Corrective Action Plans

Finding 479722 (2023-001)

Significant Deficiency 2023

Northwest Colorado Council of Governments

CO

Reporting Allowable Costs / Cost Principles Significant Deficiency § 200.502

Community Development Block Grants – Assistance Listing No. 14.228 Recommendation: We recommend that the Council record federal expenditures on the SEFA under the program in the year upon which the loan disbursement occurs using the proper report from NLF’s loan management software. Explanation of d...

Community Development Block Grants – Assistance Listing No. 14.228 Recommendation: We recommend that the Council record federal expenditures on the SEFA under the program in the year upon which the loan disbursement occurs using the proper report from NLF’s loan management software. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Fiscal Office will work with the Program Director to ensure the proper report is used to identify actual loan disbursements, rather than agreed upon loan amounts, if different, for future SEFA preparation. Name(s) of the contact person(s) responsible for corrective action: Anita Cameron, NLF Director and Becky Walter, Finance Director Planned completion date for corrective action plan: December 31, 2024

View Audit 316294

Finding 479715 (2023-002)

Significant Deficiency 2023

City of Kearney, Nebraska

NE

Internal Control / Segregation of Duties Reporting Significant Deficiency

The City council closely monitors all accounting functions and is aware of the limited number of personnel in the Finance Office and the distribution of duties.

View Audit 316282

Finding 479710 (2023-002)

Material Weakness 2023

Harvest Regional Food Bank, Inc.

AR

Special Tests & Provisions Material Weakness Reporting

All federal food commodities received will be entered into the SMF QuickBooks system and reported to the Arkansas Department of Education (ADE) within 48 hours of delivery by the Operations Manager or his assistant. All federal food receipts will be verified by a secondary employee monthly to ensure...

All federal food commodities received will be entered into the SMF QuickBooks system and reported to the Arkansas Department of Education (ADE) within 48 hours of delivery by the Operations Manager or his assistant. All federal food receipts will be verified by a secondary employee monthly to ensure ADE has received and properly processed the submission into their system. Any discrepancies will be discussed and corrected as necessary. Harvest will perform an inventory count quarterly and adjust inventory amounts as needed in the SMF QuickBooks system.

View Audit 316274

Finding 479707 (2023-006)

Significant Deficiency 2023

United Way of West Florida, INC

FL

Allowable Costs / Cost Principles Reporting

Month-end and Year-end processes are being updated and streamlined to ensure timely closing. We have requested to be added to the auditor’s schedule earlier this year. Many of the reports required for a single audit are now established and can easily be completed for the next audit.

View Audit 316262

Finding 479706 (2023-005)

Significant Deficiency 2023

United Way of West Florida, INC

FL

Reporting Subrecipient Monitoring Allowable Costs / Cost Principles

Procedures have been established to run program financial statements to monitor spending monthly. Form 1037 is being added to the comprehensive year-end checklist to ensure that the reports are completed in time.

View Audit 316262

Finding 479705 (2023-002)

Significant Deficiency 2023

Allegany County, Maryland

MD

Allowable Costs / Cost Principles HUD Housing Programs Reporting

Allegany County has developed an improved procedure to ensure financial reports are submitted within the due date. Plan includes discussions with department heads in order to better improve and understand the complex reporting process that is required by the funding agency.

View Audit 316261

Finding 479698 (2023-001)

Significant Deficiency 2023

National Restaurant Association Educational Foundation

DC

Reporting § 200.303

Finding 2023-001: Late Reporting Submission Finding: The Foundation did not submit the four quarterly reports within the required timeframe. Cause: The Foundation did not have an effective control in place to ensure the quarterly reports were submitted timely. Reports were reviewed prior to submi...

Finding 2023-001: Late Reporting Submission Finding: The Foundation did not submit the four quarterly reports within the required timeframe. Cause: The Foundation did not have an effective control in place to ensure the quarterly reports were submitted timely. Reports were reviewed prior to submission but were submitted 1-2 days late. Corrective Actions Taken or Planned: As part of the quarterly report submission process, the Foundation has added a step to help ensure that the quarterly reports will be submitted within the required timeframe, 45 days after the end of each quarter. Contact Person Responsible: Jill A. Noble Anticipated Completion Date: Completed on May 15, 2024

View Audit 316238

Finding 479691 (2023-002)

Material Weakness 2023

Family Life Center, Inc.

