner as to be able to properly track the identification and use of federal funds. RECOMMENDATION: I am recommending that the School District properly follow the guidance contained within the PA Office of the Budget, Office of Comptroller Operations Chart of Accounts for recording all expenditures of the School District, most specifically, federal program grant expenditures to comply with the recordkeeping requirements for federal funds as specified in Section 2 CFR Part 200.302(a) and 302(b) of the Uniform Guidance, to allow for the proper completion of the ‘quarterly cash on hand reconciliations’. MANAGEMENT’S CORRECTIVE ACTION PLAN: District management is in the process of revising its chart of accounts in the general ledger to properly reflect the funding source codes for federal program expenditures, and other available funding source codes (state and local) as applicable to the District. It is anticipated that the updated chart of accounts will be utilized by the District starting with the 2024-2025 fiscal year to enable the District to effectively access the necessary federal expenditure totals, by individual grant program, to document and support amounts reported as ‘total cash disbursed’ on the quarterly cash on hand reconciliations. This procedure will enable the District to comply with the recordkeeping requirements for federal funds as specified in Section 2 CFR Part 200.302(a) and 302(b) of the Uniform Guidance and PDE regulations.

View Audit 316302

Finding 479728 (2021-005)

Material Weakness 2021

Cambria Heights School District

PA

Questioned Costs Subrecipient Monitoring Reporting § 200.302

CONDITION: The District did not properly record its federal program expenditures for the GEER, ESSER, and ARP ESSER federal grant programs using the various federal funding source expenditure codes as prescribed by the Chart of Accounts for PA Local Educational Agencies maintained by the PA Office o...

CONDITION: The District did not properly record its federal program expenditures for the GEER, ESSER, and ARP ESSER federal grant programs using the various federal funding source expenditure codes as prescribed by the Chart of Accounts for PA Local Educational Agencies maintained by the PA Office of the Budget, Office of Comptroller Operations. CRITERIA: The Pennsylvania Department of Education (PDE), through the PA Office of the Budget, Office of Comptroller Operations Chart of Accounts requires School Districts to utilize specific funding source codes for federal program expenditures. In addition, Section 2 CFR 200.302(a) and 302(b) of the Uniform Guidance requires non-federal organizations such as the School District to maintain financial records which account for federal funds in such a manner as to be able to properly track the identification and use of federal funds. RECOMMENDATION: I am recommending that the School District properly follow the guidance contained within the PA Office of the Budget, Office of Comptroller Operations Chart of Accounts for recording all expenditures of the School District, most specifically, federal program grant expenditures to 1) enhance internal controls for tracking and monitoring federal program expenditures and 2) comply with the recordkeeping requirements for federal funds as specified in Section 2 CFR Part 200.302(a) and 302(b) of the Uniform Guidance and PDE regulations. MANAGEMENT’S CORRECTIVE ACTION PLAN: District management is in the process of revising its chart of accounts in the general ledger to properly reflect the funding source codes for federal program expenditures, and other available funding source codes (state and local) as applicable to the District. It is anticipated that the updated chart of accounts will be utilized by the District starting with the 2024-2025 fiscal year to enable the District to enhance its internal controls for tracking and monitoring federal program expenditures and to comply with the recordkeeping requirements for federal funds as specified in Section 2 CFR Part 200.302(a) and 302(b) of the Uniform Guidance and PDE regulations.

View Audit 316302

Finding 479197 (2021-004)

Significant Deficiency 2021

Mental Health Association of Columbia-Greene Counties Inc.

NY

Questioned Costs Procurement, Suspension & Debarment § 200.317 § 200.326

The administration will review the procurement policy in the next management meeting. Division Directors will review the procurement policy with all Program Directors and Managers. Also, see actions for 2021-003

View Audit 315733 Questioned Costs: $1

Finding 479193 (2021-003)

Significant Deficiency 2021

Mental Health Association of Columbia-Greene Counties Inc.