AL

Reporting Internal Control / Segregation of Duties

The Organization had a complex acquisition transaction that was not recorded correctly. This type of transaction is not common to the organization and additional information was obtained from the auditor to determine the correct accounting. Management will implement policies to insure that these t...

The Organization had a complex acquisition transaction that was not recorded correctly. This type of transaction is not common to the organization and additional information was obtained from the auditor to determine the correct accounting. Management will implement policies to insure that these types of transactions are reviewed and recorded correctly on a more timely basis in the future.

View Audit 316236

Finding 479690 (2023-001)

Material Weakness 2023

Family Life Center, Inc.

AL

Internal Control / Segregation of Duties Reporting Subrecipient Monitoring

Management has issued written policies and required training of all employees that handle financial transactions and will continually evaluate processes to find ways to segregate duties where possible. Management and the board of directors will continue to oversee operations closely requiring appro...

Management has issued written policies and required training of all employees that handle financial transactions and will continually evaluate processes to find ways to segregate duties where possible. Management and the board of directors will continue to oversee operations closely requiring approvals for all transactions.

View Audit 316236

Finding 479673 (2023-006)

None 2023

Universal Academy Charter School

MN

Reporting § 200.512

REPORTABLE NONCOMPLIANCE WITH FEDERAL REPORTING REQUIREMENTS – ALL FEDERAL PROGRAMS AWARDED UNDER THE UNIFORM GUIDANCE 2023-006 Federal Reporting Deadline Finding Summary 2 CFR Part 200, Subpart F, § 200.512(a)(1) requires the Academy’s audited SEFA and federal reporting package to be submitted ...

REPORTABLE NONCOMPLIANCE WITH FEDERAL REPORTING REQUIREMENTS – ALL FEDERAL PROGRAMS AWARDED UNDER THE UNIFORM GUIDANCE 2023-006 Federal Reporting Deadline Finding Summary 2 CFR Part 200, Subpart F, § 200.512(a)(1) requires the Academy’s audited SEFA and federal reporting package to be submitted to the federal audit clearinghouse within the earlier of 30 calendar days after the receipt of the auditor’s report(s), or 9 months after the end of the audit period. The Academy’s audited SEFA and federal reporting package for the fiscal year ended June 30, 2023, were not submitted to the federal audit clearinghouse within 9 months after the end of the audit period. Corrective Action Plan Actions Planned – The audit of the Academy’s SEFA for the year ended June 30, 2023 was not completed within the nine-month reporting period. The completion of the Academy’s audited annual financial statements for the year ended June 30, 2023, which is a required component of the federal reporting package, was delayed beyond the 9 month deadline pending obtaining sufficient audit evidence. Academy management will ensure that all information required to comply with federal reporting requirements will be completed and submitted in a timely manner going forward. Official Responsible – The Academy’s Executive Director, Farhiya Einte. Planned Completion Date – June 30, 2024. Disagreement With or Explanation of Finding – The Academy agrees with this finding. Plan to Monitor – The Academy’s Executive Director, Farhiya Einte, will monitor the year-end financial closing and reporting process to ensure all federal and state reporting requirements are complied with in the future.

View Audit 316231

Finding 479661 (2023-005)

Material Weakness 2023

Universal Academy Charter School

MN

Reporting Internal Control / Segregation of Duties § 200.502 § 200.510

MATERIAL WEAKNESS IN INTERNAL CONTROL OVER COMPLIANCE – SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS 2023-005 Reporting Compliance Requirement Finding Summary 2 CFR § 200.510 requires that the Academy prepare appropriate financial statements, including the Schedule of Expenditures of Federal Awar...