NY

Questioned Costs Period of Performance § 200.1 § 200.308 § 200.309 § 200.344

Invoices that are received will be scanned to “invoices”. This will direct them to our electronic software, Docuware. The item will then be forwarded to the appropriate Program Director for approval, and they will indicate the appropriate cost centers / allocations. Bookers will then review the ap...

Invoices that are received will be scanned to “invoices”. This will direct them to our electronic software, Docuware. The item will then be forwarded to the appropriate Program Director for approval, and they will indicate the appropriate cost centers / allocations. Bookers will then review the approved coding and entered fiscal software. If there is a question or concern about approved coding by the bookkeeper they will speak with Director of Finance, Ethan Terrio. Once invoices are entered into fiscal software, checks will be printed. The check stub and invoice will be attached to each other and filed in the fiscal department.Paper documents will continue to be maintained in fiscal until we go 100% paperless, then all documents will be stored in Docuware.

View Audit 315733 Questioned Costs: $1

Finding 479185 (2021-001)

Significant Deficiency 2021

Mental Health Association of Columbia-Greene Counties Inc.

NY

HUD Housing Programs Questioned Costs Special Tests & Provisions

The Division Director of Residential Services, Susie Cody, will obtain the rent reasonable checklists, a signed lease, and any other required forms when a new client is accepted into the program. Division Director, Susie Cody, will provide the Fiscal Director, Ethan Terrio, with a copy of the follo...

The Division Director of Residential Services, Susie Cody, will obtain the rent reasonable checklists, a signed lease, and any other required forms when a new client is accepted into the program. Division Director, Susie Cody, will provide the Fiscal Director, Ethan Terrio, with a copy of the following items when an apartment is brought online, there is some other change requiring the completion of these forms, or the first week of January each year: Lease, Rent Reasonableness. All forms for new apartments are to be supplied to Director of Finance prior to the issuing of any check forrent or security deposit without Executive Director approval. All forms will be scanned and placed in the resident’s electronic health record (AWARDS). The forms will also be scanned and kept in a shared finance folder.

View Audit 315733

Finding 479128 (2021-003)

Material Weakness 2021

Wyola School District No. 29

MT

Internal Control / Segregation of Duties Questioned Costs

The District is currently taking steps to provide adequate control over the payroll process. This includes the review of each payroll by the Superintendent and Financial Consultant. The newly hired Superintendent is overseeing all Human Resources functions at the District.

View Audit 315621 Questioned Costs: $1

Finding 478867 (2021-005)

Significant Deficiency 2021

Detroit Central City Cmh, Inc.

MI

Questioned Costs Program Income Subrecipient Monitoring § 200.307

FINDINGS - FEDERAL AWARDS Finding Number: 2021005 Finding Type: Significant Deficiency Condition: Program income was not used by DCCCMH to meet their matching requirements. DCCCMH reported allowable net program costs in excess of actual net allowable program costs of $15,569 and $3,446 for grants...

FINDINGS - FEDERAL AWARDS Finding Number: 2021005 Finding Type: Significant Deficiency Condition: Program income was not used by DCCCMH to meet their matching requirements. DCCCMH reported allowable net program costs in excess of actual net allowable program costs of $15,569 and $3,446 for grants M10071L5F011912 and Ml0439L5F011903, respectively. Management Response: Management acknowledges that program income generated from specific programs is to be used to cover net allowable program costs or to meet matching requirements. DCCCMH will implement measures to track program income for grant programs and will use program income to offset allowable program costs when preparing financial status reports. A final review of the use of program income will be performed by the Finance team before the annual audit commences. These measures will be incorporated into the updates to the financial policies and procedures for grant programs.

View Audit 315464 Questioned Costs: $1

Finding 478559 (2021-007)

Material Weakness 2021

City of Adelanto

CA

Questioned Costs Subrecipient Monitoring Reporting

Corrective action has been immediately implemented in response to the auditors' recommendation. As financial reporting is still in process of getting to current, the City anticipates findings to be reduced in future fiscal years.