MATERIAL WEAKNESS IN INTERNAL CONTROL OVER COMPLIANCE – SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS 2023-005 Reporting Compliance Requirement Finding Summary 2 CFR § 200.510 requires that the Academy prepare appropriate financial statements, including the Schedule of Expenditures of Federal Awards (SEFA) for the year ended June 30, 2023, which must include the total federal awards expended as determined in accordance with 2 CFR § 200.502. Management is responsible for establishing and maintaining effective internal controls over compliance with requirements applicable to federal programs, including separately tracking federal expenditures within the finance system to provide for accurate preparation of the SEFA. During our audit, we noted the Academy did not have sufficient controls in place to ensure completeness of the SEFA and compliance with this requirement. The Academy’s SEFA was understated by $158,815 in federal expenditures related to the Emergency Connectivity Fund federal program. Corrective Action Plan Actions Planned – The Academy will implement new processes and procedures which address this internal control finding to comply with the Uniform Guidance in the future. Official Responsible – The Academy’s Executive Director, Farhiya Einte. Planned Completion Date – June 30, 2024. Disagreement With or Explanation of Finding – The Academy agrees with this finding. Plan to Monitor – The Academy’s Executive Director, Farhiya Einte, will assure appropriate internal controls and procedures are in place to ensure compliance with reporting compliance requirements in the future.

View Audit 316231

Finding 479605 (2023-003)

Significant Deficiency 2023

Iron County Hospital District Dba: Iron County Medical Center

IL

Allowable Costs / Cost Principles Reporting Significant Deficiency

DEPARTMENT OF HEALTH AND HUMAN SERVICES 2023 – 003 COVID-19 Provider Relief Funding and American Rescue Plan Rural Payments Recommendation: We recommend the Medical Center design controls to ensure documentation is completed timely and sufficiently on how costs are necessary to respond to COVID-19....

DEPARTMENT OF HEALTH AND HUMAN SERVICES 2023 – 003 COVID-19 Provider Relief Funding and American Rescue Plan Rural Payments Recommendation: We recommend the Medical Center design controls to ensure documentation is completed timely and sufficiently on how costs are necessary to respond to COVID-19. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Management has identified that the Medical Center has more than a sufficient amount of lost revenues related to COVID-19 to offset this difference. Action taken in response to finding: The Medical Center will ensure that controls are put into place to capture Covid specific costs in accordance with HHS guidelines. Name of the contact person responsible for corrective action: Kayla Chamberlin, Controller Planned completion date for corrective action plan: July 1, 2023

View Audit 316188

Finding 479590 (2023-003)

Material Weakness 2023

Moniteau School District

PA

Reporting § 200.344

CONDITION: During my review of the District’s compliance with the laws and regulations related to filing its federal grant program Final Expenditure Reports (FER), I noted that the School District did not file the Final Expenditure Report for the ESSER I grant program. The report was required to b...

CONDITION: During my review of the District’s compliance with the laws and regulations related to filing its federal grant program Final Expenditure Reports (FER), I noted that the School District did not file the Final Expenditure Report for the ESSER I grant program. The report was required to be filed with the Pennsylvania Department of Education (PDE) no later than 90 days after the end date of the grant period (September 30, 2022), or within 30 days of expending all grant funding. CRITERIA: The Department of Education requires the completion and submission of a ‘Final Expenditure Report’ (FER) within 30 days of expending all grant funding. In addition, Section 2 CFR 200.344 of the Uniform Guidance requires the submission of financial reports no later than 90 calendar days after the end date of the grant period for performance. RECOMMENDATION: I recommend that the District develop fiscal procedures to ensure that ‘Final Expenditure Reports’ for future fiscal years are completed and filed in a timely manner based on supporting financial information obtained from the District’s business office, in order to 1) comply with PDE reporting requirements for the District’s applicable federal programs, and 2) to avoid any future sanctions or withholding of grant monies from PDE as a result of not filing these reports in a timely manner. MANAGEMENT’S PLANNED CORRECTIVE ACTION: Management is currently implementing procedures to ensure the timely preparation and submission of all required federal financial report filings with the Department of Education, including but not limited to, the Final Expenditure Reports in compliance with PDE rules and regulations. The timeframe for implementation of these duties is effective immediately.

View Audit 316135

Finding 479546 (2023-001)

Material Weakness 2023

Dayton's Bluff Neighborhood Housing Service, Inc.

MN

Reporting Subrecipient Monitoring Material Weakness

Dayton’s Bluff Neighborhood Housing Service and Subsidiary submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Lethert, Skwira, Schultz & Co. LLP, 170 E 7th Place, Saint Paul, MN 55101 Audit period: January 1,...

Dayton’s Bluff Neighborhood Housing Service and Subsidiary submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Lethert, Skwira, Schultz & Co. LLP, 170 E 7th Place, Saint Paul, MN 55101 Audit period: January 1, 2023 – December 31, 2023 The findings from the December 31, 2023 schedule of findings, questioned costs and recommendations. FINDINGS - FINANCIAL STATEMENT AUDIT Finding 2023-001 - Auditor Preparation of the Financial Statements Material Weakness Finding Summary: The Organization does not have an internal control system designed to provide for the preparation of the complete consolidated financial statements, including the accompanying footnotes, as required by GAAP. We were also requested to draft the financial statements and accompanying notes to the financial statements. Corrective Action Plan: It is not cost effective to have an internal control system designed to provide for the preparation of financial statements and accompanying notes. We requested that our auditors Lethert, Skwira, Schultz & Co. LLP, prepare the financial statements and the accompanying notes to the financial statements as a part of their annual audit. We have designated a member of management to review the drafted financial statements and accompanying notes. Responsible Individuals: Jim Erchul, Executive Director, 651-774-6995 Anticipated Completion Date: Ongoing

View Audit 316095

Finding 479536 (2023-001)

Significant Deficiency 2023

Accountability Lab, Inc.

DC

Reporting § 200.303 § 200.508 § 200.510

Views of Responsible Officials and Planned Corrective Actions: In 2024 during the SEFA analysis and in discussion with auditors it was determined that a USG-funded contract, attached to a grant, was incorrectly left off the SEFA. This was amended as soon as the mistake was noted. AL is required to s...

Views of Responsible Officials and Planned Corrective Actions: In 2024 during the SEFA analysis and in discussion with auditors it was determined that a USG-funded contract, attached to a grant, was incorrectly left off the SEFA. This was amended as soon as the mistake was noted. AL is required to submit financial statements to a non-US Government donor by June of each calendar year. To comply with this grant stipulation AL starts pre-audit document checks in early January and full fieldwork in mid-February following our financial year close on December 31. While the majority of our annual financial statement is complete by mid-January we have one outstanding USG grant which only reports at the end of February for an end-of-January quarter close. As a result, we are only able to provide a preliminary SEFA when the auditors request the first document checks in January. For FY 2025 we will request that the auditors start with a basic audit of Financial Statements and then submit the SEFA once all the quarterly reports have been submitted to USG. Anticipated Completion Date: Already decided for FY 2024 audit. Responsible Officials: Chief Innovation and Operations Officer and Finance Manager.

View Audit 316094

Finding 479530 (2023-002)

Material Weakness 2023

Worker Education & Resource Center INC

CA

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness

The Organization had a significant turnover in both Fiscal Manager Consultant and Executive Director during the year being audited. The Fiscal Manager Consultant was replaced by the Director of Finance in the later part of the fiscal year 2022-2023. This required the new Director of Finance to creat...

The Organization had a significant turnover in both Fiscal Manager Consultant and Executive Director during the year being audited. The Fiscal Manager Consultant was replaced by the Director of Finance in the later part of the fiscal year 2022-2023. This required the new Director of Finance to create and implement as many internal controls that were needed, that were not implemented, and/or recommended by our current CPA firm who had been previously auditing prior years. Additionally, our Director of Finance has engaged the Board of Directors in taking a more active role in the financial statement overview that was not previously recommended to them by our CPA firm.

View Audit 316070

Finding 479529 (2023-001)

Significant Deficiency 2023

Worker Education & Resource Center INC

CA

Reporting

In the year being audited (July 1, 2022-June 30, 2023), we have removed our Fiscal Audit Consultant and replaced that with a Director of Finance employee that has the skill, knowledge, and education for this matter to be resolved for subsequent audits. Also, moving forward each new grant contract wi...

In the year being audited (July 1, 2022-June 30, 2023), we have removed our Fiscal Audit Consultant and replaced that with a Director of Finance employee that has the skill, knowledge, and education for this matter to be resolved for subsequent audits. Also, moving forward each new grant contract will be discussed with our CPA firm for guidance on the proper application of the grant/contract as it relates to the proper classification of restricted and unrestricted funds. Moreover, since this was our first requirement for a single audit the SEFA form was a new introduction into our internal controls presented by our auditor during the audit and we believe assistance with this form in any subsequent audits will be limited, if needed at all.