View Audit 315185

Finding 478552 (2021-006)

Material Weakness 2021

City of Adelanto

CA

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.300 § 200.306 § 200.308 § 200.309 § 200.403

Corrective action has been immediately implemented in response to the auditors' recommendation. As financial reporting is still in process of getting to current, the City anticipates findings to be reduced in future fiscal years.

View Audit 315185 Questioned Costs: $1

Finding 478312 (2021-006)

Significant Deficiency 2021

City of Compton

CA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The City has other eligible costs that were not claimed for this grant that can be used to offset the questioned cost. Procedures are already in place to enhance payrate ...

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The City has other eligible costs that were not claimed for this grant that can be used to offset the questioned cost. Procedures are already in place to enhance payrate calculations in the future. Planned Implementation Date: Implemented as of April 2024 Responsible Person(s): City Controller

View Audit 314981 Questioned Costs: $1

Finding 406473 (2021-002)

Significant Deficiency 2021

Leech Lake Tribal College

AZ

Questioned Costs Reporting Significant Deficiency § 200.328

The College will ensure that all grant reports are reviewed in detail and information reported will be traced to the source reports by the reviewer. The College also implemented policies and procedures to ensure all grant reports are submitted prior to the due date.

View Audit 311635

Finding 406469 (2021-001)

Material Weakness 2021

Leech Lake Tribal College

AZ

Questioned Costs Material Weakness Reporting § 200.512

Management has implemented policies and procedures to ensure the timely submission of single audit reporting package.

View Audit 311635

Finding 404941 (2021-008)

None 2021

Clark County Fiscal Court

KY

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Questioned Costs § 200.303

County Judge/Executive’s Response: The Fiscal Court has contracted with Compass to ensure are compliant.

View Audit 311338

Finding 404940 (2021-007)

Material Weakness 2021

Clark County Fiscal Court

KY

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.303

County Judge/Executive’s Response: The Fiscal Court has contracted with Compass to ensure that expenses for Federal Reimbursement are eligible for reimbursement.

View Audit 311338 Questioned Costs: $1

Finding 403373 (2021-007)

Significant Deficiency 2021

First Choice Community Healthcare, Inc.

NM

Special Tests & Provisions Questioned Costs

2021-007— Special Tests and Provisions—Sliding Fee Discount Program Corrective Action: FCCH management shall ensure adherence to established policies and procedures requiring accurate patient billing, including application of eligible discounts. Person Responsible: Tammy Collins, Revenue Cycle Dire...

2021-007— Special Tests and Provisions—Sliding Fee Discount Program Corrective Action: FCCH management shall ensure adherence to established policies and procedures requiring accurate patient billing, including application of eligible discounts. Person Responsible: Tammy Collins, Revenue Cycle Director Completion Date: September 30, 2024

View Audit 310507

Finding 403372 (2021-006)

Material Weakness 2021

First Choice Community Healthcare, Inc.

NM

Allowable Costs / Cost Principles Equipment & Real Property Management Questioned Costs

2021-006—Allowable Costs Corrective Action: FCCH Management shall conduct training of human resource and accounting personnel to ensure they understand the requirement for allowable costs under 2 CFR Part 225 and shall follow the principles in 2 CFR Part 200, Subpart E. Current policies and procedu...

2021-006—Allowable Costs Corrective Action: FCCH Management shall conduct training of human resource and accounting personnel to ensure they understand the requirement for allowable costs under 2 CFR Part 225 and shall follow the principles in 2 CFR Part 200, Subpart E. Current policies and procedures shall be reviewed to ensure adequacy of measures to ensure compliance. FCCH leadership shall also be trained in the elements of allowable cost principles. Person Responsible: Shawna Gonzales, Chief Financial Officer and Abigail Jackson, Human Resources Director Completion Date: December 31, 2024

View Audit 310507 Questioned Costs: $1

Finding 402882 (2021-001)

Significant Deficiency 2021

Aldersgate United Methodist Retirement Community, Inc.