View Audit 316070

Finding 479525 (2023-003)

Material Weakness 2023

Missoula County

MT

Questioned Costs Reporting

Finding 2023-003 – Reporting U.S. Department of Treasury COVID-19 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF)- ALN 21.027 Reporting – Missoula County has implemented a dual control process over CSLFRF reporting. As part of the month end process the accountant in finance will review al...

Finding 2023-003 – Reporting U.S. Department of Treasury COVID-19 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF)- ALN 21.027 Reporting – Missoula County has implemented a dual control process over CSLFRF reporting. As part of the month end process the accountant in finance will review all expenditures related to obligated ARPA programs and reconcile this activity with each department. At the end of the quarter after all months have closed and prior to Treasury reporting an additional review of quarter will occur by the Senior Accountant in finance. This documentation will be reconciled to the Treasury quarterly reports to ensure accurate reporting. Contact Person Responsible for the Corrective Action: Michelle Denman, Deputy Financial Services Director Anticipated Completion Date of the Corrective Action: June 30, 2024

View Audit 316058 Questioned Costs: $1

Finding 479516 (2023-001)

None 2023

Carolina University

NC

Reporting

Management agrees with the finding of the auditor's report concerning the failure to timely submit our 2023 single audit reporting package and data collection form in a timely manner. We have suffered changes in personnel which had a significant impact on our ability to gather information needed to ...

Management agrees with the finding of the auditor's report concerning the failure to timely submit our 2023 single audit reporting package and data collection form in a timely manner. We have suffered changes in personnel which had a significant impact on our ability to gather information needed to finalize our accounting records. New staff members who have taken on these responsibilities are in the process of learning those procedures and adapting to our organization's specific requirements. Additionally, there were some communication challenges during the audit process which led to misunderstandings and further delays. In addressing these challenges, we are providing additional training and support for our new staff members and reevaluating our financial closing processes to ensure that reporting deadlines are met in future periods. In addition, we were awaiting two significant financial transactions that will have a direct and substantial impact on our 2022-2023 financial reports. The most significant of those transactions was a very large estate gift that was pending at the close of the fiscal year (gift receivable). The value of this gift was difficult to assess because of the nature of the gift as part of a sizeable and complicated trust (as well as a very lengthy liquidation process). The gift finally arrived in April 2024 which provided us with the correct valuations (an increase in net assets without donor restrictions of over $4 million). A gift of this magnitude had such a substantial financial impact that we needed to wait for its completion in order to properly assess our financial position. The second transaction (a sale of unused property) closed in late May which enabled us to accurately reflect the impact of these previously pending items. Responsible Official: Chris Ronk, Chief Financial Officer (800) 937-5097

View Audit 316046

Finding 479514 (2023-004)

None 2023

Christian Community Health Center

IL

Reporting

SF-425 Federal Financial Report (FFR) Reporting Planned Corrective Action: CCHC's finance department has contacted the HR.SA grants specialist, regarding the carryover of unobligated funds of $1,989,278, and the carryover funds have been approved and successfully moved into the current budget peri...

SF-425 Federal Financial Report (FFR) Reporting Planned Corrective Action: CCHC's finance department has contacted the HR.SA grants specialist, regarding the carryover of unobligated funds of $1,989,278, and the carryover funds have been approved and successfully moved into the current budget period. The grant compliance manager will assure CCHC's intention to conduct carryover of any unobligated funds by indicating it in the SF-425 reports comments section. This change will strengthen internal controls related to grant management and reporting to prevent future noncompliance incidents. Lastly, CCHC will also review and revise internal procedures for SF- 425 reporting to ensure clarity and adherence to deadlines. Person Responsible for Corrective Action Plan: Isai Ruacho, Grant Compliance Manager Anticipated Date of Completion: 07/31/2024

View Audit 316037

Finding 479485 (2023-002)

Significant Deficiency 2023

City of Torrington, Connecticut

CT

Reporting Significant Deficiency Internal Control / Segregation of Duties

Finding 2023-002 - Reporting (COVID-19 American Rescue Plan Act Local Fiscal Recovery) Significant Deficiency – Internal Control over Compliance Other Matters (Noncompliance) Description of Finding - Controls over Project and Expenditure Reports did not exist to ensure accuracy of submitted data. ...