NC

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties

Department of Health and Human Services Aldersgate United Methodist Retirement Community, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2021. Audit period: January 1, 2021 through December 31, 2021 The finding from the schedule of findings and questio...

Department of Health and Human Services Aldersgate United Methodist Retirement Community, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2021. Audit period: January 1, 2021 through December 31, 2021 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS Department of Health and Human Services 2021-001 Provider Relief Funding – Assistance Listing No. 93.498 Recommendation: We recommend the organization adopt a formal policy in which the documentation of expenditures is maintained and all expenditures are compared against source documentation to ensure appropriate recording. A review of these expenditures should be formally documented. This review should be performed by someone other than the preparer of the information. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Aldersgate is implementing a formal document retention policy including digital and email documentation to ensure documentation of expenditures is maintained for the appropriate period of time. Aldersgate is also implementing a formal policy for reviews and approvals for all transactions to ensure the reviews and posting are performed by someone other than the person initiating the transaction. Last, Aldersgate is implementing internal control audits to ensure the practices are compliant with the new policies. Name(s) of the contact person(s) responsible for corrective action: Cherie Grisso, Chief Financial Officer Planned completion date for corrective action plan: 8/31/24 If the Department of Health and Human Services has questions regarding this plan, please call Cherie Grisso, Chief Financial Officer, at 704-532-5222.

View Audit 310112 Questioned Costs: $1

Finding 402820 (2021-001)

Significant Deficiency 2021

Brownfield Regional Medical Center

NM

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency § 200.303 § 200.403 § 200.430

Recommendation: The Auditor recommends that the Entity implement controls for documenting and retaining information on expenditures charged to federal awards to follow the requirements over 2 CFR Section 200.430(g)(i) and in addition the Entity is properly paying employees at the approved pay rate. ...

Recommendation: The Auditor recommends that the Entity implement controls for documenting and retaining information on expenditures charged to federal awards to follow the requirements over 2 CFR Section 200.430(g)(i) and in addition the Entity is properly paying employees at the approved pay rate. Action Taken: 1. Policy Revision and Development: o Develop or revise existing policies to clearly define the processes for documenting and retaining expenditure information related to federal awards. These policies should explicitly follow the requirements over 2 CFR Section 200.430(g)(i), ensuring that all expenditures are properly documented and justified as per federal award conditions. Specifically, approval of differential rates will be added to those policies. o Ensure that the policy includes guidelines for regularly reviewing employee pay rates against approved rates for compliance with federal award conditions. 2. Training and Awareness Programs: o Implement comprehensive training programs for all staff involved in charging costs to federal awards. This training should cover the importance of compliance with federal regulations, specifically focusing on the documentation and retention of expenditure information and adherence to approved pay rates. o Schedule regular refresher training sessions to ensure ongoing compliance and awareness. 3. Enhanced Monitoring and Audit Trails: o Introduce monitoring mechanisms to regularly review expenditures charged to federal awards for compliance with documented policies and federal requirements. o Develop an audit trail system that allows for the easy retrieval of documentation supporting expenditures and payroll compliance. This system should enable auditors to trace the documentation back to the federal award and the approved budget items. 4. Internal Control Improvements: o Review and strengthen internal controls related to the processing of expenditures and payroll to ensure that all transactions are authorized, recorded accurately, and in compliance with federal award requirements. o Implement segregation of duties where possible, to reduce the risk of errors or fraud in the charging of costs to federal awards. 5. Regular Compliance Reviews and Updates: o Conduct periodic internal reviews to assess compliance with federal award requirements and the effectiveness of the implemented corrective actions. o Ensure that any changes in federal regulations or award-specific requirements are promptly incorporated into the hospital's policies and training programs. 6. Documentation and Communication: o Maintain comprehensive records of all actions taken to address the audit findings, including policy revisions, training sessions, and internal review outcomes. Specifically, records for those these expenditures will remain onsite and not sent to long-term storage if the employee or vendor no longer has a relationship with the facilities. o Communicate regularly with federal awarding agencies to update them on the corrective actions taken and to seek guidance on compliance matters as needed. Implementation Timeline and Responsibility Assignment: • Management positions including the CEO, CFO and CNO for the 2021 fiscal year are no longer employed by Terry Memorial Hospital District. Administration employed in 2023 acknowledges these deficiencies and accepts responsibility for developing, applying and maintaining this corrective action plan going forward. • Assign specific responsibilities to designated staff members or departments for each component of the corrective action plan. • Set clear deadlines for the completion of each action item, with an initial goal to address all significant deficiencies within one to three months from the date of the audit report. Monitoring and Reporting: • Establish a mechanism for ongoing monitoring of the effectiveness of the corrective action plan, with periodic reports to senior management and the board of directors. Feedback Loop: • Create a feedback loop with employees and management to continuously improve internal controls and compliance processes based on practical experiences and challenges encountered during implementation. Responsible Person: Whitney Wilson, CFO

View Audit 310010 Questioned Costs: $1

Finding 402384 (2021-016)

Material Weakness 2021

State of California

CA

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

Of the 20 claimants the auditor determined to be ineligible for Lost Wages Assistance (LWA) benefits, 17 were Pandemic Unemployment Assistance (PUA) claimants disqualified due to identity issues discovered through the EDD’s new fraud enhancements outlined in the response to the finding for Reference...

Of the 20 claimants the auditor determined to be ineligible for Lost Wages Assistance (LWA) benefits, 17 were Pandemic Unemployment Assistance (PUA) claimants disqualified due to identity issues discovered through the EDD’s new fraud enhancements outlined in the response to the finding for Reference Number 2021-003. The other three claimants were receiving regular Unemployment Insurance (UI) benefits (one claimant) and Pandemic Emergency Unemployment Compensation (PEUC) benefits (two claimants). Those three claimants were paid pending the adjudication of potential eligibility issues, which were later found to be disqualifying. EDD has corrected both issues that resulted in the LWA payments being made to ineligible claimants. Regarding the issue of PUA claimants paid prior to the discovery of the potential identity issues, as outlined in the response to the finding for Reference Number 2021-003, during the years 2020 and 2021, the EDD implemented multiple new fraud prevention measures. Regarding the issue of the regular UI and PEUC claimants being paid prior to the adjudication of the potential eligibility issues, the EDD resumed adjudicating all potential eligibility issues as of January 2021 and will complete the remaining retroactive workload by April 30, 2023. Estimated Implementation Date: September 2020 (Fraud Enhancements) and January 2021 (Resumption of Adjudications) Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California Employment Development Department

View Audit 309913 Questioned Costs: $1

Finding 402380 (2021-015)

Significant Deficiency 2021

State of California

CA

Reporting Questioned Costs Special Tests & Provisions § 200.303

Health Care Services agrees with the recommendation. Effective September 1, 2021, System Development Notice (SDN) 20039 made updates to the Claims Processing Accounts Receivable System, requiring the Fiscal Intermediary (FI) to record the FFP rate including the Budget Program (i.e., Medicaid Assista...

Health Care Services agrees with the recommendation. Effective September 1, 2021, System Development Notice (SDN) 20039 made updates to the Claims Processing Accounts Receivable System, requiring the Fiscal Intermediary (FI) to record the FFP rate including the Budget Program (i.e., Medicaid Assistance Program vs. Children’s Health Insurance Program) for each overpayment account receivable set up after the effective date. The FFP rate and Budget Program information for each overpayment is provided on the Action Notices to the FI. The SDN also made updates to the California Omnibus Budget Reconciliation Act of 1985 (COBRA) system to enable the system to receive the FFP rate and Budget Program information for each overpayment set up by the FI and updated COBRA reports, thereby allowing Health Care Services to report the correct FFP rate for overpayments on the CMS-64 and CMS-21. Estimated Implementation Date: September 30, 2021 Contact: Wendy Griffe, Chief Internal Audits California Department of Health Care Services

View Audit 309913 Questioned Costs: $1

Corrective Action Plans

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