Finding 2023-002 - Reporting (COVID-19 American Rescue Plan Act Local Fiscal Recovery) Significant Deficiency – Internal Control over Compliance Other Matters (Noncompliance) Description of Finding - Controls over Project and Expenditure Reports did not exist to ensure accuracy of submitted data. Statement of Concurrence or NonConcurrence - Management agrees with the finding. Corrective Action - The City has implemented additional processes and controls related to the review of treasury reporting. However, these were not in place for all of the current year. Name of Contact Person - John Monks, Comptroller Projected Completion Date - June 30, 2024

View Audit 316014

Finding 479457 (2023-001)

Significant Deficiency 2023

Spectrum Health & Human Services

NY

Subrecipient Monitoring Procurement, Suspension & Debarment Reporting

Spectrum Health and Human Services received federal funding in 2023 as a prime recipient of a grant under CFDA #93.243. The grant is subject to the Federal Funding Accountability and Transparency Act (FFATA). Under FFATA, prime recipients are required to report certain information related to subawar...

Spectrum Health and Human Services received federal funding in 2023 as a prime recipient of a grant under CFDA #93.243. The grant is subject to the Federal Funding Accountability and Transparency Act (FFATA). Under FFATA, prime recipients are required to report certain information related to subawards to the federal government using the FFATA Subaward Reporting System (FSRS). Because we did not have a procedure in place to identify federal grants that are subject to FFATA, we did not perform the required reporting under FSRS. To ensure compliance with this requirement, Spectrum Health and Human Services has identified an individual, our Contracts/Grants Manager, who will be responsible for ensuring this reporting is done going forward. Our Contracts/Grants Manager will review all grants for FFATA reporting requirements upon receipt of a federal award and track all deadlines for any reporting required. Additionally, the Contracts/Grants Manager has already reviewed our existing federal awards for any FFATA reporting requirements, and has updated the FSRS system for the required reporting of our subaward under CFDA #93.243.

View Audit 315986

Finding 479455 (2023-001)

Significant Deficiency 2023

Juneau County Housing Authority

WI

Internal Control / Segregation of Duties Reporting

Corrective Action Planned: Due to the Authority's size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size. Completion Date: Ongo...

Corrective Action Planned: Due to the Authority's size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size. Completion Date: Ongoing

View Audit 315985

Finding 479449 (2023-003)

Significant Deficiency 2023

Dr. Stanley and Pearl Goodman Jfs of Broward County, Inc.

FL

Reporting § 200.512

In connection with those identified in 2023-001 and 2023-002, Management has established a rigorous procedure for reviewing and implementing controls to ensure that all contracts from the consolidated organizations are reviewed by designated personnel, guaranteeing full compliance with reporting req...

In connection with those identified in 2023-001 and 2023-002, Management has established a rigorous procedure for reviewing and implementing controls to ensure that all contracts from the consolidated organizations are reviewed by designated personnel, guaranteeing full compliance with reporting requirements.

View Audit 315979

Finding 479448 (2023-001)

Significant Deficiency 2023

Prairie View, Inc.

KS

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

Criteria or Specific Requirement – Reporting (Reference number 2023-001) Recommendation – The Organization should continue to improve understanding of the guidance related to this type of reporting and work to identify areas for improvement prior to submission to the Provider Relief Fund reporting ...

Criteria or Specific Requirement – Reporting (Reference number 2023-001) Recommendation – The Organization should continue to improve understanding of the guidance related to this type of reporting and work to identify areas for improvement prior to submission to the Provider Relief Fund reporting portal. Management should ensure proper internal controls are put into place to ensure that allowable expenses reported are not reimbursed by other sources or in previous submission period. Views of Responsible Officials and Corrective Action Plan – Management agrees with the finding. The reporting discrepancy was due to a misunderstanding of how the cost portion of the report should have been presented. The presentation was submitted with the same methodology as the lost revenue presentation, which was on a cumulative basis vs. the incremental period required for costs. In addition, staff turnover, including the responsible official (CFO), during this period of time impacted the execution of the last repoting requirement and improper reporting to HHS. The Organization believes that it had sufficient lost revenues to justify retention of all PRF Period 4 funds. There is no expected future reporting for the Provider Relief Funds. Personnel Responsible – John Hydock, Interim CFO Timeline – There is no expected future PRF submissions, but in the event one is required, the Organization will have a quality control process in place to review reporting of expenses to ensure no duplication or carry-over of expenses occurs.

View Audit 315978

Corrective Action Plans

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